In the determinations are made by that department to justice. So to pass the amendment on the appropriations bill for the specific purpose to prosecute these cases. But to talk about systemic there was the culture of corruption baby that purses those cases it was so k . Space or somebody manipulates the records the purpose of financial gain is said that a criminal offense shouldnt that be an example set somewhere in the system . I agree. Uk there has not been any at this point you would expect the cases with least amount of evidence or manipulation or conspiracy would be the ones to be set aside your earliest because the additional cases require more work than we are working feverishly with those because it is important to get through all 93. As we finish them i know the department is anxious to get the reports to take administrative action. Are you surprised there are not criminal prosecutions . Not at this point because the fbi is still investigating. I am not surprised. It does seem like the department of justice is looking the other way. Because the situation is embarrassing to the administration. Thanks to all of you for your work to veterans p that provided even one veteran substandard care of a bite to go back with the long history with the o. I. G. Office someone in my unit i count on heavily as another set of eyes so what is implied the integrity of chiapas was influenced by the v. A. Did anyone at the v. A. Bascule to change the report to make it look better . No. Is is Standard Operating Procedure for multiple drafts to be done . Especially 170 pages. What about that methodology being questioned . This is the first time. Is it your understanding is predicated to ask for the original draft . Correct. To be very clear that report is very damaging to the v. A. The department of justice to make sure dr. Mitchell and dr. Foote there has to be an avenue where people are held accountable. That is in the process. Mj is that correct . The investigation is ongoing. But also the very first recommendation referred the names of the of veterans in the case reviews for them to conduct appropriate reviews of there was medical negligence. Does it prosecute cases . We take them to the prosecutors if we cannot get that traction. Does this report strike you, how long have you been with o. I. G. . Rick 13 years. Investigations . We have done about 520 every yearn8 for the last six years but that is average. Is there anything strikingly different about this one . It was an undertaking of the criminal investigation. A joint project where dr. Daigh people. So the staff had the responsibility to identify those that were not on the electronic wait list. To try to pull the three different disciplines together everybody on the same page with what makes sense. Guy would argue it makes sense to dr. Foote and dr. Mitchell. But with that being said with my remaining time that would be investigated but my immediate concern is to you feel in your professional judgment they move in the proper direction . To you feel at this and it is early. It is utterly. The a lot of the of late wait time issues better is a the report to identify an additional 1800 veterans that were not properly managed. To give those names to people in phoenix to make sure they got it as quickly as possible. a7 yes or no. Does it feel like cultural changes are changing the accountability . Does a complete more investigations. For my testimony to be made public. No. I yield back. Dr. Daigh and, you cannot conclusively examine all the medical records to determine the release of thema final report of the long wait times causes the death of the veterans. How can it say to us synthetically that no link the wait times if you did them and examine all the records . 2000409 records were evaluated. The Service Point looking at their records of the patients on the near system if they never made it through the maze. With that Electronic Medical record that all the cases were able to review those ted to do with of waiting list. They did very thoroughly review the cases it predetermined delayed care. And those where there were improper care prepublished those. And as a result they were harmed. An additional 17 cases where standard of care was not met republished those. I am not trying to say to people who through frustration could not make it through the barriers. I am not excusing anything but answering tough fact are these people on the cases that weve looked atnu, did we see a Significant Impact of their care . That is what we found and that is what we published. I further say i dont believe that further review needs to be determined but i put the scenarios out there hoping you would read the case is to understand the complexity and understand the difficulty and the fragility of the cases. But when they dont get care in a timely fashion horrible things are likely to have been then each person could decide do they think that was related to make their own decision. To offer the opinion of my office to see lots of data is the necessary. These families have a right to privacy so we be careful about what we publish with respect to fax of the case if people would like more data ijn understand. But the v. A. Needs to be sure to have access to care is that time and way to develop proper care. If you had a chance to go back and reevaluate what could you do it different today . No. That is so we have done this for many years it is very thorough. But i would wish it was not tied to the issue of timing isfor the impact of the old way to list and quality of care. That is a native standard a maid at standard we would have come up with Something Different so that is what we had to address i yield back. Mr. Chairman, is there a parallel fbi investigation going on right now . A joint investigation involving my people and the fbi. Investigating the same issues in asking the same questions . There is an interview happening there is fbi and it o. I. G. President. So answering a the question related to the closing out of those 12 cases of the 93 ongoing you mentioned there were closed because they met the criteria and questions were answered buy you talk about Additional Information that was not necessarily related4s. Can you talk about the Additional Information . Can you give examples . I will clarify. We did some of