and to be personally accountablu for the integrity of those practices. int we removed the 14 day scheduline goal from employee performance plans. we are increasing the transparency in the reporting of our data we will be releasing our data bimonthly from here on out. affecting secretary gibson announced an independent audit.. we are deploying a team to to f phoenix fix all aspects, notix t just the scheduling and gement management practices we are formalizing a process for the high performing sites in both lr quality access and integrity. we have directed staff to ilitis phoenix to hire additional su staff, to bring in temporary din clinical staff, to bring in mobile medical units that are currently on the ground.

to increase local contracts to include for primary care and we are removing leadership where w appropriate. we are going to -- we have suspended all s.e.s. performancs awards for vha for fy-14.ng we are focusing our hr hiringay efforts on bringing clinical engineering and administrative staff to the field. secretary gibson will travel ton a series of facilities over the weeks to meet with veterans, their families and employees toh identify obstacles to quality health care. ee and secretary gibson has said we must restore america's trust in va health care system. we must restore that one veteran at a time. our dedicated workforce over a a third of whom are veterans are engaged. mr. chairman, thank you to your dedication to and your care fore

our nation's fete rans. >> mr. griffin, you are recognized for five minutes. >> chairman miller, ranking mmi, member michode and members of the committee, thank you for th opportunity to testify tonight e to discuss the results of the office of inspector general's work related to delays in care at the phoenix health care system.i'm i'm accompanied by miss linda holiday, assistant inspector au general for audits and evaluation.dion. the issue of manipulation of of wait lists is not now va and v. since 2005, the oig has issued 18 reports that identified at both the national and local level, deficiencies in de scheduling resulting in lengthye wait times and a negative impact on patient care. we are using our combined

expertise in audit, health care inspections, and criminal c investigators to conduct a comprehensive review, requiring an in depth examination of many sources of information, necess necessitating access to records an personnel both within and external to va. we are charged with reviewing the merits of many allegations and determining whether sufficient factual evidence exists to hold va or specific individuals accountable on the s basis of criminal, civil, or administrative laws and regulations. veterans who utilize the va health care system deserve quality care and timely care. therefore, it's necessary that y information relied upon to make

mission critical management itil decisions regarding demand for g vital health care services muste be based on reliable and complete data throughout va's health care networks. to date, we have ongoing or scheduled work at 69 va medicale facilities and have identified instances of manipulation of va data that distort the legitimacy of va waiting times. when sufficient credible eviden evidence is identified supporting a potential violatiol of criminal law, we are inal coordinating our efforts with the department of justice.arrtmt our work to date has our substantiated serious conditions at the phoenix health care bstat system.at the we identified about 1,400 stem. veterans who did not have a primary care appointment but were appropriately listed on th

phoenix electronic wait list. however, we identified an additional 1700 vet raps who were waiting for a primary caree appointment but were not on thet electronic wait list.elec we reviewed a statistical sample of 226 phoenix appointments for primary case in fiscal year 2013. va national data, which was phoi reported by phoenix, showed x, these veterans waited on average 24 hour days for their first primary care appointment and only 43% waited more than 14 we days. however, our review showed that those 226 veterans in our sample waited on average 115 days for their first primary care f

appointment, witorh approximate 84% waiting more than 14 days. we did not report the results of our ongoing clinical reviews ing our interim report as to whethea any delay in scheduling a primary care appointment resulted in a delay in diagnosi or treatment, particularly for e those veterans who died awaiting care. the assessments needed to draw any conclusions require analysis of va and non-va medical records, death certificates and autopsy results. r we've made requests to ag appropriate state agencies and have subpoenas to obtain nonva medical records. all of these reports will require a detailed review by our clinical teams.ons to while we make recommendations to the va in our final report, we

made four recommendations to the va secretary for immediate implementation to insure veterans receive appropriate care.plem we will address the sufficiencye of va's implementation in our cy final report. our recommendations include tion taking immediate action to review and provide appropriate health care for the the 1700 veterans identified on, not listed on the waiting list at phoenix and to take the same action at all facilities in thei va system. this concludes my statement and we would be pleased to answer any questions.halliday >> thank you, mr. griffin, for your testimony. members, we will all do a round of questions at five minutes ins apiece and we will do a second d round, i am sure, after the first round. dr. draper, in your comments, o you said that 43% of the consults you reviewed were

closed without the veterans being seen. can you give me an explanation n as to why the care wasn't provided? >> there are various reasons, one is patient no show, cancelled appointment, either nh cancelled by the patient or the medical center. we also found instances of some records we couldn't tell, we looked at it and there was no documentation as to why the nd consults were closed. >> how does va schedule appointments? is it through a telephone call ? to the veteran or by a letter?tn >> it is typically through a >>i telephone call witht' the veter. the veteran may call us. we may call the veteran. we will notify the veteran on a recall reminder process, which does involve a letter, sir. >> that's interesting, because i've heard numerous veterans p tell me that they received letters telling them when their appointment will be and not asking whether or not t they can attend that particular

appointment. so i'm a little confused. >> sir, i've heard that as well. that is not appropriate. hear that increases our rate of no-shows.th it is not veteran centric. we need to change that. we should be having a conversation with a veteran asking him or her when they want to be seen and scheduling around their requirement. >> the va has consistently tar stated the alternate list or secret list in phoenix that was being used to populate the electronic wait list was destroyed immediately after the ewl was populated. so my question is, was there an independent verification, in fact, that every veteran on then alternate wait list was successfully transferred to the ewl or can you provide any prod documentation or assurance to us that no veteran was left off tht alternate wait list? >> i've had a team on the ground, sir, reviewing their eir practices and their scheduling i processes. i have a report that's only their first draft report.r firs i will get a final report from l

them and i will be able to dig little bit deeper.be at this point in time i don't have any reason to believe thats any veterans were left off the final ewl count. but i will await the final ewl report. . >> can you tell the committee who at the central office, if anybody, knew or instructed or coached anybody how to many nip late wait times? >> i do not know i don't know e anyone that has done that or th not in my direct experience.heye >> so you don't know whether they have or haven't? >> i certainly hope not. >> i would hope not either. a brief if may of 2009, dr. al mike davie, the national director of systems redesign indicated there were 49,743 for veterans waiting for care as ofo september 15th of 2008.08. now more than five years later, the va's audit shows and has

been reported in the media that it has risen to 57,000 veterans waiting more than 90 days for their first appointment and an n additional 64,000 veterans that appeared to have fallen through the cracks.atrough how can this be? >> the correct use of the electronic wait list is the number that's 57,000, sir. we use the electronic wait lists if we are unable to schedule a veteran who is receiving their a first specialty consult within 90 days.ys. the correct use of that is to ensure that we can work aran ino veteran into an appointment sooner. a the 57,000 number is a much more conservative number. the known direct clinical care is only 40,000. care we have to get eyes on the ewl.o we have to manage it. we have to make sure that our front line staff and our medical centers are accurately working t that list, getting veterans from waiting for an appointment intos an appointment. as for the 64,000, that was64,00 the new enrollee appointment

request list. mr. griffin had told us that res that was one of the recommendations. that if we could find that in phoenix, that we should lookeam across the entire country. as we had a team review the new enrollee appointment request list, we identified every single veteran from the beginning of e the period of enrollment who maf have at one point in time o requested an appointmentint when they provide their enrollment data.prov if we could not verify they hadw an appointment, we went ahead and added them to the list so we could begin contacting them tomorrow. >> mr. griffin, one final question before i yield to the ranking memember. have you found evidence of criminal activity in your assessment? >> we have found indications ofd some supervisors directing some of the methodologies to change the times. we have been in discussion withe the department of justice concerning those and whether or

