SPEAKER INDEX CONTENTS INSERTS BILIRAKIS 5 DONALDSON 6 9 10 11 EVANS 3 4 GARTHWAITE 12 24 26 27 29 30 31 32 33 34 35 39 40 GUTIERREZ 2 10 11 MATHER 17 23 36 38 39 MCMANUS 31 37 MILLER 21 22 28 STEARNS 1 3 5 6 9 10 11 17 21 22 23 24 26 27 29 30 31 32 33 34 35 36 37 38 39 40 WILSON 30 32 33 CONTENTS SPEAKERS INSERTS OPENING STATEMENT OF CHAIRMAN STEARNS PAGE 1 OPENING STATEMENT OF HON. LUIS V. GUTIERREZ PAGE 2 OPENING STATEMENT OF HON. LANE EVANS, RANKING DEMOCRATIC MEMBER, FULL COMMITTEE ON VETERANS' AFFARIS PAGE 3 OPENING STATEMENT OF HON. MICHAEL BILIRAKIS PAGE 5 STATEMENT OF MOLLA DONALDSON, M.S., PROJECT DIRECTOR, NATIONAL ROUNDTABLE ON HEALTH CARE QUALITY, INSTITUTE OF MEDICINE PAGE 6 STATEMENT OF THOMAS GARTHWAITE, M.D., DEPUTY UNDER SECRETARY OF HEALTH, DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY NANCY WILSON, M.D., DIRECTOR, OFFICE OF PERFORMANCE AND QUALITY, DEPARTMENT OF VETERANS AFFAIRS; JAMES MCMANUS, M.D., MEDICAL INSPECTOR, DEPARTMENT OF VETERANS AFFAIRS; AND JOHN MATHER, M.D., ASSISTANT INSPECTOR GENERAL FOR HEALTH CARE INSPECTIONS, DEPARTMENT OF VETERANS AFFAIRS; AND MAURA FARRELL MILLER, PH.D., ARNP, CS, PRESIDENT, NURSES ORGANIZATION OF VETERANS AFFAIRS PAGE 12 STATEMENT OF THOMAS GARTHWAITE, M.D. PAGE 12 STATEMENT OF DR. JOHN MATHER PAGE 17 STATEMENT OF MS. MILLER PAGE 21 INSERTS SPEAKERS CONTENTS