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81–749PS 2003

CLEANLINESS AND MANAGEMENT PRACTICES AT

THE KANSAS CITY VAMC

FIELD HEARING

BEFORE THE

SUBCOMMITTEE ON HEALTH

OF THE

COMMITTEE ON VETERANS’ AFFAIRS

HOUSE OF REPRESENTATIVES

ONE HUNDRED SEVENTH CONGRESS

SECOND SESSION

JUNE 17, 2002

Printed for the use of the Committee on Veterans’ Affairs

Serial No. 107–34

(
COMMITTEE ON VETERANS’ AFFAIRS

CHRISTOPHER H. SMITH, New Jersey, Chairman

BOB STUMP, Arizona

MICHAEL BILIRAKIS, Florida

TERRY EVERETT, Alabama

STEVE BUYER, Indiana

JACK QUINN, New York

CLIFF STEARNS, Florida

JERRY MORAN, Kansas

HOWARD P. (BUCK) MCKEON, California

JIM GIBBONS, Nevada

MICHAEL K. SIMPSON, Idaho

RICHARD H. BAKER, Louisiana

ROB SIMMONS, Connecticut

ANDER CRENSHAW, Florida

HENRY E. BROWN, JR., South Carolina

JEFF MILLER, Florida

JOHN BOOZMAN, Arkansas

LANE EVANS, Illinois

BOB FILNER, California

LUIS V. GUTIERREZ, Illinois

CORRINE BROWN, Florida

JULIA CARSON, Indiana

SILVESTRE REYES, Texas

VIC SNYDER, Arkansas

CIRO D. RODRIGUEZ, Texas

RONNIE SHOWS, Mississippi

STEPHEN F. LYNCH, Massachusetts

SHELLEY BERKLEY, Nevada

BARON P. HILL, Indiana

TOM UDALL, New Mexico

SUSAN A. DAVIS, California

PATRICK E. RYAN, Chief Counsel and Staff Director

SUBCOMMITTEE ON HEALTH

JERRY MORAN, Kansas, Chairman

CLIFF STEARNS, Florida,

HOWARD P. (BUCK) MCKEON, California

JIM GIBBONS, Nevada

MICHAEL K. SIMPSON, Idaho

RICHARD H. BAKER, Louisiana

ROB SIMMONS, Connecticut

ANDER CRENSHAW, Florida

HENRY E. BROWN, JR., South Carolina

JEFF MILLER, Florida

JOHN BOOZMAN, Arkansas

BOB FILNER, California

RONNIE SHOWS, Mississippi

SHELLEY BERKLEY, Nevada

CIRO D. RODRIGUEZ, Texas

LUIS V. GUTIERREZ, Illinois

VIC SNYDER, Arkansas

STEPHEN F. LYNCH, Massachusetts

(II)
(III)

C O N T E N T S

June 17, 2002

Page

Cleanliness and Management Practices at the Kansas City VAMC ................... 1

OPENING STATEMENTS

Chairman Moran ..................................................................................................... 1

Prepared statement of Chairman Moran ....................................................... 49

Hon. Bob Filner ....................................................................................................... 3

Hon. John Boozman ................................................................................................. 4

Hon. Karen McCarthy, a Representative in Congress from the State of

Missouri ................................................................................................................ 4

Hon. Christopher S. Bond, a U.S. Senator from the State of Missouri, prepared statement ................................................................................................... 51

WITNESSES

Baldwin, Bryan, President, Union Local 2663, American Federation of Government Employees, VA Medical Center, Kansas City, MO ............................ 25

Doran, Hugh, former Director, VA Medical Center, Kansas City, MO ............... 29

Prepared statement of Mr. Doran ................................................................... 69

Grewe, Shari, Patient Advocate, VA Medical Center, Kansas City, MO ............ 27

Prepared statement of Ms. Grewe ................................................................... 66

Hill, Kent, Director, VA Medical Center, Kansas City, MO ................................ 40

Prepared statement of Mr. Hill ....................................................................... 80

Klotz, M.D., Stephen A., Professor of Medicine, University of Arizona, Section

of Infectious Diseases, and Staff Physician, Southern Arizona VA Health

Care System, VA Medical Center, Tucson, AZ, accompanied by Teola Tillman, former Infection Control Nurse, VA Medical Center, Kansas City,

MO ......................................................................................................................... 7

Prepared statement of Dr. Klotz ..................................................................... 58

McEwen, Linda, President, Union Local 910, American Federation of Government Employees, VA Medical Center, Kansas City, MO .................................. 23

Prepared statement of Ms. McEwen ............................................................... 62

Roswell, Robert H., M.D., Under Secretary for Health, Veterans Health Administration, Department of Veterans Affairs ................................................... 36

Prepared statement of Dr. Roswell ................................................................. 76

Slachta, Jr., Michael, Assistant Inspector General for Auditing, Department

of Veterans Affairs ............................................................................................... 5

Prepared statement of Mr. Slachta ................................................................. 52

MATERIAL SUBMITTED FOR THE RECORD

Statements:

Mr. Jack Sites, veteran .................................................................................... 83

Parylayzed Veterans of America ..................................................................... 84

Vietnam Veterans of America ......................................................................... 85

Written committee questions and their responses:

Chairman Moran to Dr. Stephen Klotz .......................................................... 91

Chairman Moran to Ms. Teola Tillman .......................................................... 95

Chairman Moran to Mr. Hugh Doran ............................................................. 96

Chairman Moran to Bryan Baldwin, President, AFGE Local 2663 ............. 98

Chairman Moran to Linda McEwen, President, AFGE Local 910 ............... 102

Chairman Moran to Dr. Robert H. Roswell, Under Seretary for Health ..... 104
Page

IV

Written committee questions and their responses—Continued

Chairman Moran to Mr. Kent HIll, Director, Kansas City VAMC .............. 114
(1)

CLEANLINESS AND MANAGEMENT PRACTICES

AT THE KANSAS CITY VAMC

MONDAY, JUNE 17, 2002

HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON HEALTH, COMMITTEE ON VETERANS’ AFFAIRS, Washington, DC.

The subcommittee met, pursuant to call, at 9 a.m., VA Medical

Center, Kansas City, MO, Hon. Jerry Moran (chairman of the subcommittee) presiding.

Present: Representatives Moran, Boozman and Filner.

Also Present: Representative McCarthy of Missouri.

OPENING STATEMENT OF CHAIRMAN MORAN

Mr. MORAN. Good morning, everyone. It is good to be at the Kansas City Veterans Medical Center. This is a facility that as a Kansan, I care very much about. Many veterans from my state utilize

this facility, and I am delighted to be here as Chairman of the

Health Subcommittee of the House Veterans’ Affairs Committee to

take a look at a few issues that have surfaced over the last several

years, and certainly in the last few months.

My primary desire in having this hearing is to focus on ensuring

that the delivery of quality health care in Kansas City at this medical center now and in the future. I want to focus on the quality

of health care rather than dwelling on past occurrences. I hope that

today’s hearing will reassure veterans and their families, the staff,

and the employees of this facility that the care our veterans receive

at this medical center will be of the highest quality and will be provided in a clean and sanitary environment.

I am certain that since the publication of the article last March

describing insect and rodent infestation at the medical center, this

topic has been discussed among veterans and their families, and

certainly the staff and administration of the hospital, and I have

no doubt there was increased concern about this hospital among

veterans and their families. The VA both here and in Kansas City

and Washington, DC, will have ample opportunity this morning to

assure us that the circumstances described in that medical journal

are things of the past, and that practices, policies, and personnel

are in place to ensure that health care is appropriately delivered

to our veterans.

I also believe we can learn lessons from this hearing that will

prevent the kind of problems experienced here from occurring elsewhere in the VA health care system. That certainly is our goal, and

the veterans of our country deserve nothing less.
2

I welcome the witnesses and others in attendance today. I appreciate our veterans, the patients, veteran family members, and our

VSO officials joining us today. I thank my friend and Ranking

Democrat member of the subcommittee, Mr. Bob Filner of California, for his assistance in preparing for this hearing and his presence in Kansas City, MO, today. Also our colleague on the committee, John Boozman of Arkansas, joins us, and he is a member of

this subcommittee, and glad to have John with us in Kansas City.

My friend and travelling colleague out of Kansas City International

every Monday morning and returning every Thursday or Friday

afternoon, your local Congresswoman Karen McCarthy is joining us

today. This hospital is in her district, and I am very grateful for

her interest in this topic and in this hospital. She and I visited the

Kansas City Veterans Medical Center together 6, 8 months ago,

and I know that she has taken an abiding interest in the quality

of health care that is provided here for the veterans of the Kansas

City area.

Again, this hearing gives us the opportunity to review recent

events at the hospital. The origin of this hearing occurred in March

of this year within the publication of an article in the Archives of

Internal Medicine. My medical knowledge may limit my understanding of nasal myiasis, but I clearly understand the realities of

a mouse infestation. The author of that article is with us today,

and his hypotheses seem to me to link the chronic presence of

house mice in this medical center, and the effort to rid them, to an

infestation of flies and the subsequent discovery of nasal myiasis

in two medical intensive care unit patients.

The article reviewed a number of actions to remedy the problems, but left an impression that management did not sufficiently

act to eliminate the problem. Also it has been suggested that funds

were not sufficient to enable the medical center to cope with this

pest infestation while meeting its other responsibilities in delivering patient care to veterans.

Secretary of Veterans Affairs Anthony Principi has been to this

hospital on a couple of occasions now since that report. In my opinion, he has acted swiftly to make changes to the medical center and

has instigated two investigations by the Office of Inspector General. Those reports were published here just a couple of weeks ago,

and we have the inspector general from the VA with us today to

discuss the outcome of the inspector general’s investigations.

Today’s hearings will consider those reports. We will receive testimony from the primary author of the Archives article; the chief

VA investigator; the former chief executive of the medical center;

representatives of medical center employees; the facility’s patient

advocate; VA’s top health care official, the Under Secretary for

Health; and the current chief executive of this facility.

My subcommittee has spent the last 45 minutes with a walking

tour of the hospital. We were delighted at we saw this morning and

will continue to review circumstances that this hospital faces, all

with the goal of making certain that our veterans receive quality

health care at this hospital and that this hospital has a future in

providing those services to our veterans. We certainly received a

good impression this morning during the tour, and we especially

enjoyed the opportunity to visit with staff and employees. I can see
3

significant pride in the accomplishments in their working environment and the job they have performed.

It was my pleasure to take another tour of the hospital and to

be here. We are delighted to be able to hear some testimony, to

make some conclusions today, and again later this year.

[The prepared statement of Chairman Moran appears on p. 49.]

Mr. MORAN. I would ask Mr. Filner of California if the gentleman has any opening comments he would like to make.

OPENING STATEMENT OF HON. BOB FILNER

Mr. FILNER. Thank you, Mr. Chairman. Thank you for bringing

us here and educating us about this situation. First, I would like

to say that with Mr. Moran, who, of course, represents Kansas, and

Ms. McCarthy, who represents this district, the people in this area

have incredibly good advocates for veterans and for the community

in general. They do a great job for you back in Washington, and

they work in ways that are very effective, sometimes not always

noticed, but they are very effective Congress people.

I know, Mr. Chairman, that we all shared the sense of horror

and dismay that must have ripped through the entire VA health

care system and through every member of this committee when we

first learned about the incidents that you have mentioned. It is the

job of this committee and each one of us personally to ensure that

our veterans receive the best possible care in a clean and safe environment. Nothing less is acceptable. I know this medical center,

like many in our VA, was built half a century ago in another era

when health care delivery was very different from the health care

model and all the technological advances that we have with us

today. The cost to keep a facility of this size and importance up to

date, modern and functioning with all the modern advances, is

daunting at best.

Now, Mr. Chairman, we know and we have discussed back in

Washington at many hearings that our Nation—and this covers

both Democratic and Republican administrations—has failed in recent years to allocate the kind of funding needed to maintain VA’s

health care infrastructure. All across the board, whether it is waiting times that veterans have to suffer through, or lack of clean and

well maintained buildings, or lack of new buildings, are problems

that we have to deal with every day. And our committee has tried

to fight for more funding, although that comes out of a general political decision that is made by the total Congress. We know putting a new face on an old building doesn’t seem to have the same

emotional appeal or bang for the buck, and yet as we have had to

learn the hard way, the costs for failing to do so can have unintended and devastating consequences.

I hope we will all take the lessons provided by the circumstances

here and apply them to the bigger picture not only, Mr. Chairman,

in the specific situations that we have witnessed and hopefully are

being taken care of, but in the whole management structure of this

facility and our VA system in general.

Mr. Moran, we thank you for your commitment to veterans

health. The leadership within the Department of Veterans Affairs

is very strong, I know, and we have worked with the Secretary Mr.

Principi very well. He comes from my home town of San Diego, and
4

he took swift and decisive actions to both investigate and then resolve the longstanding and difficult conditions here. And the new

Under Secretary for Health Doctor Roswell is here today, and the

whole team of the IG for the investigations that I hope will correct

all the problems. The new leadership here at Kansas City Medical

Center and, of course, the dedicated, hard-working employees who

day in and day out serve the health care needs of the veterans in

this community are the strength and fortification that will make

this old building continue to be a quality health care system.

We have looked at the building. We have looked at some of the

improvements, but we are interested to make sure that the community understands that progress is being made, and that management improvements are also being made throughout the system. So

I look forward, Mr. Chairman, to hear the testimony and make

sure that we learn from this situation.

Mr. MORAN. Mr. Filner, thank you very much. Thank you very

much for making your way from California to Kansas City and participating today.

Mr. Boozman, welcome to Kansas City. I would welcome any

opening remarks that you might have.

OPENING STATEMENT OF HON. JOHN BOOZMAN

Mr. BOOZMAN. I would like to thank you, Mr. Chairman, for convening the meeting, and I know you and Congresswoman McCarthy have been very concerned about this. We have just got through

doing a tour of the facility, and I was impressed. I think the hospital is well on the way to—is getting there in the sense of well

on the way of getting where it should be. It is better now than it

was a year ago, and I know in the future it is going to get even

better.

What I would like for the outcome of this hearing to be is such

that we identify some of the systemic problems that allowed it to

get in this condition or in the condition it got into, and perhaps be

able to carry that over to existing VAs and again try and figure out

some resources that perhaps we can provide to help with those

other facilities.

Thank you very much.

Mr. MORAN. Thank you very much, Mr. Boozman.

Karen, I don’t need to welcome you to Kansas City. It is good to

be with you. Any opening remarks?

OPENING STATEMENT OF HON. KAREN MCCARTHY, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF MISSOURI

Ms. MCCARTHY. I am truly honored to be a part of this subcommittee’s effort. I appreciate you adopting me for the occasion,

and it is truly a bipartisan, collaborative effort for all of our

veterans.

This is a flagship institution. It is known for its quality care, and

I am—I commend the subcommittee for its ongoing efforts year

after year to try and provide more funds for our veterans. I am

usually out there on the floor championing your efforts as we go

through that process, in the appropriations and authorization, and

I think that that is at the core what may be needed to resolve both

the situation here and in other hospitals of the same age.
5

But I want to commend the staff here for what we saw this

morning and the efforts that have been taken in the recent months.

As the report was published just in April and brought to the attention to all of us the need for more continuing efforts, I find that

from our tour this morning, there have been aggressive responses

to many of the problems, and we have seen some of the improvements. And I think what we will need to do, Mr. Chairman, as we

hear the witnesses and as we get our questions answered, is

strategize on the way back to Washington today about what our

proper role will be to see that this institution can return to the

greatest—the greatness physically that it has in its reputation of

patient care.

