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VETERANS AT
RISK: THE CONSEQUENCES OF THE
U.S. DEPARTMENT OF VETERANS
AFFAIRS MEDICAL CENTER
NON-COMPLIANCE
FIELD
HEARING
BEFORE THE
COMMITTEE ON
VETERANS' AFFAIRS
U.S. HOUSE OF
REPRESENTATIVES
ONE HUNDRED
ELEVENTH CONGRESS
SECOND SESSION
JULY 13, 2010
FIELD HEARING HELD IN ST. LOUIS,
MO
SERIAL No.
111-90
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
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CORRINE BROWN, Florida
VIC SNYDER, Arkansas
MICHAEL H. MICHAUD, Maine
STEPHANIE HERSETH SANDLIN, South
Dakota
HARRY E. MITCHELL, Arizona
JOHN J. HALL, New York
DEBORAH L. HALVORSON, Illinois
THOMAS S.P. PERRIELLO, Virginia
HARRY TEAGUE, New Mexico
CIRO D. RODRIGUEZ, Texas
JOE DONNELLY, Indiana
JERRY MCNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia |
STEVE BUYER, Indiana,
Ranking
CLIFF STEARNS, Florida
JERRY MORAN, Kansas
HENRY E. BROWN, JR., South
Carolina
JEFF MILLER, Florida
JOHN BOOZMAN, Arkansas
BRIAN P.
LBRAY, California
DOUG LAMBORN, Colorado
GUS M. BILIRAKIS, Florida
VERN BUCHANAN, Florida
DAVID P. ROE, Tennessee |
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Malcom A.
Shorter, Staff Director
Pursuant to clause 2(e)(4) of
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electronic submissions are used
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hearing record, the process of
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C O N T E N T S
July 13, 2010
Veterans at Risk: The Consequences of
the U.S. Department of Veterans Affairs
Medical Center Non-Compliance
OPENING STATEMENTS
Chairman Bob Filner
Prepared statement of
Chairman Filner
Hon. Jeff Miller
Prepared statement of
Congressman Miller
Hon. Russ Carnahan
Prepared statement of
Congressman Carnahan
Hon. Roy Blunt
Hon. Jerry F. Costello
Prepared statement of
Congressman Costello
Hon. John Shimkus
Prepared statement of
Congressman Shimkus
Hon. Wm. Lacy Clay
Prepared statement of
Congressman Clay
Hon. W. Todd Akin
Hon. Blaine Luetkemeyer
WITNESSES
U.S. Department of
Veterans Affairs,
Hon. Robert A. Petzel, M.D., Under
Secretary for Health, Veterans Health
Administration
Prepared statement of
Dr. Petzel
American Legion,
Barry A. Searle, Director, Veterans
Affairs and Rehabilitation Commission
Prepared statement of
Mr. Searle
Johnson, Earlene, St. Louis, MO
Prepared statement of
Ms. Johnson
Maddux, Susan, Festus, MO
Prepared statement of
Ms. Maddux
Odom, Terri J., Imperial, MO
Prepared statement of
Ms. Odom
SUBMISSIONS FOR THE
RECORD
Hare, Hon. Phil, a Representative in
Congress from the State of Illinois
McCaskill, Hon. Claire, a United
States Senator from the State of
Missouri
MATERIAL SUBMITTED FOR
THE RECORD
Post-Hearing Questions
and Responses for the Record:
Hon. Bob Filner, Chairman, Committee on
Veterans' Affairs to Hon. Eric K.
Shinseki, Secretary, U.S. Department of
Veterans Affairs, letter dated July 29,
2010, transmitting follow-up questions
from Hon. Wm. Lacy Clay, and VA
responses
VETERANS AT RISK:
THE CONSEQUENCES OF THE U.S. DEPARTMENT
OF VETERANS AFFAIRS MEDICAL CENTER
NON-COMPLIANCE
Tuesday, July 13, 2010
U. S. House of Representatives,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to
notice, at 1:04 p.m., in the En Banc
Courtroom of the Thomas F. Eagleton U.S.
Courthouse, 111 South 10th Street, St.
Louis, Missouri, Hon. Bob Filner
[Chairman of the Committee] presiding.
Present: Representatives Filner and
Miller.
Also present: Representatives
Carnahan, Costello, Clay, Blunt,
Shimkus, Akin and Luetkemeyer.
OPENING STATEMENT
OF CHAIRMAN FILNER
The CHAIRMAN. Good afternoon. This
is an official hearing of the U.S. House
of Representatives Veterans' Affairs
Committee. I'm the Chairman of the
Committee, Bob Filner from San Diego,
California. The Ranking Member for this
hearing is Mr. Miller from Florida.
Thank you, Mr. Miller, for joining
us.
Mr. MILLER. Uh-huh.
The CHAIRMAN. I'm glad to see all of
you, but this is not the kind of
occasion which merits any celebration.
I appreciate everybody's interest in
looking into the sad and tragic events
that occurred here in St. Louis with the
oversight responsibility of Congress.
I ask unanimous consent, Mr. Miller,
for Mr. Carnahan, Mr. Costello, Mr.
Blunt, Mr. Shimkus, Mr. Akin, Mr. Clay,
and Mr. Luetkemeyer to be invited to
join us for the full Committee hearing
today.
Hearing no opposition, we welcome all
of you. This is a very large delegation
of Members of Congress who are not on
the Committee. They are here because of
the importance of the issue, so we thank
you all for being here.
I ask unanimous consent that all
Members may have 5 legislative days in
which to revise and extend their
remarks.
Hearing no objection, so ordered.
I do want to thank the staff of the
Thomas F. Eagleton Courthouse for their
generosity in providing the space for us
at today's hearing. We are all here
because we are concerned about what
happened with the dental clinic and the
dental equipment at the U.S. Department
of Veterans Affairs (VA) Medical Center
in St. Louis.
As a result of the lapse in the
protocol for cleaning dental equipment,
more than 1,800 veterans have been put
at risk, risk for having been exposed to
hepatitis B, hepatitis C, and HIV
(human immunodeficiency virus).
On behalf of all of us, we want to
make sure you know how bad everybody
feels about this situation. We want to
apologize to the citizens of St. Louis
for putting them through this very
tragic situation. The probabilities of
infection in this situation are low but
they are there, and that puts families
and the whole community at risk.
We are not only sorry for the
citizens of St. Louis, but we are
outraged that this could occur when we
are dealing with the veterans of our
Nation—those who we always pay the
highest honors, respect, and gratitude
for their service—and now in our own
medical system they have to face these
risks.
We want to get to the bottom of the
events both leading up to the lapse in
protocol for cleaning the equipment, and
in the examination of the steps that VA
officials took once they learned of this
incident, and evaluate whether they have
been effective in providing timely
information to our veterans.
I'm also very concerned with what I
see as a lack of transparency. Members
of Congress were not informed until the
matter became public. I came off a
plane from San Diego to Washington and
Congressman Carnahan approached me in
the cloakroom of the House of
Representatives and said, "Have you
heard what went on here in St. Louis?"
I was very embarrassed because I had not
heard.
I want to especially thank
Congressman Carnahan for being on top of
this and making sure all of us were
aware of what was happening, because the
information did not come to us from our
Executive Branch—as it should have.
Thank you again, Mr. Carnahan, for
being on top of all of this so quickly,
as were all of you from both Missouri
and I guess they say "across the river"
here, don't they?
When mistakes are made, the only way
to deal with them, in our view, is
through honesty and truthfulness. You
have to do that to make sure you have
the trust, and in this case, I think we
have to rebuild the trust with the
public.
How are we going to make sure that
not only this doesn't happen again in
terms of the actual cleaning of the
instruments, but of the way the public
was informed and treated with that
information? Accountability is our
bottom line here. We want to see who
was at fault and what accountability
measures will be taken to deal with
that.
We are going to hear from veterans
who were treated at the clinic and who
have received the letter that says they
are at risk. We want to understand
their situation, their fears, and their
questions while they are dealing with
this.
Unfortunately, I have to tell the
audience this is déjà vu all over
again. We've had this kind of problem
in other places, and each time we are
told it won't happen again. In December
of 2008, we had improper reprocessing of
endoscopes, which put thousands of
veterans in Tennessee and Florida at
risk of hepatitis and HIV. In February
of 2009, another 1,000 veterans in
Augusta, Georgia, received notification
that they were at risk for hepatitis and
HIV because of ear, nose and throat
endoscopes that were not cleaned
properly. Just last week, Mr. Miller,
in your State, another 80 or so veterans
were notified that they were at risk.
Clearly, we have some problems here and
I don't think we've remedied them when
they keep occurring.
I just want to raise some issues,
which my colleagues then will take up,
with the timeline of this whole thing.
Dr. Petzel, when you get here on your
panel, I hope you will respond to this.
When you look at the timeline for
what occurred, apparently the procedures
were not being followed for a whole
year, between February of 2009 and March
of 2010. They were discovered in a
routine inspection but if your routine
inspections find things that have been
going on for a year, there is something
wrong with that routine inspection. Why
do we only find out after a year of this
going on? It seems to me that this has
to be an ongoing issue. But whatever
you do, Dr. Petzel, in the VA there has
to be more rigorous and more regular
inspections. If they take place
quarterly or bimonthly, we can't let
things go on for a year.
When they discovered this in March of
this year it took until May for the VA
to put together a Clinical Risk
Assessment Advisory Board to look at the
risk. That's 2 months after they first
discovered this.
I don't understand that at all. I
think what should have happened when the
risk was discovered was to announce it.
Stand here with the Governor of the
State, with the Members of Congress,
with the Senators. Let's stand here and
say, look, this has occurred and we are
investigating it. All of the veterans
who visited the dental clinic in the
last year had better come in right away
for some tests.
Two months go by and they call a
board, who decided, as I understand it,
Dr. Petzel, that the risk was
sufficiently high—it
wasn't zero—and they said we ought to
notify everybody who was there at that
time. That took another 2 months. On
June 28th, the letters went out and they
had their meeting on May 6th.
This is a serious issue. To allow
that kind of waiting period and I know
there is a cautiousness, but you are
dealing with potentially fatal diseases
of hepatitis B and C. We know the
horrific consequences of HIV. You had 4
months where people could have given
blood to your blood bank because they
didn't know it wasn't safe or
potentially unsafe—not
to mention any sexual behavior. People
might have changed their behavior had
they known there was a risk. They
didn't even know about it. I think
that's intolerable, that it took that 4
months before anybody was notified.
As Congressman Carnahan points out,
the letter that was sent out seemed a
little cold. You have the option of
being tested. Call up our 800 number.
Now, I hope that 800 number is being
staffed. They say 24-hours a day but we
all know people who call 800 numbers and
are on hold for hours, or somebody
answers that doesn't even know what they
are talking about.
I was going to call the 800 number
this morning but I didn't have time. I
was flying here but I wanted to see how
they would actually respond to
somebody. I hope they are responding.
I will tell you if you have 1,800
people with serious risk, I would have
called in 1,800 VA employees—we have
250,000—and said, each of you is
responsible for one of these veterans.
Make sure you call them, counsel them,
and give them the emotional support they
need. Advise them of what the tests
mean and when they are going to happen,
and provide them with information about
follow-up tests.
If you can't have one-on-one, call in
600 VA employees and put three to one,
or call in 300 and make it 6 to 1. As
far as I understand it, we sent out
these letters and the veterans are
supposed to call in. Maybe we are
following up, but I doubt if we are
following up the way a case worker would
where they track down these veterans.
Such as address changes, phone number
changes, etc. You've got to track
people down. You've got to find them,
and you've got to hold their hands and
make sure they understand what's going
on. We are not doing that. We are just
not doing it. They are not only
American citizens, they are our
veterans.
It seems to me that we have to do a
far better job not only in the
transparency of a mistake, but then in
counseling and helping people. I think
we will have a panel on this. Even if
you get a negative test for HIV, you are
not always sure it's really negative.
You've got to re-test 6 months later,
but I'm sure somebody could testify to
the exact process. We are going to have
to stay with these people and be with
them long term.
We owe it to them. They have fought
for our Nation and we cannot let them
just wander around, call up an 800
number, figure out when a test is going
to be, and then maybe they will hear
about it in a few weeks. Somebody has
to be responsible for each of those
1,812 people. That's how I'm looking at
this.
Mr. Miller, I appreciate, again, you
coming from Florida to be with us to
make this an official hearing as we need
two Members of the Committee present,
and I thank you for your commitment to
our veterans that you have shown for all
of your career in Congress.
You are recognized.
[The prepared statement of
Chairman Filner appears in the
Appendix.]
OPENING STATEMENT
OF HON. JEFF MILLER
Mr. MILLER. Thank you, Mr. Chairman.
I, too, share the anger and the
frustration that you hear in the
Chairman's voice. He has already
recognized those Members that are here.
I do want to specifically mention one
that could not be here because of a
scheduling conflict, and that was
Congresswoman Jo Ann Emerson. She does
have a staff member here today.
And I, too, want to say that when
this first became public, Roy Blunt and
I had a very serious conversation in our
cloakroom and he has sent a letter to
Secretary Shinseki asking very pertinent
questions. And I hope that today we
will get the answers to some of those
questions without waiting on a response
from the Secretary.
But suffice it to say that we have
had incidents like this all across the
country. There are dedicated VA
employees out there and we salute them,
but mistakes like this have happened
over and over and over again and as the
Chairman said, Florida just had another
incident that had been notified to the
Congressional delegation in Miami.
The problem I have is that every time
we have a hearing on one of these
incidents, the VA comes forward and
says, "We are putting in new procedures,
new controls. It's not going to happen
again." But it happens again and again
and again. And unfortunately, I would
have to say that promises from VA in
issues such as this ring very hollow,
and that is not something that we would
expect from anybody in government, least
of all, those from within the Department
of Veterans Affairs.
I've got a lengthy statement and I
want to ask that it be entered into the
record because there are so many of my
colleagues here who have a vested
interest. I represent the First
Congressional District in Florida, which
is Pensacola to Destin, and I have the
most veterans of any Congressional
district in the country in my
Congressional district.
I specifically asked to be on this
Committee when I came to Washington in
2001 because I wanted to make sure that
the veterans of our Nation were getting
the care that we, as Americans, have
promised to those who have borne the
battle and worn the uniform of this
country.
But without further comment, I would
like to ask again that my statement be
entered into the record without
objection.
[The prepared statement of
Congressman Miller appears in the
Appendix.]
The CHAIRMAN. Thank you. Thank you,
Mr. Miller.
As I said, Congressman Carnahan from
St. Louis has been on top of this from
the beginning and has acted as our
liaison for knowledge. We thank you for
all the work you have done and you are
recognized for an opening statement.
OPENING STATEMENT
OF HON. RUSS CARNAHAN
Mr. CARNAHAN. Thank you, Mr.
Chairman, and to Mr. Miller for being
here traveling from Florida, as well.
For my colleagues from both sides of the
aisle and both sides of the river, we
thank you for being here.
Mr. Chairman, your prompt response to
the request of myself and Congressman
Clay to hold these field hearings in St.
Louis and to formally begin this
Congressional investigation into how our
veterans were put at risk by the safety
lapses at Cochran Medical Center.
Since we learned early this month
that veterans throughout St. Louis and
Illinois could have been exposed to
blood-borne pathogens such as hepatitis
B, hepatitis C, and HIV while receiving
dental care at Cochran, I've heard from
many constituents, veterans and their
families who are gravely concerned about
this matter.
After their service to our country,
this is not a fight our veterans should
face. They deserve answers to this
dental debacle, and relevant quality
personnel and management questions.
They deserve the best care available in
our country. On behalf of the veterans
that I am honored to represent, I'm here
to demand answers and action to make
this right.
From where I stand, there are five
core issues that I would like to see
addressed here today. First and
foremost, those 1,812 veterans who
received that cold letter in the mail
just a few weeks ago, to be sure they
are getting the special care and
follow-up they need.
Second, we need clear answers on how
this happened and how it could have gone
on for so long uncovered.
Third, I'm determined to get to the
bottom of whether an employee of the
medical center was terminated, in part,
because she raised concerns about the
sterilization procedures as far back as
August of 2009. And I have to say any
sign of retaliation or intimidation of
employees throughout this process should
not be tolerated and needs to be
reported immediately.
I want to know what concrete steps
are being taken to reach out to current
and former employees, to be sure they
are providing the necessary information
to be sure we get to the bottom of
this. We must make sure employees who
have information that is relevant to
this matter or any other problem are not
only aware of their rights, but are
encouraged to come forward and
cooperate.
Fourth, I want to determine whether
this latest incident at the dental
clinic is limited to that incident or is
part of a larger systemic problem at
this facility. The VA Medical Center
has been cited for serious infractions,
which leads me to suspect there may be
broader issues that need to be
addressed. In April of 2010, the VA
Office of Inspector General (OIG)
conducted an inspection to, "Determine
the validity of allegations regarding
ongoing issues with the Supply
Processing and Distribution (SPD)
departments related to reprocessing
endoscopes. The inspectors found that
the SPD department did not have defined
clean and dirty areas and there was
severe communication breakdowns between
staff regarding proper reprocessing
procedures.
Moreover, in the 2009 Survey of
Health Expectancies of Patients, the VA
approved Patient Satisfaction Survey
that tracks satisfaction responses from
inpatient and outpatient veterans showed
that Cochran scored the lowest score out
of 128 VA hospitals around the country
in inpatient services. A score of 46
percent is unacceptable.
And lastly, and most importantly, we
need action. We need to determine what
next steps need to be taken to restore
and rebuild the faith of our veterans.
Let me be clear. This should not be
an exercise to paint with a broad brush
in a negative way our Veterans
Administration or our health care
services. As was said earlier, there
are many professional and committed
people that work in the VA. They should
be commended and there are some
important quality measures that we
should all be proud of. But there is
broad acknowledgment that serious
mistakes have been made and there is
much work to be done.
This past week I met with a group of
30 veterans, many on my Congressional
District Veterans' Advisory Committee.
There was a strong belief in the quality
of care, but also a deep concern about
these recent problems. At the end of
the day it's critical the VA identify
and rectify any existing problems, make
sure this never happens again, and takes
actions needed to rebuild our veterans'
shaken confidence.
To all the witnesses here before us
today, thank you for being here to
appear before us to get to the bottom of
how this happened, to help us determine
the answers, reforms and actions that
honor our veterans with health care they
earned and that they deserve and that is
the best.
Thank you, Mr. Chairman, and Mr.
Miller.
[The prepared statement of
Congressman Carnahan appears in the
Appendix.]
The CHAIRMAN. Thank you, Mr.
Carnahan. Thank you for putting that so
clearly before us.
Mr. Blunt, you have shown your
commitment to veterans here during your
time in Congress. We thank you and
thank you for being here.
You are recognized.
OPENING STATEMENT
OF HON. ROY BLUNT
Mr. BLUNT. Well, thank you, Mr.
Chairman, and thank you for being here.
Thank you and Congressman Miller for
taking time to call attention here in
St. Louis where we have the most access
to witnesses. And our staff, some of
our staff was in the facility again
yesterday to talk to people at the
facility. I thank both of you for being
here.
You know, recently I've had a chance
to speak at the annual meeting of both
the Veterans of Foreign Wars (VFW) in
Missouri and the American Legion, and at
both of those meetings I told them that
of all our obligations as a country, at
the top of the list of obligations is
our obligation to our veterans. It
should be a priority for us. I know
it's a priority, Mr. Chairman and Mr.
Miller, for your Committee. And thanks
for your good work on this Committee.
Most of what needs to be said here we
are going to hear from the witnesses,
and I would just share my sense that one
of the questions are, how could 1,800
people have been exposed to this risk
over such a long period of time? How
does this go undetected, or perhaps even
detected and ignored? That's a
possibity that's been raised here today.
Secondly, as the Chairman pointed
out, how can we wait from March until
almost July to notify people?
And then third, the callousness of
that notification all were
unacceptable. All were unacceptable.
If, as the Chairman suggested, as Mr.
Costello has told me about an event in
his district in recent years, this is
déjà vu over again, it's unacceptable
all over again. And Mr. Chairman, Yogi
Berra, who is one of the most famous
given credit for that comment, grew up
just a few blocks from here. And he
grew up in a country that understood its
obligation to those who fight for
freedom, and to those who are willing to
fight for freedom. And that's what your
Committee focuses on. That's why we are
all so upset about this problem.
And you know, I've heard even earlier
today, that some unsophisticated person
getting this notice would be scared by
it. My view is the more you know, the
more you would have been scared by it.
And the notice was unacceptable the way
it went out, and apparently it's the way
the VA always deals with these issues.
And this is at the top of our list of
obligations.
And Mr. Chairman, again, thank you
for drawing attention to this in a way,
hopefully, that will make the future
problems like this dealt with in a
better way, and make this problem dealt
with in a better way from now until
every single veteran, and their family
who is affected by it, is beyond the
impact of it and hopefully and
prayerfully all beyond the impact of
that in a positive way.
And I give it back.
The CHAIRMAN. Thank you, Mr. Blunt.
Mr. Costello, you are our senior
Member here today. We thank you for all
of your years of service and commitment
to veterans.
