[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]




 
  A CONTINUED ASSESSMENT OF DELAYS IN VA MEDICAL CARE AND PREVENTABLE 
                            VETERANS DEATHS

=======================================================================

                                HEARING

                               before the


                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                        WEDNESDAY, APRIL 9, 2014

                               __________

                           Serial No. 113-64

                               __________

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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               MICHAEL H. MICHAUD, Maine, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         CORRINE BROWN, Florida
DAVID P. ROE, Tennessee              MARK TAKANO, California
BILL FLORES, Texas                   JULIA BROWNLEY, California
JEFF DENHAM, California              DINA TITUS, Nevada
JON RUNYAN, New Jersey               ANN KIRKPATRICK, Arizona
DAN BENISHEK, Michigan               RAUL RUIZ, California
TIM HUELSKAMP, Kansas                GLORIA NEGRETE McLEOD, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
PAUL COOK, California                TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana
DAVID JOLLY, Florida
                       Jon Towers, Staff Director
                 Nancy Dolan, Democratic Staff Director
                 
                 
                 
                 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
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of converting between various electronic formats may introduce 
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                            C O N T E N T S
                                                                                                               
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                                                                   Page

                        Wednesday, April 9, 2014

A Continued Assessment of Delays in VA Medical Care and 
  Preventable Veterans Deaths....................................     1

                           OPENING STATEMENTS

Hon. Jeff Miller, Chairman.......................................     1
    Prepared Statement...........................................    45

Hon. Michael Michaud, Ranking Minority Member
    Prepared Statement...........................................    46

Hon. Corrine Brown...............................................     3
    Prepared Statement...........................................    47

Steve Cohen
    Prepared Statement...........................................    47

                               WITNESSES

Barry Coates, Veteran............................................     4
    Prepared Statement...........................................    48

Daniel M. Dellinger, National Commander, The American Legion.....     6
    Prepared Statement...........................................    50

    Accompanied by:

        Edward Lilly, Senior Field Service Officer, The American 
            Legion

Thomas Lynch M.D., Assistant Deputy Under Secretary for Health 
  for Clinical Operations, VHA, U.S. Department of Veterans 
  Affairs........................................................    23
    Prepared Statement...........................................    61

    Accompanied by:

        Carolyn M. Clancy M.D., Assistant Deputy Under Secretary 
            for Quality, Safety, and Value, VHA, U.S. Department 
            of Veterans Affairs

Debra A. Draper, Director, Health Care, GAO......................    36
    Prepared Statement...........................................    64

John D. Daigh, Jr. M.D., Assistant Inspector General for 
  Healthcare Inspections, Office of the Inspector General,  U.S. 
  Department of Veterans Affairs.................................    38
    Prepared Statement...........................................    82

                        QUESTIONS FOR THE RECORD

Questions From Chairman Miller to VA.............................    90


  A CONTINUED ASSESSMENT OF DELAYS IN VA MEDICAL CARE AND PREVENTABLE 
                            VETERANS DEATHS

                              ----------                              


                        Wednesday, April 9, 2014

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                                   Washington, D.C.
    The committee met, pursuant to notice, at 10:03 a.m., in 
Room 334, Cannon House Office Building, Hon. Jeff Miller 
[chairman of the committee] presiding.
    Present:  Representatives Miller, Bilirakis, Benishek, 
Huelskamp, Coffman, Cook, Walorski, Jolly, Brown, Brownley, 
Titus, Kirkpatrick, Negrete-McLeod, and O'Rourke.
    Also Present: Representative Cohen.

           OPENING STATEMENT OF CHAIRMAN JEFF MILLER

    The Chairman. The committee will come to order. Before we 
begin, I would like to ask unanimous consent that when he 
arrives, our colleague from Tennessee, Congressman Steve Cohen, 
be allowed to sit at the dais and participate in today's 
proceedings. Hearing no objection, so ordered.
    Ladies and gentlemen, welcome to today's full committee 
hearing, a Continued Assessment of Delays in VA Medical Care 
and Preventable Veteran Deaths.
    Today's hearing is the fulfillment of a promise I made in 
early January to follow-up on delays in care at Veterans 
Affairs' Medical Centers in Columbia, South Carolina and 
Augusta, Georgia that together resulted in nine preventable 
veteran deaths.
    I had hoped that during this hearing we could be discussing 
the concrete changes that VA had made, changes that would show 
beyond a doubt that VA had placed the care of our veterans 
first and that VA's commitment to holding any employee who did 
not completely embody a commitment to excellence through 
actions appropriate to the employee's failure to be held 
accountable.
    Instead today we are faced with even more questions and an 
ever-mounting list of evidence that despite the myriad of 
patient safety incidents that have occurred at VA medical 
facilities in recent memory, the status quo is firmly 
entrenched at the Department of Veterans Affairs.
    On Monday, shortly before this public hearing, VA provided 
evidence that a total of 23 veterans have died due to delays in 
care at VA medical centers. Even with this latest disclosure as 
to where the deaths occurred, our committee still does not know 
when they may have happened beyond the statement that they most 
likely occurred between 2010 and 2012.
    These particular deaths resulted primarily from delays in 
gastrointestinal care. Information on other preventable deaths 
due to consult delays remains unavailable.
    Outside of the VA's consult review, this committee has 
reviewed at least 18 preventable deaths that occurred because 
of mismanagement, improper infection control practices, and a 
whole host, of maladies that plague the VA healthcare system 
all across this great Nation, yet the department's stone wall 
has only grown higher and more nonresponsive.
    There is no excuse for these incidents to have ever 
occurred. Congress has met every resource request that VA has 
made and I guarantee that if the department would have 
approached this committee at any time to tell us that help was 
needed to ensure that veterans received the care they required, 
every single possible action would have been taken to ensure 
that VA could, in fact, adequately care for our veterans.
    This is the third full committee hearing that I have held 
on patient safety. And I am going to save our VA witnesses a 
little bit of time this morning by telling you what I do not 
want to hear.
    I do not want to hear the rote repetition of, and I quote, 
``The department is committed to providing the highest quality 
care which our veterans have earned and that they deserve. When 
incidents occur, we identify, mitigate, and prevent additional 
risks. Prompt reviews prevent similar events in the future and 
hold those persons accountable,'' end quote.
    Another thing I do not want to hear is again, and I quote 
from numerous VA statements including a recent press release, 
``While any adverse incident for a veteran within our care is 
one too many,'' unquote, preventable deaths represent a small 
fraction of the veterans who seek care from VA every year.
    What our veterans have truly earned and deserve is not more 
platitudes and, yes, one adverse incident is one too many. 
Look, we all recognize that no medical system is infallible no 
matter how high the quality standards may be. But I think we 
also recognize that the VA healthcare system is unique because 
it has a unique, special obligation not only to its patients, 
the men and women who honorably serve our Nation in uniform, 
but also the hard-working taxpayers of the United States of 
America.
    When errors do occur, and they seem to be occurring with 
alarming frequency, what VA owes our veterans and our taxpayers 
in that order is a timely, transparent, accurate, and honest 
account about what mistakes happened, how those mistakes are 
being fixed, and what concrete actions are being taken to 
ensure accountability.
    It seems to me that my staff has been asking for further 
details on the deaths that occurred as a result of the delays 
in care at VA medical facilities now for months. And only two 
days before this hearing did VA provide any information that we 
have been asking for. Even then, that information is far from 
complete in what VA's effort is to prevent future deaths.
    It concerns me even more than that at a briefing that VA 
provided on Monday and the testimony that is provided today, 
include very few details about what, if any, specific actions 
have been taken to ensure accountability for 23 veterans who 
lost their lives and the many more who were harmed because they 
did not get the care they needed in a timely fashion.
    The VA witnesses' testimony that is provided for today is 
ridiculous. It answers no questions. It provides no new 
information. And I am tired of begging the Department of 
Veterans Affairs to answer this committee's questions.
    On our first panel today, we are going to hear from a 
veteran who sought care through the William Jennings Bryan Dorn 
VA Medical Center in Columbia, South Carolina, a facility that 
I visited earlier this year.
    That veteran, Mr. Barry Coates, is going to tell us that, 
and I quote, ``The gross negligence and crippling backlog 
epidemic of the VA system has not only handed me a death 
sentence but ruined my quality of life.''
    Mr. Coates waited for almost a year and would have waited 
even longer had he not personally persistently insisted on 
receiving the colonoscopy that he and his doctors knew that 
they needed. That same colonoscopy revealed that Mr. Coates had 
stage IV colon cancer that has metastasized to his lungs and 
his liver.
    Maybe that is why VA does not want to define accountability 
in terms of employees who have been fired. The department is 
going to testify this morning that instead we should focus our 
accountability efforts on correcting system deficiencies in 
order to prevent adverse events from occurring again.
    There is nothing wrong with fixing the system, but Mr. 
Coates deserves better than that. His adverse event already has 
happened and for him, there is no going back.

    [The prepared statement of Chairman Jeff Miller appears in 
the Appendix]

    With that, I yield to the ranking member, Ms. Brown, for 
her opening statement.

            OPENING STATEMENT OF HON. CORRINE BROWN

    Ms. Brown. Thank you, Mr. Chairman, for calling this 
hearing today.
    We can all agree that veteran safety and quality of care 
issues at the VA health facilities are the utmost concern for 
this committee. However, it is unfortunate that we must 
continually call these hearings to make sure that our Nation's 
veterans are receiving the care for which they have already 
paid dearly for on the battlefield and in service to protecting 
the freedom we all hold most dear.
    I also find it disturbing that just two days before this 
hearing, the VA has released findings that its healthcare 
personnel are not fully trained in the importance of timely 
consulting when treating a veteran.
    The definition defined a consultant as the act of seeking 
information or advice from someone with expertise in a 
particular area. The system the VA set up to make these 
consults easy obviously broke down and it is possible that at 
least five veterans died in Florida because the right 
information was not shared with the right health professionals.
    I am concerned that in the five years after the colonoscopy 
debacle in the Miami VA nothing has changed. To refresh your 
memory, in 2009, staff members at a number of VA facilities 
noticed improper reprocessing of episcopes contrary to the 
manufacturing instructions.
    The VA properly ordered all facilities to step up and get 
retrained on the procedures. We want employees to feel free to 
report questionable issues and procedures without fear of 
retribution for trying to save lives. It seems that from the 
new consultant problems that the retraining stopped at this one 
procedure.
    The fact sheet your office put out regarding consults talks 
a lot about procedures and adverse events. However, I have 
heard that before and again our veterans are suffering. And I 
am looking forward to hearing the testimony today and 
explanations for this lack of proper care and accountability 
for these mistakes.
    I yield back the balance of my time.
    The Chairman. Thank you very much, Ms. Brown.

    [The prepared statement of Corrine Brown appears in the 
Appendix]

    Joining us today for our first panel is Mr. Barry Coates. 
Mr. Coates is a disabled veteran who served in the United 
States Army and currently resides in the Palmetto State. As I 
stated earlier, he is going to share his very personal story of 
attempting to receive needed care from the Department of 
Veterans Affairs.
    Also on the first panel is Daniel Dellinger, national 
commander of The American Legion. The commander is accompanied 
by Edward Lilly, senior field officer.
    Thank you all for your service both in and out of uniform.
    Thank you in particular, Mr. Coates, for being here today 
and for agreeing to share what I know is a very painful story. 
This committee is honored to have you here before us today, and 
you are recognized for your statement, Mr. Coates.

                   STATEMENT OF BARRY COATES

    Mr. Coates. First of all, I would like to thank Chairman 
Mr. Miller, Ms. Brown, and other Members of the committee for 
the opportunity to be able to come in front of you today and 
give you my testimony.
    I would like to start, first of all, with the first part of 
my paragraph of my testimony, and I think each one of you all 
have that.
    My name is Barry Lynne Coates. And due to the inadequate 
and lack of follow-up care I received through the VA system, I 
stand here before you terminally ill today.
    I joined the army in February of 1991 anxious to serve my 
country. Near the end of basic training, an injury to my back 
derailed this plan and I was discharged around the 1st of May 
of the same year.
    After five years of fight to obtain service-connection 
status of my injury and treatment and pain management 
requirement as a result of it, I finally became eligible for 
medical treatment through the VA system. That was the start of 
the long, painful, emotional, and unnecessary journey that 
brings me here to you today.
    First of all, I appreciate the opportunity to be able to 
stand here and testify in front of the committee, one for the 
veterans who have died because of this unnecessary tragedy that 
occurred that should not have ever occurred to start with. 
Also, for the families that have lost those veterans and for 
the veterans who have suffered and are still suffering because 
of this like myself and their families, I want to be a voice to 
them and an advocate to them.
    Hopefully this testimony will prove to the VA system the 
lack of knowledge or the lack of care that they gave to myself 
and to other veterans that need to be changed. Something needs 
to be created to change the policy of the way this is done.
    I talked to numerous veterans since all this occurred and a 
lot of them, I hear the same story like my story, you know, why 
didn't we receive help, why didn't I get care earlier, why 
didn't it get outsourced. And outsourced is probably a good 
thing that needs to be put into policy if it is backed up to a 
part they cannot control.
    Another thing also that needs to be done for the veterans 
that are struggling, for the ones that have lost their husband 
or wife, it is hard to even get care and medical.
    Another thing, too, to look at, if I am serving in the 
military today and I look at what happened to veterans outside 
of the VA system and their care and I see what is going on 
there like what happened to myself and other veterans, what is 
a member of the military service going to think? They are going 
to think one thing. Well, they are not taking care of the 
veterans outside of this. Well, one day, I will be a veteran 
also. Are they going to be there to take care of myself, my 
family?
    And that is a big question that probably servicemen who are 
serving now, they are going to ask the question, why would I 
need to serve my country if they are not going to look at me 
and protect me after my service and become a veteran?
    And I think that is something we need to focus on because 
military service is really volunteer. If you look at time and 
history dating back to the Revolutionary War, it was all 
voluntary. And if it had not been for that voluntary service, 
we would not have what we got today in this country. And 
without that, we would not be here today and be able to talk to 
you all and deal with this matter.
    So something needs to be done. Someone needs to be held 
accountable for it. And I understand from other sources that no 
one has been held accountable for it. And I think someone 
should be held accountable for it, whether it be a director of 
the Dorn VA Hospital or it be the secretary of the Veterans 
Affairs or even the President of the United States.
    Thank you.

    [The prepared statement of Barry Coates appears in the 
Appendix]

    The Chairman. Thank you, sir, for your testimony.
    And before we go to questions, I do want to ask Commander 
Dellinger if he would please proceed with his statement.
    You are recognized for five minutes.

