VA Office of Inspector General

Veterans Health 

Administration
 

- Interim Report -

Review of 

Patient Wait Times, 

Scheduling Practices, 

and Alleged Patient 

Deaths at the Phoenix 

Health Care System 

May 28, 2014 

14-02603-178 
-------------- 

ACRONYMS AND ABBREVIATIONS 

CBOC Community Based Outpatient Clinic 

EWL Electronic Wait List 

FY Fiscal Year 

GAO Government Accountability Office 

HAS Health Administration Service 

HCS Health Care System 

HVAC House Veterans’ Affairs Committee 

NEAR New Enrollee Appointment Request 

OIG Office of Inspector General 

PCMM Primary Care Management Module 

PDF Portable Document Format 

VA Veterans Affairs 

VHA Veterans Health Administration 

VistA Veterans Health Information Systems and Technology Architecture 

The VA OIG Hotline is the responsible office for complaints of fraud, waste, 

abuse, and mismanagement within the Department of Veterans Affairs. Using the 

VA OIG webpage, at www.va.gov/oig, will facilitate the processing of your input. 

Federal regulations require that VA employees must report criminal matters 

involving felonies to the OIG. Complainants are protected under the Inspector 

General (IG) Act of 1978, which requires IGs to protect the identity of agency 

employees, who complain or provide other information to the IG. In addition, the 

IG Act makes reprisal against an employee contacting the IG a prohibited 

personnel practice. 

To Report Suspected Wrongdoing in VA Programs and Operations: 

Email: vaoighotline@va.gov
 

Telephone: 1-800-488-8244 

(Hotline Information: www.va.gov/oig/hotline) 
EXECUTIVE SUMMARY 

This interim report provides an overview of our ongoing review at the Phoenix Health Care 

System (HCS), identifies the allegations we have 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 our work 

is not complete, we have substantiated that significant delays in access to care negatively 

impacted the quality of care at this medical facility. 

The issues identified in current allegations are not new. Since 2005, the VA Office of Inspector 

General (OIG) has issued 18 reports that identified, at both the national and local levels, 

deficiencies in scheduling resulting in lengthy waiting times and the negative impact on patient 

care. As required by the Inspector General Act of 1978, each of the reports listed was issued to 

the VA Secretary and the Congress and is publicly available on the VA OIG website. These 

reports are identified in Appendix D. 

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) following an HVAC hearing on April 9, 2014, on delays in VA medical 

care and preventable veteran deaths. Since receiving those requests we have received other 

congressional requests including those submitted by the Chair and Ranking Members of the 

following Committees and Subcommittees: HVAC Ranking Member; HVAC Subcommittee on 

Oversight and Investigations; House Appropriations Committee; House Appropriations 

Subcommittee on Military Construction, Veterans Affairs, and Related Agencies; Senate 

Veterans’ Affairs Committee; Senate Appropriations Committee; and Senate Appropriations 

Subcommittee on Military Construction, Veterans Affairs, and Related Agencies. In addition, 

we received requests from Senators John McCain, Jeff Flake, Dianne Feinstein, Charles 

Grassley, Tom Udall, and Michael Bennet; and Representatives Kyrsten Sinema and Jack 

Kingston. We also have requests from a number of Texas House members specific to facilities 

in Texas. 

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. 

A detailed assessment of the information obtained from Phoenix HCS’ medical records and its 

business practices requires a full understanding of VA’s current and historical policies and 

procedures as well as the current practices, facts, and circumstances relating to these serious 

allegations. We have and will continue to conduct comprehensive interviews of numerous 

individuals to evaluate the many allegations, determine their validity, and if appropriate, assign 

individual accountability. Despite the number of allegations, each individual allegation is 

i 
 

nothing more than an allegation. We are charged with reviewing the merits of these allegations 

and determining whether sufficient, credible factual evidence exists to meet the standards 

required by applicable laws and regulations to hold VA, or specific individuals accountable on 

the basis of criminal, civil, or administrative law and regulations. 

In late April, the OIG assembled a multidisciplinary team comprised of board-certified 

physicians, special agents, auditors, and healthcare inspectors from across the country to address 

numerous allegations at this and other VA medical facilities. Since the Phoenix HCS story broke 

in the national media, we have received allegations of similar issues regarding manipulated 

waiting times at other Veteran Health Administration (VHA) medical facilities through the OIG 

Hotline, from members of Congress, VA employees, veterans and their families, and the media. 

In response, we have opened reviews at other VHA medical facilities to determine whether 

scheduling practices are and/or were in use that did not comply with VHA’s scheduling policies 

and procedures. Clearly, there are national implications associated with inappropriate and 

non-compliant scheduling practices, including the impact on patient care and a lack of data 

integrity. Veterans who utilize the VA health care system deserve quality care in a timely 

manner. Therefore, it is necessary that information relied upon to make mission-critical 

management decisions regarding the demand for vital health care services must be based on 

reliable and complete data throughout VA’s health care networks. It is important to note that the 

information in this interim report is dynamic and changes may occur as our review progresses. I 

have directed our teams to focus on two fundamental questions: 

(1) Did the facility’s electronic wait list (EWL) purposely omit the names of veterans waiting 

for care and, if so, at whose direction? 

(2) Were the deaths of any of these veterans related to delays in care? 

To address the allegations received thus far and remain prepared to address new allegations at 

medical facilities throughout VA, we are deploying Rapid Response Teams. We are not 

providing VA medical facilities advance notice of our visits to reduce the risk of destruction of 

evidence, manipulation of data, and coaching staff on how to respond to our interview questions. 

To date, we have ongoing or scheduled work at 42 VA medical facilities and have identified 

instances of manipulation of VA data that distort the legitimacy of reported waiting times. When 

sufficient credible evidence is identified supporting a potential violation of criminal and/or civil 

law, we have contacted and are coordinating our efforts with the Department of Justice. 

Our review at the Phoenix HCS includes the following actions: 

	 Interviewing staff with direct knowledge of patient scheduling practices and policies, 

including scheduling clerks, supervisors, patient care providers, management staff, and 

whistleblowers who have stepped forward to report allegations of wrongdoing. 

	 Collecting and analyzing voluminous reports and documents from VHA information 

technology systems related to patient scheduling and enrollment. 

	 Obtaining and reviewing VA and non-VA medical records of patients whose death 

occurred while on a waiting list, or is alleged to be related to a delay in care. 

ii 
	 Reviewing performance standards, ratings, and awards of senior facility staff. 

	 Reviewing past and new complaints to the OIG Hotline on delays in care, as well as those 

complaints shared with us by members of Congress or reported by the media. 

	 Reviewing other documents and reports relevant to these allegations, including 

administrative boards of investigations or reports of reviews conducted by VHA’s Office of 

the Medical Inspector. 

	 Reviewing over 550,000 email messages and documents, extracted from over 50 gigabytes 

of collected email. In addition, imaging and reviewing 10 encrypted computers and/or 

devices, and over 140,000 network files. 

Our reviews at a growing number of VA medical facilities have thus far provided insight into the 

current extent of these inappropriate scheduling issues throughout the VA health care system and 

have confirmed that inappropriate scheduling practices are systemic throughout VHA. One 

challenge in these reviews is to determine whether these practices exist currently or were used in 

the past and subsequently corrected by VA managers. 

To date, our work has substantiated serious conditions at the Phoenix HCS. We identified about 

1,400 veterans who did not have a primary care appointment but were appropriately included on 

the Phoenix HCS’ EWLs. However, we identified an additional 1,700 veterans who were 

waiting for a primary care appointment but were not on the EWL. Until that happens, the 

reported wait time for these veterans has not started. Most importantly, these veterans were and 

continue to be at risk of being forgotten or lost in Phoenix HCS’s convoluted scheduling process. 

As a result, these veterans may never obtain a requested or required clinical appointment. A 

direct consequence of not appropriately placing veterans on EWLs is that the Phoenix HCS 

leadership significantly understated the time new patients waited for their primary care 

appointment in their FY 2013 performance appraisal accomplishments, which is one of the 

factors considered for awards and salary increases. 

