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66–599 PDF 2011

S. HRG. 112–23 

FIELD HEARING ON IMPROVING PATIENT SAFETY 

AND QUALITY CARE AT THE DAYTON VA 

MEDICAL CENTER 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED TWELFTH CONGRESS 

FIRST SESSION 

APRIL 26, 2011 

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 

PATTY MURRAY, Washington, Chairman 

JOHN D. ROCKEFELLER IV, West Virginia 

DANIEL K. AKAKA, Hawaii 

BERNARD SANDERS, (I) Vermont 

SHERROD BROWN, Ohio 

JIM WEBB, Virginia 

JON TESTER, Montana 

MARK BEGICH, Alaska 

RICHARD BURR, North Carolina, Ranking 

Member 

JOHNNY ISAKSON, Georgia 

ROGER F. WICKER, Mississippi 

MIKE JOHANNS, Nebraska 

SCOTT P. BROWN, Massachusetts 

JERRY MORAN, Kansas 

JOHN BOOZMAN, Arkansas 

KIM LIPSKY, Staff Director 

LUPE WISSEL, Republican Staff Director 

(III) 

C O N T E N T S 

APRIL 26, 2011 

SENATORS 

Page 

Brown, Hon. Sherrod, U.S. Senator from Ohio ..................................................... 1 

WITNESSES 

Turner, Hon. Michael, U.S. Representative from Ohio ........................................ 4 

Daigh, John D., Jr., M.D., Assistant Inspector General for Health Care Inspections, Office of Inspector General, U.S. Department of Veterans Affairs; 

accompanied by George Wesley, M.D., Director, Medical Consultation and 

Review Division, Office of Health Care Inspections; and Kathleen Shimoda, 

Health Care Inspector, Office of Health Care Inspections ............................... 7 

Prepared statement .......................................................................................... 9 

Hetrick, Jack G., Network Director, Veterans Integrated Service Network 

10, Veterans Health Administration, U.S. Department of Veterans Affairs; 

accompanied by William D. Montague, Acting Director, Dayton VA Medical 

Center; and Lisa Durham, Chief, Quality Management, Dayton VA Medical 

Center .................................................................................................................... 23 

Prepared statement .......................................................................................... 24 

(1) 

FIELD HEARING ON IMPROVING PATIENT 

SAFETY AND QUALITY CARE AT THE DAYTON VA MEDICAL CENTER 

TUESDAY, APRIL 26, 2011 

U.S. SENATE, 

COMMITTEE ON VETERANS’ AFFAIRS, 

Washington, DC. 

The Committee met, pursuant to notice, at 2 p.m., at the Dayton 

VA Medical Center, Dayton, OH, Hon. Sherrod Brown of Ohio, presiding. 

Present: Senator Brown of Ohio, presiding. 

OPENING STATEMENT OF HON. SHERROD BROWN, ACTING 

CHAIRMAN, U.S. SENATOR FROM OHIO 

Senator BROWN OF OHIO. Thank you for joining us. I am Senator 

Sherrod Brown. This is an official hearing of the U.S. Senate Veterans’ Affairs Committee, an official hearing even though it is not 

in Washington. Senator Patty Murray, who is a Democrat from the 

State of Washington, has empowered me as a Member of the Veterans’ Affairs Committee to hold this hearing in Dayton at the VA 

Medical Center. 

I thank you all for joining us. I thank Senator Murray, Ryan 

Pettit of her staff, and the Veterans’ Affairs Committee staff. Also, 

John McDonald, to my right behind me, is with the Minority Staff 

of the Committee’s Ranking Member, Senator Burr, a Republican 

from North Carolina. Also behind me is Doug Babcock of my office 

staff who advises us on veterans issues. 

The investigation of the VA Dental Clinic has affected so many 

local veterans and their families that it makes sense to hold the 

hearing here. I will recognize Congressman Turner in a moment, 

who has been very, very involved in this. They will hold a hearing 

about Dayton and St. Louis in Washington with the Veterans’ Committee there soon. 

As I said, Chairman Murray and Secretary Shinseki and I have 

had many discussions about what happened, as has Congressman 

Turner with the Secretary. This hearing is a result of this work. 

It will operate with the same authority of any other hearing in the 

U.S. Senate that is held in Washington, DC. 

We will be hearing from the Office of the Inspector General of 

VA and members of the VA leadership on what happened at the 

Dayton VA Dental Clinic. We need to know how we got here. We 

need to know how we move forward. 

2 

To any audience members who would like to submit testimony 

for the official record, please contact Mr. Babcock from my office 

and Rachel, if she would put her hand up, Rachel Miller of my staff 

in our Cincinnati office. 

Before we start, I would like to ask anyone who is a veteran to 

please stand or put your hand up. Thank you. [Applause.] 

All of us thank you, and I think I can speak for the Senate here, 

thank you for your service and we commit to doing better with this 

Vet Center, as the VA does in a great majority of places around the 

country. 

A special thank you to the leaders of Ohio’s Veterans Service Organizations. Tom Burke of the Buckeye State Council, President for 

Vietnam Veterans—is Tom here? If Tom would put his hand up. 

He was going to join us. Dave Kenyon, who is a State Service Officer for the AMVETS, thank you for joining us. And Susan Getz, 

who is National Vice Chair of the Women Veterans of America— 

where is she? Thank you for joining us, too. 

For 150 years, Ohio has been a leader in providing veterans’ 

services. Ohio founded one of the Nation’s first chapters of the Veterans of Foreign Wars. Ohio has the Nation’s best county Veterans 

Service Officers and Organization. The Dayton VA Medical Center 

was one of the Nation’s first VA hospitals, providing continuous 

care and service to veterans for some 14 decades, 140 years. 

As a Member of the Senate Veterans Committee, it is not only 

an honor for me to serve our Nation’s veterans, it is a sacred responsibility that we all take when we take our oaths of office. We 

should not have to be here. This hearing should not have to take 

place. I would much rather have a hearing on the future of the VA 

in Dayton, how we can help the community leverage Federal resources to ensure that the hospital and the campus meet the needs 

of our veterans. I would rather be talking about our strong bid for 

the VA Archives, a distinction clearly earned by Ohio veterans and 

deserved by Ohio veterans. 

One of the most important duties of representing Ohio’s veterans 

on this Committee is to provide oversight of the Veterans Administration. That means undertaking what works at VA, this Vet Center, and other centers around the country. It also means making 

it better when it does not, finding out what is not working, and fixing it. In the process, it means recognizing that serving our veterans is a nonpartisan responsibility of our government. Our veterans deserve nothing less. That is why we are here today. 

Most of us are aware of the inexcusable facts and unconscionable 

consequences behind what happened at the Dayton VA Dental 

Clinic. Over the course of 18 years, the clinic failed in its duty, in 

far too many cases, to serve our veterans. A dentist disregarded 

basic sterilization practices. Nurses and assistants were ignored 

when they reported substandard care. We heard reports of employees punished for reporting unsafe practices. Petty, mean-spirited 

interpersonal dysfunction led to physical and verbal confrontations. 

Dental students allegedly provided care beyond that for which they 

were qualified based on VA standards and regulations. Management at the dental clinic and medical center studiously ignored 

problem after problem after problem, a symptom of general management chaos. These are the irrefutable, inexcusable facts. 

3 

More than 500 patients, as we know too well, at the Dayton VA 

Dental Clinic have been told that they have to be tested for bloodborne pathogens as a result of the care they received at this facility. Some experts are saying that thousands should be tested. As 

many as nine patients have tested positive for hepatitis; perhaps 

there are more. Veterans received life-threatening bloodborne 

pathogens instead of high-quality health care. 

The patients at the clinic are our Nation’s veterans and their 

families. They served our Nation when called upon. High-quality 

health care is a benefit they have earned, they deserved, and we 

have pledged to them, and in most cases, that is what the VA system does—ensure a high standard of care to veterans who have 

earned it. I often tell people that nowhere in the world will you find 

better care than when you step into a VA facility. During the debate on health insurance reform, the VA health system was an example to emulate. 

So this hearing is not a trial. It is not a witch hunt on the entire 

VA medical system. Far from it. We want to restore the public’s 

confidence in the system. We want to ensure accountability for 

those responsible for these horrific wrongs. We want to instill 

transparency as we move forward to ensure no veteran is ever 

treated with such blatant disregard. We want transparency. We 

want accountability. We want to hear about the clinic’s mistakes 

and learn from the clinic’s mistakes so those mistakes are not repeated. This hearing is grounded in those goals. 

We will explore specific questions about what happened over the 

last 18 years. Why was the clinic allowed to operate in this fashion 

for more than a decade? Why did it take so long to close the clinic? 

Has every person exposed to contagions from unsafe medical practices been notified and treated and tested? What is being done to 

hold those accountable, including those who knew and sat idly by 

and those who should have known? 

We will explore where we are today. Is the Dayton Dental Clinic 

now safe for patients who rightfully expect the world-class care 

that VA rightfully, most of the time, prides itself on? Are systems 

in place for this to never happen again? What is VA doing to make 

those exposed whole? What is VA doing to reassure every veteran 

that VA care is, in fact, the best care anywhere? We will explore 

how to restore the public’s confidence in this hospital. 

I have heard from hundreds of veterans about the Dayton VA. 

Most are angry. Many are just disappointed. I want to share two 

of them. One veteran from just north of here, from Huber Heights, 

told me, ‘‘I desperately need dental care, but not at the expense of 

my health.’’ A veteran in Minster in Auglaize County wrote, ‘‘I am 

one of the veterans who was potentially exposed by the dentist in 

question. I have been tested. Now I have to wait in limbo, being 

treated as if I am positive until said test results come back. No offense, Senator, but the testing is being done by the same agency 

that ignored the problem for 18 years. It put me in jeopardy to 

begin with. Am I to trust that the VA this time will get it right?’’ 

I am not happy with the pace of the administrative process regarding the disciplining of those involved. I understand there are 

legal and procedural hurdles, and for that matter, criminal processes that need to be followed. But people must be held accountVerDate Nov 24 2008 12:13 Jul 20, 2011 Jkt 000000 PO 00000 Frm 00007 Fmt 6633 Sfmt 6633 H:\ACTIVE\042611.TXT SVETS PsN: PAULIN
4 

able. Transparency, accountability, making sure this crisis in care 

and confidence must never, ever happen again, that is what this 

hearing is about today. 

That is why I have asked Congressman Turner to offer his testimony. Congressman Turner and I have worked together to push for 

answers and accountability. While we represent two different parties in two different chambers, we represent the same Ohio veterans. He represents Ohio’s Third Congressional District, and home 

to his district is home to this VA medical center. I have asked him 

to make a brief statement before we hear testimony. Congressman 

Turner, thank you for joining us. 

STATEMENT OF HON. MICHAEL TURNER, 

U.S. REPRESENTATIVE FROM OHIO 

Mr. TURNER. Thank you, Senator Brown. I want to thank you for 

holding this important hearing. 

The importance of what you are doing here today is that you are 

not just sitting here as the Senator from Ohio, concerned about 

these veterans and this issue that is occurring in your State. I understand that this is a hearing that is occurring under the auspices 

of the Senate Veterans’ Affairs Committee. A transcript is being 

taken, and I know this becomes a part of the official record of the 

work of the Senate in evaluating the VA, both this instance and 

nationally, so I appreciate that this is a special visit as we look to 

investigate this issue and broaden the scope, really, of what needs 

to be reviewed here at this site. 

I appreciate your statement on what occurred here. This is abhorrent, that any patient who would enter the VA would be placed 

at risk. The fact that these practices were ongoing and none of us 

knew, you acknowledged, is equally abhorrent, and I think that is 

part of what brings everyone here with such anger. 

We know that the dentist in question violated standards for practice for at least 18 years. The support staff was aware of the infractions, but apparently their reports were not followed through or 

they did not report it, because when he was found reported, the 

leadership, I believe, moved forward trying to cover up what had 

happened here and continues to not be forthcoming about the actions that had occurred here. 

I believe that the VA is acting more as an obstacle than they are 

of help to resolve this, and I think this hearing that you have 

brought forth, Senator Brown, will help us in trying to dislodge 

some of the information that has occurred, and I would like to 

highlight some of that difficulty. 

