Report No. 09-01348-49 December 14, 2009

Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Delay in Cancer Diagnosis and Treatment 

Clement J. Zablocki VA Medical Center 

Milwaukee, Wisconsin 

VA Office of Inspector General 

Washington, DC 20420 
 

 

 

To Report Suspected Wrongdoing in VA Programs and Operations 

Telephone: 1-800-488-8244 between 8:30AM and 4PM Eastern Time,

 Monday through Friday, excluding Federal holidays

 E-Mail: vaoighotline@va.gov 
Delay in Cancer Diagnosis and Treatment, Clement J. Zablocki VAMC, Milwaukee, WI 

Executive Summary 

The VA Office of Inspector General conducted an inspection at the Clement J. Zablocki 

VA Medical Center in Milwaukee, Wisconsin, after receiving a complaint regarding 

delays in cancer diagnosis and treatment. The purpose of the inspection was to determine 

the validity of the allegations. 

A complainant alleged that a radiologist failed to identify a pulmonary nodule. The 

complainant further alleged that a subsequent imaging report provided inaccurate 

information; also, it was alleged that medical center staff did not inform the patient of the 

abnormal test result. 

We substantiated that there was a delay in cancer diagnosis and treatment because a 

radiologist failed to identify a pulmonary nodule. In addition, the radiologist who noted 

the nodule on a subsequent imaging study failed to follow medical center policy for 

reporting abnormal results; the primary care provider also neglected to follow up on the 

test. These errors resulted in a 5-month lapse between the identification of the 

abnormality and initiation of a treatment plan. Thirteen months elapsed from the time the 

lung abnormality was apparent to the initiation of definitive therapy. 

We substantiated that medical center staff initially failed to inform the patient of the 

adverse event. However, after becoming aware of the abnormal imaging study, the 

primary physician discussed it with the patient. Medical center managers were unaware 

that action had not been taken in response to the abnormal test result. 

We recommended that medical center managers conduct a formal peer review and root 

cause analysis of all activities involving the care of the identified patient from the time of 

the imaging study on which the pertinent abnormality was present. We recommended 

that staff adhere to Veterans Health Administration and local incident reporting and 

adverse event disclosure policies and procedures. We also recommended that the senior 

managers consult Regional Counsel regarding disclosure to the family and explanation of 

rights. 

Management agreed with the findings and recommendations and provided acceptable 

improvement plans. We will follow up on the planned actions until they are completed. 

VA Office of Inspector General i 
VA Office of Inspector General 1 

DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

TO: Director, VA Great Lakes Health Care System (10N12) 

SUBJECT: Healthcare Inspection – Alleged Delay in Cancer Diagnosis and 

Treatment, Clement J. Zablocki VA Medical Center, Milwaukee, 

Wisconsin 

Purpose 

The VA Office of Inspector General (OIG), Office of Healthcare Inspections reviewed 

allegations that providers at the Clement J. Zablocki VA Medical Center (the medical 

center), Milwaukee, WI, delayed a patient’s cancer diagnosis and treatment and that this 

adverse event was not disclosed to the patient. The purpose of the inspection was to 

determine the validity of the allegations. 

Background 

Located in Milwaukee, WI, the medical center is part of Veterans Integrated Service 

Network (VISN) 12 and provides primary, secondary, and tertiary care. The medical 

center has 180 acute care, 113 community living center, and 356 domiciliary beds. The 

medical center has four community based outpatient clinics in Appleton, Cleveland, 

Green Bay, and Union Grove, WI, and provides services to a veteran population of about 

320,000 in southeastern and central Wisconsin. 

A complainant alleged that a radiologist failed to identify and report the presence of a left 

lower lobe (LLL) pulmonary nodule1

 on an abdominal computed tomography (CT) scan, 

causing a delay in cancer diagnosis. The complainant also alleged that a subsequent 

imaging report provided inaccurate information, describing the pulmonary abnormality as 

“new.” The complainant further alleged that medical center staff did not inform the 

patient of the adverse event. 

