working together to identify the problems and working towards the solution. no single individual has a monopoly on the answers. no single individual or institution has all the answers. the workup at of us will be hard us to work all of together in that regard. the veterans service organization, the department, this committee, the senate, and the white house. mr. chairman, i want to thank you once again for your robust advocacy for our veterans in holding all these hearings we are having for the oversight and it is my hope that when the committee asks for information from the department of veterans affairs that they provide that information in a timely manner so that we will not have to issue a subpoena to get the information we need so we can do our oversight hearings. that is our responsibility that we expect the department to help

us do our oversight hearing as well. i yield back the balance of my time. >> thank you very much for your comments this evening. i would ask that all members would waive their opening statements is customary in the committee. i would invite the witnesses to please come to the witness table and as you are coming forward, i will introduce you. we will hear from dr. debra draper, record health care for the government accountability office. koski, richard griffin, acting inspector general of the department of veterans affairs, mr. griffin is accompanied by ms. linda halliday, assistant inspector for general audits for the department of veterans affairs. witnesses to stand, raise your right hand. do you solemnly swear, under penalty of perjury, that the

testimony or about to provide is the truth, the whole truth, and nothing but the truth? thank you very much please be seated. all of your complete written statements will be entered into the record. here tonight being and dr. draper, you are recognized for five minutes. >> chairman miller, ranking member may show -- member michaud. i appreciate the elegy to be here today to discuss the difficulty veterans are having obtaining medical care. in 2000 and 2001 we recorded problems with wait times in a v8 medical facilities. in 2012, we again reported problems, including the unreliability of wait times and the innocent -- inconsistent weight times. it impacted the timely delivery of care. examiningrently v.a.'s management of specialty consults, a type of medical

appointments, and have maytified problems that hinder access to care. several common thieves have emerged -- themes. ande include weak policies result in significant variation, confusion, and increased risk have undesirable practices. software systems that do not facilitate good practices, in adequate training, unclear staffing needs and allocation priorities, and in aquatic -- in adequate oversight which relies facility's self certification. focus mainlyoday on preliminary observations from our ongoing work examining v.a.'s management of specialty care consults. we found most of the 150 consults we reviewed were not managed in accordance with the timeliness guidelines.

this ethically, we found that one in five consult requests were not triaged within the seven-day guideline. we found 38% of the consults were completed, but not within the 90 day guideline. 19% were completed within 90 days, but the provider failed to properly close out the consults in the electronic system. the remaining 43% were close without the veterans being seen. officials told us that increased demand for services, patient no-shows, and canceled appointments are among factors that lead to delays and impact their ability to meet the v.a.'s 90 day guideline. during the course of our review, we did a console in which the veteran experience delays and died prior to obtaining care. i want to walk through the timeline through this case. 2013, the veteran was diagnosed with two

aneurysms. in october, the medical center is scheduled the veteran for surgery, but the surgery was canceled due to staffing issues. in december, the medical center approved a non-v.a. care and referred the veteran for a local hospital for surgery it was discovered that the non-v.a. provider had lost the veteran's information, which the medical center resubmitted. in february 2014, the veteran died prior to the planned surgery at the non-v.a. rider. this case is insightful. while non-v.a. care may expand capacity, there are also potential that falls. non-v.a. care requires prior approval which may delay care. more coordination is needed between the v.a. medical center, the veteran, and the non-v.a. provider and wait times for non-v.a. care are not directed by v.a..

include variation on how medical centers have implemented is this rules for specialty care consults limits the usefulness of the data for monitoring systemwide. an overall lack of oversight in the process, including no independent verification. as the demand for v.a. health care continues to escalate, it is imperative that they address this access to care problems. since 2005, the number of served by v.a. has increased 20% and the number of outpatient medical clements has increased approximately 45%. in light of this, the failure to address its access to care problems will considerably worsen an already untenable situation. this concludes my opening remarks. i'm happy to answer any questions. >> thank you very much. mr. michalski, you are recognized for five minutes.

tighter said you don't have prepared, but are prepared to make comments. your recognize for five minutes. >> members of the committee, no veteran should have to wait unreasonable time for their care. they have earned this care. america plus veterans deserve better. secretary shinseki in accra tech -- acting secretary gibson have stated that we now know that within some of our health care facilities there are systemic and unacceptable lack of integrity. .his is a breach of trust it is irresponsible. it is unacceptable. i apologize to our veterans, their families, and their loved ones. congress, veteran service organizations, our employees, and the american people.

after this committee raised the issues in phoenix at the v.a. health care system in mid april, secretary shinseki directed a nationwide audit. i will be talking about that audit tonight and answering some detailed questions. is -- audit involved over 400 of the national and field staff at the senior executive level, senior manager level, and line management level. stafferviewed over 3700 members. we saw this as the opportunity for us to set a reset, to sweep a clear eyedblish assessment of our actual performance, not our reported performance and establish a system-wide understanding of the change we need to realize in our agency. we released our results this morning on all v.a. medical centers. cbo feeds andall

the results of the audit confirmed the oig interim report and the gao studies. i'm here to answer questions about this audit and other concerns. our audit revealed a number of things. number one, we have hard-working staff on the frontline who work in a high stress, complicated environment with completely outdated technology. frequent challenges cited by our staff are a lack of appointment slots in which to schedule veterans. they have a difficulty andrstanding our policies they rely on an antiquated system which requires numerous workarounds by well-intentioned staff. i have to admit that unfortunately, we found that our staff had received instructions to enter a date other than the date the veteran wanted to be

