1 00:00:00,040 --> 00:00:03,380 Ladies and gentlemen , we are going to 2 00:00:03,380 --> 00:00:05,436 call to order the military personnel 3 00:00:05,436 --> 00:00:07,380 subcommittee of the Armed Services 4 00:00:07,380 --> 00:00:10,400 Committee . Um we welcome our witnesses 5 00:00:10,710 --> 00:00:14,390 this afternoon . Um we will have some 6 00:00:14,390 --> 00:00:16,501 complications in this hearing because 7 00:00:16,501 --> 00:00:18,557 there will be a series of five votes 8 00:00:18,557 --> 00:00:20,668 that the house will be taking . So we 9 00:00:20,668 --> 00:00:22,723 will recess for a period of time and 10 00:00:22,723 --> 00:00:24,723 then come back . Hopefully we'll be 11 00:00:24,723 --> 00:00:26,834 able to get through the first panel . 12 00:00:27,640 --> 00:00:29,600 The taxpayers spent more than $50 13 00:00:29,600 --> 00:00:32,250 billion dollars each year on the 14 00:00:32,250 --> 00:00:34,560 military health system Which provides 15 00:00:34,560 --> 00:00:37,620 healthcare services to 9.6 million 16 00:00:37,620 --> 00:00:40,460 beneficiaries including service members , 17 00:00:40,470 --> 00:00:43,540 dependents and retirees . This sizable 18 00:00:43,540 --> 00:00:47,200 investment should by timely safe high 19 00:00:47,200 --> 00:00:49,270 quality care for our service members 20 00:00:49,270 --> 00:00:51,970 and their families . However , I'm not 21 00:00:51,970 --> 00:00:53,692 convinced that the military is 22 00:00:53,692 --> 00:00:56,260 delivering on this sacred obligation . 23 00:00:56,840 --> 00:00:59,460 The 2017 N . D . A . Reorganized the 24 00:00:59,460 --> 00:01:01,682 military health system and standardized 25 00:01:01,682 --> 00:01:04,130 clinical quality processes . Before the 26 00:01:04,130 --> 00:01:06,750 reform , the Army , Navy and Air Force 27 00:01:06,760 --> 00:01:08,620 each operated several healthcare 28 00:01:08,620 --> 00:01:11,770 systems and the military had 24 29 00:01:11,770 --> 00:01:14,320 different policies on patient safety 30 00:01:14,330 --> 00:01:17,000 and quality . Now the Defense Health 31 00:01:17,000 --> 00:01:19,111 Agency oversees all medical treatment 32 00:01:19,111 --> 00:01:22,970 facilities and since 2019 D . O . D . 33 00:01:22,970 --> 00:01:26,200 Has a single policy on patient safety 34 00:01:26,210 --> 00:01:29,960 and quality . But despite these changes , 35 00:01:30,540 --> 00:01:32,484 I have not seen evidence that real 36 00:01:32,484 --> 00:01:35,080 improvement has occurred . In fact , I 37 00:01:35,080 --> 00:01:37,770 hear too often about medical errors 38 00:01:37,770 --> 00:01:40,330 that caused grievous harm to patients 39 00:01:40,340 --> 00:01:42,700 and quality assurance investigations 40 00:01:42,700 --> 00:01:45,440 that drag on for years . While the 41 00:01:45,440 --> 00:01:48,960 suspect providers continue to practice . 42 00:01:49,440 --> 00:01:51,218 Our first witnesses include two 43 00:01:51,218 --> 00:01:54,130 families that have been irreparably and 44 00:01:54,130 --> 00:01:57,030 devastatingly harmed by inexcusably 45 00:01:57,030 --> 00:02:00,130 poor military healthcare . I want to 46 00:02:00,130 --> 00:02:01,963 thank you for coming forward and 47 00:02:01,963 --> 00:02:05,560 sharing your deeply personal stories . 48 00:02:06,040 --> 00:02:08,207 You are representing yourselves , your 49 00:02:08,207 --> 00:02:10,870 families and countless others who could 50 00:02:10,870 --> 00:02:14,130 not be here today . I want to hear from 51 00:02:14,130 --> 00:02:16,297 you and how you and your families were 52 00:02:16,297 --> 00:02:18,408 treated during and after your medical 53 00:02:18,408 --> 00:02:21,090 ordeals . Our first witness is Desde el 54 00:02:21,090 --> 00:02:23,910 Barba . He had a dream to follow his 55 00:02:23,910 --> 00:02:25,910 family and service to his country . 56 00:02:26,340 --> 00:02:28,840 Instead , he found a toxic environment 57 00:02:28,850 --> 00:02:31,230 in basic training where he became very 58 00:02:31,230 --> 00:02:33,960 ill . The command repeatedly ignored 59 00:02:33,960 --> 00:02:36,580 his symptoms and shamed him when they 60 00:02:36,580 --> 00:02:38,358 finally got medical treatment . 61 00:02:38,390 --> 00:02:40,520 Misdiagnosis and inexplicable 62 00:02:40,530 --> 00:02:42,340 additional delays and treatment 63 00:02:42,600 --> 00:02:46,460 resulted in an unimaginable Set of 64 00:02:46,460 --> 00:02:49,640 circumstances for what was a healthy 21 65 00:02:49,640 --> 00:02:53,460 year old , 43 Surgeries , loss of a leg 66 00:02:54,240 --> 00:02:57,470 and loss of a dream for a career in the 67 00:02:57,470 --> 00:03:00,290 military . This injury didn't happen in 68 00:03:00,290 --> 00:03:02,401 combat . It didn't even happen during 69 00:03:02,401 --> 00:03:05,260 training . Instead , it happened 70 00:03:05,260 --> 00:03:07,990 because providers failed to act in a 71 00:03:07,990 --> 00:03:10,560 timely manner . I also want to 72 00:03:10,560 --> 00:03:13,930 recognize Mr Derek Lucky , whose 19 73 00:03:13,930 --> 00:03:17,440 year old daughter Danielle Died in 2016 74 00:03:17,440 --> 00:03:19,551 after the Navy failed to diagnose her 75 00:03:19,551 --> 00:03:21,496 condition while she was aboard the 76 00:03:21,496 --> 00:03:24,060 aircraft carrier carrier USS Reagan , 77 00:03:24,740 --> 00:03:27,210 her symptoms were also repeatedly 78 00:03:27,220 --> 00:03:30,600 ignored and she paid the ultimate 79 00:03:30,610 --> 00:03:33,870 price . I cannot tell you how grateful 80 00:03:33,870 --> 00:03:35,926 I am that you are both here to share 81 00:03:35,926 --> 00:03:37,850 your stories , you to represent 82 00:03:37,860 --> 00:03:39,749 countless victims of poor quality 83 00:03:39,749 --> 00:03:42,800 medical care and I thank you . R . G . 84 00:03:42,800 --> 00:03:45,022 O . Witness . MS Sillas will shed light 85 00:03:45,022 --> 00:03:47,090 on whether defense health agency is 86 00:03:47,090 --> 00:03:49,146 adhering to its own clinical quality 87 00:03:49,146 --> 00:03:51,210 management procedures including 88 00:03:51,210 --> 00:03:53,270 provider credentialing investigating 89 00:03:53,270 --> 00:03:55,540 medical errors and holding accountable 90 00:03:55,540 --> 00:03:57,262 providers who fail to meet the 91 00:03:57,262 --> 00:03:59,710 standards of care When our service 92 00:03:59,710 --> 00:04:01,620 members suffer from poor quality 93 00:04:01,620 --> 00:04:03,740 medical care . When doctors failed to 94 00:04:03,740 --> 00:04:05,518 provide the standard of care or 95 00:04:05,518 --> 00:04:08,320 woefully ignore symptoms or conditions , 96 00:04:08,370 --> 00:04:10,426 we need to make sure that there is a 97 00:04:10,426 --> 00:04:13,030 system in place to both prevent the 98 00:04:13,030 --> 00:04:16,450 incident from happening again and hold 99 00:04:16,460 --> 00:04:18,730 the providers accountable and that's 100 00:04:18,730 --> 00:04:20,841 what we want to hear about . From the 101 00:04:20,841 --> 00:04:22,786 second panel to lieutenant general 102 00:04:23,140 --> 00:04:25,196 place and the surgeon general of the 103 00:04:25,196 --> 00:04:27,362 military departments . We want to know 104 00:04:27,362 --> 00:04:29,307 how you're holding incompetent and 105 00:04:29,307 --> 00:04:31,196 negligent providers accountable . 106 00:04:35,940 --> 00:04:37,940 How are you implementing changes to 107 00:04:37,940 --> 00:04:39,996 improve patient safety , both in the 108 00:04:39,996 --> 00:04:41,940 military hospitals and operational 109 00:04:41,940 --> 00:04:44,107 medical environments including ships . 110 00:04:44,107 --> 00:04:46,329 How are you making sure the doctors and 111 00:04:46,329 --> 00:04:48,551 nurses have the appropriate credentials 112 00:04:48,551 --> 00:04:50,773 to provide health care in our country ? 113 00:04:50,773 --> 00:04:52,829 We rightfully revere service members 114 00:04:52,829 --> 00:04:55,250 for their bravery and their sacrifice . 115 00:04:55,840 --> 00:04:58,000 It is incomprehensible and shameful 116 00:04:58,000 --> 00:05:00,050 that we cannot ensure they have the 117 00:05:00,050 --> 00:05:03,610 quality medical care they deserve . I 118 00:05:03,610 --> 00:05:05,777 also want to point out that my efforts 119 00:05:05,777 --> 00:05:07,999 to allow service members to file claims 120 00:05:07,999 --> 00:05:10,110 against the military for instances of 121 00:05:10,110 --> 00:05:11,999 medical malpractice aren't only a 122 00:05:11,999 --> 00:05:13,888 matter of justice . They're about 123 00:05:13,888 --> 00:05:16,380 accountability and I'm frustrated to 124 00:05:16,380 --> 00:05:18,547 say the least that the D . O . D . Has 125 00:05:18,547 --> 00:05:20,547 been so slow to implement the state 126 00:05:20,547 --> 00:05:22,602 School Act that Congress included in 127 00:05:22,602 --> 00:05:24,790 the 2020 N . D . A . There are a few 128 00:05:24,790 --> 00:05:26,846 incentives better than the threat of 129 00:05:26,846 --> 00:05:29,068 legal action to push an organization to 130 00:05:29,068 --> 00:05:31,620 change its behavior Before hearing from 131 00:05:31,620 --> 00:05:34,250 our 1st panel . We want to hear from 132 00:05:34,250 --> 00:05:36,361 ranking member Gallagher and give him 133 00:05:36,361 --> 00:05:38,306 an opportunity to make his opening 134 00:05:38,306 --> 00:05:40,940 remarks . Well , I thank the chairwoman 135 00:05:40,940 --> 00:05:43,360 and I want to thank both of our panels 136 00:05:43,370 --> 00:05:45,481 for being with us today and a special 137 00:05:45,481 --> 00:05:47,648 thank you to Mr Lucky and mr Del Barba 138 00:05:47,648 --> 00:05:49,592 for your willingness to share your 139 00:05:49,592 --> 00:05:52,300 personal stories and experiences in an 140 00:05:52,300 --> 00:05:54,810 effort to help us make the system 141 00:05:54,820 --> 00:05:57,610 better um in preparing for this hearing , 142 00:05:57,770 --> 00:05:59,826 I looked at some statistics from the 143 00:05:59,826 --> 00:06:02,048 National Institutes of Health and found 144 00:06:02,048 --> 00:06:04,270 that approximately 400,000 hospitalized 145 00:06:04,270 --> 00:06:06,159 patients experienced some type of 146 00:06:06,159 --> 00:06:08,190 preventable harm each year and that 147 00:06:08,190 --> 00:06:10,301 medical errors cost approximately $20 148 00:06:10,301 --> 00:06:10,980 billion 149 00:06:10,990 --> 00:06:17,560 100,000 150 00:06:17,560 --> 00:06:21,270 people dying each year within the 151 00:06:21,270 --> 00:06:23,560 Department of Defense . A 2014 review 152 00:06:23,560 --> 00:06:25,671 found that quote , While the military 153 00:06:25,671 --> 00:06:27,990 health system delivers safe timely and 154 00:06:27,990 --> 00:06:30,350 quality care that is largely comparable 155 00:06:30,350 --> 00:06:32,239 to care delivered in the civilian 156 00:06:32,239 --> 00:06:34,470 sector . The MHS demonstrated wide 157 00:06:34,470 --> 00:06:36,692 performance variability with some areas 158 00:06:36,692 --> 00:06:38,803 better than civilian counterparts and 159 00:06:38,803 --> 00:06:41,420 other areas below national and D . O . 