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S. HRG. 113–657 

THE STATE OF VA HEALTH CARE 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED THIRTEENTH CONGRESS 

SECOND SESSION 

SEPTEMBER 9, 2014 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

BERNARD SANDERS, (I) Vermont, Chairman 

JOHN D. ROCKEFELLER IV, West Virginia 

PATTY MURRAY, Washington 

SHERROD BROWN, Ohio 

JON TESTER, Montana 

MARK BEGICH, Alaska 

RICHARD BLUMENTHAL, Connecticut 

MAZIE HIRONO, Hawaii 

RICHARD BURR, North Carolina, Ranking 

Member 

JOHNNY ISAKSON, Georgia 

MIKE JOHANNS, Nebraska 

JERRY MORAN, Kansas 

JOHN BOOZMAN, Arkansas 

DEAN HELLER, Nevada 

STEVE ROBERTSON, Staff Director 

LUPE WISSEL, Republican Staff Director 

(III) 

C O N T E N T S 

SEPTEMBER 9, 2014 

SENATORS 

Page 

Sanders, Hon. Bernard, Chairman, U.S. Senator from Vermont ........................ 1 

Burr, Hon. Richard, Ranking Member, U.S. Senator from North Carolina ....... 2 

Tester, Hon. Jon, U.S. Senator from Montana ...................................................... 4 

Johanns, Hon. Mike, U.S. Senator from Nebraska ............................................... 4 

Hirono, Hon. Mazie, U.S. Senator from Hawaii .................................................... 5 

Heller, Hon. Dean, U.S. Senator from Nevada ..................................................... 6 

Blumenthal, Hon. Richard, U.S. Senator from Connecticut ................................ 8 

Moran, Hon. Jerry, U.S. Senator from Kansas ..................................................... 9 

Begich, Hon. Mark, U.S. Senator from Alaska ..................................................... 10 

Boozman, Hon. John, U.S. Senator from Arkansas .............................................. 12 

Murray, Hon. Patty, Chairman, U.S. Senator from Washington ........................ 12 

WITNESSES 

Griffin, Richard J., Acting Inspector General, U.S. Department of Veterans 

Affairs; accompanied by John D. Daigh, Jr., M.D., Assistant Inspector General for Healthcare Inspections; Linda Halliday, Assistant Inspector General for Audits and Evaluations; Maureen Regan, Counselor to the Inspector General; and Larry Reinkemeyer, Director of the Inspector General’s 

Kansas City Audit Office ..................................................................................... 14 

Prepared statement .......................................................................................... 16 

Response to request arising during the hearing by: 

Hon. Jon Tester ............................................................................................. 29 

Hon. Dean Heller .......................................................................................... 30 

Response to posthearing questions submitted by: 

Hon. Bernard Sanders .................................................................................. 40 

Hon. Mark Begich ......................................................................................... 41 

Hon. Mazie Hirono ........................................................................................ 41 

Hon. Jeff Flake .............................................................................................. 41 

McDonald, Hon. Robert A., Secretary, U.S. Department of Veterans Affairs; 

accompanied by Carolyn M. Clancy, M.D., Interim Under Secretary for 

Health ................................................................................................................... 42 

Prepared statement .......................................................................................... 45 

Response to request arising during the hearing by: 

Hon. Richard Burr ........................................................................................ 51 

Hon. Jerry Moran ......................................................................................... 62 

Response to posthearing questions submitted by: 

Hon. Bernard Sanders .................................................................................. 63 

Hon. Richard Burr ........................................................................................ 97 

Hon. Mark Begich ......................................................................................... 101 

Hon. Mazie Hirono ........................................................................................ 103 

Hon. John Boozman ...................................................................................... 104 

Hon. Jeff Flake .............................................................................................. 107 

Hon. Richard Blumenthal ............................................................................ 109 

Response to additional posthearing questions submitted by Hon. Richard 

Blumenthal .................................................................................................... 113 

(1) 

THE STATE OF VA HEALTH CARE 

TUESDAY, SEPTEMBER 9, 2014 

U.S. SENATE, COMMITTEE ON VETERANS’ AFFAIRS, Washington, DC. 

The Committee met, pursuant to notice, at 10:02 a.m., in room 

SH–216, Hart Senate Office Building, Hon. Bernard Sanders, 

Chairman of the Committee, presiding. 

Present: Senators Sanders, Murray, Tester, Begich, Blumenthal, 

Hirono, Burr, Johanns, Moran, Boozman, and Heller. 

OPENING STATEMENT OF HON. BERNARD SANDERS, 

CHAIRMAN, U.S. SENATOR FROM VERMONT 

Chairman SANDERS. Good morning and welcome to what I believe will be an important and productive hearing. Today we will 

be discussing some of the very serious issues facing the Department of Veterans Affairs on the heels of the Inspector General’s 

findings related to long wait times and poor patient care at the 

Phoenix VA. 

The IG’s report provides troubling details about a facility that 

failed to meet our Nation’s obligation to provide timely, high-quality care to veterans. What happened in Phoenix is inexcusable and 

must never happen again at any VA facility. 

I was especially disappointed to learn the extent to which Phoenix VA executives and senior clinical staff knew about inappropriate scheduling practices. 

In a telling exchange, when asked by a physician in Hawaii to 

share best practices about how the Phoenix VA had presumably 

been able to reduce its patient wait time from 238 days down to 

7 days—quite a feat—the chief of primary care e-mailed one of his 

fellow colleagues in Phoenix and stated, ‘‘Wonderful. Not sure how 

to answer this. Can I just say, ‘smoke and mirrors’?’’ And, of 

course, that is what it was. It was all smoke and mirrors. 

The people who lied, who acted dishonorably, who manipulated 

data in Phoenix and elsewhere clearly must be held accountable. 

The endemic nature of this problem, as identified by the IG, cannot 

be tolerated. 

The IG’s report detailed numerous cases of poor patient care. In 

fact, several of those cases raise serious concerns about two of 

Phoenix’s specialty care clinics. Reviews of patient files found problems with continuity of mental health care, delays in assignment 

to a dedicated psychiatrist or mental health nurse practitioner, and 

limited access to psychotherapy. 

2 

Additionally, the IG also discovered the urology department 

struggled to provide timely care. In fact, the IG has launched a 

separate investigation into this service. A report regarding the 

findings will be released in due course. 

While the results in the IG’s report paints a troublesome picture, 

the IG was ‘‘unable to conclusively assert’’ that patients died because of long wait times, as news media reports had speculated. 

I also understand, as a result of the attention focused on Phoenix, the IG has opened additional investigations at 93 sites of care 

as a result of receiving approximately 445 allegations regarding 

manipulated wait times at other VA facilities. This Committee will 

continue to monitor the results of these investigations and use this 

information to inform the Committee’s oversight efforts in the future. 

Like most Americans, I have concerns about the inability of veterans in various locations across the country to access care in a 

reasonable period of time. I will not go through all of the data, but 

the bottom line is that the reports worked on by VA and the work 

done by the IG tells us that tens of thousands of veterans were unable to get the care they needed in a timely manner. 

What I hope we will learn today from our new Secretary, Mr. 

McDonald, and the ideas of the Inspector General, Mr. Griffin, is, 

in fact, how that problem developed. I do not believe that anybody 

joins VA in order to manipulate data. How did it happen? What 

were the causes? How do we make sure this never happens again? 

What do we do? And how quickly do we get rid of dishonorable employees? We gave the new Secretary tools. We will want to hear 

how he is utilizing those tools. 

Maybe most importantly, we want to learn how we go forward 

into the future to make sure these problems never occur again. 

I noticed in the paper yesterday the Secretary held a press conference talking about—and I want to discuss it with him—his need 

to aggressively go out and bring new physicians, new nurses, new 

medical personnel into VA so we do not have these wait times 

again. And during this hearing, I look forward also to talking with 

our new Secretary about how he is going to implement the legislation that was recently passed. 

So, there is a lot to go over in this hearing. We thank the Secretary for being with us. We thank the Inspector General for being 

with us as well. 

Senator Burr. 

STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, 

U.S. SENATOR FROM NORTH CAROLINA 

Senator BURR. Well, good morning, Mr. Chairman. I would like 

to welcome to Secretary McDonald and Acting Inspector General 

Griffin, and I thank them for being here, as well as the other witnesses for today. 

Today the Committee is holding another hearing on the state of 

health care within VA, specifically focusing on the final IG report 

released last month as it relates to Phoenix. And when I say 

‘‘final,’’ Mr. Griffin, I realize that there are many more yet to come, 

and this will be absolutely crucial to the agency’s ability to continue to get a handle on the problems. 

3 

Since our last hearing on the state of VA health care, Congress 

has moved forward with historic legislation that will improve access to health care to veterans across the Nation, which was signed 

into law in August. This legislation is a first step in providing veterans with the ability to choose where they receive care if VA is 

unable to provide care within a timely manner or if they live greater than 40 miles from a VA facility. 

While this is an essential first step in addressing the systemic 

issues facing the Department of Veterans Affairs, there is still 

much more work to be done. The work of this Committee has just 

begun. As we move forward, it will be crucial for this Committee 

to conduct aggressive oversight to ensure that veterans are able to 

receive the health care they need and, more importantly, that they 

deserve. 

The IG report is instructive because it demonstrates critical 

breakdowns in the system that allowed systemic issues to take root 

not only in Phoenix but throughout the entire VA system. I would 

like to highlight two specific issues that were identified in the final 

IG report on Phoenix. 

First, the IG report describes the care received by 45 veterans 

who faced either clinically significant delays in care or questionable 

care from the Phoenix facility. Additionally, the IG reviewed 77 suicides that occurred between January 2012 and May 2014 and found 

that nine veterans experienced a delay in care. One veteran experienced a clinically significant delay, and five veterans experienced 

other substandard quality of care. 

Many veterans experiences obstacles while trying to establish 

needed care after hospitalization or being treated in the emergency 

room. The lack of follow-up, coordination, quality, and continuity of 

care that many of these veterans experienced is troubling and, 

quite frankly, unacceptable. 

Second, the most troubling issue described in the report was VA’s 

awareness of the ongoing scheduling challenges that many facilities 

faced. Furthermore, VA had opportunities to address the systemic 

culture of inappropriate scheduling practices. VA did not act to address inappropriate scheduling practices or manipulation of waittime data. This lack of accountability was further ingrained by 

VA’s decision to waive the fiscal year 2013 annual requirement for 

facility directors to certify compliance with VA scheduling directives. Why would the requirement be waived when VA knew that 

there were questions scheduling practices occurring within medical 

facilities? 

The magnitude of scheduling irregularities is demonstrated by 

the roughly 225 allegations at the Phoenix Health Care System 

and the more than 445 similar allegations at VA facilities across 

the Nation that the IG has received through numerous sources, including the IG hotline, Members of Congress, employees, veterans, 

and their families. Currently the IG is actively investigating 93 

sites, as the Chairman stated. 

In the coming weeks, months, and years, VA will continue to 

take swift and firm action to dismantle the corrosive culture that 

has taken hold within the VA and make sure it is not able to resurface. No matter what steps VA takes to address the challenges it 

faces delivering health care, VA will not be able to move forward 

4 

if this corrosive culture is not effectively addressed. I have said this 

before but I want to reiterate that the culture that has developed 

at VA and the lack of management and accountability is simply 

reprehensible. 

I commend the work that has been done over the last several 

months; however, there is much more work to be done to repair 

veterans’ trust in the system. I look forward to working with you, 

Mr. Secretary, as this Committee works on implementing and passing legislation that is needed for you to accomplish what I believe 

is a very significant reform pathway for veterans and for the VA 

itself. 

I thank the Chair. 

Chairman SANDERS. Thank you, Senator Burr. 

Senator Tester. 

STATEMENT OF HON. JON TESTER, 

U.S. SENATOR FROM MONTANA 

Senator TESTER. Thank you, Chairman Sanders. I will be brief. 

First of all, great to have you here Secretary McDonald, your 

first appearance in front of this Committee as the confirmed Secretary for the VA. Thank you for being here. I know the last 6 

weeks have been busy for you, and hopefully productive. 

The IG, thank you folks for what you have done. Thank you for 

what you are going to do. Thank you for the recommendations that 

you are putting forth. I think these are critically important for the 

VA and for us as we look to improve the VA. 

We passed an important bill before we left for the August recess. 

That important bill was signed by the President. I agree with the 

Ranking Member, it is a first step. And I hope it is not a first step 

to privatize the VA. I hope it is a first step to make the VA stronger so that it can give the services to our veterans that they have 

earned. 

With that, I look forward to your testimony and look forward to 

the opportunity to question you on that testimony as we move forward. 

Thank you, Mr. Chairman. 

Chairman SANDERS. Thank you, Senator Tester. 

Senator Johanns. 

STATEMENT OF HON. MIKE JOHANNS, 

U.S. SENATOR FROM NEBRASKA 

Senator JOHANNS. Thank you, Mr. Chairman. Mr. Chairman and 

Ranking Member Burr, let me just start out by saying thank you 

for convening what I also believe will be a very important hearing 

today. 

I also want to express my appreciation to Mr. Griffin and your 

staff for being here today to hopefully offer some insight into the 

issues that we are looking at. 

Mr. Secretary, I also welcome you. It is good to have you on 

board. You have taken over during a difficult time, but your body 

of experience I think is going to serve our Nation well. I do want 

to say I thank you for taking swift action. I hope there is more to 

come. 

5 

The Inspector General report we are here to discuss today has 

confirmed disturbing allegations about secret wait lists and barriers to health care for our veterans. It is amazing to learn of widespread examples of failures and outright coveruption by VA employees. At present, if I have this right, there are 93 other sites 

where care is provided that are under investigation. That is amazing to me. That is a remarkable number. 

I am pleased to see that the VA agreed with all 24 recommendations that were made by the Office of Inspector General. My hope 

is that VA’s plans to address the recommendations are not empty 

words, that there will be follow-through on what they have agreed 

to. Without the recommended changes, reports of mismanagement, 

fraud, and substandard care at the VA will continue. 

While tackling the issues identified in the report, the VA must 

also keep in mind other important initiatives. The VA must work 

quickly to implement the Veterans Access, Choice, and Accountability Act that was signed into law. The Choice Card provision is 

critical to our Nation’s veterans to allow them the freedom to seek 

care outside of the VA if they choose to when it is needed. Other 

programs that ensure VA has the space to provide quality care to 

our veterans are also critical, programs for construction of State 

veterans homes and medical centers, just to name a few. 

As I mentioned in this Committee many times, the VA construction backlog should be a major concern to all of us. We just simply 

have to find a solution to replace 1950s-era hospitals—we have one 

in our State—and ensure that these priorities are not lost in the 

shuffle. 

Again, I look forward to hearing how the VA intends to repair 

the damage that has been done by this scandal to regain the trust 

and confidence not only of Congress but, more importantly, our Nation’s veterans and their families. 

Mr. Chairman, again, thank you. I yield back. 

Chairman SANDERS. Thank you very much. 

Senator Hirono. 

STATEMENT OF HON. MAZIE HIRONO, 

U.S. SENATOR FROM HAWAII 

Senator HIRONO. Thank you, Mr. Chairman. 

Secretary McDonald and Acting Inspector General Griffin, thank 

you very much for being here with us this morning. 

The revelations over wait times at the Department of Veterans 

Affairs and other systemic problems at the VA have severely shaken the trust that veterans, their families, and the general public 

should have in the VA health care system. Over the last decade, 

we have sent over 2 million men and women to fight the wars in 

Iraq and Afghanistan, and some of the problems that we see in the 

VA are due to shortcomings in three major areas, as I see it: 

First, ensuring that veterans are aware of and receive access to 

VA health care and other services that the VA provides; 

Second, Congress providing sufficient resources, effective oversight, and ensuring accountability for the VA; and 

Third, improving the transition from military service to civilian 

life. 

6 

I realize that today we are focusing once again on the veterans 

health care system. To provide effective oversight and accountability, in May of this year, this Committee convened its first hearing in response to the allegations of wait-time irregularities at VA. 

And in response to testimony from that first hearing and other 

hearings in this Committee, the Veterans Access, Choice, and Accountability Act of 2014 was passed. Once again, I want to commend the Chair for his efforts in getting this law enacted. 

Our goal in passing this legislation was to provide VA with the 

tools needed to address the serious problems veterans were facing 

in accessing care, and this law not only granted the VA money to 

build internal capacity in the form of additional hiring, but also 

provided the VA the authority to lean upon the private provider 

community to ensure timely access to quality care. And I am sure, 

Secretary McDonald, you will tell us how you are implementing 

that part of the new law. 

During the August recess, I held a field hearing on the State of 

VA health care in Hawaii, and during that hearing I heard from 

veterans in my State, local VA staff, and Washington-based VA 

staff on what they were doing to improve veterans’ experience with 

the VA. The lack of providers was a common refrain heard 

throughout the hearing. The VA must do more to recruit and retain 

high-quality health care professionals within the VA system. 

You know that the veterans are a unique patient population with 

specific needs. But based on my field hearing and the previous 

hearings this Committee held this past summer, the Inspector General’s findings in his final report were not a surprise. We know that 

problems relating to patient wait times at the VA have been reported by the IG since at least 2005, without major action by the 

VA until this year. 

VA granted medical facility directors waivers in certifying compliance with VA’s scheduling directive regarding wait times. While 

Congress for its part has continued to increase VA’s budget, clearly 

congressional oversight is critical, as is VA’s efforts to increase accountability within its system. 

For example, the lack of national standardization in procedures 

and practices, while not in itself troubling, has led to this decentralized control, leading to a broad avoidance of accountability 

within the VA system. 

I look forward to working with my colleagues, the Inspector General, and Secretary McDonald in ensuring that we make the appropriate improvements. Thank you. 

Chairman SANDERS. Senator Hirono, thank you very much. 

Senator Heller. 

STATEMENT OF HON. DEAN HELLER, 

U.S. SENATOR FROM NEVADA 

Senator HELLER. Thank you, Mr. Chairman, and also to the 

Ranking Member for holding this hearing today. I want to thank 

the Secretary and also Mr. Griffin for being here today. Thank you 

for taking time and updating us. 

In the many times we have met in my office and in this Committee and in Reno just a few weeks ago, Secretary McDonald has 

7 

showed he is committed to bringing a new vision and reforms to 

the VA to better serve Nevada and the Nation’s veterans. 

But the task ahead will be VA’s most difficult challenge after 

having failed our veterans in delivering quality health care and 

timely benefits. The gross mismanagement, poor treatment of veterans, long delays revealed in Phoenix and elsewhere have shocked 

Congress and our Nation and is a significant crisis to overcome. My 

hope is that the Secretary’s goals will not get lost in the bureaucracy, and I expect consistent communication and honesty about 

what the VA needs from Congress to restore faith in the VA and 

achieve the best care possible for our veterans. 

Just last week, I had the privilege to meet with our veterans in 

Pahrump, NV. In the past 15 years, Pahrump has grown from a 

small town outside Las Vegas to a community of 36,000. In 

Pahrump and all of Nye County, there are about 9,000 veterans, 

which is why this community has fought long and hard for a larger 

VA clinic as more veterans flock to this community. 

When visiting, I told them about the promise that I made to you, 

Mr. Secretary, when we first met, and that was that every time I 

see you, I will always bring up several key issues to Nevada veterans, of course, building the VA clinic in Pahrump, improving the 

Las Vegas VA hospital, and eliminating the disability claims backlog that we have in Reno. 

Bob, you deserve credit for quickly approving the Pahrump clinic 

as soon as you were confirmed, and I also appreciate Director Duff 

and Associate Director Caron for working closely with my office to 

keep me informed. 

But there is a lot of work to be done on this clinic. A contract 

must be awarded, the clinic must be constructed, and then it must 

be fully staffed. I will be looking closely at each of these steps to 

determine if there are unnecessary bureaucratic barriers that delay 

projects like this and will hold the VA accountable. 

I also hope to see improvements in the Las Vegas VA hospital. 

There have been discussions about how to do this, and I would like 

to share a few key improvements that I think need to be made. 

First, members of the Disabled American Veterans in Nevada 

want to improve transportation of rural veterans to this hospital. 

Right now DAV, Disabled American Veterans, have a transportation program, but they are not allowed to take veterans confined 

to a wheelchair. Now, stop and think about that for a minute. DAV, 

their transportation program is forbidden to take veterans confined 

to a wheelchair or utilizing an oxygen tank to the hospital. There 

needs to be greater partnership and coordination with the VA to 

expand the VA’s own transportation service for these disabled veterans in rural areas. 

Second, appointment wait times in the Vegas hospital must be 

improved. New patients in Vegas wait 25 days on average for specialty care appointments and 16 days on average for mental health 

appointments. Director Duff has assured me her team is working 

to improve these wait times, and part of this improvement will be 

an enhanced scheduling system the VA is currently seeking. Every 

VA hospital needs modern processes and technology that will give 

directors the information they need to determine where resources 

are missing. 

8 

Next, a point that the Secretary has brought up to me is the differences in regions and management structure among the three VA 

Administrations—Health Care, Benefits, and Cemeteries. I look 

forward to working with you to improve the current structure and 

believe that reorganizing these Administrations should be a positive step forward to enhanced coordination and improved care to 

our veterans. 

And, finally, I remain committed to addressing the VA disability 

claims backlog. For years now, Nevada is the worst in the Nation 

with claims being completed in 334 days on average. As co-chair of 

the VA Backlog Working Group, I will be hosting a roundtable 

later today, along with Senator Casey, to discuss the need to overhaul the outdated claims processing system; I believe there is no 

better time to reform the claims process as while the VA transforms under Secretary McDonald’s leadership. And the working 

group’s legislation is a strong platform for some of the changes that 

need to be made. I look forward to hearing more about the changes 

and progress of improving care and benefits at the VA. Again, I 

thank you, Mr. Secretary and Inspector General Griffin, for being 

with us today. 

Thank you, Mr. Chairman. 

Chairman SANDERS. Thank you, Senator Heller. 

Senator Blumenthal. 

STATEMENT OF HON. RICHARD BLUMENTHAL, 

U.S. SENATOR FROM CONNECTICUT 

Senator BLUMENTHAL. Thank you, Mr. Chairman, and thank you 

and the Ranking Member, as well, for holding this hearing today. 

Thank you to Secretary McDonald and Inspector General Griffin. 

We are here to listen to you, not so much to talk, but even more 

important is that we listen to our veterans across the country who 

have firsthand experience beyond the Inspector General reports, 

beyond the polling, beyond the hearings that we conduct here. 

I had a town hall meeting in Newington last Friday night for a 

couple of hours and welcomed William Streitberger, the Director of 

the Hartford VA Regional Office, as well as Gerald Culliton, the Director of the VA Connecticut Health Care System, to listen to our 

veterans, and not just about the delays but the more fundamental 

gaps in care that we have right now that we are all working hard 

to fill. 

Just one example, K. Robert Louis, a veterans service officer 

from the Veterans of Foreign Wars, shared with the audience very 

compellingly his understanding that many veterans with the VFW 

have received outstanding service, but that there is a lack of providers—nurses, doctors, staff—that has caused the delays and hindered veterans’ access to care. 

I know that the Veterans Access to Care Act authorized $5 billion to enable the VA to hire additional health care providers and 

clinical staff, but, Secretary McDonald, you have identified the 

practical obstacles to meeting the needs and hiring more doctors 

and other professionals, and that is one of the central challenges 

of our time. And I hope that this Committee will play a constructive role in that task and so many others that face you in this very 

challenging time, as well as rebuilding the facilities, the infrastrucVerDate Mar 15 2010 16:05 Jul 30, 2015 Jkt 000000 PO 00000 Frm 00012 Fmt 6633 Sfmt 6633 Z:\ACTIVE\090914.TXT PAULIN
9 

ture, as at the West Haven hospital, where not just renovation but 

rebuilding are necessary to replace a 1950s structure that cannot 

accommodate the most modern technology, the equipment that is 

necessary to care for people in 21st century fashion. 

I want to say that I hope that we will continue to be of a mind 

that this health care system is in crisis. I know that ‘‘crisis’’ is an 

overused word in Washington, but it should give us the impetus 

and sense of urgency that we all feel as to the need, the immediate 

need, because health care delayed is health care denied. People 

need it now when they need it. 

So, Mr. Secretary, I want to thank you for your determination 

and the management experience that you will bring to this task. 

Finally, we all know that we are going to see a surge of veterans 

coming out of our military in the next months and years as the 

Army and the Marine Corps downsize. Many of them will have the 

horrific invisible wounds of war that we now have diagnosed as 

Post Traumatic Stress or Traumatic Brain Injury. 

I want to thank the VA for its support in efforts that I and others have made to correct the records of veterans of past wars at 

times when Post Traumatic Stress was undiagnosed and untreated 

and caused many of them, particularly from the Vietnam era, to be 

given less than honorable discharges. Those bad-paper discharges 

have been a stigma and a black mark on their records, and caused 

many of them to be homeless and jobless. I want to thank Secretary Hagel for now initiating a new era when those records can 

be corrected. 

At our side, as we sought this change in policy, was the VA, and 

most especially General Shinseki, who served in that war. I want 

to thank all of the dedicated men and women of the VA for their 

service in so many ways, most especially in the help that they provided to initiate this change in policy. And, thank you to Secretary 

Hagel for his awareness and his courage in taking this very, very 

important step to give honor and respect to veterans who were unfairly treated when they received less than honorable discharges, 

when they suffered from Post Traumatic Stress that led to those 

kinds of discharges. 

Thank you, Mr. Chairman. 

Chairman SANDERS. Thank you, Senator Blumenthal. 

Senator Moran. 

STATEMENT OF HON. JERRY MORAN, 

U.S. SENATOR FROM KANSAS 

Senator MORAN. Mr. Chairman, thank you. Thank you to you 

and Senator Burr for having this hearing. Secretary McDonald, 

thank you for your presence but, more importantly, thank you for 

your willingness to serve. I hope that you will hit the ground running. I hope that you utilize your tenure as the Secretary to make 

remarkable improvements at the Department of Veterans Affairs 

on behalf of America’s veterans. 

I hope to explore with you during my time of questioning a couple of things, in particular—with you and the Inspector General, I 

would like to hear about what the consequences to employees at 

the VA have been as a result of their misconduct. Are those currently on leave, on leave with pay, or without compensation? And 

10 

has anyone been discharged or is there a plan to discharge anyone 

as a result of what has occurred at Phoenix or elsewhere within the 

Department of Veterans Affairs? 

