The Naval Postgraduate School & The U.S. Department of Homeland Security

Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System: A Review

Department of Veterans Affairs On August 26, 2014, the Office of the Inspector General (OIG) of the U.S. Department of Veterans Affairs (VA) released a Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System report. This particular report is a follow-up to the May 28, 2014, Interim Report regarding veteran care and VA leadership practices, concerns that were previously raised due to gross misconduct allegations reported to the VA OIG Hotline. The purpose of the revised report is to provide updates to, "…the information previously provided in the Interim Report to reflect the final results…" of the review.

The report focuses on the following five questions of concern that subsequently, "…identified serious conditions at the PVAHCS [Phoenix VA Health Care System] and throughout the Veterans Health Administration (VHA)":

  • Were there clinically significant delays in care?
  • Did PVAHCS omit the names of veterans waiting for care from its Electronic Wait List (EWL)?
  • Did PVAHCS omit the names of veterans waiting for care from its Electronic Wait List (EWL)?
  • Did the PVAHCS culture emphasize goals at the expense of patient care?
  • Are scheduling deficiencies systemic throughout VHA?

To answer the aforementioned questions, a team of multidisciplinary investigators reviewed multiple sources of information to determine both administrative wrongdoing and negligent patient care. These sources include the medical records of those patients who died on wait lists, statistical samples of patient wait times, and 1 million email messages from Veterans Health Information Systems and Technology Architecture emails.

As a result of this review, multiple red flags of neglectful patient care emerged. In regards to scheduling delays, the OIG uncovered non-VHA policy compliant scheduling practices and, "…identified 28 instances of clinically significant delays in care associated with access to care or patient scheduling. Of these 28 patients, 6 were deceased." Wait list results fared no better, as investigators discovered, "…1,400 veterans waiting to receive a scheduled primary care appointment who were appropriately included on the PVAHCS EWL," and, "…3,500 additional veterans, many of whom were on what we determined to be unofficial wait lists, waiting to be scheduled for appointments but not on PVAHCS’s official EWL." Patient care deficiencies unrelated to scheduling and wait list issues were also identified as a result of this review. Electronic health records examined by the OIG, "…identified 17 care deficiencies that were unrelated to access or scheduling. Of these 17 patients, 14 were deceased."

This report concludes with 24 recommendations aimed at, "…regain[ing] the trust of veterans and the American public," to solve the crisis. On the same day this report was released, President Obama addressed the VA crisis in front of The American Legion, the largest veteran service organization in the United States. Highlights of this supplemental resource to the OIG report can be found on The White House Blog webpage under the title Our Moral Obligation: President Obama Speaks to the Nation's Largest Veteran Service Organization.