 

1

 A small mass of cells or tissue which might be a normal part of the body or an abnormal growth such as a tumor. 
Delay in Cancer Diagnosis and Treatment, Clement J. Zablocki VAMC, Milwaukee, WI 

VA Office of Inspector General 2 

Scope and Methodology 

We conducted a telephone interview with the complainant and conducted a site visit at 

the medical center. We interviewed radiologists, the patient’s primary physician, acting 

quality manager, risk manager, and other medical center staff. We reviewed the patient’s 

medical record, local clinical and administrative policies, Radiology Service standard 

operating procedures and quality management data, and Veterans Health Administration 

(VHA) policies and procedures. 

We conducted the inspection in accordance with Quality Standards for Inspections

published by the President’s Council on Integrity and Efficiency.

Case Summary 

This elderly patient had an extensive medical history that included cancer of the larynx 

and skin, cerebral infarction, hypertension, hypothyroidism, hyperlipidemia, hernias, and 

eye disorders. The patient’s surgical history included: 

• Total laryngectomy2

 (1993) 

• Eye lid surgery (1999, 2002, 2008) 

• Inguinal and umbilical hernia repair (2008) 

The patient had abnormal chest radiographs dating from 1984. Following is a summary 

of pertinent events in the patient’s clinical course, including chest imaging studies. 

Following total laryngectomy, the patient completed radiation treatment and received 

outpatient care at the medical center. Physicians ordered chest x-rays each year from 

1993 through 1997. Chest x-rays completed in 1993 and 1994 showed densities in the 

left lung fields; x-rays completed in 1995 and 1996 showed chronic pulmonary disease; 

and the x-ray completed in 1997 showed fibro-atelectatic3

 changes. In May 1999, a 

radiologist identified pulmonary fibrotic changes on a chest x-ray and reported that the 

chest was otherwise stable and free of active disease. 

Chest x-rays completed in 2000, 2001, and 2002 show scarring in both lungs, density in 

the LLL, and left lung calcifications, respectively. The following year a radiologist noted 

left pleural calcification with no evidence of active pulmonary disease. 

A CT in 2004 indicated multifocal calcified pleural plaques related to asbestos exposure, 

with no pulmonary nodules noted. A May 2006 chest x-ray showed patchy densities in 

the left lung base. The radiologist noted tiny densities throughout both lung fields and 

that a pleural calcification or plaque could not be ruled out. The August 2007 chest x-ray 

 

2

 Surgical removal of the structure of muscle and cartilage that contains the vocal cords. 

3

 Scarring or thickening of the lung and collapse of airways. 
Delay in Cancer Diagnosis and Treatment, Clement J. Zablocki VAMC, Milwaukee, WI 

VA Office of Inspector General 3 

revealed stable left pleuroparenchymal4 scarring with unchanged bilateral apical fibrotic 

changes, but a September chest x-ray showed a small opacity in the left lung base in 

addition to overlying calcified pleural plaques. The x-ray also indicated minimal 

atelectasis5

 of the left lung base. 

In December 2007, a physician admitted the patient to the medical center with 

gastrointestinal bleeding and ordered a chest x-ray prior to colonoscopy.6

 The chest xray showed stable left pleural calcification and CT of the abdomen was interpreted as 

showing calcified pleural plaques in the lower hemithorax.7

 Physicians diagnosed severe 

diverticulosis8

 as the cause of the gastrointestinal bleeding. The patient’s condition 

improved and he was discharged home. 

In March 2008 the patient reported to the medical center for preoperative evaluation prior 

to inguinal and umbilical hernia surgery. A chest x-ray showed a round opacity in the 

left base that appeared more pronounced than in August 2007. The radiologist also 

described calcified pleural plaques at the left lung base. The primary physician and 

radiologist discussed the results and scheduled a follow-up positron emission tomography 

(PET) scan.9

On an April 2008 PET scan, the radiologist identified a new LLL pulmonary nodule with 

no regional lymph node involvement or distant metastasis. Ten days later, a general 

surgeon informed the patient of the nodule and suggested that it might be malignant. The 

surgeon also informed the patient that additional studies might be required. However, the 

patient decided to proceed with surgical repair of the hernias as scheduled. The patient’s 

condition remained stable after surgery, and he was discharged home. During a routine 

follow-up appointment in early May, a radiation oncologist documented that “the patient 

had done well” and there was no evidence of disease recurrence for 15 years. In late 

May, a medical resident documented that the patient had been doing “well” since the 

repair of the hernias and noted that the patient’s lungs were clear with good inspirations 

with “no wheezes, rales, or ronchi.” However, the medical resident did not document 

knowledge of or discussion with the patient regarding the April 2008 abnormal chest PET 

scan. 