not in the opinion of the department of justice they rise to the level of criminal prosecution.osecutio that is still to be determined in most instances.s. >> i appreciate you talking with the department of justice. ap the committee has written a prce letter to them also asking that they open an investigation. also we haven't heard anything from them to date other than the fact that they got our letter. but i appreciate it. >> thank you very much, mr. chairman. dr. draper in follow-up on a question the chairman asked an about the va close consultants t due to no-shows. no what percentage were no-shows s versus the va canceling? >> well, we looked at no-shows and cancellations and we went through the consults and researched the 150 cases that w looked at, to look at the history of the consult request.s we found that more than half eih

either had a no-show or cancelem appointment.s a so that's a large percentage of the consults.e so it's a big problem for va anm what we see is that the policies at the local level vary as to h how local facilities handle no w shows and cancelled appointments. >> thank you. the gao reports that wait timesa arree generally not tracked for non-va care. ed for why don't you track wait times u for non-va care? >> historically, sir, we have not, congressman, we have two initiatives, both in full ve tw deployment at this point. in the first one is for non-va cart coordination. effectively, what is occurring e now is when we refer a veteran to care in the community, if we could not provide it.linic t it creates an appointment inside a clinic.nt it allows us to monitor that and watch that appointment. h we are now collecting time lead

details on that.th we have a nation wide contract called patient centered care in the community.erfo that contract has a performance requirement from our two contractors that they both schedule and see veterans within 30 days of the referral from use we think those two approaches will help us in the long run s insure coordination and management of non-va care. dr. draper also alluded the requirement to manage the coordination of that care.requim it's not enough just to refer o care into the community.thefer we do need to follow through as well to insure the veterans' needs are met, that that non-va. provider is respectfully workint with a veteran, her or his is family, to get into care. >> thank you.into the gao also reports that there is a consistent problem across vha with policy and procedures for handling no-shows and cancelled appointments.and i'm aware that va, that you area working on an update to this .wg scheduling policy. when do you anticipate this

revised policy to be released? and will it address the no-show consistently throughout the va . system and canceled appointments?nd >> i expect it will, sir.ad a we had a team last week t reviewing the existing policy we have today and to determine whether or not we should rescinu that policy and replace it with a clear, declarative set of instructions for our schedulers in the front line. we expect to take that action. we will replace that policy wite 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 daye 91, to actually offer that du specific instruction and tie that policy to training.n, a lot of our current policy mixes two concepts, scheduling t and practice management.sc we're going to have to make sure that we have a clear schedulingp policy and a clear practice clea management policy.r management of no-shows can be c

handled by contacting veterans,g working with veterans, to insur that they're reminded of their appointment, frankly. making sure we talk to veterans. and their families when we schedule their appointment. talw when we do those things, we canu 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 centers,s they require approval at the av chief of staff level to use non-va medical care. as part of accelerating care, wf worked on that in the i think a, the second to the last week of may. we worked on the plan may 21st, rolled it out may 22nd and began execution on the 23rd of may. we have released instructions to the field, that particularly cts where we have confidence in our wait time data, that the field h is required, if they cannot offer that care in a va, in a v. facility, first they must assess their capacity, increase their i

capacity by running nighttime o clinics, overtime, weekends and if they cannot, then they are instructed to offer non-va care to the veteran.raas then we've asked them to tell kl us, what do you need in terms ot resources to make that work?e 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.make sur >> thank you very much, mr. e chairman. >> you are recognized for five minutes.>> m >> thank you, mr. chairman, i ae appreciate the work you are doing on this issue.i one of the areas that is going to have to get further review i in colorado springs, colorado.gn and there are three anonymous whistle blowers who have come us forward and said that there aree problems with manipulating 've waiting times. i've talked to the leadership in both denver and colorado springs. have they have told me personally not that this is not going on and ii

believe them, but at the same, we have whistleblowers saying that it is going on. mr. matkovsky, how does the va treat whistle blowers?does 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? are >> part of how we designed thisw audit was to have direct access to the front line from our to h senior staff. when our auditors 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 anne announcement of who we wanted to interview.we p 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 n could and nothing, nothing

saddened me more than an who s employee who says i was trying to do it right.ayto do i know it is right. and i received instruction to do it wrong. that is just simply not tolerable. retaliation against whistle e. blowers is also not tolerable. we cannot condone that. we required a leadership and cultural shift in our way of managing. >> and i raised this a couple oa weeks ago in our last late night hearing, and that is, if you is can't rely on the data, if you y can't rely on the records because secret waiting lists by their nature are meant to conceal the truth from someone who is doing a review, like yourself.selves, does the alternative to go in and do a case-by-case analysis, talking to every single veterany who tried to get an appointmentg and doing this on a one-by-one, even if that takes hundreds or

thousands of contacts,do we how do we get to the bottom of it when the records or the not reports are not reliable? >> i believe we have to begin re 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 ss, requirements? is it not? y if not, let's fix it. the thing that's terrible about the crisis is this isn't even ai output measure. it's an activity measure.it's a what happens when we change thah activity measure is we can't ac tell where we're not timely. in no cases were we finding inga front line staffre delaying carr by moving the appointment later in the calendar, they were changing the reference point.ern when that happens, we don't know where we're late. when we don't know where we're late, we can't identify knowla 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 seenn the final days and never again where bonuses oar promotions aro based on metrics that can beti manipulated, instead of, like o youre mentioned, outcomes, like patient satisfaction or good or care that can be documented, not metrics that can be manipulatede >> i concur. >> and do either of you other >a two folks want to comment on that issue? >> mr. griffin? >> i think it comes down to to accountability of the seniore leadership out at these facilities. and once someone loses his job or gets criminally charged for doing this, it will no longer bo

a game and that will be the shot heard around the system. w >> thank you. i yield back. >> mr. brown, you are recognized for five minutes. >> thank you, mr. chairman. mi 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. right we are all on this committee because we care about the we veterans and you can be sure th only reason i'm on this sure committee is i care about the veterans and i have been on thi committee for 22 years. and so i have a couple of questions.estion dr. draper, you mentioned and ii want to thank you for your service.se but 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 erans, partner with veterans

if they can't get the service right away? >> i think it's an important an' point because, you know, there n is a lot of talk of sending moro veterans out to the community for care.alhile t while that is a way to expand capacity, as i mentioned, as 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 on, a veteran actually receives the a care that they're going out to g the community for and that was why we illustrated this particular case because this fo. 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.e. >> 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.the no complaints about once they he get in.bout 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 d as far as different kinds of ge technology working with their unique ailment. >> i would say in my experience and in reviewing various va ong facilities, i think there is variation among facilities.ties 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. the system belongs to veterans and their families. 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.think th >> what percentage of the staff. of veterans work at the va? >> over one-third of our staff

are veterans themselves. it's a matter of making sure atr however we have integrity in thr system so we can identify where access is not working. it's not okay anymore with all t due respect to say it's great l care when you can get it. get it must be that it is great care and you can get it. >> timely.it. i guess that's the key. mr. griffith, any comments about one of the problems, it seems it that a lot of the equipment. the technology that the veterans have is outdated. the computer system is in the different systems.offerent 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 i recommendation has been that they needed to have an automatem to review wait times remotely.

