[Senate Hearing 114-686]
[From the U.S. Government Publishing Office]
S. Hrg. 114-686
TOMAH VAMC: EXAMINING PATIENT CARE AND ABUSE OF AUTHORITY
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FIELD HEARING
BEFORE THE
COMMITTEE ON
HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
UNITED STATES SENATE
ONE HUNDRED FOURTEENTH CONGRESS
SECOND SESSION
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MAY 31, 2016
__________
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COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
RON JOHNSON, Wisconsin Chairman
JOHN McCAIN, Arizona THOMAS R. CARPER, Delaware
ROB PORTMAN, Ohio CLAIRE McCASKILL, Missouri
RAND PAUL, Kentucky JON TESTER, Montana
JAMES LANKFORD, Oklahoma TAMMY BALDWIN, Wisconsin
MICHAEL B. ENZI, Wyoming HEIDI HEITKAMP, North Dakota
KELLY AYOTTE, New Hampshire CORY A. BOOKER, New Jersey
JONI ERNST, Iowa GARY C. PETERS, Michigan
BEN SASSE, Nebraska
Christopher R. Hixon, Staff Director
David N. Brewer, Chief Investigative Counsel
Kyle P. Brosnan, Counsel
Brian M. Downey, Senior Investigator
Scott D. Wittmann, Investigator
Gabrielle A. Batkin, Minority Staff Director
John P. Kilvington, Minority Deputy Staff Director
Brian F. Papp, Jr., Minority Professional Staff Member
Laura W. Kilbride, Chief Clerk
Benjamin C. Grazda, Hearing Clerk
C O N T E N T S
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Page
TUESDAY, MAY 31, 2016
Opening statements:
Senator Johnson.............................................. 1
Senator Baldwin.............................................. 3
Congressman Kind............................................. 17
Congressman Walz............................................. 19
Prepared statements:
Senator Johnson.............................................. 33
Senator Carper............................................... 37
Senator Baldwin.............................................. 40
WITNESSES
Hon. Sloan D. Gibson, Deputy Secretary, U.S. Department of
Veterans Affairs; accompanied by Dr. Gavin West, Senior Medical
Advisor, Clinical Operations................................... 6
Hon. Michael J. Missal, Inspector General, U.S. Department of
Veterans Affairs; accompanied by Dr. John D. Daigh Jr.,
Assistant Inspector General for Healthcare Inspections......... 10
Alphabetical List of Witnesses
Gibson, Hon. Sloan D.:
Testimony.................................................... 6
Prepared statement........................................... 44
Missal, Hon. Michael J.:
Testimony.................................................... 10
Prepared statement........................................... 58
APPENDIX
Majority Staff Report............................................ 63
Minority Staff Views Memorandum.................................. 439
Responses to post-hearing questions for the Record from:
Mr. Gibson................................................... 443
Mr. Missal................................................... 454
TOMAH VAMC: EXAMINING PATIENT CARE AND ABUSE OF AUTHORITY
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TUESDAY, MAY 31, 2016
U.S. Senate,
Committee on Homeland Security
and Governmental Affairs,
Tomah, WI.
The Committee met, pursuant to notice, at 10 a.m., at
Cranberry County Lodge, 319 Wittig Road, Tomah, Wisconsin,
54660, Hon. Ron Johnson, Chairman of the Committee, presiding.
Present: Senator Johnson, Senator Baldwin, Hon. Tim Walz,
and Hon. Ron Kind.
OPENING STATEMENT OF SENATOR RON JOHNSON
Senator Johnson. This hearing will come to order.
I think it would be appropriate to start the day, in light
of Memorial Day being yesterday, and in light of the tragedies
of some of the finest among us, suffering at the hands of
people that should be taking care of them, if we can start this
hearing with a moment of silence?
If you will please join me?
Thank you.
I would also like to ask anybody who has served in
military, and, quite honestly, their family members as well,
because this is a service and sacrifice that affects the entire
family, if you could please rise and be recognized?
Thank you all for your service and sacrifice. The purpose
of this hearing is to make sure that the rest of America honors
its promise to you. That's what really is the heart of this
hearing. I truly want to thank everybody who as appeared and
attended this hearing today.
I want to, in particular, thank the surviving family
members of Jason Simcakoski, Thomas Baer, Chris Kirkpatrick,
and Kraig Ferrington.
In March of 2015, we held a hearing where the family
members stepped forward and whistleblowers stepped forward and
provided powerful testimony. And, it was powerful testimony. We
heard from Dr. Noelle Johnson, Mr. Ryan Honl, Marv and Heather
Simcakoski, and Candace Delis. I have to believe that their
testimony had an effect on the officials that were present that
day from the U.S. Department of Veterans Affairs (VA).
It is that type of testimony, it is that type of
highlighting a problem that is going to be required if we are
going to honor the promises of the finest among us.
I do want to thank my staff for doing, I think, an
extraordinary job of laying out the findings of a very
rigorous, a very comprehensive investigation into how exactly
the problems within the Tomah healthcare facility went on for
so long without being corrected.\1\
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\1\ The Majority Staff Report appears in the Appendix on page 63.
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I do encourage everybody, because I think we have a couple
of hundred copies, to grab one and read all 359 pages. It lays
out exactly what happened with, quite honestly, not all the
information.
I do want to say that certainly it has been my experience,
because I have traveled around the State of Wisconsin and
visited VA healthcare facilities, the vast majority of the
doctors, of the nurses, of the administrators are doing an
excellent job. They are highly concerned about the finest among
us, about our veterans. And, they are doing everything they can
to honor those promises.
But the fact of the matter is, they are working within a
single-payer, government-run bureaucratic healthcare system and
there just are inherent problems. For example, inherent
problems of accountability. Inherent problems, unfortunately,
within an Office of Inspector General (OIG) that was not living
up to its mission. Who, I would say, was captured by the VA
itself.
So, the Office of Inspector General under Richard Griffin
was loyal to the VA instead of being loyal to the finest among
us and to the American public.
This Committee, in particular, the Senate oversight
committee, relies on independent and transparent Inspectors
General (IGs). Government relies on them. The only hope we have
of fixing problems is if you have an Inspector General's office
be the independent, transparent watchdog actually doing its
job.
And, what is very apparent in our 350 page report and the
almost 4 or 5,000 supporting documents is that for years the
Office of Inspector General from the VA did not do its job.
And, what is an even greater tragedy is that these
tragedies here at Tomah, I believe, could have been prevented,
had the Office of Inspector General done its job.
As far back as 2004, Dr. David Houlihan had been referred
to as Candy Man. A number of people, as far back as 2008 and
2009, were trying to raise the alarm to a number of
Departments, a number of Agencies, a number of Offices. And
yet, somehow those alarms did not go public.
I do want to play real quickly, if people are ready, and
you can follow along on page 48, there were logs that Heather
Simcakoski asked us to basically use the Capitol Police to get
into her husband's cell phone to get a record of his call logs.
Now, during the course of our investigations, we contacted
the Federal Bureau of Investigation (FBI) about potential
contacts as it related to Tomah VA. They claimed there was no
contact. And yet, we actually have a voice from a message left
by a member of the FBI, which I would like to play right now if
we can.
[Audio]. Jason, this is Andy Chapman from the FBI returning
your call. My phone number is (608) 782-6030. Thank you. [End
of audio].
Now, we asked representatives of the FBI and the Drug
Enforcement Agency (DEA) to appear today and they declined.
They also continue to convey to this Committee, to our staff,
that they have no record of ever having been contacted by Jason
Simcakoski. I find that puzzling. I find it troubling.
Again, the failure of the Office of Inspector General to
live up to its mission was really at the root cause of why
these problems continued to go on for so long.
I do want everybody to refer to page 208 and 209, because I
think this is a classic example of how the Office of Inspector
General, in their inspection, in their investigation here,
narrowed its scope, refused to look beyond its scope, and, as a
result, did not do its job.
In 2008, according to our report, during its site visit,
this is the first site visit directed by Dr. Alan Mallinger to
the Tomah VA following reports that began in 2011. The hotline
reports. During its site visit to the Tomah Veterans Affairs
Medical Center (VAMC), VA Office of Inspector General officials
interviewed both Dr. Houlihan and Deborah Frasher. During the
interviews, both Office of Inspector General physicians and
Special Agent Porter of the VA OIG's criminal division observed
that Dr. Houlihan and Ms. Frasher appeared to be impaired.
Now, unfortunately, during that initial investigation
visit, Mr. Mario DeSanctis was not present. So, the Inspector
General's team held a phone conference with Mr. DeSanctis, and
in 2009 you can read how they informed Mr. DeSanctis about
their concern with Dr. Houlihan and Nurse Frasher potentially
being impaired, potentially being drug users. There are
numerous whistleblower reports that also suspected that Dr.
Houlihan and Nurse Frasher were drug users.
I want people to read exactly what they Office of Inspector
General did. All they did was inform Mr. DeSanctis and suggest
that Mr. DeSanctis perform drug tests on those two individuals.
We have no idea whether those drug tests were ever performed. I
would think, if they were, back in 2012, these tragedies might
have been prevented.
So, again, the bottom line of what this report shows is it
was the failure of the Office of Inspector General and the
failure of other agencies and offices to actually highlight the
problems that they were made aware of that allowed these
tragedies to occur.
And, we will get into this further in terms of the
testimony and our questions to it.
I do ask that my written prepared statement be entered into
the record\1\ without objection.
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\1\ The prepared statement of Senator Johnson appears in the
Appendix on page 33.
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And, with that, to Senator Baldwin.
OPENING STATEMENT OF SENATOR BALDWIN
Senator Baldwin. Thank you. Thank you, Chairman Johnson. I
want to thank you for organizing this hearing today and I also
want to add my words of appreciation to your staff, Senator
Carper's staff and to my staff in terms of the undertaking that
resulted in this work product. It is a very significant
investment on their part and we appreciate that.
I think the fact that we are both here again today sends an
important message to this community that we will continue to
work across the partisan aisle in order to address the problems
at the Tomah VA. In fact, I would describe it as: there is no
aisle.