So I thank you for letting me be a part of this field hearing. I

appreciate all that has gone on to improve the supervision, the

training and the hiring of new staff to address the problem, and

I know that the Veterans’ Administration and the new management of the medical center will eliminate these environmental and

sanitary problems in order to continue to provide quality care to

the patients they serve.

Thank you, Mr. Chairman.

Mr. MORAN. Thank you very much, Congresswoman McCarthy.

We are delighted to be in your community and at this hospital. I

look forward to working with you to see that only good things happen here.

Mr. MORAN. I don’t know that there is a Representative from any

other congressional offices. I know Senator Bond has submitted

written testimony, and if there is no objection, his testimony will

be placed in the record. No objection, so ordered.

[The statement of Senator Bond appears on p. 51.]

Mr. MORAN. I am told that a representative from Representative

Moore’s office is here. If you would like to stand up. Anyone who

has veteran problems may see Congressman Moore’s staff. We are

delighted to have you, and we appreciate Congressman Moore’s interest in this topic.

We will call our first panel. Our first panel consists of Dr. Stephen Klotz, professor of medicine, and also a practicing physician

at the University of Arizona School of Medicine and at the VA

Medical Center at Tucson, AZ, and this medical center’s former

chairman of the infection control committee. He is accompanied by

Ms. Teola Tillman, a retired VA nurse and former infection control

nurse at this medical center. Also Mr. Michael Slachta, Assistant

Inspector General for Auditing, from the VA Central Office in

Washington, DC. Mr. Slachta was the chief investigator who responded to the Secretary’s decision to investigate the occurrences

mentioned earlier.

Thank you for attending, Dr. Klotz, and without any additional

delay, we will begin our hearing. We will hear from Mr. Slachta.

STATEMENT OF MICHAEL SLACHTA, JR., ASSISTANT INSPECTOR GENERAL FOR AUDITING, DEPARTMENT OF VETERANS

AFFAIRS

Mr. SLACHTA. Mr. Chairman, members of the subcommittee, I

am here today to report on the results of our review of the Kansas

City Medical Center. At the request of the Secretary of Veterans
6

Affairs, we conducted a review to determine if, one, significant deficiencies existed in the sanitary conditions at the medical center;

two, whether any deficiencies found had an effect on the quality

and outcomes of medical care for patients treated; and three, what

corrective actions were taken to implement the recommendations

made in our report of the combined assessment program review of

this facility dated in January 2002.

We conducted our on site review from April 1 through April 10,

2002, and our report presents our analysis of the medical center’s

environment of care and the progress made by the medical center

in implementing four prior CAP recommendations. The medical

center’s management did not maintain the medical center at appropriate levels of cleanliness or rid the medical center of pests. The

unclean conditions date back to at least October 1997; were discussed among medical center management, staff and patients and

were well documented in medical center records. Management of

the Heartland Veterans Integrated Service Network, VISN 15, was

also aware of the poor sanitary conditions and pest control

problems.

Medical center e-mail shows that management was aware of insect and rodent infestations dating back to July 1993. E-mail messages describe incidents involving rodents and insects in the surgical intensive care unit, operating room and patient ward areas in

1993, 1994 and 1995. However, reports of filthy clinical areas, fruit

flies, gnats, flies, wasps and rodents began appearing in e-mail

messages and committee minutes with more frequency in 1998.

These records document discussions of these problems from calendar years 1998 through January 2002 involving the former medical center director, key clinical managers and providers, environmental and infection control managers and patients.

We also found that the clinicians had a program for ongoing surveillance for pathogens of medical importance, took specific effective actions to address infestation issues and outbreaks of disease,

and conducted ongoing training directed toward general and specific infectious disease topics.

Medical center clinical management also implemented effective

controls to monitor the quality of care provided to patients as the

controls related to infectious diseases and infection control. We

found that the care provided to the two patients discussed in an

article entitled Nasal Myiasis in an Intensive Care Unit Linked to

Hospital-Wide Mouse Infestation was adequate, and that the incidents described occurred because of a recurring pest control problem at the facility. We concluded that the maggots found on two

ICU patients was unacceptable and closely associated with an overall unclean patient care environment.

We determined that management did not maintain the medical

center at appropriate levels of cleanliness or rid the medical center

of insects and pests. Management of the Heartland Veterans Integrated Service Network was aware of the poor sanitary conditions

and pest control issues at the Kansas City Medical Center. These

conditions existed because network and medical center management had not acted aggressively to respond to numerous warnings

and instances brought to their attention for years. We believe top

managers were able to avoid major illnesses at the medical center
7

only because of dedicated efforts of the health care team who compensated for the lack of aggressive pest management actions and

institutional housekeeping support.

In response to our report, the Secretary concurred with our recommendations to ensure that managers are held accountable for

the sanitation of the medical center. He indicated that the Under

Secretary for Health closely monitor and provide his office reports

on implementation of the plan, corrective action developed by the

acting network director and medical center director.

This concludes my testimony. I would be pleased to answer any

questions that you or the subcommittee would have.

Mr. MORAN. Thank you very much.

[The prepared statement of Mr. Slachta appears on p. 52.]

Mr. MORAN. Dr. Klotz, we are delighted to have you with us

today. Perhaps your report is what starts this story, at least from

the perception of the public and our awareness. So we appreciate

hearing from you and Ms. Tillman, if she has remarks as well.

STATEMENT OF STEPHEN A. KLOTZ, M.D., PROFESSOR OF

MEDICINE, UNIVERSITY OF ARIZONA, SECTION OF INFECTIOUS DISEASES, AND STAFF PHYSICIAN, SOUTHERN ARIZONA VA HEALTH CARE SYSTEM, VA MEDICAL CENTER, TUCSON, AZ, ACCOMPANIED BY TEOLA TILLMAN, FORMER INFECTION CONTROL NURSE, VA MEDICAL CENTER, KANSAS

CITY, MO

Dr. KLOTZ. Thank you. I am pleased to be here this morning to

testify before this committee. The issue of the mice and maggots as

reported in a recent article is a matter of public record. It is accurate, and I hope we will not waste time rehashing the contents of

the publication. I was led to believe that this committee wanted to

address weightier problems; for example, what events or decisions

brought about such a dismal state of affairs. Hence, my interest in

appearing.

All of my adult life has been spent in Federal service, first as a

battery commander in the Army Artillery with nuclear weapons,

later as a physician with the Indian Health Service, and now as

an infectious disease physician with the Veterans’ Affairs for the

past 17 years. I mention this to point out that I have experienced

a variety of bureaucratic organizations.

There was a cataclysmic change in the managerial structure in

this organization now half a decade ago that has entirely changed

the landscape of patient care with the unfortunate result that there

has been a loss of focus on the veteran patient. Some of the decisions and their consequences were not self-evident at the time of

change. Important knowledge on how to run an effective and safe

hospital was sacrificed in no small degree at that juncture. Difficulties are only now apparent as we gaze at beleaguered VA hospitals

with increasing numbers of patients, fewer doctors and nurses, an

increasing need for expensive and effective medications, and a need

for timely consultations and operations.

The structural changes that occurred brought a measure of fiscal

responsibility to the VA. That is a good thing. However, I would

like to focus our attention on some matters that still require

change to bring about more improvement. I have limited time in
8

this statement and so will restrict myself to briefly mention five

major ongoing problems in the VA system, most a consequence of

the change in the management style some years ago. What I have

to say is applicable to all VAs, not just Kansas City. It is exceedingly difficult to uncover where trouble begins in an organization

of this size, but I believe I can disclose some areas where changes

were made leading to major deficiencies eventually impacting on

patient care.

The five major problems are as follows: 1.) The addition of an entire cadre of middle managers who embrace a business model of

management. These managers have fiscal oversight in the clinical

side of the organization and are neither sufficiently knowledgeable

nor trained in the areas they supervise.

2.) The hospital director has more real power than the chief of

staff. There is no equal partnership.

3.) A sundering of any meaningful relationship with local medical

schools.

4.) Individuals in the organization with direct patient care, for

example, physicians and nurses, have no meaningful influence in

the organization of patient care.

5.) Supervisory positions are all too frequently held until retirement.

Let us look in detail at problem 1, that is, the insertion of a business style of middle management and how this relates to current

problems. Former departmental structures were eliminated in

1996, and entirely new positions were created with supervisory and

fiscal control. I direct your attention to table 1. The real numbers

of physicians and dentists, registered nurses, licensed practical

nurses and nurses aides have declined since 1995. You will not be

surprised to hear me tell you that the numbers of support personnel has actually risen during the same time frame.

Contrast the data in table 1 with table 2, where it is evident that

the number of patients, visits and expenditures by the VA have all

risen from 1995 to the present. When all of this was occurring, it

appeared as if the possession of real credentials for a job position

was grounds for immediate disqualification. For example, we had

the unenviable experience at the Kansas City VA of witnessing the

promotion of a very fine engineer to direct line authority over the

pharmacy and housekeeping, disciplines of which he had only superficial knowledge. Internists were placed in direct charge of subspecialty surgeons whose specific requirements often went unmet.

Another fine man, in this case not a physician, was placed in

charge of pathology and radiology, disciplines that even trained

specialists in these fields struggle to direct in the VA. We were told

that the position of Chief of Staff was obsolete, and the individual

in the position was summarily dismissed, only to have the position

reinvented months later. If fiscal responsibility were the desired

goal, it would have been cheaper to hire accountants.

The entire personnel structure of hospitals was reformed around

a business model with the primary emphasis on fiscal soundness,

something we have learned to our regret doesn’t always perform

well even in the private sector, much less in the VA. In the VA system, changes like those I have described translate into process,

that is, paperwork and meetings, rather than into any actual doing,
9

that is taking care of patients. The end result following all of these

changes: it was still left to the nurses and physicians to figure out

how to deliver care in spite of the managerial impediments.

Problem 2 deals with the accumulation of power, real or perceived, in the hospital director’s office and is separate from the

middle management problem. Prior to recent changes, the Chief of

Staff representing the clinical arm of each hospital had meaningful

supervisory control of the professionals and influence on the use of

fiscal and real resources. In bureaucracies, there is always a tendency to seize more power in order to influence one’s own agenda.

In an organization such as the VA, established to provide professional services essential to patients, this can be disastrous when

the equation is tilted toward nonclinical management.

In the present setup, the Chief of Staff is literally in the pocket

of the director. He or she is incapable of instituting the best system

of medical care composed of nurses and physicians representing the

needed disciplines in order to meet hospital needs. Hence, we see

a system embracing primary care at the expense of all else. There

is disdain for specialists at the very time that HMOs are realizing

the hazards of such an approach. Specialty consultations cannot be

met in a timely fashion, and many subspecialties are inadequately

represented in the system.

Problem 3, a sundering of any meaningful relationship with local

medical schools. The VA is an important partner in the training of

physicians, pharmacists, psychologists and nurses in the United

States. One of the major reasons many professionals join the VA

is to participate in a collegial fashion with the local university medical school. Individuals may enjoy regular faculty status with their

respective schools because of their own accomplishments.

In these Dean’s Committee VAs, the control of education establishing who would teach trainees was exercised, rightfully, by the

universities. This productive working relationship is no longer extant. The medical schools are in fiscal distress, and the VA has the

money to spend on cheap workers, i.e., the resident and the interns, and a willingness to employ them. The power in this equation is enjoyed solely by VISN headquarters throughout the country. According to the new rules, residents and interns will perform

direct patient services when at the VA regardless of the increasing

number of patient encounters scheduled or the quality of the interactions. Individuals supervising such trainees are not necessarily

established as competent or even interested in medical education.

Problem 4, individuals in the organization with direct patient

care, for example, physicians and nurses, have no meaningful influence on the conduct of patient care. Diminished in numbers and

treating an increasing number of patients, the professional employees, that is the physicians, dentists, pharmacists and nurses, are

increasingly unhappy and unfulfilled. It is alarming when one

hears the best of physicians stating, ‘‘I can’t always do what is

right for the patient,’’ or, ‘‘my time is spent doing computer entry.’’

Caretakers in this organization are trapped behind computers entering data of little or no immediate clinical relevance that consumes half of the patient encounter time. Consultations, depending

upon the service requested, are often not performed in a timely

fashion. Patients are forced to utilize the private sector to obtain
10

these services, only to return to the VA for their medications,

which cost them less in the Federal system.

Contemplate the following scenario, which is the VA’s idea of a

meaningful patient encounter. Following clinic visits, patients were

asked questions mandated by VA Central Office such as, ‘‘Did your

doctor smile?’’ ‘‘Did your doctor look you in the eye?’’ ‘‘Are you

happy with your care?’’ All cosmesis, no substance.

There is no process by which to determine if your doctor is even

competent in the VA, which is an important question, since there

is no meaningful professional development for physicians in the

VA, and the distancing from the medical schools contributes in no

small way to a deterioration of the faculty. I suspect the demoralization of the professional staff will be the ultimate undoing of

this organization.

Problem 5, supervisory positions are all too frequently held for

a professional lifetime. This statement is self-explanatory. The genius of the democratic system is not that we can vote in whom we

want, but more importantly that we can vote out individuals whom

we do not want. Such is not the case in the VA.

In conclusion, changes are needed now, but they are not necessarily large ones. All of the foregoing, the good and the bad, was

accomplished by the appointment of one individual with the authority and mandate to affect change. Laws are not required, but

the reestablishment and embracing of a professional culture of

sound clinical practice is required.

Mr. MORAN. Dr. Klotz, thank you very much for your testimony

and your analysis. Look forward to asking you a few questions.

[The prepared statement of Dr. Klotz appears on p. 58.]

Mr. MORAN. Ms. Tillman, is there anything you would like to

say?

Ms. TILLMAN. I do not have a prepared statement. As you well

know, I am retired, but I would like to add in my experience, and

I am still somehow connected with the medical profession, a good

program, especially for good nurses.

Now many of our hospitals have gone to depend upon agencies.

There is nothing wrong with agency nurses, but they are here one

day and gone the next. So if we can prepare a good program—because nurses will stay when they are happy.

Mr. MORAN. Thank you very much.

Let me first ask Mr. Slachta if he has any response to Doctor

Klotz’s analysis? I know that the IG has looked at management of

the VA hospitals in a number of instances. Do you have items that

you agree or disagree with Dr. Klotz?

Mr. SLACHTA. That is a difficult question to respond to.

Mr. MORAN. Thank you.

Mr. SLACHTA. There are several points in there that I do agree

with, and there are other issues we need more information on before I give an IG position. I would like to do a lot more exploration.

Mr. MORAN. That is understandable.

Dr. Klotz, have you visited the hospital and visited with staff and

physicians currently on your visit, I assume, here to Kansas City?

Dr. KLOTZ. No.

Mr. MORAN. So you don’t have any sense whether things have

changed since you were here at the hospital?
11

Dr. KLOTZ. I am sure they have changed.

Mr. MORAN. Have they changed in a systematic way? Are they

more than cosmetic changes?

Dr. KLOTZ. Well, those type of changes were definitely needed.

And to be fair, the individuals who were in charge at that time

made every attempt to do so given their budget and their decisions.

But what concerns me is that just as I pointed out, we are going

to have, we are going to be left with the same system unless we

do something about it. That is the problem. And if I could, I would

like to, as someone pointed out, connect the dots so to speak. How

did we get from mice to the management style? May I take a few

minutes?

Mr. MORAN. Please do.

Dr. KLOTZ. Well, in 1995, or prior to, the changes that as I said,

were cataclysmic, we had a functioning housekeeping service at

this hospital directed by a fine employee. It did well. It kept the

hospital clean. We then had the mandate from Washington to

change, and everything was in turmoil. We ended up with an individual, as I stated, who was the hospital engineer, who is now suddenly in charge of a whole pyramid of agencies or departments of

which he is no more familiar with than I am. The housekeeping supervisor was either retired or dismissed. I don’t recall.