You are recognized.
OPENING STATEMENT
OF HON. JERRY F. COSTELLO
Mr. COSTELLO. Mr. Chairman, thank
you. And I want to thank you for
calling this hearing here in St. Louis
on very short notice.
I thank Mr. Miller for traveling here
today from Florida to participate in the
hearing. And let me just say that I
have a lengthy statement that I will
enter into the record so that we can
continue with our witnesses. We have
three panels.
But let me say that we are here to
get answers. I think Mr. Carnahan
outlined what some of the questions
are. We have 1,812 veterans who have
been put at risk. Three-hundred seventy
of those veterans live in the
Congressional district that I'm
privileged to represent.
It's an absolute outrage that this
happened, given that this is not the
first time that this has happened. You
outlined in your statement, and Mr.
Miller made reference to, the fact that
over 10,000 veterans were put at risk in
Tennessee, Georgia and Florida. And as
a result of that, these veterans now
here in St. Louis know that they have
been exposed but they do not know if
they have life-threatening diseases as a
result of this.
This Committee held a hearing, at my
request, in 2008 as a result of what
happened at the Marion Veteran's
Hospital in Marion, Illinois. In 2007,
nine veterans died as a result of
substandard care at the Marion Veterans'
facility. How many veterans have to be
exposed and put at risk? How many
veterans have to die before the VA gets
it right?
Let me say that, finally, as
Mr. Carnahan pointed out and others, the
vast majority of the employees at the VA
facility in Marion, Illinois, are
outstanding, dedicated employees. It's
the management that was at fault. It
was the lack of aggressive oversight
that was at fault.
And finally, in addition to the
questions that Mr. Carnahan and you
raised, Mr. Chairman, I want to know if,
in fact, anyone is going to be fired as
a result of this, as opposed to
reassigned or located somewhere else.
That happened in Marion. As opposed to
firing the Director, they just
reassigned him to another facility.
So I want to know what action is
going to be taken to the people who are
identified that, in fact, both in the
Administration and the on-line
employees, that are responsible, I want
to know what's going to happen there.
Are they going to be pushed to another
facility or are they going to be fired?
I think it's about time that agencies
like the VA start firing individuals
that do not do their job. And that may
send a message out to everyone
throughout the entire Department that,
in fact, your job could be in jeopardy
if you do not follow proper procedures.
And with that, Mr. Chairman, I thank
you and I look forward to asking
questions of our witnesses.
[The prepared statement of
Congressman Costello appears in the
Appendix.]
The CHAIRMAN. That you so much, Mr.
Costello.
Mr. Shimkus, you've joined us from
across the river, too. Thank you for
being here.
OPENING STATEMENT
OF HON. JOHN SHIMKUS
Mr. SHIMKUS. Thank you, Mr.
Chairman. And I appreciate my colleague
Congressman Miller coming up from
Florida, and of course my good friend,
Jerry Costello, who has already weighed
in on the issues that we dealt with at
the Marion VA.
And I'm sure the folks out in the
audience are hearing these stories and
they are saying, why are we continuing
to put up with this stuff? And so I
knew you would probably elaborate that.
We need to know who knew what, and
when, and then we need to do, as Jerry
said, when are we going to hold someone
accountable? When, in a big Federal
agency, are we going to start holding
people accountable for in essence
dereliction of duties?
There is a cultural issue here.
There is a cultural issue that we've
dealt with in Marion and we've dealt
with in other States that has to be
changed. I was on a major radio station
this morning in the St. Louis area and I
had a, one of the call-ins was a veteran
named Jason and he said, you know, I
visit Cochran and I can't get the
Patient Advocate to talk to me. Now,
here is a veteran who called in to a
talk show to let me know that there is
more of a problem than just this.
I have a long-established
relationship with Secretary Shinseki and
I'm very biased in my high regard and my
opinion of him, and my faith, and my
trust. If he needs tools to separate
the wheat from the chaff, then we need
to help him get those tools. And it's
unfortunate that we are here.
I welcome my colleagues to the
bi-State area and I apologize to the
veterans who have been affected on not
only this but on other issues. And I
think you've heard from the voices of my
colleagues that we are going to continue
to stay on-focus on this and start
demanding change from the Veterans
Administration.
Thank you, Mr. Chairman. I give it
back.
[The prepared statement of
Congressman Shimkus appears in the
Appendix.]
The CHAIRMAN. Thank you, Mr.
Shimkus.
Mr. Clay, again, you've been on top
of this from the beginning. We
appreciate your commitment to St. Louis
and welcome.
OPENING STATEMENT
OF HON. WM. LACY CLAY
Mr. CLAY. Thank you, Chairman Filner
and Ranking Member Miller, for holding
hearing and for inviting me to join the
investigation regarding John Cochran St.
Louis VA Medical Center, which I
represent in Congress.
Today we will examine and hopefully
learn the truth about the improper
processing of dental instruments,
including a failure to clean dental
equipment with a special detergent
before it's sterilized.
It is unacceptable that procedures
were conducted from February of 2009 to
March of 2010 without proper safeguards
in place to protect the health of
veterans receiving treatments. Making
matters worse, the VA knew about the
possibility of exposure in March of
2010, yet veterans were not notified of
the problem until June of 2010. That is
shameful and there is no excuse for
withholding that information. This
Nation owes an enormous debt to the
brave men and women who served our
country with courage and honor.
Mr. Chairman, this is about a failure
to follow proper procedure, a failure of
supervision, and a failure to keep faith
with all the brave Americans who have
defended our freedom.
The truth about this incident will be
revealed in this Committee hearing, but
we certainly need honest answers to some
critical questions. And one is, what is
the chain of command that had primary
responsibility to oversee procedures at
the VA dental clinic at Cochran?
Two, what was the supervisor in
charge—who was the supervisor in charge
and when did he or she first become
aware of the failure to follow proper
procedure? And how did the supervisor
find out about the problem during the
time that the information about the
potential contamination was withheld and
did anyone else know about it? Who made
the decision not to disclose that
information immediately?
And finally, have the individuals
involved been disciplined in any way, as
my colleague Mr. Costello has asked?
Mr. Chairman, I thank you for
conducting this hearing, and I yield
back the balance of my time.
[The prepared statement of
Congressman Clay appears in the
Appendix.]
The CHAIRMAN. Thank you.
Mr. Akin, again, thank you for
joining us and we welcome your
participation.
OPENING STATEMENT
OF HON. W. TODD AKIN
Mr. AKIN. Well, thank you, Mr.
Chairman. And I likewise have some
notes that can be submitted for the
record, but I just wanted to sort of
digress a little bit and be a little
more brief.
First of all, as a Member of the
Armed Services Committee, I'm familiar
with our soldiers. I'm familiar with
their commitment, I'm familiar with
their service, and also with the
sacrifices that they make. And I guess
it's maybe more personal. I have three
sons that have been serving as Marines,
and I've served in the Army myself. So
what's gone on here is unacceptable.
My concern largely centers around
what increasingly smells like a systems
problem. I don't believe that what
we've seen was a result of one or two
people who failed to do their job. I
believe, rather, that it is a broader
organizational management kind of
problem that we are dealing with, and
it's also a culture that appears to be
suffering from misdirected understanding
of what their priorities need to be.
Just as our sons and daughters serve
us, this should be a service
organization and service must come
first. And it appears that at a number
of levels organizationally, this is just
not the culture. So, and if it were
just limited to this one incident, we
would say, well, okay, maybe there is
one location where there has been some
difficulties. Maybe some management
problems or whatever.
This appears to be a broader kind of
problem, and so my questions are going
to be particularly from a systems point
of view and from a culture point of
view. What are we going to do to make
this time different? Because we will
not, as Members of Congress, put up with
lousy service when we are asking people
to give even their lives, at times, for
this country.
Thank you, Mr. Chairman.
The CHAIRMAN. I think you hit the
nail on the head, Mr. Akin. Thank you
so much.
Mr. Luetkemeyer, we welcome you.
This is your first term in Congress and
you are getting a great introduction to
what we do.
OPENING STATEMENT
OF BLAINE LUETKEMEYER
Mr. LUETKEMEYER. Thank you, Mr.
Chairman and Ranking Member Miller.
Thank you, gentlemen, for your service
in helping to set this Committee hearing
up, and in coming all the way to our
beautiful part of the Midwest here.
I've got a very brief statement. I
will keep it brief because I know we've
got a lot to talk about today.
Commitment to our Nation, to those
who fought for it, is a solemn
obligation. Providing safe, sanitary
health care is the least we can do for
them in light of their service and
sacrifice. It is absolutely
unacceptable that procedures were
conducted between February 1st, 2009,
and March 11th, 2010, with a lapse in
the safeguards in place to protect the
health of veterans receiving treatment.
It is deplorable that any assistance
less than the best health care
available, along with possible exposure
due to unsterile equipment, is the level
of care being offered to our veterans.
In this hearing today, we must determine
what were the causes in the breach of
standards and what the Department plans
to do to remedy this situation to ensure
that it does not happen again. Also,
that we discern why, upon discovery of
this problem, information was not
distributed in a timely matter to
impacted veterans and to other VA health
facilities.
While we are here in St. Louis today,
this situation impacted veterans all
over the bi-State region and a number of
other States. Constituents of mine in
at least 12 counties were put at risk.
Finally, I will also point out that
my colleague, Mr. Clay, and I are both
Members of the House Committee on
Oversight of Government Reform, the
chief investigative Committee of the
House of Representatives, and we
requested that that Committee conduct a
full investigation of the situation, as
well. And we will look forward to that
hearing and disclosure, as well.
Mr. Chairman, with that, I thank you
and look forward to today's testimony.
The CHAIRMAN. Thank you.
As the first panel begins to come
forward, Mr. Carnahan is going to
introduce you, but I would like to make
one other comment.
Panel one please come forward. Ms.
Maddux?
In a July 2nd issue of the St. Louis
Post Dispatch, the Chief of Dental
Services at the Cochran VA Medical
Center is quoted as saying, "Things are
done to get votes, and that's a shame."
That is, we are here today for show.
We are not here for a show. We are a
bipartisan group that wants to get to
the bottom of this for the, as all of
you have stated, our veterans. That's
our only concern here. I think that by
blaming politics, it just looks like you
are trying to shift the attention away
from the mistakes that were made. I
challenge—
Mr. SHIMKUS. Mr. Chairman, can you
yield on that?
The CHAIRMAN. Of course, I will
yield to you.
Mr. SHIMKUS. Just, with my
colleague, Jerry Costello, so the public
understands, when people die in hospital
facilities like they did in the Marion
VA, we have to take action. So I really
find that egregious on the part of that
employee to make that claim, because
this is serious business. We don't take
this lightly.
Thank you.
The CHAIRMAN. Thank you, Mr.
Shimkus.
I challenge the Chief of Dental
Service, in fact, I challenge all of you
who are here on behalf of the Department
of Veterans Affairs, to take
responsibility for this disgraceful
incident and show all of America, not
just St. Louis, but all of our veterans
what they are doing to better understand
the why and the how of this inexcusable
lapse in procedure happened.
I think the VA is already facing an
uphill battle, but you must work harder
and longer to improve training,
implement standardized procedures and,
most importantly, regain the trust of
the veterans that you serve.
I would—Mr.
Shimkus, I share your high regard, as I
think we all do, for Mr. Shinseki,
former Chief of Staff of the United
States Army, now the Secretary for the
Department of Veterans Affairs. As far
as I know—and we will ask our panel—I
don't think he was told about this until
late in the process. And if that's
true, they've got more problems than
this little incident shows.
Mr. Carnahan, again, I think these
are your constituents. I ask you to
introduce the panel.
Mr. CARNAHAN. Thank you, Mr.
Chairman.
I would just echo that. I think you
can tell from the statements here from
all the panelists that all the folks up
here, there couldn't be a more united
and focused and bipartisan effort here.
So I appreciate all those kind of
comments.
I'm honored to introduce two
veterans, Susan Maddux, who is a Gulf
War veteran, served in the United States
Air Force. She is married to another
service-connected disabled veteran; and
also Terry Odom, also a disabled
veteran, suffering from post-traumatic
stress disorder, who served in the
Navy. Both of these veterans received
one of those cold letters in the mail.
I want to thank you first for your
service, and I want to thank you for
being here to share what happened to you
and to help us find answers here today.
The CHAIRMAN. You will be recognized
for an oral statement and any written
statement you have will be made part of
our record.
Susan, you are now recognized.
STATEMENTS OF SUSAN MADDUX,
FESTUS, MO (VETERAN); AND TERRI J. ODOM,
IMPERIAL, MO (VETERAN)
STATEMENT OF SUSAN
MADDUX
Ms. MADDUX. Thank you for allowing
me to speak today.
The CHAIRMAN. And we know how
difficult this is for you but we are
very grateful that you are sharing your
experiences.
Ms. MADDUX. My name is Susan
Maddux. I'm a 40-year-old Gulf War era
veteran. I served in the United States
Air Force from 1988 to 1998 as an
Aerospace Propulsion Specialist. I'm
married to another service-connected
disabled veteran and we are the parents
of four teenage boys.
On June 29th I received a certified
letter from the John Cochran VA Hospital
stating I may have been exposed to
hepatitis B, hepatitis C and HIV. I
found this letter to be very
impersonal. In fact, there was little
difference in the contents of this
letter than from any other communication
from the VA. It may have read just like
an appointment cancellation letter if
not for the signature required to
receive it.
I was very angry with the Veterans
Administration after reading this
letter. For something as significant as
this, it should have warranted a more
delicate approach than a form letter.
The VA has advised us that there is
minimal chance of being affected by
these diseases. However, I feel that
any chance of instruments becoming
contaminated is unacceptable within a
modern medical facility.
The veterans that are eligible to use
dental services at the VA Hospital are
not normal veterans. Rather, they are
among a select population and are also
the most susceptible to harm due to
being previously compromised by other
illnesses.
Those of us that are privileged to
use the dental service are 100-percent
service-connected, service-connected for
dental health, or POW's. Then there are
some veterans that have been
hospitalized for more than 120 days that
also have access to this dental clinic.
To hear that there are some who think
that the reaction of this incident is
solely political angers me
significantly. Hospital employees are
not political appointees but, rather,
are employed to perform a job, and that
is to care for our Nation's veterans.
It is their directive to follow the
policies and procedures of their
respected profession to ensure they do
no harm.
As an Aerospace Propulsion Specialist
it was necessary to perform tasks
following procedures and policies. This
allowed the air crews to have confidence
that I had installed or repaired their
aircraft engines properly. If I didn't
follow those procedures accurately, I
put their lives at risk.
In the same sense, the VA employees
should strive to instill our trust in
that they are doing everything the
appropriate way since our lives are in
their hands. In this instance, instead
of strengthening our trust, the St.
Louis VA has weakened our confidence by
potentially risking over 1,800 veterans
lives.
On June 1st of 2005, I was admitted
to the intensive care unit at the John
Cochran VA Hospital with bacterial
meningitis. This was several months
after having neurosurgery at this VA
facility. Two forms of bacteria were
found in my cerebral fluid. One of
these infections is normally found in
the gastrointestinal tract. I nearly
lost my life due to this infection.
After recovering from meningitis, I was
just happy to be alive and I didn't
think to ask more questions as to how
this happened.
After the disclosure by the VA over
sterilization at their dental clinic, it
brought me concerns that the VA
sterilization issues are not just
confined to this one clinic. It also
raises questions in my mind as to how
long these failures in sterilization
policies have truly been going on.
I would also like to express my
concern about the length of time for the
VA to notify us about this incident. It
makes me speculate if there was an
attempt to conceal this from the
veterans. It has also taken an extended
amount of time to get the test results
back to us. They need to realize that
we have put our lives on hold while we
wait for these results.
I would ask that VA employees speak
out about policies and procedures that
are not being followed; that it should
be their duty to ensure our safety, and
the managers and administrators should
be willing to listen when informed about
these issues.
I would also ask or request the VA
administrators and managers to look
beyond saving money and follow their own
motto by "Putting Veterans First."
Thank you for allowing me to testify
today, not only for myself, but as a
voice for all veterans that use the VA
medical facilities.
[The prepared statement of
Ms. Maddux appears in the Appendix.]
The CHAIRMAN. Thank you, Ms. Maddux.
Ms. Odom?
STATEMENT OF TERRI
J. ODOM
Ms. ODOM. Yes, my name is Terri
Odom. I am actually an Army and Navy
Vet and proudly served.
First of all, I just want to say that
all of my care providers at both John
Cochran and Jefferson Barracks, from the
dentists, to the psychiatrists, to
doctors, to therapists, nurses, et
cetera, have always shown me
professionalism, compassion, and I can't
say anything more for that. That's just
me personally.
Now, in regards to the dental lapse,
I obviously have some major concerns.
On behalf of what happened, basically we
just want answers. There are more
questions coming out of there right now
than answers. And I also have major
concerns about why it took them so long
to notify me and I was notified via
certified mail in a very, very cold
letter. Like this lady said, it
basically might have said, Hey, the
parking lot is being paved. Park on the
left side. That's how it felt.
I know this mistake by the VA has
made my anxiety disorder even worse, for
obvious reasons. Like she said, our
life is on hold and it's horrifying to
know how many more tests we are going to
have to have. There has been
conflicting reports that perhaps we
won't know for 5, to 10, to 20, to 30
years if we have hepatitis C or HIV.
And that's a long time to put your life
on hold, especially if you already have
some serious health issues. And anyone
that's seeking dental care at John
Cochran has some serious health issues
that are normally service-connected.
In the information number that was
attached to the certified letter that I
received, I must say, with all due
respect to the panel, that the people
answering the phone were rude, knew
nothing more than I knew, and I realize
they were thrown together last-minute.
I even called to verify my blood
test, which was scheduled for July 6,
2010, at Jefferson Barracks Hospital. I
called on July 5th, 2010, and a nurse
actually laughed at my concerns. She
said there was such a low risk that I
had absolutely nothing to worry about.
I asked her if the blood test being
offered was because of zero risk or
risk.
Looking back now, I realize something
in the dental department was wrong.
After my first oral surgery I did have
severe pain for 28 straight days, and
some must ask why did I not return to
the dental clinic, or call.
We were taught in the military to
suck it up, keep going, and that stride
and toughness is still embedded in us
veterans today. I had another oral
surgery later and some teeth filled. I
did receive partial dentures from the
VA, but after three visits they still do
not fit and my speech is bad with them.
I also, looking back now, remember
when the dentist reached for the metal
molding piece to make my impressions for
my partial plates, that they appeared
dirty and rusty. Having a severe
anxiety disorder, my attention to detail
is somewhat greater than others, and I
will leave it at that.
In February of 2010, I was scheduled
for a colonoscopy at the St. Louis John
Cochran division but had a severe panic
attack on the table, with extreme heart
rate and elevated blood pressure. I
looked around the room and it was beyond
filthy. I felt that I could not
continue with the procedure. As a
result, I did end up in the ER and the
procedure was canceled, thankfully, to
my benefit.
Also, during a 2009 inpatient stay at
the John Cochran division for over 5
days, I was unable to shower due to the
mold and unsanitary conditions of my
bathroom. The nurses on the ward were
very nice and just said, No, honey, you
don't want to dare use that nasty
shower. They did offer me washcloths
and things of such to bathe with. I did
offer to clean it myself.
There must be a change in the VA.
What has recently happened in St. Louis
with the exposure is third-world
treatment, if not less. And yes, we are
angry and we have every right to be.
The VA put our health at great risk and
there has to be some accountability.
This issue must not just be swept away
like it never happened.
I already have major trust issues due
to my disability, and now I feel that
the very people who are supposed to have
my back are trying to put me in harm's
way, and I'm not sure why. We deserve
better than this. We are not just
veterans, but human beings. People make
mistakes. I understand that. But when
you are dealing with people's lives,
there is no room for failure. And I'm
outraged at the lack of seriousness the
St. Louis VA seems to be putting on this
horrible issue. How would any of them
like to wait in horror for test results,
and then have to wait again and again
and again?
I thank you all for being here.
[Applause].
[The prepared statement of
Ms. Odom appears in the Appendix.]
The CHAIRMAN. Thank you both. You
do have a right to be angry.
Mr. Carnahan?
Mr. CARNAHAN. Thank you both for
your honest testimony and description
here.
As you said, Ms. Odom, obviously
there has been a toughness instilled in
you, and a commitment to service, and we
recognize that and we do want to get to
the bottom of this.
I want to ask both of you, you have
very well described the coldness of
those letters that you received. I want
to ask, did you make that first phone
call to the VA to set up those
appointments, or was there any other
outreach to you beyond that letter?
Ms. ODOM. I made the call
immediately, and the person that
answered the phone was a young man and
he did not know anything about it. He
said he was just hired to answer the
phone and that a nurse would call me in
approximately 1 to 3 hours to discuss
any further details about the possible
risk.
Mr. CARNAHAN. And Ms. Maddux?
Ms. MADDUX. I called the following
day. I already had an appointment that
day to go to John Cochran, so while I
was there I went down to their clinic to
get the testing, and I've received no
other calls.
Mr. CARNAHAN. And can you describe
the process when you got to the clinic
in terms of doing the test and any
counseling that was provided to you?