To review the new patient wait times for primary care in FY 2013, we reviewed a statistical 

sample of 226 Phoenix HCS appointments. VA national data, which was reported by Phoenix 

HCS, showed these 226 veterans waited on average 24 days for their first primary care 

appointment and only 43 percent waited more than 14 days. However, our review showed these 

226 veterans waited on average 115 days for their first primary care appointment with 

approximately 84 percent waiting more than 14 days. At this time, we believe that most of the 

waiting time discrepancies occurred because of delays between the veteran’s requested 

appointment date and the date the appointment was created. However, we found that in at least 

25 percent of the 226 appointments reviewed, evidence, in veterans’ medical records, indicates 

that these veterans received some level of care in the Phoenix HCS, such as treatment in the 

emergency room, walk in clinics, or mental health clinics. 

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 

iii 
 

for those veterans who died while on a waiting list. The assessments needed to draw any 

conclusions require analysis of VA and non-VA medical records, death certificates, and autopsy 

results. We have made requests to appropriate state agencies and have issued subpoenas to 

obtain non-VA medical records. All of these records will require a detailed review by our 

clinical teams. 

Lastly, while conducting our work at the Phoenix HCS our on-site OIG staff and OIG Hotline 

received 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. However, to ensure all veterans receive appropriate care, we 

submit to the VA Secretary the following recommendations for his immediate implementation. 

We will address the sufficiency of the VA Secretary’s action to implement the following 

recommendations in our final report. 

1.	 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. 

2.	 We recommend the VA Secretary review 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 (for example, those veterans who would be new patients to a specialty clinic) 

and provide the appropriate medical care. 

3.	 We recommend the VA Secretary initiate a nationwide review of veterans on wait lists to 

ensure that veterans are seen in an appropriate time, given their clinical condition. 

4.	 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. 

We will provide VA with the list of the 1,700 veterans we identified as not being on any wait list 

so that VA can mitigate any further access delays to health care services, and deliver higher 

quality of health care. 

RICHARD J. GRIFFIN 

Acting Inspector General 

iv 
TABLE OF CONTENTS 

Executive Summary ......................................................................................................................... i
 

Results and Recommendations ........................................................................................................1
 

Issue 1 Did the Phoenix Health Care System Electronic Wait List (EWL) Purposely 

Omit the Names of Veterans Waiting for Care and, If So, At Whose 

Direction?.................................................................................................................1
 

Issue 2 Are VHA Personnel Following Established Scheduling Procedures To Ensure 

Waiting Times Are Calculated Accurately? ............................................................3
 

Recommendations....................................................................................................5
 

Appendix A Background..............................................................................................................6
 

Appendix B Scope and Methodology ..........................................................................................9
 

Appendix C Chronology of OIG and GAO Oversight of Patient Wait Times ...........................11
 

Appendix D OIG Oversight Reports on VA Patient Wait Times ..............................................15
 

Appendix E Memorandum from the Deputy Under Secretary for Health for Operations and 

Management, Dated April 26, 2010, Titled: Inappropriate Scheduling 

Practices .................................................................................................................17
 

Appendix F OIG Testimony on VA Patient Wait Times...........................................................24
 

Appendix G Office of Inspector General Contact and Staff Acknowledgments ...................... 27
 

Appendix H Report Distribution ............................................................................................... 28
 
Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix Health Care System 

RESULTS AND RECOMMENDATIONS 

Issue 1 Did the Phoenix Health Care System Electronic Wait List 

(EWL) Purposely Omit the Names of Veterans Waiting 

for Care and, If So, At Whose Direction? 

We substantiated serious conditions at the Phoenix Health Care System (HCS) 

negatively impacted access to health care services. As of April 22, 2014, we 

identified about 1,400 veterans waiting to receive a scheduled primary care 

appointment and who were appropriately included on the Phoenix HCS 

electronic waiting list (EWL). At the same time, we identified an additional 

1,700 veterans who were waiting for a primary care appointment but were not 

on the EWL. We identified these 1,700 veterans from three sources: 

	 New Enrollee Appointment Request (NEAR) tracking report at Phoenix 

HCS listed about 1,100 newly enrolled veterans who indicated they 

wanted a primary care appointment but as of April 28, 2014, had not 

received one and were not on the EWL. 

	 Screenshot Paper Printouts represented about 400 newly enrolled veterans 

who called the Phoenix HCS Helpline and requested a primary care 

appointment. As of April 2014, the facility had yet to schedule these 

veterans their primary care appointment or add them to the EWL. 

	 “Schedule an Appointment Consult” represented about 200 veterans 

referred to primary care, but the consult was still pending. These 

200 veterans were seen in a non-primary care clinic, such as mental health 

or the emergency department, but were then referred to primary care. As 

of April 2014, the facility had yet to schedule these veterans their primary 

care appointment or add them to the EWL. 

The length of time these 1,700 veterans wait for appointments prior to being 

scheduled or added to the EWL will never be captured in any VA wait time 

data because Phoenix HCS staff had not yet scheduled their appointment or 

added them to the EWL. Until that happens, the reported wait time for these 

veterans has not started. Most importantly, these veterans were and continue 

to be at risk of being lost or forgotten in Phoenix HCS’ convoluted scheduling 

practices. As a result, these veterans may never obtain their requested or 

required primary care appointment. 

NEAR Report The NEAR report is a tool used by enrollment staff to notify Primary Care 

Management Module (PCMM) coordinators or schedulers that a newly 

enrolled veteran has requested an appointment during the enrollment process. 

As of April 28, 2014, the NEAR report listed 1,138 veterans who were 

waiting for an appointment an average of 200 days. However, only 53 of the 

VA Office of Inspector General 1 
Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix Health Care System 

Screenshot 

Paper Printouts 

Schedule an 

Appointment 

Consult 

1,138 veterans were on the EWL. The remaining 1,085 patients were not on 

the EWL. Consequently, their wait time prior to being scheduled or added to 

the EWL would potentially never be captured in any VA wait time data. 

According to Health Administration Service (HAS) personnel, when veterans 

enrolled for care at the Phoenix HCS, eligibility staff provided the veteran the 

Phoenix HCS Helpline phone number to call and get their primary care 

appointment. When the veteran called the Helpline, staff from the Helpline 

collected patient demographics of the veteran, took a screenshot, and then 

printed the information. From about February 2013 through March 2014, the 

Helpline information printed directly to HAS printers in Data Management 

services. HAS personnel from Outpatient services were responsible for 

collecting the screenshot paper printouts from Data Management and adding 

the veterans from the printouts to the EWL. HAS personnel told us there were 

often delays and backlogs in adding the veterans from the printouts to the 

EWL. In addition, HAS personnel said they held the printouts for a 1-2 month 

period during the beginning of this process before adding them to the EWL. 

HAS personnel also told us they destroyed these screenshot paper printouts 

after they either scheduled the veteran an appointment, placed the veteran on 

the EWL, or determined the veteran was not a new patient. Because of this, 

we could not identify these veterans or confirm that they were ever provided 

an appointment. 

In March 2014, instead of printing the screenshot paper printouts to Data 

Management services, another HAS employee received the printouts and 

created a Portable Document Format (PDF) of the compiled screenshots each 

day and electronically forwarded the PDF to the responsible Outpatient 

services personnel. We obtained PDF screen prints from March 24 through 

April 25, 2014, and identified about 400 veterans who were waiting for an 

appointment and were not on the EWL. According to a HAS employee, these 

veterans were subsequently added to the EWL during our on-site review. For 

example, a veteran emailed the OIG Hotline on May 14, 2014, and said he 

enrolled at Phoenix HCS on April 3, 2014. At that time, he was told by 

Phoenix HCS staff he was going to be put on the EWL. He called the medical 

facility again in May to check on his status and HAS staff told him they 

placed him on the EWL on May 6, 2014, and suggested it would be another 

3-4 months before he would be seen. This veteran was one of the 400 names 

we found in the PDF screenshot paper printouts. This veteran’s wait time was 

unaccounted for during this 1-month period from April to May 2014. 

Emergency department physicians, inpatient services, and mental health 

providers at the Phoenix HCS use a “Schedule an Appointment Consult” to 

request primary care appointments for their patients. As of April 2014, there 

were 200 veterans with a pending “Schedule an Appointment Consult.” The 

wait time for patients with a pending consult starts when schedulers create the 

appointment or place them on the EWL. This means the wait time for these 

VA Office of Inspector General 2 
Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix Health Care System 

Issue 2 

New Patient 

Waiting Times 

Established 

Patient Waiting 

Times 

Inappropriate 

Scheduling 

Practices 

Corroborated at 

a Number of 

Other Facilities 

200 patients prior to being scheduled or added to the EWL will never be 

captured in any VA wait time data. 

