discussions, once they get into the system, they think the system is the best. no complaints about once they get in. can you -- both of you, can you expound upon that? and a lot of specialties that is involved in the v.a. is not necessarily out in the community, i mean, we're the cutting edge as far as different kinds 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. there's some that are very, very good, and some that are more problematic. i think it's not consistent across all v.a. facilities the quality of care. >> congresswoman brown, i think we have a good system. it's not the best it can be. the system belong to vit rans and their families. we are a system that's designed to understand their needs, to work for them, and on the front

line, you find our staff are so engaged. i think their passion is unequaled. >> what percentage of the staff of veterans that work at the v.a.? >> over 1/3 of our staff are veterans themselves. it's a matter of making sure sure however that we have integrity in the system so that we can identify where access is not working. it's not okay anymore with all due respect to say it's great care when you can get it. it must be that it is great care and you can get it. >> timely. >> timely. >> that's the key. mr. griffin, any comments about -- one of the problems it seems is that a lot of the equipment, the technology that the veterans have is outdated.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 system and the different systems. could that affect part of the scheduling problems that we're

identifying? >> absolutely. going back to 2005 on the audits that we've done, one of the recommendations has been that they needed to have an automated capability to review wait times remotely. a lot of money has been wasted, millions of dollars have been wasted on contractors trying to create a better system for capturing this data, and over the past 15 years, going back to 2000, it hasn't had any success. >> if i may congresswoman brown. i think it's important to understand that our scheduling system scheduled its first appointment in april of 1985. it has not changed in any appreciatible pg manager since that date. >> what about the equipment that i'm asking you about? the technology? i mean, we've had lots of meetings about technology, even

people coming in to the system, you know, we brought in the banking community to make sure that people can't go in and what do they call it, steal your identity, so i mean that's part of the system also, right? is that correct? >> it is. so we have -- some systems are evolving and improving. we have a new veterans health identification card which has removed the social security number from the bar code from the magnetic change. across the board, if you look at our engineering, building systems, administrative systems, these are old systems that in in cases date 20 and 30 years ago, before the internet. i was still in college, you know. these are old systems. >> yes, sir. thank you all for your service. and i'm looking forward to round two. >> thank you. >> thank you for holding the

hearing. i have a question and i know mr. -- i want to follow-up on a question. this is for you. in gao's testimony it was stated there are no detailed systemwide vha policies on how to handle patient no-shows and cancellations. are you aware of any departmentwide policy for cancellations? >> we do actually have -- in our directive, we do actually have policies for managing no shows and cancellations, and we also have a policy that is supposed to guide our staff on how to manage veteran appointments and communicate with vet vans and their families to minimize -- >> describe that policy briefly. i don't have a lot of time. >> for instance, if we have a veteran who has once not shown up for an appointment before or has repeatedly not shown up for an appointment before, we have a

no show list that allows us to contact veterans and that's actually part of our policy. and sites are supposed to be implementing it. we need to do a better job of training, following up and ensuring that practice is performed. >> i agree with that. i hear about the long wait times. i had a town meeting last week but i meet with veterans frequently. three-hour town meeting and one of the complaints of course was the wait times. everybody knows about that. missed appointments, for example, the veteran gets the appointment finally, and maybe through no fault of their own, they can't make the appointment. maybe an illness or maybe somebody just forgot, and then they have to wait another two months, for example, for an appointment. let me ask you this question, because that's a huge problem, is there any input, i mean, i hear about the lack of communication between let's say the schedulers. you can call over and over and over again. does the veteran have input on when that appointment might be?

you know, for example, they could have a conflict. a family conflict. a medical conflict, what have you. >> could i answer that? >> yeah. because that was an issue with the case that you cited. >> it is. and part of the problem is and i wanted to elaborate a little bit more on the no shows, part of the issue is the v.a. needs to better understand why the no shows and cancellations are happening, part of it is that the wait times work, pretty good scheduleser are engage in what is termed blind scheduling. they schedule appointments without being in contact with the veteran. the veteran receives the appointment through the mail and sometimes it may not be convenient or it could be that the appointment was -- the letter was received after the appointment actually was scheduled, and then we also see that sometimes the v.a. contact information is bad so the veteran may never receive that appointment notice. so there's a lot of factors that go into the no show and

cancellations, but that is a part of one of the factors that also affects that. >> have you ever asked the question of the veteran how would he or she prefer to get this information with regard to appointments? >> we need to improve the ways that veterans can see their appointments, manage their appointments, and frankly asked for appointments. we need to make that an integral part of our online system for my healthy vet. we do have a patient scheduling application which we are trying to roll into a state of production, but frankly it starts with the phones. pick up the phone, call repeatedly, and talk to a veteran and find out their preference, and then schedule. >> thank you. and again, the my healthy vets, it's a great thing to have, but again that should be in addition to the personal contact and, of course, a lot of -- some people don't have access to computer

either, so -- let me ask you one more question. i know i don't have a lot of time. again with regard to the wait list, in the hearing, this committee held on may 28th, 2014, members of this committee repeatedly and i know i asked who authorized the destruction of the interim electronic wait lists? however, dr. linch maintained it was protocol for when the appointments are canceled. if there is no departmentwide process for no shows or cancellation, now you stated there is, but what was he referring to? >> i don't know specifically. i've 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, and what they may have been doing which he referenced i believe in his comments was printing, red scheduling and then shredding

the evidence because it contains personally identifiable information. i think that's what he referenced, sir. >> all right. we'll continue to ask the questions. thank you very much. i yeel back. >> thank you. you are recognized for five minutes. >> thank you, mr. chairman. for mr. dpriven -- griffin. in your investigation, did you identify any sort of pattern when looking at wait times and scheduling practices and what i mean by this is are there some types of facilities better or worse than others, are 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 a veteran calling in for an appointment. he gets an appointment. 120 days out because that's the