Any answers at that point that were
provided?
Ms. MADDUX. Well, we were given a
folder with materials to read. Since I
already had an appointment, they kind of
walked me through it. I didn't sit
through their orientation but I sat down
with a nurse and he asked if I had any
questions at the time. And then I went
across the hall for the blood testing.
I found when I got to the VA
facility, there was people stationed at
every turn in the hallways and those
people had smiles on their face, asking
if you needed help finding anything, and
that went all the way down to the
basement and into the clinic. And I
found that to be very fake. And you
would never see that on a normal day.
And it was just ridiculous.
Mr. CARNAHAN. Let me ask you both,
are you satisfied with the advice that
you have been given in terms of what
kind of follow-up care you are going to
need?
Ms. ODOM. No. I was not, I had my
blood test, as I mentioned earlier,
drawn at Jefferson Barracks July 6th.
And when I got to the blood draw clinic,
I was told I could not have it drawn
until I spoke with a Mrs. Bart Thompson
on the second floor.
I immediately went to the second
floor. The personnel there said they
knew of no such person. I called the
800 number again. The lady informed me
that she was from out of Missouri,
out-of-state. She knew of no Ms.
Thompson on the list.
So I went back to the staff on the
second floor and said, I've called the
number. What is it? And finally I come
across a nurse, I believe she was a
nurse that said she did know of a Mrs.
Thompson who had been at the last minute
thrown into it but went on leave, and
that she would personally call back to
the blood lab and say it was okay for me
to be tested. But I had no counseling
or anything like that, sir.
Mr. CARNAHAN. And then have you been
advised in terms of the length of time
you are going to have to wait to get
results?
Ms. ODOM. I was told that because of
the incubation period, that I can
possibly return in late August, but they
are going to be doing some investigation
on how long they may have to follow us.
That it may be 2, 3, 10 to 20 years. I
had different stories about it, sir.
Mr. CARNAHAN. And Ms. Maddux?
Ms. MADDUX. I was called yesterday
with my results and I was told since my
dental treatment was at the beginning of
March, I would have to be re-tested
around September 2nd. And that's all
I've gotten.
Mr. CARNAHAN. But no advice about
any testing beyond that?
Ms. MADDUX. No.
Mr. CARNAHAN. I guess have you had
an opportunity to talk to anyone about
how this occurred or about improvements
that are being made there to help
rectify this?
Ms. MADDUX. No, I haven't.
Ms. ODOM. No, sir.
Ms. MADDUX. I find I take it upon
myself, when told I was exposed to this,
going on the internet and researching it
myself, as I do with any medication or
any treatment that I have been given, to
inform myself as best as possible.
Mr. CARNAHAN. And I guess the last
question for both of you. If you could,
in brief, tell the Committee here, what
would you like to be done to help you in
terms of being sure you get the right
care you need going forward?
Ms. ODOM. I would like just honest
answers. And I would not always
appreciate it always having to come from
the media. No disrespect, but I think
it should come from the VA. Honest
answers. It seems like, you know, I've
received ten different answers on one
question. That's unacceptable.
And I would like to know, how long do
you plan on following this group of
veterans and their families? I have a
19-year-old son. You know, I would like
to know this. I have enough issues to
deal with currently that I don't think I
need extra anxiety to worry, do I get
re-tested in August and then wait for
results? And then again in December and
so forth and so on? I would like
somebody to let us just know the truth.
We are not blaming anyone. We just want
answers, that's all. The truth.
Mr. CARNAHAN. And Ms. Maddux.
Ms. MADDUX. Yes, I would like to
have someone appointed that we can call
one person and not go through being
directed or misdirected all different
places to get the answers that we need.
Mr. CARNAHAN. Thank you both.
The CHAIRMAN. Mr. Blunt?
Mr. BLUNT. Thank you, Chairman. And
thank you both for testifying. Let me
ask a couple more questions.
On the letter, Ms. Odom, you
mentioned that you called. How long did
you wait until you called?
Ms. ODOM. I fell down to my knees—
Mr. BLUNT. Uh-huh.
Ms. ODOM [continuing]. I'm just
being honest, sir, in shock. It was the
last thing I expected. You don't
normally get certified letters from the
VA Hospital. You might get them from
the Veterans Benefits Administration
(VBA) but never from the hospital.
Mr. BLUNT. Right.
Ms. ODOM. So I opened it, read it
three times, let it sink in, fell down
to my knees and said, you've got to get
back up. I will call. It must not be
that big of a deal because, you know, we
are finding out by a certified letter.
Mr. BLUNT. Right.
Ms. ODOM. I called and, as I stated
earlier, the young gentleman said he had
just gotten hired for the 24-hour, 7-day
a week manned thing. The Educational
Department at John Cochran Division. He
said, I'm sorry, ma'am. I can't help
you. I don't know anything. But a
nurse will be calling you in 1 to 3
hours, and he or she at that time will
discuss any concern that you have.
And I waited, literally looking at my
phone for it to ring, and it did ring in
about 2 1/2 hours.
Mr. BLUNT. And when you talked to
that person, what did they tell you?
Ms. ODOM. They told me that the
risks were minimal. They told me not to
have unprotected sex, use razors,
fingernail clippers, share any bodily
fluids with anyone else until I was
tested. And they were so new into this,
they were uncertain of what all had
occurred. That we needed to wait until
all of our blood tests were back.
And they basically minimized it and
stressed over and over again that the
risk was very low, and even
mathematically. We did the math. I did
the math with them. That only one vet
out of the 1,812 could be infected. But
to me, one vet is deplorable and
unacceptable—
Mr. BLUNT. Right.
Ms. ODOM [continuing]. And
inexcusable. One person's life and
maybe their spouses, et cetera? I don't
have words for it.
Mr. BLUNT. And did you get—where did
you get this information, or just give
me a sense, that they might need to test
you over a period of time? I think you
said it could be 2 years. It could be
20 years. Who told you that?
Ms. ODOM. I got that information,
sir, from, I believe he called himself a
physician from the VA this past Sunday
that called me to tell me that, you
know, because of the incubation period
that I would be rescheduled to test
again late August.
He at that, at this time is not sure
how they are going to track the vets
that were affected and how long that we
may have to be re-tested again.
Sometimes strains of hepatitis C show up
years later.
And of course at that time, if you
did test positive, they would have to go
back to the 1,812, make sure that that
strain actually came from this exposure.
Mr. BLUNT. Well, hopefully we will
glean from later panels today, or
follow-up with the Committee, Mr.
Chairman, and get some more specific
detail on that.
I mean just the notice in July, for
reasons we've mentioned, is bad enough.
To wait that long. And then, you know,
to have to worry from the first of July
until sometime in August, that is an
incredible amount of anxiety,
particularly if you are already dealing
with service-related anxiety, but even
if you are not.
And I'm going to be anxious to find
out, for you and for me both, how long
this really is going to take before you
know that your life, as Ms. Maddux said
in her testimony, is on hold. And
hopefully we can get some answers there
that are helpful for all of us to know.
And I'm hopeful that the extent of time
that this could take is—we can find out
better answers than that.
And the only other question I would
have, Ms. Maddux, with Ms. Odom's
testimony about other procedures at the
facility, I notice you had some concerns
in your testimony about earlier
procedures. I assume those concerns are
heightened now by this incident? You
want to talk about that for just a
second?
Ms. MADDUX. Yes. I have had
numerous procedures since then. Just
last month I had a cardiac
catheterization done and I'm hoping
everything from there was clean.
And I'm concerned, like if I start
feeling a fever or something, is that
meningitis coming on again? And going
through meningitis was the worst thing
in my life. I guess I just have to wait
and see.
Mr. BLUNT. And you now think that
may have related to your care at the
hospital? At the facility, rather?
Ms. MADDUX. Well, the meningitis was
done after neurosurgery.
Mr. BLUNT. Uh-huh.
Ms. MADDUX. Leading up to it, I
started getting fevers in the evenings
and just all of a sudden a severe
headache started that I wasn't used to.
And in fact, that day I was
hospitalized. And then—
Mr. BLUNT. They had surgery, these
things happened, and then you were
hospitalized again with meningitis?
Ms. MADDUX. Right.
Mr. BLUNT. Okay.
Ms. MADDUX. It was about 7 months
since the neurosurgery that I was
hospitalized again. And while in the
hospital that time, I had to have
another neurosurgery to remove the shunt
and everything they had put in in the
last surgery.
Mr. BLUNT. And you were scheduled
for other care at the time you got the
notice and so you were—you went to the
facility pretty quickly after the notice
because you were scheduled to go there,
is that what you said?
Ms. MADDUX. Yes, I was scheduled on
June 30th for a neurology appointment,
so I knew I would be going there anyway,
so I went through their process.
Mr. BLUNT. And you got your notice
on June—
Ms. MADDUX. Twenty eighth.
Mr. BLUNT [continuing].
Twenty-eighth?
Thank you all for testifying. I know
it's hard to talk about and I'm sure
it's hard to live with the uncertainty
of this. And one of our goals here
would be to create whatever sense or
whatever level of certainty and closure
we can create, as quickly as we can help
create that. But it helps to have the
experience that you've gone through
here.
Thank you, Mr. Chairman.
The CHAIRMAN. Thank you, Mr. Blunt.
Mr. Costello?
Mr. COSTELLO. Thank you, Mr.
Chairman.
I thank both of you for your service
to our Nation and I thank you for coming
forward to testify before the Committee
today.
Ms. Odom, you mentioned seeing the
dirty and rusty dental equipment. Did
you report that to anyone when you saw
it?
Ms. ODOM. No, sir, I did not.
Mr. COSTELLO. And I take it from
your testimony, both you and Ms. Maddux,
that the VA did not assign a caseworker
or an individual to you, to either one
of you to follow up, an individual that
you could call at any time if you had
questions?
Ms. ODOM. No, not at all.
Ms. MADDUX. [Shook the head.]
Mr. COSTELLO. You were just left on
your own.
And Ms. Maddux, as far as you know,
you are going to be re-tested in early
September and there is not going to be
any other contact with the VA?
Ms. MADDUX. Not for this situation,
no.
Mr. COSTELLO. Okay. Again, I thank
you for your testimony.
Mr. Chairman, thank you. I give it
back.
The CHAIRMAN. Mr. Shimkus?
Mr. SHIMKUS. Thank you, Mr.
Chairman.
I appreciate your testimony and thank
you for your service. The quote of the
VA comes from Abraham Lincoln and says,
"Care for him who shall have borne the
battle and for his widow and orphan."
And obviously the VA failed in this
aspect, and in their opening statements
we, our concern is that this isn't an
isolated case. And that's really
telling.
If it was an isolated case, as I
think Chairman Filner and I talked about
even prior to coming here, if it's
isolated, then there are mistakes and we
can move. But if it's endemic, I mean I
would agree with my colleague, Mr. Akin,
there is a systems problem here.
So let me ask, your experience with
Cochran on an—overall, not just this
incident, on a zero-to-ten scale, ten
being great, where would you
rate—because in the opening statement
you especially, Ms. Odom, you mentioned
the caregivers and people concerned.
Overall, that facility, how would you
rate them?
Ms. Maddux first.
Ms. MADDUX. Before coming to St.
Louis—I'm originally from St. Louis—I
lived in Minnesota, so I had experience
with their VAs and I would have to give
John Cochran, at the very most, a four.
And I find it really dirty, and knowing
that there is other VAs out there that
do a wonderful job.
Mr. SHIMKUS. Ms. Odom?
Ms. ODOM. Are you talking
specifically about the facility, sir?
Or the personnel?
Mr. SHIMKUS. Just the overall, if
you've had service there and you walk
away.
Ms. ODOM. I've had many services
there, sir, and I would agree with this
lady, that overall, a four at the
highest. There is just things that we
can do better. It's mainly the
sanitation.
Mr. SHIMKUS. And my colleagues have
already asked questions about what you
saw, when you notified. Have any of you
ever used the Veteran Advocate in any
process?
Ms. ODOM. They don't call you back,
sir.
Mr. SHIMKUS. They don't call you
back.
Ms. Maddux?
Ms. MADDUX. Yes, I have. It has
been quite a few years ago, but I used
that at Jefferson Barracks and I did get
answers.
Mr. SHIMKUS. Well, and that—one more
follow-up. We have Cochran. But how
would you rate the Jefferson Barracks
component of care on a zero-to-ten
scale?
Ms. ODOM. Ten.
Mr. SHIMKUS. Ten. And as for Ms.
Odom?
Ms. MADDUX. I would say a seven.
Mr. SHIMKUS. Okay. That's all I
have, Mr. Chairman. Thank you.
I give it back.
The CHAIRMAN. Thank you.
Mr. Akin?
Mr. AKIN. Thank you, Mr. Chairman.
Just to try to get a little bit more
detail on what my friend Congressman
Shimkus was getting at, if you were to
take a look at the facility, first of
all in terms of the people who are
specifically medical doctors, how would
you rate the people that you worked
with? Did you feel like they were
competent and did a good job, sort of
one to ten, the doctors themselves?
Ms. MADDUX. As far as the doctors at
John Cochran, I would give a seven
because I find some that I'm not able to
work with.
Mr. AKIN. So the doctors, about
seven. Then how about the facility?
Just the physical facility.
Ms. MADDUX. The facility is—
Mr. AKIN. I mean the buildings and,
you know, the rooms and the bathrooms.
Ms. MADDUX. I find it really—
Mr. AKIN. What's that.
Ms. MADDUX [continuing]. Dirty.
It's—you don't want to set your purse
down on the floor. Holes in the wall.
I know it takes time and money to get
through it, but like the cleaning part
could be done much better.
Mr. AKIN. How about the other
medical personnel? Not the doctors but
the other people who are physically
doing medical kinds of things, like
nurses and other aides?
Ms. MADDUX. Nursing care I would
give a seven. But as far as clerks, I
find almost every clerk I come in
contact with is very rude. It's you are
taking up their time.
Mr. AKIN. That was going to be my
last question, was the administrative
side. Just sort of the process of
knowing who to call and getting the
right information and having ease of
access and being able to get answers
quickly and that kind of thing.
What would that be?
Ms. MADDUX. A five.
Mr. AKIN. Five.
Ms. MADDUX. I have to go through
many people to get the right answer or
to get the right clinic.
Mr. AKIN. Okay. Could I ask the
same, Ms. Odom? The same kind of
questions? First of all, doctors. You
said you felt the doctors themselves
were pretty good?
Ms. ODOM. The doctors and nurses and
the medical staff that have treated me
at John Cochran have been excellent.
Mr. AKIN. Okay. Then the actual
facility itself, the buildings, the
rooms, the bathrooms, all that kind of
stuff?
Ms. ODOM. Everyone here that's
toured the building, or any vet that's
been to John Cochran sees that there is
construction going on, improvements, but
it's absolutely deplorable and
unsanitary.
I just happened to be there yesterday
for a scheduled appointment and noticed
a lot of housecleaning going on there.
Mr. AKIN. Okay. And then last of
all, from the administrative side, just
the ease of knowing how to get in, get
your appointment scheduled, knowing who
to talk to, just the interface, do you
feel like you are a very important
customer to them, or is it the
opposite?
Ms. ODOM. I take up their time.
Mr. AKIN. Thank you.
Thank you, Mr. Chairman.
The CHAIRMAN. Thank you.
Mr. Luetkemeyer?
Mr. LUETKEMEYER. Thank you, Mr.
Chairman.
And thank you, ladies, for your
service and your willingness to be here
today. And I know it's difficult to be
in your position. You are publicly
talking about some very personal things
and we appreciate your willingness to
share, and are very sorry for your
situation. Hopefully this hearing will
rectify that and hopefully we can make
amends for that.
Just curious. I know that, Ms. Odom,
you talked a number of times about the
conditions there. Have you ever
complained to any administrative people
about the filthy conditions or unsafe or
unsanitary things that you may have seen
or experienced?
Ms. ODOM. Yes, I actually called the
Patient Advocate because it's actually
on a brochure when you are an
inpatient. I left my name, number, last
four, and I never got a response.
And actually, I felt so horrible for
the nurses that were on the floor that
said that it's been like that for years
that I didn't, I did not follow through
with trying to keep contacting the
Advocate over and over again.
You know, I don't know, I don't know
if it's lack of funds, lack of
housekeeping, but I'm not talking about
a bathroom, for instance, where I was
supposed to take a shower that was just
nasty or dirty or messed up, but
someplace that was disease-contaminated
for obvious reasons. I mean you could
not take a shower in there unless it was
the last resort.
Mr. LUETKEMEYER. But they didn't
respond to you once you called, is that
what you are saying?
Ms. ODOM. No.
Mr. LUETKEMEYER. You complained, and
there was no follow-up by them on your
complaint, to you?
Ms. ODOM. No, sir.
Mr. LUETKEMEYER. Ms. Maddux, did you
do that yet?
Ms. MADDUX. In 2003, after moving
back to St. Louis and seeing the
facilities, my husband and I both did
complain about it. We received a
call-back asking, well, what room did
you see a hole in? Or—it was almost
like I was bothering them by making a
complaint.
Mr. LUETKEMEYER. Just to reframe
what you have said here, it appears that
when you were told, when you contacted
the VA after you received your letter,
you each one got a different explanation
of what was going on.
Am I reading that correctly? Or have
you talked with each other? Or I mean—
Ms. ODOM. [Shook the head.]
Mr. LUETKEMEYER. Each one has a
different explanation of what you were
told at the time you called. Am I
getting that correct from your testimony
here today? It sounds like that.
Ms. ODOM. We've never met each
other. I mean what I understand, sir,
is I called, and she had a scheduled
appointment anyway.
I don't know if you called.
Ms. MADDUX. I called on the 30th,
you know, right before I was going there
that afternoon. And I believe my
appointment time was 3:00 and they gave
me an appointment to I guess go through
their process for 4:00.
Mr. LUETKEMEYER. I guess the point
I'm trying to get at here is, is there a
plan or have you been explained—has a
plan been explained to you on how to
take care of yourself, or how you are
going to be treated, or what they are
going to do to take care of you over the
next several months?
Ms. ODOM. No, sir.
Mr. LUETKEMEYER. No. Okay.
Ms. ODOM. Other than the nurse who
did call me back in 2 1/2 hours to
explain no unprotected sex, no
fingernails sharing, no toothbrush
sharing. You know, things like that.
Mr. LUETKEMEYER. No scheduled
follow-ups for you on a regular basis?
Ms. ODOM. No, sir.
Mr. LUETKEMEYER. All right. Have
either one of you gone to a private
doctor or a private clinic and been
checked out at all on your own?
Ms. MADDUX. With my
service-connected condition I guess I
have to sign a contract with my
physician, because I'm receiving certain
medications, that I do not go to other
doctors.
Mr. LUETKEMEYER. Okay. We are
talking today mainly about the dental
portion of this. Have either of you
been to the—had dental service more than
just once over the last several months—
Ms. ODOM. I have.
Mr. LUETKEMEYER [continuing]. During
this time period that's in question?
Ms. ODOM. I have, sir. Five times.
Mr. LUETKEMEYER. Five times.
Ms. ODOM. And I have a scheduled
appointment for the 23rd of August,
2010, which I obviously plan to cancel.
Mr. LUETKEMEYER. Okay. So you
actually could have been exposed or were
exposed five separate times, is that
what you are saying?
Ms. ODOM. Yes, sir.
Mr. LUETKEMEYER. Ms. Maddux? Were
you—
Ms. MADDUX. Twice.
Mr. LUETKEMEYER. Twice? So you
could have possibly two exposures, is
that what you are saying?
Ms. MADDUX. Yes.
Mr. LUETKEMEYER. Okay. When you
were—has anybody at this point given you
an explanation, whenever you called or
since then, given you an explanation of,
number one, why this went on this long
and what happened and why it took so
long to get to you? Have they given you
any explanation at all?
Ms. ODOM. They just keep stressing
low risk. Don't worry about it.
Mr. LUETKEMEYER. So there has been
no explanation to you of how this
happened, why it happened, or sort of
remedy why it took so long. You just,
you got a letter that said, hey, you've
got a problem perhaps, and it said, we
will take a look at it? Okay.
Ms. MADDUX. I was told I guess the
same story line as the media has gotten
about, it was found in a routine
inspection and that there is minimal
risk. Everything should be fine.
Mr. LUETKEMEYER. Okay. Again, thank
you very much for your service and being
here today. And hopefully we can get to
the bottom of this and prevent this from
happening in the future. Thank you very
much.
Thank you, Mr. Chairman. I give it
back to you.
The CHAIRMAN. Thank you. Mr.
Miller?
Mr. MILLER. I think most of the
questions have already been asked, but
first of all, thank you for your
service. And as has already been said
up here, thank you for your willingness
to step forward.
We hear you. And regardless of what
people say, I didn't come from Florida
trolling for news up here. I came here
because I wanted to hear your story and
we want to make sure that this doesn't
happen again.
If you could go to another medical
facility in the community, would you go?
Ms. ODOM. Yes.
Ms. MADDUX. Yes.
Mr. MILLER. Prior to this happening,
if you could have gone to another
facility, would you go?