160 00:06:41,420 --> 00:06:44,450 D . Benchmarks . I understand that 161 00:06:44,450 --> 00:06:46,670 reforms in the N . D . A . As well as 162 00:06:46,670 --> 00:06:49,490 the internal process improvements of D . 163 00:06:49,490 --> 00:06:51,657 O . D . Are making a positive impact . 164 00:06:51,657 --> 00:06:53,434 But the bottom line is that the 165 00:06:53,434 --> 00:06:55,790 military health system is not where we 166 00:06:55,790 --> 00:06:57,950 need it to be . One thing that I 167 00:06:57,950 --> 00:07:00,660 believe can be done is to attack that 168 00:07:00,660 --> 00:07:02,827 variation at every turn , whether it's 169 00:07:02,827 --> 00:07:04,938 in the operating room , in the clinic 170 00:07:04,938 --> 00:07:07,104 or on the battlefield . There are many 171 00:07:07,104 --> 00:07:09,160 examples within the military of high 172 00:07:09,160 --> 00:07:11,382 reliability organizations that focus on 173 00:07:11,382 --> 00:07:13,327 eliminating variation and planning 174 00:07:13,327 --> 00:07:15,271 until service members can't get it 175 00:07:15,271 --> 00:07:17,382 wrong . These organizations and power 176 00:07:17,382 --> 00:07:19,549 mary meritocratic ideals that teach us 177 00:07:19,549 --> 00:07:21,771 that every person has an important role 178 00:07:21,771 --> 00:07:23,938 on the team based on their performance 179 00:07:23,938 --> 00:07:25,993 and their professional acumen . Some 180 00:07:25,993 --> 00:07:28,049 examples include military aviation , 181 00:07:28,049 --> 00:07:30,216 nuclear propulsion and special warfare 182 00:07:30,216 --> 00:07:32,271 communities . I'd also like to add , 183 00:07:32,271 --> 00:07:34,549 although not the focus of this hearing , 184 00:07:34,549 --> 00:07:34,490 that war game is is actually another 185 00:07:34,490 --> 00:07:36,601 way to evolve our military culture in 186 00:07:36,601 --> 00:07:38,768 eliminating variation and never ending 187 00:07:38,768 --> 00:07:40,879 quest to defeat our adversaries . And 188 00:07:40,879 --> 00:07:43,046 sometimes we focus so much on the high 189 00:07:43,046 --> 00:07:45,101 end weapons systems . We forget that 190 00:07:45,101 --> 00:07:47,323 healthcare is part of our ability to be 191 00:07:47,323 --> 00:07:50,380 ready to deter and if necessary win our 192 00:07:50,380 --> 00:07:53,010 nation's wars . So um I'm really 193 00:07:53,010 --> 00:07:55,232 looking forward to better understanding 194 00:07:55,232 --> 00:07:57,177 the challenges the military health 195 00:07:57,177 --> 00:07:59,010 system has uh today , how we can 196 00:07:59,010 --> 00:08:00,788 embrace that higher reliability 197 00:08:00,788 --> 00:08:02,830 organizational culture and any 198 00:08:02,830 --> 00:08:04,719 recommendations that we should be 199 00:08:04,719 --> 00:08:06,830 thinking of as we gear up for another 200 00:08:06,830 --> 00:08:09,060 NBA cycle in order to ensure that our 201 00:08:09,060 --> 00:08:11,393 outcomes are better than they are today . 202 00:08:11,393 --> 00:08:13,560 Thank you . Thank you . Mr Gallagher , 203 00:08:13,560 --> 00:08:15,393 I ask unanimous consent to allow 204 00:08:15,393 --> 00:08:17,338 members not on the subcommittee to 205 00:08:17,338 --> 00:08:19,449 participate in today's hearing and be 206 00:08:19,449 --> 00:08:21,393 allowed to ask questions after all 207 00:08:21,393 --> 00:08:23,116 subcommittee members have been 208 00:08:23,116 --> 00:08:25,338 recognized and um we welcome Mr DeSanto 209 00:08:25,400 --> 00:08:29,220 and I believe Mr Westbrook is here , Dr 210 00:08:29,220 --> 00:08:32,550 Westbrook is here as well . Uh I ask 211 00:08:32,550 --> 00:08:34,550 unanimous consent that the chair be 212 00:08:34,550 --> 00:08:36,550 authorized to declare recess at any 213 00:08:36,550 --> 00:08:38,600 time . Is there objection ? The 214 00:08:38,600 --> 00:08:40,860 objection it is ordered . Each witness 215 00:08:40,860 --> 00:08:42,916 will have the opportunity to present 216 00:08:42,916 --> 00:08:44,971 his or her testimony and each member 217 00:08:44,971 --> 00:08:47,027 will have an opportunity to question 218 00:08:47,027 --> 00:08:49,027 the witnesses for five minutes . We 219 00:08:49,027 --> 00:08:50,916 respectfully ask the witnesses to 220 00:08:50,916 --> 00:08:53,082 summarize their testimony and as close 221 00:08:53,082 --> 00:08:54,971 to five minutes as you can , your 222 00:08:54,971 --> 00:08:54,720 written comments and statements will be 223 00:08:54,720 --> 00:08:57,240 made part of the hearing record with 224 00:08:57,240 --> 00:09:01,180 that . Mr Desde el Barba , you may 225 00:09:01,180 --> 00:09:02,458 make your opening sick 226 00:09:04,940 --> 00:09:06,940 push . You have to push that little 227 00:09:06,940 --> 00:09:09,218 button there to turn on the microphone . 228 00:09:11,540 --> 00:09:13,096 I don't think it's on yet . 229 00:09:15,540 --> 00:09:19,230 Hello . Okay , I apologize . Uh thank 230 00:09:19,230 --> 00:09:21,810 you congresswoman spear . Um my name is 231 00:09:21,810 --> 00:09:24,220 Desde el Barbara before I begin , I'd 232 00:09:24,220 --> 00:09:26,331 first like to thank Chairwoman Jackie 233 00:09:26,331 --> 00:09:28,498 Spear and everyone on the subcommittee 234 00:09:28,498 --> 00:09:30,609 for allowing for allowing me to speak 235 00:09:30,609 --> 00:09:32,887 before you all today and tell my story . 236 00:09:32,887 --> 00:09:34,887 I'd also like to thank my parents , 237 00:09:34,887 --> 00:09:36,720 comedy and Mark Del Barba and my 238 00:09:36,720 --> 00:09:38,776 girlfriend julie Ruiz for being here 239 00:09:38,776 --> 00:09:40,998 with me today from the very beginning . 240 00:09:40,998 --> 00:09:43,053 I would also like to thank my sister 241 00:09:43,053 --> 00:09:42,830 joseph , tell Barbara who is unable to 242 00:09:42,830 --> 00:09:45,190 attend and lastly my legal team , 243 00:09:45,200 --> 00:09:48,170 Daniel Maharaj and Elizabeth swivel for 244 00:09:48,210 --> 00:09:50,660 supporting me throughout this journey . 245 00:09:51,640 --> 00:09:53,862 Many people have dreams and aspirations 246 00:09:53,862 --> 00:09:56,084 of having a career in tech , medicine , 247 00:09:56,084 --> 00:09:58,470 engineering and law . I had dreams and 248 00:09:58,470 --> 00:10:00,803 aspirations of having a career in the U . 249 00:10:00,803 --> 00:10:02,803 S . Military . You know something I 250 00:10:02,803 --> 00:10:04,970 knew I always wanted to do from a very 251 00:10:04,970 --> 00:10:07,192 young age . I want to join the military 252 00:10:07,192 --> 00:10:09,137 right out of high school . However 253 00:10:09,137 --> 00:10:10,970 however I was guided to pursue a 254 00:10:10,970 --> 00:10:13,137 bachelor's degree first before getting 255 00:10:13,137 --> 00:10:15,248 commissioned as an officer . I was an 256 00:10:15,248 --> 00:10:17,414 extremely healthy and athletic 21 year 257 00:10:17,414 --> 00:10:17,210 old man before I enlisted in the US 258 00:10:17,210 --> 00:10:19,490 Army I never had any health issues 259 00:10:19,490 --> 00:10:22,180 besides a major . I've never had any 260 00:10:22,190 --> 00:10:24,246 health issues besides an A . C . L . 261 00:10:24,246 --> 00:10:26,468 Tear on my right knee . The army is the 262 00:10:26,468 --> 00:10:28,690 only branch that makes it a requirement 263 00:10:28,690 --> 00:10:30,746 for their officers to complete basic 264 00:10:30,746 --> 00:10:32,857 combat training before they contend , 265 00:10:32,857 --> 00:10:35,079 attend officer candidate school . I was 266 00:10:35,079 --> 00:10:37,190 accepted into the O . C . S . Program 267 00:10:37,190 --> 00:10:39,412 has had a few semesters of college left 268 00:10:39,412 --> 00:10:41,690 to finish . Before obtaining my degree . 269 00:10:41,690 --> 00:10:41,600 I decided to take a leave of absence 270 00:10:41,600 --> 00:10:43,850 from college to complete basic combat 271 00:10:43,850 --> 00:10:46,072 training . Return to school . Then upon 272 00:10:46,072 --> 00:10:48,239 graduation from college attend O . C . 273 00:10:48,239 --> 00:10:50,480 S . I shipped out to Fort Benning on 274 00:10:50,480 --> 00:10:53,550 January 7 , 2019 and like many young 275 00:10:53,550 --> 00:10:56,060 women men and women , I was excited , 276 00:10:56,100 --> 00:10:58,880 energetic , enthusiastic and even 277 00:10:58,880 --> 00:11:00,936 anxious for this new adventure in my 278 00:11:00,936 --> 00:11:03,280 life . I was assigned to Bravo Company , 279 00:11:03,290 --> 00:11:05,860 1st Battalion , 46th Infantry Regiment . 280 00:11:06,640 --> 00:11:08,807 However , it only took 35 days for the 281 00:11:08,807 --> 00:11:10,950 military to destroy my life . I was 282 00:11:10,950 --> 00:11:12,783 left grossly neglected in the US 283 00:11:12,783 --> 00:11:15,006 military by the us military health care 284 00:11:15,006 --> 00:11:16,783 system and by my basic training 285 00:11:16,783 --> 00:11:19,006 leadership at Fort Benning Georgia . As 286 00:11:19,006 --> 00:11:21,228 a result of the neglect I experienced . 287 00:11:21,228 --> 00:11:23,450 I have physically endured a total of 43 288 00:11:23,450 --> 00:11:25,672 surgeries . Over half of my right glute 289 00:11:25,672 --> 00:11:27,728 has been debris did and skin grafted 290 00:11:27,728 --> 00:11:29,783 both of my under arms have undergone 291 00:11:29,783 --> 00:11:31,783 debris , mint and skin grafting . I 292 00:11:31,783 --> 00:11:33,783 have an above knee amputation of my 293 00:11:33,783 --> 00:11:35,617 left leg . My right leg has been 294 00:11:35,617 --> 00:11:37,672 severely degraded and skin grafted , 295 00:11:37,672 --> 00:11:39,783 Leaving me with 70% muscle and tissue 296 00:11:39,783 --> 00:11:42,180 damage . In order to somewhat restore 297 00:11:42,180 --> 00:11:44,480 these five major areas of my body . I 298 00:11:44,480 --> 00:11:46,536 had skin donor sites on my chest and 299 00:11:46,536 --> 00:11:49,430 back mentally . I'm now diagnosed with 300 00:11:49,430 --> 00:11:52,780 severe PTSD and depression Today as I 301 00:11:52,780 --> 00:11:55,350 sit in front of you all three years 302 00:11:56,740 --> 00:11:59,240 and 93 years and 19 days have passed 303 00:11:59,240 --> 00:12:01,560 since . I have answers about what has 304 00:12:02,040 --> 00:12:04,540 happened since I contracted necrotizing 305 00:12:04,540 --> 00:12:06,770 fasciitis at Fort Benning . It's been 306 00:12:06,770 --> 00:12:09,740 1143 days and I still have no clear 307 00:12:09,740 --> 00:12:11,796 answers on the status of any quality 308 00:12:11,796 --> 00:12:14,040 assurance investigation that may or may 309 00:12:14,040 --> 00:12:16,960 not have been initiated promptly . What 310 00:12:16,960 --> 00:12:19,182 happened to me did not have to happen . 