[House Hearing, 110 Congress]
[From the U.S. Government Printing Office]


 
                    CASE STUDY ON U.S. DEPARTMENT OF 
                   VETERANS AFFAIRS QUALITY OF CARE: 
              W.G. (BILL) HEFNER VETERANS AFFAIRS MEDICAL 
                  CENTER IN SALISBURY, NORTH CAROLINA 
=======================================================================

                                HEARING

                               before the

                     SUBCOMMITTEE ON OVERSIGHT AND
                             INVESTIGATIONS

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                             APRIL 19, 2007

                               __________

                           Serial No. 110-14

                               __________

       Printed for the use of the Committee on Veterans' Affairs

                     U.S. GOVERNMENT PRINTING OFFICE

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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     RICHARD H. BAKER, Louisiana
Dakota                               HENRY E. BROWN, Jr., South 
HARRY E. MITCHELL, Arizona           Carolina
JOHN J. HALL, New York               JEFF MILLER, Florida
PHIL HARE, Illinois                  JOHN BOOZMAN, Arkansas
MICHAEL F. DOYLE, Pennsylvania       GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada              MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado            BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas             DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana                GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California           VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota

                   Malcom A. Shorter, Staff Director

                                 ______

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                  HARRY E. MITCHELL, Arizona, Chairman

ZACHARY T. SPACE, Ohio               GINNY BROWN-WAITE, Florida, 
TIMOTHY J. WALZ, Minnesota           Ranking
CIRO D. RODRIGUEZ, Texas             CLIFF STEARNS, Florida
                                     BRIAN P. BILBRAY, California

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
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                            C O N T E N T S

                               __________

                             April 19, 2007

                                                                   Page
Case Study on U.S. Department of Veterans Affairs Quality of 
  Care: W.G. (Bill) Hefner Veterans Affairs Medical Center in 
  Salisbury, North Carolina......................................     1

                           OPENING STATEMENTS

Chairman Harry E. Mitchell.......................................     1
    Prepared statement of Chairman Mitchell......................    47
Hon. Bob Filner, Chairman, Full Committee on Veterans' Affairs...     2
Hon. Ginny Brown-Waite, Ranking Republican Member................     4
    Prepared statement of Congresswoman Brown-Waite..............    47
Hon. Timothy J. Walz.............................................     4
Hon. Brian P. Bilbray............................................     5
Hon. Robin Hayes.................................................     6
Hon. Ciro D. Rodriguez...........................................     7

                               WITNESSES

U.S. Department of Veterans Affairs:
    John D. Daigh, Jr., M.D., Assistant Inspector General for 
      Healthcare Inspections, Office of the Inspector General....     8
        Prepared statement of Dr. Daigh..........................    48
    Sidney R. Steinberg, M.D., FACS, Chief of Staff, W.G. (Bill) 
      Hefner Veterans Affairs Medical Center in Salisbury, North 
      Carolina, Veterans Health Administration...................    23
        Prepared statement of Dr. Steinberg......................    50
    William F. Feeley, MSW, FACHE, Deputy Under Secretary for 
      Health for Operations and Management, Veterans Health 
      Administration.............................................    33
        Prepared statement of Mr. Feeley.........................    52

                   MATERIAL SUBMITTED FOR THE RECORD

Letter submitted by Hon. Robin Hayes, U.S. House of 
  Representatives, from Daniel F. Hoffmann, Network Director, 
  Veterans Integrated Services Network Six, Durham, NC, Veterans 
  Health Administration, U.S. Department of Veterans Affairs, 
  dated April 18, 2007, addressed to Congressman Hayes...........    55

Post-Hearing Questions and Follow-up Letter for the Record:
    Hon. Harry E. Mitchell, Chairman, and Hon. Virginia Brown-
      Waite, Ranking Republican Member, Subcommittee on Oversight 
      and Investigations, to Hon. George J. Opfer, Inspector 
      General, U.S. Department of Veterans Affairs, letter dated 
      May 21, 2007, and responses to the questions, letter dated 
      June 21, 2007..............................................    57
    Hon. Harry E. Mitchell, Chairman, and Hon. Virginia Brown-
      Waite, Ranking Republican Member, Subcommittee on Oversight 
      and Investigations, to the Hon. R. James Nicholson, 
      Secretary, U.S. Department of Veterans Affairs, letter 
      dated May 21, 2007, and their responses to the questions...    59
    Followup letter, dated December 18, 2007, from John D. Daigh, 
      M.D., Assistant Inspector General for Healthcare 
      Inspections, Office of Inspector General, U.S. Department 
      of Veterans Affairs, to Hon. Harry E. Mitchell, Chairman, 
      Subcommittee on Oversight and Investigations, Committee on 
      Veterans' Affairs, in response to inquiry from Congressman 
      Timothy J. Walz during the hearing.........................    66


                    CASE STUDY ON U.S. DEPARTMENT OF 
                   VETERANS AFFAIRS QUALITY OF CARE: 
                  W.G. (BILL) HEFNER VETERANS AFFAIRS 
                      MEDICAL CENTER IN SALISBURY, 
                             NORTH CAROLINA 

                              ----------                              


                        THURSDAY, APRIL 19, 2007

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
              Subcommittee on Oversight and Investigations,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice, at 10:00 a.m., in 
Room 334, Cannon House Office Building, Hon. Harry E. Mitchell 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Mitchell, Filner, Space, Walz, 
Rodriguez, Brown-Waite, Bilbray.

    Also present: Representatives Watt, Coble, and Hayes.

             OPENING STATEMENT OF CHAIRMAN MITCHELL

    Mr. Mitchell. Good morning. This is an Oversight and 
Investigations Subcommittee hearing for April 19, 2007. This 
particular hearing will be a Case Study on the U.S. Department 
of Veterans Affairs (VA) Quality of Care at the W.G. (Bill) 
Hefner VA Medical Center in Salisbury, North Carolina.
    I want to thank our colleagues from North Carolina for 
joining us today. I know they have been very active on this 
issue. I know the people of their great State appreciate their 
hard work on behalf of veterans in North Carolina.
    Of course, we are here today to explore the quality of care 
available to our Nation's veterans. We know there have been 
significant problems in the Salisbury VA Medical Center in 
North Carolina and we will be using Salisbury as a case study 
so we can better learn if the problems there are indicative of 
quality of care throughout the VA medical system. We will 
explore management accountability and leadership issues within 
the VA medical system.
    Today's hearing will revolve primarily around three issues. 
Firstly, how does the VA ensure access to the medical system 
that is timely and is delivering proper quality of care? 
Second, what is the process the VA uses in determining whether 
the quality of care is proper? And third, are the problems that 
occurred in Salisbury indicative of a larger set of issues that 
affect other VA medical facilities as well?
    More than 2 years ago, in March 2005, an anonymous 
allegation that improper or inadequate medical treatment led to 
the death of veterans at Salisbury prompted the VA Office of 
the Medical Inspector to conduct a review of medical care 
delivered to both medical and surgical patients. The OMI 
report, issued 3 months later, found significant problems with 
the quality of care that patients were receiving in the surgery 
service of the Salisbury facility. Unfortunately, we learned 
that Salisbury leadership had already been notified of many of 
the shortcomings in surgery service through an earlier root 
cause analysis.
    I know that all of us on the Subcommittee are particularly 
troubled to hear about the story of a North Carolina veteran 
who sought treatment at Salisbury and died. He went in for a 
toenail injury. And even though doctors knew he had an enlarged 
heart he was not treated. It was ignored. And the morning after 
he had surgery on his toe, he died of heart failure. According 
to media reports, this veteran received excessive intravenous 
fluids in the O.R. and postoperative as well. The medical 
officer of the day wrote orders for the patient without 
examining him and the patient did not receive proper assessment 
and care by the nursing staff.
    More recently, we learned through the media of another 
incident: a wrong site surgery at another VA medical facility 
on the west coast. The list goes on and on.
    We hope to hear today how the VA is working to ensure that 
these types of incidents do not happen at other facilities 
around the country and how the VA is working to deliver the 
best quality of care throughout the system. We also hope to 
hear from the VA how its leaders reacted to these problems, 
worked to solve these problems, and what lessons it learned to 
ensure that this never happens again.
    [The prepared statement of Chairman Mitchell appears on 
page 47.]
    Mr. Mitchell. At this time I ask unanimous consent that Mr. 
Watt, Mr. Coble, and Mr. Hayes of North Carolina, be invited to 
sit at the dais for the Subcommittee hearing today. Hearing no 
objections, so ordered.
    Before I recognize the Ranking Republican Member for her 
remarks, I would like first of all to recognize the Chairman of 
the Veterans' Affairs Committee, Congressman Filner.

              OPENING STATEMENT OF HON. BOB FILNER

    Mr. Filner. Chairman Mitchell, thanks so much for doing 
this and having this hearing. It is very important.
    When we got the letter from the North Carolina 
representatives, and we take requests from our colleagues very 
seriously, because we know, from our own personal experience, 
that we know what is going on in our own districts. I was 
struck by the fact, Mr. Hayes, since you represent the three, 
that your letter dated March of 2007 talked about getting a 
report from June of 2005 and September of 2006 that you had not 
seen before. That set off some bells right there, that reports 
of what is going on in the VA hospital in your area were 
unknown to you. That should not be the case. When we looked 
further into the situation, we looked at the report of 2005 
that outlined a lot of the problems in the hospital. Then in 
2006 the Inspector General did a report basically looking at 
facilities, and with no reference to the 2005 report. And then, 
as you know, the VA Secretary commissioned a report of all 
facilities just recently in the wake of the Walter Reed 
scandal, and there did not seem to be any connection between 
that report and the previous reports. So that started us 
thinking, since the paper trail is so clear, that this would be 
not only in and of itself an important hospital to look at, but 
also serve as a window into the process when there are problems 
and how we exercise accountability. And that is why we are here 
today under Chairman Mitchell's leadership.
    I happened to meet with the Inspector General soon after we 
got your letter. And I asked him about this report and why it 
did not have any reference to the earlier report. He said, ``We 
did not know about it.'' I thought that was odd. But as we 
looked further, these reports, which are so important, are not 
public. I am not sure we will find out if they are sent to this 
Committee, or whether there is just some summary, or whatever, 
but this was not a public report. Without a public report, 
there is no real accountability. And what we saw with these 
three reports, from 2005, 2006, 2007, was that there was no 
indication that any of the previous recommendations were ever 
done, ever fulfilled.
    Now we will talk to the folks today and they say, ``Well, 
of course we did those improvements.'' But we are not sure, and 
you are not sure, based on your letter, that this was done. So 
you have what the Office of the Medical Inspector does in 2005, 
it is not public, we do not know if the recommendations were 
even carried out. We get an Inspector General report in 2006, 
and we do not know if that has been carried out. And we get a 
new one in 2007. There is something broken about the 
accountability system and we are going to fix it with your 
leadership, Mr. Chairman. And this is a good example of what we 
have to deal with.
    There are problems that come up. It took somebody 
anonymously to mention them. I do not know why that should 
occur. There were twelve deaths, I think, over a period of 
time. Not everybody knew it. There was no investigation done 
since somebody actually did something. I know from my hospitals 
and other places I have been in the country, there is a, I will 
use the word ``fear.'' There is a fear about talking about the 
problems in your own hospital or in your own system. We have to 
get away from that culture. If there is fear, there is no 
honesty. And if there is no honesty, we cannot fix it. And if 
people are scared for their jobs because they are talking about 
problems with the patients they care about, there is something 
wrong with the system. So we are looking forward to fixing 
that, to making sure there is accountability.
    One last statement, if I may. In the last 60 days, three 
budget bills went through Congress. We were able to add, as a 
Congress, $13.5 billion over last year to the healthcare of our 
veterans in this Nation. That is about a 30 percent increase in 
healthcare, bigger than any in the history of this Nation. Now 
we have to make sure that those resources are spent wisely, 
that they are spent for the proper care of our veterans, and 
that the legislative branch of government knows what is 
happening, exercises oversight, and produces excellent health 
services for our veterans. I thank the Chairman.
    Mr. Mitchell. Thank you. Before we get started and I ask 
for opening statements, I would like to have all of the panels, 
the witnesses and the aides to the panels, to please rise and I 
would like to have them sworn in please. So if they would all 
please rise?
    [Witnesses sworn.]
    Thank you. And now I would like to recognize Ms. Brown-
Waite for opening remarks.

          OPENING STATEMENT OF HON. GINNY BROWN-WAITE

    Ms. Brown-Waite. I thank the Chairman very much for holding 
this hearing and for also yielding time.
    Mr. Chairman, on March 28 through March 31, 2005, at the 
request of the VA's Inspector General in September of 2004, the 
Office of Medical Inspector conducted a site visit to the W.G. 
(Bill) Hefner VA Medical Center in Salisbury, North Carolina, 
focusing on the facility's delivery of surgical services. This 
report presented some serious inadequacies of care at this 
facility. On March 21, 2007, three members of the North 
Carolina delegation, my colleagues the Hon. Howard Coble, the 
Hon. Mel Watt, and the Hon. Robin Hayes, wrote to the Committee 
expressing concern about this report. Mr. Hayes is with us 
today, and I am sure the other members, as their schedules 
permit, will also be with us.
    You know, the members asked us to look into additional 
oversight into patient safety at the VA. I am looking forward 
to hearing from our witnesses today to learn how these 
inadequacies have been addressed. I am particularly looking 
forward to Dr. Daigh's testimony providing the results of the 
Facilities 2006 OIG Combined Assessment Program (CAP) Review of 
the VA Medical Center in Salisbury, North Carolina, and the 
results of the OIG's inspection last week of the facility. I 
also look forward to hearing from Dr. Steinberg, the current 
Chief of Staff, and the former Interim Director, on how the 
facility is continuing to work to address these issues. And 
also, how the lessons that were learned at Salisbury can be 
used to implement safer delivery of healthcare services 
throughout the entire veterans system. It is my contention that 
this hearing is not to single out one facility, but to take 
lessons learned as a case study in patient care and the 
implementation of better patient safety across the entire VA 
system. I plan to continue to work with you, Mr. Chairman, to 
continue this oversight of patient safety at VA facilities 
throughout the Nation. Quality of care, everywhere, is my goal, 
and I believe the goal of members on both sides of the aisle. 
Again, I thank you Mr. Chairman. I yield back the balance of my 
time.
    [The prepared statement of Congresswoman Brown-Waite 
appears on page 47.]
    Mr. Mitchell. Thank you. At this time, I would like to ask 
Congressman Walz for his opening statement.

           OPENING STATEMENT OF HON. TIMOTHY J. WALZ

    Mr. Walz. Well, thank you, Mr. Chairman, and thank you to 
the Ranking Member for those words. I appreciate and thank all 
of the witnesses who are here today. Please make no mistake 
about it, the reason for this hearing, and the sole reason, is 
to make sure that we are providing the best medical care 
possible to our veterans. Our responsibility in this Congress 
is to make sure we are doing that in the most efficient, 
effective manner, and the use of taxpayer dollars is obviously 
a part of that. But I think it is very critical that as we are 
pointing out and trying to find areas that we can improve upon, 
the reason for that is to learn from past mistakes and it is 
not simply a scapegoat or trying to find reasons to point 
fingers. It is trying to improve across the spectrum.
    So I want to thank each of you for the work you do. I want 
to thank you for being here. I want to thank you for the open, 
honest dialog that we are going to get to because I think all 
of us on this Committee do believe that proper oversight and 
learning from past mistakes and implementing best practices is 
the best possible way to get to those solutions. So this is not 
a hearing to point out simply errors or simply weaknesses in 
the system for the sake of pointing them out. It is here to try 
and learn from this, to have you help us understand what we can 
do to implement those best practices or to help you with the 
resources and get the best possible care for these veterans, 
and that is the sole purpose of being here.
    So I want to thank you for taking time to be here with us, 
and thank you for your expertise to help us understand this 
better. I yield back.
    Mr. Mitchell. Thank you. Mr. Bilbray?

           OPENING STATEMENT OF HON. BRIAN P. BILBRAY

    Mr. Bilbray. Yes, Mr. Chairman. Mr. Chairman, the full 
Committee Chairman and I, have for 15, I guess almost 20 years 
ago, have worked together doing oversight at different 
agencies. I just ask as we go through this process, I 
understand that when we are talking about people dying it is 
human nature to focus on those deaths from the humanitarian 
point of view. But we need to have the discipline to focus on 
the systemic problems that led to those deaths, and sort of 
pull back and say, ``There is a terrible tragedy here, and we 
can focus on that.'' But if we focus on the deaths and not on 
the process that led up to the problem, or may have led up to 
that problem, then we are negating our responsibility of 
oversight. And more than the problem that Chairman Filner 
pointed out, about the fact of the whistle blower concept, the 
employee, because we always have had that. I mean, Bob and I 
know that, I do not care if it is a police officer saying a 
procedure was wrong or a county hospital saying that handling 
was done wrong, you will always have those in the system that 
always can point out faults and problems.
    What I really see of concern here is that, and I would ask 
those who are testifying to address this process where we do an 
assessment, a formal assessment of the operation, and that 
assessment is not made available. And why is it not made 
available for general review? Now, in certain situations, like 
when I was working with the trauma system in San Diego County, 
there was certain information we did not put out for liability 
reasons, for exposure reasons. And we tried to address the 
problem with the general public, because every lawyer in the 
world would be showing up to sue the hospital. And you cannot 
provide healthcare once the hospital has been shut down because 
of litigation. But this one, I do not understand why it was not 
made public. And I think Chairman Filner points out rightly 
that we ought to be addressing the issue as, is there a process 
here that we need to change? Even if it is a process that says, 
``We are not going to make it public directly, but we may hold 
it for 6 months to give the system the ability to respond to it 
so that when the report comes out there are answers, there has 
been time to address the concerns, whatever.''
    So I would ask that we really look at the systemic problem. 
It seems like a breakdown, that when you had a report that was 
out there a year ahead of the other report, and no one knew 
about it, what good is a report if there is not some review and 
action taken on that report? And so, again, I think that is 
where we can, rather than finding fault, find answers to be 
able to address the item.
    And I yield back, Mr. Chairman.
    Mr. Mitchell. Thank you. Mr. Hayes?

             OPENING STATEMENT OF HON. ROBIN HAYES

    Mr. Hayes. Thank you, Mr. Chairman, and Chairman Filner. 
Let me begin by thanking you, Chairman Mitchell, for making 
this hearing possible, and Ranking Member Ginny Brown-Waite. 
Bob Filner, we have been here for a long time. When this came 
to our attention, there was absolute confidence on my part that 
you and this Committee would look into this. And my point is, 
for not the members and others that are here, but the larger 
audience, leadership comes from all levels. But this Veterans 
Committee has provided the leadership. And today I think among 
other things, and Congressman Bilbray is right, we are 
reinforcing from the top the attitude that first, foremost, and 
always, the veteran/patient is what we are here to work on.
    Again, thank to all of you for making this possible. 
Quality, affordable, and accessible healthcare services to our 
Nation's veterans has been a top priority for me and for you as 
well. That is why I have been so concerned by recent media 
reports investigating the quality of patient care some of our 
veterans have received at the Salisbury Medical Center.
    While there are different deficiencies ranging in various 
levels of severity, I found it most troubling that a nurse 
employed by Salisbury reportedly falsified care reports on 
seriously ill veterans housed in private nursing homes and did 
not properly monitor them. This nurse's infractions included 
listing a patient in stable condition 12 days after he died. 
She was also cited in the VA Office of Inspector General's 
September 2006 report for not having visited some patients 
under her charge for over 2 years. Yet, the unnamed nurse is 
apparently still employed by the Salisbury VA. That is why I 
wrote to the Veterans Integrated Services Network (VISN) 6 
Director, Dan Hoffman, to express my concerns and to ask how 
this could happen. There have also been allegations that more 
than 12 deaths of surgical patients at the Salisbury VA had 
occurred in the last 2 years which may have been prevented. I 
do not think that all Department of Veterans Affairs healthcare 
is bad. There is excellent care being provided. I do not think 
the majority of VA healthcare employees are irresponsible or 
providing inferior care. The majority of our veterans are 
getting quality care from dedicated staff. The Veterans Affairs 
healthcare system is one of the best in the Nation, and 
continues to strive to provide better patient care. But even if 
one veteran has been or is being neglected, then that is one 
too many. If one employee is being negligent in their care, 
then that person does not need to be a part of the VA system.
    During this hearing, I look forward to hearing more about 
specific incidents and the overall situation at Salisbury so 
that we can take these lessons learned and apply them to VA 
healthcare across the country. I am also interested in how this 
relates to leadership and management within the VA, what is 
being done to ensure that their best care practices are being 
utilized.
    Caring for our older veterans and giving them the best 
access to quality healthcare is our duty as a nation. As we 
continue to sustain operations in support of the Global War on 
Terrorism, it is also imperative we send a strong signal to the 
active duty forces that our Nation will indeed care for them 
when they return home.
    I appreciate each of the witnesses from the Department of 
Veterans Affairs Office of the Inspector General, leaders of 
the Salisbury VA Medical Center, and the Department of Veterans 
Affairs Health Operations and Management for taking the time to 
appear. I believe your candor and insight can and will shed 
light on the issue for all of us. I look forward to continuing 
to work with my colleagues on this critical issue and on behalf 
of our Nation's veterans and servicemembers, again, thank you 
Mr. Chairman.
    Mr. Mitchell. Thank you. Congressman Rodriguez?

          OPENING STATEMENT OF HON. CIRO D. RODRIGUEZ

    Mr. Rodriguez. Thank you very much, Mr. Chairman. Let me 
first of all thank you for holding this hearing. My concern is 
that as we look at the VA, that what happened up here and other 
hospitals, that this might not be just an isolated situation, 
but that it might be widespread. I look forward to hearing from 
the Inspector General, and to see, if he can give us some 
guidelines as we move forward regarding how we might be able to 
help out.
    I understand also that the VA has not received the 
appropriate resources for so many years, and that they have had 
to cut staff. And I do not know if that nurse had a caseload 
that just was impractical to deal with, or what the situation 
might be. But I do know that we are going to do our best to 
begin to fund the VA appropriately with $3.6 billion additional 
moneys for 2007, and the supplemental holds some additional 
resources there. And we are going to work hard for 2008, to 
provide that $6.6 billion. But as we do that, maybe the 
Inspector General can help us out in the process to make sure 
we begin to, and the VA begins to, streamline the process that 
is needed in order to provide good healthcare. I know I get 
criticism back home from the fact that if you look at the 
private sector and what they do in certain areas, the number of 
patients that they view and then the number of patients that 
the VA views, it is day and night in comparison in some of 
those same situations. And so, we have to make sure we hold the 
system accountable, especially as we try to do the right thing.
    And I concur with the fellow colleagues that have indicated 
that this should be about making sure we have a system that is 
held accountable for our veterans and that we have a process 
there that can provide the appropriate care. And if it is not 
there for them to come forward, and to feel comfortable to come 
forward to tell us, ``There is no way we can deal with a 
waiting list unless we are provided this, this, and that.'' We 
have not had that kind of a process. And that is the process 
that we need, that if they cannot handle it, for them to come 
forward and tell us: ``Unless you provide this, this, or that, 
we cannot do that.'' And so, I am hoping that these types of 
hearings can allow us to begin to get to that level where the 
administration can come forward with those requests from us, 
and that we also come forward with whatever is necessary in 
order to make that happen.
    So Mr. Chairman, thank you very much for holding these 
hearings.
    Mr. Mitchell. Thank you. At this time we will proceed with 
Panel One. Dr. John Daigh is the Assistant Inspector General 
for Healthcare Inspections in the Office of the Inspector 
General (OIG). He is accompanied by Ms. Victoria Coates, the 
Director of the Atlanta Office of Healthcare Inspections, which 
covers Salisbury, North Carolina, as part of its regional 
mandate. Dr. Daigh, you have 5 minutes.

