times are not tracked for non-va care. why don't you track wait times for non-va care? >> historically, sir, we have not, congressman, we have two initiatives, both in full deployment at this point. the first one is for non-va care coordination. effectively, what is occurring now is when we refer a veteran to care in the community, if we could not proprietary, it creates an appointment inside a clinic. it allows us to monitor that and watch that appointment. we are now collecting time lead datas on that. we have a nation wide contract called patient centered care in the community. >> that contract has a performance requirement from our two contractors that they both schedule and see veterans within 30 days of the referral from us. we think those two approaches will help us in the long run insure coordination and management of non-va care. dr. draper also alluded the requirement to manage the coordination of that care. it's not enough just to refer care into the community. we do need to follow through as

well to insure the veterans' needs are met, that that non-va provider is respectfully working with a veteran, her or his family, to get into care. >> thank you. the gao also reports that there is a consistent problem across vha with policy and procedures for handling no-shows and cancelled appointments. i'm aware that va, that you are working on an update to this scheduling policy. when do you anticipate this revision, revised po ills to be released and we'll address the no-show consistently throughout the va system and cancelled appointment sngs. >> i expect it will, sir. we had a team last week reviewing the existing policy we have today and to determine whether or not we should rescind that policy and replace it with a clear, declaretive set of instructions for our schedulers in the front line. we expect to take that action. we will replace that policy with

a revised policy. >> that allows us to have much more concrete sets of instruction on how to schedule, specific instructions for what to do, for staff, if we're scheduling within 90 day what to do on day 91, to actually offer that specific instruction and tie that policy to training. a lot of our current policy mixes two concepts, scheduling and practice management. we're going to have to make sure that we have a clear scheduling policy and a clear practice management policy. manage:of no-shows can be handled by contacting veterans, working with veterans, to insure that they're reminded of their appointment, frankly. making sure we talk to veterans and their families when we schedule their appointment. when we do those things, we can reduce our no-shows. >> great. can you explain to what extent exercising non-va care requires additional approvals? >> yes, sir. in some of our medical center,

they require approval at the chief of staff level to use non-va medical care. as part of accelerating care, we worked on that in the i think the second to the last week of may. we worked on the plan may 21st, rolled it out may 22nd and began excukes on the 23rd of may. we have released instructions to the field, that particularly where we have confidence in our wait time data, that the field is required, if they can not offer that care in a va, in a va facility, first they must assess their capacity, increase their capacity, by running fight time clinic, overtime, weekends and if they cannot, then they are instructed to offer non-va care to the veteran. then we've asked them to tell us, what do you need in terms of resources to make that work? so we are providing a different set of instructions. to work with a veteran, it is a veteran's choice to get timely care and to make sure we offer it. >> thank you very much, mr.

chairman. >> thank you, mr. chairman, i appreciate the work you are doing on this issue. one of the areas that is going to have to get further review is in colorado springs, colorado. and there are three anonymous whistle blowers who have come forward and said that there are problems with manipulateing waiting times. ened and i've talked to the leadership in both denver and colorado springs. that i have told me personally that this is not going on and i believe them, but at the same, we have whistleblowers saying that it is going on. mr. matkovsky, how does the va treat whistle blowers? and what i'm getting at, if there is intimidation taking place, how do we change the culture from intimidation to where people are free to step forward? >> part of how we design this

audit was to have direct access to the front line from our senior staff. when our audit tores went to the field, they met at the same time with the union representation at the field and the facility management. not two separate meeting, one meeting. we did not provide advanced announce:of who we wanted to interview. we provided that when we showed up, so we could have a direct conversation. i will tell you, i have read through the open-ended comments of all of the responses that i could and nothing, nothing saddened me more than an employee who seize i was trying to do it right. i know it is right. and i received instruction to do it wrong. >> that is just simply not tolerable. retaliation against whistle blowers is also not tolerable. we can not condone that. we required a leadership and cultural shift in our way of managing. >> and i raised this a couple of

weeks ago in our last late night hearing, and that is, if you can't rely on the data, if you can't rely on the records because secret waiting lists by their nature are manet to conceal the truth from someone who is doing a review, leak yourselves. does the alternative to go in and do a case-by-case analysis, talking to every single veteran who tried to get an appointment and doing this on a one-by-one, even if that takes hundreds or thousands of contacts? how do we get to the bottom of it when the records or the reports are not reliable? >> i believe we have to begin with the end in mind. if what we want to do is to provide veterans with timely, quality health care, let's ask them. how are we doing? how is our care? how is our access? is our access meeting your requirements? is it not?

if not, let's fix it. the thing that's terrible about the crisis is this isn't even an output measure. right. it's an activity measure. what happens when we change that activity measure is we can't tell where we're not timely. we can't tell -- in no case we're finding front line staff delaying care by moving the appointment later in the calendar, they were changing the reference point. when that happens, we don't know where we're late. when we don't know where we're late, we can't identify resources or to re-align resource, when we don't know that, our entire system for requesting resources is thrown off. >> mr. matkovsky i hope we seen the final days and never again bonuses or promotions are based on metrics that can be manipulated, set the of like you mentioned and i have mentioned this before and others have also, outcomes, like patient

satisfaction or good care that can be documented. not metrics that can be manipulated. >> i concur. >> and do either of you other two folks want to comment on that issue? >> mr. griffin? >> i think it comes down to account anteof the senior leadership out at these facilities. and once someone loses his job or gets criminally charged for doing this, it will no longer be a game and that will be the shot heard around the system. >> thank you. >> mr. brown, you are recognized for five minutes. >> thank you, mr. chairman. mr. chairman, thank you for having this hearing and colleagues, i want to make sure that we are firing at the right target here tonight. we are all on this committee because we care about the

veterans and you can be sure the only reason i'm on this committee is i care about the veterans and i have been on this committee for 22 years. and so i have a couple of questions. dr. draper, you mentioned and i want to thank you for your service. be you the case that you gave about outsourcing that particular case and it wasn't the right kind of coordination, can you expound on that a little bit more? because a lot of people want to see us partner with vetted rans if they can't get the service right away? >> i think it's an important point because, you know, there is a lot of talk of sending more veterans out to the community for care. and while that is a way to expand capacity, as i mentioned, there are some pitfalls because va does need to do a better job of monitoring wait times, managing the coordination and just making sure that the veteran actually receives the care that they're going out to the community for and that was why we illustrated this

particular case because this was, you know, many points, this, you know that, did not happen and and the veteran waited a long time and ultimately died waiting for care. >> i have a question about the survey. because lot of veterans tell me and a lot of discussions, once they get into the system, they think the system is the best. no complaints about once they get in. can you, both of you, can you expound on that? and a lot of the specialties involved in the va is not necessarily out in the community. i mean, we're the cutting edge as far as different kind of technology, wokking with their unique element. >> i would say in my experience and in reviewing various va facilities, i think there is variation among facilities. there are some that are very good and some that are more problematic. so i think it's not consistent across all va facilities, the

quality of care. >> congress woman brown, i think we have a good system it is not as good as it can be. we are a system that is designed to understand their needs, to work for them and on the front line, you find our staff are so engaged, i think their passion is unequal. >> what percentage of the staff of veterans work at the va? >> over one-third of our staff are veterans, ourselves. it's a matter of making sure however we have integrity in the system so we can identify where access is not working. it's not okay anymore with all due respect to say it's great care when you can get it. it must be that it is great care and you can get it. >> timely. i guess that's the key. mr. griffith, any comments about one of the problems, it seem is

that a lot of the equipment. the technology that the veterans have is outdated. the community system is in the different systems. could that affect part of the scheduling problems that we are identifying? >> absolutely. going back to 2005 on the audits that we have done, one of the recommendation has been that they needed to have an automated to review wait times remotely. a lot of millions of dollars have been wasted on contractors trying to create a better system for capturing this data and over the past 15 years going back to 2000, it hasn't had any december. >> if i may went, miss brown, it's important to understand our

scheduling system scheduled its first appointment inen '95. it has not changed in any appreciable management since that date. >> i like the technology. we like lots of technology, even people coming into the system, you know, we brought in the banking community to make sure people can't steal your identity. that's a part of the system, also, is that correct? >> it is. >> so we have some systems are involving and improving. we have a new veteran's health identification karld which has removed the social community number from the bar code and magnetic stripe. across the board, if you look at our eng fearing systems, facility management systems, our building systems, scheduling systems, administrative systems, these are old systems that in many cases date 20 and 30 years

ago, before the internet. i was still in college. you know, these are old systems. >> yes, sir. thank you all for your service. i'm looking forward to round tw two. >> thank you, mr. chairman, thank you for holding the hearing. i will have a question and i know i want to follow up on the question. this is for mr. matkovsky. the gao's testimony, it was stated there are no system wide vha policies on how to handle no-shows and cancellations. are you aware of a department wide policy for cancellations, mr. matkovsky? >> in our directive, we have policies for managing no-shows and cancellations. we also have a policy that is supposed to guide our staff only

how to manage veteran appointments and communicate with veterans to minimize the chance. >> well, describe that policy, i don't have a lot of time. >> for instance, if we have a veteran who has once not shown up for an appointment before or repeatedly, we have a no-show list that allows us to contact veteran, that is actually a part of our policy. we need to do a better job of training following up, insuring that that practice is performed. >> i agree with that. i hear about the wait times. i meet with veterans frequently. of course, the wait times, everybody knows about that missed appointment, for example, the veteran gets the appointment finally and maybe through no fault of their own, they can't maic the appointment maybe an illness or somebody forgot. they have to wait another two

months for example for an appointment. let me ask you this question, because that's a huge problem, is there any input? i hear about the lack of communication between, let's say, the schedulers. you can call over and over and over again, does the veteran have input on when that appointment might be? you know, for example, they could have a conflict, a family conflict, a medical conflict, what have you? >> can i answer that? >> yeah, because that was an issue with the case that you cited. >> it is. and part of the problem is and i want to elaborate a little bit more on the no-show, part of the issue is va needs the better understand why the no-shows and cancellations are happening. part of it is as we found our wait times worked, some schedulers, a pretty good percent is engaged in what is termed blind scheduling. they schedule without being in contact with the vetted rance. the veteran receives the appointment through the mail.

