[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]




                               BEFORE THE

                     U.S. HOUSE OF REPRESENTATIVES


                             SECOND SESSION

                         TUESDAY, MAY 22, 2018

                           Serial No. 115-62


       Printed for the use of the Committee on Veterans' Affairs

                  [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]       

        Available via the World Wide Web: http://www.govinfo.gov

35-490                     WASHINGTON : 2019        

                   DAVID P. ROE, Tennessee, Chairman

GUS M. BILIRAKIS, Florida, Vice-     TIM WALZ, Minnesota, Ranking 
    Chairman                             Member
MIKE COFFMAN, Colorado               MARK TAKANO, California
    Samoa                            ANN M. KUSTER, New Hampshire
MIKE BOST, Illinois                  BETO O'ROURKE, Texas
BRUCE POLIQUIN, Maine                KATHLEEN RICE, New York
NEAL DUNN, Florida                   J. LUIS CORREA, California
JODEY ARRINGTON, Texas               CONOR LAMB, Pennsylvania
CLAY HIGGINS, Louisiana              ELIZABETH ESTY, Connecticut
JACK BERGMAN, Michigan               SCOTT PETERS, California
JIM BANKS, Indiana
                       Jon Towers, Staff Director
                 Ray Kelley, Democratic Staff Director

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                            C O N T E N T S


                         Tuesday, May 22, 2018


The Curious Case Of The Visn Takeover: Assessing Va's Governance 
  Structure......................................................     1

                           OPENING STATEMENTS

Honorable David P. Roe, Chairman.................................     1
Honorable Julia Brownley, Acting Ranking Member..................     3


Carolyn Clancy, M.D., Executive in Charge, Veterans Health 
  Administration, U.S. Department of Veterans Affairs............     4
    Prepared Statement...........................................    37

        Accompanied by:

    W. Bryan Gamble, M.D., Deputy Chief of Staff, Orlando VA 
        Medical Center, Veterans Health Administration, U.S. 
        Department of Veterans Affairs

Honorable Michael J. Missal, Inspector General, U.S. Department 
  of Veterans Affairs............................................     6
    Prepared Statement...........................................    39
Roscoe G. Butler, Deputy Director for Health Care, National 
  Veterans Affairs and Rehabilitation Division, The American 
  Legion.........................................................     8
    Prepared Statement...........................................    47

                       STATEMENTS FOR THE RECORD

U.S. OFFICE OF SPECIAL COUNSEL...................................    50



                         Tuesday, May 22, 2018

            Committee on Veterans' Affairs,
                    U. S. House of Representatives,
                                                   Washington, D.C.
    The Committee met, pursuant to notice, at 10:15 a.m., in 
Room 334, Cannon House Office Building, Hon. David R. Roe 
[Chairman of the Committee] presiding.
    Present: Representatives Roe, Bilirakis, Coffman, Bost, 
Poliquin, Dunn, Arrington, Bergman, Banks, Mast, Brownley, 
Kuster, Correa, Lamb, and Peters.
    Also Present: Representative Moulton.


    The Chairman. Good morning. The Committee will come to 
    Thank you for being here today to discuss issues found at 
facilities in the Veterans Integrated Service Network, or 
VISNs, 1, 5, and 22; and, more broadly, the role of VISNs in 
veterans' health care.
    Before we begin, I ask unanimous consent that Seth Moulton 
from Massachusetts be allowed to join us at the dais and 
participate today's hearings.
    Without objection, so ordered.
    On March 7th, former Secretary Shulkin held a press 
conference to announce a list of reforms to increase 
accountability, streamline operations, and remove layers of 
bureaucracy in VHA. He ordered plans to restructure the Central 
Office and to reorganize procurement and logistics functions, 
both due May 1st, as well as a third plan to reform VISNs by 
July 1st.
    Additionally, Dr. Shulkin ordered a targeted VISN 
reorganization that gave rise to the title of this hearing. He 
said, quote, ``Effective immediately, we are putting a new 
executive in charge, Dr. Bryan Gamble. Dr. Gamble is going to 
have direct accountability for three VISNs as we begin to 
redesign the role of the VISNs. Those facilities will report 
directly to Dr. Gamble, who will be here in Washington, and his 
responsibility is to oversee and to directly improve the 
accountability and performance, working with our facility 
directors to make sure that these facilities are performing up 
to the standards that we expect for our veterans.
    ``What Dr. Gamble will be doing, besides just making sure 
these three VISNs are operating under the correct performance 
standards, is that a report be given to me by July 1st of this 
year with a plan to reorganize and to improve the function of 
our networks,'' end quotes.
    These were forceful measures in a crucial time. Inexcusable 
bureaucratic failures to put veterans' health at risk in those 
areas of the country, particularly at the Washington, D.C.; 
Manchester, New Hampshire; and, Bedford, Massachusetts Medical 
    Dr. Shulkin was speaking from the D.C. Medical Center in 
the midst of its highly-publicized crisis. Not only did the 
medical supply chain completely break down, leading to 
veterans' procedures being postponed or canceled, the most 
basic functions of the hospital also fell into disarray. Many 
of us visited the facility last year and saw the situation 
firsthand. And, quite frankly, at that time when I went out 
there, I was under the impression that things were improving, 
were getting better.
    The most worrying aspect for me is the fact that the VISN 
and the Central Office knew of the problems in D.C., in many 
cases for years, yet were unable or unwilling to solve them. I 
wholeheartedly agree the VISNs are due for an overhaul. They 
should be the failsafe mechanism when a medical center goes off 
course. Unfortunately, too many of them seem to be afflicted 
with a case of learned bureaucratic helplessness.
    The VISNs were created in 1995 to decentralize budgeting, 
planning and oversight. There were originally 22 of them with 
between seven and ten employees each. Today, there are 18 VISNs 
with up to 61 employees each. They perform a much wider range 
of functions, but with some exceptions, they do so 
ineffectively. Only the VISN director has any real authority 
over the medical centers within the VISN. Many of the VISN 
employees view their roles as consultative or advisory.
    I have had many questions about the reform measures. 
Obviously, May 1st has already passed, and the Central Office 
and procurement and logistics reorganization plans are nowhere 
to be found. Have these initiatives been abandoned? Secondly, 
what has truly changed in VISNs 1, 5, and 22 as a result of the 
increased scrutiny, and how will any improvements be extended 
to other VISNs? Thirdly, what is the vision for the nationwide 
VISN redesign?
    I look forward to reading the plan, but July 1st is 
approaching fast and we have heard very little about it. If VA 
does not articulate a definition of success with measured 
outcomes, we have no guarantee that veterans will be better off 
under this restructuring.
    I held a roundtable discussion almost a year ago with VA 
and over a dozen private sector health care organizations. 
Every one of them deals with the question of centralization 
versus decentralization. Most of the large hospital systems 
have some sort of regional organization. The Choice Act 
independent assessment and the Commission on Care both closely 
examined VHA's organization. There are many places VA can look 
for guidance when considering how to reshape the relationship 
between the Central Office, the VISNs, and the medical centers.
    This Committee and the Congress as a whole are committed to 
VA's success. I think the MISSION Act and another budget making 
historic investments in veterans' health care and benefits are 
evidence of that. I have high expectations for these 
reorganization plans. It is vital to define the goals at the 
beginning, engage stakeholders, and be transparent throughout. 
This cannot merely be a public relations exercise to get 
through the crisis of the moment or more glossy reports that 
sit on shelves.
    I look forward to an open and honest conversation today 
about how we can ensure these particular VISNs and their 
medical centers live up to their purpose, and how we can 
strengthen VHA's governance so this sort of horrendous neglect 
never happens again.
    The Chairman. With that, I yield to Ms. Brownley for her 
opening statement.


    Ms. Brownley. Thank you, Mr. Chairman, for holding today's 
hearing on Veteran Integrated Service Network, or VISN, 
    The organizational structure of the Veterans Health 
Administration has long been an issue and I am concerned that 
the current VISN structure is leading to unclear roles and 
responsibilities at the highest levels of VA management. We are 
here today so we can understand how the organization and its 
leaders, and now lack of leaders, are contributing to the 
problems in facilities across the country.
    VA Medical Centers in Manchester, New Hampshire; Bedford, 
Massachusetts; Washington, D.C.; and Phoenix, Arizona all have 
one thing in common: in every case, VISN and VA Central Office 
leaders were aware of infrastructure, care, quality, and 
patient safety concerns, but did not take the appropriate 
actions until the IG or whistleblowers uncovered these issues.
    Take the D.C. VA Medical Center as the latest example. The 
medical center VISN and Central Office leadership ignored at 
least seven reports that, if considered, could have prevented 
nearly every issue that was identified during the IG's 2017 
investigation. This is very disturbing and unacceptable.
    Senior leaders must be held accountable for failing to act 
and we must take a hard look at the organization from top to 
bottom to determine what is causing this lack of 
    Last November, Congresswoman Kuster and I requested a GAO 
review of the role and responsibilities of the VISNs. Chairman 
Roe joined in that request, because our concern is a bipartisan 
    After whistleblower complaints, an IG and Office of Special 
Counsel investigations uncovered significant patient care and 
infrastructure issues at facilities within VISNs 1, 5, and 22, 
former Secretary Shulkin announced that he planned to task Dr. 
Bryan Gamble, here with us today, with overseeing a significant 
restructuring effort involving those VISNs. However, we lack an 
understanding of what this receivership or restructuring effort 
entails, and seek to understand what this announcement actually 
means. We would like you to clear that up for us today.
    It is our understanding that Dr. Gamble will not in fact be 
leading a restructuring of these three VISNs, but would instead 
provide us a report in June, or perhaps it is July. We are 
tired of receiving reports, we are tired of inaction and, as I 
mentioned before, there were seven reports on the D.C. VA 
Medical Center.
    Senior leaders in VISN 1 and at VA Central Office also 
received reports on the Manchester VA Medical Center, but did 
nothing until it became a national headline. If this 
restructuring is simply a report, then we must ask who will be 
responsible for leading VISNs 1, 5, and 22 now that they are 
leaderless, and we must ask when key senior leaders' positions 
will be filled at the VA Central Office.
    We must also ask which leaders are contributing to what the 
Inspector General describes in his testimony as a culture of 
complacency and futility at VA Medical Centers, where dedicated 
and hardworking staff believe their leaders will do nothing to 
address problems, where leaders will not address provider 
concerns, and where staff must just make do with few resources 
and a disorganized and unaccountable organization. These 
leaders should be held accountable for failing to take action. 
These leaders should also be accountable for misleading 
Congress and the press. A failure to be forthcoming about 
patient safety, quality of care, infrastructure, and patient 
access concerns hurts our ability to conduct oversight, 
contributes to the sense of futility among providers, and 
creates anxiety, mistrust, and frustrations for veterans who 
rely on VA for their health care.
    I hope today to hear more about what VA is actually doing 
in response to the top-to-bottom organizational failures that 
contributed to the most recent events in the Manchester, 
Bedford, and Washington, D.C. medical facilities.
    Thank you, Chairman Roe, and I yield back.
    The Chairman. I thank the gentlelady for yielding.
    I would now like to welcome our panel seated at the witness 
table, if you would.
    On the panel, we have Dr. Carolyn Clancy, Executive in 
Charge of the Veterans Health Administration. She is 
accompanied by Dr. Bryan Gamble, the Deputy Chief of Staff of 
the Orlando VA Medical Center. Welcome.
    On the panel, we also have the Honorable Michael Missal, 
Inspector General of the Department of Veterans Affairs, and 
Mr. Roscoe Butler, Deputy Director for Health Care, National 
Veterans Affairs and Rehabilitation Division of The American 
    Welcome each one of you to the panel.
    I ask the witnesses to stand and raise your right hand.
    The Chairman. Thank you very much. Let the record reflect 
that all witnesses have answered in the affirmative.
    Dr. Clancy, you are now recognized for 5 minutes.


    Dr. Clancy. Good morning, Chairman Roe, Ranking Member 
Brownley, and Members of the Committee. I appreciate the 
opportunity to discuss the proposed redesign of the current 
Department of Veterans Affairs Veteran Integrated Service 
Network, or VISN, structure and the status of remedial action 
at VISNs 1, 5, and 22.
    I accompanied today by Dr. Bryan Gamble, Deputy Chief of 
Staff at the Orlando VA Medical Center.
    On March 7th, as the Chairman noted, former Secretary 
Shulkin announced VA would undertake a systematic review of the 
VISNs with a specific focus on 1, 5, and 22. These three VISNs 
were challenged with leadership and management issue, low-
performing facilities, and culture issues.
    The purpose of this review is to identify VISN strengths 
and weakness, and to create a plan to improve VISN oversight, 
accountability, performance, and strengthen lines of 
communication and clarify roles and responsibilities. Based on 
his extensive leadership with the military health system, Dr. 
Bryan Gamble was asked to lead this review and provide 
recommendations with the goal of informing that redesign 
    Our goal is to streamline processes, ensure clearly-defined 
roles, responsibilities, and authorities among all levels in 
VHA, so that we are functioning in a way that is more efficient 
and, most importantly, produces better results and 
accountability. We have also been working with our national 
leadership council to develop a new model of governance to 
shape the culture, and set expectations and requirements for 
improved care for veterans.
    Under the VISN model, health care is provided through 
strategic alliances among medical centers, clinics, and other 
sites, contractual arrangements with private providers, sharing 
agreements, and other government providers. The VISN is 
designed to be the basic budgetary and planning unit of the VA 
health care system.
    Since Dr. Shulkin's announcement, a team led by Dr. Gamble 
has visited all three VISNs. And to look at best practices, the 
team also visited consistently high-performing VISN 23. A 
resounding theme was a dedicated workforce set on providing 
veterans with the best possible health care, and a clear 
understanding and willingness from leaders and employees at all 
levels to improve upon deficiencies wherever found.
    While these three networks are pretty dispersed 
geographically, the assessment team found common themes across 
these networks and facilities, including inconsistency of HR 
services and hiring; additional emphasis needed on education 
and training; unintended consequences of Management by 
Measurement; leadership challenges, including turnover, 
consistency, and psychological safety; and employee morale.
    The findings from this review will be combined with ongoing 
feedback and work from the existing network directors, and our 
ongoing modernization effort to formulate the final plan for 
redesign of the VISNs.
    One of the key concerns of this Committee is the progress 
at the Washington, D.C. VA Medical Center. While there is still 
a lot of work to be done, significant progress has been made.
    In March of 2018, as the Chairman noted, the Inspector 
General released a final report finding that the D.C. VA had 
for many years suffered a series of systemic and programmatic 
failures, making it challenging for health care providers to 
consistently deliver timely and quality patient care.
    To key on a couple of improvements made since the interim 
report was submitted by the IG in April of 2017, some of the 
improvement efforts include assuring that all patients were 
safe and none were harmed. VHA's National Center for Patient 
Safety launched a rapid-response approach with on-site visits, 
biweekly and weekly calls with the facility and VISN, and 
assured all patient-safety issues were appropriately addressed.
    We awarded a contract to construct a new, 14,200-square-
foot space for Sterile Processing and that will be completed in 
March of 2019.
    Transitioned inventory to the Generic Inventory Package 
eliminated all pending prosthetic consults greater than 30 days 
from more than 9,000 to zero. In short, ordering of prosthetics 
is not interrupted by end-of-year financial transitions, and 
allocated resources and expedited hiring into logistics and 
Sterile Processing Service vacancies.
    We know that how these networks operate is imperative. To 
get the type of accountability that we need at every place 
where veterans may seek our assistance and to ensure the best 
quality of care is delivered, we have to take a critical look 
at the processes, layers, and leaders to make sure that we 
don't see the failures that we didn't see at the D.C. VA.
    As the VHA and the D.C. VA move forward, we are putting in 
place a reliable pathway for all facilities, VISNs, and 
business lines to escalate high-priority concerns to senior 
leadership for prompt action and follow-up. We encourage all 
employees to speak up and raise concerns to leadership, because 
they are an integral part of our front-line safety net and we 
take their concerns very seriously.
    Mr. Chairman, we appreciate this Committee's continued 
support and encouragement in identifying and resolving 
    In short, there are no missing VISN directors, what we are 
losing is a past practice of inconsistencies in management and 
oversight across VISNs and all of VA health care. This enhanced 
consistency is imperative to our ability to achieve the best 
possible outcomes for veterans envisioned by the MISSION Act, 
which this Committee passed and subsequently the full House 
passed last week, as well as to assure that we get the most out 
of the new electronic health record implementation and that 
that translates into enhanced results for those who have 
    This concludes my testimony, and Dr. Gamble and I are 
prepared to respond to any questions that you might have.

    [The prepared statement of Carolyn Clancy appears in the 

    The Chairman. Thank you, Dr. Clancy.
    Mr. Missal, you are recognized for 5 minutes.


    Mr. Missal. Thank you. Mr. Chairman, Ranking Member 
Brownley, and Members of the Committee, thank you for the 
opportunity to discuss the Office of Inspector General's 
report, ``Critical Deficiencies at the Washington, D.C. VA 
Medical Center.'' We found that serious failures in leadership 
and governance contributed significantly to the problems we 
    Since becoming Inspector General 2 years ago, I have made 
examining leadership and governance issues at all levels of VA 
a priority for our work, as shortcomings in these areas affect 
the care and services provided to veterans, put Government 
assets at risk, and allow significant problems to persist for 
extended periods of time.
    In March of 2017, we received a confidential source about 
the D.C. VA alleging that supply and inventory issues put 
patients and resources at risk. After a very quick assessment, 
we determined that patients were at risk as a result of the 
supply and inventory issues, that these problems were known at 
various levels at VHA, but that VHA had failed to take the 
necessary corrective action. As a result, we took the 
extraordinary step of issuing an interim report. That interim 
report was issued on April 12th, 2017.
    We continued the inspection and issued our final report on 
March 7th, 2018. Significantly, while we found patients were 
put at unnecessary risk, we did not find any patient deaths or 
other adverse clinical outcomes relating to these deficiencies. 
This was primarily due to the efforts of a number of committed 
health care professionals who improvised as necessary to ensure 
veterans received the best possible care under the 
    Our final report contained 40 recommendations addressing 
deficiencies in multiple core functions of the D.C. VA's 
operations, all of which were agreed to by VA.
    The more significant findings in our final report related 
to patient safety include continuing supply chain and inventory 
management problems; unsafe storage of clean, sterile supplies; 
deficiencies in sterile processing service; inadequate product 
safety recall practices; backlogs of open and pending 
prosthetic consults; and staffing shortages and human resource 
    Aside from the deficiencies that resulted in risk to 
patients, we also found that the medical center continually 
mismanaged significant Government resources and did not 
adequately secure veterans' protected information. The D.C. 
VA's financial and inventory systems produced inadequate data, 
lacked effective management controls, and yielded no reasonable 
assurance that funds were appropriately expended. Accordingly, 
we could not estimate the loss to VA as a result of the 
failings identified in the final report.
    It is clear that information about at least some of the 
failings at the D.C. VA reached responsible officials in the 
D.C. VA VISN 5 and VHA Central Office as early as 2013, but 
actions taken did not effectively remediate the conditions.
    From 2013 through 2016, the D.C. VA and VISN 5 received at 
least seven written reports detailing significant deficiencies 
in logistics, sterile processing, and other services. The 
chronic deficiencies noted in these reports underscore the 
inability or unwillingness of leaders at various levels to 
implement and sustain lasting change within various services.
    In conclusion, the critical deficiencies we found in our 
inspect of the D.C. VA were serious and disturbing. While the 
failures present significant challenges, we believe the 
greatest obstacle to change is a sense of futility and a 
culture of complacency among staff and leaders. At the core, 
the D.C. VA report is about the breakdown of systems and 
leadership at multiple levels, and an acceptance by many 
personnel that things will never change.
    VHA has talented and committed people who could lead the 
turnaround at the D.C. VA. With time and concerted effort, we 
believe that positive change can be realized. VHA needs to 
recognize the urgency in making strong leadership decisions now 
to oversee that change. Although the findings and 
recommendations focus on improvements in the D.C. VA, the 
issues raised could be a checklist for other facilities, VISNs, 
and VA leaders.
    Mr. Chairman, this concludes my statement. I would be happy 
to answer any questions that you or other Members of the 
Committee may have.

