system. i believe there's no better time to reform the claims process as the va transforms under secretary mcdonald's leadership and the working group's legislation is a strong platform for some of the changes that need to be made. i look forward to hearing more about the changes and progress of improving care and benefits at the va and thank again you, mr. secretary, and the inspector general griffin for being with us today. thank you, mr. chairman. >> thank you. senator blumenthal. >> thank you, mr. chairman, and thank you for holding this hearing today and to the ranking member as well. thank you to secretary mcdonald and inspector general griffin. we're here to listen to you, not so much to talk, but even more important is that we listen to our veterans across the country who have firsthand experience beyond the inspector general reports, beyond the polling, beyond the hearings that we conduct here. i had a town hall meeting last

friday night for a couple hours and welcomed the director of the hartford va regional office as well as the director of the va connected health care system to listen to our veterans, and not just about the delays, but the more fundamental gaps in care that we have right now that we are all working hard to fill. just one example, k. robert lewis, a veteran service officer from the veterans of foreign wars, shared with the audience very compellingly his understanding that many veterans with the vfw has received outstanding service, but that there is a lack of providers, nurses, doctors, staff that have caused the delays and hindered veterans' access to care. i know that the veterans access to care act authorized $5 billion to enable the va to hire

additional health care providers and clinical staff, but secretary mcdonald, you have identified the practical obstacles to meeting the needs and hiring more doctors and other professionals, and that is one of the central challenges of our time, and i hope that this committee will play a constructive role in that task and so many others that face you in this very challenging time as well as rebuilding the facilities, the infrastructure, as in the west haven hospital where not just renovation, but rebuilding, are necessary to replace a 1950s structure that cannot accommodate the most modern technology, the equipment that is necessary to care for people in 21st century fashion. i want to say that i hope that we will continue to be of a mind

that this health care system is in crisis. i know that crisis is an overused word in washington, but it should give us the impetus and sense of urgency that we all feel as to the need -- the immediate need because health care delayed is health care denied. people need it now when they need it. and so, mr. secretary, i want to thank you for your determination and the management experience that you'll bring to this task, and finally we all know that we're going to see a surge of veterans coming out of our military in the next months and years as the army and the marine corps down size. many of them will have the horrific invisible wounds of war that we now have diagnosed as post-traumatic stress or traumatic brain injury. i want to thank the va for its

support in efforts that i and others have made to correct the records of veterans of past wars at times when post-traumatic stress was undiagnosed and untreated and caused many of them, particularly from the vietnam era, to be given less than honorable discharges. those bad paper discharges have been a stigma and a black mark on their records, caused many of them to be homeless and jobless, and i want to thank secretary hagel for now initiating a new era when those records can be corrected. at our side as we sought this change in policy was the va and most especially general shinseki who served in that war, and i want to thank all of the dedicate ed men and women of th

va for their service in so many ways, most especially in the help that they provided to initiate this change in policy, and thank you to secretary hagel for his awareness and his courage in taking this very, very important step to give honor and respect to veterans who were unfairly treated when they received less than honorable discharges when they suffered from post-traumatic stress that led to those kinds of discharges. thank you, mr. chairman. >> thank you, senator blumenthal. senator moran. >> thank you. thank you to you and senator burr for having this hearing. secretary mcdonald, thank you for your presence but more importantly thank you for your willingness to serve. i hope that you will hit the ground running. i hope that you utilize your tenure as the secretary to make remarkable improvements at the department of veterans affairs on behalf of america's veterans. i hope to explore with you during my time of questioning a

couple of things in particular. with you and the inspector general, i'd like to hear about what the consequences to employees at the va have been as a result of their misconduct. are those currently on leave on leave with pay or without compensation? and has anyone been discharged or is there a plan to discharge anyone as a result of what has occurred at phoenix or elsewhere within the department of veterans affairs? in the broader sense of the legislation we've passed, my understanding and i think i know this sufficiently well to say this, that many of the authorities that are given to the va, in fact, directives given to you in the veterans act, are already things that you have the ability in your discretion to do related to providing care outside of the va, and i'd love to hear about what's transpiring now as we wait for the implementation of this act. how are we caring for veterans

who are either through lack of timeliness or geography having a difficulty accessing veterans' medical services, in particular i'd like to hear how you intend to utilize a.r.c.h., itthe pie t program in the five states across the country and the authorities given to you in the new legislation allow you to not only extend that program, but to expand that program, and i'd like to make certain there is nothing that stands in the way of either one of those things happening from the va's perspective. and to make certain that that program, a.r.c.h. is used while we're in transition to the authorities given to you in the legislation. a couple of examples where this hits home, a gentleman in smith center, kansas, needed a colonoscopy, was told he needed to drive four hours to wichita to do that. the va changed their mind and allowed for this service to happen at home.

he qualified because of the issue of timeliness, not because of geography. another veteran who has to have cortisone shots is told by the va he must drive the 3 1/2 hours that he lives from the va. apparently he doesn't qualify for the lack of timeliness and, therefore, he ought to qualify in my view for geography, but again the va has said no. so how we implement this act in regard to timeliness and geography and what authorities you have in the interim to make certain that no one falls through the cracks while we wait. it's been discouraging to me in one hand and impressive on the other the significant changes that have been made at the va. the discouraging part is if you could react this quickly and accomplish what has been accomplished in the last month or so, why was it not being done ft. first place if we can come up with ways to solve the problems of how we get veterans in to see a physician and be treated, why was it not occurring all along when you've been able to accomplish so much

in a short amount of time. thank you, mr. chairman. >> thank you, senator moran. senator begich. >> thank you, mr. chairman. thank you for holding this hearing. secretary mcdonald, thank you very much for our meetings and conversations we've had and for the ig being here also. let me say a couple things. first, i'm very glad that the piece of legislation passed as it did a month or so ago, but the reality is, as we know, and i guess for senator moran, in alaska we've been doing this for three-plus years. we dragged the obama administration along, but they now understand and we've been doing it for three years. we deliver health care from 30 different tribes around the state through our indian health services program which is administered by alaska tribes delivering health care to veterans, native and nonnative, no matter where they live. doesn't matter if you're living up in nome or you're living all the way down to ketchikan. we can deliver care if the

veterans so chooses with the existing rules. and it wasn't easy. there is a little bit of back and forth between the va and the health and human services department to get them to understand that this is about delivering care with the same tax dollars, doesn't matter who is spending it. it was coming from the same kitty that we have to allocate. so from my perspective i'm ang shut to see how and what you will do with this recommendations, but the reality is, and to be very frank, i'm sure, mr. secretary, you'd prefer not to keep coming to meetings like this and go do the work that needs to be done. i'm glad we're doing oversight. it's important to make sure that you, the administration you're now in charge of, the obama administration, all of them are focused on this issue of delivering health care at the greatest level possible. but i think we have some great examples already that exist that we could utilize as i gave for alaska. for example, in alaska in anchorage, which is 43% of the

state's population, you can go to the va clinic or you have a choice. you can go to the anchorage neighborhood health services clinic or the alaska native hospital. and those two facilities, the last two i mentioned, if you're on the list, you get in the same day as long as it's not major medical. that's an amazing step. we did that before the piece of legislation. to be very frank with you, i'm not sure what some did in their own states. i know what i did. i had to pound away on the va. my first memo i got after six months of coming into office, they said it can't be done. not possible. unrealistic. it's two different agencies. i remember the long laundry list that i got. both from agency and veterans organizations. and we just pushed the pedal down all the way because i think they just spelled yes wrong. they spelled it no. we just had to work on it. and the end result is today we're delivering care all across the state of alaska which is

one-fifth the size, mass, of this country. so if we can do it there, we can do it anywhere. so i think in a lot of ways the piece of legislation we passed only re-emphasizes what can be done, and we gave some money. the challenge you're going to have is making sure we have enough professionals. as we know in alaska, we had a problem, still have a problem recruiting primary care doctors. that's going to be a problem not only in the va system, the indian health services and private sector. you name it, it's a problem everywhere. but what did we do there? again we used our tribal agreement to use south central clinic to admit almost 500 veterans for care because we had access and capacity there. so as you look at how to solve this problem and continue forward, look at what the assets are that are out there, and i do believe as proven before this legislation passed, we have the

