[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]

                      ENSURING QUALITY HEALTHCARE.
                            FOR OUR VETERANS



                               BEFORE THE


                                 OF THE

                         COMMITTEE ON OVERSIGHT
                               AND REFORM

                        HOUSE OF REPRESENTATIVES


                             FIRST SESSION


                             JUNE 20, 2019


                           Serial No. 116-36


      Printed for the use of the Committee on Oversight and Reform


                  Available on: http://www.govinfo.gov
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                 ELIJAH E. CUMMINGS, Maryland, Chairman

Carolyn B. Maloney, New York         Jim Jordan, Ohio, Ranking Minority 
Eleanor Holmes Norton, District of       Member
    Columbia                         Justin Amash, Michigan
Wm. Lacy Clay, Missouri              Paul A. Gosar, Arizona
Stephen F. Lynch, Massachusetts      Virginia Foxx, North Carolina
Jim Cooper, Tennessee                Thomas Massie, Kentucky
Gerald E. Connolly, Virginia         Mark Meadows, North Carolina
Raja Krishnamoorthi, Illinois        Jody B. Hice, Georgia
Jamie Raskin, Maryland               Glenn Grothman, Wisconsin
Harley Rouda, California             James Comer, Kentucky
Katie Hill, California               Michael Cloud, Texas
Debbie Wasserman Schultz, Florida    Bob Gibbs, Ohio
John P. Sarbanes, Maryland           Ralph Norman, South Carolina
Peter Welch, Vermont                 Clay Higgins, Louisiana
Jackie Speier, California            Chip Roy, Texas
Robin L. Kelly, Illinois             Carol D. Miller, West Virginia
Mark DeSaulnier, California          Mark E. Green, Tennessee
Brenda L. Lawrence, Michigan         Kelly Armstrong, North Dakota
Stacey E. Plaskett, Virgin Islands   W. Gregory Steube, Florida
Ro Khanna, California
Jimmy Gomez, California
Alexandria Ocasio-Cortez, New York
Ayanna Pressley, Massachusetts
Rashida Tlaib, Michigan

                     David Rapallo, Staff Director
              Wendy Ginsberg, Subcommittee Staff Director
                          Amy Stratton, Clerk
               Christopher Hixon, Minority Staff Director

                      Contact Number: 202-225-5051

                 Subcommittee on Government Operations

                 Gerald E. Connolly, Virginia, Chairman
Eleanor Holmes Norton, District of   Mark Meadows, North Carolina, 
    Columbia,                            Ranking Minority Member
John Sarbanes, Maryland              Thomas Massie, Kentucky
Jackie Speier, California            Jody Hice, Georgia
Brenda Lawrence, Michigan            Glenn Grothman, Wisconsin
Stacey Plaskett, Virgin Islands      James Comer, Kentucky
Ro Khanna, California                Ralph Norman, South Carolina
Stephen Lynch, Massachsetts          W. Steube, Florida
Jamie Raskin, Maryland
                          C  O  N  T  E  N  T  S

Hearing held on June 20, 2019....................................     1


Ms. Tammy Czarnecki, Assistant Deputy Undersecretary for Health 
  for Administrative Operations, Veterans Health Administration, 
  on behalf of Department of Veterans Affairs
Oral Statement...................................................     5
Mr. Michael Heimall, Director, Veteran Affairs Medical Center 
  (Washington, DC)
Oral Statement...................................................     6
The Honorable Michael Missal, Inspector General, Office of 
  Inspector General, on behalf of U.S. Department of Veterans 
Oral Statement...................................................     8

Written opening statements and witnesses' written statements are 
  available on the U.S. House of Representatives Repository: 

                           INDEX OF DOCUMENTS


The documents entered into the record are listed below, and 
  available at: https://docs.house.gov.

  * Report from the Partnership for Public Service; submitted by 
  Chairman Connolly.
  * DCVA Organizational Alignment Showing Vacancy Rate; submitted 
  by Chairman Connolly.
  * QFR: Response from Veteran Affairs Medical Center 
  (Washington, DC).
  * QFR: Response from Veteran Affairs Office of the Inspector 

                            FOR OUR VETERANS


                        Thursday, June 20, 2019

                   House of Representatives
             Subcommittee on Government Operations,
                          Committee on Oversight and Reform
                                                   Washington, D.C.

    The subcommittee met, pursuant to notice, at 1:59 p.m., in 
room 2154, Rayburn House Office Building, Hon. Gerald E. 
Connolly (chairman of the subcommittee) presiding.
    Present: Representatives Connolly, Norton, Sarbanes, 
Lawrence, Lynch, Raskin, Meadows, Massie, Hice, Comer, and 
    Also present: Representative Wexton.
    Mr. Connolly. The subcommittee will come to order. Without 
objection, the chair is authorized to declare a recess of the 
subcommittee at any time.
    The Subcommittee on Government Operations is convening 
today to hold this hearing on ensuring quality healthcare for 
our veterans. I now recognize myself for five minutes to give 
an opening statement.
    Nearly 100,000 veterans living in the Washington, DC, 
northern Virginia, and Maryland area depend upon the 
Washington, DC. Veterans Affairs Medical Center for their 
medical care. For years, serious and urgent problems festered 
at this medical center, endangering the lives and care of these 
    From 2013 to 2016, leadership at the medical center and the 
Veterans Health Administration received at least seven written 
reports detailing significant and substantial deficiencies. It 
is, in our view, shameful how many warning signs were ignored 
and for too long.
    In March 2017, a confidential complainant alerted the VA 
Office of the Inspector General to equipment and supply issues, 
and I quote, sufficient to potentially compromise patient 
safety. The conditions were so appalling that the Office of 
Inspector General took the highly unusual step of issuing an 
interim report in April of that year. The ensuing investigation 
culminated in the scathing March 2018 critical deficiency 
report which really was the genesis of today's hearing.
    There are far too many glaring problems in this 158-page 
report to enumerate, but the OIG did issue 40 recommendations, 
and we need a mechanism to monitor the progress and continuing 
implementation of those 40 recommendations. At the root of the 
deficiencies is what the Inspector General, Michael Missal, 
politely deemed, and I quote, a culture of complacency, but 
what I, frankly, would have called a culture of indifference, 
indifference to their patients.
    Leaders at multiple levels failed to address, according to 
the IG, failed to address previously identified serious issues 
with a sense of any urgency or purpose--or purpose. In 
interviews, leaders frequently abrogated individual 
responsibility and deflected blame to everybody else. How else 
do you explain the laundry list of critical deficiencies known 
to VA leadership that threatened harm to patients, and yet 
these problems persisted for the better part of a decade?
    Last month, my colleague, Eleanor Holmes Norton, and I 
visited the facility and met with the new director, Mr. 
Heimall, and his senior leadership team for several hours about 
actions that have been taken to address the exigent concerns 
raised by the OIG. Shortly after that visit, Ranking Member 
Meadows and I sent the director a letter requesting information 
regarding mental health treatment at the D.C. medical center.
    Today, I am here to put the leadership on notice. Congress 
will not stand for continued failures that threaten the health 
and safety of our veterans at what ought to be the VA's 
flagship medical center. Unfortunately, it's anything but. 
According to the OIG, the D.C., Virginia--veterans medical 
center put veterans at risk through needless hospitalizations, 
unnecessary anesthesia, failure to use preferred surgical 
techniques, all because important supplies, instruments, and 
equipment were not always accessible.
    As of March 31 of 2017, the facility had a backlog, a 
backlog of 10,904 open or pending consults for prosthetic items 
ranging from eyeglasses and hearing aids to surgical implants 
and artificial limbs. One patient waited more than one year for 
his prosthetic leg. This is a veteran we're talking about. And 
eventually, he gave up and moved to another state where a 
different veterans facility promptly filled his request.
    The level and breadth of neglect detailed in the report is 
almost inconceivable and certainly callous.
    The OIG found that some progress certainly has been made, 
as did we. After a tumultuous two-year period in which the 
facility was led by five different directors in a two-year 
period, a new permanent director testifying before the 
subcommittee has taken the helm, and all senior leadership 
positions are now occupied, I believe, by permanent staff. In 
May 2018, the OIG reported that the availability of supplies 
had improved and the prosthetics backlog eliminated, and that's 
genuine progress.
    But given the history here, we must be aware of what lies 
behind the metrics or the ostensible metrics. Leaders must 
measure and examine customer satisfaction at the end of the 
day. Are veterans receiving the appropriate care that meets 
their medical needs and treatment expectations? Are employees 
empowered to report patient safety incidents, and do they trust 
that leadership, when reported, will, in fact, address them? 
How can we ensure that this never happens again whether at this 
facility or any other that is charged with delivering care to 
those who served our Nation in uniform?
    Previous wake-up calls have come and gone, and veterans in 
need sometimes continue to suffer. In February of this year, 
one of my constituents sought inpatient admission for a drug 
withdrawal set of symptoms, including anxiety and pain 
management, at this facility. After the hospital first 
evaluated him and a second doctor decided to not admit him, the 
veteran's wife found him dead of a gunshot wound in their home 
the following week. Just last month, there was a shocking 
report of a psychiatric patient at this facility who escaped 
from a locked area and traveled to Virginia with, by the way, 
the help of one of the employees at the facility. Not that he 
was complicit, but he apparently was not suspicious of somebody 
in a hospital gown and called him a cab. He went to Virginia 
and abducted and assaulted a woman, resulting in his arrest. 
I'd like to play a clip from that NBC4 report, with the 
indulgence of my ranking member.
    [Video shown.]
    Mr. Connolly. I won't even comment.
    Incidents like this remind us there's a long road ahead. 
Putting procedures in place is the easy part. Eradicating the 
culture of indifference or complacency, that's the hard part, 
and it will take a significant investment on the part of 
    We are here today to insist that our new director, Mr. 
Heimall, rise to the task, and we'll support him, assuming he 
does, and that he stay long enough and commit to stay and work 
hard to hear every patient and employee's concerns to rectify 
those issues and to communicate needed changes that foster 
trust within the facility.
    We should never have to tell this story. Men and women who 
put on the uniform to protect our country had every reason to 
believe they would receive the highest quality healthcare as a 
statement of our commitment to them. That's our part of the 
contract. Instead, they encountered mediocrity at best. No one 
inside or outside of government can possibly accept that 
standard. For everyone who works at D.C. Veterans Medical 
Center, from the custodian to the cardiac surgeon, there must 
be one standard, one standard, and that's one of excellence. 
We'll settle for nothing less.
    With that, I call upon the distinguished ranking member, my 
friend, Mr. Meadows from North Carolina, for his statement.
    Mr. Meadows. Thank you, Mr. Chairman. I want to thank you 
for your leadership and truly for working in a bipartisan way 
to make sure that our veterans get the care that they deserve, 
the care that they were promised, and honestly, the care that 
is the least we could provide in acknowledgment of the service 
that they provided. And I just want to say thank you.
    And to the gentlewoman from the District of Columbia, I 
want to just say that this is a bipartisan effort. You have my 
100 percent commitment to work with you and the gentleman from 
Virginia whose constituents are served by this. I have the 
blessing of having one of the best VA centers in the Nation, 
the Charles George Center, where we actually get quality care, 
and we don't deal with some of the issues that have just been 
outlined by the gentleman from Virginia.
    It shouldn't take an investigative team from News4 to help 
us fix the problems. Actually, that investigative team is no 
stranger to this committee. They've done work before. They've 
done excellent work. And yet to see the kind of tale that was 
demonstrated just a few minutes ago on video is not only 
shocking, but it's truly not going to be tolerated.
    And so with that, I know that we've got a new team. And 
many of these things were systemic problems that happened 
before your watch, I get that, and yet we have to make sure 
that the inefficiencies and the deficiencies are eliminated on 
your watch, and as the gentleman was talking about, that they 
never happen again.
    I think probably the biggest frustration for us is to have 
an IG that is doing his work, that has to give, as the 
gentleman mentioned, an interim report because it is so 
unbelievably poor in terms of quality of service. Our veterans 
deserve better. And I just want all three of you to hear, and 
anybody that's watching, to understand that the commitment is 
not a 90 percent commitment; it is 100 percent commitment to 
get it right for our veterans.
    And I think, Mr. Chairman, it would probably be appropriate 
that, you know, in the next 60 days or so, that the three of us 
make a visit back to this facility to really look at the report 
card and where we are and have that.
    With that being said, I also want to acknowledge, many 
times medical facilities are very chaotic place. It seems like 
there was a little bit more--in fact, a lot more chaos at this 
facility than there should have been. And yet we have 
veterans--Director Heimall, I believe you are a veteran of 
what, 30 years, and I want to thank you for your service, 
because many times, the VA, they have actually veterans that 
are serving veterans. And yet we need to make sure that there's 
the urgency in the quality of care that they deserve.
    And so with that, I know you're the fifth director. We need 
to make sure that there is a plan in place, that after all of 
you are gone, that the next person that comes in, that we're 
not having another hearing here with a tragedy that has 
happened because we don't have a system in place.
    So what I'm looking forward to today is to hear about those 
systems, to hear about the corrections that have been made, the 
number of open items that the IG has identified, how they've 
been closed, when the rest of them are going to be closed, and 
how that we make sure that the next IG investigation is on 
something that is totally unrelated to patient care.
    And with that, I yield back.
    Mr. Connolly. I thank the distinguished ranking member. And 
I know he is committed, and especially--I mean, this issue 
knows no partisan line, and we will work together as one 
subcommittee and with one committee to try to nudge and 
support, where appropriate, to make sure that the issues that 
we have identified and that the IG has identified are fully and 
comprehensively addressed to everybody's satisfaction, 
especially the patients.
    And with that, I want to welcome our witnesses. And I would 
ask all three if you wouldn't mind standing and raising your 
right hand. It is our practice to swear in all of our 
    Do you swear or affirm that the testimony you're about to 
give is the truth, the whole truth, and nothing but the truth, 
so help you God?
    Let the record show that the witnesses answered in the 
affirmative. Thank you.
    Today, we have with us Ms. Tammy Czarnecki, who is the 
assistant deputy under secretary for Health for Administrative 
Operations at the United States Department of Veterans Affairs. 
We have Michael Heimall, the director of Washington, DC. 
Veterans Affairs Medical Center, the new director, relatively 
new, of the medical center. And also with us, we have the 
Honorable Michael Missal, the Inspector General at the 
Department of Veterans Affairs, who is, he and his team, the 
author of the report we have discussed.
    Each of you has five minutes to summarize your testimony. 
Any written statement you have will be entered into the record 
fully. And in the interest of time, we ask you to try to 
summarize within five minutes, because we know that votes are 
probably going to interrupt us at some point in this hearing.
    And with that, Ms. Czarnecki, welcome.