    [The prepared statement of Michael Missal appears in the 

    The Chairman. Thank you, Mr. Missal.
    Mr. Butler, you are recognized for 5 minutes.


    Mr. Butler. Good morning.
    In 1994, the Veterans Health Administration was structured 
into four regions. There was widespread consensus that the 
system needed a major overhaul. In that same year, President 
Clinton appointed Dr. Kenneth Kizer as VA Undersecretary for 
Health. Dr. Kizer inherited an organization famous for low-
quality health care, difficult to access, and at a cost not 
sustainable for the American taxpayers.
    Chairman Roe, Ranking Member Brownley, and distinguished 
Members of the Committee, on behalf of our National Commander 
Denise H. Rohan and The American Legion, the country's largest 
patriotic wartime service organization for veterans, comprised 
of more than 2 million members and serving every man and woman 
who has worn the uniform for this country, we thank you for 
inviting us to share our position regarding the current status 
of remedial actions at VISNs 1, 5, and 22.
    The Veterans Health Care System is the largest health care 
system in the United States. This national veteran-centric 
health care system is centrally administered, fully integrated, 
and is both funded and operated by the Federal Government. The 
purpose of creating the VISN structure was to decentralize 
decision-making authority regarding how to provide care and 
integrate the facilities to develop an interdependent system of 
care through the VISNs.
    The VISNs' primary function was to be the basic budgetary 
and planning unit of the Veterans Health Care System. However, 
as we all know, the VISN structure has morphed into an 
extensive operation consuming more staff, resources, funding, 
and physical space.
    Since the birth of Dr. Kizer's plan, VISN staff and 
functions have extended way beyond the original tent of Dr. 
Kizer's VISNs for Change. Since the creation of the VISN 
structures in 1995, both the veterans' demographic and 
geography has changed quite a bit, yet VA has not reassessed 
the VISN structure to determine if it still benefits veterans. 
However, in October 2015, VA has begun to implement a 
realignment of its VISN boundaries, which involves decreasing 
the number of VISNs from 21 to 18, and reassigning some medical 
centers to difficult VISNs.
    A concern of The American Legion is that VA officials have 
stated that they do not have plans to evaluate the realignment 
that is currently taking place. According to GAO, VA actions 
are inconsistent with Federal internal control standards for 
monitoring and risk assessments. Without adequate monitoring, 
including a plan for evaluating the VISNs' realignments, VHA 
cannot be certain that the changes they are currently making 
are effectively addressing deficiencies, nor can it ensure 
lessons learned can be applied to future organizational 
structural changes.
    There is no question that VA has endured its challenges. 
For example, the Phoenix scandal of 2014, the 2017 VA OIG 
report about equipment and supply issues at the Washington, 
D.C. VAMC, to the January 2018 report of poor patient care at 
the Manchester Medical Center. I highlighted these issues not 
to open an old wound, but would rather use them to illustrate 
that these may be evidence that the VISN structures lack 
oversight and control, and is not living up to Dr. Kizer's 
original vision of a patient-centered, integrated, independent 
system of care.
    The American Legion believes that is why former Secretary 
David Shulkin announced his plan to reorganize the Department 
VISNs network. Dr. Shulkin also discussed the appointment of a 
special team to work with VA's national leadership council to 
develop a network reorganization plan for its 23 VISNs, which 
is due to the Secretary by July 1st of this year.
    Mr. Chairman, clearly Dr. Kizer's Vision model is no longer 
living up to the expectations, but rather has gone into a high-
cost, ineffective operation. In 2016, our members acknowledged 
and voiced their concerns about this growing problem. Like most 
veterans do, they took action and passed a resolution 
discussing the effectiveness or the ineffectiveness of the 
current VISN structure.
    American Legion Resolution 194 entitled ``Department of 
Veterans Affairs Integrated Service Networks'' urged Congress 
to direct the GAO and VA OIG to conduct a comprehensive study 
to include purpose, goals, objectives, budget, and finally an 
evaluation of the effectiveness of the VISN structure as a 
    Further, The American Legion applauds former Secretary 
Shulkin for proposing to look into reorganizing the VISNs and 
the Central Office.
    In conclusion, The American Legion thanks this Committee 
for the opportunity to elucidate the positions of the over 2 
million veteran members of this organization.
    Chairman Roe, Ranking Member Brownley, and distinguished 
Members of this critical and serving Committee, The American 
Legion is so very thankful for the opportunity to be here 
today. As Memorial Day is upon us, please allow me to also 
thank each of you for the incredible work this Committee does 
every day to help those who have already helped us.
    With that, I conclude my remarks and I am happy to answer 
any questions this Committee may have.