sometimes it may not be convenient or it could be the appointment, the letter was received after the appointment actually was scheduled and ten we also see sometimes the v contact information is bad to the veteran never received that appointment notice. so there is a lot of factors that go into the no-show and cancellation, but that is a part of one of the factors that also affects. have you ever asked the question of the ved ran, how would he or she prefer to get this information the regard to appointments? >> we need to improve the ways the veterans can see their appointment, manage their appointments and, frankly, ask for appointments. we need to make that an integral part of our online system for my healthy vet. with we have a patient scheduling application, we are trying to roll into a state of production. frankly, it starts with the phones, pick up the phone, call

repeatedly, talk to a veteran and find out their preference and then schedule. >> thank you. again, the my healthy vets, it's a great thing to have. again, that should be in addition to the personal contact and, of course, a lot, some people don't have access to a computer, either. so let me ask you one more question. i know i don't have a lot of time. again, with regard to the wait list, in the hearing, this committee held on may 28, 2014, members of this committee repeatedly, i know i asked, who authorized the destruction of the interim electronic wait list? however, dr. lynch maintained that it was protocol for when the appointments were cancelled. if there is no department-wide process for no-shows or cancellation. now, you stated there is, but what was he referring to?

>> i don't know, specifically. i have not been on the ground in phoenix, myself. i do know one of the things they were working on was to try to move appointments sooner him what they may have been doing, which he referenced in his commenting wag printing, rescheduling and shreding the evidence because it contains personally identifiable information. i think that's what he referenced, sir. >> all right. i will continue to answer the questions. >> thank you very much. >> thank you, mr. chairman. for mr. given or mr. matkovsky, if your investigations in audits, did you identify any sort of pattern when looking at wait times and scheduling practices and what i mean by this, are there some times of facilities better or worse tan otherss, are wait times longer for certain types of care?

>> primary care over specialty care, for instance? >> i would say one of the principle methodologies that we have witnessed is a veteran calling in for an appointment, he gets an appointment, 1420 days out. because that's the first available appointment at that facility. and then that appointment gets scored as the desired date of the veteran and, therefore, zero waiting days. the vast majority of the cases that we have seen involve that scenario. the other scenario would be you get that appointment 120 days out, two weeks before the appointment, it gets re-created, veterans know wiser, because it's recreated for the same time

and date. once again, it reflects a waiting time, which does not reflect the reality of the amount of time that veteran has been waiting for care. >> those are similar to what we found as well. i would say if terms of the wait time data for new veterans, we tend to be able to trust that data better because it has a computer date stamp in it. it's not perfect, but it's better. we do find specialty care has longer waits among those veterans and then we also note wait times and primary care. >> that was a very clear illustration of some of the pattern. can you tell me, so in phoenix there is both wait times of this nature for eboth primary and specialty care? i saw the primary care numbers. >> we did see a significant count for primary care. there are a number on the wait list prat waiting for appointments.

what will typically happen is you will then see a 16t demand for specialty care. so as we're bringing in resources for primary care, we are also very knowingny zant of the fact that you are going to require the address specialty care in phoenix, sir. >> well, in my question, i don't want to excuse it all t. manipulation of wait times. that itself not the point of my questioning. but i want to ask you if from your data and your audits are able to comment on whether there is an underlying shortage of providers, you mentioned a scarcity of appointment slots, how many of those are attributable to a shortage of provider, how much is attributable to maybe inefficiencies in the way the facilities operate? >> i think we have to check them both. i this think in some cases we have provider shortages. i think frankly we owe it to american taxpayers to run efficient systems as well. we have to look at productive data and in clinic serving

veterans. but i think it's both. >> if i may, i think an integrated health system is the beth system for veterans who have multiple conditions that they need care for. the further you dilute the locations where care is provided, the better chance not getting reflected back in the medical record. the greater chance that particular provider for that one instance may or may not be fully aware of all the other conditions that the veteran is facing. so i think what it's about is the business process of return on investment for getting your own doctors who are committed to the va mission who are full time employees at va as opposed to the 4.8 billion.

there needs to be an assessed outcome for veterans. it is something that has to be continual because you will have a different mix of conditions from one facility to the next. >> along those lines of the integrated care connection, is there a pattern in your research to the quality of care related to whether or not a va facility is affiliated with a university hospital? >> oh, yoevenlgs i think our affiliate hospitals tend to be the more complex hospitals. we'll have a more complex set of service available to veterans. we have some of our highly rural unaffiliated hospitals wind out being top performers in industry rankings. >> thank you, mike, time is up. >> thank you very much. . >> thank you, mr. chairman. last week during the recess, i had an opportunity to do

something very personal to me. as a vietnam veteran, i when to the vietnam. we talked to the folks there that were looking for our 1,200 mias. and, quite frankly, i think we owe it to the honor of those who didn't return but-to-provide for those who did and we are not doing a very good job of that right now. one of the things i think the problem with the va system is, is that the financial incentives are lined up to not provide the care. let me give you an example. in no-show, for instance, when that's a problem with a consult, in our office and we had patients who were supposed to manage the consult, not a regularly scheduled patient, we had ways to check for those folks, if they didn't take up, they took a slot. we couldn't fill somebody else, that's just free time and i'll give you an example, i'm looking here at the, at a medical center

that saw 68,796 patients. our pla of ten doctors saw 40,000 patient visits in a year. so i think part of it is, a mr. presidentkovsky, you said it's productive. it's the incentives to make sure when you have a consult, you consult as he just said, i don't just put a patient on my list when i'm seeing a patient in my office and say, show up. i find that it's inconvenient with you, the baby-sitter. maybe my wife is sick. there are lots of reasons and you can call -- there is a thing called a telephone. you can pick up and calm somebody and mr. jones, are you going to be able to keep your appointment next week at 140:00? it doesn't require computers. it requires human beings and a personal touch. i can tell you, they present it. the patients appreciate it. they will keep their appointments. in september. i may forget about it. then i have ten other things to do. i think that's a part of the

problem. again, the finance him incentives and making them so far out and i guess the question dr. draper i had for you, did you all notice any particular kind of consult? because i think, you know, there are areas prince in cardiology you had enough, rheumatology and maybe neurology, those are very difficult positions to fill anywhere. did you notice a difference in the type of consult? >> we looked at three specialty areas, gas ro interology, physical therapy and cardiology and we heard from the va medical center fish, particularly in the areas of physical therapy and gastroenterology, there was an increase the demand did not keep pace with the number of providers that they had. so, you know, the demand kept increasing, they didn't have the providers to take care of the patients or fill the slots. >> so it didn't matter. i thought it properly did. >> we didn't look at all the

specialty, those were the three we did look at. >> one question i had, mr. matkovsky, you are paid for prnlgs i asked this, when you are evaluated is your pay for performance related to how many veterans are sent out in the private sector along with the wait times? is that a part of it? no one can give me an answer. >> i don't believe it is, sir. >> that's fine, if it's not, it's not. >> and also, mr. griffin, you know for me personally, i know the chairman asked this question about the potential when you have put a system if place that fraudulently puts information out there and then you gain financially from the taxpayers, that would seem to me to be a fraudulent case. i look at it simply as a layman. if you misled on purpose knowing that you would get a financial

bonus if you did that, which is exactly what happened, that fraud? i think it is. >> i agree, the issue is, you start with the gs-45, gs-6 schedulers who have more at the leadership facility. so you have as to work your way back up the supervisorsry cane to determine who put that order out to do it in this manner that's what we're having to do at 69 other facilities other than phoenix with the additional facilities reporting in every day. so it's not an easy task. i suspect people do start getting charged. maybe that mid-level person will say, wait a minute, i'm not going to take a fall here for somebody hire up the food chain than me who directed that we do

this? >> i certainly don't want to see a scheduler, that's not right. i yield back. >> thank you. >> thank you, mr. chairman. and thank you again for your leadership on this committee. my first question so mr. matterkovsky i understand the acting secretary has sent a triage team to phoenix as you testified, which i wholeheartedly concur with, but after reviewing today's audit footballs and some of that data, it's clear that there are other medical centers across our country who are experiencing similar or even worse wait times. greater los angeles is a great example of that, so my question is really about a triage and

phoenix is good we need triage elsewhere. what's the plan? when are we going to get to that? >> we need two things, be i the way, thank you, congress woman brownly, but two things, first, we need to reset how we measure so that we know where we are performing well and where we are not with confidence. as part of the accelerateing care, we looked at wait times we could assess. we requested medical centers to survey their capacity. we've broikt down by clinic, by medical center. we used something called stop codes so cardiology would be a stop code. we have individual wait times for each of those. we were also able to produce each wait times for each of those clinics and ask if they had low productivity and wait times. there are a couple ways to do. that i think i mentioned them, run a few more clinics per week. run some evening, some weekends. and then if you could not find

