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


                    BROKEN PROMISES: ASSESSING VA'S
                         SYSTEMS FOR PROTECTING
                      VETERANS FROM CLINICAL HARM

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

                                HEARING

                               BEFORE THE

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 OF THE

                     COMMITTEE ON VETERANS' AFFAIRS

                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                      WEDNESDAY, OCTOBER 16, 2019

                               __________

                           Serial No. 116-38

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]       


                    Available via http://govinfo.gov
                    
                               __________

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
40-994 PDF                 WASHINGTON : 2022                     
          
-----------------------------------------------------------------------------------                      
                   
                     COMMITTEE ON VETERANS' AFFAIRS

                   MARK TAKANO, California, Chairman

JULIA BROWNLEY, California           DAVID P. ROE, Tennessee, Ranking 
KATHLEEN M. RICE, New York               Member
CONOR LAMB, Pennsylvania, Vice-      GUS M. BILIRAKIS, Florida
    Chairman                         AUMUA AMATA COLEMAN RADEWAGEN, 
MIKE LEVIN, California                   American Samoa
MAX ROSE, New York                   MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire          NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia            JACK BERGMAN, Michigan
SUSIE LEE, Nevada                    JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina       ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR.,           DANIEL MEUSER, Pennsylvania
    California                       STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota        CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN,      W. GREGORY STEUBE, Florida
    Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York

                 Ray Kelley, Democratic Staff Director
                 Jon Towers, Republican Staff Director

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                 CHRIS PAPPAS, New Hampshire, Chairman

KATHLEEN M. RICE, New York           JACK BERGMAN, Michigan, Ranking 
MAX ROSE, New York                       Member
GILBERT RAY CISNEROS, JR.,           AUMUA AMATA COLEMAN RADEWAGEN, 
    California                           American Samoa
COLLIN C. PETERSON, Minnesota        MIKE BOST, Illinois
                                     CHIP ROY, Texas

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                        
                        
                        C  O  N  T  E  N  T  S

                              ----------                              

                      WEDNESDAY, OCTOBER 16, 2019

                                                                   Page

                           OPENING STATEMENTS

Honorable Chris Pappas, Chairman.................................     1
Honorable Jack Bergman, Ranking Member...........................     3
Honorable Mark Takano............................................     9
Honorable Aumua Amata Coleman Radewagen..........................    16
Honorable Gilbert Ray Cisneros, Jr...............................    16
Honorable Carol Miller...........................................    18
Honorable Joe Cunningham.........................................    20
Honorable Scott Peters...........................................    22
Honorable Jennifer Wexton........................................    24

                               WITNESSES

Ms. Sharon Silas, Director, Health Care Team, U.S. Government 
  Accountability Office..........................................     4
Dr. John Daigh, Assistant Inspector General for Healthcare 
  Inspections, Office of Inspector General, U.S. Department of 
  Veterans Affairs...............................................     6
Dr. Steven Lieberman, Acting Principal Deputy Under Secretary for 
  Health, Veterans Health Administration, U.S. Department of 
  Veterans Affairs...............................................     8

        Accompanied by:

    Dr. Gerald Cox, Deputy Under Secretary for Health for 
        Organizational Excellance, Veterans Health 
        Administration, U.S. Department of Veteran Affairs

    Ms. Jessica Bonjorni, Acting Assistant Deputy Under Secretary 
        for Health for Workforce Services, Veterans Health 
        Administration, U.S. Department of Veterans Affairs

                                APPENDIX
                     Prepared Statements of Witness

Ms. Sharon Silas Prepared Statement..............................    33
Dr. John Daigh Prepared Statement................................    57
Dr. Steven Lieberman Prepared Statement..........................    64

                       Submissions For The Record

Honorable Rick Crawford (AR-1) Prepared Statement................    71
Honorable French Hill (AR-2) Prepared Statement..................    71
Honorable John Lewis (GA-5) Prepared Statement...................    72
Honorable David McKinley (WV-1) Prepared Statement...............    75
Honorable Carol Miller (WV-1) Prepared Statement.................    75
Honorable Bruce Westerman (AR-4) Prepared Statement..............    75
Honorable Steve Womack (AR-3) Prepared Statement.................    77
The National Council of State Boards of Nursing Prepared 
  Statement......................................................    78

 
         BROKEN PROMISES: ASSESSING VA'S SYSTEMS FOR PROTECTING.
                      VETERANS FROM CLINICAL HARM

                              ----------                              


                      WEDNESDAY, OCTOBER 16, 2019

              U.S. House of Representatives
       Subcommittee on Oversight and Investigations
                             Committee on Veterans' Affairs
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 2:48 p.m., in 
room 210, House Visitors Center, Hon. Chris Pappas (chairman of 
the subcommittee) presiding.
    Present: Representatives Pappas, Rose, Cisneros, Peterson, 
Wexton, Peters, Cunningham, Takano, Bergman, Radewagen, Bost, 
Roy and Miller.

          OPENING STATEMENT OF CHRIS PAPPAS, CHAIRMAN

    Mr. Pappas. Good afternoon. I call this hearing to order. 
Without objection, the chair is authorized to declare a recess 
at any time.
    Before we begin, I would like to ask unanimous consent for 
our colleagues, Representatives Cunningham, Lewis, Miller, 
Peters and Wexton to participate in today's hearing should they 
all be able to attend.
    Without objection, so ordered.
    I would like to also welcome our full committee chair, Mark 
Takano. Thank you for being here, Mr. Chair.
    Approximately 8 weeks ago the media began reporting on a 
string of concerning incidents of patient harm and professional 
misconduct in VA medical facilities. In August, a former VA 
pathologist in Fayetteville, Arkansas was charged with 
involuntary manslaughter, fraud and making false statements in 
an attempt to conceal years of substance abuse. Over his 11-
year tenure with VA he is believed to have botched diagnoses 
for an estimated 3,000 veterans, some of whom died.
    Authorities are also investigating at least a dozen 
suspicious deaths at the VA hospital in Clarksburg, West 
Virginia. Medical examiners have now determined that 3 of these 
veterans died of homicide by insulin injection.
    Early in September a veteran receiving end of life care at 
a VA nursing home in Atlanta was bitten by ants more than 100 
times before facility staff finally moved him to a new room and 
took action to address this infestation. These reports are 
sickening.
    Over the last 2 months we have also received a steady 
stream of reports from VA's Inspector General (IG) identifying 
appalling VA quality management failures in several other 
locations.
    For example, last month the IG reported on multiple 
leadership failures at a VA facility in Veterans Integrated 
Services Network (VISN) 10 in the Midwest which allowed an 
opthalmologist to perform substandard surgery and laser 
procedures for 2 years. This doctor regularly took hours to 
complete cataract surgeries that should have taken less than 30 
minutes. The facility director and chief of staff repeatedly 
dismissed concerns that were raised by other staff members.
    Although these 2 facility level leaders had the 
responsibility and the authority to remove the provider, they 
instead chose to disregard the patient safety risks. The 
reason, according to the IG the ophthalmologist's spouse was 
also a surgeon at the facility and leaders worried that 
terminating one would entice the other to resign, leaving 
several veterans--leaving the facility with 2 physician 
vacancies.
    In the end, as a result, several veterans were referred to 
community care for further treatment to resolve complications 
arising from this surgeon's care.
    It would be easy to dismiss any one of these cases as just 
an isolated incident or just one bad apple. Collectively, these 
cases speak to wider problems with VA's ability to identify 
clinicians who are negligent, abusive or committing criminal 
acts and prevent them from practicing. The VA has got to do 
better.
    Today's hearing will explore several critical questions: 
What red flags are VA facilities missing, overlooking or 
choosing to ignore when they hire and employ clinicians; when 
concerns arise, why are not medical center officials 
investigating in a timely manner; and when concerns are 
substantiated, why isn't VA reporting them to the National 
Practitioner Data Bank, the NPDB, and to State licensing boards 
in a timely fashion.
    As today's hearing will make clear, far too much 
responsibility and authority has been placed at the local 
level. The Veterans Health Administration and its VISNs are 
doing far too little oversight to ensure that facility level 
leaders understand and are complying with policies for ensuring 
proper patient care and safety.
    Instead, VA's pervasive lack of accountability is leading 
to patient harm. That is why we have convened today's hearing. 
Veterans and their families deserve answers. They need to know 
that the VA is upholding its moral and ethical obligation to 
deliver world class health care. This is the promise our Nation 
made to those who have served, and our heroes deserve nothing 
less than that.
    This is not new territory for VA or for this subcommittee. 
In fact, 2 years ago General Bergman shared a subcommittee 
hearing on this very topic. One of our witnesses. Dr. Gerard 
Cox, testified at that hearing. Among other things, Dr. Cox 
promised that the VA would update its policies related to 
credentialing and privileging, improve the timeliness and 
reporting to the NPDB and State licensing boards, expand NPDB 
reporting to nurses and other types of clinicians instead of 
just physicians and dentists, and establish a new VISN level 
compliance process.
    As you will hear today, none of these actions have been 
made since our subcommittee's last hearing on this topic. I 
will say that again. The VA has not taken any of the actions 
that it promised during that hearing in 2017. The string of 
incidents over the last 8 weeks should serve as a wake up call. 
No one here would deny veterans deserve any less than that, but 
we must do better for VA employees who are brave enough to 
speak up when they are concerned that a colleague's clinical 
incompetence, their impairment, negligence or misconduct is 
putting veterans' lives at risk.
    As the IG found in the case of the ophthalmologist in VISN 
10, facility leaders repeatedly ignored concerns raised by 
other clinicians at the facility. The indictment of the VA 
pathologist in Arkansas states that colleagues complained to 
facility leaders repeatedly that the doctor appeared to be 
intoxicated while on duty, both before and after he completed 
an inpatient treatment program.
    In both cases it took years for facility leaders to remove 
these providers, and in the meantime our veterans suffered. It 
is not enough for VA leaders to sit here today and pledge 
policy changes. They have done that before. We need to see that 
VA is as outraged as we are and that leaders at all levels will 
be willing to walk the walk. We must see a fundamental cultural 
transformation. Something must be done to make VA a place where 
employees at all levels feel they have psychological safety and 
to be able to sound the alarm.
    Employees need to know that their concerns will be taken 
seriously, that there is a sense of urgency to address these 
concerns as soon as they arise and that VA is acting swiftly to 
guarantee these issues do not occur again in the future. Their 
lives depend on it.
    With that I would like to recognize our ranking member, 
General Bergman, for 5 minutes for any opening remarks he may 
have.

       OPENING STATEMENT OF JACK BERGMAN, RANKING MEMBER

    Mr. Bergman. Thank you, Mr. Chairman. As you stated on the 
front end, in 2017 as chair of this subcommittee I held a 
hearing on VA provider competency, which focused on VA's 
handling of providers who were found to deliver substandard 
care.
    Sadly, we are holding another hearing on this vitally 
important topic in the wake of several new reports of serious 
patient harm involving VA providers. Our veterans deserve 
better and we collectively must give them our best effort 
because they have given us their best effort through their 
service.
    When problems arise, we must take a long, hard look at what 
went wrong, why it went wrong, and what we can do to mitigate 
the risk of future failures.
    The unfortunate reality is that this is a retrospective 
process. No congressional hearing or legislation can change 
what happened. It has been said that there are 3 things that 
you can never get back in this world: The spent arrow, the 
spoken word, and the missed opportunity.
    Mr. Chairman, we have before us an opportunity to 
significantly improve the department for veterans and their 
loved ones. The committee has received several reports recently 
from the VA Inspector General and the Government Accountability 
Office (GAO) that identified failures in credentialing, 
privileging and quality management. It appears to me that there 
are polices in place that, if followed, could mitigate and/or 
avoid many of these issues.
    However, an organization's policies and procedures alone do 
not make for success. It is the leadership of the organization 
that establishes the culture, empowers individuals to think and 
act autonomously, and drives the organization toward a more 
improved version of itself. It appears that many of these 
problems are, in a large part, leadership failures.
    For example, one of the glaring issues following a recent 
GAO report was the lack of consistent and standard 
credentialing, privileging and quality management oversight 
from VISN Chief Medical Officers. The report found that the 
VISN CMOs assessments of credentialing, privileging and quality 
of care were often incomplete with inconsistent use of the 
``standardized assessment tool.'' In fact, some VISN officials 
stated that they were not using the standardized tool, but 
rather developing their own auditing tool.
    You cannot manage what you do not measure. It seems that 
there is little about the VISN's oversight of credentialing and 
privileging that is actually measured.
    Another area of concern that the inspector general has 
raised is the lack of direct observation of providers on 
Focused Professional Practice Evaluations or FPPEs. Instead, VA 
facilities rely on documents to evaluate the provider's 
performance.
    Though documents may show performance to be within 
acceptable ranges, they may not capture a practitioner's 
behavior while operating, responding during a crisis or 
confidence with a procedure. I am interested in hearing more 
about this issue from our witnesses.
    As a military commander, I know that there is always the 10 
percent who are not with the program and can sully the 
reputation of the rest of the organization. While hundreds of 
thousands of veterans receive quality health care from tens of 
thousands of VA providers every day, VA is not immune to this 
10 percent problem.
    When issues are identified, VA must act swiftly to address 
them. Therefore, I want to know what VA is doing to correct the 
identified failures and most importantly what it has learned 
from these failures and what systems and people have been put 
in place to ensure that VA avoids similar failures in the 
future.
    To kind of sum up, the observation is no clear chain of 
command, no structured review process and no requirement for 
direct observation.
    I thank all of our witnesses for being here today and I 
look forward to a productive hearing.
    With that, Mr. Chairman, I yield back.
    Mr. Pappas. Thank you, Ranking Member Bergman.
    I will now recognize our first witness. First we have Ms. 
Sharon Silas, a director of the U.S. Government 
Accountability's Office Health Care Team.
    Thank you for appearing with us today, and you are 
recognized for 5 minutes.

                   STATEMENT OF SHARON SILAS

    Ms. Silas. Thank you.
    Chairman Pappas, Ranking Member Bergman, and members of the 
subcommittee, I am pleased to be here today to discuss our 
recent body of work on provider qualifications and competence 
in VA's health care system.
    My testimony today is summarized as findings and 
recommendations from 2 recent reports on VA's response to 
adverse information when credentialing providers, and the 
reviews and reporting of VA providers when concerns are raised 
about the quality of their clinical care.
    Based on our findings from these 2 reports, we made 11 
recommendations, 9 of which remain open.
    Like other health care facilities, VA medical centers are 
responsible for ensuring that their providers deliver safe care 
to patients. VA has processes and policies in place to help 
ensure that providers have the qualifications and competence to 
deliver quality care to veterans.
    First, as part of credentialing and renewing clinical 
privileges for a provider, Veterans Health Administration (VHA) 
policy requires VA medical centers to review the NPDB which is 
a data base that collects and releases information on providers 
who, for example, have been disciplined by a State licensing 
board or other health care entity.
    Review of NPDB reports are used to verify that the 
provider's medical licenses are current and in good standing. 
However, in our 2019 report we found inconsistent adherence to 
VHA policies that disqualified providers from employment at VA 
medical centers.
    Specifically, we found that some VA medical center 
officials were not aware of key policies that govern 
credentialing reviews and that gaps exist in VHA policy that 
allow for inconsistent interpretation.
    For example, VHA did not have policies in place regarding 
Drug Enforcement Agency (DEA) registrations and the 
circumstances in which waivers may be required.
    Last, VHA's oversight of VA medical centers' reviews of 
adverse information was inadequate.
    Second, VA medical center officials are also required to 
review and, if warranted, address any concerns that may arise 
about a privileged provider's clinical care. Depending on the 
nature of the concern and the review's findings, take 
appropriate actions including limiting or preventing the 
provider from delivering care to veterans.
    VA medical center officials are also required to report the 
providers against whom they take adverse privileging actions to 
the NPDB and State licensing boards. If VA medical centers fail 
to properly review, address and report concerns that have been 
raised about the provider's performance, they may be exposing 
veterans, and potentially the public, to unsafe care.
    In our 2017 review, we found that for 148 providers that 
required clinical reviews at 5 VA medical centers, VA officials 
were unable to provide any documentation for about half of 
them. In fact, officials acknowledged that in some cases the 
required reviews were not conducted at all.
    Furthermore, VA medical centers did not always conduct 
reviews of providers' clinical care in a timely manner, some 
taking longer than 3 months and in some cases years to initiate 
reviews of a provider's performance.
    We also found that the 5 VA medical centers did not alert 
the NPDB or State licensing boards if there were serious 
concerns with regard to a provider's clinical performance as 
required by VHA policy.
    Specifically, we found that only 1 of 9 providers was 
appropriately reported to the NPDB and none of these providers 
were reported to the State licensing boards. We found that 1 of 
these providers was later fired and reported to the State 
licensing board by a non-VA facility for the same reason 
several years later.
    The causes of these deficiencies that we identified in this 
review can again be attributed to gaps in policy and inadequate 
oversight. For example, we found that VHA policy does not 
require VA medical centers to document all types of reviews of 
providers' clinical care. We also found that while VISN 
officials are responsible for overseeing the credentialing and 
privileging processes of the respective VA medical centers, 
none of the VISN officials we spoke with describe any routine 
oversight.
    In the last few months a number of high profile incidents 
involving quality and safety concerns with VA providers have 
been covered in the media. While these cases each have their 
own specific circumstances, many appear to illustrate the 
potential impact of the deficiencies we identified in our 
reviews and highlight the importance of VA implementing GAOs 
recommendations.
    Strengthening policies and oversight of VA medical center's 
credentialing and reviews of provider clinical care when 
concerns are raised are key to decreasing the risks that our 
veterans and the general public will be exposed to unsafe care.
    This concludes my prepared statement. I would be happy to 
answer any questions that you may have.

    [The Prepared Statement Of Sharon Silas Appears In The 
Appendix]

    Mr. Pappas. Thank you very much, Ms. Silas.
    Our second witness is Dr. John Daigh. He is the Assistant 
Inspector General for Health Care Inspections at the VA Office 
of Inspector General.
    Dr. Daigh, thanks for joining us, and you are recognized 
for 5 minutes.

