i think va would be the first to admit that they need additional clinical space, they need additional clinicians, they need a new scheduling process, they need a methodology by which they can remotely monitor what wait times are in las vegas or any other place in the country where they have a medical center. i think they're aware of all those things, and i believe the new secretary and his team that he's assembling are dead serious about addressing those things. we do follow up on our recommendations. we have suspend states for when things are supposed to be completed, and we will certainly follow up very aggressively on these 24 recommendations. and we also have already had some initial internal discussions about how we might

scope a future project to go out and verify that, in fact, everything is working according to the plan. >> do not want to make recommendations that just sit on the shelf. >> no. we follow up on a quarterly basis. >> i share your enthusiasm for the new secretary, and i believe he is committed to both changing the attitude of the va and making these specific reforms. do you think the bill that we just passed, the compromise bill, will be useful in addressing some of these 24 recommendations? >> i'm afraid i'm not totally versed on the bill. i know there have been a number of legislative changes made in order to assist the department in accomplishing their mission. but i'd like to take that for the record if i may. >> all right. thank you. >> thank you.

>> i yield back, mr. chairman. >> thank you very much. members, we do need to pause. i apologize to the witnesses. we think it may be about 30 minutes for us to go and do that. we'll give you a heads up when we're going to start back. and this hearing is in recess until immediately following the third vote. thank you, everybody, for rejoining us. again, i apologize for the delay. mr. griffin, i would ask a couple of things. we've got other members that are coming back. you ask that we put dr. foote's testimony from the deposition into the record. we did so without unanimous consent. we have not had an opportunity to review it.

i see where you have done some redactions. the committee would like -- we have made an agreement that we would like to not enter it into the record until we have had an opportunity in a bipartisan way to look at any other information that may need to be redacted. we obviously -- i don't mind sharing it back with you so that we're not putting something into the record that could release personally identifiable information or illnesses or diseases or anything of that nature. is that okay with you? >> that's fine. the redactions that you see are ones that were done by our privacy officer to make sure that we didn't have any names in there that should not have been there, but better to double-check. that's fine. >> because we haven't had a chance to look at it prior to introducing it into the record, we are agree in a bipartisan fashion both of the councils have come together and said we will agree to the redactions and don't mind at all sharing it back with you.

i do have -- well, now that miss kirkpatrick has returned, ill like to go ahead and yield the floor to you for your questions. so, miss kirkpatrick, you are recognized. >> thank you, mr. chairman. you know, dr. day, you brought up an interesting point, and that is that there's a criminal process and there's a civil process if, in fact, causation is found because of deaths as a result of the wait times. and is it your understanding that there is now currently an ongoing criminal investigation by the arizona attorney general, the fbi, and the department of justice? >> there is an ongoing criminal investigation. it involves the criminal investigators from the ig's office. it involves the fbi. it involves the u.s. attorney's office in phoenix. >> so there is a process if in case causation is found.

>> absolutely. >> an to your -- >> if criminal behavior is determined to have occurred. >> yes. >> right. >> and to your knowledge, you mentioned the federal tort claims act, are you aware of any cases that have been followed -- i mean filed under the federal tort claims act as a result of deaths because of wait times? >> i'm not aware of any, but that doesn't mean that there might not have been one. we checked on the 45 case reviews, and we didn't find any file on any of those 45. >> thank you. dr. foote and dr. mitchell, i want to thank you for being here and for coming forward. i'd expressed to you in the past that i appreciate your courage because all of us on this committee really are united with you in our care for veterans and making sure that they get the medical care and access to that care that they really care about. and that's why i introduced the whistle-blower protection act.

wish that had been in place for you, but hopefully that'll make things better for future whistle-blowers. and part of that act is a national hotline that patients and workers within the va system can call and that information would go directly to the secretary in hopes that there wouldn't be any kind of retaliation. but as i mentioned, this committee really is committed to access to care for our veterans, and as you know there was a bipartisan bicameral conference committee that was appointed in the summer. we met together and we passed the veterans access choice and accountability act of 2014. and one of the primary pieces of that is a new choice card that will allow veterans who live more than 40 miles from a va facility or have had to wait more than 30 days to schedule an

appointment to actually go to a local provider. and, dr. mitchell, i was concerned when you said that you didn't know if some of these people who were on the wait list knew that they had a choice to go to an outside provider. do you think the use of a choice card which is going to go out in november to our veterans, giving them that option will help improve that? >> to clarify what i said, they had an option of waubing to a va primary care clinic to get care. at this point, if they were not enrolled in the va, the va would not pay for their care anywhere else. i think the idea of getting care access is wonderful. what the ig said earlier was that veterans had a choice, they could go to an e.r., hospital, or private doctor. they don't have a choice. many americans don't have insurance. if they get sick they opt not to go to a physician. i don't know about the other members here, but frankly i

would have a hard time paying for the cost of hospitalization or an e.r. visit. many veterans will let their chronic diseases get worse. as evidenced in two cases they kept going to the e.r. because that was the only way to get their severely worsening systems taken care of. it's the equivalent of only putting out the fire but never doing anything to prevent the fire from starting. >> well, i appreciate that. and our hope is that with the choice card that will make a difference, especially the veterans in my rural area, who many of them are 40 miles away from a facility. they'll be able to go directly to a local community. and as you know, i have 12 tribes and 25% of my district's native american. they'll be able to go to their local health services facility to get their veterans care. so huge piece of the reform act was encouraging a partnership between the va and the indian health services. so again, i thank you for your testimony, for helping to guide this committee to do some meaningful reform. and we'll keep an eye on it. i yield back my time.

>> thank you very much. mr. coffman. >> thank you, mr. chairman. mr. griffin, will you provide us with all e-mails, draft discussions, and comments provided by va with regard to this report? >> i can provide the ig e-mails. they will be reviewed by our officer to make sure no one's identity is left in there that shouldn't be, and we'll provide it. >> mr. griffith, as you are aware, the department of justice has already declined to prosecute 17 cases of possible criminal violations by va

employees that your office has referred to them. what are some of the reasons the department of justice has provided for not wanting to prosecute? >> some of the reasons include that it was not determined that criminal behavior occurred. in some of the cases, they had more rigorous prosecutive standards for the cases that would rise to the level of getting prosecution as to poed to administrative action. in some of them, the fact that someone manipulated the data but there wasn't proof of a death as a result caused them not to prosecute. some of them said this has been a systemic problem in the department for a number of years

that has been allowed to perpetuate itself, and the ability to demonstrate that someone knowingly and willingly committed a criminal offense was too difficult. >> were you surprised at that? were you surprised at that response? >> no. i think that -- we work with these prosecutors every day. >> mm-hmm. last year we arrested over 500 individuals. we arrested 94 employees last year. so we're aware that they can't prosecute every case that they get. and frankly our investigators would like every case that they investigate to be prosecuted, but that's not the real world. based on the demands on the department of justice and the court system, et cetera. so determinations are made by the department of justice in

that respect, and we have to live with them. >> so -- and let me just say i passed an amendment on an appropriations bill to put more money into the line item for the department of justice for the specific purpose of prosecuting these cases. don't you think, though, somebody, when you talk about systemic, that there was a culture of corruption, and maybe the fact it was a culture of corruption versus an individual case, then i guess it was okay. >> no. >> but let me ask you this, then. when somebody does something -- manipulates records for the purpose of financial gain, isn't that a criminal offense of itself? should there be an example set by somebody being prosecuted somewhere in the system? >> i agree. and i'm not saying there won't be either. there haven't been any at this point. you would expect that the cases with the least amount of

evidence and the least amount of manipulation, if you will, or co-conspiracy would be the ones set aside the earliest because the additional cases will require more work. and we are working feverishly on those cases because we know it's important to get through all 93 of them. and as we finish them, if there will not be criminal prosecution, i know the department is anxious to get those reports so they can take appropriate administrative action. >> i just have a tiny bit of time left. are you surprised there weren't criminal prosecutions, dr. foote? >> not at this point because i think the fbi is still investigating. >> okay. dr. mitch snell. >> i'm not surprised because there's still retaliation against whistle-blowers. there would be no reason for them to prosecute the people that are per traiting it. >> mr. griffith, it does seem like the department of justice

is looking the other way because obviously the situation is embarrassing to the administration. with that, mr. chairman, i yield back. >> thank you. mr. walz, you're recognized. >> thank you, mr. chairman. i want to thank all of you for your work towards veterans, and that's what we're here to get, the situation in phoenix and elsewhere that provied even one veteran substandard care is simply unacceptable. and i would like to go back. i have a long history with the oig's office. i know someone myself counted in my unit heavily on the ig to provide another set of eyes to provide that unvarnished view of what was going on. so let's be very clear. what's being implied is that the integrity of this office was influenced by the va. so i'm going to ask very clearly, mr. griffin, did anyone at the va ask you to change the report to make it look better in their stead? >> no. >> is it normal standard operating procedure for multiple drafts of a report to be done?