capacity. few were at capacity, request the resources. if you don't have it and you need it, ask for it. part of our job as well is to make sure our staff at all levels can raise the flag so system wide, that is what we have done. i think we have at this point identified an additional requirement for $3400 million. the vast majority of it to support the acquisition of health care now. i think those funds are dropping tomorrow morning to the feel. >> so can you tell me as a follow-up how you are going to prioritize that? is there a schedule for that? >> yes. my veterans in ventura county the west l.a. facility is their primary medical facility, this data is as public as it should be. the first question my veteran community is going to be asking is when? >> tomorrow. and beginning on may 23rd, each

medical center was requested, directed, i'm sorry, to contact veterans after they could determine if we could have additional clinic capacity. if we could not have clinical capacity and we could acquire care in the community, one of the things we have to be careful about is there is not an infinite supply of primary specialty or mental health care in the unxhoochlt right. so if we can find the care, coordinate that care the next step is to peck up the phone. call and ask a veteran when they want to be seen. as of friday evening, i believe we made 50,000 phone calls in the facilities and networks across the country. we want to finish those and move onto the next set of phone calls, working back from wait times as we get closer and closer to what we think is timely care. >> that has already started and we will be tracking i think beginning this woke the rate of obligations of those fun. so we created specific account

could you describe for the funds. we'll be tracking the non-va care. >> that data you will be sharing with us? >> i will be sharing. you mentioned about my colleague here also mentioned about having enough personnel and professionals in the system as well to meet the needs. i know that the acting secretary also has ordered a hiring freeze across the va and so i want to know what that mean, because it seems to me we have to fix this airplane while it's flying and it seems to mean we should be looking for hiring practices and hiring as well as addressing some other issues that have been broken within the va. >> i think we need to look at the time it takes to hire staff, to recruit, hire on board and credential our staff. i think we have to look at that.

but the acting secretary's point here is not to restrict us from hiring staff in the field. it is to request at our network offices and at headquarters. we have a hiring freeze, the.is the to dedicate hr resources to hire through the field. at some point of time, we may when our hr staff is working, we can't be satisfied with having a vacancy and initiating the recruit. process and allow that to take six months. that means we are running at under capacity for six months in that specialty. we have to change it. we have to high ter bug, make sure we don't hire or have a conservative resource committee locally that prevents us from having the clinical resources we had when we set our fte requirement. the acting secretary is not telling us, do not hire in the field. what he is telling sus focus. >> thank you. i field back, mr. chairman.

>> thank you, mr. brownly, mr. flores, you are recognized five minutes. >> thank you, i thank witnesses for testifying today. mr. matkovsky, you referred to high performance facilities. is that correct? >> a high performing facility, yes. >> how many of those are in the vha system and roughly where are they? >> we found them in different ways, sir. we found facilities that have a good hand him on access, patient satisfaction, the acting secretary came back from his visit to san antonio and the passion, the mission the drive, the energy is palpable in some of our facilities. i will tell you that in some case, entire networks we did not find facilities that had integrity issues. in some network, we only had selected instance, both from an integrity perspective and a veteran focus perspective, we have high performers who get the process right schedule with

integrity, report with accuracy, find resoushss where you need them. we have a number of them. >> so we have these high performing facilities that have much better outcomes than the other facilities. what is it that makes it different? >> culture and leadership. >> it's the leadership of the facilities. i will move to dr. draper. in your reviews of the vha, did you find similar high performing facilities like mr. matkovsky referenced? >> as i mentioned, we see variation if facilities. i think there are only that are excellent. some that seem to struggle. i would agree, part is the leadership issue. >> mr. griffin, did you similarly find high performance facility force teams? >> if i could expand a little bit. we have done a couple of reviews of the vizi-networks and we concluded if you have seen one visit, you have seen one visit.

it seems like if have you high performing facilities, whether at the new yorker level or the medical center level, you need the export those best practices around the system. there have been issues in the past, where a problem has been identified and you send it out to the medical centers and in many instances, top leadership in vha sent out safety alerts and directives and what have you and they weren't followed. so you got an accountability issue there. you got an integrity issue there. but there ought to be a best model for similar size medical centers so that when a directive goes out, you know, okay, at this facility or at all the facilities the chief of staff owns this issue. or the chief of surgery or one individual, because some of our reports, like on reusable medical equipment not being properly sanitized after use,

there was no one person at every facility that had ownership of that issue. so you reap what you so yew. when there is no kency if ownership, the results are predictable. >> so do you concur with the other two observation, it's the leadership for those facilities that sets them apart from? >> i think it's leadership in the field. it's also leadership in headquarters. >> all right. mr. driven, the interim report cited the node to minimize coaching employees and how to respond to the oig questions. do you have any evidence that any of those activities took place, evidence, corruption, data manipulation or coaching employees? >> there is plenty of evidence of data manipulation. the question of destruction, we had a contact from the hill

staffer the first weekend in may reported that they had heard there were parties going on destroying douchlts at medical centers. we responded to 50 medical centers that weekend and didn't find any destruction is that we came upon in those unannounced visits. >> how about coaching ploy i don't see on how to respond to the questions you obtained? >> our team's questions are not similar to the questions that they were posed by the audit staff the vha sent out all of our interviews were taped interviews. people were put under oath. we asked them straight up, who told you to do this? some produced e-mails. some said we've always done it this way t. range of answers caused us to call it systemic

with our previous audits. >> one question, did you run across employees said they were willing to cooperate but they weren't because they were worried about reprisal? >> we had anecdotal reports of reprisal occurring around the system. >> thank you. >> microphone, miss titus. >> in may the va launched the accelerateing access to care initiative and this program is highlighted in your press release today. we've all talked about, we know that the goal of this is to help veterans who have been waiting for a long time get access to care in the private sector. now, i support these principles. i think that's a good idea. as you heard kind of referenced here, the u.s. is facing a significant shortage nationally, not just in the va but in the private sector. for example, in nevada, we have

a chronic shortage of doctors, both in primary care and among specialists. just the statistics. we are 46th in the nation for general and family practitioners. 50 for psychiatrists. first for general surgeons. so as a result, it's not only the veterans if las vegas who have these long wait times. everybody is affected. now there seems to be this big emphasis in getting in the private structure. that will solve the problems i wonder what you are going to do to make sure they receive care like in nevada where the issue of shortage and waiting times is not just limited to the va facilities but is out there in the community? >> unfortunately, congress woman, i do not have an easy answer for that. there are things that maybe we can explore on how we can attract clinical talent to las vegas that might help us as well.

i know we had at times talked about creating a medical school hub. one of the benefits we had in terms of having our affiliate partnerships is the ability to attract tam ent. roughly 70% of america's doctors have received some of their training from the va. one of the things that allows to us do is attract young talent that frankly falls in love with our mission and comes to work for us. so i think we do need help. we need broader help than just contracting or just va and we need to explore other solutions. i think las vegas is one of those areas. >> we have the university of nevada medical school. we have this big new hospital. what about the increase in residencys and some kind of partnership? >> absolutely. i think we need to look for that. yes, ma'am. >> one other question, is, if money were to become available now like we've herd about on the

senate side as to hire more doctors and to build more facility, are you ready for that? what are those priorities and ma metrics planning are you using to make those determinations? >> we have a significant, as i think this committee is aware, we have a significant construction requirement both to maintain our facilities, which i believe are roughly on average 60-years-old. there are land-locked facilities, as a matter of fact, in phoenix, we are talking luck talk las vegas. we have a list of priority, whether in the form of leases, in the form of minor constructions, or frankly major constructions and overhauls or just refurbishing our aging infrastructure and we clearly have an identified need for providers. over the next 30 day, however, we will take a much closer look at our current productivity and

where we find di manned and our inability to meet it. >> i know when the new hospital got opened in vegas the emergency room was determined to be too small, because the demand in the hospital was frankly less than anticipated. so i just want to be sure that as you look alt your priorities, you include in those plans some demographic calculations for growth and the need for service because once it's there, you build it and they will come. okay. i yield back. >> thank you, mr. chairman. mr. matkovsky, since the audit came from the va? >> yes, it is. >> i noticed in here that on the 14th of may, livermore, which is

in our contract area was audited. now, i sent a letter in over a month ago asking the va, requesting that each of our districts, would be given the information, whether that's a private briefing or whether we get private information. but i think every member of this committee has a right to know what's happening in their districts. is there a reason we don't have that information yet? >> the only reason is we were completeing phase one and phase two, in some of our small ccobs, there around at lot of staff. we wanted to preserve anonymity. we want to make sure we roll the data up to the parent facility, sir. i will be happy to organize briefings or similar mechanism. >> so there is no reason we shouldn't receive that information very, very soon? >> no, no reason.

the only concern i would have is in our small clings where there are a small number of folks who we interviewed, i want to preserve their anonymity. these were front line staff members. we made that promise to them when we did our interviews. >> you say in this report, some locations were flacked for further review and investigation, for instance, suspect 4d willful misconduct. where it's confirmed, appropriate actions will promptly be pursued, livermore vamc in california is on that list. >> that's correct. >> so at a certain point, i assume you are going back into that area for information? >> we are working on a plan this week to make sure we koorpd nate those reviews. we do not want to impede in the investigation, but we will. >> appropriate personnel actions will promptly be pursued, what type of personnel actions will be pursued?

