Field Hearing for the House Committee on Veterans' Affairs
"Veterans at Risk: The Consequences of VA Medical Center Non-Compliance"
Chairman Filner, members of the House Committee on Veterans Affairs and panelists, I applaud you for holding a hearing to review the vitally important issue before the Committee today - the consequences to the health and safety of our nation's veterans following revelations of safety non-compliance at the John Cochran Veterans Administration Medical Center (VAMC) in St. Louis, Missouri. I am sorry that I could not appear before you in person today because of the Senate voting schedule, and I appreciate your accepting my written statement.
As we all now know, approximately 1,812 St. Louis-area veterans were potentially exposed to blood-borne pathogens, including hepatitis B and C and HIV, as a result of possibly being treated with improperly cleaned dental devices at the John Cochran VAMC dental clinic between February 2009 and March 2010. I know that I -- and I would venture to say all Americans -- were deeply saddened and disappointed by this revelation. My colleagues Senators Bond and Durbin and I made that clear in our June 30, 2010 letter to Veterans Affairs (VA) Secretary Eric Shinseki, which I am providing today and request that you include in the record of this hearing. Veterans are our nation's heroes -- men and women who risked their health and safety for our freedom -- and it is disturbing to learn that their health and safety could have been endangered in any way, even if by accident. As we all know, such mistakes simply cannot be allowed to happen.
In addition, our veterans' trust and confidence in the VA medical system and, particularly in the John Cochran VAMC, is badly damaged by incidents like this one. It is going to take time to get that trust back, but I believe the VA can and must do so, and I know today's hearing will be part of that process.
We all agree that veterans receiving treatment at John Cochran deserve the best quality care available, including absolute assuredness that the hospital is meeting the most basic and critical professional standards of cleanliness and conduct. This one incident is disturbing enough, but unfortunately John Cochran VAMC has been the source of other violations and low customer service ratings in the past. In April 2010, the VA Inspector General released a report outlining reprocessing problems with endoscopes used at John Cochran VAMC. Prior to that, John Cochran received some of the lowest customer service satisfaction ratings of any VAMC in the country. I know that efforts have been made to address these problems by the VA, but the latest revelations about the improper dental device sterilization pose a significant setback to progress.
Further, many veterans groups have expressed concern to me about John Cochran VAMC, including the Paralyzed Veterans of America Gateway Chapter, which has strongly opposed a move of the spinal cord treatment unit to John Cochran VAMC. I have written to Secretary Shinseki about this move because I understand their concerns. I ask that the letter to Secretary Shinseki also be included in the record of this hearing.
I am also deeply concerned that the VA took four months (from March until the end of June 2010) to notify veterans who may have been endangered by the flawed procedures at John Cochran VAMC, as well as to notify the area Congressional delegation so that we might assist our constituents, many of whom have called my office worried and outraged about this incident. I appreciate that the VA acted quickly to remedy the flawed cleaning procedures, but the failure to share information in a timely fashion about the situation is unacceptable. In addition, a follow up visit to John Cochran VAMC by VA Headquarters staff was not conducted until May 2010, some two months after the initial inspection revealed problems with the cleaning of the dental devices. When a significant failure in procedures occurs, like those discovered at the John Cochran VAMC dental clinic, I would expect a more timely response and more aggressive oversight. There must be an evident and palpable sense of urgency from the VA. It is clear the VA now has such a sense of urgency and it must continue.
The VA has decided to dedicate $5 million in funding to make infrastructure and other improvements at the John Cochran VAMC in light of this troubling incident. While I applaud the VA's efforts to address aggressively underlying problems, including infrastructure problems that could have contributed to the failures in the dental clinic, I and the other members of the Missouri and Illinois delegations want to be kept closely apprised of how the $5 million in renovations will be prioritized and spent. I ask today that the VA keep me, the rest of the congressional delegation and all interested veterans and veteran service organizations, regularly informed about any follow up actions that the VA takes to train staff and improve standard operating procedures in the dental clinic and elsewhere in the hospital.
As John Cochran VAMC staff go about the task of evaluating each of the 1,812 veterans who have received letters from the VA about potential exposure from improperly handled dental devices, I ask for a full and complete accounting by the VA of any health irregularities identified and attributed to the exposure - I cannot stress enough how any exposure would be a truly tragic outcome to this case. I know that Secretary Shinseki and the staff at John Cochran VAMC value the health and safety of each and every veteran, and I strongly urge him and the John Cochran VAMC leadership to make sure that no veteran's health goes unchecked in this exposure case.
The incident at John Cochran VAMC is a sad chapter that leaves a stain on the VA system. I abhor that it happened, and I join the Committee and all Americans in demanding a full accounting and assurance that such an incident will not happen again. Because of the challenges John Cochran VAMC has continued to face, I also call for a redoubling of efforts to make improvements at the facility.
I am committed to working with the VA to provide veterans with the resources they need to heal-resources that they have earned through their great service to this country. There is much to be proud of in the work the VA does for America's veterans and there are many skilled, patriotic, selfless employees on the VA team caring for our veterans. I want to thank the VA and its staff for all it does to honor and care for America's veterans and urge everyone who is part of the VA to persevere through challenges like that which this incident poses. The men and women who receive care at the VA know a thing or two about hardship and about perseverance. They will carry on and the VA will, as well.
Thank you, once again, Mr. Chairman for accepting my statement for the record today and for holding this hearing on this important matter.