[Senate Hearing 113-657]
[From the U.S. Government Publishing Office]
S. Hrg. 113-657
THE STATE OF VA HEALTH CARE
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED THIRTEENTH CONGRESS
SECOND SESSION
__________
SEPTEMBER 9, 2014
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
Bernard Sanders, (I) Vermont, Chairman
John D. Rockefeller IV, West Richard Burr, North Carolina,
Virginia Ranking Member
Patty Murray, Washington Johnny Isakson, Georgia
Sherrod Brown, Ohio Mike Johanns, Nebraska
Jon Tester, Montana Jerry Moran, Kansas
Mark Begich, Alaska John Boozman, Arkansas
Richard Blumenthal, Connecticut Dean Heller, Nevada
Mazie Hirono, Hawaii
Steve Robertson, Staff Director
Lupe Wissel, Republican Staff Director
C O N T E N T S
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September 9, 2014
SENATORS
Page
Sanders, Hon. Bernard, Chairman, U.S. Senator from Vermont....... 1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North
Carolina....................................................... 2
Tester, Hon. Jon, U.S. Senator from Montana...................... 4
Johanns, Hon. Mike, U.S. Senator from Nebraska................... 4
Hirono, Hon. Mazie, U.S. Senator from Hawaii..................... 5
Heller, Hon. Dean, U.S. Senator from Nevada...................... 6
Blumenthal, Hon. Richard, U.S. Senator from Connecticut.......... 8
Moran, Hon. Jerry, U.S. Senator from Kansas...................... 9
Begich, Hon. Mark, U.S. Senator from Alaska...................... 10
Boozman, Hon. John, U.S. Senator from Arkansas................... 12
Murray, Hon. Patty, Chairman, U.S. Senator from Washington....... 12
WITNESSES
Griffin, Richard J., Acting Inspector General, U.S. Department of
Veterans Affairs; accompanied by John D. Daigh, Jr., M.D.,
Assistant Inspector General for Healthcare Inspections; Linda
Halliday, Assistant Inspector General for Audits and
Evaluations; Maureen Regan, Counselor to the Inspector General;
and Larry Reinkemeyer, Director of the Inspector General's
Kansas City Audit Office....................................... 14
Prepared statement........................................... 16
Response to request arising during the hearing by:
Hon. Jon Tester............................................ 29
Hon. Dean Heller........................................... 30
Response to posthearing questions submitted by:
Hon. Bernard Sanders....................................... 40
Hon. Mark Begich........................................... 41
Hon. Mazie Hirono.......................................... 41
Hon. Jeff Flake............................................ 41
McDonald, Hon. Robert A., Secretary, U.S. Department of Veterans
Affairs; accompanied by Carolyn M. Clancy, M.D., Interim Under
Secretary for Health........................................... 42
Prepared statement........................................... 45
Response to request arising during the hearing by:
Hon. Richard Burr.......................................... 51
Hon. Jerry Moran........................................... 62
Response to posthearing questions submitted by:
Hon. Bernard Sanders....................................... 63
Hon. Richard Burr.......................................... 97
Hon. Mark Begich........................................... 101
Hon. Mazie Hirono.......................................... 103
Hon. John Boozman.......................................... 104
Hon. Jeff Flake............................................ 107
Hon. Richard Blumenthal.................................... 109
Response to additional posthearing questions submitted by
Hon. Richard Blumenthal.................................... 113
THE STATE OF VA HEALTH CARE
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TUESDAY, SEPTEMBER 9, 2014
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10:02 a.m., in
room SH-216, Hart Senate Office Building, Hon. Bernard Sanders,
Chairman of the Committee, presiding.
Present: Senators Sanders, Murray, Tester, Begich,
Blumenthal, Hirono, Burr, Johanns, Moran, Boozman, and Heller.
OPENING STATEMENT OF HON. BERNARD SANDERS,
CHAIRMAN, U.S. SENATOR FROM VERMONT
Chairman Sanders. Good morning and welcome to what I
believe will be an important and productive hearing. Today we
will be discussing some of the very serious issues facing the
Department of Veterans Affairs on the heels of the Inspector
General's findings related to long wait times and poor patient
care at the Phoenix VA.
The IG's report provides troubling details about a facility
that failed to meet our Nation's obligation to provide timely,
high-quality care to veterans. What happened in Phoenix is
inexcusable and must never happen again at any VA facility.
I was especially disappointed to learn the extent to which
Phoenix VA executives and senior clinical staff knew about
inappropriate scheduling practices.
In a telling exchange, when asked by a physician in Hawaii
to share best practices about how the Phoenix VA had presumably
been able to reduce its patient wait time from 238 days down to
7 days--quite a feat--the chief of primary care e-mailed one of
his fellow colleagues in Phoenix and stated, ``Wonderful. Not
sure how to answer this. Can I just say, `smoke and mirrors'?''
And, of course, that is what it was. It was all smoke and
mirrors.
The people who lied, who acted dishonorably, who
manipulated data in Phoenix and elsewhere clearly must be held
accountable. The endemic nature of this problem, as identified
by the IG, cannot be tolerated.
The IG's report detailed numerous cases of poor patient
care. In fact, several of those cases raise serious concerns
about two of Phoenix's specialty care clinics. Reviews of
patient files found problems with continuity of mental health
care, delays in assignment to a dedicated psychiatrist or
mental health nurse practitioner, and limited access to
psychotherapy.
Additionally, the IG also discovered the urology department
struggled to provide timely care. In fact, the IG has launched
a separate investigation into this service. A report regarding
the findings will be released in due course.
While the results in the IG's report paints a troublesome
picture, the IG was ``unable to conclusively assert'' that
patients died because of long wait times, as news media reports
had speculated.
I also understand, as a result of the attention focused on
Phoenix, the IG has opened additional investigations at 93
sites of care as a result of receiving approximately 445
allegations regarding manipulated wait times at other VA
facilities. This Committee will continue to monitor the results
of these investigations and use this information to inform the
Committee's oversight efforts in the future.
Like most Americans, I have concerns about the inability of
veterans in various locations across the country to access care
in a reasonable period of time. I will not go through all of
the data, but the bottom line is that the reports worked on by
VA and the work done by the IG tells us that tens of thousands
of veterans were unable to get the care they needed in a timely
manner.
What I hope we will learn today from our new Secretary, Mr.
McDonald, and the ideas of the Inspector General, Mr. Griffin,
is, in fact, how that problem developed. I do not believe that
anybody joins VA in order to manipulate data. How did it
happen? What were the causes? How do we make sure this never
happens again? What do we do? And how quickly do we get rid of
dishonorable employees? We gave the new Secretary tools. We
will want to hear how he is utilizing those tools.
Maybe most importantly, we want to learn how we go forward
into the future to make sure these problems never occur again.
I noticed in the paper yesterday the Secretary held a press
conference talking about--and I want to discuss it with him--
his need to aggressively go out and bring new physicians, new
nurses, new medical personnel into VA so we do not have these
wait times again. And during this hearing, I look forward also
to talking with our new Secretary about how he is going to
implement the legislation that was recently passed.
So, there is a lot to go over in this hearing. We thank the
Secretary for being with us. We thank the Inspector General for
being with us as well.
Senator Burr.
STATEMENT OF HON. RICHARD BURR, RANKING MEMBER,
U.S. SENATOR FROM NORTH CAROLINA
Senator Burr. Well, good morning, Mr. Chairman. I would
like to welcome to Secretary McDonald and Acting Inspector
General Griffin, and I thank them for being here, as well as
the other witnesses for today.
Today the Committee is holding another hearing on the state
of health care within VA, specifically focusing on the final IG
report released last month as it relates to Phoenix. And when I
say ``final,'' Mr. Griffin, I realize that there are many more
yet to come, and this will be absolutely crucial to the
agency's ability to continue to get a handle on the problems.
Since our last hearing on the state of VA health care,
Congress has moved forward with historic legislation that will
improve access to health care to veterans across the Nation,
which was signed into law in August. This legislation is a
first step in providing veterans with the ability to choose
where they receive care if VA is unable to provide care within
a timely manner or if they live greater than 40 miles from a VA
facility.
While this is an essential first step in addressing the
systemic issues facing the Department of Veterans Affairs,
there is still much more work to be done. The work of this
Committee has just begun. As we move forward, it will be
crucial for this Committee to conduct aggressive oversight to
ensure that veterans are able to receive the health care they
need and, more importantly, that they deserve.
The IG report is instructive because it demonstrates
critical breakdowns in the system that allowed systemic issues
to take root not only in Phoenix but throughout the entire VA
system. I would like to highlight two specific issues that were
identified in the final IG report on Phoenix.
First, the IG report describes the care received by 45
veterans who faced either clinically significant delays in care
or questionable care from the Phoenix facility. Additionally,
the IG reviewed 77 suicides that occurred between January 2012
and May 2014 and found that nine veterans experienced a delay
in care. One veteran experienced a clinically significant
delay, and five veterans experienced other substandard quality
of care.
Many veterans experiences obstacles while trying to
establish needed care after hospitalization or being treated in
the emergency room. The lack of follow-up, coordination,
quality, and continuity of care that many of these veterans
experienced is troubling and, quite frankly, unacceptable.
Second, the most troubling issue described in the report
was VA's awareness of the ongoing scheduling challenges that
many facilities faced. Furthermore, VA had opportunities to
address the systemic culture of inappropriate scheduling
practices. VA did not act to address inappropriate scheduling
practices or manipulation of wait-time data. This lack of
accountability was further ingrained by VA's decision to waive
the fiscal year 2013 annual requirement for facility directors
to certify compliance with VA scheduling directives. Why would
the requirement be waived when VA knew that there were
questions scheduling practices occurring within medical
facilities?
The magnitude of scheduling irregularities is demonstrated
by the roughly 225 allegations at the Phoenix Health Care
System and the more than 445 similar allegations at VA
facilities across the Nation that the IG has received through
numerous sources, including the IG hotline, Members of
Congress, employees, veterans, and their families. Currently
the IG is actively investigating 93 sites, as the Chairman
stated.
In the coming weeks, months, and years, VA will continue to
take swift and firm action to dismantle the corrosive culture
that has taken hold within the VA and make sure it is not able
to resurface. No matter what steps VA takes to address the
challenges it faces delivering health care, VA will not be able
to move forward if this corrosive culture is not effectively
addressed. I have said this before but I want to reiterate that
the culture that has developed at VA and the lack of management
and accountability is simply reprehensible.
I commend the work that has been done over the last several
months; however, there is much more work to be done to repair
veterans' trust in the system. I look forward to working with
you, Mr. Secretary, as this Committee works on implementing and
passing legislation that is needed for you to accomplish what I
believe is a very significant reform pathway for veterans and
for the VA itself.
I thank the Chair.
Chairman Sanders. Thank you, Senator Burr.
Senator Tester.
STATEMENT OF HON. JON TESTER,
U.S. SENATOR FROM MONTANA
Senator Tester. Thank you, Chairman Sanders. I will be
brief.
First of all, great to have you here Secretary McDonald,
your first appearance in front of this Committee as the
confirmed Secretary for the VA. Thank you for being here. I
know the last 6 weeks have been busy for you, and hopefully
productive.
The IG, thank you folks for what you have done. Thank you
for what you are going to do. Thank you for the recommendations
that you are putting forth. I think these are critically
important for the VA and for us as we look to improve the VA.
We passed an important bill before we left for the August
recess. That important bill was signed by the President. I
agree with the Ranking Member, it is a first step. And I hope
it is not a first step to privatize the VA. I hope it is a
first step to make the VA stronger so that it can give the
services to our veterans that they have earned.
With that, I look forward to your testimony and look
forward to the opportunity to question you on that testimony as
we move forward.
Thank you, Mr. Chairman.
Chairman Sanders. Thank you, Senator Tester.
Senator Johanns.
STATEMENT OF HON. MIKE JOHANNS,
U.S. SENATOR FROM NEBRASKA
Senator Johanns. Thank you, Mr. Chairman. Mr. Chairman and
Ranking Member Burr, let me just start out by saying thank you
for convening what I also believe will be a very important
hearing today.
I also want to express my appreciation to Mr. Griffin and
your staff for being here today to hopefully offer some insight
into the issues that we are looking at.
Mr. Secretary, I also welcome you. It is good to have you
on board. You have taken over during a difficult time, but your
body of experience I think is going to serve our Nation well. I
do want to say I thank you for taking swift action. I hope
there is more to come.
The Inspector General report we are here to discuss today
has confirmed disturbing allegations about secret wait lists
and barriers to health care for our veterans. It is amazing to
learn of widespread examples of failures and outright
coveruption by VA employees. At present, if I have this right,
there are 93 other sites where care is provided that are under
investigation. That is amazing to me. That is a remarkable
number.
I am pleased to see that the VA agreed with all 24
recommendations that were made by the Office of Inspector
General. My hope is that VA's plans to address the
recommendations are not empty words, that there will be follow-
through on what they have agreed to. Without the recommended
changes, reports of mismanagement, fraud, and substandard care
at the VA will continue.
While tackling the issues identified in the report, the VA
must also keep in mind other important initiatives. The VA must
work quickly to implement the Veterans Access, Choice, and
Accountability Act that was signed into law. The Choice Card
provision is critical to our Nation's veterans to allow them
the freedom to seek care outside of the VA if they choose to
when it is needed. Other programs that ensure VA has the space
to provide quality care to our veterans are also critical,
programs for construction of State veterans homes and medical
centers, just to name a few.
As I mentioned in this Committee many times, the VA
construction backlog should be a major concern to all of us. We
just simply have to find a solution to replace 1950s-era
hospitals--we have one in our State--and ensure that these
priorities are not lost in the shuffle.
Again, I look forward to hearing how the VA intends to
repair the damage that has been done by this scandal to regain
the trust and confidence not only of Congress but, more
importantly, our Nation's veterans and their families.
Mr. Chairman, again, thank you. I yield back.
Chairman Sanders. Thank you very much.
Senator Hirono.
STATEMENT OF HON. MAZIE HIRONO,
U.S. SENATOR FROM HAWAII
Senator Hirono. Thank you, Mr. Chairman.
Secretary McDonald and Acting Inspector General Griffin,
thank you very much for being here with us this morning.
The revelations over wait times at the Department of
Veterans Affairs and other systemic problems at the VA have
severely shaken the trust that veterans, their families, and
the general public should have in the VA health care system.
Over the last decade, we have sent over 2 million men and women
to fight the wars in Iraq and Afghanistan, and some of the
problems that we see in the VA are due to shortcomings in three
major areas, as I see it:
First, ensuring that veterans are aware of and receive
access to VA health care and other services that the VA
provides;
Second, Congress providing sufficient resources, effective
oversight, and ensuring accountability for the VA; and
Third, improving the transition from military service to
civilian life.
I realize that today we are focusing once again on the
veterans health care system. To provide effective oversight and
accountability, in May of this year, this Committee convened
its first hearing in response to the allegations of wait-time
irregularities at VA. And in response to testimony from that
first hearing and other hearings in this Committee, the
Veterans Access, Choice, and Accountability Act of 2014 was
passed. Once again, I want to commend the Chair for his efforts
in getting this law enacted.
Our goal in passing this legislation was to provide VA with
the tools needed to address the serious problems veterans were
facing in accessing care, and this law not only granted the VA
money to build internal capacity in the form of additional
hiring, but also provided the VA the authority to lean upon the
private provider community to ensure timely access to quality
care. And I am sure, Secretary McDonald, you will tell us how
you are implementing that part of the new law.
During the August recess, I held a field hearing on the
State of VA health care in Hawaii, and during that hearing I
heard from veterans in my State, local VA staff, and
Washington-based VA staff on what they were doing to improve
veterans' experience with the VA. The lack of providers was a
common refrain heard throughout the hearing. The VA must do
more to recruit and retain high-quality health care
professionals within the VA system.
You know that the veterans are a unique patient population
with specific needs. But based on my field hearing and the
previous hearings this Committee held this past summer, the
Inspector General's findings in his final report were not a
surprise. We know that problems relating to patient wait times
at the VA have been reported by the IG since at least 2005,
without major action by the VA until this year.
VA granted medical facility directors waivers in certifying
compliance with VA's scheduling directive regarding wait times.
While Congress for its part has continued to increase VA's
budget, clearly congressional oversight is critical, as is VA's
efforts to increase accountability within its system.
For example, the lack of national standardization in
procedures and practices, while not in itself troubling, has
led to this decentralized control, leading to a broad avoidance
of accountability within the VA system.
I look forward to working with my colleagues, the Inspector
General, and Secretary McDonald in ensuring that we make the
appropriate improvements. Thank you.
Chairman Sanders. Senator Hirono, thank you very much.
Senator Heller.
STATEMENT OF HON. DEAN HELLER,
U.S. SENATOR FROM NEVADA
Senator Heller. Thank you, Mr. Chairman, and also to the
Ranking Member for holding this hearing today. I want to thank
the Secretary and also Mr. Griffin for being here today. Thank
you for taking time and updating us.
In the many times we have met in my office and in this
Committee and in Reno just a few weeks ago, Secretary McDonald
has showed he is committed to bringing a new vision and reforms
to the VA to better serve Nevada and the Nation's veterans.
But the task ahead will be VA's most difficult challenge
after having failed our veterans in delivering quality health
care and timely benefits. The gross mismanagement, poor
treatment of veterans, long delays revealed in Phoenix and
elsewhere have shocked Congress and our Nation and is a
significant crisis to overcome. My hope is that the Secretary's
goals will not get lost in the bureaucracy, and I expect
consistent communication and honesty about what the VA needs
from Congress to restore faith in the VA and achieve the best
care possible for our veterans.
Just last week, I had the privilege to meet with our
veterans in Pahrump, NV. In the past 15 years, Pahrump has
grown from a small town outside Las Vegas to a community of
36,000. In Pahrump and all of Nye County, there are about 9,000
veterans, which is why this community has fought long and hard
for a larger VA clinic as more veterans flock to this
community.
When visiting, I told them about the promise that I made to
you, Mr. Secretary, when we first met, and that was that every
time I see you, I will always bring up several key issues to
Nevada veterans, of course, building the VA clinic in Pahrump,
improving the Las Vegas VA hospital, and eliminating the
disability claims backlog that we have in Reno.
Bob, you deserve credit for quickly approving the Pahrump
clinic as soon as you were confirmed, and I also appreciate
Director Duff and Associate Director Caron for working closely
with my office to keep me informed.
But there is a lot of work to be done on this clinic. A
contract must be awarded, the clinic must be constructed, and
then it must be fully staffed. I will be looking closely at
each of these steps to determine if there are unnecessary
bureaucratic barriers that delay projects like this and will
hold the VA accountable.
I also hope to see improvements in the Las Vegas VA
hospital. There have been discussions about how to do this, and
I would like to share a few key improvements that I think need
to be made.
First, members of the Disabled American Veterans in Nevada
want to improve transportation of rural veterans to this
hospital. Right now DAV, Disabled American Veterans, have a
transportation program, but they are not allowed to take
veterans confined to a wheelchair. Now, stop and think about
that for a minute. DAV, their transportation program is
forbidden to take veterans confined to a wheelchair or
utilizing an oxygen tank to the hospital. There needs to be
greater partnership and coordination with the VA to expand the
VA's own transportation service for these disabled veterans in
rural areas.
Second, appointment wait times in the Vegas hospital must
be improved. New patients in Vegas wait 25 days on average for
specialty care appointments and 16 days on average for mental
health appointments. Director Duff has assured me her team is
working to improve these wait times, and part of this
improvement will be an enhanced scheduling system the VA is
currently seeking. Every VA hospital needs modern processes and
technology that will give directors the information they need
to determine where resources are missing.
Next, a point that the Secretary has brought up to me is
the differences in regions and management structure among the
three VA Administrations--Health Care, Benefits, and
Cemeteries. I look forward to working with you to improve the
current structure and believe that reorganizing these
Administrations should be a positive step forward to enhanced
coordination and improved care to our veterans.
And, finally, I remain committed to addressing the VA
disability claims backlog. For years now, Nevada is the worst
in the Nation with claims being completed in 334 days on
average. As co-chair of the VA Backlog Working Group, I will be
hosting a roundtable later today, along with Senator Casey, to
discuss the need to overhaul the outdated claims processing
system; I believe there is no better time to reform the claims
process as while the VA transforms under Secretary McDonald's
leadership. And the working group's legislation is a strong
platform for some of the changes that need to be made. I look
forward to hearing more about the changes and progress of
improving care and benefits at the VA. Again, I thank you, Mr.
Secretary and Inspector General Griffin, for being with us
today.
Thank you, Mr. Chairman.
Chairman Sanders. Thank you, Senator Heller.
Senator Blumenthal.
STATEMENT OF HON. RICHARD BLUMENTHAL,
U.S. SENATOR FROM CONNECTICUT
Senator Blumenthal. Thank you, Mr. Chairman, and thank you
and the Ranking Member, as well, for holding this hearing
today. Thank you to Secretary McDonald and Inspector General
Griffin. We are here to listen to you, not so much to talk, but
even more important is that we listen to our veterans across
the country who have firsthand experience beyond the Inspector
General reports, beyond the polling, beyond the hearings that
we conduct here.
I had a town hall meeting in Newington last Friday night
for a couple of hours and welcomed William Streitberger, the
Director of the Hartford VA Regional Office, as well as Gerald
Culliton, the Director of the VA Connecticut Health Care
System, to listen to our veterans, and not just about the
delays but the more fundamental gaps in care that we have right
now that we are all working hard to fill.
Just one example, K. Robert Louis, a veterans service
officer from the Veterans of Foreign Wars, shared with the
audience very compellingly his understanding that many veterans
with the VFW have received outstanding service, but that there
is a lack of providers--nurses, doctors, staff--that has caused
the delays and hindered veterans' access to care.
I know that the Veterans Access to Care Act authorized $5
billion to enable the VA to hire additional health care
providers and clinical staff, but, Secretary McDonald, you have
identified the practical obstacles to meeting the needs and
hiring more doctors and other professionals, and that is one of
the central challenges of our time. And I hope that this
Committee will play a constructive role in that task and so
many others that face you in this very challenging time, as
well as rebuilding the facilities, the infrastructure, as at
the West Haven hospital, where not just renovation but
rebuilding are necessary to replace a 1950s structure that
cannot accommodate the most modern technology, the equipment
that is necessary to care for people in 21st century fashion.
I want to say that I hope that we will continue to be of a
mind that this health care system is in crisis. I know that
``crisis'' is an overused word in Washington, but it should
give us the impetus and sense of urgency that we all feel as to
the need, the immediate need, because health care delayed is
health care denied. People need it now when they need it.
So, Mr. Secretary, I want to thank you for your
determination and the management experience that you will bring
to this task.
Finally, we all know that we are going to see a surge of
veterans coming out of our military in the next months and
years as the Army and the Marine Corps downsize. Many of them
will have the horrific invisible wounds of war that we now have
diagnosed as Post Traumatic Stress or Traumatic Brain Injury.
I want to thank the VA for its support in efforts that I
and others have made to correct the records of veterans of past
wars at times when Post Traumatic Stress was undiagnosed and
untreated and caused many of them, particularly from the
Vietnam era, to be given less than honorable discharges. Those
bad-paper discharges have been a stigma and a black mark on
their records, and caused many of them to be homeless and
jobless. I want to thank Secretary Hagel for now initiating a
new era when those records can be corrected.
At our side, as we sought this change in policy, was the
VA, and most especially General Shinseki, who served in that
war. I want to thank all of the dedicated men and women of the
VA for their service in so many ways, most especially in the
help that they provided to initiate this change in policy. And,
thank you to Secretary Hagel for his awareness and his courage
in taking this very, very important step to give honor and
respect to veterans who were unfairly treated when they
received less than honorable discharges, when they suffered
from Post Traumatic Stress that led to those kinds of
discharges.
Thank you, Mr. Chairman.
Chairman Sanders. Thank you, Senator Blumenthal.
Senator Moran.
STATEMENT OF HON. JERRY MORAN,
U.S. SENATOR FROM KANSAS
Senator Moran. Mr. Chairman, thank you. Thank you to you
and Senator Burr for having this hearing. Secretary McDonald,
thank you for your presence but, more importantly, thank you
for your willingness to serve. I hope that you will hit the
ground running. I hope that you utilize your tenure as the
Secretary to make remarkable improvements at the Department of
Veterans Affairs on behalf of America's veterans.
I hope to explore with you during my time of questioning a
couple of things, in particular--with you and the Inspector
General, I would like to hear about what the consequences to
employees at the VA have been as a result of their misconduct.
Are those currently on leave, on leave with pay, or without
compensation? And has anyone been discharged or is there a plan
to discharge anyone as a result of what has occurred at Phoenix
or elsewhere within the Department of Veterans Affairs?
In the broader sense of the legislation that we have
passed, my understanding is--and I think I know this
sufficiently well to say this--that many of the authorities
that are given the VA, in fact, directives given to you in the
Veterans Act, are already things that you have the ability in
your discretion to do related to providing care outside of VA.