first available appointment at that facility, and then that appointment gets scored as the desired date of the veteran and, therefore, zero waiting days. the vast majority of the cases that we have seen involve that scenario. the other scenario would be you get that appointment 120 days out, two weeks before the appointment, it gets canceled in the system, and then it gets recreated. veterans no wiser for the fact that his appointment was canceled because it's recreated for the same time and date, but once again, it reflects a waiting time which does not reflect the reality of the amount of time that veteran has been waiting for care. >> those are similar to what we found as well. i would say in terms of the wait time data for new veterans, we

tend to be able to trust that data better because it has a computer date stamp in it. it's not perfect, but it's better. we do find special care has longer waits a -- among those receipt vans we also note wait times in primary care. >> thank you. that was a very clear illustration some of the pattern. can you tell me, so in phoenix, there is both wait times of this nature for both primary and specialty care? i mean, i saw that the primary care numbers were -- >> we did see a significant count for primary care. there are a number of veterans on the the electronic wait list waiting for primary care appointments. what will typically happen is that you will then see a subsequent demand for specialty care, so as we're bringing in resources for primary care, we're also very cognizant of the fact that we're going to require to address specialty care in phoenix, sir. >> i don't want in my question, i don't want to excuse at all the manipulation of wait times.

that's not the point of my questioning. but i want to ask you if from your data and your audits are able to comment on whether there's an underlying shortage of providers. you mentioned a scarcity of appointment slots. how much of that is attributable to a shortage of providers and how much is that attributable to maybe inefficiencies in the way the facilities operate? >> i think we have to check them both. i think that in some cases we have provider shortages, but i think frankly we owe it it to the american taxpayers to run an efficient system as well. we have to look at productivity data and the amount of time in clinic serving veterans. i think it's both. >> if i may, i think an integrated health system is the best system for veterans who have multiple conditions that they need care for. the further you dilute the locations where that care is

provided, the greater chance of the care not getting properly reflected back in the medical record, the greater chance that that particular provider for that one instance of fee care may or may not be fully aware of all the other conditions that veteran is facing. i think what it's about is a business process of return on investment for getting your own doctors who are committed to the v.a. mission, who are full-time employees at v.a., as opposed to the 4.8 billion in fy 13 that we spent for fee care. i think there just has to be a strategic analysis of what in the long run is going to be the best outcome for veterans and it's something that has to be continual because you'll have different mix of conditions from one facility to the next. >> along those lines of the integrated care question, is

there a pattern in your research to the quality of care related to whether or not a v.a. facility is facilitated with a university hospital? >> i don't think so. i think our affiliate hospitals tend to be the more complex hospitals and we'll have a more complex set of services available to veterans, but we have some of our highly rural, unaffiliated hospitals and also wind up being top performers in health care industry rankings. >> thank you. my time is up. >> thank you very much. >> last week, during the recess, i had an opportunity to do something that was very personal to me as a vietnam era veteran. i went to vietnam, and we talked to the folks there that were looking for our 1,200 mias and quite frankly we owe it to the honor of those who didn't return

to provide for those who did. and we're not doing a very good job of that right now and one of the things that i think the problem with the v.a. system is is that the financial incentives are lined up to not provide the care. let me give you an example. in no-shows, for instance, when that's a problem with a consult, in our office, when we had patients who were supposed to come in as a consult, not a regularly scheduled patient, we had ways to check for those folks, if they didn't show up, they took up a slot that we couldn't fill with somebody else. there's no penalty with that at the v.a. that's free time. i'm looking here at a medical center that saw 68,798 patients. that was an entire medical center. our practice of ten doctors saw 40,000 patient visits in a year. so i think part of it as you said is productivity. it's the incentives to make sure when you have a consult on

there, you consult that. i just don't put a patient on my list and say show up. i think is it convenient with you, the baby-sitter, maybe my wife is sick, there's lots of reasons and you can call a -- there is a thing called a telephone. you can pick up and call somebody and mr. jones, are you going to be able to keep your appointment next week at 10:00. those are simple things. it doesn't require computers. it requires just a human being and a personal touch to check with that person. i can tell you they appreciate it. the patients appreciate it and they will keep their appointments if you do that. when you make something for me in september, i may forget about it by then or have ten other things to do and i think that's part of the problem. the financial incentives and making sure -- making them so far out. the question, did you notice any particular kind of consult? there are areas maybe in cardiology, you have know, but

rheumatology, maybe neurology, those are very difficult positions to fill anywhere, did you notice a difference in the type of consult? >> we looked at gastro, physical therapy and also cardio and we heard there demand didn't keep pace with the number of providers they had. the demand kept increasing and they didn't have the providers to fill the slots. >> so it didn't matter. i thought it did. >> we didn't look at all specialties but those were the three we did. >> and one question i had. how much is your pay for performance, i asked last week or week before last, when you are evaluated is your pay for performance part of how many veterans are out sent out along with wait tight times?

>> i don't believe so. >> all right. that is fine. i know the chairman asked, mr. griffin, when you put a system in place that puts misinformation out there and you gain from the taxpayers that would seem to be a fraudulent case. i am looking at it as a layman. not a lawyer. 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 happened, is that fraud? i think it is. >> i agree. the issue is you start with the gs-5/gs-6 schedulers who have many layers above them before

you get to the top leadership of the facility. you have to work up the super visery chain to determine who put that order out to do it in this manner. and that is what we are having to do at 69 facilities other than phoenix with additional facilities reporting every day. it isn't an easy task. i suspect if people start getting charged maybe that middle level person will say i am not taking a fall for someone higher up the food chain. >> i don't want to see a scheduler making appointments. >> thank you, mr. chairman and your leadership on the committee. i understand that the acting

secretary sent a triage team to phoenix as you testified, which i whole heartedly conquer with, but after reviewing today's audit numbers and some of that data it is clear that there are other medical centers across our country who are experiencing similar or even worse wait times. greater los angeles is a good example of that. their wait times exceed the wait times in phoenix. my question is really about okay. a triage in phoenix is good. we need triage else where. what is the plan. when are we going to get to that? >> we need two thing by the way. thank you.

