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THURSDAY, MAY 14, 1998
House of Representatives,
Subcommittee on Oversight and Investigations,
Committee on Veterans' Affairs,
Washington, DC.

    The subcommittee met, pursuant to notice, at 9:30 a.m., in room 334, Cannon House Office Building, Hon. Terry Everett (chairman of the subcommittee) presiding.
    Present: Representatives Everett, Spence, Mascara, Snyder, and Evans (ex officio).
    Also present: Representative Hulshof.

    Mr. EVERETT. The hearing will come to order.
    Good Morning. First, some background because the subject matter of this hearing has a 6-year history. On October 25, 1995, the Subcommittee on Hospitals and Healthcare held a hearing on the unexplained patient deaths which occurred in 1992 at the VA hospital in Columbia, MO. The VA's IG office presented testimony regarding its report on the special inquiry into allegations that there was a cover-up in the patients' death. The IG's special inquiry report concluded that, while the hospital's management had been dysfunctional, it could find no evidence of a cover-up. Dr. Gordon Christensen, the hospital employee who was a whistleblower on the problems at the hospital, disagreed and charged in his testimony that the IG report was flawed and incomplete, among other things.
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    Dr. Christensen, I believe, is in our audience this morning, and I would like to ask him to stand and be recognized.
    Thank you, Dr. Christensen. I believe that considerable efforts within the VA and IG's office to discredit you have failed. Dr. Christensen, it would be hard not to see your vindication in GAO's report released this morning. I want to thank you for your public service.
    At the hearing in 1995, Chairman Tim Hutchinson, now Senator Hutchinson, seemed skeptical of the IG's conclusion. He said calling this ''dysfunctional management'' understates it. It appears that was, basically, the consensus of the panel at the time. This subcommittee decided to follow up issues raised at the hearing and again have oversight of selected IG activities with a thorough look into the work of the IG's office on the unexplained patient deaths at Columbia. This was an important case and the IG work should be able to stand close scrutiny.
    The subcommittee essentially asked GAO to investigate whether the IG's special inquiry complied with generally-accepted standards for investigations; why the special inquiry took over 2 years; and how well the IG protected the identity of whistleblowers. We also want to continue monitoring the progress the VA has made in improving the quality assurance and risk management mechanisms for detecting and responding to situations similar to Columbia's unexplained deaths. The Veterans Health Administration's effort is now called the Patient Safety Program. It's my hope that this hearing will allow a clear, factual picture of the IG's special inquiry into the alleged cover-up. Then perhaps we can begin to draw conclusions and reach closure on at least some of these troubling issues.
    I'd like to welcome Congressman Kenny Hulshof, who represents the district in which Columbia's VA Hospital is located. He asked if he could attend his hearing even though he was not a committee member. I'm glad to agree. Mr. Hulshof has followed this subcommittee's inquiry very closely, and has been kept fully informed of its progress, and I will recognize him after subcommittee members.
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    I also would like to recognize our ranking member, Mr. Evans, who is the former chairman of this subcommittee.
    And now I recognize—well, Mr. Clyburn isn't here yet, so I'd like to at this point recognize Mr. Evans for any statements he may have.

    Mr. EVANS. Thank you, Mr. Chairman. I must say that I am equally troubled by the circumstances which have led to the need for this type of follow-up hearing 6 years after 13 to 42 veterans died from unexplained causes at the Harry S. Truman VA Medical Center in Columbia, MO in 1992. I am sure that Chairman Everett will agree that this hearing will not answer all the lingering questions about what happened 6 years ago. It will, however, raise new questions about how the VA IG's office conducted its review into these allegations. It may also lead to other lessons learned on the part of the VA IG's office and reinforce our Government's strong belief that a fully-funded, aggressive and independent Inspector General's office is a critical priority as the VA moves into the next century.
    Finally, and perhaps more importantly, I'm hopeful that today's hearing will prompt a renewed commitment to discover what went wrong at the Truman Hospital in 1992.
    Mr. Chairman, I look forward to the testimony and thank you for allowing me to make a statement.
    Mr. EVERETT. Thank you, Lane.
    Mr. Mascara.

    Mr. MASCARA. Thank you, Mr. Chairman. I have no opening statement. It is very hard for me to believe that this even occurred, but how could those responsible for this special report say—and I read this in the GAO report that is being released today—say that there is no conclusive proof of an intentional cover-up by medical center's central region officials and no evidence of criminal conduct by the management? How can that be said when the report says that they didn't even do that study? I'm looking to ask that question a little later on, but I thank you for holding this hearing. I look forward to hearing from the panels.
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    Thank you.
    Mr. EVERETT. Thank you. Mr. Hulshof.

    Mr. HULSHOF. Mr. Chairman, I want to thank you for giving me the opportunity to join the committee today to hear testimony relating to a veterans' medical facility that is located in my district in Columbia, MO in the 9th Congressional District. I want to, first of all, emphasize to the committee and to all of those present that the incidents which have provided the basis for this investigation involve a series of events which did take place in the past.
    I do want to point out that these events are not indicative of the excellent medical care currently being provided by the men and women of mid-Missouri who care for veterans day in and day out at the Harry S. Truman VA Medical Facility. Harry S. Truman was, of course, the only Missouri President that we have had, and I think everyone is familiar with the quote attributed to Harry S. Truman, ''the buck stops here.''
    Unfortunately, regarding the investigation by the Inspector General, the buck has not stopped. As the gentleman has pointed out, after almost 6 years we are still here talking about these events, and it's extremely frustrating. I'm a first-term Member and I know the former Congressman from the 9th District also was similarly interested, because we don't know many of the answers to the basic questions which initially surrounded that very tragic, horrible situation. We still don't know the who's, the what's, the where's, the when's, or the why's, and probably never will.
    I'm afraid that things have been distorted enough by some individuals at the Department of Veterans Affairs, many of whom worked outside the Veterans' Hospital in Columbia, that we will continue to be left with those doubts, as the gentleman pointed out, without any possible conclusion or explanation. But I do believe that this report by the General Accounting Office of Special Investigations Office does represent probably the best, most independent look at much of what occurred, and offers the best chance to, hopefully, put this whole episode behind the families of the veterans who lost their lives on Ward 4 East.
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    In following this situation, I had hoped that the Department of Veterans Affairs would finally accept responsibility for obvious mistakes that had been made. Instead, it looks as if we will be treated to continued attempts to deploy political spin control, to talk down some of the serious findings of the GAO investigation. And again, as the representative of many of the constituents and families in the 9th District, spin control has a very tragic affect on the families who have lost loved ones.
    And we cannot begin to imagine here in Washington, DC how it feels for the families to face 2 years of delay because of what the agency calls, quote, ''an administrative error.'' In my book, and I think Mr. Chairman, in your book, and certainly back home in the Court of Public Opinion, common sense tells us that the agency has dragged its feet from day one. It has failed to accept responsibility for the serious mistakes one made on its watch, and unfortunately, footdragging and artful dodging have left us without enough evidence to fully ascertain what happened to these honorable veterans.
    Why are we sitting here, Mr. Chairman, on May 14, 1998, nearly 6 full years after the facts still searching for answers and hoping for a conclusion? If it had not been for the perseverance of the gentleman you pointed out, a constituent of mine, Dr. Gordon Christensen, I'm convinced—I am completely convinced—that efforts by former hospital administrators and others within the Department of Veterans Affairs to sweep this whole matter under the rug might have been successful. I, too, share your commendation to Dr. Gordon Christensen, and I feel in many ways that this GAO report vindicates many of the concerns that he's raised during this 6-year struggle.
    Again, thank you for allowing me to participate and I, too, look forward to the witnesses here today.
    Mr. EVERETT. Thank you. Of course, one of the great tragedies of this is the fact that we will probably never know how these 42 patients died.
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    Dr. Snyder, we recognize you for any opening statements.
    Before we welcome our panelists, I want to play ABC's PrimeTime live segment on the Columbia VA Medical Center. This aired on January 7, 1998. It runs about 11 minutes, and I'd advise the members who have not seen it, that might be interested, to move to this side of the room, because I think it's an excellent report.
    If somebody could dim the lights for us also and turn up the volume.
    Mr. EVERETT. We showed the video for two reasons. No. 1, to show the very human side of what happened at Columbia; No. 2, to show that trust in our Government is at the very essence of this case. We wonder why the public from time to time mistrusts the Government so much. And, I'd have to tell you, too, that Columbia, MO represents that reason—or one of those reasons. The truth is that this goes to the very fiber of trust in our Government, and we obviously will never get the truth of what happened at Columbia now because of a few bad Government employees. It's just simply the fact.
    I'd ask each witness to limit your testimony to 5 minutes. The complete written statements will be made part of the official record. I ask that we hold all our questions until the entire panel testifies, and because of the nature of today's testimony, I've decided to have the witness panels with direct knowledge of events and investigative activities testify under oath.
    I now recognize panel one and welcome Mr. Eljay Bowron, Assistant Comptroller General for Special Investigations, Office of Special Investigations of the General Accounting Office. And, if you will, sir, please introduce the rest of your panel. Mr. Bowron, if you would please introduce the rest of your staff?
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    Mr. BOWRON. Thank you, Mr. Chairman.
    I have with me today Assistant Director Robert Lippencott of our Chicago office who led this particular review and, also, Mr. Don Fulwider, our Deputy Director of Investigations who supervised this effort from our headquarters.
    Mr. EVERETT. Will the panel please rise and raise your right hands and repeat after me.
    [Witnesses sworn.]
    Thank you, please be seated.
    We're going to experience a vote at this point. Let me take care of some housekeeping. As I said earlier, we'll have 5 minutes for each—if you'll limit your testimony to 5 minutes, we'll have your complete testimony made a part of the official record. And, I think at this time, rather than trying to get into the opening of the first panel, that it might be a good idea if we decide to go ahead and get the vote over with and come back as quickly as possible.
    So, I'm going to recess the committee hearing at this time.
    Thank you.
    Mr. EVERETT. You all can be seated and I'll call the committee back to order.
    Mr. Bowron, on behalf of the subcommittee, I want to thank you and commend you and the Office of Special Investigations for the year-long effort that went into your review of the IG's special inquiry. GAO is an independent review and investigative organization for Congress and enjoys the credibility few others have here in Washington these days. As Assistant Comptroller General for Special Investigations and the former Director of the U.S. Secret Service, you bring impressive credentials to the witness table.
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    Let me ask you, did I, my staff, or anyone else suggest to you what conclusions were desired or try to influence your report conclusions in any way?
    Mr. BOWRON. No, sir.
    Mr. EVERETT. Does GAO have an axe to grind in this matter?
    Mr. BOWRON. No, sir.
    Mr. EVERETT. Okay. Your report has concluded that the IG special inquiry report was misleading. I'm not surprised that your report is critical of the way in which the IG investigation was done, but I am very surprised and dismayed to hear that you believe it was misleading. You have already stated the reasons for your conclusion in your report and statement. As you know, Dr. Gordon Christensen, who is one of the whistleblowers of the Columbia VA Hospital situation, alleged in his October 1995 testimony before the Hospitals and Healthcare Subcommittee that the IG report was an incomplete, dishonest, flawed, and distorted presentation of the events that took place in Columbia. Was it any of those things?
    Mr. BOWRON. Mr. Chairman, I think, as we indicate in our report, that it was misleading. It was in places inaccurate, and it was certainly in some respects incomplete.
    Mr. EVERETT. Was it a cover-up?
    Mr. BOWRON. On the part of the Office of Inspector General, no.
    Mr. EVERETT. Was it a shoddy job at investigating a cover-up?
    Mr. BOWRON. I would say that, in terms of addressing the allegations of a cover-up, it was a shoddy job at best and arguably the allegations of a cover-up were really not pursued and investigated.
    Mr. EVERETT. And, your description of the investigation is that it was a shoddy job or an incomplete job?
    Mr. BOWRON. Yes.
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    Mr. EVERETT. Does the GAO find any basis for believing that the IG report or testimony was intentionally misleading or that there was possible misconduct on the part of the IG officials that should be explained further.
    Mr. BOWRON. No. We didn't determine any misconduct on the part of IG officials in terms of being intentionally misleading. I don't believe that the report was intentionally misleading. In terms of whether or not the VA OIG deliberately delayed its special inquiry, the Office of the Inspector General has, I think, provided the subcommittee with information that attributes to the delay to an administrative error. If you include a lack of oversight and communication under the umbrella of administrative error, I think that is an accurate description.
    Mr. EVERETT. It's my understanding that a VA employee told GAO of a comment from the IG's office that the hospital director was stonewalling the investigation. Is that correct?
    Mr. BOWRON. That particular comment was included in a document prepared by the analyst who conducted the special inquiry.
    Mr. EVERETT. As the subcommittee chairman, I asked GAO to review the 2-year delay in the IG investigation. That's why it is in the report. I understand that a VA employee interviewed by GAO has stated that she was told by an IG official that the IG's office was not going to investigate the cover-up allegations unless it had to. Did that happen? Do you find reason to believe that the delay was deliberate, and if it was not, how would you characterize it?
    Mr. BOWRON. Mr. Chairman, as I said, first of all with respect to whether that comment was made, that's a conversation that was documented by one party in the conversation, and that particular statement is documented as a part of that telephone conversation. As to whether it was a deliberate or intentional delay, I think that I already stated that we don't find that they deliberately or intentionally delayed their investigation to keep the investigation from occurring. And to a large extent, I think the best indication that mitigates that with respect to the Office of Inspector General is to say that, if they were trying as an organization to prevent the investigation from taking place, they would not have referred the complainant's allegation to the FBI in a timely fashion, which they did.
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    Mr. EVERETT. The IG responds by alleging many shortcomings in the GAO's work—and it, essentially, does not concur with GAO's overall conclusions about the misleading nature of the IG report and the shortcomings in the investigation. How do you respond to the assertion that says your report is the bad one, not theirs? That yours is inaccurate, erroneous, takes statements out of context, says things people didn't say, didn't interview people who should have been, and so forth?
    Mr. BOWRON. Well, I would respond to that by saying that, in conducting our review, we had complete access to all of the workpapers associated with this review and all of the evidence that the VA OIG had to consider. In addition to that, we interviewed knowledgeable employees of the Office of Inspector General as well as the hospital and since we, basically, have all the information they had to consider, we really have no reason to mislead or to come to one conclusion or another. As I responded to one of your opening questions, we don't have an axe to grind in this matter.
    As far as taking out of context what people said, we did detailed interviews. We provided people with information to refresh their memories. In contrast, the Office of Inspector General's criticisms are based on its review of the draft report, their only evidence.
    And the VA OIG went back out, I believe, and talked to some of the people that we interviewed and those people either provided the OIG with different information or mitigated statements that they may have made to us. Well, I can imagine that people who worked for the VA Office of Inspector General might have mitigated their statements to representatives of the Office of the Inspector General versus what they said to us. So I think that they didn't have as much information to review. They didn't even have the information to be able to put it into context because, appropriately, they didn't have our reports of interview. They don't even know the full scope of who we interviewed, let alone what they said to us.
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    Mr. EVERETT. At this point, I will recess because there is a vote going on, and we'll be back as quickly as possible.
    Mr. EVERETT. In my enthusiasm to get to the questioning, I missed the opening statements and at this point you will go ahead and give your opening statements.