First, the VA notified my office that they wished to meet with 

our staff to provide what they called an update concerning the dental clinic at the Dayton VA Medical Center. The notice was provided at 9:30 p.m. the night before the briefing, which was scheduled at 10 a.m. the next morning. At this briefing, the VA informed 

us that standards of practice concerning infection control had been 

violated, and that 535 veterans in the Dayton community were 

going to be notified that they should come in and be tested for 

bloodborne pathogens, including HIV, along with hepatitis A, B, 

and C. 

5 

Following that notification, Senator Brown, yourself, Senator 

Portman, and I requested copies of the report and that they be provided to the Greater Dayton Area Hospital Association for their review and determination as to how the community should proceed. 

Instead of embracing this relationship and working together to 

solve an obvious problem, the VA has very lethargically and reluctantly responded to our request. I will give you a few examples, 

which I know you are aware. 

First, my office requested a copy of the investigative report on 

February 17. Following that request, we were informed that the VA 

would have to redact information in the report and that would 

cause some delay. We were told that patient information was going 

to be protected. The documents really contained no patient information, but as you are aware, Senator Brown, the report that was 

released had many redactions of information which were important 

for us to be able to review as a community to determine what happened here and how we need to proceed. 

Despite numerous requests, we did not receive the reports until 

9:30 p.m. Friday, March 11, 2 days before Chairman Miller of the 

House Veterans’ Affairs Committee and I were scheduled to meet 

with the leadership in Dayton. The delay inhibited our ability to 

both inform the Greater Dayton Area Hospital Association and the 

community. We later learned that the regional facility had released 

the report to the Dayton Daily News on February 9, a full month 

before they released it as a result of Congressional request. 

Second, Chairman Miller and I visited the hospital to speak with 

the leadership to learn about what had happened. However, just 

prior to our visit, we learned that the VA had removed the director, 

Guy Richardson, from his position and moved him into a higherlevel supervisory role. We were unable to meet with Mr. Richardson and still have been unable to meet with him to date. 

Finally, during our visit, I raised concerns about the redactions 

made in the report. When I later met with the VA FOIA (Freedom 

of Information Advisory Council) office in April, they informed me 

that it took their office only 4 hours to redact the report, and it still 

took a month for the report to be released, for us to be able to provide it to the Greater Dayton Area Hospital Association. 

Senator, as you are aware, the Greater Dayton Area Hospital Association has reviewed the information to date that has been released by Veterans Affairs, and the Dayton VA Task Force has released this report which they say concludes that additional veterans need to be tested and additional veterans need to be provided 

care. They believe that the practices that occurred here exposed 

many more veterans than VA is currently acknowledging were at 

risk. We are calling on Secretary Shinseki to provide testing and 

notice to those additional patients so that they can be properly 

cared for and VA can properly acknowledge the risk that these veterans were placed in. 

With regard to the Office of Inspector General investigation that 

is the subject of discussion today, I would like to thank that panel 

for investigating this issue, but I would be remiss if I did not point 

out that the scope of the OIG investigation was limited by internal 

constraints. As the report itself states, the OIG investigative body 

was unable to interview several key witnesses simply due to their 

6 

retirement. These witnesses include the original source complainants, a fellow dentist, and the facility’s chief of staff. Their absence 

raises serious concern over the comprehensive scope of the investigation and brings their conclusions into question. 

What the investigation does do, however, is highlight a systematic flaw that allowed employees to evade the investigative process 

by retiring. This escape-hatch option neither serves our Nation’s 

veterans nor the taxpayer and merits further investigation. After 

all, our country has thousands of young men and women that are 

making a great sacrifice, just as the generations before them. We 

need to make sure that they have the peace of mind to know that 

if they need help, there will be a fully functioning and competent 

VA here to give them that help when they need it, just as was 

promised. 

Senator, thank you for reviewing this matter. Thank you for 

bringing this hearing. I believe that the VA has additional information that they need to provide to this community for us to be able 

to evaluate what happened here and what actions need to be taken 

to address the concerns of the veterans who received care, and for 

us to be able to have confidence that the other types of care beyond 

dental that are provided at this facility meet the highest standards 

for our veterans. Thank you, Senator. 

Senator BROWN OF OHIO. Thank you, Congressman Turner. 

Thank you for being here. We will address, I hope, all of those concerns that you brought up today. Thank you very much, and 

thanks for your work on this since the story broke. You got so involved. Thank you. Thanks very much, Congressman Turner. 

The first panel will consist of Dr. John Daigh, Assistant Inspector General for Health Care Inspections, Office of Inspector General. Dr. Daigh joined the VA as Associate Director of Medical Consultation in the Office of the Inspector General in January 2002 

and was appointed as the Assistant Inspector General for Health 

Care Inspections in January 2004. He is responsible for the Office 

of Inspector General initiatives that review the quality of health 

care provided to veterans in Veterans Affairs hospitals, clinics, in 

nursing homes, in addition to the care provided to veterans 

through various health care contracts. Prior to joining the Office of 

Inspector General, he was active duty with the U.S. Army for 27 

years, retiring as a Colonel 10 years ago. 

Dr. Daigh is joined by Dr. George Wesley, Director of Medical 

Consultation and Review Division, Office of Health Care Inspections; and Kathleen Shimoda, Health Care Inspector, Office of 

Health Care Inspections, and you are a registered nurse, I believe? 

Ms. SHIMODA. Yes. 

Senator BROWN OF OHIO. Yes. Dr. Daigh, please begin with your 

testimony. I may end up asking questions of the other two with 

you, and they can certainly consult with you on the answers. So 

proceed, Dr. Daigh. 

7 

STATEMENT OF JOHN D. DAIGH, JR., M.D., ASSISTANT INSPECTOR GENERAL FOR HEALTH CARE INSPECTIONS, OFFICE OF 

INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY GEORGE WESLEY, M.D., DIRECTOR, 

MEDICAL CONSULTATIONS AND REVIEW DIVISION, OFFICE 

OF HEALTH CARE INSPECTIONS; AND KATHLEEN SHIMODA, 

HEALTH CARE INSPECTOR, OFFICE OF HEALTH CARE INSPECTIONS 

Dr. DAIGH. Yes, sir. Senator Brown, it is a pleasure to be here 

in Dayton, a community that is recognized worldwide for its innovation, hard work, and success. It is especially a privilege to be 

here at a hospital that has been one of the oldest in the VA. As 

you identified, Dr. Wesley and Kathleen Shimoda are here with 

me. These are the two individuals that led the team that resulted 

in the report that was published Wednesday, or yesterday, on our 

Web site, of which you speak. 

We were both horrified and surprised when we were asked by 

the Senate and House Veterans’ Affairs Committee to come to the 

Dayton Dental Clinic and review the allegations that infection control practices were not being adequately followed. As a result of 

those efforts, we published the report that I mentioned. 

I believe that at the current time that these breaks in infection 

control policy that we saw in the dental clinic are not typical of 

what is seen in this hospital at all, nor do I believe that the issues 

that we discovered and have reported on in our report are typical 

of VA as a whole. I believe that this is an outlier from how VA normally operates. 

I have a couple of suggestions that I think should be considered 

moving forward that I hope will prevent these issues from occurring again. 

One, I think that there are a group of individuals in the hospital 

whose input may not be—and I do not speak specifically about this 

hospital but VA hospitals in general—whose input may not flow 

unfiltered to the leadership, and I would speak of the group of individuals who I would call hospital technicians. They would be the 

individuals who run the ultrasound machines, who are cath lab 

techs, who work in the ophthalmology clinic, and who would be the 

technicians in the dental clinic. I think that the physicians and 

providers, in fact, have a direct line of communication to the hospital leadership through the standard chain of command. I think 

that the nurses and the nursing staff have a direct line of communication to hospital leadership through the head nurse. I think this 

other group of people might, if talked to on a regular basis, might, 

in fact, allow some of these issues to come to light sooner and be 

dealt with more quickly. 

The second recommendation that I would have would be that 

among the senior leadership group in the hospitals, that VA consider rotating or having terms of office for those leaders, that they 

ought to plan to move from hospital to hospital or that their positions be changed up on some program basis. There is a cost to that, 

and I am not sure, we have not studied it as to whether that 

should be done in all cases. But I think it provides for a relook at 

the relationships that exist in a hospital. It requires leaders at 

lower levels to prove to their new boss that, in fact, the standards 

8 

that they have in place and the criteria that they are managing 

their organization by are effective. 

The third recommendation I would make is that the VA uses a 

policy which I think is quite excellent which deals with adverse 

event disclosure. That policy was written in 2008, and it essentially 

is the playbook that is used to try to determine who should be notified when more than one individual needs to be notified as a result 

of an outbreak or the risk of an outbreak. There have been many 

more notifications around this issue and reusable medical equipment than I think anyone expected. 

I would refer you all to the New England Journal editorial of 

September 2, 2010, which discusses the notification issue broadly 

in the United States and which lays out 30 or 40 notifications 

countrywide. VA has a few of those on the list, but there are many 

other institutions that have covered that problem. I think that it 

is reasonable to consider empaneling someone like the Institute of 

Medicine or some other group to sit down and think about the risk 

that—the risk issues, where the limit of science comes up with policy in terms of whom and how we should notify individuals. 

I think that the basic scientific fact that HIV has never been 

transmitted, that is found in published literature, through saliva 

from one patient to the next, I think is understood. The risk of 

whether hepatitis B could be transferred from one patient to another has limits in what people know and understand and what 

people think good government or good policy ought to be. So I think 

that there is a wider expanse with these issues beyond VA, and I 

think a discussion would be of some value. 

I also think that included in that discussion at the Federal level 

is the relationship between the administration and the legislature. 

I think that the policy currently lays out that the administration, 

the Principal Deputy Under Secretary for Health, the PDUSH, will 

advise the Under Secretary for Health on an action to take. These 

actions involve many individuals at great expense, and I think that 

one should consider how, in fact, those discussions occur. 

The last piece of advice or issue that I think should be considered 

is one that is difficult to articulate exactly except to say that it is 

not uncommon in medical institutions for physicians who are 

prominent in their society at that hospital, who have worked there 

for decades or many years, have established a wonderful working 

relationship in that hospital, to over time decide that their capabilities are less. What they typically then do is request a set of privileges in the hospital. It is not the full set of privileges that they 

might have had 10 years ago. 

So an example might be a surgeon who fully engaged in the operating room and in clinic might at some point in time request privileges not to operate but simply to work in the clinic for a variety 

of reasons. Maybe their hand was injured. Maybe there is some 

other issue. But I think it is incumbent upon the leadership of the 

VA to take careful thought and look and be especially careful in the 

granting of privileges when there is a change over time. One wants 

to limit the privileges of a practitioner based on data. Certainly, 

one does not want to have to have adverse events occur or patients 

be harmed before a credentialing and privileging committee makes 

9 

the decision to limit the privileges of an individual or deny privileges to an individual. 

I talked about this issue with the leadership of VHA. I think it 

is one that, through discussion and consideration, that 

credentialing and privileging committees can focus on and do a better job at that issue. I know that my office will assign more time 

to looking at that issue as we look at the performance of credentialing and privileging committees throughout VHA. I think that is the 

fourth suggestion I would have, is to have—these issues might, in 

fact, be improved and be made less likely to occur in the future. 

My staff will be privileged to take questions from you as you see 

fit. Thank you, sir. 

[The prepared statement of Dr. Daigh follows:] 

PREPARED STATEMENT OF JOHN D. DAIGH, JR., M.D., ASSISTANT INSPECTOR GENERAL

FOR HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT

OF VETERANS AFFAIRS

Senator Brown and other Members of the Committee, thank you for the opportunity to testify on the results of our review involving the Dental Clinic at the VA 

Medical Center (VAMC), in Dayton, Ohio. At the request of the Chairmen and 

Ranking Members of the Senate Committee on Veterans’ Affairs and the House 

Committee on Veterans’ Affairs, the Office of Inspector General (OIG) reviewed infection control issues at the Dental Clinic at the Dayton VAMC and on April 25, 

2011, we issued our report, Healthcare Inspection—Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio. We concluded that the subject 

dentist did not adhere to established infection control guidelines and policies, and 

multiple dental clinic staff had direct knowledge of these repeated infractions. These 

violations of infection control policies placed patients at risk of acquiring infections 

including those that are bloodborne. 