In the broader sense of the legislation that we have passed, my 

understanding is—and I think I know this sufficiently well to say 

this—that many of the authorities that are given the VA, in fact, 

directives given to you in the Veterans Act, are already things that 

you have the ability in your discretion to do related to providing 

care outside of VA. I would love to hear about what is transpiring 

now as we wait for the implementation of this Act. How are we caring for veterans who are, either through lack of timeliness or geography, having difficulty accessing veterans’ medical services? In 

particular, I would like to hear how you intend to utilize ARCH, 

the pilot program in the five States across the country. And the authorities given to you in the new legislation allow you to not only 

extend that program but to expand that program. So, I would like 

to make certain there is nothing that stands in the way of either 

one of those things happening from the VA’s perspective, and to 

make certain that that Program ARCH is used while we are 

transitioning the authorities given you in the legislation. 

A couple of examples where this hits home. A gentleman in 

Smith Center, KS, who needed a colonoscopy, was told he needed 

to drive 4 hours to Wichita to do that. The VA, upon our prodding, 

changed their mind and allowed for this service to occur near 

home. He apparently qualified because of the issue of timeliness, 

not because of geography. 

Another veteran who has to have cortisone shots is told by the 

VA he must drive 31⁄2 hours to the VA. Apparently he does not 

qualify for the lack of timeliness and, therefore, he ought to qualify, 

in my view, for geography. But, again, the VA has said no. So, how 

we implement this act in regard to timeliness and geography and 

what authorities you have in the interim to make certain that no 

one falls through the cracks while we wait is of great importance. 

It has been discouraging to me on the one hand and impressive 

on the other, the significant changes that have been made at the 

VA. The discouraging part is if you could react this quickly and accomplish what has been accomplished in the last month or so, why 

was it not being done in the first place? If we can come up with 

ways to solve the problems of how we get veterans in to see a physician and be treated, why was it not occurring all along when you 

have been able to accomplish so much in a short amount of time? 

Thank you, Mr. Chairman. 

Chairman SANDERS. Thank you, Senator Moran. 

Senator Begich. 

STATEMENT OF HON. MARK BEGICH, 

U.S. SENATOR FROM ALASKA 

Senator BEGICH. Thank you, Mr. Chairman. Thank you for holding this hearing. Secretary McDonald, thank you very much for our 

meetings and conversations we have had, and for the IG being here 

also. 

Let me just say a couple things. First, I am very glad that the 

piece of legislation passed, as it did a month or so ago, but the reality is, as we know—and I guess for Senator Moran, in Alaska, we 

11 

have been doing this for 3-plus years. We dragged the Obama administration along, but they now understand, and we have been 

doing it for 3 years. We deliver health care to 30 different tribes 

around the State through our Indian Health Services program, 

which is administered by Alaska tribes, delivering health care to 

veterans, both native and non-native, no matter where they live. It 

does not matter if you are living up in Nome or you are living all 

the way down in Ketchikan. We can deliver care if the veteran so 

chooses, with the existing rules. And it was not easy. There was 

a little bit of back-and-forth between the VA and the Health and 

Human Services Department to get them to understand that this 

is about delivering care with the same tax dollars. It does not matter who was spending it. It was coming from the same kitty that 

we have to allocate. 

So, from my perspective, you know, I am anxious to see how and 

what you will do with these recommendations, but the reality is— 

and to be very frank, I am sure, Mr. Secretary, you would prefer 

not to keep coming to meetings like this but to actually go do the 

work that needs to be done. And I am glad we are doing oversight. 

It is important to make sure that you, the administration you are 

now in charge of, the Obama administration, all of them are focused on this issue of delivering health care at the greatest level 

possible. 

But I think we have some great examples already that exist that 

we could utilize as I gave for Alaska. For example, in Anchorage, 

which is 43 percent of the State’s population, you can go to the VA 

clinic or you have a choice. You can go to the Anchorage Neighborhood Health Services clinic or the Alaska Native hospital. And in 

those two facilities, those last two I mentioned, if you are on the 

list, you get in the same day, as long as it is not major medical. 

That is an amazing step. We did that before this new piece of 

legislation. 

To be very frank with you, I am not sure what some did in their 

own States. I know what I did. I had to pound away on the VA, 

because I remember my first memo I put out on this idea, within 

6 months after coming into office; they said it cannot be done, not 

possible, unrealistic, it is two different agencies. I remember the 

long laundry list that I got, both from the agency and veterans organizations. Nonetheless, we just pushed the pedal down all the 

way, because I think they just spelled ‘‘yes’’ wrong. They spelled it 

‘‘N O.’’ We just had to work on it. The end result is today we are 

delivering care all across the State of Alaska, which is one-fifth the 

size in mass, of this country. So, if we can do it there, we can do 

it anywhere. I think in a lot of ways, the piece of legislation we 

passed only re-emphasizes what can be done, plus we gave more 

money. 

The challenge you are going to have is making sure we have 

enough professionals. As we know, in Alaska, the Matanuska Valley, the Mat-Su area, had a problem, still has a problem recruiting 

primary care doctors. That is going to be a problem not only in the 

VA system, but in the Indian Health Services, the private sector, 

and you name it, it is a problem everywhere. But what did we do 

there? Again, we used a tribal agreement to use South-Central clinVerDate Mar 15 2010 16:05 Jul 30, 2015 Jkt 000000 PO 00000 Frm 00015 Fmt 6633 Sfmt 6633 Z:\ACTIVE\090914.TXT PAULIN
12 

ic to admit almost 500 veterans for care, because we had access 

and capacity there. 

So, as you look at how to solve this problem and continue to 

move forward, look at the assets that are out there. I do believe, 

as proven before this legislation passed, we have the authority, you 

have the authority, you have the capacity to push the pedal all the 

way down. The VA, the Obama administration, can make these 

things happen if they want. So, I think what we are saying here 

today is we are glad the bill passed, we are glad we are having 

oversight, but just go do it. Make it happen. And then when there 

are problems and challenges, you need to let us know right away. 

My guess is recruitment is going to be a continual problem, not 

only for your system but for every medical system in this country, 

because it takes years to get a primary care doctor into the system. 

One of the things we want to make sure is with the VA, for example, mental health providers, which is a huge gap, are universally still not certified in cooperation with the VA to make sure our 

counselors are being able to be used. They do not have the exact 

credentials, but they are available. So, we need to make sure the 

VA makes this happen, because they are ready, they are able. 

There are huge gaps in mental health services. We want to make 

sure certification is possible. I want to make sure you have that on 

your list. 

But, again, you’ll have some big challenges in recruitment. The 

administration is moving forward. You have a huge task ahead of 

you, and I want to make sure that we are not always going to 

meetings but we are hearing results, and that is what I am looking 

for. 

Thank you. 

Chairman SANDERS. Thank you very much, Senator Begich. 

Senator Boozman. 

STATEMENT OF HON. JOHN BOOZMAN, 

U.S. SENATOR FROM ARKANSAS 

Senator BOOZMAN. Thank you, Mr. Chair, and thanks to you and 

Ranking Member Burr for the hearing. I think in the interest of 

time I would like to hear the testimony, though I may put a statement in the record. 

Chairman SANDERS. Thank you very much. 

Senator Murray. 

STATEMENT OF HON. PATTY MURRAY, 

U.S. SENATOR FROM WASHINGTON 

Senator MURRAY. Well, thank you, Mr. Chairman, for holding 

this really important hearing. I want to start by thanking the Inspector General, Richard Griffin, and the Department’s Office of Inspector General for all the work that has been done to conduct this 

review. Your investigators and staff have put together an incredibly important report on what happened at Phoenix. And completing the other investigations at nearly 100 medical centers is 

really an enormous task. So, I want to thank the OIG and all of 

your staff for the incredible dedication it is taking and will take to 

get this done. 

13 

After a lot of years of making critical contributions to veterans’ 

care and benefits, the IG, rightly, has the reputation of being objective, reliable, and thorough in your work, so we all do thank you. 

Your findings are going to be really vital as we work forward 

through this, so I appreciate it. 

I also appreciate how Secretary McDonald has hit the ground 

sprinting in his new role and has taken immediate steps to get the 

veterans off wait lists and into care. And while the VA’s latest data 

continues to show patient accessibility improving across the Department, I want you to know I still am concerned about some of 

the facilities in my homestate of Washington. Veterans receiving 

primary and specialty care within the Puget Sound Health Care 

System continue to wait longer than national averages for primary 

and specialty care. And at Spokane, the new mental health care 

patients wait over twice as long—75 days for their appointments— 

and that has got to change. 

As the VA continues to focus on providing veterans with timely 

access to care, it also has to ensure veterans receive the highest 

quality of care, and as the IG report showed, that was all too often 

not the case in Phoenix. They found that the Phoenix Health Care 

System struggles with many of the basic quality-of-care issues, 

things like leaving routine physical examinations and evaluations 

incomplete, or failing to conduct them at all, or releasing mental 

health care patients before their medications were properly stabilized, and struggling to provide dedicated mental health care providers to patients. 

So, when we are talking about caring for our Nation’s heroes and 

their families, we all expect excellence. And I want to note, as I 

have said repeatedly, as transparency and accountability increase 

at the VA, so will investigations and reports of additional concerns 

requiring even more action from the VA, the administration, and 

this Congress. 

Today, Mr. Chairman, I hope to hear how the VA is going to address the findings of the IG, the VA access audit, and the White 

House review, and I want to hear how the VA will implement the 

Veterans Access, Choice, and Accountability Act. 

Yesterday we heard the Secretary speak about VA recommitting 

itself to core values. Today we need to know how the Secretary will 

turn those commitments into real action and to improve care for 

our Nation’s heroes. 

Thank you, Mr. Chairman. 

Chairman SANDERS. Senator Murray, thank you very much. 

I think we have heard from all the Senators. Let me bring Mr. 

Griffin and his staff to the table. 

Let me welcome Richard Griffin and his staff. Mr. Griffin is the 

Acting Inspector General for the Department of Veterans Affairs at 

today’s hearing. Let me also make a comment. Normal protocol is 

for us to have the Secretary go first, and I want the Secretary to 

know that there is no disrespect in us breaking that protocol. But 

I thought it would be more important to hear what the Inspector 

General had to say and what his staff had to say and then see the 

Secretary respond to that. 

Mr. Griffin was appointed as Deputy Inspector General in 2008. 

He previously served as the VA Inspector General from 1997 to 

14 

2005, so he brings an enormous amount of experience and knowledge to his position. 

He is accompanied today by Dr. John Daigh, Jr., Assistant Inspector General for Healthcare Inspections; Ms. Linda Halliday, 

Assistant Inspector General for Audits and Evaluations; Ms. 

Maureen Regan, Counselor to the Inspector General; and Mr. Larry 

Reinkemeyer, Director of the Inspector General’s Kansas City 

Audit Office. 

Mr. Griffin, thank you so much for your work and thank you for 

being with us. The mic is yours. 

STATEMENT OF RICHARD J. GRIFFIN, ACTING INSPECTOR 

GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY JOHN D. DAIGH, JR., M.D., ASSISTANT INSPECTOR GENERAL FOR HEALTHCARE INSPECTIONS; LINDA 

HALLIDAY, ASSISTANT INSPECTOR GENERAL FOR AUDITS 

AND EVALUATIONS; MAUREEN REGAN, COUNSELOR TO THE 

INSPECTOR GENERAL; AND LARRY REINKEMEYER, DIRECTOR OF THE INSPECTOR GENERAL’S KANSAS CITY AUDIT 

OFFICE 

Mr. GRIFFIN. Mr. Chairman, Ranking Member Burr, and Members of the Committee, thank you for the opportunity to discuss the 

results of the IG’s extensive work at the Phoenix VA Health Care 

System. Our August 26 report expands upon information previously provided in the interim report and includes information on 

the reviews by OIG clinical staff of patient medical records. 

The OIG examined the medical records and other information for 

3,409 veteran patients, which included 293 deaths, and identified 

28 instances of clinically significant delays in care associated with 

access or scheduling. Of these 28 patients, 6 were deceased. In addition, we identified 17 cases of care deficiencies that were unrelated to scheduling or access issues. Of these 17 patients, 14 were 

deceased. 

The 45 cases discussed in the report reflect unacceptable and 

troubling issues in follow-up, coordination, quality, or continuity of 

care. The identity of these 45 veterans has been provided to VA. 

Decisions regarding VA’s potential liability in these matters lie 

with the Department and the judicial system under the Federal 

Tort Claims Act. Information on the qualifications of the OIG physicians who conducted these reviews can be found in the curriculum vitae submitted for the record with our written testimony. 

We identified several patterns of obstacles to care that resulted 

in a negative impact on the quality of care provided by Phoenix, 

and as of April 22, 2014, we identified about 1,400 veterans waiting 

to receive a scheduled primary care appointment who were appropriately included on the Phoenix electronic wait list. However, as 

our work progressed, we identified over 3,500 additional veterans, 

many of whom were on what we determined to be unofficial wait 

lists, waiting to be scheduled for appointments but not on Phoenix’s 

official electronic wait list. 

Urology Service was also unable to keep up with the demand for 

services. During our review, it became clear that the Urology Service at Phoenix was in turmoil during the 2012 to 2014 timeframe. 

There were a number of urology physician staffing changes, delays 

15 

in the procurement of non-VA purchased care, and difficulties coordinating urologic care. The OIG is currently working from a list 

of 3,526 patients who may be at risk for having received poor-quality urologic care. As a result, urology services at Phoenix are the 

subject of an ongoing OIG review. 

Since July 2005, OIG has published 20 oversight reports on VA 

patient wait times and access to care, yet VHA did not effectively 

address its access-to-care issues or stop the use of inappropriate 

scheduling procedures. 

When VHA concurred with our recommendations and submitted 

an action plan, many VA medical facility directors did not take the 

necessary actions to comply with VHA’s program directives and 

policy changes. 

In April 2010, in a memorandum to all VISN Directors, the thenDeputy Under Secretary for Health for Operations and Management called for immediate action to review scheduling practices 

and eliminate all inappropriate practices. 

In June 2010, VHA issued a directive reaffirming outpatient 

scheduling processes and procedures. 

In July 2011, an annual certification of wait times was 

mandated. 

In January 2012 and May 2013, the VISN 18 Director issued reports that found Phoenix did not comply with VHA’s scheduling 

policy. 

Finally, in May 2013, VHA waived the annual requirement for 

facility directors to certify compliance with the VHA scheduling directive, further reducing accountability over wait-time data integrity and compliance with appropriate scheduling practices. 

The IG opened investigations at 93 sites of care in response to 

allegations of wait-time manipulations. The investigations continue 

in coordination with the Department of Justice and the Federal Bureau of Investigation. While most are still ongoing, these investigations are confirming that wait-time manipulations were prevalent 

throughout VHA. 

This report cannot capture the personal disappointment, frustration, and loss of faith individual veterans and their family members had in the health care system that often could not respond to 

their mental and physical health needs in a timely manner. Immediate and substantive changes are needed. The VA Secretary has 

acknowledged the Department is in the midst of a serious crisis, 

and he has concurred with all 24 recommendations in our report 

and submitted acceptable corrective action plans. 

Mr. Chairman, this concludes our statement, and we would be 

pleased to answer questions any of the members may have. 

[The prepared statement of Mr. Griffin follows:] 

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Chairman SANDERS. Mr. Griffin, thank you very much for your 

testimony and for the work that you and your staff have undertaken over the last few months. 

Let me begin by asking you a question that arises from some 

media reports which have troubled me. There has been some suggestion that the IG, the Office of Inspector General for VA, is really 

not independent. And I would like to provide you with the opportunity to describe the process the IG utilizes when preparing overVerDate Mar 15 2010 16:05 Jul 30, 2015 Jkt 000000 PO 00000 Frm 00028 Fmt 6633 Sfmt 6633 Z:\ACTIVE\090914.TXT PAULIN

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sight reports, including the draft report review and comment process. In other words, are you being heavily influenced by VA? Are 

they editing the reports that you give us? Or, in fact, are you an 

independent entity finding the truth as best you can? 

Mr. GRIFFIN. Thank you for that question. Our organization over 

the last 6 years has issued over 1,700 reports addressing oversight 

issues in the Department of Veterans Affairs. We have testified at 

over 60 congressional hearings in the last 6 years about our reports. Every one of our draft reports and every draft report of anybody in the Inspector General community is submitted as a draft 

to the Department for purposes of guaranteeing accuracy of all reporting. If the Department has information that we missed in doing 

our work that they can point out to us that would be factual and 

convincing, then we may come to realize, well, we have got this one 

part wrong. 

We do not accept from the Department or from anyone else a dictated response that is based on opinion as opposed to fact. 

Chairman SANDERS. OK. Thank you very much. 

Let me ask you this: every Member of this Committee is outraged by what happened in Phoenix. We are outraged in general 

by unacceptably long wait periods for veterans to access health 

care. We have seen with disgust the manipulation of data, lying, 

et cetera. What I would like you to do is explain in plain English, 

how does this happen? 

Now, you pointed out just a moment ago that we have heard 

from VA time and time again their concerns about the appointment 

process, and yet nothing seemed to happen. So, take us to Phoenix 

and describe to us exactly how it happened that we had these long 

waiting periods that were disguised and how we had some people 

not on any waiting list at all. And all of this went on while nobody 

did anything about it. How does this happen? 

Mr. GRIFFIN. That happens when there is a failure of leadership. 

We are not just talking about Phoenix. We have reported on this 

problem for 9 years. Excellent policies were, in fact, published and 

sent out. I alluded to some of them in my oral statement. You have 

to follow it through. Wait times is not the only issue that we have 

reported on where VHA has promulgated policies to address our 

recommendations, sent them out, and were supposed to be certified 

that they were followed, and they were not. 

It is hard to explain the why of that, but when people do not follow the directive from their headquarters leadership and mislead 

them about it, there has to be a consequence. 

Chairman SANDERS. All right. Two brief questions. 

Number 1, to what degree did the 14-day directive impact the 

immediate problems? 

And, number 2, how can a facility provide timely care if they do 

not have enough doctors, nurses, space, and staff? And how does 

that not get up to the general office? How does it not happen that 

somebody says, ‘‘I cannot do it in 14 days. I just do not have the 

doctors; I do not have the staff?’’ Explain that process to me. 

Mr. GRIFFIN. I believe there was an awareness in Phoenix, based 

on some of the e-mails that we pulled and that are included in our 

report, that many people in the Phoenix hierarchy were aware that 

it was not doable. I am sure you recall the e-mail from our interim 

26 

report where someone asked for an ethics review because our 

‘‘Wildly Important Goal’’ in the success that is being reported is 

smoke and mirrors, as was mentioned earlier. 

I think a big part of the equation for the fix, as opposed to what 

we all know happened, when you look at the initial point where a 

veteran has contact at the medical center, very often you have the 

lowest-graded employees who might not be equipped to be able to 

triage this veteran who really needs to get seen in 14 days or 7 

days, or tomorrow or today, versus this veteran can wait 30 days. 

I think in the private sector you would probably have somebody 

with a little more clinical background to try and make that evaluation, so you know who really does need to come in and who does 

not. 

Chairman SANDERS. My time has expired, but the bottom line is 

if you do not have the staff, if you cannot do it, how come that is 

not transmitted up the channel? 

Mr. GRIFFIN. It should be. I believe in Phoenix it was, and the 

outcome is documented in our report that no action was taken to 

fix it. 

Chairman SANDERS. OK. Thank you very much. 

Senator Burr. 

Senator BURR. Mr. Griffin, thanks to you and to your staff for the 

job you have performed, for the undertaking that you are already 

in process with. I do not think any of us would wish it on anybody 

that they had to make the reviews that you are having to do. 

Let me just ask, had the VA listened to prior IG reports and 

fixed the problems you had pointed out, would we be here today 

talking about Phoenix or talking about any facility? 

Mr. GRIFFIN. No. 

Senator BURR. The problems within VA seem to be rooted in two 

things. One is the culture that has been created, and I think that 

culture has been created because there was a lack of accountability, 

which was evidenced by these waiting lists that operated outside 

of the electronic system and by other things. Had they just addressed those, we probably would not be here investigating Phoenix 

to the degree that we are. Is that an accurate statement? 

Mr. GRIFFIN. That is accurate, and as I mentioned previously, 

even in other areas, we would not close a recommendation unless 

we believed that they had taken the appropriate steps to resolve 

the issue. 

When you get a copy in 2010 of this mandate to knock off the 

manipulation and then 3 months later you get an updated scheduling procedure as a VHA directive, at that point you would believe 

that people got it, that it would be implemented, and it would be 

implemented to the letter. 

Senator BURR. What do you conclude—how could somebody conclude within VA not to require certification last year based upon 

all the warning signs you had provided for them? 

Mr. GRIFFIN. I think the next panel can probably better explain 

what the rationale was. I think there has been plenty of warning 

that this was going on, and I thought the certification was an excellent thing to make people declare, yes, I have reviewed it in my 

facility, and, yes, our waiting times are according to the policies 

and procedures of the Department. 

27 

Senator BURR. Now, you have been involved for 6-plus months 

investigating the current list of things, and I know you cannot get 

into specific takeaways, but let me ask: what have you learned 

about the VA over that period of time, not down to the specifics? 

Mr. GRIFFIN. Referring to the 93 other facilities? Well, we have 

some initial reporting on those. As of yesterday, we have given the 

Department 12 individual reports for them to examine and determine what action would be appropriate in view of the specifics of 

each of those reports. 

The rest of our 93 are still very much active, but I can tell you 

that at 42 different facilities of those 93, we found the practice of 

using the next available date as the desired date. It is something 

that was reported on in our interim report and in the final report. 

We have 19 facilities where an appointment was canceled and rescheduled on the same day for the same appointment time for the 

sole purpose of giving the appearance of a shorter waiting time. 

We have had 16 facilities that had paper wait lists as opposed 

to being on an EWL. We had 13 facilities where managers lied to 

my investigators about what was going on at their facilities. 

Senator BURR. Did your investigators conclude that all of these 

individuals came up with these deceptive practices on their own? 

Or was there some overarching initiative that some level of management actually pushed? 

Mr. GRIFFIN. It is a combination. Frankly, when something is 

going on for as many years—not everywhere but at a number of 

the facilities—it almost becomes the accepted way of doing scheduling. And, again, when you have lowest level employees involved 

in scheduling and they come in as a new hire and somebody says, 

‘‘This is how we do it,’’ they may not realize that someone is telling 

them the improper way to do it. So, it is a combination of things. 

The bottom line is: who is in charge? And when you get a policy 

directive from VHA, do you enforce it, or do you ignore it? I think 

that is the bottom line. 

Senator BURR. My time has expired, but let me say once again 

I thank you and your staff for the process you are going through. 

It is invaluable to our country’s veterans and to the agency. 

Mr. GRIFFIN. Thank you. 

Chairman SANDERS. Senator Burr, thank you very much. 

Senator Tester? 

Senator TESTER. Thank you, Mr. Chairman, and I, too, want to 

thank you, Inspector General Griffin, for your work and for your 

professionalism. I very much appreciate it. It is very helpful to us, 

so thank you for that work. 

Your investigations, whether it be Phoenix or whether it is the 

other 93 facilities, are focused on scheduling, correct? 

Mr. GRIFFIN. That is what we go in to look at, but along the way 

you sometimes become aware of other activities that you need to 

look at that might be tangentially related. You know, so principally 

they are on scheduling and manipulation of wait times, but there 

are some places where it has expanded. 

Senator TESTER. Is it fair to say that—I mean, the investigation 

started out in Phoenix because of some pretty damning things that 

were being said about Phoenix. Is it fair to say that the scheduling 

problems are pretty pervasive throughout the VA? 

28 

Mr. GRIFFIN. Absolutely. 

Senator TESTER. OK. Specifically for Phoenix, is—look, I mean, 

a good portion of Montana heads down there in the wintertime. 

Were there parts of the year where the scheduling was worse than 

other parts of the year? Or was it just that way all the time? 

Mr. GRIFFIN. You know, we did not try to carve out the snowbird 

aspect that might impact Phoenix, but we—— 

Senator TESTER. I was just curious. 

Mr. GRIFFIN. We did not find a good quarter in any of the quarters we looked at. 

Senator TESTER. OK. Would you say—in the conference committee opening statements we heard a lot from the members of the 

conference from both Houses that talked about that this is not a 

workforce issue. In your investigations, what would you say to 

that? 

Mr. GRIFFIN. I would say it is a complex issue with many aspects. One of those aspects is performance standards for the physicians that you do have. Without those standards, it is hard to determine exactly how many doctors and nurses you need. It is a clinical space issue. VHA guidance talks about a panel of 1,200 patients for primary care. But it assumes that there are three separate offices for each doctor so that you can have your patients 

ready to go when you come in, and in Phoenix, there was only one 

office per doctor. 

I think it is a combination of, yes, in some facilities they are 

understaffed, both nurse and doctor staffing. We have sought the 

implementation of staffing standards for years. We did a review in 

2012 on specialty care staffing standards and found that only 2 of 

33 specialties had standards. I think you need to know how many 

veterans can we anticipate this specialist seeing in a given day and 

then make sure the schedule is properly structured so you can fill 

those slots. 

Senator TESTER. You have got a number of MDs on your staff, 

and you may, in fact, be an MD. I am not sure. I cannot remember. 

You are? 

Mr. GRIFFIN. No. 

Senator TESTER. OK. When you are talking about staffing standards, do you use the private sector for your standards then? And 

maybe this should be reflected to one of the MDs on the staff. And 

I will tell you why I ask this. I am not an MD either, but it appears 

to me that if you try to apply private sector staffing standards to 

the VA it is unfair, because these folks are coming back with multiple problems, plus ones that are unseen, too. So, do you guys 

apply the staffing standards, or do you say, VA, you need to set up 

the staffing standards? 

Mr. GRIFFIN. We have said that we believe they should have 

standards so that if you are in a like-size VA facility in one part 

of the country or another, the expectation is a certain level of 

productivity. 

I would ask Dr. Daigh if he would like to elaborate upon that. 

Dr. DAIGH. Sir, we have advocated that VA create their own 

standard, aware of civilian standards, but without that data, I do 

not know how you can make proper business decisions about what 

you are going to make or what you are going to buy. 

