Apr112013
Hearing Transcript on U.S. Department of Veterans Affairs Office of Inspector General’s Open Recommendations: Are We Fixing the Problems?.
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U.S. DEPARTMENT OF VETERANS AFFAIRS OFFICE OF INSPECTOR GENERAL’S OPEN RECOMMENDATIONS: ARE WE FIXING THE PROBLEMS?
HEARING BEFORE THE COMMITTEE ON VETERANS' AFFAIRS U.S. HOUSE OF REPRESENTATIVES ONE HUNDRED ELEVENTH CONGRESS SECOND SESSION JUNE 9, 2010 SERIAL No. 111-83 Printed for the use of the Committee on Veterans' Affairs
U.S. GOVERNMENT PRINTING OFFICE For sale by the Superintendent of Documents, U.S. Government Printing Office
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CORRINE BROWN, Florida |
STEVE BUYER, Indiana, Ranking |
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Malcom A. Shorter, Staff Director 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 published in electronic form. The printed hearing record remains the official version. Because electronic submissions are used to prepare both printed and electronic versions of the hearing record, the process of converting between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process is further refined. |
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C O N T E N T S
June 9, 2010
U.S. Department of Veterans Affairs Office of Inspector General’s Open Recommendations: Are We Fixing the Problems?
OPENING STATEMENTS
Chairman Bob Filner
Prepared statement of Chairman Filner
Hon. Cliff Stearns
Hon. Jeff Miller, prepared statement of
WITNESSES
U.S. Department of Veterans Affairs:
Richard J. Griffin, Deputy Inspector General, Office of Inspector General
Prepared statement of Mr. Griffin
Hon. Robert A. Petzel, M.D., Under Secretary for Health, Veterans Health Administration
Prepared statement of Dr. Petzel
MATERIAL SUBMITTED FOR THE RECORD
Post-Hearing Questions and Responses for the Record:
U.S. DEPARTMENT OF VETERANS AFFAIRS OFFICE OF INSPECTOR GENERAL’S OPEN RECOMMENDATIONS: ARE WE FIXING THE PROBLEMS?
Wednesday, June 9, 2010
U. S. House of Representatives,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10:07 a.m., in Room 334, Cannon House Office Building, Hon. Bob Filner [Chairman of the Committee] presiding.
Present: Representatives Filner, Michaud, Perriello, Rodriguez, McNerney, Walz, Adler, Kirkpatrick, Stearns, Miller, Boozman, Buchanan, and Roe.
OPENING STATEMENT OF CHAIRMAN FILNER
The CHAIRMAN. Good morning. I want to call to order this meeting of the Committee on Veterans' Affairs.
I ask unanimous consent that all Members may have 5 legislative days in which to revise and extend their remarks. Hearing no objection, so ordered.
I think we all know that the U.S. Department of Veterans Affairs’ (VA's) Office of Inspector General (OIG) plays a critical role in ensuring proper and efficient oversight of the Department's activities.
In the first half of the fiscal year 2010, from October 2009 to March 2010, the OIG issued 120 reports, identified nearly $673 million in monetary benefits, and conducted work that resulted in 232 administrative sanctions.
It is evident that the Inspector General is essential in rooting out fraud, waste, and abuse within the VA. Today we want to examine the progress that the Department of Veterans Affairs is making in complying with the OIG's recommendations.
Currently, the Office of Inspector General has a total of 115 open reports with almost 694 open recommendations that have yet to be implemented by the VA. The target date for implementation of these recommendations is within a year of publication. Although most of these open recommendations are on track to be completed within the 1-year time frame, 16 reports containing 45 open recommendations are over 1-year old.
Additionally, recommendations on VA information security issues tracked by an independent auditor show that there are almost 40 open recommendations, 34 of which are carried over from previous years.
The timely implementation of these recommendations is crucial to ensuring our Nation's veterans receive the best care. Many of these recommendations play a critical role in ensuring patient safety and safeguarding veterans' information.
Additionally, of course, timely implementation not only reflects good management, but it always reflects responsible use of taxpayer money. The monetary benefit yet to be realized by these recommendations going unimplemented approaches $100 million.
During this country's difficult financial time brought on by the recession, the VA must realize cost savings anywhere practical. This can be done straightforwardly through the elimination of waste and by acting in a timely manner to correct the issues identified in the OIG's recommendations.
The Office of Management and Administration's Operations Division is tasked with following up on the reporting and tracking of OIG report recommendations while ensuring that all allegations made by the OIG are effectively monitored and resolved in a timely, efficient, and impartial manner.
I am pleased that they are here today with Deputy Inspector General Griffin to share with the Committee their insights on this issue.
The OIG's reports for follow-up procedures are an essential component of the oversight process. Secretary Shinseki has commented many times on the importance of accountability and ensuring veterans' care comes first.
Every agency, including the VA, must be held accountable for implementing the OIG's recommendations in a timely manner and making certain our Nation's veterans are receiving the quality of care that is reflective of their service and sacrifice.
I recognize Mr. Stearns for an opening statement.
[The prepared statement of Chairman Filner appears in the Appendix.]
OPENING STATEMENT OF HON. CLIFF STEARNS
Mr. STEARNS. Good morning and thank you, Mr. Chairman. I look forward to this morning's discussion on what the VA must do to ensure the prompt and proper resolution of audit recommendations that are issued by the Office of Inspector General.
If you do not mind, I would like to read from the Inspector General Act of 1978, as amended, in which it states, "The head of a Federal agency shall make management decisions on all findings and recommendations set forth in an audit report of the Inspector General of the agency within a maximum of 6 months after the issuance of this report and should complete final action on each management decision within 12 months after the date of the Inspector General's report."
