[Senate Hearing 117-616]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 117-616

                    EXAMINING QUALITY OF CARE IN VA
                         AND THE PRIVATE SECTOR

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             SECOND SESSION

                               __________

                              MAY 11, 2022

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
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        Available via the World Wide Web: http://www.govinfo.gov
        
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                    U.S. GOVERNMENT PUBLISHING OFFICE                    
51-398 PDF                  WASHINGTON : 2023                    
          
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                    COMMITTEE ON VETERANS' AFFAIRS

                     Jon Tester, Montana, Chairman
Patty Murray, Washington             Jerry Moran, Kansas, Ranking 
Bernard Sanders, Vermont                 Member
Sherrod Brown, Ohio                  John Boozman, Arkansas
Richard Blumenthal, Connecticut      Bill Cassidy, Louisiana
Mazie K. Hirono, Hawaii              Mike Rounds, South Dakota
Joe Manchin III, West Virginia       Thom Tillis, North Carolina
Kyrsten Sinema, Arizona              Dan Sullivan, Alaska
Margaret Wood Hassan, New Hampshire  Marsha Blackburn, Tennessee
                                     Kevin Cramer, North Dakota
                                     Tommy Tuberville, Alabama
                      Tony McClain, Staff Director
                 Jon Towers, Republican Staff Director
                           
                           
                           C O N T E N T S

                              ----------                              

                              May 11, 2022

                                SENATORS

                                                                   Page
Tester, Hon. Jon, Chairman, U.S. Senator from Montana............     1
Tuberville, Hon. Tommy, U.S. Senator from Alabama................     5
Manchin III, Hon. Joe, U.S. Senator from West Virginia...........     7
Brown, Hon. Sherrod, U.S. Senator from Ohio......................    10
Hirono, Hon. Mazie K., U.S. Senator from Hawaii..................    11
Moran, Hon. Jerry, Ranking Member, U.S. Senator from Kansas......    23
Hassan, Hon. Margaret Wood, U.S. Senator from New Hampshire......    30
Cassidy, Hon. Bill, U.S. Senator from Louisiana..................    31

                               WITNESSES
                                Panel I

Carolyn M. Clancy, MD, Assistant Under Secretary for Health for 
  Discovery, Education and Affiliate Networks, Veterans Health 
  Administration, Department of Veterans Affairs; accompanied by 
  Erica M. Scavella, MD, FACP, FACHE, Assistant Under Secretary 
  for Health for Clinical Services and Chief Medical Officer; and 
  Kristine Groves, Executive Director, Office of Quality 
  Management.....................................................     2

                                Panel II

The Honorable Michael J. Missal, Inspector General, Department of 
  Veterans Affairs; accompanied by Julie Kroviak, MD, Deputy 
  Assistant Inspector General, Office of Healthcare Inspections..    15
Jonathan B. Perlin, MD, PhD, MSHA, MACP, FACMI, President and 
  Chief Executive Officer, The Joint Commission..................    17
Gregg S. Meyer, MD, MSc, President of the Community Division and 
  Executive Vice President of Value Based Care, Professor of 
  Medicine, Massachusetts General Hospital and Harvard Medical 
  School.........................................................    19

                                APPENDIX
                          Prepared Statements

Carolyn M. Clancy, MD, Assistant Under Secretary for Health for 
  Discovery, Education and Affiliate Networks, Veterans Health 
  Administration, Department of Veterans Affairs.................    41
The Honorable Michael J. Missal, Inspector General, Department of 
  Veterans Affairs...............................................    46
Jonathan B. Perlin, MD, PhD, MSHA, MACP, FACMI, President and 
  Chief Executive Officer, The Joint Commission..................    54
Gregg S. Meyer, MD, MSc, President of the Community Division and 
  Executive Vice President of Value Based Care, Professor of 
  Medicine, Massachusetts General Hospital and Harvard Medical 
  School.........................................................    65

                        Questions for the Record

The Joint Commission response to questions asked during the 
  hearing by:
  Hon. Jerry Moran...............................................    77
  Hon. Joe Manchin...............................................    77

Department of Veterans Affairs response to questions submitted 
  by:
  Hon. Jerry Moran...............................................    79
    (See Submissions for the Record below for Attachments 
      provided in response to Questions 4, 6b, and 6c)

  Hon. Marsha Blackburn..........................................    93
  Hon. Mazie Hirono..............................................    96
  Hon. Kyrsten Sinema............................................   100
  Hon. Thom Tillis...............................................   106
  Hon. Tommy Tuberville..........................................   107

VA Office of Inspector General response to questions submitted 
  by:
  Hon. Bill Cassidy..............................................   112
  Hon. Mazie Hirono..............................................   114

Mass General Brigham response to questions submitted by:
  Hon. Bill Cassidy..............................................   116
  Hon. Mazie Hirono..............................................   117

                       Submissions for the Record

VA Office of Connected Care (OCC)
  Attachment 1--Telehealth Quality and Performance Measures 
    Virtual Care Scorecard.......................................   123

  Attachment 2--FY22 Q1-Q2: Veteran Experience Scores............   131

Veterans Health Administration (VHA)
  Attachment 3--Credentialing of Health Care Providers Directive.   134

 
                    EXAMINING QUALITY OF CARE IN VA
                         AND THE PRIVATE SECTOR

                              ----------                              


                        WEDNESDAY, MAY 11, 2022

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 3 p.m., via Webex 
and in Room SR-418, Russell Senate Office Building, Hon. Jon 
Tester, Chairman of the Committee, presiding.
    Present: Senators Tester, Brown, Blumenthal, Hirono, 
Manchin, Sinema, Hassan, Moran, Boozman, Cassidy, Rounds, and 
Tuberville.

              OPENING STATEMENT OF CHAIRMAN TESTER

    Chairman Tester. I call this meeting to order.
    Good afternoon. Evaluating the quality of care provided to 
veterans, both within the VA and in the community, will help 
ensure they are getting the top-notch care that they have 
earned. Consistently, studies have shown that the quality of 
care at VA often is comparable to, or better than, care that is 
provided in the private sector.
    I have said many times, but it is worth saying again, VA 
can outsource the work when it makes sense, but it cannot 
outsource responsibility for quality care our veterans receive 
in the community. So I want to hear more about what the VA can 
do to protect veterans seeking care in the community, but I 
recognize that VA care is not without challenges.
    In the last few years, incidences at VA facilities in West 
Virginia, Arkansas, and more recently, at a community living 
center in Montana have shown VA needs to do a better job of 
monitoring care at the local level. We will hear from the 
Inspector General that VA also needs to do a better job 
appropriately resolving IG recommendations.
    I look forward to a discussion with the VA about how its 
High Reliability Organization initiative encourage team-based 
error prevention, implements site-specific safety planning, and 
empowers employees to report harm and wrongdoing. I am 
encouraged by this initiative and its commitment to zero harm, 
but I would like to hear more about how it has progressed since 
its launch in 2019 and if it is actually working on the ground.
    We will also discuss how VA collects data related to 
quality, and part of that discussion needs to include holding 
community care providers to the same quality standards as we do 
VA. We must ensure veterans have the information they need to 
make an informed decision about where to receive care. I hope 
to hear from the VA and our outside experts about existing 
tools veterans have to compare quality between VA facilities 
and community providers and any gaps in that information. If we 
determine the information currently provided is insufficient, 
we will need to work together to address that shortcoming.
    With that--hang on here. When Senator Moran comes, he will 
be able to do his opening statement. In the meantime, we are 
going to start with panel one. Okay?
    And I want to welcome Dr. Carolyn Clancy, who is Assistant 
Under Secretary for Health for Discovery, Education and 
Affiliate Network. She is accompanied by Dr. Erica M. Scavella, 
Assistant Under Secretary for Health for Clinical Services, 
Chief Medical Officer, and Kristine Groves, which did not make 
it. Oh, she is online. Okay, cool. Kristine Groves, Executive 
Director, Office of Quality Management.
    Thank you all three for being here. Dr. Clancy, you have 
the floor.

                            PANEL I

                              ----------                              


         STATEMENT OF CAROLYN M. CLANCY ACCOMPANIED BY

             ERICA M. SCAVELLA AND KRISTINE GROVES

    Dr. Clancy. Good afternoon, Chairman Tester, Ranking Member 
Moran, members of the Committee. I appreciate the opportunity 
to discuss VHA's efforts in ensuring veterans receive high 
quality health care. As the Chair noted, I am accompanied by 
Dr. Erica Scavella and Ms. Kristine Groves.
    Our employees come to work every day to serve veterans, 
their families and caregivers, and all of us at VHA know the 
importance of patient safety and quality exhibited by the 
incredible work our employees have done during the pandemic. At 
the beginning of the pandemic, when personal protective 
equipment, or PPE, was running low for healthcare 
professionals, we created reusable, 3-D printed PPE and 
dispatched it directly to the front lines. When it was not safe 
for veterans to come into our facilities, we cared for them 
remotely by rapidly ramping up telehealth to unparalleled 
levels. And additionally, when we were informed that local 
community hospitals became overwhelmed, VHA provided beds and 
cared for hundreds of nonveterans as part of our fourth 
mission, and when vaccines became available, VHA vaccinated 
millions of Americans.
    As we slowly, but surely, emerge from COVID-19, VA has the 
opportunity to help redefine the future of health care delivery 
by focusing on our infrastructure and technology as well as the 
quality and safety and type of care we provide and where we 
provide it. And as we discuss the future of VA health care 
delivery, we are thinking about how can we best deliver high 
quality care in ways that work for our veterans, whether that 
means providing care using telehealth, inpatient care at a 
hospital, at one of our hospitals or one of our local community 
based outpatient clinics, or a referral to community partners. 
Our overarching goal is to assure that these options are 
integrated for a seamless experience, and success means that 
veterans have good information to make the best decisions for 
themselves.
    I am so proud to be part of an organization that has the 
capability and willingness to help not just our veterans but 
our fellow Americans who have been impacted by this virus. 
During these times, the Nation needs to know the VHA is not 
just leading in health care but also in compassion and 
readiness to help the community.
    We are very grateful and appreciative for independent 
investigations and oversight to improve safety and look for 
lessons and opportunities to apply lessons learned across the 
enterprise. Transparency and accountability are key principles, 
and they guide our efforts in this regard. This system of 
transparency and cross-disciplinary coordination also supports 
VHA on its journey to becoming a high reliability and learning 
organization that works to ensure the delivery of the highest 
quality and level of service to veterans. In other words, our 
ultimate aspiration is you fix the problem where it occurs but 
share and spread everywhere across our system.
    Consistently safe, high quality care for the veterans we 
serve demands a culture grounded in transparency and depends on 
employee feedback regarding their concerns, risks, potential 
patient harms, and what we sometimes call near misses. That 
cultural transformation is a work in progress. We have made 
great strides. We are not done yet.
    Patient safety characterizes our culture and permeates the 
organization. Leadership meetings begin with safety stories so 
lessons learned can be shared widely and connect the work of 
every employee to our important mission. In other words, we 
leverage our integrated system to help build that high 
reliability through strong practice sharing and organizational 
learning. We have made substantial strides in ensuring our 
veterans, their families and caregivers receive quality care as 
evidenced by independent assessments comparing the care we 
provide with the private sector and peer-reviewed research 
independent of us, comparing outcomes for veterans receiving 
care within VA with those seen in the community.
    Veterans care is our mission and our purpose. We are 
committed to ensuring that it is the most accessible, 
convenient, and high quality care possible through the VHA 
system as well as through the community providers to whom we 
refer veterans for care and that we do that in a transparent, 
veteran-centric way. Your continued support is essential to 
providing this care for veterans and their families.
    This concludes my testimony, and my colleagues and I are 
prepared to answer any questions that you have.