BACKGROUND

Dental Clinic—The Dayton Dental Clinic performs a full spectrum of dental and 

oral surgical procedures. The dental specialties recognized by the American Dental 

Association (ADA) practiced at the medical center include general dentistry, oral 

and maxillofacial surgery, oral and maxillofacial radiology, periodontics, and prosthodontics. In July 2010, the dental clinic had seven dentists and an oral surgeon, 

two dental hygienists, seven dental assistants (two expanded function, five non-expanded function), and three dental laboratory technicians. In fiscal year (FY) 2009, 

the dental clinic treated 3,164 unique patients, and in FY 2010 the clinic treated 

3,005 unique patients. 

The dentists, oral surgeon, administrative officer, expanded function dental assistants, registered dental hygienists, and dental laboratory technicians report to the 

service chief, while the non-expanded function dental assistants and administrative 

program staff report to the Dental Service’s administrative officer. The Chief of Dental Service reports to the VAMC Chief of Staff. The dental clinic has a General Practice Residency, which is an independent medical center residency (as opposed to 

being the recipient of university residents rotating through the dental clinic). At the 

time of the review, there were three residents, although it is authorized four. The 

last accreditation review occurred in September 2006, and the Commission on Dental Accreditation adopted a resolution to grant the program the accreditation status 

of ‘‘approval without reporting requirements’’ at its January 25, 2007 meeting. The 

next scheduled accreditation site inspection is scheduled for September 2013. 

VA Oversight—The Veterans Health Administration (VHA) operates a program of 

proactive inspections through its System-Wide Ongoing Assessment and Review 

Strategy (SOARS) program. Its mission is ‘‘to provide assessment and educational 

consultation to volunteer facilities using a systematic method for on-going self-improvement.’’ SOARS inspection teams are composed of program staff and field (Veterans Integrated Service Network (VISN) and medical center level) health care 

experts. 

During the week of July 20–23, 2010, a SOARS team inspected the Dayton 

VAMC. On the morning of July 21, 2010, during the course of this inspection, two 

dental clinic employees approached a team member. The employees articulated allegations about aspects of a staff dentist’s practice that pertained to this dentist’s 

10 

handling of dental burs and noncompliance with dental infection control guidelines. 

These improprieties allegedly were ongoing. 

The allegations, if true, would have represented significant breaches of both medical center and VHA national standards regarding the handling of reusable medical 

equipment (RME), adherence to standards of infection control, and professional comportment expected of VHA dentists. At that time, it was also alleged that these concerns had been previously brought to Dental Service management’s attention. 

From August 19, 2010, through September 9, 2010, the dental clinic temporarily 

suspended operations. The VISN and medical center supervised an extensive re-organization of the dental clinic. This included employee training, employee counseling, environment of care improvements, and updates in operating procedures. 

Dayton’s Quality Manager notified The Joint Commission (the JC) and the Commission on Accreditation of Rehabilitation Facilities that as of August 19, 2010, as a 

precautionary measure in order to evaluate infection control practices, dental services at the Dayton VAMC were temporarily suspended. 

The allegations set in motion no less than five VHA investigations culminating 

in the notification, on February 8, 2011, to 535 patients of the medical center, that 

infection control practices in the Dayton Dental Clinic were not always followed. 

OIG REVIEW

As a result of the requests from Congress, the OIG began a review of infection 

control issues at the Dayton Dental Clinic. Our review encompassed a review of 

VHA actions in response to the allegations as well as an evaluation of selected aspects of the daily functioning of the dental clinic and its management oversight. 

Dental infection control practices are governed by a multitude of regulations, 

standards, and recommendations related to the appropriate use of personal protective equipment (PPE), hand hygiene, reprocessing of RME, and other measures to 

safeguard the health of patients and staff. VHA, Centers for Disease Control and 

Prevention (CDC), The JC, and the Occupational Safety and Health Administration 

(OSHA) have published documents to facilitate compliance with recommendations 

and requirements. The medical center has also developed local policies related to 

hand hygiene, RME, bloodborne pathogens, and disinfectants. The medical center 

requires its employees to comply with these established infection control policies. 

We visited the VAMC from December 14–16, 2010. We interviewed relevant clinical and administrative staff at all levels of VHA, extending to the Under Secretary 

for Health, as well as medical consultants from the Prevention and Response 

Branch of the CDC, VA’s Office of Public Health and Environmental Hazards 

(OPHEH), and attorneys from VA’s Office of General Counsel. 

We reviewed already completed VHA investigations as well as Issue Briefs; VHA 

Clinical Review Board (CRB) charters, memoranda, and reports; relevant medical 

and dental literature; facility-level Standard Operating Procedures (SOPs) and policies; relevant committee minutes; credentialing and privileging documents; dental 

clinic infection control training records; and e-mail communications. We also reviewed VHA directives, CDC guidelines, OSHA’s Bloodborne Pathogens Rule, and 

ADA guidelines. 

VHA RESPONSES TO THE DENTAL SERVICE ALLEGATIONS

Immediately after the allegations concerning the Dental Service were made to the 

SOARS team, VHA launched a series of reviews and investigations at the local 

VAMC, VISN, and VA Central Office (VACO) levels. Additionally, VHA convened an 

Administrative Investigative Board (AIB) and Clinical Review Board (CRB). 

Administrative Investigative Board 

On July 29, 2010, the VISN 10 Director charged the medical center to convene an 

AIB. The AIB was composed of five members: the Chair (an Associate Chief of Staff/ 

Podiatrist), a dentist; an infection control nurse; a Supply, Processing and Distribution technical advisor; and a human resources/labor relations technical advisor (regional counsel). The AIB’s expressed purpose was to investigate the facts and circumstances regarding allegations outlined in the July 2010, SOARS Report of Contact (ROC) documents received by the VISN 10 Director from the VAMC Director. 

Initially, the AIB was tasked to determine: 

• Whether there was a deviation in any dental standard of practice and/or improper handling, cleaning and/or disinfection of dental burs during fitting procedures by the dentist as alleged in the ROC and occurring in the dental clinic and/ 

or dental laboratory at the medical center. 

• Whether there was evidence to support that the dental technicians referenced 

in the ROC (or others) communicated their concerns to their supervisor or other 

11 

management official(s) as indicated/implied in the ROC. If so, identify who knew 

what, and when, or if action was taken. 

The AIB concluded its testimony on September 14, 2010, and its findings and conclusions were accepted by the VISN 10 Network Director on October 5. During the 

course of the AIB, a total of 31 witnesses were interviewed. They offered testimony 

sworn under oath and in the presence of a court reporter. Select witnesses were 

called back two or even three times in an effort to allow AIB members to ask followup or additional questions and to provide an opportunity to obtain fully comprehensive testimony. All witnesses were afforded the option of having personal counsel 

accompany them to their depositions. 

After considering the totality of the record and the depositions, the AIB concluded 

that the subject dentist did, in fact, repeatedly violate infection control standards 

over a multiyear period. The AIB also concluded that testimony supported the subject dentist’s violations as beginning in 1992, and without curtailment of this dentist’s privileges by knowing superiors, there was potential exposure of patients to 

bloodborne pathogens. 

Clinical Review Board 

VHA Directive 2008–002, Disclosure of Adverse Events to Patients (January 18, 

2008), provides guidance for disclosure of adverse events related to clinical care to 

patients or to their personal representatives. This directive recognizes that although 

it is difficult to weigh all benefits and harms, situations prompting a decision 

whether to conduct large-scale disclosure of adverse events likely involve the following considerations: 

• Are there medical, social, psychological, or economic benefits or burdens to the 

veterans resulting from the disclosure itself? • What is the burden of disclosure to the institution, focusing principally on the 

institution’s capacity to provide health care to other veterans? • What is the potential harm to the institution of both disclosure and non-disclosure in the level of trust that veterans and Congress would have in VHA? 

The CRB may choose to recommend notification if ‘‘one patient or more in 10,000 

patients subject to the event or exposure is expected to have a short-term or longterm health effect that would require treatment or cause serious illness if 

untreated.’’ 

We found that the need to convene a CRB was anticipated early on during VHA’s 

initial investigations into the allegations. On August 30, 2010, VACO senior leadership held a meeting with subject-matter experts in which the decision was made to 

convene the full CRB. The initial scope of the CRB as outlined in the charge letter 

was to: 

• Conduct a clinical risk assessment. • Identify the types of dental procedures at risk for disease transmission. • Make a recommendation as to whether a large-scale disclosure was indicated. 

If the CRB recommended a large-scale disclosure, it was to identify which patients 

should be notified, determine whether the disclosure should include deceased veterans’ next of kin, and define the look back timeframe. The CRB was also tasked 

to provide justification for its recommendations. 

The CRB met on September 2, 2010, and issued its first report to the Principal 

Deputy Under Secretary for Health (PDUSH) on September 3, 2010. It conducted its 

review with VAMC members, the VISN 10 leadership team, members of the site 

visit team, the VHA dental program office, and the VHA National Director for Infectious Diseases. Multiple documents for fact finding included the charge letter, the 

issue brief and update, AIB testimony of one dental clinic staff member, the AIB 

summary, a VACO August fact finding team report, a dental office review by the 

Office of Dentistry Consultant for Infection Control, OPHEH reviews, VACO’s summary of the site visit to the medical center, a timeline of events, and a universal 

precautions history and synopsis. 

The CRB report identified three practices by the subject dentist that posed a potential risk for infection transmission. First, the subject dentist did not properly disinfect dentures when taking them to and from the dental laboratory. This practice 

breach potentially contaminated laboratory equipment and surfaces. Second, the 

subject dentist wore soiled gloves and gowns outside the dental operatory and the 

dental clinic and did not change gloves between patients, potentially contaminating 

common use areas. Third, the subject dentist used the same dental equipment on 

patients without cleaning or sterilizing the equipment between patients. 

In forming its recommendations, the CRB considered only the risk of transmission 

of bloodborne viral infections (HIV, hepatitis B, and hepatitis C). To assess the risk 

to patients posed by these practices, the CRB also considered reviews of the medical 

12 

and dental literature on the transmission of bloodborne viral infections in dental 

clinics. It was able to risk stratify the patients based on the invasiveness of the procedure a patient received in the clinic, including removable and fixed prosthodontics 

(crowns and bridges), restorative fillings, and invasive procedures such as extractions and periodontal scaling. 

Initial CRB Recommendations 

The initial September 3, 2010, CRB report recommended disclosure to all patients 

who had received invasive dental procedures and restorative care from the subject 

dentist since 1975. It recommended that testing for the bloodborne pathogens (HIV, 

hepatitis B, and hepatitis C) should be offered to these patients. The CRB also recommended that the AIB obtain further testimony from the dental staff to determine 

whether the subject dentist was reusing needles and/or drug vials and to clarify the 

subject dentist’s infection control practices prior to 1990. The CRB advised that, 

with evidence that the subject dentist did not reuse needles or vials and practiced 

with a dental assistant who monitored the dentist’s infection control practices prior 

to 1990, it could narrow its disclosure recommendations to include fewer patients 

and shorten the look back timeframe. 

Second CRB Review 

After multiple senior level discussions, the CRB was re-convened to further clarify 

risk assessment and disclosure issues. The CRB was to review additional AIB testimony indicating that the subject dentist did not reuse needles or vials and that he/ 

she had a dental assistant prior to 1992. The CRB was also directed to review the 

AIB’s supplemental testimony and reports. Using this additional information, it was 

to again outline a recommendation on disclosure, identify the specific patient population and dental procedures, and define the look back timeframe. 

The CRB met again on November 23, 2010, and December 2, 2010, to consider the 

new information provided by the subsequent AIB testimony, the analysis of the testimony by the Office of General Counsel, and additional VACO and VISN 10 summary reports and findings. The meetings were conducted with members of the VISN 

10 leadership team, members of the site visit team, the VHA dental program office, 

the AIB Chair, the VHA National Director for Infectious Diseases, the Director of 

Public Health Surveillance and Research, and the Senior Medical Advisor of 

OPHEH. 

A key factor in determining the CRB’s final recommendations was its conclusions 

regarding the extent and duration of the subject dentist’s infection control infractions. In its review of the testimony, the CRB felt there was sufficient evidence to 

support a conclusion that major infection control breaches did not likely occur prior 

to 1992, when the subject dentist was practicing with a dental assistant. It was also 

able to limit the size of the patient population placed at risk to those undergoing 

only more invasive procedures that might provide a portal of entry into the bloodstream. Such exposure could thus result in disease transmission from one patient 

to another. 

