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Case Study on VA Quality of Care: W.G. (Bill) Hefner VAMC in Salisbury,NC

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












APRIL 19, 2007

SERIAL No. 110-14

Printed for the use of the Committee on Veterans' Affairs





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BOB FILNER, California, Chairman


VIC SNYDER, Arkansas
JOHN J. HALL, New York
PHIL HARE, Illinois
MICHAEL F. DOYLE, Pennsylvania
TIMOTHY J. WALZ, Minnesota

STEVE BUYER,  Indiana, Ranking
HENRY E. BROWN, JR., South Carolina
BRIAN P. BILBRAY, California




Malcom A. Shorter, Staff Director

HARRY E. MITCHELL, Arizona, Chairman

TIMOTHY J. WALZ, Minnesota
GINNY BROWN-WAITE, Florida, Ranking
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 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.



April 19, 2007

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


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


U.S. Department of Veterans Affairs:

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


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, address to Congressman Hayes

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

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

Follow-up 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, 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



Thursday, April 19, 2007
U. S. House of Representatives,
Subcommittee on Oversight and Investigations,
Committee on Veterans' Affairs,
Washington, DC.

The Subcommittee met, pursuant to notice, at 10:00 a.m., in Room 334, Cannon House Office Building, Hon. Harry E. Mitchell presiding. 

Present: Representatives Mitchell, Filner, Space, Walz, Rodriguez, Brown-Waite, Bilbray .

Also present:  Representatives Watt, Coble, and Hayes.


Mr. MITCHELL.  Good morning.  This is an Oversight and Investigation 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.  First, 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 two 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 three 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 statement of Chairman Mitchell appears in the Appendix.]

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. 


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 sixty 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.]

Mr. MITCHELL.  Thank you.  And now I would like to recognize Ms. Brown-Waite for opening remarks. 


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 statement of Congresswoman Brown-Waite appears in the Appendix.]

Mr. MITCHELL.  Thank you.  At this time, I would like to ask Congressman Walz for his opening statement. 


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 dialogue 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? 


Mr. BILBRAY.  Yes, Mr. Chairman.  Mr. Chairman, the full Committee Chairman and I, have for fifteen, I guess almost twenty 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 six 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?


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 twelve 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 two 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 twelve deaths of surgical patients at the Salisbury VA had occurred in the last two 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? 


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 monies 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 five minutes.


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 three-year cycle.  So about once every three 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 fifty hotlines a year.  In 2004 we were publishing about thirty 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 twelve individuals had died on the surgery service over the prior two 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 twelve 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, three 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 time frames 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 statement of Dr. Daigh appears in the Appendix.]

Mr. MITCHELL.  I have a couple questions I will start off with.  First, 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 twelve cases to review, that takes a significant amount of manpower to do an in depth review of the care of twelve 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, I 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 two-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 one to ten, 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 ten being excellent, I would give it probably a seven to eight 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 twelve 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 three 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 six months with twelve 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 six months.  It took another, what, three 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 five 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 follow-up 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 two 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 three years?  Is there a formal follow-up 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 six months all these things were taken care of, or not?

Dr. DAIGH.  Well sir, we report to Congress all recommendations not completed within one 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, nine 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 follow-up letter from Dr. Daigh, which appears in the Appendix.]

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 dri