Are VHA Personnel Following Established Scheduling 

Procedures To Ensure Waiting Times Are Calculated 

Accurately? 

The Phoenix HCS leadership understated the time new patients waited for 

their primary care appointment listed in their FY 2013 performance appraisal 

accomplishments, which is one of the factors considered for awards and salary 

increases. To review the accuracy of new patient wait times for primary care 

in FY 2013, we reviewed a statistical sample of 226 new patient primary care 

appointments completed at Phoenix HCS. VA national wait time data, which 

was reported by Phoenix HCS, showed these 226 veterans waited on average 

24 days for their primary appointment and only 43 percent waited more than 

14 days. However, our review found these 226 veterans waited on average 

115 days for their primary care appointment, and an estimated 84 percent 

waited more than 14 days. Most of the wait time discrepancies occurred 

because of delays between the veteran’s requested appointment date and the 

date the appointment was created. We noted in at least 25 percent of the 

226 appointments reviewed, patients received some health care in the 

Phoenix HCS, such as the emergency department, walk-in clinics, or mental 

health clinics. 

We are continuing to analyze interviews of over 65 schedulers at the 

Phoenix HCS. However, at this time, it appears that a significant number of 

schedulers are manipulating the waiting times of established patients by using 

the wrong desired date of care. Instead of schedulers using a date based on 

when the provider wants to see the veteran or when the veteran wants an 

appointment, the scheduler deviates from VHA’s scheduling policy by going 

into the system to determine when the next available appointment is and using 

that as a purported desired date. This results in a false 0-day wait time. We 

evaluated FY 2013 established patient appointments in primary care and 

determined that for 66 percent of appointments, Phoenix HCS recorded 

veterans had no wait time. We will conduct interviews with facility 

scheduling supervisors and senior management and initiate additional 

document reviews to identify management’s involvement in manipulating 

wait times. 

Our review broadened to address allegations of the manipulation of patient 

wait times and inappropriate scheduling practices at other VA medical 

facilities. We are finding that inappropriate scheduling practices are a 

systemic problem nationwide. We have identified multiple types of 

scheduling practices not in compliance with VHA policy. Our preliminary 

work has revealed a number of types of scheduling schemes are in use 

VA Office of Inspector General 3 
Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix Health Care System 

Scheduling 

Scheme #1 

Scheduling 

Scheme #2 

Scheduling 

Scheme #3 

Scheduling 

Scheme #4 

VistA Audit Trail 

throughout VHA. Many of these schemes are detailed in the then Deputy 

Under Secretary for Health for Operations and Management 

April 2010 Memorandum on Inappropriate Scheduling Practices. The purpose 

of the memorandum was to call for immediate action to identify and eliminate 

VHA’s use of inappropriate scheduling practices to improve scores on clinical 

access performance measures. The memorandum discussed many of the same 

schemes we identified at Phoenix HCS and other medical facilities throughout 

VHA. The following schemes are examples we have identified and should 

not be considered a complete listing of inappropriate scheduling practices. 

The memorandum is Appendix E. 

Schedulers go into the scheduling program, find an open appointment, ask the 

veteran if that appointment would be acceptable, back out of the scheduling 

program, and enter the open appointment date as the veteran’s desired date of 

care. This makes the wait time of an established patient 0 days. 

Schedulers at several locations described a process using the Clinic 

Appointment Availability Report (or similar report) to identify individual 

schedulers whose appointments exceeded the 14-day goal. Scheduling 

supervisors told schedulers to review these reports and “fix” any appointments 

greater than 14 days. Schedulers say they were instructed to reschedule the 

appointments for less than 14 days. At one location, a scheduler told us each 

supervisor was provided a list of schedulers who exceeded the 14-day goal. 

To keep their names off the supervisor’s list, schedulers automatically 

changed the desired date to the next available appointment, thereby, showing 

no wait time. 

Staff at two VA medical facilities deleted consults without full consideration 

of impact to patients. The first facility deleted pending consults in excess of 

90 days without adequate reviews by clinical staff. Schedulers working at the 

second facility cancelled provider consults without review by clinical staff. 

Multiple schedulers described to us a process they use that essentially 

“overwrites” appointments to reduce the reported waiting times. Schedulers 

make a new appointment on top of an existing appointment of the same date 

and time. This cancels the existing appointment but does not record a 

cancelled appointment. This action allows the scheduler to overwrite the prior 

Desired Date and appointment Create Date with a new Desired Date. This 

adjusts the Create Date to the current date of entry and the Desired Date to the 

date of the appointment, thus reducing the reported wait time. 

During our review at Phoenix HCS we determined that certain audit controls 

within Veterans Health Information Systems and Technology Architecture 

(VistA) were not enabled. This limited VHA and the OIG’s ability to 

determine whether any malicious manipulation of the VistA data occurred. 

To ensure our future oversight ability is not compromised, we requested VA 

VA Office of Inspector General 4 
 

 

Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix Health Care System 

to immediately enable this audit trail capability at all VA medical facilities. 

VA completed this action. 

We are also reviewing and assessing differences between EWLs for the 

Phoenix HCS. VA’s national data showed an EWL of less than 300 veterans; 

however the Phoenix EWL included approximately 1,400 veterans. 

Recommendations 

We will make recommendations in our final report and will ask the 

VA Secretary to establish target dates and implementation plans. However, to 

ensure all veterans receive timely appropriate care, we submit to the 

VA Secretary the following recommendations for his immediate 

implementation. We will provide VA with the list of the 1,700 veterans we 

identified as not being on any wait list so that VA can address 

Recommendation 1. We will address the sufficiency of the VA Secretary’s 

action to implement the following recommendations in our final report. 

1. 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. 

2. We recommend the VA Secretary review all existing wait lists at the 

Phoenix Health Care System to identify veterans who may be at risk because 

of a delay in the delivery of health care (for example, those veterans who 

would be new patients to a specialty clinic) and provide the appropriate 

medical care. 

3. We recommend the VA Secretary initiate a nationwide review of veterans 

on wait lists to ensure that veterans are seen in an appropriate time, given their 

clinical condition. 

4. 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. 

VA Office of Inspector General 5 
Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix Health Care System 

Appendix A Background 

Phoenix VA 

Health Care 

System 

The Phoenix HCS serves veterans in central Arizona through its main medical 

facility, the Carl T. Hayden VA Medical Center. Veterans can be seen at one 

of the medical center’s three full primary care clinics or its half-clinic. 

The Phoenix HCS also has affiliated health care clinics in the communities of 

Phoenix, Surprise, Gilbert, Payson, Show Low, and Globe. 

 The Thunderbird VA Health Care Clinic in Phoenix serves veterans from 

the communities of North/Central Phoenix, Glendale, Peoria, Scottsdale, 

Avondale, Sun City, Goodyear and Surprise. 

 The Northwest Veterans Affairs Health Care Clinic in Surprise serves 

veterans from the communities of El Mirage, Glendale, Peoria, Sun City, 

Sun City West, Surprise, Wickenburg and Wittman. 

 The Southeast VA Health Care Clinic in Gilbert serves veterans on the 

east side of the valley including the communities of Ahwautukee, Apache 

Junction, Casa Grande, Chandler, Coolidge, Florence, Mesa, Superior, and 

Queen Creek. 

 The Payson Veterans Affairs Health Care Clinic is a contract clinic 

offered to veterans through a partnership with Health Net Federal 

Services. The clinic serves veterans in the greater Payson area, 

approximately 90 miles north of Phoenix and is staffed by one physician. 

 The Show Low VA Health Care Clinic in Show Low serves veterans in 

the communities of Show Low, Strawberry, Pine, Payson, Lakeside, 

Pinetop, Vernon, Concho, St. Johns, Snowflake, Taylor, Springerville, 

Eagar, Holbrook, Alpine, Greer, and Whiteriver. The clinic is 

approximately 180 miles northeast of Phoenix and has staffing allocations 

for a physician and nurse practitioner. As of May 2014, the nurse 

practitioner position was vacant. 

 The Globe-Miami VA Health Care Clinic in Globe is 87 miles east of 

Phoenix and is staffed by a nurse practitioner. 

On the following page is a map of the locations of the Phoenix area clinics. 