The CRB submitted its revised set of recommendations to the PDUSH on December 3, 2010. By a six to one vote, it recommended that the original disclosure recommendations be narrowed to include only more invasive dental procedures and that 

the look back be limited to patients treated from January 1, 1992, onward. It identified specific invasive dental procedures to include: extractions and periodontal scaling, some restorative fillings, and fixed prosthodontics (crowns and bridges). The 

dissenting voter felt there was insufficient clinical or scientific proof that hepatitis 

C or HIV has been transmitted in dental settings. The dissenter also noted that ‘‘the 

risk of patient-to-patient transmission of bloodborne pathogens from occult blood in 

saliva cannot be determined and is biologically plausible.’’ 

The CRB further recommended that the disclosure ‘‘should emphasize that the 

risk of a bloodborne infection to patients is low.’’ It also recommended that each patient be offered serologic testing for hepatitis B, hepatitis C, and HIV. This testing 

would be part of an investigation for the purpose of identifying whether exposure 

in a dental clinic is associated with transmission of bloodborne pathogens, as there 

is little scientific evidence of known transmission. OPHEH would conduct the investigation in collaboration with the VAMC. 

CRB Recommendations and Final CRB Review 

On reviewing the final CRB recommendations, VACO senior leadership required 

further clarification regarding the specifics of its decisionmaking process and justification of its conclusions. In a letter dated December 14, 2010, the PDUSH requested that the CRB address issues including the following: 

13 

• How it chose the 1992 date, whether other dates were considered, and whether 

it considered the availability of electronic versus paper records? • What was its estimate of risk to patients and was it quantified? • What information should be disclosed and to provide evidence supporting disclosed information? • Did it consider input from the OGC’s evaluation of the credibility of the witness’ 

testimony? • Did it consider the testimony of the dental residents? • Why did it defer the issue of employee risk assessment and disclosure to the 

local medical center and local public health officials rather than VISN leadership 

and OPHEH? 

The CRB met for a fourth and final time on December 17, 2010, to address the 

PDUSH’s questions regarding its decisionmaking process and risk assessments. It 

submitted a written response to the PDUSH on December 17, 2010. The Chair of 

the CRB then met with senior VACO staff to review and discuss its written 

response. 

On January 4, 2011, VACO senior management made the decision to proceed with 

a disclosure as recommended by the CRB’s final report. The patient selection for notification was based on those patients who received invasive procedures performed 

by the subject dentist from January 1, 1992, to July 28, 2010. An algorithm and 

process were developed that identified 535 patients who met the CRB criteria for 

disclosure. 

OIG Conclusions 

We concluded that the subject dentist did not adhere to established infection control guidelines and policies, and multiple dental clinic staff had direct knowledge of 

these repeated infractions. These violations of infection control policies placed patients at risk of acquiring infections including those that are bloodborne. 

This was based on many facts including: 

• A June 29, 2010, e-mail, from a clinic dentist to the Chief of Dental Services 

reporting violations of basic infection control protocols by one specific dentist. • An August 16, 2010, memorandum for the record in which the Dental Service 

Chief indicated that he witnessed violations of basic infection control protocols by 

the same dentist on several occasions. • Multiple dental clinic employees telling us they had personally observed various 

infection control policy violations by the same dentist. Violations included failure to 

disinfect, or incorrectly disinfect, denture prostheses prior to transferring them to 

the dental laboratory and wearing gloves outside the operatory. They told us that 

the subject dentist went directly from one patient to another without changing exam 

gloves and did not properly clean and disinfect the operatory. Individuals told us 

that unsterilized instruments were reused on more than one patient. 

We concluded that the AIB was thorough in its fact finding process. It deposed 

31 witnesses, some witnesses were called back for a second and even third appearance before the AIB. Witnesses included current and former leadership in the Dental Service as well as current and former staff, support staff, and trainees. Testimony was gathered by various methods including such instruments as written affidavits, verbatim transcripts, or recordings of live testimony. Conducting the AIB 

was a time-consuming assignment and was carried out seriously and conscientiously 

by the AIB. 

We also concluded that the CRB acted in good faith to address the potential risks 

to VA patients. The CRB incorporated an extensive amount of data from which to 

base its decisions. All recommendations were carefully considered, with input from 

a solid counsel of national subject area experts. Its recommendations appropriately 

followed VHA’s notification for disclosure policy. 

With regards to staffing and workplace environment issues, we found that the 

staffing levels at the dental clinic were persistently below their organizational approved FTE levels and the level recommended by VHA for optimal performance. Optimal staffing may have decreased the likelihood that deviations from approved infection control practices would occur. Senior leadership and committees at the 

VAMC did not fully support efforts to staff the dental clinic at these optimal ratios. 

During our dental clinic staff interviews, employees discussed concerns as to work 

climate and morale. We heard multiple concerns regarding ongoing staff shortages, 

favoritism, and demeaning comments to staff, and we were told of staff altercations 

that resulted in formal police investigations. We found indications that interpersonal staff relations were strained, which negatively impacted the dental clinic. 

OIG Recommendations 

The OIG made two recommendations: 

14 

• The VISN Director review the findings related to the Dayton Dental Clinic, to 

include staffing issues, and take whatever action deemed appropriate. 

• The VISN Director ensure that the Dayton VAMC Director requires the Dental 

Service to comply with the relevant infection control policies. 

The VISN Director and Medical Center Director agreed with the findings and recommendations and provided acceptable action plans. We will follow up on the 

planned actions until they are completed. 

CONCLUSION

Established infection control practices and policies were not properly or consistently adhered to at the Dayton VAMC Dental Clinic. There was evidence that staff 

assigned to the Dental Clinic observed these poor infection control practices over an 

extended time period. While Dental Clinic management was notified of these unacceptable practices, it was not until a VACO review body was at the Dayton VAMC 

conducting a routine inspection that definitive actions began. These practices constitute unacceptable breaches of patient safety precautions and a violation of the 

OSHA Bloodborne Pathogens Standard—standards that veterans have a right to expect are followed with care and diligence. 

Senator Brown and other Members, this concludes our statement and we would 

happy to answer any questions that you may. 

Senator BROWN OF OHIO. Thank you, Dr. Daigh. 

I will start with you. I have some general questions and some 

very specific questions. I want to talk first about a couple of your 

recommendations. You said at the outset, the number 1 recommendation, the inputs of individuals do not flow to leadership— 

some individuals do not flow to leadership. How do you encourage 

structurally the VA, not just in Dayton but in Chillicothe and everywhere, so that the lab techs and the rad techs and others can 

feel that they will not be punished as whistleblowers or simply that 

they can share information up the chain, that they have confidence 

and patients can have confidence that that information is heard? 

They know things that no doctor and nurse perhaps know, as the 

doctors and nurses know things they do not know. How do we build 

that structure so they can do that, let us just say in Dayton for 

now? 

Dr. DAIGH. I would say that I think that there are many different 

leadership styles, and I think individuals have different ways of 

being effective. But one way would be to have a regular meeting 

between the director or the chief of staff, to sit down and talk to 

the health techs or the senior techs in each of the different areas 

of the hospital, either as a group or individually in some, and in 

a group forum on a regular basis, where real issues are discussed, 

where real issues that are important to the hospital are discussed, 

and through the administration then or the leadership responding 

back with sound data and change, how things can be built and the 

flow of information that is helpful to preventing these sorts of 

things, I think, would occur. So it is a communication problem and 

that level of communication, I think, needs to be set up, that is separate from being filtered through the chief of the dental clinic or 

the chief of whatever service you are talking about. 

Senator BROWN OF OHIO. How do you then—understanding that 

can be the structure with the right kind of administration—how do 

you protect that worker who wants to talk about a medical person 

not changing her gloves, not doing the right kinds of sterilization 

procedures? How do you protect that x-ray technician or that— 

maybe they saw something on the elevator or whatever. How do 

15 

you protect them from any repercussions from management for 

that sort of whistleblower action that way? 

Dr. DAIGH. I think that you have to first trust that the leadership of the hospital will do the right thing and not take repercussions. If the leadership does take action which is viewed as negative toward the person who made the allegation, then they can certainly—a variety of offices—the Office of the Inspector General will 

certainly point them in the right direction of where they can get 

help. I think that we—— 

Senator BROWN OF OHIO. If I can interrupt—— 

Dr. DAIGH. Yes. 

Senator BROWN OF OHIO. Would every employee of this hospital 

right now at this center know that if they came directly, no matter 

how low paid or whatever their position here, no matter how newly 

hired, that they could go directly to the VA Inspector General 

anonymously and protect themselves from any repercussions from 

management? 

[Murmuring from audience.] 

Dr. DAIGH. So the crowd says no, but I will say that we do 

have—hopefully that our telephone number is in each of these facilities. In every report we write, we put out our identifying and 

contact information. We get over 30,000 allegations a year that 

come into our hotline, which we sit down and look at. We work 

very hard to protect the identify of those sources that choose to remain confidential. One of the issues is that people who complain 

to us often, or complain to whoever, so it is not sometimes probable 

that the name of the person who made the allegation could be discerned. But we do everything we can to protect the name of the 

person who made that allegation. So we work very hard not to have 

adverse events occur to someone who makes an allegation. We 

work very hard to ferret out what the truth of the allegation is. 

Senator BROWN OF OHIO. I would assure—and while this is a 

hearing, I will for a moment speak to the audience—I would assure 

anyone in this center or any other, whether it is an employee or 

a family of a veteran or a patient, that is in touch with my office, 

with Doug Babcock or Rachel Miller, the two people I mentioned 

earlier, that their names will be confidential and protected. I mean, 

I will assure anybody that makes complaints to us. 

Let me go in a different direction for a moment. Well, let me take 

your second recommendation, that terms rotate—that top management rotate between and among hospitals. Give me a suggestion 

there specifically. How much of top management? How long are 

they at a hospital? Where would they—would it matter, geographic 

or size of hospital movement in moving them around? Give me 

thoughts on that, if you would, more specifically. 

Dr. DAIGH. I would say that between the director, the chief of 

staff, and probably the head nurse, depending on what the organization of the hospital is, that—and again, there are a variety of 

scenarios that one could put forth that would be least disruptive 

to all concerned and yet would achieve the goal of changing the 

leadership structure and causing them to re-equilibrate and to, in 

fact, rejustify that what they are doing is the right thing. So I 

would think on a period of, I do not know, 3 or 4 years, that you 

would rotate in some pattern at least one of the members of that 

16 

group. I do not have the study to back that up. I do not have data 

to cost account this out for you, but it seems to me that that would 

be a very reasonable thing to do. 

Senator BROWN OF OHIO. OK. Every VA hospital must pass inspection by two organizations, the Joint Commission on Accreditation of Health Care Organizations, as you know, and the VA Systemwide Ongoing Assessment Review Strategy. How could what 

happened in Dayton over the last 18 years not have been ferreted 

out? How could it have slipped past both of these review panels? 

Dr. DAIGH. Well, I cannot speak for JCAHCO, but I can speak 

for—we do a—every 3 years we go to VA hospitals and do what is 

called a CAP inspection, and that CAP inspection is an inspection 

where we come in and we look at the systems within the hospital, 

like the quality assurance committees and how they function, the 

peer review process, and other committees that are set up to try 

to ensure that when bad things happen in the hospital, that the 

hospital takes that data seriously, that it reacts to that data seriously, and that change is made. So whether it is an internal review 

group from VA or the group that I operate that goes through this 

hospital and has been here three times in the last 10 or 12 years, 

that we missed it is really dreadful. I am horrified that we missed 

that. 

We look at the hospital at committees that look across all the organizational elements of the hospital. We typically do not look from 

leadership down to the dental clinic, or from surgery down to the 

plastic surgery clinic, or from medicine down to cardiology. We try 

to look at those committees that look across all elements of the organization and we did not find that. 

It also means that nobody came up and talked to us and said, 

we are here when the visit is announced, when I have five or six 

people in the hospital going through the books and records. Nobody 

came up and said, we have a problem in the dental clinic. Nobody 

called us. 