    [The prepared statement of Roscoe G. Butler appears in the 

    The Chairman. Thank you, Mr. Butler.
    I will start the questioning by thanking the Committee for 
passing the MISSION Act. The Senate will vote on it this week. 
We have had seven past Secretaries and Administrator sign 
supporting that in both Republican and Democrat 
administrations. So, thank you for that.
    And I voice some frustration because this Committee 
continues to produce legislation and this Congress, both 
Republican and Democrat, continue to produce enormous amounts 
of money for the VA, and yet what Mr. Missal tells us is that 
there is a failure of leadership and governance within these 
VISNs that he looked at.
    And I want to give a shout-out to the health care people at 
the hospitals who did the work around these things to help 
patient safety. I want them to know I appreciate that very much 
and I know that the veterans who are served there appreciate 
that very much, to know that they created as safe an 
environment as they possibly can even with these obstacles. So 
I thank them for that.
    I want to just start by just telling you how my day would 
start and end when I was in practice. If I had a big number of 
cases the next day in the operating room, the operating room 
people, folks would show up in my office at 4:30, 5 o'clock, 
5:30 when I saw my last patients, and they would say, ``Dr. 
Roe, we have everything you need for tomorrow's surgery.'' 
Maybe you are doing a laparoscopic hysterectomy or maybe you 
are doing a cancer case. We have got everything you need; we 
have got blood available, we have got all your sutures, we have 
got any prostheses you need, everything you need is ready for 
you in the morning. There was never a question about it, I 
never worried about that. I worried about doing my job.
    It looks like at the Washington VA the doctors and nurses 
had to worry about not only doing their job, but running across 
the street during a case to get things that they needed to take 
care of a patient. In one case, they put a patient to sleep and 
then woke him up because they didn't have the equipment to take 
care of him. That is absurd to do that to a patient, it is 
risky. Anesthesia is not as risky as it used to be, but still 
it is some risk to have these drugs and go to sleep.
    So I want to start just very quickly. Dr. Clancy, at the 
VA, the Washington, D.C. VA Medical Center, which many of us 
have visited, and the supply shortages, and we talked about 
postponing and so forth, but the financial mismanagement is 
unbelievable to me. Somebody paid $289 for a speculum that 
should have cost $122, $900 for butterfly needles that should 
have been $251. Eight dollars for these little yellow socks, 
those ugly socks you wear around the hospital so you won't slip 
that should cost 82 cents. And all of that should have gone 
through the medical/surgical prime vendor and saved a lot of 
    And that is my frustration is we are providing more and 
more money, and yet we are seeing this. Here is a case where 
someone rented three hospital beds for almost $900,000 when 
they could have bought them for a fraction of that, just bought 
the thing, it would have cost that. And also somebody bought $1 
million worth of copy paper. That is 60 pallets of copy paper 
and they didn't have anywhere to store it even. How do you do 
that? That would never happen in the private world. If I were a 
HCA, a hospital administrator or a hospital administrator at 
Mountain States where I worked, I would be fired, period. My 
job would be over if I did anything that bone-headed.
    So how in the world are we to sit up here and continue to 
provide these resources? We have got to go back to our 
constituents and explain. And we want to help veterans and Mr. 
Butler knows that this Committee wants to do that. That is just 
pure waste. Think about it, that is almost $1 million that 
could have been spent on health care.
    So, Dr. Clancy.
    Dr. Clancy. Mr. Chairman, I would love to tell you that you 
got some details wrong or facts, but you are absolutely right. 
But I think that a lot of what you are saying underscores why 
we need stronger networks for that kind of financial oversight, 
that simply was not happening.
    Now, I don't know entirely going back several years whether 
that is the VISN's problem or the facility's problem. People 
who want to hide things can sometimes be very creative. We are, 
as you know, getting a new financial management system, which I 
think will help a lot, but that is inexcusable and should not 
have happened, period.
    The Chairman. It absolutely shouldn't. And so I guess my 
question is, when we--and Mr. Butler pointed this out in his 
history of the VISN--do we need a VISN? I mean, it looks like--
I was trying to figure out what the VISN did and we are here to 
look at 1, 5, and 22, and I know other Members will have some 
much more detailed questions, but is it necessary? Maybe we 
could--we have regional offices and the disability, there are 
five of them I think in the country, do we need to shrink that?
    The question is, I can't figure out what the VISN does. If 
the VISN couldn't oversee that, what good are they?
    Dr. Clancy. Well, what I think is that VISNs were initially 
set up, the phrase that was bandied about a lot was 
laboratories of innovation, and if you achieved the results 
that then Undersecretary Kizer asked for, how you got there was 
fine. Since then, I think thinking in contemporary health care 
has changed quite a bit. For one thing, a whole lot more care, 
as you know from your own practice, that used to be in the 
hospital now gets done on an out-patient basis and so forth, 
which is a very, very different kind of set of challenges.
    I believe that the VISNs have a vital role and that we are 
using this opportunity to learn from other industries. I 
actually consulted with the Chief Medical Officer of HCA within 
the past couple of days. Dr. Perlin chairs an advisory group 
for us and he said the only way you can possibly get to 
consistency across a large, far-flung system is to have 
accountable regional leadership, so that you get alignment 
right down to the unit level. So that is what we are trying to 
    The Chairman. Well, my time has expired, and I will now 
yield, but I am going to throw this question out to be 
answered. What is VISN 23 doing that 1, 5, and 22 didn't do? 
Just hold your question.
    Ms. Brownley, you are recognized.
    Ms. Brownley. Thank you, Mr. Chairman.
    And I want to drill down a little bit on the Chairman's 
question. So, Dr. Clancy, and I ask you to be as specific on 
this question as you possibly can be, I wanted to zero in on 
sort of the oversight roles and responsibilities for key 
leaders within the VISN, but I wanted to drill down 
specifically on one and that is the Medical Director.
    So what is his or her responsibilities very, very 
specifically in terms of their role and responsibilities to a 
Central Office, their role and responsibility to medical 
centers, and making sure that we are optimizing patient care at 
each and every one of those facilities? If you could be very 
specific about that, I would appreciate it.
    Dr. Clancy. I just want to be clear, Congresswoman, the 
Medical Director. There is a Chief Medical Officer at the 
network level and then for every facility there is a Chief of 
Staff who is colloquially sort of the top physician. Is that 
what you mean?
    Ms. Brownley. The Network Director.
    Dr. Clancy. The Network Director, okay. So the Network 
Director has a number of key positions and this we are also 
standardizing across all of the VISNs. They have a Chief 
Medical Officer who is attentive to all of clinical oversight 
across these facilities, frankly keeping an eye on where there 
are common gaps and deficiencies. For example, sterile 
processing is an issue that we struggle with, as does much of 
private sector health care. And as well as making sure that 
clinicians are held accountable, and that their training and 
continuing education is up to date.
    And, frankly, when they uncover unexpected issues, for 
example an IT glitch resulting in consults that don't go 
through as expected, they bring that forward both to the VISN 
director and also to Central Office, so that we can figure out 
is this affecting other facilities and networks across the 
system and so forth.
    Ms. Brownley. So then why did some of these disasters 
happen in some of these VISNs? And if that is the role and 
responsibilities, why did it happen?
    Certainly in New Hampshire, in Massachusetts, it ended up 
being the headlines in the Boston Globe, and then there seemed 
to some kind of response to that and we had Inspector General 
reports. What failed?
    Dr. Clancy. What failed was we did not have a consistent 
job description for Network Directors in concrete, specific 
terms that you are asking for.
    So when I have visited with networks, and I have visited 
with quite a few and asked them how do you follow up on these 
things, what is your oversight function and so forth, tell me 
what happens if a facility gets in trouble and so forth. What I 
often heard was, well, we do the following, for example we did 
this, but that is how our network works, we don't know if that 
is how other networks do it. So we have not had that 
    It is fair to say that some of our previous Network 
Directors had a much more hands-off approach for a variety of 
reasons. I think it is also fair to say that in 2018 that is 
simply not going to be the path by which we assure that all 
veterans get great care, period.
    Ms. Brownley. Thank you.
    Mr. Missal, do you see evidence that there has been a 
streamlining in these roles and responsibilities across all 
    Mr. Missal. No, we haven't seen that. In fact, what Dr. 
Clancy said I think really was right on point, which is there 
seems to be confusion about the roles and responsibility of the 
VISN directors. Let me give you a concrete example.
    When we interviewed the VISN 5 director who is responsible 
for Washington, D.C., he said the buck stops with him, but in 
the same interview he said he wasn't responsible for any of the 
problems that were identified at the facility. So on one level 
he is saying he is responsible, on the other level he is 
pointing his finger at the medical center director saying it is 
that person's responsibility.
    So I think there is great confusion out there about what 
the VISN director is supposed to be doing.
    Ms. Brownley. Do you think we need VISNs?
    Mr. Missal. I think in certain situations they have been 
very helpful, but it all goes down to the people involved. If 
you don't have the right people in leadership, if they are not 
held accountable, I don't think it matters what structure you 
are going to have. It is going to be problematic.
    Ms. Brownley. Do you think the roles and responsibilities 
of VISNs can be narrowed pretty significantly?
    Mr. Missal. I think they certainly should be clarified and 
then we look forward to seeing what VA comes up with in terms 
of their study of the VISN system.
    Ms. Brownley. Thank you.
    My time is to an end and I yield back.
    The Chairman. I thank the gentlelady for yielding.
    Mr. Coffman, you are recognized for 5 minutes.
    Mr. Coffman. Thank you, Mr. Chairman.
    So one question is, Mr. Missal, so I think in the spring of 
2017 on VISN 5 there was a complaint that turned into an OIG 
report, I just can't see why--and maybe this is to Dr. Clancy 
as well--why the VISN just didn't respond and correct the 
problem themselves instead of wait for all the time that it 
takes to do a VA OIG of a report?
    Mr. Missal, why don't you address that first.
    Mr. Missal. When we issued the interim report, there was 
immediate action by the Secretary. He replaced the medical 
center director at the time and made some other changes. We 
then continued our inspection.
    We did see some improvements, certainly not complete 
improvement, and it wasn't clear to us how much of that was 
coming from the Secretary versus the VISN versus the medical 
center. And I guess I would defer to Dr. Clancy for more 
    Mr. Coffman. Okay. Let me follow up with a second question 
for you that the Chairman had raised and that was also raised 
by the Ranking Member, that is the structure. What you have 
mentioned, the VISN structure, and I have heard and I am sure 
everybody on this Committee has heard it, that if you have seen 
one VISN, you have seen one VISN. In other words, that there is 
no uniformity in terms of quality and based on the way that it 
is structured intentionally to allow for innovation, to allow 
for independence. However, you also, you said in your comment 
that if you don't have the right people in place, this is not a 
good structure.
    Look, I have been on this Committee now since January of 
2013 and the one thing that I have unfortunately found is a lot 
of times, for whatever reason, there is not the right person in 
place. So we need a system that inherently makes it more 
    And I think if we did away with VISNs and sought more 
uniformity, is there a savings opportunity there in terms of 
shrinking the bureaucracy, Mr. Missal?
    Mr. Missal. I think that is really hard to say. Obviously, 
VHA is a large, complex integrated health care system. It is 
important for there to be some consistency. It is also 
important for there to be flexibility at a local level. And so 
getting the right governance structure is a very tricky thing 
that deserves extensive study.
    Mr. Coffman. Isn't it true, though, that is the more 
flexibility we grant, it seems like the more problems that 
there are, when we look at procurement?
    Mr. Missal. In certain situations, that is correct, yes.
    Mr. Coffman. Dr. Clancy?
    Dr. Clancy. So, Congressman, you asked about what were the 
VISN and Central Office doing before the Inspector General 
issued their interim report. We sent in several investigative 
teams in a few months prior to April and, frankly, couldn't 
find anything.
    So what was happening was we were hearing from employees, 
many missives from home emails and so forth, not clearly 
identifying themselves, with very nonspecific issues. So we 
would send the Office of Medical Inspector over and so forth.
    Incredibly enough, shortly before the Inspector General 
issued their report, the joint commission said that the D.C. 
VA, they did pretty well on their accreditation survey, which 
amazes me to this day. What the VISN and headquarters had seen 
probably 2 to 3 months out was that there were glaring gaps in 
hiring and logistics. And if you don't have boots on the ground 
to actually make sure you have got the supplies, Dr. Roe can be 
waiting to tell people, but if there is no one there, who is 
going to get the supplies? That won't actually be very 
    Since then, we have actually done a lot of hiring. The 
Chief of Logistics was held accountable for what was going on 
there and there have been substantial improvements.
    Mr. Coffman. So when you say the Chief of Logistics has 
been held accountable, tell me what disciplinary action was 
    Dr. Clancy. He was terminated.
    Mr. Coffman. Oh, he was terminated?
    Dr. Clancy. Yeah.
    Mr. Coffman. Okay, very good, very good.
    Mr. Chairman, I yield back.
    The Chairman. I thank the gentleman for yielding.
    And I will now yield 5 minutes to Ms. Kuster. Welcome back 
to the Committee. You look healthy and well after your little 
event with a knife. And so welcome back, you look great.
    Ms. Kuster. Well, and I want to thank the chair for 
rescheduling the hearing. My new hip is going great and I 
really appreciate it. So I want to stay focused on good health 
care for our veterans.
    Thank you very much for appearing before us today and this 
is a hearing that I had requested of the chair to investigate 
VISN 1, but I am also attentive to the concerns in VISN 5 and 
    I don't want to spend a great deal of time looking back, 
but I think in order to understand where we are and how to 
restructure, we need to understand where we have been. So in 
VISN 1 in New Hampshire, Manchester VA, we were confronted with 
a four operating rooms, one of which was shut down as a result 
of a 16-year-long battle with cluster flies. You can imagine 
the concern there. We had a VA physician that had cut-and-
pasted patients' medical records without updating patients' 
conditions. And we had a situation that is really tragic of 
patients that suffered from preventable spinal damage, 
including paralysis, after the hospital failed to provide 
proper care for a treatable spine condition known as cervical 
    So in September of 2016, a group of whistleblowers 
presented their concerns to me and to our delegation on 
September 6th, 2016. And forthwith, in September, we referred 
the allegations to the Office of the Inspector General, and the 
Office of the Inspector General referred the complaints to the 
Office of Medical Inspector.
    Since then, we have been aggressively pursuing this. And I 
want to thank my co-chair, General Bergman, for coming to New 
Hampshire for an oversight hearing. We appreciate that. We have 
worked with Dr. Clancy, with certainly Secretary Shulkin. And I 
just want to point out a couple of places where I have concerns 
in order to understand the roles going forward.
    And, Dr. Clancy, in response to Julia Brownley you said 
that the role of the Medical Director is to provide clinical 
oversight across facilities, and that person reports both to 
the VISN and to Central Office. When was then Secretary Shulkin 
first made aware of our concerns from our congressional 
delegation both to the OIG and to the OSC?
    Dr. Clancy. So I believe, Congresswoman, that the New 
Hampshire delegation sent then Secretary McDonald a letter 
copied to Dr. Shulkin in the fall of 2016, but it was--and I 
know you and I have had this conversation--to protect the 
confidential of the whistleblowers, general and not very 
specific about your concerns. I can't speak to what specific 
actions were taken then.
    We became aware of the whistleblower case when the case was 
referred to the Office of Medical Inspector and then when the 
spotlight team from the Boston Globe was contacting the VISN 
and the facility and headquarters.
    Ms. Kuster. And so that is my concern. And, yes, indeed 
there was a concern of the whistleblowers that they didn't want 
to come forward and identify themselves and that constrained 
our ability to press this, but it causes me concern that it 
would have to go so far as a spotlight team at the Boston 
Globe. Why wouldn't the Medical Director who was one of the 
whistleblowers have been able to convey these concerns up 
through the chain?
    I mean, why would they need to become whistleblowers? Why 
wouldn't, you know, something as serious as paralysis because 
patients weren't being treated appropriately, why did it go 
this far is my question?
    Dr. Clancy. The short answer is, I don't know. My 
hypothesis, with some fair documentation--or confirmation, I 
guess would be a better way to say it, was that the leadership 
at that facility was not listening to some of these physicians 
who were generally concerned.
    There is a physician at Manchester who I know well because 
I trained him when he was an intern and so I called him for a 
bit of a reality check. And he told me their concerns were 
genuine, he thought incredibly well of Dr. Kois and a few other 
people. And I would vastly prefer, which is something I 
emphasize in just about every time I speak, that if people have 
concerns they speak up and that we can do something about that.
    Now, sometimes people have concerns and we are going to 
take another look and it won't exactly match what their 
conclusion was, but much, much better. People calling out 
problems is the greatest gift we have, and getting into the 
whistleblower process necessarily delays that for protecting 
confidentiality and so forth.
    Ms. Kuster. Well, thank you. My time is up, but that is one 
of the reasons why we have worked together on expanding 
protections for whistleblowers. And I certainly agree with you, 
we need to create an environment where concerns are addressed 
at the earliest possible date.
    So I yield back. Thank you.
    The Chairman. I thank the gentlelady for yielding.
    Vice Chair Bilirakis, you are recognized.
    Mr. Bilirakis. Thank you. Thank you, Mr. Chairman, I 
appreciate it very much.
    Earlier this year I got involved in a particular case at 
Bay Pines with regard to VA Health Care System, again at Bay 
Pines in St. Petersburg, just outside of my district, where a 
group of homeless veterans were in a particular facility there, 
a building, and there was no hot water, adequate, you know, hot 
water at different various times or heat during the winter for 
a six-month period of time.
    And I was notified and within a week, I contacted Secretary 
Shulkin and within a week, maybe 3 or 4 or 5 days after I got 
involved and the Secretary got involved, we remedied the 
situation, but that should not happen and I know everybody 
agrees with that. And then the media got involved and the whole 
community was really outraged.
    So my question is for Dr. Gamble. What types of barriers 
currently exist that prevent the VISNs from taking a more 
active role? And what do you think VISN directors need to 
quicker solve these issues when they arise at local medical 
centers? Is it better monitoring, is it more authority, is that 
what they need? What do we need to do to help you in this 
    Again, I went directly to the Secretary and we resolved the 
situation, once I was notified. Again, I was contacted by the 
media. And, you know, I mean, it is inexcusable for our 
veterans not to have hot water. They would have to go to 
another building, outside to another building to take a shower, 
which is ridiculous. And then again no real air conditioning or 
heat, for that matter, during the winter.
    So if you can answer that question for me, I would 
appreciate it, Doctor.
    Dr. Gamble. Thank you, Mr. Congressman, I appreciate the 
    I think it is incredibly important regardless of where you 
are in an organization, and, again, coming from my time in the 
military, that it is about leadership. It is about boots on the 
ground, walking the terrain, listening to the staff and teams 
around you, to really identify and realize that, you know, 
problems as they affect our veterans are critical to deal with 
in an expedient and timely manner, you know, and I don't know 
why it had to come up through you all the way to the Secretary 
for action.
    But, again, I think that that also states that whoever 
brought that forward realized that it was a critical need to 
push that forward.
    You know, I think that, you know, my travels around the 
VISNs and to some of these institutions, moving ahead, it 
really revolves around three things, one of which is 
leadership, second of which is communication, and the third is 
structure, because structure really sets the culture. And I 
think it has a lot to do with culture and folks bringing these 
issues up, and a sense of confidence that they will be dealt 
with promptly and effectively that really will make the 
difference going forward.
    Mr. Bilirakis. Thank you.
    My next question for Mr. Missal, does your office have the 
authority to stop the admission of patients to a medical center 
when you identify serious health and safety concerns?
    Mr. Missal. No, we would not have that authority, but we 
obviously would immediately contact VHA to take whatever action 
they thought was appropriate.
    Mr. Bilirakis. Okay.
    Dr. Clancy. And if I could just note--
    Mr. Bilirakis. Yes, please.
    Dr. Clancy [continued]. --Congressman, that we did actually 
send patient safety people in a number of times to give us a 
read. Were they worried, was the risk of harm sufficiently high 
that we should actually close down some units or just keep 
going until we rebuilt the supply chain.
    Mr. Bilirakis. Okay. So, again, how serious do these 
conditions have to be for you to close down the facility and 
make that decision? Maybe give me an example.
    Dr. Clancy. I don't have an example right at hand where we 
have done that, but for example, in one of our facilities 
several years ago they closed down an ICU for a few weeks. The 
issue at hand was that an acting director came in and inherited 
a situation where the facility was very, very short on 
housekeeping on weekends. So what that meant was that the 
nurses in the ICU were actually turning over beds and having to 
do the housekeeping and, you know, when a new patient came in, 
and the director became very concerned that they were making 
mistakes because they were exhausted.
    So what she did, which I think was exactly the right thing 
to do, was to close the unit for a few weeks until they could 
bring more custodial assistance in for the weekend, so that the 
nurses wouldn't be trying to do two or three different jobs.
    Mr. Bilirakis. Okay, thank you. Thank you very much.
    I yield back, Mr. Chairman.
    The Chairman. I thank the gentleman for yielding.
    Mr. Lamb, you are recognized for 5 minutes.
    Mr. Lamb. Thank you, Mr. Chairman.
    Dr. Clancy, I just want to ask you some questions about the 
pipeline for people that become network directors, are they 
always promoted from below essentially, like are they always 
people that were chiefs of staff of VA facilities?
    Dr. Clancy. They are not only one or two of our current 
network directors, actually one right now is a physician, most 
are health care executives and have strong leadership in that 
capability. Historically, that was exactly where they came 
from. In recent years, we have begun to recruit as broadly and 
widely as we can.
    So, you know, there are advantages to having people who 
know the system and have had experience, and several of our 
most recent network directors, who I think are really doing a 
terrific job, were terrific medical center directors, but we 
are continuing to recruit broadly and widely.
    Mr. Lamb. When you say recruit, though, are you hiring 
people from outside the VA for the network director job?
    Dr. Clancy. We would be happy to if we find a good person.
    Mr. Lamb. Okay.
    Dr. Clancy. We have not recently, but have certainly 
interviewed people and they have been fairly competitive, and I 
would say we are hiring more people outside the VA to be 
Medical Center Directors.
    Mr. Lamb. Okay. Some of whom could then presumably be--
    Dr. Clancy. Yes.
    Mr. Lamb [continued]. --promoted to VISN Director. Okay.
    Now, several of you have talked about the importance of 
culture, both making sure that complaints are heard and can 
kind of rise to the top, but also making sure that there is 
fast follow-up by the leadership so that things actually get 
solved. What suggestions do you have for how we actually do 
that? In other words, how do we find the leaders who are 
capable of creating that culture and then actually instilling 
it in the organization?
    Dr. Clancy. You know, that is a terrific question, because 
when people apply, we tend to review their background, 
experience, CVs, and so forth for their technical skills. And 
what seems to me to matter, at least as much is how engaged are 
they with the people. When I look at our best medical center 
directors, they know almost everyone who works in that 
    Now, that is a pretty tall order, some people are more 
gregarious than others, but it makes a difference. Because if 
I'm asking you how you're doing and how's your kid doing in 
Little League or whatever, I have a degree of comfort that I 
could say to you we have got a problem over here in OR-1, and 
I'm going to guess you may not have heard this or you have 
heard that everything is fine, but what I see is not fine.
    So a very, very big part of it is that kind of being able 
to engage and listen to people, and I am noticing more and more 
of our medical center directors doing this, whether it is a 
Facebook chat, walk around rounds. Someone earlier referenced 
walking around and getting out and seeing people. It is 
management by walking around is another phrase, very, very 
important. So we are beginning to talk now about how do we 
build some of that into the interview.
    I think it also helps to bring in others into the selection 
process, which we are doing now at the D.C. VA. So the 
physicians will have a role and a voice in who the next 
director will be and so forth.
    Mr. Lamb. Dr. Gamble, you were nodding. If you could just 
address that and also how do you get a similar level of 
engagement and strong leadership at the VISN level? I kind of 
see it for a medical director of a facility because they are in 
one building every day. They can meet everybody. But what are 
we doing to promote stronger leadership and accountability at 
the VISN level?
    Dr. Gamble. Mr. Congressman, I think it is--network 
directors have really taken the lead recently in helping to 
develop a way ahead. One of the key parts of their guidance and 
assistance to me has been looking at developing a play book for 
VISN directors so that these head up a consistency of roles, 
responsibilities, and accountabilities. And one of those is 
really walking around and getting to see your facilities, get 
out to meet the people. That is one of the key parts of a 
    There was a--in Kizer's report back in the 90's, there was 
a notable comment, I believe it was there, that in a network, 
you had--the span of control was critical. You really could 
only have between 8 to 12 facilities to really as a network 
director or VISN directory, really be able to have that 
control. And that is, I think, really key for the future to set 
those roles, responsibilities, and accountability, and also 
give them a terrain of an organization that they can walk 
around to get to know up close and personally.
    Mr. Lamb. Okay. Thank you, Mr. Chairman. I yield back.
    The Chairman. I thank the gentleman for yielding. General 
Bergman, you are recognized for 5 minutes.
    Mr. Bergman. Thank you, Mr. Chairman. And thanks to all of 
our witnesses here for your testimony. You know, the good news 
is I am getting to know you because I see you so often. The bad 
news is I am seeing you too often. So the point is, the flow of 
communications, as Dr. Clancy and I talked about earlier, as 
far as bringing in the boots on the ground, the everyday stuff, 
I am pleased to see that the VA is going to do that so that we, 
as a Committee, can hear it from those who are involved in the 
day to day operations.
    You know, 18 months into this first term now and in dealing 
with things that we hold near and dear to our hearts and our 
veterans' hearts, I am still learning at the cyclic rate. You 
know, I think VISN 23 touts the SAIL metrics, the strategic 
analytics for improvement and learning that you have had some 
success with.
    I would like to give you just one data point from my first 
briefing at an unnamed facility and VA related. But the point 
is the metric for success proudly touted and in a slide was 
that they had added eight full-time equivalents to their staff. 
I am not so sure that is the quality metrics that we are 
looking at is adding staff. I mean, if they had been related to 
what that meant to the outcomes and the results for the 
veterans, that might have had a different quality to it, rather 
than just saying, ``Hey, we added eight more paychecks.''
    So it is just--fyi it was meant to be a good answer. So I 
would suggest to you the leadership involved with that maybe 
needs to just kind of look at things a little different in what 
a good answer is as it relates to results for the veterans.
    And Dr. Clancy, I know you have--I have asked you this 
before, but I am going to ask again. Do the VISNs have a 
mission statement, either collectively or individually? Have we 
got something down on paper? Two or three lines? Four lines? 
Whatever it is?
    Dr. Clancy. The goal of our current redesign effort is that 
there is one mission statement that is for all VISNs. Most have 
a mission statement, but it is not looked at by anyone and we 
don't verify it. And I would guess that it probably echoes the 
department's strategic plan that say we are all about 
personalized veteran-driven high quality care, more or less.
    But it needs to be much more engaged. Dr. Gamble's point 
about a play book I think is quite instructive.
    Mr. Bergman. Okay, Mr. Butler, you know, same question for 
you. What do you think of the VISN's mission statement? What do 
you think it should be?
    Mr. Butler. What I would say that the American Legion 
Resolution calls for a study of the current VISNs. And so we 
advocate that someone look at the VISN's structures and 
determine the lead way forward to go and whether or not there 
are changes or improvements that could be made based upon 
studying the current VISN structure.
    Mr. Bergman. You know, we could talk about this for a long 
time and I can see as I look across, I have a fellow Marine, I 
am--a couple of them. You guys are--you have got me outnumbered 
now. Not outgunned, but outnumbered. Anyway. My God, I forgot 
you are over here. Thank you. You have always got my flank.
    The point is, in the Marine Corps., every word in a mission 
statement is a planned word with a specific meaning for what 
its intent is so it can flow up and down. And I would suggest 
to you that at different levels of command, sometimes that 
mission statement might be revised to the level of command that 
it is meant to oversee. So don't get caught up on one size fits 
    So with that, I yield back, Mr. Chairman.
    The Chairman. I thank the gentleman for yielding.
    Mr. Correa, you are recognized.
    Mr. Correa. Thank you, Mr. Chairman. First of all, I just 
want to thank you, Chairman Roe, for your leadership in the 
Mission Act, in moving legislation out of this Committee, onto 
the Senate. I do appreciate what you have done. I know my 
veterans appreciate your efforts as well. Thank you, sir.
    Dr. Clancy, quick question for you. Secretary Shulkin 
envisioned placing VISN's 1, 5, and 22 in receivership. Any 
thoughts about what he envisioned?
    Dr. Clancy. So I don't think he had completely followed 
through on the thought at the time of the D.C. press 
announcement. We did have subsequent conversations.
    Mr. Correa. It was an envisioning, not an actual plan. So 
    Dr. Clancy. No. I think what he wanted to do was to say 
whoa. Whatever VISN is supposed to be doing in these three 
networks is not working. Therefore, he had called Dr. Gamble in 
to get him a set of fresh eyes, informed by a great deal of 
experience outside of our health care system, which I saw as a 
real asset. But it became clear, I would say within the first 
24 hours that the span of control--it was not possible for 
someone sitting in D.C. or anywhere else to be running day to 
day operations at 23 facilities that were vastly disbursed 
    So on the ground, the deputy network director, the most 
senior VISN official, has actually been sort of an acting 
network director for day to day activities. But Dr. Gamble has 
been to each of those facilities. Does that help?
    Mr. Correa. A little bit. I guess I am still at a loss when 
it is a big network, a lot of work, a lot of important work. 
But it is not exclusive to this country. You have got the 
Kizers of the world. You have got other large networks that 
have the same challenges of management, implementation, 
accountability, responsibility, and liability. And there are 
some, for lack of a better term, best practices could be 
employed at the--and I am just trying to figure out why is it 
that we have been operating the VA as silos and why is it that 
these discoveries continue to be secrets that nobody knew 
    Dr. Clancy. So I think the last point you made is hugely 
important. And in the question about culture, I would have said 
that what is even more important before that is candor. That 
you can honestly confront your problems and don't act like it 
is a secret. Because frankly, if one of our facilities has a 
problem, it is highly likely that some other facilities are 
having the same challenge.
    And the great power of being an integrated system is that 
we could learn, rather than have--as a system, rather than 
having every single facility replicate the painful discovery of 
a delta between your aspirations and what actually happened--
    Mr. Correa. So, Dr. Clancy, your words whistleblowers are 
the greatest gift that we have.
    Dr. Clancy. Yes.
    Mr. Correa. Do we have a system to listen to 
whistleblowers? Do you have a 1-800 number, an anonymous box, 
and do you have folks that follow up on comments, suggestions, 
complaints by whistleblowers?
    Dr. Clancy. So that is done differently at most facilities. 
Some literally have suggestion boxes. Some will say--will do 
things like having Facebook chats where people can text in 
questions. Some have townhalls with employees. I don't think 
there is a magic formula. And there was one--
    Mr. Correa. But there should be a formula at each place. If 
you don't have a system and I would question whether you have a 
system at all in all of these places.
    Dr. Clancy. Well, the critical formula for me is saying if 
there is problems, I want to hear about them. And facility 
directors who communicate that, generally tend to hear about 
problems and act on them sooner than not.
    Mr. Correa. So when you have directors that hear about 
them, do these--the results of these surveys, do they reach 
Washington, D.C., or are they stuck at the local level?
    Dr. Clancy. We have been strongly encouraging more that we 
fail as a system if any of our individual facilities--
    Mr. Correa. But I guess my question, and I am running out 
of time, and that is why I am being--interrupting here. 
Suggesting, encouraging versus a system of saying this data 
will be reviewed.
    The other day I went to my local doctor. Within a couple of 
days, I got a text saying, ``Can you tell us what your 
experience was with your doctor?''
    Dr. Clancy. Right.
    Mr. Correa. ``Can you tell us what your experience was 
visiting?'' Do you have a system like that where our veterans--
    Dr. Clancy. We do. Yes.
    Mr. Correa [continued]. --can text in their experience and 
if it is a bad one, do we follow up or that is just another 
number that we, you know, put away for research in the future?
    Dr. Clancy. We have recently put in a system--we have 
always had questions at the kiosk before you check out, okay? 
And we have recently put in a system where veterans can give us 
realtime feedback from a variety of venues. That can be from a 
kiosk. They can send us an e-mail. They can drop off a note at 
the front desk. And that information gets aggregated.
    And frankly, what I am hearing from our directors is they 
love it. Occasionally they feel like they are drowning in 
information, but--
    Mr. Correa. We all do.
    Dr. Clancy [continued]. --it points out--well, it points 
out problems, I mean, in the same way that I am sure many 
people learn from their own office staff, right? Things you 
