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Witness Testimony of William Schoenhard, FACHE, Deputy Under Secretary for Health for Operations and Management, Veterans Health Administration, U.S. Department of Veterans Affairs

Chairwoman Buerkle, Ranking Member Michaud, and Members of the Committee: Thank you for the opportunity to appear and discuss the Department of Veterans Affairs’ (VA) policies and actions to prevent sexual assaults and other safety incidents at VA medical facilities. The safety and security of our Veterans, employees, and visitors are paramount to us, and we appreciate the work of the Government Accountability Office (GAO) to help us further improve our programs and facilities. Secretary Shinseki has made this issue a top priority for the Department, and this commitment is reflected in our investments over the last 2 years. This includes integrating safety and security considerations into our Strategic Capital Investment Decision Model, which evaluates and ranks proposed construction and renovation projects, as a high priority consideration that is significantly weighted.  As a result, those projects designed to improve facility security are consistently among the highest rated projects we support.

I am accompanied today by my colleagues George Arana, M.D., Acting Assistant Deputy Under Secretary for Health for Clinical Operations, and Kevin Hanretta, Deputy Assistant Secretary for Emergency Management.

VA currently uses both VA staff and physical infrastructure systems to ensure the security of our facilities, particularly residential and inpatient mental health programs. Closed circuit cameras, locks, alarms, separate facilities, and specialized training for health care professionals are some of the steps we have taken so far.  However, to develop an even more robust and secure health care system, we have convened a multi-disciplinary Workgroup to define what the Veterans Health Administration (VHA) must do to prevent sexual assault incidents and to respond to allegations of sexual victimization. This Workgroup includes representatives from VHA and VA corporate offices, including the Office of Operations, Security, and Preparedness, and the Office of General Counsel. The Workgroup held its first meeting on June 6, 2011.

VA must, and will, proactively assess and manage risks and institute appropriate precautions to maximize prevention and response measures. We must also improve our mechanisms for Veterans and staff to report incidents to law enforcement so that offenders can be held accountable. These mechanisms must also provide information to VA management so that concerns can be monitored and addressed appropriately and timely.

My testimony today will first discuss the prevalence of sexual assault and other safety incidents in VA medical facilities.  It will then cover VA policies and procedures for reporting and monitoring such incidents.  I will next detail the use of physical security precautions and the ability of VA’s Central Office to respond, provide oversight, and address vulnerabilities.  I will conclude by discussing VA’s next steps as we continue to improve the safety of our facilities for all those on our property.

Prevalence of Sexual Assault and Other Safety Incidents

VA provided health care services to 6 million unique patients in fiscal year (FY) 2010 at more than 1,300 sites of care, and VHA employs more than 244,000 individuals. While the overwhelming majority of experiences in VA facilities are safe, no system is perfect. During the 3 and a half year period of the GAO review, VA provided approximately 240 million outpatient visits and more than 2 million inpatient admissions. As stated in GAO’s report, “VA HEALTH CARE: Actions Needed to Prevent Sexual Assaults and Other Safety Incidents” (GAO-11-530), between January 2007 and July 2010, a period of 43 months, there were 284 alleged sexual assault incidents reported to VA police. Even one incident is one too many, and we must take every step we can to prevent assaults before they happen.

The GAO report indicates that these events may be under-reported. We must have procedures in place to provide the best data we can obtain. To reduce the potential for under-reporting, we will continue to encourage Veterans, families, employees and visitors to report information about an incident or a threatened incident to VA clinicians and VA police officers. We also will take additional steps, such as improving staff training, improving lighting, promoting awareness among staff and visitors, expanding access for reporting options, improving the reliability of panic alarms, and posting signs that advise staff and visitors how to report any incidents to the proper authorities. It is VHA’s policy that emergency departments, urgent care clinics, outpatient clinics, and all inpatient and residential settings have plans in place to appropriately manage the medical and psychological assessment, treatment, and collection of evidence from male and female Veterans who report acute sexual assault. We also will develop a consistent definition for these incidents that will ensure the data we collect are as accurate and reliable as possible.

VA Policies and Procedures for Reporting and Monitoring Safety Incidents

The GAO’s investigation found that many of these alleged assaults were not reported to VA leadership officials and the Office of Inspector General (OIG) as required by VA regulation. We appreciate this finding and recognize the need to improve structures for reporting incidents involving sexual victimization and other safety concerns. We are identifying several mechanisms and reporting structures to ensure the effective coordination of both prevention and response activities, and we will focus principally on strategies that provide universal precautions against sexual victimization.  In addition, we recognize the importance of our risk assessment and risk management mechanisms. Critically important, though, is a clear definition of what acts constitute an offense and how this information should be used within the required limits of patient confidentiality and privacy protections. This was GAO’s first recommendation. We agree that there is a need to establish consistent definitions of sexual assault and other safety incidents for reporting information from medical facilities to VA leadership at the Veterans Integrated Service Network (VISN) level and to VA Central Office. We will develop action plans with clear and aggressive timelines for implementation developed by July 15, and a final report to GAO on implementation by September 30, 2011, to address this concern.