So I do not have a good explanation for how this remained encapsulated for so long other than poor leadership, at least at the level 

of the head of the dental clinic, who did not over several leaders 

of the clinic enforce the standards of infection control that everyone 

knows should be enforced, both for the protection of the providers 

and, more importantly, or equally importantly, for the protection of 

the veterans. So I have no—— 

Senator BROWN OF OHIO. Dr. Daigh, if you are not sure how this 

happened as you came in from this direction in your analysis or as 

the Systemwide Ongoing Assessment Review Strategy came in, the 

VA, or JCAHCO, and I understand you cannot speak for them, 

what assures us that this will not happen other places, again in 

Dayton or in Chillicothe or in Omaha? How do we know this, that 

these panels, these review panels will not see something this 

serious? 

Dr. DAIGH. Well, I—— 

Senator BROWN OF OHIO. A better question: What have we 

learned? What does this—sorry to interrupt you. What does this review panel—what do these review panels, what did they learn from 

not being able—from the failure to find this, ferret this out on more 

17 

than one occasion over 18 years? It was not just one time that 

JCAHCO came or one time that SOARS came in, correct? 

Dr. DAIGH. That is correct. The SOARS is an internal VA group, 

but I understand your point. The group I have is a CAP, which is 

a different—but point well taken. 

I think that I have seen this actually twice, and what I have 

seen is a provider who is well-supported and respected in the community who, over time, the procedures are stepped down, if you 

will, and might go from being a full-speed dentist to someone who 

just does dentures. They might go from a practicing surgeon who 

spends time in the operating room to a surgeon who just sees patients outside the operating room. The community supports that individual; they like that individual. And that individual, over time, 

might, in fact, deviate in some way from the standard of care, and 

somehow people call it an eccentricity or they call it something 

else. There is agitation, then, when younger people come into that 

clinic and say, no, the standard of care is being broken. In this 

case, it is infection-control policies. 

Finally, when you look at it, everyone goes, oh, my gosh, what 

has happened here really is a catastrophe, and what were seemed 

to be minor deviations from the standard of care or eccentricities 

really were quite major breaks. The leadership who knows they 

should have enforced the rule, but they are friends who worked 

with that individual for a long time and did not enforce the rule 

are then wholly embarrassed at this outcome. That is the best explanation I can give you for how something like this could occur 

over a period of time. 

Senator BROWN OF OHIO. Let me ask you this, or suggest this. 

You came up with four or five, depending on how you divided them, 

very specific points about what you suggest we do differently, ‘‘we’’ 

meaning the Dayton VA. Can you come up with similar specific 

prescriptive recommendations on what SOARS should do differently, learning from their failures at the Dayton VA and apparently in St. Louis? Can you, as Inspector General, give them—is 

that in your power, and would you do that for them so they do not 

make these mistakes elsewhere or ever again here? 

Dr. DAIGH. I certainly can. We would—so the answer is yes. I 

must say that when I do an inspection proactively and I do not 

know anything is wrong. We look hard, but I simply cannot guarantee that I will uncover all problems every time I do an inspection. So I do the best I can. We lay out what we think are the most 

critical things to look at. If we find a problem, we write the pattern 

down. We bring it to the leadership’s direction and ask them to fix 

it. When I say that a hospital has passed the CAP inspection or 

has identified defects, you know, I simply cannot uncover every 

rock. 

With respect to the issues here, we will work hard to make sure 

that this does not occur again. 

Senator BROWN OF OHIO. Thank you. Walk me through the 

timeline regarding when the VA knew there was a problem and 

when patients were contacted. If I have this right, the VA closed 

the clinic in August 2010. They did not contact patients for testing 

until February 2011. That is September, October, November, December, January—6 months, more or less. Is that standard pracVerDate Nov 24 2008 12:13 Jul 20, 2011 Jkt 000000 PO 00000 Frm 00021 Fmt 6633 Sfmt 6601 H:\ACTIVE\042611.TXT SVETS PsN: PAULIN
18 

tice? Should patients have been notified? Are you agreeing with the 

process VA followed in determining who and when to notify all possible exposures? I mean, I assume that the 535 number is far, far, 

far fewer than the number of patients that said dentist had over 

the last 18 years. Why 535? Why 6 months? What did the VA not 

do that they should have? Run through those answers for us. 

Dr. DAIGH. I am going to ask Dr. Wesley. 

Dr. WESLEY. Sure. Yes, sir. I would like to speak to that a bit. 

I do agree with what I think you are implying, is that notification 

process and the Clinical Review Board process was protracted. The 

CRB, or the Clinical Review Board, which deals with large-scale 

notifications, first reported up the line to the Principal Deputy 

Under Secretary on September 3, and again, as you note, the notification letters did not go out until February 8. I think part of 

that—— 

Senator BROWN OF OHIO. Put the microphone a little closer to 

you, please. 

Dr. WESLEY. Oh, I am sorry. So the first recommendation of the 

notification went out September 3, but letters did not go out until 

February 8. Part of that was—— 

Senator BROWN OF OHIO. Was September 3 the first notification—— 

Dr. WESLEY. No. The Advisory Board that dealt with the issue 

of who, if anyone, we should notify, in essence, reports or makes 

a recommendation to the Principal Deputy Under Secretary of the 

VA for Health. They convened very early in September, I believe 

it was September 2 of 2010—— 

Senator BROWN OF OHIO. After the clinic had been closed, knowing there was a problem—— 

Dr. WESLEY. Correct. Correct. I think the clinic closed for about 

3 weeks between August and reopened about that time. So they 

convened about September 2, reported on September 3 up their 

chain, if you will, basically to the Principal Deputy Under Secretary, and, in fact, in their report recommended a fairly largescale notification, in fact, actually more than 500 patients. They actually recommended notifying virtually everyone going back to 

1975, when the dentist in question was first employed. 

Senator BROWN OF OHIO. A lot longer than the 18 years that—— 

Dr. WESLEY. Correct. Even longer than the 18 years. It was not— 

it should be appreciated that it was not a simple issue, though, because we have talked to CDC about this, and it is easy when you 

have harm, it is easy to notify when there is harm. But here, there 

was theoretical harm. It was possible harm. So, in essence, over the 

ensuing 3 months they kept revisiting the issue and attempting to 

figure out from the universe of patients who should be notified. 

Quite frankly, again, that was about a 3-month process. It was not 

until December that they came up with more definitive 

recommendations. 

Senator BROWN OF OHIO. Tell me who ‘‘they’’ is. 

Dr. WESLEY. Oh, I am sorry. I apologize. When you live this, 

it—— 

Senator BROWN OF OHIO. OK—— 

Dr. WESLEY. It is the so-called Clinical Review Board. It is an ad 

hoc advisory board which recommends to the Principal Deputy 

19 

Under Secretary if and how there should be large-scale notification 

of adverse events in a VA facility. 

Senator BROWN OF OHIO. These were all VA employees in Washington? 

Dr. WESLEY. They were VA employees, although they—experts 

throughout the system—did consult with external bodies, most specifically the CDC. 

Senator BROWN OF OHIO. So none of these were Dayton—— 

Dr. WESLEY. Dayton management certainly had input. Certainly 

at the VISN level, Dayton was involved. The Chairman of the AIB 

was involved. VA’s National Infection Control Director was involved. It was a very—again, it was a very excruciating, carefully 

thought-out process as to who to—as to what universe of people to 

notify. Again, I think the core issue is it was theoretical harm and, 

in a way, theoretical exposure rather than known exposure. 

Senator BROWN OF OHIO. It was theoretical because—was there 

no real sense of urgency among this board? Understanding—— 

Dr. WESLEY. Right. 

Senator BROWN OF OHIO. I do not want to belittle your comments 

about how complicated it is, that there were thousands of patients 

and you do not want to scare everybody and you do not want to 

test everybody. 

Dr. WESLEY. Right. 

Senator BROWN OF OHIO. I understand that. But if they settle on 

the number 535 and it takes them 6 months to do it and the word 

begins to leak out that there is a problem and nobody really quite 

knows what is next, the affected population, most of whom were 

not damaged—I understand that—but was there not some sense of 

urgency by the VA around the country or in Washington to move 

on this a little quicker to reassure these potentially thousands of 

families? 

Dr. WESLEY. I think that point is well taken. I think they worked 

very hard over 2 or 3 months, but I think by the time they decided 

in late December, and I distinctly remember meeting with the 

Under Secretary for Health on January 4, and by that time, a decision had been made to notify at 535, and again, why it takes another month, I do not know. 

Senator BROWN OF OHIO. Well, how about as you were analyzing 

this, and again, I do not belittle at all or dispute the complexity 

of it, but as you are looking at this, I would assume almost immediately, you knew that Patient X, Y, and Z, with names attached, 

some number of them were at risk, and if that is the case, why 

would you not notify them in October instead of waiting until you 

could decide on some macro system of doing this? 

Dr. WESLEY. Right. Again, I think the point is well taken. Actually, when I looked at the witness list, I regretted that the chairman of the CRB was not here. I think that is the best person to 

answer about, you know, the time course. An equally complex question is, again, what number. Do you notify, again, basically, the patients that had invasive procedures going back to 1992 or do you 

notify every patient that this dentist saw going back to 1992, which 

is what the Greater Dayton Hospital Association says? So not simple at all. 

20 

Senator BROWN OF OHIO. Do you in your mind now, or did any 

of the three of you settle on a number, what the number should 

have been? Should it be much higher than 535? Is 535 about the 

right number? 

Dr. DAIGH. Let me comment. I actually think there are—I guess 

what I was speaking to when I said there was a limit to our science 

and then after that you had to apply policy or what you thought 

were good ethics. Science would say that people who did not have 

invasive procedures or had procedures in which there was little 

chance that there was significant contact with saliva would be unlikely to get any of these bloodborne pathogens. So there is no clear 

answer. I think that what the VA authored is one of many reasonable possibilities, and I think that the Dayton—that the local view 

that much wider testing should occur is also a reasonable possibility. 

But I will say, if you go to the Ohio State Health site and you 

plot the incidence of acute hepatitis by county, by year, and you 

look at that, it is not clear to me that there has been an epidemic 

of acute hepatitis here. So I think there are data sets out there 

that one could look at, veterans versus, you know, compared to the 

excellent work done by the Ohio medical group collecting the 

incidences of these infectious diseases, to see if, in fact, there has 

been an outbreak of hepatitis in this community that could be 

traced back to this event. 

Senator BROWN OF OHIO. I appreciate that answer. I still am not 

clear. Should I walk out of here today, when I meet with a VFW 

group or a Legion group or a Vietnam Veterans group and they ask 

me, is 535 the right number? Should I be tested? Should my friends 

at this post be tested? I went to that doctor and had some minor 

surgery in 2007 or 2001 or whatever. What do I tell them? 

Dr. DAIGH. I think that the decision to test those individuals who 

had procedures by the dentist in question which were invasive and 

more likely to cause blood from the mouth to be mixed with sputum is a very reasonable set of people to test. I do not—— 

Senator BROWN OF OHIO. That number is significantly greater 

than 535. 

Dr. DAIGH. No, that would be the 535 number. 

Senator BROWN OF OHIO. That is the 535. 

Dr. DAIGH. If you only talk about people who had a denture 

pulled out, adjusted, put back in, no blood transfer, then the risk 

would be much less. The problem, sir, is that if you took a denture 

out of a person’s mouth and you did not properly sterilize it, you 

bring it to the lab where the dentures are worked on and you 

worked on that denture not being sterilized, you have contaminated the burrs in the lab. So if the next person has their dentures—— 

Senator BROWN OF OHIO. I have read in these reports the word 

‘‘burr.’’ What is that referring to? 

Dr. DAIGH. It would be a device that spins rapidly that cuts a 

tooth, drills a hole in—— 

Senator BROWN OF OHIO. I really hate when I go—— 

Dr. DAIGH. Yes. So I think there are some just absolutely practical limits from science, and I think it is a difficult answer. I think 

VA authored a reasonable solution. We knew with the hearing in 

21 

St. Louis recently, and a similar problem occurred, and I had a 

staff member sit in the audience and listen to that hearing. She sat 

next to a lady who had gotten a letter saying that her husband 

might be at risk of HIV and she was mortified. As I sit there and 

think about the letter that said, you might be at risk of HIV for, 

again, a removable—for a piece of dental equipment that was not 

properly sterilized. I mean, I personally think the risk that they 

had HIV is remote, maybe even close to zero with no reportable 

cases of transmission through saliva of HIV. I sit there and want 

to make sure that we are not creating harm when we send these 

letters that scare people absolutely to death. 

So it is a very difficult question in terms of how to decide and 

our science here. So I think there are several reasonable solutions 

to it. 

