the ig community with 25 own words for excellence. we are scruples about her independence and take pride in the performance of our mission to ensure veterans receive the care, support and recognition they have earned through service to our country. i 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 to a recent report cannot capture the personal disappointment, frustration, and loss of faith that veterans and their family members have with the health care system that could often not respond to their physical and mental needs in a timely manner. although we did not apply the standard 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 va's potential liability in these matters lies with the va, the department of justice, the judicial system, under the federal tort claims act. ..

in december, 2013. while i have views on many aspects of what has come to be known as the scandal i would like to use this statement to comment on the downplaying and frankly inadequacy of the inspector general's office that continues in the report issued august 26, 2014 that i fear is designed to minimize the scandal and protect its perpetrators rather than to provide the truth to the veterans and families that have been affected by it. all the employees receive training on their duty to report waste, fraud and abuse to the inspector general whose job it

is to investigate these allegations. i did this in february, 2011 that resulted in the indirect debate director placed on leave in which two weeks of receiving my letter and then his resignation in lieu of resignation. i sent a separate level rate cut later in 2,013th against the chief administrative services brad curry for creating a hostile workplace and engaging in personnel actions and discrimination against certain classes of employees. as far as that could help committee ig never investigated this complaint. and it appears they turned it over to the veterans integrated network director susan bowers who is both superior. susan bowers could take action against him without running the risk that the entire waiting list scandal would be exposed. in late october, 2013 ice and a third letter to the ig informing them of access to his.

i include allegations of the actions by senior staff. and i advise them of the second hit in backlog of patients contained in the schedule with primary care consulates list. i came to phoenix to investigate all of the above. i get a response from the office and december, 2013 to join a conference call with them on december. the team came up to investigate the december 16 through the 20th and at that time i and others told them about the on address scheduled appointment convoy and showed the northwest electronic folding clinic which was being used to mask the true demand for the return patient appointments. we updated them on the secret electronic waiting list summary

report showing that 22 patients had been removed because they had died. we only had the names of the two deceased because none of the employees who were working with me had the electronic keys to print the names of the deceased. we asked the inspectors if they could do it but they responded that they could not. the last response that i had from them was on december 21, 2013 when i received him out of the office until december 31, 2013 reply. i offered to fax or mail the names that we had at the time that they were unable to give me a working fax number or address to mail it to. facts and a standard mail but not encrypted e-mail are appropriate methods to transmit sensitive materials. i said far more send far more e-mails in january asking if they would like the names but i got no response. i also got no response when i advised them that several more veterans have died.

finally february 2, 2014 out of frustration with a lack of action by the ig even though we were informing them of more and more deaths i sent a letter number four with copies to everyone that i could think of who might be able to help. the only response i got was a confirmation that they have 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 that the only way that i could get the 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 the senior leaders. of the many scandals from the performance made in the top administrators by supposedly supposedly at the time goals to the harassment of employees trying to rectify the situation to the destruction of the documents and electronic records to the very real harm done for the thousands of veterans unable to receive timely medical care

nothing is more than the facts that's 293 veterans died in phoenix. the inspector general tries to minimize the damage done and the culpability of those involved by stating that none of the deaths could be conclusively tied to the treatment of uas. i've read the report many times into several things bothered me about it. throughout the case reports, the authors appeared to downplay the effects and minimize the harm. this was true in the cases six and seven where i have direct knowledge. after reading the cases it leaves me wondering what really happened in all of the rest. for example, in case number 29, how could anyone conclude that conclude but that wasn't related to the delay when the patient that needs a defibrillator to avoid sudden death did not get one in time and why was the case excluded from the ig review. a critical element proving this is a conspiracy as a potential tampering with the reporting

softball where the electronic waiting list from the beginning there 01 data showed that there is a difference between the number reported to washington and what the numbers actually were on the secret electronic waiting list. they minimized the significance of the crucial point treating it as a trivial clerical error and touting how quickly the department corrected it. rather than exploring who tampered with it in the first place. they stayed for thousand 900 veterans were waiting for the patient appointments at the phoenix va. 3,500 were not on any official list and 1,400 were on the not reporting secret electronic waiting list. 293 of the veterans are now deceased. this exceeds my original allegation that up to 40 veterans may have died while waiting for care. the ig says it isn't charged with criminal conduct.

but neither is it charged with producing reports to downplay the potential criminal conduct designed to diffuse and discourage potential criminal investigations for its diminished the public outrage. at its best to this it's best to this report is a whitewash and it's worse it is a feeble attempt to cover the report deliberately uses the language to invent the standards of proof and ignore the wide waiting list was not reporting accurate data and makes misleading statements. and i think that by outplaying the damaged information thereby protecting the officials responsible for the scandal reinforced the long-standing to delay committing i can't let the claim by that they've had to suffer with frontiers. >> you have gone three minutes over the five. i would like to say that the rest of your testimony will be entered into the record. i apologize, but i let you go

little bit longer then once we all had agreed to. if you could wrap it up in the next 20 seconds. >> secretary mcdonald said he was going to try to increase the transparency of the agency and that wouldn't comply. they didn't get the memo. the report failed miserably in the areas with of a conspiracy = to the redline concrete wall. >> doctor mitchell, you are recognized. >> i'm deeply honored by the committee's invitation to testify today. we were unable to conclusively assert that the timely club of the care cost veterans. as a physician reading the report i disagreed. specifically come a minimum of the five cases, i believed there was a very strong actual or potential causal relationship between the delay to care or proper care and a veteran death. in addition, the health care is contributed to the quality of life and for five other veterans who are terminally ill and and shorten the lifespan of one of

them. in the looking at the report, there are four cases where there is no cause of death listed and it's unclear to me how that relationship may or may not exist if there is no cause of death given. it's unclear if the veterans who are on the electronic waiting list were aware of the self referral process to the primary care clinics if they were not aware of the process, and the recently believed waiting on the waiting list was the only way to get medical care even if the symptoms were worsening. in the two cases, they gave evidence that the veterans accused or had a cute and stability acute instability to the medical disease that required repeated visits to the er and hospitalizations. iab leave that those likely contributed to the death began they didn't give a cause of death for those veterans. in terms of mental health treatment, there were eight veterans from electronic waiting list waiting for primary care who apparently just wanted a mental health mental-health

referral. two of the veterans committed suicide before they got the appointment. it was unclear if anyone told them that it was a self referral process and they could have done so any regular business day and in the mental-health care. and case number 29 there is a veteran that needed life-saving medical device implanted under his skin that would immediately shock his heart into a normal rhythm of his heart stopped. the community standard would have been to implant the device immediately. at the va, he waited for four months and still did not have happened. unfortunately, the veteran targeted stock and without the device he had to wait precious minutes for the paramedics to arrive to restart it. he was revived by but unfortunately, the family had to withdraw life support three days later. they stated that this device might have forestalled death. it is apparent that it would have forestalled death because the device is exactly what is used to treat heart rhythm that he had.