we looked at wait times to assess and looked at medical centers to survey their capacity. we used something called stopped codes. and we have individual wait times for each of those. we were able to produce the productivity number for each clinic. there were a couple ways you could do that. run a few more clinics per week. run evening and weekends. you could not find capacity if you were at capacity. request the resources if you don't have to. i think we at this point identified an additional

requirement for support of the acquisition of health care. >> can you tell me as a follow up how you will prioritize that? is there a schedule for that? my veterans in ventura county and the west los angeles facility is their public facility. this data is public as it should be but the first question my veteran community is asking is when. >> tomorrow. and beginning on may 23ered each medical center with wait times for veterans was directed to contact veterans after they could determine if they could have additional clinic capacity. if they could not and we could acquire care in the community one thing we have to be careful about is there is not a primary supply of health care in the

community so if we can find that to purchase, accord nature and the next step is picking up the phone and calling vets and asking when they want to be scene. as of friday we made 50,000 phone calls. we want to finish those and move on to the next set and work closer and closer to what is timely care. that has started. we are tracking the rate of obligation of those funds. we will track the use of those funds to accelerate care. >> and you will share that data? >> i will share that. >> thank you. you mentioned having enough personal in the system to meet the needs.

i know that the acting secretary also ordered a highering freeze across the va. -- high -- hiring -- and it seems we have to fix the airplane while it is flying and it seems we should be looking at our hiring practice and addressing the other issues within the broken va. >> i know we need to look at the time it takes to hire and recruit staff. the acting secretary's point is not to restrict from hiring staff in the field. it is to request that the network offices and head quarters we have a hiring freeze and that is to dedicate hr resources to hire in the field. we might lift that when the hr

machine is working and we can staff for vacancy. but we cannot be satisfied with having a vacancy and allowing it to take six months. that means we are under capacity for six months in that specialty. we have to hire to budget. make sure we don't hire or have a conservative resource committee locally that prevents us from having the clinical resources we have. the acting secretary isn't telling us don't hire in the field. he is saying focus. >> thank you. i yield back. >> mr. florez you are recognized. >> you referred to high performance facilities. 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

that would help us attract talent. we know that that works. one of the benefits in terms of our affiliate partnerships this ability to attract talent. 70% of america's doctors have received some training from the v.a..

this allows us to attract young talent that loves our mission and comes to work for us. we do need some help that we need broader help than just contracting or just v.a. we need to explore other solutions. >> we have the university of nevada medical school. what about the increase in residencies and some kind of partnership? >> absolutely. >> one other question -- if money were to become available now, like we have heard about on the senate side. hire more doctors and no more facilities, are you ready for list of you have a those priorities? what kind of metrics or planning are you using to make those determinations? have a significant

construction requirement to maintain our facilities, which are on average 60 years old. they are landlocked facilities in phoenix. we are talking about las vegas. we had to bring down mobile clinics in phoenix to handle the extra staff. space matters. have a list of priorities were we require space, whether in the form of leases, minor or major construction and overhauled. refurbishing infrastructure. we have a need for providers. over the next 30 days we will take a closer look at our current productivity and where we find demand and our inability to meet it. 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? ...

and it was hindered by management weaknesses. had other issues, and ca scheduling replacement project, what i just talked about. $249 million for court fls. $607 million,was and then there was a $2.4 billion program in investments this congress has made. what isit here asking the answer to the question. using outdatedl

systems when we have given hundreds of millions of dollars to the v.a.? o the va. mr. runyon, thank you. i apologize. you're recognized for five minutes. >> thank you, mr. chairman. first a on to the first of all, wants to agree with the comments my colleague, mr. denham, made to the business that my veterans visit, number four, number three. three of the facility's are all in that further review category, and a request this information that mr. denham did. i have -- for purpose of, i think, while all this started in this secret lists, so we said keystone with who, is vista not capable of scheduling to gestures out? if we did not have the metrics

that dr. lynch said here, numerous times a couple weeks ago and said these metrics are forcing us to play these games, is that a possibility? >> i think it is part of that. they go hand-in-hand. first of all, i think setting an unrealistic performance metric and dying rewards or incentives to the meeting -- again, this is not even an outcome measure. this is an activity measure. tying rewards are incentives to the attainment of that activity was a mistake. not understanding the capacity of our system when we set that was a mistake then. there are reasons we don't schedule two years in advance, quite frankly. just you don't want to hold up the entire set of appointments lots with the appointments that are so far out that they might end up getting met. there are technical reasons you would not do that, before the

most part this is a and culture question. we have found in some of our networks where staff for using the same outmoded technologies and policy. i bring that up because i think you kind of touched on it that there is a balance there. what is -- and i think it will go to my next question, and several people abroad of. standardized procedures and policies from washington. you have seen pitbull, the different visions, the wait time issues. it goes to this question that i asked last time. believe they're not, i got a response this i asked the question of an auditing feature that was turned off in the phoenix region. i got a response that it had

been turned on nationally. could any of those audit features been turned on help to the ig in the process and/or internally in that region for them to the avoid the situation? >> sure. i think the one thing that has been clear is the the audit log try it was never turned on anywhere. the concern was that it would affect system performance, create a huge data storage requirements. it is now turned on across the board. it will help us understand who edited what kind of appointment. for instance, i think one comment was how he would cancel an appointment. we could see he did that and if it occurred numerous times. we get married and up and find that behavior. >> i just want to make this

statement because on shore as chairman just said, there were millions of dollars spent for that feature and the initial of role that systems. i would say, the one thing we will be different with this acquisition is that it will not be just a proposal. part of what we will expect folks to give us is working software that is proven to integrate with our system, not a book about how the software this at some point in the future will integrate, but a working product that is part of the proposal. >> thank you. >> chairman, i yield back. >> thank you, mr. runyon. dr. rees, you're recognized for five minutes. >> thank you, mr. chairman, or holding this hearing. with the release of the department of the va access audit and the interim inspector general report palmate is clear there is a systemic failure of responsibilities. widespread misconduct and coverups that led to the deficiencies in scheduling resulting in a lengthy wait times and veterans dying waiting

