[7.1] VA Progress Discussion Is the VA making the necessary progress in improving healthcare service delivery? What might be some of the barriers to change?250 words minimum wit references and citations.C-SPAN. (2015, Aug 6). Veterans Affairs Health Care and Budget (Links to an external site.)Links to an external site. [Video file]. Retrieved from http://www.c-span.org/video/?327514-1/politico-pla…C-SPAN. (2015, Oct 6). Veterans Health Legislation (Links to an external site.)Links to an external site. [Video file]. Retrieved from http://www.c-span.org/video/?328595-1/hearing-vete…C-SPAN. (2015, Sept 16). Pending Health Benefits Legislation (Links to an external site.)Links to an external site. [Video file]. Retrieved from http://www.c-span.org/video/?113558-1/pending-heal…
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VA Office of Inspector General
Veterans Health
Administration
Review of
Alleged Patient Deaths,
Patient Wait Times, and
Scheduling Practices at the
Phoenix VA Health Care System
August 26, 2014
14-02603-267
ACRONYMS
CBOC
CBT
COPD
CPRS
CSTAT
CT
DBT
ED
EHR
EWL
FY
GAO
HAS
HRC
HVAC
ICD
LPN
NEAR
OEF/OIF/OND
OIG
PCP
PDF
PET
PSA
PTSD
PVAHCS
RSA
SPC
VA
VAMC
VHA
VISN
VistA
VSSC
WIG
Community Based Outpatient Clinic
Cognitive Behavioral Therapy
Chronic Obstructive Pulmonary Disease
Computerized Patient Record System
Consultation Stabilization Triage Assessment Team
Computerized Tomography
Dialectical Behavioral Therapy
Emergency Department
Electronic Health Record
Electronic Wait List
Fiscal Year
Government Accountability Office
Health Administration Service
Health Resource Center
House Committee on Veterans’ Affairs
Implantable Cardioverter Defibrillator
Licensed Practical Nurse
New Enrollee Appointment Request
Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn
Office of Inspector General
Primary Care Provider
Portable Document Format
Positron Emission Tomography
Prostate-Specific Antigen
Post-Traumatic Stress Disorder
Phoenix VA Health Care System
Replacement Scheduling Application
Suicide Prevention Coordinator
Department of Veterans Affairs
Veterans Affairs Medical Center
Veterans Health Administration
Veterans Integrated Service Network
Veterans Health Information Systems and Technology Architecture
Veterans Health Administration Support Service Center
Wildly Important Goal
The VA OIG Hotline is the responsible office for complaints of fraud, waste,
abuse, and mismanagement within the Department of Veterans Affairs. Using the
VA OIG Web page, at www.va.gov/oig, will facilitate the processing of your input.
Federal regulations require that VA employees must report criminal matters
involving felonies to the OIG. Complainants are protected under the Inspector
General (IG) Act of 1978, which requires IGs to protect the identity of agency
employees who complain or provide other information to the IG. In addition, the
IG Act makes reprisal against an employee contacting the IG a prohibited
personnel practice.
————-To Report Suspected Wrongdoing in VA Programs and Operations:
Email: vaoighotline@va.gov
Telephone: 1-800-488-8244
(Hotline Information: www.va.gov/oig/hotline)
(This Page Left Intentionally Blank)
EXECUTIVE SUMMARY
The VA Office of Inspector General (OIG) reviewed allegations at the Phoenix VA Health Care
System (PVAHCS) that included gross mismanagement of VA resources, criminal misconduct
by VA senior hospital leadership, systemic patient safety issues, and possible wrongful deaths.
We initiated this review in response to allegations first reported to the VA OIG Hotline. We
expanded our work at the request of the former VA Secretary and the Chairman of the House
Committee on Veterans’ Affairs (HVAC) following an HVAC hearing on April 9, 2014, on
delays in VA medical care and preventable veteran deaths. Since receiving those requests, we
have received other Congressional requests including those submitted by the Chair and Ranking
Members of the following Committees and Subcommittees. A complete list of requestors is
located in Appendix J.