I would love to hear about what is transpiring now as we wait
for the implementation of this Act. How are we caring for
veterans who are, either through lack of timeliness or
geography, having difficulty accessing veterans' medical
services? In particular, I would like to hear how you intend to
utilize ARCH, the pilot program in the five States across the
country. And the authorities given to you in the new
legislation allow you to not only extend that program but to
expand that program. So, I would like to make certain there is
nothing that stands in the way of either one of those things
happening from the VA's perspective, and to make certain that
that Program ARCH is used while we are transitioning the
authorities given you in the legislation.
A couple of examples where this hits home. A gentleman in
Smith Center, KS, who needed a colonoscopy, was told he needed
to drive 4 hours to Wichita to do that. The VA, upon our
prodding, changed their mind and allowed for this service to
occur near home. He apparently qualified because of the issue
of timeliness, not because of geography.
Another veteran who has to have cortisone shots is told by
the VA he must drive 3\1/2\ hours to the VA. Apparently he does
not qualify for the lack of timeliness and, therefore, he ought
to qualify, in my view, for geography. But, again, the VA has
said no. So, how we implement this act in regard to timeliness
and geography and what authorities you have in the interim to
make certain that no one falls through the cracks while we wait
is of great importance.
It has been discouraging to me on the one hand and
impressive on the other, the significant changes that have been
made at the VA. The discouraging part is if you could react
this quickly and accomplish what has been accomplished in the
last month or so, why was it not being done in the first place?
If we can come up with ways to solve the problems of how we get
veterans in to see a physician and be treated, why was it not
occurring all along when you have been able to accomplish so
much in a short amount of time?
Thank you, Mr. Chairman.
Chairman Sanders. Thank you, Senator Moran.
Senator Begich.
STATEMENT OF HON. MARK BEGICH,
U.S. SENATOR FROM ALASKA
Senator Begich. Thank you, Mr. Chairman. Thank you for
holding this hearing. Secretary McDonald, thank you very much
for our meetings and conversations we have had, and for the IG
being here also.
Let me just say a couple things. First, I am very glad that
the piece of legislation passed, as it did a month or so ago,
but the reality is, as we know--and I guess for Senator Moran,
in Alaska, we have been doing this for 3-plus years. We dragged
the Obama administration along, but they now understand, and we
have been doing it for 3 years. We deliver health care to 30
different tribes around the State through our Indian Health
Services program, which is administered by Alaska tribes,
delivering health care to veterans, both native and non-native,
no matter where they live. It does not matter if you are living
up in Nome or you are living all the way down in Ketchikan. We
can deliver care if the veteran so chooses, with the existing
rules. And it was not easy. There was a little bit of back-and-
forth between the VA and the Health and Human Services
Department to get them to understand that this is about
delivering care with the same tax dollars. It does not matter
who was spending it. It was coming from the same kitty that we
have to allocate.
So, from my perspective, you know, I am anxious to see how
and what you will do with these recommendations, but the
reality is--and to be very frank, I am sure, Mr. Secretary, you
would prefer not to keep coming to meetings like this but to
actually go do the work that needs to be done. And I am glad we
are doing oversight. It is important to make sure that you, the
administration you are now in charge of, the Obama
administration, all of them are focused on this issue of
delivering health care at the greatest level possible.
But I think we have some great examples already that exist
that we could utilize as I gave for Alaska. For example, in
Anchorage, which is 43 percent of the State's population, you
can go to the VA clinic or you have a choice. You can go to the
Anchorage Neighborhood Health Services clinic or the Alaska
Native hospital. And in those two facilities, those last two I
mentioned, if you are on the list, you get in the same day, as
long as it is not major medical. That is an amazing step. We
did that before this new piece of legislation.
To be very frank with you, I am not sure what some did in
their own States. I know what I did. I had to pound away on the
VA, because I remember my first memo I put out on this idea,
within 6 months after coming into office; they said it cannot
be done, not possible, unrealistic, it is two different
agencies. I remember the long laundry list that I got, both
from the agency and veterans organizations. Nonetheless, we
just pushed the pedal down all the way, because I think they
just spelled ``yes'' wrong. They spelled it ``N O.'' We just
had to work on it. The end result is today we are delivering
care all across the State of Alaska, which is one-fifth the
size in mass, of this country. So, if we can do it there, we
can do it anywhere. I think in a lot of ways, the piece of
legislation we passed only re-emphasizes what can be done, plus
we gave more money.
The challenge you are going to have is making sure we have
enough professionals. As we know, in Alaska, the Matanuska
Valley, the Mat-Su area, had a problem, still has a problem
recruiting primary care doctors. That is going to be a problem
not only in the VA system, but in the Indian Health Services,
the private sector, and you name it, it is a problem
everywhere. But what did we do there? Again, we used a tribal
agreement to use South-Central clinic to admit almost 500
veterans for care, because we had access and capacity there.
So, as you look at how to solve this problem and continue
to move forward, look at the assets that are out there. I do
believe, as proven before this legislation passed, we have the
authority, you have the authority, you have the capacity to
push the pedal all the way down. The VA, the Obama
administration, can make these things happen if they want. So,
I think what we are saying here today is we are glad the bill
passed, we are glad we are having oversight, but just go do it.
Make it happen. And then when there are problems and
challenges, you need to let us know right away.
My guess is recruitment is going to be a continual problem,
not only for your system but for every medical system in this
country, because it takes years to get a primary care doctor
into the system.
One of the things we want to make sure is with the VA, for
example, mental health providers, which is a huge gap, are
universally still not certified in cooperation with the VA to
make sure our counselors are being able to be used. They do not
have the exact credentials, but they are available. So, we need
to make sure the VA makes this happen, because they are ready,
they are able. There are huge gaps in mental health services.
We want to make sure certification is possible. I want to make
sure you have that on your list.
But, again, you'll have some big challenges in recruitment.
The administration is moving forward. You have a huge task
ahead of you, and I want to make sure that we are not always
going to meetings but we are hearing results, and that is what
I am looking for.
Thank you.
Chairman Sanders. Thank you very much, Senator Begich.
Senator Boozman.
STATEMENT OF HON. JOHN BOOZMAN,
U.S. SENATOR FROM ARKANSAS
Senator Boozman. Thank you, Mr. Chair, and thanks to you
and Ranking Member Burr for the hearing. I think in the
interest of time I would like to hear the testimony, though I
may put a statement in the record.
Chairman Sanders. Thank you very much.
Senator Murray.
STATEMENT OF HON. PATTY MURRAY,
U.S. SENATOR FROM WASHINGTON
Senator Murray. Well, thank you, Mr. Chairman, for holding
this really important hearing. I want to start by thanking the
Inspector General, Richard Griffin, and the Department's Office
of Inspector General for all the work that has been done to
conduct this review. Your investigators and staff have put
together an incredibly important report on what happened at
Phoenix. And completing the other investigations at nearly 100
medical centers is really an enormous task. So, I want to thank
the OIG and all of your staff for the incredible dedication it
is taking and will take to get this done.
After a lot of years of making critical contributions to
veterans' care and benefits, the IG, rightly, has the
reputation of being objective, reliable, and thorough in your
work, so we all do thank you. Your findings are going to be
really vital as we work forward through this, so I appreciate
it.
I also appreciate how Secretary McDonald has hit the ground
sprinting in his new role and has taken immediate steps to get
the veterans off wait lists and into care. And while the VA's
latest data continues to show patient accessibility improving
across the Department, I want you to know I still am concerned
about some of the facilities in my homestate of Washington.
Veterans receiving primary and specialty care within the Puget
Sound Health Care System continue to wait longer than national
averages for primary and specialty care. And at Spokane, the
new mental health care patients wait over twice as long--75
days for their appointments--and that has got to change.
As the VA continues to focus on providing veterans with
timely access to care, it also has to ensure veterans receive
the highest quality of care, and as the IG report showed, that
was all too often not the case in Phoenix. They found that the
Phoenix Health Care System struggles with many of the basic
quality-of-care issues, things like leaving routine physical
examinations and evaluations incomplete, or failing to conduct
them at all, or releasing mental health care patients before
their medications were properly stabilized, and struggling to
provide dedicated mental health care providers to patients.
So, when we are talking about caring for our Nation's
heroes and their families, we all expect excellence. And I want
to note, as I have said repeatedly, as transparency and
accountability increase at the VA, so will investigations and
reports of additional concerns requiring even more action from
the VA, the administration, and this Congress.
Today, Mr. Chairman, I hope to hear how the VA is going to
address the findings of the IG, the VA access audit, and the
White House review, and I want to hear how the VA will
implement the Veterans Access, Choice, and Accountability Act.
Yesterday we heard the Secretary speak about VA
recommitting itself to core values. Today we need to know how
the Secretary will turn those commitments into real action and
to improve care for our Nation's heroes.
Thank you, Mr. Chairman.
Chairman Sanders. Senator Murray, thank you very much.
I think we have heard from all the Senators. Let me bring
Mr. Griffin and his staff to the table.
Let me welcome Richard Griffin and his staff. Mr. Griffin
is the Acting Inspector General for the Department of Veterans
Affairs at today's hearing. Let me also make a comment. Normal
protocol is for us to have the Secretary go first, and I want
the Secretary to know that there is no disrespect in us
breaking that protocol. But I thought it would be more
important to hear what the Inspector General had to say and
what his staff had to say and then see the Secretary respond to
that.
Mr. Griffin was appointed as Deputy Inspector General in
2008. He previously served as the VA Inspector General from
1997 to 2005, so he brings an enormous amount of experience and
knowledge to his position.
He is accompanied today 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 to the Inspector
General; and Mr. Larry Reinkemeyer, Director of the Inspector
General's Kansas City Audit Office.
Mr. Griffin, thank you so much for your work and thank you
for being with us. The mic is yours.
STATEMENT OF RICHARD J. GRIFFIN, ACTING INSPECTOR GENERAL, U.S.
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY JOHN D. DAIGH,
JR., M.D., ASSISTANT INSPECTOR GENERAL FOR HEALTHCARE
INSPECTIONS; LINDA HALLIDAY, ASSISTANT INSPECTOR GENERAL FOR
AUDITS AND EVALUATIONS; MAUREEN REGAN, COUNSELOR TO THE
INSPECTOR GENERAL; AND LARRY REINKEMEYER, DIRECTOR OF THE
INSPECTOR GENERAL'S KANSAS CITY AUDIT OFFICE
Mr. Griffin. Mr. Chairman, Ranking Member Burr, and Members
of the Committee, thank you for the opportunity to discuss the
results of the IG's extensive work at the Phoenix VA Health
Care System. Our August 26 report expands upon information
previously provided in the interim report and includes
information on the reviews by OIG clinical staff of patient
medical records.
The OIG examined the medical records and other information
for 3,409 veteran patients, which included 293 deaths, and
identified 28 instances of clinically significant delays in
care associated with access or scheduling. Of these 28
patients, 6 were deceased. In addition, we identified 17 cases
of care deficiencies that were unrelated to scheduling or
access issues. Of these 17 patients, 14 were deceased.
The 45 cases discussed in the report reflect unacceptable
and troubling issues in follow-up, coordination, quality, or
continuity of care. The identity of these 45 veterans has been
provided to VA. Decisions regarding VA's potential liability in
these matters lie with the Department and the judicial system
under the Federal Tort Claims Act. Information on the
qualifications of the OIG physicians who conducted these
reviews can be found in the curriculum vitae submitted for the
record with our written testimony.
We identified several patterns of obstacles to care that
resulted in a negative impact on the quality of care provided
by Phoenix, and as of April 22, 2014, we identified about 1,400
veterans waiting to receive a scheduled primary care
appointment who were appropriately included on the Phoenix
electronic wait list. However, as our work progressed, we
identified over 3,500 additional veterans, many of whom were on
what we determined to be unofficial wait lists, waiting to be
scheduled for appointments but not on Phoenix's official
electronic wait list.
Urology Service was also unable to keep up with the demand
for services. During our review, it became clear that the
Urology Service at Phoenix was in turmoil during the 2012 to
2014 timeframe. There were a number of urology physician
staffing changes, delays in the procurement of non-VA purchased
care, and difficulties coordinating urologic care. The OIG is
currently working from a list of 3,526 patients who may be at
risk for having received poor-quality urologic care. As a
result, urology services at Phoenix are the subject of an
ongoing OIG review.
Since July 2005, OIG has published 20 oversight reports on
VA patient wait times and access to care, yet VHA did not
effectively address its access-to-care issues or stop the use
of inappropriate scheduling procedures.
When VHA concurred with our recommendations and submitted
an action plan, many VA medical facility directors did not take
the necessary actions to comply with VHA's program directives
and policy changes.
In April 2010, in a memorandum to all VISN Directors, the
then-Deputy Under Secretary for Health for Operations and
Management called for immediate action to review scheduling
practices and eliminate all inappropriate practices.
In June 2010, VHA issued a directive reaffirming outpatient
scheduling processes and procedures.
In July 2011, an annual certification of wait times was
mandated.
In January 2012 and May 2013, the VISN 18 Director issued
reports that found Phoenix did not comply with VHA's scheduling
policy.
Finally, in May 2013, VHA waived the annual requirement for
facility directors to certify compliance with the VHA
scheduling directive, further reducing accountability over
wait-time data integrity and compliance with appropriate
scheduling practices.
The IG opened investigations at 93 sites of care in
response to allegations of wait-time manipulations. The
investigations continue in coordination with the Department of
Justice and the Federal Bureau of Investigation. While most are
still ongoing, these investigations are confirming that wait-
time manipulations were prevalent throughout VHA.
This report cannot capture the personal disappointment,
frustration, and loss of faith individual veterans and their
family members had in the health care system that often could
not respond to their mental and physical health needs in a
timely manner. Immediate and substantive changes are needed.
The VA Secretary has acknowledged the Department is in the
midst of a serious crisis, and he has concurred with all 24
recommendations in our report and submitted acceptable
corrective action plans.
Mr. Chairman, this concludes our statement, and we would be
pleased to answer questions any of the members may have.
[The prepared statement of Mr. Griffin follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman Sanders. Mr. Griffin, thank you very much for your
testimony and for the work that you and your staff have
undertaken over the last few months.
Let me begin by asking you a question that arises from some
media reports which have troubled me. There has been some
suggestion that the IG, the Office of Inspector General for VA,
is really not independent. And I would like to provide you with
the opportunity to describe the process the IG utilizes when
preparing oversight reports, including the draft report review
and comment process. In other words, are you being heavily
influenced by VA? Are they editing the reports that you give
us? Or, in fact, are you an independent entity finding the
truth as best you can?
Mr. Griffin. Thank you for that question. Our organization
over the last 6 years has issued over 1,700 reports addressing
oversight issues in the Department of Veterans Affairs. We have
testified at over 60 congressional hearings in the last 6 years
about our reports. Every one of our draft reports and every
draft report of anybody in the Inspector General community is
submitted as a draft to the Department for purposes of
guaranteeing accuracy of all reporting. If the Department has
information that we missed in doing our work that they can
point out to us that would be factual and convincing, then we
may come to realize, well, we have got this one part wrong.
We do not accept from the Department or from anyone else a
dictated response that is based on opinion as opposed to fact.
Chairman Sanders. OK. Thank you very much.
Let me ask you this: every Member of this Committee is
outraged by what happened in Phoenix. We are outraged in
general by unacceptably long wait periods for veterans to
access health care. We have seen with disgust the manipulation
of data, lying, et cetera. What I would like you to do is
explain in plain English, how does this happen?
Now, you pointed out just a moment ago that we have heard
from VA time and time again their concerns about the
appointment process, and yet nothing seemed to happen. So, take
us to Phoenix and describe to us exactly how it happened that
we had these long waiting periods that were disguised and how
we had some people not on any waiting list at all. And all of
this went on while nobody did anything about it. How does this
happen?
Mr. Griffin. That happens when there is a failure of
leadership. We are not just talking about Phoenix. We have
reported on this problem for 9 years. Excellent policies were,
in fact, published and sent out. I alluded to some of them in
my oral statement. You have to follow it through. Wait times is
not the only issue that we have reported on where VHA has
promulgated policies to address our recommendations, sent them
out, and were supposed to be certified that they were followed,
and they were not.
It is hard to explain the why of that, but when people do
not follow the directive from their headquarters leadership and
mislead them about it, there has to be a consequence.
Chairman Sanders. All right. Two brief questions.
Number 1, to what degree did the 14-day directive impact
the immediate problems?
And, number 2, how can a facility provide timely care if
they do not have enough doctors, nurses, space, and staff? And
how does that not get up to the general office? How does it not
happen that somebody says, ``I cannot do it in 14 days. I just
do not have the doctors; I do not have the staff?'' Explain
that process to me.
Mr. Griffin. I believe there was an awareness in Phoenix,
based on some of the e-mails that we pulled and that are
included in our report, that many people in the Phoenix
hierarchy were aware that it was not doable. I am sure you
recall the e-mail from our interim report where someone asked
for an ethics review because our ``Wildly Important Goal'' in
the success that is being reported is smoke and mirrors, as was
mentioned earlier.
I think a big part of the equation for the fix, as opposed
to what we all know happened, when you look at the initial
point where a veteran has contact at the medical center, very
often you have the lowest-graded employees who might not be
equipped to be able to triage this veteran who really needs to
get seen in 14 days or 7 days, or tomorrow or today, versus
this veteran can wait 30 days.
I think in the private sector you would probably have
somebody with a little more clinical background to try and make
that evaluation, so you know who really does need to come in
and who does not.
Chairman Sanders. My time has expired, but the bottom line
is if you do not have the staff, if you cannot do it, how come
that is not transmitted up the channel?
Mr. Griffin. It should be. I believe in Phoenix it was, and
the outcome is documented in our report that no action was
taken to fix it.
Chairman Sanders. OK. Thank you very much.
Senator Burr.
Senator Burr. Mr. Griffin, thanks to you and to your staff
for the job you have performed, for the undertaking that you
are already in process with. I do not think any of us would
wish it on anybody that they had to make the reviews that you
are having to do.
Let me just ask, had the VA listened to prior IG reports
and fixed the problems you had pointed out, would we be here
today talking about Phoenix or talking about any facility?
Mr. Griffin. No.
Senator Burr. The problems within VA seem to be rooted in
two things. One is the culture that has been created, and I
think that culture has been created because there was a lack of
accountability, which was evidenced by these waiting lists that
operated outside of the electronic system and by other things.
Had they just addressed those, we probably would not be here
investigating Phoenix to the degree that we are. Is that an
accurate statement?
Mr. Griffin. That is accurate, and as I mentioned
previously, even in other areas, we would not close a
recommendation unless we believed that they had taken the
appropriate steps to resolve the issue.
When you get a copy in 2010 of this mandate to knock off
the manipulation and then 3 months later you get an updated
scheduling procedure as a VHA directive, at that point you
would believe that people got it, that it would be implemented,
and it would be implemented to the letter.
Senator Burr. What do you conclude--how could somebody
conclude within VA not to require certification last year based
upon all the warning signs you had provided for them?
Mr. Griffin. I think the next panel can probably better
explain what the rationale was. I think there has been plenty
of warning that this was going on, and I thought the
certification was an excellent thing to make people declare,
yes, I have reviewed it in my facility, and, yes, our waiting
times are according to the policies and procedures of the
Department.
Senator Burr. Now, you have been involved for 6-plus months
investigating the current list of things, and I know you cannot
get into specific takeaways, but let me ask: what have you
learned about the VA over that period of time, not down to the
specifics?
Mr. Griffin. Referring to the 93 other facilities? Well, we
have some initial reporting on those. As of yesterday, we have
given the Department 12 individual reports for them to examine
and determine what action would be appropriate in view of the
specifics of each of those reports.
The rest of our 93 are still very much active, but I can
tell you that at 42 different facilities of those 93, we found
the practice of using the next available date as the desired
date. It is something that was reported on in our interim
report and in the final report. We have 19 facilities where an
appointment was canceled and rescheduled on the same day for
the same appointment time for the sole purpose of giving the
appearance of a shorter waiting time.
We have had 16 facilities that had paper wait lists as
opposed to being on an EWL. We had 13 facilities where managers
lied to my investigators about what was going on at their
facilities.
Senator Burr. Did your investigators conclude that all of
these individuals came up with these deceptive practices on
their own? Or was there some overarching initiative that some
level of management actually pushed?
Mr. Griffin. It is a combination. Frankly, when something
is going on for as many years--not everywhere but at a number
of the facilities--it almost becomes the accepted way of doing
scheduling. And, again, when you have lowest level employees
involved in scheduling and they come in as a new hire and
somebody says, ``This is how we do it,'' they may not realize
that someone is telling them the improper way to do it. So, it
is a combination of things.
The bottom line is: who is in charge? And when you get a
policy directive from VHA, do you enforce it, or do you ignore
it? I think that is the bottom line.
Senator Burr. My time has expired, but let me say once
again I thank you and your staff for the process you are going
through. It is invaluable to our country's veterans and to the
agency.
Mr. Griffin. Thank you.
Chairman Sanders. Senator Burr, thank you very much.
Senator Tester?
Senator Tester. Thank you, Mr. Chairman, and I, too, want
to thank you, Inspector General Griffin, for your work and for
your professionalism. I very much appreciate it. It is very
helpful to us, so thank you for that work.
Your investigations, whether it be Phoenix or whether it is
the other 93 facilities, are focused on scheduling, correct?
Mr. Griffin. That is what we go in to look at, but along
the way you sometimes become aware of other activities that you
need to look at that might be tangentially related. You know,
so principally they are on scheduling and manipulation of wait
times, but there are some places where it has expanded.
Senator Tester. Is it fair to say that--I mean, the
investigation started out in Phoenix because of some pretty
damning things that were being said about Phoenix. Is it fair
to say that the scheduling problems are pretty pervasive
throughout the VA?
Mr. Griffin. Absolutely.
Senator Tester. OK. Specifically for Phoenix, is--look, I
mean, a good portion of Montana heads down there in the
wintertime. Were there parts of the year where the scheduling
was worse than other parts of the year? Or was it just that way
all the time?
Mr. Griffin. You know, we did not try to carve out the
snowbird aspect that might impact Phoenix, but we----
Senator Tester. I was just curious.
Mr. Griffin. We did not find a good quarter in any of the
quarters we looked at.
Senator Tester. OK. Would you say--in the conference
committee opening statements we heard a lot from the members of
the conference from both Houses that talked about that this is
not a workforce issue. In your investigations, what would you
say to that?
Mr. Griffin. I would say it is a complex issue with many
aspects. One of those aspects is performance standards for the
physicians that you do have. Without those standards, it is
hard to determine exactly how many doctors and nurses you need.
It is a clinical space issue. VHA guidance talks about a panel
of 1,200 patients for primary care. But it assumes that there
are three separate offices for each doctor so that you can have
your patients ready to go when you come in, and in Phoenix,
there was only one office per doctor.
I think it is a combination of, yes, in some facilities
they are understaffed, both nurse and doctor staffing. We have
sought the implementation of staffing standards for years. We
did a review in 2012 on specialty care staffing standards and
found that only 2 of 33 specialties had standards. I think you
need to know how many veterans can we anticipate this
specialist seeing in a given day and then make sure the
schedule is properly structured so you can fill those slots.
Senator Tester. You have got a number of MDs on your staff,
and you may, in fact, be an MD. I am not sure. I cannot
remember. You are?
Mr. Griffin. No.
Senator Tester. OK. When you are talking about staffing
standards, do you use the private sector for your standards
then? And maybe this should be reflected to one of the MDs on
the staff. And I will tell you why I ask this. I am not an MD
either, but it appears to me that if you try to apply private
sector staffing standards to the VA it is unfair, because these
folks are coming back with multiple problems, plus ones that
are unseen, too. So, do you guys apply the staffing standards,
or do you say, VA, you need to set up the staffing standards?
Mr. Griffin. We have said that we believe they should have
standards so that if you are in a like-size VA facility in one
part of the country or another, the expectation is a certain
level of productivity.
I would ask Dr. Daigh if he would like to elaborate upon
that.
Dr. Daigh. Sir, we have advocated that VA create their own
standard, aware of civilian standards, but without that data, I
do not know how you can make proper business decisions about
what you are going to make or what you are going to buy.
Senator Tester. That is good. Thank you very much.
There are 1,700 health care facilities in the VA; 93 are
being investigated by you at this point in time. Can you give
me any idea--or is it pretty evenly distributed between
hospitals, CBOCs, and small clinics?
Mr. Griffin. I would be guessing to give you that number,
but it is a mix.
Senator Tester. Can you give me that number?
Mr. Griffin. We can. Yes, absolutely.
Senator Tester. I would like to get that.
Mr. Griffin. And if someone at the table here has it, I
will give it to you right now.
Senator Tester. That is fine. There is nobody nodding yes,
so we will--one more, because my time just ran out.
Mr. Griffin. We will get it to you.
