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U.S. Department of Veterans Affairs Polytrauma Rehabilitation Centers: Management Issues.

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SEPTEMBER 25, 2007

SERIAL No. 110-45

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.



September 25, 2007

U.S. Department of Veterans Affairs Polytrauma Rehabilitation Centers: Management Issues


Chairman Harry E. Mitchell
    Prepared statement of Chairman Mitchell
Hon. Ginny Brown-Waite, Ranking Republican Member
    Prepared statement of Congresswoman Brown-Waite
Hon. Timothy J. Walz
Hon. Ciro D. Rodriguez


U.S. Department of Veterans Affairs:
Elizabeth Joyce Freeman, Director, Veterans Affairs Palo Alto Health Care System, Veterans Health Administration
    Prepared statement of Ms. Freeman
William F. Feeley, Deputy Under Secretary for Health for Operations and Management, Veterans Health Administration
    Prepared statement of Mr. Feeley


Post Hearing Questions and Responses for the Record:

Hon. Harry E. Mitchell, Chairman, and Hon. Ginny Brown-Waite, Ranking Republican Member, Subcommittee on Oversight and Investigations, Committee on Veterans' Affairs, to Hon. Gordon H. Mansfield, Acting Secretary, U.S. Department of Veterans Affairs, letter dated October 24, 2007


Tuesday, September 25, 2007
U. S. House of Representatives,
Subcommittee on Oversight and Investigations,
Committee on Veterans' Affairs,
Washington, DC.

The Subcommittee met, pursuant to notice at 10:06 a.m., in Room 334, Cannon House Office Building, Hon. Harry E. Mitchell [Chairman of the Subcommittee] presiding.

Present:  Representatives Mitchell, Walz, Rodriguez, and Brown-Waite.


Mr. MITCHELL.  This hearing will come to order.  I would like to welcome everyone to the Subcommittee on Oversight and Investigations.  This hearing is on the U.S. Department of Veterans Affairs (VA) Polytrauma Rehabilitation Centers.

I want to thank all of you for coming today.  I am pleased that so many folks could attend this oversight hearing on the VA Polytrauma Rehabilitation Centers.

The VA polytrauma centers help reintegrate into society servicemembers who have suffered among the worst that war can inflict.  The most severely injured servicemembers serving in Iraq and Afghanistan were medivaced out of theater through Germany to Walter Reed, Bethesda Naval Hospital and, when ready, are sent to one of the four polytrauma centers which are located in Richmond, Tampa, Minneapolis, and Palo Alto.

Most polytrauma patients have suffered traumatic brain injury (TBI) in addition to a variety of other serious injuries which must necessitate amputation.  The soldiers, sailors, airmen, and Marines who are treated at the polytrauma centers have paid a very high price for their service to their country as have their families, both of whom face a long and difficult path to recovery and sometimes a lifetime of care.

The Nation owes these servicemembers and their families everything that a Nation as rich as ours can provide.  The Nation has many who need and deserve what we can give. 

Survival rates for servicemembers injured in combat are extremely high compared to previous conflicts, partly because of greatly improved protective equipment, but also because the military has moved surgical medical care practically to the front lines.  A soldier injured in an improvised explosive device (IED) blast can be in surgery within 30 to 45 minutes or even less. 

With these advances, however, comes the need to treat injuries that would have been fatal in the past.  Injuries like traumatic brain injury and post traumatic stress disorder require medical treatment and long-term care of a new kind.  The VA polytrauma centers are an essential part of that care.

Congress has provided sufficient resources and is providing more that have enabled the VA to establish and expand polytrauma care.  It must be said that the VA has stepped up to the plate to meet this need.

In addition to the four polytrauma centers, the VA has created a network of subacute polytrauma care centers in each of the Veterans Integrated Service Networks and outreach programs throughout the country.  This is not to say that everything is as it should be.  We would not be having this hearing if that were the case.

Polytrauma care is not perfect.  There is also the sharing of electronic medical information and other issues that have been highlighted by Senator Dole and Secretary Shalala that the Subcommittee and full Committee will be addressing in the near future.

But there should be no misunderstanding.  We are not here to criticize the VA's care providers or to suggest that the quality of care to the Nation's most severely injured servicemembers is anything less than exemplary.  The Subcommittee has found some management issues that need to be addressed and that is why the title of this hearing is what it is.  The Subcommittee's oversight is intended to ensure the superb care the VA provides is provided to those who deserve it.

Data provided by the VA shows that the Palo Alto VA's Polytrauma Center from the beginning of this year through July filled only 60 percent of its available beds while the three other polytrauma centers combined have been running at 98 percent capacity.  We have found no good reason why that should be. 

The VA's Palo Alto Hospital has a beautiful facility and even more beautiful Fisher House where family members can stay and is practically married to the Stanford Medical School.  Palo Alto has all the resources it needs to provide the care for all the polytrauma patients it can take.

The Subcommittee has also found the Palo Alto Polytrauma Center would not accept minimally responsive brain-injured patients while the other polytrauma centers did so until the VA created a treatment protocol for those patients in December of 2006 and effectively forced Palo Alto to accept these patients.

This past spring, the VA's Office of Medical Investigations found disarray, morale problems, insufficient programs for families, and lack of leadership.  All of these raise obvious issues not just about local management but also about VA's Central Office.  Why, for example, did the fact that Palo Alto's failure to fill the beds while the other polytrauma centers were at full capacity not raise a red flag at Headquarters?

