Congressional Hearings
THE CURIOUS CASE OF THE VISN TAKEOVER: ASSESSING VA'S GOVERNANCE STRUCTURE
Congressional Hearings
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Congress: House of Representatives
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| AUTHORITYID | CHAMBER | TYPE | COMMITTEENAME |
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| hsvr00 | H | S | Committee on Veterans' Affairs |
[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
THE CURIOUS CASE OF THE VISN TAKEOVER: ASSESSING VA'S GOVERNANCE
STRUCTURE
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
TUESDAY, MAY 22, 2018
__________
Serial No. 115-62
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
___________
U.S. GOVERNMENT PUBLISHING OFFICE
35-490 WASHINGTON : 2019
COMMITTEE ON VETERANS' AFFAIRS
DAVID P. ROE, Tennessee, Chairman
GUS M. BILIRAKIS, Florida, Vice- TIM WALZ, Minnesota, Ranking
Chairman Member
MIKE COFFMAN, Colorado MARK TAKANO, California
AMATA COLEMAN RADEWAGEN, American JULIA BROWNLEY, California
Samoa ANN M. KUSTER, New Hampshire
MIKE BOST, Illinois BETO O'ROURKE, Texas
BRUCE POLIQUIN, Maine KATHLEEN RICE, New York
NEAL DUNN, Florida J. LUIS CORREA, California
JODEY ARRINGTON, Texas CONOR LAMB, Pennsylvania
CLAY HIGGINS, Louisiana ELIZABETH ESTY, Connecticut
JACK BERGMAN, Michigan SCOTT PETERS, California
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto
Rico
BRIAN MAST, Florida
Jon Towers, Staff Director
Ray Kelley, Democratic Staff Director
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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Tuesday, May 22, 2018
Page
The Curious Case Of The Visn Takeover: Assessing Va's Governance
Structure...................................................... 1
OPENING STATEMENTS
Honorable David P. Roe, Chairman................................. 1
Honorable Julia Brownley, Acting Ranking Member.................. 3
WITNESSES
Carolyn Clancy, M.D., Executive in Charge, Veterans Health
Administration, U.S. Department of Veterans Affairs............ 4
Prepared Statement........................................... 37
Accompanied by:
W. Bryan Gamble, M.D., Deputy Chief of Staff, Orlando VA
Medical Center, Veterans Health Administration, U.S.
Department of Veterans Affairs
Honorable Michael J. Missal, Inspector General, U.S. Department
of Veterans Affairs............................................ 6
Prepared Statement........................................... 39
Roscoe G. Butler, Deputy Director for Health Care, National
Veterans Affairs and Rehabilitation Division, The American
Legion......................................................... 8
Prepared Statement........................................... 47
STATEMENTS FOR THE RECORD
U.S. OFFICE OF SPECIAL COUNSEL................................... 50
THE CURIOUS CASE OF THE VISN TAKEOVER: ASSESSING VA'S GOVERNANCE
STRUCTURE
----------
Tuesday, May 22, 2018
Committee on Veterans' Affairs,
U. S. House of Representatives,
Washington, D.C.
The Committee met, pursuant to notice, at 10:15 a.m., in
Room 334, Cannon House Office Building, Hon. David R. Roe
[Chairman of the Committee] presiding.
Present: Representatives Roe, Bilirakis, Coffman, Bost,
Poliquin, Dunn, Arrington, Bergman, Banks, Mast, Brownley,
Kuster, Correa, Lamb, and Peters.
Also Present: Representative Moulton.
OPENING STATEMENT OF DAVID P. ROE, CHAIRMAN
The Chairman. Good morning. The Committee will come to
order.
Thank you for being here today to discuss issues found at
facilities in the Veterans Integrated Service Network, or
VISNs, 1, 5, and 22; and, more broadly, the role of VISNs in
veterans' health care.
Before we begin, I ask unanimous consent that Seth Moulton
from Massachusetts be allowed to join us at the dais and
participate today's hearings.
Without objection, so ordered.
On March 7th, former Secretary Shulkin held a press
conference to announce a list of reforms to increase
accountability, streamline operations, and remove layers of
bureaucracy in VHA. He ordered plans to restructure the Central
Office and to reorganize procurement and logistics functions,
both due May 1st, as well as a third plan to reform VISNs by
July 1st.
Additionally, Dr. Shulkin ordered a targeted VISN
reorganization that gave rise to the title of this hearing. He
said, quote, ``Effective immediately, we are putting a new
executive in charge, Dr. Bryan Gamble. Dr. Gamble is going to
have direct accountability for three VISNs as we begin to
redesign the role of the VISNs. Those facilities will report
directly to Dr. Gamble, who will be here in Washington, and his
responsibility is to oversee and to directly improve the
accountability and performance, working with our facility
directors to make sure that these facilities are performing up
to the standards that we expect for our veterans.
``What Dr. Gamble will be doing, besides just making sure
these three VISNs are operating under the correct performance
standards, is that a report be given to me by July 1st of this
year with a plan to reorganize and to improve the function of
our networks,'' end quotes.
These were forceful measures in a crucial time. Inexcusable
bureaucratic failures to put veterans' health at risk in those
areas of the country, particularly at the Washington, D.C.;
Manchester, New Hampshire; and, Bedford, Massachusetts Medical
Centers.
Dr. Shulkin was speaking from the D.C. Medical Center in
the midst of its highly-publicized crisis. Not only did the
medical supply chain completely break down, leading to
veterans' procedures being postponed or canceled, the most
basic functions of the hospital also fell into disarray. Many
of us visited the facility last year and saw the situation
firsthand. And, quite frankly, at that time when I went out
there, I was under the impression that things were improving,
were getting better.
The most worrying aspect for me is the fact that the VISN
and the Central Office knew of the problems in D.C., in many
cases for years, yet were unable or unwilling to solve them. I
wholeheartedly agree the VISNs are due for an overhaul. They
should be the failsafe mechanism when a medical center goes off
course. Unfortunately, too many of them seem to be afflicted
with a case of learned bureaucratic helplessness.
The VISNs were created in 1995 to decentralize budgeting,
planning and oversight. There were originally 22 of them with
between seven and ten employees each. Today, there are 18 VISNs
with up to 61 employees each. They perform a much wider range
of functions, but with some exceptions, they do so
ineffectively. Only the VISN director has any real authority
over the medical centers within the VISN. Many of the VISN
employees view their roles as consultative or advisory.
I have had many questions about the reform measures.
Obviously, May 1st has already passed, and the Central Office
and procurement and logistics reorganization plans are nowhere
to be found. Have these initiatives been abandoned? Secondly,
what has truly changed in VISNs 1, 5, and 22 as a result of the
increased scrutiny, and how will any improvements be extended
to other VISNs? Thirdly, what is the vision for the nationwide
VISN redesign?
I look forward to reading the plan, but July 1st is
approaching fast and we have heard very little about it. If VA
does not articulate a definition of success with measured
outcomes, we have no guarantee that veterans will be better off
under this restructuring.
I held a roundtable discussion almost a year ago with VA
and over a dozen private sector health care organizations.
Every one of them deals with the question of centralization
versus decentralization. Most of the large hospital systems
have some sort of regional organization. The Choice Act
independent assessment and the Commission on Care both closely
examined VHA's organization. There are many places VA can look
for guidance when considering how to reshape the relationship
between the Central Office, the VISNs, and the medical centers.
This Committee and the Congress as a whole are committed to
VA's success. I think the MISSION Act and another budget making
historic investments in veterans' health care and benefits are
evidence of that. I have high expectations for these
reorganization plans. It is vital to define the goals at the
beginning, engage stakeholders, and be transparent throughout.
This cannot merely be a public relations exercise to get
through the crisis of the moment or more glossy reports that
sit on shelves.
I look forward to an open and honest conversation today
about how we can ensure these particular VISNs and their
medical centers live up to their purpose, and how we can
strengthen VHA's governance so this sort of horrendous neglect
never happens again.
The Chairman. With that, I yield to Ms. Brownley for her
opening statement.
OPENING STATEMENT OF JULIA BROWNLEY, ACTING RANKING MEMBER
Ms. Brownley. Thank you, Mr. Chairman, for holding today's
hearing on Veteran Integrated Service Network, or VISN,
governance.
The organizational structure of the Veterans Health
Administration has long been an issue and I am concerned that
the current VISN structure is leading to unclear roles and
responsibilities at the highest levels of VA management. We are
here today so we can understand how the organization and its
leaders, and now lack of leaders, are contributing to the
problems in facilities across the country.
VA Medical Centers in Manchester, New Hampshire; Bedford,
Massachusetts; Washington, D.C.; and Phoenix, Arizona all have
one thing in common: in every case, VISN and VA Central Office
leaders were aware of infrastructure, care, quality, and
patient safety concerns, but did not take the appropriate
actions until the IG or whistleblowers uncovered these issues.
Take the D.C. VA Medical Center as the latest example. The
medical center VISN and Central Office leadership ignored at
least seven reports that, if considered, could have prevented
nearly every issue that was identified during the IG's 2017
investigation. This is very disturbing and unacceptable.
Senior leaders must be held accountable for failing to act
and we must take a hard look at the organization from top to
bottom to determine what is causing this lack of
accountability.
Last November, Congresswoman Kuster and I requested a GAO
review of the role and responsibilities of the VISNs. Chairman
Roe joined in that request, because our concern is a bipartisan
one.
After whistleblower complaints, an IG and Office of Special
Counsel investigations uncovered significant patient care and
infrastructure issues at facilities within VISNs 1, 5, and 22,
former Secretary Shulkin announced that he planned to task Dr.
Bryan Gamble, here with us today, with overseeing a significant
restructuring effort involving those VISNs. However, we lack an
understanding of what this receivership or restructuring effort
entails, and seek to understand what this announcement actually
means. We would like you to clear that up for us today.
It is our understanding that Dr. Gamble will not in fact be
leading a restructuring of these three VISNs, but would instead
provide us a report in June, or perhaps it is July. We are
tired of receiving reports, we are tired of inaction and, as I
mentioned before, there were seven reports on the D.C. VA
Medical Center.
Senior leaders in VISN 1 and at VA Central Office also
received reports on the Manchester VA Medical Center, but did
nothing until it became a national headline. If this
restructuring is simply a report, then we must ask who will be
responsible for leading VISNs 1, 5, and 22 now that they are
leaderless, and we must ask when key senior leaders' positions
will be filled at the VA Central Office.
We must also ask which leaders are contributing to what the
Inspector General describes in his testimony as a culture of
complacency and futility at VA Medical Centers, where dedicated
and hardworking staff believe their leaders will do nothing to
address problems, where leaders will not address provider
concerns, and where staff must just make do with few resources
and a disorganized and unaccountable organization. These
leaders should be held accountable for failing to take action.
These leaders should also be accountable for misleading
Congress and the press. A failure to be forthcoming about
patient safety, quality of care, infrastructure, and patient
access concerns hurts our ability to conduct oversight,
contributes to the sense of futility among providers, and
creates anxiety, mistrust, and frustrations for veterans who
rely on VA for their health care.
I hope today to hear more about what VA is actually doing
in response to the top-to-bottom organizational failures that
contributed to the most recent events in the Manchester,
Bedford, and Washington, D.C. medical facilities.
Thank you, Chairman Roe, and I yield back.
The Chairman. I thank the gentlelady for yielding.
I would now like to welcome our panel seated at the witness
table, if you would.
On the panel, we have Dr. Carolyn Clancy, Executive in
Charge of the Veterans Health Administration. She is
accompanied by Dr. Bryan Gamble, the Deputy Chief of Staff of
the Orlando VA Medical Center. Welcome.
On the panel, we also have the Honorable Michael Missal,
Inspector General of the Department of Veterans Affairs, and
Mr. Roscoe Butler, Deputy Director for Health Care, National
Veterans Affairs and Rehabilitation Division of The American
Legion.
Welcome each one of you to the panel.
I ask the witnesses to stand and raise your right hand.
The Chairman. Thank you very much. Let the record reflect
that all witnesses have answered in the affirmative.
Dr. Clancy, you are now recognized for 5 minutes.
STATEMENT OF CAROLYN CLANCY, M.D.
Dr. Clancy. Good morning, Chairman Roe, Ranking Member
Brownley, and Members of the Committee. I appreciate the
opportunity to discuss the proposed redesign of the current
Department of Veterans Affairs Veteran Integrated Service
Network, or VISN, structure and the status of remedial action
at VISNs 1, 5, and 22.
I accompanied today by Dr. Bryan Gamble, Deputy Chief of
Staff at the Orlando VA Medical Center.
On March 7th, as the Chairman noted, former Secretary
Shulkin announced VA would undertake a systematic review of the
VISNs with a specific focus on 1, 5, and 22. These three VISNs
were challenged with leadership and management issue, low-
performing facilities, and culture issues.
The purpose of this review is to identify VISN strengths
and weakness, and to create a plan to improve VISN oversight,
accountability, performance, and strengthen lines of
communication and clarify roles and responsibilities. Based on
his extensive leadership with the military health system, Dr.
Bryan Gamble was asked to lead this review and provide
recommendations with the goal of informing that redesign
process.
Our goal is to streamline processes, ensure clearly-defined
roles, responsibilities, and authorities among all levels in
VHA, so that we are functioning in a way that is more efficient
and, most importantly, produces better results and
accountability. We have also been working with our national
leadership council to develop a new model of governance to
shape the culture, and set expectations and requirements for
improved care for veterans.
Under the VISN model, health care is provided through
strategic alliances among medical centers, clinics, and other
sites, contractual arrangements with private providers, sharing
agreements, and other government providers. The VISN is
designed to be the basic budgetary and planning unit of the VA
health care system.
Since Dr. Shulkin's announcement, a team led by Dr. Gamble
has visited all three VISNs. And to look at best practices, the
team also visited consistently high-performing VISN 23. A
resounding theme was a dedicated workforce set on providing
veterans with the best possible health care, and a clear
understanding and willingness from leaders and employees at all
levels to improve upon deficiencies wherever found.
While these three networks are pretty dispersed
geographically, the assessment team found common themes across
these networks and facilities, including inconsistency of HR
services and hiring; additional emphasis needed on education
and training; unintended consequences of Management by
Measurement; leadership challenges, including turnover,
consistency, and psychological safety; and employee morale.
The findings from this review will be combined with ongoing
feedback and work from the existing network directors, and our
ongoing modernization effort to formulate the final plan for
redesign of the VISNs.
One of the key concerns of this Committee is the progress
at the Washington, D.C. VA Medical Center. While there is still
a lot of work to be done, significant progress has been made.
In March of 2018, as the Chairman noted, the Inspector
General released a final report finding that the D.C. VA had
for many years suffered a series of systemic and programmatic
failures, making it challenging for health care providers to
consistently deliver timely and quality patient care.
To key on a couple of improvements made since the interim
report was submitted by the IG in April of 2017, some of the
improvement efforts include assuring that all patients were
safe and none were harmed. VHA's National Center for Patient
Safety launched a rapid-response approach with on-site visits,
biweekly and weekly calls with the facility and VISN, and
assured all patient-safety issues were appropriately addressed.
We awarded a contract to construct a new, 14,200-square-
foot space for Sterile Processing and that will be completed in
March of 2019.
Transitioned inventory to the Generic Inventory Package
eliminated all pending prosthetic consults greater than 30 days
from more than 9,000 to zero. In short, ordering of prosthetics
is not interrupted by end-of-year financial transitions, and
allocated resources and expedited hiring into logistics and
Sterile Processing Service vacancies.
We know that how these networks operate is imperative. To
get the type of accountability that we need at every place
where veterans may seek our assistance and to ensure the best
quality of care is delivered, we have to take a critical look
at the processes, layers, and leaders to make sure that we
don't see the failures that we didn't see at the D.C. VA.
As the VHA and the D.C. VA move forward, we are putting in
place a reliable pathway for all facilities, VISNs, and
business lines to escalate high-priority concerns to senior
leadership for prompt action and follow-up. We encourage all
employees to speak up and raise concerns to leadership, because
they are an integral part of our front-line safety net and we
take their concerns very seriously.
Mr. Chairman, we appreciate this Committee's continued
support and encouragement in identifying and resolving
challenges.
In short, there are no missing VISN directors, what we are
losing is a past practice of inconsistencies in management and
oversight across VISNs and all of VA health care. This enhanced
consistency is imperative to our ability to achieve the best
possible outcomes for veterans envisioned by the MISSION Act,
which this Committee passed and subsequently the full House
passed last week, as well as to assure that we get the most out
of the new electronic health record implementation and that
that translates into enhanced results for those who have
served.
This concludes my testimony, and Dr. Gamble and I are
prepared to respond to any questions that you might have.
[The prepared statement of Carolyn Clancy appears in the
Appendix]
The Chairman. Thank you, Dr. Clancy.
Mr. Missal, you are recognized for 5 minutes.
STATEMENT OF THE HONORABLE MICHAEL MISSAL
Mr. Missal. Thank you. Mr. Chairman, Ranking Member
Brownley, and Members of the Committee, thank you for the
opportunity to discuss the Office of Inspector General's
report, ``Critical Deficiencies at the Washington, D.C. VA
Medical Center.'' We found that serious failures in leadership
and governance contributed significantly to the problems we
identified.
Since becoming Inspector General 2 years ago, I have made
examining leadership and governance issues at all levels of VA
a priority for our work, as shortcomings in these areas affect
the care and services provided to veterans, put Government
assets at risk, and allow significant problems to persist for
extended periods of time.
In March of 2017, we received a confidential source about
the D.C. VA alleging that supply and inventory issues put
patients and resources at risk. After a very quick assessment,
we determined that patients were at risk as a result of the
supply and inventory issues, that these problems were known at
various levels at VHA, but that VHA had failed to take the
necessary corrective action. As a result, we took the
extraordinary step of issuing an interim report. That interim
report was issued on April 12th, 2017.
We continued the inspection and issued our final report on
March 7th, 2018. Significantly, while we found patients were
put at unnecessary risk, we did not find any patient deaths or
other adverse clinical outcomes relating to these deficiencies.
This was primarily due to the efforts of a number of committed
health care professionals who improvised as necessary to ensure
veterans received the best possible care under the
circumstances.
Our final report contained 40 recommendations addressing
deficiencies in multiple core functions of the D.C. VA's
operations, all of which were agreed to by VA.
The more significant findings in our final report related
to patient safety include continuing supply chain and inventory
management problems; unsafe storage of clean, sterile supplies;
deficiencies in sterile processing service; inadequate product
safety recall practices; backlogs of open and pending
prosthetic consults; and staffing shortages and human resource
mismanagement.
Aside from the deficiencies that resulted in risk to
patients, we also found that the medical center continually
mismanaged significant Government resources and did not
adequately secure veterans' protected information. The D.C.
VA's financial and inventory systems produced inadequate data,
lacked effective management controls, and yielded no reasonable
assurance that funds were appropriately expended. Accordingly,
we could not estimate the loss to VA as a result of the
failings identified in the final report.
It is clear that information about at least some of the
failings at the D.C. VA reached responsible officials in the
D.C. VA VISN 5 and VHA Central Office as early as 2013, but
actions taken did not effectively remediate the conditions.
From 2013 through 2016, the D.C. VA and VISN 5 received at
least seven written reports detailing significant deficiencies
in logistics, sterile processing, and other services. The
chronic deficiencies noted in these reports underscore the
inability or unwillingness of leaders at various levels to
implement and sustain lasting change within various services.