29 

Senator TESTER. That is good. Thank you very much. 

There are 1,700 health care facilities in the VA; 93 are being investigated by you at this point in time. Can you give me any idea— 

or is it pretty evenly distributed between hospitals, CBOCs, and 

small clinics? 

Mr. GRIFFIN. I would be guessing to give you that number, but 

it is a mix. 

Senator TESTER. Can you give me that number? 

Mr. GRIFFIN. We can. Yes, absolutely. 

Senator TESTER. I would like to get that. 

Mr. GRIFFIN. And if someone at the table here has it, I will give 

it to you right now. 

Senator TESTER. That is fine. There is nobody nodding yes, so we 

will—one more, because my time just ran out. 

Mr. GRIFFIN. We will get it to you. 

[The information referred to follows:] 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. JON TESTER TO

RICHARD GRIFFIN, ACTING INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS

AFFAIRS

Type of Facility Number 

VA Medical Center ............................................................. 68 

Community Based Outpatient Clinic ................................. 13 

Outpatient Clinic ................................................................ 8 

Health Eligibility Center ..................................................... 1 

Health Care System ........................................................... 1 

Ambulatory Care Center ..................................................... 1 

Multi-Specialty Outpatient Clinic ...................................... 1 

Senator TESTER. When can we expect a report from you guys on 

these 93 facilities, a full report? 

Mr. GRIFFIN. As we finish each individual report—and to be finished, if it is a criminal matter, we have to present it to the U.S. 

Attorney’s Office for a prosecutive decision. If it does not meet the 

threshold for prosecution, we give the report to the Department so 

that they can take administrative action, where appropriate. 

Senator TESTER. Would it be fair to say—and I do not want to 

box you in—these would be done by the end of the year? 

Mr. GRIFFIN. I hope so. 

Senator TESTER. Thank you very much. 

Thank you, Mr. Chair. 

Chairman SANDERS. Thank you, Senator Tester. 

Senator Heller? 

Senator HELLER. Thank you, Mr. Chairman. 

I want to go back to your initial comments on the report, the 

draft report versus the final report, and some of the changes that 

were made in that report, to get some clarification as to timelines. 

It was reported that a line was inserted, and if you are the VA, 

this is the line you would want inserted in that report. That line 

says, ‘‘While the case reviews in this report document poor quality 

of care, we are unable to conclusively assert that the absence of 

timely quality care caused the deaths of these veterans.’’ Obviously 

that was pertaining to the Phoenix hospital. 

Just some timelines. Was this line included in the draft report? 

30 

Mr. GRIFFIN. There are many versions of the draft report. The 

majority of the changes in our draft report came about as a result 

of further deliberations by the senior staff of the Inspector General’s office. No one in VA dictated that sentence go in that report, 

period. 

Senator HELLER. Was the line included in the draft report that 

was sent to the VA? 

Mr. GRIFFIN. It was not included in the first version of that draft 

report. What I would like to do, if I may, is provide a timeline in 

writing to the Committee—— 

Senator HELLER. I would like that. 

Mr. GRIFFIN [continuing]. That, you know, can make it very clear 

what is going on with that allegation. 

[The information referred to follows:] 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. DEAN HELLER TO

RICHARD GRIFFIN, ACTING INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS

AFFAIRS


9914q2HE1.eps
31 

Senator HELLER. OK. I guess the question that needs to be 

asked, did the VA play any part in the inclusion of this line? 

Mr. GRIFFIN. No. 

Senator HELLER. In your report, you obtained a list of 171 patients who were waiting to seek services. Most of them were mental 

health therapies. You also noted in your report that, between January 2012 and 2014, you identified 77 suicides. These patients did 

not have their appointments scheduled or were yet to be scheduled. 

What I am trying to get to is: would a reasonable person come to 

the conclusion that wait-time manipulation contributed to patient 

deaths? Would a reasonable person come to that conclusion, that 

the manipulation of these wait times contributed to an individual’s 

death? 

Mr. GRIFFIN. I am going to ask Dr. Daigh to describe the clinical 

process review, but what I would say in general, we are not in the 

business of making odds on whether something did or did not cause 

a death, whether it is likely, unlikely, 50 percent, 30 percent, 80 

percent. That is not our purpose. Dr. Daigh will describe how we 

conducted those reviews. 

Dr. DAIGH. We looked at the fact pattern of each of the cases that 

we described for you. So, one of the issues you have to understand 

is that because you are on a wait list for audiology and you happen 

to die of a cardiac problem, the wait-list factor was not very 

important. 

If you were under the care of a urologist intensively but you were 

on a wait list to see primary care, then we may have concluded 


9914q2HE2.eps 9914q2HE3.eps
32 

that, yes, you were on a wait list, yes, you died, but we do not see 

a relationship there. 

So, for each of these cases we have reported, we wanted the fact 

pattern to demonstrate that a delay in care we thought would have 

led or dramatically impacted the likelihood that that patient would 

die, and we did not see that. We saw harm. We saw 28 cases described where delay negatively impacted care. But I could not say 

delay caused the patient to die. 

Senator HELLER. So, of the 171 patients that were delayed in 

mental health therapy, and you identified 77 suicides, you see no 

link between delayed care and these—— 

Dr. DAIGH. I did not say no link. I said that if you are trying to 

say that—— 

Senator HELLER. You see, I am in the business of trying to find 

conclusions and figuring out what reasonable people would believe. 

We had a female veteran, a blind veteran with diabetic problems 

in Nevada, who had to wait 6 hours to get care. Two weeks later 

she died. I have to believe that there is a link between the kind 

of care she was getting at that hospital and her death 2 weeks 

later. And I think any reasonable person would come to that 

conclusion. 

Dr. DAIGH. So, we looked, again, at the fact pattern for each of 

these cases. We had two physicians on my staff agree on the cases 

and the fact pattern and the conclusion we came to on each of 

these cases. When we began this review, I thought we would find 

patients with delayed care leading to death. I agree, that is a likely 

outcome. I just did not see it. All I can do is report the news that 

I find, and this is what we find. 

Senator HELLER. See, I do not want to give the VA a pass on 

this, and I believe that that is what this line does. It exonerates 

the VA of any responsibility in past manipulation of these wait 

times. 

Dr. DAIGH. I just have to disagree. I described 45 cases, 28 of 

which were negatively impacted because of delays. The only argument is, I cannot say that those that died, died because of a delay. 

In addition, I found that there was care that did not meet the 

standards of care that we would expect of the VA for an additional 

17 cases. I have laid those fact patterns out in the report, so I have 

a conclusion, and the reader can come to their own conclusion. 

Senator HELLER. Dr. Daigh, thank you. 

Thank you, Mr. Chairman. 

Chairman SANDERS. Thank you, Senator Heller. 

Senator Hirono? 

Senator HIRONO. Thank you, Mr. Chairman. 

Just following up on the previous question, Mr. Griffin, would 

you agree that attribution of negligence as a result of delay in care 

as a causation of death is basically an adjudicatorial process that 

needs to be undertaken? 

Mr. GRIFFIN. That is correct. 

Senator HIRONO. You noted in your testimony that wait times 

are not the only issue that you were focusing on, and that when 

people do not follow headquarters directives and mislead the headquarters, there have to be consequences. You are investigating 

33 

some 93 facilities. Have you completed those investigations on any 

of those facilities? 

Mr. GRIFFIN. We have completed 12. We have turned over 12 

files to the Department for their—whatever action they deem appropriate. All the others are in process. 

Senator HIRONO. As a result of these 12 files, has the VA undertaken any criminal or administrative proceedings, disciplinary 

proceedings? 

Mr. GRIFFIN. Well, the criminal decision lies with the U.S. Attorney’s Offices that we are working with around the country. VA 

owns the decision on administrative action. And, in fact, shortly 

after our first report was sent to the VA, they did take administrative action. 

We are trying to get these done as quickly as possible so that 

they can move out in every instance where they need to, but we 

have to make sure we have all the facts right prior to declaring 

that we are through and this is the final product. We are working 

diligently on that, but we have a lot of other prosecutions outside 

of wait-time areas which have led to over 500 arrests a year for the 

last 6 years that you cannot just drop. A lot of them are threat and 

assault cases, drug diversion cases, abuse of fiduciary veterans. 

We are working very seriously to try to get through the wait time 

investigations, but all these other investigations that were already 

in progress need to be seen through to fruition. 

Senator HIRONO. Thank you for giving us a fuller context in 

which the VA is undertaking these kinds of proceedings. 

You mentioned in your testimony and in your conclusion that the 

VA must address cultural changes, cultural issues. Can you talk a 

little bit more about how a system as vast as the VA can make cultural changes? What sort of cultural changes are you talking 

about? And what do you suggest that they do to implement these 

kinds of cultural changes? 

Mr. GRIFFIN. Well, I think if you have a culture where it is OK 

to disregard directives from the most senior people in your administration, you need to come to realize that that is not acceptable behavior, and perhaps you will no longer be employed by the 

Department. 

When people realize that it is a new day in that respect, I think 

they will be a little more vigilant in how they receive directives 

from their senior leaders in Washington. And I believe that the efforts that are undertaken in the various town hall meetings and 

feedback sessions with the VSOs and so on can also make the entire organization realize that these are the types of things we need 

to be doing. 

Senator HIRONO. Do you think that the provisions in the law that 

was recently passed—the veterans bill, that would allow for more 

expeditious processes for disciplining—would help to change the 

culture in the VA in a positive way? 

Mr. GRIFFIN. I think that in a number of personnel areas in the 

Federal Government, it can be frustrating at the pace that it requires in order to go through all of the due process activities. I 

think the ultimate impact that it will have on the Department is 

to be determined. It will depend on, you know, how frequently it 

is used, whether there are any challenges, being that VA is the 

34 

only department in the Government with the new abbreviated 

timeframes and so on. 

Senator HIRONO. Your report put forth a number of recommendations. I am particularly looking at Recommendations 17 to 23, and 

the VA has said that they will meet those recommendations by 

September 2015. 

Are there any of those recommendations that you consider more 

a priority than others for the VA to meet? 

Mr. GRIFFIN. Well, there is a reason why our number 1 recommendation was that the Department had to get with the Regional Council in Phoenix and with VHA medical professionals to 

look at the names of the 45 veterans we identified and to take appropriate action regarding potential liability or institutional disclosures and so on. I think that is very important. 

Senator HIRONO. So, basically your recommendations are in the 

order of priorities that you—— 

Mr. GRIFFIN. No, it is in the order of the presentation of the report, but I personally would have to say that I think that is one 

of the most important items. I would also say that as we were 

doing the work and we discovered 3,500 veterans that were not on 

an official list anywhere, we immediately turned those over to the 

Phoenix staff so they could be seeking out those veterans and not 

delay their care any more than it had already been delayed. 

Senator HIRONO. Thank you. 

Mr. Chairman, my time is up. 

Chairman SANDERS. Thank you, Senator Hirono. 

Senator Boozman? 

Senator BOOZMAN. Thank you, Mr. Chairman. 

I do appreciate the hard work, Mr. Griffin, of you and your staff. 

I think you have done a very, very good job. The report that you 

came out with is very helpful as we try and solve some of these 

problems. 

I would like to ask a little bit from both of you, you and Dr. 

Daigh, normally when you see a—when a patient goes to see a provider, the provider becomes the responsible person in the situation. 

If you sign a chart and say, ‘‘Come back in 2 weeks,’’ sometimes 

there are situations where perhaps he is going to be out of town 

or this or that or somebody is not available. I cannot imagine a situation where the scheduler would not ask the one that was scheduling, you know, ‘‘This cannot be done. What do you want to do 

about it?’’ Can you elaborate on that? What happens in the VA? 

When the provider actually writes on the chart, or however they 

do it, does the scheduler overrule that? 

The other problem I have got is when the provider sees somebody 

back, say inherit a patient like this, the cardiologist or whatever, 

and you see on the chart that he was supposed to come back in 2 

weeks and now it is 2 months, where is the outrage from the provider at that point as to why this was not done in the normal 

fashion? 

Dr. DAIGH. Sir, I think what we found at Phoenix was that— 

what you talk about are very reasonable steps an office has to have 

in order to maintain both the trust of their patients and deliver 

quality care. So, what we found was that, for example, a person 

would go to the emergency room as the point of care. The emerVerDate Mar 15 2010 16:05 Jul 30, 2015 Jkt 000000 PO 00000 Frm 00038 Fmt 6633 Sfmt 6601 Z:\ACTIVE\090914.TXT PAULIN
35 

gency room physician would provide appropriate care and, for example, diagnose diabetes and say, ‘‘You need to go see your primary care provider.’’ At Phoenix, there simply were not enough— 

there was not enough access in primary care to accommodate patients who needed to go to the primary care provider. 

So, what would happen was the patient would be given a consult, 

it would be put in a space that was not acted upon, and you would 

next see the patient show back up in the emergency room with diabetes again, with more problems with diabetes. So, you could track 

that. A consult was referred, did not get acted upon. You see the 

patient re-enter the system at a point that was not appropriate. It 

was what they needed to do, but it was not what should have 

happened. 

So, what I think you have when you do not have primary care 

properly structured, both with respect to the way they schedule, 

the way they staff the office, the efficiency with which they run the 

office, you get chaos. I think that is what we were experiencing, 

was you are looking in on a group of people who all knew they 

could not get it done correctly; they are all struggling to save patients who they thought would be at harm; and you see schedulers 

trying to schedule patients into slots that do not exist. It was just 

quite a horrible view of what was going on there. 

Senator BOOZMAN. Well, not just there, though. I mean, has that 

happened multiple other places? 

Dr. DAIGH. Well, I think this would be the worst example I have 

seen of—— 

Senator BOOZMAN. I guess what bothers me is that ER doctor— 

I can understand, you know, turning him over in the first place, 

then not getting seen, you know, in 2 weeks, or whatever the timeframe is. And sometimes it is appropriate that—you mentioned 

audiology. You know, that might stretch on without any problem 

at all or just a routine follow-up. But when the ER doctors see 

them again in the ER and they see that that consult has not been 

done, there has to be—it is the responsibility of that physician. I 

mean, where is the outrage from the doc that was seeing them, 

knowing that they had not been seen—— 

Dr. DAIGH. I think there was outrage, and they expressed their 

complaint to the leadership at the facility. And, again, if people are 

not hired or money is not put to address the problem you speak to, 

then after a while you realize that nothing is going to happen. And 

if the facility talks to the national leadership and says, ‘‘I have a 

problem,’’ and you do not get a response, then people get conditioned to think, well, this is just the way it has to be, this is the 

way it is going to be in this system. And that is unacceptable. 

So, in hearing the physicians and providers on the ground, 

nurses and docs on the ground, I think they were all anxious and 

upset at what they saw, trying to deal with it the best they could. 

Senator BOOZMAN. I know this is about scheduling, and, you 

know, you mentioned that you felt like there were not any deaths 

involved as a result of the scheduling. But in looking at some of 

the cases that you present, there might not be deaths, but there 

was certainly very poor quality of care in some of those. Poor quality of care means malpractice. Are we following up on that? Are we 

36 

in the process of doing an IG study regarding quality of care with 

these cases and other cases? 

Mr. GRIFFIN. We already concluded that there was poor quality 

of care on those. The problem as far as tort claims activity, as was 

previously stated, those are adjudicated in a court of law, and the 

experts that have to be involved in that adjudication, in the case 

of the State of Arizona, have to be people who have practiced in 

that area of specialty in the State of Arizona. And it is a program 

function of the Department to address allegations of malpractice, 

which is why we provided them with the 45 names and said that 

you need to look into these 45 cases with your attorney staff and 

with your medical staff and determine whether there is something 

that needs to be done for these people. 

Senator BOOZMAN. No, I understand, and the Chairman is going 

to rap me in a second. But I guess my concern is when you see 

these cases in that particular situation, we have a culture of, again, 

breakdown in scheduling, breakdown in communication among the 

physicians and the schedulers or whatever. My concern is that this 

sort of activity is throughout the system, and that is what I was 

referencing. Are we going to investigate to see if we have this quality of care throughout the system. 

Chairman SANDERS. Thank you, Senator Boozman. 

Senator Blumenthal? 

Senator BLUMENTHAL. Thanks, Mr. Chairman, and thanks again 

to all of our witnesses here today. 

I know that in response to Senator Tester’s question, Inspector 

General Griffin, you mentioned that these individual cases will be 

turned over to prosecutors if criminal violations are found. Is that 

correct? 

Mr. GRIFFIN. That is correct. 

Senator BLUMENTHAL. And they will be turned over on an individual basis? 

Mr. GRIFFIN. Right, because they are in different judicial districts around the country. 

Senator BLUMENTHAL. And they involve different facts. 

Mr. GRIFFIN. Right. 

Senator BLUMENTHAL. Who will make the decision about whether 

those cases should be turned over to criminal prosecutors? 

Mr. GRIFFIN. When we have evidence of potential criminality, it 

is our job to take it to the Assistant U.S. Attorney or the U.S. Attorney in that district, present the facts, and they make a determination whether or not it rises to the level of the types of things 

that they are presently involved with prosecutions of. 

Senator BLUMENTHAL. In effect, the prosecutors will be making 

those decisions, just as they would with any investigative agency, 

whether it be the FBI or the Drug Enforcement Administration. 

Mr. GRIFFIN. Correct. 

Senator BLUMENTHAL. What is the timing for beginning to turn 

over those investigative results? 

Mr. GRIFFIN. Turn over to the Department or to the—— 

Senator BLUMENTHAL. I am sorry. I was unclear in my phrasing. 

What is the timing for presenting those cases for judgments by the 

prosecutors—— 

Mr. GRIFFIN. The timing is when—— 

37 

Senator BLUMENTHAL [continuing]. Given that there is potential 

criminality? 

Mr. GRIFFIN. When we feel that we have developed the evidence 

that would support a criminal charge. 

Senator BLUMENTHAL. Has the prosecutor in any of those jurisdictions said to you, ‘‘We need that evidence as soon as possible’’? 

Have they given you a timeline? 

Mr. GRIFFIN. No. No, we are working feverishly to accomplish 

these things. Another point that I had made in your absence was 

our criminal investigators make over 500 arrests a year. We have 

had a number of cases that were already in the investigative and 

prosecutive pipeline before this happened. And as you know, it 

takes—it can take forever to work it through the prosecutive system. 

Senator BLUMENTHAL. Well, hopefully not forever. 

Mr. GRIFFIN. Well, it can sometimes feel like that. 

Senator BLUMENTHAL. I know that much well. 

Mr. GRIFFIN. Sure. So—— 

Senator BLUMENTHAL. When I was a U.S. Attorney, I would say 

to investigative agents, some of the best in the Nation, ‘‘Here is my 

timeline.’’ Not that the world would fall apart if they did not meet 

it, but there would be timelines for completing investigations. I 

gather you have not been given any. 

Mr. GRIFFIN. No, but I can tell you that the Assistant Attorney 

General for the Criminal Division sent out a memo to every U.S. 

Attorney’s Office and all the chiefs of Criminal basically giving 

them his point of view on what potential charges under Title 18 

could be brought for the various types of manipulations or different 

things—— 

Senator BLUMENTHAL. Falsification of records, destruction of 

documents. 

Mr. GRIFFIN. Right, absolutely. 

Senator BLUMENTHAL. Obstruction of justice. 

Mr. GRIFFIN. Right. 

Senator BLUMENTHAL. I am going to sort of segue to the next 

area of questioning, which you and I have talked about. I appreciate you have some very skilled and experienced investigators 

working for you. But my feeling is there simply are not enough. Do 

you disagree with me? 

Mr. GRIFFIN. I would say that we are fully engaged and could 

probably put twice as many people to work as we have assigned to 

the organization. 

Senator BLUMENTHAL. You could put twice as many to work, and 

they would all be very busy. 

Mr. GRIFFIN. Yes. 

Senator BLUMENTHAL. And they would be busy doing very, very 

important work, which would lead me to the conclusion that there 

are not enough of them, because criminal investigations here serve 

a vitally important purpose. I do not need to tell you because you 

are a very skilled and able investigative officer and Inspector General and watchdog. But the deterrent purpose of a criminal investigation, prosecution, and conviction is irreplaceable. There is nothing like the deterrent effect of a successful criminal investigation 

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38 

ness or even negligence, which can be serious enough in their consequences, but real criminality. 

So, I simply would urge you to be as aggressive as possible in 

asking for resources that are necessary for the VA to really do its 

job and deter criminality, assuming that it existed here and may 

be ongoing elsewhere in the agency, as it may be in any agency of 

our Government—State or Federal. 

Thank you for your service. My time has expired. 

Thank you, Mr. Chairman. 

Chairman SANDERS. Thank you, Senator Blumenthal. 

Senator Murray? 

Senator MURRAY. Thank you, Mr. Chairman. 

Mr. Griffin, I was really deeply disturbed to read your findings 

about how many cases of suicide and veterans with serious mental 

health problems were affected by delays in care and substandard 

care. Many facilities in my homestate of Washington are facing 

staffing problems and long wait times for mental health care, and 

I just wanted to say, if hospitals in Washington State are on your 

list of facilities for further investigation, I really hope your team 

will look very closely at the mental health care problems like they 

have done in Phoenix. 

I wanted to ask you, the Phoenix report really criticized VHA’s 

resistance to change, and both your report and the White House review found serious cultural and ethical failings across the system. 

What do you think the VA should be doing to make these kinds 

of systemwide changes? 

Mr. GRIFFIN. I think you have to hold people accountable when 

they ignore directives on how to do business. And I think after 

awhile people will begin to toe the line rather quickly—— 

Senator MURRAY. And that has not been done? 

Mr. GRIFFIN [continuing]. When they realize there is a price to 

be paid. 

Senator MURRAY. And that has not been done. 

Mr. GRIFFIN. No. I mean, how can you have a certification requirement that you abolish because some of the managers in the 

field are pushing back about it, because they might not be sure if 

their scheduling staff is doing it right, and the IG staff might come 

after them for asserting something that was not true or certifying 

something that was not true. You just do not tolerate that. 

Senator MURRAY. Yes, OK. You have mentioned several times 

here that you are following on 93 facilities’ investigations, and the 

results are confirming some of the things you found at Phoenix, 

meaning wait times are being manipulated. 

Mr. GRIFFIN. Right. 

Senator MURRAY. When your reports are completed, I really expect the VA to implement your recommendations quickly and to 

hold people accountable, as you just referred to. But I wanted to 

ask you this morning, is your impression that the motivation for 

these inappropriate practices more to show false information or is 

it more just a lack of training? 

Mr. GRIFFIN. I think it is a combination of a number of factors. 

In each of our reports going back to 2005, one of the recommendations was to ensure that the schedulers were properly trained in 

39 

the way it was supposed to be done. I mean, that was a repeat 

recommendation. 

Senator MURRAY. So, they have been hearing this for a long 

time? 

Mr. GRIFFIN. Oh, yes, as you know from your previous time with 

the Committee. 2005 was the first time and the first report that 

we had that. As I mentioned earlier, I think you have to have a 

person working the scheduling side that has some clinical knowledge of being able to triage: how bad does this veteran need to be 

seen today as opposed to somebody else. So, that is not currently 

the case and my belief at a lot of facilities. 

Senator MURRAY. Yes, and I know some of the facilities are saying, well, this is low level. We have a lot of people coming in. It 

is hard to keep up with it. Is that an excuse? 

Mr. GRIFFIN. No. I mean, I do not think there is an excuse for— 

I mean, I believe that over the years, VA’s budgets have pretty 

much been matched or exceeded by Congressional appropriators. 

But if you do not know what your demand is and how many people 

are on secret lists and you do not know, gee, we need 30 percent 

more clinicians, or whatever the number is—— 

Senator MURRAY. They cannot ask for it. 

Mr. GRIFFIN [continuing]. Then they cannot even ask for it. 

Senator MURRAY. Yes. 

Mr. GRIFFIN. I think the responsibility is, you have to do a serious strategic analysis, not just of your clinicians, but also the blend 

with fee-basis care and come up with a solid number that you can 

hang your hat on and say, in order for us to treat veterans in a 

quality manner and in a timely manner, we need this number of 

doctors and we need this amount of money for fee-basis for rural 

areas, or what have you. 

Senator MURRAY. Mr. Chairman, I know you have heard me say 

it a million times. This Congress, the country wants to be there for 

our veterans, but if we do not know what the need is accurately, 

we do not know what to provide. I echo that point. 

Let me just ask you one other thing. You have been doing this 

a long time. We have been hearing this for a long time. You have 

been doing a lot of investigations. Have you found any facilities or 

networks that have done a good job of regularly and thoroughly 

checking for scheduling gimmicks? 

Mr. GRIFFIN. We found a number of facilities out of our 93 where 

we concluded that there was no manipulation occurring, which is 

a good thing, maybe one-fourth. The bad news is on the other 

three-fourths, we are pretty confident that it was knowingly and 

willingly happening—— 

Senator MURRAY. That is a pretty high percentage. 

Mr. GRIFFIN [continuing]. And we are pursuing those. 

Senator MURRAY. Thank you, Mr. Chairman. 

Chairman SANDERS. Thank you, Senator Murray. 

Senator MURRAY. And thank you and all your team. 

Chairman SANDERS. Let me thank Mr. Griffin not only for being 

here, but for the excellent work that he and his department are 

doing. We thank all of his staff for being here as well. Thank you 

very much. 

Mr. GRIFFIN. Thank you, Mr. Chairman. 

40 

[Posthearing questions to Richard J. Griffin follows:] 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. BERNARD SANDERS TO

RICHARD GRIFFIN, ACTING INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS

AFFAIRS

COMPLIANCE WITH RECOMMENDATIONS

Question 1. Please provide detail on the process the IG uses to ensure VA complies with its recommendations. 

Response. Because ultimate responsibility to ensure implementation of corrective 

actions rests with VA senior officials, the OIG cannot force compliance with report 

recommendations. We track VA’s progress in implementing our recommendations 

through the OIG Follow-Up process, which is described below, and provide the VA 

Secretary and Congress with quarterly reports on the status of recommendations 

that remain unimplemented for more than 1 year. These reports are contained in 

the OIG Semiannual Reports to Congress and in letters from the Acting Inspector 

General to the Chairmen and Ranking Members of the U.S. Senate Veterans’ Affairs 

Committee and U.S. House Veterans’ Affairs Committee. We believe that keeping 

the VA Secretary and Congress informed of these delays is the best leverage the 

OIG has to ensure VA compliance with our recommendations. 