Senator BROWN OF OHIO. Would you personally go to the dental 

clinic here right now? 

Dr. DAIGH. Yes. 

Senator BROWN OF OHIO. OK. Ms. Shimoda? 

Ms. SHIMODA. Yes, I would. 

Senator BROWN OF OHIO. Dr. Wesley? 

Dr. WESLEY. Yes. 

Senator BROWN OF OHIO. My last request is to walk me through 

the allegations that whistleblowers have been punished. Can you 

tell me what has happened to people that have tried to speak up, 

because we know of reports that people, in fact, saw some less than 

proper practices in the dental clinic. What happened to them? 

What were their lives—tell me what happened. 

Dr. DAIGH. I do not have information on that. 

Dr. WESLEY. Yes. I—— 

Dr. DAIGH. I would have to have—well, I would not address that 

issue. 

Senator BROWN OF OHIO. Should you not? 

Dr. DAIGH. If I have to have an answer, I have to have the name 

of an individual who makes a complaint to me that that happened 

to them, and if they would like us to look at that or if you would 

like us to look at that, we would be more than happy to take a look 

at that. But whistleblower issues are generally reviewed not so 

much by our office but by the Office of Special Counsel. So if they 

would apply through the Office of Special Counsel, they are the office that looks at whistleblower retaliation issues. It has been the 

case where we have done work, but they would provide it through 

the Office of Special Counsel, who makes determinations on whistleblower actions. 

Senator BROWN OF OHIO. It seems to me from your—one more 

second, Dr. Wesley—it seems to me that from the inputs of individuals who do not flow—that the information does not flow to leadership. It seems to me that we need to know more. If you are making 

that recommendation, I appreciate that you did and I think the employees of the VA medical center in Dayton appreciate it. But we 

have to know more about what happened to whistleblowers here 

and what could happen and we need to establish protections. 

I will call on you after the hearing, OK, sir? 

We need this throughout the VA to be something that whistleblowers feel some confidence in doing. I know it is an age-old probVerDate Nov 24 2008 12:13 Jul 20, 2011 Jkt 000000 PO 00000 Frm 00025 Fmt 6633 Sfmt 6601 H:\ACTIVE\042611.TXT SVETS PsN: PAULIN
22 

lem in government, an age-old problem in government management, but we need to do that. 

Dr. Wesley, you wanted to say something? 

Dr. WESLEY. All I was going to say, briefly, to expand on your 

question and Dr. Daigh’s reply, was in this particular review, and 

we probably interviewed about 40 people and virtually everyone 

that was currently employed in the dental clinic, it was not so 

much whistleblower fear that came up. It was more of a sense of 

general frustration that if you articulated your concerns, nothing 

was done about them. So this was more frustration, I would have 

to say, than fear. 

Dr. DAIGH. The other issue, sir, is not everyone will talk with us. 

If they are an employee, we can sit down and have a conversation. 

But if they have retired, then we cannot have a conversation, 

so—— 

Senator BROWN OF OHIO. Could you address that? I said it was 

the last question before, but I was looking at my notes from Congressman Turner’s statement, his testimony, and that was a major 

concern of his. People who have retired can avoid any kinds of accountability or any kinds of reprimand or any kinds of punishment, 

apparently, unless it is criminal, correct? So what do we do about 

that? 

Dr. DAIGH. Sir, I am not a lawyer, so I am going to talk about 

what I believe the answer is. If a crime has been committed or alleged to be committed, then our Investigations Unit, which is separate from our Office of Health Care Inspections, I believe, does 

have the authority to go look at that and bring it to the AUSA as 

a potential crime, retired or not. But if a crime has not been alleged, or there is no crime that has been alleged, then our ability— 

my office’s ability to compel the discussion ends if they are not a 

VA employee. 

Senator BROWN OF OHIO. So sloppy or worse safety practices, 

procedures, surely are not a criminal offense, I would not think. I 

assume they are not. 

Dr. DAIGH. I am not a lawyer and I would assume they are not, 

too, sir. 

Senator BROWN OF OHIO. So retirement basically protects that 

employee from—shields that employee from being accountable. 

Dr. DAIGH. There is not a clawback provision. 

Senator BROWN OF OHIO. Thank you for your testimony. Thank 

you all. Thank you for being here. 

I would like to call up the second and concluding panel. Jack 

Hetrick is Network Director for the Veterans Integrated Service 

Network. Mr. Hetrick was appointed as a Network Director of VA 

Health Care System of Ohio, known as VISN 10, in November 

2006. VISN 10 is comprised of four fully functional medical centers 

that, I guess, is Cleveland, Columbus, Chillicothe—or Cleveland, 

Chillicothe, Dayton, and Cincinnati, and one independent outpatient clinic and a network of 30 Community-Based Outpatient 

Clinics, including the Dayton Veterans Area Medical Center. Dayton is the satellite and four CBOCs around you, correct? 

Mr. Hetrick is joined by Lisa Durham, who is the Chief of Quality Management at the Dayton VA Medical Center. Ms. Durham, 

thank you for joining us and for your public service. Bill Montague, 

23 

who I have known for years, is the Acting Director of the Dayton 

VA Medical Center. I thank Bill for coming out of retirement. I 

have worked with Bill in the VA, his work with the VA in the 

Cleveland Stokes VAMC, the former Director. I am pleased Secretary Shinseki convinced him to return to service, help restore a 

culture of care here. Next month, the Stokes VAMC is going to 

have the grand opening of a new state-of-the-art domiciliary, is 

that right? 

Mr. MONTAGUE. It is the domiciliary, the bed tower, and it is big, 

and thank you for your help. 

Senator BROWN OF OHIO. It is certainly large. Thank you for 

your work in that new facility. 

Mr. Hetrick, if you would proceed, and perhaps Mr. Montague or 

Ms. Durham can answer questions, too. 

STATEMENT OF JACK G. HETRICK, NETWORK DIRECTOR, VETERANS INTEGRATED SERVICE NETWORK 10, VETERANS 

HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 

AFFAIRS; ACCOMPANIED BY WILLIAM D. MONTAGUE, ACTING DIRECTOR, DAYTON VA MEDICAL CENTER; AND LISA 

DURHAM, CHIEF, QUALITY MANAGEMENT, DAYTON VA MEDICAL CENTER 

Mr. HETRICK. First of all, thank you, Senator Brown, for the opportunity to discuss the way forward for the veterans in the Dayton 

VA Medical Center. I am accompanied today by Mr. William D. 

Montague, as you introduced, Acting Director of Dayton, and Lisa 

Durham, Chief of the Quality Management at Dayton. I would like 

to request for my written statement to be submitted for the record. 

We are here today to discuss the lapse in proper infection control 

practices of one dentist at the Dayton Dental Clinic. More importantly, we are here to inform everyone about what we have done 

and will continue to do to ensure that care veterans receive meets 

the highest standards of quality and safety. We appreciate the 

OIG’s support in reviewing our program and developing recommendations, as well as our participation in today’s hearing. 

My written statement provides an overview of how we discovered 

the lapse in infection control. In the time I have now, I will discuss 

the efforts currently underway as well as those that will soon be 

implemented in response to this incident. 

Our quality management enhancement efforts have taken many 

forms. First, we provided additional education and training and updated standard operating procedures in the dental clinic. We have 

evaluated dental equipment and instruments, making changes 

where indicated, and repaired the physical infrastructure in the 

dental clinic. Monitoring and compliance are two critical aspects of 

our quality and safety programs. I directed that there be unannounced inspections of all network dental services to ensure proper 

dental policies and procedures are in place and that instruments 

are properly maintained. We have made several changes to infection control procedures, and through regular and even daily assessments we are documenting our compliance with standard practices. 

Turning to personnel matters, I convened an Administrative Investigation Board to determine if there was any deviation in dental 

standards of practice or improper handling, cleaning, or disinfecVerDate Nov 24 2008 12:13 Jul 20, 2011 Jkt 000000 PO 00000 Frm 00027 Fmt 6633 Sfmt 6601 H:\ACTIVE\042611.TXT SVETS PsN: PAULIN
24 

tion of dental equipment. I directed facility leadership and network 

staff to identify any possible trends based on available records. 

Looking ahead, our immediate focus is on implementing the recommendations our colleagues at the OIG have offered. The OIG 

made two specific recommendations, to review the findings related 

to the dental clinic, including staffing issues, to take appropriate 

action, and to ensure the Dayton Director requires the dental service to comply with infection control policies. I concur with their recommendations. 

By the end of June, we will be in full compliance with the first 

recommendation. We are taking administrative actions against the 

parties responsible for allowing this lapse to occur and we are 

modifying the organization of the dental service for better oversight. By the end of May, we will have systems in place to track 

dental service mandatory infection control training and will be randomly auditing compliance through documentation and observations to ensure quality care. 

VA’s central office has convened a Management Program Review 

Team to assess the Dayton VAMC to identify factors that may have 

allowed this particular practice to continue undetected or unreported. The team will ensure that we have implemented systems 

to properly identify and effectively address issues that require immediate response. Information from this review will help VA look 

at systemwide opportunities for management improvement. 

In closing, I would like to emphasize that this is unacceptable 

that the situation went on so long. We have taken administrative 

actions to ensure those responsible for this serious error are held 

accountable. In the days and weeks ahead, we will be working 

closely with our colleagues at the OIG as we continue to enhance 

the care we provide. I have discussed the lessons we have learned 

here at Dayton with other VA leaders so they can benefit from our 

experience. 

For those veterans who were affected by this incident, there is 

a dedicated hotline, and I will read the number, 1–877–424–8214, 

that is available 24 hours a day, 7 days a week. If veterans or family members have questions about the Dayton Dental Clinic, we 

strongly encourage them to call. We are asking veterans that want 

to be tested to report to the primary care clinic for an appointment. 

Veterans may walk in during clinic hours or call the hotline number for an appointment. 

Thank you for inviting me here to testify to discuss these plans 

and to listen to your recommendations. My colleagues and I are 

prepared to answer your questions. 

[The prepared statement of Mr. Hetrick follows:] 

PREPARED STATEMENT OF JACK G. HETRICK, FACHE, NETWORK DIRECTOR, VETERANS INTEGRATED SERVICE NETWORK (VISN) 10, VETERANS HEALTH ADMINISTRA- TION, U.S. DEPARTMENT OF VETERANS AFFAIRS

Senator Brown, Thank you for the opportunity to discuss the way forward for Veterans and the Department of Veterans Affairs Medical Center (VAMC) in Dayton, 

Ohio. I am accompanied today by Mr. William D. Montague, Acting Director, Dayton 

VAMC; and Lisa Durham, Chief, Quality Management at the Dayton VAMC. We 

are here today to address the lapse in proper infection control practices of one dentist at the Dayton VAMC’s Dental Clinic. More importantly, we are here to inform 

our stakeholders, including our Veterans, their families, the public and Congress, 

what we have done and will continue to do to ensure that the care Veterans receive 

25 

meets the highest standards of quality and safety. We also want to reassure stakeholders that we are taking action to ensure that an event like this does not occur 

again. Part of the process of restoring confidence requires an honest and transparent account of what occurred. My testimony will begin with an overview of how 

we discovered the improper practices of the single dentist. From there, I will discuss 

the actions VA has already taken in response to this incident. I will conclude by 

describing our future plans. 

INFECTION CONTROL DEFICIENCY AT THE DAYTON VAMC DENTAL CLINIC

During a scheduled internal review process by one of VA’s System-wide Ongoing 

Assessment and Review Strategy (SOARS) teams in July 2010, concerns were raised 

about adherence to infection control procedures in the Dayton VAMC Dental Clinic. 

The leadership of the facility, in consultation with me, immediately initiated a fact 

finding review to assess the concerns. Once the concerns were confirmed, I immediately expanded the investigation. Rapid response teams from VA Central Office 

helped us analyze the problem and determine corrective actions, and we decided to 

suspend dental services. The dental service closed for approximately three weeks beginning August 19, 2010, while all employees in the clinic received extensive refresher training and competency certification on proper infection control techniques. 

Investigation and outside review confirmed that a single dentist was not following 

proper infection control practices. VA initiated a Clinical Review Board (CRB) process to determine the level of risk to Veterans receiving care from this provider. This 

included an intensive review of our records dating back to January 1992. Though 

the risk for infection was considered very low, the CRB recommended VA notify Veterans who received specific procedures involving invasive dental treatment performed by this dentist. 