authority, you have the authority, you have the capacity to push the pedal all the way down. the va, the obama administration can make these things happen if they want, and i think what we're saying here today is we're glad the bill passed. we're glad we're having oversight, but just go do it. make it happen. and then when there's problems and challenges, you need to let us know right away. my guess is recruitment is going to be a continual problem not only for your system but every medical system in this country because it takes years to get a primary care doctor into the system. one of the things we want to make sure is with the va that, for example, mental health, which is a huge gap, our university is still not certified in cooperation with the va to make sure our counselors are being able to be used. they don't have the right credentials but they're available. we need to make sure the va makes this happen because they're ready, they're able. huge gaps in mental health services. we want to make sure that's possible, so i want to make sure you have that on your list. but, again, some big challenges

in recruitment. the administration is moving forward. you have a huge task ahead of you. i want to make sure we're not always going to meetings but we're hearing results and that's what i'm looking for. thank you. >> thank you very much, senator begich. senator boozman. >> thank you, mr. chair, and thanks to you and ranking member burr for the hearing. i think in the interest of time i'd like to hear the testimony, so we will put our statement in the regard. >> thank you very much. senator murray. >> well, thank you, mr. chairman, for holding this really important hearing and i want to start by thanking the inspector general richard griffin and the department's office of inspector general for all the work that's been done to conduct this review. your investigators and staff have put together an incredibly important report on what happened at phoenix and completing the other investigations at nearly 100 medical centers is really an enormous task, so i want to thank the oig and all of your

staff for the incredible dedication it is taking and will take to get this done. after a lot of years of making critical contributions to veterans' care and benefits, the ig rightly has a reputation of being objective, reliable, and thorough in your work, so we all do thank you. your findings are going to be really vital as we work forward through this, so i appreciate it. i also appreciate how secretary mcdonald has hit the ground sprinting in his new role and has taken immediate steps to get the veterans off wait lists and into care, and while the va's latest data continues to show patient accessibility improving across the department, i want you to know i still am concerned about some of the facilities in my home state of washington. veterans receiving primary and specialty care within the puget sound health care system continue to wait longer than national averages for primary and specialty care, and at spokane the new mental health care patients wait over twice as long, 75 days for their

appointments and that has got to change. so as the va continues to focus on providing veterans with timely access to care, it also has to ensure veterans receive the highest quality of care and as the ig report showed that was all too often not the case in phoenix. they found that the phoenix health care system struggled with many of the basic quality of care issues, things like leaving routine physical examinations and evaluations incomplete for failing to conduct them at all or releasing mental health care patients before their medications were properly stabilized and struggling to provide dedicated mental health care providers to patients. when we're talking about caring for our nation's heroes and their families, we all expect excellence, and i want to notice i have said repeatedly as transparency and accountability increase at the va, so are going to be the investigations into reports of additional concerns

requiring even more action from the va, the administration, and this congress. so today i hope to hear how the va is going to address the findings of the ig, the va access audit, and the white house review, and i want to hear how the va will implement the veterans access choice and accountability act. yesterday we heard the secretary speak about the va rexhcommitti itself to core values. today we need to here how it will convert to improved care for our nation's hero approximates. >> i think we have heard from all the senators. let me bring mr. griffin and his staff to the table. let me welcome richard griffin and his staff. mr. griffin is the acting

inspector general for the department of veterans affairs. let me also say a word, normal protocol is for us to have the secretary go first, and i want the secretary to know that there is no disrespect in us breaking that protocol. but i thought it would be more important to hear what the inspector general had to say and what his staff had to say and then see the secretary respond to that. mr. griffin was appointed as deputy inspector general in 2008. he previously served as the va inspector general from 1997 to 2005. s so he brings an enormous amount of experience and knowledge to his position. he's accompanied by dr. john daigh, jr. assistant inspector general for health care inspections, miss linda halliday, assistant inspector general for audits and valuations. miss maureen regan, counselor to inspector general, and larry

reinkemeyer. thank you so much for your work and thank you for being with us. the mic is yours. >> mr. chairman, ranking member burr, and members of the committee, thank you for the opportunity to discuss the results of the ig's extensive work at the phoenix va health care system. our august 26th report expands upon information previously provided in the interim report and includes information on the reviews by oig clinical staff of patient medical records. the oig examined the medical records and other information for 3,409 veteran patients which included 293 deaths and identified 28 instances of clinically significant delays in care associated with access or

scheduling. of these 28 patients, 6 were deceased. in addition, we identified 17 cases of care deficiencies that were unrelated to scheduling or access issues. of these 17 patients, 14 were deceased. the 45 cases discussed in the report reflect unacceptable and troubling issues in follow-up, coordination, quality, or continuity of care. the identity of these 45 veterans has been provided to va. decisions regarding va's potential liability this these matters lie with the department and the judicial system under the federal tort claims act. information on the qualifications of the oig physicians who conducted these reviews can be found in the

curricula vitae submitted for the record with our written testimony. we identified several patterns of obstacles to care that resulted in negative impact on the quality of care provided by phoenix. as of april 22nd, 2014, we identified about 1,400 veterans waiting to receive a scheduled primary care appointment who were appropriately included on the phoenix electronic wait list. however, as our work progressed, we identified over 3,500 additional veterans, many of whom were on what we determined to be unofficial wait lists, waiting to be scheduled for appointments but not on phoenix's official electronic wait list. you' urology service was unable to keep up with the demand for

services. during our review, it became clear that the urology service at phoenix was in turmoil during the 2012 to 2014 time frame. there were a number of urology physician staffing changes, delays in the procurement of non-va purchase care, and difficulties coordinating you're logic care. the va is working from a list of 3,526 patients who may be at risk for having received poor quality urologic care. as a result, urology services at phoenix are the subject of an ongoing oig review. since july 2005 oig has published 20 oversight reports on va patient wait times and access to care, yet vha did not

effectively address its access to care issues or stop the use of inappropriate scheduling procedures. when vha concurred with our recommendations and submitted an action plan, many va medical facility directors did not take the necessary actions to comply with vha program directives and policy changes. in april 2010 in a memo the deputy secretary for health for operations and management called for immediate action to review scheduling practices and eliminate all inappropriate practices. in june 2010 vha issued a directive reaffirming outpatient scheduling processes and procedures. in july 2011 an annual

certification of wait times was mandated. in january 2012 and may of 2013 the director issued reports that found phoenix did not comply with vha's scheduling policy. finally, in may of 2013, vha wayed the annual requirement for facility directors to certify compliance with the vha scheduling directive. further reducing accountability over wait time data integrity and compliance and appropriate scheduling practices. the ig opened investigations at 93 sites of care in response to allegations of wait time manipulations. investigations continue in coordination with the department of justice and the federal bureau of investigation. while most are still ongoing,

these investigations are confirming that wait time manipulations were prevalent throughout vha. this report cannot capture the personal disappointment, frustration, and loss of faith individual veterans and their family members had in the health care system that often could not respond to their mental and physical health needs in a timely manner. immediate and substantive changes are needed. the va secretary has acknowledged the department is in the midst of a serious crisis, and he has concurred with all 24 recommendations in our report and submitted acceptable corrective action plans. mr. chairman, this concludes our statement and we'd be pleased to answer questions any of the members may have.

>> mr. griffin, thank you very much for your testimony and for the work that you and your staff have undertaken over the last many months. let me begin in a sense by asking you a question that arises because of some media reports which have troubled me. there have been some suggestion that the ig, the office of inspector general for va, is really not independent, and i would like to provide you with the opportunity to describe the process the ig utilizes when preparing oversight reports, including the draft report review and comment process. in other words, are you being heavily influenced by the va? are they editing the reports that you give us? or, in fact, are you an independent entity finding the truth as best you can?