    Ms. Czarnecki. Good afternoon, Chairman Connolly, Ranking 
Member Meadows, and members of the committee. As of 2017, I am 
the executive over Administrative Operations, and I have 
oversight of procurement and logistics. I thank you for the 
opportunity to discuss Washington, DC. VA Medical Center, and I 
am accompanied today by Michael Heimall, the director of the VA 
Medical Center.
    The veterans healthcare facilities are designed to be safe 
havens for our women and men who have served our Nation. We are 
constantly working to improve the standards for our veterans as 
they deserve that. The D.C. VA and the extended VA Hospital 
network take provided in providing care to our veterans in an 
environment that fosters compassion, commitment, and service.
    Hospitals, though, by their very nature, are intrinsic risk 
to patients as personnel contend with unpredictable situations, 
infection control, significant care needs, and changing demands 
on a daily basis. The D.C. VA, though, is no exception, and it 
is actively pursuing high reliability organizational 
principles. The HRO core pillars are leadership, commitment, 
patient safety, and continuous process improvement.
    Additionally, we are instituting the Just Culture training 
focused on improving care to our veterans by providing a safe 
environment for our employees to report and speak up when they 
see or anticipate a problem.
    In March 2018, the inspector general issued its final 
report on critical deficiencies at the Washington, DC. VA 
Medical Center from April 2017. The report included 40 
recommendations for the medical center, VISN 5, and VHA. 
Collectively, VA has been working hard to address these 
deficiencies and to improve our administrative processes and 
environment of care at the medical center.
    Today, 28 of the 40 recommendations have been fully 
addressed and closed by the OIG. The remaining recommendations 
involve longer term monitoring of processes to ensure the 
corrective actions are sustainable. These involve monitoring 
the availability of supply stockage levels, periodic equipment 
inventories, and auditing of financial records for supplies and 
equipment purchases. We expect that all of these deficiencies 
will be closed by October 31 of 2019.
    Despite the issues raised by the OIG and events reported in 
the media, the D.C. VA is comparable to other medical 
facilities in the Washington, DC. metropolitan. According to 
the Center for Medicare and Medicaid Hospital Compare data, the 
D.C. VA recorded some of the lowest hospital mortality rates. 
The D.C. VA has realized a 50 percent reduction in hospital-
acquired infections this year compared to the first six months 
of 2018. This progress attributed to the SAIL rating increasing 
from one star to two.
    As leadership continues to build a culture of high 
reliability centered on employee engagement, we expect these 
rates to continue to drop with the goal of zero preventable 
    The OIG report also raised concerns about the sterilization 
processes resulting in unnecessary delays and risk to surgical 
patients. Tremendous progress has been made rebuilding the 
staff of sterile processing.
    During the period of April 2017 to May 2018, the D.C. VA 
canceled 20 surgical cases due to the availability of reusable 
medical equipment. Over the same period ending May 1 of 2019, 
the D.C. VA reported 5 case cancellations, the last occurring 
in December 2018. At no time during the 2018 to 2019 timeframe 
was a patient placed under anesthesia before the care team 
recognized that appropriate medical equipment was not 
    For the first time since April 2017, the D.C. VA has a 
permanent medical center director. This stability allows the 
D.C. VA to commit to a long-term plan for improvements in a 
consistent, programmatic fashion. Currently, there are only 
four key leadership vacancies among 57 department heads to be 
filled. The permanent staff has grown by approximately 130 
employees in critical areas such as nursing, sterile 
processing, supply chain, social work, and community care. The 
medical center plans to add an additional 300 employees between 
now and October 2020 to support expanded primary care, mental 
health, and surgical services across the markets.
    The chairman and ranking member have shared the committee's 
concern regarding three unfortunate incidents that happened at 
the D.C. VA. We share your concern about these incidents and 
are conducting thorough reviews in each case. And where 
appropriate, we have changed policies and procedures and 
retrained or disciplined staff to ensure that these do not 
occur in the future. Director Heimall can speak to these in 
    We look forward to the opportunity to share our progress 
and discuss our continued efforts to restore the trust of our 
veterans. We appreciate the OIG for their report and the 
subcommittee for their assistance. My colleague and I are 
prepared to respond to any questions you may have.
    Mr. Connolly. Thank you. Right on time.
    Mr. Heimall.

                         MEDICAL CENTER

    Mr. Heimall. Good afternoon, Mr. Chairman, Ranking Member 
Meadows, and members of the committee. Thank you for the 
opportunity to discuss the D.C. VA Medical Center and the work 
we are doing to restore our veterans and your confidence in our 
medical center.
    Mr. Chairman, I want to begin by thanking you and your 
staff, especially Sharon and Billy, for the warm welcome that I 
received in October and the strong relationship that we have 
built. Sharon has my cell phone number, and she knows that she 
or you can call me at any time if you have a concern that you 
would like to discuss. And I extend that offer to all members 
who represent districts in the Washington, DC. VA Medical 
Center's market. Please know that you or your staff can contact 
me at any time to help resolve a concern of one of our 
    Ms. Holmes Norton, we are building an equally strong 
partnership with your team. I am looking forward to discussing 
our community-based outpatient clinic in southeast D.C. with 
Karen and your staff tomorrow morning. I appreciate your 
collaboration on how we can work with the city and community 
partners to improve and expand the services for veterans in 
this underserved community.
    I am privileged to lead a dedicated team of medical 
professionals at the medical center. The OIG critical 
deficiencies report highlights glaring failures in the basic 
procedures of a medical center that are symptoms of a systemic 
leadership failure. That team has been working hard to improve 
our processes and ensure safe care for our veterans.
    Over the past two years, we have eliminated the backlog of 
more than 10,000 prosthetic consults. We have written and 
reviewed more than 200 standard operating procedures for 
sterile processing. We have hired 17 additional sterile 
processing technicians and new leadership in both sterile 
processing and the operating rooms, all while undertaking a 
major renovation of the sterile processing workspace.
    We have hired new leadership in supply chain, entered more 
than 12,000 items of medical supply into the generic inventory 
package, hired 29 additional supply technicians, and conducted 
a wall-to-wall inventory of all medical equipment in the 
facility and our six outlying clinics.
    In the last eight months, we have hired 149 new staff, and 
we expect to finish the year with a net gain of more than 200 
new employees. All of this is to ensure that we never repeat 
the failures highlighted in the OIG report.
    When I accepted this position, I promised our staff and the 
veterans that we are privileged to care for that I was in this 
for the long haul, and I would not leave until I could truly 
say that this medical center is once again the flagship of 
veterans healthcare, and I fully intend to fulfill that 
    Thank you again for this opportunity to discuss our 
progress and our challenges, and I look forward to answering 
your questions.
    Mr. Connolly. Thank you, Mr. Heimall.
    Mr. Missal.