VA Office of Inspector General 6 
	 	

     

Northwest Clinic

(Surprise)

Show Low Clinic

   

   

Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix Health Care System 

PHOENIX AREA COMMUNITY CLINICS

Globe – Miami Clinic

Thunderbird Clinic Payson Clinic

(Phoenix)

Southeast Clinic (Gilbert)

Source: Google©

Tracking Wait 

Time Data 

In February 2002, the then Deputy Under Secretary for Health sent a 

memorandum to the VHA Deputy Chief Information Officer for Health 

requesting the development of an EWL to effectively track the demand for 

services at VA medical facilities. The memorandum indicated that existing 

wait time measures at the time reflected the experience of veterans already in 

the system but did not capture the waiting time experience of new veteran 

enrollees or patients without a scheduled appointment. At the time “ad hoc” 

written waiting lists of new veteran enrollees to be entered in the scheduling 

system were known to exist. The memorandum attempted to formalize an 

EWL in VistA to more consistently and accurately reflect demand across 

VHA. 

In November 2002, the EWL package and Phase I enhancement to the 

primary care management module was released. At the time of release there 

had been no VHA software to list and track patients waiting for clinic 

appointments, primary care team assignments, or primary care provider 

assignments. The EWL was intended to assist VA medical facilities in 

managing veteran access to outpatient health care, assist clinics in identifying 

VA Office of Inspector General 7 
 

Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix Health Care System 

patients in need of appointments, primary care teams, and primary care 

providers. 

In the outpatient setting, patients are assigned a primary care team and 

provider who are responsible for delivering care, coordinating health care 

services, and serving as the point of access for specialty care. This is 

accomplished through the PCMM of VistA. When a patient cannot be 

assigned to a primary care team or position, the PCMM software asks if the 

patient should be placed on the EWL. PCMM Wait List reports assist in the 

management of patients awaiting a primary care team or provider assignment. 

The goal of the EWL is to provide care to the patient as quickly as possible. 

The EWL keeps track of appointments, clinics, and providers associated with 

patients on the various EWLs. Patient eligibility information and service 

connected status is also recorded and updated. The EWL runs background 

programs to determine changes in the veteran’s service-connected percentage, 

and service-connected priority, as well as changes to appointment, clinics, and 

personnel that affect EWL patients. EWL also sends messages to assigned 

mail groups to notify them of such changes. The EWL can also produce 

reports on demand regarding EWL related activities. 

VA Office of Inspector General 8 
Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix VA Health Care System 

Appendix B Scope and Methodology 

We initiated this review in response to allegations first reported to the OIG 

Hotline and expanded at the request of the VA Secretary and the Chairman 

of the House Veterans’ Affairs Committee (HVAC) following an HVAC 

hearing on April 9, 2014, on delays in VA medical care and preventable 

veteran deaths. We began a review at the Phoenix HCS in 

December 2013 and expanded our work in April 2014. We reviewed patient 

care delays, scheduling practices, and wait times at Phoenix HCS from 

FY 2013 to present. In addition, we are reviewing patient care delays of 

veterans specifically named in allegations or media publications. To address 

our review objective, we reviewed applicable laws, regulations, policies, 

procedures, guidelines, and studies. 

Our review at the Phoenix HCS includes the following actions: 

	 Interviewing staff with direct knowledge of patient scheduling practices 

and policies, including scheduling clerks, supervisors, patient care 

providers, management staff, and whistleblowers who reported 

allegations of wrongdoing. 

	 Collecting and analyzing voluminous reports and documents from VHA 

information technology systems related to patient scheduling and 

enrollment. 

	 Reviewing VA and non-VA medical records of patients whose deaths 

may be related to delays in care. 

	 Reviewing performance standards, ratings, and awards of senior facility 

staff. 

	 Reviewing past and newly reported complaints to the OIG Hotline on 

delays in care, as well as those complaints shared with us by members of 

Congress or reported by the media. 

	 Reviewing other prior reports relevant to these allegations, including 

administrative boards of investigations or reports from the VHA’s Office 

of the Medical Inspector. 

	 Reviewing over 550,000 email messages and documents, extracted from 

over 50 gigabytes of collected email. In addition, imaging and reviewing 

10 encrypted computers and/or devices, and over 140,000 network files 

for review. 

Additionally, we focused on measures contained in the FY 2013 Director’s 

Performance Measures, to include the accuracy of new patient wait times for 

primary care in FY 2013. To review this, we analyzed a statistical sample of 

appointments to evaluate whether patients received a new primary care 

VA Office of Inspector General 9 
Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix VA Health Care System 

Government 

Standards 

appointment within 14 days. We obtained the data in which Phoenix HCS 

officials identified as the source data used to support the Director’s 

FY 2013 performance appraisal. We then obtained a statistically random 

sample of 226 appointments to test the data. 

We interviewed over 120 staff, including schedulers, data analysts, 

providers, and supervisors. During the review, we visited the Phoenix HCS 

main campus and three large primary care clinics located at the community 

based outpatient sites. The review teams are using these interviews to 

determine if Phoenix HCS personnel followed established scheduling 

procedures. Additional interviews are planned. 

Our assessment of internal controls focused on those controls relating to our 

review objectives. The Office of Audits and Evaluations, the Office of 

Healthcare Inspections, and the Office of Investigations are completing this 

ongoing independent joint review in accordance with The Council of the 

Inspectors General on Integrity and Efficiency’s Quality Standards for 

Inspection and Evaluation. 

VA Office of Inspector General 10 
Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix VA Health Care System 

Appendix C Chronology of OIG and Government Accountability 

Office Oversight of Patient Wait Times 

For almost a decade, OIG and Government Accountability Office (GAO) 

reviews identified that VHA managers needed to improve efforts for 

collecting, trending, and analyzing clinical data. Because of continued 

weaknesses in quality management data, particularly the implementation and 

evaluation of corrective actions, facility senior managers needed to clearly 

state their expectations to all managers and program coordinators. Further, 

VA’s corrective actions must be evaluated until resolution is achieved. VHA 

needs to have a stronger system for corrective action implementation and 

evaluation to provide reasonable assurance that its facilities are thoroughly 

addressing quality of care and patient safety issues. 

The following provides selected highlights in a chronological summary of 

OIG oversight addressing wait times, scheduling practices, data integrity 

concerns, and the lack of physician and nurse staffing standards. 

2005 

OIG reports, in the Audit of VHA’s Outpatient Scheduling Procedures, July 2005, 

that VHA did not follow established procedures when scheduling appointments, 

resulting in inaccurate wait times and lists. 

 Nationwide electronic wait lists could be understated by as many as 10,000 

veterans 

 VHA lacks standardized training programs for scheduling 

 Insufficient oversight 

2006 

In the 2006 Performance and Accountability Report, we identified that VA 

medical facilities did not have effective controls to ensure all newly-enrolled 

veterans in need of care, received it, and within VHA’s goal of 30 days of the 

desired date of care or veterans received clinically-indicated specialty procedures 

within a reasonable time. OIG recommended VA: 

 Monitor the demand for non-institutional care 

 Direct VHA facilities to implement tracking mechanisms to identify newly 

enrolled veterans 

 Establish standardized tracking methods and appropriate performance metrics 

throughout all medical facilities 

VA Office of Inspector General 11 
Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix VA Health Care System 

2007 

OIG performed a follow-up audit, Audit of VHA’s Outpatient Wait Times, Sept 

2007, again concluding the data in the scheduling system remained inaccurate. 

We reviewed 300 consult referrals and found more than 180 veterans were not on 

a waiting list, but should have been. 

 Only 75 percent of appointments met 30 days for consults. 

 VHA disagreed and said that patient preference caused the unexplained 

differences. 

	 Although policy requires schedulers to document patient preferences, VHA 

felt this was an unreasonable expectation. 

	 VHA concluded that the system lacked documentation to support their 

position. 

	 Contrary to OIG reports, VA reported high performance in the VA 

Performance and Accountability Reports, even after we had twice reported the 

scheduling system contained inaccurate, incomplete, and unreliable data. 

	 We testified in December 2007 that these issues go beyond reported waiting 

times. Debating whose numbers are more correct only overshadows the 

primary point of both our prior audit reports, which is that the information in 

the VHA scheduling system is incomplete. 

	 As reported in the Major Management Challenges, OIG reviews have shown 

unacceptably high waiting times, and delays remain in obtaining sub-specialty 

procedures and sub-specialty medical diagnoses. OIG continues to identify 

waiting times and patient waiting lists, a problem on which OIG reported and 

sought corrective action since 2005. OIG will continue to review medical 

outcomes and quality of care issues. 