    Mr. BOWRON. Thank you, Mr. Chairman. I'll just—in fact, I'll just make a couple of brief remarks that kind of summarize what we were asked to do and what the result was.
    Mr. Chairman, you asked us to determine whether the Office of Inspector General's processes and procedures were adequate for ensuring confidentiality requested by individuals; and, also, whether the Office of Inspector General protected the confidentiality of the staff physician who made the allegations of a cover-up. We found that the current policies and procedures are adequate, and consistent adherence to and ongoing awareness of those policies should result in the effective protection of complainants and sources of information. As to the Office of Inspector General's protection of the confidentiality of the complainant in this particular instance, there were breaches of that confidentiality.
    You also asked us to look at whether the Office of Inspector General complied with its policies and procedures in conducting this special inquiry. We found some instances where they did not comply with policies for accuracy and completeness. We found statements in the report that were either not supported or were inconsistent with the evidence contained in their files.
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    Another issue that you asked us to look at, and we've already talked about it a little bit, is the 2-year delay between the receipt of cover-up allegations in February of 1993 and the beginning of the special inquiry in January of 1995. As part of that, the allegation suggested that the OIG was part of the cover-up based on that delay, but we found that the suggestion of the OIG being part of the cover-up is really greatly mitigated by the OIG's timely referral of the complainant's February 1993 letter to the FBI. I think that they did in a timely fashion refer this to their Office of Investigations and through an investigator. There were also indications that at least initially, they believed that those allegations would have been included in the criminal investigation being conducted jointly by the FBI and the Office of Inspector General.
    Really, the heart of the issue you asked us to look at is whether the special inquiry report represents the results of the Office of Inspector General's review. I think that is the primary focus of our criticism. The question really gets down to—or our position I think would be—that the Office of Inspector General's work did not reflect an intention to get to the bottom of the cover-up allegations. A fair reading, I think, of their report and its conclusions leaves the reader with the impression that they made a comprehensive effort to address the allegations. They didn't. That makes the report misleading.
    You have already indicated, Mr. Chairman, that my complete statement will be submitted for the record and that concludes my brief remarks.

    [The prepared statement of Mr. Bowron appears on p. 42.]

    Mr. EVERETT. Any other member of your panel wish to make statements?
    Mr. BOWRON. No, sir.
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    Mr. EVERETT. When we left off earlier, you mentioned that it didn't surprise you that perhaps VA employees would make mitigating statements to the VA IG as compared to the statements they may have made to you. But in the essence of what's perhaps wrong with our system here, for those of you who've followed some of the hearings I've had, I insist that there's a culture that exists within the VA. Frankly, I think it's a huge cancer that's consuming the VA. It's a culture that defies oversight—congressional oversight—we've seen time and time again hospital directors that defied, not only their superiors, but congressional oversight also. When you start mitigating your statements, to me, that means change. I know that some folks would say that means shading. But mitigating statements, isn't that one of the problems we have getting to the truth of what happened at Columbia?
    Mr. BOWRON. I think that that is one of the problems that is exhibited here. I spoke about the employees that might have been interviewed by the Office of Inspector General—employees of the Office of Inspector General that we interviewed—and who then, based on the results of our interviews and our subsequent draft report, were re-interviewed by representatives of the Office of Inspector General. I don't think that it's surprising that they would say things to us that were damaging to the Office of Inspector General, but when they were talking to representatives from the Office of Inspector General, try to err on the side of not being as harmful to the Office of Inspector General, and probably not even repeating some of the things that they said to us. That doesn't surprise me.
    The Office of Inspector General does have a vested interest in the outcome of this review. We don't. I can just say that every statement in our report can be traced either to an individual interview, statement, or document. At the conclusion of this hearing, if you've got questions about our documentation or how we came to any statement in our report, we'd be happy to sit down with the members or their respective staffs and explain exactly what we're relying on to make that statement for everything that's in our report.
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    Mr. EVERETT. Well, I won't belabor the issue, but I will again remark on the fact that I think there's a certain culture that exists within the VA that, ultimately, if it's not changed, will destroy the organization.
    GAO received a letter dated February 24, 1998 from the FBI. Each member has a copy. I ask unanimous consent that it be made a part of the record.