a lot of money has been wasted. millions of dollars have been wasted on contractors trying to create a better system for capturing this data and over th, past 15 years going back to 2000, it hasn't had any success. >> if i may, congresswoman brown. to it's important to understand our scheduling system scheduled its first appointments in april of 1985. it has not changed in any appreciable manner since that date.ou >> what about the equipment that i'm asking you ant? we have had lots of meetings and the technology. we brought in the banking ba community to make sure that eop peopleca can't go in and steal your identity. that's a part of the system, also, is that correct? >> it is.

so we have some systems are evolving and improving. we have a new veteran's health s identification card, which hasor removed the social community ree number from the bar code and magnetic stripe. the that has been a good change. across the board, if you look at our engineering systems,our facility management systems, oun 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.interne you know, these are old systemsg >> yes, sir.ese are thank you all for your service. i'm looking forward to round two. >> thank you very much. you are recognized for five minutes. >> thank you, mr. chairman, thank you for holding the hearing. h i will have a question and i know i want to follow up on theo question. this is for mr. matkovsky. the gao's testimony, it was t ws stated there are no system wide

vha policies on how to handle sw no-shows and cancellations.idows 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 a supposed to guide our staff only -- on how to manage veteran appointments and communicate ai with veterans to minimize the d chance.milies t >> well, describe that policy, i don't have a lot of time. >> for instance, if we have a t veteran who has once not shown up for an appointment before or repeatedly not shown up before,o we have a no-show list that list allows us to contact veterans va and that's part of our policy. and sites are supposed to be implementing it.te we need to do a better job of training following up, insuring that that practice is performed. >> i agree with that.nd i hear about the long wait times.

i had a town meeting last week where i meet with veterans fr freque frequently.ur one of the complaints was the wait times.missed everybody knows about that ointe missed appointment, for examplev the veteran gets the appointmen finally and maybe through no mb fault of their own, they can't make the appointment, maybe an illness or somebody forgot. they have to wait another two so months for example for an ait appointment. let me ask you this question, because that's a huge problem, a is there any input? i hear about the lack of communication between, let's say, the schedulers. let' 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 e, y could have a conflict, a family conflict, a medical conflict, what have you?onflic >> can i answer that? >> yeah, because that was an issue with the case that you cited.the >> it is.

and part of the problem is and d 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. the part of it is as we found our ln wait times worked, some i schedulers, a pretty good percent is engaged in what is termed blind scheduling. they schedule without being in contact with the veterans.nts the veteran receives the with appointment through the mail. sometimes it may not be e mail convenient or it could be the c appointment, the letter was intn received after the appointment actually was scheduled and we also see sometimes the contact information is bad to the veteran never received that appointment notice. so there is a lot of factors apr that go into the no-show and no cancellation, but that is a pari of one of the factors that also affects that. >> have you ever asked the question of the veteran, how would she or he prefer to get p

this information with regard to appointments? >> we need to improve the ways o the veterans can see their appointment, manage their can appointments and, frankly, ask t for appointments. a we need to make that an integral part of our online system for mt healthy vet. with we have a patient scheduling application, we are trying to roll into a state of production. frankly, it starts with the stt phones, pick up the phone, calln repeatedly, talk to a veteran and find out their preference a and then schedule. >> thank you.hat again, it's a draet -- great thing to have. again, that should be in addition to the personal contacu or to a computer either. so let me ask you one more me. question. i know i don't have a lot of timeag. again, with regard to the wait list, in the hearing, this held committee held on may 28, 2014, members of this committee co

repeatedly, i know i asked, whod authorized the destruction of the interim electronic wait he list? however, dr. lynch maintained r, that it was protocol for when the appointments were cancelled. if there is no department-wide process for no-shows or cancellation.ess fo now, you stated there is, but td 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 the were working on was to try to tw move appointments sooner him what they may have been doing, t which he referenced in his bele commenting wag printing, p reschedules, and shredding ther evidence because it contains personally identifiable information. i think that's what he ink that referenced, sir.t >> all right. thank you very much. i yield back. >> thank you very much.nized fo you are recognized for five minutes. >> thank you, mr. chairman.

for mr. griffin or mr. and matkovski, in your wh investigations or audits, did you identify in sort of pattern when looking at wait times and scheduling practices? what i mean by this, are there some times of facilities better or worse than others, or wait times longer for certain types of care? >> i would say one of the principle methodologies that wet have witnessed is a veteran calling in for an appointment, he gets an appointment 120 dayse because that's the first e available appointment at that facility.facil and then that appointment gets t 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.e have the other scenario would be you get that appointment 120 days out, two weeks before the appointment, it gets cap selled -- cancelled in the fact system, then it gets re-createdd veterans are no wiser, because it's re-created for the same time and date. once again, it reflects a ing te waiting time, which does not reflect the reality of the amou amount of time that veteran has been waiting for care.en wai >> those are similar to what we. found as well. i would say in 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 il longer waits among those veterans and then we also note e wait times and primary care. >> that was a very clear

illustration of some of the that patterns. can you tell me, so in phoenix there is both wait times of thir nature for both primary and specialty care? were >> we did see a significant count for primary care. there are a number on the wait list waiting for primary care appointments.poin what will typically happen is you will then see a demand for specialty care.g so as we're bringing in resources for primary care, we are also very cog zi -- wait cognizant of the fact that we are going to require the address especially care in phoenix. >> 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 ch o scarcity of appointment slots, how many of those are attributable to a shortage of tt providers, how much is attributable to maybe inefficiencies in the way the facilities operate? >> i think we have to check them both.iees ch 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 the amount of time in y clinics serving vet raps. but i think it's both. >> mr. griffin? >> if i may, i think an integrated health system is the beth system for veterans who have multiple conditions that they need care for.they the further you dilute the locations where care is eater c provided, the greater chance of the care not getting proper he reflected back in the medical record. grea the greater chance that 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 u on investment for getting your own doctors who are committed tn the va mission who are full tim employees at va as opposed to do the 4.8 billion in fy-13 that we spent for fee care.nk there needs to be a strategic analysis of what in the long run is going to be the best outcome for veterans. it is something that has to be o continual because you will have a different mix of conditions f from one facility to the next. g >> along those lines of the integrated care connection, is s there a pattern in your research to the quality of care related to whether or not a va facilityd is affiliated with a university hospital? hospita >> oh, i don't think so.

i think our affiliate hospitalsn tend to be the more complex hospitals. we'll have a more complex set o services available to vet raps. we have some of our highly rural unaffiliated hospitals wind out being top performers in industry rankings.ormers >> thank you, mike, time is up. >> thank you very much. dr. rowe, you're recognized for five minutes. >> thank you, mr. chairman. last week during the recess, i e had an opportunity to do something very personal to me.co as a vietnam veteran, i when to vietnam. we talked to the folks there that were looking for our 1,200 mias.ing for 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're not doing a very good job of that right now.odd t i th 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. t let me give you an example.no in no-shows, for instance, whens

that's a problem with a consult, in our office and we had whe patients who were supposed to ew manage the consult, not a ho regularly scheduled patient, we had ways to check for those t folks. because if they didn't show upt they took up a slot we couldn't fill up with somebody else.ul i'll give you an example, i'm t. looking here at the, at a medical center that saw 68,796 patients. that was an entire medical center.n entire our practise 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 s productivity.vity. it's the incentives to make sure when you have a consult, you co 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.he there are lots of reasons and you can call -- there is a thing called a telephone.