>> it is, especially a report of 170 pages with 24 recommendations. >> has there been a case before where your methodology has been questioned to the point where you were called in front of congress to defend the methodology, not the results, of the report? >> no. >> this is the first time. >> that's correct. >> and is it your understanding -- and, again -- that it is predicated on the interpretation of you were asked for the original draft? >> that's correct. >> okay. with that being said, the report you issued is very damming to the va. >> it is. >> and there are many things they fell down on, and the department of justice and making sure that dr. foote and dr. mitchell and everyone else who's willing to -- there has to be a route and an avenue that people are made whole and that people are held accountable. and from my understanding that is in the process, that the fbi and the department of justice are looking at that. is that correct? >> the investigation is ongoing in phoenix and other places. but we also in our very first

recommendation in that report referred the names of the 45 veterans in our case reviews to the department for them to conduct appropriate reviews to determine if there was medical negligence and if there ought to be redress to the veteran or his family who received the care. >> does the va oig prosecute cases? >> we investigate cases. we take them to the prosecutors in doj or in some instances in state court if we can't get traction on a federal violation. >> okay. does this report and the way it was handled strike you, mr. griffin -- and if i'm right, how long have you been with the snoig. >> about 13 1/2 years total. >> how many investigations have you been a part of roughly? >> well, we have done about 520 arrests every year for the last six years. that's a number that is handy to me.

but that's about an average year. >> and the methodology, the folks who work were your investigators and how you wrote the report, is there anything strikingly different about this one than any of the previous you've done? >> this was a very large undertaking, and it was a combinati combination of criminal investigators who have the same job series as fbi agents, secret service agent, et cetera, but it was a giant project where dr. day's people had ownership of the medical care and the case reviews, then halladay's staff, the audit staff, had the responsibility to try and identify all of these people who were not on an electronic wait list through a number of different sources. so her staff did that. so to try and pull the three different disciplines together and get everybody on the same page as far as what makes

sense -- i mean, there might be some language that make sense to david that might not make sense to -- >> and i would argue it makes sense to dr. foote and dr. mitchell. >> sure. >> that's coming out because there's still obviously the belief that we haven't got to the bottom of this, that we haven't got everything that's been done or there has not been held accountability. with that being said, i want to use my remaining time that that will still be investigated, my immediate concern right now is on those 24 recommendations. do you feel in your professional judgment, are they moving in the proper direction? because you have had people come here and testify before that va did not implement your recommendations and you had to come back again. do you feel at this point -- and i know it's early -- >> it is early. it's less than a month since the final report was issued. but i can tell you this -- out of the wait times issues previously identified in our interim report -- >> correct. >> -- and i know that the department started addressing those immediately, in the updated report when we identified an additional 1,800

veterans that were not on a list that were in a drawer or were just not properly being managed, we immediately gave those 1,800 names to the people in phoenix so they could make sure those veterans who had not gotten care got it as quickly as possible. >> can i ask one final quick one, just a yes or no from each of you, and i know this is very subjective but you're at the heart of this matter and you have a better insight than anyone, does it feel like cultural changes are beginning to change to hold accountability, in in your opinion? >> i think the change will come as we complete more investigations and people realize that there's a price to be paid. >> dr. foote and dr. mitch snell. >> asking for my testimony to be made public, i would not agree with that statement. i would say no. >> okay. >> i'd say no. there's lots of investigations, but there's been no substantive change. >> very good. i yield back. thank you, chairman. >> thank you very much. mr. walorski. >> thank you, mr. chairman.

dr. day, you had said earlier today i believe to chairman mill they're you did not conclusively examine all the medical records to determine if patient deaths were related to delays in care. yet in the report your colleagues released, it said, "the ig's final report in august concluded it could not conclusively assert that long wait times causeded the deaths of these veterans." can you explain to me and to the families who are watching today, going through this, especially if they've lost loved ones, how can the va emphatically say to us that you can determine no link between wait times and deaths if you didn't examine all the records? >> so let me clarify. we examined 3,409 records. to the chairman's point, we did not examine all the records of patients on the near list. that would be people who said they wanted care at va, if they never actually made it through

the maze and got an appointment. so if there was no record for me to review, give than the electronic medical record was our main source, then i could not review those cases. all of the cases that we were able to review came from a whole variety of lists, most of which had to do with waiting lists that we found at phoenix. so in those cases, we did, i think, very thoroughly review those cases. and in those cases where we determined that there was harm, delayed care, caused harm, bepublibepuwe published those. and in those cases where we found improper care, we published those. so we had 28 cases we thought people were on a waiting list and as a result of being on a waiting list they were harmed. we have an additional 17 case where is we thought the standard of care wasn't met, that -- and so we published those cases. i think that i am not trying to

say to people who couldn't get there, who through frustration couldn't make it through the barriers, i'm not trying to excuse anything at the va. i'm only trying to answer a fact. on these people, on the cases we looked at, did we see a significant impact on their care because they were on a waiting list? and that's what we found and that's what we published. i further say that i don't believe that our review necessarily need to be determinative in the sense that i put the scenarios out there hoping the citizens would read these cases and would understand the complexity that these veterans present and understand the difficulty that they have, understand the fragility of these cases so that when they don't get care in a timely fashion horrible things are likely to happen.

each person can read these cases and says a perp committed suicide, they make their own decision on that point. so i offered the opinion of my office, which has the ability to see lots of data that's not in these summaries intentionally, a lot of the data is unnecessary for the basic fact pattern. these families have a right to privacy so we try to be very careful about what we decide to publish with respect to facts to a case. so to the issue that people would like more data about these cases i understand it. but i think the va need to ensure that veterans have access to care, that it's done appropriately, that the trains run on time, and in that way the va can deliver proper care. >> i'm just curious, if you had a chance to go back and reinvestigate these cases tan procedure, would you do it differently today? >> no, i wouldn't.

i think the way we did it is the way we've done this for many, many years. i think it's very thorough, and i think proit deuit produces a result. i wish we had not been tied to was this issue of timeliness, trying to explain the impact of being on a wait list with quality care. that's -- i mean, that's a totally made-up standard based on the circumstances of the complaint of this case. if i could have picked something different to look at we would have thoughtfully come up with a different test. but that's the test we were presented with and so that's the test we had to try to address. >> thank you. thank you, mr. chairman. i yield back. >> thank you very much. miss brownlee. >> thank you, mr. chairman. mr. griffin, do you know if there's a parallel fbi investigation going on at this particular -- >> there is a joint investigation involving my people and the fbi.

>> investigating the same issues, asking the same questions? >> they're doing it together. if there's an interview happening, there's an fbi presence and there's an oig criminal investigator present. >> thank you. and, mr. griffin, you in your answering the member's question related to the closing out of 12 cases and still 3 ongoing, you mentioned something about they were closed out because they met the criteria and the questions were answered, but you talked about additional inforcyvon that was not necessarily related that you've culled together. can you talk a little bit about the additional information? is there something -- can you give me some examples and is there something -- >> let me clarify that point for you. when we did some of our 93 investigations, the 12 that we'd given to the department, we

didn't do a phoenix-level review of everyone of those facilities. that would take ten years. what we did look at is where we see delegations either through our hotline or through any other number of sources of a specific infraction going on there, and in some instances with more specific language than others, okay. so we investigate those. if the result doesn't rise to the level of the u.s. attorney's office and the district to approve criminal prosecution, that investigative package within the scope of the review that was done is giveen to the department. it's incumbent upon the department, it's their job to review that information and say, okay, maybe someone decided this

doesn't rise to the level of criminal prosecution, however, we think disciplinary action, which can range from counseling to firing, needs to be taken in this case. so in order to prove that which they'll have to do, they'll look at the piece of the investigation we did, they may determine that they need to go interview somebody else for whatever reason to support their administrative action, and if that were to result in some new information that we were not aware of, it could cause us to reopen our investigation. but it's up to the department to take those administrative actions, and that's why when there's no criminal prosecution forthcoming on a specific case we hand over our reports and transcripts, et cetera, to the va and they can take

administrative action;1! based those in large measure. >> so there's not additional information or a list of additional information that was uncovered that has not or will be investigated? >> not during our investigation. i'm just saying that if in putting together their review for purposes of administrative action, if somehow they come up with some information that wasn't -- >> "they" being the department. >> they, the department, who have to propose the action, whether it be removal or something less than that. it could cause us to say we're going to go back and look into this further. but that's just the way the process is. >> i wanted to follow up i think on miss titus' questioning and just ask very, very specifically if you believe that there ared a

kwa adequate resources to continue the ongoing investigations at the remaining sites? >> i think that some of those investigations are much more narrow scope than the magnitude of the review we're doing in phoenix. we are progressing on the remaining 81. every week there's another handful that were able to bring to closure. so the answer is yes. we have the resources. but i must say that this is not the only investigation that our people are involved with. since january the number of threat cases that have come to us and va facilities, the number of assault cases, we made 86 drug arrests since january 1, so some of these matters that are already in the prosecutive mode, i mean, we prosecuted a medical center director for 64 counts of corruption, and we certainly couldn't drop that case in order

to, you know, take on a new case when it's going through the judicial process. >> thank you, and i yield back. >> dr. day, there were 293 deaths. is that correct? >> there were 293 deaths that we reviewed, that's correct. >> how many of those were cross-referenced with medical documents? >> all of them. >> no. i think there were 28 that were on the near list that you -- i'm trying -- again, i'm honestly trying to learn, mr. griffin, and you have educated at least me as the chairman today on some things. i'm -- you -- dr. day, you said, because they were on the near list, they were not in the system so there was no medical record for you to review and you were not able to do that. >> let me please clarify. the near list included a large

number of patients. of the patients that we reviewed from the near list, we would not be able to review a patient if we did not have a medical record. so if you were on the near list, we don't have a record, then we excluded you from the review. so in our methodology section we can only look at cases that actually come to the va. >> and i understand. >> yes. >> but how can you -- and i keep going back to this -- how can you say you conclusively were able to say these individuals di not get timely care, they are now dead? >> i'm talking tact cases that we were able to review. >> i understand that. but there were cases you have just said you can't review. all i'm trying to figure out is there are cases that were part of this investigation that you apparently couldn't review them because there was no medical record for you to look at.

