of fort snelling. that is what we try to do here is to push people to think more about what does it mean when all these cultures came together? what perspectives do they have on these historic events? >> nexa government investigation looks at veterans medical care in the phoenix arizona va system. it doctor expose some of the problems at the troubled phoenix hospital testifies and we would hear from robert mcdonald and acting inspector general richard griffin. this house veterans affairs committee is chaired by congressman jeff miller.

[inaudible conversations] >> good afternoon. this hearing will come to order. i think everybody for attending this hearing which we will examine the oig report on the phoenix issue. i would also like to ask unanimous consent, he is not here yet but that our colleagues david schweikert from arizona be allowed to join us here to address this issue. without objection, so ordered. also members we do have a series of votes that will start at 1:00. i apologize for that. this hearing was moved from its original schedule time because of the joint session of congress to hear the president of the ukraine. what we will do is immediately after the final vote move back

as quickly as you can. we will resume the hearing as quickly as we possibly can so that we will not keep the witnesses waiting any longer than absolutely necessary. on the 26th of august, the va office of inspector general released its final report of the phoenix va health care system which defaulted to national attention after hearing on april the ninth. the oig confirmed that an appropriate scheduling practices are a nationwide systemic problem and found that access barriers adversely affected the quality of care for veterans at the phoenix va medical center. based on the large number of va employees who were found to have used scheduling practices contrary to veterans health administration policy the oig has opened investigations as i understand it at 93 va medical facilities and have found over

3400 veterans who may have experienced delays in care from weightless manipulation at the phoenix va medical center along. oig concluded by providing the va with 24 recommendations for improvement to avoid these problems from reoccurring. these recommendations should be implemented immediately. this committee will work tirelessly to ensure that they are in fact implemented. mr. griffin i commend you sir and your team for your work and continued oversight on these issues in the past and in the months ahead. with that said and as we have discussed, i am discouraged and concerned with the manner in which the oig report, the final report, was released along with the statements contained within

it. notably, prior to the release of the report selected information was leaked to the media apparently biosource internal to va which i believe purposefully let the public -- misled the public that there was no evidence that phoenix linking delays in care with veteran deaths. as the days progressed, and people actually read the report that falsehood actually became obvious. what the oig actually reported and what would be the subject of much discussion today is the statement by the oig quote we are unable to conclusively assert that the absence of timely quality care cause the deaths of these veterans end quote. what is most concerning to me about this statement is the fact that no one who dies while waiting for care would have to lay in care listed as the cause of death since a delay in care

is not a medical condition. following the release of this report which found pervasive problems at the facility regarding delays in care in poor quality of care committee staff was briefed by the oig regarding its findings and how specific language was chosen throughout the entire drafting process. prior to the meeting we requested oig provide us with the draft report in the format was originally provided to va three weeks before the release of the final report. after initially expressing reservations the oig provided us with the draft. what we found was that the statement that i just quoted was not in the draft report at all. another discrepancy was found between the draft and the final reports arose the statements to the effect that one of the whistleblowers here today did not provide a list of 40 veterans who had died while on a waiting list at the phoenix va

medical center. first, oig stated in a briefing to the committee staff that va inquired why such a statement was not in the report. and the oig ultimately chose to include it. further, additional information provided by the oig to our committee staff shows that based on numerous lists provided by all sources throughout the investigation oig in fact accounted for 44 deaths on the electronic waitlist alone and in an astonishing 293 total veteran deaths on all of the lists provided from multiple sources throughout this review. to be clear, it is not nor was it not my intention to offend the inspector general and the hard-working people within the agency however i think i would be remiss in my duty to conduct oversight of the department of

veterans affairs if i did not ask these questions. i would also like to point out that no one within the department or any other federal government employee including members of this committee is beyond having their records scrutinized. as such the committee will continue to ask the questions that need to be asked in order to reform our constitutional duties. it's absolutely imported that the oig's integrity and investigation be preserved. full and transparent hearings like this will help ensure that remains the case. with that i now turn to the ranking member mr. mitchell for his opening statement. >> thank you mr. chairman for having this important hearing and i would like to thank the panel is for coming today as well. today's hearing provides the opportunity to examine the va inspector general's final report on the patient wait times and scheduling practices within the phoenix va health care system.

this report did not stated directly as show relationship between the long patient wait times and veterans deaths. for some that is a major concern and acquisition of undue influence by the va on the inspector general's report will be discussed at length today. with the ig did find is that the cases included in this report clearly shows that there are serious lapse in va's follow-up, coordination, quality and continuance of care for our veterans. they also concluded that the inappropriate scheduling practices demonstrated in phoenix are a nationwide systematic problem. i do not need anymore evidence or analysis that there is no doubt in my mind that veterans were harmed by the scheduling practices and culture at the phoenix facility and across the nation. bottom line is this behavior in a detrimental effect is simply

not acceptable. my heart goes out to the families of veterans who did not receive the health care they deserved in phoenix and around the country. rest assured that we will understand what went wrong, fixx it and hold those responsible for these failures accountable. as such, my question to the va today is straightforward. what went wrong, what are you doing to fix the problems, how will you ensure that this never happens again and how are you holding those responsible accountable? i applaud secretary mcdonald were taking forceful action to begin to address the systematic failures demonstrated in phoenix. we need serious deep and broad reform, that kind of change that may be uncomfortable for some that va but so desperately needed by america's veterans. i believe that such must be

guided by a national veterans strategy that outlines a clear vision of what america owes its veterans in a set of tangible outcomes that every component of american society can a line and work towards. earlier this week i sent a letter to president obama asking him to establish a working group to engage all relevant members of the society in drafting the national veteran strategy. we know from experience that va cannot do it alone. we must develop a well-defined idea on how the entire country, government, industry, non-profits, foundations, communities and individuals meet this obligation to our veterans. va needs to become a veteran focused, customer service organization. he needs to be realigned to become the integrated organization. it should do what it does best

