Healthcare Inspection – Alleged Quality of Care Issues at the Community Based Outpatient Clinic, Casa Grande, AZ

OIG conducted an inspection in response to allegations received by Congresswoman Ann Kirkpatrick’s office concerning quality of care issues at the Community Based Outpatient Clinic (CBOC), Casa Grande, AZ. The CBOC is part of the Southern Arizona Health Care System, Tucson, AZ. We did not substantiate that 28 of 38 staff had resigned or transferred. We could not substantiate that a patient was placed “on hold” and was never able to reach a scheduler. We found that the call response time and call abandonment rate did not meet Veterans Health Administration goals. We could not substantiate that a patient suffered a heart attack, stroke, and pneumonia 3 days after trying to schedule an appointment. We did not substantiate the allegation that the patient was told she would have to wait 6 weeks for a post-hospitalization appointment in 2012. However, there were delays in assessment of the patient’s condition prior to two community hospital admissions and a delay in follow-up for the patient after one of the hospitalizations. We did not substantiate that a patient committed suicide because he was denied a mental health appointment. The patient had a scheduled appointment with a Tucson mental health provider prior to his death. According to his electronic health record, the patient canceled the appointment. We did not substantiate that patients were being “double booked” for appointments for the same provider or that a scheduler is “overriding the schedule” and overbooking evaluation appointments. We recommended that the Health Care System Director ensure that same day access appointments and post hospitalization follow-up appointments at the CBOC are triaged appropriately and timely and that processes are strengthened to improve telephone appointment scheduling practices. The Acting Veterans Integrated Service Network Director and System Director concurred with our findings and recommendations and provided acceptable improvement plans.