Now, Mr. Chairman, as of March 31st, 2010, there were 107 OIG reports with 640 open recommendations. While most of these recommendations are on track to close within the required 1-year period, I commend the VA for its timely implementation of those recommendations. We also know that there are many other recommendations that are over a year old.
The primary focus of this hearing is to get an update regarding the 11 open reports that are over 1-year old and the 23 recommendations in these reports that are still open.
According to the OIG's report, it could save taxpayers approximately $92 million if these recommendations are implemented. We must ensure a concerted effort is underway to ensure prompt implementation of the OIG's recommendation in order to realize these savings.
So I look forward to working with both the VA and the OIG on this as well as future collaborative efforts that will allow us to make VA more efficient and to ensure an improved return on investment for the taxpayers and, more importantly, Mr. Chairman, to ensure that our veterans have access to the highest quality health care and benefit delivery system as possible.
I would point out the staff and I were talking this morning that the return on investment is $14 to $1. That is for every $1 we spend with the OIG, we get $14 back. This is an enormous success and something that we should continue.
And I would be interested to know, Mr. Chairman, how the VA stacks up with the U.S. Department of Health and Human Services (HHS) and the U.S. Department of Labor (DOL) and other Federal agencies to see how well the other agencies are complying and implementing the OIG reports.
So, Mr. Chairman, I look forward to the testimony from our witnesses today and I welcome them too. Thank you.
The CHAIRMAN. Thank you, Mr. Stearns.
At this time, I welcome Richard Griffin who is the Deputy Inspector General for the Department of Veterans Affairs, accompanied by Robert Ehrlichman who is the Assistant Inspector General for Management and Administration.
Welcome. We appreciate you being here and look forward to your testimony. You are now recognized, Mr. Griffin.
STATEMENT OF RICHARD J. GRIFFIN, DEPUTY INSPECTOR GENERAL, OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY RICHARD EHRLICHMAN, ASSISTANT INSPECTOR GENERAL FOR MANAGEMENT AND ADMINISTRATION, OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS
Mr. GRIFFIN. Mr. Chairman and Members of the Committee, thank you for conducting this hearing and for the opportunity to discuss one of the Office of Inspector General's major responsibilities, which is to make recommendations to VA management to improve programs and services provided to our Nation's veterans.
Accompanying me today is Richard Ehrlichman who has the responsibility for the follow-up activity at the Office of Inspector General.
Follow-up is a critical component of OIG's oversight work. The Office of Management and Budget (OMB) requires a process to follow-up and report on the status of OIG recommendations. The OIG is required to report in its semi-annual report to Congress on the status of report recommendations.
In addition, after the Inspector General testified before this Committee in February 2007, we began providing quarterly updates to the VA Secretary and Congress on the status of open report recommendations with an emphasis on recommendations more than 1-year old.
On balance, VA does a good job implementing OIG report recommendations in a timely manner. The percentage of recommendations implemented within 1 year has increased to 94 percent from fiscal year 2007 to 2009. VA performs well based on comparative data that other Federal OIGs periodically report to Congress.
We will continue to focus on timely and full implementation of recommendations for improvement across VA programs.
In some instances, VA takes corrective actions while we are still onsite and before a final report is published. When this happens, we close out the recommendation as implemented and reflect that action in our final report. Nonetheless, the majority of our reports contain open recommendations for improvement.
Once the final report is issued, OIG follow-up staff in the Office of Management and Administration begin tracking the recommendations until they are fully implemented. For each report, we separately list recommendations and related monetary impact we expect VA to derive from implementation. In each status request, we seek a description of what actions have occurred toward implementing the recommendations during the preceding 90 days. We set a 30-day deadline for VA officials to respond in writing. The response must contain evidence such as issued policies and certifications before we will close recommendations.
The OIG also conducts follow-up reviews of some of our audit and inspection work. During these reviews, we validate implementation, evaluate the effectiveness of the recommended changes in fixing a problem, and in some cases identify repeat deficiencies.
Examples of follow-up reviews include our audit of the Veterans Benefits Administration (VBA) Fiduciary Program and our health care work on reusable medical equipment.
Opportunities exist for VA to improve its performance. As of March 31st, 2010, we had two reports with open recommendations that represented over $81 million in monetary impact. One report from September 2007 with over $21 million in monetary impact involved a recommendation to improve the acquisition and management of surgical device implants. The other report from September 2008 with over $59 million in monetary impact has multiple unimplemented recommendations on noncompetitive clinical sharing agreements.
Lengthy delays implementing OIG recommendations not only cost VA money in unrealized savings but prevent veterans from benefitting from improvements in VA programs.
We will continue to highlight those recommendations in need of attention in our reports to the VA Secretary, Congress, and in our regular meetings with senior VA officials.
Mr. Chairman, this concludes my statement. We would be happy to answer any questions you or other Members of the Committee may have.
[The prepared statement of Mr. Griffin appears in the Appendix.]
The CHAIRMAN. Thank you, Mr. Griffin.
Mr. Michaud?
Mr. MICHAUD. Thank you very much, Mr. Chairman, for having this hearing today.
I have a couple of quick questions. My first is, and I want to thank the panel for coming this morning, is why do you have a centralized follow-up staff rather than having the auditors or investigators who did the original report do the follow-up? Would it not make more sense to have those who did the original report do the follow-up?
Mr. GRIFFIN. In reality, it is a collaborative effort. The follow-up staff are really the traffic cops for receiving the reports from VA with the policies they have implemented or the procedures they have put in place or the training programs that they have created, those things do not require the absolute 100-percent attention of the audit staff or the health care personnel who did the job.