you can pick it up and call somebody and mr. jones, are youl going to be able to keep your t appointment next week at 10:00?h it doesn't require computers. b it just requires a human being and a personal touch to check with that person.th it i can tell you, they appreciate it.ey the patients appreciate it.poinm they will keep their appointments. en if you make an appointment for s me in september, i may forget nanciait. i think that's a part of the problem. did you notice any particular kind of consult, dr. draper? 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. very did you notice a difference in f the type of consult? >> we looked at three specialty areas, gastroenterology, physical therapy and cardiology

and we heard from the va medicao center fish, particularly in tht areas of physical therapy and gastroenterology, there was an increase the demand did not keep pace with the number of provider providers that they had. k so, you know, the demand kept increasing, they didn't have th. providers to take care of the patients or fill the slots. >> so it didn't matter. i thought it properly did.specia >> we didn't look at all the lt specialties, but those were the three we did look at. >> one question i had, mr. matovsky, when you're evaluated as a senior person, 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.i. >> that's fine, if it's not, it's not.at i and also, mr. griffin, you know. for me personally, i know the

chairman asked this question about the potential when you t 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. when you have gone out there and on purpose misled, knowing that you would get a financial bonus if you did that, which is exactly what happened, is that fraud? i i think it is.s-6 >> i agree. the issue is, you start with the gs-45, gs-6 schedulers who havep many layers above them before you get to the top leadership of the facility.he so you have as to work your way back up the supervisory chain hn to determine who put that order out to do it in this manner

that's what we're having to do n at 69 other facilities other fa than phoenix with the additionaa facilities reporting in every a day. so it's not an easy task. i suspect if people do start n l getting s charged, maybe that middle level person will say, wait a minute, i'm not going to take a fall here for somebody higher up the food chain than me who directed that we do this. >> i field yak. >> thank you.chairma ms. bradley, you're recognized for five minutes. >> thank you, mr. chairman.er and thank you again for your cot leadership on this committee. my first question is to mr. matovski. i understand the acting secretary has sent a triage tea to phoenix as you testified, which i wholeheartedly concur with, but after reviewing

today's audit number 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 n example of that, whose wait times exceed that of the wait times in phoenix.xod. so my question is really about e triage and phoenix is good we i need triage elsewhere. what's the plan?ngth when are we going to get to that? w >> we need two things, by the way. first, we need to reset how we measure so we know where we are performing well and where we are not with confidence. we requested medical centers to survey their capacity.

we broke it down by clinic, by medical center.r w 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 ber each wait times for each of those clinics and ask if they had low productivity and wait times to address the concerns.ru 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, 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 we levels can raise the flag. system wide, that is what we have done. i think we have at this point identified an additional of requirement for $300 million. the vast majority of it to support the acquisition of health care now. >> is there a schedule for that?

my veterans in ventura county, p would certainly, this data is t now public as it should be.unity but the first question my veteran community is going to be asking is when? >> tomorrow. and beginning may 23rd, each facility was directed to contact veterans to determine if we could have additional clinical f capacity, one of the things we e have to bere careful about is there's not an infinite supply i of mental health care in the n d community. soh if we can find the quality , health care to purchase in the community, coordinate that care the next step is to pick up thes phone, call a veteran and ask them when they want to be seen.t

as ofo friday evening, i belie, we had made 50,000 phone calls in the facilities and networks across the country. we want to finish those and movd onto the next set of phone hat i calls, working back from wait times as we get closer and closer to what we think is timely care.tis that has already started and we will be tracking i think beginning this week the rate of obligations of those. so we created specific account codes for the funds and we'll be tracking the use of those funds to accelerate care.hal shar >> that data you will be sharing with us?e >> i will be sharing. >> you mentioned about my hav colleague here also mentioned m 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 means, because im seems to me we have to fix thist airplane while it's flying and it seems to mean we should be od look at our 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 staffr to recruit, hire on board and ri credential our staff. i think we have to look at thatt but the acting secretary's point here is not to restrict us from hiring staff in the field.ne it is to request at our networkw offices and at headquartersand t we have a hiring freeze. the point is so we can dedicate our hr resources to hire through the field. at some point of time, we may when our hr staff is working, wa are able to staff for vacanciesg where we identify them.ng but we can't satisfied with having a vacancy and having a x

recruitment process and have that take six months.thsy. that means we are running at under capacity for six months in that specialty.e we have to change it.servat we have toiv make sure we don'ts hire or have a conservative resource committee locally thate prevents us from having the c p clinical resourceshe. the acting secretary is not telling us, do not hire in the field. what he is telling us is focus. >> thank you. i field back, mr. chairman. >> thank you, mr. brownly, mr. flores, you are recognized five minutes. >> thank you. 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 handle on access, patient satisfaction, the acting secretary came back from his visit to san antonio and the e passion, the mission the drive,d

the energy is palpable in some s of our facilities. i will tell you that in some case, entire networks we did not find facilities that had ome integrity issues worth us reviewing. in some networks, we only had be selected instance, both from an integrity perspective and a veteran focus perspective, we h have high performers who get the process right, schedule with integrity, report with accuracy, find resources where you need them. we have a number of them. high >> so we have these high performing facilities that have much better outcomes than the other facilities. what is it that makes it >> cul different?tuleaders >> culture and leadership. >> it's the leadership of the facilities i will move to dr. draper. in your reviews of the vha, didg you find similar high performinh facilities like mr. matkovsky referenced? >> as i mentioned, we see ferenc variation in facilities.ed

i think there are some excellent facilities and some that struggle. did i would agree, part is the leadership issue. >> mr. griffin, did you similarly find high performancee facilities or teams? i >> if i could expand a little bit. c 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 network level or theor 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. there

but there ought to be a best s model for similar size medical m centers so that when a directive goes out, you know, okay, at this facility or at all the ef facilities the chief of staff owns this issue.gery o or the chief of surgery or one individual, because some of our reports, like on reusable t not medical equipment not being rly properly sanitized after use, there was no one person at evero facility that had ownership of that issue.n so you reap what you sew. when you send it out there and c there's no consistency in ownership, the results are predictable. >> so do you concur with the is 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.rt mr. griffin, the interim report cited the need to minimize

coaching employees and how to i respond to the oig questions. do you have any evidence that o 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 ma staffer the first weekend in mae reporting that they had heardyig there were parties going on destroying documents at medical centers.ce we responded to 50 medical centers that weekend and didn't find any destruction that we came upon in those unannounced visits. >> how about coaching employees on how to respond to questions?s >> our team's questions are nots similar to the questions that they were posed by the audit

staff the vha sent out all of our interviews were taped interviewspe.m people were put under oath. we asked them straight up, who told you to do this? some produced e-mails. we some said we've always done it this way. the range of answers is what caused us to identify it as acs systemic with our previous audits.ployees >> one question, did you run wil across employees said they weret 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. i yield back. >> thank you, mr. more es.>> thk mr. titus, you're recognized for five minutes. >> microphone, miss titus. >> in may the va launched the accelerating 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 l for a long time get access to care in the private sector. t now, i support these principlesy i think that's a good idea. as you heard kind of referenceds here, the u.s. is facing a significant position shortage nationally, not just in the va, but in the private sector.ortago 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 ge practitioners. 50th for psychiatrists. 51st for general surgeons. 5 so as a result, it's not only the veterans in 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 to get care and that will solve the problems. i wonder what you are going to do to make sure they receive

care in the private sector and in communities like nevada where issue of shortage and waiting times is not just limited to the va facilities but is out there in the community? >> unfortunately, congresswoman, 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 that would help us attract talent. we have found that that works, by the way. one of the benefits we had in terms of having our affiliate partnerships is the ability to attract talent. 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. f so i think we do need help. we need broader help than just n contracting or just va and we in need to explore other solutionsh 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 i less deputies and some kind of partnership? >> absolutely.ncy? i think we need to look for that.bs yes, ma'am. >> one other question, is, if ed money were to become available e now like we've heard about on the senate side to hire more doctors and to build more f facilities, are you ready for that? do you have a list of priorities?ri what are those priorities and what metrics planning are you using to make those determinations? >> we have a significant, as i g think this committee is aware, i we have a significant tain fac construction requirement both to maintain our facilities, which i believe are roughly on average s 60-years-old. there are land-locked facilities, as a matter of factc in phoenix, we are talking aboue

las vegas, but in phoenix, we had to bring down clinics to handle the extra staff. c 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 ande where we find di manned and ourt demand and our inability to meet it. declar captions copyright national cable satellite corp. 2008 it is 2% normally but in las vegas it increased to 19%. so when you look at your priorities you include include demograp captioning performed by vitac growth and the need for service because once it is there, you build it, and they will come.