311 00:12:19,182 --> 00:12:21,930 This was preventable . I can sit here 312 00:12:21,930 --> 00:12:24,041 and speak all day about what happened 313 00:12:24,041 --> 00:12:26,041 to me , but my pictures will put my 314 00:12:26,041 --> 00:12:28,097 words into perspective of the damage 315 00:12:28,097 --> 00:12:30,152 that has been done in my body and my 316 00:12:30,152 --> 00:12:32,263 mind . Please see the attached photos 317 00:12:32,263 --> 00:12:31,810 for a better understanding of what I 318 00:12:31,810 --> 00:12:33,921 went through and what could have been 319 00:12:33,921 --> 00:12:36,088 avoided . Had the medical providers at 320 00:12:36,088 --> 00:12:38,310 Fort Benning , give me adequate medical 321 00:12:38,310 --> 00:12:40,790 attention . If I was your son . If I 322 00:12:40,790 --> 00:12:42,957 was your brother . If I was your loved 323 00:12:42,957 --> 00:12:45,012 one , would you sit stagnant waiting 324 00:12:45,012 --> 00:12:47,310 for answers ? I would hope not . You 325 00:12:47,310 --> 00:12:49,366 would fight for their rights and you 326 00:12:49,366 --> 00:12:51,421 would never stop until the questions 327 00:12:51,421 --> 00:12:53,643 are answered and the responsible people 328 00:12:53,643 --> 00:12:55,643 are held accountable . I understand 329 00:12:55,643 --> 00:12:57,754 that the medical quality assurance is 330 00:12:57,754 --> 00:12:57,290 managed by the military medical 331 00:12:57,290 --> 00:12:59,234 community . I understand that this 332 00:12:59,234 --> 00:13:01,401 takes time and patience . However , my 333 00:13:01,401 --> 00:13:03,623 medical records from Fort Benning total 334 00:13:03,623 --> 00:13:05,734 less than 100 pages and I cannot seem 335 00:13:05,734 --> 00:13:07,734 to understand or comprehend how the 336 00:13:07,734 --> 00:13:09,734 army has taken over three years and 337 00:13:09,734 --> 00:13:11,957 still has not concluded the Q . A . I . 338 00:13:11,957 --> 00:13:14,179 In my case , I have enclosed my with my 339 00:13:14,179 --> 00:13:16,290 statement all the correspondence I've 340 00:13:16,290 --> 00:13:18,012 received from the Army command 341 00:13:18,012 --> 00:13:20,123 regarding the status of my Q . AI for 342 00:13:20,123 --> 00:13:20,080 the committee To see how convoluted 343 00:13:20,080 --> 00:13:21,747 this process has been and how 344 00:13:21,747 --> 00:13:23,524 inconsistent the army is . When 345 00:13:23,524 --> 00:13:25,247 responding to inquiries made , 346 00:13:28,640 --> 00:13:31,240 I would pose the question , how can the 347 00:13:31,240 --> 00:13:33,470 military say it is adequately providing 348 00:13:33,470 --> 00:13:35,581 medical quality assurance for service 349 00:13:35,581 --> 00:13:38,060 members like myself . I'm here today , 350 00:13:38,060 --> 00:13:40,227 not only fighting for myself , but for 351 00:13:40,227 --> 00:13:42,227 all other service members that have 352 00:13:42,227 --> 00:13:44,449 been subjected to an adverse event at a 353 00:13:44,449 --> 00:13:46,504 military treatment facility center . 354 00:13:46,504 --> 00:13:48,227 And I've never had a proper or 355 00:13:48,227 --> 00:13:48,170 appropriate quality assurance 356 00:13:48,170 --> 00:13:50,320 investigation . This is a grave 357 00:13:50,320 --> 00:13:52,431 injustice for our service members and 358 00:13:52,431 --> 00:13:54,431 this is the least that they deserve 359 00:13:54,431 --> 00:13:56,542 given that some of them are no longer 360 00:13:56,542 --> 00:13:58,598 here . As a result , I cannot stress 361 00:13:58,598 --> 00:14:00,764 the negative emotional impact this has 362 00:14:00,764 --> 00:14:02,876 caused myself . Not only did I lose a 363 00:14:02,876 --> 00:14:04,876 limb , I also lost my identity , my 364 00:14:04,876 --> 00:14:06,876 self esteem and my confidence along 365 00:14:06,876 --> 00:14:09,042 with it . Activities that are supposed 366 00:14:09,042 --> 00:14:11,209 to be fun and enjoyable for someone in 367 00:14:11,209 --> 00:14:10,860 their twenties became a mental burden , 368 00:14:11,340 --> 00:14:13,451 hiding behind a fake smile every time 369 00:14:13,451 --> 00:14:15,673 I'm around others while having feelings 370 00:14:15,673 --> 00:14:17,562 of true unhappiness on the inside 371 00:14:17,562 --> 00:14:19,673 became normal . Having thoughts of it 372 00:14:19,673 --> 00:14:21,896 would be better if I just want to sleep 373 00:14:21,896 --> 00:14:24,007 and never woke up was something I was 374 00:14:24,007 --> 00:14:26,173 hoping would happen to me every single 375 00:14:26,173 --> 00:14:28,173 night before bed as the saying life 376 00:14:28,173 --> 00:14:30,920 goes on , my life will go on . I will 377 00:14:30,920 --> 00:14:33,031 eventually find the strength mentally 378 00:14:33,031 --> 00:14:34,864 and physically to work past this 379 00:14:34,864 --> 00:14:37,031 horrendous time in my life . However , 380 00:14:37,031 --> 00:14:38,976 this has reshaped my identity as a 381 00:14:38,976 --> 00:14:41,198 human being , daily things that you all 382 00:14:41,198 --> 00:14:43,309 take for granted . So just putting on 383 00:14:43,309 --> 00:14:45,476 your shoes before work , taking a walk 384 00:14:45,476 --> 00:14:47,642 around your neighborhood , going for a 385 00:14:47,642 --> 00:14:47,340 dip in the pool when it's too hot 386 00:14:47,340 --> 00:14:49,640 outside . These are all things that I'm 387 00:14:49,640 --> 00:14:51,584 not able to do either at all or as 388 00:14:51,584 --> 00:14:53,807 easily anymore . As a 24 year old man , 389 00:14:54,440 --> 00:14:56,607 I would never wish what I went through 390 00:14:56,607 --> 00:14:58,662 upon anyone . But unfortunately that 391 00:14:58,662 --> 00:15:00,884 may not be possible . Seeing that those 392 00:15:00,884 --> 00:15:03,107 responsible for the poor medical care I 393 00:15:03,107 --> 00:15:05,329 received are still employed by the army 394 00:15:05,329 --> 00:15:07,551 to treat more service members . I asked 395 00:15:07,551 --> 00:15:09,773 you take away the feeling of motivation 396 00:15:09,773 --> 00:15:09,760 from what I've shared here with you 397 00:15:09,760 --> 00:15:11,982 today . The motivation to want a better 398 00:15:11,982 --> 00:15:14,204 system that should be at its finest for 399 00:15:14,204 --> 00:15:16,204 its men and women who want to serve 400 00:15:16,204 --> 00:15:18,371 this country . Thank you for your time 401 00:15:18,371 --> 00:15:20,593 and attention and please see my written 402 00:15:20,593 --> 00:15:20,420 statement for a full accounting and 403 00:15:20,420 --> 00:15:22,531 timeline of what happened to me . I'm 404 00:15:22,531 --> 00:15:25,190 happy to answer any questions . Thank 405 00:15:25,190 --> 00:15:28,520 you . Mr Del Barba . Um extraordinary 406 00:15:28,520 --> 00:15:30,631 courage that you've shown . I want my 407 00:15:30,631 --> 00:15:32,853 colleagues to know that in your binders 408 00:15:32,853 --> 00:15:36,150 are pictures of his injuries and they 409 00:15:36,150 --> 00:15:39,850 are truly shocking . Mr Lucky 410 00:15:40,740 --> 00:15:43,860 you're recognized . Good afternoon . 411 00:15:44,840 --> 00:15:46,896 Good afternoon . Could you make sure 412 00:15:46,896 --> 00:15:48,007 your microphones on 413 00:15:51,240 --> 00:15:53,660 Good afternoon . I think it's on 414 00:15:59,060 --> 00:16:00,060 light red . 415 00:16:08,740 --> 00:16:10,750 Good afternoon . Maybe put the 416 00:16:10,750 --> 00:16:13,240 microphone a little bit closer . Yes . 417 00:16:13,250 --> 00:16:16,060 There you go . Good afternoon , 418 00:16:16,840 --> 00:16:18,870 chairwoman Spear and members of the 419 00:16:18,870 --> 00:16:21,560 committee . My name is Derek Lucky . 420 00:16:22,240 --> 00:16:24,690 I'm from Pittsburgh California . I am 421 00:16:24,690 --> 00:16:27,560 joined today by my wife Annette . We 422 00:16:27,560 --> 00:16:29,800 are the parents of the late seaman 423 00:16:29,860 --> 00:16:33,420 Daniel Lucky , Who died October 10 , 424 00:16:33,420 --> 00:16:36,550 2016 from Sepsis while serving on the 425 00:16:36,550 --> 00:16:40,390 USS Ronald Reagan . We were invited 426 00:16:40,400 --> 00:16:42,567 to appear today to share what happened 427 00:16:42,567 --> 00:16:44,460 to Danielle while she served our 428 00:16:44,460 --> 00:16:47,160 country . We were invited 429 00:16:49,340 --> 00:16:52,100 to appear today to share what happened 430 00:16:52,260 --> 00:16:54,482 to Danielle while she spoke our country 431 00:16:54,482 --> 00:16:57,970 first , let me say I am not lawyer or a 432 00:16:57,970 --> 00:17:00,300 politician . I have never done anything 433 00:17:00,300 --> 00:17:03,650 like this before . However , I am here 434 00:17:03,650 --> 00:17:06,130 today to share with you the tragedy of 435 00:17:06,130 --> 00:17:08,720 Danielle's death . She did not die in 436 00:17:08,720 --> 00:17:12,470 combat or any military operation . She 437 00:17:12,470 --> 00:17:16,140 died from growth negligence of the 438 00:17:16,140 --> 00:17:18,196 medical providers on the ships . You 439 00:17:18,196 --> 00:17:20,860 served the U . S . S . Ronald Reagan . 440 00:17:21,540 --> 00:17:23,550 Her death was very preventable . 441 00:17:23,940 --> 00:17:26,960 Instead she died in excruciating pain 442 00:17:28,840 --> 00:17:30,840 instead of being properly treated . 443 00:17:31,440 --> 00:17:33,773 When Danielle came to me and said , Dad , 444 00:17:34,640 --> 00:17:36,751 I want to join the military and serve 445 00:17:36,751 --> 00:17:38,751 my country . She wanted to join the 446 00:17:38,751 --> 00:17:41,920 Navy to start a career as a sailor on a 447 00:17:41,920 --> 00:17:44,990 ship . When she approached me , I said , 448 00:17:45,000 --> 00:17:47,760 I am concerned for you . She said Dad , 449 00:17:48,140 --> 00:17:51,350 I will be okay with that big smile . I 450 00:17:51,350 --> 00:17:54,620 remember so much a smile I would never 451 00:17:54,620 --> 00:17:55,460 see again . 452 00:18:00,540 --> 00:18:03,960 Little did I know . on 10 October 2016 453 00:18:04,340 --> 00:18:06,920 I will get that knock at the door At 454 00:18:06,920 --> 00:18:09,550 903 am telling me my daughter was dead . 455 00:18:10,840 --> 00:18:13,270 Not from bullets , but from sepsis . 