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.”

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.