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Hearing of the House Veterans' Affairs Committee - "Sacred Obligation: Restoring Veteran Trust and Patient Safety"


Location: Washington, DC

Good morning. I would like to thank everyone for attending this important hearing today.

The purpose of today's hearing is to gauge VA's response to several recent incidents that profoundly affect veterans due to the failure of some to follow policies, procedures and protocols that have been put in place to prevent such occurrences.

We are also going to look at what measures have actually been implemented to ensure that these types of lapses do not happen again.

Mr. Chairman, I have to say, and I think you would certainly agree that we have been here before! Please indulge me in my brief chronology of events.

In December 2008, we were notified of improper reprocessing of endoscopes which put thousands of veterans in Murfreesboro, Mountain Home Tennessee, and Miami, Florida, at possible risk of hepatitis and HIV.

In February 2009, another 1,000 veterans in Augusta, Georgia, received notifications that they were at risk for hepatitis and HIV because of improper processing of ear, nose, and throat endoscopes.

In July 2010, this Committee held a field hearing in St. Louis, Missouri, a hearing you attended Mr. Chairman, along with many of our colleagues today, after we had learned of lapses in protocol with the cleaning of dental equipment which put at risk 1,800 veterans.

The most recent notification, the egregious incidents at Dayton, Ohio, affected over 500 veterans and involved a whole host of problems. The findings beg the questions of proper accountability, effective oversight and enforcement of clear policies and procedures.

Policies and procedures that are sometimes not followed -- or worse -- get completely ignored. I would like to know, where is the strong, proper leadership and effective communication that is critical when you are entrusted with the care and well being of our Nation's veterans.

Let me point to another big concern as a result of these incidents and that is the absolute need for effective communication within the management ranks and below. I am sure the Secretary of Veterans' Affairs would agree with me on this.

Clearly, VA has had issues with ensuring the sterility of reusable medical equipment in the past and now, other patient safety issues have come to light, as evidenced in the continuing problem of veterans being vulnerable to infectious diseases due to the problematic, yet prevalent, issue of lack of following sound agency guidelines and policies concerning patient safety.

In addition to what has been looked at over the past three years, I am strongly dedicated to the need for ensuring that we do everything possible so that this does not happen again.

And, as we are all aware, VA has a higher commitment and a moral compact to provide the utmost level of care possible. It is this Committee's responsibility to ensure that VA has the proper resources to fulfill that mission.

I would like to acknowledge and want to recognize the VA's excellent health care services and the dedication of the vast majority of their staff.

I would also like to acknowledge the work they have done to mitigate the issues at hand. We know it has not been easy.

I look forward to hearing today's testimony.

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