>> thank you for that question. our organization over the last six years has issued over 1,700 reports addressing oversight issues in the department of veterans affairs. we have testified at over 60 congressional hearings in the last 6 years about our reports. every one of our draft reports and every draft report of anybody in the inspector general community is submitted as a draft to the department for purposes of guaranteeing accuracy of all reporting. if the department has information that we missed in doing our work that they can point out to us that would be factual and convincing, then we

may come to reali izize we've g this one part wrong. we do not accept from the department or from anyone else a dictated response that is based on opinion as opposed to fact. >> okay. thank you very much. let me ask you this, every member of this committee is outraged by what happened in phoenix. we are outraged in general by unacceptably long wait periods for veterans to access health care. we have seen with disgust the manipulation of data, lying, et cetera. what i would like you to do is explain in english, in english, how does this happen? now, you pointed out just a moment ago that we have heard from va time and time again their concerns about the appointment process, and yet nothing seemed to happen. so take us to phoenix and in

english describe to us exactly how it happened that we had these long waiting periods that were disguised, that we had son-in-law people not even on any waiting list at all, and all of this went on and nobody did anything about it. how does this happen? >> that happens when there's a failure of leadership. we're not just talking about phoenix. we have reported on this problem for nine years. excellent policies were, in fact, published and sent out. i alluded to some of them in my oral. you have to follow through. wait times is not the only issue that we've reported on where vha has promulgated pick-and-roll d address our recommendations and sent them out and was supposed to be vert certified that they

followed, and they weren't. it's hard to explain the why of that, but when people do not follow the directive from their headquarter's leadership, there has to be a consequence. >> to what degree did the 14-day directive impact the immediate problems? and second of all, how can a facility provide timely care if they don't have enough doctors, nurses, space, and staff, and how does that not get up to the general office? how does it not happen that somebody says, i can't do it in 14 days. i just don't have the doctors, i don't have the staff. what -- explain that process to me. >> i believe there was an awareness in phoenix based on some of the e-mails that we pulled and are included in our report that many people in the

phoenix hierarchy were aware that it wasn't doable. i'm sure you recall the e-mail from our interim report where someone asked for an ethics review because our wildly important goal and the success that's being reported is smoke and mirrors as was mentioned earlier. i think a big part of the equation for the fix as opposed to what we all know happened, when you look at the initial point where a veteran has c contact at the medical center, very often you have the lowest graded employees who might not be equipped to be able to triage this veteran really needs to get in in 14 days or 7 days or tomorrow or today versus this veteran can wait 30 days. i think in the private sector you would probably have somebody with a little more clinical

background to try and make that evaluation so you know who really does need to come in and who doesn't. >> my time is -- has expired, but bottom line is if you don't have the staff, if you don't -- if you can't do it, how come that is not transmitted up the channel? >> it should be. i believe in phoenix it was, and the outcome is documented in our report, that no action was taken to fix it. >> okay. thank you very much. senator burr. >> mr. griffin, thanks to you and to your staff for the job you've per forformed for the undertaking you're already in process with, and i don't think any of us would wish it on anybody that they had to make the reviews that you're having to do. let me just ask, had the va listened to prior ig reports and fixed the problems you had

pointed out, would we be here today? talking about phoenix or talking about any facility? >> no. >> the problems within va seem to be rooted in two things. one is the culture that has been created, and i think that culture has been created because there was a lack of accountability, and that was evidenced by these waiting lists that operated outside of the electronic system and other things. had they just addressed those, we probably wouldn't be here investigating phoenix to the degree that we are. is that an accurate statement? >> that is accurate. and as i mentioned previously and even in other areas, we wouldn't close a recommendation unless we believed that they had taken the appropriate steps to resolve the issue. when you get a copy in 2010 of this mandate to knock off the

manipulation and then three months later you get an updated scheduling procedure as a vha directive, at that point you would believe that people got it and that it would be implemented and it would be implemented to the letter. >> and what do you conclude -- how could somebody conclude within va not to require certification last year based upon all the warning signs you have provided? >> i think the next panel can probably better explain what the rationale was. i think there had been plenty of warning that this was going on, and i thought the certification was an excellent thing to make people declare, yes, i have reviewed it in my facility, and, yes, our waiting times are according to the policies and procedures of the department. >> now, you've been involved for

six-plus months at investigating the current list of things. and i know you can't get into specific takeaways, but let me ask, what have you learned about the va over that period of time, not down to the specifics? >> referring to the 93 other facilities? well, we've -- we have some initial reporting on those. as of yesterday we have given the department 12 individual reports for them to examine and determine what action would be appropriate in view of the specifics of each of those reports. the rest of our 93 are still very much active, but i can tell you that at 42 different facilities of those 93 we found

the practice of using the next available date as a desired date. it's something that was reported on in our interim report and in the final report. we have 19 facilities where an appointment was canceled and rescheduled on the same day for the same appointment time for the sole purpose of giving the appearance of a shorter waiting time. we've had 16 facilities that had paper wait list as opposed to being on ewl. we had 13 facilities where managers lied to my investigators about what was going on at their facility. >> did your investigators conclude that all of these individuals came up with these deceptive practices on their own or was there some overarching initiative that some level of management actually pushed? >> it's a combination.

frankly, when something is going on for as many years, not everywhere, but at a number of the facilities, it almost becomes the accepted way of doing scheduling. and, again, when you have lowest level employees involved in scheduling and they come in as a new hire and somebody says this is how we do it, they may not realize that someone is telling them the improper way to do it. so it's a combination of things. the bottom line is who is in charge, and when you get a policy directive from vha, do you enforce it or do you ignore it? i think that's the bottom line. >> my time is expired, but let me say once again i thank you and your staff for the process you're going through. it is invaluable to our country's veterans and to the agency. >> thank you. >> senator burr, thank you very much. senator tester. >> thank you, mr. chairman, and i, too, want to thank you

inspector general griffin for your work, for your professionalism. i very much appreciate it and it is very helpful to us. so thank you for that work. your investigations, whether it be phoenix or whether it's the other 93 facilities, is focused on scheduling, correct? >> that's what we go in to look at, but along the way you sometimes become aware of other activities that you need to look at that might be tangentially related but, you know, so principally they're on scheduling and manipulation of wait times but there are some places where it's expanded. >> so i mean, is it fair to say that -- i mean, the investigation started out in phoenix because of some pretty damning things that were being said about phoenix. is it fair to say that the scheduling problems are pretty pervasive throughout the va? >> absolutely. >> okay.

specifically for phoenix, look, i mean, a good portion of montana heads down there in the wintertime. was there parts of the year where the scheduling was worse than other parts of the year? or was it just that way all the time? >> you know, we did not try and carve out the snowbird aspect that might impact phoenix, but -- >> i was just curious. >> we didn't find a good quarter in any of the quarters we looked at. >> okay. would you say -- what would you say to the folks -- because in the conference committee opening statements we heard a lot from the members of the conference, from both houses that talked about this isn't a workforce issue. in your investigations, what would you say to that? >> i would say it's a complex issue with many aspects. one of those aspects is performance standards for the physicians that you do have. without those standards, it's hard to determine exactly how many doctors and nurses you

need. it's a clinical space issue. vha guidance talks about a panel of 1,200 patients for primary care, but it assumes that there are three separate offices for each doctor so that you can have your patients ready to go when you come in, and in phoenix there was only one office per doctor. so i think it's a combination of, yes, there's -- in some facilities they're understaffed both nurse and doctor staffing. we have sought the implementation of staffing standards for years. we did a review in 2012 on specialty care staffing standards and found that only 2 of 33 specialties had standards. i think you need to know how many veterans can we anticipate this specialist seeing in a given day and then make sure the

schedule is properly structured so you can fill those slots. >> and would you -- you've got a number of maryla.d.s on your st and you, in fact, may be an m.d. i'm not sure. you are? >> no. >> when you're talking about staffing standards, do you use the private sector for your staffing standards, and maybe this should be reflected by one of the m.d.s on the staff and i'll tell you why i ask this. i'm not an m.d. either but it appears to me if you try to apply private sector staffing standards to the va it's unfair because these folks are coming back with multiple problems plus ones that are unseen, too. so do you guys apply the staffing standards or do you say va, you need to set up the staffing standards? >> we have said that we believe they should have standards so that if you're going in a like-size va facility in one

part of the country or another, the expectation is a certain level of productivity. i would ask dr. daigh if he would like to elaborate on that. >> sir, we said va should create their own standards aware of civilian standards but without that data i don't know how you can make proper business decisions about what you can make or what you're going to buy. >> that's good. thank you very much. there are 1,700 health care facilities in the va. 93 are being investigated by you at this point in time. can you give me any idea or is it evenly split between hospitals and small clinics. >> i would be guessing to give you that number but -- >> can you give me that number if you went back and checked it? >> yes, absolutely, and if someone at the table here has it, i'll give it to you right now. >> that's fine. there's nobody nodding yes.

