Ensuring Quality Health Care for Our Veterans

Thursday, June 20, 2019 - 2:00pm
2154 Rayburn House Office Building, Washington, DC 20515
"Ensuring Quality Health Care for Our Veterans"



The Subcommittee will probe the VA’s efforts to address longstanding problems that cause extreme risks to veterans’ healthcare, including inventory management, sterile equipment processing, and patient safety.


  • At the end of fiscal year 2018, the DC VAMC ranked as a 1-star facility, among the bottom 10 % of 146 Veterans Health Administration (VHA) medical centers. In 2017, VA OIG published an interim summary report that warned of “a number of serious and troubling deficiencies at the Medical Center that place patients at unnecessary risk.”

  • In March 2018, the OIG published its final report, “Critical Deficiencies at the Washington DC VA Medical Center” (“Critical Deficiencies”), highlighting leadership failures and pervasive understaffing that underpinned widespread issues in inventory management, sterile processing, and patient safety.  The OIG also found mismanagement of protected information and significant government resources, putting them at risk for fraud, waste, and abuse. 

  • The OIG documented approximately $92 million, or 89% of purchase card procurements, for supplies and equipment without proper controls.  For example, the DC VAMC purchased butterfly needles for $899, which is more than $600 more per needle than the negotiated rate available through the prime vendor. 

  • According to the OIG, the ineffective leadership contributed to an environment that “placed both patients and assets of the federal government at risk.”

  • The Committee will also address several recent reports that show evidence of improper handling of mental health cases by DC VAMC employees.  In one May 2019 example, a psychiatric patient escaped from a locked area of the facility through the ventilation system and was then able to get a DC VAMC employee to call him a cab to Virginia. 


Ms. Tammy Czarnecki
Assistant Deputy Undersecretary for Health for Administrative Operations, Veterans Health Administration
Department of Veterans Affairs

Mr. Michael Heimall
Veteran Affairs Medical Center (Washington, DC)

The Honorable Michael Missal
Inspector General, Office of Inspector General
U.S. Department of Veterans Affairs

116th Congress