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96–130 2015

SCHEDULING MANIPULATION AND VETERAN 

DEATHS IN PHOENIX: EXAMINATION OF THE 

OIG’S FINAL REPORT 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED THIRTEENTH CONGRESS 

SECOND SESSION 

WEDNESDAY, SEPTEMBER 17, 2014 

Serial No. 113–87 

Printed for the use of the Committee on Veterans’ Affairs 

( 

Available via the World Wide Web: http://www.fdsys.gov 


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COMMITTEE ON VETERANS’ AFFAIRS 

JEFF MILLER, Florida, Chairman 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida, Vice-Chairman 

DAVID P. ROE, Tennessee 

BILL FLORES, Texas 

JEFF DENHAM, California 

JON RUNYAN, New Jersey 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

PAUL COOK, California 

JACKIE WALORSKI, Indiana 

DAVID JOLLY, Florida 

MICHAEL H. MICHAUD, Maine, Ranking 

Minority Member 

CORRINE BROWN, Florida 

MARK TAKANO, California 

JULIA BROWNLEY, California 

DINA TITUS, Nevada 

ANN KIRKPATRICK, Arizona 

RAUL RUIZ, California 

GLORIA NEGRETE MCLEOD, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

TIMOTHY J. WALZ, Minnesota 

JON TOWERS, Staff Director 

NANCY DOLAN, Democratic Staff Director 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Veterans’ Affairs are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to prepare 

both printed and electronic versions of the hearing record, the process of converting between 

various electronic formats may introduce unintentional errors or omissions. Such occurrences 

are inherent in the current publication process and should diminish as the process is further 

refined. 


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C O N T E N T S 

Wednesday, September 17, 2014 

Page 

Scheduling Manipulation and Veteran Deaths in Phoenix: Examination of 

the OIG’S Final Report ........................................................................................ 1 

OPENING STATEMENTS 

Jeff Miller, Chairman .............................................................................................. 1 

Prepared Statement ......................................................................................... 95 

Michael Michaud, Ranking Member ...................................................................... 3 

Prepared Statement ......................................................................................... 96 

WITNESSES 

Richard J. Griffin, Acting Inspector General, Department of Veterans’ Affairs 4 

Prepared Statement ......................................................................................... 97 

Accompanied by: 

John D. Daigh, Jr. M.D., Assistant Inspector General for Healthcare 

Inspections, Department of Veterans’ Affairs 

Linda Halliday, Assistant Inspector General for Audits and Evaluations, 

Department of Veterans’ Affairs 

Maureen Regan, Counselor to the Inspector General, Department of Veterans’ Affairs 

And 

Larry Reinkemeyer, Director, Inspector General Kansas City Audit Office, Department of Veterans’ Affairs 

Samuel H. Foote, M.D., Retired Medical Director, Diamond Community-Based 

Outpatient Center, Phoenix VA healthcare System .......................................... 6 

Prepared Statement ......................................................................................... 104 

Katherine L. Mitchell, M.D., Medical Director, Iraq and Afghanistan PostDeployment Center, Phoenix VA healthcare System ........................................ 9 

Prepared Statement ......................................................................................... 105 

Hon. Robert A. McDonald, Secretary, Department of Veteran Affairs ............... 51 

Prepared Statement ......................................................................................... 160 

Accompanied by: 

Carolyn M. Clancy, M.D., Interim Under Secretary for Health, VHA, 

Department of Veterans’ Affairs 

Lisa Thomas, PhD., Chief of Staff, Veterans Health Administration, Department of Veterans’ Affairs ..................................................................................... 76 

Accompanied by: 

Sharon Helman, Director, Phoenix VA healthcare System, Department 

of Veterans’ Affairs 

And 

Darren Deering, M.D., Chief of Staff, Phoenix VA healthcare System, Department of Veterans’ Affairs 

MATERIALS SUBMITTED FOR THE RECORD 

Letter From: Hon. Richard J. Griffin, To: Michael H. Michaud, Ranking 

Member ................................................................................................................. 169 

Questions From: Hon. Richard J. Griffin, To: VA ................................................. 170 

Letter From: Michael Michaud, Ranking Member, To: Hon. Richard J. Griffin 173 


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IV 

Responses From: Veterans’ Affairs, To: Minority Member of the Committee 

of Veterans’ Affairs .............................................................................................. 174 

Letter From: Hon. Robert A. McDonald, To: Michael H. Michaud, Ranking 

Member ................................................................................................................. 182 

Questions From: Hon. Robert A. McDonald .......................................................... 183 

Questions From: Michael Michaud, Ranking Member and Responses From: 

VA .......................................................................................................................... 185 


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SCHEDULING MANIPULATION AND VETERAN 

DEATHS IN PHOENIX: EXAMINATION OF 

THE OIG’S FINAL REPORT 

Wednesday, September 17, 2014 

U.S. HOUSE OF REPRESENTATIVES, 

COMMITTEE ON VETERANS’ AFFAIRS, 

Washington, D.C. 

The committee met, pursuant to notice, at 1:19 p.m., in Room 

334, Cannon House Office Building, Hon. Jeff Miller [chairman of 

the committee] presiding. 

Present: Representatives Miller, Lamborn, Bilirakis, Roe, 

Denham, Runyan, Benishek, Huelskamp, Coffman, Wenstrup, 

Cook, Walorski, Jolly, Michaud, Brown, Takano, Brownley, Titus, 

Kirkpatrick, Ruiz, Negrete McLeod, Kuster, O’Rourke, and Walz. 

Also Present: Representative Schweikert. 

OPENING STATEMENT OF CHAIRMAN JEFF MILLER 

The CHAIRMAN. Good afternoon. This hearing will come to order. 

I thank everybody for attending this hearing which will examine 

the OIG report on the Phoenix issue. 

I would also like to ask unanimous consent, he is not here yet, 

but that our colleague, David Schweikert, from Arizona, be allowed 

to join us here to address this issue. Without objection, so ordered. 

Also, Members, we do have a series of votes that will start at one 

o’clock. I apologize for that. This hearing was moved from its original scheduled time because of the joint session of Congress to hear 

the President of the Ukraine. 

What we will do is immediately after the final vote move back 

as quickly as you can. We will resume the hearing as quickly as 

we possibly can so that we will not keep the witnesses waiting any 

longer than absolutely necessary. 

On the 26th of August, the VA Office of Inspector General released its final report on the Phoenix VA Healthcare System which 

vaulted to national attention after our hearing on April the 9th. 

The OIG confirmed that inappropriate scheduling practices are a 

nationwide systemic problem and found that access barriers adversely affected the quality of care for veterans at the Phoenix VA 

Medical Center. 

Based on the large number of VA employees who were found to 

have used scheduling practices contrary to Veterans Health Administration policy, the OIG has opened investigations, as I understand 

it, at 93 VA medical facilities and have found over 3,400 veterans 


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who may have experienced delays in care from wait list manipulation at the Phoenix VA Medical Center alone. 

The OIG concluded by providing the VA with 24 recommendations for improvement to avoid these problems from reoccurring. 

These recommendations should be implemented immediately, and 

this committee will work tirelessly to ensure that they are, in fact, 

implemented. 

Mr. Griffin, I commend you, sir, and your team for your work 

and continued oversight on these issues in the past and in the 

months ahead. With that said and as we have discussed, I am discouraged and concerned the manner with which the OIG report, 

the final report was released along with the statements contained 

within it. 

Notably, prior to the release of the report, selective information 

was leaked to the media apparently by a source internal to VA 

which I believe purposely misled the public that there was no evidence at Phoenix linking delays in care with veteran deaths. And 

as the days progressed and people actually read the report, that 

falsehood actually became obvious. 

What the OIG actually reported and what will be the subject of 

much discussion today is the statement by the OIG, quote, ‘‘We are 

unable to conclusively assert that the absence of timely, quality 

care caused the deaths of these veterans,’’ end quote. 

Now, what is most concerning to me about this statement is the 

fact that no one who dies while waiting for care would have delay 

in care listed as the cause of death since a delay in care is not a 

medical condition. 

Following the release of this report which found pervasive problems at the facility regarding delays in care and poor quality of 

care, committee staff was briefed by the OIG regarding its findings 

and how specific language was chosen throughout the entire drafting process. 

Prior to this meeting, we requested that the OIG provide us with 

the draft report in the form it was originally provided to VA three 

weeks before the release of the final report. After initially expressing reservations, the OIG provided us with the draft. What we 

found was that the statement that I just quoted was not in the 

draft report at all. 

Another discrepancy we found between the draft and final reports arose with statements to the effect that one of the whistleblowers here today did not provide a list of 40 veterans who had 

died while on a waiting list at the Phoenix VA Medical Center. 

First, the OIG statement in the briefing to the committee staff 

that VA inquired why such a statement was not in the report and 

the OIG ultimately chose to include it. 

Further, additional information provided by the OIG to our committee staff shows that based on numerous lists provided by all 

sources throughout the investigation, the OIG, in fact, accounted 

for 44 deaths on the electronic wait list alone and an astonishing 

293 total veteran deaths on all of the lists provided from multiple 

sources throughout this review. 

To be clear, it is not nor was not my intention to offend the inspector general and the hard-working people within the agency 

that he employs. However, I think I would be remiss in my duty 


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to conduct oversight of the Department of Veterans Affairs if I did 

not ask these questions. 

I would also like to point out that no one within the department 

or any other Federal Government employee including Members of 

this committee is beyond having their records scrutinized. As such, 

the committee will continue to ask the questions that need to be 

asked in order to perform our constitutional duties. 

It is absolutely imperative that the OIG’s independence and integrity in its investigation be preserved. Full and transparent hearings like this one will help ensure that that remains the case. 

With that, I now turn to the ranking member, Mr. Michaud, for 

his opening statement. 

[THE PREPARED STATEMENT OF JEFF MILLER, CHAIRMAN APPEARS

IN THE APPENDIX] 

STATEMENT OF MICHAEL MICHAUD, RANKING MEMBER 

Mr. MICHAUD. Thank you very much, Mr. Chairman, for having 

this very important hearing. 

I would like to thank all the panelists for coming today as well. 

Today’s hearing provides the opportunity to examine the VA inspector general’s final report on the patient wait times and scheduling practices within the Phoenix VA Healthcare System. This report did not state a direct causal relationship between the long patient wait times and veterans’ death. For some, that is a major concern and accusation of undue influence by the VA on the inspector 

general’s report will be discussed at length today. 

What the IG did find is that the cases included in this report 

clearly shows that there was serious lapse in VA’s follow-up, coordination, quality, and continuum of care for our veterans. They also 

concluded that the inappropriate scheduling practices demonstrated in Phoenix are a nationwide systematic problem. 

I do not need any more evidence or analysis that there is no 

doubt in my mind that veterans were harmed by the scheduling 

practices and culture at the Phoenix facility and across the Nation. 

The bottom line is this behavior and the detrimental effect of veterans is simply not acceptable. My heart goes out to the families 

of the veterans who did not receive the healthcare they deserved 

in Phoenix and around the country. Rest assured that we will understand what went wrong, fix it, and hold those responsible for 

these failures accountable. 

As such, my question to the VA today is straightforward. What 

went wrong? What are you doing to fix the problems? How will you 

ensure that this never happens again and how are you holding 

those responsible accountable? 

I applaud Secretary McDonald for taking forceful action to begin 

to address the systematic failures demonstrated in Phoenix. We 

need serious, deep, and broad reform, that kind of change that may 

be uncomfortable for some in VA, but so desperately needed by 

America’s veterans. 

I believe that such reforms must be guided by a higher level national veteran strategy that outlines a clear vision of what America 

owes its veterans and a set of tangible outcomes that every component of American society can align and work towards. 


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Earlier this week, I sent a letter to President Obama asking him 

to establish a working group to engage all relevant members of the 

society in drafting this national veteran strategy. 

We know from experience that VA cannot do it alone. We must 

develop a well-defined idea on how the entire country, government, 

industry, nonprofits, foundations, communities, and individuals, 

will meet this obligation to our veterans. 

VA needs to become a veteran-focused, customer service organization. It needs to be realigned to become the integrated organization. It should do what it does best and partner for the rest. It 

needs to be the government model for honesty, integrity, and discipline. 

We need to complete our investigation of these problems and provide oversight on the solutions. And I look forward to today’s additional testimony about what happened in Phoenix and how the VA 

is working to ensure that it never happens again. 

So, once again, Mr. Chairman, I want to thank you for having 

this hearing and I yield back the balance of my time. 

[THE PREPARED STATEMENT OF MICHAEL MICHAUD, RANKING

MEMBER APPEARS IN THE APPENDIX] 

The CHAIRMAN. Thank you very much. 

And I would ask that all Members waive their opening statements as customary in this committee. 

Thank you to the witnesses that are here at the table and those 

that agreed to sit behind the principles. 

Today we are going to hear testimony from Acting Inspector General Richard J. Griffin who is accompanied by Dr. John Daigh, Jr., 

assistant inspector general for Healthcare Inspections; Ms. Linda 

Halliday, assistant inspector general for Audits and Evaluations; 

Ms. Maureen Regan, counselor for the inspector general; and Larry 

Reinkemeyer, director of the Kansas City Office of Audits for the 

Office of Inspector General. 

We are also going to hear from Dr. Samuel Foote, a former VA 

physician at Phoenix VA Healthcare System and Dr. Katherine 

Mitchell, current whistleblower and medical director for the Iraq 

and Afghanistan Post-Deployment Center at the Phoenix VA 

Healthcare System. 

I would ask the witnesses now to please stand so that we may 

swear you in. If you would raise your right hands. 

[Witnesses sworn.] 

The CHAIRMAN. Thank you. You may be seated. 

Let the record reflect that all of the witnesses affirmed that they 

would, in fact, tell the truth, the whole truth, and nothing but the 

truth. 

All of your complete written statements will be made a part of 

this hearing record. 

And, Mr. Griffin, you are now recognized for five minutes. 

STATEMENT OF RICHARD J. GRIFFIN 

Mr. GRIFFIN. Mr. Chairman, Ranking Member Michaud, and 

Members of the committee, thank you for the opportunity to discuss the results of the inspector general’s extensive work at the 

Phoenix VA Healthcare System. 


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Our August 26, 2014 report expands upon information previously 

provided in our May 2014 interim report and includes the results 

of the reviews of the OIG clinical staff of patient medical records. 

We initiated our review in response to allegations first reported 

through the OIG hotline on October 24, 2013 from Dr. Foote who 

alleged gross mismanagement of VA resources, criminal misconduct 

by VA senior hospital leadership, systemic patient safety issues, 

and possible wrongful deaths at Phoenix. 

The transcript of our interview with Dr. Foote has been provided 

to the committee and I request that it be included in the record. 

The CHAIRMAN. Without objection. 

Mr. GRIFFIN. We would like to thank all the individuals who 

brought forward their allegations about issues occurring at Phoenix 

and at other VA medical facilities to the attention of the IG, the 

Congress, and the Nation. 

On August 19, 2014, the chairman of the Subcommittee on Oversight and Investigations sent a letter to the IG requesting the original copy of our draft report prior to VA’s comments and adopted 

changes to the report. 

On September 2nd, a committee staff member made a similar request for a written copy of the original unaltered draft as first provided to VA on behalf of the chairman. 

Concerns seemed to come from our inclusion of the following sentence in a subsequent draft report that was not in the first draft 

report we submitted to VA. The sentence reads as follows: 

While the case reviews in this report document poor quality of 

care, we are unable to conclusively assert that the absence of timely care caused the death of these veterans. 

This sentence was inserted for clarity to summarize the results 

of our clinical case reviews that were performed by our board certified physicians whose curricula vitae are an attachment to our 

testimony. 

It replaced the sentence the death of a veteran on a wait list does 

not demonstrate causality which appeared in a prior draft, not the 

first draft that was requested, but in a subsequent draft. This 

change was made by the OIG strictly on our own initiative. Neither 

the language nor the concept was suggested by anyone at VA to 

any of my people. 

In the course of our many internal reviews of the content of our 

draft report, on July 22nd, almost a full week before the draft was 

sent to the department, one of our senior executives wrote this 

question. This is key, gentlemen and ladies. 

And I quote. ‘‘Did we identify any deaths attributed to significant 

delays?’’ This was on July 22nd. If we can’t attribute any deaths 

to the wait list problems, we should say so and explain why. After 

all, the exact wording in the draft report was were the deaths of 

any of these veterans related to delays in care. 

This type of deliberation to ensure clarity continued as it should 

after the initial draft was sent to the department. In the last six 

years, we have issued more than 1,700 reports. This same review 

and comment process has been used effectively throughout OIG 

history to provide the VA secretary and Members of Congress with 

independent, unbiased, fact-based program reviews to correct identified deficiencies and improve VA programs. 


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These reports have served as the basis for 67 congressional oversight hearings including 48 hearings before this committee. 

During these same six years, our work has been recognized by 

the IG community with 25 awards for excellence. We are scrupulous about our independence and take pride in the performance 

of our mission to ensure veterans receive the care, support, and 

recognition they have earned through service to our country. 

The VA secretary has acknowledged the department is in the 

midst of a serious crisis and has concurred with all 24 recommendations and has submitted acceptable corrective action 

plans. 

Our recent report cannot capture the personal disappointment, 

frustration, and loss of faith that veterans and their family members have with the healthcare system that often could not respond 

to their physical and mental needs in a timely manner. 

Although we did not apply the standards of determining medical 

negligence during our review, our findings and conclusions in no 

way affect the rights of a veteran or his or her family from filing 

a complaint under the Federal Tort Claims Act with VA. 

Decisions regarding VA’s potential liability in these matters lies 

with the VA, the Department of Justice, the judicial system under 

the Federal Tort Claims Act. 

Mr. Chairman, this concludes our statement. We would be happy 

to answer any questions you or other Members of the committee 

may have. 

[THE PREPARED STATEMENT OF RICHARD J. GRIFFIN APPEARS IN

THE APPENDIX ] 

The CHAIRMAN. Thank you very much, Mr. Griffin. 

Dr. Foote, you are recognized for your opening statement for five 

minutes. 

STATEMENT OF SAMUEL H. FOOTE 

Dr. FOOTE. My name is Dr. Sam Foote. I started my internal 

medicine training in 1981 at the combined Good Samaritan Phoenix VA program. I finished in 1984 and became board certified in 

internal medicine. 

I went to work full time in East Mesa, Arizona as an emergency 

physician and I returned to the VA in 1990, the same year that I 

earned by boards in emergency medicine. I ran the VA’s emergency 

department from 1990 to 1998. I was a medical service teaching attending from ‘91 to 2003 and I became an outpatient clinic director 

on December of 1994, a position which I held until my retirement 

in December of 2013. 

While I have views on many aspects of what has come to be 

known as the VA scandal, I would like to use this statement to 

comment on what I view as the foot dragging, downplaying, and, 

frankly, inadequacy of the Inspector General’s Office. 

This continues in the report issued August 26, 2014 which I fear 

is designed to minimize the scandal and protect its perpetrators 

rather than provide the truth along with closure to the many veterans and families that have been affected by it. 

All VA employees receive mandatory recurrent training on their 

duty to report waste, fraud, and abuse to the inspector general 

whose job it is to investigate these allegations. I first did this in 


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February of 2011 which resulted in then director Gabriel Perez 

being placed on leave within two weeks of the IG receiving my letter and a few months later, his resignation in lieu of termination. 

I sent a second letter to the IG in April of 2013 where I made 

allegations against the chief of Health Administrative Services, 

Brad Curry, for creating a hostile workplace, engaging in prohibitive personnel actions and discrimination against certain classes of 

employees. 

As far as I can tell, the IG never investigated this complaint and 

it appears that they turned it over to the Veterans Integrated Service Network director, Susan Bowers, who was both Helman’s and 

Curry’s superior. Susan Bowers could not take action against him 

without running the risk that the entire waiting list scandal would 

be exposed. 

In late October of 2013, I sent a third letter to the IG informing 

them of the existence of a secret waiting list where ten patients on 

that list had died while waiting for appointments. 

I also included additional allegations of prohibitive personnel actions by senior staff. Furthermore, I advised them of a second hidden backlog of patients contained in the scheduling appointment 

with primary care consult lists and that an unknown number of 

veterans had perished on it. 

I also detailed other methods that were used—in use to lower the 

apparent backlog for new patients and I implored the IG to come 

to Phoenix to investigate all the above. I got a response from the 

San Diego IG Office on December 3rd, 2013 to join a conference call 

with them on December 6th. 

Their team came out to investigate the week of December 16th 

through the 20th. At that time, I and others told them about the 

unaddressed scheduling appointment consults and showed them 

the Northwest Electronic Holding Clinic which was being used as 

were prior holding clinics to mask the true demand for return patient appointments. 

We updated them on the secret electronic waiting list summary 

report showing that 22 patients had been removed from it because 

they had died. We only had the names of two of the deceased because none of the employees who were working with me had the 

electronic keys to print the names of the deceased. 

We asked the IG inspectors if they could do it, but they responded that they could not. The last email response that I had 

from them was on December 21st, 2013 when I received an out of 

the office until Tuesday, December 31st, 2013 reply. 

I had offered to fax or mail the names we had at the time, but 

they were unable to give me a working fax number or an address 

to mail it to. Fax and standard mail but not unencrypted email are 

considered appropriate methods to transmit HIPAA sensitive materials. 

I sent four more emails in early January again asking if they 

would like me to fax or mail the patients’ names, but I got no response. I also got no response when I advised them that several 

more veterans had died. 

Finally, on February 2nd, 2014, out of frustration, with lack of 

action by the IG, even though we were informing them of more and 

more deaths, I sent IG letter number four with copies to everyone 


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who I could think of that might be able to help. The only response 

that I got from the IG was a confirmation that they had received 

my letter. 

A friend suggested that I contact the House Veterans’ Affairs 

Committee and there I found the help I needed. During this process, I was advised by several people that the only way I could get 

the IG’s Office to investigate my allegations was to make them 

public which reluctantly I did. 

In my opinion, this was a conspiracy, possibly criminal, perpetrated by senior Phoenix leaders. Of the many scandalous aspects from the performance bonuses paid to top administrators for 

supposedly meeting waiting time goals to the harassment of employees trying to rectify the situation to the destruction of documents and electronic records to the very real harm done to the 

health of thousands of veterans unable to receive timely medical 

care, nothing is more scandalous than the fact, the fact that 293 

veterans died in Phoenix. 

Yet, even now, right here in this report, the inspector general 

tries to minimize the damage done and the culpability of those involved by stating that none of the deaths can be conclusively tied 

to treatment delays. 

I have read the report many times and several things bother me 

about it. Throughout the case reports, the authors appear to have 

downplayed facts and minimized the harm. This was absolutely 

true in cases six and seven where I have direct knowledge. 

After reading these two cases, it leaves me wondering what really happened in all the rest. For example, in case number 29, how 

could anyone conclude that the death was not related to the delay 

when a patient who needs an implanted defibrillator to avoid sudden death did not get one in time and why was a cardiac death 

case excluded from the IG review? 

In addition, a critical element to proving that this was a conspiracy was the potential tampering with the reporting software of 

the electronic waiting list. From the beginning, the IG’s own data 

showed that there was a difference between the numbers reported 

to Washington and what the numbers actually were on the secret 

electronic waiting list. 

The IG clearly minimized the significance of the crucial—of this 

crucial point treating it as a trivial—as a trivial clerical error and 

touting how quickly the IT department corrected it rather than exploring who tampered with it in the first place. 

Adding it up, the IG report states 4,900 veterans were waiting 

for new patient appointments at the Phoenix VA. Three thousand 

five hundred were not on any official list and—and 1,400 were on 

the non-reporting secret electronic waiting list. Two hundred and 

ninety-three of these veterans are now deceased. 

This vastly exceeds my original allegations that up to 40 veterans may have died while waiting for care. The IG says it is not 

charged with determining criminal conduct. True. But neither is it 

charged with producing reports designed to downplay potential 

criminal conduct designed to defuse and discourage potential criminal investigations or to diminish the quite appropriate public outrage. 


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At its best, this report is a whitewash. At its worst, it is a feeble 

attempt at a coverup. The report deliberately uses confusing language and math, invents new unrealistic standards of proof, ignores why the electronic waiting list was not reporting accurate 

data, and makes misleading statements. 

In addition, the attempts to minimize bad outcome by 

downplaying damaging information and thereby protecting the VA 

officials who are responsible for this scandal just reinforces the 

VA’s longstanding culture of circling the wagons to delay, deny, 

and let the claim, story, or patient die that the veterans community 

has had to suffer with for years. 

The CHAIRMAN. Dr. Foote, I apologize. You have gone three minutes over the five. I would like to say that the rest of your testimony will be entered into the record. I apologize, but I let you go 

a little bit longer than what we all had agreed to. 

Can you wrap it up in the next 20 seconds? 

Dr. FOOTE. Yeah. Secretary McDonald said that he was going to 

try to increase the transparency of the agency and that he would 

not tolerate whistleblower retaliation. Apparently some senior 

Washington VA administrators did not get that memo. This report 

fails miserably in those areas with a transparency equivalent to a 

lead-lined, four foot thick concrete wall. 

Thank you, Mr. Chairman. 

[THE PREPARED STATEMENT OF SAMUEL H. FOOTE APPEARS IN THE

APPENDIX] 

The CHAIRMAN. Thank you very much, Doctor. 

Dr. Mitchell, you are recognized for five minutes. 

STATEMENT OF KATHERINE L. MITCHELL 

Dr. MITCHELL. I’m deeply honored by the committee’s invitation 

to testify today. The OIG wasn’t able to conclusively assert that the 

absence of timely quality care caused veterans’ death. 

As a physician reading the report, I disagreed. Specifically in a 

minimum of five cases, I believe there was a very strong actual or 

potential causal relationship between delayed care or improper care 

and veteran death. 

In addition, healthcare delays contributed to the quality of life 

and for five other veterans who were terminally ill and shortened 

the life span of one of them. 

In looking at the report, there are four cases where there is no 

cause of death listed. It’s unclear to me how a causal relationship 

may or may not exist if there is no cause of death given. 

It is unclear if 19 veterans who were on the electronic waiting 

list were aware of the self-referral process to the primary care clinics. If they were not aware of this process, then they reasonably— 

reasonably believed that waiting on the waiting list was the only 

way to get medical care even if their symptoms were worsening. 

In two cases, the OIG gave evidence that the veterans’ acute or 

had acute instability of their chronic medical disease that required 

repeated visits to the ER and hospitalization. I believe that those 

likely—those delays likely contributed to their death. But, again, 

the OIG did not give a cause of death for those two veterans. 

In terms of mental health treatment, there were eight veterans 

on the electronic waiting list waiting for primary care who apparVerDate Aug 31 2005 11:01 Dec 01, 2015 Jkt 000000 PO 00000 Frm 00013 Fmt 6633 Sfmt 6633 Y:\96-130.TXT PAT

VACREP180 with DISTILLER
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ently just wanted a mental health referral. Two of those veterans 

committed suicide before they got the appointment. 

It is unclear if anyone told them that the mental health process 

is a self-referral process and they could have done so any regular 

business day and initiated mental healthcare. 

In case number 29, there was a veteran that needed a life-saving 

medical device implanted under his skin that would immediately 

shock his heart into a normal rhythm if his heart stopped. The 

community standard would have been to implant this device immediately. At the VA, he waited four months and still did not have 

an appointment. 

Unfortunately, the veteran’s heart did stop and without the device, he had to wait precious minutes for the paramedics to arrive 

to restart it. He was revived, but, unfortunately, the family had to 

withdraw life support three days later. 

The OIG stated that this device might, quote, ‘‘might have forestalled death,’’ end quote. It’s very apparent that it would have 

fore—I’m sorry—it would have forestalled death because the 

implantable device is exactly what’s used to treat the lethal heart 

rhythm that he had. He died from complications of prolonged heart 

stoppage without the device that could have restarted his heart in 

seconds. He was denied access to specialty care. 

In case 39, a veteran with multiple risk factors for suicide came 

to the ER with intense emotional stressors including being homeless. He was put on psychiatric meds to stabilize him, but he was 

discharged back to the streets. He committed suicide 24 hours 

later. 

The community standard would have been to admit this unstable 

veteran. The OIG admitted that it would have been, quote, ‘‘a more 

appropriate management plan,’’ end quote, to admit this patient, 

but did not draw a connection between inappropriate mental health 

discharge from an ER and death from suicide within 24 hours. 

Case number 31, he died of metastatic prostate cancer that was 

not treated during the seven-month period that the VA failed to act 

on the abnormal lab. While his metastatic prostate cancer could not 

have been cured, earlier detection would have started the treatment that would have slowed down the progression of the disease 

significantly and slowed the painful spread of cancer to his bones. 

Because of unavailable urology appointment and missed labs, 

this veteran was denied timely access to specialty care that would 

have forestalled his death by months if not longer. 

In case 36, this veteran didn’t receive timely, quality care for 

evaluation of unrelenting severe pain that clearly served as the impetus for his suicide. 

In case 40, there was a premature discharge from a psychiatric 

ward for an unstable patient with multiple suicide risk factors that 

enabled the death from suicide 48 hours later. 

There are many other cases that I reviewed in my written testimony. I did not discern a difference between death on the electronic waiting list and death waiting for appropriate medical care 

for those who were already in the system. Death is death and there 

is no way to get those veterans back. 

The purpose of my testimony is not to undermine the VA or the 

OIG. The purpose is to get the VA to examine its practices and in 


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order to improve the quality of healthcare for veterans. They have 

to repair the cracks in the system so no more veterans slip 

through. 

Thank you very much for your time. 

[THE PREPARED STATEMENT OF KATHERINE L. MITCHELL APPEARS

IN THE APPENDIX] 

The CHAIRMAN. Thank you very much to everybody for your testimony. 

Mr. Griffin, in the information you provided to the committee or 

your office has provided, it shows that 28 veterans died while on 

the NEAR list or the new enrollee appointment request, essentially 

meaning they died while waiting to get their foot in the door at VA. 

And since these veterans were not yet in the VA system, your 

staff briefed us that the OIG used Social Security records which 

only show that the individual had died, not how they died; is that 

correct? 

Mr. GRIFFIN. I would say that we sought a lot of additional information from Social Security. We—we sought to find death records 

from the coroner’s office. We explored who might have been getting 

treatment under the Medicare program. But as far as the specifics 

on—on those deaths, I would defer to Dr. Daigh. 

The CHAIRMAN. Dr. Daigh, could you answer that question? 

Dr. DAIGH. Sure. The determination of—excuse me—the determination of death was by and large made from looking at the medical record and the death certificate was—was mostly how we were 

able to identify, A, that a patient clearly had died, the record was 

correct, and by reading both the medical record and the, in several 

cases, the records of their care at local hospitals. 

The CHAIRMAN. If you are on the NEAR list, is there a medical 

record? 

Dr. DAIGH. No. The NEAR list is a—is a tremendous problem. 

Patients on the NEAR list would have tried to enroll to VA and 

may not have ever been seen at VA. So you’re absolutely right. 

Anyone that’s on the NEAR list that did not make it through the 

wickets at Phoenix to be seen and does not have a medical record, 

I can’t look at. So—so those folks I’m not able to examine if they 

don’t have a record, I mean, if I have no contact with them. 

The CHAIRMAN. If that is true, then how can you conclusively or 

otherwise determine whether these deaths were related to delays 

in care? 

Dr. DAIGH. Well, in the cases that we identified that we were 

able to actually review—— 

The CHAIRMAN. Wait. The report says, conclusively says this is 

where we have some problems—— 

Dr. DAIGH. Right. 

The CHAIRMAN [continuing]. Mr. Griffin, is that there were people that were looked at in the report and your report says conclusively that there is no link to delays in care and death, yet there 

are individuals that you were not able to go back and look definitively at their medical record to determine what the cause of death 

was or if there was a delay in care; is that correct? 

Dr. DAIGH. In the report, we are trying to address the patients 

that we identified who had a delay in care and then subsequently 

received poor quality care as a result of that delay. 


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The CHAIRMAN. But if you were on the NEAR list—— 

Dr. DAIGH. Correct. 