    Mr. Missal. Thank you.
    Chairman Connolly, Ranking Member Meadows, and members of 
the subcommittee, I appreciate the opportunity to discuss the 
Office of Inspector General's recent oversight of the 
Washington, DC. VA Medical Center.
    Inspections like those performed by OIG staff at the D.C. 
medical center are a vital part of our overall efforts to 
ensure that the Nation's veterans receive high quality and 
timely healthcare services. They also promote the most 
effective use of VA resources and taxpayer dollars.
    Our March 2018 report, Critical Deficiencies at the 
Washington, DC. VA Medical Center, made troubling findings at 
the facility of systemic and programmatic failures. The issues 
we identified were complex and affected multiple patient care 
and administrative services. We did not find evidence of 
adverse clinical outcomes, meaning death, a change in 
diagnosis, a change in course of treatment, or significant 
change in a patient's level of care. This was due in large part 
to the efforts of many dedicated healthcare professionals who 
worked around these challenges to ensure veterans received the 
best quality services under the circumstances.
    Of the 40 recommendations made in the critical deficiency 
report, 28 have been implemented, and 12 remain open. The OIG 
Comprehensive Healthcare Inspection Program report published in 
January 2019 provided 18 additional recommendations, one of 
which is closed. Significantly, all senior leadership positions 
have now been assumed by permanent staff. Key service chief 
positions have also been filled with permanent managers.
    To ensure full implementation of the recommendations, we 
engage our centralized followup staff to track the 
implementation of all report recommendations with the 
responsible VA office. This consolidated function helps ensure 
specially trained OIG staff provide consistent management of 
open recommendations. It also facilitates timely and accurate 
status reporting for our website, the semiannual report to 
Congress, and other products that promote transparency.
    Overall, we found important progress being made at the 
medical center. We commend the efforts of every staff member, 
manager, and leader who has worked to make those improvements. 
Our most recent visit earlier this month showed improvements in 
patient safety and incident reporting, reprocessing of surgical 
instruments and trays, sterile processing service personnel 
training, and staffing plans. While timely hiring actions have 
helped to address the known deficiencies within logistics and 
sterile processing services, challenges with human resources 
management remain in addressing critical core services.
    While the deficiencies we identified were at the D.C. 
facility, they're not isolated to that medical center. We have 
detected some of the same problems in other facilities where 
oversight work was being conducted, whether lack of effective 
inventory management and controls, staffing shortages, 
challenges with specialty services like sterile processing, or 
routine cleanliness standards.
    Our findings and recommendations should, therefore, alert 
other VA medical facilities about what red flags to look for 
regarding how weaknesses in logistics and other key systems can 
affect patient care. It should then help guide their corrective 
    OIG recommendations, if fully implemented, should also 
improve integrated reviews of medical facilities and oversight 
by VISNs and VHA central office.
    Changing the culture that has allowed problems to persist 
for such long periods of time is never easy. It will take time 
and require the unrelenting focus and energy of VA employees 
and leaders. We will continue to monitor the advancements made 
at the D.C. facility and remain alert to signs that progress is 
either being stymied or unsustained.
    Mr. Chairman, this concludes my statement. I would be happy 
to answer any questions that you or other members of the 
subcommittee may have.
    Mr. Connolly. Thank you very much.
    And before we begin a round of questioning, I'd like to 
enter into the record a report from the Partnership for Public 
Service. They did a survey and a prescription for better 
performance for medical centers. I will say, and we just 
confirmed this in the last 48 hours, in this report, in their 
analysis they looked at 150 medical centers. And last year, 
before Mr. Heimall came on board, this center we're talking 
about ranked dead last in employee engagement, which obviously 
has a spillover effect in terms of quality care. And so I want 
to enter that report for the record. Without objection, so 
    Mr. Connolly. I'm going to call on Ms. Eleanor Holmes 
Norton, and I'll wait my turn a little bit because obviously 
she and I share jurisdictional interest in this facility. A lot 
of our constituents, and maybe yours too, Mr. Raskin, okay, 
avail themselves of the services of the center, so it affects a 
lot of us.
    Ms. Norton, for your five minutes.
    Ms. Norton. I want to thank you, Mr. Chairman, for the 
visit you and I made to this center so we could see firsthand 
what the complaints were about. And I appreciate, Mr. Heimall, 
how we were received and your briefing and the tour we had.
    Before I get to my question, please indulge me for, really, 
an urgent situation that has arisen here in the District of 
Columbia southeast, and you alluded to this. I'd like to get 
some information. Your outpatient clinic, the only clinic for 
our veterans here in the District of Columbia for medical and 
preventive care, is about to close.
    Now, I understand that this facility is, from your point of 
view, underused. It's open only about three days a week, so you 
see why it's underused, you know. When you have to keep track 
of when a facility is open in the first place, that leads to a 
vicious cycle. And it is, therefore, open on only two or three 
days, and then only half time, so you see how this plays on 
    Now, I just have to ask you, where are these veterans from 
the District of Columbia supposed to receive their care? While 
I understand that Prince George's has a facility, it's already 
understaffed, and there is Rockville in Maryland, where my good 
friend represents. But neither Prince George's nor Rockville 
are near any subway. Will you provide transportation for these 
District of Columbia veterans who don't have any place to go 
now if you close this facility?
    Mr. Heimall. Ma'am, thank you very much, and I want to 
emphasize that no decision has been made as to whether that 
facility will close or not.
    Ms. Norton. Oh, good to hear that.
    Mr. Heimall. The lease expires in September, and I do have 
to make a decision as to whether we renew that lease.
    Ms. Norton. When will you make that decision, Mr. Heimall?
    Mr. Heimall. Ma'am, I would like to make it by the middle 
July, with input from both your staff and from the Mayor's 
    Ms. Norton. So you're coming to see us and the Mayor?
    Mr. Heimall. Yes, ma'am. In fact, we have a call scheduled 
for tomorrow morning with your staff to discuss the issue.
    Ms. Norton. I appreciate that. We just don't want people to 
be left with no place to go. And these veterans don't exactly 
have the kind of resources that you and I have.
    Mr. Heimall. Yes, ma'am. And I understand it's a very 
underserved community. We do have a physician that is there two 
half days a week and one full time--one full day a week. And we 
also have a nurse that is in the clinic five days a week with a 
technician, and we provide telehealth services from there five 
days a week back to the medical center.
    The clinic has actually been closed for about the last 10 
days due to a pipe break that occurred in the building that it 
is in, and we should reopen----
    Ms. Norton. This clinic is decrepit in more ways than one.
    Mr. Heimall. Yes, ma'am. And so it's important that we look 
for a new option.
    Ms. Norton. I want to get on to Mr. Missal before my--I 
appreciate you coming to see us on that urgent matter.
    I'm interested that you issued something that I have never 
seen from an inspector general. It was--I'm sure it happens 
from time to time--an interim report. That was in 2017, in 
which you noted sufficient, quote--and I'm quoting here, 
sufficient to potentially compromise--problems to potentially 
compromise patient safety. I mean, those were the words.
    Is it common to come forward with interim reports like 
this? What were you trying to say before there was a full 
report when you issued this interim report?
    Mr. Missal. I do not believe it's common to do it. I'm not 
sure our office has ever done it. Certainly, in the three years 
I've been the inspector general, we've never issued anything 
like that.
    We got information about issues at the medical center. We 
immediately sent up a rapid response team, and within hours, 
they reported back to me of significant problems at the 
facility. We then contacted VA to let them know of these 
problems, and I didn't get the kind of response I was hoping 
for in terms of trying to make sure these issues which impacted 
patient safety----
    Ms. Norton. When you got that kind--Ms. Czarnecki, when you 
get that kind of unusual--you heard Mr. Missal say unusual 
warning, why wouldn't the VA get on it instantly to try to 
essentially, perhaps, save lives for the veterans who were 
using the facility?
    Ms. Czarnecki. I'm not sure, Ms. Norton, that I have the 
full answer to that. I do know that we did have VA central 
office staff immediately deploy to that area with specifics in 
logistics and sterile processing. But I believe that the issues 
that Mr. Missal is discussing went well beyond both logistics 
and sterile processing. And so the interim report was really 
helpful in identifying everything that we needed to do to 
support the medical center.
    Ms. Norton. It was like an emergency report----
    Ms. Czarnecki. Yes.
    Ms. Norton [continuing]. Ms. Czarnecki. And I appreciate, 
Mr. Missal, that you were willing to depart from your usual 
processes in order to alert the VA. And I must say that I would 
hope in the future to receive what Mr. Missal said was not 
immediate corrective action.
    Thank you very much, Mr. Chairman.
    Mr. Connolly. Thank you. And thank you for your leadership 
on this matter, Ms. Norton. And I look forward to continuing to 
work with you on an issue that affects so many of our 
    Mr. Massie.
    Mr. Massie. Thank you, Mr. Chairman, for calling this 
hearing on such an important topic.
    Mr. Missal, you said that many of the deficiencies that you 
identified as the IG at the D.C. facility weren't isolated to 
that facility, that there are some of those deficiencies at 
other facilities and that that could inform their improvement. 
Can you expound on that a little bit?
    Mr. Missal. Yes. We have a very active healthcare 
inspection program. We inspect 50 some-odd facilities every 
year. Every medical center is inspected on about a three-year 
cycle. In addition, we do what we call hotlines, which are if 
get allegations of specific issues, we'll do an inspection 
there as well.
    So my comment on that was really related to other findings 
we've made both in inspections and in some of the hotlines, and 
we publish all of our work product. And so just last week, we 
published one on the Loma Linda facility in California in which 
we identified environment of care issues. So we regularly put 
out reports which have similar issues. Not the same extent, but 
similar type issues.
    Mr. Massie. So some of the issues that you found at the 
D.C. facility, like specialty services for sterile processing, 
you found those at other facilities, and they should be looking 
into those?
    Mr. Missal. Yes. And that's why the D.C. report is a great 
roadmap for other facilities because they had significant 
sterile processing issues. And when we write the reports, our 