In conclusion, the critical deficiencies we found in our
inspect of the D.C. VA were serious and disturbing. While the
failures present significant challenges, we believe the
greatest obstacle to change is a sense of futility and a
culture of complacency among staff and leaders. At the core,
the D.C. VA report is about the breakdown of systems and
leadership at multiple levels, and an acceptance by many
personnel that things will never change.
VHA has talented and committed people who could lead the
turnaround at the D.C. VA. With time and concerted effort, we
believe that positive change can be realized. VHA needs to
recognize the urgency in making strong leadership decisions now
to oversee that change. Although the findings and
recommendations focus on improvements in the D.C. VA, the
issues raised could be a checklist for other facilities, VISNs,
and VA leaders.
Mr. Chairman, this concludes my statement. I would be happy
to answer any questions that you or other Members of the
Committee may have.
[The prepared statement of Michael Missal appears in the
Appendix]
The Chairman. Thank you, Mr. Missal.
Mr. Butler, you are recognized for 5 minutes.
STATEMENT OF ROSCOE G. BUTLER
Mr. Butler. Good morning.
In 1994, the Veterans Health Administration was structured
into four regions. There was widespread consensus that the
system needed a major overhaul. In that same year, President
Clinton appointed Dr. Kenneth Kizer as VA Undersecretary for
Health. Dr. Kizer inherited an organization famous for low-
quality health care, difficult to access, and at a cost not
sustainable for the American taxpayers.
Chairman Roe, Ranking Member Brownley, and distinguished
Members of the Committee, on behalf of our National Commander
Denise H. Rohan and The American Legion, the country's largest
patriotic wartime service organization for veterans, comprised
of more than 2 million members and serving every man and woman
who has worn the uniform for this country, we thank you for
inviting us to share our position regarding the current status
of remedial actions at VISNs 1, 5, and 22.
The Veterans Health Care System is the largest health care
system in the United States. This national veteran-centric
health care system is centrally administered, fully integrated,
and is both funded and operated by the Federal Government. The
purpose of creating the VISN structure was to decentralize
decision-making authority regarding how to provide care and
integrate the facilities to develop an interdependent system of
care through the VISNs.
The VISNs' primary function was to be the basic budgetary
and planning unit of the Veterans Health Care System. However,
as we all know, the VISN structure has morphed into an
extensive operation consuming more staff, resources, funding,
and physical space.
Since the birth of Dr. Kizer's plan, VISN staff and
functions have extended way beyond the original tent of Dr.
Kizer's VISNs for Change. Since the creation of the VISN
structures in 1995, both the veterans' demographic and
geography has changed quite a bit, yet VA has not reassessed
the VISN structure to determine if it still benefits veterans.
However, in October 2015, VA has begun to implement a
realignment of its VISN boundaries, which involves decreasing
the number of VISNs from 21 to 18, and reassigning some medical
centers to difficult VISNs.
A concern of The American Legion is that VA officials have
stated that they do not have plans to evaluate the realignment
that is currently taking place. According to GAO, VA actions
are inconsistent with Federal internal control standards for
monitoring and risk assessments. Without adequate monitoring,
including a plan for evaluating the VISNs' realignments, VHA
cannot be certain that the changes they are currently making
are effectively addressing deficiencies, nor can it ensure
lessons learned can be applied to future organizational
structural changes.
There is no question that VA has endured its challenges.
For example, the Phoenix scandal of 2014, the 2017 VA OIG
report about equipment and supply issues at the Washington,
D.C. VAMC, to the January 2018 report of poor patient care at
the Manchester Medical Center. I highlighted these issues not
to open an old wound, but would rather use them to illustrate
that these may be evidence that the VISN structures lack
oversight and control, and is not living up to Dr. Kizer's
original vision of a patient-centered, integrated, independent
system of care.
The American Legion believes that is why former Secretary
David Shulkin announced his plan to reorganize the Department
VISNs network. Dr. Shulkin also discussed the appointment of a
special team to work with VA's national leadership council to
develop a network reorganization plan for its 23 VISNs, which
is due to the Secretary by July 1st of this year.
Mr. Chairman, clearly Dr. Kizer's Vision model is no longer
living up to the expectations, but rather has gone into a high-
cost, ineffective operation. In 2016, our members acknowledged
and voiced their concerns about this growing problem. Like most
veterans do, they took action and passed a resolution
discussing the effectiveness or the ineffectiveness of the
current VISN structure.
American Legion Resolution 194 entitled ``Department of
Veterans Affairs Integrated Service Networks'' urged Congress
to direct the GAO and VA OIG to conduct a comprehensive study
to include purpose, goals, objectives, budget, and finally an
evaluation of the effectiveness of the VISN structure as a
whole.
Further, The American Legion applauds former Secretary
Shulkin for proposing to look into reorganizing the VISNs and
the Central Office.
In conclusion, The American Legion thanks this Committee
for the opportunity to elucidate the positions of the over 2
million veteran members of this organization.
Chairman Roe, Ranking Member Brownley, and distinguished
Members of this critical and serving Committee, The American
Legion is so very thankful for the opportunity to be here
today. As Memorial Day is upon us, please allow me to also
thank each of you for the incredible work this Committee does
every day to help those who have already helped us.
With that, I conclude my remarks and I am happy to answer
any questions this Committee may have.
[The prepared statement of Roscoe G. Butler appears in the
Appendix]
The Chairman. Thank you, Mr. Butler.
I will start the questioning by thanking the Committee for
passing the MISSION Act. The Senate will vote on it this week.
We have had seven past Secretaries and Administrator sign
supporting that in both Republican and Democrat
administrations. So, thank you for that.
And I voice some frustration because this Committee
continues to produce legislation and this Congress, both
Republican and Democrat, continue to produce enormous amounts
of money for the VA, and yet what Mr. Missal tells us is that
there is a failure of leadership and governance within these
VISNs that he looked at.
And I want to give a shout-out to the health care people at
the hospitals who did the work around these things to help
patient safety. I want them to know I appreciate that very much
and I know that the veterans who are served there appreciate
that very much, to know that they created as safe an
environment as they possibly can even with these obstacles. So
I thank them for that.
I want to just start by just telling you how my day would
start and end when I was in practice. If I had a big number of
cases the next day in the operating room, the operating room
people, folks would show up in my office at 4:30, 5 o'clock,
5:30 when I saw my last patients, and they would say, ``Dr.
Roe, we have everything you need for tomorrow's surgery.''
Maybe you are doing a laparoscopic hysterectomy or maybe you
are doing a cancer case. We have got everything you need; we
have got blood available, we have got all your sutures, we have
got any prostheses you need, everything you need is ready for
you in the morning. There was never a question about it, I
never worried about that. I worried about doing my job.
It looks like at the Washington VA the doctors and nurses
had to worry about not only doing their job, but running across
the street during a case to get things that they needed to take
care of a patient. In one case, they put a patient to sleep and
then woke him up because they didn't have the equipment to take
care of him. That is absurd to do that to a patient, it is
risky. Anesthesia is not as risky as it used to be, but still
it is some risk to have these drugs and go to sleep.
So I want to start just very quickly. Dr. Clancy, at the
VA, the Washington, D.C. VA Medical Center, which many of us
have visited, and the supply shortages, and we talked about
postponing and so forth, but the financial mismanagement is
unbelievable to me. Somebody paid $289 for a speculum that
should have cost $122, $900 for butterfly needles that should
have been $251. Eight dollars for these little yellow socks,
those ugly socks you wear around the hospital so you won't slip
that should cost 82 cents. And all of that should have gone
through the medical/surgical prime vendor and saved a lot of
money.
And that is my frustration is we are providing more and
more money, and yet we are seeing this. Here is a case where
someone rented three hospital beds for almost $900,000 when
they could have bought them for a fraction of that, just bought
the thing, it would have cost that. And also somebody bought $1
million worth of copy paper. That is 60 pallets of copy paper
and they didn't have anywhere to store it even. How do you do
that? That would never happen in the private world. If I were a
HCA, a hospital administrator or a hospital administrator at
Mountain States where I worked, I would be fired, period. My
job would be over if I did anything that bone-headed.
So how in the world are we to sit up here and continue to
provide these resources? We have got to go back to our
constituents and explain. And we want to help veterans and Mr.
Butler knows that this Committee wants to do that. That is just
pure waste. Think about it, that is almost $1 million that
could have been spent on health care.
So, Dr. Clancy.
Dr. Clancy. Mr. Chairman, I would love to tell you that you
got some details wrong or facts, but you are absolutely right.
But I think that a lot of what you are saying underscores why
we need stronger networks for that kind of financial oversight,
that simply was not happening.
Now, I don't know entirely going back several years whether
that is the VISN's problem or the facility's problem. People
who want to hide things can sometimes be very creative. We are,
as you know, getting a new financial management system, which I
think will help a lot, but that is inexcusable and should not
have happened, period.
The Chairman. It absolutely shouldn't. And so I guess my
question is, when we--and Mr. Butler pointed this out in his
history of the VISN--do we need a VISN? I mean, it looks like--
I was trying to figure out what the VISN did and we are here to
look at 1, 5, and 22, and I know other Members will have some
much more detailed questions, but is it necessary? Maybe we
could--we have regional offices and the disability, there are
five of them I think in the country, do we need to shrink that?
The question is, I can't figure out what the VISN does. If
the VISN couldn't oversee that, what good are they?
Dr. Clancy. Well, what I think is that VISNs were initially
set up, the phrase that was bandied about a lot was
laboratories of innovation, and if you achieved the results
that then Undersecretary Kizer asked for, how you got there was
fine. Since then, I think thinking in contemporary health care
has changed quite a bit. For one thing, a whole lot more care,
as you know from your own practice, that used to be in the
hospital now gets done on an out-patient basis and so forth,
which is a very, very different kind of set of challenges.
I believe that the VISNs have a vital role and that we are
using this opportunity to learn from other industries. I
actually consulted with the Chief Medical Officer of HCA within
the past couple of days. Dr. Perlin chairs an advisory group
for us and he said the only way you can possibly get to
consistency across a large, far-flung system is to have
accountable regional leadership, so that you get alignment
right down to the unit level. So that is what we are trying to
build.
The Chairman. Well, my time has expired, and I will now
yield, but I am going to throw this question out to be
answered. What is VISN 23 doing that 1, 5, and 22 didn't do?
Just hold your question.
Ms. Brownley, you are recognized.
Ms. Brownley. Thank you, Mr. Chairman.
And I want to drill down a little bit on the Chairman's
question. So, Dr. Clancy, and I ask you to be as specific on
this question as you possibly can be, I wanted to zero in on
sort of the oversight roles and responsibilities for key
leaders within the VISN, but I wanted to drill down
specifically on one and that is the Medical Director.
So what is his or her responsibilities very, very
specifically in terms of their role and responsibilities to a
Central Office, their role and responsibility to medical
centers, and making sure that we are optimizing patient care at
each and every one of those facilities? If you could be very
specific about that, I would appreciate it.
Dr. Clancy. I just want to be clear, Congresswoman, the
Medical Director. There is a Chief Medical Officer at the
network level and then for every facility there is a Chief of
Staff who is colloquially sort of the top physician. Is that
what you mean?
Ms. Brownley. The Network Director.
Dr. Clancy. The Network Director, okay. So the Network
Director has a number of key positions and this we are also
standardizing across all of the VISNs. They have a Chief
Medical Officer who is attentive to all of clinical oversight
across these facilities, frankly keeping an eye on where there
are common gaps and deficiencies. For example, sterile
processing is an issue that we struggle with, as does much of
private sector health care. And as well as making sure that
clinicians are held accountable, and that their training and
continuing education is up to date.
And, frankly, when they uncover unexpected issues, for
example an IT glitch resulting in consults that don't go
through as expected, they bring that forward both to the VISN
director and also to Central Office, so that we can figure out
is this affecting other facilities and networks across the
system and so forth.
Ms. Brownley. So then why did some of these disasters
happen in some of these VISNs? And if that is the role and
responsibilities, why did it happen?
Certainly in New Hampshire, in Massachusetts, it ended up
being the headlines in the Boston Globe, and then there seemed
to some kind of response to that and we had Inspector General
reports. What failed?
Dr. Clancy. What failed was we did not have a consistent
job description for Network Directors in concrete, specific
terms that you are asking for.
So when I have visited with networks, and I have visited
with quite a few and asked them how do you follow up on these
things, what is your oversight function and so forth, tell me
what happens if a facility gets in trouble and so forth. What I
often heard was, well, we do the following, for example we did
this, but that is how our network works, we don't know if that
is how other networks do it. So we have not had that
uniformity.
It is fair to say that some of our previous Network
Directors had a much more hands-off approach for a variety of
reasons. I think it is also fair to say that in 2018 that is
simply not going to be the path by which we assure that all
veterans get great care, period.
Ms. Brownley. Thank you.
Mr. Missal, do you see evidence that there has been a
streamlining in these roles and responsibilities across all
VISNs?
Mr. Missal. No, we haven't seen that. In fact, what Dr.
Clancy said I think really was right on point, which is there
seems to be confusion about the roles and responsibility of the
VISN directors. Let me give you a concrete example.
When we interviewed the VISN 5 director who is responsible
for Washington, D.C., he said the buck stops with him, but in
the same interview he said he wasn't responsible for any of the
problems that were identified at the facility. So on one level
he is saying he is responsible, on the other level he is
pointing his finger at the medical center director saying it is
that person's responsibility.
So I think there is great confusion out there about what
the VISN director is supposed to be doing.
Ms. Brownley. Do you think we need VISNs?
Mr. Missal. I think in certain situations they have been
very helpful, but it all goes down to the people involved. If
you don't have the right people in leadership, if they are not
held accountable, I don't think it matters what structure you
are going to have. It is going to be problematic.
Ms. Brownley. Do you think the roles and responsibilities
of VISNs can be narrowed pretty significantly?
Mr. Missal. I think they certainly should be clarified and
then we look forward to seeing what VA comes up with in terms
of their study of the VISN system.
Ms. Brownley. Thank you.
My time is to an end and I yield back.
The Chairman. I thank the gentlelady for yielding.
Mr. Coffman, you are recognized for 5 minutes.
Mr. Coffman. Thank you, Mr. Chairman.
So one question is, Mr. Missal, so I think in the spring of
2017 on VISN 5 there was a complaint that turned into an OIG
report, I just can't see why--and maybe this is to Dr. Clancy
as well--why the VISN just didn't respond and correct the
problem themselves instead of wait for all the time that it
takes to do a VA OIG of a report?
Mr. Missal, why don't you address that first.
Mr. Missal. When we issued the interim report, there was
immediate action by the Secretary. He replaced the medical
center director at the time and made some other changes. We
then continued our inspection.
We did see some improvements, certainly not complete
improvement, and it wasn't clear to us how much of that was
coming from the Secretary versus the VISN versus the medical
center. And I guess I would defer to Dr. Clancy for more
information.
Mr. Coffman. Okay. Let me follow up with a second question
for you that the Chairman had raised and that was also raised
by the Ranking Member, that is the structure. What you have
mentioned, the VISN structure, and I have heard and I am sure
everybody on this Committee has heard it, that if you have seen
one VISN, you have seen one VISN. In other words, that there is
no uniformity in terms of quality and based on the way that it
is structured intentionally to allow for innovation, to allow
for independence. However, you also, you said in your comment
that if you don't have the right people in place, this is not a
good structure.
Look, I have been on this Committee now since January of
2013 and the one thing that I have unfortunately found is a lot
of times, for whatever reason, there is not the right person in
place. So we need a system that inherently makes it more
accountable.
And I think if we did away with VISNs and sought more
uniformity, is there a savings opportunity there in terms of
shrinking the bureaucracy, Mr. Missal?
Mr. Missal. I think that is really hard to say. Obviously,
VHA is a large, complex integrated health care system. It is
important for there to be some consistency. It is also
important for there to be flexibility at a local level. And so
getting the right governance structure is a very tricky thing
that deserves extensive study.
Mr. Coffman. Isn't it true, though, that is the more
flexibility we grant, it seems like the more problems that
there are, when we look at procurement?
Mr. Missal. In certain situations, that is correct, yes.
Mr. Coffman. Dr. Clancy?
Dr. Clancy. So, Congressman, you asked about what were the
VISN and Central Office doing before the Inspector General
issued their interim report. We sent in several investigative
teams in a few months prior to April and, frankly, couldn't
find anything.
So what was happening was we were hearing from employees,
many missives from home emails and so forth, not clearly
identifying themselves, with very nonspecific issues. So we
would send the Office of Medical Inspector over and so forth.
Incredibly enough, shortly before the Inspector General
issued their report, the joint commission said that the D.C.
VA, they did pretty well on their accreditation survey, which
amazes me to this day. What the VISN and headquarters had seen
probably 2 to 3 months out was that there were glaring gaps in
hiring and logistics. And if you don't have boots on the ground
to actually make sure you have got the supplies, Dr. Roe can be
waiting to tell people, but if there is no one there, who is
going to get the supplies? That won't actually be very
effective.
Since then, we have actually done a lot of hiring. The
Chief of Logistics was held accountable for what was going on
there and there have been substantial improvements.
Mr. Coffman. So when you say the Chief of Logistics has
been held accountable, tell me what disciplinary action was
taken.
Dr. Clancy. He was terminated.
Mr. Coffman. Oh, he was terminated?
Dr. Clancy. Yeah.
Mr. Coffman. Okay, very good, very good.
Mr. Chairman, I yield back.
The Chairman. I thank the gentleman for yielding.
And I will now yield 5 minutes to Ms. Kuster. Welcome back
to the Committee. You look healthy and well after your little
event with a knife. And so welcome back, you look great.
[Laughter.]
Ms. Kuster. Well, and I want to thank the chair for
rescheduling the hearing. My new hip is going great and I
really appreciate it. So I want to stay focused on good health
care for our veterans.
Thank you very much for appearing before us today and this
is a hearing that I had requested of the chair to investigate
VISN 1, but I am also attentive to the concerns in VISN 5 and
22.
I don't want to spend a great deal of time looking back,
but I think in order to understand where we are and how to
restructure, we need to understand where we have been. So in
VISN 1 in New Hampshire, Manchester VA, we were confronted with
a four operating rooms, one of which was shut down as a result
of a 16-year-long battle with cluster flies. You can imagine
the concern there. We had a VA physician that had cut-and-
pasted patients' medical records without updating patients'
conditions. And we had a situation that is really tragic of
patients that suffered from preventable spinal damage,
including paralysis, after the hospital failed to provide
proper care for a treatable spine condition known as cervical
myelopathy.
So in September of 2016, a group of whistleblowers
presented their concerns to me and to our delegation on
September 6th, 2016. And forthwith, in September, we referred
the allegations to the Office of the Inspector General, and the
Office of the Inspector General referred the complaints to the
Office of Medical Inspector.
Since then, we have been aggressively pursuing this. And I
want to thank my co-chair, General Bergman, for coming to New
Hampshire for an oversight hearing. We appreciate that. We have
worked with Dr. Clancy, with certainly Secretary Shulkin. And I
just want to point out a couple of places where I have concerns
in order to understand the roles going forward.
And, Dr. Clancy, in response to Julia Brownley you said
that the role of the Medical Director is to provide clinical
oversight across facilities, and that person reports both to
the VISN and to Central Office. When was then Secretary Shulkin
first made aware of our concerns from our congressional
delegation both to the OIG and to the OSC?
Dr. Clancy. So I believe, Congresswoman, that the New
Hampshire delegation sent then Secretary McDonald a letter
copied to Dr. Shulkin in the fall of 2016, but it was--and I
know you and I have had this conversation--to protect the
confidential of the whistleblowers, general and not very
specific about your concerns. I can't speak to what specific
actions were taken then.