    [The information follows:]

Offset folios 1 to 2 insert here
Makes pp. 10 to 11

    Mr. EVERETT. What led up to the letter and what did it state regarding whether the scope of the FBI's criminal investigation included a cover-up?
    Mr. BOWRON. Well, what led up to the letter—and I made reference to this earlier—we wanted to determine, as part of the 2-year delay in the start of this special inquiry, at what point and time the Office of Inspector General referred the complainant's allegations to the FBI. We found that they referred those allegations to the FBI in a timely fashion. That was a request that we made for the FBI to tell us, did you get this information and when did you get it?
    The second part of that was, did you incorporate this into your investigation? In other words, did you investigate these allegations of a cover-up? The response essentially was that in view of the fact that they did not identify criminal activity, they did not conduct an investigation relative to the allegations of the cover-up. Had they found criminal—evidence of criminal activity—they would have done an investigation that would have included elements of a cover-up before, after, or during—I'm not quoting their letter exactly, but that was the message.
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    Mr. EVERETT. Did the IG investigation adequately investigate the issue of nepotism that the IG report addressed? The former Director's son is still the Chief of Human Resources at Columbia, isn't he?
    Mr. BOWRON. I believe he is, Mr. Chairman. With respect to the allegation of nepotism, we determined that the Office of Inspector General referred that to management at the hospital for their inquiry and review. They then reviewed the steps that were taken by management at the hospital which detailed the personnel practices and procedures and the basis for the selection and the timing of different events. The Office of Inspector General was satisfied that the review done by the hospital management was sufficient and was complete. That's what is reflected in their documentation. If the question is, was there an independent investigation of that allegation of nepotism, there wasn't an independent investigation of it because management, in fact, investigated their own actions; that investigation was reviewed by the Office of the Inspector General, but the allegation of nepotism was not investigated by the Office of the Inspector General.
    Mr. EVERETT. Thank you. Mr. Mascara.
    Mr. MASCARA. Thank you, Mr. Chairman.
    There must be some professional tension between GAO and the IG considering the nature of their respective functions. Can you give us some general background into the duties and responsibilities of the GAO compared to the VA IG? In what respects would you say that your roles are similar? In what respect would you say that they differ? How often does GAO sit in judgment concerning the work of the IG, and vice versa?
    Mr. BOWRON. Well, GAO's role is to respond to requests from Congress and from the Legislative branch to review and investigate the matters that concern the various committees and subcommittees. Our job and our mission is to provide accurate and impartial results and report on the facts we're able to determine by our investigations and reviews. In many respects, our work is similar to the work done by the Office of Inspector General within their own departments and with respect to the investigations that they do. In this instance, we've been asked to review the investigative work of the Office of Inspector General; that's not uncommon. We do that work probably several times each year. It's not something that we have a vested interest in and it's not something that we necessarily enjoy doing, obviously, but it's part of the job, and it's our job to try and be fair and objective and professional in the conduct of that work.
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    Mr. MASCARA. When you were asked—or the GAO was asked—to pursue this investigation, what was the mission or the goals or objectives assigned to this investigation? What did they ask you to ascertain?
    Mr. BOWRON. Our investigation?
    Mr. MASCARA. Yes, yes.
    Mr. BOWRON. Well, really to determine the matters that I outlined earlier and there were four or five specific areas that we were asked by the chairman to review that included their hotline policies; protecting confidentiality; whether they followed policies for accuracy and completeness of their investigation; and whether they appropriately protected the identity of the confidential complainant in this particular instance. The heart of the matter really was, did their report accurately reflect the results of their work.
    Mr. MASCARA. And it did not?
    Mr. BOWRON. With respect to allegations of a cover-up, we conclude their report does not accurately reflect the results of their work.
    Mr. MASCARA. Did your investigation ascertain the patient level at the VA center? In that particular ward, how many patients were assigned to a nurse? Did you deal with those kinds of information?
    Mr. BOWRON. We didn't examine that kind of information, although it was certainly a part of the documentation that we looked at. But we didn't reinvestigate this. We didn't investigate the unexplained deaths. We didn't investigate whether or not there was a cover-up. We reviewed what the Office of Inspector General did and that's the scope of our report.
    Mr. MASCARA. No one ever suggested that perhaps a State grand jury or Federal grand jury be convened? You know, after seeing the piece there from ABC, it just boggles my mind that if the director at the facility had to give a report—I was responsible for running a 250-bed nursing home back in Washington County where I was a commissioner. We got a report every day of deaths. I'm just wondering this director sat there each morning and looked down at his sheet and said, well, there's one today; there's two tomorrow; there's three next week; now there's 30; now there's 40. How anybody could continue to allow this to happen boggles my mind. I mean, it doesn't take a rocket scientist—even a person in the medical field could figure out there's something wrong. I mean, does the nurse have too many patients that he can't care for and he says, ''Well, I'll get rid of this one tonight and that one tomorrow.''? I just can't believe that we've let this go on.
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    I want to associate myself with your opening statement, Mr. Chairman. That's why there's cynicism out there about elective service and this government, that somehow the GAO, the IG, the FBI, the Justice Department could let this happen and not convene some kind of a grand jury to find out—we're going to nail this guy or this person, whoever it is that took these lives.
    Then he went on to another home and—I don't know, what did it say—how many more were killed in this private nursing home, alleged to be killed? I just don't know. Your report didn't deal with that. You were just looking at what the IG did and the IG didn't do what they were supposed to do. Was anybody ever reprimanded because they didn't do what they were supposed to do in their report?
    Mr. BOWRON. That's covered in the IG's report.
    Mr. MASCARA. Well, I haven't had an opportunity to read, fully read, both reports, but I've scanned through them. The more I read, the more upset I get.
    Mr. BOWRON. Yes, sir. If I could add one thing—I mean, I think it's only important to note that our work and our report is specific to what was requested by the chairman of the committee. So our response is specific to those requests.
    Mr. MASCARA. My staff person said that Boone County had one grand jury and there were no indictments—is that correct, Don? Yes, he's saying yes.
    Mr. EVERETT. That is correct, no indictments. The number you were searching for is an additional 30 people died at the institution, although we have no evidence of what happened.
    Mr. MASCARA. Seventy deaths and we don't have an answer? Maybe we ought to look at the budget of everybody, especially these investigations. They're not doing a very good job. Thank you, Mr. Chairman.
    Mr. EVERETT. Thank you. Mr. Evans?
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    Mr. EVANS. Thank you, Mr. Chairman.
    Mr. Bowron, many members of the committee believe that the VA IG's office lacks sufficient resources to do its job properly. In the case of the Columbia inquiry, is it your view that the IG committed sufficient resources into the inquiry? Did you ever get an indication that the IG was hampered during this inquiry because of a lack of resources?
    Mr. BOWRON. We didn't really address in the scope of our inquiry their utilization of resources. Certainly the resources that they devoted to this was a limited number. I think that this is a high-profile matter for their office. Although I don't have a specific piece of evidence that I could point to, my own belief is that the limited number of resources devoted to this high-profile matter probably is in some way related to a lack of resources.
    Mr. EVANS. Is the GAO in a position to judge the quality of work done by the IG's office on a more systemic basis? What do your findings say, if anything, about the work of the IG's office on a broader scale?
    Mr. BOWRON. Well, this particular Office of Inspector General? We really didn't do work that would judge them on a broader scale in this case. So, I mean, there were certain things in this particular instance that we found that were not adequate with regard to the investigation, the accuracy, and the thoroughness. But we can't necessarily paint the full breadth of their work with that same brush—I mean, because we wouldn't have a basis for doing that.
    Mr. EVANS. Thank you, Mr. Chairman.
    Mr. EVERETT. Thank you, Mr. Evans. Now the gentleman from Missouri.
    Mr. HULSHOF. Thank you, Mr. Chairman.
    Mr. Bowron, let me just take a minute or two to tell you what perspective I bring here before coming to Congress. I've spent 13 years in the criminal justice system in Missouri—3 years as court-appointed public defender and then 10 years as a prosecuting attorney, many times having to investigate and prosecute murder cases; indeed, capital murder cases. I've also been paying very close attention to representatives of the Office of Inspector General today who have been reacting to parts of your testimony.
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    So I want to—regarding your conclusion that you believe that the Office of Inspector General did not have an intention—and I'm paraphrasing your conclusion—did not have intention to get to the bottom of the matter, can you give us some examples of when the Office of Inspector General did not follow up in its inquiry, perhaps to link individual pieces of evidence to suggest further lines of inquiry?
    Mr. BOWRON. Yes. Maybe the best example, in part, because it was featured on the videotape that was played—they had the hospital pathologist, I believe, Dr. Adelstein, discussing a telephone conversation which he claims he was a party to. It was a conference call with the pathologist, the total quality manager, the hospital director, and the regional chief of staff. Now, Dr. Adelstein alleges that during the course of that conversation, when the issue of notifying law enforcement and the seriousness of the circumstances was raised, that there was a statement made by the regional chief of staff to the effect that, you know, the last time—and this isn't a quote—but the last time we brought in the FBI, the hospital director got fired, and are you sure you still have a problem down there? To which the hospital director responded: ''I think we can handle this locally.''
    Well, I don't know whether that telephone conversation took place or not. I can't say that conclusively. Certainly, Dr. Adelstein says it did. The Office of Inspector General interviewed one other person having information that that conversation took place. They interviewed another person with respect to that which I believe they have characterized as a neutral third party, who expressed that she didn't recall words like that being said. Well, if you were really trying to get to the bottom of a cover-up and there's a specific allegation that part of the reason for the cover-up is that people are protecting their jobs, you want to get to the bottom of that conversation. You want to know whether that happened or not.
    So, first off, there was information that the neutral third party who said she didn't recall had conversations with at least one other person who wasn't a part of that telephone conversation, that conference call, wherein she expressed that the regional chief of staff had made statements of coercion to cover up the deaths. Now she said that to someone else—allegedly. Well, that wasn't investigated.
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    Furthermore, if you really want to get to the bottom of that conversation, you're not going to stop asking questions until you've at least discussed it with the person who allegedly made the statement and the person who the statement was made to. If either one of those persons was interviewed with respect to that information, it's not reflected in their documentation. As a matter of fact, the only interview of the regional chief of staff that's documented is a relatively brief telephone interview. From an investigative standpoint, if you're going to be asking somebody a question like that—and you know this from your background—you ought to be sitting right across from them. You want to see the expression on their face and you want to see their body language. You're trying to find out whether or not they're telling the truth. That kind of effort wasn't made. That is an important allegation. Now, I'm not offering any proof that it happened, but I'm offering that there wasn't a deliberate attempt to get to the bottom of that.
    Now take that in conjunction with the fact that resulting from that same telephone conversation a board of inquiry was convened that was very limited in scope and did not include the statistical analysis. You combine that with other information that they had from an Office of Inspector General employee that suggested—and this was made mention of earlier—that the hospital director was stonewalling and encouraging hospital employees not to speak with the IG. You begin to have circumstances there that make you want to pursue a line of questioning that wasn't pursued.
    Mr. HULSHOF. Well, as you pointed out in your statement and in the GAO report, even such simplistic things of accepting at face value the hospital director's response, not recalling whether he got advice from the district counsel whether to even notify the FBI. I don't want to pull these things out and take them completely out of context, but let me make a comment and I will be happy to let the representatives of the Office of Inspector General also comment and allow you to do the same.
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    But it seems that the attitude of those who have been watching this closely from Columbia, MO—it seems that the Inspector General—when they got the information from Dr. Christensen regarding a nurse statistically linked to over 40 deaths, that the IG suspected the worst of the doctor. Yet, when finally the Inspector General turned his gaze upon Mr. Kurzejeski, who was the director, who let the same hospital nurse continue on in his capacity, as we saw from the piece, it gave the hospital administrator the benefit of the doubt. That is perhaps an unfair assessment.
    Do you have a comment? I filled that out so that the Inspector General can maybe comment as well a little bit later. Do you have any comment on that statement of mine?
    Mr. BOWRON. Well, only that included in our report there are a number of pieces of information and statements that are all related to the hospital director and/or his actions that I think, if linked together, cause you to really ask a lot of questions about why he did what he did in certain instances. To pursue a line of questioning, that was not pursued. That's why I say that there really wasn't an effort that was focused or intended to get to the bottom of those allegations, for two there reasons.
    I say that based on the things that weren't done—the lines of inquiry that were not pursued and the linking of information that was not done. I also say that because in the interviews of the people that did this work—and I think that this is an oversight and communications issue—regardless of whether you put this in the context of an investigation, management review, or administrative review; or whether you say that this was criminal or noncriminal, the fact of the matter is that based on what the people that were doing this work (the lead analyst in this case and his supervisor) said to us, the cover-up was off the table. Cover-up is not what they were looking at.
    They were looking at management response, management issues—whether management took the steps that they were supposed to take when they were supposed to take them. Now, I can only say that if they believed they were supposed to be investigating a cover-up and getting to the bottom of a cover-up, they couldn't have said more clearly to us that, in their view, anything to do with cover-up was obstruction of justice; that anything to do with cover-up relates to criminal activity and a criminal investigation; and that that kind of information is not what they were looking at. Therefore, they were not looking at a cover-up.
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    Now, again, I don't base it just on what they said. I base it also on what they did and what they didn't do. Despite the fact that the lead analyst in this case, if you look at his draft report, the original report written on this—comes to the conclusion, based on the limited information provided to the Administrative Review Board that the limited scope of the Administrative Review Board didn't make sense. Based on all the information they had, that limited scope didn't make sense. But then there wasn't the kind of investigative or review effort you would undertake to say, well, why did they do that?
    Mr. HULSHOF. As a final—my time is drawing short—we would very much like to have some closure in Columbia, MO regarding this. And after 6 long years, the obvious ''what next?'' question raises itself: What are the pros and cons of attempting to reinvestigate some of the things you've mentioned—whether there was a cover-up, obstruction of justice, witness tampering? What are your thoughts on any further review at this point?
    Mr. BOWRON. Well, first of all, I have to say that there was a large body of work done here by the FBI that I really don't have any information about, other than that it was lengthy. They referred to it as an extensive investigation that I know covered a lot of forensic work. But I don't know the details of really what questions they asked of what people. But I have to say this: They said they did an extensive investigation. They didn't come to the conclusion that there was evidence of any criminal activity. So you have to view ''what's next?'' in light of that.
    The Office of Inspector General did a considerable amount of work and developed a lot of information with respect to who did what administratively and, from a management standpoint, who knew what at what time. And there's been a lot of interviews conducted by them—and now by us. There's been an awful lot of information put into the public domain and even more with the issuance of our report.
    So I have to say that my own view is that the likelihood of having any significant results from further investigation based on the FBI's conclusions, the amount of time that has gone by, the further erosion of people's recollection of events, with an eye toward what the end goal will be—I mean, if it's criminal prosecution, there's not—based on what I've just said—a likelihood that you're going to go there. If it's administrative action against the employees, just about all the employees that were the focus of this are no longer employed by the VA.
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    So I really have to say that I don't think that there's a lot of benefit to additional investigations being undertaken. I know that's not good news, but, honestly, I don't see it being a productive effort.
    Mr. EVERETT. Mr. Hulshof, we certainly appreciate that line of questioning. It's one that I had been thinking about myself. Did not the FBI in the letter to the GAO point out that they did not investigate a cover-up?
    Mr. BOWRON. Yes, they did.
    Mr. EVERETT. For the record, I'd also like to point out that this committee has contacted the FBI on a number of occasions and asked for information, and we have not been given that information. We were told at one point that there was criminal investigation going on. Then after that criminal investigation was closed, we still have not received any information from the FBI.
    Mr. MASCARA. I'm still bewildered. Apparently, Mr. Bowron—so in other words, your investigation was done in a vacuum without concern—and I shouldn't maybe use the word ''concern''—without directing any attention to the fact that over 40 lives have been taken. You were doing some kind of an investigation that you had to set that aside and ignore the fact that some 40 people were killed, or allegedly killed.
    Mr. BOWRON. Well, our charter, our mission was to respond to the chairman and the committee's request. That's what we specifically responded to. In addition to that, you had until very recently an ongoing FBI investigation relative to the unexplained deaths. So that role was being fulfilled by the FBI in terms of investigating the deaths. I guess I just want to make it clear that our focus was narrow. It wasn't to reinvestigate this; that's not what we were asked to do. We were asked to review what the Office of Inspector General did and to determine whether or not its report accurately reflects the efforts that it made. There's a few other things, but that was the crux of the matter.
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    Mr. MASCARA. I disagree with you, but continuing to pursue this and in response to my colleague's question that—and I'll defer to him because he's a lawyer—the statute of limitations on the murder, there isn't any statute of limitations.
    Mr. HULSHOF. If the gentleman would yield, that's exactly correct. The State of Missouri, I know from State law that there is no statute of limitations on intentional homicide.
    Mr. MASCARA. Has any of the members here talked to the FBI or can we subpoena them to come in here for——
    Mr. EVERETT. This chairman has threatened to subpoena the FBI to come in. To this point, we've gotten almost no cooperation, and unless—so as a last resort, I have threatened to subpoena the FBI to come in. The scope of the investigation that GAO was asked to conduct, Mr. Bowron has described that. At the time, Justice Department was conducting a criminal investigation into the matter. You know, the good patriotic American would have seen that there would be some follow-through on that. As we now know, we've had no information from the FBI. That may be something that we should pursue.
    Mr. MASCARA. Well, I would certainly be interested in pursuing that. I mentioned earlier the grand jury investigation, and you all know what can happen with a grand jury investigation; by getting some of those people in there and giving them immunity, we might get to the bottom of it. I would like to see the chairman and this committee pursue this. I just don't think we can let this rest; I really don't.
    Mr. BOWRON. Thank you, Mr. Chairman.
    Mr. EVERETT. Thank you, Mr. Bowron. I thank this panel for the good work that you've done over this year in looking into this situation and the professionalism that you brought to it. Again, thank you, and I will now dismiss this panel.
    Mr. BOWRON. Thank you, Mr. Chairman.
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    Mr. EVERETT. Let me call up panel two, please.
    I would like to recognize the Honorable Richard Griffin, the new Inspector General of the VA. If you will, please introduce the staff with you.
    Mr. GRIFFIN. With me today is Mr. Bill Merriman, the Deputy Inspector General, and Ms. Maureen Regan, the Counselor to the Inspector General.
    Mr. EVERETT. Thank you.
    [Witnesses sworn.]
    Mr. EVERETT. Thank you very much. Please be seated. If you will, Mr. Griffin, please go ahead with your statements.