goal is for all the medical centers to be reviewing them to see 
if they have any kind of similar issues and to address them 
before we get there.
    Mr. Massie. I want to thank you very much.
    And I'm going to yield the balance of my time to Mr. 
    Mr. Meadows. I thank the gentleman from Mr. Kentucky.
    Mr. Missal, let me come back to that, because you say you 
expect other VA centers to follow the IG's report. What's your 
degree of confidence that that's actually happening? I mean, 
because I can tell you that it's even Members of Congress that 
a lot of times, we don't see the IG's report. And so to suggest 
that somehow the administration of every VA center is going to 
look at his problems and associate that they have the same 
problem, I don't know that that will really happen. What's your 
degree of confidence?
    Mr. Missal. We try to work hard to make sure that the 
information we have in the reports is disseminated as broadly 
as possible. So, for example, I sometimes meet with VISN 
directors and talk about recent cases we have, again, to 
highlight our work. We also try to talk about trends we're 
seeing in areas. Obviously, it's up to the medical center 
directors and the leadership at VHA to ensure that they're 
following what we do.
    Mr. Meadows. So you mentioned about another facility in 
California as an example, but how would any of us up here know 
whether our VA center is having that same problem? I mean, so 
you've got Kentucky, and that's the reason why the gentleman 
from Kentucky was asking you. Is it his VA center, or Georgia 
or, you know, Kentucky, Florida, or--you know, we can go all 
the way down the line. I mean, are you informing that Member of 
Congress that their particular VA center might have an issue?
    Mr. Missal. Absolutely.
    Mr. Meadows. All right.
    Mr. Missal. When we do an inspection and we're ready to 
publish it on a particular facility, we notify the Members of 
Congress whose jurisdiction it's under, and we always offer to 
come in and talk about it.
    Mr. Connolly. So in that case, no news is good news?
    Mr. Missal. It could be good news, but again, whenever we 
publish a report, we will always notify, whether it's a good 
report or a bad report, just to talk it over with Members of 
    Mr. Meadows. All right. Because one of the things that we 
talked about in my opening remarks is about making sure that 
this problem doesn't happen again. And I heard the number of 
standard operating procedures that have been put in place as a 
response, and I would assume that that's meeting with applause 
from your team. Is that correct?
    Mr. Missal. That's partially a good development. But what 
we found, particularly in this situation, is there was such a 
lack of leadership and governance issues. So no matter how many 
procedures and processes you have in place, if you don't have 
strong leadership, if you don't hold people accountable, if you 
don't have an effective governance structure, it's going to be 
very difficult to have an effective organization.
    Mr. Meadows. I'm going to yield back to the gentleman.
    Mr. Massie. Just very quickly. If you found any issues at 
the Cincinnati VA, the Lexington, Kentucky VA, the Huntington, 
West Virginia VA, or the Louisville, Kentucky VA, would you let 
me know after the hearing?
    Mr. Missal. Absolutely.
    Mr. Massie. Thank you very much.
    Mr. Connolly. I thank the gentleman.
    I now call on the gentleman from Massachusetts, Mr. Lynch, 
where there is a VA facility five minutes from my family's home 
in west Roxbury, a very big one.
    Mr. Lynch.
    Mr. Lynch. Thank you, Mr. Chairman and the ranking member, 
for all your work together on this issue in bringing it 
forward. I've got three VA facilities in my district; one in 
Brockton, one in west Roxbury near the chairman's family home, 
and also Jamaica Plain.
    I want to speak directly about the veterans and active 
military suicide issue. Mr. Hice, the gentleman from Georgia, 
and I, in the National Security Subcommittee, had a hearing 
specifically on veteran suicide and active military suicides, 
and I see the elevated numbers here at the D.C. VA center. 
There's no indication, in my briefing, about the connection 
among those suicides.
    Would you classify it as a cluster, or were those 
connections, or was there was cross-knowledge among the victims 
here or no?
    Mr. Heimall. Sir, the two that have been reported in the 
media, there was no relation between those two. They were 
separated by quite a bit of time.
    Mr. Lynch. Yes.
    Mr. Heimall. I have no knowledge that either veteran knew 
each other. The veteran that the chairman spoke about, his 
constituent, actually had not been seen in the VA for about 
five years before he had that encounter with us.
    Mr. Lynch. All right. So I'm just trying to figure, you 
know. We've got a lot of these suicides going on. We've got a 
lot of active military attempts, and unfortunately, successful 
suicides, and I'm just trying to figure out a way to get at 
    Now, we have REACH VET, a program that was initiated by the 
VA back in 2017, that tries to do this analysis on those who 
might be at risk of suicide. Have you adopted that program?
    Mr. Heimall. Yes, sir, and our suicide prevention 
coordinators are informed by that information. I think one of 
the major challenges that we have within the VA, and I 
certainly experienced it in my leadership roles in DOD, is many 
times, suicide or suicide attempts are driven by socioeconomic 
factors that we may not have visibility on. We've got 
visibility on the healthcare issues but not all the other 
things that are going on. And a more comprehensive system that 
includes that data would lead to a much better predictive 
    Mr. Lynch. Yes, yes. And that's exactly what I'm trying to 
get at. So at the Brockton VA, we have a program. We actually 
do sort of a brain scan on our military--our recruits as 
they're going into--before they deploy. And we have like 
250,000 of these brain scans, and we try to compare them with 
returning veterans to make sure there's not some TBI issue or 
something like that.
    In your experience, is there any connection between the 
high number of deployments? So members of this committee were 
in Afghanistan not a long time ago, and we typically ask who's 
here on their first tour of duty, and we met with a small rifle 
platoon of Marines, and there were Marines there that were on 
their seventh tour of duty. That's unbelievable, and I don't 
think that's ever happened in the history of our country. And 
I'm trying to figure out, is there a connection between these 
multiple tours of duty and the psychiatric stress that some of 
these young men and women are experiencing? You know, because 
if that's the case, then we're going to have some trouble going 
forward here as those burdens present.
    Ms. Czarnecki?
    Ms. Czarnecki. Yes. I'd like to comment on that. I know 
that our mental health department is actually doing what we 
call behavioral autopsies on every suicide that we become aware 
    Mr. Lynch. Okay.
    Ms. Czarnecki. And we're really trying to look for those 
key indicators that would help us prevent them from committing 
suicide in the future.
    Mr. Lynch. Yes. Have you come up with any commonalities or 
are you still in the process of developing these profiles?
    Ms. Czarnecki. The profile development is ongoing.
    Mr. Lynch. Yes.
    Ms. Czarnecki. I think that there are some key indicators, 
as Mr. Heimall talked about, a lot of the socioeconomics.
    Mr. Lynch. Yes.
    Ms. Czarnecki. So we have actually partnered with the Law 
Enforcement Training Center to develop education for the 
community on how to help us as the VA identify those veterans 
that are out in the community who are not being seen by us that 
have risk factors for suicide and try to get them engaged with 
us at the VA. So we've been doing a lot of outreach to first 
responders to provide education and training.
    Mr. Lynch. That's great.
    Mr. Chairman, I just want to make sure we don't see this 
suicide issue as just a D.C. VA Medical Center issue. It's much 
wider than that. And also, you know, I've dealt with some 
families who have struggled with this. And so, you know, our 
prayers and thoughts are with those veterans and with their 
    Thank you. I yield back.
    Mr. Connolly. The gentleman makes a great point. This is 
hardly an issue limited only to this facility or this region, 
no question about it.
    And your point about seven tours is right on. I mean, 
during the Vietnam war, two terms would raise an eyebrow; three 
would be almost unprecedented; seven did not exist. And so the 
fact that we have multiple, multiple tours obviously puts more 
and more men and women at risk of PTSD and other depressive 
effects, and it needs to be paid attention to.
    Mr. Meadows, did you want to comment?
    Mr. Meadows. Yes. I want to make one real quick comment to 
the gentleman from Massachusetts, Mr. Lynch.
    I want to say thank you for your leadership on this 
particular issue. As you know, it's very critical to me. It's 
something that I've had constituents that have lost sons, and 
it becomes very personal when you have the tears of a mom or a 
dad, you know, that have lost their loved ones, and so I just 
want to thank you for your leadership. And thank you for 
reminding us this is not just a D.C. problem; this is a United 
States problem, and it's something that we've got to come 
together on.
    And I yield back. I thank the chairman for his courtesy.
    Mr. Connolly. I thank the gentleman.
    And I do want to give Mr. Lynch one more--he puts his money 
where--how many times, Mr. Lynch, have you been to Afghanistan 
and Iraq?
    Mr. Lynch. About 45 times now.
    Mr. Connolly. Forty. That's a Member of Congress committed 
to making sure that the men and women we ask to serve have 
support from the Congress.
    The gentleman from Kentucky, Mr. Comer.
    Mr. Comer. Thank you, Mr. Chairman.
    And my questions will be for the inspector general. Sir, do 
you believe the Washington, DC. VA is moving swiftly enough to 
address the issues that you outlined in your report?
    Mr. Heimall. They're moving at a very good pace, and we're 
very glad to see it happening.
    Mr. Comer. What are the most significant remaining issues 
that the D.C. VA still has to address to ensure that our 
veterans receive the best medical care possible?
    Mr. Missal. I think it would be the H.R. function, because 
so many of the issues revolve around having proper staffing. So 
if you do not have the proper staffing, it's really hard to be 
able to provide all of the services in a timely manner, and 
they're still working through some of the H.R. issues.
    Mr. Comer. What are some actions that this committee can do 
to address some of the serious issues reported, not just at the 
D.C. VA, but other VAs that have received similar media 
attention for poor performance over the last few years? What 
are some things that we can do in Congress to address that?
    Mr. Missal. We have found staffing to be an issue across 
VA. Every year, due to a congressional request, we put out a 
staffing report which identifies major gaps in staffing in a 
number of different areas. So one of the things could be to see 
whether or not there are hurdles for VA not to be filling these 
positions. For example, a medical center director to determine 
whether or not there are any hurdles, such as compensation or 
otherwise, that prevent some of them from being filled on a 
permanent basis.
    Mr. Comer. I'm very close friends with a constituent, Mr. 
Dakota Meyer, a Medal of Honor recipient from my district, very 
close to my hometown in southern Kentucky, and he gives a lot 
of speeches across the Nation on veterans' issues, and he talks 
about the VA a lot. And one of the suggestions that he bounces 
around that I'm beginning to hear more of my veterans suggest 
