VA Office of Inspector General

Veterans Health 

Administration 

Review of 

Alleged Patient Deaths, 

Patient Wait Times, and 

Scheduling Practices at the 

Phoenix VA Health Care System 

August 26, 2014 

14-02603-267 
 

ACRONYMS 

CBOC Community Based Outpatient Clinic 

CBT Cognitive Behavioral Therapy 

COPD Chronic Obstructive Pulmonary Disease 

CPRS Computerized Patient Record System 

CSTAT Consultation Stabilization Triage Assessment Team 

CT Computerized Tomography 

DBT Dialectical Behavioral Therapy 

ED Emergency Department 

EHR Electronic Health Record 

EWL Electronic Wait List 

FY Fiscal Year 

GAO Government Accountability Office 

HAS Health Administration Service 

HRC Health Resource Center 

HVAC House Committee on Veterans’ Affairs 

ICD Implantable Cardioverter Defibrillator 

LPN Licensed Practical Nurse 

NEAR New Enrollee Appointment Request 

OEF/OIF/OND Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn 

OIG Office of Inspector General 

PCP Primary Care Provider 

PDF Portable Document Format 

PET Positron Emission Tomography 

PSA Prostate-Specific Antigen 

PTSD Post-Traumatic Stress Disorder 

PVAHCS Phoenix VA Health Care System 

RSA Replacement Scheduling Application 

SPC Suicide Prevention Coordinator 

VA Department of Veterans Affairs 

VAMC Veterans Affairs Medical Center 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VistA Veterans Health Information Systems and Technology Architecture 

VSSC Veterans Health Administration Support Service Center 

WIG Wildly Important Goal 
-------------- 

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 Web page, 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) 
(This Page Left Intentionally Blank) 
EXECUTIVE SUMMARY 

The VA Office of Inspector General (OIG) reviewed allegations at the Phoenix VA Health Care 

System (PVAHCS) that included gross mismanagement of VA resources, criminal misconduct 

by VA senior hospital leadership, systemic patient safety issues, and possible wrongful deaths. 

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

expanded our work at the request of the former VA Secretary and the Chairman of the House 

Committee on Veterans’ Affairs (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. A complete list of requestors is 

located in Appendix J. 

	 House Committee on Veterans’ Affairs 

	 HVAC Subcommittee on Oversight and Investigations 

	 House Appropriations Committee 

	 House Appropriations Subcommittee on Military Construction, Veterans Affairs, and Related 

Agencies 

	 Senate Committee on Veterans’ Affairs 

	 Senate Appropriations Committee 

	 Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

On May 28, 2014, we published a preliminary report, Review of Patient Wait Times, Scheduling 

Practices, and Alleged Patient Deaths at the Phoenix Health Care System – Interim Report, to 

ensure all veterans received appropriate care and to provide VA leadership with 

recommendations for immediate implementation. This report updates the information previously 

provided in the Interim Report to reflect the final results of our review. We focused this report 

on the following five questions and identified serious conditions at the PVAHCS and throughout 

the Veterans Health Administration (VHA). 

	 Were there clinically significant delays in care? 

	 Did PVAHCS omit the names of veterans waiting for care from its Electronic Wait List 

(EWL)? 

	 Were PVAHCS personnel following established scheduling procedures? 

	 Did the PVAHCS culture emphasize goals at the expense of patient care? 

	 Are scheduling deficiencies systemic throughout VHA? 

i 
Due to the multitude and broad range of issues, we assembled a multidisciplinary team 

comprising board-certified physicians, special agents, auditors, and health care inspectors to 

evaluate the many allegations, determine their validity, and assign individual accountability if 

appropriate. The team interviewed numerous individuals to include the principal complainants, 

Dr. Samuel Foote, a retired PVAHCS physician, and Dr. Katherine Mitchell, the Medical 

Director of the PVAHCS Operation Enduring Freedom/Operation Iraqi Freedom/and Operation 

New Dawn (OEF/OIF/OND) clinic. In addition: 

	 We obtained and reviewed VA and non-VA medical records of patients who died while on a 

wait list or whose deaths were alleged to be related to delays in care. 

	 We reviewed two statistical samples of completed primary care appointments to determine 

the accuracy of patient wait times based on our assessment of the earliest indication a patient 

desired care. 

	 We reviewed over 1 million email messages, approximately 190,000 files from 11 encrypted 

computers and/or devices, and over 80,000 converted messages from Veterans Health 

Information Systems and Technology Architecture emails. 

The patient experiences described in this report revealed that access barriers adversely affected 

the quality of primary and specialty care at the PVAHCS. In February 2014, a whistleblower 

alleged that 40 veterans died waiting for an appointment. We pursued this allegation, but the 

whistleblower did not provide us with a list of 40 patient names. From our review of PVAHCS 

electronic records, we were able to identify 40 patients who died while on the EWL during the 

period April 2013 through April 2014. However, we conducted a broader review of 

3,409 patients identified from multiple sources, including the EWL, various paper wait lists, the 

OIG Hotline, the HVAC and other Congressional sources, and media reports. 

OIG examined the electronic health records (EHRs) and other information for the 3,409 veteran 

patients, including the 40 patients reflected above in PVAHCS’s records, and identified 

28 instances of clinically significant delays in care associated with access to care or patient 

scheduling. Of these 28 patients, 6 were deceased. In addition, we identified 17 care 

deficiencies that were unrelated to access or scheduling. Of these 17 patients, 14 were deceased. 

We also found problems with access to care for patients requiring Urology Services. As a result, 

Urology Services at PVAHCS will be the subject of a subsequent report. The 45 cases discussed 

in this report reflect unacceptable and troubling lapses in follow-up, coordination, quality, and 

continuity of care. 

During our review of EHRs, we considered the responsibilities and delivery of medical services 

by primary care providers (PCPs) versus specialty care providers (such as urologists, 

endocrinologists, and cardiologists). Our analysis found that the majority of the veteran patients 

we reviewed were on official or unofficial wait lists and experienced delays accessing primary 

care—in some cases, pressing clinical issues required specialty care, which some patients were 

already receiving through VA or non-VA providers. For example, a patient may have been 

seeing a VA cardiologist, but he was on the wait list to see a PCP at the time of his death. While 

the case reviews in this report document poor quality of care, we are unable to conclusively 

assert that the absence of timely quality care caused the deaths of these veterans. 

ii 
Supplementing data gathered from the EHR, we also analyzed information, when available, from 

sources that included Medicare, non-VA health records, death certificates, media reports, and 

interviews with VA staff. Approximately 23 percent of the patients we reviewed received 

private sector medical care funded by Medicare or Medicaid, and 35 percent had insurance 

coverage beyond VA. 

We identified several patterns of obstacles to care that resulted in a negative impact on the 

quality of care provided by PVAHCS. Patients recently hospitalized, treated in the emergency 

department (ED), attempting to establish care, or seeking care while traveling or temporarily 

living in Phoenix often had difficulty obtaining appointments. Furthermore, although we found 

that PVAHCS had a process to provide access to a mental health assessment, triage, and 

stabilization, we identified problems with continuity of mental health care and care transitions, 

delays in assignment to a dedicated health care provider, and limited access to psychotherapy 

services. 

As of April 22, 2014, we identified about 1,400 veterans waiting to receive a scheduled primary 

care appointment who were appropriately included on the PVAHCS EWL. However, as our 

work progressed, we identified over 3,500 additional veterans, many of whom were on what we 

determined to be unofficial wait lists, waiting to be scheduled for appointments but not on 

PVAHCS’s official EWL. These veterans were at risk of never obtaining their requested or 

necessary appointments. PVAHCS senior administrative and clinical leadership were aware of 

unofficial wait lists and that access delays existed. Timely resolution of these access problems 

had not been effectively addressed by PVAHCS senior administrative and clinical leadership. 

From interviews of 79 PVAHCS employees involved in the scheduling process, we identified the 

following types of scheduling practices not in compliance with VHA policy. Some schedulers 

identified multiple inappropriate scheduling practices. 

	 Thirty staff stated they used the wrong desired date of care, resulting in appointments 

showing a false 0-day wait time. 

	 Eleven staff stated they “fixed” or were instructed to “fix” appointments with wait times 

greater than 14 days. They did this by rescheduling the appointment for the same date and 

time but with a later desired date. 

	 Twenty-eight staff stated they either printed out or received printouts of patient information 

for scheduling purposes. Staff said they kept the printouts in their desks for days or 

sometimes weeks before the veterans were scheduled an appointment or placed on the EWL. 

PVAHCS executives and senior clinical staff were aware that their subordinate staff were using 

inappropriate scheduling practices. In January 2012 and later in May 2013, the Veterans 

Integrated Service Network 18 Director issued two reports that found PVAHCS did not comply 

with VHA’s scheduling policy. Our review also determined PVAHCS still did not comply with 

VHA’s scheduling policy. As a result of using inappropriate scheduling practices, reported wait 

times were unreliable, and we could not obtain reasonable assurance that all veterans seeking 

care received the care they needed. 

iii 
The emphasis by Ms. Sharon Helman, the Director of PVAHCS, on her “Wildly Important Goal” 

(WIG) effort to improve access to primary care resulted in a misleading portrayal of veterans’ 

access to patient care. Despite her claimed improvements in access measures during fiscal year 

(FY) 2013, we found her accomplishments related to primary care wait times and the third-next 

available appointment were inaccurate or unsupported. After we published our Interim Report, 

the Acting VA Secretary removed the 14-day scheduling goal from employee performance 

contracts. 

Inappropriate scheduling practices are a nationwide systemic problem. We identified multiple 

types of scheduling practices in use that did not comply with VHA’s scheduling policy. These 

practices became systemic because VHA did not hold senior headquarters and facility leadership 

responsible and accountable for implementing action plans that addressed compliance with 

scheduling procedures. In May 2013, the then-Deputy Under Secretary for Health for 

Operations Management waived the FY 2013 annual requirement for facility directors to certify 

compliance with the VHA scheduling directive, further reducing accountability over wait time 

data integrity and compliance with appropriate scheduling practices. Additionally, the 

breakdown of the ethics system within VHA contributed significantly to the questioning of the 

reliability of VHA’s reported wait time data. VHA’s audit, directed by the former VA Secretary 

in May 2014 following numerous allegations, also found that inappropriate scheduling practices 

were a systemic problem nationwide. 

Since the PVAHCS story first appeared in the national media, we received approximately 

225 allegations regarding PVAHCS and approximately 445 allegations regarding manipulated 

wait times at other VA medical facilities through the OIG Hotline, from Members of Congress, 

VA employees, veterans and their families, and the media. The VA OIG Office of Investigations 

opened investigations at 93 sites of care in response to allegations of wait time manipulations. In 

particular, we focused on whether management ordered schedulers to falsify wait times and 

EWL records or attempted to obstruct OIG or other investigative efforts. Investigations 

continue, in coordination with the Department of Justice and the Federal Bureau of Investigation. 

While most are still ongoing, these investigations confirmed wait time manipulations were 

prevalent throughout VHA. As of August 2014, among the variations of wait time 

manipulations, our ongoing investigations at the 93 sites have, thus far, found many medical 

facilities were: 

 Using the next available date as the desired date to “0-out” appointment wait times. 

 Canceling appointments and rescheduling appointments to make wait times appear to be less 

than they actually were. We substantiated that management at one facility directed 

schedulers to do this. 

 Using paper wait lists rather than official EWLs. 

 Canceling consultations (consults) without appropriate clinical review. 

 Altering clinic utilization rates to make it appear the clinic was meeting utilization goals. 

Wherever we confirm potential criminal violations, we will present our findings to the 

appropriate Federal prosecutor. If prosecution is declined, we will provide documented results 

of our investigation to VA for appropriate administrative action. We will do the same if our 

iv 
investigations substantiate manipulation of wait times but do not find evidence of any possible 

criminal intent. Finally, we have also kept the U.S. Office of Special Counsel apprised of our 

active criminal investigations as they relate to the U.S. Office of Special Counsel’s numerous 

referrals to VA of whistleblower disclosures of allegations relating to wait times and scheduling 

issues. 

This report cannot capture the personal disappointment, frustration, and loss of faith of 

individual veterans and their family members with a health care system that often could not 

respond to their mental and physical health needs in a timely manner. Immediate and substantive 

changes are needed. If headquarters and facility leadership are held accountable for fully 

implementing VA’s action plans for this report’s 24 recommendations, VA can begin to regain 

the trust of veterans and the American public. Employee commitment and morale can be rebuilt, 

and most importantly, VA can move forward to provide accelerated, timely access to the 

high-quality health care veterans have earned—when and where they need it. 

The VA Secretary concurred with all 24 recommendations and submitted acceptable corrective 

action plans. We will establish a rigorous follow up to ensure full implementation of all 

corrective actions. The VA Secretary acknowledged that VA is in the midst of a very serious 

crisis and will use the OIG’s recommendations to hone the focus of VA’s actions moving 

forward. The VA Secretary also apologized to all veterans and stated VA will continue to listen 

to veterans, their families, Veterans Service Organizations, and VA employees to improve access 

to the care and benefits veterans earned and deserve. 

RICHARD J. GRIFFIN 

Acting Inspector General 

v 
TABLE OF CONTENTS 

Executive Summary ...................................................................................................................... i-v
 

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

Question 2 Did PVAHCS Omit the Names of Veterans Waiting for Care From Its 

Question 3 Were PVAHCS Personnel Following Established Scheduling 

Question 4 Did the PVAHCS Culture Emphasize Goals at the Expense of Patient 

Appendix G VHA Directive 2010-027: VHA Outpatient Scheduling Processes and 

Appendix H Memorandum From the Deputy Under Secretary for Health for 

Operations and Management, April 26, 2010, Titled: Inappropriate 

Question 1 Were There Clinically Significant Delays in Care? ............................................1
 

Recommendations .............................................................................................33
 

Electronic Wait List? ........................................................................................34
 

Recommendations .............................................................................................47
 

Procedures? .......................................................................................................49
 

Recommendations .............................................................................................53
 

Care? .................................................................................................................55
 

Recommendations .............................................................................................63
 

Question 5 Are Scheduling Deficiencies Systemic Throughout VHA?..............................65
 

Recommendations .............................................................................................74
 

Appendix A Background .......................................................................................................76
 

Appendix B Scope and Methodology....................................................................................79
 

Appendix C Statistical Sampling Methodology ....................................................................84
 

Appendix D Phoenix Outreach Campaign, Health Resource Center .....................................86
 

Appendix E Chronology of OIG Oversight of Patient Wait Times ......................................90
 

Appendix F OIG Oversight Reports on VA Patient Wait Times ..........................................94
 

Procedures, June 9, 2010...................................................................................96
 

Scheduling Practices........................................................................................107
 

Appendix I OIG Testimony on VA Patient Wait Times ....................................................114
 

Appendix J Congressional Requests...................................................................................117
 

Appendix K VA Secretary Comments.................................................................................119
 

Appendix L Office of Inspector General Contact ...............................................................132
 

Appendix M Report Distribution..........................................................................................133
 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

RESULTS AND RECOMMENDATIONS 

Question 1 Were There Clinically Significant Delays in Care? 

The patient experiences described in this report revealed that various access 

barriers adversely affected the quality of primary and specialty care at the 

Phoenix VA Health Care System (PVAHCS). In the course of patient case 

reviews, we also identified other quality of care issues unrelated to delays. 

Patients recently hospitalized, treated in the emergency department (ED), 

attempting to establish care, or seeking care while traveling or temporarily 

living in Phoenix often had difficulty obtaining appointments. 

In February 2014, a whistleblower alleged that 40 veterans died waiting for 

appointments. We pursued this allegation, but the whistleblower did not 

provide us with a list of 40 patient names. From our review of PVAHCS 

electronic records, we were able to identify 40 patients who died while on 

the EWL during the period April 2013 through April 2014. However, we 

conducted a broader review of 3,409 patients identified from multiple 

sources, including the EWL, various paper wait lists, the OIG Hotline, the 

HVAC and other Congressional sources, and media reports. 

OIG examined the Electronic Health Records (EHRs) and other information 

for the 3,409 veteran patients, including the 40 patients, and identified 

28 instances of clinically significant delays in care associated with access or 

scheduling. Of these 28 patients, 6 were deceased. In addition, we identified 

17 cases of care deficiencies that were unrelated to access or scheduling. Of 

these 17 patients, 14 were deceased. We also found problems with access to 

care for patients requiring Urology Services. As a result, Urology Services 

at PVAHCS will be the subject of a subsequent report. The 45 cases 

discussed in this report reflect unacceptable and troubling lapses in followup, coordination, quality, and continuity of care. 

During our review of EHRs, we considered the responsibilities and delivery 

of medical services of primary care providers (PCPs) versus specialty care 

providers (such as, urologists, endocrinologists, and cardiologists). Our 

analysis found that the majority of the veteran patients we reviewed were on 

official or unofficial wait lists and experienced delays accessing primary 

care; in some cases, pressing clinical issues required specialty care, which 

some patients were already receiving through VA or non-VA providers. For 

example, a patient may have been seeing a VA cardiologist, but he was on 

the wait list to see a PCP at the time of his death. While the case reviews in 

this report document poor quality of care, we are unable to conclusively 

assert that the absence of timely quality care caused the deaths of these 

veterans. 

VA Office of Inspector General 1 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Clinically 

Significant 

Delays 

Deceased 

Patients 

(Cases 1–5, 27) 

Supplementing data gathered from the EHRs, we also analyzed information, 

when available, from sources that included Medicare, non-VA health 

records, death certificates, media reports, and interviews with VA staff. 

Approximately 23 percent of the patients we reviewed received private 

sector care funded by Medicare or Medicaid, and 35 percent had insurance 

coverage beyond VA. 

Clinically significant delays were found in the medical and/or surgical care 

or mental health care of 28 patients, including 6 patients who were deceased, 

4 patients with newly diagnosed conditions, 17 patients with chronic 

conditions, and 1 patient considered to be a risk to the public. 

Case 1 

A man in his late 60s had a history of homelessness, diabetes, head injury, 

hepatitis, and low back pain. He had been seen at multiple VA health care 

facilities across the United States during 2011–2013. He presented to the 

PVAHCS ED with a minor injury and requested a place to stay. He was 

found to have markedly elevated blood glucose (477 milligrams/deciliter 

[mg/dl]) and was treated with insulin and intravenous fluids. 

The patient stated that he did not want to take insulin, an injectable 

medication, and was therefore started on metformin, an oral blood 

sugar-lowering medication. The ED physician requested that he have a 

follow-up appointment with Primary Care within 24 hours. The patient was 

not given an appointment to be seen in Primary Care; multiple visits to 

non-VA EDs ensued, and he was hospitalized at two different non-VA 

hospitals. A death certificate obtained from the State of Arizona indicates 

the patient died at a local non-VA hospital 8 weeks after the PVAHCS ED 

visit. 

Given the patient’s homelessness and uncontrolled diabetes, hospitalization 

would have been optimal. In that he was not admitted, a more urgent 

scheduling effort than a “Schedule an Appointment” consultation (consult) 

was required. 

Case 2 

A man in his late 60s had a history of homelessness, hypertension, diabetes, 

cirrhosis, congestive heart failure, and emphysema. He had been 

hospitalized at a New England VA Medical Center (VAMC) and at a Texas 

VAMC. He presented to the PVAHCS ED with 1 week of generalized 

weakness and diarrhea. He had recently moved to the Phoenix area from 

New England. 