                  STATEMENT OF DR. JOHN DAIGH

    Dr. Daigh. Chairman Pappas, Ranking Member Bergman, members 
of the subcommittee, I thank you for the opportunity to testify 
regarding Office of Inspector Generals (OIG's) work on the 
important topic of credentialing and privileging of licensed 
and independent practitioners.
    I am privileged to represent the OIG's Office of Health 
Care Inspections and the staff that prepared the reports 
discussed in our written testimony.
    I would like to begin by affirming that our work supports 
the fact that VHA usually provides quality health care to 
veterans, and that the overwhelming majority of clinical 
administrative staff at VA hospitals are committed to their 
mission.
    However, it is clear that credentialing and privileging 
processes along with the patient safety program and quality 
assurance must be improved to provide appropriate assurance 
that veterans will continue to receive high quality medical 
care.
    In numerous reports over the last few years my office has 
detailed incidents where physician care did not meet VHA 
standards and episodes where veterans were placed at risk or 
harmed as a result of too many months of unchecked substandard 
care.
    We have made recommendations to VHA to address the lapses 
in provider credentialing and privileging practice evaluations 
and a to ready acceptance by VHA privileging committees that a 
provider has the clinical skills and thought processes required 
to provide high quality care.
    We are also concerned that it takes too long for the 
leadership at a hospital to act to address poor performing 
providers.
    In particular, an August 2019 report highlights many of 
these failures with the VISN 10 medical center's decision to 
hire an opthalmologist. The individual that was hired was not 
board eligible in ophthalmology. The submitted clinical 
references did not provide comfort that the physician could 
perform cataract surgery, a surgery for which the physician was 
subsequently given privileges by the facility leadership. He 
was not adequately assessed through the FPPE process with 
respect to the ability to perform cataract surgeries. When 
concerns about the quality of this provider's surgical care 
were raised by nurses and other members of the staff, hospital 
leadership was far too slow to respond.
    Simply put, it should not be a challenge to determine there 
is a problem when cataract surgery that should take less than 
30 minutes takes hours, and it should not be a challenge to 
remedy that problem.
    While VHA needs to improve their efforts to collect and 
review all required documents for the credentialing process, 
more emphasis should be given to understanding the quality of 
the provider's prior practice through interviews and references 
from appropriate sources.
    VHA needs to look for opportunities to adopt a show me 
attitude when granting privileges. For example, observing a 
colonoscopy or reviewing the interpretation of scans and 
pathology slides should be comprehensively adopted in early 
stages of a provider's employment.
    Direct observation of clinical procedure performance and 
increased use of simulation centers could better demonstrate 
that a clinician will be more likely to provide high quality 
medical care.
    More concerning to me than the credentialing and 
privileging issues we uncover is the finding that substandard 
care was provided for months without VHA leadership action. 
Technicians and nurses tell my staff that they have no reason 
to speak up about poor provider care when they see inaction 
from providers themselves or from facility leadership.
    I am unsure if providers and staff are not making 
themselves heard or if leadership is not listening. This 
problem speaks to the need to consider changes to the patient's 
safety and quality assurance programs. They must work together 
to ensure that veterans receive quality medical care.
    While we generally believe VHA policies are reasonable, it 
is time for VHA to conduct a serious review of how it 
implements these policies. Our recent reports should not be 
discounted as isolated events that would be expected to occur 
across a large system.
    In addition to challenging how providers are evaluated in 
order to reduce variance across the system, VHA should consider 
appointing a national leader for each speciality whose primary 
responsibility is to ensure that the quality practice of that 
speciality across VA is at an outstanding level.
    A change in how local, regional and national leaders 
conduct evaluations and communicate about practitioners who 
should not be providing care to veterans is paramount given 
these missteps and delays. Many of the failures we identify can 
be traced to what is, at best, ineffective oversight from 
regional and national leaders.
    Mr. Chairman, that concludes my statement and I will be 
pleased to answer any questions.

    [The Prepared Statement Of Dr. John Daigh Appears In The 
Appendix]

    Mr. Pappas. Thank you very much, Dr. Daigh.
    Finally, I will recognize our VA witnesses, Dr. Steven 
Lieberman, the Acting Principal Deputy Under Secretary for 
Health at the Veterans Health Administration or VHA. He is 
accompanied by Dr. Gerard Cox, VHA's Deputy Under Secretary For 
Health For Organizational Excellence. Finally we have Ms. 
Jessica Bonjorni who is VHA's Acting Assistant Deputy Under 
Secretary For Health For Work Force Services.
    Thank you all for joining us today and, Dr. Lieberman, you 
are recognized for 5 minutes.

               STATEMENT OF DR. STEVEN LIEBERMAN

    Dr. Lieberman. Good afternoon, Chairman Pappas, Ranking 
Member Bergman and members of the subcommittee.
    I appreciate the opportunity to discuss the Veterans Health 
Administration's process for credentialing, privileging and 
quality management. I am joined today by Dr. Gerard Cox, Deputy 
Under Secretary For Health For Organizational Excellence, and 
Ms. Jessica Bonjorni, Acting Assistant Deputy Under Secretary 
For Health For Work Force Services.
    VA is committed to ensuring that veterans receive safe, 
high quality health care. We know that some staff do not uphold 
VA's values and we will hold accountable anyone that provides 
poor care or commits crimes in our facilities.
    Some recent events are deeply disturbing. It is extremely 
troubling that the actions of a few flawed staff might 
overshadow the great work of the nearly 348,000 employees who 
provide quality care every day to veterans and their families.
    During Fiscal Year 2019, VA clinical staff engaged patients 
more than 121 million times, completed 1.7 million more 
outpatient appointments at VA facilities over Fiscal Year 2018, 
and saw an additional 73,000 more veterans over Fiscal Year 
2018. We are proud that veterans are continuing to choose VA 
for their health care as the quality of care and access in VA 
continues to improve.
    Research studies highlight that the quality of care in VA 
is better than care in the private sector. The public does not 
often hear about the overwhelming majority of our patient 
encounters where VA staff works hard every day to optimize 
care. Our internal surveys from veterans who receive VA care 
show that their trust in our system continues to improve, most 
recently at 88 percent.
    As we grow, we are undergoing a transformation into a high 
reliability organization. This new initiative to eliminate harm 
to patients includes remedying the culture in which mistakes 
may happen. Research confirms that most errors in health care 
are unintentional. Our goal is to embrace a just culture where 
staff feel comfortable speaking up if something has gone wrong 
or could go wrong if a concern is not addressed. This creates a 
system that reduces mistakes and prevents errors from harming 
the patient.
    It is important to note that a just culture still ensures 
accountability, immediate discipline and prosecution, when 
appropriate, for those who act with maliciousness, willful 
negligence or intent to cause harm. VA demonstrated our 
commitment to that accountability with the recent incidents 
when staff did not live up to VA's high standards.
    VA removes people who willfully cause harm from patient 
care immediately.
    We learn from the mistakes that cause harm and we welcome 
investigations to ensure that we are doing everything we can to 
create a safe health care environment. We have not found a 
common thread between the recent incidents. Instead, there are 
a small number of people whom acted inappropriately.
    VA has a robust set of processes to screen all applicants 
before they join VA that includes background screening. For 
health care providers we follow the joint commission standards 
for credentialing and privileging, including checking with the 
provider's State licensing board and the National Practitioner 
Data Bank to determine if an applicant has been reported due to 
substandard care, professional misconduct or professional 
incompetence.
    VA continues to monitor provider's performance and the 
external reporting bodies to ensure they remain fit for 
service, and we react quickly when a new issue is found.
    Unfortunately, there is no way in health care to predict 
every human failing. We establish strong systems in the way 
industry standards to respond quickly and comprehensively 
whenever a patient's safety might be in jeopardy.
    In conclusion, I want to emphasize that I am sorry for any 
pain that any veteran or their families have experienced as a 
result of our employees acting inappropriately. When something 
goes wrong we learn from those experiences. As a result of 
that, we get stronger. We get stronger because of the nearly 
348,000 employees who come to work every day to provide 
excellent care to veterans.
    That completes my opening statement and we are prepared to 
answer your questions.

    [The Prepared Statement Of Dr. Steven Lieberman Appears In 
The Appendix]