    Mr. GRIFFIN. Thank you. Mr. Chairman and members of the subcommittee, I appreciate the opportunity to appear before you today for the first time in my capacity as Inspector General of the Department of Veterans Affairs. I look forward to maintaining a proactive partnership with the committee as we pursue our common goal of ensuring that veterans and their families receive the care, support, and recognition that they have earned by virtue of the sacrifices they have made for our country.
    Since assuming the duties of Inspector General, I have undertaken a review of a wide range of policies and procedures to assure that we operate as an independent, professional organization. This review will include investigative priorities, audits, healthcare inspections, and hotline activities and will continue throughout the coming months. It has been my observation in the time that I have been Inspector General, that the OIG is staffed with dedicated, hard-working public servants who are committed to carrying out their jobs in a responsible manner.
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    While the subject of this hearing pre-dates my tenure as IG, I take any indication that our reports do not meet appropriate standards as cause for serious concern. For that reason, I directed that the issues raised in the GAO report be thoroughly examined. This task was complicated by the years that have passed since this case first originated and by the retirement of several of the principals. We have contacted these former OIG employees who were associated with the special inquiry conducted at the VAMC Columbia, MO in 1995 to validate the facts as they recall them and, in particular, to respond to statements attributed to them in the GAO report.
    The results of this examination raised questions concerning the accuracy of statements made in the GAO report and some of the conclusions drawn from their work. Of particular importance are statements attributed to the former Assistant Inspector General for Departmental Reviews and Management Support and the lead analyst on the special inquiry. Both of these individuals expressed serious concerns about the accuracy and context of comments associated with their interviews by GAO. While GAO addressed some of our concerns in the final report, a number of issues still exist.
    The most significant issue that remains with the GAO report is their conclusion that the OIG special inquiry is misleading in finding that there was no evidence of a cover-up. The basis for their conclusion is the mistaken belief that, because the OIG limited its review to the issue of management's response to the increase in deaths, that the OIG did not investigate the issue of a cover-up. As discussed in exhaustive detail in our response to GAO, the complainant's allegation that there was a cover-up was based on his assessment of management's response to the increase in deaths. These are one and the same issue and not separate, distinct issues, as the GAO report suggests. A comprehensive evaluation of the issues that have been raised is attached to my statement for the committee's review.
    In closing, I'd like to add that the OIG is responsible for reviewing allegations of fraud, waste, abuse, and mismanagement. The credibility of the OIG rests in our ability to conduct these reviews in an independent and objective manner. This cannot and will not be compromised.
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    Thank you, Mr. Chairman, for the opportunity to provide my views on this matter. I will be pleased to respond to any questions you or other committee members may have. With your indulgence, I may call upon my colleagues to respond to specific questions that occurred during their time prior to my arrival at the IG for which they would have first-hand information.
    Mr. EVERETT. Without objection.
    Mr. GRIFFIN. Thank you.

    [The prepared statement of Mr. Griffin, with attachment, appears on p. 103.]