Certainly there is collaboration. If there is any question as to whether or not a recommendation should be closed based on the feedback that we have been given, we will consult with the expert who did the job and make sure that everyone is in agreement that it can and should be closed.
Mr. MICHAUD. Thank you.
My second question, actually it is a follow-up to Congressman Stearns' interest in exactly how does the VA stack up to other departments when you look at completing the recommendations?
Mr. GRIFFIN. From time to time, the Council of the Inspectors General on Integrity and Efficiency submit a report that goes to the Congress and goes to the White House and it lists a number of different performance measures involving the OIG's activities.
And as indicated in our testimony, we feel the 94 percent rate that has been demonstrated in the past 12 months by VA puts it on the high end of performance compared to some of the other departments.
Mr. MICHAUD. Thank you.
And do you feel that the OIG has all the tools that it needs to do an adequate job in looking at VA, the programs VA has or do you need additional staffing or is there something that we can do differently that would make your job easier?
Mr. GRIFFIN. I believe in the fiscal environment that we are operating in today that the OIG, depending on the outcome of the budget request from 2011, will have the tools that it needs.
We are always looking for bright, young auditors, health care specialists, and criminal investigators to bring on board to attack some of the newer issues that seem to be confronting us in the information technology (IT) world and in some of the fraud arenas. But I feel like with the Committee's support in recent years, we have been properly staffed.
Mr. MICHAUD. And does the OIG for the VA work closely with the OIG for U.S. Department of Health and Human Services (HHS) since, for example, the Federally qualified health care clinics, I can see where there would be a lot of synergies there?
Mr. GRIFFIN. There are synergies amongst a number of different OIGs, certainly in HHS with the health care work that they do and our health care staff. There is synergy with the Social Security Administration, which like VA has a huge benefits program and a process that they utilize to make benefits decisions and so on.
So there are a lot of different agencies that do have similar threads of activity and that is the purpose of the Council of Inspectors General to identify common problems, which every department might be facing. We make sure that we are sharing best practices and are sharing findings of shortcomings in other departments that might be happening in VA.
Mr. MICHAUD. Great. Thank you.
I yield back, Mr. Chairman.
The CHAIRMAN. Thank you, Mr. Michaud.
Mr. Miller?
Mr. MILLER. Thank you, Mr. Chairman. I have a statement I would also like entered into the record.
The CHAIRMAN. So ordered.
[The prepared statement of Congressman Miller appears in the Appendix.]
Mr. MILLER. And I have one question, Mr. Griffin. I was looking in your testimony. You talk about the 2005 report recommendation to implement more effective project management oversight. We are talking about 5 years that this oversight did not take place and corrective action should have been done, you say, 5 years earlier in your comments.
My question is, you know, what type of system of accountability can you put in place to prevent a 5-year lag of implementing recommendations?
Mr. GRIFFIN. Is that the major construction report you are referring to? Seven of the ten recommendations in that report address the need for a quality assurance program in order to make sure that we have proper oversight and proper program management for major construction.
A quality assurance group was established and this group was supposed to have addressed those things. When we went back and looked at it a second time, which we will do from time to time for validation, we found that, yes, the group was created, but it was not properly staffed. It did not have adequate policies and procedures in place. So it really was not a functional program oversight activity.
The other two recommendations simply were not addressed during that time period.
Mr. MILLER. I yield back.
The CHAIRMAN. You are yielding back when he did not answer the question. You asked, "What can you do to make sure that they do not go for 5 years without doing something." He responded that, yes, indeed, they went 5 years without doing something.
So how do we make sure there is oversight, if I may follow-up on your question, Mr. Miller?
Mr. GRIFFIN. I think there are a number of things we do. We spotlight anything that has not been accomplished in 1 year and it goes in our semi-annual report so that the Committee can be aware when we have got slippage on an issue.
I believe very strongly that hearings like this one are very helpful based on the flood of documentation we have received in the last 72 hours addressing various items that needed closure. So, again, I thank you for the hearing.
We do meet—
The CHAIRMAN. We should schedule one every week.
Mr. GRIFFIN. We will be here.
We do meet on a monthly basis with senior leadership from VA and certainly those issues that are the most difficult and most dated are the subject of those discussions also.
The CHAIRMAN. Thank you, sir.
Thank you, Mr. Miller.
Mr. Rodriguez?
Mr. RODRIGUEZ. You mentioned that the VA had responded by establishing a Committee that basically was not responsive or, I guess, they just responded to try to fill a recommendation that was made and it took you 3 years to go back to look at that to see whether they were effective or not effective. And you found that they were not effective. Is that the case?
Mr. GRIFFIN. That is correct.
Mr. RODRIGUEZ. Okay.
Mr. GRIFFIN. But let me say that we, notwithstanding my previous response about resources, we do not have sufficient resources that we can go back and redo every audit and every health care inspection that we do. So some of them are selectively up for review.
Mr. RODRIGUEZ. What do we need to do to help you out to carry the job or what else do we need to do to try to get them to become more responsive?
Mr. GRIFFIN. I think the documentation of those reports that become more than 1-year old, which do get reported twice a year in our semi-annual report, could be a triggering mechanism so that between the OIG organization and the Committee and the Department, if we involve all three entities to focus on fixing it, I think you could get some synergy from that.
Mr. RODRIGUEZ. Because in the field, for example, I hear reports that they were giving out contracts to contract out, for example, somebody is given a contract to do work to pay doctors to provide a service, however, doctors are complaining because it takes 3 months to pay them.