VA Office of Inspector General 2 
 

 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

A Schedule an Appointment consult for a new patient primary care 

appointment was placed on the day of the ED visit and again 2 days later. 

After an additional 2 days, the patient was hospitalized at a non-VA hospital 

for abdominal swelling and weakness. Eleven weeks after that admission, he 

was hospitalized at a different non-VA hospital for hepatic encephalopathy. 

More than 3 months after the patient’s death, PVAHCS staff attempted to 

call the patient to schedule a primary care appointment. 

Although unlikely to change the overall outcome for this patient with severe 

liver disease and other medical problems, primary care management could 

have improved symptom control and assisted with specialty care 

coordination. 

Case 3 

A man in his mid-60s had a history of diabetes, hypertension, 

hyperlipidemia, cigarette smoking, and post-traumatic stress disorder 

(PTSD). He transferred his care from a Midwest VAMC and registered for 

care at PVAHCS. The patient’s family reported that he was having flu-like 

symptoms and that they attempted to get him an appointment at PVAHCS 

several times after registration without success. 

Four months after registering at PVAHCS, the patient sought care for flu-like 

symptoms and shortness of breath at a non-VA medical facility, where he 

was diagnosed and treated for pneumonia. A computerized tomography 

(CT) scan performed at that facility revealed a large left pulmonary mass and 

enlarged lymph nodes suggesting “local spread of malignancy.” The patient 

was advised to follow up with his PCP to have a positron emission 

tomography (PET) scan. 

Two weeks later, the patient called PVAHCS and explained that he had been 

recently discharged from a local hospital and needed “another test.” He was 

advised to “walk-in,” which he did, and was seen that same day. On 

examination, a provider noted an “enlarged, firm lymph node in the 

supraclavicular [above the collarbone] area on the left side” and ordered a 

CT scan of the chest. The CT scan, completed 1 month later, revealed a 

large left hilar mass and bilateral mediastinal and hilar adenopathy. Four 

weeks after the CT scan, the patient underwent “diagnostic bronchoscopy 

with endobronchial biopsy & lavage + axillary needle biopsy.” A diagnosis 

of lung cancer was made, and a PET scan confirmed widely metastatic 

disease. Arrangements were made to enroll the patient in hospice. The EHR 

contained no information indicating where the patient died, or whether 

hospice care was actually provided prior to his death. 

VA Office of Inspector General 3 
 

 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

There are two concerns in this case. First, the patient never received a 

primary care appointment as requested when he registered at PVAHCS, 

although this does not mean that the patient’s lung cancer would have been 

detected sooner. The second concern is that once malignancy was suspected, 

at least 9 weeks elapsed before a definitive diagnostic procedure was 

performed. 

Given the size and location of the tumor at the time of diagnosis, the delay in 

care for this patient was unlikely to have had a negative effect on his overall 

prognosis. However, his care might have been improved if palliative care 

had been implemented sooner. 

Case 4 

A man in his late 70s had a history of hypertension, chronic alcohol abuse, 

and obesity. In late 2011, the patient was seen in the PVAHCS ED for 

“bronchitis vs early pneumonia.” He was not seen again at PVAHCS until 

the summer of 2013, when he presented to the PVAHCS ED with lower 

extremity edema. He was found to have deep vein thrombosis, was briefly 

hospitalized, and discharged home with anticoagulant medications. At the 

time, a Schedule an Appointment consult was entered for an urgent Primary 

Care appointment. 

The patient was seen again in the ED 2 weeks later for back pain. The 

treating provider’s note included the statement, “Follow up with assigned 

clinic or primary care physician within 72 hrs [hours] from this emergency 

room visit today.” At that time the patient was noted to be anemic 

(hematocrit 28 percent; normal is greater than 37). 

The patient presented again to the ED 1 month later with a nosebleed, and a 

nasal balloon was placed. He was seen in the ED 2 days later for removal of 

the nasal balloon, and at that time, another Schedule an Appointment consult 

was entered for Primary Care; an appointment “Within 1 week” was 

requested. 

One month later, the patient presented again to the PVAHCS ED with 

weakness and decreased urine output, and he was admitted to the hospital. 

He was noted to have a history of uncontrolled hypertension and was 

considered to be volume depleted. Laboratory testing revealed acute renal 

injury, hypoalbuminemia (low blood albumin), and nephrotic range 

proteinuria (large amount of protein in the urine). Following a 1-week 

hospitalization, he was discharged to a skilled nursing facility for 

rehabilitation. He died 5 weeks later. 

This patient had delayed Primary Care follow-up after several ED visits. 

With anticoagulation, anemia, hypertension, and kidney disease, earlier 

VA Office of Inspector General 4 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Patients With 

Newly Diagnos 

ed Conditions 

primary care management could have expedited treatment of anemia and 

hypertension and facilitated coordination of his specialty care. 

Case 5 

A man in his mid-50s had a history of pancreatitis, three cerebrovascular 

accidents (strokes), hypertension, and polysubstance abuse. He moved to the 

Phoenix area from the East Coast in early 2014. He had received treatment 

at another VAMC as well as from non-VA providers prior to his relocation 

to Phoenix. 

The patient presented to the PVAHCS ED with abdominal pain, was given 

medications for nausea and pain, instructed to follow up with a PCP “within 

72 hours,” and discharged home. According to an entry on the Schedule an 

Appointment consult record, the consult was canceled the next day and a 

note was put in the EHR documents that a message was left for the patient to 

call and schedule an appointment. 

Ten days later the patient again presented to the ED because of persistent 

pain and he had run out of pain medication. According to the nursing triage 

note, “Pt [The patient] states he forgot to take his lisinopril [a blood pressure 

lowering medication] today.” His blood pressure was 209/107 millimeters of 

mercury (mm Hg). He requested methadone and Percocet [oxycodone and 

acetaminophen] but was prescribed only a limited supply of oxycodone and a 

medication for nausea. The plan outlined by the ED physician stated that the 

patient should follow up with Primary Care within 2 days. The patient died 

12 days later at a non-VA hospital. The cause of death given on the death 

certificate was “multiple prescription medication intoxication.” 

Despite this patient’s need for blood pressure monitoring and treatment, as 

well as management of other chronic conditions, he never received an 

appointment with Primary Care. 

Case 6 

A man in his mid-50s presented to the PVAHCS ED with shortness of 

breath, excessive sweating, thirst, and numbness in both hands. His blood 

glucose level was markedly elevated (516 mg/dl), and he was prescribed 

metformin and advised to see his PCP within 1 week. He was not seen by a 

PCP, ran out of medication, and returned to the ED 1 month later with 

symptoms of uncontrolled diabetes. His medications were renewed, and a 

diabetes teaching appointment was made. Twelve weeks later he was seen in 

Primary Care. 

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

Scheduling Practices at the Phoenix VA Health Care System 

This symptomatic patient with newly diagnosed diabetes was not scheduled 

to see a PCP for almost 4 months after an ED visit at which significant 

symptoms and laboratory abnormalities were noted. 

Case 7 

A man in his late 60s was evaluated in the PVAHCS ED for a subcutaneous 

cyst on his back and treated with an antibiotic. Eight months later, he was 

seen in the ED for chest pain. His blood pressure was 

180/124 mm Hg, and an electrocardiogram showed an abnormality. After 

his hypertension was treated and testing showed no myocardial infarction, he 

was discharged with blood pressure medication and advised to follow up 

with a PCP within 2 weeks. No Cardiology appointment was made, but a 

Primary Care appointment was scheduled for 7 months later. A PVAHCS 

physician who became aware of this patient’s situation evaluated him 

5 months after the ED visit and entered a referral to cardiology. The patient 

subsequently underwent coronary artery bypass surgery. 

Although this patient had a favorable outcome, the delay in scheduling 

follow-up care after an ED visit exposed him to unnecessary risk. 

Case 8 

A man in his early 40s presented to the PVAHCS ED concerned that he 

might have melanoma, a potentially fatal form of skin cancer. 

The ED provider note described skin lesions on each arm and the left ankle, 

“present for about a year, recently getting larger, changing shape and 

darker...could be melanoma, needs further evaluation.” 

A referral to general surgery was requested by the ED provider, but this 

consultation was canceled by a general surgeon the next day with a notation 

that the patient should be evaluated and treated by dermatology. 

Approximately 10 months later, the patient was evaluated in Primary Care, 

and a consult was placed to Dermatology. The lesions were determined to be 

benign. 

Failure of basic consult management and coordination of care could have led 

to serious consequences had these lesions ultimately been diagnosed as 

melanoma. 

Case 9 

A man in his 60s was treated in the past at PVAHCS for substance abuse, 

depression, and PTSD. After 15 years, he presented to the PVAHCS Mental 

Health Clinic, and a psychiatrist wrote that he had PTSD, depression, alcohol 

abuse, and multiple problems with his “primary support system.” At that 

VA Office of Inspector General 6 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Patients With 

Chronic 

Conditions 

visit, the patient’s blood pressure was 191/102 mm Hg and a repeat 

measurement was 175/102 mm Hg; a Schedule an Appointment consult for 

routine Primary Care follow-up was entered. One week later the patient was 

added to the EWL for a PCP appointment, and an appointment was made 

for 15 weeks after the Mental Health Clinic visit. The patient was seen again 

in the Mental Health Clinic 5 weeks after the initial visit, but his blood 

pressure was not recorded. 

This patient’s hypertension warranted expeditious evaluation and treatment, 

which did not occur. 

Case 10 

A man in his 40s had a history of hypertension, traumatic brain injury, and 

alcohol abuse. He reported to the OIG Hotline that he called PVAHCS for 

an appointment to have his blood pressure checked and was told that an 

appointment would not be available for 6 months. He stated that 3 months 

after calling PVAHCS, he awoke with vertigo, nausea, and slurred 

speech. These symptoms resolved within a day, and he did not seek medical 

attention for them. After an additional 2 months, he was in an 

all-terrain vehicle accident and began having more frequent symptoms of 

slurred speech and dizziness. 

When he was seen for his scheduled Primary Care appointment, his blood 

pressure was 163/107 mm Hg, and he was started on antihypertensive 

medications, counseled on alcohol use, and asked to follow up in 2 weeks. 

However, 1 week later he returned to the ED complaining of stuttering and 

slurred speech, and brain imaging was performed that revealed a large tumor. 

He subsequently underwent craniotomy and chemoradiation with no 

apparent recurrence of tumor. 

This patient waited 6 months for a PCP appointment, during which time 

symptoms occurred that were attributed by the patient to hypertension. 

Although timely Primary Care management might have led to an earlier 

diagnosis of the patient’s brain tumor, his overall prognosis was probably 

unchanged. 

Case 11 

A man in his early 60s had a history of alcohol abuse and untreated 

hypertension. At the end of 2013, he presented to the Phoenix ED 

complaining of 2 weeks of shortness of breath. He was admitted overnight, 

diagnosed with “decompensated heart failure,” and scheduled for an 

outpatient echocardiogram. A Schedule an Appointment consult was placed 

for Primary Care. The echocardiogram was performed 3 weeks later. 

VA Office of Inspector General 7 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

He returned to the ED after another 3 weeks with extreme shortness of breath 

and vomiting, was admitted to the hospital, and soon transferred to the 

Intensive Care Unit. The result of the recent echocardiogram was not readily 

available because the interpretation had not yet been entered into the EHR. 

After evaluation by cardiology, he was transferred emergently to a non-VA 

hospital where a defibrillator and pacemaker were placed. The EHR reveals 

that on the date of that transfer, the echocardiogram was interpreted as 

showing severely decreased cardiac function (left ventricular ejection 

fraction, 10 percent). 

The Schedule an Appointment consult was closed, and the patient was placed 

on the EWL with a comment stating that the “wait time is approximately 

143 days for a new patient appointment.” 

This patient had severely impaired heart function identified by 

echocardiography. Prompt medical management might have prevented his 

subsequent deterioration. 

Case 12 

A man in his 70s was found to have an elevated prostate-specific antigen 

(PSA) and was referred by a PCP to the Urology Service. However, the 

consult was amended as “needs another psa.” A Urology appointment was 

scheduled for 3 months later, but this appointment was canceled by the 

Urology Clinic 1 week before the scheduled date because “provider not 

available”; the appointment was not rescheduled. 

The PCP entered a referral for non-VA urology care 4 months after the 

original request, but this was denied on the basis that “the facility provides 

this service.” After an additional 4 months, the facility closed the Urology 

Service consult request, indicating “no longer accepting consults.” A request 

for non-VA urology care was again submitted, and the patient was seen by a 

non-VA urologist more than 11 months after the initial request. Prostate 

biopsy revealed prostate cancer. 

This patient had a prolonged delay between the time his abnormal blood test 

was noted and a diagnosis was made. 

Case 13 

A man in his late 60s had an extensive cardiac history, including a 

myocardial infarction and placement of multiple coronary artery stents at 

non-VA facilities. After experiencing financial difficulties and unable to 

afford his medications, he was admitted to PVAHCS after presenting to the 

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

Scheduling Practices at the Phoenix VA Health Care System 

ED complaining of palpitations. Tests revealed no new abnormalities, and 

he had marked symptomatic improvement after medications were resumed. 

During his hospitalization, an outpatient cardiology appointment was 

scheduled, but that appointment was canceled because “provider sick.” The 

appointment was rescheduled for the following month, but that appointment 

was canceled due to a “change in profile.” The consult was ultimately 

discontinued as “too old.” 

Four months after his initial ED presentation, during a routine Primary Care 

appointment, another Cardiology Service consult was entered. However, the 

consult was discontinued with the notation “cardiac work-up negative, 

symptoms due to non-compliance.” 

One month later, the patient presented to the ED with chest pain and 

palpitations and was admitted to the hospital. Another Cardiology Service 

consult was requested and the patient was seen as an outpatient the following 

month. 

This patient with significant cardiac disease experienced repeated delays in 

establishing follow-up care with Cardiology. Although no negative clinical 

consequences are certain, appropriate cardiology care may have prevented 

re-hospitalization. 

Case 14 

A man in his 60s was found to have a nodular prostate. This finding 

prompted his PCP to place a referral to the PVAHCS Urology Service. An 

appointment was made for 3 months later, and the patient was seen and 

referred to an outside facility for a prostate biopsy. 

Approximately 6 weeks later, after the biopsy was completed, the patient 

delivered a pathology report describing prostate cancer to the PVAHCS 

Urology Clinic, and a VA urologist called the patient to inform him that 

surgery would be arranged at a non-VA hospital. 

In a complaint received by the OIG Hotline, the patient described a 

frustrating group of events over the next 2 months in which PVAHCS 

allegedly had no record of the non-VA referral for the procedure, the VA 

urologist who called the patient left PVAHCS, outside pathology and/or 

laboratory reports were misplaced, and multiple messages were not returned 

from the Patient Advocate’s office. In mid-November, the Patient 

Advocate’s office called the patient to state he had been approved for the 

outside surgical procedure and four follow-up visits. Eight months after the 

initial referral to Urology, the patient had an uneventful surgery. 

VA Office of Inspector General 9 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

This patient with biopsy-proven prostate cancer experienced repeated 

scheduling delays and poor coordination of care with non-VA providers. 

Case 15 

A man in his late 50s was seen in the PVAHCS ED for toe pain. Because of 

an elevated blood glucose level (206 mg/dl), he was considered to possibly 

have a new diagnosis of diabetes. He was subsequently seen in the 

Ambulatory Clinic and received foot care. 

The patient was seen in Primary Care 3 months after the ED visit and 

hospitalized after he was found to have markedly elevated blood glucose 

level (739 mg/dl). The patient reported multiple symptoms consistent with 

uncontrolled diabetes, including weight loss, excessive urination, and 

excessive drinking. He was discharged from the hospital on insulin and 

metformin (an oral blood sugar-lowering medication). 

The elapsed time between the patient’s ED visit and his initial appointment 

to be seen in Primary Care was excessive. Had the patient been scheduled 

more timely to be seen in Primary Care, it is likely that medications, 

education, and risk-appropriate screenings could have prevented his later 

inpatient admission. 

Case 16 

A man in his mid-30s had a history of anxiety and suicidal ideation. He 

called PVAHCS for an appointment and was placed on the EWL. Five 

weeks later, he was called by the facility and told he had a Primary Care 

appointment in another 4 weeks. 

The patient had been hospitalized at an East Coast VAMC for 1 week during 

the prior year for suicidal ideation and anxiety. At discharge, he declined 

further treatment, saying that he was moving to Phoenix. The East Coast 

VAMC Suicide Prevention Coordinator (SPC) wrote a note in the EHR 

indicating that PVAHCS SPC was alerted by a voice mail about this patient, 

but there was no documentation from the PVAHCS SPC that acknowledged 

receipt of that message. 

The patient was seen in a PVAHCS Primary Care Clinic as scheduled, 

and a referral was made to the Mental Health Clinic. Three weeks later, the 

patient was contacted by the Mental Health Clinic to arrange an intake 

appointment. 

For this patient with a history of hospitalization for suicidal ideation and 

anxiety, continued outpatient mental health treatment was important. The 

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

Scheduling Practices at the Phoenix VA Health Care System 

delay in scheduling an initial Primary Care appointment led to a delayed 

referral to Mental Health. 

Case 17 

A man in his 50s had a history of chronic tobacco use, chronic obstructive 

pulmonary disease (COPD), diabetes, and anxiety. In mid-December 

2013, he presented to the PVAHCS ED with symptoms suggestive of an 

upper respiratory infection and COPD. The patient was treated and 

discharged with medications. Through a Schedule an Appointment consult, 

Primary Care follow-up was requested within 1 month. 

About 1 month later, the patient returned to the ED because he ran out of his 

medications. He had not been scheduled to be seen in Primary Care. In 

early February, he returned to the ED with symptoms suggestive of another 

COPD flare. About 1 month later, he returned to the ED requesting 

medication refills. In early May, he was seen for his first scheduled 

appointment in Primary Care. 

This case reveals a missed opportunity to treat a patient with a chronic 

disease in an outpatient setting and demonstrates why some patients use the 

ED for “primary care.” At least one of the patient’s COPD exacerbations 

may have been averted if the patient had been seen in Primary Care sooner. 

Case 18 

A man in his late 80s lives in the Midwest for half the year and in Arizona 

the other half. He receives both private care and VA care, and is registered 

with and followed by Primary Care at a Midwest VAMC. 

In late December 2013, the patient presented to the PVAHCS ED with 

symptoms suggestive of a urinary tract infection, and blood tests revealed 

evidence of kidney disease. He was prescribed an antibiotic, and 

adjustments were made to his anti-hypertension regimen. 

In early January 2014, the patient walked in to Primary Care for repeat labs 

and a blood pressure check, as instructed by the ED physician. His blood 

pressure was found to be 165/82 mm Hg. He had a new patient appointment 

pending for about 3 weeks later at PVAHCS. When he arrived for that 

appointment, he was not triaged, but rather, a licensed practical nurse (LPN) 

informed him that he cannot have two Primary Care teams (that is, in 

Phoenix and the Midwest). The patient left after choosing the Midwest 

VAMC as his home base. 

While VHA policy discourages the practice of assigning more than one 

Primary Care team, it is not prohibited in all circumstances. VHA policy 

VA Office of Inspector General 11 
 

 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

allows for the assignment of two Primary Care teams when veterans split 

their time between different residences located in different geographic 

areas.1 The patient could have had a Primary Care team assigned at 

PVAHCS, while maintaining his care in the Midwest. 