    [The prepared statement of Dr. Clancy appears on page 41 of 
the Appendix.]

    Chairman Tester. Thank you for your testimony. Appreciate 
it. Once again, appreciate you for being here.
    My first question is for you, Dr. Clancy. Inspector General 
Missal and his team produced reports outlining problems at VA 
facilities. Those reports provide recommendations to correct 
problems and prevent similar mistakes from happening again. Dr. 
Clancy, how does the VA ensure that IG recommendations are 
followed in a timely manner?
    Dr. Clancy. That is a terrific question. Thank you. I will 
start, and then I will ask Dr. Scavella to chime in.
    Every recommendation has a specific recommendation for the 
facility in question or for the specific issue that they have 
been investigating, and an action plan is proposed in return. 
So we see these draft reports, and we actually negotiate with 
the Inspector General in terms of what is the right timing and 
what do we need to do to show them that we have actually 
accomplished this recommendation. In other words, this is way 
more than a paper exercise.
    And we follow that through, and we provide them periodic 
updates in terms of how we are doing. And there are times when 
we are saying, ``We think that we have accomplished this. Can 
we close this recommendation?'' And at that point, they are 
pretty tough.
    And anything you want to add, Dr. Scavella?
    Dr. Scavella. Sure. Thank you, Dr. Clancy. Additionally, we 
do share the lessons learned in each of these investigations in 
multiple formats, including daily morning meetings where we are 
convened across the country, with leadership across the 
country, so that we can not only discuss what has happened at a 
facility but what corrective actions we have taken to prevent 
that situation from happening at that facility and also at 
other facilities. So we are a learning organization, and we 
want to make sure we empower our leaders to learn from other 
people's challenges.
    Chairman Tester. So the Inspector General puts forth 
recommendations, and let us say you do not agree with the 
recommendations. Do you still implement solutions?
    Dr. Clancy. We have a conversation, and sometimes we will 
respond in a way that says, ``We concur in principle, but we 
think it might be better to do it this way,'' but that is where 
we have a negotiation. And by and large, I would say those are 
very productive conversations.
    Chairman Tester. Does it ever come down the pipe where the 
IG makes a recommendation and you just say, ``The hell with it. 
We are not going to do it''?
    Dr. Clancy. I am told that this happened once before I 
started at VHA, about eight and a half years ago. It is not 
often, no.
    Chairman Tester. Okay. Not under your watch, right?
    Okay. Many IG recommendations could be applied across the 
VA to ensure that similar problems do not occur at other 
facilities. Does the VA review IG reports and look for ways to 
prevent potential problems across the system?
    Dr. Clancy. We do indeed. As Dr. Scavella pointed out, we 
have long had these daily meetings about what is happening and 
what are we hearing from the field, but this was more of a 
headquarters activity. Right?
    During the pandemic, this became the glue that held the 
system together, and it has had a fundamental impact on our 
High Reliability journey as well as our ability to provide care 
to veterans during the pandemic because it became a matter of 
sharing equipment and people as we needed it. But that also 
became the place to say, we have had a problem here, and people 
ask questions. That is a new thing over the past couple of 
years.
    Chairman Tester. Do you have any examples of problems that 
occurred in one VA that you have applied solutions to other VA 
facilities?
    Dr. Clancy. Certainly, there are a number of issues related 
to sterile processing, which is a fairly complicated and I 
think underappreciated part of the entire enterprise, in terms 
of keeping equipment clean and having a regular process and 
quality management process for it. That would be one example.
    Reporting of problem provider to the National Practitioner 
Data Bank or State licensing boards and so forth is another 
issue that comes up a lot.
    Dr. Scavella?
    Dr. Scavella. So, Dr. Clancy, to add to that, I think just 
any of the cases where we have seen things that we think other 
organizations can learn from we will share. I think you stole 
the two examples that came to mind as the question was being 
asked.
    Chairman Tester. Okay. Good. The VA MISSION Act required VA 
to establish quality standards for VA-furnished care and also 
extended these same standards to community providers. You had 
talked about that vets need good information, and that is true. 
If they do not have good information, they are going to make 
bad decisions as to where to get care. At present, is VA 
reporting its quality measures as required under the law of the 
MISSION Act?
    Dr. Scavella. Sure, I will take this question. So, yes, we 
are. We do have a website that reports the MISSION Act 
requirements for quality. It is AccessToCare.VA.gov. There is a 
specific page that includes the quality metrics. It allows 
veterans to compare the data for timeliness and quality at 
their facility against what is present in the region and in the 
country.
    Chairman Tester. Okay. Thank you.
    Senator Tuberville.
    Dr. Clancy. I would just add one thing, sir.
    Chairman Tester. Yes, go ahead.
    Dr. Clancy. We also report on CMS's compares sites. There 
are sites for hospitals, for nursing homes, and so forth. So 
literally, on one page, you can see how VA compares with 
hospitals in the region and so forth.
    Chairman Tester. Okay. Senator Tuberville.

                    SENATOR TOMMY TUBERVILLE

    Senator Tuberville. Thank you very much, Mr. Chairman.
    Chairman Tester. You are welcome.
    Senator Tuberville. Thank you for being here today to talk 
about quality of care for VA. It is important to all of us.
    Dr. Scavella, what metrics does the VA use to evaluate the 
effectiveness of the VA's substance use disorder treatment 
program? Can you tell me that?
    Dr. Scavella. Yes, so thank you for that question, Senator 
Tuberville. We have multiple metrics that include how well 
patients are actually doing as a result of having received our 
care, and we look at those metrics to determine how well they 
are doing in a plethora of things, including how they are doing 
related to other things that affect the decisions to have a 
substance use disorder, such as mental health disorders. So we 
do look at those things across the system, and we can compare 
our outcomes to the outcomes in the community.
    And we do see a benefit to our active engagement. We have 
programs in place, such as Whole Health, that allows our 
veterans to use other modalities to both reduce pain and also 
to address any types of stressors they may have in their lives 
that may be contributing to the decisions to use substance use 
disorder, and through the Whole Health program we have seen 
reductions in the use of substance use disorder.
    Senator Tuberville. We are having good results?
    Dr. Scavella. We have good results.
    Senator Tuberville. Good, good.
    Dr. Clancy. And if I just might add, Senator, briefly, the 
entire system got a very well-known award last year for the 
work that we had done way ahead of the private sector and 
healthcare system in terms of getting--I keep calling it 
NARCAN--you know, the reversal to veterans' patients and their 
families and have saved quite a phenomenal number of lives, and 
we had the data to show it, which is really why we got the 
award.
    Senator Tuberville. So how do we measure, either one of 
you, success or failure for substance, for this substance 
disorder? How do we measure that?
    Dr. Scavella. So I would have to get back to you with the 
specific metrics. I just know that there have been several 
publications indicating that veterans are doing better and that 
they are using--they are not enrolled or receiving such 
prescriptions or proving to be misusing such prescription 
medications, but I would have to get back to you with that 
specific----

    [VA response to Senator Tuberville appears on page 107 of 
the Appendix.]

    Senator Tuberville. Do you know--go ahead.
    Dr. Clancy. Well, I was going to say, ultimately, what you 
would like to know is how many veterans were able to treat this 
disorder and stay off substance use. Now that will probably 
never be 100 percent, but what we can see are promising signs 
early on. So that is what tends to get reported as quality 
metrics, but we could also be looking into longitudinal follow-
up because I think that is what everyone wants to know.
    Senator Tuberville. If you get to 100 percent, we can find 
a way to get you the Nobel Peace Prize.
    Dr. Clancy. There you go. Well, it is really tough, yes.
    Senator Tuberville. How does the VA improve upon its 
substance--how do we improve it? I mean, do we have any ideas 
now that since we have been in this for a while? How do we 
improve it?
    Dr. Scavella. I think we continue to do evidence-based 
research to see what is working, what is helping to reduce 
that. I think a lot of us were surprised by some of the gains 
that the Whole Health program did provide as far as this 
particular area is discussed. So I think we need to continue to 
look at the research and determine what other modalities may be 
helpful.
    It makes sense that if someone is having a stressful set of 
circumstances, as well as chronic pain, that managing those two 
through exercise, counseling, other types of therapy, yoga, 
things like that, that those would actually improve one's pain 
as well as one's stress levels. So there are probably other 
things that we have not already incorporated into this program, 
but we do see improvements in the numbers of patients who are 
reporting lower amounts of pain, who are involved in this 
program.
    Senator Tuberville. In my former life as a coach, exercise 
was a huge factor. We had problems, you know, in this same 
area, and I think it is a good alternative.
    Dr. Clancy?
    Dr. Clancy. I was just going to say the power of a large 
system as well is we have seen remarkable reductions in the 
prescription of opioids across our system in the past six or 
seven years, which is nice to see and safer, and much lower 
doses than previously. When docs are very, very busy, it is 
easier to just keep writing the prescriptions rather than have 
those difficult conversations. But we have a couple of very 
active what we call communities of practice who get on the 
phone or video every couple of weeks to share tips, and we take 
advantage of telehealth for the purpose of education so that 
people feel empowered to be able to do that and have that 
difficult conversation, that this is really not helping.
    Senator Tuberville. Yes. Well, thank you for work in this 
area. It is obviously one of the main things that we have 
problems with in any hospital, in anything, any business. 
Substance abuse. But, thank you very much.
    Thank you, Mr. Chairman.
    Chairman Tester. Senator Manchin.