The GAO report identified two mechanisms for reporting incidents: the management stream of reporting and the law enforcement stream of reporting. GAO recommended that VA implement a centralized tracking mechanism to allow both alleged and substantiated sexual assault incidents to be monitored consistently and reported to senior leadership; this information will be de-identified to protect the confidentiality of victims and will be subject to strict controls on access by VA employees. VA agrees with this recommendation, and will build on our work to establish a common set of definitions to support this objective.  Already, we have begun to review the existing organizational strategies, structures, and policies to identify how best we can change or strengthen oversight and reporting processes. The multi-disciplinary Workgroup has been charged with developing and implementing this centralized reporting mechanism. VA will prepare a detailed action plan with specific deadlines by July 15 and a final report by September 30, 2011.

An important element in ensuring the accuracy and timeliness of our procedures for reporting and monitoring safety and security incidents is the establishment and growth of the Integrated Operations Center (IOC).  Established in 2009, the IOC, which operates 24 hours a day, 7 days a week, serves as a fusion point for operational, safety and security information. The IOC was established, in part, to provide the Secretary with a single office responsible for “proactively collecting, coordinating, and analyzing information in order to make recommendations to VA leadership.” VA Directive 0322, dated April 29, 2010. The IOC manages VA’s Serious Incident Report Directive (published, January 25, 2010), which mandates reporting of among other things, incidents of alleged sexual assault that occur on VA property.

Existing Security Precautions and VA Response

The GAO report notes that VA has a number of systems in place to identify potential safety risks, but concluded that these systems are deficient in critical aspects.  For example, the GAO found that some physical security precautions are not properly maintained or monitored and that inadequate installation or testing procedures contributed to these weaknesses. The GAO’s concern is that these weaknesses could lead to delayed response times to incidents and otherwise undermine our efforts to prevent or mitigate sexual assaults and other safety incidents.

We agree with these findings and will take the necessary steps to improve our systems accordingly. While VA medical centers are currently expected to have policies addressing the use and testing of panic alarm systems in compliance with the standards of The Joint Commission, VA will re-emphasize the need for routine testing of these panic alarms to ensure they are functioning properly. We will review whether existing policy needs to be revised to ensure regular preventative maintenance occurs consistent with manufacturer requirements. Regular testing of alarms is critical to ensuring the safety and security of Veterans, staff, and visitors.  VA will require VISN Directors to ensure that local facilities have established systems that meet the unique needs of that location and Veteran population.  Furthermore, by mid July, the multi­disciplinary Workgroup will complete an action plan, with specific deadlines, that will recommend any necessary policy changes.

Next Steps to Improve Safety

As VA continues to improve its incident reporting and safety monitoring systems, we know there are additional, more immediate, measures we can take to improve the safety of all those within our facilities. Participants in the multi-disciplinary Workgroup have begun already to analyze deficiencies in our system based on GAO’s recommendations, and propose specific solutions to these issues. The full Workgroup met on June 6, 2011, and began to identify solutions for improvement.  VA will brief the Committee and GAO in August after these near term recommendations are complete. VA has taken steps to improve the quality of reporting alleged incidents so we have a better understanding of the context and frequency of events.  In January 2010, VA published Directive 0321 on Serious Incident Reporting, which required VA facilities to report such data in a consistent manner. This Directive did not include, however, a common definition for alleged sexual assaults.  We are correcting that omission. VA’s multidisciplinary Workgroup will identify the scope and develop definitions for sexual victimization of Veterans, employees, and visitors. The Workgroup will also prescribe how these incidents are to be reported. Having a consistent definition for sexual assault and standardized reporting procedures will enable the IOC to collect more data that are reliable, and more easily identify trends. Analysis of this data will help VA leaders gain a better understanding of the prevalence of sexual assaults and other safety incidents in VA health care facilities and will support the development of solutions that will make our facilities even safer.  Another important step towards safer facilities will be to expand the involvement of security experts in the planning and construction phases of renovation or construction projects to ensure that safety and security issues are identified and addressed as early as possible. We will also review the availability of existing resources to determine if further training, support, or assistance is needed to improve the safety and security of our facilities.

Conclusion

While the VA health care system provides exceptional service to millions of Veterans and family members every year, even one incident that threatens the safety and well­being of a Veteran, a family member, an employee, or a visitor is unacceptable. Sexual assault is a devastating experience for victims. We are using external reviews, such as GAO’s report, and internal assessments to identify deficiencies and to correct them immediately. The Veterans Health Administration is working together with the IOC to identify, report, and monitor incidents in an almost real-time environment. We will use the Workgroup to recommend solutions with specific timelines to improve our prevention and surveillance efforts. These are important steps toward ensuring a safer and more secure system. We take a zero tolerance approach to sexual assault and will enforce the law and our policies to the maximum extent in the best interests of our Veterans, their families, and our staff. Thank you again for the opportunity to testify today.  My colleagues and I would be pleased to answer any questions you may have.