The Department of Veterans Affairs needs “tens of thousands” more personnel working in VA hospitals and clinics to meet patient demand, new VA Secretary Robert “Bob” McDonald told lawmakers Tuesday at a hearing of the Senate Veterans Affairs Committee.

The size of the staff shortage, McDonald said, explains why the VA has launched “a big recruiting effort” that he kicked off recently with visits to Duke University and University of Pennsylvania medical schools to tell students there why the “VA is where they want to work.”

Congress is pressing to clarify the VA’s staff shortage as the department struggles to recover from a patient wait-time scandal, demand for care grows because of a force drawdown, and the nation at large also copes with a shortage of health workers, particularly mental health care capacity.

McDonald got more specific than some senators expected, at one point estimating the VA staff shortage at 28,000 against current staffing of 300,000. McDonald attributed that figure to his deputy, Sloan Gibson, who was acting secretary after retired Army Gen. Eric Shinseki resigned in May.

When 28,000 elicited a “Wow” from Sen. Bernie Sanders (I-Vt.), committee chairman, McDonald added that it includes both “clinicians and other employees.”

Sen. Jon Tester (D-Mont.) later challenged the figure, telling McDonald the VA can’t hold a reliable number on its medical staff shortage before it completes an ongoing study of staff productivity and patient demand.

“How can you make a determination that you need 28,000 medical staff?” Tester asked. “I mean you’re a wonder-worker, probably, but in fact that information still hasn’t been hammered out.”

McDonald conceded the point.

“We are going through a process right now,” the secretary acknowledged, “where we are, location by location, specialty by specialty, [trying] to understand how many people we really need.”

Carolyn M. Clancy, a physician and interim under secretary for health at the VA, is leading that process. She told Tester it should be completed by year’s end and will show both the number of clinicians the VA needs and support staff “to make them as efficient and productive as possible.”

A VA spokesperson later said the 28,000 estimate is rough, and reflects both current staff vacancies as well as future need for more physicians, nurses, other care providers and administrative staff.

Tester asked what the VA would even do with more physicians given how tight office space is at VA clinics and hospitals.

“Where are you going to put these doctors,” he said, citing examining room shortages across VA including facilities in his home state.

“Obviously you’re right,” McDonald said.

The Veterans Access, Choice and Accountability Act of 2014 enacted last month allows the VA to open 27 more clinics. McDonald said he also favors leasing more space to deliver care “rather than building” facilities for a veteran population that tends to move over time.

McDonald listed the VA’s action since May and during his first five weeks as secretary to try to restore the confidence of veterans and nation in what has been a scandal-ridden health system. He praised the vast majority of employees dedicated to serving veterans and providing timely, quality care. He vowed that those who don’t put veterans first won’t be tolerated, and whistleblowers will be protected and even urged to expose wrongdoing.

Sanders held the hearing to review the final report of the VA inspector general on abusive scheduling practices uncovered at the VA hospital in Phoenix. Those practices to hide staff shortages affected patient care and led the IG to open investigations at 93 other VA care facilities. Sanders called the behavior uncovered “inexcusable,” particularly that so many executives and senior clinicians knew about manipulation of wait time data.

“The people who lied or manipulated data at Phoenix and elsewhere must be held accountable,” Sanders said.

Patient care suffered as a consequence, Acting VA Inspector General Richard J. Griffin testified. His office examined medical records and other information for 3,409 patients, which included 293 deaths. It identified 28 instances of “clinically significant delays in care” tied to access or scheduling. Of these, six patients died. The IG found another 17 cases of care deficiencies unrelated to scheduling or access. Of these, 14 died.

However, the IG could not “conclusively assert that the absence of timely quality care” caused any deaths at the Phoenix VA, Griffin testified.

That upset Sen. Dean Heller (R-Nev.) who said 77 patients on waiting lists across the VA since January 2012 committed suicide. Wouldn’t “a reasonable person” conclude wait-time manipulation contributed to some of those deaths?

Griffin said his staff is “not in the business of making odds on whether something did or didn’t cause a death, whether it’s likely or unlikely, 50 percent, 30 percent, 80 percent. That’s not our purpose.”

John D. Daigh, assistant IG for VA health care inspections, said investigating physicians looked at “fact patterns” of every death. But “if you are on a waiting list for audiology and you happen to die of a cardiac problem, the wait list factor was not very important.”

“I don’t want to give the VA a pass on this,” Heller said, “and I believe it’s what this line does. It exonerates the VA of any responsibility in past manipulation of these wait times.”

“I just have to disagree,” Daigh said. “I described 45 cases, 28 of which were negatively impacted because of delays. The only argument is I can’t say that those that died, died because of the delay.”

“We have already concluded there was poor quality of care,” Griffin explained for another senator. Whether malpractice occurred is for courts to decide or for VA to consider, he added, “which is why we provided them with the 45 names and said you need to look into these … ”

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