And so his approach to the problem was, well, let us get a consultant firm. I think over $100,000 was paid this firm to come in

and tell us how to clean a hospital. And what they provided was

a computer printout that told you, you, Joe, you go clean this room

on Tuesday, and you go clean that room on Wednesday. Unfortunately no one inputed into the computer the room next to the cafeteria where food was stored. It wasn’t cleaned for over 1 year. And

there was no supervision—no knowledge; it was all lost with this

change. What to do or even how to identify that there was a problem was lost. And then once it became apparent there was a problem, management did everything it could to control it and to improve it. They weren’t in any way creating the problem. Don’t misunderstand what I said. But therein lies the sort of things that can

happen when you just remove an entire culture of knowledge. And

I suspect there are lots of incidents like this in many VAs.

Mr. MORAN. If I understand the point that you are making about

management, it was not that they were indifferent to the

circumstances, it was that the management system did not provide

them with the information with which they could pursue the

problem?

Dr. KLOTZ. Right. And they had no knowledge or any training in

what they were supervising. This is rampant in the VA at the current time.

Mr. MORAN. Do you or have you practiced medicine outside the

VA system?

Dr. KLOTZ. Yes now currently I do. I am the chairman of the Infectious Disease fellowship program at the University of Arizona,

and I am also at the VA, which turns out to be a problem.

Mr. MORAN. Is the management critique that you provided us

this morning applicable to other hospitals outside the VA system?

Dr. KLOTZ. Well, in more ways than you want to hear. I no sooner had this paper published, and I had other Infectious Disease
12

people call me and say, ‘‘hey, these are not only VAs, we’ve got flies

in our place, we have maggots in wounds.’’ It is just not something

you are going to report to the press. And that wasn’t the point of

my report. It was this novel finding of the relationship between the

flies and the mouse infestation, and it was my duty to write this

article.

Mr. MORAN. When did the change—assuming there was a

change—occur in the role that the medical centers play in the VA

health care system? At an earlier time in your career, was the medical center much more actively engaged in this hospital and other

VA hospitals?

Dr. KLOTZ. Well, ask that question again, please.

Mr. MORAN. One of your critiques is that the roles that the medical centers play in supervision and medical education have deteriorated, if I understand your testimony.

Dr. KLOTZ. There is no doubt. I don’t think you will find a physician in the system who would deny that.

Mr. MORAN. It seems to me that that is one of the most critical

components. We need to retie the medical education and our universities together with the VA in a stronger way. Is that true?

Dr. KLOTZ. Yes. It is critical.

Mr. MORAN. What precipitated the demise of that relationship?

Dr. KLOTZ. Well, it happened concurrently, and perhaps because

of the establishment of the current management model, which involved at that time VISN’s. Suddenly VISNs had all the power in

this relationship. Now simultaneous with this was all the fiscal distress that the universities in the country underwent. They no

longer have any control in a meaningful way over what happens to

their trainees because the VAs have the salary money. They have

the money. When the trainee comes here, or any VA, the trainees

will do what the VA tells them, which is their agenda, not medical

education. So this whole thing has been skewed just a little bit, but

enough to really portend problems in the future.

Mr. MORAN. Mr. Slachta, you indicated an awareness on the part

of the VISN as well as the hospital director of filthy conditions and

rodent population. What about the knowledge or awareness of the

VA about the VISN, evidence that this information was known and,

if known, not acted on in Washington?

Mr. SLACHTA. There were no reports going to Washington about

the general cleanliness of the facility itself. There were reports

going to Washington on the maggot infestation that occurred. Reports went into the Assistant Under Secretary of Health’s office,

but they were considered incidents, and that the proper response

was taken by the hospital clinical staff to the issue.

Mr. MORAN. And any evidence that the VA in Washington attempted to correct the problem?

Mr. SLACHTA. No, sir, because they were told the problem was

corrected.

Mr. MORAN. It was just one incident.

Mr. SLACHTA. Just an incident.

Mr. MORAN. I will conclude my questions with this. I thought one

of the most significant statements in your report, which I think is

really in agreement with Dr. Klotz, is actions taken by management through March 2002 were concentrated on addressing specific
13

cleaning and pest conditions and not on organizational failures that

permitted the problems to exist or to persist. I think that is the

message I took from the report—that we can solve problems, we

can make things okay for the day, we can correct an incident, but

do we have the practices in place that prevent this from either happening in the first place or happening again.

Dr. Filner.

Mr. FILNER. Thank you, Mr. Chairman. We could spend a long

time on both of your testimonies, but first, Mr. Slachta. Is that pronounced right?

Mr. SLACHTA. Yes.

Mr. FILNER. It seems that the recommendations that were made

to address these problems—I mean, this is not rocket science.

Mr. SLACHTA. No, sir, it is not.

Mr. FILNER. I don’t understand why all these things weren’t done

continuously. But have we looked at the other hospitals in our VA

system? Do they have these same controls that you would recommend here? Do I have to go to my hospital in San Diego and

find out if they have all this in place?

Mr. SLACHTA. The Office of the Inspector General has a program

of CAP visits in process right now. The current Inspector General,

Mr. Richard Griffin, started the visits. We are making CAP visits

to all facilities. We are currently on a 5-year cycle, so we will be

getting to the facilities once every 5 years. We would like to move

to a 3-year cycle; but are there other facilities like this with these

kinds of conditions? I don’t know. I can’t answer that at this point.

Mr. FILNER. I wondered if anybody can answer that, which would

lead me to believe there is a real problem.

Dr. Klotz, I didn’t get the biography. How long have you worked

for the system here?

Dr. KLOTZ. Seventeen years.

Mr. FILNER. And you were here for also——

Dr. KLOTZ. I was here for 10 years.

Mr. FILNER. Given all these problems that occurred, why do you

stay here in the VA system?

Dr. KLOTZ. You mean in the VA?

Mr. FILNER. Yes.

Dr. KLOTZ. Well, it has offered me a lot. I have enjoyed years of

funding for my basic science research, and I enjoyed taking care of

the veteran patients. It is just like the individuals here, everyone

really cares what they are doing, but you can’t do it if you are not

given the resources to do it. And then you have these impediments,

management above you. It makes life difficult. And I would like to

interpose that it is not that these individuals are bad people. They

are all fine men and women, and I have enjoyed working with

them. But it is a philosophy. It is an understanding of what medicine is about.

Mr. FILNER. Have you brought this critique before to Washington? Do people there understand what you are saying, and have

they responded to you?

Dr. KLOTZ. No. I would be glad to now because I was driven to

this extremity by the actions of the VISN here. Even prior to the

article coming out, I had phone calls in Tucson from the Acting Director at the VA there that ‘‘you are not to talk to anyone.’’ And
14

shortly after the article came out, the VISN headquarters here

closed a lab that I formerly had six individuals working in. I wasn’t

even the principal investigator anymore. But anything that had to

do with my name was off limits. They keyed the employees out of

the lab.

Mr. FILNER. Someone told you not to talk, did you say?

Dr. KLOTZ. Yes.

Mr. FILNER. Can you tell me who told you that?

Dr. KLOTZ. I can tell you that what came right out of VISN office

is the following, verbatim: ‘‘Klotz ain’t gonna work for the VA anymore.’’ And once you are faced with this kind of problem, well, then

you end up coming up with a sort of critique of the whole system.

Mr. FILNER. This critique was not published yet. This critique,

this is not in the article that you had written. But have you communicated this before, this testimony, to Washington, to the

Secretary?

Dr. KLOTZ. Well, the VA always sends out surveys to physicians,

nurses, everyone, and provides its own data and interpretation of

such surveys.

Mr. FILNER. I mean, is it the logical conclusion of what you are

saying that no matter what we saw that was good happening here,

improvements made, that it won’t in the long run make a

difference.

Dr. KLOTZ. Well, I am not so sure it will be sustained. If we keep

saying—— Mr. FILNER. The mice will return.

Dr. KLOTZ. The mice will roar again.

Mr. FILNER. You know, the testimony of both of you seems to

say, and tell me if I am wrong on this, and clearly we don’t have

sufficient monetary resources for this system. But it seems to me

you are saying that that is not the chief problem anyway. Is that

a fair—— Dr. KLOTZ. Lack of money.

Mr. FILNER. Yes. Lack of money. That is not the major problem.

Dr. KLOTZ. No. It is the way these resources are utilized.

I would agree. The utilization of the resources, because we have a $25 billion system here. That is a lot of money, and as this committee knows, I have been one that is trying to take the lead to

provide more resources. But if what you are saying is true, then

we will have some debate about that through the rest of the morning. We should be focusing attention on other things than just lack

of money.

Mr. FILNER. Yes, I would believe so.

Thank you, Mr. Chairman.

Mr. MORAN. I thank Mr. Filner. Mr. Boozman.

Mr. BOOZMAN. Yes, Mr. Slachta, I bet I am not the first one that

has messed that up. I am Boozman instead of Boozman, so I get

confused all the time.

Mr. MORAN. He only changed his name when he became a

Congressman.

Mr. BOOZMAN. Not my name, my habits.

In reading the OIG report, there are three or four things that I

guess just kind of bothered me, that not only I think pertained to

this institution, maybe the rest of the country. One of them was
15

that it seemed like one of the problems here was that there is a

finite amount of money, and in an effort to expand other programs,

housekeeping was basically put on hold. Is that basically what your

report said?

Mr. SLACHTA. Yes, sir. I think that is a fairly accurate picture.

There is a finite pot. Management decisions were made that the

money was going to be used in other areas than housekeeping. In

fact, housekeeping was frozen, no staffing. I would say, as we said

in the report, from about 1996 to about 2001, 2002, there was no

increase in housekeeping staff, and, in fact, there was a decline.

Mr. BOOZMAN. Okay. And so I guess there is really no mechanism to prevent that in other areas of the country, or, I mean, is

that a potential problem for other hospitals also or—— Mr. SLACHTA. It is a management decision on how the resources

are going to be used in the VISN and in the medical centers. The

only mechanisms that would bring this to the attention of Washington would be a failure on the part of a facility on a joint commission visit, an article from the doctors; something special would

have to occur before Washington would be aware of it.

Mr. BOOZMAN. So really you almost have a situation where you

are expanding, and you don’t have the money to take care of what

you have got.

Mr. SLACHTA. Yes, sir.

Mr. BOOZMAN. Okay. The other—there were a couple of other

things. The hospital again in the report seemed to receive good reviews, you know, consistently, even though in your report, you use

the world ‘‘filthy’’ in some areas. How did that happen?

Mr. SLACHTA. For those of us who are veterans, when you had

an IG inspection or a performance, you put your resources into preparing for that inspection. This hospital did that as well. The deputy director of the VISN in his white paper stated that the hospital

was substandard when he came in. He was faced with a joint commission visit. The way he accomplished a good rating from the joint

commission was he hired a private contracting company to come in

to do some cleaning and had his staff concentrate on high visible

areas. So you beef up for the inspection. Once the inspection is

over, you go back to normal.

Mr. BOOZMAN. So to prevent that, then, I mean, you actually

need to reform the inspection system. I mean, evidently it is not

working if you—you know, if you have a situation where, to quote

you, filthy, and then to have a high and then to return to that.

The other thing is that also, it seemed like, again, from your report there are individuals that hierarchy was obviously upset with,

and yet they continued to receive merit bonuses.

Mr. SLACHTA. Yes, sir, that is true. The former director did receive a merit bonus after a year. The rating for this former director

was extremely good for 3 years, then he received 1 year with a very

poor rating, and then the following year he got an extremely good

rating and a good bonus.

Mr. BOOZMAN. Okay. And then I guess the last pattern that I

saw was that you seem to allude to was that there didn’t really

seem to be a lot of responsibility taken by anybody as to—you

know, when we had a problem, it seemed like throughout your report it was kind of somebody else’s fault.
16

Mr. SLACHTA. I don’t want to leave the impression that the clinical staff didn’t try to fix the problem. They did. We say in the report that high-quality medical care was given at this facility. We

believe that. The medical staff here took, I would say, extraordinary measures to keep up, and, in fact, when I was doing my reviews, it was not unusual to see clinical staff doing cleaning.

Mr. BOOZMAN. Right. No, I was speaking more of the hierarchy

not taking responsibility that it was—they didn’t want to interfere

with management style or—you have alluded to that in some of the

report.

Mr. SLACHTA. Yes, sir. The hospital director was in charge, and

his decisions were not challenged by the staff.

Mr. BOOZMAN. Okay. Can I ask you, Dr. Klotz, a quick question?

You mentioned in your testimony to the effect that some of your

colleagues said that they were not always doing what was right for

the patient?

Dr. KLOTZ. I said that they were prevented from doing what was

right.

Mr. BOOZMAN. Can you give an example? Let me let you think

about it.

The other thing that you alluded to was that a lot—half of the

patient encounter time was done doing recordkeeping. Is that higher in the VA than we experience in—I was an optometrist before

I came here, and literally I spent more time filling out the paperwork for Medicare than I did, you know, seeing the patient. I know

it is a problem elsewhere. Is it more of a problem in the VA than

it is in the private sector dealing with insurance.

Dr. KLOTZ. It is a big problem. You are using resources to increase the computerization of the VA. There isn’t any data to demonstrate anywhere that this is going to be effective, or will affect

outcomes. But I can tell you it takes at least 10 minutes per patient to sit in front of the computer to input the information that

the computer requires for each encounter. In some institutions

there are as many as 81 questions you have to strike off before you

can get on to your next patient. Patients are scheduled every 20

minutes.

Mr. BOOZMAN. Right.

Mr. KLOTZ. So, it is a problem.

Mr. BOOZMAN. Okay. Thank you.

Mr. MORAN. Ms. McCarthy.

Ms. MCCARTHY. Thank you, Mr. Chairman, and thank you to all

the panelists here today sharing this wisdom with us.

Nurse Tillman, I was struck very much by the comments that

you made, and I would like to explore those with you, if you don’t

mind. We have been listening this morning to the deteriorating

conditions and the—we know that the cost of prescription drugs

and increase in Medicare patients, all of the fiscal strain that is occurring to this hospital is occurring to other veterans hospitals and

other hospitals in our region and our community and in our Nation. So I doubt that many of the situations that keep nurses from

being happy—and you mentioned nurses stay when they are

happy, and that is not unique to this institution. I find that in my

visits with nurses all over my district. But many of the situations
17

that keep them from being happy are not necessarily unique to

here.

But I wondered if we could, you know, just reflect on this whole

utilization of resources, because it seems to me this morning we are

hearing that that has been at the core of some of the trouble. How

are the resources utilized in your mind? How would you best utilize

them for the benefit of those nurses to keep them happy and to

keep them here? They are—is there any flexibility in the allocation

of these resources, what kind of—when you were here and you

were the control nurse in this whole setting, did you have authority

and input in order to help to reallocate resources so that nurses

stayed happy, or if you could, tell us what you would like to see

as sort of the perfect plan, because without nurses, they are the

front line in patient care.

Ms. TILLMAN. Well, that is why I made the statement that I did.

Anyplace nurses work anymore is going to be difficult because patients are sicker now. Patients are living longer, we have more procedures, and as far as other institutions, I have also worked at private hospitals prior to coming here, and I, as an infection control

nurse, did not have input in the budget or allocation of funds. But

I am coming from experience in that the hours, that is important

for nurses. The average nurse, and I will stick myself out on the

line to say 80 to 99 percent of nurses, if you go into nursing, you

go into it because you care. You want to do a good job. I can hardly

note any nurse who is not about wanting to take good care of patients. But long hours are sometimes a problem. A lot of overtime.

Patient care is difficult. They get worn out and sometimes maybe

burned out.