>> we'll get it to you. >> my time just ran out. when ask we expect a report on the 93 facilities? >> as we finish each individual report and to be finished, if it's a criminal matter, we have to present it to the u.s. attorney's office for prosecutive decision. if it doesn't meet the threshold for prosecution, we give the report to the department so that they can take administrative action where appropriate. >> is it -- would it be fair to say, and i don't want to box you in, these be would done by the end of the year? >> i hope so. >> thank you very much. thank you, mr. chairman. >> thank you, senator tester. senator heller. >> thank you, mr. chairman. i want to go back on your initial comments on the report. the draft report versus the final report and some of the changes that were made in that report and get some clarification as to time lines. it was reported that a line was

inserted, and if you're the va has the line you'd want inserted in that report. that line says, while the case reviews in this report document poor quality of care, we are unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans. and obviously that was pertaining to the phoenix hospital. just some time lines. was this line included in the draft report? >> there are many versions of a draft report. the majority of the changes in our draft report came about as a result of further deliberations by the senior staff of the inspector general's office. no one in va dictated that sentence go in that report, period. >> so was the line included in the draft report that was sent to the va? >> it was not included in the first version of that draft

report. what i would like to do, if i may, is provide a time line in writing to the committee -- >> i'd like that. >> that can, you know, make it very clear what is going on with that allegation. >> okay, okay. i guess the question that needs to be asked, did the va play any, any part in the inclusion of this line? >> no. >> in your report, you obtain a list of 71 -- 171 patients whot were waiting to seek services. most of them were mental health therapies. you also noted in your report that between january of 2012 and 2014 that you identified 77 suicides. these patients did not have their appointments scheduled or

were yet to be scheduled. what i'm trying to get to is would a reasonable person come to the conclusion that wait time manipulation -- would that contribute to patient deaths? would a reasonable person come to that conclusion that the manipulation of cardiac problem

wait list factor was not very important. if you were under the care of a urologist intensively but you were on a wait list to see primary care, then we may have concluded that, yes, you were on a wait list, yes, you died, but we don't see a relationship there. so for each of these cases we've reported, we wanted the fact pattern to demonstrate that a delay in care we thought would have led or dramatically impacted the likelihood that that patient would die, and we didn't see that. we saw harm, we saw 28 cases described where the delay negatively impacted care but i couldn't say delay caused a patient to die. >> so with the 171 patients that were delayed in mental health therapy and you identified 77 suicides, you see no link, no link between delayed care and

these -- >> i didn't say no link. i said that if you're trying to say that -- >> see, i'm in the business of trying to find conclusions and of figuring out what reasonable people would believe. we had a female veteran, blind veteran, with diabetic problems in nevada. had to wait six hours, six hours to get care. two weeks later she died. and i have to believe that there's a link between the kind of care she was getting at that hospital and her death two weeks later. and i think any reasonable person would come to that conclusion. >> so we looked, again, at the fact pattern for each of these cases. we had two physicians on my staff agree on the cases and the fact staff agree on the cases and th thought we would find patients

with delayed care leading to death. i agree, that's a likely outcome. i just didn't see it. and all i can do is report the news that i find, and this is what we find. >> see, i don't want to give the va a pass on this, and i believe that's what this line does. it exonerates the va of any responsibility in past manipulation of these waiting times. >> i just have to disagree. i described 45 cases, 28 of which were negatively impacted because of delays. the only argument is i can't say that those that died died because of the delay and in addition, i found that there was care that didn't meet the standards of care that we would expect of the va for an additional 17 cases. so i think i've laid those fact patterns out in the report. so i have a conclusion, and the reader can come to their own conclusion. >> dr. daigh, thank you. thank you, mr. griffin.

>> thank you, senator heller. senator hirono. >> thank you, mr. chairman. just following up on the previous question. general griffin, would you agree attribution of negligence as a griffin, would you agree that after negligence as a result of delay in care as a causation of death is a process that needs to be undertaken. >> that's correct. >> you noted in your testimony that wait times are not the only issue that you were focusing on and that when people do not follow headquarters directives and there has to be consequences. you are investigating some 97 facilities. have you completed those investigations on any of those facilities? >> we have completed 12. we have turned over 12 files to the department for whatever action they deem appropriate. all the others are in process. >> as a result of these 12

files, has the va undertaken any criminal or administrative proceedings? >> the criminal decision lies with the u.s. attorneys offices that we're working with around the country. the va owns the decision on administrative action. shortly after our first report was sent to the va, they did take administrative action. we are trying to get these done as quickly as possible so that they can move out in every instance, but we have to make sure we have all the facts right prior to declaring that we're through and this is the final product. we're working diligently on that, but we have a lot of other prosecutions outside of wait time areas which have led to over 500 arrests a year for the last six years that you can't just drop.

a lot of them are threat and assault cases, drug diversion cases, abusive veterans. so we're working very seriously to try to get through the wait times, but all these other investigations that were already in progress need to be seen through to fruition. >> thank you for giving us a fuller context in which the va is undertaking these kinds of proceedings. you mentioned in your testimony and in your conclusion that the va must address cultural changes, cultural issues. can you talk a little bit more about how a system as vast as the va can make cultural changes and what sort of cultural

changes are you talking about and what do you suggest they do to implement these kinds of cultural changes? >> i think if you have a culture where it's okay to disregard directives from the most senior people in your administration that you need to come to realize that that is not acceptable behavior and perhaps you will no longer be employed by the department. when people realize that it's a new day in that respect, i think they will be a little more vigilant in how they receive directives from the senior leaders in washington, and i believe that the efforts that are undertaken in the various town hall meetings and feedback sessions with the vsos and so on can also make the entire organization realize these are the types of things we need to be doing. >> do you think that the provisions in the law that was passed, the veterans bill that

would allow for more expeditious processes for disciplining that that would help to change the culture in the va in a positive way? >> i think that in a number of personnel areas in the federal government, it can be frustrating at the pace that it requires in order to go through all the due process activities. i think the ultimate impact that it will have on the department is to be determined. it will depend on how frequently it's used, whether there are any challenges being the va is the only department in the government with the new

abbreviated timeframes and so on. >> the report -- your report put forth a number of recommendations and particularly look at recommendations 17 to 23 and the va has said they will meet those recommendations by september 2015. are there any of those recommendations that you consider are of more priority than others for the va to meet. >> well, there's a reason why our number one recommendation was at the department with the regional council in phoenix and with vha medical professionals to look at the names of the 45 veterans we identified and to take appropriate action regarding potential liability or institutional disclosures or something. i think that's very important. >> so basically your recommendations are in the order of priorities that you -- >> it it's in the order of the presentation of the report. but i personally would have to

say i think that's one of the most important items. i would also say as we were doing the work and we discovered 3,500 veterans that weren't on an official list anywhere, we immediately turned those over to the phoenix staff so they could be seeking out those veterans and not delay their care anymore than it had been delayed. >> mr. chairman, my time is up. >> thank you, senator. senator boozman? >> thank you, mr. chairman. i do appreciate the hard work of you and your staff. i have done a very good job. the report you came out with is very helpful as we try to solve some of these problems. i'd like to ask a little bit from both of you all, normally when you see when a patient goes and sees a provider, the provider becomes the responsible person in the situation. if you sign a chart and say come back in two weeks sometimes there are situations where perhaps he's going to be out of tour or somebody is not

available. i can't imagine that a situation where the scheduler wouldn't ask the one that was scheduling this can't be done. what do you want to do about it. and so can you elaborate on that. what happens in the va. when the provider actually writes on the chart or however they do it, does the scheduler overrule that? and the other problem to i've got is when the provider sees somebody back, say you inherit a patient like this, you see on the chart that he was supposed to come back in two weeks and mow it's two months, where's the outrage from the provider at that point as to why this wasn't done in a normal fashion. >> senator, i think what we found in phoenix is what you talk about is reasonable steps an office has to have in order

to maintain the trust of their patients and deliver quality care. what we found was that for example, a person would go to the emergency room as the point of care. the emergency room physician would provide appropriate care and diagnosis diabetes. you need to see your primary care provider. at phoenix there simply not enough access in primary care to accommodate patient who is needed to go to the primary care provider. so what would happen was the patient would then be given a consult and be put in a space that wasn't acted upon and you'd next see the patient show back up with diabetes again with more problems. so you could track that consult was referred, didn't get acted upon, you see the patient reenter the system at a point that was not appropriate. it's what they needed to do, but it wasn't what should have happened. so what i think you have when

you don't have primary care properly structured both with respect to the way they schedule, the way they staff the office, the efficiency with which they run the office, you get chaos. and i think that's what we were experiencing was you're looking at a group of people who knew they couldn't get it done correctly, struggling to save patient who is they thought would be at harm and you see a schedulers trying to schedule patients into slots that don't exist. it was just quite a horrible view of what was going on there. >> well, not just there though. does that happen in multiple other places? >> i think this would be the worst example i have seen. >> i guess what bothers me is that e.r. doctor. i can understand turning him over in the first place and not getting seen in two weeks or whatever the timeframe is. sometimes it's appropriate that

