Key language in a final report that absolves the Department of Veterans Affairs of causing patient deaths in Phoenix through delays in care was inserted after the draft version was sent to agency officials for comment, the inspector general confirmed at a Senate hearing Tuesday.
But Richard Griffin, acting inspector general for the VA, insisted the line that his investigators could not “conclusively” prove deaths were caused by unacceptable delays was not done at the behest of executives in the department.
Griffin initially evaded the questions when asked directly by Sen. Dean Heller, R-Nev., whether the language was inserted after the draft report was sent to VA administrators as part of the normal review process.
“For the VA, this is the line you would want inserted in that report,” Heller said, referring to a story published Monday by the Washington Examiner that the language was not in the draft version but did show up when the final report was issued Aug. 26.
“Was this line included in the draft report?” Heller asked.
Griffin repeated earlier statements that the majority of the changes in the Phoenix report came about because of “further deliberations” within the inspector general’s office.
“No one in VA dictated that sentence go in that report, period,” Griffin said.
“So, was the line included in the draft report that was sent to the VA?” Heller pressed.
“It was not included in the first version of that draft report,” Griffin replied, adding he wanted to address the issue further in a written timeline he would submit to the committee.
He did not say when the timeline would be delivered.
“Did the VA play any part in the inclusion of this line?” Heller continued.
“No,” Griffin said.
The Examiner reported Monday that the key language was added to the final version of the report — the only one released publicly — after the draft version of the IG’s findings was sent to agency heads for comment and recommended revisions.
The IG’s report on Phoenix confirmed widespread falsification of patient appointment lists to hide long delays in care. It also said manipulation of patient data on wait times is a long-term and “systemic” problem throughout VA.
Despite those findings, the IG also stated that it could not prove the delays or poor-quality care directly killed veterans.
“While the case reviews in this report document poor quality of care, we are unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans,” the final IG report stated in two places.
VA officials touted that sentence in a news release made public even before the final IG report was released.
The Examiner’s story Monday was based on a comparison of the two versions done by the House Veterans’ Affairs Committee, which revealed the discrepancy between the draft and final reports.
Next week the House committee will have its own hearing to examine why the language was inserted, and whether VA officials pressured the IG to make changes.
Griffin said his office followed standard procedures in making revisions to reflect agency concerns prior to publication of its report on falsified patient waiting lists in Phoenix.
“Every one of our draft reports, and every draft report of anybody in the inspector general community, is submitted as a draft to the department for purposes of guaranteeing accuracy of our reporting,” Griffin told the Senate committee.
“We do not accept from the department or from anyone else a dictated response that is based on opinion as opposed to fact,” he said.
Sen. Bernie Sanders, I-Vt., chairman of the Senate veterans’ committee, opened the questioning of Griffin by asking whether he wanted to address suggestions in the media that “the office of inspector general at the VA is really not independent.”
Sanders asked Griffin to describe the process used by his office to prepare draft and final reports.
“In other words, are you being heavily influenced by the VA?” Sanders said. “Are they editing the reports that you give us? Or, in fact, are you an independent entity finding the truth as best you can?”
Griffin thanked Sanders for the question, saying that standard procedure for his office and other inspectors general is to prepare draft reports based on the findings of an investigation and send it to the agency for review and comment.
“If the department has information that we missed in doing our work, that they can point out to us, that would be factual and convincing, then we may come to realize we’ve got this one part wrong,” Griffin said in describing the input his department receives from agency executives.
Griffin said investigators identified 45 cases where patients faced unacceptable waits or poor-quality care, and that 20 of those patients died.
“The 45 cases discussed in the report reflect unacceptable and troubling issues in follow-up, coordination, quality or continuity of care,” Griffin said.
“Decisions regarding VA’s potential liability in these matters lie with the department and the judicial system,” he said.
