Verna Jones, Director, National Veterans Affairs and Rehabilitation Commission, American Legion
Mr. Chairman and Members of the Committee:
The American Legion applauds this committee for utilizing its oversight authority to delve into this deeply troubling issue. The men and women of our armed forces are trained to go into hazardous locations in the performance of their duties. They are trained to operate under some of the most grueling and psychologically challenging circumstances. When they swear their oath they take on these challenges, and meet them with grace and valor unlike any other armed force in history.
They should not, and must not, meet grueling and psychologically challenging conditions undertaking the most basic of tasks in their civilian life post military service – seeking and receiving the health care services they have earned in the Department of Veterans Affairs (VA).
The findings of the most recent Government Accountability Office (GAO) report “Actions Needed to Prevent Sexual Assaults and Other Safety Incidents” (GAO-11-530) and previous reports addressing this matter such as “VA Has Taken Steps to Make Services Available to Women Veterans, but Needs to Revise Key Policies and Improve Oversight Procedures” (GAO-10-287) are disturbing. There are veterans who do not feel safe using the facilities provided for them for health care, and they don’t feel safe for a reason. In the last three years alone, nearly 300 incidents of sexual assault were reported to the VA police. Staggeringly, the vast majority of these reported incidents were not reported to VA leadership and/or the Office of the Inspector General (OIG). VA cannot be expected to solve patient security issues if they remain unaware of the problem at critical leadership levels.
The American Legion is aware of these concerns. Furthermore, the Legion believes the overall VA Health Care system is generally an excellent and deserved resource, and no veterans should feel they cannot utilize the system for fear of inappropriate behavior. With that in mind, The American Legion offers the following insights into the GAO report and our own research, and recommendations to improve the system and preserve the sanctity of the VA Health Care system.
What GAO Found
GAO’s most recent report tackled the period ranging from January 2007 – July 2010 with recognition that changing patient demographics were presenting unique challenges to VA in terms of providing a safe environment for all veterans. In particular, this study examined security issues stemming from unwanted sexual behavior and advances. Whether such behavior took the form of rape, inappropriate touching, forced examination, forced oral sex or other forms of sexual assault, the findings were clear. Not only were such illegal and horrifying actions occurring, over two thirds of these incidents went unreported to VA management and the OIG despite being reported to VA police.
GAO found fault with the risk assessment protocols. The protocols are simply a self-reporting process utilized to inform clinicians of sexual assault related risks, specifically regarding the lack of guidance about information collection. Because of a lack of “evidence based risk assessment tools” VHA relies on “professional judgment of clinicians” which is subjective at best. This is clearly problematic when dealing with an organization as large as VA, and one as criticized as VA is for a lack of consistency on a regional level. Because the information used to make these assessments is self-reported it is frequently incomplete, further complicating the issue.
The report found a lack adequate precautions in place at VA residential and inpatient facilities. While the sample of facilities examined was relatively small, GAO surveyed five facilities out of a system that includes 153 full medical centers, the omissions in procedures and security precautions raise large warning flags. Basic measures such as security cameras, alarm systems and so forth are inadequate or not present. In other places, there was inconsistency in the types of precautions taken, ranging from “patient behavior contracts” that varied from facility to facility, to a difference of procedures in place.
Perhaps one of the most common themes in the findings of the report was the lack of clear guidance. VA Staff had questions about what should and should not be reported. Staff frequently noted they were unclear as to the proper procedures for reporting, or even as noted above, taking histories.
Amongst other considerations, the findings seem to solidify one of the chief concerns about the entire medical system cited often in the past by The American Legion – inconsistency. As the saying goes “If you’ve seen one VA Medical Center, you’ve seen one VA Medical Center.” From VAMC to VAMC to VISN to VISN to CBOC to CBOC, each seems sometimes to operate as its own private fiefdom without consistency. The American Legion believes that while the overall plan for VA is strong, inconsistent application of that plan only leads to failure on a local level. VA must increase consistency.
What The American Legion Found
The American Legion utilizes multiple tools to find first hand information about patients in the VA Health Care system. Annually, The American Legion conducts site visits to VA medical facilities as the basis of our “System Worth Saving” (SWS) report. The SWS report covers all aspects of VA medical facility operations, and concerns of veterans utilizing the system are one of the many facets of these information gathering site visits.
In December of 2010, The American Legion further contracted with ProSidian Consulting to conduct a survey of women veterans to assess their satisfaction with the quality of healthcare delivered by the VA system. While women are by no means the only targets of sexual assault in VA and DoD facilities, Military Sexual Trauma (MST) is one of the key concerns noted specifically with reference to women veterans, and the Women Veterans Survey addressed concerns about security within VA facilities.
In the survey, 18 percent of women, or approximately one in five, stated they were “dissatisfied or very dissatisfied” with their sense of security in the VA health care system. When compared with recent figures which indicate approximately the same percentage of women in DoD have experienced military sexual trauma - 21 percent according to Department of Defense Sexual Assault Prevention and Response Office (SAPRO) – it is not unreasonable to start asking questions about whether there are lingering artifacts of the pervasive culture of the military that foster sexual assault without long term consequences.
The American Legion is deeply concerned to learn the VA and DoD actions to address this dire issue are lagging. In March 2010 the GAO conducted site visits to nine VA medical centers and ten Community Based Outpatient Clinics (CBOCs) to examine the availability of healthcare to women veterans, VA’s compliance with their policies and the challenges that they face in providing care. The GAO reported only two of the VAMCs visited had specialized residential treatment programs specifically for women who have experienced MST. Although the VA has taken steps to inform staff about their various programs offering MST treatment and counseling , VA has been thus far ineffective in informing veterans of these options. The VA has not provided this information on their external website where veterans can easily access it.