We became aware of the whistleblower case when the case was
referred to the Office of Medical Inspector and then when the
spotlight team from the Boston Globe was contacting the VISN
and the facility and headquarters.
Ms. Kuster. And so that is my concern. And, yes, indeed
there was a concern of the whistleblowers that they didn't want
to come forward and identify themselves and that constrained
our ability to press this, but it causes me concern that it
would have to go so far as a spotlight team at the Boston
Globe. Why wouldn't the Medical Director who was one of the
whistleblowers have been able to convey these concerns up
through the chain?
I mean, why would they need to become whistleblowers? Why
wouldn't, you know, something as serious as paralysis because
patients weren't being treated appropriately, why did it go
this far is my question?
Dr. Clancy. The short answer is, I don't know. My
hypothesis, with some fair documentation--or confirmation, I
guess would be a better way to say it, was that the leadership
at that facility was not listening to some of these physicians
who were generally concerned.
There is a physician at Manchester who I know well because
I trained him when he was an intern and so I called him for a
bit of a reality check. And he told me their concerns were
genuine, he thought incredibly well of Dr. Kois and a few other
people. And I would vastly prefer, which is something I
emphasize in just about every time I speak, that if people have
concerns they speak up and that we can do something about that.
Now, sometimes people have concerns and we are going to
take another look and it won't exactly match what their
conclusion was, but much, much better. People calling out
problems is the greatest gift we have, and getting into the
whistleblower process necessarily delays that for protecting
confidentiality and so forth.
Ms. Kuster. Well, thank you. My time is up, but that is one
of the reasons why we have worked together on expanding
protections for whistleblowers. And I certainly agree with you,
we need to create an environment where concerns are addressed
at the earliest possible date.
So I yield back. Thank you.
The Chairman. I thank the gentlelady for yielding.
Vice Chair Bilirakis, you are recognized.
Mr. Bilirakis. Thank you. Thank you, Mr. Chairman, I
appreciate it very much.
Earlier this year I got involved in a particular case at
Bay Pines with regard to VA Health Care System, again at Bay
Pines in St. Petersburg, just outside of my district, where a
group of homeless veterans were in a particular facility there,
a building, and there was no hot water, adequate, you know, hot
water at different various times or heat during the winter for
a six-month period of time.
And I was notified and within a week, I contacted Secretary
Shulkin and within a week, maybe 3 or 4 or 5 days after I got
involved and the Secretary got involved, we remedied the
situation, but that should not happen and I know everybody
agrees with that. And then the media got involved and the whole
community was really outraged.
So my question is for Dr. Gamble. What types of barriers
currently exist that prevent the VISNs from taking a more
active role? And what do you think VISN directors need to
quicker solve these issues when they arise at local medical
centers? Is it better monitoring, is it more authority, is that
what they need? What do we need to do to help you in this
process?
Again, I went directly to the Secretary and we resolved the
situation, once I was notified. Again, I was contacted by the
media. And, you know, I mean, it is inexcusable for our
veterans not to have hot water. They would have to go to
another building, outside to another building to take a shower,
which is ridiculous. And then again no real air conditioning or
heat, for that matter, during the winter.
So if you can answer that question for me, I would
appreciate it, Doctor.
Dr. Gamble. Thank you, Mr. Congressman, I appreciate the
question.
I think it is incredibly important regardless of where you
are in an organization, and, again, coming from my time in the
military, that it is about leadership. It is about boots on the
ground, walking the terrain, listening to the staff and teams
around you, to really identify and realize that, you know,
problems as they affect our veterans are critical to deal with
in an expedient and timely manner, you know, and I don't know
why it had to come up through you all the way to the Secretary
for action.
But, again, I think that that also states that whoever
brought that forward realized that it was a critical need to
push that forward.
You know, I think that, you know, my travels around the
VISNs and to some of these institutions, moving ahead, it
really revolves around three things, one of which is
leadership, second of which is communication, and the third is
structure, because structure really sets the culture. And I
think it has a lot to do with culture and folks bringing these
issues up, and a sense of confidence that they will be dealt
with promptly and effectively that really will make the
difference going forward.
Mr. Bilirakis. Thank you.
My next question for Mr. Missal, does your office have the
authority to stop the admission of patients to a medical center
when you identify serious health and safety concerns?
Mr. Missal. No, we would not have that authority, but we
obviously would immediately contact VHA to take whatever action
they thought was appropriate.
Mr. Bilirakis. Okay.
Dr. Clancy. And if I could just note--
Mr. Bilirakis. Yes, please.
Dr. Clancy [continued]. --Congressman, that we did actually
send patient safety people in a number of times to give us a
read. Were they worried, was the risk of harm sufficiently high
that we should actually close down some units or just keep
going until we rebuilt the supply chain.
Mr. Bilirakis. Okay. So, again, how serious do these
conditions have to be for you to close down the facility and
make that decision? Maybe give me an example.
Dr. Clancy. I don't have an example right at hand where we
have done that, but for example, in one of our facilities
several years ago they closed down an ICU for a few weeks. The
issue at hand was that an acting director came in and inherited
a situation where the facility was very, very short on
housekeeping on weekends. So what that meant was that the
nurses in the ICU were actually turning over beds and having to
do the housekeeping and, you know, when a new patient came in,
and the director became very concerned that they were making
mistakes because they were exhausted.
So what she did, which I think was exactly the right thing
to do, was to close the unit for a few weeks until they could
bring more custodial assistance in for the weekend, so that the
nurses wouldn't be trying to do two or three different jobs.
Mr. Bilirakis. Okay, thank you. Thank you very much.
I yield back, Mr. Chairman.
The Chairman. I thank the gentleman for yielding.
Mr. Lamb, you are recognized for 5 minutes.
Mr. Lamb. Thank you, Mr. Chairman.
Dr. Clancy, I just want to ask you some questions about the
pipeline for people that become network directors, are they
always promoted from below essentially, like are they always
people that were chiefs of staff of VA facilities?
Dr. Clancy. They are not only one or two of our current
network directors, actually one right now is a physician, most
are health care executives and have strong leadership in that
capability. Historically, that was exactly where they came
from. In recent years, we have begun to recruit as broadly and
widely as we can.
So, you know, there are advantages to having people who
know the system and have had experience, and several of our
most recent network directors, who I think are really doing a
terrific job, were terrific medical center directors, but we
are continuing to recruit broadly and widely.
Mr. Lamb. When you say recruit, though, are you hiring
people from outside the VA for the network director job?
Dr. Clancy. We would be happy to if we find a good person.
Mr. Lamb. Okay.
Dr. Clancy. We have not recently, but have certainly
interviewed people and they have been fairly competitive, and I
would say we are hiring more people outside the VA to be
Medical Center Directors.
Mr. Lamb. Okay. Some of whom could then presumably be--
Dr. Clancy. Yes.
Mr. Lamb [continued]. --promoted to VISN Director. Okay.
Now, several of you have talked about the importance of
culture, both making sure that complaints are heard and can
kind of rise to the top, but also making sure that there is
fast follow-up by the leadership so that things actually get
solved. What suggestions do you have for how we actually do
that? In other words, how do we find the leaders who are
capable of creating that culture and then actually instilling
it in the organization?
Dr. Clancy. You know, that is a terrific question, because
when people apply, we tend to review their background,
experience, CVs, and so forth for their technical skills. And
what seems to me to matter, at least as much is how engaged are
they with the people. When I look at our best medical center
directors, they know almost everyone who works in that
facility.
Now, that is a pretty tall order, some people are more
gregarious than others, but it makes a difference. Because if
I'm asking you how you're doing and how's your kid doing in
Little League or whatever, I have a degree of comfort that I
could say to you we have got a problem over here in OR-1, and
I'm going to guess you may not have heard this or you have
heard that everything is fine, but what I see is not fine.
So a very, very big part of it is that kind of being able
to engage and listen to people, and I am noticing more and more
of our medical center directors doing this, whether it is a
Facebook chat, walk around rounds. Someone earlier referenced
walking around and getting out and seeing people. It is
management by walking around is another phrase, very, very
important. So we are beginning to talk now about how do we
build some of that into the interview.
I think it also helps to bring in others into the selection
process, which we are doing now at the D.C. VA. So the
physicians will have a role and a voice in who the next
director will be and so forth.
Mr. Lamb. Dr. Gamble, you were nodding. If you could just
address that and also how do you get a similar level of
engagement and strong leadership at the VISN level? I kind of
see it for a medical director of a facility because they are in
one building every day. They can meet everybody. But what are
we doing to promote stronger leadership and accountability at
the VISN level?
Dr. Gamble. Mr. Congressman, I think it is--network
directors have really taken the lead recently in helping to
develop a way ahead. One of the key parts of their guidance and
assistance to me has been looking at developing a play book for
VISN directors so that these head up a consistency of roles,
responsibilities, and accountabilities. And one of those is
really walking around and getting to see your facilities, get
out to meet the people. That is one of the key parts of a
network.
There was a--in Kizer's report back in the 90's, there was
a notable comment, I believe it was there, that in a network,
you had--the span of control was critical. You really could
only have between 8 to 12 facilities to really as a network
director or VISN directory, really be able to have that
control. And that is, I think, really key for the future to set
those roles, responsibilities, and accountability, and also
give them a terrain of an organization that they can walk
around to get to know up close and personally.
Mr. Lamb. Okay. Thank you, Mr. Chairman. I yield back.
The Chairman. I thank the gentleman for yielding. General
Bergman, you are recognized for 5 minutes.
Mr. Bergman. Thank you, Mr. Chairman. And thanks to all of
our witnesses here for your testimony. You know, the good news
is I am getting to know you because I see you so often. The bad
news is I am seeing you too often. So the point is, the flow of
communications, as Dr. Clancy and I talked about earlier, as
far as bringing in the boots on the ground, the everyday stuff,
I am pleased to see that the VA is going to do that so that we,
as a Committee, can hear it from those who are involved in the
day to day operations.
You know, 18 months into this first term now and in dealing
with things that we hold near and dear to our hearts and our
veterans' hearts, I am still learning at the cyclic rate. You
know, I think VISN 23 touts the SAIL metrics, the strategic
analytics for improvement and learning that you have had some
success with.
I would like to give you just one data point from my first
briefing at an unnamed facility and VA related. But the point
is the metric for success proudly touted and in a slide was
that they had added eight full-time equivalents to their staff.
I am not so sure that is the quality metrics that we are
looking at is adding staff. I mean, if they had been related to
what that meant to the outcomes and the results for the
veterans, that might have had a different quality to it, rather
than just saying, ``Hey, we added eight more paychecks.''
So it is just--fyi it was meant to be a good answer. So I
would suggest to you the leadership involved with that maybe
needs to just kind of look at things a little different in what
a good answer is as it relates to results for the veterans.
And Dr. Clancy, I know you have--I have asked you this
before, but I am going to ask again. Do the VISNs have a
mission statement, either collectively or individually? Have we
got something down on paper? Two or three lines? Four lines?
Whatever it is?
Dr. Clancy. The goal of our current redesign effort is that
there is one mission statement that is for all VISNs. Most have
a mission statement, but it is not looked at by anyone and we
don't verify it. And I would guess that it probably echoes the
department's strategic plan that say we are all about
personalized veteran-driven high quality care, more or less.
But it needs to be much more engaged. Dr. Gamble's point
about a play book I think is quite instructive.
Mr. Bergman. Okay, Mr. Butler, you know, same question for
you. What do you think of the VISN's mission statement? What do
you think it should be?
Mr. Butler. What I would say that the American Legion
Resolution calls for a study of the current VISNs. And so we
advocate that someone look at the VISN's structures and
determine the lead way forward to go and whether or not there
are changes or improvements that could be made based upon
studying the current VISN structure.
Mr. Bergman. You know, we could talk about this for a long
time and I can see as I look across, I have a fellow Marine, I
am--a couple of them. You guys are--you have got me outnumbered
now. Not outgunned, but outnumbered. Anyway. My God, I forgot
you are over here. Thank you. You have always got my flank.
The point is, in the Marine Corps., every word in a mission
statement is a planned word with a specific meaning for what
its intent is so it can flow up and down. And I would suggest
to you that at different levels of command, sometimes that
mission statement might be revised to the level of command that
it is meant to oversee. So don't get caught up on one size fits
all.
So with that, I yield back, Mr. Chairman.
The Chairman. I thank the gentleman for yielding.
Mr. Correa, you are recognized.
Mr. Correa. Thank you, Mr. Chairman. First of all, I just
want to thank you, Chairman Roe, for your leadership in the
Mission Act, in moving legislation out of this Committee, onto
the Senate. I do appreciate what you have done. I know my
veterans appreciate your efforts as well. Thank you, sir.
Dr. Clancy, quick question for you. Secretary Shulkin
envisioned placing VISN's 1, 5, and 22 in receivership. Any
thoughts about what he envisioned?
Dr. Clancy. So I don't think he had completely followed
through on the thought at the time of the D.C. press
announcement. We did have subsequent conversations.
Mr. Correa. It was an envisioning, not an actual plan. So
what--
Dr. Clancy. No. I think what he wanted to do was to say
whoa. Whatever VISN is supposed to be doing in these three
networks is not working. Therefore, he had called Dr. Gamble in
to get him a set of fresh eyes, informed by a great deal of
experience outside of our health care system, which I saw as a
real asset. But it became clear, I would say within the first
24 hours that the span of control--it was not possible for
someone sitting in D.C. or anywhere else to be running day to
day operations at 23 facilities that were vastly disbursed
geographically.
So on the ground, the deputy network director, the most
senior VISN official, has actually been sort of an acting
network director for day to day activities. But Dr. Gamble has
been to each of those facilities. Does that help?
Mr. Correa. A little bit. I guess I am still at a loss when
it is a big network, a lot of work, a lot of important work.
But it is not exclusive to this country. You have got the
Kizers of the world. You have got other large networks that
have the same challenges of management, implementation,
accountability, responsibility, and liability. And there are
some, for lack of a better term, best practices could be
employed at the--and I am just trying to figure out why is it
that we have been operating the VA as silos and why is it that
these discoveries continue to be secrets that nobody knew
about?
Dr. Clancy. So I think the last point you made is hugely
important. And in the question about culture, I would have said
that what is even more important before that is candor. That
you can honestly confront your problems and don't act like it
is a secret. Because frankly, if one of our facilities has a
problem, it is highly likely that some other facilities are
having the same challenge.
And the great power of being an integrated system is that
we could learn, rather than have--as a system, rather than
having every single facility replicate the painful discovery of
a delta between your aspirations and what actually happened--
Mr. Correa. So, Dr. Clancy, your words whistleblowers are
the greatest gift that we have.
Dr. Clancy. Yes.
Mr. Correa. Do we have a system to listen to
whistleblowers? Do you have a 1-800 number, an anonymous box,
and do you have folks that follow up on comments, suggestions,
complaints by whistleblowers?
Dr. Clancy. So that is done differently at most facilities.
Some literally have suggestion boxes. Some will say--will do
things like having Facebook chats where people can text in
questions. Some have townhalls with employees. I don't think
there is a magic formula. And there was one--
Mr. Correa. But there should be a formula at each place. If
you don't have a system and I would question whether you have a
system at all in all of these places.
Dr. Clancy. Well, the critical formula for me is saying if
there is problems, I want to hear about them. And facility
directors who communicate that, generally tend to hear about
problems and act on them sooner than not.
Mr. Correa. So when you have directors that hear about
them, do these--the results of these surveys, do they reach
Washington, D.C., or are they stuck at the local level?
Dr. Clancy. We have been strongly encouraging more that we
fail as a system if any of our individual facilities--
Mr. Correa. But I guess my question, and I am running out
of time, and that is why I am being--interrupting here.
Suggesting, encouraging versus a system of saying this data
will be reviewed.
The other day I went to my local doctor. Within a couple of
days, I got a text saying, ``Can you tell us what your
experience was with your doctor?''
Dr. Clancy. Right.
Mr. Correa. ``Can you tell us what your experience was
visiting?'' Do you have a system like that where our veterans--
Dr. Clancy. We do. Yes.
Mr. Correa [continued]. --can text in their experience and
if it is a bad one, do we follow up or that is just another
number that we, you know, put away for research in the future?
Dr. Clancy. We have recently put in a system--we have
always had questions at the kiosk before you check out, okay?
And we have recently put in a system where veterans can give us
realtime feedback from a variety of venues. That can be from a
kiosk. They can send us an e-mail. They can drop off a note at
the front desk. And that information gets aggregated.
And frankly, what I am hearing from our directors is they
love it. Occasionally they feel like they are drowning in
information, but--
Mr. Correa. We all do.
Dr. Clancy [continued]. --it points out--well, it points
out problems, I mean, in the same way that I am sure many
people learn from their own office staff, right? Things you
thought were fine, except what you are hearing from the actual
customer of the veteran is it is not working so well for me.
And that is an opportunity to just fix that.
Mr. Correa. Mr. Chair, I am going to yield. Before I do, I
just want to say I think we need to figure out how to protect
and listen to whistleblowers--
Dr. Clancy. Absolutely.
Mr. Correa [continued]. --to move forward. Mr. Chair, I
yield.
The Chairman. Thank you, gentlemen, for yielding. Chairman
Bost, you are recognized.
Mr. Bost. First off, let me start out by saying, you know,
I was taught in college about a Peter principle, which somebody
is promoted beyond their capability of handling the job and
that is where they freeze.
I have got a statement here and, Dr. Clancy, I want to see
where you think this should go. In 2008, several congressional
Members sent a letter to then VA Secretary James Peake,
expressing their concerns about an appointment of Dr. Peter
Almenoff to be the assistant deputy undersecretary for health
and for quality and safety. Dr. Almenoff, formerly director of
the VA Heartland Network, responsible for overseeing the Marion
VA Center, Dr. Peter Almenoff had oversight authority over
Marion VA Medical Center when nine veterans died due to
substandard care. He was promoted to oversee quality and safety
for the entire VA in February of 2018.
VA announced that he is now the director of VA's office of
reporting analytics, performance, improvement, and deployment,
or RAPID health care improvement center to oversee improvement
at each low performing health center. And he reports directly
to you, Dr. Clancy.
I know the VA central office will review each of the
facilities' quality. And if the facility fails to make rapid,
substantial progress in their improvement plan, VA leadership
will take prompt action, including changing the leadership of
the medical center.
And this is not the first time of a VA employee getting
promoted after they failed at their job. Most recently, we have
heard of several concerns related to the quality team in Marion
and the quality nurse was promoted into the VISN. Where is the
accountability? At what point do start looking at your
employees and when they fail at a job, do we not--we either get
rid of them or we demote them. But no, what we do in the VA is
we promote them away so that they don't have to deal with the
problems they create. Do you have any answer on that?
Dr. Clancy. So in general, when people are promoted, we are
looking at past performance and any investigations and so
forth. I think most large organizations, health care or
otherwise, that have employees with an enormous amount of
skills that are in the wrong job, before they put them out on
the sidewalk would want to figure out how they might be working
in a job that is a better fit with the skills that they have.
Mr. Bost. Okay, maybe my concern and I have got another
question I have got to ask, but this came to mind. My real
concern because, okay, I did not run something the size of the
VA, obviously. But I did--was in business and have been in
business for years. The concern is that, do you not see with
the amount of employees that you have that some of them might
all of a sudden say, ``Okay, if I just do a bad job here, they
will move me somewhere else?''