he died from complications of prolonged heart stoppage without the device that could have restarted his heart and seconds. he was denied access to specialty care. case 39 and veteran with risk factors came to the e. r. with stressors like being homeless. he was discharged back to the street and committed suicide at 24 hours later. the community standard would have been to admit this unstable veteran. the oig admitted that it would have been a more appropriate management plan to admit the patient but didn't draw the connection between an appropriate mental health discharge and death from suicide in 24 hours. case number 31 he died of prostate cancer that wasn't treated during a seven-month period the va failed to act on the lab. it couldn't have been cured of that earlier detection would have started the treatment that would have slowed down the progression of the disease significantly and slowed the puzzles were cancer to his bone

but because of the unavailable urology appointment and domestic labs he was denied access to care that would have forestalled his death by months if not longer. in case 36 the veteran didn't receive quality care for evaluation of unrelenting severe pain that served as the impetus for suicide. case number 40 is a premature discharge for an unstable patients with multiple suicide risk factors that enabled the death from suicide 48 hours later. there are many other cases they reviewed in a written testimony. i did not discern a difference between death that on the electronic waiting list and death waiting for appropriate mental care for those already in the system. death is death and there is no way to get them back. the purpose of my testimony is not to undermine the va. it's to get the va to examine its practices and in order to improve the club of the health care for veterans they have to repair the cracks in the system so no more veterans slip

through. thank you for your time. >> thank you everybody for your testimony. mr. griffin, and the information that you provided to the committee chose 28 veterans died while on the list were the new endpoint and request essentially meaning they died while waiting to get their foot in door and since they were not yet in the system your staff briefed us that they used social security records which only show that the individual had died, not how they died is that correct? >> i would say we saw a lot of additional information from social security and we sought to find death records from the coroner's office. we explored who might have been

getting treatment under medicare programs but as far as the specifics i would defer to doctor day. >> can you answer that question? to make the determination was by and large made by the medical records and the death certificate was mostly however able to identify the patient had died and records was correct and by reading the medical record and in several cases the records of the care at local hospitals. anyone that is on the list that doesn't make it through to be seen and it doesn't have a medical record i can't look at so those folks i am not able to examine.

>> if that is true then how can you conclusively or otherwise whether these were related to deaths of care. >> indicates is that we identified that we were able to actually review. his back the report says conclusively this is where we have some problems, there were people that were looked at in the report and your report says conclusively that there is no link to the delays in care yet there are individuals that you were not able to go back and look definitively out of their medical records to determine what the cause of death was or if there was a delay in care; is that correct? >> in the reports we are trying to address the patients that we identified who had a delay in

care, and then subsequently received the poor quality care as a result. >> but if you were on the list, is that a delay in care if you did not get into the system is this system is that a delay tax >> yes. >> okay then how can you conclusively say that none of the delay is more a cause of death? >> we were referring to the patients that we were able to look at. >> i provided your staff with a breakout. >> did you -- were you able to book book includes a flea at all of those that were on the waiting list plaques. yes or no word you able to come come close if we look at all of the people that were on the wait list plaques i want to direct

you to a finding in the report regarding the veteran who died while waiting for care and it's already been talked about this morning in a staff briefing on the floor, you stated that the veteran was seen by a urologist within three days of presenting to the er so the case wasn't included in the 45 case reviews in the report. however, we have received notification from the oig yesterday stating that a mistake had been made and that this veteran was actually not seen after he was presented at the er and after informing us of this delay the oig still says it didn't contribute to his death. could you explain to me how they came to this conclusion? the >> of the patient in question has had bladder cancer for many years and he arrived at the va and was seen in the emergency

room initially and received a very reasonable evaluation. among the chief complaints is that he had blood in his urine. he also had rheumatoid arthritis and other disabilities including amputation of the leg. as a result of the business, he had microscopic -- he also didn't need to see a the physician asked that he had several consoles, oncology consult and urology consult primary care consult. the records come and this is the source of the confusion, the records stated that he had an appointment made for urology to be held on 10-22-13.

it says that they requested a rescheduling of the appointment i was then rescheduled for 11: 11:06. so some people would say the patient had an appointment to see urology and didn't keep his appointment. >> what we ask this question real quick and then i will let you finish. nobody here in this room has any faith in any of the appointments and scheduling that was going on at that time, so i have no belief that what may have been written was in fact true. >> i understand about. that. what i'm saying is this gentle man then died by what appears to be mh and a static cancer where he had it in his brain and also cancer in his lungs. so the assertion that having seen the primary care provider provider into six or eight weeks

before the emergency room visit and when he died, i don't believe that the primary care provider would have changed his death. and i refer you to page 75476 of the testimony that we provided from the transcript. >> if i may also interrupt the testimony was given as the hearing already started. we didn't have a chance to look at it we just got it handed to us. in the hallway after the gavel dropped. >> i am just saying that -- >> it was sent up to make sure that the truth was on the record having seen other witnesses testimony and needing to make sure that the committee was aware that we had a taped

transcript of the interview and people should take a hard look at the transcript. >> i appreciate it very much but your staff told us that there was a problem getting it to the committee and that's why we just got it. >> are you referring to the transcript? >> that's what i'm referring to. >> any other transcripts i need to be aware of? >> we sent about 48 hours in advance. >> of the original allegation was up to 40 veterans may have died while awaiting for care in phoenix and i think everybody knew he was referring to patients on the electronic waiting list and on the schedule. an appointment with primary care consoles so it was all

conclusive. between the two sources you've now found 83 patients, more than double the original allegation was. so i have a couple of questions and then my alternative over. but why was that information not included in the executive summary that the va, not you but the va leaked early? but you did find room to include that we, quote, pursue this obligation but the whistle blower didn't provide us with a list of 40 patients names? >> i believe that you as the chairman and received the same that we did. it stated that there were 22 that died on the electronic waiting list. and there were 18 who died on the consult list. succumb in our pursuit of finding out what happened here.

the pursuit is ongoing as you know because of the urology issues that we discovered. the obvious first question in the interview was give us to 40 names. we want to go after the records of these 40 people. and ensure that we don't miss any of the 40 because that was so definitive. now you were very careful in the hearing on april 9 to say potentially 40. as time passed others said that there were at least 40. so, that spawned 880 reports that 40 veterans died while waiting for care in phoenix. that was the story in the hearing. to not address that with the

amount of coverage and the amount of readers. so we didn't look at 40. we looked at 3400 records to make sure that we didn't miss any. >> so that was important that you draw the fact that doctor foot didn't provide you with a 40 names. that was very important. >> what was important is in the hearing in this room -- >> i'm talking about the final report. >> that was not something that was inserted in the final report. there were multiple drafts which was a very important point but it doesn't seem to be getting any traction. we were asked to provide the first draft report and that's what we provided. please provide the committee with the original draft copy.

you may have thought that it meant an unaltered copy and i have an e-mail that went to your staff that has original unaltered, we want the original draft. >> to requests from the committee. one from you and one from the chairman. one of them said unaltered into the other one said something different but there wasn't any confusion that you wanted the very first initial draft report. >> let me read this e-mail to you. you have a third one that came from the staff director of the subcommittee. to joann moffatt, chairman miller would like to know if the oig is going to provide the committee with a written copy of

the original unaltered draft copy of the phoenix report as it is first provided to the va. if so, when? >> i guess i don't see what the difference is. you asked for the first initial draft report and we provided it. >> did you ever indicate indicates to the committee or to the staff that there was more than one draft? >> we provided with the committee asked for and we also explained that in the last six years no committee has ever requested a copy of the draft report. >> here's the way that it works here. we want all of the information, we don't want you to use semantics about which copy of the draft we asked for. we asked for the draft that you

gave so the va could make their determination as to whether or not the draft was factual or not. that was the intent you knew that's what it was. >> you knew what the request was and what we were trying to get is how did that get inserted from the draft to final. now we've testimony that in fact they did not conclusively look at all the causes of death. so i still make the statement and then i'm going to yield. and i apologize to the members. we have to be honest and open with each other about what's going on and whether or not any other committee has ever asked for a draft report, shame on them. whether they've ever sat at a table with anybody other than

the office, tough. this committee is going to get the truth about all of the facts >> me i respond? this is the whole allegation. >> we were asked to provide the initial because you didn't want one that had been through two or three iterations. you you wanted the very first draft report and that was clear to us. you can did can gi about all you want. >> can you show me anywhere that it shows we asked for the first draft. >> can you tell me where we asked for the first draft report?

sumac let me find the e-mail and i will respond to your question. >> it showed a lack of awareness -- >> you are out of order. >> on the reports if i understand you correctly, you did provide the first draft of the report, but there might have been other additional drafts. >> that's correct. >> so the draft you provided was the first. but there was other drafts since the first one that came out is that correct? >> it is a deliberative process in order for us to get concurrence from the department. we have to put a draft in front of that. if we have factual errors in that draft that they can

convince us were factual errors and it would be incumbent upon us to make whatever is required so that at the end of the process, the report in its final issuance speaks the truth on all. >> when they do the reporting you could conceivably get information whether it's from the whistleblowers or the department that might not be factual and once you get information that you determine actually to be factual that's when you change the report before it gets -- >> there were some minimum changes on one of the case reviews we had numbers that were taken into different times and were reversed. to me that is not a substantive change.

we put them back the way they should have been. but that is not a substantive change. it wasn't a budget of 40 veterans. did you ever receive the list of names of those that were on that list? the interview addresses that very clearly and was even suggested that perhaps some of them might have been run over by a bus that he didn't know what the cause of death was. >> did he not give you a transcript yet? >> i apologize for arriving late but it needs to be read by everybody that has a serious interest in this matter because it was a taped transcript of the interview. >> can i respond to that interview?