  STATEMENT OF JOHN D. DAIGH, JR., M.D., ASSISTANT INSPECTOR 
  GENERAL FOR HEALTHCARE INSPECTIONS, OFFICE OF THE INSPECTOR 
 GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY 
  VICTORIA H. COATES, DIRECTOR, ATLANTA OFFICE OF HEALTHCARE 
INSPECTION, OFFICE OF THE INSPECTOR GENERAL, U.S. DEPARTMENT OF 
                        VETERANS AFFAIRS

    Dr. Daigh. Thank you, Mr. Chairman. I appreciate the 
opportunity to testify in front of this Subcommittee today. I 
prepared some written statements for the record that I hope can 
be accepted into the record.
    I and the members of the Office of Healthcare Inspection 
take very seriously our legal challenge and mandate to ensure 
the veterans receive quality healthcare. We do that through 
several mechanisms, two of which I will talk about today. One 
is a Combined Assessment Program (CAP) inspection, whereby my 
office inspects major hospitals, there are about 158 of them, 
on a 3-year cycle. So about once every 3 years we go to each 
facility. We concentrate during that inspection on the 
processes at the hospital that should ensure that patients 
receive quality healthcare: the peer review process, the 
patient notification process if there is a bad outcome, those 
internal business processes that have to be successful.
    A second mechanism that we use to try to ensure patients 
receive quality healthcare is through our hotline. My office 
publishes about 50 hotlines a year. In 2004 we were publishing 
about 30 hotlines a year. The VA OIG maintains a hotline that 
accepts complaints through a variety of mechanisms. If those 
complaints deal with quality of healthcare issues, they are 
brought to my office. And in our office we try to triage those 
complaints and address the ones we think have systemic impact 
or are most serious. Those that we cannot directly review 
because of manpower limitations, we refer back to a level of 
command at VA higher than the level of the complaint.
    I would like to refer to a fiscal year 2006 summary that we 
published this year of the quality management of VA as a result 
of the CAP inspections. And in that publication we noted 
weaknesses systemically in the peer review process; the adverse 
event reporting process, which is the process whereby the 
hospital would notify a patient that there had been an adverse 
event; and in the utilization review process.
    Let me turn specifically to the events surrounding 
Salisbury. The IG received through its hotline on August 30, 
2004, an anonymous complaint alleging 12 individuals had died 
on the surgery service over the prior 2 years through improper 
healthcare. That complaint was brought to my office, and the 
next day my office accepted that complaint as one that we, the 
Office of Healthcare Inspections, would review. Upon looking at 
our workload and the cases that we were carrying at that time, 
I determined I could not investigate this case. That is, look 
at 12 deaths intensively in the timely fashion. So I, 
therefore, referred this case to the Office of the Medical 
Inspector (OMI), who said he did have the resources to look at 
this case in a timely fashion. And so, 3 weeks after I received 
the hotline, it was referred to the Medical Inspector (MI) on 
September 24, 2004.
    The Medical Inspector then went to Salisbury in March of 
2005, and published a report in June of 2005. Between those two 
timeframes the Director of Surgery for VHA visited the facility 
in May. The effort that the Medical Inspector made at Salisbury 
was discussed in monthly meetings that my staff has with the 
Medical Inspector. The Medical Inspector's report notes that I 
referred the case to them and notes that I reviewed the draft 
of this report. So I was well aware, as the people in my office 
were, of the issues surrounding this report. And we are aware 
of all the Medical Inspectors' reports.
    In June of 2006, my CAP team led by Ms. Coates, went to 
Salisbury to conduct a CAP inspection. I did not make them 
aware of that report. In retrospect, it would have been better 
had I made them aware of that report. But in the CAP report 
they noted some problems. One, the contract community nursing 
home program did not have a Committee that it was supposed to 
have to organize and supervise its activities. They also found 
difficulties with the peer review process and the management of 
internal board of investigations and Root Cause Analyses 
(RCAs). They also found some deficiencies in the cleanliness of 
the kitchen.
    We went back in early April 2007 in preparation for this 
Subcommittee's hearing to review again whether or not the 
findings of OMI and the recommendations of OMI had been 
implemented and whether or not the findings and recommendations 
of the CAP had been implemented.
    And as my time is out, I will indicate that both the OMI 
findings and the defects that we found in our CAP report have 
been adequately addressed currently by the facility. I thank 
you for the opportunity to testify, and Ms. Coates and I would 
be glad to take further questions.
    [The prepared statement of Dr. Daigh appears on page 48.]
    Mr. Mitchell. I have a couple questions I will start off 
with. Firstly, are there any patients currently in the 
community nursing homes that are on the watch list?
    Ms. Coates. I would like to answer that question. There is 
one nursing home that Salisbury has that is currently on the 
watch list. However, the facility has increased the monitoring 
and the visitation of the clinical staff to that nursing home 
to our satisfaction.
    Mr. Mitchell. Is your microphone on, Ms. Coates? Is your 
microphone on?
    Dr. Daigh. Yes, I believe it is on.
    Ms. Coates. It says it is on. Is that better? Would you 
like me to repeat my answer? Salisbury has one nursing home 
that is on the watch list right now. That facility is being 
monitored, visitation has increased, and we believe that it has 
satisfactorily been addressed.
    Mr. Mitchell. Thank you. I have two other questions. Why 
did the OIG send the hotline to the Medical Inspector to begin 
with?
    Dr. Daigh. Well, sir, when we get an allegation we are 
never sure what we will find in the exploration of that 
allegation. So if there were 12 cases to review, that takes a 
significant amount of manpower to do an in-depth review of the 
care of 12 patients. And, at the time, in 2004 I had a full 
plate of very significant issues I was working on. So in 
discussing with the MI, the MI had staff that could look at 
this in a more timely fashion than I could, so I referred this 
case to the MI.
    Mr. Mitchell. One last one, what are your roles and 
responsibilities in overseeing the MI?
    Dr. Daigh. Well, sir, in law when the MI was created, my 
office was charged with overseeing the Medical Inspector's 
Office and with ensuring that VA provides quality care by 
looking at the mechanisms by which VA ensures that they have 
quality care. From a practical point of view, the Medical 
Inspector works for the Under Secretary of Health and in my 
eyes is an agent of the Under Secretary of Health. I work for 
the Inspector General and do not work for the Under Secretary 
of Health. We cooperate in the sense that we are aware of where 
each of us is working. We are aware of the significant issues 
that we are each dealing with. We try very hard not to 
duplicate our efforts. And I think we have been pretty 
successful in recent years at working together.
    For example, the MI published a report in Chicago a couple 
of years ago in which there were three surgical cases of 
retained instruments. That case was the basis for which my 
office set out to do a national review of patient safety in the 
operating room, which was published in March of this year. 
Again, trying to emphasize that these same-sided surgery 
mistakes should not occur, that facilities need to go through 
the policies and the procedures that VA has set up to make sure 
those things do not happen.
    Two Under Secretaries ago, the MI came to me and indicated 
that he had a report that he had written that he could not get 
VHA to act on. So having that information, I then wrote a 
letter and went to the Under Secretary for Health and said, 
``You need to act on this report.'' It turned out that there 
was then legal intervention which sort of took over in terms of 
the issues of that particular case. But if the MI feels that he 
is not being listened to then I am an outlet to try to make 
sure that he is. And we work together cooperatively as we can 
to try to ensure veterans get quality healthcare. Thank you.
    Mr. Mitchell. Ms. Ginny Brown-Waite?
    Ms. Brown-Waite. Thank you, Mr. Chairman, for yielding, and 
thank you Dr. Daigh for being here. If there is an Inspector 
General's Office, which certainly there should be in this 
agency and every agency, and there also is the OMI group, how 
does that overlap? How does that delay the process? Or is 
having both of these groups, one of which, I believe your 
office, is somewhat understaffed, is there a tug there of 
territory? That is question number one. And question number two 
relates to why do you think that it took an OMI investigation, 
your IG CAP review, and a review over a 2-year period to 
finally shake up some senior management lethargy to finally 
remedy some pretty serious shortcomings? And I look forward to 
having your answers.
    Dr. Daigh. Yes, ma'am. With respect to the first, I believe 
that my office has an independence that the OMI does not have. 
I believe that the Under Secretary of Health needs an 
individual or a group of individuals that can act as his agent 
should an issue arise that he can send out and look at episodes 
of care that might not be appropriate. The size of the group 
that he has performing that task I have not made a study of and 
I am unsure of how many people he needs to do that. I believe 
that we have a significant workload in my office and that we 
are running flat out right now.
    As to the second issue, I believe that when we did the CAP 
inspection in 2006, that we were content that the leadership at 
that facility had in fact set course to make the changes we 
thought necessary to ensure that veterans receive quality care. 
We commented that there were problems with peer review and they 
made those changes. We commented that there were problems with 
nursing homes, and once pointed out, they made those changes. 
The disappointing fact or feature is that there would be a 
problem with peer review at all. They know we are coming to 
look at their peer review Committee, we know they have a peer 
review Committee, or should have one, they know it should meet 
on a regular basis, and they know that it needs to do its work 
in a timely fashion. So, yes, we wish that we did not have to 
repeatedly find some of the same problems across the system.
    Ms. Brown-Waite. On a scale of 1 to 10, how truly effective 
to protect patients is the peer review group, in your opinion?
    Dr. Daigh. I think that it is extremely important that 
episodes of poor care be appropriately commented upon by 
physicians' and nurses' peers to allow the administration to 
decide whether or not the care provided was quality care or 
not. This information is essential to allow the hospital's 
leadership to decide who should have credentials and privileges 
to practice in that hospital. So the peer review process is 
integral to the safe functioning of a facility.
    Ms. Brown-Waite. I do not think that is what I asked you.
    Dr. Daigh. I am sorry.
    Ms. Brown-Waite. I asked you how effective you think it 
really is. Because the problem with a peer review group is, 
that I have found when I chaired the Health Care Committee in 
the Florida Senate, is that nobody wants to say anything 
questioning another medical provider's level of expertise or 
lack thereof, or even problems with substance abuse. So, you 
know, peer review is something that when it works, it works 
very well. But I also found that it is a great opportunity for 
intimidation. For example, nurses that see something that 
really say that this doctor is a danger to the patients, that 
nurse frequently will lose her job and the peer review group 
will then do nothing. So I think I would like you to tell me, 
on a scale of one to ten, in reality, and remember you are 
under oath here. How effective is the peer review in the VA?
    Dr. Daigh. Well, I think I would like to parse my answer if 
I could. I think that there are places where the peer review 
process does not work as designed, that is by policy. It does 
not meet regularly and it may not effectively get the data that 
it needs to make decisions. And where it does not meet 
effectively, I would agree with you entirely. There are places, 
however, that do have effective peer review. And, where it does 
work well, I think it does make an important contribution to 
healthcare. I believe that in the VA peer review would be, on 
10 being excellent, I would give it probably a 7 to 8 grade in 
terms of its functioning across the system.
    I will say that when we do hotline reports, and clinical 
cases are addressed, we go out and seek comments from both 
physicians within the VA and physicians outside the VA to help 
provide the technical expertise that my office needs in certain 
complex cases to determine whether the care met standard or 
not. And we have had no difficulty getting quality input to our 
reports to suggest that poor care was delivered in the VA. So 
from a personal experience, asking for VA and non-VA 
physicians, for their input, where they know the report is 
going to be put on the web, as all of our reports are put on 
the web, available to the country, we get very good, high-
quality input.
    Ms. Brown-Waite. Thank you, Dr. Daigh. I yield back the 
balance of my time.
    Mr. Mitchell. Thank you. Mr. Filner?
    Mr. Filner. Thank you, Mr. Chairman. Dr. Daigh, I was a 
little troubled by your testimony, both in some of the things 
that you said and also things you did not say, especially since 
some of us asked questions that we want to know and you did not 
address them in your remarks. I mean, we make these opening 
statements not just to hear ourselves talk but so you know what 
we are interested in.
    Let me tell you a couple things. Number one, you said you 
did not have the resources. I mean, your first response to the 
hotline was you could not do it yourself. I doubt if that was 
made known to the Congress, that you did not have sufficient 
resources to do things that you should be doing. I do not think 
so. Was any statement made to Congress that you would have 
liked to do a report of 12 deaths, but you did not have the 
resources to do it? Did anybody know about that?
    Dr. Daigh. No, sir. That is an internal prioritization in 
my office.
    Mr. Filner. Right. But if you do not have enough resources 
to do the job that you are set up to do, it is no longer 
internal, Dr. Daigh.
    Dr. Daigh. Yes, sir.
    Mr. Filner. It is a job for some of us. Now, then you said 
you took 3 weeks and you asked OMI and they got to it. You said 
in March when you asked them in September, if I recall. Come 
on, that is 6 months with 12 deaths. If it were my family, and 
my children, or my spouse, I would be in there the next day. So 
the speed of the bureaucracy worries me. That what you think is 
reasonable is forever, especially to the families that are 
trying to figure out what is going on here. So they did not 
even get to it for 6 months. It took another, what, 3 months to 
do or something like that. And then as I understand it, correct 
me if I am wrong, it is not published. Your stuff is published 
on the web. I do not think you made clear to the Subcommittee 
that the OMI stuff is not published on the web. Is that true?
    Dr. Daigh. I believe that is true, sir, but the Medical 
Inspector will be here and you can ask him about that.
    Mr. Filner. Come on, you are the Inspector General. You 
should know this stuff. You do not know? You told me in private 
that it was not public. So tell us here. I mean, come on----
    Dr. Daigh. I believe their material is not public on the 
web.
    Mr. Filner. All right. But come on, how long have you been 
in the Inspector General's Office?
    Dr. Daigh. About 5 years, sir.
    Mr. Filner. And you do not know whether the OHI report is 
public or not? Okay, and you said you were aware of the report 
but your CAP team was not. Is that not a weakness in your 
system?
    Dr. Daigh. That is a weakness, sir.
    Mr. Filner. Okay. I mean, we need to have that, I mean, how 
can the CAP team go in and report when they did not even know 
what was wrong before? So OMI, did anybody do a followup of the 
OMI report within a reasonable amount of time? Is there any 
provision for a follow up to their report in your office or any 
office?
    Dr. Daigh. I would offer, sir, the example of our published 
report on patient safety in the OR is----
    Mr. Filner. I want to know if the 2005 report by the OMI 
was ever followed up to see if the recommendations were in fact 
carried out.
    Dr. Daigh. Not specifically until last week, in 
preparation----
    Mr. Filner. For this hearing?
    Dr. Daigh. Yes, sir.
    Mr. Filner. Now we are 2 years later, great show. Now, you 
said you thought there was an adequate response. Since nobody 
actually checked down their list of recommendations, was anyone 
fired for this stuff? I mean, we had a nurse who did not know 
what to do. We had, I was told a doctor was sort of let go but 
then rehired under a different category or a different thing. 
Did anybody, was anybody held accountable for errors in terms 
of being fired?
    Dr. Daigh. I am not sure of the answer to that, sir. That 
is a personnel issue that the facility would deal with.
    Mr. Filner. You are the Inspector General. We are relying 
on you for an independent analysis of this and we do not know 
if it was followed up on, and we do not know if anybody was 
fired. How did you follow up on your CAP report that is done 
every 3 years? Is there a formal followup on that?
    Dr. Daigh. Yes, sir. There is a process by which we keep 
record of the recommendations that we make. We, in person, 
follow up those recommendations that we think are very 
significant, and those that we do not have the manpower to 
follow up on we, if the plan put forward and through the 
written correspondence of documents justifies to us that that 
issue has been closed, then we close it.
    Mr. Filner. But you do not know that that is being done in 
OMI, that same process?
    Dr. Daigh. I am uncertain of that.
    Mr. Filner. So you follow up the CAP reports in some 
organized fashion. Is there any report issued on the report? 
For example, within 6 months all these things were taken care 
of, or not?
    Dr. Daigh. Well sir, we report to Congress all 
recommendations not completed within 1 year.
    Mr. Filner. Okay, my time is up. But the process bothers 
me. The OMI report is not public. The OMI does not seem to have 
any notion of speed. Six months later, 9 months later to do 
stuff, and then we do not even know if they were carried out 
because our colleagues from North Carolina write us a letter 
and tell us that it does not look like they have done anything. 
The system is very weak, it seems to me. And what bothers me 
even more is the bureaucratic attitude on this stuff. I have 
said this before in public meetings, I do not know if you were 
at those meetings. We are talking about the deaths of human 
beings. People ought to figure out what is going on, do it 
fast, and make corrections. Here we get a bureaucratic thing 
that takes forever and then by the time it is done everybody 
forgot who died anyway. I do not see a passion for figuring out 
what is going on. And I do not see any accountability in 
personnel. There are some serious personnel problems here. It 
is hard to believe that that nurse is still there. Your report 
states that the nurse is still there, she was just transferred 
to administrative duties. What the hell is she still doing 
there? Or he, I do not know if it was a he or a she. So I think 
we need a far better system with a little bit more direct 
passion about carrying it out.
    Mr. Mitchell. Thank you. Next, Mr. Walz?
    Mr. Walz. Well, thank you Mr. Chairman and Dr. Daigh, thank 
you for your time. I represent the district of southern 
Minnesota that includes the Mayo Clinic, so I spend a lot of 
time talking about healthcare, talking with experts, especially 
on the delivery of quality care and how to improve that. And I 
think as a world renowned expert as Mayo is they have some 
insights on this. I am also concerned and spend a lot of time 
looking at organizational design and how organizations function 
or do not function, and where those gaps are. I have a couple 
questions here and I do know these questions are going to be a 
little bit subjective. But that is the nature of leadership, to 
make subjective judgments and put them into place at times. I 
know we do not always have those quantitative measures to judge 
things by, but I want you to give me your best impression as 
you see this.
    Is it your opinion, Dr. Daigh, is the Office of Inspector 
General seen as an integral part of delivering quality care? Or 
is it seen as a watchdog to appease and keep at arms' length? 
How do you see it, from the perspective of the VA facilities? 
How would you see that? And I know it is subjective.
    Dr. Daigh. I think we are an integral part of providing 
quality care, and I believe that we are perceived that way. I 
believe there are people that do not perceive us that way. I 
mean, clearly we are here to help you. When we can write 
reports that have significant impact on leaders' ability to 
perform and people's jobs, people are certainly concerned when 
they talk with us. But I believe that we speak the truth, we 
try to lay out the issues as we see them. We have access to 
senior management and we hope that people will do the right 
thing in terms of making leadership decisions in VHA and that 
Congress will take our information and make decisions useful to 
run the organization.
    Mr. Walz. Well, I can tell you from my perspective, I do 
that. I do see the OIG as being an integral part of that. I 
hope it is being seen that way. My concern is, and I share this 
with you, and I think you are stuck in a bit of a rock and a 
hard place on this one. At least in my opinion, I think many on 
this panel agree, that the OIG has been an area that has been 
severely under resourced in recent years. And I have deep 
concern over that. And I did hear your testimony, as you said, 
you have to make judgments. All of us do on the use of our 
resources. You have to prioritize.
    My next question to you is, do you think if you would have 
had more resources, more personnel, and more ability, would 
your response time and the way that you handled the situation 
at Salisbury have changed? Would it have improved?
    Dr. Daigh. I think it would have. I am sure that it would 
have. The other ambiguity here is anonymous complaints are 
sometimes difficult to ferret out what the exact facts are, and 
what resources are required. So if a complainant lets us know 
who they are and we can quickly assess what the risk is to 
people on the ground, we respond as quickly as we can. So, yes, 
with more resources, I would be able to respond more quickly 
and more aggressively.
    Mr. Walz. Do you feel any pressure to try and justify the 
budgets that are given to you from VA management? Do you feel 
the need to try and say, we have sat in this Committee and had 
pointed questions from people sitting up here ask the VA that 
they had the resources, and not a month ago they told us yes, 
they had all they needed. Now I am hearing from you that you 
think that the quality of care would have increased. I think it 
is a logical conclusion to say possibly if you had more 
resources we may have fewer deaths. That is a pretty important 
and profound statement. My question to you is, do you feel 
pressure inside the VA system to justify the budgets that are 
given to you and to not come to us? To not come outside and 
give us suggestions and say, ``Hey, we are overwhelmed here, 