and so my question is, again, of the 293 deaths, did every one of them get cross-referenced with some type of medical record? >> so the total number of people on the near list is a big number. the total -- >> i'm sorry. the 293 deaths. >> yes. but what i'm trying -- i'm just trying to be clear sir. the 293 deaths were all among patients from whatever list they were on that had a medical record that we could review. so i'm going to agree with you. they would be people who would be on a near list who did not have a medical record who we could not review an therefore they were not part of the chart because it's not possible for me to review them. so all of the deaths, there were 293, we reviewed intensively. now, the 293 number is a data

point. the 293 number is from the 3,409 patients, 293 were dead. but that number is a number that has limited meaning in the sense that it's drawn from a pop leigh that you don't know the disease burden of, and so i can't tell you whether 293 is too high or too low because the reason for death could be normal causes. i understand. i apologize, but i'm still trying to find out, because in a staff briefing, staff was told that in some instances all that could be done was a match of social security numbers then looking at a death list, and so there was no way for some of those individuals to be cross-referenced with a medical record. that is correct, is it not? >> no. i think that that would be a misunderstanding of what was said. we -- i would not purport to comment on patients that we hadn't been able to review the record for. >> but they were on the list.

correct? >> so -- and, again, in our methodology section we said wex colluded. i realize we're all talking subtleties here, and i'm really trying to be clear. i can't report on cases who i have no information of. >> and i concur. and i think that's where the cross wires are coming from, because it's very hard for me to accept a statement and a document as we've been discussing if you haven't been able to look at every single medical record. and thank you very much for clarifying that. mr. huelskamp. >> thank you, mr. chairman. i appreciate that. i was also still am confused to were you able to identify the 3,409 veterans, those are the number of cases you reviewed? >> yes, sir. >> and you had medical records for all those cases. >> yes, sir. >> okay. but in pages 34 and on in the reports you identify numerous other categories of veterans that would total well over 9,000

that are on either not on the electronic waiting list or on the electronic waiting list or near the list or scheduled appointment, consult, back list distribution. how did you determine that that number gets reduced to 3,409? >> well, the report talks about -- at phoenix there were many list, and the report talks about lists from different sources and different points in time. so if you're talking about cases that were part of a the appendix, which were va's cleanup action, those cases were not part of the -- most of those cases were not part of -- >> excuse me. i do not believe it's an appendix. it's page 34, question two identifies, again, 9,121 veterans. and, again, they may not be

cumulative. my question is how did you decide not to look at 5,600 and some cases of veterans you decided not to review their case? >> well, we looked at those lists that were collected during the time frame of when we started our review up until about june 1, and i would -- i would have to go through and work through the data set we have of the actually 3,562 names on a list which distilled to 3,409 individuals of which 293 had died and of which 743 had a physician review them. so i would have -- >> if they were on the electronic waiting list, did you look at them and review their cases or not? >> we did. everyone -- everybody that we were able to determine was on any of these waiting lists of any variety described in this

report -- >> i just gave you another 5,600 that you put in the report. i'm trying to figure out why you didn't look at, say, the -- those on the near list had 3,500. did you not look at any on the near list? >> if you were on the near list and you asked for -- to get into the va system but you never made it through the wickets and you never got care, you would not -- >> if you died waiting for care because there was a failure in the system, they don't show up in your data as a death because of the system? >> that's correct. >> wow. >> they would not have showed up -- >> isn't that the crux of the problem? thousands and thousands and thousands of veterans are waiting for care and your report says, well, we don't count them because they died before we got their record. and we're not going to go back and look at other sources. that's what i'm trying to figure out. you winnowed down 9,121. they may not all be uniques and it's pretty unclear to me and perhaps the rest of the committee. if you could provide om information to the committee as

a follow-up on how you decided to exclude the 5,600. that would be helpful as well. i want to ask you one other question as well, mr. chairman. mr. griffin, the day before you released your final report to congress a number of news outlets were carrying reports with headlines -- because i know you look closely at headlines, you counted all the news stories -- and some headlines says no proof that delays caused patient deaths, no link called between deaths and veterans care waits, and no long waits -- are r these accurate or misleading headlines? >> i've seen plenty of misleading headlines in the last two weeks, some of them -- >> the ones i read to you, mr. griffin? the ones i read to you, are they misleading? >> no, but that's part of the story here. if someone leaks something before the scheduled release date of our report and if it quoted our reports, it shouldn't have been leaked but it

doesn't -- >> so is that report he line, is that misleading? >> could i -- could you read it to me again? >> yeah. absolutely. i'm sure you've seen it before. "no deaths related to long waits." no deaths. is that misleading? >> that's an accurate representation of our conclusion that we couldn't -- >> no deaths. >> -- we couldn't assert a cause of death being associated with the waiting times. >> how about no link? >> those aren't my word. you know -- >> i'm asking you for your thought on them because you are very worried about 800 headlines that you looked very closely at. >> i'm not worried about anything. >> actually -- >> that's just a reality that you could get out of google to show the amount of coverage that was put on the statement that there were 40 dead and that it was nos if, and, or buts about it. that doesn't take a lot of research to find that. >> mm-hmm.

>> okay? so -- >> thank you. i'm still not for sure -- apparently those headlines are okay, then, they're not misleading? >> i didn't say they were okay. >> are they misleading? i think headlines are sensational to get people to read a story. >> sensational that there's 5,600 veterans cases that apparently were not reviewed and that you had in the report. and so i look forward to the determination why you decided not to review those cases because i fear there are more veterans that died because of -- >> say there was nothing to review if hay didn't get in the door. he was reviewing medical records, and if they didn't get an appointment, they didn't have any records to review. >> when you say there's no causality and they failed to get in the door and died because we didn't deliver care, i say that's causality and your statement would be misleading. >> we don't know how they died or why, nor do you. >> mr. o'rourke. >> thank you, mr. chairman. and i'll say that mr. griffin and dr. day, i think by the

criteria that you have described to us that you are using to reach your conclusions, i understand where you're coming from, and i think it is a rather narrow legalistic interpretation of data, but i understand it and i think you've made that very clear today. and so i accept within those constraints what you've concluded. but common sense tells me just from cases i've seen in my district that there is a cause and effect relationship between care that is delayed that ends up being care that is denied that end up in veterans dying. and i've used this example before, with all due dew respect to the family, but they've shared their story with me and i think it's for a purpose. you know, nick di mee coe had been trying to get mental health care at the el paso vha, was unavailable to for untreated ptsd, and after attending -- after not being able to and attending one of my town halls where veteran after veteran stood up and said i have also

not been able to get in, he was driving home, and his mom relate the story to me, he was driving home that night with her and said some of these guys have been much older than i am and have been trying to for years to get in and cannot, i don't know what i have to look forward to. and she cited that lack of hope as one of the main reasons he then took his life five days after that meeting. we know in this country 22 veterans a day sadly take their own lives. and i've got to think there's a connection between delayed, deferr deferred, and ultimately denied care and these very tragic instances of suicide. now, i don't know if it meets the strict legal criteria that you are using, but it makes a lot of sense to me to draw that connection and that conclusion. and i think that's what is prompting so many of us to try to improve the level of access and the quality of care, and i don't think you would disagree with that. your continue clugs here -- you make some very bold statements. you talk about a breakdown of the ethics system within vha,

which i take to be a comment on the largest issue that i see that we have a problem with, which is not funding and resources or number of doctors but is the cultural aspect of vha, the lack of accountability, a premium placed on performance bonuses and not on excellence of care, not only responsibility, not on patient outcomes for the veterans that purportedly the vh sashgs there to serve. i looked at your recommendations related to ethics on page 74 of your report. they were pretty narrow. i think good recommendations all of them but fairly narrow. are there other recommendations i may have missed that more fundamentally address the issue of culture within vha? and i would love the know what those are and how the secretary -- i'll ask him when he's here -- how he's going to respond to those recommendations. mr. griffin.