We begin today by hearing from the senior management of the Palo Alto Health Care System headed by its Director, Elizabeth Freeman.  Subcommittee staff has spent much time with Ms. Freeman and her team, and they are to be commended for their willingness to meet with and provide information to the Subcommittee.

We hope, indeed expect, that their testimony will describe sufficient progress in addressing the concerns of the Office of Medical Investigations (OMI) and the Subcommittee.

The second panel is headed by William Feeley, Deputy Under Secretary for Health and Operations and Management.  The Subcommittee extends its thanks to Mr. Feeley and the VA witnesses with him for their efforts to provide the best care possible to our injured servicemembers and appreciates their cooperation to the Subcommittee in meeting with and providing information to us.

We in no way doubt their good will and dedication, but there are obvious management issues for the Central Office that are raised by the fact that there were empty beds in Palo Alto, and these witnesses will be asked to address these issues.

Dr. Barbara Sigford, Dr. Shane McNamee, both of whom are personally involved in running polytrauma centers, are at the witness table as well.  We look forward to hearing from them about the good things that are going on for those who have made great sacrifices for our country.

On Sunday night, the Public Broadcasting System (PBS) began a 15-hour presentation of Ken Burns' documentary on World War II.  America achieved great things in that war, but the documentary reminds us, or perhaps more realistically teaches us, of the terrible cost of war.

We, as a Nation, owe a debt that can never be repaid to those who serve, an obligation that must be met to those, who were injured in that service.  We are here today to do our part in making sure this happens.  No one can doubt the dedication of the men and women in the military and the VA who provide care for our servicemembers.

[The statement of Chairman Mitchell appears in the Appendix.]

Mr. MITCHELL.  Before I recognize the Ranking Republican Member for her remarks, I would like to swear in our witnesses.  I ask that all witnesses stand and raise their right hand from both panels, if they would, please.

[Witnesses sworn.]

Mr. MITCHELL.  Thank you.

Now I would like to recognize Ms. Brown-Waite for her opening remarks.


Ms. BROWN-WAITE.  I thank the Chairman very much, and I also thank him for holding this hearing.

I believe that the title of this hearing is very appropriate and I am rather disappointed.  I do not know if there are any members of the media, but normally the room is filled because this is a very, very important issue as we talk about our wounded warriors from the Global War on Terrorism.  Obviously the quest for excellence should be of the utmost important.

Our Subcommittee staff recently visited several polytrauma rehabilitation centers located in Richmond, Virginia; Minneapolis, Minnesota; and the subject center, Palo Alto, California.  They did this to provide insight on the level of care being provided to our wounded servicemembers at those units.

Last Congress, while serving as the Chairman of this Committee, Ranking Member Buyer followed injured servicemembers from a combat support hospital in Iraq through the Landstuhl Army Medical Center in Germany, and on to Walter Reed and Bethesda.  Mr. Buyer has also visited the Minneapolis VA Medical Center’s Polytrauma Rehabilitation Center (PRC) to evaluate care and services received by our most critically injured servicemembers.

What I still see today is of great concern.  The tracking of medical records still includes the paperwork and hard copies of medical records accompanying the servicemembers as they transfer stateside and ultimately to the VA.

We know that that is U.S. Department of Defense's (DoD's) fault, but it is still ongoing, Mr. Chairman, and I did not know if you were aware of that.  As much as this Committee has said, "Let us move on and have electronic records," they are still doing the old paper records going with the veteran to the veteran facilities.

The Committee hears that not all the critical medical information is being forwarded to the polytrauma units by the DoD and many of the VA facilities are not using or have not heard of the Joint Patient Tracking Application (JPTA) and the Veterans Tracking Application (VTA) systems.

At the PRC in Palo Alto, our staff found several issues relating to lack of staffing and resources.  This same concern was detailed in the draft OMI report obtained by our staff prior to their visit to Palo Alto.

I would like to have the witnesses address this deficiency in care to the servicemembers and veterans who are being treated at this facility and I am also interested in learning how widespread this problem is.

During the staff visit to the PRC unit in Minneapolis, the Committee learned about the unusually high turnover rate of active-duty military liaison officers.  I am concerned about how this turnover rate affects continuity of care for our severely injured servicemembers.

PRC staff told us that there were also no electronic transfer of records between DoD and PRC in Minneapolis.  I am interested in learning what is being done to address this issue.

I know that some of our PRCs are doing a great job while it seems others are still having great difficulties.

How are the best practices being shared between PRCs, the good PRCs to provide the best possible care for our severely wounded servicemembers?

Let me give you one example.  The district that I represent is north of Tampa.  And when I was down at the Haley Hospital reviewing the polytrauma unit there, which, by the way, is excellent, I met some families from the west coast, not the west coast of Florida, but the west coast, Washington State.

They chose to have their wounded warrior go to Tampa to the polytrauma unit there.  When I asked why they did not choose to go Palo Alto, their response was because they wanted the best care available.

It is a shame that veterans and their families do not feel that the best care available is not also the closest care that would be available, namely at the Palo Alto center.

Mr. Chairman, we need to be concerned about the care our wounded servicemembers are receiving as they move from the battlefield through the line of care to our VA facilities.

Congress' responsibility to these men and women in uniform does not end with their care at the PRC units.  As the Oversight Subcommittee, we must also ensure that they have a seamless transition from active duty to civilian-veteran status.