thought were fine, except what you are hearing from the actual 
customer of the veteran is it is not working so well for me. 
And that is an opportunity to just fix that.
    Mr. Correa. Mr. Chair, I am going to yield. Before I do, I 
just want to say I think we need to figure out how to protect 
and listen to whistleblowers--
    Dr. Clancy. Absolutely.
    Mr. Correa [continued]. --to move forward. Mr. Chair, I 
    The Chairman. Thank you, gentlemen, for yielding. Chairman 
Bost, you are recognized.
    Mr. Bost. First off, let me start out by saying, you know, 
I was taught in college about a Peter principle, which somebody 
is promoted beyond their capability of handling the job and 
that is where they freeze.
    I have got a statement here and, Dr. Clancy, I want to see 
where you think this should go. In 2008, several congressional 
Members sent a letter to then VA Secretary James Peake, 
expressing their concerns about an appointment of Dr. Peter 
Almenoff to be the assistant deputy undersecretary for health 
and for quality and safety. Dr. Almenoff, formerly director of 
the VA Heartland Network, responsible for overseeing the Marion 
VA Center, Dr. Peter Almenoff had oversight authority over 
Marion VA Medical Center when nine veterans died due to 
substandard care. He was promoted to oversee quality and safety 
for the entire VA in February of 2018.
    VA announced that he is now the director of VA's office of 
reporting analytics, performance, improvement, and deployment, 
or RAPID health care improvement center to oversee improvement 
at each low performing health center. And he reports directly 
to you, Dr. Clancy.
    I know the VA central office will review each of the 
facilities' quality. And if the facility fails to make rapid, 
substantial progress in their improvement plan, VA leadership 
will take prompt action, including changing the leadership of 
the medical center.
    And this is not the first time of a VA employee getting 
promoted after they failed at their job. Most recently, we have 
heard of several concerns related to the quality team in Marion 
and the quality nurse was promoted into the VISN. Where is the 
accountability? At what point do start looking at your 
employees and when they fail at a job, do we not--we either get 
rid of them or we demote them. But no, what we do in the VA is 
we promote them away so that they don't have to deal with the 
problems they create. Do you have any answer on that?
    Dr. Clancy. So in general, when people are promoted, we are 
looking at past performance and any investigations and so 
forth. I think most large organizations, health care or 
otherwise, that have employees with an enormous amount of 
skills that are in the wrong job, before they put them out on 
the sidewalk would want to figure out how they might be working 
in a job that is a better fit with the skills that they have.
    Mr. Bost. Okay, maybe my concern and I have got another 
question I have got to ask, but this came to mind. My real 
concern because, okay, I did not run something the size of the 
VA, obviously. But I did--was in business and have been in 
business for years. The concern is that, do you not see with 
the amount of employees that you have that some of them might 
all of a sudden say, ``Okay, if I just do a bad job here, they 
will move me somewhere else?''
    Because that is what we are seeing. That is the concern I 
see is, ``Okay, I can't do this job, but I still have an 
education and a degree, so maybe they will move me over there 
and then I don't have to do this anymore.'' And call it a 
    Dr. Clancy. In general, I am not that concerned about that. 
I certainly don't want someone to struggle in a job that their 
skills are not a good fit with that is not serving veterans, if 
in fact they might be able to contribute more effectively 
    And if--to me, the bigger challenge that we struggle with a 
lot is an inconsistency in values. People who don't have values 
that resonate with our intent of serving veterans everywhere.
    Mr. Bost. Okay. My question here before the time runs out, 
Marion has a number of issues that have come to light over the 
past decade. The leadership of the VISN 15, though, does not 
seem to be adequately addressing my concerns about the morale 
at Marion. What role does a VISN play with the human resource 
department, given the unique role of the H.R. personnel have in 
the VISN? And is there a way that someone at the VISN that is 
over H.R. can explain to the Marion VA H.R. person how to do 
their job betterly (sic). That was a great word.
    Dr. Clancy. Thank you, no.
    Mr. Bost. More accurately.
    Dr. Clancy. Thank you, Congressman. That is exactly the 
direction we are going with our VISN redesign is that we will 
strengthen the capacity and oversight of the H.R. person at the 
network level so that the person at the facility level, who is 
responsible for posting jobs and making sure people get 
onboarded and so forth, actually has someone to consult with 
and someone who is keeping an eye over their shoulder to make 
sure that we are doing a consistent job.
    Mr. Bost. Thank you and I yield back.
    The Chairman. Thank you, gentleman, for yielding. Mr. 
Peters, you are recognized for 5 minutes.
    Mr. Peters. Mr. Chairman, I would defer to Mr. Moulton.
    The Chairman. He is right up after you anyway, so that is 
    Mr. Moulton. Thank you, Mr. Peters. Thank you, Mr. 
    So I represent the Bedford VA, as you know, and last week I 
testified about my concerns with the Bedford VA and the 
multiple whistleblower cases, on issues to include contract 
fraud, patient abuse and neglect, and poor facility maintenance 
had reported at that facility. Adding to that, there are issues 
with improper medical record management, a Legionnaires 
outbreak, the Office of Special Counsel findings of widespread 
asbestos exposure, a hostile work environment, and retaliation.
    Now, to Secretary Shulkin's credit, he came up at my 
request and visited on a Saturday afternoon. And we walked 
around the Bedford VA and heard their leadership team, or what 
was left of the leadership team, explain what happened, in 
particular, with a patient death. And what struck me about it 
is that there was a lot of effort put into looking backwards 
and figuring out what had occurred and very little 
accountability for making sure it didn't happen again.
    Now, you have heard from a lot of Marines on this Committee 
and I think of us as all on the same team here, not Democrats 
and Republicans. But one of the things we learn in the Marines 
is that of all of the different leadership steps: coming up 
with a great plan, doing the reconnaissance to get the 
intelligence, none of it really matters unless you supervise 
what happens. It is the most boring step in leadership, 
supervision. But you have got to make sure that your good plans 
actually come to fruition, that the Marines get the job done.
    And so my question is just what has been changed? What is 
different at Bedford, and other places, and VISN 1 and 
elsewhere, to make sure that when we have problems like this, 
we can ensure that they don't happen again in the future?
    I recently met with a new director up at the Bedford VA. It 
took about 2 years to get that person into place. And I am 
excited for her to get started. I mean, she is getting started. 
I think she will do a great job. But I fundamentally want to 
know what will be different?
    Dr. Clancy. So the Bedford VA is not far from where I grew 
up and so it is a facility I know reasonably well. And I know 
that when you visited the first time, there were a lot of 
problems and, frankly, a lot of publicity in a way that 
probably makes it a bit difficult for people to be quite as 
forthcoming, even with respect to legitimate oversight and so 
    I think the biggest good thing that has happened at the 
Bedford VA is that we will have a new network director in VISN 
1 and we are going to do everything possible for these three 
networks, the new people to actually prime them for success. So 
whether they are promoted from within or recruited from 
outside, they are going to be--have a two to three month 
training period, leadership development and so forth, which I 
think we can learn a lot about from the military. But probably 
the best thing that has happened at the Bedford VA is 
identifying and recruiting an effective director. I think she 
is going to be terrific.
    And I think what will be different is that you have someone 
who knows a lot about how the system works, both locally as a 
very senior nurse at the Boston VA, and then having worked in 
headquarters for a couple of years, focused on improving access 
to care.
    Mr. Moulton. What is the timeline that you expect from her 
for addressing these issues?
    Dr. Clancy. I expect her to be showing improvements within 
1 to 2 two years. I mean, that I can count and measure.
    Mr. Moulton. So up to 2 years to address these 
whistleblower complaints?
    Dr. Clancy. No, no, no. She is not going to address the 
whistleblower complaints. We have an external, you know, 
another office in the department that does that. What she has 
got to do--
    Mr. Moulton. And, Dr. Clancy, what is their timeline for 
addressing these complaints?
    Dr. Clancy. I don't know. I would have to take that for the 
record and get back to you.
    Mr. Moulton. Okay. I would very much appreciate--
    Dr. Clancy. I am happy to do that.
    Mr. Moulton [continued]. --that. You know, the sad thing is 
that the Bedford VA also has some extraordinary 
    Dr. Clancy. Yes.
    Mr. Moulton. They have a remarkable record with regards to 
mental health care treatment, for example, which we all know is 
top of the line for veterans in America today. And so part of 
this is ensuring that we have a VA leadership culture that 
ensures that problems get fixed. Another part of it is that 
good practices get shared.
    Dr. Clancy. Yes.
    Mr. Moulton. What are you doing to ensure that good 
practices that are happening at places like Bedford, which has 
an opioid prescription rate, Mr. Chairman, half the national 
average because they are so innovative with mental health care, 
what are you doing to ensure that those practices get shared?
    Dr. Clancy. So we are doing two things. Over the past 
couple of years, we have had a big initiative focused on 
diffusion of excellence where employees across the system are 
encouraged to submit their best practices. And we actually 
facilitate their connecting with other facilities, often far 
away from where they actually take care of veterans. And it has 
not only been a terrific way to identify good practices, it has 
been a way for people across our system to learn from folks 
they otherwise never would have met.
    Recently, I heard the individual who is leading that effort 
explain how he is going to actually take that up another level 
by identifying other practices. In other words, looking at 
measurements. What is Bedford doing about mental health care 
that could be shared with others?
    The Bedford VA was part of an initial best practices which 
focused on helping veterans and their families discuss 
preferences for end of life care as sort of a group. You could 
only do that in VA. And it has been hugely popular with 
veterans because it is actually less intimidating than a one on 
one conversation. And they get to kind of process this with 
other veterans, which is very helpful.
    Mr. Moulton. Thank you. Mr. Chairman, thank you very much 
for letting me run over.
    The Chairman. No, that is fine. Thanks for being here today 
and thanks for your service to our country.
    I am beginning to think maybe we have too many Marines on 
this particular--we need a few more Army people. And it has got 
a very New England tint today.
    Mr. Poliquin, you are recognized for 5 minutes.
    Mr. Poliquin. Thank you very much. That, to me, is you are 
a lean 6 minutes, Mr. Chairman, but thank you very much.
    Make sure I get this right, Mr. Chairman, before 1995 and 
this would probably go to Dr. Clancy, there--we have about 160 
medical centers around the country. And before 1995, they were 
roughly all autonomous and they were organized in four--loosely 
in four regional areas. But for the most part, they reported 
directly to the--to Central VA.
    And how in the heck can anybody oversee that? How can they 
hold them accountable? So in--after 1995, or since 1995, I know 
you folks originally organized, or we did, 22 VISNs and now 
they are down to 18. Is that correct? Roughly? Do I have that 
roughly right?
    Dr. Clancy. Yes.
    Mr. Poliquin. Okay, so the number of employees went from 
about 220 and 1,100. And so, to me, what it looks like, Dr. 
Clancy, is that we have created another sort of middle 
management bureaucracy here. Mr. Missal, am I pronouncing your 
name correctly?
    Mr. Missal. It is Missal.
    Mr. Poliquin. Mr. Missal, you are the I.G. for this whole 
ball of wax here. Have you found in your data, in your work 
that there has been an improvement and accountability in 
responsiveness and care as a result of this reorganization?
    Mr. Missal. We haven't looked at that specifically, but 
what we do look at in all of our work, we try to find what the 
root cause of an issue may be if we find a problem. Because 
what our role is and our goal is to help VA get better. And so 
by identifying anyone who did not act as you would expect, we 
want to identify it so that VA could take the necessary action.
    Mr. Poliquin. Thank you. Mr. Gamble, you were appointed by 
Mr. Shulkin to run VISN 1, 5, and 22 how long ago?
    Dr. Gamble. I was not appointed to run those VISNs.
    Mr. Poliquin. Oversee them.
    Dr. Gamble. That was back on, I believe, March 7th.
    Mr. Poliquin. Okay, of this year.
    Dr. Gamble. Of this year.
    Mr. Poliquin. And are you stationed out of Orlando or are 
you stationed out of D.C.?
    Dr. Gamble. I am still living in Orlando, but I am up here 
most of the week. In fact, since March 7th, I have spent most 
of my time on the road, out with these VISNs--
    Mr. Poliquin. Okay.
    Dr. Gamble. --and facilities.
    Mr. Poliquin. Okay. We are in VISN 1 up in Togus. We have 
the first medical facility--medical hospital--VA medical 
hospital in the country established after the second--excuse 
me, after the Civil War. Have you been there to visit Togus?
    Dr. Gamble. I have not been there yet, sir.
    Mr. Poliquin. Okay. Do you plan on it soon?
    Dr. Gamble. As soon as I can.
    Mr. Poliquin. Great, thank you. When will that be?
    Dr. Gamble. I will have to check my record or my schedule 
    Mr. Poliquin. Good. We will check with your office to make 
sure we know when that is going to happen. Thank you.
    There is someone by the name of Mayo-Smith and Weldon. They 
both retired as the heads of VISN 1 and 22, is that correct?
    Dr. Gamble. Sorry, Dr. Mayo-Smith was--
    Mr. Poliquin. Yes.
    Dr. Gamble [continued]. --the previous VISN director.
    Mr. Poliquin. Yes, they are gone now, right? And Weldon is 
gone too. All right, so they are both gone.
    Dr. Gamble. Twenty-two, yes sir.
    Mr. Poliquin. Okay. And Williams has been reassigned, 
correct in 5? So who are running those three VISNs?
    Dr. Gamble. Right now we have acting medical director. I am 
sorry, acting VISN directors in those positions. We have Mr. 
Barrett Franklin, who is in VISN 1.
    Mr. Poliquin. Thank you.
    Dr. Gamble. We have Dr. Ray Chung who is in VISN 5.
    Mr. Poliquin. They are all acting. Okay. I want to go back 
to what General Bergman said a minute ago. What performance 
benchmarks do you folks embrace to make sure the accountability 
is getting better, not worse? What are the specific measures? 
Give us a couple of examples.
    Dr. Clancy. Well, I--
    Mr. Poliquin. Sure, Dr.--
    Dr. Clancy [continued]. --have a little more experience. I 
will take that.
    Mr. Poliquin. Yeah.
    Dr. Clancy. So one overarching accountability measure is, 
is the performance of the facilities in your VISN better or 
    Mr. Poliquin. What does that mean?
    Dr. Clancy [continued]. --than it was when you were--
    Mr. Poliquin. How do you measure that performance?
    Dr. Clancy. What we do is we actually roll up and summarize 
all performance measures, the same ones used by the private 
sector reported to--
    Mr. Poliquin. Okay, let me give you an example. There was a 
fellow by the name of Dr. Franchini up at Togus.
    Dr. Clancy. Yes.
    Mr. Poliquin. Dr. Franchini was a foot surgeon at Togus 
from 2004 to 2010. He botched dozens and dozens and dozens of 
operations, to the extent that one of our veterans had to have 
her leg amputated. I repeat that, her leg amputated to take 
care of the pain because there was no other way to cure it.
    Now, here is the think that really hits me between the 
eyes. Not only did that happen, but it wasn't until roughly 2 
years later, 2012, that the former head of surgery who was 
responsible for getting this out to the victims and also to the 
public so Franchini couldn't operate in the private sector, it 
was about 1 to 2 years until that happened.
    Okay, you mentioned earlier, Dr. Clancy, that you need to 
make sure that people have the right job description, so their 
skill sets can fit in another job. This individual was not 
fired. He was demoted. Is there a job skill that I am missing 
here that enables this person to be reassigned within the VA 
after someone's leg was cut off because of botched surgeries 
that they did not report for 1 to 2 years? Am I missing a job 
description here or some sort of skill set that they should 
allow that individual to stay there?
    Dr. Clancy. Congressman, are you referring to the 
podiatrist or the person who supervised the podiatrist?
    Mr. Poliquin. The person who supervised the podiatrist.
    Dr. Clancy. I would have to take that for the record 
because that piece I am just not that familiar with. I 
    Mr. Poliquin. Okay. Were you responsible at that time for 
overseeing the VISNs?
    Dr. Clancy. No, I was--
    Mr. Poliquin. Who was?
    Dr. Clancy. Prior to me was Dr. Alaigh, before that Dr. 
Shulkin. What I would say, Congressman, and I didn't get a 
chance to say that--
    Mr. Poliquin. Okay. Steve Young is the fellow that is under 
you, right?
    Dr. Clancy. Yes, uh-huh.
    Mr. Poliquin. Okay. And then it goes down to the office of 
network support, then it goes down to the VISNs, right?
    Dr. Clancy. Yes.
    Mr. Poliquin. But you are the head person, correct?
    Dr. Clancy. Yes.
    Mr. Poliquin. Okay, so you are responsible.
    Dr. Clancy. Yes.
    Mr. Poliquin. You just told me you weren't.
    Dr. Clancy. No, I thought you said then. I have been in 
this job now for 7 months.
    Mr. Poliquin. Okay. And before that, how long have you been 
at the VA?
    Dr. Clancy. Four and a half years.
    Mr. Poliquin. Four and a half years okay. Okay? Go ahead. I 
will let you finish--
    Dr. Clancy. But I would be happy to get that for the 
    Mr. Poliquin. I appreciate it.
    Dr. Clancy. What I was also going to say as a result of Dr. 
Franchini and a couple of other things, we have put in new 
requirements for facility and network directors to keep 
credentialing licenses and so forth up to date. And that is 
also part of the expectations.
    Mr. Poliquin. Do me a favor, when you get back to your 
office and I appreciate it very much, Dr. Clancy, we want to 
make sure the person who was responsible for reporting this, is 
that individual still there or not. I would appreciate that 
very much.
    Dr. Clancy. Okay.
    Mr. Poliquin. Thank you, Mr. Chairman.
    The Chairman. Gentleman's time is expired. Mr. Arrington, 
you are recognized.
    Mr. Arrington. Thank you, Mr. Chairman. Mr. Butler, 
representing a vast array of veterans from various backgrounds, 
how would you rank in the customer service survey the overall 
service of the VHA to your veterans? 1 to 10, 10 being 
excellent, off the chart, zero being non-existent.
    Mr. Butler. Most veterans that we encounter tell us that 
the care and services provided by the VA is excellent.
    Mr. Arrington. Well, then why are we having this 
conversation? Because I really don't care how they skin the 
cat. I don't care how they organize. I care about the results. 
If it is excellent, why are we even having this hearing?
    Mr. Butler. But I think that, you know, there are 
situations where the care or things go awry, and every veteran 
should have that same experience. So I think that is why we are 
here today for the exceptions because all veterans' experiences 
aren't the same.
    Mr. Arrington. My perception is very different. My 
perception isn't that these cases of bad performance and bad 
service aren't the exception. I think they are too often the 
rule. But I will--you know, that is your--you are representing 
veterans and you know your veterans. And so--but I am surprised 
that we are talking about an exception. That we are spending 
all thing time, that we have done all these studies because we 
have done--I have read at least five studies on organizational 
    I care about organizational results. And if they are great, 
then I--what are we doing here? Do you think they are great, 
Mr. Missal?
    Mr. Missal. I think that a number of the issues we have 
identified are because people haven't done their job and that 
they don't have the structure in place to ensure that there is 
    Mr. Arrington. One of my favorite quotes is that you are 
either coaching it or allowing it to happen. I think you can 
overcome organizational structures. I think you can overcome 
bad systems. I think leadership, I think culture dominate on 
the outcome. And I think there are real, fundamental, deep 
seated cultural problems. Do you agree with that or do you 
disagree with that, at the VA? I am asking you, Mr. Missal.
    You are the independent Inspector General. I want an 
independent assessment. Do you think there is a cultural 
problem at the VHA?
    Mr. Missal. In many of the instances that we have looked 
at, we have seen a cultural problem where people aren't taking 
responsibility to do the right thing, not performing as they 
should be, which results in significant problems.
    Mr. Arrington. So it is not just the Washington Medical 
Center, do you think it is systemic or is that just an isolated 
    Mr. Missal. We have obviously seen more than just problems 
at D.C. We have seen them at a number of facilities. Obviously 
when either information comes to our attention or through our 
proactive efforts, we find it. We address them as quickly as 
    Mr. Arrington. We were talking about how we are going to 
have a management for performance plan for VISNs and how we are 
going to define roles and responsibilities and bring clarity to 
something that is clearly chaotic and unclear. And Mr. Gamble, 
you have mentioned that the network directors are taking the 
lead on developing these sort of plans. Did I hear you 
    Dr. Gamble. They are part of the process, sir.
    Mr. Arrington. But why--I get it. I mean, get input from 
mid-management, your regional directors, if you will. But I 
mean, they are looking to the leadership of the VHA to tell 
them what their mission is. Clearly, they don't know what their 
mission is. What is expected of them? How will they be graded? 
What does the scorecard look like? Will they be rewarded if 
they do a good job? Will they be fired if they don't do a good 
    Why are we asking them to run off and develop a plan for 
    Dr. Gamble. Mr. Congressman--
    Mr. Arrington. What is the plan, Dr. Clancy, for developing 
these--this sort of strategic management plan for the VISN so 
that they get it right, they serve our veterans? They are safe, 
they are happy, they are healthy, and we did right by our 
heroes. What is the plan?
    Dr. Clancy. That is what you just described. It will 
ultimately be deemed by central leadership, period.
    Mr. Arrington. Do we have a problem with central 
leadership? How long have you been--how long has the 
Undersecretary job been unfilled?
    Dr. Clancy. By a permanent political employee, since 
February of 2017.
    Mr. Arrington. I know my time is expired, Mr. Chairman, 
unfortunately, because I don't feel like I have gotten all of 
my questions asked or answered, but that is my fault. So I 
yield back.
    The Chairman. I thank the gentleman for yielding.
    Let me--I have a couple--let me just start a second round 
then. We have only three of us here so let's just go with a 
second round if you would like to ask a question.
    Ms. Kuster. Thank you very much. And just to pick up where 
my colleague left off, I will say that I have been in Congress 
for five and a half years and a number of us on the Committee 
came in the class of 2012, starting in January of 2013. We are 
now on our fourth Veteran Secretary, VA Secretary, since I have 
arrived in Congress.
    And so I think that that is part of the situation, to be 
honest. And I am not trying to be partisan. I want to work 
together in a bipartisan way as our Committee does, but we need 
leadership from the top. And so I just want to revisit the 
details one last time here of New Hampshire and VISN 1. I do 
have the letter from the U.S. Office of Special Counsel dated 
January 25, 2018, that I would like to submit for the record 
that lays out the situation that we had and frankly the lack of 
leadership and the lack of supervision. If I could enter that 
for the record?
    The Chairman. No objection.
    Ms. Kuster. The other person that was a focus for us was 
the director of VISN 1, Dr. Mayo-Smith. And again, I would have 
to ask you when did Dr. Mayo-Smith first become aware of our 
referral to the Office of Special Counsel, and did he ever pass 
his concerns up to central office officials? Because I think 
that was part of the breakdown for us.
    Not only did we not get from the medical director to the 
VISN, we didn't get from the VISN to the central office, again, 
until this all played out in the Boston Globe. And this was 
despite our best efforts to take it to the OIG, take it to the 
Office of Special Counsel, push forward. What was happening in 
Washington and in Boston in the 6 months in between?
    Ms. Clancy. So at headquarters, we became aware of the 
Special Counsel and the whistleblower allegations when they 
turned to us for assistance after the Inspector General was not 
able to step up at that point. And this is a routine 
occurrence. I am not singling them out.
    And I would guess that that was February or March of 2017. 
And then the Office of Medical Inspector went up and had a 
preliminary report that was sent to Office of Special Counsel, 
I want to say late May of 2017. And the whistleblowers--and 
this is all part of the process, were not completely 
comfortable with the results.
    And I think as you know, Congresswoman, we then did a much 
more extensive review of cases and have consulted directly with 
Dr. Coy (ph) and others.
    Ms. Kuster. Well, and it--you know, after it was in the 
Boston Globe that Secretary Shulkin showed up virtually the 
next day. So, I mean, we did eventually get the attention. But 
one of the problems I have is when General Bergman and I held 
this oversight and investigation Subcommittee hearing in New 
Hampshire. I mean, that is our role. We have oversight. Dr. 
Mayo-Smith didn't appear to be fully aware of the concerns, 
even at that point. That was after Dr. Shulkin had come up. And 
he was--well, I think if General Bergman was here with me, he 
would say we received unsatisfactory answers regarding the 
actions taken to rectify this situation.
    So I won't beat a dead horse, as they say where I come 
from, but I do think we need to focus on supervision at each 
level, and the role of oversight, and how to bring concerns 
forward. And it sounds as though that is the direction.
    I don't know if our witness from OIG has anything more to 
add about that, what we can do in terms of both streamlining 
the process and the types of people that we hire that will be 
focused on supervision and will be focused on continuous 
    So for Mr. Missal.
    Mr. Missal. Yes, I don't know if I have that much more to 
add. I do want to say, though, with respect to whistleblowers, 
what we are trying to do is we are trying to make sure that 
they feel comfortable coming to see us and talk to us about 
issues. We do protect their anonymity if they so desire. And a 
good example is the Washington, D.C. matter. We got a 
confidential complaint from a person at VA and we have been 
able to protect that person's confidentiality.
    And the more situations we have like that, hopefully VA 
employees and others will feel comfortable that if they come to 
us, they will be protected. They will be heard. And appropriate 
action will be taken.
    Ms. Kuster. And I appreciate that because that is a concern 
that I have. I continue to have whistleblowers come. And in the 
case that I have been talking about today, there was a long 
period of delay because the whistleblowers were concerned about 
their anonymity. Dr. Coy is a physician in the facility and 
wanted to continue to do his work.
    So we have passed legislation out of this Committee to 
address whistleblower protection. And I will yield back. But I 
want to thank, again, Dr. Roe for holding this hearing. And I 
think our oversight role is significant and we take it very 
seriously in a bipartisan way. And I appreciate you coming 
forward. Thank you.
    The Chairman. Mr. Arrington, you are recognized.
    Mr. Arrington. Thank you, Mr. Chairman. And I really 
appreciate you extending this for a second round because I have 
this general frustration, and I know my colleagues feel the 
same. And I can't imagine how the veterans must feel because, 
you know, you talked about how you would have been fired for 
some of these things. And the reason you would have been fired 
is because the health system you worked for would go out of 
business if they let you continue to do this thing.
    But the VA won't go out of business. And that is a 
fundamental challenge to breed this sort of culture of 
accountability without those external competitive forces. It is 
just really difficult. It is really difficult. And on top of 
that, I think Ms. Kuster is right. I mean, the political 
leadership is a key link in the chain of accountability up to 
us. Without them, I mean, I feel sometimes a little guilty for 
beating on you guys but you all are part of the problem and the 
    But without the continuity and political leadership, and I 
don't know if that is the Senate that is not working to get 
them through, or if it is the administration not putting them 
up but it is really, really frustrating. And I think you are 
going to get this sentiment as long as we have these gaps and 
the disconnects in the accountability chain.
    Ms. Clancy, how would you rank order the VISNs? If I just 
said rank order the VISNs from the best to the worst, could you 
do that for me? Could you submit that to the Chairman and the 
    Dr. Clancy. I would be happy to. And I agree--
    Mr. Arrington. Does that exist today?
    Dr. Clancy. I could look at a number of different 
dimensions. And respectfully, I would want to submit that for 
all of the problems you hear about in general, either we don't 
do enough of a job or if it bleeds, it leads. We--
    Mr. Arrington. Sure. I am--I know there--
    Dr. Clancy. We don't share the people who are doing well.
    Mr. Arrington. Here is my thing. I know there are good 
people who are well meaning and they want it to work. I think 
the system is fundamentally flawed. I think we have a lot to 
overcome. I think we have to do our job better. I think you 
have to do your job better.
    But let's get back to this idea of rank order.
    Dr. Clancy. Yes.
    Mr. Arrington. That supposes there is a scorecard. So there 
is a scorecard for the VISNs?
    Dr. Clancy. Yes.
    Mr. Arrington. And I would like a copy. Would you submit a 
copy to the Chairman and the Committee so we can see what their 
performance metrics are?
    Dr. Clancy. Uh-huh.
    Mr. Arrington. Okay. So that should be pretty clear then, 
if they have outcome measures that they know they have to meet, 
what happens if they don't meet those outcome measures?
    Dr. Clancy. Then they have some serious conversations with 
their boss and that becomes--
    Mr. Arrington. When is the last time the seriousness got to 
a removal because they just were not serving the veterans and 
they just consistently missed the mark on outcomes?
    Dr. Clancy. I have had a couple of direct experiences in 
the past couple of years. And it wasn't an up or out kind of 
thing. It was like no, there is no way you would get a 
recruitment/retention incentive if the performance in your 
network is not helping, and that person left.
    Mr. Arrington. The Veterans Integrated Service Network is 
what VISN stands for. I find it very ironic. I feel like it 
should be named the Veterans Siloed Aimless Unaccountable 
Service Network. That is my perception. That is my takeaway 
from reading this, from listening to you guys.
    What is the VHA's central role versus the role of the VISN 
in managing these medical centers and holding them accountable 
for serving our veterans? Is it clear or is there overlap? Is 
there confusion at that level as well?
    Dr. Clancy. There has been confusion at times, which is why 
we are working on clarity. And you absolutely cannot have a 
clear plan and roadmap for VISNs unless we have got that 
straight. In general, central office is going to set vision, 
and strategy, and tactics, and make sure that there are 
resources available. If some facilities need more, then they 
should get that, or some networks and so forth.
    And frankly, for identifying the right kind of leadership, 
because I agree with you that leadership and culture are way, 
way at the top.
    Mr. Arrington. It seems to me that they are not 
laboratories of innovation. They are laboratories of 
inefficiency. And they will continue to be until they are held 
accountable, until there is clarity in their mission, until 
they are held accountable for their performance.
    And I don't--I sit through a lot of hearing on IT systems, 
especially, and how they are so much frittered away on trying 
to do something internally when you can get it off the shelf. 
One business doing it one way. Another business is doing it a 
different way. Even though it may be working and they could 
share best practices, I am out of time, but I am going to 
continue to press in on this notion of accountability. And I 
hope we get more political leadership in so we can have these 
same discussions.
    Mr. Chairman, you have been very generous and very patient. 
Thank you. I yield back.
    The Chairman. I thank the gentleman for yielding and at 
this time, Ms. Kuster, do you have any closing comments?
    Ms. Kuster. Just very briefly, I do want to, you know, make 
that comment that we do need leadership from the top and, 
frankly, we need some consistency over a period of time. I 
mean, four Secretaries and I have only been here for 5 years 
seems a little--we are churning through VA Secretaries. So I 
hope that the President will appoint and the Senate will 
confirm the Secretary in due course and we will be able to move 
forward with our oversight role.
    I think accountability, you are hearing this message in a 
bipartisan way. The role of supervision and the role of 
oversight is critically important, and we will continue to work 
together. So thank you, Dr. Roe, and appreciate you scheduling 
this hearing. And thank you again for accommodating me.
    The Chairman. Thank you, all. And I want to thank the 
Committee Members for being here today. And I have just one 
quick question.
    Dr. Shulkin wanted to have a planning on the VISN 
reorganization done by July 1st. Is that still going to happen 
without the leadership--
    Dr. Clancy. Yes.
    The Chairman. It is--
    Dr. Clancy. Yes.
    The Chairman. So July 1st we will have that.
    Dr. Clancy. Well, we will present that to the department 
leadership, but shortly thereafter, we would look forward to 
briefing you on this.
    The Chairman. Yes, well thank you very much for that, Dr. 
Clancy. And I think you sense our frustration, but opportunity 
here with--I think the OIG has laid out a very clear pathway 
about how we should go forward. And I think Mr. Moulton brought 
up something that I, again, had a question earlier was what is 
23 doing that 1, 5, and 22 are not doing? And that should be 
pretty simple inside. And it is still unclear to me if I am a 
VISN director, what power I have.
    If something is going--in other words, if I am sitting in 
the VISN in Nashville, what power do I have over Mountain Home 
Medical Center in Johnson City, Tennessee. It is not clear to 
me, even after today's hearing, what I have. Could I go and 
would I be instrumental in removing a poorly performing medical 
center director--
    Dr. Clancy. Yes.
    The Chairman [continued]. --or would I not? I could.
    Dr. Clancy. You would--could.
    The Chairman. Could I fire them?
    Dr. Clancy. Yes.
    The Chairman. As a VISN director, I can fire a medical 
center without checking with you and the Secretary?
    Dr. Clancy. I think in general they would check and make us 
aware, but yes. And when I have called that VISN director to 
say I had--was hearing things from a particular facility, she 
has cheerfully cut her vacation short to go spend a day or two 
there to figure out what is going on, you know, so she can see 
it herself, which is exactly what you want.
    The Chairman. Do all of these VISN directors understand 
that they have that authority and power and can--and do the 
medical center directors understand my boss is right here, not 
all the way at the central office in Washington, D.C. But I 
have got a boss close by that can terminate me?
    Dr. Clancy. Yes.
    The Chairman. They do understand that?
    Dr. Clancy. Yes.
    The Chairman. Has it ever happened?
    Dr. Clancy. Yes.
    The Chairman. A VISN director has fired a medical center 
    Dr. Clancy. Yes.
    The Chairman. Can you tell me who that is or where--maybe 
we will do that off the record.
    Dr. Clancy. Yeah, I could--
    The Chairman. I would prefer to do that off the record.
    Dr. Clancy. Okay, that would be fine.
    The Chairman. Just to see that that has happened. But 
anyway, I want to thank you all. It has been helpful. I think 
you see the Committee wants to. I think legislation last week, 
14 bills we passed yesterday. 11 of them by unanimous consent--
voice voted, I mean, and 3 by--I don't think there was a 
single--or 2 or 3 no votes yesterday on all of those bills.
    So you have a Committee and a Congress that really wants 
the VA to work. We truly do. We thank the IG for helping us 
point out these problems. And Mr. Butler, as always, thank you 
for the Members and the VSOs who are always tremendously 
helpful to us in guiding us and the Committee.
    I ask unanimous consent that all Members have five 
legislative days to revise and extend their remarks and include 
extraneous material.
    Without objection, so ordered.
    The hearing is adjourned.

