Report Summary

Title: Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System
Report Number: 14-02603-178
Issue Date: 5/28/2014
City/State: Phoenix, AZ
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Audits and Evaluations
Report Type: Audits, Reviews & Evaluations
Release Type: Unrestricted
Summary: OIG provides an interim report of the ongoing review at the Phoenix Health Care System (HCS). The report identifies the allegations 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 the review is still underway, OIG has substantiated that significant delays in access to care negatively impacted the quality care at this medical facility.
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). 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.
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. Lastly, while conducting our work at the Phoenix HCS our on-site OIG staff and OIG Hotline receive 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. 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. Also, we recommend a review of 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. We recommend initiation of a nationwide review of veterans on wait lists to ensure that veterans are seen in an appropriate time, given their clinical condition. Finally, 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.