Ms. MADDUX. Yes.
Ms. ODOM. No.
Mr. MILLER. And why do you say no?
Ms. ODOM. Because it's taken me
years to trust my therapists and
doctors, and I finally have that trust
with them, that I don't feel like I want
to start from ground zero with new
doctors. That's me personally, though.
Mr. MILLER. And you say yes.
Ms. MADDUX. Yes. I just received a
new primary care physician that I don't
care for, and I'm starting all over
again getting all this testing and I
guess having her trust me.
Mr. MILLER. What happened? You say
you don't care for your primary care
physician now.
Ms. MADDUX. Yes.
Mr. MILLER. How do you get another
one? Can you?
Ms. MADDUX. Yes. Requesting a new
primary care. The last one I had, I had
for 7 years. But she moved to a
different part of the facility and the
new one is starting from zero. And with
my conditions it's, she keeps
questioning, well, do you have this
condition?
Mr. MILLER. Thank you, Mr.
Chairman. I yield back.
The CHAIRMAN. I, again, thank you.
Between your testimony, which is very
searing, and the sensitive questions of
my colleagues, I think we get a picture
that is pretty shocking. All I wanted
to say is that we are not going to
forget it. We are going to act on it.
We appreciate your testimony. Thank you
very much.
Ms. MADDUX. Thank you.
[Applause.]
The CHAIRMAN. Now, panel two, will
you come forward.
We ordinarily don't do that, but this
is a very emotional issue so I see a
hand that, if you want to just come up
and state your name and ask a question,
that will be fine, while panel two is
coming up.
VOICE. Hello. Can you hear me?
The CHAIRMAN. Yes.
VOICE. I would just as soon not give
you my name because I don't want to get
the dentist in trouble that told me
this. So—I've been to the dentist a
couple times here and I think my first
visit was in August. August/September.
And I had missed a, I had missed the
appointment and it took me months and
months to get an appointment again.
I asked him, why does it take so
long? And of course he said, we are
understaffed. We put in request after
request to get dental, to get dentists,
and maybe other staff people, I don't
know, but it keeps getting denied. This
is at John Cochran.
And then a few more minutes I talked
with the gentleman and he says, and the
other thing is we have a requirement
that if someone comes in for a dental
check and we find something wrong, like
a tooth decay, we have to see that
patient again in maybe 2 or 3 weeks.
Well, we can't do that because we are
understaffed. We have so many people
we've got to see.
I said, well, what do you do about
that? He said, well, we send up the
paperwork saying that we didn't meet
that requirement. But somewhere between
the dentist and the VA, it gets changed
to show that they are meeting their
requirements. So they don't get, they
don't have that staff. Additional
staff.
So the paperwork is getting doctored
that, I don't know, maybe the Budget
Committee is seeing. Maybe it goes to
the administration here at John
Cochran. Maybe it gets sent on further.
The CHAIRMAN. Okay.
VOICE. So they are understaffed.
The CHAIRMAN. Thank you very much.
We will be looking into that.
Our second panel consists of a former
VA dental employee, Ms. Earlene Johnson,
and Mr. Barry Searle—is that the
pronunciation?
Mr. SEARLE. That's right.
The CHAIRMAN. The Director of the
Veterans Affairs Rehabilitation
Commission for the American Legion, I
assume from Missouri or St. Louis.
Mr. SEARLE. Actually, Washington,
sir.
The CHAIRMAN. I'm sorry. From
Washington. Thank you for joining us
here today.
Ms. Johnson, we will put any written
remarks you have in the record, and
whatever you want to tell us, Earlene.
STATEMENTS OF EARLENE JOHNSON, ST.
LOUIS, MO (FORMER VA DENTAL EMPLOYEE);
AND BARRY A. SEARLE, DIRECTOR, VETERANS
AFFAIRS AND REHABILITATION COMMISSION,
AMERICAN LEGION
STATEMENT OF
EARLENE JOHNSON
Ms. JOHNSON. First of all, thank
you. Thank you very, very, very much
for this opportunity to speak.
The CHAIRMAN. If you will bring the
microphone a little closer, ma'am?
Thank you.
Ms. JOHNSON. I did not work in the
dental department. I worked in an area
called Sterile Processing. Sterile
Processing is an area where we do
cleaning processing of instrumentation.
I was terminated for trying to help
the Vets Gateway Chapter of Paralyzed
Veterans and my family members that go
to John Cochran. I never worked for the
VA Hospital nowhere else. In Oregon, I
was a manager over Sterile Processing,
in which we collected instruments
throughout the hospital. I wasn't a
lazy manager. I took that extra step.
You find at John Cochran when you
open your mouth about something, you are
either retaliated on, or targeted, or
you are just praying that the next day
you walk in, you have a job.
Unfortunately, I was on probation and
didn't keep my mouth shut. I called
Washington. I tried to warn people in
Washington. I couldn't get through. I
couldn't get through.
I knew something was going to happen
at John Cochran and I didn't give up,
even when they terminated me. I still
made calls. I have a father that's
buried at Jefferson Barracks. He was a
sergeant major. I have another father
that goes to John Cochran that can
barely walk. I have family members that
go to John Cochran and it didn't matter
to me if I was on probation. There is
something wrong. There is something
wrong.
When you hire people in positions,
you don't hire your friends. You don't
hire people that are not qualified for
that particular position. You want
people that's going to, you know, take
extra steps.
What happened in the dental clinic
shouldn't have ever happened. If people
were taking their jobs seriously, not
passing the buck and pointing the
finger, none of this would have
happened. And I apologize to the 1,800
veterans and I apologize to all of the
veterans throughout the United States.
Not just John Cochran.
I didn't know what to do. I had to
play strategic games around there. They
start transferring me from one
department to the next because I hurt my
arm and had to have surgery. In fact, I
tore my tendon. So I tell you what.
Since they were transferring me to one
department to the next department—and I
do have experience in management, I do
have experience in troubleshooting—I
just took a look at the departments that
they were transferring me to, okay?
And out of I would say four
departments, I found only two where the
management were managers. And out of
the two, the technician should have been
the manager. I've seen so much
mismanagement at John Cochran. I've
seen employees talked to like they were
kids. I've managed people and one thing
I have learned in managing is that your
employees make you. So if you are
belittling them, intimidating them, what
kind of service do you think you are
going to get?
If employees are intimidated, they
are not going to speak to you. They
need their job just like I needed mine.
I needed my job. I had medical issues
going. I wouldn't have ever done
anything to jeopardize my job. I had
medical issues going. Not just for my
arm. I had medication that I have to
take. If I don't take it every day, I
will die.
And then to top it all off, when
Unemployment did their investigation,
they found out this girl, what did you
fire this girl for? You fired her for
other reasons than misconduct. They had
30 days to appeal. They didn't appeal
it.
This isn't about me. It's about the
veterans. Has anyone talked to the
veterans about HIV and HIV on
instruments? No. Well, first of all,
if the procedures in the department was
taking that extra step like I warned
them when I was there—I told them that
you are supposed to get up and check all
of the auxiliary units. Auxiliary units
are the units like your dental, your
eye. Any instrument that needs to be
processed needs to come to this
department. I told them that.
But see, at John Cochran, to me, in
my opinion it's like, oh, that's their
department. They do it. No. No. No.
No. No. That's where a lot of people
have a misconception. When you run a
Sterile Processing department, that's
your responsibility to take that extra
step to walk around, to make sure no one
is doing any kind of processing
whatsoever, because you have the people
who have gone to school who are supposed
to know how to clean. They are
certified.
I mean if your heart was hurting, who
would you go to? An orthopedic doctor
or a heart specialist? A heart
specialist. It's simple. If you need
your instruments processed correctly,
would you take them over here to dental,
or would you take those instruments
somewhere that's located inside the
hospital to have them cleaned and
processed by people who have gone to
school, that are supposed to know how?
That wasn't the case at John Cochran.
[The prepared statement of
Ms. Jonson appears in the Appendix.]
The CHAIRMAN. Ms. Johnson, we thank
you.
Ms. JOHNSON. Okay.
The CHAIRMAN. We will have questions
for you, so thank you so much for your
testimony.
Mr. Searle?
STATEMENT OF BARRY
A. SEARLE
Mr. SEARLE. Thank you, Mr. Chairman
and Members of this Committee. Thank
you for giving this opportunity to the
American Legion to view this pressing
issue brought to light recently by
developments at the John Cochran VA
Medical Center.
The American Legion, from its
inception, has been both a strong
advocate for veterans and proponent for
an effective Federal entity whose
mission is to care for those veterans.
Central to the American Legion's
efforts is a program called "A System
Worth Saving." This Task Force, first
established in 2003, annually conducts
site visits at VA Medical Centers
nationwide to assist the quality and the
timeliness of VA health care. This Task
Force we believe has identified some
issues contributing to the issue at
hand.
In March of this year, during a
routine inspection of the John Cochran
Medical Center by VA's Infectious
Disease Program Office, it was
determined that dental instruments were
not being cleaned in accordance with
specifications of the manufacturers or
in accordance with VA's own procedures
for proper sanitation and
sterilization. These instruments were
being cleaned without proper detergent,
potentially putting veterans at risk for
blood-borne illnesses such as HIV and
hepatitis.
VA's Central Office convened a
special Committee to determine an
appropriate response. The Committee
could not determine that risk to
approximately 1,800 patients was zero,
an absolute zero chance of infection,
therefore, a decision was made to notify
all affected veterans. These 1,812
veterans, notified through certified
mail, were provided with free testing
for HIV and B and C strains of
hepatitis, and will be provided with
whatever follow-up care is deemed
necessary. As of this time, no veteran
is known to have contracted any of these
diseases through this exposure.
The American Legion feels that VA
took responsibility and demonstrated an
act of faith to bring this issue to the
attention of veterans and the public.
Placing patient safety before good
publicity deserves to be acknowledged.
However, as the American Legion
National Commander, Clarence Hill,
recently stated, this is an extremely
serious problem that has happened
before, and will happen again unless VA
ensures strict adherence to proper
sanitation and sterilization protocols.
To expose trusting veterans to
blood-borne illness through routine
medical treatment because of avoidable
errors in sanitation of medical
equipment is inexcusable. The problem
exists not in the business process
structure of this system, as the
existing protocols were designed to
prevent such exposures, but rather, in
the failure of those operating the
system to execute those protocols. This
can only be overcome by diligent
management, training and accountability.
This event is not the only reported
occurrence of failure to follow
procedures within the Veterans Health
Administration (VHA) system. The
Department of Veterans Affairs Office of
Inspector General Report from 21 April,
2010, concerning suspected issues in the
Supply Processing and Distribution
department related to endoscope
reprocessing and communications to St.
Louis facility substantiated alleged
cleaning issues of equipment.
In its findings, VA OIG identified
turnover in several key staff positions
as a serious issue. During the 2010
"System Worth Saving" Task Force visits
to 32 VA Medical Centers across the
country, a commonly repeated theme was
the shortage of personnel, especially
nurses and personnel with specialty
training.
It is the opinion of the American
Legion that turnover of personnel and
the shortage of personnel at most
facilities requires renewed emphasis on
standardized procedures, quality review,
and individual training, as well as
documentation of that training.
If an emphasis on training is
subverted to day-to-day operations,
dedicated people will make mistakes.
Further, the American Legion believes
that Central Office must maintain proper
oversight of medical care, utilization
of facilities, and resources in order to
ensure veterans receive the highest
quality of care.
On April 28th, 2010, in a Pittsburgh
Tribune Review article concerning a
reported incident at the Pittsburgh VAMC
in 2007, it was noted that the Food and
Drug Administration (FDA) had cited the
VA facility for not doing a routine
blood type certification test, a
violation of standard procedure. This
resulted in a patient receiving six
units of the wrong blood before he
died. It was reported that VA officials
told the FDA the error stemmed from a
heavier-than-usual workload in the blood
bank.
The American Legion understands that
the policies developed at Central Office
with the best of intentions are, for the
most part, executed at the discretion of
the Veterans Integrated Services Network
(VISN) Director or Facility Director
level, and therefore vary in local
implementation.
It was testified by the American
Legion, during a 1 July Subcommittee
hearing, we believe that there is a
breakdown in follow-up and
accountability by Central Office to
ensure procedures are being followed.
This autonomy of the facility directors
is a function of an overly decentralized
VA structure. It is no means unique to
VHA. It is, we believe, systemic to
VA's mode of operation.
For example, in VBA we have seen and,
in fact, been told by VA personnel
themselves that when you see one
regional office, you have seen one
regional office. The implication is
there is little standardization in VA.
Again, one of the concerns of the
American Legion, as stated in testimony
over the last few months, has been that
VA needs to do a better job in training
its people, more effectively ensuring
they understand and follow the correct
protocols that have been established.
There is also a need to enforce central
oversight of the regional VISNs, thereby
ensuring consistency and accountability
nationwide.
When a problem is identified, it is
not enough to simply move people to
different facilities doing the same
job. Unfortunately, at times
accountability means negative impact on
the individual who is responsible. With
correct and effective accountability,
there is hope for continued faith in the
veterans' health care system.
The American Legion is committed to
working with the Secretary to ensure
that this situation is successfully
resolved and that instances such as this
do not become an ongoing issue with our
otherwise excellent VA health care
system.
Mr. Chairman and Members of the
Committee, thank you.
[The prepared statement of
Mr. Searle appears in the Appendix.]
The CHAIRMAN. Thank you, sir.
Mr. Carnahan?
Mr. CARNAHAN. Thank you again, Mr.
Chairman.
And I guess I want to first start
with Mr. Searle. Thank you and the
Legion for the work they do with VA.
And I wanted to ask, with regard to any
of the prior annual site visits that are
done at Cochran, were there any red
flags that appeared in those recent
visits, and did they reflect any of the
other issues that were raised by the
Inspector General recently, or in the
recent Patient Satisfaction Surveys?
Mr. SEARLE. Well, actually, the
Legion has not been to Cochran in
several years. We do 32 facilities a
year, so we have them done on a
rotational basis, so we have not done a
follow-up on this particular facility.
Mr. CARNAHAN. So when was the last
time that you had done a site visit at
Cochran?
Mr. SEARLE. I believe it was 2007.
I can confirm that, sir.
Mr. CARNAHAN. Okay. Thank you very
much.
And Ms. Johnson, we really appreciate
you being here. From your background
and your experience in Sterile
Processing, I think you have some unique
insights to share. So we especially
appreciate your willingness to come
forward.
I want to first, I guess, ask you
about the earliest time when you began
raising concerns about any of the
sterilization processes while you were
at Cochran.
Ms. JOHNSON. I brought this up
before the supervisor. Walking and
checking like the dental clinics and the
eye, in March.
Ms. MADDUX. Of this year?
Ms. JOHNSON. 2009.
Mr. CARNAHAN. Of 2009. And I know
that you had, I understand that you had
previously provided copies of an e-mail
as far back as August—
Ms. JOHNSON. Yes.
Mr. CARNAHAN [continuing]. Of 2009,
where you outlined some improvements
that needed to be done. Could you talk
about that?
Ms. JOHNSON. Well, when I was hired
in, I saw a lot of things wrong with the
Sterile Processing department. I saw
how it was ran.
After I had suggested to my boss that
she should be walking around, you know,
checking—in the old days we used to call
it CYA. Excuse me, but that's what we
called it, you know. And—
Mr. CARNAHAN. And excuse me. Who
was your boss at the time?
Ms. JOHNSON. I can't answer that.
Mr. CARNAHAN. Okay. What department
were you in.
Ms. JOHNSON. I was in a department
called Processing and Distribution at
John Cochran Hospital. And that's what
made me start the improvement process.
I sent an e-mail to her boss as far as
improvements for the department.
Mr. CARNAHAN. That was to your
supervisor's boss?
Ms. JOHNSON. Yes. They both had
copies of it.
Mr. CARNAHAN. And this was in March
of 2009.
Ms. JOHNSON. I don't have the dates
with me, but I do have the e-mail as far
as the improvements were concerned. And
you know, nothing happened. Nothing.
It was just like I was just there and
they are going to do what they wanted to
do. That's, they didn't—whatever
improvements, they didn't want to.
Mr. CARNAHAN. And you were raising
these issues because of your prior
experience in Sterile Processing?
Ms. JOHNSON. Yes, sir. Yes, sir. I
have 27 years experience in Sterile
Processing. I started off as a
technician. I grew into a supervisory
position, and then I went on into
management in Chicago and in Oregon.
Mr. CARNAHAN. And so the earliest
time you can recall raising this is
March of 2009. Do you recall about how
many times you raised these issues?
Ms. JOHNSON. There was another time
I brought the issue up because there was
a problem in another clinic, which it
didn't get to the public.
I brought it up again and I, you
know, I told this person that, you need
to be walking around and, you know,
talking to the supervisors or directors
in these departments, making sure that
no instruments are being sterilized in
their department. All the instruments
are supposed to come to our department.
Mr. CARNAHAN. And that's the central
sterilization facility?
Ms. JOHNSON. Yes, which they call
P&D.
Mr. CARNAHAN. And that's the—you
worked in the central facility?
Ms. JOHNSON. I worked in Processing
and Distribution, where they do the
sterilization of instrumentation.
Mr. CARNAHAN. How many employees
worked there when you worked in that
department?
Ms. JOHNSON. Oh, I would say
approximately 13, 13 or 14. It might
have been more.
Mr. CARNAHAN. And when you were
terminated, what reason did they give
you?
Ms. JOHNSON. Unprofessional conduct.
Mr. CARNAHAN. What do you think that
meant?
Ms. JOHNSON. I didn't know. I asked
them, because I've always carried myself
in a professional manner, always, no
matter what they did, no matter what
they said, no matter how they tried.
I'm an Army brat and it's hard to really
break me. So I always carried myself in
a professional manner. My daddy taught
me that.
Mr. CARNAHAN. Do you still have a
pending complaint or case, or has that
been resolved?
Ms. JOHNSON. Nothing has been
resolved. It's still pending.
Mr. CARNAHAN. Were there other
people within your department that
discussed these concerns, also, besides
the supervisors?
Ms. JOHNSON. I was the only one.
Mr. CARNAHAN. We appreciate your
service and especially being here to
share your story. And again, we hope
this is an important part of getting to
the bottom of this, getting answers, so
that we can care for those veterans
impacted and be sure this doesn't happen
again.
Thank you all.
The CHAIRMAN. Thank you.
The CHAIRMAN. Mr. Blunt?
Mr. BLUNT. Thank you, Mr. Chairman.
Ms. Johnson, when did you come to
work at Cochran?
Ms. JOHNSON. I left Chicago,
Illinois, in December of 2008.
Mr. BLUNT. And when did you go to
work here?
Ms. JOHNSON. December the 22nd or
the 23rd of 2008.
Mr. BLUNT. Of 2008? Of 2008? Now,
did you ever work in the dental
sterilization area at all?
Ms. JOHNSON. No, sir.
Mr. BLUNT. And your view is, as I
understand it, that all the
sterilization should have been done in
the Sterile Processing department?
Ms. JOHNSON. Yes, sir.
Mr. BLUNT. And do you know how the
dental sterilization was done before
February 1, 2009?
Ms. JOHNSON. Processing and
Distribution was going to dental to pick
up the dirty instruments. That's why I
can't understand how this happened.
They were going making rounds, picking
up dirty dental instruments.
Mr. BLUNT. Even between February of
2009 and March of 2010, they were
picking up some of the instruments or
were not?
Ms. JOHNSON. From the time I was
hired in December of 2008 until the time
of my termination of November the 10th
of 2009, the Sterile Processing
department was picking up dental
instruments that needed cleaning and
processing.
Mr. BLUNT. And your impression would
be, from what we now know, they weren't
picking up all the instruments?
Ms. JOHNSON. Yes, sir.
Can I explain one thing?
Mr. BLUNT. Yes.
Ms. JOHNSON. This is why I'm saying
that when you hire people in, you need
to really know they know their job.
This dental clinic is located inside a
hospital. It's not located outside
somewhere in another building, where the
dental hygienists have to know
sterilization because they use smaller
equipment, tabletop sterilizers and
ultrasonic. This clinic is located
inside the hospital. Anything that's
located inside the hospital, you have a
central area for cleaning, and that
would be Sterile Processing.
So all these instruments that come to
Sterile Processing, they are processed.
They are clean. You have people who do
just that. They are supposed to know
their jobs.
Mr. BLUNT. Right. And you are
telling us that your impression is, or
your full understanding is that some
things, between the period we are
talking about here, went to the Sterile
Processing area?
Ms. JOHNSON. Yes.
Mr. BLUNT. And we don't think the
problem occurred, Mr. Chairman, in
Sterile Processing. We think it
occurred at the department level. And I
see some agreement behind you that that
is the case.
I'll be interested—and I don't know
that you would know this—but I would be
interested to know what happened
February 1, 2009, that was different
than January, 2009.
And I'm surmising that maybe
everything was going to Sterile
Processing in January, and for some
reason everything didn't go in February.
But at some point I want to know what
was different in January and what was
different after February 1. And I
assume maybe someone on the next panel
will be able to tell us that.
And I think those are the only
questions I have here, Mr. Chairman.