help us.''
    Dr. Daigh. No, sir. In the budgeting process I put down the 
proposals that I think would allow my office to deal with the 
issues that should be dealt with. I put that down in terms of 
manpower, usually, which is equatable into dollars, that goes 
forward. I do not have any direct discussion with the decision 
makers on what the VA IG appropriation is. But I feel no 
pressure to do other than tell people what we need.
    Mr. Walz. If you feel you are short, is there a process and 
what is the process inside the VA that you can go and talk to 
your superiors on where things that you think could be 
increased? How does that process work? Is it an open door 
policy? Is it a formal policy? Or how do you say, ``Hey, my 
resources are not enough?''
    Dr. Daigh. I would have to get back to you in writing, sir. 
That would be handled by the management group of the IG's 
office. I run the healthcare inspection group. And so the 
actual formulation and requesting of a budget is done by a 
different part of the IG's office.
    [The information was provided in a followup letter from Dr. 
Daigh, which appears on page 66.]
    Mr. Walz. Do you think that might be a problem? Or are you 
comfortable with it? You are the implementer. And if they are 
the appropriators and there is not a lot of communication I 
worry about that.
    Dr. Daigh. Yes, sir. I understand what you are saying.
    Mr. Walz. Okay. Thank you, Mr. Chairman.
    Mr. Mitchell. Thank you. Mr. Bilbray?
    Mr. Bilbray. Thank you, Mr. Chairman. Let me first clarify 
that I think those of us in government cop out too often that 
the answer to every problem is to throw more money at it. That 
has created major problems and a break down in the credibility 
of those of us in government to provide cost effective, 
reasonable services. And frankly, let me just tell you 
something. I am more impressed with the fact that rather than 
screaming you did not have enough money and finding excuses not 
to address the issue, that when you found out that this crisis, 
or this review needed to be done and you basically did not have 
the capability in-house, you went and looked to find somebody 
to get the job done rather than screaming that you just could 
not get it done.
    My concern is back to the procedural issue here. Were you 
aware of the 2005 report? You personally?
    Dr. Daigh. Yes, sir.
    Mr. Bilbray. Were the people doing their review that came 
out in 2006, were they aware of the 2005 report?
    Dr. Daigh. No, sir.
    Mr. Bilbray. Why were they not?
    Dr. Daigh. Because I did not tell them. The OMI publishes 
about, five, six, seven reports a year. We have an elaborate 
system so that when individuals go out on a CAP inspection they 
can see all of the IG activities, that would be the auditors, 
the healthcare activities, the hotlines, so that they are aware 
of those issues. We did not have an adequate system to let 
people know when they go out on a CAP of OMI reports. We have 
subsequently placed all of the OMI reports and current drafts 
on a share drive so everyone in OIG can see the OMI reports as 
they conduct their business.
    Mr. Bilbray. But you do not have a tickler system so that 
if somebody is going into a certain facility or a certain 
field, that they are automatically tickled that the fact that 
there are these outstanding reports that they can use as a 
base?
    Dr. Daigh. Well sir, it is standard practice to query the 
database for the site that you want to go to.
    Mr. Bilbray. Yeah?
    Dr. Daigh. Then you get a list of all the opened and closed 
issues at that site. So there is a way to look at IG work. The 
OMI work is listed in very simple format that is easy for one 
to look at. When you know you are going to go on a project you 
go look at the share drive, see the reports----
    Mr. Bilbray. So the share drive, was this available for 
them, the share drive?
    Dr. Daigh. It was not available then. It is available now 
and has been set up now.
    Mr. Bilbray. Now?
    Dr. Daigh. Yes, sir.
    Mr. Bilbray. Okay, this is the kind of testimony that we 
need.
    Dr. Daigh. Yes, sir.
    Mr. Bilbray. Was it oversight on your part of notifying 
them, ``Hey, by the way guys, you are going in there and we 
have got this report that came out and you ought to take a 
review of that?''
    Dr. Daigh. That is correct, sir. That is correct, it is my 
oversight.
    Mr. Bilbray. Okay. Now, you have now got a system that 
basically if they are going in the facility, there is a tickler 
to let them know that there are these outstanding reports that 
are already on file?
    Dr. Daigh. That is correct. There is a very simple way for 
them to see what OMI's current work is and what the OIG's 
current work is.
    Mr. Bilbray. So you are here telling us now that you made a 
mistake. The system was not working properly. But since then, 
you have been able to backfill and correct the procedural 
mistake that occurred in this instance?
    Dr. Daigh. I am saying that I made a mistake, and that we 
have corrected the problem.
    Mr. Bilbray. Hang on, when you said you corrected the 
problem, let us clarify. You corrected the procedural problem?
    Dr. Daigh. Yes, sir.
    Mr. Bilbray. Okay, go ahead.
    Dr. Daigh. I am saying that I have made OMI's work 
available to my staff so that we should not have the disconnect 
that you are concerned with here again. That should be 
corrected.
    Mr. Bilbray. Because Doctor, you admit, that when anybody 
goes into a facility the first thing they should be looking at 
is the previous reports on that facility to have a base of 
knowledge to move forward from, rather than having to reinvent 
the wheel.
    Dr. Daigh. I agree, both the previous and the ongoing 
issues at that facility.
    Mr. Bilbray. Now at this facility we have, you know, we are 
talking this facility. But this is now procedure for your 
entire review process? To where whatever facility they are 
going into they now have the ability to automatically have a 
tickler that will refer them the reports that have predated 
their investigation?
    Dr. Daigh. For years, my staff have had the ability to see 
all of the IG reports on any site. They now have the ability, 
as of very recently, the ability to see OMI's work at those 
sites.
    Mr. Bilbray. Thank you very much. I appreciate it.
    Dr. Daigh. Yes, sir.
    Mr. Bilbray. Mr. Chairman, I yield back.
    Mr. Mitchell. Thank you. Mr. Rodriguez?
    Mr. Rodriguez. Thank you very much Mr. Chairman, once 
again. And let me thank you for taking responsibility in terms 
of correcting that, and that is refreshing to hear. You 
mentioned earlier that in reference to the manpower that is 
needed that you submitted your budget. And I wanted to ask you 
if what you requested was what you received?
    Dr. Daigh. Sir, if you are talking about the actual budget 
submission, I would have to refer you to the management group 
at the IG's office who actually constructs the budget and moves 
forward. I do not really know exactly what the documents are 
that move forward with respect to the IG's budget as whole.
    Mr. Rodriguez. Because you did indicate that you needed 
more manpower, you needed more assistance, is that correct?
    Dr. Daigh. I indicate to my boss where I think we should 
allocate resources to more effectively allow me to do my job, 
yes sir.
    Mr. Rodriguez. And do you feel comfortable that you 
received what you needed?
    Dr. Daigh. I have received in the last several years an 
increase in manpower of two offices, which would be 12 people, 
plus 2 additional physicians since the 2004 timeframe. So I 
have received additional assets. I feel people have been 
generous in providing me assets. There is, however, more 
significant hotlines work than I can do. I have to triage what 
I do based on the demands on my staff's time.
    Mr. Rodriguez. Now, based on the work that you have already 
accomplished and those areas of corrective action that have 
been outlined, what are some of those areas and what still 
needs to occur in order for those corrective actions to take 
place, if they have not taken place?
    Dr. Daigh. Do you mean at Salisbury, sir?
    Mr. Rodriguez. Yes, sir. On the report there was some 
indication in terms of some corrective actions that were put 
out there. Have those corrective actions taken place?
    Dr. Daigh. It is my understanding from Ms. Coates and her 
team's report to me that the CAP issues that we identified a 
year or so ago, the corrective actions have been taken for 
those issues. It is also my understanding that corrective 
actions have been taken with respect to OMI's report on the 
surgery service. So I believe that actions have been taken on 
both of those reports.
    Mr. Rodriguez. Okay. So then are there any recommendations 
that have not been taken care of that you know of? Or that you 
need to still go back and reassess?
    Dr. Daigh. On our last visit we identified a couple of 
issues that we have asked the facility to address. One, in 
tunnels that connect buildings, there are telephones under lock 
or under key. So we have asked that one consider that patients 
will not have those keys, and so that needs to be addressed so 
that if there is an emergency in the tunnel that can be dealt 
with. Secondly, we found some sprinkler heads that were dirty 
in the kitchen and needed to be fixed. And thirdly, we 
identified that in the locked psychiatric ward there were 
exposed pipes from the wall to the toilet, and those are also a 
problem that needs to be addressed. So those three items, when 
Ms. Coates' team was there last week were made known to the 
facility to address, and we will follow up as we always do to 
make sure that those corrections occur.
    Mr. Rodriguez. Are there any other things that you feel 
that you could be doing that might help improve the situation 
there now?
    Dr. Daigh. Well sir, I believe that the facility has made 
some changes in leadership both within their surgery group and 
within the senior management of the hospital. I believe we have 
pointed out what recommendations we have and they have agreed 
to do them. So I think they need to have a chance to address 
the issues that we have just identified to you and we will 
follow up on those issues.
    Mr. Rodriguez. And once again, you are not aware if anybody 
has lost a job as a result of what has occurred, or anything to 
that nature?
    Dr. Daigh. In general, sir, once we identify the issue and 
the facility takes the correct action to deal with it, then I 
do not follow up on whether--we occasionally do but usually do 
not follow up on exactly what personnel action was taken, as 
long as we are assured that some appropriate personnel action 
was taken.
    Mr. Rodriguez. Okay. Thank you very much. Thank you, Mr. 
Chairman.
    Mr. Mitchell. Thank you. Mr. Space?
    Mr. Space. Thank you, Mr. Chairman. I do not really have a 
question, but a request. And this is following my colleague's 
question regarding personnel actions that may have been taken. 
And the request I have is that you provide this Committee with 
a written response concerning those personnel actions that have 
been taken, or are being undertaken as we speak. And the 
concern I have is that given what appears to be a callous 
disregard by a collective bureaucracy for some very fundamental 
points involving human life, I feel very compelled to request 
that we follow through and find that these responsible parties 
are not simply being shuffled from one part of that bureaucracy 
to another. So I am requesting, if you would, to provide us 
with a written response concerning those personnel actions that 
have been taken.
    Dr. Daigh. At Salisbury, I will, I would be happy to, sir.
    Mr. Space. All right. Thank you.
    [The information was provided in the response to Question 
2, directed to Dr. Pierce, in the Questions for the Record from 
the VA, which appears on page 66.]
    Mr. Mitchell. Thank you. Mr. Hayes? Oh, excuse me.
    Ms. Brown-Waite. Mr. Chairman?
    Mr. Mitchell. Yes?
    Ms. Brown-Waite. If, actually what I was going to ask was, 
I was going to ask Mr. Space if he would yield some time to me 
for a follow up on what he was requesting?
    Mr. Space. Sure.
    Ms. Brown-Waite. I appreciate the gentleman yielding. I 
would also ask if you could provide this Committee with a list 
of the people who were involved in this issue at the hospital 
in North Carolina, and the bonuses that they received over this 
period of time where obviously there was questionable quality 
of care that was rendered. The hospital administrator, the 
individuals who were involved, I think it would be very 
revealing to also know what kind of bonuses they received while 
this inferior quality of care was going on.
    Dr. Daigh. Yes, ma'am.
    Ms. Brown-Waite. And Mr. Chairman, if you do not object to 
that addition?
    Mr. Mitchell. Absolutely not, so ordered.
    Ms. Brown-Waite. Well, I think that the Inspector General 
certainly can provide that information also, am I correct, sir?
    Dr. Daigh. Yes, ma'am, I believe we can. I will get that 
for you.
    Ms. Brown-Waite. Okay. Thank you very much.
    [The information was provided in the response to Question 
1, directed to Dr. Steinberg, in the Questions for the Record 
to the VA, which appears on page 62.]
    Mr. Mitchell. Thank you. Mr. Hayes?
    Mr. Hayes. Thank you, Mr. Chairman. Dr. Daigh, thank you 
very much for your candor. We have covered a lot of important 
ground this morning but I want to focus in specifically on the 
nurse issue. I have written a letter on March 15 to the VISN 6 
Director and only received response yesterday, which was the 
18th. And again, to go back to the issue in realizing that 
there is separation between inspection, which is your purview, 
and management and care, which is the purview of others. But 
this person again reported a patient in stable condition 12 
days after the patient had passed away. And she also, I am not 
sure whether it is a she, this nurse had patients under her 
charge who were not visited in over 2 years. Now, in my 
response I am told, which is entirely unacceptable, that it was 
decided to enter into a last chance agreement with that 
employee. Again, sticking to your role as Inspector General, 
does your department get into recommending whether this was an 
offense that the person should have been terminated? Or is this 
a question that I should ask of management coming later?
    Dr. Daigh. I generally do not get into that issue. I would 
ask you to ask management coming later. There are clearly cases 
where significant action needs to be taken, and my office is 
essentially composed of healthcare professionals. And when we 
move into the issue of disciplinary action and hiring and 
firing actions, we are simply not the experts on that, and do 
not usually get into the legal issues involved in that.
    Mr. Hayes. Well, interestingly, as time passes, and it has 
been pointed out a lot of times past, then if corrective, 
proper actions are not taken then you are brought back in next 
year. Well, we have investigated and this person was not 
terminated, so do you have an opinion based on the facts if 
this individual should have been terminated? I think obviously 
they should.
    Ms. Coates. What we can tell you, sir, is that this 
particular nurse was reassigned to another area of the 
hospital, and that supervision was substantially increased. In 
the contract nursing home program, the facility has assigned a 
number of staff, has added a part-time nurse, and the 
visitation and the monitoring of the patients in the nursing 
homes really is at an acceptable level. We have confidence in 
that.
    Mr. Hayes. Well, again thank you. It certainly seems like 
unacceptable on any level behavior. In conclusion, again, I 
want to focus on the fact that dollars that are spent, and 
regardless of who is in the majority here I think there is a 
very high level of sensitivity to resources. But I feel 
compelled to make the point that there are a limited number of 
dollars. And I would say to everybody in the system, and 
everybody is important. The person providing care, whether it 
be the person who is in charge of the kitchen, or nursing, or 
doctors, the better quality of care that is provided, that 
makes it less necessary, takes less resources, for the 
inspection part. So I would hope that one of the results of 
this hearing is everybody will come away very clearly 
understanding that quality care, taking the dollars and putting 
it into care, and not further resources because they are not 
needed in inspection, would be a take away that I hope results 
and occurs from this meeting today.
    Dr. Daigh. Yes, sir.
    Mr. Hayes. I would rather have you inspecting than 
answering our questions up here, but I am glad you are here and 
we are going to follow it up. Thank you Mr. Chairman, I yield 
back.
    Mr. Mitchell. Thank you. Mr. Watt?
    Mr. Watt. Thank you, Mr. Chairman, and I want to express 
the appreciation of myself, Mr. Hayes, and Mr. Coble, our 
colleagues from North Carolina, for the expeditious manner in 
which the full Committee and this Subcommittee have followed up 
on our letter and on independent information about what was 
going on at the VA hospital in Salisbury, North Carolina. He, 
the Inspector General, pronounces it ``Salisbury,'' but in 
North Carolina we say, ``Salisbury,'' so. The hospital is in my 
congressional district, but both Mr. Coble and Mr. Hayes have 
had long associations with the hospital. It has been kind of in 
and out of various congressional districts over time, and we 
all have a strong bipartisan interest in protecting our 
veterans and making sure that they get quality are. So I want 
to thank you all for following up, having the hearing, and also 
for allowing us to be participants in the hearing as nonmembers 
of this Committee and of this Subcommittee.
    Doctor, I want to zero in on the bottom of page three of 
your testimony, and get pretty precise about the things that 
you say there. You indicate that on August 30, 2004, the Office 
of Inspector General, that is your office, received an 
anonymous hotline alleging that there had been more than 12 
surgical deaths in over 2 years on the surgical service at the 
Salisbury VA Hospital. On September 21, 2004, and I emphasize 
the next line, ``due to limited Office of Inspector General 
resources, this hotline was referred to the Office of the 
Medical Inspector.'' And the Office of the Medical Inspector 
did the follow up. And that Office of the Medical Inspector is 
not in the Inspector General's Office. Whose line of command is 
it under?
    Dr. Daigh. The Medical Inspector is an agent of the Under 
Secretary for Health.
    Mr. Watt. Okay. And is it in the VA system?
    Dr. Daigh. That is correct.
    Mr. Watt. So in a sense, that was kind of like having the 
inside people investigate their own problems at some level. I 
am not being critical of that.
    Dr. Daigh. No, you are correct, sir.
    Mr. Watt. And then the Office of the Medical Inspector, 
according to your information, followed up and did a review in 
April, in March of 2005, that was 6, 8 months after you 
received the allegations. And then you got a report in April of 
2005. And it issues its report of the hotline allegations and 
surgical services after the Office of Inspector General's 
review. I am emphasizing that again. So you reviewed that 
report after they did it.
    My question to you is on two fronts. And I am going to run 
out of time, so you may have to give me this information. When 
I walked in, you were saying that your office has sufficient 
resources now. I presume that is a change since this occurred, 
because your report says that you referred this to the Office 
of Medical Inspector because you did not have sufficient 
resources at that time. Is that a change? And the second thing 
I want to find out, because we may have some obligation to the 
families of those 12 people who may have died as a result of 
medical misconduct, or medical negligence, is I never saw 
anything in the report that suggested the outcome of the 12 
allegations that were made. Did you, in fact, find that there 
were any deaths that resulted as a result of inadequate medical 
care? And are you able to tell us how many of those 12 deaths 
that were alleged to be as a result of insufficient care, how 
many of them were actually due to insufficient medical care?
    Dr. Daigh. I am going to ask, sir, that you ask that 
question to the Medical Inspector, who wrote the report.
    Mr. Watt. I would not ask it of you except that you said 
that this report was issued after the Office of Inspector 
General reviewed it.
    Dr. Daigh. That is correct.
    Mr. Watt. So you all were involved in this after they did 
the review. Did you ever see anything that really addressed the 
allegations of the 12 deaths?
    Dr. Daigh. Yes, sir. The patients' care that was the 
subject of the report, their care was reviewed by outside 
physicians who were at a local university, a well-respected 
medical school. And they did a peer review of the care 
provided. Some of the peer reviews came back saying that the 
care provided met the standard of care. Some of them came back 
saying that, ``We might have done something different.'' And 
some of the peer reviews came back saying, ``We would disagree 
with the care that was provided.'' The hospital then is charged 
to take the information and act upon it through its privileging 
and credentials committee, and through other actions that they 
would take. So I am aware that the quality of care process 
stepped up, looked at the problem in what I think is a 
reasonable way, got outside reviews of that care. What I am 
unable to tell you, sir, specifically is for each of those 
cases, what the VA did in response to each of those cases. I am 
satisfied that people did the kinds of things that they needed 
to do to begin to properly assess this situation.
    Mr. Watt. Mr. Chairman, I realize my time is out. I do 
think there is a larger problem here, obviously, of what to do 
going forward to improve care. But there may be some 
obligations that we have to these 12 individuals, and I would 
request that the Subcommittee obtain the actual reports on 
those 12 individuals and see what dispositions were made of 
them, if it is your pleasure to do so.
    Mr. Mitchell. Yes.
    Mr. Watt. I realize I am meddling in your Subcommittee's 
business, but I would respectfully make that request.
    Mr. Mitchell. We will do that. Thank you.
    [The reports were received by the Subcommittee staff.]
    Mr. Hayes. Mr. Chairman?
    Mr. Mitchell. Yes?
    Mr. Hayes. While we are meddling, I feel compelled to say 
that, and everyone on the Subcommittee knows overlapping 
hearings, but Congressman Coble is tied up in a Judiciary 
Committee hearing and I assume will be here as soon as he can. 
But thank you for your patience.
    Mr. Watt. And I can verify that. I just came from the same 
Judiciary Committee hearing. But he is the Ranking Member of 
the Subcommittee that is having the hearing, so he did not have 
the latitude to leave quite as quickly as I did.
    Mr. Mitchell. Thank you. I appreciate you being here, and 
any post-hearing questions we will get back to you, we will 
have those in writing for you.
    Dr. Daigh. Thank you, sir.
    Mr. Mitchell. I know there are some people who have to 
leave for other hearings, so thank you. I welcome Panel Two to 
the witness table. Dr. Sidney Steinberg is the Chief of Staff 
at the W.G. (Bill) Hefner VA Medical Center in Salisbury, North 
Carolina, and has most recently been in the position to oversee 
reforms at this facility. We welcome his insight and 
perspectives. Dr. Steinberg is accompanied by Mr. Donald Moore, 
the former Director of the Salisbury facility and current 
Director of the Carl T. Hayden VA Medical Center in Phoenix, 
Arizona. Mr. Eladio Cintron, the Patient Services Coordinator 
of Salisbury, and Ms. Linda Shapleigh, the Patient Advocate, 
are also with them. Thank you. And Dr. Steinberg, you have 5 
minutes if you would like to make your statement.