>> commensurate with the nature of the problems we identify. >> firing? >> if required, yes. >> i just recently when to the palo alta, look local leaders throughout my district and i will tell you, we saw some very dedicated doctors. we saw some dedicated staff but we also saw some big glaring challenges they recognized were big challenges. we heard many times now the vista system is state of the art. dooingts sta do you think it's state of the art? >> i can speak from my do main, i am in the business applications and engineering. i can tell you for engineering, it is not state of the art. for our work order manage:biotechnician, it is for thelet state of the art. for our facilities management staff, it is not state of the art. for our housekeeping and environment am management staff,

it is not? what is the state of the art as? >> i believe that in the electronic health record as anything integrated health record that captures the documentation associate with the patient and enables the delivery of that care, it set the standard. some of these other domains, i think we need to look at the industry to find solutions. >> you are doing scheduling under that same system? >> i put scheduling square in front of that question. i think we need to look at the industry that knows how to deliver systems and acquire. >> so if all those areas are lacking, why is this not a bart of the va action plan? >> the scheduling package is a part of our action plan, sir. so one of the, the immediate things that we need to do, we are working with oimt. we plan to have an award before the end of this fis cam year for replacement scheduleing system. our intention is not to peck

someone who can write for us a book about this scheduleing system, rather to acquire a scheduling system and then deploy that scheduling system. >> and one final question, another thing i notice obviouslw this committee as well as the house feels about the firing process. we think we need to help you through that process and give you the tools to implement that type of discipline. one of the things i also saw was that the staffing system was flawed. if it's taking you three to six months to hire a doctor that is ready to be hired, you're going to lose him to the private industry every time. >> i'm not an hr professional but i agree. we need to work on our speed. >> i yield back. >> thank you, mr. denham. ms. kirkpatrick, you're recognized for five minutes. >> i'm encouraged you're looking to industry to help solve this problem. i sent a letter to the president last week recommending that be

done. we know there are organizations that do massive scheduling and they do it right and they do it well. and we want that to be available to our veterans. so thank you for that. my first question actually is to you, dr. draper. but i'd like the whole panel to address this if they could. i represent a very, very large rural district in arizona. they have four care facilities. and dr. draper, you said that there is not consistency among the various centers. i wonder if you could identify for our committee the top three reasons for that inconsistency, and what we can do to make sure this is the best health care delivery system available for our veterans. >> part of it is, as i talked about in my oral comments, ambiguous policies. i'll go back to the wait times, and -- not the wait times, the

canceling of appointments and no-show. the policy is very ambiguous. what you find is there's -- each facility develops their own policy. so we've seen anything from a 1-130 rule in one facility, one phone call, one letter. they give the veteran 30 days to respond or the consult is canceled. we've seen anything from two canceled appointments, and then it's canceled. these things play out. there's a lot of variation at the local level. the key point with the consults information is va is trying to put together a systemwide database of consults. if you have these local policies that vary, then what your data's going to reflect, it's going to reflect variations. so you're really not going to be april to compare apples to apples. we see similar things such as that. >> mr. makatsky?

>> we need to tie a handbook to the standard operating procedures that provide precise instruction, so there's not an interpretation. if we have a contact policy, this is how we do it. if you have a scheduling policy, you are to contact the veteran and work with them to schedule the appointment. we need to spell out the cob tact. there are two or three contacts followed up by a letter. we do need to do a better and spell it out in our policy so the rules are standardized. >> is there a structural problem in the administration at the veterans affairs office? i mean, it just appears that there's -- it's just all over the place. i'm wondering if there needs to be a total reorganization of the va system in terms of oversight, supervision, accountability and transparency. >> i think we just need to get back to our core of delivering safe quality health care to veterans that they expect and

that they have earned. start with that in mind. understand how we want to do that, define the practices in policy, promulgate that policy. don't allow us to have a separate policy that can interpret a different set of rules from a national policy. write a national policy, public it. >> i have a feeling the problem goes beyond that. maybe, mr. griffin, you can address it. you said the technology is outdated. it goes back to 1985. i guess i have to wonder, why? i mean, this committee wants to get this right. we've got to get to the bottom of this. but why are we still using 1985 technology? >>. >> is it a lack of funds? is it a procurement problem? >> i can come at it from a different angle. >> go ahead. >> your facility is only as good as the people working there. and basically, there are five qualities to every great team.

communication, upward and downward in communication. managers need to get out of their office and walk around the facility and find out what's going on there. second thing is collective responsibility. everybody on that team has ownership of the outcomes there. pride. be proud of helping our nation's veterans. be proud to go to work every day to help our nation's veterans. caring. of course, in a medical center, caring has got to be one of those qualities. and trust. if you have those five qualities, you're going to have a great team. i think that's what needs to be instilled in the personnel in all the facilities. >> thank you. i'm running out of time. but it sounds like, mr. chairman, that policy and personnel are two key issues in getting to the root of this problem. i yield back. >> if i can real quick, and i

apologize, mr. runnion, but i want to bring the committee up to speed because there's a very important question that needs to be answered, why are we still using outdated scheduling, software and programs? the va has requested and congress has funded i.t. enhancements to include a new scheduling system which has been dubbed a failure by gao. the scheduling replacement project was $127 million over nine years. and it was behindered by management weaknesses. then we had other issues, va scheduling replacement project which is what i just talked about. then there was a $249 million used for core fls. its follow-on was flight, $607 million. and then there's the vista fm

$2.4 billion in investments that this congress has made, and yet we sit here asking, what is the answer to the question, why are we still using outdated systems when we have given hundreds of millions of dollars to the va? mr. runyon, i apologize. you're recognized for five minutes. >> thank you, mr. chairman. i want to associate myself with the comments my colleague mr. denham made. two of the visions that my veterans visit, number 4 and number 3, three of the facilities, the philadelphia and wilmington facilities are all in the review category. i request the same information that mr. denham did.

i have a -- for purpose of, i think, why all this started, and these secret lists, so we say, as a simplistic question, is vista not capable of scheduling two years out? and if we didn't have the metrics that dr. lynch sat here numerous times a couple weeks ago and said these metrics are forcing us to play these games, is that a possibility? >> i think it is part of it. i think that they go hand in hand. but first of all, i think setting an unrealistic performance metric, tying rewards or incentives to -- again, this isn't even an outcome measure. this is an activity measure. times, rewards or incentives to the attainment of an activity was a mistake. not understanding the capacity

of our system when we set that was a mistake. there are reasons why we don't schedule two years in advance, quite frankly. just -- you don't want to hold up the entire set of appointment slots with appointments that are so far out that they might end up getting missed. there are technical reasons you wouldn't do that. for the most part this is a leadership and culture question. we have found in some of our networks where staff are using the same outmoded technology as the other staff, and scheduling with integrity. >> i bring that up, because i think you kind of touched on it there. there's a balance there. and what is it. and i think it's going to go to my next question. i think several people have brought it up. standardized procedures and policies from washington, i mean, you've seen it -- you know, the different visions, the wait time issues. it goes to this question that i

asked last time. and i, believe it or not, got a response this afternoon. there was -- i asked a question about an auditing feature that was turned off in the phoenix region there. and i got a response that it had been turned on nationally. could any of those audit features have been turned on, helped the ig in the process, or internally in that region for them to avoid these situations? >> sure. i think the one thing that i would clear up is that that audit -- the audit logging inside vista records who edited what, captures those edits, was never turned on anywhere. the concern was that it would affect system performance and create a huge data storage requirement. so it was never turned on. that is now turned on across the

board. that will help us see who edited what kind of appointment. for instance, the one comment was made, how you would cancel an appointment. we could see who did that, and if that occurred numerous times, we could marry that up and find that behavior, who edited what kind of field at what time helps. >> i just want to make this statement, because i'm sure, as chairman just said, there were millions of dollars spent for that feature in the initial outroll of that system. >> i would say the one thing we're going to do different with this acquisition is it's not just going to be a proposal. part of what we're going to expect folks to give us is working software that is proven to integrate with our system. not a book about how that software at some point in the future will integrate, but a working product. that's part of the proposal. >> thank you. mr. chairman, i yield back. >> thank you, mr. runyan.