Because that is what we are seeing. That is the concern I
see is, ``Okay, I can't do this job, but I still have an
education and a degree, so maybe they will move me over there
and then I don't have to do this anymore.'' And call it a
promotion.
Dr. Clancy. In general, I am not that concerned about that.
I certainly don't want someone to struggle in a job that their
skills are not a good fit with that is not serving veterans, if
in fact they might be able to contribute more effectively
elsewhere.
And if--to me, the bigger challenge that we struggle with a
lot is an inconsistency in values. People who don't have values
that resonate with our intent of serving veterans everywhere.
Mr. Bost. Okay. My question here before the time runs out,
Marion has a number of issues that have come to light over the
past decade. The leadership of the VISN 15, though, does not
seem to be adequately addressing my concerns about the morale
at Marion. What role does a VISN play with the human resource
department, given the unique role of the H.R. personnel have in
the VISN? And is there a way that someone at the VISN that is
over H.R. can explain to the Marion VA H.R. person how to do
their job betterly (sic). That was a great word.
Dr. Clancy. Thank you, no.
Mr. Bost. More accurately.
Dr. Clancy. Thank you, Congressman. That is exactly the
direction we are going with our VISN redesign is that we will
strengthen the capacity and oversight of the H.R. person at the
network level so that the person at the facility level, who is
responsible for posting jobs and making sure people get
onboarded and so forth, actually has someone to consult with
and someone who is keeping an eye over their shoulder to make
sure that we are doing a consistent job.
Mr. Bost. Thank you and I yield back.
The Chairman. Thank you, gentleman, for yielding. Mr.
Peters, you are recognized for 5 minutes.
Mr. Peters. Mr. Chairman, I would defer to Mr. Moulton.
The Chairman. He is right up after you anyway, so that is
fine.
Mr. Moulton. Thank you, Mr. Peters. Thank you, Mr.
Chairman.
So I represent the Bedford VA, as you know, and last week I
testified about my concerns with the Bedford VA and the
multiple whistleblower cases, on issues to include contract
fraud, patient abuse and neglect, and poor facility maintenance
had reported at that facility. Adding to that, there are issues
with improper medical record management, a Legionnaires
outbreak, the Office of Special Counsel findings of widespread
asbestos exposure, a hostile work environment, and retaliation.
Now, to Secretary Shulkin's credit, he came up at my
request and visited on a Saturday afternoon. And we walked
around the Bedford VA and heard their leadership team, or what
was left of the leadership team, explain what happened, in
particular, with a patient death. And what struck me about it
is that there was a lot of effort put into looking backwards
and figuring out what had occurred and very little
accountability for making sure it didn't happen again.
Now, you have heard from a lot of Marines on this Committee
and I think of us as all on the same team here, not Democrats
and Republicans. But one of the things we learn in the Marines
is that of all of the different leadership steps: coming up
with a great plan, doing the reconnaissance to get the
intelligence, none of it really matters unless you supervise
what happens. It is the most boring step in leadership,
supervision. But you have got to make sure that your good plans
actually come to fruition, that the Marines get the job done.
And so my question is just what has been changed? What is
different at Bedford, and other places, and VISN 1 and
elsewhere, to make sure that when we have problems like this,
we can ensure that they don't happen again in the future?
I recently met with a new director up at the Bedford VA. It
took about 2 years to get that person into place. And I am
excited for her to get started. I mean, she is getting started.
I think she will do a great job. But I fundamentally want to
know what will be different?
Dr. Clancy. So the Bedford VA is not far from where I grew
up and so it is a facility I know reasonably well. And I know
that when you visited the first time, there were a lot of
problems and, frankly, a lot of publicity in a way that
probably makes it a bit difficult for people to be quite as
forthcoming, even with respect to legitimate oversight and so
forth.
I think the biggest good thing that has happened at the
Bedford VA is that we will have a new network director in VISN
1 and we are going to do everything possible for these three
networks, the new people to actually prime them for success. So
whether they are promoted from within or recruited from
outside, they are going to be--have a two to three month
training period, leadership development and so forth, which I
think we can learn a lot about from the military. But probably
the best thing that has happened at the Bedford VA is
identifying and recruiting an effective director. I think she
is going to be terrific.
And I think what will be different is that you have someone
who knows a lot about how the system works, both locally as a
very senior nurse at the Boston VA, and then having worked in
headquarters for a couple of years, focused on improving access
to care.
Mr. Moulton. What is the timeline that you expect from her
for addressing these issues?
Dr. Clancy. I expect her to be showing improvements within
1 to 2 two years. I mean, that I can count and measure.
Mr. Moulton. So up to 2 years to address these
whistleblower complaints?
Dr. Clancy. No, no, no. She is not going to address the
whistleblower complaints. We have an external, you know,
another office in the department that does that. What she has
got to do--
Mr. Moulton. And, Dr. Clancy, what is their timeline for
addressing these complaints?
Dr. Clancy. I don't know. I would have to take that for the
record and get back to you.
Mr. Moulton. Okay. I would very much appreciate--
Dr. Clancy. I am happy to do that.
Mr. Moulton [continued]. --that. You know, the sad thing is
that the Bedford VA also has some extraordinary
accomplishments.
Dr. Clancy. Yes.
Mr. Moulton. They have a remarkable record with regards to
mental health care treatment, for example, which we all know is
top of the line for veterans in America today. And so part of
this is ensuring that we have a VA leadership culture that
ensures that problems get fixed. Another part of it is that
good practices get shared.
Dr. Clancy. Yes.
Mr. Moulton. What are you doing to ensure that good
practices that are happening at places like Bedford, which has
an opioid prescription rate, Mr. Chairman, half the national
average because they are so innovative with mental health care,
what are you doing to ensure that those practices get shared?
Dr. Clancy. So we are doing two things. Over the past
couple of years, we have had a big initiative focused on
diffusion of excellence where employees across the system are
encouraged to submit their best practices. And we actually
facilitate their connecting with other facilities, often far
away from where they actually take care of veterans. And it has
not only been a terrific way to identify good practices, it has
been a way for people across our system to learn from folks
they otherwise never would have met.
Recently, I heard the individual who is leading that effort
explain how he is going to actually take that up another level
by identifying other practices. In other words, looking at
measurements. What is Bedford doing about mental health care
that could be shared with others?
The Bedford VA was part of an initial best practices which
focused on helping veterans and their families discuss
preferences for end of life care as sort of a group. You could
only do that in VA. And it has been hugely popular with
veterans because it is actually less intimidating than a one on
one conversation. And they get to kind of process this with
other veterans, which is very helpful.
Mr. Moulton. Thank you. Mr. Chairman, thank you very much
for letting me run over.
The Chairman. No, that is fine. Thanks for being here today
and thanks for your service to our country.
I am beginning to think maybe we have too many Marines on
this particular--we need a few more Army people. And it has got
a very New England tint today.
Mr. Poliquin, you are recognized for 5 minutes.
Mr. Poliquin. Thank you very much. That, to me, is you are
a lean 6 minutes, Mr. Chairman, but thank you very much.
Make sure I get this right, Mr. Chairman, before 1995 and
this would probably go to Dr. Clancy, there--we have about 160
medical centers around the country. And before 1995, they were
roughly all autonomous and they were organized in four--loosely
in four regional areas. But for the most part, they reported
directly to the--to Central VA.
And how in the heck can anybody oversee that? How can they
hold them accountable? So in--after 1995, or since 1995, I know
you folks originally organized, or we did, 22 VISNs and now
they are down to 18. Is that correct? Roughly? Do I have that
roughly right?
Dr. Clancy. Yes.
Mr. Poliquin. Okay, so the number of employees went from
about 220 and 1,100. And so, to me, what it looks like, Dr.
Clancy, is that we have created another sort of middle
management bureaucracy here. Mr. Missal, am I pronouncing your
name correctly?
Mr. Missal. It is Missal.
Mr. Poliquin. Mr. Missal, you are the I.G. for this whole
ball of wax here. Have you found in your data, in your work
that there has been an improvement and accountability in
responsiveness and care as a result of this reorganization?
Mr. Missal. We haven't looked at that specifically, but
what we do look at in all of our work, we try to find what the
root cause of an issue may be if we find a problem. Because
what our role is and our goal is to help VA get better. And so
by identifying anyone who did not act as you would expect, we
want to identify it so that VA could take the necessary action.
Mr. Poliquin. Thank you. Mr. Gamble, you were appointed by
Mr. Shulkin to run VISN 1, 5, and 22 how long ago?
Dr. Gamble. I was not appointed to run those VISNs.
Mr. Poliquin. Oversee them.
Dr. Gamble. That was back on, I believe, March 7th.
Mr. Poliquin. Okay, of this year.
Dr. Gamble. Of this year.
Mr. Poliquin. And are you stationed out of Orlando or are
you stationed out of D.C.?
Dr. Gamble. I am still living in Orlando, but I am up here
most of the week. In fact, since March 7th, I have spent most
of my time on the road, out with these VISNs--
Mr. Poliquin. Okay.
Dr. Gamble. --and facilities.
Mr. Poliquin. Okay. We are in VISN 1 up in Togus. We have
the first medical facility--medical hospital--VA medical
hospital in the country established after the second--excuse
me, after the Civil War. Have you been there to visit Togus?
Dr. Gamble. I have not been there yet, sir.
Mr. Poliquin. Okay. Do you plan on it soon?
Dr. Gamble. As soon as I can.
Mr. Poliquin. Great, thank you. When will that be?
Dr. Gamble. I will have to check my record or my schedule
and--
Mr. Poliquin. Good. We will check with your office to make
sure we know when that is going to happen. Thank you.
There is someone by the name of Mayo-Smith and Weldon. They
both retired as the heads of VISN 1 and 22, is that correct?
Dr. Gamble. Sorry, Dr. Mayo-Smith was--
Mr. Poliquin. Yes.
Dr. Gamble [continued]. --the previous VISN director.
Mr. Poliquin. Yes, they are gone now, right? And Weldon is
gone too. All right, so they are both gone.
Dr. Gamble. Twenty-two, yes sir.
Mr. Poliquin. Okay. And Williams has been reassigned,
correct in 5? So who are running those three VISNs?
Dr. Gamble. Right now we have acting medical director. I am
sorry, acting VISN directors in those positions. We have Mr.
Barrett Franklin, who is in VISN 1.
Mr. Poliquin. Thank you.
Dr. Gamble. We have Dr. Ray Chung who is in VISN 5.
Mr. Poliquin. They are all acting. Okay. I want to go back
to what General Bergman said a minute ago. What performance
benchmarks do you folks embrace to make sure the accountability
is getting better, not worse? What are the specific measures?
Give us a couple of examples.
Dr. Clancy. Well, I--
Mr. Poliquin. Sure, Dr.--
Dr. Clancy [continued]. --have a little more experience. I
will take that.
Mr. Poliquin. Yeah.
Dr. Clancy. So one overarching accountability measure is,
is the performance of the facilities in your VISN better or
worse--
Mr. Poliquin. What does that mean?
Dr. Clancy [continued]. --than it was when you were--
Mr. Poliquin. How do you measure that performance?
Dr. Clancy. What we do is we actually roll up and summarize
all performance measures, the same ones used by the private
sector reported to--
Mr. Poliquin. Okay, let me give you an example. There was a
fellow by the name of Dr. Franchini up at Togus.
Dr. Clancy. Yes.
Mr. Poliquin. Dr. Franchini was a foot surgeon at Togus
from 2004 to 2010. He botched dozens and dozens and dozens of
operations, to the extent that one of our veterans had to have
her leg amputated. I repeat that, her leg amputated to take
care of the pain because there was no other way to cure it.
Now, here is the think that really hits me between the
eyes. Not only did that happen, but it wasn't until roughly 2
years later, 2012, that the former head of surgery who was
responsible for getting this out to the victims and also to the
public so Franchini couldn't operate in the private sector, it
was about 1 to 2 years until that happened.
Okay, you mentioned earlier, Dr. Clancy, that you need to
make sure that people have the right job description, so their
skill sets can fit in another job. This individual was not
fired. He was demoted. Is there a job skill that I am missing
here that enables this person to be reassigned within the VA
after someone's leg was cut off because of botched surgeries
that they did not report for 1 to 2 years? Am I missing a job
description here or some sort of skill set that they should
allow that individual to stay there?
Dr. Clancy. Congressman, are you referring to the
podiatrist or the person who supervised the podiatrist?
Mr. Poliquin. The person who supervised the podiatrist.
Dr. Clancy. I would have to take that for the record
because that piece I am just not that familiar with. I
apologize.
Mr. Poliquin. Okay. Were you responsible at that time for
overseeing the VISNs?
Dr. Clancy. No, I was--
Mr. Poliquin. Who was?
Dr. Clancy. Prior to me was Dr. Alaigh, before that Dr.
Shulkin. What I would say, Congressman, and I didn't get a
chance to say that--
Mr. Poliquin. Okay. Steve Young is the fellow that is under
you, right?
Dr. Clancy. Yes, uh-huh.
Mr. Poliquin. Okay. And then it goes down to the office of
network support, then it goes down to the VISNs, right?
Dr. Clancy. Yes.
Mr. Poliquin. But you are the head person, correct?
Dr. Clancy. Yes.
Mr. Poliquin. Okay, so you are responsible.
Dr. Clancy. Yes.
Mr. Poliquin. You just told me you weren't.
Dr. Clancy. No, I thought you said then. I have been in
this job now for 7 months.
Mr. Poliquin. Okay. And before that, how long have you been
at the VA?
Dr. Clancy. Four and a half years.
Mr. Poliquin. Four and a half years okay. Okay? Go ahead. I
will let you finish--
Dr. Clancy. But I would be happy to get that for the
record.
Mr. Poliquin. I appreciate it.
Dr. Clancy. What I was also going to say as a result of Dr.
Franchini and a couple of other things, we have put in new
requirements for facility and network directors to keep
credentialing licenses and so forth up to date. And that is
also part of the expectations.
Mr. Poliquin. Do me a favor, when you get back to your
office and I appreciate it very much, Dr. Clancy, we want to
make sure the person who was responsible for reporting this, is
that individual still there or not. I would appreciate that
very much.
Dr. Clancy. Okay.
Mr. Poliquin. Thank you, Mr. Chairman.
The Chairman. Gentleman's time is expired. Mr. Arrington,
you are recognized.
Mr. Arrington. Thank you, Mr. Chairman. Mr. Butler,
representing a vast array of veterans from various backgrounds,
how would you rank in the customer service survey the overall
service of the VHA to your veterans? 1 to 10, 10 being
excellent, off the chart, zero being non-existent.
Mr. Butler. Most veterans that we encounter tell us that
the care and services provided by the VA is excellent.
Mr. Arrington. Well, then why are we having this
conversation? Because I really don't care how they skin the
cat. I don't care how they organize. I care about the results.
If it is excellent, why are we even having this hearing?
Mr. Butler. But I think that, you know, there are
situations where the care or things go awry, and every veteran
should have that same experience. So I think that is why we are
here today for the exceptions because all veterans' experiences
aren't the same.
Mr. Arrington. My perception is very different. My
perception isn't that these cases of bad performance and bad
service aren't the exception. I think they are too often the
rule. But I will--you know, that is your--you are representing
veterans and you know your veterans. And so--but I am surprised
that we are talking about an exception. That we are spending
all thing time, that we have done all these studies because we
have done--I have read at least five studies on organizational
management.
I care about organizational results. And if they are great,
then I--what are we doing here? Do you think they are great,
Mr. Missal?
Mr. Missal. I think that a number of the issues we have
identified are because people haven't done their job and that
they don't have the structure in place to ensure that there is
accountability.
Mr. Arrington. One of my favorite quotes is that you are
either coaching it or allowing it to happen. I think you can
overcome organizational structures. I think you can overcome
bad systems. I think leadership, I think culture dominate on
the outcome. And I think there are real, fundamental, deep
seated cultural problems. Do you agree with that or do you
disagree with that, at the VA? I am asking you, Mr. Missal.
You are the independent Inspector General. I want an
independent assessment. Do you think there is a cultural
problem at the VHA?
Mr. Missal. In many of the instances that we have looked
at, we have seen a cultural problem where people aren't taking
responsibility to do the right thing, not performing as they
should be, which results in significant problems.
Mr. Arrington. So it is not just the Washington Medical
Center, do you think it is systemic or is that just an isolated
event?
Mr. Missal. We have obviously seen more than just problems
at D.C. We have seen them at a number of facilities. Obviously
when either information comes to our attention or through our
proactive efforts, we find it. We address them as quickly as
possible.
Mr. Arrington. We were talking about how we are going to
have a management for performance plan for VISNs and how we are
going to define roles and responsibilities and bring clarity to
something that is clearly chaotic and unclear. And Mr. Gamble,
you have mentioned that the network directors are taking the
lead on developing these sort of plans. Did I hear you
correctly?
Dr. Gamble. They are part of the process, sir.
Mr. Arrington. But why--I get it. I mean, get input from
mid-management, your regional directors, if you will. But I
mean, they are looking to the leadership of the VHA to tell
them what their mission is. Clearly, they don't know what their
mission is. What is expected of them? How will they be graded?
What does the scorecard look like? Will they be rewarded if
they do a good job? Will they be fired if they don't do a good
job?
Why are we asking them to run off and develop a plan for
themselves?
Dr. Gamble. Mr. Congressman--
Mr. Arrington. What is the plan, Dr. Clancy, for developing
these--this sort of strategic management plan for the VISN so
that they get it right, they serve our veterans? They are safe,
they are happy, they are healthy, and we did right by our
heroes. What is the plan?
Dr. Clancy. That is what you just described. It will
ultimately be deemed by central leadership, period.
Mr. Arrington. Do we have a problem with central
leadership? How long have you been--how long has the
Undersecretary job been unfilled?
Dr. Clancy. By a permanent political employee, since
February of 2017.
Mr. Arrington. I know my time is expired, Mr. Chairman,
unfortunately, because I don't feel like I have gotten all of
my questions asked or answered, but that is my fault. So I
yield back.
The Chairman. I thank the gentleman for yielding.
Let me--I have a couple--let me just start a second round
then. We have only three of us here so let's just go with a
second round if you would like to ask a question.
Ms. Kuster. Thank you very much. And just to pick up where
my colleague left off, I will say that I have been in Congress
for five and a half years and a number of us on the Committee
came in the class of 2012, starting in January of 2013. We are
now on our fourth Veteran Secretary, VA Secretary, since I have
arrived in Congress.
And so I think that that is part of the situation, to be
honest. And I am not trying to be partisan. I want to work
together in a bipartisan way as our Committee does, but we need
leadership from the top. And so I just want to revisit the
details one last time here of New Hampshire and VISN 1. I do
have the letter from the U.S. Office of Special Counsel dated
January 25, 2018, that I would like to submit for the record
that lays out the situation that we had and frankly the lack of
leadership and the lack of supervision. If I could enter that
for the record?
The Chairman. No objection.
Ms. Kuster. The other person that was a focus for us was
the director of VISN 1, Dr. Mayo-Smith. And again, I would have
to ask you when did Dr. Mayo-Smith first become aware of our
referral to the Office of Special Counsel, and did he ever pass
his concerns up to central office officials? Because I think
that was part of the breakdown for us.
Not only did we not get from the medical director to the
VISN, we didn't get from the VISN to the central office, again,
until this all played out in the Boston Globe. And this was
despite our best efforts to take it to the OIG, take it to the
Office of Special Counsel, push forward. What was happening in
Washington and in Boston in the 6 months in between?