In July, the patient reported to the medical center for outpatient clinic appointments. On 

a July chest x-ray, a radiologist found no significant change in the rounded opacity in the 

left lung base; this radiologist selected the March chest x-ray and the April chest PET 

scan for comparison. 

 

4

 Anatomical element essential for proper functioning of the membrane of the lungs. 5

 Collapse. 

6

 Diagnostic procedure that uses a scope for visualization of the colon. 7

 One side of the chest. 8

 Abnormal bulging (out pouching) of tissue in the bowel. 9

 Imaging technique which produces a 3-dimensional image or picture of functional processes in the body. 
Delay in Cancer Diagnosis and Treatment, Clement J. Zablocki VAMC, Milwaukee, WI 

VA Office of Inspector General 4 

In September 2008, the patient reported to the medical center for an outpatient clinic 

visit. At that time, a medical resident and the primary physician ordered a chest CT scan 

and submitted a consultation request to the Cardiothoracic Surgery Service. 

In October 2008, the patient underwent left eyelid surgery. A chest CT scan performed 

November 3 revealed that the LLL pulmonary nodule had increased in size since the prior 

two studies and that there were new abnormal lymph nodes. Bronchoscopy showed no 

definitive evidence of malignancy, but a CT guided needle biopsy was positive for 

squamous cell cancer. 

In early January 2009, an oncologist documented that the patient was not a candidate for 

surgery or chemotherapy because of “advanced age and performance status,” and referred 

the patient to Radiation Oncology. In mid January, a radiation oncologist discussed a 

treatment plan with the patient and early in February the patient was admitted to the 

Palliative Care Unit to begin radiation therapy, 5 days per week, for 34 treatments. 

In mid March, during the course of radiation therapy, the patient developed a cough with 

phlegm.10 The physician ordered a chest x-ray for possible pneumonia. The chest x-ray 

indicated that the known left retrocardiac opacity appeared stable. 

The patient received his last radiation treatment in late March and was discharged home 

the next day. An oncologist reported that the patient tolerated all treatments “well.” 

Throughout April the patient reported to the medical center for outpatient appointments 

and imaging procedures. Although the patient’s clinical course remained uneventful, he 

died at home in early May 2009. 

Inspection Results 

Issue 1: Delay in Cancer Diagnosis and Treatment 

We substantiated that there was a delay in cancer diagnosis and treatment. 

Failure to Identify Lung Nodule 

A radiologist failed to identify a LLL pulmonary nodule on abdominal CT scan. In 

December 2007, a physician ordered an abdominal CT to evaluate an inguinal hernia 

prior to colonoscopy. The interpreting radiologist described calcified pleural plaques. 

Upon notification of an OIG review, the same radiologist revisited the abdominal CT 

scan and acknowledged the presence of the LLL pulmonary nodule. In addition, the 

radiologist requested that a colleague assess the same radiograph. 

Unlike VHA’s 3-tier peer review rating levels, the medical center’s peer review form 

included 4 tiers for reviewer interpretation: 

 

10 Thick mucus secreted by the walls of the respiratory passages. 
Delay in Cancer Diagnosis and Treatment, Clement J. Zablocki VAMC, Milwaukee, WI 

1. Interpretation acceptable; reviewer comfortable with the interpretation. 

2. Interpretation varies slightly, but not unexpected; reviewer still comfortable 

with interpretation. 

3. Interpretation varies moderately; reviewer uncomfortable with interpretation, 

which might adversely affect patient condition. 

4. Interpretation varies significantly; reviewer very uncomfortable with 

interpretation, which probably would adversely affect patient condition. 

Levels 2–4 include subsections to allow the reviewer to submit additional comments. 

The supervisory radiologist reported that the medical center form for peer review follows 

guidelines of the American College of Radiology (ACR). The ACR scoring for peer 

review includes the following levels: 

1. Concur with interpretation. 

2. Discrepancy in interpretation/not ordinarily expected to be made 

(understandable miss). 