you mentioned of theology, that might stretch on without any problem at all. but when the e.r. doctors see them again in the e.r. and they see that consult hasn't done, there has to be -- that's the responsibility of that physician. i mean, where's the outrage from the guy that was seeing him knowing that they hadn't -- >> i think there was outrage and they expressed their complaint to the leadership at the facility. again, if people aren't hired or money isn't addressing the problem you speak to, you realize that nothing is going to happen. if the facility talks to the national leadership and says i have a problem and you don't get a response, then people get conditioned to this is just the way it has to be. this is the way it's going to be

in this system. that's unacceptable. so in hearing the physicians and providers on the ground, nurses and doctors on the ground, i think they were all anxious and upset at what they saw trying to deal with it the best they could. >> i know this is about scheduling. you mentioned that you felt like there weren't any deaths involved as a result of the scheduling, but in looking at some of the cases that you present. there might not be deaths, but there were certainly very poor quality of care in some of those. poor quality of care means malpractice. are we following up on that or are we in the process of doing a study regarding the quality of care with these cases and other cases? >> we already concluded it was

poor quality of care and there's a problem as far as tort claims activity as was previously stated. those are adjudicated in a court of law and the experts that have to be involved in that adjudication in the case of the state of arizona have to be people who have practiced in that area of specialty in the state of arizona and it is a programmed function of the department to address allegations of malpractice, which is why we provided them with the 45 names and said that you need to look into these 45 cases with your attorney staff and with your medical staff and determine whether there's something that needs to be done for these people. >> i understand. the chairman is going to wrap me in a second, but i guess my concern is when you see these cases in that particular situation, we have a culture of, again, breakdown in scheduling, breakdown in communication among the physicians and schedulers, whatever. my concern is that this sort of activity is throughout the

system and that's what i was referencing. are we going to investigate and see if we have this quality of care throughout the system. >> thank you. senator blumenthal? >> thanks, mr. chairman. thanks again to to all of our witnesses here today. i know that in response to senator testers' question, you mentioned that these individual cases will be turned over to prosecutors if criminal violations are found. is that correct? >> that's correct. >> and they will be turned over on an individual basis? >> right, because they are in different judicial districts around the country. >> and they involve different facts. >> right. >> who will make the decision about whether those cases should be turned over to criminal prosecutors?

>> when we have evidence of potential criminality it's our job to take it to the u.s. attorney in the district and they make a determination whether or not it rises to the level of the types of things that they are presently involved with prosecutions of. >> in effect, the prosecutors will be making those decisions, just as they would with any investigative agency, whether the fbi or the drug enforcement administration? >> correct. >> and what is the timing for beginning to turn over those investigative results? >> turn over to the department? >> i'm sorry. i was unclear in my phrasing. what is the timing for presenting those cases for judgments by the prosecutors? >> the timing is -- when we feel that we have developed the

evidence that would support a criminal charge. >> has the prosecutor in any of those jurisdictions said to you, we need that evidence as soon as possible? have they given you a time line? >> no. no. we are working feverishly to accomplish these things. another point that i had made in your absence was, our criminal investigators make over 500 arrests a year. we have had a number of cases that were already in the

investigative and prosecutorial pipeline before this happened. as you know, it can take forever to work it through that process. >> hopefully, not forever. >> well, it can sometimes feel like that. >> and i know that much well. >> sure. >> when i was a u.s. attorney, i would say to investigative agents, some of the best in the nation, here is my time line. not that the world would fall apart if they didn't meet it. but there would be time lines for completing investigations. i gather, you haven't been given any? >> no. but i can tell you that the assistant attorney general for the criminal division sent out a memo to every u.s. attorney's office and all the chiefs of criminal basically giving them his point of view on what potential charges under title 18 could be brought for the various types of manipulations or different things -- >> falsification of records, destruction of documents, obstruction of justice? >> right. >> i'm going to sort of segue to the next area of questioning.

you and i have talked about this issue. and i appreciate you have some very skilled and experienced investigators working for you. but my feeling, there simply are not enough. you disagree with me? >> i would say that we are fully engaged and could probably put twice as many people to work as we have assigned to the organization. >> you could put twice as many to work and they would all be very busy? >> yes. >> and they would be busy doing very, very important work. which would lead me to the conclusion that there aren't enough of them, because criminal investigations here serve a vitally important purpose. i don't need to tell you, because you are a very skilled and able investigative officer and inspector general and watchdog. but the deterrent purpose of a

criminal investigation and prosecution and conviction are irreplaceable. there is nothing like the deterrent affect of a successful criminal investigation to deter criminality. we're not talking about deterring carelessness or even negligence. which can be serious enough in their consequences. but real criminality. so i simply would urge you to be as aggressive as possible in asking for resources that are necessary for v.a. to really do its job and deter criminality assuming it existed here and may be ongoing in the agency as it may be in any agency of our government, state or federal. thank you for your service. my time has expired. thank you, mr. chairman. >> thank you.

senator murray. >> mr. griffin, i was deeply disturbed to read your findings about how many cases of suicide in veterans in serious mental health problems with affected by care. many facilities in my home state of washington are facing staffing problems and long wait times for mental healthcare. i wanted to say, if hospitals in washington state are on your list of facilities for further investigation, i really hope your team looks very closely at the mental healthcare problems like they have done in phoenix. i want to ask you, the phoenix report really criticizes vha's resistance to change. your report and the white house review found serious cultural and ethical failings across the system. what do you think the v.a. should be doing to make these

kinds of system-wide changes? >> i think you have to hold people accountable when they ignore directives how to do business. and i think after a while, people will begin to tow the line rather quickly when they realize there's a price to be paid. >> that has not been done? >> no. how can you have a certification requirement that you abolish because some of the managers in the field are pushing back about it because they might not be sure if their scheduling staff is doing it right and the ig staff might come after them for asserting something that wasn't true or certifying something that wasn't true? you just don't tolerate that. >> yeah. okay. you've mentioned several times here that you are following on

93 facilities investigation. and the results are confirming some of the things you found at phoenix, wait times are being manipulated. >> right. >> when your reports are completed, i really expect the v.a. to implement your recommendations quickly and hold people accountable, as you just referred to. but i wanted to ask you this morning, is your impression that the motivation for these inappropriate practices are more to show false information or is it more just a lack of training? >> i think it's a combination of a number of factors. in each much our reports going back to 2005, one of the recommendations was to ensure that the schedulers were properly trained on the way it was supposed to be done.

that was a repeat recommendation. >> they have been hearing this for a long time? >> oh, yes. as you know from your previous time with the committee. 2005 was the first time and the first report that we had that. as i mentioned earlier, i think you have to have a person working the scheduling side that has some clinical knowledge of being able to triage how bad does this veteran need to be

seen today as opposed to somebody else. that is not currently the case i believe in a lot of facilities. >> i know some of the facilities are saying, this is low level. we have a lot of people coming in. it's hard to keep up. is that an excuse? >> no. i mean, i don't think there is an excuse for -- i believe that over the years v.a.'s budgets have pretty much been matched or exceeded by congressional appropriators. but if you don't know what your demand is and how many are on secret lists and you don't know, we need 30% more clinicians or whatever the number is -- >> you can't ask. >> then they can't ask for it. i think the responsibility is, you have to do a serious strategic analysis not just of your clinicians but the blend with fee-basis care and come up with a solid number that you can hang your hat on and say, in order for us to treat veterans in a quality manner and in a timely manner, we need this number of doctors and we need this amount of money for fee-basis for rural areas or what have you. >> mr. chairman, i know you heard me say it a million times. this congress, the country wants

to be there for our veterans. but if we do not know what the need is accurately, we don't know what to provide. i echo that point. let me just ask you one other thing. you have been doing this a long time. we've been hearing this for a long time. you've been doing a lot of investigations. have you found any facilities or networks that have done a good job of regularly and thoroughly checking for scheduling gimmicks? >> we found a number of facilities out of our 93 where we concluded that there was no manipulation occurring. which is a good thing. maybe one-fourth. the bad news is on the other three-fourths we're confident it was knowingly and willingly happening. >> it's a pretty high percentage. >> we're pursuing those. >> thank you, mr. chairman. >> thank you, senator murray. >> thank you and your team.