The OIG follows up on VA’s implementation of recommendations by: 

• Approximately 90 days after the OIG issues a final report (and every 90 thereafter until report closure), the OIG will send a status update request to the action 

office(s) at VA to which the recommendations are addressed. 

• Each VA office is expected to submit a response to this request to the OIG within 30 days. 

• Responses need to contain supporting documentation to substantiate stated actions. 

• The OIG will analyze the response and determine whether the action office implemented any recommendations to the satisfaction of the OIG. 

• We will not close a recommendation unless supporting documentation indicates 

corrective action has occurred or action has sufficiently progressed to close the recommendation as implemented. For example, the OIG will not close a recommendation to train employees on a particular issue on a mere promise by the VA action 

office to conduct the training. The VA action office will need to submit documentation of completed training or, at a minimum, be able to demonstrate through documentation (e.g., a directive, training syllabus and schedule, etc.) that it has established a training program and begun the training in a systematic fashion—thereby 

indicating it is meeting the intent of the recommendation. 

• The Follow-up cycle will repeat until the action office implements all open recommendations. 

The OIG may conduct reviews, including unannounced visits to facilities, to determine if the action VA said was completed was actually completed. 

Question 2. Given a number of reoccurring issues in IG and GAO reports over the 

past decade, such as VA scheduling practices and data integrity concerns, does the 

IG anticipate reviewing its compliance process? 

Response. As stated in response to the first question, the OIG’s best leverage to 

ensure compliance with report recommendations is keeping the VA Secretary and 

Congress informed of delays identified through our follow-up process on a quarterly 

basis. We also conduct follow-up inspections and audits to assess compliance on a 

selective basis. We plan to continue both practices. Moreover, there are a number 

of sources that we use to periodically assess VA’s compliance with their stated action plans. Among these sources are OIG and GAO’s previously published reports 

and information from our criminal and administrative investigations. Another 

source is our analysis of allegations received through the OIG Hotline. These allegations provide us with data to identify trends on specific VA program issues as well 

as identify potential problems with particular Veterans Health Administration and 

Veterans Benefits Administration facilities. This analysis provides a basis for planning and scheduling future work and results in annual updates of the most serious 

management challenges facing VA in VA’s Performance and Accountability Report. 

41 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. MARK BEGICH TO RICHARD GRIFFIN, ACTING INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS

AFFAIRS

Question 3. Inspector General, during your investigations, what comments stood 

out to you from the VA staff that would help improve the scheduling system or access to care concerns. 

Response. Our investigations found that manipulation of wait times was systemic 

in VA. Desired dates for appointments were routinely manipulated to incorrectly appear that veterans were not required to wait longer than 14 days for an available 

appointment. Many employees advised that they did not see the harm in ‘‘zeroing 

out’’ the wait times since the date selected was the first available date for an appointment. The actual length of wait times was hidden by this process. Decisions 

regarding proper allocation of medical staff to meet the needs of veterans could not 

be properly made when the true need for services was disguised by the manipulation of wait times. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. MAZIE HIRONO TO RICHARD GRIFFIN, ACTING INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS

AFFAIRS

Question 4. Given the numerous changes that need to be made how would you 

suggest VA prioritize the implementation of each given the one year deadline it has 

promised? Which recommendations are most urgent? 

Response. In regard to the twenty-four recommendations made within our Phoenix report, VA provided an action plan containing a written response, status, and 

expected completion date for each recommendation. VA began to address some of 

these recommendations prior to publication of our final report. For example, 

throughout our review we identified veterans waiting for care. As these veterans 

were identified, we provided VA the names of these veterans. These veterans were 

contacted by VA and appointments made for those who desired care. 

Of the recommendations not yet implemented, those which directly impact patient 

care are the most pressing and time-sensitive. However, supporting recommendations, such as those pertaining to performance plans and facility goals are just as 

critical in ensuring future accountability as changes across the system are implemented, and should not be given less consideration by VA leadership. 

Question 5. Your testimony outlines that you office’s investigations have confirmed that wait time manipulations are prevalent throughout VHA at many facilities across the country. When do you anticipate completing these investigations and 

will you keep my staff informed related to any issues arising at the VA Pacific Islands Health System when they are completed? 

Response. The OIG is aggressively investigating the alleged manipulation of wait 

times at 93 sites of care. We completed reports of investigation regarding alleged 

manipulations at 18 of the 95 sites. We referred cases to the appropriate U.S. Attorneys’ Offices for prosecutive determinations when evidence corroborated allegations 

of potential criminal activity. After exhausting the potential for criminal prosecution, these reports were provided to VA’s Accountability Review Team for any administrative action deemed appropriate. We made these allegations a priority and 

have devoted the resources to ensure that all wait times cases are worked thoroughly. In many of these cases, timelines involve decisions from the U.S. Department of Justice. Investigations involving multiple complex matters often require serious contemplation before prosecutive opinions are rendered. As a result, we are 

not able to give an exact expected completion date for the cases under active investigation. However, the need to expeditiously investigate these cases is routinely conveyed to our staff. We will contact your staff when our investigation at the VA Pacific Islands Health System is finished. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. RICHARD BURR ON BE- HALF OF HON. JEFF FLAKE TO RICHARD GRIFFIN, ACTING INSPECTOR GENERAL, 

U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 6. On August 26, the Department of Veterans Affairs (VA) Office of Inspector General (OIG) submitted a report of its review of allegations of mismanagement and misconduct at the Phoenix VA Health Care System (PVAHCS). This report stated that there were ongoing investigations regarding potential criminal violations. Sharon Helman, the former director of PVAHCS, may be among those being 

42 

examined by OIG and, understandably, the details of these ongoing inquiries cannot 

be disclosed for fear of compromising the investigation. 

a. Does OIG have an estimation regarding a completion date for these ongoing investigations, which may confirm criminal violations? 

Response. We have made these allegations a priority and devoted the resources 

to ensure that all wait times cases are worked thoroughly and expeditiously. In 

many of these cases, timelines involve decisions from the U.S. Department of Justice. Investigations involving multiple complex matters often require serious deliberation before prosecutive opinions are rendered. As a result, we are not able to give 

an exact expected completion date for the cases under active investigation. The VA 

Office of Accountability Review tracks administrative action resulting from investigations of wait times manipulations. 

b. Does OIG have any plans to expand the number of investigations regarding potential criminal investigations? 

Response. We will thoroughly examine any referral of alleged criminal activity related to manipulation of wait times. Inquiries will be opened upon receipt of credible 

allegations of such conduct. Full investigations will be opened when evidence indicates that manipulation was directed by VA supervisors or managers. We notify the 

Federal Bureau of Investigation when we open investigations as described in the Attorney General Guidelines for Offices of Inspector General With Statutory Law Enforcement Authority. 

Question 7. As you know, the Veterans access, Choice, and Accountability Act of 

2014 was recently passed by Congress and signed into law by the president. Among 

other things, the purpose of this legislation is to provide the VA with increased latitude to remove agency employees when necessary. 

a. Do you believe that this legislation provides the VA with adequate authority 

to remove underperforming employees? 

Response. Until it is fully implemented, the impact is unknown. 

b. Will the added hiring and firing flexibility enable the VA to significantly improve the quality of care that it delivers to veterans? 

Response. Additional flexibility in the hiring process has the potential for VA to 

bring health providers on board in a timelier manner thus increasing timelier access 

to care. The OIG is playing a role in this regard by identifying the five VA health 

provider occupations with the greatest staffing shortages on an annual basis, which 

will allow VA to us Title 5 direct hire authority for these occupations. The impact 

of firing flexibility with respect to senior executives cannot be evaluated at this 

time. 

Chairman SANDERS. Mr. Secretary, thank you very much for 

being with us. Again, my apologies for putting you on second, but 

I thought it would be important for you and for the Committee to 

be hearing from the Inspector General first. The floor is yours and 

please take as much time as you need. 

STATEMENT OF HON. ROBERT A. McDONALD, SECRETARY, U.S. 

DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY 

CAROLYN M. CLANCY, M.D., INTERIM UNDER SECRETARY 

FOR HEALTH 

Secretary MCDONALD. Thank you, Chairman Sanders. Obviously, 

we thought it was important as well that the Inspector General go 

first, so we are very pleased to be here after the Inspector General. 

Chairman Sanders, Ranking Member Burr, and distinguished 

Members of the Committee on Veterans’ Affairs, thanks for the opportunity to discuss with you VA’s response to the recent VA Office 

of Inspector General report regarding wait times and scheduling 

practices at the Phoenix VA Hospital. I said at the time of my confirmation hearing that I will put veterans at the center of everything that we do at VA. 

So, let me begin by offering my personal apologies to all veterans 

who experience unacceptable delays in receiving care. It is clear 

that we failed in that respect, regardless of the fact that the report 

43 

on Phoenix could not conclusively tie patient deaths to delays. I am 

committed to fixing this problem and providing timely, high-quality 

care that veterans have earned and that they desire. That is how 

we regain veterans’ trust and that is how we regain your trust and 

the trust of the American people. 

The final IG report has now been issued and as the Inspector 

General said, we have concurred with all 24 of the report’s recommendations. Three of the recommendations have already been 

remediated and we are well underway in remediating many of the 

remaining 21 because we began work when the IG’s interim report 

was first issued in May. 

For accountability, we have proposed the removal of three senior 

leaders in Phoenix. As we learn more about individual supervisors’ 

and employees’ roles in the problems there, we may find that additional disciplinary actions are warranted and we will take them. 

We are grateful for the Committee’s leadership in establishing 

the recently passed Veterans Access, Choice, and Accountability 

Act of 2014. This important act streamlines the removal of VA senior executives and the appeals process if misconduct is found. However, it does not guarantee VA’s decisions will be upheld on appeal 

or allow VA to fire senior executive officers without evidence or 

cause. 

We have taken many other actions in Phoenix and the surrounding areas to improve veterans’ access to care, including, first, 

putting in place a strong acting leadership team, good people with 

a proven track record of serving veterans and solving problems. 

They are in place, they are operating in Phoenix now, and I have 

visited them on site. 

Increasing Phoenix staffing by 162 people and implementing aggressive recruitment and hiring processes to speed recruiting. 

Reaching out to all veterans identified as being on unofficial lists, 

or the facility electronic wait list, and completing over 146,000 appointments in 3 months. As of September 5, there are only ten veterans on the electronic wait list at Phoenix. 

Where VA capacity did not exist to provide timely appointments, 

we referred patients to non-VA care. From May through August, 

Phoenix made almost 15,000 referrals to non-VA care. We have secured contracts to utilize primary care physicians from within the 

community in the future. 

Since my confirmation as Secretary, I have traveled to VA facilities across the country speaking to veterans and VA employees, as 

well as visiting and speaking with Members of Congress, veteran 

service organizations, and other stakeholders. During these visits, 

I found VA employees to be overwhelmingly dedicated to serving 

veterans and driven by our strong VA institutional values of integrity, commitment, advocacy, respect, and excellence. The acronym 

we use is I-CARE and I am wearing that button here today. 

Our people are making a difference. Nationally, they have enabled the following critical achievements: as of August 15, VHA has 

reached out to over 294,000 veterans to get them off of wait lists 

and decreased the veterans on the electronic wait list by 57 percent. VHA has developed the Accelerating Care Initiative to increase timely access for care for veteran patients, decrease the 

number of veterans on the electronic wait list longer than 30 days, 

44 

and standardized the process and tools for ongoing monitoring and 

access management at all VA facilities. 

Where we have not been able to increase capacity, we have increased the use of community, non-VA care. Between May and August, we have made almost a million total referrals for non-VA 

care, over 200,000 more referrals than for the same period in 2013. 

The 14-day access measure has been removed from all employee 

performance plans to eliminate any incentive for inappropriate 

scheduling. Over 13,000 performance plans have been amended. 

We are simultaneously updating our antiquated appointment 

scheduling system and working to acquire a comprehensive, stateof-the-art commercial, off-the-shelf scheduling system. 

VA medical center directors and VISN directors are completing 

in-person reviews of their facilities’ scheduling practices that can 

be completed by the end of this month. So far, 3,000 of these reviews have been conducted nationwide. We have restructured 

VHA’s Office of the Medical Inspector to better serve veterans and 

to create strong internal audit function. 

On August 7, I asked all VA employees to reaffirm their commitment to both our mission and our I-CARE values: integrity, commitment, advocacy, respect, and excellence. I intend this reaffirmation to be repeated by each and every employee each year on the 

anniversary of our establishment as a department. If an employee 

refuses to recommit, I want to meet with them personally and will 

decide actions after that. 

We are building a more robust continuous system for measuring 

patient satisfaction to provide real-time site-specific information, 

collaborating with VSOs in this effort and learning what other 

leading health care systems are doing to track patient access information. We are working hard to create and sustain a climate that 

embraces constructive dissent, that welcomes critical feedback, and 

then ensures compliance with legal requirements. That climate 

mandates commitment to whistle-blower protections for all 

employees. 

Yesterday we announced the beginning of our Road to Veterans 

Day, our 90-day plan, which begins with our mission to better 

serve and care for those who have borne the battle and for their 

families and for their survivors. We will focus our efforts over the 

next 60 days to rebuild trust with veterans and the American people, to improve service delivery, and to set the course for long-term 

excellence and reform. 

As we move forward, we will continue to work with the IG and 

other stakeholders to ensure accountability. As you heard, there 

are over 100 ongoing investigations at VA facilities by the IG, by 

the Department of Justice, by the Office of Special Counsel, and by 

others. In each case, we await the results and will take appropriate 

disciplinary actions when all the facts and evidence are known. 

But we will not wait to provide veterans the care that they 

earned and that they desire. We are going forward. We will focus 

on sustainable accountability in the future. More than just adverse 

personnel actions, sustainable accountability means ensuring all 

employees understand how their daily work ties back to that mission of caring for veterans. We want them to understand how it 

ties back to the mission, how it ties to our values, and how it ties 

45 

to our strategies, and we want to make sure that everybody’s behavior every single day is guided by those values and that mission. 

We also want to make sure that every employee understands it 

is their responsibility to provide feedback to their supervisor when 

they are asked to do something that is impossible to do. We want 

to make sure that feedback loop is daily and that every employee 

is getting daily feedback from their supervisor and that every supervisor is giving daily feedback to their manager. 

Sustainable accountability requires we do a better job of training 

our leaders. We need to flatten our hierarchical culture, we need 

to encourage innovation, we need to encourage collaboration, and 

we need realistic ratings of everyone’s performance. Everyone cannot be the best. With sustainable accountability, employees fulfill 

their responsibility to veterans and to the Department to provide 

feedback and input on how we can better serve veterans. Who better than to help us improve our Department than the employees 

who every day are interacting with our veterans? 

We will judge the success of all these efforts against a single 

metric and that is the veterans outcomes. We do not want VA to 

meet a standard; we want VA to be recognized as the standard in 

providing health care and benefits. I know we can fix the problems 

we face and I will utilize this opportunity to transform VA to better 

serve veterans. 

Mr. Chairman, Members of the Committee, thanks for your unwavering support of our Nation’s veterans. I look forward to working with you in implementing the law and in making things better 

for all of America’s veterans. Dr. Clancy and I are prepared to take 

your questions at this time. 

[The prepared statement of Secretary McDonald follows:] 

PREPARED STATEMENT OF HON. ROBERT A. MCDONALD, SECRETARY, 

U.S. DEPARTMENT OF VETERANS AFFAIRS

Chairman Sanders, Ranking Member Burr, and Distinguished Members of the 

Senate Committee on Veterans’ Affairs, thank you for the opportunity to discuss 

with you the Department of Veterans Affairs’ (VA) response to the recent VA Office 

of Inspector General (OIG) report regarding wait times and scheduling practices at 

the Phoenix VA Health Care System (PVAHCS). 

Let me begin by saying, I sincerely apologize to all Veterans who experienced unacceptable delays in receiving care at the Phoenix facility, and across the country. 

We at VA are committed to fixing the problems and consistently providing the high 

quality care our Veterans have earned and deserve in order to improve their health 

and well-being. We owe that to each and every Veteran that is in our care. We will 

continue to listen to Veterans, our VA employees, and Veterans Service Organizations (VSO) and use their feedback to improve access to quality care in Phoenix and 

across the country and we will work hard to rebuild trust with Veterans and the 

American public. 

The VA OIG has released the final report of its review of issues with patient 

scheduling and access at PVAHCS. We have concurred with the recommendations 

in the final report and, in many cases, we have already taken action responding to 

the OIG’s recommendations, improving processes and access to care for Veterans. 

PVAHCS’ IMPLEMENTATION OF OIG RECOMMENDATIONS

The final OIG report is an update of the information previously provided by the 

OIG in its Interim Report issued on May 28, 2014, and contains final results from 

their independent review of the PVAHCS. In response to the report recommendations, we have outlined key action plans that expand access to care, improve staffing 

for primary care, and ensure accountability measures. All cases identified by OIG 

were reviewed, and determinations regarding appropriateness of disclosures to patients and families are underway. 

46 

Currently at PVAHCS, we have a strong acting leadership team producing positive results. Glenn Costie is the Acting Medical Center Director and Elizabeth Freeman is the Acting Network Director. They are good people with a proven track 

record for serving Veterans and solving problems. 

Based on the Interim report of the OIG, we began actions in Phoenix and across 

the country that have enhanced access for Veterans seeking care. In Phoenix specifically, we have taken the following actions: 

Primary Care Staffing 

PVAHCS leadership is increasing Primary Care staffing by 53 additional full-time 

equivalent employees. Aggressive recruitment and hiring processes have been implemented to speed this process. All services—physicians, nurses and clerks—have increased staffing in the clinics and Community-Based Outpatient Clinics (CBOC) and 

the facilities are securing contracts to utilize Primary Care physicians from within 

the community. Primary Care was recently added to the Patient-Centered Community Care contracts, and Health Net and TriWest are working to add Primary Care 

physicians to their networks nationwide including the Phoenix area. 

Access to Care (wait lists) 

PVAHCS, with support from the Veterans Health Administration’s (VHA) Health 

Resource Center (HRC), has reached out to all Veterans identified as being on unofficial lists or the facility Electronic Wait List (EWL). PVAHCS completed 46,997 appointments in May, 48,970 appointments in June, and 50,629 appointments in July, 

for a total of 146,596 appointments completed at PVAHCS in three months. 

As of August 15, 2014, there were 56 Veterans on the EWL at PVAHCS. PVAHCS 

is now scheduling the vast majority of patients directly into a Primary Care appointment when enrollment/registration occurs. Over 3,200 appointments have been 

made in Primary Care for new patients since this initiative began. 

Access to Care (scheduling) 

We announced on June 4, 2014, that the Department had reached out to all Phoenix, Arizona-based Veterans identified by the OIG as being on unofficial wait lists 

to immediately begin scheduling appointments for all Veterans requesting care. Nationally, VHA expeditiously deployed staff and resources from around the country 

to help PVAHCS identify patients waiting for care, clearing the way for them to get 

the care they needed. We have made progress and are publicly publishing data on 

our progress. 

Access to Care (non-VA Care) 

Clinical staff attempted to accommodate all appointments at PVAHCS. Where capacity did not exist to provide timely appointments, staff referred patients to nonVA community care in order to provide all Veterans timely access to care. From 

May 16, 2014 through August 28, 2014, PVHCS has made 14,622 referrals for appointments to community providers of non-VA care. 

Since the Accelerating Care Initiative (ACI) began, resources have been provided 

to continue to work down the number of open consults even further. Since the beginning of the ACI, $24.9 million has been obligated as part of this initiative to provide 

community-based care for Veterans in the community. 

Access to Care (new enrollees) 

PVAHCS is hiring dedicated staff to complete on-line enrollment processing. VHA 

is developing an automated system for monitoring enrollment processing at 

PVAHCS and every VA facility. This monitor will track Veterans new to the VA and 

will assess the timeframe to their first appointment within the VA health care system. The data will be reviewed monthly with VISN 18 and PVAHCS leadership. 

Locally, PVAHCS implemented process changes to ensure that Veterans receive 

appropriate care. To ensure continued success, patients waiting for care are reviewed daily and reported to facility and VISN leadership. 

In July 2014, the Acting PVAHCS Director visited all CBOCs and local Clinics to 

observe the scheduling process and interact with scheduling staff to ensure all policies are being followed to deliver Veterans the timely care they have earned. These 

interactions are now happening monthly across the country. 

VA NATIONWIDE

Since my confirmation as Secretary, I have traveled to VA facilities across the 

country speaking to employees and Veterans. I cannot overstate their enthusiasm 

for being part of the solution to our current challenges. Overwhelmingly VA employees are dedicated to serving Veterans. They are driven by strong institutional values 

that influence day-to-day behavior and performance: Integrity, Commitment, AdvoVerDate Mar 15 2010 16:05 Jul 30, 2015 Jkt 000000 PO 00000 Frm 00050 Fmt 6633 Sfmt 6621 Z:\ACTIVE\090914.TXT PAULIN
47 

cacy, Respect and Excellence, I-CARE. On my first day as Secretary I asked all VA 

employees to join me in reaffirming our commitment to these core values and I directed VA leaders to do the same with the people that work for them. As we continue to move forward, our values help cultivate a climate where all employees understand what the right thing is and then does it. VA’s way of doing business must 

conform to how we expect employees to treat Veterans and how we expect employees to treat one another. It is clear that somewhere along the line, some people’s 

behavior was at odds with VA’s mission and core values. It is up to the Department 

to reaffirm its worth and regain Veterans’ trust. Over the past months, we have 

been forced to take a hard look at ourselves and the way we do business, listening 

to Veterans, employees, Congress, VSOs and other stakeholders. 

Using their input, VA is in the process of rapidly deploying and instituting an 

array of changes aimed at fixing VA’s problems. Beyond culture issues, demand outstripped supply. This contributed to an environment that led to violations of our 

mission and our values. Demand was increased by new presumptive conditions, 

twelve years of war, the economy and significant VA outreach and education efforts. 

Peak application of care for wars is decades after the conflict ends as Veterans age. 

This issue will be with us a long time. We have to build the appropriate capacity 

now. We have initiated development of a more robust process for continuously measuring patient satisfaction at each site, and we will expand our patient satisfaction 

survey capabilities in the coming year, to capture more Veteran experience data 

through telephone, social media, and on-line means. Additional VA-wide actions include: 

Access to Care 

• As of August 15, VHA has reached out to over 266,000 Veterans to get them 

off wait lists and into clinics. 

VA has re-doubled its efforts to provide quality care to Veterans and has taken 

steps at national and local levels to ensure timely access to care. VHA has developed 

the Accelerating Care Initiative (ACI), a coordinated, system-wide initiative designed to increase timely access to care for Veteran patients; decrease the number 

of Veteran patients on the EWL waiting longer than 30 days for their care; and 

standardize the process and tools for ongoing monitoring and access management 

at VA facilities. As of August 15, VA has decreased the number of Veterans on the 

EWL 57 percent. As we continue to address systemic challenges in accessing care, 

we are providing regular data updates to enhance transparency and provide the immediate information to Veterans and the public on improvements to Veterans’ access to care. Data updates can be found on the following link: http://www.va.gov/ 

health/access-audit.asp 

• VA health care facilities nationwide continuously monitor clinic capacity in an 

effort to maximize VA’s ability to provide Veterans timely appointments appropriate 

for their clinical conditions. 

• Where VA cannot increase capacity, VA is increasing the use of care in the community through non-VA medical care. From May 16, 2014, through August 24, 2014, 

975,741 total referrals to non-VA care providers have been made. That is 203,637 

more non-VA care referrals than the same time period in 2013. 

• Each of VA’s facilities continuously reaches out to Veterans waiting longer than 

90 days for care to coordinate the acceleration of their care. 

• Facility clinical staff continuously evaluates Veterans currently waiting for care 

to ensure the timing of their appointment is medically appropriate for their individual clinical conditions. 

• VA is decreasing the number of Veterans on the EWL by standardizing the 

process and tools for ongoing monitoring and access management at VA facilities. 

• VHA utilizes call monitoring in its large national call centers. These monitoring 

practices require adequate telephony systems. VHA will introduce new monitoring 

practices through the VA Health Resource Center to assess scheduling practices performed by VA staff. 

Scheduling 

• The 14-day access measure was removed from all employee performance plans 

to eliminate any incentive for inappropriate scheduling practices or behaviors. In 

the course of completing this task, over 13,000 performance plans were amended. 

• VA has suspended the use of Desired Date Performance Accountability Report 

(PAR) performance plans. VA is currently evaluating the use of Desired Date as a 

mechanism to assess patient preferred appointment timeframes. 

• The VSOs are actively engaged in the process. We are updating the antiquated 

appointment scheduling system, beginning with near-term enhancements to the exVerDate Mar 15 2010 16:05 Jul 30, 2015 Jkt 000000 PO 00000 Frm 00051 Fmt 6633 Sfmt 6621 Z:\ACTIVE\090914.TXT PAULIN
48 

isting system and ending with the acquisition of a comprehensive, state-of-the-art, 

‘‘commercial off-the-shelf’’ scheduling system. 

Accountability 

• At VA, we depend on the service of employees and leaders who place the interests of Veterans above and beyond self-interest. Accountability, delivering results, 

and honesty are key to serving our Veterans. • Where willful misconduct or management negligence is documented, appropriate personnel actions will be taken—this also applies to whistleblower retaliation, 

which is unacceptable and intolerable at VA. • VA Medical Center Directors and VISN Directors are completing face-to-face audits of their facilities’ scheduling practices. The first round of face-to-face audits will 

be completed by September 30, 2014. So far, we have conducted 2,450 of these visits 

nationwide. • On July 8, 2014, the Deputy Secretary announced that he ordered a restructuring of the Office of the Medical Inspector (OMI) to better serve Veterans and create a strong internal audit function. This restructuring will result in revisions to 

the policies, procedures, and personnel structure by which OMI operates and establish an internal audit group that will validate VHA’s critical national performance 

measures. • On August 7, 2014, I asked all VA employees and leadership to reaffirm their 

commitment to both our mission and ‘‘I CARE’’ values—Integrity, Commitment, Advocacy, Respect and Excellence. I intend this reaffirmation to be the first of many, 

to be repeated by each employee each year in March, on the anniversary of our establishment as a Department. 