>> thank you, mr. chairman, for holding this hearing. with the release of the department of the va axis audit and interim inspector general's report, it is clear there is a systemic failure of responsibilities. widespread misconduct and cover-ups that led to the deficiencies in scheduling, resulting in lengthy wait times and veterans dying waiting for care. the veterans in my district and across our nation deserve better. i demand that the new leadership of the va put an immediate and decisive end to this severe misconduct and hold those responsible accountable for their actions. which we have discussed today, a criminal investigation is needed to remove individuals who knowingly prevented veterans from obtaining the timely health care they needed and resulted in harm or death. a criminal investigation will put an end to this wrongdoing,

will change culture, and now, and for the future. currently there are over 1,500 veterans that utilize the loma linda health care system. many of which live in my district. they are either waiting over 90 days or going without an appointment altogether. it's time that the house pass the veterans access to care act to make it easier for veterans who are too far from a va or waiting too long for an appointment to seek care outside of the va system. as a physician, i will continue to work as a member of this committee to, one, stop the misconduct, and two, give the veterans the care when they need it. after reading the audit today, i had several questions. the first, what are the possible solutions to get veterans triaged and cared for immediately, or sooner than

anticipated? now, let me preface this. that there are other veterans with aneurysms perhaps that need care now. there are other veterans with suicidal ideation that need care now. there are other veterans that have cancer that are on the verge of spreading that need care now. we must hold the individuals accountable. yes, we do, and we will, but we need to give care now to our veterans. when i was in haiti, working in a disaster zone with the 82nd airborne, there were immediate stryker teams formed that would go out, educate the population of the -- do the research, educate the population of the health care available, form teams, go out there and treat the patients. what are we doing to treat our veterans now? >> on may 23rd, we asked all of our facilities, we provided them the productivity data that we

asked them to assess if they could get more productivity out. we also gave them their local wait data, computed nationally and distributed to the field. the inspection was clear. where you can find capacity now, over time, extra clinic slots, you name it, find it in the system. this system belongs to veterans. we have to make it efficient. that's the first order of business. the second order is if we cannot identify where we can acquire that care in the community, beginning may 23rd, contacts -- ohio completed all the contacts the following week. every veteran that was waiting they called. can we make it faster? yes. we also identified $300 million in requirements in the immediate term. >> now, if you rely on a broken

syst system, you're going to get broken results. so i encourage you to find a model, a benchmark, form a special operation unit that not only identifies physicians within the national va system, but also within the private sector to rapidly deploy to the priority health care systems, and create a form of health care event, a health fair, or triage, and get them seen sooner than relying on a broken system to fix itself. >> mr. ruiz, may i respond to your desire for criminal investigation? >> yes, sir, please. >> the 69 additional facilities that we have sent rapid response teams to are all criminal investigators. we coordinate with the fbi and all of our investigations. it's a requirement of the attorney general guidelines.

whenever we open an investigation, or the fbi opens an investigation, there's mutual notification, so that we're not wasting resources. but also, for safety and efficiency considerations, so you don't find yourself going to arrest the same person at the same time and have someone get hurt. but trust me, we have an excellent criminal investigator staff, and they're pursuing all leads in this manner. >> one additional item that i would make reference to. in the case of phoenix, was the use of the disaster and emergency medical staffing team, which we called demps. that is now being used in phoenix. we have a cell which is a whole number of clibitinicians, and a willing to move across the country at a moment's notice. i think starting on sunday, there were 21 such clinical staff on the ground in phoenix providing care. >> i look forward to working

with you to see if we can extrapolate that experience to other va systems, including los angeles and other areas like loma linda, where they might have very long wait times. that's causing harm to our patients. >> thank you, doctor. >> thank you, mr. chairman. mr. matkovsky, i feel sorry for you today. because you're really representing a system that has no defense. i appreciate your apology at the beginning of your statement. i'll start today by looking at page 27 of the va's internal audit which was released today. the oscar g. johnson in michigan was listed as being in wisconsin. now, you can't place the facility in the right state, so i don't know how we can trust you with the big stuff. like i say, i feel sorry for you

standing there today. the ig's internal report said the va told them the wait times in phoenix averaged 24 days, with 43% waiting more than 14 days. but when they went there, it took a similar sample, and found the average wait time the sample was 115 days, with 85% being more than 14 days. how are we to trust anything the va says about this? >> doctor, thank you for your question. i would just tell you that we had a few slight version control versions at the end of this. we know where our mountain is. >> how am i supposed to trust this data you did today? you said that today. the last data you submitted was completely different than the ig reported shortly thereafter. you see the problem we have here. i feel sorry for you sitting there. >> every two weeks from here on

out, rather, i'm sorry, bimonthly we will produce data. as our integrity and reporting improves, we may likely see that our timeliness worsens. >> frankly, i don't believe you. i tend to associate myself with the thought of mrs. kirkpatrick across the aisle there who said that this system needs a complete revamp and restructuring, because there's no accountability here. there's complacency. i like to associate myself with mr. ruiz who strongly recommended prosecution. and with you, mr. griffin, for your comments about people aren't getting fired for not doing their job. and frankly, i think we need leadership at the va that hopefully will get that, where we have leadership that will make people responsible, and fire people that are not getting the job done. because this culture of not being able to get the job done,

and doesn't matter, has got to stop. and i appreciate your comments. you kind of slid them in there, that people need to get fired. we need to make that happen, despite whatever the work rules and all the criticism that we have. we need to have a system with the management at the top can fire the people who aren't doing their job and listen to the people at the ground who have the comments. dr. rowe talked about the simplest thing that every private practice in the world does, is they call the patients a day or two before the appointment to confirm they're coming to the appointment. the va hasn't figured that hoou? it's impossible to believe that that actually occurs. the appointment people are calling -- they're writing letters to tell them when their appointment is without talking to them. it's like, really? nobody's getting fired over this kind of decision making? it's just unbelievable that this

is occurring. and i appreciate you, mr. griffin, for your comments. we need to have leadership in the va and a system within the va that holds people accountable and makes it known that if you don't do your job, you're going to be out of there, or you're going to be prosecuted. just simply that happening will change the entire culture there. mr. griffin, i have a few more seconds left. can you comment on where do you think this leadership should come from? should it come from the top or do you think it should come from the bottom? give me some more comments on your thoughts about this. >> i think you need leadership up and down the chain of command. what we have witnessed on some of our previous work was the vha has sent out requirements, they sent out safety alerts, they directed the medical centers to address the issue, and to certify that they had taken corrective action.

>> does somebody sign these certifications? >> just to finish the thought, we went out unannounced and determined that 42% had actually did what they said they did, and the other 50% did not. even though they certified they had accomplished the directive. >> without any consequences to their career? >> not that i'm aware of. i would ask vha to speak to that. i'm not aware of anyone being held accountable for that. but i don't know how you could not hold someone accountable for a direct disobeying of an order like that. >> apparently it occurs every day. i'm out of time. thank you. >> mr. custer, you're recognized for five minutes. >> thank you, mr. chair. i want to thank you all for being here, and for your candor under obviously challenging circumstances. but the comment i want to focus in on is restoring trust. i think that's the challenge that we have, the integrity issue above all else.

i'm interested in the notion about this decision to acquire a scheduling system that works in the private sector. is that the intention, mr. matkovsky? >> yes. i won't get into the arcane process. but i want to address one comment. this audit that we did was designed to be the start of our change. i just want to be very clear. if anybody thinks that i'm not committed, if the team that did this is not committed, if we are not committed, please understand that we are committed to this change. this is the start. it's not the end, it's not the final report. in the private sector, we see resource based scheduling, which is the resources, the provider, the clinical resources, using telehealth or other mechanisms to deliver that care. in the va we have grown up around something we call sort of clinic based scheduling.

so we manage clinics as opposed to resources. it makes it tough for us to be able to aggregate all of those views of one provider, and know how many slots does dr. smith -- how much slots does she have. that's not an excuse, but we do need to move to resource based scheduling which allows us to know how much capacity do we have in our system and how does that map to the providers we have. >> so we've referenced what i think is causing the exponential effect of the loss of effective appointments with the no-shows and canceled appointments. i don't dwell on that. but getting back to the resource based, you mentioned that there's not an infinite supply of medical personnel, and what we're talking about is a lack of slots. i wanted to focus in on the issue of graduate medical

education, and one option that i've seen discussed is to relieve medical student debt, whether that's physicians, whether perhaps there could be greater use of nurse practitioners, ancillary personnel. and i'd like for you to address that, in terms of the quality. in my district, our white river junction health care center is very closely affiliated with dartmouth medical school. and it's a very positive arrangement. but i think we could replicate this around the country. >> we can. i think we discussed it a little bit earlier about the nature of our academic affiliations. it provides us a wonderful opportunity to recruit new young talent, have them exposed to the mission of our organization, which is a dedicated work force. attract them to that mission is something we can do. we do have certain authorities

to offer repayment and other programs as an incentive. i think there has been some discussion. i would have to take it for the record to give you a precise answer on what the nature of those costs may be. >> i think it's something that we could look into as well on a congressional basis. the idea that relieving medical student debt -- >> absolutely. >> -- in exchange for service within the veterans affairs. could you address the issue of nurse practitioners and ancillary services in terms of providing greater access, more efficient access? >> there i will get myself in trouble, congresswoman, so i will take that one for the record. it is a discussion we're having. >> certainly in the private sector, this is something that's happening across our health care delivery system, using more physician assistants, that type of -- >> i do know it is something we're looking at. >> great. and then, just in closing, back to the issue about restoring

trust and integrity. i appreciate the comments here -- thank you, mr. griffin. i tend to agree with you. i think a few high-profile prosecutions would clean things up rather dramatically. but i think it's important, and the time has come. so thank you very much. i yield back my 20 seconds. >> thank you, ms. kuster. >> thank you, mr. chairman. a couple questions following up on the issue of restoring trust. ms. moody from the va was before our committee, i guess two weeks ago. and her stated goal was to be open and transparent, in working with this committee, members of congress, and hopefully with the public. are you aware of any gag orders, or orders, instructions from washington that would forbid employees from visiting with the media and/or members of congress about these issues? >> i personally am not,

congressman. >> at the wichita va center, let me give you a little background on that. may 0th, a u.s. senator was told there is no one on a secret waiting list. three hours later a letter was released from the center that said there were three -- excuse me, actually nine individuals on the waiting list. and at that time, on a friday afternoon, evening, i began calling the leadership of that center and received no response until the following wednesday, when i began hearing rumors of 385 on the secret waiting list. i jumped in a vehicle, drove the one hour, happened to be fairly close to me for my district. and there was met with an e-mail from the va that forbade employees from visiting with members of congress about these issues. now, if that indeed was an accurate e-mail, do you think that helps build trust? >> it does not, sir.