    [Whereupon, at 12:05 p.m., the Committee was adjourned.]

                            A P P E N D I X


                Prepared Statement of Carolyn Clancy, MD
    Good morning Chairman Roe, Ranking Member Walz, and Members of the 
Committee. I appreciate the opportunity to discuss the proposed 
redesign of the current Department of Veterans Affairs' (VA) Veteran 
Integrated Service Network (VISN) structure and the status of remedial 
actions at VISNs 1, 5, and 22. I am accompanied today by Dr. Bryan 
Gamble, Deputy Chief of Staff at the Orlando VA Medical Center (VAMC).
    On March 7, 2018, former VA Secretary David Shulkin announced VA 
would undertake a systematic review of the VISNs, with a specific focus 
on VISNs 1, 5 and 22. These three VISNs were challenged with leadership 
and management issues, low performing facilities, and culture issues. 
The purpose of the review was to identify VISN strengths and 
weaknesses, and create a plan to improve VISN oversight, 
accountability, performance and strengthen lines of communication with 
VAMCs within that VISN and VA Central Office (VACO). Based on his 
extensive leadership experience in the military health system, Dr. 
Bryan Gamble was asked to lead this review and provide recommendations 
with the goal of informing the redesign process.
    Within the Veterans Health Administration (VHA), at times, 
functional alignment among VACO, VISNs and VAMCs has not always been 
clear. Our goal is to streamline business processes, ensure clearly 
defined roles, responsibilities and authorities among all levels in 
VHA, so that we are functioning in a way that is more efficient, 
produces better results and accountability. We have also been working 
with our national leadership council to develop a new model of 
governance to help shape the culture, and set expectations and 
requirements for improved care for Veterans.


    A VISN consists of a geographic area which encompasses a population 
of veteran beneficiaries. The VISN is defined on the basis of VHA's 
natural patient referral patterns; numbers of beneficiaries and 
facilities needed to support and provide primary, secondary and 
tertiary care; and, to a lesser extent, political jurisdictional 
boundaries such as state borders. Under the VISN model, health care is 
provided through strategic alliances among VAMCs, clinics and other 
sites; contractual arrangements with private providers; sharing 
agreements and other government providers. The VISN is designed to be 
the basic budgetary and planning unit of the Veterans health care 
    In 1995, VA adopted a new VISN organizational structure to flatten 
and decentralize VHA's field organization by replacing 4 regions, 33 
networks, and 159 independent VAMCs with 22 VISNs that report directly 
to the Office of the Deputy Under Secretary for Health for Operations 
and Management. Since that time, two significant reorganizations have 
occurred resulting in our current structure of 18 VISNs. In addition to 
these changes in geographic boundaries, investments have been made to 
standardize the management and oversight of VISNs. VHA has standardized 
the organizational makeup of the VISN staff to ensure uniformity, as 
well as strengthening the oversight and management of these positions 
from VACO. VHA also created a single organizational chart adopted by 
each VISN office and implemented Quarterly Network Director reviews, 
which allows for a formal assessment of a VISN's progress at 
implementing changes and directives.

Systematic review

    Since former Secretary Shulkin's announcement, a team led by Dr. 
Gamble has visited VISNs 1, 5, 22. To look at best practices, the team 
also visited consistently high performing VISN 23. This team also 
completed site visits to VAMCs within the following VISNs: Manchester, 
NH; White River Junction, VT; Loma Linda, CA; Phoenix and Prescott, AZ; 
Baltimore, MD; Minneapolis, MN and Washington, D.C. Interviews with 
leadership and employees were performed; walking tours and inspections 
of facilities were conducted and performance improvement group meetings 
were attended. There also were employee listening sessions and 
clinician-only listening sessions that did not include the facility 
leadership team.
    A resounding theme was a dedicated workforce set on providing 
veterans with the best health care possible, and a clear understanding 
and willingness from leaders and employees at ALL levels to improve 
upon deficiencies wherever found. While these three challenged networks 
are vastly different geographically, the assessment team found common 
themes across these networks and facilities that included the following 
opportunities for improvement:

      Inconsistency of Human Resrouces services and hiring;
      Additional emphasis needed on education and training;
      Unintended consequences of Management by Measurement;
      Leadership challenges including turnover, consistency and 
psychological safety; and
      Employee morale.

    VHA is committed to ensuring Veterans get the best care. The 
findings from this review will be combined with feedback from Network 
Directors and our on-going modernization effort to formulate the plan 
for VISN redesign.

Washington DC VA Medical Center OIG Report

    One of the key concerns of this committee is the progress of the 
Washington, DC VAMC. While there is still work to be done, significant 
progress has been made. In March 2018, the VA Office of Inspector 
General (OIG) released the report, ``Veterans Health Administration - 
Critical Deficiencies at the Washington DC VA Medical Center.'' In 
summary, OIG found that the DC VAMC (within VISN 5) has for many years 
suffered a series of systemic and programmatic failures that made it 
challenging for health care providers to consistently deliver timely 
and quality patient care.
    Over the past year, substantial progress has been made on the 
concerns raised by the OIG. These improvement efforts include:

      Establishment of the Incident Command Center (ICC) at the 
Washington, D.C. VAMC: ICC implemented a robust oversight process that 
identified and promptly addressed new supply or equipment shortages. 
ICC instituted a 24-hour hotline for ordering urgent and emergent 
medical supplies.
      Assured all patients were safe and none were harmed: 
VHA's National Center for Patient Safety launched a rapid-response 
approach with onsite visits, bi-weekly and weekly calls with the 
facility and VISN and ensured all patient safety issues were 
appropriately addressed. As of January 31, 2018, the facility has 
cleared their backlog of patient safety incident reports.
      Awarded contract to construct a 14,200 square-foot space 
for Sterile Processing Services. The $8.9 million project will be 
completed in March 2019. More than $3.1 million in surgical instruments 
have been purchased to ensure an appropriate inventory based on the 
needs of the Veterans served and our surgical teams.
      Transitioned inventory to the General Inventory Package: 
Medical Surgical Primary Inventory has been entered in the system and 
the periodic automatic replenishment levels are being validated to 
ensure stock outages do not occur.
      Secured the off-site warehouse to restrict access and 
protect medical equipment and supplies.
      Eliminated all pending prosthetics consults greater than 
30 days, more than 9,000 to zero.
      Ensured ordering of prosthetics is not interrupted by 
end-of-fiscal-year financial transitions: At the end of fiscal year 
2017, there was no disruption of prosthetic ordering due to lack of 
      Allocated resources and expedited hiring into Logistics, 
Sterile Processing Service vacancies: A year ago, Logistics Service at 
the DC VAMC was understaffed. Today, 54 staff have been hired; with 
only 7 positions remaining under recruitment. Sterile Processing 
Service currently has 15 Sterile Processing Service staff vacancies, 10 
of which are currently filled with contract staff.

    We know looking at how we operate our networks is imperative. To 
get the type of accountability that is needed, and to ensure the best 
quality care this Nation can provide our Veterans is delivered, we have 
to take a critical look at processes, layers and leaders to ensure we 
do not see the failures that we saw at the Washington, DC VAMC. As VHA 
and the Washington, DC VAMC move forward, we are putting in place a 
reliable pathway for all facilities, VISNs, and business lines to 
escalate high-priority concerns to senior leadership for prompt action 
and follow-up. We encourage all employees to speak up and raise 
concerns to leadership. They are an integral part of our front-line 
safety net and we take their concerns seriously.


