how long will it take to actually fill these positions and what happens to that soldier who calls as has been happening with jacojacob mann and others. it's a great example of the community coming forward and addressing needs not currently being met and in the end simply hires more staff will not cure all the issues, but it will certainly take a combination of changes, developing better performance methods and i concur

with you that the individual people that are there, are doing oweman's work. $5.5 million should go a long way to address those issues. i'm going up stairs and then i'll be right back down. then i look forward to everybody's testimony, thank you. >> at this time i would like to introduce the first panel. representing the va is mr. bill schoenhard, he is accompanied did antoinette seiss and dr. mary schoene. from the office of inspector general, we have dr. david day, assistant inspector general for health care inspections, accompanied by dr. michael shepherd, senior position in the ig's air force of health care inspections. also from the office of

inspector general, we have ms. linda halladahalladay. and next we will hear from nick torintino, he is a navy veteran of the iraq war and a former mental health administrator in the va and then welt will hear from retired united states marine corps major general thopgs jones. >> we have a lot of answers we need from you, so please begin. >> thank you. chairman murray. we appreciate the opportunity today to address the access to quality of mental health care services to our nation's veterans. and we appreciate so much discussion of a topic that is integral to the well-being and full living out of a fulfilled life of our nation's veterans.

mental health is integral to the overall well-being and physical health of a veteran. it's important that if there's underlying depression, problem drinking, substance abuse or other mental ailment that this be diagnosed to ensure that those who have served our country have the fundamental -- physical health aspects of medication management, staying employed and the rest which is so important to the quality of life of a veteran who has served this country. it is the sacred mission of va that this very integral part of our care is well delivered. i appreciate so much regarding your comments of the 25,000

providers who work so hard every day to treat our nation's veterans in this important mission. in the statement, i have outlined three areas of improvement and concern, but i would like to make first mention that we appreciate so much your leadership, the committee's review, and the inspector general's review. this is an important aspect of care and we appreciate all of the assistance and we will be working very closely with the inspector general as we go forward with their report as it relates to the first recommendation that i would like to address and that is if we agree with the inspector general that our appointment measurement testimony should be revised to include a combination of measures that better capture the overall efforts throughout a course of treatment for a veteran, while maintaining flexibility to accommodate a

veteran's unique condition and phase of treatment. we must also continue our efforts to strengthen mental health integration into our primary care, in order to ensure in the primary care settings that we are assessing mental health needs of our nation's veterans and also be able to address the stigma that's often associated with this that can be discussed in a primary care setting. second point i would like to make as announced by secretary shinseke said last week, we are increasing staff to increase both the access of menl health care, by hiring 1,900 additional staff, more than 1,600 are actual clinicians. we have 25,000 mental health employees in our system.

and it's also a design to increase our staffing of our crisis line, which is so integral to the identification and treatment of people who are in crisis, as ranking member brown spoke of so eloquently. and it's also an important aspect of increase in that we will be adding additional examiners for compensation and pension examinations. that's an important transition from active duty to veteran's status for those who are currently on active duty and for those who present with new conditions, we have a solemn responsibility to ensure that we increase our staff to ensure that we can handle this volume in a timely fashion and that we can do this in a way that doesn't erode our capacity to serve our existing patients. i want to emphasize, that this

additional staffing will be continued to be evaluating the assessed data and refine the staffing model. we are currently piloting this in three divisions and this is a work in progress that will be continually improved as part of our comprehensive approach to children our facilities have the resources to ensure that we accomplish this mission. and veterans have access to the most effective methods for ptsd and other mental health ailments, we are making more of it widespread and improving our training for those who are receiving care and delivering care of evidence-based treatments. we're shifting from a more traditional approach to one with newer treatments and we acknowledge that we have not

always communicated these changes as clearly as we might to our nation's veterans. so we're rebubbling our efforts to improve communication, not only to our providers, but to your veterans, to ensure that these evidence-based therapies are implemented in a way that can be supported by the veteran and fully educated and trained personnel to ensure that is delivered. in summary, we thank you again for your encouragement, for your support. this is an important part of care that is fundamental to the well-being of our nation's veterans. we look forward to answering your questions and those of the committee. >> thank you very much. ms. halladay? do you want to testify? >> madam chairman, members of the committee--thank you for

mental health occasion services. we conducted the review at the request of the committee, the va secretary and the house veterans' affairs committee. today i will discuss our efforts to determine how accurately the vha determines wait times in va facilities. dr. day, the assistant inspector general will address whether the wait times data va collects is an accurate depiction of the veteran's abilities to access those services. we are accompanied today by dr. michael shepherd, a senior physician in the office of health care inspections and mr. larry rinkermeyer. our review found that inaccuracies in data and inconsistent scheduling practices -- needed to fully assess current capacity, resource distribution and productivity across the va

