[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]


                 SCHEDULING MANIPULATION AND VETERAN 
                  DEATHS IN PHOENIX: EXAMINATION OF THE 
                  OIG'S FINAL REPORT

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

                                HEARING

                               BEFORE THE

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

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                     WEDNESDAY, SEPTEMBER 17, 2014

                               __________

                           Serial No. 113-87

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               MICHAEL H. MICHAUD, Maine, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         CORRINE BROWN, Florida
DAVID P. ROE, Tennessee              MARK TAKANO, California
BILL FLORES, Texas                   JULIA BROWNLEY, California
JEFF DENHAM, California              DINA TITUS, Nevada
JON RUNYAN, New Jersey               ANN KIRKPATRICK, Arizona
DAN BENISHEK, Michigan               RAUL RUIZ, California
TIM HUELSKAMP, Kansas                GLORIA NEGRETE McLEOD, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
PAUL COOK, California                TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana
DAVID JOLLY, Florida
                       Jon Towers, Staff Director
                 Nancy Dolan, Democratic Staff Director

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                            C O N T E N T S

                              ----------                              

                     Wednesday, September 17, 2014

                                                                   Page
Scheduling Manipulation and Veteran Deaths in Phoenix: 
  Examination of the OIG'S Final Report..........................     1

                           OPENING STATEMENTS

Jeff Miller, Chairman............................................     1
    Prepared Statement...........................................    95
Michael Michaud, Ranking Member..................................     3
    Prepared Statement...........................................    96

                               WITNESSES

Richard J. Griffin, Acting Inspector General, Department of 
  Veterans' Affairs..............................................     4
    Prepared Statement...........................................    97

Accompanied by:
    John D. Daigh, Jr. M.D., Assistant Inspector General for 
        Healthcare Inspections, Department of Veterans' Affairs
    Linda Halliday, Assistant Inspector General for Audits and 
        Evaluations, Department of Veterans' Affairs
    Maureen Regan, Counselor to the Inspector General, Department 
        of Veterans' Affairs
And
    Larry Reinkemeyer, Director, Inspector General Kansas City 
        Audit Office, Department of Veterans' Affairs

Samuel H. Foote, M.D., Retired Medical Director, Diamond 
  Community-Based Outpatient Center, Phoenix VA healthcare System     6
    Prepared Statement...........................................   104

Katherine L. Mitchell, M.D., Medical Director, Iraq and 
  Afghanistan Post-Deployment Center, Phoenix VA healthcare 
  System.........................................................     9
    Prepared Statement...........................................   105

Hon. Robert A. McDonald, Secretary, Department of Veteran Affairs    51
    Prepared Statement...........................................   160

Accompanied by:
    Carolyn M. Clancy, M.D., Interim Under Secretary for Health, 
        VHA, Department of Veterans' Affairs

Lisa Thomas, PhD., Chief of Staff, Veterans Health 
  Administration, Department of Veterans' Affairs................    76

Accompanied by:
    Sharon Helman, Director, Phoenix VA healthcare System, 
        Department of Veterans' Affairs

And

Darren Deering, M.D., Chief of Staff, Phoenix VA healthcare 
    System, Department of Veterans' Affairs

                   MATERIALS SUBMITTED FOR THE RECORD

Letter From: Hon. Richard J. Griffin, To: Michael H. Michaud, 
  Ranking Member.................................................   169
Questions From: Hon. Richard J. Griffin, To: VA..................   170
Letter From: Michael Michaud, Ranking Member, To: Hon. Richard J. 
  Griffin........................................................   173
Responses From: Veterans' Affairs, To: Minority Member of the 
  Committee of Veterans' Affairs.................................   174
Letter From: Hon. Robert A. McDonald, To: Michael H. Michaud, 
  Ranking Member.................................................   182
Questions From: Hon. Robert A. McDonald..........................   183
Questions From: Michael Michaud, Ranking Member and Responses 
  From: VA.......................................................   185

 
 SCHEDULING MANIPULATION AND VETERAN DEATHS IN PHOENIX: EXAMINATION OF 
                         THE OIG'S FINAL REPORT

                              ----------                              


                     Wednesday, September 17, 2014

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                                   Washington, D.C.
    The committee met, pursuant to notice, at 1:19 p.m., in 
Room 334, Cannon House Office Building, Hon. Jeff Miller 
[chairman of the committee] presiding.
    Present:  Representatives Miller, Lamborn, Bilirakis, Roe, 
Denham, Runyan, Benishek, Huelskamp, Coffman, Wenstrup, Cook, 
Walorski, Jolly, Michaud, Brown, Takano, Brownley, Titus, 
Kirkpatrick, Ruiz, Negrete McLeod, Kuster, O'Rourke, and Walz.
    Also Present: Representative Schweikert.

           OPENING STATEMENT OF CHAIRMAN JEFF MILLER

    The Chairman. Good afternoon. This hearing will come to 
order. I thank everybody for attending this hearing which will 
examine the OIG report on the Phoenix issue.
    I would also like to ask unanimous consent, he is not here 
yet, but that our colleague, David Schweikert, from Arizona, be 
allowed to join us here to address this issue. Without 
objection, so ordered.
    Also, Members, we do have a series of votes that will start 
at one o'clock. I apologize for that. This hearing was moved 
from its original scheduled time because of the joint session 
of Congress to hear the President of the Ukraine.
    What we will do is immediately after the final vote move 
back as quickly as you can. We will resume the hearing as 
quickly as we possibly can so that we will not keep the 
witnesses waiting any longer than absolutely necessary.
    On the 26th of August, the VA Office of Inspector General 
released its final report on the Phoenix VA Healthcare System 
which vaulted to national attention after our hearing on April 
the 9th.
    The OIG confirmed that inappropriate scheduling practices 
are a nationwide systemic problem and found that access 
barriers adversely affected the quality of care for veterans at 
the Phoenix VA Medical Center.
    Based on the large number of VA employees who were found to 
have used scheduling practices contrary to Veterans Health 
Administration policy, the OIG has opened investigations, as I 
understand it, at 93 VA medical facilities and have found over 
3,400 veterans who may have experienced delays in care from 
wait list manipulation at the Phoenix VA Medical Center alone.
    The OIG concluded by providing the VA with 24 
recommendations for improvement to avoid these problems from 
reoccurring. These recommendations should be implemented 
immediately, and this committee will work tirelessly to ensure 
that they are, in fact, implemented.
    Mr. Griffin, I commend you, sir, and your team for your 
work and continued oversight on these issues in the past and in 
the months ahead. With that said and as we have discussed, I am 
discouraged and concerned the manner with which the OIG report, 
the final report was released along with the statements 
contained within it.
    Notably, prior to the release of the report, selective 
information was leaked to the media apparently by a source 
internal to VA which I believe purposely misled the public that 
there was no evidence at Phoenix linking delays in care with 
veteran deaths. And as the days progressed and people actually 
read the report, that falsehood actually became obvious.
    What the OIG actually reported and what will be the subject 
of much discussion today is the statement by the OIG, quote, 
``We are unable to conclusively assert that the absence of 
timely, quality care caused the deaths of these veterans,'' end 
quote.
    Now, what is most concerning to me about this statement is 
the fact that no one who dies while waiting for care would have 
delay in care listed as the cause of death since a delay in 
care is not a medical condition.
    Following the release of this report which found pervasive 
problems at the facility regarding delays in care and poor 
quality of care, committee staff was briefed by the OIG 
regarding its findings and how specific language was chosen 
throughout the entire drafting process.
    Prior to this meeting, we requested that the OIG provide us 
with the draft report in the form it was originally provided to 
VA three weeks before the release of the final report. After 
initially expressing reservations, the OIG provided us with the 
draft. What we found was that the statement that I just quoted 
was not in the draft report at all.
    Another discrepancy we found between the draft and final 
reports arose with statements to the effect that one of the 
whistleblowers here today did not provide a list of 40 veterans 
who had died while on a waiting list at the Phoenix VA Medical 
Center.
    First, the OIG statement in the briefing to the committee 
staff that VA inquired why such a statement was not in the 
report and the OIG ultimately chose to include it.
    Further, additional information provided by the OIG to our 
committee staff shows that based on numerous lists provided by 
all sources throughout the investigation, the OIG, in fact, 
accounted for 44 deaths on the electronic wait list alone and 
an astonishing 293 total veteran deaths on all of the lists 
provided from multiple sources throughout this review.
    To be clear, it is not nor was not my intention to offend 
the inspector general and the hard-working people within the 
agency that he employs. However, I think I would be remiss in 
my duty to conduct oversight of the Department of Veterans 
Affairs if I did not ask these questions.
    I would also like to point out that no one within the 
department or any other Federal Government employee including 
Members of this committee is beyond having their records 
scrutinized. As such, the committee will continue to ask the 
questions that need to be asked in order to perform our 
constitutional duties.
    It is absolutely imperative that the OIG's independence and 
integrity in its investigation be preserved. Full and 
transparent hearings like this one will help ensure that that 
remains the case.
    With that, I now turn to the ranking member, Mr. Michaud, 
for his opening statement.

    [The prepared statement of Jeff Miller, Chairman appears in 
the Appendix]

          STATEMENT OF MICHAEL MICHAUD, RANKING MEMBER

    Mr. Michaud. Thank you very much, Mr. Chairman, for having 
this very important hearing.
    I would like to thank all the panelists for coming today as 
well.
    Today's hearing provides the opportunity to examine the VA 
inspector general's final report on the patient wait times and 
scheduling practices within the Phoenix VA Healthcare System. 
This report did not state a direct causal relationship between 
the long patient wait times and veterans' death. For some, that 
is a major concern and accusation of undue influence by the VA 
on the inspector general's report will be discussed at length 
today.
    What the IG did find is that the cases included in this 
report clearly shows that there was serious lapse in VA's 
follow-up, coordination, quality, and continuum of care for our 
veterans. They also concluded that the inappropriate scheduling 
practices demonstrated in Phoenix are a nationwide systematic 
problem.
    I do not need any more evidence or analysis that there is 
no doubt in my mind that veterans were harmed by the scheduling 
practices and culture at the Phoenix facility and across the 
Nation.
    The bottom line is this behavior and the detrimental effect 
of veterans is simply not acceptable. My heart goes out to the 
families of the veterans who did not receive the healthcare 
they deserved in Phoenix and around the country. Rest assured 
that we will understand what went wrong, fix it, and hold those 
responsible for these failures accountable.
    As such, my question to the VA today is straightforward. 
What went wrong? What are you doing to fix the problems? How 
will you ensure that this never happens again and how are you 
holding those responsible accountable?
    I applaud Secretary McDonald for taking forceful action to 
begin to address the systematic failures demonstrated in 
Phoenix. We need serious, deep, and broad reform, that kind of 
change that may be uncomfortable for some in VA, but so 
desperately needed by America's veterans.
    I believe that such reforms must be guided by a higher 
level national veteran strategy that outlines a clear vision of 
what America owes its veterans and a set of tangible outcomes 
that every component of American society can align and work 
towards.
    Earlier this week, I sent a letter to President Obama 
asking him to establish a working group to engage all relevant 
members of the society in drafting this national veteran 
strategy.
    We know from experience that VA cannot do it alone. We must 
develop a well-defined idea on how the entire country, 
government, industry, nonprofits, foundations, communities, and 
individuals, will meet this obligation to our veterans.
    VA needs to become a veteran-focused, customer service 
organization. It needs to be realigned to become the integrated 
organization. It should do what it does best and partner for 
the rest. It needs to be the government model for honesty, 
integrity, and discipline.
    We need to complete our investigation of these problems and 
provide oversight on the solutions. And I look forward to 
today's additional testimony about what happened in Phoenix and 
how the VA is working to ensure that it never happens again.
    So, once again, Mr. Chairman, I want to thank you for 
having this hearing and I yield back the balance of my time.

    [The prepared statement of Michael Michaud, Ranking Member 
appears in the Appendix]

    The Chairman. Thank you very much.
    And I would ask that all Members waive their opening 
statements as customary in this committee.
    Thank you to the witnesses that are here at the table and 
those that agreed to sit behind the principles.
    Today we are going to hear testimony from Acting Inspector 
General Richard J. Griffin who is accompanied by Dr. John 
Daigh, Jr., assistant inspector general for Healthcare 
Inspections; Ms. Linda Halliday, assistant inspector general 
for Audits and Evaluations; Ms. Maureen Regan, counselor for 
the inspector general; and Larry Reinkemeyer, director of the 
Kansas City Office of Audits for the Office of Inspector 
General.
    We are also going to hear from Dr. Samuel Foote, a former 
VA physician at Phoenix VA Healthcare System and Dr. Katherine 
Mitchell, current whistleblower and medical director for the 
Iraq and Afghanistan Post-Deployment Center at the Phoenix VA 
Healthcare System.
    I would ask the witnesses now to please stand so that we 
may swear you in. If you would raise your right hands.
    [Witnesses sworn.]
    The Chairman. Thank you. You may be seated.
    Let the record reflect that all of the witnesses affirmed 
that they would, in fact, tell the truth, the whole truth, and 
nothing but the truth.
    All of your complete written statements will be made a part 
of this hearing record.
    And, Mr. Griffin, you are now recognized for five minutes.

                STATEMENT OF RICHARD J. GRIFFIN

    Mr. Griffin. Mr. Chairman, Ranking Member Michaud, and 
Members of the committee, thank you for the opportunity to 
discuss the results of the inspector general's extensive work 
at the Phoenix VA Healthcare System.
    Our August 26, 2014 report expands upon information 
previously provided in our May 2014 interim report and includes 
the results of the reviews of the OIG clinical staff of patient 
medical records.
    We initiated our review in response to allegations first 
reported through the OIG hotline on October 24, 2013 from Dr. 
Foote who alleged gross mismanagement of VA resources, criminal 
misconduct by VA senior hospital leadership, systemic patient 
safety issues, and possible wrongful deaths at Phoenix.
    The transcript of our interview with Dr. Foote has been 
provided to the committee and I request that it be included in 
the record.
    The Chairman. Without objection.
    Mr. Griffin. We would like to thank all the individuals who 
brought forward their allegations about issues occurring at 
Phoenix and at other VA medical facilities to the attention of 
the IG, the Congress, and the Nation.
    On August 19, 2014, the chairman of the Subcommittee on 
Oversight and Investigations sent a letter to the IG requesting 
the original copy of our draft report prior to VA's comments 
and adopted changes to the report.
    On September 2nd, a committee staff member made a similar 
request for a written copy of the original unaltered draft as 
first provided to VA on behalf of the chairman.
    Concerns seemed to come from our inclusion of the following 
sentence in a subsequent draft report that was not in the first 
draft report we submitted to VA. The sentence reads as follows:
    While the case reviews in this report document poor quality 
of care, we are unable to conclusively assert that the absence 
of timely care caused the death of these veterans.
    This sentence was inserted for clarity to summarize the 
results of our clinical case reviews that were performed by our 
board certified physicians whose curricula vitae are an 
attachment to our testimony.
    It replaced the sentence the death of a veteran on a wait 
list does not demonstrate causality which appeared in a prior 
draft, not the first draft that was requested, but in a 
subsequent draft. This change was made by the OIG strictly on 
our own initiative. Neither the language nor the concept was 
suggested by anyone at VA to any of my people.
    In the course of our many internal reviews of the content 
of our draft report, on July 22nd, almost a full week before 
the draft was sent to the department, one of our senior 
executives wrote this question. This is key, gentlemen and 
ladies.
    And I quote. ``Did we identify any deaths attributed to 
significant delays?'' This was on July 22nd. If we can't 
attribute any deaths to the wait list problems, we should say 
so and explain why. After all, the exact wording in the draft 
report was were the deaths of any of these veterans related to 
delays in care.
    This type of deliberation to ensure clarity continued as it 
should after the initial draft was sent to the department. In 
the last six years, we have issued more than 1,700 reports. 
This same review and comment process has been used effectively 
throughout OIG history to provide the VA secretary and Members 
of Congress with independent, unbiased, fact-based program 
reviews to correct identified deficiencies and improve VA 
programs.
    These reports have served as the basis for 67 congressional 
oversight hearings including 48 hearings before this committee.
    During these same six years, our work has been recognized 
by the IG community with 25 awards for excellence. We are 
scrupulous about our independence and take pride in the 
performance of our mission to ensure veterans receive the care, 
support, and recognition they have earned through service to 
our country.
    The VA secretary has acknowledged the department is in the 
midst of a serious crisis and has concurred with all 24 
recommendations and has submitted acceptable corrective action 
plans.
    Our recent report cannot capture the personal 
disappointment, frustration, and loss of faith that veterans 
and their family members have with the healthcare system that 
often could not respond to their physical and mental needs in a 
timely manner.
    Although we did not apply the standards of determining 
medical negligence during our review, our findings and 
conclusions in no way affect the rights of a veteran or his or 
her family from filing a complaint under the Federal Tort 
Claims Act with VA.
    Decisions regarding VA's potential liability in these 
matters lies with the VA, the Department of Justice, the 
judicial system under the Federal Tort Claims Act.
    Mr. Chairman, this concludes our statement. We would be 
happy to answer any questions you or other Members of the 
committee may have.

    [The prepared statement of Richard J. Griffin appears in 
the Appendix ]

    The Chairman. Thank you very much, Mr. Griffin.
    Dr. Foote, you are recognized for your opening statement 
for five minutes.

                  STATEMENT OF SAMUEL H. FOOTE

    Dr. Foote. My name is Dr. Sam Foote. I started my internal 
medicine training in 1981 at the combined Good Samaritan 
Phoenix VA program. I finished in 1984 and became board 
certified in internal medicine.
    I went to work full time in East Mesa, Arizona as an 
emergency physician and I returned to the VA in 1990, the same 
year that I earned by boards in emergency medicine. I ran the 
VA's emergency department from 1990 to 1998. I was a medical 
service teaching attending from `91 to 2003 and I became an 
outpatient clinic director on December of 1994, a position 
which I held until my retirement in December of 2013.
    While I have views on many aspects of what has come to be 
known as the VA scandal, I would like to use this statement to 
comment on what I view as the foot dragging, downplaying, and, 
frankly, inadequacy of the Inspector General's Office.
    This continues in the report issued August 26, 2014 which I 
fear is designed to minimize the scandal and protect its 
perpetrators rather than provide the truth along with closure 
to the many veterans and families that have been affected by 
it.
    All VA employees receive mandatory recurrent training on 
their duty to report waste, fraud, and abuse to the inspector 
general whose job it is to investigate these allegations. I 
first did this in February of 2011 which resulted in then 
director Gabriel Perez being placed on leave within two weeks 
of the IG receiving my letter and a few months later, his 
resignation in lieu of termination.
    I sent a second letter to the IG in April of 2013 where I 
made allegations against the chief of Health Administrative 
Services, Brad Curry, for creating a hostile workplace, 
engaging in prohibitive personnel actions and discrimination 
against certain classes of employees.
    As far as I can tell, the IG never investigated this 
complaint and it appears that they turned it over to the 
Veterans Integrated Service Network director, Susan Bowers, who 
was both Helman's and Curry's superior. Susan Bowers could not 
take action against him without running the risk that the 
entire waiting list scandal would be exposed.
    In late October of 2013, I sent a third letter to the IG 
informing them of the existence of a secret waiting list where 
ten patients on that list had died while waiting for 
appointments.
    I also included additional allegations of prohibitive 
personnel actions by senior staff. Furthermore, I advised them 
of a second hidden backlog of patients contained in the 
scheduling appointment with primary care consult lists and that 
an unknown number of veterans had perished on it.
    I also detailed other methods that were used--in use to 
lower the apparent backlog for new patients and I implored the 
IG to come to Phoenix to investigate all the above. I got a 
response from the San Diego IG Office on December 3rd, 2013 to 
join a conference call with them on December 6th.
    Their team came out to investigate the week of December 
16th through the 20th. At that time, I and others told them 
about the unaddressed scheduling appointment consults and 
showed them the Northwest Electronic Holding Clinic which was 
being used as were prior holding clinics to mask the true 
demand for return patient appointments.
    We updated them on the secret electronic waiting list 
summary report showing that 22 patients had been removed from 
it because they had died. We only had the names of two of the 
deceased because none of the employees who were working with me 
had the electronic keys to print the names of the deceased.
    We asked the IG inspectors if they could do it, but they 
responded that they could not. The last email response that I 
had from them was on December 21st, 2013 when I received an out 
of the office until Tuesday, December 31st, 2013 reply.
    I had offered to fax or mail the names we had at the time, 
but they were unable to give me a working fax number or an 
address to mail it to. Fax and standard mail but not 
unencrypted email are considered appropriate methods to 
transmit HIPAA sensitive materials.
    I sent four more emails in early January again asking if 
they would like me to fax or mail the patients' names, but I 
got no response. I also got no response when I advised them 
that several more veterans had died.
    Finally, on February 2nd, 2014, out of frustration, with 
lack of action by the IG, even though we were informing them of 
more and more deaths, I sent IG letter number four with copies 
to everyone who I could think of that might be able to help. 
The only response that I got from the IG was a confirmation 
that they had received my letter.
    A friend suggested that I contact the House Veterans' 
Affairs Committee and there I found the help I needed. During 
this process, I was advised by several people that the only way 
I could get the IG's Office to investigate my allegations was 
to make them public which reluctantly I did.
    In my opinion, this was a conspiracy, possibly criminal, 
perpetrated by senior Phoenix leaders. Of the many scandalous 
aspects from the performance bonuses paid to top administrators 
for supposedly meeting waiting time goals to the harassment of 
employees trying to rectify the situation to the destruction of 
documents and electronic records to the very real harm done to 
the health of thousands of veterans unable to receive timely 
medical care, nothing is more scandalous than the fact, the 
fact that 293 veterans died in Phoenix.
    Yet, even now, right here in this report, the inspector 
general tries to minimize the damage done and the culpability 
of those involved by stating that none of the deaths can be 
conclusively tied to treatment delays.
    I have read the report many times and several things bother 
me about it. Throughout the case reports, the authors appear to 
have downplayed facts and minimized the harm. This was 
absolutely true in cases six and seven where I have direct 
knowledge.
    After reading these two cases, it leaves me wondering what 
really happened in all the rest. For example, in case number 
29, how could anyone conclude that the death was not related to 
the delay when a patient who needs an implanted defibrillator 
to avoid sudden death did not get one in time and why was a 
cardiac death case excluded from the IG review?
    In addition, a critical element to proving that this was a 
conspiracy was the potential tampering with the reporting 
software of the electronic waiting list. From the beginning, 
the IG's own data showed that there was a difference between 
the numbers reported to Washington and what the numbers 
actually were on the secret electronic waiting list.
    The IG clearly minimized the significance of the crucial--
of this crucial point treating it as a trivial--as a trivial 
clerical error and touting how quickly the IT department 
corrected it rather than exploring who tampered with it in the 
first place.
    Adding it up, the IG report states 4,900 veterans were 
waiting for new patient appointments at the Phoenix VA. Three 
thousand five hundred were not on any official list and--and 
1,400 were on the non-reporting secret electronic waiting list. 
Two hundred and ninety-three of these veterans are now 
deceased.
    This vastly exceeds my original allegations that up to 40 
veterans may have died while waiting for care. The IG says it 
is not charged with determining criminal conduct. True. But 
neither is it charged with producing reports designed to 
downplay potential criminal conduct designed to defuse and 
discourage potential criminal investigations or to diminish the 
quite appropriate public outrage.
    At its best, this report is a whitewash. At its worst, it 
is a feeble attempt at a coverup. The report deliberately uses 
confusing language and math, invents new unrealistic standards 
of proof, ignores why the electronic waiting list was not 
reporting accurate data, and makes misleading statements.
    In addition, the attempts to minimize bad outcome by 
downplaying damaging information and thereby protecting the VA 
officials who are responsible for this scandal just reinforces 
the VA's longstanding culture of circling the wagons to delay, 
deny, and let the claim, story, or patient die that the 
veterans community has had to suffer with for years.
    The Chairman. Dr. Foote, I apologize. You have gone three 
minutes over the five. I would like to say that the rest of 
your testimony will be entered into the record. I apologize, 
but I let you go a little bit longer than what we all had 
agreed to.
    Can you wrap it up in the next 20 seconds?
    Dr. Foote. Yeah. Secretary McDonald said that he was going 
to try to increase the transparency of the agency and that he 
would not tolerate whistleblower retaliation. Apparently some 
senior Washington VA administrators did not get that memo. This 
report fails miserably in those areas with a transparency 
equivalent to a lead-lined, four foot thick concrete wall.
    Thank you, Mr. Chairman.

    [The prepared statement of Samuel H. Foote appears in the 
Appendix]

    The Chairman. Thank you very much, Doctor.
    Dr. Mitchell, you are recognized for five minutes.

               STATEMENT OF KATHERINE L. MITCHELL

    Dr. Mitchell. I'm deeply honored by the committee's 
invitation to testify today. The OIG wasn't able to 
conclusively assert that the absence of timely quality care 
caused veterans' death.
    As a physician reading the report, I disagreed. 
Specifically in a minimum of five cases, I believe there was a 
very strong actual or potential causal relationship between 
delayed care or improper care and veteran death.
    In addition, healthcare delays contributed to the quality 
of life and for five other veterans who were terminally ill and 
shortened the life span of one of them.
    In looking at the report, there are four cases where there 
is no cause of death listed. It's unclear to me how a causal 
relationship may or may not exist if there is no cause of death 
given.
    It is unclear if 19 veterans who were on the electronic 
waiting list were aware of the self-referral process to the 
primary care clinics. If they were not aware of this process, 
then they reasonably--reasonably believed that waiting on the 
waiting list was the only way to get medical care even if their 
symptoms were worsening.
    In two cases, the OIG gave evidence that the veterans' 
acute or had acute instability of their chronic medical disease 
that required repeated visits to the ER and hospitalization. I 
believe that those likely--those delays likely contributed to 
their death. But, again, the OIG did not give a cause of death 
for those two veterans.
    In terms of mental health treatment, there were eight 
veterans on the electronic waiting list waiting for primary 
care who apparently just wanted a mental health referral. Two 
of those veterans committed suicide before they got the 
appointment.
    It is unclear if anyone told them that the mental health 
process is a self-referral process and they could have done so 
any regular business day and initiated mental healthcare.
    In case number 29, there was a veteran that needed a life-
saving medical device implanted under his skin that would 
immediately shock his heart into a normal rhythm if his heart 
stopped. The community standard would have been to implant this 
device immediately. At the VA, he waited four months and still 
did not have an appointment.
    Unfortunately, the veteran's heart did stop and without the 
device, he had to wait precious minutes for the paramedics to 
arrive to restart it. He was revived, but, unfortunately, the 
family had to withdraw life support three days later.
    The OIG stated that this device might, quote, ``might have 
forestalled death,'' end quote. It's very apparent that it 
would have fore--I'm sorry--it would have forestalled death 
because the implantable device is exactly what's used to treat 
the lethal heart rhythm that he had. He died from complications 
of prolonged heart stoppage without the device that could have 
restarted his heart in seconds. He was denied access to 
specialty care.
    In case 39, a veteran with multiple risk factors for 
suicide came to the ER with intense emotional stressors 
including being homeless. He was put on psychiatric meds to 
stabilize him, but he was discharged back to the streets. He 
committed suicide 24 hours later.
    The community standard would have been to admit this 
unstable veteran. The OIG admitted that it would have been, 
quote, ``a more appropriate management plan,'' end quote, to 
admit this patient, but did not draw a connection between 
inappropriate mental health discharge from an ER and death from 
suicide within 24 hours.
    Case number 31, he died of metastatic prostate cancer that 
was not treated during the seven-month period that the VA 
failed to act on the abnormal lab. While his metastatic 
prostate cancer could not have been cured, earlier detection 
would have started the treatment that would have slowed down 
the progression of the disease significantly and slowed the 
painful spread of cancer to his bones.
    Because of unavailable urology appointment and missed labs, 
this veteran was denied timely access to specialty care that 
would have forestalled his death by months if not longer.
    In case 36, this veteran didn't receive timely, quality 
care for evaluation of unrelenting severe pain that clearly 
served as the impetus for his suicide.
    In case 40, there was a premature discharge from a 
psychiatric ward for an unstable patient with multiple suicide 
risk factors that enabled the death from suicide 48 hours 
later.
    There are many other cases that I reviewed in my written 
testimony. I did not discern a difference between death on the 
electronic waiting list and death waiting for appropriate 
medical care for those who were already in the system. Death is 
death and there is no way to get those veterans back.
    The purpose of my testimony is not to undermine the VA or 
the OIG. The purpose is to get the VA to examine its practices 
and in order to improve the quality of healthcare for veterans. 
They have to repair the cracks in the system so no more 
veterans slip through.
    Thank you very much for your time.