The CHAIRMAN. Thank you.
Mr. Costello?
Mr. COSTELLO. Thank you, Mr.
Chairman.
Mr. Searle, you've stated in your
written testimony that, "The problem
exists not in the business process
structure of the system, and the system
protocols were designed to prevent such
exposures, but rather, in the failure of
those operating the system to execute
those protocols. This can only be
overcome by diligent and attentive
management and training."
You heard earlier about the
incidents, the veterans, over 10,000
veterans that were exposed in the three
States, Tennessee, Florida and Georgia.
You heard me and Congressman Shimkus
talk about what's happened at the VA
facility, the hospital in Marion. Those
deaths resulted in Marion because of
substandard care. Failure to follow
standard procedure.
In your position, have you ever
heard, either at the Marion facility or
any VA facility where anyone was held
accountable and actually terminated from
employment? Either an administrator or
employee?
I can tell you in the case of Marion,
as Mr. Shimkus can, the administrator
who was in charge of the facility was
transferred to be an administrator at
another facility and, in fact, we got an
Acting Administrator. This happened in
2007 and they just appointed a permanent
administrator over at the Marion
facility who started this week.
So my question is, do we just shuffle
chairs around, or do we hold people
accountable?
Mr. SEARLE. The information that the
Task Force has brought back is that
there is a shuffling of people going
on. I've not been told anyone has ever
actually gotten fired. I haven't
substantiated that. But that people
have just been moved.
Mr. COSTELLO. So basically the
people that work for the VA, the message
is that if you don't follow procedures,
you will still have a job. They may
transfer you to another facility, but no
one really is held accountable.
Mr. SEARLE. That's the trends that
we are picking up, yes, sir.
The CHAIRMAN. Good step, Mr.
Costello, for a whistleblower.
Mr. COSTELLO. And I was going to get
to that.
Ms. Johnson, I can tell you, in your
testimony where you state that they
wanted you to keep your mouth shut, they
did not want employees to give
suggestions or to criticize procedures,
that is exactly what we found from the
employees at the VA facility in Marion.
I have had, and Congressman Shimkus
had many meetings with the employees,
both at the facility and off the
facility after-hours, to hear their
complaints and to investigate some of
the issues that they raised, and we
heard the exact same thing from those
employees, that the administration did
not want to hear suggestions or
criticism and, in fact, there was
retaliation and intimidation.
So what you have testified to this
Committee today, we have seen not only
at this facility that you are testifying
about, but we saw it in Marion.
Finally, let me ask, Mr. Searle,
examining what has happened here based
upon what you know thus far, what should
the VA have done as soon as they found
out that 1,812 veterans were at risk?
Mr. SEARLE. Well, we would agree
that they could have moved faster and
put the word out sooner. I think that
it goes back to what I read in my
original testimony is that rather than
waiting until something happens, there
has got to be more oversight on a
quarterly basis, monthly basis, whatever
is set up, rather than—we feel that
there is not enough oversight from
Central Office. There are many
different issues. There are a lot of
policies that are put out, documentation
put together. But when it gets down to
the autonomy at the facility division
director, regional office level, there
is just too much leeway, in our opinion,
that they can manage it as they see
fit. And that's where the issue has
been, or it wouldn't have come up in the
first place.
Mr. COSTELLO. Thank you, Mr.
Chairman.
The CHAIRMAN. Thank you.
Mr. Shimkus?
Mr. SHIMKUS. Thank you, Mr.
Chairman.
As my friend Congressman Costello
mentioned Marion, this is a, it's
important to understand this stems two
administrations. The Marion problem was
in a previous administration and this is
in the present administration. That's
why a lot of us now are boring down on
what is it about the Veterans
Administration and the culture that's
not focused on taking care of our
veterans?
And that's why, Mr. Searle, I'm going
to be interested in following—I'm a
Legionnaire myself and my post is right
across the river, Post 365 in
Collinsville—not just "A System Worth
Saving" but a system worth reforming.
Mr. SEARLE. [Nodded the head.]
Mr. SHIMKUS. And I think we need
other eyes on the system. Obviously the
current eyes are not identifying things,
or it's being squashed.
Now, I know at Cochran when I visited
a year or 2 ago, we had a Veteran's
Advisory Committee made up of
Legionnaires. Made up of VFW's. The
only ones who complained to me at that
time was the Paralyzed Veterans, based
upon a spinal cord facility that we had
been fighting and struggling and trying
to get access to at Cochran.
I think there must be an issue there,
too. If we've got Veterans Advisory
Committees and we've got these problems
in veterans Hospitals, then our Veterans
Advisory Committees ought to be speaking
up. They ought to be calling us. They
ought to be calling the administration.
They ought to be using the 1-800 lines.
And I would suggest that veterans here
who know members on that Committee, that
we all do a more diligent job.
And Ms. Johnson—and my colleague Mr.
Costello highlighted this—you believe
you were fired for doing your job, you
were punished, where we have a system
that when people don't do their job,
they are not punished?
Ms. JOHNSON. Exactly. And that's
the way it goes. You see it.
Mr. SHIMKUS. And that's the way it
has to change.
Ms. JOHNSON. [Nodded the head.]
Mr. SHIMKUS. That's the way it has
to change.
And my question was—and you answered
it—this system seems like it's upside
down?
Ms. JOHNSON. Yes.
Mr. SHIMKUS. You should be awarding
people. When you work on a line, you
are building a vehicle and there is a
flaw in the vehicle, you pull the cord
and you stop the process, because you
don't want to sell faulty product. If
you let it go on, then there is the
whole, the whole system pays. So I
apologize.
Let me read something that came out
of the St. Louis Post Dispatch on July
7th. And this is for Ms. Johnson. "The
cleaning of endoscopes was moved from
the Supply Processing department to the
gastrointestinal unit after problems
surfaced with equipment not being
properly cleaned."
Is that—would you view that as proper
procedure, based upon your experience?
Ms. JOHNSON. Did the article—I mean
they moved the scopes from Processing to
what area?
Mr. SHIMKUS. Gastrointestinal.
Ms. JOHNSON. When did they do that?
Because Sterile Processing was doing the
processing of scopes when I was there.
Mr. SHIMKUS. I just have a snippet
from, I know it's a Post Dispatch
article. He's probably here, who wrote
it.
Ms. JOHNSON. Well, in my opinion,
when I was there Sterile Processing was
doing the scopes, processing the scopes,
cleaning scopes, and they have a machine
that do all of this.
And GI, you know, they wanted those
scopes and I thought it was proper that
GI and their staff clean the scopes if
they had well-educated employees in GI
to clean the scopes.
Mr. SHIMKUS. Okay. And the only
reason why—the story goes on. It says,
"A month later, after receiving a
complaint about endoscope sterilization,
the Veterans Affairs inspectors visited
the hospital and found several health
and safety infractions. The temperature
in the sterilization area was too high,
rags and gloves were strewn about,
decontamination area filters had not
been changed, as required, a technician
was not wearing protective gear,
chemical test strips were left exposed,
emergency exits were blocked, and
employees were unsure whether an
unattended endoscope was sterile,
according to the Inspector Report issued
in April by the VA's Office of the
Inspector General."
Those would all be errors.
Ms. JOHNSON. They kept me away from
that area.
Mr. SHIMKUS. Mr. Chairman, that's
all I have. Thank you.
The CHAIRMAN. Thank you.
Mr. Akin?
Mr. AKIN. Thank you, Mr. Chairman.
Just a couple of quick questions.
First of all, Ms. Johnson, it sounds
like you were in a way a whistleblower,
but you really tried to reform things,
get things changed from the inside. Of
course, that's tricky to do if you don't
have enough management support behind
you, and sometimes they can isolate you.
One thing, though. Did you write
some letters making recommendations,
specific recommendations, and saying, if
we don't do this, we are going to have
this problem? Did you leave any kind of
a trail in that regard?
Ms. JOHNSON. Yes, sir, I did.
Mr. AKIN. And could you make those
letters available to the Committee?
Ms. JOHNSON. Yes, I can.
Mr. AKIN. Thank you. Thank you for
your testimony.
The next question, is there any kind
of—this is for the second witness, Mr.
Searle. Is there any kind of a Customer
Satisfaction Survey type of thing that
people can fill out to say, how has your
experience at the hospital been? Do
they have any kind of procedures like
that so there is a feedback loop that
says, hey, we are missing something?
Mr. SEARLE. That's part of our
"System Worth Saving." That's part of
the investigations that we do. We go in
and we look at the facilities, we talk
to staff, and we do question patients to
see what type of—
Mr. AKIN. And what sort of data do
you get from that? Is there a pattern
of people not being very happy with the
services there, or is it no different
than other places, or—
Mr. SEARLE. Quite honestly, we find
veterans are very pleased with the
health care system overall.
Mr. AKIN. Overall.
Mr. SEARLE. But we hear a
significant, that they call it the best
care anywhere. I'm sure you've heard
that. There are very positive results.
I am a veteran and obviously I'm a
product of the Old Square VA in
Pennsylvania, and I have nothing but
positive things to say about it.
Mr. AKIN. Okay. So now we
generalized the question, but are there
certain specific facilities where you
find that the ratings are low?
Mr. SEARLE. I'm sure there are some
that are lower than others. I don't
have this year's "System Worth Saving"
compiled yet. The team is still putting
it together. It will be made available
to you as soon as—
Mr. AKIN. Because from your
testimony what I thought I heard,
because I was interested in kind of the
overall system and what's going on.
I got the impression from you that
the system is pretty independent. That
one Veterans Center may work pretty much
differently than another. There is a
lot of autonomy.
Mr. SEARLE. That's correct.
Mr. AKIN. Therefore, if that's the
case, I would think there might be some
that would be shining examples of good
care, and some other ones—at least you'd
think there would be good ones and bad
ones in the system, and a lot of ones
partly in between.
Mr. SEARLE. Oh, yes, there are.
Mr. AKIN. If that's the case and you
do have those sort of satisfaction
surveys, is that the pattern that you
see in general, do you think?
Mr. SEARLE. I would think so, yes,
sir.
Mr. AKIN. You would think so. But
have you noticed that pattern
specifically?
Mr. SEARLE. Again, I haven't seen
this year's report. I don't know.
Mr. AKIN. I'm not talking about this
year's. I'm just talking about in
general.
Mr. SEARLE. In general? Yes, sir,
we have seen some patterns.
Mr. AKIN. You do see that. And have
you seen anything in terms of the data
from the people that you have going
through, has there been a problem with
this particular facility?
Mr. SEARLE. No, sir. As I mentioned
before, the last time that we went
through this facility was in 2007.
Mr. AKIN. And at that time was there
difficulty there, or not particularly?
Mr. SEARLE. No, sir.
Mr. AKIN. It didn't stand out as
being worse than some other facilities
or something like that?
Mr. SEARLE. No, sir.
Mr. AKIN. Okay. Thank you very
much.
That's all the questions I have, Mr.
Chairman.
The CHAIRMAN. Thank you.
Mr. Luetkemeyer?
Mr. LUETKEMEYER. Thank you, Mr.
Chairman.
For Mr. Searle, you are an advocate
group for veterans with regards to VA
treatment and benefits, the care that
they get.
How is your relationship normally
with the VA? Do they accept your
suggestions? Do you have a pretty good
working relationship with them? Is it
adversarial, or what would you say?
Mr. SEARLE. I wouldn't say it's
adversarial. I think we have a good
working relationship. I'm sure that at
some times we get under their skin, but
that's part of the job of being an
advocate.
Mr. LUETKEMEYER. You know, during
your testimony you were talking they
need some increased accountability.
What were some areas? Can you define
that or explain where you thought it
would be? And specifically to this
situation.
Mr. SEARLE. Well, again, sir, what
we are looking at is that the procedures
have been set up for the sterilization
and various specifically to that are
going on, and we just are not seeing a
feedback mechanism going to Central
Office, where the facility directors can
say, yes, we are following these
procedures. This is the training that's
being conducted. These are the
specifically to that are being done. We
are not seeing anything that shows
Central Office.
Again, going back to my military, I
was a colonel. Retired colonel. The
troops do best when the boss checks.
And we are just not sure there is a
significant feedback mechanism to make
sure the troops are doing what they are
supposed to be doing.
Mr. LUETKEMEYER. During your
testimony I think you made the statement
that you hadn't been in this facility
for a while, is that correct?
Mr. SEARLE. Yes, sir, that's
correct.
Mr. LUETKEMEYER. How can you make
accountability suggestions if you
haven't been there?
Mr. SEARLE. Again, I came from
National Headquarters. We are using the
VA system, VHA, in general, not
specifically to this facility. It's
what we have found across the board at
VA, sir.
Mr. LUETKEMEYER. Okay. The
suggestions that you have made, have you
given those to the Cochran folks at this
point?
Mr. SEARLE. No, sir.
Mr. LUETKEMEYER. You have not. Have
you had any discussions with them at
this point about you are going to give
them some suggestions? Or—
Mr. SEARLE. No, sir, we have not.
Mr. LUETKEMEYER. Okay. At what
point were you notified, or the American
Legion? Or were you notified at all
about this situation?
Mr. SEARLE. We, similar to the
Committee, we saw it in the newspapers
in this case.
Mr. LUETKEMEYER. Okay. Is it normal
procedure that you not be notified?
Mr. SEARLE. By VA?
Mr. LUETKEMEYER. Yeah.
Mr. SEARLE. VA would not, has not in
the past brought anything in particular
to our attention with regard to these
kind of issues.
Mr. LUETKEMEYER. Okay. So sometimes
they do, sometimes they don't.
Generally they don't do it at all?
Mr. SEARLE. I can say that generally
they don't let us know these things.
Mr. LUETKEMEYER. Okay. All right.
What is your organization doing to
assist, or are they doing anything right
now to assist the veterans who have gone
through this dental program here and
have some problems? Are you working
with them at all? Do you have any
programs in place for them as an
individual group?
Mr. SEARLE. No, sir.
Mr. LUETKEMEYER. Okay. Do you
anticipate doing it?
Mr. SEARLE. We certainly would look
at it any time that we get comments or
questions or requests for assistance
from veterans. We do so on a daily
basis. But in this particular case we
haven't really thought about it.
Mr. LUETKEMEYER. Okay. All right.
Very good.
Thank you, Mr. Chairman. That's all
I have.
The CHAIRMAN. Thank you.
Mr. Miller?
Mr. MILLER. Ms. Johnson, you said
there are about 13 people that you
worked with in Sterile Processing?
Ms. JOHNSON. It could be a couple
more. About 14 or 15.
Mr. MILLER. A dozen or so,
thereabouts.
Ms. JOHNSON. Yes.
Mr. MILLER. And I'm just trying to
go back to your testimony. You were the
only person in that group that had any
type of problems or vocalized your
issues? Nobody else would do that?
Ms. JOHNSON. Well, they did behind
the boss's back. But as far as, you
know, changes and what was supposed to
be done and suggestions, I was the one
that came in and saw that the department
weren't being up to par, as far as I'm
concerned.
Mr. MILLER. Even if they didn't say
anything negative, would you say they
agreed with what your recommendations
were?
Ms. JOHNSON. Uh-huh. Yes, sir.
Mr. MILLER. Why do you think they
wouldn't say anything?
Ms. JOHNSON. Because they would be
retaliated on. I mean everyone needs
their job now. They wasn't going to say
anything. The only difference is my
family goes to John Cochran. My daddy
goes there. Vets go there. I did
everything out of concern for the
veterans. I come from a military
background. I opened my mouth.
It was for the best. You see what
happened. Eighteen hundred vets now
have to go and get blood tested. All
they had to do was listen.
Mr. MILLER. Did you say that—and
again, I have no medical background—but
that dental should have had all of their
equipment processed by Sterile
Processing, is that correct?
Ms. JOHNSON. May I give you
something? And that is correct.
I wanted to give you something and
Mr. Carnahan, so you have a better
understanding abut what I'm saying when
you receive this and read it.
And the other half comes from the
Department of Veterans Affairs. It
comes out of their book. So you will
have a better understanding as to what
I'm saying.
Is that okay? It will just take a
minute. It's right behind me.
Mr. MILLER. Please.
The CHAIRMAN. Go ahead.
This always gets us in trouble when
I'm advised not to do it, but the
gentleman in the back, did you want to
add something to this?
Mr. HUSKEY. Yes. There is a survey
and—
The CHAIRMAN. Would you identify
yourself?
Mr. HUSKEY. Yes. Bob Huskey. I'm
with the Gateway Chapter of Paralyzed
Veterans. And we had asked—we had to go
to the Freedom of Information Act to get
it—for a survey administered by the
Veterans Administration of 124
hospitals. John Cochran scored the
lowest in three different categories. I
have that survey, if you would like to
see it. I would be glad to give it to
you.
The CHAIRMAN. Okay. You can give it
to our staff. We would be glad to look
at it. Thanks.
Mr. COSTELLO. Mr. Chairman?
The CHAIRMAN. Mr. Costello?
Mr. COSTELLO. I wonder, before we
dismiss this panel, if I could ask two
questions?
The CHAIRMAN. Sure.
Mr. COSTELLO. We are not done yet.
The CHAIRMAN. We are not done.
Please, Ms. Johnson.
Ms. JOHNSON. Yes, sir.
Mr. MILLER. Thank you for providing
additional material. With your
indulgence we will also make it
available for all the Committee Members.
[The supplemental information is
attached to
Ms. Johnson's prepared statement,
which appears in the Appendix.]
Ms. JOHNSON. Thank you very much,
because I didn't want to leave anyone
out. No one.
Mr. MILLER. Thank you. I think I
heard you say that dental should have
had their equipment processed with
Sterile Processing, but was okay for GI
to sterilize the scopes. Why the
difference?
Ms. JOHNSON. The difference was
because when I was there, GI had the
most experienced person or personnel to
clean their scopes.
And another reason I said that was
because once the scopes are down in
Sterile Processing, it takes away the
employees from doing instrumentation.
In other words, you will have about
three people over here doing scopes
where we need these people over here to
be assembling trays. So in the process,
everybody is rushing because we are
short on this side because they are over
here doing the scopes.
Now, we in Sterile Processing, I'm
not saying that the people, the staff
wasn't qualified to process the scopes.
What I'm saying is that those scopes
should have been sent to GI because they
have the most experienced staff. And
you know, it just takes away the work
that Sterile Processing is supposed to
be doing.
Mr. MILLER. My time has expired, but
one other question. You are aware that
you can file a complaint under the
Whistleblower Protection Act, correct?
Ms. JOHNSON. No, sir, because I
don't consider myself a whistleblower.
I consider myself someone trying to help
the veterans in seeing things that
weren't being done that should have been
done. I didn't consider myself a
whistleblower. I'm not. I just wanted
things to—
Mr. MILLER. With all due respect, I
would advise you to file.
Ms. JOHNSON. Thank you.
The CHAIRMAN. Thank you.
Mr. Costello, please?
Mr. COSTELLO. Thank you, Mr.
Chairman.
And again, Ms. Johnson, I would
concur with Mr. Miller. I would
recommend that you file, as well.
But you, when Mr. Carnahan asked you
about your case, you said it was
pending. You also said earlier that the
VA had 30 days to appeal but they did
not appeal. Can you explain, one, what
you meant by that, that they didn't
appeal? Apparently there was a finding
in your favor?
Ms. JOHNSON. Yes, sir.
Mr. COSTELLO. And when that finding
was issued, the VA had 30 days to appeal
but they did not?
Ms. JOHNSON. No, they didn't.
That was on my unemployment claim.
VA had 30 days to appeal the decision
that my termination was not for
misconduct. They did not appeal that.
Mr. COSTELLO. But you said that your
case is still pending. Can you explain
what the status is?
Ms. JOHNSON. I also filed an equal
employment opportunity complaint against
VA. So that's still pending.
Mr. COSTELLO. And how long has your
case been pending?
Ms. JOHNSON. I think I filed in, I
guess about 7, 8 months.
Mr. COSTELLO. Thank you.
Mr. Searle, a final question. I'm a
little confused as to the American
Legion. How often do you visit
facilities? You mentioned that you had
not been to John Cochran since 2007. Do
you visit facilities on a regular basis,
or just when you get complaints, or can
you explain the procedure?
Mr. SEARLE. No, sir. What we do is
we—and again, this year we did 32
facilities. There are 153 different
facilities, so we go on a rotation and
we select them out of there. That's how
they do that.
Mr. COSTELLO. And if you get a
complaint, do you—
Mr. SEARLE. Yes, sir.
Mr. COSTELLO. Very good. Thank you
very much for your testimony, both of
you.
And I thank you, Mr. Chairman.
The CHAIRMAN. Okay. I just want to
compliment our visitors here today for
their questions. Usually, we think that
only those of us on the Committee know
what's going on.
But your talk, Mr. Shimkus and Mr.
Akin, about the culture and the systems
hits the mark. I think Ms. Johnson's
testimony illustrates that.
There is a well-known sociological
theory that a bureaucracy, almost
inevitably, begins to function for
itself rather than for who it serves. I
think we see that happening in many
places. Not every place and not
equally. There are still good managers
and good people, but the sense of fear
and intimidation seems to be an
indication that something is wrong.