So flexibility in the hours. Few nurses really work for the money,

very few. We all have to make a living, but if it comes to patient

care, we will work overtime whether we are paid or no because we

enjoy what we are doing. But anyone gets worn out, so I think look

to have comparable salaries. There has not been a lot wrong with

salaries here from an infection control nurse’s standpoint. I made

a very good salary. I was very pleased with it, and I don’t think

any of the nurses are complaining about that. But more resources

for them; allow them to get out of the building, to go for educational reasons, especially those of us in Kansas, we have to have

continuing education units, 30 of them, in order to get our license

renewed. Make that available, because those CEU credits are very

expensive.

So these are things. It is not hard to make nurses happy, but you

cannot overwork them.

Ms. MCCARTHY. In the structure you experienced here at this institution, what means did you have to raise these issues and try

to get them implemented? What was the chain of command or procedure you would use?

Ms. TILLMAN. If I had the opportunity, I would set forth a program especially for staff nurses, a lot in continuing education,

input from them. Nurses know how things should—how a hospital

should run. I venture to say not one nurse here doesn’t. I mean,

you may not always take everything we recommend because it is

always going to be for the patient, but nurses should have input

in structure.
18

I go back to before, there were temporary housekeepers here.

They were let go, and I know in hindsight perhaps that wasn’t the

right thing to do, but with those temporaries they kept the house

pretty clean. They were let go. And then the mistake was we were

building—we were repairing, remodeling, and then to dismiss the

temporary housekeepers put a burden on other staff members, and

they just could not keep it up, so, therefore, some things deteriorated.

But nurses will take on the burden. They will take on the cleaning of the beds, and that takes them away from patient care. I

would say input from your nurses, your staff nurses especially, because those are the ones that are at the bedside. They visit with

the patient, and they are the ones that’s really giving the patient

care.

Ms. MCCARTHY. Thank you.

Mr. Slachta, would you comment on that flexibility, that idea of

having——

Mr. SLACHTA The Department has a position of nurse executive.

It is a means of bringing the information upward. To be honest,

when we go into a hospital, we want to find out what is going on,

the first thing we do is we talk to the nurses. And I believe that

most management structures listen to their nurses. They need to

listen to the nurses. They are an integral part of most of the clinical committees. And it is through the committee structure and

their own supervisory relationships that they get you up to the

medical center director level and even to the VISN level. There is

a representative in the Central Office, nurse executive that sets the

program goals.

Ms. MCCARTHY. I am pleased to hear that last comment. How do

we get there? How do we get them to use it? How do we empower

them.

Mr. SLACHTA. I haven’t found VA nurses to be reluctant to speak.

I think their message comes forward.

Ms. MCCARTHY. Who listens then when they speak? Because I

get the feeling that just based on Nurse Tillman’s remarks this

morning that the dismissal of the temporary help to keep the place

clean, especially under construction, was of concern. It was done

anyway, and there didn’t seem to be any flexibility or any clear

channel to turn to to undo that until, of course, the paper came out

and the public was made known of it.

Mr. SLACHTA. In this facility I saw no evidence that information

was passed beyond the medical center director. I saw no evidence

that information went from here to Central Office, here to the

nurse executive. I saw the information went up to the medical centers through the committee structure, but I didn’t see anything beyond that. And I don’t know whether there was a thought given to

doing it, or was—we reported it, we are going to get on with the

job.

I saw a great deal of concern for the patient, a great deal of concern for the environment. In fact, I saw in some of the infectious

control committee minutes where the nurses were actually trying

to take on supervisory roles for the housekeeping staff, but I didn’t

see that information leaving the hospital.
19

Ms. MCCARTHY. When you saw that, why, then, wasn’t there an

intercession to bring about corrective action? Or were you reading

these reports after the fact? Perhaps I should have—— Mr. SLACHTA. The only thing that I can say, is that there was

a perceived or real, I don’t know, budgetary shortfall in the facility.

Ms. MCCARTHY. I think it was real, but I think that in—that

that is what the Central Office is designed to cope with, either by

coming to get more funds or by realigning those priorities. Yes, I

know we are short of money, and we will remain so for the foreseeable future, but this institution has a great reputation for patient

care.

But when these issues were raised, I think, you know, some conversations should have been held about—what can we reprioritize

here so that we can address this before it becomes a crisis, because

I really believe we need to keep nurses happy. It is a challenge for

all of us in America. And I would like to see it—a renewed commitment on the part of the Central Office to listen better to the nurses

and to intercede if possible when they raise these serious concerns

for patients and have those conversations and not wait for a crisis.

And thank you, Mr. Chairman. I know I have carried on a bit

long.

Ms. TILLMAN. Congressman McCarthy, I have one more comment

especially for our staff nurses. I am a strong proponent of staff

nurses because, again, they are the ones in the trenches. And I

would like to say for the professional standards board, look closer

at those nurses as far as promotions are concerned or bonuses and

not just always to individuals in management. I think the staff

nurses should be considered on every—and other employees, but I

am speaking for nurses because right now that is what we are talking about. But that should be looked at very closely.

Mr. MORAN. Committee, I am going to allow us a very brief second round of questions, in large part because I have one.

But, Ms. Tillman, first of all, just briefly, do you still have

friends who work here at the VA Medical Center?

Ms. TILLMAN. Yes.

Mr. MORAN. In your conversations with them, are things different today at this medical center than they were in the past?

Ms. TILLMAN. As far as?

Mr. MORAN. As far as cleanliness, management, the things that

you think or your colleagues here would think make a good

hospital?

Ms. TILLMAN. There is improvement, and the management, of

course, is listening to many of the recommendations. And many of

the employees, although no longer here, still have greater respect

for Dr. Klotz and his outspokenness. And, yes, much has—improvement is being done.

Mr. MORAN. Thank you very much. My real concern here is that

there is always a scapegoat. Often to me as a Member of Congress

it is we don’t have the dollars. We have significantly increased the

amount of money available for VA health care. The budget passed

by the House of Representatives is certainly the largest increase in

VA health care dollars since World War II. There is always going

to be a need for additional resources. We can find ways to spend

money.
20

There are things that we ought not overlook, and, again, I am

not defending the fact that all the dollars that need to be there are

there, but that can’t always be the excuse for everything that goes

wrong. People have to be responsible for what occurs.

We all work in certain circumstances that affect the outcome.

And today the excuse is something different than resources. In fact,

you admitted, Dr. Klotz, that it is something more than lack of dollars, it is management. I don’t know that I have a question, but

my concern is that no individual is ever responsible, it is the management system. So when we try to resolve problems and no one

can step forward and say, what happens here is my fault, it is a

consequence of a bad decision that was made. It is always: we don’t

have a management system in place to solve the problems. Maybe

that is just the reality of the way life is; that no one is responsible

because the system is responsible.

From my point of view, I guess we need to work on fixing the

system, but I refuse to give up the belief that individuals matter,

that decisions made by people, that leadership skills they have or

don’t have—all of this affects the consequences of the outcome.

Whether or not our nurses are happy is not just a matter of

whether there is dollars. In fact, Ms. Tillman indicated that she

was adequately compensated. It can’t always be just that the management system doesn’t work. It has to be that I as an individual,

I as a manager, I as a nurse, I as an employee were to make good

things happen at this hospital. And as we hear from employee representatives, maybe we will hear a little more about that.

But I only raise this issue because I am troubled by the fact that

whenever everyone is responsible, no one is responsible.

Dr. KLOTZ. Can I address that?

Mr. MORAN. Yes, sir.

Dr. KLOTZ. Briefly. You are right. If I were in my house, and we

had mice all over the place, I would conclude that maybe my mother was a bad housekeeper, or I was. And in this case you can point

to individuals; individuals do matter. Every choice we make matters. As we look at this globally, there are patterns, and we talk

of systems, and they are a problem. And what was the problem?

Well, as I tried to point out, you take individuals, and you put

them in charge of something they know nothing about, no training

in or credentials to perform the duty, and you have mistakes like

this occur. And so you can point to them and say: you did it, or

your decision, by not doing A or B, ended up in this way.

We could find individuals responsble. I think in the long run the

solution comes at looking at what we have instituted here, what we

have layered in to this organization.

Mr. MORAN. Doctor, thank you.

Mr. Filner. Dr. Filner.

Mr. FILNER. Just to follow up on something that the Chairman

just said and Mr. Boozman alluded to, and that is we can’t institute individual evaluations. Can you tell me about the evaluation

system that exists now in the VA? Everybody has testified these

problems were long-standing. Everybody knew about them. We

talked to staff members today, and they said they knew about all

this for years.
21

You said in your statement that everybody stays forever. What

is the evaluation system? The director of the hospital, the VISN director—are they evaluated, and why aren’t these conditions included in their evaluation, and why did they stay if these conditions were so bad?

Mr. SLACHTA. They are evaluated. There is a system of evaluation. The hospital director has performance standards, just as all

VA employees have performance standards.

Mr. BOOZMAN. Well, what—Mr. Chairman, I am sorry for interrupting because it is not—I was once on the school board, and you

asked if there was supervision, if there were evaluations of the

principals, and he said, certainly. And it is the exact same answer

you give. And I made the stupid follow-up, asked can I see them.

And I looked at—we had 168 schools in our school system, and they

gave me the evaluations, and every one of the 168 principals they

had checked satisfactory or unsatisfactory; satisfactory, satisfactory

needs improvement or unsatisfactory. And everybody was satisfactory. I mean, that was the extent of the evaluation system. I

managed to fire the superintendent, by the way. So he got his

evaluation.

I want the evaluation meaningful, and should people who have

bad evaluations be fired, or, you know, moved onward or demoted,

or has that ever—no principal in that system I was talking about

was ever demoted. Is any of that management personnel ever demoted in this system?

Mr. SLACHTA. I can’t speak to that.

Mr. FILNER. Dr. Klotz is smiling, so I think the answer is no.

Dr. KLOTZ. Everyone knows in the VA it is impossible to fire an

employee. I mean, you have to go to great lengths. You have to be

careful. First of all, you have got to go get counsel and, figure out

how to attack the problem. So that is a problem. But the evaluations are not very meaningful.

Mr. FILNER. Well, at some point, Mr. Chairman, I want to have

Mr. Roswell give us some evaluation forms. But it sounds to me

that we don’t do that at all in a very effective fashion—not just

based on your testimony, but my own knowledge of the system.

Mr. SLACHTA. Excuse me, Mr. Filner. I am going to disagree with

Dr. Klotz. I have fired employees. I have fired management employees. I have removed management employees. We can do it. It

is a lot of work, but you can do it. And when you have somebody

who is not doing the job as a supervisor, you are responsible for

doing that. That is your job.

Now, the Department does have a performance evaluation system, and I do know that from time to time they put in there certain

factors. They stress certain issues that they want their managers

to concentrate on. It wasn’t too many years ago that medical care

cost funding was a major concern. It still is a major concern, and

I know it was added to the directors’ performance evaluations, and

they were measured. Now, the problem comes in the measurement

because there are ways to game the measurement, and you see

those kinds of things going on. But you can hold people responsible

and should be holding them responsible.

Mr. FILNER. I wish, Mr. Chairman, we would have each panel in

series. I hope you will stay because maybe the management is
22

going to have a different point of view. Maybe the best thing would

be to have a debate between them instead of on separate panels.

But if you stay, I may ask you for comment on what is going on.

Mr. MORAN. Dr. Boozman.

Mr. BOOZMAN. Yes. Dr. Klotz, Congresswoman McCarthy was

concerned about the information from the nurses, you know, getting out things. In your testimony you mention that now the chiefs

of staff, you know, don’t seem to have any authority. Is that

correct?

Dr. KLOTZ. This is my perspective, yes.

Mr. BOOZMAN. Is that true just here, or is that true throughout

the VA system or—— Dr. KLOTZ. No, it is fairly true throughout the VA system. Of

course, when you talk about the VA, you need to be careful. There

are some flagship VAs which still retain very good working relationships with there respective medical schools. But they are the

exception, rather than the rule.

Mr. BOOZMAN. But in the past, a strong chief of staff, you know,

that did have discretion over budgetary matters and patient care,

just things in general, that was a mechanism of getting everybody

in on the patient care side of it, that is how—that was your—the

way that you expressed your viewpoint and got things done, wasn’t

it? I mean, that is how the nurses in the past would.

Dr. KLOTZ. Right. You had to have a strong chief of staff.

If I may, a short little vignette. The first VA I was a faculty

member at, the director and chief of staff couldn’t agree. They came

to a fistfight, blows in the office. What did management do? They

moved them both up to Washington, DC. My point? It was a draw.

But you have equality.

Mr. BOOZMAN. So that balances out the patient’s side of it with

the business side.

Dr. KLOTZ. Right.

Mr. BOOZMAN. Okay. Thank you.

Mr. MORAN. Ms. McCarthy.

Ms. MCCARTHY. Mr. Chairman, I am glad you pursued this

whole issue on the system and policy and management because

what prompted my questioning to Nurse Tillman was that on July

22, 1998, a nurse, a nurse, first noticed maggots from a 45-yearold patient admitted on July 12. On September 30, maggots were

noticed on another patient. And it wasn’t until October 5 that a

program was released, Program Guide 1850.2, Integrated Pest

Management, IPM, and she talked about nurses having more

input, having—you know, into the organization.

So I think as we go through the other panels today, I would like

to pursue this, the line of thinking that you raised in the second

round, to figure out where in the organization, management or otherwise, we could probably address a little bit better and that might

benefit all the veterans hospitals in our country.

Mr. MORAN. That certainly ought to be our goal, and I appreciate

this panel’s testimony in helping us reach that goal. I thank you,

all three, very much.

Mr. MORAN. Our second panel consists of Ms. Linda McEwen, the

president of Union Local 910, American Federation of Government

Employees; Mr. Bryan Baldwin, president of Local 2663, AFGE;
23

and Ms. Shari Grewe, patient advocate at this VA Medical Center;

and Mr. Hugh Doran, former director of the VA Medical Center

here in Kansas City. We welcome you.

Ms. McEwen, if you would like to begin, we would be glad to

hear from you. We are going to try to be better about our timing.

I am sorry.

STATEMENTS OF LINDA McEWEN, PRESIDENT, UNION LOCAL

910, AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES,

VA MEDICAL CENTER, KANSAS CITY, MO; BRYAN BALDWIN,

PRESIDENT, UNION LOCAL 2663, AMERICAN FEDERATION OF

GOVERNMENT EMPLOYEES, VA MEDICAL CENTER, KANSAS

CITY, MO; SHARI GREWE PATIENT ADVOCATE, VA MEDICAL

CENTER, KANSAS CITY, MO; AND HUGH DORAN, FORMER DIRECTOR, VA MEDICAL CENTER, KANSAS CITY, MO

STATEMENT OF LINDA McEWEN

Ms. MCEWEN. Chairman Moran and Ranking Member Filner,

thank you. My name is Linda McEwen. I am the president of Local

910 from AFGE, which is the American Federation of Government

Employees. My union represents the professionals, approximately

400, in this building, and that is the nurses, the doctors, the pharmacists and those people that give direct hands-on care to the patients in this facility.

I have about 30 years in nursing. The last 18 years have been

with the VA. I have a bachelor of science in nursing, I have a master’s in health service management, I am certified in gerontology,

and I was one of the charter members of this union in 1999.

I am here now to tell you that the professional staff here at this

facility were appalled. We are very frustrated. We were very dissatisfied with the way the problems never got resolved. We did bring

them forward. We did talk, and they were not acknowledged, and

they were not done. We watched our brother union of the nonprofessionals try relentlessly to get more housekeepers, but they

never came. When we came up with the second infestation of filth

and mice and stuff in the canteen, we argued to have the VA—the

canteen closed, and it wasn’t. We tried and tried through a lot of

our internal processes to make what was happening here known,

and it simply didn’t go anywhere.