2008 

In VA’s Major Management Challenges, OIG reported VA made only limited 

progress in addressing the long-standing and underlying causes of problems with 

outpatient scheduling, accuracy of reported waiting times, and completeness of 

electronic waiting lists. Of concern is VHA’s delay in implementing appropriate 

quality procedures necessary to ensure the reliability of waiting times and waiting 

lists. 

The May 2008 OIG report on Veterans Integrated Service Network (VISN) 3 

waiting times determined scheduling procedures were not followed, which 

affected the reliability of reported wait times and caused inaccuracies in the 

electronic waiting lists. OIG recommended VHA establish procedures to 

routinely test the accuracy of reported waiting times and the completeness of 

electronic waiting lists, as well as take corrective action when their testing shows 

questionable differences between the desired dates of care and those documented 

in the scheduling system. OIG reported that the problems and the causes 

associated with scheduling, wait times, and wait lists, are systemic throughout 

VHA. 

VA Office of Inspector General 12 
Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix VA Health Care System 

VHA disagreed with the OIG assessment that appropriate implementation of 

quality assurance procedures to ensure reliability of wait time and wait lists, had 

been delayed. While VHA improved the trends in access to care, which is 

independent of the issues for measuring wait times, it did implement several 

initiatives to address some quality assurance measures for wait times and waiting 

lists: 

 VHA established a formal scheduler national training program 

 Required audits of scheduler performance 

 Implemented a “no veteran left behind” initiative 

 Hired an outside consultant to provide recommendations for wait time 

measurement 

 Implemented national reporting software linking consult-creation -date 

information to: 

- Appointment creation date 

- Appointment completion date 

- Desired appointment date 

 Though comprehensive in its capabilities, the inconsistencies and inaccuracies 

of data input affected the reliability of reported waiting times 

2009 

OIG reported long-standing problems with outpatient scheduling delays, accuracy 

of reported waiting times, and incomplete electronic waiting lists. OIG 

recommended VHA implement an effective method to accurately measure and 

report outpatient appointments. VA’s response, to address variations in the 

quality of care, was to establish new directives outlining VHA’s leadership and 

accountability at all levels of the organization, and to improve communication 

throughout VA. OIG listed outpatient scheduling, waiting times, and EWL data 

integrity issues as OIG’s first “hot issues” paper in Administration transition 

briefing materials. 

2010 

OIG reported VHA lacks the management controls needed to ensure Community 

Based Outpatient Clinics (CBOCs) provided veterans consistent, quality care. 

OIG noted that CBOC primary care data is inaccurate. VA responded with new 

directives providing more detailed instruction for schedules on correct entry of 

desired date and other essential to improve the scheduling of veterans/ 

appointments. 

2012 

OIG testified before the House and Senate Veterans’ Affairs Committees that 

VHA’s mental health performance data is not accurate or reliable, and its 

measures do not adequately reflect critical dimensions of mental health care 

access. 

VA Office of Inspector General 13 
Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix VA Health Care System 

The inaccuracies in some of VHA’s data sources presently hinder the usability of 

information by VHA decision-makers to fully assess their: 

 Current capacity 

 Optimal resource distribution 

 Productivity across the system 

 Establish mental staffing and productivity standards 

In VA’s 2011 Performance Accountability Report, VHA reported 95 percent of 

first-time patients received a full mental health evaluation within 14 days. Our 

analysis of the same information calculated only 49 percent of the first-time 

patient’s initial contact in mental health and their full mental health evaluation 

occurred within their goal of 14 days. 

OIG also reported that controls over pre-authorizing of fee care services needed 

improvement. In FY 2011, OIG substantiated an allegation that the Phoenix HCS 

experienced an $11.4 million budget shortfall—20 percent of the non-VA fee care 

programs funded for that year. Health care system management did not have 

sufficient procedural and monitoring controls to establish that: 

 The official designated to pre-authorize fee care thoroughly reviewed requests 

 Clinical staff conducted necessary utilization and concurrent reviews 

 Fee staff obligated sufficient funds for fee care 

As a result, the Phoenix HCS had to obtain additional funds from the National Fee 

Program and VISN 18 and cancel equipment purchases to cover the $11.4 million 

shortfall. OIG concluded that authorization procedures, and the procedures to 

obligate sufficient funds to insure it could pay its commitments, were so weak that 

the Phoenix HCS processed about $56 million of fee claims during FY 2010 

without adequate review. 

OIG’s Audit of VHA’s Physician Staffing Levels for Specialty Care Services, 

identified the need for VHA to improve their staffing methodology by 

implementing productivity standards. OIG determined VHA had not established 

productivity standards for 31 of 33 specialty care services reviewed, and had not 

developed staffing plans that addressed the facilities’ mission, structure, 

workforce, recruitment, and retention issues to meet current or projected patient 

outcomes, clinical effectiveness, and efficiency. VA agreed to put staffing 

standards for specialty care in place by FY 2015. 

2013 

GAO testified on wait times, before the HVAC, Subcommittee on Oversight and 

Investigations, that VA needed improvements in the reliability of VHA’s reported 

medical appointment wait times, scheduling oversight and VHA initiatives to 

improve access to timely medical appointments. 

VA Office of Inspector General 14 
Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix VA Health Care System 

Appendix D OIG Oversight Reports on VA Patient Wait Times 

A list of the published OIG reports follows: 

1.	 Audit of the Veterans Health Administration's Outpatient Scheduling 

Procedures (7/8/2005) 

2.	 Audit of the Veterans Health Administration's Outpatient Waiting 

Times (9/10/2007) 

3.	 Audit of Alleged Manipulation of Waiting Times in Veterans Integrated 

Service Network 3 (5/19/2008) 

4.	 Audit of Veterans Health Administration's Efforts to Reduce Unused 

Outpatient Appointments (12/4/2008) 

5.	 Healthcare Inspection – Mammography, Cardiology, and Colonoscopy 

Management Jack C. Montgomery VA Medical Center Muskogee, 

Oklahoma (2/2/2009) 

6.	 Audit of Veterans Health Administration's Non-VA Outpatient Fee 

Care Program (8/3/2009) 

7.	 Veterans Health Administration Review of Alleged Use of 

Unauthorized Wait Lists at the Portland VA Medical Center 

(8/17/2010) 

8.	 Healthcare Inspection – Delays in Cancer Care West Palm Beach VA 

Medical Center West Palm Beach, Florida (6/29/2011) 

9.	 Healthcare Inspection – Electronic Waiting List Management for 

Mental Health Clinics Atlanta VA Medical Center Atlanta, Georgia 

(7/12/2011) 

10.	 Review of Alleged Mismanagement of Non-VA Fee Care Funds at the 

Phoenix VA Health Care System (11/8/2011) 

11.	 Healthcare Inspection – Select Patient Care Delays and Reusable 

Medical Equipment Review Central Texas Veterans Health Care 

System Temple, Texas (1/6/2012) 

12.	 Review of Veterans’ Access to Mental Health Care (4/23/2012) 

13.	 Healthcare Inspection – Access and Coordination of Care at Harlingen 

Community Based Outpatient Clinic, VA Texas Valley Coastal Bend 

Health Care System, Harlingen, Texas (8/22/2012) 

VA Office of Inspector General 15 
Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix VA Health Care System 

14.	 Healthcare Inspection – Consultation Mismanagement and Care 

Delays, Spokane VA Medical Center, Spokane, Washington 

(9/25/2012) 

15.	 Healthcare Inspection – Delays for Outpatient Specialty Procedures, 

VA North Texas Health Care System, Dallas, Texas (10/23/2012) 

16.	 Audit of VHA's Physician Staffing Levels for Specialty Care Services 

(12/27/2012) 

17.	 Healthcare Inspection – Patient Care Issues and Contract Mental 

Health Program Mismanagement, Atlanta VA Medical Center, 

Decatur, Georgia (4/17/2013) 

18.	 Healthcare Inspection – Gastroenterology Consult Delays William 

Jennings Bryan Dorn VA Medical Center Columbia, South Carolina 

(9/6/2013) 

VA Office of Inspector General 16 
 

 

Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix VA Health Care System 

Appendix E Memorandum from the Deputy Under Secretary for 

Health for Operations and Management, Dated April 26, 

2010, Titled: Inappropriate Scheduling Practices 

Department of Memorandum 

Veterans Affairs 

Date: April 26, 2010 

From: Deputy Under Secretary for Health for Operations and Management (10N) 

Subj: Inappropriate Scheduling Practices 

To: Network Director (10N1-23) 

1. The purpose of the memorandum is to call for immediate action within every 

VISN to review current scheduling practices to identify and eliminate all 

inappropriate practices including but not limited to the practice specified below. 