I had high hopes, I still do, of Mr.
Shinseki getting his arms around that.
I don't think he has yet. But there are
too many examples of the bureaucracy
functioning for its own self rather than
for the good of the veterans. This is
only one example. If they had listened
to Ms. Johnson, we might not have been
here today.
I could give you hundreds and
hundreds of similar things and decisions
being made, for example, because
somebody will have a better bottom line
on their budget, and then not want to
spend the money on behalf of a patient
so that they will get a promotion.
If things like that happen, there is
something going wrong. Again, the fear
that people have is evidence itself that
something is wrong.
No matter how much you say, we have
the best of this or the best of that, if
there is fear, something bad is
happening. I think you have given us a
good illustration of that, Ms. Johnson.
We appreciate it. Again we've got to
get our arms around this system and this
culture.
I think you have to constantly
revitalize staff from the top both in
working conditions but more, in morale
boosters. The Secretary should be seen
around the country at the different
hospitals inspiring and re-inspiring
people.
Almost everyone I have ever met in
the VA has joined because they want to
help veterans. But somehow that gets
lost in order to keep a job and to not
rattle the cages. So it's hard. I
think, Mr. Blunt would agree that the
hardest thing we have in the legislature
is getting our arm around these issues,
as a bureaucrat from here.
Mr. Luetkemeyer?
Mr. LUETKEMEYER. Yeah. Mr.
Chairman, if I may for just a moment.
Not serving on the Veterans' Affairs
Committee myself, the report that the
gentleman mentioned a while ago, do you,
as Members, get that report?
The CHAIRMAN. I think so, yes.
Mr. LUETKEMEYER. Is it something
that could be made public so that there
is some accountability to the—
The CHAIRMAN. Yes, they are public.
And the OIG and others report on their
reports.
Mr. LUETKEMEYER. Well, my point is—
The CHAIRMAN. And, on whether or not
the recommendations have been carried
out.
Mr. MILLER. They are on the Web
site.
The CHAIRMAN. As Mr. Miller points
out, they are on the Web site. They are
public reports.
Mr. LUETKEMEYER. All right. So
there could be some accountability for
those institutions and those groups that
are not providing good service and,
therefore, they can be held accountable.
The CHAIRMAN. Theoretically.
Mr. LUETKEMEYER. Okay.
The CHAIRMAN. But as we heard from
Mr. Searle and others, they always cloak
it in legal matters. We can't talk
about personnel decisions.
We've got to figure out a way that we
can talk about things that are public
policy and that accountability is there.
Unless people know they can be fired for
withholding information, change doesn't
occur.
Mr. LUETKEMEYER. Well, in the
business world you go to an Executive
Committee whenever you have an issue
that you need to talk about personnel.
And perhaps that's what needs to happen
with this Committee, is at some point
have an executive Committee so that they
can discuss one-on-one and—
The CHAIRMAN. I will be interested,
when we get back to the Hill, to hear
your impressions. You know, that would
help—
Mr. LUETKEMEYER. Thanks.
The CHAIRMAN [continuing]. This
Committee do a better job. I think you
are perfectly right.
I thank you, and we will call the
third panel. Most Committees have the
Executive Branch testify first; however,
they tend to leave the room after they
testify and never hear what the other
witnesses have to say.
We have instituted a policy, under my
Chairmanship, where the Administration
testifies last. I like to ask them
about what they've heard and what they
are going to do about it. Usually, they
don't have clearance from the Office of
Management and Budget to answer my
questions, but we try.
Dr. Petzel, I think you are on now.
Anyway, that's why they are third, so
they can take into account the views of
both the public and the stakeholders and
hear things before they leave the
premises.
The CHAIRMAN. Our witnesses on the
third panel are from the Department of
Veterans Affairs. Dr. Robert Petzel is
the Under Secretary of Health for
the Veterans Health Administration. He
is accompanied by Dr. George Arana, the
Acting Clinical Quality Assurance
Liaison for Field Operations in the VHA.
Dr. Andrea Buck is the National Director
of Medicine at the Veterans Health
Administration. And RimaAnn Nelson is
the Acting Medical Center Director at
John Cochran. Acting because? How long
have you been Acting?
Ms. NELSON. Since October 2009.
The CHAIRMAN. Then we haven't had a
permanent director there since then? Is
that—
Dr. PETZEL. We actually haven't had
a permanent Director there since January
of 2009. We are soon going to have a
permanent director.
The CHAIRMAN. Why is that, by the
way? Why have you gone so long without
a permanent Director?
Dr. PETZEL. Well, just briefly, Mr.
Chairman, before I give my opening
remarks—
The CHAIRMAN. Do they have something
to do with this?
Dr. PETZEL. We do not believe so.
The previous Chairman—the previous
Director was detailed out and we are
unable to fill a position if somebody is
detailed out of it. Once he was, once
he was permanently in his new position,
we began the search and we are very
close, Mr. Chairman, to filling it.
The CHAIRMAN. What does that mean,
you can't do something because he's
detailed? Because, you mean he still
has the job?
Dr. PETZEL. He still has that job,
yes.
The CHAIRMAN. Something is wrong.
The average person listening in the back
says, what in the hell does that mean?
If you can't fill a job because someone
left it, what are you administering back
in Washington?
Dr. PETZEL. We would be happy if you
could change that rule for us.
The CHAIRMAN. What kind of rule is
it?
Dr. PETZEL. It's a personnel rule.
The CHAIRMAN. But that comes from
you guys, not from us guys.
Dr. PETZEL. Well, it comes from the
Office of Personnel Management.
The CHAIRMAN. Well, that just
doesn't make any sense. But go ahead.
STATEMENTS OF HON. ROBERT A.
PETZEL, M.D., UNDER SECRETARY FOR
HEALTH, VETERANS HEALTH ADMINISTRATION,
U.S. DEPARTMENT OF VETERANS AFFAIRS;
ACCOMPANIED BY GEORGE W. ARANA, M.D.,
ACTING QUALITY ASSURANCE LIAISON, FIELD
OPERATIONS, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF
VETERANS AFFAIRS; ANDREA BUCK, M.D.,
J.D., NATIONAL DIRECTOR OF MEDICINE,
VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; AND
RIMAANN O. NELSON, ACTING MEDICAL CENTER
DIRECTOR, ST. LOUIS VETERANS AFFAIRS
MEDICAL CENTER, JOHN COCHRAN DIVISION,
VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS
Dr. PETZEL. Chairman Filner, Ranking
Member Miller, and distinguished Members
of the Committee, thank you for the
opportunity to appear before you today.
I am here to discuss our finding that
there was a failure to clean dental hand
pieces according to manufacturers
instructions and VA standard operating
procedures at the St. Louis Department
of Veterans Affairs were not followed.
I'm accompanied today by Dr. George
Arana, VA's Acting Quality Assurance
Liaison, Dr. Andrea Buck, VA's National
Director of Medicine, and Ms. RimaAnn
Nelson, the Acting Director at the St.
Louis VA Medical Center.
We appreciate the opportunity to
address this issue in detail and on the
record. Simply put, what happened at
St. Louis was inexcusable and
unacceptable. It's the first
responsibility of every government
agency to be open and honest to the
public and its clients. In our place,
those clients are the brave men and
women who wore the uniform and promised
to defend this Nation.
We at VA have a great privilege and a
solemn responsibility to provide quality
health care and benefits to this
population. That's why every day we
constantly monitor and inspect our more
than 1,000 hospitals and other clinical
sites. That's why we check and re-check
the safety and quality of the millions
of procedures that we perform each year.
When we discover our care does not
meet the high standards we have set, as
happened in St. Louis, we take immediate
steps to set things right. We notify
our veterans, arrange necessary care and
hold our people accountable.
Yet we understand that honesty and
good intentions are not enough. The
risk of infection to our veteran
patients in this instance is extremely
low, but nonetheless, we deeply regret
the emotional and psychological burden,
as testified to today—
The CHAIRMAN. Let me—Mr. Petzel,
it's not—
Dr. PETZEL [continuing]. That's been
placed on our veteran patients—
The CHAIRMAN [continuing]. It's not—
Dr. PETZEL [continuing]. And their
loved ones.
The CHAIRMAN. I'm being less than
decorous to stop you in the middle of
your testimony, but we've gone through
this before. You've been there.
You just made several sentences which
conflict directly with the testimony you
have heard today. Why don't you just
stop for a second and either say that it
might not have been fast enough for you
but we have to do this, or, we didn't
even do it right?
You just said, we respond as rapidly
as we can. You have heard 2 1/2 hours
of testimony where every one of us said
it wasn't fast enough. You act as if we
didn't say a word here.
Dr. PETZEL. We absolutely, I
absolutely agree with you, Mr.
Chairman. We did not respond quickly
enough.
The CHAIRMAN. But that's not what
you just said in your sentence. You
said, we acted as quickly as we could.
Dr. PETZEL. We took too long to
investigate this.
The CHAIRMAN. Well, you didn't say
that.
Dr. PETZEL. Well, it comes later in
my testimony. We took too long to
investigate this and we took too long to
notify. I absolutely agree with you on
that, Mr. Chairman. Absolutely agree.
The CHAIRMAN. Thank you.
Dr. PETZEL. The VA is grateful for
the sustained confidence in our ability
to provide world-class care and
demonstrate by our veterans, their
families, and the veteran service
organizations. We believe our system of
quality assurance and safety is second
to none. It has been proven time and
time again by a wide range of
organizations who have testified to the
general quality of care within the VA.
My written testimony provides a
chronology of the events, and documents
our responses to this situation. In the
time I have now, I would like to
acknowledge that we recognize there were
missed opportunities to uncover this
issue sooner.
Not only are we reviewing our
experience and our responses to identify
lessons learned, our policies for
identifying these lessons, these issues
earlier and notifying our veterans and
stakeholders faster; I will submit a
letter describing the improvements in
our standards for ensuring compliance by
facilities to the Committee on Veterans'
Affairs on August 15th. We have
reviewed our processes and we have
determined that these have to be
shortened; that the 108 days that we
took to bring this to public notice was
far, far too long.
The CHAIRMAN. And now you are going
to take another 30 days to notify me by
letter? That means you really learned
your lesson?
How can you say that? You just said,
you are going to notify everybody as
quick as you can. You just said, you
learned your lesson, and then you say
you are going to send a letter about
that 30 days from now.
Why not right now? What goes on in
the thinking here? You know, you've
heard, as I said, 2 1/2 hours of
testimony. Respond to it. Give us some
sense that you get it. All I hear is
the same justifications that "we've been
doing." I will let you complete your
statement, sir, but we make you sit
through the previous testimony so you
can respond to it. The frustration, the
anger, the hurt, and everything else
that you heard—you are not responding to
it. People will leave as frustrated as
when they came if you continue this way.
You are not showing that you
understand the depth of the fear, the
hurt, and the loss of trust—I mean all
these things are there. You have a
chance here to try to begin to build a
bridge and are not taking that chance.
Dr. PETZEL. Mr. Chairman, we do
recognize, as I said earlier, that this
took far too long. That we must find a
quicker way to investigate these
incidents.
The CHAIRMAN. Give me the letter
tomorrow. Why on August 15th?
Dr. PETZEL. To notify—we can
certainly send the letter to you long
before the 15th, sir.
We are committed to implementing the
high quality principles of the ISO
9001. We've talked about this before
with you. Therefore, I'm not going to
go into the details of it.
But the critical part, the critical
part, in my mind, of changing the
incidence of events in the SPD is
industrialization of the process, and
ISO 9001 is that industrial standard by
which we need to have our SPD's fully
functional.
To respond to veterans' concerns
about this issue, the VA has set up a
Call Center, beginning to operate 7 days
a week, 24 hours a day. Veterans and
their families can call this number,
1-888—
The CHAIRMAN. Did you hear what
happened when someone called?
Dr. PETZEL [continuing]. Three seven
four—
The CHAIRMAN. Respond to that.
Don't tell me you've got a 24/7
hotline. You've got new people who
don't understand a word of what they are
doing. I just called this morning and I
will tell you if I was a veteran, I
would have just started crying. The
person who answered the phone had no
sense of what I was talking about. No
sense of what I needed and you heard
this earlier, Dr. Petzel. You've heard
it and yet you still quote, "24/7, they
are always there."
It doesn't work. Besides, they've
had so much experience with the 1-800
numbers and nobody answering them that
they don't even bother to call any more.
We've tried this 800 number, and I
don't know what you do there, but nobody
seems to be there. You can wait for an
hour before it gets to be your turn.
So, they say, the hell with these 800
numbers. They don't have any confidence
in this.
You say it's working. We just heard
everybody say it's not working. It's
not an acknowledgment that we've got a
problem. That's why we have the
problem.
You said industrialization is the
answer. That's not the answer. The
answer is caring people who understand
the veterans, and who can make changes
and recommend solutions to their
supervisors without getting intimidated
and somehow the bureaucracy responds to
the real needs of people. All you keep
telling me is that bureaucracy comes
first. We've got the
industrialization. We are working as
hard as we can.
It's not working.
Dr. PETZEL. Then we will go back and
make it work, Mr. Chairman. It's
appropriate to have a 24-hour,
7-day-a-week call—
The CHAIRMAN. Not with 50 people who
were hired yesterday.
Dr. PETZEL. No. I absolutely agree
with you. They need to be answered by
compassionate, understanding people who
understand what the issues are and are
able to talk and respond directly. If
those aren't the kinds of people that
are manning that call, then we will have
those kinds of people there.
The CHAIRMAN. You just heard that
there weren't, and you didn't even
acknowledge that there were those
complaints.
Mr. MILLER. Mr. Chairman, will you
yield?
The CHAIRMAN. Mr. Miller?
Mr. MILLER. I think part of the
problem is, Doctor, that you've got
approved testimony that you have
submitted that obviously has been
reviewed by somebody, because you keep
going back to it. And I understand with
testimony that's the way that it
normally works.
I think the thing that bothers us is
the fact that the Chairman does ask the
administration officials to wait until
the end so they can hear from those that
are testifying before the Committee in
hopes that you will deviate from your
written remarks, go off-script, if you
will, and show some compassion yourself;
that you heard the people who poured out
their hearts as best they could in a
public forum.
And I read this last night. I read
it this morning. I read everybody's
testimony. But my feelings for the
testimony changed when I heard them
actually give it personally. It would
for any human being.
But I'm not hearing your testimony
change. And I would just ask if you
could fold up your testimony and speak
from the heart. Because we know that VA
cares about their people but what you
are showing is that VA cares more about
the script that's been prepared for this
hearing today.
Dr. PETZEL. Yes. I hear you,
Congressman Miller.
The CHAIRMAN. I thank the Ranking
Member for making me more eloquent.
Dr. PETZEL. So let me review, if I
may, if I could, then, before the
questions begin.
First of all, we are shocked,
appalled at this unacceptable incident.
I think I want to make that very clear
that we do not condone what happened.
We do not believe it was appropriate.
And, number one, we are, I am personally
embarrassed by the length of time that
it took the organization to respond in
two ways, one, to get the investigation
done and, two, to notify the patients.
And Mr. Chairman, as I said before, I
promise you that we will outline for you
a rapid procedure for both
identification of the issues and
problems, and notification and a new
process for notifying families.
As you heard before, we have
traditionally used this letter
phenomena. Clearly, in listening to
what was going on today, that failed to
meet the needs of these patients.
Absolutely failed to meet the needs of
these patients. It's clear that we need
to do a personal, on-the-phone,
qualified professional's initial call.
There may be letters to follow up with
at some future date, but it's clear that
this was not the appropriate way to
notify people.
And it's also clear that we don't
have the kinds of experienced people
that we need to have answering our phone
calls and leading our patients through
the process. And those things, as we
will outline in the letter to the
Chairman, need to be changed.
Absolutely need to be changed.
The CHAIRMAN. Thank you.
Dr. PETZEL. This process did not
demonstrate the kind of compassion that
I know people at St. Louis feel for
these patients, and we will change that
process.
[The prepared statement of
Dr. Petzel appears in the Appendix.]
The CHAIRMAN. Thank you.
Dr. PETZEL. Yes, sir.
The CHAIRMAN. Mr. Carnahan?
Mr. CARNAHAN. Thank you, Mr.
Chairman.
My question is for Dr. Petzel. And
first, with regard to this incident, you
heard the description from Ms. Johnson
about her being retaliated against and
the culture of really suppressing people
speaking out when they see problems,
large or small.
And I want to know, what is going to
be done from the VA to affirmatively
tell employees that they are not only
able to speak up, but encouraged to in a
safe way, without retaliation?
Dr. PETZEL. I promise you,
Congressman Carnahan, that we will, at
the John Cochran, have a program to do
exactly as you implied. To encourage
employees to come forward, tell us about
issues, tell us about problems, or to
set up a safe system whereby they can do
that. Where they can anonymously, if
you will, present their problems to the
management.
I don't, I don't condone retaliation.
Mr. SHIMKUS. Will my colleague yield
for a second on this point?
Mr. CARNAHAN. Yes.
Mr. SHIMKUS. This needs to be
system-wide. This is the same problem
we had at Marion. This has to be
system-wide. See, the employees need to
feel open to be able to air their
concerns and their problems. And the
patients need to be able to complain
without fear of retribution.
If there is fear of retribution,
either by an employee or veterans, there
is failure. So I would ask that you
take back to the Secretary these
comments and say, we've got to clean
this up.
Thanks to my colleague.
Mr. CARNAHAN. No, I appreciate that.
And that was my point, as well, that
can we learn from this incident?
Because this does not seem to be
restricted to Cochran. And in any kind
of an organization where you are
striving for quality, you have to reward
people. Not punish them. Reward them.
You know, Ms. Johnson should have been
promoted, not fired. And reward them
for speaking up about quality and how to
make those improvements.
I don't think that exists, not at
Cochran, and it doesn't seem to exist in
the VA. And their needs to be a system
in place to do that. That, to me, has
to be the critical part of continuous
improvement within an organization like
the VA.
Dr. PETZEL. I absolutely agree with
you, Congressman. We need to have a
culture where, as you say, people are
willing to speak up and become a part of
a continuous improvement process in the
hospitals. I absolutely agree with you.
The CHAIRMAN. If you will yield for
a minute, I want to get unanimous
consent from my colleagues. I like the
group here today.
I want to come back in 6 months.
Dr. Petzel, we appreciate your
promises. We appreciate your effort.
Let's see what's gone on in 6 months.
Mr. SHIMKUS. No objection. No
objection.
The CHAIRMAN. I suggest that to my
colleagues because of the frustration
here as we see this again and again and
the changes don't get made. I want to
see some changes even if it's in one
place. If it has to start here, fine.
You have all shown a real sensitivity
and a real empathy, so maybe VA can
report back to us.
Anyway, I'm sorry.
Mr. CARNAHAN. No. Thank you, Mr.
Chairman. I wholeheartedly concur.
And the other question I had, Dr.
Petzel, was the use of the
Administrative Investigation Board
versus the Inspector General of the VA,
what's the rationale for that? What's
the precedent for that?
Dr. PETZEL. For using an
Administrative Investigative Board to
look at the incident at Cochran?
Mr. CARNAHAN. Yes.
Dr. PETZEL. Well, we wanted to get
an unbiased, outside-of-the-institution,
outside-of-the-network view of why this
happened.
We know what happened and we want to
be absolutely certain about why this
happened. And when we are, then we can
decide who was responsible for this and
we can decide who needs to be
disciplined and who needs to be held
accountable. So that is our mechanism
for gathering the information to find
out who is accountable.
Mr. CARNAHAN. And you got to my last
point, and that is, how important it is
at the end of the day, when we have
discovered exactly what happened, who
was responsible, that somebody is held
accountable and we can begin to tell our
veterans that any of their confidence
that has been shaken in the system, that
it's been taken seriously, that the
shortfalls are being addressed, and in
going forward, we are going to have a
better system?
Dr. PETZEL. Absolutely agreed,
Congressman. I absolutely agree.
Mr. CARNAHAN. Thank you. I give it
back.
The CHAIRMAN. Thank you.
Mr. Blunt?
Mr. BLUNT. Well, thank you,
Chairman, and thank you for coming to
Missouri today. You know, you and I
have talked about these issues many
times but I've never got to sit on a
Committee on this topic with you. And
the intensity and the commitment you
bring to this issue is important.
And Mr. Miller, you, as well. And
you and I have talked about these
veterans issues over the years.
And I think what you can see, Doctor,
is the frustration of hearing the same
answers over and over again to the same
problem. And so I'm—how long have you
had your job?
Dr. PETZEL. I was sworn in in
February, the middle of February, 2010.
Mr. BLUNT. And what did you do
before that?
Dr. PETZEL. I was the Network
Director in Minnesota, Minneapolis,
Minnesota, for Network 23.
Mr. BLUNT. So how long have you been
with the VA?
Dr. PETZEL. Approximately 37 years.
Mr. BLUNT. So you bring your
career-long background to this. And I
would hope that if anybody could figure
out how to solve this, somebody who had
been working in this for 37 years would
be able to do it.
Dr. PETZEL. I do have many ideas
that we are just beginning to implement,
yes, sir.