   STATEMENT OF DANIEL M. DELLINGER, NATIONAL COMMANDER, THE 
  AMERICAN LEGION, ACCOMPANIED BY EDWARD LILLY, SENIOR FIELD 
              SERVICE OFFICER, THE AMERICAN LEGION

    Mr. Dellinger. Thank you.
    As the Nation's largest wartime veteran service 
organization, The American Legion dedicates significant 
resources towards working with and observing the work of the 
VA.
    Through the Legion's System, Worth Saving medical facility 
visits, Town hall meetings with veterans and the feedback we 
receive from the thousands of American Legion certified Veteran 
Service Officers across the Nation, we are able to provide you 
with the specific details in our written testimony that you 
have before you. I will highlight just a few of those details 
to you now.
    Chairman Miller and Members of the committee, on behalf of 
the two and a half million members of The American Legion, I 
want to thank you for inviting The American Legion to share our 
research and position on the important topics of delay in 
medical care and patient deaths.
    I am here today because The American Legion has no greater 
priority than ensuring that veterans receive timely and quality 
healthcare as a result of their service-connected illnesses.
    It seems a day cannot pass without a news report about the 
problems and challenges the VA faces with delays and quality of 
care issues. While we wait for things to get better, hundreds 
of thousands of veterans are waiting for their initial 
disability claim or appeal which prevents them from receiving 
VA healthcare.
    While we wait, transitioning servicemembers are falling 
through the cracks due to DoD and VA's inability to create a 
single interoperable medical record.
    While we wait, officials in the VA central offices are 
preventing hospitals from being transparent during crisis. 
While we wait, veteran suicides continue to plague our Nation 
at 22 per day with no clear strategy from VA on addressing 
suicides proactively.
    And while we wait, veterans are being over-prescribed 
medications for pain, TBI, PTSD with reluctance toward looking 
at complementary and alternative medicine because giving out 
pills is faster than providing veterans the therapy sessions 
they need.
    In January, The American Legion went to Jackson, 
Mississippi where a veteran died as a result of when all the 
blood was drained from his body because he was not properly 
monitored during a medical procedure.
    When our task force members asked the facility director for 
a copy of the action plan they were using to address their 
problems, the director refused to give them a copy.
    Last November, we visited Pittsburgh. At that time, we 
believe the Legionnaire outbreak that left six dead and more 
than 20 sick was due to equipment failure. The neglect on the 
part of the VA to notify local health officials, veterans, and 
patients was bad enough, but then later, we learned that CBS 
news reported that senior officials at the Pittsburgh VA 
actually knew that human error was behind the outbreak and not 
equipment failures as officials had suggested to this 
committee.
    Our System Worth Saving Task Force went to Atlanta in 
January where two veterans died of an overdose and one 
committed suicide which was attributed to mismanagement and an 
inability to get the mental healthcare they needed in a timely 
manner.
    Last night, there was a daughter that missed her dad saying 
goodnight. Today there is a wife who misses her husband. 
Tomorrow a father will still regret that he was able to outlive 
his son because someone at the VA did not do their job.
    Patient deaths are tragic. Preventable patient deaths are 
unacceptable. But failure to disclose safety information or 
worse, to cover up mistakes, is unforgivable and The American 
Legion will not sit quietly by while some VA employees cover up 
the truth and the VA should not either.
    We need to continue to ask the hard questions. What is VA 
doing to fix these problems and are they concerned about 
keeping me informed? How is VA holding their leaders 
accountable for these errors? And, finally, why is the VA 
reducing inpatient long-term care beds, ICU, emergency rooms, 
and closing hospitals such as Hot Springs, South Dakota?
    The American Legion will not stop asking the hard questions 
and we hope you won't either. The American Legion looks forward 
to working with this committee as we work together with the VA 
to ensure that VA provides the best healthcare anywhere.
    Thank you.

    [The prepared statement of Daniel M. Dellinger appears in 
the Appendix]