The CHAIRMAN [continuing]. Is that a delay in care? If you did 

not get into the system, is that a delay? 

Dr. DAIGH. Yes. 

The CHAIRMAN. Okay. Then how can you conclusively say that 

none of the delays were a cause of death? 

Dr. DAIGH. Well, we were referring to the universe of patients 

that we were able to look at, so the universe—— 

The CHAIRMAN. If you didn’t look at all of them—— 

Dr. DAIGH. No. I’m—I’m saying that—that I provided your staff 

with a breakout of—— 

The CHAIRMAN. Did—— 

Dr. DAIGH [continuing]. Exactly—— 

The CHAIRMAN. Did you—— 

Dr. DAIGH [continuing]. The various—— 

The CHAIRMAN. I am sorry, Dr. Daigh. Were you able to look conclusively at all of those that were on the wait lists? 

Dr. DAIGH. I’m only able to look at those—I looked at 3,000—— 

The CHAIRMAN. Yes or no, were you able to conclusively look at 

all of the people that were on wait lists? 

Dr. DAIGH. No. If—if the NEAR is considered—— 

The CHAIRMAN. Thank you. That is—— 

Dr. DAIGH. Yes. 

The CHAIRMAN. I want to direct you to an email from Dr. Deering 

found on page 38 of your report regarding a veteran who died while 

waiting for care. And it has already been talked about this morning. And in a staff briefing on the 4th, you stated that the veteran 

was seen by a urologist within three days of presenting to the ER, 

so his case was not included in the 45 case reviews in the report. 

However, we received notification from the OIG yesterday stating 

that a mistake had been made, that this veteran was actually not 

seen after he was presented at the ER. And after informing us of 

this delay, the OIG still says that this delay in care did not contribute to his death. 

Could you explain to me how the OIG came to this conclusion? 

Dr. DAIGH. So the patient in question has bladder cancer and 

had bladder cancer for many years. He arrived at the VA and was 

seen in the emergency room initially and received a very reasonable emergency room evaluation. 

Among his chief complaints were that he had blood in his urine. 

He also had chronic rheum—he had rheumatoid arthritis and some 

other disabilities including amputation of the leg. 

As a result of that visit, his urine was looked at and he had microscopic hematuria. He also did need to see a rheumatologist, and 

he did not have a primary care provider. So the ER physician 

asked that this gentleman have several consults, a vascular surgery consult, rheumatology consult, and a—and a urology consult 

and a primary care consult. 

The records, and this is the source of the confusion, the VA 

records state that he had an appointment made for urology to be 

held on 10/22/13. It says that the patient called and requested a 

rescheduling of that appointment which was then rescheduled for 

11/06/13. He no showed for that appointment. 


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So in our discussions, some people would say the patient had an 

appointment to see urology and didn’t keep his appointment. 

The CHAIRMAN. But—— 

Dr. DAIGH. But—— 

The CHAIRMAN [continuing]. I understand. 

Dr. DAIGH. [continuing]. My clarification to the staff that—— 

The CHAIRMAN. Let me ask a question real quick. 

Dr. DAIGH. Yes, sir. Yes. 

The CHAIRMAN. And I will let you finish. I apologize. Nobody 

here in this room has any faith in any of the appointments and 

scheduling that was going on at that time, so I have no belief that 

what may have been written was, in fact, true. 

Dr. DAIGH. I understand that. 

The CHAIRMAN. So please continue. 

Dr. DAIGH. And—and so from—what I’m saying is this gentleman then died of what appears to be by image metastatic cancer 

where he had metastasis to his brain and he appeared to also, I 

believe, have cancer in his lung. 

So the assertion that having seen a primary care provider in the 

six or eight weeks between the emergency room visit and when he 

died, I don’t believe that that primary care provider would have— 

that visit would have changed his death. 

And I’d refer you to page 75 or 76 of the testimony that we provided from the transcript of Dr. Foote. 

The CHAIRMAN. If I may, if I may also—— 

Dr. DAIGH. Yes, sir. 

The CHAIRMAN [continuing]. Interrupt, the testimony was given 

to us as the hearing had already started. We hadn’t even had a 

chance to look at it. We just got it handed to us—— 

Dr. DAIGH. Yes, sir. I’m just saying—— 

The CHAIRMAN [continuing]. In the hallway after the gavel 

dropped. 

Dr. DAIGH. Well, sir, I’m just saying that on—— 

Mr. GRIFFIN. That was sent up here electronically earlier in the 

day and it was sent up to—to make sure the truth was on the 

record having seen other witnesses’ testimony and needing to make 

sure that the committee was fully aware that we had a taped transcript of our interview. 

The CHAIRMAN. And that—— 

Mr. GRIFFIN. And I think people should take a hard look at that 

transcript. 

The CHAIRMAN. I appreciate it very much, but your staff told us 

there was a formatting problem getting it to the committee and 

that is why we just got it. 

Mr. GRIFFIN. Are you referring to the transcript of the interview 

of Dr. Foote? 

The CHAIRMAN. That is what I am referring to. Any other transcripts I need to be aware of? 

Mr. GRIFFIN. No. I believe we sent all the rest of the information 

up 48 hours in advance. 

The CHAIRMAN. Let me ask you, Mr. Griffin, Dr. Foote’s original 

allegation was up to 40 veterans may, may have died while awaiting care at Phoenix. And I think everybody knew that he was referVerDate Aug 31 2005 11:01 Dec 01, 2015 Jkt 000000 PO 00000 Frm 00017 Fmt 6633 Sfmt 6633 Y:\96-130.TXT PAT

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ring to patients on the electronic wait list and the schedule and appointment with primary care consults. So it was all conclusive. 

So between those two sources, you have now found 83 patients, 

more than double what the original allegation was. So I have a couple of questions and then I will turn it over to Mr. Michaud. 

But why was that information not included in the executive summary that VA, not you, VA leaked early, but you did not find room 

in it to include that we, quote, ‘‘pursued this allegation, but the 

whistleblower did not provide us with a list of 40 patient names,’’ 

end quote? 

Mr. GRIFFIN. I believe that you as the chairman received the 

same hotline that we did. It stated that there were 22 who had 

died on the electronic wait list and there were 18 who died on the 

consult list. 

So in our pursuit of finding out what happened here, which was 

an exhaustive pursuit, which is still ongoing as you know because 

of the urology issues that we discovered, the obvious first question 

in our interview with Dr. Foote was give us the 40 names. We want 

to go after the records of these 40 people and ensure that we don’t 

miss any of these 40 because it was so definitive. 

Now, you were very careful in the hearing on April 9th to say 

potentially 40. As—as time passed, it became declarative by some 

that 40 died. Others said there were at least 40. So that spawned 

800 media reports that 40 veterans died while waiting for care in 

Phoenix. That was the story as of the April 9th hearing. 

To not address that with the amount of coverage and the millions 

of readers who would have read that would have been derelict on 

our part. So we didn’t look at 40. We looked at 3,409 records to 

make sure we didn’t miss any. 

The CHAIRMAN. So it was important that you draw the fact that 

Dr. Foote did not provide you the 40 names? That was very important? 

Mr. GRIFFIN. What was important was in the April 9th hearing 

in this room—— 

The CHAIRMAN. No. I am talking about the final report, not the 

April 9th hearing now. I am talking—— 

Mr. GRIFFIN. No, that—that was not—that was not something 

that was inserted in the final report. There were multiple drafts 

which is a very important point that doesn’t seem to be getting any 

traction. We were asked to provide the first unaltered draft report 

and that’s what we provided. That’s the first time—— 

The CHAIRMAN. Let me draw—— 

Mr. GRIFFIN [continuing]. In 1,700 reports—— 

The CHAIRMAN. Let me draw a very clear distinction—— 

Mr. GRIFFIN [continuing]. We’ve been asked for one. 

The CHAIRMAN. [continuing]. About what we asked for. Okay? 

Please provide committee with the original draft copy. All right? 

You may have thought that original meant the very first—that 

meant an unaltered copy. And I have an email that went to your 

staff that has original and then in parentheses beside it, it says 

unaltered. In other words, don’t adulterate it in any way. We want 

the original draft. Again—— 

Mr. GRIFFIN. We received two requests from the committee, one 

from you and one from Chairman Coffman. One of them said un— 


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unaltered and the other said something different, but there wasn’t 

any confusion that you wanted the very first initial draft report—— 

The CHAIRMAN. Well, let me read—— 

Mr. GRIFFIN [continuing]. Which is unknown—— 

The CHAIRMAN. Sir, let me read this email to you. You have gotten a third one that came from the staff director of the OIG, the 

O&I Subcommittee to Joanne Moffett. 

Dear, Joanne, Chairman Miller would like to know if the OIG is 

going to provide the committee with a written copy of the original, 

paren, unaltered draft copy of the Phoenix report as first provided 

to VA. If so, when? 

Mr. GRIFFIN. I guess I don’t see what—what the difference is. 

You asked for the first initial draft report and we provided it. 

The CHAIRMAN. Did you ever indicate to the committee or to the 

staff that there was more than one draft? 

Mr. GRIFFIN. We did not. We provided what the—what the committee asked for and we also explained that in the last six years, 

no committee has ever requested a copy of our draft report because—— 

The CHAIRMAN. Well, shame on them, sir. 

Mr. GRIFFIN. No. No. That’s—— 

The CHAIRMAN. Shame on him. 

Mr. GRIFFIN [continuing]. The way it is in the IG community. 

The CHAIRMAN. Well, I am sorry, but—— 

Mr. GRIFFIN. A deliberative process—— 

The CHAIRMAN [continuing]. Here is the way it works here. 

Mr. GRIFFIN. We’re interested—— 

The CHAIRMAN. We want all of the information. We don’t want 

you to use semantics about which copy of the draft we asked for. 

We asked for the draft that you gave to the VA so VA could make 

their determination as to whether or not that draft was factual or 

not. That was the intent. You knew that is what it was. Just wait 

a minute. It is my time, not yours. 

Mr. GRIFFIN. Okay. 

The CHAIRMAN. You knew what the request was. What we were 

trying to get is how did that get inserted from the draft to the 

final. And now we have testimony from Dr. Daigh that, in fact, 

they did not conclusively look at all the causes of death. 

So I still make the statement, and then I am going to yield to 

Mr. Michaud, and I apologize to the Members, we have all got to 

be honest and open with each other about what is going on and 

whether or not any other committee has ever asked for a draft report, shame on them. Whether or not the OIG has ever sat at a 

table with anybody other than people from the OIG Office, tough. 

This committee is going to get the truth about all of the facts. 

Mr. Michaud. 

Mr. GRIFFIN. Mr. Michaud, may I respond to that? This is the 

crux of the whole allegation. 

Mr. MICHAUD. Yes, if the gentleman would want to respond. 

Mr. GRIFFIN. We were asked to provide the initial, because you 

didn’t want one that had been through two or three iterations. You 

wanted the very first draft report. That was clear to us. You can 

deny that all you want, but—— 


VACREP180 with DISTILLER
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The CHAIRMAN. Can you show me anywhere that it says we 

asked for the first draft report? 

Mr. GRIFFIN. I would refer to the attachments to our report 

where all of this is spelled out in writing. 

The CHAIRMAN. No. Can you tell me where we asked for the first 

draft report? 

Mr. GRIFFIN. Do you have that email, David? 

Let me find the email and—and I will respond to your question. 

The—the—— 

The CHAIRMAN. Mr. Michaud, you are now recognized. 

Mr. GRIFFIN. It showed a—a lack of awareness—— 

The CHAIRMAN. Mr. Michaud is now recognized. You are out of 

order. 

Mr. GRIFFIN. Do you want the truth? 

The CHAIRMAN. Sir, you are out of order. 

Mr. MICHAUD. Mr. Griffin, on the reports, if I understand you 

correctly, you did provide the first draft of the report, but there 

might have been other additional drafts out there? 

Mr. GRIFFIN. That’s correct. 

Mr. MICHAUD. So the draft you provided was the first draft that 

was—— 

Mr. GRIFFIN. That was requested. 

Mr. MICHAUD. Okay. But there was other drafts since the first 

one that came out; is that correct? 

Mr. GRIFFIN. It was a draft. It is a deliberative process. In order 

for us to get concurrence from the department, we have to put a 

draft in front of them. If we had factual errors in that draft that 

they can convince us were factual errors, then it would be incumbent upon us to make whatever edits are required so that at the 

end of the process, the report in its final issuance speaks the truth 

on all issues. 

Mr. MICHAUD. So when the IG does its reporting, you could conceivably get some information, whether it is from a whistleblower, 

whether it is from the department, that might not be factual and 

once you get information that you determined actually to be factual, that is when you change the report before it gets—— 

Mr. GRIFFIN. That’s correct. 

Mr. MICHAUD [continuing]. Issued to Congress? 

Mr. GRIFFIN. And then there were some minimal changes. On 

one of the case reviews, we had the blood pressure numbers that 

were taken at two different times were reversed. To me, that is not 

a substantive change. Obviously we had them wrong. When—when 

they were reviewed, it was pointed out so we—we put them back 

the way they should have been. But that is not a substantive 

change. 

Mr. MICHAUD. Okay. You mentioned that Dr. Foote mentioned an 

alleged 40 veterans. Did you ever receive the list of names of those 

that were on that list? 

Mr. GRIFFIN. No. And I would refer you to the transcript of our 

interview which addresses that very clearly. It was even suggested 

that perhaps some of them might have been run over by a bus, that 

he did not know how—what the cause of death was. 

Mr. MICHAUD. Okay. And he did not give you the definitive—I 

haven’t read that transcript yet, but—— 


VACREP180 with DISTILLER
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Mr. GRIFFIN. No. Understood. And I apologize for it arriving late, 

but it—it does need to be read by everybody who has a serious interest in this matter because it was a taped transcript of the interview. 

Dr. FOOTE. Can I respond to that, please? 

Mr. MICHAUD. No. I still got some other questions. 

My other question is, of the 93 ongoing reviews, how many have 

been closed out and when do you believe that the rest will be completed, Mr. Griffin? 

Mr. GRIFFIN. At this point, we have 12 of those that we have 

turned over to the department that I wouldn’t say were closed because we would anticipate administrative action being taken. 

They’re closed from the standpoint of we have completed the work 

that would have addressed the specific allegations that we were 

looking at. 

Now, in the department in their proceedings to make determinations concerning administrative action, if they come across additional information that was not part of our focus, we—we may have 

to do additional work on those, but we have turned over 12 so far. 

The others, they’re not being worked with any intent of, okay, a 

week from tomorrow, the other 81 are going to be all published. 

We—we will turn these over to the department, those that do not 

get accepted for any criminal action, we will promptly turn those 

over to the department so they can take administrative action. 

Mr. MICHAUD. Thank you. 

Dr. Mitchell, in your testimony, you mentioned how good the 

Phoenix VA pain management team is, but that they lack the staff 

to supply the services to Phoenix veterans. 

How did the Phoenix VA communicate their staffing needs to the 

director? Was it ever communicated and, if so, what was done, if 

anything? 

Dr. MITCHELL. I don’t have any direct knowledge of the communication between the pain management team and the senior administration to get additional staffing. 

What I do have is direct knowledge from many, many providers 

who find their panels filled with patients who are on high-dose, 

long-term narcotics and they need—and the patients need additional close monitoring and follow-up. 

What’s happening is those providers don’t have enough time to 

be able to get those patients in for sufficient appointments to be 

able to review that. 

In addition, in the community, veterans or—I’m sorry—in the 

community, patients that are on long-term narcotics are referred to 

a pain management specialist to titrate the doses, provide ongoing 

education, and monitor for side effects. Unfortunately, the staffing 

at the Phoenix VA does not allow for that. 

Mr. MICHAUD. Okay. Thank you. 

I see my time has run out, Mr. Chairman. 

The CHAIRMAN. Mr. Lamborn. 

Mr. LAMBORN. Thank you, Mr. Chairman, and thank you for having this very important hearing. 

Dr. Mitchell, briefly on page 15 of your written testimony, you 

pulled out case number 35 from the IG report as a special cirVerDate Aug 31 2005 11:01 Dec 01, 2015 Jkt 000000 PO 00000 Frm 00021 Fmt 6633 Sfmt 6633 Y:\96-130.TXT PAT

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cumstance, and please explain why you did so in this particular 

case. 

Dr. MITCHELL. I want to make it clear that I did not have access 

to the records that the OIG went through. However, anecdotally I 

was told that this was the same patient which I was familiar with 

and the details are the same with one glaring omission. 

In the OIG report, the history starts with the patient presented 

with the ER—to the ER with his family seeking mental healthcare. 

He was evaluated. He declined admission. He was discharged 

home. He committed suicide the next day. 

What was not in the report, and I believe this is the same case, 

if it’s not, it should be reported anyway, his parents—he actually 

was having problems with depression. He called his parents. They 

brought him to the walk-in mental healthcare clinic. However, because he had not been enrolled in the Phoenix VA, he was diverted 

from there to the eligibility and enrollment clinic where apparently 

he waited for hours. 

By the time he got enrolled in the system, he went back to mental health clinic and it was too late in the day for them—for him 

to be seen. So then he and his family were diverted to the ER 

where, again, they waited for a lengthy amount of time before they 

were seen by a psychiatric nurse to evaluate. 

By that time, the people that were involved said the patient was 

very tired. He wanted to go home. He declined discharge. He was 

subsequently discharged at that point with—to have follow-up the 

next day in the same clinic that wouldn’t see him earlier. 

Mr. LAMBORN. Okay. Thank you for that clarification. 

Mr. Griffin, when you shared your draft report with the VA before release, did VA propose any changes or ask any questions regarding what was in or was not in the report? 

Mr. GRIFFIN. They did. They requested that we remove several 

of the case reviews that appear at the beginning of the report. We 

refused to remove them. They suggested that we flip flop the blood 

pressure numbers that were out of order. Of course, we changed 

that. 

There were—there were two other minor things, one involving a 

date that was inconsequential to the outcome of the case review, 

so we fixed that. There were a couple of verb tenses changed and 

a recommendation that in no way whatsoever affected the intent of 

the recommendation. So those were changed. 

None of the case reviews were substantively changed and the 

secretary agreed to implement all 24 of our recommendations. 

Mr. LAMBORN. And how often do departments ask for changes before they are released to the public? 

Mr. GRIFFIN. I suspect that there has probably never been a report where there wasn’t some minor change not requested. 

Mr. LAMBORN. Well, I want to talk more about the—— 

Mr. GRIFFIN. The reason being that they have to implement what 

we have found and what they are concurring with. And so they’re 

going to scrutinize those things and make sure that—that they’re 

in total agreement and they’ll also look for those minuscule types— 

types of errors that will make the correct—the report more accurate. 


VACREP180 with DISTILLER
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Mr. LAMBORN. Well, when the language stating that you could 

not conclusively assert that there was a connection, do you know 

who leaked that to the press before the report was made public? 

Mr. GRIFFIN. No, I have no idea who leaked that. That—that 

was—that was in the report. The report had a date certain for— 

for being published. It should not have been leaked, but the fact 

is it didn’t change anything in the report. 

Mr. LAMBORN. Was it someone in your office that leaked it? 

Mr. GRIFFIN. Absolutely not. 

Mr. LAMBORN. Okay. And I didn’t think so. 

The word conclusively is not a medical term of art as far as I 

know and as a lawyer, I know it is not a legal term of art. 

On a scale of one to a hundred, where does that fall on the spectrum? 

Mr. GRIFFIN. It’s a reflection of the professional judgment of our 

board certified physicians. There have been a number of suggestions as to how we should do this. We received one from the committee saying we should unequivocally prove that delays caused 

deaths. We received that on April 9th. 

What does unequivocally prove mean? We did a review of the 

quality of care that these 3,409 veterans received. That’s what we 

do in all of our healthcare reviews. That’s what their charter calls 

for when they were created. 

Mr. LAMBORN. But there could be a connection less than conclusive. 

Mr. GRIFFIN. I think in some of them, we—we said it might have 

improved the course. But to say definitely that this person would 

not have died if they had gotten in sooner was a bridge too far for 

our clinicians. 

And I’ll let Dr. Daigh expand on that. 

Dr. DAIGH. The basic problem with this is that it’s very difficult 

to know why somebody actually died. I’m not clairvoyant. I’d ask 

you to read also the testimony submitted by Dr. Davis where he 

supported the methodology we used in our report. That would be 

death certificates plus a review of the chart. 

In the case that was discussed previously, case 29 where an individual died after failing to get an implantable heart device quickly, 

in that report, we said, and I’ll read exactly what we said, we indicated that—oh, doggone it—we indicated that—that he should 

have—he should have gotten the device more timely. He died. I 

don’t know exactly why he died. 

You’d like to think that he died because he had an arrhythmia 

to his heart and that if that device had worked, maybe it would 

have saved his life. But I don’t know that that’s why he died. There 

are circumstances around the weekend of his death that are not included in this report. 

And the reason that he came to our attention is that he was on 

a wait list for endocrine clinic. He wasn’t on a wait list for cardiology clinic. Secondly, he’s not in the group of patients initially 

where we culled those who were on a wait list to receive delayed 

care. He’s in the list of patients who we said got substandard care, 

who—who in reviewing these cases, we found cases where the care 

did not meet veterans’ quality of care. 


VACREP180 with DISTILLER
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So this gentleman was delayed in getting care between Phoenix 

and Tucson. So he’s in the part of the draft where I think he belongs. I cannot assert why he died and that’s why we had to—— 

Mr. LAMBORN. Okay, Doctor, thank you. My time is way over. 

I yield back. 

The CHAIRMAN. Mr. Takano. 

Mr. TAKANO. Thank you, Mr. Chairman. 

Thank you to all the witnesses who are appearing before the 

committee today. 

Mr. Griffin, I did read through much of the material last night. 

I have to say I am trying to understand what the controversy is. 

I understand a charge has been made by the majority impugning 

your integrity. I understand them to mean that you were forced to 

change language or were persuaded to change language. I think 

that is the heart of the allegation. 

Could you help me understand from your point of view what is 

the charge because I think the public needs to understand that and 

what is your response? 

Mr. GRIFFIN. My response is there is a lack of understanding of 

the processing of draft reports. And it’s understandable because it’s 

the first time anyone has gotten one. 

When we send a initial draft report over there, that does not 

mean that my senior staff and others—other members of our team 

aren’t continuing to review that document and make sure that 

we’ve got it correct. 

The fact that it went to the department without that statement 

isn’t proof of anything. It’s an ongoing process until the last day 

when we sign out that final report. And over the course of five different drafts, there were minor changes made for purposes of clarity. 

The minute that the draft report came up here and the reason 

that you don’t put draft reports out is because they’re subject to interpretation and they’re not final. And shortly after the draft came 

up here, it was reported in the press that here is proof that somebody in VA changed that. That’s not proof. That just means that 

you don’t understand the process. 

And I can show, as I mentioned in my oral, six days before the 

initial draft was released, we were having discussions internally 

that if we don’t declare that delay was the cause of death, we need 

to say so. Now, it took a couple more drafts before the causality 

line was included. 

But I would point out on May 15th in a Senate hearing where 

the question of the original 17 names that we received came up, 

I was asked if we had a chance to review those. I said, yes, we had 

reviewed them and that being on a wait list for care does not demonstrate causality in a person’s death. 

That’s three and a half months before this final report. So there 

should have been note taken that it does not demonstrate causality 

that you’re waiting. And I think the last statement for the record 

that I would hope everybody will read because the witness won’t 

be here, as Dr. Daigh already referred to, bears that out and bears 

out our methodology. 

Someone might ask, well, why—why did you send it over there 

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ment. We knew the department had 24 recommendations that they 

had to write an acceptable response that convinced us that they got 

it and they were going to fix it. We knew they would need time to 

do that. 

We had made a commitment to the Congress to publish that report in August. As a result, we had to—we had to cut off some 

work in order to be about the—the business of writing the report. 

And that’s why Dr. Daigh’s staff has got 3,526 urology patients 

that will be the subject of a future review. 

Mr. TAKANO. Dr. Daigh, those 45 or some odd cases that were included, I wasn’t able to read each in detail and, frankly, couldn’t 

understand each one, but they did seem to me evidence of poor 

care, of bad continuity of care. 

You said that those family members are being notified of what 

happened. Those family members can pursue litigation, I imagine, 

and the VA could be found culpable in some of those instances; is 

that right? 

Dr. DAIGH. That’s correct. So let me—let me offer this comment. 

The—the universe of patients that we set about to review in this 

review were primarily those patients culled from wait lists identified by whistleblowers, by our auditors, and by our healthcare inspectors. 

So we were looking at people who were on a list and then did 

not get an appointment timely. That’s the universe we’re starting 

with. And, in fact, some of the cases from the NEAR list were part 

of what we were looking at. 

If you weren’t seen at the VA, then I couldn’t see—I mean, my 

records don’t allow me to take a look at whether you tried to get 

to the VA or didn’t try to get to the VA. In our methodology section, 

we lay that out. 

So from those cases, we were looking for people who had a delay 

in care and had a clinical impact on that delay. And—and those are 

the 28 cases that we identify in the front, six of whom had died. 

To know why someone died is very difficult. And—and so when 

you get down to an individual commits suicide on a certain day 

after a certain event, you might like to say that event had something to do with the suicide or you might like to believe that—that 

but for going to the—the—the psychiatrist or the primary care doc, 

that event wouldn’t have occurred. 

But in—in the—in the world where we try to be able to prove 

and have data to support what we’re saying, we have a hard time 

going there. So the—the—the—the second group of patients we report on are those that we found had a poor quality of care. 

The other point I think is important to understand is that my 

charge in law, I think, is to respond to the Congress, to the secretary, and to the under secretary of Health and comment to them 

on the quality of medical care the VA provides. 

So what I usually do is we—we look at an issue, and the issues 

are all different, and the question in this one was, we took to be, 

was there a direct relationship between a missed appointment 

and—and death. That’s sort of what the media was talking about. 

We—we were forced to address that in some way. 

And so once we determined that there was, in fact, patients that 

were—that had poor quality of care, we then always switch to, 


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well, what are the systemic issues at this VA that we can address 

to try to get VA to change their practices to make this never happen again. 

When you go to the issue of exactly who committed the tort, exactly what did the—did the VA or the patient or the other hospital 

down the street or the nursing home, what exactly did they contribute to this death or this poor outcome, that’s a matter for the 

courts and that’s a matter for VA’s internal processes. 

So I get to the point of poor quality of care and then I always 

shift and focus on what can I do to work with VA to make sure 

we fix it. So I’ll talk about—and—and, again, in the last written 

testimony, I outlined 10 or 12 or 15 reports where veterans were 

injured or harmed and we worked with VA as partners to try to 

get this fixed. 

Mr. TAKANO. Thank you. 

My time has run out. Thank you, Mr. Chairman, for indulging. 

Thank you. 

The CHAIRMAN. Thank you. 

Mr. Bilirakis. 

Dr. MITCHEL.L Mr. Chairman. 

Mr. BILIRAKIS. Thank you, Mr. Chairman. 

A question for Dr. Foote. In your testimony, you indicate that 

there may have been tampering of EWL software and that the 

numbers reported to central office differed from the real numbers 

of veterans waiting. 

How is it that the EWL appointments could be overridden to zero 

out previous appointments and do you believe audit controls were 

deliberately disabled? 

Dr. FOOTE. Yes. I think there was one of two methodologies used. 

Either they had two lists, one of which was reporting a number of 

100 or 200, which the IG’s graph showed that it was—it was a 

small number and not correct, or—and they had a second list 

where they disabled the reporting function or they went in and 

tampered with the re—with the reporting software so that it would 

not give an accurate number of, say, over 200. 

Certainly the IG’s data shows that from the inception of that list, 

it never gave the right number. Dr. Deering had said that the— 

the time that’s broke out, that the waiting list time was 55 days. 

Well, on the actual non-reporting electronic waiting list, there were 

14 to 16 hundred and the wait was six months. If you threw in the 

3,500 that were scattered around on the scheduled appointment 

consults on loose paper, the wait was probably more on—on somewhere between one and a half to two years. 

But I—I know I reported this to the IG. I’ve also reported this 

to the—to the FBI. And I know they’re taking a look into it and 

hopefully they will be able to find the forensic computer evidence 

to support that claim. 

Mr. BILIRAKIS. Thank you. 

A question for Mr. Griffin. The language that was included in the 

OIG final report regarding the conclusive case of death has no relation at all to any accepted standard of measure in medicine. 

As a matter of common sense, if VA doesn’t schedule appointments early enough to treat a disease, it is highly likely that vetVerDate Aug 31 2005 11:01 Dec 01, 2015 Jkt 000000 PO 00000 Frm 00026 Fmt 6633 Sfmt 6633 Y:\96-130.TXT PAT

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erans with potentially fatal conditions will needlessly suffer from 

conditions and possibly die. 

The question, does that make sense to you and do you agree with 

that statement? 

Dr. DAIGH. So I agree with your statement. The premise is that 

if you—if your care is delayed, then you should be—you—you are 

very likely going to be harmed. And—I—when we started this review, it seemed to me that that would be what we would find over 

and over and over again. 

And we looked at these cases and we didn’t find that, so we said, 

well, why didn’t we find that. And I think there are two of Dr. 

Foote’s cases in here where, in fact, you know, he can go home and 

say he saved a life. He found a patient that was in a waiting list 

who—or in a pile who had diabetes and another one that had critical heart care and he intervened to make sure that they lived. 

It’s also clear the veterans have access to other emergency rooms 

and other sources of care beyond the VA. So in retrospect thinking 

about this question, I think that people must have been extremely 

diligent at Phoenix where they knew the trains didn’t run on time 

to try to make sure that vulnerable people got care. 

I can only report the news. This is what I found. 

Mr. BILIRAKIS. Okay. Let me ask you this. Was this measure applied when the OIG report reported that veterans died while waiting for care in South Carolina and Georgia? 

Dr. DAIGH. We—again, I’ll say that I normally go to the point 

where we determine that poor quality of care was provided. So the 

standard—— 

Mr. BILIRAKIS. But can you answer that question? 

Dr. DAIGH. I’m sorry? 

Mr. BILIRAKIS. Was this same measure applied when the OIG reported that veterans died while waiting for care in South Carolina 

or Georgia? What is your answer to that question? 

Dr. DAIGH. It’s—sir, it’s usually a fact-based—it’s usually a fact 

pattern-based decision on—on exactly what happened. I’m not sure 

exactly report—which report you’re referring to. But, sir, it’s usually—on each report, it’s usually a different fact pattern. If we— 

if we determine that poor quality of care was provided, then we try 

to look at systemic issues and try to get VA to do the right thing 

with respect to quality of care. 

Mr. BILIRAKIS. So the report discussing the delay in colonoscopies 

and those—— 

Dr. DAIGH. Oh, the Columbia? Okay. Yes, sir. 

Mr. BILIRAKIS. Can you answer that question? Was the same 

standard applied—— 

Dr. DAIGH. In—in the Columbia case, it was our—— 

Mr. BILIRAKIS [continuing]. In the report? 

Dr. DAIGH. I—I don’t think the—I—I can’t— the—the—the same 

standard wasn’t applied because the fact pattern was entirely different. In Columbia, VA had found that they had delayed 

colonoscopies in a large population of veterans and as a result, as 

you would expect, a large number of veterans developed colon cancer that probably would have been prevented had the colonoscopy 

be—had been done. And VA admitted that some of those patients 


VACREP180 with DISTILLER
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had died and VA had already undertaken the process to notify 

those patients. 

What my report was looking at was why did this happen, how 

is this possible. And what we determined was that VA does not 

have a way to ensure that nurses in—in clinics that need—if a 

nurse leaves a clinic and that job is critical to the performance of 

that clinic, refilling that position is given to a board within the hospital where administrators decide whether or not they’re going to 

fill the nurse position or a teaching position or a research position. 

So, again, we focused on what can VA do to make sure this 

doesn’t happen. And so, yes, the same standard wasn’t applied because the fact patterns were quite different. 

Mr. BILIRAKIS. All right. Thank you. 

Thank you, Mr. Chairman. I yield back. 