I cannot stress enough the importance of working toward a standard Benefits Delivery at Discharge or (BDD) documentation.  A standard BDD would include one physical to be shared between the two departments, DoD and the VA, providing servicemembers with documentation as to the benefits for which they may be eligible.

With the use of a shared BDD, we could conceivably have the claims backlog at the VA caught up in a few years.  This program was successfully tested between DoD and VA from 1995 to 1997.  It is also a strong recommendation coming from the President's Dole-Shalala Commission report.

Again, Mr. Chairman, I thank you for calling for this hearing and I look forward to learning from our witnesses how the VA is working with the DoD to improve the care for our Nation's heroes and how we can better share some of the best practices from the superior polytrauma units to the remaining polytrauma units.

Thank you, Mr. Chairman.

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

Mr. MITCHELL.  Thank you.

I understand Mr. Walz has to leave early today.  So at this time, if there are no objections, I would like to recognize him for his brief opening statement.


Mr. WALZ.  Thank you, Mr. Chairman and Ranking Member.

Thank you to each of you for being here today.  Thank you for making the choice to serve in the VA, to put your expertise and your careers in service to our veterans and it is truly a noble cause, and for those members from the VA here. 

I say it every time we are here that our job is to be partners with you in this.  Our job is to help provide the funding and the oversight and the guidance necessary to help you do your jobs.  And for what you do, I am truly appreciative of that.

My State of Minnesota is fortunate to have a polytrauma center in Minneapolis and it is one that I have been to many times and am incredibly proud of what has been done. 

All of us know that what we are doing, one soldier or one Marine or one airmen or one seaman who does not get the care that they need is one too many, and we are always dealing with a very, very high expectation.  But I do think it is important to note how often we do things right and how often you are serving that care. 

We are fortunate to have Dr. Sigford.  She is here representing today in her position as National Program Director, but she is based in Minneapolis, and for that, I am very thankful because I have been there many times and I have seen that care.  I am looking forward to this discussion. 

The one thing that I am encouraged about by the Palo Alto experience is we appear to have the ability to be able to correct and we appear to be making changes in the right direction.  And too often in this Committee, we identify issues, we identify what we need to fix, and then it just takes so long to see any changes that the frustration level grows. 

And while we are not claiming that we have got everything under control, while we are not claiming we are doing things perfectly, we are claiming that, I think, that the communication that is happening between those of us who sat here in our responsibility to provide you the resources and the guidance and those delivering that care is starting to get there.  So I thank you for that. 

All of us know that our ultimate responsibility, and I always like to quote, I represent the district that the Mayo Clinic is in, and their single charge on the wall everywhere is, "what is best for the patient is what is best."  And that comes from Dr. Will Mayo and those quotes and the way they do everything is dependent on that.

And I said when I am up on the floor and the one thing I can tell you that sticks in my mind, my last visit out to the Minneapolis center, I met with a mother.  She was from Michigan and she was there with her son who was a double amputee and a TBI patient.  And the strain of the care was showing on her and she said the only thing that gets her through is, she said the floor that she was on with her son is staffed by angels. 

And that care that she receives up there from those people is absolutely heartwarming.  We need to make sure we keep them there.  We need to make sure that the turnover rate is lowered.  We need to make sure that our nursing staff is adequate and the resources are there.  And that is why this oversight of this is so important.

So I thank you all.  I am sorry I am going to have to leave a little early for a conflicting meeting.  But we do have your written testimony, and to know that this Committee takes very seriously the work you are doing and appreciates it.

I yield back.

Mr. MITCHELL.  Thank you.

Mr. Rodriguez?

Mr. RODRIGUEZ.  I will yield until the second panel. 

Mr. MITCHELL.  Thank you.

At this time, I would like to ask unanimous consent that all Members have five legislative days to submit a statement for the record.  If there are no objections, so ordered.

We will now proceed to panel one.  Ms. Elizabeth J. Freeman is the Director of the VA Palo Alto Health Care System.  Ms. Freeman has been the Director of Palo Alto since 2001 and has been with the VA since 1983. 

We would like to thank you, Ms. Freeman, for being here and for the many years of service to our veterans.

After you introduce your panel members, you will have five minutes then to make your presentation.  Thank you.


 Ms. FREEMAN.  Thank you.  Good morning.

I would like to introduce Dr. Larry Leung, who is our Chief of Staff, and a name that is very difficult to pronounce, Dr. Stephen Ezeji-Okoye, who is our Deputy Chief of Staff to my left.

And I will go ahead and read my oral statement.

Good morning, Mr. Chairman and other Members of the Subcommittee.  Thank you for the opportunity to appear before you today to discuss the polytrauma rehabilitation center or PRC located at the Department of Veterans Affairs, Palo Alto Health Care System.

It is a privilege to be on Capitol Hill to speak and answer questions about this vital program and other issues that are important to veterans who have bravely served in Operation Iraqi Freedom and Operation Enduring Freedom.

I would like to submit my written statement for the record.

The core of the PRC at the VA Palo Alto Health Care System is a 12-bed ward located on the Palo Alto Division Campus.  The PRC is frequently the subject of interest by oversight bodies, veterans' advocates, Department of Defense personnel, media, and elected officials.

Nearly every week, we have the honor of hosting visits by distinguished guests.  The vast majority of these visits are very positive and generate considerable praise for the PRC and its dedicated staff.