Ms. Clancy. So at headquarters, we became aware of the
Special Counsel and the whistleblower allegations when they
turned to us for assistance after the Inspector General was not
able to step up at that point. And this is a routine
occurrence. I am not singling them out.
And I would guess that that was February or March of 2017.
And then the Office of Medical Inspector went up and had a
preliminary report that was sent to Office of Special Counsel,
I want to say late May of 2017. And the whistleblowers--and
this is all part of the process, were not completely
comfortable with the results.
And I think as you know, Congresswoman, we then did a much
more extensive review of cases and have consulted directly with
Dr. Coy (ph) and others.
Ms. Kuster. Well, and it--you know, after it was in the
Boston Globe that Secretary Shulkin showed up virtually the
next day. So, I mean, we did eventually get the attention. But
one of the problems I have is when General Bergman and I held
this oversight and investigation Subcommittee hearing in New
Hampshire. I mean, that is our role. We have oversight. Dr.
Mayo-Smith didn't appear to be fully aware of the concerns,
even at that point. That was after Dr. Shulkin had come up. And
he was--well, I think if General Bergman was here with me, he
would say we received unsatisfactory answers regarding the
actions taken to rectify this situation.
So I won't beat a dead horse, as they say where I come
from, but I do think we need to focus on supervision at each
level, and the role of oversight, and how to bring concerns
forward. And it sounds as though that is the direction.
I don't know if our witness from OIG has anything more to
add about that, what we can do in terms of both streamlining
the process and the types of people that we hire that will be
focused on supervision and will be focused on continuous
improvement.
So for Mr. Missal.
Mr. Missal. Yes, I don't know if I have that much more to
add. I do want to say, though, with respect to whistleblowers,
what we are trying to do is we are trying to make sure that
they feel comfortable coming to see us and talk to us about
issues. We do protect their anonymity if they so desire. And a
good example is the Washington, D.C. matter. We got a
confidential complaint from a person at VA and we have been
able to protect that person's confidentiality.
And the more situations we have like that, hopefully VA
employees and others will feel comfortable that if they come to
us, they will be protected. They will be heard. And appropriate
action will be taken.
Ms. Kuster. And I appreciate that because that is a concern
that I have. I continue to have whistleblowers come. And in the
case that I have been talking about today, there was a long
period of delay because the whistleblowers were concerned about
their anonymity. Dr. Coy is a physician in the facility and
wanted to continue to do his work.
So we have passed legislation out of this Committee to
address whistleblower protection. And I will yield back. But I
want to thank, again, Dr. Roe for holding this hearing. And I
think our oversight role is significant and we take it very
seriously in a bipartisan way. And I appreciate you coming
forward. Thank you.
The Chairman. Mr. Arrington, you are recognized.
Mr. Arrington. Thank you, Mr. Chairman. And I really
appreciate you extending this for a second round because I have
this general frustration, and I know my colleagues feel the
same. And I can't imagine how the veterans must feel because,
you know, you talked about how you would have been fired for
some of these things. And the reason you would have been fired
is because the health system you worked for would go out of
business if they let you continue to do this thing.
But the VA won't go out of business. And that is a
fundamental challenge to breed this sort of culture of
accountability without those external competitive forces. It is
just really difficult. It is really difficult. And on top of
that, I think Ms. Kuster is right. I mean, the political
leadership is a key link in the chain of accountability up to
us. Without them, I mean, I feel sometimes a little guilty for
beating on you guys but you all are part of the problem and the
opportunity.
But without the continuity and political leadership, and I
don't know if that is the Senate that is not working to get
them through, or if it is the administration not putting them
up but it is really, really frustrating. And I think you are
going to get this sentiment as long as we have these gaps and
the disconnects in the accountability chain.
Ms. Clancy, how would you rank order the VISNs? If I just
said rank order the VISNs from the best to the worst, could you
do that for me? Could you submit that to the Chairman and the
Committee?
Dr. Clancy. I would be happy to. And I agree--
Mr. Arrington. Does that exist today?
Dr. Clancy. I could look at a number of different
dimensions. And respectfully, I would want to submit that for
all of the problems you hear about in general, either we don't
do enough of a job or if it bleeds, it leads. We--
Mr. Arrington. Sure. I am--I know there--
Dr. Clancy. We don't share the people who are doing well.
Mr. Arrington. Here is my thing. I know there are good
people who are well meaning and they want it to work. I think
the system is fundamentally flawed. I think we have a lot to
overcome. I think we have to do our job better. I think you
have to do your job better.
But let's get back to this idea of rank order.
Dr. Clancy. Yes.
Mr. Arrington. That supposes there is a scorecard. So there
is a scorecard for the VISNs?
Dr. Clancy. Yes.
Mr. Arrington. And I would like a copy. Would you submit a
copy to the Chairman and the Committee so we can see what their
performance metrics are?
Dr. Clancy. Uh-huh.
Mr. Arrington. Okay. So that should be pretty clear then,
if they have outcome measures that they know they have to meet,
what happens if they don't meet those outcome measures?
Dr. Clancy. Then they have some serious conversations with
their boss and that becomes--
Mr. Arrington. When is the last time the seriousness got to
a removal because they just were not serving the veterans and
they just consistently missed the mark on outcomes?
Dr. Clancy. I have had a couple of direct experiences in
the past couple of years. And it wasn't an up or out kind of
thing. It was like no, there is no way you would get a
recruitment/retention incentive if the performance in your
network is not helping, and that person left.
Mr. Arrington. The Veterans Integrated Service Network is
what VISN stands for. I find it very ironic. I feel like it
should be named the Veterans Siloed Aimless Unaccountable
Service Network. That is my perception. That is my takeaway
from reading this, from listening to you guys.
What is the VHA's central role versus the role of the VISN
in managing these medical centers and holding them accountable
for serving our veterans? Is it clear or is there overlap? Is
there confusion at that level as well?
Dr. Clancy. There has been confusion at times, which is why
we are working on clarity. And you absolutely cannot have a
clear plan and roadmap for VISNs unless we have got that
straight. In general, central office is going to set vision,
and strategy, and tactics, and make sure that there are
resources available. If some facilities need more, then they
should get that, or some networks and so forth.
And frankly, for identifying the right kind of leadership,
because I agree with you that leadership and culture are way,
way at the top.
Mr. Arrington. It seems to me that they are not
laboratories of innovation. They are laboratories of
inefficiency. And they will continue to be until they are held
accountable, until there is clarity in their mission, until
they are held accountable for their performance.
And I don't--I sit through a lot of hearing on IT systems,
especially, and how they are so much frittered away on trying
to do something internally when you can get it off the shelf.
One business doing it one way. Another business is doing it a
different way. Even though it may be working and they could
share best practices, I am out of time, but I am going to
continue to press in on this notion of accountability. And I
hope we get more political leadership in so we can have these
same discussions.
Mr. Chairman, you have been very generous and very patient.
Thank you. I yield back.
The Chairman. I thank the gentleman for yielding and at
this time, Ms. Kuster, do you have any closing comments?
Ms. Kuster. Just very briefly, I do want to, you know, make
that comment that we do need leadership from the top and,
frankly, we need some consistency over a period of time. I
mean, four Secretaries and I have only been here for 5 years
seems a little--we are churning through VA Secretaries. So I
hope that the President will appoint and the Senate will
confirm the Secretary in due course and we will be able to move
forward with our oversight role.
I think accountability, you are hearing this message in a
bipartisan way. The role of supervision and the role of
oversight is critically important, and we will continue to work
together. So thank you, Dr. Roe, and appreciate you scheduling
this hearing. And thank you again for accommodating me.
The Chairman. Thank you, all. And I want to thank the
Committee Members for being here today. And I have just one
quick question.
Dr. Shulkin wanted to have a planning on the VISN
reorganization done by July 1st. Is that still going to happen
without the leadership--
Dr. Clancy. Yes.
The Chairman. It is--
Dr. Clancy. Yes.
The Chairman. So July 1st we will have that.
Dr. Clancy. Well, we will present that to the department
leadership, but shortly thereafter, we would look forward to
briefing you on this.
The Chairman. Yes, well thank you very much for that, Dr.
Clancy. And I think you sense our frustration, but opportunity
here with--I think the OIG has laid out a very clear pathway
about how we should go forward. And I think Mr. Moulton brought
up something that I, again, had a question earlier was what is
23 doing that 1, 5, and 22 are not doing? And that should be
pretty simple inside. And it is still unclear to me if I am a
VISN director, what power I have.
If something is going--in other words, if I am sitting in
the VISN in Nashville, what power do I have over Mountain Home
Medical Center in Johnson City, Tennessee. It is not clear to
me, even after today's hearing, what I have. Could I go and
would I be instrumental in removing a poorly performing medical
center director--
Dr. Clancy. Yes.
The Chairman [continued]. --or would I not? I could.
Dr. Clancy. You would--could.
The Chairman. Could I fire them?
Dr. Clancy. Yes.
The Chairman. As a VISN director, I can fire a medical
center without checking with you and the Secretary?
Dr. Clancy. I think in general they would check and make us
aware, but yes. And when I have called that VISN director to
say I had--was hearing things from a particular facility, she
has cheerfully cut her vacation short to go spend a day or two
there to figure out what is going on, you know, so she can see
it herself, which is exactly what you want.
The Chairman. Do all of these VISN directors understand
that they have that authority and power and can--and do the
medical center directors understand my boss is right here, not
all the way at the central office in Washington, D.C. But I
have got a boss close by that can terminate me?
Dr. Clancy. Yes.
The Chairman. They do understand that?
Dr. Clancy. Yes.
The Chairman. Has it ever happened?
Dr. Clancy. Yes.
The Chairman. A VISN director has fired a medical center
director?
Dr. Clancy. Yes.
The Chairman. Can you tell me who that is or where--maybe
we will do that off the record.
Dr. Clancy. Yeah, I could--
The Chairman. I would prefer to do that off the record.
Dr. Clancy. Okay, that would be fine.
The Chairman. Just to see that that has happened. But
anyway, I want to thank you all. It has been helpful. I think
you see the Committee wants to. I think legislation last week,
14 bills we passed yesterday. 11 of them by unanimous consent--
voice voted, I mean, and 3 by--I don't think there was a
single--or 2 or 3 no votes yesterday on all of those bills.
So you have a Committee and a Congress that really wants
the VA to work. We truly do. We thank the IG for helping us
point out these problems. And Mr. Butler, as always, thank you
for the Members and the VSOs who are always tremendously
helpful to us in guiding us and the Committee.
I ask unanimous consent that all Members have five
legislative days to revise and extend their remarks and include
extraneous material.
Without objection, so ordered.
The hearing is adjourned.
[Whereupon, at 12:05 p.m., the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Carolyn Clancy, MD
Good morning Chairman Roe, Ranking Member Walz, and Members of the
Committee. I appreciate the opportunity to discuss the proposed
redesign of the current Department of Veterans Affairs' (VA) Veteran
Integrated Service Network (VISN) structure and the status of remedial
actions at VISNs 1, 5, and 22. I am accompanied today by Dr. Bryan
Gamble, Deputy Chief of Staff at the Orlando VA Medical Center (VAMC).
On March 7, 2018, former VA Secretary David Shulkin announced VA
would undertake a systematic review of the VISNs, with a specific focus
on VISNs 1, 5 and 22. These three VISNs were challenged with leadership
and management issues, low performing facilities, and culture issues.
The purpose of the review was to identify VISN strengths and
weaknesses, and create a plan to improve VISN oversight,
accountability, performance and strengthen lines of communication with
VAMCs within that VISN and VA Central Office (VACO). Based on his
extensive leadership experience in the military health system, Dr.
Bryan Gamble was asked to lead this review and provide recommendations
with the goal of informing the redesign process.
Within the Veterans Health Administration (VHA), at times,
functional alignment among VACO, VISNs and VAMCs has not always been
clear. Our goal is to streamline business processes, ensure clearly
defined roles, responsibilities and authorities among all levels in
VHA, so that we are functioning in a way that is more efficient,
produces better results and accountability. We have also been working
with our national leadership council to develop a new model of
governance to help shape the culture, and set expectations and
requirements for improved care for Veterans.
Reorganization
A VISN consists of a geographic area which encompasses a population
of veteran beneficiaries. The VISN is defined on the basis of VHA's
natural patient referral patterns; numbers of beneficiaries and
facilities needed to support and provide primary, secondary and
tertiary care; and, to a lesser extent, political jurisdictional
boundaries such as state borders. Under the VISN model, health care is
provided through strategic alliances among VAMCs, clinics and other
sites; contractual arrangements with private providers; sharing
agreements and other government providers. The VISN is designed to be
the basic budgetary and planning unit of the Veterans health care
system.
In 1995, VA adopted a new VISN organizational structure to flatten
and decentralize VHA's field organization by replacing 4 regions, 33
networks, and 159 independent VAMCs with 22 VISNs that report directly
to the Office of the Deputy Under Secretary for Health for Operations
and Management. Since that time, two significant reorganizations have
occurred resulting in our current structure of 18 VISNs. In addition to
these changes in geographic boundaries, investments have been made to
standardize the management and oversight of VISNs. VHA has standardized
the organizational makeup of the VISN staff to ensure uniformity, as
well as strengthening the oversight and management of these positions
from VACO. VHA also created a single organizational chart adopted by
each VISN office and implemented Quarterly Network Director reviews,
which allows for a formal assessment of a VISN's progress at
implementing changes and directives.
Systematic review
Since former Secretary Shulkin's announcement, a team led by Dr.
Gamble has visited VISNs 1, 5, 22. To look at best practices, the team
also visited consistently high performing VISN 23. This team also
completed site visits to VAMCs within the following VISNs: Manchester,
NH; White River Junction, VT; Loma Linda, CA; Phoenix and Prescott, AZ;
Baltimore, MD; Minneapolis, MN and Washington, D.C. Interviews with
leadership and employees were performed; walking tours and inspections
of facilities were conducted and performance improvement group meetings
were attended. There also were employee listening sessions and
clinician-only listening sessions that did not include the facility
leadership team.
A resounding theme was a dedicated workforce set on providing
veterans with the best health care possible, and a clear understanding
and willingness from leaders and employees at ALL levels to improve
upon deficiencies wherever found. While these three challenged networks
are vastly different geographically, the assessment team found common
themes across these networks and facilities that included the following
opportunities for improvement:
Inconsistency of Human Resrouces services and hiring;
Additional emphasis needed on education and training;
Unintended consequences of Management by Measurement;
Leadership challenges including turnover, consistency and
psychological safety; and
Employee morale.
VHA is committed to ensuring Veterans get the best care. The
findings from this review will be combined with feedback from Network
Directors and our on-going modernization effort to formulate the plan
for VISN redesign.
Washington DC VA Medical Center OIG Report
One of the key concerns of this committee is the progress of the
Washington, DC VAMC. While there is still work to be done, significant
progress has been made. In March 2018, the VA Office of Inspector
General (OIG) released the report, ``Veterans Health Administration -
Critical Deficiencies at the Washington DC VA Medical Center.'' In
summary, OIG found that the DC VAMC (within VISN 5) has for many years
suffered a series of systemic and programmatic failures that made it
challenging for health care providers to consistently deliver timely
and quality patient care.
Over the past year, substantial progress has been made on the
concerns raised by the OIG. These improvement efforts include:
Establishment of the Incident Command Center (ICC) at the
Washington, D.C. VAMC: ICC implemented a robust oversight process that
identified and promptly addressed new supply or equipment shortages.
ICC instituted a 24-hour hotline for ordering urgent and emergent
medical supplies.
Assured all patients were safe and none were harmed:
VHA's National Center for Patient Safety launched a rapid-response
approach with onsite visits, bi-weekly and weekly calls with the
facility and VISN and ensured all patient safety issues were
appropriately addressed. As of January 31, 2018, the facility has
cleared their backlog of patient safety incident reports.
Awarded contract to construct a 14,200 square-foot space
for Sterile Processing Services. The $8.9 million project will be
completed in March 2019. More than $3.1 million in surgical instruments
have been purchased to ensure an appropriate inventory based on the
needs of the Veterans served and our surgical teams.
Transitioned inventory to the General Inventory Package:
Medical Surgical Primary Inventory has been entered in the system and
the periodic automatic replenishment levels are being validated to
ensure stock outages do not occur.
Secured the off-site warehouse to restrict access and
protect medical equipment and supplies.
Eliminated all pending prosthetics consults greater than
30 days, more than 9,000 to zero.
Ensured ordering of prosthetics is not interrupted by
end-of-fiscal-year financial transitions: At the end of fiscal year
2017, there was no disruption of prosthetic ordering due to lack of
funds.
Allocated resources and expedited hiring into Logistics,
Sterile Processing Service vacancies: A year ago, Logistics Service at
the DC VAMC was understaffed. Today, 54 staff have been hired; with
only 7 positions remaining under recruitment. Sterile Processing
Service currently has 15 Sterile Processing Service staff vacancies, 10
of which are currently filled with contract staff.
We know looking at how we operate our networks is imperative. To
get the type of accountability that is needed, and to ensure the best
quality care this Nation can provide our Veterans is delivered, we have
to take a critical look at processes, layers and leaders to ensure we
do not see the failures that we saw at the Washington, DC VAMC. As VHA
and the Washington, DC VAMC move forward, we are putting in place a
reliable pathway for all facilities, VISNs, and business lines to
escalate high-priority concerns to senior leadership for prompt action
and follow-up. We encourage all employees to speak up and raise
concerns to leadership. They are an integral part of our front-line
safety net and we take their concerns seriously.
Conclusion
We look forward to this opportunity for our new leadership and
improvement efforts to further restore the trust of our Veterans and
continue to improve access to care inside and outside VA. Our objective
is to give our Nation's Veterans the top quality care they have earned
and deserve. Mr. Chairman, we appreciate this Committee's continued
support and encouragement in identifying and resolving challenges as we
find new ways to care for Veterans. This concludes my testimony. My
colleagues and I are prepared to respond to any questions you may have.
Prepared Statement of Michael J. Missal
Mr. Chairman, Ranking Member Walz, and members of the Committee,
thank you for the opportunity to discuss the Office of Inspector
General's (OIG) recent report, Critical Deficiencies at the Washington,
DC VA Medical Center, and how those findings are indicative of a
breakdown of oversight at several levels within the Department of
Veteran Affairs (VA). \1\ Since becoming Inspector General two years
ago, I have made VA leadership and governance issues a priority for our
work, recognizing that deficiencies in these areas ultimately affect
the care and services provided to veterans and allow significant
problems to persist unresolved for years.
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\1\ The report was published on March 7, 2018.
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BACKGROUND
VA's Veterans Health Administration (VHA) has over 9 million
enrolled veterans. It manages the largest integrated healthcare system
in the nation, with over 145 VA medical centers (VAMCs) and
approximately 1,230 outpatient sites. Oversight for these VAMCs and
outpatient sites is the responsibility of 18 regional networks called
Veterans Integrated Service Networks (VISNs). VHA established the VISN
offices to improve access to medical care and ensure the efficient
provision of timely, quality care to our nation's veterans. In 1995,
VHA submitted a plan to Congress called Vision for Change that
restructured VHA field operations into VISNs. VHA specifically
decentralized its budgetary, planning, and decision-making functions to
the VISN offices in an effort to promote accountability and improve
oversight of daily facility operations.
The OIG has had a longstanding focus of governance issues in VHA.