[The information referred to follows:]
Response to Request Arising During the Hearing by Hon. Jon Tester to
Richard Griffin, Acting Inspector General, U.S. Department of Veterans
Affairs
------------------------------------------------------------------------
Type of Facility Number
------------------------------------------------------------------------
VA Medical Center......................................... 68
Community Based Outpatient Clinic......................... 13
Outpatient Clinic......................................... 8
Health Eligibility Center................................. 1
Health Care System........................................ 1
Ambulatory Care Center.................................... 1
Multi-Specialty Outpatient Clinic......................... 1
------------------------------------------------------------------------
Senator Tester. When can we expect a report from you guys
on these 93 facilities, a full report?
Mr. Griffin. As we finish each individual report--and to be
finished, if it is a criminal matter, we have to present it to
the U.S. Attorney's Office for a prosecutive decision. If it
does not meet the threshold for prosecution, we give the report
to the Department so that they can take administrative action,
where appropriate.
Senator Tester. Would it be fair to say--and I do not want
to box you in--these would be done by the end of the year?
Mr. Griffin. I hope so.
Senator Tester. Thank you very much.
Thank you, Mr. Chair.
Chairman Sanders. Thank you, Senator Tester.
Senator Heller?
Senator Heller. Thank you, Mr. Chairman.
I want to go back to your initial comments on the report,
the draft report versus the final report, and some of the
changes that were made in that report, to get some
clarification as to timelines.
It was reported that a line was inserted, and if you are
the VA, this is the line you would want inserted in that
report. That line says, ``While the case reviews in this report
document poor quality of care, we are unable to conclusively
assert that the absence of timely quality care caused the
deaths of these veterans.'' Obviously that was pertaining to
the Phoenix hospital.
Just some timelines. Was this line included in the draft
report?
Mr. Griffin. There are many versions of the draft report.
The majority of the changes in our draft report came about as a
result of further deliberations by the senior staff of the
Inspector General's office. No one in VA dictated that sentence
go in that report, period.
Senator Heller. Was the line included in the draft report
that was sent to the VA?
Mr. Griffin. It was not included in the first version of
that draft report. What I would like to do, if I may, is
provide a timeline in writing to the Committee----
Senator Heller. I would like that.
Mr. Griffin [continuing]. That, you know, can make it very
clear what is going on with that allegation.
[The information referred to follows:]
Response to Request Arising During the Hearing by Hon. Dean Heller to
Richard Griffin, Acting Inspector General, U.S. Department of Veterans
Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Senator Heller. OK. I guess the question that needs to be
asked, did the VA play any part in the inclusion of this line?
Mr. Griffin. No.
Senator Heller. In your report, you obtained a list of 171
patients who were waiting to seek services. Most of them were
mental health therapies. You also noted in your report that,
between January 2012 and 2014, you identified 77 suicides.
These patients did not have their appointments scheduled or
were yet to be scheduled. What I am trying to get to is: would
a reasonable person come to the conclusion that wait-time
manipulation contributed to patient deaths? Would a reasonable
person come to that conclusion, that the manipulation of these
wait times contributed to an individual's death?
Mr. Griffin. I am going to ask Dr. Daigh to describe the
clinical process review, but what I would say in general, we
are not in the business of making odds on whether something did
or did not cause a death, whether it is likely, unlikely, 50
percent, 30 percent, 80 percent. That is not our purpose. Dr.
Daigh will describe how we conducted those reviews.
Dr. Daigh. We looked at the fact pattern of each of the
cases that we described for you. So, one of the issues you have
to understand is that because you are on a wait list for
audiology and you happen to die of a cardiac problem, the wait-
list factor was not very important.
If you were under the care of a urologist intensively but
you were on a wait list to see primary care, then we may have
concluded that, yes, you were on a wait list, yes, you died,
but we do not see a relationship there.
So, for each of these cases we have reported, we wanted the
fact pattern to demonstrate that a delay in care we thought
would have led or dramatically impacted the likelihood that
that patient would die, and we did not see that. We saw harm.
We saw 28 cases described where delay negatively impacted care.
But I could not say delay caused the patient to die.
Senator Heller. So, of the 171 patients that were delayed
in mental health therapy, and you identified 77 suicides, you
see no link between delayed care and these----
Dr. Daigh. I did not say no link. I said that if you are
trying to say that----
Senator Heller. You see, I am in the business of trying to
find conclusions and figuring out what reasonable people would
believe. We had a female veteran, a blind veteran with diabetic
problems in Nevada, who had to wait 6 hours to get care. Two
weeks later she died. I have to believe that there is a link
between the kind of care she was getting at that hospital and
her death 2 weeks later. And I think any reasonable person
would come to that conclusion.
Dr. Daigh. So, we looked, again, at the fact pattern for
each of these cases. We had two physicians on my staff agree on
the cases and the fact pattern and the conclusion we came to on
each of these cases. When we began this review, I thought we
would find patients with delayed care leading to death. I
agree, that is a likely outcome. I just did not see it. All I
can do is report the news that I find, and this is what we
find.
Senator Heller. See, I do not want to give the VA a pass on
this, and I believe that that is what this line does. It
exonerates the VA of any responsibility in past manipulation of
these wait times.
Dr. Daigh. I just have to disagree. I described 45 cases,
28 of which were negatively impacted because of delays. The
only argument is, I cannot say that those that died, died
because of a delay. In addition, I found that there was care
that did not meet the standards of care that we would expect of
the VA for an additional 17 cases. I have laid those fact
patterns out in the report, so I have a conclusion, and the
reader can come to their own conclusion.
Senator Heller. Dr. Daigh, thank you.
Thank you, Mr. Chairman.
Chairman Sanders. Thank you, Senator Heller.
Senator Hirono?
Senator Hirono. Thank you, Mr. Chairman.
Just following up on the previous question, Mr. Griffin,
would you agree that attribution of negligence as a result of
delay in care as a causation of death is basically an
adjudicatorial process that needs to be undertaken?
Mr. Griffin. That is correct.
Senator Hirono. You noted in your testimony that wait times
are not the only issue that you were focusing on, and that when
people do not follow headquarters directives and mislead the
headquarters, there have to be consequences. You are
investigating some 93 facilities. Have you completed those
investigations on any of those facilities?
Mr. Griffin. We have completed 12. We have turned over 12
files to the Department for their--whatever action they deem
appropriate. All the others are in process.
Senator Hirono. As a result of these 12 files, has the VA
undertaken any criminal or administrative proceedings,
disciplinary proceedings?
Mr. Griffin. Well, the criminal decision lies with the U.S.
Attorney's Offices that we are working with around the country.
VA owns the decision on administrative action. And, in fact,
shortly after our first report was sent to the VA, they did
take administrative action.
We are trying to get these done as quickly as possible so
that they can move out in every instance where they need to,
but we have to make sure we have all the facts right prior to
declaring that we are through and this is the final product. We
are working diligently on that, but we have a lot of other
prosecutions outside of wait-time areas which have led to over
500 arrests a year for the last 6 years that you cannot just
drop. A lot of them are threat and assault cases, drug
diversion cases, abuse of fiduciary veterans.
We are working very seriously to try to get through the
wait time investigations, but all these other investigations
that were already in progress need to be seen through to
fruition.
Senator Hirono. Thank you for giving us a fuller context in
which the VA is undertaking these kinds of proceedings.
You mentioned in your testimony and in your conclusion that
the VA must address cultural changes, cultural issues. Can you
talk a little bit more about how a system as vast as the VA can
make cultural changes? What sort of cultural changes are you
talking about? And what do you suggest that they do to
implement these kinds of cultural changes?
Mr. Griffin. Well, I think if you have a culture where it
is OK to disregard directives from the most senior people in
your administration, you need to come to realize that that is
not acceptable behavior, and perhaps you will no longer be
employed by the Department.
When people realize that it is a new day in that respect, I
think they will be a little more vigilant in how they receive
directives from their senior leaders in Washington. And I
believe that the efforts that are undertaken in the various
town hall meetings and feedback sessions with the VSOs and so
on can also make the entire organization realize that these are
the types of things we need to be doing.
Senator Hirono. Do you think that the provisions in the law
that was recently passed--the veterans bill, that would allow
for more expeditious processes for disciplining--would help to
change the culture in the VA in a positive way?
Mr. Griffin. I think that in a number of personnel areas in
the Federal Government, it can be frustrating at the pace that
it requires in order to go through all of the due process
activities. I think the ultimate impact that it will have on
the Department is to be determined. It will depend on, you
know, how frequently it is used, whether there are any
challenges, being that VA is the only department in the
Government with the new abbreviated timeframes and so on.
Senator Hirono. Your report put forth a number of
recommendations. I am particularly looking at Recommendations
17 to 23, and the VA has said that they will meet those
recommendations by September 2015.
Are there any of those recommendations that you consider
more a priority than others for the VA to meet?
Mr. Griffin. Well, there is a reason why our number 1
recommendation was that the Department had to get with the
Regional Council in Phoenix and with VHA medical professionals
to look at the names of the 45 veterans we identified and to
take appropriate action regarding potential liability or
institutional disclosures and so on. I think that is very
important.
Senator Hirono. So, basically your recommendations are in
the order of priorities that you----
Mr. Griffin. No, it is in the order of the presentation of
the report, but I personally would have to say that I think
that is one of the most important items. I would also say that
as we were doing the work and we discovered 3,500 veterans that
were not on an official list anywhere, we immediately turned
those over to the Phoenix staff so they could be seeking out
those veterans and not delay their care any more than it had
already been delayed.
Senator Hirono. Thank you.
Mr. Chairman, my time is up.
Chairman Sanders. Thank you, Senator Hirono.
Senator Boozman?
Senator Boozman. Thank you, Mr. Chairman.
I do appreciate the hard work, Mr. Griffin, of you and your
staff. I think you have done a very, very good job. The report
that you came out with is very helpful as we try and solve some
of these problems.
I would like to ask a little bit from both of you, you and
Dr. Daigh, normally when you see a--when a patient goes to see
a provider, the provider becomes the responsible person in the
situation. If you sign a chart and say, ``Come back in 2
weeks,'' sometimes there are situations where perhaps he is
going to be out of town or this or that or somebody is not
available. I cannot imagine a situation where the scheduler
would not ask the one that was scheduling, you know, ``This
cannot be done. What do you want to do about it?'' Can you
elaborate on that? What happens in the VA? When the provider
actually writes on the chart, or however they do it, does the
scheduler overrule that?
The other problem I have got is when the provider sees
somebody back, say inherit a patient like this, the
cardiologist or whatever, and you see on the chart that he was
supposed to come back in 2 weeks and now it is 2 months, where
is the outrage from the provider at that point as to why this
was not done in the normal fashion?
Dr. Daigh. Sir, I think what we found at Phoenix was that--
what you talk about are very reasonable steps an office has to
have in order to maintain both the trust of their patients and
deliver quality care. So, what we found was that, for example,
a person would go to the emergency room as the point of care.
The emergency room physician would provide appropriate care
and, for example, diagnose diabetes and say, ``You need to go
see your primary care provider.'' At Phoenix, there simply were
not enough--there was not enough access in primary care to
accommodate patients who needed to go to the primary care
provider.
So, what would happen was the patient would be given a
consult, it would be put in a space that was not acted upon,
and you would next see the patient show back up in the
emergency room with diabetes again, with more problems with
diabetes. So, you could track that. A consult was referred, did
not get acted upon. You see the patient re-enter the system at
a point that was not appropriate. It was what they needed to
do, but it was not what should have happened.
So, what I think you have when you do not have primary care
properly structured, both with respect to the way they
schedule, the way they staff the office, the efficiency with
which they run the office, you get chaos. I think that is what
we were experiencing, was you are looking in on a group of
people who all knew they could not get it done correctly; they
are all struggling to save patients who they thought would be
at harm; and you see schedulers trying to schedule patients
into slots that do not exist. It was just quite a horrible view
of what was going on there.
Senator Boozman. Well, not just there, though. I mean, has
that happened multiple other places?
Dr. Daigh. Well, I think this would be the worst example I
have seen of----
Senator Boozman. I guess what bothers me is that ER
doctor--I can understand, you know, turning him over in the
first place, then not getting seen, you know, in 2 weeks, or
whatever the timeframe is. And sometimes it is appropriate
that--you mentioned audiology. You know, that might stretch on
without any problem at all or just a routine follow-up. But
when the ER doctors see them again in the ER and they see that
that consult has not been done, there has to be--it is the
responsibility of that physician. I mean, where is the outrage
from the doc that was seeing them, knowing that they had not
been seen----
Dr. Daigh. I think there was outrage, and they expressed
their complaint to the leadership at the facility. And, again,
if people are not hired or money is not put to address the
problem you speak to, then after a while you realize that
nothing is going to happen. And if the facility talks to the
national leadership and says, ``I have a problem,'' and you do
not get a response, then people get conditioned to think, well,
this is just the way it has to be, this is the way it is going
to be in this system. And that is unacceptable.
So, in hearing the physicians and providers on the ground,
nurses and docs on the ground, I think they were all anxious
and upset at what they saw, trying to deal with it the best
they could.
Senator Boozman. I know this is about scheduling, and, you
know, you mentioned that you felt like there were not any
deaths involved as a result of the scheduling. But in looking
at some of the cases that you present, there might not be
deaths, but there was certainly very poor quality of care in
some of those. Poor quality of care means malpractice. Are we
following up on that? Are we in the process of doing an IG
study regarding quality of care with these cases and other
cases?
Mr. Griffin. We already concluded that there was poor
quality of care on those. The problem as far as tort claims
activity, as was previously stated, those are adjudicated in a
court of law, and the experts that have to be involved in that
adjudication, in the case of the State of Arizona, have to be
people who have practiced in that area of specialty in the
State of Arizona. And it is a program function of the
Department to address allegations of malpractice, which is why
we provided them with the 45 names and said that you need to
look into these 45 cases with your attorney staff and with your
medical staff and determine whether there is something that
needs to be done for these people.
Senator Boozman. No, I understand, and the Chairman is
going to rap me in a second. But I guess my concern is when you
see these cases in that particular situation, we have a culture
of, again, breakdown in scheduling, breakdown in communication
among the physicians and the schedulers or whatever. My concern
is that this sort of activity is throughout the system, and
that is what I was referencing. Are we going to investigate to
see if we have this quality of care throughout the system.
Chairman Sanders. Thank you, Senator Boozman.
Senator Blumenthal?
Senator Blumenthal. Thanks, Mr. Chairman, and thanks again
to all of our witnesses here today.
I know that in response to Senator Tester's question,
Inspector General Griffin, you mentioned that these individual
cases will be turned over to prosecutors if criminal violations
are found. Is that correct?
Mr. Griffin. That is correct.
Senator Blumenthal. And they will be turned over on an
individual basis?
Mr. Griffin. Right, because they are in different judicial
districts around the country.
Senator Blumenthal. And they involve different facts.
Mr. Griffin. Right.
Senator Blumenthal. Who will make the decision about
whether those cases should be turned over to criminal
prosecutors?
Mr. Griffin. When we have evidence of potential
criminality, it is our job to take it to the Assistant U.S.
Attorney or the U.S. Attorney in that district, present the
facts, and they make a determination whether or not it rises to
the level of the types of things that they are presently
involved with prosecutions of.
Senator Blumenthal. In effect, the prosecutors will be
making those decisions, just as they would with any
investigative agency, whether it be the FBI or the Drug
Enforcement Administration.
Mr. Griffin. Correct.
Senator Blumenthal. What is the timing for beginning to
turn over those investigative results?
Mr. Griffin. Turn over to the Department or to the----
Senator Blumenthal. I am sorry. I was unclear in my
phrasing. What is the timing for presenting those cases for
judgments by the prosecutors----
Mr. Griffin. The timing is when----
Senator Blumenthal [continuing]. Given that there is
potential criminality?
Mr. Griffin. When we feel that we have developed the
evidence that would support a criminal charge.
Senator Blumenthal. Has the prosecutor in any of those
jurisdictions said to you, ``We need that evidence as soon as
possible''? Have they given you a timeline?
Mr. Griffin. No. No, we are working feverishly to
accomplish these things. Another point that I had made in your
absence was our criminal investigators make over 500 arrests a
year. We have had a number of cases that were already in the
investigative and prosecutive pipeline before this happened.
And as you know, it takes--it can take forever to work it
through the prosecutive system.
Senator Blumenthal. Well, hopefully not forever.
Mr. Griffin. Well, it can sometimes feel like that.
Senator Blumenthal. I know that much well.
Mr. Griffin. Sure. So----
Senator Blumenthal. When I was a U.S. Attorney, I would say
to investigative agents, some of the best in the Nation, ``Here
is my timeline.'' Not that the world would fall apart if they
did not meet it, but there would be timelines for completing
investigations. I gather you have not been given any.
Mr. Griffin. No, but I can tell you that the Assistant
Attorney General for the Criminal Division sent out a memo to
every U.S. Attorney's Office and all the chiefs of Criminal
basically giving them his point of view on what potential
charges under Title 18 could be brought for the various types
of manipulations or different things----
Senator Blumenthal. Falsification of records, destruction
of documents.
Mr. Griffin. Right, absolutely.
Senator Blumenthal. Obstruction of justice.
Mr. Griffin. Right.
Senator Blumenthal. I am going to sort of segue to the next
area of questioning, which you and I have talked about. I
appreciate you have some very skilled and experienced
investigators working for you. But my feeling is there simply
are not enough. Do you disagree with me?
Mr. Griffin. I would say that we are fully engaged and
could probably put twice as many people to work as we have
assigned to the organization.
Senator Blumenthal. You could put twice as many to work,
and they would all be very busy.
Mr. Griffin. Yes.
Senator Blumenthal. And they would be busy doing very, very
important work, which would lead me to the conclusion that
there are not enough of them, because criminal investigations
here serve a vitally important purpose. I do not need to tell
you because you are a very skilled and able investigative
officer and Inspector General and watchdog. But the deterrent
purpose of a criminal investigation, prosecution, and
conviction is irreplaceable. There is nothing like the
deterrent effect of a successful criminal investigation to
deter criminality. We are not talking about deterring
carelessness or even negligence, which can be serious enough in
their consequences, but real criminality.
So, I simply would urge you to be as aggressive as possible
in asking for resources that are necessary for the VA to really
do its job and deter criminality, assuming that it existed here
and may be ongoing elsewhere in the agency, as it may be in any
agency of our Government--State or Federal.
Thank you for your service. My time has expired.
Thank you, Mr. Chairman.
Chairman Sanders. Thank you, Senator Blumenthal.
Senator Murray?
Senator Murray. Thank you, Mr. Chairman.
Mr. Griffin, I was really deeply disturbed to read your
findings about how many cases of suicide and veterans with
serious mental health problems were affected by delays in care
and substandard care. Many facilities in my homestate of
Washington are facing staffing problems and long wait times for
mental health care, and I just wanted to say, if hospitals in
Washington State are on your list of facilities for further
investigation, I really hope your team will look very closely
at the mental health care problems like they have done in
Phoenix.
I wanted to ask you, the Phoenix report really criticized
VHA's resistance to change, and both your report and the White
House review found serious cultural and ethical failings across
the system.
What do you think the VA should be doing to make these
kinds of systemwide changes?
Mr. Griffin. I think you have to hold people accountable
when they ignore directives on how to do business. And I think
after awhile people will begin to toe the line rather quickly--
--
Senator Murray. And that has not been done?
Mr. Griffin [continuing]. When they realize there is a
price to be paid.
Senator Murray. And that has not been done.
Mr. Griffin. No. I mean, how can you have a certification
requirement that you abolish because some of the managers in
the field are pushing back about it, because they might not be
sure if their scheduling staff is doing it right, and the IG
staff might come after them for asserting something that was
not true or certifying something that was not true. You just do
not tolerate that.
Senator Murray. Yes, OK. You have mentioned several times
here that you are following on 93 facilities' investigations,
and the results are confirming some of the things you found at
Phoenix, meaning wait times are being manipulated.
Mr. Griffin. Right.
Senator Murray. When your reports are completed, I really
expect the VA to implement your recommendations quickly and to
hold people accountable, as you just referred to. But I wanted
to ask you this morning, is your impression that the motivation
for these inappropriate practices more to show false
information or is it more just a lack of training?
Mr. Griffin. I think it is a combination of a number of
factors. In each of our reports going back to 2005, one of the
recommendations was to ensure that the schedulers were properly
trained in the way it was supposed to be done. I mean, that was
a repeat recommendation.
Senator Murray. So, they have been hearing this for a long
time?
Mr. Griffin. Oh, yes, as you know from your previous time
with the Committee. 2005 was the first time and the first
report that we had that. As I mentioned earlier, I think you
have to have a person working the scheduling side that has some
clinical knowledge of being able to triage: how bad does this
veteran need to be seen today as opposed to somebody else. So,
that is not currently the case and my belief at a lot of
facilities.
Senator Murray. Yes, and I know some of the facilities are
saying, well, this is low level. We have a lot of people coming
in. It is hard to keep up with it. Is that an excuse?
Mr. Griffin. No. I mean, I do not think there is an excuse
for--I mean, I believe that over the years, VA's budgets have
pretty much been matched or exceeded by Congressional
appropriators. But if you do not know what your demand is and
how many people are on secret lists and you do not know, gee,
we need 30 percent more clinicians, or whatever the number is--
--
Senator Murray. They cannot ask for it.
Mr. Griffin [continuing]. Then they cannot even ask for it.
Senator Murray. Yes.
Mr. Griffin. I think the responsibility is, you have to do
a serious strategic analysis, not just of your clinicians, but
also the blend with fee-basis care and come up with a solid
number that you can hang your hat on and say, in order for us
to treat veterans in a quality manner and in a timely manner,
we need this number of doctors and we need this amount of money
for fee-basis for rural areas, or what have you.
Senator Murray. Mr. Chairman, I know you have heard me say
it a million times. This Congress, the country wants to be
there for our veterans, but if we do not know what the need is
accurately, we do not know what to provide. I echo that point.
Let me just ask you one other thing. You have been doing
this a long time. We have been hearing this for a long time.
You have been doing a lot of investigations. Have you found any
facilities or networks that have done a good job of regularly
and thoroughly checking for scheduling gimmicks?
Mr. Griffin. We found a number of facilities out of our 93
where we concluded that there was no manipulation occurring,
which is a good thing, maybe one-fourth. The bad news is on the
other three-fourths, we are pretty confident that it was
knowingly and willingly happening----
Senator Murray. That is a pretty high percentage.
Mr. Griffin [continuing]. And we are pursuing those.
Senator Murray. Thank you, Mr. Chairman.
Chairman Sanders. Thank you, Senator Murray.
Senator Murray. And thank you and all your team.
Chairman Sanders. Let me thank Mr. Griffin not only for
being here, but for the excellent work that he and his
department are doing. We thank all of his staff for being here
as well. Thank you very much.
Mr. Griffin. Thank you, Mr. Chairman.
[Posthearing questions to Richard J. Griffin follows:]
Response to Posthearing Questions Submitted by Hon. Bernard Sanders to
Richard Griffin, Acting Inspector General, U.S. Department of Veterans
Affairs
compliance with recommendations
Question 1. Please provide detail on the process the IG uses to
ensure VA complies with its recommendations.
Response. Because ultimate responsibility to ensure implementation
of corrective actions rests with VA senior officials, the OIG cannot
force compliance with report recommendations. We track VA's progress in
implementing our recommendations through the OIG Follow-Up process,
which is described below, and provide the VA Secretary and Congress
with quarterly reports on the status of recommendations that remain
unimplemented for more than 1 year. These reports are contained in the
OIG Semiannual Reports to Congress and in letters from the Acting
Inspector General to the Chairmen and Ranking Members of the U.S.
Senate Veterans' Affairs Committee and U.S. House Veterans' Affairs
Committee. We believe that keeping the VA Secretary and Congress
informed of these delays is the best leverage the OIG has to ensure VA
compliance with our recommendations.
The OIG follows up on VA's implementation of recommendations by:
Approximately 90 days after the OIG issues a final report
(and every 90 thereafter until report closure), the OIG will send a
status update request to the action office(s) at VA to which the
recommendations are addressed.
Each VA office is expected to submit a response to this
request to the OIG within 30 days.
Responses need to contain supporting documentation to
substantiate stated actions.
The OIG will analyze the response and determine whether
the action office implemented any recommendations to the satisfaction
of the OIG.
We will not close a recommendation unless supporting
documentation indicates corrective action has occurred or action has
sufficiently progressed to close the recommendation as implemented. For
example, the OIG will not close a recommendation to train employees on
a particular issue on a mere promise by the VA action office to conduct
the training. The VA action office will need to submit documentation of
completed training or, at a minimum, be able to demonstrate through
documentation (e.g., a directive, training syllabus and schedule, etc.)
that it has established a training program and begun the training in a
systematic fashion--thereby indicating it is meeting the intent of the
recommendation.
The Follow-up cycle will repeat until the action office
implements all open recommendations.
The OIG may conduct reviews, including unannounced visits to
facilities, to determine if the action VA said was completed was
actually completed.