    Mr. Pappas. Thank you, Dr. Lieberman.
    We will now turn to questions and I will begin by 
recognizing Chairman Takano for 5 minutes.
    Mr. Takano. Thank you, Chairman Pappas.
    About a month ago the full committee held a member day 
hearing where colleagues presented their veterans policy 
priorities and I was alarmed to hear from Representative Womack 
that VA either failed to provide or was slow to provide 
relevant information to his office and to other members of the 
Arkansas delegation after firing the pathologist whose botched 
diagnoses allegedly contributed to the death or harm of 
numerous veterans.
    Representative Westerman submitted a statement for the 
record for today's hearing that echos those concerns. According 
to Mr. Westerman, the VA for months ignored his request to 
convene an administrative investigation board to examine 
possible medical center leadership failures. The investigation 
was convened only after several of the facilities senior 
leaders, including the director, had retired or quit.
    I have also heard from members of the Arkansas delegation 
that VA originally only proposed reviewing the final year of 
cases handled by this individual. That is right. VA did not 
plan to fully review all 11 years of this pathologist's 
diagnoses until after Members of Congress and the IG applied 
pressure to do so.
    Dr. Lieberman, has VA now finished reviewing all 11 years 
of this provider's practice?
    Dr. Lieberman. Yes, they have, sir.
    Mr. Takano. Great. How has VA gone about informing veterans 
whose health may have been affected who might have been 
misdiagnosed by this doctor?
    Dr. Lieberman. They have reached out to every veteran or 
their family, if the veteran was no longer available, to 
disclose to them what had happened with their loved one.
    Mr. Takano. Approximately how many veterans have been 
contacted, veteran families?
    Dr. Lieberman. Approximately 30.
    Mr. Takano. 30. Are there more to be contacted because we 
are talking about 11 years worth of cases.
    Dr. Lieberman. Those are the cases where harm may have 
occurred as a result of the provider.
    Mr. Takano. All right. I will be interested to hear more 
from your office about how you arrived at those 30 and how you 
could eliminate all of the other cases.
    Dr. Lieberman. We would be happy to meet with you to 
discuss that further.
    Mr. Takano. Thank you.
    Dr. Lieberman, when and how did the VA medical center, the 
VISN and VA headquarters become aware that at least a dozen--I 
am turning now to the question of Clarksburg, West Virginia, at 
least a dozen veterans died under suspicious circumstances over 
the course of about a year and a half. How did you become 
aware? How and when did the VA medical center, the VISN, the VA 
headquarters become aware that at least a dozen veterans died 
under suspicious circumstances?
    Dr. Lieberman. As you know this is still under criminal 
investigation and we have not had confirmed the numbers. We 
have not been informed on any specific numbers. We certainly 
were informed of what had trans--that there was a concern----
    Mr. Takano. I just want to know how you all became aware. 
How did any of the medical centers, the VISN, how did you 
become aware?
    Dr. Lieberman. The facility had concerns that this was 
going on and did a review over a year ago and they informed 
their facility leadership who, once they became aware, 
immediately called leadership at the time in VA headquarters 
and then the OIG was immediately notified also.
    Mr. Takano. My question is, is it true that they only 
became aware after the IG brought it to their attention or are 
you saying that they became aware before that--the IG got 
involved?
    Dr. Lieberman. Right before the IG became involved. The IG 
was notified very soon after leadership in VA headquarters was 
made aware.
    Mr. Takano. How did you become aware of these deaths?
    Dr. Lieberman. Personally, I heard about it without any 
details, just that there was a concern at the facility from the 
OIG.
    Mr. Takano. This is after the OIG was brought into this?
    Dr. Lieberman. I was not the leadership at the time when 
the concerns were first brought forward. When I assumed my 
leadership role is when I was notified about this.
    Mr. Takano. Okay. What actions, if any, has VA taken to 
inform veterans or their next of kin who may have suffered 
unexplained hypoglycemic events or even death at the Clarksburg 
Veterans Affairs Medical Center (VAMC)?
    Dr. Lieberman. We have not reached out to anyone as this is 
an active investigation.
    Mr. Takano. Fair enough.
    Are veterans and their families expected to rely on the 
news media for this information?
    Dr. Lieberman. They certainly have the OIG available to 
answer any of their questions.
    Mr. Takano. All right. VA is not--because of the ongoing 
investigation, you have not pro-actively made any notifications 
of the families?
    Dr. Lieberman. That is correct.
    Mr. Takano. Mr. Chairman, my time is out and I yield back.
    Mr. Pappas. Thank you, Chairman Takano.
    I would now like to recognize Ranking Member Bergman for 5 
minutes.
    Mr. Bergman. Thank you, Mr. Chairman.
    Dr. Lieberman, according to the VHA handbook, 1100.19, the 
Principal Deputy Under Secretary for Health or designee is 
responsible for ensuring oversight of VHA's credentialing and 
privileging for licensed providers.
    However, the handbook also says, ``The ultimate 
responsibility for credentialing and privileging resides with 
the facility director.''
    Can you please help me reconcile who has the ultimate 
responsibility because you are higher in the chain, the chain 
of command that is, than a medical center director, correct?
    Dr. Lieberman. Correct, sir.
    Mr. Bergman. Okay. Who is at the top?
    Dr. Lieberman. Ultimately the Principal Deputy Under 
Secretary and the Under Secretary for Health have the ultimate 
responsibility for the organization to ensure that it is done 
correctly.
    Mr. Bergman. Okay. Let me ask you a question. If you are at 
the top, you know, what are your expectations as they related 
to credentialing, and privileging, and when was the last time 
that you personally laid out your expectations?
    Dr. Lieberman. Credentialing and privileging is a critical 
aspect of screening to ensure we get the right candidates for 
our positions, although there is no perfect way to predict when 
an employee is going to be problematic. There are many checks 
and balances in this process. It starts with the H.R. 
department actually, takes a look at suitability, looks for--
every employee undergoes a background check, gets 
fingerprinted.
    Then the credentialing office begins their part of the 
review, which is what is called primary source verification 
where they double check that whatever the applicant says in 
their application is correct. They will check directly to make 
sure that they got the correct diploma, the correct training, 
the----
    Mr. Bergman. Okay. Well, you know, you could talk for a lot 
because there is a lot to do there. To use the example of the 
cataract surgery taking 2 hours when we know it should take 
somewhere between 15 and 30 minutes, depending on what type of 
procedure, whether it is a temporal incision or wherever it is.
    But the point is, you know, the ASCRS, the American Society 
for Cataract and Refractive Surgery, as well as other medical 
disciplines have, you know, have criteria for performance.
    Does the VA look to these speciality groups like the 
cataract surgeons to make sure that in the end you are doing--I 
hear you are doing the paperwork, but who is doing truly the 
hands on to make sure that the surgeon can hold the 
phacoemulsification, you know, hand piece correctly so that it 
does not suck the iris out as opposed to the lens?
    Dr. Lieberman. Dr. Cox, do you want to just talk about that 
issue?
    Dr. Cox. Sure. Thank you very much for the opportunity to 
be here today.
    Each clinical community establishes its own standards for 
quality. Ultimately, to answer your question, sir; it is the 
immediate supervisor, that surgeon, the service chief in 
ophthalmology or general surgery or dermatology or whatever 
service it is that is responsible for assuring the competency 
and the quality of the practice of the people providing that 
care in that medical center.
    As you heard, there are processes in place for ongoing 
professional performance evaluation and for peer review to 
conduct that assurance.
    Mr. Bergman. When is the last time that somebody got called 
before a board of their peers for review and was, shall we say, 
given a thumb's down based on performance?
    Dr. Cox. Well, in the surgery community, the idea of having 
a sort of peer review or local review of one another's care is 
commonplace. Morbidity and mortality conferences are routine in 
every medical facility, including VA medical facilities, to 
review cases where there is an unexpected outcome or something 
that could have been done differently. That has helped 
providers learn from one another and assure the higher quality 
of care.
    Dr. Lieberman. Yes, just to respond, peer reviews get a 
thumb's down. Everyone has the responsibility to do these 
objectively. If the standard of care was not met, that is 
pointed out.
    Mr. Bergman. Is there, I hate to say, re-mediation or 
retraining?
    Again, in my time as a commercial pilot, if you could not 
pass your check ride you did not fly the line. You were not 
certified safe to operate that aircraft. You had to go back 
through training and you got a couple of chances before you 
lost your job.
    Is there such, if you will, an exact set of re-
qualification training or standards that will allow people who 
are good folks, but maybe their skill sets are not up to where 
they need--they must be to, again, to handle surgical 
instruments, is there a process?
    Dr. Cox. Well, you are exactly right, sir. It is a 
requirement that everybody be monitored in this way and the 
process depends on the specifics of each case. Each one is 
handled individually.
    It may be determined that additional training or retraining 
is the remedy. It may be something like a lesser remedy, more 
close scrutiny or more frequent oversight. As Chairman Pappas 
suggested earlier, having another surgeon directly observe the 
care of that surgeon under scrutiny in the operating room.
    Then in egregious cases where the provider's performance 
can not be improved after additional training or scrutiny of 
that type, then that is when we get into the question of taking 
action against the person's privileges to suspend them, limit 
them, or even to revoke them.
    Mr. Bergman. Well, again, what this committee looks for, 
subcommittee looks for is examples of oversight on your part. 
These are tough decisions and tough things to have to tell 
professionals, you did not make the cut. There is no pun 
intended in that at all. I mean, the idea is that you need to 
get better before we let you into an operating room or into 
whatever level of care you are providing.
    Dr. Daigh, you have raised to my staff that there is a lack 
of direct observation of providers when they are under a focus 
professional practice evaluation, the FPPE. What could be 
missed if a provider's documents are reviewed, but they are not 
directly observed?
    Dr. Daigh. Thank you, sir, for the question.
    I think in the ophthalmologist's case I think it is pretty 
clear that if at the beginning of this individual's practice 
one had simply gone to the OR, if they were already a competent 
ophthalmologist, and observed this individual provide surgery 
for a day or 2, you would probably come to the conclusion that 
this person should not be privileged to practice medicine at 
the hospital that they practiced.
    I think it is a missed opportunity, whether we are talking 
about colonoscopies or surgical procedures or the 
interpretation of slides or images to not test whether an 
individual new to your hospital with the prior practice coming 
in to test how well they actually can perform, as opposed to 
saying, you have wonderful degrees, you have been to great 
places, we are going to assume you can do this procedure.
    Thank you, sir.
    Mr. Bergman. Okay. I know my time is up.
    To relate it to a check ride, you just do not welcome a new 
pilot into your squadron without giving him a check ride first.
    Thank you, Mr. Chairman. I yield back.
    Mr. Pappas. Thank you.
    I will now recognize myself for 5 minutes of questioning.
    I would like to start with Ms. Silas. One of the things 
that I hope we can address today at this hearing is the status 
of the corrective actions that VA promised it would take in our 
last subcommittee hearing on this 2 years ago.
    I just want to reflect a little bit on your testimony. You 
indicated that the GAO made 11 recommendations. Among these 
recommendations include updating credentialing policies to 
establish a timeliness requirement reviewing quality of care 
concerns and to make clear that facilities must document these 
reviews.
    GAO also recommended that VHA direct its VISNs to audit 
facilities' compliance with requirements for preparing 
credentialing files, initiating and completing timely reviews, 
documenting those reviews and reporting adverse actions to NPDB 
and State licensing boards.
    Is it true that almost all of these recommendations remain 
unimplemented? If so, what are the status in getting VA where 
they need to be?
    Ms. Silas. Thank you for that question.
    Yes. Out of the 11 recommendations that we have made 
between the 2 reports, 9 of those recommendations remain open. 
The 2 recommendations that have been closed is the 
recommendation that the VISN chief medical officer document 
evidence that the VISNs are overseeing compliance with 
policies.
    When we did a recommendation follow up with the Veterans 
Health Administration in August 2019 they let us know that Vet 
Pro was modified to allow for documentation of the VISN chief 
medical officer reviews.
    The other recommendation that has been closed is the 
recommendation that QSV office should compile and disseminate 
best practices to the facilities. The Veterans Health 
Administration let us know that they had compiled best 
practices and codified some of those best practices at the 
time.
    Mr. Pappas. Well, thank you for that.
    It is my understanding that VHA's credentialing and 
privileging policies, the directive and handbook, were due for 
re-certification at the end of October 2017.
    Dr. Cox, I am wondering if I can ask you, you testified 
before the subcommittee almost 2 years ago pledging to update 
these policies and establish a VISN level oversight process.
    Can you reflect on those comments and where things stand 
today and why we have not gotten to implementation?
    Dr. Cox. Thank you, Mr. Chairman. I would be happy to.
    Since 2 years ago when I sat before this committee, there 
have been a number of steps that we have taken to strengthen 
and improve our credentialing and privileging and quality 
oversight.
    First of all, as you read in the GAO report, we completed a 
review; a focused review of over 70,000 providers in our system 
who had been improperly--to identify any who had been 
improperly hired because they had previously had a license that 
was revoked. That is a prohibition that we corrected. We 
removed 11 out of the 70,000 as a result of that review, and we 
reinforced the prohibition by providing additional training for 
our chiefs of staff and our credentialing officials at medical 
centers.
    We developed and piloted that standard auditing tool for 
VISN Chief Medical Officers (CMOs). This is now an automated 
tool that will be fully implemented before the end of this 
calendar year. It will not only provide a standard for all CMOs 
to use, but also automatically provide information about the 
summary of those reviews to the VHA Central Office Medical 
Staff Affairs office that is responsible for these policies.
    We strengthened the Focused Professional Practice 
Evaluation (FPPE) and Ongoing Professional Practice Evaluation 
(OPPE) monitoring practices by mandating that only a specialist 
from within the same specialty community can review the work of 
another provider. That had not been standard prior to 2016. Now 
it is the standard. Those specialty-specific criteria must be 
used at each facility, rather than having a boiler plate set of 
criteria for those reviews.
    We also, in cases where there is only one type of 
specialist, a solo physician, let us say the only general 
surgeon or the only anesthesiologist, in those cases we have 
put policy in place to make sure that their work is reviewed by 
somebody who is a true peer, somebody in the same specialty 
from a different facility rather than having a non-peer from 
within the same facility, even a clinical supervisor such as 
the chief of staff, for example, conduct those reviews.
    Mr. Pappas. I appreciate these steps. When do you expect 
that these policy updates will be completed?
    Dr. Cox. Well, the policy updates are in progress and one 
of the reasons that they have not been completed is because we 
are rewriting and expanding them to incorporate some of these 
strengths and strengthening activities.
    For example, we are separating the credentialing policy 
from the privileging policy and in the privileging policy 
adding additional information and guidance on how to conduct 
FPPE and OPPE.
    In the case of the credentialing policy, we are 
incorporating requirements now for telemedicine which add 
another level of complexity for assessing the credentials of 
somebody who might practice in one State, but via telehealth be 
taking care of veterans in another State.
    I expect both of these would be published by next summer.
    Mr. Pappas. By next summer of 2020?
    Dr. Cox. Yes, sir.
    Mr. Pappas. Okay. That is well beyond the date that you had 
indicated in the 2017 hearing, and I understand that these 
things can take months of review to actually get to the 
implementation stage. So----
    Dr. Cox. That is correct.
    Mr. Pappas.--we are going to continue to do follow up on 
that. I think this continues to be a critical area that 
requires our attention.
    My time is expired, so I would like to recognize the next 
member for questioning.
    Ms. Radewagen, you are recognized for 5 minutes.
    Ms. Radewagen. Hello for Mr. Chairman and Ranking Member. 
Thank you for holding this hearing. Thank you also to the panel 
for being here today.
    Dr. Lieberman or Dr. Cox, VHA Handbook 1100.19 states that 
the VISN CMO is responsible for oversight of the credentialing 
and privileging process of the facilities within the VISN using 
standardized assessment tool.
    Would you please explain what this tool is, and what data 
does this tool provide, and how are these data points utilized 
in oversight?
    Dr. Cox. The auditing tool is basically an electronic form 
that has standard criteria that will be used across all 18 
VISNs by each of the Chief Medical Officers. They will use it 
to review any clinical or competency reviews that are conducted 
at the facilities within that VISN.
    Just to put this in perspective, Dr. Lieberman mentioned 
there were 348,000 or so VA employees. 180,000 of them are 
licensed providers. We have 180,000 providers in our 
credentials data base. Of those, 65,000 of them are independent 
providers such as physicians and dentists and advanced practice 
nurses.
    One of the reasons that you do not hear about the 64,990-
plus providers that are not getting into trouble that are not 
providing substandard care is because they are caring, and they 
are competent, and they are committed to the care of veterans.
    Ms. Radewagen. Ms. Silas, in your written testimony you 
referenced a standardized audit tool that VA developed to help 
VISNs oversee reviews of clinical concerns. It appears to me 
that many of the problems are a result of facilities not 
appropriately using the tools that VHA has provided.
    I would like to hear your opinion as to what VHA needs to 
do to make sure that the tool is employed properly.
    Ms. Silas. That is correct. There is an audit tool that has 
been developed for the VISNs to oversee or at least conduct 
audits of the VA facilities.
    What we found was that during our review from 2017 that 
none of the VISN officials that we spoke with described any 
type of routine oversight. They were not using the audit tool 
consistently.
    We did make a recommendation that the Veterans Health 
Administration ensure that the VISNs were consistently using 
that tool to conduct their audits because currently right now 
the VISN or the VHA policy does not require VISNs to oversee 
the directors reporting to the National Practitioner Data Base 
or to the State licensing boards. This could also be 
incorporated into the tool and help to better ensure that there 
is oversight of the VA medical centers.
    Ms. Radewagen. Thank you, Mr. Chairman. I yield back.
    Mr. Pappas. Thank you.
    I would like to recognize Mr. Cisneros for 5 minutes.
    Mr. Cisneros. Thank you, Mr. Chairman. Thank you all for 
being here today.
    Dr. Lieberman, in your testimony you State that the VA has 
an obligation to notify State licensing boards of any 
substantial findings in substandard care performed at the VA by 
current or former licensed health care professionals. However, 
in instances in which faulty clinicians are still able to 
practice to the detriment of veterans still occurs.
    In your opinion what are the barriers in place that prevent 
the VA from reporting a clinician to the State licensing board?
    Dr. Lieberman. I will start and then perhaps Dr. Cox will 
have items to add.
    First of all, when we fail to do something in a timely 
manner, if we do not--any issues with any of the cases we are 
discussing, we study what went wrong and we identify the 
problems and we look in the given facility. But then we also 
look nationally at what we can do to improve it.
    Often, issues involved with failure for this would have to 
do with training of our staff and making sure that they are 
aware of the right way to proceed, and the timeliness and how 
they are supposed to proceed. Dr. Cox.
    Dr. Cox. First of all, let me clarify that reporting to the 
State licensing board is a separate process from reporting to 
the National Practitioner Data Bank (NPDB) and with different 
thresholds.
    Reporting to the licensing board is done whenever we have 
enough evidence that a provider may have failed to meet the 
acceptable standard of care and could have put patients at 
risk.
    The VA has no authority to take action against any 
provider's license. That authority resides with the licensing 
board. We provide them the evidence that we collect and then it 
is up to the board to determine whether to open their own 
investigation and whether to use that evidence to take actions 
such as restricting, removing or suspending a provider's 
license.
    The standard for National Practitioner Data Bank reporting 
is much higher. That can only be done after a complete 
investigation as well as all the due process that providers do, 
including a fair hearing where they can present their own 
evidence and call their own witnesses to defend themselves.
    At that point the National Practitioner Data Bank report is 
submitted by the Medical Center Director. To answer a question 
that came up earlier, it is the Medical Center Director who is 
the privileging authority and who has the sole and ultimate 
responsibility for making these decisions.
    In fact, VA does a pretty good job of policing itself. The 
basis for that statement is that over the last 3 and a half 
years, from January 2016 until June of this year we reported 
over 1,000 of those 65,000 licensed independent providers to 
the NPDB. We have reported over 1,000 people in that 3 and a 
half year span.
    These actions are taken all the time. They are difficult 
and complex cases. They require judicious decision-making on 
the part of that Medical Center Director. But that is what we 
need to do to protect the safety of Veterans.
    Mr. Cisneros. In the 2017 GAO report found that the VA 
medical center selected for their investigation did not report 
any of the providers with adverse privileges actions taken 
against them to State licensing boards despite it being 
required by VHA policy.
    Therefore, GAO recommended it be required that the VISN 
officials establish a process for oversight in ensuring the VA 
medical centers were reporting providers to the State licensing 
board and to the National Practitioner Data Banks.
    My understanding, to this date, the recommendation has 
still not been taken up even 2 years later. Why is this the 
case and why are there obstacles that prevent the VA from 
implementing this necessary oversight?
    Dr. Cox. Well, we agreed with the recommendation that it is 
the responsibility of the VISN to conduct that oversight. One 
of the reasons is, as I mentioned, 65,000 providers, 170 or so 
medical centers, so it is just not feasible to expect that any 
one person or office in Washington, DC. can do that. We have 
regional governance for that reason.
    Regarding the open GAO recommendations that Ms. Silas 
talked about, I just wanted to indicate that, you know, across 
the 2 GAO reports in question, the 2017 report had 4 
recommendations. It is true they are all still open. But it 
would not be fair to say that they have not been acted upon. 
That report was published in November 2017 and within 2 months, 
by January 2018 we had issued additional interim guidance to 
the field in lieu of a formal policy change, which is still in 
the works, and took the recommended actions.
    Two of those 4 open recommendations have to do with putting 
this in policy, so they can not be closed until we have 
published that formal policy as Chairman Pappas asked me about. 
The other 2 have to do with finalizing this automated auditing 
tool for chief medical officers which we will be rolling----
    Mr. Cisneros. Yes. I am running out of time here, but I 
would like to, if you could, Mr. Lieberman, or Dr. Lieberman, 
sorry, submit for the record, one of the things that you said 
was training. There was a lack of training as to why this was 
not happening.
    If you could submit for the record what that training 
program is and how are we going about training these directors 
of the medical centers to make sure that these requirements are 
met, that they do need to report these to the licensing boards 
and to the National Practitioner Data Bank, I would appreciate 
that.
    Dr. Lieberman. I would be happy to do that. I can just want 
to reemphasize what Dr. Cox was speaking about. Our VISN chief 
medical officers take this responsibility incredibly seriously 
and they have been going into the facilities and doing direct 
reviews and auditing, and we see this as really making a 
difference.
    Mr. Cisneros. All right. Thank you. I yield back my time.
    Mr. Pappas. Thank you.
    I would like to recognize Ms. Miller for 5 minutes.
    Ms. Miller. Thank you, Chairman Pappas, and Ranking Member 
Bergman, and thank you all for being here today.
    It is of utmost importance that we continue to provide and 
maintain the highest quality of care for the men and women who 
have served our country so bravely. The deaths at Lewis A. 
Johnson VA Medical Center in Clarksburg, West Virginia, and the 
sexual assault allegations in Beckley, West Virginia VA Medical 
Center are not only troubling, but they are unacceptable.
    As Members of Congress, it is our job to support swift and 
proper investigations to ensure that such instances never 
happen again. There have been considerable progress that has 
been made with the quality of care that our veterans are 
receiving following the enactment of the MISSION Act and 
efforts to address the veterans' suicide epidemic.
    Our service members should feel safe and comfortable 
seeking care at the VA and these events show that there needs 
to be additional oversight of clinicians, proper removal of bad 
actor and monitoring of care.
    The tragic deaths of our veterans at the Lewis A. Johnson 
VA Medical Center in Clarksburg and the sexual assault 
allegations at the Beckley VA Medical Center, once again, are 
unacceptable. We must work together to ensure the families of 
our Nation's heroes get the answers that they deserve and that 
we can work to prevent these tragic events in the future.
    I fully support the investigation into this matter and I 
appreciate the committee's interest and oversight.
    Dr. Lieberman, many of the veterans in my district are 
extremely faithful to the VA and the quality of care that they 
receive there. Do you have any suggestions on how we can take 
VA policies that are made here in D.C. and ensure that they 
make it down through the leadership ladder to guarantee that 
the individuals are aware of the policies and are implementing 
them correctly?
    Dr. Lieberman. Thank you for that question, a very 
important question.
    We take this very seriously when we implement policies. We 
are in the process of modernizing and that is a big part of our 
modernization is to ensure that we are adequately communicating 
to all levels of the organization. We start at the top and have 
national meetings, but ultimately it is spread through the 
VISNs and then down to the facilities.
    We also have through our clinical leadership, we expect 
them to communicate. We expect the communication to be 2 way. 
We have national calls by specialty, by different parts of the 
organization, nursing, clinical areas, and we talk about what 
are the challenges that the field is facing, what are their 
concerns if we are implementing a policy, making sure we get 
their input.
    We do not want everything to be, decisions to be made 
always at the top. We want to make sure that we get input from 
front line staff so that our policies can be most effective.
    Ms. Miller. I am glad to hear that.
    Dr. Daigh, what are the concerns and/or benefits of 
incorporating a direct observation policy?
    Dr. Daigh. Thank you for that question.
    I think that the direct observation in many instances 
allows an expert, for example, going back to the eye surgeon, 
to observe whether or not it is a go, no go using the airline 
