|Title:||Review of Alleged Consult Management Issues at the Phoenix VA Health Care System|
|VA Office:||Veterans Health Administration (VHA)
|Report Author:||Office of Audits and Evaluations
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.