VA’s Inspector General has become an enduring presence among IGs

After seven years on the job, Michael Missal is one of the senior inspectors general. He joined Veterans Affairs as IG early in the second Obama administration. He joined the Federal Drive with Tom Temin  with a progress report.

Interview Transcript: 

Tom Temin I want to start with something very specific, and that is the Electronic Health Record project. This has been, let’s say, problematic for VA, and there’s really no end in sight from the standpoint of the IG, and I know you have people working on this specifically, but what do you think is the prognosis here?

Michael Missal Well, just as a little background, the electronic health records contract, as you point out, is one of the most significant contracts in VA history. It’s signed as a ten year, $16 billion contract, although recent estimates are going to be much higher. It’s going to have an incredible impact on the quality of health care. So as a result, we’ve been looking at this very proactively, not waiting for them to finish the implementation, but really at the front end. VA has gone live at five sites, five of the medical facilities, and we’ve already issued 14 reports on the implementation and we’ve identified a number of concerns. The implementation has been stalled, delayed. VA has said we’re not going to go forward until we can fix the problems that have been identified. We made a total of 68 recommendations. 23 are currently open and we’re currently working on four more reports that should be issued in the next few months. One of them involves the many outages and degradation of services at the five facilities. So we’ll have information on root cause and and more on what happened there.

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Tom Temin And there’s been a lot of discontinuities in people in this particular project. First of all, the primary contractor was acquired and then I guess Oracle scrambled some of its jets to try to salvage the thing because it was really badly off course. And then the leadership of the program within VA seems to be constantly revolving. Do you think that’s an issue?

Michael Missal That’s always an issue. You know, in all of our work, we look at leadership and any time there’s change in leadership or you don’t have stability of leadership, it typically leads to problems and more challenges in getting the job done.

Tom Temin I mean, do you get the sense that the problems drove out successive leaders of this project or was it the other way around that the leaders said, forget about this, I’m never going to win here and moved on.

Michael Missal I think everyone has its its own story. But the bottom line is stability of leadership is critically important for any project to succeed.

Tom Temin And that gets to the larger question. In seven years of looking at VA. I mean, what’s your overall sense? The external people to VA consider it a pretty well functioning organization in its ability to deliver health care to veterans at that 1 to 1 level. But yet at the administrative, financial level it’s a big bureaucracy and it has the problems of big, big bureaucracies.

Michael Missal Yes. VA is the second largest federal agency. It has over 440,000 employees. It’s got a budget of over $320 billion now. I mean, it’s just a huge, complex organization involved in such difficult tasks, such as providing quality and timely health care and then benefits to millions of veterans. So there’s always going to be issues, there’s always going to be ways to improve. And that’s what I consider one of our most important functions, which is to help VA improve the services and benefits that they provide to veterans and their families.

Tom Temin But I mean, the signals that you have gotten as VA and overseeing as IG and overseeing all of the I mean, you’ve got a thousand employees. Does the organization, it tries, doesn’t it?

Michael Missal Oh, yeah. Let’s talk about health care. You know, for the most part, VA provides quality health care in a timely basis. However, our oversight work and just for health care, we have over 250 health care professionals doing that oversight inspections. We found a number of deficiencies and two areas where I think it’s really critical for VA to improve. One is coordination of care. You know, we’re finding breakdowns in the coordination, which leads to quality of care issues. It’s also given that more veterans are getting care in the community, meaning non VA providers are providing services to veterans. And the PACT Act, which is one of the largest increases in enrollment or VA health care for those exposed to toxic exposures makes that coordination of care issue that much more challenging. Second one is suicide prevention. Suicide prevention is VA’s number one clinical priority. Tragically, at least 17 veterans a day die by suicide. And we have seen lapses in basic suicide prevention measures such as comprehensive suicide screening. So in all of these areas, we provide recommendations on how VA can improve. And they typically take our recommendations seriously. And I believe it does improve the health care for veterans.

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Tom Temin We’re speaking with Michael Missal. He is inspector general of the Veterans Affairs Department. And I’m recalling one interview we had a few years ago when you did an emergency report on dire conditions at the VA Medical Center in Washington, D.C. But then over the years, I mean, regularly, your staff does inspections of large VAMCs. I’m wondering in the aggregate, those inspections, what are the trends? What are the common elements or deficiencies that might cross the system? Because every particular center has its own particular localized issues.