language as to whether a surgeon could actually do that job or 
not.
    If you have an individual that you are going to give 
privileges to do a colonoscopy to, and you watch that person do 
the colonoscopy, and you see the same images that that person 
doing the colonoscopy is seeing, you can have a conversation, 
are they recognizing the right landmarks, are they seeing 
pathology and biopsying it appropriately or marking it 
appropriately, did they get to where they want to go to the 
cecum to call it a complete colonoscopy.
    I think that by observing and watching an individual do the 
skills they are being hired to do, you can learn a great deal.
    There are other areas where it is much more difficult. It 
is an expensive process, but I think it is one that should be 
considered and applied much more freely than it is currently in 
the VA.
    Ms. Miller. If we were to incorporate this policy, what 
would it look like in terms of staffing, timeliness and quality 
of care?
    Dr. Daigh. I do not have an answer to that. I think that 
that would require work I have not done to try to figure out 
what the staffing requirements be or what the actual 
implementation strategy would be.
    But by observing and reporting on the cases that we have 
seen recently, we are seeing evidence now that physicians are 
making errors that we did not used to see in terms of making it 
through the system and impacting a large number of veterans.
    I think it is time to consider that we start to look at the 
quality of care provided at the beginning when we hire someone 
and do a more forceful job there observing their practice in 
addition to monitoring them with not just paperwork, but with a 
data collection system that is relevant to the care they 
provide.
    For example, monitoring how much blood loss a surgeon has 
during a surgery is important, but that may not really inform 
as to whether they can do their surgery well.
    Ms. Miller. But it also is not just the physicians.
    Dr. Daigh. I agree. There are many providers in the 
hospital who--well, let me answer it this way. Nurses in 
general are required to show me that they--prove that they can 
do a skill. You are asked to suction here, suction this. You 
are asked to put a piece of equipment together to start an IV 
or to set up an IV bag.
    Physicians are often given credit for their training and 
education and experience, and I think there should be more of a 
show me attitude as they are granted the privileges to do 
skills as other people who work in the hospital are often 
required to do.
    Ms. Miller. Because there are many other people that work 
in the hospitals.
    Dr. Daigh Absolutely.
    Ms. Miller. Thank you. I yield back my time.
    Mr. Pappas. Thank you, Ms. Miller.
    I would like to recognize Mr. Cunningham for 5 minutes.
    Mr. Cunningham. Thank you, Mr. Chair, and thank you to each 
and every one of you all for coming here today. I appreciate 
it.
    Dr. Lieberman, in 2017 a constituent of South Carolina's 
first congressional district who was also a VA patient with a 
service-related mental health disability died by asphyxiation 
while under supervision of the Doran VA Medical Center. Are you 
familiar with that case?
    Dr. Lieberman. I have heard about it. Yes.
    Mr. Cunningham. Okay. I mean, speaking more generally here 
I want to use my time to discuss the VA's approach toward 
ensuring patient safety in a mental health setting, 
particularly for those patients who have been diagnosed with a 
serious mental illness.
    Can you speak briefly about the policies or safeguards that 
the VA has in place to protect mental health patients from harm 
by hospital staff?
    Dr. Lieberman. We take this very seriously, patient safety. 
We talk about this. If there is any events that go wrong, we 
are going to take a look at it and see what happened in these 
situations. Certainly, if there is a suicide, but in this case 
it was not a suicide. It was----
    Mr. Cunningham. Physical restraint.
    Dr. Lieberman.--physical restraint. Correct. We look at 
physical restraints. We monitor for that also with--under the 
recommendation of the joint commission we are supposed to take 
a look at that. We are supposed to minimize use of physical 
restraint. When something goes wrong, we have to take a look at 
it. Our mental health leadership take this very seriously, and 
do look at this, and do talk about this in national forums 
about how we can do better when something goes wrong.
    Mr. Cunningham. Are you familiar with how personnel are 
trained under these circumstances when they have an encounter 
with someone with a serious mental health issue as was in this 
case?
    Dr. Lieberman. I would like to take that for the record and 
get back to you and make sure I get you an accurate answer of 
all the details. But we do extensive training in this area.
    Mr. Cunningham. Yes. I would like to know some more details 
about the training and also who or what department in 
particular is charged with making sure that the restraint 
protocols meet certain standards. You do not have that 
information either handy I do not suppose, do you?
    Dr. Lieberman. Not today, no. We will be happy to get you 
that.
    Mr. Cunningham. Okay. As far as the personnel thing, you 
touched on this briefly before, but what processes are in place 
to ensure the personnel are screened, they are credentialed, 
and they are retrained periodically to certify that they are 
aware of VHA policy requirements relating to the safe use of 
such techniques?
    Dr. Lieberman. When we first hire people we certainly do 
extensive background checking, doing fingerprinting, making 
sure that no one has a criminal background. Depending on the 
level of the staff, if it is licensed staff we are going to 
validate that they have the correct licenses.
    We are certainly going to check their references, important 
things like that, to make sure that they do not have any 
history in the workplace showing any concern. Then we go very 
deep for our providers, making sure that everything they put on 
their application is accurate. If there is a lapse in time that 
they work, why did that have that lapse, are they physically 
and mentally healthy. We ask for--to have a medical 
recommendation about that.
    Mr. Cunningham. Okay. I appreciate it. You will supplement 
the record and provide that information as far as who is tasked 
with training them and what that protocol is and how often it 
is reviewed, correct?
    Dr. Lieberman. Absolutely.
    Mr. Cunningham. You know, obviously as we are seeing when 
our men and women return home from service, so many of their 
scars we can not see. This is becoming, you know, a difficult 
issue to deal with. But they deserve the best care that we can 
give them. I applaud the VA for what they have done, and we are 
just seeking the areas in which they can improve upon. I 
appreciate your service.
    My question to you is, what else can we as Members of 
Congress, specifically this committee, do to ensure that this 
growing area of concern, men and women with mental health 
issues, Post Traumatic Stress Disorder (PTSD), after coming 
back from doing so much for our country are awarded the care 
that they deserve and the care that they need? Are there any 
other tools from us that you would request?
    Dr. Lieberman. I really want to emphasize how dedicated, 
how well trained most of our staff are that do the right thing 
every day.
    I have a concern when we just focus on the negative that it 
actually harms the veteran who is on the fence about whether 
they should come to the VA. We have to tell both sides. We have 
to tell the good stories because we hear that veterans hear 
about these issues, which are certainly concerning, and we 
certainly have to learn from them and improve. But we also have 
to talk about the quality of care that VA has to offer and 
especially for mental healthcare. I apologize for what happened 
at Doran. That is a very upsetting issue there for that 
particular case.
    But we have to get our veterans to be willing to come to 
us, and I just get worried when we just focus on negative in 
forums that it is harming the veteran.
    Mr. Cunningham. Yes. I would say in Charleston we have a 5-
star facility and----
    Dr. Lieberman. Uh-huh.
    Mr. Cunningham.--are very proud of that facility there in 
Charleston. I think overall that that is the impression there. 
Unfortunately, though, we do have to focus on some of the 
terrible situations we are confronted with and how to make 
things better and to ensure that they do not become a pattern. 
I think that is the purpose of being here today.
    Again, I thank you for your service, each and every one of 
you all, and I would yield back.
    Mr. Pappas. Thank you.
    Mr. Peters, you are recognized for 5 minutes.
    Mr. Peters. Thank you, Mr. Chairman, and Ranking Member 
Bergman. Also, thank you for letting me waive on this 
committee. I was pleased to serve on it in the last Congress. 
As a San Diegan I really want to say how much I appreciate the 
work you all do and appreciate your commitment to our veterans.
    I also want to acknowledge that there is a lot of fine work 
going on at the VA and that the nature of our business is that 
as oversight we are going to look at some of the things that 
are not going as well.
    I wanted to come today just to get into a little bit of a 
troubling story from the San Diego VA. I recently detailed this 
story at the VA committee member day last month, but wanted to 
summarize the story here.
    The San Diego VA participated in a study examining 
alcoholic liver disease, which was one site among other 
institutions of a larger National Institutes of Health (NIH) 
funded study led by the Pittsburgh Liver Research Center at 
University of North Carolina (UNC) Chapel Hill.
    Nine patients diagnosed with alcoholic hepatitis received 
transjugular biopsies, and according to whistleblower's 
disclosures this was not the standard of care and reported this 
to the VA's Office of Medical Inspector or OMI.
    Following OMI's report the Office of the Special Counsel, 
or OSC, conducted an independent investigation and found that 
the VA's internal report was unsatisfactory.
    The Special Counsel report alleges that these samples were 
collected improperly, sometimes without patient consent, and 
could have put patients in harm's way, not that there was 
evidence that anyone was harmed, but that was their conclusion. 
The Special Counsel urged the VA to revisit its findings in the 
matter and take a truly critical look at the research being 
conducted at the San Diego VA.
    Now we know this is not the first time that OMI has 
investigated wrongdoing and has come up short in answers 
according to the Special Counsel. According to data provided by 
inewsource, which is a San Diego news outlet who has broke the 
story, when the Office of Special Counsel reviews OMI report, 
16 percent of them are found unreasonable, which is more often 
than other executive agencies.
    My colleagues here will remember the clinical neglect at 
the Manchester VA which has been mentioned. The Special Counsel 
also find OMI's reports in that instance to be unsatisfactory.
    Again, no recorded cases of risking patient safety in this 
instance. This story presents a case, though, that could have 
consequences in other settings, especially for VA medical 
centers that conduct research onsite. We want them to do that. 
We want them to pair with academic institutions. My goal is to 
strengthen the investigatory bodies that handle these types of 
allegations so that these things do not come up.
    Dr. Cox, maybe I will ask you, since you served as the 
director of the Office of Medical Inspector, how often does OMI 
review and report on medical research issues like these?
    Dr. Cox. Thank you, Congressman. I would be happy to answer 
your question.
    First of all, it is not often that the Office of the 
Medical Inspector is involved with research oversight. VA is 
unique in having a separate and independent Office of Research 
Oversight (ORO) which participated with the Office of the 
Medical Inspector in that San Diego review.
    If I may, I just would like to clarify the sequence of 
events that you described about the liver research case.
    The 2 whistleblowers at the San Diego VA Medical Center, to 
whom we are very grateful for bringing these concerns forward, 
went to the Office of the Special Counsel (OSC). They asserted 
themselves as whistleblowers with OSC. Through the standard 
statutorily guided process, the Special Counsel of the United 
States referred the matter to the Secretary of the VA, who had 
then assigned it to the Office of the Medical Inspector (OMI) 
for Investigation.
    OMI completes dozens of these whistleblower investigations 
every year. They are part of our independent internal assurance 
and oversight capability. They are the entity that can go into 
any VA medical center and conduct an investigation and collect 
evidence to determine whether the whistleblower's allegations 
are substantiated or not.
    As you indicated, when OMI did the initial investigation, 
and wrote a report of that investigation at San Diego, they 
failed to substantiate the whistleblowers' concerns. The reason 
for that, it later became apparent, is that at least 1 key 
witness was not truthful--
    Mr. Peters. Okay.
    Dr. Cox.--was not forthcoming with information. When we 
later found out about that ourselves, we took it upon ourselves 
to go back, conduct a second visit, a second investigation. 
This is after OSC had closed the initial case and said it was 
not reasonable. On the second occasion we substantiated those 
findings, substantiated that there was egregious research 
misconduct, and voluntarily submitted that second report to the 
Special Counsel of the United States, and they are now 
considering it.
    Mr. Peters. Great. I appreciate that.
    In general, do you think that OMI has enough resources to 
thoroughly handle whistleblower complaints?
    Dr. Cox. I do. You mentioned the inewsource article and we 
were able to answer questions from the investigative reporter 
before she published the article. We conducted our own analysis 
of the rate at which the Special Counsel of the United States 
finds OMI's reports not reasonable and we came up with a very 
different number.
    She asserted 16 percent. Our number is about 5 percent. 
That track record actually has substantially improved from 2014 
when the Office of the Medical Inspector was restructured, and 
we have added additional staff since then. I believe that the 
staffing levels are now at--
    Mr. Peters. I am out of time, but to the extent you would 
like to supplement your answers in writing, I would certainly 
appreciate that. Again, I appreciate you all being here.
    Thank you.
    Dr. Cox. I would be very happy to. Thank you.
    Mr. Peters. I yield back.
    Mr. Pappas. Thank you.
    I would now like to recognize Ms. Wexton for 5 minutes.
    Ms. Wexton. Thank you, Mr. Chairman, and thank you to Mr. 
Chairman and Ranking Member for allowing me to participate in 
today's hearing.
    I represent Northern Virginia here in Congress and my 
district begins just outside of Washington D.C. and goes about 
100 miles west all the way to West Virginia. Veterans in my 
district, because we do not have a VA facility of our own, they 
have the option of either going east into the D.C. VA or west 
to Martinsburg. Both of these facilities are in VISN 5 and so 
obviously the allegations or the substantiated issues at VISN 5 
are very important to me and to my constituents.
    I was really troubled to learn about the deaths at the 
Johnson Medical Center in Clarksburg, West Virginia, and the 
sexual assault allegations at Beckley, West Virginia's VA 
medical center. I am very concerned about the serious 
allegations of wrongdoing by medical personnel at the VA 
facilities in Arkansas and Georgia.
    Our veterans have sacrificed so much for our country and 
they deserve the highest quality of care, and at a minimum they 
should feel safe in our VA facilities. I think we can all agree 
about that. Unfortunately, these facilities have failed on both 
counts.
    With the benefit of hindsight we are able to see some of 
the things that went wrong, but what I am hoping we are able to 
do with today's hearing is make sure that we have the 
protections and protocols in place to make sure that these 
things do not happen again.
    I would like to focus for a moment on the role of VISNs in 
oversight of wrongdoing at these VISN 5 facilities. There have 
been reports, Dr. Lieberman, that VA employees are hesitant to 
report suspected wrongdoing in these and other incidents. I was 
pleased to hear you talk a little bit about, you know, from top 
down, but also from bottom up to make sure that the reports are 
made.
    Are VA employees trained on the appropriate chain of 
command in reporting suspected wrongdoing at the VA medical 
center level?
    Dr. Lieberman. Thank you for that question, Congresswoman.
    This is a really critical issue and that is why we are 
undertaking this high reliability organization journey where, 
as a part of being a just culture staff feel comfortable coming 
forward. They are not concerned that they are going to get in 
trouble for this, and so we are working on this.
    At the Atlanta facility, one of the biggest failures with 
that unfortunate case was the culture there was such that it 
did not come up the chain of command of what was going wrong 
there. As a response to that, we really emphasized in a variety 
of different forums, including Dr. Stone, our executive in 
charge, sent out a letter to every employee talking to them 
about the importance, that they have an obligation, a 
responsibility to speak up when they see an unsafe situation, 
that we will protect them if they come forward.
    Certainly, if some employees will never trust their 
leadership, and so we always have the backup, there are 
hotlines, OIG. We have the compliance hotline, OSC. There is 
always that. But, really, we want to get to the point in our 
own organization where everybody feels comfortable in speaking 
up.
    Ms. Wexton. It would also be good for them to feel 
comfortable that their complaints will make it up the chain of 
command and be acted upon, and they will find out what the 
results of the investigation----
    Dr. Lieberman. Absolutely. We have to lead by example and 
show them that they are making a difference in the workplace 
when they speak up.
    Ms. Wexton. Thank you.
    Ms. Silas, I was pleased to hear you talk about the GAOs 11 
recommendations and ones that are being implemented, and 
particularly with regard to the standardized audit tool.
    Now am I to understand from your answer to an earlier 
question that there are issues with the tool that is being 
rolled out right now? Is it lacking in some way?
    Ms. Silas. No. I was not commenting that there was an issue 
with the audit tool. We are still waiting for validation that 
the tool has been rolled out.
    Ms. Wexton. Have you had an opportunity to see how this 
tool works?
    Ms. Silas. I have not personally had an opportunity to see 
how the tool works.
    Ms. Wexton. Has someone with GAO had an opportunity to see 
how this tool works?
    Ms. Silas. Yes. The team that conducted the review had 
opportunity.
    Ms. Wexton. Is it your understanding from that team that 
the tool that is going to be implemented will address the 
oversight concerns that were announced in the report?
    Ms. Silas. Yes. That is correct.
    Ms. Wexton. Okay.
    Dr. Cox, I guess you were talking about the fact that this 
tool is going to be rolled out before the end of the year; is 
that correct?
    Dr. Cox. Yes, ma'am.
    Ms. Wexton. What kind of training do you have for staff in 
order to ensure that they are properly using the oversight tool 
and that it will be a part of any sort of initial intake?
    Dr. Cox. Training of both the Chief Medical Officers at the 
VISNs who are going to be the primary ones to use this tool, 
and of the credentialing officials at every VA medical center, 
is a part of the implementation strategy. That is built into 
the roll out process.
    The tool was developed and has been piloted. There were, as 
with many new electronic things, some IT glitches. We had to 
step back a little bit and fix those bugs, and that is the 
reason that it has not already been implemented. But it is on 
track to be rolled out this year.
    Ms. Wexton. You expect that for the year 2020 it will be 
fully operational and be used in the entire facility all 
throughout the VISN?
    Dr. Cox. We do.
    Ms. Wexton. Okay. Thank you very much.
    I see my time has expired. I appreciate it. I yield back.
    Mr. Pappas. Thank you very much.
    I just have a few additional questions before we close and 
I am wondering, Dr. Daigh, if I can ask one of you.
    In your testimony you talk a little bit about the 
decentralized nature of VHA and how this places significant 
responsibility, if not all the responsibility, in the hands of 
local leaders to ensure they are employing highly qualified, 
highly competent professionals.
    But time and again your teams have discovered that leaders 
have failed to carry out certain responsibilities related to 
reviewing the quality of care concerns and taking action to 
limit or revoke privileges and reporting clinicians to 
licensing boards and the NPDB.
    In your opinion should all of these responsibilities 
inherently reside at the local level? Do we have that balance 
right, or is there an opportunity here to get VISNs and VHA 
more involved in the process?
    Dr. Daigh. I think that VISNs and VHA should be more 
involved in the process. I think that sometimes there is a lack 
of knowledge as to what an evaluation would be that is proper. 
If you hire a medical specialist who is the only person in the 
hospital who does that specialty, the chief of staff may, in 
fact, know very little about the technical aspects of that job.
    I think getting larger involvement or more specific 
involvement by national leaders would be important.
    Mr. Pappas. Thank you.
    Dr. Lieberman or the VA, would you like to comment on that 
at all?
    Dr. Lieberman. I think we are, or we are moving in that 
direction. As we mentioned before, the chief medical officers 
are having much more involvement with oversight and auditing of 
the process as well as our national offices are. Certainly a 
lot of the suggestions that Dr. Daigh has mentioned we are 
taking under serious consideration and taking a look at.
    Mr. Pappas. Okay. Dr. Lieberman, one more thing before we 
close, and this has to do with the situation with the 
pathologist in Arkansas.
    One of the things that really does not sit well with me is 
that this individual completed a 3-month inpatient rehab 
program and then was returned to his position as the chief of 
pathology. He went on not only to conceal his continued 
impairment, but was also changing, you know, recommendations 
and he was believed to have falsified veterans' medical records 
in that process.
    I am wondering if you could talk broadly about the 
acceptability of an individual returning to a supervisory 
position. Shouldn't we have individuals watching this person's 
work as opposed to this individual being tasked with watching 
the work of other folks?
    Dr. Lieberman. Thank you for that question.
    In this country about 10 to 15 percent of American citizens 
will have a problem with alcohol or other forms of substance 
abuse during their lifetimes, and that is no different than 
health care providers. It is an unfortunate fact, but that is 
part of our society.
    It has been shown that for physicians that they actually 
have a very high long-term success rate with rehabilitation, 
upwards of 80 to 90 percent abstain from alcohol. It is thought 
that those individuals truly love what they do in their 
careers, and they are committed to this and they are 
successful.
    In health care, in society, individuals are given a chance. 
This individual went through rehab. Most people who go through 
rehab will not--if the allegations are true about what the OIG 
has said about this individual, this person was very trained 
and skilled and found a substance that most people in health 
care have not even heard of, and knew that this could cause 
intoxication and also would not be detectable on screening.
    I was not there or not involved with the decision, but 
certainly one could look at the decision to immediately put 
this individual back as the service chief. You might have 
decided to observe them in a non-leadership position for a 
while just to confirm.
    Again, this individual was getting repeated alcohol tests 
and they were turning out to be negative. There were no obvious 
warning signs about that initially.
    Mr. Pappas. Well, I certainly believe in second chances and 
supporting an individual's recovery is crucial, especially in 
the workplace. But I think that additional steps should have 
been taken in this case.
    I am wondering, Dr. Daigh, if you have any thoughts on that 
particular case.
    Dr. Daigh. I would like not to talk about the case at hand, 
but talk more generally. I certainly do believe in second 
chances. I do think, though, when someone has a physical 
impairment or a mental impairment, be it Hepatitis or drug 
abuse or substance abuse, and they are brought back on to 
practice medicine that there should be close oversight of the 
quality of the work they do. Whether or not they are a manager 
or not, I think that is more of a local decision. But I think 
that the care they provide post-whatever the event was ought to 
be critical and be focused.
    Mr. Pappas. Well, thank you. Thank you to our panel.
    I would like to see if General Bergman has any additional 
questions or if he would like to close.
    Mr. Bergman. The answer is both.
    Mr. Pappas. Okay.
    Mr. Bergman. One quick question. Ms. Bonjorni, you have 
been sitting there very quiet and patient for this entire time. 
I noticed that in your bio that you are certified both in human 
resource and project management.
    It is my understanding that there are organizations that 
certify credentialing specialists. Does VHA require 
credentialing personnel to be certified and, if not, has VA 
explored the benefits of requiring certification and, if so, 
what did it find?
    Ms. Bonjorni. Well, thank you for your question, sir.
    I do not believe that we have explored that, but we are 
actually in the beginning stages of a process to look at the 
organizational structure and the position and career paths for 
people who do credentialing work within VHA. That is absolutely 
a concept that we could explore to determine whether that would 
make a significant positive impact.
    Mr. Bergman. Well, you know, we are all here. You know, 
several of us have used the word just recently within the last 
minute or so we believe in second chances. We also believe that 
if--we have to look inside ourselves as an organization and 
what is it we are trying to achieve, and are our tactics, 
techniques and procedures or processes that we would use for 
ensuring that, number 1, the best quality outcome for the 
veterans, and that starts with providers who are credentialed, 
certified, re-certified from time to time to ensure that they 
are up to standard.
    I would just like to, if I can just incorporate my closing 
into this, Mr. Chairman.
    Mr. Pappas. Sure.
    Mr. Bergman. You know, again, thanks for the hearing. You 
know, it has been about 2 years since I chaired the 
subcommittee hearing on this topic. I guess to say I am not 
troubled would not be true. I am troubled that we continue to 
have the same conversations about leadership and policy 
implementation. We can and we must do better.
    I intend to work with all of you and all our other 
witnesses to leverage your experience, because you are where 
the rubber meets the road, to leverage your experiences, your 
responsibilities, to improve VA's processes for credentialing, 
privileging and quality management.
    That said, I am encouraged by the fact that several of the 
incidents referenced today reached OIG through VA employees who 
were willing to stand up and call out what they believed to be 
substandard care, substandard practitioning, if you will.
    We have had a series of hearings on the process for VA 
staff to report serious concerns, and with another one on the 
horizon I wanted to take a moment just to thank these 
individuals who have utilized the system to bring attention to 
these serious, serious issues.
    With that, Mr. Chairman, I yield back.
    Mr. Pappas. Thank you very much, General Bergman.
    Thank you as well to our panel for being here today.
    I think it is critical that we understand that we are all 
looking out for the veteran, the end-user of the care offered 
by the VA to ensure that it is top notch and to ensure that 
their health safety is always protected.
    Veterans need to trust that the VA is fulfilling its 
responsibilities for credentialing and privileging. They also 
need to know that this department is taking appropriate action 
to investigate concerns that arise about clinical care and 
remove clinicians who deliver substandard care or engage in 
misconduct.
    We as a subcommittee have a duty to ensure that VA fulfills 
all of its responsibilities and, unfortunately, I think today's 
testimony means that we have some more work to do. I am 
committed to working alongside General Bergman and to the 
members of this subcommittee as well as our congressional 
colleagues on both sides of the aisle to continue our oversight 
work and to continue to encourage the VA to be moving in the 
right direction.
    I thank you for all of your efforts. I thank the workforce 
at the VA and its providers for the care that they offer for 
our veterans day in and day out. I just hope we can continue 
this conversation and continue to understand that there is a 
sense of urgency that is there for our veterans to make sure 
that the steps that have been outlined today are implemented as 
quickly as possible.
    Members have 5 legislative days to revise and extend their 
remarks, and include any extraneous material.
    Again, thank you all for joining us today. Without 
objection, the subcommittee stands adjourned.
    [Whereupon, at 4:16 p.m., the subcommittee was adjourned.]
     