Mr. BLUNT. Well, it will be
interesting to see, 6 months from now,
if you've implemented them or not.
I will say that, you know, I have
people from southwest Missouri, from my
district, that are among these 1,800 and
I believe 1,812 people. People from a
significant number of States, because of
the uniqueness of this particular
facility, are among the 1,800 people.
And on July the 1st, I sent a letter to
the Secretary and, like others here, I
have great hopes for his leadership of
the VA. I was pleased to see, just a
few weeks ago, that he had done some
things long overdue to try to cut the
paperwork, to try to cut all of the
application process to get this done.
But this is a time when we need to
get to the bottom of some of these
problems and use all of the new things
available. You know, we've got a new
Veterans Clinic in Branson that I walked
through the other day. They have a
doctor there just for traveling
veterans. And that doctor for traveling
veterans can pull up any veterans'
health records because the VA is ahead
in this.
But we need to figure out, okay, we
are ahead in that. What else can we,
how can we use the time we used to spend
looking for records—because all those
records are on Health IT now—how do we
use the time we used to spend looking
for records to get ahead somewhere else?
And I would charge you to do that.
And I would hope—you know, the six
questions that I asked on July 1, the
day after I heard about this problem,
are the six questions we've been asking
today. Now, if I can figure out these
six questions within 24 hours, it is
amazing to me that it would take, you
know, months to decide how are we going
to, are we going to notify people? And
then even more months, up until today,
to figure out that we've notified these
people in the wrong way, the VA has.
That when you get that letter, you
know, we heard Ms. Odom say that she
just fell to her knees. And I tell you,
a lot of people would fall to their
knees if they got that letter, wondering
which of these things they might have
and why they've got this letter that, as
she described it, was like getting a
notification that the parking lot was
going to be repaved on the south side
next week, instead of the reaching out.
As the Chairman said the very first
thing, why don't you find 1,800 people
that can be assigned to each of these
people until the problem is solved?
And you know, I've got several
questions here. Look at the six
questions I asked you, line one. And
we've answered some of them today, but I
would like an answer and I would like it
before next July 1.
And surely after this hearing
somebody can sit down and just write a
letter that answers these six questions
so that I know that at least somebody
there is responding to what we are
asking.
Now, what was different? I think the
Acting Director of the hospital is here,
or of this facility is here, is that
right?
Ms. NELSON. That's correct.
Mr. BLUNT. How long have you been
the Acting Director?
Ms. NELSON. Since October, 2009.
Mr. BLUNT. Of this? Now, are you
the Acting Director of the John Cochran
VA Medical Center?
Ms. NELSON. Yes, I am.
Mr. BLUNT. And you've done that
since October of 2009?
Ms. NELSON. Yes.
Mr. BLUNT. Tell me what you were
doing different in January of 2009 than
they were in February of 2009. Why is
this a problem that only goes back to
February 1, and what changed between
January 31 and February 1 that makes
this problem start on February 1?
Ms. NELSON. Well, and I started in
October 2009. But what happened—
Mr. BLUNT. Well, surely you know the
answer to that question. Surely this is
a question you asked somebody when they
said this started February 1. I don't
care when you started. Surely you asked
that question.
What was the answer?
Ms. NELSON. What happened prior to
February 1, 2009, was that we had an
inspection of the dental clinic area,
which showed that we were following
cleaning procedures per manufacturing
guidelines.
After February 1st, 2009, we are not
sure that those procedures were followed
and so we wanted to make sure that we
took care of all veterans seen in the
dental clinic, so we chose February 1st,
2009, as the date because we did not
have any evidence after February 1,
2009, that the procedures were still
being followed.
Mr. BLUNT. So are you telling me
that this routine inspection that I
asked about in the letter—according to
information provided by VA staff, this
situation was discovered during a
routine inspection conducted by the
National Infectious Diseases Program
Office.
Dr. PETZEL. Congressman Blunt, let
me explain. Prior to February of 2009,
all of the instruments were going down
to Sterile Processing and being both
washed and sterilized in Central
Processing.
Mr. BLUNT. All of the—okay.
Dr. PETZEL. All of the instruments.
Mr. BLUNT. Now, is that—do you agree
with that answer? I don't know why you
didn't say that.
Dr. PETZEL. I think she didn't quite
understand the question.
Then after February of 2009 the
dental service, because they weren't
getting back all of the instruments in
the right packets that they wanted,
said, we will do the washing. They
didn't say it but they started doing the
washing, they packaged the instrument
packets, and then they went down to be
sterilized.
And our problem with that and
everybody's problem with that is that
they weren't doing the prewash in
exactly the right fashion.
Therefore, even though the
instruments were pre-washed, in a way,
and were indeed sterilized in the
sterilizer, we cannot definitively say
that they were sterile. That's the
issue that was discovered, then, on
March 10th of 2010.
Mr. BLUNT. All right. So now let me
be sure I understand this. Did they
change the process just because, right
after an inspection, and they, why did
they—
Dr. PETZEL. They changed the
process, as I am led to believe—
Mr. BLUNT. Was there an inspection
in January of 2009 or not?
Dr. PETZEL. No.
Mr. BLUNT. Now, I thought you just
said there was an inspection in January
of 2009 and it didn't come around again
until—and that's why you picked the day,
is that not right?
Ms. NELSON. We did an internal audit
where we walked through the dental
clinic and saw that the procedure was
being followed at the time of the
audit. This was our own audit conducted
by our Quality Management Department.
Mr. BLUNT. And the procedure at that
time was everything was going somewhere
else to get sterilized?
Ms. NELSON. Yes. It was going down
to the Sterilized Processing Area.
Mr. BLUNT. And you believe that
changed, but it didn't change any
earlier than February 1, 2009. Sometime
after that they decided they weren't
getting their equipment back in the
order they wanted it in?
Ms. NELSON. That's correct.
Dr. PETZEL. That's right.
Mr. BLUNT. All right. So that's why
it starts on that date. And you are
confident it couldn't have been earlier
than that? I'm hearing maybe it might
have been a few days later than that,
but you are confident it couldn't have
been earlier than that, is February 1,
2009?
Ms. NELSON. Yes, we are confident
that February 1, 2009, is the risk
period and would capture all the
patients that were seen in dental that
would have potentially been exposed.
Mr. BLUNT. And the 1,812 of them,
can somebody give me an idea how long
these people—could it possibly be 20
years before you know whether this is
still a problem or not?
Dr. PETZEL. I would like to turn to
Dr. Arana, who is prepared to answer
that question for you, Congressman.
Dr. ARANA. Mr. Blunt, in response to
that question, the issue of the window
of exposure, that is, if you get exposed
to hepatitis B or hepatitis C or HIV on
July 1st, you don't know whether you
have those or you've essentially gotten
infected until 6 months later. So
that's a 6-month window of time that we
have to wait and make certain that we've
captured every single vulnerable vet in
terms of infection.
So the, right now we have notified
all the veterans. We have tested
approximately 950 of those. To date we
have the number, the latest number from
yesterday close of business is that 826
of those veterans were negative on all
three illnesses: HIV, hepatitis B and
hepatitis C. Up to yesterday's close of
business, 261 of them were notified.
Mr. BLUNT. And then they are outside
the 6-month window, the ones you are
notifying?
Dr. ARANA. Some of them are. Some
of them aren't.
Mr. BLUNT. All right. Well, once
you get outside the 6-month window, 6
months from the last person impacted
here, which would be March the 10th, 6
months from then, if that last person
that was seen on March 10th has a test
and it comes back negative, do they have
to worry for the next 20 years that it
may not be negative or not?
Dr. ARANA. No, sir. They only have
to worry until September, when they get
re-tested at that time. The 10-year,
20-year number that we heard somebody
mention is usually the period of time
that it takes for some of these
illnesses to manifest. But in terms of
testing and being certain that they have
been infected, that is a 6-month period
of time.
Mr. BLUNT. So, okay. Let me be
sure. This is one point I want to make
and I'm sure the people have other
questions. And they will be questions I
might have asked, but let's let them ask
them.
The one point I want to be sure I'm
clear on here is 6 months from the last
time you were in this dental clinic, if
you are not testing positive, you are
not positive. And if you are testing
positive, it could be a long, sometime
in the future before hepatitis C or
whatever manifests itself.
But if you are not positive 6 months
later, you don't have to worry about 10
years from now.
Dr. ARANA. You don't have to worry
about—at 6 months if you are testing
negative, you are finished worrying.
Mr. BLUNT. Okay. Susan and Julie,
does that help? At least in 6 months.
But then if you say, okay, you are
testing positive for it, you've got the
hepatitis C positive test—
Dr. ARANA. Right.
Mr. BLUNT [continuing]. At that point
you do have to continue to be concerned,
but only if you are told that at that
point?
Dr. ARANA. Yes.
Mr. BLUNT. Is that right, Dr. Arana?
Dr. ARANA. That's true.
Mr. BLUNT. All right. That's
helpful to me. And it's not, it's
obviously not as good as if this didn't
happen, and it's obviously not as good
as if all of the people we hope test
negatively.
But whoever has the sense that you
won't know for 20 years whether you've
got this or not, that's not true. You
won't know for 20 years, if you've got
it, whether it might manifest itself or
not.
Dr. ARANA. Correct.
Mr. BLUNT. Is what—
Dr. ARANA. That's a correct
statement. That is that if you end up
testing positive, then you can, over
time, convert to having the illness.
But at that point what you have is you
have evidence in the blood of exposure,
but you don't have the disease.
Mr. BLUNT. But 6 months from the
last day you were in that dental
situation, you should be able to know
one way or another whether this is over
for you, or you have to continue to
worry, right?
Dr. ARANA. Yes.
Mr. BLUNT. And if the last day you
were there was 6 months ago and you took
the test tomorrow, you would know
tomorrow—
Dr. ARANA. Yes.
Mr. BLUNT [continuing]. Or whenever
the test is reported back, you would
know one way or another that you have to
worry about this or you don't?
Dr. PETZEL. That's correct.
Mr. BLUNT. All right. Did somebody
else want to answer a question there?
Any time I see somebody grab a
microphone, I don't want to not let you
ask a question, if you want to.
Do you have anything else you want to
say?
Dr. PETZEL. No. You've got this
exactly right, Congressman Blunt.
Mr. BLUNT. Thank you. Thank you,
Mr. Chairman.
The CHAIRMAN. Has anybody in those
latest tests, tested positive in
anything?
Dr. ARANA. No.
The CHAIRMAN. So far it's zero.
VOICE. That's not true.
Dr. ARANA. No. No. We have, what
we have is we have some that have tested
positive, but we have to go back and
verify exactly when they were in the
clinic in terms of the risk.
So the evaluation is not complete
until we have checked back when they
were actually seen in the clinic. So
although we have found some positives,
we don't know that they are positive
until we verify—
The CHAIRMAN. Of course you wouldn't
"no" treat them.
Mr. BLUNT. Mr. Chairman, there is
somebody back there saying that's not
true. Can you ask her what she means by
that?
The CHAIRMAN. Some people are
yelling. Ma'am in the red.
Ms. HENRY. Yeah, my father was—
The CHAIRMAN. Identify yourself,
please.
Ms. HENRY. My name is a Lisa Henry.
I wasn't planning on speaking today.
I'm sorry.
My father was in the dental clinic in
May and several times after that, and he
was in full liver failure at the VA in
January, hepatitis B. They had to
transfer him to Barnes for a workup for
a liver transplant. He was seen in the
VA dental clinic four times. He had
normal liver function tests prior to
being diagnosed with hepatitis B.
So I don't know 100 percent this is
where he got it, but a 72-year-old man
who doesn't have any other risk factors—
The CHAIRMAN. By the way, they are
going to argue that he was not tested in
this program, so they don't still have
any positives.
But you had better understand what
happened to that man.
Dr. ARANA. Absolutely.
Ms. HENRY. He almost died.
The CHAIRMAN. Thank you. One or two
more. We shouldn't do this but—in the
back, please?
Mr. HART. Yes, my name is Richard
Hart. And at the VA they overdosed me
with botulism. You was talking about
tests being run. Well, they gave me
1,000 units in 45 days. It almost
killed me. They did a Doppler on my leg
and they said I was fine for blockage,
but later I go to the Social Security
doctor—
The CHAIRMAN. We need to look at
that, sir, but that's a little bit
different problem than what we are
discussing.
If you would let our staff know about
your situation, we will look into that,
please.
Mr. HART. What I'm saying, their
test comes up different than what
everybody else's test comes up.
The CHAIRMAN. Okay.
Mr. HART. I had three different
tests and it came up good for them. But
when I went to a different facility,
they found out something different.
The CHAIRMAN. Okay. Thank you.
Dr. PETZEL. We will follow up with
that, as well.
The CHAIRMAN. One more question in
the back. Go ahead, please, ma'am.
Mrs. SHANDS. I've got one quick
comment for the Committee.
Please get a board certified
hepatologist with experience in dealing
with all the different forms of
hepatitis, from A through G, who knows
about C, who knows that, one, you cannot
always find it that easily, and two,
just because you test 6 months later and
you come up negative, it doesn't
necessarily mean it's not there.
For example, in the case of my
husband, who died at John Cochran of
hepatocellular carcinoma, which is
hepatitis C related liver cancer, he
tested negative in his serum until the
day before his death.
Dr. Chenowitz called me the day
before, because VA doctors did not
believe he had cellular carcinoma, he
said, Mrs. Shands, please, may we do a
biopsy and confirm it? I gave my
permission. They found it, once the
biopsy was done, in the tissue but it
never showed up in the blood. So
please, get a board certified
hepatologist and get the facts.
Thank you.
The CHAIRMAN. Thank you.
The CHAIRMAN. Mr. Costello, please.
Mr. COSTELLO. Mr. Chairman, thank
you.
Mr. Chairman, let me applaud your
approach to Mr. Petzel's testimony. I
almost said, take the testimony, turn it
over, and tell us what you know and what
you are going to do about it. What's
the action that we are going to take
from here on out.
We realize you've only been in your
position a very short period of time,
your current position, and I'm sure that
you have every intention of trying to
make the changes that are necessary to
be made here, but I've got to tell you,
based upon my experience and the track
record of the Agency, I'm very skeptical
that the change will take place.
You know, I talked about the Marion
facility. That was in 2007. We talked
about what happened to veterans who were
exposed in Tennessee, Georgia and
Florida. And this Committee, at my
request and Mr. Shimkus' request, held a
hearing on the VA facility in Marion.
And I've got to tell you that it was
most troubling that after 2 years, we
requested that the Inspector General
take a look at the Marion facility to
see what improvements were made. After
2 years of discovering the problem and
nine veterans dying, that the Office of
the Inspector General discovered in 2009
that Marion had not improved on their
procedures. That's the Inspector
General, 2 years after it was discovered
that nine veterans died because of
substandard care.
So I would just suggest, Mr.
Chairman, as you have, that this, the
only way that action is going to be
taken and the only way the change will
come about is if this Committee provides
aggressive oversight to make certain
that the VA is doing what they tell us
they are going to do.
It's my experience, in Chairing the
Aviation Subcommittee, that the Federal
Aviation Administration has all of the
good intentions in the world, but unless
the Subcommittee keeps pressure on them,
they do not act. And that is my fear
with John Cochran.
So I'm pleased to hear you say that
in 6 months or whatever the time period,
there will be another hearing of this
Committee, and I think that's an
excellent suggestion. It puts the VA on
notice that someone is looking over
their shoulder and will continue to.
I personally, and Congressman Shimkus
and Senator Durbin, have met on a
regular basis at the VA facility since
the Inspector General's report came out
in 2009. We are starting to see some
improvements, but it's because they know
that someone is looking over their
shoulder and we will expose it if they
are not taking proper action.
Having said that, let me ask just two
quick questions for Dr. Petzel.
Dr. Petzel, my understanding is that
on June 26th of 2009, the VHA directed,
has a directive that states that VHA
policy requires each facility to have
standardization and oversight plans for
reprocessing reusable medical equipment
according to the manufacturer's
instructions.
Number one, who approves those plans
and ensures that they are followed?
Dr. PETZEL. There are several
mechanisms, Congressman Costello. One
is that each one of the networks has an
oversight board for Supply Processing
and Distribution. And that board is
responsible for doing both announced and
unannounced inspections of each one of
the facilities within that network to
ensure that they are indeed following
those processes.
Number two is that we ask the
facility directors to certify to the
effect that they are indeed following
all of those processes and procedures.
Does that catch this every time?
Does that mean that I can say
definitively that we are never going to
have another incident in another Supply
Processing and Distribution area or in
another dental clinic? It doesn't.
Unless we've got good surveillance and
good oversight, as you were about to
point out, to ensure that these things
are being done, we can't make those
kinds of assurances.
Mr. COSTELLO. If, in fact, the
second part of your procedure that you
explained—did, in fact, the Acting
Director at this facility sign a
certification that those procedures were
followed?
Dr. PETZEL. I believe so, they were
signed just before she became the
Acting.
Ms. NELSON. They were signed prior
to my arriving.
Mr. COSTELLO. And when would that
have been?
Ms. NELSON. This would have been
prior to October 2009.
Mr. COSTELLO. I would request, Mr.
Chairman, that that documentation, not
only the certification that was signed
before you became the Acting Director, I
would like to see if in fact a
certification was signed, and the dates
for the last few years. The last 2
years.
Dr. PETZEL. We will do that, sir.
The CHAIRMAN. And how often do you
have to sign one? Every year or every 2
years?
Dr. PETZEL. This was a result of
the—
The CHAIRMAN. No? When did she have
to sign one?
Dr. PETZEL. She would have been
signing as a result of—she wouldn't have
to sign one independently, Mr.
Chairman. She would, someone had to
sign the certification at the time that
we sent that out.
Now, if we have to find out, I don't
know who was the Acting here or whether
the previous Director was here, but
that's the individual that would have
certified that.
Mr. COSTELLO. Well, what does the,
what is the procedure? Does the
procedure say that a certification has
to be signed every month, every 6
months, every year? What's the—
Dr. PETZEL. That was just a one-time
event associated with the publication of
that new directive, as I remember it.
Mr. COSTELLO. So if I understand you
correctly, the Acting Director had to do
the certification one time and that's
it?
Dr. PETZEL. The certification was a
one-time that they have looked at,
inspected all of the facilities and we,
then, are indeed following all those
procedures that was in that directive.
That was just a one-time event
associated with the issuance of that
directive.
Now, there are a number of inspection
groups that go and look at our Supply
Processing and Distribution centers.
Some of them come out of the network,
some of them come out of Central Office,
Infection Control. There is also a
national group, now, of Supply
Processing and Distribution that reviews
and inspects our procedures in each one
of the medical centers. That's the
external methods for accounting.
In addition to that, the Joint
Commission every 3 years comes in and
looks at these things. The Inspector
General, in their Combined Assessment
Program visits, comes in and looks at
our Supply Processing and Distribution
and we have Systematic Ongoing
Assessment and Review Strategy, an
internal group that also looks at it.
Mr. COSTELLO. My understanding is
that the letters that were sent out to
the 1,812 veterans, that in the letter
that the Center says between February 1,
2009, and March 10, 2010.
Why did it take this long to go
undetected?
Dr. PETZEL. I don't know the answer
to that, Congressman, to be honest with
you. That's part of what we are trying
to find out with the Administrative
Investigative Board. Who should have
known that this was not proper and
appropriate? Why didn't they know and
why didn't we know?
Mr. COSTELLO. Are there procedures
in place now? I mean for a year this
went on. Are there procedures in place
now that inspections have to take place
or a review has to take place on a
regular basis?
Dr. PETZEL. What we've done first to
assure that this doesn't happen with
dental is that we now require, and we
have certification from every one of the
medical centers, we require that all
processing of dental equipment, the
prewash and the sterilization, must
occur in the Supply Processing and
Distribution central center. That's our
mechanism for being certain that we are
not doing what happened before.
In addition to that, there should be
walking rounds that occur in a medical
center to ensure periodically that
indeed that process is being followed.
Finally, the Supply Processing and
Distribution people are alert now to the
fact that they are supposed to be
receiving the unwrapped dental
instruments. If that should not happen,
if they should be coming down wrapped,
then that's a red flag to say this is
not happening correctly.
Mr. COSTELLO. Finally—the last
question because I'm out of time
here—what did the Agency learn from the
incidents that happened in Tennessee,
Georgia and Florida that should have
happened here with the notification of
the 1,812 veterans? I mean surely the
Agency learned something from those
incidents.
Dr. PETZEL. I think we did. It's
very interesting, Congressman. We
notified by letter all of the people,
and we received absolutely no feedback
or pushback about the way that
happened. So clearly, we didn't learn
from that that the method of notifying
was not sensitive to the patients' needs
and was not, didn't recognize the
seriousness of this event in the lives
and minds of the patients. So that's a
lesson we didn't learn.
We did learn how to go about
organizing ourselves for an event like
this. We did learn that we need to have
counseling available. We did learn that
we need to have professionals available.
The things that we did not learn
were, number one, the time and the
implications that it was going to have
on both Congress and the public in terms
of the time it took us to discover this,
and the reaction that the patients would
have to the letters that we sent out.
In retrospect, it's obvious.
