[Senate Hearing 112-23]
[From the U.S. Government Publishing Office]






                                                         S. Hrg. 112-23

   FIELD HEARING ON IMPROVING PATIENT SAFETY AND QUALITY CARE AT THE 
                        DAYTON VA MEDICAL CENTER

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

                               __________

                             APRIL 26, 2011

                               __________

       Printed for the use of the Committee on Veterans' Affairs









        Available via the World Wide Web: http://www.fdsys.gov/





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                     COMMITTEE ON VETERANS' AFFAIRS

                   Patty Murray, Washington, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Daniel K. Akaka, Hawaii              Johnny Isakson, Georgia
Bernard Sanders, (I) Vermont         Roger F. Wicker, Mississippi
Sherrod Brown, Ohio                  Mike Johanns, Nebraska
Jim Webb, Virginia                   Scott P. Brown, Massachusetts
Jon Tester, Montana                  Jerry Moran, Kansas
Mark Begich, Alaska                  John Boozman, Arkansas
                       Kim Lipsky, Staff Director
                 Lupe Wissel, Republican Staff Director








                            C O N T E N T S

                              ----------                              

                             April 26, 2011
                                SENATORS

                                                                   Page
Brown, Hon. Sherrod, U.S. Senator from Ohio......................     1

                               WITNESSES

Turner, Hon. Michael, U.S. Representative from Ohio..............     4
Daigh, John D., Jr., M.D., Assistant Inspector General for Health 
  Care Inspections, Office of Inspector General, U.S. Department 
  of Veterans Affairs; accompanied by George Wesley, M.D., 
  Director, Medical Consultation and Review Division, Office of 
  Health Care Inspections; and Kathleen Shimoda, Health Care 
  Inspector, Office of Health Care Inspections...................     7
    Prepared statement...........................................     9
Hetrick, Jack G., Network Director, Veterans Integrated Service 
  Network 10, Veterans Health Administration, U.S. Department of 
  Veterans Affairs; accompanied by William D. Montague, Acting 
  Director, Dayton VA Medical Center; and Lisa Durham, Chief, 
  Quality Management, Dayton VA Medical Center...................    23
    Prepared statement...........................................    24

 
   FIELD HEARING ON IMPROVING PATIENT SAFETY AND QUALITY CARE AT THE 
                        DAYTON VA MEDICAL CENTER

                              ----------                              


                        TUESDAY, APRIL 26, 2011

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2 p.m., at the 
Dayton VA Medical Center, Dayton, OH, Hon. Sherrod Brown of 
Ohio, presiding.
    Present: Senator Brown of Ohio, presiding.

OPENING STATEMENT OF HON. SHERROD BROWN, ACTING CHAIRMAN, U.S. 
                       SENATOR FROM OHIO

    Senator Brown of Ohio. Thank you for joining us. I am 
Senator Sherrod Brown. This is an official hearing of the U.S. 
Senate Veterans' Affairs Committee, an official hearing even 
though it is not in Washington. Senator Patty Murray, who is a 
Democrat from the State of Washington, has empowered me as a 
Member of the Veterans' Affairs Committee to hold this hearing 
in Dayton at the VA Medical Center.
    I thank you all for joining us. I thank Senator Murray, 
Ryan Pettit of her staff, and the Veterans' Affairs Committee 
staff. Also, John McDonald, to my right behind me, is with the 
Minority Staff of the Committee's Ranking Member, Senator Burr, 
a Republican from North Carolina. Also behind me is Doug 
Babcock of my office staff who advises us on veterans issues.
    The investigation of the VA Dental Clinic has affected so 
many local veterans and their families that it makes sense to 
hold the hearing here. I will recognize Congressman Turner in a 
moment, who has been very, very involved in this. They will 
hold a hearing about Dayton and St. Louis in Washington with 
the Veterans' Committee there soon.
    As I said, Chairman Murray and Secretary Shinseki and I 
have had many discussions about what happened, as has 
Congressman Turner with the Secretary. This hearing is a result 
of this work. It will operate with the same authority of any 
other hearing in the U.S. Senate that is held in Washington, 
DC.
    We will be hearing from the Office of the Inspector General 
of VA and members of the VA leadership on what happened at the 
Dayton VA Dental Clinic. We need to know how we got here. We 
need to know how we move forward.
    To any audience members who would like to submit testimony 
for the official record, please contact Mr. Babcock from my 
office and Rachel, if she would put her hand up, Rachel Miller 
of my staff in our Cincinnati office.
    Before we start, I would like to ask anyone who is a 
veteran to please stand or put your hand up. Thank you. 
[Applause.]
    All of us thank you, and I think I can speak for the Senate 
here, thank you for your service and we commit to doing better 
with this Vet Center, as the VA does in a great majority of 
places around the country.
    A special thank you to the leaders of Ohio's Veterans 
Service Organizations. Tom Burke of the Buckeye State Council, 
President for Vietnam Veterans--is Tom here? If Tom would put 
his hand up. He was going to join us. Dave Kenyon, who is a 
State Service Officer for the AMVETS, thank you for joining us. 
And Susan Getz, who is National Vice Chair of the Women 
Veterans of America--where is she? Thank you for joining us, 
too.
    For 150 years, Ohio has been a leader in providing 
veterans' services. Ohio founded one of the Nation's first 
chapters of the Veterans of Foreign Wars. Ohio has the Nation's 
best county Veterans Service Officers and Organization. The 
Dayton VA Medical Center was one of the Nation's first VA 
hospitals, providing continuous care and service to veterans 
for some 14 decades, 140 years.
    As a Member of the Senate Veterans Committee, it is not 
only an honor for me to serve our Nation's veterans, it is a 
sacred responsibility that we all take when we take our oaths 
of office. We should not have to be here. This hearing should 
not have to take place. I would much rather have a hearing on 
the future of the VA in Dayton, how we can help the community 
leverage Federal resources to ensure that the hospital and the 
campus meet the needs of our veterans. I would rather be 
talking about our strong bid for the VA Archives, a distinction 
clearly earned by Ohio veterans and deserved by Ohio veterans.
    One of the most important duties of representing Ohio's 
veterans on this Committee is to provide oversight of the 
Veterans Administration. That means undertaking what works at 
VA, this Vet Center, and other centers around the country. It 
also means making it better when it does not, finding out what 
is not working, and fixing it. In the process, it means 
recognizing that serving our veterans is a nonpartisan 
responsibility of our government. Our veterans deserve nothing 
less. That is why we are here today.
    Most of us are aware of the inexcusable facts and 
unconscionable consequences behind what happened at the Dayton 
VA Dental Clinic. Over the course of 18 years, the clinic 
failed in its duty, in far too many cases, to serve our 
veterans. A dentist disregarded basic sterilization practices. 
Nurses and assistants were ignored when they reported 
substandard care. We heard reports of employees punished for 
reporting unsafe practices. Petty, mean-spirited interpersonal 
dysfunction led to physical and verbal confrontations. Dental 
students allegedly provided care beyond that for which they 
were qualified based on VA standards and regulations. 
Management at the dental clinic and medical center studiously 
ignored problem after problem after problem, a symptom of 
general management chaos. These are the irrefutable, 
inexcusable facts.
    More than 500 patients, as we know too well, at the Dayton 
VA Dental Clinic have been told that they have to be tested for 
bloodborne pathogens as a result of the care they received at 
this facility. Some experts are saying that thousands should be 
tested. As many as nine patients have tested positive for 
hepatitis; perhaps there are more. Veterans received life-
threatening bloodborne pathogens instead of high-quality health 
care.
    The patients at the clinic are our Nation's veterans and 
their families. They served our Nation when called upon. High-
quality health care is a benefit they have earned, they 
deserved, and we have pledged to them, and in most cases, that 
is what the VA system does--ensure a high standard of care to 
veterans who have earned it. I often tell people that nowhere 
in the world will you find better care than when you step into 
a VA facility. During the debate on health insurance reform, 
the VA health system was an example to emulate.
    So this hearing is not a trial. It is not a witch hunt on 
the entire VA medical system. Far from it. We want to restore 
the public's confidence in the system. We want to ensure 
accountability for those responsible for these horrific wrongs. 
We want to instill transparency as we move forward to ensure no 
veteran is ever treated with such blatant disregard. We want 
transparency. We want accountability. We want to hear about the 
clinic's mistakes and learn from the clinic's mistakes so those 
mistakes are not repeated. This hearing is grounded in those 
goals.
    We will explore specific questions about what happened over 
the last 18 years. Why was the clinic allowed to operate in 
this fashion for more than a decade? Why did it take so long to 
close the clinic? Has every person exposed to contagions from 
unsafe medical practices been notified and treated and tested? 
What is being done to hold those accountable, including those 
who knew and sat idly by and those who should have known?
    We will explore where we are today. Is the Dayton Dental 
Clinic now safe for patients who rightfully expect the world-
class care that VA rightfully, most of the time, prides itself 
on? Are systems in place for this to never happen again? What 
is VA doing to make those exposed whole? What is VA doing to 
reassure every veteran that VA care is, in fact, the best care 
anywhere? We will explore how to restore the public's 
confidence in this hospital.
    I have heard from hundreds of veterans about the Dayton VA. 
Most are angry. Many are just disappointed. I want to share two 
of them. One veteran from just north of here, from Huber 
Heights, told me, ``I desperately need dental care, but not at 
the expense of my health.'' A veteran in Minster in Auglaize 
County wrote, ``I am one of the veterans who was potentially 
exposed by the dentist in question. I have been tested. Now I 
have to wait in limbo, being treated as if I am positive until 
said test results come back. No offense, Senator, but the 
testing is being done by the same agency that ignored the 
problem for 18 years. It put me in jeopardy to begin with. Am I 
to trust that the VA this time will get it right?''
    I am not happy with the pace of the administrative process 
regarding the disciplining of those involved. I understand 
there are legal and procedural hurdles, and for that matter, 
criminal processes that need to be followed. But people must be 
held accountable. Transparency, accountability, making sure 
this crisis in care and confidence must never, ever happen 
again, that is what this hearing is about today.
    That is why I have asked Congressman Turner to offer his 
testimony. Congressman Turner and I have worked together to 
push for answers and accountability. While we represent two 
different parties in two different chambers, we represent the 
same Ohio veterans. He represents Ohio's Third Congressional 
District, and home to his district is home to this VA medical 
center. I have asked him to make a brief statement before we 
hear testimony. Congressman Turner, thank you for joining us.