>> the original draft report had four or five recommendations speaking to ethics. they were very narrowly constructed so they were combined into one global ethics recommendation. the secretary previously was the chief ethics officer at png. he was the chief compliance officer at png. i suspect that we are going to see ethics placed at a level where it should be. we did not find that in our review in phoenix when there was a request for an ethical review and not all of the recommendations were followed that were put forward by the person who submitted them. there was a reorganization in vha which removed the chief medical ethics officer from the inner circle of the highest tier

of management in vha and was relegated to a lower level which removed that person from a seat at the table with the most senior people. i suspect;kñ that we'll see a change in that. and i think what had been ethics just from the medical ethics perspective is something that will be expanded beyond vha to other areas in the department. >> and i haven't read every single page of this report, and i'm currently reading it and i need to do that, but what i haven't seen -- and i've read through the ethics section of it -- what i haven't seen are some specific recommendations on accountability, on people losing their jobs. we've heard the most egregious instances of dereliction of duty, abuse, of fraud, and later learned that those people are still on the job. i can't argue with anything you said about the incoming secretary or any secretary. had a chance to meet with him yesterday, and i'm really

looking forward to his leadership, but i think we need to institutionalize these cultural changes. and you were asked a question earlier by one of my colleagues. anything in that july compromise bill that you think would help change the situation? i think the ability to fire senior executive, get the dead wood and the fraudulent actors out of the way quickly so that we can bring up those who are the best and brightest and have the outcome of the veteran first and foremost in mind is what we really need to do. and i'm not seeing that still, and throughout the system, incluing in the part of the system where i have the honor of serving veterans there. i realize that i'm out of time. i appreciate the chairman's indulgence. >> thank you. dr. roe? >> thank the chairman. i'm going to approach this a little differently. and dr. day and dr. foote and dr. mitchell know what i'll be talking act, and this is grand rounds. and for those of you who don't

know, when you're in training you present cases to staff and they critique your care of those cases. and i had a chance to review many of these cases, and to draw the conclusion, dr. day, that you did, and maybe it's the criteria as mr. o'rourke said, that it had no effect on the outcome of those patients is outrageous. i mean, you would have lost both limbs where i was -- if you tried to convince a staff member or me when i was a staff member. and i think the question i posed to you in one of these cases, if this were your family member, yours, just like case number 29, that had the congestive heart failure, this was your dad there and -- would you be happy with the explanation you just gave of his death? and secondly, would you accept that? now, my suspicion is no, because you know that if your dad had gotten his allergy testing and an implantable defibrillator, the outcome may have been very different. that's why we put these devices in and prevent sudden cardiac death. secondly, case number seven,

this one the va just got lucky on. i mean, a guy in his mid-60s comes in to see a doctor with chest pain and has nothing done for seven months? i mean, all you can say is you got lucky because he very well could have died of coronary disease, which he had a bypass operation, but it was certainly nothing the va did to help him prevent that. and one of the reasons -- and i can assure you that in most private facilities if this guy had come in the emergency room like this he would have had a hypertension, mid-60s and chest pain, you can't wave redder flag than that. and what does this guy get? they control his blood pressure and send him out. an they're just really, really lucky. case 31, a man with an elevate psa. i have a little sensitivity to that. i've had one elevated before. it's a little worrisome when you're a veteran with an

elevated psa. it looks to me like this veteran got sort of ignore for a while. would he have died? i think you can say. and what i would like to do is have these criteria or have this looked at by the institute of medicine or some other outside source to see if they draw the same conclusion, because i certainly don't draw the same conclusions that you did. you're right, you can't absolutely say that this veteran -- this -- missing this appointment or whatever, but it's the culture that i see. i mean, right, you miss one appointment, that probably didn't cause your death. i got that. but the culture, nobody follows up. ct scans are missed. dr. foote, i want you to comment. you've been a clinical director for 19 years. do you agree or disagree with what i've just said? >> oh, absolutely. and what my point was before about how the ig has somewhat

down played the case, and let's talk about case seven, and what really happened in that case was quite different. he had been waiting 12 months for an appointment with the va when he presented in january with the chest pain, having an ekg was run. and it was called a abnormality, suggestive of an anterior cardial cardi cardial myofarction. he now had qas through -- >> unstable? >> right. echo card gram showed he had an injection fraction of 35%. 50 is normal. anterior wall abnormality. my analysis of this case is that he had a heart attack in the 12 months while he was waiting. he further extended that. fortunately, fortunately, we

were able to get him urgently cathed and bypassed. he saved his life but lost 30% of his heart function. and the ig report referred to that as a favorable outcome. >> well, i guess if you don't go to a funeral, it is a favorable outcome. i can tell you -- if that was my family, i would have been -- or if it had been me or anybody sitting, you wouldn't have been happy. i looked at this one veteran at a time. how did that one veteran get their care? would this care pass muster we have to pass in the private sector to get paid by medicare or anybody else. the answer is, of course it would not. i'm embarrassed by this. when i read a lot of these cases it was embarrassing. dr. mitchell, you want to comment? >> yes. i would like to go on the record against the entire oig. when you have a patient who's unstable, psychiatrically, with suicidal ideaization like in

case 39, if you discharge him home, he will commit suicide unless something intervenes. in this case, nothing did and he committed suicide. for the gentleman, case number 40, he was demonstrating psychiatrically unstable behavior as an inpatient. the psychiatrist had the option to stop his discharge. if you discharge a psychiatrically unstable patient who's got a history of hurting himself, he's got a history of suicidal ideation, he will commit suicide. the only question that should be asked is when. this is national suicide prevention month. the va has a wonderful program on the power of one. which means one person, one kind act, one question can stop a suicide. this gentleman -- both of these gentlemen should have had the power of one. one being the department of the va. this was totally inappropriate medical care for a psychiatric patient. and i -- on behalf of every mental health prior in the united states, i will say that if you discharge an unstable

psychiatric patient who's verbalizing suicidal ideation, something will happen unless something is done to intervene. >> i thank the chair. yield back. >> ms. brown. mr. griffin, in my 22 years on this keshgs i have never heard anything from the inspector general that would make me believe the office of the inspector general has worked with the va to soften the findings. nothing. nothing there but i think, it seems to me, that people seem to think that because i make an allegation that that is a criminal offense and, therefore, i should be fired without any due process. can you explain that to me? i'm thinking about the 93 ongoing review cases. >> right. we received many, many

allegations. in the last 12 months we got is 34,000 allegations to our hot line, okay? that's why we have investigators, doctors, other clinicians, so when we get an allegation, if we have the resources available and it rises to a level where we feel compelled to take it, that's why we go out and do our reviews and either conclude, yes, this allegation is correct or, no, it isn't. until such time as we've accomplished that, an allegation is an allegation. >> it seems as if everybody seems to think that every veteran is eligible to participate in the va and that is not accurate. i know that the formal secretary open it up to millions of

additional veterans. can you explain that? in other words, everyone that was in the department of defense, not necessarily eligible to participate with the va. i know we expanded the net, but to a large extent it was not. >> dr. day was an army doctor for more than 20 years. he's well versed on coverage that's available to vee tires, in addition to veterans. let him to speak to the options that are available. >> you're correct. not all veterans are eligible for care in the vp the va was set up to take care of the indigent and those disabled in combat or otherwise.

so, the inclusion recently of all veterans who returned from the wars has certainly expanded the eligibility for va. and then when category 8s were allowed to join, that would be people who are veterans but not financially -- disqualified from previous groups, that has significantly increased the number of people who could come. the gates to come in and not get in have been changed over time. that's about all i know about it right now, ma'am. >> but we have expanded that area. in which i applaud. in expanding it, it created additional problems as far as processing them through the system. i recently spoke to a veterans group and they indicated that it was such a horrible experience. and i said, well, what was the horrible experience? once you got in to see the doctor? no. when i went for my appointment, the person at the desk was on the phone and they didn't stop and take care of me.

i understand we downgraded the intake person so that veteran, when they come in, not necessarily getting the right kind of experience that could have happened in the offices. if you don't have a person that is the first contact, not a person at a certain level to -- for that intake. >> yes, ma'am. >> i guess i was asking a question as to how could we improve the system as far as veterans feeling that the system -- once that person got in with the doctor, everything was fine. but it's just getting that person into the system. >> i think there are a couple things. the communications systems, which are quite complex between va. in phoenix, we found, for example, that many patients who

travel to phoenix part time, snow birds, if you will, they had a very difficult time getting into care. they were blocked out of the primary care group that was set up and their access was diminished. i think you have to look at what you mean by access to care assist a system. have you to implement the systems to make it work. mostly computer systems. and i think you also have to incentivize everyone who works in the va to have a how can i help you, i can't help you too much attitude. those are part of what i believe the current secretary understands and what i believe he will try to work on. >> thank you. i yield back the balance of my time. >> mr. jolly, you're recognized. >> thank you, mr. chairman. mr. griffin, i have questions and, dr. day, about the analytical model behind your statement. it matters not to me if va

influences this report. i take you at your word that it did not starnlly influence the statements. the office at bay pines is in my district. i hear constituent concerns, complaints and comments about the ig. in a way maybe other members don't. what i know is words matter. and so your statement that you cannot conclusively assert that the lack of timely care caused the death of veterans. certainly is an accurate statement, based on your analytical model. can you also conclusively assert that wait list did not contribute? to deaths of veterans? >> no. >> did you say that in the report? was that reflected in the report that you cannot conclusively -- >> no. >> why not? >> what i had hoped -- >> no. let me go through this line of questioning because it's very important. >> this is why not. we put in here the stories of

all these people who we thought did not get proper care. and it was my assumption by reading these stories you could understand where the waits were. you could arrive at your own conclusions. >> i understand. you made a very powerful statement businessed on analytical model not based on the other side of the kashg. the reason it matters is because for six months we've been investigating the deaths of veterans. ig words matter, frankly, more than any political appointee. we challenge political appointee words all the time. and a lot of times they are wrong and misleading. we expect the ig not to about. so the statement you made that you cannot conclusively assert that that it led to deaths is a substantive statement. yet you didn't assert that you can't conclusively assert it didn't, right? would you be willing to say the wait list contributed to the

deaths? >> the first 24 -- >> would you be willing to say the wait list contributed to the deaths? >> yes. >> you would? >> in fact, the title of the first 28 cases are cases where we thought patients were harmed because of the wait list. there were six deaths out of that group. >> did it contribute to the death -- >> yes. >> the wait list contribute to the deaths of veterans? >> no problem. direct relationship, how tight a relationship do you want? that's where the difficulty is here. >> i understand. but that puts you down a road that gets very interesting. as you said earlier, you have no ability to determine the causes of death. which then asks at the very beginning, what's the point of the study? if you're not able to make a determination, then the analysis that suggest you can't draw a causation creates a great question that ultimately undermines what's in the report.