okay. thank you. i yield back. >> mr. denim you are recognized. >> thank you. is this the audit from the va? >> yes, . . may, livermore which is in our contract area, was audited. i sent a letter in over a month ago requesting each district is given the information whether it is private briefing or public information. but i think every member of this committee has a right to know what is happening in their own district. is there a reason we don't have that? >> we were competing phase one and two. there are not a lot of

respondants or staff. we guaranteed the front line staff animity and we want to preserve that. i would be happy to organize briefings or similar mechanisms. >> so there is no reason we should not receive that information soon? >> no reason. the only concern i have is in our very small clinics where there were a small numbers of folks we interviewed i will preserve them. these were front line staff members and we made that promise to them during the interviews. >> you say some locations were flagged for further review and investigation. for instance, suspected willful misconduct. livermore, vamc, and california is on that list. >> that is correct. >> at a certain point i assume

you are going back into that facility to get more? >> we are. we will be meeting this week and working out a plan. >> appropriate personal actions will be pursued. what type of personal actions will be pursued? >> based on the problems we identify. >> firing? >> if required, yes. >> i just went to pal alto. took a group of local veteran leaders throughout my district and i will tell you we saw dedicated doctors and dedicated staff. but we saw big glaring challenges they recognized were big challenges. we have heard the vista system is state of the art. do you think it is state of the art? >> i can speak for my domain.

i am in the finance and business application and engineering. i can tell you for engineering. it is not state of the art. for our work order management and bio med technicians it is not state of the art. for our facility management and house keeping and environmental staff it isn't. i believe that the in the electronic health record that captures all documentation associated with a patient and it set the standard. some of these other domains i know we need to look to industry to find out. i put scheduling in front of that. i think we need to look to the dustry that knows how to deliver

systems. >> if those areas are lacking why isn't this part of the action plan? >> the schedule plan is part of it action plan. we are working with ornt and plan to have an award for replacement scheduling system. our intention isn't to pick someone who can write a book about developing a scheduling system but to acquire a system and deploy that scheduling system. >> and one final question. another thing i notice there. obviously you have seen how this committee and 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. but another thing i saw was the staffing system was flawed. if it is taking you 3-6 months to hire a doctor that is ready to be hired you are going to lose them to the private industry every time.

>> i am not an hr professional but i agree we need to work on our speed. >> i yield back. >> thank you. >> i am encouraged by the fact you are looking to industry to help solve the problem. i sent a letter to the president recommending that be done because we know there are organizations that do massive scheduling and they do it right and do it good. so thank you for that. my first question is to you dr. draper but i would like the whole panel to address this, if they could. i represent a large rural district in arizona and they go to four facilities and dr. draper you said there is not consistency among the various centers.

i wonder if you could identify the top three reasons for that inconsistency and what we can do to make sure this it the best health care delivery system for the veterans. >> part is the weak policies. one example, i will go back to the wait times and no shows and canceled appointments. you will find each facility develops their own policy. so we have seen anything from a 1-130 facility and one phone call and give the veterans 30 days to respond or it is canceled. we see two canceled appointments and then it is canceled. so the key point with the consult information is the va is

trying to put together system-wide database of consu consults. the data is going to reflect variation and you will not be able to compare apples to apples and see similar things like that. >> can you address that? >> i would agree with dr. draper. the policy sets the operating principles but we need a hand book to that to provide precise instruction so there is not interp interpretation. there are three or four telephoneic attempts throughout the day and followed up by a letter. we need to do a better job. >> is there a structural problem

in the administration at the veterans office? i am wondering if there needs to be reorganization in terms of oversight, supervision, accountability and transparency. >> i know we need to get back to the core of delivering safe and reliable health care they have earned. start with that. find how to do that, make that policy and don't allow us to have a different policy that is different from a national policy. write a national policy and hold people to it. >> i have a feeling the problem is beyond that. you had the technology is outdated going back to 1985. i have to wonder -- why? this committee wants to get to the bottom of this. but my are we still using 1985

technology? is it lack of funds? >> i would approach it from a different angle. >> go ahead. >> your facility is only as good as the people working there. and there are five qualities to every great team. communication, upward and downward lateral communication. managers need to get out of the office and walk around and find out what is 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 to help our nation's veterans. caring. of course, in a medical center caring has to be one of those qualities. and trust.

if you have those five qualities you will have a great team and that is what needs to be in stilled in the personal at all of the facilities. >> thank you. i am running out of time. but it sounds like policy and personal are two key issues in getting to the root of this problem. i yield back. >> if i can -- real quick and i apologize, but i want to bring the committee up to speed because there is a very important question that needs to be answered. why are we still using outdated scheduling software and programs? ...

and then there's these -- the vista fm, two and a half billion dollars och in investments that this congress is made. and yet we sit here asking, what is the answer to the question why are we still hough using oud systems when we have given hundreds of millions of dollars to the va. mr. runyon, thank you. i apologize. you're recognized for five minutes. >> thank you, mr. chairman. first a on to the first of all,

wants to agree with the comments my colleague, mr. denham, made to the business that my veterans visit, number four, number three. three of the facility's are all in that further review category, and a request this information that mr. denham did. i have -- for purpose of, i think, while all this started in this secret lists, so we said keystone with who, is vista not capable of scheduling to gestures out? if we did not have the metrics that dr. lynch said 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 that.

they go hand-in-hand. first of all, i think setting an unrealistic performance metric and dying rewards or incentives to the meeting -- again, this is not even an outcome measure. this is an activity measure. tying rewards are incentives to the attainment of that activity was a mistake. not understanding the capacity of our system when we set that was a mistake then. there are reasons we don't schedule two years in advance, quite frankly. just you don't want to hold up the entire set of appointments lots with the appointments that are so far out that they might end up getting met. there are technical reasons you would not do that, before the most part this is a and culture question. we have found in some of our networks where staff for using the same outmoded technologies and policy. i bring that up because i think you kind of touched on it that

there is a balance there. what is -- and i think it will go to my next question, and several people abroad of. standardized procedures and policies from washington. you have seen pitbull, the different visions, the wait time issues. it goes to this question that i asked last time. believe they're not, i got a response this i asked the question of an auditing feature that was turned off in the phoenix region. i got a response that it had been turned on nationally. could any of those audit features been turned on help to the ig in the process and/or internally in that region for them to the avoid the situation?