Michael Missal Sure. And so we do a regular inspection of all the VA medical centers. There’s about 170 VA medical centers with clinics attached to them. So there’s about 1200 places where veterans can get health care services. So in about a three year cycle, we’re doing inspections of those facilities. And we really focus on five areas which we think are really key to quality health care. One is leadership. As I previously talked about, leadership is so critical to a well-running organization. Another is quality, safety and value making sure that VA is not only providing quality health care, but they have systems in place to ensure that is happening. Medical staff privileging, ensuring that the right people are getting privileges that they have the appropriate licenses. Environment of care. We literally walk around facilities checking to see for cleanliness and making sure that there are the appropriate facilities in terms of the care they’re providing. And then the last one, which I talked about already is suicide prevention. I can’t talk enough about how important this is and how we’re helping the VA improve the way they are providing suicide prevention services and health and mental health care services.

Tom Temin And how well do these medical centers and the medical staff, especially in the area of suicide prevention, coordinate and collaborate and get information from the Defense Department from which all veterans ultimately emanate?

Michael Missal That’s a challenge. In fact, just yesterday, we put out a report about opioid use and service members who had opioid use issues. And does it then carry does the care, then carry over to VA? And we found real gaps in that. The VA wasn’t aware of the services that were provided when they were in the military. And that of course, it’s again, coordination of care issue causes real issues. So I think there are ways that the transition from the military to VA can clearly be improved.

Tom Temin Because there would be some inconsistency there otherwise, because VA knows that everything it gets from a care standpoint is inherited from the military. Hearing loss, for example a common occurrence for people that regularly fire howitzers or something or shoulder mounted bazookas, this kind of thing, they have hearing loss. So you would expect maybe VA to be alert to that phenomenon across the possible health outcomes.

Michael Missal And that’s one of the theories behind the electronic health records transition, which is they want one health care records so that when a service member is in the military that their health records from the military then convert over to VA. Currently, that doesn’t occur. And so if this can be successful, there clearly would be benefits for veterans.

Tom Temin And just a detail question. You have recently completed a report about the VAMC in the Philippines. I didn’t know they had one over there. How does that compare to the stateside medical facilities?

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Michael Missal So we did an inspection. VA has one medical facility outside the U.S. that’s in Pasay City in the Philippines, which is outside Manila, and they serve about 7000 veterans who live in the Philippines. It’s an outpatient clinic. They do primary care, mental health services, and they do some specialty care. And so like all other VA facilities, we do a regular inspection. We just published our report on Pasay City a couple of weeks ago. We identified a couple of issues where they can improve, but for the most part, it’s a very well functioning facility.

Tom Temin And by the way, does the secretary ever get over there to check it out?

Michael Missal I don’t believe this secretary has been there, yet. But the previous secretary did visit the facility.

Tom Temin And in your years as inspector general, I’m counting, there’s probably been five VA secretaries.

Michael Missal There actually been seven people in my seven years who have either been the secretary or the acting secretary.

Tom Temin Okay. What’s your assessment and how do they relate to the IG’s office? Because that can be both cooperative and also maybe a little head butting.

Michael Missal There always is some tension there. It’s a natural tension because of the oversight work that we do. But I find that with all the people in that chair, they’ve recognized our independence and they’ve provided the support that is really necessary for us to do our job.

Tom Temin And let’s talk about the staffing of the VA’s Office of Inspector General itself. It’s a large staff. It’s bigger than some small agencies of a thousand people, roughly. What have been your human capital requirements and how are you able to keep it fully staffed?

Michael Missal We have such an important mission that we’re able to attract and retain really outstanding candidates. And in any organization, it’s all about your people. And we have an incredibly talented, experienced and dedicated staff. And so right now, when we put out a job opening, we put them out on USA Jobs. We get lots of applications and resumes. And as I said, we see a lot of really talented people that apply for jobs here.

Tom Temin Are you looking for a financial acumen? Sociology could be their medicine, knowledge. I mean, the range of knowledges that you would need in a specialized agency that also has gigantic finance, information technology and personnel challenges. It also does medicine, highly specialized. That seems like a like a wide range of things given person would need to know. So do you look for specialists?

Michael Missal Absolutely. So given, as you point out, VA is so large, so complex, there’s so much to to do. Oversight. We really are looking for people with a variety of education backgrounds, skill set. So just on health care alone, we have about 250 health care professionals in our health care inspection group. Each one has lots of initials after their name, some M.D. for the the kind of work they do. We also have criminal investigators. We also have performance auditors. We also have a number of lawyers doing special reviews and other areas of work. So, yes, everybody in our organization is really well qualified to do the job.

Tom Temin We’re speaking with Michael Missal. He is inspector general of the Veterans Affairs Department. One of the areas I’ve investigated a lot, so to speak, through a series of interviews, is the research a function at VA which is not as well known to the general public. It’s certainly very well known in medical circles outside of the VA. What’s your assessment of their efficiency and economy and and general output for the inputs that they get?