Patient Satisfaction 

• We are building a more robust, continuous system for measuring patient satisfaction to provide real-time, site-specific information on patient satisfaction. We will 

augment our existing survey with expanded capabilities in the coming year to capture more Veteran experience data using telephone, social media, and on-line 

means. Our effort includes close collaboration with VSOs to plan our efforts. We are 

learning what other leading healthcare systems are doing to track patient access experiences. 

Whistleblower Protections 

We have made great strides in improving care and services to Veterans in Phoenix and nationwide because employees in Phoenix and elsewhere had the moral 

courage to do the right thing. They made their voices heard about what they saw 

happening. Those employees are examples of I-CARE at its best. Our collective ability to deliver the best services and care to Veterans is inextricably linked to sustaining an organizational culture that protects and empowers the voices of all employees and leverages the diverse talent of all our human resources. This includes 

creating a climate that embraces constructive dissent, welcomes critical feedback 

and ensures compliance with legal requirements. As part of our commitment toward 

embracing this culture we have reinforced our commitment to whistleblower protections to all employees and VA recently registered for and published an implementation plan to receive certification from the Office of Special Council’s Section 2302(c) 

Certification Program. 

Accountability 

We will continue to work with IG and other stakeholders to take appropriate action, but accountability is about more than personnel actions. We must focus on sustainable accountability. Sustainable accountability means ensuring all employees 

understand how daily work supports our mission, values and strategy. Sustainable 

accountability is about more than top-down, hierarchical behavior modification. It 

is collaborative. Supervisors provide feedback, every day, to every subordinate to 

recognize what is going well and identify where improvements are necessary. In 

that same spirit, employees fulfill their responsibility to Veterans and to the Department to provide feedback and input on how we can better serve Veterans. 

To achieve sustainable accountability we will do a better job training leadership, 

flatten our hierarchical culture to encourage innovation and collaboration and we 

will rate the relative performance of employees because everyone cannot be the best. 

We have strong institutional values: I-CARE. These are mission-critical ideals that 

must profoundly influence our day-to-day behavior and performance. In performance 

that mission, guided by those values, we will judge the success of our efforts against 

a single metric—customer outcomes, Veterans’ outcomes. We hold ourselves accountable to these standards. We do not want VA to meet a standard. We want VA recognized as the standard in health care and in benefits. 

49 

CONCLUSION

Mr. Chairman, the health and well-being of the men and women who have bravely and selflessly served this Nation remains VA’s highest priority. By recommitting, 

as a Department, to our values, I know we can fix the problems and utilize this opportunity to transform VA to better serve Veterans. This concludes my testimony. 

Dr. Clancy and I are prepared to answer questions you or the other Members of the 

Committee may have. 

Chairman SANDERS. Mr. Secretary, thank you very much for 

being here, for your patience, and hearing the discussion with the 

Inspector General, and I think I am paraphrasing one of the other 

members who indicated that the perception is you have hit the 

ground sprinting, which is exactly what this Committee wanted 

from you and we appreciate that very, very much. 

I want to reiterate a point that you just made, and that is that 

the vast majority of VA employees—I know this is the case in 

Vermont and all over the country—work tirelessly and work very 

hard to do everything they can for our veterans, and we should 

never forget that. 

We should also not forget that while we are focusing today on the 

issue of timeliness and the need to make sure that every veteran 

in this country gets timely care, we also know that—I can tell you 

absolutely in Vermont that most veterans believe the care they are 

getting once they are in the system is of high quality. They appreciate the care they are getting and the work the staff is doing. 

What I just want to do is—in a sense you talked about this in 

your opening remarks—but let us focus on three or four basic 

issues. Every Member of this Committee is outraged by the long 

wait periods veterans in various parts of the country are experiencing. Number 1, I want you to tell us briefly what kind of 

progress you have made in reducing those wait periods. 

Number 2, we all agree it is unacceptable for VA staff or high 

ranking people to be lying, to be manipulating data. What have you 

done to get rid of people who are acting dishonorably? What plans 

do you have in the future? 

Number 3—and this is tough stuff—how do we make sure—how 

do you lay the groundwork that what we have seen in Phoenix 

never happens again? How do you address, in fact, what is a national problem? I think Senator Begich raised the issue. It is no 

great secret that we have a serious crisis in the number of physicians we have, especially primary care physicians, the number of 

nurses that we have in various parts of this country. 

We have given you some tools, and I am very proud of the work 

that came out of this Committee. We have given you tools, for example, in the Education Debt Reduction Program, which is similar 

to the National Health Service Corps, which now gives you the tool 

to go to medical schools. Maybe you could tell us a little bit about 

that. 

And tell people who otherwise would graduate, young doctors 

deeply in debt, that we now have a strong debt forgiveness program in the VA. In other words, what are you going to do to address the very difficult issue of bringing more quality physicians, 

nurses, and other medical personnel into the system? Those are my 

questions. 

Secretary MCDONALD. Thank you, Chairman Sanders. First, in 

relationship to the first question, access to care, we have reached 

50 

out to over 294,000 veterans to get them off of wait lists and into 

clinics as of September 5. As a result, VA has decreased the electronic wait list by more than 32,000 nationwide since May 15. That 

is from over 57,000 in May to around 24,500 as of August 15. We 

have reduced the new enrollee appointment request list from nearly 64,000 to right now approximately 1,700, which is a reduction 

of about 62,000. 

Chairman SANDERS. Mr. Secretary, this is a combination of expanding VA capacity and sending people out to the private sector? 

Secretary MCDONALD. Yes, sir. It includes things like in Phoenix, 

we moved in three mobile units from around the region. We increased clinical hours. We worked on overtime. It is a matter of 

putting the resources where they need to be put. We collaborated 

with the Department of Defense in some sites, collaborating with 

Indian Health Service. These were the things that were done. 

Also, we have had more people that we have put into the private 

sector; 246,300 more patients have gone into the private sector. 

And each one of those referrals actually has resulted in, on average, seven appointments. So, in a sense, that number understates 

the care that has actually been provided. 

So, we are making progress there, but more work needs to be 

done, and obviously the bill that you mentioned is going to help us 

do that, by providing greater access points, 27 more new points, 

and the ability to hire more doctors and nurses. 

You asked about disciplinary actions. I talked in my opening remarks about the three individuals in Phoenix who were seeking— 

who we have proposed disciplinary action for. We have a new acting director there in Phoenix. In my American Legion speech, I 

mentioned that we have over 30 actions that we have taken. 

Around five include members of the Senior Executive Service. 

About two dozen include medical professionals. 

We are following up as quickly as we can. As soon as we get information that suggests we should take disciplinary action, we are 

taking it. We have stood up a separate team called the Accountability Team. I met with them as recently as yesterday. They report to me and their single job is to get after these as quickly as 

possible. 

Chairman SANDERS. All right. Let me interrupt you—— 

Secretary MCDONALD. Yes, sir. 

Chairman SANDERS [continuing]. Because I am running out of 

time. I just wanted to revisit the third question. The Inspector 

General made a good point, that it is hard to know what you need 

unless you have good information. I mean, in your judgment, how 

many more doctors, nurses, medical staff do you need, and how 

would you, at a time when this country is not producing enough 

primary care physicians, et cetera, are you going to get them? 

Secretary MCDONALD. We need tens of thousands. Deputy Secretary Gibson said in his testimony, I think it was around 28,000. 

We are now going through a process—— 

Chairman SANDERS. Let me repeat that because that is an important point. You are telling us you believe you need 28,000 new 

medical staff? 

Secretary MCDONALD. Including clinicians and other employees. 

Chairman SANDERS. Wow. 

51 

Secretary MCDONALD. We are in the process of going through a 

big recruiting effort. I was at Duke University Medical School. I 

was with Senator Burr in Charlotte and I then went to Duke. We 

talked to over 500 members of the Duke medical community. I was 

in Philadelphia last Friday. I talked to members of the University 

of Pennsylvania Medical School. 

We are trying to demonstrate to young people studying in the 

medical profession that VA is where they want to work. They want 

to work there because we have had three Nobel Prize winners. We 

have had seven Lasker Award winners. We do great up-front research. Did you know that the nurse worked at the VA who developed the use of the bar code for tracking patients and medication? 

We are known for innovation and young people should come work 

for us. The help that you gave us with student loan forgiveness, 

debt forgiveness, doubling the number is going to be very helpful 

to help us recruit. 

Chairman SANDERS. All right. I have far exceeded my time. 

Senator Burr. 

Senator BURR. Thank you, Mr. Chairman. Mr. Secretary, welcome and thank you for the role that you are filling. I have just 

got a couple areas, one on an item you just mentioned, that every 

private sector referral triggers seven additional visits. If you would, 

and you can have Dr. Clancy speak to this, I would love to see the 

data on that. I know that that is what VA actuaries have stated 

and what they believe. 

I think we need to get to the bottom of it, figure out why. Is this 

a contractual problem where we have contracted with the private 

physician where they see an opening to bring a patient back seven 

times? Under Medicare, that would all be under a bundled payment. If we are going to utilize the private sector right, then we 

have got to figure out whether we are doing it right today. 

But I cannot envision where every time we referred somebody to 

a private sector doctor, it triggers seven additional appointments, 

visits that we are going to pay for. And if that is the case, I would 

love to see the specifics on that when you are able to gather them. 

With everything that you just went through, it is probably hard 

to believe that I would ask you this question, because you detailed 

greatly all the changes that we are making, but my question is 

this: how do you plan to change the culture at VA and how do you 

plan to measure it? 

Secretary MCDONALD. First, we will get you data on those seven 

visits. As you know, many of our veterans have multiple illnesses, 

but we will get you the data and we will sit down together and talk 

about that. 

[Responses were not received within the Committee’s timeframe 

for publication.] 

In terms of changing the culture, changing the culture is probably one of the most difficult leadership challenges, whether it is 

in the private sector or the public sector. I think the most important thing we have got to do is to open up the culture. As I described earlier, high performance organizations have the improvements made by the employees, not by the leadership. 

The leadership certainly helps. They pick the strategies, they 

pick the leaders, and they help create the culture. But we have got 

52 

to get every employee involved. On the very first week I met with 

the union leadership. The majority of our employees are union 

members; about 65 percent are union members. I met with the 

union leadership three times in my first 5 weeks, and I am asking 

them to recommit themselves to our values, our mission, and to 

help me engineer the changes that we need to make. 

Every time I go to a site, I meet with the union leadership as 

well. I include them in our leadership meetings. I also make sure 

I talk to the whistle-blowers from that site, and I always do a town 

hall where I explain to the employees that I want every employee 

to be a whistle-blower. I want every employee causing us to 

change. 

I have used a diagram—I used it yesterday and I have used it 

with employees—that basically says that most people think of an 

organization structure like a pyramid. At the Proctor & Gamble 

Company, you would have a CEO. At the Department of Veterans 

Affairs, you would have a Secretary. 

Well, I take that and I turn it on its head and I say, this is 

where our veterans are. Our veterans are at the broad base of this 

pyramid. The people caring for those veterans are the most important people in the organization. I am on the bottom. I am at the 

apex. What I have got to do is make sure the communication is 

flowing up and down that pyramid to make sure we care for those 

veterans. 

So, the boss of this operation is the veteran. The boss is the person next to the veteran, serving the veteran. Frankly, some of the 

things that have happened in the past do not fit that picture. For 

example, we had some of our positions who serve the veteran 

downgraded and the annual salary is hundreds—is not hundreds— 

tens of thousand dollars less that we are able to pay them. 

Well, those are important people. We have got to—so I have encouraged all of our leaders to seek exceptions to that policy and we 

have got to get back to putting the best talent up working and 

serving the veteran. Culture change is difficult, but I think we can 

do it. 

Dr. CLANCY. May I just make one point? 

Senator BURR. Go ahead, Dr. Clancy. 

Dr. CLANCY. Just to make one point, the point about measurement. VA has a unique all-employee survey, which is now going out 

into the field to all employees, and it is much more thorough than 

other Federal departments. One of the areas that we can measure 

and do track closely is psychological safety. In other words, do people feel empowered to say, ‘‘We have got a problem here on the 

front lines. I need help. This is not working.’’ We will be keeping 

a very close eye on that. 

Senator BURR. Good. 

Secretary MCDONALD. Yeah, we sent that out last week and I 

will be happy to share the results with the Committee when it 

comes back. 

Senator BURR. Thank you. One last question. In the press release 

that VA sent out prior to the release of the IG’s report, the release 

stated that you had asked for an independent review at scheduling 

and access practices beginning this fall by a joint commission. I 

have got a very simple question. Why? Why do we need a joint 

53 

commission to look at the same thing that the IG is looking at in 

93 facilities right now which the IG has reported on since 2005, 

and are we waiting until the fall to implement changes in that 

until we have got a joint commission’s report back? 

Secretary MCDONALD. I will ask Dr. Clancy to clarify my comments, but it is not just any commission. It is a commission that 

does this kind of work for a living. 

Senator BURR. This town is full of commissions. As soon as we 

hear the word commission, we all start looking for who is hiding. 

Secretary MCDONALD. Well, it is not about hiding. It is about 

bench-marking best practices and this Commission does this across 

the country and will help us understand best practices in all facilities, not just the 93 that the IG is looking at. So, we plan to use 

this Commission to improve. It is unfortunate their name is commission, but that is—— 

Dr. CLANCY. So, just to expand for one moment, they do accredit 

the vast majority of private sector hospitals. In fact, they cannot 

get paid by Medicare or Medicaid if they are not accredited. So, 

this is following a standard practice in the private sector. These are 

going to be unannounced surveys, so we have put a huge amount 

of effort into making sure that the schedulers are trained, that we 

have enough people hired. 

We are looking for ways to get exceptions to get their grades increased, as the Secretary just indicated, but this is also going to 

be looking at, is it really working? How does patient flow work? 

What happens to people who wait in the emergency room then 

leave because they have been waiting too long and so forth. It is 

going to be an independent check for us and it will give us an opportunity to spread both good practices and opportunities for improvement across the system. 

Senator BURR. Thank you. Thank you, Mr. Chairman. 

Chairman SANDERS. Thank you, Senator Burr. 

Senator Tester. 

Senator TESTER. Thank you, Mr. Chairman. Once again, thank 

you for being here, Secretary McDonald. Just as a sidebar, I would 

love to have you incorporate Montana into your travel plans. Some 

time by the middle of next month would be great. Next, highest 

number of per capita veterans in the country, and they are some 

of the best veterans in the country, too, but I am a little partial 

about that. 

Let me ask you this. You said you removed three leaders from 

the Phoenix office. Were they reassigned or were they terminated? 

Secretary MCDONALD. What I said, Senator Tester, is that we 

have proposed disciplinary action against three leaders. This is the 

process that has to be taken for leaders who are in that strata of 

employee. We have proposed the disciplinary action. It now goes to 

a board and there is a process that it goes through. Since we have 

proposed that action, we have taken the leaders I talked about, 

moved them to Phoenix, and they are in an acting role. 

Senator TESTER. New leaders? 

Secretary MCDONALD. Yes, sir. 

Senator TESTER. I think one of the concerns we had was, I think, 

you have to protect employee’s rights, but we also need to be able 

to terminate people when they deserve to be terminated. 

54 

Secretary MCDONALD. I agree with you entirely. 

Senator TESTER. All right, good. 

Secretary MCDONALD. And believe me, we are, as I said in my 

prepared remarks, we are following the disciplinary—we are following the investigations and as soon as we are capable, we are 

taking action. 

Senator TESTER. The IG made many good points. One of the 

things he brought up was the analysis, because of the scheduling, 

really do not have a clear pattern on how many folks out there 

really need the kind of services they need. And then there is also 

the fee-based information that is out there. I do not know if that 

is better or not as good, or the same. 

How can you make a determination that you need 28,000 medical 

staff? I mean, you are a wonder worker probably, but the fact is, 

that information still has not been hammered out. 

Secretary MCDONALD. No. We are going through a process right 

now where we are going location by location, specialty by specialty 

to understand how many people we really need. 

Senator TESTER. When do you think that process will be done? 

Secretary MCDONALD. Let me ask Dr. Clancy to comment on that 

because she is leading that process. 

Senator TESTER. Sure. 

Dr. CLANCY. In response to a previous report from the Inspector 

General, and Dr. Daigh mentioned this briefly, we have been—we 

have created and are deploying a tool to assess productivity—— 

Senator TESTER. Got you. 

Dr. CLANCY [continuing]. Which includes space and all that. I 

would guess by early—at the end of this calendar year, early next 

year. 

Senator TESTER. All right. Then you will have a firm grip on how 

many medical staff you will need to have when that process is done 

because you will have already set up standards for doctors, because 

that is part of the thing, too, right? 

Dr. CLANCY. Yes, in addition to how many support staff do they 

need to make them as efficient and productive as possible. 

Senator TESTER. OK. Now I want to kick back to something else 

the IG said, because I tried to pin him down on the staffing thing 

and he said staffing is part of it. The other part of it is facilities. 

Where are you going to put these docs and medical staff if you hire 

them? Because quite frankly, I can tell you, in Montana facilities, 

I do not know if they are as big of a problem, but they are certainly 

pretty damn close to as big a problem as not having enough staff. 

I mean, you will have docs there, but you are not going to have 

any examination rooms. Do you have a construction plan moving 

forward? I know it is unfair, since you have only been in the job 

6 weeks. I am not trying to be critical. 

Secretary MCDONALD. I think it is five actually. 

Senator TESTER. That is good. 

Secretary MCDONALD. Obviously, you are right. Facilities are 

very important and the action you took with the bill gives us the 

ability to have 27 more facilities. Not surprisingly, one of the facilities will go in Phoenix where, obviously, we have a need. 

We have an issue right now that we are working. It is around 

leasing. We have been following an appropriate, I think, strategy 

55 

of leasing facilities rather than building them because the population, as you know, is moving, and you have talked about the increase in veterans in Montana. 

Senator TESTER. Right. 

Secretary MCDONALD. We are currently working through the 

GSA on this process because the GSA—— 

Senator TESTER. But to get down to it, Secretary McDonald, I appreciate you telling me what you are doing, but also what I want 

to know is, do you have a construction plan moving forward for the 

next year, 3 years, 5 years? So that you can come to us—some of 

us are appropriators on this Committee—and say, look, guys, we 

need this much money if we are going to be able to serve the veterans that are coming back. 

Secretary MCDONALD. We have a construction plan, but we are 

going to be renewing our forecasting, as I mentioned during my 

confirmation hearing, because I am not happy. I am not satisfied 

that our forecasting is robust enough. 

Senator TESTER. OK. I want to talk about the ARCH program 

very, very briefly because I do not have much time. It is pushed 

out for another 2 years. Is it open to all hospitals if they contact 

the VA? Let us say the Great Falls Hospital in Great Falls, MT, 

wants to get in on the ARCH program. What do they do? 

Secretary MCDONALD. Let us know. Again, our principals will 

look at everything through the lens of the veteran—— 

Senator TESTER. OK. 

Secretary MCDONALD [continuing]. And if it is good for the veteran, we want to do it. 

Senator TESTER. OK. I think that in particularly rural areas, 

that is going to be critically important. With that, I have got some 

other questions I am going to put in the record, quite frankly, for 

you as we move forward. But know that I know you are committed 

to the job. I know you are surrounded with people who are committed to the job. Middle management has been a problem, not 

only with this Administration, but the previous one. I think that 

you need to hold them accountable, too. 

Secretary MCDONALD. Well, I want to spend some time with you 

on the planned Road for Veterans Day, because one of the steps we 

are going to take is to reorganize the Department. 

Senator TESTER. OK. 

Secretary MCDONALD. We have nine different geographic maps 

for this Department. We have 14 Web sites that all require a different user name and password. The veteran does not want that. 

The veteran wants one geographic map, one Web site, and that 

simplification, I think, will flatten the hierarchy that you described 

and provide for information coming up and down a lot more 

quickly. 

Senator TESTER. Thank you for your work. 

Chairman SANDERS. Thank you, Senator Tester. 

Senator Heller. 

Senator HELLER. Thank you, Mr. Chairman, and Secretary, 

thank you for visiting Reno. 

Secretary MCDONALD. Reno and Las Vegas. 

Senator HELLER. And Las Vegas. On behalf of myself and the 

Governor—— 

56 

Secretary MCDONALD. Yes. 

Senator HELLER [continuing]. Perhaps minus the Tesla locating 

in the State of Nevada. It was a terrific opportunity for him to discuss with you, as myself, the concerns that we both share about 

Nevada’s veterans. So, thank you again. 

Secretary MCDONALD. You are welcome. And may I say that 

working with the State governments is critically important for our 

success. 

Senator HELLER. Well, you are proving that. Thank you for doing 

so. I want to talk about the Reno or the Nevada VARO just for a 

couple of minutes. As you are probably aware, in the Inspector 

General’s report, they did a VA two-year claims initiative and were 

able to recognize that about 32 percent of those claims reviewed 

were inaccurate. 

Unfortunately, for the State of Nevada, the IG report that they 

did in June focusing on Reno VARO, found that 51 percent of the 

claims reviewed were inaccurate. That being the case, have you 

had an opportunity to review these reports from the IG? 

Secretary MCDONALD. I have, but I also have to say that I have 

asked the IG to give me all of the reports over the last 5 years and 

to give me a triage version of those reports because I want to go 

back and look at all of the reports that have been issued and not 

acted upon. 

Senator HELLER. Yeah. 

Secretary MCDONALD. Now, I do know the situation in Reno, 

having been there. We have new leadership on the ground. We are 

making some progress, but we are not to where we need to be and 

the new leadership knows that. 

Senator HELLER. Let us talk about that leadership for just a moment. As you know, I called for management changes in the Reno 

VARO. Do we have a permanent director in that VARO at this 

point? Or what is the timeline for getting that? 

Secretary MCDONALD. We have an acting director right now, but 

we are in the process of, obviously, identifying the permanent 

director. 

Senator HELLER. You also mentioned in that—— 

Secretary MCDONALD. And we will partner with you on that. 

Senator HELLER. OK. You also mentioned that there perhaps is 

a need for four additional employees in that particular office. What 

is the status of that? 

Secretary MCDONALD. I have to check the hiring status, but we 

do need more employees in the Veterans Benefits Administration 

and we need them in that office. There is nothing holding us back 

from hiring them. We do need more employees in Veterans Benefits 

Administration. 

Right now we have, as you know, in that office and elsewhere 

around the country, we have all of our employees working mandatory overtime. We are stopping mandatory overtime October 1 because it is not sustainable. But, in order to be able to sustain our 

progress going forward and continuing to drive this backlog down, 

we have got to hire more people. 

There was some money in the bill that was recently passed that was taken out of the bill. I think it was $400 million. We are going 

to need some of that money back and we are going to cost-save to 

57 

try to find money to be able to hire those employees and continue 

to work that backlog down. 

Senator HELLER. I am sure you tend to agree with me that overtime is not an answer, you know, long term. Short term perhaps 

we could make some headway, but long term overtime pay and 

over-working some of these employees probably is not the answer. 

I think there really is a structural overall change that needs to 

happen in some of these VAROs and I will repeat it, but at 345 

days for benefits and medical claims processing, it is just unacceptable at this point. 

We would certainly hope that additional employees, obviously, 

would be one of the answers. Whatever the resources are necessary. As you know, I talked to the management in Reno to try 

to find out what they need, and they told us additional resources 

were not necessary. Please let me know if there is anything I can 

do to help, because it is just absolutely unacceptable; and I also 

think change needs to occur. 

I know you have not been in your position real long, but do you 

have a direction that you really want to go for these wholesale 

changes that are going to be necessary to reduce these backlogs? 

Secretary MCDONALD. We have made progress. The claim backlog is down by 56 percent. I think Deputy Secretary Gibson has 

said, and I agree with him, that the changes made in the Veterans 

Benefits Administration over the last couple of years have just 

been astounding. But you are right. We have done it by brute force 

and what we need to do now is re-engineer the process and get the 

resources we need to do it on a sustainable basis and drive down 

the backlog to zero by 2015, which is our commitment. 

Senator HELLER. Well, if there is anything that I can do to help 

and support—we have initiatives here. Senator Casey and I are 

working on those. We would certainly like to offer our services in 

any way that we can. 

I want to change directions real quickly and that is on women 

veterans. As you know, there are nearly 2.3 million women veterans that have served in the military and that number, as you 

also know, is continuing to grow. 

Since you have been Secretary, have you reviewed the care and 

services for these women veterans to make sure that it is 

adequate? 

Secretary MCDONALD. I have and we have work to do. In fact, 

every stop I go to, whether it is Phoenix, Memphis, Las Vegas, and 

I go into the medical center, one of the things that strikes me is 

how we built facilities years ago for male veterans because there 

were no female veterans. I also check in to see, do we have medical 

practitioners in OB-GYN and other areas. I look in the prosthetics 

labs to see, are we used to making prosthetics? 

We were just talking with Gary of the Disabled American Veterans and they have done a study now on what it means to make 

a prosthetic for a female who is pregnant. These are things that 

we have never had to deal with before, but now with 11 or 12 percent of the veteran population being female, and as you have indicated, continuing to increase in absolute numbers, these are things 

we have got to get after. 

58 

Senator HELLER. I think it may take some legislation to expand 

this care and I am eager to help your Administration move forward 

on these initiatives. I know something needs to be done and I look 

forward to assisting. 

Secretary MCDONALD. We would love to partner with you on 

that. 

Senator HELLER. Mr. Chairman, thank you. 

Chairman SANDERS. Thank you very much, Senator Heller. 

Senator Murray. 

Senator MURRAY. Thank you very much. Before I ask my questions, I just want to say to Senator Heller, thank you for asking 

that question. There is a lot of work left to do in terms of privacy, 

in terms of doctors that know how to care for women. But we also 

know that one of the barriers for women to get care is child care, 

because if you do not have a place to leave your kids that is safe, 

you do not show up; particularly for mental health this is a serious 

issue. I would love to work with you on that as well. 