>> sure. i think the one thing that has been clear is the the audit log try it was never turned on anywhere. the concern was that it would affect system performance, create a huge data storage requirements. it is now turned on across the board. it will help us understand who edited what kind of appointment. for instance, i think one comment was how he would cancel an appointment. we could see he did that and if it occurred numerous times. we get married and up and find that behavior. >> i just want to make this statement because on shore as chairman just said, there were millions of dollars spent for that feature and the initial of role that systems. i would say, the one thing we will be different with this

acquisition is that it will not be just a proposal. part of what we will expect folks to give us is working software that is proven to integrate with our system, not a book about how the software this at some point in the future will integrate, but a working product that is part of the proposal. >> thank you. >> chairman, i yield back. >> thank you, mr. runyon. dr. rees, you're recognized for five minutes. >> thank you, mr. chairman, or holding this hearing. with the release of the department of the va access audit and the interim inspector general report palmate is clear there is a systemic failure of responsibilities. widespread misconduct and coverups that led to the deficiencies in scheduling resulting in a lengthy wait times and veterans dying waiting for care. the veterans in my district and across our nation deserve better i did it -- i demand that the new of the va put an immediate and decisive end to this severe misconduct and of those responsible accountable.

as i have called on in the past and we have discussed today, a criminal investigation is needed to remove individuals who knowingly prevented veterans from receiving the timely and quality health care they need and resulted in harm or death. a criminal investigation will put an end to this wrongdoing, will change culture now one for the future. currently there are over 1500 veterans a unified -- realize the loma linda health care system, many of which live in my district that are either awaiting over 90 days or going without an appointment altogether. it is time that the house passed the veterans access to care act, h.r. 4810, to make it easier for veterans who are too far from a va or are waiting to 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, stopped the scheduling misconduct and, too, that treat the veterans, give them the care when they needed it. after reading the audit today i have several questions. the first, what are the possible solutions to get veterans triages and cared for immediately. let me preface this. 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 there were

immediate striker teams formed that would go out, educate the population, do the research, educate the population of the health care available, form teams, go out there and treat the patients. when are we doing to treat veterans now? >> on may 203rd we ask all of our facilities, provided them productivity data and ask them to assess if they could get more productivity out fee. we also gave them their local wake the dead competed nationally and distributed to the field. construction was clear. where you can find capacity now overtime. this system launched a veterans. we have to make it efficient. that is the first order of business. the second order is, if we cannot identify where we can require that care in the community beginning may 23rd

contacts are going out to the field, network ten, which is ohio, completed all of its contact the following week, all of them. every veteran who was waiting, they called. can we make it that? yes. we also identified $300 million requirements in the immediate term. >> if you are relying on a broken system, you are going to give brokers results. i encourage you to find a model, a benchmark, former special operations unit that not only identifies positions within the national va system, but also within the private sector to rapidly deploy to the priority healthcare systems and create a form of health care events, tree gosh, and get them seen sooner than rely on a broken system to fix it.

>> may respond? >> please. >> the 69 additional facilities that we have sent rapid response teams to are all criminal investigators. i coordinate with the fbi. it is a requirement of the him attorney general guidelines. mutual notification for safety and efficiency considerations, you don't find yourself going to arrest the same person at the same time. trust me, we have an excellent criminal investigative staff and they are pursuing all leads in this manner. >> i make reference to the case of phoenix, the use of the disaster and emergency medical staffing t-mobile that is being

used in phoenix. how willing to identify across the country at a moment's notice. starting on sunday there were 21 such black styles. >> i look forward to working with you to see if we can extrapolate that experience the other va systems including los angeles and other areas like where they might have been very long wait times. >> thank you, doctor. you are recognized for five minutes. >> thank you, mr. chairman. >> i feel sorry for you being here today because you are representing a system that really has no defense and i appreciate your apology. i will start today by looking at

page 27 of the va internal audit which was released today. a medical system, the hospital and i am not michigan as being in wisconsin. now, you cannot place the facility in the right state. i don't know how we can trust you with the big stuff. as i said, i feel sorry freestanding that today. you know, the va internal report said that the va told them, the wait time in phoenix averaged 24 days at 43% weighting within 14 days. well, when they went there i took a similar sample and found the average wait time more sample was 115 days. 85 percent being more than 14 days. how are we supposed to address anything that va says about this ? >> thank you for your question. i would tell you that we had the fuse light version control issues to the tail end of this.

we know where our anomaly is. it did not make it in the final. >> how am i supposed to trust the data you did today? you know, the last 80 submitted was completely different than the ig reported shortly thereafter. you see the problem that we have here. i feel sorry for you sitting there. >> every two weeks from here on out -- i'm sorry, bimonthly we will produce data. has 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 mrs. kirkpatrick across the aisle who says that the system needs a complete revamp and restructurings because there is no accountability here. there is complacency. i like to associate myself with mr. ruiz is strongly recognize for the prosecution and would you, mr. griffin, for your

comments about people not getting fired for not doing a job. frankly, i think we need leaders and hopefully we will get it, some leaders that will make people responsible and fire people than are not getting the job done because this culture of not being able to get the job done and it does not matter has got to stomped. i appreciate your comments. you kind of slid them and there. people need to get fired. we can make that happen despite the work rules and all the criticism that we get. we need to have a system that can fire the people that are not doing their job and to listen to people at the ground who have the comments. they talked about the simplest and that every private practice in the world does, called a patients a day or two before the bombing to confirm that they're coming. that va has not figured that out

? it is impossible to believe that that actually occurs. that, there are -- the employment people are writing people letters without talking to them. it is like, really? no one is getting fired over this kind of decision making? it is unbelievable that this is occurring. i appreciate you for your comments. we need to have leaders within 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 will be out of there or prosecuted. just simply that happening will change the entire culture. >> could you comment? i have a few seconds last. where do you think this should come from? the top or the bottom? give me some comments on your thoughts about this. >> i think you need leaders up and down the chain of command.

while we have witnessed on some of our previous work was that veterans affairs has sent out requirements, safety alerts, directed the medical centers to address the issue and to certify that they have taken corrective actions. >> does somebody sign these certifications? >> just to finish the thought, we went out unannounced and determined that 42 percent had actually done what they said they did and the other 50 percent did not even though they certify that they had accomplished the directive. >> without any consequences? >> not that i am aware. i would ask them to speak to that. i am not aware of anyone being held accountable, but i don't know how you could not hold someone accountable for a direct disobedience. >> apparently it occurs every day. i am out of time. thank you.

>> thank you. mr. custer, you're recognized for five minutes. >> thank you, mr. chair. i wanted thank you all then obviously challenge and circumstance, bugboy. i am anxious about the decision to require a schedule system that works in the private sector. is that the intention, mr. make up the? >> i'm not going to get into the arcane about us design process. i want to address one comment. this audit that we did was designed to be the start of our change. i want to be clear. if anyone thinks i have not submitted to make the team is not committed, please understand that we are committed to this.

this is the start, not the end, not the final report. >> in the private sector we see resource-based scheduling, which is the resources that are provided, of a clinical resources. in the va we have grown up around something we call sort of clinic-based scheduling. we manage clinics as opposed to resources, and it makes it tough for us to deal tagger in all those views as one provider and know how many slots dr. smith has. makes it tough for us to do that. it is not an excuse but we need to move to resource-based schedule and which allows us to know how much capacity we have in our system and how that maps to the providers. >> we have reverenced what i think is causing the exponential factor of the loss of effective appointments.

i will not dwell on that, but getting back to the resource stage, you mentioned that there is not an infant supply of medical personnel hamel we are talking about is a lack of slots. i wanted to focus in on the issue of graduate medical education. one option that i have seen discussed this to relieve medical student that, whether that is physicians, weather, perhaps, there could be greater use of nurse practitioners, ancillary personnel. and i would like for you to address that in terms of equality in my district, right -- white river junction health care center is closely affiliated with dartmouth medical school. it is a very positive arrangement, but think that we could replicate this around the

country. >> i can. that -- weekend. think we discussed it earlier. providing a wonderful opportunity to new, young talent and have them exposed to the mission of our organization which is a noble mission and a dedicated work force. the people who serve our veterans. i would have to take you for the record. >> something that we could look into, the idea that we are blue where a leading medical student debt in return for service. did you discuss ancillary services and providing greater or more efficient access?