This was an elderly patient with a change in his blood pressure medication 

regimen and significantly reduced renal function. The patient, after being on 

his new regimen for 1 week, had persistent hypertension and might have 

benefited from a medication adjustment. The patient presented for a 

scheduled appointment but left after being given misinformation regarding 

VHA management of veterans who split their residence between two 

different locations. 

Case 19 

A man in his late 50s who had a history of methamphetamine abuse 

presented to PVAHCS in early May 2013 complaining of new blurry vision 

and was found to have a blood pressure of 224/124 mm Hg. He was 

evaluated that day by Ophthalmology and referred to Primary Care. The 

ophthalmologist who saw the patient in the following week attributed his 

visual changes to hypertension. 

Four months after his initial ED visit, the patient went to the ED requesting a 

refill of medications he had been prescribed a few days earlier at a non-VA 

hospital. He reported that he had been diagnosed with a stroke there. The 

ED physician who saw him submitted another consult request for Primary 

Care follow-up. 

In early October, the patient contacted the facility requesting a new Primary 

Care appointment “as soon as possible.” The first successfully scheduled 

Primary Care appointment was made for 1 month later. In early December, 

the patient completed an appointment in Primary Care. About a month later, 

the patient was admitted to a non-VA hospital for a new stroke, which 

resulted in significant loss of vision in both eyes. 

The patient was an amphetamine abuser and had dangerously elevated blood 

pressure during his initial visit. His wait for Primary Care was excessive, 

and while waiting, he suffered a stroke. A timelier Primary Care visit could 

have improved his blood pressure control and allowed for treatment of his 

substance abuse which could have reduced his risk for stroke. 

1

 VHA Directive 2007-016, Coordinated Care Policy for Traveling Veterans, May 9, 2007. 

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

Scheduling Practices at the Phoenix VA Health Care System 

Case 20 

A man in his mid-50s was seen in the PVAHCS ED in late 

January 2014, 2 weeks after his release from incarceration. He stated that his 

blood pressure was 180/120 mm Hg while incarcerated and that he had not 

been taking his medications after being released. In the ED, his blood 

pressure was 162/128 mm Hg, and his urine tested positive for 

amphetamines and cocaine. He was prescribed two medications for his 

blood pressure and instructed to follow up with a PCP, even if outside the 

VA system, or at an ED if his blood pressure readings remained markedly 

elevated. 

With blood pressure readings so high in a patient with significant heart 

disease, any delay in follow-up and primary care is concerning. The EHR 

did not reflect a sufficiently aggressive approach. 

Case 21 

A man in his early 60s had a history of diabetes, COPD, obstructive sleep 

apnea, and obesity. He had been seen regularly at a PVAHCS Primary Care 

Clinic from 2007 through 2011. He had no further encounters until early 

March 2014 when he presented as a “walk-in” complaining of swelling and 

shortness of breath. He said that he had recently lost his private insurance 

and no longer had any medication. A nurse noted that his oxygen saturation 

was reduced (89 percent; normal is greater than 95 percent). After 

consulting with the physician on staff, the nurse advised the patient that she 

was going to call Emergency Medical Services so that patient could be 

transported to the nearest ED. The patient refused but did agree to drive 

himself to the PVAHCS ED. 

After an evaluation at the PVAHCS ED, the patient was admitted to the 

medicine ward. He was restarted on his medications, pulmonary function 

and other tests were scheduled, and a Schedule an Appointment consult was 

placed for Primary Care. Six weeks later pulmonary function tests were 

performed, revealing significant COPD. Nineteen weeks after 

hospitalization, the patient had not been scheduled with a PCP. 

Despite discharge instructions indicating a need for Primary Care follow-up 

within 2 weeks, this patient with significant pulmonary disease had not been 

scheduled for Primary Care. 

Case 22 

A man in his late 60s was seen at the PVAHCS ED for right knee pain. In 

the course of his evaluation, the patient was also found to have a markedly 

elevated blood pressure (241/137 mm Hg). The ED provider treated his 

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

Scheduling Practices at the Phoenix VA Health Care System 

hypertension and requested that the patient be seen by Primary Care within a 

week. Seven months later, the patient had not been scheduled for a Primary 

Care appointment nor had he made other visits to PVAHCS. 

This patient’s blood pressure elevation warranted treatment in the immediate 

weeks after his ED visit, but no treatment was documented for the next 

7 months. 

Case 23 

A man in his early 40s had a history of major depressive disorder, diabetes, 

hyperlipidemia, and hypertension. His initial contact with PVAHCS was in 

October 2013, when he was hospitalized for a major depressive disorder. At 

that time laboratory values indicated very poor diabetes control and marked 

cholesterol elevation (total cholesterol, 470 mg/dl; LDL cholesterol, 

307 mg/dl). His medical regimen at discharge included drugs for diabetes 

and hypercholesterolemia, including insulin, glyburide, metformin, and 

atorvastatin. 

The discharge summary specified, “please schedule for a new patient 

Primary Care appointment.” The patient was not scheduled in Primary Care 

for 6 months. When he was seen, his diabetes control was even worse and he 

had blurred vision. 

This patient, with very poorly controlled diabetes and extreme 

hyperlipidemia, had substantially delayed care. 

Case 24 

This patient is a man in his early 40s who registered for care at PVAHCS in 

September 2012, and his first primary care appointment was 8 months later. 

At that appointment, he revealed a history of hypertension, hyperlipidemia, 

severe alcohol abuse, anxiety, and depression. He was later diagnosed with 

steatohepatitis. The patient subsequently underwent successful treatment for 

alcohol abuse. 

This patient with significant mental and physical health issues waited 

8 months for initiation of treatment. 

Case 25 

A man in his 60s presented to the PVAHCS ED in late January 2014 with 

chest pain and shortness of breath. He reported that he had recently been 

treated at a non-VA hospital for coronary artery disease and had a stent 

placed. In the ED, an electrocardiogram showed no abnormalities, and blood 

tests were negative for acute myocardial infarction. He was considered to 

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

Scheduling Practices at the Phoenix VA Health Care System 

Patient Who 

Committed 

Suicide 

(Case 27) 

have “atypical chest pain,” and a Schedule an Appointment consult was 

placed. An appointment for Primary Care was made for 2 months later. 

When he presented for that appointment, he was sent to the ED, where he 

was admitted with a cough and shortness of breath. He was subsequently 

evaluated by a pulmonologist and his symptoms were attributed to 

gastroesophageal reflux. 

This patient with known significant coronary artery disease had a delay in 

initial primary care that might have exposed him to unnecessary risk. 

Case 26 

This man in his early 40s has a history of polysubstance abuse, panic 

disorder, and homelessness. 

In early December 2013, he was seen in the ED for a rash, and an ED 

physician placed a consult for a PCP assignment. Throughout January 

2014, the patient repeatedly sought care in the ED, frequently requesting 

narcotics, and multiple references were made as to the need for “follow-up 

with PCP.” In late January, an ED physician again entered a consult 

requesting PCP services. 

This high-risk patient with polysubstance abuse was utilizing the ED for 

basic health care needs. As of June 3, 2014, the patient had not been seen in 

Primary Care. 

Case 27 

A man in his late 50s had a history of bipolar disorder, alcohol dependence, 

and four suicide attempts. He moved to Phoenix from Texas where he had 

been followed by both Mental Health and Primary Care. His last visit with 

his mental health provider in Texas was in late July 2013, with plans for a 

follow-up in 4 months, which the patient did not attend. 

In early December, the patient registered with PVAHCS and applied for an 

outpatient medical appointment. He was placed on the EWL 3 days later. In 

early April 2014, the patient contacted PVAHCS about the status of his 

appointment and reported he was having “ongoing issues.” A medical 

services assistant informed the patient that he could come into any clinic as a 

“walk-in.” 

On two occasions in mid-April, PVAHCS staff unsuccessfully attempted to 

call the patient to set up a new appointment and left voice messages. In late 

April, the patient called to schedule an appointment; he was informed that 

someone would contact him. In early May, the facility made another 

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

Scheduling Practices at the Phoenix VA Health Care System 

Patient for 

Whom Risk to 

the Public Was 

a Concern 

Other Quality 

of Care Issues 

Deceased 

Patients 

(Cases 29–42) 

unsuccessful attempt to contact the patient and also sent a letter to the patient 

with the facility’s contact information. 

Three days later, the patient committed suicide by gunshot. His brother told 

the suicide prevention social worker that the patient had been depressed for a 

long time. 

This patient was at increased risk of suicide. A timely Primary Care 

appointment was not available at the time of initial contact, and the patient 

was placed on the facility’s EWL. Better availability of an appointment for 

this patient might have changed the outcome. 

Case 28 

This man in his early 60s had a history of schizophrenia. He was released 

from prison after being incarcerated for 16 years following a conviction for 

manslaughter. One year later, he registered for care at PVAHCS at a “Stand 

Down” (a homeless veteran outreach event), and he was given an 

appointment for primary care for 4 months later. He was seen in Primary 

Care 2 weeks before his scheduled appointment, and hallucinations and 

suicidal ideation were discussed. He was referred to Mental Health. 

Although it is unclear what PVAHCS knew about his history at the time of 

registration, this patient was a potential threat to himself and others. He had 

schizophrenia and a history of violence and was without medication and 

having auditory hallucinations and suicidal ideation. A timely appointment 

at the time of registration should have been provided. 

In addition to the 28 cases discussed earlier that had clinically significant 

delays, OIG identified deficiencies unrelated to delays in the care of 

17 patients, including 14 who were deceased. 

Case 29 

A man in his early 60s had a history of severe cardiomyopathy (disease of 

the heart muscle), hypertension, poorly controlled diabetes, hepatitis B, 

hepatitis C, and tobacco use. An echocardiogram performed in late summer 

2013 showed the patient’s cardiac function was severely depressed, 

indicating severe heart failure and increased risk for abnormal heart rhythms 

and sudden death. 

The patient was followed in PVAHCS’s Primary Care and Cardiology 

Clinics. Two days following the echocardiogram, a cardiologist entered a 

consult to the Tucson, AZ, VAMC’s Cardiology-Electrophysiology Service 

for consideration of an implantable cardioverter defibrillator (ICD) with or 

without cardiac resynchronization. The patient had an ICD placed 

VA Office of Inspector General 16 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

approximately 5 years previously, but it was removed because of 

complications caused by either infection or metal allergy. 

Two weeks after the consult to the Tucson VAMC was entered, a Cardiology 

nurse practitioner at the Tucson VAMC called the patient. During that 

conversation, the patient stated that he wanted allergy testing before any new 

device was placed. 

Five weeks later, an allergy patch test revealed no reaction to metals. The 

PVAHCS cardiologist sent a note attached to the consult to the Tucson 

VAMC’s Cardiology-Electrophysiology Service stating that the patient “can 

now be scheduled for CRT-D [cardiac resynchronization therapy with 

defibrillator].” The cardiologist recommended that the procedure be done in 

the next 4 to 5 weeks. 

One month later, the patient was seen by a PVAHCS cardiologist. The 

cardiologist added another note to the Tucson VAMC 

Cardiology-Electrophysiology consult stating that the patient needed to be 

seen for device implantation. 

In early 2014, the patient had a routine follow-up appointment at PVAHCS 

in Primary Care. One week later PVAHCS was informed of his death. 

Medical records from a local non-VA hospital indicated that 3 days prior to 

his death, the patient’s family witnessed him collapse in his kitchen. Upon 

arrival, Emergency Medical Services notes indicated that the patient was 

pulseless and in ventricular fibrillation. 

According to PVAHCS records, the patient was on an EWL for an 

Endocrinology Service consult that had been placed in late spring of 2013 for 

management of the patient’s poorly controlled diabetes. The patient 

reportedly agreed to an appointment 1 month later, but he did not go to that 

appointment. 

The ICD should have been placed within a few months of the most current 

plan. This patient’s severe cardiac disease placed him at risk for sudden 

death at any time. ICD placement might have forestalled that death. 

Case 30 

A man in his mid-50s had a history of hypertension and chronic pain due to 

degenerative joint disease involving his neck. He was followed by Primary 

Care, and his pain management plan consisted of physical therapy and 

limited use of hydrocodone. He was awaiting a Neurosurgery evaluation of 

his neck to determine if a surgical intervention could help with his pain. 

VA Office of Inspector General 17 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

In mid-2013, the patient called his PCP requesting stronger pain medication, 

as his usual medication was not helping his “torso pain.” Two days later, the 

provider documented that the patient could pick up an alternative pain 

medication at the outpatient pharmacy. There is no documentation in the 

EHR that the provider evaluated the patient by phone or in person. 

Two days after starting the new medication, the patient presented to the ED 

complaining of severe abdominal pain. He was noted to have “10/10” (worst 

possible) abdominal pain, a temperature of 95 degrees Fahrenheit, and a 

pulse of 111 beats per minute. He was evaluated by an ED physician within 

20 minutes. A CT scan of his abdomen, completed 2 hours later, showed a 

perforated bowel (a hole in the wall of the bowel that can quickly lead to 

life-threatening infection and/or sepsis). A surgical consult was requested 

4 hours after the CT scan, and another hour passed before a surgery resident 

evaluated the patient. The patient was taken to the operating room for an 

exploratory laparotomy (a surgery that opens the abdominal cavity) within 

2 hours of the surgeon’s evaluation. The patient remained on pressors 

(intravenous medications used to elevate blood pressure in the setting of 

shock) and ventilator support postoperatively. Two days later, the family 

removed life support and the patient died. 

This patient being treated for chronic neck pain described a new location of 

pain, and this description should have prompted a telephone or face-to-face 

assessment. At his final presentation to the ED, hypothermia and tachycardia 

warranted prompt and intensive interventions. Earlier diagnosis and 

treatment might have altered the outcome in this case. 

Case 31 

A man in his mid-60s had a history of prostate cancer, diabetes, PTSD, and 

morbid obesity. He was followed routinely in Primary Care at PVAHCS. 

The patient was diagnosed with prostate cancer at another VA facility in the 

fall of 2010. He was treated with radiation therapy followed by leuprolide 

injections. 

His last normal recorded PSA was at the “undetectable” level, noted at a 

2012 Urology Clinic follow-up appointment. The patient was instructed by 

the urologist to return in 6 months for an examination and repeat PSA. 

According to the patient’s EHR, that follow-up appointment was canceled by 

Urology staff 3 months before the appointment was to occur. There was no 

evidence in the EHR indicating that staff attempted to contact the patient to 

reschedule this appointment. 

Three months after the “canceled” appointment, during a Compensation and 

Pension examination, another PSA level was ordered. The result showed a 

VA Office of Inspector General 18 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

value of 0.90 ng/ml. (In a patient with a history of prostate cancer and a 

history of post-treatment undetectable PSA levels, any measurable PSA 

suggests recurrence of disease.) Seven months later, as part of a routine 

appointment, the patient’s PCP ordered laboratory tests, including a PSA. 

The value was then 98 ng/ml. A Urology Service consult was placed. 

Later that month, the patient was seen at the PVAHCS ED complaining of 

2 months of back pain. X-rays revealed lytic (bone destructive) lesions in his 

lumbar spine, presumably from metastatic prostate cancer. Urology 

evaluated the patient that same day, and treatment was initiated. In early 

2014, the patient was admitted to hospice; he died 2 months later. 

At one of this patient’s canceled Urology Service appointments, providers 

might have identified or confirmed the patient’s rising PSA, which could 

have prompted an earlier initiation of aggressive treatment. 

Case 32 

A man in his late 50s was hospitalized at PVAHCS in late 2013 after liver 

nodules were found on a CT scan obtained at a non-VA hospital. A liver 

biopsy was required for a definitive diagnosis, and this was anticipated to be 

done after discharge from PVAHCS. Two Schedule an Appointment 

consults were entered during that inpatient stay—both for Primary Care and 

both were routine. Two days after discharge, a post-hospitalization call was 

made to the patient, but staff were unable to make contact with the patient, as 

his listed contact information was incorrect. Two additional attempts to 

reach the patient and discuss biopsy scheduling were also documented. 

A week after discharge the patient was seen in the PVAHCS ED. He was 

under the impression that he was to return that day to be admitted for a liver 

biopsy. He was sent home and advised to contact his PCP; he was seen in 

Primary Care 3 days later at an initial visit to establish care. 

One week later, the patient was readmitted to PVAHCS for severe groin pain 

and worsening edema. He was evaluated by the Hematology/Oncology 

Service the following day, but because of his advanced disease, 

chemotherapy was not advised. He died 3 days later in the PVAHCS 

Community Living Center hospice unit. 

In the care of this patient, there was significant confusion surrounding when 

or if the patient would have a liver biopsy. Given his clinical state, when the 

patient returned to the ED with intractable abdominal pain and probable 

metastatic disease, an admission for pain control should have been 

considered. Ultimately, a biopsy was not performed due to impaired blood 

coagulation, making the risk of bleeding complications too great to safely 

undergo the procedure. 

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

Scheduling Practices at the Phoenix VA Health Care System 

Case 33 

A man in his mid-60s had a history of aortic valve replacement and was 

being treated with an anticoagulant medication. He also had a history of 

coronary heart disease, hypertension, and iron deficiency anemia. He was 

followed routinely at PVAHCS and was admitted from the ED in the 

summer of 2013 for an abnormality in his bloodwork that suggested his 

anticoagulant dosage needed adjusting. At that time, he reported symptoms 

of fatigue and blood in his stool, received iron infusions, and was discharged 

with plans to get a colonoscopy and upper gastrointestinal endoscopy as an 

outpatient. The patient was contacted 5 days after discharge to set up an 

appointment with gastroenterology, but he informed the caller that he 

planned to get his care “outside the VA.” For the following 3 months, the 

patient’s only contact with PVAHCS was with the Anticoagulation Clinic 

staff. 

Six weeks after discharge from the hospital, the patient reported to the 

Anticoagulation Clinic pharmacist that he had dizziness and a low home 

blood pressure reading (93/47 mm Hg). The pharmacist advised the patient 

to hold his blood pressure medications, come to the clinic for an evaluation, 

and contact his provider. On the following day, the patient’s PVAHCS PCP 

acknowledged receipt of the pharmacist’s note. The final note in the EHR 

was approximately 5 weeks later when the patient’s wife called to inform 

facility staff of his death. 

This patient had symptomatic hypotension that was brought to the attention 

of a PCP. There is, however, no indication that anyone from Primary Care 

attempted to contact the patient. Though it appears in the record that the 

patient was getting private medical care, a patient reporting symptomatic 

hypotension should have been immediately contacted by a staff member to 

ensure an appropriate evaluation. 

Case 34 

A man in his mid-60s had a history of tobacco use and persistent cough. He 

presented to the PVAHCS ED in the spring of 2013 with symptoms 

suggestive of an acute stroke. He was admitted, and during the 

hospitalization, a chest X-ray revealed a large density in the right lung. The 

radiologist recommended a CT scan of the chest for further evaluation of this 

lesion. The discharge summary from that admission cited the lung 

abnormality and advised that the patient make an appointment in Primary 

Care, and obtain a CT scan of his chest in 2 months. 

Six weeks later, the patient presented to the ED complaining of shortness of 

breath. He was admitted to the facility and diagnosed with advanced 

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

Scheduling Practices at the Phoenix VA Health Care System 

non-small cell lung cancer. The patient was discharged to home hospice and 

died several days later. 