seen. we know there is an integrity issue here. among some of our leaders. we can and will address this issue. i want to make a comment about repot -- reprisals against employees. acting secretary gibson had mentioned is and is not tolerated. we need staff at all levels, but most importantly at the point of care. we need them to tell us how to improve our system to be able to deliver care better for veterans and they must feel safe to identify problems and they must feel empowered to find solutions. acting secretary gibson has announced immediate action. we will expand and create new veteran satisfaction surveys for patient care. we will begin with veterans and their perspectives. we are holding senior leaders accountable for it of all of our senior leaders in the field over the next few days are expected

to inspect their practices and their facilities and to be personally accountable for the integrity of those practices. we removed the 14 day schedule goal from employee performance plans. we are increasing the transparency in the reporting of our data and will be releasing our act as an time limits data bimonthly from here on out. acting secretary gibson audit of an external our metrics. we're deploying a team to phoenix to fix all aspects. we are formalizing a process for those high-performing sites in both quality, access, and dignity -- integrity to provide guidance to facilities that require support. we have directed staff to phoenix to hire additional staff, to bring in multiple medical units that are currently on the ground, to increase local

contracts to include for primary care and we are removing leadership where appropriate. eshave suspended all as forormance awards for fy 14 the v.a. and we are focusing our hiring efforts to bring more engineering staff to the field. secretary gibson will travel to a series of facilities over the next few weeks to meet with friends, their families, employees, and to identify obstacles to timely health care. secretary gibson has said that we must restore america's trust in the v.a. health care system and we must restore that one veteran at a time. overedicated workforce, of whom are veterans, are engaged. for yourman, thank you dedication to and care for our nation pot that transferred --

nation's veterans. >> mr. griffin, you are recognized for five minutes. >> chairman miller, members of the committee, thank you for the opportunity to testify tonight to discuss the interim results related to delays in care at the phoenix health care system. i am accompanied by ms. linda halliday, assistant inspector general for audits and evaluation. the issue of manipulation of weight list is not new to be a. since 2005, the oig has issued a 18 reports that identified at both the national and local level deficiencies in scheduling resulting in lengthy wait times and a negative impact on patient care. we are using our combined

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

mission-critical management decisions regarding demand for vital health care services must be based on reliable and complete data throughout v.a.'s health care networks. ongoing we have scheduled work at 69 v.a. medical facilities and have identified instances of manipulation of the a data that this -- of v.a. dated that distort the legitimacy of waiting times. when sufficient credible evidence is identified supporting a potential violation of criminal law, we are courting getting our efforts with the department of justice. our work to date has substantiated serious conditions at the phoenix health care system. we identified about 1400 veterans who did not have a primary care appointment, but

were appropriately listed on the phoenix electronic weight list. -- wait list. we identified 1700 veterans who are waiting for a primary care appointment but were not on the electronic weight list. 0-- wait list. v.a. national data, which was reported by phoenix, showed these 226 veterans waited on average 24 days for their first primary care appointment and only 43% waited more than 14 days. however, a review show that veterans waited on average 115 days for their first primary care appointment with

approximately 84% waiting more than 14 days. results ofreport the our ongoing clinical reviews in our interim report as to whether any delay in scheduling a primary care appointment resulted in a delivery -- a delay in diagnosis or treatment, particularly for those veterans who died awaiting care. to tryessment needed conclusion regarding the analysis of v.a. and non-v.a. deficit because, medical records, and autopsy results. we have made request to agencies and have subpoenas to obtain non-v.a. medical records. these records will require a detailed review by our clinical themes. -- teams. while we make recommendations to

the v.a. in our final report, we made four recommendations to the secretary for immediate implementation to make sure veterans receive appropriate care greater we will address -- care. we will address the efficiency of these implementations in our final report. a recommendations include it taking immediate action to review and provide appropriate health care to the 1700 veterans identified -- not listed on the waiting list in phoenix and to take the same action at all facilities in the v.a. system. mr. chairman, this concludes my stated -- statement. >> thank you for your testimony. members, we will all do a round of questions at five minutes apiece and we will do a second round, i sure, after the first round. commentsr, and your

you said that 43% of the console reviewed without the close -- without the veterans being seen. can you give me a reason? >> one is patient no-shows. canceled appointment. canceled either by the patient or the medical center. of --o found instances some records we could not help her we look at it -- we could not tell. there was no documentation as to why the consults were close. >> mr. matkovsky, how does the v.a. schedule appointments? is that a telephone call or a letter? >> is typically to a telephone call. we may call the veteran, they may call us. we will notify the veteran on a recall process. >> i have had numerous veterans tell me that they have received them where the appointment will be and not

asking whether or not they can attend that particular appointment. i am a little confused. >> i have heard that as well. that is not appropriate. that increases error rate of no-shows. it is not veteran-centric. we need to change that. conversationve a and schedule around their requirement. >> v.a. has stated that the alternate list or secret list in phoenix that was being used to populate the electronic wait list was destroyed immediately after the twl was populated -- ewl was populated. was there any independent verification that every veteran on the alternate wait list was successfully transferred to the providean you documentation that no veteran was left off the waitlist? a team on the ground reviewing scheduling processes.