House Committee on Veterans’ Affairs

HVAC Subcommittee on Oversight and Investigations

House Appropriations Committee

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and Related
Agencies

Senate Committee on Veterans’ Affairs

Senate Appropriations Committee

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and
Related Agencies
On May 28, 2014, we published a preliminary report, Review of Patient Wait Times, Scheduling
Practices, and Alleged Patient Deaths at the Phoenix Health Care System – Interim Report, to
ensure all veterans received appropriate care and to provide VA leadership with
recommendations for immediate implementation. This report updates the information previously
provided in the Interim Report to reflect the final results of our review. We focused this report
on the following five questions and identified serious conditions at the PVAHCS and throughout
the Veterans Health Administration (VHA).

Were there clinically significant delays in care?

Did PVAHCS omit the names of veterans waiting for care from its Electronic Wait List
(EWL)?

Were PVAHCS personnel following established scheduling procedures?

Did the PVAHCS culture emphasize goals at the expense of patient care?

Are scheduling deficiencies systemic throughout VHA?
i
Due to the multitude and broad range of issues, we assembled a multidisciplinary team
comprising board-certified physicians, special agents, auditors, and health care inspectors to
evaluate the many allegations, determine their validity, and assign individual accountability if
appropriate. The team interviewed numerous individuals to include the principal complainants,
Dr. Samuel Foote, a retired PVAHCS physician, and Dr. Katherine Mitchell, the Medical
Director of the PVAHCS Operation Enduring Freedom/Operation Iraqi Freedom/and Operation
New Dawn (OEF/OIF/OND) clinic. In addition:

We obtained and reviewed VA and non-VA medical records of patients who died while on a
wait list or whose deaths were alleged to be related to delays in care.

We reviewed two statistical samples of completed primary care appointments to determine
the accuracy of patient wait times based on our assessment of the earliest indication a patient
desired care.

We reviewed over 1 million email messages, approximately 190,000 files from 11 encrypted
computers and/or devices, and over 80,000 converted messages from Veterans Health
Information Systems and Technology Architecture emails.
The patient experiences described in this report revealed that access barriers adversely affected
the quality of primary and specialty care at the PVAHCS. In February 2014, a whistleblower
alleged that 40 veterans died waiting for an appointment. We pursued this allegation, but the
whistleblower did not provide us with a list of 40 patient names. From our review of PVAHCS
electronic records, we were able to identify 40 patients who died while on the EWL during the
period April 2013 through April 2014. However, we conducted a broader review of
3,409 patients identified from multiple sources, including the EWL, various paper wait lists, the
OIG Hotline, the HVAC and other Congressional sources, and media reports.
OIG examined the electronic health records (EHRs) and other information for the 3,409 veteran
patients, including the 40 patients reflected above in PVAHCS’s records, and identified
28 instances of clinically significant delays in care associated with access to care or patient
scheduling. Of these 28 patients, 6 were deceased. In addition, we identified 17 care
deficiencies that were unrelated to access or scheduling. Of these 17 patients, 14 were deceased.
We also found problems with access to care for patients requiring Urology Services. As a result,
Urology Services at PVAHCS will be the subject of a subsequent report. The 45 cases discussed
in this report reflect unacceptable and troubling lapses in follow-up, coordination, quality, and
continuity of care.
During our review of EHRs, we considered the responsibilities and delivery of medical services
by primary care providers (PCPs) versus specialty care providers (such as urologists,
endocrinologists, and cardiologists). Our analysis found that the majority of the veteran patients
we reviewed were on official or unofficial wait lists and experienced delays accessing primary
care—in some cases, pressing clinical issues required specialty care, which some patients were
already receiving through VA or non-VA providers. For example, a patient may have been
seeing a VA cardiologist, but he was on the wait list to see a PCP at the time of his death. While
the case reviews in this report document poor quality of care, we are unable to conclusively
assert that the absence of timely quality care caused the deaths of these veterans.
ii
Supplementing data gathered from the EHR, we also analyzed information, when available, from
sources that included Medicare, non-VA health records, death certificates, media reports, and
interviews with VA staff. Approximately 23 percent of the patients we reviewed received
private sector medical care funded by Medicare or Medicaid, and 35 percent had insurance
coverage beyond VA.
We identified several patterns of obstacles to care that resulted in a negative impact on the
quality of care provided by PVAHCS. Patients recently hospitalized, treated in the emergency
department (ED), attempting to establish care, or seeking care while traveling or temporarily
living in Phoenix often had difficulty obtaining appointments. Furthermore, although we found
that PVAHCS had a process to provide access to a mental health assessment, triage, and
stabilization, we identified problems with continuity of mental health care and care transitions,
delays in assignment to a dedicated health care provider, and limited access to psychotherapy
services.
As of April 22, 2014, we identified about 1,400 veterans waiting to receive a scheduled primary
care appointment who were appropriately included on the PVAHCS EWL. However, as our
work progressed, we identified over 3,500 additional veterans, many of whom were on what we
determined to be unofficial wait lists, waiting to be scheduled for appointments but not on
PVAHCS’s official EWL. These veterans were at risk of never obtaining their requested or
necessary appointments. PVAHCS senior administrative and clinical leadership were aware of
unofficial wait lists and that access delays existed. Timely resolution of these access problems
had not been effectively addressed by PVAHCS senior administrative and clinical leadership.
From interviews of 79 PVAHCS employees involved in the scheduling process, we identified the
following types of scheduling practices not in compliance with VHA policy. Some schedulers
identified multiple inappropriate scheduling practices.