 STATEMENT OF SIDNEY R. STEINBERG, M.D., FACS, CHIEF OF STAFF, 
     W.G. (BILL) HEFNER VETERANS AFFAIRS MEDICAL CENTER IN 
SALISBURY, NORTH CAROLINA, VETERANS HEALTH ADMINISTRATION, U.S. 
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY DONALD F. MOORE, 
 R.PH., MBA, MEDICAL CENTER DIRECTOR, CARL T. HAYDEN VETERANS 
       MEDICAL CENTER, PHOENIX, ARIZONA, VETERANS HEALTH 
  ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS (FORMER 
 DIRECTOR, JUNE 2004-OCTOBER 2006, W.G. (BILL) HEFNER VETERANS 
 AFFAIRS MEDICAL CENTER IN SALISBURY, NORTH CAROLINA); ELADIO 
   CINTRON, PATIENT SERVICES COORDINATOR, W.G. (BILL) HEFNER 
 VETERANS AFFAIRS MEDICAL CENTER IN SALISBURY, NORTH CAROLINA; 
   AND LINDA SHAPLEIGH, PATIENT ADVOCATE, W.G. (BILL) HEFNER 
  VETERANS AFFAIRS MEDICAL CENTER IN SALISBURY, NORTH CAROLINA

    Dr. Steinberg. Thank you very much, Mr. Chairman. As a 
veteran and someone who served in two previous wars, it is my 
pleasure to address your Committee and the members here 
present. I would like to thank you for giving me this 
opportunity to address your concerns regarding the quality of 
healthcare provided to our veterans at the W.G. Hefner Veterans 
Affairs Medical Center in Salisbury, North Carolina. The focus 
of my remarks will be the improvements and expansion of 
healthcare at Salisbury.
    The Medical Center in Salisbury provides quality healthcare 
to our veterans in our primary care clinics, including Winston-
Salem, North Carolina, and Charlotte, North Carolina, and 
across many specialties of medicine and surgery with our 
academic partner Wake Forest University School of Medicine. In 
recent years, Salisbury has made a concerted effort to improve 
the quality of our healthcare and to make access to care 
readily available to our veterans. We measure our improvements 
in these areas on a regular basis using a variety of measures, 
both internal and external. We track disease prevention, 
treatment outcomes, physician performance, educational 
processes, and patient satisfaction surveys. VA is committed to 
make the needs of our veterans, whatever it takes, absolutely 
positive, and Salisbury is totally committed to that process.
    Several years ago with the help of our VISN, the Veterans 
Integrated Service Network, with their leadership and a handful 
of very dedicated physicians, VA sought to make improvements in 
Salisbury department by department. VA leadership brought 
together the financial and manpower resources necessary to make 
these changes possible. For example, the waiting list of 
veterans seeking primary care appointments was a challenge and 
as a result we now have in place a system where every veteran 
on the wait list is seen promptly. VA was delighted to have 
members of Congress join with our former Secretary and Network 
Director to address the challenges that we faced in 2003 and 
2004 with the addition of more than 13,000 veterans to our 
primary care system.
    To accommodate specialty care services in the past, 
Salisbury had to rely upon a geographic partnership with the 
Asheville VA Medical Center. However, the addition of such a 
large number of new patients made it apparent that Salisbury 
would need to develop its own specialty support system for our 
veterans. To accomplish this task, VA established a new and 
stronger relationship with our academic affiliate Wake Forest 
University. Meeting with the dean of the medical school and the 
faculty leaders paved the way for the beginning of a new 
partnership to serve our patients with state of the art 
healthcare in many areas of need. These efforts led to the 
establishment of resident physician training programs in a 
number of specialties. We now have 10 approved positions, 
including ophthalmology, urology, ENT, psychiatry, medicine, 
and infectious disease. The superb eye service that we provide 
with multi-specialty support provided care to 27,000 patients 
in ophthalmology during the last fiscal year.
    VISN leadership continues to engage the Office of Academic 
Affairs on the regular basis to assist Salisbury in adding more 
resident positions in primary care, internal medicine, and 
other specialties. This year, we have added a new affiliation. 
This particular affiliation is very dear to our hearts and is 
one which we warmly welcome, with Virginia Tech University in 
Blacksburg, Virginia. This relationship is key to the 
development of expanded primary care in the future.
    The real benefit of residency training programs to our 
veterans is that they bring with them the highly skilled 
faculty members who are capable of providing state of the art 
care to all of our veterans. The progress VA has made in 
Salisbury touches every veteran and every employee of the 
Medical Center. Our staff, our patients, our community leaders, 
and our medical school educators, recognize the quality of 
these additions. These improvements in facility staffing and 
structure allowed us to provide care to more than 400,000 
outpatient visits in fiscal year 2006, as well as providing 
support for one of our principal components, the Veterans 
Benefit Administration office in Winston-Salem.
    The mental health needs of our veterans are important to 
all of us and represent a program of excellence in Salisbury. 
In this area of clinical expertise, we lead our VISN and have 
on our staff one of the world's most prestigious investigators 
in the area of traumatic brain injury. Through her efforts and 
those of her principal neuroscientist, we now have a 
collaboration with Massachusetts Institute of Technology, 
Harvard School of Medicine, and the Department of Defense, in 
providing care and evaluation for patients with traumatic brain 
injury. This team also serves as a key investigative and 
educational center for the Mental Illness Research, Education, 
and Clinical Center know as MIRECC. And this center has the 
focus of post-deployment mental health evaluations and 
treatment. Together with other VA Medical Centers in VISN 6, 
this program strives to advance the study, education, and 
treatment of all mental health conditions resulting from war.
    Mr. Mitchell. Doctor, could you please wrap it up? You are 
past the 5 minutes, but more importantly we have to go take a 
vote.
    Dr. Steinberg. Absolutely.
    Mr. Mitchell. As soon as you are through with your wrap up 
right now then we are going to recess for 15 minutes while we 
go vote and be back. But go ahead and finish, wrap up.
    Dr. Steinberg. I will skip to just a brief statement about 
the surgery programs since that has been a focus of your 
interest. We faced challenges in the quality of our surgery 
program in 2003. We have turned the corner and now have a much 
improved program. The surgery department is totally new. It is 
headed by a new Chief from Vanderbilt University, and strong 
clinical staff from other major universities in the country. We 
have training programs with Wake Forest in many of our 
specialties, and we are very proud of the progress we have 
made.
    I will be happy to answer any questions you have, sir.
    [The statement of Dr. Steinberg appears on page 50.]
    Mr. Mitchell. Thank you very much. And as soon as we get 
back from voting, after the recess we will come back and ask 
the questions.
    [Recess.]
    The first question I have, is the Joint Commission on 
Accreditation for Health Organizations (JCHO) on June 21, 2006, 
the report on Salisbury said that there was no documentation to 
indicate that staff was educated regarding the ability to 
report concerns of patient safety and quality of care to the 
Joint Commission. This includes documentation supporting facts 
that no disciplinary action or retaliation will be taken toward 
the individual. Can you tell me what that means?
    Dr. Steinberg. Well, we do have processes in place that 
address the importance of that issue. We have an online 
reporting system which allows patients, family members, members 
of the staff, to report incidents to the Office of Performance 
and Quality which we can address. And we do have within our 
organization a fairly strong peer review program, which 
addresses a lot of these concerns. We had a brief interlude 
when the peer review program had to be held in abeyance because 
of conflicts with other governmental agencies, and that had to 
do with releasing confidential information outside the 
organizational structure. That has fortunately been relieved by 
the Office of the Under Secretary, and we are now in synch with 
a very strong and very positive peer review program that 
addresses all these issues. And we do take disciplinary action 
and that action is very firm.
    Mr. Mitchell. Two very quick follow ups on this. The report 
also states that there was an incident, and I just want to 
report these incidents, where a patient was on oxygen when 
admitted to a home-based program. However, there was no order 
for the oxygen until September 2, when the patient was 
admitted--excuse me. The order was for oxygen, until September 
2 when the patient was admitted on March 5. So there was a real 
gap between when they ordered the oxygen, and when they 
released him with the need for oxygen. Is this problem still 
going on? And how do you keep this from happening?
    Dr. Steinberg. I do not know the specific answer to that 
question, sir, but I will assure you that I will find the 
answer to that and send it to your Committee.
    Mr. Mitchell. All right, I would appreciate that. And also, 
the Joint Commission Report stated that nursing staff were not 
aware of the safe storage temperature ranges for the 
medications administered by injection. This was their report. 
Do you have any written guidelines from the pharmacy on safe 
temperatures to ensure that the nurses are able to verify 
medications, and that they are stable prior to administration?
    Dr. Steinberg. Those are all part of the hospital policy, 
and the nurses are well educated in that regard. We have had 
some problems in the past with nursing leadership. Those have 
been addressed, and those modifications in nursing leadership 
have been taken care of.
    Mr. Mitchell. Would you say all these incidents that were 
part of this Joint Commission, that they brought up, you have 
corrected all of these?
    Dr. Steinberg. Yes, sir.
    Mr. Mitchell. Is there any written verification that they 
have been corrected?
    Dr. Steinberg. Our Office of Quality Management addresses 
all of these, and reports these questions back to the Joint 
Commission on a regular basis. I have just recently made a 
correspondence with the Joint Commission to address other 
issues, as well. We have a website that we log onto from our 
Office of Performance and Quality, the Joint Commission 
website, that gives us information about our progress, what we 
are doing, and how we have responded.
    Mr. Mitchell. Thank you. Mr. Bilbray?
    Mr. Bilbray. Yes. Doctor, you know there are references to 
the construction projects and the expansion of the facilities, 
and I would just like to comment, give you a chance to comment 
on, frankly my perception is the problem is not your space, it 
is the breakdown in the entire operational process. And how 
would you reflect the issue of the construction and how that 
may be part of addressing the systemic problems that we saw on 
the operational?
    Dr. Steinberg. We would love to have a new hospital, but I 
will leave that aside. We took apart every single piece of the 
hospital, building by building, and restructured it. The first 
place we started was in the surgical department, where we got 
the appropriate funding to build three new major operating room 
suites. Those suites will open effectively on May 1 this year. 
State of the art facility which will provide the support that 
Wake Forest needs, and we need, for providing the technical 
capabilities of the surgery department that we want to have.
    The second thing we did was to take apart all of primary 
care. With 60,000-plus patients in primary care, we wanted to 
have a consolidated building to reduce the traveling that 
veterans had to have from building to building across this 150-
acre campus. We consolidated all of primary care into one 
building, so there was a single site for primary care within 
the facility. And part of this is in preparation for the 
opening of two other clinics, one in Hickory, North Carolina, 
and one in Charlotte. But we now have a model within Salisbury 
that handles all of primary care within a large building.
    Mr. Bilbray. Well doctor, my point being, though, is that 
as you talk about, and that is easy because there is some 
vision, and there is concept of building it. You can buy the 
most modern vehicle in the world with, you know, anti-roll and 
all this other stuff. But if it is a reckless driver driving 
the vehicle, you know, we are still going to have problems. And 
I do not see where space and a lot of these capital projects 
have to do with operational problems, like having a patient sit 
there for over 24 hours, or 12 hours, without having 
postoperative observation made by a nurse. All of these 
facilities will not change that. So I think that in all 
fairness, it is almost like a bait and switch I am focusing 
here. It is, again, we need more money for construction, but 
when we get down to the deficiencies, the deficiencies were 
more internal, operational issues.
    Let me just sort of, and accept that as a cheap shot if you 
think it is a cheap shot. I appreciate that. But you have got 
positions with vacancies now. Specifically, some of these 
vacancies, how long have they been open and what are you doing 
to take care of them?
    Dr. Steinberg. We actually do not have very many vacancies 
on the clinical side of the house. We have added probably 40 or 
50 new clinical positions over the last year and a half. We 
have gone to various medical schools around the country and 
recruited some of the top physicians from the Mayo Clinic.
    Mr. Bilbray. How about your Chief Nursing position?
    Dr. Steinberg. Chief Nurse is filled. We have a wonderful 
new Chief Nurse who has joined us. She was the former Chief 
Nurse for the U.S. Naval Hospital in Charleston.
    Mr. Bilbray. How long was that position vacant?
    Dr. Steinberg. That position was vacant probably about 4 or 
5 months.
    Mr. Bilbray. Four or 5 months?
    Dr. Steinberg. The process of bringing on a key individual 
at that level is a difficult process because there are a lot of 
human resource requirements in recruiting and selecting an 
individual for that----
    Mr. Bilbray. So you are telling this Subcommittee, under 
oath, that it was 4 or 5 months. Which one was it?
    Dr. Steinberg. I do not really know the exact timeline.
    Mr. Bilbray. But it was not, your testimony today, doctor, 
is that it was not over 5 months?
    Dr. Steinberg. The position was never vacant because in the 
absence of a Chief Nurse there was someone appointed 
temporarily to that position until the new Chief Nurse could be 
selected.
    Mr. Bilbray. So are you saying to this Subcommittee, under 
oath, that there was a temporary Chief Nurse for no more than 5 
months.
    Dr. Steinberg. I am not sure of the exact timeline of her 
visits with us as an interim Chief Nurse, but Mr. Moore could 
perhaps answer that.
    Mr. Moore. I believe the current Nurse Executive was 
removed from his position in December and the replacement was 
brought in, December of 2004, and the replacement was brought 
in approximately June of 2005. And as Dr. Steinberg had 
mentioned, at that level recruitment is extended, takes an 
extended period of time to put an appropriate search Committee 
together, to interview, most of these candidates apply from 
around the country so the interview process is quite lengthy.
    Mr. Bilbray. So now the number kind of, that, look I was a 
history major not a math major. But June tells me that it might 
have been a little longer than 5 months if it was December to 
June. Right? Is that fair to say?
    Mr. Moore. Five to 6 months, yes sir.
    Mr. Bilbray. Okay. Thank you, Mr. Chairman.
    Mr. Mitchell. Over the last few years, have you had any 
problems with credentialing?
    Dr. Steinberg. Well, we have a very good system called 
VetPro, which looks at someone's pre-appointment credentials so 
that we know before someone is officially appointed whether 
they meet the appropriate professional standards to be on the 
staff. And this process is repeated every 2 years to be certain 
that there are no gaps in the system. This includes a track 
with the National Practitioner Data Bank and other issues, and 
our credentialing system is very good, very capable.
    Mr. Mitchell. Thank you. Mr. Watt?
    Mr. Watt. Thank you, Mr. Chairman. And I thank you and Mr. 
Bilbray for allowing us to be here. I want to do something that 
is kind of out of the ordinary, which is somewhat spring to the 
defense of Dr. Steinberg. You will note that he has been in 
this position only since October of 2006. And Mr. Moore has 
been in his position longer, but I will tell you from my own 
personal experiences representing this area and this VA medical 
facility that there was a period of time when there were major, 
major problems throughout the whole campus. And at least part 
of it was due to a Director of the entire operation who really 
had some serious problems, management issues, over a period of 
time. And it took a while to kind of work through getting him 
out.
    I can tell you based on the number of complaints that we 
get in our office that substantial progress is being made. And 
that the work that is being done by this group of managers, 
while it may still leave a lot to be desired in terms of 
accomplishing the overall mission, I can tell you from my own 
experience that it is light-years better than the prior 
management. That is not to be taken as a ringing endorsement of 
everything that is going on at the VA. Obviously, there are 
some problems in Salisbury. But I hope we will not cast all the 
blame on this management team, because there was a management 
team there before that was not as devoted to this. And I think 
a lot of the problems that we are addressing today are a 
function of that management team rather than this particular 
one.
    Having said that, Mr. Moore and Dr. Steinberg, I want to be 
reassured and have the Subcommittee reassured that you all have 
looked at all 12 or 13 of the points that were made in the 
evaluation that was done by the OIG and the Medical Director, 
and have taken specific, concrete steps to address each one of 
those areas that was identified as shortcomings. Would you be 
able to verify that you either have taken steps or are in the 
process of taking steps? And with respect to the ones that you 
are not now satisfied that you have reached a satisfactory 
conclusion, would you identify those specifically either today 
or in writing and tell the Committee what specific steps are 
being taken in response, ongoing steps, are being taken in 
response to those?
    Dr. Steinberg. We have taken those steps and we are still 
taking them. Our Morbidity and Mortality Review Program is as 
good as any can be within the setting that we have. It is done 
in concert with a very superb surgical faculty. We have taken 
steps to improve peer review, including within our peer review 
system the entire Medical Center peer review, not just for 
physicians, but nurses, rehabilitation medicine, physical 
therapists. All of the peer review programs that the hospital 
identifies and looks at are all brought under one roof for 
evaluations. We have taken steps to, one of, probably the most 
important one, was to bring to the Medical Center a whole new 
post-anesthesia care unit staff, which we did not have in 2003. 
That was one of the critical shortfalls of the Medical Center. 
And we now have nine fully trained and certified critical care, 
or rather PACU nurses as they are called, Post Anesthesia 
Recovery Nurses, who run an operation which allows us to 
provide care 24/7 for the surgical patients in the hospital. We 
have done all those things and we are addressing on a 
continuing basis through the Office of Quality and Management 
all of those issues, yes sir.
    Mr. Watt. Let me ask you to be, in follow up, more specific 
on the things that are still in process, not necessarily right 
now because I am out of time and I know we are up against the 
voting deadline. But if you could just outline, unless you have 
done so in your written testimony, the specific steps that you 
have taken that are still in process at a subsequent time.
    Dr. Steinberg. Right. One of the specific things that is 
still in process is to improve our educational program. And we 
are doing that in several ways. But one of the things that we 
felt was very important was to continue the ongoing educational 
processes that are important for things like peer review, 
morbidity and mortality review, educational processes that 
physicians, nurses, and other staff members need to be certain 
that they have the tools to address these issues on a regular 
basis. The anonymous reporting system that we have for staff 
members at the hospital that allows us to have in our hands, 
anonymously, any issue that anyone wants to bring to our table 
to discuss is something we welcome, and we are expanding that 
program on a regular basis.
    Mr. Mitchell. Thank you. Thank you. Mr. Hayes?
    Mr. Hayes. Thank you, Dr. Steinberg and Mr. Moore and 
others for coming today. I think fairness is important. I 
appreciate Congressman Watt's comments. I, too, would like to 
say that in our district office we have had a number of 
compliments for exceptional care, and that is important. And we 
do have an occasional complaint, and we are talking about some 
very serious issues. Dr. Steinberg or Mr. Moore, should the 
nurse that I referred to in my statement have been fired?
    Mr. Moore. Actually, I had proposed removal of that nurse. 
And we were planning to fire her. Then upon advice from 
regional counsel and human resources, they recommended that we 
not fire her and it was based on three issues. One, she had had 
no adverse, any other adverse, actions in nearly 30 years of 
service. While what she did was just terrible, it had no effect 
at all on patient care. She was not the patients' caregiver in 
these nursing homes. Her role was an oversight role, a vendor 
oversight, to see that the vendors did under contract what they 
were supposed to do. And third, regional counsel said it was 
very unlikely that any outside disciplinary appeals board would 
uphold the firing. That we could go through a protracted length 
of time, hundreds of thousands of dollars, and wind up with her 
back. So they had several recommendations which I felt were too 
light for this situation. I went with the proposed removal, and 
then did hold it in abeyance for 2 years.
    Mr. Hayes. I appreciate the completeness and the detail of 
your answer. However, the facts would ask that additional 
oversight be provided here for someone to report that a patient 
was stable 12 days after they had died. And again, let me stop 
there and back up just a minute. We appreciate the service of 
veterans hospital employees and others who are tremendous civil 
servants. And there are requirements, and those employees have 
rights and deserve to be protected as well. So with the 
qualification, again I would like you to report back to me and 
Congressman Watt and others, is to, the reluctance of the 
oversight board, the problems of a termination here. I think we 
should look at that a little bit more closely because number 
one, you have got the 12 days after which the person had passed 
away, but you have also got over 2 years where this person had 
not visited. Something was wrong. This person had issues that 
were keeping them from doing their job, but let us look more 
deeply into that. Because the confidence of the Subcommittee, 
the public, and other members of the VA, it is not as important 
as the care of the patient, but it is very important going 
forward that we do not have a system that allows someone whose 
performance determines life or death, in some instances, of the 
patient, let us investigate that further and review it more.
    Dr. Steinberg. That, sir, is a very important statement. 
And the CAP survey did point out another very serious flaw in 
the system, which I would address with you, and that I think we 
have corrected. What we found was that we were never notified 
by any of the contract nursing homes when they had been placed 
on a Licensed Agency Watch List. In other words, they had done 
something which had raised a red flag about the care that they 
provided in these contract nursing homes. We had no way of 
getting that information automatically. We have had our 
contracting folks change the rules now, so that as part of 
their contract if they are notified by any agency that they are 
placed on the Watch List that they have to report that to us 
within 10 days. That is a very important change in the system, 
and is a reflection, I think, of the findings from the CAP 
survey.
    Mr. Hayes. It is important. Thank you for pointing that 
out. Mr. Cintron, or Ms. Shapleigh, do you have anything you 
would like to add to that? That is what the newspaper always 
does when they want to trick you into saying something. Thank 
you very much. Mr. Chairman, I yield back.
    Mr. Mitchell. Thank you. And I would just like to tell the 
panel, any reports that were asked by either Mr. Watt or Mr. 
Hayes, if you would address those to the Subcommittee, and then 
we will distribute those to the members of this Subcommittee 
and those who ask for it. So, please give those reports to us.
    Just very quickly, a couple questions to Mr. Moore. And Mr. 
Moore, it is good to see you. He took me on a tour of the Carl 
T. Hayden Medical Center in Phoenix not too long ago. Just very 
quickly, how are doctors and nurses screened throughout the 
whole VA system to ensure that they are in compliance with the 
VA medical guidelines?
    Mr. Moore. Well, as Dr. Steinberg had alluded to, we have 
an extensive credentialing and privileging process. And I 
really can only speak to the hospitals that were under my 
management, but the systems are common to all hospitals. There 
is a, I would venture to say our screening and prescreening 
process is far more stringent than any private sector. We have 
actually had some physicians decide maybe not to come to the VA 
because we went so far back in their history, getting all of 
the, assuring that all of the credentials were appropriate for 
them.
    Mr. Mitchell. So, all their verifications with their 
licenses and their practices, this is all done----
    Mr. Moore. Before they walk in the door, yes sir.
    Mr. Mitchell. Okay. I have one other question, Mr. Moore. I 
want to depart from what we have been saying here. One question 
that my constituents would like to know, are there any quality 
care issues at the Carl Hayden VA Facility in Phoenix that I 
should know about? Especially in light of issues that we are 
addressing today. I do not want to find out that there are 
problems at the Carl Hayden VA Hospital from the newspaper, 
like some of the reports that we have been finding out lately. 
So, are there any quality of care issues that we need to know 
about at the Phoenix facility? And if there are, what are they 
and what are we doing about it?
    Mr. Moore. Well, I certainly hope that there are not. There 
is always clinical issues that we are looking at. We look at 
different rates of deaths in intensive care units and other 
areas. But there is nothing that I am aware of that should be 
of major concern that would put any of our veterans patients 
and their care in jeopardy at the Carl T. Hayden VA Medical 
Center.
    Mr. Mitchell. So you do not think there is going to be 
anything I am going to be reading about in the paper about the 
Carl Hayden Medical Facility in terms of quality of care?
    Mr. Moore. No, sir. There was an Office of the Inspector 
General CAP survey at the Carl T. Hayden VA Medical Center I 
believe just several weeks before I got there. And it was one 
of the best CAP survey reports that I have read. So I was very 
proud to be coming into a facility that achieved such a great 
survey.
    Mr. Mitchell. All right. I do not want to read about any 
problems with that facility. Thank you. Thank you very much. 
And we are going to recess this Subcommittee hearing until 
after the vote, which is about 15 minutes.
    Mr. Bilbray. Mr. Chairman, can I just ask quick question? 
Doctor?
    Dr. Steinberg. Yes, sir.
    Mr. Bilbray. The sort of the last ditch tickler that there 
is a major problem is usually the morbidity review. There are 
no minutes of a Committee reviewing the deaths in the facility. 
Did you have a review process or was there a review process?
    Dr. Steinberg. We review every death at the hospital. We do 
a lot of RCAs to look at these.
    Mr. Bilbray. Do you do it with a review Committee?
    Dr. Steinberg. We have a review Committee, we absolutely--
--
    Mr. Bilbray. Is there a reason why there were no minutes to 
the Committee?
    Dr. Steinberg. Well, I think we have minutes.
    Mr. Bilbray. Now?
    Dr. Steinberg. I do not know what the history was, you 
know? I was not there for that at the time, but we have good 
minutes now.
    Mr. Bilbray. Okay.
    Dr. Steinberg. They are well recorded, and our morbidity 
and mortality data ranks the VA Medical Center in Salisbury 
within the top eight VAs in the country. We are below the 
morbidity and mortality levels----
    Mr. Bilbray. But prior to your arrival?
    Dr. Steinberg. The numbers were not good. You know, part of 
the reason for the issues that were brought up by that 
anonymous call had to do with the fact that there were 
procedures done in the operating room which belonged in an 
endoscopy suite. And if you look carefully as we did at the 12 
alleged deaths, many of these were in terminally ill patients 
who were part of the hospice unit who had feeding tubes put in 
for palliative reasons. And their deaths were anticipated 
deaths, and they were not related to a surgical procedure per 
se.
    Mr. Bilbray. That is not what I was concerned about. Again, 
I am going over the procedure. We have corrected the procedure 
that, the reports I had was that they did not have a 
functioning Committee reviewing these deaths, or at least we do 
not have any records of them. And that, let us face it, that is 
sort of the last ditch catch all, is always reviewing every 
time we have a death in a facility, is to make sure that the 
process that led up to that death was well within the 
parameters of the facility.
    Dr. Steinberg. I would not minimize the problems that were 
there in years past, because they were significant. It is my 
hope and prayer that we address all of them effectively as we 
have in the last few years, and that we will continue to do 
that. But there were mistakes made and there were serious 
problems and we think they have been corrected.
    Mr. Bilbray. Thank you very much, Mr. Chairman.
    Mr. Mitchell. Thank you. We are going to take about a 20 
minute recess. And when we come back we will see Panel Three 
and will continue. This meeting is recessed.
    [Recess.]
    Mr. Mitchell. We will reconvene the Subcommittee on 
Oversight and Investigations for the Committee on Veterans' 
Affairs. And I would like to just mention that the Ranking 
Member will not be here. She is tending to one of her own 
bills, which is having a hearing right now. So instead I will 
have the Minority Counsel follow the line of questioning that 
would have occurred.
    At this time we are welcoming Panel Three. Mr. William 
Feeley, the Deputy Under Secretary for Health for Operations 
and Management is here courtesy of the VA and I would like to 
welcome his thoughts. He is accompanied by Dr. James Bagian, 
the Chief Patient Safety Officer, Dr. Barbara Fleming, the 
Chief Quality and Performance Officer, and Dr. John Pierce, the 
Medical Inspector. Mr. Feeley, you have 5 minutes to make your 
comments.

   STATEMENT OF WILLIAM F. FEELEY, MSW, FACHE, DEPUTY UNDER 
 SECRETARY FOR HEALTH FOR OPERATIONS AND MANAGEMENT, VETERANS 
  HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
  ACCOMPANIED BY JAMES P. BAGIAN, M.D., CHIEF PATIENT SAFETY 
  OFFICER, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 
 VETERANS AFFAIRS; BARBARA FLEMING, M.D., PH.D., CHIEF QUALITY 
 AND PERFORMANCE OFFICER, VETERANS HEALTH ADMINISTRATION, U.S. 
   DEPARTMENT OF VETERANS AFFAIRS; AND JOHN R. PIERCE, M.D., 
    MEDICAL INSPECTOR, VETERANS HEALTH ADMINISTRATION, U.S. 
                 DEPARTMENT OF VETERANS AFFAIRS