    Mr. EVERETT. Mr. Griffin, now, as you point out, you were not the Inspector General at the time that these events occurred and they occurred before your tenure began. I understand the fact that you would want to defend the organization you now lead. As a former Deputy Director of the Secret Service, you bring excellent credentials to the witness table, and I appreciate those credentials and your public service. I hope you will consider any criticism directed at the IG organization as constructive and in no way intended to harm your office. I believe the IG organization should be strengthened and it is essential to have it independent from VA management and resources.
    I'm very keenly aware that IG staffing is not at adequate levels and, as you know, on February 17—over 3 months ago—1998, I sent a letter to the Secretary about the subject. I'm still, after 3 months, awaiting a reply from the Secretary, who I understand has consulted you on the matter.
    Let me get into the questioning. Did the IG special inquiry, which I'm going to refer to as ''the investigation'' hereafter, include a check of the background of former VA nurse, Richard Williams, his employment history and management's personnel decisions regarding him?
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    Mr. MERRIMAN. If I may, Mr. Chairman——
    Mr. EVERETT. Yes, Mr. Merriman, certainly go right ahead.
    Mr. MERRIMAN. I don't know if the special inquiry looked into that, but I believe that the FBI investigation did.
    Mr. EVERETT. The reason I asked is because reliable information has come to my attention that he was fired from his previous job in 1989 as a licensed practical nurse with St. Johns Hospital in Springfield, MO, and the VA hospital knew it before hiring him. How could that have happened? Do we have any idea?
    Mr. MERRIMAN. I'm sorry, I——
    Mr. EVERETT. You have no knowledge of that, either way?
    Mr. MERRIMAN. I believe it was referred to by the FBI, but I——
    Mr. EVERETT. The IG's conclusion that the hospital management at Columbia was dysfunctional but not engaged in misconduct has loomed very large in this whole affair. The IG report did not find a cover-up, but turned on a memorandum dated March 9, 1994 from a former hospital director to Dr. Christensen ordering him not to have—ordering him—not to have further contact with the FBI or IG and the IG said it was improper. Each member has a copy of the memo, and I ask unanimous consent it be made a part of the record.

    [The information follows:]
Offset folio 3 insert here
makes p. 22

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    Mr. EVERETT. You know what obstruction of justice is. It includes witness tampering.
    The Federal Criminal Code, Title 18, Section 1512, states: ''Whoever knowingly threatens or corruptly persuades another person, or attempts to do so''—let me repeat that part: ''attempts to do so''—''or engages in misleading conduct toward another person with intent to hinder, delay, or prevent communications to a law enforcement officer or information related to the commission, or possible commission of a Federal offense, shall be fined under the title of imprisonment, or imprisoned not more than 10 years, or both.''
    It also states, ''whoever intentionally harasses another person and thereby hinders, delays, prevents, or dissuades any person from reporting to a law enforcement office the commission, or possible commission, of Federal offense or attempts to do so''—again: ''or attempts to do so''—''shall be fined under this title or imprisoned not more than one year, or both.''
    I'm not a lawyer, but as a former newspaper editor, I can read and comprehend pretty well. Now how is it that none of the conduct described in the GAO's report and in your report and the director's memo to Dr. Christensen is not covered by criminal provisions?
    Mr. GRIFFIN. Mr. Chairman, I would join you in saying that I'm not a lawyer. I think there's been previous testimony that he was wrong in instructing anyone that they couldn't come to the IG; that's pretty clear in the IG Act. The criminal code, though, as you point out, talks about knowingly and willingly and with criminal intent, and that ''knowingly'' portion, from the layman's perspective, from my previous time in law enforcement, has a burden of having knowledge that the person who wants to come forward has ''criminal'' investigative information. Perhaps my counselor can clean that up for me because she has looked at this matter.
    Mr. EVERETT. Ms. Regan, certainly go ahead, please.
    Ms. REGAN. One part that is missing is that there has to be proof of motive. If I can just read you from one case, U.S. v. San Martin, 575F.2d 317, they have to prove—the Government has to prove the defendant knew or reasonably believed that the recipient of the threat had information which he or she had given or would give to the agents of the FBI, and that he called and threatened the individual in response to that belief in order to prevent, obstruct, or delay further communications. There was no evidence that the director knew that the individual he instructed not to go to the FBI had any specific information that the director didn't want given to the FBI. In fact——
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    Mr. EVERETT. How can you possibly make that statement?
    Ms. REGAN. Because of the circumstances at the time that memo was created; plus, the fact that the individual was not involved in any of the care given to the patients. That individual had had numerous contacts with the FBI regarding the statistical analysis and other things and was never stopped from talking to the FBI. What was going on at that time had to do with the letter going to the licensing board. There was concern about releasing confidential information that shouldn't have been released from the hospital. That was what happened at the time that that instruction was given. It was not given to say to this person who had evidence of a crime that ''I don't want you to give it to the FBI'' and that's pretty much what our workpapers show. It was researched.
    We've also discussed this with the criminal people and even more recently with our people, some of the U.S. attorneys, and they didn't see any evidence of criminal activity.
    Mr. EVERETT. With all due respect, that's exactly the type of explanation that infuriates the American public. I mean, it's exactly that sort of double-talk that just absolutely infuriates. You mean this director just contacted this guy and wasn't trying to get to the bottom of this; he had no interest in getting to the bottom of these 40 deaths?
    Ms. REGAN. I'm sorry, but I——
    Mr. EVERETT. All right, you have 40 deaths over here. You've got a whistleblower who, again, as some of you know from my previous committee meetings, I am determined to protect, and we have not only in this situation, but other situations that have been before this committee. We've had whistleblowers threatened and not a single thing has been done to the person who threatened them. To me, I don't understand why this is not the same situation.
    Ms. REGAN. The problem—the difference is that the threat to a whistleblower may be relevant to an administrative action, but we're talking about a criminal obstruction-of-justice charge. The criteria is different for bringing a criminal charge. Now from an administrative standpoint, if somebody does threaten an employee for talking to the IG or talking to the FBI, then there should be some administrative action. The initial question was whether or not it rose to the level of being a criminal violation such as obstruction of justice. With respect to the 40 deaths, by the time that order was given, the FBI was almost 2 years into the investigation, or at least a year and a half. By that time, the FBI had interviewed over 200 people, including that individual on several occasions, had exhumed bodies, had conducted autopsies, and had interviewed everybody related to the care provided to those patients, including the people who responded to the codes and who were there at the time of the death. There was no indication that justice had been obstructed or that witnesses were not allowed to talk to the FBI. The interviews are there. Nobody was told they couldn't talk to the FBI.
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    Mr. EVERETT. How do you know what Dr. Christensen may have wanted to talk to the FBI about?
    Ms. REGAN. Dr. Christensen talked to the FBI after that, and we can go by those interviews and what he said at that time. There was no indication that he had any specific information he wanted to impart to them or did he tell us that when he was interviewed.
    Mr. MERRIMAN. If I may?
    Mr. EVERETT. Certainly, Mr. Merriman.
    Mr. MERRIMAN. I think also that this took place in March of 1994. As early as April or May, Dr. Christensen was back to us with additional allegations of reprisal. According to Mr. Kroll, when he read the GAO report and responded to us, he said that he sat down with Dr. Christensen—which he did—before we issued our report to go over the draft report with him. Although Dr. Christensen was not buying some of our conclusions in the report, according to Mr. Kroll, he didn't bring up at that time any evidence that he was—unable to provide. In other words, he wasn't saying that there were things that he knew about that he did not provide to authorities because of the director's letter to him. We don't condone what the director did. It was wrong. He's not allowed to write letters like that. We say in our report that, had he still been there, we would have asked for administrative action against him. Unfortunately, it's not that uncommon in the Department—in frustration or stupidity—for these types of statements to be made. As you know, you've heard of other cases in some of our other reviews where a director will tell their staff not to talk to the IG. We do try to take immediate steps to prevent that from happening or to correct the situation when we're aware of it. But we know of nothing that Dr. Christensen had to provide to authorities that he did not provide because of that admonition.
    Mr. EVERETT. I thought—I'm getting my dates mixed up a little bit, I guess. I thought he retired a year after that, after the time period you're discussing?
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    Mr. MERRIMAN. He did, but at the time we did our review I believe he was retired.
    Mr. EVERETT. Okay. So the VA did not only not take any action against him for doing that, but gave him a $5,000 retirement bonus and $25,000 buyout.
    Mr. MERRIMAN. I believed he received an $8,000 bonus. I don't know whether he got a buyout or not.
    Mr. EVERETT. I think it was—I've got it—a little bit later we'll get to it, but I think it was a $25,000 buyout.
    My time is up and I'll yield to Mr. Evans at this moment.
    Mr. EVANS. Mr. Griffin, I understand your office disagrees strongly with the GAO's findings with respect to your investigation of allegations at the facility. Your response to the GAO's report spells this out in exhaustive details. Despite these strong objections, are there any GAO criticisms that you believe to be legitimate? If so, what steps can or has your office taken to address those kinds of errors?
    Mr. GRIFFIN. I think that the GAO report did make some legitimate points. As I indicated in my opening statement, as the new Inspector General in the Department, I'm in the process of reviewing all of the procedures there. Certainly, there's no denying by anyone that any time you're involved in an investigation whether it's a special inquiry, which in our parlance is an administrative reviewer, or a criminal investigation, a timely response is critical. Without that timely response, you have witnesses whose memories have faded; you lose what might be the best available evidence—whether it's written documents, whether it's statements made that were overheard, or other forensic materials that could be key to making a case.
    You also have all of the key people still available to be interviewed. Clearly, the passage of time caused a number of people—both within the IG staff and at the hospital—to have retired and moved on. Certainly, that's not a good time to try and probe their memory as to what happened 5 years ago—or 6 years ago, when the case had its first origins.
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    I would agree that there's a need for better coordination within our office. Sometimes you can get a breakdown, even though you're trying to do something good. We have a group of criminal investigators who must carry out their work based on Federal Rules of Criminal Procedures, who must protect grand jury information, and who must conduct themselves in a manner focused on eventual prosecution of the case. In doing that, when you're dealing with grand jury material, that material is not to be shared with people who are not cleared to have it.
    What has happened in the past, frankly, is there's been a breakdown in communications by virtue of trying to put a fence around that sensitive information. Sometimes information that has application in our special inquiry section or in our healthcare section doesn't always get communicated in the way that it should. So we're in the process right now of establishing a better system of controls, so that everyone in the organization will at least be aware of ongoing initiatives. This will be accomplished by using identifiers which might include the location of a facility, the name of a suspect, a victim, or complainant or what have you. We're still putting the system together to make sure that we can't have something get lost in one section of the organization when it may still have some application in another area.
    We certainly take great concern from reading that there's a perception that we do not protect the confidentiality of witnesses or complainants that come to us. From my 26 years in law enforcement, I certainly learned that you would be out of business quickly if the word was on the street that you didn't protect your sources. So you need to be constantly vigilant to protect people who bring information to you. That will be a priority that we make sure that happens in the future.
    Finally, there's the independence that must always be identified with Inspector General organizations. Clearly, in order to perform the role which has been established by the act of 1978, you have to be independent. You can't be bullied into accepting anyone's position. You have to go out and find the facts, report the facts, and let the facts speak for themselves. That's a very high standard.
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    Very often the outcome that you reach might not be the desired outcome in the eyes of everyone that's out there. That doesn't mean that you alter the facts. We have a mandate to identify the facts and report truthfully, and that's what we will do.
    Mr. EVANS. Thank you. Thank you, Mr. Chairman.
    Mr. EVERETT. Thank you. Mr. Merriman, as a Deputy IG you testified at the October 1995 hearing on the Columbia deaths and presented a report that GAO has described as misleading. Do you agree that the report's conclusions were overstated, as a former Assistant IG has reportedly told the GAO? What role did you have in it, in it's preparation, review, and approval?
    Mr. MERRIMAN. No, I don't believe it's overstated. At the time we began that review, which was about January of 1995, Dr. Christensen had gone to the press and made allegations about the destruction of records and mentioned that he had come to us with other evidence. The Inspector General at that time decided we would initiate a two-pronged review. We'd have our criminal investigators look at the destruction of documents, which would clearly be in the criminal area. We would also have our administrative investigators look at Dr. Christensen's other allegations. They would work together.
    Initially, they conducted joint interviews with Dr. Christensen. They went and they sat down with him. He backed away from his allegation of destruction of records. Records were being shredded—they were copies not originals. He said he was satisfied that there was no problem there.
    He also turned over to our criminal investigator and our administrative investigator the material he had at that time. They went through the material. They decided that on its face the information looked like administrative issues.
    We started out on our review of what he alleged. Now during the review, he came in on March 27, 1995 with a fairly extensive document that broke out his allegations in terms of cover-up, obstruction of justice, and other things. When that came in, the Inspector General read it. He wrote a note on it to the AIG involved and said that he wanted these allegations looked at extensively. We patterned our review on looking at Dr. Christensen's allegations. He is the one that called certain actions to be obstruction of justice or cover-up. He established what they were, and we picked up on that pattern and that's what we looked at.
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    If you look at our report, it's in four sections. A section will start out by saying that it is alleged that there is a cover-up. In conversations with the informant, he identified those activities that indicated a cover-up. We looked at those activities. So in our mind, Dr. Christensen established the charge of either cover-up, obstruction of justice, or whatever else it was. He established what the events were that led him to believe that. We believe we looked at those events. You may challenge the conclusions we reached, but I don't see how anybody can say that we didn't look at the issues that he raised. I think the report accurately represents his allegations. Our testimony in 1995 accurately represented what was in the report.
    Mr. EVERETT. Thank you. Before I dismiss this panel, let me—Mr. Griffin, Ms. Regan, and Mr. Merriman—my anger is not directed at you personally and I know that you know that. I have expressed many times my appreciation for the dedicated work and hard work that professional people in your organization—that you've done. But we still have 42 deaths in Columbia, MO and we have no idea how they occurred. As a matter of fact, the evidence that I have seen indicated that those deaths did not—were not caused by natural means. There's a strong possibility that we have at least some of those 42 people—if not all those 42 people—murdered. Because of the way this has been handled over the past few years, I'm just simply frustrated that we can't get to the bottom of it.
    Again, I do appreciate the work that you've done on it. You're right, Mr. Merriman, we may not—we may have different opinions on the conclusions that you have reached and that GAO has reached, but we have a terrible situation here, one that in my estimation, my mind, is simply inexcusable. We have 42 deaths and there's a strong possibility that these were not by natural causes. We have no way to get to the bottom of it.
    Again, I thank you for your appearance here today. At this point, I'll dismiss this panel and call up the third panel. Thank you again.
    Mr. GRIFFIN. Thank you, Mr. Chairman.
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    Mr. EVERETT. The Honorable Thomas Garthwaite, Deputy Under Secretary of the Veterans Health Administration if you'll introduce your panel, please. Dr. Wilson, I believe?
    Dr. GARTHWAITE. Yes, Dr. Nancy Wilson, our Chief, Office of Performance and Quality.
    Mr. EVERETT. Okay.
    [Witnesses sworn.]
    If you will proceed with your testimony, I ask you to hold it to about 5 minutes. Your complete statement will be put into the record.