For example, in March 2012, the OIG issued two reports dealing with
VISN management and structure: the Audit of VHA's Financial Management
and Fiscal Controls for Veterans Integrated Service Network Offices and
the Audit of VHA's Management Control Structures for Veterans
Integrated Service Network Offices. \2\ Our work determined that VHA
did not have adequate data to monitor VISN operations or staffing
levels. This weakness led to inadequate oversight of VISN operations, a
lack of accountability, and noncompliance with policies. Work we have
conducted since that time suggests that there continues to be
leadership and governance issues between medical centers and their
VISN, as well as between VISNs and the VA central office. Strong
leadership and governance are critical to not only consistently
achieving goals, but also to creating a culture that fosters personal
accountability and positive change, frequent and effective
communications, and compliance with policies and high-quality
standards. Where there are deficiencies in leadership and governance
there likely will be a cascade of persistent and pervasive problems
like those we found at the DC VAMC. Although the report on that
facility is our focus for this testimony, the lessons learned can be
applied to VISNs and medical centers across the nation.
---------------------------------------------------------------------------
\2\ Both reports were issued on March 27, 2012.
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A CASE STUDY: THE WASHINGTON, DC VA MEDICAL CENTER
The OIG received information from a confidential source about the
Washington, DC VAMC (DC VAMC) in March 2017 alleging that patients and
resources were at risk. Due to the seriousness of the allegations and
the initial findings, the OIG issued an interim report on April 12,
2017, that included the following findings: \3\
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\3\ Interim Summary Report - Healthcare Inspection - Patient Safety
Concerns at the Washington DC VA Medical Center, Washington, DC
Inaccurate and underutilized supply, instrument, and
equipment inventories that made it difficult to meet healthcare
provider and patient needs
Inadequate product safety recall processes
Dirty conditions in some clean/sterile storerooms
Millions of dollars in noninventoried supplies and
equipment
Numerous vacancies in key positions that would make
remediation of these conditions difficult
The OIG continued the inspection for the next nine months and
reported in March 2018 on significant pervasive problems that affected
risks to patient care and safety, service deficiencies that impeded
healthcare providers' efforts, lack of control over assets, and
leadership failures at multiple levels of VA. The report also details
that many management offices at VHA Central Office (VHACO), VISN 5
leaders, and leaders at the DC VAMC had been given reports regarding
many of these documented problems but they failed to appreciate the
impact on patient care or had failed to take the necessary actions to
correct the problems in many cases. \4\ Significantly, we did not find
any patient deaths or other adverse clinical outcomes relating to these
deficiencies, primarily due to the efforts of a number of committed
healthcare professionals who improvised as necessary to ensure veterans
received the best possible care under the circumstances. The final
report contained 40 recommendations addressing deficiencies in multiple
core functions of the DC VAMC's operations-all of which were agreed to
by VA.
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\4\ VISN 5, VA Capitol Health Care Network, includes the
Washington, DC VAMC.
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Service Deficiencies Affecting Patient Care
Although the medical center and VISN 5 have taken steps to address
the supply chain inventory management issues described in the OIG
Interim Report (such as detailing additional personnel to enter data
into the authorized inventory system), problems persisted during the
time of our inspection in getting supplies, instruments, and equipment
to patient care areas when they are needed. The OIG identified wide-
ranging factors involving multiple deficiencies across several key
services in the medical center, including the following:
Continuing supply chain and inventory management problems
Unsafe storage of clean/sterile supplies
Deficiencies in the Sterile Processing Service
Backlogs of open and pending prosthetic consults
Staffing shortages and human resources mismanagement
Lack of control over assets
Supply Chain and Inventory Management Problems
The Generic Inventory Package (GIP) is the authorized software
program used by VHA medical facilities to manage the receipt,
distribution, and maintenance of supplies. The DC VAMC was required to
use the GIP system until early May 2015 when the facility was directed
to implement a new inventory system called Catamaran. However, as noted
in the final report, medical center staff informed the OIG that the
Catamaran system was never relied upon. Although the medical center had
nominally transitioned to Catamaran in May 2015, VHA Procurement and
Logistics Office (P&LO) staff were aware by January 2016 that the
medical center had reverted to its manual inventory management
practices and was not using the Catamaran system. These staff told OIG
inspectors that they had no authority over the medical center, could
not compel it to comply, and did not escalate the matter to VHA P&LO
leaders. VHA subsequently terminated the Catamaran contract. Prior to
the OIG receiving the allegations discussed in our report, VA's Policy,
Assistance, and Quality (PAQ) staff from the VHA P&LO, conducted a
review of inventory management at the medical center. PAQ staff
determined in its January 2017 report that the medical center did not
have a VHA-authorized inventory system in place.
On March 21, 2017, the Deputy Under Secretary for Health for
Operations and Management (DUSHOM) instructed the VISN 5 Director and
the Medical Center Director via an emailed memo to provide an action
plan addressing the PAQ concerns. Staff were detailed to the DC VAMC to
take corrective action. Despite those efforts, the concerns were not
adequately addressed and the OIG final report provided many examples of
how inventory mismanagement contributed to the lack of medical supplies
being available where and when they were needed, including oxygen nasal
cannula tubing, disposable surgical staplers, and tubing for blood
transfusions.
We continued to find ongoing inaccuracies in the data entered in
GIP. Even for a small number of items, the medical center could not
reconcile its actual inventory with the data in GIP. As a result of the
medical center's underutilization of GIP (estimates of 15-25 percentage
of items included), it could not rely on the system to identify when
supplies were running low or out of stock. \5\ The product recall
process was also vulnerable because an accurate inventory was not kept.
The medical center did institute a stop-gap measure to deal with
supplies that may have been subject to a recall, but that was
inadequate because Logistics Service and clinical staff had no way of
verifying that all specified items had been removed from use. Without
an accurate inventory, there is a heightened risk to patients that
recalled products could be mistakenly used. In addition to patient
risks associated with the medical center running out of supplies or
using recalled products being elevated, the lack of accurate stock
levels contributed to urgent reordering, some overstocking, and waste
of government resources.
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\5\ In response to OIG findings, VA has reported that the DC VAMC
has transitioned inventory to the GIP system and addressed stock
levels, which will be assessed in OIG's follow-up process.
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Unsafe Storage of Clean/Sterile Supplies
To advance both patient safety and sound financial management,
inventoried items must be secured and maintained in clean conditions.
Proper storage of clean/sterile supplies is essential to preventing
contamination and patient infections, as well as product deterioration.
According to VHA directive, to maintain supplies properly, clean/
sterile storerooms must have stable temperature and humidity,
restricted access, weekly shelf-cleaning by Logistics Service staff,
and solid bottom shelves at least eight inches from the floor.
Logistics Service staff must sign a weekly log stating that the area
has been checked for expired supplies, cleanliness, and damage. While
Logistics Service staff have responsibility for some specific cleaning
tasks in clean/sterile storerooms, the Environmental Management Service
(EMS) is responsible for the overall cleanliness of the rooms.
EMS and Logistics Services reported having difficulties hiring and
retaining qualified staff. VISN 5 knew of the staffing shortages in EMS
in early fiscal year (FY) 2017 and knew of the Logistics Service
staffing issues as early as 2014 from an external consultant's report.
However, adequate steps to remedy the deficiencies were not taken.
After our interim report, we noted some improvements in the
cleanliness of storage rooms. The medical center had entered into a
contract with a commercial cleaning service in June to supplement the
medical center EMS staff but some areas were still of concern. As of
September 2017, the Acting Human Resources Director reported to the OIG
that 138 of 147 authorized EMS positions were filled.
Deficiencies in the Sterile Processing Service
The OIG detailed multiple deficiencies in the Washington DC VAMC's
Sterile Processing Service (SPS). These ranged from broken and
discolored instruments reaching clinical areas; incomplete surgical
trays in the operating room; improper tracking and reprocessing
procedures for loaner instruments; missing or expired SPS supplies;
failure to follow reprocessing instructions; inadequate documentation
of staff competencies; and not separating clean and dirty items in
satellite reprocessing areas.
These problems were not new. Prior reviews were shared with the
medical center, the VISN, and VHACO that consistently revealed
deficiencies in SPS processes and procedures, staffing and leadership
within SPS, and environment of care concerns that dated back to at
least 2015. The National Program Office for Sterile Processing reported
concerns in April 2015, September 2015, and October 2016. The October
2016 report had 140 corrective actions including some repeat findings.
In response to why conditions were uncorrected for so long, SPS
managers cited chronic understaffing of SPS and difficulties retaining
qualified personnel.
In November 2017, the OIG received a complaint about cancellation
of nine surgeries at the medical center. The OIG confirmed the
cancellations and that the medical center had reported to VHACO that
spotting and discoloration were found on some instruments. A contractor
was hired and examined 8,931 pieces of equipment and instruments over a
two-day period. The contractor reported finding rust on about 30
instruments; those items were polished and returned to service. On
further inspection the same contractor recommended replacing 216
instruments. Our report found that historically even when new
instruments were purchased, they could not always be reprocessed
appropriately nor were they always stored appropriately. In its
response to the OIG report, VA stated that it purchased more than $3
million in surgical instruments and contracted to construct additional
space for SPS.
Backlog of Open and Pending Prosthetic Consults
VHA requires that quality patient care be provided by furnishing
properly prescribed prosthetic equipment, sensory aids, and devices in
an economical and timely manner. To order a prosthetic appliance or
implant, a medical center provider must initiate and submit a consult
(a request for an item that allows for subsequent tracking) in the
electronic health record to the Prosthetics Service.
A prosthetic consult is considered ``closed'' when a patient
receives an in-stock item, a purchasing agent ships an in-stock item to
the patient, or a purchasing agent places an order with a vendor for a
nonstocked item to be shipped directly to the patient. A prosthetic
consult is placed in a ``pending'' status if other actions must be
taken before the consult can be completed and should be documented in
the prosthetic consult to allow for tracking through completion. VHA
business practice guidelines for prosthetic consult management states
that pending prosthetic consults ``must be reviewed at least weekly by
the Chief, [Prosthetic and Sensory Aids Services] and the Prosthetic
employee responsible for completing that consult.'' VHA requires the
closure of pending prosthetic consults upon the earlier of 45 working
days or 60 calendar days.
Medical center and VISN 5 leaders became aware of the increasing
number of open and pending prosthetic consults in May 2016 but due to
incomplete administrative actions by the medical center leaders to
provide access to its systems, VISN 5 could not take the necessary
steps to provide assistance in addressing the increasing number of open
and pending prosthetic consults.
To resolve the consults backlog identified by the OIG, the Acting
Medical Center Assistant Director reported VA had efforts in progress
to hire staff, redesign the organizational structure, claim 2,000
square feet of warehouse space for inventory, and develop a walk-in
clinic. In addition, he reported that nine purchasing agents had been
assigned from across VHA to assist with resolving open and pending
prosthetic consults.
On August 29, 2017, OIG staff spoke with the Acting Chief of
Prosthetics who confirmed that through the use of additional staffing,
the medical center had been able to reduce the number of prosthetic
consults to approximately 6,130, of which 3,800 were more than 30 days
old. Also in August, the DC VAMC chartered an Administrative
Investigative Board to determine accountability for the failures
identified within the Prosthetics Service. In its response to our final
report, VHA stated that ``as of January 2018, the DC VAMC had no
pending prosthetics consults over 30 days.'' We will verify this
information during our follow-up process.
Staffing Shortages and Human Resources Mismanagement
Medical center personnel often attributed deficiencies in Logistics
Service and SPS to chronic understaffing. To obtain additional staff,
the medical center's policy specifies that Service Chiefs must
determine the minimum number of positions needed to perform the
functions of their services and submit requests for new positions or
changes in the grade of already approved positions to the Resource
Management Committee (RMC). The Associate Director of the medical
center chairs the RMC, which makes recommendations to the Director
regarding approval or disapproval of these requests, based in part on
budgetary considerations. The medical center Human Resources Management
(HR) is responsible for executing actual hiring actions.
The OIG determined that Logistics Service and SPS had experienced
historically high vacancy rates. A number of factors contributed to
these rates, including a failure to maintain accurate data on the
numbers of authorized positions throughout the medical center; the RMC
not performing its duties in accordance with policy; and HR not
completing hiring actions appropriately.
The OIG confirmed that high turnover rates in HR leadership may
have contributed to the failure to resolve staffing issues. VHACO and
VISN 5 provided teams and personnel to support the medical center's
general HR functions, but the DC VAMC did not implement action plans
developed from those consultative site visits.
VA reports progress in hiring but vacancy rates for SPS staff are
still high at the medical center, although VA reports some of those
positions being filled by contractors in their response to the OIG
report.
Lack of Control Over Assets
The medical center continually mismanaged significant government
resources and did not adequately secure veterans' protected
information. Its financial and inventory systems produced inadequate
data, lacked effective management controls, and yielded no reasonable
assurance that funds were appropriately expended. Accordingly, the OIG
could not estimate the loss to VA as a result of the failings
identified in the final report. A number of examples are provided in
the report, however, that show significant overpayments for particular
products; unsecured access to and mismanagement of more than 500,000
items accumulated in an off-site warehouse that included purchases not
meeting medical center needs, overstocked items, and some items that
appeared damaged; abuse of purchase cards; and other failures to use
taxpayer dollars appropriately.
The following are examples of how government resources were at risk
for or subject to fraud, waste, and abuse:
There was excessive use of government purchase cards for
medical equipment and supply purchases (89 percent of the medical
center's total purchase card use was for medical supplies) instead of
approved federal contracts that leverage buying power and helped ensure
appropriate pricing and purchasing. Purchase card use was not as
closely scrutinized and did not take advantage of the typically lower
prices associated with buying under federal contracts. They were
misused, in part, because leaders failed to ensure proper controls or
fix an inventory system-which sometimes led to urgent purchases needing
to be made on purchase cards for quick delivery as a workaround for
supply problems.
The VISN 5 Agency/Organization Program Coordinator (A/
OPC) for the purchase card program reported potentially fraudulent
purchase orders to medical center leaders and the Chief of Prosthetics
in September 2016. After no action was taken by either, the VISN 5 A/
OPC took action to reduce a purchasing agent's limit and initiated an
audit. Also VA policy limited the number of purchase card accounts for
which an approving official is responsible to not more than 25. At the
medical center, the Chief Logistics Officer (CLO) was responsible for
approving expenditures made by all of the 86 cardholders.
A general lack of controls was found over acquisition of
medical supplies and equipment, including the inability to consistently
provide documentation such as purchase orders, invoices, receiving
reports, or other item-level records required for proper auditing. For
example, the medical center incurred nearly $875,000 in rental fees for
three specialized hospital beds for patients' in-home use that could
have been purchased new for a total of about $21,000.
The medical center failed to segregate duties so that the
same individual was not both purchasing and receiving or inventorying
goods to ensure the integrity of procurement processes and prevent
theft or abuse.
The medical center lacked an updated and accurate
inventory for nonexpendable equipment. VA requires medical facilities
to perform an annual physical inventory of all nonexpendable items and
maintain an Equipment Inventory List (EIL). EIL includes all
nonexpendable property with assigned numbers that correspond to the
responsible department. Although the EIL Custodial Officer is
responsible for completing and signing the EIL, the Medical Center
Director and CLO (or their designee) must ensure accountability and
oversight for all nonexpendable property and equipment in their
facility. The Medical Center CLO failed to submit data for the VHA
Quarterly EIL reports for three years. Furthermore, a March 2017 memo
from the DUSHOM to the VISN Director and the Medical Center Director
stated that Reports of Survey listing lost or stolen property had not
been completed for more than five years.
Because of failures in Records Management, more than
1,300 boxes of unsecured documents, including some patient protected
health information and personally identifiable information were found
in various locations including the off-site warehouse, on-site storage,
the DC VAMC basement, and a dumpster.
Risks to Patient Care
It is clear that functions typically thought of as administrative
in nature can have a profound impact on the ability of healthcare
providers to do their jobs effectively and on the risk of harm to
patients. During extensive interviews conducted by the OIG's Rapid
Response Team and other personnel, 13 healthcare providers stated that
they had reported their concerns to the Chief of Surgery and 12
healthcare providers stated that they had reported supply, instrument,
or equipment concerns to the Medical Center Chief of Staff. As I will
discuss further, these and other issues at the DC VAMC were reported to
the VISN and by program offices within VA.
For our review, OIG healthcare staff independently reviewed the
care provided to 124 DC VAMC patients to determine if they experienced
adverse clinical outcomes because their healthcare provider did not
have the appropriate supplies, instruments, or equipment. As discussed
earlier, while the OIG did not find that patients suffered adverse
clinical outcomes for the review period, staff provided several
examples that illustrated an impact on patients when supplies,
instruments, and equipment were not available when needed. These
included unnecessary anesthesia, prolonged procedures or
hospitalizations, and alternative surgical techniques due to failure to
ensure the availability of instruments or supplies. For example, a
``mesher'' used to place small holes in the skin to assist with
drainage had a missing handle and the surgeon needed to conduct the
procedure manually, which can result in uneven drainage. In some cases,
procedures needed to be delayed, rescheduled, or required staff to
leave the facility to borrow what was needed from a nearby private
hospital. For example, an instrument was not sterilized since its last
use and was unavailable to the surgeon after the patient received
general anesthesia, resulting in the procedure being cancelled and
rescheduled two days later, which unnecessarily exposed the patient to
the risks associated with the anesthesia. In another case, staff went
``across the street'' to a medical facility to acquire mesh while the
operation was ongoing. We found that staff lacked confidence that
managers and leaders overseeing the facility would fix these problems
and resorted to creating their own workarounds to ensure patients
received proper care.
Patient Safety Reports
Patient safety reports allow for the reporting and tracking of
adverse events and ``close calls'' as well as allowing VA medical
facilities to identify and address unsafe conditions. For the interim
report review, OIG staff found 193 patient safety reports at the DC
VAMC since January 1, 2014, were entered into VHA's National Center for
Patient Safety (NCPS) database. However, we determined that the number
of patient safety events was under-reported and at least 376 patient
safety events related to supplies, instruments, or equipment were
reported within the medical center. Of those, 206 patient safety events
were entered into the facility's system, but were not entered into the
VHA database as required. Overall, the DC VAMC failed to appropriately
score, trend, and record patient safety events and the patient safety
manager did not properly identify that further analysis was warranted.
Within an individual medical center, the patient safety manager can
identify emerging trends that could potentially compromise patient
safety through event reporting and analysis. At the national level, the
VHA NCPS analyzes data reported from all medical facilities to identify
emerging trends that have the potential to compromise patient safety in
multiple facilities. At DC VAMC, although data were available, the
patient safety manager did not detect the widespread nature of the
supply, instrument, and equipment problems until June 2016, when an
individual root cause analysis was conducted on an incident involving
the use of expired surgical supplies during a surgical procedure.
Other mechanisms for aggregating information to inform VISN and
medical center leaders about emerging issues include the work of
quality management and safety committees. The OIG conducted an
extensive review of meeting minutes from the Executive Committee of the
Governing Body (ECGB), which is responsible for oversight of critical
quality and patient safety monitors, and its subordinate committees.
The ECGB oversees the Medical Executive Committee and Quality Council
as well as other organizational patient safety and performance
improvement initiatives.
VHA policy requires the ECGB to keep minutes that describe and
track issues to resolution, as well as to make recommendations to
leaders. The OIG review of minutes from October 2015 through April 2017
revealed a pattern of reporting and oversight deficits. In addition to
the ECGB meeting minutes, the OIG reviewed meeting minutes of other
committees that provide oversight for patient safety and performance
improvement initiatives. Review of the Director's morning report also
revealed a lack of appropriate follow-up actions for surgical
instrument issues.