Question 2. Given a number of reoccurring issues in IG and GAO
reports over the past decade, such as VA scheduling practices and data
integrity concerns, does the IG anticipate reviewing its compliance
process?
Response. As stated in response to the first question, the OIG's
best leverage to ensure compliance with report recommendations is
keeping the VA Secretary and Congress informed of delays identified
through our follow-up process on a quarterly basis. We also conduct
follow-up inspections and audits to assess compliance on a selective
basis. We plan to continue both practices. Moreover, there are a number
of sources that we use to periodically assess VA's compliance with
their stated action plans. Among these sources are OIG and GAO's
previously published reports and information from our criminal and
administrative investigations. Another source is our analysis of
allegations received through the OIG Hotline. These allegations provide
us with data to identify trends on specific VA program issues as well
as identify potential problems with particular Veterans Health
Administration and Veterans Benefits Administration facilities. This
analysis provides a basis for planning and scheduling future work and
results in annual updates of the most serious management challenges
facing VA in VA's Performance and Accountability Report.
______
Response to Posthearing Questions Submitted by Hon. Mark Begich to
Richard Griffin, Acting Inspector General, U.S. Department of Veterans
Affairs
Question 3. Inspector General, during your investigations, what
comments stood out to you from the VA staff that would help improve the
scheduling system or access to care concerns.
Response. Our investigations found that manipulation of wait times
was systemic in VA. Desired dates for appointments were routinely
manipulated to incorrectly appear that veterans were not required to
wait longer than 14 days for an available appointment. Many employees
advised that they did not see the harm in ``zeroing out'' the wait
times since the date selected was the first available date for an
appointment. The actual length of wait times was hidden by this
process. Decisions regarding proper allocation of medical staff to meet
the needs of veterans could not be properly made when the true need for
services was disguised by the manipulation of wait times.
______
Response to Posthearing Questions Submitted by Hon. Mazie Hirono to
Richard Griffin, Acting Inspector General, U.S. Department of Veterans
Affairs
Question 4. Given the numerous changes that need to be made how
would you suggest VA prioritize the implementation of each given the
one year deadline it has promised? Which recommendations are most
urgent?
Response. In regard to the twenty-four recommendations made within
our Phoenix report, VA provided an action plan containing a written
response, status, and expected completion date for each recommendation.
VA began to address some of these recommendations prior to publication
of our final report. For example, throughout our review we identified
veterans waiting for care. As these veterans were identified, we
provided VA the names of these veterans. These veterans were contacted
by VA and appointments made for those who desired care.
Of the recommendations not yet implemented, those which directly
impact patient care are the most pressing and time-sensitive. However,
supporting recommendations, such as those pertaining to performance
plans and facility goals are just as critical in ensuring future
accountability as changes across the system are implemented, and should
not be given less consideration by VA leadership.
Question 5. Your testimony outlines that you office's
investigations have confirmed that wait time manipulations are
prevalent throughout VHA at many facilities across the country. When do
you anticipate completing these investigations and will you keep my
staff informed related to any issues arising at the VA Pacific Islands
Health System when they are completed?
Response. The OIG is aggressively investigating the alleged
manipulation of wait times at 93 sites of care. We completed reports of
investigation regarding alleged manipulations at 18 of the 95 sites. We
referred cases to the appropriate U.S. Attorneys' Offices for
prosecutive determinations when evidence corroborated allegations of
potential criminal activity. After exhausting the potential for
criminal prosecution, these reports were provided to VA's
Accountability Review Team for any administrative action deemed
appropriate. We made these allegations a priority and have devoted the
resources to ensure that all wait times cases are worked thoroughly. In
many of these cases, timelines involve decisions from the U.S.
Department of Justice. Investigations involving multiple complex
matters often require serious contemplation before prosecutive opinions
are rendered. As a result, we are not able to give an exact expected
completion date for the cases under active investigation. However, the
need to expeditiously investigate these cases is routinely conveyed to
our staff. We will contact your staff when our investigation at the VA
Pacific Islands Health System is finished.
______
Response to Posthearing Questions Submitted by Hon. Richard Burr on
Behalf of Hon. Jeff Flake to Richard Griffin, Acting Inspector General,
U.S. Department of Veterans Affairs
Question 6. On August 26, the Department of Veterans Affairs (VA)
Office of Inspector General (OIG) submitted a report of its review of
allegations of mismanagement and misconduct at the Phoenix VA Health
Care System (PVAHCS). This report stated that there were ongoing
investigations regarding potential criminal violations. Sharon Helman,
the former director of PVAHCS, may be among those being examined by OIG
and, understandably, the details of these ongoing inquiries cannot be
disclosed for fear of compromising the investigation.
a. Does OIG have an estimation regarding a completion date for
these ongoing investigations, which may confirm criminal violations?
Response. We have made these allegations a priority and devoted the
resources to ensure that all wait times cases are worked thoroughly and
expeditiously. In many of these cases, timelines involve decisions from
the U.S. Department of Justice. Investigations involving multiple
complex matters often require serious deliberation before prosecutive
opinions are rendered. As a result, we are not able to give an exact
expected completion date for the cases under active investigation. The
VA Office of Accountability Review tracks administrative action
resulting from investigations of wait times manipulations.
b. Does OIG have any plans to expand the number of investigations
regarding potential criminal investigations?
Response. We will thoroughly examine any referral of alleged
criminal activity related to manipulation of wait times. Inquiries will
be opened upon receipt of credible allegations of such conduct. Full
investigations will be opened when evidence indicates that manipulation
was directed by VA supervisors or managers. We notify the Federal
Bureau of Investigation when we open investigations as described in the
Attorney General Guidelines for Offices of Inspector General With
Statutory Law Enforcement Authority.
Question 7. As you know, the Veterans access, Choice, and
Accountability Act of 2014 was recently passed by Congress and signed
into law by the president. Among other things, the purpose of this
legislation is to provide the VA with increased latitude to remove
agency employees when necessary.
a. Do you believe that this legislation provides the VA with
adequate authority to remove underperforming employees?
Response. Until it is fully implemented, the impact is unknown.
b. Will the added hiring and firing flexibility enable the VA to
significantly improve the quality of care that it delivers to veterans?
Response. Additional flexibility in the hiring process has the
potential for VA to bring health providers on board in a timelier
manner thus increasing timelier access to care. The OIG is playing a
role in this regard by identifying the five VA health provider
occupations with the greatest staffing shortages on an annual basis,
which will allow VA to us Title 5 direct hire authority for these
occupations. The impact of firing flexibility with respect to senior
executives cannot be evaluated at this time.
Chairman Sanders. Mr. Secretary, thank you very much for
being with us. Again, my apologies for putting you on second,
but I thought it would be important for you and for the
Committee to be hearing from the Inspector General first. The
floor is yours and please take as much time as you need.
STATEMENT OF HON. ROBERT A. McDONALD, SECRETARY, U.S.
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY CAROLYN M.
CLANCY, M.D., INTERIM UNDER SECRETARY FOR HEALTH
Secretary McDonald. Thank you, Chairman Sanders. Obviously,
we thought it was important as well that the Inspector General
go first, so we are very pleased to be here after the Inspector
General.
Chairman Sanders, Ranking Member Burr, and distinguished
Members of the Committee on Veterans' Affairs, thanks for the
opportunity to discuss with you VA's response to the recent VA
Office of Inspector General report regarding wait times and
scheduling practices at the Phoenix VA Hospital. I said at the
time of my confirmation hearing that I will put veterans at the
center of everything that we do at VA.
So, let me begin by offering my personal apologies to all
veterans who experience 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 desire. That is how we regain veterans'
trust and that is how we regain your trust and the trust of the
American people.
The final IG report has now been issued and as the
Inspector General said, we have concurred with all 24 of the
report's recommendations. Three of the recommendations have
already been remediated and we are well underway in remediating
many of the remaining 21 because we began work when the IG's
interim report was first issued in May.
For accountability, we have proposed the removal of three
senior leaders in Phoenix. As we learn more about individual
supervisors' and employees' roles in the problems there, we may
find that additional disciplinary actions are warranted and we
will take them.
We are grateful for the Committee's leadership in
establishing the recently passed Veterans Access, Choice, and
Accountability Act of 2014. This important act streamlines the
removal of VA senior executives and the appeals process if
misconduct is found. However, it does not guarantee VA's
decisions will be upheld on appeal or allow VA to fire senior
executive officers without evidence or cause.
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, good people with a proven track record of serving
veterans and solving problems. They are in place, they are
operating in Phoenix now, and I have visited them on site.
Increasing Phoenix staffing by 162 people 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 3 months. As of
September 5, there are 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 to non-VA
care. We have secured contracts to utilize primary care
physicians from within the community in the future.
Since my confirmation as Secretary, I have traveled to VA
facilities across the country speaking to veterans and VA
employees, as well as visiting and speaking with Members of
Congress, veteran service organizations, and other
stakeholders. During these 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. The acronym we use is I-CARE
and I am wearing that button here today.
Our people are making a difference. Nationally, they have
enabled the following critical achievements: as of August 15,
VHA has reached out to over 294,000 veterans to get them off of
wait lists and decreased the veterans on the electronic wait
list by 57 percent. VHA has developed the Accelerating Care
Initiative to increase timely access for care for veteran
patients, decrease the number of veterans on the electronic
wait list longer than 30 days, and standardized the process and
tools for ongoing monitoring and access management at all VA
facilities.
Where we have not been able to increase capacity, we have
increased the use of community, non-VA care. Between May and
August, we have made almost a million total referrals for non-
VA care, over 200,000 more referrals than for the same period
in 2013. The 14-day access measure has been removed from all
employee performance plans to eliminate any incentive for
inappropriate scheduling. Over 13,000 performance plans have
been amended. We are simultaneously updating our antiquated
appointment scheduling system and working to acquire a
comprehensive, state-of-the-art commercial, off-the-shelf
scheduling system.
VA medical center directors and VISN directors are
completing in-person reviews of their facilities' scheduling
practices that can be completed by the end of this month. So
far, 3,000 of these reviews have been conducted nationwide. We
have restructured VHA's Office of the Medical Inspector to
better serve veterans and to create strong internal audit
function.
On August 7, I asked all VA employees to reaffirm their
commitment to both our mission and our I-CARE values:
integrity, commitment, advocacy, respect, and excellence. I
intend this reaffirmation to be repeated by each and every
employee each year on the anniversary of our establishment as a
department. If an employee refuses to recommit, I want to meet
with them personally and will decide actions after that.
We are building a more robust continuous system for
measuring patient satisfaction to provide real-time site-
specific information, collaborating with VSOs in this effort
and learning what other leading health care systems are doing
to track patient access information. We are working hard to
create and sustain a climate that embraces constructive
dissent, that welcomes critical feedback, and then ensures
compliance with legal requirements. That climate mandates
commitment to whistle-blower protections for all employees.
Yesterday we announced the beginning of our Road to
Veterans Day, our 90-day plan, which begins with our mission to
better serve and care for those who have borne the battle and
for their families and for their survivors. We will focus our
efforts over the next 60 days to rebuild trust with veterans
and the American people, to improve service delivery, and to
set the course for long-term excellence and reform.
As we move forward, we will continue to work with the IG
and other stakeholders to ensure accountability. As you heard,
there are over 100 ongoing investigations at VA facilities by
the IG, by the Department of Justice, by the Office of Special
Counsel, and by others. In each case, we await the results and
will take appropriate disciplinary actions when all the facts
and evidence are known.
But we will not wait to provide veterans the care that they
earned and that they desire. We are going forward. We will
focus on sustainable accountability in the future. More than
just adverse personnel actions, sustainable accountability
means ensuring all employees understand how their daily work
ties back to that mission of caring for veterans. We want them
to understand how it ties back to the mission, how it ties to
our values, and how it ties to our strategies, and we want to
make sure that everybody's behavior every single day is guided
by those values and that mission.
We also want to make sure that every employee understands
it is their responsibility to provide feedback to their
supervisor when they are asked to do something that is
impossible to do. We want to make sure that feedback loop is
daily and that every employee is getting daily feedback from
their supervisor and that every supervisor is giving daily
feedback to their manager.
Sustainable accountability requires we do a better job of
training our leaders. We need to flatten our hierarchical
culture, we need to encourage innovation, we need to encourage
collaboration, and we need realistic ratings of everyone's
performance. Everyone cannot be the best. With sustainable
accountability, employees fulfill their responsibility to
veterans and to the Department to provide feedback and input on
how we can better serve veterans. Who better than to help us
improve our Department than the employees who every day are
interacting with our veterans?
We will judge the success of all these efforts against a
single metric and that is the veterans outcomes. We do not want
VA to meet a standard; we want VA to be recognized as the
standard in providing health care and benefits. I know we can
fix the problems we face and I will utilize this opportunity to
transform VA to better serve veterans.
Mr. Chairman, Members of the Committee, thanks for your
unwavering support of our Nation's 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 at this time.
[The prepared statement of Secretary McDonald follows:]
Prepared Statement of Hon. Robert A. McDonald, Secretary,
U.S. Department of Veterans Affairs
Chairman Sanders, Ranking Member Burr, and Distinguished Members of
the Senate Committee on Veterans' Affairs, thank you for the
opportunity to discuss with you the Department of Veterans Affairs'
(VA) response to the recent VA Office of Inspector General (OIG) report
regarding wait times and scheduling practices at the Phoenix VA Health
Care System (PVAHCS).
Let me begin by saying, I sincerely apologize to all Veterans who
experienced unacceptable delays in receiving care at the Phoenix
facility, and across the country. We at VA are committed to fixing the
problems and consistently providing the high quality care our Veterans
have earned and deserve in order to improve their health and well-
being. We owe that to each and every Veteran that is in our care. We
will continue to listen to Veterans, our VA employees, and Veterans
Service Organizations (VSO) and use their feedback to improve access to
quality care in Phoenix and across the country and we will work hard to
rebuild trust with Veterans and the American public.
The VA OIG has released the final report of its review of issues
with patient scheduling and access at PVAHCS. We have concurred with
the recommendations in the final report and, in many cases, we have
already taken action responding to the OIG's recommendations, improving
processes and access to care for Veterans.
pvahcs' implementation of oig recommendations
The final OIG report is an update of the information previously
provided by the OIG in its Interim Report issued on May 28, 2014, and
contains final results from their independent review of the PVAHCS. In
response to the report recommendations, we have outlined key action
plans that expand access to care, improve staffing for primary care,
and ensure accountability measures. All cases identified by OIG were
reviewed, and determinations regarding appropriateness of disclosures
to patients and families are underway.
Currently at PVAHCS, we have a strong acting leadership team
producing positive results. Glenn Costie is the Acting Medical Center
Director and Elizabeth Freeman is the Acting Network Director. They are
good people with a proven track record for serving Veterans and solving
problems.
Based on the Interim report of the OIG, we began actions in Phoenix
and across the country that have enhanced access for Veterans seeking
care. In Phoenix specifically, we have taken the following actions:
Primary Care Staffing
PVAHCS leadership is increasing Primary Care staffing by 53
additional full-time equivalent employees. Aggressive recruitment and
hiring processes have been implemented to speed this process. All
services--physicians, nurses and clerks--have increased staffing in the
clinics and Community-Based Outpatient Clinics (CBOC) and the
facilities are securing contracts to utilize Primary Care physicians
from within the community. Primary Care was recently added to the
Patient-Centered Community Care contracts, and Health Net and TriWest
are working to add Primary Care physicians to their networks nationwide
including the Phoenix area.
Access to Care (wait lists)
PVAHCS, with support from the Veterans Health Administration's
(VHA) Health Resource Center (HRC), has reached out to all Veterans
identified as being on unofficial lists or the facility Electronic Wait
List (EWL). PVAHCS completed 46,997 appointments in May, 48,970
appointments in June, and 50,629 appointments in July, for a total of
146,596 appointments completed at PVAHCS in three months.
As of August 15, 2014, there were 56 Veterans on the EWL at PVAHCS.
PVAHCS is now scheduling the vast majority of patients directly into a
Primary Care appointment when enrollment/registration occurs. Over
3,200 appointments have been made in Primary Care for new patients
since this initiative began.
Access to Care (scheduling)
We announced on June 4, 2014, that the Department had reached out
to all Phoenix, Arizona-based Veterans identified by the OIG as being
on unofficial wait lists to immediately begin scheduling appointments
for all Veterans requesting care. Nationally, VHA expeditiously
deployed staff and resources from around the country to help PVAHCS
identify patients waiting for care, clearing the way for them to get
the care they needed. We have made progress and are publicly publishing
data on our progress.
Access to Care (non-VA Care)
Clinical staff attempted to accommodate all appointments at PVAHCS.
Where capacity did not exist to provide timely appointments, staff
referred patients to non-VA community care in order to provide all
Veterans timely access to care. From May 16, 2014 through August 28,
2014, PVHCS has made 14,622 referrals for appointments to community
providers of non-VA care.
Since the Accelerating Care Initiative (ACI) began, resources have
been provided to continue to work down the number of open consults even
further. Since the beginning of the ACI, $24.9 million has been
obligated as part of this initiative to provide community-based care
for Veterans in the community.
Access to Care (new enrollees)
PVAHCS is hiring dedicated staff to complete on-line enrollment
processing. VHA is developing an automated system for monitoring
enrollment processing at PVAHCS and every VA facility. This monitor
will track Veterans new to the VA and will assess the timeframe to
their first appointment within the VA health care system. The data will
be reviewed monthly with VISN 18 and PVAHCS leadership.
Locally, PVAHCS implemented process changes to ensure that Veterans
receive appropriate care. To ensure continued success, patients waiting
for care are reviewed daily and reported to facility and VISN
leadership.
In July 2014, the Acting PVAHCS Director visited all CBOCs and
local Clinics to observe the scheduling process and interact with
scheduling staff to ensure all policies are being followed to deliver
Veterans the timely care they have earned. These interactions are now
happening monthly across the country.
va nationwide
Since my confirmation as Secretary, I have traveled to VA
facilities across the country speaking to employees and Veterans. I
cannot overstate their enthusiasm for being part of the solution to our
current challenges. Overwhelmingly VA employees are dedicated to
serving Veterans. They are driven by strong institutional values that
influence day-to-day behavior and performance: Integrity, Commitment,
Advocacy, Respect and Excellence, I-CARE. On my first day as Secretary
I asked all VA employees to join me in reaffirming our commitment to
these core values and I directed VA leaders to do the same with the
people that work for them. As we continue to move forward, our values
help cultivate a climate where all employees understand what the right
thing is and then does it. VA's way of doing business must conform to
how we expect employees to treat Veterans and how we expect employees
to treat one another. It is clear that somewhere along the line, some
people's behavior was at odds with VA's mission and core values. It is
up to the Department to reaffirm its worth and regain Veterans' trust.
Over the past months, we have been forced to take a hard look at
ourselves and the way we do business, listening to Veterans, employees,
Congress, VSOs and other stakeholders.
Using their input, VA is in the process of rapidly deploying and
instituting an array of changes aimed at fixing VA's problems. Beyond
culture issues, demand outstripped supply. This contributed to an
environment that led to violations of our mission and our values.
Demand was increased by new presumptive conditions, twelve years of
war, the economy and significant VA outreach and education efforts.
Peak application of care for wars is decades after the conflict ends as
Veterans age. This issue will be with us a long time. We have to build
the appropriate capacity now.
We have initiated development of a more robust process for
continuously measuring patient satisfaction at each site, and we will
expand our patient satisfaction survey capabilities in the coming year,
to capture more Veteran experience data through telephone, social
media, and on-line means. Additional VA-wide actions include:
Access to Care
As of August 15, VHA has reached out to over 266,000
Veterans to get them off wait lists and into clinics.
VA has re-doubled its efforts to provide quality care to Veterans
and has taken steps at national and local levels to ensure timely
access to care. VHA has developed the Accelerating Care Initiative
(ACI), a coordinated, system-wide initiative designed to increase
timely access to care for Veteran patients; decrease the number of
Veteran patients on the EWL waiting longer than 30 days for their care;
and standardize the process and tools for ongoing monitoring and access
management at VA facilities. As of August 15, VA has decreased the
number of Veterans on the EWL 57 percent. As we continue to address
systemic challenges in accessing care, we are providing regular data
updates to enhance transparency and provide the immediate information
to Veterans and the public on improvements to Veterans' access to care.
Data updates can be found on the following link: http://www.va.gov/
health/access-audit.asp
VA health care facilities nationwide continuously monitor
clinic capacity in an effort to maximize VA's ability to provide
Veterans timely appointments appropriate for their clinical conditions.
Where VA cannot increase capacity, VA is increasing the
use of care in the community through non-VA medical care. From May 16,
2014, through August 24, 2014, 975,741 total referrals to non-VA care
providers have been made. That is 203,637 more non-VA care referrals
than the same time period in 2013.
Each of VA's facilities continuously reaches out to
Veterans waiting longer than 90 days for care to coordinate the
acceleration of their care.
Facility clinical staff continuously evaluates Veterans
currently waiting for care to ensure the timing of their appointment is
medically appropriate for their individual clinical conditions.
VA is decreasing the number of Veterans on the EWL by
standardizing the process and tools for ongoing monitoring and access
management at VA facilities.
VHA utilizes call monitoring in its large national call
centers. These monitoring practices require adequate telephony systems.
VHA will introduce new monitoring practices through the VA Health
Resource Center to assess scheduling practices performed by VA staff.
Scheduling
The 14-day access measure was removed from all employee
performance plans to eliminate any incentive for inappropriate
scheduling practices or behaviors. In the course of completing this
task, over 13,000 performance plans were amended.
VA has suspended the use of Desired Date Performance
Accountability Report (PAR) performance plans. VA is currently
evaluating the use of Desired Date as a mechanism to assess patient
preferred appointment timeframes.
The VSOs are actively engaged in the process. We are
updating the antiquated appointment scheduling system, beginning with
near-term enhancements to the existing system and ending with the
acquisition of a comprehensive, state-of-the-art, ``commercial off-the-
shelf'' scheduling system.
Accountability
At VA, we depend on the service of employees and leaders
who place the interests of Veterans above and beyond self-interest.
Accountability, delivering results, and honesty are key to serving our
Veterans.
Where willful misconduct or management negligence is
documented, appropriate personnel actions will be taken--this also
applies to whistleblower retaliation, which is unacceptable and
intolerable at VA.
VA Medical Center Directors and VISN Directors are
completing face-to-face audits of their facilities' scheduling
practices. The first round of face-to-face audits will be completed by
September 30, 2014. So far, we have conducted 2,450 of these visits
nationwide.
On July 8, 2014, the Deputy Secretary announced that he
ordered a restructuring of the Office of the Medical Inspector (OMI) to
better serve Veterans and create a strong internal audit function. This
restructuring will result in revisions to the policies, procedures, and
personnel structure by which OMI operates and establish an internal
audit group that will validate VHA's critical national performance
measures.
On August 7, 2014, I asked all VA employees and leadership
to reaffirm their commitment to both our mission and ``I CARE''
values--Integrity, Commitment, Advocacy, Respect and Excellence. I
intend this reaffirmation to be the first of many, to be repeated by
each employee each year in March, on the anniversary of our
establishment as a Department.
Patient Satisfaction
We are building a more robust, continuous system for
measuring patient satisfaction to provide real-time, site-specific
information on patient satisfaction. We will augment our existing
survey with expanded capabilities in the coming year to capture more
Veteran experience data using telephone, social media, and on-line
means. Our effort includes close collaboration with VSOs to plan our
efforts. We are learning what other leading healthcare systems are
doing to track patient access experiences.
Whistleblower Protections
We have made great strides in improving care and services to
Veterans in Phoenix and nationwide because employees in Phoenix and
elsewhere had the moral courage to do the right thing. They made their
voices heard about what they saw happening. Those employees are
examples of I-CARE at its best. Our collective ability to deliver the
best services and care to Veterans is inextricably linked to sustaining
an organizational culture that protects and empowers the voices of all
employees and leverages the diverse talent of all our human resources.
This includes creating a climate that embraces constructive dissent,
welcomes critical feedback and ensures compliance with legal
requirements. As part of our commitment toward embracing this culture
we have reinforced our commitment to whistleblower protections to all
employees and VA recently registered for and published an
implementation plan to receive certification from the Office of Special
Council's Section 2302(c) Certification Program.
Accountability
We will continue to work with IG and other stakeholders to take
appropriate action, but accountability is about more than personnel
actions. We must focus on sustainable accountability. Sustainable
accountability means ensuring all employees understand how daily work
supports our mission, values and strategy. Sustainable accountability
is about more than top-down, hierarchical behavior modification. It is
collaborative. Supervisors provide feedback, every day, to every
subordinate to recognize what is going well and identify where
improvements are necessary. In that same spirit, employees fulfill
their responsibility to Veterans and to the Department to provide
feedback and input on how we can better serve Veterans.