whereas if you say it contributed to, that should be the headline. we talked a lot about headlines. if you're an american person sitting at the kitchen table today that in april learned there were 40 deaths, we can play with semantics all we want, mr. griffin, but right here at the table, it was acknowledged by the ig's office that the wait list contributed to the deaths of veterans. that's an accurate statement, right, doctor? >> that's an accurate statement. >> mr. griffin, would you agree with that as well? that the wait list contributed to the cause of death of veterans? >> in our report, a careful reading would report that in some of those cases, we say they might live longer. they could have had a better quality of life at the end and so on. >> sir -- >> is that true or not? >> would you agree that wait lists contributed to the deaths of veterans? it's a yes or no. please, yes or no. >> no. >> words mean something and you need to be precise with your answer. yes, you do? >> no. i would say it may have contributed to their death but we can't say conclusively it

caused their death. >> obviously. you can't say conclusively it didn't. dr. day said we'll say it contributed. you're not willing to say it contributed, is that right? >> no, that's not right. i think what the report says is it may have contributed -- >> so you have confidence in the ig by not being able to answer that very simple question. did it contribute to the deaths of veterans, yes or no? >> it could have. >> that's your answer and i note dr. day disagrees with you. >> i don't think he disagreed. >> he answered it very differently. i'm going to conclude with this. in law there's the notion of res ip sew looker to. the facts speak for themselves. we know people were on the waiting list. we know they died as a result of conditions for which they were awaiting treatment. and we know that your office has made criminal referrals related to that. and so i appreciate, dr. day,

you at least willing to say wait list contributed to the deaths of veterans. because that is not the story that has come out as a result of the ig report. thank you, mr. chairman. i yield back. >> thank you very much. mr. schweikert. >> thank you for letting me sit in on this committee. i have the opportunity and joy of actually representing a large area of phoenix. and have had a number of the folks that, shall we say, have been effected by the va in my office we've sat down with them over coffee. and this is one of those difficult subjects because from the accounting math world, we want to say, is it binary? is it yes and no, as the discussion we were just having and the reality, whenever we deal with people, our health is

not necessarily binary, yes or no. but some of this is really tough. i mean, a few months ago, the sitdown coffee with the widow, and you think to yourself as a really tough guy that you've dealt with lots of this and you're driving home and you can't get that lump out of your throat and you're trying not to try. and you haven't cried since you were a child. so, hopefully everyone here understands the emotional impact. now we sort of work through the mechanics of what does this report really say and what are the fixes? how do we never, ever, ever have these types of hearings and these sorts of experiences, and i never sit down with a widow that breaks m heart ever again. and first for mr. griffin, i just -- maybe it's the term of art, but very quickly, when going through the report, the word significant is rolled through a number of times.

was it a significant causation. was it a significant factor in the death. you do see within the questions of the right and left here, how many times we say significant could have a wide interpretation. is that how you meant to write it? was that the goal saying, look, there's a wide path here of causation? >> our clinical staff did those reviews. i would ask dr. day to answer your question. >> and, dr. day, i'm trying to be fair-minded here and not, you know, let my ee emotion drive my questions. am i being fair-minded? >> i think so. i think, first of all, it takes a great deal of effort for the people that work for me who write these stories with no emotion.

and so what people read when these stories is an emotionless layout of fact. you don't see the outrage we feel. so if we start from a universe of patients, it's reasonable to assume they are all harmed just by the fact they didn't get delays in care. >> dr. daigh, you notched on something i want to touch on in an observation. i was disturbed by -- the fact you knew there were 800 articles. ig, facts, facts, facts. promise me you're not tracking the press articles and saying, we're up, we're down, they didn't see it as nicely. that's our world. that's not -- never should be

the auditor's world. two quick things. tell me what you learned from the hot line. did the hot line ever -- did you ever map out a pattern or a division or specialty that there was something wrong, something came up repeatedly, and that could be dr. -- or mr. griffin -- >> let me respond to the 800 articles very briefly. it took about 60 seconds to determine -- >> the sheer fact you had any curiousty. it wasn't curiousty. we alluded to the original allegation of 40 deaths. that is what got reported over and over and over again. >> once again, you work for, ultimately, us, the taxpayers, the agency, not the media. the media should never influence the professionalism in what you do. doctor, sorry, you were moving up to the microphone.

>> would you repeat the question, sir? >> any patterns from the hot line. i would say the pattern we saw in the cases was not that -- was essentially people who were denied their care because they were on wait list. and the hot line cases were usually a little more clear in the delay or the impact of the for us, the timing of not getting care and then being able to see impact in the hot line cases than it was on the long list of cases we look through of people who were delayed trying to determine whether there was an impact. >> mr. chairman, i appreciate -- >> the urology group, the urology clique was one area we saw a pattern. >> you saw the pattern. >> the other pattern is people had a very difficult time getting into primary care. so if you were impanelled in primary care at phoenix, which was an adequate panel size, then you had at least one access to get consults or move your way through the system. if you were not in the primary

care panel, then you had a very difficult time navigating the system. i would say those would be two examples. >> forgive me, mr. chairman, thank you for your patience. i will -- for all of you, i actually have some written questions that i will shoot your way. thank you, mr. chairman. >> dr. benishek. >> thank you, mr. chairman. i guess the question comes up, the chairman brought it up, the thing that concerns me the most about this is, this is really bad stuff that happened to our veterans. and the care that was outlined -- i read through those cases that whoa have here. like 40 cases, these case summaries. i know they're incomplete, but, boy, you know, just to see how our veterans have suffered and

subject to delays in care, that was most effort from these short -- these short excerpts here, you know, your argument that the delay didn't -- the causation with the death. i understand that argument. but the delays that occurred here, they certainly wouldn't be unacceptable in my practice. if you referred someone to short-term follow-up and due to screw up of scheduling, two-day didn't follow up for months. this is just unacceptable. i think you all agree on that. is that right? >> sir, the title above the first 28 cases is clinically significant delays. the only point i wish -- >> well -- >> wish we had worded better is this idea that delay caused

death. >> the only thing that upsets me is the media has taken there's no problem, not that big of a problem. this is a big problem. this is a huge problem. this is a problem that has to be addressed. and, you know, hopefully with the changes that are happening in the -- we now have a new secretary and reform and hopefully a new culture within the va that that will happen. i think we all just want to be sure that we have an inspector general that we can rely on to be expecting independently of va coercion or enforcement or discussion. and i think that's really the gist of where i -- what i get from this hearing. mr. grich, you want to comment on -- >> i do. we don't have an inspector general right now in our office. it is a presidential appointment. it's been vacant since january

first. everybody that worked on this report is a career federal employee. we don't pick sides. i think the rigor of our interim report issued on may 28th led to very large change in a department, including the most senior leadership. i think the 24 recommendations in this report address the issues that we found and the notion that somehow we would have issued either of these reports, if we were complicit with the department, doesn't wash with me. >> let me just go over -- in a different direction. i missed some of the hearing because hi to do another thing. is has anybody been prosecuted? have people been referred to the department of justice for prosecution. >> there are ongoing

investigations. >> so, nothing's happened yet? >> no one has been prosecuted yet. >> have you heard from the department of justice? are they -- >> we have heard from the department of justice. the assistant attorney general for the criminal division sent guidance out to all the u.s. attorney's offices, laying out for them his view of what the potential charges could be based on his knowledge of the manipulation of records, potential destruction of records and so on. that was sent to every u.s. attorney's office in the country. we're working in partnership with the fbi on the ongoing phoenix investigation. and in a number of the other locations. believe me, we have no desire to see people escape who deserve criminal charges. as iz mentioned earlier, we -- we arrested 94 va employees last year on charges unrelated to waiting times. so, we're not bashful about arresting people had they break