The PRC is also subjected to the oversight of the Veterans Health Administration or VHA.  Earlier this year, the VHA Office of the Medical Inspector or OMI came to Palo Alto and assessed the PRC.  The OMI reviewed allegations related to a delay in accreditation, inappropriate declinations of referrals, and lack of effective leadership at the program level.

I will comment briefly on these three areas.

Regarding accreditation, Palo Alto has been and continues to be fully accredited.  Palo Alto was due for its triennial Commission on Accreditation of Rehabilitation Facilities or CARF survey of rehabilitation programs in February of 2007.  Based on internal and external assessments, I determined we needed additional time to prepare for the survey.  Consequently, I asked and received approval from CARF to delay its survey for a few months.

I am pleased to report to the Subcommittee that the CARF survey occurred July 19th and 20th, 2007, and resulted in full accreditation for another maximum three-year period.  I would like to emphasize that at no time did our accreditation with CARF lapse.

Regarding referrals, I would like to note that the OMI did not substantiate the allegation that the PRC was inappropriately declining or otherwise cherry picking patients to produce favorable outcomes.  Nonetheless, I have instituted changes that will make it easier for referring sites to send us patients. 

There is now a single point of contact for referrals to the PRC and a clearly defined physician to accept them.  The acceptance decision will be promptly communicated to the referring site, patient, and family.  If, for any reason, the referring site disagrees with a decision, the referring site will be encouraged to appeal the decision to the Palo Alto Chief of Staff. 

We have improved our process for tracking the disposition of all referrals to the PRC and will report results monthly to the Veterans Integrated Service Network 21 Office and to VA's Central Office. 

I have instructed my staff to look for every possible way to accept as many patients as possible in either the PRC or a more appropriate setting.  I have also intensified our communication with and outreach to potential referring sites. 

Just yesterday, I went to National Naval Medical Center in Bethesda, Maryland, and met with senior medical and social work staff.  I was pleased to learn that the VHA Polytrauma System are including the PRC at Palo Alto are their first choice for referrals. 

I will follow-up on this productive meeting by sending a clinical team from my PRC to this and other referring sites to foster collaboration and eliminate any impediments to referrals.  I will also invite and encourage referring sites to send a clinical team from their facilities to Palo Alto.

Regarding leadership at the program level, the OMI expressed concerns about the leadership and communication in the PRC.  I have addressed leadership challenges in both the short-term and long-term horizons.  I have established an Associate Chief of Staff for Polytrauma.  The Associate Chief of Staff for Polytrauma will provide clear and stable leadership and the Associate Chief of Staff designation will signal its organizational importance.

I have already started recruitment for the Associate Chief of Staff for Polytrauma and established a Search Committee.  I am pleased to report that Stanford University will participate in the recruitment and offer a faculty position to the successful candidate.

In the interim, I have appointed a physician to serve as the PRC Program Director and to be responsible for day-to-day operations in the PRC including the disposition of referrals.  This individual has the necessary leadership, team building and interpersonal skills to achieve outstanding clinical results and to meet the expectations of families.  The PRC Program Director has already generated widespread support from the PRC staff.

In closing, I would like to emphasize the quality of care provided at the PRC has been and continues to be outstanding.  As the referrals and needs of our patients change, the PRC evolves.

My staff and I have developed a forward-looking plan to significantly increase the intensity of services and associated staffing.  We have also received funding for significant equipment purchases and infrastructure improvement.

My staff and I are fully committed to making any improvements necessary to meet the needs and exceed the expectations of our Nation's heroes and their families.

Again, thank you, Mr. Chairman, for the opportunity to testify at this hearing.  I and the staff who accompanied me would be delighted to address any questions.

[The statement of Ms. Freeman appears in the Appendix.]

Mr. MITCHELL.  Thank you, Ms. Freeman.  And I appreciate you being here today.  I appreciate it very much. 

And we appreciate the good work that all of your colleagues at Palo Alto are doing to provide the care to our veterans.  And we are particularly appreciative of the care that Palo Alto's Polytrauma Unit has provided to our most seriously injured Iraq and Afghanistan veterans.

As I said in the opening statement, we are not here to question you or your colleagues' dedication or suggest that the care at Palo Alto's Polytrauma Unit provides anything short of what is the best. 

That said, however, we cannot ignore the fact that Palo Alto has a history of empty beds in sharp contrast to the full beds at the other polytrauma centers.

The Office of Medical Investigations may have concluded that Palo Alto has not been cherry picking patients, but that just begs the question of why Palo Alto had empty beds.

I appreciate very much that Palo Alto currently has more than its allocation of polytrauma patients, but I am disappointed that it took the scrutiny of this Subcommittee to make that happen.

I can assure you that the scrutiny that you are getting now will continue and that our staff will be visiting Palo Alto again soon.

What we need and what our servicemembers giving their all to this war need is not only your assurance that Palo Alto will never again have empty beds, but also how your specific plans for operating the polytrauma center will ensure those results.  And I heard you outline your plan and what you plan to do hopefully. 

When the Subcommittee staff visits you again in a few months, what can we expect them to find?

Ms. FREEMAN.  Thank you.  Thank you for the question.

We have been aware that our average daily census has been less than 12 and we have 12 beds on the Polytrauma Unit.  And the number of beds that are occupied, that average daily census or ADC is dependent on the number of patients we accept and that is dependent on the number of patients that are referred. 

And we are now aware of this perception that we had been receiving less referrals.  And so the outreach efforts that we have made in order to increase the number of referrals and thus increase the number of admissions is the outreach that I described in my oral statement and by personally reaching out to those at other military treatment facilities beginning with the case managers in trying to identify any difficulties there.