To achieve sustainable accountability we will do a better job
training leadership, flatten our hierarchical culture to encourage
innovation and collaboration and we will rate the relative performance
of employees because everyone cannot be the best. We have strong
institutional values: I-CARE. These are mission-critical ideals that
must profoundly influence our day-to-day behavior and performance. In
performance that mission, guided by those values, we will judge the
success of our efforts against a single metric--customer outcomes,
Veterans' outcomes. We hold ourselves accountable to these standards.
We do not want VA to meet a standard. We want VA recognized as the
standard in health care and in benefits.
conclusion
Mr. Chairman, the health and well-being of the men and women who
have bravely and selflessly served this Nation remains VA's highest
priority. By recommitting, as a Department, to our values, I know we
can fix the problems and utilize this opportunity to transform VA to
better serve Veterans. This concludes my testimony. Dr. Clancy and I
are prepared to answer questions you or the other Members of the
Committee may have.
Chairman Sanders. Mr. Secretary, thank you very much for
being here, for your patience, and hearing the discussion with
the Inspector General, and I think I am paraphrasing one of the
other members who indicated that the perception is you have hit
the ground sprinting, which is exactly what this Committee
wanted from you and we appreciate that very, very much.
I want to reiterate a point that you just made, and that is
that the vast majority of VA employees--I know this is the case
in Vermont and all over the country--work tirelessly and work
very hard to do everything they can for our veterans, and we
should never forget that.
We should also not forget that while we are focusing today
on the issue of timeliness and the need to make sure that every
veteran in this country gets timely care, we also know that--I
can tell you absolutely in Vermont that most veterans believe
the care they are getting once they are in the system is of
high quality. They appreciate the care they are getting and the
work the staff is doing.
What I just want to do is--in a sense you talked about this
in your opening remarks--but let us focus on three or four
basic issues. Every Member of this Committee is outraged by the
long wait periods veterans in various parts of the country are
experiencing. Number 1, I want you to tell us briefly what kind
of progress you have made in reducing those wait periods.
Number 2, we all agree it is unacceptable for VA staff or
high ranking people to be lying, to be manipulating data. What
have you done to get rid of people who are acting dishonorably?
What plans do you have in the future?
Number 3--and this is tough stuff--how do we make sure--how
do you lay the groundwork that what we have seen in Phoenix
never happens again? How do you address, in fact, what is a
national problem? I think Senator Begich raised the issue. It
is no great secret that we have a serious crisis in the number
of physicians we have, especially primary care physicians, the
number of nurses that we have in various parts of this country.
We have given you some tools, and I am very proud of the
work that came out of this Committee. We have given you tools,
for example, in the Education Debt Reduction Program, which is
similar to the National Health Service Corps, which now gives
you the tool to go to medical schools. Maybe you could tell us
a little bit about that.
And tell people who otherwise would graduate, young doctors
deeply in debt, that we now have a strong debt forgiveness
program in the VA. In other words, what are you going to do to
address the very difficult issue of bringing more quality
physicians, nurses, and other medical personnel into the
system? Those are my questions.
Secretary McDonald. Thank you, Chairman Sanders. First, in
relationship to the first question, access to care, we have
reached out to over 294,000 veterans to get them off of wait
lists and into clinics as of September 5. As a result, VA has
decreased the electronic wait list by more than 32,000
nationwide since May 15. That is from over 57,000 in May to
around 24,500 as of August 15. We have reduced the new enrollee
appointment request list from nearly 64,000 to right now
approximately 1,700, which is a reduction of about 62,000.
Chairman Sanders. Mr. Secretary, this is a combination of
expanding VA capacity and sending people out to the private
sector?
Secretary McDonald. Yes, sir. It includes things like in
Phoenix, we moved in three mobile units from around the region.
We increased clinical hours. We worked on overtime. It is a
matter of putting the resources where they need to be put. We
collaborated with the Department of Defense in some sites,
collaborating with Indian Health Service. These were the things
that were done.
Also, we have had more people that we have put into the
private sector; 246,300 more patients have gone into the
private sector. And each one of those referrals actually has
resulted in, on average, seven appointments. So, in a sense,
that number understates the care that has actually been
provided.
So, we are making progress there, but more work needs to be
done, and obviously the bill that you mentioned is going to
help us do that, by providing greater access points, 27 more
new points, and the ability to hire more doctors and nurses.
You asked about disciplinary actions. I talked in my
opening remarks about the three individuals in Phoenix who were
seeking--who we have proposed disciplinary action for. We have
a new acting director there in Phoenix. In my American Legion
speech, I mentioned that we have over 30 actions that we have
taken. Around five include members of the Senior Executive
Service. About two dozen include medical professionals.
We are following up as quickly as we can. As soon as we get
information that suggests we should take disciplinary action,
we are taking it. We have stood up a separate team called the
Accountability Team. I met with them as recently as yesterday.
They report to me and their single job is to get after these as
quickly as possible.
Chairman Sanders. All right. Let me interrupt you----
Secretary McDonald. Yes, sir.
Chairman Sanders [continuing]. Because I am running out of
time. I just wanted to revisit the third question. The
Inspector General made a good point, that it is hard to know
what you need unless you have good information. I mean, in your
judgment, how many more doctors, nurses, medical staff do you
need, and how would you, at a time when this country is not
producing enough primary care physicians, et cetera, are you
going to get them?
Secretary McDonald. We need tens of thousands. Deputy
Secretary Gibson said in his testimony, I think it was around
28,000. We are now going through a process----
Chairman Sanders. Let me repeat that because that is an
important point. You are telling us you believe you need 28,000
new medical staff?
Secretary McDonald. Including clinicians and other
employees.
Chairman Sanders. Wow.
Secretary McDonald. We are in the process of going through
a big recruiting effort. I was at Duke University Medical
School. I was with Senator Burr in Charlotte and I then went to
Duke. We talked to over 500 members of the Duke medical
community. I was in Philadelphia last Friday. I talked to
members of the University of Pennsylvania Medical School.
We are trying to demonstrate to young people studying in
the medical profession that VA is where they want to work. They
want to work there because we have had three Nobel Prize
winners. We have had seven Lasker Award winners. We do great
up-front research. Did you know that the nurse worked at the VA
who developed the use of the bar code for tracking patients and
medication? We are known for innovation and young people should
come work for us. The help that you gave us with student loan
forgiveness, debt forgiveness, doubling the number is going to
be very helpful to help us recruit.
Chairman Sanders. All right. I have far exceeded my time.
Senator Burr.
Senator Burr. Thank you, Mr. Chairman. Mr. Secretary,
welcome and thank you for the role that you are filling. I have
just got a couple areas, one on an item you just mentioned,
that every private sector referral triggers seven additional
visits. If you would, and you can have Dr. Clancy speak to
this, I would love to see the data on that. I know that that is
what VA actuaries have stated and what they believe.
I think we need to get to the bottom of it, figure out why.
Is this a contractual problem where we have contracted with the
private physician where they see an opening to bring a patient
back seven times? Under Medicare, that would all be under a
bundled payment. If we are going to utilize the private sector
right, then we have got to figure out whether we are doing it
right today.
But I cannot envision where every time we referred somebody
to a private sector doctor, it triggers seven additional
appointments, visits that we are going to pay for. And if that
is the case, I would love to see the specifics on that when you
are able to gather them.
With everything that you just went through, it is probably
hard to believe that I would ask you this question, because you
detailed greatly all the changes that we are making, but my
question is this: how do you plan to change the culture at VA
and how do you plan to measure it?
Secretary McDonald. First, we will get you data on those
seven visits. As you know, many of our veterans have multiple
illnesses, but we will get you the data and we will sit down
together and talk about that.
[Responses were not received within the Committee's
timeframe for publication.]
In terms of changing the culture, changing the culture is
probably one of the most difficult leadership challenges,
whether it is in the private sector or the public sector. I
think the most important thing we have got to do is to open up
the culture. As I described earlier, high performance
organizations have the improvements made by the employees, not
by the leadership.
The leadership certainly helps. They pick the strategies,
they pick the leaders, and they help create the culture. But we
have got to get every employee involved. On the very first week
I met with the union leadership. The majority of our employees
are union members; about 65 percent are union members. I met
with the union leadership three times in my first 5 weeks, and
I am asking them to recommit themselves to our values, our
mission, and to help me engineer the changes that we need to
make.
Every time I go to a site, I meet with the union leadership
as well. I include them in our leadership meetings. I also make
sure I talk to the whistle-blowers from that site, and I always
do a town hall where I explain to the employees that I want
every employee to be a whistle-blower. I want every employee
causing us to change.
I have used a diagram--I used it yesterday and I have used
it with employees--that basically says that most people think
of an organization structure like a pyramid. At the Proctor &
Gamble Company, you would have a CEO. At the Department of
Veterans Affairs, you would have a Secretary.
Well, I take that and I turn it on its head and I say, this
is where our veterans are. Our veterans are at the broad base
of this pyramid. The people caring for those veterans are the
most important people in the organization. I am on the bottom.
I am at the apex. What I have got to do is make sure the
communication is flowing up and down that pyramid to make sure
we care for those veterans.
So, the boss of this operation is the veteran. The boss is
the person next to the veteran, serving the veteran. Frankly,
some of the things that have happened in the past do not fit
that picture. For example, we had some of our positions who
serve the veteran downgraded and the annual salary is
hundreds--is not hundreds--tens of thousand dollars less that
we are able to pay them.
Well, those are important people. We have got to--so I have
encouraged all of our leaders to seek exceptions to that policy
and we have got to get back to putting the best talent up
working and serving the veteran. Culture change is difficult,
but I think we can do it.
Dr. Clancy. May I just make one point?
Senator Burr. Go ahead, Dr. Clancy.
Dr. Clancy. Just to make one point, the point about
measurement. VA has a unique all-employee survey, which is now
going out into the field to all employees, and it is much more
thorough than other Federal departments. One of the areas that
we can measure and do track closely is psychological safety. In
other words, do people feel empowered to say, ``We have got a
problem here on the front lines. I need help. This is not
working.'' We will be keeping a very close eye on that.
Senator Burr. Good.
Secretary McDonald. Yeah, we sent that out last week and I
will be happy to share the results with the Committee when it
comes back.
Senator Burr. Thank you. One last question. In the press
release that VA sent out prior to the release of the IG's
report, the release stated that you had asked for an
independent review at scheduling and access practices beginning
this fall by a joint commission. I have got a very simple
question. Why? Why do we need a joint commission to look at the
same thing that the IG is looking at in 93 facilities right now
which the IG has reported on since 2005, and are we waiting
until the fall to implement changes in that until we have got a
joint commission's report back?
Secretary McDonald. I will ask Dr. Clancy to clarify my
comments, but it is not just any commission. It is a commission
that does this kind of work for a living.
Senator Burr. This town is full of commissions. As soon as
we hear the word commission, we all start looking for who is
hiding.
Secretary McDonald. Well, it is not about hiding. It is
about bench-marking best practices and this Commission does
this across the country and will help us understand best
practices in all facilities, not just the 93 that the IG is
looking at. So, we plan to use this Commission to improve. It
is unfortunate their name is commission, but that is----
Dr. Clancy. So, just to expand for one moment, they do
accredit the vast majority of private sector hospitals. In
fact, they cannot get paid by Medicare or Medicaid if they are
not accredited. So, this is following a standard practice in
the private sector. These are going to be unannounced surveys,
so we have put a huge amount of effort into making sure that
the schedulers are trained, that we have enough people hired.
We are looking for ways to get exceptions to get their
grades increased, as the Secretary just indicated, but this is
also going to be looking at, is it really working? How does
patient flow work? What happens to people who wait in the
emergency room then leave because they have been waiting too
long and so forth. It is going to be an independent check for
us and it will give us an opportunity to spread both good
practices and opportunities for improvement across the system.
Senator Burr. Thank you. Thank you, Mr. Chairman.
Chairman Sanders. Thank you, Senator Burr.
Senator Tester.
Senator Tester. Thank you, Mr. Chairman. Once again, thank
you for being here, Secretary McDonald. Just as a sidebar, I
would love to have you incorporate Montana into your travel
plans. Some time by the middle of next month would be great.
Next, highest number of per capita veterans in the country, and
they are some of the best veterans in the country, too, but I
am a little partial about that.
Let me ask you this. You said you removed three leaders
from the Phoenix office. Were they reassigned or were they
terminated?
Secretary McDonald. What I said, Senator Tester, is that we
have proposed disciplinary action against three leaders. This
is the process that has to be taken for leaders who are in that
strata of employee. We have proposed the disciplinary action.
It now goes to a board and there is a process that it goes
through. Since we have proposed that action, we have taken the
leaders I talked about, moved them to Phoenix, and they are in
an acting role.
Senator Tester. New leaders?
Secretary McDonald. Yes, sir.
Senator Tester. I think one of the concerns we had was, I
think, you have to protect employee's rights, but we also need
to be able to terminate people when they deserve to be
terminated.
Secretary McDonald. I agree with you entirely.
Senator Tester. All right, good.
Secretary McDonald. And believe me, we are, as I said in my
prepared remarks, we are following the disciplinary--we are
following the investigations and as soon as we are capable, we
are taking action.
Senator Tester. The IG made many good points. One of the
things he brought up was the analysis, because of the
scheduling, really do not have a clear pattern on how many
folks out there really need the kind of services they need. And
then there is also the fee-based information that is out there.
I do not know if that is better or not as good, or the same.
How can you make a determination that you need 28,000
medical staff? I mean, you are a wonder worker probably, but
the fact is, that information still has not been hammered out.
Secretary McDonald. No. We are going through a process
right now where we are going location by location, specialty by
specialty to understand how many people we really need.
Senator Tester. When do you think that process will be
done?
Secretary McDonald. Let me ask Dr. Clancy to comment on
that because she is leading that process.
Senator Tester. Sure.
Dr. Clancy. In response to a previous report from the
Inspector General, and Dr. Daigh mentioned this briefly, we
have been--we have created and are deploying a tool to assess
productivity----
Senator Tester. Got you.
Dr. Clancy [continuing]. Which includes space and all that.
I would guess by early--at the end of this calendar year, early
next year.
Senator Tester. All right. Then you will have a firm grip
on how many medical staff you will need to have when that
process is done because you will have already set up standards
for doctors, because that is part of the thing, too, right?
Dr. Clancy. Yes, in addition to how many support staff do
they need to make them as efficient and productive as possible.
Senator Tester. OK. Now I want to kick back to something
else the IG said, because I tried to pin him down on the
staffing thing and he said staffing is part of it. The other
part of it is facilities. Where are you going to put these docs
and medical staff if you hire them? Because quite frankly, I
can tell you, in Montana facilities, I do not know if they are
as big of a problem, but they are certainly pretty damn close
to as big a problem as not having enough staff.
I mean, you will have docs there, but you are not going to
have any examination rooms. Do you have a construction plan
moving forward? I know it is unfair, since you have only been
in the job 6 weeks. I am not trying to be critical.
Secretary McDonald. I think it is five actually.
Senator Tester. That is good.
Secretary McDonald. Obviously, you are right. Facilities
are very important and the action you took with the bill gives
us the ability to have 27 more facilities. Not surprisingly,
one of the facilities will go in Phoenix where, obviously, we
have a need.
We have an issue right now that we are working. It is
around leasing. We have been following an appropriate, I think,
strategy of leasing facilities rather than building them
because the population, as you know, is moving, and you have
talked about the increase in veterans in Montana.
Senator Tester. Right.
Secretary McDonald. We are currently working through the
GSA on this process because the GSA----
Senator Tester. But to get down to it, Secretary McDonald,
I appreciate you telling me what you are doing, but also what I
want to know is, do you have a construction plan moving forward
for the next year, 3 years, 5 years? So that you can come to
us--some of us are appropriators on this Committee--and say,
look, guys, we need this much money if we are going to be able
to serve the veterans that are coming back.
Secretary McDonald. We have a construction plan, but we are
going to be renewing our forecasting, as I mentioned during my
confirmation hearing, because I am not happy. I am not
satisfied that our forecasting is robust enough.
Senator Tester. OK. I want to talk about the ARCH program
very, very briefly because I do not have much time. It is
pushed out for another 2 years. Is it open to all hospitals if
they contact the VA? Let us say the Great Falls Hospital in
Great Falls, MT, wants to get in on the ARCH program. What do
they do?
Secretary McDonald. Let us know. Again, our principals will
look at everything through the lens of the veteran----
Senator Tester. OK.
Secretary McDonald [continuing]. And if it is good for the
veteran, we want to do it.
Senator Tester. OK. I think that in particularly rural
areas, that is going to be critically important. With that, I
have got some other questions I am going to put in the record,
quite frankly, for you as we move forward. But know that I know
you are committed to the job. I know you are surrounded with
people who are committed to the job. Middle management has been
a problem, not only with this Administration, but the previous
one. I think that you need to hold them accountable, too.
Secretary McDonald. Well, I want to spend some time with
you on the planned Road for Veterans Day, because one of the
steps we are going to take is to reorganize the Department.
Senator Tester. OK.
Secretary McDonald. We have nine different geographic maps
for this Department. We have 14 Web sites that all require a
different user name and password. The veteran does not want
that. The veteran wants one geographic map, one Web site, and
that simplification, I think, will flatten the hierarchy that
you described and provide for information coming up and down a
lot more quickly.
Senator Tester. Thank you for your work.
Chairman Sanders. Thank you, Senator Tester.
Senator Heller.
Senator Heller. Thank you, Mr. Chairman, and Secretary,
thank you for visiting Reno.
Secretary McDonald. Reno and Las Vegas.
Senator Heller. And Las Vegas. On behalf of myself and the
Governor----
Secretary McDonald. Yes.
Senator Heller [continuing]. Perhaps minus the Tesla
locating in the State of Nevada. It was a terrific opportunity
for him to discuss with you, as myself, the concerns that we
both share about Nevada's veterans. So, thank you again.
Secretary McDonald. You are welcome. And may I say that
working with the State governments is critically important for
our success.
Senator Heller. Well, you are proving that. Thank you for
doing so. I want to talk about the Reno or the Nevada VARO just
for a couple of minutes. As you are probably aware, in the
Inspector General's report, they did a VA two-year claims
initiative and were able to recognize that about 32 percent of
those claims reviewed were inaccurate.
Unfortunately, for the State of Nevada, the IG report that
they did in June focusing on Reno VARO, found that 51 percent
of the claims reviewed were inaccurate. That being the case,
have you had an opportunity to review these reports from the
IG?
Secretary McDonald. I have, but I also have to say that I
have asked the IG to give me all of the reports over the last 5
years and to give me a triage version of those reports because
I want to go back and look at all of the reports that have been
issued and not acted upon.
Senator Heller. Yeah.
Secretary McDonald. Now, I do know the situation in Reno,
having been there. We have new leadership on the ground. We are
making some progress, but we are not to where we need to be and
the new leadership knows that.
Senator Heller. Let us talk about that leadership for just
a moment. As you know, I called for management changes in the
Reno VARO. Do we have a permanent director in that VARO at this
point? Or what is the timeline for getting that?
Secretary McDonald. We have an acting director right now,
but we are in the process of, obviously, identifying the
permanent director.
Senator Heller. You also mentioned in that----
Secretary McDonald. And we will partner with you on that.
Senator Heller. OK. You also mentioned that there perhaps
is a need for four additional employees in that particular
office. What is the status of that?
Secretary McDonald. I have to check the hiring status, but
we do need more employees in the Veterans Benefits
Administration and we need them in that office. There is
nothing holding us back from hiring them. We do need more
employees in Veterans Benefits Administration.
Right now we have, as you know, in that office and
elsewhere around the country, we have all of our employees
working mandatory overtime. We are stopping mandatory overtime
October 1 because it is not sustainable. But, in order to be
able to sustain our progress going forward and continuing to
drive this backlog down, we have got to hire more people.
There was some money in the bill that was recently passed
that was taken out of the bill. I think it was $400 million. We
are going to need some of that money back and we are going to
cost-save to try to find money to be able to hire those
employees and continue to work that backlog down.
Senator Heller. I am sure you tend to agree with me that
overtime is not an answer, you know, long term. Short term
perhaps we could make some headway, but long term overtime pay
and over-working some of these employees probably is not the
answer. I think there really is a structural overall change
that needs to happen in some of these VAROs and I will repeat
it, but at 345 days for benefits and medical claims processing,
it is just unacceptable at this point.
We would certainly hope that additional employees,
obviously, would be one of the answers. Whatever the resources
are necessary. As you know, I talked to the management in Reno
to try to find out what they need, and they told us additional
resources were not necessary. Please let me know if there is
anything I can do to help, because it is just absolutely
unacceptable; and I also think change needs to occur.
I know you have not been in your position real long, but do
you have a direction that you really want to go for these
wholesale changes that are going to be necessary to reduce
these backlogs?
Secretary McDonald. We have made progress. The claim
backlog is down by 56 percent. I think Deputy Secretary Gibson
has said, and I agree with him, that the changes made in the
Veterans Benefits Administration over the last couple of years
have just been astounding. But you are right. We have done it
by brute force and what we need to do now is re-engineer the
process and get the resources we need to do it on a sustainable
basis and drive down the backlog to zero by 2015, which is our
commitment.
Senator Heller. Well, if there is anything that I can do to
help and support--we have initiatives here. Senator Casey and I
are working on those. We would certainly like to offer our
services in any way that we can.
I want to change directions real quickly and that is on
women veterans. As you know, there are nearly 2.3 million women
veterans that have served in the military and that number, as
you also know, is continuing to grow.
Since you have been Secretary, have you reviewed the care
and services for these women veterans to make sure that it is
adequate?
Secretary McDonald. I have and we have work to do. In fact,
every stop I go to, whether it is Phoenix, Memphis, Las Vegas,
and I go into the medical center, one of the things that
strikes me is how we built facilities years ago for male
veterans because there were no female veterans. I also check in
to see, do we have medical practitioners in OB-GYN and other
areas. I look in the prosthetics labs to see, are we used to
making prosthetics?
We were just talking with Gary of the Disabled American
Veterans and they have done a study now on what it means to
make a prosthetic for a female who is pregnant. These are
things that we have never had to deal with before, but now with
11 or 12 percent of the veteran population being female, and as
you have indicated, continuing to increase in absolute numbers,
these are things we have got to get after.
Senator Heller. I think it may take some legislation to
expand this care and I am eager to help your Administration
move forward on these initiatives. I know something needs to be
done and I look forward to assisting.
Secretary McDonald. We would love to partner with you on
that.
Senator Heller. Mr. Chairman, thank you.
Chairman Sanders. Thank you very much, Senator Heller.
Senator Murray.
Senator Murray. Thank you very much. Before I ask my
questions, I just want to say to Senator Heller, thank you for
asking that question. There is a lot of work left to do in
terms of privacy, in terms of doctors that know how to care for
women. But we also know that one of the barriers for women to
get care is child care, because if you do not have a place to
leave your kids that is safe, you do not show up; particularly
for mental health this is a serious issue. I would love to work
with you on that as well.
Mr. Secretary, thank you, again, for being here. I want to
start with talking about the fact that the IG found several
cases in which veterans face delays in care or substantial care
and subsequently took their own lives. VA's newest wait time
data still shows it takes far too long to get into care, but
the IG's findings also said that just simply meeting the wait
time metric is not enough. Veterans also need to be assigned to
a regular provider, they need care coordinated across the
hospital and between specialists, and to get the type of care
they need when they need it.
We have been working on this problem for a long time now,
and I wanted to ask you today, why do you think the VA
continues to struggle with providing appropriate mental health
care?
Secretary McDonald. Senator Murray, I think mental health
care is a problem in the United States and I think it is a
problem in the VA. One of the things that excites me about this
job is that many of the things we see at the VA is we are kind
of the pathfinder for the country, whether it is, for example,
the use of the bar code in a hospital to make sure somebody
gets good care.
I think one of the things we have to do is to increase the
number of students studying mental health in school. When I was
at Duke University Medical School, I met with 17 residents who
graduated from the medical school all working with the VA. Only
one was a psychiatrist. So, I asked the question, why are young
people not going into psychiatry and mental health? Because it
is an area that we are learning a lot more about today than we
knew in the past.
My father-in-law, who was a prisoner of war in World War
II, he was a B-24 tail gunner. He was shot down over Germany--
over Austria. He walked across Germany. I am sure he had Post
Traumatic Stress, but we did not know what to call it.
Senator Murray. Right.
Secretary McDonald. He never wanted to talk about it until
he joined a VA group of POWs who felt comfortable talking about
it. And what they told me was, the biggest issue is that
insurance reimbursements for mental health are far below the
cost. Somehow we have got to get a handle on what is going on
in this area and find ways to encourage people to go to school
in mental health.
In all of my recruiting speeches so far, I have talked
about the importance of mental health and I am trying to
encourage young people to get into the discipline. I really
think it is a national problem, but VA is on the cutting edge
of it.
Senator Murray. Well, continue work on that because that,
to me, is a serious issue. You are right. It is a country
issue, but our veterans are at the front of this line----
Secretary McDonald. Absolutely.
