Secretary gibson will travel ton a series of facilities over the weeks to meet with veterans, their families and employees toh identify obstacles to Quality Health care. Ee and secretary gibson has said we must restore americas trust in Va Health Care system. We must restore that one veteran at a time. Our dedicated workforce over a a third of whom are veterans are engaged. Mr. Chairman, thank you to your dedication to and your care fore our nations fete rans. Mr. Griffin, you are recognized for five minutes. Chairman miller, ranking mmi, member michode and members of the committee, thank you for th opportunity to testify tonight e to discuss the results of the office of Inspector Generals work related to delays in care at the Phoenix Health care system. Im im accompanied by miss linda holiday, assistant inspector au general for audits and evaluation. Dion. The issue of manipulation of of wait lists is not now va and v. Since 2005, the oig has issued 18 reports that identified at both the national and local level, deficiencies in de scheduling resulting in lengthye wait times and a negative impact on patient care. We are using our combined expertise in audit, health care inspections, and criminal c investigators to conduct a comprehensive review, requiring an in depth examination of many sources of information, necess necessitating access to records an personnel both within and external to va. We are charged with reviewing the merits of many allegations and determining whether sufficient factual evidence exists to hold va or specific individuals accountable on the s basis of criminal, civil, or administrative laws and regulations. Veterans who utilize the Va Health Care system deserve quality care and timely care. Therefore, its necessary that y information relied upon to make Mission Critical management itil decisions regarding demand for g Vital Health Care services muste be based on reliable and complete data throughout vas health care networks. To date, we have ongoing or scheduled work at 69 va medicale facilities and have identified instances of manipulation of va data that distort the legitimacy of va waiting times. When sufficient credible eviden evidence is identified supporting a potential violatiol of criminal law, we are inal coordinating our efforts with the department of justice. Arrtmt our work to date has our substantiated serious conditions at the Phoenix Health care bstat system. At the we identified about 1,400 stem. Veterans who did not have a primary care appointment but were appropriately listed on th phoenix electronic wait list. However, we identified an additional 1700 vet raps who were waiting for a primary caree appointment but were not on thet electronic wait list. Elec we reviewed a statistical sample of 226 phoenix appointments for primary case in fiscal year 2013. Va national data, which was phoi reported by phoenix, showed x, these veterans waited on average 24 hour days for their first primary care appointment and only 43 waited more than 14 we days. However, our review showed that those 226 veterans in our sample waited on average 115 days for their first primary care f appointment, witorh approximate 84 waiting more than 14 days. We did not report the results of our ongoing clinical reviews ing our interim report as to whethea any delay in scheduling a primary care appointment resulted in a delay in diagnosi or treatment, particularly for e those veterans who died awaiting care. The assessments needed to draw any conclusions require analysis of va and nonva medical records, death certificates and autopsy results. R weve made requests to ag appropriate state agencies and have subpoenas to obtain nonva medical records. All of these reports will require a detailed review by our clinical teams. Ons to while we make recommendations to the va in our final report, we made four recommendations to the va secretary for immediate implementation to insure veterans receive appropriate care. Plem we will address the sufficiencye of vas implementation in our cy final report. Our recommendations include tion taking immediate action to review and provide appropriate health care for the the 1700 veterans identified on, not listed on the waiting list at phoenix and to take the same action at all facilities in thei va system. This concludes my statement and we would be pleased to answer any questions. Halliday thank you, mr. Griffin, for your testimony. Members, we will all do a round of questions at five minutes ins apiece and we will do a second d round, i am sure, after the first round. Dr. Draper, in your comments, o you said that 43 of the consults you reviewed were closed without the veterans being seen. Can you give me an explanation n as to why the care wasnt provided . There are various reasons, one is patient no show, cancelled appointment, either nh cancelled by the patient or the Medical Center. We also found instances of some records we couldnt tell, we looked at it and there was no documentation as to why the nd consults were closed. How does va schedule appointments . Is it through a telephone call . To the veteran or by a letter . Tn it is typically through a i telephone call witht the veter. The veteran may call us. We may call the veteran. We will notify the veteran on a recall reminder process, which does involve a letter, sir. Thats interesting, because ive heard numerous veterans p tell me that they received letters telling them when their appointment will be and not asking whether or not t they can attend that particular appointment. So im a little confused. Sir, ive heard that as well. That is not appropriate. Hear that increases our rate of noshows. Th it is not veteran centric. We need to change that. We should be having a conversation with a veteran asking him or her when they want to be seen and scheduling around their requirement. The va has consistently tar stated the alternate list or secret list in phoenix that was being used to populate the electronic wait list was destroyed immediately after the ewl was populated. So my question is, was there an independent verification, in fact, that every veteran on then alternate wait list was successfully transferred to the ewl or can you provide any prod documentation or assurance to us that no veteran was left off tht alternate wait list . Ive had a team on the ground, sir, reviewing their eir practices and their scheduling i processes. I have a report thats only their first draft report. R firs i will get a final report from l them and i will be able to dig little bit deeper. Be at this point in time i dont have any reason to believe thats any veterans were left off the final ewl count. But i will await the final ewl report. Can you tell the committee who at the central office, if anybody, knew or instructed or coached anybody how to many nip late wait times . I do not know i dont know e anyone that has done that or th not in my direct experience. Heye so you dont know whether they have or havent . I certainly hope not. I would hope not either. A brief if may of 2009, dr. Al mike davie, the National Director of systems redesign indicated there were 49,743 for veterans waiting for care as ofo september 15th of 2008. 