As Americans, we are united. We are united by an eternal
bond with the families and friends of our fallen. And, we are
also united by the sacred trust that we have with our veterans
and their families.
Today, as we hear the story of how that sacred trust with
our veterans and their families has been broken, it is
important for us to keep in mind what unites us.
One profound thing that I have learned about the tragic
problems at the Tomah VA is that veterans, their families, and
whistleblowers all want the same thing. They want answers and
accountability, but most importantly they want solutions to the
problems at the Tomah VA so that these sort of tragedies never
ever happen again.
What I am committed to is fixing what has been broken. What
I am focused on is restoring the sacred trust that we have with
our veterans and their families.
The Committee's reports makes clear much of what we have
known for some time. The problems at the Tomah VA have had
tragic and preventable consequences.
The report sheds light on the failures surrounding the
deaths of Kraig Ferrington, Dr. Christopher Kirkpatrick, Jason
Simcakoski and Thomas Baer. What this report can never do is
repair the damage that their losses have had on families, many
of whom are here with us today.
It is just as clear to me today, as it was a long time ago,
that the VA prescribed Jason Simcakoski a deadly mix of drugs
that led to his death. And, those responsible at the Tomah VA
for this tragic failure should have been held accountable long
ago. In fact, they should have been accountable before Jason's
death.
The record is clear, for far too long, serious problems
have existed at the Tomah VA and they were simply ignored or
not taken seriously, as they should have been, by the VA and
the VA Inspector General.
My office was just one of many voices who were trying to
expose the problems at the VA.
When my Senate office was first contacted in March 2014
with complaints about the Tomah VA, including prescribing
practices, they came from an anonymous whistleblower. Someone
who still remains anonymous today.
We immediately brought those concerns to the Tomah VA and
then to the VA Office of Inspector General, and then to the
U.S. Department of Veterans Affairs headquarters in Washington,
D.C.
Four months prior to Jason's death, I called for a full
review and investigation from the Tomah VA.
Two months prior to Jason's death I called for a full
review and investigation from the U.S. Department of Veterans
Affairs and the VA Office of Inspector General.
On August 30, 2014, Jason tragically died at the Tomah VA
as a result of what was medically deemed, mixed-drug toxicity.
The Simcakoski family lost a son, a husband, a father, and
we lost somebody who faithfully served his country.
If there is one thing that I want to come out of this
hearing and one thing that comes from this report, I want it to
be this. I want everyone to hear the voice of Jason's wife
Heather who said, and I quote, ``When I look back at the past,
I want to know we made a difference. I want to believe we have
leaders in our country who care. I want to inspire others to
never give up because change is possible.''
Jason's family, just like veterans and their families in
this community and communities across Wisconsin, are not
interested in finger pointing and a blame game and neither am
I. That is why over the past year I have focused on solutions
to the problems at the VA. I have worked across party lines to
advance reforms that will improve transparency, strengthen
protections for whistleblowers, and to provide stronger
oversight of VA prescribing practices.
I authored a reform that was recently signed into law which
requires the VA Inspector General to submit reports to Congress
and make them available to the public. That is the standard
that must now be met.
Last year, I had the honor of working with Jason's family
to develop legislation to provide the VA with the tools that it
needs to prevent this type of tragedy from occurring to other
veterans and their families.
One year ago, I introduced this bipartisan legislation in
Jason's name that earned the support of many veterans service
organization. And, I am so proud, Senator Johnson, to have you
join in this effort.
I am pleased that the House of Representatives recently
passed a version of Jason's bill and I am equally grateful to
members of the Senate Veterans' Affairs Committee for their
bipartisan support of Jason's bill, the Jason Simcakoski
Memorial Opioid Safety Act. It is a critical reform and it
continues to move forward. Families like Jason's have a story
to tell, and it needs to be heard, and the movement of their
legislation is strong evidence that their voice is being heard.
My goal is to put these reforms in place to prevent Jason's
tragedy from ever happening to another veteran or any of our
veterans' families.
Change is indeed possible. Heather's words inspire me and
it is my hope that they will inspire all of us to work together
and to prevent these problems and tragedies from ever happening
again.
I thank you, Senator Johnson, for providing me with this
opportunity to join you today and I look forward to continuing
our work together.
Senator Johnson. Thank you, Senator Baldwin.
Senator Carper, who is our Ranking Member of the Committee,
has a statement\1\ and a Minority Views Memo\2\ that he would
like in the record without objection.
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\1\ The prepared statement of Senator Carper appears in the
Appendix on page 37.
\2\ Minority Views Memo submitted by Senator Carper appears in the
Appendix on page 439.
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It is the tradition of this Committee to swear in
witnesses, so if you will all four rise and raise your right
hand?
Do you swear that the testimony that you will give before
this Committee will be the truth, the whole truth and nothing
but the truth, so help you, God?
Dr. West. I do.
Mr. Gibson. I do.
Mr. Missal. I do.
Dr. Daigh. I do.
Senator Johnson. Please be seated.
Our first witness is Sloan Gibson. Mr. Gibson is the Deputy
Secretary of the Department of Veterans Affairs. Deputy
Secretary Gibson is accompanied by Dr. Gavin West, Senior
Medical Advisor of Clinical Operations, Department of Veterans
Affairs. Mr. Gibson.
TESTIMONY OF THE HONORABLE SLOAN GIBSON,\1\ DEPUTY SECRETARY OF
THE U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY DR.
GAVIN WEST, SENIOR MEDICAL ADVISOR OF CLINICAL OPERATIONS, U.S.
DEPARTMENT OF VETERANS AFFAIRS
Mr. Gibson. Let me begin by expressing my heartfelt
sympathy to the Simcakoski family. I know that no words can
ease the pain of your loss, but I would be remiss if I did not
recognize the courage and the compassion and the deep devotion
that you have displayed in all the work that you have done
since Jason's death to make real difference in the lives of
many other veterans.
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\1\ The prepared statement of Mr. Gibson appears in the Appendix on
page 44.
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Thank you and God bless you.
I am accompanied today, as you mentioned by Dr. Gavin West.
I wanted to point out, prior to his appointment to the
responsibilities you have described, Dr. West served as the
Chief of Primary Care and Associate Chief of Medicine,
accountable for the delivery of evidence-based, high-quality,
patient-centered care across VA. He continues to practice
medicine at the Salt Lake City VA Healthcare System where he
teaches medical students and treats veterans in primary care
with a focus on pain management and substance abuse.
He understands the issues and challenges we are facing at
Tomah from years of traveling across the country working to
optimize clinical care at many site visits to VA Medical
Centers, including visits here at Tomah.
Most importantly, perhaps, is that Dr. West served as the
co-chair of VA's National Opioid Safety Program.
Jason's death forced us to dive deeply into the Tomah
system. What we found was an organization facing numerous
challenges in dire need of change and new leadership.
The problems at Tomah have been well documented. Failures
related to the prescribing practices of controlled substances,
examples of inadequate oversight appear, and failure related to
culture.
We own those challenges and problems, those failures. I own
those problems, those failures.
Avoidable harms to veterans are not acceptable. When they
do occur, our obligation is to act with urgency to investigate
and prevent a recurrence.
At Tomah there was a clear and inexcusable lack of
leadership that created and exacerbated these serious problems.
The excellent frontline staff here at Tomah--that you have
acknowledged in your comments, Mr. Chairman--working under new
leadership, is fixing those problems.
On October 5, we appointed Victoria Brahm as Acting
Director. In her new role, Vicki did not wait to take action to
improve veteran care. On November 27, she began executing
Tomah's 100-Day Plan. For those of you that are unfamiliar with
this concept, 100-Day Plans are a best practice of new leaders
as they transition into their roles. They are not meant to fix
everything, but to set a clear and bold direction while
delivering near-term tangible results.
The 100-Day Plan period ended in March, but the work
continues to transform the way Tomah leaders operate, to change
how Tomah treats their veteran patients, and to rebuild trust
with veterans, employees, and the community.
Thanks to this ambitious plan and the dedication of caring
frontline staff, Tomah, once a symbol of the overuse of
opioids, is actually on its way to becoming a model for change
and best practices.
Let me highlight some of the great work by Vicki and the
staff.
In April, Tomah completed more than 98 percent of their
appointments with in 30 days. In fact, nearly 17,000
appointments were completed in April. Of all of those, 217 were
over 30 days from the day that the veteran wished to be seen.
Their wait times are consistently among the best in all of
the VA.
For primary care, less than 3 days. Specialty care, less
than 6 days. And, for mental health, a little more than 2 days.
Vicki and the team are working to restore trust among
veterans. She is opening lines of communication with our
veterans by opening her door, meeting with countless veterans
these past months.
Other continuing efforts include developing an academic
detailing team to review the medical center's most complex
chronic pain patients and provide additional recommendations
for their care.
To support this initiative, more than 30 primary care and
mental health providers attended academic detailing educational
sessions in the month of March.
She is also creating a veteran pain school to assess and
customize alternative pain management strategies for veterans.
Importantly, Tomah has reduced the number of veterans receiving
opioids by nearly one fourth.
Tomah partners with the Wisconsin State Prescription Drug
Monitoring Program, a program designed to ensure veterans are
not obtaining opioid medications from multiple providers.
Another step forward is the effective use of VA's audit
tool, which allows doctors to improve practice and safety by
seeing all the medications veterans are taking on a single
dashboard.
Vicki has made overdose education and Naloxone rescue kits
available to patients at risk of accidental or intentional
overdose. Naloxone has proven effective in reversing an opioid
overdose. Simply put, she is finding options, alternatives, and
solutions other than just a bag of pills.
Let me tell you about one of Tomah's best practices.
Evidence shows that the best outcomes in pain management occur
with a comprehensive approach across multiple disciplines with
the patient as the central focus. This empowers the veteran to
be an active participant in decision making regarding pain care
options.
Tomah developed the integrated pain university, which is
strongly based on patient education and empowerment. This whole
health perspective identifies and addresses biological,
psychological, and social aspects of pain management in
conjunction with assessment by the Patient Aligned Care Team
and any necessary specialty consults.