And so how do we streamline that? How do we make it more responsive in terms of trying to get it done? I hate to think that we would have to ask for more reports and more reports because then that also bogs it down. So how do we get the system to become more responsive?
Mr. GRIFFIN. I think in the area of acquisition and procurement, it is complicated by the current division of labor that exists between our medical specialists and our acquisition specialists. And I think without both of those entities being on the same page, you cannot always have the medical side claiming that, well, I am the doctor, I know best about this particular device or this procedure. This is what I want. You buy it for me.
I think when it comes to acquisition, you need a little more independence in the acquisition function.
Mr. RODRIGUEZ. The other issues that we hear complaints about is, and I am sure we have made assessments in the past, the workload in the private sector versus the public sector. The doctors will tell me, Ciro, I used to do 15 procedures and now I am doing half of them here. I could do more, but it does not happen.
How do we move on those? Do we have any—I am sure we have asked for studies in that area and comparisons. How do we move the system to become more responsive?
Mr. GRIFFIN. You are saying that VA doctors are complaining they do not get enough work?
Mr. RODRIGUEZ. Yes, sir.
Mr. GRIFFIN. I have not experienced that.
Mr. RODRIGUEZ. Well, I have direct people that have said, look, I used to do this and now I am being told that I only have this. They also get clients that, because they are 10, 15 minutes late, they get told to come back 3 months later, stuff like that.
How do we get past this situation?
Mr. GRIFFIN. I think I would defer to the Veterans Health Administration (VHA) on the performance measures for their doctors.
Mr. RODRIGUEZ. Okay. Now, you mention also you do not have the resources to follow back. And one of the arguments that we have talked about in trying to get the system sometimes, for example, on the computers, we talked about getting them, even an outside system, to look at moving them in that direction.
And have we come up with any other way of making it more responsive?
Mr. GRIFFIN. Making—
Mr. RODRIGUEZ. Well, for example, you mentioned IT, and the computer systems and all those when we make those mistakes, trying to get one hospital to talk to another and getting all that straightened out.
Is it going to require an outside group coming in basically doing it because they are unable to get it done themselves?
Mr. GRIFFIN. I think it is a combination. I think the IT world is so rapidly changing that the planning time and the implementation time in some instances is overcome by the next generation of tool that becomes available.
I know that there have been a number of projects that the Assistant Secretary has canceled because they became too old and they were no longer viable projects. And we applaud that.
But as far as whether or not the level of expertise is proper that exists in the Department, I would defer to Assistant Secretary Baker on the second panel on that question.
Mr. RODRIGUEZ. Okay. Now, if I can follow-up, I know he had talked about the Capital Asset Realignment for Enhanced Services (CARES) Program that went around the country looking at vacancy issues.
From that, have we seen any need to do any follow-up on that? From your perspective, do you think we ought to be looking or inspecting any of our facilities for utilization purposes and those kind of things and maybe restructuring that?
Mr. GRIFFIN. I do not believe that the OIG Office has done any recent work on vacant buildings.
Mr. RODRIGUEZ. On occupancy rates and those kind of things?
Mr. GRIFFIN. Certainly if we have vacant buildings that we are paying to maintain and they are not being utilized, it would make sense that we should divest ourselves of those. But we have not done any recent work.
Mr. RODRIGUEZ. Are you doing any work right now on the new piece of legislation where we fund them in advance? I know it is going to take them a while to come into it and make the transfers there, but, we are doing that for the first time, so I am sure that is going to require them to do a lot of things differently.
But it is going to be able to plan in advance, so are we doing any assessments from your perspective or should we?
Mr. GRIFFIN. Now you are referring to—
Mr. RODRIGUEZ. The appropriations to fund direct appropriations a year in advance.
Mr. GRIFFIN. We have not looked at that. I think it makes sense to have the flexibility though.
Mr. RODRIGUEZ. Does it make sense for you to be able to look at it from the onset in terms of the implementation of it and see how that is going?
Mr. GRIFFIN. We could examine that if you would like. We do do the financial statement audit every year and look at all of the financial activities of the Department. And we could make it an adjunct to that perhaps.
Mr. RODRIGUEZ. Okay. Thank you.
The CHAIRMAN. Thank you, Mr. Rodriguez.
Mr. Stearns?
Mr. STEARNS. Thank you, Mr. Chairman.
Mr. Griffin, in reviewing the Combined Assessment Program (CAP) reviews of VA medical centers, are there specific items that the OIG finds recurring that would indicate a system-wide breakdown of procedures that should be addressed not only at the local medical center but also throughout all of the VHA through the use of a directive from the Central Office and what are these recurring items?
Mr. GRIFFIN. When we do a series of CAP reviews, normally we will look at eight or ten specific items. And when we have multiple findings on an item, we will do a roll-up report to VHA so that they can look at it from a systemic perspective.
One such item that we recently published was in the area of quality management. And we looked at 44 different facilities during the time period in question. We identified four that we thought had serious issues.
Mr. STEARNS. Was the VA medical facility in Gainesville, Florida, one of them?
Mr. GRIFFIN. No, it was not.
Mr. STEARNS. Okay.
Mr. GRIFFIN. But we specifically mentioned those four facilities in our report to VHA and we would expect that there would be follow-up activity by VHA on those.
Mr. STEARNS. Can you tell me those four facilities? Can you name them?
Mr. GRIFFIN. Manila, Honolulu, Marion, Illinois, and give me a minute and I will come up with the fourth one.
Mr. STEARNS. Okay.
Mr. GRIFFIN. Fayetteville.
Mr. STEARNS. Fayetteville. Okay.
Mr. GRIFFIN. Yes, sir.
Mr. STEARNS. And what are the recurring items?