Senator Murray [continuing]. And we have got to make sure
we have got the providers, but we also have the understanding
across the VA and across the culture of the VA to really watch
for this.
In your testimony, you talked about improving the
Department's leadership training and breaking down some of the
VA's bureaucracy as a way of enhancing accountability. That
needs to happen at all levels, at all levels, and I liked your
little chart where the veterans are at the top. But there are a
lot of people between you and them.
Secretary McDonald. That is why I gave out my cell phone
number.
Senator Murray. Well, we need to look at everything from
training new clinic managers to oversight and effective
intervention by medical centers and network leaders. How do you
make sure that these changes happen at all of those levels
across the VA? It is a huge system.
Secretary McDonald. It is a huge system. It starts by
getting out and going to these different sites and meeting the
people and understanding, are we providing the right
leadership? Do we have the right strategic choices? Do we have
the right systems? Are we, you know, doing things that
repeatedly will lead to a good result? And do we have the right
culture?
For example, I was at a site. I was actually in Reno and a
young person was talking to me in a town hall about ways we can
improve our computer system. And one of the senior managers
stepped in front to try to stop the conversation, and I had to
ask that senior manager to move out of the way. It just was not
appropriate.
I was in Philadelphia last week. This was a site that had a
training program on town halls that used Oscar the Grouch in
there. I had to talk to those employees about, no matter what
the intent, perception is what is important and the perception
of Oscar the Grouch on a presentation is not going to be
acceptable.
We simply have to dive into the culture and dig and figure
out what is going on that is wrong and then set the example to
do it right. I tell everyone to call me Bob. I was Bob before I
became Secretary, I might be Bob after I am done being
Secretary. That is not trite. That is done because we need to
flatten the hierarchy. We need people to be like a family, to
call each other by their first names, to feel comfortable
turning in problems.
We need to reward people who turn in problems, not chastise
them or not ostracize them. So, these are some of the things we
are doing. It is hard work, but it is underway.
Senator Murray. OK. And really quickly, you said you have
committed the VA to acquiring and fielding a modern scheduling
system. Can you tell me when you think that will be done and
the training for employees to use that?
Secretary McDonald. Right now, we are doing some quick
fixes on the established system. Those quick fixes are coming
out periodically over the next few months. To really change the
whole system and bring in a new one is going to take some time.
But we would like it to be done in 2015.
Senator Murray. 2015. And that includes the training for
everybody?
Secretary McDonald. Yes, of course. In fact, when you put
in a new system, we want to commission it, we want to verify
people know how to use it before they sit down and are
qualified to use.
Senator Murray. Thank you very much.
Chairman Sanders. Thank you, Senator Murray.
Senator Moran.
Senator Moran. Mr. Chairman, thank you. Mr. Secretary, I do
not think I will call you Bob in this setting, but, Mr.
Secretary, thank you very much for your presence as I said
earlier. I have a series perhaps of convoluted questions all
related to the same topic. First of all, I would like to offer
my assistance, as I have done with previous Secretaries.
You have testified, the Chairman of this Committee has
great interest in trying to help the VA have the necessary
professionals to meet the needs of veterans. I have asked the
previous VA Secretary how can I help. What do you need? What
tools do you not have to help solve this problem? With no
response. Again, if there are changes in the law, programs that
are necessary to encourage loan forgiveness, whatever the story
is that would help you attract professionals, I would like to
be of assistance. I would like to be an ally.
Here is my scenario of a couple of stories. Lee Mahin is a
Smith Center veteran. I mentioned him in my opening remarks. He
had the good fortune of the VA calling him to tell him that he
no longer needed to drive 4 hours to Omaha, NE, from Smith
Center, KS, to have a colonoscopy. That is the piece of good
news. So, that suggests to me that there is change afoot. Thank
you.
Down the road about an hour in Plainville, KS, Larry
McIntyre tells me that last week he drove 3 hours to Wichita to
get a cortisone shot in his shoulder. He goes to Wichita
several times a week for other minor procedures. There is a
CBOC within 25 miles of Plainville, but the CBOC does not have
the professional capability, as I understand it, of providing
cortisone shots.
What does exist is a hometown hospital, Rooks County
Medical Center, Plainville, KS, that could provide a cortisone
shot that is in the same town where Mr. McIntyre lives, and
certainly less than the 3\1/2\-hour drive to Wichita. So, on
the one hand, we have had some success. On the other, there
still remains these issues that we are trying to get at within
the VA, but also in implementation to the Care Act.
First of all, in implementation to the Care Act, when 40
miles is the determining factor as to whether or not you can
access health care, how are you going to treat what that CBOC
is capable of doing in determining whether or not that veteran
lives within 40 miles of a facility? Is it a facility or is it
a facility that can perform the service that the veteran needs?
Secretary McDonald. That is a really excellent question and
I am glad you brought it up, because one of the technical
changes that we are working with the Committee on is to give
the Secretary the authority to interpret that the way it should
be interpreted. In other words, let us look at it through the
lens of the veteran. Does it make sense for that veteran to get
a cortisone shot closer to home? What makes sense?
And one of the things we are asking is to give the
Secretary that flexibility in the technical changes to the Care
Bill.
Senator Moran. You do not believe you have that authority
to make that determination now?
Secretary McDonald. No, sir, but I think just by simply
putting in a phrase, it would be very simply handled, and we
have been working that with the staff.
Senator Moran. Does there seem to be any impediment toward
accomplishing that?
Secretary McDonald. No, sir.
Senator Moran. OK. Then let me go back to ARCH. In the
interim before the Care Act is implemented, which my guess is
November being the best scenario, you have set aside $25
million for outside of the VA care. That, I assume, funding
expires at the end of the fiscal year, September 30, now 3
weeks away. ARCH is in existence and the Care Act gives you the
authority to do two things with ARCH. One is to extend the
contracts, extend the program, and the second is to expand the
program beyond the geography that is currently served by an
ARCH program.
Do you have any questions about your ability to extend the
program, ARCH, and do you have any questions about your ability
to expand the program?
Secretary McDonald. One of the technical changes that we
are asking for in the bill that pertains to ARCH is the ability
to just extend the contracts that we already have which will
allow us to accelerate the expansion of ARCH.
Senator Moran. So, the language in the Care Act is
insufficient to allow you to extend the contracts?
Secretary McDonald. It just needs a modest modification.
Senator Moran. But when do those contracts expire?
Secretary McDonald. Well, it is not--I do not think it is
the expiration as much as it is just the assumption that we can
use them moving forward so we can move more quickly rather than
going through an entire rebidding process for new contracts.
Senator Moran. ARCH is not going to go out of business----
Secretary McDonald. No.
Senator Moran [continuing]. Those pilot programs before you
get a technical change? The contract will continue?
Secretary McDonald. I think--let me check on this to make
sure. It is extended for 6 months, but what we are trying to do
is extend the expansion as quickly as we can, and the way to do
that is this technical change.
Senator Moran. So, you do not need an expansion. You do not
need technical language to expand for 6 months. You need
something to----
Secretary McDonald. To extend for 6 months, no.
Senator Moran. And your expansion authority?
Secretary McDonald. We are OK on that, but I think, again,
the technical change we are seeking would allow us to
accelerate the expansion.
Senator Moran. Mr. Chairman, with your indulgence, I would
only say that I was surprised, as an author of this
legislation, that the pilot programs were so narrow to begin
with, very small geographic areas. My expectation was the VA
would choose five sites that are Statewide or VISN-wide. We
expected the entire VISN to be the pilot program, not a matter
of a county or two.
Do you have an opinion? Do you have thoughts about your
willingness to expand ARCH to a larger Statewide or VISN
geographic area?
Secretary McDonald. Well, again, consistent with Deputy
Secretary Gibson said, we need to look at this again from the
standpoint of the veteran, and if it is good for the veteran,
then we should expand it. I think that is what he said. We will
expand it. We are looking forward to working with you on that.
Senator Moran. If you can get us the analysis of the ARCH
program done by the VA, which we have asked for a long time (at
least months), we would like to see what the report says about
how the Department of Veterans Affairs analyzed the program. I
assume it would say good things.
Secretary McDonald. I would assume so, too, about providing
care.
[Adequate responses were not received within the
Committee's timeframe for publication.]
Senator Moran. Thank you.
Chairman Sanders. All right. Although long, I think it has
been a productive hearing.
Secretary McDonald. Mr. Chairman, may I say one thing?
Chairman Sanders. Sure.
Secretary McDonald. First of all, I want to clarify one
comment I made. I recall I said that the funding for VBA was
roughly $400 million. That was part of our original $17.6
billion request. It did not end up getting passed. So, that is
why we brought that up, because we want to continue to drive
down the claims.
Second, I was trying to say earlier that leasing becomes
very important. Leasing is a strategy that we are using to move
our footprint out, provide greater access and care, and right
now we have an issue that we are trying to resolve with the
General Services Administration, the GSA, where they rescinded
our blanket delegation of authority in July for lease
contracts.
Now, every one of our leased contracts needs an individual
delegation from the GSA, and those that exceed $2.85 million,
which many of them do--59 percent of the 27 do--need to go
through a relatively laborious process. So, we are working with
GSA to resolve this. But while we do that, we believe there is
a need and a case to be made for an independent 20-year medical
lease authority for VA to carry out its mission and to continue
to provide these points of access. I just wanted to make sure
that I got that right.
Chairman Sanders. Sure. This has been a long and ongoing
problem, so we look forward to working with you.
Secretary McDonald. Thank you.
[Posthearing questions to Hon. Robert McDonald follows:]
Response to Posthearing Questions Submitted by Hon. Bernard Sanders to
Hon. Robert A. McDonald, Secretary, U.S. Department of Veterans Affairs
delays in care
Question 1. While no deaths were attributed to delays in care, the
Department of Veterans Affairs (VA) Office of Inspector General's (IG)
August 26, 2014, report, Review of Alleged Patient Deaths, Patient Wait
Times, and Scheduling Practices at the Phoenix VA Health Care System,
found more than 3,500 veterans were on unofficial lists waiting for
appointments, many of them for years, and were unable to obtain the
care and services they deserve, in a timely manner. What steps has VA
taken to ensure it eliminates the use of unofficial waiting lists?
Response. VA has reviewed 88,000 fiscal year 2014 employee
performance plans. Upon review, 13,000 plans were modified to remove
scheduling and wait time metrics or goals. In accordance with the
Veterans Access, Choice, and Accountability Act of 2014 (VACAA), these
factors have been removed from inclusion in employee performance
evaluations and when calculating whether to pay performance awards. VA
will continue to review and modify employee performance plans for
future years.
VA revised Human Resources handbook 5021 to include provisions
related to penalties for employees who falsify data regarding access to
care or quality measures. The policy has been updated to list,
``Willfully submitting or directing others to submit false data
concerning wait times for health care or quality measures related to
health care,'' as an offense related to falsification. The explicit
inclusion of the terminology ``wait times'' and ``quality measures''
will reinforce the expectation of the Department that no employee shall
manipulate or falsify data regarding wait times or quality measures.
Question 2. For those veterans who were offered the option to see
a health care provider in their community, as part of VA's Accelerating
Access to Care Initiative, how many veterans opted to wait for VA
health care?
Response. Since the beginning of the VA's Accelerating Access to
Care Initiative, local facilities have been contacting those Veterans
who have an appointment scheduled 60 or more days into the future. As
of September 17, 2014, about one-third (104,474) of those Veterans
contacted decided to keep their scheduled VA appointment.
Question 3. Are the mobile medical units being used at the Phoenix
VA Health Care System (PVAHCS) being staffed by PVAHCS staff or
augmented staff? How will information on the care veterans receive
through the mobile medical units be shared with their PVAHCS health
care teams to ensure continuity of care?
Response. The Medical Mobile Units (MMU) were staffed by VA's
Disaster Emergency Management Personnel System and the Phoenix VA
Health Care System (PVAHCS) staff simultaneously. Two clinics were set
up in the MMUs and the third MMU was used as an administrative area.
The first clinic was an Unassigned Patient Aligned Care Team (PACT)
Walk-in Clinic. This clinic was designed for new patients who were not
yet assigned a primary care provider (PCP). For example, a Veteran who
was seen in the Emergency Room, but did not have a PCP established
could be seen in the unassigned PACT clinic until they were assigned to
a PACT team. Additionally, traveling Veterans who did not need to be
assigned to a PCP in Phoenix could be seen by the Unassigned PACT Team.
The creation of the Unassigned Walk-in Clinic created a central clinic
for this method of care to occur.
The second MMU was established to leverage tele-health support from
other VA facilities in the event those tele-health staff resources were
to become available.
The third MMU was used as an administrative area; the facility was
able to move administrative staff from the current Primary Care
clinics, which freed up additional clinical space. As a result, enough
space was created in the Turquoise Clinic to house up to five
additional PACTs. This decision was made for the convenience of
patients and to minimize exposure to heat for Veterans attempting to
locate the MMUs.
The information captured during care delivered in the MMUs was
captured through VA's Electronic Medical Record known as the
Computerized Patient Record System (CPRS). The MMUs had full
functionality with VA's CPRS and patient interactions were recorded in
the same manner as any patient-provider interaction. The MMUs were
utilized at PVAHCS from June 11th through August 8, 2014, at which time
they were returned to their home sites.
Question 4. As part of the Accelerated Access to Care Initiative,
VA has extended clinic hours to expand capacity. How many veterans have
used these extended hours? Please discuss whether extended clinic hours
for patient care are sustainable or part of a long-term access
solution.
Response. The number of Veteran encounters during extended hours
for Mental Health, Primary and Specialty Care has increased since
May 2014. The Outpatient Extended Hour Encounters between May to
September 2014 totaled 629,925 as compared to 553,433 during May to
September 2013 (see attached chart below). The data demonstrates a 14
percent increase in the volume of extended hour encounters used by
Veterans during the same timeframe (May to September) between 2014 and
2013.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Extended clinic hours can, and must be, part of VHA's long term
access solution to meet the preferences of Veterans. To provide
personalized, patient-driven care, VHA must be accessible at times that
are convenient for Veterans. Shifting tours of duty will help alleviate
the space limitations facing a number of facilities. In addition to
current staff who have altered their schedules, new staff who are hired
will need to embrace working extended hours and in non-traditional
tours. This additional flexibility can help with recruiting and
retaining needed staff. However, in order to be fully sustainable, this
cultural shift may require modification of VA's policies regarding
physician tours of duty and leave.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
data manipulation
Question 5. The Committee requests information on the steps VA is
taking to ensure the access data being reported bi-monthly, as a
response to its Access Audit, is accurate.
Response. As a result of the System-wide Access Audit, VA has
renewed its focus on ensuring the integrity of the data used throughout
the system. Actions have been implemented to strengthen the process and
improve the integrity of VA's access data at each step of the process:
data input, data aggregation, data reporting, data distribution, and
publication. To ensure the integrity of the access data in the input
stage, VA recently launched an automated access and scheduling audit
tool designed to monitor and flag any potential data integrity issues.
This tool is programmed with a preset algorithm, designed by scheduling
subject matter experts that will score scheduling practices at each
facility and clinic and highlight those clinics that require additional
follow-up. This tool is available for use by each medical center and
Veterans Integrated Service Network (VISN) leadership team. This tool
is also being routinely monitored in VHA Central Office by a national
monitoring group and the VHA senior leadership team. Once the data are
input into the system, the data from each Veterans Health Information
Systems and Technology Architecture (VistA) system are transmitted to
Austin Information Technology Center and aggregated into national files
containing appointment and Electronic Wait List (EWL) records. These
national files are used by the VHA Support Services Center for
calculation and reporting of wait times. The date stamps in each
appointment and EWL record are used to calculate the wait time in days.
After the wait time and EWL data are prepared for public release, each
number is independently verified against the VHA Support Services
Center, to ensure accuracy. All data that pertain to Veteran access to
care, including non-VA care, are verified by a team independent of the
data production process prior to distribution and publication.
accountability
Question 6. The Committee requests the following information on
the Administrative Investigation Board that was established to
determine whether administrative action should be taken against
management officials at the Phoenix VA Health Care System as a result
of the IG's final Phoenix report:
A list of the individuals who serve on the board;
Information on the Board's mission--specifically, are they
only reviewing information gathered by the IG or are they conducting
their own investigation; and
A list of VA personnel being considered for administrative
action by the Board.
A list of VA personnel who have been put on administrative
leave or removed from their positions as a result of the IG's final
report on Phoenix.
Response. The board members consisted of a director, human
resources consultants and counsels, none of whom were from the Phoenix
VAMC or from VISN 18. The AIB has reviewed the OIG report and will
review the underlying witness testimony and other evidence before
traveling to Phoenix to begin its investigation. To the extent that OIG
has already found facts or gathered evidence sufficient to support
discipline, the AIB will not repeat that work, but will focus on
establishing individual leader culpability and other issues not fully
resolved by OIG. The AIB will also review leader culpability for
whistleblower retaliation, which was not within the scope of OIG's
review. The AIB will look at culpability, if any, on the part of the
PVAHCS Chief of Staff, Darren Deering, MD; Associate Director, Lance
Robinson; and Chief of Health Administration, Brad Curry. The latter
two individuals were put on administrative leave, as was Director
Sharon Helman. Ms. Helman was removed from employment effective
November 24, 2014.
Question 7. The Committee requests VA's plan to hold local VA
medical center leadership accountable for misconduct, negligence, and
failure to address serious access problems identified that may be
identified during the more than 100 ongoing investigations at VA
facilities by the IG, Department of Justice, Office of Special Counsel.
To include a list of VA personnel that have been fired, transferred, or
subject to administrative action as a result of the finds of such
investigations.
Response. VA takes the allegations and findings of misconduct
seriously and is moving quickly to address the situation. Since
allegations of delayed care and employee misconduct surfaced, VA has
been conducting internal reviews to evaluate appointment scheduling
procedures and patient care in Phoenix and nationwide. VA has initiated
the process for removing senior leaders at the PVAHCS, and VA has
directed an independent site team to assess scheduling and
administrative practices at PVAHCS. This team began its work in April,
and VA is taking action on multiple recommendations from the team's
findings. VA recognizes there is a leadership and integrity problem
among some of the leaders of our health care facilities, which can and
will be fixed. Breaches of integrity are indefensible and VA will use
all authorities at its disposal to enforce accountability among senior
leaders.
As of December 1, 2014, OIG has completed its reviews of scheduling
and wait list practices at 23 sites. At seven sites, no significant
misconduct was found. At three sites--Phoenix, Cheyenne, and Fort
Collins--serious misconduct was found. Six disciplinary actions have
been completed at Cheyenne and Fort Collins (which are both under the
same leadership team) and one at Phoenix (see response to question 6
above). Additional actions may be taken at Phoenix following VA's
administrative investigation there (see response to question 6). VA is
reviewing the evidence OIG collected at the fourteen other sites where
OIG is done, and will determine based on that evidence whether further
investigation and/or accountability actions are warranted.
The Office of Accountability Review commenced an accountability
audit that is taking place at facilities that are not under current
investigation by the Inspector General (IG) and DOJ, or have been
cleared by those entities. VA wants to be as proactive as possible,
while respecting the need of the IG and DOJ to conclude their own
investigations. The purpose of the accountability audit is to determine
what senior leaders at each facility did to ensure the integrity of
their wait time data and that front-line schedulers were aware of the
rules and were following them. In situations where leadership
misconduct, negligence, or other leadership failures appear to have
occurred, the Office of Accountability Review will investigate to
obtain evidence to support appropriate personnel actions against
culpable leaders.
emergency room used as primary care
Question 8. The IG's final report on Phoenix identified numerous
veterans that were forced to visit the Emergency Room because they were
unable to obtain a primary care appointment. The Committee requests
VA's plan to address its system-wide shortage of primary health care
providers.
Response. As the Nation's largest integrated health care delivery
system, VHA's workforce challenges mirror those of the health care
industry as a whole.
As physician shortages exist throughout the private sector, medical
schools are growing to address these shortages. In order to carry out
the primary patient care mission of VHA and to assist in providing an
adequate supply of health personnel to the Nation, VA is authorized by
Title 38 Section 7302 to provide clinical education and training
programs for developing health professionals. VA conducts the largest
education and training effort for health professionals in the United
States. In fiscal year (FY) 2013, 40,420 physician residents and
fellows in graduate medical education programs rotated to a VA clinical
facility for education and training.
VA employs an aggressive, multi-faceted strategy to recruit and
hire physicians. Executive and clinical leaders at 150 medical centers
assess physician staffing needs. Physician shortages or deficits at
specific locations are addressed by increased marketing and recruitment
efforts on a case-by-case basis. In addition to actively recruiting
primary care physicians, increasing and further incorporating nurse
practitioners and physician assistants with specialized training and
experience in primary care into care teams will increase Veterans
access to care. Marketing is also targeted to academic affiliates,
professional health care associations, the Department of Defense, the
Department of Health and Human Services, and Office of Personnel
Management.
VHA's National Recruitment Program (NRP) provides an in-house team
of skilled professional recruiters employing private sector best
practices to the agency's most critical clinical and executive
positions. NRP has increased its targeted recruitment efforts for
mission critical clinical vacancies that directly impact and, once
filled, will improve access to care. These specialties include primary
care, mental health, and critical medical subspecialties. The national
recruiters, all of whom are Veterans, work directly with VISN
Directors, Medical Center Directors, and clinical leadership in the
development of comprehensive, client-centered recruitment strategies
that address both current and future critical needs. Since its founding
in April 2009, VHA's NRP efforts resulted in filling 1,327 mission-
critical vacant positions (as of September 23, 2014), which increased
access to care in rural communities and contributed to Title 38 Veteran
hiring goals. In FY 2014, as of September 23, 2014, the recruiters have
placed 561 health care providers:
91.80 percent are physicians
32.97 percent are primary care physicians
24.95 percent will go to rural/highly rural facilities
15.68 percent are Veterans
16 of these Veteran hires will fill clinical and executive
leadership roles at VA hospitals
The national recruiters are attending conferences to showcase
clinical practice opportunities to potential candidates. These include
American College of Physicians, American Psychiatric Association, and
American Psychological Association. The team will also attend
additional conferences through the end of 2014, targeting specialties
such as Anesthesia, Gastroenterology, Family Medicine, Emergency
Medicine, and Pharmacy.
VHA, in partnership with the Office of Academic Affiliations,
pioneered the agency's first-ever recruitment outreach program
targeting health professions trainees. The ``Take a Closer Look''
Initiative provides VHA with a standardized outreach strategy to
recruit health professions trainees from VHA affiliate programs for
employment upon completion of training. Throughout their programs,
residents and fellows receive information on careers at VHA, as well as
guidance on contacting and facilitating employment with a National
Recruiter.
In addition to actively recruiting primary care physicians,
increasing and further incorporating nurse practitioners and physician
assistants with specialized training and experience in primary care
into care teams will increase Veterans access to care. Additionally, VA
continues to recruit for a variety of administrative, technical, and
professional occupations to ensure the right mix of staff are available
to provide safe, quality care to Veterans.
VHA has a number of education and loan repayment programs, which
include providing education/tuition assistance, education debt
reduction and loan repayment programs, to recruit and retain Title 38
medical professionals. VHA utilizes the Education Debt Reduction
Program (EDRP) for candidates in hard-to-recruit or retain Title 38
occupations who would otherwise decline or leave VHA. Employees or
their lender(s) receive loan reimbursements for up to five years as
long as the employee remains employed by VHA in the position that was
approved for EDRP, thereby serving as a significant retention
incentive. Public Law 113-146, The Veterans Access, Choice, and
Accountability Act of 2014 (VACAA), increased the EDRP loan
reimbursement cap from $60,000 to $120,000. This cap can be waived for
specific critical clinical specialty positions, including mental health
specialties such as psychiatrists, psychologists, and mental health
nurses. There is ample capacity in the program to reach clinical
providers in hard to recruit and retain positions for mental health,
primary care, and specialty care positions around the country. In
addition, VHA is in the process of implementing direct loan repayment
to the lender.
The Employee Incentive Scholarship Program (EISP) authorizes VA to
award scholarships to employees pursuing degrees or training in health
care disciplines for which recruitment and retention of qualified
personnel is difficult. The National Nursing Education Initiative
(NNEI) and VA's National Education for Employees Program (VANEEP) are
policy-derived programs which originated from the legislative authority
of EISP. EISP awards cover tuition and related expenses such as
registration, fees, and books. NNEI is limited to funding Registered
Nurses (RN) pursuing associate, baccalaureate, and advanced nursing
degrees. VANEEP provides replacement salary dollars to VA facilities
for scholarship participants to accelerate their degree completion by
attending school full-time. Participants incur a 1 to 3-year service
obligation following completion of their program.
timely access to care
Question 9. Due to the backlog of new patient Primary Care
appointments discovered the IG's final report on Phoenix, 544
appointments as of March 31, 2014, PVAHCS now monitors all new veterans
to ensure timely access to care. The Committee requests:
Information on the monitoring process that the Phoenix VA
is using, and
A list of VA employees, and a description of their
positions, responsible for the monitoring process.