Additionally, veterans receive information through a
variety of elective classes taught by their respective health
care professionals, which include pain medications, pain and
nutrition, pain and sleep, aroma therapy, mindfulness, the
neuroscience of pain, introduction to movement, staying
motivated, and spirituality.
The result of these and other efforts. As of the second
quarter of fiscal year (FY) 2016, just over 9 percent of
veterans at Tomah are prescribed some form of opioid.
Across the entire country, across all of the VA's
population, that national rate is nearly 13 percent.
Vicki and the team are also listening. They are listening
to veterans, to the community, and to employees. Listening led
to the development of the Tomah VAMC Veterans Experience
Council and Strategic Partnership Committee. The Veterans
Experience Council will help make sure that Tomah leaders have
a clear understanding of how veterans perceive VA, while the
Strategic Partnership Committee will work to strengthen and
promote a unified approach to veteran care throughout the
community.
Vicki has hosted more than 15 employee listening sessions
covering all work shifts at the Medical Center. These listening
sessions are critical in getting a sense of how staff can
better serve veterans while using input from these sessions to
improve employee engagement, making sure employees are
satisfied with their work environment. Monthly staff meetings,
quarterly nurse town hall, and roundings with local union
officers are all part of the larger efforts of our commitment
to employees.
As a result of these and many other actions, we are seeing
Tomah's performance improve, as measured both internally and by
veterans themselves.
By understanding the challenges and taking ownership in the
problems, Vicki and the leadership team are improving the
organizational culture and climate, providing more oversight,
effective oversight, of care delivery, and addressing problems
and prescribing practices.
While there is more work to be done, this strategic
direction has led to a real positive change.
Vicki is modeling effective leadership by taking ownership
and accepting accountability of past mistakes in order to make
tangible progressin caring for our Nation's veterans.
Bob McDonald and I talk a lot about sustainable
accountability. Making sure employees understand our mission,
values, and strategy. It has accountability that results in
positive veteran outcomes, not just in the very near term, but
over the long term as well.
And I believe that is what we are seeing here at Tomah.
Across all of the VA, our work to change prescribing
practices and develop alternative approaches to pain management
is delivering steady progress. We have also developed a
predictive model and a clinical decisions support tool to
identify patients being treated with opioids, who may be at
risk of suicide-related events or overdose.
This tool for opioid risk mitigation estimates the
likelihood of an overdose or suicide event in the next year
providing patient-tailored recommendations for risk mitigation
and nonopioid pain management options.
Lessons learned have caused a greater engagement and
improves lives.
We are also getting unwanted drugs out of veterans hands.
Removal of veterans unwanted and unneeded medications reduces
the risk of diversion, as well as intentional or unintentional
overdose or poisonings.
As of May 1, approximately 27,000 pounds of unwanted and
unneeded medication have been collected and destroyed in an
environmentally responsible manner.
The overuse and misuse of opioids is a national problem,
not just a VA problem. What we are doing here at Tomah and
across the VA is part of a broader national effort to fight
opioid addiction and overprescribing of powerful drugs.
Our hope is that VA's efforts here and elsewhere will
become part of the national approach that will benefit not just
veterans, but all Americans.
We still have work to do.
With your support and the support of many others, we will
succeed. The needs of veterans cannot be secondary to other
agendas. It is unacceptable to VA leadership and should be
unacceptable to anyone claiming to care about our Nation's
veterans.
I need your help to change the dialogue and a perception of
this facility in order to get the right people interested in
these jobs.
Mr. Chairman, I appreciate your Committee's support in
identifying and resolving challenges here in Tomah. And, we
look forward to your questions.
Senator Johnson. Thank you, Mr. Gibson. Our next witness is
Michael Missal. Mr. Missal is the Inspector General for the
Department of Veterans Affairs.
I had the privilege of going on the Senate floor and asking
unanimous consent to have you confirmed. I know Senator Baldwin
and members were calling for a firm Inspector General and we
are glad we have one.
Mr. Missal is accompanied by Dr. John Daigh, Assistant
Inspector General for the Healthcare Inspections within the VA
Office of Inspector General. Inspector General Missal.
TESTIMONY OF THE HONORABLE MICHAEL J. MISSAL,\1\ INSPECTOR
GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY
DR. JOHN DAIGH, ASSISTANT INSPECTOR GENERAL FOR HEALTHCARE
INSPECTIONS, OFFICE OF THE INSPECTOR GENERAL, U.S. DEPARTMENT
OF VETERANS AFFAIRS
Mr. Missal. Thank you. Chairman Johnson, Senator Baldwin.
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\1\ The prepared statement of Mr. Missal appears in the Appendix on
page 58.
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Chairman Johnson, Senator Baldwin, Congressman Kind and
Congressman Walz, thank you for the opportunity to appear today
regarding the Office of Inspector General's past inspections of
the Tomah VA Medical Center and our work in the area of pain
management and opioid use.
I am accompanied by Dr. John Daigh, Assistant Inspector
General for Healthcare Inspections. He is a retired Army
Colonel and has spent over 25 years providing healthcare to
soldiers.
First, on a personal note. I want to thank all veterans for
their great and selfless service to our Nation.
In addition, I want to express my sympathies to the
families of those impacted by events at Tomah. All of us at the
OIG need to take these experiences and use them to improve VA's
operations.
Finally, as the son of a World War II veteran, I had a
strong reminder of our mission's importance when I had the
great honor of attending the wreath laying ceremony at
Arlington National Cemetery yesterday.
On May 2, 2016, I was sworn in as the Inspector General.
Since then, I have immersed myself to understand the people,
work and goals of our office. I have been impressed with the
OIG staff, many of whom are veterans, and their focus on
bringing about positive changes in the integrity, efficiency
and effectiveness of VA operations. While my integration has
gone very well, I know there is much more to learn.
I strongly advocate three overriding principals for our
office. First, we must maintain our independence in all of our
work, including avoiding the mere appearance of any undue
outside influence. Second, we must be as transparent as
possible, while safeguarding the privacy of veterans,
whistleblowers, and others. Third, we must produce work of the
highest quality, making sure it is accurate, timely, fair,
objective and thorough.
During my first month, I have spent significant time
reviewing our healthcare inspections of Tomah. I have also met
with the Homeland Security staff on two occasions to ensure
they have the necessary information about our work as it
pertains to Tomah.
My written statement contains a timeline of events related
to the Tomah Administrative Closure and I will not repeat it
here. The inspection was administratively closed given the
totality of the facts identified at that time.
Specifically, that the allegations could not be
substantiated, the impact that disclosure of unsubstantiated
allegations could have on an individual's reputation and
privacy, and knowing our forthcoming 2014 national report would
highlight many deficiency in VA providers' compliance with
opioid prescribing guidelines.
I would like to comment on the White Paper about the Tomah
inspection that was issued by my office on June 4, 2015. I do
not agree with its tone or the gratuitous attacks on the
reputation of individuals mentioned in it. It does not meet the
high standards expected of our office.
We have learned important lessons from this experience,
including increasing the transparency of our work that should
help us better meet our mission going forward.
The changes made should increase the confidence that
veterans, Veterans Service Organizations (VSOs), Congress, and
the public have in us.
Subsequent to last year's hearing here, we released two
additional inspections regarding Tomah. In June we issued a
report with local and national recommendations focused on acute
stroke treatment. And, in August we issued a report regarding
the unexpected death of a patient during treatment at Tomah.
This report had four recommendations.
Notably we recommended that the facility ensure clinicians
comply with VA policy regarding written informed consent when
administering hazardous drugs.
The issues associated with the use of opioids to treat
chronic pain and other conditions are a serious concern, not
just at Tomah, but throughout our Nation.
We continue to focus on VA's opioid prescription practices,
publishing two reports on the topics earlier this year. That
work identified many of the same issues reported in our May
2014, national review.
We found VA was not following its own policies and
procedures in six key areas, including follow-up evaluations of
patients on take-home opioids, prescribing and dispensing of
benzodiazepines concurrently with opioids, and routine and
random urine drug tests prior to and during take-home opioid
therapy.
We note VA has taken actions to implement that report's
recommendations, but they must monitor facility compliance with
opioid prescription policies.
Later this year we expect to publish a wide-ranging
national review of VA's pain management services, substance use
treatment programs, use of non-VA treatments, opioid
prescribing practices, and access to State prescription drug
monitoring programs.
Yesterday our Nation paid tribute to the sacrifices of
those who gave their lives in our defense. It is a valuable
reminder for us at the OIG to rededicate ourselves to ensuring
that our work is independent, accurate, timely, fair, objective
and thorough.
Dr. Daigh and I look forward to your questions.
Senator Johnson. Thank you, Inspector General Missal.
Mr. Gibson, let me start with you. When did the problems
here at Tomah first hit your radar screen? When did you first
hear about them? And, you have been in the VA how long?
Mr. Gibson. I have been in VA for 2 years and 3 months--2
years and 4 months--right around there.
I think I am going to go from broad recollection, because I
did not go back to check the record. I am going to say probably
sometime around January.
Senator Johnson. Ok. When the news story broke, basically?
Mr. Gibson. Yes, that is correct.
Senator Johnson. So, in your experience with the VA, what
was--during that time frame, what was the attitude of the VA?
The main Department with the Office of Inspector General?
Mr. Gibson. I would tell you, coming into the organization,
I have always viewed, whether it is called an IG or some other
entity, an auditor, that having a working relationship, a
constructive relationship, albeit recognizing their
independence, is vital, because, at the end of the day, we are
after the same thing.
I have worked to try to create that kind of relationship. I
always find it amusing when folks suggest that the IG has been
management's lap dog, because, if you go look, they issue over
300 reports a year, which means we are getting wire-bushed
about six times a week, every single week, and you scan the
array of IG reports and you will find that there is no
pandering to VA interest there. It is a very strong and
independent entity.
Senator Johnson. This Committee, does a lot of work with
different Inspectors General. We see kind of a spectrum, quite
honestly.