and partner for the rest. he needs to be the government model for honesty, integrity and discipline. we need to complete our investigation of these problems and provide oversight on the solutions. i look forward to today's additional testimony about what happened in phoenix and how the va is working to ensure that it never happens again. once again mr. chairman i want to thank you for having this hearing and i yield back the balance of my time. >> thank you very much and i would ask that all members waved their opening statements as customary in this hearing and yankee to those who agree to sit behind the principles. today we are going to hear testimony from acting inspector general richard j. griffin was accompanied by dr. john day jr. assistant inspector general for health care inspections miss brenda holiday assistant inspector general for audits and evaluation and maureen reagan concert for the inspector and the director of the office of

inspector general. we will also hear from dr. samuel foote former position at the va health care system and dr. catherine mitchell current whistleblower and medical director for the iraq and afghanistan post-deployment center at the phoenix va health care system. i would ask the witnesses now to please stand so we may swear you in. if you would raise your right hand. do you solemnly swear under penalty of perjury the testimony you are about to provide us the truth the whole truth and nothing but the truth? thank you. you may be seated. let the record reflect that all of the witnesses affirm that they would in fact tell the truth, the whole truth truth and nothing but the truth. all of your complete written statements will be made a part of this hearing record and mr. griffin you are now recognized for five minutes. >> mr. chairman, ranking member

michaud and members of the committee thank you for the opportunity to discuss the results of inspector general's extensive work at the phoenix va health care system. our august 26, 2014 report expands upon information previously provided in our may 2014 interim report and includes the results of the reviews of the oig clinical staff of patient medical records. we initiated our review in response to allegations first reported through the oig hotline on october 24, 2013 from dr. foote who alleged gross mismanagement of va resources, criminal misconduct iba senior hospital leadership, systemic patient safety issues and possible wrongful deaths at phoenix. the transcript of our interview

with dr. foote has been provided to the committee and i request that it be included in the record. >> without objection. >> we would like to thank all the individuals who brought forward their allegations about issues occurring in phoenix and other va medical facilities to the attention of the ig, the congress and the nation. on august 19, 2014 the chairman of the subcommittee on oversight and investigation sent a letter to the ig requesting the original copy of our draft report prior to va's comments and adopted changes to the report. on september 2, the committee staff member made a similar request for a written copy of the original unaltered draft s. 1 provided to va and the chairman. concerns seem to come from our

inclusion the following sentence in a subsequent draft report that was not in the first draft report submitted to va. the sentence reads as follows. while the case reviews in this report document poor quality of care we are unable to conclusively assert that the absence of timely care caused the death of these veterans. this sentence was inserted for clarity to summarize the results of our clinical case reviews that were performed by our board-certified physicians whose curricula are an attachment to the testimony. it replaced the sentence, the death of a veteran on a wait list does not demonstrate causality.

which appeared in a prior draft, not the first draft that was requested but in a subsequent draft. this change was made by the oig strictly on our own initiative. neither the language nor the concept was suggested by any of my people. in the course of our many internal reviews of the content of our draft report, on july 22, almost a full week before the draft was sent to the department, one of our senior executives wrote this question. this is key gentlemen and ladies. and i quote did we identify any deaths attributed to significant delays? this is on july 22. if we can't attribute any deaths to the wait list problems we should say so and explain why.

after all, the exact wording in the draft report was, where the deaths of many of these veterans related to delays in care? this type of deliberation to ensure clarity continued as it should after the initial draft was sent to the department. in the last six years we have issued more than 1700 reports. this same review and comment process has been used effectively throughout the oig history to provide the va secretary and members of congress with an independent, unbiased, fact-based program reviews to correct and identified deficiencies and improve va programs. these reports has served as a basis for 67 congressional

oversight hearings including 48 hearings before this committee. during the same six years, our work has been recognized by the ig community with 25 awards or excellence. we are scrupulous about her independence and take pride in the performance of her mission to ensure veterans receive the care, support and recognition they have earned through service to our country. the va secretary has acknowledged the department is in the midst of a serious crisis and has concurred with all 24 recommendations and has submitted acceptable corrective action plans. a recent report cannot capture the personal disappointment, frustration and loss of faith with veterans and their family members have with a health care system that often did not

respond to their physical and mental needs in a timely manner. although we did not apply the standards of determining medical negligence during our review, our findings and conclusions in no way reflect the rights of a veteran or his or her family from filing a complaint under the federal tort claims act with va. decisions regarding b.a.s potential liability in these matters lies with the va, the department of justice, thieves judicial system and the federal tort claims act. mr. chairman this concludes her statement and i'd be happy to answer any questions you or any members of the committee may have. >> thank you very much mr. griffin. dr. foote you are recognized for your opening statement for five minutes. >> i started my internal

medicine training in 1981 at the phoenix va prevented a finish in 1984 and became board-certified in internal medicine. i went to work full-time as an emergency visit should then return to the va 1990 the same year i earned my boards and medicine could i ran the va department for not from 199219 and a pair of service teaching attendant for 91 to 2003 and i became an outpatient director in december of 1994 they but they physicians -- position which i held since my retirement. while i have views on many aspects come to be known as the va scandal i would like to use the statement to comment on what i view as the foot-dragging downplaying an inadequacy of the inspector general's office. this continues in a report issued august 262014 which i fear is designed to minimize the scandal and protect its perpetrators rather than to provide the truth along with closer to veterans and families

would have been affected by it. all the employees has received training on a duty to report waste fraud and abuse. to the inspector general whose job is to investigate these allegations. they resulted in director gabriel perez being placed on leave within two weeks of the ig receiving my letter and a few months later his recognition -- resignation in lieu of termination rates in the second letter in april of 2013 brin made allegations against the chief of services brad curry for creating a hostile workplace. engaging in personal actions and discrimination against certain classes and employees. as far as i can tell the ig never investigated these complaints and it appears they turned over to the veterans integrated service network director susan bowers who was their superior. susan bowers could not take action against him without running the risk the entire waiting with scandal would -- in