Mr. GRIFFIN. There are occasional findings involving environment of care in our Community-Based Outpatient Clinic (CBOC) reviews, which mimic the CAP reviews. We have had recurring issues over contract management at each of the CBOCs.
Mr. STEARNS. But specifically are there any that involve patient safety?
Mr. GRIFFIN. Well, from the standpoint of quality management being your overall umbrella, which would include how well patients are being treated, whether you have got the proper peer review processes in place, whether you are doing the proper after action and analysis when there is an adverse event, whether you are properly notifying family about adverse events, and so on.
Mr. STEARNS. So patient safety in those four hospitals you mentioned, is that a serious recurring problem?
Mr. GRIFFIN. I would not say patient safety per se. It is just that all of the activities, which I just touched upon, many of those may not have occurred at all four facilities, but some combination of those things were not happening at those facilities.
Mr. STEARNS. You mentioned in the follow-up audit of the VHA major construction award administration and cite that while the VHA officials have taken actions to address your most recent recommendations, the corrective actions should have been put in place 5 years earlier, I think is what you were saying.
So what do you believe is the root cause for these delays in implementing these corrective actions? Five years is a long time.
Mr. GRIFFIN. It is a long time. I am not able to give you an answer as to why it took 5 years.
Mr. STEARNS. Well, should we ask the VA then? But nobody on your staff could help us out here?
Mr. GRIFFIN. I could give—
Mr. STEARNS. Just from your observation. I mean, not necessarily scientific.
Mr. GRIFFIN. Again, in the follow-up process, when the quality assurance activity was documented in their directive and how it was supposed to work, someone in our organization must have been convinced that would address the issues. And it was only when we went back to do it, we realized that those seven items were not properly addressed.
Mr. STEARNS. Well, that is 60 months. You would think during that time, somebody could have taken care of that. I think a lot of us just want to see more efficiency at the VA. And, you know, the Chairman and I and others have talked about the backlog of processing and how slow it has been. In fact, we have given more money and more people for this, yet the backlog still remains there.
So thank you, Mr. Chairman.
The CHAIRMAN. Thank you, Mr. Stearns.
Mr. Walz?
Mr. WALZ. Thank you, Mr. Chairman.
And, Mr. Griffin, thank you for being here and the work you do.
I think we all understand that one of our main responsibilities here is hearings just like this to provide the oversight that is necessary because at the end of the day, it is all about how do we provide the best quality care and resources to our veterans while ensuring taxpayer dollars are watched more.
And so I have to say there is good news in here and I think we should applaud those things when they happen.
The endoscope issue was very troubling for many of us in that hearing and the way that that was pointed out, the hearing that was done, the recommendations for oversight and the follow-up all happening between June and basically September of last year. To have the VA get clear marks on that is a sign that the system can work and it is working. So I very much appreciate you on that.
I wanted to just ask one question, I guess. It is dealing with, and I know it is a complicated one, the issue of procurement and contracting and this issue. It especially hits home in letting out of the contracts for the CBOCs that are so important in rural America. And these things seem to just continue to drag on and drag on and drag on. And the best intentions of everyone is, yes, this will be the date we will get it to you. And it just keeps getting pushed down.
And I am wondering, the recommendations go back to what Mr. Miller asked about in terms of project management and quality assurance programs. From the OIG’s side of things, is there anything we can do there that is better in terms of cutting out fraud, waste, and abuse but moving these things forward? Is there anything you can say on that, Mr. Griffin, that will help me understand why it seems to take so long? I am not so certain that the time lag is doing anything to improve the contracting.
Mr. GRIFFIN. We always try to bring something to the attention of the Department at the earliest possible moment. We have only been doing these CBOC reviews for a number of months now, probably several months. But in each review that we did, we found that the contract was poorly written, each one was a little different, most of them called for a per capita payment basis tied to whether or not a veteran had been seen in the last 12 months.
There are terms for removing somebody from the rolls which means that you are not paying the contractor for that person for that particular time period and so on. And what we found in repeated visits to different CBOCs was that no one was paying attention to the terms of the contract.
So Dr. Daigh, from our staff, quickly brought that to the attention of VHA and told them you need a standardized contract that everybody understands and that everybody can apply across the board. And when someone dies or someone should be disenrolled for some other reason, we need to make sure that happens.
We need to make sure that when there are disincentive clauses included in the contract that the people managing the contract are aware of those and looking for opportunities to recover monies that should not have been paid and so on.
But we did not wait until the end of a year or a year and a half worth of reviews. Once we realized that this was a systemic problem, we quickly called for a meeting with VHA. And Dr. Daigh sat down with them and explained what we were finding so that we can cut off the bleeding as early as possible.
Mr. WALZ. Well, I appreciate that because one of the things that I talked about here, I am very proud of what we have done in terms of enhancing VA and enhancing care for our veterans, but one of the things I have been talking about and warning everyone here about is if we are not good stewards of these dollars, that is going to be a tragedy in this, that we do not improve the care. So I appreciate you doing that as quickly as possible.
One last thing. VBA’s process on employee effectiveness of how we are going to measure what we are getting done, how we measure work process and everything as it deals with again the backlog on this.
Are you seeing anything from the OIG’s side of how do we ensure that is happening?
Mr. GRIFFIN. Well, we recently started a new initiative. That is the Benefit Inspection Division that goes out and does a review of five different categories to check on a number of things.
One is to check on the accuracy of the rating that was given to determine whether or not people have the proper training so that they can do it right the first time and not expend that extra amount of time redoing the claims.