The OIG confirmed through interviews and analyses of documents
provided that action plans, if implemented, were not consistently
effective at resolving issues as evidenced by ongoing deficiencies in
many areas. The VISN Quality Management Officer who has responsibility
for overseeing all aspects of quality management and performance
improvement at VISN 5 facilities acknowledged these concerns in an
interview with OIG staff, and reported that he would be ``pushing for a
rapid process improvement initiative.'' VA has also reported that
following our findings, the DC VAMC cleared its backlog of patient
safety incident reports.
Failures in Leadership
It is clear that information and documentation outlining some, if
not most, of the failings in the medical center reached responsible
officials in DC VAMC, VISN 5, and VHACO as early as 2013, but actions
taken did not effectively remediate the conditions.
From 2013 through 2016, the DC VAMC and VISN 5 received at least
seven written reports detailing significant deficiencies in Logistics,
Sterile Processing, and other Services, many of which were identified
as persistent at the time of the OIG 2017 on-site visits.
Management Quality Assurance Service (MQAS) Report (2013)
- This report evaluated the performance of selected areas of logistics
operations and identified areas requiring improvement. This report was
provided to the Medical Center Director in January 2013 as well as
VHACO Procurement and Logistics Office (P&LO) and VISN 5 leaders. It
contained 52 conditions including nine repeat findings and two concerns
related to compliance with VA and VHA directives that required
management attention.
There was an exchange of information between MQAS and the Medical
Center Director in March and May 2013 but in December 2013, MQAS staff
emailed medical center staff requesting an update as the completion
dates were past due. Again in February 2014, MQAS staff reached out for
an update but the Medical Center did not respond. In June 2014, MQAS
requested assistance from VHA P&LO. VHACO contacted the VISN CLO for an
update and to offer assistance. Moreover, the VISN 5 CLO admitted that
the VISN ``may have dropped the ball on response.'' In October 2014,
MQAS advised the VISN 5 CLO that they would elevate these issues if the
DC VAMC did not provide information. The medical center responded in
piecemeal fashion. In December 2015, MQAS determined based on
representations from the Medical Center, that all but one
recommendation was satisfied. As late as February 2017, MQAS continued
to follow up with DC VAMC Logistics Service for required reports.
VISN 5 Network External Review (NER) (2013) - Each VISN
was required to conduct an annual review of its facilities' logistics
operations. In May 2013, the VISN Director sent the Medical Center
Director the NER relating to Logistics Service containing 55
observations including a finding that the medical center was not using
GIP to manage its inventory. In June 2013, the Associate Medical Center
Director responded and provided estimated implementation dates for each
of the 55 areas.
VISN 5 Consultant Report (2013) - In December 2013, at
the direction of VISN 5, a consultant reviewed the medical center's
Facility Management Service and Safety Programs. The report was
presented to medical center leadership and detailed numerous concerns,
including that ``the Sterile Processing Service (SPS), a high
visibility program with critical responsibility toward patient safety,
is working in an area that was identified to be outside of required
environmental controls (humidity), and environmental monitoring is not
being consistently or continuously conducted.'' In addition, the
consultant noted that documentation of SPS staff competencies was not
available. The OIG is unable to determine what remedial efforts were
made, if any. Any improvements were not sustained because the SPS
deficiencies identified in the 2013 Consultant Report persisted at the
time of the 2017 OIG site visits.
VISN 5 Logistics Study (2014) - VISN 5 engaged an
external consultant to study Logistics Service operations within its
facilities in 2014. After reviewing the consultant's observations, the
VISN noted the DC VAMC's Logistics Service staffing was significantly
lower than similar facilities and the facility had high staff vacancy
rates in both the expendable supply and nonexpendable equipment
Logistic Service. The medical center's CLO attempted to increase
staffing but contended efforts were impeded by a lack of support from
the medical center's HR staff. The OIG identified emails alerting the
leadership of this issue.
Nursing Report (2016) - VISN 5 reviewed nurse staffing
and related issues in its facilities in 2016. In May 2016, the VISN
shared the results with the DC VAMC Director, which included the
facility was short approximately 98 nurses and the supply chain was
broken. The Medical Center Director acknowledged the vacancies and
commented that there were no sentinel events at the facility.
National Program Office on Sterile Processing (NPOSP)
Reports (2015 and 2016) - In April 2016, the medical center reported it
had ``closed'' (satisfied) 25 of 28 recommendations arising out of the
September 2015 site visit. The medical center reported that it planned
to resolve two recommendations on or before May 20, 2016, and that the
final recommendation relating to workflow would be addressed during a
renovation of SPS planned for 2017. However, a repeat visit from NPOSP
in October 2016 identified recurring issues previously reported as
resolved, including environmental issues, lack of SOPs, and inadequate
documentation of staff competencies. NPOSP issued additional
recommendations, some of which were repeat findings from the 2015
visits.
In response to the October 2016 NPOSP recommendations, the medical
center submitted another detailed action plan on December 9, 2016, with
periodic progress updates thereafter. Documentation shows that the
medical center updates falsely reported that some action items
identified in the NPOSP 2016 visit had been completed, resulting in
VISN 5 reopening an action item in April 2017 previously reported as
corrected.
The chronic medical center deficiencies noted in the 2013-2017
reports speak to leaders' at various levels inability or unwillingness
to implement and sustain lasting change within various services.
Ineffective Follow Up
Turnover and inadequate governance affect remediation. For example,
in terms of staffing, the DC VAMC has had five Associate Directors
since 2013, most of who assumed the role in an acting capacity. The
Associate Director is responsible for the managerial and administrative
services and operations that are the subject of the report, including
Logistics Service, HR, Fiscal Service, and EMS. Lack of consistent
leadership in this key role since December 2015 made it more likely
that the medical center managerial and administrative deficiencies
would remain unaddressed.
Many recommendations from previous reports concerning the sterile
processing of instruments and Logistics Service functions were deemed
implemented or ``closed'' but were not effectively addressed. VISN 5
leaders and some VHACO personnel were aware of many of the problems
identified and did not ensure that adequate corrective action had been
taken by the medical center to address them. Methods used by the VISN
and VHACO to oversee the medical center were either inadequate or did
not include accurate or complete data on key aspects of medical center
operations. As the Director of VISN 5 acknowledged, the VISN
responsibility should be to intervene when it has notice of a problem.
Or, as the Director bluntly conceded, ``the buck stops with him.''
There has been significant focus recently on the ratings given by
the Strategic Analytics for Improvement and Learning (SAIL). The DC
VAMC was rated a 2-star (slightly below average) rating from 2011
through the third quarter of FY 2015, and then improved to a 3-Star
(average) rating, maintaining that rating through March 31, 2017. \6\
The SAIL rating is based on clinical measures but does not include
supply chain inventory and logistic issues even though such functions
have clinical impact. The SAIL model incentivizes facilities to take
action to improve the quality of care, however its minimal focus on
administrative functions that support patient care can leave patients
vulnerable.
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\6\ VA no longer publishes star ratings but based on SAIL data, the
facility is currently between 1 and 2 stars.
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Our report also found that VHACO receives information daily from
medical centers and VISNs to inform policymaking, but that information
is not always shared with officials who can take action to remedy the
deficiency.
OTHER OIG WORK ASSESSING LEADERSHIP AND GOVERNANCE
We seek to address in all of our work-whether an audit, review, or
inspection-the underlying cause (or causes) of the identified condition
and who is responsible. This focus has revealed that there is often a
lack of oversight for compliance with policies and procedures,
reporting mechanisms are not reliable, and operations are not effective
or efficient. \7\
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\7\ Healthcare Inspection - Evaluation of System-Wide Clinical,
Supervisory, and Administrative Practices, Oklahoma City VA Health Care
System, Oklahoma City, Oklahoma, November 2, 2017; Review of Research
Service Equipment and Facility Management, Eastern Colorado Health Care
System, March 29, 2018; Audit of Beneficiary Travel Program, Special
Mode of Transportation, Eligibility and Payment Controls, May 7, 2018.
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One specific example is the change we made in April 2017 regarding
our cyclical review of VAMCs. We now include a review section on the
leadership at the facility when conducting our Comprehensive Healthcare
Inspection Program (CHIP) reviews. We provide a descriptive evaluation
of VHA facility leadership performance and effectiveness as evidenced
by the reduction of organizational risks and provision of quality care
that result in positive patient outcomes and experiences and optimal
levels of employee engagement and satisfaction. Our work will continue
to examine leadership and governance issues throughout VA.
CONCLUSION
We found critical deficiencies in our inspection of DC VAMC.
Although the findings and recommendations focus on improvements in that
facility, the issues raised could be used almost as a checklist for
other facilities, VISNs, and VHA leaders.
While the concrete deficiencies present significant challenges, we
believe the greatest obstacle to change is the sense of futility or
culture of complacency among some staff and leaders. At the core, the
DC VAMC report is about the breakdown of systems and leadership at
multiple levels, and an acceptance by many personnel that things will
never change. This was evidenced by
staff that got used to ``making do,''
acceptance or normalization of non-compliant practices,
acceptance of information/data at face-value without
asking the next question, and
willingness to rationalize poor practices with ``nobody's
been harmed.''
We fervently believe that VHA has talented and committed people
that could lead the turnaround at the DC VAMC and other facilities. We
saw healthcare professionals and other staff making significant efforts
to ensure patients were safe and receiving quality care by using
workarounds or trying to do the right thing. With time and concerted
effort, we know that positive change can be realized. VHA needs to
recognize the urgency in making strong leadership decisions now to
oversee that change.
Mr. Chairman, this concludes my statement. I would be happy to
answer any questions you or other members of the Committee may have.
Prepared Statement of Roscoe G. Butler
Chairman Roe, Ranking Member Walz, and distinguished members of the
Committee; on behalf of National Commander Denise H. Rohan and The
American Legion, the country's largest patriotic wartime service
organization for veterans, comprised of more than 2 million members,
and serving every man and woman who has worn the uniform for this
country, we thank you for inviting The American Legion to testify today
to share our position regarding the current status of remedial actions
at VISNS 1,5, and 22.
Background
In 1994, the Veterans Health Administration (VHA) was structured
into four regions, and individual VA medical centers reported directly
to VHA for budgeting and program management purposes. At that time, VHA
was responsible for the care of approximately 25 million veterans.
Each region was led by a region director located in the field
(Linthicum, MD; Ann Arbor, MI; Jackson, MS; and San Francisco, CA). The
four region directors supervised the operation of the medical care
facilities in their regions (which ranged from 36 to 45 facilities per
region).
The veterans health care system is the largest health care system
in the United States, although it is an anomaly in American health care
in so far as being a centrally administered, fully integrated, national
health care system that is both funded and operated by the federal
government. As it grew in size and complexity, the system became
increasingly cumbersome and bureaucratic. It was often perceived to be
unresponsive to individual needs and changing circumstances. It seemed
to be chronically underfunded and short of staff and supplies, despite
its rising costs. By the mid-1990s, the system was widely criticized
for being difficult to access, for having long wait times and poor
service, for providing care of unpredictable and irregular quality, and
for being inefficient and expensive. Many policymakers and health care
professionals questioned whether it had a future. \1\
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\1\ Kizer KW, Dudley RA. Extreme makeover: Transformation of the
veterans health care system. Annu Rev Public Health. 2009;30:313-39.
doi: 10.1146/annurev.publhealth.29.020907.090940.
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By 1994, the VA had grown to be the country's largest health care
provider, with an annual medical care budget of $16.3 billion; 210,000
full-time employees; 172 acute care hospitals, which had 1.1 million
admissions per year; 131 skilled nursing facilities, which housed some
72,000 elderly or severely disabled adults; 39 domiciliaries
(residential care facilities), which cared for 26,000 persons per year;
350 hospital-based outpatient clinics, which had 24 million annual
patient visits; and 206 counseling facilities, which provided treatment
for posttraumatic stress disorder (PTSD). The VHA also partnered with
almost all states to fund state-owned skilled nursing facilities for
elderly veterans and administered a contract and fee-basis care program
paying for $1 billion of out-of-network services each year. \2\
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\2\ Kizer KW, Dudley RA. Extreme makeover: Transformation of the
veterans health care system. Annu Rev Public Health. 2009;30:313-39.
doi: 10.1146/annurev.publhealth.29.020907.090940.
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The VHA was a system based on inpatient care, in contrast to
substantially less expensive and patient-friendly ambulatory care.
Specialists rather than primary-care physicians dominated the
workforce. Finally, like many publicly funded health systems throughout
the world, the client base was increasingly needy and growing in
numbers.
There was widespread consensus that the veterans health care system
needed a major overhaul but little agreement about how to effect the
change. Further, the system had to remain fully operational while it
was being overhauled.
In 1994, President Bill Clinton appointed Dr. Kenneth Kizer as VA
Undersecretary for Health. Dr. Kizer inherited an organization famous
for low quality, difficult to access, and high-cost care. \3\ Under new
leadership recruited from outside the system-the first time this had
occurred in more than 30 years-a plan to radically transform VA health
care was developed in the winter of 1994-1995, vetted with the Congress
(as required by law) and the VA's myriad stakeholders in the spring and
summer of 1995, and launched in October 1995. \4\
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\3\ https://rogerlmartin.com/docs/default-source/Articles/
incentives-governance/aligningthestars
\4\ Kizer KW, Dudley RA. Extreme makeover: Transformation of the
veterans health care system. Annu Rev Public Health. 2009;30:313-39.
doi: 10.1146/annurev.publhealth.29.020907.090940.
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In March 1995, Dr. Kizer submitted a plan to Congress titled The
Vision for Change - A Plan to Restructure the Veterans Health
Administration. \5\ The reorganization plan was the first step in VHA
becoming a more efficient and patient-centered health care system.
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\5\ https://www.va.gov/HEALTHPOLICYPLANNING/vision--for--change.asp
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This new structure intended to decentralize decision-making
authority regarding how to provide care and integrate the facilities to
develop an interdependent system of care through a new structure - the
Veterans Integrated Service Network (VISN). The VISN's primary function
was to be the basic budgetary and planning unit of the veterans' health
care system.
Dr. Kizer's plan suggested that the number of staff needed to
manage a VISN would range between seven and ten full-time employees
initially, which over the years ballooned to 220 employees working at
the VISN. The geographical boundaries for each new VISN were defined
based on natural patient referral patterns at VA medical centers and
outpatient clinics, the number of enrolled veterans in the system, and
the type of facilities needed to provide care. \6\
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\6\ https://www.burr.senate.gov/imo/media/doc/VISNAct.pdf
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In September 1995, Congress authorized VA to implement the plan.
The 22 network directors were officially named on September 21, 1995.
VISN Directors began assuming their new positions in October 1995, and
all were on board by January 29, 1996. The transition of operations
from the regional offices to the networks commenced in October 1995.
In October 1995, the restructuring of VHA headquarters also begun.
Restructuring included eliminating certain positions and offices,
reorganizing other offices and functions, and establishing new offices
of Policy, Planning and Performance; Chief Information Officer; and
Employee Education. In addition, the Chief Network Officer became part
of the integrated Office of the Under Secretary for Health.
At the same time VHA was tasked with implementing Dr. Kizer's VISN
for Change, it also had the daunting task of implementing one of the
most dramatic legislative changes impacting veterans health care in the
20th century, The Veterans' Health Care Eligibility Reform Act of 1996.
\7\ This law was enacted to help VA improve its management of care and
provide this care in more cost-effective ways; it also sought to
increase veterans' equity of care. To improve cost-effectiveness, the
act allowed VA to provide needed hospital care and health care services
to veterans in the most clinically appropriate setting.
---------------------------------------------------------------------------
\7\ https://www.congress.gov/bill/104th-congress/house-bill/3118
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Since then, VISN staff and functions have expanded way beyond the
original intent of Dr. Kizer's Vision for Change. Since the creation of
VISNs in 1995, there has been a significant shift in veterans'
demographics and geographically where they access care; however, VA has
not reassessed the VISN structure.
In September 2016, the Government Accountability Office (GAO)
issued a report entitled VA Health Care: Processes to Evaluate,
Implement, and Monitor Organizational Structure Changes Needed. GAO
reported that internal and external reviews of VHA operations have
identified deficiencies in its organizational structure and recommended
changes that would require significant restructuring to address,
including eliminating and consolidating program offices and reducing
VHA central office staff. However, VHA does not have a process that
ensures recommended organizational structure changes are evaluated to
determine appropriate actions and implemented. \8\
---------------------------------------------------------------------------
\8\ GAO report (Oct 27, 2016): VA Health care: Processes to
Evaluate, Implement, and Monitor Organizational Structure Changes
Needed
---------------------------------------------------------------------------
For example, VHA chartered a task force to develop a detailed plan
to implement selected recommendations from the independent assessment
of VHA's operations required by the Veterans Access, Choice, and
Accountability Act of 2014. \9\ It found, among other things, that VHA
central office programs and staff had increased dramatically in recent
years, resulting in a fragmented and ``siloed'' organization without
any discernible improvement in business or health outcomes. It
recommended restructuring and downsizing the VHA's central office. \10\
The task force of 18 senior VA and VHA officials conducted work over
six months, but did not produce a documented implementation plan or
initiate implementation of the recommendations. Without a process that
documents the assessment, approval, and implementation of
organizational structure changes, VHA cannot ensure that it is making
appropriate changes, using resources efficiently, holding officials
accountable for taking action, and maintaining documentation of
decisions made.
---------------------------------------------------------------------------
\9\ https://www.congress.gov/bill/113th-congress/house-bill/3230
\10\ https://www.va.gov/opa/choiceact/documents/assessments/
integrated--report.pdf
---------------------------------------------------------------------------
In October 2015, VHA began to implement a realignment of its VISN
boundaries, which involves decreasing the number of VISNs from 21 to 18
and reassigning some VA medical centers (VAMC) to different VISNs. VHA
officials anticipate this process will be completed by the end of
fiscal year 2018. VHA officials on the task force implementing the
realignment told GAO they thought VISNs could implement the realignment
independently without the need for close monitoring. VHA also did not
provide guidance to address VISN and VAMC challenges that could have
been anticipated, including challenges with services and budgets,
double-encumbered positions (two officials in the same position in
merging VISNs), and information technology. Further, VHA officials said
they do not have plans to evaluate the realignment. VHA's actions are
inconsistent with federal internal control standards for monitoring
(management should establish monitoring activities, evaluate results,
and remediate identified deficiencies) and risk assessment (management
should identify, analyze, and respond to changes that could affect the
system). Without adequate monitoring, including a plan for evaluating
the VISN realignment, VHA cannot be certain that the changes are
effectively addressing deficiencies; nor can it ensure lessons learned
can be applied to future organizational structure changes.
In March 2018, former VA Secretary David Shulkin announced his plan
to reorganize the department's central office by May 1. \11\ May 1st
has come and gone, but the reorganization has not occurred. A statement
from Dr. Shulkin's March 2018 release, he stated:
---------------------------------------------------------------------------
\11\ https://www.usatoday.com/story/news/politics/2018/03/07/va-
chief-consolidates-oversight-23-va-hospitals-start-restructuring-
effort/404632002/
``The VISN model was put in place close to 20 years ago, a very
innovative model that has served VA well,'' Shulkin said. ``But like
any business, the times change, the needs change and it's time for us
to look at how we operate our networks differently to get the type of
accountability that's needed to make sure we don't see the failures
---------------------------------------------------------------------------
that we saw here in the Washington, D.C. VA.''