i have a first-round of corporate i will get a final report from them and i will be able to dig a permit at this point -- dig deeper. i don't have any reason to believe that any veterans were left off the finalewl count. >> can you tell the committee who, at the central office, if instructed were coached anybody how to manipulate weight times -- wait times? >> i do not know. not in my direct experience. >> you don't know whether they have or have not? theycertainly hiope have not. in may of 2009, dr. mike davies of the national director of systems redesign indicated there were 49,743 veterans waiting for care as of september 15, 2008. more than five years later,

v.a.'s audit shows that it has risen to 57,000 veterans waiting more than 90 days for their first appointment and additional 64,000 appears -- veterans that appear to have fallen through the cracks. how can this be? >> the correct use of the waitlist is the number that is 57,000. we use the electronic wait list if we are unable to schedule a veteran who is receiving their first specialty care consult within 90 days. the correct use of that is to ensure that we can work a veteran into an appointment sooner. the 57,000 number is a much more conservative number. the known direct clinical care is 40,000. we have to get eyes on the ewl. we have to make sure centers are working that with, getting veterans from waiting for an appointment into an appointment. as for the 64,000, that was a

new enrollment point request list. mr. griffin had told us that was one of the recommendations. if we could find that in phoenix, we should look across the entire country. we had a team review the new enrollee appointment request list. we identified every single veteran from the beginning of the period of enrollment who may have requested an appointment at a facility where they provided their data. if we could not verify that they had an appointment, we went ahead and added them to the list so we can begin contacting them tomorrow. >> mr. griffin, one final question before i yield to the ranking member. have you found evidence of criminal activity in your assessment? indication ofnd some supervisors directing some of the methodologies to change the times.

we have been in discussion with the department of justice concerning those and whether or not, and the opinion of the department of justice, they rise to the level of criminal prosecution is still to be determined in most instances. >> i appreciate you talking with the department of justice. the committee has written a letter also asking they open an investigation. we have not heard anything from them to date other than they got her letter. i appreciate it. mr. michaud. >> dr. draper and follow-up on a question the chairman asked about the v.a. closing due to no-shows. what percentage were no-shows first of the v.a. canceling? >> we looked at no-shows and cancellation. andent to the 150 consults did a research all consults rate of the 150 cases that we looked at to look at the history of the consult request rate of we found that -- consult request.

we had over half were a no-show. it is a big problem for the v.a. and what we see is the policies at the local level very as to how the local facilities handle no-shows and canceled appointments. >> thank you. mr. matkovsky, gao reports that the weight times are generally not tracked for non-v.a. care. why don't you track wait times for non-v.a. care? >> historically, we have not. we have two initiatives, both of them in full deployment. the first one is for non-v.a. care coordination. effectively, what is occurring now is when we refer a veteran to care in the community of we cannot provide it, it creates an appointment in a clinic that allows us to watch that appointment. we are not collecting data on that. every collecting data on

we also have a patient centered care in the community great that contract has a performance requirement from our contractors that they both schedule and see veterans within 30 days of the referral from a spirit we think those two -- from us. we think those two points will help. dr. draper also alluded that the requirement of the management of that care. it is not enough to refer care into the community. we need to follow through as well in ensuring that the veteran's needs are met. but they are working respectfully with the family to get him into care. >> the gao also reports that there is a consistent problem across bha -- vha with policies and procedures for handling canceled procedures. i wear that you are working on an update to the scheduling policy. when you anticipate this

revised policy to be released? we will address the no-show consistently. >> i expect it will. we had a team last week reviewing the existing policy and whether or not we should resend that policy and replace it with a clear, declarative set of instructions on the frontline. we expect to take that action. we will replace that policy with a revised policy that allows us to have much more contrary -- concrete sets of instructions on how to schedule, instructions for what staff to do. if we are scheduling what -- within 90 days, what to do on day 91. isot of our current policy to concentrate in practice and scheduling management. we need to have a clear scheduling policy and clear practice management policy.

management of no-shows can be handled by contacting and working with veterans to make sure they are reminded with their appointments. making sure we talk to veterans and their families when they schedule their appointment. when we do those things, we can reduce no-shows. >> can you explain to what extent exercising non-v.a. care requires additional approvals? >> yes, sir. and some of our medical centers, they require approval at the chief of staff level to use non-v.a. medical care. as part of our accelerating care, we worked on that in the second to last week of may. we worked on the plan may 21 and rolled it out may 22 and began execution on the 23rd. we released instructions to the field that where we have confidence in error weight time data, -- in our wait time data, that if they cannot offer the care in the v.a. facility, they

must assess their capacity and increase it by running overtime and weekends and if they cannot, then they are instructed to offer non-v.a. care to the veteran. we have asked them to tell us what they need in terms of resources to make that work. we are providing a different set of instructions. to work with a veteran, it is a veteran's choice to get timely care and to make sure we offer it. >>. very much -- thank you very much. >> i appreciate the work that you are doing on this issue. that is goingas review to get further was in colorado springs, colorado. there are three anonymous and -- anonymous people who have come forward and say there are problems with manipulating wait times. i have talked to the leadership in dental and -- denver and colorado springs. they have told me personally that this is not going on.