    Mr. Feeley. Good afternoon Mr. Chairman and mmbers of the 
Subcommittee, and I want to thank you for the opportunity to be 
here today. I want to state that Salisbury has turned a corner 
and I am pleased with the positive steps they have taken to 
improve the quality of care provided at the VA Medical Center 
during the past 2 years. In my statement, I will focus on the 
many ways VA monitors the healthcare of our veterans and 
returning warriors and ensures that our VHA facilities learn 
from this process.
    In the late eighties, VA healthcare programs came under 
intense scrutiny because of the perception that quality was not 
comparable to that found in the private sector. Since that 
time, VA has implemented numerous programs to ensure that 
quality of healthcare provided to our veterans is world class. 
The results of these efforts have brought national recognition 
to VA as consistently being recognized as one of the premier 
healthcare providers in the United States. VA's successes can 
be attributed to the leadership and contributions made by the 
offices of the talent sitting with me today, as well as the 
daily efforts of the VHA workforce.
    VA's performance measuring system is a key part of the 
transformation of care that started in the mid-1990's. The 
system has over 100 performance measurements in the areas of 
access, satisfaction, cost, and quality. Data on these measures 
are collected monthly and all performance is shared and 
distributed in a quarterly report to the field facilities with 
information broken down into aggregated totals for facilities, 
network, and the VHA overall performance. Patient complaints 
are assessed by a series of questions on the inpatient and 
outpatient satisfaction survey asking whether each veteran has 
a complaint about VA care and whether the veteran was satisfied 
with the resolution of the complaint. Patient advocates in the 
National VA Patient Advocacy Office monitor these results 
closely to ensure that veterans' voices are being heard daily.
    VA utilizes a learning system that exports and disseminates 
information to all segments of the VA healthcare system so that 
providers can learn how to deliver care that is not only safe, 
efficient, cost effective, but clinically measurable and 
evidence based. For example, the systematic ongoing assessment 
and review strategy, known as SOARS, is a unique internal 
initiative that was implemented within VHA in 2004. Our own 
staff are trained to conduct assessments of more than 30 major 
processes at facilities to identify weaknesses, best practices, 
and help educate staff required for functions and activities 
across the country. These are not people reviewing their own 
facilities; these are people reviewing other facilities. This 
innovative approach promotes a culture of continuous learning 
and readiness throughout the organization.
    As a public system the VA undergoes intense scrutiny from a 
variety of accreditation agencies, both external and internal. 
There are approximately 45 different types of reviews that can 
occur at our Medical Centers during any period of time. One of 
the most recognized is the Joint Commission on Accreditation 
and Healthcare. All our VA facilities are accredited. Also, the 
Office of the Inspector General, the Government Accounting 
Office, are frequently visiting our facilities and giving us 
feedback on how to improve our system. Both the JCHO and OIG 
reviews give us ongoing opportunities to identify our strengths 
and weaknesses.
    I appreciate the opportunity to talk with you today. The 
events at Salisbury have spurred us to go even farther in our 
monitoring process than I have described to you. I am 
instituting additional rigor with oversight in transporting our 
learning throughout the system. The more rapidly we learn, the 
better our patient care impacts will be. I look forward to 
taking any questions that you might have, and that concludes my 
statements. Thank you.
    [The prepared statement of Mr. Feeley appears on page 52.]
    Mr. Mitchell. Thank you, Mr. Feeley. I have a couple 
questions for Dr. Pierce. I know the focus here is on 
Salisbury, but we are also trying to find out if procedures and 
things at Salisbury are also going on in other hospitals, 
because this is a concern we all have. In the June 9, 2005, 
report you stated that the culture of surgery service was not 
one of quality improvement. You stated that there has been 
inadequate ongoing review of the quality of care provided by 
the surgery service, as their participation in performance 
improvement has been lacking. Firstly, I want to know, what has 
Salisbury done to rectify this? And is this problem solely one 
that is at Salisbury, or is this problem found in any other VA 
hospitals?
    Dr. Pierce. Good afternoon, sir. I feel like Salisbury has 
done a very good job to correct this. I think they have turned 
this program around 180 degrees. And if they were, if I were to 
grade them from when we first went I would have to give them 
probably a D minus, but I would have to give them a very strong 
B plus now because they have grabbed this problem by the throat 
and taken care of it, I think. They have new personnel, and 
they have a new commitment to quality management. They have a 
new quality management nurse that is in the surgery service, 
and they have grasped the requirements and they are doing a 
good job with that.
    We have seen some, probably not quite as broad, but some 
similar issues at other facilities. For example, we went to a 
place to look at their surgical program and they were doing 
surgical morbidity and mortality Committee meetings but they 
were not doing minutes. And so we took that information back to 
the National Director of Surgery and on a systemwide conference 
call he made sure all the Chiefs of Surgery understood that not 
only do they have to do an M and M Committee meeting but they 
have to do minutes of that Committee. And that was spread 
throughout the whole system. So we do take the information we 
find and try to transport it throughout the whole system.
    Mr. Mitchell. I think you understand that our concern is 
that while we know that you said maybe Salisbury had a D minus, 
and it was very bad, and so that is why you came in. But we 
want to make sure that other hospitals do not ever reach that 
level. I think it is up to you to make sure that what you found 
in other hospitals is transmitted. And if you had a conference 
call, for example, on minutes I would hope that there are 
systemwide conference calls very frequently so that what you 
find in one place can be transmitted and everybody is aware of 
how to correct these.
    Let me ask also, Dr. Pierce, have you gone back to 
Salisbury for a follow up from your initial visit in 2005?
    Dr. Pierce. Yes sir, we went back last month. You know, 
when we first went there, what our process is, is when we go to 
a site visit and we come back and write our report, we usually 
make a number of suggestions for them to change things to 
improve things. And those things, when they are agreed to by 
the Under Secretary for Health, the facility does an action 
plan addressing each and every one of those items. And I think 
the initial Salisbury report had 18 findings on it that they 
had to address. The facility did an action plan, and addressed 
each one of those 18 findings. We reviewed the action plan, and 
then we approved the action plan. And over the course of the 
next year, we tracked those items with input from the facility 
to show to us that they had corrected these things.
    Mr. Mitchell. And they have met them?
    Dr. Pierce. There is follow up on our reports. That came up 
before, that we follow those reports up and every finding that 
we have, an action plan is done and we track that with the 
facility, and make sure that those things are done. And then 
once they are done, which sometimes it takes a year or so for 
everything to be accomplished to our satisfaction, we usually 
close the report.
    Mr. Mitchell. Have they been closed?
    Dr. Pierce. We did close the Salisbury report in August of 
2006.
    Mr. Mitchell. Thank you.
    Dr. Pierce. And we did go back about a month ago to make 
sure, just to check everything, and we felt like that they had 
responded appropriately to all of the things that we had found 
there. We did find that, we had asked them to make sure that 
they informed the families about autopsy findings. And we asked 
them to show us their autopsy reports for the last couple 
years. They do not do a lot of autopsies there, and there were 
seven total reports. And of those seven reports they were not 
all done to our satisfaction. They need to improve that, and I 
think they are aware of that. So there was only two of those 
where there was documentation in the medical record that the 
family had been notified. There was another documentation 
elsewhere that letters had been sent to the family. There were 
a couple that apparently they could not document they had 
actually talked to the family about the autopsy results. So 
that was one of our findings that they have not completely 
responded to.
    Mr. Mitchell. All right, let me ask just one quick follow 
up. Every time you find a deficiency in these, I would hope 
that you would pass this finding onto other medical facilities. 
That you would not have to go to each facility and say, ``Oh 
yeah, we just had this same problem in another State.'' That 
you would make sure, that if these things were not followed in 
Salisbury, for example, communicating with family members, I 
assume they probably were not being followed in other hospitals 
as well. I would think that every time you find a problem in 
one, that you have a conference call or you have something that 
says, ``Hey, we need to make sure.'' If it is done in one, I 
suspect it is going to be done in another. Thank you. Mr. Wu?
    Mr. Wu. Mr. Chairman, Ms. Brown-Waite, the Ranking Member 
of your Subcommittee appreciates your indulgence in allowing 
the Minority Counsel to pursue her line of questioning, and I 
thank you again.
    Mr. Feeley, we have read in your testimony about how the 
VA's National Center for Patient Safety has made great strides 
to have VHA understand and prevent adverse events to our 
veterans patients. I would like to recognize Dr. Jim Bagian, 
who is accompanying you, for all his efforts in spearheading 
these preventive, lifesaving measures. I especially appreciate 
his efforts in bringing the dangerous practice of incorrectly 
cleaning and disinfecting a special ultrasound device used for 
prostate biopsies. His discovery and immediate alert on this 
potentially extremely dangerous practice prompted this 
Subcommittee to bring the FDA lack of interest in issuing a 
national alert to the forefront, and resulted in a national 
alert warning to help protect all patients, not just veterans. 
Thank you, Dr. Bagian. Would you like to talk on your role in 
how we use the Patient Safety Center that you head up in 
recognizing these adverse events and trends so that you can 
prevent them on a systemic basis using Salisbury as a study?
    Dr. Bagian. Sure. Yes, I would be glad to. Thank you. I 
would like to make a few remarks to start out with. Earlier the 
question was asked, I think, of Dr. Daigh, how collegial, the 
word was not collegial, but the interaction between OMI, OIG, 
and the VA. And I would like to say from the beginning when we 
set up the Patient Safety Program with the VA one of the first 
sets of meetings I had, and they were the predecessors of Dr. 
Pierce and Dr. Daigh, was to talk to them because my view, and 
I think the view of VHA, was that though it might not always 
seem that way, we are working toward the same goal, and that is 
to deliver the best quality of care and safest care we can to 
our patients. And if they would know something or discover 
something that we did not know, and that certainly can happen, 
we want to profit by that. So that is one thing I would like to 
get out front, and we continue to have, I think, a good ongoing 
relationship in that regard.
    We have numerous ways that we find out about things. Some 
are through formal reporting systems, and we have several of 
those. I would point out that we look not only at adverse 
events that happen, some of which have been discussed today, 
but we also look at close calls. Close calls are those events 
that could have resulted in harm to the patient but did not, 
either due to a good catch by somebody or sometimes just good 
luck.
    Mr. Wu. Well, let me interrupt you for a second here. In 
your reporting system on close calls and non-attribution on 
reporting near misses, using your system and the way you have 
educated the system and tried to promulgate that, did any of 
the events at Salisbury ever rise to your attention based upon 
the system that you utilize?
    Dr. Bagian. Absolutely yes. In fact, the one case that was 
talked about is the index case, the surgical case that was 
mentioned a little bit earlier. That case occurred, if I recall 
correctly, on July 14. The RCA Panel was convened and charged 
on July 14, and I believe on August 23 they had concluded the 
RCA with their recommendations and action plans were filed. So 
it was well within the prescribed period of time to respond and 
action was already being taken. I mean, that is one for example 
I know of in detail, off the top of my head.
    Mr. Wu. Well, how would you follow up, once it reaches your 
radar screen, and the RCA, the Root Cause Analysis is done, 
that you follow up, or what is the follow up mechanism of 
whether or not that facility and those findings are corrected 
or remedied?
    Dr. Bagian. Okay. When an RCA is submitted, well, there are 
a couple of things in the flow. Firstly, when the incident is 
first discovered and is SACed, that is when they prioritize it 
and that is where we have a very explicit method by which we 
decide does this rise to the level that requires action. In the 
case of that surgical case, that met that mark. Even if it does 
not, it is filed in our data collection system so we get it 
right then. At that time, we will review that. If we think it 
is something that has global impact based on just a few 
sentences that were reported. We do not know all the things 
yet, it is just that it happened. If we think this is 
something, and that is what happened with the ultrasound you 
talked about. Before the RCA, Root Cause Analysis, was even 
completed we realized this was much bigger than that and we in 
parallel did the things that you referred to.
    Mr. Wu. Well, how was your system used in those issues that 
rose to your attention out of Salisbury then?
    Dr. Bagian. Okay. So what happens is, in this case the 
Salisbury incident, that first report that there had been a 
patient incident was not enough to say is this a generic 
widespread thing, as the Chairman talked about a few moments 
ago. It was not clear. So we waited for the results of the root 
cause analysis. When the root cause analysis is finished, it is 
submitted to the National Center for Patient Safety. They are 
all filed with us, and they are reviewed by our analysts there. 
And there are a number of criteria. But then they feed back to 
the institution if there are things that appear to be lacking, 
for instance specificity of causation statements or weaknesses 
of corrective actions, and that is fed back in a short period 
of time.
    At that point, in the forms, in the system, it also sets 
reminders. So, for instance, if they say----
    Mr. Wu. And Dr. Bagian, I see that my time is up and I do 
not want to outlive my welcome with Chairman Mitchell. And I 
will pursue this on the second line of questioning. Thank you, 
Chairman Mitchell.
    Mr. Mitchell. Thank you. Mr. Watt?
    Mr. Watt. Thank you, Mr. Chairman. And this is likely to be 
my last opportunity to reinforce something I said earlier to 
you and the Ranking Member of this Subcommittee and to the 
Chairman and Ranking Member of the full Committee how much we 
appreciate, Congressman Hayes, Congressman Coble, and myself, 
the speed with which you all undertook this review and the 
thoroughness and attention that you have paid to it. And also, 
to thank you once again for allowing us, as nonmembers of the 
Veterans Affairs' Committee, to be active participants in 
today's hearing. So I know I have said that three times now, so 
three times is the charm and I will try not to say it again.
    Mr. Pierce, I think I want to follow up with you because 
the Inspector General kind of threw a ball to you. And I want 
to break this down as concretely as I can. This original 
investigation was started by an anonymous phone call that 
alleged that twelve veterans had died as a result of improper 
medical care. And I am putting myself in the position of the 
family members of those 12 people. And I would like to know, 
obviously what Mr. Feeley has said, that attention has been 
given to correcting the problems and that the VA Hospital at 
Salisbury has a B plus report. We hope it gets up to an A at 
some point going forward, and that quality medical care is 
provided to all veterans going forward. But the other side of 
this is that the question I raised this morning, is our 
responsibility to those 12 families. An investigation was done 
by your office, and an evaluation was made individually, I 
assume, of those 12 cases. Is that correct?
    Dr. Pierce. Sir, our office did not look at all 12 of those 
cases. Those 12 cases, in fact, let me back up a little bit. 
The anonymous information we had had no names of patients.
    Mr. Watt. Yes.
    Dr. Pierce. It mentioned one patient, the gentleman that 
was the surgical index case in our report of 2005. The other, 
we did not have any names for.
    Mr. Watt. Well, at Salisbury VA Hospital, how many deaths 
would you have on average in a 1 or 2 year period before this 
anonymous tip came?
    Dr. Pierce. The information that I have looked at from the 
facility, their reports, including the nursing home and the 
psychiatric units, they have about 50 deaths every 6 months. So 
it is about 100 deaths a year.
    Mr. Watt. So you would have had to go back individually and 
review all 100 of those cases for the prior year?
    Dr. Pierce. Well, the assumption was that these were from 
the surgical service because of the way the letter was----
    Mr. Watt. Okay, how many would you have in the surgical 
service?
    Dr. Pierce. Well, I think these 12 deaths, what they did is 
they went back 2 years and it equated to about 12 deaths, and 
they had all 12 deaths reviewed by their affiliate medical 
school.
    Mr. Watt. Now----
    Dr. Pierce. We looked at those, and we looked at those 
reviews that the medical school did, and thought they had done 
an acceptable job in reviewing those.
    Mr. Watt. Okay.
    Dr. Pierce. We pulled out the case that became the index 
case for us because we thought that was particularly 
problematic, and went to the facility to specifically look at 
that case and the care that that gentleman got.
    Mr. Watt. Okay, well let us look at the other 11 cases 
first. You are saying that your determination in the other 11 
cases was that there was no lower than expected quality of 
care?
    Dr. Pierce. In those 11 cases, 5 of them were rated as they 
received care that every other doctor would give.
    Mr. Watt. Okay.
    Dr. Pierce. Five were rated that we might have done some 
things a little different, and two were rated we would have 
done it differently.
    Mr. Watt. Okay. Let us look at the seven, then, that we 
have narrowed this down to, and what I am trying to get to is 
what is our obligation then, what then happens with the 
families of those seven people? There is a possibility that 
less than adequate medical care has been provided to their 
loved one. There is a possibility that their loved one may have 
died as a result of that lower quality medical care. What is 
our responsibility? What is our follow up? What do we do with a 
family in that situation?
    Dr. Pierce. We have a requirement if an adverse event has 
occurred, whether it results in a death or not, but just an 
adverse event occurs to a patient, the patient has to be told 
about that. And so in these seven cases or, you know, we would 
look at those cases----
    Mr. Watt. Well, we know an adverse event occurred. They 
died. So that was an adverse event. Who would have the 
responsibility of going out and communicating with the family 
of that patient and looking them in the eye? And what would you 
say about the quality of care? Would you just say your loved 
one died and it is unfortunate? Or how much information would 
we give the family about the circumstances of that 
investigation?
    Dr. Pierce. I think full disclosure is what we would like 
to see. That if we have done something incorrect medically, the 
family should be told about that and should be offered the 
opportunity to file a claim about that.
    Mr. Watt. Okay. All right. I know I am out of time. I am 
sorry.
    Mr. Mitchell. Thank you. We can come back. Mr. Coble?
    Mr. Coble. Thank you, Mr. Chairman. I want to reiterate 
what Congressman Watt said. Thank you for extending the 
courtesy to him, Congressman Hayes, and me for this. And I want 
to thank Congressman Watt also for explaining my absence 
earlier. I was tied up in a Judiciary Committee hearing and 
simply could not get over here.
    Congressman Watt, Congressman Hayes, and I are involved. 
The facility is located in Congressman Watt's district. He and 
I share the county in which it is located, and Congressman 
Hayes represents the adjoining county. So that explains why we 
are the triumvirate in this matter. We received responses from 
our joint letter from Salisbury and it appears they are 
responding favorably to criticisms that were leveled earlier. I 
guess one thing that prompted a lot of attention, not only to 
Salisbury but elsewhere, when the problems at Walter Reed 
surfaced, I think many folks said, ``My gosh, if it is this bad 
at Walter Reed, what is it like in the hinterland?'' And I 
think that may have triggered a lot of the attention.
    As an aside, Dr. Pierce, this has nothing to do, well, this 
has something to do with Salisbury as a matter of fact. Most of 
the complaints that we received down home, Mr. Chairman, in my 
district, do not involve the delivery of quality healthcare. 
Most of my veterans are not unhappy with that. That is not to 
say we do not get complaints, we do. But for the most part, the 
complaints zero in on the delay that the veterans incur before 
claims are approved, as an example. And that is just for your 
information. I want to throw that out.
    And Mr. Chairman, let me ask you a question if I may. Does 
the Committee on Veterans' Affairs plan to follow up on the 
Salisbury matter?
    Mr. Mitchell. Yes, Mr. Coble. In fact, in earlier panels 
there were some reports that were asked for by Mr. Hayes and 
Mr. Watt.
    Mr. Coble. Okay.
    Mr. Mitchell. And when we get those report back we will 
communicate them.
    Mr. Coble. And I think that is important, and that pretty 
much exhausts my line of questioning because I haven't been 
here earlier. And I again apologize for my delay, but thank you 
for having the hearing. Thank you all for being here.
    Mr. Mitchell. Thank you. Mr. Wu, do you have any followup?
    Mr. Wu. After you, sir.
    Mr. Mitchell. I do not have any. I am fine.
    Mr. Wu. Thank you, Chairman Mitchell. Question for Mr. 
Feeley. In your testimony you stated that by issuing a 
multitude of important directives to improve patient safety, 
``VA has acquired the ability as the largest integrated 
healthcare system to affect change and impact millions of 
patients.'' I think this is very important, and you can stack 
those directives from the floor to the ceiling, but can you 
explain how you can ensure implementation? And what is the 
process to go back and check for the continuing compliance?
    Mr. Feeley. I think we are really operating with a trust 
and verify design. We have numerous ways that we get 
information out: emails, teleconferences, directives. But we 
also have a training that employees get and we have numerous 
systems in place where we go out and review. And one of those 
systems is the SOARS process. There are 42 different checklists 
that we have got in the SOARS process, not dissimilar to the 
same type of checklist that a flight crew would use before it 
takes off. So you want to make sure everything is in place and 
working. That goes on at a national level, it goes on at a 
network level, and it also goes on at a facility level via our 
quality management department and utilization review programs. 
So the more rapidly we transport learning, the better we are 
going to perform. But also, we are out there verifying that 
actions are being taken.
    Mr. Bilbray. Mr. Feeley, I have a question for you. Your 
SOARS Program has been in place for how long?
    Mr. Feeley. Since 2004.
    Mr. Bilbray. So what happened at Salisbury that this was 
not detected, then?
    Mr. Feeley. SOARS visits sites on a schedule, and we I 
think visit 47 sites per year. I do not know whether a SOARS 
visit has occurred at Salisbury, but would like to defer to Dr. 
Steinberg.
    Dr. Steinberg. I am right here. We had a SOARS visit this 
past year. I am not aware of a previous one.
    Mr. Wu. Mr. Feeley, could we have the results of that SOARS 
report for Salisbury? The other question I have, and I am 
trying to make efficient time for my 5 minutes here for the 
minority. Dr. Pierce, it is my understanding that you have 
issued six OMI reports in the recent past. Is that not correct? 
Two part question. Is a follow up to those OMI reports any more 
expeditious and thorough than what has been done on the 
Salisbury 2005 OMI report? And two, to the best of my 
recollection as the staff director of this Subcommittee for the 
minority side, we have asked for all OMI reports on a timely 
basis upon release, and unless our mail system has failed us 
abjectly I do not believe that we are in possession of the 
majority of those OMI reports. And I know that those are, I 
would not say close hold, but is there a reason why we have not 
received those, this Subcommittee?
    Dr. Pierce. Sir, I do not know if there is. We have 
forwarded your request several times, that these reports be 
sent up to you once they are approved by the Secretary.
    Mr. Wu. Do you think it is the Subcommittee? Me? That we 
are not receiving these?
    Dr. Pierce. I will look into it, sir. I cannot answer that.
    Mr. Wu. All right.
    Dr. Pierce. The first part of that is, the follow up of our 
reports depend upon the things that have to be done. Some of 
the things that the facility has to do are relatively minor and 
can be done fairly quickly. Others take longer. With this 
report we had 18 things the facility needed to do and so that 
took longer to accomplish.
    Mr. Wu. All right. If it would not be unreasonable to 
request all outstanding OMI reports for the past 2 years. If we 
could have them by close of business tomorrow, if that is not 
too adverse and laborious an issue. We would like to see that. 
I understand that there is also an OMI report on Asheville?
    Dr. Pierce. Yes, sir.
    Mr. Wu. Okay. Mr. Chairman, if we could get those delivered 
to us.
    [The Subcommittee received the OMI reports from VA.]
    I do have one other question, here. Dr. Fleming I hate to 
have you come up here without being able to say anything and we 
are bringing you up here. I know that you would rather not say 
anything. But as the Chief of Quality and Performance, how 
would you rate the 100 performance measures in the areas of 
access, satisfaction, and quality at Salisbury right now?
    Dr. Fleming. We checked all of our numbers. We have audited 
their credentialing, we have looked at their performance from 
2002 when there were really problems, we have looked at our 
Joint Commission reports, we have looked at the OIG reports, we 
have looked at the OMI reports. Salisbury is really a success 
story. It is, in my view, a phenomenal story. They are now 
ranked I believe 35 in terms of quality, access, and 
satisfaction aggregate score of our facilities.
    Mr. Wu. Out of the 152 facilities?
    Dr. Fleming. We have enough data actually to rank I think 
140 of those. So they have just done a phenomenal job. The 
measures that we have looked at that they have had problems 
with, they have really turned around. They have processes in 
place that we actually have also replicated on a national 
level. That team at that facility took their problems to heart 
and really did some fixes. So I would be pleased to get care, 
personally, there, and I think our veterans should feel very 
comfortable at that facility at this point in time.
    Mr. Wu. All right, Dr. Fleming, I know the red light is on, 
Mr. Chairman, Mr. Feeley, and Dr. Pierce, how would you rate 
Salisbury today? If you were the teacher, what would the report 
card be? You can all three confer and come up with an average.
    Mr. Feeley. I am going to stick with Dr. Pierce's rating of 
B plus. Having said that, though, the goal here is to get an A, 
because I think veterans deserve that and we had better be 
constantly looking to improve in every one of our locations.
    Dr. Fleming. And I just would like to add that they are 
actually a model for the kinds of improvement and the kinds of 
commitment to improvement with this team that is currently 
there.
    Mr. Wu. Thank you very much. One last comment I would like 
to make is I am retired from the military, and I see your Chief 
of Staff at Salisbury, Dr. Sid Steinberg, used to be the 
Commander at the Fort Belvoir Hospital, and he had such a 
reputation of being such a hard charging guy that I made every 
effort that I did not have to work for him. But I am sure that 
you are in good stead with him.
    Dr. Steinberg. Nothing has changed.
    [Laughter.]
    Mr. Wu. Thank you very much, Mr. Chairman.
    Mr. Mitchell. Thank you. And just add one thing to what Mr. 
Coble said, I think that every Congressman and every Senator 
here would say the same thing. When they get complaints, the 
biggest complaint is time and waiting in line. And something 
really needs to be done with that, because that is a universal 
complaint that I think we all hear. Mr. Watt.
    Mr. Watt. Thank you, Mr. Chairman, once again. And I will 
not prolong this, but with two questions, one of which I hope 
you will follow up with the Committee to provide the answers 
to. A full report of whatever exists on the contacts that were 
made with the families of those seven individuals that we have 
narrowed this down to now, because it may have some 
implication, may not, for how we deal with families and what 
kind of rules of the road may be important going forward. And 
second, on the one that we really zeroed in on at the end of 
the day, tell us, if you can, what the remedies are in the 
current legal framework that we have set up for veterans. If 
somebody were in the private sector, there would be some 
possibility of pursuing a cause of action for medical 
negligence. What is the counterpart to that in the VA system? I 
mean, what is the remedy?
    Mr. Feeley. I would like to comment that Dr. Pierce 
described the policy and the policy is when there is a clear 
mistake we have made, we have a responsibility to sit down with 
the patient. And if the patient is deceased with the family 
members and explain what has happened. That is usually done by 
the Quality Management Department Head and the Chief of Staff, 
the Director might become involved, and at that point in time 
usually some sort of investigation has occurred and findings 
have occurred, and we are going to discuss with them what has 
happened. We are then going to advise and give them counsel on 
how to file a tort claim, which is how they seek compensation 
from the Federal Government for any error that----
    Mr. Watt. So it is under the Federal Tort Claims Act?
    Mr. Feeley. Correct.
    Mr. Watt. Okay. All right.
    Mr. Feeley. And I would say to you that this is the way it 
is supposed to be, and I think we have many, many people 
operating that way. Healthcare providers come to work to do a 
good job, but they also know the only way we are going to learn 
is unfortunately from errors that we make and get better.
    Mr. Watt. And when you sit down with the family, once that 
is done is there a report rendered on that meeting? I mean, can 
the Subcommittee expect at the end of each one of these seven 
processes that there will be a report of a meeting with a 
family?
    Mr. Feeley. What I would indicate to you is I described the 
way the process would happen in any case, across the country. 
As it relates to the seven cases, I did not pick up, Mr. Watt, 
what Dr. Pierce said, whether there was a negligence issue in 
these cases. I may have misunderstood him.
    Dr. Pierce. Well, two of the seven were level three 
findings. And the other five were level two findings. And so 
there may not have been any negligence, and a level two finding 
is that some people might have done this differently but some 
people would have done it the way you did it. And so there----
    Mr. Watt. What would you say to a family under those 
circumstances? I guess what I am trying to figure out is what 
would be the protocol when there is even a question raised 
insofar as dealing with the family member or members.
    Dr. Pierce. I think that different physicians would handle 
that differently. I doubt if they would have a meeting with the 
Chief of Staff in a situation where the finding was that some 
people would have done this the same way, and so there was no 
malpractice there.
    Mr. Watt. No, in those seven, as I understand it, there was 
a determination that some people would have done it a different 
way. The five you eliminated because some people, would all 
people who reviewed it said they would have done it the same 
way. The seven, that is the reason I zeroed in on the, what I 
am trying to find out is what is the protocol when that 
question is raised. There might be a protocol for those, and 
then there might be a separate protocol for those where you 
actually make a determination, ``Yes, somebody did something 
wrong.'' But there should be a protocol for both and I think it 
is our responsibility to the families to know what the protocol 
is and if requires adjustment, have the Committee make an 
evaluation of it. That is the only question I am raising. I am 
not saying anybody did anything improper. I just, this is 
information that is being generated retrospectively just as the 
Council is trying to get information about information going 
forward. So that is the request I would make.
    Mr. Mitchell. Mr. Coble, anything? I think that exhausts 
our questions, but I do have a concern. I know this was a case 
study on Salisbury. But how many medical centers did you say we 
have throughout the Nation?
    Mr. Feeley. One fifty-four.
    Mr. Mitchell. One fifty-four?
    Mr. Feeley. Be aware, too, Mr. Chairman that we have about 
850 clinics.
    Mr. Mitchell. Right.
    Mr. Feeley. So we take it very seriously in monitoring the 
quality in those clinics as well.
    Mr. Mitchell. Well, my concern is that because of the 
spotlight that has been on Salisbury, things everybody has 
said, even panel members here, or members of the Subcommittee, 
that things have improved a great deal and are super. But my 
concern is, that is because the spotlight is on here, what are 
you doing with all these others? You know, I understand there 
are reports out there from Asheville, Phoenix just had a report 
that has not been released yet. But I am concerned, what I 
would like to see is the same kind of oversight, the same type 
of concern that you put on Salisbury on every one of these 
medical centers. And I am not so sure that has happened. How 
are we going to know that what, the findings you have made at 
Salisbury are also going to be implemented and carried out in 
all the other medical centers?
    Mr. Feeley. There are multiple mechanisms through which 
that occurs. As the SOARS process which was developed in 2004, 
I have been in this position about 13 months. We have added 
additional resources to that group, and we are cross working 
all findings from what the SOARS group finds, and the IG finds, 
and JCHO finds, or any outside review group, so we see 
recurrent themes, shows us where we need to do training, we 
take these issues up on national conference calls with our 
quality managers and our chief medical officers at a network 
level. Again, our goal is to transport that learning rapidly 
across the system. I think the Committee has a legitimate 
concern, that a sense of urgency exists when we do this. And 
now we see Dr. Pierce going out on an issue within 24 hours. 
That has happened probably four times in the last month, where 
we have had a concern and we wanted to look at something. When 
we go out and look, we had a wrong site surgery occur, we are 
going to transport that across the system.
    Mr. Mitchell. I heard you say that Salisbury is now maybe 
about a 35 out of 140. I would like all those below that, the 
other 100----
    Dr. Fleming. Correct.
    Mr. Mitchell [continuing]. To be at the same level, all 
above average.
    Dr. Fleming. I wanted to comment on a couple of things. I 
do not think there is another medical system that measures 
itself as intensively and comprehensively as this one does. 
Every month facilities get reports on how they are doing that 
month. Every quarter we roll that data up so that facilities 
see how they are doing, their network director also sees for 
the network. As a system of care, every quarter we look across 
those measures and we say, ``Do we have a systems issue? Do we 
have 1 facility that is really doing poorly in 1 area, or do we 
have 10 facilities?'' When we do that, then there are a variety 
of things that we do, including making sure that our leadership 
gets that report, or picking up the telephone and calling the 
Chief Medical Officer and saying, ``You know, you have got one 
extra case this month we need you to review. Can you go back 
and do a case review and let us know what you find?'' So there 
is a tremendous amount of feedback that occurs, and a 
tremendous effort to ask, ``Have we got a systems issue?'' So 
hopefully we do that.
    One thing I think is important to know, when the VA is 
benchmarked against the private sector we do very well. For the 
outpatient measures we consistently have trumped the private 
sector for all of the 15 commonly measured and reported 
outpatient measures. For the inpatient measures we have a 
little bit more of a challenge, but we still consistently do 
the same as or better than the private sector for most of the 
measures that we measure. When it comes to patient satisfaction 
there is only one nationally standardized survey, it is the 
American Customer Satisfaction Index. And the VA consistently 
does five points better than the rest of the world. Do we have 
things we want to work on? Absolutely. Are we doing that? 
Absolutely. But overall, I think our quality, the quality of 
care that our veterans receive is excellent and there is 
tremendous commitment to that. And we are working very hard 
every day to make sure that that quality gets better and 
better.
    Mr. Mitchell. Well, I would hope that if it is, if what you 
need is resources, that that request is made. And I would hope 
that we have no more case studies before this Committee on 
particular health centers. The last question is Mr. Wu.
    Mr. Wu. Thank you, Chairman Mitchell. Mr. Hayes is asking 
for his letter that was responded to him by the VISN Director, 
Dan Hoffman of VISN 6 dated April 18, 2007, addressing his 
concerns that were in the Charlotte Observer be entered into 
the record.
    Mr. Mitchell. So be it.
    [The referenced letter to Congressman Hayes from VA appears 
on page 55.]
    If there are no other comments?
    Mr. Wu. Well, just one other comment, sir. Dr. Fleming, 
great benchmarks against the private sector. I think great 
kudos to the VA healthcare delivery system. Is there any 
possibility in talking with Mr. Feeley said about all your 
cross walk and measuring performance in the SOARS report, the 
IG report, the OMI reports, that you rank order these 
facilities in some public forum? Is that not a good idea?
    Dr. Fleming. We do rank order the facilities and we do rank 
order the networks. Now at the network level there is hardly, I 
mean, the networks are clustered very tightly. And the facility 
ranks, there is probably maybe a 10-point difference in our 
aggregate rankings. But I would also tell you that when we look 
at our worst facilities, and we just actually ran these 
numbers, our worst facilities based on VA standards compare to 
private sector averages are still better than the private 
sector averages. So----
    Mr. Wu. I appreciate that. But I am talking about within, 
we are concerned about veterans.
    Dr. Fleming. I am sorry, I guess I missed----
    Mr. Wu. Do we rank, not bench marking against private 
sector, but just an internal benchmark?
    Dr. Fleming. We do internal bench marking on a quarterly 
basis.
    Mr. Wu. And is that in a public forum? Or how is that 
displayed?
    Dr. Fleming. It is displayed, it is sent out to the field. 
It is sent up in the VA. So everyone within the VA knows it. As 
you know, there was an executive order August of 2006 that has 
mandated all Federal entities will do public reporting at the 
provider level.
    Mr. Wu. Correct.
    Dr. Fleming. So we are on a, in fact we are ahead of our 
2009 timeline to do that. So our other Federal agencies will be 
with us in doing that. So at that point, the veteran, or the 
Medicare beneficiary, or whomever, will have access to the 
provider data.
    Mr. Wu. Thank you, Dr. Fleming. Dr. Bagian, Mr. Feeley, Dr. 
Fleming, Dr. Pierce, I think there was a lot that was discussed 
today and brought out and echoing Chairman Mitchell about we 
now understand Salisbury, but how are we dealing with this on a 
systemic basis? I would hope that when issues that rise to this 
level, as Salisbury did indicate in 2005, that this Committee 
and this Subcommittee and members that are affected in 
facilities are notified on a timely basis by the VA and not by 
the Charlotte Observer, the St. Pete Times, or the New York 
Times. Thank you very much, Mr. Chairman.
    Mr. Mitchell. Thank you. And with that, this meeting is 
adjourned.
    [Whereupon, at 1:32 p.m., the Subcommittee was adjourned.]












