Michael Missal Well, VA;s research function has really brought a lot of great improvements and breakthroughs for health care across the country. You know, VA has a lot of different functions and one of them is its research function. And so we’ve looked at it on occasion and we found for the most part, they’re really providing great value. There’s always room for improvement and we’ve made the necessary recommendations and VA has improved as they’ve implemented those recommendations.

Tom Temin And we’ve been talking about Veterans Health Administration for most of the interview. But there’s also the Veterans Benefits Administration, which would be a big agency in and of itself, and they’ve had issues with backlogs. And then when they get through those some new law, like the PACT Act, dumps a whole brand new issuance of claims and so forth. And lots of people that had not had claims have them now in the millions. What’s your assessment of how VBA is navigating the last few years?

Michael Missal Well, they certainly have seen this issue coming, as you point out, the PACT Act which may be the largest expansion of VA benefits in the history of the agency. They prepared for it. They currently are doing a lot of things to ensure that the veterans are getting benefits in a timely basis, that the benefits are correct. We’ve increased our oversight work, been very proactive in looking at PACT Act and VBA has been great in terms of providing us information on what they’re doing and their plans. And I meet regularly with senior leadership from VBA to ensure we’re currently informed on the issues.

Tom Temin And how do you coordinate with the Government Accountability Office or do you coordinate? They get their orders from Congress and they look at VA regularly also. I’m always curious as to how the IG’s and the GAO people either butt heads or coordinate or say, well, we’re going to look at that, you don’t need to, etc..

Michael Missal So that’s that’s a great question because you’re right, the GAO and IGs have overlapping jurisdiction on many of the areas. I feel it’s critically important that we coordinate very closely with them because given that there’s so much oversight work that can be done, I want to make sure it’s as effective and impactful as possible. So I meet with Gene Dodaro the Comptroller General, the head of GAO, on a regular basis to talk about priorities and strategic issues, and our staffs meet on a very regular basis to talk about what they’re doing, what we’re doing to making sure we’re not doing the same issues. And then we work closely together to share information, which helps both of our oversight efforts.

Tom Temin And you’ve worked in a number of federal domains in your career private law, but also other areas of the government. And there’s this group called CIGIE, the Council on Inspectors General for Integrity and Efficiency. And that group has even had a few challenges because there have been some challenged IG’s. IG’s are like priests and rabbis. You know, not all of them are exactly examples of rectitude, but that’s because they’re human beings. What’s your sense of the strength of the CIGIE community at this point? Because it’s been through some tough times and been through some pretty good times.

Michael Missal I think CIGIE is a really important organization. There are 74 federal IG’s, about half are appointed by the president, the other half are appointed by agency heads. CIGIE helps share information, best practices coordinate. I’m involved with CIGIE in a lot of levels, including as the chair of the CIGIE Investigations Committee, which helps coordinate the law enforcement efforts. There’s about 3500 law enforcement officials at various IGs. And so we ensure that we’re all kept up to speed on current developments, training, etc..

Tom Temin And so you’re one of the law enforcement inspectors general.

Michael Missal There’s about 50 IGs that have the law enforcement authorities. And so I help lead that effort, although I’m involved in all the issues that CIGIE gets involved in.

Tom Temin Well, that just leads to a kind of a tail question here. And that is VA has a police force at its facilities. And have you looked at that one? Because I don’t think people realize that there’s dedicated Veterans Affairs police department. I think it’s called. Right?

Michael Missal Yeah. VA has one of the largest federal police forces out there that ensures that the many thousands of VA facilities are kept safe. So we’ve issued over the years a number of different reports about the effectiveness of the VA police. One of the issues that we’ve identified is the governance structure has pretty decentralized system. Like, for instance, the VA chief of police does not have authority over the various police departments at facility. So we’ve identified that as an issue for VA to look at to determine how best to organize their police operations.

Tom Temin And is that something that can be rectified at the secretary’s level or does that require some congressional intervention, do you think.

Michael Missal Though, that could be rectified within the VA and they are working through and have made improvements in the area. But I think there’s more to be done.

Tom Temin So for those that might get appointed to an IG post, not modified, but the inspector general post in the future, what’s your best advice for new IGs.

Michael Missal Or advice for new IGs is really get to know the agency that you’re conducting oversight of. Make sure you have good relations with the senior leadership. Even though we’re independent, they don’t tell us what to do. It’s really important to make sure you understand their priorities and strategies and then hire the very best people in the IG’s office. If you don’t have great staff, it’s really going to be difficult to do this really difficult job that we have.

Tom Temin And are all your people back at the office or are you one of these hybrid mode situations?

Michael Missal It really depends. Myself, my deputy, all the senior leaders are pretty much back every day. I’ve not teleworked one day. I’ve been in the office every day throughout and it really depends on the status of the individual. We do a lot of site work, so even if they’re not in the office, they may be at a VA facility.

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