Article 57. Veterans Health Administration Interim Report 

Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System 

Comment by Lawrence Rosier
It is important to realize that even though the Office of Inspector General's report is professional and is focused at getting to the bottom of VA Problems, the OIG does not have the expertise for implementing reforms correcting the mass systemic problems of the VA.  See My Article 56. for how sweeping reform of the VA should be approached.

I have Included only the executive summary for the entire report go to: http://www.va.gov/oig/pubs/VAOIG-14-02603-178.pdf

EXECUTIVE SUMMARY

This interim report provides an overview of our ongoing review at the 
Phoenix Health Care System (HCS), identifies the allegations we have 
substantiated to date, and provides recommendations that VA should 
implement immediately. 
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. 
While our work is not complete, we have substantiated that significant 
delays in access to care negatively impacted the quality of care at this
medical facility. 

The issues identified in current allegations are not new. Since 2005, the 
VA Office of Inspector General (OIG) has issued 18 reports that identified, 
at both the national and local levels, deficiencies in scheduling resulting in 
lengthy waiting times and the negative impact on patient care. As required 
by the Inspector General Act of 1978, each of the reports listed was issued 
to the VA Secretary and the Congress and is publicly available on the VA 
OIG website. These reports are identified in Appendix D. 

We initiated this review in response to allegations first reported to the OIG Hotline
 and expanded it at the request of the VA Secretary and the Chairman of the House
Veterans’ Affairs Committee (HVAC) following an HVAC hearing on April 9, 2014, 
on delays in VA medical care and preventable veteran deaths. Since receiving those 
requests we have received other congressional requests including those submitted 
by the Chair and Ranking Members of the following Committees and Subcommittees: 
HVAC Ranking Member; HVAC Subcommittee on Oversight and Investigations; House Appropriations Committee; House Appropriations Subcommittee on Military 
Construction, Veterans Affairs, and Related Agencies; Senate Veterans’ Affairs 
Committee; Senate Appropriations Committee; and Senate Appropriations 
Subcommittee on Military Construction, Veterans Affairs, and Related Agencies. In addition,we received requests from Senators John McCain, Jeff Flake, Dianne 
Feinstein, Charles Grassley, Tom Udall, and Michael Bennet; and Representatives 
Kyrsten Sinema and Jack Kingston. We also have requests from a number of Texas 
House members specific to facilities in Texas. 

Due to the multitude and broad range of issues, we are conducting a comprehensive review

requiring an in-depth examination of many sources of information necessitating 
access to records and personnel, both within and external to VA.

We are using our combined expertise in audit, healthcare inspections, and criminal investigations, along with our institutional knowledge of VA programs and operations and legal authority to conduct a review of this nature and scope. 

A detailed assessment of the information obtained from Phoenix HCS’ medical 
records and its business practices requires a full understanding of VA’s current and
historical policies and procedures as well as the current practices, facts, and 
circumstances relating to these serious allegations. We have and will continue to 
conduct comprehensive interviews of numerous individuals to evaluate the many 
allegations, determine their validity, and if appropriate, assign individual accountability. Despite the number of allegations, each individual allegation is nothing more than an allegation.

We are charged with reviewing the merits of these allegations and determining whether sufficient, credible factual evidence exists to meet the standards

          


required by applicable laws and regulations to hold VA, or specific individuals 
accountable on the basis of criminal, civil, or administrative law and regulations.

In late April, the OIG assembled a multidisciplinary team comprised of board-
certified physicians, special agents, auditors, and healthcare inspectors from 
across the country to address numerous allegations at this and other VA medical 
facilities. Since the Phoenix HCS story broke in the national media, we have 
received allegations of similar issues regarding manipulated waiting times at other Veteran Health Administration (VHA) medical facilities through the OIG Hotline, from
 members of Congress, VA employees, veterans and their families, and the media. 
In response, we have opened reviews at other VHA medical facilities to determine 
whether scheduling practices are and/or were in use that did not comply with 
VHA’s scheduling policies and procedures. Clearly, there are national implications 
associated with inappropriate and non-compliant scheduling practices, including 
the impact on patient care and a lack of data integrity. Veterans who utilize the 
VA health care system deserve quality care in a timely manner. Therefore, it is 
necessary that information relied upon to make mission-critical management 
decisions regarding the demand for vital health care services must be based on 
reliable and complete data throughout VA’s health care networks. It is important 
to note that the information in this interim report is dynamic and changes may 
occur as our review progresses.  I have directed our teams to focus on two 
fundamental questions:

(1) Did the facility’s electronic wait list (EWL) purposely omit the names of 
veterans waiting for care and, if so, at whose direction?