I will follow that up with sending my clinical team to Walter Reed, Bethesda, Madigan, and other referring centers.  I will also invite the clinical teams from those centers to come to Palo Alto and to be assured that the quality of care that we provide is excellent.

Mr. MITCHELL.  Thank you.

Ms. Brown-Waite?

Ms. BROWN-WAITE.  I thank the Chairman very much.

I am going to have to leave the Subcommittee to go to a markup, so I will be leaving in a few minutes.  But before leave, I had a few questions.

Ms. Freeman, I understand that the Under Secretary for Health asked VHA National Center of Organizational Development to visit all four polytrauma centers and assess current structure and staff.

Would you share with us the findings and recommendations of this visit?

My second question—actually, if you would answer them in reverse—I understand that last February, you asked for a delay in the scheduled triennial accreditation. 

Knowing this important accreditation process was upcoming, what were the reasons for the requested delay?  And I also understand that you just recently successfully passed the accreditation. 

Would you elaborate what specific steps were taken between February and July to mitigate your concerns about passing the accreditation?

Ms. FREEMAN.  Certainly.  Thank you for that question, and I will go ahead and answer the question about accreditation first.

First of all, I just want to assure the Subcommittee that our accreditation, as I said in my statement, it never lapsed and we remain fully accredited.

We had performed some internal and external assessments.  We had an external consultant help us prepare for CARF and she commented that the quality of the care was outstanding, but she thought there were some structural components that needed to be put in place. 

So my reason in asking for the delay was to give us time to get the paperwork and other processes in place to be able to demonstrate to CARF that we should continue our accreditation.

And as I reported, when they did visit on July 19th through 20th, we did successfully pass that survey.  And they were very, very complimentary.

I would also comment that requesting that sort of delay is something I would do in any other area where we are preparing for an external survey.  If I had similar information, I would make the same decision. 

Regarding your question on the National Center for Organizational Development (NCOD), we very much appreciated the Under Secretary asking them to come and visit us and the other four polytrauma centers.  I think it was terrific for the staff morale.  They very much enjoyed it.  I believe we had 48 staff on the unit and 43 of them interviewed with the NCOD staff. 

And as far as their recommendations, the areas that the staff identified that were of concern to them were most focused on building and maintaining appropriate boundaries between the care team and the families.  There were also issues about referral patterns and the discharge process and also concerns about training.

And so we have taken all of those recommendations.  We have an internal team that is going to develop action plans on those recommendations.  And we are making progress as we speak.

Ms. BROWN-WAITE.  And if I may follow-up.  Could you elaborate a little bit more on the review that you had where it was suggested that there be a change in structural components?  Could you elaborate a little bit more on that?

Ms. FREEMAN.  Sure.  Thank you for that question.

Some of the structures that we need to put in place were data management and evaluation of data and quality improvement processes.  So not that those were not occurring, but the documentation of them and making it easy for a surveyor to identify and recognize and give us credit for.

Ms. BROWN-WAITE.  Are you aware of family reluctance to have the polytrauma veteran treated at Palo Alto?

Ms. FREEMAN.  I am not aware of any individual case where a family expressed concern about Palo Alto, but I would be very happy to follow-up with you, if I may, after the hearing about that family situation.

Ms. BROWN-WAITE.  So no one has ever said, I am not going to go to the polytrauma unit closest to my home city, my home state, but rather travel across the country to another one?  You have never heard this?  This is the first time you have heard this?

Ms. FREEMAN.  I cannot speak for what a family member expressed to a referral coordinator as to their reason as to why they would select one polytrauma center over another.

Ms. BROWN-WAITE.  Would you not want that information?

Ms. FREEMAN.  I would be very happy to get that information and act on that information and understand what that family's concerns were and correct them.

Ms. BROWN-WAITE.  Well, Mr. Chairman, Ms. Freeman, with all due respect, I would think that that would be a primary focus which might help to determine what some of the problems are at Palo Alto.

Well over a year ago, because I have the polytrauma unit so close to me, I began to look at, okay, why are there so few there and there is a waiting list at some of the other facilities.  And so this is nothing new to me nor any of the Members who have been on the Committee for a while.  So I would think in your position, you would want to know this.

Ms. FREEMAN.  Again, I am not aware of any particular family stating that they did not want to be referred to Palo Alto.  And if that information was conveyed to me, I would promptly act upon it.

Mr. MITCHELL.  Excuse me.

Ms. BROWN-WAITE.  I yield back the balance of my time.

Mr. MITCHELL.  Thank you.

I would like to just kind of follow-up.  Do you know of any other patients that were denied access to Palo Alto but ended up at either Richmond, Tampa, or Minneapolis?

Ms. FREEMAN.  One of the programs that we had not initiated that the other four polytrauma centers initiated was in the area of emerging consciousness, so there could have been patients that might have been referred to Palo Alto that were referred to those other programs before we instituted our program.

Mr. MITCHELL.  What does that mean?

Ms. FREEMAN.  Emerging consciousness?

Mr. MITCHELL.  The question was, were there people who were rejected at Palo Alto?

Ms. BROWN-WAITE.  Or rejected Palo Alto.

Mr. MITCHELL.  Well, yes.  You asked that.

But I am saying who you did not accept, did they end up at any of the other polytrauma centers?