late october 2013-the third letter to the ig informing them of the existence of a secret waiting list for 10 patients on the list had died while waiting for appointments. i also included additional allegations of prohibitive personal actions by senior staff. furthermore i advised him of a second hidden backlog of patients contained in the schedule appointment with lists and an unknown number of veterans had pierced on. i also detailed other methods that were used, and used to lower the apparent backlog for new patients and i imported the ig to come to phoenix to investigate all of the above. i got a response from the san diego ig office in december 3, 2015 to join a conference call with them on december 6. their team investigated the week of december 16 through the 20th. at that time i and others told them about the unaddressed scheduling appointments complex and show them the electronic

holding clinic which is being used as to mask the true demand for return patient wednesday reinstated them on the secret waiting with summary report showing 22 patients have been removed because they had died. we only had the names of two to seize seize because none of employers working with me have the electronic keys to print the names of the deceased. we asked the ig inspectors they could do it but they responded that they could not. the last e-mail response that i have from there were some december 21st, 2013 when i received it a reply. i offered to facts or mail the names we had at the time but they were unable to give me a working facts number or an address to mail it to. i send for more e-mails in early january again asking if they would like me to facts or mail a

patient's names but i got no response. i also got no response from my advisor to several veterans had died. finally on february 2nd, 2014 out of frustration with lack of action by the ig even though we were informing them of more desai standout ig letter number forward copies to everyone i could think of that might be able to help. the only response i got from the ig was a confirmation that they had received my letter. a friend suggested i contact the house veterans affairs committee and there i found the help i needed. during this process i was advised by several people the only way to get the ig office to investigate my allegations was to make them public which reluctantly i did. in my opinion this was a conspiracy possibly criminal perpetrated by senior phoenix leaders. of the many scandals from the performance top administrators supposedly wait time goals to the harassment of employees

trying to rectify the situation to the destruction of documents and electronic records to the very real harm done to the health of thousands of veterans nothing is more scandalous than the fact that 293 veterans died in phoenix. even now right here in this report the inspector general tries to minimize the damage done the culpability of those involved by stating none of that death can be conclusively tied to treatment delays. i have read the report many times in several things bother me about it. throughout the case reports the office appeared to have downplayed past. this is true in cases six and seven where i have direct knowledge that after reading these two cases it leaves me wondering what really happened in all the rest. for example and case number 29 how could anyone conclude that the death was not related to the delay when a patient who needs an implanted defibrillator to avoid sudden death did not get one in time and why was the

cardiac death case excluded from the ig review? in addition a critical element to proving this was a conspiracy was a potential tampering with the reporting software of the list. from the beginning of the igs own data showed there was a difference between the numbers reported to washington and what the numbers actually were on the secret electronic waiting list. the ig clearly minimize the significance of this crucial point treating it as a trivial clerical error and touting how quickly that idc department corrected it rather than exploring who tampered with that in the first place. adding it up the ig report states 4900 veterans are waiting for new patient appointments at the phoenix va. 3500 were not on any official list and 104,400 romba in not reporting secret electronic waiting list. 293 of these veterans are now deceased.

this vastly exceeds my original allegations that up to 40 veterans may have died while waiting for care. the ig says it is not charged with determining criminal conduct. true but neither so charged with reports designed to downplay potential criminal conduct designed to defuse and discourage potential criminal investigations or diminish the quite appropriate public outreach. at its best this report is a whitewash. at its worst is a feeble feeble attempt at a cover-up. the report liberal uses confusing language and math and that's new unrealistic standards ignores what electronic list was not reporting accurate data and makes misleading statements. in addition the attempt to minimize bad bad outcomes like outplaying damaging information and thereby protecting the va officials who are responsible for the scandal reinforces the long-standing culture of circling the wagons to delay tonight and let the claim story or patient either the veterans community has had to suffer with for years.

>> dr. foote, i apologize. you have gone three minutes over the five. i would like to say the rest of your testimony will be entered into the record. i apologize that i let you go a little bit longer than what we all had agreed to. can you wrap it up in the next 20 seconds? >> secretary mcdonald said he was going to increase transparency of agency and would not tolerate whistleblower retaliation. families on the administrators did not get the memo. this report fails miserably in those areas and is the transparency equivalent to a four-foot thick concrete wall. >> thank you very much dr. mitchell you are recognized for five minutes. >> i am honored by the committee's invitation just by today. the oig was unable to assert the absence of timely quality care. as a physician reading the report i disagreed specifically in the minimum of five cases i believe there was a very strong potential causal relationship between delayed care or improper

care and veteran death. in addition health care delays contributed to the quality of life and for five other veterans who were terminally ill and shorten the lifespan of one of them. in looking at the report there are four cases where there is no cause of death listed. some clear to me how a causal relationship may or may not exist if there is no cause of death given. it's unclear if 19 veterans who are on the electronic waiting lists were aware of the self referral process to the primary care clinics. if they were not aware of this process then they reasonably believed that waiting on the waiting list was the only way to get medical care even if their symptoms were worsening. ..

>> >> and without the device had to wait precious minutes for the paramedics to restart but unfortunately the family had to withdraw life support and three days later it may have forestalled death. but it would have because it is exactly what is used to treat the heart rhythm he

died from complications of prolonging to heart stoppage in was denied access to specialty care. and in case number 39 coming to the e.r. was dresser's including homeless he was put on medications to stabilize the discharge back to the streets and committed suicide 24 reseda the community standard would be to admit the veteran and said it would be more appropriate management plan but did not draw a connection from the e r a and death and suicide within 24 hours. and one doubt pluses not treated for prostate cancer over seven months earlier detection would start the treatment to slow down the progression significantly a.

and then was denied timely access to forestall his death five months if not under. number 36 there was not timely quality care for unrelenting pain ended with multiple suicide risk factors that had just suicide 48 hours later mania other cases i reviewed i could not discern a difference between on the medical waiting list were those of the system but a death is the death. the purpose is to get the of the gate to let the practices they have to repair the system so no more slips through. thank you for your time.