This was a patient with a newly described lung mass who required further 

diagnostic evaluation. If the CT scan could not have been performed during 

the patient’s hospitalization, an acceptable alternative would have been to 

discharge the patient with a scheduled appointment in radiology. The 

hospital discharge plan specified that the patient should schedule an 

appointment in Primary Care in 1–2 weeks and “obtain a CT scan of the 

chest in two months”; this is an unacceptable follow-up recommendation for 

a large lung mass in a patient with a history of cough and tobacco use. 

Case 35 

A man in his late 40s with a history of depression presented to the PVAHCS 

ED in July of 2013. He had been living on the West Coast, getting private 

psychiatric care, when he began having paranoid delusional thoughts. He 

called his parents in Arizona asking for help. They traveled to his home and 

brought him immediately to the PVAHCS ED. 

The patient was evaluated by a mental health nurse in the ED. The patient 

reported to the nurse that he had been started on sertraline 5 days earlier. 

Additionally, he commented that 6 years prior, he had been prescribed 

paroxetine but had to stop taking this medication when he began having 

suicidal thoughts. He denied any history of suicide attempts and also denied 

any current suicidal or homicidal ideation. He declined hospital admission 

but did agree to stay with his parents and report to the Mental Health Clinic 

the following morning. At approximately 11 a.m. the following morning, the 

patient committed suicide. 

This patient’s symptoms at presentation were consistent with a 

depression-induced psychosis. Given his previous reaction to an 

antidepressant medication, as well as the fact that he was recently started on 

another antidepressant, hospital staff should have pursued processes for 

involuntary admission. 

Case 36 

A man in his late 60s had a history of multiple medical problems with 

depression and chronic pain. He was hospitalized at PVAHCS after 

presenting to the facility’s Mental Health Clinic in the spring of 2012. He 

continued to be followed by Primary Care, with some limited involvement of 

the Pain Clinic. His last primary care visit was in the spring of 2013 for pain 

control follow-up; at that time his pain medications were adjusted, his 

sleeping medication dose was increased, and he was instructed to return in 

6 months. 

VA Office of Inspector General 21 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Three days later, the patient presented to the ED complaining of ongoing 

pain that was unresponsive to treatment. Though the patient denied suicidal 

or homicidal ideation at this visit, the ED physician documented that the 

patient stated, “the pain is so frustrating, it might make him suicidal.” The 

patient was described as “despondent” when he left the ED after being given 

a cervical collar and pain medication. 

Several days later, the patient presented unscheduled to the Primary Care 

Clinic and was evaluated by a registered nurse. He denied suicidal or 

homicidal ideation. According to the EHR, “Vet states is in ‘so much pain 

right now I could cry’.” The nurse documented that she suggested he report 

to the Mental Health Walk-In Clinic, but the patient declined. 

On the same day, the patient called the National Suicide Prevention Hotline. 

He complained of severe and chronic pain unresponsive to treatment, but no 

response is recorded regarding questions about suicidal ideation or intent. 

According to the EHR, the “Veteran stated his doctor is not calling him 

back.” A consult was sent to the local SPC at PVAHCS, but the consult was 

closed with a comment from the local SPC: “Call not related to SDV 

[self-directed violence]. Will forward to Veteran's PACT team. Please close 

consult.” Six days later, the patient committed suicide. 

Because of his past hospitalization for suicidal ideation, his voicing of ideas 

about suicide in the ED, and his call to the National Suicide Prevention 

Hotline, this patient should have been identified and managed as a patient at 

high risk for suicide. 

Case 37 

A man in his 60s moved to Phoenix in August 2010 to care for his elderly 

mother. He reported a history of chronic cough and occupational exposure to 

asbestos to a PVAHCS provider 2 months later. A chest X-ray showed a 

suspicious lesion, and the patient underwent a CT-guided lung biopsy in 

early December. The biopsy did not reveal malignancy, but it was noted that 

the tissue may not “represent the lesion” and close follow-up was 

recommended. A request for a CT scan to be done 3 months later was 

entered, but the scan was never scheduled, and the order was canceled with a 

comment from the radiology staff to “resubmit if needed.” 

The patient was seen for a routine appointment 5 months after the biopsy, but 

there was no documented discussion of the CT scan and the scan was not 

reordered. The patient was seen 5 months later, and X-rays were obtained to 

evaluate knee pain. About 3 weeks later, he was seen in the ED with 

persistent leg pain. 

VA Office of Inspector General 22 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Eleven months after the lung biopsy, a PVAHCS social worker documented 

a phone call from a non-VA hospital indicating that the patient had a 

craniotomy and was diagnosed with metastatic malignant melanoma. He 

subsequently received comprehensive palliative care at the PVAHCS prior to 

his death 6 months later. 

This patient had poor follow-up care following a lung biopsy. Although the 

cause of this patient’s death was metastatic melanoma and may not have 

been related to the lung mass, management of the mass was inadequate. 

Case 38 

A man in his late 20s was seen by PVAHCS Mental Health and Primary 

Care beginning in 2010. He had a history of PTSD, bipolar disorder, and 

polysubstance abuse. In early 2012, he was hospitalized for suicidal 

behavior and a psychotic episode related to substance abuse. He completed a 

sobriety program and was followed by Mental Health every 1 to 2 months for 

the next several months. His last visit with Mental Health was in the 

summer of 2012, and his psychiatrist recommended follow-up in 

“1-2 months, or sooner as needed.” The patient did not keep the follow-up 

appointment scheduled for 6 weeks after that last appointment, and an 

attempt to contact him was not made until 12 weeks later. The patient 

contacted the facility 3 days after the missed appointment and spoke with a 

nurse about a worsening skin lesion. He was instructed to go to the ED for 

evaluation, but there were no further encounters with PVAHCS documented. 

He died 5 weeks later, and the death certificate obtained by OIG states that 

the cause of death was accidental “acute heroin toxicity.” 

This patient was at high risk given recent suicidal behavior and 

hospitalization with psychosis. He was lost to follow-up after he did not 

appear for an appointment. More timely attempts to contact the patient 

should have occurred. 

Case 39 

A man in his 30s was first seen at PVAHCS in mid-2011. He had transferred 

his care from another VAMC, where he had been treated for schizoaffective 

disorder with disorganized thinking, paranoid ideation, and hallucinations; he 

also had a history of PTSD. The patient had made three suicide attempts, 

requiring hospitalization, in the prior 2 years. He was admitted to the 

inpatient mental health unit at PVAHCS in the spring of 2012 and transferred 

to a non-VA hospital after assaulting a staff member on the unit. 

He presented to the PVAHCS ED 2 months later after calling the crisis line. 

He reportedly called 911 and said that he was suicidal because he could not 

afford to stay at his motel. He told the triage nurse that he “hates life and it 

VA Office of Inspector General 23 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

is so stressful he doesn’t want to be in it.” He was evaluated by a mental 

health consultant, and his risk for suicide was considered to be low. The 

patient reported that he “would feel okay if he gets some place to live.” In 

the ED, he was treated with new medications (loxapine and mirtazapine) 

with a plan to follow up with his private mental health provider or the 

PVAHCS Mental Health Walk-In Clinic. The following day the patient 

committed suicide. 

Because this patient had a history of multiple suicide attempts, psychosis, 

and an unstable housing situation, an admission to monitor initiation of 

antipsychotic and antidepressant medications would have been a more 

appropriate management plan. 

Case 40 

A man in his 20s had been evacuated from Afghanistan in 2009 because of 

shrapnel injuries and loss of consciousness. He had a history of seven 

mental health hospitalizations while in the military and a history of 

self-injurious behavior. He presented to PVAHCS in September 2012 with 

anxiety and several weeks later was admitted to a non-VA hospital following 

a suicide attempt. He was subsequently admitted to the PVAHCS inpatient 

mental health unit after presenting to the ED complaining of feeling angry all 

the time. He reported suicidal ideation, thoughts of harming his brother, and 

his sense that once enraged, he did not know if he could stop himself. 

The following day, a team had a conference, to which the patient presented 

as upset. His mother stated that the patient told his brother that “all I would 

have to do when I get out is point a gun at a cop and they would shoot me. I 

won’t have to kill myself.” The patient’s mother expressed concerns 

regarding the safety of the patient. Documentation noted the patient “is not 

exhibiting signs of SI/HI [suicidal or homicidal ideation] or medication 

withdrawal. Veteran’s mother verbalized she was unwilling to petition 

[pursuit of involuntary admission] him at this time.” He was discharged. 

Two days later, he was found dead in his apartment of a possible overdose on 

medication. 

There was not a delay in care, but this case raised a quality of care concern. 

In the context of his presentation the day before and at the conference, his 

prior mental health history, and the fact that he had not been stabilized on 

medication, it would have been prudent to either observe or stabilize the 

patient for a longer period, or for the providers to pursue a petition of 

involuntary admission, if the patient was unwilling to stay. 

VA Office of Inspector General 24 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Case 41 

A man in his 70s had a history of significant dementia. The case 

management notes stated, that for a period of time the veteran lived “off the 

grid,” with no electricity or telephone at his residence. He was followed in a 

PVAHCS Primary Care Clinic since 2008, at which time he had not been 

seen by a medical provider for over 4 years. The patient was seen several 

times in 2008 with his case manager present but then only for an ED visit in 

May of 2009, at which time he opted not to wait after being triaged for “flu 

like” symptoms. 

The medical record noted that the patient had been scheduled for three 

appointments in 2010 and 2011, all of which were canceled by the clinic 

staff without any notation explaining the reason for cancelation. In addition, 

there is no documentation that attempts were made to reschedule these 

canceled appointments. A death certificate obtained from the State of 

Arizona indicated that the patient was found dead in April 2014. The cause 

of death was listed as “hypertensive and arteriosclerotic cardiovascular 

disease.” 

In a patient with such severe cognitive impairment, his remote and isolated 

living conditions would have made his care management challenging; 

however, it is concerning that three appointments were scheduled and 

subsequently canceled by PVAHCS staff without a documented effort to 

reschedule. Such a pattern would likely discourage any patient from relying 

on this facility for his or her health care, but in a patient with such significant 

cognitive impairment, it is unlikely that he could have initiated the process of 

rescheduling these canceled appointments. 

Case 42 

A man in his mid-50s had a history of hypertension, stroke, chronic 

hepatitis C, and alcohol and polysubstance abuse disorders. His first 

presentation to the VA system was when he visited the PVAHCS ED with a 

complaint of dizziness. He was prescribed medications for nausea and 

dizziness and discharged. The plan was for the patient to follow up with 

Primary Care within 1 week. 

The patient was admitted to the PVAHCS Substance Abuse Residential 

Rehabilitation Treatment Program 3 weeks later. He completed the 

treatment program after approximately 1 month and was discharged, taking 

only blood pressure medications. A suicide risk assessment completed prior 

to discharge found the patient’s suicide risk to be “low or nil.” Discharge 

instructions included that the patient was “to go to eligibility to get a Primary 

Care physician assigned for further follow up.” Three days after discharge, 

VA Office of Inspector General 25 
Other Patients 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

an appointment to establish care with a PCP was made for 12 weeks later, 

but the patient committed suicide 2 weeks before the appointment. 

Although any relation to the patient’s death is unlikely, this patient should 

have had follow-up established with a PCP or mental health provider sooner 

than the 12 weeks that were planned. 

Case 43 

A man in his mid-60s had a history of asthma and COPD. He presented to 

the PVAHCS ED after having been recently discharged from a non-VA 

hospital with several medications that needed to be filled. A Schedule an 

Appointment consult was placed that requested Primary Care follow-up 

“within one week.” Two weeks later, the patient was hospitalized at another 

non-VA hospital for pneumonia. Three months later, he was again 

hospitalized for an asthma exacerbation. 

He presented to PVAHCS Primary Care approximately 1 week later as a 

“walk-in,” seeking to have his prescriptions from an outside hospitalization 

filled. At that time, he received both prescriptions as well as a new patient 

appointment for 10 days later. The patient completed that appointment and 

is currently followed as an outpatient. 

With the history of asthma and COPD as well as a recent hospitalization, this 

patient should have received primary care follow-up soon after his initial 

ED visit. It is possible that earlier management and monitoring within 

Primary Care may have prevented subsequent hospitalizations. 

Case 44 

A man in his mid-50s had a past history of hyperlipidemia. He registered for 

care at PVAHCS in the spring of 2012, requesting a routine appointment in 

Primary Care. The patient was given an appointment for 4 months later. In 

mid-June, the appointment was canceled by the “clinic” and not rescheduled. 

The patient was not made aware of the cancelation and he reported that he 

showed for the appointment only to discover it had been canceled. There is 

no evidence in the EHR that the patient was offered another appointment 

time. At the end of 2013, the patient reported to an outside ED with chest 

pain and was taken the following day to the cardiology lab for left heart 

catheterization with stent placement. 

A week later, the patient reported to a PVAHCS Primary Care Clinic 

requesting medications and cardiology follow-up at PVAHCS. The patient 

was seen by a physician that day, and at that time, a consult for cardiology 

was placed, as the patient could not afford to “pay out-of-pocket” for a 

post-procedure cardiology office visit. 

VA Office of Inspector General 26 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Access to 

Mental Health 

Care at 

PVAHCS 

The patient also reported that when he submitted all the medical bills from 

his outside hospital care to the PVAHCS business office, he was denied 

reimbursement, as “he was not enrolled in a Primary Care Clinic within the 

VA.” 

The delay between the patient’s registration and initial request for care and 

an actual appointment was excessive, and when that appointment was 

inexplicably canceled, PVAHCS staff did not attempt to reschedule the 

patient. In addition, managing the patient’s post-procedure cardiology 

follow-up and reimbursing him for life-saving interventions at an outside 

facility failed to happen in a timely and coordinated manner. 

Case 45 

A man in his late 60s was followed in a PVAHCS Primary Care Clinic. He 

had a history of diabetes, hypertension, COPD, coronary artery disease, 

PTSD, depression, and gastroesophageal reflux. He underwent a barium 

swallow X-ray at a non-VA facility, and 2 days later, home telemetry 

recorded a blood pressure of 82/67 and that “he’s been terrible sick the past 

two day since he had his barium swallow ... he’s had a terrible headache, 

chest pain, abdominal pain and constipation.” The patient and his wife 

presented to his PCP as instructed and were advised to “push fluids, 7 cups 

water daily,” as the patient’s wife admitted his fluid intake had been low. 

The patient’s temperature was not taken, no abdominal exam was recorded, 

and no diagnostic studies were obtained. Two days later, the patient’s wife 

took him to a non-VA hospital where he was febrile and admitted for 

urosepsis. 

The quality of care concern in this case relates to an incomplete evaluation of 

an ill hypotensive patient, including the lack of a temperature recording or 

examination of the abdomen. Earlier treatment could have been initiated if 

an appropriate evaluation had been conducted. 

Although we found a process to provide ready access to mental health 

assessment, triage, and stabilization had been in place at PVAHCS, we 

identified issues with continuity of care, care transitions, delays in 

assignment to a dedicated psychiatrist/mental health nurse practitioner in the 

outpatient mental health clinic, and impaired access to specific types of 

evidence-based psychotherapies. Mental health leadership had been 

addressing these issues at the time of our April–May 2014 visits to the 

facility. 

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

Scheduling Practices at the Phoenix VA Health Care System 

Access, 

Continuity of 

Care, and 

Provider 

Assignment 

For several years, PVAHCS has increasingly used a mental health 

consultation stabilization triage assessment team (CSTAT) to address access 

for mental health patients. The CSTAT essentially serves as a daily walk-in 

clinic. New patients presenting for assessment, patients discharged from the 

hospital, and patients in need of a follow-up appointment but who could not 

get a timely appointment with their assigned provider in the mental health 

outpatient clinic, were told to go to CSTAT. On one hand, sending patients 

to a CSTAT clinic can provide ready and potentially critical access to mental 

health care, especially for outpatients in need of timely assessment and/or 

stabilization interventions, and can enhance timely follow-up when a mental 

health outpatient service is short-staffed. However, when a facility becomes 

reliant on a CSTAT-like clinic to increasingly provide daily routine or 

ongoing mental health services because of diminished access to the regular 

outpatient mental health clinic, issues with provider continuity, care 

transitions, and provider assignment arise. 

One issue raised during our interviews was that if a new mental health 

patient could not be seen for a scheduled appointment with an assigned 

mental health provider in a mental health clinic, they would be seen in 

CSTAT instead. If provider availability was still an issue, additional 

follow-up appointments would occur in CSTAT until assignment to a 

provider could be accommodated. Although patients could readily access 

mental health care, actual assignment to a provider might not occur or could 

be delayed several months. Some new patients might receive a timely initial 

visit but not a full comprehensive multidisciplinary evaluation until a few 

months later. In addition, since CSTAT appointments were not with a 

particular provider, at each CSTAT visit, patients might see different 

clinicians, an arrangement that lacks continuity of care and the inherent 

benefits of being assessed and treated by a consistently assigned provider and 

treatment team. 

Two additional concerns expressed were: (1) when a mental health provider 

leaves the facility, the process has been to send the provider’s former patients 

to CSTAT instead of redistributing or reassigning the patients among 

existing mental health outpatient clinicians, and (2) transfer patients are sent 

for walk-in appointments instead of being scheduled for regular 

appointments. 

Further, if an assigned patient’s provider did not have availability for a 

patient to be seen for follow-up in the clinician’s recommended time frame, 

the patient might also be sent to CSTAT, again raising continuity of care 

issues. 

Although CSTAT enabled patients to be seen, broader qualitative issues, 

such as continuity of care and delayed assignment to a dedicated mental 

VA Office of Inspector General 28 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Care 

Transitions 

Changes 

Instituted by the 

Chief of 

Psychiatry 

health provider, are not addressed by overreliance on this alternative clinic 

structure. 

Patients discharged from the inpatient Mental Health Service, especially but 

not exclusively those without an assigned Mental Health provider, were often 

sent to CSTAT for their 14-day follow-up appointment, which is required by 

VHA policy.2 CSTAT, by design, was a walk-in clinic to provide ready 

access. However, because it was a walk-in clinic, depending on the patient 

volume and acuity, the day a recently discharged patient presented for 

follow-up, the patient might experience a several hour wait to be seen. 

Patients recently discharged from inpatient mental health care are at 

increased risk, which in part is the rationale for VHA’s goal to maintain at 

least phone contact with these patients within 7 days of discharge and 

face-to-face contact within 14 days of discharge. A concern raised during an 

interview was that some recently discharged patients would become 

frustrated and opt to leave CSTAT before being seen by a clinician because 

of long waits in this walk-in clinic. Though certainly better than a situation 

where access is not available, the arrangement is not ideal when compared 

with having a traditional scheduled appointment with an assigned provider in 

a mental health clinic. 

Since coming to PVAHCS in October 2013, the new Chief of Psychiatry 

successfully recruited 13 additional mental health-prescribing clinicians to 

the facility within a 7-month period and has begun reorganizing the service. 

Nine of the new providers are presently on board (several we interviewed in 

early June had started within the prior 2–3 months), one was due to start the 

first week in June, and three were in the credentialing process. The influx in 

new psychiatrists has provided an ability to assign patients to a mental health 

provider and an availability of new and established patient appointments. 