2. It has come to my attention that in order to improve scores on assorted 

access measures, certain facilities have adopted use of inappropriate scheduling 

practices sometimes referred to as "gaming strategies." Example: as a way to 

combat Missed Opportunity rates some medical centers cancel appointments for 

patients not checked-in 10 or 15 minutes prior to their scheduled appointment 

time. Patients are informed that it is medical center policy that they must check in 

early and if they fail to do so, it is in the medical center's right to cancel that 

appointment. This is not patient centered care. 

3. For your assistance, attached is a listing of the inappropriate scheduling 

practices identified by a multi-VISN workgroup charted by the Systems Redesign 

Office. Please be cautioned that since 2008, additional new or modified gaming 

strategies may have emerged, so do not consider this list a full description of all 

current possibilities of inappropriate scheduling practices that need to be 

addressed. These practices will not be tolerated. 

4. For questions, please contact Michael Davies, MD, Director, VHA Systems 

Redesign (Michael.Davies@va.gov) or Karen Morris, MSW, Associate Director 

(Karen.Morris@va.gov). 

William Schoenhard, FACHE 

Attachment 

VA Office of Inspector General 17 
 

 

 

Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix VA Health Care System 

ATTACHMENT 

Scheduling Practices to Avoid: Strategies leading to poor customer service and 

misrepresentation of Performance Measures/Monitors 

Introduction 

The purpose of this chapter is to provide assistance in ensuring scheduling accuracy during consultative site 

visits. It will provide an outline for consultants to better assess scheduling practices and recommend 

improvements. 

As we strive to improve access to our veterans we must ensure in fact that improvement does not focus or 

rely on workarounds. Workarounds have the potential to compromise the reliability of the data as well as 

the integrity and honesty of our work. 

Workarounds may mask the symptoms of poor access and, although they may aid in meeting performance 

measures, they do not serve our veterans. They may prevent the real work of improving our processes and 

design of systems. 

We need to speak in a unified voice when interacting with staff at all levels. Our expectations are that there 

will be no workarounds, and that access will continue to improve with integrity and honesty in all the work 

that we do. 

Systems Redesign principles provide us with the opportunity to improve not only access, but also quality, 

because without access there can be no quality; satisfaction, because waiting is a huge source of 

dissatisfaction; and cost of care because, delay creates waste and waste costs money. Please review the 

practices below to better equip you and your team during your upcoming site visits. 

Scheduling Practices to Avoid 

	 Limiting/Blocking appointment scheduling to 30-day booking. Clinic profiles are created to allow for 

no more than 30-day scheduling. When patients require appointments beyond the 30 days, 

o	 they are told to call back another month to make their request, or 

o	 staff holds the appointments without scheduling until capacity opens within 30 days. 

o	 Evaluation Method: Ask the scheduler to make an appointment past 30 days. Review the use 

of recall system and EWL. 

	 Use of a log book or other manual system. Using this method, appointments are scheduled in VistA 

at a later date instead of placing patients on the EWL. This has been observed in mental health and in 

other clinics. The use of log books are now prohibited. 

o	 Evaluation Method: Interview clinical staff and scheduling staff, especially in 

mental health. Ask specifically about whether log books are used and ask whether 

patients schedule directly with the scheduler or if they must schedule with the 

clinician. Check Display Clinic Availability listing to assure the patients are being 

scheduled in VISTA. 

	 Creation and cancellation of New patient visits: A New patient visit is created for a date within 30 

days. This visit is cancelled by the clinic; however, it is entered in Appointment Management as 

"cancelled by patient" instead of "cancelled by clinic" and rescheduled for another date within 30 

days of the cancellation. The performance measure would show a wait time under 30 days, though it 

should have been calculated at >30 days if entered correctly as "cancelled by clinic." There are 

VA Office of Inspector General 18 
Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix VA Health Care System 

several ways this has been observed: 

o	 Scheduling the New patient visit at a time the patient would prefer not to come in and then

re-scheduling. 

o	 Creating a New patient appointment without notifying the patient. This creates a very high

likelihood that the patient will no-show which allows for another rebooking with a restarted 

wait time. 

o	 Sites may also appropriately enter "cancelled by clinic" in Appointment Management, but

inappropriately reschedule the appointment 1+ days later, which restarts the wait time clock. 

o	 Evaluation Method: Conduct random audits of patient appointments, sampling a variety of

clinics. Critically assess the scheduling process using both CPRS and Appointment 

Management. Check performance measure clinics with unusually low no show rates and 

wait times. 

	 Auto-Rebooking: This scheduling option removes critical scheduling data (including Desired Date)

from the Appointment Management scheduling package, which prevents us from verifying that the 

patient was scheduled within 30 days. Recommend against using this option. 

o	 Evaluation Method: Conduct random audits of patient appointments. Enter "Expanded

Profile" in Appointment Management on the "*** Clinic Wait Time Information ***" screen 

and make sure that the "Request Type" does not state "AUTO REBOOK" (see screenshot 

below): 

	 Use of the recall system to "hold" patients until slots within 30 days open up.

o	 Evaluation Method: Conduct random audits of patient appointments entered in the recall

system. If recall is being used properly, there should be evidence in the CPRS Progress

Notes supporting the appointment date in the recall system.

VA Office of Inspector General 19 
Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix VA Health Care System 

	 Use of slot for Test Patient so that this slot cannot be used but then cancelling the Test Patient and 

scheduling a patient in the appointment slot. Some providers also use the Test Patient to book up 

their clinics if they are going on vacation so they do not have to cancel their clinic. 

o	 Evaluation Method: Interview schedulers and randomly look at the future clinic grids (e.g., t 

+ 90 days) to see if test patients are scheduled. 

	 Block scheduling: Numerous patients are scheduled at one block of time (e.g., 8:00-12:00 pm) and 

have to wait a long time to be seen. Each patient should have his/her own appointment slot. 

o	 Evaluation Method: Randomly look at the future clinic grids to see if several patients are 

scheduled at one time. If so, ask the respective schedulers whether block scheduling is being 

used. Note: Clinics often legitimately schedule 2+ patients in each appointment slot because 

they are staffed with enough clinicians to manage patients 1:1. 

	 Cancelling patients before the appointment time has passed if: 

o the patient does not confirm the appointment in response to a reminder call/letter, or if 

o the patient does not show up 15 minutes before the appointment time. 

This strategy inappropriately eliminates the patient from the Missed Opportunity measure and is 

misleading to patients who will show up for their appointments. 

o	 Evaluation Method: Interview schedulers to determine if this practice occurs. Clinics with 

unusually low Missed Opportunity rates should be investigated more closely. 

	 For established patients, entering a Desired Date that is later than what the provider/patient agreed 

upon in order to fit the patient in within 30 days. 

o	 Evaluation Method: Cross-reference the provider's desired date from CPRS (i.e., progress 

note) with the Desired Date entered in Appointment Management. Also interview schedulers 

to determine if this practice occurs. Verify that the dates on routing slips (if used) match the 

Desired Date entered in Appointment Management. 

	 Allowing providers to request RTC dates in windows (e.g., 4-6 months). This practice allows the 

scheduler to enter a Desired Date based on clinic availability instead of when the patient needs to be 

seen. 

o	 Evaluation Method: Cross-reference the provider's Desired Date from CPRS (i.e., progress 

note) with the Desired Date entered in Appointment Management. Also interview schedulers 

and providers to determine if this practice occurs. Some facilities may have a policy 

allowing schedulers to make appointments within 2 weeks before and after the provider's 

date. Interview staff and request the policy if this is occurring. If this occurs, there needs to 

be an entry in the "Comments" section of Appointment Management describing the 

provider's/patient's preference. 