is that perhaps we would be better off eliminating the VA and 
providing our veterans with a gold card, to where if they need 
medical attention and they can get that medical attention at 
home, then that would allow them to do it at home, and it would 
be paid for. And perhaps the savings from not having the VA 
would somewhere, somehow, come close to paying for that. I 
don't know if that theory is accurate or not.
    I was wondering your opinion on that, because like my 
colleague, Mr. Massie, my district is spread out. It's five 
hours from the eastern part of my district to the western part 
of my district, so my caseworkers are constantly handling VA 
cases, probably more VA cases than anything our caseworkers do. 
And in my district, part of my constituents go to Louisville, 
Kentucky VA; Lexington, Kentucky; Nashville; Evansville, 
Indiana; and Marion, Illinois. So they're served by five 
different VAs in four different states.
    So I was just wondering what you thought about that 
proposition that Mr. Meyer and other veterans have brought up 
    Mr. Missal. I have not done a comparison of the quality of 
the healthcare between the private sector and what VA provides. 
However, I would say, in my time as inspector general, I've 
seen a lot of very high-quality healthcare that veterans 
receive and that VA is preeminent in a number of different 
areas such as mental health and spinal injuries. And when you 
look at some of the surveys done of veterans, many veterans 
really value and enjoy the services they get at VA. However, 
there's issues that come up, and that's why our office, when we 
see them, is going to report on them fairly and accurately.
    Mr. Comer. Right. And I don't think that that bold proposal 
would happen any time soon, but one thing I would like to see 
is more choice for our veterans. Obviously, if a veteran 
received a serious specialized wound, like missing an limb or 
something like that, the VA is certainly more qualified than 
most of the rural healthcare systems in my state to handle 
that. But there are a lot of issues that I think that we deal 
with from a caseworker standpoint that our constituents are 
having to travel two hours to a VA when they could be better 
served from the local hospitals. I have 28 hospitals in my 
congressional district.
    So that's something that gets mentioned a lot. I just 
wanted to hear your thoughts on that, and look forward to 
hearing from you in the future. Hopefully, we can get this 
serious issue solved with the VA. And again, if there are 
things that we can do in Congress, please let us know.
    Mr. Chairman, I yield back.
    Mr. Connolly. I thank the gentleman.
    The gentleman from Maryland, Mr. Raskin.
    Mr. Raskin. Mr. Chairman, thank you very much. Thanks to 
all of our witnesses.
    Mr. Heimall, you have not been on the job that long, less 
than a year still, I think. Is that right?
    Mr. Heimall. Yes, sir. Eight months.
    Mr. Raskin. I wanted to commend you, because I know you 
came from being the director of the Walter Reed National 
Military Medical Center in Bethesda, but you've definitely 
brought a lot of focus and purpose to the task here.
    And I have a number of constituents, a whole lot of 
constituents who go down to the D.C. VA, and they continue to 
have problems, but we are aware that you are trying to respond, 
and you've certainly been working well with our staff when we 
call up. I understand you're still--you're doing these monthly 
meetings with congressional staff members.
    Mr. Heimall. Yes, sir.
    Mr. Raskin. And also with, you know, other interested 
stakeholders, and so I want to thank you. I want to thank Ms. 
Wimberly from your staff who I know has been very helpful to us 
as well.
    But the morale situation is very tough with a lot of 
employees there, and I wonder what is it you're trying to do to 
address that and to what do you attribute it? What is your 
sense of the situation there?
    Mr. Heimall. Thank you, sir. I think it's probably one of 
the top two challenges that we have at the D.C. VA is employee 
engagement, morale, and commitment. The chairman referenced the 
survey that we're in the process of retaking for 2019.
    And to put some things in perspective, in 2018, 2017, we 
had 33, 34 percent participation rate in that survey. This 
morning, we had more than 65 percent of our employees who took 
the all-employee survey. That is going to give us some very 
powerful feedback on the pain points of their everyday work 
environment that we can put action plans in place with them and 
actually have employee-led groups to improve them.
    I think the biggest challenge our employees have had has 
been psychological safety and fear of retribution should they 
report a medical error or should they report a mistake that 
they made, and that is a culture that we are trying hard to 
break and encourage people to speak up. And I'm encouraged by 
the data that we're seeing. In 2018, there were about 780 
patient safety reports filed by our staff. Now, that may 
include a patient incident. It may include a near-miss. Like a 
patient--there was a question about a patient getting the right 
medication delivered the right way, and a staff member did the 
right thing and asked the question. And we asked those to be 
put in our patient safety system so we can trend what is 
happening and we can look where we need to make process 
    Mr. Raskin. Is it the kind of fear that whistleblowers 
experience, a fear of retribution?
    Mr. Heimall. I believe that's part of it. And so what we've 
seen this year so far is we have about 870 patient--we have 
more patient safety reports now than we had all of Fiscal Year 
2018, and 80 percent of those reports have a person's name on 
it so we can followup with them. We can ask them what they've 
done, what the issue was, and we can give them feedback on what 
we're going to do to prevent it from happening again.
    Mr. Raskin. You're trying to dispel this culture of fear 
which is a hangover from, what, prior leadership, prior----
    Mr. Heimall. Yes, sir. I believe so.
    Mr. Raskin. Okay. Well, thank you for that.
    I have received a couple of complaints from constituents 
about the IT situation and the huge backlog in requests for IT 
assistance. And obviously, today, you really can't run a 
functional organization if you don't have effective IT. Can you 
explain what is behind that and what you're doing to address 
that problem?
    Mr. Heimall. Yes, sir. There is a significant backlog. As 
of this morning, I talked to the area manager who reports up to 
the assistant secretary for OI&T, and there are about 4,000 
open work order tickets within the D.C. VA and our six outlying 
clinics. They have had a significant problem with staffing in 
the past. They are almost fully staffed now. They're authorized 
25 people, and they have 22 on board with two more being 
recruited and one person who just left that they've got to 
process the action on.
    The team is very engaged. Mr. Gfrerer, the assistant 
secretary for OI&T, visited the hospital about two months ago 
and spent an hour with the area manager talking about the 
issues and challenges. And these concern me a great deal 
because, as we get ready for the electronic health record 
deployment at some point in the future, I need the IT team 
really working on upgrading the infrastructure of the facility, 
not working on a backlog of IT tickets.
    Mr. Raskin. Okay. Finally, would you be willing to compare 
your experience at Walter Reed with your experience at the VA? 
Walter Reed really now is a hyperefficient, up-to-date, state-
of-the-art kind of facility. And can you compare that to where 
you are now and to what you would attribute the difference?
    Mr. Heimall. Sir, it really gets to leadership, and it's a 
very different patient population. At Walter Reed, primarily 
retirees, Active Duty servicemembers and their family members. 
At the D.C. VA, we do have a large portion of our population 
that is economically challenged and financially challenged--or 
financially insecure would be the best term for it. Their 
healthcare status and their engagement in their healthcare is 
different than it was at Walter Reed.
    I think the other piece of it is Walter Reed was an 
incredibly highly functional organization when I got there. 
Routine things happen routinely, regardless of who the leader 
is, and I followed two very talented leaders in Admiral Mike 
Stocks and Major General Jeff Clark.
    At the D.C. VA, the struggle has been and was routine 
things happening routinely and how we build that into our 
culture and empower employees to just make those things 
function every day regardless of who the leader is.
    Mr. Connolly. I thank the gentleman.
    Mr. Connolly. Before I call on the gentleman from Florida, 
Mr. Steube, without objection, I'd like to enter into the 
record the organizational alignment showing the vacancy rate 
for all of the positions at this facility. And it goes from a 
high of human resources, which, Mr. Missal, we're going to 
return to that, 68 percent vacancy rate to prosthetics, zero. 
So we've made progress in some, but there's still a lot of room 
for improvement in the top five or six categories here.
    And so I'll enter that into the record, without objection, 
as a document for our perusal.
    Mr. Connolly. Mr. Steube.
    Mr. Steube. Thank you, Mr. Chair.
    My question is for Ms. Czarnecki? Am I pronouncing that 
    Ms. Czarnecki. Yes.
    Mr. Steube. And I know you probably won't have the answer 
to this question, so I would just ask that you get back with me 
or my office the information.
    I represent southwest central Florida, so most of my 
district, the nearest veterans center or veterans hospital is 
Bay Pines. It's been reported to me that Bay Pines has stopped 
referring patients in need of in-patient mental health and 
substance abuse service to approved non-VA community care 
providers. Instead, these veterans are being added to a waiting 
list that already includes over 70 patients and will take one 
to three months before receiving treatment.
    It appears there is significant confusion in VISN 8 about 
how to appropriately implement the MISSION Act. My 
understanding is the purpose of the MISSION Act is to increase 
veterans' access to healthcare, yet veterans in VISN 8 are 
experiencing much greater delays in mental health and substance 
abuse treatment. Can you explain why this is happening and what 
can be done in the near term to ensure that these veterans are 
getting the mental health and substance abuse treatment that 
they need?
    Ms. Czarnecki. I will be glad to take that for the record 
and get that response back to you.
    Mr. Steube. All right. Thank you.
    Mr. Connolly. Does the gentleman yield back?
    Mr. Steube. I'll yield back to Mr. Meadows.
    Mr. Meadows. Thank you.
    And so since you're going to take that back, I'm a big one 
on timeframes. When can we expect a response? Because 
literally, these can be life or death kind of--so within the 
next 30 days can you get back to this committee and Mr. Steube 
on that request?
    Ms. Czarnecki. Absolutely.
    Mr. Meadows. All right. Thank you so much.
    I thank the gentleman from Florida.
    Let me followup real quickly. When you mention your IG 
report and sharing it, one of the things that just came to me 
is--I mentioned in my opening statement, I have the luxury of 
having a five-star quality VA center. And yet every VA center 
is not without its challenges and difficulties and delays. And 
yet there are some good practices that I know have been 
implemented at that particular facility.
    What mechanism is out there to share those good practices 
with perhaps the director here in D.C.? Is there a mechanism to 
do that?
    Mr. Missal. Well, that's why what we try to do in our 
reports is we try to really get into the root cause of any 