456 00:18:16,440 --> 00:18:18,730 Like many who have Children who have 457 00:18:18,780 --> 00:18:21,120 served in the military , we live in 458 00:18:21,120 --> 00:18:23,370 fear of two officers knocking at our 459 00:18:23,370 --> 00:18:26,290 door . Danielle was not in combat . We 460 00:18:26,290 --> 00:18:28,457 were crushed when they told us she had 461 00:18:28,457 --> 00:18:31,460 died cardiac arrest . We thought it was 462 00:18:31,460 --> 00:18:34,250 impossible . How could my daughter die 463 00:18:34,250 --> 00:18:37,970 of cardiac arrest ? Our lives changed 464 00:18:37,970 --> 00:18:41,490 forever . Daniel died on the Uss Ronald 465 00:18:41,490 --> 00:18:45,030 Reagan not at war . This tragedy . This 466 00:18:45,040 --> 00:18:48,780 tragedy . This tragedy tragedy was 467 00:18:48,780 --> 00:18:51,390 completely avoidable . Her death was 468 00:18:51,390 --> 00:18:53,930 the result of gross negligence 469 00:18:53,940 --> 00:18:56,900 malpractice . If the medical providers 470 00:18:56,910 --> 00:18:59,580 on the USs Ronald Reagan had given her 471 00:18:59,590 --> 00:19:02,230 a simple treatment of antibiotics 472 00:19:02,240 --> 00:19:04,860 instead of turning her away . She would 473 00:19:04,860 --> 00:19:08,800 be here today when we reached 474 00:19:08,800 --> 00:19:10,967 out to attorneys around the country to 475 00:19:10,967 --> 00:19:12,967 represent us . They said no that we 476 00:19:12,967 --> 00:19:15,133 couldn't do anything . Someone told us 477 00:19:15,133 --> 00:19:18,160 to reach out to eternally to attorney 478 00:19:18,940 --> 00:19:21,980 Natalie Kwame . They said she was a 479 00:19:21,980 --> 00:19:24,380 strong fighter for military . We did 480 00:19:24,510 --> 00:19:26,510 and she was willing to help us seek 481 00:19:26,510 --> 00:19:30,360 justice for Danielle MS . Kwan told 482 00:19:30,360 --> 00:19:34,250 us that you Chairman Spear are 483 00:19:34,250 --> 00:19:36,472 an incredible advocate for our military 484 00:19:36,472 --> 00:19:38,620 and that you are the champion of the 485 00:19:38,620 --> 00:19:40,480 Richard statistical military 486 00:19:40,490 --> 00:19:44,030 accountability act . So today I did 487 00:19:44,030 --> 00:19:46,252 come here to share with you the tragedy 488 00:19:46,252 --> 00:19:48,780 of our daughter's death and to share 489 00:19:48,780 --> 00:19:50,947 with you what is wrong with the system 490 00:19:50,947 --> 00:19:53,520 you created to seek justice when 491 00:19:53,520 --> 00:19:56,880 sailors like Mike Danielle died when 492 00:19:56,880 --> 00:19:59,960 they are victims of medical malpractice . 493 00:20:01,040 --> 00:20:04,080 We all believe when Congress passed the 494 00:20:04,080 --> 00:20:07,230 S . F . C . Richards disco military 495 00:20:07,240 --> 00:20:09,450 accountability act . Under your 496 00:20:09,450 --> 00:20:12,760 leadership , we would finally have 497 00:20:12,760 --> 00:20:14,927 justice and accountability for victims 498 00:20:14,927 --> 00:20:17,550 like Danielle . Unfortunately we could 499 00:20:17,550 --> 00:20:20,440 not seek justice for Danielle . As you 500 00:20:20,450 --> 00:20:23,160 this Congress has intended and we hope 501 00:20:26,540 --> 00:20:29,030 sadly we learned from our attorney 502 00:20:29,130 --> 00:20:32,920 attorneys at for military dot com 503 00:20:32,930 --> 00:20:35,740 that despite your hard work , Chairman 504 00:20:35,740 --> 00:20:39,360 Spear And Congress is intense . 505 00:20:39,940 --> 00:20:42,140 The Department of Defense has decided 506 00:20:42,140 --> 00:20:45,210 not to allow claims from sailors on 507 00:20:45,210 --> 00:20:47,950 vessels . Our ships like Danielle's . 508 00:20:48,080 --> 00:20:50,460 That is not what Congress intended . It 509 00:20:50,460 --> 00:20:52,770 is the opposite . I have also learned 510 00:20:53,140 --> 00:20:55,130 that they will not allow claims by 511 00:20:55,130 --> 00:20:57,510 sailors or soldiers when they are 512 00:20:57,510 --> 00:21:00,520 treated at military facilities outside 513 00:21:00,530 --> 00:21:02,710 the United States , in places like 514 00:21:02,720 --> 00:21:06,360 Italy Germany and England where we have 515 00:21:06,940 --> 00:21:10,080 big U . S . Military hospitals . So 516 00:21:10,080 --> 00:21:13,660 just because a military hospital is not 517 00:21:14,140 --> 00:21:17,930 in the US , the care doesn't have the 518 00:21:17,930 --> 00:21:20,960 same medical standards . This is wrong . 519 00:21:22,240 --> 00:21:25,260 The D . O . D . Issued guidelines that 520 00:21:25,260 --> 00:21:27,240 do not align with what Congress 521 00:21:27,240 --> 00:21:29,850 intended justice for victims of medical 522 00:21:29,850 --> 00:21:33,240 malpractice . Worse , I am told if a 523 00:21:33,240 --> 00:21:35,460 sailor like Danielle were to file a 524 00:21:35,460 --> 00:21:38,450 claim and be denied . The appeal of the 525 00:21:38,450 --> 00:21:41,120 denial goes back to the panel made up 526 00:21:41,120 --> 00:21:44,640 by either army , navy or air force . So 527 00:21:44,640 --> 00:21:48,240 the military decides the cases and the 528 00:21:48,240 --> 00:21:51,970 appeal . That's like the home team 529 00:21:51,980 --> 00:21:54,260 getting to be their own referee in a 530 00:21:54,260 --> 00:21:57,720 football game . This is not this , 531 00:21:58,090 --> 00:22:01,500 This is just not fair . What I think 532 00:22:01,510 --> 00:22:05,220 you intended . These denials should be 533 00:22:05,230 --> 00:22:08,060 heard by an independent federal judge . 534 00:22:08,440 --> 00:22:10,910 Like other federal claims , that would 535 00:22:10,910 --> 00:22:14,470 be fair . Chairwoman spear the 536 00:22:14,470 --> 00:22:17,060 law as written today can't bring 537 00:22:17,060 --> 00:22:19,840 justice to Danielle or me or my wife . 538 00:22:19,850 --> 00:22:21,850 But you can make changes that would 539 00:22:21,850 --> 00:22:25,290 allow for these other problems like the 540 00:22:25,290 --> 00:22:27,810 appeal and where the hospital is 541 00:22:27,810 --> 00:22:29,866 located . Be corrected without these 542 00:22:29,866 --> 00:22:32,800 changes . The military will continue 543 00:22:32,810 --> 00:22:35,270 policing theirselves 544 00:22:44,540 --> 00:22:46,596 without these changes , the military 545 00:22:46,596 --> 00:22:50,200 will continue policing itself . The 546 00:22:50,200 --> 00:22:52,367 military will decide if they are right 547 00:22:52,367 --> 00:22:54,478 or wrong . And worse , they will also 548 00:22:54,478 --> 00:22:57,720 determine the appeals If someone like 549 00:22:57,720 --> 00:23:00,940 me were to lose the case . I urge you 550 00:23:00,940 --> 00:23:02,900 to stop this now and correct these 551 00:23:02,900 --> 00:23:05,160 problems . I know you and other 552 00:23:05,160 --> 00:23:07,300 Congress members care about our 553 00:23:07,300 --> 00:23:09,560 military and want them to have the best 554 00:23:09,940 --> 00:23:12,330 medical care possible . And when that 555 00:23:12,340 --> 00:23:15,810 care causes their death or harm , they 556 00:23:15,810 --> 00:23:18,460 should be compensated for the harmful 557 00:23:19,540 --> 00:23:22,560 for for that harmful maltreatment . 558 00:23:23,340 --> 00:23:25,562 Please make these changes and bring our 559 00:23:25,562 --> 00:23:27,860 military and our families justice today 560 00:23:28,940 --> 00:23:31,860 Daniel was robbed of her life in her 561 00:23:31,860 --> 00:23:35,160 career . Let her mistreatment and death 562 00:23:35,160 --> 00:23:37,350 remind us that our military and 563 00:23:37,350 --> 00:23:40,800 families deserve justice . Now please 564 00:23:40,800 --> 00:23:43,710 fix the bicycle act to work the way you 565 00:23:43,710 --> 00:23:46,270 intended to bring justice to victims 566 00:23:46,280 --> 00:23:49,520 and their families . Thank you . Thank 567 00:23:49,520 --> 00:23:52,450 you . Mr . Lucky again . This committee 568 00:23:52,630 --> 00:23:54,408 warns with you the loss of your 569 00:23:54,408 --> 00:23:58,040 daughter . MS sillas from the general 570 00:23:58,050 --> 00:23:59,900 accountability office . You are 571 00:23:59,990 --> 00:24:03,400 recognized . Thank 572 00:24:03,400 --> 00:24:07,130 you . Chairwoman , sphere ranking 573 00:24:07,130 --> 00:24:09,130 member Gallagher and members of the 574 00:24:09,130 --> 00:24:11,297 subcommittee . I am pleased to be here 575 00:24:11,297 --> 00:24:13,241 today to discuss geos ongoing work 576 00:24:13,241 --> 00:24:15,352 reviewing D . O . D . S monitoring of 577 00:24:15,352 --> 00:24:17,574 providers qualifications , incompetence 578 00:24:17,574 --> 00:24:20,390 in military medical facilities . My 579 00:24:20,390 --> 00:24:22,557 testimony today summarizes preliminary 580 00:24:22,557 --> 00:24:24,668 observations we have developed during 581 00:24:24,668 --> 00:24:27,420 the course of our review . D . O . D . 582 00:24:27,420 --> 00:24:29,309 Provides health care to over nine 583 00:24:29,309 --> 00:24:31,198 million beneficiaries through its 584 00:24:31,198 --> 00:24:33,253 military health system and employs a 585 00:24:33,253 --> 00:24:35,309 variety of physicians , dentists and 586 00:24:35,309 --> 00:24:37,531 other providers that provide a range of 587 00:24:37,531 --> 00:24:39,531 health care services , from routine 588 00:24:39,531 --> 00:24:41,364 examinations to complex surgical 589 00:24:41,364 --> 00:24:43,420 procedures as such . It's imperative 590 00:24:43,420 --> 00:24:45,364 that D . O . D . Ensure that these 591 00:24:45,364 --> 00:24:47,587 providers are delivering timely quality 592 00:24:47,587 --> 00:24:49,642 care to military service members and 593 00:24:49,642 --> 00:24:51,698 their families and then any concerns 594 00:24:51,698 --> 00:24:53,753 that may arise about the quality and 595 00:24:53,753 --> 00:24:55,920 safety of caribbean delivered by these 596 00:24:55,920 --> 00:24:59,010 providers is immediately addressed like 597 00:24:59,010 --> 00:25:01,232 other health care systems . D . O . D . 598 00:25:01,232 --> 00:25:03,399 Is responsible for ensuring that their 599 00:25:03,399 --> 00:25:05,621 providers still living are safe care to 600 00:25:05,621 --> 00:25:07,677 patients . Since the Military health 601 00:25:07,677 --> 00:25:09,510 Systems review of D . O . Do you 602 00:25:09,510 --> 00:25:11,732 provide our quality of care issues ? In 603 00:25:11,732 --> 00:25:14,010 2014 , Congress has required D . O . D . 604 00:25:14,010 --> 00:25:15,954 To transfer management of domestic 605 00:25:15,954 --> 00:25:15,870 medical facilities from the military 606 00:25:15,870 --> 00:25:19,120 departments to D . H . A . In 2019 . 607 00:25:19,120 --> 00:25:21,260 DHS issued standardized clinical 608 00:25:21,260 --> 00:25:23,427 quality management procedures intended 609 00:25:23,427 --> 00:25:25,649 to ensure that individual providers are 610 00:25:25,649 --> 00:25:28,030 qualified and competent to deliver safe 611 00:25:28,030 --> 00:25:30,320 high quality care to patients across 612 00:25:30,320 --> 00:25:34,010 all military departments . G . O . Is 613 00:25:34,180 --> 00:25:36,180 currently reviewing procedures that 614 00:25:36,180 --> 00:25:38,013 occur under DHS clinical quality 615 00:25:38,013 --> 00:25:40,490 management , potentially improving 616 00:25:40,710 --> 00:25:43,270 focus prevention practice evaluations 617 00:25:43,640 --> 00:25:45,807 in the review of potential compensable 618 00:25:45,807 --> 00:25:47,862 events that is patient safety events 619 00:25:47,940 --> 00:25:49,996 that could result in payments to the 620 00:25:49,996 --> 00:25:51,829 patients or their families . And 621 00:25:51,829 --> 00:25:53,940 generally found a number of instances 622 00:25:53,940 --> 00:25:56,107 where facilities and D . H . A . We're 623 00:25:56,107 --> 00:25:59,070 not adhering to procedures 1st . As 624 00:25:59,070 --> 00:26:01,070 part of credentialing and assigning 625 00:26:01,070 --> 00:26:03,237 clinical privileges to providers . D . 