    [The prepared statement of Katherine L. Mitchell appears in 
the Appendix]

    The Chairman. Thank you very much to everybody for your 
testimony.
    Mr. Griffin, in the information you provided to the 
committee or your office has provided, it shows that 28 
veterans died while on the NEAR list or the new enrollee 
appointment request, essentially meaning they died while 
waiting to get their foot in the door at VA.
    And since these veterans were not yet in the VA system, 
your staff briefed us that the OIG used Social Security records 
which only show that the individual had died, not how they 
died; is that correct?
    Mr. Griffin. I would say that we sought a lot of additional 
information from Social Security. We--we sought to find death 
records from the coroner's office. We explored who might have 
been getting treatment under the Medicare program. But as far 
as the specifics on--on those deaths, I would defer to Dr. 
Daigh.
    The Chairman. Dr. Daigh, could you answer that question?
    Dr. Daigh. Sure. The determination of--excuse me--the 
determination of death was by and large made from looking at 
the medical record and the death certificate was--was mostly 
how we were able to identify, A, that a patient clearly had 
died, the record was correct, and by reading both the medical 
record and the, in several cases, the records of their care at 
local hospitals.
    The Chairman. If you are on the NEAR list, is there a 
medical record?
    Dr. Daigh. No. The NEAR list is a--is a tremendous problem. 
Patients on the NEAR list would have tried to enroll to VA and 
may not have ever been seen at VA. So you're absolutely right. 
Anyone that's on the NEAR list that did not make it through the 
wickets at Phoenix to be seen and does not have a medical 
record, I can't look at. So--so those folks I'm not able to 
examine if they don't have a record, I mean, if I have no 
contact with them.
    The Chairman. If that is true, then how can you 
conclusively or otherwise determine whether these deaths were 
related to delays in care?
    Dr. Daigh. Well, in the cases that we identified that we 
were able to actually review----
    The Chairman. Wait. The report says, conclusively says this 
is where we have some problems----
    Dr. Daigh. Right.
    The Chairman [continuing]. Mr. Griffin, is that there were 
people that were looked at in the report and your report says 
conclusively that there is no link to delays in care and death, 
yet there are individuals that you were not able to go back and 
look definitively at their medical record to determine what the 
cause of death was or if there was a delay in care; is that 
correct?
    Dr. Daigh. In the report, we are trying to address the 
patients that we identified who had a delay in care and then 
subsequently received poor quality care as a result of that 
delay.
    The Chairman. But if you were on the NEAR list----
    Dr. Daigh. Correct.
    The Chairman [continuing]. Is that a delay in care? If you 
did not get into the system, is that a delay?
    Dr. Daigh. Yes.
    The Chairman. Okay. Then how can you conclusively say that 
none of the delays were a cause of death?
    Dr. Daigh. Well, we were referring to the universe of 
patients that we were able to look at, so the universe----
    The Chairman. If you didn't look at all of them----
    Dr. Daigh. No. I'm--I'm saying that--that I provided your 
staff with a breakout of----
    The Chairman. Did----
    Dr. Daigh [continuing]. Exactly----
    The Chairman. Did you----
    Dr. Daigh [continuing]. The various----
    The Chairman. I am sorry, Dr. Daigh. Were you able to look 
conclusively at all of those that were on the wait lists?
    Dr. Daigh. I'm only able to look at those--I looked at 
3,000----
    The Chairman. Yes or no, were you able to conclusively look 
at all of the people that were on wait lists?
    Dr. Daigh. No. If--if the NEAR is considered----
    The Chairman. Thank you. That is----
    Dr. Daigh. Yes.
    The Chairman. I want to direct you to an email from Dr. 
Deering found on page 38 of your report regarding a veteran who 
died while waiting for care. And it has already been talked 
about this morning. And in a staff briefing on the 4th, you 
stated that the veteran was seen by a urologist within three 
days of presenting to the ER, so his case was not included in 
the 45 case reviews in the report.
    However, we received notification from the OIG yesterday 
stating that a mistake had been made, that this veteran was 
actually not seen after he was presented at the ER. And after 
informing us of this delay, the OIG still says that this delay 
in care did not contribute to his death.
    Could you explain to me how the OIG came to this 
conclusion?
    Dr. Daigh. So the patient in question has bladder cancer 
and had bladder cancer for many years. He arrived at the VA and 
was seen in the emergency room initially and received a very 
reasonable emergency room evaluation.
    Among his chief complaints were that he had blood in his 
urine. He also had chronic rheum--he had rheumatoid arthritis 
and some other disabilities including amputation of the leg.
    As a result of that visit, his urine was looked at and he 
had microscopic hematuria. He also did need to see a 
rheumatologist, and he did not have a primary care provider. So 
the ER physician asked that this gentleman have several 
consults, a vascular surgery consult, rheumatology consult, and 
a--and a urology consult and a primary care consult.
    The records, and this is the source of the confusion, the 
VA records state that he had an appointment made for urology to 
be held on 10/22/13. It says that the patient called and 
requested a rescheduling of that appointment which was then 
rescheduled for 11/06/13. He no showed for that appointment.
    So in our discussions, some people would say the patient 
had an appointment to see urology and didn't keep his 
appointment.
    The Chairman. But----
    Dr. Daigh. But----
    The Chairman [continuing]. I understand.
    Dr. Daigh. [continuing]. My clarification to the staff 
that----
    The Chairman. Let me ask a question real quick.
    Dr. Daigh. Yes, sir. Yes.
    The Chairman. And I will let you finish. I apologize. 
Nobody here in this room has any faith in any of the 
appointments and scheduling that was going on at that time, so 
I have no belief that what may have been written was, in fact, 
true.
    Dr. Daigh. I understand that.
    The Chairman. So please continue.
    Dr. Daigh. And--and so from--what I'm saying is this 
gentleman then died of what appears to be by image metastatic 
cancer where he had metastasis to his brain and he appeared to 
also, I believe, have cancer in his lung.
    So the assertion that having seen a primary care provider 
in the six or eight weeks between the emergency room visit and 
when he died, I don't believe that that primary care provider 
would have--that visit would have changed his death.
    And I'd refer you to page 75 or 76 of the testimony that we 
provided from the transcript of Dr. Foote.
    The Chairman. If I may, if I may also----
    Dr. Daigh. Yes, sir.
    The Chairman [continuing]. Interrupt, the testimony was 
given to us as the hearing had already started. We hadn't even 
had a chance to look at it. We just got it handed to us----
    Dr. Daigh. Yes, sir. I'm just saying----
    The Chairman [continuing]. In the hallway after the gavel 
dropped.
    Dr. Daigh. Well, sir, I'm just saying that on----
    Mr. Griffin. That was sent up here electronically earlier 
in the day and it was sent up to--to make sure the truth was on 
the record having seen other witnesses' testimony and needing 
to make sure that the committee was fully aware that we had a 
taped transcript of our interview.
    The Chairman. And that----
    Mr. Griffin. And I think people should take a hard look at 
that transcript.
    The Chairman. I appreciate it very much, but your staff 
told us there was a formatting problem getting it to the 
committee and that is why we just got it.
    Mr. Griffin. Are you referring to the transcript of the 
interview of Dr. Foote?
    The Chairman. That is what I am referring to. Any other 
transcripts I need to be aware of?
    Mr. Griffin. No. I believe we sent all the rest of the 
information up 48 hours in advance.
    The Chairman. Let me ask you, Mr. Griffin, Dr. Foote's 
original allegation was up to 40 veterans may, may have died 
while awaiting care at Phoenix. And I think everybody knew that 
he was referring to patients on the electronic wait list and 
the schedule and appointment with primary care consults. So it 
was all conclusive.
    So between those two sources, you have now found 83 
patients, more than double what the original allegation was. So 
I have a couple of questions and then I will turn it over to 
Mr. Michaud.
    But why was that information not included in the executive 
summary that VA, not you, VA leaked early, but you did not find 
room in it to include that we, quote, ``pursued this 
allegation, but the whistleblower did not provide us with a 
list of 40 patient names,'' end quote?
    Mr. Griffin. I believe that you as the chairman received 
the same hotline that we did. It stated that there were 22 who 
had died on the electronic wait list and there were 18 who died 
on the consult list.
    So in our pursuit of finding out what happened here, which 
was an exhaustive pursuit, which is still ongoing as you know 
because of the urology issues that we discovered, the obvious 
first question in our interview with Dr. Foote was give us the 
40 names. We want to go after the records of these 40 people 
and ensure that we don't miss any of these 40 because it was so 
definitive.
    Now, you were very careful in the hearing on April 9th to 
say potentially 40. As--as time passed, it became declarative 
by some that 40 died. Others said there were at least 40. So 
that spawned 800 media reports that 40 veterans died while 
waiting for care in Phoenix. That was the story as of the April 
9th hearing.
    To not address that with the amount of coverage and the 
millions of readers who would have read that would have been 
derelict on our part. So we didn't look at 40. We looked at 
3,409 records to make sure we didn't miss any.
    The Chairman. So it was important that you draw the fact 
that Dr. Foote did not provide you the 40 names? That was very 
important?
    Mr. Griffin. What was important was in the April 9th 
hearing in this room----
    The Chairman. No. I am talking about the final report, not 
the April 9th hearing now. I am talking----
    Mr. Griffin. No, that--that was not--that was not something 
that was inserted in the final report. There were multiple 
drafts which is a very important point that doesn't seem to be 
getting any traction. We were asked to provide the first 
unaltered draft report and that's what we provided. That's the 
first time----
    The Chairman. Let me draw----
    Mr. Griffin [continuing]. In 1,700 reports----
    The Chairman. Let me draw a very clear distinction----
    Mr. Griffin [continuing]. We've been asked for one.
    The Chairman. [continuing]. About what we asked for. Okay? 
Please provide committee with the original draft copy. All 
right? You may have thought that original meant the very 
first--that meant an unaltered copy. And I have an email that 
went to your staff that has original and then in parentheses 
beside it, it says unaltered. In other words, don't adulterate 
it in any way. We want the original draft. Again----
    Mr. Griffin. We received two requests from the committee, 
one from you and one from Chairman Coffman. One of them said 
un--unaltered and the other said something different, but there 
wasn't any confusion that you wanted the very first initial 
draft report----
    The Chairman. Well, let me read----
    Mr. Griffin [continuing]. Which is unknown----
    The Chairman. Sir, let me read this email to you. You have 
gotten a third one that came from the staff director of the 
OIG, the O&I Subcommittee to Joanne Moffett.
    Dear, Joanne, Chairman Miller would like to know if the OIG 
is going to provide the committee with a written copy of the 
original, paren, unaltered draft copy of the Phoenix report as 
first provided to VA. If so, when?
    Mr. Griffin. I guess I don't see what--what the difference 
is. You asked for the first initial draft report and we 
provided it.
    The Chairman. Did you ever indicate to the committee or to 
the staff that there was more than one draft?
    Mr. Griffin. We did not. We provided what the--what the 
committee asked for and we also explained that in the last six 
years, no committee has ever requested a copy of our draft 
report because----
    The Chairman. Well, shame on them, sir.
    Mr. Griffin. No. No. That's----
    The Chairman. Shame on him.
    Mr. Griffin [continuing]. The way it is in the IG 
community.
    The Chairman. Well, I am sorry, but----
    Mr. Griffin. A deliberative process----
    The Chairman [continuing]. Here is the way it works here.
    Mr. Griffin. We're interested----
    The Chairman. We want all of the information. We don't want 
you to use semantics about which copy of the draft we asked 
for. We asked for the draft that you gave to the VA so VA could 
make their determination as to whether or not that draft was 
factual or not. That was the intent. You knew that is what it 
was. Just wait a minute. It is my time, not yours.
    Mr. Griffin. Okay.
    The Chairman. You knew what the request was. What we were 
trying to get is how did that get inserted from the draft to 
the final. And now we have testimony from Dr. Daigh that, in 
fact, they did not conclusively look at all the causes of 
death.
    So I still make the statement, and then I am going to yield 
to Mr. Michaud, and I apologize to the Members, we have all got 
to be honest and open with each other about what is going on 
and whether or not any other committee has ever asked for a 
draft report, shame on them. Whether or not the OIG has ever 
sat at a table with anybody other than people from the OIG 
Office, tough. This committee is going to get the truth about 
all of the facts.
    Mr. Michaud.
    Mr. Griffin. Mr. Michaud, may I respond to that? This is 
the crux of the whole allegation.
    Mr. Michaud. Yes, if the gentleman would want to respond.
    Mr. Griffin. We were asked to provide the initial, because 
you didn't want one that had been through two or three 
iterations. You wanted the very first draft report. That was 
clear to us. You can deny that all you want, but----
    The Chairman. Can you show me anywhere that it says we 
asked for the first draft report?
    Mr. Griffin. I would refer to the attachments to our report 
where all of this is spelled out in writing.
    The Chairman. No. Can you tell me where we asked for the 
first draft report?
    Mr. Griffin. Do you have that email, David?
    Let me find the email and--and I will respond to your 
question. The--the----
    The Chairman. Mr. Michaud, you are now recognized.
    Mr. Griffin. It showed a--a lack of awareness----
    The Chairman. Mr. Michaud is now recognized. You are out of 
order.
    Mr. Griffin. Do you want the truth?
    The Chairman. Sir, you are out of order.
    Mr. Michaud. Mr. Griffin, on the reports, if I understand 
you correctly, you did provide the first draft of the report, 
but there might have been other additional drafts out there?
    Mr. Griffin. That's correct.
    Mr. Michaud. So the draft you provided was the first draft 
that was----
    Mr. Griffin. That was requested.
    Mr. Michaud. Okay. But there was other drafts since the 
first one that came out; is that correct?
    Mr. Griffin. It was a draft. It is a deliberative process. 
In order for us to get concurrence from the department, we have 
to put a draft in front of them. If we had factual errors in 
that draft that they can convince us were factual errors, then 
it would be incumbent upon us to make whatever edits are 
required so that at the end of the process, the report in its 
final issuance speaks the truth on all issues.
    Mr. Michaud. So when the IG does its reporting, you could 
conceivably get some information, whether it is from a 
whistleblower, whether it is from the department, that might 
not be factual and once you get information that you determined 
actually to be factual, that is when you change the report 
before it gets----
    Mr. Griffin. That's correct.
    Mr. Michaud [continuing]. Issued to Congress?
    Mr. Griffin. And then there were some minimal changes. On 
one of the case reviews, we had the blood pressure numbers that 
were taken at two different times were reversed. To me, that is 
not a substantive change. Obviously we had them wrong. When--
when they were reviewed, it was pointed out so we--we put them 
back the way they should have been. But that is not a 
substantive change.
    Mr. Michaud. Okay. You mentioned that Dr. Foote mentioned 
an alleged 40 veterans. Did you ever receive the list of names 
of those that were on that list?
    Mr. Griffin. No. And I would refer you to the transcript of 
our interview which addresses that very clearly. It was even 
suggested that perhaps some of them might have been run over by 
a bus, that he did not know how--what the cause of death was.
    Mr. Michaud. Okay. And he did not give you the definitive--
I haven't read that transcript yet, but----
    Mr. Griffin. No. Understood. And I apologize for it 
arriving late, but it--it does need to be read by everybody who 
has a serious interest in this matter because it was a taped 
transcript of the interview.
    Dr. Foote. Can I respond to that, please?
    Mr. Michaud. No. I still got some other questions.
    My other question is, of the 93 ongoing reviews, how many 
have been closed out and when do you believe that the rest will 
be completed, Mr. Griffin?
    Mr. Griffin. At this point, we have 12 of those that we 
have turned over to the department that I wouldn't say were 
closed because we would anticipate administrative action being 
taken. They're closed from the standpoint of we have completed 
the work that would have addressed the specific allegations 
that we were looking at.
    Now, in the department in their proceedings to make 
determinations concerning administrative action, if they come 
across additional information that was not part of our focus, 
we--we may have to do additional work on those, but we have 
turned over 12 so far.
    The others, they're not being worked with any intent of, 
okay, a week from tomorrow, the other 81 are going to be all 
published. We--we will turn these over to the department, those 
that do not get accepted for any criminal action, we will 
promptly turn those over to the department so they can take 
administrative action.
    Mr. Michaud. Thank you.
    Dr. Mitchell, in your testimony, you mentioned how good the 
Phoenix VA pain management team is, but that they lack the 
staff to supply the services to Phoenix veterans.
    How did the Phoenix VA communicate their staffing needs to 
the director? Was it ever communicated and, if so, what was 
done, if anything?
    Dr. Mitchell. I don't have any direct knowledge of the 
communication between the pain management team and the senior 
administration to get additional staffing.
    What I do have is direct knowledge from many, many 
providers who find their panels filled with patients who are on 
high-dose, long-term narcotics and they need--and the patients 
need additional close monitoring and follow-up.
    What's happening is those providers don't have enough time 
to be able to get those patients in for sufficient appointments 
to be able to review that.
    In addition, in the community, veterans or--I'm sorry--in 
the community, patients that are on long-term narcotics are 
referred to a pain management specialist to titrate the doses, 
provide ongoing education, and monitor for side effects. 
Unfortunately, the staffing at the Phoenix VA does not allow 
for that.
    Mr. Michaud. Okay. Thank you.
    I see my time has run out, Mr. Chairman.
    The Chairman. Mr. Lamborn.
    Mr. Lamborn. Thank you, Mr. Chairman, and thank you for 
having this very important hearing.
    Dr. Mitchell, briefly on page 15 of your written testimony, 
you pulled out case number 35 from the IG report as a special 
circumstance, and please explain why you did so in this 
particular case.
    Dr. Mitchell. I want to make it clear that I did not have 
access to the records that the OIG went through. However, 
anecdotally I was told that this was the same patient which I 
was familiar with and the details are the same with one glaring 
omission.
    In the OIG report, the history starts with the patient 
presented with the ER--to the ER with his family seeking mental 
healthcare. He was evaluated. He declined admission. He was 
discharged home. He committed suicide the next day.
    What was not in the report, and I believe this is the same 
case, if it's not, it should be reported anyway, his parents--
he actually was having problems with depression. He called his 
parents. They brought him to the walk-in mental healthcare 
clinic. However, because he had not been enrolled in the 
Phoenix VA, he was diverted from there to the eligibility and 
enrollment clinic where apparently he waited for hours.
    By the time he got enrolled in the system, he went back to 
mental health clinic and it was too late in the day for them--
for him to be seen. So then he and his family were diverted to 
the ER where, again, they waited for a lengthy amount of time 
before they were seen by a psychiatric nurse to evaluate.
    By that time, the people that were involved said the 
patient was very tired. He wanted to go home. He declined 
discharge. He was subsequently discharged at that point with--
to have follow-up the next day in the same clinic that wouldn't 
see him earlier.
    Mr. Lamborn. Okay. Thank you for that clarification.
    Mr. Griffin, when you shared your draft report with the VA 
before release, did VA propose any changes or ask any questions 
regarding what was in or was not in the report?
    Mr. Griffin. They did. They requested that we remove 
several of the case reviews that appear at the beginning of the 
report. We refused to remove them. They suggested that we flip 
flop the blood pressure numbers that were out of order. Of 
course, we changed that.
    There were--there were two other minor things, one 
involving a date that was inconsequential to the outcome of the 
case review, so we fixed that. There were a couple of verb 
tenses changed and a recommendation that in no way whatsoever 
affected the intent of the recommendation. So those were 
changed.
    None of the case reviews were substantively changed and the 
secretary agreed to implement all 24 of our recommendations.
    Mr. Lamborn. And how often do departments ask for changes 
before they are released to the public?
    Mr. Griffin. I suspect that there has probably never been a 
report where there wasn't some minor change not requested.
    Mr. Lamborn. Well, I want to talk more about the----
    Mr. Griffin. The reason being that they have to implement 
what we have found and what they are concurring with. And so 
they're going to scrutinize those things and make sure that--
that they're in total agreement and they'll also look for those 
minuscule types--types of errors that will make the correct--
the report more accurate.
    Mr. Lamborn. Well, when the language stating that you could 
not conclusively assert that there was a connection, do you 
know who leaked that to the press before the report was made 
public?
    Mr. Griffin. No, I have no idea who leaked that. That--that 
was--that was in the report. The report had a date certain 
for--for being published. It should not have been leaked, but 
the fact is it didn't change anything in the report.
    Mr. Lamborn. Was it someone in your office that leaked it?
    Mr. Griffin. Absolutely not.
    Mr. Lamborn. Okay. And I didn't think so.
    The word conclusively is not a medical term of art as far 
as I know and as a lawyer, I know it is not a legal term of 
art.
    On a scale of one to a hundred, where does that fall on the 
spectrum?
    Mr. Griffin. It's a reflection of the professional judgment 
of our board certified physicians. There have been a number of 
suggestions as to how we should do this. We received one from 
the committee saying we should unequivocally prove that delays 
caused deaths. We received that on April 9th.
    What does unequivocally prove mean? We did a review of the 
quality of care that these 3,409 veterans received. That's what 
we do in all of our healthcare reviews. That's what their 
charter calls for when they were created.
    Mr. Lamborn. But there could be a connection less than 
conclusive.
    Mr. Griffin. I think in some of them, we--we said it might 
have improved the course. But to say definitely that this 
person would not have died if they had gotten in sooner was a 
bridge too far for our clinicians.
    And I'll let Dr. Daigh expand on that.
    Dr. Daigh. The basic problem with this is that it's very 
difficult to know why somebody actually died. I'm not 
clairvoyant. I'd ask you to read also the testimony submitted 
by Dr. Davis where he supported the methodology we used in our 
report. That would be death certificates plus a review of the 
chart.
    In the case that was discussed previously, case 29 where an 
individual died after failing to get an implantable heart 
device quickly, in that report, we said, and I'll read exactly 
what we said, we indicated that--oh, doggone it--we indicated 
that--that he should have--he should have gotten the device 
more timely. He died. I don't know exactly why he died.
    You'd like to think that he died because he had an 
arrhythmia to his heart and that if that device had worked, 
maybe it would have saved his life. But I don't know that 
that's why he died. There are circumstances around the weekend 
of his death that are not included in this report.
    And the reason that he came to our attention is that he was 
on a wait list for endocrine clinic. He wasn't on a wait list 
for cardiology clinic. Secondly, he's not in the group of 
patients initially where we culled those who were on a wait 
list to receive delayed care. He's in the list of patients who 
we said got substandard care, who--who in reviewing these 
cases, we found cases where the care did not meet veterans' 
quality of care.
    So this gentleman was delayed in getting care between 
Phoenix and Tucson. So he's in the part of the draft where I 
think he belongs. I cannot assert why he died and that's why we 
had to----
    Mr. Lamborn. Okay, Doctor, thank you. My time is way over.
    I yield back.
    The Chairman. Mr. Takano.
    Mr. Takano. Thank you, Mr. Chairman.
    Thank you to all the witnesses who are appearing before the 
committee today.
    Mr. Griffin, I did read through much of the material last 
night. I have to say I am trying to understand what the 
controversy is. I understand a charge has been made by the 
majority impugning your integrity. I understand them to mean 
that you were forced to change language or were persuaded to 
change language. I think that is the heart of the allegation.
    Could you help me understand from your point of view what 
is the charge because I think the public needs to understand 
that and what is your response?
    Mr. Griffin. My response is there is a lack of 
understanding of the processing of draft reports. And it's 
understandable because it's the first time anyone has gotten 
one.
    When we send a initial draft report over there, that does 
not mean that my senior staff and others--other members of our 
team aren't continuing to review that document and make sure 
that we've got it correct.
    The fact that it went to the department without that 
statement isn't proof of anything. It's an ongoing process 
until the last day when we sign out that final report. And over 
the course of five different drafts, there were minor changes 
made for purposes of clarity.
    The minute that the draft report came up here and the 
reason that you don't put draft reports out is because they're 
subject to interpretation and they're not final. And shortly 
after the draft came up here, it was reported in the press that 
here is proof that somebody in VA changed that. That's not 
proof. That just means that you don't understand the process.
    And I can show, as I mentioned in my oral, six days before 
the initial draft was released, we were having discussions 
internally that if we don't declare that delay was the cause of 
death, we need to say so. Now, it took a couple more drafts 
before the causality line was included.
    But I would point out on May 15th in a Senate hearing where 
the question of the original 17 names that we received came up, 
I was asked if we had a chance to review those. I said, yes, we 
had reviewed them and that being on a wait list for care does 
not demonstrate causality in a person's death.
    That's three and a half months before this final report. So 
there should have been note taken that it does not demonstrate 
causality that you're waiting. And I think the last statement 
for the record that I would hope everybody will read because 
the witness won't be here, as Dr. Daigh already referred to, 
bears that out and bears out our methodology.
    Someone might ask, well, why--why did you send it over 
there if it wasn't ready, because we have to put it in front of 
the department. We knew the department had 24 recommendations 
that they had to write an acceptable response that convinced us 
that they got it and they were going to fix it. We knew they 
would need time to do that.
    We had made a commitment to the Congress to publish that 
report in August. As a result, we had to--we had to cut off 
some work in order to be about the--the business of writing the 
report. And that's why Dr. Daigh's staff has got 3,526 urology 
patients that will be the subject of a future review.
    Mr. Takano. Dr. Daigh, those 45 or some odd cases that were 
included, I wasn't able to read each in detail and, frankly, 
couldn't understand each one, but they did seem to me evidence 
of poor care, of bad continuity of care.
    You said that those family members are being notified of 
what happened. Those family members can pursue litigation, I 
imagine, and the VA could be found culpable in some of those 
instances; is that right?
    Dr. Daigh. That's correct. So let me--let me offer this 
comment. The--the universe of patients that we set about to 
review in this review were primarily those patients culled from 
wait lists identified by whistleblowers, by our auditors, and 
by our healthcare inspectors.
    So we were looking at people who were on a list and then 
did not get an appointment timely. That's the universe we're 
starting with. And, in fact, some of the cases from the NEAR 
list were part of what we were looking at.
    If you weren't seen at the VA, then I couldn't see--I mean, 
my records don't allow me to take a look at whether you tried 
to get to the VA or didn't try to get to the VA. In our 
methodology section, we lay that out.
    So from those cases, we were looking for people who had a 
delay in care and had a clinical impact on that delay. And--and 
those are the 28 cases that we identify in the front, six of 
whom had died.
    To know why someone died is very difficult. And--and so 
when you get down to an individual commits suicide on a certain 
day after a certain event, you might like to say that event had 
something to do with the suicide or you might like to believe 
that--that but for going to the--the--the psychiatrist or the 
primary care doc, that event wouldn't have occurred.
    But in--in the--in the world where we try to be able to 
prove and have data to support what we're saying, we have a 
hard time going there. So the--the--the--the second group of 
patients we report on are those that we found had a poor 
quality of care.
    The other point I think is important to understand is that 
my charge in law, I think, is to respond to the Congress, to 
the secretary, and to the under secretary of Health and comment 
to them on the quality of medical care the VA provides.
    So what I usually do is we--we look at an issue, and the 
issues are all different, and the question in this one was, we 
took to be, was there a direct relationship between a missed 
appointment and--and death. That's sort of what the media was 
talking about. We--we were forced to address that in some way.
    And so once we determined that there was, in fact, patients 
that were--that had poor quality of care, we then always switch 
to, well, what are the systemic issues at this VA that we can 
address to try to get VA to change their practices to make this 
never happen again.
    When you go to the issue of exactly who committed the tort, 
exactly what did the--did the VA or the patient or the other 
hospital down the street or the nursing home, what exactly did 
they contribute to this death or this poor outcome, that's a 
matter for the courts and that's a matter for VA's internal 
processes.
    So I get to the point of poor quality of care and then I 
always shift and focus on what can I do to work with VA to make 
sure we fix it. So I'll talk about--and--and, again, in the 
last written testimony, I outlined 10 or 12 or 15 reports where 
veterans were injured or harmed and we worked with VA as 
partners to try to get this fixed.
    Mr. Takano. Thank you.
    My time has run out. Thank you, Mr. Chairman, for 
indulging. Thank you.
    The Chairman. Thank you.
    Mr. Bilirakis.
    Dr. Mitchel.l Mr. Chairman.
    Mr. Bilirakis. Thank you, Mr. Chairman.
    A question for Dr. Foote. In your testimony, you indicate 
that there may have been tampering of EWL software and that the 
numbers reported to central office differed from the real 
numbers of veterans waiting.
    How is it that the EWL appointments could be overridden to 
zero out previous appointments and do you believe audit 
controls were deliberately disabled?
    Dr. Foote. Yes. I think there was one of two methodologies 
used. Either they had two lists, one of which was reporting a 
number of 100 or 200, which the IG's graph showed that it was--
it was a small number and not correct, or--and they had a 
second list where they disabled the reporting function or they 
went in and tampered with the re--with the reporting software 
so that it would not give an accurate number of, say, over 200.
    Certainly the IG's data shows that from the inception of 
that list, it never gave the right number. Dr. Deering had said 
that the--the time that's broke out, that the waiting list time 
was 55 days. Well, on the actual non-reporting electronic 
waiting list, there were 14 to 16 hundred and the wait was six 
months. If you threw in the 3,500 that were scattered around on 
the scheduled appointment consults on loose paper, the wait was 
probably more on--on somewhere between one and a half to two 
years.
    But I--I know I reported this to the IG. I've also reported 
this to the--to the FBI. And I know they're taking a look into 
it and hopefully they will be able to find the forensic 
computer evidence to support that claim.
    Mr. Bilirakis. Thank you.
    A question for Mr. Griffin. The language that was included 
in the OIG final report regarding the conclusive case of death 
has no relation at all to any accepted standard of measure in 
medicine.
    As a matter of common sense, if VA doesn't schedule 
appointments early enough to treat a disease, it is highly 
likely that veterans with potentially fatal conditions will 
needlessly suffer from conditions and possibly die.
    The question, does that make sense to you and do you agree 
with that statement?
    Dr. Daigh. So I agree with your statement. The premise is 
that if you--if your care is delayed, then you should be--you--
you are very likely going to be harmed. And--I--when we started 
this review, it seemed to me that that would be what we would 
find over and over and over again.
    And we looked at these cases and we didn't find that, so we 
said, well, why didn't we find that. And I think there are two 
of Dr. Foote's cases in here where, in fact, you know, he can 
go home and say he saved a life. He found a patient that was in 
a waiting list who--or in a pile who had diabetes and another 
one that had critical heart care and he intervened to make sure 
that they lived.
    It's also clear the veterans have access to other emergency 
rooms and other sources of care beyond the VA. So in retrospect 
thinking about this question, I think that people must have 
been extremely diligent at Phoenix where they knew the trains 
didn't run on time to try to make sure that vulnerable people 
got care.
    I can only report the news. This is what I found.
    Mr. Bilirakis. Okay. Let me ask you this. Was this measure 
applied when the OIG report reported that veterans died while 
waiting for care in South Carolina and Georgia?
    Dr. Daigh. We--again, I'll say that I normally go to the 
point where we determine that poor quality of care was 
provided. So the standard----
    Mr. Bilirakis. But can you answer that question?
    Dr. Daigh. I'm sorry?
    Mr. Bilirakis. Was this same measure applied when the OIG 
reported that veterans died while waiting for care in South 
Carolina or Georgia? What is your answer to that question?
    Dr. Daigh. It's--sir, it's usually a fact-based--it's 
usually a fact pattern-based decision on--on exactly what 
happened. I'm not sure exactly report--which report you're 
referring to. But, sir, it's usually--on each report, it's 
usually a different fact pattern. If we--if we determine that 
poor quality of care was provided, then we try to look at 
systemic issues and try to get VA to do the right thing with 
respect to quality of care.
    Mr. Bilirakis. So the report discussing the delay in 
colonoscopies and those----
    Dr. Daigh. Oh, the Columbia? Okay. Yes, sir.
    Mr. Bilirakis. Can you answer that question? Was the same 
standard applied----
    Dr. Daigh. In--in the Columbia case, it was our----
    Mr. Bilirakis [continuing]. In the report?
    Dr. Daigh. I--I don't think the--I--I can't-- the--the--the 
same standard wasn't applied because the fact pattern was 
entirely different. In Columbia, VA had found that they had 
delayed colonoscopies in a large population of veterans and as 
a result, as you would expect, a large number of veterans 
developed colon cancer that probably would have been prevented 
had the colonoscopy be--had been done. And VA admitted that 
some of those patients had died and VA had already undertaken 
the process to notify those patients.
    What my report was looking at was why did this happen, how 
is this possible. And what we determined was that VA does not 
have a way to ensure that nurses in--in clinics that need--if a 
nurse leaves a clinic and that job is critical to the 
performance of that clinic, refilling that position is given to 
a board within the hospital where administrators decide whether 
or not they're going to fill the nurse position or a teaching 
position or a research position.
    So, again, we focused on what can VA do to make sure this 
doesn't happen. And so, yes, the same standard wasn't applied 
because the fact patterns were quite different.
    Mr. Bilirakis. All right. Thank you.
    Thank you, Mr. Chairman. I yield back.
    The Clerk. Mr. Chairman, if----
    The Chairman. I apologize. We have had a vote called and I 
would like Ms. Titus to have an opportunity to ask her 
questions before we recess to go to the vote.
    Ms. Titus, you are recognized.
    Ms. Titus. Thank you, Mr. Chairman.
    Mr. Griffin, like has been mentioned before and many of my 
colleagues, I am eagerly awaiting the results of the 
investigations at the other VHA facilities.
    Southern Nevada is home to the newest VA hospital and many 
people think it is the best. It is state of the art. And we 
also have a large medical system there.
    Now, I have been asked by a number of my constituents are 
the same problems happening here as in Phoenix because once you 
hear something like that, then, of course, it makes you worry 
and begin to think that there are problems.
    I have talked to Isabel Duff once a week practically to be 
reassured that they aren't, but still I want to encourage you 
to finish up because not only do we want to solve any problems 
you might find, but I think that is a big part of restoring 
trust in the VA is to get that done and move on with it.
    Also, you put forth 24 recommendations and as I look at 
them, I think there are 11 that relate specifically to Phoenix 
which that is important, but the rest of them look at the 
systemic problems.
    Now, you have given those to the VA, said you recommend 
that they do this. This is a big dose, a large order that you 