Mr. Gibson. I am sure you do.
Senator Johnson. As Ranking Member of a Subcommittee of
this Committee, we uncovered the corruption within the Office
of Inspector General at the Department of Homeland Security and
Charles Edwards basically moved on ahead of the posse, so have
seen the lack of independence.
Mr. Gibson. Yes.
Senator Johnson. What I thought was quite shocking as we
got involved in this situation, is that the Office of Inspector
General had 140 reports on investigations and inspections that
it buried, that it was covered up, it did not make public. Now,
I have mentioned that to other Inspectors General and I asked
them, how many reports have you not made public? And, they
really look at me like I am from some other planet.
I think I have had one Inspector General say, well, there
was one we did not publish, because of concerns about national
security.
So, do you think it is appropriate that there are 140--now
there is, by the way, another 70 percent reports on different
wait time problems that apparently now the Office of Inspector
General was starting to produce on a rolling basis, but that is
a shocking number of reports on investigations and inspections
from an independent transparent office that were not made
public.
What is your take on that?
Mr. Gibson. Well, my take is that, in general, they should
be made public. And, I think that is the stance that the IG has
taken. There have been instances where this Office of Inspector
General has identified things in the course of their
investigation that were not related to what they were seeking
to look into where they have come to me specifically to say,
you need to know about this and where we have taken appropriate
actions in the wake of that.
That is the kind, I think, frankly, part of what you see
here, and I was not here 4 years ago, so I cannot talk
knowledgeably about what was or was not the environment and the
practice. But I will tell you, over my two plus years here,
that the IG has been willing to bring things to me, and I think
it is a much more principled base view. I think some of this,
we get wrapped up in the rules, and we get so wrapped up in the
rules, we lose sight of the principles.
And so, here is a case where I think, quite frankly, this
is my view from the outside looking in, where we got focused on
the rules. And, the rules basically said, this is what we are
here to investigate, and we did step back and look more broadly
at principles and I think the IG has demonstrated the
willingness and the ability to do that in subsequent events. I
do not know whether they learned from this particular instance
or from other, but I think that is what we owe veterans.
And, I am going to go back and say that, ahead of anything
else, this is a leadership failure. There is lots of finger
pointing and everything else. At the end of the day, we own
this. VA leadership owns this. We had ample opportunity over a
period of years to fix this. That was the leadership's
responsibility.
And, we failed to get it done.
Senator Johnson. I appreciate that. Dr. Daigh, you were
part of the inspection team for Tomah, correct?
Dr. Daigh. That is correct.
Senator Johnson. One of the things that come across in our
report is the confusion over what is the standard for
substantiating a claim? For example, in so many instances, this
was not a he said/she said, which, again, I have been in
business. I have had these employees situations where it is
kind of difficult when it is he said/she said. This is a case
with Dr. Houlihan where it was he said/they said. I mean, there
was so much corroboration of the allegations.
How did you come to the conclusion that so many of these
charges were unsubstantiated? What is the standard?
Dr. Daigh. Well, maybe what I could do is go through the
allegations one by one and we can talk about them.
Senator Johnson. Let us talk about, why we do not talk
about the allegations of a climate of fear, a culture of fear
within the--I mean, there was so many reports and it was so
obvious that Dr. Houlihan, according to testimony, was a bully
and created that and retaliated, and there were people fired as
a result. And, Chris Kirkpatrick committed suicide after he was
fired. I mean, there was so much accumulated evidence, how
could that not be substantiated?
Dr. Daigh. So, we did substantiate that there was an issue
with the relationship between the Chief of Staff and the
pharmacists, primarily. And, we transmitted that information to
the Veterans Health Administration (VHA). It was not a
surprise. And, the proof that we transmitted that, and that it
was not a surprise is at the end our review. We sat down and
talked with both the Director of Tomah and the Veterans
Integrated Service Network (VISN) Director, and they told us at
the time that we were outbriefing them, of the changes they had
made so that the Chief of Staff no longer supervised the
pharmacists.
They were aware of problems in the pharmacy and were
working to try to correct them. So, with respect to the
relationship between the Chief of Staff and the pharmacists,
our Administrative Closure lays it out clearly that that was an
issue.
It was not, in my view, the primary problem that was
addressed at Tomah.
The primary problem was the allegation that Tomah providers
were providing narcotics outside of the standard of care and
that narcotics were being distributed in such a way that the
rules of law were being broken.
We looked extensively to find out whether that was true or
not.
Medical experts reviewed many charts. We reviewed many
emails of 17 providers at VA looking for evidence of a problem.
Evidence of criminality.
Our investigators went undercover looking for evidence of
criminality.
So, I am left with the problem of, there are allegations,
and I just do not have the facts to support many of those
allegations.
Senator Johnson. I mean, most people reading our report
will say there is a lot of substantiated evidence to support
that charge.
Just quick before I turn over to Senator Baldwin.
On page 270, we have your signature on the Administrative
Closure sheet. Every ounce of evidence that we can find shows
that Administrative Closure occurred in August of 2014. I want
everybody to take a look at page 270. It completely looks like
this has been doctored from 8-12-14 to 3-12-14.
Dr. Daigh. It has not been doctored.
Senator Johnson. So what, what further evidence, other than
this, what appears to be a doctored----
Voice. Liar.
Senator Johnson [continued]. Signature, what other evidence
would indicate that you closed this out in March versus August?
Dr. Daigh. So, when information flows, I would sign a
document, as I signed this one. And, in the Administrative
Closures they come to my desk. I sign them and I write a date
on it.
Senator Johnson. Is that normally how you write a three?
With an eight kind of embodied within the three?
Dr. Daigh. That is what I wrote.
Senator Johnson. Is there any further evidence that this
was actually administratively closed in March of 2014, because
everything else shows that you administratively closed this in
August?
Dr. Daigh. No, I do not know what you are talking about.
The actual date that I signed the report, it then goes into
other systems, which are systems of record, and it is entered
into what we call a different computer system, and it was
closed at that time.
Senator Johnson. I find this unbelievably puzzling and I do
want to get to the bottom of this. Senator Baldwin.
Senator Baldwin. Thank you. So, I want to kind of start
where Senator Johnson left off with regard to this process on
this Administrative Closure.
The report, Committee report outlines a very long
inspection, investigation. You used the words somewhat
interchangeably.
Now, the work product after the inspection, the visits, the
interviews, etc., seems to have gone through a number of
iterations prior to there being a decision to make this an
Administrative Closure. I know that, and you will see this
throughout the Committee report, frustrations expressed about
documents that were requested from the Inspector General, but
were not granted to the Committee.
But we had an opportunity granted by the IG's office in the
last couple of weeks to inspect the draft reports. Could not
take notes--and I did not do it, but my staff went in to see
them, and so the Committee has reviewed some of the drafts
prepared during the Tomah investigation, and I was disturbed to
learn, after I was briefed, that things that the IG staff was
aware of did not make it into the final Administrative Closure.
For example, one case study referenced in an IG draft
report explained that Dr. Houlihan had increased one patient's
dosage of oxycodone more than eight fold in one year. And, that
there was not always a rationale noted in the chart. During the
same time frame, this patient had nine refills of a Schedule II
controlled substance dispensed more than a week early.
Probably more disturbing, the case study explained, and I
am paraphrasing, because there were not copies available, that
Dr. Houlihan miscalculated the number of pills prescribed to
the patient and that Dr. Houlihan made up for the shortage by
refilling the prescription early.
Can you explain to me why details of these case studies
referenced in the draft report did not make it into the final
Administrative Closure?
Dr. Daigh. My instruction to the staff was, because the
draft report did not substantiate what I thought were the
significant allegations that we were looking at, I asked them
then to write an Administrative Closure. So, the same people
that wrote the draft report wrote the Administrative Closure.
There were no instructions as to what to put in or what to put
out.
If you will take a look at the 140 Administrative Closures
that we had done previously, and I will say that it was my
understanding and our practice that if I took a hotline, I
would either publish it to the web or I would note in the Semi-
Annual report (SAR) to the Congress that we had an
Administrative Closure. So they were, in my view, made public
there, although, albeit, not with very much detail. Some years
there was a lot of detail, some years there was not, but I
asked them to write an Administrative Closure. So they chose,
for I do not know what reason, to shorten it up, and it was, 11
pages for the Administrative Closure. Most of the
Administrative Closures that we publish are one or two pages,
so they were trying to put in the detail they thought was
relevant.
Senator Baldwin. Well, I mean, on that Administrative
Closure, you did note that patients requested early refills,
but the document does not state that Dr. Houlihan wrote in
files that he miscalculated the prescriptions and made up for
the shortages by refilling the prescriptions. And, to me, this
tells a different story. There is also no mention that he did
not always provide a rationale in the charts for substantially
increasing already high prescriptions like the example I just
mentioned.
So we gathered, in March of 2015, this, the Senate Homeland
Security and Governmental Affairs Committee, and you testified.
You testified that staff at Tomah were at the outer boundary of
acceptable prescribing practices. And, this statement seems to
imply to me that there may have been some unusual practices
happening at the Tomah facility and within the facility's
leadership.
So, is the example I just raised the type of thing that was
on the outer boundary of acceptable prescribing practices or is
it beyond that boundary.
Dr. Daigh. I would say that our view was that, in summary,
he was at the outer boundary. And, the facts that you described
would be, in my view, probably over the outer boundary. But we
thought that the totality of the care provided, was at the
outer boundary.
Senator Baldwin. Inspector General Missal, I know you are
new to this position, but you have read this Committee report,
and I guess I want to know your opinion on putting out a policy
that outlines what the standard ought to be in your Agency for
substantiating or unsubstantiating allegations, at least for
cases like this where you think it might be a close call or
right outside those boundaries?
Mr. Missal. Yes. I have looked at that. I have had the
opportunity to review the report. Standard of care is a
complicated issue. For instance, when we are doing an
investigation, we look to see if somebody did something wrong.
The standard to me is preponderance of the evidence. Is it more
likely than not that somebody did it?