>> of the 93 ongoing reviews, how many have been closed out and when do you use the leave the rest will be completed? >> at this point we have 12 that we have turned over to the department that i wouldn't say were closed because we would anticipate administrative action being taken from the standpoint that we have completed the work that would have addressed the specific allegations that we were looking at. in the department proceedings to make determinations concerning the administrative action if they come across additional information that wasn't part of our focus we may have to do additional work. we turned over 12 so far. the others are not being worked with any.

the other 81 are going to be all published. we will turn these over to the department. those that do not get accepted for any criminal action we will promptly turn those over to the department so that they can take administrative action. >> thank you. doctor mitchell, in your testimony you mentioned how good the phoenix pain management team is that as they lack the staff and supply to service the veterans how do they communicate to their staffing needs to the director? was ever communicated and if so, what was done? >> i don't have any direct knowledge between the pain management team and the senior administration official staffing. but i do have is erect knowledge from many providers who find their panels filled with patients who are on long-term

narcotics and patients need additional close monitoring and follow-up. those providers don't have enough time to get those patients in for the sufficient appointment to be able to review that. in the community patients that are on long-term narcotics are referred to a pain management specialist to treat the ongoing education and monitor for side effects. unfortunately the staffing does not allow for that. >> thank you for having this important hearing. doctor mitchell, briefly on page 15 you pointed out case number 45 and a special circumstance. please explain why you did so in this case. >> i didn't have access to the records however anecdotally i was told that this is the same

patient i was familiar with and the details are the same with one oh mission. in the report the history starts with the patient presented with his family seeking mental health care. he was evaluated and declined and was discharged home and committed suicide the next day. what wasn't in the report and i believe this is the same case and if it's not it should be reported anyway, he was having problems with depression and called his parents and they brought him to the mental health care clinic however because he he had been enrolled in the dag was diverted from their to the enrollment clinic where he waited for hours. by the time he was enrolled in the system he went back to the mental health clinic and it was too late in the day to be seen so that he and his family were diverted to the er where again they waited a link the amount of time before they were seen by a psychiatric nurse to evaluate and by that time the people

involved said that the patient was tired and wanted to go home, he declined to discharged and was discharged at that point to have a follow-up the next day in the same clinic that wouldn't see in earlier. >> thank you for that verification. when you shared your draft report did the da propose any changes or ask questions regarding what asked questions regarding what was or was not in the report? >> needed. they requested that we remove several of the case reviews that appeared at the beginning of the report and we refused to them. they suggested that we flip-flopped and put numbers that were out of order. of course we changed that. there were two other things one involving a data that was inconsequential to the outcome of the case reviews we fixed that. there were a couple of tenses

changed in the recommendation that in no way whatsoever affected the intent of the recommendations of those who changed. none of the case reviews were substantively changed and the secretary agreed to implement all 24 of the recommendations. >> how often do departments ask for changes before the release to the public? >> i suspect that there's probably never been a report where there wasn't some minor change in that request. >> if we implement what they found and what they are concurring with that they are going to scrutinize those things and make sure that they are in total agreement and also look for those miniscule types of errors that will make the report

more accurate. >> in the language that you couldn't conclusively asserted that there wasn't a connection do you know who leaked back to the press before the report was made public? >> i have no idea. >> was it someone in your office click >> absolutely not. >> i didn't think so. on the scale of one to 100 where does that fall on the spectrum? >> it's a reflection of the

professional judgment of the board certified physicians there've been a number of suggestions as to how we should do this and we have received one from the committee saying that we should unequivocally prove that these cause death. what is unequivocally programmed as we do a review of the quality of care that these 3409 veterans received. that's what we do in all of our healthcare reviews and with the charter calls for when they were created. >> that there could be a connection less than conclusive. >> i think in some of them we said it might have improved the course but to say definitively that this person wouldn't have died if they had gotten in sooner was a bridge too far for the clinician's. now can you expand on that?

>> the basic problem is it is difficult to know why somebody actually died, not clairvoyant you i would ask you to read the testimony submitted by doctor davis where he supported the methodology that we used in the report that would be death certificates, plus the review of the chart. in the case that was discussed previously pretty individual died after failing to get get the implants of all hearts device quickly and that report you said, and i will read exactly what we said we indicated that he should have gotten the device more timely. i don't know exactly why he died. you would like to think that he died and that if that device had worked maybe it would have saved

his life but i don't know that that's why he died. there are circumstances that are not included in this report and the reason that he came to our attention is that he was on a wait list. he wasn't on a wait list for the cardiology clinic. second he's not in the group of patients initially where we called those who are on a wait list of the delayed care is on the list of patients that got substandard care when reviewing these cases where the care did not meet veterans quality of care so this gentleman was delayed in getting care between phoenix and tucson. so the part of the draft where he belongs i cannot assert why he died.

>> i have to say i am trying to understand what the controversy is and i understand the charges that have been made by the majority impugning her integrity and i understand that it means you are forced to change language and persuaded to change the language and that is the heart of the allegations. can you help me understand what is the charge and what is the response? >> my response is that there is a lack of understanding of the processing of draft report and it's understandable because it is the first time that anyone has gotten one. when we send an initial draft report, that doesn't mean that my senior staff and other members of the team are not

continuing to review the document and make sure that we've got it correct. the fact that it went to the department without the statement it's a process until the last day that we sign a final report. it came up in the reason you don't put draft report out because they are subject to interpretation and they are not final and shortly after the draft came up here it was reported in the press but here's proof that somebody in the va changed it. that is not proof that just means you don't understand the process and i can show six days

before the initial draft is released we were having discussions internally that if we don't declare that delay was the cause of death, we need to say so. it took a couple more drafts before it was concluded that on may 14 in the hearing where the original 17 names that we received came up i was asked if we had a chance to review those. it doesn't demonstrate the causality in a person's death. that is three and a half months before this final report. so there should have been no taking that it doesn't demonstrate the causality and i think the last statement for the

record that i would hope everybody would read is that as doctor day already referred to bears that out. they have to write an acceptable response to convince us that they got it and they were going to fix it. we have made a commitment to the congress to publish that report in august. we had to cut off some work in order to be about the business of writing the report and that is why they've gotten 3526 urology patients that would be the subject of the future review

>> i was able to read in detail each one but it does seem to me evidence of poor care. is it possible that those families are being notified of what happened. >> those family members can pursue litigation and the va could be found culpable is that right? >> that's correct. those patients called by the auditors and healthcare inspectors so they were on the list and couldn't get an appointment timely. some of the cases from the list were part of what we were

looking at. our methodology section laid that out. these are the 28 cases that we identify. to know why someone died is very difficult. so when you get down to an individual who commits suicide on a certain day after a certain event. the event wouldn't have occurred and in the world that feature to be able to prove we have a hard time going there.