are calling for.
    Are you confident that the VA has the facilities, the 
means, the intent, the ability to carry out those 
recommendations and solve these problems so this does not 
happen again?
    Mr. Griffin. I would agree with your assessment that at 
present, they don't have the facilities. I think VA would be 
the first to admit that they need additional clinical space. 
They need additional clinicians. They need a new scheduling 
process. They need a methodology by which they can remotely 
monitor what wait times are in Las Vegas or any--any other 
place in the country where they have a medical center.
    I think they're aware of all those things and I believe the 
new secretary and--and his team that he's assembling are--are 
dead serious about addressing those things. We do follow-up on 
our 
recommendations. We have suspense dates for when things are 
supposed to be completed and we certainly will follow-up very 
aggressively on these 24 recommendations.
    And we also have already had some initial internal 
discussions about how we might scope a future project to go out 
and verify that, in fact, everything is working according to 
the plan.
    Ms. Titus. That is good. You don't want to make 
recommendations that just sit on the shelf----
    Mr. Griffin. No.
    Ms. Titus [continuing]. Just for the sake of it.
    Mr. Griffin. We--we follow-up on those on a quarterly 
basis.
    Ms. Titus. I share your enthusiasm for the new secretary 
and I believe he is committed to both changing the attitude of 
the VA and making these specific reforms.
    Do you think the bill that we just passed, the compromise 
bill, will be useful in addressing some of these 24 
recommendations?
    Mr. Griffin. I'm afraid I'm not totally versed on the bill. 
I know there have been a number of legislative changes made in 
order to assist the department in accomplishing their mission. 
But I'd like to take that for the record, if I may.
    Ms. Titus. All right. Thank you.
    Mr. Griffin. Thank you.
    Ms. Titus. I will yield back, Mr. Chairman.
    The Chairman. Thank you very much.
    Members, we do need to pause. I apologize to the witnesses. 
We think it may be about 30 minutes for us to go and do that. 
We will give you a heads up when we are going to start back.
    And this hearing is in recess until immediately following 
the third vote.
    [Recess.]
    The Chairman. Thank you, everybody, for rejoining us. 
Again, I apologize for the delay.
    Mr. Griffin, I would ask a couple of things. We have got 
other Members that are coming back. You asked that we put Dr. 
Foote's testimony from his deposition into the record. We did 
so without unanimous consent. We have not had an opportunity to 
review it. I see where you have done some redactions.
    We have made an agreement that we would like to not enter 
it into the record until we have had an opportunity in a 
bipartisan way to look at any other information that may need 
to be redacted. I don't mind even sharing it back with you, so 
that we are not putting something into the record that could 
release personally identifiable information or illnesses or 
diseases or anything of that nature.
    Is that okay with you?
    Mr. Griffin. That's fine. The--the redactions that you see 
are ones that were done by our privacy officer to make sure 
that--that we didn't have any names in there that should not 
have been there, but better to--to double check. That's fine.
    The Chairman. Yeah. Because we hadn't had a chance to look 
at it prior to introducing it into the record, we have agreed 
in a bipartisan fashion, both of counsels have come together 
and said we will agree to the redactions and don't mind at all 
sharing it back with you.
    Well, now that Ms. Kirkpatrick has returned, I would like 
to go ahead and yield the floor to you for your questions. So, 
Ms. Kirkpatrick, you are recognized.
    Ms. Kirkpatrick. Thank you, Mr. Chairman.
    You know, Dr. Daigh, you brought up an interesting point 
and that is that there is a criminal process and there is a 
civil process if, in fact, causation is found because of deaths 
as a result of the wait times.
    And is it your understanding that there is now currently an 
ongoing criminal investigation by the Arizona attorney general, 
the FBI, and the Department of Justice?
    Mr. Griffin. There is an ongoing criminal investigation but 
doesn't----
    Ms. Kirkpatrick. To your----
    Mr. Griffin. It involves the criminal investigators from 
the IG's Office. It involves the FBI. It involves the U.S. 
Attorney's Office in Phoenix.
    Ms. Kirkpatrick. So there is a process if in case causation 
is found?
    Mr. Griffin. Absolutely.
    Ms. Kirkpatrick. And to your----
    Mr. Griffin. If criminal behavior is--is determined to have 
occurred.
    Ms. Kirkpatrick. Yes.
    Mr. Griffin. Right.
    Ms. Kirkpatrick. And to your knowledge, you mentioned the 
Federal Tort Claims Act, are you aware of any cases that have 
been filed under the Federal Tort Claims Act as a result of 
deaths because of wait times?
    Mr. Griffin. I'm not aware of any, but that--that doesn't 
mean that there might not have been one. We checked on the 45 
case reviews and we didn't find any filed on any of those 45.
    Ms. Kirkpatrick. Thank you.
    Dr. Foote and Dr. Mitchell, I want to thank you for being 
here and for coming forward.
    And I have expressed to you in the past that I appreciate 
your courage because all of us on this committee really are 
united with you in our care for veterans and making sure that 
they get the medical care and access to that care that they 
really care about.
    And that is why I introduced the Whistleblower Protection 
Act. I wish that had been in place for you, but hopefully that 
will make things better for future whistleblowers. And part of 
that is a national hotline that patients and workers within the 
VA system can call and that information would go directly to 
the secretary in hopes that there wouldn't be any kind of 
retaliation.
    But as I mentioned, this committee really is committed to 
access to care for our veterans. And, as you know, there was a 
bipartisan, bicameral Conference Committee that was appointed 
in the summer. We met together and we passed the Veterans 
Access, Choice, and Accountability Act of 2014.
    And one of the primary pieces of that is a new choice card 
that will allow veterans who live more than 40 miles from a VA 
facility or have had to wait more than 30 days to schedule an 
appointment to actually go to a local provider.
    And, Dr. Mitchell, I was concerned when you said that you 
didn't know if some of these people who were on the wait list 
knew that they had a choice to go to an outside provider.
    Do you think the use of a choice card, which is going to go 
out in November to our veterans, giving them that option will 
help improve that?
    Dr. Mitchell. Thank you.
    To clarify what I said, they had the option of walking into 
a VA primary care clinic to get care. At this point, if they 
were not enrolled in the VA, the VA would not pay for their 
care anywhere else. I think the idea of getting care access is 
wonderful.
    What the IG said earlier was that, well, the veterans had a 
choice. They could go to an ER, a hospital, or a private 
doctor. They don't have a choice. Many Americans don't have 
insurance. If they get sick, they opt not to go to a physician. 
I don't know about the other members here, but, frankly, I 
would have a hard time paying for the cost of hospitalization 
or ER visit.
    Many veterans will let their chronic diseases get worse. As 
evidenced in two cases, they kept going to the ER because that 
was the only way to get their severely worsening symptoms taken 
care of. That's the equivalent of only putting out the fire but 
never doing anything to prevent the fire from starting.
    Ms. Kirkpatrick. Well, I appreciate that. And our hope is 
that with the choice card that will make a difference, 
especially the veterans in my rural area who many of them are 
40 miles away from a facility. They will be able to go directly 
to a local community.
    And as you know, I have 12 tribes and 25 percent of my 
district is Native American. They will be able to go to their 
local Indian health services facility to get their veterans' 
care. So a huge piece of the reform act was encouraging a 
partnership between the VA and the Indian health services.
    So, again, I thank you for your testimony, for helping to 
guide this committee to do some meaningful reform. And we will 
keep an eye on it.
    I yield back my time.
    The Chairman. Thank you very much.
    Mr. Coffman.
    Mr. Coffman. Thank you, Mr. Chairman.
    Mr. Griffin, will you provide us with all emails, draft 
discussions, and comments provided by VA with regard to this 
report?
    Mr. Griffin. I can provide the IG emails. They will be 
reviewed by our privacy officer to make sure no one's identity 
is, you know, left in there that shouldn't be and we'll provide 
them.
    Mr. Coffman. Mr. Griffin, as you are aware, the Department 
of Justice has already declined to prosecute 17 cases of 
possible criminal violations by VA employees that your office 
has referred to them.
    What are some of the reasons the Department of Justice has 
provided for not wanting to prosecute?
    Mr. Griffin. Some of the reasons include that there--it was 
not determined that criminal behavior occurred. In some of the 
cases, they had more rigorous prosecutive standards for the 
cases that would rise to the level of getting prosecution as 
opposed to administrative action. In some of them, the fact 
that someone manipulated the data, but there wasn't proof of a 
death as a result caused them not to prosecute.
    Some of them said this has been a systemic problem in the 
department for a number of years that has been allowed to 
perpetuate itself and the ability to demonstrate that someone 
knowingly and willingly committed a criminal offense was too 
difficult.
    Mr. Coffman. Were you surprised at that? Were you surprised 
at their response?
    Mr. Griffin. Well, I think that we work with these 
prosecutors every day.
    Mr. Coffman. Yes.
    Mr. Griffin. Last year, we arrested over 500 individuals. 
We arrested 94 employees last year. So we're aware that they 
can't prosecute every case that they get. And, frankly, our 
investigators would like every case that they investigate to be 
prosecuted, but that's not the real world based on--on the 
demands on the Department of Justice and the court system, et 
cetera. So determinations are made by the Department of Justice 
in that respect and--and we have to live them.
    Mr. Coffman. And let me just say I passed an amendment on 
an appropriations bill to put more money into the line item for 
the Department of Justice for the specific purpose of 
prosecuting these cases.
    Don't you think, though, when you talk about systemic that 
there was a culture of corruption and maybe the fact that it 
was a culture of corruption versus an individual case, then I 
guess it was okay?
    But let me ask you this then. But when somebody does 
something, manipulates records for the purpose of financial 
gain, isn't that a criminal offense of itself? Shouldn't there 
be an example set by somebody being prosecuted somewhere in the 
system?
    Mr. Griffin. I agree. And I am not saying there will not 
be, either. There have not been any at this point. You would 
expect that the cases with the least amount of evidence and the 
last amount of manipulation, if you will, or co-conspiracy 
would be the ones that would be set aside earliest. Because the 
additional cases will require more work. We are working 
feverishly on those cases because we know it is important to 
get through all 93 of them. And as we finish them if there will 
not be criminal prosecution I know the department is anxious to 
get those reports so they can take appropriate administrative 
action.
    Mr. Coffman. And Dr. Foote and Dr. Mitchell, I just have a 
tiny bit of time left. Tell me, are you surprised that there 
were not criminal prosecutions, Dr. Foote?
    Dr. Foote. Not at this point because I think the FBI is 
still investigating.
    Mr. Coffman. Okay. Dr. Mitchell?
    Dr. Mitchell. I am not surprised because there is still 
retaliation against whistleblowers. There would be no reason to 
prosecute the people who are perpetrating it.
    Mr. Coffman. And Mr. Griffin, it does seem like the 
Department of Justice is looking the other way because 
obviously this situation is embarrassing to the administration. 
With that, Mr. Chairman, I yield back.
    The Chairman. Thank you. Mr. Walz, you are recognized.
    Mr. Walz. Well, thank you, Mr. Chairman. I want to thank 
all of you for your work towards veterans and that is what we 
are here to get. The situation in Phoenix and elsewhere that 
provided even one veteran substandard care is simply 
unacceptable. And I would like to go back, I have a long 
history with the OIG's Office. I know as someone myself, I 
counted in my unit heavily on the IG to provide another set of 
eyes to provide that unvarnished view of what was going on. So 
let us be very clear, what is being implied is that the 
integrity of this office was influenced by the VA. So I am 
going to ask very clearly, Mr. Griffin. Did anyone at the VA 
ask you to change the report to make it look better in their 
stead?
    Mr. Griffin. No.
    Mr. Walz. Is it normal standard operating procedure for 
multiple drafts of a report to be done?
    Mr. Griffin. It is, especially a report of 170 pages with 
24 recommendations.
    Mr. Walz. Has there been a case before where your 
methodology has been questioned to the point where you were 
called in front of Congress to defend the methodology, not the 
results of the report?
    Mr. Griffin. No.
    Mr. Walz. This is the first time?
    Mr. Griffin. That is correct.
    Mr. Walz. And is it your understanding and again to get it, 
that it is predicated on the interpretation if you were asked 
for the original draft?
    Mr. Griffin. That is correct.
    Mr. Walz. Okay. With that being said, I want to be very 
clear. The report you issued is very damning to the VA.
    Mr. Griffin. It is.
    Mr. Walz. And there are many things that they fell down on. 
And the Department of Justice, and making sure that Dr. Foote 
and Dr. Mitchell and everyone else who is willing to correct 
things, there has to be a route and an avenue that people are 
made whole and that people are held accountable. And from my 
understanding, that is in the process. That the FBI and the 
Department of Justice are looking at it. Is that correct, Dr. 
Griffin?
    Mr. Griffin. The investigation is ongoing in Phoenix and 
other places. But we also in our very first recommendation in 
that report referred the name of the 45 veterans in our case 
reviews to the department for them to conduct appropriate 
reviews to determine if there was medical negligence and if 
there ought to be redress to the veteran or his family----
    Mr. Walz. Does----
    Mr. Griffin [continuing]. For receiving poor care.
    Mr. Walz. Does the VA OIG prosecute cases?
    Mr. Griffin. We investigate cases. We take them to the 
prosecutors in DoJ, or in some instances in state court if we 
cannot get traction on a federal violation.
    Mr. Walz. Okay. Does this report and the way it was handled 
strike you, Mr. Griffin, and if I am right how long have you 
been with the OIG?
    Mr. Griffin. About thirteen and a half years total.
    Mr. Walz. How many investigations have you been a part of 
roughly?
    Mr. Griffin. Well we have done about 520 arrests every year 
for the last six years. I, that is a number that is handy to 
me. But that is about an average year for us.
    Mr. Walz. And the methodology, the folks who work for you, 
your investigators and how you wrote the report, is there 
anything strikingly different about this one than any of those 
previous ones you have done?
    Mr. Griffin. This was a very large undertaking and it was a 
combination of our criminal investigators, who are the same job 
series as FBI agents, Secret Service agents, etcetera. But it 
was a joint project where Dr. Daigh's people had ownership of 
the medical care and the case reviews. Linda Halliday's staff, 
the audit staff, had the responsibility to try and identify all 
of these people who were not on an electronic wait list through 
a number of different sources. So her staff did that. So to try 
and pull the three different disciplines together and get 
everybody on the same page as far as what makes sense, I mean, 
there might be some language that makes sense to David that 
might not make sense to----
    Mr. Walz. Because, and I would argue that it makes sense to 
Dr. Foote and Dr. Mitchell.
    Mr. Griffin. Sure.
    Mr. Walz. That is coming out. Because there is still 
obviously the belief that we have not gotten to the bottom of 
this. That we have not gotten everything that has been done, or 
there has not been held accountability. With that being said I 
want to use my remaining time that that will still be 
investigated. My immediate concern right now is on those 24 
recommendations. Do you feel in your professional judgment are 
they moving in the proper direction? Because you have had 
people come here and testify before that VA did not implement 
your recommendations and you had to come back again. Do you 
feel at this point, and I know it is early----
    Mr. Griffin. It is early. It is less than a month since the 
final report was issued. But I can tell you this. A lot of the 
wait times issues were previously identified in our interim 
report.
    Mr. Walz. Correct.
    Mr. Griffin. And I know that the department started 
addressing those immediately. In the updated report when we 
identified an additional 1,800 veterans that were not on a list 
that were in a drawer or were just not properly being managed, 
we immediately gave those 1,800 names to the people in Phoenix 
so they could make sure those veterans who had not gotten care 
got it as quickly as possible.
    Mr. Walz. Can I ask one final quick one? Just a yes or no 
from each of you. And I know this is very subjective but you 
are at the heart of this matter and you have a better insight 
than anyone. Does it feel like cultural changes are beginning 
to change to hold accountability, in your opinion?
    Mr. Griffin. I think the change will come as we complete 
more investigations and people realize that there is a price to 
be paid.
    Mr. Walz. Dr. Foote and Dr. Mitchell?
    Dr. Foote. I would say asking for my testimony to be made 
public, I would not agree with that statement. I would say no.
    Mr. Walz. Okay.
    Dr. Mitchell. I would say no. There is lots of 
investigations but there has been no substantive change.
    Mr. Walz. Very good. I yield back. Thank you, Chairman.
    The Chairman. Thank you very much. Ms. Walorski?
    Mrs. Walorski. Thank you, Mr. Chairman. Dr. Daigh, you had 
said earlier today I believe to Chairman Miller that you did 
not conclusively examine all the medical records to determine 
if patient deaths were related to delays in care. Yet in the 
report your colleagues released it said, ``The IG's final 
report in August concluded that it could not conclusively 
assert that long wait times caused the deaths of these 
veterans.'' Can you explain to me and to the families who are 
watching today who have been going through this, especially if 
they have lost loved ones, how can the VA emphatically say to 
us that you can determine no link between wait times and deaths 
if you did not examine all the records? Dr. *Daigh.* So let me 
clarify. We examined 3,409, 3,409 records. To the chairman's 
point, we did not examine all the records of patients on the 
near list, that would be people who said they wanted care at 
VA, if they never actually made it through the maze and got an 
appointment. So if there was no record for me to review, given 
that the electronic medical record was our main source, then I 
could not review those cases.
    All of the cases that we were able to review came from a 
whole variety of lists, most of which had to do with waiting 
lists that we found at Phoenix. So in those cases we did I 
think very thoroughly review those cases. And in those cases 
where we determined that there was harm, the delayed care 
caused harm, we published those. And in those cases where we 
found improper care, we published those. So we have 28 cases 
that we thought people were on a waiting list and as a result 
of being on a waiting list, they were harmed. We have an 
additional 17 cases where we thought the standard of care was 
not met, that, and so we published those cases.
    I think that I have, I am not trying to say to people who 
could not get there, who through frustration could not make it 
through the barriers, I am not trying to excuse anything at the 
VA. I am only trying to answer a fact. On these people, on the 
cases we looked at, did we see a significant impact on their 
care because they were on a waiting list? And that is, that is 
what we found and that is what we published.
    I further say that I do not believe that our review 
necessarily needs to be determinative. In the sense that I put 
the scenarios out there hoping the citizens would read these 
cases and would understand the complexity that these veterans 
present, and understand the difficulty that they have, 
understand the fragility of these cases. So that when they do 
not get care in a timely fashion, horrible things are likely to 
happen. And each person then can read these cases and they can 
decide whether a person who might have unfortunately committed 
suicide, do they think that was related to timeliness? They can 
make their own decision on that point. So I offered the opinion 
of my office, which has the ability to see lots of data that is 
not in these summaries intentionally. A lot of the data is 
unnecessary for the basic fact pattern. These families have a 
right to privacy, so we try to be very careful about what we 
decide to publish with respect to facts to a case. So to the 
issue that people would like more data about these cases, I 
understand it. But I think, I think that the VA needs to ensure 
that veterans have access to care that is done appropriately, 
that the trains run on time, and in that way the VA can deliver 
proper care.
    Mrs. Walorski. I am just curious. If you had a chance to go 
back and reinvestigate these cases and the procedure, would you 
do it differently today?
    Dr. Daigh. No, I, I would not. I think the way we did it is 
the way we have done this for many, many years. I think it is 
over thorough and I think it produces a fair result. What I 
would wish we had, which I wish we had not been tied to was 
this issue of timeliness. Trying to explain the impact of being 
on a wait list with quality care, that is, I mean, that is a 
totally made up standard based on the circumstances of the 
complaint at this case. If I could have picked something 
different to look at we would have thoughtfully come up with a 
different test. But that is the test we were presented with and 
so that is the test we had to try to address.
    Mrs. Walorski. Thank you. Thank you, Mr. Chairman. I yield 
back.
    The Chairman. Thank you very much. Ms. Brownley.
    Ms. Brownley. Thank you, Mr. Chairman. Mr. Griffin, is, do 
you know if there is a parallel FBI investigation going on at 
this particular?
    Mr. Griffin. There is a joint investigation involving my 
people and the FBI.
    Ms. Brownley. Investigating the same issues? Asking the 
same questions?
    Mr. Griffin. They are doing it together. If there is an 
interview happening there is an FBI presence and there is an 
OIG criminal investigator present.
    Ms. Brownley. Thank you. And Mr. Griffin, you in your 
answering a member's question when, related to the closing out 
of 12 cases and still 93 ongoing, you mentioned something about 
they were closed out because they met the criteria and the, the 
questions were answered. But you talked about additional 
information that was not necessarily related that you have 
culled together. Can you talk a little bit about the additional 
information? Is there something, can you give me some examples, 
and is there something----
    Mr. Griffin. Let me clarify that point for you. When we did 
some of our 93 investigations, the 12 that we have given to the 
department, we, we did not do a Phoenix level review of every 
one of those facilities. That would take ten years. What we did 
look at is where we received allegations, either through our 
hotline or from any number of other sources of a specific 
infraction going on there. And in some instances with more 
specific language than others. Okay? So we investigate those. 
If it, if the result does not rise to the level of the U.S. 
Attorney's Office in that district to approve criminal 
prosecution, that investigative package within the scope of the 
review that was done is given to the department. It is 
incumbent upon the department, it is their job to review that 
information and say, okay, maybe someone decided this does not 
rise to the level of criminal prosecution, however we think 
disciplinary action, which can range from counseling to firing, 
needs to be taken in this case.
    So in order to prove that, which they will have to do, they 
will look at the piece of the investigation we did. They may 
determine that they need to go interview somebody else for 
whatever reason to support their administrative action. And if 
that were to result in some new information that we were not 
aware of, it could cause us to reopen our investigation. But it 
is, it is up to the department to take those administrative 
actions. That is why when there is no criminal prosecution 
forthcoming on a specific case we hand over our reports and 
transcripts, etcetera, to the VA and they can take 
administrative action based on those in large measure.
    Ms. Brownley. So there is not additional information or a 
list of additional information that was uncovered that has 
not----
    Mr. Griffin. No, we----
    Ms. Brownley [continuing]. Or will be investigated?
    Mr. Griffin. Not during our investigation. I am just saying 
that if, if in putting together their review for purposes of 
administrative action, if somehow they come up with some 
information that was not----
    Ms. Brownley. They being the department?
    Mr. Griffin. They the department, who have to propose the 
action whether it be removal or something less than that. It 
could cause us to say we are going to go back and look into 
this further. But that is just the way the process is.
    Ms. Brownley. I wanted to follow up I think on Ms. Titus' 
questioning and just ask, you know, very, very specifically if 
you believe that there are adequate resources to continue and 
to complete the ongoing investigations at the remaining sites?
    Mr. Griffin. I think that some of those investigations are 
of much more narrow scope than the magnitude of the review we 
are doing in Phoenix. We are progressing on the remaining 81. 
Every week there is another handful that we are able to bring 
to closure. So, you know, the answer is yes. We have the 
resources. But I must say that this is not the only 
investigation that our people are involved with. Since January 
the number of threat cases that have come to us on VA 
facilities, the number of assault cases. We have made 86 drug 
arrests since January 1. So some of these matters that are 
already in the prosecutive mode, I mean we prosecuted a medical 
center director for 64 counts of corruption. And we certainly 
could not drop that case in order to, you know, take on a new 
case when it is going through the judicial process.
    Ms. Brownley. Thank you, and I yield back.
    The Chairman. Dr. Daigh, there were 293 deaths, is that 
correct?
    Dr. Daigh. There were 293 deaths that we reviewed, that is 
correct.
    The Chairman. How many of those were cross referenced with 
medical documents?
    Dr. Daigh. All of them.
    The Chairman. No, I think there were 28 that were on the 
near list that you, I am, I am trying, again, I am honestly 
trying to learn, Mr. Griffin. And you have educated at least me 
as the chairman today on some things. I am, you, Dr. Daigh, you 
said because they were on the near list they were not in the 
system so there was no medical record for you to review and you 
were not able to do that. So you----
    Dr. Daigh. So let me, let me please clarify. The near list 
included a large number of patients. Of the patients that we 
reviewed from the near list we would not be able to review a 
patient if we did not have a medical record. So if you were on 
the near list, we do not have a record, then we excluded you 
from the review. So in our methodology section, we can only 
look at cases that actually come to the VA.
    The Chairman. And, and I understand.
    Dr. Daigh. Yes.
    The Chairman. But how can you, and I keep going back to 
this, how can you say you conclusively were able to say these 
individuals did not get timely care? They are now dead.
    Dr. Daigh. I am talking about the cases that we were able 
to review.
    The Chairman. I understand that. But there were cases that 
you have just said that you cannot review and I, that is, all I 
am trying to figure out is there are cases that were part of 
this investigation that you apparently could not review them 
because there was no medical record for you to look at. And so 
my question is, again, of the 293 deaths, did every one of them 
get cross referenced with some type of medical record?
    Dr. Daigh. So the total number of people on the near list 
is a big number. The total----
    The Chairman. [continuing]. I am sorry, the 293 deaths----
    Dr. Daigh. Yes, but what I am trying, what I am trying, I 
am just trying to be clear, sir.
    The Chairman. Okay.
    Dr. Daigh. The 293 deaths were all among patients, from 
whatever list they were on, that had a medical record that we 
could review. So I am going to agree with you. There would be 
people who would be on a near list, who did not have a medical 
record, who we could not review. And therefore they were not 
part of the chart because it is not possible for me to review 
them. So all of the deaths, there were 293, we reviewed 
intensively.
    Now the 293 number is a data point. The 293 number is from 
the 3,409 patients, 293 were dead. But that number is a number 
that has limited meaning in the sense that we, it is drawn from 
a population that you do not know the disease burden of. And so 
I cannot tell you whether 293 is too high or too low. Because 
the reason for death could be normal, normal causes.
    The Chairman. I understand. I apologize, but I am still 
trying to find out. Because in a staff briefing staff was told 
that in some instances all that could be done was a match of 
social security numbers, then looking at a death list. And so 
there was no way for some of those individuals to be cross-
referenced with a medical record. That is correct, is it not?
    Dr. Daigh. No, I think that that would be a 
misunderstanding of what was said. We, I would not purport to 
comment on cases that we had not been able to review the record 
for. That----
    The Chairman. But they were on the lists, correct?
    Dr. Daigh. Well so in, again, in our methodology section we 
said we excluded--so I realize we are all talking subtleties 
here and I am not, I am really trying to be clear. I cannot 
report on cases who I have no information of. So----
    The Chairman. And that, and I concur. And I think that is 
where the crossed wires are coming from. Because it is very 
hard for me to accept a statement in a document, as we have 
been discussing, if you have not been able to look at every 
single medical record, and thank you very much for clarifying 
that.
    Mr. Huelskamp.
    Dr. Huelskamp. Thank you, Mr. Chairman. I appreciate that 
line of questions because I was also, still am confused of 
where you were able to identify the, excuse me, 3,409 veterans, 
those were the number of the cases that you reviewed?
    Dr. Daigh. Yes, sir.
    Dr. Huelskamp. And you had medical records for all those 
cases?
    Dr. Daigh. Yes, sir.
    Dr. Huelskamp. Okay. But in pages 34 and on in the report 
you identify numerous other categories of veterans that would 
total well over 9,000 that are on, either not on electronic 
waiting lists, or on the electronic waiting list, or on the 
near list, or 600 printouts, or schedule and appointment 
consults, a backlog redistribution. How did you decide the 
9,121 gets reduced to 3,409?
    Dr. Daigh. Well the report talks about in Phoenix there 
were many lists. And the report talks about lists from 
different sources and different points in time. So if you are 
talking about cases that were part of the Appendix, which were 
the VA, were VA's cleanup action, those cases were not part of 
the, most, by, by, by, by most, most of those cases were not 
part of----
    Dr. Huelskamp. But excuse me, my, this is, I do not believe 
it is in the Appendix. It is page 34, question two identifies 
again 9,121 veterans. And again, they may not be cumulative. My 
question is how did you decide not to look at 5,600-and-some 
cases of veterans, you decided not to review their case?
    Dr. Daigh. Well we looked at those lists that were 
collected during the time frame of when we started our review 
up until about June 1. And I would, I would have to go through 
and work through the data set we have of the, of the actually 
3,562 names on a list, which distilled to 3,409 uniques, 
individuals, of which 293 had died and of which 743 had a 
physician review them. So I would have----
    Dr. Huelskamp. If they were on the electronic waiting list 
did you look at them and review their cases or not?
    Dr. Daigh. We did. So everywhere, everybody that we were 
able to determine was on any of these waiting lists of any 
variety described in this report----
    Dr. Huelskamp. But I just gave you another 5,600 that you 
put in the report. I am trying to figure out why you did not 
look at, say, the, those on the near list had 3,500. Did you 
not look at any on the near list?
    Dr. Daigh. If you were on the near list and you asked for 
veteran, to get into the VA system, but you did not ever, you 
never made it through the wickets and you never got care, you 
would not----
    Dr. Huelskamp. So if you died waiting for care because 
there was a failure in the system they do not show up in your 
data as a death because of the system?
    Dr. Daigh. That is, that is correct. They----
    Dr. Huelskamp. Wow.
    Dr. Daigh [continuing]. Would not have showed up----
    Dr. Huelskamp. Is that not the crux of the problem? 
Thousands and thousands and thousands of veterans are waiting 
for care and your report says, well, we do not count them 
because they died before we got their records. And we are not 
going to go back and look at other sources.
    Dr. Daigh. I----
    Dr. Huelskamp. That is what I am trying to figure out. 
Because you winnow it down to 9,121, and they may not all be 
uniques. And it is pretty unclear to me, and perhaps the rest 
of the committee, maybe they get that. If you could provide 
some information to the committee as a follow up of how you 
decided to exclude the 5,600. And that would be helpful as 
well. And I want to ask you one other question as well, Mr. 
Chairman. Mr. Griffin, the day before you released your final 
report to Congress a number of news outlets were carrying 
reports with headlines, because I know you look closely at 
headlines, you have counted all the news stories, and some of 
the headlines says, ``No proof that delays caused patient 
deaths,'' ``No links found between deaths and veterans care 
delays,'' and ``No deaths related to long waits.'' Do you think 
these are accurate? Or are they misleading headlines?
    Mr. Griffin. I have seen plenty of misleading headlines in 
the last two weeks. Some of them directed at my organization.
    Dr. Huelskamp. But the ones I read to you, Mr. Griffin.
    Mr. Griffin. Okay.
    Dr. Huelskamp. The ones I read to you, are they misleading?
    Mr. Griffin. The ones, no. But that is part of the story 
here. If someone leaks something before the scheduled release 
date of our report, and if it quoted our report, it should not 
have been leaked but that does not mean it is not true.
    Dr. Huelskamp. Have you ever seen a leak before? So is that 
report headline, is that misleading?
    Mr. Griffin. Could I, could you read it to me again?
    Dr. Huelskamp. Yeah, absolutely. And I am sure you have 
seen it before. ``No deaths related to long waits.'' No deaths. 
Is that misleading?
    Mr. Griffin. That is an accurate representation of our 
conclusion, that we could not----
    Dr. Huelskamp. No deaths?
    Mr. Griffin [continuing]. We could not assert a cause of 
death being associated with the waiting times.
    Dr. Huelskamp. How about no link?
    Mr. Griffin. Those are not my words, I, you know.
    Dr. Huelskamp. But I am asking you for your thought on 
them. Because you were very worried about 800 headlines that 
you looked very closely at.
    Mr. Griffin. I am not worried about anything.
    Dr. Huelskamp. Well actually----
    Mr. Griffin. I am just, that is just the reality that you 
could get out of Google to show the amount of coverage that was 
put on the statement that there were 40 dead and that there was 
no ifs, ands, or buts about it. That does not take a lot of 
research to find that, okay?
    Dr. Huelskamp. Yes.
    Mr. Griffin. Okay. So----
    Dr. Huelskamp. Yes. Well, thank you. I just, I still am not 
for sure if you, apparently those headlines are okay, then? 
They are not misleading?
    Mr. Griffin. I did not say they were okay.
    Dr. Huelskamp. Well are they misleading?
    Mr. Griffin. I think headlines are sensational to get 
people to read a story. They----
    Dr. Huelskamp. Well I think it is sensational that there is 
5,600 veterans cases that apparently were not reviewed and that 
you have in the report. And so I look forward to the 
determination of why you decided not to review those cases. 
Because I fear there are more veterans that died----
    Mr. Griffin. I think as Dr. Daigh said there was nothing to 
review if they did not get in the door. He was reviewing 
medical records and if they did not get an appointment, they 
did not have any records to review.
    Dr. Huelskamp. But when you said there was no causality and 
they fail to get in the door and die because we did not deliver 
care, I say that is causality and your statement would be 
misleading, then. I----
    Mr. Griffin. We do not know how they died or why, nor do 
you.
    The Chairman. Mr. O'Rourke.
    Mr. O'Rourke. Thank you, Mr. Chairman. And I will say that 
Mr. Griffin and Dr. Daigh, I think by the criteria that you 
have described to us that you are using to reach your 
conclusions, I understand where you are coming from. And I 
think it is a rather narrow legalistic interpretation of the 
data, but I understand it and I think you have made that very 
clear today. And so I accept within those constraints what you 
have concluded. But common sense tells me, just from cases that 
I have seen in my district, that there is a cause and effect 
relationship between care that is delayed, that ends up being 
care that is denied, that ends up in veterans dying. And I have 
used this example before, with all due respect to the family, 
but they have shared their story with me and I think it is for 
a purpose.
    You know, Nick D'Amico, who had been trying to get mental 
healthcare at the El Paso VHA was unable to for untreated PTSD. 
And after attending, after not being able to and attending one 
of my town halls where veteran after veteran stood up and said, 
``I also have not been able to get in,'' he was driving home 
and his mom related this story with me, to me, that he was 
driving home that night with her and said, you know, ``Some of 
these guys are much older than I am and have been trying for 
years to get in and cannot. I do not know what I have to look 
forward to.'' And she cited that lack of hope as one of the 
main reasons that he then took his life five days after that 
meeting. We know in this country 22 veterans a day sadly take 
their own lives. And I have got to think there is a connection 
between delayed, deferred, and ultimately denied care, and 
these very tragic instances of suicide.
    Now I do not know if it meets the strict legal criteria 
that you are using. But it makes a lot of sense to me, and to 
draw that connection and that conclusion. And I think that is 
what is prompting so many of us to try to improve the level of 
access and the quality of care. And I do not think you would 
disagree with that. I mean, your conclusions here, you make 
some very bold statements. You talk about a breakdown of the 