=======================================================================


                         A  P  P  E  N  D  I  X

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


                    Prepared Statements of Witnesses

                              ----------                              


                 Prepared Statement of Ms. Sharon Silas
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                ------                                


                Prepared Statement of Dr. John D. Daigh

    Chairman Pappas, Ranking Member Bergman, and members of the 
Subcommittee, thank you for the opportunity to discuss the Office of 
Inspector General's (OIG's) oversight of Veterans Health Administration 
(VHA) efforts to ensure its medical facilities are effectively 
implementing their provider credentialing and privileging (C&P) 
processes. The mission of the OIG is to oversee the efficiency and 
effectiveness of VA's programs and operations through independent 
audits, inspections, reviews, and investigations. For many years, the 
OIG has conducted reviews and investigations that have identified 
concerns with VHA's C&P operations.
    This statement focuses on barriers and challenges to VHA's efforts 
to implement programs that ensure licensed independent healthcare 
practitioners have the appropriate qualifications to provide medical 
care services within the scope of their license. The need for VHA to 
properly manage and oversee these programs cannot be understated, as 
they are key to ensuring veterans receive health care from highly 
qualified providers. Although VHA has national policies governing the 
C&P process, the decentralized structure of VHA puts significant 
responsibility on local leaders and physicians to actually execute the 
C&P process. The OIG has completed several reports recently in response 
to allegations of inappropriate or incomplete C&P processes. While the 
OIG has found general compliance with C&P processes during the course 
of recurring comprehensive healthcare inspections,\1\ other focused OIG 
healthcare reviews related to specific incidents have identified 
concerning lapses in protocols that could have or have led to patient 
harm.
---------------------------------------------------------------------------
    \1\  The OIG's Comprehensive Healthcare Inspection Program and the 
Comprehensive Healthcare Inspection Summary Report Fiscal Year 2018 are 
discussed in the background section of this statement.
---------------------------------------------------------------------------
    After providing some context for the discussion of C&P 
deficiencies, several reports are highlighted to provide examples of 
failures the OIG has identified in the C&P process.
     background on credentialing, privileging, and skill assessment
    VHA has defined procedures for credentialing and privileging ``all 
health care professionals who are permitted by law and the facility to 
practice independently--without supervision or direction, within the 
scope of the individual's license, and in accordance with individually 
granted clinical privileges.'' \2\ These healthcare professionals are 
also referred to as licensed independent practitioners (LIPs).
---------------------------------------------------------------------------
    \2\  VHA Handbook 1100.19, Credentialing and Privileging, October 
15, 2012 (This VHA Handbook was scheduled for recertification on or 
before the last working date of October 2017 and has not been 
recertified.) Healthcare professionals such as clinical pharmacists, 
nurses, and technologists are evaluated on their competency to perform 
core and specific skills and techniques, often using objective 
assessments, such as test-taking and completing simulations. These 
processes are entirely separate from the C&P process and are not 
addressed in this statement.
---------------------------------------------------------------------------
    Credentialing ``refers to the systematic process of screening and 
evaluating qualifications.'' \3\ Credentialing involves ensuring an 
applicant has the required education, training, experience, and mental 
and physical health. This process also ensures that the applicant has 
the skill to fulfill the requirements of the position and to support 
the requested clinical privileges.
---------------------------------------------------------------------------
    \3\  VHA Handbook 1100.19.
---------------------------------------------------------------------------
    Clinical privileging is the process by which an LIP is permitted by 
law and the facility to provide medical care services within the scope 
of the individual's license. Clinical privileges are specific to the 
medical procedure performed. They are based on the individual's 
clinical competence, recommendations by service chiefs (typically the 
LIP's supervisor) and the Medical Staff Executive Committee, and with 
approval by the facility director. Peer references, professional 
experience, health status, education, training, and licensure inform 
decisions about a provider's clinical competence and ability to 
successfully accomplish clinical privileges. Clinical privileges are 
granted for a period not to exceed 2 years, and LIPs must undergo 
reprivileging prior to expiration.\4\
---------------------------------------------------------------------------
    \4\  VHA Handbook 1100.19.
---------------------------------------------------------------------------
    VHA also mandates processes to check the skills of providers during 
their term of employment. A Focused Professional Practice Evaluation 
(FPPE) is a time-limited process conducted in three instances: (1) for 
all new LIPs who are requesting initial privileges or scope of 
practice; (2) when a provider requests a new clinical privilege or 
scope of practice; and (3) when issues affecting the provision of safe, 
high-quality patient care are identified. VHA requires that all LIPs 
new to the facility have FPPEs completed, documented in the provider's 
electronic profile, and reported to an appropriate committee of the 
medical staff.\5\ The process involves evaluating the provider's 
privilege-specific competencies. This may include periodic chart 
review, direct observation, monitoring diagnostic and treatment 
techniques, or discussion with other individuals involved in the care 
of patients.\6\
---------------------------------------------------------------------------
    \5\  VHA Handbook 1100.19.
    \6\  VHA Handbook 1100.19.
---------------------------------------------------------------------------
    To monitor an LIP's performance during his or her service and help 
assist in determining whether a provider will be reprivileged, VHA uses 
the Ongoing Professional Practice Evaluation (OPPE). This oversight 
process involves the service chief's evaluation of the provider's 
professional performance and includes data specific to the provider's 
practice, such as reviews of surgical cases, electronic health records, 
infection control, and drug usage evaluation. Data must be provider-
specific, reliable, easily retrievable, timely, justifiable, and 
comparable. The OPPE includes data from direct observation and reviews 
and confirms the quality of care delivered by privileged providers. 
OPPEs allow the facility to identify professional practice trends 
affecting patient safety and quality of care. The service chief is 
responsible for establishing whether a provider does or does not meet 
established criteria.
    the oig's comprehensive healthcare inspection program focus on 
           evaluating credentialing and privileging processes
    The OIG uses its Comprehensive Healthcare Inspection Program (CHIP) 
to provide cyclical, focused evaluation of the quality of care 
delivered in the inpatient and outpatient settings of VHA facilities. 
Each inspection covers a consistent and predetermined set of key 
clinical and administrative processes that are associated with 
promoting quality care across facilities. These inspections are one 
element of the overall efforts of the OIG to ensure that the Nation's 
veterans receive high-quality and timely VA healthcare services.
    OIG CHIP teams evaluate areas of clinical and administrative 
operations that reflect quality patient care, with focused review areas 
changing every fiscal year.\7\ C&P processes were evaluated in Fiscal 
Year (FY) 2018, whereas Fiscal Year 2019 and Fiscal Year 2020 have 
focused on privileging.
---------------------------------------------------------------------------
    \7\  The eight areas for Fiscal Year 2018 were quality, safety, and 
value; credentialing and privileging; environment of care; medication 
management; mental health; long-term care; women's health; and high-
risk processes. The nine areas for Fiscal Year 2019 were leadership and 
organizational risks; quality, safety, and value; medical staff 
privileging; environment of care; medication management; mental health; 
long-term care; women's health; and high-risk processes. The ten areas 
for Fiscal Year 2020 are leadership and organizational risks; quality, 
safety, and value; medical staff privileging; environment of care; 
medication management; care coordination; mental health; women's 
health; high risk processes; and veterans integrated service networks.
---------------------------------------------------------------------------
  comprehensive healthcare inspection summary report fiscal year 2018.
    In Fiscal Year 2018, OIG staff completed 51 CHIP reports, which are 
rolled-up in an Fiscal Year 2018 Summary Report. Those reports were 
based, in part, on OIG staff interviews with facility leaders and 
reviews of C&P documentation for LIPs initially hired within 18 months 
before site visits and LIPs reprivileged within 12 months before the 
visits.\8\ The OIG evaluated
---------------------------------------------------------------------------
    \8\  Comprehensive Healthcare Inspection Summary Report Fiscal Year 
2018, October 10, 2019.

      performance indicators for credentialing processes, such 
---------------------------------------------------------------------------
as current licensure and verification of primary source information;

      privileging processes, such as verifying existing 
privileges and the details of the recommendations and approvals for 
requested privileges;

      FPPEs; and

      OPPEs.

    The Fiscal Year 2018 CHIP Summary Report generally found compliance 
with requirements for C&P processes but identified concerns with the 
FPPE and OPPE processes.
    The Summary Report made four recommendations to the Under Secretary 
for Health to improve the C&P process nationally, based upon aggregate 
data collected during the Fiscal Year 2018 CHIP site visits. The first 
recommends that VHA ensure that the FPPEs are reported properly to 
committees for review. The second recommends that the FPPEs clearly 
delineate timeframes for review in compliance with VHA policy. The 
third recommends that VHA verify that clinical managers include 
service-specific data in ongoing professional practice evaluations and 
monitor clinical managers' compliance. The fourth recommends VHA verify 
that clinical managers include specialty-specific elements in 
gastroenterology, pathology, nuclear medicine, and radiation oncology 
providers' OPPEs and monitor clinical managers' compliance. The 
Executive in Charge for VHA concurred with the first, third, and fourth 
recommendations and in principle with the second recommendation.\9\ The 
Executive in Charge projected that these recommendations would be fully 
implemented by June 2020. OIG staff will monitor VA's progress.
---------------------------------------------------------------------------
    \9\  VHA concurred in principle to our recommendation that FPPEs 
have clearly delineated timeframes, noting that the Joint Commission 
describes FPPEs as focusing on either a period of time or a certain 
number of procedures for infrequent activities.
---------------------------------------------------------------------------
             credentialing & privileging process breakdowns
    Ensuring that VHA providers have the training and education to care 
for the veterans they serve is imperative in the delivery of high-
quality health care. Without effective implementation of the 
credentialing process, veterans are at risk of receiving care from 
providers who are not appropriately licensed, adequately skilled, or 
trained. Despite the importance of credentialing, OIG reports, such as 
the following, have documented breakdowns when VHA staff have not 
actually verified and obtained the required documentation or confirmed 
the accounts of job applicants' references.
leadership failures related to training, performance, and productivity 
  deficits of a provider at a veterans integrated service network 10 
                           medical facility.
    In December 2018, the OIG became aware of allegations of 
mismanagement, waste of funds, and safety risks at a Veterans 
Integrated Service Network (VISN) 10 medical facility.\10\ A 
complainant alleged an ophthalmologist lacked training, provided 
substandard care, and failed to meet productivity expectations. In 
spite of these reported concerns, the facility's chief of staff 
intended to reappoint the surgeon following the probationary period.
---------------------------------------------------------------------------
    \10\  Leadership Failures Related to Training, Performance, and 
Productivity Deficits of a Provider at a Veterans Integrated Service 
Network 10 Medical Facility, September 24, 2019.
---------------------------------------------------------------------------
    The OIG substantiated the surgeon lacked adequate training to 
perform cataract and laser surgery as the surgeon did not 
satisfactorily complete an approved residency training program, was 
ineligible for board certification in ophthalmology, and did not meet 
the facility's ophthalmologist hiring requirements. Additionally, the 
OIG found several C&P activities that did not comply with VHA policy. 
Facility staff could not explain to the OIG why primary source 
verification was not obtained from all foreign educational institutions 
the surgeon listed in the credentialing paperwork, and staff did not 
document when attempts to do so were unsuccessful. In addition to 
documentation to support claims of education and training, VHA requires 
physician applicants to provide the names of references with knowledge 
of the applicant's ability to perform the work for which they are being 
hired. Specifically, information is sought about the individual's level 
of performance, number and type of procedures performed, 
appropriateness, and outcomes of care provided. The four references the 
surgeon at issue provided were all flawed. Two non-VHA references had 
no direct knowledge of the surgeon's ability to perform cataract 
surgeries. The third could not provide actual numbers of surgeries or 
describe outcome quality. And, the fourth could not describe the 
surgeon's technical performance.
    Facility leaders continued to employ the surgeon despite 
substandard performance and staff in associated specialties expressing 
concerns about the surgeon's quality within months of hire. The surgeon 
did not consistently demonstrate the skills to assure good outcomes, 
was unable to meet surgical productivity expectations, and surgery 
times exceeded norms. For example, the chief of staff was told that the 
surgeon was taking one-to-two hours to complete a cataract surgery, as 
compared with VHA's average of 26 minutes. Retrospective clinical 
reviews by two other ophthalmologists within the same VISN reflected 
these deficits.
    Despite these ongoing concerns, the chief of staff endorsed the 
surgeon's reappointment as the facility's sole ophthalmologist. At the 
time of the interviews, facility staff told the OIG that they believed 
the surgeon would be reappointed because facility leaders needed the 
services of the surgeon's spouse, who was also a surgeon, and facility 
leaders described them as a ``package set,'' admitting that 
relationship was a consideration. As a result, for 2 years before the 
surgeon was terminated, patients were placed at unnecessary risk for 
potential surgical complications. The OIG made five recommendations 
related to C&P processes, professional practice evaluations, management 
of performance deficits, and the chief of staff's actions. OIG staff 
continue to monitor VA's progress until all proposed actions are 
complete.
              professional practice evaluation breakdowns
    In addition to being credentialed, before rendering services, the 
facility's medical leaders must determine if a provider meets the 
specific criteria for conducting procedures. Importantly, the facility 
considers the provider to be privileged only for particular medical 
procedures and must repeat the privileging process if the provider 
wishes to conduct different patient care services. Therefore, VHA 
policy dictates that providers are privileged using identified 
provider-, service-, and facility-specific privileges. A critical 
feature of ensuring that providers are delivering high-quality care is 
the focused evaluation (FPPE) and the ongoing evaluation (OPPE). Once a 
provider begins rendering care to veterans, proper use of the FPPE to 
monitor performance at the start of employment or if a question of the 
provider's skills is raised can mitigate risks. A properly executed 
OPPE is critical for VHA's determination whether it wishes to retain 
the services of a current provider. However, numerous OIG reports have 
identified a lack of diligence across VHA facilities in executing FPPEs 
and OPPEs as the following examples demonstrate.
   intraoperative radiofrequency ablation and other surgical service 
  concerns at the samuel s. stratton va medical center in albany, new 
                                 york.
    The OIG conducted a healthcare inspection in response to 
confidential allegations regarding lack of quality oversight of the 
facility's Surgery Service, including communications to patients about 
surgery complications; the peer review process; and surgery outcomes 
for a surgical oncologist.\11\ OIG's inspection revealed the facility 
did not meet VHA's C&P requirements. A lack of documentation regarding 
the surgical oncologist's supervision and competencies during the 
initial FPPE period may have contributed to the facility later not 
recognizing that the surgeon had missed diagnosing and removing tumors 
from veterans. The OIG could not determine if the surgeon was 
supervised when conducting the intraoperative radiofrequency ablation 
procedures, and there were no written evaluations of the procedures. 
The surgery manager's use of the FPPE was ineffective for practice 
evaluation.
---------------------------------------------------------------------------
    \11\  Intraoperative Radiofrequency Ablation and Other Surgical 
Service Concerns at the Samuel S. Stratton VA Medical Center Albany, 
New York, August 29, 2018.
---------------------------------------------------------------------------
    Additionally, the surgeon's OPPE was flawed. The forms contained 
incomplete data and did not address specific competencies related to 
the surgical specialty. Further complicating matters, the chief of 
surgery failed to collect sufficient data to evaluate the surgeon's 
practice and surgical outcomes. The quarterly data used by the chief of 
surgery to evaluate the surgeon's competency also contained errors over 
a 2-year period, thus failing to trigger a focused review of the 
surgeon. OIG staff could not determine if healthcare quality data or 
patient safety trends were affected by poor FPPE/OPPE processes because 
of the unreliable data. The OIG also found failures related to the 
facility's quality management. Patients were not timely notified that 
the surgeon did not completely remove tumors. Nine recommendations were 
made, and one recommendation related to establishing a process to 
track, monitor, and report on intraoperative radiofrequency ablation 
outcomes remains open.
    This report underscores the need for adherence to VHA policy that 
ongoing assessments of a provider's competence must focus on the 
specific provider and examine his or her particular skills and judgment 
as they relate to the requested privilege. To ensure thorough and 
accurate evaluations, VHA policy has appropriately mandated that 
reviews be conducted by a physician with similar training and 
privileges.
 quality of care concerns in thoracic surgery, bay pines va healthcare 
                           system in florida.
    This healthcare inspection focused on anonymous allegations 
regarding the quality of care provided by a thoracic surgeon at the Bay 
Pines VA Healthcare System.\12\ While the review did not substantiate 
that the thoracic surgeon was incompetent, the OIG identified a 
deficiency in the system's process for evaluating a surgeon's 
competency. Contrary to policy, the criteria used in the surgeon's 
initial FPPE were not privilege-specific and was inadequate to fully 
assess a practitioner's skills. The OIG recommended that the system's 
director ensure that FPPE review criteria are sufficient to evaluate 
the privilege-specific competence for thoracic surgeons.
---------------------------------------------------------------------------
    \12\  Quality of Care Concerns in Thoracic Surgery Bay Pines VA 
Healthcare System Bay Pines, Florida, August 16, 2017.
---------------------------------------------------------------------------
    The surgeon had been employed with VA long enough to have undergone 
a routine recredentialing OPPE, which was conducted by an 
administrative psychiatrist. New VHA guidance had been issued, but was 
not yet in force, mandating OPPEs be conducted by a provider with 
similar training and privileges. Based on the OIG's recommendation made 
during the site visit, the system arranged for the surgeon to be 
proctored in order to confirm whether the surgeon had the ability and 
skills. A thoracic surgeon from another VA facility directly observed 
the thoracic surgeon's operative skills and did not have concerns 
regarding his surgical technique. VHA has satisfactorily completed 
action on OIG recommendations. This report highlights the benefit of 
having performance determinations made with specificity and by an 
independent peer.
   credentialing and privileging process failures have patient care 
                                impacts
    Additional reports from the OIG further demonstrate that failures 
to execute C&P processes properly occur across the VHA system and 
affect its provision of patient care and quality management.
  facility leaders' oversight and quality management processes at the 
        gulf coast va health care system in biloxi, mississippi.
    The OIG conducted a healthcare inspection to examine the C&P 
process, as well as the facility's understanding of quality management 
practices, in response to multiple allegations of another thoracic 
surgeon's poor quality of care.\13\ A review of the surgeon's C&P files 
revealed that before hiring the surgeon in August 2013, facility 
leaders knew of malpractice issues as well as the surgeon having 
relinquished a State medical license in October 2006 to prevent 
prosecution in a disciplinary case. Still, the facility director hired 
the surgeon after the Credentialing Committee recommended the 
appointment.
---------------------------------------------------------------------------
    \13\  Facility Leaders' Oversight and Quality Management Processes 
at the Gulf Coast VA Health Care System, August 28, 2019. Two other 
allegations received were addressed in the OIG report, Inadequate 
Intensivist Coverage and Surgery Service Concerns, VA Gulf Coast 
Healthcare System Biloxi, Mississippi, March 29, 2018.
---------------------------------------------------------------------------
    Process failures continued after the surgeon's hiring. Facility 
leaders did not complete components of the surgeon's focused and 
ongoing evaluations. In addition, the OIG team found that facility 
leaders were deficient in granting and continuing the surgeon's 
clinical privileges without required evidence of competency. During the 
OIG's April 2018 site visit, the OIG team found that although the 
surgeon resigned from VHA in December 2017, the chief of surgery did 
not provide C&P staff with details regarding an exit-interview 
statement about the surgeon's failure to meet standards of practice 
until June 2018. This information was needed to inactivate the 
surgeon's C&P file.
    Facility leaders removed the surgeon in October 2017 from clinical 
care without following required processes, including notifications to 
external reporting agencies. As a result, facility leaders were unable 
to report the surgeon to the National Practitioner Data Bank and were 
delayed in reporting to State licensing boards.
    The failures to follow C&P processes with the surgeon led the OIG 
to review service file documentation for 50 other facility care 
providers who were newly appointed to the medical staff from October 
2016 through December 2017. The following table reflects deficiencies 
in facility oversight responsibilities.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