>> thank you to everybody for your testimony. mr. griffin in the information you provided to the committee that 28 veterans died while on the list is essentially meaning they died while waiting to get the foot in the door in since they were not in the system that the zero i gu is a social security records the italy showed that the individual died but not how. correct? >> and to find death records from the coroner's office in hugh may be getting

treatment under the medicare program but that goes to the doctor's statement can you answer the question? >> that determination from looking at the medical records. >> it clearly the patient had died and in several cases the care of their local hospital. >> it is a tremendous problem patients on the list so you are absolutely right anybody on the lists that did not make it to be seen in a dozen have medical record that i cannot look castle i cannot examine if they don't have a record

there is no contact. >> if that is true how can you conclusively or otherwise if it was related to a delay of care? >> the report says conclusively this is rehab problems. there were people looked as if noone the report and it says conclusively that there is no link to delays of care of death but there are individuals to go back to look definitively at the medical records but there was a delay of care is that correct? >> we try to address the patient that we identified with the delay in care and

subsequently received for quality care. >> but if you were on that list to not getting into the system is that the delay? >> and to say that none of those delays were a cause of death? >> we were talking about the patients we looked at. >> i provided your staff with the breakout. >> the doctor for you able to look conclusively at all of those on the wait list? >> i can only will get those , 3,000. >> yes or no? >> could you conclusive lew look? >> no. >> i want to direct you to a

and e-mail on page 38 of your report regarding a veteran while waiting for care. and in a staff briefing you stated that he was seen by a urologist within three days of presenting to the e are so his case was not included in the report however to receive notification as he was not presented was not seem. and then that contributes to his death could you explain to me out oic came to this conclusion? >> the patient had bladder cancer for many years. and two b.c. in the

emergency room evaluation in. among the chief complaints were blunted his urine and also remove to '08 arthritis with disabilities including amputations of the leg. as a result he was looked at and did need to see rheumatologist and did that have a primary care provider. the er physician and from that consults and primary-care consoles. the records and this is the first of the confusion but v.a. records said said he had an appointment for ecology put the patient call to request a rescheduling of

that appointment which was rescheduled for november 6, 2013 and was a no show. so some would say he had an appointment and did not keep that. >> right. let me ask a question. i will the you finish. nobody here in this room has any faith in any of the appointments are scheduling going on at that time so i have no belief that what may have been written was true. >> dash understand. >> but then he died by metastatic cancer with to had cancer of his brain and his long and so having seen a primary care provider

retrieve that emergency visit and when he died i don't believe that primary-care provider would have changed his death. and refer you to page 75 of the testimony provided the testimony as a the hearing already started. it was just handed to us. >> then it to make sure the truce was of the record having seen other witnesses' testimony it was fully aware of the taped transcript of

our interview and people should take a hard look at that transcript i appreciated very much by your staff told us there was a formatting problem and that is why we just got that. are you referring to that transcript? any other transcripts and i need to be aware of? >> i believe we send the information 48 hours in advance. >> the original allegation was that 40 veterans may have died while awaiting care and it everybody knew he was referring to patients on the electronically list to schedule an appointment with primary-care consult so

between those touche sources you now have 83 patients patients, more than double the original allocation. so i have a couple of questions. why was that information not included in the executive summary that the v.a. leaked but you had time to see that we pursued this allegation that the whistleblower did not provide with a list of 40 patient names''. >> i believe that you as the chairman received the same hot line that there were 22 who died of electronically last and 18 who died on the consulate's list. in our pursuit of finding a what happened which wusses

exhaustive because of the urology issues with the obvious first question and was give us the for the games we want to go after the records of these 40 people to make share we don't miss any. but the you -- but we were careful to say potentially 40 but as time passed it was declared if that four days some said at least four days so that spawned 800 media reports that 40 veterans died waiting and that was the story. to not address that with the amount of coverage than

those readers that would've been derelict on our part to so rule of that those 3400 records. >> it was important you draw the fact that he did not gave you the for the names? >> in the april 9 hearing. >> i am talking about the of final report. >> that was not inserted into the final report there were multiple drafts it doesn't seem to be getting traction grasped to provide the first of an altered report that its will be provided. >> i am asking what we ask for. we provide with the original

draft copy maybe you thought the first of an altered copy and i have an e-mail that went to your staff that has original and then in parentheses is says unaltered matt adulterated anyway. >> we have one for new once said of an altered the other said something different but there was no confusion you wanted the very first initial draft. >> let me read it that i e-mail. the third came from the staff director from the of subcommittee to joanne moffett chairman of the right to know if the zero wedgie will provide the committee with a written copy the us an altered draft

report as provided to issa v.a.. if so, when? >> i guess i don't see what the difference is. you ask for the first initial draft report that we provided. >> did you ever indicate to the committee or the staff there was more than one draft? >> we did not. we provided with the committee asked for a and explained in the past six years nobody has ever ask for a copy. >> schaede on the. >> we don't want you to use semantics of which copy of the draft we ask for. we ask for the draft that

you gave to the v.a. so they can make their determination whether or not that was or not a and you knew that is what it was. that is my time. hill new the request of what we were trying to get from the draft to the final. that they did not conclusively behalf tell the causes of death and i apologize to the members we have to be honest and open about what is going on and whether or not it ended in another committee asks for a draft report shave on then if the allied g ever sat at a table with anybody from

the zero whitey office, a tough. of this committee will get the truth about all of the facts. >> this is the crux of vol allegation. >> we were asked to provide the initial not one that had been through 23 iterations but the very first draft report you candy night that all you wants to mickey and you show me anywhere in says the first draft. >>. >> show me where we ask for the first draft report.