And much like the contracts and CBOCs, when our staff finds a problem in the course of doing their daily reviews in the Regional Offices, on a daily basis, they provide to the director those claims that we reviewed in which we found problems with the rating determination and they fix them on the spot.
So I think what we are finding is the volume of work continues to grow and the lack of adequate training and the nuances of the rating schedule and the fact that you have so many new hires that it is like a perfect storm as far as what you need for good performance measures and program management that is not there right now.
Mr. WALZ. Well, I am afraid you are right on that. And that is one of the things we have a concern about at the end of the day is none of those things are going to get a reduction in the backlog of claims or inaccuracy which is, of course, the paramount issue, accuracy in the claim.
I yield back. Thank you, Mr. Chairman.
The CHAIRMAN. Thank you, Mr. Walz.
Mr. Roe?
Mr. ROE. Thank you, Mr. Chairman.
And just to start off on what Congressman Rodriguez said, I, too, Mr. Griffin, have heard exactly the same thing about specifically in colonoscopy. One of my good friends is a gastrointestinal (GI) physician at a VA and complains all the time that he could do twice as many colonoscopies if he were allowed to do it. When he was in private practice, he did. And I think that is a quality of care issue because it delays care of our veterans.
And I do plan on coming back next term and the quality of care issues are the ones that I want to focus on. I think that is paramount. That is why we have a VA hospital system—to provide the best quality of care that we possibly can.
And one of the questions I have is, and I really appreciate the work you all are doing. And I know in practice, we had a weekly conference, patient conference where we looked at all the difficult cases. We had a standard of care, but we did not have any person like yourself to come in because we all think we are providing good care.
But at the end of the day, maybe we are not, when you have someone objectively come in and look at that. So that is why it is important for you to continue doing what you are doing.
How robust, and I think one of the things that brought this up was the incident that occurred with the brachytherapy, that was not very good, and how robust is the evaluation and peer review of dysfunctional or practitioners that are outside the standard of care?
Mr. GRIFFIN. How dysfunctional is it for—
Mr. ROE. No. I mean, how robust is your evaluation, I guess a peer review of practitioners who fall outside the standard of care like this physician in the brachytherapy case that we looked at last year?
Mr. GRIFFIN. Well, unfortunately, sometimes it takes a call to our hotline for a case to come to our attention or during the course of one of our cyclical reviews at a medical center, someone will approach a member of our staff and say you really need to look at this or that area.
When you talk about how robust is our ability to examine those areas—
Mr. ROE. Well, yeah, I guess. Well, both. I mean, how robust is your ability and then how does that investigation actually occur? And Congressman Walz brought up the colonoscopy issue last year, which I thought was handled very well once it was discovered.
Mr. GRIFFIN. Well, I can tell you that from when I first arrived at VA in 1997, we had 16 people in our health care unit to do quality oversight for the whole VA. Clearly inadequate number.
Mr. ROE. Inaccurate.
Mr. GRIFFIN. They are presently up to 119. They have a number of different disciplines. Dr. Daigh has been able to hire a number of excellent physicians, but he also knows that when we do not have the expertise on our staff we will go out and pay for that expertise and bring in an outside expert which is something we did in the brachytherapy work.
Mr. ROE. Well, another question I have then is on the CBOCs. There are, I do not know, 1,200 of them in the country, over 1,000 anyway. And the way the current oversight and investigation, there is an investigation or evaluation, I should say, every 20 years. And we just added $50 million to hopefully get this down to 3 to 4 years.
Is that enough money? Do you have enough resources to do what we have asked you to do?
Mr. GRIFFIN. Well, the 20-year cycle is clearly unacceptable.
Mr. ROE. Yeah, it is.
Mr. GRIFFIN. We thought that 3 years would be a more reasonable number to work with. And if we get the additional funds, that is what we will do. We will make it a 3-year cycle.
Mr. ROE. And that is—
Mr. GRIFFIN. We are still building the database. Some of those are clinics that are run by a VA full-time equivalent. Some of them are private contractors.
So it kind of gets back to the question about does the private sector person have a greater caseload than the VA person. We are going to be able to do at that type of analysis on the CBOCs once we get a little more in depth in our database.
Mr. ROE. So we should be able to have that information in fairly short order, a couple of years, 3 years—
Mr. GRIFFIN. Right.
Mr. ROE [continuing]. Something like that?
Mr. GRIFFIN. Right. And we will do it after the 1st year and then we will continue to build upon it.
Mr. ROE. Well, you know, it is a huge system. You have got over 300,000 employees in the VA system or around 300,000 people. That is an enormous job that we have asked you to do, but it is an incredibly important one.
And, again, as I know, when you look at what I thought I was doing well sometimes, when it is evaluated, you find out it is not. And it is not a problem to change once you get accurate information. It is not that you do not want to do the right thing. You may not know you are not doing the right thing.
So, Mr. Chairman, I yield back.
The CHAIRMAN. Thank you, Mr. Roe.
Mr. McNerney?
Mr. MCNERNEY. Thank you, Mr. Chairman.
Inspector Griffin, my understanding is that the OIG does not make recommendations for improvements that are expected to take longer than 1 year to implement. Is that correct?
Mr. GRIFFIN. Except in rare circumstances. And if there is a project that realistically cannot be done in a year, we will accept those recommendations as long as there is a timeline that shows here is phase one and by a date certain, we are going to have the alpha portion of this project completed. And here is the next date and the next date and we will at least track those activities.
Mr. MCNERNEY. Okay. You know, implementing OIG recommendations clearly has benefits both in terms of fiscally and in responsiveness of the VA to veterans’ needs.
Are there any instances in which using VA assets to address OIG recommendations has detrimental effects in terms of direct services to the vets? Are there any cases that you are aware of?
