Hon. Jeff Miller
The committee will come to order.
Before we begin I’d like to ask unanimous consent for our colleage from Tennessee, Congressman Steve Cohen to sit at the dais and participate in today’s proceedings.
Hearing no objection, so ordered.
Welcome to today’s full committee oversight hearing, “a continued assessment of delays in VA medical care and preventable veteran deaths.”
Today’s hearing is the fulfillment of a promise i made in early January to follow-up on delays in care at department of veterans affairs (VA) medical centers in Columbia, South Carolina, and Augusta, Georgia, that, together, resulted in nine preventable veteran deaths.
I had hoped that during this hearing, we would be discussing the concrete changes VA had made - changes that would show beyond a doubt that VA had placed the care our veterans receive first and that VA’s commitment to holding any employee who did not completely embody a commitment to excellence through actions appropriate to the employee’s failure accountable.
Instead, today we are faced with even with more questions and ever mounting evidence that despite the myriad of patient safety incidents that have occurred at VA medical facilities in recent memory, the status quo is still firmly entrenched at VA.
On Monday – shortly before this public hearing – VA provided evidence that a total of twenty-three veterans have died due to delays in care at VA medical facilities. Even with this latest disclosure as to where the deaths occurred, we still don’t know when they may have happened beyond VA’s stated “most likely between 2010 and 2012.” These particular deaths resulted primarily from delays in gastrointestinal care. Information on other preventable deaths due to consult delays is still unavailable.
Outside of the VA’s consult review, this committee has reviewed at least eighteen preventable deaths that occurred because of mismanagement, improper infection control practices, and a host of other maladies plaguing the VA health care system nationwide. Yet, the department’s stonewall has only grown higher and non-responsive.
There is no excuse for these incidents to have occurred.
Congress has met every resource request that VA has made and i guarantee that if the department would have approached this committee at any time to tell us that help was needed to ensure that veterans received the care they required, every possible action would have been taken to ensure that VA could adequately care for those veterans. This is the third full committee patient safety hearing we have held since i have been chairman and i am going to save our VA witnesses some time by telling them what i don’t want to hear from the department this morning.
I don’t want to hear the rote repetition of - and i quote from several prior VA statements, including the written testimony that was provided for this hearing - “the department is committed to providing the highest quality care, which our veterans have earned and deserve. When incidents occur, we identify, mitigate, and prevent additional risks. Prompt reviews prevent similar events in the future and hold those responsible accountable.”
Another thing I don’t want to hear is – and, again, I quote from numerous VA statements, including a recent press statement - “while any adverse incident for a veteran within our care is one too many,” preventable deaths represent a small fraction of the veterans who seek care from VA every year.
What our veterans have truly “earned and deserve” is not more platitudes and, yes, one adverse incident is indeed one too many. We all recognize that no medical system is infallible, no matter how high the quality standards might be. But I think we all also recognize that the VA health care system is unique because it has a special obligation not only to its patients – the men and women who honorably serve our nation in uniform – but also to its financers – the hard-working American taxpayers.
When errors do occur – and they seem to be occurring with alarming frequency - what VA owes our veterans and our taxpayers, in that order, is a timely, transparent, accurate, and honest account about what mistakes happened, how they are being fixed, and what concrete actions are being taken to ensure accountability.
It concerns me that my staff has been asking for further details on the deaths that occurred as a result of delays in care at VA medical facilities for months and only two days before this hearing did VA provide the information we have been asking for. Even then that information is far from a complete description of the problem and VA’s efforts to prevent future deaths.
It concerns me even more that VA’s briefing Monday and testimony today include very few details about what, if any, specific actions have been taken to ensure accountability for the twenty-three veterans who lost their lives and the many more who were harmed because they didn’t get the care they needed in a timely manner.
On our first panel today, we are going to hear from a veteran who sought care through the William Jennings Bryan Dorn VA medical center in Columbia, South Carolina. That veteran – Mr. Barry Coates - is going to tell us that, and I quote, “…the gross negligence…and crippling backlog epidemic of the VA [health care] system has not only handed me a death sentence but ruined my quality of life…”
Mr. Coates waited for almost a year and would have waited even longer had he not actively, persistently insisted on receiving the colonoscopy that he and his doctors knew he needed. That same colonoscopy revealed that Mr. Coates had stage four colon cancer that had metastasized to his lungs and his liver. Maybe that is why VA does not want to define accountability in terms of employees who have been fired.
The department is going to testify this morning that, instead, we should focus our accountability efforts on correcting systems deficiencies in order to prevent adverse events from occurring again.
There is nothing wrong with fixing systems. But Mr. Coates deserves better than that. His adverse event already happened and, for him, there is no going back. With that, I now yield to acting ranking member brown for any opening statement she may have.