>> but you're certainly not aware at all that those type of e-mails were sent out through the va system, at least there were actually, and they wouldn't provide me a copy of the e-mail, i think there were probably 100 different names it was going to. i didn't know them. i knew the one at the end, which said don't talk to anybody. so you're absolutely not aware of any such e-mail? >> i don't know, congressman. i've been sort of working on the audit, and some preparations. it is possible that -- >> why would an e-mail like that ever be sent out? >> i think the one reason, congressman, would be the following reason. we were going to release an audit that would contradict a statement that someone locally might make to say everything's fine, we have no issues here, and we're about to release an audit that might contradict that. so that would be the concern that i would have. i would hate for somebody to tell you everything's fine, and along comes an audit that says

not everything is fine, and, oh, by the way, here's the official data. >> in your audit that you released today is 104 veterans waiting in wichita for the care. the facility says 385. how are those two numbers different? >> i will need to compare the numbers. >> there's a difference. >> here's how. i'm not certain that this is the cause. but the data that we published today was current as of may 15th. if you went to the facility on may 30th, you would pull a local number that might be bigger. one of the things we identified with the audit is we went to sites, that prior to coming to the sites there started being a change in some of the -- >> let me interrupt you. in this specific circumstance, the facility said they knew of 385 on may 21st. then they told the public zero. then they told us nine. then they said maybe 385. and until i knocked on the door they wouldn't confirm the 385. so the numbers have changed. in the middle of this, you have a gag order.

i would like a quick response on that. certainly much quicker than the march 2013 request i gave to the committee that's not been fulfilled yet. that is, how do you access people who are in clear violation of the policy? has anybody been fired or punished, or otherwise for violating those rules? >> we've begun the removal process. >> you have not yet responded to that question. i have not seen those policies. >> i'm sorry. >> is there a reason you didn't respond to that question in committee? >> i'm not sure what the question was, sir. >> you go back to the testimony, i'll be happy to provide that to you again. >> okay. >> that question is, matches up with an april 26, 2010, memo, and i know my colleague felt sorry for you. but this is not new stuff. >> it is not. >> and you came before this committee, i wasn't here yet, and said you had 26 different schemes for gaming the system?

and have you changed any of those? has anybody lost their job for doing this? we know veterans have lost their lives. and i don't have any clue, or any information if anybody's been punished, if anybody's lost their bonus, or otherwise because of something you've known for years. 36 different reports from the gao, and the oig about this. you come here and say, we're going to do better next year. yield back, mr. chairman. >> thank you, sir. mr. o'rourke, you're recognized for five minutes. >> thank you, mr. chairman. dr. draper, you -- first of all, i appreciate your work. i'm learning a lot listening to you this evening. one of the things you talked about was the cancellations and the no-shows. in el paso, we've heard anecdotally of cancellations that are recorded as no-shows. a veteran last week, for

example, told me that she had gone to the va in el paso for a mental health care appointment. a second appointment was made by that psychiatrist. the va called her to cancel that appointment. she thereafter requested a copy of her medical record and found that that cancellation was recorded as a no-show. it hits against her record. it doesn't hurt the va's wait times reporting. have you found evidence of those kinds of practices in your investigations thus far? >> not specifically that. but we did find, as i mentioned, more than 50% of the 150 cases that we looked at had at least one no-show, or canceled appointment. and we found clinics, we found in ten of the -- we looked at each facility, we looked at 30 consults, and 10 consults per the three specialty areas we looked at. so we did look at one of the -- it was interesting, because one

of the specialty areas, they canceled all ten appointments. all ten of the appointments that i ran were canceled. it raises questions whether they were really canceled or there were other things going on. >> in el paso, we had long heard from veterans who said they couldn't get a mental health care appointment. and certainly couldn't get it within 14 days. and the discrepancy between what the va was saying, which is that they were survey, we released a report and found that 36 percent of the veterans el paso requesting mental health care were unable to get the point man at all. taiwan's a thank-you and the va fur not challenging the fact that it was a well designed, well implemented survey, large sample size. instead, that the viejo jay z is now working with us to identify

the one-third of veterans, hundred of thousands who could not give amounts of fair employment. i appreciate that. a not get a mental health care appointment. so i appreciate that.it and i also appreciate the auditw that you released today, that shows that new patient mental or health care average wait times in el paso are 60 days. that's the fourth worst in the s nation. but i'llr tell you that may 9th i received this report from dr.t petsel, and mr. john mendoza, the va administrator in el pasof showing that -- not just the v month before that, but the month before that, at worst 15% of veterans waited more.fo so, you know, simple question os following your audit. which should i believe, the e yr information that dr. petsel gave me which showed no wait times over 14 days or your informatiol

today that shows it's 60 days? >> the information today.y i would tell you that as we improve the integrity of our reporting and our wait times, the established patient data may also get worse as it becomes a m more valid reflection of reality. that is important to have.re >> that news would be welcome.re as you said, it would be rootede in reality, and the facts, and a what we're hearing from our w constituents and the people we serve. be able to ret correct this problem until weci know how extensive it is.will i appreciate your commitment to that as well. and on a related note, i will be introducing a bill this week to essentially replicate what we did in el paso throughout the va system. we cannot right now trust the va to tell us how the va's doing. but we can trust veterans to tell us how the va is doing. we should ask them directly what their wait times have been. i really like your commitment that you made earlier, that when you have a no-show, that no-show -- that veteran has been

recorded as a no-show, will hav a phone call fromwh the va to ha confirm that that is what has happened. is that essentially what you ati committed to earlier? >> i have.e the we do patient satisfaction datae today. and veteran patients by and large rate the quality of theiri health care experience overall as very high. but they also tell us in our satisfaction surveys that they rate their access as pretty lowe >> so i would just ask for your continued cooperation.g an we're going to introduce this rt bill this week, the ask veterano act. i thinke having an independent s third wparty, oig, gao, someone apart from governmental together asking veterans what their waite times are is part of the ate solution, in that we'll get rea information that we can make better decisions exfrom. appreciate your help and hat appreciate the testimony and the expertise from everyone on the panel. and with that, mr. chair, i >> y would yield back. >> thank you, mr. o'rourke.t

mr. kaufman, you're recognized for five minutes. >> thank you, mr. chairman. i want to thank the veterans administration here today. this is my second year on this committee. and i'm proud as a marine corpsu veteran.ld t it's the most bipartisan gatio committee in the congress. we're making sure that the nation meets its obligations to the veterans of this country and the military. i feeli that every hearing i've had prior to this, it's deny, cover up, and then delay giving any information to us.en no accountability, no ha transparency on behalf of the eo veterans administration. and, you know, i've got to tell. you, i think there are a lot oft great men andh women who work fr the veterans administration, and a lot of them are the b whistleblowers who have put

themselves at risk, that if not for them, we wouldn't be here today. hi cleaning up this problem. and i just want to say that i think a third, if i understand n it right, of the men and women . that work in the veterans administration are in fact as veterans themselves.e and i would love if you would o look at increasing whatever yout can do to increase that number.e i think there's nobody that understands the needs of veterans more than those who i have worn the uniform. so whatever you can do to get that third up, i'd really appreciate it. when we get to this 14-day wait period, and then i heard that li it's, quote, simply not attainable, end quote. what is realistic? >> i honestly don't know tonight. i do know what is unreasonable. i think 90 days is unreasonable. i thinkis 60 days is unreasonab. i don't know what the right an measure is.d we have to study it. we have to look at what is right

for an individual veteran. it's based on his or her own preferences. acuity also needs to come into the mix for cardiology. 14 days is not soon enough, right? it has to be based on an individual veteran's urag requirement. i think setting an ness, st across-the-board standard encourages an attempt to meet that standard. we'll still measure timeliness, we'll still aspire to be faster, but we won't tie rewards or incentives to that activity. >> in that benchmark, when you interjected financial rewards into that, would it fuel the incentive to manipulate these e. wait times?u >> in our surveys, we didn't asa people -- >> in your opinion, don't you think that that -- that it was a financial reward, that inult incentivized the procedures, the secret waiting lists where

veterans were ultimately denied care as aot result of this wit manipulation?h l >> simply stating the fact that this is our goal, even without a financial incentive might drivel that behavior. ow >> wouldn't theyn have spoken out, though, wouldn't they be more inclined to speak out without the financial incentive, that what's going on is wrong here? >> we have to look at the second question. i think they're two separate questions, sir. >> okay. -- what is the -- i think it's c going to be so hard. i think that the culture of bureaucratic incompetence and ue corruption is so deep. so and i appreciate the forthright nature of your testimony today. but i think it is so deep, and so ingrained in this organization, that it's going to be very hard to turn around. and what i hope occurs from this, is that veterans have a choice, that veterans have an option, that if you're not able

to meet, you know, their healthe care needs, that they can go outside the system. and i hope that that then ight incentivizes the veterans administration to see them as r customers, to see them as theira patients. right now, i don't think ween that's -- you know, i think there's great variances between facilities, as you mentioned. i think across this country. i think there has to be incentive to see them as their patients, to drive quality standards, for them to care. >> if our veterans are happy and more of them choose to come to us, we're having a good year.not if we can provide quality health care that's timely -- >> if not, they ought to be abli to go outside the system.rt tha as you mentioned, dr. draper, the management structure really. isn't there to support that. and i think it needs to be f developed to support that. with that, mr. chairman, i yield back. >> thank you, mr. kaufman.ank y mr. walsh, you're recognized fog five minutes. >> thank you, mr. chairman.