    Dr. GARTHWAITE. Thank you. I have a summary discussion around the full statement.
    Mr. Chairman, I'm here to discuss the Veterans Health Administration's Patient Safety Program and changes that have been made to reduce adverse outcomes related to medical treatment. Before discussing our current patient safety initiatives, I'd like to briefly discuss elements of policy that relate directly to the Office of Inspector General and others' review of deaths that occurred at the Harry S. Truman VA Medical Center in 1992.
    First, the Veterans Health Administration agreed with the Inspector General's 1995 report that the management team in place at the time did not act as promptly and as fully as we would have expected. The 1995 report also contained recommendations for important policy and systems changes that we have implemented. These changes should guide management to promptly and appropriately respond to any similar circumstances in the future.
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    For example, current policy provides guidance on (1) reporting to appropriate law enforcement officials if a statistically-significant association between a practitioner and increases in mortality, morbidity, or other adverse occurrence is found and there's no other credible explanation; (2) for promptly removing a practitioner from clinical duties when suspected of criminal activity; and (3) reporting to the appropriate State licensing board when a practitioner leaves VA employment and a statistically-significant association with adverse events is found. This policy will apply to all employees, currently employed employees, effective early June.
    Ongoing review of mortality data and review of statistical findings by designated statistical consultants are now available in every network. They have specific individuals designated with this expertise to aid facilities regarding data analysis for patient safety, for quality assessment, and performance management purposes.
    These policies and systems changes were developed from the review of the events that occurred at Columbia in 1992. Had these policies been in place at that time, I believe and hope the response would have been different.
    I'd like to turn now to our current Patient Safety Program. We have designed our program with an ambitious goal. We want to be national leaders in improving patient safety for VA and non-VA healthcare systems.
    A number of well-publicized and tragic events during the last few years have made it clear that increasing patients' safety should be a national priority for all healthcare systems. In the Harvard Medical Practice Study, researchers reviewed over 30,000 records in 51 non-Federal hospitals, and estimated that over 1 million patients are injured or disabled annually because of adverse events. Two-thirds of the injuries are thought to be preventable.
    In response to the growing recognition that systems are more often at fault than are the people in those systems, we have recently implemented an improved Patient Safety Program that I believe will place VA at the forefront of efforts to provide safer medical care. Indeed, various private sector organizations have been highly complimentary of our policies and plans.
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    We're using several different strategies to identify making the changes. First, our facilities routinely analyze all service delivery systems and processes to identify redesigns that are likely to reduce the likelihood of errors. For example, because of reported blood transfusion errors, by early July, we will implement an additional barcode check to match the patient with the blood being transfused at the time it is being administered.
    A second procedure to increase safety is to intensively review all adverse events from two points of view: the point of view of the local site and the point of view of the entire system. Locally, these reviews identify the root causes of each incident and the changes in design of systems needed to prevent recurrence in any indicated personnel actions.
    All reviews of adverse events are sent to the network and then to headquarters, where they are reviewed to identify the adequacy of the facilities review, the patterns of adverse events or system problems, and any redesigns in the system that should be adopted throughout the network or nationally. Any needed changes in national policies and procedures and lessons that have been learned can be shared throughout VA and hopefully into other healthcare systems as well.
    The sharing of patient safety information between our facilities, particularly innovative system designs, is a key aspect of our improved program. All current VHA communication media is being used for this purpose. VHA is determined to further enhance the design of our patient care systems to reduce preventable adverse events and untoward outcomes. Implicit in this process is the need to breakdown current disincentives for addressing medical errors. These disincentives include the traditional culture that finds it difficult to acknowledge errors and mistakes, and fears of litigation and adverse media coverage.
    We are working now to create a culture that permits medical care personnel to acknowledge the occurrence of errors and encourage open and complete reporting of adverse events. Of course, the system also has to ensure that, where appropriate, personnel actions will be taken against employees whose negligence led to the patient injury. We are convinced that the real payoff in improving patient safety will come from addressing the root causes and designing into the systems a greater margin of safety.
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    In addition to our internal Patient Safety Program, we have taken the lead in forming a national Patient Safety Partnership, since the issue of patient safety is not one that individual healthcare organizations can or should take on alone. Members of this public/private partnership besides the Veterans Health Administration include the American Hospital Association, the National Patient Safety Foundation at the American Medical Association, the American Nurses Association, the Joint Commission on Accreditation of Healthcare Organizations, and the Association of American Medical Colleges. The primary goal of this partnership is to focus these healthcare leadership organizations on preventing adverse events in healthcare.
    Finally, we are developing a quality control system modeled after the Aviation Incident Safety Reporting System, a system using aviation for the last 22 years. In aviation, this system is voluntary, nonpunitive, confidential, objective, and independent of the FAA and the airline industry. Its goal is the accumulation of knowledge that can be used to increase safety.
    Our voluntary incident reporting system will require substantial changes in thinking on the part of our employees and stakeholders. We must learn to recognize dangerous situations, near misses, and to acknowledge honest mistakes, whether these mistakes cause injury or not. An honest mistake made once, leading to permanent improved system design, is unavoidable and in our opinion, should be acceptable. The same mistake, never analyzed, repeated by every healthcare system until it is learned, and then repeated until it is fixed, in our mind, is unacceptable.
    We're committed to establishing a system that enables the Veterans Health Administration to acknowledge, understand, and address today's barriers for improving patient safety. We believe it is critical and the right thing to do.
    Overall, Mr. Chairman, while I believe VA's record on patient safety is a good one when compared to other healthcare systems, all of healthcare has room for improvement. To carry the airline industry analogy of this further, the only tenable goal for airlines is no crashes sustained forever. The only tenable goal for healthcare is zero preventable errors sustained forever. I believe our present framework for ensuring quality of care which includes a new patient safety policy will move VA closer to that goal.
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    That concludes our statement and I welcome questions.

    [The prepared statement of Dr. Garthwaite appears on p. 132.]