    We look forward to this opportunity for our new leadership and 
improvement efforts to further restore the trust of our Veterans and 
continue to improve access to care inside and outside VA. Our objective 
is to give our Nation's Veterans the top quality care they have earned 
and deserve. Mr. Chairman, we appreciate this Committee's continued 
support and encouragement in identifying and resolving challenges as we 
find new ways to care for Veterans. This concludes my testimony. My 
colleagues and I are prepared to respond to any questions you may have.

                Prepared Statement of Michael J. Missal
    Mr. Chairman, Ranking Member Walz, and members of the Committee, 
thank you for the opportunity to discuss the Office of Inspector 
General's (OIG) recent report, Critical Deficiencies at the Washington, 
DC VA Medical Center, and how those findings are indicative of a 
breakdown of oversight at several levels within the Department of 
Veteran Affairs (VA). \1\ Since becoming Inspector General two years 
ago, I have made VA leadership and governance issues a priority for our 
work, recognizing that deficiencies in these areas ultimately affect 
the care and services provided to veterans and allow significant 
problems to persist unresolved for years.
    \1\ The report was published on March 7, 2018.


    VA's Veterans Health Administration (VHA) has over 9 million 
enrolled veterans. It manages the largest integrated healthcare system 
in the nation, with over 145 VA medical centers (VAMCs) and 
approximately 1,230 outpatient sites. Oversight for these VAMCs and 
outpatient sites is the responsibility of 18 regional networks called 
Veterans Integrated Service Networks (VISNs). VHA established the VISN 
offices to improve access to medical care and ensure the efficient 
provision of timely, quality care to our nation's veterans. In 1995, 
VHA submitted a plan to Congress called Vision for Change that 
restructured VHA field operations into VISNs. VHA specifically 
decentralized its budgetary, planning, and decision-making functions to 
the VISN offices in an effort to promote accountability and improve 
oversight of daily facility operations.
    The OIG has had a longstanding focus of governance issues in VHA. 
For example, in March 2012, the OIG issued two reports dealing with 
VISN management and structure: the Audit of VHA's Financial Management 
and Fiscal Controls for Veterans Integrated Service Network Offices and 
the Audit of VHA's Management Control Structures for Veterans 
Integrated Service Network Offices. \2\ Our work determined that VHA 
did not have adequate data to monitor VISN operations or staffing 
levels. This weakness led to inadequate oversight of VISN operations, a 
lack of accountability, and noncompliance with policies. Work we have 
conducted since that time suggests that there continues to be 
leadership and governance issues between medical centers and their 
VISN, as well as between VISNs and the VA central office. Strong 
leadership and governance are critical to not only consistently 
achieving goals, but also to creating a culture that fosters personal 
accountability and positive change, frequent and effective 
communications, and compliance with policies and high-quality 
standards. Where there are deficiencies in leadership and governance 
there likely will be a cascade of persistent and pervasive problems 
like those we found at the DC VAMC. Although the report on that 
facility is our focus for this testimony, the lessons learned can be 
applied to VISNs and medical centers across the nation.
    \2\ Both reports were issued on March 27, 2012.


    The OIG received information from a confidential source about the 
Washington, DC VAMC (DC VAMC) in March 2017 alleging that patients and 
resources were at risk. Due to the seriousness of the allegations and 
the initial findings, the OIG issued an interim report on April 12, 
2017, that included the following findings: \3\
    \3\ Interim Summary Report - Healthcare Inspection - Patient Safety 
Concerns at the Washington DC VA Medical Center, Washington, DC

      Inaccurate and underutilized supply, instrument, and 
equipment inventories that made it difficult to meet healthcare 
provider and patient needs
      Inadequate product safety recall processes
      Dirty conditions in some clean/sterile storerooms
      Millions of dollars in noninventoried supplies and 
      Numerous vacancies in key positions that would make 
remediation of these conditions difficult

    The OIG continued the inspection for the next nine months and 
reported in March 2018 on significant pervasive problems that affected 
risks to patient care and safety, service deficiencies that impeded 
healthcare providers' efforts, lack of control over assets, and 
leadership failures at multiple levels of VA. The report also details 
that many management offices at VHA Central Office (VHACO), VISN 5 
leaders, and leaders at the DC VAMC had been given reports regarding 
many of these documented problems but they failed to appreciate the 
impact on patient care or had failed to take the necessary actions to 
correct the problems in many cases. \4\ Significantly, we did not find 
any patient deaths or other adverse clinical outcomes relating to these 
deficiencies, primarily due to the efforts of a number of committed 
healthcare professionals who improvised as necessary to ensure veterans 
received the best possible care under the circumstances. The final 
report contained 40 recommendations addressing deficiencies in multiple 
core functions of the DC VAMC's operations-all of which were agreed to 
by VA.
    \4\ VISN 5, VA Capitol Health Care Network, includes the 
Washington, DC VAMC.

Service Deficiencies Affecting Patient Care

    Although the medical center and VISN 5 have taken steps to address 
the supply chain inventory management issues described in the OIG 
Interim Report (such as detailing additional personnel to enter data 
into the authorized inventory system), problems persisted during the 
time of our inspection in getting supplies, instruments, and equipment 
to patient care areas when they are needed. The OIG identified wide-
ranging factors involving multiple deficiencies across several key 
services in the medical center, including the following:

      Continuing supply chain and inventory management problems
      Unsafe storage of clean/sterile supplies
      Deficiencies in the Sterile Processing Service
      Backlogs of open and pending prosthetic consults
      Staffing shortages and human resources mismanagement
      Lack of control over assets

Supply Chain and Inventory Management Problems

    The Generic Inventory Package (GIP) is the authorized software 
program used by VHA medical facilities to manage the receipt, 
distribution, and maintenance of supplies. The DC VAMC was required to 
use the GIP system until early May 2015 when the facility was directed 
to implement a new inventory system called Catamaran. However, as noted 
in the final report, medical center staff informed the OIG that the 
Catamaran system was never relied upon. Although the medical center had 
nominally transitioned to Catamaran in May 2015, VHA Procurement and 
Logistics Office (P&LO) staff were aware by January 2016 that the 
medical center had reverted to its manual inventory management 
practices and was not using the Catamaran system. These staff told OIG 
inspectors that they had no authority over the medical center, could 
not compel it to comply, and did not escalate the matter to VHA P&LO 
leaders. VHA subsequently terminated the Catamaran contract. Prior to 
the OIG receiving the allegations discussed in our report, VA's Policy, 
Assistance, and Quality (PAQ) staff from the VHA P&LO, conducted a 
review of inventory management at the medical center. PAQ staff 
determined in its January 2017 report that the medical center did not 
have a VHA-authorized inventory system in place.
    On March 21, 2017, the Deputy Under Secretary for Health for 
Operations and Management (DUSHOM) instructed the VISN 5 Director and 
the Medical Center Director via an emailed memo to provide an action 
plan addressing the PAQ concerns. Staff were detailed to the DC VAMC to 
take corrective action. Despite those efforts, the concerns were not 
adequately addressed and the OIG final report provided many examples of 
how inventory mismanagement contributed to the lack of medical supplies 
being available where and when they were needed, including oxygen nasal 
cannula tubing, disposable surgical staplers, and tubing for blood 
    We continued to find ongoing inaccuracies in the data entered in 
GIP. Even for a small number of items, the medical center could not 
reconcile its actual inventory with the data in GIP. As a result of the 
medical center's underutilization of GIP (estimates of 15-25 percentage 
of items included), it could not rely on the system to identify when 
supplies were running low or out of stock. \5\ The product recall 
process was also vulnerable because an accurate inventory was not kept. 
The medical center did institute a stop-gap measure to deal with 
supplies that may have been subject to a recall, but that was 
inadequate because Logistics Service and clinical staff had no way of 
verifying that all specified items had been removed from use. Without 
an accurate inventory, there is a heightened risk to patients that 
recalled products could be mistakenly used. In addition to patient 
risks associated with the medical center running out of supplies or 
using recalled products being elevated, the lack of accurate stock 
levels contributed to urgent reordering, some overstocking, and waste 
of government resources.
    \5\ In response to OIG findings, VA has reported that the DC VAMC 
has transitioned inventory to the GIP system and addressed stock 
levels, which will be assessed in OIG's follow-up process.

Unsafe Storage of Clean/Sterile Supplies

    To advance both patient safety and sound financial management, 
inventoried items must be secured and maintained in clean conditions. 
Proper storage of clean/sterile supplies is essential to preventing 
contamination and patient infections, as well as product deterioration. 
According to VHA directive, to maintain supplies properly, clean/
sterile storerooms must have stable temperature and humidity, 
restricted access, weekly shelf-cleaning by Logistics Service staff, 
and solid bottom shelves at least eight inches from the floor. 
Logistics Service staff must sign a weekly log stating that the area 
has been checked for expired supplies, cleanliness, and damage. While 
Logistics Service staff have responsibility for some specific cleaning 
tasks in clean/sterile storerooms, the Environmental Management Service 
(EMS) is responsible for the overall cleanliness of the rooms.
    EMS and Logistics Services reported having difficulties hiring and 
retaining qualified staff. VISN 5 knew of the staffing shortages in EMS 
in early fiscal year (FY) 2017 and knew of the Logistics Service 
staffing issues as early as 2014 from an external consultant's report. 
However, adequate steps to remedy the deficiencies were not taken.
    After our interim report, we noted some improvements in the 
cleanliness of storage rooms. The medical center had entered into a 
contract with a commercial cleaning service in June to supplement the 
medical center EMS staff but some areas were still of concern. As of 
September 2017, the Acting Human Resources Director reported to the OIG 
that 138 of 147 authorized EMS positions were filled.

Deficiencies in the Sterile Processing Service

    The OIG detailed multiple deficiencies in the Washington DC VAMC's 
Sterile Processing Service (SPS). These ranged from broken and 
discolored instruments reaching clinical areas; incomplete surgical 
trays in the operating room; improper tracking and reprocessing 
procedures for loaner instruments; missing or expired SPS supplies; 
failure to follow reprocessing instructions; inadequate documentation 
of staff competencies; and not separating clean and dirty items in 
satellite reprocessing areas.
    These problems were not new. Prior reviews were shared with the 
medical center, the VISN, and VHACO that consistently revealed 
deficiencies in SPS processes and procedures, staffing and leadership 
within SPS, and environment of care concerns that dated back to at 
least 2015. The National Program Office for Sterile Processing reported 
concerns in April 2015, September 2015, and October 2016. The October 
2016 report had 140 corrective actions including some repeat findings. 
In response to why conditions were uncorrected for so long, SPS 
managers cited chronic understaffing of SPS and difficulties retaining 
qualified personnel.
    In November 2017, the OIG received a complaint about cancellation 
of nine surgeries at the medical center. The OIG confirmed the 
cancellations and that the medical center had reported to VHACO that 
spotting and discoloration were found on some instruments. A contractor 
was hired and examined 8,931 pieces of equipment and instruments over a 
two-day period. The contractor reported finding rust on about 30 
instruments; those items were polished and returned to service. On 
further inspection the same contractor recommended replacing 216 
instruments. Our report found that historically even when new 
instruments were purchased, they could not always be reprocessed 
appropriately nor were they always stored appropriately. In its 
response to the OIG report, VA stated that it purchased more than $3 
million in surgical instruments and contracted to construct additional 
space for SPS.

Backlog of Open and Pending Prosthetic Consults

    VHA requires that quality patient care be provided by furnishing 
properly prescribed prosthetic equipment, sensory aids, and devices in 
an economical and timely manner. To order a prosthetic appliance or 
implant, a medical center provider must initiate and submit a consult 
(a request for an item that allows for subsequent tracking) in the 
electronic health record to the Prosthetics Service.
    A prosthetic consult is considered ``closed'' when a patient 
receives an in-stock item, a purchasing agent ships an in-stock item to 
the patient, or a purchasing agent places an order with a vendor for a 
nonstocked item to be shipped directly to the patient. A prosthetic 
consult is placed in a ``pending'' status if other actions must be 
taken before the consult can be completed and should be documented in 
the prosthetic consult to allow for tracking through completion. VHA 
business practice guidelines for prosthetic consult management states 
that pending prosthetic consults ``must be reviewed at least weekly by 
the Chief, [Prosthetic and Sensory Aids Services] and the Prosthetic 
employee responsible for completing that consult.'' VHA requires the 
closure of pending prosthetic consults upon the earlier of 45 working 
days or 60 calendar days.
    Medical center and VISN 5 leaders became aware of the increasing 
number of open and pending prosthetic consults in May 2016 but due to 
incomplete administrative actions by the medical center leaders to 
provide access to its systems, VISN 5 could not take the necessary 
steps to provide assistance in addressing the increasing number of open 
and pending prosthetic consults.
    To resolve the consults backlog identified by the OIG, the Acting 
Medical Center Assistant Director reported VA had efforts in progress 
to hire staff, redesign the organizational structure, claim 2,000 
square feet of warehouse space for inventory, and develop a walk-in 
clinic. In addition, he reported that nine purchasing agents had been 
assigned from across VHA to assist with resolving open and pending 
prosthetic consults.
    On August 29, 2017, OIG staff spoke with the Acting Chief of 
Prosthetics who confirmed that through the use of additional staffing, 
the medical center had been able to reduce the number of prosthetic 
consults to approximately 6,130, of which 3,800 were more than 30 days 
old. Also in August, the DC VAMC chartered an Administrative 
Investigative Board to determine accountability for the failures 
identified within the Prosthetics Service. In its response to our final 
report, VHA stated that ``as of January 2018, the DC VAMC had no 
pending prosthetics consults over 30 days.'' We will verify this 
information during our follow-up process.

Staffing Shortages and Human Resources Mismanagement

    Medical center personnel often attributed deficiencies in Logistics 
Service and SPS to chronic understaffing. To obtain additional staff, 
the medical center's policy specifies that Service Chiefs must 
determine the minimum number of positions needed to perform the 
functions of their services and submit requests for new positions or 
changes in the grade of already approved positions to the Resource 
Management Committee (RMC). The Associate Director of the medical 
center chairs the RMC, which makes recommendations to the Director 
regarding approval or disapproval of these requests, based in part on 
budgetary considerations. The medical center Human Resources Management 
(HR) is responsible for executing actual hiring actions.
    The OIG determined that Logistics Service and SPS had experienced 
historically high vacancy rates. A number of factors contributed to 
these rates, including a failure to maintain accurate data on the 
numbers of authorized positions throughout the medical center; the RMC 
not performing its duties in accordance with policy; and HR not 
completing hiring actions appropriately.
    The OIG confirmed that high turnover rates in HR leadership may 
have contributed to the failure to resolve staffing issues. VHACO and 
VISN 5 provided teams and personnel to support the medical center's 
general HR functions, but the DC VAMC did not implement action plans 
developed from those consultative site visits.
    VA reports progress in hiring but vacancy rates for SPS staff are 
still high at the medical center, although VA reports some of those 
positions being filled by contractors in their response to the OIG 

Lack of Control Over Assets

    The medical center continually mismanaged significant government 
resources and did not adequately secure veterans' protected 
information. Its financial and inventory systems produced inadequate 
data, lacked effective management controls, and yielded no reasonable 
assurance that funds were appropriately expended. Accordingly, the OIG 
could not estimate the loss to VA as a result of the failings 
identified in the final report. A number of examples are provided in 
the report, however, that show significant overpayments for particular 
products; unsecured access to and mismanagement of more than 500,000 
items accumulated in an off-site warehouse that included purchases not 
meeting medical center needs, overstocked items, and some items that 
appeared damaged; abuse of purchase cards; and other failures to use 
taxpayer dollars appropriately.
    The following are examples of how government resources were at risk 
for or subject to fraud, waste, and abuse:

      There was excessive use of government purchase cards for 
medical equipment and supply purchases (89 percent of the medical 
center's total purchase card use was for medical supplies) instead of 
approved federal contracts that leverage buying power and helped ensure 
appropriate pricing and purchasing. Purchase card use was not as 
closely scrutinized and did not take advantage of the typically lower 
prices associated with buying under federal contracts. They were 
misused, in part, because leaders failed to ensure proper controls or 
fix an inventory system-which sometimes led to urgent purchases needing 
to be made on purchase cards for quick delivery as a workaround for 
supply problems.
      The VISN 5 Agency/Organization Program Coordinator (A/
OPC) for the purchase card program reported potentially fraudulent 
purchase orders to medical center leaders and the Chief of Prosthetics 
in September 2016. After no action was taken by either, the VISN 5 A/
OPC took action to reduce a purchasing agent's limit and initiated an 
audit. Also VA policy limited the number of purchase card accounts for 
which an approving official is responsible to not more than 25. At the 
medical center, the Chief Logistics Officer (CLO) was responsible for 
approving expenditures made by all of the 86 cardholders.
      A general lack of controls was found over acquisition of 
medical supplies and equipment, including the inability to consistently 
provide documentation such as purchase orders, invoices, receiving 
reports, or other item-level records required for proper auditing. For 
example, the medical center incurred nearly $875,000 in rental fees for 
three specialized hospital beds for patients' in-home use that could 
have been purchased new for a total of about $21,000.
      The medical center failed to segregate duties so that the 
same individual was not both purchasing and receiving or inventorying 
goods to ensure the integrity of procurement processes and prevent 
theft or abuse.
      The medical center lacked an updated and accurate 
inventory for nonexpendable equipment. VA requires medical facilities 
to perform an annual physical inventory of all nonexpendable items and 
maintain an Equipment Inventory List (EIL). EIL includes all 
nonexpendable property with assigned numbers that correspond to the 
responsible department. Although the EIL Custodial Officer is 
responsible for completing and signing the EIL, the Medical Center 
Director and CLO (or their designee) must ensure accountability and 
oversight for all nonexpendable property and equipment in their 
facility. The Medical Center CLO failed to submit data for the VHA 
Quarterly EIL reports for three years. Furthermore, a March 2017 memo 
from the DUSHOM to the VISN Director and the Medical Center Director 
stated that Reports of Survey listing lost or stolen property had not 
been completed for more than five years.
      Because of failures in Records Management, more than 
1,300 boxes of unsecured documents, including some patient protected 
health information and personally identifiable information were found 
in various locations including the off-site warehouse, on-site storage, 
the DC VAMC basement, and a dumpster.

Risks to Patient Care

    It is clear that functions typically thought of as administrative 
in nature can have a profound impact on the ability of healthcare 
providers to do their jobs effectively and on the risk of harm to 
patients. During extensive interviews conducted by the OIG's Rapid 
Response Team and other personnel, 13 healthcare providers stated that 
they had reported their concerns to the Chief of Surgery and 12 
healthcare providers stated that they had reported supply, instrument, 
or equipment concerns to the Medical Center Chief of Staff. As I will 
discuss further, these and other issues at the DC VAMC were reported to 
the VISN and by program offices within VA.
    For our review, OIG healthcare staff independently reviewed the 
care provided to 124 DC VAMC patients to determine if they experienced 
adverse clinical outcomes because their healthcare provider did not 
have the appropriate supplies, instruments, or equipment. As discussed 
earlier, while the OIG did not find that patients suffered adverse 
clinical outcomes for the review period, staff provided several 
examples that illustrated an impact on patients when supplies, 
instruments, and equipment were not available when needed. These 
included unnecessary anesthesia, prolonged procedures or 
hospitalizations, and alternative surgical techniques due to failure to 
ensure the availability of instruments or supplies. For example, a 
``mesher'' used to place small holes in the skin to assist with 
drainage had a missing handle and the surgeon needed to conduct the 
procedure manually, which can result in uneven drainage. In some cases, 
procedures needed to be delayed, rescheduled, or required staff to 
leave the facility to borrow what was needed from a nearby private 
hospital. For example, an instrument was not sterilized since its last 
use and was unavailable to the surgeon after the patient received 
general anesthesia, resulting in the procedure being cancelled and 
rescheduled two days later, which unnecessarily exposed the patient to 
the risks associated with the anesthesia. In another case, staff went 
``across the street'' to a medical facility to acquire mesh while the 
operation was ongoing. We found that staff lacked confidence that 
managers and leaders overseeing the facility would fix these problems 
and resorted to creating their own workarounds to ensure patients 
received proper care.