Mr. GRIFFIN. No, I cannot say that I am. I suspect that if that were the case, we would have heard about it.
Mr. MCNERNEY. So you have a good feedback mechanism from the—
Mr. GRIFFIN. Absolutely.
Mr. MCNERNEY [continuing]. Providers? So okay. That is good. Do you feel that providing the OIG with additional authority in cases where the VA is severely late in implementing recommendations would be effective in assisting the VA with its obligations? In other words, how can additional resources be helpful to you or the VA in implementing your programs?
Mr. GRIFFIN. I do not know that it is a resource issue. I think that some of these issues are extremely difficult. And the reality also is that we have seen turnover in some of the most senior positions. We see it every 4 years obviously.
But in the middle of a term, you might have somebody who holds a top position for a couple years and he is gone. People are in an acting capacity during that time period. They are not always certain that they want to make a radical decision on something that is difficult. So I think there is a combination of factors that come into play.
Mr. MCNERNEY. Thank you.
Well, you recommended that the time it takes the VA to implement your recommendations has improved over the past. What do you attribute that improvement to in the time that it takes to implement?
Mr. GRIFFIN. I think Mr. Ehrlichman has the percentages to demonstrate that improvement from 2007 through 2009 and I am sure he could answer the rest of that question.
Mr. EHRLICHMAN. Thank you.
What we have done and we started it late in 2006 is myself and the Deputy OIG at the time went around and met with all of the principals throughout the Department, all the Assistant Secretaries and the Under Secretaries and their staff.
We talked about trying to change the follow-up process significantly and we talked about trying to come up with recommendations that were specific, measurable, that could be implemented within a year, and that we were going to have a lot more frequent contact. We were going to be a little bit more persistent.
If we were not hearing that there was progress, we were probably going to make an appointment, meet with them. We were going to bring the health care inspectors, the auditors, follow-up staff and we have done much better.
In 2007, we were at about 86 percent. In 2008, it went up to 88 percent. And the last complete fiscal year, we were at 94 percent implemented within 1 year.
Mr. MCNERNEY. So basically you made it a priority and you held their feet to the fire once the recommendations were made?
Mr. EHRLICHMAN. That and a lot more direct communications, a lot more meetings. As Mr. Griffin had mentioned, we began meeting on a monthly basis with principals in all the administrations and the staff offices and I think that has helped a lot, having the communications.
Mr. MCNERNEY. Okay. Thank you, Mr. Chairman. I yield back.
The CHAIRMAN. Thank you, Mr. McNerney.
Mr. Boozman, congratulations on your victory yesterday. You have to get the TV networks to concentrate on Boze rather than Booz.
Mr. BOOZMAN. Thank you, Mr. Chairman.
I think we need an OIG investigation as to whether or not you were behind my chair being broken over here.
I just have, and, again, this might be kind of a dumb question, but we have all of these things outstanding and some of them are important in regards to patient care. Others are important in regard to a monetary sense. And it all goes back to be important to veterans.
Do we prioritize which ones are the most important? Does that make sense? We have all of these things. It is almost overwhelming, and we have to be helpful and push this thing forward. Is there the ability to kind of rank the ones that we need to really get on the stick and use our ability with oversight to push forward?
Mr. GRIFFIN. I think clearly there is a need to realize which ones are most important. But when we start an audit or we start a health care review, we might think we know what the condition is that we are going to find, but we really do not know with certainty until we do it.
And when we have completed our work, if we do have recommendations, we will forward them to the Department to fix.
I would be shocked if the Department were to say anything other than those issues that are most critical for patient safety and those issues that are most critical from a monetary standpoint rise to the top of the pile. I would be very surprised if that was not the case.
But within the OIG, we might have our own views which ones are the most critical, but we do not rank our audits and inspections per se.
I think that if they were easy, the fixes would be made while we were on site which does happen on some occasions as I already mentioned. So I think it is the complexity of some of the issues and it is the huge decentralized health care system and benefit system that the VA represents that makes it difficult.
And as far as ranking them, it is not something that we do, but I would have to believe the Department evaluates things based on the criticality of the timing of the fixes.
Mr. BOOZMAN. Thank you very much.
Thank you, Mr. Chairman.
The CHAIRMAN. Thank you, Mr. Boozman.
Mrs. Kirkpatrick?
Mrs. KIRKPATRICK. Thank you, Mr. Chairman.
My concern is about inefficiencies in the follow-up process. So my first question is, why do you use a centralized staff to do follow-up rather than the auditors and the investigators who did the initial reports?
Mr. GRIFFIN. It is done on a centralized basis because the auditors and the inspectors who did the audit on inspection are doing additional work. They have moved on to do other work.
But while the follow-up group itself is pursuing closure of those recommendations, they will call upon the auditor or the lead health care inspector who did the job and consult with them on whether or not the response that we are getting to the recommendation satisfies the finding.
So it is a shared responsibility. It is centrally controlled here because, frankly, that is where most of the headquarters’ replies are coming out of VHA and VBA and the Office of Information and Technology (OI&T) and the National Cemetery Administration (NCA). The senior managers are here. And those are the senior managers that we will meet with on about a monthly basis to make sure that people are aware of what is out there and what needs to be done.
Mrs. KIRKPATRICK. You talked about the need to standardize contracts. Do you use a checklist system when you are doing that follow-up review? I mean, is there some uniformity in terms of the staff review and how they work that process?
Mr. GRIFFIN. There is uniformity in the timing of our request every 90 days and we ask for a response within 30 days. But there is not a one-size-fits-all sheet that you could apply to every health care inspection and every audit or every administrative investigation and so on.