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

h.r. 4810, to make it easier for veterans who are too far from a va or are waiting to long for an appointment to seek care outside of the va system. as a physician, i will continue to work as a member of this committee to, one, stopped the scheduling misconduct and, too, that treat the veterans, give them the care when they needed it. after reading the audit today i have several questions. the first, what are the possible solutions to get veterans triages and cared for immediately. let me preface this. there are other veterans with aneurysms, perhaps, that need care now. there are other veterans with suicidal ideation that need care now. there are other veterans that have cancer that are on the verge of spreading that need

care now. we must hold the individuals accountable. yes, we do, and we will. but we need to give care now to our veterans. when i was in haiti working in a disaster zone there were immediate striker teams formed that would go out, educate the population, do the research, educate the population of the health care available, form teams, go out there and treat the patients. when are we doing to treat veterans now? >> on may 203rd we ask all of our facilities, provided them productivity data and ask them to assess if they could get more productivity out fee. we also gave them their local wake the dead competed nationally and distributed to the field. construction was clear. where you can find capacity now overtime.

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

healthcare systems and create a form of health care events, tree gosh, and get them seen sooner than rely on a broken system to fix it. >> may respond? >> please. >> the 69 additional facilities that we have sent rapid response teams to are all criminal investigators. i coordinate with the fbi. it is a requirement of the him attorney general guidelines. mutual notification for safety and efficiency considerations, you don't find yourself going to arrest the same person at the same time. trust me, we have an excellent criminal investigative staff and

they are pursuing all leads in this manner. >> i make reference to the case of phoenix, the use of the disaster and emergency medical staffing t-mobile that is being used in phoenix. how willing to identify across the country at a moment's notice. starting on sunday there were 21 such black styles. >> i look forward to working with you to see if we can extrapolate that experience the other va systems including los angeles and other areas like where they might have been very long wait times. >> thank you, doctor. you are recognized for five minutes. >> thank you, mr. chairman.

>> i feel sorry for you being here today because you are representing a system that really has no defense and i appreciate your apology. i will start today by looking at page 27 of the va internal audit which was released today. a medical system, the hospital and i am not michigan as being in wisconsin. now, you cannot place the facility in the right state. i don't know how we can trust you with the big stuff. as i said, i feel sorry freestanding that today. you know, the va internal report said that the va told them, the wait time in phoenix averaged 24 days at 43% weighting within 14 days. well, when they went there i took a similar sample and found the average wait time more sample was 115 days.

85 percent being more than 14 days. how are we supposed to address anything that va says about this ? >> thank you for your question. i would tell you that we had the fuse light version control issues to the tail end of this. we know where our anomaly is. it did not make it in the final. >> how am i supposed to trust the data you did today? you know, the last 80 submitted was completely different than the ig reported shortly thereafter. you see the problem that we have here. i feel sorry for you sitting there. >> every two weeks from here on out -- i'm sorry, bimonthly we will produce data. has our integrity and reporting improves we may likely see that our timeliness worsens. >> frankly, i don't believe you. i tend to associate myself with mrs. kirkpatrick across the aisle who says that the system needs a complete revamp and

restructurings because there is no accountability here. there is complacency. i like to associate myself with mr. ruiz is strongly recognize for the prosecution and would you, mr. griffin, for your comments about people not getting fired for not doing a job. frankly, i think we need leaders and hopefully we will get it, some leaders that will make people responsible and fire people than are not getting the job done because this culture of not being able to get the job done and it does not matter has got to stomped. i appreciate your comments. you kind of slid them and there. people need to get fired. we can make that happen despite the work rules and all the criticism that we get. we need to have a system that can fire the people that are not doing their job and to listen to people at the ground who have

the comments. they talked about the simplest and that every private practice in the world does, called a patients a day or two before the bombing to confirm that they're coming. that va has not figured that out ? it is impossible to believe that that actually occurs. that, there are -- the employment people are writing people letters without talking to them. it is like, really? no one is getting fired over this kind of decision making? it is unbelievable that this is occurring. i appreciate you for your comments. we need to have leaders within the va and a system within the va that holds people accountable and makes it known that if you don't do your job you will be out of there or prosecuted. just simply that happening will change the entire culture.

>> could you comment? i have a few seconds last. where do you think this should come from? the top or the bottom? give me some comments on your thoughts about this. >> i think you need leaders up and down the chain of command. while we have witnessed on some of our previous work was that veterans affairs has sent out requirements, safety alerts, directed the medical centers to address the issue and to certify that they have taken corrective actions. >> does somebody sign these certifications? >> just to finish the thought, we went out unannounced and determined that 42 percent had actually done what they said they did and the other 50 percent did not even though they certify that they had accomplished the directive. >> without any consequences? >> not that i am aware. i would ask them to speak to

that. i am not aware of anyone being held accountable, but i don't know how you could not hold someone accountable for a direct disobedience. >> apparently it occurs every day. i am out of time. thank you. >> thank you. mr. custer, you're recognized for five minutes. >> thank you, mr. chair. i wanted thank you all then obviously challenge and circumstance, bugboy. i am anxious about the decision to require a schedule system that works in the private sector. is that the intention, mr. make up the? >> i'm not going to get into the arcane about us design process.