                      SENATOR JOE MANCHIN

    Senator Manchin. Chairman Tester, thank you for holding 
this hearing today on quality care and patient safety for all 
of our veterans across the country. I worked hard as a member 
of the Committee to ensure the horrific murders that occurred 
in my home State of West Virginia and specific problems that 
led to these murders never happen anywhere else in the country. 
We must make meaningful changes at the VA so that veterans in 
West Virginia and across the country can begin to rebuild their 
trust in the VA's care. This is the first time since the 
Clarksburg VA murders that we are having a comprehensive look 
at the accountability and culture of the VA, and I thank you; I 
truly do.
    Today, we will get to talk to the Veterans Health 
Administration and the VA Office of Inspector General. We look 
forward to that.
    I am also pleased that the Joint Commission is here today. 
As you all know, the Joint Commission, which accredits VA 
facilities across the country, gave Clarksburg VA a 
consistently passing score before and during the murders of 
more than seven veterans at the facility. Before and after. In 
fact, the Joint Commission did an onsite review at the 
Clarksburg VAMC on May of 2017, and Clarksburg passed the 
review. Less than eight weeks later, the vicious trail of 
veteran murders at the Clarksburg facility began.
    Oversight is our duty on the Committee. We must hold those 
responsible for incidents that have placed our veterans at risk 
accountable, and I look forward to hearing from our panelists 
on how we can prevent these mistakes from occurring absolutely 
ever again.
    Dr. Clancy, later in the hearing, we are going to hear from 
the VA Inspector General, Mike Missal, with which I had great 
conversations throughout this whole process, and I appreciate 
that.
    But in the written testimony, Inspector Missal states that 
when it comes to incidents like Clarksburg the common 
contributing ``factors the OIG has identified are poor, 
inconsistent, or ineffective leadership that cultivate a 
complacent and disengaged medical facility culture in which the 
VA's goal of zero patient harm is improbable, if not 
impossible.'' That is clearly the case of Clarksburg VA, and 
yet, individuals in positions of leadership were able to simply 
resign, able to simply resign, and keep their valuable VA 
benefits, like retirement benefits.
    I will never forget the setting when all this was unveiled 
and we heard. We learned more in the one week that Mr. Missal 
was there than we had from the administration who had been 
there forever and the head of nursing. And I looked at the head 
of nursing, and I said, ``Sir, with all due respect, you are 
either lying to me or you are totally incompetent, one of the 
two, but you have no right of sitting here.'' That was in that 
hearing. It was that bad.
    So how do we hold the VA leaders responsible with incidents 
like the murders at Clarksburg? How do those people stay in the 
system? How are they able to retire with the benefits with such 
disrespect and such neglect and malfeasance of doing their job?
    Dr. Clancy. Senator, you have just said very well--and I 
certainly do not need to tell you--what a horrific, horrific 
tragedy this was. And in my view, the only way we can possibly, 
possibly honor the experiences of those veterans and their 
families--I cannot even imagine what it felt like to be told 
your loved one would be exhumed.
    Senator Manchin. What are we doing to cure that so that 
people that would make these grave----
    Dr. Clancy. Yes.
    Senator Manchin [continuing]. Horribly grave mistakes and 
intentionally or unintentionally would be able to be benefited 
by doing such an incompetent job?
    Dr. Clancy. We have a whole new leadership team in there, 
as you know, as well as a number of new nursing leaders. We 
have made some very concrete, specific changes in how things 
are done so a nursing assistant would not be able to get in and 
get insulin or other kinds of drugs to do the kind of horrible 
things that----
    Senator Manchin. Well, I am saying legislation that I think 
we are talking----
    Dr. Clancy. Yes.
    Senator Manchin [continuing]. And Mr. Missal and I talked 
about that allows us to subpoena those people and if we find 
them in error and they are responsible they would not get the 
Federal pension. They are losing that for giving such horrible 
treatment to our veterans. Is that accurate?
    Dr. Clancy. Yes.
    Senator Manchin. We passed that, so hopefully, that should 
help tremendously.
    Also, when a quality of care incident like what happened at 
either Clarksburg or in Arkansas occurs, how do you all apply 
the lessons learned after evaluating so they do not continue to 
repeat themselves? Is that an alert? Do you have a nationwide 
alert to all the VA hospitals and CBOCs and everything else?
    Dr. Clancy. The lessons learned from Clarksburg and from 
Fayetteville were discussed widely and continue to be, and when 
Dr. Scavella mentioned our daily calls and when we have, you 
know, big leadership meetings, we start with a patient safety 
story. And we are talking now about tough issues that are not 
so easy to say in front of colleagues and things we did not 
discuss, I would say, several years ago.
    We had a problem. We did this wrong. You all have got to 
pay attention because it should not happen at your place, and 
we screwed up.
    Senator Manchin. I am just saying it is just inconceivable 
that absolute murders happened in a hospital in VA, 
intentionally.
    Dr. Clancy. Yes.
    Senator Manchin. Not by accident. Intentional. More than 
seven, but we knew seven we confirmed.
    When I was Governor, we had mine disasters. It got to the 
point I had to close every mine down just for safety reasons 
until--not let any miner go back in that mine.
    Something that atrocious happened. You would think that it 
would be raised to a level where you just had absolutely 
automatic, every VA, every review process, how your nursing 
supervisors--the control of all of your substance and all of 
your medical equipment and all of your drugs, if you will. That 
should have been reviewed immediately through every VA. I mean, 
shut it down and tighten it up until it is right. That is the 
only thing I would say.
    I know my time has run out, but I will have another round, 
hopefully. I thank you all for being here, and I am glad we are 
finally doing this. The country needs to know that we are not 
going to allow this to happen to any of veterans anywhere in 
this country.
    Dr. Clancy. And, Senator, if I might, I want to thank you 
and the Inspector General because it is--these events are, 
thankfully, of this magnitude of horror, rare.
    Senator Manchin. Yes.
    Dr. Clancy. But it is even rarer to hold the right people 
accountable, and I think it is a tribute to the Inspector 
General, the attorneys, and yourself, so thank you for that.
    Senator Manchin. Thank you.
    Thank you, Mr. Chairman.
    Chairman Tester. Yes. Senator Manchin, just so you know and 
for IG Missal, too, the subpoena, IG subpoena power bill passed 
the Senate, and the House is due to take it up next week.
    Senator Manchin. That is tremendous, what we have done to 
bring these people back and hold them accountable.
    Chairman Tester. It will be a game-changer.
    Senator Manchin. Yes. And they cannot collect the pension 
if they have done just irreparable harm to our VA, to our 
veterans.
    Chairman Tester. Senator Brown.

                     SENATOR SHERROD BROWN

    Senator Brown. Thank you, Mr. Chairman, Senator Tester.
    Thank you both for joining us. Dr. Clancy, good to see you, 
I guess the second week in a row.
    We talked last week about workforce shortages and 
healthcare provider burnout at VA, which the broader medical 
profession sees as well, as you know so well. I would like to 
talk about holistic care veterans receive at VA and what I 
heard about veterans' experiences in the community in light of 
the potential closing at Chillicothe VA Medical Center south of 
Columbus, an hour south of Columbus. I have been there three 
times in the last probably 40 days.
    The recent recommendation to close the hospital will likely 
mean more veterans in central and southeast Ohio relying on 
community care. Some of them can go to Huntington in Senator 
Manchin's State. Most of them, an overwhelming number, want to 
go in Ohio. That is where their relationships are, stay at the 
VA in Chillicothe.
    The VA's own publicity available--I am sorry. In the VA's 
own publically available hospital compare data tool the 
Chillicothe VAMC ranks a majority of the closest hospitals and 
community hospitals in care. My concern is that we move forward 
with closures in some part of the country; we would be sending 
veterans into healthcare systems that are frankly inferior, 
that do not provide the same comprehensive quality care our 
veterans deserve. How are you ensuring that that community 
care, that the providers, the community care providers are 
adhering to the same high VA standards that you set?
    Dr. Clancy. So we are putting in place a program--and we 
cannot apply this everywhere--for States that are sparsely 
populated and that there are few community providers. This is a 
tougher sell. I do not think this would apply to the great 
State of Ohio or many of parts of it.
    Senator Brown. That part it might, but go ahead.
    Dr. Clancy. Where we have preferred providers so that they 
are meeting--they are doing better than the 50th percentile in 
a number of different quality metrics. This is in addition to 
the routine things that the providers we contract with have to 
do in terms of credentialing and privileging and making sure 
that their doctors' licenses are up-to-date and all of that 
kind of aspect. That is de minimis, right? But this actually--
this preferred provider program actually looks more at ongoing 
quality measurements, which I think is a good thing.
    I am quite sure, I do have to say, that a number of people 
in our system I have met who cared deeply and passionately 
about quality all have roots in Chillicothe. This has not 
escaped my attention, and it is not our intention to leave any 
market.
    And it is also important to note that a lot of care that 
was provided in hospitals when I was training is all outpatient 
now. You know, having your gall bladder out used to be this 
very big deal. You were in the hospital for a couple of weeks, 
and you know, you were out of work at least six weeks. And now 
you do not even stay overnight anywhere, right? It is a day 
procedure. And we are going to be seeing more and more of that.
    So I do not see that veterans in that area will be 
deprived, but that is all going to be part of the commission 
process in terms of how do we make sure that for every part of 
this country veterans have the opportunity to get the right 
care.
    Senator Brown. Well, they are certainly locally unconvinced 
of that, as you know. No surprise.
    Dr. Clancy. I----
    Senator Brown. And I also would note that Chillicothe has a 
reputation bigger than their size in their region in mental 
health treatment, particularly important, perhaps no more in 
that part of the State than Montana or West Virginia or Hawaii 
or Alabama, but known to be very important with all the 
problems around.
    Let me follow up on Senator Tester's question related to 
VHA and OIG negotiations. If VHA disagrees with an OIG 
recommendation, what are the steps of negotiating? What do 
those steps look like, and what happens when you disagree?
    Dr. Clancy. In general, what the Inspector General's team 
will come over and do is make a presentation of what they found 
and here are the draft recommendations, and then we discuss 
them among ourselves, and we will get back to them. I would say 
we probably agree with the majority, and more of our 
negotiations are about how rapidly we can do it and how robust 
does our response need to be to be persuasive to them. And you 
can see they set a pretty high bar, that we have really changed 
whatever the issue is, you know, that we have made a meaningful 
change across the system or at a particular facility.
    I mentioned that we sometimes say ``Concur on principle. We 
agree with you. This should not have happened, but we think 
there might be an alternative to fix this problem.'' Again, I 
am relying on memory, serving as Acting Under Secretary, but I 
would guess that is 10 to 15 percent of the time. And that is 
where we have a good conversation.
    Senator Brown. Good. Thank you.
    Thank you, Mr. Chairman.
    Chairman Tester. Senator Hirono.

                      SENATOR MAZIE HIRONO

    Senator Hirono. Thank you, Mr. Chairman. As I sit here, 
focusing on VA care, it just occurs to me that it is kind of a 
perennial concern, the quality of care, the veterans that need 
to be outreached to, and all of that.
    So I am wondering, Dr. Clancy. You have worked at VA for 
some eight years or so in various capacities. And when you took 
on this position, current position, what was your first goal 
that you wanted to accomplish in this position, and how are you 
doing in achieving that goal?
    Dr. Clancy. My biggest goal was to make sure that the 
future health professionals that we train we have a big impact 
on the future workforce in this country across like 60 
disciplines and the research we support, which is quite 
considerable thanks to the generosity of the Congress, is very 
tightly connected to the day-to-day care for veterans so that 
when we are supporting research on how to improve care for 
veterans or testing new treatments that that is translated into 
practice as rapidly as possible. We are not just a research 
organization sitting out here. We are actually embedded in a 
very important system, the Nation's largest integrated system. 
So that was my idea.
    We also have a group that focuses a lot on healthcare 
innovations, looking at very different ways of providing care, 
and that too has to be grounded in the day-to-day operations.
    Senator Hirono. So are you moving toward those goals? Are 
things happening that let you say, aha, we are getting there?
    Dr. Clancy. Yes, I would say that we are getting there.
    Senator Hirono. I think the research aspects are really 
important because you have really a way that your research can 
be applied to the services that you provide. But you talk about 
staffing. That is a perennial issue, the fact that you have a 
shortage of staffing. So we have even provided you more 
flexibility in how the VA goes about hiring people, and yet, 
here we are. You know, it is a perennial issue.
    And you talk about one of the goals was for you to have 
your staff, and I take it there is always turnover and all 
that. So how are you attaining that goal in terms of the 
training that you do? And by the way, there is a shortage of 
nurses in the VA system, isn't there?
    Dr. Clancy. Yes, I would say just about every health system 
in this country right now either has a shortage of nurses or I 
think it is coming next week, and they are probably right. A 
lot of this is the emotional impact and burnout from the 
pandemic.
    Senator Hirono. Yes.
    Dr. Clancy. Some of it is--and I think this may be true in 
our own system--not being thoughtful enough about how to give 
nurses more flexibility in their work schedules and so forth. 
These are solvable problems, but we are clearly going to need 
more nurses because----
    Senator Hirono. Yes.
    Dr. Clancy [continuing]. Many of them are approaching 
retirement age.
    Senator Hirono. And when you have staffing shortages, it is 
pretty hard to be flexible in terms of their work hours, et 
cetera.
    Do you recruit nurses from the Philippines, by the way?
    Dr. Clancy. I do not know. I know this country does. I 
would have to take that and get back to you, Senator, and I 
would be happy to do that.

    [For VA response to Senator Hirono, see Question 2b on page 
97 of the Appendix.]