               STATEMENT OF HON. MICHAEL TURNER, 
                 U.S. REPRESENTATIVE FROM OHIO

    Mr. Turner. Thank you, Senator Brown. I want to thank you 
for holding this important hearing.
    The importance of what you are doing here today is that you 
are not just sitting here as the Senator from Ohio, concerned 
about these veterans and this issue that is occurring in your 
State. I understand that this is a hearing that is occurring 
under the auspices of the Senate Veterans' Affairs Committee. A 
transcript is being taken, and I know this becomes a part of 
the official record of the work of the Senate in evaluating the 
VA, both this instance and nationally, so I appreciate that 
this is a special visit as we look to investigate this issue 
and broaden the scope, really, of what needs to be reviewed 
here at this site.
    I appreciate your statement on what occurred here. This is 
abhorrent, that any patient who would enter the VA would be 
placed at risk. The fact that these practices were ongoing and 
none of us knew, you acknowledged, is equally abhorrent, and I 
think that is part of what brings everyone here with such 
anger.
    We know that the dentist in question violated standards for 
practice for at least 18 years. The support staff was aware of 
the infractions, but apparently their reports were not followed 
through or they did not report it, because when he was found 
reported, the leadership, I believe, moved forward trying to 
cover up what had happened here and continues to not be 
forthcoming about the actions that had occurred here.
    I believe that the VA is acting more as an obstacle than 
they are of help to resolve this, and I think this hearing that 
you have brought forth, Senator Brown, will help us in trying 
to dislodge some of the information that has occurred, and I 
would like to highlight some of that difficulty.
    First, the VA notified my office that they wished to meet 
with our staff to provide what they called an update concerning 
the dental clinic at the Dayton VA Medical Center. The notice 
was provided at 9:30 p.m. the night before the briefing, which 
was scheduled at 10 a.m. the next morning. At this briefing, 
the VA informed us that standards of practice concerning 
infection control had been violated, and that 535 veterans in 
the Dayton community were going to be notified that they should 
come in and be tested for bloodborne pathogens, including HIV, 
along with hepatitis A, B, and C.
    Following that notification, Senator Brown, yourself, 
Senator Portman, and I requested copies of the report and that 
they be provided to the Greater Dayton Area Hospital 
Association for their review and determination as to how the 
community should proceed. Instead of embracing this 
relationship and working together to solve an obvious problem, 
the VA has very lethargically and reluctantly responded to our 
request. I will give you a few examples, which I know you are 
aware.
    First, my office requested a copy of the investigative 
report on February 17. Following that request, we were informed 
that the VA would have to redact information in the report and 
that would cause some delay. We were told that patient 
information was going to be protected. The documents really 
contained no patient information, but as you are aware, Senator 
Brown, the report that was released had many redactions of 
information which were important for us to be able to review as 
a community to determine what happened here and how we need to 
proceed.
    Despite numerous requests, we did not receive the reports 
until 9:30 p.m. Friday, March 11, 2 days before Chairman Miller 
of the House Veterans' Affairs Committee and I were scheduled 
to meet with the leadership in Dayton. The delay inhibited our 
ability to both inform the Greater Dayton Area Hospital 
Association and the community. We later learned that the 
regional facility had released the report to the Dayton Daily 
News on February 9, a full month before they released it as a 
result of Congressional request.
    Second, Chairman Miller and I visited the hospital to speak 
with the leadership to learn about what had happened. However, 
just prior to our visit, we learned that the VA had removed the 
director, Guy Richardson, from his position and moved him into 
a higher-level supervisory role. We were unable to meet with 
Mr. Richardson and still have been unable to meet with him to 
date.
    Finally, during our visit, I raised concerns about the 
redactions made in the report. When I later met with the VA 
FOIA (Freedom of Information Advisory Council) office in April, 
they informed me that it took their office only 4 hours to 
redact the report, and it still took a month for the report to 
be released, for us to be able to provide it to the Greater 
Dayton Area Hospital Association.
    Senator, as you are aware, the Greater Dayton Area Hospital 
Association has reviewed the information to date that has been 
released by Veterans Affairs, and the Dayton VA Task Force has 
released this report which they say concludes that additional 
veterans need to be tested and additional veterans need to be 
provided care. They believe that the practices that occurred 
here exposed many more veterans than VA is currently 
acknowledging were at risk. We are calling on Secretary 
Shinseki to provide testing and notice to those additional 
patients so that they can be properly cared for and VA can 
properly acknowledge the risk that these veterans were placed 
in.
    With regard to the Office of Inspector General 
investigation that is the subject of discussion today, I would 
like to thank that panel for investigating this issue, but I 
would be remiss if I did not point out that the scope of the 
OIG investigation was limited by internal constraints. As the 
report itself states, the OIG investigative body was unable to 
interview several key witnesses simply due to their retirement. 
These witnesses include the original source complainants, a 
fellow dentist, and the facility's chief of staff. Their 
absence raises serious concern over the comprehensive scope of 
the investigation and brings their conclusions into question.
    What the investigation does do, however, is highlight a 
systematic flaw that allowed employees to evade the 
investigative process by retiring. This escape-hatch option 
neither serves our Nation's veterans nor the taxpayer and 
merits further investigation. After all, our country has 
thousands of young men and women that are making a great 
sacrifice, just as the generations before them. We need to make 
sure that they have the peace of mind to know that if they need 
help, there will be a fully functioning and competent VA here 
to give them that help when they need it, just as was promised.
    Senator, thank you for reviewing this matter. Thank you for 
bringing this hearing. I believe that the VA has additional 
information that they need to provide to this community for us 
to be able to evaluate what happened here and what actions need 
to be taken to address the concerns of the veterans who 
received care, and for us to be able to have confidence that 
the other types of care beyond dental that are provided at this 
facility meet the highest standards for our veterans. Thank 
you, Senator.
    Senator Brown of Ohio. Thank you, Congressman Turner. Thank 
you for being here. We will address, I hope, all of those 
concerns that you brought up today. Thank you very much, and 
thanks for your work on this since the story broke. You got so 
involved. Thank you. Thanks very much, Congressman Turner.
    The first panel will consist of Dr. John Daigh, Assistant 
Inspector General for Health Care Inspections, Office of 
Inspector General. Dr. Daigh joined the VA as Associate 
Director of Medical Consultation in the Office of the Inspector 
General in January 2002 and was appointed as the Assistant 
Inspector General for Health Care Inspections in January 2004. 
He is responsible for the Office of Inspector General 
initiatives that review the quality of health care provided to 
veterans in Veterans Affairs hospitals, clinics, in nursing 
homes, in addition to the care provided to veterans through 
various health care contracts. Prior to joining the Office of 
Inspector General, he was active duty with the U.S. Army for 27 
years, retiring as a Colonel 10 years ago.
    Dr. Daigh is joined by Dr. George Wesley, Director of 
Medical Consultation and Review Division, Office of Health Care 
Inspections; and Kathleen Shimoda, Health Care Inspector, 
Office of Health Care Inspections, and you are a registered 
nurse, I believe?
    Ms. Shimoda. Yes.
    Senator Brown of Ohio. Yes. Dr. Daigh, please begin with 
your testimony. I may end up asking questions of the other two 
with you, and they can certainly consult with you on the 
answers. So proceed, Dr. Daigh.

  STATEMENT OF JOHN D. DAIGH, JR., M.D., ASSISTANT INSPECTOR 
   GENERAL FOR HEALTH CARE INSPECTIONS, OFFICE OF INSPECTOR 
 GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY 
GEORGE WESLEY, M.D., DIRECTOR, MEDICAL CONSULTATIONS AND REVIEW 
   DIVISION, OFFICE OF HEALTH CARE INSPECTIONS; AND KATHLEEN 
     SHIMODA, HEALTH CARE INSPECTOR, OFFICE OF HEALTH CARE 
                          INSPECTIONS

    Dr. Daigh. Yes, sir. Senator Brown, it is a pleasure to be 
here in Dayton, a community that is recognized worldwide for 
its innovation, hard work, and success. It is especially a 
privilege to be here at a hospital that has been one of the 
oldest in the VA. As you identified, Dr. Wesley and Kathleen 
Shimoda are here with me. These are the two individuals that 
led the team that resulted in the report that was published 
Wednesday, or yesterday, on our Web site, of which you speak.
    We were both horrified and surprised when we were asked by 
the Senate and House Veterans' Affairs Committee to come to the 
Dayton Dental Clinic and review the allegations that infection 
control practices were not being adequately followed. As a 
result of those efforts, we published the report that I 
mentioned.
    I believe that at the current time that these breaks in 
infection control policy that we saw in the dental clinic are 
not typical of what is seen in this hospital at all, nor do I 
believe that the issues that we discovered and have reported on 
in our report are typical of VA as a whole. I believe that this 
is an outlier from how VA normally operates.
    I have a couple of suggestions that I think should be 
considered moving forward that I hope will prevent these issues 
from occurring again.
    One, I think that there are a group of individuals in the 
hospital whose input may not be--and I do not speak 
specifically about this hospital but VA hospitals in general--
whose input may not flow unfiltered to the leadership, and I 
would speak of the group of individuals who I would call 
hospital technicians. They would be the individuals who run the 
ultrasound machines, who are cath lab techs, who work in the 
ophthalmology clinic, and who would be the technicians in the 
dental clinic. I think that the physicians and providers, in 
fact, have a direct line of communication to the hospital 
leadership through the standard chain of command. I think that 
the nurses and the nursing staff have a direct line of 
communication to hospital leadership through the head nurse. I 
think this other group of people might, if talked to on a 
regular basis, might, in fact, allow some of these issues to 
come to light sooner and be dealt with more quickly.
    The second recommendation that I would have would be that 
among the senior leadership group in the hospitals, that VA 
consider rotating or having terms of office for those leaders, 
that they ought to plan to move from hospital to hospital or 
that their positions be changed up on some program basis. There 
is a cost to that, and I am not sure, we have not studied it as 
to whether that should be done in all cases. But I think it 
provides for a relook at the relationships that exist in a 
hospital. It requires leaders at lower levels to prove to their 
new boss that, in fact, the standards that they have in place 
and the criteria that they are managing their organization by 
are effective.
    The third recommendation I would make is that the VA uses a 
policy which I think is quite excellent which deals with 
adverse event disclosure. That policy was written in 2008, and 
it essentially is the playbook that is used to try to determine 
who should be notified when more than one individual needs to 
be notified as a result of an outbreak or the risk of an 
outbreak. There have been many more notifications around this 
issue and reusable medical equipment than I think anyone 
expected.
    I would refer you all to the New England Journal editorial 
of September 2, 2010, which discusses the notification issue 
broadly in the United States and which lays out 30 or 40 
notifications countrywide. VA has a few of those on the list, 
but there are many other institutions that have covered that 
problem. I think that it is reasonable to consider empaneling 
someone like the Institute of Medicine or some other group to 
sit down and think about the risk that--the risk issues, where 
the limit of science comes up with policy in terms of whom and 
how we should notify individuals.
    I think that the basic scientific fact that HIV has never 
been transmitted, that is found in published literature, 
through saliva from one patient to the next, I think is 
understood. The risk of whether hepatitis B could be 
transferred from one patient to another has limits in what 
people know and understand and what people think good 
government or good policy ought to be. So I think that there is 
a wider expanse with these issues beyond VA, and I think a 
discussion would be of some value.
    I also think that included in that discussion at the 
Federal level is the relationship between the administration 
and the legislature. I think that the policy currently lays out 
that the administration, the Principal Deputy Under Secretary 
for Health, the PDUSH, will advise the Under Secretary for 
Health on an action to take. These actions involve many 
individuals at great expense, and I think that one should 
consider how, in fact, those discussions occur.
    The last piece of advice or issue that I think should be 
considered is one that is difficult to articulate exactly 
except to say that it is not uncommon in medical institutions 
for physicians who are prominent in their society at that 
hospital, who have worked there for decades or many years, have 
established a wonderful working relationship in that hospital, 
to over time decide that their capabilities are less. What they 
typically then do is request a set of privileges in the 
hospital. It is not the full set of privileges that they might 
have had 10 years ago.
    So an example might be a surgeon who fully engaged in the 
operating room and in clinic might at some point in time 
request privileges not to operate but simply to work in the 
clinic for a variety of reasons. Maybe their hand was injured. 
Maybe there is some other issue. But I think it is incumbent 
upon the leadership of the VA to take careful thought and look 
and be especially careful in the granting of privileges when 
there is a change over time. One wants to limit the privileges 
of a practitioner based on data. Certainly, one does not want 
to have to have adverse events occur or patients be harmed 
before a credentialing and privileging committee makes the 
decision to limit the privileges of an individual or deny 
privileges to an individual.
    I talked about this issue with the leadership of VHA. I 
think it is one that, through discussion and consideration, 
that credentialing and privileging committees can focus on and 
do a better job at that issue. I know that my office will 
assign more time to looking at that issue as we look at the 
performance of credentialing and privileging committees 
throughout VHA. I think that is the fourth suggestion I would 
have, is to have--these issues might, in fact, be improved and 
be made less likely to occur in the future.
    My staff will be privileged to take questions from you as 
you see fit. Thank you, sir.
    [The prepared statement of Dr. Daigh follows:]
  Prepared Statement of John D. Daigh, Jr., M.D., Assistant Inspector 
 General for Healthcare Inspections, Office of Inspector General, U.S. 
                     Department of Veterans Affairs
    Senator Brown and other Members of the Committee, thank you for the 
opportunity to testify on the results of our review involving the 
Dental Clinic at the VA Medical Center (VAMC), in Dayton, Ohio. At the 
request of the Chairmen and Ranking Members of the Senate Committee on 
Veterans' Affairs and the House Committee on Veterans' Affairs, the 
Office of Inspector General (OIG) reviewed infection control issues at 
the Dental Clinic at the Dayton VAMC and on April 25, 2011, we issued 
our report, Healthcare Inspection--Oversight Review of Dental Clinic 
Issues, Dayton VA Medical Center, Dayton, Ohio. We concluded that the 
subject dentist did not adhere to established infection control 
guidelines and policies, and multiple dental clinic staff had direct 
knowledge of these repeated infractions. These violations of infection 
control policies placed patients at risk of acquiring infections 
including those that are bloodborne.
                               background
    Dental Clinic--The Dayton Dental Clinic performs a full spectrum of 
dental and oral surgical procedures. The dental specialties recognized 
by the American Dental Association (ADA) practiced at the medical 
center include general dentistry, oral and maxillofacial surgery, oral 
and maxillofacial radiology, periodontics, and prosthodontics. In 
July 2010, the dental clinic had seven dentists and an oral surgeon, 
two dental hygienists, seven dental assistants (two expanded function, 
five non-expanded function), and three dental laboratory technicians. 
In fiscal year (FY) 2009, the dental clinic treated 3,164 unique 
patients, and in FY 2010 the clinic treated 3,005 unique patients.
    The dentists, oral surgeon, administrative officer, expanded 
function dental assistants, registered dental hygienists, and dental 
laboratory technicians report to the service chief, while the non-
expanded function dental assistants and administrative program staff 
report to the Dental Service's administrative officer. The Chief of 
Dental Service reports to the VAMC Chief of Staff. The dental clinic 
has a General Practice Residency, which is an independent medical 
center residency (as opposed to being the recipient of university 
residents rotating through the dental clinic). At the time of the 
review, there were three residents, although it is authorized four. The 
last accreditation review occurred in September 2006, and the 
Commission on Dental Accreditation adopted a resolution to grant the 
program the accreditation status of ``approval without reporting 
requirements'' at its January 25, 2007 meeting. The next scheduled 
accreditation site inspection is scheduled for September 2013.
    VA Oversight--The Veterans Health Administration (VHA) operates a 
program of proactive inspections through its System-Wide Ongoing 
Assessment and Review Strategy (SOARS) program. Its mission is ``to 
provide assessment and educational consultation to volunteer facilities 
using a systematic method for on-going self-improvement.'' SOARS 
inspection teams are composed of program staff and field (Veterans 
Integrated Service Network (VISN) and medical center level) health care 
experts.
    During the week of July 20-23, 2010, a SOARS team inspected the 
Dayton VAMC. On the morning of July 21, 2010, during the course of this 
inspection, two dental clinic employees approached a team member. The 
employees articulated allegations about aspects of a staff dentist's 
practice that pertained to this dentist's handling of dental burs and 
noncompliance with dental infection control guidelines. These 
improprieties allegedly were ongoing.
    The allegations, if true, would have represented significant 
breaches of both medical center and VHA national standards regarding 
the handling of reusable medical equipment (RME), adherence to 
standards of infection control, and professional comportment expected 
of VHA dentists. At that time, it was also alleged that these concerns 
had been previously brought to Dental Service management's attention.
    From August 19, 2010, through September 9, 2010, the dental clinic 
temporarily suspended operations. The VISN and medical center 
supervised an extensive re-organization of the dental clinic. This 
included employee training, employee counseling, environment of care 
improvements, and updates in operating procedures. Dayton's Quality 
Manager notified The Joint Commission (the JC) and the Commission on 
Accreditation of Rehabilitation Facilities that as of August 19, 2010, 
as a precautionary measure in order to evaluate infection control 
practices, dental services at the Dayton VAMC were temporarily 
suspended.
    The allegations set in motion no less than five VHA investigations 
culminating in the notification, on February 8, 2011, to 535 patients 
of the medical center, that infection control practices in the Dayton 
Dental Clinic were not always followed.
                               oig review
    As a result of the requests from Congress, the OIG began a review 
of infection control issues at the Dayton Dental Clinic. Our review 
encompassed a review of VHA actions in response to the allegations as 
well as an evaluation of selected aspects of the daily functioning of 
the dental clinic and its management oversight.
    Dental infection control practices are governed by a multitude of 
regulations, standards, and recommendations related to the appropriate 
use of personal protective equipment (PPE), hand hygiene, reprocessing 
of RME, and other measures to safeguard the health of patients and 
staff. VHA, Centers for Disease Control and Prevention (CDC), The JC, 
and the Occupational Safety and Health Administration (OSHA) have 
published documents to facilitate compliance with recommendations and 
requirements. The medical center has also developed local policies 
related to hand hygiene, RME, bloodborne pathogens, and disinfectants. 
The medical center requires its employees to comply with these 
established infection control policies.
    We visited the VAMC from December 14-16, 2010. We interviewed 
relevant clinical and administrative staff at all levels of VHA, 
extending to the Under Secretary for Health, as well as medical 
consultants from the Prevention and Response Branch of the CDC, VA's 
Office of Public Health and Environmental Hazards (OPHEH), and 
attorneys from VA's Office of General Counsel.
    We reviewed already completed VHA investigations as well as Issue 
Briefs; VHA Clinical Review Board (CRB) charters, memoranda, and 
reports; relevant medical and dental literature; facility-level 
Standard Operating Procedures (SOPs) and policies; relevant committee 
minutes; credentialing and privileging documents; dental clinic 
infection control training records; and e-mail communications. We also 
reviewed VHA directives, CDC guidelines, OSHA's Bloodborne Pathogens 
Rule, and ADA guidelines.
            vha responses to the dental service allegations
    Immediately after the allegations concerning the Dental Service 
were made to the SOARS team, VHA launched a series of reviews and 
investigations at the local VAMC, VISN, and VA Central Office (VACO) 
levels. Additionally, VHA convened an Administrative Investigative 
Board (AIB) and Clinical Review Board (CRB).
Administrative Investigative Board
    On July 29, 2010, the VISN 10 Director charged the medical center 
to convene an AIB. The AIB was composed of five members: the Chair (an 
Associate Chief of Staff/Podiatrist), a dentist; an infection control 
nurse; a Supply, Processing and Distribution technical advisor; and a 
human resources/labor relations technical advisor (regional counsel). 
The AIB's expressed purpose was to investigate the facts and 
circumstances regarding allegations outlined in the July 2010, SOARS 
Report of Contact (ROC) documents received by the VISN 10 Director from 
the VAMC Director. Initially, the AIB was tasked to determine:

     Whether there was a deviation in any dental standard of 
practice and/or improper handling, cleaning and/or disinfection of 
dental burs during fitting procedures by the dentist as alleged in the 
ROC and occurring in the dental clinic and/or dental laboratory at the 
medical center.
     Whether there was evidence to support that the dental 
technicians referenced in the ROC (or others) communicated their 
concerns to their supervisor or other management official(s) as 
indicated/implied in the ROC. If so, identify who knew what, and when, 
or if action was taken.

    The AIB concluded its testimony on September 14, 2010, and its 
findings and conclusions were accepted by the VISN 10 Network Director 
on October 5. During the course of the AIB, a total of 31 witnesses 
were interviewed. They offered testimony sworn under oath and in the 
presence of a court reporter. Select witnesses were called back two or 
even three times in an effort to allow AIB members to ask follow-up or 
additional questions and to provide an opportunity to obtain fully 
comprehensive testimony. All witnesses were afforded the option of 
having personal counsel accompany them to their depositions.
    After considering the totality of the record and the depositions, 
the AIB concluded that the subject dentist did, in fact, repeatedly 
violate infection control standards over a multiyear period. The AIB 
also concluded that testimony supported the subject dentist's 
violations as beginning in 1992, and without curtailment of this 
dentist's privileges by knowing superiors, there was potential exposure 
of patients to bloodborne pathogens.
Clinical Review Board
    VHA Directive 2008-002, Disclosure of Adverse Events to Patients 
(January 18, 2008), provides guidance for disclosure of adverse events 
related to clinical care to patients or to their personal 
representatives. This directive recognizes that although it is 
difficult to weigh all benefits and harms, situations prompting a 
decision whether to conduct large-scale disclosure of adverse events 
likely involve the following considerations:

     Are there medical, social, psychological, or economic 
benefits or burdens to the veterans resulting from the disclosure 
itself?
     What is the burden of disclosure to the institution, 
focusing principally on the institution's capacity to provide health 
care to other veterans?
     What is the potential harm to the institution of both 
disclosure and non-disclosure in the level of trust that veterans and 
Congress would have in VHA?

    The CRB may choose to recommend notification if ``one patient or 
more in 10,000 patients subject to the event or exposure is expected to 
have a short-term or long-term health effect that would require 
treatment or cause serious illness if untreated.''
    We found that the need to convene a CRB was anticipated early on 
during VHA's initial investigations into the allegations. On August 30, 
2010, VACO senior leadership held a meeting with subject-matter experts 
in which the decision was made to convene the full CRB. The initial 
scope of the CRB as outlined in the charge letter was to:

     Conduct a clinical risk assessment.
     Identify the types of dental procedures at risk for 
disease transmission.
     Make a recommendation as to whether a large-scale 
disclosure was indicated. If the CRB recommended a large-scale 
disclosure, it was to identify which patients should be notified, 
determine whether the disclosure should include deceased veterans' next 
of kin, and define the look back timeframe. The CRB was also tasked to 
provide justification for its recommendations.

    The CRB met on September 2, 2010, and issued its first report to 
the Principal Deputy Under Secretary for Health (PDUSH) on September 3, 
2010. It conducted its review with VAMC members, the VISN 10 leadership 
team, members of the site visit team, the VHA dental program office, 
and the VHA National Director for Infectious Diseases. Multiple 
documents for fact finding included the charge letter, the issue brief 
and update, AIB testimony of one dental clinic staff member, the AIB 
summary, a VACO August fact finding team report, a dental office review 
by the Office of Dentistry Consultant for Infection Control, OPHEH 
reviews, VACO's summary of the site visit to the medical center, a 
timeline of events, and a universal precautions history and synopsis.
    The CRB report identified three practices by the subject dentist 
that posed a potential risk for infection transmission. First, the 
subject dentist did not properly disinfect dentures when taking them to 
and from the dental laboratory. This practice breach potentially 
contaminated laboratory equipment and surfaces. Second, the subject 
dentist wore soiled gloves and gowns outside the dental operatory and 
the dental clinic and did not change gloves between patients, 
potentially contaminating common use areas. Third, the subject dentist 
used the same dental equipment on patients without cleaning or 
sterilizing the equipment between patients.
    In forming its recommendations, the CRB considered only the risk of 
transmission of bloodborne viral infections (HIV, hepatitis B, and 
hepatitis C). To assess the risk to patients posed by these practices, 
the CRB also considered reviews of the medical and dental literature on 
the transmission of bloodborne viral infections in dental clinics. It 
was able to risk stratify the patients based on the invasiveness of the 
procedure a patient received in the clinic, including removable and 
fixed prosthodontics (crowns and bridges), restorative fillings, and 
invasive procedures such as extractions and periodontal scaling.
Initial CRB Recommendations
    The initial September 3, 2010, CRB report recommended disclosure to 
all patients who had received invasive dental procedures and 
restorative care from the subject dentist since 1975. It recommended 
that testing for the bloodborne pathogens (HIV, hepatitis B, and 
hepatitis C) should be offered to these patients. The CRB also 
recommended that the AIB obtain further testimony from the dental staff 
to determine whether the subject dentist was reusing needles and/or 
drug vials and to clarify the subject dentist's infection control 
practices prior to 1990. The CRB advised that, with evidence that the 
subject dentist did not reuse needles or vials and practiced with a 
dental assistant who monitored the dentist's infection control 
practices prior to 1990, it could narrow its disclosure recommendations 
to include fewer patients and shorten the look back timeframe.
Second CRB Review
    After multiple senior level discussions, the CRB was re-convened to 
further clarify risk assessment and disclosure issues. The CRB was to 
review additional AIB testimony indicating that the subject dentist did 
not reuse needles or vials and that he/she had a dental assistant prior 
to 1992. The CRB was also directed to review the AIB's supplemental 
testimony and reports. Using this additional information, it was to 
again outline a recommendation on disclosure, identify the specific 
patient population and dental procedures, and define the look back 
timeframe.
    The CRB met again on November 23, 2010, and December 2, 2010, to 
consider the new information provided by the subsequent AIB testimony, 
the analysis of the testimony by the Office of General Counsel, and 
additional VACO and VISN 10 summary reports and findings. The meetings 
were conducted with members of the VISN 10 leadership team, members of 
the site visit team, the VHA dental program office, the AIB Chair, the 
VHA National Director for Infectious Diseases, the Director of Public 
Health Surveillance and Research, and the Senior Medical Advisor of 
OPHEH.
    A key factor in determining the CRB's final recommendations was its 
conclusions regarding the extent and duration of the subject dentist's 
infection control infractions. In its review of the testimony, the CRB 
felt there was sufficient evidence to support a conclusion that major 
infection control breaches did not likely occur prior to 1992, when the 
subject dentist was practicing with a dental assistant. It was also 
able to limit the size of the patient population placed at risk to 
those undergoing only more invasive procedures that might provide a 
portal of entry into the bloodstream. Such exposure could thus result 
in disease transmission from one patient to another.
    The CRB submitted its revised set of recommendations to the PDUSH 
on December 3, 2010. By a six to one vote, it recommended that the 
original disclosure recommendations be narrowed to include only more 
invasive dental procedures and that the look back be limited to 
patients treated from January 1, 1992, onward. It identified specific 
invasive dental procedures to include: extractions and periodontal 
scaling, some restorative fillings, and fixed prosthodontics (crowns 
and bridges). The dissenting voter felt there was insufficient clinical 
or scientific proof that hepatitis C or HIV has been transmitted in 
dental settings. The dissenter also noted that ``the risk of patient-
to-patient transmission of bloodborne pathogens from occult blood in 
saliva cannot be determined and is biologically plausible.''
    The CRB further recommended that the disclosure ``should emphasize 
that the risk of a bloodborne infection to patients is low.'' It also 
recommended that each patient be offered serologic testing for 
hepatitis B, hepatitis C, and HIV. This testing would be part of an 
investigation for the purpose of identifying whether exposure in a 
dental clinic is associated with transmission of bloodborne pathogens, 
as there is little scientific evidence of known transmission. OPHEH 
would conduct the investigation in collaboration with the VAMC.
CRB Recommendations and Final CRB Review
    On reviewing the final CRB recommendations, VACO senior leadership 
required further clarification regarding the specifics of its 
decisionmaking process and justification of its conclusions. In a 
letter dated December 14, 2010, the PDUSH requested that the CRB 
address issues including the following:

     How it chose the 1992 date, whether other dates were 
considered, and whether it considered the availability of electronic 
versus paper records?
     What was its estimate of risk to patients and was it 
quantified?
     What information should be disclosed and to provide 
evidence supporting disclosed information?
     Did it consider input from the OGC's evaluation of the 
credibility of the witness' testimony?
     Did it consider the testimony of the dental residents?
     Why did it defer the issue of employee risk assessment and 
disclosure to the local medical center and local public health 
officials rather than VISN leadership and OPHEH?

    The CRB met for a fourth and final time on December 17, 2010, to 
address the PDUSH's questions regarding its decisionmaking process and 
risk assessments. It submitted a written response to the PDUSH on 
December 17, 2010. The Chair of the CRB then met with senior VACO staff 
to review and discuss its written response.
    On January 4, 2011, VACO senior management made the decision to 
proceed with a disclosure as recommended by the CRB's final report. The 
patient selection for notification was based on those patients who 
received invasive procedures performed by the subject dentist from 
January 1, 1992, to July 28, 2010. An algorithm and process were 
developed that identified 535 patients who met the CRB criteria for 
disclosure.
OIG Conclusions
    We concluded that the subject dentist did not adhere to established 
infection control guidelines and policies, and multiple dental clinic 
staff had direct knowledge of these repeated infractions. These 
violations of infection control policies placed patients at risk of 
acquiring infections including those that are bloodborne.
    This was based on many facts including:

     A June 29, 2010, e-mail, from a clinic dentist to the 
Chief of Dental Services reporting violations of basic infection 
control protocols by one specific dentist.
     An August 16, 2010, memorandum for the record in which the 
Dental Service Chief indicated that he witnessed violations of basic 
infection control protocols by the same dentist on several occasions.
     Multiple dental clinic employees telling us they had 
personally observed various infection control policy violations by the 
same dentist. Violations included failure to disinfect, or incorrectly 
disinfect, denture prostheses prior to transferring them to the dental 
laboratory and wearing gloves outside the operatory. They told us that 
the subject dentist went directly from one patient to another without 
changing exam gloves and did not properly clean and disinfect the 
operatory. Individuals told us that unsterilized instruments were 
reused on more than one patient.

    We concluded that the AIB was thorough in its fact finding process. 
It deposed 31 witnesses, some witnesses were called back for a second 
and even third appearance before the AIB. Witnesses included current 
and former leadership in the Dental Service as well as current and 
former staff, support staff, and trainees. Testimony was gathered by 
various methods including such instruments as written affidavits, 
verbatim transcripts, or recordings of live testimony. Conducting the 
AIB was a time-consuming assignment and was carried out seriously and 
conscientiously by the AIB.
    We also concluded that the CRB acted in good faith to address the 
potential risks to VA patients. The CRB incorporated an extensive 
amount of data from which to base its decisions. All recommendations 
were carefully considered, with input from a solid counsel of national 
subject area experts. Its recommendations appropriately followed VHA's 
notification for disclosure policy.
    With regards to staffing and workplace environment issues, we found 
that the staffing levels at the dental clinic were persistently below 
their organizational approved FTE levels and the level recommended by 
VHA for optimal performance. Optimal staffing may have decreased the 
likelihood that deviations from approved infection control practices 
would occur. Senior leadership and committees at the VAMC did not fully 
support efforts to staff the dental clinic at these optimal ratios.
    During our dental clinic staff interviews, employees discussed 
concerns as to work climate and morale. We heard multiple concerns 
regarding ongoing staff shortages, favoritism, and demeaning comments 
to staff, and we were told of staff altercations that resulted in 
formal police investigations. We found indications that interpersonal 
staff relations were strained, which negatively impacted the dental 
clinic.
OIG Recommendations
    The OIG made two recommendations:

     The VISN Director review the findings related to the 
Dayton Dental Clinic, to include staffing issues, and take whatever 
action deemed appropriate.
     The VISN Director ensure that the Dayton VAMC Director 
requires the Dental Service to comply with the relevant infection 
control policies.

    The VISN Director and Medical Center Director agreed with the 
findings and recommendations and provided acceptable action plans. We 
will follow up on the planned actions until they are completed.
                               conclusion
    Established infection control practices and policies were not 
properly or consistently adhered to at the Dayton VAMC Dental Clinic. 
There was evidence that staff assigned to the Dental Clinic observed 
these poor infection control practices over an extended time period. 
While Dental Clinic management was notified of these unacceptable 
practices, it was not until a VACO review body was at the Dayton VAMC 
conducting a routine inspection that definitive actions began. These 
practices constitute unacceptable breaches of patient safety 
precautions and a violation of the OSHA Bloodborne Pathogens Standard--
standards that veterans have a right to expect are followed with care 
and diligence.
    Senator Brown and other Members, this concludes our statement and 
we would happy to answer any questions that you may.