    Mr. EVERETT. Thank you, Doctor.
    As I understand it, the cause of many of those deaths is still officially declared as undetermined at Columbia—the 42 deaths there?
    Dr. GARTHWAITE. The cause of death on the death certificate is made by a clinician caring for the patient, unless there's an autopsy. So it's made based on the clinical circumstances surrounding that death. The official cause of death on the death certificates I'm not aware of at this time. We could——
    Mr. EVERETT. In other words, you're not aware of whether or not they're listed as undetermined or not?
    Dr. GARTHWAITE. I'm not aware of that.
    Mr. EVERETT. Thank you. I'm sure that you agree that one of the best ways to ensure quality of patient care is to have the very best healthcare professionals you can employ. Yet, it's come to my attention that Nurse Richard Williams had been fired in 1989 from a previously licensed practical nurse job at St. Johns Hospital in Springfield, MO before the VA hired him. The VA knew that when they hired him. Can you tell me how that would happen?
    Dr. GARTHWAITE. Well, sir, as I understand—and I have relatively sketchy details on this—is that the individual who interviewed and was responsible for hiring Mr. Williams noted on the application that he had correctly filled out his application; that he had been released in a dispute with his supervisor over the administration of a medication at the previous facility. They did call the facility, who declined to elaborate further on it. The more forthcoming of the two individuals was Mr. Williams at the time. Based on that, they weighed the evidence and other information that they had from other references and made a decision to hire.
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    I think, looking back in the record myself, I would love to have seen a better description of this decisionmaking process by those individuals as to why—how they weighed that evidence. But I wasn't there at the time and I don't know.
    Mr. EVERETT. In your Patient Safety Program, have you addressed this problem?
    Dr. GARTHWAITE. Not to my knowledge. I was not aware of this particular fact until about a week and a half ago or a week ago.
    Mr. EVERETT. Okay. I was not at the October 1995 hearing. Is it correct that the former hospital director at Columbia, who was dysfunctional, Mr. Kurzejeski, who retired in 1994 with a good performance appraisal, a $5,000 SES bonus, and a $25,000 buyout?
    Dr. GARTHWAITE. I had not heard the buyout. I know he did receive a performance bonus the last year that he worked for us.
    Mr. EVERETT. On page 2 of your oral testimony, you state, when a practitioner is suspected of criminal activity, it harms patients. The practitioner is to be removed from clinical duties until the suspicion has been resolved. Also, physical materials that could provide proper evidence are to be collected and stored for possible analysis by law enforcement officials. Who's supposed to collect these physical materials?
    Dr. GARTHWAITE. Obviously, we would like to bring law enforcement officials instantly and have them sustain a chain of evidence on collected materials, if that's possible. But the sensitivity we're trying to alert our practitioners to is not to discard it and protect it until we can make those contacts and allow proper chain of evidence to be maintained.
    Mr. EVERETT. In other words, you have a system set up to—so that practitioners undergo training to preserve evidence that they may be involved in?
    Dr. GARTHWAITE. The policy is to raise management's awareness that it's their responsibility and to think of those things when it happens. Most of what we do is not about collecting evidence; we're about improving healthcare.
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    Mr. EVERETT. You've stated that the fatality rate data is reviewed by all VA healthcare facilities. Who's designated to do that?
    Dr. GARTHWAITE. Which data?
    Mr. EVERETT. Mortality rate.
    Dr. GARTHWAITE. Quality management in the facilities review that on a routine basis.
    Mr. EVERETT. Whose team—which team?
    Dr. GARTHWAITE. Quality management. Each medical center will have a quality management coordinator usually and quality management teams. Various medical centers will have different arrays of committees and teams.
    Mr. EVERETT. Which are normally appointed by the director?
    Dr. GARTHWAITE. Everyone works for the director in our facilities.
    Mr. EVERETT. Can you tell me how this would work when you get a red flag-type situation?
    Dr. GARTHWAITE. I'll let Nancy.
    Mr. EVERETT. Sure. Dr. Wilson, please.
    Dr. WILSON. Thank you. What we've specified is that, when a red flag comes up, the appropriate committees that are designated to look at this will search for any kind of association between that death or rate of adverse events, looking specifically for associations with locations, such as particular wards, particular timeframes—is it always on the nightshift versus the dayshift? Also, looking for associations with particular practitioners. The team really has to look for the pattern across the array of services that are given at that facility.
    In our patient safety policy we have a step-by-step procedure for the facility. If they find that to be the case with a practitioner I would refer you to our Patient Safety Policy.
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    Mr. EVERETT. When is the VISN notified?
    Dr. GARTHWAITE. We expect the VISN to be notified almost instantaneously whenever they have any significant deviation.
    Mr. EVERETT. Is that spelled out in your policy?
    Dr. WILSON. The policy does not specify when—for a statistical association—the network is notified. We have two things in place. One is that any untoward death is to be called to the network office within 24 hours of that unexpected death—every single death; then within another 24 hours, the network is to call headquarters. So, in addition to relying on their surveillance at the facility to look for statistical associations in the death rate, we're insisting that they—and the policy is in place—that they call every single death forward. We are all looking at—and we are all counting—those numbers and looking at the data.
    Mr. EVERETT. Correct me if I'm wrong here, but if this system had been in place at Columbia, still nothing would have left the hospital? None of these deaths were red-flagged?
    Dr. WILSON. I would think that—I certainly don't want to disagree with you, but——
    Mr. EVERETT. If I'm wrong, please correct me. I have no problem with that.
    Dr. WILSON. Given that any death—any death that occurs that is not basically a ''do not resuscitate'' patient—a patient with advance directives that is defined as expected—every single death is, by policy, called to the network office within 24 hours. So it's not just that the facility director is saying ''gee, I had one; gee, I had two''—such as had been described before. But we have a quality management officer at the network office overseeing this data plus the network director, the chief medical officer of the network, plus a Patient Safety Oversight Committee in headquarters that is comprised of the medical inspector, a physician representative from Patient Care Services, my office, and the office of the chief network officer.
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    So we feel, with those layers of—with all layers of the organization calling the data in and tracking the numbers, that we would find—we would find these and explore and evaluate each of these deaths.
    Dr. GARTHWAITE. As I remember the data surrounding Columbia, this was really discovered by the quality management group. Nancy, I believe, has a call every week with all the quality managers around the country. So this is—the communication and the number of routes of communication around the potential obstruction to the flow of information I think has been significantly changed.
    Mr. EVERETT. Of course, what I'm searching for is we had 42 deaths within a 6-month period here and nobody ever raised a red flag.
    Dr. GARTHWAITE. It's my understanding that the total number of deaths during the period was not increased—in fact, decreased from the previous year. It was the number of codes that triggered the investigation and led to the further understanding in the statistical association. So that the characterization that there were a lot of extra deaths is, in my understanding, not correct. In fact, there was an increased number of codes—increased number of deaths that weren't expected at that time. Virtually everyone who died had significant illnesses. The question was the timing—the timing during the day, and so forth.
    Mr. EVERETT. I think I'm referring to exactly that—the timing during the day and, plus, the fact that things were on one ward under the care of one nurse. You know, that's what concerns me—nothing went up. Is there a possibility of this kind of thing repeating itself?
    Dr. GARTHWAITE. The answer is that——
    Mr. EVERETT. Before you answer, let me say that, if there is, then we've got something really wrong that we need to straighten out. We're talking—I mean, there's evidence that was presented that, in my opinion, should have triggered a red flag somewhere. Okay.
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    Dr. GARTHWAITE. Yes. I understand, sir. If everything were stable, then monitoring the number of deaths, comparing it to the number of employees, and achieving a statistical significance for which you could then accuse someone of murder is—would be hard enough if it were all stable. In the last 3 years, to improve the efficiency and effectiveness of our care, we've reduced the number of beds in half; we've combined wards; we've changed how practice is done; we have turnover of staff—the mathematical complexity of determining what you're asking is not simple.
    Now, the answer is, are we looking at that? Are we making efforts to look at the association of deaths with who's on the ward and the locations, and so forth? Yes. Is it a perfect system, you know, and what level can it pickup sensitive and minor changes? It's not a system that's perfect.
    Mr. EVERETT. What concerns me—I'm sorry, Dr. Wilson, go ahead.
    Dr. WILSON. I think that the issue of needing multiple mechanisms of communication is an important one. We feel that it is going to take time to change the culture of this organization such that people at all levels of the organization feel comfortable coming forward and letting people know that any kind of adverse event is occurring. That is, our recognition of the need to change that culture is precisely why we're putting in a whole quality control system where people can call all of these things in with confidentiality protected, so that we can have multiple mechanisms in learning about these things.
    My one other point is that we conduct a meeting every month. The Under Secretary personally conducts our Quality Management Integration Council that communicates with all levels of the organization. He is constantly reiterating the importance of people coming forward and not allowing any barrier at any level of the organization to block reporting of these untoward events.
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    Mr. EVERETT. Well, that's one of the things that concerns me. Hopefully, we can change that culture—you know, I have to tell you that this committee has seen case after case where people have come forward, have been threatened or penalized, or chastised, or whatever. Perhaps communication is the answer. It's obviously either an open secret or a whispered secret that there was something very wrong in Ward 4 on the nightshift. Somehow or other, that did not trigger a red flag.
    Mr. Mascara.
    Mr. MASCARA. I didn't have the benefit of your testimony, but—and I missed the second panel, which is the one I wanted to dearly speak to and ask some questions, and I might submit some questions to that second panel.
    Mr. EVERETT. Without objection. As a matter of fact, all panelists will be given additional questions.
    Mr. MASCARA. Good. Thank you, Mr. Chairman.

    (See p. 137.)