i want to address one comment. this audit that we did was designed to be the start of our change. i want to be clear. if anyone thinks i have not submitted to make the team is not committed, please understand that we are committed to this. this is the start, not the end, not the final report. >> in the private sector we see resource-based scheduling, which is the resources that are provided, of a clinical resources. in the va we have grown up around something we call sort of clinic-based scheduling. we manage clinics as opposed to resources, and it makes it tough for us to deal tagger in all those views as one provider and know how many slots dr. smith has. makes it tough for us to do that. it is not an excuse but we need to move to resource-based schedule and which allows us to know how much capacity we have

in our system and how that maps to the providers. >> we have reverenced what i think is causing the exponential factor of the loss of effective appointments. i will not dwell on that, but getting back to the resource stage, you mentioned that there is not an infant supply of medical personnel hamel we are talking about is a lack of slots. i wanted to focus in on the issue of graduate medical education. one option that i have seen discussed this to relieve medical student that, whether that is physicians, weather, perhaps, there could be greater use of nurse practitioners, ancillary personnel. and i would like for you to address that in terms of equality in my district, right

-- white river junction health care center is closely affiliated with dartmouth medical school. it is a very positive arrangement, but think that we could replicate this around the country. >> i can. that -- weekend. think we discussed it earlier. providing a wonderful opportunity to new, young talent and have them exposed to the mission of our organization which is a noble mission and a dedicated work force. the people who serve our veterans. i would have to take you for the record. >> something that we could look into, the idea that we are blue

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

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

at that time on a friday afternoon evening i have begun calling the leaders and received no response until a fallen wednesday when i began hearing rumors of 385 on a six rating last. i jumped in a vehicle, drove for one hour. and was met with an e-mail. >> that, indeed was an accurate ino. do you think that helps build trust? >> it does not, sir, but you are certainly not aware all that those types of e-mails were sent out through the va system, at least there were actually guy and they would not provide me a copy of the milk, probably 100 different names. that did not know them. i knew the one sentence at the end, don't talk to anybody.

you are absolutely not aware. >> i don't know, congressman. sort of working on the audit in some preparations. it is possible. >> why would an e-mail like that be sent out? >> one reason would be the following. we were going to release an audit that would contradict the statement that someone locally might make to say everyone to have everything is fine. no issues and are about to release an audit that might contradict that. so that would be the concern that i would have. i would hate for somebody to tell you everything is fine and along comes a knock at this is not everything is fine. by the way, here's the additional data. >> your audit edifies 104 veterans waiting in wichita for care. 385. how are those two numbers different? >> i would need to compare. >> year is out. i am not certain that this is

the cause. the data was current as of may 15th. if you went to the decision you would pull all local number that might be better. prior to coming to the sites. >> let me interrupt you. the facility said that they knew of 385 on may 21st. then they told the public and as senator robert zero. then they told us nine. then they said may be 385. until i knocked on the door they would not confirm the 385. numbers have changed. and in the middle of this you have a gag order. i would like a quick response, certainly much quicker than the march 2013 request to get to the committee that has not been filled yet. how do you handle folks to game the system illegally in clear violation of the policy. asked at that time, as any one violated those rules?

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

you come here and say we will do better next year. >> yield back, mr. chairman. >> thank you, mr. >> one of the things he talked about was the cancellations and an anxious. in el paso we heard anecdotally of cancellations that are recorded as no-shows', of veteran last week, for example, told me that she had gone to that va in el paso from its of their apartment she thereafter requested a copy of her medical record and found that that cancellation was recorded as a no-show.

hits against her record is not heard the va wait time reporting. have you found it evidence of those kinds of practices in your investigations thus far? >> not specifically that. we did find more than 50 percent of the 150 cases that we looked at had at least one no-show or cancel the appointment. and, you know, we found clinics. we found -- we like to ask -- for each facility we looked at 30 consoles and spam consoles for the three specialty areas we looked at. we did look at one of those. one of the specialty areas, they cancel all ten appointments. all ten of the apartments were canceled. it raises questions of whether there were canceled. >> in el paso we have long heard from veterans who said that they could not get a mental health care plan.

certainly could not get it within about 13 days. there are seeing everyone within 14 days kamal were hearing is so great that we commissioned a survey, we released a report and found that 36 percent of the veterans el paso requesting mental health care were unable to get the point man at all. taiwan's a thank-you and the va fur not challenging the fact that it was a well designed, well implemented survey, large sample size. instead, that the viejo jay z is now working with us to identify the one-third of veterans, hundred of thousands who could not give amounts of fair employment. i appreciate that. and i also appreciate the audit the release today that shows that new patient mental health care average wait times in el

paso are 60 days. that is the port or stagnation. but i will tell you that if may 9 to receive this report from dr. pencil and mr. john mendoza that showed that zero veterans waited more than 14 days, not just the previous month, but the model for that, the month before that. at worst 15% of veterans waited more. simple question, which should i believe, the information that shows no wait times for 14 days are your animation that shows that it is 60 days? >> the information today. i tell you that as we improve the integrity and reporting wait time, establish basin data will get worse as it becomes more fallible. that is important. >> that news will be welcome because, as you said, it would be rooted in reality and the

facts and what we are hearing from our constituents and the people of we serve. we will not be able to correct this problem until we know extensive it is. i appreciate your commitment. on a related note, i will be introducing veterans can't record as a no-show will have a phone call from the va to confirm that that is what has happened. was that essentially what you committed to? >> i have. we do patient satisfaction data. veteran patients rate the quality of their health care experience sib. they also tell us in our satisfaction survey that the

rate their access as per below. so i were just as for your continued cooperation. we will introduce this bill this week. i think having an independent third party, the oic, the gao, someone apart from government altogether asking veterans what they're wait times are is part of the solution in that we will get real information and make better decisions. appreciate your help and appreciate the testimony and the expertise from everyone on the panel. with that we'll adapt -- >> you're recognized for five minutes. >> thank you. of want to thank the veterans administration here tim. this is the first of all of -- r

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

needs of veterans more than those who have worn the uniform. whenever you can do to get that out, i appreciate it. so when we get to this 14-day wait time, and i heard that it is simply not attainable. well, what is realistic? i don't know what the right measure is. we have to study it, looked at what is right for an individual veteran based on his our own preferences, vacuities to come into the next for cardiology 14 days is not soon enough. it has to be based on an individual veterans requirement. i think setting an across-the-board standard encourages an attempt to meet