    Senator Brown of Ohio. Thank you, Dr. Daigh.
    I will start with you. I have some general questions and 
some very specific questions. I want to talk first about a 
couple of your recommendations. You said at the outset, the 
number 1 recommendation, the inputs of individuals do not flow 
to leadership--some individuals do not flow to leadership. How 
do you encourage structurally the VA, not just in Dayton but in 
Chillicothe and everywhere, so that the lab techs and the rad 
techs and others can feel that they will not be punished as 
whistleblowers or simply that they can share information up the 
chain, that they have confidence and patients can have 
confidence that that information is heard? They know things 
that no doctor and nurse perhaps know, as the doctors and 
nurses know things they do not know. How do we build that 
structure so they can do that, let us just say in Dayton for 
now?
    Dr. Daigh. I would say that I think that there are many 
different leadership styles, and I think individuals have 
different ways of being effective. But one way would be to have 
a regular meeting between the director or the chief of staff, 
to sit down and talk to the health techs or the senior techs in 
each of the different areas of the hospital, either as a group 
or individually in some, and in a group forum on a regular 
basis, where real issues are discussed, where real issues that 
are important to the hospital are discussed, and through the 
administration then or the leadership responding back with 
sound data and change, how things can be built and the flow of 
information that is helpful to preventing these sorts of 
things, I think, would occur. So it is a communication problem 
and that level of communication, I think, needs to be set up, 
that is separate from being filtered through the chief of the 
dental clinic or the chief of whatever service you are talking 
about.
    Senator Brown of Ohio. How do you then--understanding that 
can be the structure with the right kind of administration--how 
do you protect that worker who wants to talk about a medical 
person not changing her gloves, not doing the right kinds of 
sterilization procedures? How do you protect that x-ray 
technician or that--maybe they saw something on the elevator or 
whatever. How do you protect them from any repercussions from 
management for that sort of whistleblower action that way?
    Dr. Daigh. I think that you have to first trust that the 
leadership of the hospital will do the right thing and not take 
repercussions. If the leadership does take action which is 
viewed as negative toward the person who made the allegation, 
then they can certainly--a variety of offices--the Office of 
the Inspector General will certainly point them in the right 
direction of where they can get help. I think that we----
    Senator Brown of Ohio. If I can interrupt----
    Dr. Daigh. Yes.
    Senator Brown of Ohio. Would every employee of this 
hospital right now at this center know that if they came 
directly, no matter how low paid or whatever their position 
here, no matter how newly hired, that they could go directly to 
the VA Inspector General anonymously and protect themselves 
from any repercussions from management?
    [Murmuring from audience.]
    Dr. Daigh. So the crowd says no, but I will say that we do 
have--hopefully that our telephone number is in each of these 
facilities. In every report we write, we put out our 
identifying and contact information. We get over 30,000 
allegations a year that come into our hotline, which we sit 
down and look at. We work very hard to protect the identify of 
those sources that choose to remain confidential. One of the 
issues is that people who complain to us often, or complain to 
whoever, so it is not sometimes probable that the name of the 
person who made the allegation could be discerned. But we do 
everything we can to protect the name of the person who made 
that allegation. So we work very hard not to have adverse 
events occur to someone who makes an allegation. We work very 
hard to ferret out what the truth of the allegation is.
    Senator Brown of Ohio. I would assure--and while this is a 
hearing, I will for a moment speak to the audience--I would 
assure anyone in this center or any other, whether it is an 
employee or a family of a veteran or a patient, that is in 
touch with my office, with Doug Babcock or Rachel Miller, the 
two people I mentioned earlier, that their names will be 
confidential and protected. I mean, I will assure anybody that 
makes complaints to us.
    Let me go in a different direction for a moment. Well, let 
me take your second recommendation, that terms rotate--that top 
management rotate between and among hospitals. Give me a 
suggestion there specifically. How much of top management? How 
long are they at a hospital? Where would they--would it matter, 
geographic or size of hospital movement in moving them around? 
Give me thoughts on that, if you would, more specifically.
    Dr. Daigh. I would say that between the director, the chief 
of staff, and probably the head nurse, depending on what the 
organization of the hospital is, that--and again, there are a 
variety of scenarios that one could put forth that would be 
least disruptive to all concerned and yet would achieve the 
goal of changing the leadership structure and causing them to 
re-equilibrate and to, in fact, rejustify that what they are 
doing is the right thing. So I would think on a period of, I do 
not know, 3 or 4 years, that you would rotate in some pattern 
at least one of the members of that group. I do not have the 
study to back that up. I do not have data to cost account this 
out for you, but it seems to me that that would be a very 
reasonable thing to do.
    Senator Brown of Ohio. OK. Every VA hospital must pass 
inspection by two organizations, the Joint Commission on 
Accreditation of Health Care Organizations, as you know, and 
the VA Systemwide Ongoing Assessment Review Strategy. How could 
what happened in Dayton over the last 18 years not have been 
ferreted out? How could it have slipped past both of these 
review panels?
    Dr. Daigh. Well, I cannot speak for JCAHCO, but I can speak 
for--we do a--every 3 years we go to VA hospitals and do what 
is called a CAP inspection, and that CAP inspection is an 
inspection where we come in and we look at the systems within 
the hospital, like the quality assurance committees and how 
they function, the peer review process, and other committees 
that are set up to try to ensure that when bad things happen in 
the hospital, that the hospital takes that data seriously, that 
it reacts to that data seriously, and that change is made. So 
whether it is an internal review group from VA or the group 
that I operate that goes through this hospital and has been 
here three times in the last 10 or 12 years, that we missed it 
is really dreadful. I am horrified that we missed that.
    We look at the hospital at committees that look across all 
the organizational elements of the hospital. We typically do 
not look from leadership down to the dental clinic, or from 
surgery down to the plastic surgery clinic, or from medicine 
down to cardiology. We try to look at those committees that 
look across all elements of the organization and we did not 
find that.
    It also means that nobody came up and talked to us and 
said, we are here when the visit is announced, when I have five 
or six people in the hospital going through the books and 
records. Nobody came up and said, we have a problem in the 
dental clinic. Nobody called us.
    So I do not have a good explanation for how this remained 
encapsulated for so long other than poor leadership, at least 
at the level of the head of the dental clinic, who did not over 
several leaders of the clinic enforce the standards of 
infection control that everyone knows should be enforced, both 
for the protection of the providers and, more importantly, or 
equally importantly, for the protection of the veterans. So I 
have no----
    Senator Brown of Ohio. Dr. Daigh, if you are not sure how 
this happened as you came in from this direction in your 
analysis or as the Systemwide Ongoing Assessment Review 
Strategy came in, the VA, or JCAHCO, and I understand you 
cannot speak for them, what assures us that this will not 
happen other places, again in Dayton or in Chillicothe or in 
Omaha? How do we know this, that these panels, these review 
panels will not see something this serious?
    Dr. Daigh. Well, I----
    Senator Brown of Ohio. A better question: What have we 
learned? What does this--sorry to interrupt you. What does this 
review panel--what do these review panels, what did they learn 
from not being able--from the failure to find this, ferret this 
out on more than one occasion over 18 years? It was not just 
one time that JCAHCO came or one time that SOARS came in, 
correct?
    Dr. Daigh. That is correct. The SOARS is an internal VA 
group, but I understand your point. The group I have is a CAP, 
which is a different--but point well taken.
    I think that I have seen this actually twice, and what I 
have seen is a provider who is well-supported and respected in 
the community who, over time, the procedures are stepped down, 
if you will, and might go from being a full-speed dentist to 
someone who just does dentures. They might go from a practicing 
surgeon who spends time in the operating room to a surgeon who 
just sees patients outside the operating room. The community 
supports that individual; they like that individual. And that 
individual, over time, might, in fact, deviate in some way from 
the standard of care, and somehow people call it an 
eccentricity or they call it something else. There is 
agitation, then, when younger people come into that clinic and 
say, no, the standard of care is being broken. In this case, it 
is infection-control policies.
    Finally, when you look at it, everyone goes, oh, my gosh, 
what has happened here really is a catastrophe, and what were 
seemed to be minor deviations from the standard of care or 
eccentricities really were quite major breaks. The leadership 
who knows they should have enforced the rule, but they are 
friends who worked with that individual for a long time and did 
not enforce the rule are then wholly embarrassed at this 
outcome. That is the best explanation I can give you for how 
something like this could occur over a period of time.
    Senator Brown of Ohio. Let me ask you this, or suggest 
this. You came up with four or five, depending on how you 
divided them, very specific points about what you suggest we do 
differently, ``we'' meaning the Dayton VA. Can you come up with 
similar specific prescriptive recommendations on what SOARS 
should do differently, learning from their failures at the 
Dayton VA and apparently in St. Louis? Can you, as Inspector 
General, give them--is that in your power, and would you do 
that for them so they do not make these mistakes elsewhere or 
ever again here?
    Dr. Daigh. I certainly can. We would--so the answer is yes. 
I must say that when I do an inspection proactively and I do 
not know anything is wrong. We look hard, but I simply cannot 
guarantee that I will uncover all problems every time I do an 
inspection. So I do the best I can. We lay out what we think 
are the most critical things to look at. If we find a problem, 
we write the pattern down. We bring it to the leadership's 
direction and ask them to fix it. When I say that a hospital 
has passed the CAP inspection or has identified defects, you 
know, I simply cannot uncover every rock.
    With respect to the issues here, we will work hard to make 
sure that this does not occur again.
    Senator Brown of Ohio. Thank you. Walk me through the 
timeline regarding when the VA knew there was a problem and 
when patients were contacted. If I have this right, the VA 
closed the clinic in August 2010. They did not contact patients 
for testing until February 2011. That is September, October, 
November, December, January--6 months, more or less. Is that 
standard practice? Should patients have been notified? Are you 
agreeing with the process VA followed in determining who and 
when to notify all possible exposures? I mean, I assume that 
the 535 number is far, far, far fewer than the number of 
patients that said dentist had over the last 18 years. Why 535? 
Why 6 months? What did the VA not do that they should have? Run 
through those answers for us.
    Dr. Daigh. I am going to ask Dr. Wesley.
    Dr. Wesley. Sure. Yes, sir. I would like to speak to that a 
bit. I do agree with what I think you are implying, is that 
notification process and the Clinical Review Board process was 
protracted. The CRB, or the Clinical Review Board, which deals 
with large-scale notifications, first reported up the line to 
the Principal Deputy Under Secretary on September 3, and again, 
as you note, the notification letters did not go out until 
February 8. I think part of that----
    Senator Brown of Ohio. Put the microphone a little closer 
to you, please.
    Dr. Wesley. Oh, I am sorry. So the first recommendation of 
the notification went out September 3, but letters did not go 
out until February 8. Part of that was----
    Senator Brown of Ohio. Was September 3 the first 
notification----
    Dr. Wesley. No. The Advisory Board that dealt with the 
issue of who, if anyone, we should notify, in essence, reports 
or makes a recommendation to the Principal Deputy Under 
Secretary of the VA for Health. They convened very early in 
September, I believe it was September 2 of 2010----
    Senator Brown of Ohio. After the clinic had been closed, 
knowing there was a problem----
    Dr. Wesley. Correct. Correct. I think the clinic closed for 
about 3 weeks between August and reopened about that time. So 
they convened about September 2, reported on September 3 up 
their chain, if you will, basically to the Principal Deputy 
Under Secretary, and, in fact, in their report recommended a 
fairly large-scale notification, in fact, actually more than 
500 patients. They actually recommended notifying virtually 