>> i will find the e-mail and i will respond to your question. it showed a lack of awareness to make you are out of order. >> do you want the truth? >> mr. griffin. >> if i understand you correctly you provided the first draft but there may have been other additional drops. >> correct. >> somoza you provided was the first that was requested. but there was other once since the first one? >> of is they delivered it of process to get clearance from the department we have to put a draft in front of them if there are factual errors and they can convince

us were factual then it is incumbent upon us to make that edits that are required so at the end of the process with its final issuance speaks the truth on all issues. >> when the i e.g. does the reporting you could get information whether from the whistle-blower or the department and once you get information they you determined to be factual that is when you change the report? >> correct. there were amenable changes. with the blood pressure numbers taken at two different times but to me that is not the substantive change. so we put them back the way

they should have been. but that is not a substantive change. >> you mentioned the alleged 40 veterans did you receive the names of those of the list? >> no. i refer you to that transcript that perhaps that he did not know the cause of death perhaps he was run over by a up bus. >> he did not? i have not read the transcript yes. >> i apologize for our rights being late but it does need to re-read because it was a taped transcript of the interview. >> can i respond? >> no. i have other questions of

those 93 ongoing reviews how many have been closed out and when will the rest be completed? >> at this point we have 12th we have turned over to the department because we could anticipate administrative action from the standpoint have completed them. specific allegations with the department to make determinations concerning administrative action if they come across additional and permission we may have to do additional work but the others they will be

published we will turn those over to the department those other not accepted for criminal action. you will turn those over to the department for administrative action. >> dr. mitchell in your testimony talking about that paid management team with the lack of services how did they communicate their staffing needs to the director? was never communicated and what was done if anything? >> 1/2 direct knowledge between the senior administration that what i do have is direct knowledge from many providers who find that panel's rob long term narcotics in the patient's

need additional close monitoring and follow-up but providers still have enough time to get those patients in for sufficient appoint ince to review that. that those the from long-term narcotics refer to the pate and management specialists. >> my time has run out of. >> ag for having this important hearing. briefly on page 15 of your written testimony you have case number 35 baba i.g. report as the special circumstance and please explain why. >> i did not have access to this a record set they went through but i was told was the same patient that i was

familiar with them the details are the same. with the i.g. report is starts he presented to the year with his family seeking health care and evaluated can discharge thank committed suicide the next day. lot was not in the report if not it should be any way. he was having problems with depression his parents brought him to the clinic but because he was not enrolled he went to the clinic where he waited for hours to be enrolled in by the time he was enrolled you aback to mental health clinic there was too late to be seen so then they were referred to the er before they receive by a psychiatric nurse by that

time that patient was very tired and declined discharged to follow up the next day. >>. >> did they propose any changes are ask questions'' what was in the report? >> they requested we remove several case reviews we refused to remove them. suggesting we flip-flop the blood pressure numbers so we did change that and another date that was inconsequential to the outcome there were some verb

tenses that in a way affected the intent of the recommendations. in the secretary agreed to implement all recommendations. >> how often do they ask for changes for the release to the public? >> i suspect there has never been a report without some minor change not requested. >> they have to implement with what they can occur and they have to scrutinize to look for that munis -- miniscule errors.

>> but with the language that you cannot conclusively assert there was a connection who leaked that to the press before it was made public? >> i have no idea. that was a new report with a date certain for being published. but it did not change anything in the report. >> is it someone in your office? >> absolutely not. >> i did not think so but the were conclusively is not a medical term or legal term. where does that fall on the spectrum? >> it is a reflection of the

board certified physicians a number of suggestions as how to do this in to do in a quickly proved receiving an april 9. but what does unequivocally prove. we did a review of the quality of care that the veterans received. that is what we do for all health care reviews. >> it is a less than conclusive? >> that might have improved the course but to say it definitively that they would have died if cotton in souter was a bridge too far.

but it is very difficult to know why somebody died. in to support that methodology plus a review of the charge. and discussing previously case number 2090 individual died after failing to get the implantable heart device promptly and it said we indicated that he should have gotten fed device more timely. he died. i don't know why. we would like to think because of the wrist me and to his heart and maybe it

would have saved his life but i don't know that is why. in the reason he was on a wait list not for cardiology clinic. so not in the group of patients was the waitlist to receive a bit because those who had substandard care when reviewing the cases where the care did not meet the quality of care. this gentleman was delayed getting care between phoenix and tucson. >> i yield back my time. >> thank you mr. chairman i did read through much of the

material last night. i have to say and trying to understand what the controversy is. sanders and then it means you are forced to change in language could you help to understand from your point to end view what is the charge? and what is the response? >>. >> a lack of understanding of processing the draft report is. permitted is responsible for understandable is the first time anybody has got one it does not mean my a senior staff or other rivers of the

tumor not continuing that document but the fact it went to the department it is the ongoing process to sign amount those drafts there were minor changes made but the minute that draft report came out is because they are subject to interpretation and not final and shortly after the draft it was reported that it was proof the somebody changed it is not prove it just means you don't understand the process.

and six days before to have discussions internally we were not clear that delay was the cause of death we need to say so. but i would point out on may may 15 in a senate hearing the original 17 names that we received came up if i was asked if we had a chance to review those. i said yes in being on a wait list for care does not determine causality. period half months before the report. so there should have shown that it does not show causality.

because the witness want to be here. then why would you send it over for it was not ready? we have to put it in front of the department in they had 24 recommendations that they got it and they would fix it. we've paid a report to the congress to publish in august in to be the business to write the report in those urology patients less subject of a future review. >> with those 45 cases but

they did seem to be evidence is it possible those family members are notified those that can pursue litigation. said the a could be found culpable? >> let me offer this comment. those that we set about to review our poor rarely those patients that were identified by whistleblowers and health care perspective. and those that did not get the appointment timely.

said is part of what we're looking at. and whether you try to get to the v.a. for not and to have had a delay in cater and dec critical impact. but to know why someone died is very difficult. when you get down to the individual who commit suicide on a certain day after the event i would like to say it is assisted suicide or going to the primary care doctor wrote not have occurred by in the world where we try to prove we have a hard time going there.