The Clerk. Mr. Chairman, if—— 

The CHAIRMAN. I apologize. We have had a vote called and I 

would like Ms. Titus to have an opportunity to ask her questions 

before we recess to go to the vote. 

Ms. Titus, you are recognized. 

Ms. TITUS. Thank you, Mr. Chairman. 

Mr. Griffin, like has been mentioned before and many of my colleagues, I am eagerly awaiting the results of the investigations at 

the other VHA facilities. 

Southern Nevada is home to the newest VA hospital and many 

people think it is the best. It is state of the art. And we also have 

a large medical system there. 

Now, I have been asked by a number of my constituents are the 

same problems happening here as in Phoenix because once you 

hear something like that, then, of course, it makes you worry and 

begin to think that there are problems. 

I have talked to Isabel Duff once a week practically to be reassured that they aren’t, but still I want to encourage you to finish 

up because not only do we want to solve any problems you might 

find, but I think that is a big part of restoring trust in the VA is 

to get that done and move on with it. 

Also, you put forth 24 recommendations and as I look at them, 

I think there are 11 that relate specifically to Phoenix which that 

is important, but the rest of them look at the systemic problems. 

Now, you have given those to the VA, said you recommend that 

they do this. This is a big dose, a large order that you are calling 

for. 

Are you confident that the VA has the facilities, the means, the 

intent, the ability to carry out those recommendations and solve 

these problems so this does not happen again? 

Mr. GRIFFIN. I would agree with your assessment that at 

present, they don’t have the facilities. I think VA would be the first 

to admit that they need additional clinical space. They need additional clinicians. They need a new scheduling process. They need 

a methodology by which they can remotely monitor what wait 

times are in Las Vegas or any—any other place in the country 

where they have a medical center. 

I think they’re aware of all those things and I believe the new 

secretary and—and his team that he’s assembling are—are dead 

serious about addressing those things. We do follow-up on our 


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recommendations. We have suspense dates for when things are 

supposed to be completed and we certainly will follow-up very aggressively on these 24 recommendations. 

And we also have already had some initial internal discussions 

about how we might scope a future project to go out and verify 

that, in fact, everything is working according to the plan. 

Ms. TITUS. That is good. You don’t want to make recommendations that just sit on the shelf—— 

Mr. GRIFFIN. No. 

Ms. TITUS [continuing]. Just for the sake of it. 

Mr. GRIFFIN. We—we follow-up on those on a quarterly basis. 

Ms. TITUS. I share your enthusiasm for the new secretary and I 

believe he is committed to both changing the attitude of the VA 

and making these specific reforms. 

Do you think the bill that we just passed, the compromise bill, 

will be useful in addressing some of these 24 recommendations? 

Mr. GRIFFIN. I’m afraid I’m not totally versed on the bill. I know 

there have been a number of legislative changes made in order to 

assist the department in accomplishing their mission. But I’d like 

to take that for the record, if I may. 

Ms. TITUS. All right. Thank you. 

Mr. GRIFFIN. Thank you. 

Ms. TITUS. I will yield back, Mr. Chairman. 

The CHAIRMAN. Thank you very much. 

Members, we do need to pause. I apologize to the witnesses. We 

think it may be about 30 minutes for us to go and do that. We will 

give you a heads up when we are going to start back. 

And this hearing is in recess until immediately following the 

third vote. 

[Recess.] 

The CHAIRMAN. Thank you, everybody, for rejoining us. Again, I 

apologize for the delay. 

Mr. Griffin, I would ask a couple of things. We have got other 

Members that are coming back. You asked that we put Dr. Foote’s 

testimony from his deposition into the record. We did so without 

unanimous consent. We have not had an opportunity to review it. 

I see where you have done some redactions. 

We have made an agreement that we would like to not enter it 

into the record until we have had an opportunity in a bipartisan 

way to look at any other information that may need to be redacted. 

I don’t mind even sharing it back with you, so that we are not putting something into the record that could release personally identifiable information or illnesses or diseases or anything of that nature. 

Is that okay with you? 

Mr. GRIFFIN. That’s fine. The—the redactions that you see are 

ones that were done by our privacy officer to make sure that—that 

we didn’t have any names in there that should not have been 

there, but better to—to double check. That’s fine. 

The CHAIRMAN. Yeah. Because we hadn’t had a chance to look at 

it prior to introducing it into the record, we have agreed in a bipartisan fashion, both of counsels have come together and said we will 

agree to the redactions and don’t mind at all sharing it back with 

you. 


VACREP180 with DISTILLER
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Well, now that Ms. Kirkpatrick has returned, I would like to go 

ahead and yield the floor to you for your questions. So, Ms. Kirkpatrick, you are recognized. 

Ms. KIRKPATRICK. Thank you, Mr. Chairman. 

You know, Dr. Daigh, you brought up an interesting point and 

that is that there is a criminal process and there is a civil process 

if, in fact, causation is found because of deaths as a result of the 

wait times. 

And is it your understanding that there is now currently an ongoing criminal investigation by the Arizona attorney general, the 

FBI, and the Department of Justice? 

Mr. GRIFFIN. There is an ongoing criminal investigation but 

doesn’t—— 

Ms. KIRKPATRICK. To your—— 

Mr. GRIFFIN. It involves the criminal investigators from the IG’s 

Office. It involves the FBI. It involves the U.S. Attorney’s Office in 

Phoenix. 

Ms. KIRKPATRICK. So there is a process if in case causation is 

found? 

Mr. GRIFFIN. Absolutely. 

Ms. KIRKPATRICK. And to your—— 

Mr. GRIFFIN. If criminal behavior is—is determined to have occurred. 

Ms. KIRKPATRICK. Yes. 

Mr. GRIFFIN. Right. 

Ms. KIRKPATRICK. And to your knowledge, you mentioned the 

Federal Tort Claims Act, are you aware of any cases that have 

been filed under the Federal Tort Claims Act as a result of deaths 

because of wait times? 

Mr. GRIFFIN. I’m not aware of any, but that—that doesn’t mean 

that there might not have been one. We checked on the 45 case reviews and we didn’t find any filed on any of those 45. 

Ms. KIRKPATRICK. Thank you. 

Dr. Foote and Dr. Mitchell, I want to thank you for being here 

and for coming forward. 

And I have expressed to you in the past that I appreciate your 

courage because all of us on this committee really are united with 

you in our care for veterans and making sure that they get the 

medical care and access to that care that they really care about. 

And that is why I introduced the Whistleblower Protection Act. 

I wish that had been in place for you, but hopefully that will make 

things better for future whistleblowers. And part of that is a national hotline that patients and workers within the VA system can 

call and that information would go directly to the secretary in 

hopes that there wouldn’t be any kind of retaliation. 

But as I mentioned, this committee really is committed to access 

to care for our veterans. And, as you know, there was a bipartisan, 

bicameral Conference Committee that was appointed in the summer. We met together and we passed the Veterans Access, Choice, 

and Accountability Act of 2014. 

And one of the primary pieces of that is a new choice card that 

will allow veterans who live more than 40 miles from a VA facility 

or have had to wait more than 30 days to schedule an appointment 

to actually go to a local provider. 


VACREP180 with DISTILLER
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And, Dr. Mitchell, I was concerned when you said that you didn’t 

know if some of these people who were on the wait list knew that 

they had a choice to go to an outside provider. 

Do you think the use of a choice card, which is going to go out 

in November to our veterans, giving them that option will help improve that? 

Dr. MITCHELL. Thank you. 

To clarify what I said, they had the option of walking into a VA 

primary care clinic to get care. At this point, if they were not enrolled in the VA, the VA would not pay for their care anywhere 

else. I think the idea of getting care access is wonderful. 

What the IG said earlier was that, well, the veterans had a 

choice. They could go to an ER, a hospital, or a private doctor. They 

don’t have a choice. Many Americans don’t have insurance. If they 

get sick, they opt not to go to a physician. I don’t know about the 

other members here, but, frankly, I would have a hard time paying 

for the cost of hospitalization or ER visit. 

Many veterans will let their chronic diseases get worse. As evidenced in two cases, they kept going to the ER because that was 

the only way to get their severely worsening symptoms taken care 

of. That’s the equivalent of only putting out the fire but never 

doing anything to prevent the fire from starting. 

Ms. KIRKPATRICK. Well, I appreciate that. And our hope is that 

with the choice card that will make a difference, especially the veterans in my rural area who many of them are 40 miles away from 

a facility. They will be able to go directly to a local community. 

And as you know, I have 12 tribes and 25 percent of my district 

is Native American. They will be able to go to their local Indian 

health services facility to get their veterans’ care. So a huge piece 

of the reform act was encouraging a partnership between the VA 

and the Indian health services. 

So, again, I thank you for your testimony, for helping to guide 

this committee to do some meaningful reform. And we will keep an 

eye on it. 

I yield back my time. 

The CHAIRMAN. Thank you very much. 

Mr. Coffman. 

Mr. COFFMAN. Thank you, Mr. Chairman. 

Mr. Griffin, will you provide us with all emails, draft discussions, 

and comments provided by VA with regard to this report? 

Mr. GRIFFIN. I can provide the IG emails. They will be reviewed 

by our privacy officer to make sure no one’s identity is, you know, 

left in there that shouldn’t be and we’ll provide them. 

Mr. COFFMAN. Mr. Griffin, as you are aware, the Department of 

Justice has already declined to prosecute 17 cases of possible criminal violations by VA employees that your office has referred to 

them. 

What are some of the reasons the Department of Justice has provided for not wanting to prosecute? 

Mr. GRIFFIN. Some of the reasons include that there—it was not 

determined that criminal behavior occurred. In some of the cases, 

they had more rigorous prosecutive standards for the cases that 

would rise to the level of getting prosecution as opposed to administrative action. In some of them, the fact that someone manipulated 


VACREP180 with DISTILLER
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the data, but there wasn’t proof of a death as a result caused them 

not to prosecute. 

Some of them said this has been a systemic problem in the department for a number of years that has been allowed to perpetuate itself and the ability to demonstrate that someone knowingly 

and willingly committed a criminal offense was too difficult. 

Mr. COFFMAN. Were you surprised at that? Were you surprised 

at their response? 

Mr. GRIFFIN. Well, I think that we work with these prosecutors 

every day. 

Mr. COFFMAN. Yes. 

Mr. GRIFFIN. Last year, we arrested over 500 individuals. We arrested 94 employees last year. So we’re aware that they can’t prosecute every case that they get. And, frankly, our investigators 

would like every case that they investigate to be prosecuted, but 

that’s not the real world based on—on the demands on the Department of Justice and the court system, et cetera. So determinations 

are made by the Department of Justice in that respect and—and 

we have to live them. 

Mr. COFFMAN. And let me just say I passed an amendment on 

an appropriations bill to put more money into the line item for the 

Department of Justice for the specific purpose of prosecuting these 

cases. 

Don’t you think, though, when you talk about systemic that there 

was a culture of corruption and maybe the fact that it was a culture of corruption versus an individual case, then I guess it was 

okay? 

But let me ask you this then. But when somebody does something, manipulates records for the purpose of financial gain, isn’t 

that a criminal offense of itself? Shouldn’t there be an example set 

by somebody being prosecuted somewhere in the system? 

Mr. GRIFFIN. I agree. And I am not saying there will not be, either. There have not been any at this point. You would expect that 

the cases with the least amount of evidence and the last amount 

of manipulation, if you will, or co-conspiracy would be the ones that 

would be set aside earliest. Because the additional cases will require more work. We are working feverishly on those cases because 

we know it is important to get through all 93 of them. And as we 

finish them if there will not be criminal prosecution I know the department is anxious to get those reports so they can take appropriate administrative action. 

Mr. COFFMAN. And Dr. Foote and Dr. Mitchell, I just have a tiny 

bit of time left. Tell me, are you surprised that there were not 

criminal prosecutions, Dr. Foote? 

Dr. FOOTE. Not at this point because I think the FBI is still investigating. 

Mr. COFFMAN. Okay. Dr. Mitchell? 

Dr. MITCHELL. I am not surprised because there is still retaliation against whistleblowers. There would be no reason to prosecute 

the people who are perpetrating it. 

Mr. COFFMAN. And Mr. Griffin, it does seem like the Department 

of Justice is looking the other way because obviously this situation 

is embarrassing to the administration. With that, Mr. Chairman, 

I yield back. 


VACREP180 with DISTILLER
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The CHAIRMAN. Thank you. Mr. Walz, you are recognized. 

Mr. WALZ. Well, thank you, Mr. Chairman. I want to thank all 

of you for your work towards veterans and that is what we are here 

to get. The situation in Phoenix and elsewhere that provided even 

one veteran substandard care is simply unacceptable. And I would 

like to go back, I have a long history with the OIG’s Office. I know 

as someone myself, I counted in my unit heavily on the IG to provide another set of eyes to provide that unvarnished view of what 

was going on. So let us be very clear, what is being implied is that 

the integrity of this office was influenced by the VA. So I am going 

to ask very clearly, Mr. Griffin. Did anyone at the VA ask you to 

change the report to make it look better in their stead? 

Mr. GRIFFIN. No. 

Mr. WALZ. Is it normal standard operating procedure for multiple 

drafts of a report to be done? 

Mr. GRIFFIN. It is, especially a report of 170 pages with 24 recommendations. 

Mr. WALZ. Has there been a case before where your methodology 

has been questioned to the point where you were called in front of 

Congress to defend the methodology, not the results of the report? 

Mr. GRIFFIN. No. 

Mr. WALZ. This is the first time? 

Mr. GRIFFIN. That is correct. 

Mr. WALZ. And is it your understanding and again to get it, that 

it is predicated on the interpretation if you were asked for the 

original draft? 

Mr. GRIFFIN. That is correct. 

Mr. WALZ. Okay. With that being said, I want to be very clear. 

The report you issued is very damning to the VA. 

Mr. GRIFFIN. It is. 

Mr. WALZ. And there are many things that they fell down on. 

And the Department of Justice, and making sure that Dr. Foote 

and Dr. Mitchell and everyone else who is willing to correct things, 

there has to be a route and an avenue that people are made whole 

and that people are held accountable. And from my understanding, 

that is in the process. That the FBI and the Department of Justice 

are looking at it. Is that correct, Dr. Griffin? 

Mr. GRIFFIN. The investigation is ongoing in Phoenix and other 

places. But we also in our very first recommendation in that report 

referred the name of the 45 veterans in our case reviews to the department for them to conduct appropriate reviews to determine if 

there was medical negligence and if there ought to be redress to 

the veteran or his family—— 

Mr. WALZ. Does—— 

Mr. GRIFFIN [continuing]. For receiving poor care. 

Mr. WALZ. Does the VA OIG prosecute cases? 

Mr. GRIFFIN. We investigate cases. We take them to the prosecutors in DoJ, or in some instances in state court if we cannot get 

traction on a federal violation. 

Mr. WALZ. Okay. Does this report and the way it was handled 

strike you, Mr. Griffin, and if I am right how long have you been 

with the OIG? 

Mr. GRIFFIN. About thirteen and a half years total. 


VACREP180 with DISTILLER
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Mr. WALZ. How many investigations have you been a part of 

roughly? 

Mr. GRIFFIN. Well we have done about 520 arrests every year for 

the last six years. I, that is a number that is handy to me. But that 

is about an average year for us. 

Mr. WALZ. And the methodology, the folks who work for you, 

your investigators and how you wrote the report, is there anything 

strikingly different about this one than any of those previous ones 

you have done? 

Mr. GRIFFIN. This was a very large undertaking and it was a 

combination of our criminal investigators, who are the same job series as FBI agents, Secret Service agents, etcetera. But it was a 

joint project where Dr. Daigh’s people had ownership of the medical 

care and the case reviews. Linda Halliday’s staff, the audit staff, 

had the responsibility to try and identify all of these people who 

were not on an electronic wait list through a number of different 

sources. So her staff did that. So to try and pull the three different 

disciplines together and get everybody on the same page as far as 

what makes sense, I mean, there might be some language that 

makes sense to David that might not make sense to—— 

Mr. WALZ. Because, and I would argue that it makes sense to Dr. 

Foote and Dr. Mitchell. 

Mr. GRIFFIN. Sure. 

Mr. WALZ. That is coming out. Because there is still obviously 

the belief that we have not gotten to the bottom of this. That we 

have not gotten everything that has been done, or there has not 

been held accountability. With that being said I want to use my remaining time that that will still be investigated. My immediate 

concern right now is on those 24 recommendations. Do you feel in 

your professional judgment are they moving in the proper direction? Because you have had people come here and testify before 

that VA did not implement your recommendations and you had to 

come back again. Do you feel at this point, and I know it is 

early—— 

Mr. GRIFFIN. It is early. It is less than a month since the final 

report was issued. But I can tell you this. A lot of the wait times 

issues were previously identified in our interim report. 

Mr. WALZ. Correct. 

Mr. GRIFFIN. And I know that the department started addressing 

those immediately. In the updated report when we identified an additional 1,800 veterans that were not on a list that were in a drawer or were just not properly being managed, we immediately gave 

those 1,800 names to the people in Phoenix so they could make 

sure those veterans who had not gotten care got it as quickly as 

possible. 

Mr. WALZ. Can I ask one final quick one? Just a yes or no from 

each of you. And I know this is very subjective but you are at the 

heart of this matter and you have a better insight than anyone. 

Does it feel like cultural changes are beginning to change to hold 

accountability, in your opinion? 

Mr. GRIFFIN. I think the change will come as we complete more 

investigations and people realize that there is a price to be paid. 

Mr. WALZ. Dr. Foote and Dr. Mitchell? 


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Dr. FOOTE. I would say asking for my testimony to be made public, I would not agree with that statement. I would say no. 

Mr. WALZ. Okay. 

Dr. MITCHELL. I would say no. There is lots of investigations but 

there has been no substantive change. 

Mr. WALZ. Very good. I yield back. Thank you, Chairman. 

The CHAIRMAN. Thank you very much. Ms. Walorski? 

Mrs. WALORSKI. Thank you, Mr. Chairman. Dr. Daigh, you had 

said earlier today I believe to Chairman Miller that you did not 

conclusively examine all the medical records to determine if patient 

deaths were related to delays in care. Yet in the report your colleagues released it said, ‘‘The IG’s final report in August concluded 

that it could not conclusively assert that long wait times caused the 

deaths of these veterans.’’ Can you explain to me and to the families who are watching today who have been going through this, especially if they have lost loved ones, how can the VA emphatically 

say to us that you can determine no link between wait times and 

deaths if you did not examine all the records? Dr. *Daigh.* So let 

me clarify. We examined 3,409, 3,409 records. To the chairman’s 

point, we did not examine all the records of patients on the near 

list, that would be people who said they wanted care at VA, if they 

never actually made it through the maze and got an appointment. 

So if there was no record for me to review, given that the electronic 

medical record was our main source, then I could not review those 

cases. 

All of the cases that we were able to review came from a whole 

variety of lists, most of which had to do with waiting lists that we 

found at Phoenix. So in those cases we did I think very thoroughly 

review those cases. And in those cases where we determined that 

there was harm, the delayed care caused harm, we published those. 

And in those cases where we found improper care, we published 

those. So we have 28 cases that we thought people were on a waiting list and as a result of being on a waiting list, they were 

harmed. We have an additional 17 cases where we thought the 

standard of care was not met, that, and so we published those 

cases. 

I think that I have, I am not trying to say to people who could 

not get there, who through frustration could not make it through 

the barriers, I am not trying to excuse anything at the VA. I am 

only trying to answer a fact. On these people, on the cases we 

looked at, did we see a significant impact on their care because 

they were on a waiting list? And that is, that is what we found and 

that is what we published. 

I further say that I do not believe that our review necessarily 

needs to be determinative. In the sense that I put the scenarios out 

there hoping the citizens would read these cases and would understand the complexity that these veterans present, and understand 

the difficulty that they have, understand the fragility of these 

cases. So that when they do not get care in a timely fashion, horrible things are likely to happen. And each person then can read 

these cases and they can decide whether a person who might have 

unfortunately committed suicide, do they think that was related to 

timeliness? They can make their own decision on that point. So I 

offered the opinion of my office, which has the ability to see lots 


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of data that is not in these summaries intentionally. A lot of the 

data is unnecessary for the basic fact pattern. These families have 

a right to privacy, so we try to be very careful about what we decide to publish with respect to facts to a case. So to the issue that 

people would like more data about these cases, I understand it. But 

I think, I think that the VA needs to ensure that veterans have access to care that is done appropriately, that the trains run on time, 

and in that way the VA can deliver proper care. 

Mrs. WALORSKI. I am just curious. If you had a chance to go back 

and reinvestigate these cases and the procedure, would you do it 

differently today? 

Dr. DAIGH. No, I, I would not. I think the way we did it is the 

way we have done this for many, many years. I think it is over 

thorough and I think it produces a fair result. What I would wish 

we had, which I wish we had not been tied to was this issue of 

timeliness. Trying to explain the impact of being on a wait list with 

quality care, that is, I mean, that is a totally made up standard 

based on the circumstances of the complaint at this case. If I could 

have picked something different to look at we would have thoughtfully come up with a different test. But that is the test we were 

presented with and so that is the test we had to try to address. 

Mrs. WALORSKI. Thank you. Thank you, Mr. Chairman. I yield 

back. 

The CHAIRMAN. Thank you very much. Ms. Brownley. 

Ms. BROWNLEY. Thank you, Mr. Chairman. Mr. Griffin, is, do you 

know if there is a parallel FBI investigation going on at this particular? 

Mr. GRIFFIN. There is a joint investigation involving my people 

and the FBI. 

Ms. BROWNLEY. Investigating the same issues? Asking the same 

questions? 

Mr. GRIFFIN. They are doing it together. If there is an interview 

happening there is an FBI presence and there is an OIG criminal 

investigator present. 

Ms. BROWNLEY. Thank you. And Mr. Griffin, you in your answering a member’s question when, related to the closing out of 12 

cases and still 93 ongoing, you mentioned something about they 

were closed out because they met the criteria and the, the questions were answered. But you talked about additional information 

that was not necessarily related that you have culled together. Can 

you talk a little bit about the additional information? Is there 

something, can you give me some examples, and is there something—— 

Mr. GRIFFIN. Let me clarify that point for you. When we did 

some of our 93 investigations, the 12 that we have given to the department, we, we did not do a Phoenix level review of every one 

of those facilities. That would take ten years. What we did look at 

is where we received allegations, either through our hotline or from 

any number of other sources of a specific infraction going on there. 

And in some instances with more specific language than others. 

Okay? So we investigate those. If it, if the result does not rise to 

the level of the U.S. Attorney’s Office in that district to approve 

criminal prosecution, that investigative package within the scope of 

the review that was done is given to the department. It is incumVerDate Aug 31 2005 11:01 Dec 01, 2015 Jkt 000000 PO 00000 Frm 00036 Fmt 6633 Sfmt 6633 Y:\96-130.TXT PAT

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bent upon the department, it is their job to review that information 

and say, okay, maybe someone decided this does not rise to the 

level of criminal prosecution, however we think disciplinary action, 

which can range from counseling to firing, needs to be taken in this 

case. 

So in order to prove that, which they will have to do, they will 

look at the piece of the investigation we did. They may determine 

that they need to go interview somebody else for whatever reason 

to support their administrative action. And if that were to result 

in some new information that we were not aware of, it could cause 

us to reopen our investigation. But it is, it is up to the department 

to take those administrative actions. That is why when there is no 

criminal prosecution forthcoming on a specific case we hand over 

our reports and transcripts, etcetera, to the VA and they can take 

administrative action based on those in large measure. 

Ms. BROWNLEY. So there is not additional information or a list 

of additional information that was uncovered that has not—— 

Mr. GRIFFIN. No, we—— 

Ms. BROWNLEY [continuing]. Or will be investigated? 

Mr. GRIFFIN. Not during our investigation. I am just saying that 

if, if in putting together their review for purposes of administrative 

action, if somehow they come up with some information that was 

not—— 

Ms. BROWNLEY. They being the department? 

Mr. GRIFFIN. They the department, who have to propose the action whether it be removal or something less than that. It could 

cause us to say we are going to go back and look into this further. 

But that is just the way the process is. 

Ms. BROWNLEY. I wanted to follow up I think on Ms. Titus’ questioning and just ask, you know, very, very specifically if you believe 

that there are adequate resources to continue and to complete the 

ongoing investigations at the remaining sites? 

Mr. GRIFFIN. I think that some of those investigations are of 

much more narrow scope than the magnitude of the review we are 

doing in Phoenix. We are progressing on the remaining 81. Every 

week there is another handful that we are able to bring to closure. 

So, you know, the answer is yes. We have the resources. But I 

must say that this is not the only investigation that our people are 

involved with. Since January the number of threat cases that have 

come to us on VA facilities, the number of assault cases. We have 

made 86 drug arrests since January 1. So some of these matters 

that are already in the prosecutive mode, I mean we prosecuted a 

medical center director for 64 counts of corruption. And we certainly could not drop that case in order to, you know, take on a 

new case when it is going through the judicial process. 

Ms. BROWNLEY. Thank you, and I yield back. 

The CHAIRMAN. Dr. Daigh, there were 293 deaths, is that correct? 

Dr. DAIGH. There were 293 deaths that we reviewed, that is correct. 

The CHAIRMAN. How many of those were cross referenced with 

medical documents? 

Dr. DAIGH. All of them. 


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The CHAIRMAN. No, I think there were 28 that were on the near 

list that you, I am, I am trying, again, I am honestly trying to 

learn, Mr. Griffin. And you have educated at least me as the chairman today on some things. I am, you, Dr. Daigh, you said because 

they were on the near list they were not in the system so there was 

no medical record for you to review and you were not able to do 

that. So you—— 

Dr. DAIGH. So let me, let me please clarify. The near list included 

a large number of patients. Of the patients that we reviewed from 

the near list we would not be able to review a patient if we did not 

have a medical record. So if you were on the near list, we do not 

have a record, then we excluded you from the review. So in our 

methodology section, we can only look at cases that actually come 

to the VA. 

The CHAIRMAN. And, and I understand. 

Dr. DAIGH. Yes. 

The CHAIRMAN. But how can you, and I keep going back to this, 

how can you say you conclusively were able to say these individuals did not get timely care? They are now dead. 

Dr. DAIGH. I am talking about the cases that we were able to review. 

The CHAIRMAN. I understand that. But there were cases that you 

have just said that you cannot review and I, that is, all I am trying 

to figure out is there are cases that were part of this investigation 

that you apparently could not review them because there was no 

medical record for you to look at. And so my question is, again, of 

the 293 deaths, did every one of them get cross referenced with 

some type of medical record? 

Dr. DAIGH. So the total number of people on the near list is a 

big number. The total—— 

The CHAIRMAN. [continuing]. I am sorry, the 293 deaths—— 

Dr. DAIGH. Yes, but what I am trying, what I am trying, I am 

just trying to be clear, sir. 

The CHAIRMAN. Okay. 

Dr. DAIGH. The 293 deaths were all among patients, from whatever list they were on, that had a medical record that we could review. So I am going to agree with you. There would be people who 

would be on a near list, who did not have a medical record, who 

we could not review. And therefore they were not part of the chart 

because it is not possible for me to review them. So all of the 

deaths, there were 293, we reviewed intensively. 

Now the 293 number is a data point. The 293 number is from 

the 3,409 patients, 293 were dead. But that number is a number 

that has limited meaning in the sense that we, it is drawn from 

a population that you do not know the disease burden of. And so 

I cannot tell you whether 293 is too high or too low. Because the 

reason for death could be normal, normal causes. 

The CHAIRMAN. I understand. I apologize, but I am still trying 

to find out. Because in a staff briefing staff was told that in some 

instances all that could be done was a match of social security 

numbers, then looking at a death list. And so there was no way for 

some of those individuals to be cross-referenced with a medical 

record. That is correct, is it not? 


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Dr. DAIGH. No, I think that that would be a misunderstanding 

of what was said. We, I would not purport to comment on cases 

that we had not been able to review the record for. That—— 

The CHAIRMAN. But they were on the lists, correct? 

Dr. DAIGH. Well so in, again, in our methodology section we said 

we excluded—so I realize we are all talking subtleties here and I 

am not, I am really trying to be clear. I cannot report on cases who 

I have no information of. So—— 

The CHAIRMAN. And that, and I concur. And I think that is 

where the crossed wires are coming from. Because it is very hard 

for me to accept a statement in a document, as we have been discussing, if you have not been able to look at every single medical 

record, and thank you very much for clarifying that. 

Mr. Huelskamp. 

Dr. HUELSKAMP. Thank you, Mr. Chairman. I appreciate that 

line of questions because I was also, still am confused of where you 

were able to identify the, excuse me, 3,409 veterans, those were the 

number of the cases that you reviewed? 

Dr. DAIGH. Yes, sir. 

Dr. HUELSKAMP. And you had medical records for all those cases? 

Dr. DAIGH. Yes, sir. 

Dr. HUELSKAMP. Okay. But in pages 34 and on in the report you 

identify numerous other categories of veterans that would total 

well over 9,000 that are on, either not on electronic waiting lists, 

or on the electronic waiting list, or on the near list, or 600 printouts, or schedule and appointment consults, a backlog redistribution. How did you decide the 9,121 gets reduced to 3,409? 

Dr. DAIGH. Well the report talks about in Phoenix there were 

many lists. And the report talks about lists from different sources 

and different points in time. So if you are talking about cases that 

were part of the Appendix, which were the VA, were VA’s cleanup 

action, those cases were not part of the, most, by, by, by, by most, 

most of those cases were not part of—— 

Dr. HUELSKAMP. But excuse me, my, this is, I do not believe it 

is in the Appendix. It is page 34, question two identifies again 

9,121 veterans. And again, they may not be cumulative. My question is how did you decide not to look at 5,600-and-some cases of 

veterans, you decided not to review their case? 

Dr. DAIGH. Well we looked at those lists that were collected during the time frame of when we started our review up until about 

June 1. And I would, I would have to go through and work through 

the data set we have of the, of the actually 3,562 names on a list, 

which distilled to 3,409 uniques, individuals, of which 293 had died 

and of which 743 had a physician review them. So I would 

have—— 

Dr. HUELSKAMP. If they were on the electronic waiting list did 

you look at them and review their cases or not? 

Dr. DAIGH. We did. So everywhere, everybody that we were able 

to determine was on any of these waiting lists of any variety described in this report—— 

Dr. HUELSKAMP. But I just gave you another 5,600 that you put 

in the report. I am trying to figure out why you did not look at, 

say, the, those on the near list had 3,500. Did you not look at any 

on the near list? 


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Dr. DAIGH. If you were on the near list and you asked for veteran, to get into the VA system, but you did not ever, you never 

made it through the wickets and you never got care, you would 

not—— 

Dr. HUELSKAMP. So if you died waiting for care because there 

was a failure in the system they do not show up in your data as 

a death because of the system? 

Dr. DAIGH. That is, that is correct. They—— 

Dr. HUELSKAMP. Wow. 

Dr. DAIGH [continuing]. Would not have showed up—— 

Dr. HUELSKAMP. Is that not the crux of the problem? Thousands 

and thousands and thousands of veterans are waiting for care and 

your report says, well, we do not count them because they died before we got their records. And we are not going to go back and look 

at other sources. 

Dr. DAIGH. I—— 

Dr. HUELSKAMP. That is what I am trying to figure out. Because 

you winnow it down to 9,121, and they may not all be uniques. And 

it is pretty unclear to me, and perhaps the rest of the committee, 

maybe they get that. If you could provide some information to the 

committee as a follow up of how you decided to exclude the 5,600. 

And that would be helpful as well. And I want to ask you one other 

question as well, Mr. Chairman. Mr. Griffin, the day before you released your final report to Congress a number of news outlets were 

carrying reports with headlines, because I know you look closely at 

headlines, you have counted all the news stories, and some of the 

headlines says, ‘‘No proof that delays caused patient deaths,’’ ‘‘No 

links found between deaths and veterans care delays,’’ and ‘‘No 

deaths related to long waits.’’ Do you think these are accurate? Or 

are they misleading headlines? 

