[Senate Hearing 113-657]
[From the U.S. Government Publishing Office]





                                                        S. Hrg. 113-657

                      THE STATE OF VA HEALTH CARE

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

                                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

                              ----------                              

                           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

                              ----------                              


                       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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