the law. >> you don't know the timeline when this is going to be done? >> i think -- i think as we complete the investigation, it's going to be a rolling process. it's not like there's a date certain when all 93 will be closed. but every week, we will make additional progress. and if they're not prosecuted -- >> are you doing more referrals? did you do any referrals to the justice department? >> i think we had a new case last week in minnesota. whenever we open a case that has criminal potential, the attorney general guidelines require us to notify the fbi so that we're not duplicating services. >> thank you. >> mr. secretary has been waiting for well over an hour to come and appear, so i appreciate your indulgence for waiting through the vote series. i do have -- again, i've learned a lot in this -- in this hearing

today. i honestly had no idea that the oig would go back and forth with the drafts to the va. i was under the impression that it was a single draft that went to them to be checked for factual corrections that needed to be made. i would ask that you provide the committee copies of the drafts that were done. the fact remains that from the very first draft, there was no inclusion of the statement that has caused me concern because it took away the entire focus from all of the work your office had done. so much so that it was leaked just that part prior to -- in fact, i think it even caused you to move up the release of the final report because it

exonerated the department. well, it didn't exonerate the department and i just -- i don't think anybody here thinks that it did 37. >> i don't think it did, mr. chairman. i'm sorry to interrupt, but i don't believe it exonerated them one bit. >> now, here's the question that i still -- i need to ask before we close. in your testimony, you gave the impression that the committee suggested the appropriate standard to be used, to determine causality of death is to unequivocally prove. i think that was a comment that you made. that a delay in care caused death. and reading the document that you, in fact, cited as an exhibit in your testimony, it states that a committee staff member sought specific information in order for this committee to prove that delays were related to death.

do you believe cause and related mean the exact same thing? >> i think in the context of this document, which is attachment "b" for those who would like to review it, it's attachment "b." it reads to unequivocally these deaths, parens all 40, are related to delays in care. now, the document includes -- >> comma. >> -- 17 names -- >> comma. >> -- all 40. we were in pursuit of -- >> you didn't finish. there's a comma there. it says o&i, which means oversight and investigation, needs access to va's computerized record system to pull up these veteran files or to request them from va.

>> right. to unequivocally prove -- >> for the committee. not you, but the committee. >> does the committee have the clinicians to make that determination? >> i don't know that that's -- in your testimony, though, you're saying we put that burden on you. that burden was not placed on you. we said that about ourselves. whether we have the clinicians to do it or not is not relevant. the fact is, you were saying that we said that. and my question is, is caused and related, do they mean the exact same thing. you're saying they do. >> what i'm saying is un unequivocally prove is an extremely high standard. that's not the standard dr dr. daigh's -- >> we didn't ask sk for that. >> your memo sent to us on april 9th after the hearing said that

in order to unequivocally prove that these deaths, all 40 -- remember, they were potential deaths. as it continued on, it was declarative there were 40, that all 40 are related to delays in care. >> o&i, meaning the committee. >> right. again, the unequivocal was not placed as a burden. it was placed on us. we placed it on ourselves. >> you alluded to that. >> i did. this was sent in an e-mail by your staff saying, here are most of the documents. meaning documents that surfaced in the april 9th hearing. and this document comes down with 17 names and it says, unequivocally prove that all 40 -- well, there's only 17 names. i mean, it's -- >> that's, again, sir, that's -- i'm sorry, but that's -- you're

trying to say we set a higher standard for you to prove when we did not set that standard. is that correct? >> i'll let the document speak for itself. >> but you -- >> that's why we -- >> you're testifying to the fact that we set that bar for you to meet. this clearly says, in order to unequivocally prove that these deaths, all 40, are related to delays in care, comma, o&i needs access -- o&i meaning the committee, not you. but you took from this that we were trying to set a standard that you could not meet. in fact, i think dr. daigh said something about a standard that could not be met. and i'm just -- again, we're having communication issues. and i understand that. >> i'd be pleased -- i'd be pleased to answer for the record

the other suggestions that came from the committee as to how this should be done, including one that was sent to us as the ink was drying on the final report. which had we modified would have been a violation of general government accounting standards. >> well, again, i'm talking specifically about something you included and you are saying that this was a directive to you to meet standards you could not meet, unequivocal. is that true or not? >> the document says says so o&i staff can look at this. that's fine. why was it sent to us if o&i staff wanted to look at these things? it could have asked the medical department for these records. clearly we were being asked -- in some circles it says we were ordered to expand our investigation in order to look into the issues. >> not from this committee.

tell me what it is. >> i'm telling you what -- >> you're googling again. >> no. you can make all the fun you want of that. that's a reality. that the basis for this thing getting legs was the allegation of 40 specific deaths. and we just couldn't find the trigger for those 40. instead, we looked at 3409. so, i -- i don't -- >> you found 293 deaths. >> right. you now have a statement that says you could not -- and then i'm through -- you cannot conclusively -- if these deaths were related to delays in care.

that is -- that was inserted after the first draft, correct? can you -- >> that's correct. we've been down this road. there were multiple deaths -- >> i learned -- >> on july 22nd one our staff, senior tracking changes on the report, which you'll see, indicated if we can't conclude this, we should say so. eventually that's what we got to. >> and so you -- can you conclusively say that no deaths occurred because of delays in care? >> no. we don't know. it's the causality thing which is bore out in the testimony for the record from the witness who is not here today, who is the president of the national association of medical examiners. i don't know who requested this, but he says we got it right. so, people are entitled to their own opinion.

>> thank you. i appreciate very much your testimony. >> thank you, mr. -- >> you have a job to do. we appreciate the job that you do. we have a job to do as well. i appreciate the committee members for their questions and you are now excused. >> more now from this hearing on the inspector general's report of the phoenix va facility. veterans' affairs secretary robert mcdonald provides an update on the actions taken by the va in fixing the problems at the phoenix facility and the va overall. secretary mcdonald said, the ig recommendations are being adopted and should be complete by 016. you can read the inspector general's report on our website c-span.org. as a link when watching the hearing.

>> on our next panel we're going to hear from the honorable rop either mcdonald, secretary for the department of veterans' affairs. mr. secretary, first of all, we apologize for keeping you waiting for so long. he is accompanied by dr. carolyn clancy, interim undersecretary of the veterans health administration. your entire statement will be made a part of the hearing record. we like to say welcome to you, to our committee room. we look forward to working with you in the future. you are now recognized for your opening statement. >> thank you, chairman miller. i look forward to working with you and the rest of the committee to improve the department of veterans affairs to provide the type of care our

veterans deserve. chairman miller, ranking miller michaud, thank you for this opportunity to discuss with you va's response to the recent ig report on phoenix. first, let me offer my personal apolols to all veterans who received unacceptable delays in receiving care. it's clear that we failed in that respect. regardless of the fangt that the report on phoenix could not conclusively tie patient deaths to delays. i'm committed to fixing this problem and providing timely, high quality care that veterans have earned and that they deserve. that's howl would he regain veterans' trust and the trust of the american people. the final report on phoenix has now been issued and we concurred with all of the 24 recommendation. three of the recommendations have already been remediated and we're well under way to

remediating the final 21. we have proposed the removal of three senior leaders in phoenix and we eaglely await the results of the department of justice investigations. nationally there are over 100 ongoing investigations of va facilities by the ig, by the department of justice, by the office of special counsel and others. in each case, we look forward to receiving the results so that we can take the appropriate disciplinary actions when the investigations are complete. when we have the evidence and when we know the facts. we're grateful for the committee's -- this law stream lines the removal of va senior executives and the appeals process if misconduct is found. however, it doesn't eliminate the appeal process, the guarantee that va's decisions

will be upheld on appeal or allow va to fire senior executives without evidence or cause. and it applies only to senior executives who are less than half of 1% of va's employees. now, we've taken many other actions in phoenix and surrounding areas to improve veterans' access to care, including, first, putting in place a strong acting leadership team. these are good people with proven track records of serving veterans and solving problems. increasing phoenix staffing by 162 personnel and implementing aggressive recruitment and hiring processes to speed recruiting. reaching out to all veterans identified as being on unofficial lists or the facility electronic wait list and completing over 146,000 appointments in three months. as of september 5th, there were only ten veterans on the

electronic wait list at phoenix. where va capacity didn't exist to provide timely appointments, we referred patients to non-va care. from may through august, phoenix made almost 15,000 referrals for non-va care. we've secured contracts to utilize primary care physicians from within the community in the future. since my confirmation as secretary, 51 days ago, i have traveled the va facilities across the country, including phoenix. speaking to veterans and va employees as well as visiting and speaking with members of congress, veteran service organizations and other stakeholders. during those visits, i found va employees to be overwhelmingly dedicated to serving veterans and driven by our strong va institutional values of integrity, commitment, advocacy, respect and excellence held in this acronym icare.