>> let me thank mr. griffin not only for being here but for the excellent work that he and his department are doing. we thank all of his staff for being here as well. thank you very much. >> thank you, mr. chairman. mr. secretary, thank you very much for being with us. again, my apologies for putting you on second. i thought it would be important for you and for the committee to be hearing from the inspector general first. but the floor is yours. please, take as many time as you need. >> thank you. obviously, we thought it was important as well that the inspector general go first. so we're very pleased to be here after the inspector general.

chairman sanders, ranking member burr and distinguished members of the committee on veterans' affairs, thanks for the opportunity to review with the report regarding wait times and scheduling practices at the phoenix v.a. hospital. i said at the time of my confirmation hearing that i will put veterans at the center of everything that we do at v.a. so let me begin by offering my personal apologies to all veterans who experienced unacceptable delays in receiving care. it's clear that we failed in that respect regardless of the fact 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 desire. that's how we regain veterans' trust and that's how we regain your trust and the trust of the american people. the final report has been issued. and as the inspector general said, we have concurred with all 24 of the reports' recommendations. three of the recommendations have already been remediated and we're well under way in remediating many of the

remaining 21 because we began work when the issue was first issued in may. for accountability, we have proposed the removing of three senior leaders in phoenix. as we learn more about supervisors and the problems there, we may find that additional disciplinary actions are warranted and we will take them. we're grateful for the committee's leadership in establishing the recently passed veterans access choice and accountability act of 2014. this important act streamlines the removal of v.a. senior executives and the appeals process if misconduct is find. however, it does not guarantee v.a.'s decisions will be upheld on appeal or allow v.a. to fire senior executive officers without evidence or cause. we have taken many other actions to improve veterans' access to

care including, first, putting in place a strong acting leadership team, good people with proven track record of serving veterans and solving problems. they are operating in phoenix now. i have visited them on site. increasing staffing by 162 people 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. completing over 146,000 appointments in three months. as of september 5th, there are only ten veterans on the electronic wait list at phoenix. where v.a. capacity didn't exist to provide timely appointments, we referred patients to non-v.a. care. from may through august, phoenix made almost 15,000 referrals to non-v.a. care.

we have secured contracts in the future. since my confirmation, i have traveled to v.a. facilities across the country speaking to veterans and v.a. employees as well as visiting and speaking with members of congress, veterans service organizations and other stake holders. during these visits, i found v.a. employees to be overwhelmingly dedicated to serving veterans and driven by our strong v.a. institutional values of integrity, commitment, advocacy, respect and excellence. the acronym is i care and i'm wearing that button here today. our people are making a difference. nationally they have enabled the following critical achievements. as of august 15, vha reached out to over 294,000 veterans to get

them off of wait lists and decrease the veterans on the electronic wait list by 57%. vha has developed the initiative to increase timely access for care for veteran patients, decrease the number of veterans on the wait list longer than 30 days and standardize the process and tools for ongoing monitoring and access management at all v.a. facilities. where we haven't been able to increase capacity we have increased the use of community non-v.a. care. between may and august, we have made almost a million total referrals for non-v.a. care. over 200,000 more referrals than for same period in 2013. the 14-day access measure has been removed from all employee performance plans to eliminate any incentive for inappropriate scheduling. over 13,000 performance plans have been amended. we're updating our appointment

scheduling system and working to acquire a comprehensive state-of-the-art commercial off the shelf scheduling system. v.a. medical center directors are completing reviews. 3,000 of these reviews have been conducted nationwide. we have restructured the office of the medical inspector to better serve veterans and to create strong internal audit function. on august 7, i asked all v.a. employees to reaffirm their commitment to both our mission and our i care values, intel rit -- integrity, care. i intend for this to happen each year on the anniversary of our establishment as a department.

i want to meet with them personally and we will decide actions after that. we are building a more robust continuous system for measuring patient satisfaction to provide real time site specific information, collaborating with vsos and learning what other leading healthcare systems are doing to track patient access information. we're working hard to create and sustain a climate that embraces constructive dissent, that welcomes critical feedback and that ensures compliance with legal requirements. that climate mandates commitment to whistle-blower protection for all employees. yesterday we announced the beginning of our road to veterans day, our 90-day plan which begins with our mission to better serve those who are born the battle and for their families and survivors. we will focus our efforts to rebuild trusts with veterans and the american people to improve service delivery and to set the course for long-term excellence and reform. as we move forward, we will

continue to work with the ig and other stake holders to ensure accountability. as you heard, there are over 100 ongoing investigations at v.a. facilities by the ig. by the department of justice, by the office of special council and by others. in each case, we await the results and will take appropriate disciplinary actions when all the facts and evidence are known. we will not wait to provide veterans the care that they earned and that they desire. we're going forward. we will focus on sustainable accountability in the future. more than just adverse personnel actions, sustainable accountability means ensuring all employees understand how their daily work ties back to that mission of caring for veterans. we want them to understand how it ties back to the mission, how it ties to our values and how it ties to our strategies. we want to make sure that

everybody's behavior every day is guided by those values and that mission. we also want to make sure that every employee understands, it's their responsibility to provide feedback to their supervisor when they are asked to do something that is impossible to do. we want to make sure that feedback loop is daily and that every employee is getting daily feedback from their supervisor and that every supervisor is giving daily feedback to their manager. sustainable accountability requires we do a better job of training our leaders. we need to flatten our culture. we need to encourage innovation. we need to encourage collaboration. and we need realistic ratings of performance. everyone cannot be the best. employees fulfill their responsibility to the department to provide feedback and input on how we can better serve veterans. who better than the employees who have every day are interacting with our veterans. we will judge the success of all

these efforts against a single metric, the veterans' outcomes. we don't want to meet a standard. we want v.a. to be the standard in providing healthcare and benefits. i know we can fix the problems we face and i will utilize this opportunity to transform v.a. to better serve veterans. mr. chairman, members of the committee, thanks for your unwavering support of our nation's veterans. i look forward to working with you in implementing the law and in making things better for all of america's veterans. we are prepared to take your questions at this time. >> mr. secretary, thank you very much for being here, for your patience and hearing the discussion with the inspector general. i think i'm paraphrasing one of

the other members that indicated that the perception is you have hit the ground sprinting, which is what we wanted from you. we appreciate that. i want to reiterate a point that you just made. that is that the vast majority of v.a. employees -- i know this is the case in vermont and all over the country -- work tirelessly and work very hard to do everything they can for our veterans. we should never forget that. and we should also not forget that while we're focusing on the issue of timeliness and the need to make sure that every veteran in this country gets timely care, we also know that i can tell you absolutely in vermont that most veterans believe that the care they are getting once they are in the system is of

high quality and they appreciate what care they are getting and the work that the staff is doing. what i just want to do is -- in a sense, you have talked about this in your opening remarks. let's focus on three or four basic issues. every member of this committee is outraged by the long wait periods that veterans in various parts of the country are experiencing. number one, i want you to tell us briefly what kind of progress that you have made in reducing those wait periods. number two, we all agree it is unacceptable for v.a. staff or high ranking people to be lying, to manipulate data. what have you done to get rid of people who are acting dishonorably, what plans do you have in the future? thirdly -- this is tough stuff -- how do we make sure -- how do you lay the groundwork that what we have seen in phoenix never happens again? how do you address, in fact,

what is a national problem? i think the senator raised the issue. it's no great secret that we have a serious crisis in the number of physicians we have, especially primary care, the number of nurses we have in various parts of this country. we have given you some tools and are proud of the work that came out of this committee. we gave you tools in the education debt reduction program which now gives you the tool to go to medical schools. tell us about that. tell people who otherwise would graduate, young doctors in debt that we now have a debt -- strong debt forgiveness program. what are you going to do to address the very difficult issue of bringing more quality physicians, nurses and other ed me -- other medical personnel into the system? >> access to care, we reached

out to over 294,000 veterans to get them off wait lists and into clinics as of september 5th. as a result, v.a. has decreased electronic wait list by more than 32,000 nationwide since may 15th. that's from over 57,000 in may to around 24,500 as of august 15th. we have reduced the new enrollee from 64,000 to right now approximately 1,700, which say reduction of about 62,000 -- >> this is a combination of expanding v.a. capacity and sending people out to the private sector? >> yes, sir. it includes things like in phoenix we moved in three mobile units from around the region. we increased clinical hours. we worked on overtime. it's a matter of putting the resources where they need to be put. we collaborated with the department of defense, with health service.

these were the things that were done. we have had more people that we have put into the private sector. 246,300 more patients have gone into the private sector. each one of those referrals actually is resulted in seven appointments. so we're making progress there. more work needs to be done. obviously, the bill that you mentioned is going to help us do that by providing greater access points, 27 more new points. and the ability to hire more doctors and nurses. you asked about disciplinary actions. we talked -- i talked in my opening remarks about the three individuals in phoenix who were seeking -- who we proposed disciplinary action for. we have new acting director there in phoenix. in my american legion speech, i mentioned that we have over 30 actions that we have taken.