Mr. Secretary, thank you, again, for being here. I want to start 

with talking about the fact that the IG found several cases in 

which veterans face delays in care or substantial care and subsequently took their own lives. VA’s newest wait time data still 

shows it takes far too long to get into care, but the IG’s findings 

also said that just simply meeting the wait time metric is not 

enough. Veterans also need to be assigned to a regular provider, 

they need care coordinated across the hospital and between specialists, and to get the type of care they need when they need it. 

We have been working on this problem for a long time now, and 

I wanted to ask you today, why do you think the VA continues to 

struggle with providing appropriate mental health care? 

Secretary MCDONALD. Senator Murray, I think mental health 

care is a problem in the United States and I think it is a problem 

in the VA. One of the things that excites me about this job is that 

many of the things we see at the VA is we are kind of the pathfinder for the country, whether it is, for example, the use of the bar 

code in a hospital to make sure somebody gets good care. 

I think one of the things we have to do is to increase the number 

of students studying mental health in school. When I was at Duke 

University Medical School, I met with 17 residents who graduated 

from the medical school all working with the VA. Only one was a 

psychiatrist. So, I asked the question, why are young people not 

going into psychiatry and mental health? Because it is an area that 

we are learning a lot more about today than we knew in the past. 

My father-in-law, who was a prisoner of war in World War II, he 

was a B–24 tail gunner. He was shot down over Germany—over 

Austria. He walked across Germany. I am sure he had Post Traumatic Stress, but we did not know what to call it. 

Senator MURRAY. Right. 

Secretary MCDONALD. He never wanted to talk about it until he 

joined a VA group of POWs who felt comfortable talking about it. 

And what they told me was, the biggest issue is that insurance reimbursements for mental health are far below the cost. Somehow 

we have got to get a handle on what is going on in this area and 

find ways to encourage people to go to school in mental health. 

59 

In all of my recruiting speeches so far, I have talked about the 

importance of mental health and I am trying to encourage young 

people to get into the discipline. I really think it is a national problem, but VA is on the cutting edge of it. 

Senator MURRAY. Well, continue work on that because that, to 

me, is a serious issue. You are right. It is a country issue, but our 

veterans are at the front of this line—— 

Secretary MCDONALD. Absolutely. 

Senator MURRAY [continuing]. And we have got to make sure we 

have got the providers, but we also have the understanding across 

the VA and across the culture of the VA to really watch for this. 

In your testimony, you talked about improving the Department’s 

leadership training and breaking down some of the VA’s bureaucracy as a way of enhancing accountability. That needs to happen 

at all levels, at all levels, and I liked your little chart where the 

veterans are at the top. But there are a lot of people between you 

and them. 

Secretary MCDONALD. That is why I gave out my cell phone 

number. 

Senator MURRAY. Well, we need to look at everything from training new clinic managers to oversight and effective intervention by 

medical centers and network leaders. How do you make sure that 

these changes happen at all of those levels across the VA? It is a 

huge system. 

Secretary MCDONALD. It is a huge system. It starts by getting 

out and going to these different sites and meeting the people and 

understanding, are we providing the right leadership? Do we have 

the right strategic choices? Do we have the right systems? Are we, 

you know, doing things that repeatedly will lead to a good result? 

And do we have the right culture? 

For example, I was at a site. I was actually in Reno and a young 

person was talking to me in a town hall about ways we can improve our computer system. And one of the senior managers 

stepped in front to try to stop the conversation, and I had to ask 

that senior manager to move out of the way. It just was not 

appropriate. 

I was in Philadelphia last week. This was a site that had a training program on town halls that used Oscar the Grouch in there. 

I had to talk to those employees about, no matter what the intent, 

perception is what is important and the perception of Oscar the 

Grouch on a presentation is not going to be acceptable. 

We simply have to dive into the culture and dig and figure out 

what is going on that is wrong and then set the example to do it 

right. I tell everyone to call me Bob. I was Bob before I became Secretary, I might be Bob after I am done being Secretary. That is not 

trite. That is done because we need to flatten the hierarchy. We 

need people to be like a family, to call each other by their first 

names, to feel comfortable turning in problems. 

We need to reward people who turn in problems, not chastise 

them or not ostracize them. So, these are some of the things we are 

doing. It is hard work, but it is underway. 

Senator MURRAY. OK. And really quickly, you said you have committed the VA to acquiring and fielding a modern scheduling sysVerDate Mar 15 2010 16:05 Jul 30, 2015 Jkt 000000 PO 00000 Frm 00063 Fmt 6633 Sfmt 6601 Z:\ACTIVE\090914.TXT PAULIN
60 

tem. Can you tell me when you think that will be done and the 

training for employees to use that? 

Secretary MCDONALD. Right now, we are doing some quick fixes 

on the established system. Those quick fixes are coming out periodically over the next few months. To really change the whole system and bring in a new one is going to take some time. But we 

would like it to be done in 2015. 

Senator MURRAY. 2015. And that includes the training for 

everybody? 

Secretary MCDONALD. Yes, of course. In fact, when you put in a 

new system, we want to commission it, we want to verify people 

know how to use it before they sit down and are qualified to use. 

Senator MURRAY. Thank you very much. 

Chairman SANDERS. Thank you, Senator Murray. 

Senator Moran. 

Senator MORAN. Mr. Chairman, thank you. Mr. Secretary, I do 

not think I will call you Bob in this setting, but, Mr. Secretary, 

thank you very much for your presence as I said earlier. I have a 

series perhaps of convoluted questions all related to the same topic. 

First of all, I would like to offer my assistance, as I have done with 

previous Secretaries. 

You have testified, the Chairman of this Committee has great interest in trying to help the VA have the necessary professionals to 

meet the needs of veterans. I have asked the previous VA Secretary 

how can I help. What do you need? What tools do you not have to 

help solve this problem? With no response. Again, if there are 

changes in the law, programs that are necessary to encourage loan 

forgiveness, whatever the story is that would help you attract professionals, I would like to be of assistance. I would like to be an 

ally. 

Here is my scenario of a couple of stories. Lee Mahin is a Smith 

Center veteran. I mentioned him in my opening remarks. He had 

the good fortune of the VA calling him to tell him that he no longer 

needed to drive 4 hours to Omaha, NE, from Smith Center, KS, to 

have a colonoscopy. That is the piece of good news. So, that suggests to me that there is change afoot. Thank you. 

Down the road about an hour in Plainville, KS, Larry McIntyre 

tells me that last week he drove 3 hours to Wichita to get a cortisone shot in his shoulder. He goes to Wichita several times a week 

for other minor procedures. There is a CBOC within 25 miles of 

Plainville, but the CBOC does not have the professional capability, 

as I understand it, of providing cortisone shots. 

What does exist is a hometown hospital, Rooks County Medical 

Center, Plainville, KS, that could provide a cortisone shot that is 

in the same town where Mr. McIntyre lives, and certainly less than 

the 31⁄2-hour drive to Wichita. So, on the one hand, we have had 

some success. On the other, there still remains these issues that 

we are trying to get at within the VA, but also in implementation 

to the Care Act. 

First of all, in implementation to the Care Act, when 40 miles 

is the determining factor as to whether or not you can access 

health care, how are you going to treat what that CBOC is capable 

of doing in determining whether or not that veteran lives within 

61 

40 miles of a facility? Is it a facility or is it a facility that can perform the service that the veteran needs? 

Secretary MCDONALD. That is a really excellent question and I 

am glad you brought it up, because one of the technical changes 

that we are working with the Committee on is to give the Secretary 

the authority to interpret that the way it should be interpreted. In 

other words, let us look at it through the lens of the veteran. Does 

it make sense for that veteran to get a cortisone shot closer to 

home? What makes sense? 

And one of the things we are asking is to give the Secretary that 

flexibility in the technical changes to the Care Bill. 

Senator MORAN. You do not believe you have that authority to 

make that determination now? 

Secretary MCDONALD. No, sir, but I think just by simply putting 

in a phrase, it would be very simply handled, and we have been 

working that with the staff. 

Senator MORAN. Does there seem to be any impediment toward 

accomplishing that? 

Secretary MCDONALD. No, sir. 

Senator MORAN. OK. Then let me go back to ARCH. In the interim before the Care Act is implemented, which my guess is November being the best scenario, you have set aside $25 million for 

outside of the VA care. That, I assume, funding expires at the end 

of the fiscal year, September 30, now 3 weeks away. ARCH is in 

existence and the Care Act gives you the authority to do two things 

with ARCH. One is to extend the contracts, extend the program, 

and the second is to expand the program beyond the geography 

that is currently served by an ARCH program. 

Do you have any questions about your ability to extend the program, ARCH, and do you have any questions about your ability to 

expand the program? 

Secretary MCDONALD. One of the technical changes that we are 

asking for in the bill that pertains to ARCH is the ability to just 

extend the contracts that we already have which will allow us to 

accelerate the expansion of ARCH. 

Senator MORAN. So, the language in the Care Act is insufficient 

to allow you to extend the contracts? 

Secretary MCDONALD. It just needs a modest modification. 

Senator MORAN. But when do those contracts expire? 

Secretary MCDONALD. Well, it is not—I do not think it is the expiration as much as it is just the assumption that we can use them 

moving forward so we can move more quickly rather than going 

through an entire rebidding process for new contracts. 

Senator MORAN. ARCH is not going to go out of business—— 

Secretary MCDONALD. No. 

Senator MORAN [continuing]. Those pilot programs before you get 

a technical change? The contract will continue? 

Secretary MCDONALD. I think—let me check on this to make 

sure. It is extended for 6 months, but what we are trying to do is 

extend the expansion as quickly as we can, and the way to do that 

is this technical change. 

Senator MORAN. So, you do not need an expansion. You do not 

need technical language to expand for 6 months. You need something to—— 

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Secretary MCDONALD. To extend for 6 months, no. 

Senator MORAN. And your expansion authority? 

Secretary MCDONALD. We are OK on that, but I think, again, the 

technical change we are seeking would allow us to accelerate the 

expansion. 

Senator MORAN. Mr. Chairman, with your indulgence, I would 

only say that I was surprised, as an author of this legislation, that 

the pilot programs were so narrow to begin with, very small geographic areas. My expectation was the VA would choose five sites 

that are Statewide or VISN-wide. We expected the entire VISN to 

be the pilot program, not a matter of a county or two. 

Do you have an opinion? Do you have thoughts about your willingness to expand ARCH to a larger Statewide or VISN geographic 

area? 

Secretary MCDONALD. Well, again, consistent with Deputy Secretary Gibson said, we need to look at this again from the standpoint of the veteran, and if it is good for the veteran, then we 

should expand it. I think that is what he said. We will expand it. 

We are looking forward to working with you on that. 

Senator MORAN. If you can get us the analysis of the ARCH program done by the VA, which we have asked for a long time (at 

least months), we would like to see what the report says about how 

the Department of Veterans Affairs analyzed the program. I assume it would say good things. 

Secretary MCDONALD. I would assume so, too, about providing 

care. 

[Adequate responses were not received within the Committee’s 

timeframe for publication.] 

Senator MORAN. Thank you. 

Chairman SANDERS. All right. Although long, I think it has been 

a productive hearing. 

Secretary MCDONALD. Mr. Chairman, may I say one thing? 

Chairman SANDERS. Sure. 

Secretary MCDONALD. First of all, I want to clarify one comment I made. I recall I said that the funding for VBA was roughly $400 

million. That was part of our original $17.6 billion request. It did 

not end up getting passed. So, that is why we brought that up, because we want to continue to drive down the claims. 

Second, I was trying to say earlier that leasing becomes very important. Leasing is a strategy that we are using to move our footprint out, provide greater access and care, and right now we have 

an issue that we are trying to resolve with the General Services 

Administration, the GSA, where they rescinded our blanket delegation of authority in July for lease contracts. 

Now, every one of our leased contracts needs an individual delegation from the GSA, and those that exceed $2.85 million, which 

many of them do—59 percent of the 27 do—need to go through a 

relatively laborious process. So, we are working with GSA to resolve this. But while we do that, we believe there is a need and 

a case to be made for an independent 20-year medical lease authority for VA to carry out its mission and to continue to provide these 

points of access. I just wanted to make sure that I got that right. 

Chairman SANDERS. Sure. This has been a long and ongoing 

problem, so we look forward to working with you. 

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Secretary MCDONALD. Thank you. 

[Posthearing questions to Hon. Robert McDonald follows:] 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. BERNARD SANDERS TO

HON. ROBERT A. MCDONALD, SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

DELAYS IN CARE

Question 1. While no deaths were attributed to delays in care, the Department 

of Veterans Affairs (VA) Office of Inspector General’s (IG) August 26, 2014, report, 

Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at 

the Phoenix VA Health Care System, found more than 3,500 veterans were on unofficial lists waiting for appointments, many of them for years, and were unable to 

obtain the care and services they deserve, in a timely manner. What steps has VA 

taken to ensure it eliminates the use of unofficial waiting lists? 

Response. VA has reviewed 88,000 fiscal year 2014 employee performance plans. 

Upon review, 13,000 plans were modified to remove scheduling and wait time 

metrics or goals. In accordance with the Veterans Access, Choice, and Accountability 

Act of 2014 (VACAA), these factors have been removed from inclusion in employee 

performance evaluations and when calculating whether to pay performance awards. 

VA will continue to review and modify employee performance plans for future years. 

VA revised Human Resources handbook 5021 to include provisions related to penalties for employees who falsify data regarding access to care or quality measures. 

The policy has been updated to list, ‘‘Willfully submitting or directing others to submit false data concerning wait times for health care or quality measures related to 

health care,’’ as an offense related to falsification. The explicit inclusion of the terminology ‘‘wait times’’ and ‘‘quality measures’’ will reinforce the expectation of the 

Department that no employee shall manipulate or falsify data regarding wait times 

or quality measures. 

Question 2. For those veterans who were offered the option to see a health care 

provider in their community, as part of VA’s Accelerating Access to Care Initiative, 

how many veterans opted to wait for VA health care? 

Response. Since the beginning of the VA’s Accelerating Access to Care Initiative, 

local facilities have been contacting those Veterans who have an appointment scheduled 60 or more days into the future. As of September 17, 2014, about one-third 

(104,474) of those Veterans contacted decided to keep their scheduled VA 

appointment. 

Question 3. Are the mobile medical units being used at the Phoenix VA Health 

Care System (PVAHCS) being staffed by PVAHCS staff or augmented staff? How 

will information on the care veterans receive through the mobile medical units be 

shared with their PVAHCS health care teams to ensure continuity of care? 

Response. The Medical Mobile Units (MMU) were staffed by VA’s Disaster Emergency Management Personnel System and the Phoenix VA Health Care System 

(PVAHCS) staff simultaneously. Two clinics were set up in the MMUs and the third 

MMU was used as an administrative area. The first clinic was an Unassigned Patient Aligned Care Team (PACT) Walk-in Clinic. This clinic was designed for new 

patients who were not yet assigned a primary care provider (PCP). For example, a 

Veteran who was seen in the Emergency Room, but did not have a PCP established 

could be seen in the unassigned PACT clinic until they were assigned to a PACT 

team. Additionally, traveling Veterans who did not need to be assigned to a PCP 

in Phoenix could be seen by the Unassigned PACT Team. The creation of the Unassigned Walk-in Clinic created a central clinic for this method of care to occur. 

The second MMU was established to leverage tele-health support from other VA 

facilities in the event those tele-health staff resources were to become available. 

The third MMU was used as an administrative area; the facility was able to move 

administrative staff from the current Primary Care clinics, which freed up additional clinical space. As a result, enough space was created in the Turquoise Clinic 

to house up to five additional PACTs. This decision was made for the convenience 

of patients and to minimize exposure to heat for Veterans attempting to locate the 

MMUs. 

The information captured during care delivered in the MMUs was captured 

through VA’s Electronic Medical Record known as the Computerized Patient Record 

System (CPRS). The MMUs had full functionality with VA’s CPRS and patient 

interactions were recorded in the same manner as any patient-provider interaction. 

The MMUs were utilized at PVAHCS from June 11th through August 8, 2014, at 

which time they were returned to their home sites. 

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Question 4. As part of the Accelerated Access to Care Initiative, VA has extended 

clinic hours to expand capacity. How many veterans have used these extended 

hours? Please discuss whether extended clinic hours for patient care are sustainable 

or part of a long-term access solution. 

Response. The number of Veteran encounters during extended hours for Mental 

Health, Primary and Specialty Care has increased since May 2014. The Outpatient 

Extended Hour Encounters between May to September 2014 totaled 629,925 as compared to 553,433 during May to September 2013 (see attached chart below). The 

data demonstrates a 14 percent increase in the volume of extended hour encounters 

used by Veterans during the same timeframe (May to September) between 2014 and 

2013. 

Extended clinic hours can, and must be, part of VHA’s long term access solution 

to meet the preferences of Veterans. To provide personalized, patient-driven care, 

VHA must be accessible at times that are convenient for Veterans. Shifting tours 

of duty will help alleviate the space limitations facing a number of facilities. In addition to current staff who have altered their schedules, new staff who are hired will 

need to embrace working extended hours and in non-traditional tours. This additional flexibility can help with recruiting and retaining needed staff. However, in 

order to be fully sustainable, this cultural shift may require modification of VA’s 

policies regarding physician tours of duty and leave. 


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DATA MANIPULATION

Question 5. The Committee requests information on the steps VA is taking to ensure the access data being reported bi-monthly, as a response to its Access Audit, 

is accurate. 

Response. As a result of the System-wide Access Audit, VA has renewed its focus 

on ensuring the integrity of the data used throughout the system. Actions have been 

implemented to strengthen the process and improve the integrity of VA’s access 

data at each step of the process: data input, data aggregation, data reporting, data 

distribution, and publication. To ensure the integrity of the access data in the input 

stage, VA recently launched an automated access and scheduling audit tool designed 

to monitor and flag any potential data integrity issues. This tool is programmed 

with a preset algorithm, designed by scheduling subject matter experts that will 

score scheduling practices at each facility and clinic and highlight those clinics that 

require additional follow-up. This tool is available for use by each medical center 

and Veterans Integrated Service Network (VISN) leadership team. This tool is also 

being routinely monitored in VHA Central Office by a national monitoring group 

and the VHA senior leadership team. Once the data are input into the system, the 

data from each Veterans Health Information Systems and Technology Architecture 

(VistA) system are transmitted to Austin Information Technology Center and aggregated into national files containing appointment and Electronic Wait List (EWL) 

records. These national files are used by the VHA Support Services Center for calculation and reporting of wait times. The date stamps in each appointment and 

EWL record are used to calculate the wait time in days. After the wait time and 

EWL data are prepared for public release, each number is independently verified 

against the VHA Support Services Center, to ensure accuracy. All data that pertain 

to Veteran access to care, including non-VA care, are verified by a team independent 

of the data production process prior to distribution and publication. 

ACCOUNTABILITY

Question 6. The Committee requests the following information on the Administrative Investigation Board that was established to determine whether administrative 

action should be taken against management officials at the Phoenix VA Health Care 

System as a result of the IG’s final Phoenix report: 

• A list of the individuals who serve on the board; 

• Information on the Board’s mission—specifically, are they only reviewing information gathered by the IG or are they conducting their own investigation; and 

• A list of VA personnel being considered for administrative action by the Board. 

• A list of VA personnel who have been put on administrative leave or removed 

from their positions as a result of the IG’s final report on Phoenix. 

Response. The board members consisted of a director, human resources consultants and counsels, none of whom were from the Phoenix VAMC or from VISN 18. 

The AIB has reviewed the OIG report and will review the underlying witness testimony and other evidence before traveling to Phoenix to begin its investigation. To 

the extent that OIG has already found facts or gathered evidence sufficient to support discipline, the AIB will not repeat that work, but will focus on establishing individual leader culpability and other issues not fully resolved by OIG. The AIB will 

also review leader culpability for whistleblower retaliation, which was not within 

the scope of OIG’s review. The AIB will look at culpability, if any, on the part of 

the PVAHCS Chief of Staff, Darren Deering, MD; Associate Director, Lance Robinson; and Chief of Health Administration, Brad Curry. The latter two individuals 

were put on administrative leave, as was Director Sharon Helman. Ms. Helman was 

removed from employment effective November 24, 2014. 

Question 7. The Committee requests VA’s plan to hold local VA medical center 

leadership accountable for misconduct, negligence, and failure to address serious access problems identified that may be identified during the more than 100 ongoing 

investigations at VA facilities by the IG, Department of Justice, Office of Special 

Counsel. To include a list of VA personnel that have been fired, transferred, or subject to administrative action as a result of the finds of such investigations. 

Response. VA takes the allegations and findings of misconduct seriously and is 

moving quickly to address the situation. Since allegations of delayed care and employee misconduct surfaced, VA has been conducting internal reviews to evaluate 

appointment scheduling procedures and patient care in Phoenix and nationwide. VA 

has initiated the process for removing senior leaders at the PVAHCS, and VA has 

directed an independent site team to assess scheduling and administrative practices 

at PVAHCS. This team began its work in April, and VA is taking action on multiple 

recommendations from the team’s findings. VA recognizes there is a leadership and 

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integrity problem among some of the leaders of our health care facilities, which can 

and will be fixed. Breaches of integrity are indefensible and VA will use all authorities at its disposal to enforce accountability among senior leaders. 

As of December 1, 2014, OIG has completed its reviews of scheduling and wait list 

practices at 23 sites. At seven sites, no significant misconduct was found. At three 

sites—Phoenix, Cheyenne, and Fort Collins—serious misconduct was found. Six disciplinary actions have been completed at Cheyenne and Fort Collins (which are both 

under the same leadership team) and one at Phoenix (see response to question 6 

above). Additional actions may be taken at Phoenix following VA’s administrative 

investigation there (see response to question 6). VA is reviewing the evidence OIG 

collected at the fourteen other sites where OIG is done, and will determine based 

on that evidence whether further investigation and/or accountability actions are 

warranted. 

The Office of Accountability Review commenced an accountability audit that is 

taking place at facilities that are not under current investigation by the Inspector 

General (IG) and DOJ, or have been cleared by those entities. VA wants to be as 

proactive as possible, while respecting the need of the IG and DOJ to conclude their 

own investigations. The purpose of the accountability audit is to determine what 

senior leaders at each facility did to ensure the integrity of their wait time data and 

that front-line schedulers were aware of the rules and were following them. In situations where leadership misconduct, negligence, or other leadership failures appear 

to have occurred, the Office of Accountability Review will investigate to obtain evidence to support appropriate personnel actions against culpable leaders. 

EMERGENCY ROOM USED AS PRIMARY CARE

Question 8. The IG’s final report on Phoenix identified numerous veterans that 

were forced to visit the Emergency Room because they were unable to obtain a primary care appointment. The Committee requests VA’s plan to address its systemwide shortage of primary health care providers. 

Response. As the Nation’s largest integrated health care delivery system, VHA’s 

workforce challenges mirror those of the health care industry as a whole. 

As physician shortages exist throughout the private sector, medical schools are 

growing to address these shortages. In order to carry out the primary patient care 

mission of VHA and to assist in providing an adequate supply of health personnel 

to the Nation, VA is authorized by Title 38 Section 7302 to provide clinical education and training programs for developing health professionals. VA conducts the 

largest education and training effort for health professionals in the United States. 

In fiscal year (FY) 2013, 40,420 physician residents and fellows in graduate medical 

education programs rotated to a VA clinical facility for education and training. 

VA employs an aggressive, multi-faceted strategy to recruit and hire physicians. 

Executive and clinical leaders at 150 medical centers assess physician staffing 

needs. Physician shortages or deficits at specific locations are addressed by increased marketing and recruitment efforts on a case-by-case basis. In addition to actively recruiting primary care physicians, increasing and further incorporating 

nurse practitioners and physician assistants with specialized training and experience in primary care into care teams will increase Veterans access to care. Marketing is also targeted to academic affiliates, professional health care associations, 

the Department of Defense, the Department of Health and Human Services, and Office of Personnel Management. 

VHA’s National Recruitment Program (NRP) provides an in-house team of skilled 

professional recruiters employing private sector best practices to the agency’s most 

critical clinical and executive positions. NRP has increased its targeted recruitment 

efforts for mission critical clinical vacancies that directly impact and, once filled, 

will improve access to care. These specialties include primary care, mental health, 

and critical medical subspecialties. The national recruiters, all of whom are Veterans, work directly with VISN Directors, Medical Center Directors, and clinical 

leadership in the development of comprehensive, client-centered recruitment strategies that address both current and future critical needs. Since its founding in 

April 2009, VHA’s NRP efforts resulted in filling 1,327 mission-critical vacant positions (as of September 23, 2014), which increased access to care in rural communities and contributed to Title 38 Veteran hiring goals. In FY 2014, as of September 23, 2014, the recruiters have placed 561 health care providers: 

• 91.80 percent are physicians 

• 32.97 percent are primary care physicians 

• 24.95 percent will go to rural/highly rural facilities 

• 15.68 percent are Veterans 

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• 16 of these Veteran hires will fill clinical and executive leadership roles at VA 

hospitals 

The national recruiters are attending conferences to showcase clinical practice opportunities to potential candidates. These include American College of Physicians, 

American Psychiatric Association, and American Psychological Association. The 

team will also attend additional conferences through the end of 2014, targeting specialties such as Anesthesia, Gastroenterology, Family Medicine, Emergency Medicine, and Pharmacy. 

VHA, in partnership with the Office of Academic Affiliations, pioneered the agency’s first-ever recruitment outreach program targeting health professions trainees. 

The ‘‘Take a Closer Look’’ Initiative provides VHA with a standardized outreach 

strategy to recruit health professions trainees from VHA affiliate programs for employment upon completion of training. Throughout their programs, residents and fellows receive information on careers at VHA, as well as guidance on contacting and 

facilitating employment with a National Recruiter. 

In addition to actively recruiting primary care physicians, increasing and further 

incorporating nurse practitioners and physician assistants with specialized training 

and experience in primary care into care teams will increase Veterans access to 

care. Additionally, VA continues to recruit for a variety of administrative, technical, 

and professional occupations to ensure the right mix of staff are available to provide 

safe, quality care to Veterans. 