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

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

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

from there. want to thank you on the work for the ig in the gao. we go way back on these things. when the system works right you are here as a ranking member with murfreesboro and miami with contaminated equipment. we brought in best practices to my implemented across the system. by all accounts we made a correction. they're is model to try and do this. that being said, as you look around, there are many that have long institutional knowledge. many of them have been coming and talking to us and telling us . incredibly frustrating. the breakdown comes when i have to be honest with you. i have proven myself and trying to get this right. i have seen this as an abstraction and nuisance. i have restitution in my district that was offered to help.

perhaps i can get a call. this has gone on and on and on. i am a loss. they -- their people sitting back behind you. i think your sincerity in the work you have done, certainly i am not going to question it. i am reading, this is from dr. heaney and armstrong. they quoted peter drucker and said the greatest danger in times of turbulence is not the turbulence but to act with yesterday's logic. the question was, where is the big idea. my question is, where is the big idea? if you're right to come and ask for technology money, that is a cursory thing they found. when they pull the testimony of the people on the questions, you are going to be embarrassed and my guess is you will not want to, and as for that money.

my question to you is, where is the big idea? where is the vision? >> it is a big idea. it may not sound as such, but it is back to basics. back to delivering safe, quality health care at timely manner, knowing where we can achieve it and where we cannot. an open engagement from partners, a veteran service organizations were not mentioned enough today, but they are our partners. talk and listen with them. they have good ideas about how to get back to basics, not to listen to veterans to what they want, what they're telling a spirit at work with members. some of those things, when we listen and worker when we started measuring wait times there were too long. i don't have a big idea, sir. our idea is back to basics. can be a great system. as phenomenal employees who are mission-driven. our idea is to get back to

basics to deliver veterans care in their system. >> mr. griffin, is that possible as it currently stands with the leaders and structure that are there, in your opinion? >> in my opinion it will take a fair amount of time. it will not happen overnight. there are number of different areas that need to be addressed. when you are talking about timely quality care one of those is performance standards. i heard dr. road tar previously about people who dg i work in the private sector. maybe a are at hmo and know every day i have to do x number of colonoscopy is everyday. when we get out with you in december of 12, specialty care, we have 33 specialty areas. only two of them a performance. how many of the procedures, then

generate the number. >> and i like my colleagues have been questioning all the data, the satisfaction surveys, everything that is coming out. it is frustrating. i would leave it with this before my time runs out to you, today and this report that comes out and you heard mr. denham and others, when you find those entities that are out there, those locations, you do realize every single veteran that attends those is tonight calling, wondering, asking what happened, was there, what is going on. and we don't have a hard time line when you will come back or an idea where it goes. now instead of creating a transparency and that honesty and the reconciliation on this we have created another layer that is causing a stir among veterans. so i would just encourage you, we have to look at this a different way paribas.

>> you are recognized for five minutes. following about, the white house deputy chief of staff visited the cincinnati medical center in the area where many of my constituents are veterans that go there, and i learned that as a result of the internal audit that they were flagged as requiring further investigations. at this time can you tell me what is happening at the cincinnati medical center that got them flag to and should veterans in my district be apprehensive about the care that they are receiving are the timely fashion in which they received? >> they should not be concerned about the quality of kin -- quality of care they're receiving. there are specifics behind each one. it could be a single concern that came in at the time that we were there. we felt those cases, when needed to make sure we listed that.

>> get the details of why that was light. >> i do not know yet, but i won't. we have to move back quicker. we reduce the level of banks to. we have to do that. >> the problems that we have i come from private practice. veterans seeking care in some ways are a liability to the system or to the administered. they're not a desired customer. we have talked about that. and we really need to have incentives for quality and incentives for proficiency. you know, we need -- private practice, a no-show is a liability, i huge liability. you cannot keep your doors open if you have them. they're needs to be not a reward for this. they're needs to be a reward for coming up with ideas of increasing access to private practice will do.

the other thing i am concerned about is the council. obviously sometimes there's a level of urgency depending upon, as you mentioned, the acuity of the problem. you know, if i am referring a patient for an acute problem and will get on the phone and talk to that person i am referring to to say can you get the man? this is something that we do in private practice. you want to make sure your patient is taken care of. when we have a no-show if it is someone that you have been treating and they do not show up as a practitioner you have a personal responsibility to that patient. you find out why. my feeling is, you move forward. you talk about the big idea. at the administrative level we have to look for someone outside the va.

if you spent your whole career and a va system you don't know what you don't know. you don't know these things that make an efficient system. it is not on your radar because you have not had to do it, and it is changing an entire culture if you're going to get someone with in the same culture we're probably going down a problem. we need people that understand. as you said to me of someone desires to be there, that is a good day. you'll get is to have competition. would you agree with that concept of may be coming from outside the va? >> i am an old consultant by training. for me, time is money. and the availability of the time is billable their is a balance. we don't want to turn into a 15 that appointments are ten men and apartments when no one likes to you. they're must be balance and accountability for time. we talk about resources and the management of resources.

time is the most valuable asset in our system. we have to manage that time. we have to extract value, be respectful of the way we do it, but competition, to know that we can get more plants to more veterans who want to come in our system and are happy with our system, we need to introduce some of those concepts in our thinking. >> the quality of care and the patient's perception. that is always the challenge in private practice, someone needs more time that someone else. maybe you give it and find a way to work within that system and make sure that when they leave there they feel satisfied. my advice at this time, one, i want to your what is going on in cincinnati obviously, but i also would really suggest that we take a look outside of the va system because if that has been your whole life, you don't understand how that it could be. and i think competition is the key.

i yield back. >> thank you, doctor. you're recognized for five minutes. >> thank you, mr. chairman. i find myself again tonight -- i associate myself with the comments of everybody on this committee. the more i learn sitting here in the more backward i am on the things that we heard two weeks ago and the things that we are hearing tonight. primarily on behalf of every american taxpayer, where the heck is the money, the billions of dollars that this congress and previous congresses have allocated to itea grace? what do you tangibly have? we have done this. what does that va tangibly spend money on that is working right now? >> i would have to take that for the record. we have veterans benefit management systems.