    Senator Hirono. I think, my understanding is, that there 
are a lot of Filipino nurses that I would think would want to 
come to this country, but there are probably visa issues and 
all kinds of things that we could possibly help you with.
    The other thing that is a perennial issue is your 
electronic health record modernization. I remember when 
Secretary Gates, Secretary of Defense, and Secretary Shinseki, 
VA Secretary said we are going to have this seamless electronic 
health record system that combines and tracks the active duty 
person and then into the VA, and after a billion dollars are 
spent, pretty much zip.
    So now you have the modernization that you are doing, and 
we just had a recent incident where I think the system crashed 
and it impacted hospitals. One hospital even stopped admitting 
patients, and that certainly has an impact.
    So are you taking steps to move us forward in having this 
kind of electronic system so that the kind of care that you 
provide is based on that person's health records, accurate 
health records?
    Dr. Clancy. Absolutely, we are. One thing I learned when I 
was working very closely with Secretary McDonough when he first 
came in as Acting Deputy Secretary, is we talked to a lot of 
people in the private sector, and to a person, they all said 
the initial deployment of an electronic record is painful and 
chaotic and everyone hates it and wonders why are we doing 
this. We got that part.
    But we are being quite vigilant. We have restructured how 
this works, and it reports right up to the Deputy Secretary 
now, Donald Remy. And by and large, we have not had recent 
system crashes. We have had times when the system slows down, 
but there are already built-in processes for people to be able 
to handle that so that patient care is not disrupted. So I am 
quite optimistic at the moment that once we get through the 
painful part this is going to make care much better for 
veterans, and frankly, I think it is going to make it easier 
for us to detect the impact of current and future exposures to 
toxic substances or other military experiences.
    Senator Hirono. We just have to get it right.
    Just one comment, Mr. Chairman. Relating to the 
prescription refills, the delays, and prescription drugs 
through the mail, so I hope that this is a--when I looked at 
your website, it says, prescriptions usually arrive within 
three to five days of being ordered and maybe 60 hours from 
filling to delivery, but there has been recent reporting that 
there are a lot of delays. It could take up to four weeks, and 
of course, that is going to impact the patients, patient care. 
So I hope that you are taking steps to not only address these 
delays but figure out a way to alleviate these delays for our 
veterans.
    Dr. Clancy. Well, we do not actually control the postal 
service----
    Senator Hirono. Oh, I know that.
    Dr. Clancy [continuing]. But our pharmacy team is on this 
at all times and regularly reviewing how rapidly are 
prescriptions being delivered to veterans. What that has meant 
is that we have moved up when we provide refills and so forth, 
and in some cases, we will overnight it if it is that urgent. 
But by and large, our track record has been great, but again, 
we are not just counting on that we got it straight for a day. 
This is a focus of continuous vigilance.
    Senator Hirono. Yes. Thank you.
    Thank you, Mr. Chairman.
    Chairman Tester. Senator Manchin, if you have additional 
questions for Dr. Clancy, I would defer to you.
    Senator Manchin. Thank you, Mr. Chairman.
    Dr. Clancy, in recent years, our veterans have experienced 
massive breaches of trust in all the employees, especially in 
Clarksburg, and the employee who murdered multiple veterans at 
Clarksburg never went through a proper hiring process. What I 
am speaking to you about is the hiring process, the need that 
we have, and the shortages that we are having.
    So how has the VA updated its hiring process to reflect 
basically lessons learned, vetting? They only had to make one 
phone call, and they could have caught this woman before she 
ever got in the door. So how are you doing that, and how is 
your retention?
    Dr. Clancy. We have been going through a pretty extensive 
human resources modernization over the past several years, and 
I am happy to say that we are starting to see progress. It was 
not easy in the beginning, to put it mildly, because hiring is 
a problem, but a lot of our leaders are both reinforcing the 
importance of this vetting. As you say, a phone call almost 
certainly would have prevented this, which is unbearably 
painful to think about.
    But also, coming up with ways to speed the whole process 
up, the pandemic allowed us to do--to postpone some aspects of 
the usual hiring process, which can take a number of weeks, to 
bring on rapidly because we needed that. We now have been 
expressing in a hearing here last week additional flexibilities 
that might be helpful and look forward to working with that 
committee on this.
    Our retention, by and large, particularly for nursing is 
much better than the private sector, but we have seen it start 
to drop a bit, which is why we are very worried about the 
nursing workforce.
    Senator Manchin. Let me go to the security of the cameras 
and holding people accountable and all that that we talked 
about. We have a piece of legislation we have all worked 
together on, the Chairman, myself, and others. Senate Bill 2041 
is the VA Provider Accountability Act. I think you are aware of 
that Senate Bill 2041. And what it would do in the VA 
healthcare system by instituting requirements to keep VA and 
healthcare providers accountable, it is monitoring and cameras. 
It would give the Office of Inspector General the tools they 
need to make sure when they do their investigation they have 
all of the real-time information.
    First of all, I know you all supported this, this 
legislation. Do you find it to be favorable, would be helpful?
    Dr. Clancy. I would have to check on that. I honestly----
    Senator Manchin. Okay, Okay.
    Dr. Clancy. Yes.
    Senator Manchin. Well, we would like to get your input on 
that if not.
    Dr. Clancy. Sure.
    Senator Manchin. It is bipartisan. I think that we have a 
great deal of this Committee that is on that piece of 
legislation, and I wish you would look into that to give us the 
support that we need to make sure you do not believe it 
interrupts or interferes. That is not what our purpose is. Our 
purpose is to make sure that we have the proper information at 
the proper time.
    Dr. Clancy. We will follow up with that.
    Senator Manchin. If you would do that, I would appreciate 
it.
    Those are all the questions I have, Mr. Chairman. I 
appreciate it.
    Chairman Tester. Well, thank you.
    We will get our second panel. And I want to thank the three 
participants in this panel for being here, virtually and in 
person.
    And we look forward to seeing you next week, Dr. Clancy, as 
long as it has been two weeks, might as well make it three in a 
row. No, I do not think you are on the agenda for next week, 
but who knows. Maybe you are.
    Dr. Clancy. Thank you.
    Chairman Tester. And we will get the second panel settled 
in here, and I will do a little introduction of them. We are 
going to hear from officials from the VA Office of Inspector 
General as well as from outside experts on quality care on this 
panel.
    First, we have Inspector General Michael J. Missal, who is 
somebody that we have gotten to know pretty well in this 
Committee, and not to let somebody else steal you away from the 
VA, but somebody who I think is incredibly competent and 
professional at the job that he does. And we appreciate you, 
Mike, and we appreciate you being here today.
    He is accompanied by Dr. Julie Kroviak, who is Deputy 
Assistant Inspector General at the IG's Office of Healthcare 
Inspections.
    We also have Dr. Jonathan Perlin, who is President and 
Chief Executive Officer at The Joint Commission and former 
Under Secretary for Health at the VA.
    And joining us virtually, we have Dr. Gregg Meyer, who is 
President of the Community Division and Executive Vice 
President of Value Based Care at Mass General-Brigham, and 
Professor of Medicine at Massachusetts General Hospital and 
Harvard Medical School.
    We appreciate all of you for being here, both in person and 
in Dr. Meyer's case, virtually. We will hear from Inspector 
General Missal now.

                            PANEL II

                              ----------                              


          STATEMENT OF THE HONORABLE MICHAEL J. MISSAL

                  ACCOMPANIED BY JULIE KROVIAK

    Mr. Missal. Thank you, Chairman Tester and committee 
members. I appreciate the opportunity to discuss the OIG's 
oversight of the quality of care provided by VHA. Testifying 
with me is Dr. Julie Kroviak, Deputy Assistant Inspector 
General for Healthcare and a former VHA physician.
    We know VHA staff strive to provide high quality, 
compassionate care to over six million veterans each year. 
However, there are real challenges in delivering care to 
veterans with generally complex medical and psychological 
conditions often related to their military service. VHA's 
integrated approach to caring for veterans is unique in its 
attempt to meet their clinical needs while providing an array 
of support services. The OIG is grateful to VHA staff for 
delivering such comprehensive care, especially during the 
pandemic.
    VHA's critical role in supporting our Nation's health care 
delivery underscores the need for the OIG's strong and 
independent oversight. That oversight routinely identifies 
incidents and conditions in which quality of care and patient 
safety have been compromised. The events leading to these 
failings are often nuanced and multifactorial. However, a 
common theme is poor, inconsistent, or ineffective leadership 
which cultivates a complacent and disengaged culture in which 
VHA's goal of zero patient harm is improbable.
    Consider, for example, incidents in the Fayetteville, 
Arkansas VA facility, where oversight failures allowed a former 
pathologist to misdiagnose over 3,000 veteran specimens over 
multiple years while he worked impaired. In another VA medical 
facility in Clarksburg, West Virginia, a former nursing 
assistant pled guilty to killing seven veterans by 
administering insulin. Although by no means typical, these 
tragic examples demonstrate how disengaged leaders and the lack 
of a culture of accountability can put patients at risk of 
serious harm. Our reports consistently chronicle less 
devastating, but often widespread or persistent, problems 
affecting patient care that only effective leadership can 
address.
    Healthcare facilities committed to patient safety have 
strong leaders who engage staff and empower reporting, sustain 
a supportive culture, and promote continuous improvements. They 
have a structured and proactive quality and safety management 
team that investigates concerns. They capture real-time 
incident data and task multidisciplinary teams to conduct root 
cause analyses. Reported concerns are reviewed thoroughly and 
promptly resolved.
    While VHA has taken actions to address recruitment and 
staff burnout, staffing challenges persist. Even before the 
pandemic, the OIG emphasized the need for VHA to develop 
effective staffing models to inform hiring and community care 
decisions. Continued staff fatigue and shortages, as well as 
referral backlogs, increase the demand for community care. Yet, 
the coordination of care between VHA and community providers 
remains a challenge. Persistent administrative and 
communication problems undermine safe, seamless, and quality 
care for veterans.
    No initiative better reflects the many challenges VA faces 
than deploying the new electronic health record system. Our 
three recent reports on the initial deployment in Spokane 
detail significant concerns. For example, data migration 
deficiencies resulted in patients having inaccurate or 
incomplete medication lists in their records and made simple 
activities, such as refilling a prescription, more challenging. 
Leaders must be responsive to clinical staff who rely on the 
system, and patient safety cannot be compromised to satisfy 
timelines that fail to account for remediating identified 
problems.
    This Committee and VA are committed to improving the 
quality of veterans' health care. The cultural transformation 
being pursued within VHA must be guided by accountable and 
attentive leaders that prioritize the safety of each veteran 
they encouraged. The sense of urgency to effect change is 
understandable and justified, but the reality is it will take 
some time. The OIG will continue to focus on both incident 
specific and system-level improvements and make meaningful 
recommendations for corrective action that VA should promptly 
carry out. Veterans and their families deserve nothing less.
    Chairman Tester, Ranking Member Moran, and members of the 
Committee, this concludes my statement. I would be happy to 
answer any questions that any of you may have.

    [The prepared statement of Mr. Missal appears on page 46 of 
the Appendix.]

    Chairman Tester. Thank you, IG Missal, and there will be 
questions after we hear from our next two panelists. Dr. 
Jonathan Perlin, President and Chief Executive Office at The 
Joint Commission--and just so you know, The Joint Commission 
accredits both VA and private sector facilities.
    The floor is yours, Dr. Perlin.