As a nurse, and as a union officer, I would like to ask Congress

what you guys can do to help us. And I think to start with, your

congressional investigation and your staff certainly having initiated

a lot of activity, and that is good. And to his credit, Secretary

Principi has responded and has really done some stuff to help solve

the underlying problems. And, of course, we have a new director,

and that is excellent. He is really trying to focus us on the direct

patient care issues rather than surveys about patient satisfaction

and joint commission scores, and that is good.

But I would also say to you that I am still very concerned for our

future because directors come and go, and it seems to me that we

need to do a bit more than field hearings to solve this problem so

that it doesn’t happen again, not only here, but in other VAs.

I guess, as you said before, funding is always an issue because

we need appropriate numbers of professional and support staff to
24

give the care. That is the truth. But money alone is not the answer,

and we feel there clearly needs to be some systematic checks and

balances to prevent such an awful thing from happening anywhere

else.

Part of that, we believe, is from the VISN and from Washington.

There are routine reports that are given to Washington from the

VISN. The problem about that, ladies and gentlemen, is that they

are too distant, they aren’t about the front line, and some managers do try to manipulate them. I would share with you that none

of the front-line staff have any opportunity to review those reports

or make any comments on them. So, for example, there are programs—there are surveys to patient satisfaction. Well, as a union

member, if management would have asked the union about those

numbers, we would have objected, and we would have objected to

them because we felt like that they were being manipulated.

You can gloss over the problems in reports to Washington, but

what you cannot do is show the doctors and the nurses and the

other professionals that are doing hands-on care. We know. We

know what is happening. I am an advocate for the patient because

I am a nurse. But as the union president for the professionals, I

really feel that it is important we have a real voice in the workplace; that we tell management what the problems are; that we

discuss the working conditions, even if it is kind of an ugly picture,

which it has been lately. It is important that we do that. It is also

important that we stand ready to help management in terms of

solving these issues.

My thoughts on these issues are you do need a robust, a robust,

labor/management relationship. It is absolutely required if you

hope to have quality of care. It is absolutely required. Information

from the professionals that give the care, who know the systems,

should not be dismissed and should not be ignored. Especially with

the VA, as it tries to become more market-based, we run like a

business. Sometimes when you get down to the bottom line, it

takes away the compassion, and it can divert your attention from

the quality of care. That is where we were, and that cost a lot of

money.

As Dr. Klotz alluded to in his testimony, we were under a ‘‘do

more with less’’ type of management philosophy, and if there is a

good management relationship, it is the individuals who can sit

down with management and say, you know what, less is less. That

is it. It just is.

I recognize that you can’t legislate respect, we understand that,

but you do write the laws that decide what we can say and what

we can do as the representatives of the professionals, and we would

like to urge you to do three things. One is that we would like for

you to require that management should get union information on

reports and be able to comment on the key recommendations or the

content of the report. I think you and Secretary Principi deserve

the rest of the story, and it is the union that can help give you

that.

I think that there has to be strong union partnerships. What we

are asking from Congress, is for your support, to be an advocate

for that and to monitor it, because it is our opinion if you find the

hospital where there is poor or nonexistent labor management, you
25

will find a hospital with problems, and they aren’t just with labor

management. There is actually a very strong underlying basis for

that, and you should look at that. We are asking that you would.

Secondly, we would—or third, we would like for you to know that

as the professionals, we are the ones that play the vital role in delivering the patient care. We know the issues. We know the challenges. But the truth is, ladies and gentlemen, I can’t bring those

up at the bargaining table, because in the VA the law prohibits me

from bringing up any issue that has to do with direct care. So if

you really want to help and you really want to see all of the VAs

better, and you want to be able to monitor that, you need to really

look at 38 US Code 7422. It prevents the professionals who are the

ones who are doing the care from actually talking to management

about the care, and that is a big problem. That is a big problem.

We need a voice in the workplace. We need a strong voice, and we

would hope that you would support strong labor relations; that you

encourage management to hear from us about getting the rest of

the story; and that you look at that law and how you are preventing the very professionals who give the care from bringing up concerns about that care.

Thank you for the opportunity to——

Mr. MORAN. Thank you, Ms. McEwen.

[The prepared statement of Ms. McEwen appears on p. 62.]

Mr. MORAN. Mr. Baldwin.

STATEMENT OF BRYAN BALDWIN

Mr. BALDWIN. Well, Ladies and Gentlemen, my name is Bryan

Baldwin, and I am president of the AFGE Local 2663 here, and

that is basically the LPNs, the health techs, the trades and all the

construction trades, electricians, carpenters, plumbers and the people that do a lot of the front-line work. I am also a life member

of the DAV. I am a life member of the VFW, past commander of

my VFW post.

I was elected in 1997 as president of this local, and right off the

bat there was some concerns about the staffing levels. There had

been a reorganization that went through in 1996 and 1997. There

were a lot of changes that have come about. As a result of these

changes, it seemed like there were certain numbers were going to

be put on exactly how many personnel were allowed in a section.

And right off in just a short period of time, we started experiencing

problems and complaints.

I know there were doctors and nurses in this hospital, sir, that

were sending photographs down to the VISN of what was going on

behind the walls and stuff. I know Ms. Crosetti was aware of those

situations, and evidently she had supposedly discussed them with

Mr. Doran. So, it seemed like next time, we will have to find out

what was wrong.

And I would like to correct the figure that Mr. Klotz mentioned

there. It was $54,000 that was spent on a consultant survey in

1997, and right off the bat they said, you are at least 16 people

short at a minimum to maintain this facility in an acceptable level.

Well, I thought this is all we were going to need. We have got this

survey here. You know, a consultant’s report, and—16 more people
26

are going to show up. And, ladies and gentlemen, that just didn’t

happen.

And I want to tell you, it is my opinion, that the veteran population of Kansas City in this area around here is just about one of

the most fortunate group of veterans anywhere in this country, because I know that the front-line staff around here, the nurses and

the LPNs, the doctors and the people that actually were doing the

hands-on care were doing outstanding job, because I think of the

adverse situation and conditions they had to function under, they

went the extra mile for this veteran population.

Well, I know, conditions just, in my opinion, kept getting worse,

and I kept addressing them. I did everything a labor leader can do.

I tried to negotiate. There was not going to be any negotiations. I

had to file 76 unfair labor practices just to force the management

at this facility to come to the bargaining table, and then it was a

slow process of stall it, stall it, stall it. And I get the one part to

the end—we will just cut to the chase here.

It comes to this canteen situation, and I believe that is in your

report there, that an employee coming in said, have you been up

there in the back? And I said, no. He said, it is deplorable. He said,

it is unbelievable. So I called Mr. Doran, and we got Mr. John

Howard, who was the program facilities manager of this area, and

I took my safety officer, Mr. Bob Cheatham, and we went on a tour

in the back of that canteen. And sir, I—it just—it was unbelievable.

Mr. Doran seen it. We left the area. He said he would take care

of it.

I informed Ms. McEwen here what we saw. She sent an e-mail

out, asking her people not to use the canteen until it was cleaned

up and taken care of. As a result of that e-mail, Mr. Doran had

some rather harsh comments to me about even informing somebody

of something like this. He said he would take care of it. I was

told—by e-mail through the program manager that that weekend

that they had went in and done a real thorough job, and on Tuesday, their own people, the infection control nurse, the safety officer,

the health—employee health nurse here, we (AFGE) weren’t invited to go back again.

Anyway, they went back in, and the first thing they found was

mouse manure in the coffee and the cocoa powder that people

drank that morning. And, ladies and gentlemen, you don’t allow a

condition to exist like that. Feeding people mouse manure is not

right. And, I mean, it was bad. I mean, I see people out here laughing, but it is not funny. It really isn’t.

Well, nothing happened. Nothing was done. A week went by, and

I took these e-mails and I put them in an envelope and put a cover

letter on it, and I said, would you please do something about this?

And I sent it certified mail to Ms. Pat Crosetti’s office. I thought

maybe if she knew, something would be done. It just went on.

I took it to a—every 3 months stakeholders meeting up in the director’s conference room. That is where they invite the service officers and people like that to come in. And I held these e-mail documents up and these consultants reports, and I thought maybe if I

could catch them in a—you know, a situation where the constituents would see it, and Mr. Doran said, well, that was a Cadillac;

16 more people, and I didn’t have money, so I bought the Buick.
27

Some old vet made a crack back there, says, it sounds to me like

you got a Ford Escort, and everybody laughed, and it went on, but

nothing got done.

The thing, as a labor management person I would go to Mr.

Doran and would say, this is mandated to me by the VISN. I would

call Ms. Crosetti, and she would say, well, that is a local issue. You

deal with it. And they just played ping-pong with me. I couldn’t get

anything done.

And what was really sad, I guess, in the outcome of this investigation, and I think you people should know this, I am the individual that provided the documentation to Senator Bond when this

broke, because the documents that I have—and he shared them

with Mr. Principi, and, yes, things immediately started happening,

but it shouldn’t be that way. I watched on television that night

after the story broke, and they had the news media here, and they

said, oh, this was an isolated incident; this happened 4 years ago,

and we took care of it. Ladies and gentlemen, the bug zappers and

the plastic was put up 15 minutes before the news media took that

tour. The employees had to hustle to get up there that morning and

get it done before the media got here. That is just like I call hide,

conceal and cover up, and it went on at this facility.

So I don’t know. Like Ms. McEwen said, I think that if we—if

nothing else, that these reports and so forth that go to Washington

that is sent out by the managers, it can be very easily manipulated. I don’t know the answer. I think that in this situation we

could all use more money, but it is like you say, just throwing

money at a situation when it is mismanaged at that extent or level,

here I don’t know.

I feel sorry for the employees. They worked hard. Can you imagine every day, sir, that you would come into your job and you are

going to be doing something different that was forced by our management? They were at one time down to 32 housekeepers, and

they were supposed to have 46 plus an additional 16, and they

were down to 32. These people, they were paid like 19,000 hours

overtime. They were burning these people up. Instead of an 80-

hour pay period in 2 weeks, there were employees here working

120 and 130 hours every 2 weeks, and they couldn’t get ahead.

Mr. MORAN. Thank you.

Mr. BALDWIN. Thank you.

Mr. MORAN. Thank you, sir, very much. Ms. Grewe.

STATEMENT OF SHARI GREWE

Ms. GREWE. Hi. Mr. Chairman, members of the subcommittee,

and the members of the congressional delegation, for the Kansas

City VAMC my name is Shari Grewe, and I have been a veterans

supporter all my life, but in 1997 I was selected as the patient advocate for the veterans at this facility. Thank you for the opportunity to share the voices of many thousands of veterans that I

have dealings with all the time. They have one common goal. That

goal is to receive the best quality care in a clean, sanitary environment, with leading top-quality care of anywhere in the Nation.

They deserve it. They have provided many years of their lives to

protect our liberties. They deserve nothing less than the best.
28

Their focus is not on the cleanliness of this facility at the time

this occurred. They came in preoccupied. Their perceptions were

overshadowed because of the high-quality, excellent care provided

to them by the nurses and physicians and other staff of this facility. They have been overlooking the conditions of the cleanliness for

a long time, but let me assure you they will not overlook continued

areas of uncleanliness.

I am summarizing my report, and the reason I am is because I

look out among this crowd, and I see so many ex-prisoner of war

veterans, I see the dedicated, committed patient population of this

facility, and I feel that they deserve the very best. Their concerns

are focused on timely access to care. They shouldn’t have to wait

6 months to get into primary care for the very first time. They

shouldn’t have to wait hours for an unscheduled appointment or

wait for a scheduled appointment. They are ill. They want to be

seen.

But the first primary concern that the veterans are having is

that they don’t even know how they are going to get here for at

appointment half the time. They live out in the community, out in

the remote area. Thank goodness we have DAV, Disabled American

Veterans, who have devoted millions of hours in transporting these

veterans that are scared to death to drive from their home to our

facility, or they don’t have a car to drive to Kansas City for their

appointment. That is their first problem, and we have got to try

and solve that.

The second problem is that they are worried about their medications. They don’t believe that they should be billed for their medication. They believe that Congress promised them a long time ago

that their health care services would be provided to them at no

charge. They are angry. They believe that the government has lied

to them. They come into our facility angry with that concept.

They believe their mileage reimbursement isn’t enough. It is 11

cents a mile for them to come. Many veterans are driving 3 hours

to get here for their care. They are sick. They are worried about

their health care. They are making tough choices. Should they buy

their medication? Should they buy food to put on their table instead? Or should they purchase their wife’s medication? So those

are the tough questions that are facing our veteran population

today.

They are worried because their service-connected claim has taken

years to be processed. They are worried because they can’t work,

but they can’t get VA un-employability because they have to be

unemployed for a while before they can apply for this benefit. During that time when they aren’t working, what are they going to use

to put food on the table? Those are the concerns of our veteran

population.

We owe a great thank you to the committed service of the nurses

and the physician staff taking care of our veterans here. For that

reason there was not that many complaints that came through regarding the cleanliness of the facility. But let me share with you,

those that did come forward and speak with me were outraged.

They don’t deserve it. They deserve the highest degree of respect.

That respect should begin as those veterans are coming up that

drive. It should follow them through the facility to each encounter
29

they have. They deserve that. They deserve the dignity that they

have earned. They deserve the care at this facility because they

have earned it, not as a gift, but they deserve it. Thank you.

Mr. MORAN. Thank you very much for that reminder.

[The prepared statement of Ms. Grewe appears on p. 66.]

Mr. MORAN. Mr. Doran, welcome, we look forward to your

testimony.

STATEMENT OF HUGH DORAN

Mr. DORAN. Thank you for the opportunity to appear before you

today. I consider this a distinct honor and privilege. I am further

gratified that I will have the opportunity to present my position on

this unfortunate chain of events.

On March 5, 1995, I became the director of the VA Medical Center here. My first day I toured the hospital, and I was appalled at

the medieval conditions our veterans were hospitalized in. Nurses

had difficulty getting monitoring equipment to the patients bedside

in the intensive care units. The patients were in poor bedrooms

where they could reach over and touch each other. It was antiquated and outdated. We were in a 45-year-old building that had

very little upgrading other than air conditioning.

Our veterans indeed deserve better. My administration was centered on two areas, quality of patient care and patient satisfaction.

All of my decisions were based on this. I immediately conveyed my

priorities to our employees and the management staff. I also told

everyone that, the veteran service organizations, my board of directors. I told all concerned that we were going to become a patientfocused hospital.

The unfortunate incident involving the maggots was handled expeditiously and appropriately by our staff, including monitoring

and follow-up by our medical staff. I took immediate action to insure our adjacent construction site was secure, informed my superiors, and discussed the incident with the families involved.

There is absolutely no evidence to establish a relationship between the two nasal myiasis cases and the alleged mouse problem.

You have an obviously disgruntled former employee’s opinion who

managed to get the article published. There are many others who

disagree. Mice were never trapped or observed at any time in the

intensive care units. No mice were ever noted to have larvae or

flies associated with them. The blowfly is extremely common in the

Kansas City area. No one can prove the fly did not come in the

front door.

I hope you don’t think that this is the only case of a maggot

being discovered in a hospitalized patient. Unfortunately, it is not

uncommon; certainly underreported, but not unusual. There were

three incidents of flying insects that invaded the operating room in

1999. Immediate action was taken to protect the patient and clean

the area. This situation was closely monitored by the operating

room supervisor and to my knowledge was an isolated incident in

November of that year.