so the second group of patients that we report on. it's also important to understand that the charge is to respond to the congress, congress, to the secretary got to the under secretary of health and comments to them on the quality of medical care that is provided. so what i usually do is we look at an issue and the issues are all different and the question of this one was there a direct relationship between disappointment and got. once we determined that there was in fact agents that have poor quality of care, we then always switch to the systemic issues that we can address.

when you go to the issue of exactly who committed the va or the patient or the other hospital down the street or the nursing home what exactly do they contribute to this event or to this poor outcome that is a matter for the courts. the veterans were injured or harms and work with the va as partners to try to get this fixed.

there may have been tampering of the software it's different from the real numbers of waiting. how is it that the appointments could be overridden to zero out the previous employment come and do you believe that the audit controls were deliberately disabled? >> yes i think there was one of two methodologies used. they show that it was there was a small number and not correct and they had a second list where they disabled the reporting function and went into the reporting software so that it would end give an accurate number of say over 200. the data shows from the inception of the list it never

gives the right number. at the time is broke and out and it was 55 days. the wait was six months to get through to the 3,500. at the wait the wait was somewhere between one and a half to two years. we know they are taking a look into it and hopefully they will be able to find the forensic evidence to support that claim. >> a question for mr. griffith. the language that was included in the final report regarding the come close that case of death has no relation at all to any measure of medicine. as a matter of common sense the va doesn't schedule appointments

early enough to carry a disease that is highly likely that it is a potentially fatal condition that would suffer from the conditions. does that make sense to you and do you agree with that statement? if your care is delayed comment you are very likely going to be harmed. when we started this review it seemed that with what we would find over and over again and we looked at these cases and we didn't find that so we said why didn't we find that and i think there are two of the cases in here where in fact they could say they saved a life, found a patient and a waiting list who had diabetes and critical heart care and intervened to make sure that they lived. it's also clear that the veterans have access to other

sources of care beyond the va. so much nurture respect thinking about the question i think that people must have been extremely diligent where they knew the trains to and from time to try to make sure that horrible people that care. >> does this apply when the report reported that veterans die while waiting for care in south carolina and georgia? the poor quality of care was divided. >> can you answer the question was the same measure applied when they died while waiting for care in south carolina or georgia what is your answer to that? >> it is usually a fact pattern on exactly what happened. i'm not sure exactly what report you are referring to.

but usually it is a different fact pattern if we determine the quality was provided then we try to look at the system and try to get the va to do the right thing which is effective quality of care. >> so the report that you were discussing in the delay because of -- delay it colonoscopy. the same applies to you to >> in the columbia case in the report. in colombia they found that they have delay the colonoscopy is in a large population of veterans and as a result as you would expect a large number of veterans developed colon cancer that probably would have been prevented had the colonoscopy being done. the va had already taken the process to notify.

why did this happen, how is this possible and what we determined is that the va doesn't have a way to ensure that nurses and clinics if that job is critical to the clinic, refilling that position is given to the hospital where administrators decide whether or not they are going to fill the nurse position or teaching position or research position. the fact patterns were quite different. >> thank you. i apologize we have had a rollcall and i would like you to have an opportunity to ask questions before we recess to go to the vote. >> thank you mr. chairman. like it's been mentioned before

i am eagerly awaiting the results of the investigation that the other facilities in southern nevada is home to the newest va hospital many people think it is the best they have the largest medical system and i'm getting asked by a member of my constituents are the same number is happening here in phoenix because once you hear something like that and of course it makes you worry and begin to think that there are problems. i've talked to isabel once a week to be reassured that they aren't but still i just want to encourage you to finish up because not only do we not want to solve any problems you might find that i think that is a big problem of restoring trust is to get that done and move on with it. also, you put forth the 24 recommendations and as i look at them i think there are enough and that relates specifically to phoenix, but the rest of them look at the systemic problem. you've given those to the va.

this is a big dose, a large order that you are calling for. are you confident that the va has the facilities and the means and the intent and the ability to carry out those recommendations and solve these problems so this does not happen again? >> it would be the first to admit that they need additional clinical space. they need additional clinicians and a new scheduling process. they need a methodology by which they can remotely monitor what the wait times are in las vegas or any other place in the country where they have a medical center. i think they are aware of all these things and the new secretary and his team that he

is assembling our dead serious about addressing those things. we do follow up on the recommendations and we have suspended states when things are supposed to be completed and we certainly follow very aggressively on these 24 recommendations and we had internal discussions about how we might scope a future project to go out and verify that everything is working according to plan. >> we follow up on those on a quarterly basis. >> i share your enthusiasm for the new secretary and i believe he is committed to the changing the attitude of the va and making these specific reforms. do you think the bill that bill that we just passed, the compromise bill will be useful

in addressing some of these 24 recommendations? >> i'm not totally reversed on the bill. there've been a number of of what is later changes to assist the department in accomplishing their mission but i would like to take that for the record if i may. ..

>> mr. griffin, i would ask a couple of things. we have other members that are coming back. you asked that we put doctors let's testimony -- dr. foote testimony from his deposition into the record. we did so without unanimous consent. we have not had an opportunity to review it. i.c. were you done some redactions. the committee would like, we have made an agreement that we would like to not enter it into the record until we've had an opportunity in a bipartisan way to look at any other information that may need to be redacted. i don't mind even sharing it back with you so that we're not putting something into the record that could release personally identifiable information or illnesses or diseases or anything of that nature, is that okay? >> that's fine. the redactions that you see are

ones that were done by our privacy officer to make sure that we didn't have any names in there that should not depend. but better to double check, that's fine. >> because we didn't have a chance to look apart to introducing it into the record, we agreed in a bipartisan fashion both councils of come together and said we will agree to the redactions and don't find at all sure and get back with you. i do have -- well, now that mr. kirkpatrick has returned, i would like to go ahead and yield the floor to you for your questions. so mr. patrick, your recognize. >> thank you, mr. chairman. dr. daigh, you brought up an interesting point and that is that there is a criminal process and there's a civil process if, in fact, causation founded because of death as a result of the way times. and is it your understanding that there is now currently an

ongoing criminal investigation by the arizona attorney general, the fbi and the department of justice? >> there is an ongoing criminal investigation. it involves the criminal investigators from the ig's office. it involves the fbi. it involves u.s the u.s. attorns office in phoenix. >> so there is a process if in case causation is found. >> absolutely. criminal behavior is determined to have occurred. >> yes. and to your notes you mentioned the federal tort claims act. are you aware of any cases that have been filed under the federal tort claims act as result of deaths because of wait times at? >> are not aware of any, but that doesn't mean that it might not have been. we checked on the 45 these reviews comment and we didn't find any file on any of those 45. >> thank you.