(2) Were the deaths of any of these veterans related to delays in care?  To address the allegations received thus far and remain prepared to address new allegations at

medical facilities throughout VA, we are deploying Rapid Response Teams. We are 
not providing VA medical facilities advance notice of our visits to reduce the risk 
of destruction of evidence, manipulation of data, and coaching staff on how to 
respond to our interview questions. To date, we have ongoing or scheduled work 
at 42 VA medical facilities and have identified instances of manipulation of VA 
data that distort the legitimacy of reported waiting times.  When sufficient 
credible evidence is identified supporting a potential violation of criminal and/or 
civil law, we have contacted and are coordinating our efforts with the Department 
of Justice.  Our review at the Phoenix HCS includes the following actions:

Interviewing staff with direct knowledge of patient scheduling practices and policies,

including scheduling clerks, supervisors, patient care providers, management staff, 
and whistle blowers who have stepped forward to report allegations of wrongdoing.

Collecting and analyzing voluminous reports and documents from VHA 
information technology systems related to patient scheduling and enrollment.

Obtaining and reviewing VA and non-VA medical records of patients whose death

occurred while on a waiting list, or is alleged to be related to a delay in care.

Reviewing performance standards, ratings,and awards of senior facility staff.
Reviewing past and new complaints to the OIG Hotline on delays in care, as 
well as those complaints shared with us by members of Congress or reported by the media.

Reviewing other documents and reports relevant to these allegations, including
 administrative boards of investigations or reports of reviews conducted by 

VHA’s Office of the Medical Inspector.

Reviewing over 550,000 email messages and documents, extracted from over 50 
gigabytes of collected email. In addition, imaging and reviewing 10 encrypted 
computers and/or devices, and over 140,000 network files.  Our reviews at a growing number

of VA medical facilities have thus far provided insight into the current extent of 
these inappropriate scheduling issues throughout the VA health care system and have confirmed that inappropriate scheduling practices are systemic throughout 
VHA.  One challenge in these reviews is to determine whether these practices 
exist currently or were used in the past and subsequently corrected by VA 
managers.

To date, our work has substantiated serious conditions at the Phoenix HCS. 
We identified about 1,400 veterans who did not have a primary care 
appointment but were appropriately included on the Phoenix HCS’ EWLs. 
However, we identified an additional 1,700 veterans who were waiting for a 
primary care appointment but werenot on the EWL. Until that happens, the 
reported wait time for these veterans has not started. Most importantly, these 
veterans were and continue to be at risk of being forgotten or lost in Phoenix
HCS’s convoluted scheduling process. As a result, these veterans may never 
obtain a requested or required clinical appointment. 

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.  To review the new patient wait times for primary care in FY 2013, we 
reviewed a statistical sample of 226 Phoenix HCS appointments.  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. 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. At this time, 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. 
However, we found that in at least 25 percent of the 226 appointments reviewed, 
evidence, in veterans’ medical records, indicates that these veterans received some 
level of care in the Phoenix HCS, such as treatment in the emergency room, walk in 
clinics, or mental health clinics. 

Our reviews have identified multiple types of scheduling practices that are not in compliance with VHA policy. Since the multiple lists we found were something other than the official EWL,these additional lists may be the basis for allegations of creating “secret” wait lists. We are not reporting the results of our clinical reviews in this interim report on whether any delay in scheduling a primary care appointment resulted in a delay in diagnosis or treatment, particularly for those veterans who died while on a waiting list. The assessments needed to draw any conclusions require analysis of VA and non-VA medical records, death certificates, and autopsy results. 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. 

Lastly, while conducting our work at the Phoenix HCS our on-site OIG staff and OIG Hotline

received 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.

We will make recommendations in our final report and ask the VA Secretary to submit target

dates and implementation plans. However, to ensure all veterans receive appropriate care, we submit to the VA Secretary the following recommendations for his immediate implementation.

We will address the sufficiency of the VA Secretary’s action to implement the following

recommendations in our final report.

1. We recommend the VA Secretary take immediate action to review and provide appropriate

health care to the 1,700 veterans we identified as not being on any existing wait list.

2. We recommend the VA Secretary review all existing wait lists at the Phoenix Health Care

System to identify veterans who may be at greatest risk because of a delay in the delivery

of health care (for example, those veterans  who would be new patients to a specialty clinic)

and provide the appropriate medical care.

3. We recommend the VA Secretary initiate a nation wide review of veterans on wait lists to

ensure that veterans are seen in an appropriate time, given their clinical condition.

4. We recommend the VA Secretary direct the Health Eligibility Center to run a nationwide

New Enrollee Appointment Request report by facility of all newly enrolled veterans and

direct facility leadership to ensure all veterans have received appropriate care or are shown

on the facility’s electronic waiting list.  We will provide VA with the list of the 1,700 veterans we identified as not being on any wait list so that VA can mitigate any further access delays to health care services, and deliver higher quality of health care. 

RICHARD J. GRIFFIN

Acting Inspector General