Mr. GRIFFIN. I have seen plenty of misleading headlines in the 

last two weeks. Some of them directed at my organization. 

Dr. HUELSKAMP. But the ones I read to you, Mr. Griffin. 

Mr. GRIFFIN. Okay. 

Dr. HUELSKAMP. The ones I read to you, are they misleading? 

Mr. GRIFFIN. The ones, no. But that is part of the story here. If 

someone leaks something before the scheduled release date of our 

report, and if it quoted our report, it should not have been leaked 

but that does not mean it is not true. 

Dr. HUELSKAMP. Have you ever seen a leak before? So is that report headline, is that misleading? 

Mr. GRIFFIN. Could I, could you read it to me again? 

Dr. HUELSKAMP. Yeah, absolutely. And I am sure you have seen 

it before. ‘‘No deaths related to long waits.’’ No deaths. Is that misleading? 

Mr. GRIFFIN. That is an accurate representation of our conclusion, that we could not—— 

Dr. HUELSKAMP. No deaths? 

Mr. GRIFFIN [continuing]. We could not assert a cause of death 

being associated with the waiting times. 

Dr. HUELSKAMP. How about no link? 

Mr. GRIFFIN. Those are not my words, I, you know. 


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Dr. HUELSKAMP. But I am asking you for your thought on them. 

Because you were very worried about 800 headlines that you 

looked very closely at. 

Mr. GRIFFIN. I am not worried about anything. 

Dr. HUELSKAMP. Well actually—— 

Mr. GRIFFIN. I am just, that is just the reality that you could get 

out of Google to show the amount of coverage that was put on the 

statement that there were 40 dead and that there was no ifs, ands, 

or buts about it. That does not take a lot of research to find that, 

okay? 

Dr. HUELSKAMP. Yes. 

Mr. GRIFFIN. Okay. So—— 

Dr. HUELSKAMP. Yes. Well, thank you. I just, I still am not for 

sure if you, apparently those headlines are okay, then? They are 

not misleading? 

Mr. GRIFFIN. I did not say they were okay. 

Dr. HUELSKAMP. Well are they misleading? 

Mr. GRIFFIN. I think headlines are sensational to get people to 

read a story. They—— 

Dr. HUELSKAMP. Well I think it is sensational that there is 5,600 

veterans cases that apparently were not reviewed and that you 

have in the report. And so I look forward to the determination of 

why you decided not to review those cases. Because I fear there are 

more veterans that died—— 

Mr. GRIFFIN. I think as Dr. Daigh said there was nothing to review if they did not get in the door. He was reviewing medical 

records and if they did not get an appointment, they did not have 

any records to review. 

Dr. HUELSKAMP. But when you said there was no causality and 

they fail to get in the door and die because we did not deliver care, 

I say that is causality and your statement would be misleading, 

then. I—— 

Mr. GRIFFIN. We do not know how they died or why, nor do you. 

The CHAIRMAN. Mr. O’Rourke. 

Mr. O’ROURKE. Thank you, Mr. Chairman. And I will say that 

Mr. Griffin and Dr. Daigh, I think by the criteria that you have described to us that you are using to reach your conclusions, I understand where you are coming from. And I think it is a rather narrow 

legalistic interpretation of the data, but I understand it and I think 

you have made that very clear today. And so I accept within those 

constraints what you have concluded. But common sense tells me, 

just from cases that I have seen in my district, that there is a 

cause and effect relationship between care that is delayed, that 

ends up being care that is denied, that ends up in veterans dying. 

And I have used this example before, with all due respect to the 

family, but they have shared their story with me and I think it is 

for a purpose. 

You know, Nick D’Amico, who had been trying to get mental 

healthcare at the El Paso VHA was unable to for untreated PTSD. 

And after attending, after not being able to and attending one of 

my town halls where veteran after veteran stood up and said, ‘‘I 

also have not been able to get in,’’ he was driving home and his 

mom related this story with me, to me, that he was driving home 

that night with her and said, you know, ‘‘Some of these guys are 


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much older than I am and have been trying for years to get in and 

cannot. I do not know what I have to look forward to.’’ And she 

cited that lack of hope as one of the main reasons that he then took 

his life five days after that meeting. We know in this country 22 

veterans a day sadly take their own lives. And I have got to think 

there is a connection between delayed, deferred, and ultimately denied care, and these very tragic instances of suicide. 

Now I do not know if it meets the strict legal criteria that you 

are using. But it makes a lot of sense to me, and to draw that connection and that conclusion. And I think that is what is prompting 

so many of us to try to improve the level of access and the quality 

of care. And I do not think you would disagree with that. I mean, 

your conclusions here, you make some very bold statements. You 

talk about a breakdown of the ethics system within VHA, which I 

take to be a comment on the largest issue that I see that we have 

a problem with. Which is not funding and resources or number of 

doctors, but is the cultural aspect of VHA, the lack of accountability, a premium based on performance bonuses and not on excellence of care. Not on responsibility, not on patient outcomes for the 

veterans that purportedly the VHA is there to serve. 

I looked at your recommendations related to ethics on page 74 

of your report. They were pretty narrow. I think good recommendations all of them, but fairly narrow. Are there other recommendations I may have missed that more fundamentally address the 

issue of culture within VHA? And I would love to know what those 

are and how the Secretary, I will ask him when he is here, how 

he is going to respond to those recommendations. Mr. Griffin? 

Mr. GRIFFIN. The original draft report had four or five recommendations speaking to ethics. They were very narrowly constructed so they were combined into one global ethics recommendation. The Secretary previously was the Chief Ethics Officer at P&G, 

he was the Chief Compliance Officer at P&G. I suspect that we are 

going to see ethics placed at a level where it should be. We did not 

find that in our review in Phoenix, when there was a request for 

an ethical review and not all of the recommendations were followed 

that were put forward by the person who submitted them. There 

was a reorganization in VHA which removed the Chief Medical 

Ethics Officer from the inner circle of the highest tier of management in VHA and was relegated to a lower level, which removed 

that person from a seat at the table with the most senior people. 

I suspect that we will see a change in that. And I think what had 

been ethics just from the medical ethics perspective is something 

that will be expanded beyond VHA to other areas in the department. 

Mr. O’ROURKE. I, and I have not read every single page of this 

report, and I am currently reading it and I need to do that. But 

what I have not seen, and I have read through the ethics section 

of it, what I have not seen are some specific recommendations on 

accountability, on people losing their jobs. We have heard the most 

egregious instances of dereliction of duty, of abuse, of fraud, and 

later learn that those people are still on the job. I cannot argue 

with anything you said about the incoming Secretary, or new Secretary. I had a chance to meet with him yesterday and I am really 

looking forward to his leadership. But I think we need to instituVerDate Aug 31 2005 11:01 Dec 01, 2015 Jkt 000000 PO 00000 Frm 00042 Fmt 6633 Sfmt 6633 Y:\96-130.TXT PAT

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tionalize these cultural changes. And you were asked a question 

earlier by one of my colleagues, anything in that July compromise 

bill that you think would help change the situation. I think the 

ability to fire senior executives, get the dead wood and the fraudulent actors out of the way quickly so that we can bring up those 

who are the best and brightest and have the outcome of the veteran first and foremost in mind is what we really need to do. And 

I am not seeing that still. And throughout the system, including in 

the part of the system where I have the honor of serving veterans 

there. I realize that I am out of time. I appreciate the chairman’s 

indulgence, thank you. 

The CHAIRMAN. Thank you. Dr. Roe. 

Dr. ROE. I thank the chairman. I am going to approach this a 

little differently. And Dr. Daigh, and Dr. Foote, and Dr. Mitchell 

know what I will be talking about, and this is grand rounds. And 

for those of you who do not know, when you are in training you 

present cases to staff and they critique your care of those cases. 

And I had a chance to review many of these cases and to draw the 

conclusion, Dr. Daigh, that you did, and maybe it is the criteria as 

Mr. O’Rourke said, that it had no effect on the outcome of those 

patients is outrageous. I mean, you would have lost both limbs 

where I was if you had tried to convince a staff a member where 

I am, or me when I was a staff member. 

And I think the question I posed to you in one of these cases if 

this were your family member, yours, just like case number 29 that 

had the congestive heart failure. If this was your dad there and 

would you be happy with the explanation you just gave of his 

death? And secondly, would you accept that? And my suspicion is 

no. Because you know that if your dad had gotten his allergy testing and an implantable defibrillator, the outcome may have been 

very different. That is why we put these devices in and prevent 

sudden cardiac death. And secondly of case number seven, this one 

the VA just got lucky on. I mean, a guy in his mid-sixties comes 

in to see a doctor with chest pain and has nothing done for seven 

months? I mean, all you can say is you got lucky. Because he very 

well could have died of coronary disease, which he had a bypass operation. But it was certainly nothing the VA did to help him prevent that. And one of the reasons, and I can assure you that in 

most private facilities if this guy had come in the emergency room 

like this he would have had a cath. Hypertension, mid-sixties, and 

chest pain, you cannot wave a redder flag than that. And what 

does this guy get? They control his blood pressure and send him 

out. And they are just really, really lucky. 

Case 31, a man with an elevated PSA. I have a little sensitivity 

to that. I have had one elevated before. It is a little worrisome 

when you are a veteran with an elevated PSA. This, it looks to me 

like this veteran just sort of got ignored for a while. Now would he 

have died and you cannot say, I think you can say, and what I 

would like to do is to have these criteria, or have this looked at by 

the Institute of Medicine or some other outside source to see if they 

draw the same conclusions. Because I certainly do not draw the 

same conclusions that you did. 

You are right. You cannot absolutely say that this veteran, missing this appointment or whatever. But it is the culture that I see. 


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I mean, right, you miss one appointment, that probably did not 

cause your death. I have got that. But the culture of, I just do not 

understand it, where you do not follow up. People drop through the 

cracks. CT scans reordered, nobody gives a follow up on these. And 

Dr. Foote, I want to stop because I am going to use all my time. 

But I want you to comment. You have been a clinical director for 

19 years. Do you agree or disagree with what I just said? 

Dr. FOOTE. Oh, absolutely. And my point was before about how 

the IG had somewhat downplayed the case. And let us talk about 

case seven. And what really happened in that case is quite different. And he had been waiting 12 months at the time, for an appointment with the VA, when he presented in January with the 

chest pain, having chest pain several times a week. All right? An 

EKG was done and the IG referred to it as an abnormality. The 

abnormality was Q waves in V1 through 3, suggestive of a prior anterior myocardial infarction—— 

Dr. ROE. Infarction, yes. 

Dr. FOOTE [continuing]. In a patient having chest pain. All right? 

He was given an appointment in October from January. Only because my MAO spotted it in June when they gave us those appointments did I get him in sooner. At that point he was having daily 

chest pain and he now had Q waves in V1 through V4. 

Dr. ROE. So he had unstable angina. 

Dr. FOOTE. Right, absolutely. And an echocardiogram showed 

that he had an ejection fraction of 35 percent, 50 is normal, and 

he had anterior wall abnormalities. So my, my analysis of this case 

is that he had a heart attack in the 12 months while he was waiting. He further extended that, and fortunately, fortunately we were 

able to get him urgently cathed and bypassed. But, and he, so he 

is a guy that saved his life but lost 30 percent of his heart function. 

And the IG report referred to that as a favorable outcome. 

Dr. ROE. Well I guess if you do not go to a funeral it is a favorable outcome. But I can tell you that, that was not, if that had been 

my family I would have been very, if it had been me, or if it had 

anybody sitting at that dais you would not have been happy with 

the care you got. And I went through case, I looked at this at one 

veteran at a time and evaluated it not as a system or whatever just 

how did that one veteran get their care, and would this care pass 

muster that we have to pass in the private sector to get paid by 

Medicare or anybody else. The answer is of course it would not. 

And I am embarrassed by this. I mean, when I read a lot of these 

cases it was embarrassing. Dr. Mitchell, would you like to comment? 

Dr. MITCHELL. Yes, I would like to go on the record against the 

entire OIG. When you have a patient who is unstable psychiatry, 

who is verbalizing suicidal ideation, like in case number 39, if you 

discharge him home he will commit suicide unless something intervenes. In this case nothing did and he committed suicide. 

For the gentleman in case number 40 he was demonstrating psychiatrically unstable behavior as an inpatient. The psychiatrist had 

the option to stop his discharge. If you discharge a psychiatrically 

unstable patient who has got a history of hurting himself, he has 

got a history of suicidal ideation, he will commit suicide. The only 

question that should be asked is when. 


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This is National Suicide Prevention Month. The VA has a wonderful program on the Power of One, which means that one person, 

one kind act, one question can stop a suicide. This gentleman 

should have had, both of these gentlemen should have had the 

Power of One, but One being the Department of the VA. This was 

totally inappropriate medical care for psychiatric patients. And on 

behalf of every mental health provider in the United States, I will 

say that if you discharge an unstable psychiatric patient who is 

verbalizing suicidal ideation, he will commit suicide unless something happens to intervene. 

Dr. ROE. I thank the chairman. I yield back. 

The CHAIRMAN. Ms. Brown. 

Ms. BROWN. Thank you, Mr. Chairman. Mr. Griffin, in my 22 

years on this committee I have never heard anything from the Inspector General that would make me believe that the Office of the 

Inspector General has worked with the VA to soften the findings. 

Nothing. Nothing there. But I think it seems to me that people 

think that because an allegation is a criminal offense and therefore 

should be fired without any due process. Can you explain that to 

me? And I am thinking about the 93 ongoing review cases. 

Mr. GRIFFIN. Right. 

Ms. BROWN. Yes. 

Mr. GRIFFIN. We receive many, many allegations. In the last 12 

months we got 34,000 allegations through our hotline, okay? That 

is why we have investigators and auditors and doctors and other 

clinicians. So when we get an allegation if we have the resources 

available and it rises to a level where we feel compelled to take it, 

that is why we go out and do our reviews and either conclude yes, 

this allegation is correct, or no, it is not. But until such time as 

we have accomplished that, an allegation is an allegation. 

Ms. BROWN. It seems as if everybody seems to think that every 

veteran is eligible to participate in the VA. And that is not accurate. I know that the former Secretary opened it up to millions of 

additional veterans. Can you explain that? In other words, everyone that was in the Department of Defense is not necessarily eligible to participate with the VA. Now I know we have expanded that 

net. But to a large extent, it was not. 

Mr. GRIFFIN. You know, Dr. Daigh served our country in the 

Army. He was an Army doctor for more than 20 years. He is well 

versed on coverage that is available to retirees in addition to veterans, so let me ask him to speak to the options that are available. 

Dr. DAIGH. I am not sure I can address it very factually except 

to say that you are correct, not all veterans are eligible for care in 

the VA. And generally the VA I believe was set up to take care of 

the indigent and those who were disabled in combat or otherwise. 

So the inclusion recently of all veterans who returned from the 

Wars has certainly expanded the eligibility for VA. And then when 

category eights were allowed to join, that would be people who are 

veterans but are not financially disqualified from previous groups, 

that has significantly increased the number of people who could 

come. But the gates to get in and not get in have been changed 

over time. That is about all I know about it right now, ma’am. 

Ms. BROWN. Okay. But we have expanded that area. And which 

I applaud. But in expanding it it created additional problems as far 


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as processing them through the system. I recently spoke to a veterans group and they indicated that it was such a horrible experience. And I said, well what was the horrible experience? Once you 

got into see the doctor? No, when I went for my appointment the 

person at the desk was on the phone and they did not stop and 

take care of me. That, I understand we lowered the job description 

of the front desk person so that veterans when they come in are 

not necessarily getting the right kind of experience that could have 

happened in any of our other offices if you do not have a person 

that is the first contact not a person at a certain level to, for that 

intake. 

Dr. DAIGH. Yes, ma’am. 

Ms. BROWN. I guess I was asking the question as to how could 

we improve the system as far as veterans feeling that the system, 

once that person got in with the doctor everything was fine. But 

it is just getting that person into the system. 

Dr. DAIGH. Well, I think there are a couple of things. One is the 

systems that, by which you make appointments, that you make 

consults, the communications systems which are actually quite 

complex between VA. And in Phoenix we found for example that 

many patients who traveled to Phoenix part-time, snow birds if you 

will, they had a very difficult time getting into care. They were sort 

of blocked out of the primary care group that was set up and their 

access was diminished. So I think you have to look at what you 

mean by access to care as a system. You are going to have to implement the systems to make it work, mostly computer systems. And 

then I think you also have to incentivize everyone who works in 

the VA to have a customer focused, friendly, polite, how can I help 

you, I cannot help you too much attitude. So I think all those 

issues are part of what I believe the current Secretary understand 

and what I believe he will try to work on. 

Ms. BROWN. Thank you. I yield back the balance of my time. 

The CHAIRMAN. Thank you, Ms. Brown. Mr. Jolly, you are recognized. 

Mr. JOLLY. Thank you, Mr. Chairman. Mr. Griffin, I have questions, and Dr. Daigh, about the analytical model behind your statements. And it goes to what Mr. O’Rourke said, and Mr. Roe, and 

Mr. Huelskamp. It matters not to me if VA influenced this report. 

I take you at your word to suggest it did not substantively influence your statements. The IG Office at Bay Pines is in my district. 

So believe it or not I hear constituent concerns, complaints, and 

compliments about the IG in a way maybe other members do not. 

What I know is words matter. And so your statement that you cannot conclusively assert that the lack of timely care caused the 

death of veterans certainly is an accurate statement based on your 

analytical model. Can you also conclusively assert that wait lists 

did not contribute to the deaths of veterans? 

Dr. DAIGH. No. I, no. 

Mr. JOLLY. And did you say that in the report? Was that reflected in the report? 

Dr. DAIGH. I, I—— 

Mr. JOLLY. That you could not conclusively assert that wait lists 

had no contribution? 

Dr. DAIGH. No. 


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Mr. JOLLY. And why not? 

Dr. DAIGH. What I had hoped was that—— 

Mr. JOLLY. Hold on a minute. Let me go through this line of 

questioning. Because this is very important. 

Dr. DAIGH. This is, this is why not. We put in here the stories 

of all these people who we thought did not get proper care. And it 

was my assumption that by reading these stories you could understand where the rate, where the waits were and you could arrive 

at your own conclusions—— 

Mr. JOLLY. I understand. You made a very powerful statement 

based on an analytical model that has not been reflected on the 

other side of the equation. And the reason it matters is because for 

six months we have been investigating the deaths of veterans. And 

IG words matter. Frankly more than any political appointee. We 

challenge political appointee words all the time and a lot of times 

they are wrong and misleading. We expect the IG not to be. And 

so the statement you made that you cannot conclusively assert that 

it led to deaths is a substantive statement that addresses work we 

have done six months, and yet you did not assert that it may, that 

you cannot conclusively assert it did not. Right? So you can say it 

did not cause. Would you be willing to say that wait lists contributed to the deaths? 

Dr. DAIGH. The first 28 cases—— 

Mr. JOLLY. Would you be willing to say that wait lists contributed to the deaths? 

Dr. DAIGH. Yes. 

Mr. JOLLY. You would. 

Dr. DAIGH. In fact the title of the first 28 cases are cases where 

we thought patients were harmed because of the wait lists. 

Mr. JOLLY. Did it contribute? Did it—— 

Dr. DAIGH. There were six deaths out of that group. 

Mr. JOLLY. Did it contribute to the death? 

Dr. DAIGH. Yes. 

Mr. JOLLY. Wait lists contributed—— 

Dr. DAIGH. Yes. 

Mr. JOLLY [continuing]. To the deaths of veterans? 

Dr. DAIGH. No problem with that. The issue is caused, or—— 

Mr. JOLLY. Of course. 

Dr. DAIGH [continuing]. A direct relationship. How tight a relationship do you want? That is where, that is where the difficulty 

is here. 

Mr. JOLLY. I understand. But that puts you down a road that 

gets very interesting. Because as you said earlier you have, you 

have no ability to determine the cause of death. When then asks 

at the very beginning what is the point of the study? If you are not 

able to make a determination then the analysis that suggests you 

cannot draw a causation creates a great question that actually undermines most of what is in the report. Whereas if you say it contributed to, that should be the headline. We have talked a lot about 

headlines. And if you are an American person sitting at the kitchen 

table today and in April learned that there were 40 deaths, we can 

play with semantics all we want, Mr. Griffin. But right here at the 

table it was acknowledged by the IG’s Office that the wait lists conVerDate Aug 31 2005 11:01 Dec 01, 2015 Jkt 000000 PO 00000 Frm 00047 Fmt 6633 Sfmt 6633 Y:\96-130.TXT PAT

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tributed to the deaths of veterans. That is an accurate statement, 

right doctor? 

Dr. DAIGH. That is an accurate statement. 

Mr. JOLLY. Mr. Griffin, would you agree with that as well? That 

the wait lists contributed to the cause of death in veterans? 

Mr. GRIFFIN. I think in our report a careful reading would show 

that in some of those cases we say that they might have lived 

longer, they could have had a better quality of life at the end, and 

so on. 

Mr. JOLLY. Sir, I—— 

Mr. GRIFFIN. Is that true or not? 

Mr. JOLLY. Would you agree that wait lists contributed to the 

deaths of veterans? It is a yes or no. 

Mr. GRIFFIN. I would agree—— 

Mr. JOLLY. Please, yes or no. 

Mr. GRIFFIN. No, I—— 

Mr. JOLLY. Words mean something and you need to be precise 

with your answers. 

Mr. GRIFFIN. Yes, they do. 

Mr. JOLLY. Yes, you do? 

Mr. GRIFFIN. No. I would say that it may have contributed to 

their death. But we cannot say conclusively it caused their death. 

Mr. JOLLY. Of course. And you cannot say conclusively it did not. 

And so Dr. Daigh said we will use the word contribute. And he said 

it did contribute. You are not willing to say it contributed, is that 

right? 

Mr. GRIFFIN. No, that is not right. 

Mr. JOLLY. Well then you are willing to say—— 

Mr. GRIFFIN. I think what the report says is it may have contributed and there is no denying it may have contributed. 

Mr. JOLLY. So you are undermining the confidence we have in 

the IG by not being able to answer that very simple question. 

Mr. GRIFFIN. No, I answered—— 

Mr. JOLLY. Did it contribute to the deaths of veterans, yes or no? 

Mr. GRIFFIN. It could have. 

Mr. JOLLY. Okay, that is your answer. 

Mr. GRIFFIN. That is right. 

Mr. JOLLY. And I know Dr. Daigh disagrees with you. In law—— 

Mr. GRIFFIN. I do not think he disagreed with you. 

Mr. JOLLY. He answered it very differently. 

Dr. DAIGH. For the—— 

Mr. JOLLY. He did. And listen, I am going to conclude with this. 

Dr. DAIGH. Yes, sir. 

Mr. JOLLY. In law there is the notion of res ipsa loquitur, the 

facts speak for themselves, in cases of negligence and death. We 

know people were on the waiting lists. We know they died as a result of conditions for which they were awaiting treatment. And we 

know that your office has made criminal referrals related to that. 

And so I appreciate Dr. Daigh you at least willing to say wait lists 

contributed to the deaths of veterans. Because that is not the story 

that has come out as a result of the IG report. Thank you, Mr. 

Chairman. I yield back. 

The CHAIRMAN. Thank you very much. Mr. Schweikert. 


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Mr. SCHWEIKERT. Thank you, Mr. Chairman. And Mr. Chairman 

and to the Ranking Member, I appreciate you letting me sit in on 

this committee. I have the opportunity and the joy of actually representing a large area of Phoenix. And have had a number of the 

folks that shall we say have been affected by the VA in my office. 

We have sat down with them over coffee. And this is one of those 

difficult subjects. Because for those of us from sort of the accounting math world we want to say is it binary, is it yes and no, as 

the discussion we were just having. And the reality whenever we 

deal with people, people, human beings, our health is not necessary 

binary, yes or no. 

But some of this is really tough. I mean, a few months ago the 

sit down coffee with the widow, and you think of yourself as a really tough guy, that you have dealt with lots of this, and you are 

driving home, and you cannot get that lump out of your throat, and 

you are trying not to cry. And you have not cried since you were 

a child. So hopefully everyone here understand the emotional impact. Now we sort of work through the mechanics of what does this 

report really say, and what are the fixes? How do we never, ever, 

ever have these types of hearings, and these sorts of experiences, 

and I never sit down with a widow that breaks my heart every 

again? 

And first, for Mr. Griffin, I just, maybe it is the term of art. But 

very quickly, when going through the report the words significant 

is rolled through a number of times. Was it a significant causation? 

Was it a significant factor in the death? You do see within the 

questions of both the right and the left here how many times we 

say significant and it can have a wide interpretation. Is that how 

you meant to write it? Was that the goal, saying look, there is a 

wide path here of causation? 

Mr. GRIFFIN. Our clinical staff did those reviews. I would ask Dr. 

Daigh to answer your question. 

Mr. SCHWEIKERT. And Dr. Daigh, I am trying to be really fair 

minded here and not, you know, let my emotion drive my questions. Am I being fair minded? 

Dr. DAIGH. I think so. I think first of all it takes a great deal 

of effort for the people that work for me to write these stories with 

no emotion. And so what people read when they read these stories 

is an emotionless layout of fact. You do not see the outrage we feel. 

So if we start from a universe of patients who all were delayed in 

getting their care, it is reasonable to assume that they are all 

harmed just by the fact they did get delays in care. 

Mr. SCHWEIKERT. Okay. And Dr. Daigh, you sort of nudged up 

to something I just want to touch on just as an observation. I was 

actually a little disturbed by, and Mr. Griffin I will write you a 

note of this and hopefully we will just do it in writing, the fact you 

knew there were 800 articles. IG, facts, facts, facts. Promise me 

you are not tracking the press articles and saying, oh, we are up, 

we are down, oh, they did not see it as nicely. That is our world. 

That is not, never, ever, ever should be the auditors’ world. And 

it bothered me that you knew there had been 800-some articles. 

Two quick things. Tell me what you learned from the hotline. 

Did the hotline ever, did you ever map out a pattern or a division 


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or a specialty that there was something wrong? Something came up 

repeatedly? And it could be doctor or Mr. Griffin. Whoever—— 

Mr. GRIFFIN. Let me just respond to the 800 articles very briefly. 

It took about 60 seconds to determine that—— 

Mr. SCHWEIKERT. The sheer fact you had any curiosity at all—— 

Mr. GRIFFIN. It was not curiosity. We were being challenged for 

the fact that we alluded to the original allegation of 40 deaths, and 

that is what got reported over and over and over again. 

Mr. SCHWEIKERT. And once again you work for ultimately us, the 

taxpayers, the agency, not the media. The media should never influence the professionalism of what you do. So doctor, sorry, you 

were moving up to the microphone. 

Dr. DAIGH. Would you repeat the question, sir? 

Mr. SCHWEIKERT. It just, tell me, any patterns from the hotline? 

Dr. DAIGH. I would say that the pattern that we saw in the cases 

was not that, was essentially people who were denied their care because they were on wait lists. And the hotline cases were usually 

a little more clear in the delay or the impact of, for us, the timing 

of not getting care and then being able to see impact was clearer 

in the hotline cases than it was on the long list of cases we looked 

through who people who were delayed tried to determine whether 

there was an impact. 

Mr. SCHWEIKERT. Mr. Chairman, I appreciate—— 

Dr. DAIGH. The urology group, the urology clinic was one area 

that became clear to us—— 

Mr. SCHWEIKERT. Where you saw a pattern? 

Dr. DAIGH [continuing]. We saw a pattern. The other pattern was 

that people had a very difficult time getting into primary care. So 

if you were already impaneled in primary care at Phoenix, which 

was an inadequate panel size, then you had at least one access to 

get consults or move your way through the system. If you were not 

in the primary care panel, then you had a very difficult time navigating the system. 

Mr. SCHWEIKERT. Okay. 

Dr. DAIGH. I would say those would be two examples that—— 

Mr. SCHWEIKERT. And forgive me. Mr. Chairman, thank you for 

your patience. I will, for all of you I actually have some written 

questions that I will shoot your way. Thank you, Mr. Chairman. 

The CHAIRMAN. Dr. Benishek. 

Dr. BENISHEK. Thank you, Mr. Chairman. I guess the question 

that I, comes up, and the chairman brought it up, and the thing 

that concerns me the most about this is that this is really bad stuff 

that happened to our veterans. And the care that was outlined in 

the, I read through those cases that we have here. I do not know, 

like 40 cases. These case summaries. And I know they are incomplete, but boy, I, you know, just to see how our veterans have suffered and subject to delays in care that was most evident from 

these short excerpts here. That, you know, your argument that the 

delay did not, the causation, with the death. I mean, I understand 

that, that argument. But the delays that occurred here, boy, they 

certainly would be unacceptable in my practice. Where if you referred somebody to a short term follow up and then due to a screw 

up of scheduling, you know, a two-day follow up did not occur for 


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months. And you know, this is just unacceptable. And I think that, 

I think you all agree on that. Is that right? Doctor—— 

Dr. DAIGH. Sir, the title above the first 28 cases is clinically significant delays. So I completely agree with you. The only point that 

I wish—— 

Dr. BENISHEK. Well I—— 

Dr. DAIGH [continuing]. Wish we had worded better was this idea 

that delay caused death. That was—— 

Dr. BENISHEK. Well the only thing that upsets me about this is 

that somehow the media has taken that there is no problem, or 

there is not that big of a problem. This is a big problem. This is 

a huge problem. This is a problem that has to be addressed. And 

you know, hopefully with the changes that are happening in the 

VA now, we have a new Secretary, and reform, and hopefully a 

new culture within the VA, that that will happen. I think we all 

just want to be sure that we have an Inspector General that we 

can rely on to be inspecting independently of VA coercion or enforcement or discussion. And I think that is really the gist of where 

I, what I get from this hearing. Mr. Griffin, do you want to comment on what I just said? 

Mr. GRIFFIN. I do. I do. We do not have an Inspector General 

right now in our office. It is a presidential appointment. It has been 

vacant since January 1st. Everybody who worked on this report is 

a career federal employee. We do not pick sides. I think the rigor 

of our interim report issued on May 28th led to very large change 

in the department, including the most senior leadership. I think 

the 24 recommendations in this report address the issues that we 

found. And the notion that, that somehow we would have issued either of these reports if we were complicit with the department just 

does not wash with me. 

Dr. BENISHEK. I mean, let me just go over in a different direction, and I missed some of the hearing because I had to do another 

thing. But has anybody been prosecuted? I mean, has people—— 

Mr. GRIFFIN. There are—— 

Dr. BENISHEK. [continuing]. Referred to the Department of Justice for prosecution—— 

Mr. GRIFFIN. There are ongoing investigations. 

Dr. BENISHEK. So nothing has happened yet? 

Mr. GRIFFIN. No one has been prosecuted yet. 

Dr. BENISHEK. I see. Have you heard from the Department of 

Justice? Have you, are they—— 

Mr. GRIFFIN. We have heard from the Department of Justice. 

The Assistant Attorney General for the Criminal Division sent 

guidance out to all the U.S. Attorney’s Offices laying out for them 

his view of what the potential charges could be based on his knowledge of the manipulation of records, potential destruction of 

records, and so on. That was sent to every U.S. Attorney’s Office 

in the country. We are working in partnership with the FBI on the 

ongoing Phoenix investigation and in a number of the other locations. Believe me, we have no desire to see people escape who deserve criminal charges. As I mentioned earlier, we arrested 94 VA 

employees last year on charges unrelated to waiting times. So we 

are not bashful about arresting people when they break the law. 


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Dr. BENISHEK. So you do not know the timeline when this is 

going to be done? 

Mr. GRIFFIN. I think, I think as we complete the investigations 

it is going to be a rolling process. It is not like there is a date certain when all 93 will be closed. But every week we will make additional progress. And if they are not prosecuted—— 

Dr. BENISHEK. Are you doing more referrals? Did you do any referrals to the Justice Department in the last week? 

Mr. GRIFFIN. I think we had a new case last week in Minnesota. 

Dr. BENISHEK. All right. 

Mr. GRIFFIN. Whenever we open a case that has criminal potential the Attorney General guidelines require us to notify the 

FBI—— 

Dr. BENISHEK. Right. 