>> she asked a question and you gave the answer. using 1985 programs. 1985. the ig people sat right here. we ask the nasdaq stock has questions. in fact, i specifically asked them, who is in charge? do you have enough money to purchase what you need to get this system moving. the answer was yes ma'am. we have seen all these budgets, funded everything under the sun. it is baffling. the thing that i lead is interesting, did you not have any idea based upon mr. griffin's comments from

2005. eighteen months and that have heard the ig report after gao report. i know that there is problem. you said you are the business side, the engineering side, to those reports never make it to you? >> i agree with the report. april of 2013. in response to that report we went back and looked at how we computed the wait times for veterans. if you're not a star systems. podiatry. >> we change the performance measure from using the desired date. we switzer the creativity. give us a much more valid measure. we started measuring veterans who were waiting longer routes of time that's ever tried to change that. >> can you say that today? that is a failure? you guys did it at the intermediary level? >> we did not know at that point

in time. >> the two things that i came away with the mother has to be criminal investigation. one breaking news to the american public. i agree. back nine hoosiers will have the same questions. well, what do i do? i guess i will take that on the record. we will get information when we get it. i have a question. i am sensing that where we are going to end up in one of these grand revelations is that this i tea department, this id system is unbelievably must about. we have asked the question, but we have not been provided truth and it has come to those kinds of things. as you know, only authorized to use one electronic list. according sieur written

testimony officials piloting another system stated that revaluating decided not to use this approach. to you know if that is vetted by the whole idea of this? >> we found that when we spoke with va that they had not done a system-wide check. and this is related to the super care. >> would you identify that -- with the program be legitimate? >> it may not be legitimate. one of the problems, the data does not end up in the consul data that is going to be used as a monetary system. can be problematic. >> could that not also be considered a separate electronic system? the system out there. >> we have seen in the last few months that the business rules for the council, the medical centers that we have been speaking with, they are changing

their process these. they start out with something and change their processes. it is confusing, and i think that all of the different ways of the medical center's a using, you know, tracking those future care consols has not really been vetted with al qaeda -- va. >> i yield back my time. >> you are recognized for five minutes. >> thank you, mr. chair. i guess everything in washington comes full circle. waste, fraud, and abuse, going back through my brain, housing group tonight. a couple of questions. by the way, mr. griffin, unannounced. i am delighted that you went in there. the last time we had a hearing she asked the question about the individuals on the panel that came down to phoenix. i believe it was on a friday. did not work on the weekend.

it is any one declaring a state of emergency, let's work weekends, let's work maybe six to six? if we are going to send a striker teams or -- people are dying on our watch to has this ever occurred to people to, hey, we have to do something about this? >> absolutely. we are encouraging and requiring our staff to work longer clinical hours, nights, weekends you know, we are all -- >> maybe i am missing something feet. encouraging to my am looking for a better action verb. can they go down there? asked. >> we have put folks on the ground. they have been on the ground working fix and the problems on the ground at my direction. they're working hard enough finding ways to improve the practice. we are bringing folks in.

they are on the ground. >> let's go back. you know, in the military we are there, that units, fully combat ready or not combat ready? i have to ask myself, some of the hospitals fully mission capable and some not mission capable. others partially. do we have revaluate that? i am getting the feeling that each hospital does their own thing because the policies are

different and open, ambiguous and that was the word that i heard correctly and open to interpretation. anyone? >> we have some great facilities think we also released today data shows quality, efficiency, and others and provide quantitative comparisons. there are some of lower. >> you hit it on this. what you are talking about, trust and all those things which i think some of us all believe in. but unless you have standardization coming from washington and verification of the outcomes, are we working at cross purposes if it is open to interpretation? >> i think the expression trust but verify. >> absolutely. you are stealing my -- holy cow. >> in our organization we get to

50 medical centers a year for a one week review of specific areas of interest. we go to 100 outpatient clinics a year and the role of the results and can tell the under secretary of veterans health administration that x percent of your facilities are not measuring up in these two categories. then we would expect there to be corrective action on those. >> i am sure you have whistle-blowers. after i get out of the marine corps and became a college professor high. every student has a thing called rate your professor. you want to find out how good, bad, different your to read that ? i am wondering. i was trying to go through a look at different hospitals, sometimes it's eye opening. sometimes you need that self evaluation.

i am looking for a more standardized evaluation process and how they are completing the mission. i have begin do that we will have bad results in the future. >> if i would respond. combined assessment program where we go to those of the facilities, one of the last documents in the back of those reports is a vh a document called the sale report, and it ranks every hospital on about 100 different report it to outperform its metrics and is published in those reports. the data is corrected and available. someone needs to act upon the ones that are not measuring up. >> can i respond to your -- >> yes. >> yes, just, you know, what we found is great reluctance on the part of va to standardize policies and procedures. that leads to also complications when you're trying to do

oversight. i think there are issues there. >> the only thing i wanted to say, this came up this year with the cost of the military units. they're is a deficiency in training, this report would have those deficiencies that could be corrected. all i am saying is i would hope that that va looked at more standardization. >> a cute. you are recognized for five minutes. >> thank you, mr. chairman. just to confirm, you said there were 69 cases where you are now following up to review possible criminal implications. >> there are 69 separate facilities beyond phoenix that we have sent rapid response teams to as allegations have come into us. >> specifically criminal allegations? >> first of all, they are just allegations. >> short. >> criminal investigators are said to take sworn testimony and try and get to the ground truth.

in some instances your only as good as your source. >> i understand. and allegations have to be vetted out. you use the term critical to a criminal. this is different from the follow-up visits that are required as of the institutions. >> that is correct. >> totally separate. okay. the timing -- and i know it has come up for additional information go weeks or months? >> putting together a plan which we started. i agree we need to make sure that it is quality care and what we have identified is questions a practice integrity. >> congress gets frustrated.