Thirty staff stated they used the wrong desired date of care, resulting in appointments
showing a false 0-day wait time.

Eleven staff stated they “fixed” or were instructed to “fix” appointments with wait times
greater than 14 days. They did this by rescheduling the appointment for the same date and
time but with a later desired date.

Twenty-eight staff stated they either printed out or received printouts of patient information
for scheduling purposes. Staff said they kept the printouts in their desks for days or
sometimes weeks before the veterans were scheduled an appointment or placed on the EWL.
PVAHCS executives and senior clinical staff were aware that their subordinate staff were using
inappropriate scheduling practices. In January 2012 and later in May 2013, the Veterans
Integrated Service Network 18 Director issued two reports that found PVAHCS did not comply
with VHA’s scheduling policy. Our review also determined PVAHCS still did not comply with
VHA’s scheduling policy. As a result of using inappropriate scheduling practices, reported wait
times were unreliable, and we could not obtain reasonable assurance that all veterans seeking
care received the care they needed.
iii
The emphasis by Ms. Sharon Helman, the Director of PVAHCS, on her “Wildly Important Goal”
(WIG) effort to improve access to primary care resulted in a misleading portrayal of veterans’
access to patient care. Despite her claimed improvements in access measures during fiscal year
(FY) 2013, we found her accomplishments related to primary care wait times and the third-next
available appointment were inaccurate or unsupported. After we published our Interim Report,
the Acting VA Secretary removed the 14-day scheduling goal from employee performance
contracts.
Inappropriate scheduling practices are a nationwide systemic problem. We identified multiple
types of scheduling practices in use that did not comply with VHA’s scheduling policy. These
practices became systemic because VHA did not hold senior headquarters and facility leadership
responsible and accountable for implementing action plans that addressed compliance with
scheduling procedures. In May 2013, the then-Deputy Under Secretary for Health for
Operations Management waived the FY 2013 annual requirement for facility directors to certify
compliance with the VHA scheduling directive, further reducing accountability over wait time
data integrity and compliance with appropriate scheduling practices. Additionally, the
breakdown of the ethics system within VHA contributed significantly to the questioning of the
reliability of VHA’s reported wait time data. VHA’s audit, directed by the former VA Secretary
in May 2014 following numerous allegations, also found that inappropriate scheduling practices
were a systemic problem nationwide.
Since the PVAHCS story first appeared in the national media, we received approximately
225 allegations regarding PVAHCS and approximately 445 allegations regarding manipulated
wait times at other VA medical facilities through the OIG Hotline, from Members of Congress,
VA employees, veterans and their families, and the media. The VA OIG Office of Investigations
opened investigations at 93 sites of care in response to allegations of wait time manipulations. In
particular, we focused on whether management ordered schedulers to falsify wait times and
EWL records or attempted to obstruct OIG or other investigative efforts. Investigations
continue, in coordination with the Department of Justice and the Federal Bureau of Investigation.
While most are still ongoing, these investigations confirmed wait time manipulations were
prevalent throughout VHA. As of August 2014, among the variations of wait time
manipulations, our ongoing investigations at the 93 sites have, thus far, found many medical
facilities were:

Using the next available date as the desired date to “0-out” appointment wait times.