system. if va's fiscal year 2011 in the performance accountability report, vha reported 95% of veterans received -- we concluded that that 14-day reported measure has no real value as an access to care measure. because the ig measured how long it took to conduct the evaluation, not how long the patient to receive that evaluation. we calculated the days between the first contact of the veteran for mental health and the completion of their treatment. we see that the va only complete 54% within 14 days, of either the veteran's request, on average it took vha 60 days to

provide the full evaluation. once the vha -- schedules the patient for an appointment to begin tree. in fiscal year 2011, we determined that vha completed approximately 168,000 or 54% new patient appointments for treatment within 14 days of their desired date. that's approximately 94,000 or 36%. vha data showed that 95% received timely care. we also projected that vha completed approximately $8.8 million or 88% for follow-up for treatment in 14 days nachlt's approximately 1.2 million or 12% of the appointments nationwide exceeded 14 days, in contrast,

va reported 98% received timely care for treatment. we based our analysis on the dates documented in vha's medical records. however we have concerns regarding the integrity of the data information because providers told us they used the desired date of care based on their schedule availability. i want to point out that we reported concerns with vha's calculated wait time data in our audits of outpatient scheduling procedures in 2005, and outpatient wait times in 2007. during both audits, we found schedulers were entering an incorrect desire date. and our current practice -- for new patient appointments, the schedulers frequently stated they used the next vablg appointment slot as the desired date of appointment for new patients. this practice greatly distorts the actual waiting time for

appointments. to illustrate, vrksz arksz received approximately 211,000 new patients received their appoint onto on the -- vl ha,'s data would show a 0-day wait time. based on discussions with medical center staff and our review of the zeta, we contend it is not plausible to have that many appointments scheduled on the exact day of the patient's desire. offer the rest of my time to dr. day who will provide the overall oi zbrks conclusion. o'. >> ranking chairman, members of the committee, it's an honor to testify before you today. i, my staff in the -- daily basis deal with clinical square issues in va and we know that both the employees and the

leadership in va strive to provide the highest quality health care. in fact, with respect to quality metrics, i believe va leads the nation with respect to both the use of data and the pub case li of that data on the website. when it comes to matrix of care reports, those are flawed. a group will be put together to try to resolve the issue and get the access to care metrics in line. i plan to talk about some of the access to care metrics in the private sector, but i think what i would like to make are two different statements after hearing your opening statement. the first would be, i think the

va as a number of missions. they have a mission to provide health care. they have a mission to do research, they have a mission to training people who will work in the health care industry. they have a mission to be available in times of natural disasters. i think as individuals in those hospitals decide how they're going to spend their time, those missions are generally accepted as being equal. there's not a waiting that says the primary mission is the delivery of health care and we will address those assets first as professionals schedule their time or allocate their time. so i think when we have a crisis like we have, a prioritization of mission, again, stated clearly from top to bottom would allow individuals across the system to rethink how they're spending their time. the second issue i think that's important is to set a standard of productivity, i realize that

health care can't be numbers driven. i realize it's a personal interaction between a patient and a provider, but at the same time, there has to be some method to determine that you're getting enough work or productivity from the people that are working for you. and so i think although va has worked on these issues for a while, i think that there just has to be a clear measurable and in my view productivity standard that is easily relate bable to work done in the private sector by a similar provider. so that one can decide whether the money spent is actually being effectively used. i think the other issues that i brought forward are in terms of the kind of access to care standards we could use.

>> madam chairman, senator brown, members of the committee. as a combat veteran i'm honored to appear here today to discuss deep concerns of the the -- based on my experience as a va another minute straif officer as well as service on several va national work groups and a back ground in quality management that led to an mba degree. failure to provide immediate care ultimately led to my -- let me also acknowledge that va's recent announcements to add mental health workers to its

workforce are problems you have had to uncover. but additional staff alone will not remedy the systemic problems in the va management of health care. i do not wish to discredit the va or its mental health staff, they work diligently to help veterans, but for all it strives to do, the va's mental health system is deeply flawed. the system is too open to putting medical performance goals ahead of health care needs. it is too susceptible to gaming practices to make the facility look good. these systemic problems compromise the work of a dedicated mental health staff and fail our veterans. like many va medical centers, the overriding objective at our facility was to immediate our numbers. meaning to meet our performance measures, the goal was to see as many veterans as possible, but

not necessarily to provide them the best health care. it creates incentive to find loopholes that will allow the center to meet it's goals without offering the services. many factors including under staffing make it very difficult to meet performance requirements, but administrators don't feel they can acknowledge that. instead as soon as new performance management books were published, va nlgt began to -- even with colleagues of mine across the country to find loopholes to gain requirements that couldn't be met. while i detailed multiple examples in my full statement. i would like to share two of them now. several performance measurings main date that mental health be seen during first -- demand for health care was great and staff