626 00:26:03,237 --> 00:26:05,014 H . A . Policy requires medical 627 00:26:05,014 --> 00:26:07,237 military medical facilities to verify a 628 00:26:07,237 --> 00:26:09,126 provider's qualifications such as 629 00:26:09,126 --> 00:26:11,292 education and licensure when providers 630 00:26:11,292 --> 00:26:13,292 are first on boarded at the medical 631 00:26:13,292 --> 00:26:15,181 facility and then to periodically 632 00:26:15,181 --> 00:26:17,292 assess the provider's credentials and 633 00:26:17,292 --> 00:26:19,514 privileges thereafter . However as part 634 00:26:19,514 --> 00:26:21,626 of our ongoing review , we have found 635 00:26:21,626 --> 00:26:23,737 that the selected facilities were not 636 00:26:23,737 --> 00:26:23,730 always following the D . H . A . 637 00:26:23,730 --> 00:26:25,397 Credentialing and privileging 638 00:26:25,397 --> 00:26:27,341 procedures . For example , we have 639 00:26:27,341 --> 00:26:29,119 learned the facilities were not 640 00:26:29,119 --> 00:26:31,286 consistently verifying that all of our 641 00:26:31,286 --> 00:26:33,508 providers medical licenses were valid . 642 00:26:33,508 --> 00:26:35,508 In addition , it appears that about 643 00:26:35,508 --> 00:26:37,341 three quarters of the applicable 644 00:26:37,341 --> 00:26:39,341 providers . These facilities do not 645 00:26:39,341 --> 00:26:41,119 have documentation that ongoing 646 00:26:41,119 --> 00:26:43,174 evaluations were conducted every six 647 00:26:43,174 --> 00:26:46,350 months as required . 2nd , military 648 00:26:46,350 --> 00:26:48,572 medical facilities are also required to 649 00:26:48,572 --> 00:26:50,683 conduct focused professional practice 650 00:26:50,683 --> 00:26:52,660 evaluations for cause which are 651 00:26:52,660 --> 00:26:54,604 conducted when concerns are raised 652 00:26:54,604 --> 00:26:56,771 about the providers care . Our ongoing 653 00:26:56,771 --> 00:26:58,938 review indicates that for the 20 folks 654 00:26:58,938 --> 00:27:01,080 evaluations we reviewed documentation 655 00:27:01,080 --> 00:27:03,470 that two key requirements criteria and 656 00:27:03,470 --> 00:27:05,230 metrics were not consistently 657 00:27:05,230 --> 00:27:07,286 documented in the focused evaluation 658 00:27:07,286 --> 00:27:09,080 plans . Another important to 659 00:27:09,080 --> 00:27:11,136 determining whether the provider has 660 00:27:11,136 --> 00:27:13,358 successfully completed the evaluation . 661 00:27:13,940 --> 00:27:16,218 Lastly based on our work today , D . J . 662 00:27:16,218 --> 00:27:18,218 Has not always completed reviews of 663 00:27:18,218 --> 00:27:20,051 patient safety events that could 664 00:27:20,051 --> 00:27:22,162 potentially result in compensation or 665 00:27:22,162 --> 00:27:24,218 did eventually result in payments to 666 00:27:24,218 --> 00:27:26,273 the patients or their families . For 667 00:27:26,273 --> 00:27:27,940 example , for the 12 cases we 668 00:27:27,940 --> 00:27:30,107 identified that did result in payments 669 00:27:30,107 --> 00:27:32,329 to patients or their families For about 670 00:27:32,329 --> 00:27:32,240 half of the cases . Dhs reviews were 671 00:27:32,240 --> 00:27:34,590 not completed within a 270 day 672 00:27:34,590 --> 00:27:36,960 requirement and further none of these 673 00:27:36,960 --> 00:27:39,200 cases were reported as required to H . 674 00:27:39,200 --> 00:27:41,740 H . S . S . National Repository that 675 00:27:41,740 --> 00:27:43,962 contains information on adverse actions 676 00:27:43,962 --> 00:27:46,184 taken against the provider and provider 677 00:27:46,184 --> 00:27:48,407 medical practice malpractice payments , 678 00:27:48,940 --> 00:27:50,940 filing our preliminary observations 679 00:27:50,940 --> 00:27:52,829 indicate the D . H . A . Does not 680 00:27:52,829 --> 00:27:54,607 sufficiently monitor facilities 681 00:27:54,607 --> 00:27:56,496 adherence to its clinical quality 682 00:27:56,496 --> 00:27:58,607 management procedures . For example , 683 00:27:58,607 --> 00:28:00,607 DHS officials told us they run some 684 00:28:00,607 --> 00:28:02,662 reports related to credentialing and 685 00:28:02,662 --> 00:28:04,884 privileging from a database , but those 686 00:28:04,884 --> 00:28:06,496 reports are pretty limited . 687 00:28:06,496 --> 00:28:08,496 Furthermore . The database does not 688 00:28:08,496 --> 00:28:10,718 include all required documentation such 689 00:28:10,718 --> 00:28:10,160 as the documents related to the 690 00:28:10,160 --> 00:28:13,430 provider ongoing evaluations . We also 691 00:28:13,430 --> 00:28:15,152 learned that DHS has not begun 692 00:28:15,152 --> 00:28:17,390 monitoring of facilities implementation 693 00:28:17,390 --> 00:28:19,612 of its reviews of potential compensable 694 00:28:19,612 --> 00:28:21,970 events . Instead , D . J . Is focusing 695 00:28:21,980 --> 00:28:24,170 on only monitoring compensable events 696 00:28:24,170 --> 00:28:28,000 cases that have resulted in payments as 697 00:28:28,000 --> 00:28:30,300 DHS continues to implement its clinical 698 00:28:30,300 --> 00:28:32,640 quality management procedures ensuring 699 00:28:32,640 --> 00:28:34,930 D . H . A . Policy and procedures are 700 00:28:34,930 --> 00:28:36,930 properly adhered to by the military 701 00:28:36,930 --> 00:28:39,152 medical facilities . Can help to ensure 702 00:28:39,152 --> 00:28:41,530 that service members military retirees 703 00:28:41,530 --> 00:28:43,586 and their families receive safe high 704 00:28:43,586 --> 00:28:45,808 quality care and when the care does not 705 00:28:45,808 --> 00:28:47,808 meet those standards . Dhe can hold 706 00:28:47,808 --> 00:28:49,919 those providers accountable . We will 707 00:28:49,919 --> 00:28:52,141 continue to assess these issues as part 708 00:28:52,141 --> 00:28:54,252 of our ongoing work and we'll plan to 709 00:28:54,252 --> 00:28:56,363 make recommendations as appropriate . 710 00:28:56,363 --> 00:28:58,530 Thank you . That concludes my prepared 711 00:28:58,530 --> 00:29:00,419 statement and I would be happy to 712 00:29:00,419 --> 00:29:02,419 answer any questions that you might 713 00:29:02,419 --> 00:29:04,641 have . Thank you . Mr Ellis . Uh We are 714 00:29:04,641 --> 00:29:06,808 in the middle of a roll call but there 715 00:29:06,808 --> 00:29:09,030 are still 300 members who haven't voted 716 00:29:09,030 --> 00:29:11,330 so what I'd like to do is um give 717 00:29:11,330 --> 00:29:13,330 members the opportunity to ask some 718 00:29:13,330 --> 00:29:16,980 questions . Mr Gallagher . I'll start 719 00:29:16,980 --> 00:29:19,258 with . Mr Thank you madam . Chairwoman . 720 00:29:19,258 --> 00:29:21,147 Um Can you tell us more about the 721 00:29:21,147 --> 00:29:23,258 shortcomings Gdf found in D . H . S . 722 00:29:23,258 --> 00:29:25,620 Efforts to monitor medical facilities 723 00:29:25,620 --> 00:29:27,770 adherence to procedures . Why is this 724 00:29:27,770 --> 00:29:29,992 important ? And what more could D . H . 725 00:29:29,992 --> 00:29:31,714 A . B . Doing to make sure its 726 00:29:31,714 --> 00:29:31,410 facilities are adhering to those 727 00:29:31,410 --> 00:29:32,170 procedures ? 728 00:29:35,340 --> 00:29:38,070 So as I mentioned we looked at three 729 00:29:38,070 --> 00:29:40,014 different types of procedures . We 730 00:29:40,014 --> 00:29:42,237 looked at credentialing and privileging 731 00:29:42,237 --> 00:29:44,181 which we looked at a sample of 100 732 00:29:44,181 --> 00:29:46,450 providers from four military treatment 733 00:29:46,450 --> 00:29:49,740 facilities . Um We found instances of 734 00:29:49,740 --> 00:29:52,080 where the during the credentialing 735 00:29:52,080 --> 00:29:54,247 process the facilities were not always 736 00:29:54,247 --> 00:29:56,580 verifying providers licenses as I 737 00:29:56,580 --> 00:29:58,524 mentioned in my testimony . So for 738 00:29:58,524 --> 00:30:00,440 example a provider could have um 739 00:30:00,440 --> 00:30:03,900 licenses in multiple states . Um And we 740 00:30:03,900 --> 00:30:05,956 would find that some of the licenses 741 00:30:05,956 --> 00:30:08,730 haven't been verified . Um We also 742 00:30:08,730 --> 00:30:10,470 looked at ongoing professional 743 00:30:10,480 --> 00:30:13,580 evaluation or practice evaluations um 744 00:30:13,580 --> 00:30:16,350 and these are routine evaluations that 745 00:30:16,360 --> 00:30:19,610 um occur every six months and we found 746 00:30:19,610 --> 00:30:21,443 that about three quarters of the 747 00:30:21,443 --> 00:30:24,260 providers did not have documentation 748 00:30:24,260 --> 00:30:26,970 that these were even conducted . Um the 749 00:30:26,980 --> 00:30:29,580 other procedures that we looked at were 750 00:30:29,580 --> 00:30:31,302 under our focused professional 751 00:30:31,302 --> 00:30:33,620 evaluations for cause we looked at 20 752 00:30:33,620 --> 00:30:36,620 evaluations um from the four military 753 00:30:36,620 --> 00:30:39,040 treatment facilities and we found for 754 00:30:39,040 --> 00:30:42,240 example that um facilities were rarely 755 00:30:42,240 --> 00:30:44,018 documenting all of the required 756 00:30:44,018 --> 00:30:46,600 elements that are needed to determine 757 00:30:46,600 --> 00:30:48,267 whether or not a provider had 758 00:30:48,267 --> 00:30:51,350 successfully um met all of the 759 00:30:51,360 --> 00:30:54,290 requirements for the evaluation . Um 760 00:30:54,290 --> 00:30:56,970 And then lastly we looked at patient 761 00:30:56,970 --> 00:30:59,650 safety events . We looked at two groups 762 00:30:59,650 --> 00:31:01,594 of events . We looked at potential 763 00:31:01,594 --> 00:31:04,140 compensable potential compensable 764 00:31:04,150 --> 00:31:07,090 events . Um we identified 19 from the 765 00:31:07,090 --> 00:31:09,090 floor of facilities included in our 766 00:31:09,090 --> 00:31:11,570 review and we found two issues of non 767 00:31:11,570 --> 00:31:13,980 inherent one at the beginning of the 768 00:31:13,990 --> 00:31:16,700 review facilities are supposed to 769 00:31:16,700 --> 00:31:18,867 consider taking an adverse privileging 770 00:31:18,867 --> 00:31:21,230 action against a provider um if the 771 00:31:21,230 --> 00:31:23,008 safety events were particularly 772 00:31:23,008 --> 00:31:25,119 egregious and we found that there was 773 00:31:25,119 --> 00:31:27,341 no documentation that any consideration 774 00:31:27,341 --> 00:31:29,508 was ever taken . Um we also found that 775 00:31:29,508 --> 00:31:31,674 there