VHA has a number of education and loan repayment programs, which include providing education/tuition assistance, education debt reduction and loan repayment 

programs, to recruit and retain Title 38 medical professionals. VHA utilizes the 

Education Debt Reduction Program (EDRP) for candidates in hard-to-recruit or retain Title 38 occupations who would otherwise decline or leave VHA. Employees or 

their lender(s) receive loan reimbursements for up to five years as long as the employee remains employed by VHA in the position that was approved for EDRP, 

thereby serving as a significant retention incentive. Public Law 113–146, The Veterans Access, Choice, and Accountability Act of 2014 (VACAA), increased the EDRP 

loan reimbursement cap from $60,000 to $120,000. This cap can be waived for specific critical clinical specialty positions, including mental health specialties such as 

psychiatrists, psychologists, and mental health nurses. There is ample capacity in 

the program to reach clinical providers in hard to recruit and retain positions for 

mental health, primary care, and specialty care positions around the country. In addition, VHA is in the process of implementing direct loan repayment to the lender. 

The Employee Incentive Scholarship Program (EISP) authorizes VA to award 

scholarships to employees pursuing degrees or training in health care disciplines for 

which recruitment and retention of qualified personnel is difficult. The National 

Nursing Education Initiative (NNEI) and VA’s National Education for Employees 

Program (VANEEP) are policy-derived programs which originated from the legislative authority of EISP. EISP awards cover tuition and related expenses such as registration, fees, and books. NNEI is limited to funding Registered Nurses (RN) pursuing associate, baccalaureate, and advanced nursing degrees. VANEEP provides replacement salary dollars to VA facilities for scholarship participants to accelerate 

their degree completion by attending school full-time. Participants incur a 1 to 3- 

year service obligation following completion of their program. 

TIMELY ACCESS TO CARE

Question 9. Due to the backlog of new patient Primary Care appointments discovered the IG’s final report on Phoenix, 544 appointments as of March 31, 2014, 

PVAHCS now monitors all new veterans to ensure timely access to care. The Committee requests: 

• Information on the monitoring process that the Phoenix VA is using, and 

• A list of VA employees, and a description of their positions, responsible for the 

monitoring process. 

Response. PVAHCS, through its Health Administration Service (HAS) monitors 

and reports data from the EWL and the New Enrollee Appointment Request 

(NEAR) on a daily basis. Medical Support Assistants under the supervision of their 

respective sections monitor the list daily and contact the patient. The process for 

monitoring the EWL is administered in the Primary Care Call Center. The NEAR 

is reviewed daily by the Eligibility and Enrollment department. Both teams pull the 

names from the EWL and the NEAR and contact the Veterans to offer them an appointment. The teams make three attempts to contact the Veteran and then send 

a certified letter. The teams obtain the EWL and NEAR from reports in VA’s mainframe architecture also known as VistA. 

69 

Personnel involved in the monitoring process include supervisors, patient service 

assistants and medical support specialists. The results of these reports are reported 

daily to the Medical Center Director, Executive Leadership and all Service Line 

Chiefs at Morning Report. 

STAFFING MODEL

Question 10. In 2012, the IG found only 2 of 33 VA health care specialties had 

staffing standards. Has VA developed staffing models for each health care specialty? 

If so, please provide the Committee with a copy of each staffing model. If not, please 

provide the Committee VA’s plan to develop a staffing model for each health care 

specialty. 

Response. Attached is the Report on the Specialty Physician Productivity & Staffing Operational Plan and Status Report. VA concurred with the OIG recommendation to develop productivity and staffing models for all physician specialties by the 

end of FY 2015. The current status of the recommendations resulting from the OIG 

report is that all physician specialties, except for Anesthesia and Emergency Medicine, have productivity and staffing standards in place. Productivity and Staffing 

Models for Anesthesia and Emergency Medicine have been developed and will be 

fully implemented in FY 2015. 


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There are staffing standards for SCI/D (VHA Directive 2008–085, Spinal Cord Injury Staffing and Beds: https://www1.va.gov/vhapublications/ 

ViewPublication.asp?pub_ID=1816). This directive will be updated after an SCI/D 

nurse staffing pilot is completed. 

OFFICE OF THE MEDICAL INSPECTOR

Question 11. When does VA expect to complete the Office of Special Council’s Section 2302(c) Certification Program? 

Response. VA registered for the Office of Special Counsel (OSC) 2302(c) Certification Program on July 11, 2014. The Certification Program ensures that VA meets 

its statutory obligation to inform its employees about the rights and remedies available to them under the Whistleblower Protection Act, the Whistleblower Protection 

Enhancement Act, and related civil service laws. VA received OSC certification on 

October 3, 2014. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. RICHARD BURR TO

HON. ROBERT A. MCDONALD, SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 12. In response to a question from Chairman Sanders, the Secretary indicated that then-Acting Secretary Gibson proposed the Department of Veterans Affairs (VA) would need 28,000 additional staff to meet the current demands of VA. 

a. Please provide the Committee with a detailed breakdown of the number and 

type of providers (separated by specialty), the number and general schedule level 

of Title 5 positions, and the number of and position titles of any Title 38-hybrids. 

Response. Please see the attached spreadsheet with the breakouts of the 28,000 

number from the August 27, 2014 pull of VA’s WebHR data. WebHR is a new Web 

application VHA is now using to track vacancies nationally; it was first deployed 

in June 2014. The 28,000 number is shown by occupation type, in separate 

groupings for Title 38, Title 38 Hybrid, and Title 5. This 28,000 represents funded 

but vacant positions, based on the snapshot in time of WebHR data. 


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b. For any positions that would not be assigned to the Veterans Health Administration (VHA), please identify the number of positions and office, agency, or administration to which the position would be assigned. 

Response. None of the positions would be assigned outside VHA. 

c. For any medical personnel included in the 28,000, please provide the Committee 

with a detailed staffing analysis VA used to determine the number of providers 

needed for each type of provider (please separate out by specialty) and which VA 

Medical Center (VAMC) those providers would be located. 

Response. The 28,000 represents the number of vacancies captured in WebHR as 

of August 27, 2014, for clinical positions. WebHR is a Web application VHA is using 

to track vacancies nationally and was first deployed in June 2014. The functionality 

for collecting vacancies in this application is relatively new. Transactions against 

the management of positions occur daily as the system captures new and completed 

recruitment actions in real time. The 28,000 number was not based on a detailed 

staffing analysis. 

d. Please identify which positions are intended to be located in VA Central Office 

(VACO) or the ‘‘Field;’’ for VACO positions, please identify which Administration or 

Staff office (VHA, the Veterans Benefit Administration, the National Cemeteries Administration, the headquarters of the Office of Public and Intergovernmental Affairs, the headquarters of the Office of Information Technology, etc.). For VHA Field 

positions, please identify whether the personnel are to be assigned to the Veterans 

Integrated Service Network or VAMC. 

Response. None of the positions identified in these data sets are intended to be 

located at VA Central Office or VHA Central Office; they are all field positions assigned to medical facilities. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. MARK BEGICH TO

HON. ROBERT A. MCDONALD, SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 13. Mr. Secretary, we have talked a lot about hiring people for VA. That 

is important in Alaska as well. I have told you about how important it is to me that 

we leverage Federal resources wherever they come as we provide care to Veterans. 

We are doing some great work in Alaska. A model really increasing coordination 

and collaboration. 

a. That said, as you are hiring all of these people, where are you going to put 

them? Do you lease, do you build? 

Response. We are proud of our staff and facilities in Alaska, and the quality of 

services provided there. The Alaska Department of Veterans Affairs (VA) 

Healthcare System currently has capacity within the seven Alaska VA facilities, 

throughout the state, to accommodate all current employees, as well as currently 

recruited positions. 

VA has several capital and non-capital tools at its disposal to address evolving 

space needs to provide care. Leasing is a flexible vehicle that allows VA to provide 

care to Veterans at the right place at the right time with less lead time than construction. In addition, VA can execute capital renovation projects at existing owned 

or leased space to increase capacity within the existing footprint. VA can also use 

telehealth and other modalities for newly hired staff to engage with veterans despite 

limited space. 

b. Do you have the flexibilities you need in law and authority to get the space 

that you need? For example how would VA partner with IHS facilities? 

Response. We already have collaborative relationships in place with Indian Health 

Service. In addition, the Alaska VA Healthcare System has agreements with 26 

Alaska Native Tribal Healthcare Organizations, which provide rural health care access for eligible Alaska Native and American Indian (AN/AI) and non-AN/AI Veterans in approximately 150 rural Alaskan communities. Under these agreements, 

VA reimburses Alaska Native Tribal Healthcare Organizations for direct care services they provide to eligible AN/AI and non-AN/AI Veterans throughout Alaska. The 

Veterans Access, Choice, and Accountability Act of 2014 (Choice Act) affords us the 

flexibilities to expand our own internal resources, as well as interagency relationships, to help ensure Veterans have access to quality, affordable health care. Also 

under Choice Act, VA has identified about 400 projects to renovate, repair, or replace much of our aging health care infrastructure, and expand at some sites, at 

a cost of $1.3 billion. The Choice Act will fund these projects during fiscal year (FY) 

2015 and FY 2016. 

Question 14. Mr. Secretary, as you know with Veterans Access Choice and Accountability Act passed, it brought in some needed resources, such as hiring more 

clinical staff, this is good. However, in remote and rural areas like Alaska, we have 

102 

had problems with recruiting and retention, specifically for primary care doctors. 

The Mat-Su Valley is an example, we are fortunate to have a native clinic across 

the road that is taking up to 400 veterans a day. 

a. What are the plans for VA to hire and keep clinical staff in rural areas? 

Response. One of the strategic objectives of the Office of Rural Health (ORH) is 

to develop innovative methods to identify, recruit and retain health care professionals and requisite expertise in rural and highly rural communities. ORH has 

made significant investments in strengthening the rural VA provider workforce and 

is continuously seeking to understand the current and future rural workforce needs, 

as well as all of the potential opportunities to expand and improve our current efforts. ORH investments are aimed at both mitigating common factors that contribute to providers leaving rural practice, as well as providing experiences that may 

attract providers to rural practice. The goal is that these investments into rural 

workforce programs will retain rural providers thereby impacting subsequent periods without physician care. In FY 2013 and 2014, ORH invested more than $15 million to support rural provider education and training initiatives. The targeted efforts 

by ORH are intended to supplement the existing workforce strategies implemented 

nationally, regionally, and locally by the Veterans Health Administration (VHA). 

Question 15. Alaska’s Licensed Professional Counselors have proudly served our 

military and veterans community in their time of need after 13 years of war. However, these professionals have recently been told their experience and credentials 

will not suffice to continue treating our veterans’ mental health needs. In recent letters to the TRICARE and the Army I pressed them to reconsider new accreditation 

policies that unintentionally omitted Alaskan counselors. 

Will you commit to reviewing the LPC accreditation issue in my state? Highly 

qualified counselors are excluded from filling many of these highly difficult to fill 

positions, and the veterans are the one who suffer. 

Response. The VA qualification standard for Licensed Professional Mental Health 

Counselors includes the basic requirement of a master’s degree in mental health 

counseling, or a related field, from a program accredited by the Council on Accreditation of Counseling and Related Educational Programs (CACREP). This was developed by a group of highly qualified Subject Matter Experts (SME), leadership within 

VHA’s Mental Health Services, and VA’s Office of Human Resources Management. 

The qualification standard is based on the health care industry standards for the 

profession and licensure and/or certification requirements. Additionally, the standard was developed to assure the provision of the highest quality of care to our Nation’s Veterans. The SMEs reviewed documentation on current industry standards 

and practices and included consideration of all state requirements, including the licensing requirements for the State of Alaska. It is important to note, the qualification standards for each core mental health profession require that an individual in 

that discipline have graduated from a program that is accredited by an approved 

accrediting body that accredits training programs in that discipline. This rule applies to all VA core mental health disciplines (Psychology, Psychiatry, Social Work, 

Nursing, Licensed Professional Mental Health Counseling, and Marriage and Family Therapy). 

Question 16. It was recently shared with me that scheduling vendors are providing commercialized off-the-shelf scheduling software system that can significantly 

solve most of the scheduling challenges facing the Veterans Administration within 

the budget parameters. 

a. What are you and the department doing to ensure that systems like these, from 

non-traditional government vendors, are considered in addressing the scheduling 

software program across the entire VA? 

Response. VA will procure a commercial-off-the-shelf (COTS) replacement for its 

medical appointment scheduling system from the private sector. The Department is 

seeking a COTS scheduling system to provide a resource management-based solution. VA chose a full- and open-competitive acquisition strategy to benefit from the 

innovative marketplace. 

In addition, VA has worked closely with industry to ensure requirements are 

clearly understood. VA conducted an ‘‘Industry Day’’ to brief industry representatives on VA’s scheduling system needs. As a result, VA received and responded to 

over 100 questions from industry. After the successful Industry Day, VA met oneon-one with interested vendors, during which the VA achieved a better understanding of the marketplace, different vendor approaches, and associated risks. VA 

also issued a draft of its request for proposal (RFP) in order to solicit industry feedback to improve the language before release of the full RFP. 

b. What are the most important criteria you are looking for in the selection of a 

national scheduling software solution?’’ 

103 

Response. In its meetings with industry and in the documents VA has made publicly available, the following key criteria have been emphasized: 

• Proactive resource management-based scheduling that schedules staff, facilities, 

equipment • Transparency to balance supply with demand 

– Provide single, consolidated view of resource availability (e.g. one calendar 

for a clinician) 

– Provide single, consolidated list of appointment requests (e.g. single view of 

the patient) 

– Improved transparency through richer data for reporting 

• Consistent implementation and visibility of business rules to support scheduling 

policies and directives 

c. ‘‘What is your timeline for consideration and award of a contract for a national 

scheduling software solution?’’ 

Response. VA is planning to issue a RFP for the medical appointment scheduling 

system under a full and open competition in the first quarter of FY 2015. Offerors 

will have 45 days to respond from the day of issuance. The solicitation may require 

a two-part demonstration of capabilities: a written proposal and a technical demonstration to scheduling staff. VA expects to award the contract within the second 

quarter of FY 2015. 

Question 17. I do have a bill for loan repayment of Psychiatrists and other incentives to recruit mental health providers to the VA. I understand recruiting and retaining Psychiatrists is a top need for VA. 

Would a loan repayment help with this recruitment? (Right now it’s the discretion 

of the VISN on whom and how many get the loans) As you may know I have a bill 

to do this. 

Response. Yes. VA believes loan repayment would help with recruitment and retention of Psychiatrists. The passage of recent legislation would assist VA with the 

recruitment and retention efforts. 

Specifically, the passage of Public Law 113–146, the Veterans Access, Choice, and 

Accountability Act of 2014, increased the maximum Education Debt Reduction Program (EDRP) loan amount from $60,000 to $120,000. In addition, the Secretary has 

the ability to waive the cap for specific critical clinical specialty positions, including 

the top physician specialties of primary care, psychiatry, gastroenterology, orthopedic surgery, emergency medicine, and cardiology; nurse specialties of head nurse, 

staff nurse, nurse practitioner, mental health and substance abuse, inpatient community living centers, and certified registered nurse anesthetist. Furthermore, Section 408 of the VA Expiring Authorities Act of 2014 allows VA to directly pay the 

lenders for qualified loans. Therefore, the authority to provide a higher level of loan 

repayment for psychiatrists is already in place through the existing EDRP program. 

Question 18. VA has suspended all VHA senior executive performance awards for 

fiscal year 2014 and increased accountability for senior leaders. 

Do you expect to bring back these awards in 2015? If not, what is the plan to 

attract and retain superior executive leadership in the future. 

Response. While it is the Secretary’s prerogative to pay or withhold performance 

awards, no final decision has been made for FY 2015 at this time. Since Senior Executive performance awards are based on organizational results, as well as individual performance, it would not be appropriate to predict final decisions one year 

in advance. Regarding the Secretary’s decision to approve no performance awards 

for FY 2014 in VHA, the Secretary had significant performance indicators to determine FY 2014 organizational results could not be accurately validated based on 

performance. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. MAZIE HIRONO TO

HON. ROBERT A. MCDONALD, SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 19. What was the rationale behind the then-Deputy Under Secretary for 

Health for Operations Management waiving the requirement to certify compliance 

of VA’s scheduling directive in May 2013 and does VA plan to reinstate that 

requirement? 

Response. At the time the requirement was waived, there was concern that it was 

hard to reach full compliance with the scheduling directive and also hard to maintain it. By a Medical Center Director certifying in writing that they were in compliance, this puts them at risk if a subsequent external audit or review found weaknesses. Directors felt it was a no-win situation. The decision was made at a time 

when the environment was characterized by performance measure and certification 

104 

fatigue. There are plans to reinstate the requirement in the new scheduling directive, but this time it will be accompanied by significantly better training of clinic 

managers and better tools to monitor performance. 

Question 20. How will the policy actions taken and to be taken by VA be communicated to the Veteran and Veteran Service organizations? Do you plan any changes 

to the policy as a result of this nationwide review and how do you plan to communicate it to veterans and to different generations of veterans? 

Response. There are a number of important changes related to improving access 

to health care that will be communicated to Veterans. The changes are driven by 

policy decisions and by the Veterans Access, Choice, and Accountability Act of 2014 

(VACAA), which established the Veterans Choice Program. With respect to the 

Choice Program, the Department of Veterans Affairs (VA) will communicate information regarding eligibility and Program operations directly to Veterans through 

the mail, a new call center, press releases, and communications on VA’s main Web 

site, and communications on VA medical facility Web sites. VA also anticipates Veterans Service Organization briefings and town hall meetings at VA facilities to educate Veterans about any changes that may impact them. 

Question 21. In your testimony, you state ‘‘where willful misconduct or management negligence is documented, appropriate personnel actions will be taken.’’ At 

nearly 5 months after the allegations at Phoenix surfaced, what appropriate personnel actions have been taken and with the newly enacted authorities to dismiss 

certain personnel, how will you exercise it to meet your commitment to address misconduct at the VA? 

Response. VACAA facilitates and promotes sustainable accountability. For instance, the Act allows VA to resolve Senior Executive Service (SES) removal actions 

more quickly than before. VA has used the expedited SES removal authority in 

VACAA to remove the Phoenix Director and other SES-level VA leaders. Now that 

the criminal investigations at the Phoenix VAMC have concluded, VA is moving to 

close out its administrative investigations of non-SES leaders there and expects to 

issue final decisions in all Phoenix leadership cases after the administrative investigations are concluded. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JOHN BOOZMAN TO

HON. ROBERT A. MCDONALD, SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 22. Secretary McDonald, in the Veterans Access, Choice and Accountability Act of 2014 (hereinafter ‘‘the Choice Act’’), that Congress recently passed, 

there were provisions that significantly expanded your ability to remove senior VA 

employees for poor performance or misconduct. On August 26, 2014, the VA OIG 

published a report that addressed the scheduling problem at the Phoenix VA as well 

as other issues. In the report, it clearly states that executives in the Phoenix VA 

were well aware that subordinate staffs were manipulating wait times. I am also 

aware that a number of my colleagues here in the Senate have expressed frustration 

that the former director of the Phoenix VA Health Care system is still on paid administrative leave. I understand your desire to ensure that all VA employees receive 

due process and I appreciate that. However, I believe that in order for you to make 

real reforms within the VA, there must be a change in the institutional culture and 

to do so, I believe you have to hold people accountable. I would like to know, what 

do you consider a ‘‘fireable offense,’’ and how do you plan to implement this new 

authority that you have? 

Response. The Department is firmly committed to instituting a culture of sustainable accountability. As we confront our challenges in VA, it is also essential we empower employees to speak up when they see wrongdoing, and protect them from unlawful retaliation. On June 4, 2014, VA announced new procedures to ensure that 

we fully consider disciplinary action against managers and supervisors who commit 

discrimination and retaliation against employees. VA will hold those who violate 

this precept accountable. This is a Department-wide responsibility. On August 22, 

2014, the Secretary called for every VA employee to reaffirm his or her commitment 

to the VA values—integrity, commitment, advocacy, respect, and excellence (I 

CARE). Further, all employees were reminded, in addition to demonstration of VA 

I CARE values, failure to adhere to ethical, legal, and/or professional standards of 

conduct may be considered as factors when evaluating performance. 

There is not a simple definition of a ‘‘fireable offense.’’ A decision to terminate an 

individual is informed by several factors including, but not limited to, (1) the seriousness of the offense; (2) whether the offense was malicious or done for personal 

gain; (3) whether alternative sanctions would work; and (4) whether or not the employee is otherwise salvageable. Typically, if an employee otherwise has a clean disVerDate Mar 15 2010 16:05 Jul 30, 2015 Jkt 000000 PO 00000 Frm 00108 Fmt 6633 Sfmt 6621 Z:\ACTIVE\090914.TXT PAULIN
105 

ciplinary record, such an employee would have to commit an egregious act of misconduct in order to be removed on his/her first offense. Serious offenses often involve 

breaches of institutional values. 

Regarding the new authorities provided in the Choice Act, VA has developed a 

new policy codifying the process by which the Secretary will determine when a Senior Executive Service (SES) employee’s performance or misconduct warrants removal 

or transfer to a non-SES position. 

• The new policy will give the employee five business days to review and reply 

to the evidence and charges supporting the removal. • VA’s policy requires that a removal or transfer for misconduct or poor performance be supported by substantial evidence. The Merit Systems Protection Board will 

review any appeals against the higher standard of a preponderance of the evidence. 

The lengthier historic process will still apply to all disciplinary actions taken 

against SES employees other than removal or transfer to a GS position. 

Question 23. Is the fact that senior officials at the Phoenix VA were placed on 

paid administrative leave prior to Congress passing the Choice Act prohibiting you 

from using the provisions contained in the Choice Act to remove them? 

Response. It should be noted that the Choice Act provisions apply only to Senior 

Executives, not to non-Senior Executive Service leaders. The Medical Center Director is the only Senior Executive among the Phoenix VAMC leadership team. The 

fact that a Senior Executive was placed on paid administrative leave prior to enactment of the Choice Act should not preclude a removal action being taken under that 

authority. 

Question 24. The use of unofficial waiting lists was a prevalent practice at the 

Phoenix VA and has proven to be a systemic problem across the VA. What are you 

doing to ensure that this sort of problem does not happen again? 

Response. The use of an unofficial wait list is not an acceptable practice. To ensure this problem is corrected, the Veterans Health Administration (VHA) provided 

immediate remedial training to 9,000 key staff from all networks in July and August 2014. This training reinforces the appropriate policies and processes associated 

with scheduling patients. Likewise, VHA is designing a clinic manager training program which is scheduled to begin in early 2015 that will include training on appropriate use of the Electronic Wait List (EWL). To ensure the integrity of the access 

data in the input stage, VA recently launched an automated access and scheduling 

audit tool designed to monitor and flag any potential data integrity issues. This tool 

is programed with a preset algorithm, designed by scheduling subject matter experts 

that will score scheduling practices at each facility and clinic and highlight those 

clinics that require additional follow-up. This tool is available for use by each medical center and Veterans Integrated Service Network (VISN) leadership team. This 

tool is also being routinely monitored in VHA Central Office by a national monitoring group and the VHA senior leadership team. 

Additionally, VA has eliminated the unrealistic 14-day access measure from all 

employees on the Executive Career Field Performance Plan, Title 5 Performance Appraisal Program, and the Title 38 Proficiency Rating System. This action will eliminate incentives to engage in inappropriate scheduling practices or behaviors. To reinforce these measures, Medical Center and VISN Directors are conducting in-person visits to all of their assigned facilities. These in-person site inspections include 

observing daily scheduling processes and interacting with scheduling staff to ensure 

all scheduling practices are appropriate and allowing front line staff to provide 

unfiltered feedback directly to the facility’s and VISN’s senior leadership team. 

Question 25. Within the Phoenix VA, a number of medical areas where identified 

as being deficient. Mental health and psychotherapy where specifically mentioned. 

What has been done to correct this problem and ensure continuity of care and increased access to providers? 

Response. As stated in the OIG report, Mental Health leadership had been addressing these issues at the time of the OIG visit in April—May 2014. The new 

Chief of Psychiatry successfully recruited 13 additional mental health-prescribing 

clinicians to the facility within a seven-month period. He has also begun reorganizing the service. The influx in new psychiatrists has provided an ability to assign 

patients to a mental health provider and an availability of new and established patient appointments. 

As of early June 2014, Psychology leadership reported 11 vacancies for which 9 

candidates had been selected and were pending offer acceptance, credentialing, 

privileging, and/or on-boarding. As of November 2014, Psychology has eight remaining vacancies; seven of these were new positions added in October 2014 (i.e., only 

one of the positions from June 2014 remains unfilled). Of the remaining eight vacancies, four have been selected and are in the onboarding process, and four have not 

106 

been selected yet. Phoenix VA Health Care System (PVAHCS) has leveraged nonVA care via the TriWest/Patient-Centered Community Care contract to obtain psychotherapy for patients who cannot be seen within 30 days. 

In addition to the increased staff, PVAHCS has concurred with the four recommendations related to this issue which are listed in the OIG Final Report and has 

developed action plans which are available for review in Appendix K of the final 

report. 

Question 26. The OIG report recommended that the VA Secretary direct the Veterans Health Administration to establish a process that requires facility directors 

to notify, through their chain of command, the Under Secretary of Health when 

their facility cannot meet access or quality of care standards. The report indicated 

that VHA has already implemented this recommendation. Since this process has already been implemented, has the VHA had to notify the Under Secretary of any facilities that cannot meet access or quality of care standards? If so, what facilities 

have made such a notification and for what reason? 

Response. Issues related to access no longer solely depend on local leadership raising the concern up through a chain of command. VHA has increased its transparency by making data (described below) available and easily accessible to the public and the entire organization. Transparency of data facilitates timely, honest, and 

open discussion throughout the organization, among leadership peers, among employees, and among Veterans. 

Twice monthly, VHA publishes data on access to care on a public Web site (http:// 

www.va.gov/health/access-audit.asp). Leadership at all levels use the same data to 

determine trends, foretell access shortfalls, and address underlying issues that impede Veterans’ access. These data include: the number of appointments scheduled 

at each facility; the number of requested appointments that are on each facility’s 

EWL; the number of newly enrolled patients who have not yet been scheduled by 

facility; and average wait times for mental health, primary care, and specialty care 

at each facility, for both new and established patients. 

