[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
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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
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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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