A Matter of Life and Death: Examining Pre- Ventable Deaths, Patient Safety Issues, and Bonuses for Va Execs Who Oversaw Them

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A Matter of Life and Death: Examining Pre- Ventable Deaths, Patient Safety Issues, and Bonuses for Va Execs Who Oversaw Them A MATTER OF LIFE AND DEATH: EXAMINING PRE- VENTABLE DEATHS, PATIENT SAFETY ISSUES, AND BONUSES FOR VA EXECS WHO OVERSAW THEM FIELD HEARING BEFORE THE COMMITTEE ON VETERANS’ AFFAIRS U.S. HOUSE OF REPRESENTATIVES ONE HUNDRED THIRTEENTH CONGRESS FIRST SESSION MONDAY, SEPTEMBER 9, 2013 FIELD HEARING HELD IN PITTSBURGH, PA Serial No. 113–32 Printed for the use of the Committee on Veterans’ Affairs ( U.S. GOVERNMENT PRINTING OFFICE 82–893 WASHINGTON : 2014 For sale by the Superintendent of Documents, U.S. Government Printing Office Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800 Fax: (202) 512–2104 Mail: Stop IDCC, Washington, DC 20402–0001 VerDate Aug 31 2005 12:52 Jul 24, 2014 Jkt 000000 PO 00000 Frm 00001 Fmt 5011 Sfmt 5011 Y:\113THC~1\FC\FIRSTS~1\9-9-13\GPO\82893.TXT LEN VACREP180 with DISTILLER COMMITTEE ON VETERANS’ AFFAIRS JEFF MILLER, Florida, Chairman DOUG LAMBORN, Colorado MICHAEL H. MICHAUD, Maine, Ranking GUS M. BILIRAKIS, Florida CORRINE BROWN, Florida DAVID P. ROE, Tennessee MARK TAKANO, California BILL FLORES, Texas JULIA BROWNLEY, California JEFF DENHAM, California DINA TITUS, Nevada JON RUNYAN, New Jersey ANN KIRKPATRICK, Arizona DAN BENISHEK, Michigan RAUL RUIZ, California TIM HUELSKAMP, Kansas GLORIA NEGRETE MCLEOD, California MARK E. AMODEI, Nevada ANN M. KUSTER, New Hampshire MIKE COFFMAN, Colorado BETO O’ROURKE, Texas BRAD R. WENSTRUP, Ohio TIMOTHY J. WALZ, Minnesota PAUL COOK, California JACKIE WALORSKI, Indiana HELEN W. TOLAR, Staff Director and Chief Counsel Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records of the Committee on Veterans’ Affairs are also published in electronic form. The printed hearing record remains the official version. Because electronic submissions are used to prepare both printed and electronic versions of the hearing record, the process of converting between various electronic formats may introduce unintentional errors or omissions. Such occur- rences are inherent in the current publication process and should diminish as the process is further refined. ii VerDate Aug 31 2005 12:52 Jul 24, 2014 Jkt 000000 PO 00000 Frm 00002 Fmt 0486 Sfmt 0486 Y:\113THC~1\FC\FIRSTS~1\9-9-13\GPO\82893.TXT LEN VACREP180 with DISTILLER C O N T E N T S September 9, 2013 Page A Matter Of Life And Death: Examining Preventable Deaths, Patient Safety Issues, And Bonuses For VA Execs Who Oversaw Them ................................. 1 OPENING STATEMENTS Hon. Jeff Miller, Chairman, .................................................................................... 1 Prepared Statement of Chairman Miller ........................................................ 61 Hon. Michael H. Michaud, Ranking Minority Member ........................................ 4 Hon. Michael F. Doyle, U.S. House of Representatives, (PA-14) ......................... 5 Hon. Tim Murphy, U.S. House of Representatives, (PA-18) ................................ 6 Hon. Keith J. Rothfus, U.S. House of Representatives, (PA-12) .......................... 7 WITNESSES Brandie Petit, Veteran Family Member, Atlanta, GA .......................................... 8 Prepared Statement of Ms. Petit ..................................................................... 63 Gerald J. Rakiecki, Veteran and VA Police Officer, Buffalo, NY ........................ 10 Prepared Statement of Mr. Rakiecki .............................................................. 68 Sydney W. Schoellman, Veteran Family Member, Dallas, TX ............................. 13 Prepared Statement of Ms. Schoellman ......................................................... 70 Phyllis A.M. Hollenbeck, M.D., FAAFP, VA Primary Care Physician, Jackson, MS ......................................................................................................................... 15 Prepared Statement of Ms. Hollenbeck .......................................................... 72 Robert E. Nicklas, Veteran Family Member, Pittsburgh, PA .............................. 17 Prepared Statement of Mr. Nicklas ................................................................ 85 Accompanied by: Judy Nicklas, Veteran Family Member, Pittsburgh, PA Maureen A. Ciarolla, Veteran Family Member, Pittsburgh, PA ......................... 19 Prepared Statement of Ms. Ciarolla ............................................................... 88 Hon. Robert A. Petzel, Under Secretary for Health, U.S. Department of Vet- erans Affairs ......................................................................................................... 34 Prepared Statement of Hon. Petzel ................................................................. 