around five include members of the senior executive -- the senior executive service. about two dozen include medical professionals. so we are following up as quickly as we can. as soon as we get information that suggests we should take disciplinary action, we are taking it. we have the accountability team. i met with them as recently as yesterday. they report to me. their single job is to get after these as quickly as possible. >> let me interrupt you. i'm running out of time. i wanted to ask the third question. the inspector general made a good point that it's hard to know what you need unless you

have good information. i mean, in your judgment, how many more doctors, nurses, medical staff do you need? how, at a time when this country is not producing enough physicians, are you going to get them? >> we need tens of thousands. deputy secretary gibson said around 28,000. we are going through a process. >> let me repeat that. you are telling us you believe you need 28,000 new medical staff? >> including clinicians and other employees. we're in the process of going through a big recruiting effort. i was at duke university medical school. i was with senator burr in charlotte. i went to duke. we talked to over 500 members of

the duke medical community. i was in philadelphia last friday. i talked to members of the university of pennsylvania medical school. we are trying to demonstrate to young people studying in the medical profession that v.a. is where they want to work. they want to work there because we have had three nobel prize winners. we do great up-front research. did you know that the nurse work at the v.a. developed the use of tracking patient and medication with bar codes. young people should come work for us. the help you gave us with student loan forgiveness, debt forgiveness, doubling the number is going to be very helpful to help us recruit. >> i far exceeded my time. senator burr? >> thank you, mr. chairman. mr. secretary, welcome and thank you for the role that you are filling. i have a couple areas. one, on an item that you mentioned, that every private sector referral triggering seven additional visits. if you would -- you can have dr. clancy do this.

i know that's what v.a. actuaries have stated and believe. i think we need to get to the bottom of it, figure out why. is this a contractual problem where we have contracted with the private physician where they see an opening to bring a patient back seven times? under medicare that would be under a bundle payment. if we're going to do private sector, then we have to figure out whether we're doing it right today. i can't envision where every time we refer somebody to a private sector doctor it triggers seven additional appointments, visits that we're going to pay for. if that's the case, i would love to see the specifics on that when you are able to do that. with everything that you just

went through, it's probably hard to believe that i would ask you this question. because you detailed greatly all the changes that we're making. my question is this. how do you plan to change the culture at v.a. and how do you plan to measure it? >> first, we will get you the data on those seven visits. many of our veterans have multiple illnesses. we will get you the data and we will sit down together and talk about that. in terms of changing the culture, changing the culture is probably one of the most

difficult leadership challenges whether private or public. the most important thing we have do is to open up the culture. as i described earlier, high performance organizations have the improvements made by the employees not by the leadership. the leadership certainly helps. they pick the strategies. they pick the leaders. they help create the culture. but we have to get every employee involved. so on the very first week i met with the union leadership. the the majority of our employees are union members. 65% are union members. i met with the union leadership. i met with them three times in my first five weeks. i'm asking them to recommit themselves to our values and mission and help me engineer changes that we need to make. every time i go to a site, i meet with the leadership. i talk to the whistle blowers.

i do a town hall where i explain that i want every employee to be a whistle-blower. i want every employee causing us to change. i've used a diagram. i used it yesterday and i have used it with employees that basically says that most people think of an organization like a pyramid. you would have a ceo. at the department of veterans affairs, you would have a secretary. i take that and i turn it on its head. i say, this is where our veterans are. our veterans are at the broad base of this pyramid. the people caring for the veterans are the most important people in the organization. i'm on the bottom. i'm at the apex. what i have do is make sure the communication is flowing up and down that pyramid to make sure we care for those veterans. the boss of this operation is the veteran. the boss is the person next to the veteran serving the veteran. frankly, some of the things that have happened in the past don't fit that picture. for example, we had some of our positions who serve the veteran downgraded. annual salary is tens of thousands of dollars less that we're able to pay them. those are important people. we have to -- i have encouraged our leaders to seek exceptions to that policy.

we have to put the best talent up working and serving the veteran. culture change is difficult. i think we can do it. >> go ahead. >> just to make one point. a point about measurement, v.a. has a unique all employee survey going out into the field to all employees. it's much more thorough than other federal departments. one area that we can measure and track is psychological safety. do people feel empowered to say we have a problem here on the front lines? i need help. this isn't working. we will be keeping a close eye on that. >> we sent that out last week. i will show the results with the committee when it comes back. >> thank you. one last question. in the press release that v.a. sent out prior to the release of the ig's report, the release stated that you had asked for an independent review at scheduling

and access practices beginning this fall by a joint commission. i have a very simple question. why? why do we need a joint commission to look at the same thing that the ig is looking at in 93 facilities right now? the ig reported on since 2005 and are we waiting to the fall to implement changes in that until we have got a joint commission's report back? >> i will ask dr. clancy to clarify my comments. it's not just any commission. it's a commission that does this kind of work for a living. >> as soon as we hear the word commission, we look for who is hiding. >> it's about benchmarking best practices. this commission does this across the country and will help us information best practices in all facilities, not just the 93 the ig is looking at. we plan to use this commission to improve.

it's unfortunate their name is commission. >> just to expand for one moment. they acredit private hospital. they cannot get paid if they're not accredited. this is following a standard practice in the private sector. these are unannounced surveyed. we have put a huge amount of effort into making thur schedulers are trained. we're looking for ways to get exceptions to get their grades increased as the secretary indicated. but this is also going to be looking at is it really working, how does patient flow work? what happens to people who wait in the emergency room who leave because they have been waiting too long and so forth? it's an independent check for us. it will give us an opportunity to spread both good practices and opportunities for improvement across the system. >> thank you. thank you, mr. chairman. >> thank you. >> thank you. thank you for being here, secretary mcdonald. i would love to have you incorporate montana into your travel plans by the middle of next month. they are some of the best veterans in the country. i'm partial on that. let me ask you this. you moved three leaders from the phoenix office. we they terminated or reassigned?

>> what i said is that we have proposed disciplinary action against three leaders. this is the process that has to be taken for leaders who are in that stra ta of employee. we have proposed discipline ari action. it goes to a board. there's a process that it goes through. since we have proposed that action, we have taken the leaders i talked about, moved them to phoenix. they are in an acting role. >> new leaders? >> yes, sir. >> you have to protect employees' rights. but we need to terminate people when they deserve to be terminated. >> i agree entirely. believe me, we are -- as i said in my remarks, we are following the disciplinary -- we're following the investigations. as soon as we're capable, we are taking action. >> the ig made good points. he brought up the analysis because of the scheduling really don't have a clear pattern of

how many folks out there really need the kind of services they need. and then there's also the fee-based information that's out there. i don't know if that's better or not as good or the same. how can you make a determination that you need 28,000 medical staff? you're a wonder worker probably. the fact is, that information still hasn't been hammered out. >> we're going through a process right now where we're going location by location, specialty by specialty to understand how many people we need. >> when do you think that will be done? >> she's leading that process. >> in response to a previous report from the inspector again, we have been -- we have created and are deploying a tool to assess productivity which

includes -- i would guess by early -- the end of this calendar year, early next year. >> then you will have a firm grip on how many medical staff you will need to have when that process is done because you will have set up standards for doctors? >> yes. in addition to how many support staff do they need to make them as efficient as productive as possible. >> i want to kick back to something else the ig said. i tried to pin him down on the staffing thing. he said, staffing is part of it. the other part is facilities. where are you going to put these doctors and medical staff if you hire them? i can tell you in montana, facilities -- i don't know if they are as big of a problem but they are close to as big a problem as not having people. you have doctors there but you don't have examination rooms. do you have a construction plan moving forward? i know it's unfair. you have been in the job six

weeks. i'm not trying to be critical. >> it's five, actually. >> all right. >> obviously, you are right. facilities are very important. the action you took with the bill gives us the ability to have 27 more facilities. not surprisingly, one of the facilities will go in phoenix where, obviously, we have a need. we have an issue right now that we're working. it's around leasing. we have been following an appropriate, i think, strategy of leasing facilities rather than building them. because the population is moving. you have talked about the increase in veterans in montana. we're currently working through the gsa on this process. because the -- >> to get down to it, i appreciate you telling me what you are doing. all i want to know is, do you have a construction plan moving forward for the next year, three years, five years? so that you can come to us -- some of us are appropriators -- and say, we need this much money if we're going to serve the veterans coming back.