Patient Safety Reports

    Patient safety reports allow for the reporting and tracking of 
adverse events and ``close calls'' as well as allowing VA medical 
facilities to identify and address unsafe conditions. For the interim 
report review, OIG staff found 193 patient safety reports at the DC 
VAMC since January 1, 2014, were entered into VHA's National Center for 
Patient Safety (NCPS) database. However, we determined that the number 
of patient safety events was under-reported and at least 376 patient 
safety events related to supplies, instruments, or equipment were 
reported within the medical center. Of those, 206 patient safety events 
were entered into the facility's system, but were not entered into the 
VHA database as required. Overall, the DC VAMC failed to appropriately 
score, trend, and record patient safety events and the patient safety 
manager did not properly identify that further analysis was warranted.
    Within an individual medical center, the patient safety manager can 
identify emerging trends that could potentially compromise patient 
safety through event reporting and analysis. At the national level, the 
VHA NCPS analyzes data reported from all medical facilities to identify 
emerging trends that have the potential to compromise patient safety in 
multiple facilities. At DC VAMC, although data were available, the 
patient safety manager did not detect the widespread nature of the 
supply, instrument, and equipment problems until June 2016, when an 
individual root cause analysis was conducted on an incident involving 
the use of expired surgical supplies during a surgical procedure.
    Other mechanisms for aggregating information to inform VISN and 
medical center leaders about emerging issues include the work of 
quality management and safety committees. The OIG conducted an 
extensive review of meeting minutes from the Executive Committee of the 
Governing Body (ECGB), which is responsible for oversight of critical 
quality and patient safety monitors, and its subordinate committees. 
The ECGB oversees the Medical Executive Committee and Quality Council 
as well as other organizational patient safety and performance 
improvement initiatives.
    VHA policy requires the ECGB to keep minutes that describe and 
track issues to resolution, as well as to make recommendations to 
leaders. The OIG review of minutes from October 2015 through April 2017 
revealed a pattern of reporting and oversight deficits. In addition to 
the ECGB meeting minutes, the OIG reviewed meeting minutes of other 
committees that provide oversight for patient safety and performance 
improvement initiatives. Review of the Director's morning report also 
revealed a lack of appropriate follow-up actions for surgical 
instrument issues.
    The OIG confirmed through interviews and analyses of documents 
provided that action plans, if implemented, were not consistently 
effective at resolving issues as evidenced by ongoing deficiencies in 
many areas. The VISN Quality Management Officer who has responsibility 
for overseeing all aspects of quality management and performance 
improvement at VISN 5 facilities acknowledged these concerns in an 
interview with OIG staff, and reported that he would be ``pushing for a 
rapid process improvement initiative.'' VA has also reported that 
following our findings, the DC VAMC cleared its backlog of patient 
safety incident reports.

Failures in Leadership

    It is clear that information and documentation outlining some, if 
not most, of the failings in the medical center reached responsible 
officials in DC VAMC, VISN 5, and VHACO as early as 2013, but actions 
taken did not effectively remediate the conditions.
    From 2013 through 2016, the DC VAMC and VISN 5 received at least 
seven written reports detailing significant deficiencies in Logistics, 
Sterile Processing, and other Services, many of which were identified 
as persistent at the time of the OIG 2017 on-site visits.

      Management Quality Assurance Service (MQAS) Report (2013) 
- This report evaluated the performance of selected areas of logistics 
operations and identified areas requiring improvement. This report was 
provided to the Medical Center Director in January 2013 as well as 
VHACO Procurement and Logistics Office (P&LO) and VISN 5 leaders. It 
contained 52 conditions including nine repeat findings and two concerns 
related to compliance with VA and VHA directives that required 
management attention.

    There was an exchange of information between MQAS and the Medical 
Center Director in March and May 2013 but in December 2013, MQAS staff 
emailed medical center staff requesting an update as the completion 
dates were past due. Again in February 2014, MQAS staff reached out for 
an update but the Medical Center did not respond. In June 2014, MQAS 
requested assistance from VHA P&LO. VHACO contacted the VISN CLO for an 
update and to offer assistance. Moreover, the VISN 5 CLO admitted that 
the VISN ``may have dropped the ball on response.'' In October 2014, 
MQAS advised the VISN 5 CLO that they would elevate these issues if the 
DC VAMC did not provide information. The medical center responded in 
piecemeal fashion. In December 2015, MQAS determined based on 
representations from the Medical Center, that all but one 
recommendation was satisfied. As late as February 2017, MQAS continued 
to follow up with DC VAMC Logistics Service for required reports.

      VISN 5 Network External Review (NER) (2013) - Each VISN 
was required to conduct an annual review of its facilities' logistics 
operations. In May 2013, the VISN Director sent the Medical Center 
Director the NER relating to Logistics Service containing 55 
observations including a finding that the medical center was not using 
GIP to manage its inventory. In June 2013, the Associate Medical Center 
Director responded and provided estimated implementation dates for each 
of the 55 areas.
      VISN 5 Consultant Report (2013) - In December 2013, at 
the direction of VISN 5, a consultant reviewed the medical center's 
Facility Management Service and Safety Programs. The report was 
presented to medical center leadership and detailed numerous concerns, 
including that ``the Sterile Processing Service (SPS), a high 
visibility program with critical responsibility toward patient safety, 
is working in an area that was identified to be outside of required 
environmental controls (humidity), and environmental monitoring is not 
being consistently or continuously conducted.'' In addition, the 
consultant noted that documentation of SPS staff competencies was not 
available. The OIG is unable to determine what remedial efforts were 
made, if any. Any improvements were not sustained because the SPS 
deficiencies identified in the 2013 Consultant Report persisted at the 
time of the 2017 OIG site visits.
      VISN 5 Logistics Study (2014) - VISN 5 engaged an 
external consultant to study Logistics Service operations within its 
facilities in 2014. After reviewing the consultant's observations, the 
VISN noted the DC VAMC's Logistics Service staffing was significantly 
lower than similar facilities and the facility had high staff vacancy 
rates in both the expendable supply and nonexpendable equipment 
Logistic Service. The medical center's CLO attempted to increase 
staffing but contended efforts were impeded by a lack of support from 
the medical center's HR staff. The OIG identified emails alerting the 
leadership of this issue.
      Nursing Report (2016) - VISN 5 reviewed nurse staffing 
and related issues in its facilities in 2016. In May 2016, the VISN 
shared the results with the DC VAMC Director, which included the 
facility was short approximately 98 nurses and the supply chain was 
broken. The Medical Center Director acknowledged the vacancies and 
commented that there were no sentinel events at the facility.
      National Program Office on Sterile Processing (NPOSP) 
Reports (2015 and 2016) - In April 2016, the medical center reported it 
had ``closed'' (satisfied) 25 of 28 recommendations arising out of the 
September 2015 site visit. The medical center reported that it planned 
to resolve two recommendations on or before May 20, 2016, and that the 
final recommendation relating to workflow would be addressed during a 
renovation of SPS planned for 2017. However, a repeat visit from NPOSP 
in October 2016 identified recurring issues previously reported as 
resolved, including environmental issues, lack of SOPs, and inadequate 
documentation of staff competencies. NPOSP issued additional 
recommendations, some of which were repeat findings from the 2015 

    In response to the October 2016 NPOSP recommendations, the medical 
center submitted another detailed action plan on December 9, 2016, with 
periodic progress updates thereafter. Documentation shows that the 
medical center updates falsely reported that some action items 
identified in the NPOSP 2016 visit had been completed, resulting in 
VISN 5 reopening an action item in April 2017 previously reported as 
    The chronic medical center deficiencies noted in the 2013-2017 
reports speak to leaders' at various levels inability or unwillingness 
to implement and sustain lasting change within various services.

Ineffective Follow Up

    Turnover and inadequate governance affect remediation. For example, 
in terms of staffing, the DC VAMC has had five Associate Directors 
since 2013, most of who assumed the role in an acting capacity. The 
Associate Director is responsible for the managerial and administrative 
services and operations that are the subject of the report, including 
Logistics Service, HR, Fiscal Service, and EMS. Lack of consistent 
leadership in this key role since December 2015 made it more likely 
that the medical center managerial and administrative deficiencies 
would remain unaddressed.
    Many recommendations from previous reports concerning the sterile 
processing of instruments and Logistics Service functions were deemed 
implemented or ``closed'' but were not effectively addressed. VISN 5 
leaders and some VHACO personnel were aware of many of the problems 
identified and did not ensure that adequate corrective action had been 
taken by the medical center to address them. Methods used by the VISN 
and VHACO to oversee the medical center were either inadequate or did 
not include accurate or complete data on key aspects of medical center 
operations. As the Director of VISN 5 acknowledged, the VISN 
responsibility should be to intervene when it has notice of a problem. 
Or, as the Director bluntly conceded, ``the buck stops with him.''
    There has been significant focus recently on the ratings given by 
the Strategic Analytics for Improvement and Learning (SAIL). The DC 
VAMC was rated a 2-star (slightly below average) rating from 2011 
through the third quarter of FY 2015, and then improved to a 3-Star 
(average) rating, maintaining that rating through March 31, 2017. \6\ 
The SAIL rating is based on clinical measures but does not include 
supply chain inventory and logistic issues even though such functions 
have clinical impact. The SAIL model incentivizes facilities to take 
action to improve the quality of care, however its minimal focus on 
administrative functions that support patient care can leave patients 
    \6\ VA no longer publishes star ratings but based on SAIL data, the 
facility is currently between 1 and 2 stars.
    Our report also found that VHACO receives information daily from 
medical centers and VISNs to inform policymaking, but that information 
is not always shared with officials who can take action to remedy the 


    We seek to address in all of our work-whether an audit, review, or 
inspection-the underlying cause (or causes) of the identified condition 
and who is responsible. This focus has revealed that there is often a 
lack of oversight for compliance with policies and procedures, 
reporting mechanisms are not reliable, and operations are not effective 
or efficient. \7\
    \7\ Healthcare Inspection - Evaluation of System-Wide Clinical, 
Supervisory, and Administrative Practices, Oklahoma City VA Health Care 
System, Oklahoma City, Oklahoma, November 2, 2017; Review of Research 
Service Equipment and Facility Management, Eastern Colorado Health Care 
System, March 29, 2018; Audit of Beneficiary Travel Program, Special 
Mode of Transportation, Eligibility and Payment Controls, May 7, 2018.
    One specific example is the change we made in April 2017 regarding 
our cyclical review of VAMCs. We now include a review section on the 
leadership at the facility when conducting our Comprehensive Healthcare 
Inspection Program (CHIP) reviews. We provide a descriptive evaluation 
of VHA facility leadership performance and effectiveness as evidenced 
by the reduction of organizational risks and provision of quality care 
that result in positive patient outcomes and experiences and optimal 
levels of employee engagement and satisfaction. Our work will continue 
to examine leadership and governance issues throughout VA.


    We found critical deficiencies in our inspection of DC VAMC. 
Although the findings and recommendations focus on improvements in that 
facility, the issues raised could be used almost as a checklist for 
other facilities, VISNs, and VHA leaders.
    While the concrete deficiencies present significant challenges, we 
believe the greatest obstacle to change is the sense of futility or 
culture of complacency among some staff and leaders. At the core, the 
DC VAMC report is about the breakdown of systems and leadership at 
multiple levels, and an acceptance by many personnel that things will 
never change. This was evidenced by

      staff that got used to ``making do,''
      acceptance or normalization of non-compliant practices,
      acceptance of information/data at face-value without 
asking the next question, and
      willingness to rationalize poor practices with ``nobody's 
been harmed.''

    We fervently believe that VHA has talented and committed people 
that could lead the turnaround at the DC VAMC and other facilities. We 
saw healthcare professionals and other staff making significant efforts 
to ensure patients were safe and receiving quality care by using 
workarounds or trying to do the right thing. With time and concerted 
effort, we know that positive change can be realized. VHA needs to 
recognize the urgency in making strong leadership decisions now to 
oversee that change.
    Mr. Chairman, this concludes my statement. I would be happy to 
answer any questions you or other members of the Committee may have.

                 Prepared Statement of Roscoe G. Butler
    Chairman Roe, Ranking Member Walz, and distinguished members of the 
Committee; on behalf of National Commander Denise H. Rohan and The 
American Legion, the country's largest patriotic wartime service 
organization for veterans, comprised of more than 2 million members, 
and serving every man and woman who has worn the uniform for this 
country, we thank you for inviting The American Legion to testify today 
to share our position regarding the current status of remedial actions 
at VISNS 1,5, and 22.


    In 1994, the Veterans Health Administration (VHA) was structured 
into four regions, and individual VA medical centers reported directly 
to VHA for budgeting and program management purposes. At that time, VHA 
was responsible for the care of approximately 25 million veterans.
    Each region was led by a region director located in the field 
(Linthicum, MD; Ann Arbor, MI; Jackson, MS; and San Francisco, CA). The 
four region directors supervised the operation of the medical care 
facilities in their regions (which ranged from 36 to 45 facilities per 
    The veterans health care system is the largest health care system 
in the United States, although it is an anomaly in American health care 
in so far as being a centrally administered, fully integrated, national 
health care system that is both funded and operated by the federal 
government. As it grew in size and complexity, the system became 
increasingly cumbersome and bureaucratic. It was often perceived to be 
unresponsive to individual needs and changing circumstances. It seemed 
to be chronically underfunded and short of staff and supplies, despite 
its rising costs. By the mid-1990s, the system was widely criticized 
for being difficult to access, for having long wait times and poor 
service, for providing care of unpredictable and irregular quality, and 
for being inefficient and expensive. Many policymakers and health care 
professionals questioned whether it had a future. \1\
    \1\ Kizer KW, Dudley RA. Extreme makeover: Transformation of the 
veterans health care system. Annu Rev Public Health. 2009;30:313-39. 
doi: 10.1146/annurev.publhealth.29.020907.090940.
    By 1994, the VA had grown to be the country's largest health care 
provider, with an annual medical care budget of $16.3 billion; 210,000 
full-time employees; 172 acute care hospitals, which had 1.1 million 
admissions per year; 131 skilled nursing facilities, which housed some 
72,000 elderly or severely disabled adults; 39 domiciliaries 
(residential care facilities), which cared for 26,000 persons per year; 
350 hospital-based outpatient clinics, which had 24 million annual 
patient visits; and 206 counseling facilities, which provided treatment 
for posttraumatic stress disorder (PTSD). The VHA also partnered with 
almost all states to fund state-owned skilled nursing facilities for 
elderly veterans and administered a contract and fee-basis care program 
paying for $1 billion of out-of-network services each year. \2\
    \2\ Kizer KW, Dudley RA. Extreme makeover: Transformation of the 
veterans health care system. Annu Rev Public Health. 2009;30:313-39. 
doi: 10.1146/annurev.publhealth.29.020907.090940.
    The VHA was a system based on inpatient care, in contrast to 
substantially less expensive and patient-friendly ambulatory care. 
Specialists rather than primary-care physicians dominated the 
workforce. Finally, like many publicly funded health systems throughout 
the world, the client base was increasingly needy and growing in 
    There was widespread consensus that the veterans health care system 
needed a major overhaul but little agreement about how to effect the 
change. Further, the system had to remain fully operational while it 
was being overhauled.
    In 1994, President Bill Clinton appointed Dr. Kenneth Kizer as VA 
Undersecretary for Health. Dr. Kizer inherited an organization famous 
for low quality, difficult to access, and high-cost care. \3\ Under new 
leadership recruited from outside the system-the first time this had 
occurred in more than 30 years-a plan to radically transform VA health 
care was developed in the winter of 1994-1995, vetted with the Congress 
(as required by law) and the VA's myriad stakeholders in the spring and 
summer of 1995, and launched in October 1995. \4\
    \3\ https://rogerlmartin.com/docs/default-source/Articles/
    \4\ Kizer KW, Dudley RA. Extreme makeover: Transformation of the 
veterans health care system. Annu Rev Public Health. 2009;30:313-39. 
doi: 10.1146/annurev.publhealth.29.020907.090940.
    In March 1995, Dr. Kizer submitted a plan to Congress titled The 
Vision for Change - A Plan to Restructure the Veterans Health 
Administration. \5\ The reorganization plan was the first step in VHA 
becoming a more efficient and patient-centered health care system.
    \5\ https://www.va.gov/HEALTHPOLICYPLANNING/vision--for--change.asp
    This new structure intended to decentralize decision-making 
authority regarding how to provide care and integrate the facilities to 
develop an interdependent system of care through a new structure - the 
Veterans Integrated Service Network (VISN). The VISN's primary function 
was to be the basic budgetary and planning unit of the veterans' health 
care system.
    Dr. Kizer's plan suggested that the number of staff needed to 
manage a VISN would range between seven and ten full-time employees 
initially, which over the years ballooned to 220 employees working at 
the VISN. The geographical boundaries for each new VISN were defined 
based on natural patient referral patterns at VA medical centers and 
outpatient clinics, the number of enrolled veterans in the system, and 
the type of facilities needed to provide care. \6\
    \6\ https://www.burr.senate.gov/imo/media/doc/VISNAct.pdf
    In September 1995, Congress authorized VA to implement the plan. 
The 22 network directors were officially named on September 21, 1995. 
VISN Directors began assuming their new positions in October 1995, and 
all were on board by January 29, 1996. The transition of operations 
from the regional offices to the networks commenced in October 1995.
    In October 1995, the restructuring of VHA headquarters also begun. 
Restructuring included eliminating certain positions and offices, 
reorganizing other offices and functions, and establishing new offices 
of Policy, Planning and Performance; Chief Information Officer; and 
Employee Education. In addition, the Chief Network Officer became part 
of the integrated Office of the Under Secretary for Health.
    At the same time VHA was tasked with implementing Dr. Kizer's VISN 
for Change, it also had the daunting task of implementing one of the 
most dramatic legislative changes impacting veterans health care in the 
20th century, The Veterans' Health Care Eligibility Reform Act of 1996. 
\7\ This law was enacted to help VA improve its management of care and 
provide this care in more cost-effective ways; it also sought to 
increase veterans' equity of care. To improve cost-effectiveness, the 
act allowed VA to provide needed hospital care and health care services 
to veterans in the most clinically appropriate setting.
    \7\ https://www.congress.gov/bill/104th-congress/house-bill/3118
    Since then, VISN staff and functions have expanded way beyond the 
original intent of Dr. Kizer's Vision for Change. Since the creation of 
VISNs in 1995, there has been a significant shift in veterans' 
demographics and geographically where they access care; however, VA has 
not reassessed the VISN structure.
    In September 2016, the Government Accountability Office (GAO) 
issued a report entitled VA Health Care: Processes to Evaluate, 
Implement, and Monitor Organizational Structure Changes Needed. GAO 
reported that internal and external reviews of VHA operations have 
identified deficiencies in its organizational structure and recommended 
changes that would require significant restructuring to address, 
including eliminating and consolidating program offices and reducing 
VHA central office staff. However, VHA does not have a process that 
ensures recommended organizational structure changes are evaluated to 
determine appropriate actions and implemented. \8\
    \8\ GAO report (Oct 27, 2016): VA Health care: Processes to 
Evaluate, Implement, and Monitor Organizational Structure Changes 
    For example, VHA chartered a task force to develop a detailed plan 
to implement selected recommendations from the independent assessment 
of VHA's operations required by the Veterans Access, Choice, and 
Accountability Act of 2014. \9\ It found, among other things, that VHA 
central office programs and staff had increased dramatically in recent 
years, resulting in a fragmented and ``siloed'' organization without 
any discernible improvement in business or health outcomes. It 
recommended restructuring and downsizing the VHA's central office. \10\ 
The task force of 18 senior VA and VHA officials conducted work over 
six months, but did not produce a documented implementation plan or 
initiate implementation of the recommendations. Without a process that 
documents the assessment, approval, and implementation of 
organizational structure changes, VHA cannot ensure that it is making 
appropriate changes, using resources efficiently, holding officials 
accountable for taking action, and maintaining documentation of 
decisions made.
    \9\ https://www.congress.gov/bill/113th-congress/house-bill/3230
    \10\ https://www.va.gov/opa/choiceact/documents/assessments/
    In October 2015, VHA began to implement a realignment of its VISN 
boundaries, which involves decreasing the number of VISNs from 21 to 18 
and reassigning some VA medical centers (VAMC) to different VISNs. VHA 
officials anticipate this process will be completed by the end of 
fiscal year 2018. VHA officials on the task force implementing the 
realignment told GAO they thought VISNs could implement the realignment 
independently without the need for close monitoring. VHA also did not 
provide guidance to address VISN and VAMC challenges that could have 
been anticipated, including challenges with services and budgets, 
double-encumbered positions (two officials in the same position in 
merging VISNs), and information technology. Further, VHA officials said 
they do not have plans to evaluate the realignment. VHA's actions are 
inconsistent with federal internal control standards for monitoring 
(management should establish monitoring activities, evaluate results, 
and remediate identified deficiencies) and risk assessment (management 
should identify, analyze, and respond to changes that could affect the 
system). Without adequate monitoring, including a plan for evaluating 
the VISN realignment, VHA cannot be certain that the changes are 
effectively addressing deficiencies; nor can it ensure lessons learned 
can be applied to future organizational structure changes.
    In March 2018, former VA Secretary David Shulkin announced his plan 
to reorganize the department's central office by May 1. \11\ May 1st 
has come and gone, but the reorganization has not occurred. A statement 
from Dr. Shulkin's March 2018 release, he stated:
    \11\ https://www.usatoday.com/story/news/politics/2018/03/07/va-

    ``The VISN model was put in place close to 20 years ago, a very 
innovative model that has served VA well,'' Shulkin said. ``But like 
any business, the times change, the needs change and it's time for us 
to look at how we operate our networks differently to get the type of 
accountability that's needed to make sure we don't see the failures 
that we saw here in the Washington, D.C. VA.''

