First, I would like to thank Chairman Filner for responding to our request on short notice to hold today’s field hearing to examine the U.S. Department of Veterans Affairs (VA) actions in failing to comply with standard operating procedures and the possible risks our veterans were exposed to from inadequately cleaned and sterilized dental equipment at the John A. Cochran Veterans Medical Center (VAMC).

As we now know, 1,812 veterans were notified on June 28, 2010 that they were at risk, the same day Congress was made aware of this situation.  Of the 1,812, 370 of these veterans reside in the congressional district I am privileged to represent.  I am outraged at what happened, which is particularly egregious as it is not the first time the VA has jeopardized the health of veterans by improperly cleaning medical equipment.  In 2009, an investigation by the Office of Inspector General discovered that 10,320 veterans were exposed to Hepatitis B and C, or HIV because VA hospitals were not properly cleaning endoscopic equipment in Murfreesboro, Tennessee; Augusta, Georgia; and Miami, Florida. 

In my congressional district in Southern Illinois, we are dealing with similar inabilities to follow basic, routine procedures and quality management standards at the Marion VAMC.  These events led to the unfortunate deaths of nine veterans in 2007 and caused a lack of confidence in patients receiving care from the Marion Veterans Medical Center.

Equally troubling, this committee has previously investigated failures in VA procedures, including basic sterilization processes, and assured these problems were resolved.  The evident inability of the VA to ensure these procedures are implemented is shocking.   I am eager to hear from the VA if our existing Veterans Integrated Service Network (VISN)—which is charged with maintaining oversight at the facilities—and its review processes are capable of addressing inefficiencies in a timely and effective manner.  Simply issuing guidelines is not sufficient and the VISN and facility leadership are responsible for ensuring those guidelines are successfully followed.  It is fair to ask if the VA can effectively institute system-wide standards—and provide the necessary oversight to make certain that the standards are being followed.

Hopefully, none of the 1,812 veterans contracted a disease because of this breakdown in procedure.  The VA must explain how they will handle the matter if any veteran does contract a disease.  At the same time, the VA will not be vindicated if all remain healthy—the key question here is the VA’s ability to follow their own routine procedures.  I want to know why such a time lapse occurred between the breakdown in procedure and when veterans were notified.  I also want to know the exact dates of when regional and Washington D.C. officials were notified of this breakdown.  I think we must follow this timeline closely to determine if the VA’s reaction to this situation was slow and ineffective.

For everything that our veterans have sacrificed for us, we must ensure that the health care they receive at VA facilities is of the highest quality care.   I look forward to hearing from our witnesses regarding these questions and how the VA will assure patient safety moving forward.