Response. PVAHCS, through its Health Administration Service (HAS)
monitors and reports data from the EWL and the New Enrollee Appointment
Request (NEAR) on a daily basis. Medical Support Assistants under the
supervision of their respective sections monitor the list daily and
contact the patient. The process for monitoring the EWL is administered
in the Primary Care Call Center. The NEAR is reviewed daily by the
Eligibility and Enrollment department. Both teams pull the names from
the EWL and the NEAR and contact the Veterans to offer them an
appointment. The teams make three attempts to contact the Veteran and
then send a certified letter. The teams obtain the EWL and NEAR from
reports in VA's mainframe architecture also known as VistA.
Personnel involved in the monitoring process include supervisors,
patient service assistants and medical support specialists. The results
of these reports are reported daily to the Medical Center Director,
Executive Leadership and all Service Line Chiefs at Morning Report.
staffing model
Question 10. In 2012, the IG found only 2 of 33 VA health care
specialties had staffing standards. Has VA developed staffing models
for each health care specialty? If so, please provide the Committee
with a copy of each staffing model. If not, please provide the
Committee VA's plan to develop a staffing model for each health care
specialty.
Response. Attached is the Report on the Specialty Physician
Productivity & Staffing Operational Plan and Status Report. VA
concurred with the OIG recommendation to develop productivity and
staffing models for all physician specialties by the end of FY 2015.
The current status of the recommendations resulting from the OIG report
is that all physician specialties, except for Anesthesia and Emergency
Medicine, have productivity and staffing standards in place.
Productivity and Staffing Models for Anesthesia and Emergency Medicine
have been developed and will be fully implemented in FY 2015.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
There are staffing standards for SCI/D (VHA Directive 2008-085,
Spinal Cord Injury Staffing and Beds: https://www1.va.gov/
vhapublications/ViewPublication.asp?pub_ID=1816). This directive will
be updated after an SCI/D nurse staffing pilot is completed.
office of the medical inspector
Question 11. When does VA expect to complete the Office of Special
Council's Section 2302(c) Certification Program?
Response. VA registered for the Office of Special Counsel (OSC)
2302(c) Certification Program on July 11, 2014. The Certification
Program ensures that VA meets its statutory obligation to inform its
employees about the rights and remedies available to them under the
Whistleblower Protection Act, the Whistleblower Protection Enhancement
Act, and related civil service laws. VA received OSC certification on
October 3, 2014.
______
Response to Posthearing Questions Submitted by Hon. Richard Burr to
Hon. Robert A. McDonald, Secretary, U.S. Department of Veterans Affairs
Question 12. In response to a question from Chairman Sanders, the
Secretary indicated that then-Acting Secretary Gibson proposed the
Department of Veterans Affairs (VA) would need 28,000 additional staff
to meet the current demands of VA.
a. Please provide the Committee with a detailed breakdown of the
number and type of providers (separated by specialty), the number and
general schedule level of Title 5 positions, and the number of and
position titles of any Title 38-hybrids.
Response. Please see the attached spreadsheet with the breakouts of
the 28,000 number from the August 27, 2014 pull of VA's WebHR data.
WebHR is a new Web application VHA is now using to track vacancies
nationally; it was first deployed in June 2014. The 28,000 number is
shown by occupation type, in separate groupings for Title 38, Title 38
Hybrid, and Title 5. This 28,000 represents funded but vacant
positions, based on the snapshot in time of WebHR data.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
b. For any positions that would not be assigned to the Veterans
Health Administration (VHA), please identify the number of positions
and office, agency, or administration to which the position would be
assigned.
Response. None of the positions would be assigned outside VHA.
c. For any medical personnel included in the 28,000, please provide
the Committee with a detailed staffing analysis VA used to determine
the number of providers needed for each type of provider (please
separate out by specialty) and which VA Medical Center (VAMC) those
providers would be located.
Response. The 28,000 represents the number of vacancies captured in
WebHR as of August 27, 2014, for clinical positions. WebHR is a Web
application VHA is using to track vacancies nationally and was first
deployed in June 2014. The functionality for collecting vacancies in
this application is relatively new. Transactions against the management
of positions occur daily as the system captures new and completed
recruitment actions in real time. The 28,000 number was not based on a
detailed staffing analysis.
d. Please identify which positions are intended to be located in VA
Central Office (VACO) or the ``Field;'' for VACO positions, please
identify which Administration or Staff office (VHA, the Veterans
Benefit Administration, the National Cemeteries Administration, the
headquarters of the Office of Public and Intergovernmental Affairs, the
headquarters of the Office of Information Technology, etc.). For VHA
Field positions, please identify whether the personnel are to be
assigned to the Veterans Integrated Service Network or VAMC.
Response. None of the positions identified in these data sets are
intended to be located at VA Central Office or VHA Central Office; they
are all field positions assigned to medical facilities.
______
Response to Posthearing Questions Submitted by Hon. Mark Begich to
Hon. Robert A. McDonald, Secretary, U.S. Department of Veterans Affairs
Question 13. Mr. Secretary, we have talked a lot about hiring
people for VA. That is important in Alaska as well. I have told you
about how important it is to me that we leverage Federal resources
wherever they come as we provide care to Veterans. We are doing some
great work in Alaska. A model really increasing coordination and
collaboration.
a. That said, as you are hiring all of these people, where are you
going to put them? Do you lease, do you build?
Response. We are proud of our staff and facilities in Alaska, and
the quality of services provided there. The Alaska Department of
Veterans Affairs (VA) Healthcare System currently has capacity within
the seven Alaska VA facilities, throughout the state, to accommodate
all current employees, as well as currently recruited positions.
VA has several capital and non-capital tools at its disposal to
address evolving space needs to provide care. Leasing is a flexible
vehicle that allows VA to provide care to Veterans at the right place
at the right time with less lead time than construction. In addition,
VA can execute capital renovation projects at existing owned or leased
space to increase capacity within the existing footprint. VA can also
use telehealth and other modalities for newly hired staff to engage
with veterans despite limited space.
b. Do you have the flexibilities you need in law and authority to
get the space that you need? For example how would VA partner with IHS
facilities?
Response. We already have collaborative relationships in place with
Indian Health Service. In addition, the Alaska VA Healthcare System has
agreements with 26 Alaska Native Tribal Healthcare Organizations, which
provide rural health care access for eligible Alaska Native and
American Indian (AN/AI) and non-AN/AI Veterans in approximately 150
rural Alaskan communities. Under these agreements, VA reimburses Alaska
Native Tribal Healthcare Organizations for direct care services they
provide to eligible AN/AI and non-AN/AI Veterans throughout Alaska. The
Veterans Access, Choice, and Accountability Act of 2014 (Choice Act)
affords us the flexibilities to expand our own internal resources, as
well as interagency relationships, to help ensure Veterans have access
to quality, affordable health care. Also under Choice Act, VA has
identified about 400 projects to renovate, repair, or replace much of
our aging health care infrastructure, and expand at some sites, at a
cost of $1.3 billion. The Choice Act will fund these projects during
fiscal year (FY) 2015 and FY 2016.
Question 14. Mr. Secretary, as you know with Veterans Access
Choice and Accountability Act passed, it brought in some needed
resources, such as hiring more clinical staff, this is good. However,
in remote and rural areas like Alaska, we have had problems with
recruiting and retention, specifically for primary care doctors. The
Mat-Su Valley is an example, we are fortunate to have a native clinic
across the road that is taking up to 400 veterans a day.
a. What are the plans for VA to hire and keep clinical staff in
rural areas?
Response. One of the strategic objectives of the Office of Rural
Health (ORH) is to develop innovative methods to identify, recruit and
retain health care professionals and requisite expertise in rural and
highly rural communities. ORH has made significant investments in
strengthening the rural VA provider workforce and is continuously
seeking to understand the current and future rural workforce needs, as
well as all of the potential opportunities to expand and improve our
current efforts. ORH investments are aimed at both mitigating common
factors that contribute to providers leaving rural practice, as well as
providing experiences that may attract providers to rural practice. The
goal is that these investments into rural workforce programs will
retain rural providers thereby impacting subsequent periods without
physician care. In FY 2013 and 2014, ORH invested more than $15 million
to support rural provider education and training initiatives. The
targeted efforts by ORH are intended to supplement the existing
workforce strategies implemented nationally, regionally, and locally by
the Veterans Health Administration (VHA).
Question 15. Alaska's Licensed Professional Counselors have
proudly served our military and veterans community in their time of
need after 13 years of war. However, these professionals have recently
been told their experience and credentials will not suffice to continue
treating our veterans' mental health needs. In recent letters to the
TRICARE and the Army I pressed them to reconsider new accreditation
policies that unintentionally omitted Alaskan counselors.
Will you commit to reviewing the LPC accreditation issue in my
state? Highly qualified counselors are excluded from filling many of
these highly difficult to fill positions, and the veterans are the one
who suffer.
Response. The VA qualification standard for Licensed Professional
Mental Health Counselors includes the basic requirement of a master's
degree in mental health counseling, or a related field, from a program
accredited by the Council on Accreditation of Counseling and Related
Educational Programs (CACREP). This was developed by a group of highly
qualified Subject Matter Experts (SME), leadership within VHA's Mental
Health Services, and VA's Office of Human Resources Management. The
qualification standard is based on the health care industry standards
for the profession and licensure and/or certification requirements.
Additionally, the standard was developed to assure the provision of the
highest quality of care to our Nation's Veterans. The SMEs reviewed
documentation on current industry standards and practices and included
consideration of all state requirements, including the licensing
requirements for the State of Alaska. It is important to note, the
qualification standards for each core mental health profession require
that an individual in that discipline have graduated from a program
that is accredited by an approved accrediting body that accredits
training programs in that discipline. This rule applies to all VA core
mental health disciplines (Psychology, Psychiatry, Social Work,
Nursing, Licensed Professional Mental Health Counseling, and Marriage
and Family Therapy).
Question 16. It was recently shared with me that scheduling
vendors are providing commercialized off-the-shelf scheduling software
system that can significantly solve most of the scheduling challenges
facing the Veterans Administration within the budget parameters.
a. What are you and the department doing to ensure that systems
like these, from non-traditional government vendors, are considered in
addressing the scheduling software program across the entire VA?
Response. VA will procure a commercial-off-the-shelf (COTS)
replacement for its medical appointment scheduling system from the
private sector. The Department is seeking a COTS scheduling system to
provide a resource management-based solution. VA chose a full- and
open-competitive acquisition strategy to benefit from the innovative
marketplace.
In addition, VA has worked closely with industry to ensure
requirements are clearly understood. VA conducted an ``Industry Day''
to brief industry representatives on VA's scheduling system needs. As a
result, VA received and responded to over 100 questions from industry.
After the successful Industry Day, VA met one-on-one with interested
vendors, during which the VA achieved a better understanding of the
marketplace, different vendor approaches, and associated risks. VA also
issued a draft of its request for proposal (RFP) in order to solicit
industry feedback to improve the language before release of the full
RFP.
b. What are the most important criteria you are looking for in the
selection of a national scheduling software solution?''
Response. In its meetings with industry and in the documents VA has
made publicly available, the following key criteria have been
emphasized:
Proactive resource management-based scheduling that
schedules staff, facilities, equipment
Transparency to balance supply with demand
- Provide single, consolidated view of resource availability
(e.g. one calendar for a clinician)
- Provide single, consolidated list of appointment requests
(e.g. single view of the patient)
- Improved transparency through richer data for reporting
Consistent implementation and visibility of business rules
to support scheduling policies and directives
c. ``What is your timeline for consideration and award of a
contract for a national scheduling software solution?''
Response. VA is planning to issue a RFP for the medical appointment
scheduling system under a full and open competition in the first
quarter of FY 2015. Offerors will have 45 days to respond from the day
of issuance. The solicitation may require a two-part demonstration of
capabilities: a written proposal and a technical demonstration to
scheduling staff. VA expects to award the contract within the second
quarter of FY 2015.
Question 17. I do have a bill for loan repayment of Psychiatrists
and other incentives to recruit mental health providers to the VA. I
understand recruiting and retaining Psychiatrists is a top need for VA.
Would a loan repayment help with this recruitment? (Right now it's
the discretion of the VISN on whom and how many get the loans) As you
may know I have a bill to do this.
Response. Yes. VA believes loan repayment would help with
recruitment and retention of Psychiatrists. The passage of recent
legislation would assist VA with the recruitment and retention efforts.
Specifically, the passage of Public Law 113-146, the Veterans
Access, Choice, and Accountability Act of 2014, increased the maximum
Education Debt Reduction Program (EDRP) loan amount from $60,000 to
$120,000. In addition, the Secretary has the ability to waive the cap
for specific critical clinical specialty positions, including the top
physician specialties of primary care, psychiatry, gastroenterology,
orthopedic surgery, emergency medicine, and cardiology; nurse
specialties of head nurse, staff nurse, nurse practitioner, mental
health and substance abuse, inpatient community living centers, and
certified registered nurse anesthetist. Furthermore, Section 408 of the
VA Expiring Authorities Act of 2014 allows VA to directly pay the
lenders for qualified loans. Therefore, the authority to provide a
higher level of loan repayment for psychiatrists is already in place
through the existing EDRP program.
Question 18. VA has suspended all VHA senior executive performance
awards for fiscal year 2014 and increased accountability for senior
leaders.
Do you expect to bring back these awards in 2015? If not, what is
the plan to attract and retain superior executive leadership in the
future.
Response. While it is the Secretary's prerogative to pay or
withhold performance awards, no final decision has been made for FY
2015 at this time. Since Senior Executive performance awards are based
on organizational results, as well as individual performance, it would
not be appropriate to predict final decisions one year in advance.
Regarding the Secretary's decision to approve no performance awards for
FY 2014 in VHA, the Secretary had significant performance indicators to
determine FY 2014 organizational results could not be accurately
validated based on performance.
______
Response to Posthearing Questions Submitted by Hon. Mazie Hirono to
Hon. Robert A. McDonald, Secretary, U.S. Department of Veterans Affairs
Question 19. What was the rationale behind the then-Deputy Under
Secretary for Health for Operations Management waiving the requirement
to certify compliance of VA's scheduling directive in May 2013 and does
VA plan to reinstate that requirement?
Response. At the time the requirement was waived, there was concern
that it was hard to reach full compliance with the scheduling directive
and also hard to maintain it. By a Medical Center Director certifying
in writing that they were in compliance, this puts them at risk if a
subsequent external audit or review found weaknesses. Directors felt it
was a no-win situation. The decision was made at a time when the
environment was characterized by performance measure and certification
fatigue. There are plans to reinstate the requirement in the new
scheduling directive, but this time it will be accompanied by
significantly better training of clinic managers and better tools to
monitor performance.
Question 20. How will the policy actions taken and to be taken by
VA be communicated to the Veteran and Veteran Service organizations? Do
you plan any changes to the policy as a result of this nationwide
review and how do you plan to communicate it to veterans and to
different generations of veterans?
Response. There are a number of important changes related to
improving access to health care that will be communicated to Veterans.
The changes are driven by policy decisions and by the Veterans Access,
Choice, and Accountability Act of 2014 (VACAA), which established the
Veterans Choice Program. With respect to the Choice Program, the
Department of Veterans Affairs (VA) will communicate information
regarding eligibility and Program operations directly to Veterans
through the mail, a new call center, press releases, and communications
on VA's main Web site, and communications on VA medical facility Web
sites. VA also anticipates Veterans Service Organization briefings and
town hall meetings at VA facilities to educate Veterans about any
changes that may impact them.
Question 21. In your testimony, you state ``where willful
misconduct or management negligence is documented, appropriate
personnel actions will be taken.'' At nearly 5 months after the
allegations at Phoenix surfaced, what appropriate personnel actions
have been taken and with the newly enacted authorities to dismiss
certain personnel, how will you exercise it to meet your commitment to
address misconduct at the VA?
Response. VACAA facilitates and promotes sustainable
accountability. For instance, the Act allows VA to resolve Senior
Executive Service (SES) removal actions more quickly than before. VA
has used the expedited SES removal authority in VACAA to remove the
Phoenix Director and other SES-level VA leaders. Now that the criminal
investigations at the Phoenix VAMC have concluded, VA is moving to
close out its administrative investigations of non-SES leaders there
and expects to issue final decisions in all Phoenix leadership cases
after the administrative investigations are concluded.
______
Response to Posthearing Questions Submitted by Hon. John Boozman to
Hon. Robert A. McDonald, Secretary, U.S. Department of Veterans Affairs
Question 22. Secretary McDonald, in the Veterans Access, Choice
and Accountability Act of 2014 (hereinafter ``the Choice Act''), that
Congress recently passed, there were provisions that significantly
expanded your ability to remove senior VA employees for poor
performance or misconduct. On August 26, 2014, the VA OIG published a
report that addressed the scheduling problem at the Phoenix VA as well
as other issues. In the report, it clearly states that executives in
the Phoenix VA were well aware that subordinate staffs were
manipulating wait times. I am also aware that a number of my colleagues
here in the Senate have expressed frustration that the former director
of the Phoenix VA Health Care system is still on paid administrative
leave. I understand your desire to ensure that all VA employees receive
due process and I appreciate that. However, I believe that in order for
you to make real reforms within the VA, there must be a change in the
institutional culture and to do so, I believe you have to hold people
accountable. I would like to know, what do you consider a ``fireable
offense,'' and how do you plan to implement this new authority that you
have?
Response. The Department is firmly committed to instituting a
culture of sustainable accountability. As we confront our challenges in
VA, it is also essential we empower employees to speak up when they see
wrongdoing, and protect them from unlawful retaliation. On June 4,
2014, VA announced new procedures to ensure that we fully consider
disciplinary action against managers and supervisors who commit
discrimination and retaliation against employees. VA will hold those
who violate this precept accountable. This is a Department-wide
responsibility. On August 22, 2014, the Secretary called for every VA
employee to reaffirm his or her commitment to the VA values--integrity,
commitment, advocacy, respect, and excellence (I CARE). Further, all
employees were reminded, in addition to demonstration of VA I CARE
values, failure to adhere to ethical, legal, and/or professional
standards of conduct may be considered as factors when evaluating
performance.
There is not a simple definition of a ``fireable offense.'' A
decision to terminate an individual is informed by several factors
including, but not limited to, (1) the seriousness of the offense; (2)
whether the offense was malicious or done for personal gain; (3)
whether alternative sanctions would work; and (4) whether or not the
employee is otherwise salvageable. Typically, if an employee otherwise
has a clean disciplinary record, such an employee would have to commit
an egregious act of misconduct in order to be removed on his/her first
offense. Serious offenses often involve breaches of institutional
values.
Regarding the new authorities provided in the Choice Act, VA has
developed a new policy codifying the process by which the Secretary
will determine when a Senior Executive Service (SES) employee's
performance or misconduct warrants removal or transfer to a non-SES
position.
The new policy will give the employee five business days
to review and reply to the evidence and charges supporting the removal.
VA's policy requires that a removal or transfer for
misconduct or poor performance be supported by substantial evidence.
The Merit Systems Protection Board will review any appeals against the
higher standard of a preponderance of the evidence.
The lengthier historic process will still apply to all disciplinary
actions taken against SES employees other than removal or transfer to a
GS position.
Question 23. Is the fact that senior officials at the Phoenix VA
were placed on paid administrative leave prior to Congress passing the
Choice Act prohibiting you from using the provisions contained in the
Choice Act to remove them?
Response. It should be noted that the Choice Act provisions apply
only to Senior Executives, not to non-Senior Executive Service leaders.
The Medical Center Director is the only Senior Executive among the
Phoenix VAMC leadership team. The fact that a Senior Executive was
placed on paid administrative leave prior to enactment of the Choice
Act should not preclude a removal action being taken under that
authority.
Question 24. The use of unofficial waiting lists was a prevalent
practice at the Phoenix VA and has proven to be a systemic problem
across the VA. What are you doing to ensure that this sort of problem
does not happen again?
Response. The use of an unofficial wait list is not an acceptable
practice. To ensure this problem is corrected, the Veterans Health
Administration (VHA) provided immediate remedial training to 9,000 key
staff from all networks in July and August 2014. This training
reinforces the appropriate policies and processes associated with
scheduling patients. Likewise, VHA is designing a clinic manager
training program which is scheduled to begin in early 2015 that will
include training on appropriate use of the Electronic Wait List (EWL).
To ensure the integrity of the access data in the input stage, VA
recently launched an automated access and scheduling audit tool
designed to monitor and flag any potential data integrity issues. This
tool is programed with a preset algorithm, designed by scheduling
subject matter experts that will score scheduling practices at each
facility and clinic and highlight those clinics that require additional
follow-up. This tool is available for use by each medical center and
Veterans Integrated Service Network (VISN) leadership team. This tool
is also being routinely monitored in VHA Central Office by a national
monitoring group and the VHA senior leadership team.
Additionally, VA has eliminated the unrealistic 14-day access
measure from all employees on the Executive Career Field Performance
Plan, Title 5 Performance Appraisal Program, and the Title 38
Proficiency Rating System. This action will eliminate incentives to
engage in inappropriate scheduling practices or behaviors. To reinforce
these measures, Medical Center and VISN Directors are conducting in-
person visits to all of their assigned facilities. These in-person site
inspections include observing daily scheduling processes and
interacting with scheduling staff to ensure all scheduling practices
are appropriate and allowing front line staff to provide unfiltered
feedback directly to the facility's and VISN's senior leadership team.
Question 25. Within the Phoenix VA, a number of medical areas
where identified as being deficient. Mental health and psychotherapy
where specifically mentioned. What has been done to correct this
problem and ensure continuity of care and increased access to
providers?
Response. As stated in the OIG report, Mental Health leadership had
been addressing these issues at the time of the OIG visit in April--
May 2014. The new Chief of Psychiatry successfully recruited 13
additional mental health-prescribing clinicians to the facility within
a seven-month period. He has also begun reorganizing the service. The
influx in new psychiatrists has provided an ability to assign patients
to a mental health provider and an availability of new and established
patient appointments.
As of early June 2014, Psychology leadership reported 11 vacancies
for which 9 candidates had been selected and were pending offer
acceptance, credentialing, privileging, and/or on-boarding. As of
November 2014, Psychology has eight remaining vacancies; seven of these
were new positions added in October 2014 (i.e., only one of the
positions from June 2014 remains unfilled). Of the remaining eight
vacancies, four have been selected and are in the onboarding process,
and four have not been selected yet. Phoenix VA Health Care System
(PVAHCS) has leveraged non-VA care via the TriWest/Patient-Centered
Community Care contract to obtain psychotherapy for patients who cannot
be seen within 30 days.
In addition to the increased staff, PVAHCS has concurred with the
four recommendations related to this issue which are listed in the OIG
Final Report and has developed action plans which are available for
review in Appendix K of the final report.
Question 26. The OIG report recommended that the VA Secretary
direct the Veterans Health Administration to establish a process that
requires facility directors to notify, through their chain of command,
the Under Secretary of Health when their facility cannot meet access or
quality of care standards. The report indicated that VHA has already
implemented this recommendation. Since this process has already been
implemented, has the VHA had to notify the Under Secretary of any
facilities that cannot meet access or quality of care standards? If so,
what facilities have made such a notification and for what reason?
Response. Issues related to access no longer solely depend on local
leadership raising the concern up through a chain of command. VHA has
increased its transparency by making data (described below) available
and easily accessible to the public and the entire organization.
Transparency of data facilitates timely, honest, and open discussion
throughout the organization, among leadership peers, among employees,
and among Veterans.
Twice monthly, VHA publishes data on access to care on a public Web
site (http://www.va.gov/health/access-audit.asp). Leadership at all
levels use the same data to determine trends, foretell access
shortfalls, and address underlying issues that impede Veterans' access.
These data include: the number of appointments scheduled at each
facility; the number of requested appointments that are on each
facility's EWL; the number of newly enrolled patients who have not yet
been scheduled by facility; and average wait times for mental health,
primary care, and specialty care at each facility, for both new and
established patients.
Additionally, VHA publishes a scorecard model for internal quality
of care benchmarking. The Strategic Analytics for Improvement and
Learning (SAIL) Value Model assesses 25 quality measures in areas such
as mortality, complications, and customer satisfaction, as well as
overall efficiency. SAIL benchmark tables can be found at http://
www.hospitalcompare.va.gov/docs/SAILData.pdf
Question 27. Since 2005, the IG has published 20 reports focused
on patient wait times and access to care issues. However, VHA has yet
to effectively address the issues associated with patient wait times,
inappropriate scheduling practices, and access to care. The IG has, in
total, received approximately 225 allegations regarding Phoenix VA and
roughly 445 allegations regarding similar issues related to wait times
at other VA facilities. It appears that this problem has been going on
for 9 years now and VA has continually failed to correct it. What is
your plan to effectively resolve this problem once and for all?
Response. Over the past 9 years, VA has considered and acted upon
each of the IG's reports and implemented changes as recommended.