    Mr. MASCARA. You spoke, Dr. Wilson, about changing the culture at these facilities—that somehow that would encourage people to come forward. People that we hire, and I am hoping this includes the VA when they hire somebody, that they hire decent human beings who are moral and have ethics and would feel free to come forward to someone. If it's not the hospital administrator, then the head nurse, or the physician on duty, and speak out about a death they felt somehow was caused by an employee of that facility. Somehow we have to engender them in some meetings that we might hold to tell them what one supposed to do in these situations. If you hear about or you see someone being mistreated, that you'll feel free to come forward. Do we need to reschool these people about coming forward?
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    If the Whistleblower Act has any significance, I think they should feel comfortable about coming forward. I can see not wanting to go to the former administrator, you know, because he condones it, apparently, and would possibly engage in a possible cover-up of what occurred there.
    Dr. GARTHWAITE. I think there are two issues of culture here. One is the culture in all of healthcare which makes it relatively hard because of tort claims and other reasons to think—to admit you made a mistake and to bring forward the sense that you're going to improve the systems. We have a tendency to blame the individual and not fix the things that support the systems. Pilots have a lot of systems in place to help them do their job. We tend to blame individuals for not knowing everything, instead of developing better systems to help them remember those sort of things.
    The second issue of culture that I think the chairman has spoken to is about management culture. Dr. Kizer and I have been involved with the help of many, many people for about 3 years trying to dramatically change the way the Veterans Health Administration does its business. We have fundamentally put into place about 15 things we think will help to improve the culture. They range from signed performance agreements where bonuses for leaders are given because the outcomes for patients improve, to surveying our employees. We've started a 360-degree evaluation. That is to say, my evaluation will be, in part, dependent upon the people that I serve and that I interrelate with, that will be fed back and given to me to help me improve but also can become part of my assessment. We're starting with top management. We're not starting in lower parts of the organization. We've surveyed employees as to their working environment. We've developed an external recruitment process, so that a fairly inbred system where we've almost always had our leaders chosen from within also brings in the best from the outside to help give us new ideas and fresh eyes to see if there are things we can do better.
    We're teaching everyone how to interview prospective applicants, so that the interviewing and selection process of employees is not left to chance, because it's not done that often for most of us, so that they use the best scientific method they possibly can. We have new ways of discipline and taking action about senior management where we get more people involved, because we've learned that sometimes communication can be an issue. We've issued a statement and are teaching all employees about our values: trust, respect, excellence, compassion, and commitment.
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    We believe that, when we move employees around the system, that we have to do that clearly for a reason. We have a new policy that says, if someone's going to go to a new medical center, there will be a reason unless they go into a competitive process and compete for that directorship. If they're moved because they need a new environment, there's an expectation of how they're going to improve their performance at the new place. It's the first step in understanding.
    Those are just a few of the things that we've put into place. Because I really do believe the chairman is correct that the culture of the VA was not perfect. It is not perfect today, but I think it's vastly improved and on its way to being a much better organization.
    Mr. MASCARA. In response to the chairman's question regarding the number of deaths, you said that's not unusual for that period of time?
    Dr. GARTHWAITE. If you compare the number of deaths during the period of time in question, it's my understanding——
    Mr. MASCARA. What was the period of time? You want to refresh my memory?
    Dr. GARTHWAITE. I can probably——
    Mr. EVERETT. Through August of 1992.
    Dr. GARTHWAITE. Yes. It's in August, December——
    Mr. EVERETT. Six to 8 months.
    Mr. MASCARA. So you have—but if you compared the deaths there in an 8-month period——
    Dr. GARTHWAITE. We compared the exact same period the year before, the number of deaths——
    Mr. MASCARA. But not increased in one ward. You've never had that experience before?
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    Dr. GARTHWAITE. But what triggered the investigation, to my understanding, is that there were an increased number of codes called——
    Mr. MASCARA. Certainly where people rush and try to resuscitate the individuals.
    Dr. GARTHWAITE. That seemed to be an unusual number of those and an unusual number in a particular area.
    Mr. MASCARA. They were unusual? What do you mean by unusual?
    Dr. GARTHWAITE. I'm sorry, more codes than were expected.
    Mr. MASCARA. Regardless of how they died, is it unusual to have that number of people die in a certain ward with a certain nurse on duty at certain times?
    Dr. GARTHWAITE. Yes.
    Mr. MASCARA. I hate to make light of this, but I recall back in my district, when I was county commissioner a number of years ago—and this reminds me of that—and I hate to make light of it, but the district attorney said, after a man was found at a garbage dump with his hands tied behind his back and shot from behind his head, he suspected foul play. It almost seems to me that somehow people just overlooked the obvious. Didn't they have some idea, some clue that something was happening? This administrator—administrator, director, or whatever you call him—he gets these reports every day in his office. Was anybody able to determine or ascertain whether he gets these reports daily of the deaths that occur at the facility?
    Dr. GARTHWAITE. I think at the time he probably received the deaths and he would have—and the quality assurance folks would be reviewing those, and they would not have noted that the number of deaths was any different from the previous year during that time period. They had made some ward changes where they combined some wards and they put some of the sickest people on this particular ward. So that at that time, the number of deaths didn't stand out just as the number of deaths. What stood out was that they weren't expected right at that moment. These were sick people, but they were expected to die and codes were called.
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    Mr. MASCARA. Thank you, Mr. Chairman.
    Mr. EVERETT. Thank you for your questions. Mr. Hulshof.
    Mr. HULSHOF. Thank you, Mr. Chairman.
    I don't want to flog this horse if he's dead. But Dr. Garthwaite, you used the term ''significant deviation.'' The word ''significant'' is open to interpretation. Dr. Wilson, you mentioned any untoward death, and again, that's somewhat subjective as to what is untoward. I think the chairman asked the question—it's a bit beyond my bailiwick because I'm not on this committee, but I'm compelled to follow up with this.
    The quality management team—let's talk about the changes that have been made that you envision and that you're trying to implement, but the quality management team still answers to the hospital director, correct? So let's assume these facts to be true for the purpose of this hypothetical. Let's say that you have a hospital director that is receiving information that on a particular ward there are these additional codes that are being called; that this particular hospital director makes a decision: We shall keep this internal. Even Dr. Wilson, if you were to call up the hospital and to ask—this particular director, says, there's nothing untoward happening in our hospital.
    Let's assume further that this same hospital director is strongly suggesting, and some perhaps even say intimidating, people that are working there from going to the authorities under threat of losing their jobs——
    Mr. EVERETT. Would the gentleman yield?
    Mr. HULSHOF. Yes.
    Mr. EVERETT. That's exactly what happened. We had a situation that we had to introduce legislation to correct when the EEOC officer had to report to the director. It was the director who was guilty of the sexual harassment. So this is a possibility—certainly a possibility—the situation that you're describing.
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    Mr. HULSHOF. Well, I thank the chairman. Let's assume that this hospital director is again strongly encouraging those not to talk beyond—that it would be handled internally. Do you believe that the mechanisms you now have in place would root out this type of situation? So that we can have the confidence and I can go back to Columbia, MO and everybody here can go back to their respective constituents and say, look, something positive has happened from the Columbia, MO situation. Can you give me that confidence, Dr. Garthwaite, that the procedures that you have in place now would prohibit something like this from happening in the future?
    Dr. GARTHWAITE. Yes, I can. I feel very confident that we've changed dramatically the openness which our people have the ability to report. The quality managers don't just report to the medical center director; they can have direct communication on a weekly basis and do, with quality and performance.
    So I think that better data systems can help us assure that, and we're moving to some of those things as well, and have some good national data systems that transcend all that. But I think, to the maximum extent possible, we have good communication, direct communication, and openness. Dr. Kizer and I receive direct communication on a regular basis and have routinely examined that information and followed up on it personally to make sure that we're getting to the bottom of things.
    Mr. EVERETT. Dr. Wilson, anything to add?
    Dr. WILSON. I would agree completely with Dr. Garthwaite. I would add that having 22 network directors responsible for hospitals within their area is an additional structure that really helps with the oversight of what is going on in each of the facilities. I would reiterate that the quality management officers at the network office also help with that process. So, unlike when there were four regions and the regional person was trying to pay attention to a much larger number of facilities, we have a responsible person overseeing perhaps 5 to 10 facilities. The oversight is much stronger.
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    Mr. HULSHOF. Dr. Garthwaite, just in general, what are the most important lessons that you and your Department have learned from this situation?
    Dr. GARTHWAITE. I think if you look at management's response at the time, the first priority you have to have is patient safety. So the first action you have to take is to guarantee patient safety.
    The second thing that I think—I know Dr. Kizer and I believe strongly—is you need to lay all the facts bare. We often use the Inspector General or a medical inspector or others to lay the facts open. We'll deal with whatever the facts are.
    The third after that is to fix whatever you find. You have to take into account the rights of the patient first, but you still have to take into the rights of the individuals who are involved. So that becomes, you know, the third order of mechanics here. Patient safety first, baring of all the facts, good assessment and fix everything we can.
    Mr. HULSHOF. We will hold you to that standard. I probably should state for the record that in the contact that I've had with the men and women, the employees, of the Truman Hospital that your goal of providing good quality healthcare is being accomplished by those who are walking the wards. To the families of the veterans who have met these, I believe, untimely deaths, I suppose I could apologize, but I think an apology falls woefully short of what is necessary here.
    Mr. Chairman, I appreciate you letting me participate in this. I think that the actions regarding this whole situation have been shameful. I think that America's veterans and their families deserve much better than this. I hope and pray that the light from this hearing will somehow shine to help us learn from the mistakes we've made; that we can put this tragic event behind us, and again, hopefully, to those who are present here, that this hearing has provided some vindication for coming forward. Because had that not happened, I struggle to think of how many additional, untimely, untoward deaths may have occurred.
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    But, Mr. Chairman, again, thank you for the opportunity to be here.
    Mr. EVERETT. Mr. Hulshof, I appreciate your participation here today and also very much appreciate your interest in this matter from the very first day you became a Member of this Congress.
    Whatever you want to call it—this dysfunctional cover-up, whitewash, stonewalling, damage control—I think there's ample evidence in the whole record to support a reasonable belief that a former VA hospital director was attempting to keep the patient death situation from going outside the hospital. On at least one occasion, he attempted to impede or obstruct the FBI and the IG investigations. I have no authority to direct the IG or the FBI to reach any conclusion. It seems likely that there will be no criminal investigation, no grand jury, and no trial on obstruction, although it's been pointed out here there is no time limit on prosecuting murder.
    In any event, whatever was being attempted did not succeed in the end. I do not believe that it's feasible to reinvestigate cover-up allegations, as much as I'd like to have it done.
    I do believe that nepotism question regarding the hiring of the former hospital director's son has never had anything more than a self-serving explanation by the Columbia VA Hospital management. It should be objectively investigated, and I'm going to ask the GAO to do that.
    In fact, we have a fairly clear picture of what occurred within the VA on the patient deaths and now the IG investigation. I know there is anger and frustration over what has happened; I personally have anger and frustration over it. We can't change it. But we are taking, and seeing, steps taken to minimize the possibility that something like the unexplained Columbia deaths can happen again. The subcommittee will continue to look into the FBI investigation of these deaths, and hopefully, from that investigation, we can see something move forward on the possible murders that took place at Columbia.
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    I also intend to send a letter to Chairman Mica regarding the problem of VA hospital directors, and this is not the first time we've seen this—of VA hospital directors being allowed to retire with impunity, with bonuses, even without ever being held accountable for their misconduct and mismanagement. These get-out-of-jail-free cards for senior government management must stop.
    Members will have 5 legislative days to submit the statements and questions to the witnesses.
    The meeting is adjourned. Thank you all very much for attending.
    Whereupon, at 12:30 p.m., the subcommittee adjourned subject to the call of the chair.]