VA Investigation Reveals Poor Care, Fake Reports and 'Nationwide Systemic Problem'

WASHINGTON –A scathing report issued by the inspector general for the Department of Veterans Affairs confirmed that former military personnel faced persistent problems accessing care at the agency’s medical facilities and that staff faked reports indicating the appointments operation was running smoothly.

Acting Inspector General Richard J. Griffin couldn’t, however, substantiate earlier reports that 40 deaths or more could be attributed to poor VA care, noting that the whistleblower who made the allegation “did not provide us with a list of 40 patient names.”

Regardless, the patient experiences described in the report “revealed that access barriers adversely affected the quality of primary and specialty care” at the VA healthcare facility in Phoenix where the problems originally were detected. The inspector general was able to identify 40 patients who died while on the facility’s electronic waiting list from April 2013 through April 2014.

Griffin concluded that inappropriate scheduling practices at VA medicals facilities are “a nationwide systemic problem.”

“We identified multiple types of scheduling practices in use that did not comply with VHA’s (Veterans’ Health Administration’s) scheduling policy,” Griffin said. “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 department waived the requirement that facility directors certify compliance with the VHA scheduling directive, further reducing accountability over wait time data integrity and compliance with appropriate scheduling practices.

In Phoenix, the focus of whistleblower allegations, the report identified several patterns of obstacles to care that carried a negative impact on those awaiting treatment.

“Patients recently hospitalized, treated in the emergency department, attempting to establish care or seeking care while traveling or temporarily living in Phoenix often had difficulty obtaining appointments,” the report said.

As of April 22, 2014, the inspector general identified about 1,400 veterans waiting to receive a scheduled primary care appointment. But the investigation further discovered more than 3,500 additional veterans -- many of whom were on unofficial wait lists -- waiting to be scheduled.

“These veterans were at risk of never obtaining their requested or necessary appointments,” the report said. Senior administrative staff at the Phoenix facility were aware of unofficial wait lists and that access delays existed.

The report further found a “breakdown of the ethics system” that “contributed significantly to the questioning of the reliability of VHA’s reported wait time data.” Inappropriate scheduling practices, Griffin wrote, are “a systemic problem nationwide.”

The report included a series of case studies demonstrating some of the serious problems resulting from the lax treatment.

In one instance, a man in his early sixties with a history of severe heart muscle disease, hypertension, poorly controlled diabetes, hepatitis B and hepatitis C had an echocardiogram performed in late summer 2013 that showed depressed cardiac function, indicating severe heart failure and increased risk for abnormal heart rhythms and sudden death.

The man once had an implantable defibrillator placed in his heart but it had been removed. A Phoenix cardiologist recommended that he have a similar device implanted in four to five weeks. In early 2014, still without the procedure, the man collapsed in his kitchen and died three days later.

“The ICD should have been placed within a few months of the most current plan,” the report said. “This patient’s severe cardiac disease placed him at risk for sudden death at any time. ICD placement might have forestalled that death.”