ethics system within VHA, which I take to be a comment on the 
largest issue that I see that we have a problem with. Which is 
not funding and resources or number of doctors, but is the 
cultural aspect of VHA, the lack of accountability, a premium 
based on performance bonuses and not on excellence of care. Not 
on responsibility, not on patient outcomes for the veterans 
that purportedly the VHA is there to serve.
    I looked at your recommendations related to ethics on page 
74 of your report. They were pretty narrow. I think good 
recommendations all of them, but fairly narrow. Are there other 
recommendations I may have missed that more fundamentally 
address the issue of culture within VHA? And I would love to 
know what those are and how the Secretary, I will ask him when 
he is here, how he is going to respond to those 
recommendations. Mr. Griffin?
    Mr. Griffin. The original draft report had four or five 
recommendations speaking to ethics. They were very narrowly 
constructed so they were combined into one global ethics 
recommendation. The Secretary previously was the Chief Ethics 
Officer at P&G, he was the Chief Compliance Officer at P&G. I 
suspect that we are going to see ethics placed at a level where 
it should be. We did not find that in our review in Phoenix, 
when there was a request for an ethical review and not all of 
the recommendations were followed that were put forward by the 
person who submitted them. There was a reorganization in VHA 
which removed the Chief Medical Ethics Officer from the inner 
circle of the highest tier of management in VHA and was 
relegated to a lower level, which removed that person from a 
seat at the table with the most senior people. I suspect that 
we will see a change in that. And I think what had been ethics 
just from the medical ethics perspective is something that will 
be expanded beyond VHA to other areas in the department.
    Mr. O'Rourke. I, and I have not read every single page of 
this report, and I am currently reading it and I need to do 
that. But what I have not seen, and I have read through the 
ethics section of it, what I have not seen are some specific 
recommendations on accountability, on people losing their jobs. 
We have heard the most egregious instances of dereliction of 
duty, of abuse, of fraud, and later learn that those people are 
still on the job. I cannot argue with anything you said about 
the incoming Secretary, or new Secretary. I had a chance to 
meet with him yesterday and I am really looking forward to his 
leadership. But I think we need to institutionalize these 
cultural changes. And you were asked a question earlier by one 
of my colleagues, anything in that July compromise bill that 
you think would help change the situation. I think the ability 
to fire senior executives, get the dead wood and the fraudulent 
actors out of the way quickly so that we can bring up those who 
are the best and brightest and have the outcome of the veteran 
first and foremost in mind is what we really need to do. And I 
am not seeing that still. And throughout the system, including 
in the part of the system where I have the honor of serving 
veterans there. I realize that I am out of time. I appreciate 
the chairman's indulgence, thank you.
    The Chairman. Thank you. Dr. Roe.
    Dr. Roe. I thank the chairman. I am going to approach this 
a little differently. And Dr. Daigh, and Dr. Foote, and Dr. 
Mitchell know what I will be talking about, and this is grand 
rounds. And for those of you who do not know, when you are in 
training you present cases to staff and they critique your care 
of those cases. And I had a chance to review many of these 
cases and to draw the conclusion, Dr. Daigh, that you did, and 
maybe it is the criteria as Mr. O'Rourke said, that it had no 
effect on the outcome of those patients is outrageous. I mean, 
you would have lost both limbs where I was if you had tried to 
convince a staff a member where I am, or me when I was a staff 
member.
    And I think the question I posed to you in one of these 
cases if this were your family member, yours, just like case 
number 29 that had the congestive heart failure. If this was 
your dad there and would you be happy with the explanation you 
just gave of his death? And secondly, would you accept that? 
And my suspicion is no. Because you know that if your dad had 
gotten his allergy testing and an implantable defibrillator, 
the outcome may have been very different. That is why we put 
these devices in and prevent sudden cardiac death. And secondly 
of case number seven, this one the VA just got lucky on. I 
mean, a guy in his mid-sixties comes in to see a doctor with 
chest pain and has nothing done for seven months? I mean, all 
you can say is you got lucky. Because he very well could have 
died of coronary disease, which he had a bypass operation. But 
it was certainly nothing the VA did to help him prevent that. 
And one of the reasons, and I can assure you that in most 
private facilities if this guy had come in the emergency room 
like this he would have had a cath. Hypertension, mid-sixties, 
and chest pain, you cannot wave a redder flag than that. And 
what does this guy get? They control his blood pressure and 
send him out. And they are just really, really lucky.
    Case 31, a man with an elevated PSA. I have a little 
sensitivity to that. I have had one elevated before. It is a 
little worrisome when you are a veteran with an elevated PSA. 
This, it looks to me like this veteran just sort of got ignored 
for a while. Now would he have died and you cannot say, I think 
you can say, and what I would like to do is to have these 
criteria, or have this looked at by the Institute of Medicine 
or some other outside source to see if they draw the same 
conclusions. Because I certainly do not draw the same 
conclusions that you did.
    You are right. You cannot absolutely say that this veteran, 
missing this appointment or whatever. But it is the culture 
that I see. I mean, right, you miss one appointment, that 
probably did not cause your death. I have got that. But the 
culture of, I just do not understand it, where you do not 
follow up. People drop through the cracks. CT scans reordered, 
nobody gives a follow up on these. And Dr. Foote, I want to 
stop because I am going to use all my time. But I want you to 
comment. You have been a clinical director for 19 years. Do you 
agree or disagree with what I just said?
    Dr. Foote. Oh, absolutely. And my point was before about 
how the IG had somewhat downplayed the case. And let us talk 
about case seven. And what really happened in that case is 
quite different. And he had been waiting 12 months at the time, 
for an appointment with the VA, when he presented in January 
with the chest pain, having chest pain several times a week. 
All right? An EKG was done and the IG referred to it as an 
abnormality. The abnormality was Q waves in V1 through 3, 
suggestive of a prior anterior myocardial infarction----
    Dr. Roe. Infarction, yes.
    Dr. Foote [continuing]. In a patient having chest pain. All 
right? He was given an appointment in October from January. 
Only because my MAO spotted it in June when they gave us those 
appointments did I get him in sooner. At that point he was 
having daily chest pain and he now had Q waves in V1 through 
V4.
    Dr. Roe. So he had unstable angina.
    Dr. Foote. Right, absolutely. And an echocardiogram showed 
that he had an ejection fraction of 35 percent, 50 is normal, 
and he had anterior wall abnormalities. So my, my analysis of 
this case is that he had a heart attack in the 12 months while 
he was waiting. He further extended that, and fortunately, 
fortunately we were able to get him urgently cathed and 
bypassed. But, and he, so he is a guy that saved his life but 
lost 30 percent of his heart function. And the IG report 
referred to that as a favorable outcome.
    Dr. Roe. Well I guess if you do not go to a funeral it is a 
favorable outcome. But I can tell you that, that was not, if 
that had been my family I would have been very, if it had been 
me, or if it had anybody sitting at that dais you would not 
have been happy with the care you got. And I went through case, 
I looked at this at one veteran at a time and evaluated it not 
as a system or whatever just how did that one veteran get their 
care, and would this care pass muster that we have to pass in 
the private sector to get paid by Medicare or anybody else. The 
answer is of course it would not. And I am embarrassed by this. 
I mean, when I read a lot of these cases it was embarrassing. 
Dr. Mitchell, would you like to comment?
    Dr. Mitchell. Yes, I would like to go on the record against 
the entire OIG. When you have a patient who is unstable 
psychiatry, who is verbalizing suicidal ideation, like in case 
number 39, if you discharge him home he will commit suicide 
unless something intervenes. In this case nothing did and he 
committed suicide.
    For the gentleman in case number 40 he was demonstrating 
psychiatrically unstable behavior as an inpatient. The 
psychiatrist had the option to stop his discharge. If you 
discharge a psychiatrically unstable patient who has got a 
history of hurting himself, he has got a history of suicidal 
ideation, he will commit suicide. The only question that should 
be asked is when.
    This is National Suicide Prevention Month. The VA has a 
wonderful program on the Power of One, which means that one 
person, one kind act, one question can stop a suicide. This 
gentleman should have had, both of these gentlemen should have 
had the Power of One, but One being the Department of the VA. 
This was totally inappropriate medical care for psychiatric 
patients. And on behalf of every mental health provider in the 
United States, I will say that if you discharge an unstable 
psychiatric patient who is verbalizing suicidal ideation, he 
will commit suicide unless something happens to intervene.
    Dr. Roe. I thank the chairman. I yield back.
    The Chairman. Ms. Brown.
    Ms. Brown. Thank you, Mr. Chairman. Mr. Griffin, in my 22 
years on this committee I have never heard anything from the 
Inspector General that would make me believe that the Office of 
the Inspector General has worked with the VA to soften the 
findings. Nothing. Nothing there. But I think it seems to me 
that people think that because an allegation is a criminal 
offense and therefore should be fired without any due process. 
Can you explain that to me? And I am thinking about the 93 
ongoing review cases.
    Mr. Griffin. Right.
    Ms. Brown. Yes.
    Mr. Griffin. We receive many, many allegations. In the last 
12 months we got 34,000 allegations through our hotline, okay? 
That is why we have investigators and auditors and doctors and 
other clinicians. So when we get an allegation if we have the 
resources available and it rises to a level where we feel 
compelled to take it, that is why we go out and do our reviews 
and either conclude yes, this allegation is correct, or no, it 
is not. But until such time as we have accomplished that, an 
allegation is an allegation.
    Ms. Brown. It seems as if everybody seems to think that 
every veteran is eligible to participate in the VA. And that is 
not accurate. I know that the former Secretary opened it up to 
millions of additional veterans. Can you explain that? In other 
words, everyone that was in the Department of Defense is not 
necessarily eligible to participate with the VA. Now I know we 
have expanded that net. But to a large extent, it was not.
    Mr. Griffin. You know, Dr. Daigh served our country in the 
Army. He was an Army doctor for more than 20 years. He is well 
versed on coverage that is available to retirees in addition to 
veterans, so let me ask him to speak to the options that are 
available.
    Dr. Daigh. I am not sure I can address it very factually 
except to say that you are correct, not all veterans are 
eligible for care in the VA. And generally the VA I believe was 
set up to take care of the indigent and those who were disabled 
in combat or otherwise. So the inclusion recently of all 
veterans who returned from the Wars has certainly expanded the 
eligibility for VA. And then when category eights were allowed 
to join, that would be people who are veterans but are not 
financially disqualified from previous groups, that has 
significantly increased the number of people who could come. 
But the gates to get in and not get in have been changed over 
time. That is about all I know about it right now, ma'am.
    Ms. Brown. Okay. But we have expanded that area. And which 
I applaud. But in expanding it it created additional problems 
as far as processing them through the system. I recently spoke 
to a veterans group and they indicated that it was such a 
horrible experience. And I said, well what was the horrible 
experience? Once you got into see the doctor? No, when I went 
for my appointment the person at the desk was on the phone and 
they did not stop and take care of me. That, I understand we 
lowered the job description of the front desk person so that 
veterans when they come in are not necessarily getting the 
right kind of experience that could have happened in any of our 
other offices if you do not have a person that is the first 
contact not a person at a certain level to, for that intake.
    Dr. Daigh. Yes, ma'am.
    Ms. Brown. I guess I was asking the question as to how 
could we improve the system as far as veterans feeling that the 
system, once that person got in with the doctor everything was 
fine. But it is just getting that person into the system.
    Dr. Daigh. Well, I think there are a couple of things. One 
is the systems that, by which you make appointments, that you 
make consults, the communications systems which are actually 
quite complex between VA. And in Phoenix we found for example 
that many patients who traveled to Phoenix part-time, snow 
birds if you will, they had a very difficult time getting into 
care. They were sort of blocked out of the primary care group 
that was set up and their access was diminished. So I think you 
have to look at what you mean by access to care as a system. 
You are going to have to implement the systems to make it work, 
mostly computer systems. And then I think you also have to 
incentivize everyone who works in the VA to have a customer 
focused, friendly, polite, how can I help you, I cannot help 
you too much attitude. So I think all those issues are part of 
what I believe the current Secretary understand and what I 
believe he will try to work on.
    Ms. Brown. Thank you. I yield back the balance of my time.
    The Chairman. Thank you, Ms. Brown. Mr. Jolly, you are 
recognized.
    Mr. Jolly. Thank you, Mr. Chairman. Mr. Griffin, I have 
questions, and Dr. Daigh, about the analytical model behind 
your statements. And it goes to what Mr. O'Rourke said, and Mr. 
Roe, and Mr. Huelskamp. It matters not to me if VA influenced 
this report. I take you at your word to suggest it did not 
substantively influence your statements. The IG Office at Bay 
Pines is in my district. So believe it or not I hear 
constituent concerns, complaints, and compliments about the IG 
in a way maybe other members do not. What I know is words 
matter. And so your statement that you cannot conclusively 
assert that the lack of timely care caused the death of 
veterans certainly is an accurate statement based on your 
analytical model. Can you also conclusively assert that wait 
lists did not contribute to the deaths of veterans?
    Dr. Daigh. No. I, no.
    Mr. Jolly. And did you say that in the report? Was that 
reflected in the report?
    Dr. Daigh. I, I----
    Mr. Jolly. That you could not conclusively assert that wait 
lists had no contribution?
    Dr. Daigh. No.
    Mr. Jolly. And why not?
    Dr. Daigh. What I had hoped was that----
    Mr. Jolly. Hold on a minute. Let me go through this line of 
questioning. Because this is very important.
    Dr. Daigh. This is, this is why not. We put in here the 
stories of all these people who we thought did not get proper 
care. And it was my assumption that by reading these stories 
you could understand where the rate, where the waits were and 
you could arrive at your own conclusions----
    Mr. Jolly. I understand. You made a very powerful statement 
based on an analytical model that has not been reflected on the 
other side of the equation. And the reason it matters is 
because for six months we have been investigating the deaths of 
veterans. And IG words matter. Frankly more than any political 
appointee. We challenge political appointee words all the time 
and a lot of times they are wrong and misleading. We expect the 
IG not to be. And so the statement you made that you cannot 
conclusively assert that it led to deaths is a substantive 
statement that addresses work we have done six months, and yet 
you did not assert that it may, that you cannot conclusively 
assert it did not. Right? So you can say it did not cause. 
Would you be willing to say that wait lists contributed to the 
deaths?
    Dr. Daigh. The first 28 cases----
    Mr. Jolly. Would you be willing to say that wait lists 
contributed to the deaths?
    Dr. Daigh. Yes.
    Mr. Jolly. You would.
    Dr. Daigh. In fact the title of the first 28 cases are 
cases where we thought patients were harmed because of the wait 
lists.
    Mr. Jolly. Did it contribute? Did it----
    Dr. Daigh. There were six deaths out of that group.
    Mr. Jolly. Did it contribute to the death?
    Dr. Daigh. Yes.
    Mr. Jolly. Wait lists contributed----
    Dr. Daigh. Yes.
    Mr. Jolly [continuing]. To the deaths of veterans?
    Dr. Daigh. No problem with that. The issue is caused, or--
--
    Mr. Jolly. Of course.
    Dr. Daigh [continuing]. A direct relationship. How tight a 
relationship do you want? That is where, that is where the 
difficulty is here.
    Mr. Jolly. I understand. But that puts you down a road that 
gets very interesting. Because as you said earlier you have, 
you have no ability to determine the cause of death. When then 
asks at the very beginning what is the point of the study? If 
you are not able to make a determination then the analysis that 
suggests you cannot draw a causation creates a great question 
that actually undermines most of what is in the report. Whereas 
if you say it contributed to, that should be the headline. We 
have talked a lot about headlines. And if you are an American 
person sitting at the kitchen table today and in April learned 
that there were 40 deaths, we can play with semantics all we 
want, Mr. Griffin. But right here at the table it was 
acknowledged by the IG's Office that the wait lists contributed 
to the deaths of veterans. That is an accurate statement, right 
doctor?
    Dr. Daigh. That is an accurate statement.
    Mr. Jolly. Mr. Griffin, would you agree with that as well? 
That the wait lists contributed to the cause of death in 
veterans?
    Mr. Griffin. I think in our report a careful reading would 
show that in some of those cases we say that they might have 
lived longer, they could have had a better quality of life at 
the end, and so on.
    Mr. Jolly. Sir, I----
    Mr. Griffin. Is that true or not?
    Mr. Jolly. Would you agree that wait lists contributed to 
the deaths of veterans? It is a yes or no.
    Mr. Griffin. I would agree----
    Mr. Jolly. Please, yes or no.
    Mr. Griffin. No, I----
    Mr. Jolly. Words mean something and you need to be precise 
with your answers.
    Mr. Griffin. Yes, they do.
    Mr. Jolly. Yes, you do?
    Mr. Griffin. No. I would say that it may have contributed 
to their death. But we cannot say conclusively it caused their 
death.
    Mr. Jolly. Of course. And you cannot say conclusively it 
did not. And so Dr. Daigh said we will use the word contribute. 
And he said it did contribute. You are not willing to say it 
contributed, is that right?
    Mr. Griffin. No, that is not right.
    Mr. Jolly. Well then you are willing to say----
    Mr. Griffin. I think what the report says is it may have 
contributed and there is no denying it may have contributed.
    Mr. Jolly. So you are undermining the confidence we have in 
the IG by not being able to answer that very simple question.
    Mr. Griffin. No, I answered----
    Mr. Jolly. Did it contribute to the deaths of veterans, yes 
or no?
    Mr. Griffin. It could have.
    Mr. Jolly. Okay, that is your answer.
    Mr. Griffin. That is right.
    Mr. Jolly. And I know Dr. Daigh disagrees with you. In 
law----
    Mr. Griffin. I do not think he disagreed with you.
    Mr. Jolly. He answered it very differently.
    Dr. Daigh. For the----
    Mr. Jolly. He did. And listen, I am going to conclude with 
this.
    Dr. Daigh. Yes, sir.
    Mr. Jolly. In law there is the notion of res ipsa loquitur, 
the facts speak for themselves, in cases of negligence and 
death. We know people were on the waiting lists. We know they 
died as a result of conditions for which they were awaiting 
treatment. And we know that your office has made criminal 
referrals related to that. And so I appreciate Dr. Daigh you at 
least willing to say wait lists contributed to the deaths of 
veterans. Because that is not the story that has come out as a 
result of the IG report. Thank you, Mr. Chairman. I yield back.
    The Chairman. Thank you very much. Mr. Schweikert.
    Mr. Schweikert. Thank you, Mr. Chairman. And Mr. Chairman 
and to the Ranking Member, I appreciate you letting me sit in 
on this committee. I have the opportunity and the joy of 
actually representing a large area of Phoenix. And have had a 
number of the folks that shall we say have been affected by the 
VA in my office. We have sat down with them over coffee. And 
this is one of those difficult subjects. Because for those of 
us from sort of the accounting math world we want to say is it 
binary, is it yes and no, as the discussion we were just 
having. And the reality whenever we deal with people, people, 
human beings, our health is not necessary binary, yes or no.
    But some of this is really tough. I mean, a few months ago 
the sit down coffee with the widow, and you think of yourself 
as a really tough guy, that you have dealt with lots of this, 
and you are driving home, and you cannot get that lump out of 
your throat, and you are trying not to cry. And you have not 
cried since you were a child. So hopefully everyone here 
understand the emotional impact. Now we sort of work through 
the mechanics of what does this report really say, and what are 
the fixes? How do we never, ever, ever have these types of 
hearings, and these sorts of experiences, and I never sit down 
with a widow that breaks my heart every again?
    And first, for Mr. Griffin, I just, maybe it is the term of 
art. But very quickly, when going through the report the words 
significant is rolled through a number of times. Was it a 
significant causation? Was it a significant factor in the 
death? You do see within the questions of both the right and 
the left here how many times we say significant and it can have 
a wide interpretation. Is that how you meant to write it? Was 
that the goal, saying look, there is a wide path here of 
causation?
    Mr. Griffin. Our clinical staff did those reviews. I would 
ask Dr. Daigh to answer your question.
    Mr. Schweikert. And Dr. Daigh, I am trying to be really 
fair minded here and not, you know, let my emotion drive my 
questions. Am I being fair minded?
    Dr. Daigh. I think so. I think first of all it takes a 
great deal of effort for the people that work for me to write 
these stories with no emotion. And so what people read when 
they read these stories is an emotionless layout of fact. You 
do not see the outrage we feel. So if we start from a universe 
of patients who all were delayed in getting their care, it is 
reasonable to assume that they are all harmed just by the fact 
they did get delays in care.
    Mr. Schweikert. Okay. And Dr. Daigh, you sort of nudged up 
to something I just want to touch on just as an observation. I 
was actually a little disturbed by, and Mr. Griffin I will 
write you a note of this and hopefully we will just do it in 
writing, the fact you knew there were 800 articles. IG, facts, 
facts, facts. Promise me you are not tracking the press 
articles and saying, oh, we are up, we are down, oh, they did 
not see it as nicely. That is our world. That is not, never, 
ever, ever should be the auditors' world. And it bothered me 
that you knew there had been 800-some articles.
    Two quick things. Tell me what you learned from the 
hotline. Did the hotline ever, did you ever map out a pattern 
or a division or a specialty that there was something wrong? 
Something came up repeatedly? And it could be doctor or Mr. 
Griffin. Whoever----
    Mr. Griffin. Let me just respond to the 800 articles very 
briefly. It took about 60 seconds to determine that----
    Mr. Schweikert. The sheer fact you had any curiosity at 
all----
    Mr. Griffin. It was not curiosity. We were being challenged 
for the fact that we alluded to the original allegation of 40 
deaths, and that is what got reported over and over and over 
again.
    Mr. Schweikert. And once again you work for ultimately us, 
the taxpayers, the agency, not the media. The media should 
never influence the professionalism of what you do. So doctor, 
sorry, you were moving up to the microphone.
    Dr. Daigh. Would you repeat the question, sir?
    Mr. Schweikert. It just, tell me, any patterns from the 
hotline?
    Dr. Daigh. I would say that the pattern that we saw in the 
cases was not that, was essentially people who were denied 
their care because they were on wait lists. And the hotline 
cases were usually a little more clear in the delay or the 
impact of, for us, the timing of not getting care and then 
being able to see impact was clearer in the hotline cases than 
it was on the long list of cases we looked through who people 
who were delayed tried to determine whether there was an 
impact.
    Mr. Schweikert. Mr. Chairman, I appreciate----
    Dr. Daigh. The urology group, the urology clinic was one 
area that became clear to us----
    Mr. Schweikert. Where you saw a pattern?
    Dr. Daigh [continuing]. We saw a pattern. The other pattern 
was that people had a very difficult time getting into primary 
care. So if you were already impaneled in primary care at 
Phoenix, which was an inadequate panel size, then you had at 
least one access to get consults or move your way through the 
system. If you were not in the primary care panel, then you had 
a very difficult time navigating the system.
    Mr. Schweikert. Okay.
    Dr. Daigh. I would say those would be two examples that----
    Mr. Schweikert. And forgive me. Mr. Chairman, thank you for 
your patience. I will, for all of you I actually have some 
written questions that I will shoot your way. Thank you, Mr. 
Chairman.
    The Chairman. Dr. Benishek.
    Dr. Benishek. Thank you, Mr. Chairman. I guess the question 
that I, comes up, and the chairman brought it up, and the thing 
that concerns me the most about this is that this is really bad 
stuff that happened to our veterans. And the care that was 
outlined in the, I read through those cases that we have here. 
I do not know, like 40 cases. These case summaries. And I know 
they are incomplete, but boy, I, you know, just to see how our 
veterans have suffered and subject to delays in care that was 
most evident from these short excerpts here. That, you know, 
your argument that the delay did not, the causation, with the 
death. I mean, I understand that, that argument. But the delays 
that occurred here, boy, they certainly would be unacceptable 
in my practice. Where if you referred somebody to a short term 
follow up and then due to a screw up of scheduling, you know, a 
two-day follow up did not occur for months. And you know, this 
is just unacceptable. And I think that, I think you all agree 
on that. Is that right? Doctor----
    Dr. Daigh. Sir, the title above the first 28 cases is 
clinically significant delays. So I completely agree with you. 
The only point that I wish----
    Dr. Benishek. Well I----
    Dr. Daigh [continuing]. Wish we had worded better was this 
idea that delay caused death. That was----
    Dr. Benishek. Well the only thing that upsets me about this 
is that somehow the media has taken that there is no problem, 
or there is not that big of a problem. This is a big problem. 
This is a huge problem. This is a problem that has to be 
addressed. And you know, hopefully with the changes that are 
happening in the VA now, we have a new Secretary, and reform, 
and hopefully a new culture within the VA, that that will 
happen. I think we all just want to be sure that we have an 
Inspector General that we can rely on to be inspecting 
independently of VA coercion or enforcement or discussion. And 
I think that is really the gist of where I, what I get from 
this hearing. Mr. Griffin, do you want to comment on what I 
just said?
    Mr. Griffin. I do. I do. We do not have an Inspector 
General right now in our office. It is a presidential 
appointment. It has been vacant since January 1st. Everybody 
who worked on this report is a career federal employee. We do 
not pick sides. I think the rigor of our interim report issued 
on May 28th led to very large change in the department, 
including the most senior leadership. I think the 24 
recommendations in this report address the issues that we 
found. And the notion that, that somehow we would have issued 
either of these reports if we were complicit with the 
department just does not wash with me.
    Dr. Benishek. I mean, let me just go over in a different 
direction, and I missed some of the hearing because I had to do 
another thing. But has anybody been prosecuted? I mean, has 
people----
    Mr. Griffin. There are----
    Dr. Benishek. [continuing]. Referred to the Department of 
Justice for prosecution----
    Mr. Griffin. There are ongoing investigations.
    Dr. Benishek. So nothing has happened yet?
    Mr. Griffin. No one has been prosecuted yet.
    Dr. Benishek. I see. Have you heard from the Department of 
Justice? Have you, are they----
    Mr. Griffin. We have heard from the Department of Justice. 
The Assistant Attorney General for the Criminal Division sent 
guidance out to all the U.S. Attorney's Offices laying out for 
them his view of what the potential charges could be based on 
his knowledge of the manipulation of records, potential 
destruction of records, and so on. That was sent to every U.S. 
Attorney's Office in the country. We are working in partnership 
with the FBI on the ongoing Phoenix investigation and in a 
number of the other locations. Believe me, we have no desire to 
see people escape who deserve criminal charges. As I mentioned 
earlier, we arrested 94 VA employees last year on charges 
unrelated to waiting times. So we are not bashful about 
arresting people when they break the law.
    Dr. Benishek. So you do not know the timeline when this is 
going to be done?
    Mr. Griffin. I think, I think as we complete the 
investigations it is going to be a rolling process. It is not 
like there is a date certain when all 93 will be closed. But 
every week we will make additional progress. And if they are 
not prosecuted----
    Dr. Benishek. Are you doing more referrals? Did you do any 
referrals to the Justice Department in the last week?
    Mr. Griffin. I think we had a new case last week in 
Minnesota.
    Dr. Benishek. All right.
    Mr. Griffin. Whenever we open a case that has criminal 
potential the Attorney General guidelines require us to notify 
the FBI----
    Dr. Benishek. Right.
    Mr. Griffin [continuing]. So that we are not duplicating 
efforts.
    Dr. Benishek. I am sorry. Thank you for your indulgence, 
Mr. Chairman.
    The Chairman. Thank you very much, members. The Secretary 
has been waiting well over an hour now to come and appear. So I 
appreciate your indulgence for waiting through the vote series. 
I do have, again, I have learned a lot in this hearing today. I 
honestly had no idea that the OIG would go back and forth with 
drafts to the VA. I was under the impression that it was a 
single draft that went to them to be checked for factual 
corrections that needed to be made. I would ask that you 
provide the committee copies of the drafts that were done. The 
fact remains that from the very first draft there was no 
inclusion of the statement that has caused me concern. Because 
it did, it took away the entire focus from all of the work that 
your office had done. So much so that it was leaked, just that 
part, prior to. In fact, I think it even caused you to move up 
the release of the final report because it exonerated the 
department. Well it did not exonerate the department. And I 
just, you know, I do not think anybody here thinks that it did.
    Mr. Griffin. I do not think it did. Mr. Chairman, I am 
sorry to interrupt. But I do not believe it exonerated them, 
one bit.
    The Chairman. Well, now and here is the question that I 
still, I need to ask before we close. In your testimony you 
gave the impression that the committee suggested that the 
appropriate standard to be used to determine causality of death 
is to unequivocally prove, I think that was a comment that you 
made, that a delay in care caused death. And reading the 
document that you in fact cited as an exhibit in your testimony 
it states that a committee staff member sought specific 
information in order for this committee to prove that delays 
were related to death. And so what I need for you to tell me is 
do you believe that caused and related mean the exact same 
thing?
    Mr. Griffin. I think the context of this document, which is 
Attachment B for those who would like to review it. It is 
Attachment B to our statement. It reads, ``In order to 
unequivocally prove that these deaths (all 40) are related to 
delays in care.'' Now the document----
    The Chairman. Comma----
    Mr. Griffin [continuing]. Includes 17 names----
    The Chairman. Comma----
    Mr. Griffin [continuing]. But it says all 40.
    The Chairman. Comma----
    Mr. Griffin. That is why we were in pursuit of the 40.
    The Chairman. You did not finish. You did not finish. There 
is a comma there. It says, ``O&I,'' which means Oversight and 
Investigations, ``needs access to VA's computerized patient 
record system to pull up these veteran files or to request them 
from VA.''
    Mr. Griffin. Right, to unequivocally prove.
    The Chairman. For the committee.
    Mr. Griffin. Yes.
    The Chairman. Not you, but the committee.
    Mr. Griffin. Does the, does the committee have the 
clinicians to make that determination?
    The Chairman. I do not know that that is, you, in your 
testimony, though, you are saying that we put that burden on 
you. That burden was not placed on you. We said that about 
ourselves. Whether we have the clinicians to do it or not is 
not relevant. The fact is you were saying that we said that. 
And my question is, is caused and related, do they mean the 
exact same thing? Now you are saying they do.
    Mr. Griffin. No. What I am saying is unequivocally prove is 
an extremely high standard and it is not the standard that Dr. 
Daigh's people were using. That is all I am saying.
    The Chairman. And we did not ask, and we did not ask for 
that, correct?
    Mr. Griffin. No, no. Your memo that was sent to us on April 
9th after the hearing said that in order to unequivocally prove 
that these deaths, all 40, remember they were potential deaths, 
and as continued on it was declarative that there were 40, that 
all 40 are related to delays in care.
    The Chairman. O&I, meaning the committee.
    Mr. Griffin. Right.
    The Chairman. So, again, the unequivocal was not placed as 
a burden, was not placed on you, it was placed on us. We placed 
it on ourselves.
    Mr. Griffin. Yes, you did.
    The Chairman. Okay. But it was not placed on you. And 
that----
    Mr. Griffin. Well this----
    The Chairman [continuing]. You alluded to that----
    Mr. Griffin. I did allude to that. Because this was sent 
down here on an email by your staff saying here are the, here 
are most of the documents, meaning documents that surfaced in 
the April 9th hearing, and this document comes down with 17 
names. And it says we are going to unequivocally prove that all 
40, well there is only 17 names. I mean, it is, it is----
    The Chairman. That is, again sir, that is, I am sorry, but 
that is, you are trying to say we set a higher standard for you 
to prove when we did not set that standard. Is that correct?
    Mr. Griffin. I will let the document speak for itself.
    The Chairman. But you----
    Mr. Griffin [continuing]. That is why we put it on the 
record----
    The Chairman. But you made the testimony. You are 
testifying to the fact that we set that bar for you to meet. 
We, that, this clearly says in order to unequivocally prove 
that these deaths, all 40, are related to delays in care, O&I 
needs access, O&I meaning the committee, not you. But you took 
from this that we were trying to set a standard that you could 
not meet. In fact, I think Dr. Daigh said something about a 
standard that could not be met. And I, I am just, again we are 
having communication issues. And I understand that. But we----
    Mr. Griffin. I would be pleased, I would be pleased to 
answer for the record the other suggestions that came from the 
committee as to how this should be done, including one that was 
sent to us as the ink was drying on the final report. Which had 
we modified would have been a violation of general government 
accounting standards.
    The Chairman. Well again, we, I am talking specifically 
about something you included and you are saying that this was a 
directive to you to meet a standard you could not meet, 
unequivocal. Is that true or not?
    Mr. Griffin. The document staff says so O&I staff can look 
at this. That is fine. Why was it sent to us if O&I staff 
wanted to look at these things? They could have asked the 
department for these medical records. Clearly we were being 
asked, as a matter of fact in some circles it says we were 
ordered to expand our investigation in order to look into the 
issues----
    The Chairman. Not, not from this, not from this committee. 
I mean, if you have proof let me, tell me what it is.
    Mr. Griffin. Well, I am telling you what has been reported, 
that we were ordered----
    The Chairman. Oh, you are reading, you are googling again?
    Mr. Griffin. No. You can make all the fun you want of that. 
That is a reality that the basis for this thing getting eggs 
was the allegation of 40 specific deaths and we just could not 
find the trigger for those 40. Instead of looked at 3,409. So I 
do not understand----
    The Chairman. And you found 293 deaths.
    Mr. Griffin. Right, there were 293 dead out of that number.
    The Chairman. And you now have a statement that says that 
you could not, and then I am through, you cannot conclusively 
or otherwise, whether these deaths were related to delays in 
care. That, that is, and that was inserted after the first 
draft, correct? Can you----
    Mr. Griffin. That is correct. And we have been down this 
road. There were multiple drafts----
    The Chairman. Yes. I have learned, and I told you I learned 
that.
    Mr. Griffin. On July 22nd one of our staff in a senior, 
tracking changes on the report, which you will see, indicated 
if we cannot conclude this we should say so. Eventually that is 
what we got to.
    The Chairman. And so you can also----
    Mr. Griffin. Now----
    The Chairman [continuing]. Can you conclusively say that no 
deaths occurred because of delays in care?
    Mr. Griffin. No. We do not know. It is the causality thing, 
which is bore out in the testimony for the record from the 
witness who is not here today who is the President of the 
National Association of Medical Examiners. I do not know who 
requested this, but he says we got it right. So people are 
entitled to their own opinion. Whether we----
    The Chairman. Thank you. I appreciate very much your 
testimony.
    Mr. Griffin. Thank you, Mr. Chairman.
    The Chairman. You have a job to do and we appreciate the 
job that you do. We have a job to do as well. I appreciate the 
committee members for their questions and you are now excused.
    And we will take just a second. The Secretary will be 
coming in so we will have our second of three panels.
    We are going to hear from the Honorable Robert McDonald, 
Secretary for the Department of Veterans Affairs. Mr. 
Secretary, first of all we apologize for keeping you waiting 
for so long. He is accompanied by Dr. Carolyn Clancy, Interim 
Under Secretary for Health at the Veterans Health 
Administration. Your entire statement will be made a part of 
the hearing record. We would like to say welcome to you, to our 
committee room. We look forward to working with you in the 
future. And you are now recognized for your opening statement.