issue that we find. Because when we find an issue, it's not 
good enough for us just to say we found a problem. We really 
want to get into why it happened, and we see themes. And that's 
why in our reports we're going----
    Mr. Meadows. Yes. But that's more on problems than good 
practices. And so while I appreciate that, it's the good 
    Ms. Czarnecki, is there any way to do that?
    Ms. Czarnecki. Yes. VA actually has a number of mechanisms 
to share good practices. We have an innovation program where 
employees can submit good practices and they can be shared 
across the system.
    Mr. Meadows. So how do they get rewarded for that?
    Your pause concerns me.
    Here's the thing, is you get more of what you reinforce. 
And what I'm saying is if there's a great practice that they 
come up with, and let's say someone comes up and saves the VA 
hospital a million dollars, how do we make sure that that is 
rewarded, or do they just get a pat on the back and say, ata 
boy, ata girl, and go on?
    Ms. Czarnecki. I believe that it's a mix, sir. I do believe 
that in some cases there are team awards. Generally, a best 
practice is not just an individual; it's generally team based.
    Mr. Meadows. Here's what I would like. And I didn't mean to 
cut you off. And here's what I'd like, is the best practices--
listen, you've had just an unbelievably terrible track record 
that we've got to fix. And the problem is each little thing 
that you do wrong now will be judged based on the bad track 
record. It won't be judged--you know, you may be in your 
honeymoon phase right now, but because of the systemic problems 
that have been outlined in the IG's report, if you even mess up 
a little bit, they're going to say nothing's changed.
    So I guess what I would like from the two of you, if you 
would, is to get back to this committee in the next 60 days, 
how do we best share best practices and reinforce those? 
Because part of the survey problem that you're having with 
employee engagement is they don't feel like their input is 
being valued. Would you agree with that, Director?
    Mr. Heimall. Yes, sir, I would. And from a best practice 
standpoint, we've brought a number of best practices from 
around the VA to the Washington, DC. medical center, and we 
have exported some. The work that was done in prosthetics 
specifically, our chief of prosthetics actually went through 
the VA shark tank process at a previous facility. He brought 
best practices to us. And some of the things that he put in 
place at our facility are now being spiraled out across the VA 
as best practices.
    Mr. Meadows. That's what I wanted to hear.
    I'll yield back. I thank the chairman.
    Mr. Connolly. I thank the gentleman.
    The gentlelady from Michigan, Mrs. Lawrence.
    Mrs. Lawrence. I want to thank the chair for acknowledging 
    I want to say for the record I have four VA facilities in 
my district. And this is something that I hear and I know that 
the best practices--and I think the line of questioning that my 
colleague just entered into is extremely important.
    But I hear consistently from the user, from the veterans, 
from those who are using the facility, their discontent, the 
lack of followup and the long waits. And so are we including a 
way to get the voice of the patient? Because so often they feel 
discounted. So it's one thing to talk to all of the employees 
and get those best practices. But at the end of the day, if you 
still have veterans piling into their office of--the Members of 
Congress telling them that they're not being respected, they're 
not getting timely response, and that they need services that 
they cannot get, you may try to put stars on your wall, but are 
we really achieving the goal?
    I would really love to hear a comment on that.
    Ms. Czarnecki. I'll talk a little bit about the national 
level, and then I'll ask Mr. Heimall to comment on what happens 
at the medical center.
    A couple of years ago, we started a veterans experience 
office at the department level. And we're collecting real 
feedback, real time from veterans so that we can trend and 
track those, and do service recovery in real time as opposed to 
waiting for survey results.
    Mr. Heimall.
    Mr. Heimall. I think the survey results are great, but 
they're not--they lag the process. The Veterans Signals, 
VSignals, is a much more real-time system where we can see how 
veterans are reporting. I look at that on--a couple of times a 
week. And it also has a very robust written comments section.
    What I find interesting in that is the positive comments 
outweigh the negative about two to one as I go through that. 
And then I spend a lot of time talking with our patient 
advocates and with veterans across the medical center in our 
various clinics. You have to deal with their issues up front 
when they walk into your office with them. And unfortunately, a 
lot of times a veteran will come into my office demanding to 
see me and I'm not in the building because I'm out visiting an 
outlying clinic or I'm in a meeting, but if I'm available, I 
want to come out and I want to try to resolve that myself.
    One of the things that does is it role models--it sets the 
example for the rest of our staff that if you have an unhappy 
veteran in your clinic today, don't send them down to the 
patient advocate. Do everything that you can to resolve their 
issue in the clinic and let them----
    Mrs. Lawrence. It's about empowering the staff that you 
have the ability to address that issue.
    One other thing, and please help me because I'm having one 
of those moments. The facilities that's not a medical hospital 
that's in the community, what do we call that?
    Mr. Heimall. Community-based outpatient clinic, CBOC.
    Mrs. Lawrence. That's it, CBOC. Those work very well.
    So I'm hearing about this disconnect of the long traffic. 
And I actually got involved because the veteran services were 
trying to close it. And when I visit that facility, the 
veterans who are there, they love it. It's a smaller 
environment. You're using telemedicine, which you're going to 
have to use more of to be more responsive.
    And one of the things that was impressive for me was the 
mental health; that they could, through telemedicine, talk to a 
therapist. And they go in, and it's not all this long walk, 
it's not crowded. The staff there were probably the most 
engaged that I've seen. They took such personal pride in it. 
And I really want you to know that those work and that we--I 
feel there's a place for that. Even if we look at closing a 
facility, you must increase those CBOCs, as they say. Yes.
    Mr. Heimall. Yes, ma'am. And I think the MISSION Act drives 
us to doing that. The access--the drive time access standards 
that the department has put in place really encourage us to 
take the care out closer to where veterans live and work. And 
especially in the D.C. market, I'm very concerned, because we 
have patients that it may take them an hour and a half, two 
hours to get to the medical center.
    In Northern Virginia, the chairman knows, we have a clinic 
at Fort Belvoir, Virginia, but for a veteran living in Loudoun 
County, that could be an hour and a half commute during rush 
hour. And we're going to lose that patient to the community. So 
we are working with it. There's a vet center extension center 
in Loudoun County that we are putting a telemedicine system 
into. And in the next couple of years, we're going to look hard 
at putting a much more larger CBOC in Northern Virginia.
    Mrs. Lawrence. The last thing. I would love for you to 
engage with the chairman, I would love to talk about how we, 
when we get complaints from veterans, to be able to fill out a 
form about the customer satisfaction so that we can help you, 
because we're gathering that data, because we--that's--my 
veteran is my largest caseload.
    Thank you.
    Mr. Connolly. I thank the gentlelady. And she makes a 
really good point. I mean, in a perverse way, Mr. Heimall, 
being at the bottom of the pile means, presumably, you can only 
go up. But establishing a baseline of performance and 
satisfaction is something I think we have to have so we can 
measure real progress and celebrate it when it occurs.
    I also want to ask unanimous consent that my colleague, the 
gentlelady from Virginia, Ms. Wexton, be recognized for the 
purpose of participating in this hearing as a full member of 
the committee. Without objection, so ordered.
    I'm going to take my five minutes and then call upon you 
Ms. Wexton.
    Mr. Meadows. Yes. They've just been yielding to me. I 
haven't had my turn.
    Mr. Connolly. Oh, I'm so sorry. I thought----
    Mr. Meadows. I had plenty to say and not enough time to say 
    Mr. Connolly. Yes. All right.
    Do you want to go now?
    Mr. Meadows. Yes, that'd be great.
    Mr. Connolly. Okay. Sure. I recognize not myself but the 
gentleman from North Carolina.
    Mr. Meadows. Thank you, Mr. Chairman. And again, I want to 
say thank you for your leadership.
    Director, let me just come to you. We have a number of 
hearings where we get people that come in and make excuses. And 
I want to say thank you for not making an excuse for what we 
saw in the video where the I-Team did their investigation. 
Thank you for taking it seriously. I know we've had 
discussions. I appreciate the fact that you not only have a 
concern for our veterans, but you want to get it right.
    Here's what I would ask you. And Mrs. Lawrence just made a 
comment about that. Every year, we have what we call a veterans 
seminar where we actually go to three different parts of my 
district where we bring all the people together and we talk 
about serving the veteran as a whole. So it's not just the VA. 
It's the eligibility. It's everything that we have in that and 
bring it together. Sometimes it's adjudication.
    What we find in those are the weak spots that we have in 
our delivery system. And I don't suggest that we can do that 
across the board. But I do think it's important for us as 
Members of Congress to understand where the weakness is.
    Do you think it would be helpful if we actually get a 
random survey of veterans that are served across the entire VA 
system, not just D.C. but across the entire--that it comes back 
and lets us know, you know, what the scorecard is? The chairman 
has a scorecard, which is called FITARA, that actually gives a 
rating, and we're able to follow that on IT.
    What if we had a rating system that we were able to do that 
for veterans? Do you think that that would be helpful in 
holding people accountable?
    Mr. Heimall. Sir, I think that one of the challenges with 
that is there are a lot of surveys out there. There are at 
least two surveys that our veterans get. If you're an 
inpatient, you get the HCAHP survey that CMS uses. If you're an 
outpatient, you get the VA's outpatient survey, and you get 
pinged for the VSignals on an occasional basis. And so those 
are statistically designed surveys that have statistically set 
sample sizes. There may be something that's missing from that 
and feedback from Members of Congress or from the committee as 
to how to improve that survey may we very useful. But I'd 
encourage you to look at the development of that survey.
    Mr. Meadows. All right. So let's assume we've got two 
surveys. Obviously, they're not working. Wouldn't you agree 
with that? I mean, you know, if the surveys would have stopped 
the poor healthcare results--and maybe I use healthcare more 
broadly, but the problems that we had at your facility where 
you are, if we had just the survey and it was an action item, 
we wouldn't be having this hearing. Would you agree?
    Mr. Heimall. Sir, I think the question is what was 
leadership doing with those survey results and how were they 
trying to address those.
    Mr. Meadows. All right. And that's exactly where I was 
trying to get.
    How do we make sure that the information that we gather is 