Ms. FREEMAN.  We have received 173 referrals from the time we became a polytrauma center in February of 2005.  And we have accepted 143 or about 81 percent of those patients. 

And while I do not recall every instance of the 30 some who were not accepted at our polytrauma center, in general, the reason would be that they might have had—there might have been a more threatening, life-threatening condition that needed to be addressed first before they were referred into the polytrauma unit such as substance abuse or post traumatic stress disorder.

Mr. MITCHELL.  Let me follow-up.  Excuse me for taking this privilege here.

Would they have been released from Bethesda or Walter Reed under those conditions and sent out to you if they did not feel that they should be in the center?

Ms. FREEMAN.  I am sorry.  Could you repeat the question?

Mr. MITCHELL.  I think the patients that you receive or are referred to you are referred from Walter Reed, Bethesda.

Ms. FREEMAN.  Walter Reed, Bethesda, Madigan—

Mr. MITCHELL.  Okay.

Ms. FREEMAN.  —other—of the 173 referrals—

Mr. MITCHELL.  Right.

Ms. FREEMAN.  —I described, it is many locations, not just Walter Reed and—

Mr. MITCHELL.  And you are saying that some of those referred from those particular hospitals probably should not have been referred?  They should have stayed in those hospitals?  Why would—just one example—why would Walter Reed refer someone to a polytrauma center that they did not feel was ready to be referred?

Ms. FREEMAN.  Some of the referrals that I am speaking of with the other symptoms or other disease states that needed to be treated, they might not have been from Walter Reed or Bethesda.  They could have been from another place.

Mr. MITCHELL.  Okay.  Any of them, any number of them.  Are you saying that some of those people would be referred when they should not have been?

Ms. FREEMAN.  I am going to ask Dr. Ezeji-Okoye to help me because I am not doing a good job of explaining this to you.  But there could be other reasons that I am not explaining.

Mr. MITCHELL.  Let me ask this question.  The people that you get are referred; is that correct?

Ms. FREEMAN.  Yes.

Mr. MITCHELL.  And what you are saying is some that are referred, I get the impression, should not have been referred because they were not ready to be referred to this next level of treatment; is that right?

Ms. FREEMAN.  Could you help me?


Thank you, Congressman.

The VA operates a polytrauma system of care and that system of care encompasses multiple areas as well as multiple disciplines.  Patients are referred in for evaluation and appropriate placement into the correct area within the polytrauma system of care. 

Patients who initially may be referred from an outpatient setting, for example, may have conditions, as Ms. Freeman mentioned, such as substance abuse which would interfere or prevent them from being able to fully benefit from the acute inpatient rehabilitation on a PRC and so they are directed to the most appropriate setting either within Palo Alto or within another healthcare system within VA.

Mr. MITCHELL.  So what you are saying is that those hospitals that are doing the referring are not really doing the job they should when they referred them to the next level of treatment; is that correct?

Dr. EZEJI-OKOYE.  No, sir.  That is not what I was meaning to imply.  The centers when they refer in some cases such as many of the cases we get from Walter Reed and Bethesda, it is clear that the patient is suffering from polytrauma and that is the major and overwhelming issue.  And they are accepted. 

Other sites refer to the polytrauma network or the polytrauma system of care because they want assistance in evaluating what are the deficiencies and deficits that the veteran may be suffering from and help in assessing what the correct placement for that patient may be.

The polytrauma system of care may take that initial admission information and then in reviewing the documentation and discussing with the team make a determination that the most appropriate setting is actually not the PRC but perhaps a substance abuse center or post traumatic stress disorder center, and then after completion of that treatment would then come to the PRC.

Mr. MITCHELL.  Would you say that you have a higher level of rejection of those referred than the other centers?

Dr. EZEJI-OKOYE.  I do not know the information, sir, on the acceptance and rejection rate of other centers.  We have tried to accept every—

Mr. MITCHELL.  Excuse me.  It seems to me it is kind of obvious when you have 60 percent of the beds filled, the others have in the 90s, that you must be rejecting more or they are just not referring more to you to begin with, one or the other.

Dr. EZEJI-OKOYE.  We have not been denying patients.  We have been trying to find the most appropriate setting for each of those patients.  As Ms. Freeman mentioned, we have been concerned of this recent information about the perception that we were not accepting or were difficult to refer to.  And then that is why we have been doing the outreach to the other centers to make sure that perception is not continued.

Mr. MITCHELL.  Well, it must be a perception because either one or the other.  Either you are rejecting more than everybody else or you are getting less referrals, one or the other.

Thank you.

Mr. Rodriguez?

Mr. RODRIGUEZ.  Thank you very much.

And let me say that, first of all, I guess, to the next panel, thank you very much.  We are looking forward to being the fifth polytrauma center in San Antonio, so we look forward to working with our soldiers that are in need.

Let me just, I guess, from a political perspective, I have always judged politicians based on those that get elected because they want to be there and those that want to make something happen and actually do the work.

One of the biggest problems we find is veterans going and feeling like they are being neglected or not wanted there.  And that attitude of, I guess, maybe also that reflects on the work ethic of the people that are there in terms of not wanting to deliver the work.

And that would be, you know, the biggest concerns that I would have.  Not only you say there is a perception, but there is a reality also that you have only had 60 percent.

Do you communicate at all with the other four centers?  Do you meet at all and discuss, you know?

Ms. FREEMAN.  Yes, sir.  There are conference calls between our leadership at our PRC and Headquarters that all of the polytrauma sites are participating in. 