we'll continue to work with the ig and other stakeholders to ensure accountability. as i said, there were over 100 ongoing investigations. by our department, ig, department of special counsel and others. in each case we await the results and will take the appropriate disciplinary actions when all the facts and evidence are known but we will not wait, and i want to emphasize, we will not wait to provide veterans the care they've already earned. going forward we'll focus on sustained accountability. this means creating a culture where all employees understand how their work, their daily work, supports our mission our values, our strategies. it requires supervisors to provide daily feedback to every subordinate, to recognize what's going well and identify where improvements are necessary. we're moving forward on several fronts and i discussed thesis major initiatives with veterans

affairs committee and with many members here. last week we announced the beginning of our road to veterans day, focusing on the next 60 days. we're focusing on three strategies. rebuilding trust with veterans and american people, on improved service delivery and most importantly, setting the course for long-term excellent and reform. this week we released our blueprint for excellence. dr. carolyn clancy on my left and dr. jonathan perlynn, former under secretary for health and now chief medical officer at hca, one of the largest medical providers in the country, helped us lay out this blueprint. four broad themes, sen essential strategies, to help us simultaneously improve the performance of vha health care now, develop a positive culture, transition from sick care to health care in the broadest sense and develop efficient transparent accountable, agile

business and management processes. and to increase timely access to care, we're recruiting to hire more clinicians. as part of that effort, i've proposed increases to the minimum and maximum rates for eligible va physicians and dentist. more competitive salaries we'll be in better position to track and hire more health care providers to treat veterans and in better position to retain those who are performing at a high level. we will judge the success of all of our efforts against a single metric, that's veteran outcomes. we don't want va to meet a standard. we want va recognized as the standard in providing health care and benefits. i know we can fix the problems we face. and i know we can utilize this opportunity to transform va to better serve veterans. mr. chairman, members of the committee, thanks for your unwaving support for veterans.

i look forward to working with you in implementing the law and making things better for all of america's veterans. dr. clancy and i are prepared to take your questions. >> thank you, mr. secretary, very much for your testimony. i have a number of questions in here that are, i guess, designed to rip and punch and do all kinds of things. and i'm not going to do that. this committee is committed to being a full and complete partner with you as you work towards repairing the damage that has been done to va over a number of years, not just recently, but over a number of years. and i think what we want to know is -- you've only been there 50 days, do you have the tools that you need, or are you finding that you need more -- we talked

about this at breakfast last week, that we need to help you with legislatively so that you can make the changes that are necessary to deliver the benefits to the veterans that have earned them. >> mr. chairman, thank you. we have gone through and looked at the legislation that governs our department. we have put together some proposals which are currently with the office of management and budget and we would enjoy the opportunity to be able to share those with you within the next few weeks as we get them back from the office of management and budget. we have a lot of tools at our disposal. as i said, i thank you for the act that you all passed. it was a great show of bipartisanship for veterans. but i think there are going to be things we could use help with. longer term, i know that we'll continue the conversation so that we can get -- work together to identify those legislative needs.

>> i think you're probably going to hear from both sides that it appears nobody has been fired yet. i know that the wheels have begun, but some points, you know, we're at 110 days. you know, is it that hard in the federal system or at va to fire somebody who's been caught red-handed doing something? >> first of all, having come from the private sector, having run $84 million global company, it's a misperception to think that even in the private sector you walk in one day and you fire someone. it's frankly what i call failure of accountability. if you do a good job managing an individual you're giving them daily feedback. that should result in a relationship that when something

goes awry, the action can be taken quickly but with due process allowed. in our particular case, around 65% of our employees are union members and our ability to separated them from their jobs depends upon the specific union contracts we have in our facilities 7 as i said, the revision you all made in the new act does shorten the appeal time for our senior executive service employees. and we welcome that. there is still a due process. as you know in phoenix, we've got two senior executive service people who we have proposed action against. we give you a report every week. the report we gave you, inc., yesterday, has 19 separate disciplinary actions on it and we're going to work with you to continue to track it and keep you up to date as we learn new information.

beneed to get these investigations done and i was pleased to hear that the inspector general thinks we can get them sdon relativedone rela quickly. >> mr. michaud. >> i want to thank you, secretary and dr. clancy for being here today. i want to say from the outset, mr. secretary, i'm very pleased with what i've seen so far with their leadership style and the fact that not only have you taken the time to visit with employees at the va, which hasn't been done, is my understanding, in the last five years, but your willingness to reach out not only to members of congress and particularly this committee, but also veteran service organizations to get their input and insight into how we can provide better services for our veterans. i really do appreciate that.

as i mentioned before we met as confirmed as secretary, yes, the va is going through some turbulent times right now. but it's also a time for opportunity, to really change the cultural structure within the department and its employees but also a time to really think big on a national strategy and where we should be going as far as the department of veterans administration. i want to thank you for your willingness to step up to the plate. some of my requests -- you mentioned about the 24 recommendations under the oig report. how long do you think it will take you to complete all of those recommendations? >> we have actually put that in our report. i think it's by the end of about 2016, 2015, but, of course, it's over time. . it depends on how systematic and how big the chains.

we are meeting every week in trying to get nose remediations sdon. and i separately have asked the ig for all past ig reports that have not been remediated. i would like to go back and look at the history and understand what we need to do on the things that have not been remediated because my understanding from the ig is there's quite a few things. believe me, having run a public company, on two audits, on two different boersdz of directors, i like what the ig does. i need the ig's help. we all need the ig's help and the work they do is critically important to us improving the organization. in fact, as i've gone to these various sites, i've now been to nine different cities, 21 different operations of the va. over my first 50 days. i tell people i want every employee to be a whistle blower. i want every employee helping us change the ig. i welcome the criticism that

anyone has. i even perhaps made the mistake of giving out my cell phone number publicly. it's been published online. it's in "the washington post." and i've answered 150 phone calls so far. >> thank you. speaking about the whistle-blower, i know that's still a concern, talking to some va employees, but whether or not they will be protected if they come forward, when will the va be certified by the office of special counsel section 2302-c on the whistle-blower protection? >> well, i -- i and deputy secretary gibson, the interim, have demanded -- haveedended -- from the very beginning that whistle blowers be protected. i'll have to get back to you a specific date on that. one of the thins i tried to do, because this is about changing culture. many you have asked about changing culture, is as a

leader, your behavior is looked at as a demonstration of a new culture. when i go to sites, those 21 different sites i talked about, i asked to meet with the whistle-blowers. i asked for the whistle-blowers to be in the town hall meetings. i asked for the union leadership to be in these meetings. we can't do this alone. we have to get every employee in the tent and working together so our veterans benefit. >> a lot of the focus has been on vha because of the phoenix, arizona. do you have any plans to look at vba and the national cemetery administration for similar leadership shortcomings and integrity type of issues? >> yes, sir. in fact, as you and i had talked, part of our problem in va is we're a siloed organization. we have been brought together over the years without really any idea to integrating the organization. as we talked, we have nine

different geographic maps of organization structure for va. that means no decision. nobody represents the secretary of veterans affairs at any lower level than the secretary, or the office of secretary. we simply have to get that fixed. it's a long-term effort. it's part of our road to veterans day. it's in the third column, we say set the course for longer term excellence. but i wanted to get to a point where our organization is so simple for the veteran to understand that they can plug into our organization any way they want. we'll be there. if it's a smartphone for an iraq veteran, we'll be there. if it's paperwork for a world war ii veteran, we'll be there. i want them to think of the va. i want every veteran in the country to say, this is my va and i'm proud of it. >> once again, i see my time is expired. i want to thank you for your leadership, your willingness toe do this. i'm optimistic and hopeful that

with your leadership style, that this change will continue in a positive direction. i want to wish you the best of luck -- >> thank you. it will take the partnership of all of us. >> thank you. >> mr. lamborn. >> thank you, mr. secretary, for being here today. we with really appreciate hearing from you. there's a lot of things we can talk about, but the need at the moment is to try to get to the bottom of what the details are surrounding this inspector general's report that has just come out. you may have heard the testimony of the inspector general earlier today that while the waiting list in phoenix contributed to some or all of the 40 deaths of the veterans in phoenix, it may be -- it did not cause their deaths and they made a distinction between contributing to their deaths and causing their deaths. in light of that, was it misleading for some of the press headlines after a leak was made

to have headlines like no deaths related to long waits, which was one, or another that said, no links found between deaths and veterans care delays? >> sir, i am reacting as if every shortage of care, every shortage of access to care is incredibly important. someone said it earlier, you have to think about this one veteran at a time i am a veteran. i do have injuries from my time in the service. i think this -- my father-in-law was a prisoner of war. he had post-traumatic stress. he was -- he was shot down in world war ii. until we got him to the va, we didn't know what the problem was. my uncle suffers from agents orange, 10st airborne division. this is very personal to me so we're acting as if every shortage is important and we're going to fix it with your help. >> so, are those headlines

accurate? >> i'm telling you, i'm going to act as if every veteran deserves the care they need. and i'm going to provide it to them. that's what i'll acting. >> well, what do you think about the fact that someone in the inspector general said it wasn't their office leaked to the press an important sentence out of the report before it was released to the public. do you have any concern about that? >> i don't know anything about that. >> is it any violation of va ethics or rules or regulations or law to release something before public release? >> i don't know. >> are you going to look into this? >> well, we -- certainly, we've had lots of leaks all over the place. i read about dr. foote's testimony in the newspaper this morning. >> okay. let me change -- >> the important thing, sir s to create a culture.