In a 50-year-old building you are going to have an ongoing rodent

problem. The key thing is what does one do about it? There were

various rodent-control initiatives over the years, including our own

employee as a pest controller, followed by contracts with private
30

companies. No one can absolutely rid a hospital this old of mice

and rodents. They will always be there. We tried to control this

problem as best we could in this antiquated building in a neighborhood full of vacant lots and vacant buildings.

There was an occasion when both local union presidents brought

to my attention evidence of mice in the canteen area. I immediately

examined the area, asked the canteen officer and our facilities program director to clean up the grease area of the stove in question,

and relocated the store room. I asked our infection control nurse

to conduct daily inspections and report back to me her observations. I personally inspected the area several times following this

incident and was satisfied the problem was addressed. I did not

have the money to do anything to this area at this time, as I was

in the process of building a new cafeteria in the basement, which

was scheduled to be opened in several months.

Regarding the budget, ladies and gentlemen, each year as the director of this hospital, I started the fiscal year in the red, each year

$4 million to $10 million in the red. Each year this deficit was

brought to the attention of my superiors without relief. Despite a

meager increase each year in my total budget, I faced each year

with a daunting task. I funded our supply allocation, for example,

pharmacy, supplies, et cetera, and what was left was devoted to

salaries. For this reason, I went from 1,400 employees in 1995 to

980 employees in 2001. Each year was a struggle. Our only alternative was really to reduce employment. Physicians’ and nurses’ positions were not reduced.

The budget allocation process in VISN 15 discriminated against

the tertiary care hospitals, Kansas City, Columbia and St. Louis.

Tertiary care is very expensive, and we received many referrals for

needed care from other hospitals in VISN 15. The transfer pricing

scheme was woefully inadequate in paying us for the expensive

care we gave, further diminishing our meager allotment. For example, the total hip patient referred from Leavenworth resulted in a

$4,000 allocation in transfer pricing. I had to buy the hip joint for

$4,000. So I was losing money before the patient was ever

admitted.

The pharmacy budget increased from $8 million to 18 million

during my tenure. Medical supply inflation runs took 10 to 15 percent each year. We received less than a 3 percent increase in our

budget. Do you get the feeling now for the challenges I faced each

day in trying to remain fiscally solvent?

Construction, it is important to note that 10 to 15 years ago

there was a $45 million renovation project requested by the VA for

the Kansas City VA Medical Center. Congress did not fund this

project, despite it being requested each year for several years. I can

assure you that if this project was supported at that time, we probably would not be here today.

When I arrived in 1995, I decided that the $45 million project

would never be funded, and we had to go in a different direction.

With the support of the VISN, we designed several $3 million to

$4 million projects that we could do each year and completely rebuild the important patient care areas of the hospital in 6 to 7

years. We started with the new state-of-the-art 13-bed medical intensive care unit followed by a 13-bed surgical intensive care unit.
31

In addition to these very important initiatives, we completed several local projects that included a new endoscopy clinic, a new primary care clinic, the new ambulatory surgery suite and rooms, new

ENT and ophthalmology clinics, a new cafeteria, renovated this

room, the front lobby, opened the only learning center in the VA

or private sector for patients and employees, and relocated the administrative areas from prime patient care space on the first floor

up to the fifth floor. We are nearing completion on the new laboratory, which is being completely reconstructed to support tests sent

to us from other VISN hospitals.

The 70-bed medical ward was completed in the spring of 2001

providing rooms which were as nice as any in the city. Our veterans deserve nothing less.

At this time we began construction on the new operating room

suite to be completed in the fall of 2002. This was our crowning

achievement, a much-needed facility for the veterans of Missouri

and Kansas. This was a major accomplishment, and my appreciation to our local Representatives and Senators in both States. For the past 6 years I had two $3 million projects to renovate the

halls and the walls. I made the decision that the patient-care-related projects were far more important than the cosmetic changes in

the halls and walls. We definitely need this project, and it was my

plan to do it after the operating room was completed, along with

the project to renovate the fifth floor to accommodate surgery beds

and our new SPD.

The SPD area has been the subject of attention. I also had a roof

project that we all knew was needed. The SPD problems were directly related to the leaking roof. At no time was patient care compromised because of anything in SPD. Upon completion of the two

projects, we would have a wonderful state-of-the-art facility second

to none.

Workload. During my tenure our workload dramatically increased. Patients treated went from 12,000 to 32,000, and outpatient visits went from 130,000 to over 200,000. Our hospital became a popular place for patients we served. A significant number

of veterans came to us from the State of Kansas. I believe this dramatic increase in patients was a result of our patient-focused

health care environment initiatives. There is nothing more important than quality of care and service. The Kansas City VA and

dedicated employees were the best, and the veterans came to us.

Sanitation. It is interesting to note the most—that the most vocal

individuals regarding sanitation at the hospital are well-known

malcontents and/or disgruntled employees or former employees. I

can honestly say the housekeeping staff was not reduced any more

or any less than other areas. In fact, in late 1997, early 1998, I

added eight positions to the housekeeping staff and purchased

$200,000 worth of equipment. The decision was the subject of our

presentation to the joint commission identifying a problem and our

solution to it.

At this period of time several decisions impacted the quality of

our sanitation efforts. Our local union objected to our compensated

work therapy program, wherein we were able to use housekeeping

job assignments in the rehabilitation program for veteran patients.

At any time there may have been 10 patients in various assign-
32

ments. We were forced to stop this very worthwhile program, patient care program, while other hospitals in the VA benefited tremendously from it.

Supervisory positions were reduced throughout the hospital.

Housekeeping was no exception. In fact, we allowed the night

housekeeping staff to function with a work leader. I agreed to this

organization after meeting with the union and employees and

granting their request for individual promotions for these individuals versus a supervisory position. This did not work out as well

as we had thought, and when we involved a supervisor in determining work in that area, that is when we were hit with the 72

unfair labor practices that was referred to earlier.

More importantly, joint commission reviewed the hospital in the

fall of 1998, reviewing sanitation with everything else; gave us

compliments on the cleanliness of the hospital and a score of 97.

In the fall of 2001, another joint commission review—and the joint

commission, like it or not, is the gold standard for hospitals—in

2001 they gave a score of 99, the highest in the VA system, and

probably the highest in the country. Several service organizations

conducted cyclic reviews and did not report any significant problems with housekeeping during this time frame. We had many visitors, and I talked to many patients and families. Housekeeping or

the lack of it was not a major topic of conversation.

Much has been written about the consultants’ report. In the 1998

time frame, I contracted with a firm to tell us what was needed in

housekeeping. I was mainly interested in his plan for cleaning the

respective areas and frequency needed. The consultant and I discussed his recommendations and agreed that my present staff in

housekeeping was equivalent to the Ford Escort. An additional 14

positions would give me the Cadillac, the difference being frequency of cleaning. We discussed what I needed for a Pontiac, and

he said around eight positions, and that is what we ended up increasing the staff.

During this 1998 time frame, the VISN director Ms. Crosetti

called me and told me that she had been at a service organization

picnic, and one of the members had told her that he noticed a slippage in the housekeeping efforts. She said that she had noticed it

also. I told her that was true and that I was taking the necessary

steps to address the problem. I further explained that I had the

consultants’ report and was hiring positions that I had lost, and

that I had lost the services of the CWT program. Everything happened in a short period of time, and we were turning things

around.

I would have liked to have a cleaner hospital. Unfortunately, I

did not have the resources to support housekeeping as I would

have preferred. I can assure everyone that patient care did not suffer because of the lack of housekeeping. We must not lose sight of

the purpose we are all here for, and that is to provide the highest

quality of care, and no one can argue with our success.

IG report on the relationship with Crosetti. It was disturbing to

read Ms. Crosetti’s comments concerning my performance in the inspector general report. She never told me that she thought I was

unsatisfactory. I did receive a low evaluation in 1999 because of a

personal issue, and I was accused of lobbying Congress for the op-
33

erating room project. Guilty as charged for the lobbying effort. It

is hard to believe that she would give me a minimal successful rating in 1999 and an outstanding rating in 2000, about 10 months

later. She even gave me a bonus, as was mentioned before.

Suffice it to say my relationship can be measured in outcomes.

Ms. Crosetti took great pride in VISN 15 being the best in the

country for several years in a row in performance measures and

patient satisfaction. Kansas City was the best hospital in VISN 15

for 5 years in a row in these areas. I always used to say Kansas

City is the engine that pulls the VISN 15 train.

Summary. I have dedicated 38 years of my life in service to the

veterans in 16 hospitals throughout this wonderful country. While

the recent publicity has been terribly biased and one-sided, I have

been heartened by the many calls and cards from patients’ families

employees and volunteers. This episode has been a terrible disservice to me and to the many dedicated and compassionate employees

at this medical center. Our employees are the finest in the country.

The accomplishments in the past 6 years cannot be overlooked:

Joint commission scores of 97 and 99, number 1 in performance

measures, et cetera; morbidity and mortality rates are in the top

5 percent of all hospitals; dramatic increases in satisfied patients

using our hospital; and the many construction projects mentioned

earlier. We have achieved a true patient-focused environment, my

goal in 1995.

Due to budget constraints, I had to make choices, and I chose patient care. I provided the highest quality of care to the veterans of

Missouri and Kansas, and I am damn proud of it. Our judge and

jury is the patient that we serve, and our patients are saying, we

are glad you made the decisions you did. The Kansas Department

of Disabled American Veterans organization presented me with

their achievement award in the year 2000, the only director of a

VA hospital ever honored in this manner. Secretary Principi completely vindicated me as the director when he ordered the hospital

to receive $10 million 2 months ago for the halls and walls project

and for additional employees. I ask you, what could I have done

with $10 million?

Thank you for this opportunity to appear. We do need to move

on. Our employees need to keep—to get on with keeping the promises to our Nation’s veterans. I will address any and all questions.

Mr. MORAN. Mr. Doran, thank you very much.

[The prepared statement of Mr. Doran appears on p. 69.]

Mr. MORAN. Committee, we are going to have to be very precise

in our comments and remarks if we are going to have any semblance of staying on schedule.

Mr. Baldwin and Ms. McEwen, I asked the director today during

our tour if there was any place in the hospital that they would not

want me to see, I would like to see it. They indicated I could see

any place, and that there wasn’t any place that they would not

want to have observed. Any place that I should see today before I

leave the hospital? Everything in good shape?

Mr. Baldwin.

Mr. BALDWIN. I think, sir, that we have put on a new face, but

this is an old building. My safety officer is very astute to construction, has informed me that as soon as this kind of dies down, he
34

would like to take the director on a tour and show him some things

behind the walls dealing basically with some of the plumbing

issues, the electrical issues that basically need upgrades. And I

think in time those will be corrected, but it is dealing with the

hard core type of construction that we have.

We put in some new equipment for which we do not have enough

electrical power to run all of it at the same time. I have been informed our new OR project that is going on out here, it is on schedule, and it is doing good, but the cooling system that was designed

to put into it in a really hot situation in the summer may not be

able to take care of it all, and we are going to investigate that and

look into it.

Mr. MORAN. Thank you very much.

The hospital administration indicated to me this morning that

Mr. Doran is right, ten million additional dollars can make a difference. He indicated that while a significant amount of that money

has been contracted to be spent, very little of the work has actually

been done, a lot of work yet to come. I understand the importance

of cosmetics and changes that have been made. I think we need to

reassure our veterans and their families about the quality of care,

the cleanliness, and sanitation.

We do want to make sure that there are changes. We heard some

things from earlier panels and from your testimony that indicated

that we need to continue to work with you and make sure good

things happen at this hospital.

Ms. Grewe, I noticed in your written testimony that there are rumors that this discussion is nothing more than an opportunity to

close the hospital. I can’t imagine that being the case, and we will

try to get the reassurance from our VA officials from Washington

to let you and the veteran patients know that there is a long-term

commitment to the Kansas City VA Medical Center.

Mr. MORAN. Dr. Filner.

Mr. FILNER. Thank you, Mr. Chairman, and thank you all for

your candid discussions.

Ms. McEwen and Mr. Baldwin, I take to heart very much your

testimony. You made some very clear recommendations that we

should look at, and I promise you we will look at them. I found

them very compelling. Your testimony, both Ms. Grewe and Mr.

Doran, I just find very distressing, or ununderstandable. You separated, you very clearly separated, patient care from cleanliness. I

don’t understand how you can separate those two. One says something about the other, and to make that distinct thing, I think, is

completely unsupportable. There is no way if everything is dirty

that you are going to have good patient care. I just can’t see it. I

will give you a chance to comment later, but I just don’t understand that demarcation.

Ms. GREWE. I think as far as the patients go, what the patient

did is because of the satisfaction and the excellent care that they

had received, they overlooked the uncleanliness situation.

Mr. FILNER. Well, maybe. It only means that they are not as informed as they ought to be about the situation in which they found

themselves. I would find that that is not informed consent here in

terms of what is happening. But, be that as it may, that is just my

layman’s approach to things.
35

Ms. GREWE. That doesn’t make it right, and that doesn’t make

it acceptable. That just means the patient is saying, I like the nursing care. I like the physician’s care. I like the facility.

Mr. FILNER. Right, but that doesn’t mean that any manager

could say, well, that makes my management fine because the patient said it was—— Mr. DORAN. Well, if I could respond now. Obviously you can’t

separate patient care from sanitation. It is all connected together.

In the end result, the patient care is the overriding factor.

The sanitation was a problem. I admit that it was a problem. I

have never denied that it was a problem. But with the resources

that was given—that were given to me, we addressed the problem

as best we could and maintained the problem—on top of the problem as best we could. That is my point.

Mr. FILNER. Maybe.

Mr. Doran, I believe you asked to be here and I guess you want

to justify your management at the time.

Mr. DORAN. I really did not ask to be here to justify anything.

I asked to be here because I couldn’t fathom a hearing concerning

the hospital and happened at the hospital for the last 5 or 6 years

without the director of the hospital being here.

Mr. FILNER. I am glad you are here. But I will tell you, I have

been a member, as I said, of a school board, a city council, and

have been in Congress for a decade. I will tell you, out of my experience of dealing with management justifications, that any manager who justifies what he or she is doing by mentioning disgruntled former employees as malcontents, any person who does that is

automatically suspect in my mind. That is, we have heard again

and again from employees from this institution over a long period

of time of problems. To say that there is one malcontent is completely dismissive and not understanding of the problem and, in my

mind, is, a prime example of bad management. If you are not taking your employees seriously, if you are blaming somebody’s objections on somebody’s personality or their problems, you are not a

good manager. In fact, you left out, by the way, in your oral testimony your justification on the canteen that you don’t have any supervisor direction. That is not what people have told me your powers are as a medical director. You have direct control over the canteen, as every other place in the institution.

Mr. DORAN. I don’t know who said that, but I don’t have direct

control over the canteen.

Mr. FILNER. You cannot, if you wanted changes in there, you

could not order them?

Mr. DORAN. No, I could not.

Mr. FILNER. Well, I find that at odds——

Mr. DORAN. That is true in any VA hospital you are in.

Mr. FILNER. Well, we will hear other testimony about that. I

have asked people, and nobody, nobody agrees with your assessment of your own power there.

In any case, you don’t need to respond. The vocabulary used and

the tone you use to defend yourself makes your testimony suspect

in my eyes and it is contradictory to everything that we have heard

over the years about problems here. So I will tell you if you had

to have me vote on who I was going to believe here, I would vote
36

for the employees on the first line and I would have to say, you,

sir, are the weakest link.

Mr. MORAN. Mr. Boozman.

Mr. BOOZMAN. I really don’t have any questions except that, Ms.