3. Discrepancy in interpretation/should be made most of the time. 

4. Discrepancy in interpretation/should be made almost every time 

(misinterpretation of findings). 

The ACR recommends that peer review scores of 3 and 4 be sent for internal arbitration, 

for example, review by the Chair or Medical Director or Quality Assurance Committee. 

The supervisory radiologist reported that he did not inform medical center managers of 

the peer review or the reviewer’s interpretation of the December 2007 abdominal CT 

scan. 

During the onsite interviews, a supervisory radiologist reported that the Radiology 

Service recently instituted a quality improvement program that requires a second reading 

of randomly selected radiographs. 

Failure to Follow Up and Failure to Notify 

The primary physician did not follow up on an abnormal chest PET scan. On the April 

2008 PET scan, a radiologist identified a new LLL pulmonary nodule. Medical center 

policy requires that if a radiograph reveals a significant new abnormality, the radiologist 

must contact the ordering (referring) physician immediately and submit an electronic 

notification. Medical center policy also requires that unexpected radiologic findings or 

those requiring immediate medical attention be directly communicated (personally or by 

telephone) to the referring physician or surrogate. The communication must be 

VA Office of Inspector General 5 
Delay in Cancer Diagnosis and Treatment, Clement J. Zablocki VAMC, Milwaukee, WI 

documented in the radiology report with the date, time, and name of the person who 

received the results. The supervisory radiologist reported that the radiologist who 

identified the pulmonary nodule on the April 2008 chest PET scan did not submit an 

electronic view alert. The primary physician did not remember receiving a telephone call 

or an electronic view alert regarding the abnormal finding. Additionally, we did not find 

documentation that the referring physician received a telephone call or an electronic view 

alert regarding the abnormal finding. 

We found no documentation that physicians initiated a treatment plan to follow up on the 

abnormal PET scan until late September, when the patient reported to the medical center 

for an outpatient clinic appointment. At that time, physicians consulted the 

Cardiothoracic Surgery Service and ordered a chest CT. The chest CT was completed in 

early November, and the patient underwent diagnostic procedures during November and 

December until the mid December pathology report described squamous cell lung cancer. 

Issue 2: Inaccurate information on Imaging Report 

We substantiated that an imaging report subsequent to the December 2007 abdominal CT 

scan included inaccurate information. In mid-March 2008, a pre-operative chest x-ray 

showed calcified pleural plaques at the left base. The primary physician ordered a chest 

PET scan for additional evaluation of the x-ray report. 

In April 2008, a second radiologist noted a “new” LLL pulmonary nodule on a chest PET 

scan. The radiologist did not reference the December 2007, abdominal CT scan. 

During our onsite interview, the radiologist reported selecting similar radiographs for 

comparison reviews. The radiologist selected three previous chest reports for comparison 

radiographs for the April 1, 2008, chest PET scan. The radiologist did not select the 

December 2007, abdominal CT scan for comparison. However, the same radiologist 

interpreted the November chest CT scan and selected the December 2007 abdominal CT 

scan for comparison. 

Issue 3: Failure to Disclose 

We substantiated that medical center staff failed to disclose the adverse event to the 

patient. Medical center policy defines an adverse event as an untoward incident, 

therapeutic misadventure, iatrogenic injury, or other undesirable occurrence directly 

associated with care or services provided within the jurisdiction of a medical center, 

outpatient clinic, or other VHA facility. This policy also defines examples of adverse 

events that warrant disclosure. These include: 

• Adverse events that have had or are expected to have a clinical effect on the 

patient that is perceptible to either the patient or the health care team. 

• Adverse events that necessitate a change in the patient’s care. 

VA Office of Inspector General 6 
Delay in Cancer Diagnosis and Treatment, Clement J. Zablocki VAMC, Milwaukee, WI 

VA Office of Inspector General 7 

• Adverse events with a known risk of serious future health consequences, even if 

the likelihood of that risk is extremely small. 

VHA11 and local adverse event disclosure policies require forthright and empathetic 

discussion of clinically significant facts between treating clinicians and or other VHA 

personnel and patients and their representatives about the occurrence of an adverse event 

that resulted in patient harm, or could result in harm in the foreseeable future. There was 

no evidence to support that managers were aware of the delay in cancer diagnosis or 

subsequent 5-month delay in formulating a treatment plan as an adverse event. 