were issues with kind of meeting 776 00:31:31,674 --> 00:31:33,563 the time frames the required time 777 00:31:33,563 --> 00:31:35,750 frames for these reviews . Um the 778 00:31:35,750 --> 00:31:37,750 facilities were supposed to conduct 779 00:31:37,750 --> 00:31:39,639 these potential compensable event 780 00:31:39,639 --> 00:31:42,090 reviews within 100 days , 180 days of 781 00:31:42,090 --> 00:31:44,550 notification That the event had 782 00:31:44,550 --> 00:31:47,060 happened . And we found about 80% of 783 00:31:47,060 --> 00:31:49,171 those cases were not completed within 784 00:31:49,171 --> 00:31:51,890 that required time . We saw that these 785 00:31:51,890 --> 00:31:54,880 cases the days ranged from 91 to 786 00:31:54,880 --> 00:31:58,840 546 days in some instances For 787 00:31:58,840 --> 00:32:00,870 the second group of patient safety 788 00:32:00,870 --> 00:32:02,537 events that we looked at , we 789 00:32:02,537 --> 00:32:04,900 identified 12 patient safety events 790 00:32:04,900 --> 00:32:07,670 that resulted in payments to either the 791 00:32:08,040 --> 00:32:11,200 service member or their families . Um 792 00:32:11,210 --> 00:32:13,099 We found that D . H . A . Did not 793 00:32:13,099 --> 00:32:15,154 complete these reviews for reporting 794 00:32:15,154 --> 00:32:17,080 these . Um reporting out on these 795 00:32:17,080 --> 00:32:19,290 reviews within the required timeframe 796 00:32:19,290 --> 00:32:21,730 which was 270 days . We found that 797 00:32:21,730 --> 00:32:23,740 about half of the 12 cases were 798 00:32:23,740 --> 00:32:26,060 incomplete and exceeded that time frame 799 00:32:26,540 --> 00:32:28,900 but in particular what we found too is 800 00:32:28,900 --> 00:32:32,050 that for those reviews that were not 801 00:32:32,050 --> 00:32:35,600 completed within the 270 day time frame 802 00:32:35,610 --> 00:32:37,930 none of those reports . None of those 803 00:32:37,930 --> 00:32:40,097 cases or those providers were reported 804 00:32:40,097 --> 00:32:42,263 to the national practitioner data bank 805 00:32:42,263 --> 00:32:45,100 which is uh H . H . S . S . Uh 806 00:32:45,100 --> 00:32:48,690 huh . Repository for information on 807 00:32:48,690 --> 00:32:50,912 provider quality care issues so that if 808 00:32:50,912 --> 00:32:53,023 a provider has an average privileging 809 00:32:53,023 --> 00:32:55,134 action that's taken against them they 810 00:32:55,134 --> 00:32:57,500 would be recorded two to H . H . S . Um 811 00:32:57,500 --> 00:32:59,280 And in this instance there's a 812 00:32:59,280 --> 00:33:01,447 requirement within D . H . D . H . A . 813 00:33:01,447 --> 00:33:04,440 Procedures that if these patient safety 814 00:33:04,450 --> 00:33:06,810 events that have resulted in payment 815 00:33:06,820 --> 00:33:10,110 exceeds the 270 day requirement then 816 00:33:10,110 --> 00:33:11,888 they need to be reported to the 817 00:33:11,888 --> 00:33:14,340 national practitioner Databank . Uh 818 00:33:14,350 --> 00:33:16,350 Well thank you . I was gonna see my 819 00:33:16,350 --> 00:33:18,461 time to Mr Jackson but I'm almost out 820 00:33:18,461 --> 00:33:20,406 of it . Um But we have I think 300 821 00:33:20,406 --> 00:33:22,294 people left to vote so . Well you 822 00:33:22,294 --> 00:33:24,406 should have a full five minutes if we 823 00:33:24,406 --> 00:33:26,628 go but also in the 50 seconds remaining 824 00:33:26,628 --> 00:33:28,794 I just would ask . Mr Lucky and Mr Del 825 00:33:28,794 --> 00:33:31,190 Barba what is the single biggest lesson 826 00:33:31,190 --> 00:33:33,600 you've learned from this terrible and 827 00:33:33,600 --> 00:33:36,210 tragic experience that you've had with 828 00:33:36,210 --> 00:33:37,988 the military health care system 829 00:33:40,840 --> 00:33:44,830 in either order . Uh Sir the military 830 00:33:44,830 --> 00:33:47,210 health care system does not listen to 831 00:33:47,220 --> 00:33:49,950 the needs of the service members . It's 832 00:33:49,950 --> 00:33:53,190 that simple . We go and we ask for help 833 00:33:53,190 --> 00:33:54,857 and we are denied treatment . 834 00:33:58,940 --> 00:33:59,560 Mr Lucky . 835 00:34:04,440 --> 00:34:08,020 My daughter . My daughter 836 00:34:08,270 --> 00:34:11,260 shouldn't shouldn't have to be 837 00:34:12,040 --> 00:34:14,920 denied medical , she signed up to serve 838 00:34:14,920 --> 00:34:17,142 her country . That's all she wanted was 839 00:34:17,142 --> 00:34:19,370 to serve her country and to be denied 840 00:34:19,370 --> 00:34:22,470 medical . That's not that's not right . 841 00:34:23,840 --> 00:34:26,830 Thank you . And in both of your cases a 842 00:34:26,830 --> 00:34:30,760 simple antibiotic given over a period 843 00:34:30,760 --> 00:34:33,960 of 5-7 days would have solved the 844 00:34:34,340 --> 00:34:38,180 problem , correct ? Yes correct . 845 00:34:38,190 --> 00:34:40,560 And I actually went to sick call and 846 00:34:40,940 --> 00:34:43,330 physical therapists say a total of six 847 00:34:43,330 --> 00:34:46,160 times before my body went septic 848 00:34:48,240 --> 00:34:51,250 and Danielle she went to medical 849 00:34:51,260 --> 00:34:54,650 several times and was turned away and 850 00:34:54,650 --> 00:34:57,970 each time it got worse . Thank you Miss 851 00:34:57,970 --> 00:35:00,081 Hoolahan , you're recognized for five 852 00:35:00,081 --> 00:34:59,760 minutes . 853 00:35:03,640 --> 00:35:06,330 I I've been struggling with whether or 854 00:35:06,330 --> 00:35:08,710 not to even ask my prepared questions 855 00:35:08,720 --> 00:35:10,831 mostly because I just want to say I'm 856 00:35:10,831 --> 00:35:13,270 sorry uh and to express my deep 857 00:35:13,270 --> 00:35:15,440 appreciation and gratitude to you all 858 00:35:15,440 --> 00:35:18,100 for sharing your stories and also to 859 00:35:18,100 --> 00:35:20,990 your families for being there for your 860 00:35:21,000 --> 00:35:23,740 loved ones . And and um I know how hard 861 00:35:23,740 --> 00:35:26,570 this process is and how scary it is to 862 00:35:26,570 --> 00:35:29,470 tell your truth . So thank you . Um I 863 00:35:29,470 --> 00:35:31,637 served in the military myself and grew 864 00:35:31,637 --> 00:35:33,859 up in a military family and so I know a 865 00:35:33,859 --> 00:35:35,859 couple of few things about military 866 00:35:35,859 --> 00:35:37,859 healthcare . Um And I would like to 867 00:35:37,859 --> 00:35:40,720 understand better maybe with my one 868 00:35:40,720 --> 00:35:44,450 question from a parenting perspective 869 00:35:44,460 --> 00:35:47,290 from a loved one's perspective what 870 00:35:47,290 --> 00:35:49,690 could we be doing better to better 871 00:35:49,700 --> 00:35:53,300 integrate um other people from a family 872 00:35:53,310 --> 00:35:55,580 into the decision making process in 873 00:35:55,580 --> 00:35:58,150 healthcare and into frankly your 874 00:35:58,150 --> 00:35:59,910 experience when your daughter 875 00:35:59,910 --> 00:36:01,966 unfortunately did pass away and your 876 00:36:01,966 --> 00:36:04,188 experience of of learning of her health 877 00:36:04,188 --> 00:36:07,210 care journey . I know that you're an 878 00:36:07,210 --> 00:36:09,432 adult . I know that your daughter is an 879 00:36:09,432 --> 00:36:12,230 adult . Um but I'm struck by this uh 880 00:36:12,240 --> 00:36:14,240 this need that we have to make sure 881 00:36:14,240 --> 00:36:16,296 that we're also including people who 882 00:36:16,296 --> 00:36:18,407 may not be physically present in your 883 00:36:18,407 --> 00:36:20,530 family . Um but who might want to be 884 00:36:20,530 --> 00:36:22,752 engaged and involved in the health care 885 00:36:22,752 --> 00:36:24,974 choices and processes that you're going 886 00:36:24,974 --> 00:36:27,141 through . So I'd love to know from you 887 00:36:27,141 --> 00:36:29,363 all if there's any lessons learned that 888 00:36:29,363 --> 00:36:31,530 we can be taking advantage of before I 889 00:36:31,530 --> 00:36:33,697 let you answer . It's reflective madam 890 00:36:33,697 --> 00:36:35,752 Chair of our experience with Vanessa 891 00:36:35,752 --> 00:36:37,752 Gillian and her family as well . Uh 892 00:36:37,752 --> 00:36:39,919 different circumstances , but just the 893 00:36:39,919 --> 00:36:42,141 same kind of feeling of these are young 894 00:36:42,141 --> 00:36:44,141 people who are experiencing medical 895 00:36:44,141 --> 00:36:46,620 trauma or trauma in general . And how 896 00:36:46,620 --> 00:36:48,490 can we better involve the family 897 00:36:48,490 --> 00:36:49,050 members . 898 00:36:53,530 --> 00:36:56,460 Tell us the truth . Don't try to hide . 899 00:36:57,530 --> 00:36:59,308 We want to know what happened . 900 00:37:05,430 --> 00:37:07,652 It's just not right how they treated my 901 00:37:07,652 --> 00:37:11,580 daughter and me personally , I 902 00:37:11,580 --> 00:37:13,960 wouldn't I don't want any other family 903 00:37:14,330 --> 00:37:17,360 to have to experience what we're 904 00:37:17,360 --> 00:37:20,970 experiencing now . Like I said , this 905 00:37:20,970 --> 00:37:24,420 has changed our whole life . Daily 906 00:37:24,430 --> 00:37:27,130 functions is is difficult every day is 907 00:37:27,130 --> 00:37:30,350 a difficult day . My daughter 908 00:37:31,430 --> 00:37:34,660 should have never been denied medical 909 00:37:35,030 --> 00:37:38,150 treatment on the ship . She served the 910 00:37:38,150 --> 00:37:40,370 U . S . S . Ronald Reagan . That ship 911 00:37:40,370 --> 00:37:43,140 is named after the 40th president of 912 00:37:43,140 --> 00:37:45,480 the United States and she wanted to 913 00:37:45,480 --> 00:37:47,050 serve on that ship . 914 00:37:49,630 --> 00:37:52,710 Thank you sir and Mr Barbra Barbra 915 00:37:52,720 --> 00:37:56,420 Barbra , I think it's just 916 00:37:56,420 --> 00:37:59,630 accountability for myself and for other 917 00:37:59,640 --> 00:38:03,550 service members . Um The military isn't 918 00:38:03,550 --> 00:38:07,030 accountable for their actions . Um It's 919 00:38:07,030 --> 00:38:10,600 not fair to not only myself but to my 920 00:38:10,600 --> 00:38:13,530 family putting them through what they 921 00:38:13,530 --> 00:38:17,150 went through . It's 922 00:38:18,120 --> 00:38:22,040 it's sad and it's something that 923 00:38:22,040 --> 00:38:25,020 shouldn't happen to anybody um when 924 00:38:25,020 --> 00:38:27,320 you're sick and you need medicine , you 925 00:38:27,320 --> 00:38:29,850 should not be denied the medicine , you 926 00:38:29,850 --> 00:38:31,517 should be taken seriously . I 927 00:38:31,517 --> 00:38:33,628 understand there's people in training 928 00:38:33,628 --> 00:38:35,890 that try to get out of training and try 929 00:38:35,890 --> 00:38:38,130 to fake it , but it should be taken 930 00:38:38,130 --> 00:38:40,297 seriously . Every single person should 931 00:38:40,297 --> 00:38:43,170 be taken seriously because most of 932 00:38:43,170 --> 00:38:45,730 these people that aren't taken 933 00:38:45,730 --> 00:38:47,940 seriously aren't as lucky as I am . 