    Additionally, the OIG noted weaknesses in quality management, 
documentation of basic and advanced cardiac life support certification, 
administrative closure of electronic health record notes, posting of 
confidential data to the facility's internal website, adverse event 
reporting, completion of institutional disclosures, and administrative 
investigation board timeliness.
    The OIG made 18 recommendations related to professional practice 
evaluation processes, National Practitioner Data Bank and State 
licensing board reporting, documenting sufficient detail in committee 
meeting minutes to reflect decisionmaking, and protecting certain 
confidential information. Recommendations also centered on reporting 
events to the Patient Safety Committee, reporting surgery patients' 
deaths as required, completing proactive risk assessments, and 
institutional disclosure and administrative investigation board review 
processes. OIG staff will monitor VA's progress until all proposed 
actions are complete.
    facility hiring processes and leaders' responses related to the 
 deficient practice of a radiologist at the charles george va medical 
                  center in asheville, north carolina.
    An OIG healthcare inspection team evaluated concerns regarding 
deficiencies identified in the practice and oversight of a fee-basis 
radiologist during a 6-month tenure in 2014.\14\ The concerns were 
identified during the facility's 2018 CHIP review in response to 
questions related to the radiologist's initial C&P, the radiologist's 
deficient delivery of care, and the facility's delayed evaluation of 
the deficient care.\15\
---------------------------------------------------------------------------
    \14\  Facility Hiring Processes and Leaders' Responses Related to 
the Deficient Practice of a Radiologist at the Charles George VA 
Medical Center Asheville, North Carolina, September 30, 2019.
    \15\  Comprehensive Healthcare Inspection Program Review of the 
Charles George VA Medical Center, Asheville, North Carolina, October 
16, 2018.
---------------------------------------------------------------------------
    The OIG determined that facility leaders did not complete the C&P 
of the radiologist in line with VHA and facility requirements. First, 
the references used to approve the radiologist's request for privileges 
did not include a reference from peers and a most recent employer. In 
fact, the references were from three non-radiologist physicians and a 
non-physician radiology technician. These are individuals who are not 
``qualified to provide authoritative information regarding training/
experience, competence, [and] health status.'' The failure to secure a 
reference from the radiologist's last employer is notable given the 
radiologist had been working at a VA medical center in Altoona, 
Pennsylvania (Altoona VAMC). Second, in June 2014, the radiologist 
denied having been notified of any malpractice-related judicial 
proceedings. However, the radiologist was sent notification by the 
Altoona VAMC in January 2014 that they were named in a tort claim, with 
a separate notice sent a later in June. VHA Central Office and 
Asheville VAMC leaders explained to the OIG that they were unaware of 
these tort claims and would not have known before final adjudication of 
the claims unless the radiologist disclosed them.
    As the radiologist began providing medical services in 2014, there 
was inadequate oversight of the radiologist, most vividly demonstrated 
by the facility's failure to complete an FPPE within VHA-established 
timelines. The chief of imaging, the radiologist's supervisor, did not 
complete the FPPE for 174 days, well past the 90-day deadline. This 
failure was undetected because facility managers did not have a 
tracking system to monitor such action items. When the chief of imaging 
did finally review the radiologist's work, it was noted as 
``unsatisfactory'' with concerns about diagnostic interpretations. The 
facility also did not complete a review of the radiologist's work until 
after 2016 and did not submit an issue brief to VISN 6 leaders alerting 
them to the clinical failures until 2018, after the OIG identified the 
concerns in the CHIP review. If the facility had conducted the FPPE 
within required timelines, the radiologist could have been removed from 
service more quickly. As it happened, two patients received disclosures 
resulting from the radiologist's deficient practices. The facility also 
received help from VHA's National Teleradiology Program to assist with 
reviews of the radiologist's work, identifying dozens of other images 
that were not read to standard.
    Facility leaders failed to take proper actions to curtail the 
radiologist's practice after not renewing the radiologist's contract in 
December 2014 and did not promptly complete the subject radiologist's 
exit memorandum within 7 days as required by VHA to comply with State 
licensing boards' reporting requirements. The results were not made to 
the facility professional standards board until August 2018, 3 years 
after the required date. Due to the failure to complete the exit 
memorandum, the patient safety manager was not promptly notified to 
trigger mandated administrative reviews. After the OIG review 
commenced, the facility director issued notices in January 2019 to 
eight State licensing boards stating that the radiologist failed to 
meet generally accepted standards of clinical practice. The OIG 
subsequently made four recommendations to the facility and VISN related 
to C&P requirements, State licensing board reporting, reporting of 
adverse events, and potential administrative actions. OIG staff will 
monitor VA's progress until all proposed actions are complete.
 alleged inappropriate anesthesia practices at the james e. van zandt 
                     vamc in altoona, pennsylvania.
    In 2018, the OIG reported on C&P concerns also involving the 
Altoona VAMC in response to a complainant's allegations about the 
services provided by an anesthesiologist at the facility.\16\ The 
anesthesiologist allegedly did not follow VHA and facility policies for 
controlling medication waste and did not individualize patient 
medication dosing and used more anesthetic/sedation medication than the 
recommended guidelines for outpatient procedures. The OIG found the 
anesthesiologist used more anesthetic/sedation medication for 
outpatient procedures than the FDA-approved manufacturer's instructions 
for 17 of 20 identified patients. This OIG-directed review was 
conducted by the chief of anesthesiology at the Corporal Michael J. 
Crescenz VA Medical Center in Philadelphia, Pennsylvania. While the OIG 
found issues with dosing above the recommended guidance, OIG staff did 
not find that the reviewed patients suffered related adverse outcomes.
---------------------------------------------------------------------------
    \16\  Alleged Inappropriate Anesthesia Practices at the James E. 
Van Zandt VAMC, Altoona, Pennsylvania, July 5, 2018.
---------------------------------------------------------------------------
    The OIG examined the facility's adherence to VHA and facility-level 
privileging policies as well as reporting the provider's conduct to 
oversight bodies. Although the facility did not identify issues to 
report to the National Practitioner Data Bank or the anesthesiologist's 
pertinent State licensing board upon the anesthesiologist's discharge 
from employment, the OIG recommended that the facility should 
reevaluate if the provider should be reported for the practice of 
administering medications inconsistent with FDA-approved manufacturer's 
instructions.
    Facility leaders did not provide oversight of the anesthesiologist 
according to VHA and facility privileging and ongoing monitoring 
policies. When facility leaders renewed the anesthesiologist's 
privileges in 2017, the privileges were not facility-specific, which is 
a key component of privileging. The anesthesiologist's privileges 
included management of patients under general anesthesia during 
surgical and certain other medical procedures and supervision of 
critically ill patients in special care units, which the facility does 
not have. Therefore, facility leaders should not have granted those 
privileges to the anesthesiologist.
    Additionally, the anesthesiologist's OPPE did not include 
monitoring of drug usage, which is a relevant, provider-specific data 
element. The reason for this was unclear; however, a review of drug 
usage data may have identified a pattern of the anesthesiologist 
prescribing anesthesia medications inconsistent with FDA-approved 
manufacturer's instructions, which increased the patients' risks of 
respiratory and cardiac arrest and/or failure. The OIG made four 
recommendations, which are now closed. The facility subsequently 
reported the anesthesiologist to the National Practitioner Data Bank 
and State licensing board.
                national and local oversight weaknesses
    Many of the issues identified in the cited OIG reports are united 
with common themes of management and programmatic failures. Many of 
these failures are due to ineffective oversight from regional and 
national leaders. The OIG has not found evidence that national leaders 
are actively engaged in the determination, collection, and analysis of 
standardized quality-related data. The OIG has also found that local 
leaders do not always have tools to track and follow-up on completion 
of provider evaluations. These gaps can lead to situations in which 
local leaders receive actionable information later than desired to 
promptly resolve problems.
    Additionally, because VHA first uses a local peer to review a 
clinician's performance, smaller facilities that have few specialists 
can be at a disadvantage. The reviewing clinician may be placed in the 
awkward position of attempting to review medical decision-making 
without the requisite skills or education. When VHA medical facilities 
face physician staffing shortages, this problem intensifies as the 
clinician is required to devote time to conducting the review in 
addition to their daily tasks, such as accomplishing their patient care 
duties.
    The C&P issues reported by OIG should not be discounted as isolated 
events expected across a large system. Rather, changes should be 
considered to the C&P processes by requiring LIPs to demonstrate the 
skills required to perform specific clinical activities. For example, 
during the FPPE process, the regular use of direct observation of 
clinical procedure performance and increased use of simulation centers 
would better demonstrate that a clinician will provide high-quality 
medical care. VHA should also consider appointing a national leader for 
each specialty whose primary responsibility is to ensure the highest 
quality practices across all facilities, with active involvement in 
overseeing the FPPE and OPPE processes. The need for changes in how 
local, regional, and national leaders conduct evaluations and 
communicate about practitioners who should not be providing care to 
veterans could not be more urgent given the missteps and delays the OIG 
has observed.
                               conclusion
    VHA's goal is to deliver high-quality, timely health care to 
veterans. To achieve this objective, it is clear that VHA must improve 
its efforts to ensure physicians have the training, skills, and 
techniques they claim to possess. The OIG has repeatedly identified 
deficiencies in the management and execution of the C&P processes that 
inevitably lead to mistakes and failures in the delivery of health care 
to veterans. To more efficiently use its resources in delivering health 
care, VHA must continue to implement OIG and other oversight 
recommendations and properly staff clinical positions to provide the 
capacity needed for properly conducting the C&P processes.
    Mr. Chairman, this concludes my statement. I would be happy to 
answer any questions you or other members of the Subcommittee may have.
                                 ______
                                 

               Prepared Statement of Dr. Steven Lieberman

    Good morning, Chairman Pappas, Ranking Member Bergman, and Members 
of the Subcommittee. I appreciate the opportunity to discuss VA's 
processes for ensuring the competency and quality administration of 
care by the health care professionals we employ. I am accompanied today 
by Dr. Gerard Cox, Deputy Under Secretary for Health for Organizational 
Excellence (VHA) and Ms. Jessica Bonjorni, Acting Assistant Deputy 
Under Secretary for Health for Workforce Services.
                              introduction
    VA is committed to ensuring that Veterans receive safe, high-
quality health care. VA serves over 320,000 Veterans every day. The 
vast majority of VA employees are committed to doing the right thing 
while serving America's Veterans. In fact, as VA recently testified, 
many of VA's providers are called to serve in our medical facilities 
not because of money or acclaim, but because of their commitment to 
VA's mission to care for Veterans.
    As in any large health care system, we must also face the 
unfortunate reality that some individual employees have not upheld that 
commitment. The actions of those few are deeply troubling. It is also 
deeply troubling that those actions might taint the reputations and 
undermine the good work of the nearly 348,000 VHA employees who run our 
medical facilities and take care of Veterans every day. These few 
people do not represent VA's values, and we will continue to hold 
accountable those who would commit crimes or provide poor care in our 
facilities.
    VA takes great care to screen employees for their character and 
suitability and for their eligibility for a personal identity 
verification credential before bringing them on duty, including 
conducting criminal background checks. We also conduct extensive 
scrutiny of prospective health care providers' medical credentials, and 
after hiring, we monitor those providers to ensure they are clinically 
competent and are providing safe, high-quality care. While we must do 
everything we can to make sure our employees are well-qualified and 
suitable for their jobs, we also recognize that we cannot guarantee 
that VA will never hire another person who fails to uphold VA's 
commitment to Veterans. What we have done in the face of that reality 
is establish a system in which wrongdoing can be identified quickly and 
swift action can be taken to minimize the harm to Veterans. We will 
learn everything we can from the problems that have given rise to this 
hearing to strengthen our system. We have also found in our reviews of 
recently publicized cases that the monitoring and reporting systems we 
have in place typically work well in identifying potential 
inappropriate behavior or inadequate care earlier than before, and that 
VA's leaders do, in fact, take quick action to ensure that patients are 
safe.
                      screening: background checks
    VA requires that all individuals working directly with Veterans are 
thoroughly and properly vetted. For all potential employees, this 
starts with a background screening before entering on duty. The 
background screening process applies to all applicants, appointees, 
employees, contractors, affiliates, and other individuals who require 
physical or electronic access to VA information or information systems 
to perform their jobs.
    VA conducts different levels of background checks on employees 
based on their position description, function, and scope of practice, 
as required by Office of Personnel Management (OPM) rules. Most front-
line facility-level positions, including direct patient care positions, 
require a Low-Risk/Non-Sensitive Investigation. Upon receiving a 
conditional offer of employment, selected applicants undergo pre-
screening for an interim suitability and personal identity verification 
(PIV) credentialing determination consisting of a review of their FBI 
criminal check results and employment history. If this review is 
favorable, the applicant is given a firm offer of employment. If 
derogatory information exists and cannot be mitigated, the subject's 
job offer is normally rescinded.
    Following the pre-screening and interim suitability and 
credentialing determination, a full background investigation, that 
includes work and criminal history, etc., is initiated. DoD's Defense 
Counterintelligence and Security Agency (DCSA) conducts these 
background investigations and returns them to the local VA facility for 
adjudication. An OPM-trained suitability adjudicator in the facility 
Human Resources Office reviews all investigative information and must 
establish a reasonable expectation that the person's employment or 
continued employment either would or would not protect the integrity 
and promote the efficiency of the Department. When there is a 
reasonable expectation that a person's employment would not do so, the 
person is found unsuitable. The process to remove an unsuitable VA 
employee varies depending on the length of the subject's employment 
(probationary vs. non-probationary).
                     credentialing and privileging
    The next step in hiring a health care professional is the 
credentialing process. VHA's medical credentialing and privileging 
policies apply to all licensed health care professionals, including 
physicians, dentists, advanced practice nurses, physician assistants, 
and clinical pharmacists who work in any VA health care facility, as 
well as those in Veterans Integrated System Network (VISN) offices and 
the VHA Central Office.