Mr. GRIFFIN [continuing]. So that we are not duplicating efforts. 

Dr. BENISHEK. I am sorry. Thank you for your indulgence, Mr. 

Chairman. 

The CHAIRMAN. Thank you very much, members. The Secretary 

has been waiting well over an hour now to come and appear. So 

I appreciate your indulgence for waiting through the vote series. I 

do have, again, I have learned a lot in this hearing today. I honestly had no idea that the OIG would go back and forth with drafts 

to the VA. I was under the impression that it was a single draft 

that went to them to be checked for factual corrections that needed 

to be made. I would ask that you provide the committee copies of 

the drafts that were done. The fact remains that from the very first 

draft there was no inclusion of the statement that has caused me 

concern. Because it did, it took away the entire focus from all of 

the work that your office had done. So much so that it was leaked, 

just that part, prior to. In fact, I think it even caused you to move 

up the release of the final report because it exonerated the department. Well it did not exonerate the department. And I just, you 

know, I do not think anybody here thinks that it did. 

Mr. GRIFFIN. I do not think it did. Mr. Chairman, I am sorry to 

interrupt. But I do not believe it exonerated them, one bit. 

The CHAIRMAN. Well, now and here is the question that I still, 

I need to ask before we close. In your testimony you gave the impression that the committee suggested that the appropriate standard to be used to determine causality of death is to unequivocally 

prove, I think that was a comment that you made, that a delay in 

care caused death. And reading the document that you in fact cited 

as an exhibit in your testimony it states that a committee staff 

member sought specific information in order for this committee to 

prove that delays were related to death. And so what I need for you 

to tell me is do you believe that caused and related mean the exact 

same thing? 

Mr. GRIFFIN. I think the context of this document, which is Attachment B for those who would like to review it. It is Attachment 

B to our statement. It reads, ‘‘In order to unequivocally prove that 

these deaths (all 40) are related to delays in care.’’ Now the document—— 

The CHAIRMAN. Comma—— 

Mr. GRIFFIN [continuing]. Includes 17 names—— 

The CHAIRMAN. Comma—— 


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Mr. GRIFFIN [continuing]. But it says all 40. 

The CHAIRMAN. Comma—— 

Mr. GRIFFIN. That is why we were in pursuit of the 40. 

The CHAIRMAN. You did not finish. You did not finish. There is 

a comma there. It says, ‘‘O&I,’’ which means Oversight and Investigations, ‘‘needs access to VA’s computerized patient record system 

to pull up these veteran files or to request them from VA.’’ 

Mr. GRIFFIN. Right, to unequivocally prove. 

The CHAIRMAN. For the committee. 

Mr. GRIFFIN. Yes. 

The CHAIRMAN. Not you, but the committee. 

Mr. GRIFFIN. Does the, does the committee have the clinicians to 

make that determination? 

The CHAIRMAN. I do not know that that is, you, in your testimony, though, you are saying that we put that burden on you. That 

burden was not placed on you. We said that about ourselves. 

Whether we have the clinicians to do it or not is not relevant. The 

fact is you were saying that we said that. And my question is, is 

caused and related, do they mean the exact same thing? Now you 

are saying they do. 

Mr. GRIFFIN. No. What I am saying is unequivocally prove is an 

extremely high standard and it is not the standard that Dr. Daigh’s 

people were using. That is all I am saying. 

The CHAIRMAN. And we did not ask, and we did not ask for that, 

correct? 

Mr. GRIFFIN. No, no. Your memo that was sent to us on April 9th 

after the hearing said that in order to unequivocally prove that 

these deaths, all 40, remember they were potential deaths, and as 

continued on it was declarative that there were 40, that all 40 are 

related to delays in care. 

The CHAIRMAN. O&I, meaning the committee. 

Mr. GRIFFIN. Right. 

The CHAIRMAN. So, again, the unequivocal was not placed as a 

burden, was not placed on you, it was placed on us. We placed it 

on ourselves. 

Mr. GRIFFIN. Yes, you did. 

The CHAIRMAN. Okay. But it was not placed on you. And 

that—— 

Mr. GRIFFIN. Well this—— 

The CHAIRMAN [continuing]. You alluded to that—— 

Mr. GRIFFIN. I did allude to that. Because this was sent down 

here on an email by your staff saying here are the, here are most 

of the documents, meaning documents that surfaced in the April 

9th hearing, and this document comes down with 17 names. And 

it says we are going to unequivocally prove that all 40, well there 

is only 17 names. I mean, it is, it is—— 

The CHAIRMAN. That is, again sir, that is, I am sorry, but that 

is, you are trying to say we set a higher standard for you to prove 

when we did not set that standard. Is that correct? 

Mr. GRIFFIN. I will let the document speak for itself. 

The CHAIRMAN. But you—— 

Mr. GRIFFIN [continuing]. That is why we put it on the 

record—— 


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The CHAIRMAN. But you made the testimony. You are testifying 

to the fact that we set that bar for you to meet. We, that, this 

clearly says in order to unequivocally prove that these deaths, all 

40, are related to delays in care, O&I needs access, O&I meaning 

the committee, not you. But you took from this that we were trying 

to set a standard that you could not meet. In fact, I think Dr. 

Daigh said something about a standard that could not be met. And 

I, I am just, again we are having communication issues. And I understand that. But we—— 

Mr. GRIFFIN. I would be pleased, I would be pleased to answer 

for the record the other suggestions that came from the committee 

as to how this should be done, including one that was sent to us 

as the ink was drying on the final report. Which had we modified 

would have been a violation of general government accounting 

standards. 

The CHAIRMAN. Well again, we, I am talking specifically about 

something you included and you are saying that this was a directive to you to meet a standard you could not meet, unequivocal. Is 

that true or not? 

Mr. GRIFFIN. The document staff says so O&I staff can look at 

this. That is fine. Why was it sent to us if O&I staff wanted to look 

at these things? They could have asked the department for these 

medical records. Clearly we were being asked, as a matter of fact 

in some circles it says we were ordered to expand our investigation 

in order to look into the issues—— 

The CHAIRMAN. Not, not from this, not from this committee. I 

mean, if you have proof let me, tell me what it is. 

Mr. GRIFFIN. Well, I am telling you what has been reported, that 

we were ordered—— 

The CHAIRMAN. Oh, you are reading, you are googling again? 

Mr. GRIFFIN. No. You can make all the fun you want of that. 

That is a reality that the basis for this thing getting eggs was the 

allegation of 40 specific deaths and we just could not find the trigger for those 40. Instead of looked at 3,409. So I do not understand—— 

The CHAIRMAN. And you found 293 deaths. 

Mr. GRIFFIN. Right, there were 293 dead out of that number. 

The CHAIRMAN. And you now have a statement that says that 

you could not, and then I am through, you cannot conclusively or 

otherwise, whether these deaths were related to delays in care. 

That, that is, and that was inserted after the first draft, correct? 

Can you—— 

Mr. GRIFFIN. That is correct. And we have been down this road. 

There were multiple drafts—— 

The CHAIRMAN. Yes. I have learned, and I told you I learned 

that. 

Mr. GRIFFIN. On July 22nd one of our staff in a senior, tracking 

changes on the report, which you will see, indicated if we cannot 

conclude this we should say so. Eventually that is what we got to. 

The CHAIRMAN. And so you can also—— 

Mr. GRIFFIN. Now—— 

The CHAIRMAN [continuing]. Can you conclusively say that no 

deaths occurred because of delays in care? 


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Mr. GRIFFIN. No. We do not know. It is the causality thing, which 

is bore out in the testimony for the record from the witness who 

is not here today who is the President of the National Association 

of Medical Examiners. I do not know who requested this, but he 

says we got it right. So people are entitled to their own opinion. 

Whether we—— 

The CHAIRMAN. Thank you. I appreciate very much your testimony. 

Mr. GRIFFIN. Thank you, Mr. Chairman. 

The CHAIRMAN. You have a job to do and we appreciate the job 

that you do. We have a job to do as well. I appreciate the committee members for their questions and you are now excused. 

And we will take just a second. The Secretary will be coming in 

so we will have our second of three panels. 

We are going to hear from the Honorable Robert McDonald, Secretary for the Department of Veterans Affairs. Mr. Secretary, first 

of all we apologize for keeping you waiting for so long. He is accompanied by Dr. Carolyn Clancy, Interim Under Secretary for Health 

at the Veterans Health Administration. Your entire statement will 

be made a part of the hearing record. We would like to say welcome to you, to our committee room. We look forward to working 

with you in the future. And you are now recognized for your opening statement. 

STATEMENT OF HON. ROBERT A. MCDONALD 

Secretary MCDONALD. Thank you, Chairman Miller. I look forward to working with you and the rest of the committee to improve 

the Department of Veterans Affairs to provide the kind of care that 

our veterans deserve. 

Chairman Miller, Ranking Member Michaud, and members of 

the Committee on Veterans’ Affairs, thanks for this opportunity to 

discuss with you VA’s response to the recent VA IG report on Phoenix. 

First, let me offer my personal apologies to all veterans who experienced unacceptable delays in receiving care. It is clear that we 

failed in that respect regardless of the fact that the report on Phoenix could not conclusively tie patient deaths to delays. I am committed to fixing this problem and providing timely, high quality 

care that veterans have earned and that they deserve. That is how 

we will regain veterans’ trust, and the trust of the American people. 

The final IG report on Phoenix has now been issued and we have 

concurred with all 24 of the report’s recommendations. Three of the 

recommendations have already been remediated and we are well 

underway to remediating many of the remaining 21 because we 

began work when the IG’s interim report was issued in May. 

We have proposed the removal of three senior leaders in Phoenix 

and we eagerly await the results of the Department of Justice investigations. Nationally there are over 100 ongoing investigations 

of VA facilities by the IG, by the Department of Justice, by the Office of Special Counsel, and others. In each case we look forward 

to receiving the results so that we can take the appropriate disciplinary actions when the investigations are complete, when we 

have the evidence, and when we know the facts. 


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We are grateful for the committee’s leadership in establishing the 

recently passed Veterans Access Choice and Accountability Act of 

2014. This law streamlines the removal of VA senior executives 

and the appeals process if misconduct is found. However, it does 

not eliminate the appeal process, the guarantee that VA’s decisions 

will be upheld on appeal, or allow VA to fire senior executives without evidence or cause. And it applies only to senior executives, who 

are less than half of one percent of VA’s employees. 

Now we have taken many other actions in Phoenix and the surrounding areas to improve veterans’ access to care including, first, 

putting in place a strong acting leadership team. These are good 

people with proven track records of serving veterans and solving 

problems. Increasing Phoenix staffing by 162 personnel and implementing aggressive recruitment and hiring processes to speed recruiting. Reaching out to all veterans identified as being on unofficial lists or the facility electronic wait list, and completing over 

146,000 appointments in three months. As of September 5th there 

were only ten veterans on the electronic wait list at Phoenix. 

Where VA capacity did not exist to provide timely appointments we 

referred patients to non-VA care. From May through August Phoenix made almost 15,000 referrals for non-VA care. We have secured 

contracts to utilize primary care physicians from within the community in the future. 

Since my confirmation as Secretary 51 days ago I have traveled 

to VA facilities across the country, including Phoenix, speaking to 

veterans and VA employees as well as visiting and speaking with 

members of Congress, veterans service organization, and other 

stakeholders. During those visits I found VA employees to be overwhelmingly dedicated to serving veterans and driven by our strong 

VA institutional values of integrity, commitment, advocacy, respect, 

and excellence held in this acronym I CARE. 

We will continue to work with the IG and other stakeholders to 

ensure accountability. As I said, there are over 100 ongoing investigations at VA facilities by our IG, by the Department of Justice, 

by the Office of Special Counsel, and others. In each case we await 

the results and will take the appropriate disciplinary actions when 

all the facts and evidence are known. But we will not wait, and I 

want to emphasize that, we will not wait to provide veterans the 

care that they have already earned. 

Going forward we will focus on sustainable accountability. More 

than just adverse personnel actions, this means creating a culture 

where all employees understand how their work, their daily work, 

supports our mission, our values, our strategies. It requires supervisors to provide daily feedback to every subordinate, to recognize 

what is going well and identify where improvements are necessary. 

We are moving forward on several fronts and I have discussed 

these major initiatives with the chairman and ranking members of 

the Veterans’ Affairs Committee and with many of the members 

here. 

Last week we announced the beginning of our Road to Veterans 

Day, focusing on the next 60 days. We are focusing on three strategies, rebuilding trust with veterans and the American people; on 

improving service delivery; and importantly on setting the course 

for long term excellence and reform. 


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This week we released our Blueprint for Excellence. Dr. Carolyn 

Clancy, on my left, and Dr. Jonathan Perlin, a former Under Secretary for Health and now the Chief Medical Officer at HCA, one 

of the largest medical providers in the country, helped us lay out 

this blueprint. Four broad themes, ten essential strategies to help 

us simultaneously improve the performance of VHA Healthcare 

now; develop a positive culture; transition from sick care to 

healthcare in the broadest sense; and develop efficient, transparent, accountable, agile business and management processes. 

And to increase timely access to care we are recruiting to hire 

more clinicians. As part of that effort I have proposed increases to 

the minimum and maximum rates of annual pay for eligible VA 

physicians and dentists. With more competitive salaries we will be 

better positioned to attract and hire more healthcare providers to 

treat veterans and will be better positioned to retain those who are 

performing at a high level. 

We will judge the success of all our efforts against a single metric, and that is veterans’ outcomes. We do not want VA to meet a 

standard. We want VA recognized as the standard in providing 

healthcare and benefits. I know we can fix the problems we face 

and I know we can utilize this opportunity to transform VA to better serve veterans. 

Mr. Chairman, members of the committee, thanks for your unwavering support for veterans. I look forward to working with you 

in implementing the law and in making things better for all of 

America’s veterans. Dr. Clancy and I are prepared to take your 

questions. 

[THE PREPARED STATEMENT OF HON. ROBERT MCDONALD APPEARS

IN THE APPENDIX] 

The CHAIRMAN. Thank you, Mr. Secretary, very much for your 

testimony. I have a number of questions in here that are I guess 

designed to rip and punch and do all kinds of things. And I am not 

going to do that. I, this committee is committed to being a full and 

complete partner with you as you work towards repairing the damage that has been done to VA over a number of years. Not just recently but over a number of years. And I think what we want to 

know is, and you have only been there 50 days, do you have the 

tools that you need or are you finding that you need more? And we 

talked about this at breakfast last week. That we need to help you 

with legislatively, so that you can make the changes that are necessary to deliver the benefits to the veterans that have earned 

them. 

Secretary MCDONALD. Mr. Chairman, thank you. We have gone 

through and looked at the legislation that governs our department. 

And we have put together some proposals which are currently with 

the Office of Management and Budget. And we would enjoy the opportunity to be able to share those with you within the next few 

weeks as we get them back from the Office of Management and 

Budget. 

We have a lot of tools at our disposal, and as I said I thank you 

for the act that you all passed. It was a great show of bipartisanship for our veterans. But I think there are going to be things that 

we could use help with. And longer term I know that we will conVerDate Aug 31 2005 11:01 Dec 01, 2015 Jkt 000000 PO 00000 Frm 00057 Fmt 6633 Sfmt 6633 Y:\96-130.TXT PAT

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tinue the conversation so that we can work together to identify 

those legislative needs. 

The CHAIRMAN. I think you are probably going to hear from both 

sides that it appears that nobody has been fired yet. I know that 

the wheels have begun. But, you know, at some point, we are at 

110 days and, you know, is it that hard in the federal system or 

at VA to fire somebody who has been caught red-handed doing 

something? 

Secretary MCDONALD. Well first of all coming from the private sector, having run a $84 billion global company, it is a 

misperception to think that even in the private sector you walk in 

one day and you fire someone. It is frankly a failure of what I call 

sustainable accountability. If you are doing a good job managing an 

individual you are giving them daily feedback. And that daily feedback should result in a relationship that when something goes 

awry the action can be taken quickly but with the due process allowed. 

In our particular case around 65 percent of our employees are 

union members and our ability to separate them from their jobs depends upon the specific union contracts that we have in our facilities. As I said, the revision you all made in the new act does shorten the appeal time for our senior executive service employees. And 

we welcome that. But there still is a due process. 

As you know, in Phoenix we have got two senior executive service people who we have proposed action against. We give you a report every week. The report we gave you I think yesterday has 19 

separate disciplinary actions on it. And we are going to work with 

you to continue to track it and keep you up to date as we learn 

new information. We need to get these investigations done and I 

was pleased to hear that the Inspector General thinks we can get 

them done relatively quickly. 

The CHAIRMAN. Mr. Michaud. 

Mr. MICHAUD. Thank you very much, Mr. Chairman. And I want 

to thank you, Mr. Secretary and Dr. Clancy, for being here today. 

And I want to say from the outset, Mr. Secretary, I am very 

pleased with what I have seen so far with your leadership style 

and the fact that not only have you taken the time to visit with 

employees at the VA, which has not been done as my understanding in the last five years, but your willingness to reach out 

not only to members of Congress, and particularly this committee, 

but also the veterans service organizations to get their input and 

insight into how we can provide better services for our veterans. So 

I really do appreciate that. 

And as I mentioned when we met before you were confirmed a 

Secretary that, yes the VA is going through some turbulent times 

right now. But it is also a time for opportunity to really change the 

cultural structure within the department and its employees, but 

also a time to really think big on a national strategy and where we 

should be going as far as the Department of Veterans Administration. So I want to thank you for your willingness to step up to the 

plate. 

Some of my questions, you mentioned about the 24 recommendations under the OIG report, how long do you think it will take you 

to complete all of those recommendations? 


VACREP180 with DISTILLER
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Secretary MCDONALD. We have actually put that in our report 

and I think it is by the end of about 2016, 2015. But of course it 

is over time and it depends upon how systemic and how big the 

changes. We are meeting every week and trying to get those remediations done. And I separately have asked the IG for all past IG 

reports that have not been remediated. I would like to go back and 

look at the history and understand what we need to do on the 

things that have not been remediated. Because my understanding 

from the IG is there is quite a few things. Believe me, having run 

a public company, having been on two audit committees on two different boards of directors, I like what the IG does. I need the IG’s 

help. We all need the IG’s help. And the work that they do is critically important to us in improving the organization. 

In fact as I have gone to these various sites, I have now been to 

nine different cities, 21 different operations of the VA over my first 

50 days. I tell people that I want every employee to be a whistleblower. I want every employee helping us change the IG. So I welcome the criticism that anyone has. I even perhaps made the mistake of giving out my cell phone number publicly. It has been published online. It is in the Washington Post. And I have answered 

150 phone calls so far. 

Mr. MICHAUD. Thank you. Speaking about the whistleblower, I 

know that is still a concern talking to some VA employees about 

whether or not they will be protected when they come forward. 

When will the VA be certified by the Office of Special Counsel, Section 2302(c), on the whistleblower protection? 

Secretary MCDONALD. Well I and Deputy Secretary Gibson, the 

interim, or acting, have demanded from the very beginning that 

whistleblowers be protected. I will have to get back to you with a 

specific date on that. 

But one of the things I have tried to do, because this is about 

changing culture and I know many of you asked about changing 

culture, is as a leader your behavior is looked at as a demonstration of a new culture. When I go to sites, those 21 different sites 

I talked about, I asked to meet with the whistleblowers. I asked 

for the whistleblowers to be in the town hall meetings. I asked for 

the union leadership to be in these meetings. We cannot do this 

alone. We have to get every employee in the tent and working together so our veterans benefit. 

Mr. MICHAUD. A lot of the focus has been on VHA because of the 

Phoenix, Arizona. Do you have any plans to look at VBA and the 

National Cemetery Administration for similar leadership shortcomings and integrity type of issues? 

Secretary MCDONALD. Yes, sir. In fact as you and I had talked, 

part of our problem in VA is we are a siloed organization. We have 

been brought together over the years without really any idea to integrating the organization. As we talked, we have nine different geographic maps of organization structure for VA. That means no decision, nobody represents the Secretary of Veterans Affairs at any 

lower level than the Secretary or the Office of the Secretary. We 

simply have to get that fixed. It is a long term effort. It is part of 

our Road to Veterans Day. It is in the third column, we say set the 

course for longer term excellence. But I want to get to a point 

where our organization is so simple for the veteran to understand 


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that they can plug into our organization any way they want, we 

will be there. If it is a smart phone for an Iraq veteran? We will 

be there. If it is paperwork for a World War II veteran? We will 

be there. And I want them to think of the VA as their VA. I want 

every veteran in this country to say this is my VA and I am proud 

of it. 

Mr. MICHAUD. Well, once again I see my time is expired. 

So I want to thank you once again, Mr. Secretary, for your leadership, your willingness to do this. I am very optimistic and very 

hopeful that with your leadership style that this change will continue in a positive direction, so I want to wish you the best of luck. 

Secretary MCDONALD. Thank you, Your Honor. 

Mr. MICHAUD. And thank you. 

Secretary MCDONALD. It will take the partnership of all of us. 

Mr. MICHAUD. Great, thank you. 

The CHAIRMAN. Mr. Lamborn. 

Mr. LAMBORN. Thank you, Mr. Chairman, and thank you, Mr. 

Secretary for being here today; we really appreciate hearing from 

you. 

Secretary MCDONALD. Yes, sir. 

Mr. LAMBORN. There are a lot of things we could talk about, but 

the need at the moment is to try to get to the bottom of what the 

details are surrounding this Inspector General’s report that has 

just come out. 

You may have heard the testimony of the Inspector General earlier today that while the waiting list in Phoenix contributed to 

some or all of the 40 deaths of veterans in Phoenix, it may be— 

it did not cause their deaths, and they made a distinction between 

contributing to their deaths and causing their deaths. 

In light of that, was it misleading for some of the press headlines 

after a leak was made to have headlines like, ‘‘No deaths related 

to long waits,’’ which was one, or another that said, ‘‘No links found 

between deaths and veterans care delays’’? 

Secretary MCDONALD. Sir, I am reacting as if every shortage of 

care, every shortage of access to care is incredibly important. Someone said it earlier, you have to think about this one veteran at a 

time. I am a veteran—— 

Mr. LAMBORN. Yes. 

Secretary MCDONALD [continuing]. I do have injuries from my 

time in the service. I think about this—my father-in-law was a 

prisoner of war, he had post-traumatic stress, he was shot down in 

World War II. Until we got him to the VA we didn’t know what 

the problem was. My uncle suffers from Agent Orange, 101st Airborne Division. So this is very personal to me. 

Mr. LAMBORN. So—— 

Secretary MCDONALD. And so we are acting as if every shortage 

is absolutely important, and we are going to fix it, with your help. 

Mr. LAMBORN. Okay. So are those headlines accurate? 

Secretary MCDONALD. To me that—I am telling you I am going 

to act as if every veteran deserves the care they need and I am 

going to provide it to them, and that is what I am acting. 

Mr. LAMBORN. Well, what do you think about the fact that someone in the—and the Inspector General said it wasn’t someone in 

their office, leaked to the press an important sentence out of the 


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report before it was released to the public? Do you have any concern about that? 

Secretary MCDONALD. I don’t know anything about that. 

Mr. LAMBORN. Is it any violation of VA ethics or rules or regulations or law to release something before public release? 

Secretary MCDONALD. I don’t know. 

Mr. LAMBORN. Are you going to look into this? 

Secretary MCDONALD. Well, we—certainly we have had lots of 

leaks all over the place. I read about Dr. Foote’s testimony in the 

newspaper this morning. 

Mr. LAMBORN. Okay. Let me change here—— 

Secretary MCDONALD. The important thing, sir, is to create a culture. 

Mr. LAMBORN. Yeah. 

Secretary MCDONALD. We have got to create a culture that is 

open and transparent and that works on veterans’ issues, that 

looks at every single issue from the veterans’ lens, okay? 

Mr. LAMBORN. And I agree with that. 

Secretary MCDONALD. And the three hours I spend waiting to 

testify is time I am not spending working on veterans’ issues in the 

field where the veterans are being cared for. 

Mr. LAMBORN. Okay, let me pursue something you were talking 

to the chairman about. I hear from veterans all the time that they 

are amazed that no one in Phoenix has been fired for the unacceptable waiting lists in Phoenix. Apparently—— 

Secretary MCDONALD. Sir, I said that we have proposed disciplinary action against two of the SES employees in Phoenix. 

Mr. LAMBORN. Are those the two that are on paid leave? 

Secretary MCDONALD. That—that is—that is currently under 

way. That is the rule of law. If you would like to change the 

law—— 

Mr. LAMBORN. We did change the law. 

Secretary MCDONALD. Sir, you changed the law so it affects the 

appeal only. 

Mr. LAMBORN. Yeah. So the two that are on paid leave, is that 

the extent of what we are going to look at as far as any kind of 

consequences? 

Secretary MCDONALD. I think you heard Mr. Griffin say that the 

FBI and other investigative sources are in Phoenix right now, and 

you also have received a report from me every week that tells you 

the people who we are disciplining. 

Mr. LAMBORN. Okay. 

Secretary MCDONALD. The report we gave you yesterday has 19 

people on it, we will track that report weekly, we will update it 

weekly, and we will make sure that we discuss with you whatever 

you would like to discuss about that report. 

Mr. LAMBORN. Now, are those the people that the Department of 

Justice declined to do criminal prosecutions of? 

Secretary MCDONALD. I am not familiar with those people, that 

is with Mr. Griffin. You would have to handle that—— 

Mr. LAMBORN. Okay. 

Secretary MCDONALD. These are the people that we administratively feel should be called out and brought to task for what they 


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did, which is an important part of changing the culture, as the IG 

said. 

Mr. LAMBORN. I—that is—— 

Secretary MCDONALD. We have to hold people accountable or you 

are not going to change the culture. 

Mr. LAMBORN. Mr. McDonald, that is why I want you to take 

some action, because that is part of the culture. 

Secretary MCDONALD. Sir, I am taking all the action the law allows me to take. 

Mr. LAMBORN. Well, I will—— 

Secretary MCDONALD. With due process. 

Mr. LAMBORN. We are here to help you and let us get it done. 

Secretary MCDONALD. I know you are, and we have talked with 

the chairman about potentially working together on other legislative remedies. 

Mr. LAMBORN. Okay. 

Secretary MCDONALD. And we look forward to working with you 

on that. 

Mr. LAMBORN. Okay. Thank you. Let us get it done. 

Secretary MCDONALD. Yes, sir. Thank you. 

Mr. LAMBORN. I yield back, Mr. Chairman. 

The CHAIRMAN. Ms. Brown. 

Ms. BROWN. Thank you, Mr. Chairman. 

First of all welcome, welcome to the veterans’ committee, and I 

hope in the future that we will have the common courtesy not to 

have the secretary waiting, even if we need to stand down one committee in order to bring you in, because I want you out there doing 

what—you should be for veterans. Thank you for your service. 

Secretary MCDONALD. Thank you. 

Ms. BROWN. As I mentioned when you came to my office, my first 

secretary, Jessie Brown, his motto was putting veterans first, and 

I like that, and yours is Road to Veterans Day, which is my birthday, November the 11th, but what exactly do you mean? 

Secretary MCDONALD. For me the Road to Veterans Day is really 

about using the first 90 days that the chairman and the ranking 

member suggested to make as many changes as we can as quickly 

as we can to improve our service for veterans. 

So as I said, we have three strategies. One is about rebuilding 

trust, and the effort I am doing to get around to talk to people, to 

learn about what is going wrong, all stakeholders, all shareholders, 

veterans themselves, we are compiling a list of the changes that 

need to be made. 

At the same time we are forming teams of employees from without—from within the department. Part of the issue before was the 

organization was closed and wasn’t communicating from bottom to 

top and top to bottom. We need to get employees involved in making these changes because they are the ones closest to serving the 

veterans. So we are in the process of putting that together. 

That will form a strategic plan, we will roll out that strategic 

plan, we will make those changes. We will improve access, we will 

go ahead and get down a number of benefits in the backlog that 

we have, and it is all—it is all designed so that in the end the veteran will know how to plug into VA and think of this as their VA. 

That is really what we want. 


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Ms. BROWN. One of the problems that I guess I keep having with 

the whistleblower is that it always seems like it is negative, but 

I don’t think feedback has to be negative, I think it should be a 

way that employees could come forward and say this is how the 

system can improve. I don’t think every complaint should be 

viewed as us against them. 

Secretary MCDONALD. Well, that is exactly right, and that is the 

culture we have to create. But I can understand that in this moment in time whistleblowers who had been retaliated against are 

skeptical as to whether I mean what I say or whether I can deliver 

what I say. 

Ms. BROWN. Yes. 

Secretary MCDONALD. The only remedy to that is to get out, talk 

to people, demonstrate it through our behavior, put in place a new 

leadership team which will believe in the culture that we believe 

in, an open culture that needs the people at the lowest level of the 

organization making the biggest changes, because that is how we 

improve our work. 

Ms. BROWN. I like the army’s motto, one team, one fight, and I 

think if we are all fighting to improve the situation for the veterans then we will do what we have said we have done for over 

75 years, delivering assistance to the veterans that we can all be 

proud of. 

Thank you very much for your service—— 

Secretary MCDONALD. Yes, ma’am. 

Ms. BROWN [continuing]. And your committment, and I am sure 

that you have a lot of team members that are willing to work with 

you. 

Thank you, and I yield back the balance of my time. 

The CHAIRMAN. Thank you, Ms. Brown. 

I can assure you while the secretary was delayed in coming and 

testifying he was working, because I actually went in the room 

and—— 

Secretary MCDONALD. The chairman is correct. 

The CHAIRMAN [continuing]. Saw him—saw him meeting with individuals. 

Mr. Huelskamp. 

Dr. HUELSKAMP. Thank you, Mr. Chairman. 

I would like to follow up on a couple questions Congressman 

Lamborn had, and thank you for joining us today. 

The OIG report, maybe this a question for Dr. Clancy as well, 

what I didn’t hear in the testimony and in—from the last panel 

was at what level at the VA in the collaborative process, that is the 

language from the OIG, is the report altered and the recommendations and changes? Is it at the secretary level or what level did that 

actually take place? 

Secretary MCDONALD. It was not at my level, and I don’t know. 

Before my time too. 

Dr. CLANCY. I am sorry. We have an office within—that reports 

to the undersecretary, actually reports to the principal deputy undersecretary for health that routinely interfaces with the Inspector 

General, with the Government Accountability Office, and so forth 

getting clarification on recommendations, and frankly, tracks to see 

that we are on track with recommendations that we have agreed 


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with our dates and so forth, and as you heard from the Inspector 

General previously the issue of looking at a draft report and draft 

recommendations and they are asking for factual information to 

make sure that it is accurate is routine. 

Dr. HUELSKAMP. What office is that? Could you provide that for 

the committee? 

Dr. CLANCY. Sure, it is Management Review Services is what it 

is called. 

Dr. HUELSKAMP. Okay. Who is in charge of that office? 

Dr. CLANCY. Dr. Rasmussen. 

Dr. HUELSKAMP. Okay. And I appreciate that, because there apparently was a leak that has created some concerns about that and 

I didn’t know what level that was and that hadn’t come out earlier 

and that was the—part of the concern, you were busy, didn’t hear 

that testimony, but the concern about how many veterans were actually impacted. 

And you might have missed as well, I had a line of questions 

with OIG that perhaps there were 5,600 veterans that escaped review during that process, and I am sure you are as concerned as 

I am about its impact potentially on veterans. 

Two other areas of questions, I think my colleagues also mentioned the issue of the whistleblowers. Just last week we heard 

more harrowing stories from whistleblowers over retaliation, intimidation, retribution, these are the things that have all occurred 

in the last few weeks since you have been on board, and from their 

perspective what we heard in subcommittee last week very little 

has changed. Can you describe again and show me what your commitment is? Because this is on your watch and some of it is carried 

over, but we are still hearing those stories and that is very worrisome. 