i believe them, but at the same time we have whistleblowers saying that it is going on. how does the v.a. treat whistleblowers? what i'm getting at, there is intimidation taking place. how do we change the culture from intimidation to where people are free to step forward? >> part of how we designed this audit was to have direct access to the frontline from our senior staff. when our auditors went to the field, they met at the same time with unions representation at the field and the facility management. not two separate meetings. one meeting. did not have an announcement of who we wanted to interview. we provided that we showed up so we can have a direct conversation. i will tell you. i have read through the open-ended comments of all of andresponses that i could

nothing saddened me more than an employee who said i was trying to do it right and i received instruction to do it wrong. that is simply not tolerable. retaliation against whistleblowers is also not tolerable. we cannot condone that. we require a leadership and cultural shift in error weight of managing -- way of managing. >> i raised this a couple of weeks ago at our last late-night hearing. rely on the data, if you can't rely on the records because secret waiting lists, by their nature, are meant to conceal the truth from someone who is doing a review like alternativeas the to go in and do a case-by-case analysis, talking to every single veteran who tried to get an appointment in doing this on

a one by 1 -- even if it takes hundreds of thousands of contacts? how do we get to the bottom of it when the records or reports are not reliable? >> i believe we have to begin with the end in mind. providewe want to do is veterans with timely, quality health care, let's ask them, how are we doing? how is our care? how is our access? is our access meeting your requirements? if not, let's fix it. the thing that is terrible about this crisis is that this isn't even an output measure. it is an activity measure. what happens when we change that activity measure is we can't tell where we are not timely. if we can't tell were -- in no cases were we finding frontline staff were delaying care by moving the appointment later in the calendar. they were changing the reference point. when that happens, we don't know where we are late.

we don't know, we can't find where to align resources and we don't do that, our entire system of requesting resources is thrown off. , i hope we have seen the final days and never again were bonuses -- hwere baseds or promotions are on metric second be manipulated and outcomes like patient satisfaction for good care that can be documented, not metrics that can be manipulated. >> i concur. other twoer of you folks want to comment on that issue? i think it comes down to accountability of the senior leadership at these facilities. job ormeone loses his gets criminally charged for doing this, they will no longer

be a game and that will be the shot heard around the system. >> thank you. i yield back. >> mr. brown, you're recognized for five minutes. >> mr. chairman, thank you for having this hearing. colleagues, i want to make sure that we are firing at the right target tonight. we're all in this committee because we care about the veterans and you can be sure that the only reason i on this committee is because i care about the veterans and i have been on this committee for 22 years. i have a couple of questions. dr. draper, you mention -- i want to thank you for your service. the case that you gave about outsourcing a particular case and it was not the right kind of coordination, can you expound a little more? a lot of people want to see a partner -- us partner.

if the veterans can i get the service right away. >> is important because there is a lot of talk about sending more veterans out to the community for care. while that is a way to expand capacity, there are some pitfalls. v.a. does need to do a better job of monitoring wait times, and making sure that the veteran receives the care that they are going out for. that is why we illustrated this particular case. at many points, that did not in the veteran waited a long time and ultimately die waiting for care. >> i have a question about the survey. and aof veterans tell me lot of discussions, once they get into the system, they think the system is the best. no complaints about it once they get in. both of you, can you expound upon that? that of the specialties

are involved in the v.a. is not necessarily out in the community. we are the cutting edge as far as different types of technology, working with their unique ailment. >> i would say in my experience in reviewing various v.a. facilities, i think there is variation among facilities. i think there are some that are very good and some that are more problematic. consistentis not across all facilities, the quality of care. i think we have a good system. it is not the best it can be. the system blocks to veterans and their families. to understandd and needs, to work for them and on the frontline you find our staff are so engaged. i think their passion is unequaled. >> what percentage of the staff are veterans at work at the v.a.? >> over 1/3 of our staff are

veterans themselves. it is making sure that we have integrity of the system so we can identify were as is not working. it is not ok anymore, with all due respect, to say it is great care when you can get it. it must be great care and you can get it. >> that is the key. comments abouty -- one of the problems, it seems, is that a lot of the equipment, the technology that the veterans have is outdated. you know, the computer systems and different systems. part of theffect scheduling problems that we are identifying? >> absolutely. auditsack to 2005 on the that we have gone, one of the recommendations has been that they needed to have an automated capability to review wait times are mostly -- remotely.

millions of dollars have been wasted on contractors trying to system fortter over the this data and past 15 years, gone back to 2000 , it has not had any success. i think it is important to understand that our scheduling system scheduled its first appointment in april of 1985. it has not changed in any appreciable manner and that date -- since that day. >> what about the equipment, the technology? we have lots of meeting about technology. even people coming into the system, we brought in the banking community to make sure that people can't go in and -- what do they call it, still your identity? that is part of the system also.

is that correct? >> it is. some systems are evolving and improving. we have a new veterans health identification cards which has removed the social security card from the magnetic stripe. across the board, if you look at our engineering systems, or building systems, our scheduling systems, these are old systems that in many cases date 20 and 30 years ago before the internet. i was still in college. these are old systems. >> thank you all for your service and i am looking forward to round 22. two.ound >> i have a question. i want to follow-up on mr. michaud's question. this is for mr. matkovsky. as mr. michaud said, it was stated there was no detail

systemwide vha policies and how to handle page it no-shows -- patient no-shows and cancellations. are you await -- aware of a department wide cancellation policy? in our directive, we have policies for managing no-shows and cancellations and we also have policy that is supposed to guide our staff on how to manage veteran appointments and communicate with veterans and their families to minimize the chance -- >> describe that also briefly. >> for instance, if we have a veteran who has repeatedly not shown up for an appointment, we have a no-show list that allows us to contact veterans and that is part of our policy. sites are supposed to implement it. we have to do a better job of following up and ensuring that practices perform. >> i agree with that.

