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

In another instance, a man in his seventies was found to have an elevated prostate -specific antigen (PSA) and was referred by a PCP to a VA urology service. It was determined a second test was required so an appointment was made for three months later. That session was cancelled one week before it was slated to take place because “provider not available.”

The appointment was not rescheduled. The patient ultimately was seen by a non-VA urologist more than 11 months after the initial request. A biopsy revealed prostate cancer.

“This patient had a prolonged delay between the time his abnormal blood test was noted and a diagnosis was made,” the IG report said.

“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,” the report concluded. “Immediate and substantive changes are needed.”

If VA leadership is held accountable for implementing the needed reforms, the report held, the agency “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.”

In response, Veterans’ Affairs Secretary Robert McDonald, who assumed leadership after the problems became public, concurred with the IG’s recommendations and acknowledged that the department is “in the midst of a very serious crisis.”

“We sincerely apologize to all Veterans who experienced unacceptable delays in receiving care,” McDonald said. “We will continue to listen to veterans, our VA employees, and Veterans Service Organizations to improve access to quality care in Phoenix and across the country and we will work hard to rebuild trust with veterans and the American public.”

McDonald said some reform steps already have been taken to expand access to care, improve staffing for primary care and implement accountability measures. As of Aug. 15, the Veterans Health Administration has reached out to more than 266,000 veterans to get them off wait lists and into clinics.

“We’ve initiated development of a more robust process for continuously measuring patient satisfaction at each site and will expand our patient satisfaction survey capabilities in the coming year, to capture more veteran experience data through telephone, social media, and on-line means,” said Interim Under Secretary for Health Carolyn Clancy.

About 200,000 new VA appointments nationwide were scheduled between May 15 and June 15, according to the department, and nearly 912,000 total referrals to non-VA care providers have been made in the last two months – over 190,000 more referrals to non-VA care providers than the same period in 2013.

On Aug. 8, McDonald announced that every VA medical center will undergo an independent review of scheduling and access practices beginning this fall by the Joint Commission, the nation's oldest and largest standards-setting and accrediting body in health care. On Aug. 5 he directed all VA health care and benefits facilities to hold town-hall events by the end of September to improve communication with veterans nationwide.

The department also has updating an antiquated appointment scheduling system and directed medical center director to conduct regular in-person visits to all of their clinics, to include interacting with scheduling staff to ensure all scheduling practices are appropriate.