                STATEMENT OF JONATHAN B. PERLIN

    Dr. Perlin. Thank you, sir. Good afternoon, Chairman 
Tester, Ranking Member Moran, and distinguished members of the 
Committee. I was privileged to work with some of you during my 
tenure as Under Secretary, and I cannot sit here now with you 
in this room without hearing the echoes of the voices of 
Senators Akaka, Isakson, and Rockefeller. My gratitude to them 
and to you as champions for VA's mission of service to 
veterans.
    I would like to address two themes in my immediate 
comments. First, I will discuss The Joint Commission's role in 
advancing quality and safety, and second, I will share my 
perspective about quality and safety in the Veterans Health 
Administration.
    The Joint Commission conducts unannounced surveys of 
hospitals on a three-year cycle to assess compliance with 
standards relating to the safe delivery of health care, 
standards derived from evidence for achieving the better 
patient outcomes, as well as from a number of regulatory 
authorities. Demonstrating compliance with standards leads to 
accreditation.
    A survey lasts three or more days depending on hospital 
size, and survey teams generally include a physician, one or 
more nurses, a hospital engineer, and other experts. Hospitals 
are surveyed for documentary evidence of compliance with 
critical processes, like infection prevention, medication 
management, and fire safety. So for example, the team assesses 
whether appropriate sterilization of surgical instruments has 
been recorded, whether records of medication use are adequate, 
and whether there is a safety plan for fire or other hazards.
    But this is not just a paper exercise. A survey expert 
traces how sterilization is performed, how medications are 
managed, and even inspects for holes in firewalls.
    While I have been on the receiving side of many surveys 
before, this past week, I observed a survey a mid-sized 
hospital. The most frequent request I heard surveyors make of 
staff was, show me. Show me how you would sterilize an 
instrument. Show me what you would do if there were a fire.
    I made a number of observations. First, the caregivers and 
the other staff were caring and mission-driven. That said, 
there were more times than I expected that individuals did not 
know critical information.
    This leads to an important point. The surveys are not only 
meant to demonstrate accountability but to be educational. The 
care teams know these things now.
    If deficiencies are found, they are recorded as 
requirements for improvement. Some deficiencies are minor and 
can be resolved right away. More serious breaches are termed 
immediate threats to life and safety and require immediate 
remediation. Any deficiency requires a plan of correction, and 
hospital leadership is not only responsible for making 
corrections but for maintaining continuous compliance between 
surveys.
    The routine triennial survey is like a general physical 
exam. It surveys all systems, and the sampling of a complex 
medical center may miss something.
    On the other hand, The Joint Commission conducts ``for 
cause'' surveys for unreported Sentinel Events which are 
defined as safety events that can result in death or permanent 
harm. Like an examination for heart disease, these surveys go 
deep on a particular issue. Organizations are strongly 
encouraged, but not required, to report Sentinel Events to us. 
Health systems with a policy of reporting Sentinel Events is a 
best practice as our teams can assist in a thorough root cause 
analysis.
    Now let me offer a perspective on quality and safety in VA. 
There are quite a number of documented areas where VA 
outperforms private sector and many others where care is on 
par.
    That said, here are some suggested opportunities for 
further improvement. First, VHA should extend its SAIL 
analytics to continuously look at outcomes by nursing unit, by 
care provider, and by procedure to systemically identify both 
problem and best practices. This is especially important as 
more care goes to the community and internal procedure volumes 
decrease. In short, the more you do the better you do, a 
phenomenon known as the volume-outcomes relationship.
    Second, VA has more insight into care quality internally 
than it can have externally. Deep clinical performance data are 
not available publicly, and private sector has not developed 
the performance measurement systems that VA has in place. While 
this makes it difficult to direct veterans to the very best 
clinician specifically, some data may predict higher performing 
hospitals. VA must be vigilant in information sharing to assure 
that care is both well-coordinated across VA and non-VA sites 
and attuned to veteran-specific issues.
    Third, an issue that concerns me greatly is obtaining the 
best leadership at every level of the organization. 
Noncompetitive compensation for administrators divides the 
ranks into those who are highly competent and are at VA for 
mission and others who may be more junior or less skilled than 
colleagues in comparable roles in private sector. I recommend 
that VA establish a mentoring program that pairs it's both 
seasoned and successful administrators with less-seasoned 
colleagues, especially at hospitals that have had challenges.
    That brings me to my final recommendation. If something is 
an issue on one unit, assume that it may be a risk throughout 
the hospital, and if something is an issue at one hospital, 
assume that it is a risk systemwide. The goal is not to 
disparage or to add work but, rather, to add value by 
addressing risk before becoming manifest as problems. This is 
essential throughout health care and especially so as a 
grateful nation cares for those who have borne the battle.
    Thank you.

    [The prepared statement of Dr. Perlin appears on page 54 of 
the Appendix.]

    Chairman Tester. Thank you, Dr. Perlin.
    Next, virtually, we have Dr. Gregg Meyer, who, I guess he 
most easily said, is from the private sector.
    So, Gregg, the floor is yours.

                  STATEMENT OF GREGG S. MEYER

    Dr. Meyer. Good afternoon, Chairman Tester, Ranking Member 
Moran, and distinguished members of the Committee. Thank you 
for the opportunity to testify today about the quality of 
health care provided to our Nation's veterans.
    My responses reflect my perspective as a physician and 
proud U.S. Air Force veteran who has dedicated my career to 
improving the quality and safety of health care. In my 
testimony, I will briefly address four questions.
    The first is: How does the quality of health care provided 
to veterans in Department of Veterans Affairs facilities and 
civilian facilities compare? Although there have been times 
where the VA has clearly fallen short, for example, the access 
crisis leading to the passage of the Veterans Access, Choice, 
and Accountability Act and, more recently, the horrific tragedy 
at the Clarksburg VA, it is important to not lose sight of the 
VA's leadership in health care quality.
    A 2003 report of the Institute of Medicine recommended that 
Federal direct care programs, including the Veterans Health 
Administration and the Military Health System, be used to 
evaluate policy options for improving quality and value. In 
fact, the VA had already been a quality improvement leader 
prior to that publication. For example, the VA was an early 
adopter of electronic health records and telehealth. Given that 
history and the debt we owe our Nation's veterans, it is safe 
to conclude that the VA has an obligation to lead in quality 
and safety.
    A straightforward question is whether direct care in VA is 
good value for the veteran and taxpayer, but patient 
preferences, geography, availability of services, along with 
other factors, can bias comparisons and lead to erroneous 
conclusions. As a result, the findings of studies investigating 
this question are more directional than dispositive.
    With that caveat in mind, a review of VA versus civilian 
care in all six domains of quality--safety, effectiveness, 
patient-centeredness or, in the case of the VA, veteran-
centeredness, timeliness, efficiency, and equity--reveals a 
relatively consistent direction.
    In terms of the safety and effectiveness quality domains, 
these comparisons suggest that direct care in the VA has 
comparable and, in many cases, superior quality and safety of 
ambulatory and inpatient care compared with civilian 
alternatives.
    In terms of veteran-centered care, studies have generally 
found that VA facilities again matched or outperformed their 
civilian counterparts.
    Studies of efficiency in the VA generally demonstrate good 
value in terms of expenditures. One widely cited study by the 
National Bureau of Economic Research found that veterans cared 
for in VA hospitals had lower mortality rates and 21 percent 
lower spending relative to civilian health care.
    The two domains where the VA faces the greatest challenge 
in comparison with civilian care are equity and timeliness. 
Timeliness remains a persistent challenge, but the most recent 
assessments of wait times suggest improvement. But this remains 
an area where Congress should focus attention over time.
    The second question is: What measures should be used to 
compare VA versus civilian care? Despite a legitimate desire 
for clarity and simplicity, there is no single measure or 
thermometer which can capture all the domains of quality which 
must be assessed to ensure veterans are receiving the high 
quality care they deserve from both VA and civilian facilities. 
As a result, Congress should continue to be provided with 
information covering all six domains of quality.
    Availability of data in community care, especially rural 
areas with less data infrastructure, will remain a challenge. 
In assessing VA versus civilian care, Congress should be aware 
of this limitation and, to the extent possible, provide both 
the resources and requirements for quality reporting on metrics 
of interest as part of its expectations of civilian facilities 
caring for veterans.
    It is also essential that Congress avoid the temptation of 
extrapolating isolated failures to be universally indicative of 
widespread problems. In this regard, the recent tragedy at the 
Clarksburg VA is neither a distraction nor is it indicative of 
a failure of care within the VA overall. The ongoing demand for 
transparency, focus on systems, and addressing issues across 
the system to ensure learning from failures are appropriate 
expectations we have of the VA, but perfection is not.
    The third question is: How can the quality of care provided 
in VA facilities be improved? While comforting in terms of 
aggregate quality in general, the majority of studies comparing 
VA with civilian health care share another feature with 
civilian healthcare studies: There is often wide variation 
across facilities. This is a place where congressional 
oversight is essential.
    A review of the tools used by the VA to improve care at its 
facilities demonstrates they are on par or better than the 
majority of civilian health systems. When compared with the 
measurement dashboards used within my own system, the two areas 
where additional metrics should be considered are those related 
to equity and workforce safety. Addressing the variation in 
quality within the VA also requires appropriate resourcing and 
support for these activities, another area for congressional 
attention.
    The VA also has a rich history of leadership in health care 
quality research, and examinations of quality and cost of VA as 
compared with civilian care should be encouraged.
    The fourth question is: What are the future best practices 
for collecting and analyzing quality in the VA? This is one 
area where the VA can once again take a lead in quality. The VA 
should leverage its capabilities in data science, the 
availability of clinical data from electronic health records, 
and its close relationship with veterans to move beyond the 
current set of metrics it and the majority of civilian health 
facilities employ to a new more meaningful generation of 
electronic clinical quality measures. In addition, the VA could 
become a leader in the collection of patient-reported outcome 
measures.
    In conclusion, I would say the American public should be 
both reassured, yet unsatisfied, with the quality of care 
provided to its veterans. Reassured that the care provided by 
the VA direct care system is comparable to, and often times 
better than, that available through civilian facilities in most 
of the domains of quality. Yet unsatisfied that we can do 
better for our veterans by continuing to improve care, learning 
from failures, and working to ensure that veterans will receive 
high quality care regardless of where they access the system.
    Finally, a fulsome assessment of the value of VA-based care 
compared with that available in the civilian sector for 
veterans should incorporate an assessment of the full range of 
benefits and learnings the VA systems affords. This includes 
not only the direct impact of that care on veterans and their 
families but also an appreciation of the potential leadership 
role of the VA in defining and delivering care that our 
veterans deserve, which can help the VA meet its ongoing 
responsibilities and serve as a national model.
    That concludes my statement. I look forward to your 
questions.

    [The prepared statement of Dr. Meyer appears on page 65 of 
the Appendix.]