so that a second group of patients has up for quality of care. budget is to respond to the congress and secretary an undersecretary of health to comment on the quality of medical care the va provides. so we look at an issue in what we took to be was a direct relationship between the appointment and that we were forced to address that in some way and then once we determine patients that had for quality of care we always switched that what are the system issues tear try to get them to change their practices?

going to the issue of exactly what does the v.a. for the patient or the high-school or the nursing home, what do they contribute to the outcome? >> that is a matter for a the process of five get to quality of care and always focus on what can i do to work with the v.a. to make sure we fix it? and then looking at those reports when veterans were harmed as we try to get this fixed. >> thank you chairman for indulging. >> mr. chairman? >> in your testimony you

indicate there may have been tampering of the software now the central offers some -- office deferred. how is it those appointments could be overridden to zero out the previous appointments? you believe it was deliberately disabled? >> i think there was one or two methodologies. and then that i agees shows it was a small number and not correct and to have the sec can list with the function or they tampered with the reporting software so it would bag give an accurate number of over 200. certainly the i.g. data shows a never gave the right

number. they said the waiting list time was 55 days but there were between 14 and 1600 with the 3,500 scattered around it was somewhere breezeway one-and-a-half banded two years. i reported this to the i.g. and fbi they're taking a look and hopefully they can find the forensic evidence to support that point. >> fell language included in the final report regarding the conclusive case of death has no relation to a standard of measure in medicine. but since then if the va is on schedule appointments

early enough to treat a disease it is highly likely that veterans with fatal conditions could suffer from conditions or die. does that make sense to you anti-you agree with that statement? >> i a agree. the premise is you are very likely going to be harmed to. borough police started it is what we would find over and over. police said why not? i think there are too doctor cases to say he saved the life. patient on a low rating less to had diabetes and another had critical part kerry and he intervened. it is clear and then to have

the extremely diligent. >> said then while veterans died in south carolina and georgia? >> and then to determine that for quality of care. >> was the say measure applied while waiting for care in south carolina? >> is usually a fact based decision but it was the

different fact pattern if we determine different quality of care was provided to get v.a. to do the right thing. >> so it is discussing the delays? >> key you answer that question statement given the cover of the case the same standard was not applied but in colombia v.a. found they had delayed colonoscopy is anna at as a result as you would expect they develop colon cancer in v.a. and admitted they had died.

but my report look dash out why did this happen? said v.a. does not have go way to insure that if a nurse and leaves the clinic and the job is critical to fill that position is given to a board in the hospital where administrators decided they will fill that nurse or teaching or research position. so what can we do to make sure this does not have been? the same standard was not applied because the fact patterns were different. >> i apologize we have a role call at lake a chance to ask her questions before we recess. >> mr. griffin from those

other facilities it is the best date and the art also with the medical system i will ask a number of my constituents is the same problem happening here as phoenix? because then it makes you worry. i talk once a week to be reassured that they are not but not only do they want to solve its problems they could find but that is a big part to restore trust to get that done. also to put forth 24 recommendations and there are 11 specifically to phoenix but the rest of the public at the systematic problem.

to you recommend that a duse's? are you confident the v.a. has the facilities or the means or the intent to carry out those recommendations so it does not have been again? been a guy agree at present they don't have the facilities to need additional clinical space and additional clinicians in the new scheduling process and the methodology by which they can remotely monitor what the over eight times are in and las vegas are in either place reverses' of medical center. in the new secretary and the team he assembles are dead

serious about addressing those things. we do follow up on our recommendations copper when things are to be completed and will follow-up aggressively and also had some initial internal discussions about how we may scopa future project to verify a according to russa plans. >> leaf follow-up civic i share your excitement for the do secretary he is excited to make the specific reforms. do you think the best -- the bill we just passed would be

useful to address these recommendations? >> i am afraid i am not first on the bill. to assist the department but for the record. >> members redo need to pause. i apologize to the witnesses it may be about 30 minutes to do that. we will give you a heads up when we will start back and the hearing is in recess and tell immediately following the third vote. [inaudible conversations]

>> thank you for rejoining this och -- again and started for the delay be have other members coming back. to put that testimony from the deposition in to the of reckoned the have dash had an opportunity to review with icu have done some reductions we have made an agreement to enter into the record in the bipartisan way. in to play into the record of personally and identifiable information is that no k? >> the redaction is done by

the privacy officer to make sure we had no names better to double check. >> but prior to introducing into the record that the council has come together we will agree to separate actions and don't mind coming back with you. and mr. patrick you are recognized. and there is that a criminal process and the civil process because of causation as a result of the wait time

now there is criminal investigation by the attorney-general, fbi and department of justice spee victory is the ongoing criminal investigation to involve the criminal investigators from the i.g. office and the attorney's office in phoenix. >> there is out process. spinach damaging the federal tort claims act has anything been filed as a result of those great time? >> i am not aware of that but we checked in.not if hurricane any filed with those 45 spin the thank you

for being here and coming forward in die have expressed in the past to appreciate your courage because we are united with you in our care to make sure they get the medical care and access that they care about. that is why i introduced the protection act that has been in place for a year but will hopefully make things better for future whistle-blowers sam part of that is a hot line that patients and workers within the v.a. system can call to go directly to the secretary in hopes of no retaliation. put the committee is committed to access it was

the bipartisan bicameral conference committee appointed in the summer that we've met together to pass the veterans access choice of 2014 and one of the primary pieces of that is a new choice card to allow veterans that a live more than 40 miles from the va facility or had to wait more than 30 days to schedule an appointment to go to a local provider and i was concerned when you said you did not know if they had the choice but ideas they in the use of the choice card going on in november will help to improve that? >> but to clarify a to walking into the primary care clinic at this point if not enrolled it would not