i think all of you here when out system of government works right, is a reflection on our tt constituents. and i think youio heackr it. i would hope you hear it loud clear. the frustration, the lack of trust. it's universal. many decades of good work can be erased very. quickly by bad actors. i want to thank you all for the work you did on the ig and the a gao. we go way back on many of these things. when the system works right, yod were here with dr. roerds, a ranking member, and in miami o with the contaminated equipment. sy we brought in best practices.c we fixed that. we implemented it across the system. by all accounts, we made a correction based on that. there is a model to try and do this. with thatt being said, as you look around, there are many in o this room that have a long s institutional knowledge. many of them are sitting behind you. many have been coming to us and talking us their issues. the idea that this is anything

i new is incredibly frustrating t. many of us.seen i think i've proven myself of in trying toce get this right when i'm seen more as an obstruction and nuisance to try to get them, instead of being a partner to this.hat that in itself is systemic cultural issues. i have an institution in my district that has offered to ps helpca and i've gotten no response. when the mayo clinic wants to help you with this, perhaps you can get a call. but this is going on and on. i'm at a loss why that is.ehind the people here are committed. they're speaking with the voice. of their veterans. there's people sitting behind you that sit in my office and ask us to do this. and we send a letter and get nothing back from it. i i think your sincerity and the work you've done, i'm not going to question it. but the issue i have here, thisd is from dr. haney in armstrong in syracuse.the they quoted peter drucker and said the greatest danger of times ini turbulence is not theu

turbulence, it's to act with dea yesterday's logic. question to you is, where is y the big idea for reform? if you're going to come here and wh ask foren technology money. that was a cursory thing they found. when they pulled the testimony of the people whoy set there an the questions that i set here t and asked about technology, you are going to be embarrassed.? you will not come and ask for that money.a my question is, where's the bigi idea?is bac where's the vision? >> i think the big idea may not sound like a big idea, but it ih back to basics.nn back to delivering safe quality health care in a timely manner,e knowing where we can achieve n that and where we cannot. it's an open engagement with our partners. veteransh organizations are not mentioned enough today. they are our partners, we talk a and listen with them, and they have good ideas for us about hoy to get back to basics. listen to veterans, what they want, what they're telling us. i've worked with members of this committee staff in the past. some of those things actually t

when we listened and worked, or when we started measuring wait times that were too long and , directing care to veterans who we thought were waiting too long, i don't have a big idea, sir.n b i think our idea is back to p basics. it is al good system.loy it can be a great system. it has phenomenal employees whoo are mission driven.et our big idea is to get back to basics, to deliver veterans care system.h >> mr. griffin, is that possiblp as it currently stands, with the leadership and structure that's there, in your opinion? ar >> in my opinion, it will take a fair amount of time.resse it won't happen overnight, a that's for sure.b q there are au number of differenm areas that need to be addresseds when you're talking about timely quality care, one of those is performance standards.o dg i've heard dr. rowe talk previously about people who do d gi work in the private sector, and maybde they're at an hmo ora somewhere else, and they know every day i have to do x number of colonoscopies, every day.12,

and when we did our review in 33 december of '12, of specialty care, we looked at 33 specialty areas, and only 2 of them had performance standards. the other 31 did not. so if you don't know how many colonoscopies you're going to do in a day, or how many other procedures, you need that basici information to be able to e generate the number of doctors c you need. >> i like my colleagues in om questioning the data, i'm hi questioning thes satisfaction surveys.ome it's very frustrating. i would leave it with this before my time runs out. today in this report that comesh out, and you heard mr. denham, t and others say this, when you e flagged those entities that are out there, those locations, you, do realize every single veteran that attends those is tonight calling, wondering, asking, whae happened, what's there, what's going on.where and we don't have a hard time line when you're going to come c

back. we don't have and idea where itc goes. now, instead ofion creating a e transparency and honesty and a r reconciliation on athis, we've created another layer there. that is causing angst mongs e to veterans. i wouldt just encourage you -- we've got to look at this a yoa different way. i yield back. >> thank you, mr. walsh. dr. winstrom, you're recognized for five minutes. e >> thank you, mr. chairman. following up with what mr. walsh just referred to.sit last week the white house deputy chief of staff rob nabors visited the cincinnati va t medical center.s an area where many of my udit veterans, that e go there. f and i learned that as a result of the internal audit, that thel were flagged as requiring further investigation.ed so at this time, can you tell me what's happening at the c cincinnati va medical center?hih should members in my district be apprehensive about the care qual they're receiving or in a timelr fashion? >> they should not be concerned about the quality of the care

they're receiving. i think they're -- there are specifics behind each one that c listed. i'm not saying this is in at cincinnati, but in some cases iw could be a single concern that e came in as an anonymous whistleblower concern at the e time that we were there.>> g and we felt those cases that we needed to make sure we listed that. >> do you know when we'll gentoi the details of why that was 't. flagged? and what we should be m doing?qi >> i do not know yet. but i will accelerate that. we have to move that quicker so we address the angst. i'll make sure we get that donei quickly. >> i would appreciate that. i that we have within the system, in my opinion, i cr come from private practicee as well. t you know,h a veteran seeking cam is in some ways a liability to d the va system, or to those in ad the administration. we talked about that. dr. rowe talked about it. and we really need to have incentives for quality, and

incentives for proficiency.y, we need to -- when private u can practice, a no-show is a h liability. a huge liability.. you can't keep your doors open b if you have no-shows. and there needs to be not a to reward for this.ce there needs to be a reward for coming up with ideas of increasing access. which a private practice will do. how can i seeh more patients, gt the patient in with the doctor in a more timely fashion. the other thing i'm concerned m about iset with the consults. there's obviously sometimes with consults, a level of urgency, u depending upon, as you mentioned before, the acuity of the problem. and if i'm referring a patient o an acuteb problem, that needs t be addressed right away, i will get on the phone and talk to s i that person i'm referring to, tn say, can you get them in. will you get them in.ou this is something that we do in private practice. we want to make sure the patiene is taken care of.w also, when we have a no-show, if it's somebody you've been

treating and they don't show up, as a practitioner, you have a responsibility to that patient. you're finding out why they missed. you get them in that evening ord the next day, whatever the case may be.abo my feeling is, you move forward and talk about a big idea. at the administrative level, va we've got to look for someone outside the va.ow because if you spent your whole career in theu va system, you n don't know what you don't know. you don't know these things thao make an efficient system. e it's not on your radar because i you haven't had to do it. and it is changing an entire g culture. and if you'rea going to get and somebody within the same culture, we're probably going to have a problem. we've got to have people that o understand what competition is about.me and as you said, if somebody desires to be at that va, that's a good day. i that's what the va should be seeking. the only way you're going to geu that and deal with human nature is to have competition. would you agree with that concept of maybe coming from ng. with outside the va?

>> i'm an old consultant by is training. so for me time is money.don the availability of your time was billable.5 i think there's a balance.and we don't wantap to turn into, y know, 15-minute appointments or 10-minute appointments where nobody looks at iyou.lk there has to be a balance. but there hast to be accountability for time.st we talk about resources, and the management of resources. time is the most valuable asset in our system.. we have to manage that time. we have to extract value from it, be respectful the way we doo it, but i agree, competition td know that we a can get more e clients, more veterans who wanto to come in our system, whoer happy with our system. we need to introduce some of y f those concepts into our thinking. >> it is just the time.l it is the quality of care and the patient's perception of aret they being cared for.ls that's always a challenge in private practice.ou somebody needs more time than someone else. or someone needs more time than you planned on that day. but you find a way to work within that system to make sureh that when they leave there, thei

feel satisfied.ncinn my advice at this time, one, i want to hear what's going on ina cincinnati obviously. but i also would really suggestt that we take a look outside of c the va system. because if that's been your s whole life, you don't really i understand how it could be.. and i think competition is the t key. i yieldoyo back.. >> thank you, doctor. >> thank you, mr. chairman.f mr. matkovsky, i associate myself with the comments on i ao everybody on this committee. the more i learn here, the more baffled i am on the things that we heard two weeks ago, and the things we're hearing tonight.r,w but primarily, i guess on behalf of every american taxpayer, la where the heck is the money, the billions, with a "b," dollars that this congress and previous congresses have allocated to i.t. upgrades?

what do you have tangibly have? we funded all kinds of things ok that the chairman just read. what did the va tangibly spend t money on that's working right now? >> i'm going to have to take that one for the record. there are a number of things maa that we have developed and delivered in the i.t. domain. we have veterans management paperless claims development -- >> sir, isk apologize for interrupting. but miss kirkpatrick asked the g question and you gave the answer, we're using 1985 programs. 1985. i've only been here 18 months g and we'vpee allocated millions dollars. and the i.t. people right here, que that somebody else referred to, and we asked and asked, all kinds of questions. in fact, i specifically asked them, sir, who's in charge of the i.t. department, do you havs enough money to purchase what you need to get this va system fund moving? and the answerr was,th yes, ma we've seen all these budgets.ba we've funded everything under the sun.