              STATEMENT OF HON. ROBERT A. MCDONALD

    Secretary McDonald. Thank you, Chairman Miller. I look 
forward to working with you and the rest of the committee to 
improve the Department of Veterans Affairs to provide the kind 
of care that our veterans deserve.
    Chairman Miller, Ranking Member Michaud, and members of the 
Committee on Veterans' Affairs, thanks for this opportunity to 
discuss with you VA's response to the recent VA IG report on 
Phoenix.
    First, let me offer my personal apologies to all veterans 
who experienced unacceptable delays in receiving care. It is 
clear that we failed in that respect regardless of the fact 
that the report on Phoenix could not conclusively tie patient 
deaths to delays. I am committed to fixing this problem and 
providing timely, high quality care that veterans have earned 
and that they deserve. That is how we will regain veterans' 
trust, and the trust of the American people.
    The final IG report on Phoenix has now been issued and we 
have concurred with all 24 of the report's recommendations. 
Three of the recommendations have already been remediated and 
we are well underway to remediating many of the remaining 21 
because we began work when the IG's interim report was issued 
in May.
    We have proposed the removal of three senior leaders in 
Phoenix and we eagerly await the results of the Department of 
Justice investigations. Nationally there are over 100 ongoing 
investigations of VA facilities by the IG, by the Department of 
Justice, by the Office of Special Counsel, and others. In each 
case we look forward to receiving the results so that we can 
take the appropriate disciplinary actions when the 
investigations are complete, when we have the evidence, and 
when we know the facts.
    We are grateful for the committee's leadership in 
establishing the recently passed Veterans Access Choice and 
Accountability Act of 2014. This law streamlines the removal of 
VA senior executives and the appeals process if misconduct is 
found. However, it does not eliminate the appeal process, the 
guarantee that VA's decisions will be upheld on appeal, or 
allow VA to fire senior executives without evidence or cause. 
And it applies only to senior executives, who are less than 
half of one percent of VA's employees.
    Now we have taken many other actions in Phoenix and the 
surrounding areas to improve veterans' access to care 
including, first, putting in place a strong acting leadership 
team. These are good people with proven track records of 
serving veterans and solving problems. Increasing Phoenix 
staffing by 162 personnel and implementing aggressive 
recruitment and hiring processes to speed recruiting. Reaching 
out to all veterans identified as being on unofficial lists or 
the facility electronic wait list, and completing over 146,000 
appointments in three months. As of September 5th there were 
only ten veterans on the electronic wait list at Phoenix. Where 
VA capacity did not exist to provide timely appointments we 
referred patients to non-VA care. From May through August 
Phoenix made almost 15,000 referrals for non-VA care. We have 
secured contracts to utilize primary care physicians from 
within the community in the future.
    Since my confirmation as Secretary 51 days ago I have 
traveled to VA facilities across the country, including 
Phoenix, speaking to veterans and VA employees as well as 
visiting and speaking with members of Congress, veterans 
service organization, and other stakeholders. During those 
visits I found VA employees to be overwhelmingly dedicated to 
serving veterans and driven by our strong VA institutional 
values of integrity, commitment, advocacy, respect, and 
excellence held in this acronym I CARE.
    We will continue to work with the IG and other stakeholders 
to ensure accountability. As I said, there are over 100 ongoing 
investigations at VA facilities by our IG, by the Department of 
Justice, by the Office of Special Counsel, and others. In each 
case we await the results and will take the appropriate 
disciplinary actions when all the facts and evidence are known. 
But we will not wait, and I want to emphasize that, we will not 
wait to provide veterans the care that they have already 
earned.
    Going forward we will focus on sustainable accountability. 
More than just adverse personnel actions, this means creating a 
culture where all employees understand how their work, their 
daily work, supports our mission, our values, our strategies. 
It requires supervisors to provide daily feedback to every 
subordinate, to recognize what is going well and identify where 
improvements are necessary. We are moving forward on several 
fronts and I have discussed these major initiatives with the 
chairman and ranking members of the Veterans' Affairs Committee 
and with many of the members here.
    Last week we announced the beginning of our Road to 
Veterans Day, focusing on the next 60 days. We are focusing on 
three strategies, rebuilding trust with veterans and the 
American people; on improving service delivery; and importantly 
on setting the course for long term excellence and reform.
    This week we released our Blueprint for Excellence. Dr. 
Carolyn Clancy, on my left, and Dr. Jonathan Perlin, a former 
Under Secretary for Health and now the Chief Medical Officer at 
HCA, one of the largest medical providers in the country, 
helped us lay out this blueprint. Four broad themes, ten 
essential strategies to help us simultaneously improve the 
performance of VHA Healthcare now; develop a positive culture; 
transition from sick care to healthcare in the broadest sense; 
and develop efficient, transparent, accountable, agile business 
and management processes.
    And to increase timely access to care we are recruiting to 
hire more clinicians. As part of that effort I have proposed 
increases to the minimum and maximum rates of annual pay for 
eligible VA physicians and dentists. With more competitive 
salaries we will be better positioned to attract and hire more 
healthcare providers to treat veterans and will be better 
positioned to retain those who are performing at a high level.
    We will judge the success of all our efforts against a 
single metric, and that is veterans' outcomes. We do not want 
VA to meet a standard. We want VA recognized as the standard in 
providing healthcare and benefits. I know we can fix the 
problems we face and I know we can utilize this opportunity to 
transform VA to better serve veterans.
    Mr. Chairman, members of the committee, thanks for your 
unwavering support for veterans. I look forward to working with 
you in implementing the law and in making things better for all 
of America's veterans. Dr. Clancy and I are prepared to take 
your questions.

    [The prepared statement of Hon. Robert McDonald appears in 
the Appendix]