                            A P P E N D I X

                              ----------                              

              Prepared Statement of Hon. Harry E. Mitchell
         Chairman, Subcommittee on Oversight and Investigations
    This hearing will come to order.
    I want to thank our colleagues from North Carolina for joining us 
today. I know they have been very active on this issue, and I know the 
people of their great state appreciate their hard work on behalf of 
veterans in North Carolina.
    Of course, we are here today to explore the quality of care 
available to our Nation's veterans. We know there have been significant 
problems at the Salisbury VA Medical Center in North Carolina and we'll 
be using Salisbury as a case study so we can better learn if the 
problems there are indicative of quality of care throughout the VA 
medical system.
    We will explore management accountability and leadership issues 
within the VA medical system.
    Today's hearing will revolve primarily around three issues:
    Firstly, how does the VA ensure access to the medical system is 
timely and is delivering proper quality of care?
    Secondly, what is the process the VA uses in determining whether 
the quality of care is proper?
    And, thirdly, are the problems that occurred in Salisbury 
indicative of a larger set of issues that affect other VA medical 
facilities as well?
    More than 2 years ago--in March 2005--an anonymous allegation that 
improper or inadequate medical treatment led to the death of veterans 
at Salisbury prompted the VA office of Medical Inspector to conduct a 
review of care delivered to both medical and surgical patients.
    The OMI report--issued 3 months later--found significant problems 
with the quality of care that patients were receiving in the Surgery 
Service of the Salisbury facility.
    Unfortunately, we learned that Salisbury leadership had already 
been notified of many of the shortcomings in Surgery Service through an 
earlier Root Cause Analysis.
    I know that all of us on the Subcommittee are particularly troubled 
to hear about the story of a North Carolina veteran who sought 
treatment at Salisbury and died. . . . He went in for a toe nail 
injury, and even though doctors knew he had an enlarged heart, he 
wasn't treated . . . it was ignored . . . and the morning after he had 
surgery on his toe, he died from heart failure the next morning.
    According to media reports, this veteran received excessive 
intravenous fluids in the OR and post-operatively as well; the medical 
officer of the day wrote orders for the patient without examining him; 
and the patient did not receive proper assessment and care by the 
nursing staff.
    More recently, we also learned through the media of another 
incident--a wrong site surgery at another VA medical facility on the 
west coast. . . . The list goes on and on. . . .
    We hope to hear today how the VA is working to ensure that these 
types of incidents do not happen at other facilities around the country 
and how the VA is working to deliver the best quality of care 
throughout the VA system.
    We also hope to hear from the VA how its leaders reacted to these 
problems, worked to solve these problems, and what lessons it learned 
to make sure this never happens again.
                                 
              Prepared Statement of Hon. Ginny Brown-Waite
                       Ranking Republican Member
    Thank you for yielding me time, Mr. Chairman.
    Mr. Chairman, on March 28 through March 31, 2005, at the request of 
the VA's IG in September 2004, the Office of the Medical Inspector 
conducted a site visit to the W.G. (Bill) Hefner VA Medical Center in 
Salisbury, North Carolina, focusing on the facility's delivery of 
surgical services. This report presented some serious inadequacies of 
care at this facility. On March 21, 2007, three members of the North 
Carolina delegation, my colleagues, the Honorable Howard Coble, the 
Honorable Mel Watt, and the Honorable Robin Hayes, [who are present at 
this hearing,] wrote to our Committee expressing concern about this 
report, requesting additional oversight into patient safety at the VA.
    I am looking forward to hearing from our witnesses today to learn 
how these inadequacies have been addressed. I am particularly looking 
forward to Dr. Daigh's (DAY's) testimony providing the results of the 
facility's 2006 OIG Combined Assessment Program (CAP) Review of the VA 
Medical Center in Salisbury, North Carolina, and the results of the 
OIG's inspection last week of the facility. I also look forward to 
hearing from Dr. Steinberg, the current Chief of Staff and the former 
Interim Director on how the facility is continuing to work to address 
these issues, and how the lessons learned at Salisbury can be used to 
implement safer delivery of healthcare to our veterans.
    It is my contention that this hearing is not to single out one 
facility, but to take lessons learned as a case study in patient care, 
and implement better patient safety across the entire VA. I plan to 
continue to work with you, Chairman Mitchell to continue this oversight 
of Patient Safety at VA facilities across the Nation. Quality of care 
everywhere is my goal.
    Again, thank you Mr. Chairman, and I yield back my time.

                                 
                 Statement of John D. Daigh, Jr., M.D.
         Assistant Inspector General for Healthcare Inspections
  Office of the Inspector General, U.S. Department of Veterans Affairs
INTRODUCTION
    Mr. Chairman and Members of the Subcommittee, thank you for the 
opportunity to testify today on patient quality of care issues at 
Department of Veterans Affairs (VA) medical facilities. Today I will 
present the results of the Office of Inspector General (OIG) Evaluation 
of Quality Management in Veterans Health Administration Facilities 
Fiscal Year 2006; the OIG Evaluation of Quality Management in Veterans 
Health Administration Facilities Fiscal Year 2004 and 2005; and the OIG 
Combined Assessment Program (CAP) Review of the W.G. (Bill) Hefner VA 
Medical Center Salisbury, North Carolina, published on September 25, 
2006. I will also present the facts surrounding the OIG hotline call 
that resulted in the Office of the Medical Inspector (OMI) report of 
June 9, 2005, Review of the Delivery of Surgical Services Veterans 
Integrated Service Network 6 W.G. (Bill) Hefner VA Medical Center 
Salisbury, N.C., and the results of our followup inspection at the 
Hefner VA Medical Center (VAMC) conducted during the week of April 9-
13, 2007. I am accompanied by Ms. Victoria Coates, Director of the 
Atlanta Office of Healthcare Inspections.
    Since the early 1970's VA has required its healthcare facilities to 
operate comprehensive quality management (QM) programs to monitor the 
quality of care provided to patients and to ensure compliance with VA 
directives and accreditation standards. Public Laws 99-166 and 100-322 
require the VA OIG to oversee VA QM programs at every level. QM review 
has been a constant focus during the OIG Combined Assessment Program 
(CAP) reviews since 1999. The CAP review is an OIG initiative that 
involves an inspection and publication of the inspection's findings for 
approximately one-third of VA's medical centers each year.
    A comprehensive VA QM program should include the following program 
areas: quality management and performance improvement Committees, peer 
review activities, patient safety activities (healthcare failure mode 
and effects analysis, aggregated root cause analyses, and national 
patient safety goals), disclosure of adverse events protocols, 
utilization management programs, patient complaint management programs, 
medication management programs, medical record documentation reviews, 
blood and blood products usage reviews, operative and other invasive 
procedures reviews, patient outcomes of resuscitation efforts reviews, 
restraint and seclusion usage reviews, and staffing effectiveness 
reviews.
OIG Summary Reports
    The OIG published a summary of the CAP findings regarding VA 
medical center QM findings for fiscal year 2006 in March of 2007 and 
for fiscal years 2004 and 2005 in December of 2006. The report of FY 
2006 QM findings identified three QM activities that required 
systemwide improvements: peer review activities, adverse event 
disclosure procedures, and utilization management programs. For FY 
2006, OIG reported peer review activities were established in 46 of 47 
inspected medical centers. Only 40 of 46 peer review committees 
complied with Veterans Health Administration (VHA) policy to met 
quarterly and only 49 percent of the Committees completed their reviews 
within the required 120 days. VHA facilities have an obligation to 
disclose adverse events to patients who have been harmed in the course 
of their care. In FY 2006, 39 of the 47 inspected facilities documented 
that patients had experienced serious adverse outcomes. Of these, 29 
documented that the clinical discussions occurred with the veteran or 
family member, and 22 documented that the discussion informed the 
patient of the right to file tort claims or claims for increased 
benefits. Utilization management is the process of evaluating and 
determining the appropriateness of medical care services across the 
patient healthcare continuum to ensure the proper use of resources. In 
FY 2006, our review found that when resource utilization exceeded 
standards, referral was not made to physician advisors 16 percent of 
the time, thus bypassing appropriate review of resource utilization. 
Recommendations regarding peer review, adverse event reporting, and 
utilization review were made and accepted by the Acting Under Secretary 
of Health.
    In the OIG report on FYs 2004 and 2005, VA medical center QM 
programs indicated that 2 of 93 facilities did not have comprehensive 
programs in place. These programs were identified to VA in CAP reports. 
Recent CAP reports indicate that one of the two facilities made 
significant improvements in their QM program, while the other has been 
less successful at improving the components of its QM program. There 
are ongoing personnel changes at this facility and OIG will closely 
monitor this facility's QM program. The FYs 2004 and 2005 QM review 
made recommendations to improve the analysis of patient resuscitation 
episodes, better consider the alternatives and document the use of 
restraints, and adjust current directives regarding re-privileging 
activities to ensure effective implementation of the continuous 
professional practice evaluation process.
W.G. (Bill) Hefner Medical Center in Salisbury, North Carolina
    The OIG maintains a hotline call center to permit stakeholders to 
notify the OIG of problems. On August 30, 2004, OIG received an 
anonymous hotline alleging that there had been more that 12 surgical 
deaths in over 2 years on the surgical service at the Hefner VAMC. On 
September 21, 2004, due to limited OIG resources, this hotline was 
referred to the OMI. The OMI was onsite at Salisbury from March 28-31, 
2005. The VHA Director of Surgery conducted a review from April 5-6, 
2005. OMI issued its report of the hotline allegations and surgical 
services, after an OIG review, on June 9, 2005. It contained 18 
recommendations that were accepted by the Under Secretary of Health. A 
regularly scheduled CAP inspection was conducted June 19-23, 2006. An 
OMI followup inspection of the Hefner VAMC occurred between March 26-
27, 2007, and an OIG followup inspection occurred April 9-13, 2007.
OIG CAP Review--June 2006
    During the week of June 19-23, 2006, the OIG CAP team evaluated 
clinical care and patient outcomes at the Hefner VAMC. The CAP team 
reported as an organizational strength, the fact that medical center 
staff had significantly improved their ability to provide timely 
laboratory support for the evaluation of patients who present with a 
possible myocardial infarction.
    The OIG CAP inspection found that the clinicians properly addressed 
specific treatment issues related to diabetes that arise in the use of 
atypical antipsychotic medications. The review of breast cancer 
management found that clinicians at the facility met the VHA 
performance measure for breast cancer screening, provided timely 
surgical and oncology consultative and treatment services, promptly 
informed patients of diagnoses and treatment options, and developed 
coordinated interdisciplinary treatment plans. A review of the 
inpatient and outpatient Survey of Healthcare Experiences of Patients 
found that the Hefner VAMC measures were within acceptable ranges when 
compared to national and Veterans Integrated Service Network data. The 
OIG report noted the efforts taken by the VAMC leadership to respond to 
this patient-derived data.
    The OIG inspection team found several conditions needing 
improvement in the Contract Nursing Home Program, the Quality 
Management Program, and the medical center environment of care. The 
Contract Nursing Home Program policy requires regular, periodic visits 
to veterans in nursing homes by VA nursing staff. These did not occur 
between October 2003 and June 2006 in the selected patient sample. In 
addition, OIG inspectors found that 4 of the 11 contract nursing homes 
were on the State nursing home ``watch list,'' meaning that they had 
been found to be deficient during their last State inspection. Despite 
these deficiencies, program managers continued to place veterans in 
these homes without taking prudent steps to ensure veterans would 
receive quality care at these homes. The medical center did not 
establish the required Contract Nursing Home Oversight Committee. The 
OIG inspectors made recommendations in the CAP report that were 
accepted by facility managers to remedy these conditions.
    OIG inspectors identified deficiencies in the medical center's QM 
program in that peer reviews were not completed as required between 
July 2005 and June of 2006. Further, the Peer Review Committee had not 
met since November of 2005 because of actions taken by the VA's Office 
of Resolution Management to review information that was protected by 38 
USC  5705, Confidentiality of medical quality-assurance records. The 
chief of staff acknowledged the importance of peer review activities 
and reported that the peer review meetings would resume, but stated 
that he would not disclose protected information to the Office of 
Resolution Management. OIG did not make recommendations as the medical 
center leadership indicated that the peer review process would be 
resumed. A review of the Root Cause Analysis processes at this medical 
center found several defects, as did a review of the Administrative 
Board of Investigation process. OIG recommended and VA leadership 
agreed to make the changes required to bring these programs into 
compliance with appropriate policy.
    A review of the facility environment of care identified several 
issues that were addressed prior to the inspection team leaving the 
facility. The OIG team also found that managers at the facility had not 
addressed environment of care issues that were previously identified to 
facility managers in 2005. Facility managers agreed with OIG 
recommendations to address this issue.
OIG CAP Review--April 2007
    OIG inspectors visited the Hefner VAMC between April 9-13, 2007, in 
preparation for this hearing with two goals: to evaluate the surgical 
service programs and processes to determine if clinical care meets with 
community standards, and to determine if the facility had taken 
appropriate followup actions in response to the CAP report of 2006 and 
the OMI report of 2005. Our review of the facility Surgical Service 
Performance Improvement Program, National Surgical Quality Improvement 
Program data, morbidity and mortality minutes, surgical staffing, peer 
review, and surgery infection control data combined with discussions 
with hospital staff and leadership leads us to conclude that the Hefner 
VAMC surgery services meet or exceed community standards. Our review of 
the actions taken by the leadership of this facility in response to our 
CAP recommendations permits us to conclude that these recommendations 
have been appropriately addressed.
    The OIG inspectors identified two new issues to facility leadership 
during the April 9-13, 2007, visit. On the locked mental health unit, 
there are exposed pipes that should be covered, going from the wall to 
toilet fixtures. In addition, telephones in tunnels connecting 
buildings on the campus were accessible by staff who had a key, but not 
by patients. OIG will followup to ensure these issues are addressed.
Summary
    The OIG will continue to review QM in VA medical centers as part of 
the CAP process. With respect to the W.G. (Bill) Hefner Medical Center 
in Salisbury, North Carolina, we believe that VA leadership has 
responded appropriately to recommendations made by OMI and OIG in 
reports.
    Mr. Chairman, thank you again for this opportunity and I would be 
pleased to answer any questions that you or other members of the 
Subcommittee may have.

                                 
              Statement of Sidney R. Steinberg, M.D., FACS
 Chief of Staff, W.G. (Bill) Hefner Veterans Affairs Medical Center in
       Salisbury, North Carolina, Veterans Health Administration
                  U.S. Department of Veterans Affairs
    Good morning Mr. Chairman and Members of the Committee. Thank you 
for giving me an opportunity to address your concerns regarding the 
quality of healthcare provided to our veterans at the W.G. Hefner 
Veterans Affairs Medical Center in Salisbury, North Carolina 
(Salisbury). The focus of my remarks will be the improvements and 
expansion of healthcare at Salisbury.
Overview
    The Medical Center in Salisbury provides quality healthcare to our 
veterans in our primary care clinics including Winston Salem and 
Charlotte across many specialties of medicine and surgery with our 
academic partner, Wake Forest University. In recent years, Salisbury 
has made a concerted effort to improve the quality of our healthcare 
and to make access to care readily available. We measure our 
improvements in these areas on a regular basis utilizing both internal 
and external tools. We track disease prevention, treatment outcomes, 
physician performance, educational processes and patients' satisfaction 
surveys. VA is committed to meet the needs of our veterans, whatever it 
takes. At Salisbury our commitment is total.
Improvements to Patient Care
    Several years ago, with the help of our Veterans Integrated Service 
Network (VISN) leadership and a handful of dedicated clinicians, VA 
sought to make improvements at Salisbury, department by department. VA 
leadership brought together the financial and manpower resources 
necessary to make these changes possible. For example, the waiting list 
of veterans seeking a primary care appointment was a challenge. The 
VISN came through with funding for recruitment of new employees. As a 
result, every veteran on the wait list in 2003-2004 was enrolled in a 
primary care clinic, examined, and received his or her initial care 
needs. VA was delighted to have members of Congress join the former 
Secretary and our Network Director to personally thank the dedicated 
staff who gave so much of themselves to achieve that goal.
Academic Affiliate and Specialty Care Services
    To accommodate Specialty Care Services in the past, Salisbury 
relied upon the geographic partnership with the Asheville VA Medical 
Center. However, the addition of a large number of new patients made it 
apparent that Salisbury would need to develop its own specialty support 
system for our veterans. To accomplish this task, VA established a new 
and stronger relationship with our Academic Affiliate, Wake Forest 
University School of Medicine in Winston Salem, North Carolina. 
Meetings with the Dean of the Medical School and faculty leaders paved 
the way for the beginning of a new partnership to serve our patients 
with state of the art healthcare in many areas of need. These efforts 
led to the establishment of resident physician training programs in a 
number of disciplines. We now have 10 approved resident positions which 
include ophthalmology, urology, otolaryngology, psychiatry, medicine, 
infectious disease and dermatology. The superb eye clinic with its 
multispecialty support provided care to 27,000 patient visits in fiscal 
year (FY) 2006. Ten major eye operations are performed weekly by Wake 
Forest faculty and resident physicians.
    VISN leadership continues to engage the Office of Academic Affairs 
on a regular basis to assist Salisbury in adding more resident 
positions in primary care, medicine and other specialties. This year we 
have added a new affiliation agreement with Virginia Tech University 
and will work to incorporate their staff and residents in coming years 
to expand primary care. The real benefit of the residency program to 
our veterans is that they bring with them the highly skilled faculty 
members who are capable of providing state of the art care to our 
veterans. The progress VA has made at Salisbury touches every veteran 
and employee at the Medical Center. Our staff, our patients, our 
community leaders, and our medical school educators recognize the 
quality of these additions. These improvements in facility staffing and 
structure allowed us to see more than 400,000 out patients in FY 2006 
as well as providing support for our Veterans Benefit Administration 
office in Winston Salem.
Mental Health
    The Mental Health needs of our veterans are important to all of us 
and represent a program of excellence at Salisbury. In this area of 
clinical expertise, we lead our VISN and have on our staff one of the 
world's most prestigious investigators in the area of Traumatic Brain 
Injury. Through her efforts and those of her principal neuroscientist, 
there is collaboration with MIT, Harvard and the Department of Defense. 
This team also serves as a key investigative and educational center for 
the Mental Illness Research, Education, and Clinical Center (MIRECC). 
This Center has a focus on post-deployment mental health. Together with 
the other VA medical centers in VISN 6, this program strives to advance 
the study, education, and treatment of all mental health conditions 
resulting from war-time experience. This investigative center leads VHA 
nationally in these efforts. Our medical center's research programs 
have generated a full Association for the Accreditation of Human 
Research Protection Programs accreditation through the year 2010.
Women's Health Program
    Our expanded Women's Health program now serves our patients as well 
as those from the Asheville and Fayetteville VA Medical Centers. The 
program is headed by a Gynecologist from the University of Virginia. 
The new director of our Imaging Department came to us from the M.D. 
Anderson Cancer Center in Houston, with additional fellowship training 
at the University of North Carolina. Her new colleagues in the 
department are from Duke University and Wake Forest, respectively. The 
Women's Health Program is just moving this week into newly renovated 
space where additional special services are now provided. A new bone 
densitometer, digital mammography and urodynamic devices are now 
available. A current NRM (Non Recurring Maintenance) project is now 
underway to provide more bed space for women veterans with private 
rooms and private baths.
Surgery Programs
    We faced challenges in the quality of our program in 2003. But we 
have turned the corner and now have a much improved surgical program. 
The Salisbury Surgery Department is totally new and is headed by a 
chief from Vanderbilt University. A strong surgical program is 
essential to our veterans' health needs and must be one of impeccable 
quality. With the VISN's busiest emergency department and increasing 
demands for care dictated by our 62,000 enrolled patients, our efforts 
were directed to making this department a solid high quality program. 
The support of our affiliate, Wake Forest University, is vital to this 
effort. As additional surgical staff and residents from Wake Forest 
join this effort, it will continue to gain in strength and expertise. 
Our new construction project in Surgery will be completed in about 30 
days and will provide the needed space and modernization required to 
meet the highest standards for operating room construction. Our new 
Chief is joined by a staff of surgeons from Johns Hopkins, the 
University of Maryland and the University of West Virginia. Other key 
members of the Surgery and Anesthesia Staff came from Emory University, 
Duke University, the Cleveland Clinic, the Mayo Clinic and the 
University of Michigan. We are recruiting for a new chief of Pathology, 
crucial to our post mortem evaluations and tissue studies. Our Chief of 
Infectious Disease and our fellowship program have brought a fresh and 
important look to the evaluation, prevention and treatment of 
infectious diseases at our medical center. Our large numbers of 
hepatitis and HIV patients are now receiving the care they must have to 
maintain their health and life.
    Our approach to primary care was modified last year to provide more 
adequate care to our patients with more complex diseases. At the 
Salisbury VAMC we have made a concerted effort to ensure that every 
patient now has been assigned to a primary care provider. Our efforts 
in Primary Care were given a tremendous boost by the VISN's support of 
a total renovation of all primary care clinic space to assure that each 
primary physician had at least two examination rooms per physician. 
This space adjustment has made it possible to meet the demands of a 
higher patient volume.
Conclusion
    Mr. Chairman, we acknowledge that Salisbury has faced problems with 
the quality of surgical processes in the past. However, that's behind 
us now, due to the hard work of the highly professional and dedicated 
staff at Salisbury. We are proud of Salisbury and the patients we 
serve. Through strong and meaningful leadership, our staff has turned 
the focus toward a future of excellence. We will continue these efforts 
in our commitment to our Nation's finest, our veterans.
    Mr. Chairman, this concludes my statement. At this time I would be 
pleased to answer any questions that you may have.