doctor foot and dr. mitchell, i want to thank you for being here and for coming forward. i've expressed to you in the past that i appreciate your courage. because all of us on the committee really are united with you in our care for veterans and make sure they get the medical care and access to the care that they really care about. that's why introduce the whistleblower protection act, which that had been placed for you but hopefully that will make things better for future whistleblowers. part of the fact is a national hotline that patients and workers within the va system can call and that information will go directly to the secretary in hopes that there wouldn't be any kind of retaliation. as i mentioned, this committee is really committed to access, to care for our veterans. and as you know there was a bipartisan bicameral conference

committee that was appointed in the summer. we met together and we passed the veterans access choice and accountability act of 2014. and one of the primary pieces of that is a new choice card that will allow veterans who live more than 40 miles from a va facility or have had to wait more than 30 days to schedule an appointment to actually go to a local provider. dr. mitchell, i was concerned when you said that you didn't know if some of these people who are on the wait list knew they had a choice to go to an outside provider. do you think the use of a choice card which is going to go out in november to our veterans, giving them the option, will help improve that? >> to clarify what i said. had the option of walking into a va primary care clinic to get care. at this point if they were not enrolled in the va the va would

not pay for the care anywhere else. i think the idea of getting care access is wonderful. what the ig said earlier was that by the veterans had a choice but to go to er, hospital or private doctor can then have a choice. many americans don't have insurance. if they get sick they ought not to go to physician. i don't know about other members here, and, frankly, i would have hard time paying for the cost of hospitalization or er visits. any veterans will let the chronic diseases get worse. as evidenced into cases they get going to the er because that was the only way to get taken care. the equivalent of only putting out the fire but everything anything to prevent the fire from starting. >> i appreciate that and our hope is that with the choice card that will make a difference, especially it for veterans in the rural area who many of them are 40 miles away from a facility. they will be able to go directly to a local community. as you know i have 12 tribes in

25% in my district is made americans. they go to the local health services facility to get their veterans care. a huge piece of the reform act was encouraging a partnership between the va and the indian health services. so i can i think h if her testimony, for helping to guide this committee dues so meaningful reform, and will keep an eye out. i yield back my time. >> thank you very much. mr. coffman. >> thank you, mr. chairman. mr. griffin, will you provide us with all e-mails, drafted discussions, and comments provided by va with regard to this report? >> i can provide the ig e-mails. it will be reviewed by our

privacy offer to make sure no one's identity is, you know, left in there that shouldn't be, and i will provide them. >> mr. griffin come as you are aware, the department of justice is already declined to prosecute 17 cases of possible criminal violations by va employees. that your office has referred to them. what are some of the reasons the department of justice has provided for not wanting to prosecute? >> some of the reasons include that it was not determined that criminal behavior occurred. in some of the cases, they had more rigorous prosecutorial standards for the cases that would rise to the level of getting prosecution as opposed

to administrative action. and some of them, the fact that someone manipulated the data but there wasn't proof of a death as a result caused them not to prosecute. some of them said this has been a systemic problem in the department for a number of years that has been allowed to perpetuate itself, and the ability to demonstrate that someone knowingly and willingly committed a criminal offense wasn't too difficult. >> were you surprised at that? were you surprised at that response? >> no. i think -- we work with his prosecutors every day. last year we arrested over 500 individuals. we arrested 94 employees last year. so we are aware that they can't

prosecute every case that they get. and, frankly, our investigators would like every case that they investigate to be prosecuted but that's not the real world, based on the demands on the department of justice and the court system at center. so determinations are made by the department of justice in that respect. and we have to live with them. >> let me just say, i passed an amendment on an appropriations bill to put more money into the line item for the department of justice for the specific purpose of prosecuting these cases. don't you think they'll when somebody come when you talk about systemic, that was a cultural dropship maybe the fact is a cultural corruption person an individual case, then i guess it was okay, but let me ask you this then.

but when somebody does something to manipulate records for the purpose of financial gain, isn't that a criminal offense of itself? shouldn't you be an example set by somebody being prosecuted summer and assistant? >> i agree. i'm not saying there won't be either. there have been any at this point. you would expect that the cases with the least amount of evidence and the least amount of manipulation, if you will, or co-conspiracy would be the ones that would be set aside earliest because the additional cases will require more work. we are working feverishly on those cases. because we know it's important to get through all 93 of them. and as we finish them, if they will not be criminal prosecuti prosecution, i know the department is anxious to get those reports so they can take

appropriate administrative action. >> just a tiny bit of time left. i suppose there were not criminal prosecutions, doctor for? >> not at this point because i think the fbi is still investigating. >> i'm not surprised because they're still retaliation against whistleblowers. they would be no reason to prosecute the people who are perpetrating it. >> it does seem like the department of justice is looking the other way. because obviously the situation is investing to the administration. with that, mr. chairman, i yield back. >> thank you. mr. walz, your recognize. >> thank you, mr. chairman. i want to thank all of you for your work towards veterans. substandard care is unacceptable. i would like to go back, i have a long history with the oig's office. i know some of myself. i count in my unit heavily on the ig to provide another set of eyes to provide that unvarnished

view of what was going on. so let's be very clear what is being implied is the integrity of this office was influenced by the va. i'm going to ask very clear, did anyone at the the ask you to change the report to make it look better? >> no. >> is it normal standard operating procedure for multiple drafts of reports to be done? >> it is, especially a report of 170 pages with 24 recommendations. >> has there been a case before where your methodology has been questioned to the point where you called in front of congress to defend the methodology, not the results of the report? >> no. >> this is the first i'm? >> that's correct. >> it is your instant it is predicated on the interpretation of you are asked for the original draft? >> that's correct. >> okay. with that being said i want to be very clear. the report issued is very

damning to the va. >> it is. >> there are many things they fell down on and the department of justice and, making sure dr. foote and dr. mitchell and if and else, there has to be around, and added that people are made whole and people held accountable. from my understanding that is in the process, that the fbi and the department of justice are looking at, is that correct? >> the investigation is ongoing in phoenix and other places. we also in a very first recommendation in that report referred the names of the 45 veterans in our case reviews to the department for them to conduct appropriate reviews to determine if there was medical negligence, and if there are to be redress to the veteran or his family. >> does the va oig prosecute cases? >> we investigate cases. we take them to the prosecutors in doj or in some incidents in state court, if we can't get

traction in a federal violation. >> does this report and the way it was handled strike you, mr. griffin, and if i'm right, how long have you been with the oig? >> about 13 and a half years. >> how many investigations have you been a part of, roughly? >> well, we have done about 520 arrests every year for the last six years. that's the number that is handed to me. that's about an average. >> and the methodology, the folks who work for you, your investigators and how you wrote the report, is there anything different about this will in any of those previous ones you've done? >> this was a very large undertaking, and it was a combination of a criminal investigators who are the same job series as fbi agents, secret service agents, et cetera. but it was a joint project where doctor days people had ownership of the medical care in the case

reviews, linda halliday staff, the audit staff address the response but to try and identify all of these people who are not on an electronic way to list through a number of different sources ask of her staff did that. so to try and pull the three different disciplines together and get everybody on the same page as far as what makes sense, there might be some language that make sense today that might not make sense speed is i would argue to make sense to dr. foote and dr. mitchell, because there's still obviously the belief that we haven't gotten to the bottom of this, that we have gohavegot everything has been tr there's not been held accountability. with that being said, i want to use my remaining time that that will still be investigated. my concern right now is on those 24 recommendations. do you feel, are they moving in the proper direction? you that people come and testify before that va did not intimate

your recommendations and joy to come back again. do you feel at this point, i know it's early -- >> it is early. it's less than a month since the final report was issued, but i can tell you this. a lot of the way time issues were previously identified in our interim report, and a note that the department started addressing those immediately. in the updated report when identified an additional 1800 veterans that were not on a list that were in a drawer or which is not properly being managed, we immediately gave those 1800 names to the people in phoenix so they could make sure those veterans who have not gotten care got as quickly as possible. >> one final quick yes or no from each of you. this is subjective but you're at the heart of this matter and give a better insight than anyone. does if you like cultural changes are beginning to change the old accountability, in your opinion? >> i think the change will come as we complete more

investigations and people realize that there's a price to be paid. >> dr. foote, dr. mitchell? >> asking for my testimony to be made public, i would not agree with that statement and say no. >> i would say no. there's lots of investigations but there has been no substantive change. >> very good. i yield back. thank you, mr. chairman. >> thank you very much. ms. walorski. >> thank you, mr. chairman. dr. daigh, you had said earlier today i believe to chairman note that you did not exclusively examine all the medical records to determine if patient has led to delays in care. yet in the report your colleaguecolleagues released ite the igs the report in august completed that it could not assert that long wait times caused the death of these veterans. can you explain to me and families are watching today who have been going through this how can the va emphatically say to us that you can determine no