the some of the problems in the viejo. he spoke about non va care in your terms being the veterans joyce. this is one of the issues that i have raised repeatedly now. within the current system the ability to get to non va care sometimes is obstructed by process where a patient has to go to the very same medical staff said they did not needed. has that changed? basis choice, has that changed? >> it is. it will take time. in conjunction with accelerating tariff provided training to roughly 1900 and none of our facility and regional staff. that was over about six days. in addition to that we have delivered training to about 2700 staffer appropriate use of the scheduling package and how they manage no-shows him how to schedule appointments.

it's going to take a lot of that. if we have seen delays and not use of non va medical care, it is incumbent upon us and the network and a facility to ask the question why. >> has there been a change in the same medical staff and initially said no having the sun often not saying yes? >> changes the degree of business that we have the communication of our objective the venture must be offered a choice. >> okay. i think each of you have agreed there is problem within management as opposed to the staff and some of the doctors. currently in some facilities private sector of this systems provide management. different than just seeing a non va physician.

is there value in expanding the use of regional health care system providers to provide the management? so i understand from a number of the veterans i speak to, they want to stay within that va system. the idea of using the voucher program is not something i believe the community would embrace. can we expand the use of private sector health care systems? providing management for facilities, what would your thoughts beyond that? >> in some cases we do do that. with contracts community health patient clinics we do have some partners in the private sector that help us manage and some of our outpatient clinics. >> those are really smaller facilities, right? what about the very large hospitals where peer to peer -- and lead is be honest. there simply cannot be private-sector efficiencies and a large va osbourne currently.

is there value in looking at larger facilities? >> sure. we can look at it. the one thing i am telling you. this is taught me to question everything. >> has there ever been a comparative study performance based upon management from private sector? >> periodically. one thing that i would -- just one moment of concern. a lot of our measure is a revenue-based metric which is to generate revenue. so i would say that, you know, other agencies, medicare and others, have had issues with that. our version of productivity, to have some measure of skepticism in the interpretation of that productivity data is tied to revenue. >> i wanted thank you again. i really do appreciate your candor and will tell you, two weeks ago we were asking for urgency. i think we have heard that from you tonight. the acting secretary has

demonstrated that his approach is one of urgency as well. thank you very much. i yield back. >> i ask unanimous consent that the former chairman of the subcommittee of oversight and investigation be allowed to ask questions. without objection you're recognized for five minutes. >> thank you. thank you to my colleagues for allowing me to participate. some of want to focus on the ideas you as subcommittee chair one of my very first request of that va was to show me the i t architecture for the va. i don't know what your tea -- i t background is, so i do not mean ted be insulting. do you know what and i t architecture is? >> i do. >> do you realize it is now going on for years and we still

did not have the i t architecture? you know, i sat with the secretary in his office and gave him an analogy. an analogy that he is familiar with. as a battlefield commander you would not go into a conflict -- i mean, our young people that we are now trying to take care of and their veteran years when they were serving depended upon leaders to make good, strategic decisions and know what the enemy at out in front of us, know what our capabilities or offset those risks and threats. they have the same expectation now of the va to understand what their needs harbor and with the capabilities are that are required to meet them. that va has hundreds and hundreds of i t systems. you made a statement a little earlier ago. you said, i think, to my

colleague, one of the systems you said you would not approve it until it was proven to integrate with auerbach current system. .. as you are looking and investigating into what the problem is. part of the reforms that the va needs to get to is coming into the 21st century with i.t. not

only in terms of systems but in the systematic processes and current state-of-the-art methodologies for managing those systems. mr. murkowski when are we going to see what the va plans to do with its information architecture? >> sir i will have to take that back. >> i heard that three years ago and i'm not trying to be disrespectful but that's the same old question. it's like a dog race. we come out every two years and we chase the rabbit around the circle and then we put the dogs up and so we ask it again. >> i think we have to ask what do we want. in this case for scheduling we want to be able to abide timely accurate information about one veterans want to be seen in what capacity we have in her system. i would rather buy with the industry has an knows it works. health care industry has something called hl seven which

is interface language. most modern systems speak that language so does frankly our old legacy vista system and i would like to add complicated interfaceinterface s but leverage with the industry can show us. >> i would agree with you because i suggested to the secretary in 2012. he said there are three priorities for laminating the homeless problem reducing the backlog and getting an electronic health record. i would not approve a single new dollar of new i.t. spending until someone in that i.d. to -- i.t. department could show me the current architecture and how these systems fit together and how i.t. spending will affect that and make me -- let me make one more point. talked about the electronic health record in the mid- positive comments. i confess that i don't know where the status is of today but

i can tell you at the 2012 we had a joint hearing with secretary shinseki and secretary panetta and they were proudly saying that we were going to have a single transparent electronic health record for military from start to finish within the next five years. he had been working on it for 10 years. this is not a matter of can do. it's a matter of want to and the department does not it is there today if they really wanted to do it. mr. chairman i yield back. thanks for giving me the opportunity. >> thank you very much mr. johnson. members the clock says >> in a few moments, a look at today's headlines plus your calls live on "washington journal."

the house of representatives will be back in session for general speeches at 10:00 eastern with legislative business at noon. today's agenda includes more work on the spending bill for the departments of transportation and housing. >> and about 45 minutes, republican representative doug collins of georgia will discuss his bill that would establish a bipartisan commission to consolidate or cut redundant federal programs and agencies. at 845 eastern, we will be joined by the head of the veterans affairs committee, vermont independent bernie sanders who will have the latest on legislation he and arizona republican senator john mccain are working on to address problem's in the v.a. health care system. "washington journal" is next and you can join the conversation on facebook and twitter. host: a breakdown of what was

found in that veterans affairs inspector general report when it comes to wait times. over 57,000 veterans were thatng for appointments could not be scheduled within 90 days. in the past 10 years, over 63,000 new enrollees had requested appointments that were never scheduled. bas --the result of the v.a.'s report.