    The Chairman. Thank you, Commander.
    Mr. Coates, in the more or less year that it took for you 
to receive a colonoscopy through the Department of Veterans 
Affairs, did anybody at any time ever tell you that you could 
be authorized to receive the procedure that you needed done 
through a private provider in the community enabling you to get 
a diagnosis sooner?
    Mr. Coates. No, sir. I never was advised during that time 
period. During that time period, I seen from January of 2011 
when I first complained about it till the day of my colonoscopy 
which was December the 9th of 2011, I seen four different 
doctors that was in the VA system.
    One was Rock Hill Clinic outpatient, Dr. Verna. She was my 
outpatient clinic doctor I had in Rock Hill, South Carolina. I 
presently moved to the location I live now. I transferred. It 
takes roughly anywhere from four to six months to get a 
transfer to a different location for outpatient care which 
would have been the Florence Clinic.
    Upon that, I seen Dr. Verna on January, March, and I think 
May of that same year and each time, my problem got worse. And 
she made notes in her comments because I retrieved copies of 
those from the VA. And she made note of those saying may need 
colonoscopy. Never set a consult up for it.
    Upon getting transferred to the Florence Clinic in June of 
2011, if I remember correctly, Dr. Naumann was my clinic doctor 
there. And being a new patient, he done a full exam, looked 
over information from Dr. Verna prior to treating me. And he 
kind of got upset because she did not have me on a certain 
prescription because of taking pills for pain would cause 
certain problems and that I should have been on something 
already from that from being on those for quite a few years.
    But he immediately set me a consult up with a GI surgeon 
which I did not ever get an appointment with her until probably 
either around the eighth month, maybe the ninth month, if I 
remember correctly, Dr. Kim.
    And upon seeing her, I seen her twice, she delayed it 
another two to three months and I went back to her again around 
the tenth month. We did not have a good communication ability 
between each other because she kind of made me mad from my 
first appointment because of things that she could have done 
then that would have resulted earlier and set the consult up 
for a colonoscopy earlier if she would have done a couple other 
procedures other than a physical exam.
    I learned that she could have done a CT exam or a CT scan. 
She could have done a lithoscope exam which would have found 
the tumor that was only five inches in the area, in the lower 
rectum area.
    After that appointment with her on the 10th, she set me up 
for a consult for the colonoscopy to be done which I received 
the appointment in the mail two weeks later. And it was 
actually scheduled for April of the following year. We are 
talking six more months out and I had already been in pain for 
eight months already and suffering because of this. But I did 
not let that stand in front of me, so I called the department 
that scheduled that appointment and they told me that is the 
normal time is usually around six months before you can get a 
colonoscopy. There was nothing that she could do to get it done 
earlier, that the only way you could get it done earlier is 
request your physician to write the chief GI surgeon or either 
the gastroenterologist to get it done sooner or you could call 
each day and see if anyone dropped off from the appointment 
schedule.
    And I asked her could she write my name down and call me if 
someone dropped off. She said she could not do that. But, 
fortunately, due to the Lord's grace, she called me the next 
morning at 9:30 and asked me could I come to an appointment 
around 2:30 that day which I did. And then that is when I was 
set up for the colonoscopy done at the Fort Jackson Military 
Hospital on December the 9th.
    So from January to December the 9th was a whole year.
    The Chairman. One other question. Do you know what an 
institutional disclosure is? Have you ever heard that term 
before?
    Mr. Coates. No, sir.
    The Chairman. It is where VA notifies a patient when there 
has been an adverse event such as a consult delay that 
ultimately resulted in the failure to diagnose an issue.
    So you are saying you never received an institutional 
notice?
    Mr. Coates. Not to my knowledge, no, sir.
    The Chairman. Ms. Brown.
    Ms. Brown. Thank you.
    I think I will ask the first question to The American 
Legion, Mr. Dellinger.
    During your System Worth Saving visits outlined in your 
testimony, did you encounter common themes throughout the VA 
medical center and how long have you all been doing this?
    Mr. Coates. We have been doing these System Worth Saving 
for the last ten years.
    Ms. Brown. ten years?
    Mr. Coates. Yes, we have.
    Ms. Brown. Yes, sir.
    Mr. Coates. And we go in. We do a town hall meeting the day 
before with the local veterans to learn their concerns and then 
we go into the hospitals and we review their procedures and do 
visit the hospital.
    Ms. Brown. Since you have been doing it for ten years, and 
I have been on this committee for 22, have you seen any 
improvements over the last ten years in the system?
    Mr. Coates. I would say yes, we have seen improvements. 
There are still areas that need improving dramatically, but for 
the overall system, yes.
    I was actually in Salt Lake City a couple months ago and 
the director, first thing she had in her hand was a water 
quality test to show that she had done it. So they have started 
knowing when we are coming to be prepared and they do a better 
job.
    Ms. Brown. Okay. Thank you very much.
    Mr. Coates, let me ask you a couple of questions.
    First of all, I want to thank you for your service.
    Mr. Coates. Thank you, ma'am.
    Ms. Brown. And you are serving today being here. And I also 
want you to know that no one can determine when we are going to 
leave here. That is in the hands of the Lord. And they have a 
lot of new technology and equipment. And I know someone that 
they released him, said that you are going to die right away 
and four years later, they are still living. So we got to 
continue to work to make sure you get the best treatment that 
is needed.
    When you were going through this process, did you ever talk 
to any top officials? You were getting the runaround with the 
system it seems, but did you ever try to talk to the head of 
the VA at the particular hospital or anything like that?
    Mr. Coates. No, ma'am, I did not, which I probably should 
have been more aggressive like I was trying to get an earlier 
appointment.
    Ms. Brown. Uh-huh.
    Mr. Coates. And not to discredit what you said, you should 
not have to do that.
    Ms. Brown. No, you should not. But we do not want you to be 
a victim either.
    Mr. Coates. No, ma'am.
    Ms. Brown. Yes, sir.
    Mr. Coates. No, ma'am. And nobody wants to be a victim and 
no one wants to be pointing a finger, too, but I should have 
but I did not. But a lot of times, you learn from hard things 
you do and mistakes that you make and give that advice to other 
vets and which I do.
    I represent a lot of other veterans around my community and 
my state that I help with VA compensation claims and also tort 
claims. I help with them also and get them filed, how you file 
things, how you get things started because the VA system does 
not volunteer any information a lot of times. And a lot of 
times, you ask questions and you ask other veterans on how you 
get that.
    But to answer your question fully, no, ma'am, I did not ask 
anybody which I was, I guess, ignorant to that.
    Ms. Brown. Let me just ask you one other question. You 
indicated that maybe the VA should not farm out, but you could 
go to outside--outside the system and that might be more 
efficient.
    Most of the times when we have testimony, let's say women 
veterans, they say, well, we want to be served in the VA, but 
we do not like this and that.
    So do you think that we should consider maybe giving, 
particularly in some areas, an opportunity to go to the 
outside? I mean, I know you can, but making sure you know that 
you can.
    Mr. Coates. Yes, ma'am. I would say I think you should be 
able to give more opportunity. I think it should be put in a 
form or documentation when you are being treated, as common 
knowledge, same way as the handbook, the handout. I think that 
should be probably wrote in there somewhere you have options 
due to the VA system or you can request outsourced services.
    Presently now I have been dealing with the VA system for a 
little over two years now going to the oncology department at 
the Dorn VA.
    Ms. Brown. Yes.
    Mr. Coates. I am well satisfied with my doctor I have and I 
give him credit. It is Dr. Babcock. He retired from private 
practice after 30 years. And I guess he wanted to serve 
veterans or either work somewhere that dealt with veterans. And 
he goes three days at the Dorn VA and works there as oncology.
    When I first started, I actually got him the first week he 
came into the system which I think that was something the Lord 
had planned all together. And he is a real good Christian man. 
He said there is not a night that he does not go to bed at 
night and pray for me.
    But after all his works and what I have learned through the 
VA system medically, they have to request and get certain 
medication or certain different treatments to be done for 
cancer. I asked what he is doing.
    Recently I'm inquiring now after I have been there working 
for two years and now from my last scan I had a couple weeks 
ago spots on my lungs, liver, and a new spot has came up now in 
the abdominal area that they have grown and multiplied.
    And I am presently getting ready to go back on chemo in the 
next week, but I am looking for outside services now. I have 
acquired information now through the MSU--well, the MUSC out of 
Charleston which is another cancer research. They have ability 
to do--a lot more scientists to research different cancer and 
be able to offer more availability to treat me a lot better 
than what the VA has.
    And I have applied and checked on it and hopefully I can 
get payment due from the VA to be able to go to that hospital 
and try something new, you know, because I am talking about my 
life.
    Ms. Brown. Yes.
    Mr. Coates. And like you said, no one knows the exact 
moment that the Lord is going to call you home.
    Ms. Brown. Uh-huh.
    Mr. Coates. But you also got sense enough to know that try 
your best while you are here and stay as long as you can. And I 
am at the process now where I am getting information together 
to them so they can look at my case and see what they can do. 
And it is always good to have another option because, you know, 
I am talking about myself and my life and my family.
    Ms. Brown. Yes.
    Mr. Coates. And I am sure each one of you all here in this 
room now would do the same thing if it was you in my shoe. You 
would look for other things because I have been doing this for 
two years now and it has worked pretty good, but I think I am 
at the end of the line of where I am at now with the VA system.
    Ms. Brown. Yes, sir.
    Mr. Coates. And I am having to go outside of that.
    Ms. Brown. Thank you.
    My time is up, but let me just say I want to recommend a 
couple of the hospitals in my area. I have a couple of good 
ones. Shands and Mayo, they have some excellent work. So let me 
yield back the balance of my time, but I will make sure I get 
you that information.
    Mr. Coates. Yes, ma'am.
    Ms. Brown. Thank you.
    Mr. Coates. Thank you.
    Ms. Brown. Thank you, sir.
    The Chairman. Mr. Huelskamp, you are recognized for five 
minutes.
    Dr. Huelskamp. Thank you, Mr. Chairman. I appreciate the 
opportunity to participate in this hearing today.
    And, Mr. Coates, I would like to apologize on behalf of the 
failed system that has created such pain for you. And I know 
words probably do not mean much, but I mean that from the 
bottom of my heart. Thank you for coming here today. This 
probably was not easy.
    But in your testimony, I do note you do mention four 
different doctors, Dr. Verna, Dr. Naumann, Dr. Kim, and a Dr. 
Sarbah.
    Do you know if any of these doctors or related staff have 
faced any punishment or discipline for the failures in this 
situation?
    Mr. Coates. Thank you for the compliment.
    And as far as I know, there has not been any discipline. I 
would say out of two doctors in that four I mentioned would be 
one Dr. Verna. She had three occasions to set me up a consult, 
January, March, and May.
    Upon seeing Dr. Naumann my first time in that same year, he 
immediately looked over the information, set me a consult up 
with Dr. Kim, the GI surgeon, which I think he should have set 
me up with probably a different department that handled the 
colonoscopies. I know it is something to do with 
gastroenterology department, but he should have set me up with 
someone other than a GI surgeon.
    But he did make effort and I give him credit for that 
because he is the only one on the first initial meeting.
    Dr. Kim was the GI surgeon I mentioned. She could have done 
a lot better than what she did if you missed my prior 
information about that as far as the procedure she could have 
done on my first visit with her and delayed it further.
    The last doctor was the one who actually done the 
colonoscopy and he done a real good job. And he was the chief 
doctor that done that and he was very sensitive to me and my 
family about that. And after that, he would see me in the 
hospital getting treatment and he would come up and talk to me 
and ask how everything is going, you know, everything.
    But now I have learned that he has left the system and they 
have lost a great man from that down at the VA, at Dorn. He 
called me a couple weeks before he left and he said, Barry, he 
said I just want to let you know that I am leaving the system 
here at the VA. He did not mention where he was going, but he 
asked me how I was doing which is very fortunate, you know, for 
a doctor to give a rapport like that, but----
    Dr. Huelskamp. Mr. Coates, your interaction with other VA 
staff other than the doctors, can you describe that and was 
that simply taken up with the appointments or were there any 
visits with them, any attempts to help you move through the 
morass of bureaucracy and can you describe that as well for the 
committee?
    Mr. Coates. You are referring to appointments as far as 
what, set up the consults?
    Dr. Huelskamp. Well, any other staff. I mean, you have 
mentioned the doctors and those that really went above and 
beyond the call of duty and those that perhaps did not.
    What about other staff at this center? I mean, were they 
helpful? You had to fight your own way through the process? Can 
you describe that a little bit more?
    Mr. Coates. Well, I will say yes and no to that answer. 
There were ones who were helpful, but they only had a limited 
source. And the ones that was not trying to be helpful, they 
really did not care. And I can say that from knowledge of a 
record that I received from the VA upon the GI surgeon from 
filling her notes after she learned of the result from my 
colonoscopy.
    I had a meeting with her that same day at 1:00 or 1:30 and 
she came into the office. And that is the same woman that I had 
words with on the first initial meeting. And the only thing she 
could say was, Mr. Coates, I am so sorry, I did not expect 
that. I looked at her and I told her, I said, see there, I told 
you I was hurting. I said from now on, you need to start 
listening to your veterans and doing more for them on their 
first initial visit.
    And that way, you know, when you can look back and say I 
done the best thing I could do because I told her the same 
thing, that I looked up things that she could have done and she 
did not do it. And if she had done, it would have been a little 
sooner. And the only thing she could say I am sorry. Well, 
sorry does not change that. And nothing happened to her. No 
punishment came upon her.
    Learning from other surgeons in that same department, I 
cannot reveal their names, but because they work in that 
department and they told me that her policy changed after that 
to where now if any veteran comes in that has any bleeding or 
pain in the rectum area, that she immediately sets them up for 
consult for the colonoscopy.
    So I am thankful that, I had to be the one to suffer to get 
that done, that other veterans that won't suffer now. But she 
has been there. She was a seasoned doctor. And I think the lack 
of her ability, not her knowledge because she had the knowledge 
to know what was going on, but the lack of care it might be. I 
do not really know what it was, but there was a lot of things 
that she could have done more than what she did and she did not 
do it.
    Dr. Huelskamp. Thank you, Mr. Coates. I appreciate it.
    I yield back.
    The Chairman. Ms. Brownley, you are recognized for five 
minutes.
    Ms. Brownley. Thank you, Mr. Chairman. And I really want to 
thank you for holding this hearing today. It is clearly a very 
important one.
    And, Mr. Coates, I want to thank you for your testimony 
this morning and truly on behalf of this committee and our 
Nation, I really want to apologize for the care that you 
received or the care that you did not receive.
    And clearly you agreed to serve our Nation and we agreed to 
take care of you when you came home, and we did not hold up our 
end of the bargain. And so I truly want to apologize to you.
    And I am the ranking member on the Health Subcommittee here 
for veterans. And when I learned of this, I actually wrote a 
letter to Dr. Benishek who chairs the Subcommittee on Health 
and was very obviously saddened by what I had learned about 
nineteen preventable deaths.
    And I even question nineteen preventable deaths. I mean, 
really, nineteen? I am sure I believe in my heart of hearts 
that there are probably more than nineteen, but nineteen that 
we know about.
    So I am, you know, very, very grateful that we are having 
this hearing today and it is incumbent on all of us here to 
make sure that the VA is held accountable for what has happened 
and is accountable to you, Mr. Coates, and to the other men and 
women who have served our country and who have not received the 
proper care.
    I just wanted to ask you, we have already asked a lot of 
questions around this, but during the time that you have gone 
through, were you aware of any recourse that you could take or 
did anyone suggest to you that there is someone in the VA that 
you could reach out to, a patient advocate, anything like that 
during the course of these delays?
    Mr. Coates. No, ma'am.
    Ms. Brownley. And I know that you mentioned just in your 
last answer that Dr. Kim ultimately apologized to you for her 
lack of diagnosis and care.
    But have you had any formal apology from the VA?
    Mr. Coates. None.
    Ms. Brownley. And in your experience, again, how would you 
describe, I guess I want to say sort of the bedside manner in 
terms of how you were treated? Clearly there were these delays, 
but did you experience from any VA employees or doctors that 
you encountered any sensitivity or concern about your 
frustration?
    Mr. Coates. Yes and no answer to that. No to a couple of 
the physicians that I had and yes to a couple of physicians 
that I had. I mentioned, I think, briefly those ones that I 
mentioned. The lack of concern, I look at this way, and I have 
been going to the VA for quite a few years now since early 
1990s, same hospital, and you see a lot of different things 
going there from different physicians and things like that.
    You got physicians that care about people and you got 
physicians that look at it as just a job to do. You got nurses 
and other officials there that look at it the same way. You got 
some that cares for the veteran themself and enjoy what they 
do. And then you got some that does it for a job.
    And I think that is what happened to a lot of people in 
America today. They do not look at the honor of having 
something and appreciate it anymore. I am not saying that 
anybody does not, but a lot of people do not. They come and go 
to work and go home. They want it for one thing and one thing 
only and they do it for their self.
    And I think if everybody worked together and do something 
for each other like it is supposed to and originally was set 
up, then we would probably be a lot greater Nation today.
    Ms. Brownley. Thank you, Mr. Coates. And, again, I thank 
you for your testimony today and it means a great deal. And I 
hope that through your testimony today, it will pave the way 
for other men and women who serve our country, that they will 
not be treated as you were through this process. So I am very 
grateful to you. Thank you very much.
    Mr. Coates. Thank you, ma'am.
    Ms. Brownley. I yield back, Mr. Chair.
    The Chairman. The gentle lady yields back.
    Mr. Cook, you are now recognized for five minutes.
    Mr. Cook. Thank you, Mr. Chair.
    Mr. Coates, thank you very much to come here. I know this 
is tough on you and your family and everything like this.
    Last year, I lost my sister with colon cancer and it is 
horrible for the family and everything else. She was much older 
than you are.
    Can I ask how old you are, sir?
    Mr. Coates. Forty-four.
    Mr. Cook. You do not have to tell me.
    Mr. Coates. Forty-four years young.
    Mr. Cook. Okay. And obviously you are expected to live much 
longer and that is why this is so tragic.
    I want to ask the commander, you know, Commander, you said 
that you think the VA has improved in certain areas, but the 
culture of the VA in terms of taking care of patients like Mr. 
Coates, it seems as though that is lacking.
    And do you share my concern about the culture, quite 
frankly, taking care of our veterans, taking care of the troops 
and that?
    And I am not trying to preach here and everything, but, you 
know, I spent a long time in the military. We have all had 
stories when people that where a grenade was thrown in there, 
somebody would land on a grenade, get killed, and save five, 
six people for the unit or going out on a battlefield and 
somebody was wounded and take them back under fire.
    And we have all heard these horror stories and very, very 
frustrating. And it seems as though the culture of the VA is 
such that there is not a sense of urgency or, hey, we have got 
to take care of this veteran. You know, this is general orders.
    And if you could just comment. And maybe it is just me, but 
I have reached the breaking point on this where, you know, 
excuse after excuse after excuse after excuse.
    The gentlewoman from Texas talked about, I believe, or 
Julia talked about we expect more for somebody that has signed 
up to do their duty, the veterans, and return. That is what 
they are there for. That is their mission.
    So I finally got around to my question. Sorry.
    Mr. Coates. That is all right.
    You know, it is continuity. As I go around the country 
visiting these hospitals, you can tell the ones that are the 
caring ones just as Mr. Coates stated. You know, you have where 
they are there really for the patients and others are there to 
get a paycheck. And that is the difference.
    And I think it comes from the top down. VA needs to be 
accountable from the top down through the secretary, through 
the under secretary, all the way down to the directors and to 
the chief of staff. I have seen some great chiefs of staffs and 
other ones that are just there biding their time until they 
retire.
    Mr. Cook. You know, this is probably the most bipartisan 
committee, I think, in Congress. And I chaired the Veterans 
Committee in California and it was very bipartisan. And I do 
not think it is a democrat or republican. I really, really 
think it is culture that is not ingrained. You know, all talk 
is cheap.
    But in terms of actually talking about the suicides, we 
talked about all these, and we go on and on and on, and it is 
like business as usual and we cannot tolerate that. And maybe, 
you know, maybe we do have to fire people, but we certainly 
should not give them merit increases and all those things that 
go along with it, particularly in the IG investigations and 
everything else.
    If somebody is not doing what they are supposed to do in 
terms of, as I said earlier, taking care of our veterans, not 
just on the battlefield, but after they come back, then 
somebody deserves to be replaced or fired and have somebody in 
there that understands that is the primary mandate.
    If you could comment briefly. I know we have a lot of----
    Mr. Coates. I agree. I mean, just as in the military, you 
disobey an order, you get court-martialed.
    Mr. Cook. That is right.
    Mr. Coates. Here we have seen instances where there have 
been some reprimands, but they are still on the job.
    Mr. Cook. That is right.
    Mr. Coates. And others are allowed to resign and then there 
is nothing. There is no----
    Mr. Cook. That is right. You have a rank structure, but 
that rank structure, your primary responsibility is to take 
care of everyone under you. And if you do not, that is why you 
are the first one out the helicopter if you are in command. You 
are going to get drilled. That is just the way it is and I am 
afraid that it is not carried over.
    The Chairman. Thank you much, Mr. Cook.
    Mr. O'Rourke, you are recognized for five minutes.
    Mr. O'Rourke. Thank you, Mr. Chair.
    And for Mr. Coates, your testimony and the answers to the 
questions posed so far has been so powerful, so clear, so 
honest, really the questions that are left that I have are 
really for the VA, for ourselves, for this committee, for this 
country.
    What are we going to do now that we know the consequences 
of lack of access, delay, and ultimately denial really is what 
we are talking about in care and lack of accountability?
    So I just will use my time to personally and on behalf of 
the veterans that I have the honor of representing in El Paso 
thank you for your service, for your courage, for your 
testimony, and being here today and focusing our attention on 
something that we desperately need to fix. So thank you very 
much.
    Mr. Chair, I yield back.
    The Chairman. Thank you very much.
    Ms. Walorski, you are recognized for five minutes.
    Mrs. Walorski. Thank you, Mr. Chairman.
    And, Mr. Coates, I sit here and I think you are an example 
of the finest America has to offer. And it seems so petty to 
sit here and apologize on behalf of a bureaucratic system that 
is broken, but I do apologize. I am so sorry to you and your 
family sitting here of what you have gone through and that you 
are going to have to stand and be an advocate for the rest of 
these veterans.
    And I promised my veterans in my district when I ran for 
Congress that they answered the call, they did what this Nation 
asked them to do, and it was my turn to fight for them. That is 
what we do on this committee. We fight for the right of 
veterans to get the benefits they were promised, to be treated 
with the best care.
    I sit here as a freshman lawmaker so frustrated that there 
is a bureaucracy that is out of control. And if this happened 
in the civilian world where negligence was proven time and time 
again, we would be in the streets with signs saying shut them 
down. It is an outrage is what it is. This is an outrage.
    And so I just join the rest of my colleagues here. This is 
not a partisan issue. This is an American disaster that we have 
sat here and witnessed for me probably 16 months. And if I 
could change your circumstance, I would. I would do it in a 
heartbeat.
    Mr. Coates. Thank you.
    Mrs. Walorski. My dad was a veteran that died of colon 
cancer. This is so personal to me. And as a committee, I can 
tell you right now what the VA is going to say when they sit 
here. They are going to say what the chairman read in his 
opening remarks. They are going to give us long dramatic 
answers and nothing is going to change unless we in this 
Congress on the House and the Senate side decide to stand up 
and take on one of the biggest issues in this Nation which is 
this negligence toward taking care of the people that fight for 
freedom, fought for liberty, and allow us to sit and serve in a 
place called the U.S. Congress.
    And I just want to say today I hope that your testimony, I 
hope that your advocacy, and the truth of what you are saying 
changes the culture. It has changed the culture in this room. I 
can tell you that. But my prayer is for you and your family----
    Mr. Coates. Thank you.
    Mrs. Walorski [continuing]. And that together we can stand 
and change the culture in this country and say that today was a 
different day in the history of this VA. I do not know how they 
sleep at night, I really do not. But I can tell you that we are 
your brothers and sisters to stand and fight for you in every 
way that we possibly can.
    Mr. Coates. Appreciate it. Thank you.
    Mrs. Walorski. And to The American Legion, sir, you guys 
come in here faithfully every single time there are hearings, 
you and the many other advocacy organizations for the VA and 
for our veterans, and I just want to commend you for 
consistently coming, consistently telling the story, 
consistently being eyes and ears for all of us that have 
decisions to make and hopefully can improve a failed system. I 
so much appreciate what you do in your world and standing 
consistently for veterans.
    But, you know, this is so personal to me today because I 
had to advocate for my dad and I could and I did. And we did 
everything we could possibly do all the way down to the wire. 
And that is what I am going to do for you, Mr. Coates, and for 
the veterans in my district. I am going to stand here and 
continue to fight every day until we change a broken system.
    So God bless you.
    Mr. Coates. Thank you.
    Mrs. Walorski. And together, let's change this system so no 
other veteran ever, ever has to do what you are going through 
and your family as well. And you are in our thoughts and 
prayers. We will stand with you through this as you continue to 
go through this process. But God bless you for being here 
today.
    Mr. Coates. Thank you, ma'am.
    The Chairman. The gentle lady yields back her time.
    Dr. Ruiz, you are recognized.
    Dr. Ruiz. Thank you very much, Mr. Chairman.
    First, Mr. Coates, I apologize again for the missed 
diagnoses that occurred in your case. Thank you for your 
strength. Thank you for your honor, your dignity. Thank you for 
being a voice for all those other missed diagnoses that has 
occurred.
    I am an emergency medicine doctor, and I see here that the 
ER doc recommended a colonoscopy. That was the right thing to 
do. It is unacceptable, and as someone who pursues excellence 
in medical care, it is very infuriating to know that a 
gentleman who comes in with rectal bleeding at any point did 
not have a rectal exam or an endoscopy or any other diagnostic 
study that would have detected your rectal nodules.
    I think that what we need to do now and, you know, I look 
at my colleagues, Mr. Cook and Ms. Walorski, and I thank you 
for your passion and I am sorry to hear about your father as 
well. And Mr. Cook, I can only imagine your memories of those 
soldiers who have given up themselves and their lives to 
protect others and I thank you for your service. It is very 
strong, coming from the heart.
    And I believe this to my--I say this to my colleagues, is 
that in this individual case we have missed a diagnoses and I 
hope that our committee does not miss the diagnoses that we 
must pursue in order to remedy this, to determine 
systematically whether or not we have more medical errors, more 
complaints from patient care and more litigations that were 
found successful to the VA versus any private healthcare system 
that we would consider the gold standard because we not only 
expect the gold standard, we expect our VA system to be beyond 
the gold standard because our veterans are beyond the gold 
standards of our citizenry in our country.
    And so if there is a study or if there is a commission that 
we would be able to start as a committee to compare and 
contrast, to determine if there is a systematic increase of 
maltreatment, misdiagnoses, then I would be very much inclined 
to look at that diagnoses and take adequate treatment because 
we missed a diagnosis in this individual case. I want to make 
sure that the rectal nodule and cancer of our VA system gets 
removed as well.
    Thank you. I yield back my time.
    The Chairman. The gentleman yields back.
    Mr. Bilirakis, you are recognized for five minutes.
    Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it so 
very much. And sir, thank you very much for your service. You 
are an extraordinary individual. Thank you for coming today and 
sharing your story.
    I wanted to ask, sir, the VA has an ethical and legal 
obligation to disclose to patients adverse or potentially 
harmful events that have been sustained in the course of the 
patient's VA care. I know the gentle lady touched on this and I 
want to ask once again, sir, were you notified and informed of 
your rights and recourse?
    Mr. Coates. To my knowledge, no, sir.
    Mr. Bilirakis. Say that again, sir. I am sorry.
    Mr. Coates. To my knowledge, no, sir.
    Mr. Bilirakis. No, sir, okay. And I know in your statement, 
in your testimony you may have mentioned this in your opening 
statement, and forgive me, I was a little late for the meeting, 
but you state and I quote, ``The gross negligence of my ongoing 
problems and crippling backlog epidemic of the VA medical 
system has not only handed me a death sentence, but ruined by 
quality of life.''
    That is simply heartbreaking to hear. So would you like to 
elaborate some more? I want to give you the opportunity to, if 
you will.
    Mr. Coates. As far as ruining the quality of my life?
    Mr. Bilirakis. Quality of life, yes.
    Mr. Coates. Yes, sir. Thank you for the opportunity. Yes, 
it has dampered my quality of life to a great deal. Other than 
what I mentioned earlier about still having to go on with the 
chemo treatments and for now over two years now, and looking 
for other avenues but, you know, I have other family members 
other than myself to look at and like any one of us here, you 
know, you have children and you have grandchildren. I have 
children and I have grandchildren.
    The question is, and you don't never know how much longer 
you have. You better enjoy them and them enjoy you. You take 
one day at a time. That is my philosophy. You live every day as 
it is going to be your last day. And once you do that, then the 
next day will come and you start again and you live that like 
it is your last day.
    And this has dampered a lot of what I can do, a lot of 
enjoyment. You know, I am 44 years old. I will be 45 in May of 
this year, but I am fairly young and a lot of things I can't 
do. I can't get out and enjoy playing with my grandchildren. I 
can't enjoy doing things that I could as a normal 45-year-old 
man.
    A lot of things has been taken from me because of that. I 
wanted to do things as far as--an example, if I want to get out 
there and play baseball with my grandchildren and do running or 
anything, I am not capable of doing that. I can't lift but so 
much weight because I have a ostomy from that.
    If I decided I wanted to--at my age, you know, you probably 
look at me and say I am crazy--if I want to have another child, 
I can't do that now. That option there is gone. And there are a 
lot of other things that, you know, I enjoy doing that I use to 
do that I can't do now, and it has affected my life a lot and 
my family's life a lot and now I look at what my children and 
my grandchildren look at me and they probably look and think, 
well, why can't my--why doesn't my dad, can't enjoy himself. 
And my grandchildren say, well, why can't you come out and play 
with me and do things like the other dads or other granddads do 
with them. And so that is something I am going to have to live 
with and deal with the rest of my life and hopefully my being 
here today, that maybe I am saving another father or another 
mother from having to go through the same tragedy that I went 
through and have a better quality of life for doing it.
    Mr. Bilirakis. I will tell you, sir, you are a tremendous 
role model for those children and grandchildren. I know they 
are very proud of you.
    I have one question for Mr. Dellinger, if I may, Mr. 
Chairman.
    I understand from your written testimony that The American 
Legion has been waiting for five months to receive a report 
from VA regarding the Jackson VA Medical Center. Is it common 
for your organization to experience lengthy wait times to get 
information from the Department?
    Mr. Coates. Yes, we do see lengthy delays with the fact 
that everything is centralized in Washington, D.C. They try to 
do everything out of Washington. We think it is very important 
that they empower the medical centers and the directors to be 
able to address crisis in a timely and quick manner.
    Mr. Bilirakis. Thank you very much. We got to do something 
about that, Mr. Chairman.
    Thank you very much for your testimony and I appreciate it. 
I yield back the balance of my time.
    The Chairman. Ms. Negrete-McLeod, you are recognized for 
five minutes.
    Dr. Benishek has not returned.
    Mr. Coffman, you are recognized for five minutes.
    Mr. Coffman. Mr. Coates, thank you so much for your service 
to our country. Which branch were you in again?
    Mr. Coates. Army.
    Mr. Coffman. Fantastic. And again, on behalf of the 
American people, I certainly apologize as so many other members 
of this committee have to you for the treatment that you got 
from the VA system. Let me ask you this question. Do you think, 
if you were given an option to be able to go outside the VA 
system and have it compensated through the VA for medical care, 
would you have taken that option?
    Mr. Coates. Knowing what I know now, yes, I would.
    Mr. Coffman. Do you think other veterans ought to have that 
option that if there are such delays in the system, if they are 
unable to do proper diagnosis and something as simple as blood 
in the stools, that veterans ought to have choices?
    Mr. Coates. Yes, sir, I think they should and the reason 
for that is, if you get in a situation like that when you 
approach somebody's health and their quality of life or life or 
death situation, and even under civilian medicals, you have a 
choice of what doctor you want to go to. And under the VA 
system, I think you should have the same opportunity there, 
what health care you want to use, what physician you want to 
use, what specialty physicians you want to use. And especially 
when you get in a situation where you have a backlog like there 
was and the bad and the sad part of it and I think this comes 
from Mr. Miller, I remember hearing, I think there was money 
allotted to the VA system at Dorn back in 2011 and it was 
misused.
    The Chairman. It was over a million dollars.
    Mr. Coates. Correct. And no one has asked for that yet. I 
don't know where it went. They say it was misappropriated. 
Well, what happened to it and who is responsible for that? Why 
didn't it go where it went? We can't answer that, but we can 
find out why and make sure it doesn't happen again.
    Second of all, that was to help the backlog of those 
patients and the sad part of it is that was during the time I 
was going through that in 2011.
    The Chairman. Let me ask you this. The reality is you are 
the victim of the system that did not care as much as they 
should have about their patients. Do you think that culture or 
that system exists because of the fact that they don't see 
themselves competing, that you are their only choice, that they 
don't see themselves competing with anybody else, so that if 
you had an option to go outside the system and they would have 
to pay for that and that was your freedom to make that 
decision, do you think that they would have handled your case 
any differently?
    Mr. Coates. I think they probably would have. Any time it 
comes down to--and I am not the only one who probably knows 
this and anybody across America has known this--when it comes 
to spending government money, there are a lot of things that 
they like to spend it on and there are a lot of things that 
they pinch pennies about. If it is for national defense and it 
needs to be done, why, they jump on it. If it something saving 
somebody's life, they get in a big debate about it, why does it 
need to be spent, where does it need to be spent at, and we 
have run across this and here recently in the past year, 
debates in the House and debates in the Senate, the debt 
ceiling being raised and allocated money for where it goes.
    But reality and you look into it, and you look at what we 
spend for different small items and you can probably request 
this information from somewhere, and I have heard this from 
other sources, what we pay for little small things like a 
hammer, a toilet seat, you know, $150, $350, when you can go to 
anywhere and buy it for $10, $12, we spend money where we think 
it needs to be at and where it not needs to go.
    And the sad part of it is, we don't get choices like that 
of knowing where it goes and where it doesn't go. There are the 
people who have the authority to rest upon where it goes at.
    Mr. Coffman. Well, Mr. Coates, I again am sorry about your 
advanced rectal cancer as a result of substandard medical care 
by the VA, and I just want to say that they have received, the 
system has received a higher appropriation every single year. 
And so it is the question of how that money is utilized.
    And with that, Mr. Chairman, I yield back.
    The Chairman. I have a bunch of questions, but I am not 
going to ask them. You have given of your time today. Your 
story is more than compelling. I, like the other members of 
this panel, want to say thank you for your service in and out 
of uniform.
    Ms. Brown. Thank you. My question is really for the 
commander. My question is, you know, I have been on this 
committee for 22 years as I have mentioned and you have been 
here, well, I believe, almost as long as--more than ten years. 
But my question, some of the members say that the VA system is 
broken. I don't feel like it is broken. I feel like we need to 
do what we need to do to fix it.
    But I have traveled to, I can't tell you how many 
hospitals. I was in one that's going to be one soon yesterday, 
all day. But the point is, my feeling is that the VA people 
that I met with and talked to, I think they really care and it 
can't be just my district. It can't be just those areas in 
Florida or Tampa that I have been to or Jacksonville or 
Gainesville or Lake City. I mean, I have been to California 
and, you know, I have met with the people there and when I went 
out there I found out we had 400 units that just was sitting 
there and people could be using them.
    So the point is, on a one to ten, if you are going to 
evaluate the system, and I know we got problems. We are sitting 
here listening to the problems and I really think we need to be 
able to go outside the system to get certain services.
    How would you evaluate the system?
    Mr. Coates. It is a great question. I really believe I need 
to break that into two aspects. First, being the medical care 
that you receive at the medical centers and at the community-
based outreach clinics. I think that is an eight to a nine 
because as you mentioned, they really do care. They really want 
to help.
    But what I think is broken is when you talk about the 
oversight and the works of the VA central offices and regional 
offices, I would rate that at about a five. They need a lot of 
improvement. Where we see most of our problems are at the 
regional and the central offices, not at the medical facilities 
themselves.
    Yes, there are instances just like Mr. Coates, but the 
overall system there, I think they are wanting to do better and 
just as a director tried to do, you know, wherever you see 
blood at this point, you get a colonoscopy. They are addressing 
these.
    Ms. Brown. That is common sense.
    Mr. Coates. It is common sense. But when you have a failure 
at the--just like during the Legionella in Pittsburgh when they 
had a statement ready to go out and they had to send it back to 
Central Office so that they would evaluate the statement. It 
never got released. It is such a bureaucracy.
    Ms. Brown. Okay. So you are saying the part of the problem 
with the culture is that it is too--you don't have enough 
responsibility on the regional level?
    Mr. Coates. I think regional, central area, yes, across the 
area.
    Ms. Brown. Okay. Okay. But I really find that this, you 
know, maybe in this particular case, the person, it could have 
been cultural differences as far as--I mean I just can't 
imagine somebody not caring. I mean, I serve on this committee 
because I care. And I think the people working in the VA, to 
just say that they work for a check is way beyond me because 
these people have served us, and what we are doing is giving 
back. This is the other opportunity to serve.
    Mr. Coates. Ms. Brown, I have with me Field Service Officer 
Lilly and he is out there every day. He goes to the System 
Worth Saving, he goes to the regional and central offices. I 
would like for him to make a comment on this also.
    Ms. Brown. Thank you. Thank you.
    Mr. Lilly. Thank you, Commander, and thank you, Ms. Brown. 
I wanted to comment on what you said earlier about employees 
coming forward and trying to address the problem before it 
escalates and I completely agree with you there because what 
happens is there is this negative stigma of whistleblowers. 
That is what those employees become or they are former 
employees.
    So the local facilities on the local level need to be 
empowered to address crises when they happen, and that is not 
how it is right now and that is what our commander was 
referring to when he was saying that it takes a long time for 
these facilities to address what has happened because they have 
to get approval from Washington, DC. And that is what we have 
seen in Pittsburgh, Jackson, Atlanta, all these different 
trips.
    The veterans are scared. They are nervous. They are afraid 
to go to their own healthcare system because they just don't 
know what steps the VA is taking to address the issue.
    Ms. Brown. Well, thank you very much, and thanks again, 
thank all of you for your service.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Ms. Brown. Thank you, Members, for 
holding your questions until the next panel.
    And thank you very much, Mr. Coates, for being here.
    Commander, thank you and you are excused.
    Members, we are going to switch up the witnesses and we 
will take VA next instead of waiting until the third panel, so 
we will be preparing the table for the second panel.
    Members, joining us at the second panel is Dr. Thomas 
Lynch. He is the Assistant Deputy Under Secretary for Health 
for Clinical Operations and Management.
    Dr. Lynch is accompanied this morning by Dr. Carolyn 
Clancy. She is the Assistant Deputy Under Secretary for 
Quality, Safety and Value.
    Dr. Lynch, you are recognized for your testimony.

