VA OIG releases interim report on Phoenix facility

An ongoing review of the Department of Veterans Affairs Phoenix Health Care System by the department's Office of Inspector General has identified 1,700 veterans who were waiting for a primary care appointment but were not on the facility's waiting list, according to an interim report issued by the OIG.

The May 28 report said the OIG also identified about 1,400 vets who did not have primary care appointments, but who in fact were appropriately included on the waiting list

The OIG is investigating two primary questions concerning the center—first, whether the facility’s electronic wait list (EWL) purposely omitted the names of veterans waiting for care and, if so, who ordered the move; and second, whether the deaths of any veterans were related to delays in care.

"Allegations at the Phoenix HCS include gross mismanagement of VA resources and criminal misconduct by VA senior hospital leadership, creating systemic patient safety issues and possible wrongful deaths," the report stated. "While the review is still underway, OIG has substantiated that significant delays in access to care negatively impacted the quality care at this medical facility."

The report said that reviews so far "have identified multiple types of scheduling practices that are not in compliance with [Veterans Health Administration] policy."

"Since the multiple lists we found were something other than the official EWL," the report said. "these additional lists may be the basis for allegations of creating 'secret' wait lists."

The report highlighted the connection between VA waiting lists and managers' performance appraisals.

"A direct consequence of not appropriately placing veterans on EWLs is that the Phoenix HCS leadership significantly understated the time new patients waited for their primary care appointment in their FY 2013 performance appraisal accomplishments, which is one of the factors considered for awards and salary increases," the report stated.

To reveal discrepancies in reporting, the OIG examined a statistical sample of 226 vets who waited for appointments at the Phoenix HCS. While the Phoenix HCS reported that the 226 vets waited on average 24 days for their first primary care appointment and only 43 percent waited more than14 days, the OIG's review showed that those 226 vets actually waited on average 115 days for their first primary care appointment, with about 84 percent waiting more than 14 days.

"At this time," the OIG said, "we believe that most of the waiting time discrepancies occurred because of delays between the veteran’s requested appointment date and the date the appointment was created."

In terms of patient deaths, the OIG noted that because it is still investigating whether scheduling was at fault, it did not include information on that aspect of the review in the interim report.

"The assessments needed to draw any conclusions [on the deaths] require analysis of VA and non-VA medical records, death certificates, and autopsy results," the report stated. "We have made requests to appropriate state agencies and have issued subpoenas to obtain non-VA medical records. All of these records will require a detailed review by our clinical teams."

The Phoenix investigation has also sparked other allegations concerning the facility, the report noted—with on-site OIG staff and the OIG Hotline alike receiving "numerous allegations daily of mismanagement, inappropriate hiring decisions, sexual harassment, and bullying behavior by mid- and senior-level managers at this facility."

"We are assessing the validity of these complaints and if true, the impact to the facility’s senior leadership’s ability to make effective improvements to patients’ access to care," the report said.

Reader comments

Wed, Jun 25, 2014

Funny about the Phx VA - they kept calling my house to try and get my Dad to make an appt. with one of the new general practiciners at the VA...only problem is my Dad passed away almost six years ago. They have a long way to go.

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