Mr. RODRIGUEZ.  You get to see what the others are doing and not doing?

Ms. FREEMAN.  Yes, sir.

Mr. RODRIGUEZ.  One of the things that I would be concerned in terms of your staffing there is in terms of their attitudes and, you know, how aggressive they might be or the lack of aggressiveness in terms of responding as to why they are there.  And that is to work and work for our veterans.

And so I would be concerned in terms of no matter what you do, if that attitude is not there and it is not brought up from the leadership perspective and if you are just there to be there for the sake of having a job, you know, I tell the staff that I have, and, again, the only analogy I can give you of my own, and that is that when staff comes to me, they are only on board as long as I am there, which is only two years at a time, and I expect them to have that aggressive attitude in terms of trying to make things happen versus just being there and biding their time while they are being employed.

And so I would hope that your attitude there is also in terms of service to our constituents and service to our veterans that are out there.  And that requires—I do not know how you can change that attitude, but it has to come from the leadership.

Ms. FREEMAN.  Yes, sir.  And I want to assure you that our staff are highly motivated to accept as many patients as possible.  They are extremely, extremely committed to providing outstanding care to those patients.  I would invite you to come and visit our unit and see for yourself the close connection between our case managers and the families and the patients that they care for, the close connection among the therapy staff, the physician staff, and the patients and families that we have the honor to serve.

Mr. RODRIGUEZ.  Yeah, because nothing worse than an attitude of you do not want to go there, I want to go somewhere else, and/or with the occupancy rates.  That also says that if you have the same workload, you know, and the others are carrying much more of a workload, there is something wrong with that picture also, especially when the need is there.     

And I can tell you in San Antonio, we have a large number of veterans at Brooke Army Medical Center and both out there at Wilford Hall and the other trauma centers as well as the Audie Murphy veteran needs in terms of services.

And so we look forward to doing that.  So I would, you know, hope that as you move forward, you know, there continues dialogue with the others and seeing what they are doing or not doing or whether a shift in staff needs to occur in order to make that happen in terms of the type of clientele.

Now, you mentioned some connection in terms of the type of clients that are being referred and why the others might be at a higher rate and you are not.  And you mentioned, was that some type of designation?

Ms. FREEMAN.  Emerging consciousness.

Mr. RODRIGUEZ.  Yes.  Tell me about that.

Ms. FREEMAN.  I am going to let Dr. Ezeji-Okoye describe emerging consciousness patients.

Dr. EZEJI-OKOYE.  Thank you.

Thank you, Congressman.

The Emerging Consciousness Program is a program that was developed through VA that encompasses family support, the care of the injured patient through programs such as Multi-Sensory Stimulation as well as other rehabilitation efforts.

Palo Alto offered many components or most components of the Emerging Consciousness Program, but we did not offer the Multi-Sensory Stimulation Program.  At that time, it was the opinion of our clinical leadership that the evidence was not sufficient to support that program.  However, over time and with discussion with the other VA centers, it was agreed that the situation had evolved and that we thought it would be beneficial to also include this service at Palo Alto.  And so in the fall of 2006, we began to put in place our own Multi-Sensory Stimulation Program and accepted our first emerging consciousness patient in November of that year.

Mr. RODRIGUEZ.  Thank you.  I think I have run out of time.  Thank you.

Mr. MITCHELL.  Thank you.

Ms. Brown-Waite?

Ms. BROWN-WAITE.  Thank you.

You may have said this and I missed it.  We are supposed to have a vote and I am trying to find out when I have to leave for the other Committee.  But how many current inpatients are there in the polytrauma unit?

Ms. FREEMAN.  Actually, as of last night, there were 17.  We have 12 beds designated for polytrauma.  There are 17 inpatients.  We have three polytrauma patients on our spinal cord injury unit and one patient in our intensive care unit.

Ms. BROWN-WAITE.  And how many are outpatients?  Do you have outpatients in the polytrauma unit?

Ms. FREEMAN.  We have a transitional program, and bear with me for just one moment.  Within our transitional program, we have 12 beds in the transitional program and I believe—I can check with you for the record the exact number as of yesterday, but we had five participants who were using our lodger beds and I believe there are others who are using that program but reside in the community.

Ms. BROWN-WAITE.  One of the other questions is, I believe I heard you say that you have conferences regularly with the other polytrauma units.  I understand that is a weekly teleconference; is that correct?

Ms. FREEMAN.  Yes.

Ms. BROWN-WAITE.  At some point, do you discuss the patient count, the utilization rate, and has this come up in your conversation with other polytrauma units about the difference in the number of patients that you treat versus the other facilities?

Ms. FREEMAN.  Thank you.

I do not personally participate in those conferences.  The Program Director and Medical Director participate in the conferences.  And so to my knowledge, I have not been personally aware of the difference between the ADC for our center and the other centers until Mr. Bestor brought it up on his visit. 

And I do not know if Dr. Ezeji-Okoye wants to comment on that.

Dr. EZEJI-OKOYE.  I participated in some of the conference calls and the conference calls have generally focused on making sure that we are developing quality programs across all of the polytrauma centers.  And that has been the primary focus of the calls that I have been on.

Ms. BROWN-WAITE.  So are best practices shared during these conference calls?

Dr. EZEJI-OKOYE.  Part of the conference call has been focusing on each polytrauma site taking a leadership role in developing what would be best practices within the polytrauma sites overall and then sharing those.  We have been charged with looking at some of the educational and training portions of the polytrauma system of care and developing those.