i hear about the long wait times. i had a meeting last week where i met with veterans. one of the complaints was the wait times. everyone knows about that. missed appointments, for example the veteran gets the appointment and maybe through no fault of their own, they can't make the appointment. maybe in ailments were someone ness or someone forgot and the have to wait two months. let me ask you a question because that is a huge problem. is there any input? i hear about the lack of communication between the schedulers. you can call over and over again. does a veteran have input on what that appointment might be? for example, they could have a conflict, a family conflict, medical conflict, what have you. >> could i answer that? >> yes.

i was an issue with the case that you cited. >> part of the problem is, and i want to elaborate more on the notion -- part of the issue is that v.a. needs to understand why the notion and cancellations are happening and part of it is we found the wait times were not good. a good percentage of schedulers are engaged in what is termed as blind scheduling. they schedule appointment without being in contact with the veteran. the veteran receives the appointment through the mail and sometimes it may not be convenient or could be the appointment -- the letter was received after the appointment was scheduled. that sometimes the v.a. contact information is bad. the veteran may never receive that appointment notice. there are a lot of factors that go into the no-shows and cancellations. that is a part of one of the factors that also affects that. >> have you ever asked the , howion of the veteran

would he or she preferred to get this information with regard to appointments? the wayed to improve that veterans can see their appointments, manage their appointments, and asked for appointments. to make that an integral part of our online system for my healthy that. we have a patient scheduling system we are trying to roll into our state of production. it starts with the phones. pick up the phone, call repeatedly, and talk to a veteran and find out the preference bird and then schedule. >> again, my healthy vets is a great thing to have. again, that should be in addition to the personal contact and some people don't have access to computers, either. let me ask you one more question. again, with regard to the wait list, in the hearing this 28,ittee held on may

members of the committee repeatedly, and i know i asked who authorized the destruction of the interim electronic wait list? dr. lynch maintained that it was protocol for one the appointments were canceled. if there is no department-wide process for no-shows or cancellation -- you stated there is. what was he referring to? >> i don't know specifically. i have not been on the ground in phoenix myself. i do know that one of the things they were working on was to try to move appointments sooner. what they may have been doing which he referenced in his comments was printing, rescheduling, and then shredding the evidence because it contains personally identifiable information. i think that is what he referenced. >> we will continue ask questions. >> thank you, mr. chairman.

for mr. griffin or mr. matkovsky , in your investigations, did you identify any sort of pattern when looking at wait times and scheduling practices? what i mean by this is, are there some types of facilities that are better or worse than others? our wait times longer for certain types of care? >> primary care versus certain specialty care, for instance? >> i would say one of the principal methodologies that we have witnessed is veteran calling in for an appointment. he gets an appointment 120 days out because that is the first available appointment at that facility. scored asntment gets the desired date of the veteran and therefore, zero waiting days. the vast majority of the cases

that we have seen involved that scenario. the other scenario would be you get that appointment 120 days out. two weeks before the appointment, it's gets canceled in the system and he gets re-created. the veteran is no wiser for the fact that his appointment was canceled because it is re-created for the same time and date. once again, it reflects a waiting time which does not reflect the reality of the amount of time that veteran has been waiting for care. what we are similar to found as well. of the waitin terms time data for new veterans, we tend to be able to trust that data better because it has a computer date stamp in it. it is not perfect but it is better. we do find specialty care has longer waits among veterans.

we also know wait times in primary care. >> thank you. that was a very clear disruption of the pattern. both phoenix, there was wait times of this nature for both primary and specialty care. >> we did see a significant count for primary care. a number of veterans on the electronic wait list waiting for primary care appointments. will typically happen is that you can see a subsequent demand for specialty care. as we are with -- bringing in resources for riemer care, that's primary care -- >> in my question, i don't want an excuse at all. -- the point of my question i want to ask you from your data and audits, if you are able to

comment on whether there is an underlying shortage of providers. you mentioned a scarcity of appointment slots. how much of that is attributed and shortage of providers attribute all to inefficiencies in the way they operate? >> we have to check them both. i think in some cases we have provider shortages but we owe it to the american taxpayers to run an efficient system as well. we have to look at the productivity data. i think it is both. think anay, i integrated health system is the best system for veterans who have multiple conditions that they need care for. thefurther you dilute locations for that care is provided, the greater the chance of the care not getting properly reflected back in the medical record. the greater chance that that

particular provider may or may understand the conditions that veterans is facing. i think what the thing is about is a business process of returning on investment for getting your own doctors. committed to the v.a. mission who are full-time ploys at the v.a. -- employees at the v.a. as opposed to the 4.8 billion in fy for feewas spent here. there has to be a strategic analysis of in the long run, what is going to be the best outcome for veterans. it has to be continue. >> is there a pattern in your research for the quality of care

of whether a v.a. facility is associated with the university hospital? >> we have some of our highly rural, unaffiliated performers ending up being near the top in the health care rankings. >> thank you. >> doctorow, you are recognized for five minutes. week, as a vietnam era veteran, i went to vietnam and we talked to the folks that there were looking for her 1200 mias. owe it to the honor of those who did not return but provide for those who did. we are not doing a very good job of that right now. financial incentives are lined

up to not provide the care. many give you an example. in no-shows, when that is a problem with a consult, in our office, and we had patients who were supposed to not be a regularly scheduled patient, we had ways for check -- to check for them. if they did not show up, they took up a slot. there is no penalty at the v.a.. that is free time. our practice of 10 doctors sound -- found that, i don'tlt just put a patient on my list when i am seeing a patient in my office and say, show up.

you can call -- there is a thing called a telephone. you can pick up and call someone and mr. jones, are you going to be able to keep your appointment next week at 10:00? those are simple things. it requires a personal touch. -- the financial assistance making them so out. foress the question i have you, did you notice any particular type of consult? cardiology,eas in the rheumatology. did you notice a difference in the type of consult?