	 For Established patients, allowing the Desired Date not to be documented prevents sites from 

knowing whether the patient was given an appointment within 30 days: 

o	 For call-ins and walk-ins, schedulers should enter patient requests into the "Comments" field 

in VistA's Appointment Management system. 

o	 For normal RTC appointments, providers should document the Desired Date using 

electronic orders in CPRS. These orders must include the provider's name, the clinic name, 

and the requested RTC date. It is recommended that routing slips not be used, as they are 

shredded daily and the information is lost. Instead, some sites require providers to complete 

their treatment plan progress note before patients leave, which documents the RTC date in a 

CPRS progress note. 

o	 Evaluation Method: Interview schedulers in various clinical areas to determine whether 

VA Office of Inspector General 20 
Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix VA Health Care System 

routing slips are being used for RTC appointments. Also, randomly sample appointments to 

determine whether adequate documentation exists for call-ins, walk-ins, and standard RTC 

appointments. 

	 Basing the Desired Date on clinic availability: When a provider writes RTC in 3 weeks, the clerk 

enters +3W to find the availability of future appointments. Once a date/time is found, the clerk exits 

the system and then starts over using the identified date/time as the Desired Date. 

o	 Evaluation Method: Cross-reference the provider's Desired Date from CPRS (i.e., progress 

note) with the Desired Date entered in Appointment Management to ensure they match. 

Also, witness schedulers making appointments, watching for this practice. 

	 When clinics are cancelled and the patients need to be rescheduled, patients will be called and 

offered the next available appointment for that clinic. If they accept it, the scheduler will enter that 

date as the Desired Date as per patients' request, instead of next available. 

o	 Evaluation Method: Try to observe the way appointments are rescheduled following a clinic 

cancellation. Interview schedulers to determine whether this is happening. One option is to 

call a sampling of scheduled patients and ask how their future appointment was offered to 

them. 

	 Patients (New and Established) are offered appointments beyond 30 days, but they are documented 

as being >30 days per patient request. 

o	 New patient appointments will still fail the performance measure because the clock starts on 

the Creation Date. Nevertheless, this strategy misrepresents the patient's Desired Date. 

Patients should be asked when they would like an appointment and that date should be 

entered as the Desired Date for Established patients and entered in the Comments field for 

New patients. 

o	 Evaluation Method: The team can interview front-line schedulers, asking for the wording 

used to schedule an appointment with patients. The best method for evaluating, however, 

would be to directly observe schedulers/patients while appointments are being scheduled. 

One option is to call a sampling of scheduled patients and ask how their future appointment 

was offered to them. 

	 Access data and Performance Measures meet the standard but when you view the clinic schedules, 

they are full for the next 30+ days. This suggests the site may be gaming the system. 

o	 Evaluation Method: Examine random clinic grids 30 days into the future to determine 

whether there are any open slots. If not, ask the respective schedulers and/or service chiefs 

how they are able to meet the 30-day standard when the grids are booked 30+ days. 

o	 It is possible that they are legitimately meeting the measure if they are feeing out all New 

patients who cannot get an appointment within 30 days, or if they open clinics for extended 

hours on an as needed basis to increase supply. 

	 Not including the patient in scheduling the appointment. This occurs most often in specialty clinics 

when scheduling New patients off consults. It creates poor customer service, a high Missed 

Opportunity rate, and considerable rework to reschedule these missed appointments. 

o	 Evaluation Method: For specialty services, interview schedulers and other staff to determine 

how consults are processed and scheduled. Is there clinical review of the consults? If a 

clinician reviews the consult, does he/she reschedule the appointment him/herself? Does a 

nurse review the consult and schedule the appointment him/herself? Ask staff if they include 

patients in scheduling initial appointments and, if possible, observe their practices. 

VA Office of Inspector General 21 
 

 

Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix VA Health Care System 

	 Consult management: 

o	 When clinics are full within 30 days, consults are Cancelled or Discontinued with comments 

for the requesting provider to re-submit at a later date. This practice makes wait times 

appear shorter than they are and compromises patient care. 

 Evaluation Method: Interview Consult Manager to determine how consults are 

managed when no appointments within 30 days are available. Also, run the 

consult tracking report (Service Consults By Status [GMRC RPT CONSULTS BY 

STATUS]) to assess whether an unusually high percentage of consults are being 

Cancelled or Discontinued. If yes, investigate closer. This strategy may be 

occurring. The service may also have a Service Agreement in place that isn't 

working. 

o	 Holding a consult without scheduling the visit but marking the consult as completed. This 

method does not give the patient timely care, yet it allows the service to pass the 7-day 

monitor to act upon a consult. 

 Evaluation Method: Use the Completion Time Statistics ([GMRC COMPLETION 

STATISTICS]) report. This will display how many consults are completed 

without results or without a note attached. 

o	 Completing the consult when the appointment is scheduled rather than when the patient is 

seen. 

 Evaluation Method: Look in the Comments of the consult request. You will see 

that the appointment was made for a future date and the consult status is 

completed. 

o	 Discontinuing/Cancelling consults for simple reasons, forcing the consult to go back and 

forth between the requester and specialist until the clinic has availability within 30 days. 

 Evaluation Method: Run the consult tracking report to assess whether an 

unusually high percentage of consults are being discontinued or cancelled. 

Services with poor access are more likely to use this method to decrease their 

demand. Also, randomly select discontinued/ cancelled consults from the consult 

tracking report and examine them in CPRS to determine if they appear legitimate. 

o	 Not linking the consult to a scheduled appointment. If the patient no-shows or cancels, it 

would have to be manually recorded on the consult to make it active again. If it were 

attached, the consult would automatically return to an "active status for no-shows or 

cancellations and show as incomplete. Thus, not linking the consult properly will falsely 

improve your compliance with the timeliness of acting on a consult. 

 Evaluation Method: Use the Completion Time Statistics ([GMRC COMPLETION 

STATISTICS]) report. This will show how many appointments are not linked to a 

consult. 

o	 Cancelling and re-establishing consults on the day of the appointment. This practice 

effectively makes it appear that there are no outstanding consults and no waiting times for 

consults to be "acted on." 

 Evaluation Method: Run the consult tracking report and randomly select consults 

to review. Verify in CPRS that consults weren't being cancelled and reestablished, as above. Auditors can also verify that the requesting physician of the 

consult did not belong to the service receiving the consult. 

o	 Consults are not "acted on" within 7 days, which delays the start of the wait time measure. 

Sites should develop a process to monitor this. 

 Evaluation Method: Run the VSSC New and Established Wait Time report. This 

will tell you the number of days between the consult request date and the 

appointment creation date. 

 Below is a Fileman Template for Action on a Consult, developed in VISN 12, that 

can help sites monitor this: 

VA Office of Inspector General 22 
 

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Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix VA Health Care System 

SORT TEMPLATE: 

OUTPUT FROM WHAT FILE: REQUEST/CONSULTATION// 

SORT BY: FILE ENTRY DATE// @'DATE OF REQUEST

START WITH DATE OF REQUEST: FIRST// T-7 (MAR 25, 2008) 

GO TO DATE OF REQUEST: LAST// T (APR 01, 2008)

WITHIN DATE OF REQUEST, SORT BY: (CPRS STATUS ["ACTIVE")! (CPRS STATUS ["PENDING") 

WITHIN (CPRS STATUS ["ACTIVE")!(CPRS STATUS["PENDNING"), SORT BY: TO SERVICE: 

REQUEST SERVICES FIELD: ASSOCIATED STOP CODE (multiple)

ASSOCIATED STOP CODE SUB-FIELD: ASSOCIATED STOP CODE: 

CLINIC STOP FIELD: @AMIS REPORTING STOP CODE

START WITH AMIS REPORTING STOP CODE: FIRST// 303 

GO TO AMIS REPORTING STOP CODE: LAST// 303

WITHIN AMIS REPORTING STOP CODE, SORT BY:

STORE IN 'SORT' TEMPLATE: DE CONSULTS NOT ACTED ON 

(Apr 01, 2008@07:47) User #673 File #123 SORT OUTPUT 

FROM WHAT FILE: 

SHOULD TEMPLATE USER BE ASKED 'FROM'-'TO' RANGE FOR 'DATE OF REQUEST'? NO//YES 

SHOULD TEMPLATE USER BE ASKED 'FROM'-'TO' RANGE FOR 'AMIS REPORTING STOP CODE'? 