Canceling appointments and rescheduling appointments to make wait times appear to be less
than they actually were. We substantiated that management at one facility directed
schedulers to do this.

Using paper wait lists rather than official EWLs.

Canceling consultations (consults) without appropriate clinical review.

Altering clinic utilization rates to make it appear the clinic was meeting utilization goals.
Wherever we confirm potential criminal violations, we will present our findings to the
appropriate Federal prosecutor. If prosecution is declined, we will provide documented results
of our investigation to VA for appropriate administrative action. We will do the same if our
iv
investigations substantiate manipulation of wait times but do not find evidence of any possible
criminal intent. Finally, we have also kept the U.S. Office of Special Counsel apprised of our
active criminal investigations as they relate to the U.S. Office of Special Counsel’s numerous
referrals to VA of whistleblower disclosures of allegations relating to wait times and scheduling
issues.
This report cannot capture the personal disappointment, frustration, and loss of faith of
individual veterans and their family members with a health care system that often could not
respond to their mental and physical health needs in a timely manner. Immediate and substantive
changes are needed. If headquarters and facility leadership are held accountable for fully
implementing VA’s action plans for this report’s 24 recommendations, VA can begin to regain
the trust of veterans and the American public. Employee commitment and morale can be rebuilt,
and most importantly, VA can move forward to provide accelerated, timely access to the
high-quality health care veterans have earned—when and where they need it.
The VA Secretary concurred with all 24 recommendations and submitted acceptable corrective
action plans. We will establish a rigorous follow up to ensure full implementation of all
corrective actions. The VA Secretary acknowledged that VA is in the midst of a very serious
crisis and will use the OIG’s recommendations to hone the focus of VA’s actions moving
forward. The VA Secretary also apologized to all veterans and stated VA will continue to listen
to veterans, their families, Veterans Service Organizations, and VA employees to improve access
to the care and benefits veterans earned and deserve.
RICHARD J. GRIFFIN
Acting Inspector General
v
TABLE OF CONTENTS
Executive Summary ………………………………………………………………………………………………………. i-v
Results and Recommendations …………………………………………………………………………………………..1
Question 1
Were There Clinically Significant Delays in Care? ……………………………………..1
Recommendations …………………………………………………………………………………33
Question 2
Did PVAHCS Omit the Names of Veterans Waiting for Care From Its
Electronic Wait List? …………………………………………………………………………….34
Recommendations …………………………………………………………………………………47
Question 3
Were PVAHCS Personnel Following Established Scheduling
Procedures? ………………………………………………………………………………………….49
Recommendations …………………………………………………………………………………53
Question 4
Did the PVAHCS Culture Emphasize Goals at the Expense of Patient
Care? …………………………………………………………………………………………………..55
Recommendations …………………………………………………………………………………63
Question 5
Are Scheduling Deficiencies Systemic Throughout VHA?…………………………65
Recommendations …………………………………………………………………………………74
Appendix A
Background ………………………………………………………………………………………….76
Appendix B
Scope and Methodology…………………………………………………………………………79
Appendix C
Statistical Sampling Methodology …………………………………………………………..84
Appendix D
Phoenix Outreach Campaign, Health Resource Center……………………………….86
Appendix E
Chronology of OIG Oversight of Patient Wait Times ………………………………..90
Appendix F
OIG Oversight Reports on VA Patient Wait Times ……………………………………94
Appendix G
VHA Directive 2010-027: VHA Outpatient Scheduling Processes and
Procedures, June 9, 2010………………………………………………………………………..96
Appendix H
Memorandum From the Deputy Under Secretary for Health for
Operations and Management, April 26, 2010, Titled: Inappropriate
Scheduling Practices…………………………………………………………………………….107
Appendix I
OIG Testimony on VA Patient Wait Times …………………………………………….114
Appendix J
Congressional Requests………………………………………………………………………..117
Appendix K
VA Secretary Comments………………………………………………………………………119
Appendix L
Office of Inspector General Contact ………………………………………………………132
Appendix M
Report Distribution………………………………………………………………………………133
Review of …
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