                                 
               Statement of William F. Feeley, MSW, FACHE
    Deputy Under Secretary for Health for Operations and Management
  Veterans Health Administration, U.S. Department of Veterans Affairs
    Good morning, Mr. Chairman and Members of the Subcommittee. Thank 
you for the opportunity to be here today to discuss the many positive 
steps the Department of Veterans Affairs (VA) utilizes to monitor the 
healthcare of our veterans and returning warriors. In my role as Deputy 
Under Secretary for Health for Operations and Management, I am 
responsible for the day to day activities at all of our facilities 
across the country. I would like to focus my attention on how the 
Veterans Health Administration (VHA) addresses quality improvement 
activities on a systemwide basis. I am accompanied by Dr. John Pierce, 
Medical Inspector, Dr. James Bagian, the Chief Patient Safety Officer, 
and Dr. Barbara Fleming, Chief Quality and Performance Officer.
OVERVIEW
    In the late eighties, VA healthcare programs came under a great 
deal of scrutiny because of the perception that quality was not 
comparable to that found in the private sector. Since that time, 
numerous programs have been implemented by VA to address and ensure 
that the quality of healthcare provided to our veterans is world class. 
The results of these efforts and achievements have brought national 
recognition to VA as consistently being recognized as one of the 
premier healthcare providers within the United States. For example, on 
January 20, 2006, the Washington Post published an article entitled 
``VA Care is Rated Superior to That in Private Hospitals,'' and the 
January/February 2005 issue of the Washington Monthly published an 
articled entitled ``The Best Care Anywhere.'' And the August 27, 2006 
issue of Time magazine had a feature article entitled, ``How Veterans 
Hospitals Became the Best Health Care''. While VA has transformed 
itself, we continue to strive to improve the quality of healthcare 
provided to our Nation's veterans through shared learning, research, 
and vigorous and stringent quality management and patient safety 
programs.
    The results of this work can be attributed to the leadership and 
contributions made by the offices represented by those accompanying me 
today--the Office of the Medical Inspector, the National Center for 
Patient Safety, and the Office of Performance and Quality--as well as 
the efforts of our VA workforce who are directly involved in patient 
care.
    VHA ensures the consistent quality of care that is delivered in its 
Veterans Integrated Service Networks through----

          Patient safety activities;
          Systems that listen, teach and detect problems early;
          Ongoing measurement of clinical processes;
          Establishment and control of quality standards for 
        both clinical protocols (Peer Review, Evidence-Based 
        Guidelines, Utilization Management) and for the providers of 
        care (National Credentialing and Privileging);
          Personal and anonymous patient surveys after the care 
        has been provided;
          Oversight by external organizations such as the Joint 
        Commission; and
          Oversight by internal organizations such as 
        Systematic Ongoing Assessment and Review Strategy (SOARS), 
        Office of Medical Inspector (OMI), Office of Inspector General 
        (OIG), Government Accountability Office (GAO), Veterans Service 
        Organizations (VSO).

PATIENT SAFETY
    The VA National Center for Patient Safety (NCPS) is guided by a 
mission to prevent harm to patients. The focus is to prevent 
inadvertent or accidental harm that may occur as a result of incidents 
such as patient falls, medication errors, malfunction or misuse of 
medical devices, and hospital-acquired infections. The NCPS works with 
Patient Safety Managers in all VA medical centers and Patient Safety 
Officers in the network offices to facilitate the implementation of an 
integrated patient safety improvement program throughout VHA. The 
primary methodology used in VHA to understand and prevent adverse 
events is Root Cause Analysis (RCA). The RCA teams focus on determining 
what happened, why it happened, and what systems changes should be made 
to prevent similar incidents from recurring. Information from RCAs is 
used to inform other VAMCs of potential problems, potential solutions, 
and in the development of VHA-wide policies and practices to prevent 
adverse events from occurring in VHA facilities.
    The NCPS also issues Patient Safety Alerts (Alerts) and Advisories 
on specific issues relating to medical devices and products, and other 
potential sources of harm to patients. Several Alerts have brought 
problems coupled with recommended solutions to the attention of other 
government agencies such as the Food and Drug Administration (FDA), and 
organizations such as the Joint Commission. Topics of recent Alerts of 
special interest included one that led to the withdrawal of Benzocaine 
spray from our facilities due to its high potential for accidental 
misuse and dangerous overdoses, and another one that described the 
correct way to clean and disinfect a special ultrasound device used for 
prostate biopsies. Both Alerts were of special interest to the FDA and 
resulted in FDA disseminating the potential vulnerabilities brought to 
light by VA to hospitals in the private sector.
    Another method to improve quality and patient safety is to reduce 
ineffective variation in practices. This is where VHA Directives 
(Directives) are issued to address patient safety topics.  Based on 
information from RCAs, emerging standard practices, and other sources, 
VA has developed and implemented several important Directives to 
improve patient safety such as: Ensuring Correct Surgery and Invasive 
Procedures; Prevention of Retained Surgical Items;  Out-of-Operating 
Room Airway Management; Recall of Defective Medical Devices and Medical 
Products; Planning for Fire Response; Reducing the Fire Hazard of 
Smoking when Oxygen Treatment is Expected; and Required Hand Hygiene 
Practices (based on the CDC's Guideline on this topic). These topics 
vary widely but are all related to preventing harm to patients as they 
receive care at a VA facility. By issuing these Directives, VA has 
acquired the ability, as the largest integrated healthcare system, to 
effect change that impacts millions of patients.
PERFORMANCE MEASUREMENT
    VA's performance measurement system is a key part of the 
transformation of care that started in the mid-nineties. The system has 
over 100 performance measures in the areas of access, satisfaction, 
cost, and quality. Data on these measures are collected monthly and all 
performance is shared and distributed on a quarterly basis to the field 
facilities with information broken out into aggregate totals for 
facilities, networks and VHA overall. The aggregated quarterly data is 
also used to produce detailed annual reports shared with senior 
leadership and the field.
    Special reports are also produced that focus on particular measures 
of concern or special populations. For example, reports have been 
provided on minority health, women's health, the health of Operation 
Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) veterans, and 
characteristics of facilities and networks leading to high performance 
with Best Practices shared across the system via video conferences 
which are web-based and enhanced and national face to face meetings.
    These data analyses lead directly to quality improvement efforts. 
When quality concerns are identified, working task groups have been 
convened to further explore these issues using collected data and 
working directly with the VA facilities to find and share solutions to 
the quality problems. VA consistently benchmarks its performance data, 
both internally and externally. Ongoing reports are prepared that 
compare VHA to other Federal and private sector healthcare 
organizations.
    The successful use of the performance measurement system for 
driving quality is based upon widespread dissemination of information 
and feedback to individuals at all levels of the healthcare system. 
Also, it is important to link measures not only in performance 
evaluations but also incentives in a variety of local and national 
means, for example, through awards to facilities, and networks. Linkage 
of measures to performance contracts result in personal accountability. 
In addition, for each quarter, I conduct individual performance reviews 
with each Network Director to personally review performance measure 
results for their VISN and to discuss plans for improving performance 
in areas that are needed. The Network Directors are held accountable 
for performance improvement through performance measurements.
CREDENTIALING AND PEER REVIEW
    VA also has a very sophisticated electronic credentialing program 
that is used system wide. We believe that careful credentialing is a 
cornerstone of assuring quality. The quality of privileging, which 
defines the practice scope of a provider, is also essential to 
maintaining a good clinical staff.
    Peer review is another mechanism in place to assure that the 
highest quality of care is delivered. Peer review is intended to 
contribute to quality improvement efforts of the individual provider, 
in a non-punitive way.
UTILIZATION MANAGEMENT
    Utilization Management (UM) allows the VA to determine that the 
right care is provided to the right patient at the right place for the 
right amount of time. A national Utilization Management Committee has 
put standards for UM in place, adopted nationally standardized 
criteria, conducted extensive training, and is beginning the 
implementation of a national data base to assure that there is 
facility, national, and network learning and quality improvement around 
the data collected.
    Patient complaints are assessed by a series of questions on the 
inpatient and outpatient surveys asking whether the veteran had a 
complaint about VHA care, and whether the veteran was satisfied with 
the resolution of that complaint. Patient advocates and the national 
VHA Patient Advocacy Office monitor these results closely to ensure 
that veterans' and their families' voices are being heard.
SYSTEMATIC ONGOING ASSESSMENT AND REVIEW STRATEGY
    The VA utilizes a learning system that exports and disseminates 
information to all segments of the VA healthcare system so that 
providers can learn how to deliver care that is not only safe, 
efficient, cost-effective, but clinically measurable and evidence-
based. For example, the Systematic Ongoing Assessment and Review 
Strategy (SOARS) is an internal review initiative that was initially 
implemented within the VA as an internal voluntary program that 
facilities could use as a systematic method for on-going self-
improvement and to support the culture of continuous readiness. Now, 
based on the success of this program, all VA facilities participate in 
a SOARS site visit every 3 years. As the SOARS team members interview 
staff, they frequently become aware of an excellent practice 
implemented at the surveyed site that could improve patient care 
quality or efficiency or reduce costs that could easily be shared with 
other VA facilities. The information regarding these ``Strong 
Practices'' is kept on the SOARS VA intranet Web site that is easily 
accessed by all VA staff.
OFFICE OF THE MEDICAL INSPECTOR
    Another internal review mechanism involves the reviews done by the 
Office of the Medical Inspector who evaluates quality of care concerns 
raised by veterans and other stakeholders and makes recommendations to 
enhance and improve the quality of care provided by VHA. These 
recommendations are directed at the facility involved in the site 
visit. When common issues are identified, the recommendations may 
result in a Directive or guidance to the entire VHA system.
EXTERNAL OVERSIGHT
    As a public system, the VA undergoes intense scrutiny from a 
variety of accreditation agencies, both internal and external 
reviewers. All VA medical facilities are accredited by the Joint 
Commission on Accreditation for Healthcare or organizations on a 
triennial cycle.
    The Office of the Inspector General (OIG) for the VA, and the 
Government Accountability Office are frequent inspectors of care 
provided at individual VA facilities and often address issues that cut 
across specific VAMCs. For each review, VHA drafts a response and 
action plan to respond to findings. We welcome the opportunity for 
external regulators to help us identify areas where improvement is 
needed and strives hard to make those improvements.
CONCLUSION
    As a system, VA is continuously looking for opportunities to learn 
and improve. The components described above provide a solid foundation 
for identification of problem areas and challenges for the system of 
care that can be transported to improve our entire healthcare delivery 
system for individuals.
    One of the advantages of being a large integrated healthcare 
organization is that VHA has the ability to learn and share examples of 
best practices from our clinicians and administrators across our entire 
system. I personally speak with the Veterans Integrated Service Network 
(VISN) Directors as well as Facility leadership on a weekly basis; best 
practices are identified and shared via these teleconferences. In 
addition, conference calls are held by my colleagues with patient 
safety and quality management staff. There are many examples of how VA 
learns from specific clinical incidents.
    I appreciate the opportunity to talk with you today. The events at 
Salisbury have spurred us to go even farther in our monitoring process 
than I have described here. I have asked that the Network Chief Medical 
Officers and Quality Managers heighten their personal ownership of 
issues affecting their facilities and ensure that best practices are 
shared systemwide. Mr. Chairman, this concludes my statement. At this 
time I would be pleased to answer any questions that you may have.

                                 

                                U.S. Department of Veterans Affairs
                                     Veterans Health Administration
                           Veterans Integrated Services Network Six
                                                        Durham, NC.
                                                     April 18, 2007
Hon. Robin Hayes
U.S. House of Representatives
Washington, DC 20515

    Dear Congressman Hayes:

    Thank you for the opportunity to respond to your letter of March 
15, 2007, regarding article in The Charlotte Observer detailing the 
actions of a nurse at our Salisbury VA Medical Center (VAMC) who 
reportedly falsified care reports on VA patients in contract nursing 
homes. You indicate that while what may have happened previously is of 
concern, you are troubled by the article's assertion that the nurse is 
still employed by the VA in Salisbury. You ask why, if the assertion is 
correct, did VA not find this behavior grounds for dismissal?
    These are appropriate questions, which relate to our oversight of 
long-term care of our veterans and our personnel action procedures with 
staff. I can assure you that we have taken both matters very seriously. 
The VA Office of Inspector General (OIG) Review of Contract Nursing 
Home Oversight at our Salisbury VA Medical Center was conducted June 
19-23, 2006. The OIG report is indicative of VA's internal monitoring 
to promote quality of care.
    I apologize for the delay in responding to you, but a second OIG 
review was just completed last week concerning the oversight of nursing 
home care for our Salisbury VAMC patients. Although we do not have the 
final written repot, we received an oral summary, which emphasized that 
oversight is underway.
    At the time of the original report, from October 2003 to June 2006, 
Salisbury VA Medical Center had placed 17 veterans in 11 contract 
nursing homes. We can confirm that all these veterans had been visited 
at least monthly by a Salisbury VAMC Social Worker. This VA staff 
member met with each veteran; spoke with clinical providers; reviewed 
progress notes regarding each veteran's care; and made every reasonable 
effort assure that appropriate followup treatment was being provided. 
The Social Worker involved family members in the care plans for their 
loved ones. Neither the veterans in these contracted nursing homes nor 
the family members expressed any safety concerns or requested placement 
in another facility.
    Salisbury quickly assigned another nurse to resume monthly visits 
to these veterans, and an Administrative Board of Investigation was 
convened to analyze Salisbury VA Medical Center's oversight of veterans 
placed in contracted nursing homes.
    The former Salisbury VA Medical Center Director reviewed the 
recommendations with the employee and that individual's 
representatives. The VA Regional Counsel was consulted and it was 
decided to enter into a ``last-chance'' agreement with the employee. As 
a result this nurse continues to be employed at the Salisbury facility 
but is no longer involved with the Contract Nursing Home Program or 
with patient care. The North Carolina Board of Nursing is investigating 
the individual at this time. If a bar is placed on this individual's 
license, then VA will terminate this nurse's employment.
    We currently have 11 veterans placed by Salisbury VAMC for long-
term care in eight contracted nursing home facilities, and the program 
is working well to the benefits of these patients.
    Recent media reports about this facility notwithstanding, I can 
assure that our team at Salisbury is serving our veterans effectively. 
With funding and other support from you and other members of Congress, 
we are constructing a new 65,000 square-foot VA Outpatient Clinic in 
Charlotte and another facility, of approximately 20,000 square feet, in 
Hickory. These new sites of care will extend the outreach of primary 
care, general mental health, eye care and other services to our 
veterans in these areas. Both of these facilities will be staffed and 
managed by the Salisbury VA Medical Center, along with our major clinic 
in Winston-Salem.
    Our Salisbury VA Medical Center and its clinics provided care to 
60,000 veterans last year. It is our leading site for care of our 
newest veterans returning from duty in Operations Iraqi and Enduring 
Freedom, caring for 4,248 of these individuals out of approximately 
16,000 served since September 11, 2001, in our Network facilities.
    We want to extend a cordial invitation to you and your staff to 
visit the Salisbury facility at your convenience. Please contact Dr. 
Dave Raney at 919-956-5541 and he can assist you.
    Please be assured that throughout our 8 VA Medical Centers and our 
current 10 and soon to be 15 outpatient facilities, our mission is to 
provide safe, efficient, effective, and compassionate care to the more 
than 292,000 veterans we so proudly serve. I greatly appreciate your 
personal support of the development of an outpatient clinic in Hamlet 
and your other efforts to enhance healthcare services to our Nation's 
veterans.
            Sincerely,
                                          Daniel F. Hoffmann, FACHE
                                           Network Director, VISN 6

                                 
                        QUESTIONS FOR THE RECORD

                                     Committee on Veterans' Affairs
                       Subcommittee on Oversight and Investigations
                                                    Washington, DC.
                                                       May 21, 2007

Honorable George J. Opfer
Inspector General
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

    Dear Mr. Opfer:

    On Thursday, April 19, 2007, the Subcommittee on Oversight and 
Investigations of the House Committee on Veterans' Affairs held a 
hearing using the VA Medical Center in Salisbury, North Carolina as 
case study for the quality of care veterans receive across the country.
    During the hearing, the Subcommittee heard testimony from Dr. John 
D. Daigh, the Assistant Inspector General for Healthcare Inspections. 
As a followup to that hearing, the Subcommittee is requesting that Dr. 
Daigh answer the following question for the record:

        1.  Your site visit indicated that 4 of the 11 contract nursing 
        homes were on the state ``watch list'' meaning that they had 
        been found deficient during their last state inspection. Is it 
        not disturbing that Salisbury would continue to place veterans 
        in these homes? And furthermore, the medical center did not 
        establish the required Contract Nursing Home Oversight 
        Committee. When was this glaring deficiency finally remedied? 
        Would you not characterize this situation as less than 
        proactive and a symptom of senior management malaise?
        2.  How and when did you realize that your budget and staffing 
        would not allow you to address these investigations?

    We request you provide responses to the Subcommittee no later than 
close of business, Friday, June 8, 2007.
    If you have any questions concerning these questions, please 
contact Subcommittee on Oversight and Investigations Acting Staff 
Director, Dion S. Trahan, Esq., at (202) 225-3569 or the Subcommittee 
Republican Staff Director, Arthur Wu, at (202) 225-3527.

            Sincerely,

                                                  HARRY E. MITCHELL
                                                           Chairman

                                               VIRGINIA BROWN-WAITE
                                          Ranking Republican Member
                               __________
                                U.S. Department of Veterans Affairs
                                        Office of Inspector General
                                                     Washington, DC
                                                      June 21, 2007

Hon. Harry Mitchell Chairman
Hon. Ginny Brown-Waite
Subcommittee on Oversight and Investigations
Committee on Veterans' Affairs
U.S. House of Representatives
Washington, DC 20515

    Dear Mr. Chairman and Congresswoman Brown-Waite:

    Enclosed are responses to followup questions from the April 19, 
2007, hearing before the Subcommittee that were included in a letter 
from you and the Ranking Republican Member. A similar letter is being 
sent to the Ranking Republican Member of the Subcommittee.
    Thank you for your interest in the Department of Veterans Affairs.

            Sincerely,
                                                    George J. Opfer
                                                  Inspector General
    Enclosure
                               __________
          Questions from Hon. Harry E. Mitchell, Chairman and
           Hon. Ginny Brown-Waite, Ranking Republican Member
            Subcommittee on Oversight and Investigations, to
   Mr. Opfer, Inspector General, U.S. Department of Veterans Affairs

    Question: Your site visit indicated that 4 of 11 contract nursing 
homes were on the state ``watch list'' meaning that they had been found 
deficient during their last state inspection. Is it not disturbing that 
Salisbury would continue to place veterans in these homes? And 
furthermore, the medical center did not establish the required Contract 
Nursing Home Oversight Committee. When was this glaring deficiency 
finally remedied? Would you not characterize this situation as less 
than proactive and a symptom of senior management malaise?

    Answer: A nursing home may be placed on a state watch list for a 
variety of reasons ranging from not meeting safe food preparation and 
storage standards to inadequate care practices. Inclusion of a nursing 
home on a state watch list is not by itself disqualifying for placement 
of veterans. However, OIG expects that in these circumstances medical 
center staff review and consider watch list data to ensure that the 
nursing home is appropriate for the veteran's clinical condition. A 
patient's family should also be provided the opportunity to participate 
in the selection of a nursing home and be made aware of watch list and 
other data regarding the nursing home's performance. As reported in the 
results of our 2006 CAP review, we found that veterans were placed in 
four substandard nursing facilities that were on the state watch list 
without proper oversight by medical center staff. We recommended that 
medical center staff increase monitoring of substandard nursing 
facilities where veterans remain under contract care. A Contract 
Nursing Home Oversight Committee was established just prior to our site 
visit in June 2006. The lack of a VHA contract nursing home oversight 
Committee is not acceptable and is not consistent with VHA policy.

    Question: How and when did you realize that your budget and 
staffing would not allow you to address these investigations?

    Answer: Due to resource limitations, OIG has historically lacked 
the capacity to meet all demands for review of complaints about VA 
services and programs. OIG has adopted a system of triaging incoming 
work to determine which cases require independent OIG review based on 
the seriousness and urgency of the complaint and current workload 
priorities. A substantial number of cases are referred to other VA 
elements for fact-finding and review. In these cases, the responsible 
VA office reports their findings back to us for final review before a 
case is closed.
    The OIG Hotline received allegations from an anonymous complainant 
that 12 patient deaths occurred on the surgical service of the W.G. 
(Bill) Hefner Medical Center in Salisbury, North Carolina, on August 
30, 2007. The next day, the case was referred to and accepted by the 
OIG Office of Healthcare Inspections (OHI) based on the serious nature 
of the allegations. OHI staff began development of an inspection plan, 
staff requirements, and project schedule. During this early planning 
phase, however, it became apparent that the scope and significance of 
the project demanded more immediate attention then OHI originally 
anticipated. After careful assessment of OHI's workload and priorities, 
OHI contacted the Office of the Medical Inspector (OMI), and both 
offices agreed that OMI was better positioned from a resource 
perspective to conduct and complete the review. Shortly thereafter, on 
September 21, 2007, the OIG made a written referral to OMI to conduct 
the review and to report back its findings. Consistent with OIG policy, 
we reviewed the OMI report prior to its issuance. Given current 
resource levels and workload, OIG will continue to triage incoming work 
and make referrals to OMI and other VA elements when appropriate.