we've got to create a culture that's open and transparent and that works on veterans issues, that looks at every single issue from the veterans' lens, okay? >> and i -- >> the three hours i spend waiting to testify is time i'm not spending working on veterans' issues in the field, where the veterans are being cared for. >> let me pursue something you were talking to the chairman about. i hear from veterans all the time that they are amazed that no one in phoenix has been fired for the unacceptable waiting list in phoenix. >> i said we brproposed disciplinary action against two of the employees in phoenix. >> the two employees on paid leave? >> that's currently under way. that is the rule of law. if you would like to change the law -- >> we did change the law. >> sir, you changed the law so it affects the appeal only. >> so, the two on paid leave, is that the extent of what we're going to look at as far as any

kind of -- >> i think you heard mr. griffin say that the fbi and other investigative sources are in phoenix right now. and you also received a report from me every week that tells you the people who we are disciplining. the report we gave you yesterday has 19 people on it. we'll track that report weekly. we will update it weekly. and we will make sure we discuss with you whatever you would like to discuss about that report. >> now, are those people the department of justice declined to do criminal prosecutions of? >> i'm not familiar with those people. that's with mr. grich. you would have to handle -- these are people we administratively feel should be called out and brought to task for what they did, which is an important part of changing the culture, as the ig said. have you to hold people accountable or you're not going to change the culture. >> mr. mcdonald, that's why i

want you to take some action, because that is part -- >> sir, i am taking all the action the law allows me to take, with due process. >> well, we're here to help you. >> i know you are. we talked to the chairman about potentially working together on other legislative remedies. we look forward to working with you on that. >> thank you. let's get it done. >> ms. brown. >> thank you, mr. chairman. welcome. welcome to the veterans committee. i hope in the future that we will have the common courtesy not to have the secretary waiting, even if we need to stand down one committee in order to bring you in because i want you out there doing what, you know -- thank you for your service that you're doing. >> thank you. >> as i mentioned when you came to my office, the first secretary, jesse brown, his motto was putting veterans first. and i like that. and yours is road to veterans day, which is my birthday, november the 11th, but what

exactly do you mean? >> for me, the road to veterans day is really about using the first 90 days, as the chairman and ranking members suggested, to make as many changes as we can, as quickly as we can, to improve our service for veterans. strategies. one is about rebuilding trust, and the effort i'm doing to get around, to talk to people, to learn about what's going wrong, all stakeholders, shareholders, veterans themselves, we're compiling a list of the changes that need to be made. at the same time, we're forming teams of employees from within the department. part of the issue before was the organization was closed and wasn't communicating from bottom to top and top to bottom. we need to get employees involved in making these changes because they're the ones closest to serving the veterans. so we're in the process of putting that together. that'll form a strategic plan. we'll roll out that strategic plan. we'll make those changes. we'll improve access. we'll go ahead and get down the

number of benefits in the backlog that we have. and it's all designed so that in the end, the veteran will know how to plug in the va and think of this as their va. that's really what we want. >> one of the problems that i guess i keep having with the whistleblower is it always seems like it's negative. but i don't think feedback have to be negative. ping it should be a way that employees could come forward and say, this is how the system can't improve. i don't think every complaint should be viewed as us against them. >> well, that's exactly right. and that's the culture we have to create. but i can understand that in this moment in time, whistleblowers who have been retaliated against are skeptical, as to whether i mean what i say or whether i can deliver what i say. the only remedy to that is get out, talk to people, demonstrate it through our behavior, put in

place a new leadership team, which will believe in the culture that we believe in, an open culture that needs the people at the lowest level making the biggest changes. >> i like the army's motto, one team, one fight. i think if we're all fighting to improve the situation for the veterans, then we will do what we've said we've done for 75 years, delivering a system to the veterans we can all be proud of. thank you very much for your service and your commitment. i'm sure you have a lot of team members willing to work with you. thank you, and i yield back the balance of my time. >> thank you. i can assure you while the secretary was delayed in coming and testifying, he was working. i actually went in the room -- >> the chairman is correct. >> saw him meeting with individuals. >> thank you, mr. chairman. i'd like to follow up on a

couple questions. thank you for joining us today. maybe this is a question for dr. clancy as well. what i didn't hear in the testimony from the last panel was what level of the va has the collaborative process? that's the language from the oig, in which the report is altered and recommendations changes. what level did that actually take place? >> it was not at my level. >> and i don't know. >> before my time too. >> we have an office that reports to the undersecretary, actually reports to the principal undersecretary for health that routinely interfaces with the inspector general with the government accountability office and so forth getting clarification on recommendations. frankly, tracks to see that we are on track with recommendations that we have

agreed with. as you heard from the inspector general previously, the issue of looking at a draft report and draft recommendations, and they're asking for factual information to make sure that it's accurate. >> what office is that? could you provide that? >> sure. it's management review services. >> okay. who's in charge of that office? >> dr. rasmussen. >> okay. appreciate that. because there apparently was a leak that's created some concerns about that and didn't know what level that was. that hadn't come out earlier. that was the concern. you were busy, didn't hear that testimony, but the concern about how many veterans were actually impacted. and you might have missed as well that perhaps there were 5600 veterans that escaped review during that process. i'm sure you're as concerned as i am about its impact, potentially on veterans. two other areas of questions. i think my colleagues also

mentioned the issue of the whistleblowers. just last week we heard more harrowing stories from whistleblowers of retaliation, intimidation, retribution. these are all things that have occurred in the last few weeks since you've been on board. what we heard last week, very little has changed. can you describe again and show me what your commitment is? this is on your watch. some of it's carried over. we're still hearing those stories. that's very worrisome. >> i've spoken to many whistle blowers in the organization myself. when i go to a location, i ask to speak to the whistleblowers. i've had many of them call me on my cell phone. i've had conversations with them. as i've said, and as i've said publicly within the department and as i've said in every town hall i've held in the last 50 days, in 21 different sites, i welcome whistleblowers. i welcome people criticizing the operation. and i welcome employees who want to get involved on some of these

re-engineering teams we're putting together so they can help re-engineer the processes they're criticizing. i don't think there's any lack of clarity. i may have missed a site. i may not have talked to a particular person or maybe an activity that arrived before i did. but with the communications i've done, which have been two videos that have gone out to every employee, many letters, one of which, which you might be interested in, is a discussion of sustainable accountability and this whole idea of how do we get daily feedback going and how do we get the organization working together. i've met with union leadership four times. >> thank you. thank you for that. i wanted to you to restate that. i appreciate the commitment because there are some folks between your level on down that haven't got the message. >> well, tell them to call me. >> check out our committee, subcommittee hearing from last week. that's your job. you got all the people to do that. we had a whistleblowers. hopefully you've checked on that. came forward to the subcommittee, announced this is

still going on. third thing, i'm glad you welcome criticism. in real areas of the country, the va is doing a pretty poor job of meeting the needs of our veterans. >> i've been out to nevada and have worked this particularly in nevada. i was in san diego. we're working very hard on telehealth. >> let me give you a better option. that's in the bill and that's va choice. giving the veterans choice for local health care. it can be implemented fully and it may not be. currently -- i understand there's current law there were options not used. in my district, i have veterans who go to four different clinics. 300, 400 miles. i have va employees who say, too bad, get in a car and drive. we need to make certain they have local options, even after this trial period is over, two years, i would like to continue

to see efforts by the va saying, you know what, we can do a better job. >> as i said, if you look at these issues through the lens of a veteran, the answer becomes very clear. we want to get care to veterans. if we don't have the technology, if distance is an issue, if capacity is an issue, then we should help that veteran get the care in the private sector. >> this is not capacity. this is not distance. the issue is getting permission from the va to go to the local hospital. they're willing to do that. i encourage you to look into that. i don't know if you've ever lived in a rural area. >> please give us their name and we'll work on it. >> i will continue to do that. >> the point is, there are a lot of folks that would like that choice. we need to see that choice being offered by the va. thank you. >> thank you. >> thank you, mr. chairman. mr. secretary, welcome. first time i've had a chance to meet you. i hope we have a chance to -- >> we'll get together soon. >> yeah, thank you.

mr. secretary, some of these -- well, the phoenix va wait list scandal happened many layers below the secretary level. how can you be sure that the leadership teams that are near you are going to be able to tell you the truth or be able to get to the truth so you're not insulated and that you can count on people getting you accurate information? >> it's going to require a change in culture. those of us who have experience running in large organizations know that's probably the most difficult thing to do. but it starts with the purpose, values, and principles which are the bedrock of any organization. the first thing i did was i asked for every employee to recommit themselves to it the mission of caring for veterans and to the values of the organization represented in the

i care acronym. we've used that as a leadership exercise to talk to employees about the values, about the mission. the second thing we've tried to do is tried to demonstrate we want a very open culture. we've talked about the positive aspects of whistleblowing. we've talked about the positive aspects of criticism. i've used a couple diagrams. most people think of an organization like this and the customers on the bottom and the ceo is on top. but i turn that on its head. this is a va we want. we want the veterans on top. those people next to the veterans every single day, the doctors, the nurses, the schedulers, the clinicians, those are the people that we should honor and make sure are paid properly and are rewarded. then the ceo or secretary is on bottom. the leadership's job is to make sure these people can properly care for veterans. this is a different kind of culture. to demonstrate that, i've cut