Dr. Shulkin also discussed the appointment of a special team to
work with its national leadership council to develop a nationwide
reorganization plan for its 23 VISNs, which was due to the secretary by
July 1. \12\
---------------------------------------------------------------------------
\12\ https://www.dav.org/learn-more/news/2018/va-secretary-
announces-immediate-transformations-in-wake-of-scathing-ig-report/
---------------------------------------------------------------------------
On March 8, 2018, Dr. Shulkin announced the appointment of a new
executive in charge, Bryan Gamble, to oversee three VISNs: the New
England Health Care System and the Capitol Health Care Network, which
includes Washington, D.C., and parts of Maryland and Virginia, as well
as the Desert Pacific Healthcare Network in California, New Mexico and
Arizona. \13\
---------------------------------------------------------------------------
\13\ https://federalnewsradio.com/veterans-affairs/2018/03/shulkin-
promises-reorganization-plan-for-va-central-office-after-troubling-ig-
report/
---------------------------------------------------------------------------
The Way Forward
The purpose for creating the VISN structure was to decentralize
decision-making authority regarding how to provide care and integrate
the facilities to develop an interdependent system of care through the
VISNs. The VISN's primary function was to be the basic budgetary and
planning unit of the veterans' health care system. However, as we all
know, the VISN structure has morphed into a broader operation,
consuming more staff, resources, funding, and physical space.
As more veterans enrolled in the VA health care system, the VISN
responsibility for budget and planning increased and it became more
difficult for the VISN to manage. Reoccurrence of system- wide failures
are becoming routine that are attributable to leadership failures at
the VAMC, VISN and Central Office level. According to the March 7, 2018
VAOIG report citing Critical Deficiencies at the Washington DC VA
Medical Center, the VAOIG cited numerous failures at the Washington DC
VA Medical Center, the VISN, and VA Central Office. \14\ Medical
Center, VISN 5, and some VACO leaders knew for years about at least
some of the problems outlined in the VAOIG report. The report stated
information and documentation outlining some of the failings in the
Medical Center reached responsible officials in the Medical Center,
VISN 5, and VACO as early as 2013, but there where failures at multiple
levels of leadership, in accountability, responsibility, and oversight.
This lack of ownership and a pervasive practice of shifting blame to
others contributed to a culture of complacency and neglect that placed
both patients and assets of the federal government at risk.
---------------------------------------------------------------------------
\14\ https://www.va.gov/oig/pubs/VAOIG-17-02644-130.pdf
---------------------------------------------------------------------------
Clearly, Dr. Kizer's VISN model is no longer living up to
expectations, but rather has grown into a high cost ineffective
operation.
In 2016, The American Legion membership voiced serious concerns
about the effectiveness of the VISNs and passed Resolution 194,
entitled Department of Veterans Affairs Veteran Integrated Service
Networks. The resolution urges Congress to direct the GAO and VAOIG to
conduct a comprehensive study to include purpose, goals, objective,
budget and evaluation of the effectiveness of the VISN structure. \15\
---------------------------------------------------------------------------
\15\ American Legion Resolution No. 194 (2016): Department of
Veterans Affairs Veteran Integrated Service Networks
---------------------------------------------------------------------------
The American Legion applauds former Secretary David Shulkin for
proposing to look into reorganizing the VISN and VA Central Office. The
American Legion believes that the Central Office and VISN realignment
is in keeping with Resolution 194, and should continue its course with
Veteran Service Organizations being consulted throughout the process to
ensure, from a veteran perspective, their concerns are addressed.
Conclusion
As always, The American Legion thanks this Committee for the
opportunity to elucidate the position of the 2 million veteran members
of this organization. For additional information regarding this
testimony, please contact Assistant Director of the Legislative
Division, Jeff Steele, at (202) 861-2700 or jsteele@legion.org.
Statements For The Record
U.S.Office of Special Consel, Henry J.Kerner Special Counsel
January 25, 2018
The President The White House
Washington, D.C. 20500
Re: OSC File Nos. DI-16-5687. DI-16-5688, DI-16-5689, and DI-16-
5690
Dear Mr. President:
Pursuant to 5 U.S.C. Sec. 1213(e)(3), I am forwarding reports from
Department of Veterans Affairs (VA) based on disclosures of wrongdoing
at the Department of Veterans Affairs (VA), VA Medical Center
Manchester (VAMC Manchester), Manchester, New Hampshire. The four
whistleblowers in this matter, Dr. Ed Kois, Dr. Stuart Levenson, Dr. Ed
Chibaro, and Dr. Erik Funk (the whistleblowers), who consented to the
release of their names, disclosed that a large number ofVAMC Manchester
patients have developed serious spinal cord disease as a result of
clinical neglect at the VA; that the former Chief of the Spinal Cord
Unit, Dr. Muhammad Huq improperly copied and pasted patient chart notes
for over 10 years; and that VAMC Manchester's operating room (OR) has
repeatedly been infested with flies.
These cases are representative ofVA's ongoing difficulties in
providing appropriate and expeditious patient care and appear to
demonstrate issues with VA' s efforts to ensure allegations are
appropriately reviewed. The agency reports received by the Office of
Special Counsel (OSC) were not fully responsive and were frequently
evasive in their reluctance to acknowledge wrongdoing. \1\
---------------------------------------------------------------------------
\1\ The Office of Special Counsel (OSC) is authorized by law to
receive disclosures of information from federal employees alleging
violations of law, rule, or regulation, gross mismanagement, a gross
waste of funds, an abuse of authority, or a substantial and specific
danger to public health and safety. 5 U.S.C. Sec. 1213(a) and (b). OSC
does not have the authority to investigate a whistleblower's
disclosure; rather, if the Special Counsel determines that there is a
substantial likelihood that one of the aforementioned conditions
exists, he is required to advise the appropriate agency head of her
determination, and the agency head is required to conduct an
investigation of the allegations and submit a written report. 5 U.S.C.
Sec. 1213(c). Upon receipt, the Special Counsel reviews the agency
report to determine whether it contains all of the information required
by statute and that the findings of the head of the agency appear to be
reasonable. U.S.C. Sec. 1213(eX2). The Special Counsel will determine
that the agency's investigative findings and conclusions appear
reasonable if they are credible, consistent, and complete based upon
the facts in the disclosure, the agency report, and the comments
offered by the whistleblower under 5 U.S.C. Sec. 1213(e)(l).
---------------------------------------------------------------------------
It appears that the VA acknowledged and responded to confirmed
wrongdoing after the publication of a July 15, 2017, Boston Globe
article based on information provided by the individuals identified
above and others. \2\ The VA was on notice of these allegations when
OSC referred them for investigation in early January 2017, but did not
take any action to remove responsible management officials or initiate
a comprehensive review of the facility until after the Boston Globe
article was published in July. This sends an unacceptable message to VA
whistleblowers that only the glaring spotlight of public scrutiny will
move the agency to action, not disclosures made through statutorily
established channels.
---------------------------------------------------------------------------
\2\ Jonathan Saltzman and Andrea Estes, ``At a four-star veterans'
hospital: Care gets 'worse and worse,''' Boston Globe (July 15, 2017),
available at https://www.bostonglobe.com/metro/2017/07/15/four-star-
case-failure-manchester/n9VV7BerswvkL5akCgNzvK/story.html.
---------------------------------------------------------------------------
1 Background
The whistleblowers' allegations focused on the care of patients
with a serious spinal cord condition known as myelopathy. They noted
that despite the significant decline in prevalence of this condition in
the general population of the United States, 100 out of approximately
170 patients treated in the VAMC Manchester Spinal Cord Unit had some
degree of myelopathy. The whistleblowers attributed this high incidence
to a number of factors, including:
Under VA policy, patients with these conditions are
referred to VA's Boston Spinal Cord Injury and Disorder (SCI/D) Center
for more complete evaluation. The whistleblowers alleged that transfers
between the VAMC Manchester and the Boston SCI/D Center were not
performed in a timely manner, in violation of agency policy.
The whistleblowers alleged that surgical care at the
Boston SCI/D Center was also substandard. They provided two
illustrative examples: (1) a patient who developed a spinal infection
and eventually died from surgical complications after surgeons damaged
his dura mater during a procedure; and (2) an instance where a patient
developed a spinal infection after surgery but survived.
The whistleblowers alleged that the prior chief of the
Spinal Cord Unit, Dr. Muhammad Huq, engaged in the inappropriate
practice of copying and pasting chart notes for patients between 2002
and 2012. They asserted that this misconduct contributed to the high
incidence of myelopathy in the VAMC Manchester patient population.
In addition to the allegations connected to myelopathy, the
whistleblowers further alleged that the VAMC Manchester OR has been
repeatedly infested with flies. Starting in 2012, after the OR was
remodeled, the rooms in this suite have consistently been infested with
flies during warmer months. While the VAMC Manchester has attempted to
remediate this problem by hiring exterminators to perform pest-control
measures and installing UV fly lights, the flies have returned during
the spring and summer every year. The whistleblowers asserted that
surgeries have been cancelled and delayed due to these unsanitary and
unsterile conditions.
IL The Agency Reports
OSC found that a substantial likelihood of wrongdoing existed based
on the information provided by the whistleblowers, and referred the
matter to former VA Secretary Robert McDonald to conduct an
investigation pursuant to 5 U.S.C. Sec. 1213 (c) and (d). The matter
was investigated by the Office of the Medical Inspector (OMI), which
provided OSC with a report on June 20, 2017. The report contained
internally inconsistent conclusions at odds with the information
adduced in the investigation. OSC requested two supplemental reports to
address many of these issues and provide updates on external chart
reviews. With respect to spinal cord care:
VA Investigators found that in fiscal years 2015 and
2016, 11 consult appointments, or 20 percent of appointments, were not
made in the required time, and in more than half of these instances
there was no documented reason for the delay. In spite of these
findings, VA Investigators were ``unable to substantiate'' that the
referral process from VAMC Manchester to the Boston SCI/D Center
created undue delays in care.
Regarding the patient who died from surgical
complications, the VA noted it was ``unclear'' if the surgery
contributed to his disease progression, but later concluded that his
care was appropriate. Neyertheless, it stated that the treatment of
this patient, as well as six others, would be reviewed by an
independent, non-VA external reviewer, raising questions regarding the
sufficiency in the initial review of this information.
During his interview, Dr. Kois provided OMI with 97 patient charts
that he viewed as evidence of substandard care. OMI initially
determined that in 74 of 97 cases, care was appropriate. However, in
supplemental reports, the VA indicated that external non-VA reviewers
would examine these charts to determine whether appropriate care was
provided. The VA anticipates this review will be completed in February
2018. In light of the ongoing review of patient charts, OSC finds the
VA cannot yet conclude whether the whistleblowers' allegations were
unsubstantiated.
The VA's decision not to interview Dr. Chima Ohaegbulam, a non-VA
employed neurosurgeon with experience treating myelopathy patients, is
at odds with the VA's prior assertion that review by external experts
was necessary. Dr. Ohaegbulam treated many of the patients at issue in
this matter on a fee basis after referral from the VAMC Manchester, and
was uniquely positioned to assist in the review of the patient care
rendered. In a supplemental report, the agency asserted that it was
unnecessary to interview Dr. Ohaegbulam as Dr. Kois provided sufficient
documentary evidence.
The findings regarding Dr. Huq were flawed due to their
inconsistency. The report first acknowledged that he engaged in the
practice of inappropriately copying and pasting chart notes between
2008 and 2012, but asserted no harm resulted because associated patient
records did not contain any indicia of adverse patient outcomes. The
report subsequently acknowledged that investigators only reviewed his
charts from a limited time period, yet claimed they had sufficient
information to broadly conclude that no patients were harmed.
VAMC Manchester management was on notice of Dr. Huq's misconduct as
early as 2008; however, no disciplinary or corrective action was tak;en
until 2010. Despite the fact that nurses raised concerns to facility
leadership during this time, there was no explanation for the delay.
Dr. Huq received a verbal counseling in November 2010, but continued
copying and pasting chart notes. He was issued a written counseling for
this continued misconduct in late 2011. In early 2012, he was counseled
again after the discovery of additional instances of copying and
pasting. Finally, in July 2012 VA reassigned Dr. Hug to Primary Care on
a full-time basis, then transferred him to another VA facility in
August 2015.
Despite this long-established history of misconduct, investigators
determined that there were no adverse patient outcomes attributable to
this practice, after reviewing the care of patients whose charts were
copied and pasted. Notwithstanding this conclusion, investigators
indicated they were unable to review Dr. Huq's notes prior to 2008.
Rather, their conclusions relied on a review of the audits associated
with prior disciplinary action. Accordingly, OMI was unable to review
six years of patient outcomes, or more than half of the total time Dr.
Hug worked in this unit. Given the seriousness of the medical issues
involved, a review of Dr. Huq's entire history with the unit appears
appropriate, especially given the ease of obtaining these medical
records, which under agency policy, must be maintained for 75 years.
With respect to the alleged fly infestation, the report found that
the OR #2 was repeatedly infested with cluster flies starting in the
early fall of 2014. The room was terminally cleaned, but flies returned
later in the fall and the following winter. A pest control company was
hired in April 2015, but did not spray insecticides outside the
building during that summer. In August and September of 2015, staff
again began noticing cluster flies in OR #2. The room was eventually
closed due to this issue from September 2015 until January 2016.
Despite additional efforts, flies were still observed in the room in
January 2017. The report stated that cluster flies pose no known health
problems to humans, but subsequently acknowledged that ``flies of
various types'' were found in a light trap during a site visit,
suggesting that additional species of insects were present. The report
explained that despite the closure of this room, no surgeries were
delayed.
Ill The Whistleblowers' Comments
The whistleblowers' comments highlighted inconsistencies in the
reports, and were the basis for OSC requesting two supplemental reports
from the VA. Notably, the whistleblowers' comments questioned the
sufficiency of the investigation, explaining that OMI appeared
dismissive of Dr. Kois' efforts to provide patient charts, and that
their findings did not appear to analyze the large number of assistive
durable medical devices given to patients as evidence of worsening
function and clinical neglect.
The whistleblowers also voiced concerns regarding the failure to
interview Dr. Ohaegbulam, and challenged the specific clinical
conclusions reached regarding the two illustrative examples provided in
their initial disclosure. The comments further reflected the concern
that the review of Dr. Huq's patients was limited and appeared to
ignore the connection between his conduct and the decline in function
of many spinal cord patients.
Finally, the comments noted that OMI appeared to dismiss and
ultimately did not investigate serious allegations provided to them by
the whistleblowers, including dirty and rusted surgical instruments.
The whistleblowers asserted that it was ``clear that [OMI] had no
interest in a fair and impartial and complete investigation into the
systemic problems that directly impacted patient care in Manchester.''
JV The Special Counsel's Analysis and Findings
I have reviewed the original disclosures, the agency reports, and
the whistleblowers' comments. I have determined that the reports meet
the statutory requirements, but the findings do not appear reasonable.
First, I note that the agency appears to have chosen not to review
allegations concerning dirty and potentially contaminated surgical
instruments because they did not appear in OSC's original referral
letter. This position is at odds with the conduct and disposition of
prior investigations of allegations referred by OSC. It further
demonstrates a myopic approach that could potentially cause harm by
ignoring allegations of substantial and specific dangers to public
health and safety.
I take further issue with the recommendations in the report when
viewed in light of the VA's response after the Boston Globe article was
published in July. Notably, the initial OMI report simply recommended
additional chart reviews, routine monitoring of chart entries, and that
OR staff continue checking for flies in the suite before starting
procedures.
The Boston Globe article was published late in the day on Saturday,
July 15, 2017. It discussed the spinal cord care issues, Dr. Huq's
conduct, flies in the OR, and dirty surgical instruments. On Sunday
July 16, within hours of the Boston Globe's publication, VA Secretary
David J. Shulkin removed VAMC Manchester's Director Danielle Ocker and
Chief of Staff James Schlosser pending the outcome of a ``top to
bottom'' review of the facility. On August 4, Secretary Shulkin visited
the hospital, and subsequently removed the Head of Patient and Nursing
Services, Carol Williams. Secretary Shuklin also indicated that the
department planned on spending $30 million dollars at VAMC Manchester
to improve care.
Significantly, OSC had already referred these same allegations to
the VA in early January 2017, six months before the Boston Globe story
ran. The contrast between the VA's response to the Boston Globe vis-a-
vis OSC highlights the issues OSC has with VA's reply to OSC's referral
and the whistleblowers' allegations. The VA did not initiate
substantive changes to resolve identified issues until over seven
months had elapsed, and only did so after widespread public attention
focused on these matters. It is critical that whistleblowers be able to
have confidence that the VA w. ill addres.s public health and safety
issues immediately, regardless of what news coverage an issue receives.
Given the ongoing and potentially lengthy chart reviews of patients
involved in these matters, OSC will request updates on the progress of
this analysis as well as findings when the reviews are completed.
Specifically, OSC will request an update in writing every six months
regarding the disposition of these reviews, and the expected timeline
for completion. OSC will also request a summary of the findings upon
completion.
As required by 5 U.S.C. Sec. 1213(e)(3), I have sent a copy of
this letter, unredacted versions of the agency reports, and the
whistleblowers' comments to the Chairmen and Ranking Members of the
Senate and House Committees on Veterans' Affairs. I have also filed the
letter to the President, the whistleblowers' comments, and redacted
copies of the agency reports in our public file, which is available at
www.osc.gov. This matter is now closed.
Respectfully,
Henry J. Kerner Special Counsel
Enclosures
[all]
| MEMBERNAME | BIOGUIDEID | GPOID | CHAMBER | PARTY | ROLE | STATE | CONGRESS | AUTHORITYID |
|---|---|---|---|---|---|---|---|---|
| Bilirakis, Gus M. | B001257 | 7881 | H | R | COMMMEMBER | FL | 115 | 1838 |
| Walz, Timothy J. | W000799 | 8001 | H | D | COMMMEMBER | MN | 115 | 1856 |
| Coffman, Mike | C001077 | 7864 | H | R | COMMMEMBER | CO | 115 | 1912 |
| Roe, David P. | R000582 | 8148 | H | R | COMMMEMBER | TN | 115 | 1954 |
| Brownley, Julia | B001285 | H | D | COMMMEMBER | CA | 115 | 2106 | |
| Takano, Mark | T000472 | H | D | COMMMEMBER | CA | 115 | 2110 | |
| Peters, Scott H. | P000608 | H | D | COMMMEMBER | CA | 115 | 2113 | |
| Esty, Elizabeth H. | E000293 | H | D | COMMMEMBER | CT | 115 | 2114 | |
| Kuster, Ann M. | K000382 | H | D | COMMMEMBER | NH | 115 | 2145 | |
| O'Rourke, Beto | O000170 | H | D | COMMMEMBER | TX | 115 | 2162 | |
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| Poliquin, Bruce | P000611 | H | R | COMMMEMBER | ME | 115 | 2247 | |
| Rice, Kathleen M. | R000602 | H | D | COMMMEMBER | NY | 115 | 2262 | |
| Dunn, Neal P. | D000628 | H | R | COMMMEMBER | FL | 115 | 2315 | |
| Mast, Brian J. | M001199 | H | R | COMMMEMBER | FL | 115 | 2322 | |
| Banks, Jim | B001299 | H | R | COMMMEMBER | IN | 115 | 2326 | |
| Higgins, Clay | H001077 | H | R | COMMMEMBER | LA | 115 | 2329 | |
| Bergman, Jack | B001301 | H | R | COMMMEMBER | MI | 115 | 2333 | |
| Arrington, Jodey C. | A000375 | H | R | COMMMEMBER | TX | 115 | 2350 | |
| Lamb, Conor | L000588 | H | D | COMMMEMBER | PA | 115 | 2367 |
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