everyone going back to 1975, when the dentist in question was 
first employed.
    Senator Brown of Ohio. A lot longer than the 18 years 
that----
    Dr. Wesley. Correct. Even longer than the 18 years. It was 
not--it should be appreciated that it was not a simple issue, 
though, because we have talked to CDC about this, and it is 
easy when you have harm, it is easy to notify when there is 
harm. But here, there was theoretical harm. It was possible 
harm. So, in essence, over the ensuing 3 months they kept 
revisiting the issue and attempting to figure out from the 
universe of patients who should be notified. Quite frankly, 
again, that was about a 3-month process. It was not until 
December that they came up with more definitive 
recommendations.
    Senator Brown of Ohio. Tell me who ``they'' is.
    Dr. Wesley. Oh, I am sorry. I apologize. When you live 
this, it----
    Senator Brown of Ohio. OK----
    Dr. Wesley. It is the so-called Clinical Review Board. It 
is an ad hoc advisory board which recommends to the Principal 
Deputy Under Secretary if and how there should be large-scale 
notification of adverse events in a VA facility.
    Senator Brown of Ohio. These were all VA employees in 
Washington?
    Dr. Wesley. They were VA employees, although they--experts 
throughout the system--did consult with external bodies, most 
specifically the CDC.
    Senator Brown of Ohio. So none of these were Dayton----
    Dr. Wesley. Dayton management certainly had input. 
Certainly at the VISN level, Dayton was involved. The Chairman 
of the AIB was involved. VA's National Infection Control 
Director was involved. It was a very--again, it was a very 
excruciating, carefully thought-out process as to who to--as to 
what universe of people to notify. Again, I think the core 
issue is it was theoretical harm and, in a way, theoretical 
exposure rather than known exposure.
    Senator Brown of Ohio. It was theoretical because--was 
there no real sense of urgency among this board? 
Understanding----
    Dr. Wesley. Right.
    Senator Brown of Ohio. I do not want to belittle your 
comments about how complicated it is, that there were thousands 
of patients and you do not want to scare everybody and you do 
not want to test everybody.
    Dr. Wesley. Right.
    Senator Brown of Ohio. I understand that. But if they 
settle on the number 535 and it takes them 6 months to do it 
and the word begins to leak out that there is a problem and 
nobody really quite knows what is next, the affected 
population, most of whom were not damaged--I understand that--
but was there not some sense of urgency by the VA around the 
country or in Washington to move on this a little quicker to 
reassure these potentially thousands of families?
    Dr. Wesley. I think that point is well taken. I think they 
worked very hard over 2 or 3 months, but I think by the time 
they decided in late December, and I distinctly remember 
meeting with the Under Secretary for Health on January 4, and 
by that time, a decision had been made to notify at 535, and 
again, why it takes another month, I do not know.
    Senator Brown of Ohio. Well, how about as you were 
analyzing this, and again, I do not belittle at all or dispute 
the complexity of it, but as you are looking at this, I would 
assume almost immediately, you knew that Patient X, Y, and Z, 
with names attached, some number of them were at risk, and if 
that is the case, why would you not notify them in October 
instead of waiting until you could decide on some macro system 
of doing this?
    Dr. Wesley. Right. Again, I think the point is well taken. 
Actually, when I looked at the witness list, I regretted that 
the chairman of the CRB was not here. I think that is the best 
person to answer about, you know, the time course. An equally 
complex question is, again, what number. Do you notify, again, 
basically, the patients that had invasive procedures going back 
to 1992 or do you notify every patient that this dentist saw 
going back to 1992, which is what the Greater Dayton Hospital 
Association says? So not simple at all.
    Senator Brown of Ohio. Do you in your mind now, or did any 
of the three of you settle on a number, what the number should 
have been? Should it be much higher than 535? Is 535 about the 
right number?
    Dr. Daigh. Let me comment. I actually think there are--I 
guess what I was speaking to when I said there was a limit to 
our science and then after that you had to apply policy or what 
you thought were good ethics. Science would say that people who 
did not have invasive procedures or had procedures in which 
there was little chance that there was significant contact with 
saliva would be unlikely to get any of these bloodborne 
pathogens. So there is no clear answer. I think that what the 
VA authored is one of many reasonable possibilities, and I 
think that the Dayton--that the local view that much wider 
testing should occur is also a reasonable possibility.
    But I will say, if you go to the Ohio State Health site and 
you plot the incidence of acute hepatitis by county, by year, 
and you look at that, it is not clear to me that there has been 
an epidemic of acute hepatitis here. So I think there are data 
sets out there that one could look at, veterans versus, you 
know, compared to the excellent work done by the Ohio medical 
group collecting the incidences of these infectious diseases, 
to see if, in fact, there has been an outbreak of hepatitis in 
this community that could be traced back to this event.
    Senator Brown of Ohio. I appreciate that answer. I still am 
not clear. Should I walk out of here today, when I meet with a 
VFW group or a Legion group or a Vietnam Veterans group and 
they ask me, is 535 the right number? Should I be tested? 
Should my friends at this post be tested? I went to that doctor 
and had some minor surgery in 2007 or 2001 or whatever. What do 
I tell them?
    Dr. Daigh. I think that the decision to test those 
individuals who had procedures by the dentist in question which 
were invasive and more likely to cause blood from the mouth to 
be mixed with sputum is a very reasonable set of people to 
test. I do not----
    Senator Brown of Ohio. That number is significantly greater 
than 535.
    Dr. Daigh. No, that would be the 535 number.
    Senator Brown of Ohio. That is the 535.
    Dr. Daigh. If you only talk about people who had a denture 
pulled out, adjusted, put back in, no blood transfer, then the 
risk would be much less. The problem, sir, is that if you took 
a denture out of a person's mouth and you did not properly 
sterilize it, you bring it to the lab where the dentures are 
worked on and you worked on that denture not being sterilized, 
you have contaminated the burrs in the lab. So if the next 
person has their dentures----
    Senator Brown of Ohio. I have read in these reports the 
word ``burr.'' What is that referring to?
    Dr. Daigh. It would be a device that spins rapidly that 
cuts a tooth, drills a hole in----
    Senator Brown of Ohio. I really hate when I go----
    Dr. Daigh. Yes. So I think there are some just absolutely 
practical limits from science, and I think it is a difficult 
answer. I think VA authored a reasonable solution. We knew with 
the hearing in St. Louis recently, and a similar problem 
occurred, and I had a staff member sit in the audience and 
listen to that hearing. She sat next to a lady who had gotten a 
letter saying that her husband might be at risk of HIV and she 
was mortified. As I sit there and think about the letter that 
said, you might be at risk of HIV for, again, a removable--for 
a piece of dental equipment that was not properly sterilized. I 
mean, I personally think the risk that they had HIV is remote, 
maybe even close to zero with no reportable cases of 
transmission through saliva of HIV. I sit there and want to 
make sure that we are not creating harm when we send these 
letters that scare people absolutely to death.
    So it is a very difficult question in terms of how to 
decide and our science here. So I think there are several 
reasonable solutions to it.
    Senator Brown of Ohio. Would you personally go to the 
dental clinic here right now?
    Dr. Daigh. Yes.
    Senator Brown of Ohio. OK. Ms. Shimoda?
    Ms. Shimoda. Yes, I would.
    Senator Brown of Ohio. Dr. Wesley?
    Dr. Wesley. Yes.
    Senator Brown of Ohio. My last request is to walk me 
through the allegations that whistleblowers have been punished. 
Can you tell me what has happened to people that have tried to 
speak up, because we know of reports that people, in fact, saw 
some less than proper practices in the dental clinic. What 
happened to them? What were their lives--tell me what happened.
    Dr. Daigh. I do not have information on that.
    Dr. Wesley. Yes. I----
    Dr. Daigh. I would have to have--well, I would not address 
that issue.
    Senator Brown of Ohio. Should you not?
    Dr. Daigh. If I have to have an answer, I have to have the 
name of an individual who makes a complaint to me that that 
happened to them, and if they would like us to look at that or 
if you would like us to look at that, we would be more than 
happy to take a look at that. But whistleblower issues are 
generally reviewed not so much by our office but by the Office 
of Special Counsel. So if they would apply through the Office 
of Special Counsel, they are the office that looks at 
whistleblower retaliation issues. It has been the case where we 
have done work, but they would provide it through the Office of 
Special Counsel, who makes determinations on whistleblower 
actions.
    Senator Brown of Ohio. It seems to me from your--one more 
second, Dr. Wesley--it seems to me that from the inputs of 
individuals who do not flow--that the information does not flow 
to leadership. It seems to me that we need to know more. If you 
are making that recommendation, I appreciate that you did and I 
think the employees of the VA medical center in Dayton 
appreciate it. But we have to know more about what happened to 
whistleblowers here and what could happen and we need to 
establish protections.
    I will call on you after the hearing, OK, sir?
    We need this throughout the VA to be something that 
whistleblowers feel some confidence in doing. I know it is an 
age-old problem in government, an age-old problem in government 
management, but we need to do that.
    Dr. Wesley, you wanted to say something?
    Dr. Wesley. All I was going to say, briefly, to expand on 
your question and Dr. Daigh's reply, was in this particular 
review, and we probably interviewed about 40 people and 
virtually everyone that was currently employed in the dental 
clinic, it was not so much whistleblower fear that came up. It 
was more of a sense of general frustration that if you 
articulated your concerns, nothing was done about them. So this 
was more frustration, I would have to say, than fear.
    Dr. Daigh. The other issue, sir, is not everyone will talk 
with us. If they are an employee, we can sit down and have a 
conversation. But if they have retired, then we cannot have a 
conversation, so----
    Senator Brown of Ohio. Could you address that? I said it 
was the last question before, but I was looking at my notes 
from Congressman Turner's statement, his testimony, and that 
was a major concern of his. People who have retired can avoid 
any kinds of accountability or any kinds of reprimand or any 
kinds of punishment, apparently, unless it is criminal, 
correct? So what do we do about that?
    Dr. Daigh. Sir, I am not a lawyer, so I am going to talk 
about what I believe the answer is. If a crime has been 
committed or alleged to be committed, then our Investigations 
Unit, which is separate from our Office of Health Care 
Inspections, I believe, does have the authority to go look at 
that and bring it to the AUSA as a potential crime, retired or 
not. But if a crime has not been alleged, or there is no crime 
that has been alleged, then our ability--my office's ability to 
compel the discussion ends if they are not a VA employee.
    Senator Brown of Ohio. So sloppy or worse safety practices, 
procedures, surely are not a criminal offense, I would not 
think. I assume they are not.
    Dr. Daigh. I am not a lawyer and I would assume they are 
not, too, sir.
    Senator Brown of Ohio. So retirement basically protects 
that employee from--shields that employee from being 
accountable.
    Dr. Daigh. There is not a clawback provision.
    Senator Brown of Ohio. Thank you for your testimony. Thank 
you all. Thank you for being here.
    I would like to call up the second and concluding panel. 
Jack Hetrick is Network Director for the Veterans Integrated 
Service Network. Mr. Hetrick was appointed as a Network 
Director of VA Health Care System of Ohio, known as VISN 10, in 
November 2006. VISN 10 is comprised of four fully functional 
medical centers that, I guess, is Cleveland, Columbus, 
Chillicothe--or Cleveland, Chillicothe, Dayton, and Cincinnati, 
and one independent outpatient clinic and a network of 30 
Community-Based Outpatient Clinics, including the Dayton 
Veterans Area Medical Center. Dayton is the satellite and four 
CBOCs around you, correct?
    Mr. Hetrick is joined by Lisa Durham, who is the Chief of 
Quality Management at the Dayton VA Medical Center. Ms. Durham, 
thank you for joining us and for your public service. Bill 
Montague, who I have known for years, is the Acting Director of 
the Dayton VA Medical Center. I thank Bill for coming out of 
retirement. I have worked with Bill in the VA, his work with 
the VA in the Cleveland Stokes VAMC, the former Director. I am 
pleased Secretary Shinseki convinced him to return to service, 
help restore a culture of care here. Next month, the Stokes 
VAMC is going to have the grand opening of a new state-of-the-
art domiciliary, is that right?
    Mr. Montague. It is the domiciliary, the bed tower, and it 
is big, and thank you for your help.
    Senator Brown of Ohio. It is certainly large. Thank you for 
your work in that new facility.
    Mr. Hetrick, if you would proceed, and perhaps Mr. Montague 
or Ms. Durham can answer questions, too.