Consequently, this information was not disclosed to the patient or family. 

Conclusions 

We substantiated that there was a delay in cancer diagnosis and treatment because a 

radiologist failed to identify a lung nodule on a December 2007 abdominal CT scan. A 

different radiologist noted the nodule on an April imaging study but failed to notify the 

referring physician as required by medical center policy. In addition, the referring 

primary care provider neglected to follow up on the test. These errors resulted in a 5-

month lapse between the identification of the abnormality and initiation of a treatment 

plan. Thirteen months elapsed from the time the lung abnormality was apparent 

(December 2007) to the initiation of definitive therapy (February 2009). 

We substantiated that an imaging report subsequent to the December 2007 abdominal CT 

scan included inaccurate information. The report of the April 2008 chest PET scan, 

described a “new” pulmonary nodule which in fact was present on the December 2007 

abdominal CT scan. 

We substantiated that medical center staff failed to disclose the delays in diagnosis to the 

patient. However, the primary physician discussed the abnormal chest PET finding with 

the patient in September 2008. Medical center managers were unaware of the delay in 

diagnosis and results of radiology peer review. 

Recommendations 

Recommendation 1. We recommended that the VISN Director ensure that the Medical 

Center Director requires a formal peer review and Root Cause Analysis of all activities 

involving care of the identified patient from December 2007 to May 2009.

Recommendation 2. We recommended that the VISN Director ensure that the Medical 

Center Director requires that staff adhere to VHA and local incident reporting and 

adverse event disclosure policies and procedures. 

 

11 VHA Directive 2008-002, Disclosure of Adverse Events to Patients, January 18, 2008. 
Delay in Cancer Diagnosis and Treatment, Clement J. Zablocki VAMC, Milwaukee, WI 

VA Office of Inspector General 8 

Recommendation 3. We recommended that the VISN Director ensure that the Medical 

Center Director consults Regional Counsel regarding disclosure to the family and 

explanation of rights. 

Comments 

The VISN and Medical Center Directors agreed with the findings and recommendations 

and provided acceptable corrective actions. (See Appendixes A and B, pages 9–12, for 

the full text of the Directors’ comments.) We will follow up on the planned actions until 

they are complete. 

 (original signed by:)

JOHN D. DAIGH, JR., M.D. 

Assistant Inspector General for 

Healthcare Inspections 
Delay in Cancer Diagnosis and Treatment, Clement J. Zablocki VAMC, Milwaukee, WI

Appendix A 

VISN Director Comments 

VA Office of Inspector General 9 

Department of 

Veterans Affairs Memorandum

Date: October 8, 2009 

From: Director, Clement J, Zablocki VA Medical Center, 

Milwaukee, Wisconsin (695/00) 

Subject: Healthcare Inspection – Alleged Delay in Cancer Diagnosis and 

Treatment, Clement J. Zablocki VA Medical Center, 

Milwaukee, Wisconsin 

Thru: Director, Management Review Service (10B5) 

To: Director, Chicago and Kansas City Offices of Healthcare 

Inspections (54CH/KC) 

I have reviewed and concur with the attached response from 

the Milwaukee VAMC regarding the above referenced 

healthcare inspection. Thank you. 

VICTORIA BRAHM

 For in the absence of 

JEFFREY A. MURAWSKY, M.D. 
Delay in Cancer Diagnosis and Treatment, Clement J. Zablocki VAMC, Milwaukee, WI

Appendix B 

Medical Center Director Comments 

VA Office of Inspector General 10 

Department of 

Veterans Affairs Memorandum

Date: October 8, 2009 

From: Director, Clement J. Zablocki VA Medical Center (695/00) 

Subject: Healthcare Inspection – Alleged Delay in Cancer Diagnosis and 

Treatment, Clement J. Zablocki VA Medical Center, 

Milwaukee, Wisconsin

To: Director, VA Great Lakes Health Care Network (10N12) 

I concur with the findings and recommendations in the draft report. 

The following corrective actions will be taken in response to the 

recommendations. 