934 00:38:47,960 --> 00:38:50,071 They don't have their lives anymore . 935 00:38:53,720 --> 00:38:55,776 No , and this is the thing that I am 936 00:38:55,776 --> 00:38:58,130 also struck by is how young you are , 937 00:38:58,140 --> 00:39:00,362 how young your daughter was . I want to 938 00:39:00,362 --> 00:39:03,250 make sure that we're treating the , 939 00:39:04,520 --> 00:39:06,464 when somebody goes to the doctor , 940 00:39:06,464 --> 00:39:08,687 they're going because they're genuinely 941 00:39:08,687 --> 00:39:10,520 sick . It should be the going in 942 00:39:10,520 --> 00:39:12,687 assumption . Uh and I know that that's 943 00:39:12,687 --> 00:39:14,798 not always the case with young people 944 00:39:14,798 --> 00:39:16,964 and particularly uh people in of color 945 00:39:16,964 --> 00:39:19,187 specifically . Uh And so I think that's 946 00:39:19,187 --> 00:39:21,020 something that we should be very 947 00:39:21,020 --> 00:39:22,964 attentive in tune to thank you . I 948 00:39:22,964 --> 00:39:25,076 yield back gentleman yields back . Uh 949 00:39:25,076 --> 00:39:27,460 The gentleman from texas Mr dr Jackson 950 00:39:27,460 --> 00:39:29,571 is recognized for five minutes and my 951 00:39:29,571 --> 00:39:31,793 apologies to miss escobar , you were in 952 00:39:31,793 --> 00:39:34,640 line ahead of him . Thank you , Madam 953 00:39:34,640 --> 00:39:36,900 Chair , appreciate it . Uh First off , 954 00:39:36,910 --> 00:39:38,966 thank you to the witnesses for being 955 00:39:38,966 --> 00:39:40,799 here . Uh really appreciate your 956 00:39:40,799 --> 00:39:43,021 testimony to to you . Mr dale Barbara . 957 00:39:43,021 --> 00:39:45,410 Uh I can't tell you how sorry we are 958 00:39:45,410 --> 00:39:47,632 for the disability and the way this has 959 00:39:47,632 --> 00:39:49,688 changed your life . Mr Lucky I can't 960 00:39:49,688 --> 00:39:51,966 our condolences to you and your family . 961 00:39:51,966 --> 00:39:54,132 I can't imagine what it's like to have 962 00:39:54,132 --> 00:39:56,132 your child taken from you at such a 963 00:39:56,132 --> 00:39:58,021 young age like that . Coming from 964 00:39:58,021 --> 00:39:57,480 military medicine , having been a 965 00:39:57,480 --> 00:39:59,740 military provider , it's just it's 966 00:39:59,740 --> 00:40:01,851 horrifying to hear your stories and I 967 00:40:01,851 --> 00:40:03,907 really appreciate you being here and 968 00:40:03,907 --> 00:40:06,129 telling us , telling us how this goes . 969 00:40:06,129 --> 00:40:08,240 I I will say that , you know , having 970 00:40:08,240 --> 00:40:10,462 come from military medicine , I can say 971 00:40:10,462 --> 00:40:10,330 that I think overall , you know , the 972 00:40:10,330 --> 00:40:12,552 military does a fairly good job in most 973 00:40:12,552 --> 00:40:14,719 aspects with health care , but the the 974 00:40:14,719 --> 00:40:16,997 stories that you tell are unacceptable . 975 00:40:16,997 --> 00:40:18,997 They can uh , they can never happen 976 00:40:18,997 --> 00:40:21,163 again if we can prevent this , we have 977 00:40:21,163 --> 00:40:23,274 to do everything we can to figure out 978 00:40:23,274 --> 00:40:25,052 how we stop this . I think that 979 00:40:25,052 --> 00:40:27,219 practicing military medicine is a very 980 00:40:27,219 --> 00:40:26,760 unique . It's it's unique environment 981 00:40:26,760 --> 00:40:28,871 to practice and having come from that 982 00:40:28,871 --> 00:40:31,093 from that particular environment . I'll 983 00:40:31,093 --> 00:40:33,038 tell you there's there's a balance 984 00:40:33,038 --> 00:40:35,260 between operational requirements and in 985 00:40:35,260 --> 00:40:35,220 the medical training and competency 986 00:40:35,220 --> 00:40:37,387 that required that's different than if 987 00:40:37,387 --> 00:40:39,498 you were just practicing medicine out 988 00:40:39,498 --> 00:40:39,220 in the civilian sector . There are 989 00:40:39,220 --> 00:40:41,390 other time constraints and and and 990 00:40:41,400 --> 00:40:44,000 other other requirements that you have 991 00:40:44,000 --> 00:40:46,167 to factor in your schedule , that that 992 00:40:46,167 --> 00:40:48,167 ultimately , and unfortunately take 993 00:40:48,167 --> 00:40:50,389 away from some of your ability to to to 994 00:40:50,389 --> 00:40:52,444 provide maybe the best care that you 995 00:40:52,444 --> 00:40:54,556 could for patients at times . I think 996 00:40:54,556 --> 00:40:56,722 also it's complicated by the fact that 997 00:40:56,722 --> 00:40:58,667 in the military and we all have to 998 00:40:58,667 --> 00:40:58,590 watch for this , and I know that the 999 00:40:58,600 --> 00:41:00,822 the flag and general officers here from 1000 00:41:00,822 --> 00:41:02,933 our medical community will will agree 1001 00:41:02,933 --> 00:41:05,044 with me on this , that it's difficult 1002 00:41:05,044 --> 00:41:07,100 in military medicine sometimes to to 1003 00:41:07,100 --> 00:41:06,780 always be thinking about worst case 1004 00:41:06,780 --> 00:41:08,780 scenario when you're really used to 1005 00:41:08,780 --> 00:41:11,002 taking care of a very young and healthy 1006 00:41:11,002 --> 00:41:13,100 population . Uh and and we don't see 1007 00:41:13,100 --> 00:41:15,322 the population of patients that you see 1008 00:41:15,322 --> 00:41:17,600 in the civilian sector with , you know , 1009 00:41:17,600 --> 00:41:19,711 with with the very young and the very 1010 00:41:19,711 --> 00:41:21,822 old and some of the really sick folks 1011 00:41:21,822 --> 00:41:23,989 and some of the horrible tragic things 1012 00:41:23,989 --> 00:41:23,890 that happened to you to you , Mr dale 1013 00:41:23,890 --> 00:41:25,870 Barbie Barbara and to your to your 1014 00:41:25,870 --> 00:41:27,759 daughter . Mr . Lucky , those are 1015 00:41:27,759 --> 00:41:29,814 things that are there , they're more 1016 00:41:29,814 --> 00:41:31,870 rare in the in the military practice 1017 00:41:31,870 --> 00:41:31,130 environment than they are in the 1018 00:41:31,130 --> 00:41:33,352 civilian practice . But that's on us to 1019 00:41:33,352 --> 00:41:35,519 figure out how to fix that . That's on 1020 00:41:35,519 --> 00:41:37,630 us to go out and make sure that we're 1021 00:41:37,630 --> 00:41:36,940 getting that training out in the 1022 00:41:36,940 --> 00:41:39,162 civilian sector and that we're exposing 1023 00:41:39,162 --> 00:41:41,218 ourselves to that type of stuff , so 1024 00:41:41,218 --> 00:41:43,384 that we don't uh that we don't put put 1025 00:41:43,384 --> 00:41:45,607 your family members and your loved ones 1026 00:41:45,607 --> 00:41:47,718 uh in in in a situation where they're 1027 00:41:47,718 --> 00:41:49,551 the victims of of you know , our 1028 00:41:49,551 --> 00:41:51,496 inability to to to recognize those 1029 00:41:51,496 --> 00:41:53,496 kinds of things . Uh And I will say 1030 00:41:53,496 --> 00:41:55,218 that there's a little bit of a 1031 00:41:55,218 --> 00:41:57,162 component on you know , this uh us 1032 00:41:57,162 --> 00:41:59,384 coming together with the three branches 1033 00:41:59,384 --> 00:42:01,329 of the military recently trying to 1034 00:42:01,329 --> 00:42:03,273 combine and in practice as one and 1035 00:42:03,273 --> 00:42:05,440 learn how to how to approach things as 1036 00:42:05,440 --> 00:42:07,218 as one organization , not three 1037 00:42:07,218 --> 00:42:09,440 separate organizations , the army , the 1038 00:42:09,440 --> 00:42:11,384 Navy and the Air Force . So mr mrs 1039 00:42:11,384 --> 00:42:13,607 salads , I was gonna ask you a question 1040 00:42:13,607 --> 00:42:15,773 In your experience , is there any what 1041 00:42:15,773 --> 00:42:17,496 part of the the issues we were 1042 00:42:17,496 --> 00:42:19,496 discussing earlier earlier with the 1043 00:42:19,496 --> 00:42:21,496 credentialing issues , the training 1044 00:42:21,496 --> 00:42:23,329 shortfalls , the lack of quality 1045 00:42:23,329 --> 00:42:25,551 assurance , things of that nature , how 1046 00:42:25,551 --> 00:42:27,718 much of that is related to our efforts 1047 00:42:27,718 --> 00:42:27,270 right now . I mean , we started this 1048 00:42:27,270 --> 00:42:30,190 effort back in 2012 I think to bring 1049 00:42:30,200 --> 00:42:32,256 military medicine under one umbrella 1050 00:42:32,400 --> 00:42:34,344 with the H . A . How much of it is 1051 00:42:34,344 --> 00:42:36,511 related to the fact that we still have 1052 00:42:36,511 --> 00:42:38,567 not got there where we got everybody 1053 00:42:38,567 --> 00:42:40,678 together under one umbrella . And how 1054 00:42:40,678 --> 00:42:40,530 much is is because we're dropping the 1055 00:42:40,530 --> 00:42:43,230 ball because we have , you know , we 1056 00:42:43,230 --> 00:42:45,286 don't have clear responsibilities in 1057 00:42:45,286 --> 00:42:47,840 certain areas . Thank you for the 1058 00:42:47,840 --> 00:42:49,729 question . I think it's very much 1059 00:42:49,729 --> 00:42:51,896 related . Um I think that , you know , 1060 00:42:51,896 --> 00:42:54,007 and again , these are all preliminary 1061 00:42:54,007 --> 00:42:56,062 observations from our ongoing work . 1062 00:42:56,062 --> 00:42:58,229 The sense that we get from this review 1063 00:42:58,229 --> 00:43:01,340 is that when the facilities are not 1064 00:43:01,350 --> 00:43:03,620 generally are not adhering to a lot of 1065 00:43:03,630 --> 00:43:05,760 the procedures for the you know 1066 00:43:05,760 --> 00:43:07,927 credential introversion and the safety 1067 00:43:07,927 --> 00:43:10,130 events and the focus of valuations . 1068 00:43:10,130 --> 00:43:13,030 The things that we looked at . Um the 1069 00:43:13,040 --> 00:43:15,860 procedures that were the policies and 1070 00:43:15,860 --> 00:43:18,070 procedures that were published . I 1071 00:43:18,070 --> 00:43:20,237 think there's a lack of clarity around 1072 00:43:20,237 --> 00:43:21,903 those procedures . Um There's 1073 00:43:21,903 --> 00:43:23,848 definitely the sense of moving and 1074 00:43:23,848 --> 00:43:26,014 trying to bring the different military 1075 00:43:26,014 --> 00:43:28,000 services under D . H . A . I think 1076 00:43:28,000 --> 00:43:30,056 there needs to be some clarification 1077 00:43:30,056 --> 00:43:32,222 around the procedures and the language 1078 00:43:32,222 --> 00:43:34,167 that's used in there . Some of the 1079 00:43:34,167 --> 00:43:36,333 facilities or interpreting some of the 1080 00:43:36,333 --> 00:43:38,333 language and the process procedures 1081 00:43:38,333 --> 00:43:40,222 differently . There was a lack of 1082 00:43:40,222 --> 00:43:42,389 awareness of some of The different new 1083 00:43:42,389 --> 00:43:44,500 procedures . I mean this is 2019 when 1084 00:43:44,500 --> 00:43:46,667 they were implemented . I think that a 1085 00:43:46,667 --> 00:43:49,000 lot of facilities are adjusting to that . 