   STATEMENT OF JACK G. HETRICK, NETWORK DIRECTOR, VETERANS 
INTEGRATED SERVICE NETWORK 10, VETERANS HEALTH ADMINISTRATION, 
U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY WILLIAM D. 
 MONTAGUE, ACTING DIRECTOR, DAYTON VA MEDICAL CENTER; AND LISA 
  DURHAM, CHIEF, QUALITY MANAGEMENT, DAYTON VA MEDICAL CENTER

    Mr. Hetrick. First of all, thank you, Senator Brown, for 
the opportunity to discuss the way forward for the veterans in 
the Dayton VA Medical Center. I am accompanied today by Mr. 
William D. Montague, as you introduced, Acting Director of 
Dayton, and Lisa Durham, Chief of the Quality Management at 
Dayton. I would like to request for my written statement to be 
submitted for the record.
    We are here today to discuss the lapse in proper infection 
control practices of one dentist at the Dayton Dental Clinic. 
More importantly, we are here to inform everyone about what we 
have done and will continue to do to ensure that care veterans 
receive meets the highest standards of quality and safety. We 
appreciate the OIG's support in reviewing our program and 
developing recommendations, as well as our participation in 
today's hearing.
    My written statement provides an overview of how we 
discovered the lapse in infection control. In the time I have 
now, I will discuss the efforts currently underway as well as 
those that will soon be implemented in response to this 
incident.
    Our quality management enhancement efforts have taken many 
forms. First, we provided additional education and training and 
updated standard operating procedures in the dental clinic. We 
have evaluated dental equipment and instruments, making changes 
where indicated, and repaired the physical infrastructure in 
the dental clinic. Monitoring and compliance are two critical 
aspects of our quality and safety programs. I directed that 
there be unannounced inspections of all network dental services 
to ensure proper dental policies and procedures are in place 
and that instruments are properly maintained. We have made 
several changes to infection control procedures, and through 
regular and even daily assessments we are documenting our 
compliance with standard practices.
    Turning to personnel matters, I convened an Administrative 
Investigation Board to determine if there was any deviation in 
dental standards of practice or improper handling, cleaning, or 
disinfection of dental equipment. I directed facility 
leadership and network staff to identify any possible trends 
based on available records.
    Looking ahead, our immediate focus is on implementing the 
recommendations our colleagues at the OIG have offered. The OIG 
made two specific recommendations, to review the findings 
related to the dental clinic, including staffing issues, to 
take appropriate action, and to ensure the Dayton Director 
requires the dental service to comply with infection control 
policies. I concur with their recommendations.
    By the end of June, we will be in full compliance with the 
first recommendation. We are taking administrative actions 
against the parties responsible for allowing this lapse to 
occur and we are modifying the organization of the dental 
service for better oversight. By the end of May, we will have 
systems in place to track dental service mandatory infection 
control training and will be randomly auditing compliance 
through documentation and observations to ensure quality care.
    VA's central office has convened a Management Program 
Review Team to assess the Dayton VAMC to identify factors that 
may have allowed this particular practice to continue 
undetected or unreported. The team will ensure that we have 
implemented systems to properly identify and effectively 
address issues that require immediate response. Information 
from this review will help VA look at systemwide opportunities 
for management improvement.
    In closing, I would like to emphasize that this is 
unacceptable that the situation went on so long. We have taken 
administrative actions to ensure those responsible for this 
serious error are held accountable. In the days and weeks 
ahead, we will be working closely with our colleagues at the 
OIG as we continue to enhance the care we provide. I have 
discussed the lessons we have learned here at Dayton with other 
VA leaders so they can benefit from our experience.
    For those veterans who were affected by this incident, 
there is a dedicated hotline, and I will read the number, 1-
877-424-8214, that is available 24 hours a day, 7 days a week. 
If veterans or family members have questions about the Dayton 
Dental Clinic, we strongly encourage them to call. We are 
asking veterans that want to be tested to report to the primary 
care clinic for an appointment. Veterans may walk in during 
clinic hours or call the hotline number for an appointment.
    Thank you for inviting me here to testify to discuss these 
plans and to listen to your recommendations. My colleagues and 
I are prepared to answer your questions.
    [The prepared statement of Mr. Hetrick follows:]
    Prepared Statement of Jack G. Hetrick, FACHE, Network Director, 
    Veterans Integrated Service Network (VISN) 10, Veterans Health 
          Administration, U.S. Department of Veterans Affairs
    Senator Brown, Thank you for the opportunity to discuss the way 
forward for Veterans and the Department of Veterans Affairs Medical 
Center (VAMC) in Dayton, Ohio. I am accompanied today by Mr. William D. 
Montague, Acting Director, Dayton VAMC; and Lisa Durham, Chief, Quality 
Management at the Dayton VAMC. We are here today to address the lapse 
in proper infection control practices of one dentist at the Dayton 
VAMC's Dental Clinic. More importantly, we are here to inform our 
stakeholders, including our Veterans, their families, the public and 
Congress, what we have done and will continue to do to ensure that the 
care Veterans receive meets the highest standards of quality and 
safety. We also want to reassure stakeholders that we are taking action 
to ensure that an event like this does not occur again. Part of the 
process of restoring confidence requires an honest and transparent 
account of what occurred. My testimony will begin with an overview of 
how we discovered the improper practices of the single dentist. From 
there, I will discuss the actions VA has already taken in response to 
this incident. I will conclude by describing our future plans.
     infection control deficiency at the dayton vamc dental clinic
    During a scheduled internal review process by one of VA's System-
wide Ongoing Assessment and Review Strategy (SOARS) teams in July 2010, 
concerns were raised about adherence to infection control procedures in 
the Dayton VAMC Dental Clinic. The leadership of the facility, in 
consultation with me, immediately initiated a fact finding review to 
assess the concerns. Once the concerns were confirmed, I immediately 
expanded the investigation. Rapid response teams from VA Central Office 
helped us analyze the problem and determine corrective actions, and we 
decided to suspend dental services. The dental service closed for 
approximately three weeks beginning August 19, 2010, while all 
employees in the clinic received extensive refresher training and 
competency certification on proper infection control techniques.
    Investigation and outside review confirmed that a single dentist 
was not following proper infection control practices. VA initiated a 
Clinical Review Board (CRB) process to determine the level of risk to 
Veterans receiving care from this provider. This included an intensive 
review of our records dating back to January 1992. Though the risk for 
infection was considered very low, the CRB recommended VA notify 
Veterans who received specific procedures involving invasive dental 
treatment performed by this dentist.
    When the extensive review of records was completed and validated, 
it was determined that 535 Veterans should be notified about the 
possible exposure. The Dayton VAMC provided Veterans information 
regarding their potential exposure, and extended an opportunity for 
testing. As of April 15, 2011, all 535 Veterans have been contacted. 
506 have been tested. Two new cases of hepatitis B have been 
identified. While it is impossible at this time to determine if the 
source of the infection arose from the dentist's failure to comply with 
infection control practices, the investigation through VA's Office of 
Public Health is continuing, and these patients are being actively 
evaluated and followed.
    There have been no new cases of HIV identified, and only one 
patient has tested positive for hepatitis C. This patient does not 
exhibit evidence of illness and, again, we cannot determine the source 
of infection at this time. Testing to confirm hepatitis C, and research 
to determine a possible relationship to the dental clinic, is ongoing. 
If additional cases are confirmed, and even if we cannot determine if 
the source of the infection arose from treatment in the dental clinic, 
VA will offer treatment to any newly diagnosed Veteran.
  actions taken to ensure high quality care at the dayton vamc dental 
                                 clinic
    VA has taken a series of actions to assure high quality care is 
provided and maintained in the dental clinic at the Dayton VAMC. We 
have provided additional education and training for dental staff and 
completed a review of staff competencies related to the education and 
training they received. During the dental clinic closure, we updated 
and standardized operating procedures in the dental clinic. We also 
evaluated dental equipment and instruments and made changes where 
indicated. In addition, we completed repairs to improve the physical 
environment of the dental clinic. These measures are in addition to 
those taken to improve conditions for employees, which we expect will 
improve morale and performance. Improvements to increase communication 
among all dental employees, including leadership, have been 
implemented. Regular meetings and morning huddles provide the 
opportunity for increased communication and openness. The Acting Chief 
of the Dental Service held regular conference calls with other Dental 
Chiefs within the VISN to make certain they benefited from the lessons 
learned at Dayton. This information was also shared nationally among 
dental professionals.
    Beginning last July, a number of initiatives were instituted at the 
Network level. I convened an Administrative Investigation Board (AIB) 
to determine if there was a deviation in any dental standards of 
practice or improper handling, cleaning, or disinfection of dental 
equipment. This Board was composed of experienced external clinical 
members and an internal infection control professional. I directed the 
Dayton VAMC leadership and VISN 10 staff to review results of previous 
investigations, workplace evaluations, performance improvement plans, 
credentialing and privileging, VISN Readiness Reviews, and environment 
of care rounds. Patient safety and risk management reports were 
carefully reviewed to determine if there were any trends. Based upon 
the events at Dayton, I directed VISN professional staff members to 
conduct unannounced inspections of all VISN 10 dental services to 
ensure all expected dental policies and procedures were in place, all 
dental equipment and instruments were properly maintained, and all 
practices were in compliance with standards. I required VISN 10 
facility directors to visit and conduct similar reviews of their 
internal dental operations. I received the final AIB report in October 
and accepted the findings and conclusions. After reviewing the AIB 
report, Dayton VAMC Leadership proposed administrative actions. The 
dentist in question chose to retire before that process was complete. 
In December, I attended a meeting in Washington, DC, to discuss the 
lessons we learned at Dayton with other Network Directors from across 
the country. VISN 10 staff has continued to conduct follow-up, 
unannounced, inspections of the Dayton Dental Service and other areas 
of the facility related to infection control.
    In the area of infection control, the Dayton VAMC now includes a 
dentist as the Dental Representative on the Infection Control 
Committee. A dashboard was developed to summarize infection control 
practices and compliance. The Dayton VAMC infection control staff 
conducts quarterly observations of dental staff proficiency. Infection 
Control Practitioners maintain a daily log of their activities to 
document compliance with standard practices. Dayton developed a 
checklist for conducting clinical inspections and chart reviews to meet 
the requirements of focused and ongoing peer review programs. New 
standard operating procedures were implemented prior to the reopening 
of the clinic in September.
    VA's National Center for Organizational Development staff visited 
Dayton and offered a number of recommendations that have subsequently 
been enacted. In the area of leadership, the Dayton dental 
organizational chart was revised to ensure oversight and sufficient 
staffing support. Position descriptions have been reviewed and revised. 
Dayton has updated performance appraisal plans to emphasize 
accountability for safe and quality care, and these updates have been 
communicated and issued to employees. Efforts are underway throughout 
the Dayton VAMC to improve communication by offering additional 
opportunities for providing information to leadership through regular 
meetings, committee assignments, and participation in the relationship-
based care initiative.
    We are evaluating staffing levels in the Dental Clinic. A new 
position of Assistant Chief for Dental Service was established. 
Recruitment has been completed for a new Lead Dental Assistant and 
Dental Lab Technician. Recruitment is being finalized for a general 
dentist and administrative support staff. Dental hygienists have been 
relocated into larger space to accommodate clinical need, and 
administrative support was added to improve customer service and 
scheduling. The Dayton VAMC set up a dedicated Dental Communication 
Center Hotline (1-877-424-8214) that is available 7 days a week, 24 
hours a day. If Veterans or family members have any questions about the 
care provided at the Dayton VAMC Dental Clinic, we strongly encourage 
them to call. A special clinic was established for Veterans to come in 
for testing. Since we have been successful in contacting all of the 
Veterans, in the identified cohort, we are asking remaining Veterans 
that are interested in being tested to report to Primary Care, Monday 
through Friday from 8:00 a.m. to 4:30 p.m. and follow-up with their 
Primary Care provider. Veterans may walk-in during clinic hours or call 
the hotline number for an appointment.
    Since we began this series of improvements last summer, the Dayton 
VAMC has been inspected multiple times by various VA teams and the 
Office of the Inspector General (OIG). We appreciate the OIG's 
independence and counsel and have collaborated with them to ensure they 
have access to any information they need. In November, The Joint 
Commission conducted an unannounced review of the Dayton VAMC, with an 
additional surveyor focused specifically on the Dental Clinic. There 
were no dental service infection control issues identified.. The 
hospital has received full 3-year accreditation.
    the way ahead: continuing to deliver high quality care at dayton
    We have made significant progress and major changes to ensure that 
health care is delivered timely, safely and appropriately at the Dayton 
VAMC. While these accomplishments are notable, we still have more to 
do. We will continually strive to be the Veteran-centered, results-
oriented and forward-looking organization the Secretary has called us 
to be, and that our Veterans deserve. Our immediate focus is on 
implementing the recommendations our colleagues at the OIG offered 
following their review of infection control practices at the Dayton 
VAMC in December 2010. The OIG issued a draft report to the VISN in 
March. We provided our comments on this report back to them in early 
April.
    The OIG made two specific recommendations: first, I am to review 
the findings related to the Dayton VAMC Dental Clinic, including 
staffing issues, and take appropriate action; and second, I am to 
ensure the Dayton VAMC Director requires the Dental Service to comply 
with relevant infection control policies. I concurred with their 
recommendations. By the end of June, we will be in full compliance with 
the first recommendation as all necessary actions will have been taken. 
Administrative actions have been initiated against the parties 
responsible for allowing these lapses of infection control practices 
and inadequate oversight to occur. We will be finished modifying our 
Dental Service organizational structure consistent with findings in the 
OIG report. Regarding the second recommendation, by the end of May, 
systems will be in place to track all Dental Service mandatory 
infection control training. We will institute periodic random audits of 
infection control training compliance and observations, and will 
document staff knowledge of the infection control on the checklist in 
the Dental Dashboard. We will continue to work closely with infection 
control experts available in VA's system to ensure infection control 
practices are current with health care standards and expectations.
    We are also taking other actions to improve the care we deliver 
beyond the OIG's recommendations. First and of greatest importance, we 
will continue to reach out to Veterans who had contact with this 
dentist to provide them whatever support they may need. VA Central 
Office has convened a Management Program Review Team to conduct an 
organizational assessment of the Dayton VAMC. The primary purpose of 
this assessment is to identify any organizational or leadership factors 
that may have allowed this particular practice to continue undetected 
or unreported. The Team's report will be used to evaluate operations 
and to assess whether similar conditions may be potentially present in 
other parts of the Dayton facility and potentially at other VA 
facilities. The Team will ensure that current key leaders have 
implemented systems to properly identify and effectively address 
clinical or administrative issues that require immediate response. The 
Team is being asked to do a retrospective review of the organizational 
and management structure and governance, operational dynamics and 
culture, key reporting structures, leadership, attitudinal factors, and 
other pertinent areas. Information gathered from this review will help 
VA look at system-wide opportunities for management improvement. The 
Team consists of experts with years of experience across the VA system, 
and will also include a representative from the National Center for 
Organizational Development, who will serve as a consultant and advisor. 
A member of my staff will accompany and support the team as needed.
                               conclusion
    Our primary mission is to serve the Nation's Veterans. We sincerely 
apologize to the Veterans who received notices regarding infection 
risks related to dental procedures while under our care. We also 
apologize to the public, whose trust may have been questioned. It is 
unacceptable that this situation went on for so long. The Dayton VAMC 
leadership took action when employees raised concerns in an internal 
review process, and the facility has been inspected multiple times by 
VA and non-VA experts. We have taken administrative actions to ensure 
that those responsible for this serious error are held accountable. In 
the days and weeks ahead, we will be working closely with our 
colleagues at the OIG to ensure we have addressed the concerns 
identified and to institute changes in the organizational and 
management structure and governance, operational dynamics and culture, 
and the overall environment of care. We will work closely with national 
VA program offices to make certain our practices and policies are 
current and responsive to changes in health care standards.

    Thank you for inviting me here to testify today to discuss these 
plans and to listen to your recommendations. My colleagues and I are 
prepared to answer your questions.