    Dr. Shulkin also discussed the appointment of a special team to 
work with its national leadership council to develop a nationwide 
reorganization plan for its 23 VISNs, which was due to the secretary by 
July 1. \12\
    \12\ https://www.dav.org/learn-more/news/2018/va-secretary-
    On March 8, 2018, Dr. Shulkin announced the appointment of a new 
executive in charge, Bryan Gamble, to oversee three VISNs: the New 
England Health Care System and the Capitol Health Care Network, which 
includes Washington, D.C., and parts of Maryland and Virginia, as well 
as the Desert Pacific Healthcare Network in California, New Mexico and 
Arizona. \13\
    \13\ https://federalnewsradio.com/veterans-affairs/2018/03/shulkin-

The Way Forward

    The purpose for creating the VISN structure was to decentralize 
decision-making authority regarding how to provide care and integrate 
the facilities to develop an interdependent system of care through the 
VISNs. The VISN's primary function was to be the basic budgetary and 
planning unit of the veterans' health care system. However, as we all 
know, the VISN structure has morphed into a broader operation, 
consuming more staff, resources, funding, and physical space.
    As more veterans enrolled in the VA health care system, the VISN 
responsibility for budget and planning increased and it became more 
difficult for the VISN to manage. Reoccurrence of system- wide failures 
are becoming routine that are attributable to leadership failures at 
the VAMC, VISN and Central Office level. According to the March 7, 2018 
VAOIG report citing Critical Deficiencies at the Washington DC VA 
Medical Center, the VAOIG cited numerous failures at the Washington DC 
VA Medical Center, the VISN, and VA Central Office. \14\ Medical 
Center, VISN 5, and some VACO leaders knew for years about at least 
some of the problems outlined in the VAOIG report. The report stated 
information and documentation outlining some of the failings in the 
Medical Center reached responsible officials in the Medical Center, 
VISN 5, and VACO as early as 2013, but there where failures at multiple 
levels of leadership, in accountability, responsibility, and oversight. 
This lack of ownership and a pervasive practice of shifting blame to 
others contributed to a culture of complacency and neglect that placed 
both patients and assets of the federal government at risk.
    \14\ https://www.va.gov/oig/pubs/VAOIG-17-02644-130.pdf
    Clearly, Dr. Kizer's VISN model is no longer living up to 
expectations, but rather has grown into a high cost ineffective 
    In 2016, The American Legion membership voiced serious concerns 
about the effectiveness of the VISNs and passed Resolution 194, 
entitled Department of Veterans Affairs Veteran Integrated Service 
Networks. The resolution urges Congress to direct the GAO and VAOIG to 
conduct a comprehensive study to include purpose, goals, objective, 
budget and evaluation of the effectiveness of the VISN structure. \15\
    \15\ American Legion Resolution No. 194 (2016): Department of 
Veterans Affairs Veteran Integrated Service Networks
    The American Legion applauds former Secretary David Shulkin for 
proposing to look into reorganizing the VISN and VA Central Office. The 
American Legion believes that the Central Office and VISN realignment 
is in keeping with Resolution 194, and should continue its course with 
Veteran Service Organizations being consulted throughout the process to 
ensure, from a veteran perspective, their concerns are addressed.


    As always, The American Legion thanks this Committee for the 
opportunity to elucidate the position of the 2 million veteran members 
of this organization. For additional information regarding this 
testimony, please contact Assistant Director of the Legislative 
Division, Jeff Steele, at (202) 861-2700 or [email protected]

                       Statements For The Record

      U.S.Office of Special Consel, Henry J.Kerner Special Counsel
    January 25, 2018

    The President The White House
    Washington, D.C. 20500
    Re: OSC File Nos. DI-16-5687. DI-16-5688, DI-16-5689, and DI-16-

    Dear Mr. President:

    Pursuant to 5 U.S.C. Sec. 1213(e)(3), I am forwarding reports from 
Department of Veterans Affairs (VA) based on disclosures of wrongdoing 
at the Department of Veterans Affairs (VA), VA Medical Center 
Manchester (VAMC Manchester), Manchester, New Hampshire. The four 
whistleblowers in this matter, Dr. Ed Kois, Dr. Stuart Levenson, Dr. Ed 
Chibaro, and Dr. Erik Funk (the whistleblowers), who consented to the 
release of their names, disclosed that a large number ofVAMC Manchester 
patients have developed serious spinal cord disease as a result of 
clinical neglect at the VA; that the former Chief of the Spinal Cord 
Unit, Dr. Muhammad Huq improperly copied and pasted patient chart notes 
for over 10 years; and that VAMC Manchester's operating room (OR) has 
repeatedly been infested with flies.
    These cases are representative ofVA's ongoing difficulties in 
providing appropriate and expeditious patient care and appear to 
demonstrate issues with VA' s efforts to ensure allegations are 
appropriately reviewed. The agency reports received by the Office of 
Special Counsel (OSC) were not fully responsive and were frequently 
evasive in their reluctance to acknowledge wrongdoing. \1\
    \1\ The Office of Special Counsel (OSC) is authorized by law to 
receive disclosures of information from federal employees alleging 
violations of law, rule, or regulation, gross mismanagement, a gross 
waste of funds, an abuse of authority, or a substantial and specific 
danger to public health and safety. 5 U.S.C. Sec.  1213(a) and (b). OSC 
does not have the authority to investigate a whistleblower's 
disclosure; rather, if the Special Counsel determines that there is a 
substantial likelihood that one of the aforementioned conditions 
exists, he is required to advise the appropriate agency head of her 
determination, and the agency head is required to conduct an 
investigation of the allegations and submit a written report. 5 U.S.C. 
Sec.  1213(c). Upon receipt, the Special Counsel reviews the agency 
report to determine whether it contains all of the information required 
by statute and that the findings of the head of the agency appear to be 
reasonable. U.S.C. Sec.  1213(eX2). The Special Counsel will determine 
that the agency's investigative findings and conclusions appear 
reasonable if they are credible, consistent, and complete based upon 
the facts in the disclosure, the agency report, and the comments 
offered by the whistleblower under 5 U.S.C. Sec.  1213(e)(l).
    It appears that the VA acknowledged and responded to confirmed 
wrongdoing after the publication of a July 15, 2017, Boston Globe 
article based on information provided by the individuals identified 
above and others. \2\ The VA was on notice of these allegations when 
OSC referred them for investigation in early January 2017, but did not 
take any action to remove responsible management officials or initiate 
a comprehensive review of the facility until after the Boston Globe 
article was published in July. This sends an unacceptable message to VA 
whistleblowers that only the glaring spotlight of public scrutiny will 
move the agency to action, not disclosures made through statutorily 
established channels.
    \2\ Jonathan Saltzman and Andrea Estes, ``At a four-star veterans' 
hospital: Care gets 'worse and worse,''' Boston Globe (July 15, 2017), 
available at https://www.bostonglobe.com/metro/2017/07/15/four-star- 

1 Background

    The whistleblowers' allegations focused on the care of patients 
with a serious spinal cord condition known as myelopathy. They noted 
that despite the significant decline in prevalence of this condition in 
the general population of the United States, 100 out of approximately 
170 patients treated in the VAMC Manchester Spinal Cord Unit had some 
degree of myelopathy. The whistleblowers attributed this high incidence 
to a number of factors, including:

      Under VA policy, patients with these conditions are 
referred to VA's Boston Spinal Cord Injury and Disorder (SCI/D) Center 
for more complete evaluation. The whistleblowers alleged that transfers 
between the VAMC Manchester and the Boston SCI/D Center were not 
performed in a timely manner, in violation of agency policy.
      The whistleblowers alleged that surgical care at the 
Boston SCI/D Center was also substandard. They provided two 
illustrative examples: (1) a patient who developed a spinal infection 
and eventually died from surgical complications after surgeons damaged 
his dura mater during a procedure; and (2) an instance where a patient 
developed a spinal infection after surgery but survived.
      The whistleblowers alleged that the prior chief of the 
Spinal Cord Unit, Dr. Muhammad Huq, engaged in the inappropriate 
practice of copying and pasting chart notes for patients between 2002 
and 2012. They asserted that this misconduct contributed to the high 
incidence of myelopathy in the VAMC Manchester patient population.

    In addition to the allegations connected to myelopathy, the 
whistleblowers further alleged that the VAMC Manchester OR has been 
repeatedly infested with flies. Starting in 2012, after the OR was 
remodeled, the rooms in this suite have consistently been infested with 
flies during warmer months. While the VAMC Manchester has attempted to 
remediate this problem by hiring exterminators to perform pest-control 
measures and installing UV fly lights, the flies have returned during 
the spring and summer every year. The whistleblowers asserted that 
surgeries have been cancelled and delayed due to these unsanitary and 
unsterile conditions.

IL The Agency Reports

    OSC found that a substantial likelihood of wrongdoing existed based 
on the information provided by the whistleblowers, and referred the 
matter to former VA Secretary Robert McDonald to conduct an 
investigation pursuant to 5 U.S.C. Sec.  1213 (c) and (d). The matter 
was investigated by the Office of the Medical Inspector (OMI), which 
provided OSC with a report on June 20, 2017. The report contained 
internally inconsistent conclusions at odds with the information 
adduced in the investigation. OSC requested two supplemental reports to 
address many of these issues and provide updates on external chart 
reviews. With respect to spinal cord care:

      VA Investigators found that in fiscal years 2015 and 
2016, 11 consult appointments, or 20 percent of appointments, were not 
made in the required time, and in more than half of these instances 
there was no documented reason for the delay. In spite of these 
findings, VA Investigators were ``unable to substantiate'' that the 
referral process from VAMC Manchester to the Boston SCI/D Center 
created undue delays in care.
      Regarding the patient who died from surgical 
complications, the VA noted it was ``unclear'' if the surgery 
contributed to his disease progression, but later concluded that his 
care was appropriate. Neyertheless, it stated that the treatment of 
this patient, as well as six others, would be reviewed by an 
independent, non-VA external reviewer, raising questions regarding the 
sufficiency in the initial review of this information.

    During his interview, Dr. Kois provided OMI with 97 patient charts 
that he viewed as evidence of substandard care. OMI initially 
determined that in 74 of 97 cases, care was appropriate. However, in 
supplemental reports, the VA indicated that external non-VA reviewers 
would examine these charts to determine whether appropriate care was 
provided. The VA anticipates this review will be completed in February 
2018. In light of the ongoing review of patient charts, OSC finds the 
VA cannot yet conclude whether the whistleblowers' allegations were 
    The VA's decision not to interview Dr. Chima Ohaegbulam, a non-VA 
employed neurosurgeon with experience treating myelopathy patients, is 
at odds with the VA's prior assertion that review by external experts 
was necessary. Dr. Ohaegbulam treated many of the patients at issue in 
this matter on a fee basis after referral from the VAMC Manchester, and 
was uniquely positioned to assist in the review of the patient care 
rendered. In a supplemental report, the agency asserted that it was 
unnecessary to interview Dr. Ohaegbulam as Dr. Kois provided sufficient 
documentary evidence.
    The findings regarding Dr. Huq were flawed due to their 
inconsistency. The report first acknowledged that he engaged in the 
practice of inappropriately copying and pasting chart notes between 
2008 and 2012, but asserted no harm resulted because associated patient 
records did not contain any indicia of adverse patient outcomes. The 
report subsequently acknowledged that investigators only reviewed his 
charts from a limited time period, yet claimed they had sufficient 
information to broadly conclude that no patients were harmed.
    VAMC Manchester management was on notice of Dr. Huq's misconduct as 
early as 2008; however, no disciplinary or corrective action was tak;en 
until 2010. Despite the fact that nurses raised concerns to facility 
leadership during this time, there was no explanation for the delay. 
Dr. Huq received a verbal counseling in November 2010, but continued 
copying and pasting chart notes. He was issued a written counseling for 
this continued misconduct in late 2011. In early 2012, he was counseled 
again after the discovery of additional instances of copying and 
pasting. Finally, in July 2012 VA reassigned Dr. Hug to Primary Care on 
a full-time basis, then transferred him to another VA facility in 
August 2015.
    Despite this long-established history of misconduct, investigators 
determined that there were no adverse patient outcomes attributable to 
this practice, after reviewing the care of patients whose charts were 
copied and pasted. Notwithstanding this conclusion, investigators 
indicated they were unable to review Dr. Huq's notes prior to 2008. 
Rather, their conclusions relied on a review of the audits associated 
with prior disciplinary action. Accordingly, OMI was unable to review 
six years of patient outcomes, or more than half of the total time Dr. 
Hug worked in this unit. Given the seriousness of the medical issues 
involved, a review of Dr. Huq's entire history with the unit appears 
appropriate, especially given the ease of obtaining these medical 
records, which under agency policy, must be maintained for 75 years.
    With respect to the alleged fly infestation, the report found that 
the OR #2 was repeatedly infested with cluster flies starting in the 
early fall of 2014. The room was terminally cleaned, but flies returned 
later in the fall and the following winter. A pest control company was 
hired in April 2015, but did not spray insecticides outside the 
building during that summer. In August and September of 2015, staff 
again began noticing cluster flies in OR #2. The room was eventually 
closed due to this issue from September 2015 until January 2016. 
Despite additional efforts, flies were still observed in the room in 
January 2017. The report stated that cluster flies pose no known health 
problems to humans, but subsequently acknowledged that ``flies of 
various types'' were found in a light trap during a site visit, 
suggesting that additional species of insects were present. The report 
explained that despite the closure of this room, no surgeries were 

Ill The Whistleblowers' Comments

    The whistleblowers' comments highlighted inconsistencies in the 
reports, and were the basis for OSC requesting two supplemental reports 
from the VA. Notably, the whistleblowers' comments questioned the 
sufficiency of the investigation, explaining that OMI appeared 
dismissive of Dr. Kois' efforts to provide patient charts, and that 
their findings did not appear to analyze the large number of assistive 
durable medical devices given to patients as evidence of worsening 
function and clinical neglect.
    The whistleblowers also voiced concerns regarding the failure to 
interview Dr. Ohaegbulam, and challenged the specific clinical 
conclusions reached regarding the two illustrative examples provided in 
their initial disclosure. The comments further reflected the concern 
that the review of Dr. Huq's patients was limited and appeared to 
ignore the connection between his conduct and the decline in function 
of many spinal cord patients.
    Finally, the comments noted that OMI appeared to dismiss and 
ultimately did not investigate serious allegations provided to them by 
the whistleblowers, including dirty and rusted surgical instruments. 
The whistleblowers asserted that it was ``clear that [OMI] had no 
interest in a fair and impartial and complete investigation into the 
systemic problems that directly impacted patient care in Manchester.''

JV The Special Counsel's Analysis and Findings

    I have reviewed the original disclosures, the agency reports, and 
the whistleblowers' comments. I have determined that the reports meet 
the statutory requirements, but the findings do not appear reasonable.
    First, I note that the agency appears to have chosen not to review 
allegations concerning dirty and potentially contaminated surgical 
instruments because they did not appear in OSC's original referral 
letter. This position is at odds with the conduct and disposition of 
prior investigations of allegations referred by OSC. It further 
demonstrates a myopic approach that could potentially cause harm by 
ignoring allegations of substantial and specific dangers to public 
health and safety.
    I take further issue with the recommendations in the report when 
viewed in light of the VA's response after the Boston Globe article was 
published in July. Notably, the initial OMI report simply recommended 
additional chart reviews, routine monitoring of chart entries, and that 
OR staff continue checking for flies in the suite before starting 
    The Boston Globe article was published late in the day on Saturday, 
July 15, 2017. It discussed the spinal cord care issues, Dr. Huq's 
conduct, flies in the OR, and dirty surgical instruments. On Sunday 
July 16, within hours of the Boston Globe's publication, VA Secretary 
David J. Shulkin removed VAMC Manchester's Director Danielle Ocker and 
Chief of Staff James Schlosser pending the outcome of a ``top to 
bottom'' review of the facility. On August 4, Secretary Shulkin visited 
the hospital, and subsequently removed the Head of Patient and Nursing 
Services, Carol Williams. Secretary Shuklin also indicated that the 
department planned on spending $30 million dollars at VAMC Manchester 
to improve care.
    Significantly, OSC had already referred these same allegations to 
the VA in early January 2017, six months before the Boston Globe story 
ran. The contrast between the VA's response to the Boston Globe vis-a-
vis OSC highlights the issues OSC has with VA's reply to OSC's referral 
and the whistleblowers' allegations. The VA did not initiate 
substantive changes to resolve identified issues until over seven 
months had elapsed, and only did so after widespread public attention 
focused on these matters. It is critical that whistleblowers be able to 
have confidence that the VA w. ill addres.s public health and safety 
issues immediately, regardless of what news coverage an issue receives.
    Given the ongoing and potentially lengthy chart reviews of patients 
involved in these matters, OSC will request updates on the progress of 
this analysis as well as findings when the reviews are completed. 
Specifically, OSC will request an update in writing every six months 
regarding the disposition of these reviews, and the expected timeline 
for completion. OSC will also request a summary of the findings upon 
    As required by 5 U.S.C. Sec.  1213(e)(3), I have sent a copy of 
this letter, unredacted versions of the agency reports, and the 
whistleblowers' comments to the Chairmen and Ranking Members of the 
Senate and House Committees on Veterans' Affairs. I have also filed the 
letter to the President, the whistleblowers' comments, and redacted 
copies of the agency reports in our public file, which is available at 
www.osc.gov. This matter is now closed.


    Henry J. Kerner Special Counsel