link between wait times and death if he didn't examine all the records? >> let me clarify. we examined 3409 records. to the chairman's point, we did not examine all the records of patients on the near list. it would be people who said they wanted care at va, if they never actually made it through the maze, got an appointment. so there was no record for me to review given the electronic medical record was the main source, then i could not review those. all of the cases that were able to review came from a whole variety, most of which have to do with waiting lists that we found that phoenix. so in those cases we did i think very thoroughly review those cases, and in those cases where we determined that there was

harm of delayed care cost harm, we published does. and in those cases where we found improper care, we publish those and we have 28 cases that we thought able on the waiting list and as a result of being on a waiting list they were harmed. we have an additional 17 cases where we thought the standard of care wasn't met. so we published does. i think that, i'm not trying to say people who couldn't get there, through frustration couldn't make it. i'm not trying to excuse anything at va. i'm only trying to answer a fact. on these people, on the cases we looked at, did we see a significant impact on their care because they were on a waiting list? that's what we do and that's what we published. i would further say that i don't believe that our review necessary needs to be determinative in the sense that

i put the scenarios out there, hoping that citizens would read these cases and would understand the complexities that these veterans present. and understand the difficulty that they have come understand the fragility of these cases. so that when they don't get care in a timely fashion, horrible things are likely to happen. and each person can read these cases and they can decide whether a person who might have unfortunately committed suicide, do they think that was related to time in this? a to make their own decision on that point. so i offered the opinion of my office, which has the ability to see lots of data that's not in these, intentionally. a lot of the data is unnecessary for the basic fact pattern. these families have a right to privacy so we tried to be very careful about what we decided to publish. to the issue that people would like more data about these cases, i understand it, but i

think, i think that the va needs to ensure that veterans have access to care, it's done properly, and in that way the va can deliver proper care. >> i'm just curious if you had a chance to go back and reinvestigate these cases in the procedure would you do it carefully did i? >> no. i wouldn't. i think the way we did it is the way we've done it for many years. i think it's very through. what i would wish we had, i wish we had not been tied to with this issue was time in this. i tried to bring him back to being on a waiting list with quality care. that's a totally made a standard based on the circumstances of the case but if i could pick something different to look at we would have fully come up with a different test but that's the test we're presented with and so that's what we have to address.

>> thank you. thank you, mr. chairman. i yield back. >> thank you very much. ms. brownley. >> thank you, mr. chairman. mr. griffin, do you know if there's a parallel fbi investigation going on? >> there is a joint investigation involving my people and the fbi spent investigating the same issues? asking the same question? >> they are doing it together. if there's an interview happening there's an fbi presence and an oig criminal investigator present. >> thank you. and mr. griffin, you in your answering to members question wind, related to the closing out of 12 cases until dashed and still nicer ongoing you mentioned something about they were closed out because they met the criteria and the questions were answered, but you talked about additional information

that was not necessarily related that you called together. can utah olympic about the additional information? is there something, can you give me some examples and is there something -- >> let me clarify that point for you. when we did some of our 93 investigations, the 12 that we have given to the department, we didn't do a phoenix level review of every one of those facilities. they would take 10 years. what we did look at is where we received allegations, either through our hotline or from any number of other sources, of a specific infraction going on there. in some instances with more specific language than others, okay. so we investigate those.

if the result doesn't rise to the level of the u.s. attorney's office to prove criminal prosecution, that investigative package within the scope of the review that was done is given to the department. it's incumbent upon the department, it's their job to review that information and say okay, maybe someone decided this doesn't rise to the level of criminal prosecution. however, we think disciplinary action which can range from counseling to firing needs to be taken in this case. so in order to prove that, which they will have to do, they will look at the piece of the investigation we did. they may determine that they need to go into give somebody else for whatever reason to support their administrative

mentioned but if that were to result in some new information that we were not aware of, it could cause us to reopen our investigation. but it's up to the department to take those administrative actions, and that's why when there's no criminal prosecution forthcoming on a specific case, we hand over our reports and transcripts, et cetera, to va and they can take administrative action based on those. >> so there's not additional information or a list of additional information that was uncovered that has not or -- >> not during our investigation. i'm just saying that in putting together their review for purposes of administrative action, if somehow they come up with some information that wasn't -- >> they being the department? >> the department, who have to proposed action, or removal or something, it could cause us to

say we're going to go back and look into this further. but that's just the way the process is spent a wonderful i think on ms. titus questioning and just ask him yet, very specifically if you believe that there are adequate resources to continue and to complete the ongoing investigations of the remaining sites. >> i think that some of those investigations are much more narrow scope and magnitude of the review we are doing in phoenix. we are progressing at the remaining 81. every week there's another handful that were able to bring to closure. so the answer is yes. we have the resources but i must say that this is not the only investigation that our people are involved with.

since january, the number of threat cases that come to us and va facilities, the number of assault cases, we have made 86 drug arrests since january 1. so some of these matters that are already in the prosecuted mode, i mean, we prosecute a medical center directly for 64 counts of corruption. and we certainly couldn't drop that case in order, you know, take on a new case when it's going through the judicial process. >> thank you, and i yield back. >> dr. daigh, there were 293 deaths come is that correct? >> they were 293 deaths that we reviewed, correct. >> how many of those were cross-referenced with medical documents? >> all of them. >> i think there were 28 that were on the new list. i'm trying, again, i'm annecy

trying to learn, mr. griffin, and you have educated at least me as the chairman today as on some things. dr. daigh, you said because there on your list they were not in the system so there was no medical record for you to review and junot able to do that so -- >> let me please clarify. a new list included a large number of cases. of the patients that we reviewed from the near list we would not be able to review a patient but in the have a medical record. so if you're on a near list, we don't have a record and exclude you from the review. so in our methodology section we can only look at cases that actually come to the va. >> and i understand, but how can you come and they keep going back to this, how can you say you conclusively were able to say, these individuals did not

get timely care? they are now dead. >> i'm talking about the cases that we're able to review. >> i understand that but there were cases that you just said that you can't review. that's all i'm trying to figure out is to our cases that were part of this investigation that you apparently couldn't review them because there was no medical record for you to look at. and so my question is again, of the 293 deaths, did everyone over them get cross-referenced with some type of medical record? >> the total number of people on the near list is a big number. the total -- >> i'm sorry, the 293 deaths -- >> but, just trying to be clear. 293 deaths were all among patients whatever list they were on, that had a medical record that needs to be reviewed. i'm going to agree with you.

it would be people who would be on a near list we did not have in medical record who we could not review and, therefore, they were not part of the chart because it's not possible for me to review them. so all of the deaths, 293 we reviewed, the 293 number is a data point. the 293 number is from the 3409 patients. 293 were dead but that number is a number that has -- it's drawn from the population that we don't know the burden of slick into whether 293 is too high or too low because the reason for death could be normal causes. >> i understand. i apologize but it still can't find that because in a staff briefing, staff was told that in some instances all that could be

done was a match of social security numbers, looking at a death list, and so there was no way for some of those individuals to be cross-referenced with a medical record. that is correct, isn't not speak what i think it would be a misunderstanding of what was said. i would not comment on patients who have been able to view the record for. >> but they were on the list, correct? >> again, in our methodology section we said we excluded. i will israel talking subtleties and i'm really trying to be sincere. i can report on cases that i have no information. >> and i concur and i think that's where the crossed wires are coming from because it's very hard for me to accept a statement in a document as we've been discussing if you have been able to look at every single medical record. and think approach for clarifying that. >> thank you, mr. chairman.