the 93 investigations of what we gave to the department department, agreed did not join phoenix level review of every one of those facilities. It would take 10 years. Free did look at where there were allegations from any number of sources that were specific infractions going on. Some have more specific language than others. We handover reports and transcripts except drop to the va, and they can take administration action. So there is not Additional Information or a list of Additional Information that was uncovered that had not been already investigated . I am just saying that together, their review for purposes of administrative action, somehow they come up with some information that was not available. In that apartment, they have to propose the action whether it be removal or something less than that, it could cause us to say that we are going to go back and put look into this further. As is the weather processes. Zero one the followup on the questioning and asked very specifically if you believe there are adequate resources to continue and to complete the Ongoing Investigations. Some of those investigations are much more narrow in scope than the magnitude of the review we are doing in phoenix. We are progressing. Every week there is another handful that were able to bring to closure. So the answer is, yes, we have the resources, but i must say that this is not the only investigation that our people are involved in. Since january the number of threats cases that have come to us at va facilities, progress, so some of these matters that are already in the prosecuting mode, i mean, we prosecuted at director for 64 counts of corruption and certainly could not drop that case in order to, you know, take on a new case when it is going through the judicial process. Thank you, and i yield back. There were 293 deaths. Is that correct . 293 deaths that we reviewed. That is correct. How many of those were cross reference the medical documents . All of them. I think there were 28 that were on the list. I am trying again, i am honestly trying to learn, mr. Griffin. And you have educated at least me as the chairman today on some things. You said because they were on the list that they were not in the system so there was no medical record to review, and you were not able to do that. Let me please clarify. The list included a large number of patients. Of the patients that we reviewed from the list we would not be able to review a patient if we did not have the medical records. If you were on the list and do not have a record then we excluded you from the review. So in our methodology section we can only look at cases that actually come to the va. And i understand. But how can you i keep going back to, how do you say you conclusively were able to say these individuals did not get timely care . They are now dead. I am talking about the case is that we were able to review. I have a stand that, but there were cases that you just said you can review. All i am trying to figure out is, there are cases that were part of this investigation that you apparently could not review because there was no medical record for you look at. And so my question is, again, of the 293 deaths, he did every one of them get cross referenced with some type of medical record . The total number of people on the list is a big number. 293 had. But what i am trying im just trying to clarify. The 293 deaths were all among patients from whenever list there on that had a medical record that we could review. So i am going to agree with you. There would be people who would be on the list to did not have a medical record that we could not review. Therefore they were not part of the chart because it is not possible to review. So all of the deaths, 2903 that we reviewed, that number is a datapoint. That number is 3409 patient, 293 were dead. But that number is a number that has limited meaning in the sense that it is drawn from a population that you do not know the Disease Burden of the laws i cannot tell you whether it is too high or too low because the reason for death could be normal causes. I understand. I apologize, but i am still trying to find out because and a staff briefing, staff was told that in some instances all that could be done was a match of Social Security numbers, looking ahead list. So there was no way for some of those individuals to be cross referenced for the medical record. That is correct. I think that would be a misunderstanding of what was said. I would not support that we have not been able to review the record. But they were on the list, correct . Again, and our methodology section we said we excluded. I am really trying to be clear. I cannot report on cases that i have no information on. And i concur. I think that is why the crossed wires are coming. It is very hard for meanwhile to sit accept the statement and a document as we have been discussing if you have not been able to look at every single medical record. Thank you for clarifying. Thank you, mr. Chairman. I appreciate that line of questions. Still, i am confused. 3,409 veterans. Medical records for all those cases. Yes, sir. But in pages 34 and on in the reports you identify numerous other categories of veterans that would total well over 9,000. Either not on the electronic wedding less or not or on the new list. Printouts are scheduled appointment consults to the backlog. How did you decide that 9121 is reduced to 3,409 . Six. Well, the report dr. Upper in phoenix there were many. The report talked about some different sources and points. So if you are talking about cases that were a part, which were the va clinic action, those cases were not part of the most of those cases were not part. Excuse me. Page 34. Question to identifies 9,121 veterans. They may not be cumulative. My question is how did you decide not to look at 9,600 some cases of veterans, you decided not to review their case. Well, we looked at those with a collection date of within the timeframe of the start of our review up until about june 1. I would have to go through and it looked through that date is set that we have of the actually 3,562 names on a last, 3409 unique individuals of which 293 have died in 743 had a position review them. If they were on an electronic wedding listed you look at them and review the patients are not . We