>> we look at three specialty areas. the demand and not keep pace at the providers they had. demand kept increasing and he did not have the providers to always take care of the patients. >> so it did not matter? i thought it might did. >> we did not look at all specialties, but those were the three we did. >> mr. matkovsky, one question i had. are pay-for-performance, i asked this last week -- when you are evaluate it as a senior person at the v.a., is are pay-for-performance related to how many veterans are sent out in the private sector along with the wait times? is that part of it? no one could give me an answer. >> i don't believe it is, sir. >> that is fine. -- for megriffin

personally, i know the chairman asked this question about the potential. when you have put a system in place that fraudulently puts information out there and then you gain financially from the taxpayers, that would seem to me to be a fraudulent case. i'm simply looking at it as a way man -- a layman. when you go out there and on purpose misled knowing that you would get a financial bonus if you did that, which is exactly what has happened, is that fraud? i think it is. >> i agree. is, you start with the is --e, gs6 schedule schedulers who have many layers above them before you get to the

leaders of guilty. you have to work up that supervisory chain to determine who put that order out to do it this matter and that is what we are having to do with 69 facilities other than phoenix right now with additional facilities reporting in everyday. it is not an easy task. i suspect if people do start getting charged, maybe that middle level person will say, wait a minute. i am not going to take a fall for someone higher up the food chain than me who directed that we do this. >> i do not want to see a schedule or making someone's appointment's and role. that is not right. i yield back. >> ms. radley, you are recognized for five minutes. >> thank you for your leadership on this committee. my first question is to mr. matkovsky. i understand that the acting secretary sent a triage team to phoenix as you testified. --old ardently

wholeheartedly concur with. after reviewing today's audit numbers, and some of that data, it is clear that there are other medical centers across our experiencingre similar or worse wait times. greater los angeles is a good example of that whose wait times exceed the wait times in phoenix . -- in phoenix is good. we need triage elsewhere. when we get to that? >> we need two thanks. measureto reset how we so that we will know where we are performing well and where we are not with confidence. care, wef accelerated requested medical centers to survey their capacity.

we broken down by clinic and medical center. we use something called stop code. code and wee a stop have individual wait times for those. we would also be able to increase the productivity numbers for each of those clinics and ask if they have low productivity and wait times to address productivity concerns. week.few more clinics per run some evening, run some weekends. if you could not find capacity, if you were at capacity, request the resources. if you do not have it and need it, as four. make surer job is to our staff at all levels can raise the flag. systemwide we have done that. i think we have identified an additional requirement or $300 billion, the vast million -- going tority of it health care now.

>> can you tell me as a follow-up how you're going to prioritize that? is there a schedule for that? my veterans inventor of county, therest l.a. facility is primary facility. the data is not as public as it should be. the first question my community will be asking is when. >> tomorrow. eachning on may 23, medical center with waiting to haves directed clinical capacity. one of the things we have to be careful about is that there is not a insufficient supply of primary care or mental care in the community. in thean find the care

community, coordinate that care, the next step is to pick up the aske, call a veteran, and when they went to be seen. as of friday evening, we have made 50,000 phone calls in networks across the country. we want to finish those phone calls and we want to move on to the next set of phone calls, working back from wait times as we get closer to closer to what we think is timely care. that has already started and i think we'll be tracking, beginning this week, the rate of obligations for those funds. we created specific account codes for the funds it will be tocking the non-fee a chair -- not v.a. care. >> you mentioned about my enoughue having personnel and professionals in the system to meet the needs. i know the acting secretary has also ordered a hiring freeze

across the v.a.. i want to know what that means. me that we have toems to fix this airplane while we are flying. at ourld be looking hiring practices and hiring as it addresses the other issues that are broken within the v.a. howe need to take a look at long it takes to hire staff. the secretary's point is not to restrict us from hiring staff in the field. it is teaser just that in our network offices we have a hiring freeze. we can dedicate our hr resources to hiring for the field. at some point in time, we may lift that. satisfied with

having a vacancy and initiating the recruitment process and allowing that to take six months. that means that we are running it under capacity for six months. we have to change it. er the budget or have a security resource facility. the secretary is not telling us not to higher in the field. >> i also think the witnesses for testified today. is that correct? >> yes. >> how many of those are in the vha system and rough laly wheree they? >> we have facilities with a good handle on patient

satisfaction i think in san antonio. the passion, mission and drive is there in some of the facilities. in some cases, entire networks didn't have integrity issues and in some networks only certain instances. but we have high performers who get the process right, schedule with integrity and find resources where you need them. we have a number of them. >> we have high performing facilities that have much better outcomes than the others. what makes it different? >> culture and leadership. >> okay. the leadership. i will fgoing to maybe to dr. draper. did you find similar high performing facilities like

referenre referen referenced >> we see variation. i think some are great and some struggle. part of it is the leadership. >> and mr. griffin did you similarly find high performance facilities or team? >> if i could expand. we did a couple reviews of the networks and we concluded if you have seen one you have seen them all. if you have high performing facilities at the network level or whatnot you need to export the best things in the system. there have been issues where a problem has been identified and you send it out and top leadership and vha sent out safety alerted and directives and what have you and they were not followed. so you have accountability