i appreciate that life question because i was also still am confused if you're able to identify 3409 veterans the number of cases be reviewed? >> yes, sir. >> your medical records for all those cases? >> yes, sir spent in pages 34 and on in the report you identified numerous other categories of veterans of the total well over 9000. either not on electronic waiting list on electronic waiting list or on the near list or 6-under printouts are scheduled appointments, backlog redistribution. how did you decide and 9121 is reduced to 3409? >> well, the report talks about, in phoenix there were many lists, and the report talks about lists from different sources and different points of time but if you're talking about cases that were part of, where

va's cleanup action, those cases were not part of, most of those cases -- >> excuse me. i do not believe in sin -- page 34 question to identify taken 9121 veterans. again they may not be cumulative the. my question is, how did you decide not to look at 5600 cases of veterans who decided not to review their case? >> well, we looked at those lives that were collected during the timeframe when we started our review, up until about june 1. and i would have to go through and work through the data set we have of the actually 3562 names

on the list, individuals, of which 293 died and of which 743 had a physician review them. so i will -- >> if you on electronic waiting list, did you look at them and review the cases? >> we did. everybody that we were able to determine was on any of these waiting list of any variety described in this report. >> i just give you another 5000 6-under that you put in the report. confronted why didn't look at, say, those on the near list at 3500 to two do not look at any on the near list? >> if you were on the near list and you as to get into the system but you never made it, then you never got care, you would not -- >> so if you died waiting for care because there's a very consistent, they don't show up as a death? >> that's correct. they would not have showed up. >> isn't that the crux of the

problem? thousands and thousands and thousands of veterans are waiting for care. your ports as we don't have to because they died before we got the record. with a clinical back and look at other sources. that's what kind of figure out because you wanted it down -- it's pretty unclear to me and pressed the rest of the committee, could you provide his mission to the committee as a follow-up of how you decided to exclude the 5600? that would be helpful as well. after one of question as well. mr. griffin, the day before you release your final report to congress the number and news outlets were, you can all the news stories, some of headlines said no proof that delay caused patient deaths. no links found between deaths and veteran care delays. do you think these are accurate or on the misleading headlines?

>> i have seen plenty of misleading headlines in the last two weeks. some of them speak the ones i read to you, mr. griffin? >> okay. >> are the misleading? >> the best part of the story here, if someone leaks something before the scheduled release date of a report, and if it quoted our report, it shouldn't have been leaked. but -- >> hasn't been leaked before? so that headline report, is that misleading? >> could you read it can against? >> absolutely. i'm sure you've seen it before. no deaths related to long waits, no deaths, is that misleading? >> that's an accurate representation of our conclusion, that we couldn't -- >> no deft? >> we couldn't assert a cause of death being associate with the waiting times. >> how about no link? >> those aren't my words.

>> i'm asking you for your thoughts on them. because you are very worried about 800 headlines. >> i'm not worried about anything. that's just the reality that you can get out of google to show the amount of coverage that was put on the statement of the report, there were no ifs, ands or buts about it. that doesn't take a lot of research to find that. >> thank you. i'm still not sure -- apparently those headlines are okay then. they are not misleading? >> i didn't say they were okay. i'm saying headlines are sensational to get people to read a story. >> i think it's sensational their 5600 veteran cases that apparently were not reviewed and that you have been the report. i look forward to the ditto nationwide decided not to review those cases because i fear there are more veterans that died. ideal back. >> i didn't say there was nothing to do if they didn't get in the door. he was reviewing medical records

and if they didn't get an appointment, they didn't have any records to review. >> when you said there was no causality and they failed to get in the door, and i because we didn't deliver care, i would say that was causality. >> we don't know how they died or why, nor do you. >> mr. o'rourke. >> thank you, mr. chairman. i will say that mr. griffin and dr. daigh, i think by the criteria that you have described to us that you're using to reach your conclusions, i understand where you're coming from. i think it is a rather narrow legalistic interpretation of data. i understand i think you made that very clear today. so i accept within those constraints what you have concluded. but common sense tells me just in case i've seen in my district that there is a cause and effect relationship between care that is delayed and in something care that is denied that ends up with veterans dying. i've used this example before

come with all due respect to the family, but they have share their story with me and i think it's more a purpose. nick d'amico been trying to get mental health care at the el paso vha was unable to for untreated ptsd. after not being able to attend one of my town halls, i also not been able to get in. he was driving home and his mom relayed the story to me that he was driving home that night with her and said, some of these guys are much older than i am and they been trying for years to get in and cannot. i don't know what i have to look forward to. and she cited that lack of hope as one of the main reasons that he then took his life i've days after that meeting. we know in this country 22 veterans a day sadly take the own lives. i've got to think there's a connection between delay, defer and ultimately denied care and he's very tragic instances of suicide.

i don't know if it meets the strict legal criteria that you are using, but it makes a lot of sense to me to draw that connection and a conclusion and i think that's what is pumping so many of us to try to improve the level of access and quality of care. i don't think you disagree with that. your conclusions here, you make some very bold statements and to talk about the breakdown of the ethics system within vha, which i take to be a comment on the largest issue that i separate a problem which is not funding and resources or number of doctors but it's the cultural aspect of vha. the lack of accountability, a premium placed on performance bonuses and not on excellence of care, not on responsibility, not a patient outcomes for the veterans that purportedly vha is there to serve. i look at your recommendations on page 74 of the report.

they were pretty narrow. i think good recommendations, all of them, but fairly narrow. are there other recommendations i may have missed that more fundamentally address the issue of culture within vha? i would like to know what those are and have the secretary has to i will ask him when he is here, how he's going to respond to those recommendations. >> mr. griffin. >> the original draft report had four or five recommendations speaking to ethics. they were very narrowly constructed, so their combined into one global ethics recommendation. the secretary previously was a chief ethics officer at p&d. he was the chief compliance officer at p&g. i suspect that we're going to see ethics place at a level where it should be.

we did not find that in over here in phoenix when there was a request for an ethical review, and not all of the recommendations were followed that were put forward by the person who submitted them. there was a reorganization at vha which removed the chief medical ethics officer from the inner circle of the highest tier of management in vha and was relegated to a lower level, which removed that person from a seat at the table with the most senior people are i suspect we'll see a change in that. and i think what had been ethics just from medical ethics perspective is something that will be expanded beyond vha to other areas in the department. >> and i haven't read every single page of this report and

i'm currently leading a. i need to do that, but what i haven't seen adequate to the ethics section, what i haven't seen its specific recommendations on account of the people losing their jobs. we for the most egregious instances of dereliction of duty, abuse, fraud and to those people are still on the job. i can't argue with anything you said about the incoming secretary. had a chance to be with you missed it and i'm looking forward to his leadership but i think we need to institutionalize these cultural changes. you asked a question for you about one of my colleagues, anything in that july compromise bill that you think would help change the situation i think the ability to fire senior executives, get the deadwood and the fraudulent actors out of the way quickly so that we can bring up those who are the best and brightest and how the outcome of the veterans first and foremost in mind is what we really need to do. and i am not seeing that still

throughout the system, including in the part of the system were i had the honor of serving veterans. i realize i'm out of time. i appreciate the chairman's intelligence. >> thank you. >> i'm going to approach this a little differently. dr. daigh and dr. foote and dr. mitchell know what i will be talking about. for those of you who don't know, when you're in training you present cases to staff and they critique your care of those cases. i had a chance to review many of these cases your entry to the conclusion, dr. daigh, but you did, that it had no effect on the outcome of those patients is outrageous. you would've lost both the lens and i was to try to convince the staff come on me when i was a staff member. i think the question i posed to you in one of these cases, if this were your family member, yours, just like case number 29