However, it was not until the System-wide Access Audit, conducted in
May 2014, that VHA came to truly understand the full extent of the
problem. In retrospect, both the findings contained in the OIG reports,
and the remedial actions taken by VHA to address those findings, only
had limited impact on what we now know was a much larger systemic
issue. VA has taken immediate steps to address portions of what are
believed to be the underlying systemic issues.
In addition to those immediate actions, Secretary McDonald has set
a course to reshape the organization and reset the culture throughout
the Department. This effort will refocus the organization on the
Veterans.
Aided by the thoughtful audits of the OIG, VA will continue to
improve its access and availability to services for our Nation's
Veterans. Through continuing program evaluations VA will, over time,
ensure Veterans are receiving the care they have earned when, where and
in the manner they desire.
Question 28. I am pleased to see that VA is aggressively
recruiting new health care professionals in order to meet the needs of
our veterans. However, I remain concerned that VA is not utilizing
existing health care professionals in an efficient manner. Physicians
in the private sector consistently have higher caseloads than VA
physicians and more efficiently utilize nurses and physician
assistants. Simply put, a veteran does not need to see a doctor for
every health care need; nurses and physician assistants have the
training and expertise to address many heath issues which allows
physicians to focus on more serious and complex matters. What is the VA
doing to ensure that all the health care professionals employed by VA
are being utilized to the maximum extent practicable?
Response. VHA overhauled the primary care model in 2010 to
emphasize team-based care, called Patient Aligned Care Teams (PACT),
focusing on a teamlet (which includes a provider, registered nurse,
medical assistant (typically licensed practical nurse or health
technician) and clerical associate (typically a scheduling assistant)).
In addition, most PACT's also have a clinical pharmacist, social
worker, dietitian, and/or behavioral therapist available to provide
assistance. This focus on team-based care allows, among other things, a
distribution of workload among the whole team to ``share the care.''
This emphasis has been associated with increased utilization of
telephone care and secure messaging as non-provider team members play
important roles in patient care. VA is expanding primary care capacity
by adding new PACTs, focusing on team-based care, and utilizing all
staff in a manner that optimizes their capabilities.
Question 29. Secretary McDonald, a number of the senior positions
within VA are being filled by personnel in an ``acting'' status. Mr.
Griffin for example is the Acting Inspector General. Is this
problematic? Do you foresee this creating problems in implementing the
Choice Act?
Response. VA follows a formal process for placing an individual
into an ``Acting'' role. Typically there is a request with
justification provided for why a position must be filled in this manner
and why this is the most appropriate person to fill this role. There is
a defined time limit prescribed and finally there are a number of
senior level personnel who will review and eventually approve this
request.
The point of appointing ``Acting'' individuals into any given
position is to ensure continuity of on-going day-to-day operations. The
designation of individuals as ``Acting'' is needed to ensure someone is
performing the duties and overseeing the activities of the organization
or operational unit that is temporarily lacking permanent leadership.
The length of time an individual is designated as ``Acting'' varies,
and often cannot be predicted. For example, a person may be designated
as ``Acting'' in a leadership position while recruitment is ongoing,
the incumbent may be temporarily absent while on a rotational
assignment in response to critical Departmental needs in an alternate
location or position; on a developmental assignment, experiencing long-
term medical issues, or similar issue. Ensuring leadership is in place
to see to the day-to-day activities of an organization or operational
unit supports rather than harms the Department's ability to implement
the Choice Act.
______
Response to Posthearing Questions Submitted by Hon. Richard Burr on
Behalf of Hon. Jeff Flake to Hon. Robert A. McDonald, Secretary, U.S.
Department of Veterans Affairs
Question 30. During your confirmation hearing on July 22, 2014,
you stated that you intended to travel the Nation to meet with veterans
and staff at various VA facilities across the country.
a. Have there been any significant takeaways from these visits?
Response. The Secretary continues to travel to various Department
of Veterans Affairs' (VA) facilities to meet with Veterans, the VA
workforce (including whistleblowers), and other stakeholder groups
including local leadership from Veterans Service Organizations, our
Union partners, Congressional members and staff, and media. As he has
publicly stated at each visit, we must regain the trust of Veterans and
other stakeholders, improve service delivery, and set the course for
longer term excellence and reform. He has also asked employees to
reaffirm their commitment to VA's mission and core values (I CARE:
Integrity, Commitment, Advocacy, Respect, and Excellence).
At each visit, the Secretary has found that the overwhelming
majority of the VA workforce is dedicated to serving Veterans, and
cares deeply about the VA mission. He has made it clear that each
member of the workforce is critical to identifying barriers and
improving service delivery, and that he welcomes all constructive
input, including that of whistleblowers, who seek to improve service to
Veterans.
The Secretary has also found the Town Halls with Veterans and other
stakeholders extremely valuable in restoring trust and communication.
He originally directed all VA health care and benefits facilities to
hold a Town Hall event by the end of September 2014 to improve
communication with, and hear directly from, Veterans nationwide.
Congressional and state representatives, as well as other stakeholders
from these areas were invited to attend. He has since directed these
Town Halls be held quarterly.
Finally, the Secretary has also met with local VA leadership during
each site visit. Many have identified local barriers and other
challenges to improving service. The issues raised at these meetings,
together with others, are being both assessed and addressed as quickly
as possible. VA is aggressively implementing its Accelerated Access to
Care Initiative and the provisions of the Veterans Access, Choice, and
Accountability Act of 2014 (Choice Act). The Secretary also initiated a
national effort to recruit medical professionals into VA to address
staffing shortages.
b. Do you believe that the recommendations provided by OIG go far
enough in addressing some of the systemic issues plaguing the VA?
Response. VA greatly appreciates and supports the Office of
Inspector General's (OIG) extensive ongoing efforts to identify
systemic barriers to the access and high-quality care that the Nation's
Veterans have earned and deserve. OIG continues to review wait time and
scheduling issues at a large number of Veterans Health Administration
(VHA) facilities, and the Department will fully consider their
recommendations.
In addition to the OIG's recommendations, the Department will
receive input from other reviews such as those required by Choice Act.
The Department has also conducted various internal reviews.
This collection of insights has, and will continue to provide, VA
with important feedback as it addresses systemic issues related to
access and care shortfalls. VA is committed to restoring the trust of
Veterans and other stakeholders, and to improving access to high-
quality care. Comprehensive action is underway.
Question 31. This OIG report lists 24 recommendations aimed at
improving the quality of care for veterans. The VA has since concurred
with all of these recommendations and vowed to implement them. However,
as cited in this report and elsewhere, OIG notified the Veterans Health
Administration (VHA) in 2012 that staff at PVAHCS was not complying
with VHA scheduling policies.
a. Although the VA has known for some time about inappropriate
scheduling practices at facilities across the country, the problem has
yet to be remedied. Are you confident that the VA will successfully
implement the reforms outlined by OIG?
Response. VA has concurred with all recommendations and is working
hard to implement the reforms outlined by OIG. VA will make every
attempt to fully and successfully implement all reforms outlined by
OIG. At the same time it is important to understand that scheduling
appointments requires human interactions that can be subject to error.
Even with the best reforms VA cannot guarantee that all instances of
appointment scheduling will be error-free.
b. Are there any reforms that you believe are necessary but where
omitted by the OIG report?
Response. OIG did a thorough job of making recommendations. In the
course of following the recommendations, VA will make every attempt to
write clear and comprehensive policy, design effective training, and
implement oversight that complies with OIG recommendations.
Question 32. As you know, the Veterans Access, Choice, and
Accountability Act of 2014 was recently passed by Congress and signed
into law by the president. Among other things, the purpose of this
legislation is to provide the VA with increased latitude to remove
agency employees when necessary.
a. Do you believe that this legislation provides the VA with
adequate authority to remove underperforming employees?
Response. VA notes this law only applies to Senior Executive
Service employees, which constitute less than 1 percent of VA's
workforce. One of the goals of the Senior Executive Service is to
ensure accountability for efficient and effective government. This is
achieved by holding senior executives accountable for their individual
and organizational performance through an effective and rigorous
performance appraisal program, as well as taking immediate steps to
address performance or conduct issues. This legislation provides that
authority. While VA previously had authorities to take action to hold
employees and executives accountable for performance or misconduct, the
amendments will strengthen or enhance those authorities.
b. Will the added hiring and firing flexibility enable the VA to
significantly improve the quality of care that it delivers to veterans?
Response. Removing Senior Executives who are not performing as
expected by the Secretary will ultimately be a benefit to Veterans and
the delivery of care. Added hiring flexibilities will allow the VA to
have the necessary staffing required to improve the quality of care
delivered to Veterans.
______
Response to Additional Posthearing Questions Submitted by Hon. Richard
Blumenthal to Hon. Robert A. McDonald, Secretary, U.S. Department of
Veterans Affairs
funding to hire additional va health care providers
I participated in a VA Town Hall Meeting in Newington, Connecticut,
along with William Streitberger, the Director the Hartford VA Regional
Office, and Gerald F. Culliton, the Director of the VA Connecticut
Healthcare System. This Town Hall offered Connecticut veterans, family
members and constituents the opportunity to provide the VA with
feedback and recommendations on local operations and programs.
During the Town Hall, we heard from K. Robert Lewis, a Veterans'
Service Officer from the Veterans of Foreign Wars. He shared with the
audience his understanding that many veterans with the VFW have
received outstanding service from Connecticut VA facilities, but that
the lack of providers remains a pervasive challenge that has hindered
our veterans' access to care. I know that the Veterans Access to Care
Act authorized $5 billion to enable the VA to hire additional health
care providers and clinical staff as well as provide enhanced
incentives to attract more health care professionals to the VA.
Question 33. Secretary McDonald, how will you implement this
funding to demonstrate your continued commitment to hiring new
physicians, nurses and staff to address these challenges? What, if
anything, is the impediment to hiring mental health professionals and
how can we ensure that our veterans receive the mental health
assistance they require?
a. How will you implement this funding to demonstrate your
continued commitment to hiring new physicians, nurses and staff to
address these challenges?
Response. The Office of Finance will distribute the available
funding per the implementation plan associated with individual medical
center staffing needs.
b. What, if anything, is the impediment to hiring mental health
professionals and how can we ensure that our veterans receive the
mental health assistance they require?
Response. In order to provide Veterans with the services they need
and desire to aid in recovery from mental health issues, the Department
of Veterans Affairs (VA) must have access to the appropriate number of
mental health professionals who can deliver their services to sites
where the Veterans want to receive their care. A significant challenge
in meeting the needs of Veterans is the rapid growth rate in demands
for mental health services. Between 2005 and 2013, the number of
Veterans who received mental health care from VA grew by 63 percent,
over three times the rate of increase seen in the overall number of VA
users (Figure 1). As a consequence, the proportion of Veterans
receiving mental health services has increased from 19 percent in 2005
to 26 percent in 2013. The growth in the number of mental health
encounters or treatment visits has been even more dramatic; mental
health encounters have increased from 10.5 million in 2005 to 18.0
million in 2013--a 71-percent increase.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Figure 1. Percent growth since 2005 in numbers of Veterans using VA
mental health services and VA health care services overall.
The recent rapid growth in the number of Veterans seeking mental
health treatment in VA has posed challenges in the area of staffing. In
Figure 2, the growth in numbers of Veterans using mental health
services is depicted by the solid line, which shows an increase from
897,643 in 2005 to 1,464,700 in 2013. (The number of patients is
expressed in terms of hundreds in order to show staff and patient
numbers on the same graph. For example, 10,000 on the vertical axis
represents 1,000,000 patients.) Current projections for future growth
show a somewhat slower rate than has been experienced over the past
decade.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Figure 2. Growth in annual numbers of patients using mental health
services and in outpatient and inpatient full-time equivalent staffing
levels since 2005.
This graph also shows the growth in numbers of mental health
clinical staff, measured in terms of the full-time equivalent (FTE)
staff providing outpatient and inpatient treatment. Consistent with the
increased reliance on outpatient care, the inpatient mental health
staff FTEs began to level off after 2009. The hiring of outpatient
mental health clinical staff grew somewhat faster than mental health
patient numbers through 2010 and then began leveling off. A 2012 hiring
initiative resulted in gains in both inpatient and outpatient staff
FTEs.
Thus, VA has been addressing the need to hire and retain new mental
health staff to meet new demand for some time. The recent hiring
initiative allowed mental health staffing growth to keep up with growth
in demand. With expected ongoing increases in demand, VA will need to
keep hiring. However, a focus on the overall ratio of mental health
staff to Veterans for the entire system does not fully identify or
address a different and critical issue for VA. Unfortunately, the areas
with lower availability of mental health professionals often coincide
with sites where VA is faced with the challenge of meeting high and/or
growing Veteran demand. VA is working on a variety of mechanisms to
meet that hiring challenge including: (1) use of recruitment and
retention incentives; (2) use of loan repayments; (3) creation of a
mechanism for higher, overall salaries for VA psychiatrists; and (4)
consideration of other approaches to recruit and retain necessary
staff. VA is also working to expand targeted use of tele-mental health
services.
While VA has been effective, overall, in hiring on a nationwide
basis, putting those resources to maximum use also depends on having
appropriate space in which professionals can work. While VA is
increasing use of mental health services delivered into the Veteran's
home, use of extended hour clinics (so that available space can be more
fully used), and use of non-VA care to decrease the impact of
restricted space, the need for rapid expansion of office and group room
space at some sites remains. VA is pushing forward with space
improvements to address this need.
Staff must also be appropriately trained and equipped. As staff is
hired, plans are being made to meet their needs for computers and other
supports for modern practice of mental health care. Already, over 6,000
providers have been trained in evidence-based psychotherapy, and VA is
exploring ways to expand that training to even more clinicians.
Finally, VA is looking toward the future by engaging in projects
aimed at measuring and predicting capacity for various aspects of care
including mental health. VA capacity to deliver mental health care
refers to the availability of resources required for timely delivery of
high-quality mental health services. A work group has embarked on a
plan to assess and understand the numerous facets of capacity and their
impact on the delivery of mental health care in a large, complex health
care system. Continued work will make prediction and management of VA
mental health capacity more sophisticated in the future.
Having sufficient staff with sufficient space, equipment, and
training does not guarantee that Veterans will receive all of the
appropriate care they need. VA, through the Office of Mental Health
Operations (OMHO), Mental Health Services and collaborating units, sets
policy for care and monitors compliance with those policies. Each year,
one-third of facilities are surveyed by a well-trained team of clinical
experts using a semi-structured interview as well as a review of
specific clinical and administrative measures that assess access,
efficiency, staffing, and other important dimensions of mental health
service functions. These surveys lead to strategic action plans to
address any shortcomings in performance or resourcing. Progress on
these plans is reviewed quarterly by OMHO staff who work in close
collaboration with Veterans Integrated Service Network (VISN) and local
mental health leaders. OMHO uses its three program evaluation centers
to monitor important metrics, including Veteran and provider
satisfaction, in a wide variety of VA Mental Health programs. The
program evaluation centers have created easily accessible Web sites
where individual VISNs and facilities can monitor their own performance
regularly. Finally, VA has created mechanisms by which productivity of
providers of various disciplines can be monitored at local and higher
levels, so that facilities and VISNs can take action to optimize the
amount of care that is provided by staff. Taken together, these
mechanisms provide VA leadership many indications of how the VA mental
health system is functioning as a whole and at local levels.
hiring additional veterans
I have additionally spoken to members of my Veterans' Advisory
Council of Connecticut Veterans and community leaders who have concerns
regarding VA hiring practices. These constituents expressed the
difficulties that many qualified Veterans encounter in applying for
jobs at the VA. I am concerned that VA, which should lead the Federal
Government, does not hire as many Veterans as it should.
Question 34. Secretary McDonald, as you move forward to hire new
staff for VA facilities, what is your operational plan to hire more
veterans, specifically members of the National Guard and Reserve?
Response. The percentage of new Veteran hires in government is at
its highest since the mid-1970s. VA is helping to lead the way in
Veteran hiring and now ranks second only to the Department of Defense
in the number of Veterans in our workforce. As of the end of fiscal
year (FY) 2014, we had a total of 113,432 Veterans on board, which
accounts for 32.66 percent of our workforce.
With the passage of the Veterans Access, Choice, and Accountability
Act of 2014, we are executing an extensive recruitment plan to increase
access to care through the hiring of physicians and other medical
staff. This effort calls for VA to hire tens of thousands more medical
professionals--an ambitious undertaking, especially considering the
current nationwide shortage of certain medical professionals. Given the
scope of this effort, and the often limited supply of Veteran medical
professionals, VA has determined that we will focus our goal for the
percentage of Veterans in our workforce to 35 percent by the end of FY
2017. This short-term goal is not only attainable and realistic; we are
confident that we can find some of the best and brightest Veterans to
join our workforce to achieve this hiring goal. Our Veteran Employment
Services Office (VESO) will work collaboratively with our
Administrations and Staff Offices to meet this hiring goal. In October,
VESO participated in 30 Veteran-focused hiring events nationwide, which
include several disabled Veteran-specific events and employment
briefings for transitioning Servicemembers including National Guard and
Reserve forces and attend Yellow Ribbon Program events. Our VESO office
provides Federal employment services to all Servicemembers and
Veterans. We are also actively participating in an inter-agency work
group focused on increasing our women Veteran population in the Federal
workforce through targeted strategies. In addition, as a part of the
hiring initiative, The Secretary has traveled to several Medical
Centers and Medical Schools to recruit medical professionals to join
the VA.
west haven va
Many Connecticut veterans who utilize the West Haven VA facilities
are pleased with the quality of care they receive and hope to maintain
access to that level of care, even while capacity is expanded. The West
Haven medical facilities must have the funding to make necessary
upgrades in infrastructure and capacity to build more facilities and
ensure that it can keep pace with the needs of Veterans, especially
female Veterans.
Question 35. Secretary McDonald, how do you plan to bring the West
Haven facilities into the 21st century and will you ensure that the
West Haven facility is not overlooked in capital improvements?
Response. VA Connecticut Health Care System (VACTHCS) is actively
using the strategic planning process to identify and prioritizing
critical infrastructure reinvestment needs of its campuses in West
Haven (WH) and Newington (NEW). In support of this initiative, VISN 1
is in the process of completing a VISN-wide master plan that is
intended to help facilitate better planning and utilize all capital
solutions to ensure Veterans needs are met.
The plan includes both short range and long range initiatives to
address the needs of the Veterans as well as the required
infrastructure improvements that support the mission. Below are some of
the projects and initiatives VA is currently pursing. This list will
change as new issues arise and new requirements are encountered.
In addition to the planned project work, VACTHCS continues to
improve its infrastructure and space through the active construction
and maintenance. Many new improvements, repairs, renovations were
successfully accomplished this past year.
Projects in process
Infrastructure upgrades
- Boiler and Domestic Water improvements 689-12-052 (WH)--
Replaces antiquated water pumps.
- Replace 120,000 Gallon Oil Tank 689-14-101 (WH)--Replaces
current oil tank that has corrosion issues.2
- 010 Boiler Corrections 689-10-213 (WH)--Corrects safety
deficiencies and compliance issues.
- Replace Load Center 1A, 689-13-151 (WH)--Replacement of
electrical load center which supplies the facility main
electrical feed.
- Electrical Control Systems upgrade, 689-13-155 (WH)--
Upgrades to existing electrical systems.
- Replace Load Center 2&5, 689-13-154 (WH)--Replacement of
electrical load centers in poor condition.
- Building Envelope Repairs B1 & 2, 689-12-202 (WH)--Corrects
water infiltrations through windows that are in urgent need of
replacement.
- Supply Backup Power for Buildings 3, 4, 5, 27 & 34, 689-13-
150 (WH)--Installation of emergency generator power feeds.
- Building 36 Structural Corrections, 689-12-001 (WH)--Repair
structural deficiencies in Bldg. 36.
- Replace Roofs B35, 35A & 36, 689-12-120, (WH)--Replaces
roofs
- Building 27 & 34 Heating, Ventilation and Air Conditioning
Corrections, 689-14-002, (WH)--Current unit has exceeded its
useful life.
- OR Heating, Ventilation, and Air Conditioning, 689-10-121
(WH)--replaces deteriorating Operating Suite HVAC components.
- Correct Electrical Deficiencies Phase 2, Veterans Health
Administration-689A4-2013-10500, (WH)--Corrects deficiencies
and installs back up separation requirements.
- (Approved and in design or pending construction) Expand
Primary Care Clinic, 689-402, (NEW)--This project will add a
single level addition to the northwest corner of Building 2E
and renovate the first floor of Building 2C to accommodate the
expansion of the Primary Care Clinic by approximately 9,691
square feet.
- In-Patient Unit Rehabilitation, 689-12-102, (WH)--This
project will completely renovate an existing outdated medical/
surgery ward in building 1, 4th floor, east side.
- Psych Emergency Department (ED) Expansion, 689-390, (WH)--
Project will add an approximately 12,000 square feet addition
adjacent to the existing Medical ED and renovate 1200
additional square feet.
- Replacements of high tech/high cost equipment and upgrades
to Catherization Lab, X-Ray, and Computed Tomography Scanners.
Projects identified through the planning process for future
implementation as funding allows:
Infrastructure upgrades
- Electrical Deficiencies Phase 2, (WH)--Addresses
deficiencies (Arc flash condition) identified in electrical
study.
- Chiller Plant (WH)--Address undersized and antiquated
chilled water distribution system feeding the campus.
- Elevator Replacements, (WH/NEW)--This project will address
outdated and aging elevators systems.
- Replace Roofs B1, 2, 11, 12, 15 & 16--NEW B6, 7 & 8
- SPS Air Handler Replacement, (WH)--Corrects environmental
conditions in the Sterile Processing Service.
- Water Treatment System, (WH/NEW)--This project will help
address the aging pipes and plumbing systems throughout VACTHCS
and activate a water treatment system.
- Correct and Upgrade Exterior, PH1 689A4-12-211, (NEW)--
Corrects building envelope facade which is compromised and
causing water infiltration.
- Domestic Water and Sanitary Main Pipe Replacements, (WH)--
Replaces aging pipes and corrects deficiencies.
Patient/Safety/Environmental upgrades
- Surgical Core (WH)--the project consolidates the operating
room and other surgical and related services such as the
sterile processing service and patient acute care unit.
- Parking Garage (WH)--Design and construction for a 409 car
parking garage. Project will greatly enhance access to care due
to inadequate parking spaces.
- Nursing Home--Conceptual project to address the lack of
community living center beds. Project would greatly enhance
access and quality of care.
______
Response to Additional Posthearing Questions Submitted by Hon. John
Boozman to Hon. Robert A. McDonald, Secretary, U.S. Department of
Veterans Affairs
Question 36. The VA IG report details the death of a number of
veterans. Has VA done anything to assist and support the surviving
spouses and families of veterans whose deaths were reported by the IG?
More specifically, have these spouses and family members received
counseling from the VA about any benefits that they may be entitled to?
Response. The Phoenix Regional Office has attempted to contact all
next of kin of deceased Veterans identified in the OIG Report. The
Regional Office provided benefits information to the individuals it was
able to reach and answered additional benefits-related questions.
Question 37. At the macrolevel, does VA have a system in place to
advise surviving spouses and family members of whether they qualify for
benefits and to assist in filing for such benefits? Especially veterans
who are in the care of the VA at the time of death? If a veteran is
terminally ill and receiving end of life care from the VA, does the VA
proactively provide assistance to the spouse/family of that veteran to
help prepare them once their loved one passes?
Response. VBA's Pension and Fiduciary Service and regional offices'
Public Contact employees work closely with the Veterans Health
Administration and other stakeholders to conduct outreach for survivors
and ensure they are aware of benefits they may be eligible to receive.
Survivors can access information on VBA benefits by contacting VBA call
center agents at 1-800-827-1000, by appearing in person at a VA
regional office, or by mailing or emailing a request for information or
assistance to VBA. VBA's call center agents and public contact
employees are trained to provide one-on-one guidance to survivors to
help them understand their benefits and assist them through the process
of submitting a claim for benefits. Spouses of Veterans who are under
care in one of VA's medical facilities may contact the facility's
Office of Decedent Affairs, which also works closely with the family to
assist with benefits and guide them through the process.
VBA has developed fact sheets detailing its benefit programs to
assist Veterans and their family members. These fact sheets include
survivor's benefits and application instructions, and are available at
http://www.benefits.va.gov/BENEFITS/factsheets.asp. In addition, VBA
has taken steps to automate the payment of certain benefits to
survivors (Veteran's benefit payment for the month of death, burial
allowance, and some dependency and indemnity compensation) when it
receives notice of a Veteran's death. This automation ensures that
survivors receive the benefits they need as quickly as possible during
the difficult time that follows a Veteran's death.
Chairman Sanders. Mr. Secretary, Dr. Clancy, thank you very
much for being with us. Thank you for the hard work that you
are putting in right now and for the changes that we are
seeing.
This hearing is now adjourned.
[Whereupon, at 12:35 p.m., the hearing was adjourned.]
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