In site visits conducted as a part of the System Worth Saving Task Force, one American Legion staffer noted a woman came to VA enrollment desk seeking to report military sexual trauma. The veteran was directed to “fill out that packet over there and send it in” with no further follow up or concern from the VA employee. This veteran could have, and should have, been connected with the facility’s Military Sexual Trauma Coordinator and the employee could further have assisted the veteran by asking to speak to her in a more appropriate setting instead of drawing out the conversation in full view of the public in the waiting area. Sensitivity in this area goes a long way towards establishing trust with veterans whose trust has already been damaged. While the Legion staffer was able to conduct outreach to that veteran on the spot and immediately to ensure she got the treatment and aid needed, VA should not and must not rely on outside service organizations to conduct their vital role of outreach.
Put simply, The American Legion has found all too often that even if proper programs are in place and the resources are available to veterans, staff indifference and poor advertisement of these programs, including but not limited to poorly conveyed information in facilities and on VA’s own website, contributes to an veterans feeling there is no support for them in the system. The findings of GAO indicate there are serious flaws in the system to begin with, but when VA cannot even implement what is there already in the system, they are failing veterans. These veterans need to have access to and utilize the tools available to them.
What The American Legion Recommends
The problems represented within VA are hardly unique to VA. The American Legion recognizes there are cultural considerations both DoD and VA have long strove to overcome. Previous testimony has addressed concerns about those cultural considerations. If there is to be substantial change to rectify the unsatisfactory state of affairs, the change must affect the cultural environment. Clearly, no agency would support the sad state described in the GAO report. VA has regulations and policies already existing which attempt to provide a means to counter unwanted sexual behavior. However, it is abundantly clear these policies are not being consistently enforced, if enforced at all. Actions speak louder and more convincingly than words. VA’s actions must show their commitment to a policy geared towards ending the sexual assaults and other security incidents.
There are signs of an encouraging start. VHA Directive 2010-033 issued July 14, 2010 provided for VISN level MST Coordinators, as well as MST Coordinators at a facility level. The American Legion supports the establishment of such coordinators and recognizes the strength of such assets in outreach to veterans and spreading the message of support services available as well as following up on behalf of any veterans within the system who may experience these issues. However, although the Legion has determined all facilities now have such a coordinator, in many or most locations, the position is not a full time position, and is often an additionally duty of an employee tasked with other responsibilities.
The American Legion strongly recommends enhancing the role of these coordinators to full time status, and giving them the authority and scope of mission to act as advocates within the system for veterans who experience sexual trauma, and to ensure policies are carried out in VA facilities in keeping with the nature of the expectations of VA Central Office. Utilize these employees to be the front line defenders for those veterans who experience sexual trauma, whether it be in DoD or in VA itself.
The disorganized nature of VA’s overall plan for dealing with incidents of this nature requires revision. In this The American Legion agrees with the findings of the GAO report. Clarity and direction is necessary in multiple areas, including standards procedures for reporting, risk assessment and ensuring implementation of procedures again as noted by GAO.
VA must act now to meet the basic needs found in the GAO report. Promote a clear understanding of the definition of sexual assault. Establish a clear set of expectations regarding what should and should not be reported up the chain of command. GAO’s recommendations also call for an automated system to forward all reports of a criminal nature brought to the attention of VA security to the attention of OIG for investigation. Given previous records of reporting of material to OIG for proper follow up and investigation, automating this procedure may overcome whatever institutional roadblocks are already in place.
One of the stated concerns was the establishment of a centralized tracking system to monitor sexual assault incidents across VA medical facilities. Obviously this idea has merit and is an important tool. VA’s existing medical health care record system is already a recognized tool of excellence in necessary information sharing for medical treatment. However, given VA’s past record regarding data security, and the extremely sensitive nature of the subject matter involved and the already damaged psychological picture of the victims involved, the absolute utmost care is necessary to ensure such a system is secure beyond doubt. This is material of the most sensitive nature possible, and past VA mistakes and missteps with data security must not be allowed to compromise this reporting system. In The American Legion’s survey of women veterans, fully one quarter of these veterans felt VA’s handling of personal and sensitive information was “Poor to Moderate [Moderate being defined as less than Good]”.
The American Legion would note the most important consideration in reacting to this problem is to avoid the previous pattern exemplified by VA response to incidents of concern. In the past, VA policy has been to create an expanded section of Central Office to “manage and provide oversight” over a certain field, and enhanced Central Office bloat while allowing the problem to perpetuate at the local level because of a lack of direct oversight to the ground level operating environment. What is not needed is another floor of VA bureaucracy to deal with this issue.
What is needed is a clearly dictated policy made transparent to employees and the public at all levels, increased scrutiny at a ground floor level to ensure operations are complying with the stated mission, and accountability for those employees who fail to meet the standards. Put simply, hold individuals accountable for their actions, and make clear in no uncertain terms that this kind of behavior will not be tolerated. Then allow the local level to act out that policy without need for another hundred bureaucrats in Washington.
House Resolution 2074, the “Veterans Sexual Assault Prevention Act” works very much in the spirit of what The American Legion is proposing here. The bill provides for exactly the sort of concise and clear definitions and consistent policy required to help right the ship of VA’s treatment of these matters. The American Legion supports this legislation, but also notes continued oversight and follow up will be necessary to ensure compliance. The lack of clarity and consistency within VA on this matter indicate a potentially resistant culture, which will require the actions of all stakeholders to rectify. The American Legion stands ready to work with Congress, the VA, and all affected veterans and veteran service organizations to ensure proper due diligence is exercised and this matter does not slip from the forefront of our attention. This is a problem we all must work to solve, and The American Legion is eager to help.