Additionally, VHA publishes a scorecard model for internal quality of care 

benchmarking. The Strategic Analytics for Improvement and Learning (SAIL) Value 

Model assesses 25 quality measures in areas such as mortality, complications, and 

customer satisfaction, as well as overall efficiency. SAIL benchmark tables can be 

found at http://www.hospitalcompare.va.gov/docs/SAILData.pdf 

Question 27. Since 2005, the IG has published 20 reports focused on patient wait 

times and access to care issues. However, VHA has yet to effectively address the 

issues associated with patient wait times, inappropriate scheduling practices, and 

access to care. The IG has, in total, received approximately 225 allegations regarding Phoenix VA and roughly 445 allegations regarding similar issues related to wait 

times at other VA facilities. It appears that this problem has been going on for 9 

years now and VA has continually failed to correct it. What is your plan to effectively resolve this problem once and for all? 

Response. Over the past 9 years, VA has considered and acted upon each of the 

IG’s reports and implemented changes as recommended. However, it was not until 

the System-wide Access Audit, conducted in May 2014, that VHA came to truly understand the full extent of the problem. In retrospect, both the findings contained 

in the OIG reports, and the remedial actions taken by VHA to address those findings, only had limited impact on what we now know was a much larger systemic 

issue. VA has taken immediate steps to address portions of what are believed to be 

the underlying systemic issues. 

In addition to those immediate actions, Secretary McDonald has set a course to 

reshape the organization and reset the culture throughout the Department. This effort will refocus the organization on the Veterans. 

Aided by the thoughtful audits of the OIG, VA will continue to improve its access 

and availability to services for our Nation’s Veterans. Through continuing program 

evaluations VA will, over time, ensure Veterans are receiving the care they have 

earned when, where and in the manner they desire. 

Question 28. I am pleased to see that VA is aggressively recruiting new health 

care professionals in order to meet the needs of our veterans. However, I remain 

concerned that VA is not utilizing existing health care professionals in an efficient 

manner. Physicians in the private sector consistently have higher caseloads than VA 

physicians and more efficiently utilize nurses and physician assistants. Simply put, 

a veteran does not need to see a doctor for every health care need; nurses and physician assistants have the training and expertise to address many heath issues which 

allows physicians to focus on more serious and complex matters. What is the VA 

doing to ensure that all the health care professionals employed by VA are being utilized to the maximum extent practicable? 

107 

Response. VHA overhauled the primary care model in 2010 to emphasize teambased care, called Patient Aligned Care Teams (PACT), focusing on a teamlet (which 

includes a provider, registered nurse, medical assistant (typically licensed practical 

nurse or health technician) and clerical associate (typically a scheduling assistant)). 

In addition, most PACT’s also have a clinical pharmacist, social worker, dietitian, 

and/or behavioral therapist available to provide assistance. This focus on teambased care allows, among other things, a distribution of workload among the whole 

team to ‘‘share the care.’’ This emphasis has been associated with increased utilization of telephone care and secure messaging as non-provider team members play important roles in patient care. VA is expanding primary care capacity by adding new 

PACTs, focusing on team-based care, and utilizing all staff in a manner that optimizes their capabilities. 

Question 29. Secretary McDonald, a number of the senior positions within VA are 

being filled by personnel in an ‘‘acting’’ status. Mr. Griffin for example is the Acting 

Inspector General. Is this problematic? Do you foresee this creating problems in implementing the Choice Act? 

Response. VA follows a formal process for placing an individual into an ‘‘Acting’’ 

role. Typically there is a request with justification provided for why a position must 

be filled in this manner and why this is the most appropriate person to fill this role. 

There is a defined time limit prescribed and finally there are a number of senior 

level personnel who will review and eventually approve this request. 

The point of appointing ‘‘Acting’’ individuals into any given position is to ensure 

continuity of on-going day-to-day operations. The designation of individuals as ‘‘Acting’’ is needed to ensure someone is performing the duties and overseeing the activities of the organization or operational unit that is temporarily lacking permanent 

leadership. The length of time an individual is designated as ‘‘Acting’’ varies, and 

often cannot be predicted. For example, a person may be designated as ‘‘Acting’’ in 

a leadership position while recruitment is ongoing, the incumbent may be temporarily absent while on a rotational assignment in response to critical Departmental 

needs in an alternate location or position; on a developmental assignment, experiencing long-term medical issues, or similar issue. Ensuring leadership is in place 

to see to the day-to-day activities of an organization or operational unit supports 

rather than harms the Department’s ability to implement the Choice Act. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. RICHARD BURR ON BEHALF OF HON. JEFF FLAKE TO HON. ROBERT A. MCDONALD, SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 30. During your confirmation hearing on July 22, 2014, you stated that 

you intended to travel the Nation to meet with veterans and staff at various VA 

facilities across the country. 

a. Have there been any significant takeaways from these visits? 

Response. The Secretary continues to travel to various Department of Veterans 

Affairs’ (VA) facilities to meet with Veterans, the VA workforce (including whistleblowers), and other stakeholder groups including local leadership from Veterans 

Service Organizations, our Union partners, Congressional members and staff, and 

media. As he has publicly stated at each visit, we must regain the trust of Veterans 

and other stakeholders, improve service delivery, and set the course for longer term 

excellence and reform. He has also asked employees to reaffirm their commitment 

to VA’s mission and core values (I CARE: Integrity, Commitment, Advocacy, Respect, and Excellence). 

At each visit, the Secretary has found that the overwhelming majority of the VA 

workforce is dedicated to serving Veterans, and cares deeply about the VA mission. 

He has made it clear that each member of the workforce is critical to identifying 

barriers and improving service delivery, and that he welcomes all constructive 

input, including that of whistleblowers, who seek to improve service to Veterans. 

The Secretary has also found the Town Halls with Veterans and other stakeholders extremely valuable in restoring trust and communication. He originally directed all VA health care and benefits facilities to hold a Town Hall event by the 

end of September 2014 to improve communication with, and hear directly from, Veterans nationwide. Congressional and state representatives, as well as other stakeholders from these areas were invited to attend. He has since directed these Town 

Halls be held quarterly. 

Finally, the Secretary has also met with local VA leadership during each site visit. 

Many have identified local barriers and other challenges to improving service. The 

issues raised at these meetings, together with others, are being both assessed and 

addressed as quickly as possible. VA is aggressively implementing its Accelerated 

108 

Access to Care Initiative and the provisions of the Veterans Access, Choice, and Accountability Act of 2014 (Choice Act). The Secretary also initiated a national effort 

to recruit medical professionals into VA to address staffing shortages. 

b. Do you believe that the recommendations provided by OIG go far enough in 

addressing some of the systemic issues plaguing the VA? 

Response. VA greatly appreciates and supports the Office of Inspector General’s 

(OIG) extensive ongoing efforts to identify systemic barriers to the access and highquality care that the Nation’s Veterans have earned and deserve. OIG continues to 

review wait time and scheduling issues at a large number of Veterans Health Administration (VHA) facilities, and the Department will fully consider their recommendations. 

In addition to the OIG’s recommendations, the Department will receive input from 

other reviews such as those required by Choice Act. The Department has also conducted various internal reviews. 

This collection of insights has, and will continue to provide, VA with important 

feedback as it addresses systemic issues related to access and care shortfalls. VA 

is committed to restoring the trust of Veterans and other stakeholders, and to improving access to high-quality care. Comprehensive action is underway. 

Question 31. This OIG report lists 24 recommendations aimed at improving the 

quality of care for veterans. The VA has since concurred with all of these recommendations and vowed to implement them. However, as cited in this report and elsewhere, OIG notified the Veterans Health Administration (VHA) in 2012 that staff 

at PVAHCS was not complying with VHA scheduling policies. 

a. Although the VA has known for some time about inappropriate scheduling 

practices at facilities across the country, the problem has yet to be remedied. Are 

you confident that the VA will successfully implement the reforms outlined by OIG? 

Response. VA has concurred with all recommendations and is working hard to implement the reforms outlined by OIG. VA will make every attempt to fully and successfully implement all reforms outlined by OIG. At the same time it is important 

to understand that scheduling appointments requires human interactions that can 

be subject to error. Even with the best reforms VA cannot guarantee that all instances of appointment scheduling will be error-free. 

b. Are there any reforms that you believe are necessary but where omitted by the 

OIG report? 

Response. OIG did a thorough job of making recommendations. In the course of 

following the recommendations, VA will make every attempt to write clear and comprehensive policy, design effective training, and implement oversight that complies 

with OIG recommendations. 

Question 32. As you know, the Veterans Access, Choice, and Accountability Act 

of 2014 was recently passed by Congress and signed into law by the president. 

Among other things, the purpose of this legislation is to provide the VA with increased latitude to remove agency employees when necessary. 

a. Do you believe that this legislation provides the VA with adequate authority 

to remove underperforming employees? 

Response. VA notes this law only applies to Senior Executive Service employees, 

which constitute less than 1 percent of VA’s workforce. One of the goals of the Senior Executive Service is to ensure accountability for efficient and effective government. This is achieved by holding senior executives accountable for their individual 

and organizational performance through an effective and rigorous performance appraisal program, as well as taking immediate steps to address performance or conduct issues. This legislation provides that authority. While VA previously had authorities to take action to hold employees and executives accountable for performance or misconduct, the amendments will strengthen or enhance those authorities. 

b. Will the added hiring and firing flexibility enable the VA to significantly improve the quality of care that it delivers to veterans? 

Response. Removing Senior Executives who are not performing as expected by the 

Secretary will ultimately be a benefit to Veterans and the delivery of care. Added 

hiring flexibilities will allow the VA to have the necessary staffing required to improve the quality of care delivered to Veterans. 

109 

RESPONSE TO ADDITIONAL POSTHEARING QUESTIONS SUBMITTED BY HON. RICHARD

BLUMENTHAL TO HON. ROBERT A. MCDONALD, SECRETARY, U.S. DEPARTMENT OF

VETERANS AFFAIRS

FUNDING TO HIRE ADDITIONAL VA HEALTH CARE PROVIDERS

I participated in a VA Town Hall Meeting in Newington, Connecticut, along with 

William Streitberger, the Director the Hartford VA Regional Office, and Gerald F. 

Culliton, the Director of the VA Connecticut Healthcare System. This Town Hall offered Connecticut veterans, family members and constituents the opportunity to 

provide the VA with feedback and recommendations on local operations and programs. 

During the Town Hall, we heard from K. Robert Lewis, a Veterans’ Service Officer 

from the Veterans of Foreign Wars. He shared with the audience his understanding 

that many veterans with the VFW have received outstanding service from Connecticut VA facilities, but that the lack of providers remains a pervasive challenge 

that has hindered our veterans’ access to care. I know that the Veterans Access to 

Care Act authorized $5 billion to enable the VA to hire additional health care providers and clinical staff as well as provide enhanced incentives to attract more 

health care professionals to the VA. 

Question 33. Secretary McDonald, how will you implement this funding to demonstrate your continued commitment to hiring new physicians, nurses and staff to 

address these challenges? What, if anything, is the impediment to hiring mental 

health professionals and how can we ensure that our veterans receive the mental 

health assistance they require? 

a. How will you implement this funding to demonstrate your continued commitment to hiring new physicians, nurses and staff to address these challenges? 

Response. The Office of Finance will distribute the available funding per the implementation plan associated with individual medical center staffing needs. 

b. What, if anything, is the impediment to hiring mental health professionals and 

how can we ensure that our veterans receive the mental health assistance they 

require? 

Response. In order to provide Veterans with the services they need and desire to 

aid in recovery from mental health issues, the Department of Veterans Affairs (VA) 

must have access to the appropriate number of mental health professionals who can 

deliver their services to sites where the Veterans want to receive their care. A significant challenge in meeting the needs of Veterans is the rapid growth rate in demands for mental health services. Between 2005 and 2013, the number of Veterans 

who received mental health care from VA grew by 63 percent, over three times the 

rate of increase seen in the overall number of VA users (Figure 1). As a consequence, the proportion of Veterans receiving mental health services has increased 

from 19 percent in 2005 to 26 percent in 2013. The growth in the number of mental 

health encounters or treatment visits has been even more dramatic; mental health 

encounters have increased from 10.5 million in 2005 to 18.0 million in 2013—a 71- 

percent increase. 

Figure 1. Percent growth since 2005 in numbers of Veterans using VA mental 

health services and VA health care services overall. 


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The recent rapid growth in the number of Veterans seeking mental health treatment in VA has posed challenges in the area of staffing. In Figure 2, the growth 

in numbers of Veterans using mental health services is depicted by the solid line, 

which shows an increase from 897,643 in 2005 to 1,464,700 in 2013. (The number 

of patients is expressed in terms of hundreds in order to show staff and patient 

numbers on the same graph. For example, 10,000 on the vertical axis represents 

1,000,000 patients.) Current projections for future growth show a somewhat slower 

rate than has been experienced over the past decade. 

Figure 2. Growth in annual numbers of patients using mental health services and 

in outpatient and inpatient full-time equivalent staffing levels since 2005. 

This graph also shows the growth in numbers of mental health clinical staff, 

measured in terms of the full-time equivalent (FTE) staff providing outpatient and 

inpatient treatment. Consistent with the increased reliance on outpatient care, the 

inpatient mental health staff FTEs began to level off after 2009. The hiring of outpatient mental health clinical staff grew somewhat faster than mental health patient numbers through 2010 and then began leveling off. A 2012 hiring initiative 

resulted in gains in both inpatient and outpatient staff FTEs. 

Thus, VA has been addressing the need to hire and retain new mental health staff 

to meet new demand for some time. The recent hiring initiative allowed mental 

health staffing growth to keep up with growth in demand. With expected ongoing 

increases in demand, VA will need to keep hiring. However, a focus on the overall 

ratio of mental health staff to Veterans for the entire system does not fully identify 

or address a different and critical issue for VA. Unfortunately, the areas with lower 

availability of mental health professionals often coincide with sites where VA is 

faced with the challenge of meeting high and/or growing Veteran demand. VA is 

working on a variety of mechanisms to meet that hiring challenge including: (1) use 

of recruitment and retention incentives; (2) use of loan repayments; (3) creation of 

a mechanism for higher, overall salaries for VA psychiatrists; and (4) consideration 

of other approaches to recruit and retain necessary staff. VA is also working to expand targeted use of tele-mental health services. 

While VA has been effective, overall, in hiring on a nationwide basis, putting 

those resources to maximum use also depends on having appropriate space in which 

professionals can work. While VA is increasing use of mental health services delivered into the Veteran’s home, use of extended hour clinics (so that available space 

can be more fully used), and use of non-VA care to decrease the impact of restricted 

space, the need for rapid expansion of office and group room space at some sites 

remains. VA is pushing forward with space improvements to address this need. 

Staff must also be appropriately trained and equipped. As staff is hired, plans are 

being made to meet their needs for computers and other supports for modern practice of mental health care. Already, over 6,000 providers have been trained in evidence-based psychotherapy, and VA is exploring ways to expand that training to 

even more clinicians. 


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Finally, VA is looking toward the future by engaging in projects aimed at measuring and predicting capacity for various aspects of care including mental health. 

VA capacity to deliver mental health care refers to the availability of resources required for timely delivery of high-quality mental health services. A work group has 

embarked on a plan to assess and understand the numerous facets of capacity and 

their impact on the delivery of mental health care in a large, complex health care 

system. Continued work will make prediction and management of VA mental health 

capacity more sophisticated in the future. 

Having sufficient staff with sufficient space, equipment, and training does not 

guarantee that Veterans will receive all of the appropriate care they need. VA, 

through the Office of Mental Health Operations (OMHO), Mental Health Services 

and collaborating units, sets policy for care and monitors compliance with those policies. Each year, one-third of facilities are surveyed by a well-trained team of clinical 

experts using a semi-structured interview as well as a review of specific clinical and 

administrative measures that assess access, efficiency, staffing, and other important 

dimensions of mental health service functions. These surveys lead to strategic action 

plans to address any shortcomings in performance or resourcing. Progress on these 

plans is reviewed quarterly by OMHO staff who work in close collaboration with 

Veterans Integrated Service Network (VISN) and local mental health leaders. 

OMHO uses its three program evaluation centers to monitor important metrics, including Veteran and provider satisfaction, in a wide variety of VA Mental Health 

programs. The program evaluation centers have created easily accessible Web sites 

where individual VISNs and facilities can monitor their own performance regularly. 

Finally, VA has created mechanisms by which productivity of providers of various 

disciplines can be monitored at local and higher levels, so that facilities and VISNs 

can take action to optimize the amount of care that is provided by staff. Taken together, these mechanisms provide VA leadership many indications of how the VA 

mental health system is functioning as a whole and at local levels. 

HIRING ADDITIONAL VETERANS

I have additionally spoken to members of my Veterans’ Advisory Council of Connecticut Veterans and community leaders who have concerns regarding VA hiring 

practices. These constituents expressed the difficulties that many qualified Veterans 

encounter in applying for jobs at the VA. I am concerned that VA, which should lead 

the Federal Government, does not hire as many Veterans as it should. 

Question 34. Secretary McDonald, as you move forward to hire new staff for VA 

facilities, what is your operational plan to hire more veterans, specifically members 

of the National Guard and Reserve? 

Response. The percentage of new Veteran hires in government is at its highest 

since the mid-1970s. VA is helping to lead the way in Veteran hiring and now ranks 

second only to the Department of Defense in the number of Veterans in our workforce. As of the end of fiscal year (FY) 2014, we had a total of 113,432 Veterans 

on board, which accounts for 32.66 percent of our workforce. 

With the passage of the Veterans Access, Choice, and Accountability Act of 2014, 

we are executing an extensive recruitment plan to increase access to care through 

the hiring of physicians and other medical staff. This effort calls for VA to hire tens 

of thousands more medical professionals—an ambitious undertaking, especially considering the current nationwide shortage of certain medical professionals. Given the 

scope of this effort, and the often limited supply of Veteran medical professionals, 

VA has determined that we will focus our goal for the percentage of Veterans in 

our workforce to 35 percent by the end of FY 2017. This short-term goal is not only 

attainable and realistic; we are confident that we can find some of the best and 

brightest Veterans to join our workforce to achieve this hiring goal. Our Veteran 

Employment Services Office (VESO) will work collaboratively with our Administrations and Staff Offices to meet this hiring goal. In October, VESO participated in 

30 Veteran-focused hiring events nationwide, which include several disabled Veteran-specific events and employment briefings for transitioning Servicemembers including National Guard and Reserve forces and attend Yellow Ribbon Program 

events. Our VESO office provides Federal employment services to all Servicemembers and Veterans. We are also actively participating in an inter-agency work 

group focused on increasing our women Veteran population in the Federal workforce 

through targeted strategies. In addition, as a part of the hiring initiative, The Secretary has traveled to several Medical Centers and Medical Schools to recruit medical professionals to join the VA. 

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WEST HAVEN VA

Many Connecticut veterans who utilize the West Haven VA facilities are pleased 

with the quality of care they receive and hope to maintain access to that level of 

care, even while capacity is expanded. The West Haven medical facilities must have 

the funding to make necessary upgrades in infrastructure and capacity to build 

more facilities and ensure that it can keep pace with the needs of Veterans, especially female Veterans. 

Question 35. Secretary McDonald, how do you plan to bring the West Haven facilities into the 21st century and will you ensure that the West Haven facility is not 

overlooked in capital improvements? 

Response. VA Connecticut Health Care System (VACTHCS) is actively using the 

strategic planning process to identify and prioritizing critical infrastructure reinvestment needs of its campuses in West Haven (WH) and Newington (NEW). In support of this initiative, VISN 1 is in the process of completing a VISN-wide master 

plan that is intended to help facilitate better planning and utilize all capital solutions to ensure Veterans needs are met. 

The plan includes both short range and long range initiatives to address the needs 

of the Veterans as well as the required infrastructure improvements that support 

the mission. Below are some of the projects and initiatives VA is currently pursing. 

This list will change as new issues arise and new requirements are encountered. 

In addition to the planned project work, VACTHCS continues to improve its infrastructure and space through the active construction and maintenance. Many new 

improvements, repairs, renovations were successfully accomplished this past year. 

Projects in process 

• Infrastructure upgrades 

– Boiler and Domestic Water improvements 689–12–052 (WH)—Replaces antiquated water pumps. 

– Replace 120,000 Gallon Oil Tank 689–14–101 (WH)—Replaces current oil 

tank that has corrosion issues.2 

– 010 Boiler Corrections 689–10–213 (WH)—Corrects safety deficiencies and 

compliance issues. 

– Replace Load Center 1A, 689–13–151 (WH)—Replacement of electrical load 

center which supplies the facility main electrical feed. 

– Electrical Control Systems upgrade, 689–13–155 (WH)—Upgrades to existing 

electrical systems. 

– Replace Load Center 2&5, 689–13–154 (WH)—Replacement of electrical load 

centers in poor condition. 

– Building Envelope Repairs B1 & 2, 689–12–202 (WH)—Corrects water infiltrations through windows that are in urgent need of replacement. 

– Supply Backup Power for Buildings 3, 4, 5, 27 & 34, 689–13–150 (WH)—Installation of emergency generator power feeds. 

– Building 36 Structural Corrections, 689–12–001 (WH)—Repair structural deficiencies in Bldg. 36. 

– Replace Roofs B35, 35A & 36, 689–12–120, (WH)—Replaces roofs 

– Building 27 & 34 Heating, Ventilation and Air Conditioning Corrections, 

689–14–002, (WH)—Current unit has exceeded its useful life. 

– OR Heating, Ventilation, and Air Conditioning, 689–10–121 (WH)—replaces 

deteriorating Operating Suite HVAC components. 

– Correct Electrical Deficiencies Phase 2, Veterans Health Administration– 

689A4–2013–10500, (WH)—Corrects deficiencies and installs back up separation 

requirements. 

– (Approved and in design or pending construction) Expand Primary Care Clinic, 689–402, (NEW)—This project will add a single level addition to the northwest corner of Building 2E and renovate the first floor of Building 2C to accommodate the expansion of the Primary Care Clinic by approximately 9,691 square 

feet. 

– In-Patient Unit Rehabilitation, 689–12–102, (WH)—This project will completely renovate an existing outdated medical/surgery ward in building 1, 4th 

floor, east side. 

– Psych Emergency Department (ED) Expansion, 689–390, (WH)—Project will 

add an approximately 12,000 square feet addition adjacent to the existing Medical ED and renovate 1200 additional square feet. 

– Replacements of high tech/high cost equipment and upgrades to Catherization Lab, X-Ray, and Computed Tomography Scanners. 

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Projects identified through the planning process for future implementation as funding allows: 

• Infrastructure upgrades 

– Electrical Deficiencies Phase 2, (WH)—Addresses deficiencies (Arc flash condition) identified in electrical study. 

– Chiller Plant (WH)—Address undersized and antiquated chilled water distribution system feeding the campus. 

– Elevator Replacements, (WH/NEW)—This project will address outdated and 

aging elevators systems. 

– Replace Roofs B1, 2, 11, 12, 15 & 16—NEW B6, 7 & 8 

– SPS Air Handler Replacement, (WH)—Corrects environmental conditions in 

the Sterile Processing Service. 

– Water Treatment System, (WH/NEW)—This project will help address the 

aging pipes and plumbing systems throughout VACTHCS and activate a water 

treatment system. 

– Correct and Upgrade Exterior, PH1 689A4–12–211, (NEW)—Corrects building envelope fac ̧ade which is compromised and causing water infiltration. 

– Domestic Water and Sanitary Main Pipe Replacements, (WH)—Replaces 

aging pipes and corrects deficiencies. 

• Patient/Safety/Environmental upgrades 

– Surgical Core (WH)—the project consolidates the operating room and other 

surgical and related services such as the sterile processing service and patient 

acute care unit. 

– Parking Garage (WH)—Design and construction for a 409 car parking garage. Project will greatly enhance access to care due to inadequate parking 

spaces. 

– Nursing Home—Conceptual project to address the lack of community living 

center beds. Project would greatly enhance access and quality of care. 

RESPONSE TO ADDITIONAL POSTHEARING QUESTIONS SUBMITTED BY HON. JOHN

BOOZMAN TO HON. ROBERT A. MCDONALD, SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 36. The VA IG report details the death of a number of veterans. Has 

VA done anything to assist and support the surviving spouses and families of veterans whose deaths were reported by the IG? More specifically, have these spouses 

and family members received counseling from the VA about any benefits that they 

may be entitled to? 

Response. The Phoenix Regional Office has attempted to contact all next of kin 

of deceased Veterans identified in the OIG Report. The Regional Office provided 

benefits information to the individuals it was able to reach and answered additional 

benefits-related questions. 

Question 37. At the macrolevel, does VA have a system in place to advise surviving spouses and family members of whether they qualify for benefits and to assist in filing for such benefits? Especially veterans who are in the care of the VA 

at the time of death? If a veteran is terminally ill and receiving end of life care from 

the VA, does the VA proactively provide assistance to the spouse/family of that veteran to help prepare them once their loved one passes? 

Response. VBA’s Pension and Fiduciary Service and regional offices’ Public Contact employees work closely with the Veterans Health Administration and other 

stakeholders to conduct outreach for survivors and ensure they are aware of benefits 

they may be eligible to receive. Survivors can access information on VBA benefits 

by contacting VBA call center agents at 1–800–827–1000, by appearing in person 

at a VA regional office, or by mailing or emailing a request for information or assistance to VBA. VBA’s call center agents and public contact employees are trained to 

provide one-on-one guidance to survivors to help them understand their benefits and 

assist them through the process of submitting a claim for benefits. Spouses of Veterans who are under care in one of VA’s medical facilities may contact the facility’s 

Office of Decedent Affairs, which also works closely with the family to assist with 

benefits and guide them through the process. 

VBA has developed fact sheets detailing its benefit programs to assist Veterans 

and their family members. These fact sheets include survivor’s benefits and application instructions, and are available at http://www.benefits.va.gov/BENEFITS/factsheets.asp. In addition, VBA has taken steps to automate the payment of certain 

benefits to survivors (Veteran’s benefit payment for the month of death, burial allowance, and some dependency and indemnity compensation) when it receives notice 

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of a Veteran’s death. This automation ensures that survivors receive the benefits 

they need as quickly as possible during the difficult time that follows a Veteran’s 

death. 

Chairman SANDERS. Mr. Secretary, Dr. Clancy, thank you very 

much for being with us. Thank you for the hard work that you are 

putting in right now and for the changes that we are seeing. 

This hearing is now adjourned. 

[Whereupon, at 12:35 p.m., the hearing was adjourned.] 

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