not just important to you--because I can tell, you're taking it 
serious. How do we make sure that when you're gone, that the 
next person that takes the directorship of this particular 
facility, how do we make sure that he or she is taking it 
    Mr. Heimall. Sir, I think that needs to be on the report 
card that Congress looks at.
    Mr. Meadows. But even on the report card--I mean, I guess 
at what point do we start holding people accountable?
    Here's the problem I've got. I've got veterans that enjoy 
great service in my district. And when they tell the stories to 
other veterans in other states, all of a sudden the other 
states, they go, well, we don't have anything like that. And I 
want to give a shout-out to Ms. Breyfogle. Who's no longer in 
my district. In fact, I weeped tears. And, actually, we got a 
good replacement. The director there now is great. But Ms. 
Breyfogle did what you just mentioned that you had done with 
the chairman, is gave me her cell phone number so that when I 
had a problem and it came and was elevated, I could take make a 
phone call and it was taken care of in minutes. And you know 
what happened? They ended up empowering their staff to take 
care of the problems where they didn't need to contact me.
    And so how can we do that? Can you get to this committee 
some recommendations on how we can make sure that this D.C. 
debacle does not continue to happen here, but also, that it 
doesn't happen in Arizona or California or Minnesota or 
anywhere in between? Can you get some recommendations to us on 
those good practices that you were talking about sharing?
    Mr. Heimall. Yes, sir. And I would love to do that when we 
submit back on our questions for the record. I'll take that one 
for the record, because I would like to put some thought into 
    Mr. Meadows. Thank you so much.
    I yield back.
    Mr. Connolly. Well, thank you, Mr. Meadows.
    And just following up on that, I think--and we talked about 
this when we met at the facility a couple of months ago. I 
think because of the unique nature of this facility and the 
problems that have plagued it in the past, we've got to create 
a matrix for setting goals that have been set certainly by the 
IG's office and meeting them and institutionalizing them, so 
that, God forbid, but, you know, if you're hit by a bus 
tomorrow, your successor has to follow through and has that in 
front of them.
    Remember, we're doing all this for our veterans to make 
sure they are best served. So I'd like you to give some thought 
about that, because I think we want to institutionalize 
following your progress. This is not going to be a one-time 
hearing. And we have a model we've created for IT in Federal 
Government with, you know, seven factors, and we grade. And 
we're going to have a hearing on that next week, if you want to 
see what it looks like.
    But we'd welcome your suggestion on that. And yours as 
well, Mr. Missal.
    Let me ask you. You're the IG, and you talked about a 
culture of complacency. Could you tell us what you meant by 
that? What led you to characterize activities at the--this 
facility as a--constituting a culture of complacency?
    Mr. Missal. What we found is that the problems that we 
identified were pretty well known throughout the facility, that 
a number of staff raised those issues, did not get them 
resolved, did not get them worked out to their satisfaction. 
And rather than working harder to get them raised either to our 
office or others who could do something about it, that they 
just decided they were going to live with them and have work-
arounds so that they could make sure that the patients got the 
best quality care under the circumstances. So they just were 
satisfied because they felt they had no other route other than 
try to get the best quality care for the patients.
    Mr. Connolly. So what you've just described are sort of 
institutional barriers to providing quality service, and they 
did work-arounds to try to give that quality service the 
barriers within the system notwithstanding?
    Mr. Missal. They felt leadership was either not listening 
to them or not taking appropriate action, and so they felt that 
there were no other avenues to pursue.
    Mr. Connolly. In some cases, however--I mean, for example, 
we had a case where I think, if I recall, the blood supply had 
to be destroyed because it had not properly been stored. Is 
that correct?
    Mr. Missal. I believe that's correct, yes.
    Mr. Connolly. Is that a function of management or a 
function of maintenance and making sure things kind of work 
    Mr. Missal. It has to do with the leadership at the 
facility across all departments and all levels. And they have 
to understand what they're supposed to do, be properly trained. 
But then if there's an issue, to raise their hand. Not be 
afraid to raise an issue. That if they do, that they'll in some 
way be retaliated against. And that's one thing we found at the 
facility. A number of people who didn't raise their hand felt 
that if they did, there would be retaliation against them.
    Mr. Connolly. Mr. Heimall, would you agree that that was a 
problem when you took over, that raise your hand and be 
empowered and there's no retaliation based on what you report? 
And what have you done to change that and encourage it?
    Mr. Heimall. Sir, it was a problem when I arrived at the 
facility. And, quite honestly, there are still pockets of that 
fear across the organization today. And the only way that we 
can really overcome that is by demonstrating that leadership 
takes those concerns seriously, we're going to address them, 
and we actually say thank you to people who bring them to our 
attention, and recognize them publicly. Reward the type of 
behavior from our employees that we want to see.
    Mr. Connolly. Well, both the ranking member and I spent a 
lot of time in the private sector. And one thing I think both 
of us would observe is--and you had a line of questioning that 
got to that. But it's what's rewarded. You can say all you 
want, but if people notice, that's not what's rewarded. And, in 
fact, it could be punished. It's not going to change behavior.
    So presumably, you're looking for some high profile 
opportunities to show you are committed to what you just said 
you are committed to.
    Mr. Heimall. Yes, sir. I try a couple times a week to send 
out a tell-me-something-good story to all the staff where 
either a veteran has thanked somebody for doing the right thing 
or going above and beyond, or a staff member discovered an 
issue that they raised and they prevented a problem from 
happening. I would like to be able to do those every single 
day. And I would like to have a weekly good-catch award where 
we could recognize somebody.
    Unfortunately, the challenge I have right now is we still 
tend to focus on the negative event and not finding those 
positive events where we should be recognizing those behaviors.
    Mr. Connolly. Right. Presumably, there's an in-between 
where we reward someone who takes the initiative to avoid the 
negative happening, and that's a positive.
    Mr. Heimall. And that's exactly what we have to have in 
healthcare if we're going to become high reliability 
    Mr. Connolly. Let me explore the issue of HR. H.R. is the 
one--the No. 1 office still with a 68 percent vacancy rate. So 
out of 78 designated positions, only 25 are on board, 53 are 
vacant. What can go wrong with that, Mr. Missal, that high 
vacancy rate in an H.R. office?
    Mr. Missal. What could go wrong is you're not going to be 
able to hire the people in the other departments and divisions 
that you're going to need. And that was what we found when we 
came onsite at D.C. is their H.R. department was so broken that 
they had outsourced it to the Baltimore medical center. So the 
Baltimore medical center H.R. department was not only trying to 
staff Baltimore, but D.C. as well. And without effective HR, it 
is extremely challenging to make sure you have the resources 
and the staff necessary to do the job necessary.
    Mr. Connolly. So H.R. is kind of key to an enterprise. If 
you want to--you want to have new hires, they've got to be 
    Mr. Missal. Absolutely.
    Mr. Connolly. H.R. does that.
    Mr. Missal. Absolutely.
    Mr. Connolly. If certain things have to--personnel actions 
have to be adjudicated: termination, promotion, demotion, 
demerits, whatever. All of that has to, in some fashion, go 
through HR. Is that correct?
    Mr. Missal. I think the administrative part, but you may 
have employee relations as well that deals with some of those 
issues. But they should be working very closely with HR.
    Mr. Connolly. Well, if I'm terminating someone, I got--the 
paperwork at least is done by HR?
    Mr. Missal. Correct. Administratively, you have to go 
through HR.
    Mr. Connolly. Right. And I got--let me see--how many 
people--2,564 people. And you're going to have some turnover. 
And some of it generated by performance, some just generated 
naturally: retirement attrition, move on. That could keep an 
H.R. office pretty busy.
    Mr. Missal. Yes.
    Mr. Connolly. And I still have 964 positions vacant. Is 
that correct, Mr. Heimall?
    Mr. Heimall. Yes, sir.
    Mr. Connolly. So I got 25 people to do all of that. I need 
78. So I'm--if I'm running HR, I'm under a lot of pressure. 
And, frankly, it may be almost an impossible task, given the 
numbers. I don't know.
    Mr. Heimall, what are you finding as the relatively new 
director is--what's the impediment to filling these critical 
positions in HR, and what do you propose to do to try to 
resolve it?
    Mr. Heimall. Yes, sir. And I would like to--you know, 
beyond some of the examples you said, the 965 number of 
vacancies, I'm trying to hire back 425 of those. In our data 
system that we pulled that data from for your staff, those 
remainder positions that we are not going to hire back, we 
should inactivate in the system so it doesn't look like there's 
a vacancy there. That would be the proper way to do it. And one 
of the challenges with the shortage that we have in H.R. is 
we're not able to do that properly, which means we create a 
false picture of what our vacancies are.
    Mr. Connolly. I'm sorry. When you say inactivated, it just 
sounds so Nixonian. So if you were inoperative, inactive----
    Mr. Meadows. Can you find a different word?
    Mr. Heimall. The term we used when I--my year in the 
private sector was funded head count. All right? This is head 
count that I am not going to fund, I am not going to hire back. 
And so there's a way to code that in the system so it does not 
look like a vacancy.
    Mr. Connolly. And I take that point. And we'll--that's 
fine. But you've still got a vacancy problem in HR, which is 
kind of critical to your being able to manage the enterprise 
and do everything you want to do. Improve morale, improve 
productivity, have a more empowered staff that feels they can 
actually make decisions, as Mr. Meadows said.
    Mr. Heimall. So we have an arrangement with work force 
management consultants from the VHA's human resources division 
that provides 17 full-time equivalent staff to help us process 
hiring actions. And, quite honestly, that is--the way we are 
surviving on a day-to-day basis right now is that two-year 
arrangement that we have with work force management 
    We have prioritized, in our hiring strategy, filling those 
H.R. vacancies. Within the VHA, we are also going to an H.R. 
consolidation at the VISN level. So we have already 
consolidated the classification of position descriptions which 
determines the pay grade we bring someone on at the VISN level. 
We are in the process of now working through consolidating, 
across the six facilities, the other human resource functions. 
And on a national level, we are going to begin consolidating 
our retirement processing.
    Every time the central office comes up with a--for example, 