So that is why it is critical, as you point out, to have the subject matter experts collaborate with our follow-up team to make sure that we got it right.
Mrs. KIRKPATRICK. Well, my last question is about on-site review. It seems to me that that is probably the best way to garner the information about whether or not the different departments are doing their job. I guess I wonder why you do not do on-site review on every report.
Mr. GRIFFIN. Because it would be too manpower intensive to try and go back and redo every one. There is a number, a percentage, you know, that would make sense. It is not 100 percent. The exact number, I guess, depends on whether we are suspicious as to whether or not the recommendation and the proposed fix was the right fix. Perhaps we will get a call to our hotline where we get 29 to 30,000 calls a year. If we get multiple calls suggesting that we still have a problem in a certain area, that might trigger us to go back.
And our CAP cycle, which is a 3-year cycle, every time when we go back to a medical center, we will take a look at the previous report and we will see what the recommendations were in that report and we will validate whether or not, in fact, they were addressed to our satisfaction.
Mrs. KIRKPATRICK. Your answer conjures up one more question.
Mr. GRIFFIN. Okay.
Mrs. KIRKPATRICK. Would it not be better to do the CAP review every year as opposed to every 3 years?
Mr. GRIFFIN. Well, that is a resource issue. You know, we are at these medical centers for a week, which is not a long time, and that is why their scope is such that there is no way you can go in and look at every activity in a medical center.
So every 6 months or so, we will decide these are the pulse points as we call them, these are the areas that we are going to look at for the next 6 months. And if we have repeat findings on one or more of those, we will bring that to the attention of VHA so that we can say this is not something that we found at one medical center. This is something that eight out of the last ten seem to be having a problem with or, you know, 15 out of 20, whatever the number might be. And then they know, okay, it is not an anecdotal situation.
They either need to clarify the policy, write new policy or get on the phone and find out why someone is not following the policy.
Mrs. KIRKPATRICK. Thank you very much.
I yield back, Mr. Chairman.
The CHAIRMAN. Thank you.
Let me just wind up our questioning. First, thank you so much for your testimony, Mr. Griffin.
Given the open recommendations and especially the last recommendations, what is your sense? What is the most important outstanding recommendation either by policy issue or by money, that we should focus on to save money?
Mr. GRIFFIN. I think when you are talking about money and policy, I think procurement represents a huge dollar value for the Department. I think the acquisition area on a number of different fronts, not just the drugs that we purchase, but the clinical health care specialists that we contract for, the contracts that we have with medical experts from the affiliates, contracts at CBOCs—
The CHAIRMAN. What is the problem there? How would you define the problem?
Mr. GRIFFIN. I would define the problem that you have the acquisition staff in Washington writing policy for how procurement and acquisition should be done. You have a contracting officer who works for the Veterans Integrated Service Network (VISN) who is working for a different master. And you have some Contracting Officer's Technical Representatives (COTRs) that are working in conjunction with the contracting officers who are also out at the medical center taking their direction at the medical center.
And too frequently what we find is the acquisition regulations and even VA regulations about the order that procurements are supposed to occur in do not happen. In addition, there is inadequate attention to monitoring the performance of what is in the contract and there is a lot of money left on the table as a result.
The CHAIRMAN. Money left because there are not tough enough negotiations or is there anything—
Mr. GRIFFIN. I think negotiation is part of it. I think when you establish a contract, if you do adequate analysis of what the need is and you put the proper parameters in for where you are going to go to get that person or that item and then after the contract which is properly competed, if it is a competitive contract, you have a COTR that monitors compliance with what is in the contract.
The CHAIRMAN. Give us the name of that acronym.
Mr. GRIFFIN. I am sorry. That is the contract officer’s technical representative.
So it is a combination of things, but part of the issue is the people who write the policy are back in Washington and where the rubber meets the road is out in the field. And as I alluded to earlier in some instances, we will have a medical expert who says forget about the supply schedule or forget about what you are hearing from them, I want this prosthetic for my patient.
And I am sure there are occasions when for medical reasons that is 100 percent correct and that prosthetic should be the one used. But I think there are a lot of times where the sentiment is we cannot be bothered with contracting and procurement issues. We have veterans to take care of. So you have that constant struggle.
The CHAIRMAN. I mean, the Secretary is recommending that we have a new Under Secretary for Acquisition and Procurement.
Do you think that would help, or does that further move the focus to Washington as opposed to the sites?
Mr. GRIFFIN. I think given the proper authority to the position, that can help.
The CHAIRMAN. Has the office ever looked at the decision-making process for deciding what drugs may be on the formulary that the VA uses? Have you ever looked at that?
Mr. GRIFFIN. I am not aware that we have done any recent work in that area.
The CHAIRMAN. There are situations where new drugs are coming on the market and the people who are deciding on the formulary are looking too closely at the direct cost.
Let us say hypothetically that a new diabetes drug is online and it costs $50. The other drug costs $1. Of course, it seems $1 versus $50 is a clear monetary decision and, yet, the $50 drug one may help the quality of life of the patient. For example, taking a shot once every 2 weeks instead of twice a day may prevent complications in the future, and we are saving money in the future.
That is a process where people have to make decisions. Have we never looked at that directly?
Mr. GRIFFIN. No.
The CHAIRMAN. Okay. We might want to.
How about the processes used for looking at innovation in general in the VA, new technologies, new equipment, new ways of doing things?
We have a lot of complaints about not having new innovations available. Is there no real way for this bureaucracy to make these decisions? We tend to reject new ideas as opposed to embracing them. Have you ever looked at the situation?
Mr. GRIFFIN. I cannot say we have looked at that,
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