With respect to healthcare inspections, you are looking at
the quality of care, which is a far more complicated area. And,
it really depends on a variety of things of what you are
looking at. For example, what the literature says, what experts
may say, etc., but I understand the point. I know it was a
significant issue and we intend to look very closely at that
and to talk about standard of care and the standards that we
are going to be using going forward, so we will be doing that.
Senator Baldwin. Well, with the advantage of hindsight,
this does not look all that complicated to me.
Mr. Missal. We are going to look at that very closely.
Senator Johnson. Thank you, Senator Baldwin.
What is amazing is they had a pretty high standard for,
substantiating a claim in their OIG report, but yet in the
White Paper, they had no problem rushing out a report that
literally threw the whistleblowers and these individuals under
the bus. It is really quite remarkable.
I also appreciate the fact that you were talking about the
frustration this Committee has had in obtaining the
information. I just want to refer everybody to page 324. This
is what one of the documents looks like provided by the Office
of Inspector General, who has not yet complied with our full
subpoena. I mean, think about that. This Committee had to
subpoena the Office of Inspector General to get the
information. And now, 16 months later, well, it is really about
a year later, because we issued the subpoena at the end of
April, still has not been complied with, so, Mr. Missal, again,
we look forward to working with you on that.
I do want to welcome Representative Kind and Representative
Walz from Minnesota, and we will not hold that against you.
Congressman Kind.
OPENING STATEMENT OF CONGRESSMAN KIND
Mr. Kind. Thank you, Senator. I want to thank you too for
yours and the Committee's invitation for me and Representative
Walz to participate in today's hearing.
Yesterday, as many of us were at Memorial Day commemoration
events, and during it, it is a sober reminder of not only our
obligation to honor our fallen heroes, but the unfinished work
of making sure that our veterans, those who served our nation
are receiving the care and the treatment that they have earned
and that they deserve. And, that has always been my guiding
star throughout this whole process, given the tragedy, given
the mistakes that were made at Tomah, which, according to your
testimony here today, has not been unusual in regards to the VA
medical system throughout the nation. If we keep our focus on
the veterans and making sure that that is our true guiding
star, then hopefully we can bring some good out of a tragedy.
And, I know that is exactly what has been motivating the
Simcakoski family this whole time.
I have been proud and honored to be able to work with each
one of them when it comes to fixing the problems to ensure that
no veteran in the future goes through what that family has
done. Jason's wife Heather, and his parents, Linda and Marv,
have been intimately involved in not only providing feedback on
the legislation we have been working on to honor his legacy,
the Jason Simcakoski Promise Act, but they have even taken the
extra step of making phone calls to appropriate Committee
Members, even to Speaker Ryan, about the importance and the
urgency of getting this legislation done and implemented as
quickly as possible.
In fact, Heather and Linda and Heather's daughter Aniah
were out just out in Washington a couple of weeks ago to make
some last minute visits, but also to personally witness the
passage of the Jason Simcakoski Promise Act unanimously on the
House floor, and we look forward to working with this Committee
and you Senators in order to ensure that this reaches the
President's desk and get this done and implement it as quickly
as possible.
Heather asked today if I would be willing to read a short
two-paragraph statement for the record and I ask unanimous
consent to do so at this time.
Senator Johnson. Sure.
Mr. Kind. She writes, and I quote, ``It is encouraging to
see the Congressional delegation working together in honor of
Jason, to ensure no other families go through what we had to
endure. We are proud of the progress made so far in passing
legislation named after Jason. We look forward to working with
the Congressional delegation to make sure the legislation
becomes law.
``We are grateful for an opportunity to see everyone come
together to turn such tragedy into something that has the
potential to save so many lives in the future. As we can
continue moving forward, we are committed to remaining focused
on the bipartisan support for this legislation.''
Clearly the job is not done yet, but I do want to commend
Acting Director Vicki Brahm, for the progress that has been
made at Tomah. This comes on the heels of the work that then
Acting Director John Rohrer when he came in, and inherited the
challenge that existed and what they are trying to build on
right now--the community outreach, working with the staff on
best practices, but especially listening to the families and to
the veterans themselves, making sure that they have input and
say in what is taking place there.
I think it is important that we stay focused in that
endeavor.
But I also would be remiss if I did not mention the good
work that has been done at Tomah. I have been somewhat
surprised by the number of veterans who have gone out of their
way to personally notify me at how happy they are with the care
and treatment they have received at Tomah. Any my guess is this
would be fairly consistent around the country too.
So, although there were serious allegations and mistakes
made, I do not think we should overlook a lot of the
dedication, a lot of the professionalism, a lot of compassion
that is taking place at places like Tomah each and every day,
and sometimes, given the sensation of these stories and what
the media tends to focus on, that gets lost in kind of the fog
of everything that we are trying to accomplish.
But, Mr. Missal, while we have you here, and we know you
are new to the position, and it has been raised already by the
Senators, we did have some communication problems with the IG's
office when it comes to conducting the investigation, proper
notification.
I know that when I had received an anonymous letter back in
September of 2011, I immediately forwarded that onto the OIG's
office, asking them to look into it and conduct an
investigation. Received notification that they were going to do
that and that we be notified at the end of that investigation.
Now, listen, I am a former special prosecutor and I have
been involved in a lot of investigations myself. You do not
know when you go into an investigation how long it is going to
take, how complex it is going to be. You talk to one witness
and suddenly 10 more names appear. I get all of that. But what
was problematic to me and to the Committees of jurisdiction was
the lack of notification when the IG's office administratively
closed it with certain reforms and changes that had to be made
and we were operating in the dark, because there was no
notification again.
And, I also want to commend Representative Walz who serves
on the House Committee on Veterans' Affairs for the work that
he has done. He has been a good partner through all of this,
along with Gus Bilirakis, a real bipartisan effort, but we are
only as good as the information that is given to us.
And, Dr. Daigh, when the report did come out, and I later
found out that we were not notified, I called you and others
that were involved in the investigation into my office
immediately to get clarification on what was taking place. To
your credit, you guys owned up, that the ball had been dropped,
notification was not given when the intent was--I know this was
coming at the time of Phoenix and other news stories that were
breaking at the time, but in light of all that, I introduced
legislation, the Inspector General Transparency Act, which I am
glad was included in the year-end budget last year, which now
requires that notification.
So, Mr. Missal, on that point specifically, is that going
to help in your mind, as far as the lines of communication,
keeping policy makers informed of what changes and reforms have
to be made, so we can be working together and in tandem to make
sure that this gets done?
Mr. Missal. Yes, I think it will help, but hopefully we do
not need legislation to become more transparent.
My goal is to communicate better with the public, with
Congress and with the Department on issues. There were a number
of mistakes made by my office at the time and we agree that one
of the mistakes was not keeping Congress better informed on
this issue. And, I am going to work very hard to make sure that
does not happen again.
Mr. Kind. Mr. Gibson, I appreciate your testimony, written
and your oral testimony today, about the need to continue on a
more coordinated, integrated veteran-focused healthcare
delivery system. I think a lot of ways--the VA system
throughout the country has been good in driving that, that
goal, that momentum in that direction, but, clearly, more work
needs to be done.
Mr. Gibson. Yes.
Mr. Kind. Is there any other things that Congress needs to
be working with the VA on right now to make sure that you are
given the policy prescription, but also the tools and resources
in order to get this accomplished?
Mr. Gibson. I appreciate the request, and I appreciate your
recognizing the good work that goes on every day. Because, you
are right, it does not get reported. It does not diminish the
challenges that we have, but it is part of the context. The
short answer is yes. And, we have been working, really, with
both of our authorizing committees on an array of legislative
priorities that we have, many of which get at some of these
very issues. I am thinking most immediately of the request to
make all of our Medical Center Directors and Network Directors
Title 38.
Quite frankly, if I had that authority in my hip pocket
right now, the lady sitting behind me would already be the
Medical Center Director here. But I am probably going to get in
trouble for committing a prohibited personnel practice for
having said that, but, she is doing awesome work and she is the
kind of person--and having the kind of ability to, to direct
hire and a little flexibility around compensation would make
that possible, among a large number of other priorities that
you have identified. Thank you for asking, sir.
Mr. Kind. Thank you.
Senator Johnson. Congressman Walz.
OPENING STATEMENT OF CONGRESSMAN WALZ
Mr. Walz. Thank you Senator Johnson, for including me in
this hearing and the past one.
Thank you, Senator Baldwin and Congressman Kind, for all
three of you, the work that you do.
I am Tim Walz. I represent Minnesota's First Congressional
District. It is just a little bit west of here across the river
and then all the way out to South Dakota. And, that river may
separate us on football loyalty, but it does not separate us as
Americans.
And, many of my constituents use this facility.
Also, prior to being in Congress I spend 24 years as an
artilleryman and retired as a Command Sergeant Major and spent
the last 10 years on the House Veterans' Affairs Committee, so
I have spent the last 35 years, not just talking about veterans
issues, but being part of that.
And, I can tell you this--that, as a member of Congress,
the security of this nation and the care of our warriors is our
number one priority. That is also the number one priority of
all of you sitting out there and every constituent in my
District and Ron's District and across Wisconsin and Minnesota.
It is also the number one priority of these folks sitting up
here.
And, you just do not get in this and leave. For example,
Mr. Gibson, some of you do not know, my capacity of working
with him prior to his current position was, he ran the United
Service Organizations (USO), a fabulous organization that cares
for our warriors, which he did with grace, skill,
effectiveness, and I think for all of us trying to find
solutions to the best care possible is what we are here for, so
I appreciate all of you coming out on a day like this.
And, to the family, you heard it. And, I think that is the
thing that always most strikes me. In the midst of heart-
wrenching tragedy that I will not even attempt to understand, a
family seeking justice, which they deserve, and we should
deliver, but also transferring that into solutions to make sure
no other family goes through it too, whether they meet them or
not. And, that is a very powerful call to action for us. So, I
look at it as, our responsibility is to get them the justice,
find out what went wrong, find out who is responsible and hold
them accountable, but simultaneously making sure that the
changes that are being made do not happen.