    STATEMENT OF THOMAS LYNCH, M.D., ASSISTANT DEPUTY UNDER 
 SECRETARY FOR HEALTH FOR CLINICAL OPERATIONS, VETERANS HEALTH 
     ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS, 
ACCOMPANIED BY CAROLYN M. CLANCY, M.D., ASSISTANT DEPUTY UNDER 
   SECRETARY FOR QUALITY, SAFETY, AND VALUE, VETERANS HEALTH 
      ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

                   STATEMENT OF THOMAS LYNCH

    Dr. Lynch. Mr. Chairman, let me begin by saying that we 
have heard a compelling story. I need to recognize the fact 
that what we have heard is a sad story.
    Before I walked up here, I apologized to Mr. Coates. I told 
him that I am sorry for what happened. If he did not receive an 
institutional disclosure, I initiated that by extending my 
apology on behalf of VHA.
    I also commit that we will look into what happened so that 
we can understand and he can get a better explanation and the 
explanation that he deserves.
    I was looking around. It appears that he has left the room. 
I did and I want to publicly thank him for his service. I want 
to thank him for reminding us of what we are here for and for 
the people that we are serving through VHA and our healthcare 
system.
    I am going to go pretty much off script. I want to let you 
know that Dr. Clancy and I are here because I think we share a 
common value with you, sir, and with the committee, and that 
value is to provide quality care to our veterans.
    I would also suggest that we are here because we share 
common concerns and those are concerns regarding harm that has 
occurred to veterans in our healthcare system.
    I think it is good that we hear these stories, that we not 
ignore when harm has occurred. They are powerful. We need to 
learn from them and we need to do better.
    I think also I would like to acknowledge publicly that I 
think the relationship between VA and Congress has been a 
constructive relationship in the past. I think many good things 
have occurred in VHA healthcare because of the concerns you 
have expressed and because of the actions we have taken.
    In the late 1980s there were significant concerns about the 
quality of surgical care in the VA. The VA developed what was 
then called NSQIP, the National Surgical Quality Improvement 
Program. It is now called VASQIP. It gives us a risk adjusted 
model to assess outcomes in our surgical programs.
    It is so powerful, it has been adopted by the American 
College of Surgeons. It is now used to provide oversight and 
evidence to healthcare systems and to physicians to allow them 
to improve the services that they provide.
    In the mid-1990s, there were concerns expressed on behalf 
of Congress regarding the quality of our healthcare system. In 
response, the VA developed the electronic medical record. This 
is an advance that has now been adopted by the private sector.
    The VA has also moved towards looking at the way we deliver 
care and how we focus care with respect to prevention; 
preventing illness, not necessarily treating illness. This 
means that we don't necessarily have to put people into 
hospitals. We can treat them as outpatients. It is a model that 
is now being adopted in the private sector.
    I want to go back and make one point from what had been my 
prepared statement, Mr. Chairman, and that is that over a third 
of our employees are veterans and the fact that everyone in VA 
is constantly striving to eliminate the clinical and 
administrative errors that may occur.
    We strive, sir, to be transparent in disclosing what has 
happened. As a system, we have taken a lead in being 
transparent, we have taken a lead in clinical disclosure. We 
are not perfect, sir. We are a learning organization.
    When errors occur, we do try to express apologies to the 
involved patients and to their families. I think I will close 
with a statement from Ralph Gabarro. He is the former CEO of 
the Mayo Regional Hospital in Dover-Foxcroft, Maine. I think he 
has said it best, sir.
    To paraphrase, preventable patient deaths are a nightmare 
for our entire medical community, but our feelings, what we are 
going through, pales in relationship to what the families are 
dealing with and we understand that, sir.
    We are now prepared to take your questions.

    [The prepared statement of Thomas Lynch appears in the 
Appendix]