NO//YES 

PRINT TEMPLATE: 

FIRST PRINT FIELD: PATIENT NAME;L25

THEN PRINT FIELD: TO SERVICE;L20

THEN PRINT FIELD: DATE OF REQUEST;L20

THEN PRINT FIELD: CPRS STATUS 

THEN PRINT FIELD: TO SERVICE://

THEN PRINT REQUEST SERVICES FIELD: ASSOCIATED STOP CODE 

OUTPUT: 

PATIENT NAME TO SERVICE DATE OF REQUEST CPRS STATUS 

ASSOCIATED STOP CODE 

TEST TEST ECHOCARDIOGRAM – IRO MAR 17,2008 12:12 PENDING CARDIOLOGY 

TEST TEST ECHOCARDIOGRAM – IRO MAR 17,2008 14:34 PENDING CARDIOLOGY 

o	 Not scheduling consults for Established patients within 30 days. Sites may schedule only 

New patients within 30 days, even if the Established patient is presenting with a new 

problem. This practice provides untimely care to Established patients simply because they 

have been seen within the past 2 years. 

 Evaluation Method: 

- Search consults for Established patient and lookup the appointment 

information in Appointment Management. Verify that the Desired Date 

was not entered for a date into the future. If so, the service is not providing 

timely care to these Established patients with new problems. 

- The VSSC new and Established Wait Time Report will give you a list of 

established patients that have a consult linked to the appointment. You will 

need real SSN access to drill down to patient names. 

VA Office of Inspector General 23 
Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix VA Health Care System 

Appendix F OIG Testimony on VA Patient Wait Times 

The following testimony provides a broad overview of OIG’s oversight and 

reporting to the Congress on patient wait times. 

Congressional Testimony - 5/15/2014 - Statement of Richard J. Griffin, 

Acting Inspector General, Office of Inspector General, Department of 

Veterans Affairs, Before the Committee on Veterans’ Affairs, United States 

Senate, Hearing on “The State of VA Health Care” 

Congressional Testimony - 4/9/2014 - Statement of John D. Daigh, 

Jr., M.D., Assistant Inspector General for Healthcare Inspections, 

Office of Inspector General, Department of Veterans Affairs, Before the 

Committee on Veterans’ Affairs, United States House of Representatives, 

Hearing on “A Continued Assessment of Delays in VA Medical Care and 

Preventable Veteran Deaths” 

Congressional Testimony - 8/7/2013 - Statement of Michael L. Shepherd, 

M.D., Before the Committee on Veterans’ Affairs, United States Senate, 

Field Hearing: “Ensuring Veterans Receive the Care They Deserve: 

Addressing VA Mental Health Program Management” 

Congressional Testimony - 3/13/2013 - Statement of Linda A. Halliday, 

Assistant Inspector General For Audits and Evaluations, Office of Inspector 

General, Department of Veterans Affairs, Before the Subcommittee on 

Health, Committee on Veterans’ Affairs, United States House of 

Representatives, Hearing on “Meeting Patient Care Needs: Measuring the 

Value of VA Physician Staffing Standards” 

Congressional Testimony - 2/13/2013 - Statement of Office of Inspector 

General, Department of Veterans Affairs, to the Committee on Veterans’ 

Affairs, United States House of Representatives, Hearing on “Honoring The 

Commitment: Overcoming Barriers to Quality Mental Health Care for 

Veterans” 

Congressional Testimony - 9/14/2012 - Statement of Office of Inspector 

General, Department of Veterans Affairs, to Subcommittee on Health 

Committee on Veterans’ Affairs, United States House of Representatives, 

Hearing on “VA Fee Basis: Examining Solutions to a Flawed System” 

Congressional Testimony - 5/8/2012 - Statement of Office of Inspector 

General, Department of Veterans Affairs, before the Committee on 

Veterans’ Affairs, United States House of Representatives, Hearing on “VA 

Mental Health Care Staffing: Ensuring Quality and Quantity” 

VA Office of Inspector General 24 
Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix VA Health Care System 

Congressional Testimony - 4/25/2012 - Statement of Office of Inspector 

General, Department of Veterans Affairs, Before the Committee on 

Veterans’ Affairs, United States Senate, Hearing on “VA Mental Health 

Care: Evaluating Access and Assessing Care” 

Congressional Testimony - 11/15/2011 - Statement of Belinda J. Finn, 

Assistant Inspector General for Audits and Evaluations, Office of Inspector 

General, U.S. Department of Veterans Affairs, Before the Committee on 

Veterans’ Affairs, United States House of Representatives, Hearing on 

“Potential Budgetary Savings Within VA: Recommendations From 

Veterans Service Organizations” 

Congressional Testimony - 3/9/2011 - Statement of Richard J. Griffin, 

Deputy Inspector General, Office of Inspector General, U.S. Department of 

Veterans Affairs, before the Subcommittee on Military Construction, 

Veterans Affairs, and Related Agencies; Committee on Appropriations, 

United States House of Representatives, Hearing on “The State of the 

Department of Veterans Affairs” 

Congressional Testimony - 9/10/2009 - Statement of Maureen T. Regan, 

Counselor to the Inspector General, Office of Inspector General, 

Department of Veterans Affairs, Before the Subcommittee on Economic 

Opportunity, Committee on Veterans' Affairs, United States House of 

Representatives, Hearing on “The Review of SPAWAR and VA’s 

Interagency Agreement” 

Congressional Testimony - 5/6/2008 - Statement of Michael Shepherd, 

M.D., Senior Physician, Office of Healthcare Inspections, Office of 

Inspector General, Department of Veterans Affairs, Before the Committee 

on Veterans' Affairs, United States House of Representatives, Hearing on 

“Veterans' Suicides” 

Congressional Testimony - 2/27/2008 - Statement of the Office of Inspector 

General, Before Subcommittee on Military Construction, Veterans Affairs, 

and Related Agencies; Committee on Appropriations, United States House 

of Representatives, Hearing on “The Fiscal Year 2009 Budget for the Office 

of the Inspector General, Department of Veterans Affairs” 

Congressional Testimony - 2/13/2008 - Statement of Jon A. Wooditch, 

Deputy Inspector General, Department of Veterans Affairs, Before the 

Subcommittee on Oversight and Investigations, Committee on Veterans' 

Affairs, United States House of Representatives, Hearing on “The FY 2009 

Budget for the Office of Inspector General” 

Congressional Testimony - 12/12/2007 - Statement of Belinda J. Finn, 

Assistant Inspector General for Auditing, Office of Inspector General, 

VA Office of Inspector General 25 
Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix VA Health Care System 

Department of Veterans Affairs, Before the Subcommittee on Oversight and 

Investigations and the Subcommittee on Health, Committee on Veterans' 

Affairs, United States House of Representatives, Hearing on “Veterans 

Health Administration’s Outpatient Waiting Times” 

Congressional Testimony - 10/3/2007 - Statement of Larry Reinkemeyer, 

Director, Kansas City Audit Operations Division, Office of Inspector 

General, Department of Veterans Affairs, Before the Special Committee on 

Aging, United States Senate, Hearing on “Audit of the Veterans Health 

Administration’s Outpatient Waiting Times” 

VA Office of Inspector General 26 
 

 

Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix VA Health Care System 

Appendix G Office of Inspector General Contact and Staff 

Acknowledgments 

OIG Contact For more information about this report, please 

contact the Office of Inspector General at 

(202) 461-4720. 

VA Office of Inspector General 27 
Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths 

at the Phoenix VA Health Care System 

Appendix H Report Distribution 

VA Distribution 

Office of the Secretary
 

Veterans Health Administration
 

Veterans Benefits Administration 

National Cemetery Administration
 

Assistant Secretaries
 

Office of General Counsel 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans 

Affairs, and Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans 

Affairs, and Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

United States Senate: Michael Bennet, Jeff Flake, Dianne Feinstein, 

Charles Grassley, John McCain, Tom Udall, 

United States House of Representatives: Ron Barber, Joe Barton, 

Kevin Brady, Michael Burgess, John Carter, Mike Conaway, 

John Culberson, Blake Farenthold, Bill Flores, Trent Franks, Pete Gallego, 

Louis Gohmert, Paul Gosar, Kay Granger, Raúl M. Grijalva, Ralph Hall, 

Jeb Hensarling, Sam Johnson, Jack Kingston, Ann Kirkpatrick, 

Kenny Marchant, Michael McCaul, Randy Neugebauer, Pete Olson, 

Ed Pastor, Ted Poe, Matt Salmon, David Schweikert, Pete Sessions, 

Kyrsten Sinema, Lamar Smith, Mac Thornberry, Randy Weber, 

Roger Williams 

This report is available on our Web site at www.va.gov/oig. 

VA Office of Inspector General 28