issue, integrity. but there ought to be a best model for similar sized medical centers so when a directive goes out you know at this facility or all of the facilities the chief of staff owns this or the chief of surgery or one individual. some of our reports like on reusable medical equipment not being properly sanitized. there was no one person that had ownership of that one issue. you reap what you sew. >> do you conquer with the other two observations that is the leadership? >> leadership in the field and also in head quarters. >> the report sited the need to

coach employees on how to respond to the oig questions. do you have any evidence that any of those activities took place? coaching employees or data manipulation? >> there is plenty of evidence of data manipulation. we had reports in may reporting there were parties going on destroying documents at medical centers. we responded to 50 medical centers that weekend and didn't find any destruction in those unannounced visits. >> how about coaching employees on how to respond to the team's question? >> our team's questions are not

similar to the ones by the audit staff. all of our interviews were taped. people were put under other and we asked them straight up who told you to do this? some produces e-mails. some said we have always done it this way. the range of answers is what caused us to identify it as systemic. >> and did you run across any employees that said they would be willing to cooperate but they were concerned about repiesal >> we had reports of that throughout the system. >> thank you. >> in may the va launched the

care system and this was highlighted in your press release. we know the goal is to help the veterans get care in the private sector. i support the good ideas. as you heard references the united states is facing a physician shortage nationally. not just in the va but the private sector. in nevada, we have a chronic shortage of doctors in primary care and specialist. 46 in the nation for general, 50 for psychologist and 5 is >> there are things we can

explore about how to attract talent to las vegas. the meta-school school hub that would help us with talent. we have found that that works. doctors70% of america's have received some of their training from the v.a. attract union talent thal falls in love with the mission and comes to work for us. we need help but broader help

than contracting and va. i think las vegas is one of those areas >> we have the university of nevada medical school, we have a big new hospital, what about the increase in residency? >> absolutely. >> if money were to become available now like we heard about on the senate side to more more doctors and build more facilities are you ready for that? do you have a list of priorities? what are they? and what metric planning are you using to make those determinations? >> we have a significant construction requirement to maintain facilities which on average is 60 years old. they are landlocked. in phoenix, we had to bring down mobile clinics to handle the

extra staff. space matters. we need space so we do have a list of priorities where we require space rather in the form of leases, minor construction or overhauls. or refurbishing even. we have an identified need for providers. we will take a closer look at the productivity and the demand. >> i know before the hospital in las vegas opened before it was started the emergency room was declared too small. it is 2% normally but in las vegas it increased to 19%. so when you look at your priorities you include demographic calculations for growth and the need for service

because once it is there, you build it, and they will come. okay. thank you. i yield back. >> mr. denim you are recognized. >> thank you. is this the audit from the va? >> yes, it is. >> i notice on the 14th of may, livermore which is in our contract area, was audited. i sent a letter in over a month ago requesting each district is given the information whether it is private briefing or public information. but i think every member of this committee has a right to know what is happening in their own district. is there a reason we don't have that? >> we were competing phase one

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

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

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

dustry that knows how to deliver systems. >> if those areas are lacking why isn't this part of the action plan? >> the schedule plan is part of it action plan. we are working with ornt and plan to have an award for replacement scheduling system. our intention isn't to pick someone who can write a book about developing a scheduling system but to acquire a system and deploy that scheduling system. >> and one final question. another thing i notice there. obviously you have seen how this committee and the house feels about the firing process. we think we need to help you through that process and give you the tools to implement that type of discipline. but another thing i saw was the staffing system was flawed. if it is taking you 3-6 months

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

draper you said there is not consistency among the various centers. i wonder if you could identify the top three reasons for that inconsistency and what we can do to make sure this it the best health care delivery system for the veterans. >> part is the weak policies. one example, i will go back to the wait times and no shows and canceled appointments. you will find each facility develops their own policy. so we have seen anything from a 1-130 facility and one phone call and give the veterans 30 days to respond or it is canceled. we see two canceled appointments and then it is canceled.

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

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

this committee wants to get to the bottom of this. but my are we still using 1985 technology? is it lack of funds? >> i would approach it from a different angle. >> go ahead. >> your facility is only as good as the people working there. and there are five qualities to every great team. communication, upward and downward lateral communication. managers need to get out of the office and walk around and find out what is going on there. second thing is collective responsibility. everybody on that team has ownership of the outcomes there. pride. be proud of helping our nation's veterans. be proud to go to work to help our nation's veterans. caring. of course, in a medical center caring has to be one of those

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

the scheduling replacement process was hindered by management issues. then there was a $249 million used for core fls. $700ollow-on was flight million. , $2.4here is the vista fm billion in investments that this congress has made. asking, what is the answer to the question why are we still hough using oud systems when we have given hundreds of millions of dollars to the va. mr. runyon, thank you. i apologize.

you're recognized for five minutes. >> thank you, mr. chairman. first a on to the first of all, wants to agree with the comments my colleague, mr. denham, made to the business that my veterans visit, number four, number three. three of the facility's are all in that further review category, and a request this information that mr. denham did. i have -- for purpose of, i think, while all this started in this secret lists, so we said keystone with who, is vista not capable of scheduling to gestures out? if we did not have the metrics that dr. lynch said here, numerous times a couple weeks ago and said these metrics are forcing us to play these games, is that a possibility?