    The Chairman. Thank you, Dr. Lynch. Your recent National 
Consult Delay Review disclosed two deaths in Arizona, but 
committee investigation show that it appears that it could be 
much worse than you know or if you do know that it is worse 
than what the committee has been told, so I want to tell you 
about some information that we have received here in the 
committee as it relates to Phoenix.
    I have been made aware of internal emails from within the 
VA that suggest that Phoenix VA may have been using an 
unofficial electronic waiting list where veterans were placed 
on that unofficial list until an appointment became available.
    These lists were supposedly designed to give the appearance 
that veterans were only waiting for appointments for 24, 25 
days or less and they potentially contain thousands of names. 
In cross referencing the two lists, it appears as though there 
could be as many as forty veterans whose deaths could be 
related to delays in care.
    Were you made aware of these unofficial lists in any part 
of your look back?
    Dr. Lynch. Mr. Chairman, I was not. And Mr. Chairman, I 
would say that I have tried to work with your committee. I have 
visited with your staff. I was in Atlanta. I was in Columbia. I 
was in Augusta when you made those visits. I have tried to 
share the information that we have gained as we are obtaining 
it. I know it is not perfect information, sir, but I know there 
is a desire on your part to know that information as we obtain 
it.
    I am more than willing to meet with your staffers and take 
their information so that I can use it, sir. If I don't have 
that information, I can't act on it.
    The Chairman. So your people had two lists and they kept it 
from your knowledge. So my question is, does that make you even 
internally question the validity of the information being 
utilized in your look back or your review?
    Dr. Lynch. At the moment, sir, it does not, but I am open, 
I am happy to meet with your staffers, I am happy to look at 
the data so that we can understand it and see what the issues 
and the problems are.
    The Chairman. I want to provide you with a request for a 
preservation order for all potential evidence at Phoenix VAMC 
and I would also ask the Inspector General for Health care, Mr. 
Daigh, to look into this issue as soon as possible. I will be 
putting a letter to you quickly, but I make this as an official 
request on the record and we are ready to assist by providing 
our evidence and any assistance that Dr. Daigh may need as he 
goes forward.
    It has been mentioned a couple of times in here about Dorn 
being awarded a little over a million, 1.02 million or some 
number like that to help in the backlog of fee-basis 
colonoscopies and money was provided in September of 2011. I 
have still not been able to get a solid answer where that money 
went, so I am hoping that you might be able to provide an 
insight this afternoon.
    Dr. Lynch. Mr. Chairman, I know that that information has 
passed through VHA. I took the opportunity to listen to the 
Deputy Secretary's hearing the other day. I know he has 
committed to increasing the communication with Congress and 
with this committee, and I support his efforts and will do what 
I can to get you the information that you need, sir.
    The Chairman. So, again, another piece of information the 
committee awaits. I specifically asked for a complete 
accounting of those dollars when I was at Dorn earlier this 
year.
    On the 22nd of February in a Health Committee hearing, Dr. 
Benishek asked Dr. Petzel to provide a list of circumstances 
surrounding the removal of six SES employees over the last two 
years. Dr. Petzel promised at that hearing that he would 
provide that information at the end of that week.
    This is April 9th. It has been six weeks since the 
committee asked for the information. We have not received it. 
This information was referenced in a subcommittee on economic 
opportunity hearing that was chaired by Mr. Flores and, by the 
way, Mr. Flores is absent today because he is at the memorial 
for Fort Hood Texas, and the committee staff has made numerous 
requests.
    So I would also note that this statistic was also noted in 
your written statement for this hearing. So why is VA keeping 
this information from the committee when it was an entirely 
reasonable request?
    Dr. Lynch. Sir, I wish I had an answer for you that you 
would find acceptable. I could only repeat that I support the 
Deputy Secretary's efforts to get you the information.
    The Chairman. I have a bill right now, Dr. Lynch, that 
gives the secretary additional flexibility to fire SES 
employees. Out of the 320,000 employees at the Department of 
Veterans Affairs, we are only talking about 450 individuals. 
The secretary is pushing back saying that he has the tools and 
that he has, in fact, taken the necessary steps and we are 
talking about six people and we have been waiting months now to 
get that information, and I just--as the chairman and 
subcommittee chairman and the ranking members sit here just 
wondering why in the world it takes so long.
    In January, following my visit to Columbia and Augusta, 
which you were at, to follow up on the delays in care, I wrote 
a letter to the secretary asking for specific information 
regarding consult backlogs at those facilities and others in 
general. And though I requested a response be provided within 
thirty days, I have yet to receive a response, an answer from 
the department, so I ask you again, as somebody who should be 
intimately involved in the preparation of the secretary's 
response, when can the committee expect to receive that 
information?
    Dr. Lynch. I don't want to sound like a broken record, sir. 
I realize that you take this seriously. I realize that your 
committee takes the responsibility seriously, and I accept the 
fact that there can be a constructive relationship between the 
committee and the VA, and I hope to be part of that solution, 
sir, and not the problem.
    The Chairman. Ms. Brownley, you are recognized.
    Ms. Brownley. Thank you, Mr. Chair. And I wanted to ask, I 
know we skipped over a panel, but I wanted to refer back to 
some of the testimony that I reviewed from Dr. Daigh who spoke 
specifically around the problems in Columbia, around the 
consult backlog, and one of the indications that he gave was 
the availability of fee-based care, that it had been reduced.
    I wanted to just hear your comments on that and why fee-
based care was reduced in Columbia.
    Dr. Lynch. I don't have the full explanation for that, 
Congresswoman. I believe the facility felt at the time they had 
the resources to solve the problem. In retrospect, they did 
not. I think, however, Congresswoman, that in the process of 
looking back over what happened, we have developed a tool that 
gives the facility, that gives the network and it gives VA 
Central Office eyes on delays and helps us ask critical 
questions of a facility in terms of should they be using fee-
basis care.
    We have improved our fee-basis process. We have implemented 
the PC3 process which helps us interact with the community to 
obtain services. I think we have the ability to identify where 
our demand exceeds our capacity, to understand why that may be 
occurring, and as we move forward, to effectively use fee 
basis.
    Ms. Brownley. Thank you. And this tool that you are 
speaking of, can you give me some more details about what that 
is? What triggers you to begin to look at it? How long do the 
backlogs have to be before you begin to put your eyes on the 
problem and try to rectify it?
    Dr. Lynch. I think, first of all, the answer is that it is 
individualized, but let me explain the tool to you. As we began 
to look back at our consults after the incidents in Columbia 
and Augusta, we observed that there were flaws in our consult 
process that allowed consults to remain open or unresolved.
    That put noise in our system and it prevented us from 
trying to identify those facilities where there was need for an 
alternative, such as fee-basis care.
    Over the past year, after the incidents in Columbia and 
Dorm, we went back. We examined over 250 million consults since 
1999 in VA. We identified where there were delays. We had to 
resolve those consults and make sure that they were closed 
appropriately and that services were provided. And in the 
process of doing that, we implemented new business rules that 
helped us separate our clinical consults from what had become 
some administrative uses of that consult system.
    We are in the process of completing that review. It should 
be completed in the next month or two. With that and with new 
business rules, we will have the ability to look at a facility, 
to look at individual specialties within a facility, to take a 
look at trends in delays and to ask critical questions; whether 
the facility has the resources to address those delays, whether 
the facility thinks those delays are temporary, transient, or 
whether the trend is an indication of increasing delays, and to 
then work with the facility to decide do we need to add more 
staff or do we need to use fee-basis services.
    Ms. Brownley. Thank you. Are you collecting any data as we 
speak, looking ahead--we talked a lot about looking to the past 
and what needs to be done for the future--but looking ahead, 
are you collecting data and benchmarks vis-a-vis consult 
backlogs throughout the VA. Obviously, we have determined there 
was some VISNs, there have been some real problems, but are we 
going to collect that data to understand the data that data 
gets shared with the committee and where are the trigger points 
that we can make an immediate fix to what potentially could be 
a very, very serious problem.
    Dr. Lynch. I think the answer to that is yes, 
Congresswoman. In fact, about six months ago, using some 
initial data that we were beginning to collect, we sent over a 
$100 million out to the field for facilities to use to contract 
for fee-basis services. We reduced the wait time, the backlog 
at that point, by almost 50 percent or 50,000 patients.
    So we have begun to use that tool. I think we can also 
begin to use that tool to look at what I think is the critical 
issue when we look at access, and that is delayed care. We 
focus on fourteen day access, but really, importantly, we need 
to look at where care is delayed. And we can set the filters on 
this system to look at delays at variable lengths of time, and 
as we get control of the system, slowly reduce backlog from 
ninety days to sixty days to thirty days based on the 
information that we will get.
    Ms. Brownley. Thank you. I yield back.
    The Chairman. Mr. Huelskamp, you are recognized for five 
minutes.
    Dr. Huelskamp. Thank you, Mr. Chairman. Just a couple of 
follow questions if I might. First, in reference to our 
previous speaker, Mr. Coates, are you familiar with the 
specifics of his situation?
    Dr. Lynch. I have not reviewed the specifics of his 
situation. I assure you, I will.
    Dr. Huelskamp. And Dr. Clancy, have you any familiarity 
with this situation?
    Ms. Clancy. Not before what I heard this morning. Not 
before what I heard this morning.
    Dr. Huelskamp. Okay. I would ask if you could also follow 
up on the situation in prior discussions with Mr. Coates that 
currently VA is requiring him to drive almost four hours for 
some follow-up treatments instead of being able to receive it 
right close to home. Would you please follow up on that and see 
if that is indeed that case?
    Ms. Clancy. Absolutely.
    Dr. Huelskamp. Okay. Additionally, I would like to ask a 
couple of questions of Dr. Lynch. What specific person at the 
VA Medical Center level is responsible for ensuring timely care 
is delivered to veterans?
    Dr. Lynch. Ultimately, it is the Medical Center director, 
sir, working with his quadrad, the director, the chief of 
staff, the chief of nursing and the associate director who 
often deals with engineering and environment of care.
    Dr. Huelskamp. And what specific person or position at the 
VISN is responsible for ensuring timely care?
    Dr. Lynch. Ultimately, it is the network director, sir. He 
or she works with the chief medical officer and with the 
quality medical officer.
    Dr. Huelskamp. And then at the VA Central Office level, who 
is responsible for timely care?
    Dr. Lynch. Ultimately, that would go to the office of the 
deputy under-secretary for operations and management and to Dr. 
Petzel.
    Dr. Huelskamp. And out of the people in positions you have 
just named and anywhere from twenty to forty deaths by delay of 
veterans, do you know if anybody at all has received any 
disciplinary action whatsoever?
    Dr. Lynch. I believe that Dr. Petzel discussed disciplinary 
action the last time he was here. I believe we have identified 
two physicians in Memphis, which is another issue, where there 
was discipline. There was discipline in Augusta, as well as 
Columbia, and there was discipline in Atlanta.
    Dr. Huelskamp. And did anybody lose their job?
    Dr. Lynch. I can't answer that specifically, sir.
    Dr. Huelskamp. You don't have the information or is it a 
refusal to----
    Dr. Lynch. No, I don't have the information, sir. If I did, 
I would share it with you. I guess I would say, maybe in 
response--I understand your concern. I understand the 
chairman's concern regarding accountability and I think that is 
important and I think VA has some very prescribed purposes for 
that.
    I am troubled a little bit by whether or not firing 
somebody is necessarily the answer. I think, as I mentioned 
earlier, almost a third of our employees are veterans.
    Dr. Huelskamp. Would you be opposed to taking away their 
bonus?
    Dr. Lynch. Pardon?
    Dr. Huelskamp. Would you be opposed to taking away their 
bonus?
    Dr. Lynch. Could I just continue for just a second?
    Dr. Huelskamp. I don't have time for that answer.
    Dr. Lynch. I think we need to be careful about punishing 
everybody for what may have occurred at one or two medical 
centers. I think by and large, sir, we have good people who 
care for veterans, who deliver quality care. And I think in 
those circumstances they should be rewarded. I don't think we 
should punish the system for what may be incidents that 
occurred in individual medical centers.
    Dr. Huelskamp. Lastly, Dr. Lynch, I am looking at your 
handbook that provides the procedures for disclosure of adverse 
events to patients.
    Dr. Lynch. Yes, sir.
    Dr. Huelskamp. And it is pretty clear of the ethical 
requirements: ``Unwavering ethical obligation to disclose to 
patients harmful adverse events that have been sustained in the 
course of their VA care.'' Has this been disclosed to Mr. 
Coates?
    Dr. Lynch. It would appear from his testimony that it 
hasn't, sir. I think VA has taken a lead in this area. I don't 
think we are perfect, but I think we have a good system and it 
can be better.
    Dr. Huelskamp. And if one failed to disclose this as 
apparently it is the case to Mr. Coates, what is the 
punishment? Who is punished for failure to meet an unwavering 
ethical obligation?
    Dr. Lynch. Sir, at this point I don't know. I need to 
understand the circumstances that occurred and I will be 
looking into that.
    Dr. Huelskamp. Yeah, I would appreciate the specifics on 
Mr. Coates, but the general question is who is responsible for 
meeting this unwavering, ethical obligation?
    Dr. Lynch. The handbook would tell you that it is the 
executive team of the hospital. It is the director. It is the 
chief of staff. It is the chief of nursing.
    Dr. Huelskamp. Thank you, Mr. Chairman. Yield back.
    The Chairman. Mr. O'Rourke, five minutes.
    Mr. O'Rourke. Thank you, Mr. Chair.
    Dr. Lynch. Mr. Coates made a very powerful case that the 
delay of service to a veteran can effectively mean denial of 
life-saving care to a veteran, and I think you have made the 
commitment to look at his case specifically; find out what you 
can learn from that; apply those lessons to improving the VA, 
and specifically what happened with those specific doctors and 
he relayed an anecdote or anecdotes of poor performance on 
behalf of the doctor, but he also showed us that there are some 
truly terrific public servants working for the VA. He mentioned 
the doctor who retired from private practice and is spending 
time within the VA because he cares about veterans and he wants 
to make sure that they get the best care.
    I have found that to be the case in El Paso, that we have 
really wonderful doctors, terrific care for veterans who can 
get in my community, and far too often in other parts of the 
country is that it is very hard to get into the VA and get an 
appointment and see a doctor. Anecdotally, I have heard from 
veterans who served as back as World War II, who need simple 
procedures like cortisone treatment who have to, as Mr. 
Huelskamp just described, travel four or five hours to the 
nearest VA hospital in Albuquerque to get that care. They 
decide not to get the care and they end up either suffering, 
choosing an alternative or just going without.
    I have spoken to countless veterans who just delay or just 
do not receive appropriate treatment, procedures, or surgeries 
for the same reasons. That anecdotal information has been borne 
out by the recent SAIL report that the VA OIG recently produced 
that showed that El Paso is arranged 123 out of 128 VHA 
facilities for access to care, and when we drilled down into 
the numbers a little bit further, we found that as recently as 
six months ago, only 18 percent of veterans seeking to make an 
appointment were actually able to get an appointment within a 
reasonable period of time, a standard that you all set for 
yourselves. So for those 82 other out of every 100 veterans 
trying to make an appointment, they can't get in and find care.
    So, you know, Mr. Huelskamp approached this, I think 
rightfully so from a perspective of accountability, and what do 
we do when people don't perform, when veterans don't get access 
and we have these poor outcomes?
    To look at the other side of the question: What are you 
missing in resources to be able to provide the access that we 
need to hire the very best doctors, or in El Paso's case, 
enough doctors so that veterans can get in and get an 
appointment? What are we not providing to you and to the VA 
that you need to be able to turn this situation around?
    Dr. Lynch. Dr. Clancy.
    Ms. Clancy. So first, I want to say to you and your 
colleagues here that we very much appreciate the privilege and 
opportunity and honor of serving the men and women who have 
effectively written a blank check to this country; there is no 
higher calling, really, in medical care delivery.
    The issue of timely access is one that we take seriously, 
so to the extent that you have additional information that we 
haven't seen, we would love to see and work on that with you.
    Mr. O'Rourke. Here's the thing--and I appreciate what you 
just said, but I have spoken to Dr. Petzel about this. You all 
had measured it and seen the outcomes and the lack of service. 
I am with Ms. Brownley and others who question whether the 
number of preventable deaths is really accurate. Who knows how 
many of those in El Paso who are not able to get an appointment 
or who were told they had to make a ten-hour roundtrip and 
those not to have the procedure, who knows who their outcomes 
were. I don't know if we are effectively measuring that.
    What I want to know--and I have tried to do this in the 
most cooperative, polite, diplomatic fashion I can think of--
what I want to know is what you are going to do to turn that 
situation around, and if you need something additional from me, 
as a Member of Congress, from us as a committee, from the 
House, the Senate, in terms of appropriating resources, what 
are you missing that is preventing you from delivering the 
standard of care that our veterans should be able to expect?
    Ms. Clancy. What we are working on right now are new 
programs to improve our ability to schedule appointments in a 
timely fashion. In addition to that, particularly for folks who 
live in rural areas where traveling great distances often is a 
big challenge, we are looking into other options when it is 
feasible. Obviously, if you need an injection or a procedure, 
you can't do that remotely, but we are looking at a variety of 
telehealth options sometimes for video consultation. It seems 
to be a very, very effective way to improve access for people 
who have mental health appointments, and other venues so that 
we can be able to get people in faster, and I will personally 
follow up with Dr. Petzel about your request.
    I wanted to make one other comment, just about rankings. If 
you have 152 hospitals or centers in a system, there will be a 
number one and a number 152. I think the real question is: Is 
123, how does that stack up against the private sector and what 
is the gap between best possible care and----
    Mr. O'Rourke. And use the other metric that I gave you, 
which is 82 out of every 100 veterans trying to make an 
appointment in El Paso cannot get in, in a reasonable amount of 
time, a standard in which you set. And I have asked Mr. Petzel 
publicly. We have talked to the office privately.
    When can we get something in writing that will tell us when 
you will be able to meet the standard of care that you, 
yourselves, have set for the veterans in El Paso, and the 
veterans all around this country, and I am still waiting for 
the reply. So I am going to ask you, again, publicly, to please 
work with Dr. Petzel and our office to get us that reply.
    Mr. Chair, thank you.
    Ms. Clancy. I will do that.
    The Chairman. The gentleman's time has expired.
    Dr. Benishek----
    Dr. Benishek. Thank you.
    The Chairman [continuing]. Chairman of the health 
subcommittee, you are recognized for five minutes.
    Dr. Benishek. Thank you very much, Mr. Chairman.
    I thank both of you for being here this morning. Frankly, 
this makes me really angry, all right. I mean Mr. Coates is 
here testifying about this care at the VA where he has going to 
die and as far--I am a general surgeon. I do colonoscopies. I 
do colonoscopies at the VA.
    This man did not receive the standard of care and it is 
very frustrating for me to be here and have people calmly 
explain to me how they are working really hard to make things 
happen when there is not an emergency. This is an emergency. 
This gentleman did not receive the standard of care, all right. 
He did not receive an apology.
    It is hard for me to understand, you know, when I ask Dr. 
Petzel for what are you doing for this kind of stuff?
    And it was six people have been disciplined and then I 
can't even get an answer from him as to which people and why. 
So how can I believe that the VA is serious about putting a 
stop to this stuff when I ask a simple question and I can't 
even get an answer to it. It is very frustrating to me that we 
have to come up with some sort of legislative fix for how you 
people manage your department.
    I mean it should be a management decision that, you know, a 
physician who is not giving a colonoscopy when people have 
rectal bleeding or blood in the stool. This has been the 
standard of care for 30 years. And, you know, for not even 
getting a consultation for a colonoscopy for a year and then to 
get six months before he is--from what I can understand from 
the timing--six months.
    This is an emergency. If I see somebody in my office with 
rectal bleeding, they get a colonoscopy like the next day or 
within the week. And I don't know--you know, I just get so 
frustrated by people like you that come here and calmly say we 
are going to fix it and it never gets fixed.
    Dr. Lynch. Congressman, I am a surgeon by training. I have 
spent the last 30 years working in the VA system working with 
veterans, training residents, working with medical school 
students. I am angry, as well, sir. I share your anger.
    I have been working for the last year since I have been 
here in central office to put together the tools that give us 
what we need to manage our system in a fashion so we can 
identify where there are delays and----
    Dr. Benishek. No, I understand.
    See, you calmly answer me----
    Dr. Lynch. I am not calmly answering you, Congressman. I am 
angry like you are angry.
    Dr. Benishek. But I don't see any progress, Dr. Lynch. I 
don't see any progress.
    I mean all I asked of Dr. Petzel was for some things here. 
We don't see where you are actually fixing it. All we get is 
calm responses from people that are assuring us that we are 
actually doing it, but we don't see any progress and, you know, 
when I see a case like that case that was presented here 
earlier by Mr. Coates, I just can't stand--what are you doing? 
I mean what mechanism do you have to find out about stuff like 
this?
    What happened to that doctor? Why wasn't she working on--at 
the standard of care? I mean these are the kind of questions 
that we need answers to and we don't ever get them, and so I am 
very disappointed with the quality and the management of the 
VA. I mean I worked at the VA for 20 years myself. I think that 
the VA has made tremendous improvements over the last 20 years, 
there is no doubt about it, and I applaud you for doing your 
career there, but, you know, coming from that system, where I 
worked as a physician, and I come here, and knowing, you know, 
how the bureaucrats work there, the physicians, to me, didn't 
have enough input as to how things were done; it was the 
bureaucrats that decided about a lot of this stuff.
    So I would be happy to work with you to give you my insight 
as to how to do this better. You know----
    Dr. Lynch. Congressman----
    Dr. Benishek [continuing]. Like I said, it is great----
    Dr. Lynch [continuing]. I would be happy to meet with you.
    Dr. Benishek. What is the second half of that?
    Dr. Lynch. Dr. Clancy and I would both be happy to meet 
with you, sir.
    Dr. Benishek. I will yield back my time and hope----
    Ms. Clancy. And I do want to be clear that we both share 
your anger and are very, very upset and we know that we can't 
take that back; it can't be undone. So, a young man who will 
die prematurely, we get that. But what it inspires us to do is 
to work harder to make sure that we don't do it again and we 
have a system in place to make it foolproof so that we don't--
--
    Dr. Benishek. Well, my frustration is how can I tell what 
is happening when I can't even get a simple answer to a simple 
question from Dr. Petzel? Thank you.
    The Chairman. Ms. Titus, you are recognized for five 
minutes.
    Ms. Titus. Thank you, Mr. Chairman.
    I want to ask Dr. Lynch, I am sure you are aware that the 
IG is currently investigating the death of Sandi Niccum at the 
VA hospital out from Las Vegas. That investigation came at the 
request of the chairman and myself. It is taken awhile, and we 
hope to get the results soon, but just wonder when the results 
come to this investigation or any, what you do to follow up; 
how you assure us that you have made the changes; implemented 
the recommendations.
    Could you comment, maybe, specifically about the Las Vegas 
case or--and also generally?
    Dr. Lynch. I can't comment specifically about the Las Vegas 
case. I have not seen the OIG's report yet. I can tell you that 
when those reports come in, I do read them. I do look at the 
recommendations and we do have a process for tracking to make 
sure that those recommendations are acted upon and closed.
    Ms. Titus. Can you elaborate on that process for tracking 
them so that we can be sure that there is transparency and 
accountability and I can go back to my constituents and say 
this was the problem and this has happened to correct it.
    Dr. Lynch. There is an office in VHA whose specific 
responsibility is to work with the OIG. They obtain those 
reports and they work with the OIG until such time as he 
accepts the actions that have been taken and closes the 
recommendation.
    Ms. Titus. And that is public?
    Ms. Clancy. Yes, that is public information in terms of 
what was the response of the VA Health System and the follow-up 
and so forth. So I think we can both commit to you that we will 
follow-up with you when that report is done.
    I want to stress, though, that we don't wait for the 
Inspector General. The Inspector General is a very valuable 
resource and a source of information for us, but we have many 
internal processes. So our National Center for Patient Safety, 
for example, routinely is collecting information about adverse 
events and near misses; in other words, circumstances that set 
people up for errors.
    I have heard a lot of concern from all of you this morning, 
and we share that, about harms to patients and patient safety. 
And I would love to tell you that we can build an error-free 
system and that is not possible.
    What we can do, and are strongly committed to doing, is 
identifying things at the earliest possible phase so they can 
be fixed and the much longer-term consequences and more serious 
consequences can be prevented. So, we pay a lot of attention to 
the IG reports to reports by the GAO, but we also have our own 
internal processes where we are relying on every single 
employee who works at VA to let us know; it is called Stop the 
Lying. If you see something, say something. If you see 
something that could be unsafe, we need to hear about it and 
you need to let people know so that we can act on it, and 
together, across the system can learn about it.
    Ms. Titus. Can you tell us then--and I appreciate that, I 
think that is a good thing that you have--but if something is 
being done to follow up on the Sandi Niccum case independent of 
the report that we are waiting on?
    Ms. Clancy. I can get back to you with that. I am not 
familiar with the specifics of that, but we will definitely get 
back to you.
    Ms. Titus. Thank you very much.
    And I yield back, Mr. Chairman.
    The Chairman. Could you tell me why the video, the 
surveillance video that day in the hospital that showed Ms. 
Niccum, who was an elderly lady, was in severe pain and ended 
up dying, was erased, deleted, how did that occur?
    Dr. Lynch. The only explanation I have heard is that after 
30 days, the videotapes are overwritten and we don't have that 
information; and I understand that I don't know the 
relationship between your request and when that tape was 
erased.
    I think from our standpoint, it is unfortunate; we would 
like to have seen what happened as well.
    The Chairman. Wouldn't you think, though, as a matter of 
principle and good business practice, that if a death occurred 
in your facility and you had a video of that death--30 days--
man, I can understand if it was 24 hours, maybe it got 
deleted--but 30 days before it got taped over?
    Dr. Lynch. If I recall the case, which is now coming back, 
I don't believe that Ms. Niccum died that day. I believe she 
died subsequently, following hospitalization. So I think the 
concern was that her care was delayed in the emergency 
department and there was a delay in her receiving radiology 
service. She went home and was subsequently admitted to another 
facility and died at that time.
    So it wasn't that we had a death in the facility at that 
time, which I absolutely agree with you, Congressman, would 
have required that we review those videotapes and look at them.
    The Chairman. The GAO, in their written testimony for this 
morning's hearing, alleges that oversight of the implementation 
of VHA's business rules has been limited and has not included 
independent verification of VAMC actions. So my question to you 
is: Would the Department be willing to increase oversight of 
the new business rules and pursue independent verification of 
VA Medical Center implementation?
    Dr. Lynch. I did read the GAO's testimony, sir. I am not 
sure that we agree that there is value to auditing of the 
facilities. We think that we have provided adequate training. 
We think that we have provided the education that the 
facilities need to implement those. We know that the facilities 
have begun to implement and use consult management teams. We 
feel very strongly that the consult tool that is resulting from 
this review will give us that individual oversight by facility 
and by specialty.
    The Chairman. And they also allege in their statement that 
the Department did not require medical centers to document how 
they address unresolved consults that were opened greater than 
90 days; is that true?
    Dr. Lynch. That is true, sir.
    But we felt we had a process defined that identified which 
consults could be closed. When there were individual patient 
consults which remained unresolved that resulted--that related 
to clinical care, that we had a process and an expectation of 
our medical centers, that those would be reviewed individually.
    The Chairman. In their written statement this morning, GAO 
references one VA Medical Center where specialty care providers 
have allegedly been instructed to discontinue consults for 
appointments that are not needed within 90 days and to track 
these consults outside the consult system and to resubmit them 
closer to the date that they are needed.
    Is this an acceptable practice?
    Dr. Lynch. We have a process, as we implement new business 
rules that will identify consults for what we term ``future 
care.'' Future care would be somebody who perhaps had an 
endoscopy----
    The Chairman. So the answer to that question is: Yes, it is 
an acceptable practice?
    Dr. Lynch. The answer to that is: Yes, we have a process in 
place to be able to identify those and be sure that we have 
eyes on those future care consults, sir.
    The Chairman. So we have a dual track list?
    Dr. Lynch. No, sir. We have an electronic process that 
follows those and kicks them out at the appropriate time back 
into our system so that we are aware that an endoscopy or a 
consult needs to be scheduled at the appropriate time.
    The Chairman. Can you respond to the comment made in the 
IG's written statement that there seems to be a lack of focus 
on healthcare delivery as priority one at VA medical 
facilities, as evidenced by the length of time that it takes to 
fill a vacant position. I think that any one of us that goes to 
a VA Medical Center for a visit are often not surprised anymore 
by the number of people that have the word ``acting'' before 
their name or that there are positions that are important that 
are vacant.
    Can you respond to those comments?
    Dr. Lynch. Yes, sir.
    First of all, I think if we look back through VHA, the 
system that we currently have was initially developed around 
1940 by Omar Bradley, and by Dr. Paul Holly. It focused on 
clinical care. It focused on academic affiliation and the 
education of medical school students and residents, and it 
focused on the value of research.
    I realize that healthcare has changed. I respect the IG's 
recommendations and thoughts. I think we do need to re-examine 
our system, but I would disagree that I think we are ignoring 
clinical care in favor of research or education. I think they 
are both critical components of what we do in VHA. The research 
that we have done has helped to improve patient care and the 
care that we deliver. I can give you two recent examples.
    There was VHA research on the treatment of PTSD that has 
resulted in new treatments for patients with PTSD, as well as 
tools for identifying TBI. There was a study on the use of the 
drug Prazosin and its value in patients with PTSD that has been 
implemented, not only in VA, but also in the private sector. I 
think that research plays a critical role in helping us assure 
that we have quality care for our veterans.
    The Chairman. Final question from me: Does the VA have 
every legal authority it needs to pay for a veteran's care 
whose care is delayed, to receive care outside of the VA 
system?
    Dr. Lynch. To my knowledge, sir, yes.
    The Chairman. So, would it be correct to say that failure 
to deliver care in a timely fashion is simply a question of 
poor leadership at VA?
    Dr. Lynch. I think that would be a stretch, sir. I think 
that our system strives to treat patients within VHA because we 
think we do provide good care. We think we provide quality 
care. I hope that we can identify those circumstances where it 
may be necessary to send somebody into the private sector. I 
think we have to use all the resources that we have, sir.
    The Chairman. Ms. Brownley. any further questions?
    Ms. Brownley. I don't have any further questions, but I do 
have a comment that I would like to make, and to say, I, too, 
share the frustration of the committee that we are not able to 
get the answers that we want.
    And I think, you know, we are looking for specifics, data, 
metrics, et cetera, and, feel--I always feel as though we never 
get them. We get answers like ``We have a system that provides 
eyes on the process''; ``We have tools.'' But we are really 
looking for the specifics.
    Our staffs assure us that you know the questions that we 
are going to ask and what we are interested in knowing through 
these hearings and it is just my feeling and my only conclusion 
that I can come to, if you are not willing to reveal the facts, 
that there is something that you don't want the public to hear, 
and I just want to make that statement. I don't know what else 
to conclude when we don't get the facts and the information 
that we are specifically asking for.
    Dr. Lynch. Congresswoman, I would point out that, in fact, 
one of your staff members of the HVAC did meet with Dr. Mike 
Davies of our staff and did go over the consult tool that we 
are developing and was shown how it works.
    The Chairman. Mr. O'Rourke or Ms. Titus, any further 
questions?
    Thank you very much for being here with us, and the second 
panel is dismissed.
    Members, joining us on the third and final panel--and thank 
you very much for your indulgence in allowing VA to give their 
testimony before you--is Deborah Draper, Director of Healthcare 
for the Government Accountability Office, and, Dr. John Daigh, 
Assistant Inspector General for Healthcare Inspections for the 
VA Office of the Inspector General. The committee appreciates 
both of you for being here today and thank you for your hard 
work and advocacy on behalf of America's veterans.
    Ms. Draper, we will begin with you, you are recognized for 
five minutes for your opening testimony.