Ms. BROWN-WAITE.  Thank you.

I yield back, Mr. Chairman.

Mr. MITCHELL.  Does anyone have any other questions they would like to ask?

[No response.]

Mr. MITCHELL.  Thank you, and thank you very much for being here. 

And I do want you to know that, as I mentioned in my opening statement, that Members of this Subcommittee staff will probably be out to visit again.

Very good.  Thank you.

Ms. FREEMAN.  Thank you.

Dr. EZEJI-OKOYE.  Thank you very much.

Mr. MITCHELL.  At this time, I would like to welcome the second panel to the witness table.

Mr. William Feeley is the Deputy Under Secretary for Health of Operations and Management at the VA and the Chief Operations Officer for the VHA.  Deputy Under Secretary Feeley has over 30 years as a career civil servant, spending the majority of that time in the VA. 

And I want to thank you, Mr. Feeley, for your commitment to help our Nation's veterans and welcome you.

And before we start your five-minute presentation, would you please introduce the staff that you brought with you.

Mr. FEELEY.  Thank you, Mr. Chairman.

I have Dr. Ed Huycke from the—

Ms. BROWN-WAITE.  You might want to turn your microphone on, sir.

Mr. FEELEY.  Sorry.  I have got Dr. Ed Huycke to my right from the Office of Seamless Transition; Dr. Shane McNamee, Medical Director at the Richmond Polytrauma Center.  I've got Lu Beck, Chief Consultant of Rehabilitation Services in Headquarters and Dr. Barbara Sigford, National Program Director for Physical Medicine and Rehabilitation.

Mr. MITCHELL.  Thank you. 

Before you begin, I would like to recognize Mr. Rodriguez, if it is all right.


Mr. RODRIGUEZ.  Thank you, Mr. Chairman.  Thank you for allowing me to make some opening comments that I did not make initially.  I just first want to thank you.     

And I think it was the right thing for San Antonio to be selected as the next site for the fifth polytrauma center as they announced recently, you know, the fifth one.

But first off, I also want to express my extreme disappointment with the fact that I, and the Committee, were not informed about the new polytrauma center in San Antonio, only after the media inquiry asked me to comment on it.  And I think that the VA could have been more courteous to the Members of the Committee especially to letting us know in terms of the selection process.

And since the designation, my office has been in touch with the VA staff.  And from what I have been told, the VA has little information in terms of the new facility.  And so I am glad today that I will have the opportunity to be able to ask you some questions and be able to dialogue with you and work with you to make that happen because there is no doubt that there is a tremendous need out there and we are hoping to fill that need.

So thank you very much for allowing me to make those opening comments.  Thank you, Mr. Chairman.

Mr. MITCHELL.  Thank you.

Mr. Feeley.


Mr. FEELEY.  Good morning, Chairman and Members of the Subcommittee.  I want to thank you for the opportunity to discuss the Veterans Health Administration's ongoing efforts to improve the quality of care that we provide to veterans suffering from traumatic brain injury and complex multiple trauma.

The focus of my testimony today will be on treatment and rehabilitation provided by VA to veterans recovering from TBI and complex multiple trauma and the current initiatives to further enhance these services to our veterans within the system of care.

The mission of the VA Polytrauma System of care is to provide the highest quality of medical rehabilitation and support services for veterans and active-duty servicemembers injured in service to our country.

This integrated, nationwide system of care has been designed to produce access for life-long rehabilitation care for veterans and active-duty servicemembers recovering from polytrauma and TBI.

The four VHA polytrauma centers located in Minneapolis, Palo Alto, Richmond, and Tampa and soon to be San Antonio are the flagship facilities of the polytrauma system of care.  These centers serve as hubs for acute medical and rehabilitation care, research and education related to polytrauma and TBI.

During fiscal year 2007, the four PRCs added transitional rehabilitation programs at these sites.  These programs serve veterans and active-duty servicemembers with polytrauma and/or TBI who have physical, cognitive, or behavioral difficulties that persist after the acute phase of rehabilitation and prevent them from effectively reintegrating into community or returning to active duty.

Transitional residential rehabilitation offers a progressive return to independent living through a structured program focused on restoring psychosocial and vocational skills in a controlled therapeutic setting.

All remaining VHA medical centers provide an aspect of the continuum of polytrauma system of care based on the levels of intervention available at the site.  The definition of these levels was included in my written testimony and in the interest of time, I will not elaborate on those definitions now.

The coordination of transition of care is critical.  Care management across the entire continuum is a critical function in the polytrauma system of care to ensure life-long coordination of services for patients recovering from polytrauma and TBI.

At the direction of the Secretary, 100 transitional patient advocates (TPAs) have been recruited nationwide.  The TPAs contact the patient and family while in the military treatment facility.  One of their responsibilities is to ensure that all questions concerning VA are answered and each case is expedited through the VA benefits process.

If necessary, the transitional patient advocate will travel with the family and veteran from the military treatment facility to their home and provide transportation to all VHA appointments.

Psychosocial support for families of injured servicemembers is paramount as decisions are made to transition from the acute medical setting of a military treatment facility to a rehabilitation setting.

VA social workers or nurse liaisons are located at the ten military treatment facilities including our most frequent referral sources, Walter Reed Army Medical Center and Bethesda National Naval Medical Center.  These individuals provide necessary psychosocial support to families during the transition process, ad