08. Now more than five years later, the vas audit shows and has been reported in the media that it has risen to 57,000 veterans waiting more than 90 days for their first appointment and an n additional 64,000 veterans that appeared to have fallen through the cracks. Atrough how can this be . The correct use of the electronic wait list is the number thats 57,000, sir. We use the electronic wait lists if we are unable to schedule a veteran who is receiving their a first specialty consult within 90 days. Ys. The correct use of that is to ensure that we can work aran ino veteran into an appointment sooner. A the 57,000 number is a much more conservative number. The known direct Clinical Care is only 40,000. Care we have to get eyes on the ewl. O we have to manage it. We have to make sure that our front line staff and our Medical Centers are accurately working t that list, getting veterans from waiting for an appointment intos an appointment. As for the 64,000, that was64,00 the new enrollee appointment request list. Mr. Griffin had told us that res that was one of the recommendations. That if we could find that in phoenix, that we should lookeam across the entire country. As we had a team review the new enrollee appointment request list, we identified every single veteran from the beginning of e the period of enrollment who maf have at one point in time o requested an appointmentint when they provide their enrollment data. Prov if we could not verify they hadw an appointment, we went ahead and added them to the list so we could begin contacting them tomorrow. Mr. Griffin, one final question before i yield to the ranking memember. Have you found evidence of criminal activity in your assessment . We have found indications ofd some supervisors directing some of the methodologies to change the times. We have been in discussion withe the department of justice concerning those and whether or not in the opinion of the department of justice they rise to the level of criminal prosecution. Osecutio that is still to be determined in most instances. S. I appreciate you talking with the department of justice. Ap the committee has written a prce letter to them also asking that they open an investigation. Also we havent heard anything from them to date other than the fact that they got our letter. But i appreciate it. Thank you very much, mr. Chairman. Dr. Draper in followup on a question the chairman asked an about the va close consultants t due to noshows. No what percentage were noshows s versus the va canceling . Well, we looked at noshows and cancellations and we went through the consults and researched the 150 cases that w looked at, to look at the history of the consult request. S we found that more than half eih either had a noshow or cancelem appointment. S a so thats a large percentage of the consults. E so its a big problem for va anm what we see is that the policies at the local level vary as to h how local facilities handle no w shows and cancelled appointments. Thank you. The gao reports that wait timesa arree generally not tracked for nonva care. Ed for why dont you track wait times u for nonva care . Historically, sir, we have not, congressman, we have two initiatives, both in full ve tw deployment at this point. In the first one is for nonva cart coordination. Effectively, what is occurring e now is when we refer a veteran to care in the community, if we could not provide it. Linic t it creates an appointment inside a clinic. Nt it allows us to monitor that and watch that appointment. H we are now collecting time lead details on that. Th we have a nation wide contract called patient centered care in the community. Erfo that contract has a performance requirement from our two contractors that they both schedule and see veterans within 30 days of the referral from use we think those two approaches will help us in the long run s insure coordination and management of nonva care. Dr. Draper also alluded the requirement to manage the coordination of that care. Requim its not enough just to refer o care into the community. Thefer we do need to follow through as well to insure the veterans needs are met, that that nonva. Provider is respectfully workint with a veteran, her or his is family, to get into care. Thank you. Into the gao also reports that there is a consistent problem across vha with policy and procedures for handling noshows and cancelled appointments. And im aware that va, that you area working on an update to this. Wg scheduling policy. When do you anticipate this revised policy to be released . And will it address the noshow consistently throughout the va. System and canceled appointments . Nd i expect it will, sir. Ad a we had a Team Last Week t reviewing the existing policy we have today and to determine whether or not we should rescinu that policy and replace it with a clear, declarative set of instructions for our schedulers in the front line. We expect to take that action. We will replace that policy wite a revised policy. That allows us to have much more concrete sets of instruction on how to schedule, specific instructions for what to do, for staff, if were scheduling within 90 day what to do on daye 91, to actually offer that du specific instruction and tie that policy to training. N, a lot of our current policy mixes two concepts, scheduling t and practice management. Sc were going to have