                  STATEMENT OF DEBRA A. DRAPER

    Ms. Draper. Chairman Miller and Members of the Committee, I 
am pleased to be here today to discuss access problems in VA 
that may delay needed medical care for veterans. GAO and 
others, including VA's Inspector General, have continued to 
report that VA medical centers do not always provide timely 
care, and in some cases, these delays have resulted in harm to 
veterans.
    My statement today covers two access-to-care concerns. 
First, I will highlight preliminary observations from our on-
going work related to VHA's management of outpatient specialty 
care consults. Second, I will discuss concerns regarding VHA's 
medical appointment wait times, and scheduling, including 
progress VHA has reported making in implementing our December 
2012 recommendations.
    VHA providers request and manage consults for specialty 
care using VHA's clinical consult process, which is supported 
by an electronic system. Clinical consults include both 
clinical consultations, such as an evaluation of a patient's 
clinical concern, as well as specialty procedures, such as a 
colonoscopy. The specialty care provider who receives the 
consult request is to review it within 7 days of it being sent 
to determine whether it is needed and appropriate. VHA's 
guideline is for consults to be completed within 90 days.
    In 2012, VHA created a database to capture all consults 
systemwide; however, the data were deemed inadequate for 
monitoring purposes. One issue was the lack of standard 
processes and uses of the electronic consult system. For 
example, in addition to requesting consults for clinical 
concerns, the system was also being used to request a variety 
of administrative tasks, such as requesting veterans' travel to 
appointments. Additionally, VHA could not accurately determine 
whether veterans actually received the care requested or 
received it in a timely manner. At the time the database was 
created, there were approximately two million consults open for 
more than 90 days.
    In May 2013, VHA began an initiative to standardize aspects 
of the consults process with the goal of developing consistent 
and reliable systemwide consult information. Among other tasks, 
VA medical centers were to complete a clinical review as 
warranted, and as appropriate, close all consults open for more 
than 90 days.
    Through our on-going work on outpatient specialty care 
consults, we found examples of delays in care at each of the VA 
medical centers included in our review. For example: For three 
of ten gastroenterology consults reviewed in one facility, up 
to 210 days elapsed from the dates the consults were requested 
to when they were completed.
    In another facility, for three of ten physical therapy 
consults reviewed, more than 100 days elapsed with no apparent 
actions taken to schedule appointment. These consults were 
eventually sent back to the requesting providers without the 
veterans involved receiving the requested care. According to 
the patients' files, no non-service connected evaluations were 
being accepted due to resource constraints.
    We also found variation in how VHA's consult initiative is 
playing out at the local level. For example: VA medical centers 
have developed different strategies for clinical consults that 
are needed beyond the 90-day completion guideline. Some 
facilities are managing these future-care consults outside of 
the electronic system, and consequently, these consults do not 
appear in VHA's systemwide data.
    VA medical centers are also not required to document how 
they address consults open for more than 90 days. None of the 
facilities in our review were able to provide us specific 
documentation in this regard. VHA officials estimated that as 
of April 2014, of the two million open consults that existed 
when the systemwide database was created in 2012, 450,000 
remained unresolved.
    Additionally, oversight of VHA's consult initiative has 
been limited, and has not included independent verification of 
VHA medical centers' actions. Without this verification, VHA 
cannot be assured that the actions have been implemented 
correctly. Furthermore, VHA's consult data may not accurately 
reflect whether veterans received the care needed, or if they 
received it in a timely manner.
    The second access-to-care concern that I wanted to 
highlight today relates to our December 2012 report and 
subsequent Congressional testimony. We reported that VHA's 
outpatient medical appointment wait times were unreliable, and 
that there were problems in the implementation of VHA's 
scheduling policy. We recommended VA take actions to: Improve 
the reliability of medical appointment wait time measures, 
Ensure the consistent implementation of a scheduling policy, 
Allocate scheduling resources based on needs and Improve 
telephone access for medical appointments.
    VA concurred with our recommendations and has reported 
continued actions to address them. For example, VHA officials 
told us they have implemented new wait time measures, which 
they say are more reliable. We believe that work needs to 
continue to fully implement our recommendations. It is 
essential that VHA also assess the actions taken to ensure that 
they are achieving the intended improvements.
    Mr. Chairman, this concludes my opening remarks, I am happy 
to answer any questions.

    [The prepared statement of Debra Draper appears in the 
Appendix]

    The Chairman. Thank you very much.
    Dr. Daigh, you are recognized for five minutes.

             STATEMENT OF JOHN D. DAIGH, JR., M.D.