And, for some of you to think on this is, there really is
nothing new under the sun. I think about this, and the folks up
here, and Ron and I have talked about this and have worked
together on.
The first two things that I was able to do when I got to
Congress would actually put into law and effected was first
increasing the budget for the VA Inspector General, which at
that time was incredibly low and you simply did not have enough
people to go out. We would send in a request, and you would
say, I do not have people to cover this and we could not find
those eyes on it.
And, secondly was passing step pain management on opioid
reduction. In 2007 people were already thinking about that. Not
just me, but folks up here and folks that understood this were
trying to implement that. And, I guess for me, we made a good
effort, and I think the VA and Mr. Gibson are right. This is an
issue that is systemic to our entire culture. And, it is a huge
problem. Now you hear lots of people talking about it. That is
great, but there are solutions out there. We need to implement
them and move them forward.
And, I know that the bill that I passed went from 2009 to
2014. We were only able to implement 31 percent of it by the
time it expired in terms of doing this. And, these are best
practices that are out there.
So, I think today in the time that we are going to have
here today, I am going to attempt to try to focus on what has
changed at Tomah. And, trust me on this. Dr. Houlihan or anyone
else involved in this, justice needs to be served and we will
find that. Senator Johnson will continue to do that and Senator
Baldwin.
As a member of the House Veterans' Affairs Committee, I
want to know what you have done to make a difference. What
happens with my veterans from Houston County who come over to
Tomah now and what has changed?
And, with my remaining time I am going to start on a line
of questioning on this is, and, Mr. Gibson, maybe you can help
me with this. How do I know things are better at Tomah? How do
I know, if someone asked me, is it better at Tomah or is it the
same thing that happened when the reputation that, that started
this was there?
Mr. Gibson. I think some of the activities that I described
earlier, Vicki has been engaging in; the open door with
veterans, the outreach into the community, and looking for ways
where we bring the community together to help support our
veterans.
And, one of the things that we started doing recently,
because access is such a critical issue for us, is we started,
at our kiosks, asking the one very simple question, how
satisfied were you that you got today's appointment when you
wanted it. At Tomah the answer is 93 percent satisfied or
completely satisfied.
They are doing so many things so well. You can look at the
sale data.
Many of you may not realize VA leads the country, perhaps
the world, in reducing healthcare associated infections.
Healthcare associated infections--second leading cause of death
in
America--more than automobile accidents and breast cancer
combined.
And when, and external studies, when looked, who was, who
was doing this better than any other organization? It was not
the Cleveland Clinic. It was not Kaiser Permanente. It was not
Geisinger. It was VA.
Mr. Walz. Not even Mayo.
Mr. Gibson. Guess who? Guess who leads VA? Tomah, in
minimizing healthcare associated infections.
I will tell you, the number one area where they have work
to do is in employee satisfaction and employee engagement. And,
that is the culture problem. And, that is why leadership
matters so much.
So, veterans are telling us, you are hearing from veterans
that are saying--I have heard from veterans here. And, I will
tell you, my classmate was a patient here in the Community
Living Center (CLC) for 23 years. And, the family in his
obituary said the staff here made them feel like they were part
of their family.
That is what is happening with so many of the Wisconsinites
that are working right here, caring for our veterans, are they
doing the right thing, but we did not have the right leadership
in place. And, I think, I think we have a good clue----
Mr. Walz. We need to give them the tools because----
Mr. Gibson. Yes, we do.
Mr. Walz. We owe them nothing less. You hear that.
Mr. Gibson. Yes.
Mr. Walz. But, and equally important as holding
accountable, and if it is firing, or whatever needs to be done
to those people, we need to have the ability, as you said, and
I am with you on the Title 38. We need to be able to hire the
best and possible, because we cannot fire away to a fix, but we
can simultaneously get rid of the bad and bring in the good.
Mr. Gibson. You got it.
Mr. Walz. And, I yield back.
Mr. Gibson. You got it.
Senator Johnson. Thank you, Congressman Walz.
Let me continue on that vein about accountability.
In 2015 I introduced the Ensuring Veterans Safety Through
Accountability Act and I testified with Senator Baldwin when
she introduced the Jason Simcakoski--I always forget the full
name.
Senator Baldwin. Opioid Safety Act.
Senator Johnson. Opioid Safety Act at the Veterans' Affairs
Committee. I was more than disappointed when the
representatives from the VA testified against the
Accountability Act.
Now, fortunately, a similar provision introduced by Marco
Rubio, which I cosponsored, was passed by the VA Committee, but
having been in business for 30 some years, I mean, I understand
that probably the most corrosive thing to any organization is
not being able to hold the bad actors accountable. And, yet
here you have the representatives of VA saying, nah, we do not
want that authority to hold people accountable.
I mean, that is at the heart. I agree with you. I think all
of us here agree. As we tour around and talk to the doctors and
nurses, and as I said in my opening statement, they do an
extraordinary job. They are really concerned, but unless we
really have the ability to hold people accountable, that is
what causes these types of tragedies, so is that something that
the VA will now embrace? The ability to actually discipline and
terminate and hold people accountable through the VA system.
Mr. Gibson. I would say the answer is an unequivocal yes.
Senator Johnson. Good. We will move on.
Mr. Gibson. Well, that has been part of my own personal
obligation as a leader since I first got to VA. I am the guy
that takes action on senior leaders in the department. I am the
guy that issued the removal on DeSanctis. And, I am the guy
that looks at other instances of particular notoriety to ensure
that we are taking the appropriate action.
Senator Johnson. Good. But we want to give you that
authority, because you have to have it.
Another piece of legislation I introduced was the Dr. Chris
Kirkpatrick--let me give you the full title of that one as
well: The Christopher Kirkpatrick Whistleblower Protection Act.
And, this was really prompted by a Committee hearing we had
where Sean Kirkpatrick testified before our Committee, and one
thing that I have been literally shocked by, again, coming from
the private sector, even though we have all these whistleblower
protection laws on the books for a hundred years, the level of
retaliation against those people that have the courage to come
forward, like Dr. Noelle Johnson, like Ryan Honl, like Chris
Kirkpatrick, is jaw dropping.
So, again, I hope that the VA will embrace and help support
the passage of that piece of legislation to give those
whistleblowers the protection they really need.
And, by the way, I would announce again that my
Committee has set up the whistleblower hotline. It is just
[email protected]. People are using that.
And, I think it is also an important step that is required, so
that whistleblowers within the VA--and, by the way, the highest
level of retaliation, according to the Office of Special
Counsel (OSC), is within the Veterans Administration, which is
a real problem.
So, again, will you support the Christopher Kirkpatrick
Whistleblower Protection Act?
Mr. Gibson. I do not know what is in the Act and I also do
not know what is in the Accountability legislation you referred
to earlier.
But what I will tell you is that I personally, as the
Acting Secretary, met with Carolyn Lerner, the Special Counsel
of the United States. I committed to VA becoming certified, the
first large Federal department that became certified as a
whistleblower protecting organization. I have publicly
recognized and, and presented awards to whistleblowers. I meet
with whistleblowers in every location where I go visit. When I
came to this location last year, I met with Ryan Honl. I do
that. Coming out of the private sector, I understand that your
most valuable source of information on how to do things better
are your frontline employees.
The last thing you want are people that are afraid to raise
their hand, so everything we are doing as an organization has
to do with creating that kind of culture.
A little bit along the lines of what Mike said earlier, I
do not need a law to tell me to do that. That is back to just
good leadership. Not necessarily from me, but from people
across the Department.
Senator Johnson. I appreciate that.
Dr. Daigh, as I am going through the Committee's report.
And, you see that the first hotline notice, really, is about
March 2011. And, for whatever reason, it did not rise to the
level. And, then in August 2011, partly because of
Representative Kind's inquiry, it all of a sudden became a
Congressional hotline or Congressional inquiry, gained a little
steam and got the notice, but it took until 2014 to complete
this inspection, investigation, and then issue some kind of
report.
There is an awful lot of activity and I think the first
site visit was in 2012, and not a whole lot happened in 2013
into whatever date it actually was closed. What was happening
during that point in time?
Dr. Daigh. Well, let me first set the record straight on
the issue of the date at the bottom of the report. That date is
accurate. And, if you will look at the e-mails which transmit
the pdf of the report I signed, you will find that those dates
are consistent with the date I signed.
Senator Johnson. OK, good. Great. I appreciate that.
Dr. Daigh. That is absolutely the truth. And, I believe
that data may be in your hands now. I am not absolutely sure
how many of the thousands of records we gave you, you have.
The problem with this Tomah allegation was, we got a letter
very early on, that laid out a whole series of cases which
alleged that there was horrible care provided. And,
unfortunately, I received many more allegations than I have the
resources to investigate or inspect. So, with that letter, we
read it. I did not have the resources at the date that came in,
and so I sent it to VHA. I usually send it to one management
level above, so it would go the VISN. And, the VISN wrote us
back a letter with each of the cases outlying how the quality
of care has been appropriate. So, we read that letter. And, we
said, OK, this makes sense. We will say that, we will close
this at this point in time.
As part of the Combined Assessment Program (CAP) process,
we have an employee survey where we ask employees what their
view of the world is with respect to quality of care at a
facility. And, we did a CAP about that time and a number of
Tomah employees indicated that there were concerns about
medication abuse at Tomah. We had that fact.
We got a letter from Congressman Kind, saying there was an
issue, so we said OK. We need to go out to Tomah and figure out
what the real story is. And so, that launched our hotline
review.
I sent a team out there, as you note, and we made calls
before. We got all the data we could ahead of time. We went out
there. And, the allegations continued to increase. I think the
Administrative Closure lists 32 or 33 different allegations.
So, as the allegations increase, you go down more and more
tracks. And, as we would go down a track, unfortunately we got
a lot of dead ends. People would say, a certain transaction had
occurred at a certain place. We could not find any data for
that. We could not find evidence for that.