      Medical Credentialing is the process of obtaining and 
verifying documents related to the applicant's professional education, 
licensure, and certification, (such as copies of medical licenses, 
medical or nursing school diplomas, board certification certificates, 
etc.). The medical credentialing process also includes a review of the 
applicant's health status; previous experience, including any gaps in 
training and employment longer than 30 days; professional references; 
malpractice history and adverse actions; and/or criminal violations, as 
appropriate. These requirements are established by The Joint 
Commission, which accredits most health care facilities across the 
U.S., including all VA Medical Centers (VAMC). VA does not make firm 
employment offers to health care professionals until the medical 
credentialing process is completed.
      Privileging is the process by which the authorized 
official at an individual VAMC (generally the Medical Center Director) 
determines whether to grant clinical privileges to permit a licensed 
independent practitioner to provide medical care services within the 
scope of his or her licensure, training, and experience. According to 
The Joint Commission's standards, the decision whether to grant 
clinical privileges to an applicant to the medical facility's medical 
staff must be made at the local facility level.

    Every applicant for a position on the medical staff of a VA 
facility is required to disclose information about any history of 
malpractice claims, adverse actions taken against licensure or 
privileges held in a previous position, prior misdemeanor or felony 
convictions, etc. VA's mandatory screening procedures also require 
queries of the appropriate State Licensing Board (SLB), the Federation 
of State Medical Boards, and the National Practitioner Data Bank (NPDB) 
to determine whether an applicant has been reported to any of these 
entities due to substandard care, professional misconduct, or 
professional incompetence. VA verifies the information disclosed by the 
provider to ensure the hiring official has a full picture of the 
applicant from an objective source.
    All information obtained through the medical credentialing process 
must be carefully considered before appointment and privileging 
decision actions are made. Hiring officials take this process very 
seriously when considering a potential employee. The local Medical 
Center Director has the ultimate decision authority about whether an 
employee should be hired and whether clinical privileges should be 
granted, based on the outcome of the medical credentialing process.
                     monitoring and investigations
    VA has an obligation to reasonably ensure that its health care 
staff meet or exceed generally accepted professional standards for 
patient care and has the obligation to alert those entities charged 
with licensing health care professionals when there is serious concern 
about a licensed health care professional's clinical practice.
    This obligation includes monitoring the care that our providers 
deliver in medical facilities. It also includes notifying SLBs of any 
substantiated findings of substandard care performed at VA by current 
or former licensed health care professionals and responding to 
inquiries from SLBs concerning the clinical practice of those 
professionals.
    Whenever concern arises about a privileged provider's ability to 
deliver safe, high-quality patient care, the first consideration is 
whether that provider presents an imminent danger to the health and 
safety of any individual based upon the knowledge at hand. If there is 
an imminent danger, the VAMC Director invokes a summary suspension of 
clinical privileges which immediately removes the provider from patient 
care to ensure patient safety. Summary suspension can range from 
suspending a single privilege to perform a specific procedure to 
suspension of all clinical privileges; however, the purpose of summary 
suspension is to afford time for a focused review of the clinical care 
concern or issue. This action can be taken by a facility Medical Center 
Director immediately, allowing VA to ensure Veterans' safety without 
delay to conduct an investigation. Providers receive a notice of 
suspension that includes their due process rights to respond.
    The focused clinical care review generally takes the form of a 
retrospective review of the care that has been provided in the clinical 
care area of concern. Retrospective reviews are completed by 
independent health care professionals of the same specialty who hold 
privileges in the area being reviewed. These specialists provide an 
expert opinion regarding whether the provider under scrutiny has met 
the standard of care. The facility's clinical leaders then decide on 
whether action should be taken based on the findings of the review. If 
a review of the findings does not identify a risk to patients, 
appropriate action may involve intensive monitoring of the provider's 
practice for a defined period. In more serious cases, an adverse 
privileging action may be warranted, such as reducing, restricting, or 
denying privileges or, in the most egregious cases, revoking all 
privileges and terminating employment with VA.
                 npdb screening and ongoing monitoring
    As described above, all applicants are thoroughly screened, 
including a review of any reports made to NPDB. Each report is 
individually reviewed in detail and primary source information is 
obtained from the reporting entity to outline the circumstances that 
led to the report. If information obtained through this process calls 
into question the professional competence or conduct of an individual 
applying to VA, the selecting official and facility leadership review 
the facts and circumstances to determine what action would be 
appropriate, possibly including non-selection.
    After being appointed to the medical staff of a VA facility, all 
privileged providers are enrolled in and monitored through the NPDB 
Continuous Query Program. VA mandated this voluntary, proactive measure 
so that we receive immediate alerts whenever any privileged provider is 
reported by any entity to the NPDB, including reports that arise from 
problems that occurred prior to VA employment. Once the alert is 
received, VA expeditiously obtains primary source information related 
to the report entered and takes immediate action as needed. For 
example, if an NPDB report is entered by an SLB, VA can review the 
information obtained from the reporting licensing board and determine 
if a licensure action has been taken which would immediately disqualify 
a provider from a VA appointment in accordance with section 7402(f) of 
title 38, United States Code. The review of licenses and determination 
of qualification for employment is made by the facility Human Resources 
Officer in consultation with the District Counsel Attorney. VA takes 
the matter of license revocation very seriously, as we continue to keep 
sight of the well-being of our Veterans in our care.
    We note that VA is like all other health care systems in this area. 
All accredited VAMCs and systems adhere to Joint Commission standards 
for medical credentialing and monitoring care. If there were some way 
of entirely avoiding misconduct or poor clinical care, there would be 
no need for the industry to use an NPDB, or for SLBs to have review 
procedures. We are, unfortunately, unable to predict and account for 
every issue that may arise, which is why we must respond quickly and 
comprehensively whenever Veterans' safety might be in jeopardy.
    In 1980, VA established the Office of the Medical Inspector (OMI) 
to assess and report on quality of care issues within VHA. In Public 
Law 100-322, Veterans' Benefits and Services Act of 1988, Congress 
expanded the functions of OMI and assigned the VA Inspector General an 
oversight role. This law addressed the Department's quality assurance 
activities, upgraded and expanded OMI, and increased its number of 
employees to ensure independence, objectivity, and accountability.
    As an integral element of VHA's oversight and compliance program, 
OMI is responsible for assessing the quality of VA health care through 
independent, objective, and thorough health care investigations. In 
2014, following the VA wait times crisis, the Acting Secretary of 
Veterans Affairs appointed Dr. Cox as the Interim Medical Inspector. 
Under his leadership, we restructured the policies, procedures, and 
human resources of OMI.
                               conclusion
    VA remains committed to earning Veterans' trust in our system and 
will continue to do everything we can to ensure that our patients 
receive appropriate and safe health care. Although VA cannot always 
foresee and prevent wrongdoing, we will continue to monitor patient 
care diligently and take quick action when Veterans' safety is at risk. 
Mr. Chairman this concludes my testimony. My colleagues and I are 
prepared to respond to any questions you may have.
    
=======================================================================


                 Additional Submissions for the Record

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


                       Submissions for the Record

                              ----------                              


        Prepared Statement of The Honorable Rick Crawford (AR-1)

    Chairman Pappas and Ranking Member Bergman, thank you for holding 
this hearing regarding the Veterans Affairs health system.
    I would like to thank the committee for its attention to the 
disturbing matter that occurred in the Fayetteville VA Hospital from 
2015 to 2018.
    Due to the failure of leadership within the Veterans Health Care 
System of the Ozark (VHSO), Dr. Robert Morris Levy's irresponsible 
actions have resulted in over 3,000 misdiagnoses and 15 deaths.
    Our great Veterans deserve the best care and should have never been 
exposed to the personal tragedies that resulted from Mr. Levy's 
malpractice.
    We should all use this terrible situation as an opportunity to 
review and amend rules and regulations within the Department of 
Veterans Affairs to ensure that our Veterans receive quality healthcare 
and accurate diagnoses.
    While I am not a member of the Committee on Veterans Affairs, I am 
committed to providing support for any proposals that will help the 
Department of Veterans Affairs avoid similar tragic situations in the 
future.
    One important change to consider would be to prohibit individuals 
from taking supervisory roles immediately after being rehabilitated 
from substance abuse.
    I believe that many common-sense changes can be made to ensure that 
this never happens again.
    I would especially like to thank the Department of Veterans Affairs 
Office of Inspector General for its extensive investigation that 
resulted in Federal charges.
    Again, thank you Chairman Pappas and Ranking Member Bergman for 
your time and attention to this matter.
                                 ______
                                 

         Prepared Statement of The Honorable French Hill (AR-2)

    Chairman Pappas, Ranking Member Bergman, and Members of the 
Committee:
    I appreciate the opportunity to submit this statement in support of 
this critical hearing today examining patient harm at U.S. Department 
of Veterans Affairs (VA) medical facilities.
    As you may be aware, in my home State, Dr. Robert Morris Levy was 
chief pathologist at the VA Medical Center of the Ozarks in 
Fayetteville, Arkansas, and was recently indicted for allegedly 
botching diagnoses for an estimated 3,000 veterans between 2005 to 
2017, and responsible for at least 15 deaths.
    This alleged gross negligence by a physician charged with caring 
for our veterans is a disturbing revelation and a clear failure to 
uphold the VA's mission to the men and women who served our Nation in 
uniform.
    Congress has provided the VA with the necessary tools to remove bad 
actors, such as Dr. Levy. Failing to dismiss physicians and any other 
employees whose work is unsatisfactory does a disservice to our 
veterans.
    Dr. Levy's case is especially troubling, as his history of issues 
with substance abuse and run ins with the law were evident for years.
    Nine years before VA even hired him in 2005, he was arrested and 
convicted of drunken driving. He hid his abuse at VA for a decade until 
an employee reported him to supervisors as intoxicated in 2015, but Dr. 
Levy denied the allegation and no further action was taken.
    In 2016, Dr. Levy was found to be intoxicated when he was called to 
the radiology department to assist with a biopsy. His blood alcohol 
level was at 0.4, five times the legal limit in Arkansas of 0.08. He 
was suspended and entered a 3-month inpatient treatment program, at 
taxpayer expense.
    After completing treatment, Dr. Levy returned to his work at VA, as 
if nothing happened.
    In 2017, Dr. Levy was sent home after appearing drowsy and 
``speaking nonsense phrases'' when he arrived to chair an October 2017 
meeting of the hospital's tumor board. The hospital was forced to 
cancel multiple surgeries and medical procedures that required a 
pathologist.
    His clinical privileges were suspended but he was allowed to return 
to nonclinical work. Again, allowing this reckless behavior to 
continue.
    It would be almost an entire year before VA began a deeper dive of 
his work, finding a number of misdiagnoses.
    In March 2018, Dr. Levy was arrested for driving under the 
influence after local police spotted him driving erratically in a post 
office parking lot. He was finally fired by VA the next month.
    I was proud to support the VA Accountability and Whistleblower 
Protection Act of 2017, which was signed into law on June 23, 2017, and 
instituted necessary reforms at the VA by providing the Secretary with 
the authority to remove, demote, or suspend any VA employee, including 
Senior Executive Service (SES) employees, for performance or 
misconduct.
    This would have proved vital to Dr. Levy's case, who had a 
staggering record of being impaired on the job and yet continued to 
evaluate patients even after numerous complaints against him.
    My district is home to many of our brave veterans and service 
members at Little Rock Air Force Base and Camp Robinson, and they 
deserve to know that VA is giving them the best possible care.
    I share your commitment to rigorous oversight to protect the men 
and women who sacrificed and served our country and will hold those who 
break the law and undermine the mission of the VA accountable.
    Thank you again for holding this critical hearing and putting the 
care of our Nation's veterans above all else.
                                 ______
                                 

         Prepared Statement of The Honorable John Lewis (GA-5)

    Good afternoon, Chairman Pappas, Ranking Member Bergman, and 
Members of the Subcommittee.
    Thank you for inviting me to testify on this important matter. I am 
grateful that the Subcommittee is holding this hearing. It is critical 
that safe, quality, consistent, compassionate patient care become a top 
priority at all VA Medical Centers. A United States Veteran should 
never experience what Airman Joel Marrable and his family endured.
    The Atlanta Veterans Affairs Health Care System (VAMC) is one of 
the largest in the country. In Atlanta alone, there are more 18,000 
Veterans, who may rely on the services provided at VA medical 
facilities. The Atlanta VAMC is one of eight Department of Veterans 
Affairs (VA) medical facilities that comprise the VA Southeast Network. 
This expansive network serves 1.4 million Veterans in Georgia, South 
Carolina, and Alabama. This is the third largest veteran population in 
the country.
    Many Veterans throughout the region rely on the Atlanta VAMC to 
provide general and service-related health care. Located in Decatur, 
Georgia, the Atlanta VAMC oversees community-based clinics and health 
facilities throughout Metro Atlanta and surrounding areas. The Eagle's 
Nest Community Living Center is one of several facilities in the VA 
Southeast Network responsible for providing Veterans with long term 
care. Fulfilling their mission should require the highest level of 
attentive and empathetic care.
    The importance of these facilities and the expectation of quality, 
safe care are the reasons that Air Force Veteran, and cancer patient, 
Joel Marrable's case is so horrific. When news broke last month 
detailing how Airman Marrable endured more than 100 ant bites while in 
care at the VAMC's Eagles Nest Community Living Center, a facility in 
my district, I was disgusted and heartbroken.
    I want you to close your eyes. Imagine that after serving your 
nation around the world, you face the greatest battle of your life--the 
fight against cancer. It is a constant struggle, and the pain seems 
insurmountable. When you feel as if the suffering could not get any 
worse, you are attacked by an infestation of ants--covering your body 
and your room, biting you constantly-- as you fight for your life.
    This is what Airman Marrable endured. This is how a daughter 
discovered her father. This was their lasting memory of Atlanta VAMC. 
The staff told his daughter, Ms. Laquana Ross, that they thought her 
father passed away because of the magnitude of ants covering his body. 
I cannot comprehend how a person could be so neglected that the staff 
could not tell if he was still alive.
    The record should be clear--the Atlanta VAMC failed Airman Marrable 
in his final days. It was Ms. Ross who discovered that her father was 
still alive and still fighting for his life. It was Ms. Ross who 
insisted that her father to receive the care and dignity that he 
deserved in his final hours. A clean room, a bathed body, a bed without 
biting bugs, and regular health checks are not extraordinary 
expectations. These are the basics, and the VAMC failed to provide 
them.
    In Airman Marrable's last days, his family could not even comfort 
him without causing pain. Ms. Ross recalled that her father was in so 
much agony from the ant bites that he would flinch whenever she touched 
his swollen hands. Mr. Chairman, these were his final moments. This was 
the care that his government gave Airman Marrable as he transitioned 
from this world.
    When something is not right, it is our duty as Members of Congress 
to speak up and speak out. We have a moral obligation to do what is 
just and what is fair. Mr. Chairman, I shared my concerns with 
Department of Veterans Affairs Secretary, Robert Wilkie, and Ms. Ann 
Brown, the Director of the Atlanta VA healthcare system in a letter, 
which I would like to submit for the record. I am here today, because I 
want to ensure that what Airman Marrable endured never occurs again. He 
deserved better, and his country failed him and his family in their 
time of need.
    The men and women who serve and sacrifice for our country deserve 
exceptional care from an agency and their contractors whose sole 
purpose is to care for those who valiantly protected our Nation. I am 
grieved by the inept response and negligence surrounding Airman 
Marrable's care. It is appalling to know that in his last days, Airman 
Marrable and his family were left to resolve this crisis when they 
should have been afforded the opportunity to cherish their last 
precious moments together.
    Throughout my congressional district, Veterans are an integral part 
of the fabric of our community. These patriots put their lives on the 
line and their family, friends, and personal ambition on the back 
burner as they serve our Nation. They work, live, and contribute to the 
vibrancy of our country and deserve the highest level of respect and 
care.
    Mr. Chairman, similar to many congressional offices, the majority 
of my office's constituent casework concerns Servicemembers, Veterans, 
and their families.. Upon hearing of this horrific case, my District 
Office caseworkers began a desperate search to provide support and 
solace to Airman Marrable and his. family. We extended our deepest 
condolences and ensured that the Marrable family knew that our office 
was a resource in their darkest hour.
    The challenge of timely, quality, consistent service at VA 
facilities remains constant and widespread. My caseworkers are 
constantly fielding stories from frustrated and distraught constituents 
and their families. There is a sense of disarray and a lack, of 
appreciation for the important work of VA patient advocates, who are 
key intermediaries between congressional offices, the VA, and the 
Veterans. Responses to congressional inquiries languish, and those 
caseworkers and advocates who dedicate their careers to serving United 
States' Veterans and Servicemembers increasingly feel hopeless.
    I believe that the commitment to the health and well-being of our 
Veterans takes priority over politics and party lines. We must 
demonstrate that the sacrifices made by these brave men and women were 
not in vain. These women and men sacrificed selflessly, and their 
country's appreciation should be proudly displayed by the quality of 
care at every VA Medical Facility.
    As a nation and as a people, we can do better, and we must do 
better. The care our Veterans receive is a direct reflection of how our 
Nation shows gratitude to those who fight bravely to preserve our 
freedoms. Compassion, empathy, and respect should be our compass, our 
mission, and our mandate. At every opportunity, we should work 
tirelessly to correct the errors and shortcomings of the systems upon 
which they rely and strengthen the agency to support future generations 
of Veterans and their families.
    Again, I thank you, Mr. Chairman, for the opportunity to testify 
this afternoon.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                ------                                