limited. we got the order, focus only on the veterans' immediate problem, treat it quickly in that appointment, usually with medication and don't ask further questions about needs, because, and i quote, we don't want to know or we'll have to treat it. another directive requires that a patient who's actively at risk for suicide or at high risk for suicide, should be seen at least once a week for four weeks. this is to ensure that the veteran is getting the health care needed to decrease the -- instead of providing these high risk patients individual therapy, manchester created a group for them, a group that was clinically inappropriate and veterans who refused to join the group were often labelled resistant to treatment. the idea that group therapy be

substituted for menl health. the mental health committee promoted this idea as a so-called best practice. even though it was not clinical practice, it was a good way to meet performance measures, i i believe most va center -- va lacks a methodology to know what health -- in a misguided attempt to justify more mental health staff at manchester, the head of our mental health service stated that the priority be quantity rather than quality. chief said and i quote, have contact with as many veterans as we can, even if we weren't able to help them. the outcome was that the facility continued to enroll a growing number of veterans, far more than our health clinicians could handle and as a result

veterans fell through the cracks. every year at the -- office survey to assess facility compliance with the va's main date to provide high quality services. many of our answers were changed to say that required services were being provided when they in fact weren't. during my years at manchester, other members of the mental health staff and i repeatedly raised concerns with both facility and network leadership regarding practices we believe were unethical or violated va policy. those concerns largely fell on deaf ears. our staff also repeatedly brought concerns to our ethics kbhe, but they -- for me the final straw was the medical center's failure to take meaningful action upon discovery that a mental health physician was visibly intoxicated while

providing mental health care to a vetd tran. i very much hope the va will make real changes to address the systemic problems i describe. i believe there are steps the va can take beyond adding staff. i humbly offer these suggestions. first the va should stop monetarily rewarding -- they're not real measure -- the va should institute a much more extensive oversight as to exactly how the -- the funds actually go to the programs they are intended to supplement. finally i would urge this committee to implement and develop a very long overdue and periodically supported staff and health methodology. so there's no need to guess whether 1,900 more staff will be

enough. i am happy to share my -- i would be very pleased to answer any questions you may have. thank you. >> thank you very much. major general jones. [ inaudible ] >> can you hear me now? >> move the mike up to you. >> i'm thomas jones, i don't have any expertise in menl health, but i have a lot of experience dealing with those who have mental health issues. i have been visiting walter reed and bethesda every week since the start of the war in afghanistan in 2001. i have met thousands of folks. i have been privileged to be on

the board of a special fund bring wives run by wives to deal with the families of the wounded. i also started, semper fi -- it started as a normal transition course, bethesda was grievously wounded over several times the next several years. and in ---rj naturally started i -- patently obvious after a while that the mental health issues were really such that we got into the whole issue of z l dealing with mental health. because of my background, i was able to bring a lot of folks in from the outside, i noticed navy psychiatrist dr. bill nash, he was so moved by the experience that he had me be involved in a number of gathering of mental

health professionals. from that i'm able to, becau st project looking at best practices on mental health. what we have done, we have run 30 sessions now, week-long sessions. chiefly used facilities, what we have done is build on a volunteer strategy, with team leaders and almost all the people involved are in voluntary category, what has transpired is this whole issue of trust, cohesion and bonding which works in the military, work when you're dealing with veterans. 30 sessions, 35 or so on average attend each time, just had one last week. so we have dealt with over 1,000 not only veterans, but those soon to be discharged from the military.

we work in con tsang -- so it gives us an index of what problems we're having in the military and precisely what we're having in the veteran community. and what we have found is that many if not most of the people who are undergoing clinics's care have not divulged even the source of the stressor that's creating the problem. i don't think the numbers of additional mental health coordinators is soleably going to solve the problem, i think that the mental health coordinator has to have a better understanding of what the demands are of an individual awarded. one thing that we have learnedthrough our experience, which -- get a better per executive of what these individuals are facing through interaction with them so. i would encourage other folks

here, even my panel members if they're so inclined to be involved. because i think the insights and the site picture it provides you is absolutely illuminating. what we have learned, i call them seeing outcoming. we can see the same things you get in a normal transition course, or we're getting break throughs where people are coming forward and talking about demons that they had never talked about befo before. we built a trust that is lasting, not just in the sense of a transition course, but a network that will follow them after they leave the experience. most importantly what we have learned is the fact that a large percentage and a growing percentage of folks are having mental health issues. and i would say, this is my opinion, but i think it's a pretty well founded opinion, that the numbers are going to be growing in the future. and i would think that we need experiences where folks that do deal with the setting of a

clinician have a better understanding of what the issues are that they're dealing with. i'm very honored to be here, i thank you very much, i will answer any questions and i would certainly encourage any staff members of your staff to visit. >> mr. schoenehart, first let me say that i'm very happy to say that the va is finally acknowledging there's a problem. when the department is saying there's near perfect compliance, but every other indication is there are major problems, i think it is an incredible failure of leadership that no one was looking into this, in fact when you sit at that table before this committee, we expect you to take seriously the issues that are raised here. it should not take multiple hearings and surveys and letters and ultimately an ig investigation to get you to act. i also would like to