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Hon. Harry E. Mitchell, Chairman, and a Representative in Congress from the State of Arizona

This hearing will come to order.

I want to thank our colleagues from North Carolina for joining us today.  I know they have been very active on this issue, and 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 at the Salisbury VA Medical Center in North Carolina and we’ll 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 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 Medical Inspector to conduct a review of 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 veterans who sought treatment at Salisbury and died… He went in for a toe nail injury, and even though doctors knew he had an enlarged heart, he wasn’t treated… it was ignored… and the morning after he had surgery on his toe, he died from heart failure the next morning.

According to media reports, this veteran received excessive intravenous fluids in the OR and post-operatively 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 also 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 VA 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 make sure this never happens again.