and it is baffling to me -- it has to be baffling to the american taxpayers watching tonight that we're using 1985 te antiquated system.th here's my other question.eresti i guess the thing thatng i thin is very, very interesting is, did you and i have any idea, based on mr. griffin's commentsp from 2005? been here 18 months.u said i've heard ig report after ig eh report after ig report and i th know there's a problem.to you said you're the business side, the engineering side, did the ig reports never make it to you? >> i reviewed the report and wet had testimony in april of 2013.o in response to the gao report, we went back and looked at how a we computed the wait times for veterans who were new to a clinic. maybe not new tory our system, t it was the first time they were going to podiatry or -- meas >> were you satisfied with the results and thought that you fixed them? >> we changed the performance measure from using the desired o

date to new appointment wait times. date.eched to the create it gave us a much more valid measure. we startede measuring veterans who were waiting longer periods of time.y and we started trying to change that. >> can you say that ytoday, that's a failure, what you guys did at an intermediary level?. >> i would say we did not know a at that pointt in time, h the congresswoman, the nature and ha scope of the sproblem. cr >> i guess the two things that i came away with two weeks ago was this. there has to be a criminal o investigation. and to know b that there are 69 criminal investigations going on i think is breaking news to the american public. i agree. indianapolis and danville, wi indiana, are on your list for further investigations. my hoosiers in the state of indiana are going to ask the same questions, what do i do? when are we going to get the t t information? i guess i'll take that on the record that we're going to get information when you get it. sen but i have a question for dr. i draper, because it goes to this issue of i.t.th i'm sensing that where we're thi going to end up, in one of these

grand ierevelations, is that tht i.t. department, this i.t. u system is unbelievably messed eo up. andse we've asked the questions but we've been -- we've not been provided truth when it's come th those kinds of things.one dr. draper, as you know, the vha is only used to use the ewl. according to your written s testimony, ma'am, officials froc the va medical center piloting h another electronic system, they decided not to use this approach.e f do you know if that pilot at program was vetted by the va's office? not done a systemwide check. this is related to the future ie care consults. >> correct. but would you identify that problem -- would that program be legitimate? >> it may noetnd bep legitimate one of the problems is some of those programs, the data does pr not end up in the consults data as a monitoring tool. it can bea problematic. >> could that not also be considered a separate electronic

list? if nobody's in charge of it, bus there's at system that is out there? >> well, we've seen in the last few months, as the business , rules -- for the consults, a the new business rules, that the ch medical centers that we've been speaking stwith, the five inclue i reviewed, they'res. changing a theirn processes. they changed their processes. it's really very confusing. k i think all the different ways e that the medical centers are etd using -- tracking those future care consults has not really been vetted always with va.. >> thank you. mr. chairman, i yield back my a time. >> thank you. gues colonel cook, you're rec nigh recognized for five minutes. >> thank you, mr. chair. gr waste, fraud and abuse is going, back through my housing group tonight. but a couple of questions. by the way, mr. griffin, ther

unannounced inspections.we i am delighted that you went in there. miss titus, the last time we had a hearing here, she asked a d question about one of the askede one of the individuals on the panel that came down to a phoenix, i believe it was on a friday. didn't work on the weekend and left the beginning of next week. has anyone declared a state of emergency, decided to say, hey,x let's work weekends? let's work maybe 6 to 6? ou if we're going to send striker teams or people are dying on our watch. has this ever occurred to people to, hey, we have to do somethinu about this? re >> absolutely.ger we are encouraging and requirins our staff to work longer clinic

hours, nights, weekends. we >> can they go down there? >> yes, we have put folks on the ground in phoenix, they are working hard, they are finding ways to improve the practice.he we are bringing foeb ining folk other departments. they are working on the ground. >> okay. let's go back to the subject of mission performance standards, public administration 101 if you will. in the military, there's a number of us that were there. we evaluated combat units, whether they're c-1 or c-4.k fully combat ready or not combat ready. and i have to ask myself, are some of the hospitals fully mission capable and some not cap mission capable?

or others partially? do we ever evaluate that -- i'm not trying to lead you, but i'mb getting the feeling that each hospital does their own thing iu because the policies are rd different and open, ambiguous, if that was the word i heard . correctly, and open to thin interpretation. anyone?y >> we have some great ws facilities, i think we also released today data that shows quality efficiency and others and provides quantitative comparisons of our hospitals.. and there are some that are lower and we work with those to try to improve their performance directly. >> you kind ofh hinted on this, you know what you're talking iee about, trust in all those things which i think some of us are familiar --co all believe in.

but unless you have i standardization coming fromf tan washington, and the verification of outcomes. are we, woulding across purposes if it's open to interpretation? >> i think the expression trust but verify is what we're talking about. >> you're stealing my -- >> that our -- in our organization.g we go to 50 medical centers a year for one week review on are specificof areas of interest.enc we go to about 100 outpatient clinics a year, and then we rols up the results and we can tell r the undersecretary of veterans health administration that x uld percent of your facilities ion aren't measuring up in these twe categories. we would expect therew wouldhi corrective action on those. >> i follow this, and i'm sure o you have whistle blowers and everything else, after i got out of the marine corps, i became a college professor, dangerous g place for c me to be. every student nowadays, they o d have a thing called rate your y

professor.com. and i tell you,o you want to fid out how good, bad, indifferent o you are or whether a student g reads that. i'm just wondering, i was trying to go through and look at different hospitals, rate your u va hospital dot com sometimes it's eye opening and sometimes you need that self-evaluation. i obviously am looking for a more standardized evaluation method on whether they are o completing the mission, i would hope we could do that, or we'ref just going to have, i think bad results in the future. >> one of the last documents in the back of thosee r reports is vha document called the sale report. it ranks every hospital on the metrics and it's published in those reports.

the data is collected and is available. someone needs to act upon the ones that aren't measuring up. >> can i also respond to your -- >> yes. what we found is a great reluctance to policies and procedures, that lieds to complications when you're trying do oversite, i think there are issues there.t >> this report would have you have those deficiencies that could be corrected. all i'm saying is that i would hope that the va would look to more standardization. you, colonel. mr. jolly, you're recognized fom five minutes. >> thank you, mr. chairman, jut to confirm, mr. griffin said there were 69 cases where you are now following up to review d possible criminal implications?

>> there are 69 separate facilities, beyond phoenix that we have sent rapid response teams to as allegations have come into us. >> specifically criminal nd investigations? >> no, they're allegations. we send investigators there to get to the truth. you're only as good as your t source, right? >> no,r i understand, and allegations have to be vetted d out.t you use the term criminal, i t wanted to confirm. >> that's correct.of the >> this is different, though, from the follow-up visits that r are required of some of the s institutions based on your ng audit, correct? >> that is correct. >> totallyon alseparate. >> the timing, and i know it's come up for additional information on those follow-up visits. weeks or months -- >> weeks, we'll be working withh the office of the inspector general this week, putting together a plan, which we've ned already started and then it will be a matter of weeks. i agree that we need to make s

sure that veterans understand cr that their care is still qualita care, and that what we've identified here is questions of practice integrity. >> okay. i want to thank you for your candor this evening. often gets into problems dealing with this administration. and i want to thank you for yor honesty and the frank problems s in the va.ues tha you spoke about nonva care beinn the veteran's choice.hin this is one of the issues you've raised repeatedly now. i think within the current system, the ability to get to nonva care sometimes is ed obstructed by ai process where patient has to go to the very same medical staff that said they didn't need it.ch has that changed?? your term now, patient's choicen has that changed? >> it has changed.pr it's going to take time, in conjunction with accelerating care, we provided training to

roughly 1900 of our facility and regional staff, that was over a period of about six days.o in addition to that, we've since offered and delivered training to about 2700 staff for appropriate use of the scheduling package and how to manage no shows, how to schedult appointments, et cetera, it's that, o take a lot of it's going to take constant f communication. and franklyd monitoring, if we r seee delays and we don't see ush of enonva medical care, it's incumbent on us in washington, and at the network and iffacili to ask the question why. >> has there been a change in the same medical staff that th originally said atno, having to sign off on now to say yes. >> the change in vigilance thaty we have, and the veteran must be offered a choice. >> okay. along those lines of nonva care, each of you would relate to

management in the system as opposed to the staff and doctors that provide great care? currently, private sector health care systems provide managementh different than just seeing the nonva physician. is there value in expanding the use of regional health care system providers to provide thet management? so i understand from a number of the veterans i speak to, they want to stay within the va system, they like their va hospital, the idea that some e havevo suggested of just feedin everybody out or using a vouchem program, is not something i e believe the veteran's community wouldh embrace. but can we expand the use of private sector health care systems to provide management for facilities? what would youracts thoughts be that. >> in some cases we do use thate

we have some partners in the ni. private sector that help us smae manage it, some of our abo outpatient clinics. >> those are really smaller facilities, right? what about the very large th hospitals wheree pier to pier -i and let's be honest, it's not a critici criticism, there cannot be the private sectorisin l efficienci the large va hospital currently. is there value in looking at >>s larger facilities and saying, can we provide private sector management? >> sure, i think we can look at this it, the one thing we can tell you, if this crisis has taught c me omanything, it's to question the intent behind everything.t >> has there ever been a study h performance baseda on managemen from the private sector? >> periodically we do. the one thing -- just one momenm of concerne. a lot of the metrics is to generate revenue. i would say that other agencies, medicare and others have had me issues of a