    Dr. Daigh. Chairman Miller, Members of the Committee, it is 
an honor to be able to testify before you here today. I would 
like to recognize the courage of Mr. Coates for his testimony 
this morning. It was extremely important to hear and I think 
very sad.
    My staff works tirelessly to try to ensure that these 
events don't occur and this is a failure for us to see a story 
like this. I believe the VA has lost its focus on the 
importance of providing quality medical care as its primary 
mission. In the day-to-day decisions that managers at all 
levels make, that they take for granted often times, and assume 
that quality medical care will be provided.
    When addressing the competing demands to provide medical 
education, research, support to our nation in time of national 
disaster, comp and pen exams, the fight against homelessness, 
managers have lost focus on the importance of making quality 
medical care delivery their number one priority.
    In my written statement, I addressed three events that we 
have recently published that have occurred at more than two 
institutions. One is the colon cancer issue that we discussed 
here previously, the second would be veterans at Miami and 
Atlanta who died in VA hospitals from overdoses of street 
drugs, and in both cases, basic policies were not followed.
    In Buffalo and Salisbury, North Carolina, insulin pens 
designed to be used for one patient to take multiple doses 
were, instead, used on the ward for multiple patients, putting 
hundreds of veterans at risk for the risk of blood-borne viral 
infections. There is no good explanation for these events. They 
are not consistent with good medical practice. They are not 
consistent with common sense, and they are not consistent with 
VA policies that exist.
    The most important factor in preventing these events, in my 
view, is excellent leadership that instills a culture of safety 
and accountability. In addition, I believe that a review of 
VHA's organization and business rules is appropriate to 
determine if there are changes that would support the singular 
importance of quality of care and improve the ability of 
leadership to deliver that high quality medical care across the 
system.
    For example, one might identify positions within the 
medical center that are deemed essential for the delivery of 
medical care, and should one of those positions become vacant, 
for instance, the nurse in the colonoscopy suite or the GI 
nurse, that job would automatically be refilled. It wouldn't 
have to compete for being refilled within the administration 
for medical education or a technician who might want to be 
hired for research. So, again, a way to try to focus the budget 
and resources on healthcare.
    In addition, VISN and hospital instructions are not 
standardized. It is not possible to look at--the position 
descriptions are not the same. The areas of responsibility are 
not the same. So if you ask the simple question: Who owns the 
operating room? You are not really sure if it is the chief of 
surgery; is it the chief of anesthesia; is it the chief of 
surgical care line; is it the head nurse?
    So I believe that these rules that currently exist which--
and I will be the first to admit that the VISN system and the 
mantra that all healthcare is local has served the VA very 
well. I believe that these systems ought to be looked at to see 
if it is time to change some of these rules.
    With that, I will end this portion of my testimony and be 
pleased to take questions.

    [The prepared statement of John Daigh, Jr. appears in the 
Appendix]

    The Chairman. Thank you, both.
    I was looking at the written statement for the GAO and you 
talked about, and the IG talks about it, too, that VA 
experienced difficulty in hiring and retaining specialists for 
gastroenterology and physical therapy. And the question is: Did 
you find any reason for that?
    Dr. Daigh. I guess----
    The Chairman. Either can answer on it.
    Ms. Draper. Yeah, I think what we heard in some locations 
was that for some high volume specialities, there is a national 
shortage of some specialists, so it is difficult to hire. I 
think we heard, generally, that there was an increased volume 
of requests for certain specialty services which is 
complicating providing care. So, you know, if you have a 
shortage of providers, you can't backfill and, you know, 
increase the capacity that you have within the specialty 
clinics, so we did hear some of that.
    The Chairman. I would suspect that if you had a shortage of 
providers or you had vacancies that you couldn't fill, then the 
obvious thing would be a fee-for-service if possible, and then 
the question begs to be answered: Do you think VA makes 
adequate or even maximum use of fee-bases resources when those 
specialists are not available?
    Ms. Draper. We have not looked at this in any great detail. 
I mean it varies considerably from facility to facility. And at 
one facility, for example, they fee-based two to three hundred 
GI consults a month. In other facilities, they do very little. 
It is hard to understand what the variation is, but it does 
vary considerably from one facility to another.
    Dr. Daigh. I would say, sir, that this is not a new 
problem. We published, you know, a similar report in 2006 that 
outlined the difficulty that VA had in following up on patients 
who were being screened for colonoscopy and needed tests to 
look for the presence of colon cancer on a regular basis. And 
so I think, A, you have to have a system in place, but, B, you 
are just talking about a procedure and the procedure can be 
done by a variety of people trained to do that procedure.
    So the question is: If you need a colonoscopy done, well, 
maybe a PA could do that or maybe a nurse could do that--to 
have the training and to assist the physicians and other staff 
to make sure that this simple procedure got done adequately, 
and where a physician needed to impart additional insight into 
what one should do, you could schedule visits for that. So I 
think this is just not a new problem.
    The other point I would make is that many VAs, probably 100 
of them, are affiliated with medical schools, so you have right 
there a whole set of physicians that are in the community that 
are available, so that if you could work with that group of 
patients, a group of facilities, one could probably construct 
solutions that would be worthwhile.
    So, I think fee-basis consults, creative uses and training 
of your resources and your people to plan for what you know are 
going to be on-going problems; they are all parts of the 
solution here.
    The Chairman. Ms. Draper, have you ever seen an instance or 
instances where a VISN director or a medical center director 
restricted the use of fee-basis care funds or diverted those 
funds to be used in other programs?
    Ms. Draper. I have not, but for this work we have not 
looked at that in any great detail.
    But I do want to say one thing about fee-basis, as well, is 
that these are not tracked the same way, so you don't know what 
the wait times are. So when you fee-base something out there, 
you lose that tracking ability to see, so you may not really be 
accomplishing something--you may not be getting the care in a 
timely way, it is just that VA doesn't--they don't really track 
that.
    The Chairman. And, again, they should.
    Ms. Draper. They should, and we pointed that out in our 
previous report.
    The Chairman. We found this issue in Atlanta, in 
particular, where mental health care was an issue where 
basically once VA fees something out, it appeared that they 
just dropped off the radar screen and they weren't watching it 
or tracking it again.
    Just because they are not getting care in a VA facility 
doesn't mean that they are not VA's patient or America's 
patient and VA had darn sure better----
    Ms. Draper. Right. And VA is paying the bill, so--I mean 
that was one of the issues that we pointed out in our 2012 
report is that is was not tracked.
    The Chairman. Actually, a grateful American taxpayer is 
paying the bill and I think VA forgets that sometimes; it is 
the taxpayers' funds, not theirs.
    Ms. Brown.
    Ms. Titus.
    Ms. Titus. We have been here a long time. Thank you, Mr. 
Chairman.
    I just keep hearing a theme over and over that these things 
seem to vary have facility to facility, and I understand 
perhaps the need for some flexibility because some hospitals 
may be associated with the medical school, different 
demographics, different geography, and all of that. But it 
seems to me there is some need for some kind of standardized 
policy to some extent.
    I know at the Las Vegas hospital, they are flying in 
emergency room doctors from all over the country on contract 
for a few day schedules. That doesn't seem very practical to 
me. I mean there must be all of the Las Vegas Valley, some 
emergency room doctors who could do that. It seems like you 
would save money and get more of a buy in from the medical 
community than these kind of flying in doctors.
    I would like that addressed, but I also would like to go 
back to the Sandi Niccum case. Dr. Lynch kind of got his memory 
back in the course of answering that question, but I would like 
to ask ya'll if you can give us some kind of progress report so 
we can find out if that is moving and when we are able to get 
some results.
    Dr. Daigh. Yes, the research on that has been done. The 
report has been written. It is in draft phase, and it will be 
out within a couple--three or four weeks. So we are--we will be 
ready.
    In the normal process, I would like to clarify a little bit 
what was said previous. We would write a report and lay out the 
facts as we see them. We would then send a report to VHA at 
multiple levels, including the hospital in Las Vegas, ask them 
to read the report and verify they think the facts are correct. 
We would then make recommendations in the report and ask them 
to respond to the recommendations and they would, in writing, 
respond to those recommendations.
    At that point, we would offer the Committee and you a 
briefing on the findings and we would publish the report to the 
web where it would be public, that would be our report, plus 
their response.
    The response sometimes takes awhile for VA to follow back 
up on, so we then have a part of our office that does follow-
up. Usually, it is that we ask for records to prove that X and 
Y were done, and if they provide records that X and Y were 
done, then we usually close it.
    Occasionally, we say this is so important an issue that we 
personally will go back and re-visit the facility and try to do 
a follow-up. The follow-up documents, though, are not made 
public unless they are requested, so they are internal to us. I 
see them, you ask for them, you can get them. We do provide a 
list to Congress multiple times a year of those recommendations 
that have not been filled within a year.
    So where we have not been unable to close a recommendation 
on one of our reports within a year, we make that available to 
you as an item and we are happy to talk about those.
    Ms. Titus. Okay. So when you say the report will be 
finished within three weeks or so, is that the stage in which 
you send it to the hospital or----
    Dr. Daigh. No, I think this should be publishable within 
three weeks or so, three to four weeks.
    Ms. Titus. Well, I will look forward to getting that.
    And it seems to me that sometimes these reports that focus 
on a specific problem in a specific hospital are used to 
address just that and not taken in the broader, I don't know, 
perspective, so that they can be used to solve problems at 
other facilities.
    Dr. Daigh. Well, I think in terms of just producing a 
report and making sure it is accurate, I have to narrow the 
scope often times to what I can be accurate about.
    Ms. Titus. Uh-huh.
    Dr. Daigh. But if one looks at the reports that we put out 
or you ask us to talk about it--I am familiar with the reports 
that we put out--we are happy to try and talk about patterns 
that we see.
    Certainly, VHA gets the reports and they can look for 
patterns and we are aware of patterns, so I think you are 
right; there is a difficulty in that they don't all talk to the 
universe, but I can't do that and get it out timely.
    Ms. Titus. I understand that.
    Mr. Chairman, thank you. I yield back.
    The Chairman. Mr. O'Rourke.
    Mr. O'Rourke. Thank you, Mr. Chair.
    Dr. Daigh, a couple things that you said really struck home 
in terms of trying to figure out what is going wrong and how we 
fix it. You said it was a question of leadership and you also 
said it is a question of having a culture that prioritizes 
safety and accountability. And those issues are so big and so 
tough to address in a five-minute question and response.
    But I will just tell you that I have had the chance to meet 
Secretary Shinseki. I have heard him testify here. I have no 
question whatsoever that he has the highest and deepest 
commitment to improving the service of the VA--and if he were 
here, I am sure that he would agree and share everyone's 
frustration--and say that the results that we described today 
are unacceptable, and I also have no doubt about Dr. Lynch and 
Dr. Clancy and their commitment.
    The people that I meet within the VA are good people who 
are trying, and yet, the awful numbers that I gave for El Paso 
earlier are not new. In 2008 we had the worst access not 
country to be able to get in to see a doctor and it has 
improved only marginally since then. So, despite good people 
doing good work and assuring us of their efforts, it is not 
getting better--certainly not quickly enough for the veterans 
who need to see care.
    Let me ask you this: In assessing the job that I am doing 
and the job that Congress and this Committee is doing, you 
know, the primary responsibility for these veterans is within 
the VA. The ultimate responsibility is within Congress. We have 
the power and responsibility of authorizing, appropriating, and 
oversight, and so I will ask you the question that I asked Dr. 
Lynch: What could we be doing that we are not doing now to 
change the outcome and to get veterans the care that is being 
delayed and ultimately denied, as we heard with Mr. Coates and 
as I see every single day in El Paso?
    Dr. Daigh. I have watched this system for awhile; I would 
agree that the people who work in it are excellent. They are 
committed. Many of them are veterans and they are of the 
highest quality when you sit and talk with them. That is why I 
expressed the frustration over the events that I talked about 
when you say ``Well, what really happened?''
    And often, I think--so let me go to your point. I think 
that serious thought needs to go into the business model that 
VA uses now to deliver care. So if you are in the middle of 
Manhattan and you have multiple medical schools and many 
hospitals, you have a different group of folks to deal with in 
terms of trying to resource and provide care. You would make 
different decisions about how you provided care. You may decide 
that cardiac surgery is so great at this hospital that why 
shouldn't I get into that business, why wouldn't it use it all 
the time.
    And if you are a different facility someplace, you have 
entirely different business needs, and I think that the VA 
structure has not morphed over the last number of years, as I 
think it should. In the past, I think most veterans lived in 
the shadow of the hospital. If they drove and could get there, 
they were enrolled in that facility.
    If the goal is deliver one standard of care to all veterans 
who are eligible for that particular piece of care, the ones 
that live on the other side of the mountain and across the 
river, I think you have to rethink a little bit how you are 
doing that. And so I would take a serious look at, given that 
the information flow has changed; data requirements have 
changed; data is available--the capabilities of computing are 
different. I think it is time to take a look and fix what needs 
to be fixed bureaucratically to drive efficiency and drive 
standardization, but try very hard to preserve the mantra that 
all healthcare is local, so that local folks can make important 
local decisions.
    Mr. O'Rourke. And I appreciate the fact that 
representatives from the VA are here listening to this, and I 
am sure at headquarters, they are listening as well, and to a 
certain degree, they can choose to adopt these recommendations 
administratively, but just to put a finer point on the question 
that I am asking: Are you suggesting that, again, despite the 
best efforts within the VA and current leadership, we are not 
seeing the kind of change that we need? That the recommendation 
that you are making needs to come in the form of a legislative 
proposal, a bill that would force the VA to change how it 
delivers cares?
    Dr. Daigh. So how change occurs, I am not quite the expert 
on, whether it needed to be law or discussion. But, certainly, 
if you were to change business structure, I am assuming that 
you would need to change some law.
    But what I am pointing to is in a GI clinic where you are 
scheduling colonoscopies and you have people who need 
colonoscopies, you know what the demand is. If you lose a 
critical player in that clinic, then you know that you can't do 
the work that you did before. So the people in that clinic, the 
doctors, the nurses, everybody, needs to have an easy conduit 
to drive change and make it happen.
    If the complaint is that at the local level within a 
hospital, they can't get the positions filled, they need filled 
to ensure that what gets done gets done, and those people who 
are not bureaucratically responsible for the delivery of care 
are somehow able to drive resources outside of the delivery of 
primary care, I think that needs to be fixed.
    I think there ought to be a study. I think there ought to 
be a good look at how VA is currently set up and see if there 
are not better ways to manage this system in 2014 and forward.
    Mr. O'Rourke. Thank you, Dr. Daigh, and, Ms. Draper, I 
thank you for your answers.
    Mr. Chair, I yield back.
    The Chairman. The gentleman yields back.
    Ms. Titus, do you have a request?
    Ms. Titus. I do, Mr. Chairman, thank you.
    I would like to submit Mr. Michaud's written statement for 
the record because he couldn't be here.
    The Chairman. Without objection.
    The Chairman. Being no further questions from the 
Committee, we will be submitting some questions for the record. 
We would appreciate a timely response from all the witnesses 
today.
    I do ask unanimous consent that all members would have five 
legislative days with which to revise and extend or add 
extraneous material to their remarks.
    Without objection, so ordered.
    And, once again, thank you to all of the witnesses for 
being here today.
    This hearing is adjourned.
    [Whereupon, at 12:41 p.m., the Committee was adjourned.]
                                APPENDIX
                                