    Senator Brown of Ohio. Thank you, Mr. Hetrick.
    You heard the Inspector General, Dr. Daigh's, 
recommendations. Give me general thoughts on implementing his 
ideas.
    Mr. Hetrick. Well, I think, first of all, the 
recommendation about making sure that the management team, 
regardless of where the hospital is located at, listening to 
employees within the various levels of their organization is 
clearly a sound recommendation. I would not argue with that. I 
think that, as our testimony goes on, Mr. Montague will show 
you some of the things that he has already done to try to make 
that happen here at Dayton by getting the message out to 
employees in the hospital and making sure they understand that 
they have the option to talk or to write anonymously, as the 
case may be, with their name, whatever way they want to do it. 
We certainly will listen.
    I have the advantage in my office, which is located, as you 
know, in Cincinnati, but we receive messages, letters, e-mails 
from a variety of employees from around the network with 
concerns. I have said publicly when I visit a hospital, have a 
town hall meeting, or whatever forum that I am asked to speak 
in that we will address every issue that comes to our 
attention, whether we know who it was that brought that issue 
to our attention, even--I cannot obviously respond to somebody 
who sent me something anonymously, but we will document it for 
our records in the case we hear about it again or see something 
that happens similar in the future that we looked into it. If 
an employee has an issue and they bring it to my attention 
personally or through some other of the many message chains we 
have available to us, we will get back to them and give them an 
explanation of what happened.
    We, just as in this case, when the situation was uncovered 
in the dental clinic, one of the first things we did was inform 
the employees who were working there they had two options. They 
could let the Joint Commission, as Dr. Daigh referenced in his 
testimony, they can call them and they would, in turn, come and 
perhaps do an on-site review of that issue. They would notify 
us of that complaint and we could look into it and get back to 
them, or they could call the OIG hotline number, which was 
provided to the employees at the time the incident was 
uncovered.
    We certainly work very closely--Dr. Daigh mentioned, I 
think, 30,000 complaints his office gets. I am pleased to 
report we do not get that many in Ohio, but we do get referrals 
from the OIG hotline, and we provide a very comprehensive 
review and response back to them. So I am all for that. I think 
we will do everything within our power to make certain that we 
try to expand those levels of communication so we get to as 
many people as possible within the organization.
    I am not sure--I only heard Dr. Daigh's recommendation 
about management movements in a period of time. I really have 
no comment on that at this point. I would need some time to 
think about that. But I am really rather focused on how we can 
continue to make things better with the people we have to work 
with.
    Senator Brown of Ohio. Mr. Montague, tell us, if you would, 
from listening to Dr. Daigh's recommendations and thinking 
about what you have implemented since you have been here, give 
me the two or three most important things, most important 
changes you have recommended based on, or not based on, the IG 
report.
    Mr. Montague. Well, I think the most important change we 
made is we made the lines of communication and the lines of 
authority and responsibility the same. Authority and 
responsibility are now at the same level, and there is no 
ambiguity as to whose task or whose responsibility something 
is, and they have the necessary authority to implement it. That 
helps with communications. It helps with figuring out what goes 
on.
    For example, I think--well, number 2 would be patient 
satisfaction. We have truly emphasized patient satisfaction 
when we made a distinct change. In the past, the complaint 
department, namely the patient representatives, who are 
excellent, were given the responsibility for patient 
satisfaction. That is too late in the game. We made a formal 
move to give nursing responsibility for patient satisfaction, 
obviously in collaboration with the physicians and the support 
staff. But the nurses now own the wards. They know they own the 
wards. They have a number of relationship-based care 
initiatives which should cement better relationships between an 
individual patient and the staff.
    Then, finally, on the cultural affairs question that you 
have been asking, we are sending cards to everyone that say, do 
not be afraid. We have to know. It is part of our quality 
management program.
    Senator Brown of Ohio. Do you know, Mr. Hetrick, the total 
number of patients seen by the dentist in question?
    Mr. Hetrick. I do not, sir, have the exact number at my 
disposal. The numbers range, because of the long period of time 
and the reliance on paper records versus computerized records, 
so we are more certain about the time period about the--when 
records are electronic versus the----
    Senator Brown of Ohio. What year was that?
    Mr. Hetrick. I believe that goes back for dental in the 
early 2000s, if my memory serves me correct.
    Senator Brown of Ohio. Can you give me a rough estimate, 
within a few hundred, of how many he saw over 18 years?
    Mr. Hetrick. Over 18 years? I do not know. I would have 
to--I was not totally involved in that. Let me----
    Mr. Montague. Twenty-three hundred.
    Mr. Hetrick. Twenty-three hundred, OK.
    Senator Brown of Ohio. Twenty-three hundred? OK.
    Mr. Hetrick. Yes. Thank you.
    Senator Brown of Ohio. If someone wants to be tested and 
was not in, what do you call it----
    Mr. Hetrick. The cohort.
    Senator Brown of Ohio [continuing]. The cohort----
    Mr. Hetrick. Yes.
    Senator Brown of Ohio [continuing]. The identified cohort, 
what do they do?
    Mr. Hetrick. I would point out that the defined cohort of 
535 number, we have tested close to 100 the last time I checked 
outside of the cohort because they showed up and wanted to be 
tested.
    Senator Brown of Ohio. So some were of the difference 
between 2,300 and 500, 100 of those 1,800, roughly.
    Mr. Hetrick. Mm-hmm.
    Senator Brown of Ohio. When they are tested, they get--if 
they are tested positively, they, I assume, get total VA 
benefits and compensation and care?
    Mr. Hetrick. All patients that have--a special clinic was 
set up for the testing and counseling and explanation of what 
the next steps would be, should there be a positive finding. So 
the answer would be yes. That will be part of what will play 
out.
    Senator Brown of Ohio. You have been in this position since 
November 2006, in the position of being the head, if you will, 
of these four medical centers, a very responsible position. How 
do you think this could have happened in one of your four 
medical centers without your knowing it?
    Mr. Hetrick. Well, I have asked myself that question a 
number of times----
    Senator Brown of Ohio. I am sure you have.
    Mr. Hetrick. It is very troubling. I do not want to be 
using the same words as others, but I cannot find any other 
word to fully describe----
    Senator Brown of Ohio. Is there some culture----
    Mr. Hetrick [continuing]. How troubled----
    Senator Brown of Ohio. Our office--we have been working 
with this--I have only been in office since the same time you 
took office, around 2006, 2007, and we had been working to try 
to improve--there were significant management problems here. We 
knew that. We did not know anything about the dental issue. 
Maybe not a culture of recklessness, but morale was an issue. 
There were all kinds of patients--I mean, all kinds of 
employee-employer/management-labor issues going on. Did that 
not alert somebody like you, or else somebody else, to a 
carelessness, a recklessness, or a dysfunction that should have 
meant a deeper look at what was happening here?
    Mr. Hetrick. Yes. If I remember correctly, I think this 
goes back to about April 2007, and you and some folks from here 
and myself had a conversation on the telephone about the issues 
you just raised. I think we had a very strong response to that 
at the time.
    Addressing patient satisfaction was an issue with me across 
the network, not just here in Dayton. Despite the fact we have 
very good numbers with many performance measures and many with 
access numbers among the best anywhere in the VA system, we 
still had ongoing issues with our patient satisfaction results, 
primarily inpatient. So that was clearly something that I was 
very concerned about, and it resonated with me that you brought 
it up, and I certainly appreciated your support at the time, 
because I think that helped us to move into a number of new 
territories. Although it has not been as fast as I would like, 
we continuously see improvement in those numbers.
    Now, with regards to the culture of the facility and the 
management, that part of your question, we worked very closely 
with the National Center for Organizational Development, 
affectionately known in our group as NCOD, which is sort of 
bipartisan in a way. They come in and do organizational 
assessments. They help figure out what is going on, what works 
right and what does not work right and how we can set a course 
to try to make improvements.
    We took all of that--that followed your initial call with 
us and they came in, and they did a very top all the way down 
assessment and met with hundreds of employees, did all kinds of 
individual assessments, and really put together a good plan. 
Mr. Richardson at the time brought somebody in from their 
organization to be onsite to help carry that out. While Dayton 
was not the leader in moving up in employee satisfaction or 
results, they had made steady improvements in that area and 
were actually above the VA average, as I recall, the last time 
on the all employee satisfaction.
    So when looking at those kinds of things, I saw things 
moving in the right direction. Was it perfect? No. We always 
have a lot of work to do. But I was satisfied that we were 
moving--that still does not answer the 18-year gap. I think 
that what I am trying to do now is to make sure that that never 
happens again and pooling all the resources I have available to 
me to figure out the way that we can possibly change that, that 
no one ever thinks it is OK to observe something that is wrong 
and not report it. So that is what I am trying to focus on now, 
because I just realize I am not going to be able to explain to 
you 18 years.
    I sat down after this incident came to my attention. We 
went through every record that we had in our office and every 
review, every organization, and it has been the OIG, it has 
been SOARS, it has been you name it, they have been here. We 
looked to see, did we miss a trend? Did we miss something that 
should have alerted us? And, quite frankly, there were no--we 
did not have any record of patient complaints that came to us, 
any letters from an individual saying they had a concern about 
the dental practices. If any of those things had been there and 
I had missed that, I would be the first person to acknowledge 
that. But I did not see that, and so what I am trying to do now 
is just do the best we can to make sure we never have that 
situation happen again.
    Senator Brown of Ohio. Was there an issue with--did you, or 
have you heard from others within the Dayton Medical Center 
that there was perhaps a problem with staffing shortages, that 
there was too much work being done by too few people here?
    Mr. Hetrick. Well, staffing is always an interesting 
subject to take up. I would say most departments, if we went 
around and asked, might say they did not have enough staff. I 
think that the board, during their investigation, addressed 
that in terms of staffing--particularly in relationship to the 
residency program that they were operating--and I believe, and 
have discussed this with Mr. Montague, that he feels that the 
recommendations that they made in terms of what should have 
been in place, we do not disagree with.
    Whether or not there are--I think that over the years, and 
again, this covers a long period of time and what rationale 
related to what decisions at that point in time is hard to 
speculate on, but I do think that as practice patterns change 
over time and more dentists now have assistants in use, I think 
we need to move along with that. I think they were partway 
there and not the entire way there. We have since done a top-
down review. We are making, of course, changes once again to 
make sure that that staffing mix is right for the amount of 
work they have to do.
    Senator Brown of Ohio. Does the VA put more emphasis on not 
rocking the boat than it does on patient care?
    Mr. Hetrick. Well, that is a tough question. Not in my 
network. I personally do not think that we emphasize that in 
the field level. I really feel that since Secretary Shinseki 
has been in place--this is not about him, of course, but he has 
been very engaged in talking with leadership at the VISN level. 
As a matter of fact, tomorrow morning, I have a briefing with 
him on another subject. This is unprecedented in my time in the 
VA.
    So I think that we are moving beyond rocking the boat. No 
one in the chain of command above me has attempted to make 
light of this or to slow things down. I think that folks were 
appalled at all levels and tried very hard to work their way 
through. You know, rocking the boat is something, I think, all 
of us should do all the time whenever patient care is involved.
    Senator Brown of Ohio. Does the VA owe veterans in the 
Miami Valley an apology?
    Mr. Hetrick. Well, I think we have done that. I know I 
personally wish I could meet every single one of them and 
apologize for what happened over the course of these years 
without--I mean, the only reason why we exist is to take care 
of veterans, so there is no question whatsoever about our 
mission, and what we should be doing. I believe that if anyone 
has been shaken in our confidence, we have a big job ahead of 
us to try to gain that confidence back, and I think that that 
has been the focus, once we got past the issues involving 
investigation and all the things that come with that. Now the 
work here at this hospital under the leadership of Mr. Montague 
and his staff is to try to restore that confidence, and 
whatever I can do as a Network Director, we will be certainly 
participating in.
    Senator Brown of Ohio. Thank you for that. What kind of 
notification or outreach are you doing to those people outside 
the identified cohort of 535 patients?
    Mr. Hetrick. There has been no direct communication via 
calls or letters to those outside the cohort.
    Senator Brown of Ohio. Should there be?
    Mr. Hetrick. Well, that is a policy question that I believe 
that many very highly qualified experts looked at, and I go 
back to Dr. Daigh's statement about notifying someone about 
something that is a very, very low risk can sometimes cause 
more harm than what it solves.
    If the decision is made to do that, we would certainly do 
everything in our power to get to those folks and bring them 
back. But again, I think the focus is on doing sort of 
grassroots efforts now, that Mr. Montague and his staff are 
meeting with various groups, service organizations, and others 
to try to restore the confidence. Again, if someone wants to be 
tested, they are welcome to come forward.
    Senator Brown of Ohio. For my last question, Mr. Montague, 
tell us what you are doing to restore trust to a public that 
includes veterans and non-veterans alike in the Miami Valley 
and the area beyond the Miami Valley that this clinic serves, 
that this hospital serves, what specifically are you doing to 
give people more trust and more faith and more certainty that 
this is not going to happen again here?
    Mr. Montague. Well, our goal, day one, when Congressman 
Turner had the last presentation, we brought the media into the 
dental clinic, and we would invite anybody else to come into 
the dental clinic and actually see it. We will go to any 
organization that invites us, any service organization, any 
community, town, whatever, explain what happened, why. We stand 
ready to test anybody that wishes to be tested, and if the CRB 
changes its guidelines, we stand ready, willing, and able to 
test whomever it is clinically determined is appropriate.
    Senator Brown of Ohio. How many Veterans Service 
Organizations and others have you gone out to speak to so far, 
roughly?
    Mr. Montague. Thus far, I have visited the Chief Service 
Officer of each of the six major service organizations. I have 
not been to a post or an American Legion hall yet, but I did 
offer the invitation to the leadership. I am involved in the 
Memorial Day parade, and I am sure--you know how many times I 
came to Lorain.
    Senator Brown of Ohio. I do know that. [Pause.]
    Thank you for your testimony and for your service.
    I will adjourn the Committee meeting in a moment. For 
people who want to talk to me specifically, I will stay around 
for 30-40 minutes or so. My staff will stay around a little 
longer than that, I assume. I will stay around pretty much as 
long as I need to and people can individually bring up things 
to me. Understand, be assured that anyone that wants to speak 
to me or to my staff or to the Inspector General or to the VA, 
I will protect their confidentiality. That is a commitment from 
me to any of you or to your family members or to your 
coworkers.
    The Committee will prepare a print of this hearing. The 
Committee staff and I may have other questions of the 
witnesses, which we will submit in writing to them, which they 
will, I would assume, answer promptly and that will be in the 
Committee print, also.
    I thank the six witnesses. I thank you for your service. I 
thank particularly the people that work here and the patients 
who have served here. The apology from the VA was, I think, 
heartfelt, but the actions were not excusable and we need to 
assure people and we need to make sure that this does not 
happen again at this fine institution or any other, the Vet 
Centers, and the Community-Based Outpatient Clinics that serves 
veterans in this State. Your service is too important to 
deserve anything less. I thank you for your service.
    The Senate Committee on Veterans' Affairs is adjourned.
    [Whereupon, at 3:20 p.m., the Committee was adjourned.]
      

                                  
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