    The Chairman. Thank you, Mr. Secretary, very much for your 
testimony. I have a number of questions in here that are I 
guess designed to rip and punch and do all kinds of things. And 
I am not going to do that. I, this committee is committed to 
being a full and complete partner with you as you work towards 
repairing the damage that has been done to VA over a number of 
years. Not just recently but over a number of years. And I 
think what we want to know is, and you have only been there 50 
days, do you have the tools that you need or are you finding 
that you need more? And we talked about this at breakfast last 
week. That we need to help you with legislatively, so that you 
can make the changes that are necessary to deliver the benefits 
to the veterans that have earned them.
    Secretary McDonald. Mr. Chairman, thank you. We have gone 
through and looked at the legislation that governs our 
department. And we have put together some proposals which are 
currently with the Office of Management and Budget. And we 
would enjoy the opportunity to be able to share those with you 
within the next few weeks as we get them back from the Office 
of Management and Budget.
    We have a lot of tools at our disposal, and as I said I 
thank you for the act that you all passed. It was a great show 
of bipartisanship for our veterans. But I think there are going 
to be things that we could use help with. And longer term I 
know that we will continue the conversation so that we can work 
together to identify those legislative needs.
    The Chairman. I think you are probably going to hear from 
both sides that it appears that nobody has been fired yet. I 
know that the wheels have begun. But, you know, at some point, 
we are at 110 days and, you know, is it that hard in the 
federal system or at VA to fire somebody who has been caught 
red-handed doing something?
    Secretary McDonald. Well first of all coming from the 
private sector, having run a $84 billion global company, it is 
a misperception to think that even in the private sector you 
walk in one day and you fire someone. It is frankly a failure 
of what I call sustainable accountability. If you are doing a 
good job managing an individual you are giving them daily 
feedback. And that daily feedback should result in a 
relationship that when something goes awry the action can be 
taken quickly but with the due process allowed.
    In our particular case around 65 percent of our employees 
are union members and our ability to separate them from their 
jobs depends upon the specific union contracts that we have in 
our facilities. As I said, the revision you all made in the new 
act does shorten the appeal time for our senior executive 
service employees. And we welcome that. But there still is a 
due process.
    As you know, in Phoenix we have got two senior executive 
service people who we have proposed action against. We give you 
a report every week. The report we gave you I think yesterday 
has 19 separate disciplinary actions on it. And we are going to 
work with you to continue to track it and keep you up to date 
as we learn new information. We need to get these 
investigations done and I was pleased to hear that the 
Inspector General thinks we can get them done relatively 
quickly.
    The Chairman. Mr. Michaud.
    Mr. Michaud. Thank you very much, Mr. Chairman. And I want 
to thank you, Mr. Secretary and Dr. Clancy, for being here 
today. And I want to say from the outset, Mr. Secretary, I am 
very pleased with what I have seen so far with your leadership 
style and the fact that not only have you taken the time to 
visit with employees at the VA, which has not been done as my 
understanding in the last five years, but your willingness to 
reach out not only to members of Congress, and particularly 
this committee, but also the veterans service organizations to 
get their input and insight into how we can provide better 
services for our veterans. So I really do appreciate that.
    And as I mentioned when we met before you were confirmed a 
Secretary that, yes the VA is going through some turbulent 
times right now. But it is also a time for opportunity to 
really change the cultural structure within the department and 
its employees, but also a time to really think big on a 
national strategy and where we should be going as far as the 
Department of Veterans Administration. So I want to thank you 
for your willingness to step up to the plate.
    Some of my questions, you mentioned about the 24 
recommendations under the OIG report, how long do you think it 
will take you to complete all of those recommendations?
    Secretary McDonald. We have actually put that in our report 
and I think it is by the end of about 2016, 2015. But of course 
it is over time and it depends upon how systemic and how big 
the changes. We are meeting every week and trying to get those 
remediations done. And I separately have asked the IG for all 
past IG reports that have not been remediated. I would like to 
go back and look at the history and understand what we need to 
do on the things that have not been remediated. Because my 
understanding from the IG is there is quite a few things. 
Believe me, having run a public company, having been on two 
audit committees on two different boards of directors, I like 
what the IG does. I need the IG's help. We all need the IG's 
help. And the work that they do is critically important to us 
in improving the organization.
    In fact as I have gone to these various sites, I have now 
been to nine different cities, 21 different operations of the 
VA over my first 50 days. I tell people that I want every 
employee to be a whistleblower. I want every employee helping 
us change the IG. So I welcome the criticism that anyone has. I 
even perhaps made the mistake of giving out my cell phone 
number publicly. It has been published online. It is in the 
Washington Post. And I have answered 150 phone calls so far.
    Mr. Michaud. Thank you. Speaking about the whistleblower, I 
know that is still a concern talking to some VA employees about 
whether or not they will be protected when they come forward. 
When will the VA be certified by the Office of Special Counsel, 
Section 2302(c), on the whistleblower protection?
    Secretary McDonald. Well I and Deputy Secretary Gibson, the 
interim, or acting, have demanded from the very beginning that 
whistleblowers be protected. I will have to get back to you 
with a specific date on that.
    But one of the things I have tried to do, because this is 
about changing culture and I know many of you asked about 
changing culture, is as a leader your behavior is looked at as 
a demonstration of a new culture. When I go to sites, those 21 
different sites I talked about, I asked to meet with the 
whistleblowers. I asked for the whistleblowers to be in the 
town hall meetings. I asked for the union leadership to be in 
these meetings. We cannot do this alone. We have to get every 
employee in the tent and working together so our veterans 
benefit.
    Mr. Michaud. A lot of the focus has been on VHA because of 
the Phoenix, Arizona. Do you have any plans to look at VBA and 
the National Cemetery Administration for similar leadership 
shortcomings and integrity type of issues?
    Secretary McDonald. Yes, sir. In fact as you and I had 
talked, part of our problem in VA is we are a siloed 
organization. We have been brought together over the years 
without really any idea to integrating the organization. As we 
talked, we have nine different geographic maps of organization 
structure for VA. That means no decision, nobody represents the 
Secretary of Veterans Affairs at any lower level than the 
Secretary or the Office of the Secretary. We simply have to get 
that fixed. It is a long term effort. It is part of our Road to 
Veterans Day. It is in the third column, we say set the course 
for longer term excellence. But I want to get to a point where 
our organization is so simple for the veteran to understand 
that they can plug into our organization any way they want, we 
will be there. If it is a smart phone for an Iraq veteran? We 
will be there. If it is paperwork for a World War II veteran? 
We will be there. And I want them to think of the VA as their 
VA. I want every veteran in this country to say this is my VA 
and I am proud of it.
    Mr. Michaud. Well, once again I see my time is expired.
    So I want to thank you once again, Mr. Secretary, for your 
leadership, your willingness to do this. I am very optimistic 
and very hopeful that with your leadership style that this 
change will continue in a positive direction, so I want to wish 
you the best of luck.
    Secretary McDonald. Thank you, Your Honor.
    Mr. Michaud. And thank you.
    Secretary McDonald. It will take the partnership of all of 
us.
    Mr. Michaud. Great, thank you.
    The Chairman. Mr. Lamborn.
    Mr. Lamborn. Thank you, Mr. Chairman, and thank you, Mr. 
Secretary for being here today; we really appreciate hearing 
from you.
    Secretary McDonald. Yes, sir.
    Mr. Lamborn. There are a lot of things we could talk about, 
but the need at the moment is to try to get to the bottom of 
what the details are surrounding this Inspector General's 
report that has just come out.
    You may have heard the testimony of the Inspector General 
earlier today that while the waiting list in Phoenix 
contributed to some or all of the 40 deaths of veterans in 
Phoenix, it may be--it did not cause their deaths, and they 
made a distinction between contributing to their deaths and 
causing their deaths.
    In light of that, was it misleading for some of the press 
headlines after a leak was made to have headlines like, ``No 
deaths related to long waits,'' which was one, or another that 
said, ``No links found between deaths and veterans care 
delays''?
    Secretary McDonald. Sir, I am reacting as if every shortage 
of care, every shortage of access to care is incredibly 
important. Someone said it earlier, you have to think about 
this one veteran at a time. I am a veteran----
    Mr. Lamborn. Yes.
    Secretary McDonald [continuing]. I do have injuries from my 
time in the service. I think about this--my father-in-law was a 
prisoner of war, he had post-traumatic stress, he was shot down 
in World War II. Until we got him to the VA we didn't know what 
the problem was. My uncle suffers from Agent Orange, 101st 
Airborne Division. So this is very personal to me.
    Mr. Lamborn. So----
    Secretary McDonald. And so we are acting as if every 
shortage is absolutely important, and we are going to fix it, 
with your help.
    Mr. Lamborn. Okay. So are those headlines accurate?
    Secretary McDonald. To me that--I am telling you I am going 
to act as if every veteran deserves the care they need and I am 
going to provide it to them, and that is what I am acting.
    Mr. Lamborn. Well, what do you think about the fact that 
someone in the--and the Inspector General said it wasn't 
someone in their office, leaked to the press an important 
sentence out of the report before it was released to the 
public? Do you have any concern about that?
    Secretary McDonald. I don't know anything about that.
    Mr. Lamborn. Is it any violation of VA ethics or rules or 
regulations or law to release something before public release?
    Secretary McDonald. I don't know.
    Mr. Lamborn. Are you going to look into this?
    Secretary McDonald. Well, we--certainly we have had lots of 
leaks all over the place. I read about Dr. Foote's testimony in 
the newspaper this morning.
    Mr. Lamborn. Okay. Let me change here----
    Secretary McDonald. The important thing, sir, is to create 
a culture.
    Mr. Lamborn. Yeah.
    Secretary McDonald. We have got to create a culture that is 
open and transparent and that works on veterans' issues, that 
looks at every single issue from the veterans' lens, okay?
    Mr. Lamborn. And I agree with that.
    Secretary McDonald. And the three hours I spend waiting to 
testify is time I am not spending working on veterans' issues 
in the field where the veterans are being cared for.
    Mr. Lamborn. Okay, let me pursue something you were talking 
to the chairman about. I hear from veterans all the time that 
they are amazed that no one in Phoenix has been fired for the 
unacceptable waiting lists in Phoenix. Apparently----
    Secretary McDonald. Sir, I said that we have proposed 
disciplinary action against two of the SES employees in 
Phoenix.
    Mr. Lamborn. Are those the two that are on paid leave?
    Secretary McDonald. That--that is--that is currently under 
way. That is the rule of law. If you would like to change the 
law----
    Mr. Lamborn. We did change the law.
    Secretary McDonald. Sir, you changed the law so it affects 
the appeal only.
    Mr. Lamborn. Yeah. So the two that are on paid leave, is 
that the extent of what we are going to look at as far as any 
kind of consequences?
    Secretary McDonald. I think you heard Mr. Griffin say that 
the FBI and other investigative sources are in Phoenix right 
now, and you also have received a report from me every week 
that tells you the people who we are disciplining.
    Mr. Lamborn. Okay.
    Secretary McDonald. The report we gave you yesterday has 19 
people on it, we will track that report weekly, we will update 
it weekly, and we will make sure that we discuss with you 
whatever you would like to discuss about that report.
    Mr. Lamborn. Now, are those the people that the Department 
of Justice declined to do criminal prosecutions of?
    Secretary McDonald. I am not familiar with those people, 
that is with Mr. Griffin. You would have to handle that----
    Mr. Lamborn. Okay.
    Secretary McDonald. These are the people that we 
administratively feel should be called out and brought to task 
for what they did, which is an important part of changing the 
culture, as the IG said.
    Mr. Lamborn. I--that is----
    Secretary McDonald. We have to hold people accountable or 
you are not going to change the culture.
    Mr. Lamborn. Mr. McDonald, that is why I want you to take 
some action, because that is part of the culture.
    Secretary McDonald. Sir, I am taking all the action the law 
allows me to take.
    Mr. Lamborn. Well, I will----
    Secretary McDonald. With due process.
    Mr. Lamborn. We are here to help you and let us get it 
done.
    Secretary McDonald. I know you are, and we have talked with 
the chairman about potentially working together on other 
legislative remedies.
    Mr. Lamborn. Okay.
    Secretary McDonald. And we look forward to working with you 
on that.
    Mr. Lamborn. Okay. Thank you. Let us get it done.
    Secretary McDonald. Yes, sir. Thank you.
    Mr. Lamborn. I yield back, Mr. Chairman.
    The Chairman. Ms. Brown.
    Ms. Brown. Thank you, Mr. Chairman.
    First of all welcome, welcome to the veterans' committee, 
and I hope in the future that we will have the common courtesy 
not to have the secretary waiting, even if we need to stand 
down one committee in order to bring you in, because I want you 
out there doing what--you should be for veterans. Thank you for 
your service.
    Secretary McDonald. Thank you.
    Ms. Brown. As I mentioned when you came to my office, my 
first secretary, Jessie Brown, his motto was putting veterans 
first, and I like that, and yours is Road to Veterans Day, 
which is my birthday, November the 11th, but what exactly do 
you mean?
    Secretary McDonald. For me the Road to Veterans Day is 
really about using the first 90 days that the chairman and the 
ranking member suggested to make as many changes as we can as 
quickly as we can to improve our service for veterans.
    So as I said, we have three strategies. One is about 
rebuilding trust, and the effort I am doing to get around to 
talk to people, to learn about what is going wrong, all 
stakeholders, all shareholders, veterans themselves, we are 
compiling a list of the changes that need to be made.
    At the same time we are forming teams of employees from 
without--from within the department. Part of the issue before 
was the organization was closed and wasn't communicating from 
bottom to top and top to bottom. We need to get employees 
involved in making these changes because they are the ones 
closest to serving the veterans. So we are in the process of 
putting that together.
    That will form a strategic plan, we will roll out that 
strategic plan, we will make those changes. We will improve 
access, we will go ahead and get down a number of benefits in 
the backlog that we have, and it is all--it is all designed so 
that in the end the veteran will know how to plug into VA and 
think of this as their VA. That is really what we want.
    Ms. Brown. One of the problems that I guess I keep having 
with the whistleblower is that it always seems like it is 
negative, but I don't think feedback has to be negative, I 
think it should be a way that employees could come forward and 
say this is how the system can improve. I don't think every 
complaint should be viewed as us against them.
    Secretary McDonald. Well, that is exactly right, and that 
is the culture we have to create. But I can understand that in 
this moment in time whistleblowers who had been retaliated 
against are skeptical as to whether I mean what I say or 
whether I can deliver what I say.
    Ms. Brown. Yes.
    Secretary McDonald. The only remedy to that is to get out, 
talk to people, demonstrate it through our behavior, put in 
place a new leadership team which will believe in the culture 
that we believe in, an open culture that needs the people at 
the lowest level of the organization making the biggest 
changes, because that is how we improve our work.
    Ms. Brown. I like the army's motto, one team, one fight, 
and I think if we are all fighting to improve the situation for 
the veterans then we will do what we have said we have done for 
over 75 years, delivering assistance to the veterans that we 
can all be proud of.
    Thank you very much for your service----
    Secretary McDonald. Yes, ma'am.
    Ms. Brown [continuing]. And your committment, and I am sure 
that you have a lot of team members that are willing to work 
with you.
    Thank you, and I yield back the balance of my time.
    The Chairman. Thank you, Ms. Brown.
    I can assure you while the secretary was delayed in coming 
and testifying he was working, because I actually went in the 
room and----
    Secretary McDonald. The chairman is correct.
    The Chairman [continuing]. Saw him--saw him meeting with 
individuals.
    Mr. Huelskamp.
    Dr. Huelskamp. Thank you, Mr. Chairman.
    I would like to follow up on a couple questions Congressman 
Lamborn had, and thank you for joining us today.
    The OIG report, maybe this a question for Dr. Clancy as 
well, what I didn't hear in the testimony and in--from the last 
panel was at what level at the VA in the collaborative process, 
that is the language from the OIG, is the report altered and 
the recommendations and changes? Is it at the secretary level 
or what level did that actually take place?
    Secretary McDonald. It was not at my level, and I don't 
know. Before my time too.
    Dr. Clancy. I am sorry. We have an office within--that 
reports to the undersecretary, actually reports to the 
principal deputy undersecretary for health that routinely 
interfaces with the Inspector General, with the Government 
Accountability Office, and so forth getting clarification on 
recommendations, and frankly, tracks to see that we are on 
track with recommendations that we have agreed with our dates 
and so forth, and as you heard from the Inspector General 
previously the issue of looking at a draft report and draft 
recommendations and they are asking for factual information to 
make sure that it is accurate is routine.
    Dr. Huelskamp. What office is that? Could you provide that 
for the committee?
    Dr. Clancy. Sure, it is Management Review Services is what 
it is called.
    Dr. Huelskamp. Okay. Who is in charge of that office?
    Dr. Clancy. Dr. Rasmussen.
    Dr. Huelskamp. Okay. And I appreciate that, because there 
apparently was a leak that has created some concerns about that 
and I didn't know what level that was and that hadn't come out 
earlier and that was the--part of the concern, you were busy, 
didn't hear that testimony, but the concern about how many 
veterans were actually impacted.
    And you might have missed as well, I had a line of 
questions with OIG that perhaps there were 5,600 veterans that 
escaped review during that process, and I am sure you are as 
concerned as I am about its impact potentially on veterans.
    Two other areas of questions, I think my colleagues also 
mentioned the issue of the whistleblowers. Just last week we 
heard more harrowing stories from whistleblowers over 
retaliation, intimidation, retribution, these are the things 
that have all occurred in the last few weeks since you have 
been on board, and from their perspective what we heard in 
subcommittee last week very little has changed. Can you 
describe again and show me what your commitment is? Because 
this is on your watch and some of it is carried over, but we 
are still hearing those stories and that is very worrisome.
    Secretary McDonald. Well, I have spoken to many 
whistleblowers in the organization myself. When I go to a 
location I ask to speak to the whistleblowers. I have had many 
of them call me on my cell phone and I have had conversations 
with them. And as I have said and as I have said publicly 
within the department and as I have said in every town hall I 
have held in the last 50 days, in 21 different sites, I welcome 
whistleblowing, I welcome people criticizing the operation, and 
I welcome employees who want to get involved on some of these 
reengineering teams that we are putting together so that they 
can help reengineer the process that they are criticizing.
    So, I don't think there is any lack of clarity. I may have 
missed a site, I may not have talked to a particular person or 
it may be an activity that arrived before I did, but with the 
communications I have done, which have been two videos that 
have gone out to every employee, many letters, one of which, 
which you might be interested in, is a discussion of 
sustainable accountability and this whole idea of how do we get 
daily feedback going and how do we get the organization working 
together. I have met with the union leadership four times.
    Dr. Huelskamp. Well, thank you for that, and I wanted you 
to restate that. I appreciate the commitment, because there are 
some folks between your level on down that haven't got the 
message.
    Secretary McDonald. Well, tell them to call me.
    Dr. Huelskamp. You know, check out our committee, 
subcommittee hearing from last week, that is your job, you have 
all the people to do that, we had a whistleblower. Hopefully 
you have checked on that. That came forward to the subcommittee 
and now this is still going on.
    The third thing, I am glad you welcome criticism, because I 
want to see our rural areas of the country, the VS a doing a 
pretty poor job of meeting the needs of our veterans.
    Secretary McDonald. In fact I am concerned about that 
myself.
    Dr. Huelskamp. Exactly.
    Secretary McDonald. I have been out to Nevada and have 
worked this--particularly in Nevada, I was in San Diego, we are 
working very hard on tele-health, we also think----
    Dr. Huelskamp. Well, let me give you a better option, and 
that is in the bill, and that is VA choice, giving the veterans 
a choice.
    Secretary McDonald. Well, that is in the bill.
    Dr. Huelskamp. I know, but it can be implemented----
    Secretary McDonald. And we have been doing it.
    Dr. Huelskamp [continuing]. Fully and it may not be, and 
currently I understand our current law there are some options 
that there weren't used. But I am saying in my district I have 
veterans that go to four different VISNs, hundreds, 300, more 
than 300 miles----
    Secretary McDonald. Yeah.
    Dr. Huelskamp [continuing]. And I have VA employees say, 
well, too bad, get in a car and drive, but we need to make 
certain they have local options.
    Even after this trial period is over, two years, I would 
hopefully like to continue to seek efforts at the VA to say, 
you know what, we can do a better job and provide that access 
closer to home, which is important for the veteran, but more 
important for the family and the local community that provides 
the services.
    Secretary McDonald. Well, as I said, if you look at these 
issues through the lenses of veterans then the answer becomes 
very clear.
    Dr. Huelskamp. Yeah.
    Secretary McDonald. We want to get care to veterans.
    Dr. Huelskamp. Yeah.
    Secretary McDonald. If we don't have the technology, if 
distance is an issue, if capacity is an issue then we should 
help that veteran get the care in the private sector.
    Dr. Huelskamp. The issue is not capacity, the issue is not 
distance, the issue is getting permission from the VA to go to 
the local hospital. If they are willing to do that, I just 
encourage you to look into that. I don't know if you have every 
lived in a rural area----
    Secretary McDonald. Please give us their name and we will 
work on it.
    Dr. Huelskamp. Okay, I will continue to do that. But the 
point is there are a lot of folks out there that would like 
that choice and we need to see that choice being offered by the 
VA.
    So thank you, Mr. Secretary, I appreciate it. Mr. Chairman.
    The Chairman. Thank you, Mr. Huelskamp,
    Mr. Takano.
    Mr. Takano. Thank you, Mr. Chairman.
    Mr. Secretary, welcome, this is the first time I have had a 
chance to meet you, I hope we have a chance to----
    Secretary McDonald. We will get together soon.
    Mr. Takano. Yeah, thank you.
    Mr. Secretary, some of these--well, the Phoenix VA wait 
list scandal happened many layers below the secretary level, 
and how can you be sure that the leadership teams that are near 
you are going to be able to tell you the truth or be able to 
get to the truth and so you are not insulated and that you can 
count on people getting you accurate information?
    Secretary McDonald. It is going to require a change in 
culture, and those of us who have experience running large 
organizations know that is probably the most difficult thing to 
do, but it starts with the purpose, values, and principles, 
which are the bedrock of any organization.
    So the first thing I did was I asked for every employee to 
recommit themselves to the mission of caring for veterans and 
to the values of the organization represented in the ICARE 
acronym. We have used that as an leadership exercise for our 
leaders to talk with their employees about the mission, about 
the values.
    The second thing that we have tried to do is we have tried 
to demonstrate that we want a very open culture. We talked 
about the positive aspects of whistleblowing, we have talked 
about the positive aspects of criticism. I have used a couple 
of diagrams. Most people think of an organization like this and 
the customers is on the bottom and the CEO is on top, but I 
turn that on its head and I said this is the VA we want. We 
want the veterans on top and those people who are next to the 
veterans every single day, the doctors, the nurses, the 
schedulers, the clinicians, those are the people that we should 
honor and make sure are paid properly and are rewarded, and 
then the CEO or the secretaries on the bottom, and the 
leadership's job is to make sure these people can properly care 
for veterans. This is a different kind of culture.
    To demonstrate that I have cut down the size of the 
secretary's office, I no longer travel with the entourage that 
maybe once existed, and we are simply trying to make very 
visible that this is a different culture.
    Mr. Takano. Are you sort of like the Pope, you know, travel 
in like a little tiny car?
    Secretary McDonald. I am much less than that. Remember, I 
am on the bottom of the pyramid, I am flying coach.
    Mr. Takano. Well, you know, I have to say I sympathize with 
my colleague, Mr. Huelskamp's four--he has three or four VISNs 
divided, I wish you could do something about that. I think 
there is--you know, if you could fix that I would certainly 
appreciate it.
    Secretary McDonald. We talked with Ranking Member Michaud 
in his office about this. Again, the veteran should not be 
punished for having a barrier between VA and DoD. The veteran 
should not be punished for having nine different maps of 
organization structure. These are things that we have got to 
simplify so that every--I will give you another example. We 
have 14 different web sites that require different user names 
and password.
    Mr. Takano. Wow.
    Secretary McDonald. Now, I don't know about you, but I hate 
keeping track of user names and passwords for all these web 
sites. You should be able to plug in the VA in the easiest way 
and then get your care, and that is what we are working on.
    Mr. Takano. You know, I am the ranking member of the 
Economic Opportunity Committee and I have a lot of concerns 
about the educational benefits, and I know you have been maybe 
paying attention to what has been going on in the for-profit 
college sector and making sure there is not undue predatory 
behavior.
    Secretary McDonald. I got my MBA using the GI Bill. My dad 
and my father-in-law got their college using the GI Bill. 
Again, it is very personal. We cannot allow people to take 
advantage of our veterans, it is really that simple.
    And I am thrilled with the work that was done in the new 
bill, I have told the chairman that, because you have expanded 
our ability to get doctors and nurses reimbursement for their 
study if they work for the VA, and we need more medical 
professionals. So that was a really big win for us.
    I have been out to Duke University Medical School, I was 
talking to the dean of Pennsylvania University Medical School, 
Penn, and just two days ago I was in San Diego with the dean of 
UC San Diego. These relationships for us are critical and 
getting those doctors, nurses, particularly mental health 
professionals into VA is very important.
    Mr. Takano. Well, I want you not to forget that I just 
wrote you a letter asking you for a plan on how we would use 
the medical residencies. That is a huge thing, you know, on the 
Medicare, Medicaid budgets, and we have been frozen in terms of 
the supply of doctors, and really we have a supply--we don't 
have a supply problem with the med students, we have a problem 
matching them to residencies, and I am looking forward to your 
ideas on how this can even help the broader community. Of 
course the primary function is the VA, and I think it will help 
the rural areas as well as impacted areas such as mine and Ms. 
Titus' and Ms. Kirkpatrick's.
    Secretary McDonald. It is very important, in fact we talked 
with Congresswoman Titus the other day about this, we are 
working to develop a medical school at UNLV, University of 
Nevada Las Vegas, we want the residents to work for the VA at 
the Las Vegas Hospital. These are critically important things, 
and I think we are going to have to work together to get more 
medical schools contributing more graduates for our rural 
areas, and so I would offer that as something we would like to 
partner with you on.
    Mr. Takano. I certainly would love to work with you on a 
plan like that.
    Secretary McDonald. Yes, sir.
    Mr. Takano. Thank you.
    The Chairman. Dr. Roe.
    Dr. Roe. Thank the chairman.
    And first of all, Mr. Secretary, I thank you for taking the 
job.
    Secretary McDonald. Yes, sir, thank you.
    Dr. Roe. Thank you for your service to our country, and I 
certainly appreciate that, and I think I said during these long 
hearings we went through that if you ask someone at the VA who 
they work for they would say the VA, and the right answer was I 
work for the veteran, and you got that right when you flipped 
that chart upside down.
    And I also appreciate the fact that you just said that you 
know that the front of the airplane gets there only slightly 
before the back of the airplane does, so you can save a little 
money there, and anything is helpful.
    Secretary McDonald. I used to jump out of them and I would 
not recommend that.
    Dr. Roe. Well, I have done that a time of two and then 
questioned my sanity about why would anybody jump out of a 
perfectly good airplane, so.
    Secretary McDonald. Particularly a doctor.
    Dr. Roe. Yeah, exactly. Why would you do that?
    I think one of the things that--a question I always ask our 
secretary every year when we come in with budget, is do you 
have enough money to carry out your mission, number one? And 
two, do you have adequate staff to carry out your mission?
    And I think that is a question you may not have time to 
answer right now, but that is a question you will get next year 
when we go through the budgets. And we want to be sure that we 
provide the resources to take care of our veterans. And I can 
tell you the America people want their veterans taken care of.
    And I know with Mark, Mr. Takano, we worked with him on 
that--on the residency slots, and I would like to personally 
offer you an opportunity to visit east Tennessee to our VA, and 
let me tell you why. It is one of five medical schools, it is 
now a 30-year-old school, it is on a VA campus. It actually was 
started with a T Cranston bill, so our students, our medical 
students actually go to the VA campus every day for their 
education and they go to the VA Hospital--along with the public 
hospitals too. It is a very good model, and maybe we should as 
we look at these shortages of physicians and we know that 
doctors are creatures of habit, we stay where we are like most 
people like to if you are comfortable, and it is a great way to 
get doctors to stay and make a career at the VA as Dr. Foote 
did. He was a career VA doctor.
    So I want to--I don't really have any questions other than 
just to thank you for taking the job and----
    Secretary McDonald. Yes, sir.
    Dr. Roe [continuing]. You come from a great company, you 
have a great background, you have run a big organization 
before, so I think you are going to be a great secretary.
    Secretary McDonald. Thank you, sir.
    I would just say, and I know the chairman knows this, but 
70 percent of the doctors in the United States have worked for 
the VA at one time or another, and the best operations we have, 
at least in my 50-day review so far, are those connected with 
medical schools, whether it be our Palo Alto facility with 
Stanford, our Durham facility with Duke, our Philadelphia 
facility with Penn, so we want to do more of that, it is really 
a great way, and we all benefit.
    Dr. Roe. I am going to selfishly promote my school, but----
    Secretary McDonald. And east Tennessee of course.
    Dr. Roe. Yeah, it is one of the--it is one of the five top 
primary care putting doctors in rural areas in the country, so 
it is----
    Secretary McDonald. We need that, we need that badly.
    Dr. Roe [continuing]. One of the things that we do, and it 
is one of the things that Mr. Takano was talking about and Dr. 
Huelskamp talking about, getting people out to rural areas, 
which is rural America is where I live, and it is a challenge 
for us.
    Secretary McDonald. And our veterans just so you know 
demographically are moving more to rural areas than they are to 
urban areas, so this situation will only get exacerbated so we 
need to get ahead of it.
    Dr. Roe. Yeah, I think ten percent of my district are 
veterans, so a big number there.
    Dr. Clancy. So I will just say it is a very strong primary 
care school as I recall as well, and definitely on the list for 
a visit.
    And we just want to thank you and everyone else for the 
additional residency slots, because we recognize that we are in 
tight competition with the private sector in terms of 
recruiting and hiring, but we think we have got the best 
mission.
    Dr. Roe. I think long term it is a great method to do. I 
mean just think in 10, 20, 30 years when nobody is even going 
to know who we were, it will provide benefits for the VA and 
for the veterans.
    Mr. Chairman, I yield back.
    The Chairman. Thank you.
    Ms. Brownley.
    Ms. Brownley. Thank you, Mr. Chairman, and thank you, Mr. 
Secretary, for being here. I certainly enjoyed my meeting with 
you last week and appreciate it very, very much, and I went 
back to my district and told my veterans you should have hope, 
I met with you, and I really appreciate your can do and will do 
leadership style and approach, and particularly your sense of 
urgency around reforming and changing and making that cultural 
change, making veterans first within the VA organization. So I 
am very, very much encouraged.
    I think one of the--you know, one of the more global issues 
I think I wanted to raise with you in this hearing is in the 
time that I have served on this committee it has been 
extremely, extremely frustrating getting information from the 
VA, and I hope, and my dream is that as you move forward and 
set out a plan for change within the VA that we will all 
collectively, we as members of this committee, you at the 
bottom of your organization, and certainly the veterans and the 
VSOs most importantly, that we all can collectively agree on 
the direction the organization is going and then set the 
appropriate outcome measures that we are looking for so that we 
can again collectively monitor and watch and evaluate the 
progress as we move forward.
    So for me that is, you know, a very essential thing, 
because it is really the only way that we can tell the American 
people that we are, you know, that we are on track and we are 
making progress. So if you could just comment.
    Secretary McDonald. Yes, ma'am. As we talked I want to be 
your partner and that is why I am sharing with everyone our 
Road to Veterans' Day plan for the next 90 days, and as we are 
renewing our strategic plan, which we are starting as a 
leadership team this Friday doing, we will share that with you 
as well.
    I know from my confirmation hearing and from talking to the 
chairman the communications has been a challenge for us, and 
frankly some of the communications have come to my desk, I have 
rewritten myself because I have just been totally unhappy with 
our ownership for the problem, or with our ownership for the 
issue.
    The Chairman. I want it integrated so that we are saying 
the same message, but that is not an attempt to centralize. In 
fact what we talked with the chair about was decentralizing so 
that you can go to the subject matter expert and get the answer 
and it doesn't necessarily need to be cleared with one tip of a 
funnel.
    I think what has happened in the past is the organization 
has done that, they have made everything go through one person, 
and when you do that it obviously backs things up. And 
everybody should be capable enough to be able to answer, and of 
course I would ask your indulgence that you would have to 
realize that if you got a wrong answer it may be temporary or 
it may be incompetence, but the person is not trying to deceive 
you. And we will work together to make sure we clear up any 
miscommunications.
    Ms. Brownley. Thank you for that.
    And I am a strong believer in data driven decision making, 
I think the data is extremely, extremely important. I would--my 
two cents would be in terms of the data that will be presented 
to you is trust, but verify. I don't think I have necessarily 
the confidence of the data that has been presented to us and 
don't have the confidence there, and in some ways want to just 
clean the table and start all over again in terms of the data 
collection, but I know there is--I am sure there is some good 
data that is there also. But there does need to be----
    Secretary McDonald. Well, the point is they are getting the 
right values and the right mission in place and making sure 
people look at everyone through the lens of veterans.
    Step two is getting the right leaders in place, and we are 
in the process of doing that.
    Step three is getting the right culture in place, and then 
we have got to get the right strategies. Right now we have a 
group of strategies that frankly no one is working against. 
They are in the desk drawn somewhere, but if my test is: can I 
go to the lowest level employee, or in my case I would say the 
highest level employee, and do they know how their work every 
day is tying back to caring for veterans? If they don't stop 
the work.
    I had somebody bring to me a binder full of information the 
other day. I said, well, what is this for? And one binder was a 
series of reports. And I said, well, I have already seen all 
this information, let us stop doing it. And so that got rid of 
a whole bunch of work. Another binder was testimony I gave at 
the Senate hearing. Why do I need to see my own testimony? Let 
us stop doing that.
    So we have got to stop a bunch of things and then redeploy 
all of that effort against caring for veterans.
    Ms. Brownley. Thank you, my time has expired.
    Secretary McDonald. Yes, ma'am.
    Ms. Brownley. But thank you, and I look forward to working 
with you, and I yield back.
    The Chairman. Thank you.
    Dr. Wenstrup, you are recognized.
    Dr. Wenstrup. Thank you, Mr. Chairman.
    Mr. Secretary, it is a pleasure to be with you today and I 
do thank you publicly for taking on this task.
    I benefit from living in the City of Cincinnati where 
Proctor & Gamble is located and all the great things that you 
have brought to our community with Proctor & Gamble has 
benefited so many people.
    But as you take on this job there are so many things to 
consider, and I know it is a monumental task, but it is not one 
that you are unfamiliar with, and why so many of us for a while 
have been talking about needing an outside influence, someone 
from the private sector, because we are talking about 
acquisitions, cost versus productivity, changing a culture, 
assuring quality and care as well as access to care, all these 
things that go into being successful.
    And I just want to say I think if there is anyone that can 
create a brand it is someone who has been at Proctor & Gamble, 
because that is what you--and not only that, you build trust 
with that, and that is going to be the key. So if you can build 
trust in the VA brand in the same way that you have done Tide I 
think we will be in good shape.
    And I appreciate your openness and the ability to work with 
you every day. Thank you.
    Secretary McDonald. I look forward to working with you and 
I appreciate the fact of the commitment of all the members of 
this committee, which really means a lot to all of us at the 
VA.
    The Chairman. Ms. Titus.
    Ms. Titus. Thank you, Mr. Chairman.
    Mr. Secretary, thank you for being here. There was a lot of 
enthusiasm when you were appointed and I think anybody who has 
heard you testify today will certainly have that feeling 
reinforced and erase any doubts that you are the man for the 
job. So we appreciate it.
    Also thank you for coming by to see me. It meant a lot that 
you had already taken time to visit Nevada, both our service 
center in Reno that has had so many problems and the new 
hospital. It shows that you are really personally vested in 
that and we appreciate it.
    Also it has been nice to hear all my colleagues talk about 
our bill to create more residencies in the hospitals, and I 
would just point out again as we talked about in our meeting, 
that we want to be sure that those residencies don't just go to 
the big hospitals that already exist, but really go to the 
places where they are needed. I know Mr. Beto also worked on 
that and there are areas that are under served and that was the 
real intent. So we want to be sure they do that.
    Also we are very supportive of your notion of reorganizing 
not just middle management but also the geographic regions, 
because Las Vegas is in several different areas that just don't 
really make much sense.
    And finally maybe you could share with the committee and 
for the record some of the things you told me about the new 
emphasize on women veterans, because they are our silent 
veterans, they have had serious problems, one in four hospitals 
doesn't have a gynecologist. I know that is a new priority of 
yours, which I am very supportive of and want to work with you 
on, and maybe just put on the record some of the things that 
you are doing that.
    Secretary McDonald. Yes, ma'am. Well, thank you very much, 
and we look forward to working with you.
    I know that--I know that apportioning those additional 
residencies will be very important and we will work with you on 
that, because we have got to--I have played hockey, we have got 
to go to where the puck is going to go rather than where it has 
been, and so we have got to--we have got to get after that, and 
we will work with you on that so we are making a decision 
together.
    Relative to women veterans, to me this is critically 
important. Right now we have about 11 percent of veterans or 
women, but of course the percentage in the army--or in the 
armed forces is much, much higher, so obviously it is going to 
increase over times.
    Many of our facilities were built in the 1950s when we were 
virtually a single gender army, and so when you think about the 
kinds of equipment we have, when you think about the kind of 
doctors we have, you are right, we need to hire more OBGYNs. We 
have got to get ahead of this, because it is quickly becoming 
an issue for us already.
    One of the things that we have also done is many people see 
the mission of VA as articulated in Abraham Lincoln's second 
inaugural address where he said, for him who have borne the 
battle for his widow and his orphan, and we have changed that, 
we have paraphrased it, and if you look at our mission the way 
we call it out here in our 90-day plan we say, better serve and 
care for those who have borne the battle for their families and 
their survivors. And while that seems like a modest change in 
words, it has meant a lot to our female veterans to know that 
we are looking out for them or we are thinking about them, and 
we have got to get ahead of the things we need to do so that we 
are able to meet the capacity.
    Maybe Dr. Clancy can talk a little bit more about this, 
because I know this is of particular interest--area of interest 
to her.
    Dr. Clancy. I would agree with everything the secretary 
just said, and it is a very high priority for us, and it has 
changed a lot in recent years, but we are not going to slow 
down until every single facility has got a topnotch women's 
health coordinator.
    All of our health coordinators across the system just got 
reinforcement of all the training that they get to make sure 
that we are meeting those needs, and it will remain a high 
priority.
    So thank you for your continued support, because we can see 
where the numbers are going as the secretary just noted.
    The Chairman. Mr. Jolly.
    Mr. Jolly. Thank you, Mr. Chairman.
    Mr. Secretary, welcome, we haven't had an opportunity to 
meet. I echo my colleagues' comments, thank you for serving.
    Secretary McDonald. Thank you, I look forward to getting 
together with you soon.
    Mr. Jolly. My predecessor was here for 43 years and one of 
your predecessors once nominated he counseled, he said, please 
don't take this job, you are not going to be able to change the 
VA, and I will never forget that as a young staffer in that 
meeting, and I know this challenge that you face.
    I appreciate your comments today. I want to express a 
little bit of concern and maybe give you an opportunity to 
revisit your exchange with by colleague, Mr. Lamborn when he 
asked about whether you believe that wait lists contributed to 
the deaths of veterans. I understand that is a hard question 
for you to ask, but if we are talking about changing the 
culture it is a very important one, because you have spoken a 
lot of organizational changes, but as you step into this role 
do you believe that the negligence of the VA has contributed to 
the deaths of veterans over the past several years?
    Secretary McDonald. Again, I think it is very simple, there 
are veterans who haven't had access, there are veterans who 
haven't gotten proper care, I don't really need to go any 
further than that.
    Mr. Jolly. Well, no----
    Secretary McDonald. That says there is a problem. That says 
I have got to get it down. I am focused on our veterans.
    Mr. Jolly. Sir, I mean this very respectfully, I got a 
little heated in the last exchange, I shouldn't have.
    Secretary McDonald. What value is there in having this 
discussion?
    Mr. Jolly. Because that actually speaks----
    Secretary McDonald. Is it going to help more veterans?
    Mr. Jolly [continuing]. Because that actually speaks to the 
cultural change of the department. I understand the 
administrative changes and the organizational changes and I 
think it is needed.
    Deputy Sloan Gibson--Deputy Secretary Sloan Gibson when he 
was acting sat there and apologized to the Congress and the 
American people for the failures of the department and what it 
led to for veterans.
    You got into an exchange with Mr. Lamborn and you just did 
now as well that doesn't show an acknowledgment, and to me that 
is not a cultural change, that is going backwards.
    I understand nobody wants this on their fingertips, you 
weren't there, I get that, I am not holding you accountable. 
But in terms of the culture that you bring to the top 
leadership posts at the VA do you believe with conviction that 
the wait list problem contributed to the deaths of veterans or 
do you not?
    Secretary McDonald. Sir, in my opening statement I said I 
apologize on behalf of myself and the Veterans Administration--
Veterans Affairs Department. I have said that in every 
testimony I have given.
    Mr. Jolly. Right.
    Secretary McDonald. I have said that when I have gone out 
to town hall meetings when I have talked to veterans. I own 
this. It is not because I wasn't there, I own this. I wouldn't 
have taken this job if I thought that somehow I could not own 
this. I own this and I am committing to you that I am going to 
fix it. I don't know that you can ask for a bigger commitment 
than that.
    Mr. Jolly. Well, I mean it is a very simple question, I am 
just asking you to acknowledge that the wait list and the 
negligence that the VA contributed to the deaths of veterans 
that we have had hearings on for six months, that is all.
    Secretary McDonald. And I am acknowledging--I am 
acknowledging that I own it, that they didn't get the proper 
care, and that we need to improve.
    Mr. Jolly. Okay. Well----
    Secretary McDonald. And that not getting proper care has 
adverse effects.
    Mr. Jolly. And I very respectfully will take that as an 
answer. I don't think it is a complete answer, I don't think it 
is an acknowledgment of a cultural change that you continue to 
espouse, but I understand why you need to guard your words 
carefully in a public hearing and in front of the press, and 
hopefully privately you acknowledge that the negligence of the 
VA has led to the deaths of veterans.
    Secretary McDonald. Let me again say I own this problem.
    Mr. Jolly. I understand.
    Secretary McDonald. And one of the things my West Point 
classmate I thought did so well, and he is a great leader as 
the interim secretary, is he owned it and he is helping the 
organization own it and I am too. We have to own it. If we 
don't own it, as you have said, we can't change.
    Mr. Jolly. And I appreciate that. I look forward to working 
with you. Thank you for serving, I appreciate it.
    The Chairman. Ms. Kirkpatrick.
    Ms. Kirkpatrick. Thank you, Mr. Chairman.
    Mr. Secretary, first of all thank you for taking the job, 
and then thank you for visiting the Phoenix facility as your 
first stop after you were confirmed, that really gave a message 
to our veterans in Arizona that you care and you are paying 
attention.
    Now this--I want to focus on accountability, because our 
committee has heard from people who say they are getting 
excellent care at the VA and that the employees at the VA care 
about veterans, many of them are veterans, but I am sure that 
you are familiar with the business motto, if you will, that an 
organization is only as good as its weakness link, and we know 
that there are weak links in the VA. And I just want to get 
your thoughts about how you insure that there is continuing 
accountability, and I just want to tell you some of the ideas 
that we are heard, and then if you could comment on them.
    One is rolling audits, review by a neutral party. Mr. 
Michaud has an idea about setting up a blue ribbon committee 
that would develop a strategy for the VA. I have a veteran in 
Flagstaff who talks with me frequently about the idea of a 
volunteer board of veterans who really don't have any 
connection with the administration at all but are sort of a 
sounding board and a way to solve this. I have one idea I 
introduced by Whistleblower Protection Act, which includes an 
anonymous hotline for patients and employees to report things. 
And would you just give us your thoughts about that?
    Secretary McDonald. Well, I think accountability is a huge 
issue, and it has got to be a big part of the cultural change.
    One of the things we have done is we have talked a lot of 
about it, we have talked about that concept that I mentioned in 
my prepared remarks, sustainable accountability. It is not just 
about firing people, it is about giving day-to-day feedback.
    I mean my standard is that an individual would never need 
to be fired unless it was an egregious activity because you are 
providing day-to-day feedback so that person should never be 
surprised. That should be the standard.
    Relative to external groups we--Deputy Secretary Gibson 
when he was interim secretary hired Jonathan Perlin who was the 
chief medical officer of HCA to join us in developing the 
blueprint for 
excellence for the hospital network. That was an attempt to 
bring outside benchmarking into VA. We are very much in favor 
of that. The new bill provides for a commission which we will 
help stand up.
    There also is--I am trying to rejuvenate some of the 23 
different standing committees we have which are supposed to 
help the secretary. There are 23 of them, one could argue maybe 
that is too many, but there are 23 of them that are supposed to 
be helping the secretary. I want to reenergize those and I want 
to get the right people on them. One of them Dr. Clancy and I 
are in the process of hiring new doctors and nurses and 
clinicians to help us to join that.
    So we want to do exactly what you are saying, but the most 
important thing for me is we have got to get every single 
employee in the organization to feel accountable for the 
outcomes of that veteran rather than worrying about the 
internal workings of VA.
    Ms. Kirkpatrick. And let me just mention one of the more 
troubling things that our committee has heard, and that is 
bonuses and that people who perform poorly still get their 
bonus and that there is this sense of a bonus is an entitlement 
to the employees, and what is your plan to address that? Can 
you give us your idea about that problem and what is the--a 
good use of the bonuses?
    Secretary McDonald. All right. Well, first of all, Deputy 
Secretary Gibson when he was interim secretary took the 
immediate step of the rescinding the bonuses for 2014.
    Second of all he took the 14-day metric out of peoples' 
performance plans because that was helping to cause people to 
behave in the wrong way based on outcome for veterans.
    Third thing is I have gone back and I have reviewed what 
can we do about bonuses? In private sector there is something 
called a claw-back provision so that if an individual receives 
a bonus and you later discover, because we have 100 
investigations going on, you can claw back past bonuses in 
order to do that, and many audit committees, which I have 
served on, have put rules in place to do that.
    In the government right now there is not a potential for 
clawback because apparently when the law was written the law 
was written in such a way that when the political parties 
changed you didn't want to allow the new political party to 
clawback from the past political party. I have got to get into 
this in more detail, but that is the way I understand it right 
now, but that is the practice in the private sector.
    Ms. Kirkpatrick. Thank you, Mr. Secretary, we look forward 
to working with you.
    Secretary McDonald. I look forward to it too. Thank you.
    The Chairman. Mr. Secretary, I will tell you that there is 
a bill that has been filed, H.R. 5094 and it allows you to do 
just that should we be allowed to pass that through the full 
house and then on to the Senate.
    Mr. O'Rourke you are recognized.
    Mr. O'Rourke. Thank you, Mr. Chairman.
    Mr. Secretary, I want to join all my colleagues in thanking 
you for your service and taking on this very difficult but not 
impossible task of bringing the VA back up to where it should 
be.
    And I want to thank you for meeting with me and just from 
that meeting and some of the issues we discussed in your follow 
up to those items, including an email today from Dr. Clancy, I 
think that speaks very well of your ownership of these issues, 
your attitude of accountability, and some of the things that we 
will have to look forward to on the bigger issues confronting 
the VA.
    I also appreciate your commitment in our meetings to insure 
that El Paso, which is currently I would argue one of the 
worst, if not the worst, operations in the VA become it is 
model. I think you have no greater opportunity to demonstrate 
turnaround than you do in El Paso.
    And I wanted to use the example in El Paso to make a larger 
point about the system and get your response. Following what we 
learned about El Paso, despite our assurances from the VA to 
the contrary that we were seeing people within 14 days, we 
learned that fully one-third of veterans couldn't get in to see 
a mental healthcare appointment, the average wait time you 
could get in was 71 days, that average appointment when 
scheduled was canceled at least once on average or rescheduled 
at least once.
    When we had the VHA audit in the spring we learned that we 
were the worst for established mental healthcare appointments, 
worst in terms of being able to see a doctor or provider, 
fourth worst for new patients, second worst for specialty care, 
on and on and on. So we had that attention, that focus.
    VA committed $5.2 million in additional funds. The acting 
secretary, Sloan Gibson, visited the VA. We had our chairman, 
Chairman Miller visited the VA in El Paso. We had Mr. Matkovsky 
visit the VA. We had primary care teams, mental healthcare 
teams that you sent down there.
    And yet when I went there two weeks ago, and I often go by 
just to talk to veterans and see how things are doing, greet 
them in the parking lot, I met a number of people who said, 
hey, I got excellent care, wonderful treatment, thumbs up, you 
guys are doing a great job, and a number of people who had 
complications or issues and we tried to help them with them, 
but one was very glaring to me, and it was a gentleman who 
said, you know, I was given an appointment today and that was 
months back that I scheduled it, I called yesterday to confirm 
my appointment with Dr. B, this is a mental healthcare 
provider, and they said, yes, we have got you there to see Dr. 
B at 1 o'clock tomorrow, we look forward to seeing you.
    The gentleman shows up, and I don't know how hard it was 
for him to travel there, but he gets to the VA, shows up for 
his 1 o'clock appointment to be informed that Dr. B no longer 
works at the VA and hasn't worked there for a month.
    And so I thought with all of the attention that I have been 
bringing to this issue, that the VA has been bringing to this 
issue, for us to fail this veteran that badly is indicative of 
some deeper, larger issue. And I think of the 20 IG reports 
since 2005 that we have had about scheduling problems within 
the VA that all of us, Congress, and administration have known 
about, and yet we haven't resolved those issues.
    Tell me, to Mr. Jolly, and others who brought up this 
point, answer that concern that we have about culture. We can 
as we did in El Paso throw money and attention at it, 
personnel, flexibility in how you fire and hire people, but I 
think there is a deeper cultural issue. How will you address 
that in a minute and a half?
    Secretary McDonald. As I said, cultural change is very 
difficult to achieve, but it starts with the mission and the 
values, and I would wonder in an organization have they really 
committed themselves to the mission and the values if an 
individual can be signed up for an appointment with a doctor 
that doesn't exist?
    Frankly in a situation like this let us know, we will go 
back and check and we will get back to you and find out what 
happened in the specific instance. Any specific anecdotes you 
can provide us are very helpful, because it allows us to go 
back and understand what really went wrong and then correct it 
in the future. So it starts with the mission and values.
    Secondly, I think it starts with leadership behavior, and 
that is why I have gotten out to as many places as I have. I 
have to get to El Paso.
    Third, I think there is a big issue in the openness or lack 
of openness in this organization. I mean how could you have a 
situation where employees were lying to one of the most 
honorable men I have every known in my life in General 
Shinseki? Why would that exist? Why would that happen? Why 
would we have meetings where union leadership wasn't involved 
or weren't invited? Why would we have people feeling their only 
recourse was to be a legal whistleblower? You know, that is why 
I demand the town hall meetings, and when it demanded them some 
of the feedback I got was, well, we can't hold a town hall 
meeting, it will be counterproductive, it will be violent, 
whatever. That is exactly why we have to do them.
    We have got to open the culture up, we have got to get 
communication moving, we have got to get ownership for the 
problems, and we have got to get people feeling responsible. 
Because in the end the only thing that matters is the veteran. 
This is going to take time, but we are going to build it into 
our strategies.
    When I think of a high-performance organization it starts 
with mission and values, and I think we have got that, we are 
under way there. We have got to look at our leadership and see 
do we have the leadership to create this new culture? If a 
leader is unwilling to embrace this new culture then they 
shouldn't go on the journey with us. Do we have the right 
strategies in place in order to perpetrate this culture to make 
it happen across? And we are taking a look at that. Do we have 
the right systems in place? The system would be so that if you 
asked me how could this happen in the scheduling system that 
this doctor who doesn't even work there gets made an 
appointment.
    And then the last is do we have the right high-performance 
culture where people flow to the work and people work on 
veterans' issues? It is going to take time. It is going to take 
time. But I really do believe we can do it.
    Mr. O'Rourke. As I yield back to the chair let me just 
offer my assistance. If you are missing legislative authority 
to do any of the things that you are talking about doing to 
turn around and improve the culture at the VA I hope that you 
will come to us as quickly as you know that. We will be your 
partner in offering that legislation and getting it passed.
    So, thank you again for your service.
    Secretary McDonald. Thank you very much.
    Mr. O'Rourke. Thank you, Mr. Chairman.
    The Chairman. Mr. Walz.
    Mr. Walz. Thank you, chairman, and thank you, Mr. Secretary 
again to assuming this sacred trust and awesome responsibility. 
I am grateful you are there. I think restoring that trust is 
one of the first and paramount things.
    And I also want to say you scored big points with my chief 
of staff who is a Minnesota hockey player with your reference. 
I often as a football coach talk about pursuit angles, but it 
is the same thing, where do we need to anticipate?
    And I have been saying, and I applaud other members and Mr. 
Michaud for his take, I have been saying for a long time I 
never understood as a military person myself why there was no 
equivalent of the quadrennial defense review? Secretary Hagel 
has that his dispense and I was just thinking about this, think 
to not have that and defend. I went back and looked at the 1971 
under then Secretary Cohen talking about--1997, think about 
that, we are dramatically safer than during the Cold War, but 
wild card threats are more than likely to happen, and they 
started anticipating where those threats would come from once 
the full out eastern European threat was gone or whatever, that 
allowed us to start tailoring the force to be prepared to 
respond to those things. The VA does not have that. The VA did 
not do that. And here we are trying to figure out that we are 
going to add a whole bunch of veterans are Iraq and 
Afghanistan.
    So, I would encourage you whatever that form looks like, 
Mr. Michaud and others are doing this, this is something that 
would help you enculturate this need to get that there is it 
would give you that guiding document and it would force us to 
go back on a periodic basic, whether it is quadrennial or 
whatever it would be, to get that done. So, I would encourage 
you to do that.
    And then I would say you are at a unique perspective here, 
this is the time as I have been saying, let us think big, let 
us do the reforms that have stymied people, let us breakthrough 
the barriers that have been there, let us crush this thing.
    And you know what, it is going to be hard to change 
cultural, it is going to be difficult, but here is what I would 
say is, if not you, who? If not us, who then? And if not now, 
when is this ever going happen? And if the country believes 
that is important, as I know they do, if all of us in this room 
believe it is important, let us get there.
    And I think something you can bring, and I would just be 
interested to hear your thoughts, Mr. Secretary, we have got to 
break down this false construct of government versus the 
private sector. We work together best, this is service of 
veterans, if the private sector can deliver, if we can work in 
conjunction, if you can do it quit that argument that a dead-
end that it is trying to find versus them. This is our veterans 
trying to get it right.
    So, I would ask you how do we speed collaboration? I 
represent the Mayo Clinic, a great medical institution, but 
also in a rural area that has roots in combat medicine and 
that. How can you bring your experience from P&G to bridge that 
and break down this ridiculous us versus them argument on the 
care of our veterans?
    Secretary McDonald. Well, we are going to embrace it in our 
strategies. We believe that we can't do this by ourselves and 
that we have to partner. We have to partner with medical 
schools as we have already talked, we have to partner in the 
private sector, we have to partner with members of Congress. 
And so the important thing for us will be to figure out 
everybody's role and to create a system which takes advantage 
of that.
    I will give you an example. I was in Las Vegas in 
Congresswoman Titus' district, and there we are very close to 
Nellis Air Force Base, and the doctors at Nellis Air Force Base 
can't keep up their medical proficiency without seeing VA 
patients, they just don't get enough--a broad enough piece of 
work doing only flight physicals for pilots at Nellis. So it is 
great. We have the DoD doctors come over to the VA, they serve 
our clientele, the doctors at Nellis love it, we love it.
    So one of the things I did in preparation for this--not 
this hearing--but for this role, was to get a map of all the 
federal facilities in the country, I know most of the private 
facilities because we had a healthcare business at Proctor & 
Gamble, and to figure out what is the right combination where 
if we don't have those OBGYNs that Carolyn and I talked about 
we can--we can borrow them from someone elsewhere--or DoD, 
Indian Health Service is another example in rural areas. Indian 
Health Service has some terrific facilities.
    So these are the kinds of things that we want to do, and 
our strategic work is to figure out what is the right 
combination of these things and inherently it will be local. I 
mean the details will be in each locale trying to figure out 
what the right combination is, because it will probably be 
different.
    Mr. Walz. Well, I would echo Mr. O'Rourke said, if there is 
something we can do, whether it is credentialing or whatever 
the things that--I mean some of these things are difficult and 
they are deep and they are tough, I understand that, but let us 
get there.
    But I want to give an example to my colleagues where I too 
have been frustrated with some of the flow of information, but 
I recognize the incredible work that gets down at times. If 
this is a glimmer of the potential last week in Minneapolis a 
whistleblower, the press was reporting a story, we were in 
contact with them, we have been working with this. This 
happened on a Friday night and by Monday there were people out 
there on the ground addressing or attempting to address on 
this, and there was a real sense of collaboration with both the 
public, the veterans, the member of Congress, all of are 
working together, where was the gap, where can we fill the gap, 
and how do we fix it?
    So, I have to say I am seeing that and I very much 
appreciate that I was seen as a partner trying to fix this as 
was the press as was the whistleblower in the case, and we will 
see what goes forward. Because I am with you, Mr. Secretary, we 
can't be afraid to point out our failings, we cannot be afraid 
to continue to move forward.
    Secretary McDonald. No, sir, and if any member of the 
committee ever senses that they are being treated as an 
adversary I would like to know that, because we know that we 
need to partner with you to make these changes.
    Mr. Walz. I appreciate it.
    I yield back. Thank you, Chairman.
    The Chairman. Thank you very much, Mr. Secretary for being 
here. We are very appreciative as has been said over and over 
again that you would be willing to stand in the gap for those 
who need leadership, and again, we would reiterate that it is 
our desire to stand with you as a full partner in serving those 
who have worn the uniform of this company.
    Mr. Michaud, do you have a closing?
    Mr. Michaud. No, I do want to thank Mr. Secretary for 
coming here, I look forward to working with you, and I agree 
with everything that Chairman Miller has just said. So thank 
you very much for your service and look for ward to a strong 
partnership.
    Secretary McDonald. Thank you, I look forward to working 
with you all, and I know every person in VA does as well.
    The Chairman. Thank you, Mr. Secretary.
    Secretary McDonald. Thank you.
    The Chairman. Member, we have--the votes have been called, 
and it looks like it is going to be a series that will last 
about 50 minutes. It is your--5-0--it is your choice. We can 
begin with the third panel, they have no opening statement so 
we can monitor the clock and carry on if you wish.
    Okay, if we could ask the second--or third panel to come 
forward. Thank you, as the third and final panel comes to the 
witness table and we are setting up the name plates I will tell 
you who we are going to hear from. Dr. Lisa Thomas, Chief of 
Staff of the Veterans Health Administration. Dr. Thomas is 
accompanied by Dr. Darren Deering, Chief of Staff of the 
Phoenix VA.
    If you would I would ask you to stand, I was going try and 
catch you before you sat down, raise your right hand.
    [Witnesses sworn.]
    The Chairman. Thank you. And let the record show that both 
witnesses responded in the affirmative.
    Secretary McDonald has already provided an opening 
statement on behalf of the Department of Veterans Affairs, so 
we will move directly into a round of questions.