As part of a reorganization process, starting in April 2014, the facility has 

begun implementing a team-based model whereby each day the walk-in 

clinic will be arranged around teams comprising three to four prescribing 

clinicians (psychiatrists and nurse practitioners), one psychologist, one social 

worker, and nursing staff. Each of the new teams were rolled out in 2-week 

intervals. In place of CSTAT, each team has been assigned a clinic day 

during which clinicians will see both new patients with scheduled 

appointments in addition to walk-in patients. The new patients and walk-in 

patients (who do not already have an assigned Mental Health provider) who 

are seen that day will then become assigned to one of that team’s providers 

and be followed by that provider in his or her regular Mental Health 

Outpatient Clinic. As of July 10, 2014, all five teams were operational with 

2

 VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and 

Clinics, September 11, 2008. 

VA Office of Inspector General 29 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Delayed Access 

to Individual 

and Specialized 

Psychotherapy 

Services 

some prescribing providers covering 2 days and use of a locum tenens 

(temporary) physician as part of the Friday team. Newly hired providers 

who came on board in mid-July were to complete the teams allowing one 

distinct team of providers per day. The new structure should help provide 

both enhanced access and continuity of care. 

VHA has disseminated different evidence-based psychotherapies during 

recent years including cognitive behavioral therapy (CBT) and acceptance 

and commitment therapy for depression, cognitive processing therapy and 

prolonged exposure therapy for PTSD, and dialectical behavioral therapy 

(DBT) for issues with regulation and modulation of emotions. 

Within the general mental health clinic there are CBT-based groups for 

depression, anxiety, and mindfulness that were described to us as “tier 1” 

groups. These groups meet for 4 weeks, and patients can participate in these 

groups more than once. PVAHCS has fairly ready access to these groups. 

The anger management group, which begins every other month; the CBT 

coping skills group, which begins every 5 weeks; and the pathfinders group 

(“DBT lite”) comprising three 5-week modules, were described to us as 

“tier 2” groups. Reportedly, these groups are geared toward stabilizing 

patients to a level at which they would be ready for individual psychotherapy 

if indicated and desired. Intensive DBT therapy group, which runs from 

6 to 12 months in duration, and individual psychotherapies were described as 

“tier 3” groups. 

Several clinicians and clinic staff reported that depending on the 

circumstances, access to tier 2 groups might be delayed at least 2 months, 

while access to individual psychotherapy and the intensive DBT group was 

impaired and involved prolonged, several-month-long waits. Some 

clinicians expressed frustration that patients referred for individual or 

intensive therapies were screened using rigorous threshold criteria and 

deemed inappropriate for these therapies. Psychology leadership reported 

that some patients referred for these therapies are not stable enough for the 

level of intensity. Psychology leadership also reported that by 2011, the 

division had lost a significant number of clinical staff and was not allowed 

by the prior PVAHCS director to fill the vacancies. As of early 

June 2014, Psychology leadership reported 11 vacancies for which 

9 candidates had been selected and were pending offer acceptance, 

credentialing, privileging, and/or on-boarding. 

We obtained a list of patients waiting for individual therapy or specialized 

mental health therapy services. These services are unrelated to PVAHCS 

facility leadership performance evaluation metrics. The list contained 

171 patient names with the longest wait dating back to November 2013. In 

early May 2014, the facility had begun working to provide services to these 

patients through the Non-VA Medical Care program. In June 2014, we 

VA Office of Inspector General 30 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Suicides 

reviewed patient EHRs. None of the patients on the list were deceased. We 

found some of the patients on the list were being seen internally at the 

PVAHCS for the requested individual or specialized therapy. A few were 

being seen by an outside vendor. Some of the patients had either declined or 

opted to wait to receive therapy internally rather than through Non-VA Care. 

For the majority of patients, however, Non-VA Care consults had been 

authorized, but appointments had not yet been scheduled. Of the 

128 patients for whom the EHR indicated authorization but scheduling of an 

appointment via TriWest was still pending, status updates via the TriWest 

portal indicated that for 96 patients, the authorizations were erroneously sent 

directly to the patients instead of to TriWest.3 A few of these patients used 

this “vendor of choice” authorization and initiated Non-VA Care with a 

provider of choice in the community. Among the other 32 patients, 

9 authorizations sent to TriWest were either never received or loaded by the 

TriWest staff into its system; 8 of the patients had completed initial 

appointments or had upcoming appointments as of July 9, 2014; 8 other 

patients had not yet been scheduled by TriWest with a provider; and 

7 patients declined appointments/services when contacted by TriWest. 

Upon discovery in early July that authorizations had been sent to patients 

instead of directly to TriWest or had not been received by TriWest, 

PVAHCS purchased care leadership promptly informed fee basis 

management so its staff could re-upload or re-send authorizations 

immediately in order not to further delay care. 

OIG physicians reviewed the EHRs for 77 patients who committed suicide 

from January 1, 2012, to May 2014. Chronic pain conditions and relational 

discord were issues in several cases. Table 1 summarizes the findings. 

Table 1. Veterans on PVAHCS EWL 

Suicides Physician 

Reviewed 

Delays in 

Care 

Clinically 

Significant 

Delays 

Other 

Quality of 

Care Issues 

77 77 9 1 5 

Source: VA OIG 

A clinically significant delay was identified for one patient related to primary 

care. Details of this case were described in a previous section of this report. 

Quality of care issues and non-clinically significant delays were related to 

Mental Health, Primary Care, and the ED. 

3

 In 2013, TriWest Healthcare Alliance was awarded a 5-year contract by VA to administer 

the VA Patient-Centered Community Care program to serve nearly half of the veterans 

eligible for care in the country. 

VA Office of Inspector General 31 
 

Conclusion 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

According to the most recent PVAHCS Governing Council Quarterly 

Suicide Prevention Report, from October 2013 to May 2014, 27 suicides 

were known to the suicide prevention coordinator (SPC). According to the 

PVAHCS Governing Council Quarterly Suicide Prevention Report, among 

these patients, 48 percent were followed by a PCP at the facility, 37 percent 

were seen by the mental health service, 18.5 percent had chronic pain issues, 

and 29.6 percent had contact with a clinic or program (for example, 

Audiology) at the facility within 30 days of death. Twenty-six percent of the 

patients were not under VA care (that is, they were seen exclusively outside 

of VA). 

The Council’s report recommended an action plan that included: 

	 Hiring a family services coordinator with specialized training in marital 

and family therapy and two additional family services clinicians with 

specialized training in marital and family therapy, as PVAHCS does not 

presently have a clinician specialized in marital and family therapy and 

family services programs are beginning to be implemented at some other 

VAMCs to provide couples and family counseling, OEF/OIF/OND 

family support, and suicide prevention education. 

	 Mandatory suicide prevention training for employees that is tracked and 

expanding the VHA SAVE4

 training at orientation from 15 minutes to 

1 hour. 

	 Completion of safety plans for all patients seen in mental health, not just 

those rated moderate risk or above. 

	 Suicide risk assessments to be completed on all patients seen by a social 

worker in the ED. 

Patients at PVAHCS experienced access barriers that adversely affected the 

quality of primary and specialty care provided for them. They frequently 

encountered obstacles when they or their providers attempted to establish 

care, when they needed outpatient appointments after hospitalizations or ED 

visits, and when seeking care while traveling or temporarily living in 

Phoenix. The cases discussed in this report reflect unacceptable and 

troubling lapses in follow-up, coordination, quality, and continuity of care. 

Although we found that a process to provide access to mental health 

assessment, triage, and stabilization was in place at PVAHCS, we identified 

problems with the continuity of mental health care and care transitions, 

delays in assignment to a dedicated provider, and limited access to 

psychotherapy. 

4

 Training developed by VHA on steps in suicide prevention. The acronym stands for: 

Signs of suicidal thinking, Ask questions, Validate the person’s experience, Encourage 

treatment, and Expedite getting help. 

VA Office of Inspector General 32 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Management 

Comments 

OIG Response 

In addition, we found substantial problems with access to care for patients 

requiring Urology Services. Urology Services at PVAHCS will be the 

subject of a subsequent OIG report. 

Recommendations 

1.	 We recommended the VA Secretary direct the Veterans Health 

Administration to review the cases identified in this report to determine 

the appropriate response to possible patient injury and allegations of 

poor quality of care. For patients who suffered adverse outcomes, the 

Phoenix VA Health Care System should confer with Regional Counsel 

regarding the appropriateness of disclosures to patients and families. 

2.	 We recommended the VA Secretary require the Phoenix VA Health 

Care System to ensure the continuity of mental health care, improve 

delays in assignments to a dedicated provider, and expand access to 

psychotherapy services. 

3.	 We recommended the VA Secretary require the Phoenix VA Health 

Care System to reevaluate and make the appropriate changes to its 

method of providing veterans primary care to ensure they provide 

veterans timely and quality access to care. 

4.	 We recommended the VA Secretary direct the Veterans Health 

Administration to establish a process that requires facility directors to 

notify, through their chain of command, the Under Secretary of Health 

when their facility cannot meet access or quality of care standards. 

The VA Secretary concurred with our findings and recommendations and 

stated that VHA would implement Recommendations 1, 2, and 3 by 

August 2015 and that VHA had already implemented Recommendation 4. 

The Secretary’s entire verbatim response is located in Appendix K. 

The VA Secretary’s planned corrective actions are acceptable. We will 

monitor VA’s progress and follow up on the implementation of our 

recommendations until all proposed actions are completed. Based on VA’s 

actions, we consider Recommendation 4 closed. 

VA Office of Inspector General 33 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Question 2 

Veterans 

Waiting for 

Care 

Unofficial Wait 

Lists 

Did PVAHCS Omit the Names of Veterans Waiting for 

Care From Its Electronic Wait List? 

PVAHCS did not include all veterans on its EWL. As a result, we identified 

serious conditions at PVAHCS that resulted in delays, some significant, in 

veterans’ access to health care services. As of April 22, 2014, we identified 

about 1,400 veterans waiting to be scheduled for a Primary Care appointment 

and who were appropriately included on the PVAHCS EWL. However, we 

also identified over 3,500 additional veterans who were waiting to be 

scheduled for an appointment. Those 3,500 veterans were not on the EWL 

as of April 2014; most were on what we determined to be unofficial wait 

lists. 

According to VHA Directive 2010-027, VHA Outpatient Scheduling 

Processes and Procedures, (Appendix G), the EWL is the official VHA wait 

list for outpatient clinical care appointments. The EWL is used to list 

patients waiting to be scheduled or waiting to be assigned a PCP. The EWL 

tracks new patients with whom the primary care or specialty care provider 

does not have an established relationship, such as the patient has not been 

seen before in the clinic at that facility.5 The EWL usually consists of newly 

registered, newly enrolled, or new specialty care consult requests for patients 

waiting for their first scheduled appointment in a particular clinic. Facilities 

can establish EWLs for multiple clinics within their facility. No other wait 

list formats (paper, electronic spreadsheets, or others) are to be used for 

tracking requests for outpatient appointments. 

PVAHCS had over 3,500 individual veterans who were waiting to be 

scheduled for an appointment and were not on the EWL. We identified these 

veterans from the New Enrollee Appointment Request (NEAR) list, Helpline 

paper printouts, Schedule an Appointment consults, consults closed without 

clinical review, and unprocessed enrollment applications. Some of the over 

3,500 individual veterans were on multiple lists discussed in the following 

sections. 

VHA measures new patient wait times from the date a scheduler creates an 

appointment in the Veterans Health Information Systems and Technology 

Architecture (VistA), which becomes the appointment create date, with the 

date the appointment is completed. If an appointment cannot be scheduled 

due to lack of capacity, the veteran is added to the EWL. The date the 

scheduler adds the veteran to the EWL becomes the start date in lieu of the 

appointment create date. Consequently, the length of time these 

3,500 veterans will actually wait for appointments prior to being scheduled 

5

 A clinic refers to a primary care service or specialty care service within a medical center, 

such as a primary care clinic, mental health clinic, and urology clinic. 

VA Office of Inspector General 34 
NEAR List 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

or added to the EWL will never be accurately reflected in VA wait time data 

because PVAHCS staff had not yet scheduled their appointments or added 

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

veterans does not start. These veterans were at risk of being lost in 

PVAHCS’s scheduling processes and thus never obtaining their requested or 

necessary appointments. 

The NEAR list, a computer-generated report, identifies newly enrolled 

veterans who requested an appointment during the enrollment process. 

There were approximately 1,800 enrolled veterans on the PVAHCS’s NEAR 

list who indicated they wanted a Primary Care appointment but were not yet 

scheduled for one and were not on the EWL. Of the approximately 

1,800 veterans, nearly 1,700 had been on the NEAR list longer than 30 days. 

The Health Administration Service (HAS)—an administrative service at 

PVAHCS that provides support to the patient processing activities, such as 

enrollment, eligibility verification, and scheduling—did not use the NEAR 

list to contact veterans for an appointment. Therefore, it became a de facto 

unofficial wait list because of the inordinate amount of time veterans spent 

on the list before the facility scheduled the veterans’ appointments or placed 

them on the EWL. In addition, veterans’ wait times spent on the NEAR list 

prior to being scheduled for appointments or added to the EWL were not 

captured in VA wait time data. HAS supervisors stated they were unaware 

of the existence of the NEAR list until April 2014. However, they should 

have been aware of the NEAR list because VHA policy and multiple other 

documents that were available to PVAHCS management and staff discussed 

the NEAR list. 

 A January 2009 VHA NEAR training guide indicated the NEAR list is 

available and provided information to enable staff to manage new 

enrollee appointment requests and their placement on the VistA EWL. 

 A Veterans Integrated Service Network (VISN) 18 site visit in 

May 2013 recommended that PVAHCS develop appropriate training 

materials and train staff on the use of the NEAR list. 

In addition, Mr. Lance Robinson, Associate Director, sent an email in 

April 2014 to Ms. Sharon Helman, the Director of PVAHCS, and others 

stating that a management analyst knew about the NEAR list after the VISN 

team left in May 2013 but failed to continue to run it and utilize it. The 

management analyst sent an email to Dr. Darren Deering, Chief of Staff; and 

the Assistant Chief of HAS, in response to the email from Mr. Robinson. 

The management analyst copied Mr. Robinson; Ms. Michelle Bagford, 

Associate Chief Nurse; and the Chief of HAS. 

VA Office of Inspector General 35 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Email From a 

Management 

Analyst, 

May 2, 2014 

Helpline Paper 

Printouts 

I am behind in e-mail and I would like to clarify the statement 

below. 

I did not fail to continue to run it [the NEAR list]. I looked at it a 

few times when I first got here and spoke to [the former Assistant 

Chief of HAS] about it. . . . I also recall that it came up after the 

VISN Team left and I told [the former Assistant Chief of HAS] that it 

had come up in conversation with them and [the former Assistant 

Chief of HAS] said she was going to talk to Eligibility about it. 

We identified about 600 screen shot paper printouts from the PVAHCS 

Helpline representing newly enrolled veterans who called the Helpline to 

request primary care appointments but were not scheduled for appointments 

or on the EWL. The 600 printouts consisted of: 

 Compiled printouts from March through April 2014 (530) 

 Printouts found in a drawer in a Primary Care Clinic in June 2014 (70) 

The supervisor of eligibility and enrollment—a service within HAS—told us 

that his staff entered veterans’ enrollment form information into VistA, 

creating an electronic record for the veterans. Instead of scheduling an 

appointment at the time of enrollment, staff provided the newly enrolled 

veteran with the phone number to the PVAHCS Helpline—also a service 

within HAS—to call and request an appointment. 

According to HAS personnel, when a veteran called the Helpline to schedule 

an appointment, staff from the Helpline collected patient demographics of 

the veteran and then printed a screen shot. From approximately 

February 2013 through March 2014, the Helpline staff printed the screen 

shots containing this information directly to printers in HAS’s data 

management services. HAS personnel from outpatient services periodically 

collected the screen shot printouts from data management and were supposed 

to be adding the veterans to the EWL. HAS personnel told us there were 

often delays before adding the veterans from the printouts to the EWL. This 

occurred because they did not pick up the printouts every day, and there were 

only a few staff assigned regularly to add these veterans to the EWL. 

Although this printout process started around February 2013, HAS staff did 

not begin to fully use the EWL until around April 2013. HAS staff placed 

only 1 veteran on the EWL in March 2013, 93 veterans in April 2013, and a 

little over 850 veterans in May 2013. 

HAS personnel told us that because the printouts contained personally 

identifiable information, they destroyed them after they either scheduled the 

veterans’ appointments or placed the veterans on the EWL. Because staff 

destroyed the printouts over the course of time this process was in place, we 

VA Office of Inspector General 36 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Schedule an 

Appointment 

Consults 

could not identify those veterans affected by this process or confirm that they 

were eventually placed on the EWL or provided an appointment. 

From the end of March through April 2014, a HAS employee created a daily 

Portable Document Format (PDF) of compiled printed screen shots and 

emailed them to responsible outpatient services’ personnel. We obtained 

those PDF screen shots, which included approximately 550 individual 

veterans. We determined that 530 of those veterans were not on the EWL as 

of April 2014 and were still waiting to be scheduled for an appointment. 

The following example highlights the problem experienced by one of the 

veterans who was included in the PDF screen shot printouts we identified. A 

veteran emailed the OIG Hotline on May 14, 2014, and said he enrolled at 

PVAHCS. According to the veteran’s electronic record, he enrolled on 

April 3, 2014. At the time he enrolled, he was told by PVAHCS 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. The staff member suggested it would be another 3 to 4 months 

before the veteran would be seen. This veteran’s wait time was unaccounted 

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

In June 2014, a scheduler provided us with about 200 additional paper 

printouts that identified veterans who called the Helpline around 

December 2013. She received these printouts from a coworker who found 

the printouts in a drawer in a Primary Care Clinic. Upon review, the 

scheduler determined that about 70 of the 200 veterans were not scheduled 

for an appointment and were not on the EWL. According to the scheduler, 

she subsequently added the veterans to the EWL in June 2014. 

Pending Schedule an Appointment consults represented 307 veterans 

referred to primary care, but the facility had yet to schedule their 

appointments or add them to the EWL as of April 2014. The wait time for 

patients with pending consults begins when schedulers create the 

appointments or place the veterans on the EWL. This means the wait time 

for these veterans prior to being scheduled or added to the EWL was not 

captured in VA wait time data. 

PVAHCS ED physicians and inpatient services providers used Schedule an 

Appointment consults in an attempt to ensure that veterans who did not have 

a PCP would have a follow-up appointment scheduled post-discharge. These 

consults were sent to notify HAS staff of a veteran without a PCP in need of 

a Primary Care appointment. According to HAS staff, if a consult was noted 

as routine, they would add the veteran to the EWL. If a consult was noted as 

urgent, they would send it to a provider for review. 

VA Office of Inspector General 37 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Email From 

Dr. Deering, 

December 14, 2013 

We were told by a HAS employee that no one reviewed Schedule an 

Appointment consults from approximately August 2013 through 

December 2013. Although we could not confirm this statement, our review 

of emails determined there was a significant backlog of 1,300 pending 

Schedule an Appointment consults as of December 2013. 

A meeting with a veteran’s family resulted in Dr. Deering realizing the 

facility did not have an adequate plan to ensure patients leaving the ED 

obtained timely follow-up appointments. The following excerpt is from a 

December 14, 2013, email from Dr. Deering to Dr. Christopher Burke, Chief 

of Primary Care Services; Dr. Timothy Wright, Chief of the Emergency 

Department; the Nurse Manager of the Emergency Department; Dr. James 

Felicetta, former Chief of Medical Services; and the Chief of HAS. 

Mr. Robinson and Ms. Nancy Claflin, Nurse Executive, also received the 

email. 