a retirement processing, I'm happy to take advantage of the 
centralization of that, because it means I can get better 
service for my employees who are retiring and free up my 
internal H.R. staff to be working staffing, recruitment, 
disciplinary actions.
    Mr. Connolly. But just to be clear, I want to make--you 
can--however you answer, but I want to make sure I don't 
misunderstand you. You are not saying outsourcing H.R. is the 
long-term solution?
    Mr. Heimall. No, I am not.
    Mr. Connolly. It's just a short-term solution because of 
the dire need for functioning and to buy yourself some time to 
fill these vacancies in HR?
    Mr. Heimall. Yes, sir.
    Mr. Connolly. Mr. Missal, and then I'm going to call on Ms. 
    Mr. Missal. Mr. Chairman, I just would also like to add 
that a staffing model is so critical to ensure you have the 
proper staff. We've been talking about numbers here and 
vacancies. I don't know if those are the right numbers, because 
until you have a good staffing model which tells you what you 
need and where you need it, it's really hard to know whether or 
not it's effective.
    And we put out a staffing report every year across VA. And 
it's been very frustrating, because, for years, we've been 
saying VA needs to have staffing models across all the 
disciplines. They've done a pretty good job on primary care, 
but there's a number of other specialty areas which they 
haven't done it. And I don't want that to be missed. And that 
was one of our recommendations. It's still open with respect to 
staffing models.
    Mr. Connolly. Thank you.
    The gentlelady from Virginia is now recognized for her five 
minutes, Ms. Wexton.
    Ms. Wexton. Thank you, Mr. Chairman, for yielding and for 
inviting me to participate in today's hearing. And thank you to 
the witnesses for coming to testify before the committee today.
    So my district, I represent the top triangle of Northern 
Virginia, far Northern Virginia. My district starts just 
outside of Washington, DC, and goes all the way out to the west 
to the Shenandoah Valley. So somebody at the midpoint of my 
district could go to either the D.C. VA or to Martinsburg, West 
Virginia. And it would be a little bit more than an hour in 
each direction for those folks.
    Now, most of the folks live on the eastern side of my 
district, though, who need those services. But what we have 
encountered in terms of a constituent service standpoint is 
that more and more of our veterans want to go to Martinsburg 
because they are not getting the satisfying care that they need 
at the D.C. VA.
    And I'm glad that you guys have made progress. It looks 
like you're really digging in and doing what you can in the 
short time you've had thus far. But there obviously are still 
some ongoing issues that the patients there are having to face. 
I think understaffing has been a lot of the cause of that. It 
seems that everybody agrees. It's resulted in longer than usual 
wait times and unresponsive departments. And a lot of our 
constituents are reaching out to our office in assistance of 
transferring their cases from D.C. to Martinsburg, despite the 
fact that it's going to take them longer to get there.
    Now, Chairman Connolly talked a little bit about the 
staffing issues. And I know that you have had pervasive 
staffing issues across multiple departments. Have you hired yet 
or is there a plan to prioritize hiring a new H.R. director, 
Mr. Heimall?
    Mr. Heimall. Yes, ma'am. Our new H.R. director came on 
board, I believe, in September 2018.
    Ms. Wexton. Okay. And is there a staffing plan to fill the 
vacancies that you have?
    Mr. Heimall. Yes, ma'am, there is.
    Ms. Wexton. How are you prioritizing which positions you're 
trying to fill first?
    Mr. Heimall. We looked at where our greatest pain points 
were. When I first came on board, we had prioritized 45 
housekeepers as one of our top priorities, but we had a very 
functional housekeeping contract that was supporting the 
facility and actually doing a wonderful job. I reprioritized 
those positions lower on our priority list, and I moved up 
positions like human resources, our patient safety manager, and 
our infection control nurses so that we could provide better 
care and we could also hire them on board the staff that we 
need to support the medical center.
    Ms. Wexton. So you moved up the positions that have direct 
patient contact care, those kinds of----
    Mr. Heimall. Yes, ma'am. Or ones that were absolutely 
critical for us bringing on board the people that we needed to 
bring on. We also prioritized some of our logistics in SPS 
positions a little higher on the list so that we could fill 
those critical gaps as well.
    Ms. Wexton. Okay. Very good.
    And one of the things that Mr. Missal brought up in his 
remarks at the end of the chairman's questioning was that a lot 
of your data from 2017 and 2018 were unavailable when it came 
to staffing vacancies in the H.R. system because it was not 
properly maintained as the system of record for a position 
management. So basically, you didn't know what you didn't know, 
    Mr. Heimall. Exactly, ma'am.
    Ms. Wexton. Okay. What changes has the facility implemented 
to ensure that you have accurate tracking about vacancies and 
    Mr. Heimall. We have validated an organization chart for 
every single one of our departments. And technically, under 
H.R. modernization, H.R. belongs to the VISN, but I validated 
their staffing chart as well so I could make sure I have the 
local staff that I need to support the medical center. That 
information now needs to be corrected in the H.R. system so 
that we have a position management system that allows us to 
function and prioritize our needs. And that is the last piece 
that needs to be completed from the two recommendations on H.R. 
in the IG report.
    Ms. Wexton. And do you have a timeline for that to take 
    Mr. Heimall. We expect that will be completed by 30 
September of this year.
    Ms. Wexton. Okay. Very good.
    And what steps is the facility taking to retain top talent, 
especially medical talent? Nurses. I know that there's been a 
lot of turnover and a lot of them working a whole lot of 
overtime, which has cost them in terms of their satisfaction.
    Mr. Heimall. Yes, ma'am. We're looking very hard at the 
salary rates among our competitors. Somebody sent me a flyer 
last night that one of our local competitors is offering a 
$20,000 recruitment bonus for nurses. That means we've got to 
put recruitment bonus in all of our job announcements for 
nurses and try to match that. And if any of our nurses tell us 
that they're going to leave for that $20,000 recruitment bonus, 
I would like the opportunity to match that with a retention 
bonus before they make a decision.
    Ms. Wexton. Thank you very much.
    I see my time has expired, so I will yield back.
    Mr. Connolly. Wouldn't it be nice if there were a retention 
bonus for Members of--no. No. Just talking crazy here.
    Mr. Meadows. You're going to regret that question.
    Mr. Connolly. Let the record show I didn't approve of that. 
I just asked.
    Mr. Meadows. You're against it, I'm sure, right?
    Mr. Connolly. I'm against it, as is----
    Mr. Meadows. As I am, yes.
    Mr. Connolly. Go ahead.
    Mr. Meadows. I want to make just two requests and a closing 
comment. And the chairman has afforded me that luxury, and I 
thank him.
    Director, whenever you have a hearing like this, there's 
two things that come out of it, is either a good action plan--
and it sounds like you're well on your way to addressing the 
outstanding issues. And I understand by October, you're going 
to have those outstanding issues on the IG's report done. Is 
that correct?
    Mr. Heimall. Yes, sir. We expect everything to be completed 
by 30 September.
    Mr. Meadows. But there is a tidal wave of complaints that 
will come in for people that have been watching this hearing. 
And I just--they're going to call the I-Team investigator and 
say, yes, but. They're going to call our staffs. And the 
chairman and the gentlewoman from Virginia and the gentlewoman 
from the District of Columbia will get a number of complaints.
    And so here is my ask of you, is when those come in, if--
will you remain committed to address all of those as 
expeditiously as you have testified here today? Are you 
committed to do that and give rapid response on those 
complaints that come in?
    Mr. Heimall. Yes, sir, I absolutely am.
    Mr. Meadows. All right. And I'll close with this. I can 
tell that you're sincere. And I came into this hearing so angry 
and so upset that our veterans had not been served, partly by 
the investigative team work that's done, partly by the numbers 
that we've seen. We know that you didn't create this problem. 
In fact, this is a systemic problem that has been there, it 
appears, for a number of years. And so I want to say thank you 
for having a sobering response and not pretending like 
everything is fixed. I appreciate that.
    One of the telling things is when you talked about how 
teams were afraid--the IG pointed out teams were afraid to come 
to management. And you admitted there are still pockets of that 
now. Very transparent. I don't know that most witnesses would 
do that. I want to thank you for doing that.
    We would also like a good health report over the next 60 to 
90 days on where you're coming. And if you would be willing to 
commit to do that, I think the chairman and I would love to 
look at this very closely. Are you willing to do that?
    Mr. Heimall. Yes, sir, I am. And I would love to have both 
of you visit the facility.
    Mr. Meadows. I thank you.
    And I thank, again, the chairman for his leadership, and I 
yield back.
    Mr. Connolly. I thank my friend.
    So in conclusion, we're going to develop a matrix for 
monitoring progress, and it's got to be a workable matrix to 
you and for us. And we welcome your involvement and that of 
your office, Mr. Missal, so that it meets your concerns as 
    So if all of us sign off on, yes, that's the way we're 
going to measure, then we can look at how well we're doing. But 
we got to first agree on what are the metrics. We need to see 
to be satisfied that all the people we're accountable to can 
see or not see the progress we're making.
    You've made a commitment, Mr. Heimall, to stick around. 
You've made a professional and, I think, moral commitment to 
the men and women we serve to get this right. You're not 
leaving until we do. And we want to hold you to that. But we 
also want you to know we understand the nature of that 
professional commitment. And for God's sake, please keep it.
    Mr. Heimall. Sir, that is one I--I love the team that I 
work with. I love the veterans that we are privileged to care 
for. And if something were to arise that would cause me to 
question that commitment, it would be an incredibly painful day 
for me, so I am here for the long haul.
    Mr. Connolly. But I also think, when you have the kind of 
turnover in leadership that your facility has had, it's--it has 
a huge toll on productivity and morale with the work force. And 
it adds to that culture of complacency or indifference that we 
talked about, because I know I can wait you out. Average life 
spans of one of you people is three months, or whatever it is. 
And I think that's had a hugely deleterious impact on the 
quality of care at this facility and the commitment to the 
    Having stable leadership that exacts standards of 
performance, rewards good performance but also holds people 
accountable for bad performance can have a very salutary 
effect. And the beneficiaries of that salutary effect are the 
men and women who wore that uniform who are counting on us to 
deliver quality care for them and their families.
    I thank you for coming here today. This hearing is 
    [Whereupon, at 3:44 p.m., the subcommittee was adjourned.]