pay for their care anywhere else but to get that is wonderful what the i.g. said earlier they go to a hospital or private doctor if they get sick they will not go to a physician but frankly i would have fought hard time to pay for hospitalization. many veterans let their problem get worse they kept only to the e.r. because that was the only way to get the severe symptoms taken care of socially puts out the fire but nothing to prevent it. >> i darr appreciate that and we hope with the choice card will make us a difference especially in my area if they are 40 miles away from a facility to go to a local community and i

have 25 percent of my business grows to the health services facility so here is a piece of the reform act. so i thank you for your time to guide the committee to do meaningful reform and we will keep an eye on it. i yield back. >> mr. chairman, will you provide us with all emails and drop discussions incumbents provided by a v.a. for this report? >> i can provide the balance

reviewed by the officer to reassure no one to identity will be provided. >> as you are aware the department of justice says declined to prosecute 17 cases of criminal violations. your office has referred to what are some of the reasons for not wanting to prosecute? and it. >> some of them include it was not determined to criminal behavior ochered in some of the cases. they have more rigorous as

opposed to move mr. evection. -- administrative action. but the fact someone manipulated the data a prepared was not prove of death as a result causes them not to prosecute. some said it is a systematic problem in the department for a number of years and has been allowed to perpetuate and the ability to do demonstrate that they knowingly and willingly committed the offense was too difficult. >> were you surprised but we work with these prosecutors every day. last year rearrested over 500 individuals than 94 employees.

we are aware that they cannot prosecute every case that they get. frankly our investigators would like every case to be prosecuted but that is not the real world based on the demands of the court system by the department of justice. but let me say i passed an amendment to to put more money into easy line item for the specific process of the cases. but don't you think win talking about a systematic maybe the fact is cultural cases. >> it is okay.

>> 178 dennis a feint to manipulate the records coming in and shouldn't there be an example sets somewhere in the system spin if there are none at this plane did you expect those with the least amount of evidence and to those of the ones to be satisfied earliest because additional cases require more work. >> we know is important to kids through all 93 and as we finish it is the criminal prosecution i know the department is anxious to get the reports to take

appropriate administrative action. >> tell me your use surprise there was not a criminal prosecution? >> not at this point because the fbi is still investigating. >> i am not surprised there is still retaliation for whistleblowers. >> it does seem like the department of justice is looking fee of their way. because obviously. >> i want to saying you for your work towards veterans in that situation in phoenix or elsewhere that provided one better in substandard care but i have along history with the i.g. office and i counted on my unit heavily for another set of

eyes with that of unvarnished view. so let's be clear what is implied the integrity of the office was influenced by that v.a.. did anyone ask you to change their report to make it look better? >> space rick is is standard operating procedure for multiple drafts? >> it is especially of 107 pages with 24 recommendations. >> has there been a case before where your methodology has been questioned to the point to call into congress? >> no. this is the first time. >> is a your understanding it is predicated on the interpretation the you were asked for the original draft? >> correct. >> ok with that being said the report you issued is very damning to the v.a.

than many things they fell down a of the department of justice to make sure that everyone involved past to have a rally that people are made whole and held accountable. from a understanding that is in the process. the. >> the investigation is ongoing other place is also a the report refers the names of those 45 veterans to the department for them to conduct appropriate reviews to determine if there was medical negligence and if there should be redress were the of veteran or his family. >> does the v.a. i.g. investigate? >> we take them to the prosecutors or the state court if we cannot get

traction under a federal violation. >> does this report and the way it was handled, how long have you ben with i.g.? how investigations roughly? >> we have done 520 arrests every year over the next -- the last six years that is an average. >> that methodology? says there have anything strikingly different? >> do was so large undertaking and a combination for the criminal investigators with the same of the service agents but it was a giant project whether dr. days people had an ownership to have the

responsibility to identify all these people who were not on the electronic wait list syria different sources so her staff did that to pull those three the different disciplines together to give every ready on the same page as far as what makes sense. >> i would argue a makes sense to is the doctor because obviously there is still the belief we haven't gotten to the bottom but with that being said of one to use my remaining time it is investigated that my immediate concern is the us 24 recommendations are they in the proper direction? people have testified before they did not implement to

come back again do you feel at this point it is less then of month since it was issued but at of the wait times issues previously identified i know the department started to address those immediately when we identified the additional 1800 veterans that were properly being managed reid gave them to the people in phoenix to make sure those veterans rest quick as possible. >> i know this is subjective but this is that the heart of the matter does it feel like cultural changes are beginning to change? >> i think the change will

come as we complete more investigations as people realize there is a price to be paid. >> was asking for my testimony to be made public no. >> no. lot of investigations but no substantial change. >> i yield back. >> dr., you said earlier that you did not conclusively examine all the medical records those and related to the delays of care that the tea 27 reforested it could not assert that those long wait times apply to veterans but could you explain how could the v.a. state to was that you could determine the length between wait times if

you did not examine all the records? >> let me clarify 200409 records. to the chairman's point we did not examine all the records if they never made it through the maze. the electronic record was the main source. and of all the cases we're able to review in those cases where we determine

there was harm of delayed care be published them in those cases. >> and we thought the people on the waiting list and as a result we have additional 17 cases where the standard of care was not met. >> i am not trying to say to people only trying to answer fact did we see a significant impact on their care? that is what we fail and. >> but i a don't believe our review needs to be

determinative to put the scenarios out there helping citizens would read these cases is to understand the complexity and the difficulty that they have. so horrible things are likely to have been so they can decide the person who commits suicide if that was related they can make their own decision. it has the ability to see that micro data intentionally necessary for the basic pattern these families have the right to privacy so we're careful about what we decided to publish to the issue people would like more data but the

v.a. needs to have access to care to deliver proper care. >> if you have a chance to go back to reinvestigate would you do it differently today? >> no. the way we did is the way we have done it for many years. it is the row. but i would wish we had not then with the issue of timing is. but it is based on the circumstances of the case. if i pick something different to look at that is

the what we had but but we had to use i yield back. >> mr. griffin do you know, if there is the parallel going space? >> there is said to wait investigation involving people. >> investigating the same issues. >> there is the l.a. g investigation with the i.g.. and related to the closing of the closing of 12 cases coming mentioned they've met the criteria and the questions were answered buy

you talk to the additional information not necessarily related? can you talk about the additional information? >> let me clarify. and of those 93 investigations and 12 given to use the department reid did not to raid the knicks muffled in view. but we did the cat where we received an allocation is through the hot line or other services there is a specific infection and in some cases than and there's. so if the result does not

rise to the level of the u.s. attorney's office and the investigative package within the scope this given to said the for retail ended is incumbent to review that information to say maybe someone decided this is to not rise to the level of criminal prosecution. however we think disciplinary action from counseling to firing needs to be taken. so. >> it could be the piece of the investigation that we did that day need to interview someone else for whatever reason.