Mr. COSTELLO. Would you agree with
the Chairman's statement earlier that
all 1,812 should have a caseworker or
someone assigned to them so that they
can have a contact, and ask the
caseworker questions throughout this
process?
Dr. PETZEL. Yes. I believe that
each one of those people should have a
contact person that they can go to, that
they know will answer their questions,
that they know is available, and help
them with whatever issues they might
have.
It's interesting, though. Most—not
most. Some of the people are going to
reject that. When we called after we
sent the letters out, there are numbers
of people who don't want to be tested,
don't want to be involved.
Mr. COSTELLO. How soon do you intend
to implement that so each one who wants
a caseworker has a name and a phone
number of an individual to call?
Dr. PETZEL. We can start that
tomorrow.
Mr. COSTELLO. We can or we are going
to?
Dr. PETZEL. We will start that
tomorrow.
Mr. COSTELLO. Thank you, Mr.
Chairman.
The CHAIRMAN. As long as every one
of the 1,812 doesn't have the same
caseworker.
You have to figure out how to ask
these questions with these guys.
Mr. Akin?
Mr. AKIN. Thank you, Mr. Chairman.
First of all, Secretary Petzel, you
are not, you haven't been assigned
specifically to your job but you've been
in this business a long time, so just
first of all, do you have, across the
Nation, do you have any sort of a
feedback loop, first from the employees,
if they want to talk to you about
something? If somebody is going to be a
whistleblower, are they a legitimate
whistleblower and do they have
legitimate concerns? And do you have
some sort of a feedback loop from your
own employees?
And second of all, do you have a
feedback loop from the veterans that are
getting service, so that you have any
way of knowing or monitoring whether
you've got problems in certain
locations? Is there anything like that?
Dr. PETZEL. Well, there is a system
within the VA of what we call incident
reporting. Every medical center has
suggestion boxes, which are places that
people can put complaints, where people
can put suggestions that they have for
making improvements.
I think we have some work to do in
terms of providing a mechanism for
employees to provide us with feedback,
to provide us with information in a
completely and totally, an atmosphere
that's free of reprisal or intimidation.
We are—and I have been in a medical
center as a chief of staff. I was a
network director. And I can tell you
that in those positions, you are a
victim of what you don't know. And
these people can provide you with
valuable information about events that
may lead you to an incident, say, such
as what happened at Cochran.
So I think we have work to do. I
have not got a specific idea of how it
should be done, but I think it's
something that needs to be addressed.
Mr. AKIN. Probably, I would think,
after the last couple of hours you would
probably have gotten sensitized to the
fact that the people here, that are just
to some degree outside observers, have a
sense of frustration.
And part of the sense of frustration
is not so much that we don't trust that
you would like to make things better, or
that you, if we put pressure on you,
will say, it will be better. The
question is, can you make it better?
And do you have a plan to make it
better, and are you going to be able to
execute that plan?
It seems like, to me, the front end
of that plan might be that, better than
suggestion box, you have an organized
system that works across your veterans'
hospitals to give you feedback to let
you know if you've got problems.
And it would seem like that one of
the things that you are desperate for is
feedback from veterans as to what kind
of quality service do they think they
have. If you really care about the
service you are providing, then you are
going to need to have that sort of
feedback loop. And also, you need to
have it better than a suggestion box.
Obviously that's not a very reliable
system. So it would seem like that
might be the front end.
I'm an engineer by training. I don't
mind being critical, but I always want
to say, hey, here are some ideas. The
first thing is you'd better get some
feedback as to where you are going to
go. If you don't have that loop in
place, you are not going to convince any
of us that you are going to change
anything. First of all, you have to be
collecting some data.
It seems—and second of all, I wanted
to ask this question in a general
sense. You put your hat on and go to
work each day. There have to be
some—what are a couple of the biggest
challenges you have in your job? All of
a sudden you've got this new job. You
are in charge of all these things and
you are going to be there for some
period of time. What are some of the
challenges that you face?
We have heard several things that
sound to me like they would be really
serious challenges. The first is we
have a lot of trouble with turnover.
The second one is we don't have enough
staffing. Are those two things that
keep you up at night? Are those things
that you are worried about? If those
things are true and I were in your
position, I would be worried about
that. Are those the sort of things you
are worried about?
And the, part of where I'm going with
this question is do you have the
capability of changing it even if you
wanted to? Do you have—the authority
that you've been granted, can you deal
with the cost of how much it costs?
Because my understanding—I don't serve
with the Chairman. He seems like a
pretty good Chairman, by the way.
But my understanding of veterans
stuff is there is tremendous demand for
your services and fairly limited
resources to try to provide those
services. So just like a lot of medical
places, it costs a lot of money and it's
hard to try to provide that level of
service for the funds and the people.
Is that something that you struggle
with?
Dr. PETZEL. Well, first of all, let
me address the turnover issue that you
mentioned. That is something that I
feel I have control over. I can
control. I can do the things, or I can
help the organization do the things that
contribute to less turnover. A more
satisfying working environment, things
such as that. So I do.
In terms of resources, I believe that
across the country this organization has
the resources that it needs. I believe,
also, that there probably are places
where those resources are being used
better than there are places, than at
some other places. And if—
Mr. AKIN. Do you have a mechanism to
know?
Dr. PETZEL. I do. I do. We do have
a way of looking at the efficiency, the
effectiveness, et cetera, of the money
that's being spent. We have very
detailed ways of looking at, again, how
the money is being spent. Changing that
may take a lot more effort, et cetera,
but knowing what's going on, yes, we
do. Yes, we do.
Mr. AKIN. I would think that—I won't
speak for everybody on the Committee,
but I would be skeptical if you are
telling me that you are going to change
some of the patterns that we've seen,
particularly what appears to be a pretty
casual attitude towards the veterans you
are supposed to be serving on the part
of many staff people. I would be
skeptical.
You would say, we are going to change
it tomorrow, Congressman Akin, but I
would be skeptical that you could do
that unless you have some plan in place,
which is going to take a look at the
overall situation and figure out what
you've got to change, and analyze it,
and how you are going to solve the
problem.
And I would think that some type of
report back to the Members of this
meeting today, and the Committee, would
make a lot of sense and would give us a
sense of, hey, they've got ten things
they are going to do. And we've got
three of them done. We are working on
the fourth. That type of thing would
give us the sense that there is some,
some forward progress.
Dr. PETZEL. I hear you.
Mr. AKIN. Thank you.
Thank you, Mr. Chairman.
The CHAIRMAN. Thank you.
Mr. Luetkemeyer?
Mr. LUETKEMEYER. Thank you, Mr.
Chairman.
I've got a constituent or two of my
district here today who is listening to
the testimony, and one of the questions
that they've got is what
recourse/restitution does the veteran
who has been diagnosed as positive or
had positive tests done, what do they
have? What kind of restitution do they
have?
Dr. PETZEL. Well, it's my
understanding, first of all, we would
provide them with whatever medical care
they need.
Secondly, they can file a tort claim
and if we are held to be responsible for
having created that condition, let's say
hepatitis C or HIV infection, they can
be compensated for that through the tort
claim process.
Mr. LUETKEMEYER. What about the
individual that were to find out who
this person is, or this group who are
responsible for doing this? Are they
being held liable at all? Personally
liable?
Dr. PETZEL. Financially liable?
Mr. LUETKEMEYER. Well, either you
are financially liable or you go to
jail. One or both of them.
Dr. PETZEL. Well, the Federal Tort
Claim Act would protect them from
financial liability if they were acting
within the scope of their job, but they
certainly can be disciplined, punished.
Mr. LUETKEMEYER. Yeah, but if it's
negligence on their part, just simply
criminal negligence, are they protected
by Federal law then? I would think not.
Dr. PETZEL. If it's criminal
negligence, they would not be
protected. But if they were acting
within the scope of their job, then they
would be protected.
Mr. LUETKEMEYER. Okay. Are you
looking at other procedures? I mean we
will talk today about this, about the
dental situation, but obviously if this
is going on, there may or may not be
other things.
Are you looking at all at other
procedures that are going on in this
particular facility that may be
improper—
Dr. PETZEL. We are not only looking
at all the procedures in this particular
facility, we are looking across the
country.
As I said, we brought all the dental
processing into our Central Processing
Unit. And we are bringing everything
into, eventually, the Central Processing
Unit so that we don't have any
reprocessing or processing of reusable
medical equipment occurring anyplace but
in our Central SPD units. So yes, we
are.
Mr. LUETKEMEYER. What are you doing
for the folks, or do you have a program
in place if somebody tests positive?
What about their spouse, or their
partner, or other people who they come
in contact with? What are your plans to
take care of those people?
Dr. PETZEL. Certainly we would
provide them with counseling. We would
provide them with testing. And quite
frankly, Congressman, I cannot answer
your question about what our legal
responsibility is, but I will get back
to you.
[The VA subsequently provided the
following information:]
During the oversight
hearing on July 13, Dr. Petzel was asked
if VA had in place a program for the
spouse or partner of an affected
veteran. Unless the spouse is eligible
for CHAMPVA care (38 U.S.C. 1781), VA
has no legal authority to extend such an
offer to the spouse of a veteran. If the
intimate partner of a patient who has
been newly diagnosed with a viral
infection is also found to have positive
test results, the intimate partner could
file a tort claim with the Regional
Counsel seeking damages, including the
cost of past and future medical care.
The decision on whether such a claim
would be payable would depend on whether
the supporting evidence showed that the
patient’s infection was more likely than
not associated with the dental equipment
and not other possible causes.
Mr. LUETKEMEYER. Okay. Well, I just
want to close with just a remark. I
mean as we have said here today, and I
think you've heard the Chairman and all
of the individuals, the Congressmen here
that testified.
You know, I think that as I listened
to your testimony—and this doesn't
apply, it applies not only to you, Dr. Petzel,
but to other members of the panel. I
don't hear the concern for the
veterans. I don't hear the angst over
what happened. I don't hear the empathy
for the people who have been harmed by
this.
In my world, as a former businessman
and now as a Congressman, I always try
and put myself in the place of the
person across the table from me and try
and say, how do they feel? How can I
help them? What are their real
concerns? I don't see that from this
group today and that concerns me,
because that's exactly what you should
be doing.
Yours is not a job. Yours is a
responsibility of care. And we don't
see that, the understanding that there
is a responsibility on your part to take
care.
And if you look at what happened, it
took a year to find it, 13 months to
find it. It took 90 days to notify the
people, or more. One hundred eight days
to notify the people. That is, that
shows there is nothing there of concern,
or that the process and programs in
place are not working, the bureaucracy
is not working, and that can't happen
because you are in a people business.
You have to understand that.
With that, Mr. Chairman, I give it
back.
The CHAIRMAN. Thank you, Mr.
Luetkemeyer.
Let me make a suggestion along those
lines. I think you hit the nail on the
head. You said you would try to get
some case managers by tomorrow?
Dr. PETZEL. Yes.
The CHAIRMAN. May I suggest, in a
very humble way, that the Acting
Director take a dozen, you take a dozen,
the Secretary of Veterans Affairs take a
dozen.
Let's show that we care by talking to
these people directly. Don't leave it
to the person that was hired yesterday.
Find out what's going on with these
people. Just call six of them up. See
how they are doing. What don't you
understand? If you were affected you
would want someone to show compassion.
You are administrators and you have
someone else making these calls when you
ought to be doing it.
Dr. PETZEL. Good idea.
The CHAIRMAN. I just make a modest
proposal. If the Secretary says, "let
the Chairman do it," I will be happy
to. Just give me some names and phone
numbers.
I think we ended when Mr. Carnahan
asked you some quick questions.
You may not be able to answer this,
but do you know when the Secretary was
notified about this incident?
Dr. PETZEL. I don't.
The CHAIRMAN. That bothers me. I
didn't understand this Administrative
Investigative Board. Who are they and
why isn't the OIG brought in?
Dr. PETZEL. Why wasn't the OIG
brought in? Because we wanted to do an
administrative evaluation that we can
use for disciplinary actions if need be,
and the OIG's business is not available
for that purpose.
The CHAIRMAN. That's the first time
I've ever heard it.
Dr. PETZEL. These are people from
across the country, a team of about four
people.
The CHAIRMAN. Is it private and you
hire them?
Dr. PETZEL. No. These are VA
employees.
The CHAIRMAN. VA employees?
Dr. PETZEL. VA employees who are
going in and looking at what happened
there.
The CHAIRMAN. And why would they be
independent?
Dr. PETZEL. Well, because—
The CHAIRMAN. We just heard is Ms.
Johnson still here?
Ms. JOHNSON. Yeah, I'm here. I'm
here. I'm listening to everything you
are saying, Mr. Chairman.
The CHAIRMAN. I want you to—
Ms. JOHNSON. It's my business.
The CHAIRMAN. I want you in court,
to use what Dr. Petzel said about what
should happen at all the Central
Offices. He said exactly what you said,
exactly. Except you had premature
sensibility to this, so you were fired.
But he said it exactly the way—that
all the cleaning and the sterilization
should take part in—
Ms. JOHNSON. In your department.
The CHAIRMAN [continuing]. In your,
in that department.
Ms. JOHNSON. May I say something?
The CHAIRMAN. I just don't
understand. How is it independent with
employees? Don't they care? Aren't
they worried about their next job and
everything else?
Dr. PETZEL. Well, don't you think
that they are able to rise above that?
They are concerned about what happened?
The CHAIRMAN. They are able to rise
above it if you guys are able to rise
above it. I mean we've had people fired
for saying stuff, so how can they rise
above it?
Dr. PETZEL. I do believe that they
are capable, they are capable of looking
independently and without bias at what
the circumstances were in this incident.
The CHAIRMAN. Well, I would hire
some people from the Congress rather
than from the VA, then. I would trust
any one of our offices to do that
better. We are sitting here for 2 1/2
hours talking about intimidation and
fear, and now you are telling me you are
going to have the independent
investigation from the very employees
who fear for their jobs? That doesn't
make any sense to me.
Dr. PETZEL. I don't think these
employees fear for their jobs, that are
going to be doing this investigation.
The CHAIRMAN. Oh, so it's just the
ones that are already up there. So why
should I trust them, then?
Dr. PETZEL. Well, Mr. Chairman, are
you implying that we can't do an
unbiased investigation?
The CHAIRMAN. I'm not implying. I'm
saying it. You said you wanted an
independent investigation. Now I find
out that it's VA employees that are
going to do it.
Even if they could rise above it, the
perception is that they can't. Now you
are telling me that the Inspector
General is not independent or
something. I don't know what you are
telling me about that, but that's been
our traditional approach. I've got to
look into what the Administrative
Investigative Board is.
One last question. Why, from your
perspective—and I'm sure you have a
justification for it—why did it take 2
months for this Board to be set up to
investigate this? And why did it take 2
months, after they decided that people
should be notified, to be notified?
What is going on with the bureaucracy
that puts the process above the people?
Dr. PETZEL. I have absolutely no
justification for that, Mr. Chairman.
The CHAIRMAN. What's going on? They
couldn't find a date for a meeting so
they kept putting it off and they all
got together or somebody was on vacation
so they couldn't meet then? I mean
what's going on there?
Dr. PETZEL. I think there were
probably a number of different things,
all of which were inappropriate.
The CHAIRMAN. All right. You will
get that in your letter to me.
Mr. Carnahan, you have been on top of
this from day one. You get the
concluding questions.
Mr. CARNAHAN. Thank you. I just
have a couple of quick follow-ups.
Specifically, Dr. Petzel, how is the
VA going to advise employees that they
are not only encouraged to step up and
speak out about this specific case, but
cases and any problems going forward?
How are they going to be advised of that
to sort of break this culture of real or
perceived retaliation?
Dr. PETZEL. I can't tell you,
Congressman Carnahan, exactly what we
are going to do, but it needs to be in
the nature of a campaign. It needs to
be written notification to employees.
It needs to be setting up—just as was
pointed out by another Congressman, that
we need to set up a mechanism for them
to bring their concerns forward in a
completely un-intimidating,
no-fear-of-reprisal kind of atmosphere.
And I'm not, I'm not prepared to say
exactly how that can be done. I do know
what needs to be done but I don't know
exactly how we are going to do it.
Mr. CARNAHAN. Well, we are going to
need, we are going to need to know
exactly how that's going to be done.
Dr. PETZEL. I can appreciate that.
Mr. CARNAHAN. Because I think that's
going to be critical to going forward.
And I'm assuming the process of
evaluating those kind of concerns that
have come up at Cochran before.
Is there a process in place if—and I
direct this to Ms. Nelson. Prior to
this incident, was there a process in
place at Cochran to take complaints or
suggestions and be evaluated for
implementing them?
Ms. NELSON. Yes, there is a process
in place. Employees are notified
through New Employee Orientation exactly
what it is that they can do if they
discover problems. We also have an
annual reminder for employees to remind
them of what they can do.
We have informed them that they can
contact the Joint Commission or the
Inspector General at any time if they
feel that the quality and safety of the
patients, the veterans in the hospital
isn't up to the standard. And that's
exactly what happened in the OIG report.
Mr. CARNAHAN. And based on what
you've heard here today and other
conversations, do you think that system
is sufficient?
Ms. NELSON. It sounds like we need
to do some more work to improve it,
based on what we've heard today.
Mr. CARNAHAN. Okay. Now, and then
lastly I want to ask, we heard Ms.
Johnson here today and her reference to
conversations she had, but also a copy
of an e-mail from August 24th of 2009
and the title, "Here is an outline of
improvements for Sterile Processing."
This is from August of 2009.
Was this brought to anybody's
attention, that you are aware of?
Ms. NELSON. No, I'm not aware of
that.
Dr. PETZEL. We've looked, we've
looked for e-mails in both of our e-mail
systems from Ms. Johnson to anybody in
the organization during her employment,
and we cannot find but one. That was
not one of them.
Mr. CARNAHAN. Well, we will want to
hear more about that, as well.
Mr. Chairman, thank you.
The CHAIRMAN. Thank you. I want to
thank my colleagues. I have not served
on a Committee with most of these
gentlemen, but I think you helped us get
to some really important things here.
I want to assure those of you in
attendance, especially those who are
veterans who are affected, this is not
just a hearing for show. We are going
to look at all 1,812 and take care of
you until you are assured there is no
problem. We want to make sure you know
that.
You heard me and Dr. Petzel have
some, or me, at least, have some
exchange. He knows, and I've said in
public how much I respect him. I feel
like I'm talking to someone who can
understand it.
We are going to come back with the
same group in 5 or 6 months. We may
have a different Chair or we may not
have a different Chair. I don't know
yet. But we are all committed to seeing
that some of the issues that came up
today have real follow-through. We may
find out Dr. Petzel was fired because he
raised too many questions, and the next
guy will say, I don't know what he
promised, so we are going to start over
again. I hope that doesn't happen, but
I've seen it too often.
We take this hearing very seriously.
We have every word written down and we
are going to hold people accountable.
And I think we have found both a
Republican and Democrat community of
interest here and that is going to
ensure we continue our follow-up. I
assure all of you we are going to do
that.
I especially thank the Missouri
delegates for joining us.
Dr. Petzel you look like you want the
last word. I will give it to you.
Dr. PETZEL. Thank you, Mr. Chairman.
I look forward to joining you back
here in 6 months to demonstrate some
progress on the issues we've discussed
today.
The CHAIRMAN. Fantastic.
This hearing is adjourned.
[Whereupon, at 4:33 p.m., the
Committee was adjourned.]
APPENDIX
Prepared Opening
Statements:
Prepared statement of
Hon. Bob Filner, Chairman, and a
Representative in Congress from the
State of California
Prepared statement of
Hon. Jeff Miller, a Representative
in Congress from the State of Florida
Prepared statement of
Hon. Russ Carnahan, a Representative
in Congress from the State of Missouri
Prepared statement of
Hon. Jerry F. Costello, a
Representative in Congress from the
State of Illinois
Prepared statement of
Hon. John Shimkus, a Representative
in Congress from the State of Illinois
Prepared statement of
Hon. Wm. Lacy Clay, a Representative
in Congress from the State of Missouri
Prepared Witness
Statements:
Prepared statement of
Susan Maddux, Festus, MO
Prepared statement of
Terri J. Odom, Imperial, MO
Prepared statement of
Earlene Johnson, St. Louis, MO
Prepared statement of
Barry A. Searle, Director, Veterans
Affairs and Rehabilitation Commission,
American Legion
Prepared statement of
Hon. Robert A. Petzel, M.D., Under
Secretary for Health, Veterans Health
Administration, U.S. Department of
Veterans Affairs
Submissions for the
Record:
Prepared statement of
Hon. Phil Hare, a Representative in
Congress from the State of Illinois
Prepared statement of
Hon. Claire McCaskill, a United
States Senator from the State of
Missouri
Material Submitted for
the Record:
Post-Hearing Questions
and Responses for the Record:
Hon. Bob Filner, Chairman, Committee on
Veterans' Affairs to Hon. Eric K.
Shinseki, Secretary, U.S. Department of
Veterans Affairs, letter dated July 29,
2010, transmitting follow-up questions
from Hon. Wm. Lacy Clay, and VA
responses