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

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

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

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

and decisive end to this severe misconduct and of those responsible accountable. as i have called on in the past and we have discussed today, a criminal investigation is needed to remove individuals who knowingly prevented veterans from receiving the timely and quality health care they need and resulted in harm or death. a criminal investigation will put an end to this wrongdoing, will change culture now one for the future. currently there are over 1500 veterans a unified -- realize the loma linda health care system, many of which live in my district that are either awaiting over 90 days or going without an appointment altogether. it is time that the house passed the veterans access to care act, h.r. 4810, to make it easier for veterans who are too far from a va or are waiting to long for an

appointment to seek care outside of the va system. as a physician, i will continue to work as a member of this committee to, one, stopped the scheduling misconduct and, too, that treat the veterans, give them the care when they needed it. after reading the audit today i have several questions. the first, what are the possible solutions to get veterans triages and cared for immediately. let me preface this. there are other veterans with aneurysms, perhaps, that need care now. there are other veterans with suicidal ideation that need care now. there are other veterans that have cancer that are on the verge of spreading that need care now. we must hold the individuals accountable. yes, we do, and we will. but we need to give care now to our veterans.

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

require that care in the community beginning may 23rd contacts are going out to the field, network ten, which is ohio, completed all of its contact the following week, all of them. every veteran who was waiting, they called. can we make it that? yes. we also identified $300 million requirements in the immediate term. >> if you are relying on a broken system, you are going to give brokers results. i encourage you to find a model, a benchmark, former special operations unit that not only identifies positions within the national va system, but also within the private sector to rapidly deploy to the priority healthcare systems and create a form of health care events, tree

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

disaster and emergency medical staffing t-mobile that is being used in phoenix. how willing to identify across the country at a moment's notice. starting on sunday there were 21 such black styles. >> i look forward to working with you to see if we can extrapolate that experience the other va systems including los angeles and other areas like where they might have been very long wait times. >> thank you, doctor. you are recognized for five minutes. >> thank you, mr. chairman. >> i feel sorry for you being here today because you are representing a system that really has no defense and i appreciate your apology.

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

i would tell you that we had the fuse light version control issues to the tail end of this. we know where our anomaly is. it did not make it in the final. >> how am i supposed to trust the data you did today? you know, the last 80 submitted was completely different than the ig reported shortly thereafter. you see the problem that we have here. i feel sorry for you sitting there. >> every two weeks from here on out -- i'm sorry, bimonthly we will produce data. has our integrity and reporting improves we may likely see that our timeliness worsens. >> frankly, i don't believe you. i tend to associate myself with mrs. kirkpatrick across the aisle who says that the system needs a complete revamp and restructurings because there is no accountability here. there is complacency. i like to associate myself with

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

bombing to confirm that they're coming. that va has not figured that out ? it is impossible to believe that that actually occurs. that, there are -- the employment people are writing people letters without talking to them. it is like, really? no one is getting fired over this kind of decision making? it is unbelievable that this is occurring. i appreciate you for your comments. we need to have leaders within the va and a system within the va that holds people accountable and makes it known that if you don't do your job you will be out of there or prosecuted. just simply that happening will change the entire culture. >> could you comment? i have a few seconds last. where do you think this should come from? the top or the bottom? give me some comments on your

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

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

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

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

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

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

following upon the issue of restoring trust. when before our committee two weeks ago. their stated goal was to be open and transparent in working with this committee, members of congress, and hopefully with the public. are you aware of any gag orders or orders or instructions from washington that would prevent the employees from visiting with the media and our members of congress? >> i personally am not, congressman. >> let me give a little background on that. friday, may 38, told that there was no one on a secret waiting list. three hours later a letter was released that said that there were three @booktv sees me, actually nine. at that time on a friday afternoon evening i have begun calling the leaders and received no response until a fallen wednesday when i began hearing

rumors of 385 on a six rating last. i jumped in a vehicle, drove for one hour. and was met with an e-mail. >> that, indeed was an accurate ino. do you think that helps build trust? >> it does not, sir, but you are certainly not aware all that those types of e-mails were sent out through the va system, at least there were actually guy and they would not provide me a copy of the milk, probably 100 different names. that did not know them. i knew the one sentence at the end, don't talk to anybody. you are absolutely not aware. >> i don't know, congressman. sort of working on the audit in some preparations. it is possible.

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

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

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

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

investigations thus far? >> not specifically that. we did find more than 50 percent of the 150 cases that we looked at had at least one no-show or cancel the appointment. and, you know, we found clinics. we found -- we like to ask -- for each facility we looked at 30 consoles and spam consoles for the three specialty areas we looked at. we did look at one of those. one of the specialty areas, they cancel all ten appointments. all ten of the apartments were canceled. it raises questions of whether there were canceled. >> in el paso we have long heard from veterans who said that they could not get a mental health care plan. certainly could not get it within about 13 days. there are seeing everyone within

14 days kamal were hearing is so great that we commissioned a survey, we released a report and found that 36 percent of the veterans el paso requesting mental health care were unable to get the point man at all. taiwan's a thank-you and the va fur not challenging the fact that it was a well designed, well implemented survey, large sample size. instead, that the viejo jay z is now working with us to identify the one-third of veterans, hundred of thousands who could not give amounts of fair employment. i appreciate that. and i also appreciate the audit the release today that shows that new patient mental health care average wait times in el paso are 60 days. that is the port or stagnation. but i will tell you that if may 9 to receive this report from dr. pencil and mr. john

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

on a related note, i will be introducing veterans can't record as a no-show will have a phone call from the va to confirm that that is what has happened. was that essentially what you committed to? >> i have. we do patient satisfaction data. veteran patients rate the quality of their health care experience sib. they also tell us in our satisfaction survey that the rate their access as per below. so i were just as for your continued cooperation. we will introduce this bill this

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

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

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

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

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

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

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