I just spent about 45 minutes with a veteran’s family who is very 

upset. 

Their father was discharged from the ER [Emergency Room] on 

September 28th and the ER Doc [doctor] requested a one-week f/u 

[follow-up] with a PCP. 

A “scheduled an appointment” consult was placed in CPRS 

[Computerized Patient Record System]. 

The veteran died on November 30th. 

Someone called the family on Dec 6th to schedule the appointment. 

They feel that we were negligent in his care and that earlier 

intervention would have prolonged his life. 

They have a copy of his records including the ‘schedule an appt’ 

[appointment] consult that wasn’t addressed for 2 months. 

. . . . . . . 

My intent is that I need you, as leaders of the ER, Primary Care, and 

HAS to come together and develop a plan about how we can make 

sure that patients who are leaving the ER get a follow-up and that 

the information is communicated to the veteran in a timely manner. 

Please work on this and let us know what is needed to make this 

happen or what your plan is by Dec 30th. Although it may not have 

made a difference in the outcome of this patient, it is a process that 

needs to be hardwired before it does impact someone. 

VA Office of Inspector General 38 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Email From 

Dr. Abbaszadegan, 

December 19, 2013 

New Patient 

Backlog 

Redistribution 

On December 19, 2013, Dr. Hamed Abbaszadegan, Chief of Clinical 

Informatics, sent the following email to Dr. Robbi Venditti, staff physician, 

discussing new patient scheduling and noting that the Schedule an 

Appointment consult was a broken process. He also copied a number of 

other clinical staff, including Dr. Burke, Dr. Wright, Dr. Deering, and 

Ms. Bagford. 

This week the inspector general was here regarding the issue of new 

patient scheduling (those without a PCP). Ironically, there has been 

some side conversation regarding this issue this week as well...The 

consult called “Schedule an Appointment” has >1300 open consults 

in a pending stage, most coming from the ED. I feel we have a 

broken process that can be improved. Thus, I am requesting to 

improve/change this process. I will personally represent informatics 

to help find a solution to new appointments which is tied to access as 

well as quick (1-2 week) post-ED visits. 

Thoughts? 

We found no evidence that PVAHCS developed a plan to ensure that patients 

leaving the ED received a follow-up appointment. 

In October 2012, HAS data management staff identified new patient 

appointments in Primary Care that were scheduled later than 

December 1, 2012. Some of these appointments were scheduled for almost a 

year in the future. This represented a backlog of 2,501 appointments. The 

goal at the time was to redistribute this backlog of new patient appointments 

among the PCPs and reschedule these veterans for earlier appointments. 

HAS data management staff divided the list of 2,501 patients among 

43 providers. Twenty-eight providers at the main facility were assigned over 

1,800 patients, with the remainder assigned to providers at the clinics. Most 

providers received about 67 new patients. 

Despite the effort to redistribute the veterans to other providers with the 

intent of getting an earlier appointment, we determined 544 of the 

2,501 veterans had not received Primary Care appointments as of 

March 31, 2014. We reviewed 200 of the 544 veterans who had not received 

an appointment. According to our review of the veterans’ EHRs, 143 of the 

200 veterans (72 percent) appeared to still be waiting for Primary Care 

appointments. The other 57 veterans were no longer waiting for care from 

PVAHCS because they had moved out of the area, could not be reached, 

decided they no longer wanted VA care, or had died.6

 On June 17, 2014, we 

provided the names of the 544 veterans to Mr. Steve Young, Interim 

PVAHCS Director, for review and appropriate action with these veterans. 

6

 These deaths were included in the case reviews addressed under Question 1. 

VA Office of Inspector General 39 
 

 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Urology 

Consults 

Closed 

Email From 

Dr. Venditti, 

January 13, 2014 

Unprocessed 

Enrollment 

Applications 

According to Urology staff, from May 2013 through September 2013, two 

urologists left PVAHCS and only one was replaced. This left PVAHCS’s 

Urology Service with two urologists and a nurse practitioner. 

Urology staff told us they informed PVAHCS management of access and 

staffing issues starting in August 2013. In January 2014, to address the 

Urology Service’s concerns about providing care to patients with a minimal 

number of providers, the ability of PVAHCS providers to write new 

outpatient Urology consults was disabled. In addition, PVAHCS 

administratively closed 344 pending Urology consults for 339 individual 

veterans on 2 separate days without first identifying how the veterans would 

receive needed care. Following is a January 13, 2014, email Dr. Venditti 

sent to Dr. Deering that acknowledged the disabling of consults to Urology 

Services. 

As of last week all outpatient consults for GU [General Urology] 

were disabled. On Friday 250 active and pending consults were 

discontinued. These two actions should eliminate and/or reduce the 

extra demands placed on the current GU staff. (This left appr. 

[approximately] 136 scheduled Veterans through March and appr. 

136 scheduled veterans that did not have a real appointment.) 

One item on the action plan is to determine who/how the cancelled 

Veterans are reviewed for ongoing medical needs. 

We reviewed 115 veterans whose consults were closed and determined 

68 veterans (59 percent) did not receive a Urology appointment. Of those, 

eight veterans either transferred to another facility or said they no longer 

wanted urology care at PVAHCS, three veterans had 

died,7

 two veterans were in hospice care, and one veteran had a chart review 

completed and was determined to not need care. The remaining 47 veterans 

(41 percent) eventually received Non-VA Care Urology appointments but 

waited an average of 167 days for those appointments (ranging from 21 to 

396 days). On June 17, 2014, we provided the names of these veterans to 

Mr. Young for review and appropriate follow-up action with those veterans. 

Due to the substantial problems with access to care for patients requiring 

Urology Services at PVAHCS, Urology Services will be the subject of a 

subsequent OIG report. 

On June 6, 2014, Dr. Katherine Mitchell, the Medical Director of the 

PVAHCS OEF/OIF/OND Clinic, provided the OIG with a folder of 

69 individual VA enrollment applications. Dr. Mitchell stated that the 

veterans whose applications were in the folder had not been processed for 

enrollment. The unprocessed enrollment applications were from veterans 

7

 These deaths were included in the case reviews addressed under Question 1. 

VA Office of Inspector General 40 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

EWL Data 

Entry Issue 

who enrolled at a PVAHCS outreach effort in late 2013. However, 

PVAHCS still had not processed their enrollment information over 6 months 

later. We reviewed the enrollment forms to determine how the applicants 

answered the question on the form of whether they wanted care. Based on 

the applicants’ answers, we determined 36 individuals did not want care, 

18 wanted care, and 15 did not answer that question. On June 9, 2014, we 

provided the forms to Mr. Young’s office for PVAHCS’s review and 

appropriate follow-up action with these veterans. 

In April 2014, VHA’s national data in the Veterans Health Administration 

Support Service Center (VSSC) showed fewer than 300 veterans waiting for 

care on PVAHCS’s EWL. However, we found that actually about 

1,400 veterans were waiting for care, according to PVAHCS’s VistA EWL 

report. The EWL data obtained from PVAHCS’s VistA system listed a 

much higher number of veterans than the EWL data we obtained from the 

VSSC. VHA staff identified a data entry issue that prevented the total 

number of veterans that were actually on the PVAHCS EWL from being 

reflected in the national EWL data. 

We were unable to determine when PVAHCS first became aware that the 

national EWL data was not capturing all veterans on the wait list. On 

April 22, 2014, the Chief of HAS told us he was aware the number of 

veterans on PVAHCS’s EWL showed more than what was reported in 

national data. According to national information technology support, on 

April 30, 2014, PVAHCS submitted an information technology trouble 

ticket, and the data entry issue was fixed the next day. 

As shown in Figure 1, national data did not reflect the same number of 

veterans waiting on PVAHCS’ EWL prior to correcting the data entry issue. 

As of May 1, 2014, the national data reported about 1,400 veterans—the 

same as the PVAHCS’s EWL. 

VA Office of Inspector General 41 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Figure 1. Veterans on PVAHCS EWL 

0 

200 

400 

600 

800 

1000 

1200 

1400 

1600 

1800 

Veterans on PVAHCS EWL 

PVAHCS 

VistA 

Data 

VHA 

VSSC 

Data 

Deceased 

Veterans on 

the EWL 

Source: PVAHCS EWL data obtained from VistA and VHA national EWL data obtained 

from VSSC 

Because PVAHCS’s EWL was not accurately reflected in the national EWL 

data, the time period during which those veterans were on PVAHCS’s EWL 

was not captured in VHA wait time data. Accurate wait list information is 

necessary to provide VHA with the information it needs and the ability for 

early identification of access issues and determination of the right mix and 

number of resources needed. 

A PVAHCS employee told us that coworkers may have changed death 

dispositions of veterans who died while on the EWL, causing the veterans to 

reappear on the EWL. In addition, four of the schedulers interviewed stated 

they were also aware of deceased veterans that they had previously removed 

from the EWL (because they were told the veterans were deceased) who later 

reappeared on the EWL. 

Certain audit controls within VistA were not enabled, which limited our 

ability to determine whether any malicious manipulation of the VistA data 

occurred. At our request, VA enabled this audit trail capability at PVAHCS 

and nationwide. We identified nine veterans whose EWL record indicated a 

“Date of Death Error.” We were able to review seven of nine veterans’ 

records that had been identified as altered after VA turned on the VistA audit 

trail function on April 24, 2014. For those seven veterans, the VistA audit 

trail showed “Postmaster” as the user name. These actions were processed as 

an electronic action that removed the death disposition and added “Date of 

VA Office of Inspector General 42 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

New Enrollee 

Scheduling 

Process 

Death Error” to the records. This occurred because there was no date of 

death recorded in the veteran’s record by PVAHCS. The Postmaster 

automated routine deletes an EWL “Death” disposition if there is no date of 

death in the veteran’s record and enters the reopen reason as “Date of Death 

Error” as an electronic control to prevent errors in reporting deaths. 

PVAHCS local policy, which refers to deaths inside the facility, states 

schedulers should notify Decedent Affairs8

 or the Administrative Officer of 

the Day about a veteran’s death. According to a Decedent Affairs employee, 

upon verification of death, Decedent Affairs should record the veteran’s date 

of death in the electronic records. We found at least one example in which a 

scheduler noted a veteran’s death in VistA, but Decedent Affairs did not 

record the veteran’s date of death in the electronic records until about 

3 months later. Because the Postmaster automated routine deletes an EWL 

“Death” disposition if there is no date of death entered in the veteran’s 

record, we believe it is imperative that staff timely notify Decedent Affairs, 

and Decedent Affairs staff timely verify and record veteran deaths in VistA. 

We concluded that the scheduling processes for new enrollees used at 

PVAHCS contributed to access delays. Prior to February 2013, when new 

patients to PVAHCS requested an appointment, PVAHCS staff referred them 

to eligibility and enrollment staff to verify eligibility. The eligibility and 

enrollment staff scheduled a primary care appointment for the veteran, 

regardless of the available time frame for an appointment. A prolonged 

period between the appointment request and the available appointment date 

was not unusual. Figure 2 depicts the typical scheduling process at the 

PVAHCS prior to February 2013. 

Figure 2. PVAHCS Scheduling Process Prior To Using the EWL 

Source: VA OIG analysis of PVAHCS scheduling processes 

As part of the restructuring and clinic clean-up process, the Chief of HAS 

issued a memo requesting the removal of scheduling responsibilities from a 

list of individuals. This list included eligibility and enrollment staff as well 

as Helpline staff. As a result, the process to obtain an appointment became 

8

 Decedent Affairs staff at PVAHCS are responsible for verifying a veteran’s death and 

inputting the veteran’s date of death in the electronic records. 

VA Office of Inspector General 43 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Management 

Awareness 

Email From 

Ms. Helman to 

Dr. Deering, 

July 2, 2012 

more complicated for the veteran. Instead of scheduling an appointment for 

a newly enrolled veteran or adding them to the EWL, eligibility and 

enrollment staff gave the veteran the Helpline phone number to call to 

schedule an appointment. The Helpline, in turn, printed screen shots 

representing veteran appointment requests directly to printers in HAS data 

management services instead of actually scheduling the appointment. HAS 

personnel from outpatient services collected the screen shot printouts from 

data management to place the veterans on the EWL, and eventually contact 

the veteran to schedule an appointment. Figure 3 depicts the scheduling 

process at PVAHCS following those changes. 

Figure 3. PVAHCS Scheduling Process After EWL 

Source: VA OIG analysis of PVAHCS scheduling processes 

Ultimately, new patient primary care appointment requests from enrollment, 

Helpline, ED, or inpatient providers were funneled to only about three staff 

responsible (sometimes more staff during overtime work) for adding veterans 

to the EWL and contacting the veterans to schedule an appointment. This 

change in process resulted in delays in veterans receiving appointments. 

PVAHCS senior management was aware of the existence of access delays, as 

well as many of the documents that we identified as unofficial wait lists. The 

following email excerpts provide further insight into what was known and 

when. 

I would like for Dr. Piatt to provide us with an action plan by next 

Monday for all the cbocs [sic] and next steps that need to be taken to 

start getting Veterans in. 

I want him to address staffing, weekend/evening clinics, blocked 

admin [administrative] time, etc. This is not just a ‘staffing fix’. 

The plan needs to have short term and long term fixes. 

VA Office of Inspector General 44 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Email From 

Dr. Burke to 

Dr. Deering, 

February 4, 2014 

As I mentioned Friday, this wait (a year long in some clinics) is 

unacceptable and we need to have a plan in place that we are 

striving towards so that the [sic] we all support and move in the 

same direction. 

Dr. Burke sent an email to Dr. Deering discussing concerns with the 

reasonableness of the standards and the rate of veterans receiving an 

appointment within 14 days looking better than it truly was. 

The Electronic Waiting List (EWL) is supposed to be used when we 

cannot get a new pt [patient] appointment within 90 days. Therefore, 

the fact that we currently have an EWL (with 1000+ pts on it) 

suggests that we cannot get a new patient appointment within 

90 days. So how can we get a new patient appointment within 

14 days? And how can we do it at a 50% rate? Or 40%? Or 30, or 

20, or even 10%? It makes no sense. 

Occasionally a pt will cancel an appt [appointment] and this will 

open up a sooner slot, but this cannot account for 50% of our new 

pts. There are a couple of possibilities for why our numbers look 

better than they truly are: 

	 We are purposely not pulling patients off the EWL until or unless 

we know we can get them an appointment within 14 days. 

	 Our EWL is so inefficiently managed that the clerical folks are 

not able to keep up with it and there are hundreds of future new 

pt appts sitting empty because they have not been able to move 

pts into those appts quickly enough. 

I have asked HAS if clerks have been told to selectively NOT book 

appts beyond 14 days in order to make us look good and was told no. 

So my best guess is that the management of the EWL is so poor that 

even though there are hundreds of open new pt appt slots between 

now and 90 days, the clerical staff responsible for pulling pts off the 

EWL and booking those appts is only, at any given time, booking 

appts in the next ~30 days. The result is that a lot of the appts are 

actually booked out <14 days, giving the appearance that our access 

is better than it truly is. 

If the clerical folks (the “appointment people” as Dr. Corrie might 

call them) actually got on the ball and started filling all the available 

appts between now and 90 days from now, our access numbers (as 

reflected by the 14 day metric) would start to look worse. 

VA Office of Inspector General 45 
 

 

 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Email From 

Management 

Analyst 

March 7, 2014 

Email From 

Dr. Burke, 

March 13, 2014 

So when you ask what happened to cause our 14 day number to drop 

from 50% to 35%, the answer is that the clerical folks started being 

more efficient and effective in pulling folks off the EWL. 

All we have done in Primary Care is triple the number of daily new 

pt slots. Unfortunately we have no control over the daily demand for 

new pt appts. To get a true representation of our new pt access we 

need to fill every new pt appt between now and 90 days before we 

use the EWL. 

Unfortunately, while this will dramatically shrink our EWL (it might 

even eliminate it) it will also point out the fact that we continue to 

have significant new pt access problems. 

A management analyst sent an email to Mr. Robinson and Dr. Deering, and 

copied the Chief of HAS, Dr. Venditti, and Dr. Abbaszadegan. It was 

subsequently forwarded to Ms. Helman. This was in response to an email 

from Ms. Susan Bowers, former VISN 18 Director, regarding VHA’s 

concern about inappropriately closing open consults, stating VHA has “zero 

tolerance” for consults open over 90 days. When forwarding Ms. Bowers’ 

message to certain PVAHCS staff, Mr. Robinson asked what the effect was 

of establishing EWLs if clinics cannot schedule a new patient within 90 days. 

In response to Mr. Robinson’s email, the management analyst expressed her 

concerns. 

Is there the appropriate number of staff to manage an EWL? 

... I do not feel we can start an EWL in an area unless we know for 

sure that the clinic capacity really is out 90 days. 

... Unfortunately, in my humble opinion, I think some of the “pain” 

staff are feeling in dealing with this is all the incorrect practices that 

have been occurring: consults not being received, future 

appointments not being made or placed into Recall; and there has 

been a great deal of “blind scheduling” (appts [appointments] are 

made w/o [without] any contact with the pt [patient]) going on at 

this Facility for some time. Any of the latter, would on the surface 

appear to make scheduling easy and quick, but for what should be 

obvious reasons, is not only the wrong thing to do to our patients but 

is against the Directive. 

A physician at the VA Pacific Islands Health Care System emailed Dr. Burke 

to ask how PVAHCS was able to get new patient wait times down to 7 days 

from 238 days. The VA Pacific Islands Health Care System was 

experiencing a similar scheduling problem with their EWL for new patients. 

Dr. Burke sent this email to one of his PVAHCS colleagues: 

VA Office of Inspector General 46 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Phoenix 

Veteran 

Outreach 

Conclusion 

Wonderful. Not sure how to answer this. Can I just say smoke and 

mirrors? 

The day after the publication of our May 28, 2014, Interim Report, PVAHCS 

requested the VA’s Health Resource Center (HRC) contact veterans waiting 

for care. Outreach efforts of HRC were based on the 1,700 veterans’ names 

we provided to VHA at the time of our Interim Report, as well as additional 

veterans PVAHCS identified from its own review. After identifying 

duplicate entries, veterans with no telephone numbers, and deceased 

veterans, HRC determined that 2,881 veterans needed to be contacted. Out 

of 2,881 contacts, 11 veterans needed crisis or emergency services, 

146 veterans requested appointments within 7 days, and 722 veterans 

requested appointments within 30 days. The remaining 2,002 veterans 

requested appointments within 90 days, already had an appointment, had 

transferred to another VA medical facility, requested not to be contacted, or 

the HRC was not able to contact them. A detailed summary of the results of 

the Phoenix outreach is in Appendix D. 

PVAHCS maintained what we determined to be unofficial wait lists, and 

used inappropriate scheduling processes, which delayed veterans’ access to 

health care services. We identified over 3,500 additional veterans who were 

waiting to be scheduled for appointments. Those 3,500 veterans were not on 

the EWL as of April 2014; most were on what we determined to be 

unofficial wait lists. PVAHCS management was aware of many of the 

documents that we identified as unofficial wait lists and that access delays 

existed in PVAHCS. Senior PVAHCS administrative and clinical leaders 

did not effectively address these access problems. 

Recommendations 

5.	 We recommended the VA Secretary review all existing wait lists at the 

Phoenix VA Health Care System to identify veterans who may be at 

risk because of a delay in the delivery of health care and provide the 

appropriate medical care. We provided this recommendation to the 

former VA Secretary in the Interim Report. 