               Prepared Statement of Chairman Jeff Miller

    Good morning.
    The committee will come to order.
    Before we begin I'd like to ask unanimous consent for our colleague 
from Tennessee, Congressman Steve Cohen to sit at the dais and 
participate in today's proceedings.
    Hearing no objection, so ordered.
    Welcome to today's full committee oversight hearing, ``a continued 
assessment of delays in VA medical care and preventable veteran 
deaths.''
    Today's hearing is the fulfillment of a promise I made in early 
January to follow-up on delays in care at department of veterans 
affairs (VA) medical centers in Columbia, South Carolina, and Augusta, 
Georgia, that, together, resulted in nine preventable veteran deaths.
    I had hoped that during this hearing, we would be discussing the 
concrete changes VA had made--changes that would show beyond a doubt 
that VA had placed the care our veterans receive first and that VA's 
commitment to holding any employee who did not completely embody a 
commitment to excellence through actions appropriate to the employee's 
failure accountable.
    Instead, today we are faced with even with more questions and ever 
mounting evidence that despite the myriad of patient safety incidents 
that have occurred at VA medical facilities in recent memory, the 
status quo is still firmly entrenched at VA.
    On Monday--shortly before this public hearing--VA provided evidence 
that a total of twenty-three veterans have died due to delays in care 
at VA medical facilities. Even with this latest disclosure as to where 
the deaths occurred, we still don't know when they may have happened 
beyond VA's stated ``most likely between 2010 and 2012.'' These 
particular deaths resulted primarily from delays in gastrointestinal 
care. Information on other preventable deaths due to consult delays is 
still unavailable.
    Outside of the VA's consult review, this committee has reviewed at 
least eighteen preventable deaths that occurred because of 
mismanagement, improper infection control practices, and a host of 
other maladies plaguing the VA health care system nationwide. Yet, the 
department's stonewall has only grown higher and non-responsive.
    There is no excuse for these incidents to have occurred.
    Congress has met every resource request that VA has made and I 
guarantee that if the department would have approached this committee 
at any time to tell us that help was needed to ensure that veterans 
received the care they required, every possible action would have been 
taken to ensure that VA could adequately care for those veterans. This 
is the third full committee patient safety hearing we have held since I 
have been chairman and I am going to save our VA witnesses some time by 
telling them what I don't want to hear from the department this 
morning.
    I don't want to hear the rote repetition of--and I quote from 
several prior VA statements, including the written testimony that was 
provided for this hearing--``the department is committed to providing 
the highest quality care, which our veterans have earned and deserve. 
When incidents occur, we identify, mitigate, and prevent additional 
risks. Prompt reviews prevent similar events in the future and hold 
those responsible accountable.''
    Another thing I don't want to hear is--and, again, I quote from 
numerous VA statements, including a recent press statement--``while any 
adverse incident for a veteran within our care is one too many,'' 
preventable deaths represent a small fraction of the veterans who seek 
care from VA every year.
    What our veterans have truly ``earned and deserve'' is not more 
platitudes and, yes, one adverse incident is indeed one too many. We 
all recognize that no medical system is infallible, no matter how high 
the quality standards might be. But I think we all also recognize that 
the VA health care system is unique because it has a special obligation 
not only to its patients--the men and women who honorably serve our 
nation in uniform--but also to its financers--the hard-working American 
taxpayers.
    When errors do occur--and they seem to be occurring with alarming 
frequency--what VA owes our veterans and our taxpayers, in that order, 
is a timely, transparent, accurate, and honest account about what 
mistakes happened, how they are being fixed, and what concrete actions 
are being taken to ensure accountability.
    It concerns me that my staff has been asking for further details on 
the deaths that occurred as a result of delays in care at VA medical 
facilities for months and only two days before this hearing did VA 
provide the information we have been asking for. Even then that 
information is far from a complete description of the problem and VA's 
efforts to prevent future deaths.
    It concerns me even more that VA's briefing Monday and testimony 
today include very few details about what, if any, specific actions 
have been taken to ensure accountability for the twenty-three veterans 
who lost their lives and the many more who were harmed because they 
didn't get the care they needed in a timely manner.
    On our first panel today, we are going to hear from a veteran who 
sought care through the William Jennings Bryan Dorn VA medical center 
in Columbia, South Carolina. That veteran--Mr. Barry Coates--is going 
to tell us that, and I quote, `` . . . the gross negligence . . . and 
crippling backlog epidemic of the VA [health care] system has not only 
handed me a death sentence but ruined my quality of life . . . ''
    Mr. Coates waited for almost a year and would have waited even 
longer had he not actively, persistently insisted on receiving the 
colonoscopy that he and his doctors knew he needed. That same 
colonoscopy revealed that Mr. Coates had stage four colon cancer that 
had metastasized to his lungs and his liver. Maybe that is why VA does 
not want to define accountability in terms of employees who have been 
fired.
    The department is going to testify this morning that, instead, we 
should focus our accountability efforts on correcting systems 
deficiencies in order to prevent adverse events from occurring again.
    There is nothing wrong with fixing systems. But Mr. Coates deserves 
better than that. His adverse event already happened and, for him, 
there is no going back. With that, I now yield to acting ranking member 
Brown for any opening statement she may have.

                            __________________

         Prepared Statement of Michael Michaud, Ranking Member

    Thank you, Mr. Chairman, for holding this hearing today. We all 
agree that patient safety and quality of care issues remain top 
priorities for this Committee.
    I read with concern the testimony provided by our first two panels. 
All too often, members of this Committee hear the same issues raised 
again and again in reports by agencies such as the Government 
Accountability Office and the VA's Office of Inspector General.
    Findings such as inadequate training, improper oversight, lack of 
guidance, no accountability, and failing to follow proper procedures 
already in place, are too common.
    Mr. Chairman, I understand that the Department is a very large 
agency and not without its challenges. I also understand that mistakes 
are going to be made. I also believe no matter how transparent the 
Department is, something clearly has to change.
    My frustration lies in the fact that findings are made and plans 
are implemented, but the situation does not seem to get better. 
Veterans, like Mr. Coates from our first panel, have suffered terribly 
from these ongoing mistakes. As Mr. Coates states in his testimony:
    ``I am not here today for me. I am here to speak for those to come, 
so that they might be spared the pain I have already endured and know 
that I have yet to face.''
    Mr. Chairman, we owe it to the veterans of this nation to do 
everything we possibly can to improve the processes that will help 
prevent such incidents' happening in the future, and ensure proper 
accountability for those who are responsible.
    Veterans are not statistics, a number or a column on a spreadsheet. 
They are people who have fought for the freedoms we so enjoy today. We 
need to remember that and the Department needs to make much stronger 
efforts to turn this issue around.
    In today's day of advanced systems and rapid technology 
development, there is no excuse for ``losing track'' of vital consults 
and appointments. Ensuring proper tracking and timely appointments is 
critical.
    Mr. Chairman, I do not want to revisit this issue in six months. It 
is time to stem the tide of rationalizations and excuses. Let's get 
this done.
    I look forward to hearing from our panelists today and want to 
thank everyone for being here.
    Mr. Chairman I yield back the balance of my time.

                Prepared Statement of Hon. Corrine Brown

    Thank you, Mr. Chairman, for calling this hearing today. We can all 
agree that veteran safety and quality of care issues at the VA health 
facilities are of utmost concern for this Committee.
    However, It is unfortunate that we must continually call these 
hearings to make sure that our nation's veterans are receiving the care 
for which they have already paid dearly for on the battlefields and in 
service to protect the freedoms we all hold most dear.
    I find it disturbing that just two days before this hearing, the VA 
has releases findings that its healthcare personnel are not fully 
trained in the importance of timely consults when treating a veteran.
    The dictionary defines a consult as the act of seeking information 
or advice from someone with expertise in a particular area.
    The system the VA set up to make these consults easier obviously 
broke down and it is possible that at least ficve veterans died in 
Florida because the right information was not shared with the right 
health professionals.
    I am concerned that in the five years after the colonoscopy debacle 
at the Miami VA, nothing has changed.
    To refresh your memory, in 2009, staff members at a number of VA 
facilities noticed improper reprocessing of endoscopes contrary to the 
manufacturer's instructions. The VA properly ordered all facilities to 
Step-Up and get retrained on the procedures. We want employees to feel 
free to report questionable issue and procedures without fear of 
retribution for trying to save lives.
    It seems that from this new consult problem that the retraining 
stopped at that one procedure.
    The fact sheet your office put out regarding the consults talks a 
lot about procedure and adverse events. However, I have heard that 
before and again our veterans are suffering.
    I look forward to hearing the testimony today and explanations for 
this lack of proper care and accountability for these mistakes.
    VA we have appropriated much money over the years to overhaul your 
computer system, and yet, you could not separate that heart consults 
are of a higher priority than a ride across town?
    What kind of training did employees get before and how is the 
training different now?

                          ____________________

             Prepared Statement of Hon. Steve Cohen (TN 9)

    Thank you, Chairman Miller, for allowing me to submit a statement 
into the record for today's hearing on preventable veteran deaths. 
While I do not sit on the VA Committee, today's hearing touches on an 
issue that unfortunately has affected veterans and their families in my 
home of Memphis, Tennessee. I appreciate the Committee for accepting my 
statement.
    In October 2013, the VA Office of Inspector General released a 
concerning report regarding three deaths at the Memphis VA Medical 
Center Emergency Department. The report, which was based on a May 29-
31, 2013 site visit, found that certain actions and inactions taken by 
physicians at the VA may have contributed to the death of the veterans 
mentioned in the report. I do not dispute the report's findings but 
instead am interested in learning what Congress and our VA medical 
centers can do to help prevent incidents like these from reoccurring in 
my home and at VA medical centers across America.
    As soon as this report was released, I sent a letter to VA 
Secretary Eric Shinseki raising my concerns about its findings as well 
as those of my constituents. In the same spirit of learning what can be 
done to prevent avoidable deaths at VA medical centers, in my letter I 
also invited the Secretary to visit the Memphis facility to meet with 
Memphis veterans and hospital staff. I asked that he offer any 
suggestions that would improve care at the Memphis VA center--whether 
it be increased funding, personnel, technology or equipment.
    While I am waiting to hear back from the Secretary's office 
regarding my invitation, I hope that the witnesses present at this 
hearing will offer corrective actions that can be taken to improve care 
at VA medical centers. I am also interested in their suggestions for 
incorporating standards of care at these facilities so that preventable 
deaths do not occur in the future.
    I have been in close contact with Director C. Diane Knight at the 
Memphis VA Medical Center, who was appointed in July 2013. While the 
deaths and the IG site visit occurred prior to her leadership, I am 
confident that the reforms she has put into place since becoming 
director and in light of the report will greatly improve patient care 
at the facility. I hope that the witnesses' testimonies will reflect 
this and again, offer constructive suggestions for how we all can work 
to improve conditions at the VA medical center in Memphis and across 
America. Our veterans bravely risked their lives for us and we owe them 
the very best care we can offer.
    Mr. Chairman, again, thank you for accepting my statement and I 
look forward to reviewing the testimonies.

                                ____

                 Prepared Statement of Barry L. Coates

    My name is Barry Lynn Coates and due to the inadequate and lack of 
follow up care I received through the VA system, I stand before you 
terminally ill today. I joined the Army in February of 1991 anxious to 
serve my country. Near the end of basic training an injury to my back 
derailed those plans and I was discharged around the first of May that 
same year.
    After a five year fight to obtain service connection status for my 
injury and the treatment and pain management required as a result of 
it, I finally became eligible for medical treatment through the VA 
system. That was the start of the long, painful, emotional, and 
unnecessary journey that brings me to you.
    On November 22, 2010 severe abdominal pain sent me to Carolina 
Pines Regional Medical Center in Hartsville SC, where a spinal CT 
showed that my lungs were clear and my liver were normal however, there 
was blood seen in the stool so a follow-up was recommended and 
consideration of a colonoscopy was suggested. That follow-up 
recommendation was completed at the Rock Hill Clinic with Dr. Anuradha 
Verma on January 20, 2011. No rectal exam was done, I was basically 
told to continue taking my medications previously prescribed and to 
come back if things did not improve or things got worse.
    Due to increased pain and constipation, on February 25, 2011 I 
requested to be seen by a doctor or to be referred to a GI Specialist. 
I saw Dr. Verma again on March 3, 2011 because of increased pain and 
rectal bleeding. I reminded her of the suggestion made by the ER doctor 
that a colonoscopy might be needed. I was sent home with hemorrhoidal 
suppositories and the promise that a colonoscopy might be done at some 
point. I was not seen until May of 2011 and the results were the same.
    I had relocated in October 2010 but had to continued to be seen at 
the Rock Hill, SC Clinic due to the back log at the Florence, SC 
Clinic. I was first seen by Dr. Eric Naumann at the Florence Clinic in 
June 2011. He started by putting me on 100 mg of the stool softener 
``Docusate'' in order to counteract the constipation caused by 
narcotics necessary to treat the ongoing back pain to my previous 
injury. He also expressed dismay that this had not be done previously. 
Most importantly, he agreed that a colonoscopy needed to be done.
    However my first GI consult did not occur until August 2011 with 
Dr. Sylvia Kim. I informed Dr. Kim of the ongoing pain, constipation, 
and bloody stools that I had been dealing with for over a year only to 
repeatedly have it dismissed as hemorrhoids. I was simply told to 
return in two months, still no referral for colonoscopy despite my 
request. In a conversation with Andy Pigge, Rn at the Florence Clinic, 
I made it known that my requests were being ignored and I felt it was 
jeopardizing my health.
    On September 1, 2011 after ample time on the Docusate I sent Dr. 
Naumann a message via my healthyvet.com informing him that I was still 
bleeding every bowel movement and still experiencing pain. As of 
September 15, 2011 I began having trouble urinating in addition to the 
other problems and only found some relief sitting in warm water. Dr. 
Naumann was informed of these new symptoms at this time. He stated that 
I may need to see a surgeon and may need to be considered for a 
colonoscopy. Dr. Naumann requested for the second time a colonoscopy 
October 4, 2011.
    I saw Dr. Kim October 12, 2011 and told her that the pain was now 
constant as well as the rectal bleeding and that my stools have become 
smaller and bright red in color. I was finally scheduled to have a 
colonoscopy consultation in April of 2012, which would be approximately 
a year and a half after the beginning of this journey.
    Tired of living in constant pain and knowing that my problems were 
bigger than hemorrhoids, I persistently called on the chance that there 
might be an earlier opening or cancellation. I was able to secure an 
opening for consultation appointment for November 30, 2011 and finally 
had the colonoscopy done December 9, 2011. The procedure was done at 
the Fort Jackson Hospital by Dr. Steedman Sarbah which found that I had 
a 5.5 mm nodule located six to eight centimeters from the anal verge 
with almost total luminal obstruction. I was diagnosed with stage four 
colon rectal cancer. Further tests revealed metastatic nodules on the 
right lung in the upper lobe along with liver lesions. It was stated 
that because of the post proximity of the nodules to anal verge a 
proper rectal exam would have easily found it and prompted treatment 
sooner.
    I saw Dr. Kim days later on the 14 of December 2012 and expressed 
to her sentiments of the doctor that performed the colonoscopy along 
with my own that a doctor should take time to listen to her patients as 
they know their bodies and can often sense when something is wrong. 
After ``supposedly'' not being able to feel the tumor during prior exam 
after seeing the images she was suddenly able to locate it easily.
    I had surgery on December 16, 2012 for a post diverting loop 
colostomy and started chemotherapy in January of 2012 followed by 26 
radiation treatments. The tumor was removed July 22, 2012 with a total 
anal recession. I have since had to endure a permanent colostomy which 
requires multiple bag changes per day along with catherization several 
times daily because of the bladder nerves being severed in order to 
remove the tumor. I am totally and permanently impotent as well as 
incontinent. The extensive chemotherapy has resulted in permanent 
neuropathy in both my hands and feet causing constant discomfort and 
pain.
    A follow up exam on April 2, 2014 has shown even further spreading 
of cancer with new lesions on my liver, multiple new lesions on both 
lungs, plus growth of the existing lesions and a referral for a MRI as 
the doctor fears it may have spread to my brain. Another round of 
Chemotherapy would have been started immediately but was postponed so I 
would be able to come and speak to all of you.
    It is likely too late for me, the gross negligence of my ongoing 
problems and crippling backlog epidemic of the VA medical system has 
not only handed me a death sentence but ruined the quality of my life I 
have for the meantime. I am not here today for me, I am here to speak 
for those to come so that they might be spared the pain I have already 
endured and know that I have yet to face.
    My situation is made even more unnecessary knowing that a 1.2 
million dollar grant was given to the Dorn VA Center to reduce backlog 
and improve care and treatment of veterans only to learn that the money 
was misallocated by diverting it to other uses instead of using it for 
the intended purpose. Only 1/3 of those funds were used properly.
    Men and women across this country volunteer every day to serve in 
the armed forces. The fact that our military stays well-manned and 
strong solely on the willingness of those volunteers to risk their 
lives for the protection of the nation as a whole is truly awe-
inspiring. Other nations have to force service in order to maintain a 
strong military. The very least this country should do is to ensure 
that those volunteers are taken care of after they have made sacrifices 
to take care of our country. I am not a unique case in the VA health 
care system as 19 others have already died and 60 more are in the same 
terminal status. I am here because proper care was not given exams were 
not performed properly, and diagnostic tests were either postponed or 
not done at all.
    In the civilian world, these doctors would face malpractice suits 
and medical review boards. As the saying goes ``heads would roll.'' In 
the VA system oversight is not as clear cut and complaints are often 
either lost or covered up by bureaucracy. So I ask you today, how many 
more vets will be allowed to suffer and die before someone is held 
accountable?
    Thank you for your time,
    Barry Coates
    
    
    
    
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