    Chairman Tester. Thank you, Dr. Meyer and Dr. Perlin and IG 
Missal, for your testimony.
    I am going to start with you, Mr. Missal. I would like to 
take the opportunity to thank you for your work that the IG 
does to improve VA care overall.
    The questions I have are going to be similar to the ones I 
asked Dr. Clancy, only from your perspective. Is there anything 
the VA could improve upon when it comes to implementation of 
your IG report recommendations?
    Mr. Missal. Yes, several things I can think of. One is when 
we include a recommendation, we are looking to address a 
certain issue. So when we close out a recommendation, that 
means that VA has convinced us that they have implemented the 
recommendation as proposed and it is sustainable.
    One thing that I think they could do to really help with 
the recommendations is to ensure it is accomplishing the goal 
to which it was made so that they can continue to look at it 
down the road to see if it is continuing to meet its objective.
    Secondly, I think they can do a much better job circulating 
and distributing our findings and recommendations to other 
facilities. VHA is an extremely decentralized system, and as a 
result, information does not flow down or up as well as it 
could. And we have found issues where information from our 
reports does not go to the other facilities as well as it 
should.
    Chairman Tester. Thank you. It is my belief that if you are 
finding certain problems at one VA facility they are bound to 
exist at others. I think Dr. Perlin expressed that same 
sentiment. Inspector General what is your sense of whether the 
VA takes your recommendations and does implement them 
systemwide?
    Mr. Missal. Some of our recommendations are systemwide 
recommendations so that those would be implemented across the 
system, but again, I think we found that certainly looking at 
whether or not other facilities are aware of our reports, our 
findings, our recommendations, we have found that it is not as 
well as it should be.
    For example, in our CHIP report, our Comprehensive 
Healthcare Inspection Program, talks to leaders, one of the 
things they talk to them about is other oversight work that is 
being done. And what we found is just a general lack of 
awareness of the work we do, GAO, and other oversight bodies, 
and so I think they could do much better ensuring that findings 
and recommendations are distributed across the entire system.
    Chairman Tester. So let me ask it to you this way. Are you 
finding problems that you flag in one report occurring at other 
facilities in another report later down the line?
    Mr. Missal. Yes, and let me give you a couple of examples. 
A few years back, there were massive inventory failures at the 
D.C. Medical Center. They did not have a working inventory 
system. It was so critical to patient safety that we put out an 
interim report, which was very unusual, to make sure that the 
whole system knew there could be inventory problems outside of 
D.C. as well. We then published the final report. So now we 
have two reports out there. We were very disappointed when 
about a year later we found similar inventory issues at yet 
another VA facility.
    More recently, deficiencies in patient safety programs have 
been an issue, both in Clarksburg, Fayetteville, and elsewhere. 
Secretary McDonough was very concerned about the findings. He 
asked Dr. Kroviak, Assistant Inspector General, Dr. David 
Daigh, and me talk to VISN directors about the issues and how 
they need to focus in on patient safety. We spoke to all the 
VISN directors, and the message was: patient safety programs 
are critical to the quality of care. We found these 
deficiencies. Please check to ensure yours are up and running.
    And we recently found that one facility did not have a 
patient safety program. The person in charge was essentially 
absent. We are finishing up the work in that area, and we will 
be publishing a report in the near term.
    Chairman Tester. Dr. Perlin, you noted challenges with 
leadership turnover and stability. If you could, as briefly as 
you could, but as comprehensive as you could, expand on this 
and provide recommendations for the VA.
    Dr. Perlin. Yes. Well, first, Mr. Chairman, let me thank 
you and Senator Boozman for his work on the RAISE and the WISE 
Acts. The compensation in VA is not on par with private sector, 
and that is a fundamental problem in attracting talent.
    In four statements: One, I would benchmark competencies at 
leadership levels with private sector to assure that the best 
talent is in place. Second, I think VA has great learning 
organization but can further build its pipeline of leadership 
development. Third, develop mentorship programs that would be 
effective in helping to cultivate the next generation of 
exceptional leaders. And, I would encourage more exchange with 
private sector so that individuals can cultivate an 
understanding of some of the complexities of medical center 
operations such that they can have that sixth sense of 
experience that would identify problems be they at Clarksburg 
or Fayetteville or elsewhere. Thanks.
    Chairman Tester. Thank you.
    Senator Moran.

                      SENATOR JERRY MORAN

    Senator Moran [presiding]. Chairman, thank you.
    Dr. Meyer, let me start with you. In your written 
testimony, you advocate for an approach that balances quality 
measures. You go on to write that the large number of measures, 
quote, threatens to shift resources from improving quality in 
areas of greatest need to cover a plethora of measures that may 
have limited impact on veterans. That captures my attention 
because surely we ought to be focused on the things that have 
the most--the greatest level of consequence.
    Can you explain how the VA should balance measures to make 
certain areas with the greatest needs are at the forefront? 
Which measures do you feel are more important to veterans than 
the civilian population?
    Dr. Meyer. First of all, I would begin by saying this is a 
challenge in the civilian sector and, as you know, for the VA. 
And the reality is that we have gotten very good at collecting 
information, at least in some organizations, and particularly 
with the VA with its electronic systems.
    With that said, that can lead to what I would call 
measurement distraction. And what I would advocate for is that 
the VA to focus on something important in each of those 
domains, in safety, effectiveness, efficiency, veteran-
centeredness, equity, and timeliness, but not to have 15 
measures of each, just to have two or three.
    In addition, one of the things that we heard consistently 
over the course of the testimony this afternoon is the 
importance of focusing on leadership. And the VA has been a 
leader in collecting information on safety, culture, and 
engagement of its employees, and I think in both of those areas 
that is very important qualitative data that has not surfaced 
in many of the current benchmarks that people follow.
    And so I would suggest focusing on fewer measures in each 
of those domains, making sure that we are paying attention to 
culture, which is a direct reflection of leadership, and 
finally ensuring that we are looking that we have an engaged 
and safe workforce.
    Senator Moran. Thank you. Thank you for your devotion to 
this topic in this hearing.
    Dr. Perlin, good to see you again. I am interested in 
hearing about the ``for cause'' survey process as it pertains 
to VHA facilities. What are some examples of events that could 
trigger a ``for cause'' survey?
    Dr. Perlin. Thank you, Mr. Ranking Member. A ``for cause'' 
survey will occur if there are allegations of something that is 
quite egregious, if there are a cluster of complaints, or 
frankly, if there is, as I mentioned, a Sentinel Event, 
something that either resulted in death or could have had the 
potential of death or permanent harm. The Joint Commission will 
come in and go very deep to look at a particular system.
    Since it has come up a number of times, let us tackle the 
issue of Clarksburg. The Joint Commission learned about 
Clarksburg in August 2019, well after the events occurred. Had 
The Joint Commission learned at an earlier point, we would have 
come in and helped to conduct a root cause analysis to 
understand what some of the contributing factors were in terms 
of the lapses that led to the hiring of the individual.
    But we consider it then a best practice not to wait for a 
media event, not to wait for complaints, but at the moment a 
failure is recognized or at the risk of a serious failure, to 
call The Joint Commission and have our experts go through the 
root cause analysis to understand what the failure modes were 
and, most importantly, to build robust defenses so those modes 
will not happen again. This is a matter of policy, by the way, 
in the Department of Defense. Thanks.
    Senator Moran. Has The Joint Commission ever performed a 
``for cause'' survey to a VHA facility as a result of an OIG 
report or patient safety concern, and have any of those 
facilities or programs lost accreditation as a result of 
failing that survey?
    Dr. Perlin. Well, I am two months into the role and do not 
know the specific genesis of any of the ``for cause'' surveys. 
My understanding is that The Joint Commission, over the past 
decade, has conducted about 10 percent of its surveys as ``for 
cause'' surveys or special surveys. That would be about 29 
surveys.
    Senator Moran. Maybe you could follow up if----
    Dr. Perlin. I would be happy to provide that information.
    Senator Moran. Thank you very much.
    Dr. Perlin. Thank you.

    [The Joint Commission response to Senator Moran appears on 
page 77 of the Appendix.]

    Senator Moran. In 43 seconds, Mr. Missal, I have always 
admired your work, and I appreciate your presence here today. I 
think you and your office are hugely important to this 
Committee and, more importantly, hugely important to the 
veterans that the Department of Veterans Affairs serves.
    While conducting a particular review--let me give a little 
background in the few seconds I have. Mr. Missal, your office 
recently published a report on purchases of smartphones and 
tablets for veterans used during COVID-19 pandemic. This report 
and that review found that the VHA, through the Office of 
Connected Care Officials, incurred approximately $2.3 million 
in wasted taxpayer funds for purchased iPhones and iPads that 
remained in storage with activated data plans instead of being 
sent directly to intended veterans.
    While conducting this review, did your office look 
specifically into any quality of care issues that occurred 
within this specific program? For example, did veterans who 
resided in rural or highly rural areas of the country 
experience more quality of care issues due to lack of 
connectivity than their urban counterparts?
    Mr. Missal. Well, first, Senator Moran, thank you so much 
for your words. The answer to the question is we did not look 
at quality of care in that project. What we were looking at was 
the cost of the smartphones and the iPads for veterans 
experiencing homelessness.
    However, we have looked at connectivity issues in several 
other work projects. In one of them, we did find serious issues 
given that VA was doing more and more telehealth work in rural 
areas. And in July 2020, as the pandemic was really starting 
and VA announced that they were going to be moving more and 
more toward telehealth, what we did was we looked at 16 highly 
rural CBOCs that were having connectivity issues to see whether 
or not there would be adequate community care resources 
available to them, and what we found in 12 of the 16 they did 
not have the kind of community care services that you would 
hope for in these highly rural areas.
    Senator Moran. Thank you for your answer.
    The Senator from West Virginia, Senator Manchin.
    Senator Manchin. Thank you, Chairman Moran.
    First of all, I want to thank the second panel for being 
here. And, Mr. Missal, as the VA Inspector General, you and I 
have had a lot of conversations, and they have been vital to 
patient safety and quality of care at VA. And I appreciate very 
much all your work to keep me updated on specific issues that 
we are facing in West Virginia.
    Dr. Perlin, I really appreciate you being here, and I will 
say this, you are new. You were not there when all this 
happened. So I want to make sure we clarify that because my 
remarks were not that kind to The Joint Commission after this. 
But you are new, and I hope that these changes will come.
    As you know, I am extremely concerned about the current 
state of the relationship between The Joint Commission and the 
VA. Like I said at the beginning of this hearing, The Joint 
Commission consistently gave the Clarksburg VA a passing score 
for accreditation before and after the horrific murders 
occurred at the facility.
    The Joint Commission was even onsite at the Clarksburg VA 
for a review which Clarksburg passed. They passed it. That was 
less than eight weeks before the murders began. That year, the 
VA paid The Joint Commission almost $6 million for their 
services. That really does not set right with me, knowing the 
amount of money that we have invested there and the return we 
got.
    As a Senator or as a West Virginian, it all comes back to 
accountability. It really does. And I look forward to hearing 
your answers to my questions, and I will start with Dr. Perlin, 
with you, on this question here. How did The Joint Commission 
miss this blatant oversight during their May 2017 onsite 
survey? And, sir, you were not in charge at that time, and I 
want to clarify that again.
    Dr. Perlin. Thank you, Senator. First, let me thank you for 
your passion around this topic. My career has largely been 
devoted to VA as Under Secretary for Health and otherwise, and 
I join you with outrage and also join you in sympathy to the 
families of those veterans so tragically affected.
    I have had reason, obviously, to review the history of The 
Joint Commission's presence there. As I mentioned, a broad 
survey sort of skims the surface. It is a vehicle for 
accountability.
    I did not appreciate exactly how strong a vehicle for 
accountability it was until I personally went on a survey, on 
the survey side, this past week. And I saw that you see things 
that you do not see in the place you live or work. I mean, it 
is like your home, where you may know that I do not plug in the 
toaster with the coffee pot because it blows the fuse. Only, 
this is health care. This is people's lives. And The Joint 
Commission, when we are onsite, can see those sorts of things.
    In the survey done, the broad exam of the facility in 
2017--and as I understand it, that particular nurse tech was 
hired in 2015--it is like that that particular chart would not 
have come up for review. In retrospect, clearly, there were HR 
issues. Clearly, there were medication management issues.
    When VA came back, not at the time that the Inspector 
General was available to evaluate in 2018, but when it found 
out with the rest of the public late in 2019, as I understand 
it, based on your passion and the passion of VA leadership, a 
lot of things were in place. So there is an artifact of timing.
    That said, I am not comfortable with an organization that 
cannot go deeper on these sorts of things.
    Senator Manchin. We are hoping you make these changes. Here 
is the problem if these changes do not--The Joint Commission 
standards and ability of your surveys to identify violations do 
not align did not align, with protecting patient safety. That 
makes me wonder why we continue to use The Joint Commission 
while there are several other accreditation bodies, including 
State surveyors through the Centers for Medicare and Medicaid 
Services, that seem to have done and been able to do a better 
judgment for our veterans and their families.
    I will finish with this one. Has The Joint Commission ever 
revoked accreditation status? As you look back in the history, 
has that ever happened?
    Dr. Perlin. I am unaware that VA has revoked 
accreditation--that The Joint Commission has revoked VA 
accreditation.
    Senator Manchin. Did The Joint Commission issue any 
corrective action for Clarksburg VA following these murders?
    Dr. Perlin. I believe that there were issues that were 
identified that would relate to the issues----
    Senator Manchin. Again, sir, I know being new, and again, I 
say this; I appreciate you being here. If I could get more 
direct answers, if you could look back into that and get me 
more direct answers, how The Joint Commission--when Mr. Missal 
went through, I found out more in the seven days they were 
there than I found out through the whole time of the 
investigations.
    Dr. Perlin. Right. Well, the Inspector General, of course, 
did a very focused ``for cause'' review, and I will find out 
what we had.