When the extensive review of records was completed and validated, it was determined that 535 Veterans should be notified about the possible exposure. The Dayton 

VAMC provided Veterans information regarding their potential exposure, and extended an opportunity for testing. As of April 15, 2011, all 535 Veterans have been 

contacted. 506 have been tested. Two new cases of hepatitis B have been identified. 

While it is impossible at this time to determine if the source of the infection arose 

from the dentist’s failure to comply with infection control practices, the investigation 

through VA’s Office of Public Health is continuing, and these patients are being actively evaluated and followed. 

There have been no new cases of HIV identified, and only one patient has tested 

positive for hepatitis C. This patient does not exhibit evidence of illness and, again, 

we cannot determine the source of infection at this time. Testing to confirm hepatitis C, and research to determine a possible relationship to the dental clinic, is ongoing. If additional cases are confirmed, and even if we cannot determine if the 

source of the infection arose from treatment in the dental clinic, VA will offer treatment to any newly diagnosed Veteran. 

ACTIONS TAKEN TO ENSURE HIGH QUALITY CARE AT THE DAYTON VAMC DENTAL CLINIC

VA has taken a series of actions to assure high quality care is provided and maintained in the dental clinic at the Dayton VAMC. We have provided additional education and training for dental staff and completed a review of staff competencies related to the education and training they received. During the dental clinic closure, 

we updated and standardized operating procedures in the dental clinic. We also 

evaluated dental equipment and instruments and made changes where indicated. In 

addition, we completed repairs to improve the physical environment of the dental 

clinic. These measures are in addition to those taken to improve conditions for employees, which we expect will improve morale and performance. Improvements to increase communication among all dental employees, including leadership, have been 

implemented. Regular meetings and morning huddles provide the opportunity for increased communication and openness. The Acting Chief of the Dental Service held 

regular conference calls with other Dental Chiefs within the VISN to make certain 

they benefited from the lessons learned at Dayton. This information was also shared 

nationally among dental professionals. 

Beginning last July, a number of initiatives were instituted at the Network level. 

I convened an Administrative Investigation Board (AIB) to determine if there was 

a deviation in any dental standards of practice or improper handling, cleaning, or 

disinfection of dental equipment. This Board was composed of experienced external 

clinical members and an internal infection control professional. I directed the Dayton VAMC leadership and VISN 10 staff to review results of previous investigations, 

workplace evaluations, performance improvement plans, credentialing and privileging, VISN Readiness Reviews, and environment of care rounds. Patient safety 

26 

and risk management reports were carefully reviewed to determine if there were 

any trends. Based upon the events at Dayton, I directed VISN professional staff 

members to conduct unannounced inspections of all VISN 10 dental services to ensure all expected dental policies and procedures were in place, all dental equipment 

and instruments were properly maintained, and all practices were in compliance 

with standards. I required VISN 10 facility directors to visit and conduct similar 

reviews of their internal dental operations. I received the final AIB report in October and accepted the findings and conclusions. After reviewing the AIB report, Dayton VAMC Leadership proposed administrative actions. The dentist in question 

chose to retire before that process was complete. In December, I attended a meeting 

in Washington, DC, to discuss the lessons we learned at Dayton with other Network 

Directors from across the country. VISN 10 staff has continued to conduct followup, unannounced, inspections of the Dayton Dental Service and other areas of the 

facility related to infection control. 

In the area of infection control, the Dayton VAMC now includes a dentist as the 

Dental Representative on the Infection Control Committee. A dashboard was developed to summarize infection control practices and compliance. The Dayton VAMC 

infection control staff conducts quarterly observations of dental staff proficiency. Infection Control Practitioners maintain a daily log of their activities to document 

compliance with standard practices. Dayton developed a checklist for conducting 

clinical inspections and chart reviews to meet the requirements of focused and ongoing peer review programs. New standard operating procedures were implemented 

prior to the reopening of the clinic in September. 

VA’s National Center for Organizational Development staff visited Dayton and offered a number of recommendations that have subsequently been enacted. In the 

area of leadership, the Dayton dental organizational chart was revised to ensure 

oversight and sufficient staffing support. Position descriptions have been reviewed 

and revised. Dayton has updated performance appraisal plans to emphasize accountability for safe and quality care, and these updates have been communicated 

and issued to employees. Efforts are underway throughout the Dayton VAMC to improve communication by offering additional opportunities for providing information 

to leadership through regular meetings, committee assignments, and participation 

in the relationship-based care initiative. 

We are evaluating staffing levels in the Dental Clinic. A new position of Assistant 

Chief for Dental Service was established. Recruitment has been completed for a new 

Lead Dental Assistant and Dental Lab Technician. Recruitment is being finalized 

for a general dentist and administrative support staff. Dental hygienists have been 

relocated into larger space to accommodate clinical need, and administrative support 

was added to improve customer service and scheduling. The Dayton VAMC set up 

a dedicated Dental Communication Center Hotline (1–877–424–8214) that is available 7 days a week, 24 hours a day. If Veterans or family members have any questions about the care provided at the Dayton VAMC Dental Clinic, we strongly encourage them to call. A special clinic was established for Veterans to come in for 

testing. Since we have been successful in contacting all of the Veterans, in the identified cohort, we are asking remaining Veterans that are interested in being tested 

to report to Primary Care, Monday through Friday from 8:00 a.m. to 4:30 p.m. and 

follow-up with their Primary Care provider. Veterans may walk-in during clinic 

hours or call the hotline number for an appointment. 

Since we began this series of improvements last summer, the Dayton VAMC has 

been inspected multiple times by various VA teams and the Office of the Inspector 

General (OIG). We appreciate the OIG’s independence and counsel and have collaborated with them to ensure they have access to any information they need. In November, The Joint Commission conducted an unannounced review of the Dayton 

VAMC, with an additional surveyor focused specifically on the Dental Clinic. There 

were no dental service infection control issues identified.. The hospital has received 

full 3-year accreditation. 

THE WAY AHEAD: CONTINUING TO DELIVER HIGH QUALITY CARE AT DAYTON

We have made significant progress and major changes to ensure that health care 

is delivered timely, safely and appropriately at the Dayton VAMC. While these accomplishments are notable, we still have more to do. We will continually strive to 

be the Veteran-centered, results-oriented and forward-looking organization the Secretary has called us to be, and that our Veterans deserve. Our immediate focus is 

on implementing the recommendations our colleagues at the OIG offered following 

their review of infection control practices at the Dayton VAMC in December 2010. 

The OIG issued a draft report to the VISN in March. We provided our comments 

on this report back to them in early April. 

27 

The OIG made two specific recommendations: first, I am to review the findings 

related to the Dayton VAMC Dental Clinic, including staffing issues, and take appropriate action; and second, I am to ensure the Dayton VAMC Director requires 

the Dental Service to comply with relevant infection control policies. I concurred 

with their recommendations. By the end of June, we will be in full compliance with 

the first recommendation as all necessary actions will have been taken. Administrative actions have been initiated against the parties responsible for allowing these 

lapses of infection control practices and inadequate oversight to occur. We will be 

finished modifying our Dental Service organizational structure consistent with findings in the OIG report. Regarding the second recommendation, by the end of May, 

systems will be in place to track all Dental Service mandatory infection control 

training. We will institute periodic random audits of infection control training compliance and observations, and will document staff knowledge of the infection control 

on the checklist in the Dental Dashboard. We will continue to work closely with infection control experts available in VA’s system to ensure infection control practices 

are current with health care standards and expectations. 

We are also taking other actions to improve the care we deliver beyond the OIG’s 

recommendations. First and of greatest importance, we will continue to reach out 

to Veterans who had contact with this dentist to provide them whatever support 

they may need. VA Central Office has convened a Management Program Review 

Team to conduct an organizational assessment of the Dayton VAMC. The primary 

purpose of this assessment is to identify any organizational or leadership factors 

that may have allowed this particular practice to continue undetected or unreported. 

The Team’s report will be used to evaluate operations and to assess whether similar 

conditions may be potentially present in other parts of the Dayton facility and potentially at other VA facilities. The Team will ensure that current key leaders have 

implemented systems to properly identify and effectively address clinical or administrative issues that require immediate response. The Team is being asked to do a 

retrospective review of the organizational and management structure and governance, operational dynamics and culture, key reporting structures, leadership, attitudinal factors, and other pertinent areas. Information gathered from this review will 

help VA look at system-wide opportunities for management improvement. The Team 

consists of experts with years of experience across the VA system, and will also include a representative from the National Center for Organizational Development, 

who will serve as a consultant and advisor. A member of my staff will accompany 

and support the team as needed. 

CONCLUSION

Our primary mission is to serve the Nation’s Veterans. We sincerely apologize to 

the Veterans who received notices regarding infection risks related to dental procedures while under our care. We also apologize to the public, whose trust may have 

been questioned. It is unacceptable that this situation went on for so long. The Dayton VAMC leadership took action when employees raised concerns in an internal review process, and the facility has been inspected multiple times by VA and non-VA 

experts. We have taken administrative actions to ensure that those responsible for 

this serious error are held accountable. In the days and weeks ahead, we will be 

working closely with our colleagues at the OIG to ensure we have addressed the 

concerns identified and to institute changes in the organizational and management 

structure and governance, operational dynamics and culture, and the overall environment of care. We will work closely with national VA program offices to make certain our practices and policies are current and responsive to changes in health care 

standards. 

Thank you for inviting me here to testify today to discuss these plans and to listen to your recommendations. My colleagues and I are prepared to answer your 

questions. 

Senator BROWN OF OHIO. Thank you, Mr. Hetrick. 

You heard the Inspector General, Dr. Daigh’s, recommendations. 

Give me general thoughts on implementing his ideas. 

Mr. HETRICK. Well, I think, first of all, the recommendation 

about making sure that the management team, regardless of where 

the hospital is located at, listening to employees within the various 

levels of their organization is clearly a sound recommendation. I 

would not argue with that. I think that, as our testimony goes on, 

Mr. Montague will show you some of the things that he has already 

28 

done to try to make that happen here at Dayton by getting the 

message out to employees in the hospital and making sure they understand that they have the option to talk or to write anonymously, 

as the case may be, with their name, whatever way they want to 

do it. We certainly will listen. 

I have the advantage in my office, which is located, as you know, 

in Cincinnati, but we receive messages, letters, e-mails from a variety of employees from around the network with concerns. I have 

said publicly when I visit a hospital, have a town hall meeting, or 

whatever forum that I am asked to speak in that we will address 

every issue that comes to our attention, whether we know who it 

was that brought that issue to our attention, even—I cannot obviously respond to somebody who sent me something anonymously, 

but we will document it for our records in the case we hear about 

it again or see something that happens similar in the future that 

we looked into it. If an employee has an issue and they bring it to 

my attention personally or through some other of the many message chains we have available to us, we will get back to them and 

give them an explanation of what happened. 

We, just as in this case, when the situation was uncovered in the 

dental clinic, one of the first things we did was inform the employees who were working there they had two options. They could let 

the Joint Commission, as Dr. Daigh referenced in his testimony, 

they can call them and they would, in turn, come and perhaps do 

an on-site review of that issue. They would notify us of that complaint and we could look into it and get back to them, or they could 

call the OIG hotline number, which was provided to the employees 

at the time the incident was uncovered. 

We certainly work very closely—Dr. Daigh mentioned, I think, 

30,000 complaints his office gets. I am pleased to report we do not 

get that many in Ohio, but we do get referrals from the OIG hotline, and we provide a very comprehensive review and response 

back to them. So I am all for that. I think we will do everything 

within our power to make certain that we try to expand those levels of communication so we get to as many people as possible within the organization. 

I am not sure—I only heard Dr. Daigh’s recommendation about 

management movements in a period of time. I really have no comment on that at this point. I would need some time to think about 

that. But I am really rather focused on how we can continue to 

make things better with the people we have to work with. 

Senator BROWN OF OHIO. Mr. Montague, tell us, if you would, 

from listening to Dr. Daigh’s recommendations and thinking about 

what you have implemented since you have been here, give me the 

two or three most important things, most important changes you 

have recommended based on, or not based on, the IG report. 