                                 

                                     Committee on Veterans' Affairs
                       Subcommittee on Oversight and Investigations
                                                    Washington, DC.
                                                       May 21, 2007
Honorable R. James Nicholson
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

    Dear Secretary Nicholson:

    On Thursday, April 19, 2007, the Subcommittee on Oversight and 
Investigations of the House Committee on Veterans' Affairs held a 
hearing using the VA Medical Center in Salisbury, North Carolina as 
case study for the quality of care veterans receive across the country.
    During the hearing, the Subcommittee heard testimony from Mr. 
William F. Feeley, the Deputy Under Secretary for Health for Operations 
and Management; Dr. Sidney Steinberg, the Chief of Staff at the 
Salisbury VAMC; Mr. Donald Moore, the former Director of the Salisbury 
VAMC and current Director of the VAMC in Phoenix, Arizona; and various 
other officials from the VA and the Salisbury facility. As a followup 
to that hearing, the Subcommittee is requesting that the following 
questions be answered for the record:

Questions for Mr. Feeley:

        1.  What was the Peer Review process at Salisbury VAMC, and how 
        has it changed to ensure better patient care and reduce the 
        incidents of surgical and post surgical deaths? Please be 
        specific in your response.
        2.  How frequently does the OMI investigate and provide 
        oversight to a VAMC such as Salisbury when allegations are made 
        about inadequacies of care?
        3.  What changes have been made to the culture of care 
        providers, such as surgeons, nursing staff, attending 
        physicians, and anesthesiologists at Salisbury VAMC to provide 
        better quality of care? Has VHA taken lessons learned at 
        Salisbury and implemented directives to the rest of VHA to 
        provide better care throughout the VA?
        4.  Is it your opinion that the problems outlined during the 
        March 2005 investigation by the OMI have been resolved, and if 
        so, what changes occurred to implement the changes necessary to 
        resolve these issues?
        5.  Please provide the results of the last SOURCE visit to 
        Salisbury.
        6.  Please provide SES Bonus information for staff at the 
        Salisbury VAMC and VISN 6 during the time period in question.

Questions for Dr. Steinberg:

        1.  According to your testimony, the Salisbury Surgery 
        Department has made improvements since the March 2005 OMI 
        report, Congress received in June of 2005. Most of these 
        improvements deal with new construction projects. How have 
        surgical facilities expanded, and how do you anticipate further 
        improvements in care stemming from these expansions?
        2.  When do you anticipate filling the Chief of Pathology 
        position? How long has this position been empty? What criteria 
        are you using to evaluate candidates for this position?
        3.  How long had the Chief nursing position been empty prior to 
        the OMI report, and after the issuance of the OMI report?
        4.  It should be noted that the Women's Health Program is 
        moving into a newly renovated space in order to provide 
        additional services specific to the medical needs of women. How 
        many female veterans do you anticipate being able to serve in 
        this new space? When will this facility be fully staffed?
        5.  What future plans for construction do you anticipate for 
        the future at Salisbury in order to continue to meet the needs 
        of the veteran community in western North Carolina?
        6.  What specific actions have been taken to hold personnel 
        found at fault in the deaths of the twelve patients which 
        initiated the original OMI investigation accountable?

Questions for Mr. Moore:

        1.  Now that you are in a position of greater responsibility 
        and bigger staff, how do you insure all egregious IG and OMI 
        findings of 22 inadequate actions in identifying and 
        implementing specific corrective actions do not reoccur under 
        your leadership in Phoenix?
        2.  Did you receive any performance bonuses during your tenure 
        at Salisbury?

Questions for Dr. Pierce:

        1.  What were the steps taken to follow up on personnel 
        reviews, oversight, and holding individuals accountable at the 
        Salisbury VAMC? How did your office ensure all recommendations 
        were being complied with? Please be specific in your response.
        2.  Please provide written documentation of all actions taken 
        against personnel in Salisbury, North Carolina following the 
        misconduct/malpractice instances of the seven deaths?

    We request you provide responses to the Subcommittee no later than 
close of business, Friday, June 8, 2007.
    If you have any questions concerning these questions, please 
contact Subcommittee on Oversight and Investigations Acting Staff 
Director, Dion S. Trahan, Esq., at (202) 225-3569 or the Subcommittee 
Republican Staff Director, Arthur Wu, at (202) 225-3527.

            Sincerely,
                                                  HARRY E. MITCHELL
                                                           Chairman

                                               VIRGINIA BROWN-WAITE
                                          Ranking Republican Member
                               __________
          Questions from Hon. Harry E. Mitchell, Chairman, and
           Hon. Ginny Brown-Waite, Ranking Republican Member
            Subcommittee on Oversight and Investigations to
                   Hon. R. James Nicholson, Secretary
                  U.S. Department of Veterans Affairs

    Case Study on the Department of Veterans Affairs (VA) Quality of 
Care: W.G. Hefner VA Medical Center in Salisbury, North Carolina

Questions for Mr. Feeley:

    Question 1: What was the Peer Review process at Salisbury VAMC, and 
how has it changed to ensure better patient care and reduce the 
incidents of surgical and post surgical deaths? Please be specific in 
your response.

    Response: The peer review process at the Salisbury VA Medical 
Center (VAMC) included critical reviews of episodes of care performed 
by a peer or by a group of peers.
    Inspectors from the Office of the Inspector General (OIG) 
identified deficiencies in the Salisbury VAMC's quality management 
program during a June 2006 combined assessment program (CAP) survey. 
They found that peer reviews were not completed as required between 
July 2005 and June 2006. They also found that the peer review Committee 
(PRC) had not met since November 2005.
    The local peer review process was stopped in response to VA Office 
of Resolution Management's request to review information protected by 
38 USC  5705, Confidentialityof Medical Quality-Assurance Records. 
When informed that the confidentiality of documents regarding peer 
reviews would be compromised, the physicians refused to further 
participate in what is understood to be a confidential process.
    During the OIG CAP survey, the chief of staff acknowledged the 
importance of peer review activities and reported that the peer review 
meetings would resume, but stated that he would not disclose protected 
information to the Office of Resolution Management. The OIG did not 
make recommendations as the medical center leadership indicated that 
the peer review process would be resumed. The peer review process was 
resumed immediately.

    Question 2: How frequently does the OMI investigate and provide 
oversight to a VAMC such as Salisbury when allegations are made about 
inadequacies of care?

    Response: The Office of the Medical Inspector (OMI) investigates 
all allegations made about inadequate quality of care provided to 
veterans brought to their attention--The OMI monitors, along with the 
Deputy Under Secretary Health for Operations and Management, the VA 
medical center's action plan, developed as a result of the OMl's 
recommendations.

    Question 3: What changes have been made to the culture of care 
providers, such as surgeons, nursing staff, attending physicians, and 
anesthesiologists at Salisbury VAMC to provide better quality of care? 
Has VHA taken lessons learned at Salisbury and implemented directives 
to the rest of VHA to provide better care throughout the VA?

    Response: A total change in surgical, anesthesia and nursing 
leadership was effected. Dr. Charles Graham was appointed as chief of 
surgery with concurrence of Dr. Ralph DePalma, national director of 
surgery. With his guidance, new policies and procedures were 
implemented directed at improving and maintaining the highest quality 
of surgical care. A new chief of anesthesia was appointed, Dr. Robert 
Slok, from Ohio University with an assistant chief, Dr. John Murphy 
from Duke University. Ms. Judith Pennington, RN, was selected as the 
new chief operating room nurse from a major medical center in Denver, 
Colorado.
    With this leadership team in place, all aspects of surgical care 
are being addressed, including fundamental education of staff, addition 
of critical support staff and establishment of key management tools to 
assure highest quality and adherence to all performance measures. Input 
from existing staff was readily sought and team building was begun in a 
new and dynamic fashion.
    Everyone involved in surgical care was brought to the table to 
learn, address and execute a comprehensive plan for ``their'' surgical 
program. The result has been a dramatic improvement in all aspects of 
surgical care, surpassing all national quality standards for morbidity 
and mortality.
    The Veterans Health Administration (VHA) has published several 
handbooks and directives regarding provision of quality, safe patient 
care. In addition, a weekly national conference call is held which 
includes the presentation of lessons learned and best practices in the 
delivery of patient care. In January 2007, the VA national surgical 
quality improvement program (NSQIP) sent out a newsletter to the field 
that provided information, data and updates on the program.

    Question 4: Is it your opinion that the problems outlined during 
the March 2005 investigation by the OMI have been resolved, and if so, 
what changes occurred to implement the changes necessary to resolve 
these issues?

    Response: Yes. To begin the process of correcting problems 
identified by the OMI, removal of some staff was required. The existing 
chief of surgery was removed and his surgical privileges terminated. 
The physician in charge of the medical management issues was terminated 
and no longer practices medicine. The anesthesia chief was terminated.
    Conferences and training programs are now in place to assure 
adequate continuing education for all staff. Preoperative and 
postoperative care issues are continually reviewed to assure quality of 
care at every step, A new medical center director and the chief of 
staff provide day to day oversight. All issues reported in the OMI 
report have been addressed and resolved.

    Question 5: Please provide the results of the last SOURCE visit to 
Salisbury.

    Response: A system wide ongoing assessment and review strategy 
(SOARS) site visit was conducted at the Salisbury VA medical center 
(VAMC) December 6-9, 2005. Written reports were not required during 
this period, a verbal out-briefing of findings and recommendations were 
provided to facility leadership and staff at the conclusion of the 
visit. The visit found many areas of compliance with standards, and 
others that appeared to be improving. Areas identified as needing 
attention and improvement included:

      Medication and controlled substance management. Comprised 
of several issues around medication storage.
      Information security. Specifically related to ensuring 
that access to computer systems are terminated immediately when 
employees, volunteers, and contractors leave VA service.
      Patient transportation. Ensuring that all drivers meet 
standards for training, physical screening, and license checks.
      General safety concerns related to fire extinguishers and 
exit doors.
      Process improvements needed to enhance medical care cost 
recovery insurance identification and billing.

    The discrepancies identified during the SOARS site visit have been 
addressed.

Questions for Dr. Steinberg:

    Question 1: Please provide SES Bonus information for staff at the 
Salisbury VAMC and VISN 6 during the time period in question.

    Response: The following individual received bonuses at that time:

    Timothy May--Director Salisbury VAMC
        2000--no VISN records of any awards or bonuses
        2001--no VISN records of any awards or bonuses
        2002--no VISN records of any awards or bonuses
        2003--no VISN bonuses--retired

    Stephen Lemons--Director Salisbury VAMC--11/1/03-6/12/04
        2003--$20,000

    Donald Moore--Director Salisbury VAMC--6/13/2004-11/11/2006
        2004--0
        2005--$12,000
        2006--$9,000

    James L. Robinson III Associate Director, Salisbury VAMC
        August 4, 2004--$1,000
        August 8, 2004--$2,000
        September 15, 2004--$3,000
        April 22, 2005--$5,000
        November 15, 2005--$5,000
        November 14, 2006--$4,000
        January 18, 2007--$5,000

    Sidney R. Steinberg Chief of Staff, Salisbury VAMC
        September 15, 2004 $5,000
        April 22, 2005--$5,000
        April 22, 2005--$2,500
        November 15, 2005--$5,000
        January 24, 2007--$5,000

    Mark Shelhorse, MD Chief Medical Officer--VISN 6
        2001--$6000
        2002--$15,000
        2003--$15,000
        2004--$24,500
        2005--$25,000
        2006--$19,000

    Daniel F. Hoffmann Network Director--VISN 6
        2000--$15,000
        2001--$12,000
        2002--$26,000
        2003--$26,000
        2004--$29,120
        2005--$20,000
        2006--$24,000

    Question 2: According to your testimony, the Salisbury Surgery 
Department has made improvements since the March 2005 OMI report, 
Congress received in June of 2005. Most of these improvements deal with 
new construction projects. How have surgical facilities expanded, and 
how do you anticipate further improvements in care stemming from these 
expansions.

    Response: In mid-2003, a vigorous recruiting effort was begun to 
attract the highest quality professional staff to the VAMC at 
Salisbury. Efforts were also initiated to build an academic 
relationship with Wake Forest University School of Medicine to gain 
their support in improving the professional staff at Salisbury and to 
develop the framework for establishing training programs for resident 
education in a variety of medical and surgical specialties. Contingent 
on developing a strong and effective surgical program was the need to 
improve surgical nursing capabilities, anesthesia support, an 
appropriate post anesthesia care unit (PACU) and improving both the 
equipment available and the physical plant.
    Project requests were submitted to address the physical plant needs 
through a nonrecurring maintenance proposal. The physical plant 
improvements included the construction of a completely new surgical 
suite with adequate space and proper air flow to improve the safety and 
efficiency of surgical care. Better air flow reduces the risk of 
airborne infection and cross contamination. The larger space allows for 
introduction of modern endoscopic equipment important for safer 
inpatient and ambulatory surgical interventions with reduced operative 
morbidity and mortality. This construction replaced an out-dated 
operating room and air handling system essential to improve quality of 
care. The addition of both space and staff for the PACU assures maximum 
post anesthesia safety for patients. The first part of this project 
will be completed in the summer of 2007. A second proposal to complete 
the physical plant modifications has been submitted. The completed 
projects will allow for the addition of important specialties and 
better support from our academic affiliate with the addition of vital 
resident training programs and faculty.
    Nursing support was completely retooled. A new and very experienced 
operating room supervisor, Judith Pennington, RN, was recruited from 
Denver and is the nurse in charge of surgical operations. She has 
selected a superb staff of qualified and experienced surgical nurses in 
a variety of discipline specialties to support the surgical programs. A 
PACU staff was recruited and is now in place.
    Key surgical staff members were recruited. Dr. Charles Graham, 
Vanderbilt University trained, was selected as the new chief of 
surgery. Dr. David Crist, Johns Hopkins trained, was selected to head 
the section of gastrointestinal surgery. Dr. Valerie Moore was 
recruited from the University of Maryland to provide expertise in 
breast surgery and laparoscopic surgery. Dr. Anthony Burke from West 
Virginia University joined the staff with expertise in colon and rectal 
surgery. The women's surgical unit was expanded to provide expert 
gynecological surgery with the addition of Dr. Helen Malone from the 
University of Virginia.
    Key anesthesia staff were recruited and added to the staff. Drs 
Block, Murphy and Breton, all highly qualified anesthesiologists have 
added great expertise in anesthesia and pain management at the medical 
center.
    Expanded training programs in ophthalmology, and otolaryngology 
were established with Wake Forest University with both resident and 
faculty support from the University. A new program in urologic surgery 
supported by Wake Forest is set to begin the summer of 2007. A new 
chief of urology has been selected, Dr. Hector Henry, an adjunct 
clinical Professor from Duke University.
    All quality measures including morbidity and mortality data exceed 
national standards. Effective monitoring is in place to ensure 
continued high quality performance and excellent patient care outcomes. 
Additional residency program commitments from Wake Forest and the 
Office of Academic Affairs are being sought to further the professional 
expertise at Salisbury.
    Additional support in other related disciplines has been added. 
These include critical care specialists, infectious disease 
specialists, and others.

    Question 3: When do you anticipate filling the Chief of Pathology 
position? How long has this position been empty? What criteria are you 
using to evaluate candidates for this position?

    Response: The position is posted and a team of highly regarded 
pathologists has been appointed to serve on the selection Committee. 
Several excellent candidates have been identified and a selection is 
anticipated by September 2007. The current pathologist will remain in 
place until a new chief is selected and has had adequate time to be 
oriented to the department.

    Question 4: How long had the Chief nursing position been empty 
prior to the OMI report, and after the issuance of the OM I report?

    Response: The chief nurse on staff during the OMI site visit was 
removed on December 30, 2004. A new executive nurse was selected and 
joined the staff on June 10, 2005.

    Question 5: It should be noted that the Women's Health Program is 
moving into a newly renovated space in order to provide additional 
services specific to the medical needs of women. How many female 
veterans do you anticipate being able to serve in this new space? When 
will this facility be fully staffed?

    Response: The new women's health clinic space was completed in May 
2007 and is now occupied. A complete staff is in place and includes a 
gynecologist, physician assistant, two nurses, a clinic clerk, an 
administrative officer and a dedicated primary care physician. Plans to 
add an additional staff gynecologist are in place and recruitment will 
be completed in the fall of 2007. The new space will allow for 
important additions to the women's health program, Primary care 
physicians will be added to the clinic in order to provide 
comprehensive care to our female patients. This is particularly 
important for those women with a history of military sexual trauma. 
Additionally, for completeness in our comprehensive approach to women's 
health, the new space will include a new digital mammography unit for 
prompt breast cancer screening for all patients.
    Capacity will be doubled, thus allowing the center to increase the 
number of female veterans seen and referred for complex gynecologic 
issues from Fayetteville and Asheville VAMCs along with the anticipated 
surge from Charlotte's new facility scheduled to open in early 2008. 
Currently the number of women veterans represents nearly 3000 veterans. 
With expansion into Charlotte and Hickory, numbers should exceed 5000 
by the end of 2008.

    Question 6: What future plans for construction do you anticipate 
for the future at Salisbury in order to continue to meet the needs of 
the veteran community in western North Carolina?

    Response: Two minor projects have been funded and are currently 
under design for construction in 2008 and 2009. These projects will add 
9,000 square feet to the existing medical surgical building and will 
provide space for radiology, pharmacy, dental service, a post 
anesthesia care unit (PACU) and special clinic space for urology and 
oncology.
    There is a renovation project currently underway to add additional 
patient rooms with private baths to accommodate the needs of female 
patients and an expanded medicine service. A new eight bed intensive 
care unit is included in the project. Additional renovations are 
planned for the surgical care unit. A major project has been submitted 
to add additional needed space for specialty clinics and 
rehabilitation. This project is essential to meet the demand for 
additional services at Salisbury and is particularly important with the 
future addition of major clinics in our service area at Charlotte and 
Hickory. Major renovations have also been completed in mental health 
and existing primary care units.

    Question 7: What specific actions have been taken to hold personnel 
found at fault in the deaths of the 12 patients which initiated the 
original OMI investigation accountable?

    Response: There were three specific actions taken that affected 
hospital personnel.

      The chief of surgery was removed from his position. His 
surgical privileges were withdrawn permanently. After consultation with 
VA authorities, he was allowed to remain on the staff in a non-surgical 
capacity with the provision that he obtain additional training and meet 
the requirements for and obtain re-certification in his specialty. He 
will, however, not be allowed to operate independently again.
      The second index case was a non-surgical case and 
involved poor care on the part of an internal medicine physician. He 
was removed from the staff, his license to practice medicine in North 
Carolina was terminated and he moved from the State. To our knowledge 
he no longer practices medicine in any venue.
      The nursing issue that led to the failure to notify the 
appropriate on call physician in the index surgical case resulted in 
changing nursing leadership at the medical center and on the care unit 
involved.

    The allegation of 12 suspicious deaths was not substantiated by the 
OMl or the national surgical director. After a review of all deaths at 
the medical center for a period of 1 year, there were two index cases, 
where death was related to substandard care. One surgical index case as 
noted, and one medical index, as noted. The personnel actions taken 
were related to those cases.

Questions for Mr. Moore:

    Question 1: Now that you are in a position of greater 
responsibility and bigger staff, how do you insure all egregious IG and 
OMI findings of 22 inadequate actions in identifying and implementing 
specific corrective actions do not reoccur under your leadership in 
Phoenix?

    Response: The Carl T. Hayden VAMC has multiple systems/structures 
in place to anticipate or prevent adverse events. These include the 
following:

      Chief of Staff Oversight--The chief of staff provides 
oversight of clinical programs, is involved in medical staff activities 
and leaders are held accountable for performance.

      Performance Improvement Program--The program has active 
participants from both clinical and administrative staff. There is an 
executive performance improvement council which meets monthly to review 
performance and other key indicators in the medical center.

      Peer Review Committee--The Committee meets quarterly and 
provides oversight for the peer review program. The peer review program 
meets standards required by VHA Directive 2004-054, Peer Review for 
Quality Management and is chaired by the chief of staff.

      Risk Management Program--The program includes 
anticipation of risk, staff education and prevention of adverse events. 
It also includes disclosure of adverse events to patients and review of 
100 percent of patient deaths and adverse events.

      Surgical Risk Assessment Program--This facility 
participates in the national surgical quality improvement program 
(NSQIP). Surgical cases are reviewed and compared with all VA 
facilities nationally for mortality and morbidity. Outliers are 
immediately identified and actions taken to address any concerns.

      Patient Safety Program--This active program promotes a 
strong safety culture. Both clinical and administrative staff are 
involved with ongoing patient safety activities.

      Infection Control Program--The comprehensive infection 
control program focuses on prevention and monitoring of infections. The 
infection control committee works with providers offering feedback to 
clinicians about infection and related issues in the medical center. 
Infection control also serves as liaison with local and State health 
departments for reporting and followup activities related to infections 
that are public health concerns.

      Medical Staff Monitoring & Active Medical Staff 
Committees--The external peer review program (EPRP) is in place. There 
are several active medical staff Committees which monitor and improve 
patient care. These include the invasive procedures Committee, 
transfusion Committee, pharmacy and therapeutics Committee, medical 
records Committee.

      Review by External Agencies--We are reviewed by Joint 
Commission and had successful surveys. The next survey is expected 
during 2008.

      Review by Internal VA Agencies--We are reviewed by the 
Office of the Inspector General, Office of Research, etc. Our most 
recent OIG/ CAP review was completed in November 2006 and was 
successful resulting in only one recommendation.

      Credentialing and Privileging--This program provides 
oversight for a credentialing and privileging system of medical staff. 
VetPro (VHA's electronic system) used for credentialing all providers, 
assures appropriate documentation, credentialing, privilege delineation 
and service review and adheres to VA's regulations.

    Question 2: Did you receive any performance bonuses during your 
tenure at Salisbury?

    Response: Yes. $12,000 in 2005, $9,000 in 2006

Questions for Dr. Pierce:

    Question 1: What were the steps taken to follow up on personnel 
reviews, oversight, and holding individuals accountable at the 
Salisbury VAMC? How did your office ensure all recommendations were 
being complied with? Please be specific in your response.

    Response: Personnel issues are outside the purview of the OMI; 
however, as part of the closure of the case resulting in the report, 
Review of the Delivery of Surgical Services, Salisbury VAMC, of June 9, 
2005, we noted that the following actions were taken by the VHA 
leadership ``the physician involved in the surgical case has had his 
privileges removed and the physician in the medical case resigned after 
having a summary suspension of his privileges'' as part of the medical 
center's fulfillment of its corrective action plan.
    Medical centers are routinely required to submit a corrective 
action plan responding to all OMI recommendations within 2 weeks of 
their receiving the final report approved by the Under Secretary for 
Health. The OMI makes a judgment to accept the corrective action plan 
based on the medical center's timely, positive, and enthusiastic 
response; whether the proposed actions will suitably address the 
recommendations; and after reviewing evidence of proposed corrections. 
Some actions, e.g., clear VAMC policy on a particular issue, may be 
judged complete on the documentation; other actions, e.g., suitable 
nursing coverage, may require more intense follow up, such as 
conference calls and additional documentation. In some cases, the OMI 
conducts follow up site visits to be certain the corrective actions are 
all in place and effective.
    In this case, the corrective action plan was accepted by the OMI, 
monitored, and the investigation closed when the intent of the 
recommendations were met. However, due to publicity surrounding this 
report and Congressional interest, the OMI conducted a follow up visit 
March 26-27, 2007 to assure all parties that the recommended corrective 
actions had been completed.

    Question 2: Please provide written documentation of all actions 
taken against personnel in Salisbury, North Carolina following the 
misconduct/malpractice instances of the seven deaths.

    Response: Personnel issues are outside the purview of the OMI. With 
regard to the seven deaths, these cases were reviewed under VHA's peer 
review program which is governed by title 38 United States Code 5705 
Confidentiality of Medical Quality Assurance Records and found to be 
Level two on a scale of one to three. This means, ``Most experienced, 
competent practitioners might have managed the case differently in one 
or more aspects.'' However, this difference in practice does not equate 
to misconduct/malpractice.

                                 

                                U.S. Department of Veterans Affairs
                                        Office of Inspector General
                                                    Washington, DC.
                                                  December 18, 2007
Hon. Harry E. Mitchell
Chairman, Subcommittee on
Oversight and Investigations
Committee on Veterans Affairs
U.S. House of Representatives
Washington, DC 20515

    Dear Mr. Chairman:

    During the Subcommittee hearing on April 19, 2007, on Case Study on 
U.S. Department of Veterans Affairs (VA) Quality of Care: W.G. (Bill) 
Hefner Veterans Affairs Medical Center in Salisbury, North Carolina, 
Congressman Walz inquired about the process for requesting additional 
resources within the Office of Inspector General (OIG). We indicated 
that we would provide additional information for the record.
    The OIG is an independent entity within the VA and has a separate 
line item in the VA appropriations bill. During the year, the funds 
available to the OIG are limited to this specific budget authority. The 
VA may not reprogram funds to augment the OIG's funding nor can VA take 
funding away from the OIG. The only way to ensure the OIG has 
sufficient resources to meet its mandated oversight responsibilities is 
though the annual internal VA budget formulation process and subsequent 
congressional appropriation actions.
    Thank you for your interest in the Department of Veterans Affairs.

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