to make sure that we have a clear schedulingp policy and a clear practice clea management policy. R management of noshows can be c handled by contacting veterans,g working with veterans, to insur that theyre reminded of their appointment, frankly. Making sure we talk to veterans. And their families when we schedule their appointment. Talw when we do those things, we canu reduce our noshows. Great. Can you explain to what extent exercising nonva care requires additional approvals . Yes, sir. In some of our Medical Centers,s they require approval at the av chief of staff level to use nonva medical care. As part of accelerating care, wf worked on that in the i think a, the second to the last week of may. We worked on the plan may 21st, rolled it out may 22nd and began execution on the 23rd of may. We have released instructions to the field, that particularly cts where we have confidence in our wait time data, that the field h is required, if they cannot offer that care in a va, in a v. Facility, first they must assess their capacity, increase their i capacity by running nighttime o clinics, overtime, weekends and if they cannot, then they are instructed to offer nonva care to the veteran. Raas then weve asked them to tell kl us, what do you need in terms ot resources to make that work . E so we are providing a different. Set of instructions. To work with a veteran, it is a veterans choice to get timely care and to make sure we offer it. Make sur thank you very much, mr. E chairman. You are recognized for five minutes. M thank you, mr. Chairman, i ae appreciate the work you are doing on this issue. I one of the areas that is going to have to get further review i in colorado springs, colorado. Gn and there are three anonymous whistle blowers who have come us forward and said that there aree problems with manipulating ve waiting times. Ive talked to the leadership in both denver and colorado springs. Have they have told me personally not that this is not going on and ii believe them, but at the same, we have whistleblowers saying that it is going on. Mr. Matkovsky, how does the va treat whistle blowers . Does and what im getting at, if there is intimidation taking place, how do we change the culture from intimidation to where people are free to step forward . Are part of how we designed thisw audit was to have direct access to the front line from our to h senior staff. When our auditors went to the field, they met at the same time with the Union Representation at the field and the Facility Management. Not two separate meeting, one meeting. We did not provide advanced anne announcement of who we wanted to interview. We p we provided that when we showed up, so we could have a direct conversation. I will tell you, i have read through the openended comments of all of the responses that i n could and nothing, nothing saddened me more than an who s employee who says i was trying to do it right. Ayto do i know it is right. And i received instruction to do it wrong. That is just simply not tolerable. Retaliation against whistle e. Blowers is also not tolerable. We cannot condone that. We required a leadership and cultural shift in our way of managing. And i raised this a couple oa weeks ago in our last late night hearing, and that is, if you is cant rely on the data, if you y cant rely on the records because secret waiting lists by their nature are meant to conceal the truth from someone who is doing a review, like yourself. Selves, does the alternative to go in and do a casebycase analysis, talking to every single veterany who tried to get an appointmentg and doing this on a onebyone, even if that takes hundreds or thousands of contacts,do we how do we get to the bottom of it when the records or the not reports are not reliable . I believe we have to begin re with the end in mind. If what we want to do is to provide veterans with timely, Quality Health care, lets ask them. How are we doing . How is our care . , how is our access . Is our access meeting your ss, requirements . Is it not . Y if not, lets fix it. The thing thats terrible about the crisis is this isnt even ai output measure. Its an activity measure. Its a what happens when we change thah activity measure is we cant ac tell where were not timely. In no cases were we finding inga front line staffre delaying carr by moving the appointment later in the calendar, they were changing the reference point. Ern when that happens, we dont know where were late. When we dont know where were late, we cant identify knowla resources or to realign resource, when we dont know that, our entire system for requesting resources is thrown off. Mr. Matkovsky i hope we seenn the final days and never again where bonuses oar promotions aro based on metrics that can beti manipulated, instead of, like o youre mentioned, outcomes, like Patient Satisfaction or good or care that can be documented, not metrics that can be manipulatede i concur. And do either of you other a two folks want to comment on that issue . Mr. Griffin . I think it comes down to to accountability of the seniore leadership out at these facilities. And once someone loses his job or gets criminally charged for doing this, it will no longer bo a game and that will be the shot heard around the system. W thank you. I yield back. Mr. Brown, you are recognized for five minutes. Thank you, mr. Chairman. Mi mr. Chairman, thank you for having this hearing and colleagues, i want to make sure that we are firing at the right target here tonight. Right we are all on this committee because we care about the we veterans and you can be sure th only reason im on this sure committee is i care about the veterans and i have been on thi committee for 22 years. And so i have a couple of questions. Estion dr. Draper, you mentioned and ii want to thank you for your service. Se but the case that you gave about outsourcing that particular case and it wasnt the right kind of coordination, can you expound on that a little bit more . Because a lot of people want to erans, partner with veterans if they cant get the service right away . I think its an important an point because, you know, there n is a lot of talk of sending moro veterans out to the community for care. Alhile t while that is a way to expand capacity, as i mentioned, as there a