Mr. MONTAGUE. Well, I think the most important change we 

made is we made the lines of communication and the lines of authority and responsibility the same. Authority and responsibility 

are now at the same level, and there is no ambiguity as to whose 

task or whose responsibility something is, and they have the necessary authority to implement it. That helps with communications. 

It helps with figuring out what goes on. 

29 

For example, I think—well, number 2 would be patient satisfaction. We have truly emphasized patient satisfaction when we made 

a distinct change. In the past, the complaint department, namely 

the patient representatives, who are excellent, were given the responsibility for patient satisfaction. That is too late in the game. 

We made a formal move to give nursing responsibility for patient 

satisfaction, obviously in collaboration with the physicians and the 

support staff. But the nurses now own the wards. They know they 

own the wards. They have a number of relationship-based care initiatives which should cement better relationships between an individual patient and the staff. 

Then, finally, on the cultural affairs question that you have been 

asking, we are sending cards to everyone that say, do not be afraid. 

We have to know. It is part of our quality management program. 

Senator BROWN OF OHIO. Do you know, Mr. Hetrick, the total 

number of patients seen by the dentist in question? 

Mr. HETRICK. I do not, sir, have the exact number at my disposal. The numbers range, because of the long period of time and 

the reliance on paper records versus computerized records, so we 

are more certain about the time period about the—when records 

are electronic versus the—— 

Senator BROWN OF OHIO. What year was that? 

Mr. HETRICK. I believe that goes back for dental in the early 

2000s, if my memory serves me correct. 

Senator BROWN OF OHIO. Can you give me a rough estimate, 

within a few hundred, of how many he saw over 18 years? 

Mr. HETRICK. Over 18 years? I do not know. I would have to— 

I was not totally involved in that. Let me—— 

Mr. MONTAGUE. Twenty-three hundred. 

Mr. HETRICK. Twenty-three hundred, OK. 

Senator BROWN OF OHIO. Twenty-three hundred? OK. 

Mr. HETRICK. Yes. Thank you. 

Senator BROWN OF OHIO. If someone wants to be tested and was 

not in, what do you call it—— 

Mr. HETRICK. The cohort. 

Senator BROWN OF OHIO [continuing]. The cohort—— 

Mr. HETRICK. Yes. 

Senator BROWN OF OHIO [continuing]. The identified cohort, what 

do they do? 

Mr. HETRICK. I would point out that the defined cohort of 535 

number, we have tested close to 100 the last time I checked outside 

of the cohort because they showed up and wanted to be tested. 

Senator BROWN OF OHIO. So some were of the difference between 

2,300 and 500, 100 of those 1,800, roughly. 

Mr. HETRICK. Mm-hmm. 

Senator BROWN OF OHIO. When they are tested, they get—if they 

are tested positively, they, I assume, get total VA benefits and compensation and care? 

Mr. HETRICK. All patients that have—a special clinic was set up 

for the testing and counseling and explanation of what the next 

steps would be, should there be a positive finding. So the answer 

would be yes. That will be part of what will play out. 

Senator BROWN OF OHIO. You have been in this position since 

November 2006, in the position of being the head, if you will, of 

30 

these four medical centers, a very responsible position. How do you 

think this could have happened in one of your four medical centers 

without your knowing it? 

Mr. HETRICK. Well, I have asked myself that question a number 

of times—— 

Senator BROWN OF OHIO. I am sure you have. 

Mr. HETRICK. It is very troubling. I do not want to be using the 

same words as others, but I cannot find any other word to fully describe—— 

Senator BROWN OF OHIO. Is there some culture—— 

Mr. HETRICK [continuing]. How troubled—— 

Senator BROWN OF OHIO. Our office—we have been working with 

this—I have only been in office since the same time you took office, 

around 2006, 2007, and we had been working to try to improve— 

there were significant management problems here. We knew that. 

We did not know anything about the dental issue. Maybe not a culture of recklessness, but morale was an issue. There were all kinds 

of patients—I mean, all kinds of employee-employer/managementlabor issues going on. Did that not alert somebody like you, or else 

somebody else, to a carelessness, a recklessness, or a dysfunction 

that should have meant a deeper look at what was happening 

here? 

Mr. HETRICK. Yes. If I remember correctly, I think this goes back 

to about April 2007, and you and some folks from here and myself 

had a conversation on the telephone about the issues you just 

raised. I think we had a very strong response to that at the time. 

Addressing patient satisfaction was an issue with me across the 

network, not just here in Dayton. Despite the fact we have very 

good numbers with many performance measures and many with 

access numbers among the best anywhere in the VA system, we 

still had ongoing issues with our patient satisfaction results, primarily inpatient. So that was clearly something that I was very 

concerned about, and it resonated with me that you brought it up, 

and I certainly appreciated your support at the time, because I 

think that helped us to move into a number of new territories. Although it has not been as fast as I would like, we continuously see 

improvement in those numbers. 

Now, with regards to the culture of the facility and the management, that part of your question, we worked very closely with the 

National Center for Organizational Development, affectionately 

known in our group as NCOD, which is sort of bipartisan in a way. 

They come in and do organizational assessments. They help figure 

out what is going on, what works right and what does not work 

right and how we can set a course to try to make improvements. 

We took all of that—that followed your initial call with us and 

they came in, and they did a very top all the way down assessment 

and met with hundreds of employees, did all kinds of individual assessments, and really put together a good plan. Mr. Richardson at 

the time brought somebody in from their organization to be onsite 

to help carry that out. While Dayton was not the leader in moving 

up in employee satisfaction or results, they had made steady improvements in that area and were actually above the VA average, 

as I recall, the last time on the all employee satisfaction. 

31 

So when looking at those kinds of things, I saw things moving 

in the right direction. Was it perfect? No. We always have a lot of 

work to do. But I was satisfied that we were moving—that still 

does not answer the 18-year gap. I think that what I am trying to 

do now is to make sure that that never happens again and pooling 

all the resources I have available to me to figure out the way that 

we can possibly change that, that no one ever thinks it is OK to 

observe something that is wrong and not report it. So that is what 

I am trying to focus on now, because I just realize I am not going 

to be able to explain to you 18 years. 

I sat down after this incident came to my attention. We went 

through every record that we had in our office and every review, 

every organization, and it has been the OIG, it has been SOARS, 

it has been you name it, they have been here. We looked to see, 

did we miss a trend? Did we miss something that should have 

alerted us? And, quite frankly, there were no—we did not have any 

record of patient complaints that came to us, any letters from an 

individual saying they had a concern about the dental practices. If 

any of those things had been there and I had missed that, I would 

be the first person to acknowledge that. But I did not see that, and 

so what I am trying to do now is just do the best we can to make 

sure we never have that situation happen again. 

Senator BROWN OF OHIO. Was there an issue with—did you, or 

have you heard from others within the Dayton Medical Center that 

there was perhaps a problem with staffing shortages, that there 

was too much work being done by too few people here? 

Mr. HETRICK. Well, staffing is always an interesting subject to 

take up. I would say most departments, if we went around and 

asked, might say they did not have enough staff. I think that the 

board, during their investigation, addressed that in terms of staffing—particularly in relationship to the residency program that 

they were operating—and I believe, and have discussed this with 

Mr. Montague, that he feels that the recommendations that they 

made in terms of what should have been in place, we do not disagree with. 

Whether or not there are—I think that over the years, and again, 

this covers a long period of time and what rationale related to what 

decisions at that point in time is hard to speculate on, but I do 

think that as practice patterns change over time and more dentists 

now have assistants in use, I think we need to move along with 

that. I think they were partway there and not the entire way there. 

We have since done a top-down review. We are making, of course, 

changes once again to make sure that that staffing mix is right for 

the amount of work they have to do. 

Senator BROWN OF OHIO. Does the VA put more emphasis on not 

rocking the boat than it does on patient care? 

Mr. HETRICK. Well, that is a tough question. Not in my network. 

I personally do not think that we emphasize that in the field level. 

I really feel that since Secretary Shinseki has been in place—this 

is not about him, of course, but he has been very engaged in talking with leadership at the VISN level. As a matter of fact, tomorrow morning, I have a briefing with him on another subject. This 

is unprecedented in my time in the VA. 

32 

So I think that we are moving beyond rocking the boat. No one 

in the chain of command above me has attempted to make light of 

this or to slow things down. I think that folks were appalled at all 

levels and tried very hard to work their way through. You know, 

rocking the boat is something, I think, all of us should do all the 

time whenever patient care is involved. 

Senator BROWN OF OHIO. Does the VA owe veterans in the 

Miami Valley an apology? 

Mr. HETRICK. Well, I think we have done that. I know I personally wish I could meet every single one of them and apologize for 

what happened over the course of these years without—I mean, the 

only reason why we exist is to take care of veterans, so there is 

no question whatsoever about our mission, and what we should be 

doing. I believe that if anyone has been shaken in our confidence, 

we have a big job ahead of us to try to gain that confidence back, 

and I think that that has been the focus, once we got past the 

issues involving investigation and all the things that come with 

that. Now the work here at this hospital under the leadership of 

Mr. Montague and his staff is to try to restore that confidence, and 

whatever I can do as a Network Director, we will be certainly participating in. 

Senator BROWN OF OHIO. Thank you for that. What kind of notification or outreach are you doing to those people outside the identified cohort of 535 patients? 

Mr. HETRICK. There has been no direct communication via calls 

or letters to those outside the cohort. 

Senator BROWN OF OHIO. Should there be? 

Mr. HETRICK. Well, that is a policy question that I believe that 

many very highly qualified experts looked at, and I go back to Dr. 

Daigh’s statement about notifying someone about something that is 

a very, very low risk can sometimes cause more harm than what 

it solves. 

If the decision is made to do that, we would certainly do everything in our power to get to those folks and bring them back. But 

again, I think the focus is on doing sort of grassroots efforts now, 

that Mr. Montague and his staff are meeting with various groups, 

service organizations, and others to try to restore the confidence. 

Again, if someone wants to be tested, they are welcome to come 

forward. 

Senator BROWN OF OHIO. For my last question, Mr. Montague, 

tell us what you are doing to restore trust to a public that includes 

veterans and non-veterans alike in the Miami Valley and the area 

beyond the Miami Valley that this clinic serves, that this hospital 

serves, what specifically are you doing to give people more trust 

and more faith and more certainty that this is not going to happen 

again here? 

Mr. MONTAGUE. Well, our goal, day one, when Congressman Turner had the last presentation, we brought the media into the dental 

clinic, and we would invite anybody else to come into the dental 

clinic and actually see it. We will go to any organization that invites us, any service organization, any community, town, whatever, 

explain what happened, why. We stand ready to test anybody that 

wishes to be tested, and if the CRB changes its guidelines, we 

33 

stand ready, willing, and able to test whomever it is clinically determined is appropriate. 

Senator BROWN OF OHIO. How many Veterans Service Organizations and others have you gone out to speak to so far, roughly? 

Mr. MONTAGUE. Thus far, I have visited the Chief Service Officer 

of each of the six major service organizations. I have not been to 

a post or an American Legion hall yet, but I did offer the invitation 

to the leadership. I am involved in the Memorial Day parade, and 

I am sure—you know how many times I came to Lorain. 

Senator BROWN OF OHIO. I do know that. [Pause.] 

Thank you for your testimony and for your service. 

I will adjourn the Committee meeting in a moment. For people 

who want to talk to me specifically, I will stay around for 30–40 

minutes or so. My staff will stay around a little longer than that, 

I assume. I will stay around pretty much as long as I need to and 

people can individually bring up things to me. Understand, be assured that anyone that wants to speak to me or to my staff or to 

the Inspector General or to the VA, I will protect their confidentiality. That is a commitment from me to any of you or to your family members or to your coworkers. 

The Committee will prepare a print of this hearing. The Committee staff and I may have other questions of the witnesses, which 

we will submit in writing to them, which they will, I would assume, 

answer promptly and that will be in the Committee print, also. 

I thank the six witnesses. I thank you for your service. I thank 

particularly the people that work here and the patients who have 

served here. The apology from the VA was, I think, heartfelt, but 

the actions were not excusable and we need to assure people and 

we need to make sure that this does not happen again at this fine 

institution or any other, the Vet Centers, and the CommunityBased Outpatient Clinics that serves veterans in this State. Your 

service is too important to deserve anything less. I thank you for 

your service. 

The Senate Committee on Veterans’ Affairs is adjourned. 

[Whereupon, at 3:20 p.m., the Committee was adjourned.] 

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