6.	 We recommended the VA Secretary take immediate action to ensure 

the Phoenix VA Health Care System reviews and provides appropriate 

health care to all veterans identified as being on unofficial wait lists. 

We provided this recommendation to the former VA Secretary in the 

Interim Report. 

7.	 We recommended the VA Secretary ensure all new enrollees seeking 

care at the Phoenix VA Health Care System receive an appointment 

VA Office of Inspector General 47 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Management 

Comments 

OIG Response 

within the time frames directed by Veterans Health Administration 

policy. 

8.	 We recommended the VA Secretary ensure the Phoenix VA Health 

Care System timely process enrollment applications. 

9.	 We recommended the VA Secretary ensure the Phoenix VA Health 

Care System follows VA consultation guidance and appropriately 

reviews consultations prior to closing them to ensure veterans receive 

necessary medical care. 

10.	 We recommended the VA Secretary ensure the Phoenix VA Health 

Care System staff timely verify and record veteran deaths in the 

Veterans Health Information Systems and Technology Architecture. 

The VA Secretary concurred with our findings and recommendations and 

stated that VHA would implement Recommendations 7, 8, 9, and 10 by 

August 2015 and that VHA had already implemented Recommendations 

5 and 6. The Secretary’s entire verbatim response is located in Appendix K. 

The VA Secretary’s planned corrective actions are acceptable. We will 

monitor VA’s progress and follow up on the implementation of our 

recommendations until all proposed actions are completed. Based on VA’s 

actions, we consider Recommendation 5 closed. We will close 

Recommendation 6 when VHA provides us documentation it contacted the 

veterans we identified as being on unofficial wait lists and provided to VHA 

after June 4, 2014. Also, in response to problems we identified with the 

consult process at the PVAHCS, Urology Services will be the subject of a 

subsequent report. 

VA Office of Inspector General 48 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Question 3 

Inappropriate 

Scheduling 

Practices 

Desired Date 

Manipulation 

Were PVAHCS Personnel Following Established 

Scheduling Procedures? 

From interviews with 79 HAS staff involved in the scheduling process,9 we 

identified multiple types of scheduling practices not in compliance with 

VHA policy. Many of these scheduling schemes are described in the 

April 2010 Memorandum on Inappropriate Scheduling Practices issued by 

the then-Deputy Under Secretary for Health for Operations and 

Management. The stated purpose of the memorandum was to identify and 

eliminate VHA’s use of inappropriate scheduling practices to improve scores 

on clinical access performance measures. Manipulating the desired date, 

using the Clinic Appointment Availability Report to identify and reschedule 

appointments with wait times greater than 14 days, and using paper printouts 

were frequently mentioned by schedulers as common practice at PVAHCS. 

Schedulers used the incorrect desired date of care, which resulted in 

manipulated wait times of established patient appointments. VHA policy 

states the patient defines the desired date without regard to schedule 

capacity. Schedulers must not alter the desired date to reflect an appointment 

date the patient acquiesces to for lack of appointment availability. 

According to VHA data of completed FY 2013 established patient 

appointments, PVAHCS veterans ostensibly had a 0-day wait time in 

66 percent of Primary Care appointments. 

We asked 40 Primary Care schedulers and supervisors how they determined 

the veteran’s desired date when scheduling an appointment, and only 

10 schedulers said they used the date the patient wanted to be seen as the 

patient’s desire date. The remaining 30 stated they based the desired date on 

the provider’s availability or next available appointment date. This deviation 

from VHA’s scheduling policy resulted in appointments showing a false 

0-day wait time. For example, schedulers would access the scheduling 

program, find an open appointment, and ask the veteran if that appointment 

would be acceptable. They would then 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 reflect 0 days for an established patient. Ten 

of the 30 schedulers said they had been taught to determine when the next 

available appointment is and use that as the purported desired date. 

9

 This included 68 Primary Care schedulers and supervisors, 2 data management 

analysts, 7 Helpline staff, the Chief of Outpatient Services, and the Assistant Chief of HAS. 

VA Office of Inspector General 49 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Email From 

Dr. James Felicetta, 

Former Chief of 

Medical Services, 

October 16, 2012 

Clinic 

Appointment 

Availability 

Report 

Overwriting 

Appointments 

Dr. Felicetta sent an email to Dr. Theresa Nieman, a staff physician, and 

copied Dr. Deering and the Chief of HAS. This message was in response to 

the physician protesting increasing specialty clinic appointment slots by 

10 percent without additional staff to schedule patients in a timely and 

correct manner. It identifies Dr. Felicetta’s concerns in meeting performance 

standards and suggests ways to meet the 14-day standard. 

Teri, you’re correct that there can be no reprieves, because we 

really do want to meet the national performance standard. Please 

work as closely as you can with HAS to make sure they NEVER use 

the next available scheduling function; that is a killer on the 

98% performance standard. Always give them [patient] a time frame 

for when any patient, new or established, is to be seen; one month, 

two months, etc. That date then becomes the desired date, which 

hopefully you can hit within 14 days; it’s actually a 28-day range, 

because the appointment can be before or after the desired date. Be 

sure to discharge as many patients as you possibly can from clinic; 

don’t accumulate them. Screen those incoming consults very 

aggressively so that a number of them do not have to be seen face-toface. 

Supervisors told schedulers to review the Clinic Appointment Availability 

Report in VistA and to review appointments they scheduled with wait times 

greater than 14 days. According to one scheduling supervisor’s directions to 

staff, the report was a tool used to determine clinic access issues by looking 

at appointments made greater than 14 days, and it was the responsibility of 

the scheduler to correct any scheduling errors. We interviewed 

34 schedulers and supervisors familiar with the Clinic Appointment 

Availability Report, and 11 told us that they “fixed” or were instructed to 

“fix” appointments on the report. 

Schedulers did this by rescheduling the appointment for the same date and 

time but with a later desired date. This practice can reduce or “0-out” the 

reported wait time. Schedulers said they felt pressure or were expected to 

ensure their appointments on their Clinic Appointment Availability Report 

showed less than a 14-day wait time. Scheduling supervisors told us the 

report was used to correct scheduling errors. However, one scheduling 

supervisor said he instructed schedulers to change the desired date to under 

14 days. 

Seven of the 11 staff noted above described a process they used to overwrite 

existing appointments to reduce the reported wait times. Schedulers created 

a new appointment for the same date and time as the existing appointment. 

This eliminated the existing appointment and allowed the scheduler to 

overwrite the prior desired date to one that is closer to the appointment date. 

The create date of the appointment is effectively reset, thus reducing the 

VA Office of Inspector General 50 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Holding 

Appointment 

Requests 

Email From 

Dr. Burke, 

February 5, 2014 

reported wait time. Schedulers stated their supervisors instructed them to 

“address” or “fix” the appointments on the Clinic Appointment Availability 

Report, and the schedulers used this overwrite process to reduce the reported 

wait times. 

PVAHCS HAS staff—including Primary Care schedulers, data management 

staff, and Helpline staff—admitted that around the time the EWL first started 

at PVAHCS, the standard process in Primary Care Clinics was to hold paper 

printouts of patients seeking an appointment. VHA policy states that no 

other wait list formats (paper, electronic spreadsheets, and so on) are to be 

used for tracking requests for outpatient appointments. We asked 55 HAS 

staff about printouts and 28 stated they either printed out or received 

printouts of patient information for scheduling purposes, representing 

appointment requests. For example, if a veteran called or walked into a 

Primary Care Clinic seeking an appointment, schedulers captured their 

information, took a screen shot, and printed it out instead of scheduling an 

appointment or placing the patient on the EWL. 

Of these 28 schedulers, 20 said they handed the printouts off to someone else 

or held them until someone came to pick them up. Staff said they kept the 

printouts in their desks for days or sometimes weeks before the veterans 

were scheduled an appointment or placed on the EWL. One scheduler said 

she compiled them for about 2 to 3 months. Our review of emails found that 

in April 2013, a management analyst asked a scheduler if she had any paper 

printouts she was holding for the EWL. The scheduler responded that she 

had roughly 200. According to the Northwest Community Based Outpatient 

Clinic (CBOC) supervisor, the Northwest CBOC Primary Care Clinic was 

still using this paper printout process in May 2014. 

In February 2014, Dr. Burke sent an email to Dr. Deering with concerns that 

PCP schedules were sparsely scheduled. 

[The Chief of HAS] is aware. Every so often I look at random PCP 

schedules to see how far out they are scheduled with new pts 

[patients] and I have consistently found that in the timeframe of 

T+30 [within 30 days] to T+90 [within 90 days] days they are very 

sparsely scheduled. I bring it up with HAS and they tell me they are 

working on it, are offering overtime for clerks to work weekends 

scheduling pts off EWL, are enlisting the team MSA’s, etc. For our 

part (the provider end of things) we have asked PCP’s to see 

additional new pts and have communicated this information to [a 

management analyst] who has updated each PCP’s Vista grid 

indicating when the new pts are to be scheduled, thus allowing the 

clerks doing the scheduling to know where to book the pts, but the 

actual booking of the appts [appointments] is a clerical function for 

which we depend on them. At times [the Chief of HAS] has 

VA Office of Inspector General 51 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Email From a 

Scheduler to Chief 

of Outpatient 

Services, 

December 20, 2012 

PVAHCS 

Management 

Aware of 

Scheduling 

Practices 

mentioned pushback from PCPs but this is a copout because the new 

pt slots are open for EVERY clerical/HAS person to book. 

Because VA’s recorded wait times for new patients begins at the time the 

scheduler creates the appointment or places the veteran on the EWL, wait 

time data do not capture the wait time that occurs when schedulers hold 

veterans’ appointment requests. In addition, this practice introduces high 

and unnecessary risks that veterans seeking an appointment may be forgotten 

and not provided the access to needed care. HAS personnel told us that 

because the printouts contained personally identifiable information, they 

destroyed these printouts after they added the veteran to the 

EWL. Therefore, we could not identify those veterans, confirm that they 

were ever provided an appointment, or determine their wait times. This 

practice also occurred in other clinics as described in the following email. 

Earlier this morning [a Licensed Practical Nurse] from Orthopedics 

Clinic, came in to the MSA [Medical Support Assistant] area in front 

of the Specialty Clinic looking for paperwork that was supposed to 

be faxed. She asked [a MSA], new MSA, to look through a drawer at 

the desk that, up until Monday December 17th, was occupied by [a 

departed MSA]. When opening the drawer, the new MSA noticed 

stacks of consults, patient schedules and cancelation lists were 

shoved in the drawers. There was old rotten food in the drawerssome stuck to the consults. There were consults for the Orthopedic 

Clinic dating back to September 2012 in the drawer along with other 

stacks of patient paperwork. We are currently looking through the 

consults to see if these patients have been scheduled. 

In January 2012, VISN 18 issued a scheduling report finding that facilities 

throughout the VISN did not comply with VHA policy. The report described 

issues at PVAHCS that included the incorrect use of desired dates and failure 

to appropriately place patients on the EWL. The report recommended the 

PVAHCS Director ensure a veteran’s desired date is accurately recorded as 

the date on which the veteran or provider wants the patient to be seen and 

ensure the veteran is entered on the EWL when appropriate. 

In April 2013, Ms. Bowers expressed concerns to Ms. Helman that her 

facility staff were not following VHA scheduling directives. In addition, 

Ms. Bowers stated that PVAHCS leadership did not appear to disseminate 

the previous communication regarding scheduling best practices to all front 

line staff and supervisors. 

According to the VISN 18 Executive Officer, VISN 18 conducted another 

site visit in May 2013 as part of a review of scheduling practices at facilities 

not currently meeting the minimum score for same-day appointment 

availability. The review found scheduling requirements were not fully 

VA Office of Inspector General 52 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Training 

Conclusion 

implemented as prescribed in VHA policy, including using a systematic 

process for the identification and avoidance of inappropriate scheduling 

activities and full implementation of the EWL. The VISN team also noted 

that their review of PVAHCS was limited by strict oversight from the 

Assistant Chief of HAS. 

VISN 18 staff required PVAHCS to submit monthly progress updates 

beginning in August 2013. On July 7, 2014, PVAHCS was still not in full 

compliance with the scheduling policy. Specifically, according to 

VISN 18 staff, PVAHCS had not completely trained their clerks or 

established EWLs in the clinics. 

According to VHA policy, all staff must complete required training prior to 

obtaining access to VistA scheduling. This did not occur at PVAHCS. VHA 

requires schedulers to complete a mandatory EES-010 VHA Schedulers 

Training Curriculum. The training consists of four courses that the employee 

must complete prior to receiving access to scheduling capabilities in VistA. 

We analyzed training records of schedulers assigned to Primary Care Clinics 

and determined only about 53 percent of the schedulers at PVAHCS 

completed the entire EES-010 VHA Schedulers Curriculum as of 

May 22, 2014. Although scheduler training is critical, the training provides 

little value if facility leadership does not ensure schedulers perform 

scheduling procedures in accordance with VHA policy. 

PVAHCS personnel did not always follow established VHA scheduling 

practices. Some schedulers acknowledged they manipulated appointment 

dates by using prohibited scheduling practices because of pressure to meet 

wait time goals imposed by leaders at VHA and PVAHCS. In addition, 

nearly half of the primary care schedulers at PVAHCS had not completed the 

entire VHA Schedulers training curriculum. As a result of using 

inappropriate scheduling practices, reported wait times were unreliable and 

the actual wait times were unknown to key stakeholders, to include veterans 

seeking health care. 

Recommendations 

11.	 We recommended the VA Secretary ensure the Phoenix VA Health 

Care System establish an internal mechanism to perform routine 

quality assurance reviews of scheduling accuracy. 

12.	 We recommended the VA Secretary ensure all Phoenix VA Health 

Care System staff with scheduling privileges satisfactorily complete the 

mandatory Veterans Health Administration scheduler training. 

VA Office of Inspector General 53 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Management 

Comments 

OIG Response 

The VA Secretary concurred with our findings and recommendations and 

stated that VHA would implement Recommendations 11 and 12 by 

August 2015. The Secretary’s entire verbatim response is located in 

Appendix K. 

The VA Secretary’s planned corrective actions are acceptable. We will 

monitor VA’s progress and follow up on the implementation of our 

recommendations until all proposed actions are completed. 

VA Office of Inspector General 54 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Question 4 

Overstated 

Accomplishments 

Emphasis on 

Director’s 

“Wildly 

Important 

Goal” 

Did the PVAHCS Culture Emphasize Goals at the 

Expense of Patient Care? 

Despite obvious access issues at PVAHCS, Ms. Helman claimed successful 

improvements in access measures during FY 2013. In Ms. Helman’s 

FY 2013 self-assessment of her Senior Executive Performance Agreement, 

she claimed the following significant improvements in access to care. 

. . . I drove tremendous improvement in primary care access in 

FY 13. At the beginning of the FY, I identified a severe facility 

weakness in access. I realigned priorities and resources and 

developed a Wildly Important Goal (WIG) to engage staff and 

increase access. My leadership to achieve WIG of improving access 

was realized in the dramatic improvement in multiple measures. 

7 days for Avg [average] 3rd Next Available appointments for new 

and existing patients was the facility metric. For new patients, the 

facility began with an Avg 3rd Next Available improved 1400% from 

338 days to 22 days. WIG resulted in multiple PACT [Patient 

Aligned Care Team] improvements from FY12 to FY13 including: 

70.0% of patients were seen within 7 days to 86%; 24.1% of patients 

received a same day appointment with their PCP to 49%. . . . In new 

patients receiving an appointment within 14 days of create date I 

improved from 32% in FY12 to 50% in FY13. 

This self-assessment addressed portions of the five critical elements that 

VA’s Performance Review Board considered in determining Ms. Helman’s 

performance rating. As a result of her rating, Ms. Helman received a 

1.5 percent pay increase from $169,900 to $172,449 and a performance 

award of $8,495. During our review, VA rescinded the 1.5 percent pay 

increase and performance award of $8,495. 

In 2013, Ms. Helman established a “Wildly Important Goal” (WIG) effort to 

improve access to Primary Care. According to PVAHCS, the problem to be 

resolved was that in FY 2012, 2,700 new patients were waiting to access 

care. The WIG was to have all PCPs have a third-next available appointment 

of 7 days or less for all patients in Primary Care. The third-next available 

appointment was selected as a measure for the WIG, as it is commonly used 

in the private sector to measure access. It is used because the first two 

available appointment slots may represent openings created by patients 

canceling appointments and does not always represent true availability. 

HAS management displayed WIG posters prominently throughout the 

facility to show each clinic’s success or failure in meeting the WIG. The 

following email questioned the validity of a WIG chart showing the decline 

of new patient appointments in April 2013. 

VA Office of Inspector General 55 
 

 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Email From an 

Administrative 

Assistant, 

June 12, 2013 

Email From 

Dr. Burke 

August 12, 2013 

The administrative assistant sent this email because he questioned why a 

veteran who requested to see a PCP on May 17, 2013, had not been 

scheduled as of June 10, 2013. He was told the veteran was placed on the 

EWL on April 8, 2013. The email was sent to a number of staff, to include 

the Chief of HAS. 

. . . I also thought it was interesting that a very large chart on the 

wall in Room D641 shows a steady decline in the number of days to 

schedule New Patient Appointments. The latest information posted 

(April 2013) shows the average wait times for a new patient 

appointment is 36.8 days. [Veteran’s name removed], a 

60% service-connected Veteran, has been waiting over 60 days for 

new patient appointment. Not really noteworthy compared to wait 

times at the beginning of the year until one considers the latest 

reported wait time. Why the variance? 

Has access to new patient appointments significantly diminished 

since April? 

The administrative assistant ends his email by giving this warning. 

Granted, I only have the two (1.25) examples to go off of, but the 

above raises questions regarding validity of the methodology to 

calculate the reported numbers. Given the importance of the Access 

WIG to the facility’s leadership, I do believe it prudent to examine 

that methodology before the Medical Center Director reports these 

numbers to a non-PVAHCS entity that may also see a disparity. 

To achieve the WIG, inappropriate scheduling processes and practices were 

used prevalently throughout PVAHCS. For example, a scheduler stated that 

nurses and providers instructed them to cancel patient appointments in an 

effort to open up appointment slots in order to keep the third-next available 

appointment slot within the 7-day goal. Following is an August 12, 2013, 

email string from Dr. Burke to a management analyst requesting third-next 

available data to update the Primary Care Clinic’s WIG score sheets and 

highlights the importance of the goal and its link to physician pay. 

[Dr. Burke]: Can you please get me the 3rd next available data for 

the weeks of July 22, 29, Aug [August] 5, and 12? Before he left, 

[name removed] had been sending the weekly data to me and I need 

to update my score sheets. Thanks. 

After the management analyst replied that she would follow up, Dr. Burke 

provided the following response. 

VA Office of Inspector General 56 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Email From 

Dr. Burke, 

January 9, 2014 

Third-Next 

Available 

Purportedly 

Improved From 

338 Days to 

22 Days 

[Dr. Burke]: Thanks. This is very important not only for the WIG 

but also because primary care physician’s performance pay is 

based, in part, on their 3rd next available. 

Another email excerpt in which Dr. Burke responded to a staff physician 

expressing concerns with his performance pay and access score of 0 out of 

10 follows. 

I will be in the clinic tomorrow morning so I will try to find you. 