Grewe, I also was a little bit concerned in reading your testimony

about perhaps some people think this was a ploy to find a reason

to shut down the—again the VA here. Again, I would like also, as

Chairman Moran indicated, to say that the purpose of my visit

here is to, you know, to help the situation, and I am totally committed to the, you know, the Kansas City VA and its continuance,

and just want to make it get better. Hopefully we can, you know,

ascertain some useful material that would not only help this hospital, but the rest of the others in the rest of the country.

Mr. MORAN. Ms. McCarthy.

Ms. MCCARTHY. I will be very brief. Ms. Grewe, I want to visit

with you a little bit more about the 11-cent-a-mile reimbursement,

find out historically why it is trapped at that level for our veterans.

I would like to visit with you on the 7422 collective bargaining statute and find out why that is unique to the VHA.

And Director Doran, I had the pleasure of getting to know you

while I got to know the Congress, and I think you have done a terrific job at this institution, and I think that what we are trying to

get about is how to prevent such things in the future in any veterans’ hospital. So I just wanted my colleagues to know that as we

toured today and saw some of the new improvements and things

that it was under your leadership that much of that was instituted,

and I was honored to work with you to get the funding from the

Federal Government to make some of that possible.

I want to thank the whole panel because have you really enlightened us, and we are pressed on our time, so I will visit with you

individually when we break on those other matters.

Thank you, Mr. Chairman.

Mr. MORAN. Thank you all very much. I thank the panel for your

time. We are glad to be with you and appreciate you taking the

time to educate us today.

Our third and final panel consists of Dr. Robert Roswell, who is

the Under Secretary for Health at the VA Central Office in our Nation’s capital, along with Mr. Kent Hill, the current, relatively new

director of this medical center, and we are delighted to have the

Under Secretary with us. He follows in the footsteps of his boss

who was here not too long ago and we appreciate the attention that

the Central Office is playing in Kansas City. Dr. Roswell, you may

begin.

STATEMENTS OF ROBERT H. ROSWELL, M.D., UNDER SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, DEPARTMENT OF VETERANS AFFAIRS, AND KENT

HILL, DIRECTOR, VA MEDICAL CENTER, KANSAS CITY, MO

STATEMENT OF ROBERT H. ROSWELL, M.D.

Dr. ROSWELL. Thank you, Mr. Chairman. Let me begin by thanking all of the members, Dr. Filner, Dr. Boozman, Ms. McCarthy, for

being here. This is a unique field hearing in my personal experience to see it so well attended by members who clearly have a very
37

strong desire for the welfare of veterans. And as I have had the opportunity to sit in this hearing room this morning and listen to the

witnesses, I think to a person each witness and each member in

their own way shares a burning and compassionate desire for the

same thing and that is to better serve our veterans. And to that

extent, it is rewarding, it is gratifying, it is reassuring to me to see

that level of commitment to America’s veterans.

Certainly it is a commitment I share. I have spent 20 years in

the VA. I have been a chief of staff in three medical centers. I have

been on the faculty of four medical schools. I have spent the overwhelming majority of my career in direct patient care and working

with medical schools, working in the field. And I think I know

some of the frustrations that occur in the field.

It was only about 2-and-a-half months ago that I was privileged

to be confirmed as the Under Secretary for Health. But I wanted

to deviate there from my testimony for just a moment and share

with you some of the issues that are being addressed.

We heard Ms. Tillman speak of nursing, and I share her concern

for nursing. One of the things I have already done is to realign the

nursing service in the VA Central Office so that it reports not

through the patient care services but directly to my office to make

sure that our commitment to nursing, to expanding the nursing

profession and the practice opportunities in VA continues to expand. We have just completed a very extensive call for action that

addresses a large number of initiatives to expand the nursing professional practice in VA as well as recruitment, improving and enhancing pay and benefits. And many of the things you spoke of,

Ms. Tillman, are included, including the tuition reimbursement

and benefits.

Someone spoke of a strained relationship with America’s medical

schools. There clearly are problems with America’s medical schools

that in many respects are similar to VA’s, and at a time when challenges are great, I have reached out to renew our commitment to

America’s medical schools. I have met with Dr. Jordan Cohen, the

President of the Association of American Medical Colleges, on several occasions since my confirmation. I have re-established a meeting with the Council of Deans of America’s medical schools and am

working aggressively with them to make sure that those relationships, which in large measure are responsible for the quality of

health care in the VA are still continued and enhanced.

We heard about our medical record documentation. The computerized patient record system, Dr. Boozman, in fact requires less

documentation and it is actually designed to enhance the documentation effort by automating it. It is a unique application which

has been cited by the Smithsonian Institute and others as an outstanding records system and at the very cutting edge. But not

only——

Mr. FILNER. Could you tell us how many minutes would be required by a doctor for each visit with that system?

Dr. ROSWELL. Unfortunately, Dr. Filner, I can’t do that because

it depends upon the type of encounter. The lengthy type of things

we heard about are typically with the new patient registration. It

also depends upon how clinical reminders are applied in that. But

the computerized patient record system allows us to capture docu-
38

mentation and share it at virtually all locations of care in our medical system and do that expediently. And while I have worked personally and directly with many clinicians, many nursing staff who

have opposed the implementation of the computerized patient

records system, almost to a person after they have had an opportunity to experience it, they have said that it really has enhanced

their ability to provide high quality care.

Many of our performance measures are captured through the

computerized patient record system. While the format we use for

evaluation of senior executives is a simple ‘‘check the box,’’ that is

because that is the standardized government format for senior executives. However, behind that we have an extensive performance

measurement system with literally dozens of measures, all of which

are verifiable and documentable. We have quarterly performance

measures reviews for every VISN director who in turn passes that

on to each medical center director across a whole array of performance issues. And it will be my pleasure after this hearing to share

with you that performance measurement system. In fact, I would

be delighted to send you a complete quarterly report four times a

year showing how the performance is being measured throughout

the system.

There was some talk about labor management. And I would point

out with all due respect to Ms. McEwen that you are correct, that

section 7421 of title 38, which is the professional employment statute for VA, not the title 5, does preclude that, but it never, ever

precludes nursing leadership talking with clinical leadership, talking with medical center leadership. And while I deeply regard and

respect your advocacy for the professional members of your union

you represent, I would still strongly encourage you to make sure

that your communication with Mr. Hill is open, as I know it will

be. Thank you.

Mr. Baldwin talked about some issues behind the walls. There is

no question that we have extensive problems. We have made available $10 million for this medical center and it may not be sufficient

to meet all the needs. Just last week I had authorized the expenditure of an additional $5.7 million to do an engineering evaluation

of 18 VA medical centers around the country who share similar

electrical distribution problems and infrastructure problems with

plumbing because of their advanced age, and this medical center is

one of those 18. So there are some significant issues. But it is, as

I said, it is rewarding for me to see the almost universal commitment to serving veterans. And while we may not all agree upon the

specifics or the facts of the testimony, it is hard to refute the fact

that we are all committed to providing that care.

I would like to share with you several actions that the Secretary

and my office have taken to assure that this situation that occurred

in this medical center does not occur elsewhere in the VA health

care system.

First, we have asked all facilities to review their physical plants,

the cleanliness of their facilities, and their pest control programs,

and certify in writing that they are being properly maintained. The

certification has been concurred on in writing by each network director or each of the VISN directors.
39

I have asked all facilities to assure that their senior leaders are

conducting regular weekly environmental rounds and that they

have mechanisms in place for rapidly addressing issues and environmental deficiencies when they are noted.

I have also asked network directors to conduct environmental

rounds at each facility when they visit to assure that local managers are indeed attending to these issues.

Further, I am incorporating the expectation of maintaining facilities into the performance measures that I spoke of for network and

facility directors this coming year.

Finally, I have asked the VHA Office of Performance to closely

monitor and trend all reports from accrediting bodies, review

groups, including our own inspector general, and others to track

what actions are taken to correct deficiencies.

The senior staff in my office will review these reports frequently

and provide appropriate counseling and follow-up with managers

having accountability for remedial activities.

Secretary Principi, in a personal discussion with all VHA network managers and through follow-up correspondence, has made it

clear that managers will be held personally accountable for correcting deficiencies in their facilities when they are noted and where

they are under their control.

I also feel it is important to hold managers accountable for maintaining their facilities. In recognition of the gravity of this situation

and the potential for the new information to arise during today’s

hearing, the department has deferred initiating action regarding

top management officials until the hearing proceedings are

completed.

In summary, the cleanliness environment for care was allowed to

deteriorate unacceptably at the Kansas City VA Medical Center

over the past several years. An aggressive action plan has been developed and I am convinced that this plan will bring the facility

back to a superior level of cleanliness. I have full confidence in the

leadership Mr. Hill brings to the facility and know that he and his

team will work tirelessly to complete corrective actions and maintain the cleanliness of this facility in the future. I am particularly

pleased that the quality of care has been high at the Kansas City

VA Medical Center and I am confident that it will remain high.

It is my honor to serve the veterans in this community. They deserve nothing less than a facility that provides the highest quality

of care.

And in closing, I appreciate your commitment to veterans by

your presence here today.

[The prepared statement of Dr. Roswell appears on p. 76.]

Mr. MORAN. Mr. Secretary, thank you very much. I appreciate

your testimony. We will have a few questions for you.

The next witness is Kent Hill. Congresswoman McCarthy indicated her knowledge and good working relationship with Mr.

Doran. I don’t know Mr. Doran, but I do know Mr. Hill. He comes

to Kansas City from Wichita. I appreciate the strong working relationship that I had with you and I wish you well in your assignment here. And I am grateful that you are here to testify and to

tell us what has transpired since your arrival.
40

STATEMENT OF KENT HILL

Mr. HILL. Thank you, Mr. Chairman and members of the subcommittee, and Congresswoman McCarthy. Thank you for the opportunity to bring you up to date on some of the specific accomplishments that we have had to date, and plans for further corrections of the deficiencies at the medical center. I will provide you

with some information on immediate actions taken on items identified by the inspector general’s office and on some of the long-range

goals for maintaining the facility into the future.

Although the Kansas City Medical Center leadership had in the

weeks just before the Archives of Internal Medicine article begun

to review and slowly phase in measures to correct housekeeping

and maintenance deficiencies, the articles and the subsequent inspector general audit brought national attention to the environmental problems and required the medical center to expedite its

plans on corrective actions.

Indeed, as the 21-member inspector general team conducted its

environment-of-care audit and provide almost daily feedback on its

findings, medical center personnel promptly corrected those that it

could, while formulating written plans to accelerate the rebuilding

of a housekeeping and maintenance infrastructure.

Most of the environmental problems reported by the IG fell into

one of several categories: First, an overall lack of cleanliness, 2.)

failure to maintain equipment, furniture, utilities, hospital services, and lastly, inadequate pest control.

The correction of these problems with so many facets required

expertise and a thoughtfully designed plan. However, until the

plan could be completed, interim steps were taken. Specifically, we

worked a lot of overtime using medical center personnel. We also

detailed housekeeping personnel from the eastern Kansas facility

to help us. A very seasoned environmental care manager was also

detailed from eastern Kansas. He brought the expertise we needed

to direct the additional personnel and to help us begin developing

a long-range plan. Additional housekeeping equipment was purchased immediately. Recruitment of our temporary housekeeping

personnel was initiated until we could get the permanent staff on

board.

The environmental care manager initiated a systematic training

effort to increase the existing staff skills. The pest control contract

wasn’t adequate, and action to acquire a more effective contract

had already been done. The medical center accelerated efforts to

hire a nationally recognized company that would respond to us immediately. The new contract also required the contractor to keep

and report performance data to monitor the effectiveness of his

treatments. The policy was changed to require more participation

of facility management to include the union representatives and

provide for a mechanism for following up on deficiencies. Employee

food storage policies have been redeveloped and implemented, and

confusion between the medical center and canteen personnel over

responsibilities for housekeeping duties has been eliminated by the

development of a memorandum of understanding between the canteen and the hospital. This memo clearly delineates the lines of responsibility. It calls for regular inspection of all canteen areas and

establishes penalties for noncompliance. The supply and processing
41

distribution area, SPD, where many of the medical center’s supplies and instruments are sterilized, was cited by the IG for poor

maintenance, cleanliness, and inadequate support and space. While

a long-range solution to this problem is a new SPD, a contract for

which we are currently negotiating, immediate corrective actions

had been taken and cleanable surfaces have been installed, ceilings

repaired, and professional duct work cleaning initiated.

The inspector general audit reported that the wall covering located throughout the facility was poorly maintained, it was dark,

it had a potential for harboring dust and dirt particles. The medical

center had already recognized this problem and had begun a systematic removal of the material and upgraded treatment areas over

a period of years through its recurring maintenance program. Nevertheless, the IG findings elevated the urgency of this work and immediate steps were taken to finish upgrading treatment areas.

Non-recurring maintenance contracts to remove the material and

repair and upgrade ceilings and floors will be awarded this and

next calendar year. Until then, a DOD contract for labor was utilized to remove sisal in several clinics and wards and install bright

wall surfaces and adjust hall lighting. The results are very remarkable and give some indication of what the facility will look like

when the contracts are completed.

The medical center has had no interior design plan to help select

appropriate clinical furniture, wall coverings or wall services. An

interior designer was brought from Eastern Kansas Medical Center

to help us assess and correct the most acute problems. Replacement furniture for many of the waiting areas has been ordered.

Floor coverings designed for high traffic use are now in place. The

contract to replace insect screens on all exterior stairwells has been

awarded and a window-washing project has begun.

Other contracting activities have been initiated to renovate some

of the public restrooms, seal the building exterior, replace leaking

roofs, correct and find deficiencies in the emergency room involving

patient privacy, and upgrade or replace worn floors and cabinetry.

The corrections I have mentioned so far will, when completed,

bring the facility and its environment up to an exceptional level of

cleanliness and maintenance. However, we are establishing an organizational structure that will sustain these improvements over

time. Our plans call for re-establishing an appropriate number of

permanent personnel in housekeeping and engineering, providing a

supervisory structure operating under a formal environmental

management program. This will include communication of expectations and training and monitoring and feedback. Open communication with our union partners and employees at all levels is critical

to the ongoing success of this plan.

In summary, the Kansas City Medical Center is in the middle of

an environmental improvement plan that will bring the facility

back to a high level of cleanliness and maintenance. You have

heard about the quality of care offered and the superior efforts of

those who provide it. It is an honor for me to work with the outstanding staff here and to serve the veterans of our community.

Thank you.

[The prepared statement of Mr. Hill appears on p. 80.]

Mr. MORAN. Mr. Hill, thank you very much.
42

Mr. Secretary, let me first give you the opportunity to belie any

fears that anyone may have about the future of the Kansas City

Medical Center. Would you describe the VA’s commitment to the

hospital here?

Dr. ROSWELL. There is no question that the VA has a strong commitment to making sure that the health care needs of veterans of

the Kansas City area are met both now and in the future. The department is going through a capital asset realignment process to

evaluate all of our infrastructure to identify the best utilization of

that infrastructure, both today and to meet the veterans’ needs into

the next several decades. And that process will evaluate the physical infrastructure of all facilities and determine their best utilization. But I think it is safe to say, given the large number of veterans who are served throughout the Greater Metropolitan area and

the long and distinguished track record of outstanding quality care

delivery at this facility, that the future outlook for this medical

center is very, very positive.

Mr. FILNER. Dr. Roswell, I had a conversation when you first

took over and I said you are known as a straight-talking, clearthinking person. I hope that the bureaucracy doesn’t incorporate

you into its thinking, and I just want to you review the comments

from the transcript of what you just said.

Dr. ROSWELL. Let me——

Mr. FILNER. That is exactly what I feared. So please read it.