>> we have a construction plan. we're going to be renewing our forecasting as i mentioned because i'm not satisfied our forecasting is robust enough. >> it's pushed out for two years. is it open to all hospitals? let's say the great falls hospital wants to get in the program. what do they do? >> let us know. again, we look through the lens of the veteran. if it's good for the veteran, we want to do it. >> in rural areas, that's going to be critically important. i have other questions i'm going to put on the record for you as we move forward. know that i know you are committed to the job. i know you are surrounding your people. middle management has been a problem not only with this administration but the previous one. you need to hold them accountable, too.

>> i want to spend time with you on the plan road to veterans day. we are going to reorganize the department. we have nine different geographic maps for this department. we have 14 websites that require different user name and password. the veteran doesn't want that. the veteran wants one map, up with website. that will flatten the hierarchy that you describe and provide for information coming up and down a lot more quickly. >> thank you for your work. >> thank you. >> thank you, mr. chairman. thank you for visiting reno. >> reno and las vegas. >> and las vegas. on behalf of myself and the governor, perhaps minus relocating and locating in the state of nevada, it was a terrific opportunity for him to discuss with you, as myself, the concerns that we both share about nevada's veterans. >> you are welcome.

may i say that working with the state governments is important for our success. >> you are proving that. thank you for doing so. i want to talk about the nevada -- as you are aware, the inspector general's report, they did a v.a. two year claims initiative and were able to recognize in 32% of those claims reviewed were inaccurate. unfortunately for the state of nevada, that ig report that they did in june, found that 51% of the claims reviewed were inaccurate. that being the case, have you had an opportunity to review these reports from the ig? >> i have. but i also have to say that i have asked the ig to give me all of the reports over the last five years and to give me a triage version of those reports. i want to go back and i want to look at all of the reports that have been issued and not acted upon. i do know the situation in reno having been there. we have new leadership on the ground.

we're making some progress. but we're not to where we need to be. the new leadership knows that. >> let's talk about that leadership for a moment. as you know, i called for management changes in the reno area. have we -- do we have a permanent director at this point? what's the time line for getting that? >> we have an acting right now. we're in the process of obviously identifying the permanent director. >> you mentioned -- >> we will partner with you on that. >> okay. you also mentioned that there was a need for four additional employees in that particular office. what's the status of that? >> i have to check the hiring status. but we need more employees in

the veterans administration and we need them in that office. there's nothing holding us back from hiring them. we do need more employees in m overtime october 1st because it's not sustainable. in order to be able to sustain our progress going forward and continuing to drive these claim and backlog down, we have to hire more people. there was money in the bill that was recently passed that was taken out of the billie think it was $400 million. we are going to need some of that money back. we are going to cost save to try to find money to be able to hire the employees and work this backlog back down. >> overtime is not an answer. long-term. short-term perhaps we can make headway, but long-term overtime

ñ employees probably is not the answer. i think there is a structural overall change that needs to happen. i will repeat it, but at 345 days out, for benefits and medical claims, it's unacceptable at this point. i hope that additional employees would be willing to answer, i talked to management in reno to find out what you need and they told us additional resources were not necessary. let me know. anything that i can do to be of help, it's absolutely unacceptable. i think change needs to occur. i know you haven't been in your position real long, but do you have a direction that you really want to go for the wholesale changes that will be necessary to reduce the backlogs? >> we made progress. the claim black bog is down by

56%. i agree that the changes made in the veterans benefit administration over the last couple of years have been astounding, but we have done it by brute force. we need to reengineer the process and get the resources in a sustainable basis and drive down the backlog to by 2015 which is our commitment. >> if there is anything i can do to help and support, we are working on those and we would like to offer our services any way we can. i want to change directions quickly on women veterans. there nearly 2.3 million women veterans who served in the military and that number continues to grow. since you have been secretary, have you reviewed the services for the women veterans to make sure it is adequate sn. >> i have and we have work to do. in fact every stop i go to whether it's phoenix, memphis,

las vegas, gi into the medical center and one of the things that strikes me is how we built facilities years ago for male veterans. there were not female veterans. i check in to see if we have medical practitioners and ob-gyn and other areas. i look into the prosthetics labs to see if we are used to making prosthetics. we were talking to gary of the disabled american veterans and they have done a study on what it means to make a prosthetic for a female who is pregnant. these are things we never had to deal with before, but with 11 to 12% of the veterans being female and continueing it increase in numbers, these are things we have to get after. >> it may take legislation to expand and i'm eager to help your administration and moving forward on these initiatives and something needs to be done to look forward to assist. >> we would love to partner with

ow that. >> thank you very much. senator murray sn. >> thank you very much. before i asked my questions, i wanted to say thank you for asking the question. there is a lot of work left to do in terms of privacy and in terms of doctors that know how to care for women. we also know that one of the barriers for women to get care is child care. if you don't have a place to leave your kids and particularly for mental health, this is a serious issue. i would love to work with you on that as well. thank you again for being here. i want to start with talking about the fact that the ig found several cases in which veterans faced delays or substantial care and took their own lives. the newest wait time data shows it takes far to go to get into care and simply meaning the wait time is not enough. veterans need to be assigned to a regular provider and they need

care coordinated across the hospital and between specialists and to get the type of care they need when they need it. we have been working on this problem for a long time now. i wanted to ask you today, why do you think the va continues to struggle with why do you think they struggle with providing appropriate health care sn and one of the things that excites me about this job, we are the path finder for the country. whether it's the use of a bar code in the hospital to make sure somebody gets good care, one of the things we have to do is increase the number of students studying mental health in school. when i was at duke university, i met with 17 residents who graduated from the medical school all working at the va.

only one was a psychiatrist. i asked the question, why are young people not going into psychiatry and mental health sn it's an area that we are learning a lot more about today than we knew in the past. my father in law who was a prisoner of war was a b 24 shot down over austria. he walked across germany. i'm sure he had post traumatic stress. we didn't know what to call it. he never wanted to talk about it until he joined a va group of pows who felt comfortable talking about it. they said the biggest issue is that insurance reimbursements are far below cost. we have to get a handle on this area and find ways to encourage people to go to school with mental health. in all of my recruiting speeches so far, i talked about the importance of mental health and i'm trying to encourage young people to get into the

discipline. i think it's a national problem. va is on the cutting edge of it. >> continue to work on that because that to me is a serious issue. it's a country issue, but our veterans are at the front of this line. we are to make sure we have the providers and the understanding across the va and the culture of the va to really watch for this. in your testimony, you talked about improving the department's leadership and breaking down the va's bureaucracy as a way of enhancing accountability. that needs to happen at all levels. i liked your chart here at the top. there is a lot of people between you and them. we need to -- >> that's why i gave out my cell phone number. >> we need to look at everything from training new clinic managers to oversight intervention by medical centers and network leaders. how do you make sure that these changes happen at all of those levels across the va sn it's a

huge system. >> it is a huge system. >> it starts by getting out and going to the different sites and meet the people and understanding are we providing the right leadership and do we have the right choices and do we have the right systems sn are we doing things that will lead to a good result and do we have the right culture sn for example, i was at a site in reno and a young person was talking to me in a town hall about ways we could improve our computer system. one of the stopped the conversation. they had to ask to move out of the way. it just wasn't appropriate. i was in philadelphia last week. this was the site that had a training program on town halls. they used oscar the grouch in there. i had to talk to those employees

about no matter what the intent. no matter what's important. the perception of oscar the grouch, it's not going to be acceptable. they had to dive into the culture and dig. they set the example to do it right. i told everyone to call me bob. i might be bob after i'm done being secretary. that's done because we need to flatten the hierarchy and need people to be like a family. they need to feel comfortable turning in problems. we need to reward people who turn in problems, not chastise or ostracize them. it's hard work, but it's under way. >> quickly, you said you committed the va to acquiring and feeling a modern scheduling system. can you tell me when you think that will be done and the training for employees to use that sn. >> right now we are doing quick

fixes on the established system. those quick fixes are coming out president cally over the next few months to really change the whole system and bring in a new one will take time. we would like it to be done in 2015. >> and that includes the training sn. >> yes, of course. when you put in a new system, we want to commission it. we want to verify people know how to use it before they sit down and are qualified to use it. >> thank you very much. >> thank you, senator murray. >> mr. chairman, thank you. mr. secretary, i don't think i will call you bob, but mr. secretary, thank you very much for your presence as i said earlier. a series of convoluted questions related to the same poppic. i would like to offer my assistance as i have done with previous secretaries. you have testified and the chairman has great interest in trying to help the va h