        DR. THOMAS AND DR. DEERING ARE JOINING THE PANEL

    Dr. Thomas, on March 14th of 2013, the ONI Committee 
revealed wait time in healthcare delays in Augusta, Georgia; 
Columbia, South Carolina; and Dallas, Texas. Who months later 
in May, VA waived the fiscal year 2013 annual requirement for 
facility director to certify compliance with VA policy further 
reducing accountability over wait time, data integrity, and the 
scheduling practices.
    Are you familiar with that?
    Dr. Thomas. Yes, sir. I am.
    The Chairman. Did you approve or recommend the waiver of 
the requirement?
    Dr. Thomas. No, I did not.
    The Chairman. So you knew the waiver was given?
    Dr. Thomas. After the fact.
    The Chairman. After the fact, and what action did you take 
after the fact recognizing that there was a real problem?
    Dr. Thomas. In the spring of this year is when we realized 
that we really missed the boat in VHA, that the situations 
regarding delays in care were more of a systemic issue, rather 
than looking at each case individually. And in the spring of 
this year when we went back and researched it, the memo that 
you reference that was issued in 2010 was prior to my tenure as 
the chief of staff, so I went back and looked at that. It was 
in the media; it was hard not to realize that we had this memo 
talking about our scheduling problems and the gaming of the 
system.
    And we looked at that in relationship to all of the other 
issues that were going on around the country and realized, 
albeit too late, that we had a systemic issue. We should have 
taken a holistic approach to looking at it, rather than looking 
at each individual instance in isolation.
    The Chairman. We have the original Inspector General report 
on Phoenix and we have the one that VA released. I assume that 
you are aware that there was a crucial change in language made 
in the executive summary that said the physician whose 
allegations this committee had carefully verified could not 
tell the Inspector General the 40 names of the veterans who had 
died. I think this gave a false impression right up front that 
the whole matter was untrue.
    So my question to you is did you have any idea that 
language like this was going to be inserted in the IG's report?
    Dr. Thomas. No, I did not.
    The Chairman. Your--let me see if I can find it real 
quick--according to your fiscal year 2013 performance review, 
by the way, 500 out of 500 is what you received on your 
review--perfect, one of your responsibilities as Veteran Health 
Administration Chief of Staff is being able to identify 
critical OIG reports that could produce negative media 
attention and ensure talking points in communication plans are 
developed before the final report was released to increase the 
Department's responsiveness.
    So could you give the committee a little idea as to how 
that works?
    Dr. Thomas. Absolutely. Sir, first, what I would like to 
say is we sincerely apologize to all the veterans. No veteran 
should have to wait for care and it is unacceptable to us. We 
did get the IG report in several drafts and at each draft stage 
of getting a draft, it was our responsibility to make sure that 
we were putting together an accurate communication plan so that 
we could then communicate to all of our stakeholders what the 
IG found, but more importantly, what we were going to do to fix 
it. We really focus on more of the edits and looking at what we 
are going to do in the action plan, than the actual OIG report.
    And as Dr. Clancy said, we have a management review service 
and they are responsible for looking at that and making sure 
that all the correct subject matter experts look at that report 
and if there is anything factually that they think needs to be 
corrected, they provide that information. And what we also do 
is making sure that all the subject matter experts come 
together to identify what is the corrective action that is 
needed so that we can meet the needs of veterans.
    The communications folks that report to me were doing that 
every iteration, and so every iteration of the report we were 
trying to highlight for them what was the differene from the 
last report to the next report so that they could accurately 
and very efficiently get a communication plan together. One of 
those changes was a change from 28 recommendations to 24. The 
consolidation of a number of individual recommendations 
regarding ethics were rolled into one. Highlighting those for 
them makes it easier for them to be more responsive to have a 
document that is pulled together so we can communicate to all 
of our veterans, the public, and the stakeholders what was 
found and what we are going to do to fix it.
    The Chairman. Okay. I am going to ask you to pause right 
there.
    Members, we need to move to the floor. We have got less 
than five minutes to get to the vote and we will be back as 
soon as we can.

    [Whereupon, at 4:52 p.m., the committee recessed, to 
reconvene at 5:36 p.m., the same day.]

