The Department of Veterans Affairs (VA) Office of Inspector General (OIG) initiated this review of alleged consult management issues at the Phoenix VA Health Care System (PVAHCS) in response to allegations reported to the OIG by the House Committee on Veterans’ Affairs in July 2015. These allegations, communicated by a confidential complainant, were received about one year after the OIG published a report confirming allegations of patient care delays, wait times, and problematic scheduling practices at PVAHCS. We reviewed these more recent allegations that PVAHCS staff inappropriately discontinued and canceled consults, management provided staff inappropriate direction, patients died waiting for consultative appointments, more than 35,000 patients were waiting for consults, and other allegations received during our review, to assess the adequacy of managing patient consults at PVAHCS. We substantiated that in 2015, PVAHCS staff inappropriately discontinued consults. We determined that staff inappropriately discontinued 74 of the 309 specialty care consults (24 percent) we reviewed. This occurred because staff were generally unclear about specific consult management procedures, and services varied in their procedures and consult management responsibilities. As a result, patients did not receive the requested care or they encountered delays in care. Of the 74 inappropriately discontinued consults, 53 patients never received the requested care at PVAHCS. We did not substantiate that the Acting Chief of Health Administration Service (HAS) instructed administrative staff to discontinue inappropriately the consults of patients before a provider reviewed the consult. We also did not substantiate that PVAHCS management removed a scheduler from Vascular Service because the scheduler identified and reported problems. We did not substantiate that a paper list of patients waiting for chiropractic care, reported to us by the complainant and PVAHCS leadership, was an unofficial wait list. However, we also determined that the PVAHCS Chiropractic Service had inappropriately canceled consults. Canceled consults resulted in patients not receiving a scheduled appointment and, therefore, not receiving the requested chiropractic care. Within the 30 canceled consults we reviewed, 28 patients had not received the requested chiropractic care at PVAHCS.
The OIG’s Office of Healthcare Inspections (OHI) reviewed a total of 294 facility consults for 215 individual patients who had open consult requests at the time of their deaths, or had consults discontinued after the date of their deaths. In addition, OHI reviewed nine deceased patients’ records with nine discontinued consults from a list of discontinued vascular consults provided by the complainant. Of the 215 individual patients’ records reviewed, OHI determined that untimely care from PVAHCS may have contributed to the death of 1 patient. OHI also determined that the records reviewed of the remaining patients indicated the patient had not died because they did not receive the requested consult in a timely fashion before they died. We did not substantiate that the facility was having non clinical staff discontinue consults for vascular patients to hide the fact that a patient died while waiting for care. In regard to the consults reviewed of patients who died while they had open consults, we found that PVAHCS closed these consults because VHA and PVAHCS business rules and policy both required that a consult be discontinued if the patient is deceased. However, facility staff did not consistently comply with this policy and some consults remained open long after patients’ deaths.
We determined that, as of August 12, 2015, more than 22,000 individual patients had 34,769 open consults at PVAHCS. The total open consults included all categories, statuses, and ages of consults. Of all the open consults at that time, about 4,800 patients had nearly 5,500 consults for appointments within PVAHCS that exceeded 30 days from their clinically indicated appointment date. In addition, more than 10,000 patients had nearly 12,000 community care consults exceeding 30 days. Consults for care in the community included traditional non VA care and Choice. The remaining approximately 17,000 open consults were for prosthetics, administrative purposes, and/or did not exceed 30 days. VHA does not require staff to complete prosthetics consults immediately. We substantiated that one patient waited in excess of 300 days for vascular care. A patient received vascular care in October 2015 following a consult request from a clinician in Vascular Surgery in June 2013. As of August 12, 2015, we identified 13 open consults of patients waiting for Vascular Lab more than 30 days beyond the clinically indicated date of the provider, ranging from 32 to 157 days. We also found that the PVAHCS Vascular Service staff did not properly link clinicians’ notes for the completed appointments to the corresponding consults, which meant consults remained open even though the patient received the care. During the past two years, the OIG has reviewed a myriad of allegations at PVAHCS and issued six reports involving policy, access to care, scheduling and canceling of appointments, staffing, and consult management. Although VHA has made efforts to improve the care provided at PVAHCS, these issues remain. This report contains 14 recommendations. The Under Secretary for Health concurred with the recommendation to update VHA’s consult policy, and VHA published a new directive on August 23, 2016. The VISN 22 Director also concurred with the remaining recommendations to improve consult management at PVAHCS and submitted acceptable corrective action plans.