Secretary MCDONALD. Well, I have spoken to many whistleblowers in the organization myself. When I go to a location I ask 

to speak to the whistleblowers. I have had many of them call me 

on my cell phone and I have had conversations with them. And as 

I have said and as I have said publicly within the department and 

as I have said in every town hall I have held in the last 50 days, 

in 21 different sites, I welcome whistleblowing, I welcome people 

criticizing the operation, and I welcome employees who want to get 

involved on some of these reengineering teams that we are putting 

together so that they can help reengineer the process that they are 

criticizing. 

So, I don’t think there is any lack of clarity. I may have missed 

a site, I may not have talked to a particular person or it may be 

an activity that arrived before I did, but with the communications 

I have done, which have been two videos that have gone out to 

every employee, many letters, one of which, which you might be interested in, is a discussion of sustainable accountability and this 

whole idea of how do we get daily feedback going and how do we 

get the organization working together. I have met with the union 

leadership four times. 

Dr. HUELSKAMP. Well, thank you for that, and I wanted you to 

restate that. I appreciate the commitment, because there are some 

folks between your level on down that haven’t got the message. 

Secretary MCDONALD. Well, tell them to call me. 


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Dr. HUELSKAMP. You know, check out our committee, subcommittee hearing from last week, that is your job, you have all 

the people to do that, we had a whistleblower. Hopefully you have 

checked on that. That came forward to the subcommittee and now 

this is still going on. 

The third thing, I am glad you welcome criticism, because I want 

to see our rural areas of the country, the VS a doing a pretty poor 

job of meeting the needs of our veterans. 

Secretary MCDONALD. In fact I am concerned about that myself. 

Dr. HUELSKAMP. Exactly. 

Secretary MCDONALD. I have been out to Nevada and have 

worked this—particularly in Nevada, I was in San Diego, we are 

working very hard on tele-health, we also think—— 

Dr. HUELSKAMP. Well, let me give you a better option, and that 

is in the bill, and that is VA choice, giving the veterans a choice. 

Secretary MCDONALD. Well, that is in the bill. 

Dr. HUELSKAMP. I know, but it can be implemented—— 

Secretary MCDONALD. And we have been doing it. 

Dr. HUELSKAMP [continuing]. Fully and it may not be, and currently I understand our current law there are some options that 

there weren’t used. But I am saying in my district I have veterans 

that go to four different VISNs, hundreds, 300, more than 300 

miles—— 

Secretary MCDONALD. Yeah. 

Dr. HUELSKAMP [continuing]. And I have VA employees say, well, 

too bad, get in a car and drive, but we need to make certain they 

have local options. 

Even after this trial period is over, two years, I would hopefully 

like to continue to seek efforts at the VA to say, you know what, 

we can do a better job and provide that access closer to home, 

which is important for the veteran, but more important for the 

family and the local community that provides the services. 

Secretary MCDONALD. Well, as I said, if you look at these issues 

through the lenses of veterans then the answer becomes very clear. 

Dr. HUELSKAMP. Yeah. 

Secretary MCDONALD. We want to get care to veterans. 

Dr. HUELSKAMP. Yeah. 

Secretary MCDONALD. If we don’t have the technology, if distance 

is an issue, if capacity is an issue then we should help that veteran 

get the care in the private sector. 

Dr. HUELSKAMP. The issue is not capacity, the issue is not distance, the issue is getting permission from the VA to go to the local 

hospital. If they are willing to do that, I just encourage you to look 

into that. I don’t know if you have every lived in a rural area—— 

Secretary MCDONALD. Please give us their name and we will 

work on it. 

Dr. HUELSKAMP. Okay, I will continue to do that. But the point 

is there are a lot of folks out there that would like that choice and 

we need to see that choice being offered by the VA. 

So thank you, Mr. Secretary, I appreciate it. Mr. Chairman. 

The CHAIRMAN. Thank you, Mr. Huelskamp, 

Mr. Takano. 

Mr. TAKANO. Thank you, Mr. Chairman. 


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Mr. Secretary, welcome, this is the first time I have had a chance 

to meet you, I hope we have a chance to—— 

Secretary MCDONALD. We will get together soon. 

Mr. TAKANO. Yeah, thank you. 

Mr. Secretary, some of these—well, the Phoenix VA wait list 

scandal happened many layers below the secretary level, and how 

can you be sure that the leadership teams that are near you are 

going to be able to tell you the truth or be able to get to the truth 

and so you are not insulated and that you can count on people getting you accurate information? 

Secretary MCDONALD. It is going to require a change in culture, 

and those of us who have experience running large organizations 

know that is probably the most difficult thing to do, but it starts 

with the purpose, values, and principles, which are the bedrock of 

any organization. 

So the first thing I did was I asked for every employee to recommit themselves to the mission of caring for veterans and to the values of the organization represented in the ICARE acronym. We 

have used that as an leadership exercise for our leaders to talk 

with their employees about the mission, about the values. 

The second thing that we have tried to do is we have tried to 

demonstrate that we want a very open culture. We talked about 

the positive aspects of whistleblowing, we have talked about the 

positive aspects of criticism. I have used a couple of diagrams. Most 

people think of an organization like this and the customers is on 

the bottom and the CEO is on top, but I turn that on its head and 

I said this is the VA we want. We want the veterans on top and 

those people who are next to the veterans every single day, the doctors, the nurses, the schedulers, the clinicians, those are the people 

that we should honor and make sure are paid properly and are rewarded, and then the CEO or the secretaries on the bottom, and 

the leadership’s job is to make sure these people can properly care 

for veterans. This is a different kind of culture. 

To demonstrate that I have cut down the size of the secretary’s 

office, I no longer travel with the entourage that maybe once existed, and we are simply trying to make very visible that this is 

a different culture. 

Mr. TAKANO. Are you sort of like the Pope, you know, travel in 

like a little tiny car? 

Secretary MCDONALD. I am much less than that. Remember, I 

am on the bottom of the pyramid, I am flying coach. 

Mr. TAKANO. Well, you know, I have to say I sympathize with my 

colleague, Mr. Huelskamp’s four—he has three or four VISNs divided, I wish you could do something about that. I think there is— 

you know, if you could fix that I would certainly appreciate it. 

Secretary MCDONALD. We talked with Ranking Member Michaud 

in his office about this. Again, the veteran should not be punished 

for having a barrier between VA and DoD. The veteran should not 

be punished for having nine different maps of organization structure. These are things that we have got to simplify so that every— 

I will give you another example. We have 14 different web sites 

that require different user names and password. 

Mr. TAKANO. Wow. 


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Secretary MCDONALD. Now, I don’t know about you, but I hate 

keeping track of user names and passwords for all these web sites. 

You should be able to plug in the VA in the easiest way and then 

get your care, and that is what we are working on. 

Mr. TAKANO. You know, I am the ranking member of the Economic Opportunity Committee and I have a lot of concerns about 

the educational benefits, and I know you have been maybe paying 

attention to what has been going on in the for-profit college sector 

and making sure there is not undue predatory behavior. 

Secretary MCDONALD. I got my MBA using the GI Bill. My dad 

and my father-in-law got their college using the GI Bill. Again, it 

is very personal. We cannot allow people to take advantage of our 

veterans, it is really that simple. 

And I am thrilled with the work that was done in the new bill, 

I have told the chairman that, because you have expanded our ability to get doctors and nurses reimbursement for their study if they 

work for the VA, and we need more medical professionals. So that 

was a really big win for us. 

I have been out to Duke University Medical School, I was talking 

to the dean of Pennsylvania University Medical School, Penn, and 

just two days ago I was in San Diego with the dean of UC San 

Diego. These relationships for us are critical and getting those doctors, nurses, particularly mental health professionals into VA is 

very important. 

Mr. TAKANO. Well, I want you not to forget that I just wrote you 

a letter asking you for a plan on how we would use the medical 

residencies. That is a huge thing, you know, on the Medicare, Medicaid budgets, and we have been frozen in terms of the supply of 

doctors, and really we have a supply—we don’t have a supply problem with the med students, we have a problem matching them to 

residencies, and I am looking forward to your ideas on how this can 

even help the broader community. Of course the primary function 

is the VA, and I think it will help the rural areas as well as impacted areas such as mine and Ms. Titus’ and Ms. Kirkpatrick’s. 

Secretary MCDONALD. It is very important, in fact we talked 

with Congresswoman Titus the other day about this, we are working to develop a medical school at UNLV, University of Nevada Las 

Vegas, we want the residents to work for the VA at the Las Vegas 

Hospital. These are critically important things, and I think we are 

going to have to work together to get more medical schools contributing more graduates for our rural areas, and so I would offer that 

as something we would like to partner with you on. 

Mr. TAKANO. I certainly would love to work with you on a plan 

like that. 

Secretary MCDONALD. Yes, sir. 

Mr. TAKANO. Thank you. 

The CHAIRMAN. Dr. Roe. 

Dr. ROE. Thank the chairman. 

And first of all, Mr. Secretary, I thank you for taking the job. 

Secretary MCDONALD. Yes, sir, thank you. 

Dr. ROE. Thank you for your service to our country, and I certainly appreciate that, and I think I said during these long hearings we went through that if you ask someone at the VA who they 

work for they would say the VA, and the right answer was I work 


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for the veteran, and you got that right when you flipped that chart 

upside down. 

And I also appreciate the fact that you just said that you know 

that the front of the airplane gets there only slightly before the 

back of the airplane does, so you can save a little money there, and 

anything is helpful. 

Secretary MCDONALD. I used to jump out of them and I would 

not recommend that. 

Dr. ROE. Well, I have done that a time of two and then questioned my sanity about why would anybody jump out of a perfectly 

good airplane, so. 

Secretary MCDONALD. Particularly a doctor. 

Dr. ROE. Yeah, exactly. Why would you do that? 

I think one of the things that—a question I always ask our secretary every year when we come in with budget, is do you have 

enough money to carry out your mission, number one? And two, do 

you have adequate staff to carry out your mission? 

And I think that is a question you may not have time to answer 

right now, but that is a question you will get next year when we 

go through the budgets. And we want to be sure that we provide 

the resources to take care of our veterans. And I can tell you the 

America people want their veterans taken care of. 

And I know with Mark, Mr. Takano, we worked with him on 

that—on the residency slots, and I would like to personally offer 

you an opportunity to visit east Tennessee to our VA, and let me 

tell you why. It is one of five medical schools, it is now a 30-yearold school, it is on a VA campus. It actually was started with a T 

Cranston bill, so our students, our medical students actually go to 

the VA campus every day for their education and they go to the 

VA Hospital—along with the public hospitals too. It is a very good 

model, and maybe we should as we look at these shortages of physicians and we know that doctors are creatures of habit, we stay 

where we are like most people like to if you are comfortable, and 

it is a great way to get doctors to stay and make a career at the 

VA as Dr. Foote did. He was a career VA doctor. 

So I want to—I don’t really have any questions other than just 

to thank you for taking the job and—— 

Secretary MCDONALD. Yes, sir. 

Dr. ROE [continuing]. You come from a great company, you have 

a great background, you have run a big organization before, so I 

think you are going to be a great secretary. 

Secretary MCDONALD. Thank you, sir. 

I would just say, and I know the chairman knows this, but 70 

percent of the doctors in the United States have worked for the VA 

at one time or another, and the best operations we have, at least 

in my 50-day review so far, are those connected with medical 

schools, whether it be our Palo Alto facility with Stanford, our Durham facility with Duke, our Philadelphia facility with Penn, so we 

want to do more of that, it is really a great way, and we all benefit. 

Dr. ROE. I am going to selfishly promote my school, but—— 

Secretary MCDONALD. And east Tennessee of course. 

Dr. ROE. Yeah, it is one of the—it is one of the five top primary 

care putting doctors in rural areas in the country, so it is—— 

Secretary MCDONALD. We need that, we need that badly. 


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Dr. ROE [continuing]. One of the things that we do, and it is one 

of the things that Mr. Takano was talking about and Dr. 

Huelskamp talking about, getting people out to rural areas, which 

is rural America is where I live, and it is a challenge for us. 

Secretary MCDONALD. And our veterans just so you know demographically are moving more to rural areas than they are to urban 

areas, so this situation will only get exacerbated so we need to get 

ahead of it. 

Dr. ROE. Yeah, I think ten percent of my district are veterans, 

so a big number there. 

Dr. CLANCY. So I will just say it is a very strong primary care 

school as I recall as well, and definitely on the list for a visit. 

And we just want to thank you and everyone else for the additional residency slots, because we recognize that we are in tight 

competition with the private sector in terms of recruiting and hiring, but we think we have got the best mission. 

Dr. ROE. I think long term it is a great method to do. I mean 

just think in 10, 20, 30 years when nobody is even going to know 

who we were, it will provide benefits for the VA and for the veterans. 

Mr. Chairman, I yield back. 

The CHAIRMAN. Thank you. 

Ms. Brownley. 

Ms. BROWNLEY. Thank you, Mr. Chairman, and thank you, Mr. 

Secretary, for being here. I certainly enjoyed my meeting with you 

last week and appreciate it very, very much, and I went back to 

my district and told my veterans you should have hope, I met with 

you, and I really appreciate your can do and will do leadership 

style and approach, and particularly your sense of urgency around 

reforming and changing and making that cultural change, making 

veterans first within the VA organization. So I am very, very much 

encouraged. 

I think one of the—you know, one of the more global issues I 

think I wanted to raise with you in this hearing is in the time that 

I have served on this committee it has been extremely, extremely 

frustrating getting information from the VA, and I hope, and my 

dream is that as you move forward and set out a plan for change 

within the VA that we will all collectively, we as members of this 

committee, you at the bottom of your organization, and certainly 

the veterans and the VSOs most importantly, that we all can collectively agree on the direction the organization is going and then 

set the appropriate outcome measures that we are looking for so 

that we can again collectively monitor and watch and evaluate the 

progress as we move forward. 

So for me that is, you know, a very essential thing, because it 

is really the only way that we can tell the American people that 

we are, you know, that we are on track and we are making 

progress. So if you could just comment. 

Secretary MCDONALD. Yes, ma’am. As we talked I want to be 

your partner and that is why I am sharing with everyone our Road 

to Veterans’ Day plan for the next 90 days, and as we are renewing 

our strategic plan, which we are starting as a leadership team this 

Friday doing, we will share that with you as well. 


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I know from my confirmation hearing and from talking to the 

chairman the communications has been a challenge for us, and 

frankly some of the communications have come to my desk, I have 

rewritten myself because I have just been totally unhappy with our 

ownership for the problem, or with our ownership for the issue. 

The CHAIRMAN. I want it integrated so that we are saying the 

same message, but that is not an attempt to centralize. In fact 

what we talked with the chair about was decentralizing so that you 

can go to the subject matter expert and get the answer and it 

doesn’t necessarily need to be cleared with one tip of a funnel. 

I think what has happened in the past is the organization has 

done that, they have made everything go through one person, and 

when you do that it obviously backs things up. And everybody 

should be capable enough to be able to answer, and of course I 

would ask your indulgence that you would have to realize that if 

you got a wrong answer it may be temporary or it may be incompetence, but the person is not trying to deceive you. And we will 

work together to make sure we clear up any miscommunications. 

Ms. BROWNLEY. Thank you for that. 

And I am a strong believer in data driven decision making, I 

think the data is extremely, extremely important. I would—my two 

cents would be in terms of the data that will be presented to you 

is trust, but verify. I don’t think I have necessarily the confidence 

of the data that has been presented to us and don’t have the confidence there, and in some ways want to just clean the table and 

start all over again in terms of the data collection, but I know there 

is—I am sure there is some good data that is there also. But there 

does need to be—— 

Secretary MCDONALD. Well, the point is they are getting the 

right values and the right mission in place and making sure people 

look at everyone through the lens of veterans. 

Step two is getting the right leaders in place, and we are in the 

process of doing that. 

Step three is getting the right culture in place, and then we have 

got to get the right strategies. Right now we have a group of strategies that frankly no one is working against. They are in the desk 

drawn somewhere, but if my test is: can I go to the lowest level 

employee, or in my case I would say the highest level employee, 

and do they know how their work every day is tying back to caring 

for veterans? If they don’t stop the work. 

I had somebody bring to me a binder full of information the other 

day. I said, well, what is this for? And one binder was a series of 

reports. And I said, well, I have already seen all this information, 

let us stop doing it. And so that got rid of a whole bunch of work. 

Another binder was testimony I gave at the Senate hearing. Why 

do I need to see my own testimony? Let us stop doing that. 

So we have got to stop a bunch of things and then redeploy all 

of that effort against caring for veterans. 

Ms. BROWNLEY. Thank you, my time has expired. 

Secretary MCDONALD. Yes, ma’am. 

Ms. BROWNLEY. But thank you, and I look forward to working 

with you, and I yield back. 

The CHAIRMAN. Thank you. 

Dr. Wenstrup, you are recognized. 


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Dr. WENSTRUP. Thank you, Mr. Chairman. 

Mr. Secretary, it is a pleasure to be with you today and I do 

thank you publicly for taking on this task. 

I benefit from living in the City of Cincinnati where Proctor & 

Gamble is located and all the great things that you have brought 

to our community with Proctor & Gamble has benefited so many 

people. 

But as you take on this job there are so many things to consider, 

and I know it is a monumental task, but it is not one that you are 

unfamiliar with, and why so many of us for a while have been talking about needing an outside influence, someone from the private 

sector, because we are talking about acquisitions, cost versus productivity, changing a culture, assuring quality and care as well as 

access to care, all these things that go into being successful. 

And I just want to say I think if there is anyone that can create 

a brand it is someone who has been at Proctor & Gamble, because 

that is what you—and not only that, you build trust with that, and 

that is going to be the key. So if you can build trust in the VA 

brand in the same way that you have done Tide I think we will 

be in good shape. 

And I appreciate your openness and the ability to work with you 

every day. Thank you. 

Secretary MCDONALD. I look forward to working with you and I 

appreciate the fact of the commitment of all the members of this 

committee, which really means a lot to all of us at the VA. 

The CHAIRMAN. Ms. Titus. 

Ms. TITUS. Thank you, Mr. Chairman. 

Mr. Secretary, thank you for being here. There was a lot of enthusiasm when you were appointed and I think anybody who has 

heard you testify today will certainly have that feeling reinforced 

and erase any doubts that you are the man for the job. So we appreciate it. 

Also thank you for coming by to see me. It meant a lot that you 

had already taken time to visit Nevada, both our service center in 

Reno that has had so many problems and the new hospital. It 

shows that you are really personally vested in that and we appreciate it. 

Also it has been nice to hear all my colleagues talk about our bill 

to create more residencies in the hospitals, and I would just point 

out again as we talked about in our meeting, that we want to be 

sure that those residencies don’t just go to the big hospitals that 

already exist, but really go to the places where they are needed. 

I know Mr. Beto also worked on that and there are areas that are 

under served and that was the real intent. So we want to be sure 

they do that. 

Also we are very supportive of your notion of reorganizing not 

just middle management but also the geographic regions, because 

Las Vegas is in several different areas that just don’t really make 

much sense. 

And finally maybe you could share with the committee and for 

the record some of the things you told me about the new emphasize 

on women veterans, because they are our silent veterans, they have 

had serious problems, one in four hospitals doesn’t have a gynecologist. I know that is a new priority of yours, which I am very 


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supportive of and want to work with you on, and maybe just put 

on the record some of the things that you are doing that. 

Secretary MCDONALD. Yes, ma’am. Well, thank you very much, 

and we look forward to working with you. 

I know that—I know that apportioning those additional 

residencies will be very important and we will work with you on 

that, because we have got to—I have played hockey, we have got 

to go to where the puck is going to go rather than where it has 

been, and so we have got to—we have got to get after that, and we 

will work with you on that so we are making a decision together. 

Relative to women veterans, to me this is critically important. 

Right now we have about 11 percent of veterans or women, but of 

course the percentage in the army—or in the armed forces is much, 

much higher, so obviously it is going to increase over times. 

Many of our facilities were built in the 1950s when we were virtually a single gender army, and so when you think about the 

kinds of equipment we have, when you think about the kind of doctors we have, you are right, we need to hire more OBGYNs. We 

have got to get ahead of this, because it is quickly becoming an 

issue for us already. 

One of the things that we have also done is many people see the 

mission of VA as articulated in Abraham Lincoln’s second inaugural address where he said, for him who have borne the battle for 

his widow and his orphan, and we have changed that, we have 

paraphrased it, and if you look at our mission the way we call it 

out here in our 90-day plan we say, better serve and care for those 

who have borne the battle for their families and their survivors. 

And while that seems like a modest change in words, it has meant 

a lot to our female veterans to know that we are looking out for 

them or we are thinking about them, and we have got to get ahead 

of the things we need to do so that we are able to meet the capacity. 

Maybe Dr. Clancy can talk a little bit more about this, because 

I know this is of particular interest—area of interest to her. 

Dr. CLANCY. I would agree with everything the secretary just 

said, and it is a very high priority for us, and it has changed a lot 

in recent years, but we are not going to slow down until every single facility has got a topnotch women’s health coordinator. 

All of our health coordinators across the system just got reinforcement of all the training that they get to make sure that we 

are meeting those needs, and it will remain a high priority. 

So thank you for your continued support, because we can see 

where the numbers are going as the secretary just noted. 

The CHAIRMAN. Mr. Jolly. 

Mr. JOLLY. Thank you, Mr. Chairman. 

Mr. Secretary, welcome, we haven’t had an opportunity to meet. 

I echo my colleagues’ comments, thank you for serving. 

Secretary MCDONALD. Thank you, I look forward to getting together with you soon. 

Mr. JOLLY. My predecessor was here for 43 years and one of your 

predecessors once nominated he counseled, he said, please don’t 

take this job, you are not going to be able to change the VA, and 

I will never forget that as a young staffer in that meeting, and I 

know this challenge that you face. 


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I appreciate your comments today. I want to express a little bit 

of concern and maybe give you an opportunity to revisit your exchange with by colleague, Mr. Lamborn when he asked about 

whether you believe that wait lists contributed to the deaths of veterans. I understand that is a hard question for you to ask, but if 

we are talking about changing the culture it is a very important 

one, because you have spoken a lot of organizational changes, but 

as you step into this role do you believe that the negligence of the 

VA has contributed to the deaths of veterans over the past several 

years? 

Secretary MCDONALD. Again, I think it is very simple, there are 

veterans who haven’t had access, there are veterans who haven’t 

gotten proper care, I don’t really need to go any further than that. 

Mr. JOLLY. Well, no—— 

Secretary MCDONALD. That says there is a problem. That says I 

have got to get it down. I am focused on our veterans. 

Mr. JOLLY. Sir, I mean this very respectfully, I got a little heated 

in the last exchange, I shouldn’t have. 

Secretary MCDONALD. What value is there in having this discussion? 

Mr. JOLLY. Because that actually speaks—— 

Secretary MCDONALD. Is it going to help more veterans? 

Mr. JOLLY [continuing]. Because that actually speaks to the cultural change of the department. I understand the administrative 

changes and the organizational changes and I think it is needed. 

Deputy Sloan Gibson—Deputy Secretary Sloan Gibson when he 

was acting sat there and apologized to the Congress and the American people for the failures of the department and what it led to 

for veterans. 

You got into an exchange with Mr. Lamborn and you just did 

now as well that doesn’t show an acknowledgment, and to me that 

is not a cultural change, that is going backwards. 

I understand nobody wants this on their fingertips, you weren’t 

there, I get that, I am not holding you accountable. But in terms 

of the culture that you bring to the top leadership posts at the VA 

do you believe with conviction that the wait list problem contributed to the deaths of veterans or do you not? 

Secretary MCDONALD. Sir, in my opening statement I said I 

apologize on behalf of myself and the Veterans Administration— 

Veterans Affairs Department. I have said that in every testimony 

I have given. 

Mr. JOLLY. Right. 

Secretary MCDONALD. I have said that when I have gone out to 

town hall meetings when I have talked to veterans. I own this. It 

is not because I wasn’t there, I own this. I wouldn’t have taken this 

job if I thought that somehow I could not own this. I own this and 

I am committing to you that I am going to fix it. I don’t know that 

you can ask for a bigger commitment than that. 

Mr. JOLLY. Well, I mean it is a very simple question, I am just 

asking you to acknowledge that the wait list and the negligence 

that the VA contributed to the deaths of veterans that we have had 

hearings on for six months, that is all. 


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Secretary MCDONALD. And I am acknowledging—I am acknowledging that I own it, that they didn’t get the proper care, and that 

we need to improve. 

Mr. JOLLY. Okay. Well—— 

Secretary MCDONALD. And that not getting proper care has adverse effects. 

Mr. JOLLY. And I very respectfully will take that as an answer. 

I don’t think it is a complete answer, I don’t think it is an acknowledgment of a cultural change that you continue to espouse, but I 

understand why you need to guard your words carefully in a public 

hearing and in front of the press, and hopefully privately you acknowledge that the negligence of the VA has led to the deaths of 

veterans. 

Secretary MCDONALD. Let me again say I own this problem. 

Mr. JOLLY. I understand. 

Secretary MCDONALD. And one of the things my West Point 

classmate I thought did so well, and he is a great leader as the interim secretary, is he owned it and he is helping the organization 

own it and I am too. We have to own it. If we don’t own it, as you 

have said, we can’t change. 

Mr. JOLLY. And I appreciate that. I look forward to working with 

you. Thank you for serving, I appreciate it. 

The CHAIRMAN. Ms. Kirkpatrick. 

Ms. KIRKPATRICK. Thank you, Mr. Chairman. 

Mr. Secretary, first of all thank you for taking the job, and then 

thank you for visiting the Phoenix facility as your first stop after 

you were confirmed, that really gave a message to our veterans in 

Arizona that you care and you are paying attention. 

Now this—I want to focus on accountability, because our committee has heard from people who say they are getting excellent 

care at the VA and that the employees at the VA care about veterans, many of them are veterans, but I am sure that you are familiar with the business motto, if you will, that an organization is 

only as good as its weakness link, and we know that there are 

weak links in the VA. And I just want to get your thoughts about 

how you insure that there is continuing accountability, and I just 

want to tell you some of the ideas that we are heard, and then if 

you could comment on them. 

One is rolling audits, review by a neutral party. Mr. Michaud has 

an idea about setting up a blue ribbon committee that would develop a strategy for the VA. I have a veteran in Flagstaff who talks 

with me frequently about the idea of a volunteer board of veterans 

who really don’t have any connection with the administration at all 

but are sort of a sounding board and a way to solve this. I have 

one idea I introduced by Whistleblower Protection Act, which includes an anonymous hotline for patients and employees to report 

things. And would you just give us your thoughts about that? 

Secretary MCDONALD. Well, I think accountability is a huge 

issue, and it has got to be a big part of the cultural change. 

One of the things we have done is we have talked a lot of about 

it, we have talked about that concept that I mentioned in my prepared remarks, sustainable accountability. It is not just about firing people, it is about giving day-to-day feedback. 


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I mean my standard is that an individual would never need to 

be fired unless it was an egregious activity because you are providing day-to-day feedback so that person should never be surprised. That should be the standard. 

Relative to external groups we—Deputy Secretary Gibson when 

he was interim secretary hired Jonathan Perlin who was the chief 

medical officer of HCA to join us in developing the blueprint for 

excellence for the hospital network. That was an attempt to bring 

outside benchmarking into VA. We are very much in favor of that. 

The new bill provides for a commission which we will help stand 

up. 

There also is—I am trying to rejuvenate some of the 23 different 

standing committees we have which are supposed to help the secretary. There are 23 of them, one could argue maybe that is too 

many, but there are 23 of them that are supposed to be helping the 

secretary. I want to reenergize those and I want to get the right 

people on them. One of them Dr. Clancy and I are in the process 

of hiring new doctors and nurses and clinicians to help us to join 

that. 

So we want to do exactly what you are saying, but the most important thing for me is we have got to get every single employee 

in the organization to feel accountable for the outcomes of that veteran rather than worrying about the internal workings of VA. 

Ms. KIRKPATRICK. And let me just mention one of the more troubling things that our committee has heard, and that is bonuses and 

that people who perform poorly still get their bonus and that there 

is this sense of a bonus is an entitlement to the employees, and 

what is your plan to address that? Can you give us your idea about 

that problem and what is the—a good use of the bonuses? 

Secretary MCDONALD. All right. Well, first of all, Deputy Secretary Gibson when he was interim secretary took the immediate 

step of the rescinding the bonuses for 2014. 

Second of all he took the 14-day metric out of peoples’ performance plans because that was helping to cause people to behave in 

the wrong way based on outcome for veterans. 

Third thing is I have gone back and I have reviewed what can 

we do about bonuses? In private sector there is something called 

a claw-back provision so that if an individual receives a bonus and 

you later discover, because we have 100 investigations going on, 

you can claw back past bonuses in order to do that, and many 

audit committees, which I have served on, have put rules in place 

to do that. 

In the government right now there is not a potential for clawback 

because apparently when the law was written the law was written 

in such a way that when the political parties changed you didn’t 

want to allow the new political party to clawback from the past political party. I have got to get into this in more detail, but that is 

the way I understand it right now, but that is the practice in the 

private sector. 

Ms. KIRKPATRICK. Thank you, Mr. Secretary, we look forward to 

working with you. 

Secretary MCDONALD. I look forward to it too. Thank you. 

The CHAIRMAN. Mr. Secretary, I will tell you that there is a bill 

that has been filed, H.R. 5094 and it allows you to do just that 


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should we be allowed to pass that through the full house and then 

on to the Senate. 

Mr. O’Rourke you are recognized. 

Mr. O’ROURKE. Thank you, Mr. Chairman. 

Mr. Secretary, I want to join all my colleagues in thanking you 

for your service and taking on this very difficult but not impossible 

task of bringing the VA back up to where it should be. 

And I want to thank you for meeting with me and just from that 

meeting and some of the issues we discussed in your follow up to 

those items, including an email today from Dr. Clancy, I think that 

speaks very well of your ownership of these issues, your attitude 

of accountability, and some of the things that we will have to look 

forward to on the bigger issues confronting the VA. 

I also appreciate your commitment in our meetings to insure that 

El Paso, which is currently I would argue one of the worst, if not 

the worst, operations in the VA become it is model. I think you 

have no greater opportunity to demonstrate turnaround than you 

do in El Paso. 

And I wanted to use the example in El Paso to make a larger 

point about the system and get your response. Following what we 

learned about El Paso, despite our assurances from the VA to the 

contrary that we were seeing people within 14 days, we learned 

that fully one-third of veterans couldn’t get in to see a mental 

healthcare appointment, the average wait time you could get in 

was 71 days, that average appointment when scheduled was canceled at least once on average or rescheduled at least once. 

When we had the VHA audit in the spring we learned that we 

were the worst for established mental healthcare appointments, 

worst in terms of being able to see a doctor or provider, fourth 

worst for new patients, second worst for specialty care, on and on 

and on. So we had that attention, that focus. 

VA committed $5.2 million in additional funds. The acting secretary, Sloan Gibson, visited the VA. We had our chairman, Chairman Miller visited the VA in El Paso. We had Mr. Matkovsky visit 

the VA. We had primary care teams, mental healthcare teams that 

you sent down there. 

And yet when I went there two weeks ago, and I often go by just 

to talk to veterans and see how things are doing, greet them in the 

parking lot, I met a number of people who said, hey, I got excellent 

care, wonderful treatment, thumbs up, you guys are doing a great 

job, and a number of people who had complications or issues and 

we tried to help them with them, but one was very glaring to me, 

and it was a gentleman who said, you know, I was given an appointment today and that was months back that I scheduled it, I 

called yesterday to confirm my appointment with Dr. B, this is a 

mental healthcare provider, and they said, yes, we have got you 

there to see Dr. B at 1 o’clock tomorrow, we look forward to seeing 

you. 

The gentleman shows up, and I don’t know how hard it was for 

him to travel there, but he gets to the VA, shows up for his 1 

o’clock appointment to be informed that Dr. B no longer works at 

the VA and hasn’t worked there for a month. 

And so I thought with all of the attention that I have been bringing to this issue, that the VA has been bringing to this issue, for 


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us to fail this veteran that badly is indicative of some deeper, larger issue. And I think of the 20 IG reports since 2005 that we have 

had about scheduling problems within the VA that all of us, Congress, and administration have known about, and yet we haven’t 

resolved those issues. 