       Prepared Statement of The Honorable David McKinley (WV-1)

    We cannot begin to understand the grief and anger the families of 
those killed at the Clarksburg VA Medical Center have felt this last 
year. To find out that your loved ones were killed while in the care of 
a hospital is unimaginable.
    The investigation into the suspicious deaths at the Clarksburg VA 
Medical Center has now gone on for more than 16-months and has left 
families with more questions than answers. It is imperative that the 
authorities conclude this investigation as soon as possible and provide 
answers to the public, closure to the families and justice to those who 
lost loved ones.
    While hindsight is 20/20, we now know that several red flags should 
have been raised soon after the deaths. At the time, many of these 
deaths did not raise suspicions, and family members trusted the VA 
hospital when they were told the deaths were natural.
    While it is clear several missteps were made, we would be remiss if 
we did not give credit to the Clarksburg VA Medical Center, for self-
reporting the suspicious deaths once a pattern was noticed.
    This incident has damaged the trust veterans and their families' 
have in the VA, and we owe it to them to find out what happened. I hope 
the committee will use today's hearing to find solutions that will 
protect our veterans and restore their belief that they are receiving 
the best quality of care possible.
                                 ______
                                 

        Prepared Statement of The Honorable Carol Miller (WV-3)

    Thank you, Chairman Pappas and Ranking Member Bergman for holding 
this hearing today.
    It is of utmost importance that we continue to provide and maintain 
the highest quality of care for the men and women who have bravely 
served our country.
    The deaths at Louis A. Johnson VA Medical Center in Clarksburg, 
West Virginia and the sexual assault allegations at Beckley, West 
Virginia VA Medical Center are troubling and unacceptable. As Members 
of Congress, it is our job to support swift and proper investigations 
to ensure that such instances never happen again.
    There has been considerable progress with the quality of care that 
our veterans receive following the enactment of the MISSION Act and 
efforts to address the veteran's suicide epidemic. Our service members 
should feel safe and comfortable seeking care at the VA, and these 
events show that there needs to be additional oversight of clinicians, 
proper removal of bad actors, and monitoring of care.
    The tragic deaths of our veterans at the Louis A. Johnson VA 
Medical Center in Clarksburg and the sexual assault allegations at the 
Beckley VA Medical Center are unacceptable. We must work together to 
ensure the families of our Nation's heroes get the answers that they 
deserve, and that we can work to prevent these tragic events in the 
future. I fully support the investigation into this matter and 
appreciate the Committee's interest and oversight.
                                 ______
                                 

       Prepared Statement of The Honorable Bruce Westerman (AR-4)

    Chairman Pappas and Ranking Member Bergman, distinguished Members 
of the Committee, and today's witnesses, thank you for hosting today's 
hearing and allowing me to submit a statement for the record.
    As many of you now know, the Veterans Health Care System of the 
Ozarks (VHSO) suffered a catastrophic failure to hold one of their 
highest-ranking providers accountable, Chief Pathologist Dr. Robert 
Morris Levy.
    Since his firing in 2018, only after he was arrested for a DUI, it 
has been uncovered that his malpractice resulted in the death of 15 of 
our Nation's veterans and 15 others whose health was irreparably 
harmed.
    An additional 3,007 errors and misdiagnosis date back to 2005. It's 
now been uncovered that Dr. Levy had a misdiagnosis rate of 9 percent. 
Over 12 times the average pathology error rate.
    In total, Dr. Levy diagnosed over 21,000 individuals and viewed 
33,902 total cases during his tenure.
    We may never know the true extent of the damage he caused, but the 
systemic problems that allowed it to occur in the first place must be 
addressed, and that starts with leadership.
    When I first learned of the issues with Dr. Levy in May 2018, I 
immediately requested more information on how veterans and their 
families would be notified of the lookback process, and what resources 
would be made available to those seeking more information.
    The VA did set up a dedicated phone line for patients, but when my 
staff tested it, they sat on hold for over 22 minutes.
    Imagine learning from a televised press conference that you may 
have had your cancer misdiagnosed, and you call a number to learn more 
about what you can do, only to wait almost half an hour before you can 
talk to anyone.
    That's simply unacceptable, and the problems didn't end there.
    We requested for months that the VHSO put together an 
Administrative Investigative Board (AIB) to internally review the 
processes and problems that enabled this to happen, but it wasn't 
completed until September 17, 2018, almost 4 months after first 
learning of the problems with Dr. Levy.
    At that time, many of the senior leadership staff had retired or 
quit, limiting the ability for the Board to conduct a substantive 
investigation.
    Furthermore, we were told that the AIB was limited to assessing the 
validity of the allegations against Dr. Levy related to quality of 
care, and that they could not investigate the quality of care and 
oversight because the Office of the Inspector General (OIG) was 
investigating these issues.
    My staff inquired with the OIG's office to assess if this was in 
fact true, and we were told the OIG does not believe they would have 
directed the VHSO to avoid those topics.
    I would like to know why the AIB took so long to be commenced and 
completed and why, or if, it was limited in scope per the VHSO's 
communication to my office?
    I also have concerns regarding the VHSO's decision to first only 
conduct a short retrospective review of Dr. Levy's cases.
    It took the VA Inspector General requesting a full, comprehensive 
review to be done instead of the VA making this decision on their own--
potentially harming the health of veterans who received care from Dr. 
Levy at other stages of his career.
    The lookback process seems as if it was made up as it went along 
without any proven and tested systems in place to ensure each and every 
case was reviewed in depth and in a timely manner.
    Does the VA have a standard lookback or review process for cases 
involving medical malpractice, and if so, was it properly followed?
    Additionally, why was Dr. Levy allowed to immediately return to a 
position of authority after rehabilitating from substance abuse?
    This allowed Dr. Levy to conceal misdiagnosis that may have been 
caused by his substance abuse. He was able to remove and delete cases 
that may have shown evidence of misdiagnosing patients, and even 
falsely claim a second physician had reviewed his cases for quality 
control.
    The VA must look at the processes and procedures for reinstating 
physicians after substance abuse issues to ensure they do not relapse 
or hide medical mistakes without proper oversight.
    Another issue we discovered was the length of time it took for VISN 
Director Skye McDougall to put a permanent Medical Center Director in 
place following the retirement of Dr. Worley in June 2018, the previous 
Medical Center Director and supervisor to Dr. Levy.
    From communications my staff had with Director McDougall, she 
stated that a replacement candidate had been submitted for approval in 
May 2018--yet this makes no sense because Dr. Worley was still there at 
the time.
    That candidate, Mr. Kelvin Parks, was not formally approved until 
the end of November 2018.
    Why did it take 6 months to hire a permanent director, one who had 
been serving as an Interim Medical Center Director the whole time, 
during a time when strong leadership was needed?
    And was a proper interview process followed that included other 
candidates to assess who may serve the VHSO best?
    Additionally, what processes are in place to ensure a timely and 
efficient hiring process is in place, and what can be done, whether 
administratively or legislatively, to ensure the hiring process can be 
improved?
    Although more issues were uncovered, the examples I present here 
today show a pattern of leadership failures when problems arise, and we 
need to ensure these failures don't happen again.
    The members of America's Armed Forces are promised care for life 
due to the sacrifice they make to serve our Nation. We owe it to them 
to ensure that promise is kept, and that the care they receive is of a 
high quality.
    The men and women that work at the VA are honorable, hard-working 
and highly qualified medical personnel who provide our Nation's 
veterans with great care, but that care can always be improved.
    And when malpractice like this happens, it's imperative we do 
everything we can to ensure it's made right and corrected so it may 
never happen again.
    As Members of Congress, how can we support the VA, and are there 
legislative changes we need to make to help stem leadership and 
accountability failures and ensure our veterans get the best care 
possible?
    Again, thank you Chairman Pappas and Ranking Member Bergman for 
allowing me this opportunity, and I trust that we will all work 
together to ensure this may never happen again.
                                 ______
                                 

        Prepared Statement of The Honorable Steve Womack (AR-3)

    Chairman Pappas, Ranking Member Bergman, distinguished members of 
the subcommittee, thank you for holding this important hearing focused 
on the Veterans Affairs health system.
    As many of you know, Robert Levy, a former employee of the Veterans 
Health System of the Ozarks (VHSO), was recently indicted in the 
Western District of Arkansas on three counts of involuntary 
manslaughter and 28 counts of mail fraud, wire fraud, and making false 
statements to law enforcement.
    These charges stem from Mr. Levy's conduct while serving as Chief 
of Pathology and Laboratory Medical Services for the VHSO, which is 
located in my district in Fayetteville, Arkansas.
    While he was serving as Chief of Pathology, Mr. Levy was 
responsible for diagnosing veterans after examining their fluid and 
tissue samples. He repeatedly showed up to work intoxicated, first from 
alcohol and then, in order to pass mandated alcohol tests, from a 
substance called 2M-2B. This compound produces a sensation like alcohol 
but cannot be detected on normal alcohol screenings. Mr. Levy was 
finally fired from the VA in April 2018 following 2M-2B being detected 
in a fluid sample.
    This was not Mr. Levy's first time failing an alcohol test. He was 
required to pass mandatory alcohol screenings because in 2016 he was 
found to be intoxicated while on duty. His blood alcohol content was 
0.396--almost 5 times the legal limit--during the time he was scheduled 
to consult on a biopsy for a patient.
    I was given the opportunity to speak about this situation at your 
committee's Member Day Hearing last month. During my testimony, I asked 
your committee to investigate the circumstances surrounding Mr. Levy's 
reinstatement, specifically how he was allowed to return to duty as a 
supervisor. I want to thank each and every one of you for responding to 
my request by holding this hearing.
    While I understand this hearing is intended to look broadly at the 
VA's credentialing system, I would ask you to pay special attention to 
the physician reinstatement process. Particularly, the process for 
determining whether a physician should be returned to a supervisory 
position.
    As Mr. Levy's indictment clearly shows, he was able to conceal 
misdiagnoses that may have occurred because of his intoxication due to 
his supervisory position. This position allowed him to ensure any 
conflicting diagnoses were removed or deleted and, in some cases, he 
was able to falsely claim a second physician conducted a review when no 
review was completed.
    As I previously stated, I do not understand why, at the very least, 
an independent review procedure was not put in place to ensure Mr. 
Levy's subordinates were able to submit their reviews without 
interference. I think this committee and the VA should look at the 
procedures for reinstating a physician following a substance abuse 
issue. Furthermore, I hope you will look at whether or not those 
physicians should be returned to supervisory positions.
    I truly appreciate your attention to these matters. The people of 
Northwest Arkansas and across the country are well-served by your 
diligence and knowledge. I look forward to any solutions that come from 
this hearing and stand ready to help you in any way.
    Our veterans stepped forward to defend our country and our values. 
They answered the call of duty, and it is now up to us to support these 
patriots. This hearing is the first step to ensuring the VA's 
credentialing system is appropriate for that mission.
    Thank you again for your time and attention.
                                 ______
                                 

 Prepared Statement of The National Council of State Boards of Nursing

    Thank you for the opportunity to provide input on the House 
Committee on Veterans' Affairs, Subcommittee on Oversight and 
Investigations hearing: Broken Promises: Assessing VA's System for 
Protecting Veterans from Clinical Harm. The National Council of State 
Boards of Nursing (NCSBN) commends the Subcommittee for holding this 
hearing and addressing provider accountability issues within the 
Veterans Health Administration (VHA).
    NCSBN is an independent, non-profit association comprising 59 
boards of nursing (BONs) from across the U.S., the District of Columbia 
and four U.S. territories. BONs are responsible for protecting the 
public through regulation of licensure, nursing practice, and 
discipline of the 4.9 million registered nurses (RNs), licensed 
practical/vocational (LPN/VNs), and advanced practice registered nurses 
(APRNs) in the U.S. with active licenses.
    NCSBN has a longstanding relationship with the VA, including 
working extensively with the Office of Nursing Services and Telehealth 
Services in support of regulatory changes that improve veterans' access 
to providers and the care they deliver. We strongly support VA as they 
endeavor to care for our Nation's veteran population and seek to serve 
as a partner and resource in the Department's efforts to improve 
quality of care and patient safety. With those goals in mind, our 
comments focus on two issues that we believe are critical to improving 
patient safety in the VA.
      reporting to state licensing boards (slbs) and the national 
                     practitioner data bank (npdb)
    In November 2017, the Government Accountability Office (GAO) 
released a study entitled, ``Improved Policies and Oversight Needed for 
Reviewing and Reporting Providers for Quality and Safety Concerns.'' 
\1\ The report found that between October 2013 and March 2017, the five 
VA Medical Centers under review had taken adverse privileging actions 
against nine providers that should have been reported to SLBs and NPDB. 
Of those nine providers, only one was reported to NPDB and none of them 
were reported to SLBs. The report exposed a major gap in public 
protection that exposes veterans and other patients to potentially 
risky care providers. GAO made four recommendations in the report, 
which included making sure that proper VISN oversight was in place to 
ensure timely reporting of providers to NPDB and SLBs.
---------------------------------------------------------------------------
    \1\  GAO, VA Health Care: Improved Policies and Oversight Needed 
for Reviewing and Reporting Providers for Quality and Safety Concerns, 
GAO-18-63 (Washington, DC.: Nov. 15, 2017). https://www.gao.gov/assets/
690/688378.pdf.
---------------------------------------------------------------------------
    VA concurred with GAO's recommendations, and set September 2018 as 
a targeted completion date for the first two recommendations and 
October 2018 for the second two recommendations. NCSBN is pleased that 
VA concurred with GAO's recommendations and developed plans to address 
them. However, we were disappointed to learn, according to testimony 
before this Subcommittee by Comptroller General Gene L. Dodaro on May 
22, 2019, that all of GAO's recommendations remain open and that VA 
revised completion dates to August 2019 and August 2020, respectively. 
We encourage the VA to provide additional updates related to 
implementing these recommendations.
    As a means to further address these ongoing patient safety issues, 
NCSBN encourages the passage of the Department of Veterans Affairs 
Provider Accountability Act (S. 221), which would require VHA 
facilities to report any covered major adverse action taken against a 
VHA provider, particularly those that affect patient safety, to the 
NPDB and the appropriate SLBs. The Senate Committee on Veterans Affairs 
has already held a hearing on the bill and introduction of a House 
companion is likely in the coming months.
    Additionally, NCSBN strongly encourages VHA, in consultation with 
SLBs, to revise and update VHA Handbook 1100.18-Reporting and 
Responding to SLBs, which outlines procedures that VHA facilities must 
follow when reporting providers to and interacting with SLBs. This 
section of the Handbook was originally drafted in 2005 and was 
scheduled for recertification in 2010, however no action has been 
taken. The current handbook language is both antiquated and complex, 
leading to VHA employee confusion about reporting responsibilities and 
limiting communication between SLBs and VHA facility staff.
               ongoing monitoring of provider credentials
    In February 2019, GAO released a report entitled, ``Greater Focus 
on Credentialing Needed to Prevent Disqualified Providers from 
Delivering Patient Care.'' \2\ The report identified several issues 
with how VHA reviews provider credentials, and highlighted a need for 
ongoing monitoring of provider licensure. In response, GAO made the 
following recommendation and VA concurred.
---------------------------------------------------------------------------
    \2\  GAO, Broken Promises: Assessing VA's System for Protecting 
Veterans from Clinical Harm, GAO 19-6, (Washington, DC.: February 28, 
2019). https://www.gao.gov/assets/700/697173.pdf.
---------------------------------------------------------------------------
    Recommendation 6-The Under Secretary for Health should direct the 
VHA facilities to periodically review provider licenses using NPDB 
adverse-action reports, similar to recent VHA-wide reviews. Facility 
officials should take appropriate action on providers who do not meet 
the licensure requirements, and report the findings to VHA VISN and 
Central Office officials for review.
    NCSBN supports ongoing verification of VHA provider licensure to 
ensure that our Nation's veterans are being treated by safe, competent 
providers. Over the past 2 years, NCSBN has had a tremendous 
partnership with the VA Office of Nursing Services, helping them better 
monitor the license status of VA nurses in real-time by offering direct 
assistance to several VHA facilities in implementing Nursys e-Notify, a 
free service for institutions who want to receive automated nurse 
license status updates. Nursys e-Notify informs a VHA facility if one 
of its employed RNs or LPN/VNs receives public discipline or alerts 
from their licensing jurisdiction(s). It also notifies the facility if 
licenses are expiring. Pilot sites for implementing Nursys e-Notify 
include: Baltimore, Maryland VAHCS, Beckley, WV VAMC, Dallas (North), 
TX VHCS, and Marion, IL VAMC. Nearly 20 VHA facilities have implemented 
Nursys e-Notify to date.
    NCSBN is pleased with ongoing efforts to implement Nursys e-Notify 
at all VHA facilities and encourages VA to require its implementation 
at every VHA facility nationwide. This will enable nurse leaders at 
every facility across the country to have real-time information 
regarding the license and discipline status of their entire nursing 
workforce.
                               conclusion
    NCSBN and State boards of nursing look forward to continued 
partnership with the VHA, Congressional VA Committees, VA providers, 
and our Nation's veterans. We aim to help ensure that veterans seeking 
care from the VHA enjoy the same patient safety protections as patients 
in the private sector.
    NCSBN appreciates the opportunity to share our perspective and 
expertise with the Subcommittee on this important matter. If you have 
any questions or would like any additional information, please do not 
hesitate to contact us. Elliot Vice, NCSBN's Director of Government 
Affairs, can be reached at [email protected] and 202-624-7781. We look 
forward to continuing the dialog on these important issues.

                                 [all]