that have the congestive heart failure, this was your dad, and would you be happy with the explanation you just gave of his death? secondly would you accept that? i say no because you know if your dad had gotten his allergy testing and differently, the outcome may been very different. that's why we put these devices and. and prevent sudden cardiac death. secondly, case number seven, this one in the va got lucky on. a guy in his mid '60s comes in to see a doctor with chest pain and has nothing done for seven months? all you can say is, you got lucky. because he very well could have died of coronary disease, which he had a bypass operation but it was certainly nothing that needed to help prevent that. one of the reasons, and i can assure you that at most private facilities it is guided come in the emergency room like this, he would have had a cast hypertension mid-sixties and chest pain, you can't wave a

more red flags than that. what does this guy get? a control of blood pressure and sent them out. they are just really, really lucky. case 31, a man with an elevated psa. i have a little sensitivity. i've had one elevated before. it's a little worrisome. it looks to me like this that are just sort of got ignored for a while. would he have died and you can't say -- what i would like to do is to have these criteria or have this look or have this looked advocacy of medicine are some of the outside source to see if they draw the same conclusion. i surve sort of don't draw the e conclusions that you did. you're right, you can't absently say that this veteran, just missing disappointment or whatever, it's the culture that i see. you miss one opponent, that probably didn't cause your death. i got fat, but the culture, i just don't understand it.

you don't follow up. people drop through the cracks, ct scans we ordered. nobody gets a follow up on these. dr. foote, i'm going to stop because of going to use all my time. i want you to comment, you've been a director for 19 years. be a agree or disagree with i just said? >> absolutely. my point was before about how the ig summit county the case. let's talk about cases seven. what really happened in the case is quite different in have been waiting 12 months at the time for an appointment with the when he presented in january with having chest pains several times a week. and ekg was done and the ig referrerefer to that more valle. at o'malley, 12 12123 suggestiof a prior interior myocardial infarction, patient having chest pains. he was given an appointment in october from january. only because they spotted in june when they gave him an

appointment that they give them incentive. at that point he was having daily chest pain and denied -- >> unstable. >> absolutely. and echocardiogram showed that he had an injection 35%, 50 is normal and the interior wall abnormality. my analysis is he had a heart attack and the 12 months while he was waiting. he further extended that and fortunately, fortunately, we're able to get him urgently cast and bypassed. so he's a guy, saved his life the lost 30% of his heart function and the ig report refer to that as a favorable outcome. >> i guess if you don't do to a funeral it is a favorable outcome. i can tell you, that was not connected in my family, if it had been made or if they did anybody sitting at that dais you wouldn't have gotten a picture you got. i look at this one veteran at and evaluate not as a system or whatever, one veteran, and with this care pass muster we have to

get paid by medical anybody else. of course, it would not. i'm embarrassed by this. i read a lot of these cases but it was embarrassing. dr. mitchell, to what you? >> i would like to go in the record against the entire oig. when you have a patient whose unstable, psychiatrically who is verbalizing suicidal ideation like case number 39, if you discharge him home he will commit suicide and was something intervenes. in this case that they did and he committed suicide. case number 40, it was devastating psychiatric or unfavorably heider as an inpatient. the psychiatrist had the option to stop the discharge. if you discharge a psychiatrically unfavorable patient who has a history of hurting himself, a history of suicidal ideation, he will commit suicide. the only question that should be asked is when. this is national suicide prevention month. the va has a wonderful program

on the power of one come which means on one person, one can't k him one question could stop a suicide. this gentleman should have both the showmanship that the power of one, but one thing the department of the. this is inappropriate. and on behalf of every mental health provider in the united states, i will say that if you discharge and unstable psychiatric patient, verbalizing suicidal ideation, he will commit suicide unless something happens to intervene. >> thank the chairman to i yield back. >> ms. brown. >> thank you, mr. chairman. mr. griffin, in my 22 years on this committee i have never heard anything from the inspector general that would make me believe that the office of inspector general has worked with the va to stalled findings. nothing there. but i think it seems to me that people seem to think that

because i make an allegation, that that is a criminal offense, and, therefore, i should be fired without any due process. can you explain that to me? and i'm thinking about the 93 on board review cases. >> right. we received many, many allegations in the last 12 months we got 3400 allocations to outline. that's why we have investigators and auditors and doctors and other clinicians so when we get an allegation, if we have the resources available and it rises to the level where we feel compelled to take it, that's when we go out and do our reviews and either conclude yes, this allegation is correct or no, it isn't. but until such time as we've

accomplished that, and allegation is an allegation. >> it seems as if everybody seems to think that every veteran is eligible to participate in the va. and that is not accurate. i know that they former secretary opened it up to millions of additional veterans. can you explain that? in other words, everyone that was in the department of defense is not necessarily eligible to participate with the va. now, i know we have expanded that net, but to a large extent it was not. >> you know, doctor day served our country in the army. he was an army doctor for more than 20 years. he's well-versed on coverage that's available to retirees, in

addition to veterans. to let me ask him to speak to the options that are available. >> i'm not sure i can address it very factual except to say that your credit, not all veterans get equal care in the. generally enviably was sent to take care of those who are disabled in combat or otherwise. the inclusion result of all veterans who returned from the war has certainly expanded the eligibility. and then when category eight were allowed to join in with the people who are veterans but not financially disqualified from previous groups. and that has significant increase the number of people to come. but decades to get in and not to get in have been changed overall. that's bout all i know about tht right now. >> but we have expanded the area. which i applaud, but again expanding at a created

additional problems, processing them through the system. ibis we spoke to a veteran group and indicated that it was such a horrible experience. and i said what was the horrible experience? once you got it is your doctor, though, when i went to see my point, the person at the desk was on the phone and even stopped at a kidney. i understand we downgraded the intake persons so that veterans when they come in, not necessarily getting the right kind of experience that could've happened in any other offices if you don't have a person that is the first contact, not a person that, at a certain level for the intake. >> yes, ma'am. >> i guess i was asking a question as to how can we improve the system as far as

veterans feeling that the system, once that person gets in with the doctor everything was fine. but it's just getting that person into the system. >> a couple things. one is the systems by which you make appointments and you may consult, the communication systems which are actually quite complex between va. and in phoenix we found many patients who travel to phoenix part-time, they had a very difficult time getting in. they were sort of walked out of the primary care group that was set up an access was diminish. i think it to look at what you mean by access to care. you have to implement the system to make it work. mostly computer systems. then i think you also have to incentivize people who works in va to have a customer focused, friendly, polite, how can i help you, i can't help you too much attitude. i think all those issues are part of what i believe the

current secretary understands and what i believe he will try to work on. >> thank you. i yield back the balance of my time. >> mr. jolly, you're recognized. >> thank you, mr. chairman. mr. griffin, i have questions, and dr. daigh, about the analytical model behind your statements but then it goes to what others have said. it matters not to me if the eight influences this report. i take your word. the ig office is in my district. so believe it or not i hear constituent concerns, complaints and couplets about the ig in the way of the members don't. what i know is words matter. and so your statement that you cannot conclusively assert that the lack of timely care caused the death of veterans. certainly is an accurate statement based on your analytical model. can you also conclusively assert that we do lists did not

contribute -- waitlisted that continue to the death of veteran? >> no. >> and did you say that in the report? is that reflected? >> no. >> why not? >> what i hope -- >> this is an important -- >> this is why not. we put in here the stories of all these people who we thought did not get proper care, and it was my assumption that by reading these stories you could understand where the weights were and you could of to arrive at your own conclusion. >> you made a very powerful statement based on analytical model that is not reflected on the other side of the question. the reason it matters is because for six months we have been investigating the death of veterans. and i.t. words matter. franklin more than any political appointee. we challenge political appointee worked all the time and a lot of times they are wrong and

misleading. respect the ig not to be. so the statement you made it you cannot conclusively assert that led to deaths is a substantive statement that addresses work done in six months. ..