Hearing of the House Veterans' Affairs Committee - Preventable Deaths and Patient Safety Issues

Hearing

Good morning, and welcome to today's full committee hearing "A Matter of Life and Death: Examining Preventable Deaths, Patient Safety Issues and Bonuses for VA Execs Who Oversaw Them."

I would like to thank the good people of Allegheny County for hosting us today.

As most of you are aware, the Department of Veterans Affairs' Veterans Health Administration provides health care services for millions of American veterans, but a rash of preventable veteran deaths, suicides and infectious disease outbreaks at several VHA facilities throughout the country has put the organization under intense scrutiny.

Despite the fact that multiple VA Inspector General reports have linked a number of these incidents to widespread mismanagement at VHA facilities, the department has consistently given executives who presided over these events glowing performance reviews and cash bonuses of up to sixty-three thousand dollars.

Many Americans have watched in disbelief as these events have unfolded on their television screens and in the pages of their local newspapers.

For some, however, these tragic incidents hit much closer to home.

So I would like to take a moment to recognize all of the family members of those who have suffered preventable deaths at VA medical facilities as well as any veterans who have endured VA patient-safety incidents here in attendance today.

Additionally, I would like to recognize former American Legion National Commander Ray Conley, for whom the Pittsburgh Legionnaires' disease outbreak is very personal because he was at the 1976 American Legion convention and in the hotel during the original Legionnaires' disease outbreak in Philadelphia.

To the families of the fallen, I know I speak for every member of Congress here today and every member of our committee when I say that we are deeply sorry for your loss and we simply will not tolerate substandard care for our veterans under any circumstances.

When we hear about it, we will investigate it, and keep the pressure on VA until the problems are solved, and those responsible for letting patients fall through the cracks are held accountable.

That is precisely why we're here today.

The purpose of this hearing is to examine whether VA has the proper management and accountability structures in place to stop the emerging pattern of preventable veteran deaths and serious patient-safety issues at VA medical centers across the country.

In doing so, we will specifically look at VA's handling of recent events in Pittsburgh, Atlanta, Buffalo, New York, Dallas, and Jackson, Mississippi.

For the folks we just recognized, the good people of Pittsburgh, and all those watching this hearing over the Internet, what you're about to hear may be painful.

But just so everyone understands the significance of the five locations I just named, I want to offer a brief rundown of why these incidents are so troubling to the members of our committee.

In Pittsburgh, VA officials knew they had a Legionnaires' disease outbreak on their hands, but they kept it secret for more than a year.

Five veterans are now dead.

Despite all of that, VA Pittsburgh director Terry Gerigk Wolf received a perfect performance review during a period that covered the bulk of the outbreak and regional director Michael Moreland, who oversees VA Pittsburgh, accepted a sixty-three thousand dollar bonus just three days after VA's inspector general reported VA Pittsburgh's response to the outbreak was plagued by persistent mismanagement.

In Atlanta, two VA inspector-general reports identified serious instances of mismanagement that led to the drug-overdose death of one patient and the suicides of two others.

True to form, VA doled out nearly sixty-five thousand dollars in performance bonuses to the medical-center director who presided over the negligence.

During a visit to the hospital in early May, hospital officials told me that although they had identified specific employees whose actions had contributed to patient deaths, no one had been fired.

When I asked a roomful of Atlanta VAMC leaders if there were any other serious patient-care incidents Congress needed to know about, they said no, failing to reveal a previously unreported suicide the media would expose just four days later.

At the Buffalo, New York, VAMC, hundreds of veterans were potentially exposed to Hepatitis and HIV after facility staff had been reusing multi-use, disposable insulin pens.

At least eighteen veteran patients have tested positive for Hepatitis so far.

Additionally, officials at hospitals in Buffalo and Battavia failed to properly maintain medical records, leading to the damage of thousands of patient files.

Despite all of this, David West, the man tasked with overseeing the Buffalo facility, pocketed nearly twenty-six thousand dollars in bonuses.

The Dallas VA Medical Center has been the subject of a series of allegations from VA workers, patients and family members regarding poor care at the facility as well as more than thirty certification agency complaints in the last three years.

The fact that there have been so many allegations of poor care at this facility is troubling enough.

What's also troubling is that Congresswoman Eddie Bernice Johnson, of Dallas, worked for more than a year behind the scenes to get VA officials in Washington to seriously investigate the matter.

Amidst these accusations, two top VA health administrators in Texas have collected a combined fifty thousand dollars in bonuses since 2011.

The situation in Dallas mirrors another instance of VA's apparent failure to take multiple allegations of poor patient care seriously -- this time in Jackson, Mississippi.

At the VA medical center there, a series of whistleblower complaints from medical center employees to an independent federal watchdog called the Office of Special Counsel, or OSC, raised concerns about poor sterilization procedures, understaffing and misdiagnoses.

Based on OSC's recommendations, VA was required to investigate the complaints, but VA Undersecretary for Health Dr. Robert Petzel downplayed the problems by referring to them as "kerfuffles."

So is it any wonder that the OSC wrote to President Obama in March of this year to voice serious concerns with the outcome of VA's investigation and the manner in which it was conducted?

In her letter to the president, U.S. Special Counsel Carolyn Lerner said "it does not appear that the agency has taken significant steps in improving the quality of management, staff training, or work product" and that the whistleblower complaints "raise serious questions about the ability of this facility to care for the veterans it serves."

To me, that's about as far away from a kerfuffle as it gets.

There are two sides to every story, of course.

Later, you will hear from VA officials, who will likely tell you that these problems are all in the past.

But just last Friday, VA's inspector general released another report that will challenge that assertion.

After an investigation into the VAMC in Columbia, South Carolina, the I-G found that mismanagement at the facility helped create a backlog of thousands of gastro-intestinal consultations, leading to nineteen instances of serious injury or death for veteran patients.

We have a photo on display here that I, myself, took during a recent visit to a VAMC facility in Albuquerque, New Mexico.

It depicts a quote from Dr. Petzel that was emblazoned on the wall of the facility.

It reads "Improving our work, is our work."

Well, it appears the work is not improving and the question VA officials must now answer is "where is the accountability?'

We are not here as part of a witch-hunt, to make VA look bad or to score political points.

We simply want to ensure that veterans across the country are receiving the care and benefits they have earned.

No one is questioning whether VA officials are sorry for these incidents or if VA officials are committed to providing the best care possible.

We know that they are.

We also know that the vast majority of the department's more than three hundred thousand employees are dedicated and hard-working, and many veterans are satisfied with the medical care they receive from VA.

What we are questioning is whether VA has the proper organizational culture, accountability and management structures to minimize the future occurrence of heartbreaking situations like the ones I just described.

Considering that the VA executives who presided over the incidents I just described are more likely to have received a bonus or glowing performance review than any sort of punishment, the question we are asking here today is entirely valid.

By now it's abundantly clear to most people that a culture change at VA is in order.

Today, we will find out if VA leaders agree.

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