    The Chairman. The committee will resume its hearing. Again, 
we apologize to the witnesses. That will be our final 
interruption for the day.
    Dr. Deering, thank you for attending. I would like to know 
if you have reached out to any of the whistleblowers about 
resolving their cases, and if no--if so, how many have you 
worked with?
    Dr. Deering. I have not personally reached out to the 
whistleblowers at the Phoenix VA about their specific cases.
    The Chairman. Would that be something that you ordinarily 
would do or would somebody else do that?
    Dr. Deering. I believe somebody else is working with them 
on their cases.
    The Chairman. But in a normal course, I mean I understand 
that Phoenix is somewhat of an anomaly, normally, would you be 
the one who would reach out to whistleblowers?
    Dr. Deering. Certainly. I mean I have had other employees 
who have brought up concerns within the organization and I work 
with them closely to address those. I had an employee just 
about two weeks ago sent me a message on my personal cell phone 
saying that she had concerns she would like to discuss. She 
didn't feel safe talking about them at work and I met her off 
campus to discuss those issues.
    The Chairman. Has anybody prevented you from talking with 
whistleblowers or advised you not to talk to them?
    Dr. Deering. No, I have not been advised not to.
    The Chairman. Okay. Of the 293 deaths that were identified 
by the Office of Inspector General, how many required 
institutional disclosures?
    Dr. Deering. I don't have that information because I have 
not reviewed those 293 cases specifically. I would have to 
crosswalk those to see how many would require institutional 
disclosures. We are in the process of reviewing the 45 cases 
that were outlined in the Inspector General's report to see 
which of those would require institutional disclosure, if 
necessary.
    The Chairman. You are the chief of staff of the Phoenix 
healthcare system and you don't know if there are institutional 
disclosures?
    Dr. Deering. I haven't been provided the specific names of 
those 293 veterans, sir. I can get the list of names of who we 
have conducted institutional disclosures on and I don't know if 
those happen to be on that same list.
    The Chairman. Well, let's go this way. How many 
institutional disclosures have been made at Phoenix in the last 
two years?
    Dr. Deering. In the last two years--and I can get that 
specific number--but it is around six or seven institutional 
disclosures have been conducted.
    The Chairman. Say that number again.
    Dr. Deering. Somewhere around six or seven.
    The Chairman. Okay. Did you order OIG report case number 
seven's schedule an appointment with primary care consult to be 
removed from his chart?
    Dr. Deering. Can you repeat that question for me? I am 
sorry.
    The Chairman. Report case number seven, which was in the 
OIG report, there was a schedule an appointment with primary 
care, but it was removed from a chart, and my question is: Did 
you remove this from his chart or if you didn't, who did?
    Dr. Deering. I don't recall instructing anyone to remove a 
consult from someone's chart, but specifically to case number 
seven, I don't have that patient's demographics. I would have 
to go back and look at that and get back to you with that 
information.
    The Chairman. Who at Phoenix can remove those kinds of 
records or can wipe a chart clean?
    Dr. Deering. Consults typically aren't removed; they are 
discontinued or cancelled or completed. So even if they are 
discontinued or cancelled, they would still stay in that 
veteran's chart and they would show that they were discontinued 
or cancelled.
    The Chairman. It was a primary care appointment that was 
taken off of number seven's chart, so, again, I am just trying 
to get to the bottom and find out exactly what happened.
    Dr. Maher is it Hutman? Huttam.
    Dr. Deering. Huttam.
    The Chairman. Huttam.
    Dr. Deering. Huttam, yes.
    The Chairman. Huttam, reported health and patient safety 
issues to leadership and was fired. I am sure you are aware of 
his firing and I guess was fired by Ms. Hellman. Did she ask or 
require you to do a board on Dr. Huttam?
    Dr. Deering. Specifically regarding Dr. Huttam, I don't 
recall him bringing patient safety concerns to my attention. 
Regarding his termination, a summary review board was convened 
to look at his case specifically and make a recommendation to 
the medical center director.
    The Chairman. But you did conduct a board on him?
    Dr. Deering. I did not conduct a board. I convened a board 
and it was ran by another physician.
    The Chairman. Can I ask you--it is a personal question, but 
I think it is pretty simple--after all that has happened at the 
Phoenix VA medical facility, how is it that you are still 
employed there?
    Dr. Deering. Sir, I think that is a fair question, and if I 
may, I grew up in the VA. My father, who was a veteran and 
passed away in October received all of his care through the VA 
healthcare system and I have memories from being a child 
growing up in waiting rooms where we would often show up and 
wait all day for an appointment, and often be turned away at 
the end of the day not being seen.
    I came to work at the VA after training there as a medical 
student, as an intern and resident. Dr. Foot was my attending 
when I was a resident. I am very committed to this mission. I 
worked one year in the private sector and I ran back to the VA 
when I had the opportunity. I have committed my whole career 
and a lot of my personal life to try and improve the VA.
    The Phoenix VA is certainly not perfect and I have said 
that before. I don't think that any healthcare system is 
perfect. We certainly have made mistakes. We are learning from 
them and we are moving forward, and a good example is after the 
interim report came out from the Inspector General, I helped 
lead the initiative to get all of those patients that were on 
unofficial lists in for care, contact them and get them in, in 
a short duration of time.
    I am very committed to this mission and to the cause and 
have spent a large part of my life either as a child growing up 
or as a trainee or student or as a provider in the system. I 
believe in the system.
    The Chairman. Mr. Michaud.
    Mr. Michaud. Thank you very much, Mr. Chairman.
    Dr. Thomas, were you aware of VISN's 18 director's report 
in January of 2012 and again in May, 2013, that found that the 
Phoenix healthcare system was using unauthorized scheduling 
practices and not complying with VHA's scheduling policies?
    Dr. Thomas. I was not aware of the report until it was 
cited in the media and then we asked for a copy of it.
    Mr. Michaud. Is it your job to ensure that Phoenix complied 
with the VHA's policies?
    Dr. Thomas. I think it is all of our job in central office 
to make sure that we have a system that has policies in place 
that the field can understand, that it can implement, and we do 
need to improve our oversight to ensure the field is following 
policy. That is one of the things that both Dr. Clancy and the 
secretary are looking to change as part of the change in the 
culture to make sure that we have the appropriate oversight in 
the central office and the auditing function to make sure that 
things are happening the way that they are supposed to be.
    Mr. Michaud. Can you explain to the committee what your job 
is?
    Dr. Thomas. I can. As the chief of staff, I think the best 
explanation I can think of is I really serve a function as an 
advisor to the Under Secretary, whoever that may be, but I am 
really like an air traffic controller. I don't get to fly any 
planes. I am not responsible for making sure the plane takes 
off or lands safely; I am the one who is there to make sure 
that all of the planes are flying on time, going in the right 
direction, which is set by the secretary and the under 
secretary for health. So I need to have a broad understanding 
of everything that is going on within VHA, but, unfortunately, 
that means I am not a subject-matter expert. I can't drill down 
into each one of those areas and know in detail exactly how it 
works.
    Mr. Michaud. Okay. So you are looking at the planes as they 
take off and land properly, since Phoenix, Arizona, was not 
complying with VHA policy, not complying with it, you set a 
path for them to follow. They did not follow it. So who is 
responsible at VHA, is it the under secretary or your job as 
chief of staff----
    Dr. Thomas. I think----
    Mr. Michaud [continuing]. Or is your job of chief of staff 
is to be a--to make sure the secretary doesn't understand what 
is going on in the VISN office?
    Dr. Thomas. I think it is all of our responsibility in 
central office. If I could, sir, if you would allow me, when 
the first panel was here you asked a very important question 
and you said really what we need to know is what happened; why 
did it happen; how do we move forward; and how do we hold 
people accountable?
    And I think that is really key. And what did happen was 
that we have an overly complex scheduling system and process, 
which we are in the process of fixing. We also have an undue 
focus on performance metrics, and as you heard the secretary 
say, all of the performance metrics are related to the wait, 
the fourteen-day wait time metric has been removed.
    We do have capacity issues and the Choice Act which was 
recently passed is going to help us do that. We are going to 
hire 9600 clinicians just in fiscal year----
    Mr. Michaud. Okay. Since my time is running out, I guess 
the big concern I have--yes, we gotta find out what happened 
and how are we going to solve the problem, but if you were part 
of the problem in the under secretary's office that knew that 
Phoenix, Arizona, and other facilities were not complying with 
policies that were set by the Department, I guess it is your 
responsibility, and that is a big concern. I know I have it and 
I know that other committee members have is if you are part of 
the problem, how am I going to feel comfortable that you are 
not still going to be part of the problem?
    Dr. Thomas. Sir, unfortunately, we did not know of the 
problems in Phoenix until the spring and we did not know of the 
previous reports that the network had commissioned and saw that 
they had a problem, and I am not sure where that decision broke 
down, why we didn't know, but I do know that with a change in 
culture that the secretary has set forth for us, we are going 
to remedy that issue.
    Mr. Michaud. Did you see a problem with the Under Secretary 
Petzel and Secretary Shinseki, as far as not moving in the same 
direction or is there undercutting occurring between the two?
    Dr. Thomas. I was very rarely in the same meetings as the 
two gentlemen. I only knew what I heard the secretary say in 
the meetings I was in and what the under secretary would say 
when he would come back from meetings with the secretary. I was 
not privy to those personal conversations.
    Mr. Michaud. My last question moving forward is, is there--
what--as the VHA Chief of Staff, what have you done to make 
sure that scheduling problems do not continue to occur?
    Dr. Thomas. We have two very major initiatives that we have 
taken on. The first one was the audit, the access audit, which 
I know you have been briefed on so I won't go into detail. But 
that was very important for us to understand if this was 
isolated instances around the country or if we had more 
pervasive systemic issue, and sadly we know today it was a more 
systemic and pervasive issue.
    So we then launched into the accelerating access for care 
and make sure that we can put resources to all of the veterans 
who are waiting for care. Anyone who was waiting more than 30 
days we contacted. We reached out to every single one of them 
and offered for them to come in for care earlier or refer them 
to the community for care.
    For those that we could not contact, we made three attempts 
by phone, we sent a letter, and we are also working with 
partners trying to see if we can locate those veterans. So we 
are taking those extra steps to make sure we can identify who 
they are so we can bring them in for the needed care.
    Mr. Michaud. Okay. And last question--I know I am a little 
over time, Mr. Chairman--but do you think that there is too 
much autonomy at the VISN level and that is part of the 
problem, as far as following the directive from the Secretary 
or Under Secretary of Health?
    Dr. Thomas. My personal opinion is that we are not well-
standardized. A lot of people talk about centralization/
decentralization; I think that is the wrong conversation. I 
think we need to have a standardized system of healthcare that 
we can consistently provide quality healthcare to all of the 
veterans, whether they are in the large cities or in the rural 
areas.
    Mr. Michaud. Thank you, and thank you, Mr. Chairman.
    The Chairman. Mr. Huelskamp, you are recognized.
    Dr. Huelskamp. Thank you, Mr. Chairman.
    I am new on this committee and maybe it is just me, but 
trying to understand and--what is being reported in the numbers 
can be very difficult at times. I will note there is at least 
41 individuals that you did not reach on the outreach campaign 
that is reported as deceased, and I will note for the committee 
I think that is part of the records that did not get reviewed 
by the OIG where those--at least those 43.
    One thing I want to bring attention to that is disturbing 
to me is, Dr. Thomas and Dr. Deering, we have student rosters 
including employees from Dr. Deering's office, emails on VA 
purchases approved by the VISN and VA-sponsored training using 
a book called, ``How to lie with statistics.''
    And the author explains that his book is primarily used in 
the way to use statistics to deceive and a well-wrapped 
statistic is better than the big lie because it misleads you 
and it cannot be pinned on you. One of the techniques described 
in this book--and this is again, techniques that are taught in 
a course for VA employees--but I think it might have been used 
here before the committee. On July 11th, this was a chart 
provided to us by, I believe Dr. Deering's office or folks out 
of Phoenix, that led the committee, I believe, to suggest well, 
we have a problem with not enough employees.
    And if you look at the blue, you say, oh my goodness, look 
at the increase of the number of visits and needs of patients 
and the green line is the number of the FTEs increased, but 
when you put the two charts together, you will find out that 
they are on different scales and they are about flat. They are 
about even. This is about equal growth if you pull those 
numbers out there. But I look at that and the average American 
looks at that and says, oh my gosh, we just didn't spend enough 
money or didn't have enough employees there.
    But I think it is pretty clear. You can look at this 
graphic. You pull it down, and you look at what your employees 
are learning from in a book in the courses and my question of 
this probably to Dr. Deering or Dr. Thomas, but who 
orchestrated what appears to be a purposeful intent to deceive 
veterans, Congress, and the American people?
    Dr. Deering.
    Dr. Deering. Well, regarding the book, that, from what I 
recall, that was actually a VISN-sponsored training for 
coaching sessions. I wasn't involved with purchasing that book.
    The graph that you are showing on the screen right now is 
part of our congressional briefing to our local delegates. 
There was no intent there to mislead anyone. We were trying to 
basically outline the framework of how we got to where we were 
in Phoenix as part of Mr. Michaud's question.
    Dr. Huelskamp. Well, why would you do two different scales 
and put those together. I think that is very misleading, 
because if you actually use the same scale, the growth in the 
FTEs and the number of visits is about the same.
    Dr. Deering. I appreciate that feedback. The intent was not 
to mislead. The----
    Dr. Huelskamp. What is the intent to show there?
    Dr. Deering. The intent to show here is we have had 
continued growth in the outpatient setting on a number of 
visits that are coming into our facility over the last several 
years, and when you look at the increase in the FTE, it has 
gone up a little bit, but the key point here was back in fiscal 
year 2010, my personal belief is that we still, at that point, 
we did not have enough personnel to meet the needs. We were in 
the process of trying to hire staffing and get people on board.
    Dr. Huelskamp. But why would your employees be learning 
from a book about how to lie with statistics?
    Dr. Deering. Sir, I can't speak to that. That is a title of 
a book. I don't--I don't----
    Dr. Huelskamp. Well, there are employees from your office, 
I believe that are learning from this course. And so you have 
never seen this book before?
    Dr. Deering. I have seen the book. I haven't read it.
    Dr. Huelskamp. Are you saying that your employees have the 
book and are using it?
    Dr. Deering. I don't know which employees would have that.
    Dr. Huelskamp. Okay. Well, where did you see the book?
    Dr. Deering. I saw the book when the coaching session 
happened. This was quite a long time ago.
    Dr. Huelskamp. But I don't understand. What is a coaching 
session? You are coaching them to use this book to mislead the 
public?
    Dr. Deering. No, not at all, sir. Not at all, sir.
    Dr. Huelskamp. Well, describe why you would use a book like 
this which, again, demonstrates how one can misuse statistics--
and I have a background in this, this is part of my Ph.D.--and 
misuse statistics to mislead folks? Can you describe why would 
you be coaching people with this book?
    Dr. Deering. I can't speak to that because I wasn't--I 
didn't coordinate that training session through the VISN, sir, 
and I don't know if they were trying to teach people how to 
notice when statistics are not being used appropriately.
    Dr. Huelskamp. Well, actually, it says how to lie.
    Dr. Deering. Right. So I don't know if the content of that 
book is teaching people how to notice when people aren't being 
honest with statistics or if it is teaching people how to lie 
with statistics. I don't know what the intent of that book is 
without reading it.
    Dr. Huelskamp. This is your chart coming from your office--
--
    Dr. Deering. Yes, I know.
    Dr. Huelskamp [continuing]. And I think it is very 
misleading and it is difficult as a policymaker to get to the 
bottom of the facts of the matter, and we just had a hearing 
earlier, a few hours ago--you might have been here--but trying 
to figure out how many folks were on the waiting lists. And the 
numbers are very confusing coming out of the OIG, but this 
would suggest that gosh darn it, that there has been enormous 
growth, but there has not. It is a scheduling problem, and we 
have heard that again and again from the OIG, as well as from 
your office and I think that is very misleading.
    So, Mr. Chairman, I just want to make certain--I just will 
say--and I appreciate the time, Mr. Chairman-- it is so 
difficult to follow what the numbers actually are, and we have 
gone so far as to say the numbers don't matter anymore because 
it is driving bonuses and I think that both of you have pretty 
significant bonuses.
    Dr. Thomas, you have had bonuses for how many years in a 
row?
    Dr. Thomas. I don't know, but I would be happy to provide 
that information. I have the last two years here that I would 
be happy to leave with you.
    Dr. Huelskamp. Okay. I think mine show five or six or seven 
years in a row, and also doing very well.
    So with that, Mr. Chairman, I would have to share this with 
the rest of the committee, let's be very careful with what we 
see, unless it matches up with reality.
    Can you fix up this chart to match up--put on the same 
scale so we are comparing apples to apples?
    Dr. Deering. Sure, we can do that for you.
    The Chairman. Thank you.
    Dr. Huelskamp. Thank you.
    Ms. Kirkpatrick.
    Ms. Kirkpatrick. Thank you, Mr. Chairman.
    Dr. Thomas and Dr. Deering, as you can see, the committee 
has a lot of whys and since this problem has been brought to 
our attention, and as Dr. Huelskamp said, we want to get to the 
facts. And it is not that we want to harass you, but we want to 
understand the whys in order to craft some policy that makes 
sense.
    And for instance one of my puzzling whys has been this memo 
of 2010 that outlined all of the scheduling problems, and I 
just would out of curiosity like to know if either of you or 
both of you, maybe, saw that memo and what happened next?
    Dr. Thomas. I can answer first, Congresswoman. That memo 
was signed and distributed prior to my tenure. I believe it was 
in April of 2010 when that memo was signed and I started in my 
position in 2011. I did not have awareness of it until we 
realized what we were having in the spring of this year that we 
were having significant issues around our system and started 
doing the research and pulling all the pieces together and 
became aware of that memo on that.
    Ms. Kirkpatrick. Thank you for that honest answer.
    Dr. Deering.
    Dr. Deering. My answer would be very similar. I came into 
this position in 2012. Prior to that, I worked as an inpatient 
hospitalist. I ran the inpatient side of the hospital and I 
didn't work with the outpatient side very much, so I wasn't 
familiar with that memo, and I didn't become aware of it until 
this crisis surfaced.
    Ms. Kirkpatrick. You know, that is troubling to us, but at 
least it is helpful to know, because obviously there is a 
problem in communication in terms of checklists of things that 
need to be done and improved.
    I appreciate that you are trying to identify the vets who 
need care and need scheduling. I represent a very large rural 
district in Arizona and I just want to tell you that the VSOs 
in my district are very willing to help you identify those 
veterans, especially on tribal land. So we have vast areas 
where it is very difficult to reach veterans, but they have 
reiterated over to me over and over again that they are willing 
to assist. A lot of them know them personally. We just want to 
make sure that they got--that they get access to care.
    Dr. Deering. And I am very happy to work with them, as 
well, to try to connect those veterans to their care.
    You know, we were talking earlier about rural health. I 
grew up in a town of 400 people. The VA saved my father's life. 
He had melanoma and there was not a dermatologist within 
probably 60 miles of our home and the local VA was able to 
leverage teledermatology to get him care in St. Louis and this 
was in 1992, 1993, so this was years ago that the VA leveraged 
that type of tool to get care for my father, so there are 
resources, and I am more than happy to talk with you afterwards 
on that.
    Ms. Kirkpatrick. I appreciate that and the VSOs will be 
very happy to hear that, and I yield back the balance of my 
time.
    The Chairman. Thank you.
    Dr. Deering, prior to your current role, you said that you 
started in 2012, had you ever been a clinic director of a 
medical facility?
    Dr. Deering. A director of a medical facility, no; I was 
the chief of the hospitalist service at our facility and was 
responsible for the care of the inpatient side of the house.
    The Chairman. Okay. So you have never been a clinic 
director or service chief of a medical facility?
    Dr. Deering. No, sir.
    The Chairman. Okay, thank you.
    Were you aware that scheduling manipulation of any kind was 
occurring in Phoenix before, really, I guess April 9th when it 
hit?
    Dr. Deering. When I became chief of staff in 2012 we 
started working on improving access to the veterans and one of 
the things that we had learned in that process was that some of 
our ambulatory care clinics had carved out time during their 
day to do administrative work instead of patient care, so we 
systematically started going through that process to 
standardize the expectations for frontline staff in the 
clinics. I don't know if I would call it manipulation, but 
there were certainly some providers who were working very hard 
seeing a lot of patients and there were some providers who had 
managed to block out parts of their clinical time to not see as 
many patients and I don't think that is fair to our veterans. 
So the expectation would be that we would standardize that 
across the healthcare system and go through and clean those 
profiles up for our providers.
    And unfortunately or fortunately in the process, some of 
those providers felt that they did not want to continue the 
journey with us and they left and others continued to feel like 
things were being rectified and made more fair in the process 
and it helped to improve appointment availability for our 
veterans.
    The Chairman. Are you both aware of the litigation hold 
that was placed on the Phoenix records?
    Dr. Deering. Yes.
    Dr. Thomas. Yes.
    The Chairman. Have--remember that you are both under oath--
have either of you deleted, removed, or made unavailable, any 
emails related to the scandal in the Phoenix area, any 
communication at all?
    Dr. Thomas. I have not.
    Dr. Deering. I have not.
    The Chairman. Okay. Dr. Thomas, there was a news report 
this morning on CBS news--I don't know if you were able to see 
it--citing a whistleblower in the central office who talked 
about how VA officials sought to soften the Inspector General 
Phoenix report, and I want to paraphrase kind of what the 
whistleblower said. He said that the VA was worried that the IG 
report was going to damn the organization, which it did, 
therefore it was important for VA to introduce language that 
softened the blow.
    So my question to you is did you ask or are you aware of 
any employee in the central office who asked the IG to change 
the report or questioned the IG about any language, verbiage in 
the report? I mean there has been a hang-up on specific words 
and I get that--well, I will let you answer that, yes or no?
    Dr. Thomas. Thank you very much. I am happy that you asked 
that question. I think it is a very important question. What 
the IG found----
    The Chairman. No, that would be a yes or no.
    Dr. Thomas. It is a more complex situation than that, sir.
    The Chairman. My question to you is: Yes or no, did you ask 
for any changes in the verbiage? I know the process----
    Dr. Thomas. I did not.
    The Chairman. Okay. Thank you very much, and I appreciate 
your doing that under oath.
    How did you find out that the verbiage had been changed and 
what was your reaction when you heard it?
    Dr. Thomas. We saved--as I mentioned earlier, the process 
is a standard process that we use with the OIG and we get draft 
reports. We then begin to draft our response in terms of an 
action plan, as well as any communication products, such as 
fact sheets and communication plans that need to go along with 
that.
    On one of the iterations of the report, in fact, I do 
remember the very first report made no mention at all of the 40 
deaths. The second or third iteration, a paragraph arose in 
that new draft. It was a little bit confusing. I am not exactly 
sure what it was communicating, and then in the final draft 
that we got--and we were already working our final action plans 
and every time we submitted something another draft came in--so 
we would go back and say what is different in this draft so 
that we can then address it and update our data.
    In the last draft that we received, it did have the 
sentence that is in there in the final report.
    The Chairman. So what was the language that was confusing?
    Dr. Thomas. There was a paragraph in one of the drafts that 
talked about the number of cases. It mentioned something about 
the 40. I don't remember off the top of my head exactly what it 
said, but it talked about the various levels of concern, so 
many patients this and so many patients that. I'm sure, since 
you request it from the IG, you'll see those copies and see 
exactly what it says, but I don't know off the--I can't 
remember verbatim.
    The Chairman. So the changes were made at about the third 
iteration?
    Dr. Thomas. Well, there were changes on every iteration of 
the draft.
    The Chairman. Okay. We are talking about two specific 
changes. It is my understanding--and I should have asked this 
of Dr. Day when he was here--but it is given to the--again, I 
learned today that there are numerous iterations that go back 
and forth. I thought the IG produced a report, gave it to VA, 
VA reviewed it for factual issues, and a final report came out.
    Now, I understand it that there was a back-and-forth 
conversation between the Office of Inspector General and I 
assume you?
    Dr. Thomas. No, sir.
    The Chairman. Who?
    Dr. Thomas. I am sorry, I didn't hear you?
    The Chairman. Who?
    Dr. Thomas. I don't know. I do not know. I just know that I 
did not have any communication----
    The Chairman. Well, the secretary said in his testimony 
that he was not a party to the conversation, so as the chief of 
staff of Veteran Health Administration, you have no idea who 
was involved?
    Dr. Thomas. I had no direct contact with the IG whatsoever 
during the process.
    The Chairman. That is not my question. My question is, you 
have no idea who is involved--I mean your--part of your bonus 
and your review specifically talks about the OIG reports and 
the negative impact that they may have and the light that they 
may show. So you are telling me that you had no communication 
at all?
    Dr. Thomas. That is correct.
    The Chairman. Okay. Yet you got a--but you got a perfect 
performance evaluation and a double-digit bonus, yet you 
weren't involved at all?
    Dr. Thomas. What do you mean I wasn't involved at all? I 
wasn't involved at all in any direct conversations with the IG 
about changing any portion of the report. What I was involved 
with was taking the reports that they submitted to us and 
making sure that we had a good action plan to correct the 
issues at hand and to have a communications plan that clearly 
communicated to the Members of Congress and the public about--
--
    The Chairman. Okay. And so your action plan, at what point, 
when apparently there were two statements that were entered 
into the report that were not in the original, one was that Dr. 
Foot did not give the 40 names, which, can you tell me why that 
would need to be----
    Dr. Thomas. I have no idea.
    The Chairman. Yeah? I mean I am just trying to figure out 
why that would need to be in a report.
    And then the other about conclusively cannot, which they 
have now said they couldn't also say that it didn't cause 
death. So at what point did you learn that that was in the 
report?
    Dr. Thomas. When we see the final draft to respond to.
    The Chairman. The final draft?
    Dr. Thomas. Yes.
    The Chairman. Okay. So it wasn't in the third iteration; it 
was----
    Dr. Thomas. And I am not even clear, sir, on how many 
iterations there were. I know that I personally saw three.
    The Chairman. I think the OIG said there were five.
    Dr. Thomas. Well, I personally only saw three.
    The Chairman. Okay. So you did see three?
    Dr. Thomas. Yes.
    The Chairman. Okay. Very good.
    Thank you for appearing under oath and answering these 
questions. I appreciate that.
    Mr. Michaud.
    Mr. Michaud. I will set this one out.
    The Chairman. Dr. Huelskamp.
    Dr. Huelskamp. Thank you, Mr. Chairman.
    As I understand the answer to your last question in terms 
of Dr. Thomas, you saw the iterations, but weren't able to make 
any amendments? They were just sent to you via email or hard 
copy and here is what is out there. Can you describe that a 
little further?
    Dr. Thomas. As with all OIG reports, they are provided to 
us either on hard copy and/or on email and they are stamped 
with instructions to guard it and it is only to be used for 
official purposes. When we receive that, we then work with it. 
We have, as Dr. Clancy said, an organization within VHA that is 
responsible for coordinating the effort----
    Dr. Huelskamp. Is there a distribution--sorry to interrupt 
you--because I think you answered part of that already. Because 
if I understood, you had no idea who asked for changes, but you 
received those adaptations.
    Was there an email distribution list or is it blind copied 
to you?
    Dr. Thomas. No, it went out to a number of people who 
needed that document.
    Dr. Huelskamp. Can you describe--can you identify a few of 
those folks who were receiving that document that needed to?
    Dr. Thomas. I am sorry, I didn't hear the question?
    Dr. Huelskamp. The other individuals that needed to see the 
document--I guess yours was view only. You couldn't amend it. 
You make no suggestions to amend it, but somebody else did?
    Dr. Thomas. It is not view only. It is provided on email so 
that if we needed to cut and paste some words to be able to put 
into the action plan, we didn't have to retype it. I understand 
the concerns of the committee, I really do.
    Dr. Huelskamp. But my question, though, is who was making 
the changes? We still don't know. I asked the secretary--well, 
that is not me that is somebody down there. You seem to be the 
one at the level and you saw the iterations, but you are 
telling me from the VA side who suggested changes?
    Dr. Thomas. I do not.
    Dr. Huelskamp. Okay. Do you know who would know who made 
the changes?
    Dr. Thomas. I do not.
    Dr. Huelskamp. Do you know who was on the distribution 
list? Did you ever see another email? Can you name one other 
person that received a copy of the drafts?
    Dr. Thomas. I would have to go back and look at my email to 
see who was on there, because there was a listing on an email, 
I do recall, saying here is who we sent it to and here is who 
is getting a hard copy of it because we wanted to limit the 
distribution on email because of the fact it was such a high-
visibility case and that many people would be interested in 
seeing several of the drafts.
    Dr. Huelskamp. Well, what happened with the leak, and I can 
appreciate that concern, but the folks that were looking at or 
reviewing the draft, were they all in your office?
    Dr. Thomas. No.
    Dr. Huelskamp. No. Can you identify another office that 
they might have been from?
    Dr. Thomas. There were members from management review 
service. There were members from the operations side of the 
organization. I am sure that the field probably----
    Dr. Huelskamp. Public relations, did they get a chance to 
review that?
    Dr. Thomas. Absolutely. Our communications office that 
reports to me needs those documents. They received each 
iteration because, as I said, they needed to start working on 
the communications plan. We needed to work very efficiently and 
we couldn't wait until something was published and then have 
them start understanding the report and working on a 
communications plan.
    Dr. Huelskamp. Yes. Has a report like this ever been leaked 
before to your knowledge?
    Dr. Thomas. There are lots of things that are leaked. I 
don't----
    Dr. Huelskamp. To your knowledge, has a report like this 
been leaked before? Do you have any policies against leaking?
    Dr. Thomas. Absolutely.
    Dr. Huelskamp. If someone is found out to be leaking the 
document or authorizing it, what is the punishment?
    Dr. Thomas. I think absolutely that they should be held 
accountable.
    Dr. Huelskamp. What is the punishment?
    Dr. Thomas. We would have to work with our H.R. experts to 
find out. It depends upon that individual if they have had 
prior disciplinary action because we have progressive 
discipline within the federal government and VA, and so if they 
have committed prior acts, the discipline that would be 
proposed for them would be stronger than if it was a first-time 
offense.
    Dr. Huelskamp. Dr. Deering, I want to ask you some specific 
questions, and, again, trying to understand what was going on 
in Phoenix, if I might. The OIG report identified, for example, 
1800 individuals on near. Did you know there were any folks--
are you aware that there was a near list?
    Dr. Deering. I was not aware that there was a near list 
until Chairman Miller brought the concerns up on April 9th and 
we quickly started trying to peel this back and see what was 
going on.
    Dr. Huelskamp. And when did you find out that there were 
1800 names on that list?
    Dr. Deering. It was sometime in late April. It was probably 
two or three weeks, approximately, from what I can recall, 
after the disclosure of the information from Chairman Miller.
    Dr. Huelskamp. Okay. The other thing that is--there is a 
lot of things in here, these urology consults, the numerous 
other 600 printouts. When did you become aware that some member 
of staff was printing out a scheduling request and sticking it 
in a folder, when did you find out that was going on?
    Dr. Deering. Around the same time that I found out about 
the near report.
    Dr. Huelskamp. Okay. And what did you do about it then once 
you discovered that that was occurring, and would it be your 
responsibility to take care of this or is it somebody else's 
job?
    Dr. Deering. Yeah, so my role as a chief of staff at the 
facility level is a little bit different than Dr. Thomas. At 
the facility level, the chief of staff is responsible for the 
physicians and the clinical side of the house. The scheduling 
process that you are referring to falls under more of the 
business side of the house, so those were not my employees. I 
cannot really speak to what happened with those employees, but 
I do know that they quickly put a stop to that process and 
started educating staff about the--those employees about the 
correct process to schedule patients.
    Dr. Huelskamp. Well, there is actually ten years of OIG 
reports of the scheduling practices, so there was no quick 
stoppage to it. There might have been about this one once it 
hit the fan, but that is a real concern as well, as it has been 
going on. I mean those 
reports were out there in public for years before you took the 
job, so I was just curious what had happened with those.
    Again, I am not sure what the numbers--as I stated earlier 
to some Members of the Committee--of unreviewed documents and 
files, and it could have been anywhere from three to four to 
five thousand. It was very unclear from the OIG report, Mr. 
Chairman.
    So thank you for the time. I yield back.
    The Chairman. Ms. Kirkpatrick.
    Ms. Kirkpatrick. Thank you, Mr. Chairman.
    Dr. Thomas, we have all been concerned about the antiquated 
IT system and you stated that it is an overly complex 
scheduling system and you are in the process of fixing that. I 
just want to know what that entails, what you are looking at 
and just give me some--an update on that process.
    Dr. Thomas. Absolutely, Congresswoman. I think there are 
two components to that. The first is our policy. We need to 
have a clear policy that is easily understood by all of our 
employees that they can follow. The second component would be 
the system, the IT system to allow us to do that. I do know 
that just recently we did a call out to the field to make it 
easier for our schedulers and offered each one of them dual 
screens because of the IT system that they are currently using, 
it would make it easier for them to do their job to have 
multiple monitors.
    We are doing interim updates and fixes to our current 
scheduling system while we do a more long-term solution which 
we have had an industry day lately in trying--just recently--in 
trying to get an off-the-shelf solution for our scheduling 
concerns.
    Ms. Kirkpatrick. Do you have any idea of your timeline for 
that, when you think that you'll be able to get an off-the-
shelf system and really bring it back into the 21st century?
    Dr. Thomas. I should know that. I sit in the daily 
briefings that we have on this topic and we brief the schedule 
once a week, but I cannot think of that off the top of my head. 
I would be happy to get that information for you.
    Ms. Kirkpatrick. That is fine. Thank you.
    I yield back the balance of my time.
    The Chairman. Mr. Michaud.
    Mr. Michaud. Yeah. Dr. Thomas, you said that you looked at 
three of the draft reports. Did you provide any input to the 
IG, either directly or through another staff person, to the IG 
as far as changing that report?
    Dr. Thomas. I did not.
    Mr. Michaud. Why--you are the chief of staff, and 
particularly with this particular case, the level of publicity 
that it has received, why did you not look at all five of the 
reports?
    Dr. Thomas. I don't think I had an awareness of all five of 
them. In preparation for this hearing, obviously, I went back 
and looked through the history of what I saw and when I saw it 
and what I looked at in my in-box and what I have reviewed 
were, I could see the interim report and three drafts of the 
final.
    Mr. Michaud. So you made no comment to anyone else at VA, 
as far as the report and changes you would like to see in it to 
VA employees?
    Dr. Thomas. We had plenty of conversations about the 
report. I think that when the first draft came out, we were all 
quite surprised that there was no mention of the 40 deaths, but 
we--I, personally, made absolutely no attempt whatsoever to 
intervene or change that. It seemed quite odd since that was 
what was in the news, as the IG had mentioned, all over the 
news and we personally have answered questions of our neighbors 
and our families of, you work for the VA, did you kill 40 
people? That is what people thought, but that is not the most 
important part of that IG report.
    The most important part is that it identified that we have 
delays in care and problems with coordination and that is what 
we have to fix. I personally was interested that the report 
should address the 40 deaths because my concern was that the 
veterans would not have faith in their healthcare system and 
they need to be able to come to us for care if they needed 
healthcare.
    Mr. Michaud. Now, when you had mentioned--you just said 
``that we''--I guess the part that concerns me is that you are 
the chief of staff and particularly this case has got a lot of 
news and I think we do have to move forward, but we are trying 
to get back to where the disconnect is. And when you mention 
``we,'' who is the ``we''?
    Dr. Thomas. I said ``we'' and then I corrected myself to I, 
because I am under oath and I can only speak to myself.
    Mr. Michaud. But who did you talk with within the 
Department?
    Dr. Thomas. I think there were--I know that there were 
multiple meetings within VHA, with leadership, with 
communication staff, with the congressional folks, both within 
VHA and--I mean it was a topic. It was in the news and we were 
waiting with bated breath to get the report to see what did it 
say because we did take immediate action right after the 
interim report and we wanted to know where else are we falling 
short where we are not providing quality care to veterans. We 
need to get our act together to fix it. We wanted the report to 
see what else do we need to put in place.
    Mr. Michaud. Is that we, Dr. Petzel? Is the we, Secretary 
Shinseki? Or is the we, some staff below you?
    Dr. Thomas. I think collectively everybody in the 
Department. We have over 300,000 employees in VHA and I am sure 
almost every single one of them gets up every single day to 
make a difference for veterans, just as I do, and we don't come 
to work to try to mislead or hide or obfuscate anything.
    Mr. Michaud. Yeah, I realize that you have that many 
employees, but when you said that ``we discussed the report,'' 
I am sure you didn't discuss that report with the 300,000 
employees, so I was just trying to narrow down the ``we'' that 
you were talking about. And I know that being the chief of 
staff that you, oh, that is your job, but it is a very 
important job, and you set the tone, as well as the Under 
Secretary, so I do have a concern with some of your answers 
today. But with that, Mr. Chairman, I yield back.
    The Chairman. I have one final question. Dr. Thomas, who do 
you believe commissioned this OIG report?
    Dr. Thomas. I believe that the OIG report was initially 
started because of a hotline call out from a physician from 
Phoenix and that after the April 9th hearing that the IG was 
directed to do so.
    The Chairman. By who?
    Dr. Thomas. I believe Congress charged them with 
investigating the issue. It is my belief, I could be wrong.
    The Chairman. No, you are correct.
    Dr. Thomas. Okay.
    The Chairman. And so my question is, how is it that you got 
the final report before Congress got it?
    Dr. Thomas. The final draft?
    The Chairman. The final report.
    Dr. Thomas. I did not get the final report.
    The Chairman. Final draft. Call it a draft. Call it a 
report. How did you get--how did you see the final copy, 
whatever it was--how--if you saw the final draft, you saw the 
final report. How did you see it before Congress?
    Dr. Thomas. I am sorry. I don't know when Congress got it. 
I know the report was publicly released on, I believe August 
26th and we see the final draft because we have to respond to 
it before it is published.
    The Chairman. Okay. Well, it has been your testimony, both 
of you, that neither one of you knew that any of this was 
happening; is that correct?
    Dr. Thomas. Can you be more specific in your question, sir, 
any of what was happening?
    The Chairman. Oh, I don't know, manipulation of data, 
problems with scheduling, any issues with delays in care. You 
weren't aware of any?
    Dr. Thomas. In the spring.
    The Chairman. But you came to work in July of 2011?
    Dr. Thomas. 2011.
    The Chairman. And so you weren't aware of any delays in 
care until April 9th of 2014?
    Dr. Thomas. As I said when I started this hearing, sir, I 
think VHA missed the boat. We were getting----
    The Chairman. No, I am talking about you individually.
    Dr. Thomas [continuing]. Individual reports from the IG.
    The Chairman. I am sorry, I am talking about you 
personally.
    Dr. Thomas. And I am a member of VHA and a team that wants 
to provide excellent care to veterans.
    The Chairman. You are telling me that you were not aware of 
any of the problems until the hearing on April 9th?
    Dr. Thomas. What I am trying to explain is that as the 
situation arises, we were looking at that as an isolated event, 
as we were each of the IG reports, rather than taking a 
holistic approach and a more comprehensive approach and looking 
at them together.
    The Chairman. So, again, your testimony is that you were 
not aware of any of the scheduling problems and delays in care 
until April 9th?
    Dr. Thomas. I was not aware of the extent of the problem.
    The Chairman. What does that mean?
    Dr. Thomas. As I said, each time an IG report was issued, 
we would look at it, respond to it, and create an action plan 
for any of the national reports.
    The Chairman. Well, the interesting thing--what VA usually 
does is they do respond to it. It is interesting that they 
accept all of the recommendations--in every report that I think 
has ever been handed to them. It is interesting. Now I see how 
it works. I mean if the IG and the VA are working hand in glove 
backwards and forwards, they already know what they are going 
to agree to.
    This is the first time that I can remember that VA actually 
is doing some of the things that they have in the past 
certified that they have done.
    Dr. Thomas. Sir, respectfully, I would not agree with your 
characterization of our relationship with the OIG.
    The Chairman. I understand and I will retract that 
statement, but you did, I learned today, you get drafts, you 
respond, you make changes, it goes back to the--do you not?
    Dr. Thomas. I think it is a very important distinction to 
make----
    The Chairman. For factual--for factual----
    Dr. Thomas [continuing]. Between the OIG report and the 
action plan.
    The Chairman. No, no, I am not talking about your action 
plan; I am talking about the IG report.
    But then the IG then makes 23 recommendations in this 
report?
    Dr. Thomas. Twenty-four.
    The Chairman. Twenty-four recommendations and three have 
already been done. I guess what I am saying is congratulations 
to VA for the first time that I can recall for actually moving 
on the recommendations, not just certifying them and then we 
find out months and years later that they haven't been done. 
But we appreciate your being here. We do apologize for the 
length that you have had to be here today, but thank you very 
much. Ms. Kirkpatrick.
    Ms. Kirkpatrick. Thank you, Mr. Chairman, and thank you, 
Ranking Member. And I just want to thank our staffs. You know, 
we started this at noon and it has been a long day, but we need 
to put in this kind of effort to get it right for our veterans, 
so I just want to say that I really appreciate everybody's 
effort.
    The Chairman. Thank you very much.
    And again, Members, I would like to let each of you know 
that Sharon Helman was also invited to appear and we reached 
out to her attorney and we never received a response to the 
invitation that was issued, but she, in fact, was invited to 
appear, and with that, this hearing is adjourned.
    [Whereupon, at 6:26 p.m., the committee was adjourned.]

                                APPENDIX

               Prepared Statement of Chairman Jeff Miller

    I would like to welcome everyone to today's hearing titled, 
``Scheduling Manipulation and Veteran Deaths in Phoenix: Examination of 
the OIG's Final Report.''
    On August 26, the VA Office of Inspector General released its final 
report on the Phoenix VA healthcare system, which vaulted to national 
attention after an April 9 hearing by this committee. The OIG confirmed 
that inappropriate scheduling practices are a nationwide systemic 
problem and found that access barriers adversely affected the quality 
of care for veterans at the Phoenix VA medical center.
    Based on the large number of VA employees who were found to have 
used scheduling practices contrary to Veterans Health Administration 
policy, the OIG has opened investigations at ninety three (93) VA 
medical facilities, and it found over thirty-four hundred (3,400) 
veterans who may have experienced delays in care from wait list 
manipulation at the Phoenix VA medical center alone. The OIG concluded 
by providing the VA with twenty-four (24) recommendations for 
improvement to avoid these problems from recurring. These 
recommendations should be implemented immediately, and this committee 
will work tirelessly to ensure that they are.
    Mr. Griffin, I commend you and your team for your work and 
continued oversight on these issues in the months ahead.
    With that said, I am concerned regarding the manner with which the 
OIG report was released, along with some of the statements contained 
within it. Notably, prior to the release of the report, selective 
information was leaked to the media, apparently by a source internal to 
VA, which purposely misled the public that there was no evidence at 
Phoenix linking delays in care with veteran deaths. As days went on, 
and people actually read the report, that falsehood became obvious. 
What the OIG actually reported, and what will be the subject of much 
discussion today, is this statement by the OIG: ``we are unable to 
conclusively assert that the absence of timely quality care caused the 
deaths of these veterans.''
    What is most concerning about this statement is the fact that no 
one who dies while waiting for care would have ``delay in care'' listed 
as the cause of death, since a delay in care is not a medical 
condition. Following the release of this report, which found pervasive 
problems at the facility regarding delays in care and poor quality of 
care, committee staff was briefed by the OIG regarding its findings and 
how specific language was chosen throughout the drafting process.
    Prior to this meeting, we requested that the OIG provide us with 
the draft of the report in the form it was originally provided to VA 
three weeks before the release of the final report.
    After initially expressing reservations, the OIG provided us with 
the draft.
    What we found was that the statement I just quoted was not in the 
draft report at all.
    Another discrepancy we found between the draft and final reports 
arose with statements to the effect that one of the whistleblowers here 
today did not provide a list of forty (40) veterans who had died while 
on waiting lists at the Phoenix VA medical center. First, the OIG 
stated in the briefing to committee staff that VA inquired why such a 
statement was not in the report, and the OIG ultimately chose to 
include it. Further, additional information provided by the OIG to 
committee staff shows that, based on the numerous lists provided by all 
sources throughout the investigation, the OIG in fact accounted for 
forty-four (44) deaths on the electronic wait list alone, and an 
astonishing two hundred and ninety-three (293) total veteran deaths on 
all of the lists provided from multiple sources throughout this review.
    To be clear, it was not and is not my intention to offend the 
Inspector General and the hard-working investigators he employs. 
However, I would be remiss in my duty to conduct rigorous oversight of 
the Department of Veterans Affairs if I did not ask these questions. I 
would also like to point out that no one within the department, or any 
other federal government employee, including the members of this 
committee, is above reproach.
    As such, the committee will continue to ask the questions that need 
to be asked in order to perform our constitutional duty. It is 
absolutely imperative that the OIG's independence and integrity in its 
investigations be preserved. Full and transparent hearings like this 
one will help ensure that remains the case.

        Prepared Statement of Michael H. Michaud, Ranking Member

    Thank you, Mr. Chairman.
    Today's hearing provides the opportunity to examine the VA 
Inspector General's final report on the patient wait times and 
scheduling practices within the Phoenix VA healthcare System.
    This report did not state a direct causal relationship between long 
patient wait times and veteran deaths. For some, that is a major 
concern, and accusations of undue influence by the VA on the IG report 
will be discussed at length today.
    What the IG did find is that the cases included in this report 
clearly show there were serious lapses in VA's follow-up, coordination, 
quality, and continuity of healthcare to veterans. They also concluded 
that the inappropriate scheduling practices demonstrated in Phoenix are 
a nationwide systemic problem.
    I do not need any more evidence or analysis. There is no doubt in 
my mind that veterans were harmed by the scheduling practices and 
culture at the Phoenix facility and across the nation. The bottom line 
is this behavior, and its detrimental effect on veterans, is simply not 
acceptable.
    My heart goes out to the families of the veterans who did not 
receive the healthcare they deserved in Phoenix and around the country. 
Rest assured, we will understand what went wrong, fix it, and hold 
those responsible for these failures accountable.
    As such, my questions to the VA today are straightforward--what 
went wrong, what are you doing to fix the problems, how will you ensure 
this never happens again, and how are you holding those responsible 
accountable?
    I applaud Secretary McDonald for taking forceful action to begin to 
address the systemic failures demonstrated in Phoenix. We need serious, 
deep and broad reform--the kind of change that may be uncomfortable for 
some in VA, but so desperately needed by America's veterans.
    I believe that such reform must be guided by a higher-level 
National Veterans Strategy that outlines a clear vision of what America 
owes its veterans, and a set of tangible outcomes that every component 
of American society can align and work towards. Earlier this week, I 
sent a letter to President Obama asking him to establish a working 
group to engage all relevant members of society in drafting this 
National Veterans Strategy.
    We know from experience that VA cannot do it alone. We must develop 
a well-defined idea of how the entire country--government, industry, 
non-profits, foundations, communities and individuals--will meet its 
obligation to veterans.
    VA needs to become a veteran-focused, customer service 
organization. It needs to be realigned to become an integrated 
organization. It should do what it does best, and partner for the rest. 
It needs to be the government model for honesty, integrity, and 
discipline.
    We need to complete our investigation of the problems and provide 
oversight on the solutions.
    I look forward to today's additional testimony about what happened 
in Phoenix, and how the VA is working to ensure it never happens again.
    I yield back the balance of my time.
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 
    
               Prepared Statement of Samuel H. Foote M.D.

                         Death Reports by Source
------------------------------------------------------------------------
 
------------------------------------------------------------------------
On the Secret non-reporting Electronic        44
 Waiting list.
From the Schedule an Appointment with         39
 Primary Care Consults.
Backlog never completed.....................  41
Expired on AW Backlog.......................  2
House Veterans Affairs Committee............  17
On the New Enrollee Appointment Request List  28
OIG Hotline calls...........................  21
Media reports...............................  8
Suicides....................................  74
Urology.....................................  4
Helpline....................................  3
Paper wait list.............................  1
Institutional disclosure....................  1
------------------------------------------------------------------------
    Total deaths............................  293
------------------------------------------------------------------------

    My original allegation was that up to 40 Veterans may have died 
while waiting for care at the Phoenix VA. The two sources that we were 
looking at were the Secret non-reporting Electronic Waiting List and 
the Schedule an Appointment with Primary Care Consults. As you can see 
from the above, the actual number from those two sources was 83, more 
than double my original estimate and nowhere close to the 293 total 
deaths. Primarily, it appears from the report that reviews were done on 
the VA's Electronic Health Records. One can imagine that it would be 
very difficult to determine what actually happened on patients trying 
to get into the system who died prior to being seen.
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 


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