So, we decided then that what we needed to do was to pull
all the emails for employees that worked there for a certain
period of time, so you have to stop and say, ``OK let us go get
the emails.'' We had an email pull. It was insufficient the
first time. Then we had to go actually to their computers and
pull the email off their computers, and get that back. You have
to read that email. We were in continuous conversation with the
DEA, trying to understand where they were or did they have any
issues with this?
I then met with our agents and they investigated it, the
investigators. They agreed to go on-site. So, they went on site
and did work. So, it took a long time, if you have a relatively
small number of people and you have allegations that explode,
to run down each of these tracks.
Senator Johnson. And, I appreciate that, and yes, the VA,
when they undertook their own investigation, together with this
Committee, in just a couple of months pretty well substantiated
the charge and started holding people accountable, so.
Dr. Daigh. I think, for me, the important question is
whether or not VA was aware as we were doing our work of what
we were finding and were they aware that there were issues at
Tomah? And, I believe that they were at the local level, the
VISN level, and at the Veterans Affairs Central Office (VACO),
aware that there were issues at Tomah that needed to be
addressed and that we were in communication with them. Not
every fact was presented to them until we were able to assemble
the facts and put them out there, and lay them out for everyone
to see clearly.
Senator Johnson. I would argue that the responsibility of
the Inspector General is to make that information public and
also make sure that something is done about it. And, that did
not happen.
I am out of time here. Senator Baldwin.
Senator Baldwin. On the issue of accountability, I have a
questions for you, Mr. Gibson.
Dr. Houlihan was fired from the VA. And, at the time that
he was fired, I wrote to the VA to ensure that veterans would
not ultimately be referred to his practice outside the VA
through the Veterans Choice Program.
Subsequently, through public reports, his license was
suspended by the State of Wisconsin. And, I received a letter
back from the VA indicating that he would not be eligible to
serve veterans under the Choice Program because his license was
suspended.
You may or may not be aware, again, through public
reporting it appears that an Administrative Law Judge (ALJ) has
reinstated his license during the pendency of proceedings
before this State.
And so, I want to, first of all, get assurances from you
that in light of that new development, that Dr. Houlihan would
not be getting referrals of veterans through the Veterans
Choice Program.
Mr. Gibson. Absolutely not.
Senator Baldwin. And----
Senator Johnson. Senator Baldwin, if I can briefly
interrupt. That is an incredibly important point you are
making. That Administrative Law Judge is citing the White
Paper, so Inspector General Missal, would you repudiate that so
that that can no longer be used by the Administrative Law
Judge? That White Paper?
Mr. Missal. Yes. My office took the White Paper off its
website, so to me that means it no longer is a document of the
Inspector General's Office.
Senator Johnson. Thank you. Senator Baldwin.
Senator Baldwin. So, this correspondence between me and the
VA has highlighted for me that nothing in the VA Choice
legislation explicitly requires that somebody who is fired or
suspended from the VA for cause related to their service, to
our nation's veterans, there is nothing that explicitly
addresses this in the law. And so, I feel like this is a
dangerous loophole that we currently have.
I have recently introduced bipartisan legislation that just
passed the Senate, although it has not made it all the way
through the legislative process. That legislation requires the
VA Secretary to block the healthcare provider from
participating in community programs if that provider was fired
or suspended from the VA, violated his or her medical license,
had a Department certification revoked, or otherwise broke the
law.
Secretary Gibson, are there steps that the VA can take
right now to ensure that this loophole is not being exploited
to taken advantage of by other providers other than the case
that we are talking about today?
Mr. Gibson. I have not discussed the matters specifically
with the folks that are working here in the community, but I
will do so. There is no reason why we cannot implement a policy
that accomplishes the same thing without the need for
legislation.
Senator Baldwin. During our Chairman's opening statement,
he drew our attention to portions of the Committee report
discussing the concern that two of the witnesses during the
inspection were impaired, possibly by drugs or alcohol. It was
a suspicion. There is a lot of discussion in the Committee
report on this.
I think disturbing was that the only two follow-up actions
were a doctor emailed the VA OIG's General Counsel wanted to
discuss a concern regarding possibly an impaired interviewee,
or interviewees, and subsequently, and off-the-record
discussion with the Tomah VA's Director at the time, Mario
DeSanctis.
There is no clear record of whether that tip was followed
up on or not.
My question is, will the VA Office of Inspector General
adopt new policies or procedures so that if this happen in a
future case, and, of course, we hope it never does, that the IG
suspects that a witness employed by the VA is under the
influence of a controlled substance that there is a procedure
that will be followed that would provide greater accountability
and safety for our Nation's veterans?
I would like to hear both of you on that, but, this was
first noticed by the team doing the inspection, and so, I want
to hear what the Inspector General has to say about procedures
if this should ever happen again. And, then I would like to
hear from you, Deputy Secretary Gibson.
Mr. Gibson. I would love to share my two cents worth, yes,
ma'am.
Mr. Missal. With respect to my view on that, if I ever see
a situation where I think somebody, particularly somebody
providing healthcare to veterans, may be in a situation where
they are impaired in one way, I would immediately make sure
appropriate people within VHA or above that were aware of that
and to follow up and to make sure that that situation was
resolved to our satisfaction as quickly as possible.
Senator Baldwin. And, in this particular case, do you have
any knowledge that the Committee does not about whether
anything was followed up on by Director DeSanctis?
Mr. Missal. I do not have any more information.
Mr. Gibson. I am going to tell you, based upon the first
time I ever heard of this was reading it in the report. First
time ever. We are right back to leadership. That is what this
is about. This is about delivering safe care to veterans. And,
the failure of leadership that happened here was the failure on
the part of the Medical Center Director to take appropriate
action.
And, everything that I mentioned earlier, I issued the
removal on the Medical Center Director. I reviewed hundreds and
hundreds of pages of evidence. And, I will tell you, not doing
something about this would be very consistent with the pattern
of behavior that I saw there. It was a failure of leadership.
It should not have happened. Period.
The principles here, you said, put the veteran at the
center of everything that you are doing, and that is exactly
what we are trying to do. And, understanding--making leadership
in the organization understand the sense of urgency with which
they must act when something has been presented to them that
suggests, that the safety of the veteran, the care of the
veteran, may be at risk, that is an urgent situation. You have
to act and you have to act timely and promptly. That is what
these folks have been doing.
There was an instance that happened--these folks, and I am
not going to--I will not get into the great details, but here
is the timeline. They became aware on November 19, 2015, that
there was misconduct. They launched a Fact Finding the next
day, November 20, 2015. The Fact Finding was completed on
December 7 and the proposed removal was issued on December 8.
That is the kind of timely action and follow-up. That is what
good leaders do. And, that is what we have to ensure we have in
place all across this Department.
Senator Johnson. I could not agree more.
Mr. Gibson. We do not need a watchdog to tell us how to do
our job. Important to have a good watchdog, but we do not need
one to tell us how to do our job.
Senator Johnson. Congressman Kind.
Mr. Kind. Than you, Senator.
Mr. Gibson, let me stay with you, because, clearly, one of
the problems we had at Tomah was chain of command. We had a
Chief of Staff, in this case Dr. Houlihan, who was also
prescribing medication. And, getting back to the team or
coordinated approach to proper healthcare delivery, there was a
culture of intimidation----
Mr. Gibson. Yes.
Mr. Kind [continuing]. That was created by Dr. Houlihan
that made it almost impossible for someone with a dissenting
view or dissenting opinion to come forward in order to change a
certain treatment regimen.
Mr. Gibson. Yes.
Mr. Kind. Has that been fixed now? Not just in Tomah, but
throughout the VA Medical System?
Mr. Gibson. I know it has been fixed here in Tomah. I think
the issues that has been raised here prompts a review across
our organization to ensure that we have appropriate separation
of authority here.
Very early on, in fact, at the very beginning of the
Medical Center Director's tenure, the issue of separating the
reporting relationship for pharmacy was raised. The Medical
Center Director refused to do that, until, I am going to say,
roughly a year and a half later, when he finally got a new
Associate Director in place. We had problems in construction
with VA and, and the Executive Director responsible for that
area was encouraged to leave, and he did leave.
I accepted direct responsibility for construction and
facilities management until such time as we got the leadership
in place. That is precisely the kind of action that should have
been taken here.
Mr. Kind. That is the thing that probably made me the
angriest, the information coming out, and probably for more
most people in this room, was that culture of intimidation.
Mr. Gibson. Yes.
Mr. Kind. The bullying that was taking place. Good people
trying to do the right thing, keeping the focus on the veterans
were cut off. And, one instance led to a suicide. Other
instances led to firing or people leaving their positions
because of this culture that was created. I think it is just
essential that we fix that throughout the entire system or we
are going to have another hearing somewhere else in this
country, I am afraid, talking about the same set of facts.
Mr. Gibson. The day you and I were here in Tomah, last
year, together, was the day that Houlihan was placed on
administrative leave.
Mr. Kind. I remember that.
Mr. Gibson. He had been removed from clinical duties, but
it became evident to me that he was still exerting undue
influence on other providers in the organization. That was the
day he was removed.
Mr. Kind. Back to my original question--what more can
Congress be doing working with you? I think in your written
testimony, you said we have to adequately fund the OSC to make
sure that there are resources to hire additional investigators.
Do you still have that opinion?
Mr. Gibson. I do. We work very closely and very
collaboratively with the Office of Special Counsel. I would say
to my brethren next to me here that there is probably an
opportunity for the Office of Special Counsel and our IG to
work more collaboratively together. Sometimes things have
gotten in the way of that. But between our investigation
resources, their investigative resources, and the Office of
Special Counsel's investigative resources, I think there was an
opportunity for us to do better by taxpayers and better by
veterans both.
Mr. Kind. I would be happy to follow up with you in
regards----
Mr. Gibson. Yes.
Mr. Kind [continuing]. To funding levels and that, but--and
I know the VA here in Tomah are also exploring more
alternatives and complimentary forms of medical treatment----
Mr. Gibson. Yes.