Dr. ROSWELL. Let me display the candor that Bob Roswell would

like to display. Secretary Principi has asked that departmental officials not make any pronouncements about the outcome of the

CARES process. The CARES process will examine every single facility in our inventory, and because it will be examining hospitals

that could be closed or more likely be converted to outpatient facilities, Secretary Principi has asked all members of the department,

including myself, not to publicly speculate on the outcomes of the

CARES process. So respecting the Secretary’s wishes, I was admittedly a bit evasive, but I hope you understand why.

If you ask me, clearly this is a medical center. It is a tertiary

medical center that serves a very large number of patients. It

would be difficult for me to even imagine a CARES process that

would recommend closing this facility.

Mr. FILNER. But this whole problem that was raised, you will

agree with all of us, is not a ploy to close this system.

Dr. ROSWELL. No, it is really not, Dr. Filner. I mean,as I said,

I am trying to honor the Secretary’s guidance. You know, this is

an unfortunate situation. It is something that we can learn from,

that we have learned from. And I appreciate the committee’s interest in it. But there is no intent in any form or fashion to use this

as justification to close a medical center. In fact, just the opposite,

this is an opportunity to allow us to expedite the renovation and

enhancements of the environment of care of this very important

medical center.

Mr. MORAN. Dr. Roswell, why does it take the publication of the

circumstances about the sanitation of this hospital to get the attention that this facility needs to improve its circumstances? One of

the things that Mr. Doran said that struck me: ‘‘if I only had $10
43

million.’’ What is it about a system that requires a publication of

a significant problem to direct the resources where they need to go?

Dr. ROSWELL. It is a very complex answer, Mr. Chairman. I think

what we are dealing with is a situation where there were competing priorities, limited resources, ineffectual communication between

various levels of management, and less than ideal monitoring. And

I think in each of those areas, we are looking at this situation to

make improvements.

Mr. MORAN. What was the awareness at the central VA office

about the problems of sanitation and cleanliness here at the hospital over the last several years, say from 1996, 1997, on?

Dr. ROSWELL. And please understand I can’t speak prior to April

of this year when I was confirmed, but to my knowledge, there was

not ongoing communication from the field that there were significant problems with sanitation.

Mr. MORAN. As you look at your files, there are no reports coming from this hospital, from this VISN to the Central Office, saying

we have got a serious problem here?

Dr. ROSWELL. Not from the hospital, not from the VISN. There

were, in fairness, deficiencies identified through the Office of Inspector General’s combined assessment program or CAP survey. In

fairness, they were pointed out. But there was also a follow-up action plan which appeared to have indicated that those problems

had or were being resolved.

Mr. MORAN. Mr. Hill, I read earlier from the inspector general’s

report that actions taken by management were concentrated on addressing specific cleaning and pest conditions, and not on organizational failures that permitted the problems to exist. Please tell me

that we are not simply addressing specific instances, but we are

putting in place a process by which these instances don’t reoccur.

We are not just crisis-managing. Is that true?

Mr. HILL. That is true.

Mr. MORAN. Anything else? Actually you are helping me conclude

this meeting on time, so I ought to take advantage of your brevity.

Mr. HILL. As I was saying, we really think that in the short term

we want to get some things done, and we went ahead and we are

fixing some of those specific things, but we really feel the long-term

solution is in re-establishing an organizational structure which will

support the maintenance of the facility over time.

Mr. MORAN. Dr. Roswell, Dr. Klotz’ testimony mentioned five recommendations. I don’t expect you to respond to those today, but I

would welcome the department’s response to each one of those five

suggestions. Your thoughts about what the VA is and isn’t doing

to address those areas.

Mr. MORAN. You mentioned the university relationships. I think

there is a number of things that this subcommittee ought to be

paying attention to as outlined by Dr. Klotz, and I would like to

have the department’s response to his suggestions.

Dr. ROSWELL. We will certainly do that. It is distressing to me

that Dr. Klotz spoke of the need to share the information, and, yet,

despite repeated requests he was not willing to share his testimony

prior to the hearing today. So I had no opportunity to review his

testimony. As all, of course, as you know, executive branch employees, our testimonies are required to be cleared before they are sub-
44

mitted. But I found it confusing. I mean table one in his testimony,

as I looked at it, shows that in fact the level of direct patient care

employees is virtually identical to where it was in 1996. So I don’t

know the interpretation. We have actually improved the number of

the percentage of employees in direct patient care results or roles

as a result of performance measurement system.

Mr. MORAN. Well, despite the fact that you hadn’t seen the doctor’s testimony before today, you and I will be around for a while

longer, and we can spend some time working our way through

those recommendations. I would look forward to that opportunity.

Mr. Filner has already utilized most of my time, so we will go

to Mr. Boozman.

Mr. BOOZMAN. I have just got a couple things. I kind of see a

thing that goes through this a little bit with a few things. One

thing I am concerned about, it was started with Mr. Slachta’s testimony, was that the hospital received really good ratings despite the

fact that I think everybody that has testified agreed that, you

know, statements were made it was filthy, others said it wasn’t

clean. So everybody has agreed. How do you go about designing a

system where the ratings really do reflect the total picture? Evidently if you get almost a perfect rating, you know, how do you fix

it where you can’t go in and do these things when the investigators

get here and then leave? Some of the major food chains and things,

with theirs, they will do unexpected things. It is almost like we

could learn from some of these other agencies that do a good job.

But I would like to see that, you know, if the patients, if Congress,

if you see a rating that there should be some correlation——

Dr. ROSWELL. The point is an excellent one. The Joint Commission on Accreditation of Health Care Organization visits each of

our medical centers every 3 years and, as has been pointed out

very convincingly in this hearing today, you can prepare for that

triennial visit, throw resources at a cleanliness problem and

achieve very good results. What wasn’t made clear is that the joint

commission also has unannounced visits periodically throughout

the 3-year interim between visits. And that is another opportunity

for a condition of what we call the standard for environment of care

to come to light through the joint commission process.

Mr. BOOZMAN. Are those published?

Dr. ROSWELL. They are available, yes, they are discoverable. I

know the joint commission maintains a web site. They are available, yes. As I pointed out, we have not actually put environment

of care per se as a performance measure in the director’s performance measurement system, but that is a change that we will be

making, as I have indicated.

Mr. BOOZMAN. The other concern I had was that again there

doesn’t seem to be any real sense of responsibility. Even Mr. Baldwin, you know, he said that he went to his supervisor, he said it

is the VISN’s fault, the VISN said it is the local issue. And the inspector general’s report, you know, the VISN didn’t want to take

responsibility, saying this was a day-to-day thing, that they didn’t

have jurisdiction over that. It seems like that needs to get sorted

out, that, you know, who is responsible for what. Again, I don’t

know that argument at all to be honest.
45

Dr. ROSWELL. I found it a bit circular myself. Again, as I said,

the opportunity to be here and listen has been extremely helpful

for me this morning. I would go back to the labor management relations that were alluded to. Strong labor management relations, in

my opinion, through a management assistant council or a partnership council are an absolutely essential way to make sure that we

have effective communication. And that is something that we will

be looking into. Because that seems to have broken down here.

Mr. BOOZMAN. The last thing, as Chairman Moran indicated, I

also would be interested especially about the role of the chiefs of

staff, you know, if you would comment at some point in written

whatever, you know, if the role of the chief of staff is broken down

in this. Perhaps we have gone too far the other way where we don’t

have a good advocate for the doctors and nurses.

Dr. ROSWELL. I found that puzzling. I don’t know that the doctor

has served as a chief of staff. I have actually served as a chief of

staff at three facilities. The chief of staff does report to the medical

center director. It is not a co-equal relationship. The chief of staff

is employed and responsible to the director of the medical center.

That is the way it is. That is the way it is organized. But as the

chief of staff, you have the accountability, you have the responsibilities to relay the status of clinical care, the support of clinical care

to the medical center director. I have never ever in three different

institutions where I have served in that role found that difficult.

It is not to say that I didn’t have disagreements, but I was able

to air those disagreements. That is a responsibility of that office.

I don’t see that it is broken.

Mr. BOOZMAN. I guess that is my question, as time has evolved

over the last few years if that has changed any. And is that more— is that the individual hospital, do they determine the role of the

chief of staff?

Dr. ROSWELL. It is possible that there is some variation in how

the chief of staff office is utilized or functions. But I think in reality

the most significant variable is the personality of the individual

who serves in that role.

Mr. BOOZMAN. Thank you.

Mr. MORAN. Because I have to ride on a plane with you, Dr. Filner, we will allow you to ask additional questions. Dr. Filner.

Mr. FILNER. Thank you, Mr. Chairman. I think we all agreed and

are impressed with the specific changes that have occurred here.

We can all assure the patients in this area that they are going to

get quality care in a sanitary facility. We all can agree with that.

What I hope that we can talk about in the future is some of the

systemic problems that seem to be evident. And I hope, Mr. Hill,

that when you have heard the employees feel that they have not

been heard, and you have indicated in your testimony that you

have already institutionalized ways that they can be heard, I hope

you continue down that path and institutionalize the methods. If

people perceive they are not heard, then they are not heard. And

you have to figure out a way that there are no disgruntled malcontents in the system. You have to listen. They may not always

be right. You may not have the resources to do it. But a dialogue

and communication deals with those things. So it seems to me that

you are moving in that direction.
46

I think Dr. Roswell has bigger systemic things to think about. In

your written testimony you pointed out a number of deficiencies

here. It seems to me you need to be looking at how we didn’t know

about this earlier. You said just a minute ago the communication

seems to have broken down here. I think you better think that the

communication is broken down everywhere, just assume that for a

minute, and begin to take the steps to make sure that that is not

the case.

You talk about the IG’s investigations. It seems to me this is potentially everywhere the same situation. And we have to institutionalize those kinds of evaluations of our facilities.

Dr. ROSWELL. You are absolutely right, Dr. Filner. I agree with

you. We have actually made changes to include those types of

measures in the performance measurement system. We are restructuring the governance of the 21 VISNs in a way that will provide

a broader oversight and more detailed day-to-day communication

facilities. And I would be happy to discuss those at some point.

Mr. FILNER. I hope Dr. Klotz’ testimony is not overlooked. I don’t

want to compare it to Ms. Rowley’s cry for help from the Minneapolis division of the FBI to the Central Office that was not heard. It

was not heard. And we had tragedy that may have resulted from

the lack of being heard. I think you ought to take these kinds of

things very seriously. I sensed in your tone of voice you may not

have, but I hope you do. I hope that the systemic issues here are

addressed. The chairman had asked for a response. I don’t necessarily want a response because I would like to see some dialogue.

I would like to see some debate. I said I would like to see them

on the same panel. Maybe in Washington we could do that. We ask

questions, you give us back answers. I find that very unfulfilling.

You already have convinced me you are a master at the bureaucratic language. I would like to hear it, you know, in English, us

talking together.

Again, we are not trying to prosecute anybody, we are trying to

come to an understanding of the issues here. Maybe we could have

a dialogue in private or public about these kinds of issues.

I have received communications from other doctors and other

union people and other employees about similar issues. I have

found that Dr. Klotz’ way of putting it synthesized a whole lot of

things that I had heard, which leads me to think it has some merit.

Because rather than take an individual thing in Kansas City or in

San Diego or Chicago, he seems to be talking about a whole pattern. I hope we take it seriously and look at them. He could be

wrong, but he may be right. And I think you ought to sponsor a

nationwide dialogue about this, put his thing on your Internet, on

your web, and see what other people say. I think it is worth a systemwide discussion maybe in the way we haven’t done before. And

all the specific problems at Kansas City may help us make the

whole system better for our veterans.

Mr. MORAN. Under the theory that no member of Congress ever

has the last word, the potential last word is the local Congresswoman, Ms. McCarthy.

Ms. MCCARTHY. I will be brief, Mr. Chairman. I want to thank

you for inspiring this session and thank your committee staff for

the efforts to put together terrific panels and experts for us. While
47

I am not on the subcommittee, I would like to work with the subcommittee as you do the follow-up on the issues raised here today.

And, in particular, you know, there are other VA facilities 50 years

old, like this one. They are going to need maintenance funds to upgrade. We have heard from the witnesses that it is possible these

kinds of things could happen there. Given the current fiscal situation, Mr. Secretary, I hope we can—I am very happy for that $10

million. This is great. It will help a great deal. But I think we

ought to all be very realistic, too, about the other needs out there

in our country and just come to grips with how to do some of the

upgrading and wonderful things that Mr. Hill is accomplishing

right here in Kansas City. I would like to work with you on that.

Mr. Hill, I am very heartened by what I learned here today in

this conversation. I very much appreciate your emphasis on sustaining these changes, these improvements over time. I look forward to working with you and to come back as often as I can to

visit with you and see what more I can be doing in my role.

Thank you, Mr. Chairman, for including me in this very, very informative session.

Mr. MORAN. Thank you so much for joining us. Proving the theory is correct, Mr. Filner has asked for an additional moment.

Mr. FILNER. I want to ask for some reassurance, Dr. Roswell. I

hope it is not the same answer that you gave to the Chairman

when he asked for reassurance about the medical center here.

There was a statement made earlier that—I may have this

wrong, Dr. Klotz, that someone in the VISN said Klotz ain’t going

anywhere. Could you assure us that there will be no retaliation, for

his testimony here or any testimony that we have had today?

Dr. ROSWELL. No.

Mr. FILNER. You are not going to assure us?

Dr. ROSWELL. I said no, there will be no retaliation. I don’t know

where that statement came from, but it certainly is not the kind

of behavior nor the kind of statement that any of us could condone.

I can assure you that you won’t see retaliation.

Mr. MORAN. It is my understanding that Dr. Klotz is not here as

an employee of the VA, he is a part-time physician with the VA in

Arizona. He is here as a private citizen, as a university professor,

and we are delighted that you took the time to join us in Kansas

City. I don’t think the article that you published ever mentioned

the hospital. In fact, I know it didn’t ever focus the attention upon

Kansas City or the VA. So the committee and I really appreciate

the opportunity we have had to be together this morning to garner

some information, gain an understanding, hopefully reassure our

veterans and citizens in the Kansas City area about the importance

of this hospital, our care and concern for its staff, its employees,

its administration management, and that we have the opportunity

to do things as Members of Congress, as policymakers, that make

good things happen for our veterans and for this community. I have

just become the Chairman recently of this subcommittee and look

forward to continued efforts.

Again I appreciate the relationship that I have developed with

Mr. Hill and wish him well here in Kansas City. Patricia Crosetti

and Matt Kelly, I had a good working relationship with them in

their roles in covering the State of Kansas, and I appreciate the
48

chance to get acquainted with people who care a lot about our veterans. This is a great committee assignment, a great opportunity

to try to do something good for other people. We are particularly

grateful to the VISN Director Norby and Ms. Greer and their staffs

for all of the arrangements that were made today for our committee to be here and help us prepare for this hearing.

There are a number of people who have submitted written testimony. Without objection, their written testimony will be made a

part of our record. This record will remain open for 5 days. If anyone else would like to submit written testimony to the committee,

they may do so.

Our record will remain open for written testimony and I just encourage people that have concerns here at the hospital to talk to

their elected officials and others. And we try to take these comments and concerns very seriously. Again, this is about the future.

And we look forward to doing the things necessary to provide a

bright future for Kansas City VA Medical Center, and this hearing

has gone a long way toward educating us in that regard. And I

very much appreciate the time and attention you provided, and our

subcommittee meeting is adjourned.

[Whereupon, the subcommittee was adjourned.]
49

A P P E N D I X
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51
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57
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63
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66
67
68
69
70
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72
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82
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STATEMENT OF JACK SITES
84
85
86
87
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89
90
91

WRITTEN COMMITTEE QUESTIONS AND THEIR RESPONSES

CHAIRMAN MORAN TO DR. STEPHEN KLOTZ
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93
94
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98
99
100
101
102
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