did. Everybody that we were able to determine on any of these waiting less of any variety described in this report. I just give you another 5,602 put in the report. Why did you not look at those on the list at 3500. Did you not look at any . If you were on the list and for asking for a veteran to get into the va system it never made it into the system. If you died waiting for care because there was a failure in the system does not show up . Thats correct. Well. Isnt that the crux of the problem . Thousands and thousands and thousands of veterans are waiting for care that we dont count them because they died before we get their records. Were not going to go back and look at other sources. It is unclear to me. If you could provide information to the committee, how you decided to exclude. That would be helpful. One of the questions, the day before you release your final report to congress and number of news outlets were carrying reports. He looked closely at headlines uncounted resources. Delays caused patient deaths. No links found between deaths and care delays and no deaths due to long waits. Are these accurate or just for headlines . I have seen plenty of misleading headlines in the past two weeks. The ones i read okay. The ones i read to you [inaudible conversations] that is part of the story here. If someone leaks something before the schedule released a report, and if it quoted our report, it should not have been leaked. Is that report headline misleading . Could you read it to me again . Absolutely. I am sure you have seen it before. No death. Is that misleading . That is an accurate representation of our conclusion that we could not assert a cause of death being associated with the waiting times. How about a link . Those are not my words. Earth. I am asking you for your thought. You were worried about 800 headlines. Are not worried about anything. That is just a reality to show the amount of coverage that was put on this statement and that there were no ifs, ands, or buts about it. That does not take a lot of research. I am still not for sure. Those headlines are okay, misleading. I did not say that there are okay. The headlines are sensational to get people to read a story. Sensational that there are 5600 veterans cases that apparently were not reviewed. You have them in the report. I look forward to the determination of why you decided not to review those cases because i fear there are more veterans that have died. There was nothing to review if they did not kid in the door. He was reviewing medical records. If they did not get an appointment they did not have records to review. Said there is no causality and they fail to get in the door and i because we did not deliver care, i would say that is causality interested in it would be misleading. We do not know how or why they died, an ordeal. Mr. Orourke. Thank you, mr. Chairman. And i will say that mr. Griffin and dr. Richard griffin, by that criteria you have described your using to reach your conclusion i understand where youre coming from. I think that it is a rather narrow legalistic interpretation of data. I understand and think you made it very clear. I accept within those constraints would you conclude. Common sense tells me from cases i have seen in my district that there is a cause and effect relationship between care that is delayed and is up being care that is denied that affects the veterans that spirit i use the example before with all due respect to the families. They have shared their story with me. It is for a purpose. You know, vic the mego have been trying to get health care and was unable to for entreated ptsd after attending after not being able to and attending one of my town halls where veteran actor veterans set up and said have also not been able to get income he was driving, and is not related the story to me that he was driving home that night. Some of these guys are much older than i am and have been trying for years to get in and cannot. I do not know what i have to look forward to. And she cited that lack of hope as one of the main reasons that he then took his life five days after that meeting. We know in this country 22 veterans day sadly take their own lives, and i have got to think that theres a connection between the way deferred and ultimately denied guarantees very tragic instances of suicide now, do not know if it meets the strict and legal criteria that you are using, but it makes a lot of sense to me to draw that connection and conclusion. I think that is what is causing so many of us to try to hamper the level of access and the quality of care. I do not think that you would disagree with that. Conclusions, you make some very bold statements. You talk about a breakdown in the ethics system within vha, which i take to be a comment on the largest issue that i have seen that we have a problem with, which is not funding and resources a number of doctors but the cultural aspect, the lack of accountability, a premium placed on performance bonuses and not excellence of care, not responsibility, and not on Patient Outcomes for the veterans that purportedly the vh a serve. Look to your recommendations related to ethics on page 74 of your report. They were pretty narrow. I think it recommendations all, but fairly narrow. Are there other recommendations i may have messed that more fundamentally address an issue of culture within vha . Would love to know what those are and how the secretary i will ask him when he is here, how he will respond to the recommendations. Mr. Griffin. The original draft report had four or five recommendations speaking to ethics. They were very narrowly constructed, so they were combined into one Global Ethics recommendation. The secretary previously was the chief ethics officer at p g, the chief Compliance Officer at p g. I suspect that we are going to see ethics placed at a level where it should be. We did not find that in our review in phoenix when there was a request for an ethical review and not all of the recommendations were found and put forward by the person who submitted them. There was a reorganization of cha which removed the chief medical ethics officer from the inner circle of the highest tier of management in vha and was relegated to a lower level which removed that person from a seat at the table with the mo