VA Inspector General Finds 1,700 Veterans “Forgotten or Lost” Within Healthcare System

Department of Veterans Affairs Seal The Office of the Inspector General (OIG) of the U.S. Department of Veterans Affairs (VA) released today an Interim report that investigates allegations of “gross mismanagement…and criminal misconduct” by VA officials at the Phoenix Health Care System (PHCS). Allegations reported to the OIG Hotline indicated that the mismanagement and misconduct of VA officials “[created] systemic patient safety issues and possible wrongful deaths.” This report provides an overview of the allegations OIG was able to substantiate to date and provides recommendations to the VA for immediate implementation.

The investigation specifically focused on the wait list process and wait times for patients within the PHCS. The two main questions that drove this report are the following: “Did the [PHCS] Electronic Wait List (EWL) purposely omit the names of veterans waiting for care and, if so, at whose direction?” and “Are VHA [Veterans Health Administration] personnel following established scheduling procedures to ensure waiting times are calculated accurately?”

At this time, the OIG is able to confirm that “inappropriate scheduling practices are systemic throughout VHA.” The investigation found that around 1,400 veterans included on the PHCS EWL did not have an appointment, while about 1,700 veterans waiting for an appointment were not scheduled on the EWL. According to the OIG, the veterans in the latter group “were and continue to be at risk of being forgotten or lost in PHCS’s convoluted scheduling process.” Not only does this mismanagement cause incorrect wait time estimates for those on the list, but it can also lead to wrongful death for veterans who became “forgotten or lost” within the EWL.  

To immediately address these scheduling issues, the OIG provides four main recommendations to the VA. These recommendations include providing healthcare to the 1,700 veterans not on any waiting list, identifying the veterans in the PHCS at the greatest risk of a delay in the delivery of healthcare, initiating a nationwide review of veterans on wait lists, and directing the Health Eligibility Center to run a nationwide New Enrollee Appointment Request report to ensure that all veterans receive appropriate care or appear on the facility’s EWL. The OIG anticipates making further recommendations in its final report.

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