>> the erin going to give myself in trouble. >> i would be very interested. this is something that is happening across our health care systems using more physician assistants, that type. >> i know that it is something we are looking at. >> great. and then justing close to the closing, back to the issue of restoring trust and integrity, i appreciate the comments. i tend to agree with you. how few high-profile prosecutions would create themselves rather dramatically. >> a couple of questions following upon the issue of restoring trust.

when before our committee two weeks ago. their 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 or instructions from washington that would prevent the employees from visiting with the media and our members of congress? >> i personally am not, congressman. >> let me give a little background on that. friday, may 38, told that there was no one on a secret waiting list. three hours later a letter was released that said that there were three @booktv sees me, actually nine. at that time on a friday afternoon evening i have begun calling the leaders and received no response until a fallen wednesday when i began hearing rumors of 385 on a six rating

last. i jumped in a vehicle, drove for one hour. and was met with an e-mail. >> that, indeed was an accurate ino. do you think that helps build trust? >> it does not, sir, but you are certainly not aware all that those types of e-mails were sent out through the va system, at least there were actually guy and they would not provide me a copy of the milk, probably 100 different names. that did not know them. i knew the one sentence at the end, don't talk to anybody. you are absolutely not aware. >> i don't know, congressman. sort of working on the audit in some preparations. it is possible. >> why would an e-mail like that be sent out? >> one reason would be the

following. we were going to release an audit that would contradict the statement that someone locally might make to say everyone to have everything is fine. no issues and are 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 is fine and along comes a knock at this is not everything is fine. by the way, here's the additional data. >> your audit edifies 104 veterans waiting in wichita for care. 385. how are those two numbers different? >> i would need to compare. >> year is out. i am not certain that this is the cause. the data was current as of may 15th. if you went to the decision you would pull all local number that might be better. prior to coming to the sites.

>> let me interrupt you. the facility said that they knew of 385 on may 21st. then they told the public and as senator robert zero. then they told us nine. then they said may be 385. until i knocked on the door they would not confirm the 385. numbers have changed. and in the middle of this you have a gag order. i would like a quick response, certainly much quicker than the march 2013 request to get to the committee that has not been filled yet. how do you handle folks to game the system illegally in clear violation of the policy. asked at that time, as any one violated those rules? >> you have not yet responded. >> is there reason you did not respond to that? >> i am not sure what the

question was. >> when we go back in testimony would be happy to provide that to you. that question is -- matches up with the april 262010 mobs. my colleague kind of felt sorry for you, but this is not the stuff. >> it is not. >> it is not new stuff. >> i was not here yet. the 26 different schemes for gaming the system. avi -- have you changed any of those? veterans have lost their lives, and i don't have any clue, any indication because of something you have known for years. thirty-six different reports. you come here and say we will do better next year. >> yield back, mr. chairman. >> thank you, mr.

>> one of the things he talked about was the cancellations and an anxious. in el paso we heard anecdotally of cancellations that are recorded as no-shows', of veteran last week, for example, told me that she had gone to that va in el paso from its of their apartment she thereafter requested a copy of her medical record and found that that cancellation was recorded as a no-show. hits against her record is not heard the va wait time reporting. have you found it evidence of those kinds of practices in your investigations thus far? >> not specifically that.

we did find more than 50 percent of the 150 cases that we looked at had at least one no-show or cancel the appointment. and, you know, we found clinics. we found -- we like to ask -- for each facility we looked at 30 consoles and spam consoles for the three specialty areas we looked at. we did look at one of those. one of the specialty areas, they cancel all ten appointments. all ten of the apartments were canceled. it raises questions of whether there were canceled. >> in el paso we have long heard from veterans who said that they could not get a mental health care plan. certainly could not get it within about 13 days. there are seeing everyone within 14 days kamal were hearing is so great that we commissioned a 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. and i also appreciate the audit the release today that shows that new patient mental health care average wait times in el paso are 60 days. that is the port or stagnation. but i will tell you that if may 9 to receive this report from dr. pencil and mr. john mendoza that showed that zero

veterans waited more than 14 days, not just the previous month, but the model for that, the month before that. at worst 15% of veterans waited more. simple question, which should i believe, the information that shows no wait times for 14 days are your animation that shows that it is 60 days? >> the information today. i tell you that as we improve the integrity and reporting wait time, establish basin data will get worse as it becomes more fallible. that is important. >> that news will be welcome because, as you said, it would be rooted in reality and the facts and what we are hearing from our constituents and the people of we serve. we will not be able to correct this problem until we know extensive it is. i appreciate your commitment. on a related note, i will be introducing veterans can't

record as a no-show will have a phone call from the va to confirm that that is what has happened. was that essentially what you committed to? >> i have. we do patient satisfaction data. veteran patients rate the quality of their health care experience sib. they also tell us in our satisfaction survey that the rate their access as per below. so i were just as for your continued cooperation. we will introduce this bill this week. i think having an independent third party, the oic, the gao,

someone apart from government altogether asking veterans what they're wait times are is part of the solution in that we will get real information and make better decisions. appreciate your help and appreciate the testimony and the expertise from everyone on the panel. with that we'll adapt -- >> you're recognized for five minutes. >> thank you. of want to thank the veterans administration here tim. this is the first of all of -- r the shoulder. to make sure that our nation meet its obligations to those who serve this country. the military. i feel that every year and have had prior to this, it is denied,

cover-up , and delay getting information to this no accountability, no transparency on behalf of the veterans of ministration. you know, i have to tell you, i think there are a lot of great men and women who work for the veterans administration. a lot of them are whistle-blowers who have put themselves a risk. if not for them we would not be here today cleaning up this problem. and so -- and i just want to say that i think one third of the men and women now work in the veterans administration, are in fact veterans themselves. i would love if you would look at increasing, whenever we can do to increase that number. there is no one understands the needs of veterans more than those who have worn the uniform. whenever you can do to get that out, i appreciate it. so when we get to this 14-day wait time, and i heard that it

is simply not attainable. well, what is realistic? i don't know what the right measure is. we have to study it, looked at what is right for an individual veteran based on his our own preferences, vacuities to come into the next for cardiology 14 days is not soon enough. it has to be based on an individual veterans requirement. i think setting an across-the-board standard encourages an attempt to meet that standard. we will still measured timeliness, still aspire to be faster. we won't try rewards are incentives to that activity. >> that benchmark, you

interjected financial rewards into that, fuelling the incentive to manipulate these wait times? >> i do not. i mean, and our surveys we did not as people. >> don't you think that it was the financial reward that incentivizes behavior? the seeker waiting list were veterans were ultimately denied care as a result of this manipulation. >> the simple lack devastating this is our goal thus should not do anything other than this, with other financial incentive much of that behavior. >> wouldn't it be more inclined to speak out without the fed's own sense of point --