    [The Joint Commission response to Senator Manchin appears 
on page 77 of the Appendix.]

    That said, let me just make two points. First, you know, we 
get our driver's license, and that is a demonstration of basic 
competencies and safety if you abide by the rules of the road. 
This was a malevolent individual with intent to harm. I wish I 
could sit here and tell you that would never happen again. It 
is not possible.
    Senator Manchin. Yes.
    Dr. Perlin. What I can tell you is that in contrast to the 
other accrediting bodies The Joint Commission has a broad range 
of standards that go far deeper into both the culture of safety 
and the mechanisms of safety and into accountability than the 
others.
    Senator Manchin. Sir, I am sorry to cut you off. I just 
want to ask Mr. Missal one question because I have got to go 
vote.
    Mr. Missal, understanding that every incident is different, 
what are the standards the OIG uses when assessing and 
investigating VA facilities both before and after the OIG has 
made findings and issue recommendations? What is your follow-up 
procedures before and after?
    Mr. Missal. Well, the standards we follow are VHA policies 
and procedures and determine whether or not the facility is 
complying with those policies and procedures. We will, on 
occasion, make comments if we do not believe the policy or 
procedure is adequate.
    We do follow up on at least a quarterly basis. We will look 
at any open recommendations and work with the facility to try 
to close those, but again, they have to be to our satisfaction, 
that we believe they have met the objective and it is 
sustainable.
    Senator Manchin. Let me just say this. Every member we have 
that serves on this Committee is here for a--we have chosen to 
be on this Committee because of the veterans, because of people 
in our families, our communities, and what they have served and 
sacrificed for all of us. So we care deeply, and when something 
happens this tragic--and there is more than seven that we know 
of. That is all she admitted to. We know there is more.
    You can only imagine looking at these families saying, ``My 
dad was okay. He was okay two days ago. What happened?'' And 
there were no answers given. That is the reason that we are in 
this the way we are.
    I appreciate all of you. I do not want this to happen in 
New Hampshire or in Alabama. It should not happen anywhere and 
to go through this. So how do we prevent it? How do you hire? 
What is the vetting process? Locking things down. Making sure. 
That should be recognized beforehand.
    I am so sorry. They are going to cut me off here anyway, 
but if you want to answer very quickly, please do.
    Mr. Perlin. On the hiring, I think that is so critically 
important. There are things I learned in private sector that I 
wish I had known when I had the privilege of leading VA.
    You indicated a tension right now between the shortages in 
workforce and the whole vetting of an individual.
    Senator Manchin. Yes.
    Mr. Perlin. Here is an approach which is a stoplight 
report. Green: good credentials, clean background. Yellow: 
maybe some problems in competencies, maybe some problems in 
background, needs a VISN approval. Red: absolute dead stop and 
that can only be approved in the Under Secretary's Office or 
the Office of the Secretary.
    Senator Manchin. Thank you.
    Thank you, Mr. Chairman. I am sorry for taking a little bit 
privilege there.
    Senator Moran. An important topic. Terrible tragedy in West 
Virginia.
    Senator Tuberville.
    Senator Tuberville. Thank you, Mr. Chairman.
    Thank you for being here today. That was interesting. We 
all find that sad things happen.
    Inspector General, I want to ask you about issues related 
to coordination of medical care between the VHA and community 
providers. I believe your office has identified multiple 
examples of providers in the community not reviewing 
documentation from VA providers and vice versa when providing 
care to veterans, which slows down the delivery of effective 
treatment and diagnoses for veterans. Does your office provide 
recommendations on how to address these situations, and those 
recommendations, are they acknowledged and resolved by either 
the VA or the community provider?
    Mr. Missal. Our recommendations will be to VA, not to the 
community providers, and we do look at community care. We have 
issued a number of reports already. We have others in progress.
    We recognize the importance of community care. And we have, 
as you pointed out, recognized issues with documentation, where 
if a veteran goes out in the community sometimes the 
documentation does not come back to VA. And to have care 
coordination, you need to have a complete record, and we 
sometimes do not see that, so we have made recommendations to 
ensure that those records are back.
    And I will turn it over to Dr. Kroviak if she has any other 
thoughts on that.
    Dr. Kroviak. I would just add and actually endorse what Mr. 
Missal just described. That information sharing is critical. 
And we repeatedly find shortcomings, and we have addressed it 
at the facility level, where we find those issues, where 
communication was not consistent, where records were not 
returned to the facility on time.
    And unfortunately, what typically happens is the providers 
on the VA side are going out of their way to find out what type 
of care the veteran received in the community, and that is an 
inefficient use of their expertise. That should be spent taking 
care of the patient, not doing paperwork.
    Senator Tuberville. What kind of feedback do we normally 
get, you know, on this? Do we get--either one of you--you know, 
the feedback that you provided through these recommendations?
    Dr. Kroviak. From the facility or from VA?
    Senator Tuberville. Yes.
    Dr. Kroviak. So classically, the conversations are 
productive, and we reach an agreement and a consensus that they 
agree with our findings. And they put forward an action plan 
that we can accept, and we will ultimately wait to see what 
kind of evidence they provide throughout that process to close 
the recommendation.
    But as Dr. Clancy suggested, our standards are quite high, 
to see not only the evidence is valid and shows that it met the 
intent of the recommendation but that they are sustaining that 
improvement through the action plan. So it is not easy for them 
to get closure of our recommendations.
    Mr. Missal. And I would just add that both of our goals, 
the OIG and VHA, is to help improve services for veterans. So 
we have that same objective, and that is why when we have 
discussions we are all trying to reach the same point.
    We typically get involved when we may have identified an 
issue. We believe we understand what the root cause is because 
whenever we do a report we look at root causes because if you 
do not understand why something happened it is hard to fix it. 
We are the ones who decide what we think is the most 
appropriate manner in which to address it. We will talk to VA 
to make sure we have not missed anything, but at the end of the 
day, we are the ones who issue the recommendations.
    Senator Tuberville. Thank you. In the case of Tuscaloosa VA 
Medical Center, where your staff confirmed, you know, numerous 
visits--after numerous visits, recommendations over a three-
year period, that the facility continues to fail VHA mandated 
standards for patient safety. What is the responsibility of the 
IG here?
    Veterans are being seen there continuously, still every 
day. And what avenues can the IG leverage besides confirming 
that there are failed standards? I mean, what can we do? I 
mean, we have got an ongoing process here. All three of you, if 
you can answer, that would be great.
    Mr. Missal. Our responsibility is to conduct oversight and 
identify issues. Tuscaloosa is yet another example where we 
came in, we found issues with the patient safety program, came 
back about a year later, they still had not fixed what we 
thought they were going to fix. So when we see facilities which 
have continuous problems or more serious leadership issues, 
then we are going to watch it that much more closely, and 
Tuscaloosa is a good example of a facility where we are 
watching closely and we have other active projects in that 
area.
    It is up to VA to fix it. We can identify the problem, make 
recommendations, but it is up to VA----
    Senator Tuberville. Is it usually personnel, or is it 
usually just restrictions or guidelines that they do not 
follow?
    Mr. Missal. It is really a host of different things it 
could be. They have different policies that they have in place. 
They are required to follow it by their own policies. So we 
will identify it, but if there are other issues that we 
identify which impact patient safety or just the efficiency of 
health care, we will raise those as well.
    Senator Tuberville. Anybody else got a comment on that?
    Dr. Kroviak. If I could just add, it is often leadership. 
VA has a plethora of policies specific to patient safety, but 
if the leaders are not promoting the staff repeatedly carrying 
out those policies to actually feel responsible and empowered 
to carry out those policies, we will always have these repeated 
findings.
    Senator Tuberville. It always starts with leadership.
    Dr. Kroviak. Absolutely.
    Senator Tuberville. We all know that. And does anybody ever 
lose their job over this? Do you know? Is there any examples of 
people?
    Mr. Missal. I can give you one example. The example I 
brought up with the Washington, DC inventory system, where we 
found significant issues, I personally briefed the then 
Secretary on that issue, and he told me he was making a change 
in leadership that day, and he did so. And I am sure there are 
other examples that we could think of as well.
    Senator Tuberville. Thank you. Thank you very much.
    Chairman Tester [presiding]. Senator Hassan.

                  SENATOR MARGARET WOOD HASSAN

    Senator Hassan. Well, thank you, Mr. Chair, and I want to 
thank you and the Ranking Member for holding this hearing. And 
to our witnesses, thank you so much for being here.
    Mr. Missal, the VA has routinely dismissed whistleblower 
claims, including whistleblowers at VA facilities that Granite 
State veterans rely on for their care. Last year, the Office of 
Special Counsel published a really troubling report that 
reinforces that the VA failed to take seriously whistleblower 
complaints, this time regarding allegations at the White River 
Junction Medical Center, right over the river from New 
Hampshire in Vermont.
    This case is just one example where the VA failed to treat 
allegations seriously and failed to safeguard whistleblowers, 
which impacts patient safety, quality of care, and the VHA 
workforce. How can the VA address the culture of silence and 
whistleblower retaliation at VHA facilities in its strategy to 
address patient safety?
    Mr. Missal. I will keep repeating that it really comes back 
to the leadership. When you have a culture like that, the tone 
is set at the top, and leaders really have to say that when 
there is an issue, you should raise it. You need to have a 
climate where staff, whistleblowers, and others who raise 
complaints, feel comfortable coming forward, and we hear time 
and time again that people are not comfortable in doing so. 
That is why we appreciate the training bill that you introduced 
because I think the more the VA staff understands the OIG and 
other outlets they may have and that they can make their 
complaints anonymously, that they will be protected, et cetera, 
I think that will have a good effect and hopefully change the 
culture.
    Senator Hassan. Well, thank you.
    Dr. Meyer. Senator, may I comment on that question?
    Senator Hassan. Yes, sure.
    Dr. Meyer. I do think there is a clear way to do that, that 
we actually know that we can actually measure among our staff 
their psychological safety and their safety culture. And I do 
believe holding leaders accountable for their safety culture 
results as part of their performance, just like you hold them 
accountable for financial performance, you hold them 
accountable for quality performance, you hold them accountable 
for safety performance, holding them accountable for culture 
performance is a mechanism to achieve exactly that.
    Senator Hassan. Well, I appreciate that, and let me just 
follow up then a little bit on what you just said, Mr. Missal. 
Your testimony noted that the common contributing factors to 
Veterans Health Administration failings ``are poor, 
inconsistent, or ineffective leadership that cultivate 
complacent and disengaged medical facility culture in which the 
VHA goal of zero patient harm is improbable, if not 
impossible.''
    So we have talked a little bit about the whistleblower 
issue and that the importance of culture and leadership there. 
But from the many incidents specific in Veterans Health 
Administration's systemwide reports that the Office of the 
Inspector General produces, what are some of the other 
challenges VHA faces?
    Mr. Missal. Ensuring people are held accountable because if 
there are issues and that people are not accountable, then that 
again corrodes the culture that they have. There also has to be 
a recognition that mistakes are going to be made. And a real 
key is not so much the mistake, you get into the root cause, 
but what happens afterward.
    Senator Hassan. Right.
    Mr. Missal. You want to make sure that they raise it and 
that it is dealt with appropriately.
    Senator Hassan. Right. Thank you. And you mentioned that 
the bill that I have in bipartisan legislation with Senator 
Boozman. I just want to let my colleagues know I am grateful 
for your support of it.
    The VA currently offers an optional 45-minute whistleblower 
training to employees, but what we find now is many VA 
employees have opted out of the training and they often 
therefore lack the skills to spot the early indicators of 
fraud, potential crimes, or deficiencies in patient care. I am 
pleased that this Administration supported a directive that now 
makes this training mandatory, but I do believe we need to make 
that directive permanent and in statute.
    So I am grateful to Senator Boozman for the work, and if 
there is anything else you would like to add about the 
importance of that legislation, please feel free now before I 
run out of my time.
    Mr. Missal. No, we agree it is critically important. Even 
though there is a directive in place, a future Secretary could 
take that directive away. We have been asking previous 
Secretaries for that same training. Secretary McDonough is the 
first one to agree to do it, and so legislating the requirement 
of the training, I think, would be critically important going 
forward.
    Senator Hassan. Well, thank you. I appreciate that, and 
thanks, Mr. Chair.
    Chairman Tester. Senator Cassidy.