Mr. Kind [continuing]. Just not loading the vets up on a
cocktail of prescription drugs and expecting that to solve all
the problems, but there is also a danger of overreacting. And,
I have some feedback from veterans that it is a little more
difficult for them to get the prescription meds, the opioids
that they need for proper pain management. I know it is a
difficult balance, but how well are we doing on that front.
Mr. Gibson. Dr. West.
Dr. West. Thank you for that question, and you bring up a
very important point that you cannot overreact, right. I mean,
I am a physician that still treats patients every week, in my
own clinic, and you know, I kind of see it every week.
Forever, the medical system as a whole, including VA and
our academic centers, was moving forward prescribing pills. We
found out that was wrong, and that that was actually killing
people.
Now we are turning a big aircraft carrier around, and the
way we are doing it is through exactly what you mentioned,
complimentary and alternative medicines, and there are other
medicines to treat pain. There are not just opiates. There are
neuromodulating agents, new agents coming out all the time.
So, as a clinician, you have to be very sensitive to the
patient and the individual case and really work through the
patient's--I mean, this is all a veteran-centric work-through,
and it takes a long time. You need things like this. This is a
brilliant thing that they have come up with at Tomah to support
frontline physicians in decisionmaking for patients, education
for patients, and other treatments for patients that they can
use for their pain.
Mr. Kind. I would also encourage the VA to continue the
efforts to provide an avenue or a line of communication for the
family members themselves. I still think they are the best line
of defense in all of this. They are going to know what is
working and what is not with the loved one and their family, so
making sure we foster that receptive environment for them.
And, finally, Mr. Gibson, we have to get the message to the
Directors of all the VA Medical Centers that they have to be as
candid and truthful and honest with us, because many of us are
visiting these campuses all the time. Check in on the veterans.
Find out what is working, what is not working. And, I am at
Tomah. I am up in the Cities. I try to get down to Madison too.
And, I am always asking, what do I need to be aware of? Are
there any problems here that I need to be aware of that we can
work with you on?
And, that did not happen, unfortunately, under Director
DeSanctis's leadership. And, I was on campus. I was looking him
in the eyes. What do I need to know? What is going on? Is there
any problems? And, I later found out that just 2 months, 2
months before I had been on campus one time, the IG was there,
with the conclusion of the report with recommendations and
changes that they were already moving forward on. And, I asked
them and they did not breathe of word of it. And, it is just so
frustrating, because if you lose that trust, and then something
like this blows up, there is a lot of preventable error and a
lot that we could accomplish, so we need to communicate with
the leadership of our medical centers. They have to be up front
and honest with us policymakers for us to make the changes that
are necessary.
Mr. Gibson. One of the things that we have been doing under
Leaders Developing Leaders, the Secretary and I have personally
met with the 600 top leaders of the entire Department, and one
of the messages that we deliver is the message that you just
spoke. It is the importance of getting news, whether it be good
news or bad news. This is a 180 degree change for this
organization. First of all, folks--they were not talking to
members of Congress or to the media under any circumstance.
What we are trying to do is to get them to talk, both when
there is good news or when there is bad news, let us get it out
on the table, own the problem, start tackling it, and get it
fixed. I mean, that is how you earn trust back.
Mr. Kind. I again commend Acting Director Brahm, because
the open policy that she has had, it has been a sea change, and
I am sure we are going to see that continue in the future.
Mr. Gibson. Yes, sir.
Senator Johnson. Congressman Walz.
Mr. Walz. Thank you, Senator. I am going to continue down
this kind of same line. And, it is about improvement, about
working towards that, and you have heard it, culture of fear,
and Senator Johnson rightfully expressed, and I am grateful for
him, on protection of whistleblowers, of making sure, folks.
And, I think that is an unfortunate name we give people. If you
look it up, the synonyms are not positive on this. These are
ethical employees trying to improve the care for veterans, and
that is how they need to be referred to and that is how they
should be treated.
And, Deputy Secretary Gibson and I have both privately and
publicly discussed this issue. And, this is frustrating amongst
all of you out there and my constituents. Nothing makes me more
boiling mad than when you are saying you know someone did
something, and then you see they are put on administrative
leave with pay, and you are thinking, I would have gotten fired
at my job on that. And, all of us up here--in 5 months, all of
us are up for that. We get a performance review, and that is
good, up or down on how it works. There is that sense of
frustration, but it is also balancing, and you have done--we
have talked through this.
Due process is important to our system of rule of law. That
is due process for the employee and due process for the veteran
and their family of trying to strike that balance.
And, I think as you work with--Mr. Kind is right about
this. It is the transparency. It is restoring the trust of the
veteran and their family so that know they are going to get the
best care, but they trust that it is going to work for them.
So, when you hear Mr. Gibson talk about this, this is no small
matter. When you hear Title 38 and some of these terms or
whatever, this part of the authority he is talking about. Laws
that both the Senate and the House passed to allow them to work
with their special executive service folks. These are the top-
ranked administrators. Those are the things we are trying to
get at.
And, I am not going--and it is not the appropriate place. I
think it is an appropriate debate, but the idea of employee due
process, sometimes this idea that you should be able to walk
in, point a finger and say, you are gone, for any reason, I do
not think any of us want to live under that. And, I do not
think any of us want to get rid of the good employees who are
there. So, what I worry about is, we go gung ho to say, just
clean the dang place out and fire all these. You have a food
service worker who has been stripped of their right to have
someone represent them, bring an allegation forward against bad
management, and they do not have anyone to stand for them, and
they are gone. And, the bad management still sits there.
So, Secretary Gibson, your point on this is you do not need
a law to do a lot of these things. What you need is an ethical
compass and the moral responsibility to care for our veterans,
which I believe we are starting to get there, but what we are
hearing from up here is, what can we do to ensure that the
public believes that? Believes that we are not protecting bad
employees? Believe we are not protecting and giving rights that
no one else in society would have for bad employees to continue
to draw a paycheck? Does the Title 38 and some of these tools--
because I can tell you now, if you think it takes a long time
to fire somebody, try and hire them at the VA. It takes longer.
You have fresh-faced graduates, psychiatrists, wanting to
serve this nation's veterans and they wait 9 months to even
hear back if they are going to get a job. These people are like
Sasquatch. If you find them, take a picture. Because there is
none of them. There is none of them.
And, again, how can we compete if they can go to Mayo
Clinic or Cleveland Clinic and make five times more?
Now, I know these people want to serve, but there has to be
a fairness, so I am just asking you, Mr. Secretary, how do we
strike this balance between appeasing the public's right for
justice and getting rid of bad actors, because I deal with
this.
I am a school teacher too. And, I know people always say,
oh, you cannot get rid of a bad school teacher. You know who
wants to get rid of a bad school teacher more than anybody? A
good school teacher teaching next door to them.
Do you know who wants to get rid of a bad VA employee? A
good VA employee.
So, how would describe what we can do to ensure you have
those tools?
Mr. Gibson. I think first of all, the Title 38 provision
around senior executives is precisely the right place to go to
give us both the authority that we need on hiring as well as
the authority that we need from a disciplinary standpoint.
I freely admit there are instances where I start wading
into a particular case, and I ask out loud, who is the advocate
for the veteran in all of this, because there are lots of
advocates for the employee. Who is the advocate for the
veteran? And, I step up and fill that particular void.
We have to ensure that we are restoring balance there and I
would tell you, one of the most powerful things that any member
can do--we all know that there are a lot of good thing going on
at VA. We all know that. And, when there are opportunities to--
I am not saying, ``do not talk about the bad things,'' because
there are bad things that we have to do, as well, Just tell the
whole picture. Yes, we have to fix this. We have to fix this,
but did you know they are doing this? They are doing this?
Because the real tragedy comes when veterans who need to
come to VA for help or for care do not, because of what they
have been reading in the media and they stay away. That is the
tragedy. You look at some of the suicide numbers and the
statistics, and I think we are close to coming out with some
refined statistics there, but, what we have seen consistently
when we have looked, is that the preponderant number of
suicides that veterans commit, each day are veterans that are
not in the VA Healthcare System.
And, you look at--the old number has been 17 of the 22 are
veterans that are not receiving care at VA. We want those
veterans into the VA Healthcare System if there is any way,
shape or form for us to get them.
There were things that we do--Gavin and I have been having
this conversation because of some of the transformational work
that he is doing. If we sat here and spent 30 minutes and
talked about all of the things that VA does around mental
healthcare, you would not realize. There is no healthcare
organization in America, perhaps even in the world, that does
the things, that has the capability that VA has. 550,000
completed mental health outpatient appointments every single
month. I mean, all of the ancillary support services that we
alluded to earlier.
Mr. Walz. I would argue with you on that. I think this is a
very important point you are bringing up and this is why that
simultaneous----
Mr. Gibson. Thank you very much.
Mr. Walz [continuing]. Accountability with improvement, if
I could, Senator Johnson, just end with this, that we as a
Nation need to not talk about those 22. We do not need to set
expectations that this is an outcome that is going to happen.
We have to talk about names and individuals, so when we are
talking about the mistake here, it is Jason and his family.
Mr. Gibson. Yes.
Mr. Walz. What we are going to produce in the future is
that individual and I think that attitude----
Mr. Gibson. Yes.
Mr. Walz [continuing]. Takes us in a better direction.
Mr. Gibson. Yes.
Voice. Thank you, sir.
Senator Johnson. Thank you, Congressman Walz.
I want to be respectful of everybody's time here. Another
round of questions would definitely eat into that time, so I
certainly encourage the Members of the Committee here and the
Congressmen to certainly submit their questions for the record.
I am sure we all have additional questions.
I want to thank our witnesses, but I particularly want to
thank the families that have suffered this tragedy and the
whistleblowers for coming forward and having the courage to
make this public. I know it is not all that easy, but this is
what transparency is all about. It is what really does produce
the kind of accountability that, and justice that really is
deserved here.
So, with that--I know I have the magic words here
somewhere. I have them.
The hearing record will remain open for 15 days until June
15, at 5:00 p.m. for the submission of statements and questions
for the record.
This hearing is adjourned.
[Whereupon, at 11:49 a.m., the Committee was adjourned.]
A P P E N D I X
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