if that would result in new information and that we were not aware of it could cause us with our investigation but it is up to the department to take those actions and that is why there is no criminal case we hand over the reports to the v.a. to take administrative action. >> there is not rationed that's. >> i am just saying that in pulling together or if they come up with it the information's. >> if they propose the

action caused us to say look into this further. phrases. >> but to follow up to ask very specifically to you believe there are adequate resources to continue and complete the ongoing investigation? >> i think some of those are much more narrow scope than the magnitude of the review in phoenix. we're progressing on the remaining 81 and another handful to bring to closure. the answer is yes. we have the resources but i must say this is not the only investigation.

since january the number of cases that have come to us that the day as facilities such 68 drug arrest but some of those we've prosecuted and reid could not dropped the case. >> i yield back there were 293 deaths is that correct. >> avenue were cross referenced with medical documents? it shows 28. again i am honestly trying

to learn in into it. >> you have said they were not in this and. >> let me clarify that list of those patients that we reviewed. >> we do have the medical record then we would exclude you from the review. in that methodology we can only look at case is that come to that v.a. >> i interesting and. i keep going back but how can you say conclusively you

could say that these individuals did not get timely care and they are now dead? >> i talked about the cases we could review. >> five understand but there were case is that you said you cannot review. i try to figure out the cases part of this investigation the you could not review because there was no medical record. so of those 293 deaths if everyone were a cross reference with the medical record? limit the total number of people on the new year list is the big numbers. >> un saree 293 deaths. >> and just trying to be clear. those are from whatever list they were on with the medical record in meeting review. so i will agree people would

be on the list did not have a medical record who we could now read you. and therefore not part of the chart because it is not possible. of all the deaths we reviewed intensively. that to 93 number is said datapoint from the patient's 293 word that. but that number has the limited meaning in the sense it is responsible for the populations of white cannot tell you if to 93 is too high or too low. >> renders stand i apologize. because of the staff briefing the staff was told in some instances all that

could be done is a match of social security numbers while looking at a death list so there was no way for those individuals to be cross reference to with the medical record? >> no. that is a misunderstanding. i would not purport to comment on patients we cannot view the record. >> but they were on the list >> with that methodology section i realize we're talking subtleties but i cannot report on cases. >> i concur. that is where those crossed wires come from because it is hard for me to accept the statement in a document if you cannot look at every single medical record. thank you for clarifying

that. >> i appreciate the questions because i was confused if you could identify those 3,000 veterans as what you revered and you have medical records for all of those? >> yes, sir. >> that on page 34 you identified numerous other categories of veterans that is well over 9,000 put to consult in the bath log redistribution in had a sick kid in first. >> and report to the with

the clean-up action foods. >> berndt lecter page 34 to identify 9,001 injury 21 veterans. it is cumulative but how did you decide not to look at 5,600 cases and not review their case? >> we looked at that list collected during the time frame. up until june 1. i would have to go through to look through the data set that we have of 320-0562

names on the list of which 293 died. >> just like the electronic waiting list. >> everybody we could determine. >> i just gave another 5,600 and then trying to free your act sublimities an applicant at any of that new year's list you last but you never got care spending but they don't show up because of the system's been that correct. >> is said that the crux of

the problem? thousands and thousands of veterans are waiting it you said we don't count them because they died before we got the records? i am trying to figure out they may not all be unique but it is clear to me if you can provide information to the committee to know you decided to exclude them that would be helpful. one other question in the day before were he released her final report news outlets were saving the headlines seven said no proof that delay caused the patient death do you think these are accurate or misleading? >> i have seen plenty of

misleading headlines in the past two weeks. >> the ones that i read? >> that is part of the story. if someone leaks before the scheduled release date and if it quoted the report it should not have been leaked. >> so it is that misleading? >> no deaths related. no deaths? spinning that is an accurate representation of our conclusion. >> no death? >> we cannot assert the cause of death being associated with the waiting time. >> no link?

been a that is not my words. >> you are looking at 800 headlines. >> that is just a reality from google to show the amount of coverage put on the statement in there were no ifs ands or buts about it. does not take a lot of research. >> apparently those are okay? >> are they misleading? >> they seem sensational that there is 5600 bittering cases that were not reviewed in the report so i'll look forward to the determination why you did not review those cases because more veterans died. >> they said there was nothing to review of a did not get in the door.

day did not get an appointment they did not have records to review. >> no causality they died because we did not deliver care? i think that is causalities. >> but we don't know how they died were why. nor do you. >> mr. chairman i will say that's i think by the criteria that you use to reach your conclusions i've understand where you're coming from and it is a rather narrow legalistic interpretation but i understand it and you made it clear so i except what you have concluded but common sense tells me from cases in my district that there is a cause and effect relationship between care that is delayed purses care denied that is from veterans

and i used the example before with all due respect to the family that share their story with me that one had tried to get mental health care at el paso was not able to for ptsd. after not attending my a town hall i'll also found out he was driving home and said some of these guys are much older and cannot get in bin i don't know what i have to look forward to. she cited that lack of hope that he took his life five days later we know 22 veterans the days that they take their own lives i think there has to be a connection between a delayed or denied care and these tragic instances of suicide.

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