ROBERT H. BELLER 
Delay in Cancer Diagnosis and Treatment, Clement J. Zablocki VAMC, Milwaukee, WI

Director’s Comments 

to Office of Inspector General’s Report 

The following Director’s comments are submitted in response to the 

recommendations in the Office of Inspector General’s report: 

OIG Recommendations

Recommendation 1. We recommended that the VISN Director ensure that 

the Medical Center Director requires a formal peer review and Root Cause 

Analysis of all activities involving care of the identified patient from 

December 2007 to May 2009. 

Concur Target Completion Date: November 20, 2009 

A focused review was performed on the care provided to the identified 

patient by the staff of the Office of Quality Management and Safety. This 

focused review triggered initial formal peer reviews by both 

Hematology/Oncology (on April 29, 2009) and Primary Care (on May 12, 

2009). The peer reviews were discussed at the Peer Review Committee 

meeting on August 3, 2009. As a result of the committee discussion, a 

memorandum was sent from the Chief of Staff (Chairperson of the Peer 

Review Committee) to the Medical Imaging Division Manager on 

August 20 requesting a written review and summary of the identification 

process for flagging abnormal PET scans. In addition, a formal Medical 

Imaging peer review on the services provided to the identified patient was 

requested. This information will be reviewed at the October 5 meeting of 

the Peer Review Committee. In addition, the Medical Center Director has 

required a Root Cause Analysis of all activities involving care of the 

identified patient to be completed no later than November 20. 

Recommendation 2. We recommended that the VISN Director ensure that 

the Medical Center Director requires that staff adhere to VHA and local 

incident reporting and adverse event disclosure policies and procedures. 

Concur Target Completion Date: November 25, 2009 

Specific information, on VHA and local incident reporting and adverse 

event disclosure policies and procedures, is provided to all new employees 

by the Office of Quality Management and Safety at New Employee 

Orientation every 2 weeks and through mandatory annual education for all 

employees. In addition, the Office of Quality Management and Safety will 

VA Office of Inspector General 11 
Delay in Cancer Diagnosis and Treatment, Clement J. Zablocki VAMC, Milwaukee, WI 

VA Office of Inspector General 12 

provide guidelines for all Division and Program Managers to conduct 

additional targeted in-service education in all areas on local incident 

reporting and adverse event disclosure policies and procedures. This 

additional education will be completed by November 25, 2009. 

Recommendation 3. We recommended that the VISN Director ensure that 

the Medical Center Director consults Regional Counsel regarding 

disclosure to the family and explanation of rights.

Concur Target Completion Date: October 22, 2009 

Clinical disclosure has already been provided to the identified patient. The 

Associate Medical Center Director, the Chief of Staff, and the Deputy, 

Office of Quality Management and Safety met with Regional Counsel on 

October 7, 2009. Regional Counsel advised Institutional Disclosure with the 

patient’s family. The patient’s surviving family member (son) was 

contacted on October 7. A meeting to provide Institutional Disclosure was 

scheduled at the family member’s convenience on October 22. 
Delay in Cancer Diagnosis and Treatment, Clement J. Zablocki VAMC, Milwaukee, WI

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Verena Briley-Hudson, MN, RN 

Director, Chicago and Kansas City Offices of Healthcare 

Inspections 

(708) 202-2672 

Acknowledgments Reba B. Ransom, MSN, RN 

Jennifer Reed, RN 

Jerome E. Herbers, Jr., MD 

Paula Chapman, CTRS 

Clarissa Reynolds, LNHA 

Judy Brown 

VA Office of Inspector General 13 
Delay in Cancer Diagnosis and Treatment, Clement J. Zablocki VAMC, Milwaukee, WI 

Appendix D 

VA Office of Inspector General 14 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Great Lakes Health Care Network (10N12) 

Director, Clement J. Zablocki VA Medical Center (695/00) 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senate: Russell D. Feingold, Herb Kohl 

U.S. House of Representatives: Tammy Baldwin, Steve Kagen, Ron Kind, Gwen Moore, 

David R. Obey, Thomas E. Petri, Paul Ryan, F. James Sensenbrenner, Jr. 

This report is available at http://www.va.gov/oig/publications/reports-list.asp.