Tell me, to Mr. Jolly, and others who brought up this point, answer that concern that we have about culture. We can as we did 

in El Paso throw money and attention at it, personnel, flexibility 

in how you fire and hire people, but I think there is a deeper cultural issue. How will you address that in a minute and a half? 

Secretary MCDONALD. As I said, cultural change is very difficult 

to achieve, but it starts with the mission and the values, and I 

would wonder in an organization have they really committed themselves to the mission and the values if an individual can be signed 

up for an appointment with a doctor that doesn’t exist? 

Frankly in a situation like this let us know, we will go back and 

check and we will get back to you and find out what happened in 

the specific instance. Any specific anecdotes you can provide us are 

very helpful, because it allows us to go back and understand what 

really went wrong and then correct it in the future. So it starts 

with the mission and values. 

Secondly, I think it starts with leadership behavior, and that is 

why I have gotten out to as many places as I have. I have to get 

to El Paso. 

Third, I think there is a big issue in the openness or lack of 

openness in this organization. I mean how could you have a situation where employees were lying to one of the most honorable men 

I have every known in my life in General Shinseki? Why would 

that exist? Why would that happen? Why would we have meetings 

where union leadership wasn’t involved or weren’t invited? Why 

would we have people feeling their only recourse was to be a legal 

whistleblower? You know, that is why I demand the town hall 

meetings, and when it demanded them some of the feedback I got 

was, well, we can’t hold a town hall meeting, it will be counterproductive, it will be violent, whatever. That is exactly why we 

have to do them. 

We have got to open the culture up, we have got to get communication moving, we have got to get ownership for the problems, 

and we have got to get people feeling responsible. Because in the 

end the only thing that matters is the veteran. This is going to 

take time, but we are going to build it into our strategies. 

When I think of a high-performance organization it starts with 

mission and values, and I think we have got that, we are under 

way there. We have got to look at our leadership and see do we 

have the leadership to create this new culture? If a leader is unwilling to embrace this new culture then they shouldn’t go on the 

journey with us. Do we have the right strategies in place in order 

to perpetrate this culture to make it happen across? And we are 

taking a look at that. Do we have the right systems in place? The 

system would be so that if you asked me how could this happen 

in the scheduling system that this doctor who doesn’t even work 

there gets made an appointment. 

And then the last is do we have the right high-performance culture where people flow to the work and people work on veterans’ 


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issues? It is going to take time. It is going to take time. But I really 

do believe we can do it. 

Mr. O’ROURKE. As I yield back to the chair let me just offer my 

assistance. If you are missing legislative authority to do any of the 

things that you are talking about doing to turn around and improve the culture at the VA I hope that you will come to us as 

quickly as you know that. We will be your partner in offering that 

legislation and getting it passed. 

So, thank you again for your service. 

Secretary MCDONALD. Thank you very much. 

Mr. O’ROURKE. Thank you, Mr. Chairman. 

The CHAIRMAN. Mr. Walz. 

Mr. WALZ. Thank you, chairman, and thank you, Mr. Secretary 

again to assuming this sacred trust and awesome responsibility. I 

am grateful you are there. I think restoring that trust is one of the 

first and paramount things. 

And I also want to say you scored big points with my chief of 

staff who is a Minnesota hockey player with your reference. I often 

as a football coach talk about pursuit angles, but it is the same 

thing, where do we need to anticipate? 

And I have been saying, and I applaud other members and Mr. 

Michaud for his take, I have been saying for a long time I never 

understood as a military person myself why there was no equivalent of the quadrennial defense review? Secretary Hagel has that 

his dispense and I was just thinking about this, think to not have 

that and defend. I went back and looked at the 1971 under then 

Secretary Cohen talking about—1997, think about that, we are 

dramatically safer than during the Cold War, but wild card threats 

are more than likely to happen, and they started anticipating 

where those threats would come from once the full out eastern European threat was gone or whatever, that allowed us to start tailoring the force to be prepared to respond to those things. The VA 

does not have that. The VA did not do that. And here we are trying 

to figure out that we are going to add a whole bunch of veterans 

are Iraq and Afghanistan. 

So, I would encourage you whatever that form looks like, Mr. 

Michaud and others are doing this, this is something that would 

help you enculturate this need to get that there is it would give you 

that guiding document and it would force us to go back on a periodic basic, whether it is quadrennial or whatever it would be, to 

get that done. So, I would encourage you to do that. 

And then I would say you are at a unique perspective here, this 

is the time as I have been saying, let us think big, let us do the 

reforms that have stymied people, let us breakthrough the barriers 

that have been there, let us crush this thing. 

And you know what, it is going to be hard to change cultural, it 

is going to be difficult, but here is what I would say is, if not you, 

who? If not us, who then? And if not now, when is this ever going 

happen? And if the country believes that is important, as I know 

they do, if all of us in this room believe it is important, let us get 

there. 

And I think something you can bring, and I would just be interested to hear your thoughts, Mr. Secretary, we have got to break 

down this false construct of government versus the private sector. 


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We work together best, this is service of veterans, if the private 

sector can deliver, if we can work in conjunction, if you can do it 

quit that argument that a dead-end that it is trying to find versus 

them. This is our veterans trying to get it right. 

So, I would ask you how do we speed collaboration? I represent 

the Mayo Clinic, a great medical institution, but also in a rural 

area that has roots in combat medicine and that. How can you 

bring your experience from P&G to bridge that and break down 

this ridiculous us versus them argument on the care of our veterans? 

Secretary MCDONALD. Well, we are going to embrace it in our 

strategies. We believe that we can’t do this by ourselves and that 

we have to partner. We have to partner with medical schools as we 

have already talked, we have to partner in the private sector, we 

have to partner with members of Congress. And so the important 

thing for us will be to figure out everybody’s role and to create a 

system which takes advantage of that. 

I will give you an example. I was in Las Vegas in Congresswoman Titus’ district, and there we are very close to Nellis Air 

Force Base, and the doctors at Nellis Air Force Base can’t keep up 

their medical proficiency without seeing VA patients, they just 

don’t get enough—a broad enough piece of work doing only flight 

physicals for pilots at Nellis. So it is great. We have the DoD doctors come over to the VA, they serve our clientele, the doctors at 

Nellis love it, we love it. 

So one of the things I did in preparation for this—not this hearing—but for this role, was to get a map of all the federal facilities 

in the country, I know most of the private facilities because we had 

a healthcare business at Proctor & Gamble, and to figure out what 

is the right combination where if we don’t have those OBGYNs that 

Carolyn and I talked about we can—we can borrow them from 

someone elsewhere—or DoD, Indian Health Service is another example in rural areas. Indian Health Service has some terrific facilities. 

So these are the kinds of things that we want to do, and our strategic work is to figure out what is the right combination of these 

things and inherently it will be local. I mean the details will be in 

each locale trying to figure out what the right combination is, because it will probably be different. 

Mr. WALZ. Well, I would echo Mr. O’Rourke said, if there is 

something we can do, whether it is credentialing or whatever the 

things that—I mean some of these things are difficult and they are 

deep and they are tough, I understand that, but let us get there. 

But I want to give an example to my colleagues where I too have 

been frustrated with some of the flow of information, but I recognize the incredible work that gets down at times. If this is a glimmer of the potential last week in Minneapolis a whistleblower, the 

press was reporting a story, we were in contact with them, we have 

been working with this. This happened on a Friday night and by 

Monday there were people out there on the ground addressing or 

attempting to address on this, and there was a real sense of collaboration with both the public, the veterans, the member of Congress, all of are working together, where was the gap, where can 

we fill the gap, and how do we fix it? 


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So, I have to say I am seeing that and I very much appreciate 

that I was seen as a partner trying to fix this as was the press as 

was the whistleblower in the case, and we will see what goes forward. Because I am with you, Mr. Secretary, we can’t be afraid to 

point out our failings, we cannot be afraid to continue to move forward. 

Secretary MCDONALD. No, sir, and if any member of the committee ever senses that they are being treated as an adversary I 

would like to know that, because we know that we need to partner 

with you to make these changes. 

Mr. WALZ. I appreciate it. 

I yield back. Thank you, Chairman. 

The CHAIRMAN. Thank you very much, Mr. Secretary for being 

here. We are very appreciative as has been said over and over 

again that you would be willing to stand in the gap for those who 

need leadership, and again, we would reiterate that it is our desire 

to stand with you as a full partner in serving those who have worn 

the uniform of this company. 

Mr. Michaud, do you have a closing? 

Mr. MICHAUD. No, I do want to thank Mr. Secretary for coming 

here, I look forward to working with you, and I agree with everything that Chairman Miller has just said. So thank you very much 

for your service and look for ward to a strong partnership. 

Secretary MCDONALD. Thank you, I look forward to working with 

you all, and I know every person in VA does as well. 

The CHAIRMAN. Thank you, Mr. Secretary. 

Secretary MCDONALD. Thank you. 

The CHAIRMAN. Member, we have—the votes have been called, 

and it looks like it is going to be a series that will last about 50 

minutes. It is your—5–0—it is your choice. We can begin with the 

third panel, they have no opening statement so we can monitor the 

clock and carry on if you wish. 

Okay, if we could ask the second—or third panel to come forward. Thank you, as the third and final panel comes to the witness 

table and we are setting up the name plates I will tell you who we 

are going to hear from. Dr. Lisa Thomas, Chief of Staff of the Veterans Health Administration. Dr. Thomas is accompanied by Dr. 

Darren Deering, Chief of Staff of the Phoenix VA. 

If you would I would ask you to stand, I was going try and catch 

you before you sat down, raise your right hand. 

[Witnesses sworn.] 

The CHAIRMAN. Thank you. And let the record show that both 

witnesses responded in the affirmative. 

Secretary McDonald has already provided an opening statement 

on behalf of the Department of Veterans Affairs, so we will move 

directly into a round of questions. 

DR. THOMAS AND DR. DEERING ARE JOINING THE PANEL 

Dr. Thomas, on March 14th of 2013, the ONI Committee revealed wait time in healthcare delays in Augusta, Georgia; Columbia, South Carolina; and Dallas, Texas. Who months later in May, 

VA waived the fiscal year 2013 annual requirement for facility director to certify compliance with VA policy further reducing acVerDate Aug 31 2005 11:01 Dec 01, 2015 Jkt 000000 PO 00000 Frm 00080 Fmt 6633 Sfmt 6633 Y:\96-130.TXT PAT

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countability over wait time, data integrity, and the scheduling 

practices. 

Are you familiar with that? 

Dr. THOMAS. Yes, sir. I am. 

The CHAIRMAN. Did you approve or recommend the waiver of the 

requirement? 

Dr. THOMAS. No, I did not. 

The CHAIRMAN. So you knew the waiver was given? 

Dr. THOMAS. After the fact. 

The CHAIRMAN. After the fact, and what action did you take after 

the fact recognizing that there was a real problem? 

Dr. THOMAS. In the spring of this year is when we realized that 

we really missed the boat in VHA, that the situations regarding 

delays in care were more of a systemic issue, rather than looking 

at each case individually. And in the spring of this year when we 

went back and researched it, the memo that you reference that was 

issued in 2010 was prior to my tenure as the chief of staff, so I 

went back and looked at that. It was in the media; it was hard not 

to realize that we had this memo talking about our scheduling 

problems and the gaming of the system. 

And we looked at that in relationship to all of the other issues 

that were going on around the country and realized, albeit too late, 

that we had a systemic issue. We should have taken a holistic approach to looking at it, rather than looking at each individual instance in isolation. 

The CHAIRMAN. We have the original Inspector General report on 

Phoenix and we have the one that VA released. I assume that you 

are aware that there was a crucial change in language made in the 

executive summary that said the physician whose allegations this 

committee had carefully verified could not tell the Inspector General the 40 names of the veterans who had died. I think this gave 

a false impression right up front that the whole matter was untrue. 

So my question to you is did you have any idea that language 

like this was going to be inserted in the IG’s report? 

Dr. THOMAS. No, I did not. 

The CHAIRMAN. Your—let me see if I can find it real quick—according to your fiscal year 2013 performance review, by the way, 

500 out of 500 is what you received on your review—perfect, one 

of your responsibilities as Veteran Health Administration Chief of 

Staff is being able to identify critical OIG reports that could 

produce negative media attention and ensure talking points in communication plans are developed before the final report was released 

to increase the Department’s responsiveness. 

So could you give the committee a little idea as to how that 

works? 

Dr. THOMAS. Absolutely. Sir, first, what I would like to say is we 

sincerely apologize to all the veterans. No veteran should have to 

wait for care and it is unacceptable to us. We did get the IG report 

in several drafts and at each draft stage of getting a draft, it was 

our responsibility to make sure that we were putting together an 

accurate communication plan so that we could then communicate 

to all of our stakeholders what the IG found, but more importantly, 

what we were going to do to fix it. We really focus on more of the 


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edits and looking at what we are going to do in the action plan, 

than the actual OIG report. 

And as Dr. Clancy said, we have a management review service 

and they are responsible for looking at that and making sure that 

all the correct subject matter experts look at that report and if 

there is anything factually that they think needs to be corrected, 

they provide that information. And what we also do is making sure 

that all the subject matter experts come together to identify what 

is the corrective action that is needed so that we can meet the 

needs of veterans. 

The communications folks that report to me were doing that 

every iteration, and so every iteration of the report we were trying 

to highlight for them what was the differene from the last report 

to the next report so that they could accurately and very efficiently 

get a communication plan together. One of those changes was a 

change from 28 recommendations to 24. The consolidation of a 

number of individual recommendations regarding ethics were rolled 

into one. Highlighting those for them makes it easier for them to 

be more responsive to have a document that is pulled together so 

we can communicate to all of our veterans, the public, and the 

stakeholders what was found and what we are going to do to fix 

it. 

The CHAIRMAN. Okay. I am going to ask you to pause right there. 

Members, we need to move to the floor. We have got less than 

five minutes to get to the vote and we will be back as soon as we 

can. 

[Whereupon, at 4:52 p.m., the committee recessed, to reconvene 

at 5:36 p.m., the same day.] 

The CHAIRMAN. The committee will resume its hearing. Again, 

we apologize to the witnesses. That will be our final interruption 

for the day. 

Dr. Deering, thank you for attending. I would like to know if you 

have reached out to any of the whistleblowers about resolving their 

cases, and if no—if so, how many have you worked with? 

Dr. DEERING. I have not personally reached out to the whistleblowers at the Phoenix VA about their specific cases. 

The CHAIRMAN. Would that be something that you ordinarily 

would do or would somebody else do that? 

Dr. DEERING. I believe somebody else is working with them on 

their cases. 

The CHAIRMAN. But in a normal course, I mean I understand 

that Phoenix is somewhat of an anomaly, normally, would you be 

the one who would reach out to whistleblowers? 

Dr. DEERING. Certainly. I mean I have had other employees who 

have brought up concerns within the organization and I work with 

them closely to address those. I had an employee just about two 

weeks ago sent me a message on my personal cell phone saying 

that she had concerns she would like to discuss. She didn’t feel safe 

talking about them at work and I met her off campus to discuss 

those issues. 

The CHAIRMAN. Has anybody prevented you from talking with 

whistleblowers or advised you not to talk to them? 

Dr. DEERING. No, I have not been advised not to. 


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The CHAIRMAN. Okay. Of the 293 deaths that were identified by 

the Office of Inspector General, how many required institutional 

disclosures? 

Dr. DEERING. I don’t have that information because I have not 

reviewed those 293 cases specifically. I would have to crosswalk 

those to see how many would require institutional disclosures. We 

are in the process of reviewing the 45 cases that were outlined in 

the Inspector General’s report to see which of those would require 

institutional disclosure, if necessary. 

The CHAIRMAN. You are the chief of staff of the Phoenix 

healthcare system and you don’t know if there are institutional disclosures? 

Dr. DEERING. I haven’t been provided the specific names of those 

293 veterans, sir. I can get the list of names of who we have conducted institutional disclosures on and I don’t know if those happen to be on that same list. 

The CHAIRMAN. Well, let’s go this way. How many institutional 

disclosures have been made at Phoenix in the last two years? 

Dr. DEERING. In the last two years—and I can get that specific 

number—but it is around six or seven institutional disclosures 

have been conducted. 

The CHAIRMAN. Say that number again. 

Dr. DEERING. Somewhere around six or seven. 

The CHAIRMAN. Okay. Did you order OIG report case number 

seven’s schedule an appointment with primary care consult to be 

removed from his chart? 

Dr. DEERING. Can you repeat that question for me? I am sorry. 

The CHAIRMAN. Report case number seven, which was in the OIG 

report, there was a schedule an appointment with primary care, 

but it was removed from a chart, and my question is: Did you remove this from his chart or if you didn’t, who did? 

Dr. DEERING. I don’t recall instructing anyone to remove a consult from someone’s chart, but specifically to case number seven, I 

don’t have that patient’s demographics. I would have to go back 

and look at that and get back to you with that information. 

The CHAIRMAN. Who at Phoenix can remove those kinds of 

records or can wipe a chart clean? 

Dr. DEERING. Consults typically aren’t removed; they are discontinued or cancelled or completed. So even if they are discontinued 

or cancelled, they would still stay in that veteran’s chart and they 

would show that they were discontinued or cancelled. 

The CHAIRMAN. It was a primary care appointment that was 

taken off of number seven’s chart, so, again, I am just trying to get 

to the bottom and find out exactly what happened. 

Dr. Maher is it Hutman? Huttam. 

Dr. DEERING. Huttam. 

The CHAIRMAN. Huttam. 

Dr. DEERING. Huttam, yes. 

The CHAIRMAN. Huttam, reported health and patient safety 

issues to leadership and was fired. I am sure you are aware of his 

firing and I guess was fired by Ms. Hellman. Did she ask or require 

you to do a board on Dr. Huttam? 

Dr. DEERING. Specifically regarding Dr. Huttam, I don’t recall 

him bringing patient safety concerns to my attention. Regarding 


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his termination, a summary review board was convened to look at 

his case specifically and make a recommendation to the medical 

center director. 

The CHAIRMAN. But you did conduct a board on him? 

Dr. DEERING. I did not conduct a board. I convened a board and 

it was ran by another physician. 

The CHAIRMAN. Can I ask you—it is a personal question, but I 

think it is pretty simple—after all that has happened at the Phoenix VA medical facility, how is it that you are still employed there? 

Dr. DEERING. Sir, I think that is a fair question, and if I may, 

I grew up in the VA. My father, who was a veteran and passed 

away in October received all of his care through the VA healthcare 

system and I have memories from being a child growing up in waiting rooms where we would often show up and wait all day for an 

appointment, and often be turned away at the end of the day not 

being seen. 

I came to work at the VA after training there as a medical student, as an intern and resident. Dr. Foot was my attending when 

I was a resident. I am very committed to this mission. I worked 

one year in the private sector and I ran back to the VA when I had 

the opportunity. I have committed my whole career and a lot of my 

personal life to try and improve the VA. 

The Phoenix VA is certainly not perfect and I have said that before. I don’t think that any healthcare system is perfect. We certainly have made mistakes. We are learning from them and we are 

moving forward, and a good example is after the interim report 

came out from the Inspector General, I helped lead the initiative 

to get all of those patients that were on unofficial lists in for care, 

contact them and get them in, in a short duration of time. 

I am very committed to this mission and to the cause and have 

spent a large part of my life either as a child growing up or as a 

trainee or student or as a provider in the system. I believe in the 

system. 

The CHAIRMAN. Mr. Michaud. 

Mr. MICHAUD. Thank you very much, Mr. Chairman. 

Dr. Thomas, were you aware of VISN’s 18 director’s report in 

January of 2012 and again in May, 2013, that found that the Phoenix healthcare system was using unauthorized scheduling practices 

and not complying with VHA’s scheduling policies? 

Dr. THOMAS. I was not aware of the report until it was cited in 

the media and then we asked for a copy of it. 

Mr. MICHAUD. Is it your job to ensure that Phoenix complied 

with the VHA’s policies? 

Dr. THOMAS. I think it is all of our job in central office to make 

sure that we have a system that has policies in place that the field 

can understand, that it can implement, and we do need to improve 

our oversight to ensure the field is following policy. That is one of 

the things that both Dr. Clancy and the secretary are looking to 

change as part of the change in the culture to make sure that we 

have the appropriate oversight in the central office and the auditing function to make sure that things are happening the way that 

they are supposed to be. 

Mr. MICHAUD. Can you explain to the committee what your job 

is? 


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Dr. THOMAS. I can. As the chief of staff, I think the best explanation I can think of is I really serve a function as an advisor to 

the Under Secretary, whoever that may be, but I am really like an 

air traffic controller. I don’t get to fly any planes. I am not responsible for making sure the plane takes off or lands safely; I am the 

one who is there to make sure that all of the planes are flying on 

time, going in the right direction, which is set by the secretary and 

the under secretary for health. So I need to have a broad understanding of everything that is going on within VHA, but, unfortunately, that means I am not a subject-matter expert. I can’t drill 

down into each one of those areas and know in detail exactly how 

it works. 

Mr. MICHAUD. Okay. So you are looking at the planes as they 

take off and land properly, since Phoenix, Arizona, was not complying with VHA policy, not complying with it, you set a path for 

them to follow. They did not follow it. So who is responsible at 

VHA, is it the under secretary or your job as chief of staff—— 

Dr. THOMAS. I think—— 

Mr. MICHAUD [continuing]. Or is your job of chief of staff is to 

be a—to make sure the secretary doesn’t understand what is going 

on in the VISN office? 

Dr. THOMAS. I think it is all of our responsibility in central office. 

If I could, sir, if you would allow me, when the first panel was here 

you asked a very important question and you said really what we 

need to know is what happened; why did it happen; how do we 

move forward; and how do we hold people accountable? 

And I think that is really key. And what did happen was that 

we have an overly complex scheduling system and process, which 

we are in the process of fixing. We also have an undue focus on 

performance metrics, and as you heard the secretary say, all of the 

performance metrics are related to the wait, the fourteen-day wait 

time metric has been removed. 

We do have capacity issues and the Choice Act which was recently passed is going to help us do that. We are going to hire 9600 

clinicians just in fiscal year—— 

Mr. MICHAUD. Okay. Since my time is running out, I guess the 

big concern I have—yes, we gotta find out what happened and how 

are we going to solve the problem, but if you were part of the problem in the under secretary’s office that knew that Phoenix, Arizona, and other facilities were not complying with policies that 

were set by the Department, I guess it is your responsibility, and 

that is a big concern. I know I have it and I know that other committee members have is if you are part of the problem, how am I 

going to feel comfortable that you are not still going to be part of 

the problem? 

Dr. THOMAS. Sir, unfortunately, we did not know of the problems 

in Phoenix until the spring and we did not know of the previous 

reports that the network had commissioned and saw that they had 

a problem, and I am not sure where that decision broke down, why 

we didn’t know, but I do know that with a change in culture that 

the secretary has set forth for us, we are going to remedy that 

issue. 


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Mr. MICHAUD. Did you see a problem with the Under Secretary 

Petzel and Secretary Shinseki, as far as not moving in the same 

direction or is there undercutting occurring between the two? 

Dr. THOMAS. I was very rarely in the same meetings as the two 

gentlemen. I only knew what I heard the secretary say in the meetings I was in and what the under secretary would say when he 

would come back from meetings with the secretary. I was not privy 

to those personal conversations. 

Mr. MICHAUD. My last question moving forward is, is there— 

what—as the VHA Chief of Staff, what have you done to make sure 

that scheduling problems do not continue to occur? 

Dr. THOMAS. We have two very major initiatives that we have 

taken on. The first one was the audit, the access audit, which I 

know you have been briefed on so I won’t go into detail. But that 

was very important for us to understand if this was isolated instances around the country or if we had more pervasive systemic 

issue, and sadly we know today it was a more systemic and pervasive issue. 

So we then launched into the accelerating access for care and 

make sure that we can put resources to all of the veterans who are 

waiting for care. Anyone who was waiting more than 30 days we 

contacted. We reached out to every single one of them and offered 

for them to come in for care earlier or refer them to the community 

for care. 

For those that we could not contact, we made three attempts by 

phone, we sent a letter, and we are also working with partners trying to see if we can locate those veterans. So we are taking those 

extra steps to make sure we can identify who they are so we can 

bring them in for the needed care. 

Mr. MICHAUD. Okay. And last question—I know I am a little over 

time, Mr. Chairman—but do you think that there is too much autonomy at the VISN level and that is part of the problem, as far 

as following the directive from the Secretary or Under Secretary of 

Health? 

Dr. THOMAS. My personal opinion is that we are not well-standardized. A lot of people talk about centralization/decentralization; 

I think that is the wrong conversation. I think we need to have a 

standardized system of healthcare that we can consistently provide 

quality healthcare to all of the veterans, whether they are in the 

large cities or in the rural areas. 

Mr. MICHAUD. Thank you, and thank you, Mr. Chairman. 

The CHAIRMAN. Mr. Huelskamp, you are recognized. 

Dr. HUELSKAMP. Thank you, Mr. Chairman. 

I am new on this committee and maybe it is just me, but trying 

to understand and—what is being reported in the numbers can be 

very difficult at times. I will note there is at least 41 individuals 

that you did not reach on the outreach campaign that is reported 

as deceased, and I will note for the committee I think that is part 

of the records that did not get reviewed by the OIG where those— 

at least those 43. 

One thing I want to bring attention to that is disturbing to me 

is, Dr. Thomas and Dr. Deering, we have student rosters including 

employees from Dr. Deering’s office, emails on VA purchases apVerDate Aug 31 2005 11:01 Dec 01, 2015 Jkt 000000 PO 00000 Frm 00086 Fmt 6633 Sfmt 6633 Y:\96-130.TXT PAT

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proved by the VISN and VA-sponsored training using a book called, 

‘‘How to lie with statistics.’’ 

And the author explains that his book is primarily used in the 

way to use statistics to deceive and a well-wrapped statistic is better than the big lie because it misleads you and it cannot be pinned 

on you. One of the techniques described in this book—and this is 

again, techniques that are taught in a course for VA employees— 

but I think it might have been used here before the committee. On 

July 11th, this was a chart provided to us by, I believe Dr. 

Deering’s office or folks out of Phoenix, that led the committee, I 

believe, to suggest well, we have a problem with not enough employees. 

And if you look at the blue, you say, oh my goodness, look at the 

increase of the number of visits and needs of patients and the 

green line is the number of the FTEs increased, but when you put 

the two charts together, you will find out that they are on different 

scales and they are about flat. They are about even. This is about 

equal growth if you pull those numbers out there. But I look at 

that and the average American looks at that and says, oh my gosh, 

we just didn’t spend enough money or didn’t have enough employees there. 

But I think it is pretty clear. You can look at this graphic. You 

pull it down, and you look at what your employees are learning 

from in a book in the courses and my question of this probably to 

Dr. Deering or Dr. Thomas, but who orchestrated what appears to 

be a purposeful intent to deceive veterans, Congress, and the 

American people? 

Dr. Deering. 

Dr. DEERING. Well, regarding the book, that, from what I recall, 

that was actually a VISN-sponsored training for coaching sessions. 

I wasn’t involved with purchasing that book. 

The graph that you are showing on the screen right now is part 

of our congressional briefing to our local delegates. There was no 

intent there to mislead anyone. We were trying to basically outline 

the framework of how we got to where we were in Phoenix as part 

of Mr. Michaud’s question. 

Dr. HUELSKAMP. Well, why would you do two different scales and 

put those together. I think that is very misleading, because if you 

actually use the same scale, the growth in the FTEs and the number of visits is about the same. 

Dr. DEERING. I appreciate that feedback. The intent was not to 

mislead. The—— 

Dr. HUELSKAMP. What is the intent to show there? 

Dr. DEERING. The intent to show here is we have had continued 

growth in the outpatient setting on a number of visits that are 

coming into our facility over the last several years, and when you 

look at the increase in the FTE, it has gone up a little bit, but the 

key point here was back in fiscal year 2010, my personal belief is 

that we still, at that point, we did not have enough personnel to 

meet the needs. We were in the process of trying to hire staffing 

and get people on board. 

Dr. HUELSKAMP. But why would your employees be learning from 

a book about how to lie with statistics? 


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Dr. DEERING. Sir, I can’t speak to that. That is a title of a book. 

I don’t—I don’t—— 

Dr. HUELSKAMP. Well, there are employees from your office, I believe that are learning from this course. And so you have never 

seen this book before? 

Dr. DEERING. I have seen the book. I haven’t read it. 

Dr. HUELSKAMP. Are you saying that your employees have the 

book and are using it? 

Dr. DEERING. I don’t know which employees would have that. 

Dr. HUELSKAMP. Okay. Well, where did you see the book? 

Dr. DEERING. I saw the book when the coaching session happened. This was quite a long time ago. 

Dr. HUELSKAMP. But I don’t understand. What is a coaching session? You are coaching them to use this book to mislead the public? 

Dr. DEERING. No, not at all, sir. Not at all, sir. 

Dr. HUELSKAMP. Well, describe why you would use a book like 

this which, again, demonstrates how one can misuse statistics— 

and I have a background in this, this is part of my Ph.D.—and misuse statistics to mislead folks? Can you describe why would you be 

coaching people with this book? 

Dr. DEERING. I can’t speak to that because I wasn’t—I didn’t coordinate that training session through the VISN, sir, and I don’t 

know if they were trying to teach people how to notice when statistics are not being used appropriately. 

Dr. HUELSKAMP. Well, actually, it says how to lie. 

Dr. DEERING. Right. So I don’t know if the content of that book 

is teaching people how to notice when people aren’t being honest 

with statistics or if it is teaching people how to lie with statistics. 

I don’t know what the intent of that book is without reading it. 

Dr. HUELSKAMP. This is your chart coming from your office—— 

Dr. DEERING. Yes, I know. 

Dr. HUELSKAMP [continuing]. And I think it is very misleading 

and it is difficult as a policymaker to get to the bottom of the facts 

of the matter, and we just had a hearing earlier, a few hours ago— 

you might have been here—but trying to figure out how many folks 

were on the waiting lists. And the numbers are very confusing coming out of the OIG, but this would suggest that gosh darn it, that 

there has been enormous growth, but there has not. It is a scheduling problem, and we have heard that again and again from the 

OIG, as well as from your office and I think that is very misleading. 

So, Mr. Chairman, I just want to make certain—I just will say— 

and I appreciate the time, Mr. Chairman— it is so difficult to follow what the numbers actually are, and we have gone so far as to 

say the numbers don’t matter anymore because it is driving bonuses and I think that both of you have pretty significant bonuses. 

Dr. Thomas, you have had bonuses for how many years in a row? 

Dr. THOMAS. I don’t know, but I would be happy to provide that 

information. I have the last two years here that I would be happy 

to leave with you. 

Dr. HUELSKAMP. Okay. I think mine show five or six or seven 

years in a row, and also doing very well. 


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So with that, Mr. Chairman, I would have to share this with the 

rest of the committee, let’s be very careful with what we see, unless 

it matches up with reality. 

Can you fix up this chart to match up—put on the same scale 

so we are comparing apples to apples? 

Dr. DEERING. Sure, we can do that for you. 

The CHAIRMAN. Thank you. 

Dr. HUELSKAMP. Thank you. 

Ms. Kirkpatrick. 

Ms. KIRKPATRICK. Thank you, Mr. Chairman. 

Dr. Thomas and Dr. Deering, as you can see, the committee has 

a lot of whys and since this problem has been brought to our attention, and as Dr. Huelskamp said, we want to get to the facts. And 

it is not that we want to harass you, but we want to understand 

the whys in order to craft some policy that makes sense. 

And for instance one of my puzzling whys has been this memo 

of 2010 that outlined all of the scheduling problems, and I just 

would out of curiosity like to know if either of you or both of you, 

maybe, saw that memo and what happened next? 

