An internal VA investigation shows the massive scope of the failure at the agency’s Phoenix facility, where veterans were placed on secret waiting lists, increasing the “risk of being forgotten or lost.”
“Allegations at the Phoenix [Health Care System] include gross mismanagement of VA resources and criminal misconduct by VA senior hospital leadership, creating systemic patient safety issues and possible wrongful deaths,” reads an interim report, published by the VA’s office of the inspector general on Wednesday.
The scandal gripping the Phoenix VA began with a CNN report that discovered that some veterans were being placed on hidden electronic waiting lists, despite VA policy which requires new patients to receive care within 14 days of their first contact.
“We have substantiated that significant delays in access to care negatively impacted the quality of care at this medical facility,” reads the report.
About 1,400 veterans were properly included on electronic waiting lists — or EWLs — at the Phoenix facility.
“However, we identified an additional 1,700 veterans who were waiting for a primary care appointment but were not on the EWL,” the report says.
In their analysis, the inspector general’s office reviewed a statistical sample of 226 new patient cases for veterans receiving primary care at the Phoenix facility in fiscal year 2013.
“VA national data, which was reported by Phoenix HCS, showed these 226 veterans waited on average 24 days for their first primary care appointment and only 43 percent waited more than 14 days,” the notes the report.
“However, our review showed these 226 veterans waited on average 115 days for their first primary care appointment with approximately 84 percent waiting more than 14 days.”
Until veterans are placed on the EWLs, the reported waiting times for patients does not begin.
And while consequences of delaying the process are potentially dire for veterans, hospital administrators have an incentive to do so, the report states.
“Most importantly, these veterans were and continue to be at risk of being forgotten or lost in Phoenix HCS’s convoluted scheduling process,” says the report, adding that “as a result, these veterans may never obtain a requested or required clinical appointment.”
A “direct consequence” of keeping veterans off of the waiting lists was that the Phoenix hospital’s leadership “significantly understated the time new patients waited for their primary care appointment in their FY 2013 performance appraisal accomplishments.”
That metric “is one of the factors considered for awards and salary increases,” the report says.
The allegations are not new, according to the report. Since 2005, the VA inspector general has issued 18 reports that identified scheduling deficiencies and lengthy wait times at both local and national facilities.
The report also states that investigations are ongoing or scheduled in 42 VA medical facilities where “identified instances of manipulation of VA data that distort the legitimacy of reported waiting times.”
The hospitals are not being informed of planned investigations in order to “reduce the risk of destruction of evidence, manipulation of data, and coaching staff on how to respond to our interview questions.”
The has led many lawmakers and veteran’s groups to call for VA Secretary Eric Shinseki to resign. Efforts to allow VA top brass to discipline senior executives within the agency have been blocked by Senate Democrats.