                      SENATOR BILL CASSIDY

    Senator Cassidy. Thank you all. Mr. Missal, you had 
mentioned at the Washington--there was a change in leadership 
in the inventory system, but you did not specifically say the 
person accountable was fired. You just said there was a change 
in leadership. To your knowledge, was the person responsible 
for this fired?
    Mr. Missal. I do not recall all the personnel actions. I 
know there were a number of changes made at the facility, but 
that would be VA who does those. We do not get involved in 
personnel actions.
    Senator Cassidy. There is a woman behind you shaking her 
head ``yes,'' and so either she approves of the question or she 
knows the answer.
    Dr. Clancy. Yes, that person was fired.
    Senator Cassidy. Yes. Thank you. I appreciate that.
    Now you mentioned that there are--I forget your 
nomenclature, but that there are a group of low-performing 
hospitals that are characterized by constant turnover in 
leadership. Now what percent of VA facilities are low 
performing with the criteria that you specified?
    Mr. Missal. The report that is mentioned in the testimony, 
we looked at one particular VISN and looked at medical centers 
within that VISN. One was higher performing; one was lower-
performing. You have the same VISN leadership. You would think 
they would be pretty similar. So the question was: Why is one 
higher-performing and one is lower-performing?
    And one of the things that really stuck out to us after 
doing the inspection was that the higher-performing facility 
had more stable leadership.
    Senator Cassidy. I get that; I get that.
    Mr. Missal. Okay. But we did not look beyond that. That 
report was just for those two facilities, our----
    Senator Cassidy. Let me ask then. I am a little--and I am 
sorry I have not read your report. I have read your testimony. 
But you talk about episodes across the Nation that--you know, 
the people in Arizona, the people in Clarksburg, the people in 
Arkansas and Alabama. So it sounds like you did some work 
outside of one particular VISN, or were those just anecdotes 
that you were investigating?
    Mr. Missal. No, in every project, we do look at leadership. 
Leadership is so important.
    Senator Cassidy. But my point--I guess what I am after, we 
need some sort of statistical evaluation as to what percent of 
these hospitals are miserable because they have leadership 
which is constantly overturning and someone like Dr. Levy is 
allowed to do these terrible things which, as a physician, just 
outrages me.
    Now if all we can do is just do a sample and only from that 
sample know the results of that particular sample as opposed to 
extrapolation, I am not sure that is as helpful as to say that 
these are the characteristics of a poorly functioning facility 
and therefore require more attention just because they have 
these characteristics. Now did you do any of that, or would it 
just be a matter of extrapolating your findings for someone 
else like the VA to go do that?
    Mr. Missal. No. We did it in this particular report. We 
looked at what are the characteristics of leadership at a well 
performing facility----
    Senator Cassidy. But did you extrapolate those results to 
see if they apply to other facilities?
    Mr. Missal. We did not specifically extrapolate, but we 
look at dozens and dozens of facilities a year. We do look at 
leadership and assess how they are doing and the impact that 
they are having.
    Senator Cassidy. And, sir, knowing that they have done this 
work and knowing that you all reviewed this, do you take the 
criteria of this kind of tumultuous leadership, constantly 
changing, et cetera, as a means to more closely scrutinize some 
facilities as opposed to others?
    Dr. Perlin. One of the most important sections of The Joint 
Commission's standards is the chapter on leadership, and 
leadership turnover is a sign----
    Senator Cassidy. But that is not my question. But if there 
is tumultuous turnover, do you therefore focus more intently 
upon that facility?
    Dr. Perlin. That would be a clue to the surveyors that, 
yes, they would increase their level of scrutiny.
    Senator Cassidy. Gotcha. Thank you. I do not mean to be 
rude.
    Dr. Perlin. No, no, no, sir.
    Senator Cassidy. Dr. Meyer?
    Mr. Missal. But if I could say----
    Senator Cassidy. Yes, sir.
    Mr. Missal. One thing we do when we inspect we do look at 
tenure of all the leaders there, and one thing we found that 
was disturbing is at about half the facilities their director, 
the leader of that facility, had been in place two years or 
less.
    Senator Cassidy. Is that half of the facilities VA-wide or 
just those at which you looked?
    Mr. Missal. That we looked at, but we look at about a third 
of the facilities every year. We are at about a three year 
cycle. So it is a pretty significant percentage.
    Senator Cassidy. Dr. Meyer, I think you are somewhere out 
there on Zoom. I think we heard that a third of the facilities 
have turnover in their leadership, which is associated with 
poor outcomes. You reviewed the literature. I gather that you 
have written some of the literature which you review, which 
finds a similarity and even indeed, at times, an increase or 
better care among VA facilities versus the community.
    But if we hear that a third of them have this kind of 
turnover in leadership, which is a hallmark of not doing well, 
is it just that we are burying our mistakes in the mean, or if 
we looked at a distribution of results, will we see that there 
is a subset of VA hospitals which underperform?
    Dr. Meyer. There is always going to be a subset which 
underperform, and I think that is one of the points I tried to 
make in my earlier testimony. And that is that although it can 
be comforting that in the aggregate the VA does well, there is 
wide variation, and it is really focusing in on that variation 
that is so important. One of the factors, obviously, is 
stability of leadership, but there are others that really 
create those outliers where attention should be directed.
    Senator Cassidy. So, Dr. Meyer, do we know that the VA is 
taking that subset of hospitals, which apparently you and the 
Inspector General can look at and The Joint Commission can look 
at and say they are at risk? Do we know that the VA is looking 
at that subset and doing a deep dive so that if there is a 
pathologist who is falsifying results that that pathologist is 
discovered? Is that a ``yes'' or a ``no''? Do you know? Do we 
know if they are doing that?
    Dr. Meyer. I do not know if they are doing that.
    Senator Cassidy. Gotcha. Dr. Meyer, I am almost out of 
time, but--well, I am out of time, but I am the last one here, 
so why not. Can I go a little bit further?
    Chairman Tester. [Inaudible.]
    Senator Cassidy. You mentioned the greater efficiency of 
the VA facilities versus the private sector. A concern of mine, 
though, has been--at least, maybe this has changed, but the 
lack of effective utilization review for those veterans who go 
out of the VA system to get their care. I did not completely 
review the NBER study that you reference that referenced the 
increased efficiency. But if there is a VA hospital in which, 
because of the lack of UR, the veteran is going to a private 
facility and getting a complete workup, sometimes maybe 
duplicative of that which has already been done, is that being 
counted toward the efficiency of the VA, or is that not being 
included? I do not know that; I am asking.
    Dr. Meyer. Yes, that study by the NBER, that that would be 
considered to be civilian care, and so they would not be 
included with the VA----
    Senator Cassidy. Even though the VA was paying that bill?
    Dr. Meyer. Even though the VA was paying for that because 
what they do is they tracked veterans who were eligible for 
Medicare and VA care, and what they did is they looked to see 
of all them going to an emergency room how many of them end up 
getting their care on the civilian side versus the VA side. 
They tag the VA with a----
    [Simultaneous discussion.]
    Senator Cassidy. But I guess what I am asking----
    Dr. Meyer [continuing]. The civilian side with civilian 
side.
    Senator Cassidy. So if it is only restricted to those who 
are on Medicare as opposed to the younger veteran for whom the 
VA would be paying for that service provided by the private 
sector, then that study is flawed because the VA is not getting 
dinged for perhaps excessive services occurring in the private 
sector that are only occurring because there is inadequate 
utilization review. Is that a fair critique?
    Dr. Meyer. That is a fair critique. However, I would say 
that in general, when you look across very, very broadly, 
across the costs per veteran of health care and compare that 
with the costs per civilian in health care, the VA is generally 
lower. It could be an issue.
    Senator Cassidy. In that NBER study that I read, it looked 
like some of that was driven by end-of-life care where the VA 
was more efficient with end-of-life care, and that is very 
expensive. And so if you take out end-of-life and you look at 
the other health care, I would be interested in knowing--and 
again, you would not know. It would be the authors of the 
study. As to--because I am concerned that people are going to--
that the lack of utilization review by the VA is resulting in 
people going to private clinics and getting excessive testing.
    Anecdotally, I have seen evidence of that, but it is all 
anecdote, does not mean it is data, but it seems if you are 
ignoring that. And again, if you take out the end-of-life care, 
which would, of course, help the Veterans Administration look 
lower per patient--I think I have developed my point. I am 
worried about the validity of that study.
    Dr. Meyer. I would say I think the study is valid for 
looking at segments of the VA population. I think your concern 
about lack of UR is an important consideration and something 
that needs to be addressed.
    I would also note, in addition to improved end-of-life 
care, I think that the VA offers three things that are special 
compared with civilian care that I think do allow it to be more 
efficient. The first is continuity of care, that veterans tend 
to be loyal to the system. The second is their electronic 
health records that allow them to follow patients over time and 
space. And the third one is veteran's care is integrated much 
more so than the care afforded in most civilian facilities. So 
there are several other factors that I think make the VA 
different, and all would lean toward them being more efficient.
    Senator Cassidy. Thank you. I thank you all for coming 
here, and I yield.
    Chairman Tester. Thank you, Dr. Cassidy, and I think it is 
important that when studies are done we are comparing apples 
with apples. And I would also say we had a panel that Dr. 
Clancy was on that may be able to answer your question about 
whether they are doing in-depth reviews on underperforming 
clinics.
    Senator Cassidy. We will do that as a QR.
    Chairman Tester. You bet. Absolutely.
    Do you have anything, Senator Moran, before I close this 
out?
    Senator Moran. I do not, Mr. Chairman.
    Chairman Tester. Okay. So I just want to thank everybody 
for being here today, thank all our witnesses. I look forward 
to continuing to work to ensure that we are providing veterans 
with the highest quality care possible.
    The record will be kept open for a week, and this hearing 
is adjourned.
    [Whereupon, at 4:43 p.m., the Committee was adjourned.]

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