Dr. THOMAS. I can answer first, Congresswoman. That memo was 

signed and distributed prior to my tenure. I believe it was in April 

of 2010 when that memo was signed and I started in my position 

in 2011. I did not have awareness of it until we realized what we 

were having in the spring of this year that we were having significant issues around our system and started doing the research and 

pulling all the pieces together and became aware of that memo on 

that. 

Ms. KIRKPATRICK. Thank you for that honest answer. 

Dr. Deering. 

Dr. DEERING. My answer would be very similar. I came into this 

position in 2012. Prior to that, I worked as an inpatient hospitalist. 

I ran the inpatient side of the hospital and I didn’t work with the 

outpatient side very much, so I wasn’t familiar with that memo, 

and I didn’t become aware of it until this crisis surfaced. 

Ms. KIRKPATRICK. You know, that is troubling to us, but at least 

it is helpful to know, because obviously there is a problem in communication in terms of checklists of things that need to be done 

and improved. 

I appreciate that you are trying to identify the vets who need 

care and need scheduling. I represent a very large rural district in 

Arizona and I just want to tell you that the VSOs in my district 

are very willing to help you identify those veterans, especially on 

tribal land. So we have vast areas where it is very difficult to reach 

veterans, but they have reiterated over to me over and over again 

that they are willing to assist. A lot of them know them personally. 

We just want to make sure that they got—that they get access to 

care. 

Dr. DEERING. And I am very happy to work with them, as well, 

to try to connect those veterans to their care. 

You know, we were talking earlier about rural health. I grew up 

in a town of 400 people. The VA saved my father’s life. He had 

melanoma and there was not a dermatologist within probably 60 

miles of our home and the local VA was able to leverage teledermatology to get him care in St. Louis and this was in 1992, 1993, so 


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this was years ago that the VA leveraged that type of tool to get 

care for my father, so there are resources, and I am more than 

happy to talk with you afterwards on that. 

Ms. KIRKPATRICK. I appreciate that and the VSOs will be very 

happy to hear that, and I yield back the balance of my time. 

The CHAIRMAN. Thank you. 

Dr. Deering, prior to your current role, you said that you started 

in 2012, had you ever been a clinic director of a medical facility? 

Dr. DEERING. A director of a medical facility, no; I was the chief 

of the hospitalist service at our facility and was responsible for the 

care of the inpatient side of the house. 

The CHAIRMAN. Okay. So you have never been a clinic director 

or service chief of a medical facility? 

Dr. DEERING. No, sir. 

The CHAIRMAN. Okay, thank you. 

Were you aware that scheduling manipulation of any kind was 

occurring in Phoenix before, really, I guess April 9th when it hit? 

Dr. DEERING. When I became chief of staff in 2012 we started 

working on improving access to the veterans and one of the things 

that we had learned in that process was that some of our ambulatory care clinics had carved out time during their day to do administrative work instead of patient care, so we systematically started 

going through that process to standardize the expectations for 

frontline staff in the clinics. I don’t know if I would call it manipulation, but there were certainly some providers who were working 

very hard seeing a lot of patients and there were some providers 

who had managed to block out parts of their clinical time to not 

see as many patients and I don’t think that is fair to our veterans. 

So the expectation would be that we would standardize that across 

the healthcare system and go through and clean those profiles up 

for our providers. 

And unfortunately or fortunately in the process, some of those 

providers felt that they did not want to continue the journey with 

us and they left and others continued to feel like things were being 

rectified and made more fair in the process and it helped to improve appointment availability for our veterans. 

The CHAIRMAN. Are you both aware of the litigation hold that 

was placed on the Phoenix records? 

Dr. DEERING. Yes. 

Dr. THOMAS. Yes. 

The CHAIRMAN. Have—remember that you are both under oath— 

have either of you deleted, removed, or made unavailable, any 

emails related to the scandal in the Phoenix area, any communication at all? 

Dr. THOMAS. I have not. 

Dr. DEERING. I have not. 

The CHAIRMAN. Okay. Dr. Thomas, there was a news report this 

morning on CBS news—I don’t know if you were able to see it— 

citing a whistleblower in the central office who talked about how 

VA officials sought to soften the Inspector General Phoenix report, 

and I want to paraphrase kind of what the whistleblower said. He 

said that the VA was worried that the IG report was going to damn 

the organization, which it did, therefore it was important for VA 

to introduce language that softened the blow. 


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So my question to you is did you ask or are you aware of any 

employee in the central office who asked the IG to change the report or questioned the IG about any language, verbiage in the report? I mean there has been a hang-up on specific words and I get 

that—well, I will let you answer that, yes or no? 

Dr. THOMAS. Thank you very much. I am happy that you asked 

that question. I think it is a very important question. What the IG 

found—— 

The CHAIRMAN. No, that would be a yes or no. 

Dr. THOMAS. It is a more complex situation than that, sir. 

The CHAIRMAN. My question to you is: Yes or no, did you ask for 

any changes in the verbiage? I know the process—— 

Dr. THOMAS. I did not. 

The CHAIRMAN. Okay. Thank you very much, and I appreciate 

your doing that under oath. 

How did you find out that the verbiage had been changed and 

what was your reaction when you heard it? 

Dr. THOMAS. We saved—as I mentioned earlier, the process is a 

standard process that we use with the OIG and we get draft reports. We then begin to draft our response in terms of an action 

plan, as well as any communication products, such as fact sheets 

and communication plans that need to go along with that. 

On one of the iterations of the report, in fact, I do remember the 

very first report made no mention at all of the 40 deaths. The second or third iteration, a paragraph arose in that new draft. It was 

a little bit confusing. I am not exactly sure what it was communicating, and then in the final draft that we got—and we were already working our final action plans and every time we submitted 

something another draft came in—so we would go back and say 

what is different in this draft so that we can then address it and 

update our data. 

In the last draft that we received, it did have the sentence that 

is in there in the final report. 

The CHAIRMAN. So what was the language that was confusing? 

Dr. THOMAS. There was a paragraph in one of the drafts that 

talked about the number of cases. It mentioned something about 

the 40. I don’t remember off the top of my head exactly what it 

said, but it talked about the various levels of concern, so many patients this and so many patients that. I’m sure, since you request 

it from the IG, you’ll see those copies and see exactly what it says, 

but I don’t know off the—I can’t remember verbatim. 

The CHAIRMAN. So the changes were made at about the third 

iteration? 

Dr. THOMAS. Well, there were changes on every iteration of the 

draft. 

The CHAIRMAN. Okay. We are talking about two specific changes. 

It is my understanding—and I should have asked this of Dr. Day 

when he was here—but it is given to the—again, I learned today 

that there are numerous iterations that go back and forth. I 

thought the IG produced a report, gave it to VA, VA reviewed it 

for factual issues, and a final report came out. 

Now, I understand it that there was a back-and-forth conversation between the Office of Inspector General and I assume you? 

Dr. THOMAS. No, sir. 


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The CHAIRMAN. Who? 

Dr. THOMAS. I am sorry, I didn’t hear you? 

The CHAIRMAN. Who? 

Dr. THOMAS. I don’t know. I do not know. I just know that I did 

not have any communication—— 

The CHAIRMAN. Well, the secretary said in his testimony that he 

was not a party to the conversation, so as the chief of staff of Veteran Health Administration, you have no idea who was involved? 

Dr. THOMAS. I had no direct contact with the IG whatsoever during the process. 

The CHAIRMAN. That is not my question. My question is, you 

have no idea who is involved—I mean your—part of your bonus 

and your review specifically talks about the OIG reports and the 

negative impact that they may have and the light that they may 

show. So you are telling me that you had no communication at all? 

Dr. THOMAS. That is correct. 

The CHAIRMAN. Okay. Yet you got a—but you got a perfect performance evaluation and a double-digit bonus, yet you weren’t involved at all? 

Dr. THOMAS. What do you mean I wasn’t involved at all? I wasn’t 

involved at all in any direct conversations with the IG about changing any portion of the report. What I was involved with was taking 

the reports that they submitted to us and making sure that we had 

a good action plan to correct the issues at hand and to have a communications plan that clearly communicated to the Members of 

Congress and the public about—— 

The CHAIRMAN. Okay. And so your action plan, at what point, 

when apparently there were two statements that were entered into 

the report that were not in the original, one was that Dr. Foot did 

not give the 40 names, which, can you tell me why that would need 

to be—— 

Dr. THOMAS. I have no idea. 

The CHAIRMAN. Yeah? I mean I am just trying to figure out why 

that would need to be in a report. 

And then the other about conclusively cannot, which they have 

now said they couldn’t also say that it didn’t cause death. So at 

what point did you learn that that was in the report? 

Dr. THOMAS. When we see the final draft to respond to. 

The CHAIRMAN. The final draft? 

Dr. THOMAS. Yes. 

The CHAIRMAN. Okay. So it wasn’t in the third iteration; it 

was—— 

Dr. THOMAS. And I am not even clear, sir, on how many 

iterations there were. I know that I personally saw three. 

The CHAIRMAN. I think the OIG said there were five. 

Dr. THOMAS. Well, I personally only saw three. 

The CHAIRMAN. Okay. So you did see three? 

Dr. THOMAS. Yes. 

The CHAIRMAN. Okay. Very good. 

Thank you for appearing under oath and answering these questions. I appreciate that. 

Mr. Michaud. 

Mr. MICHAUD. I will set this one out. 

The CHAIRMAN. Dr. Huelskamp. 


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Dr. HUELSKAMP. Thank you, Mr. Chairman. 

As I understand the answer to your last question in terms of Dr. 

Thomas, you saw the iterations, but weren’t able to make any 

amendments? They were just sent to you via email or hard copy 

and here is what is out there. Can you describe that a little further? 

Dr. THOMAS. As with all OIG reports, they are provided to us either on hard copy and/or on email and they are stamped with instructions to guard it and it is only to be used for official purposes. 

When we receive that, we then work with it. We have, as Dr. 

Clancy said, an organization within VHA that is responsible for coordinating the effort—— 

Dr. HUELSKAMP. Is there a distribution—sorry to interrupt you— 

because I think you answered part of that already. Because if I understood, you had no idea who asked for changes, but you received 

those adaptations. 

Was there an email distribution list or is it blind copied to you? 

Dr. THOMAS. No, it went out to a number of people who needed 

that document. 

Dr. HUELSKAMP. Can you describe—can you identify a few of 

those folks who were receiving that document that needed to? 

Dr. THOMAS. I am sorry, I didn’t hear the question? 

Dr. HUELSKAMP. The other individuals that needed to see the 

document—I guess yours was view only. You couldn’t amend it. 

You make no suggestions to amend it, but somebody else did? 

Dr. THOMAS. It is not view only. It is provided on email so that 

if we needed to cut and paste some words to be able to put into 

the action plan, we didn’t have to retype it. I understand the concerns of the committee, I really do. 

Dr. HUELSKAMP. But my question, though, is who was making 

the changes? We still don’t know. I asked the secretary—well, that 

is not me that is somebody down there. You seem to be the one at 

the level and you saw the iterations, but you are telling me from 

the VA side who suggested changes? 

Dr. THOMAS. I do not. 

Dr. HUELSKAMP. Okay. Do you know who would know who made 

the changes? 

Dr. THOMAS. I do not. 

Dr. HUELSKAMP. Do you know who was on the distribution list? 

Did you ever see another email? Can you name one other person 

that received a copy of the drafts? 

Dr. THOMAS. I would have to go back and look at my email to 

see who was on there, because there was a listing on an email, I 

do recall, saying here is who we sent it to and here is who is getting a hard copy of it because we wanted to limit the distribution 

on email because of the fact it was such a high-visibility case and 

that many people would be interested in seeing several of the 

drafts. 

Dr. HUELSKAMP. Well, what happened with the leak, and I can 

appreciate that concern, but the folks that were looking at or reviewing the draft, were they all in your office? 

Dr. THOMAS. No. 

Dr. HUELSKAMP. No. Can you identify another office that they 

might have been from? 


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Dr. THOMAS. There were members from management review 

service. There were members from the operations side of the organization. I am sure that the field probably—— 

Dr. HUELSKAMP. Public relations, did they get a chance to review 

that? 

Dr. THOMAS. Absolutely. Our communications office that reports 

to me needs those documents. They received each iteration because, 

as I said, they needed to start working on the communications 

plan. We needed to work very efficiently and we couldn’t wait until 

something was published and then have them start understanding 

the report and working on a communications plan. 

Dr. HUELSKAMP. Yes. Has a report like this ever been leaked before to your knowledge? 

Dr. THOMAS. There are lots of things that are leaked. I don’t—— 

Dr. HUELSKAMP. To your knowledge, has a report like this been 

leaked before? Do you have any policies against leaking? 

Dr. THOMAS. Absolutely. 

Dr. HUELSKAMP. If someone is found out to be leaking the document or authorizing it, what is the punishment? 

Dr. THOMAS. I think absolutely that they should be held accountable. 

Dr. HUELSKAMP. What is the punishment? 

Dr. THOMAS. We would have to work with our H.R. experts to 

find out. It depends upon that individual if they have had prior disciplinary action because we have progressive discipline within the 

federal government and VA, and so if they have committed prior 

acts, the discipline that would be proposed for them would be 

stronger than if it was a first-time offense. 

Dr. HUELSKAMP. Dr. Deering, I want to ask you some specific 

questions, and, again, trying to understand what was going on in 

Phoenix, if I might. The OIG report identified, for example, 1800 

individuals on near. Did you know there were any folks—are you 

aware that there was a near list? 

Dr. DEERING. I was not aware that there was a near list until 

Chairman Miller brought the concerns up on April 9th and we 

quickly started trying to peel this back and see what was going on. 

Dr. HUELSKAMP. And when did you find out that there were 1800 

names on that list? 

Dr. DEERING. It was sometime in late April. It was probably two 

or three weeks, approximately, from what I can recall, after the 

disclosure of the information from Chairman Miller. 

Dr. HUELSKAMP. Okay. The other thing that is—there is a lot of 

things in here, these urology consults, the numerous other 600 

printouts. When did you become aware that some member of staff 

was printing out a scheduling request and sticking it in a folder, 

when did you find out that was going on? 

Dr. DEERING. Around the same time that I found out about the 

near report. 

Dr. HUELSKAMP. Okay. And what did you do about it then once 

you discovered that that was occurring, and would it be your responsibility to take care of this or is it somebody else’s job? 

Dr. DEERING. Yeah, so my role as a chief of staff at the facility 

level is a little bit different than Dr. Thomas. At the facility level, 

the chief of staff is responsible for the physicians and the clinical 


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side of the house. The scheduling process that you are referring to 

falls under more of the business side of the house, so those were 

not my employees. I cannot really speak to what happened with 

those employees, but I do know that they quickly put a stop to that 

process and started educating staff about the—those employees 

about the correct process to schedule patients. 

Dr. HUELSKAMP. Well, there is actually ten years of OIG reports 

of the scheduling practices, so there was no quick stoppage to it. 

There might have been about this one once it hit the fan, but that 

is a real concern as well, as it has been going on. I mean those 

reports were out there in public for years before you took the job, 

so I was just curious what had happened with those. 

Again, I am not sure what the numbers—as I stated earlier to 

some Members of the Committee—of unreviewed documents and 

files, and it could have been anywhere from three to four to five 

thousand. It was very unclear from the OIG report, Mr. Chairman. 

So thank you for the time. I yield back. 

The CHAIRMAN. Ms. Kirkpatrick. 

Ms. KIRKPATRICK. Thank you, Mr. Chairman. 

Dr. Thomas, we have all been concerned about the antiquated IT 

system and you stated that it is an overly complex scheduling system and you are in the process of fixing that. I just want to know 

what that entails, what you are looking at and just give me some— 

an update on that process. 

Dr. THOMAS. Absolutely, Congresswoman. I think there are two 

components to that. The first is our policy. We need to have a clear 

policy that is easily understood by all of our employees that they 

can follow. The second component would be the system, the IT system to allow us to do that. I do know that just recently we did a 

call out to the field to make it easier for our schedulers and offered 

each one of them dual screens because of the IT system that they 

are currently using, it would make it easier for them to do their 

job to have multiple monitors. 

We are doing interim updates and fixes to our current scheduling 

system while we do a more long-term solution which we have had 

an industry day lately in trying—just recently—in trying to get an 

off-the-shelf solution for our scheduling concerns. 

Ms. KIRKPATRICK. Do you have any idea of your timeline for that, 

when you think that you’ll be able to get an off-the-shelf system 

and really bring it back into the 21st century? 

Dr. THOMAS. I should know that. I sit in the daily briefings that 

we have on this topic and we brief the schedule once a week, but 

I cannot think of that off the top of my head. I would be happy to 

get that information for you. 

Ms. KIRKPATRICK. That is fine. Thank you. 

I yield back the balance of my time. 

The CHAIRMAN. Mr. Michaud. 

Mr. MICHAUD. Yeah. Dr. Thomas, you said that you looked at 

three of the draft reports. Did you provide any input to the IG, either directly or through another staff person, to the IG as far as 

changing that report? 

Dr. THOMAS. I did not. 


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Mr. MICHAUD. Why—you are the chief of staff, and particularly 

with this particular case, the level of publicity that it has received, 

why did you not look at all five of the reports? 

Dr. THOMAS. I don’t think I had an awareness of all five of them. 

In preparation for this hearing, obviously, I went back and looked 

through the history of what I saw and when I saw it and what I 

looked at in my in-box and what I have reviewed were, I could see 

the interim report and three drafts of the final. 

Mr. MICHAUD. So you made no comment to anyone else at VA, 

as far as the report and changes you would like to see in it to VA 

employees? 

Dr. THOMAS. We had plenty of conversations about the report. I 

think that when the first draft came out, we were all quite surprised that there was no mention of the 40 deaths, but we—I, personally, made absolutely no attempt whatsoever to intervene or 

change that. It seemed quite odd since that was what was in the 

news, as the IG had mentioned, all over the news and we personally have answered questions of our neighbors and our families of, 

you work for the VA, did you kill 40 people? That is what people 

thought, but that is not the most important part of that IG report. 

The most important part is that it identified that we have delays 

in care and problems with coordination and that is what we have 

to fix. I personally was interested that the report should address 

the 40 deaths because my concern was that the veterans would not 

have faith in their healthcare system and they need to be able to 

come to us for care if they needed healthcare. 

Mr. MICHAUD. Now, when you had mentioned—you just said 

‘‘that we’’—I guess the part that concerns me is that you are the 

chief of staff and particularly this case has got a lot of news and 

I think we do have to move forward, but we are trying to get back 

to where the disconnect is. And when you mention ‘‘we,’’ who is the 

‘‘we’’? 

Dr. THOMAS. I said ‘‘we’’ and then I corrected myself to I, because 

I am under oath and I can only speak to myself. 

Mr. MICHAUD. But who did you talk with within the Department? 

Dr. THOMAS. I think there were—I know that there were multiple meetings within VHA, with leadership, with communication 

staff, with the congressional folks, both within VHA and—I mean 

it was a topic. It was in the news and we were waiting with bated 

breath to get the report to see what did it say because we did take 

immediate action right after the interim report and we wanted to 

know where else are we falling short where we are not providing 

quality care to veterans. We need to get our act together to fix it. 

We wanted the report to see what else do we need to put in place. 

Mr. MICHAUD. Is that we, Dr. Petzel? Is the we, Secretary 

Shinseki? Or is the we, some staff below you? 

Dr. THOMAS. I think collectively everybody in the Department. 

We have over 300,000 employees in VHA and I am sure almost 

every single one of them gets up every single day to make a difference for veterans, just as I do, and we don’t come to work to try 

to mislead or hide or obfuscate anything. 

Mr. MICHAUD. Yeah, I realize that you have that many employees, but when you said that ‘‘we discussed the report,’’ I am sure 


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you didn’t discuss that report with the 300,000 employees, so I was 

just trying to narrow down the ‘‘we’’ that you were talking about. 

And I know that being the chief of staff that you, oh, that is your 

job, but it is a very important job, and you set the tone, as well 

as the Under Secretary, so I do have a concern with some of your 

answers today. But with that, Mr. Chairman, I yield back. 

The CHAIRMAN. I have one final question. Dr. Thomas, who do 

you believe commissioned this OIG report? 

Dr. THOMAS. I believe that the OIG report was initially started 

because of a hotline call out from a physician from Phoenix and 

that after the April 9th hearing that the IG was directed to do so. 

The CHAIRMAN. By who? 

Dr. THOMAS. I believe Congress charged them with investigating 

the issue. It is my belief, I could be wrong. 

The CHAIRMAN. No, you are correct. 

Dr. THOMAS. Okay. 

The CHAIRMAN. And so my question is, how is it that you got the 

final report before Congress got it? 

Dr. THOMAS. The final draft? 

The CHAIRMAN. The final report. 

Dr. THOMAS. I did not get the final report. 

The CHAIRMAN. Final draft. Call it a draft. Call it a report. How 

did you get—how did you see the final copy, whatever it was— 

how—if you saw the final draft, you saw the final report. How did 

you see it before Congress? 

Dr. THOMAS. I am sorry. I don’t know when Congress got it. I 

know the report was publicly released on, I believe August 26th 

and we see the final draft because we have to respond to it before 

it is published. 

The CHAIRMAN. Okay. Well, it has been your testimony, both of 

you, that neither one of you knew that any of this was happening; 

is that correct? 

Dr. THOMAS. Can you be more specific in your question, sir, any 

of what was happening? 

The CHAIRMAN. Oh, I don’t know, manipulation of data, problems 

with scheduling, any issues with delays in care. You weren’t aware 

of any? 

Dr. THOMAS. In the spring. 

The CHAIRMAN. But you came to work in July of 2011? 

Dr. THOMAS. 2011. 

The CHAIRMAN. And so you weren’t aware of any delays in care 

until April 9th of 2014? 

Dr. THOMAS. As I said when I started this hearing, sir, I think 

VHA missed the boat. We were getting—— 

The CHAIRMAN. No, I am talking about you individually. 

Dr. THOMAS [continuing]. Individual reports from the IG. 

The CHAIRMAN. I am sorry, I am talking about you personally. 

Dr. THOMAS. And I am a member of VHA and a team that wants 

to provide excellent care to veterans. 

The CHAIRMAN. You are telling me that you were not aware of 

any of the problems until the hearing on April 9th? 

Dr. THOMAS. What I am trying to explain is that as the situation 

arises, we were looking at that as an isolated event, as we were 


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each of the IG reports, rather than taking a holistic approach and 

a more comprehensive approach and looking at them together. 

The CHAIRMAN. So, again, your testimony is that you were not 

aware of any of the scheduling problems and delays in care until 

April 9th? 

Dr. THOMAS. I was not aware of the extent of the problem. 

The CHAIRMAN. What does that mean? 

Dr. THOMAS. As I said, each time an IG report was issued, we 

would look at it, respond to it, and create an action plan for any 

of the national reports. 

The CHAIRMAN. Well, the interesting thing—what VA usually 

does is they do respond to it. It is interesting that they accept all 

of the recommendations—in every report that I think has ever been 

handed to them. It is interesting. Now I see how it works. I mean 

if the IG and the VA are working hand in glove backwards and forwards, they already know what they are going to agree to. 

This is the first time that I can remember that VA actually is 

doing some of the things that they have in the past certified that 

they have done. 

Dr. THOMAS. Sir, respectfully, I would not agree with your characterization of our relationship with the OIG. 

The CHAIRMAN. I understand and I will retract that statement, 

but you did, I learned today, you get drafts, you respond, you make 

changes, it goes back to the—do you not? 

Dr. THOMAS. I think it is a very important distinction to 

make—— 

The CHAIRMAN. For factual—for factual—— 

Dr. THOMAS [continuing]. Between the OIG report and the action 

plan. 

The CHAIRMAN. No, no, I am not talking about your action plan; 

I am talking about the IG report. 

But then the IG then makes 23 recommendations in this report? 

Dr. THOMAS. Twenty-four. 

The CHAIRMAN. Twenty-four recommendations and three have already been done. I guess what I am saying is congratulations to VA 

for the first time that I can recall for actually moving on the recommendations, not just certifying them and then we find out 

months and years later that they haven’t been done. But we appreciate your being here. We do apologize for the length that you have 

had to be here today, but thank you very much. Ms. Kirkpatrick. 

Ms. KIRKPATRICK. Thank you, Mr. Chairman, and thank you, 

Ranking Member. And I just want to thank our staffs. You know, 

we started this at noon and it has been a long day, but we need 

to put in this kind of effort to get it right for our veterans, so I just 

want to say that I really appreciate everybody’s effort. 

The CHAIRMAN. Thank you very much. 

And again, Members, I would like to let each of you know that 

Sharon Helman was also invited to appear and we reached out to 

her attorney and we never received a response to the invitation 

that was issued, but she, in fact, was invited to appear, and with 

that, this hearing is adjourned. 

[Whereupon, at 6:26 p.m., the committee was adjourned.] 


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APPENDIX 

PREPARED STATEMENT OF CHAIRMAN JEFF MILLER

I would like to welcome everyone to today’s hearing titled, ‘‘Scheduling Manipulation and Veteran Deaths in Phoenix: Examination of the OIG’s Final Report.’’ 

On August 26, the VA Office of Inspector General released its final report on the 

Phoenix VA healthcare system, which vaulted to national attention after an April 

9 hearing by this committee. The OIG confirmed that inappropriate scheduling practices are a nationwide systemic problem and found that access barriers adversely 

affected the quality of care for veterans at the Phoenix VA medical center. 

Based on the large number of VA employees who were found to have used scheduling practices contrary to Veterans Health Administration policy, the OIG has 

opened investigations at ninety three (93) VA medical facilities, and it found over 

thirty-four hundred (3,400) veterans who may have experienced delays in care from 

wait list manipulation at the Phoenix VA medical center alone. The OIG concluded 

by providing the VA with twenty-four (24) recommendations for improvement to 

avoid these problems from recurring. These recommendations should be implemented immediately, and this committee will work tirelessly to ensure that they 

are. 

Mr. Griffin, I commend you and your team for your work and continued oversight 

on these issues in the months ahead. 

With that said, I am concerned regarding the manner with which the OIG report 

was released, along with some of the statements contained within it. Notably, prior 

to the release of the report, selective information was leaked to the media, apparently by a source internal to VA, which purposely misled the public that there was 

no evidence at Phoenix linking delays in care with veteran deaths. As days went 

on, and people actually read the report, that falsehood became obvious. What the 

OIG actually reported, and what will be the subject of much discussion today, is this 

statement by the OIG: ‘‘we are unable to conclusively assert that the absence of 

timely quality care caused the deaths of these veterans.’’ 

What is most concerning about this statement is the fact that no one who dies 

while waiting for care would have ‘‘delay in care’’ listed as the cause of death, since 

a delay in care is not a medical condition. Following the release of this report, which 

found pervasive problems at the facility regarding delays in care and poor quality 

of care, committee staff was briefed by the OIG regarding its findings and how specific language was chosen throughout the drafting process. 

Prior to this meeting, we requested that the OIG provide us with the draft of the 

report in the form it was originally provided to VA three weeks before the release 

of the final report. 

After initially expressing reservations, the OIG provided us with the draft. 

What we found was that the statement I just quoted was not in the draft report 

at all. 

Another discrepancy we found between the draft and final reports arose with 

statements to the effect that one of the whistleblowers here today did not provide 

a list of forty (40) veterans who had died while on waiting lists at the Phoenix VA 

medical center. First, the OIG stated in the briefing to committee staff that VA inquired why such a statement was not in the report, and the OIG ultimately chose 

to include it. Further, additional information provided by the OIG to committee staff 

shows that, based on the numerous lists provided by all sources throughout the investigation, the OIG in fact accounted for forty-four (44) deaths on the electronic 

wait list alone, and an astonishing two hundred and ninety-three (293) total veteran 

deaths on all of the lists provided from multiple sources throughout this review. 

To be clear, it was not and is not my intention to offend the Inspector General 

and the hard-working investigators he employs. However, I would be remiss in my 

duty to conduct rigorous oversight of the Department of Veterans Affairs if I did 

not ask these questions. I would also like to point out that no one within the department, or any other federal government employee, including the members of this 

committee, is above reproach. 

As such, the committee will continue to ask the questions that need to be asked 

in order to perform our constitutional duty. It is absolutely imperative that the 

OIG’s independence and integrity in its investigations be preserved. Full and transparent hearings like this one will help ensure that remains the case. 


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PREPARED STATEMENT OF MICHAEL H. MICHAUD, RANKING MEMBER

Thank you, Mr. Chairman. 

Today’s hearing provides the opportunity to examine the VA Inspector General’s 

final report on the patient wait times and scheduling practices within the Phoenix 

VA healthcare System. 

This report did not state a direct causal relationship between long patient wait 

times and veteran deaths. For some, that is a major concern, and accusations of 

undue influence by the VA on the IG report will be discussed at length today. 

What the IG did find is that the cases included in this report clearly show there 

were serious lapses in VA’s follow-up, coordination, quality, and continuity of 

healthcare to veterans. They also concluded that the inappropriate scheduling practices demonstrated in Phoenix are a nationwide systemic problem. 

I do not need any more evidence or analysis. There is no doubt in my mind that 

veterans were harmed by the scheduling practices and culture at the Phoenix facility and across the nation. The bottom line is this behavior, and its detrimental effect 

on veterans, is simply not acceptable. 

My heart goes out to the families of the veterans who did not receive the 

healthcare they deserved in Phoenix and around the country. Rest assured, we will 

understand what went wrong, fix it, and hold those responsible for these failures 

accountable. 

As such, my questions to the VA today are straightforward—what went wrong, 

what are you doing to fix the problems, how will you ensure this never happens 

again, and how are you holding those responsible accountable? 

I applaud Secretary McDonald for taking forceful action to begin to address the 

systemic failures demonstrated in Phoenix. We need serious, deep and broad reform—the kind of change that may be uncomfortable for some in VA, but so desperately needed by America’s veterans. 

I believe that such reform must be guided by a higher-level National Veterans 

Strategy that outlines a clear vision of what America owes its veterans, and a set 

of tangible outcomes that every component of American society can align and work 

towards. Earlier this week, I sent a letter to President Obama asking him to establish a working group to engage all relevant members of society in drafting this National Veterans Strategy. 

We know from experience that VA cannot do it alone. We must develop a welldefined idea of how the entire country—government, industry, non-profits, foundations, communities and individuals—will meet its obligation to veterans. 

VA needs to become a veteran-focused, customer service organization. It needs to 

be realigned to become an integrated organization. It should do what it does best, 

and partner for the rest. It needs to be the government model for honesty, integrity, 

and discipline. 

We need to complete our investigation of the problems and provide oversight on 

the solutions. 

I look forward to today’s additional testimony about what happened in Phoenix, 

and how the VA is working to ensure it never happens again. 

I yield back the balance of my time. 


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PREPARED STATEMENT OF SAMUEL H. FOOTE M.D. 

Death Reports by Source 

On the Secret non-reporting Electronic Waiting list ............................................................................................... 44 

From the Schedule an Appointment with Primary Care Consults .......................................................................... 39 

Backlog never completed ........................................................................................................................................ 41 

Expired on AW Backlog ............................................................................................................................................ 2 

House Veterans Affairs Committee ......................................................................................................................... 17 

On the New Enrollee Appointment Request List ..................................................................................................... 28 

OIG Hotline calls ...................................................................................................................................................... 21 

Media reports ........................................................................................................................................................... 8 

Suicides ................................................................................................................................................................... 74 

Urology ..................................................................................................................................................................... 4 

Helpline .................................................................................................................................................................... 3 

Paper wait list ......................................................................................................................................................... 1 

Institutional disclosure ............................................................................................................................................ 1 

Total deaths .................................................................................................................................................... 293 

My original allegation was that up to 40 Veterans may have died while waiting 

for care at the Phoenix VA. The two sources that we were looking at were the Secret 

non-reporting Electronic Waiting List and the Schedule an Appointment with Primary Care Consults. As you can see from the above, the actual number from those 

two sources was 83, more than double my original estimate and nowhere close to 

the 293 total deaths. Primarily, it appears from the report that reviews were done 

on the VA’s Electronic Health Records. One can imagine that it would be very difficult to determine what actually happened on patients trying to get into the system 

who died prior to being seen. 


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