>> this culture of bureaucratic incompetence and corruption is so deep. i appreciate the forthright nature of your testimony today. i think it is so deep and so ingrained that it will be hard to turn around. i held veterans of the choice. if you're not able to meet there of kenny's that they can go outside the system. i hope that that then incentivizes to see them as customers. right about there are variances between facilities across this country. incentives to drive quality standards with our veterans are happy, we are having a good year

. >> if not they ought to be allowed to read go outside the system. the massive structure really is not there to support that, and that think it needs to be developed. would that i yield back. >> thank you. you are recognized for five minutes. >> thank you, mr. chairman. thank you for being here. when our system of government works right it is to be a reflection of our constituents, and that that you hear it to my would hope, loud and clear. the frustration, the lack of trust is universal. many decades of good work can be erased quickly bought bad actors the question is whether we go from there. want to thank you on the work for the ig in the gao. we go way back on these things. when the system works right you are here as a ranking member with murfreesboro and miami with contaminated equipment. we brought in best practices to

my implemented across the system. by all accounts we made a correction. they're is model to try and do this. that being said, as you look around, there are many that have long institutional knowledge. many of them have been coming and talking to us and telling us . incredibly frustrating. the breakdown comes when i have to be honest with you. i have proven myself and trying to get this right. i have seen this as an abstraction and nuisance. i have restitution in my district that was offered to help. perhaps i can get a call. this has gone on and on and on. i am a loss. they -- their people sitting back behind you.

i think your sincerity in the work you have done, certainly i am not going to question it. i am reading, this is from dr. heaney and armstrong. they quoted peter drucker and said the greatest danger in times of turbulence is not the turbulence but to act with yesterday's logic. the question was, where is the big idea. my question is, where is the big idea? if you're right to come and ask for technology money, that is a cursory thing they found. when they pull the testimony of the people on the questions, you are going to be embarrassed and my guess is you will not want to, and as for that money. my question to you is, where is the big idea? where is the vision? >> it is a big idea. it may not sound as such, but it is back to basics. back to delivering safe, quality health care at timely manner, knowing where we can achieve it

and where we cannot. an open engagement from partners, a veteran service organizations were not mentioned enough today, but they are our partners. talk and listen with them. they have good ideas about how to get back to basics, not to listen to veterans to what they want, what they're telling a spirit at work with members. some of those things, when we listen and worker when we started measuring wait times there were too long. i don't have a big idea, sir. our idea is back to basics. can be a great system. as phenomenal employees who are mission-driven. our idea is to get back to basics to deliver veterans care in their system. >> mr. griffin, is that possible as it currently stands with the leaders and structure that are there, in your opinion? >> in my opinion it will take a fair amount of time. it will not happen overnight.

there are number of different areas that need to be addressed. when you are talking about timely quality care one of those is performance standards. i heard dr. road tar previously about people who dg i work in the private sector. maybe a are at hmo and know every day i have to do x number of colonoscopy is everyday. when we get out with you in december of 12, specialty care, we have 33 specialty areas. only two of them a performance. how many of the procedures, then generate the number. >> and i like my colleagues have been questioning all the data, the satisfaction surveys, everything that is coming out. it is frustrating. i would leave it with this before my time runs out to you, today and this report that comes

out and you heard mr. denham and others, when you find those entities that are out there, those locations, you do realize every single veteran that attends those is tonight calling, wondering, asking what happened, was there, what is going on. and we don't have a hard time line when you will come back or an idea where it goes. now instead of creating a transparency and that honesty and the reconciliation on this we have created another layer that is causing a stir among veterans. so i would just encourage you, we have to look at this a different way paribas. >> you are recognized for five minutes. following about, the white house deputy chief of staff visited the cincinnati medical center in the area where many of my constituents are veterans that

go there, and i learned that as a result of the internal audit that they were flagged as requiring further investigations. at this time can you tell me what is happening at the cincinnati medical center that got them flag to and should veterans in my district be apprehensive about the care that they are receiving are the timely fashion in which they received? >> they should not be concerned about the quality of kin -- quality of care they're receiving. there are specifics behind each one. it could be a single concern that came in at the time that we were there. we felt those cases, when needed to make sure we listed that. >> get the details of why that was light. >> i do not know yet, but i won't. we have to move back quicker. we reduce the level of banks to. we have to do that.

>> the problems that we have i come from private practice. veterans seeking care in some ways are a liability to the system or to the administered. they're not a desired customer. we have talked about that. and we really need to have incentives for quality and incentives for proficiency. you know, we need -- private practice, a no-show is a liability, i huge liability. you cannot keep your doors open if you have them. they're needs to be not a reward for this. they're needs to be a reward for coming up with ideas of increasing access to private practice will do. the other thing i am concerned about is the council. obviously sometimes there's a level of urgency depending upon, as you mentioned, the acuity of the problem.

you know, if i am referring a patient for an acute problem and will get on the phone and talk to that person i am referring to to say can you get the man? this is something that we do in private practice. you want to make sure your patient is taken care of. when we have a no-show if it is someone that you have been treating and they do not show up as a practitioner you have a personal responsibility to that patient. you find out why. my feeling is, you move forward. you talk about the big idea. at the administrative level we have to look for someone outside the va. if you spent your whole career and a va system you don't know what you don't know. you don't know these things that make an efficient system. it is not on your radar because you have not had to do it, and it is changing an entire culture if you're going to get someone

with in the same culture we're probably going down a problem. we need people that understand. as you said to me of someone desires to be there, that is a good day. you'll get is to have competition. would you agree with that concept of may be coming from outside the va? >> i am an old consultant by training. for me, time is money. and the availability of the time is billable their is a balance. we don't want to turn into a 15 that appointments are ten men and apartments when no one likes to you. they're must be balance and accountability for time. 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, be respectful of the way we do it, but competition, to know that we can get more plants to more veterans who want to come in our system and are happy with our

system, we need to introduce some of those concepts in our thinking. >> the quality of care and the patient's perception. that is always the challenge in private practice, someone needs more time that someone else. maybe you give it and find a way to work within that system and make sure that when they leave there they feel satisfied. my advice at this time, one, i want to your what is going on in cincinnati obviously, but i also would really suggest that we take a look outside of the va system because if that has been your whole life, you don't understand how that it could be. and i think competition is the key. i yield back. >> thank you, doctor. you're recognized for five minutes. >> thank you, mr. chairman. i find myself again tonight -- i associate myself with the comments of everybody on this committee. the more i learn sitting here in

the more backward i am on the things that we heard two weeks ago and the things that we are hearing tonight. primarily on behalf of every american taxpayer, where the heck is the money, the billions of dollars that this congress and previous congresses have allocated to itea grace? what do you tangibly have? we have done this. what does that va tangibly spend money on that is working right now? >> i would have to take that for the record. we have veterans benefit management systems. >> she asked a question and you gave the answer. using 1985 programs. 1985.

the ig people sat right here. we ask the nasdaq stock has questions. in fact, i specifically asked them, who is in charge? do you have enough money to purchase what you need to get this system moving. the answer was yes ma'am. we have seen all these budgets, funded everything under the sun. it is baffling. the thing that i lead is interesting, did you not have any idea based upon mr. griffin's comments from 2005. eighteen months and that have heard the ig report after gao report. i know that there is problem. you said you are the business side, the engineering side, to those reports never make it to you? >> i agree with the r