91 iii VerDate Aug 31 2005 12:52 Jul 24, 2014 Jkt 000000 PO 00000 Frm 00003 Fmt 0486 Sfmt 0486 Y:\113THC~1\FC\FIRSTS~1\9-9-13\GPO\82893.TXT LEN VACREP180 with DISTILLER Page Hon. Robert A. Petzel, Under Secretary for Health, U.S. Department of Vet- erans Affairs—Continued Accompanied by: Michael E. Moreland, FACHE, Network Director, VA Healthcare (VISN 4), Veterans Health Administration, U.S. Department of Veterans Affairs Leslie B. Wiggins, Medical Center Director, Atlanta VA Medical Center, Veterans Health Administration, U.S. Department of Veterans Af- fairs Brian G. Stiller, Medical Center Director, VA Western New York Healthcare System, Veterans Health Administration, U.S. Depart- ment of Veterans Affairs Jeffrey L. Milligan, Medical Center Director, VA North Texas Health Care System, Veterans Health Administration, U.S. Department of Veterans Affairs Joe D. Battle, Medical Center Director, G.V. (Sonny) Montgomery VA Medical Center, Veterans Health Administration, U.S. Department of Veterans Affairs Charles Sepich, FACHE, Network Director, VA Southeast Network (VISN 7), Veterans Health Administration, U.S. Department of Veterans Affairs James Cody, Interim Network Director, VA Health Care Upstate New York (VISN 2), Veterans Health Administration, U.S. Department of Veterans Affairs Lawrence Biro, Network Director, VA Heart of Texas Health Care Network (VISN 17), Veterans Health Administration, U.S. Depart- ment of Veterans Affairs Rica Lewis-Payton, Network Director, South Central VA Health Care Network (VISN 16), Veterans Health Administration, U.S. Depart- ment of Veterans Affairs Terry Gerigk Wolf, Medical Center Director and Chief Executive Offi- cer, VA Pittsburgh Healthcare System, Veterans Health Adminis- tration, U.S. Department of Veterans Affairs QUESTIONS FOR THE RECORD Questions From: Chairman Miller, To: U.S. Department of Veterans Affairs ... 99 Responses From: U.S. Department of Veterans Affairs, To: Chairman Miller .. 99 STATEMENT FOR THE RECORD Congressman Brian Higgins, (NY-26) .................................................................... 100 SUBMISSION FOR THE RECORD The Veterans Health Administration (VHA) ......................................................... 103 iv VerDate Aug 31 2005 12:52 Jul 24, 2014 Jkt 000000 PO 00000 Frm 00004 Fmt 0486 Sfmt 0486 Y:\113THC~1\FC\FIRSTS~1\9-9-13\GPO\82893.TXT LEN VACREP180 with DISTILLER A MATTER OF LIFE AND DEATH: EXAMINING PREVENTABLE DEATHS, PATIENT SAFETY ISSUES, AND BONUSES FOR VA EXECS WHO OVERSAW THEM Monday, September 9, 2013 U.S. HOUSE OF REPRESENTATIVES, COMMITTEE ON VETERANS’ AFFAIRS, Washington, D.C. The Committee met, pursuant to notice, at 9:00 a.m., in Room 410 of the Gold Room, Allegheny County Courthouse, 436 Grant Street, Pittsburgh, Pennsylvania, Hon. Jeff Miller [Chairman of the Committee] presiding. Members present: Representatives Miller and Michaud. Also present: Representatives Doyle, Murphy, and Rothfus. OPENING STATEMENT OF CHAIRMAN MILLER The CHAIRMAN. Good morning and welcome to today’s Full Com- mittee hearing entitled, ‘‘A Matter of Life and Death: Examining Preventable Deaths, Patient Safety Issues, and Bonuses for VA Ex- ecutives Who Oversaw Them.’’ Before we begin, I would like to ask unanimous consent that our colleagues from Pennsylvania, Mr. Doyle, Mr. Murphy, and Mr. Rothfus be allowed to sit at the dais and participate in today’s pro- ceedings. Without objection, so ordered. And I would also like to thank the good people of Allegheny County for hosting us today here. As most of you are aware, the Department of Veterans Affairs, Veterans Health Administration provides health care services for millions of American veterans, but recently a rash of preventable veteran deaths, suicides, and infectious disease outbreaks at sev- eral VHA facilities throughout the country has put this organiza- tion under intense scrutiny. Despite the fact that multiple VA Inspector General reports have linked a number of these incidents to widespread mismanagement at VHA facilities, the Department has consistently given executives who presided over these events glowing performance reviews and cash bonuses of up to $63,000. Many Americans have watched in disbelief as these events have unfolded on their television screens and in the pages of their local newspapers. For some, however, this tragic incident has hit much closer to home. So I would like to take a moment to recognize all the family members of those who have suffered preventable deaths at VA (1) VerDate Aug 31 2005 12:52 Jul 24, 2014 Jkt 000000 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 Y:\113THC~1\FC\FIRSTS~1\9-9-13\GPO\82893.TXT LEN VACREP180 with DISTILLER 2 medical centers, as well as any veterans who have endured VA pa- tient-safety incidents that are here in attendance today. Additionally, I want to recognize former American Legion Na- tional Commander Ron Conley,
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