1086 00:43:49,000 --> 00:43:51,222 Um I also think at least at the D . H . 1087 00:43:51,222 --> 00:43:53,840 A . Level um they are really still 1088 00:43:53,840 --> 00:43:55,507 amping up their monitoring of 1089 00:43:55,507 --> 00:43:57,700 facilities adherence to um these 1090 00:43:57,700 --> 00:44:00,490 procedures they're trying to still ramp 1091 00:44:00,490 --> 00:44:02,920 up capacity . They are trying to 1092 00:44:02,920 --> 00:44:05,120 determine what information they need , 1093 00:44:05,120 --> 00:44:07,320 where that information is located and 1094 00:44:07,320 --> 00:44:10,010 then the tools they need to actually um 1095 00:44:10,010 --> 00:44:12,460 conduct the monitoring . Thank you . I 1096 00:44:12,460 --> 00:44:14,571 appreciate that . And I'll just close 1097 00:44:14,571 --> 00:44:16,793 by saying you know I I do think it is a 1098 00:44:16,793 --> 00:44:19,016 problem especially when you when you're 1099 00:44:19,016 --> 00:44:20,960 looking at our other providers are 1100 00:44:20,960 --> 00:44:22,793 medics are Corman , our physical 1101 00:44:22,793 --> 00:44:24,904 therapist , R . P . A . S . Things of 1102 00:44:24,904 --> 00:44:26,960 that nature with them taking care of 1103 00:44:26,960 --> 00:44:28,960 the mostly healthy young population 1104 00:44:28,960 --> 00:44:28,820 that we have right now . I know when I 1105 00:44:28,820 --> 00:44:30,764 was a physician in charge of those 1106 00:44:30,764 --> 00:44:32,653 types of folks , it was one of my 1107 00:44:32,653 --> 00:44:32,440 biggest fears that we're gonna miss 1108 00:44:32,440 --> 00:44:34,662 something like that because the mindset 1109 00:44:34,662 --> 00:44:36,718 wasn't out there looking for it . So 1110 00:44:36,718 --> 00:44:38,884 it's we cannot excuse what happened to 1111 00:44:38,884 --> 00:44:40,884 to to you and your families . We we 1112 00:44:40,884 --> 00:44:42,884 will try our best to to fix this to 1113 00:44:42,884 --> 00:44:44,940 make this right . And once again , I 1114 00:44:44,940 --> 00:44:44,660 really appreciate your time for being 1115 00:44:44,660 --> 00:44:46,827 here and telling your story . It makes 1116 00:44:46,827 --> 00:44:48,938 a really big difference with that . I 1117 00:44:48,938 --> 00:44:51,790 yield back man , there are still 146 1118 00:44:51,790 --> 00:44:54,140 members that haven't voted , would you 1119 00:44:54,140 --> 00:44:56,029 like to go forward ? MS escobar , 1120 00:44:56,170 --> 00:44:58,448 escobar is recognized for five minutes . 1121 00:44:58,448 --> 00:45:00,940 Thank you Madam Chair . Um I first want 1122 00:45:00,940 --> 00:45:03,750 to say to mr and mrs lucky how 1123 00:45:03,750 --> 00:45:06,550 incredibly sorry I am for your loss . I 1124 00:45:06,550 --> 00:45:09,610 cannot imagine what you all have had to 1125 00:45:09,610 --> 00:45:12,860 endure um to Mr Del Barba and his 1126 00:45:12,860 --> 00:45:16,020 family also so incredibly sorry for 1127 00:45:16,020 --> 00:45:19,420 what you've endured . Um and it has 1128 00:45:19,420 --> 00:45:21,930 taken . I know tremendous courage to be 1129 00:45:21,930 --> 00:45:24,330 here in front of us and to tell your 1130 00:45:24,330 --> 00:45:27,940 story and to hold us accountable and I 1131 00:45:27,940 --> 00:45:29,996 really appreciate that you are doing 1132 00:45:29,996 --> 00:45:31,940 that and that you are here to tell 1133 00:45:31,940 --> 00:45:34,162 Congress that we need to do something . 1134 00:45:34,162 --> 00:45:36,830 Um so we hear you loudly and clearly I 1135 00:45:36,830 --> 00:45:39,190 also want to recognize in the audience . 1136 00:45:39,190 --> 00:45:42,150 Meira Gideon , who is the sister of 1137 00:45:42,150 --> 00:45:44,094 Vanessa , the late Vanessa again , 1138 00:45:44,094 --> 00:45:46,206 thank you for being here , she's here 1139 00:45:46,206 --> 00:45:49,940 with Counsel . I have a question 1140 00:45:49,940 --> 00:45:53,490 for MS Silas just 1141 00:45:53,500 --> 00:45:57,300 listening to the litany of issues 1142 00:45:57,310 --> 00:46:00,890 and the lack of following procedure and 1143 00:46:00,890 --> 00:46:04,000 the the amount of time that it's taken 1144 00:46:04,010 --> 00:46:07,910 um to understand and digest and 1145 00:46:08,380 --> 00:46:11,540 and follow policies and processes . I 1146 00:46:11,550 --> 00:46:15,000 cannot wrap my head around why that is 1147 00:46:15,000 --> 00:46:18,620 so um and you're during this whole 1148 00:46:18,620 --> 00:46:20,620 process as you as you were taking a 1149 00:46:20,620 --> 00:46:24,000 look um at all of this , what do you 1150 00:46:24,000 --> 00:46:26,480 think is behind that ? Is it lack of 1151 00:46:26,480 --> 00:46:30,180 resources ? Is it a culture that 1152 00:46:30,190 --> 00:46:33,440 refuses to change ? Is it still too 1153 00:46:33,440 --> 00:46:36,100 much bureaucracy ? Um What what what 1154 00:46:36,100 --> 00:46:37,211 are your thoughts ? 1155 00:46:39,980 --> 00:46:42,720 I think that there's a couple of things 1156 00:46:42,720 --> 00:46:45,790 going on . Um One is this is a massive 1157 00:46:45,790 --> 00:46:48,230 transition that's happening . Um And 1158 00:46:48,230 --> 00:46:50,397 it's going to require not only kind of 1159 00:46:50,397 --> 00:46:53,280 putting the right procedures in place 1160 00:46:53,280 --> 00:46:55,570 and the tools that I mentioned , but 1161 00:46:55,570 --> 00:46:58,170 also it's gonna mean a change in 1162 00:46:58,170 --> 00:47:01,630 culture Um and in 2000 and it's been a 1163 00:47:01,630 --> 00:47:03,710 couple of years now and we have the 1164 00:47:03,710 --> 00:47:05,877 policies and we have the procedures in 1165 00:47:05,877 --> 00:47:08,180 place . There definitely needs to be a 1166 00:47:08,180 --> 00:47:11,740 look at those procedures to ensure that 1167 00:47:11,740 --> 00:47:13,962 there's some clarity around some of the 1168 00:47:13,962 --> 00:47:16,129 language that's in there . I think the 1169 00:47:16,129 --> 00:47:17,851 staff at the facility level is 1170 00:47:17,851 --> 00:47:20,260 definitely trying to adhere to these 1171 00:47:20,260 --> 00:47:23,280 procedures as well as they can , but 1172 00:47:23,280 --> 00:47:25,360 the procedures are not necessarily 1173 00:47:25,360 --> 00:47:27,471 written as clearly as they could be . 1174 00:47:27,471 --> 00:47:29,360 And so that's leading to a lot of 1175 00:47:29,360 --> 00:47:31,138 interpretation . And again as I 1176 00:47:31,138 --> 00:47:33,010 mentioned , D . H . A . Is still 1177 00:47:33,010 --> 00:47:35,610 continuing to ramp up their monitoring . 1178 00:47:35,620 --> 00:47:37,676 Um One of the things that I think we 1179 00:47:37,676 --> 00:47:40,260 found in our review is you know there's 1180 00:47:40,260 --> 00:47:42,960 a centralized data base 60 cause where 1181 00:47:42,970 --> 00:47:45,390 a lot of the information around 1182 00:47:45,390 --> 00:47:47,223 credentialing and privileging is 1183 00:47:47,223 --> 00:47:49,168 supposed to be entered but it also 1184 00:47:49,168 --> 00:47:51,390 doesn't contain a lot of information or 1185 00:47:51,390 --> 00:47:53,612 documentation that's needed for some of 1186 00:47:53,612 --> 00:47:55,779 the other processes or procedures that 1187 00:47:55,779 --> 00:47:58,150 are need to be monitored . So I think 1188 00:47:58,150 --> 00:48:00,372 there's just still a lot of work needed 1189 00:48:00,372 --> 00:48:02,710 to kind of lay the groundwork . Um In 1190 00:48:02,710 --> 00:48:04,766 terms of you know a centralized data 1191 00:48:04,766 --> 00:48:07,290 system where information is going to be 1192 00:48:07,300 --> 00:48:11,070 um um where you know information is 1193 00:48:11,070 --> 00:48:14,400 going to be put and that D . H . A . Um 1194 00:48:14,410 --> 00:48:16,521 in their monitoring understands where 1195 00:48:16,521 --> 00:48:19,010 that information is and then how to how 1196 00:48:19,010 --> 00:48:22,230 to use it . I appreciate that . It's 1197 00:48:22,240 --> 00:48:25,630 it's it's just mind boggling that it's 1198 00:48:25,640 --> 00:48:28,640 it's taken the federal government this 1199 00:48:28,640 --> 00:48:31,760 long really to to do right by the 1200 00:48:31,760 --> 00:48:35,150 people who are in our care ? Should be 1201 00:48:35,150 --> 00:48:38,130 in our care . Well a second question 1202 00:48:38,140 --> 00:48:40,890 about the current malpractice claims 1203 00:48:40,890 --> 00:48:43,670 process , how can we improve it to 1204 00:48:43,670 --> 00:48:45,670 better allow for accountability and 1205 00:48:45,670 --> 00:48:48,200 protections of victims of negligence ? 1206 00:48:49,970 --> 00:48:52,130 Well the scope of our current review 1207 00:48:52,130 --> 00:48:54,890 does not include um a review of milk 1208 00:48:55,270 --> 00:48:58,890 practice claims . Um We the new law 1209 00:48:58,890 --> 00:49:02,400 that's governing malpractice claims um 1210 00:49:02,410 --> 00:49:04,850 is relatively new and so there weren't 1211 00:49:04,860 --> 00:49:07,090 any cases at the time within the scope 1212 00:49:07,090 --> 00:49:09,390 of a time frame for our review um to 1213 00:49:09,390 --> 00:49:11,557 include them . So I can't really speak 1214 00:49:11,557 --> 00:49:13,279 directly to that . It would be 1215 00:49:13,279 --> 00:49:15,690 interesting to follow I think to make 1216 00:49:15,690 --> 00:49:18,660 sure that that we understand going 1217 00:49:18,660 --> 00:49:22,620 forward um Whether that is as efficient 1218 00:49:22,620 --> 00:49:25,710 a process as needs to be because key to 1219 00:49:25,710 --> 00:49:28,860 account that that is in my view uh 1220 00:49:28,870 --> 00:49:32,390 core function of accountability and 1221 00:49:32,400 --> 00:49:36,060 a way for families to try to achieve 1222 00:49:36,060 --> 00:49:38,360 some justice . Um With that amount of 1223 00:49:38,360 --> 00:49:41,500 time . Thank you all again , especially 1224 00:49:41,770 --> 00:49:43,980 um to the Del Barba family , to the 1225 00:49:43,980 --> 00:49:46,240 lucky family , really appreciate your 1226 00:49:46,240 --> 00:49:48,390 presence here today . Your your 1227 00:49:48,400 --> 00:49:51,220 testimony was really powerful madam 1228 00:49:51,220 --> 00:49:53,387 Chair . I yield back . The gentlewoman 1229 00:49:53,387 --> 00:49:55,930 yields back . Uh there are 99 persons 1230 00:49:55,930 --> 00:49:58,550 who have yet to vote . So 69 . Oh I 1231 00:49:58,550 --> 00:50:01,160 can't read . Alright . So Um we are 1232 00:50:01,160 --> 00:50:04,260 going to um stand in recess . It will 1233 00:50:04,260 --> 00:50:06,427 probably be a little more than like an 1234 00:50:06,427 --> 00:50:08,538 hour and 15 minutes because we have a 1235 00:50:08,538 --> 00:50:10,760 series of votes and then we will return 1236 00:50:10,760 --> 00:50:12,400 and continue the questioning . Thanks