There were 2 goals for access, both heavily weighted (along with 

PACT related stuff, access was a big priority last year). One goal 

was a facility goal of getting at least 40% of new pt [patient] appts 

[appointments] completed within 14 days of appt create date. It was 

worth 10 points and believe it or not we actually met that one, 

barely. The other access goal was an individual goal of 3rd next 

available follow up appt slot of <7 days, average weekly value 

during the 4th quarter (July, August, and Sept), also worth 10 pts 

[points]. You can see what your (and other Diamond Clinic 

providers) 3rd next available was on the poster boards in the clinic. 

Unfortunately you did not average <7 days so you did not meet that 

goal. 

In July 2013, Ms. Helman communicated to all staff the “extraordinary” 

progress made towards the goal of having all PCPs having a third-next 

available appointment of 7 days or less. She stated that many of the Primary 

Care teams reached this goal. Subsequently, Ms. Helman changed the WIG 

to focus on the percentage of new patients in Primary Care who are seen 

within 14 days, to be in line with VISN and VHA goals and metrics. 

Specifically, the new WIG was set as, “By September 30th, more than 

40 percent of our new patients in Primary Care will be seen within 14 days of 

the date that their appointment is created.” Ms. Helman told staff they were 

currently at 36.7 percent, which was up from 32 percent just a few months 

prior. 

On her FY 2013 self-assessment, Ms. Helman claimed the third-next 

available appointment for new patients in Primary Care improved from 

338 days to 22 days. PVAHCS officials could not provide data to support 

that the third-next available appointment ever averaged 338 days for Primary 

Care. Facility officials provided an internal report that indicated 

improvements from an average of 231 days to an average of about 24 days 

until the third-next available appointment for new patients. We determined 

the claimed reductions in the third-next available appointment were related 

to two facility actions. 

VA Office of Inspector General 57 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Email From 

Dr. Burke, 

February 4, 2013 

	 From October 2012 to November 2012, the third-next available dropped 

from 231 days to about 129 days. This occurred because the facility 

began its new patient backlog redistribution for each physician to cancel 

new patient appointments that were beyond 90 days and provide those 

veterans with an earlier appointment. 

	 From February 2013 through May 2013, the third-next available dropped 

from 111 days to about 18 days. During this period, the facility 

transitioned to using the EWL in Primary Care, and schedulers admitted 

to holding new patient appointment requests instead of scheduling the 

appointments. 

In addition, providers could achieve a low number of days until their 

third-next available appointment by not using available appointment slots. 

An excerpt of an email from Dr. Burke to Dr. William White regarding 

access issues and the ratio between providers’ third-next available 

appointment and their current backlog follows. Dr. Burke described to 

Dr. White what the third-next available measure and backlog represents. 

Dr. Burke also provided Dr. White his providers’ figures on their third-next 

available appointment and their current backlog, and concluded the 

following. 

. . . In looking at this we can see that [7 providers] do pretty well. 

[Provider 8] clearly is an outlier in both 3rd next available and 

backlog, reflecting pretty poor access. [Provider 9] has a long 

3rd next available delay and a fairly long backlog. [Provider 10] 

also has a pretty big backlog for only having a 3rd next available of 

3 days, but this may reflect a large number of new pts [patients] in 

her schedule. In the case of [Provider 11] (and especially 

[Provider12]), their 3rd next available is deceiving because it would 

suggest that pts can get appts [appointments] within 1-2 days, but 

their backlog suggests that they are carving out appts. I know 

[Provider 12] has given his team instructions on how to schedule pts 

but when I looked back at the last month I found that the majority of 

the 8:00 [a.m.] slots are not being used, and that raises a red flag. 

Also it appears that he may not be using the last appt of the day 

regularly either. Please know that the Pentad is looking at this 

closely as well and they are aware what the numbers suggest. Can 

you (discreetly) share this with your providers? 

By August 2013, when the facility had its lowest average third-next available 

appointment of about 12 days, it also had about 1,200 veterans on the EWL 

waiting to be scheduled for an appointment. Figure 4 illustrates PVAHCS’s 

reported improvements in the average third-next available appointment for 

new patients. PVAHCS’s WIG target was 7 days. 

VA Office of Inspector General 58 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Patient 

Appointments 

Purportedly 

Completed 

Within 7 Days 

of Desired Date 

New Patient 

Appointments 

Purportedly 

Completed 

Within 14 Days 

Figure 4. Average Days Until Third-Next Available Appointment 

for New Patients 

Average Days 

250 

200 

150 

100 

50 

0 

231 

129 111 

18 24 

12 

Source: PVAHCS 

Ms. Helman claimed 86 percent of all primary care patients were seen within 

7 days of the patient’s desired date. According to PVAHCS, this was based 

on the facility’s performance in June, July, and August 2013. We reviewed a 

statistical sample of all primary care appointments completed during these 

3 months to determine the earliest indication a patient requested care. Our 

results estimated only about 59 percent of all Primary Care appointments 

were completed within 7 days of the patient’s desired date. This analysis 

considered only those veterans who completed appointments and did not 

include those veterans who were still waiting for an appointment. Most of 

the wait time discrepancies occurred because schedulers used the incorrect 

desired date of care. 

Ms. Helman claimed 50 percent of new patients received a Primary Care 

appointment within 14 days in FY 2013. According to PVAHCS, this was 

based on the facility’s performance in August 2013. We reviewed a 

statistical sample of new patient Primary Care appointments completed 

during August 2013 to determine the earliest indication a patient desired 

care. We estimated only about 16 percent of new patients received a Primary 

Care appointment within 14 days. We also reviewed a statistical sample of 

new patient Primary Care appointments completed during all of FY 2013 and 

VA Office of Inspector General 59 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Ethics 

Consultation 

Review of the 

WIG 

Email From a 

Program Analyst, 

July 3, 2013 

estimated only about 13 percent of new patients received a Primary Care 

appointment within 14 days. This analysis considered only those veterans 

who completed appointments and did not include those veterans who were 

still waiting for an appointment. Most of the wait time discrepancies 

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

and the date the appointment was created. 

On April 18, 2012, Ms. Helman spoke at a PVAHCS Chiefs and Supervisors 

monthly meeting and stated that she wanted everyone to be very ethical. 

While serving as the Director of Edward Hines Jr. VA Hospital, Ms. Helman 

recalled hearing Hines providers telling clerks not to schedule veterans. She 

heard staff telling veterans that they would have to call back because they 

could not book an appointment within a couple of weeks. Ms. Helman also 

talked about hearing about unethical behavior involving Medicaid and 

Medicare while she was the acting director for the Spokane VA medical 

facility. She said that no one reported it to the OIG or VISN Director 

because they were fearful for their jobs. Ms. Helman ended her talk saying 

she did not want an environment like that. Also, she said that if she tells 

anyone to do something that goes against policies, directives, rules, or laws, 

they should tell someone about it. 

On July 3, 2013, the PVAHCS Director’s office sent an email to all 

PVAHCS staff that publicized extraordinary progress made towards the WIG 

of having a third-next available appointment within 7 days. In an email on 

the same date, which later was forwarded to Ms. Helman and Dr. Deering, a 

PVAHCS program analyst challenged the ethics of calling the WIG a 

success. 

I have to say, I think it’s unfair to call any of this a success when 

Veterans are waiting 6 weeks on an electronic waiting list before 

they’re called to schedule their first PCP appointment. Sure, when 

their appointment is created, it’s [sic] can be 14 days out, but we’re 

making them wait 6-20 weeks to create that appointment. 

That is unethical and a disservice to our Veterans. 

Even when we were scheduling 8-24 weeks out, at least we could 

provide ancillary services and they could try coming in as a walk-in 

to slip into a no-show/cancellation slot. Without a PCP assigned, 

and that first appointment scheduled out, new or re-establishing 

Veterans are totally out of luck without going through the 

Emergency Department or C-STAT [Consultation Stabilization 

Triage Assessment Team]. I would appreciate it if you passed my 

sentiments along to Ms. Helman. 

VA Office of Inspector General 60 
 

 

 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

PVAHCS Work 

Environment 

Each facility must establish a local ethics program, led by the facility 

director, who appoints an Integrated Ethics Program Officer as the 

day-to-day head of the local program. An ethics consultation meeting was 

held on July 11, 2013. The attendees discussed the need to provide more 

information to veterans. They concluded that: 

	 Important information had been excluded from the July 3, 2013, email, 

and as a result, it did not provide all of the information necessary for 

veterans and staff members to make informed decisions. 

	 By failing to provide all of the information, veterans may believe they 

will be seen as a new patient sooner than is currently feasible. 

The ethics consultation report recommended publishing both the wait time 

successes and the number of patients on the current EWL for new patient 

appointments to all PVAHCS staff. The report also recommended that HAS 

develop a clear process for educating veterans regarding enrollment and 

accessing health care during the wait time until their new patient 

appointments. The goal of the third recommendation was to provide 

reasonable expectations to veterans for obtaining new patient appointments. 

Ms. Helman received the report and recommendations. Our review of emails 

found that PVAHCS stated it developed a New Veteran Orientation booklet 

to address recommendations 2 and 3.10 However, according to an email from 

Ms. Claflin, PVAHCS did not publish the number of veterans on the EWL at 

that time because the EWL was still being implemented in various clinics. 

While conducting our work at PVAHCS, OIG staff and the OIG Hotline 

received allegations of mismanagement, inappropriate hiring decisions, 

sexual harassment, and bullying behavior by mid- and senior-level managers 

at this facility. We interviewed or received OIG Hotline complaints from 26 

current and former staff who specifically reported issues of harassment, 

bullying, improper use of resources, reprisal, and general fear of losing their 

jobs. Staff in more than one department called the culture “toxic.” 

Many of these hostile work environment issues reported to us related to 

facility management, human resources, and the Chief of HAS. The staff 

made statements indicating these individuals were aggressive and demeaning 

toward employees and managed through intimidation, fear, and retaliation. 

We could not substantiate the allegations because most were anecdotal and 

based on third-party conversations. 

10 We did not see this booklet during our site visits at PVAHCS and cannot verify whether 

the contents addressed recommendation 2 and 3. 

VA Office of Inspector General 61 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Email From LPN, 

December 12, 2013 

Federal 

Employee 

Viewpoint 

Survey 

The following is an abbreviated email from an LPN sent to Ms. Helman, 

Dr. Deering, and Mr. Robinson on December 12, 2013, concerning poor 

treatment of veterans. 

I have been an LPN at the Thunderbird CBOC since July of this 

year. I was previously employed at the Northwest CBOC. 

I have seen some things at this clinic done by the staff that have 

disturbed me greatly, some of whom are in leadership roles. I would 

hope that the things that I have witnessed here will not only be 

disturbing to you as well, but hopefully enough to merit 

investigating. I have seen, specifically related to my sister team, 

walk in patients deliberately made to wait in the lobby for at least 

2 hours, as “punishment” for not scheduling an appointment. (This 

was told to me directly by the team nurse assistant [name removed], 

while laughing about it.) I have seen patients come in for RN 

[Registered Nurse] appointments with our Team Leader, [name 

removed], and after waiting for nearly two hours to be seen by her, 

leave the clinic without being seen because they had to wait for so 

long. Meanwhile, during the time that the patient was waiting, 

[name removed] was in her Nurse Assistants office discussing 

costumes to wear to an upcoming retirement party, which I 

witnessed. 

. . . I have also reported this behavior not only to my current Nurse 

Manager at the time, but also to 3 other Nurse Managers, and 

nobody will take any responsibility for investigating it. In fact, once 

I did report these things to my Nurse Manager, she then spoke to my 

team leader about it, which then began a wide array of harassment 

towards me from her, which I also reported. 

. . . I have submitted my letter of resignation effective 12/13/13 due 

to the feeling of being in a hostile work environment with no 

recourse. I also can no longer sit by and watch our Veterans be 

treated in the manner in which they are at this facility. It’s very 

unfortunate to me that this can occur in this day and age and nobody 

will do anything about it. Please look into it. This is not OK. 

Ms. Helman sent an email the same day to Dr. Deering and Mr. Robinson 

saying not to send this out to anyone until they decided together on how to 

address the issue. 

In late April through June 2013, the Office of Personnel Management asked 

Federal employees to provide input to the 2013 Federal Employee Viewpoint 

Survey to influence change at their agencies. The Federal Employee 

Viewpoint Survey is a tool that measures employees’ perceptions of whether, 

VA Office of Inspector General 62 
 

Conclusion 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

and to what extent, conditions that characterize successful organizations are 

present in their agencies. The survey included 10 leadership questions, 

13 agency questions, and 9 satisfaction questions. For 26 of those 

32 questions, PVAHCS employees were less positive compared with the 

overall results of VA and VHA employees. 11 Table 2 provides three 

examples in which PVAHCS employees were less positive with their 

leadership’s performance. 

Table 2. Federal Employee Viewpoint Survey Results 

My organization’s leaders maintain high standards 

of honesty and integrity. 

Positive Neutral Negative 

VA 49.3% 24.9% 25.8% 

VHA 49.6% 25.0% 25.4% 

PVAHCS 43.6% 23.8% 32.6% 

How satisfied are you with the policies and practices 

of your senior leaders? 

VA 40.2% 29.7% 30.1% 

VHA 40.8% 29.8% 29.4% 

PVAHCS 35.7% 27.9% 36.4% 

I have a high level of respect for my organization’s senior leaders. 

VA 50.3% 24.4% 25.3% 

VHA 50.5% 24.5% 25.0% 

PVAHCS 45.5% 24.5% 30.0% 

Source: 2013 Federal Employee Viewpoint Survey 

PVAHCS’s emphasis on goals resulted in a misleading portrayal of veterans’ 

access to patient care. Despite Ms. Helman’s claims of successful 

improvements in access measures during FY 2013, we found those 

accomplishments were inaccurate and unsupported. 

Recommendations 

13.	 We recommended that upon the completion of the investigation the VA 

Secretary confer with appropriate VA staff and determine whether 

administrative action should be taken against management officials at 

11 The definitions for the Positive, Neutral, and Negative responses vary in the following 

ways across the response scales used in the survey. Positive: Strongly Agree/Very Satisfied 

and Satisfied/Very Good and Good; Neutral: Neither Agree nor Disagree/Neither Satisfied 

nor Dissatisfied/Fair; Negative: Disagree and Strongly Disagree/Dissatisfied and Very 

Dissatisfied/Poor and Very Poor. 

VA Office of Inspector General 63 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Management 

Comments 

OIG Response 

the Phoenix VA Health Care System and ensure that action is taken 

where appropriate. 

14.	 We recommended the VA Secretary ensure the Phoenix VA Health 

Care System include an employee satisfaction measure and a veteran 

satisfaction measure in the Phoenix VA Health Care System 

management’s performance plans and facility goals. 

The VA Secretary concurred with our findings and recommendations and 

stated that VHA would implement Recommendation 13 after completion of 

all external reviews and Recommendation 14 by March 2015. The 

Secretary’s entire verbatim response is located in Appendix K. 

The VA Secretary’s planned corrective actions are acceptable. We will 

monitor VA’s progress and follow up on the implementation of our 

recommendations until all proposed actions are completed. 

VA Office of Inspector General 64 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Question 5 

Allegations of 

Inappropriate 

Scheduling 

Practices 

Found 

Nationwide 

Are Scheduling Deficiencies Systemic Throughout 

VHA? 

Inappropriate scheduling practices are a systemic problem nationwide. We 

identified multiple types of scheduling practices that did not comply with 

VHA’s policy. VHA missed opportunities to hold senior headquarters and 

field facility leadership responsible and accountable for implementing action 

plans that addressed compliance with scheduling procedures. Then in 

May 2013, the Deputy Under Secretary for Health for Operations 

Management waived the FY 2013 annual requirement for facility directors to 

certify compliance with the VHA scheduling directive, further reducing 

accountability over wait time data integrity and compliance with appropriate 

scheduling practices. Additionally, the breakdown of the ethics system 

within VHA also contributed significantly to the questioning of the reliability 

of wait time data in the scheduling system. 

Since the PVAHCS story first appeared in the national media, we have 

received approximately 225 allegations regarding PVAHCS and 

approximately 445 allegations of similar issues regarding wait times at other 

VA medical facilities through the OIG Hotline, from Members of Congress, 

VA employees, veterans and their families, and the media. The VA OIG 

Office of Investigations has opened investigations at 93 sites of care in 

response to allegations of wait time manipulations. In particular, we focused 

on whether management ordered schedulers to falsify wait times and EWL 

records, or attempted to obstruct OIG or other investigative 

efforts. Investigations are being worked in coordination with the Department 

of Justice and the Federal Bureau of Investigation. Our investigations 

confirmed that wait time manipulations are prevalent throughout VHA. 

Among the variations of wait time manipulations our ongoing investigations, 

as of August 2014, at the 93 sites have, thus far, found many medical 

facilities were: 

	 Using the next available date as the desired date to “0-out” appointment 

wait times. 

	 Canceling appointments and rescheduling them to make wait times 

appear to be shorter than they actually were. To date, we substantiated 

that management at one facility directed schedulers to do this. 

	 Using paper wait lists rather than official EWLs. 

	 Canceling consults without appropriate clinical review. 

	 Altering clinic utilization rates to make it appear the clinic was meeting 

utilization goals. 

VA Office of Inspector General 65 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Scheduling 

Scheme #1
 

Scheduling 

Scheme #2
 

Scheduling 

Scheme #3
 

Scheduling 

Scheme #4
 

Wherever we confirm potential criminal violations, we will present our 

findings to the appropriate Federal prosecutor. If prosecution is declined, we 

will provide documented results of our investigation to VA for whatever 

administrative action they deem appropriate. We will do the same if our 

investigations substantiate manipulation of wait times but do not find 

evidence of any possible criminal intent. Finally, we have also kept the 

U.S. Office of Special Counsel apprised of our active criminal investigations 

as they relate to the U.S. Office of Special Counsel’s numerous referrals to 

VA of whistleblower disclosures of allegations relating to wait times and 

scheduling issues. 

We identified multiple types of scheduling practices that did not comply with 

VHA policy and a number of types of scheduling schemes in use throughout 

VHA. Many of these schemes were detailed in the then-Deputy Under 

Secretary for Health for Operations and Management Memorandum on 

Inappropriate Scheduling Practices (April 2010), included in this report at 

Appendix H. The memorandum stated that in order to improve scores on 

assorted access measures, certain facilities have adopted the use of 

inappropriate scheduling practices that were not in line with patient-centered 

care. The following examples are schemes we identified. 

Schedulers accessed the scheduling program, found an open appointment, 

and asked the veteran if that appointment would be acceptable. They then 

backed out of the scheduling program and entered the open appointment date 

as the veteran’s desired date of care. This made the wait time of an 

established patient 0 days. 

Schedulers described a process with the Clinic Appointment Availability 

Report (or similar report) that supervisors used to identify individual 

schedulers whose appointments exceeded the 14-day goal. Scheduling 

supervisors told schedulers to review these reports and correct any 

appointments with wait times greater 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 deleted consults without full consideration of the effect on patients. 

They deleted or canceled provider consults without adequate reviews by 

clinical staff in an effort to reduce their backlog of consults. 

Multiple schedulers described a process they used that essentially 

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

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

and time and for the same veteran. This removed the existing appointment 

date but did not record a canceled appointment. This action allowed the 

scheduler to overwrite the prior desired date and appointment create date 

with a new desired date. This adjusted the create date to the current date of 

VA Office of Inspector General 66 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Scheduling 

Scheme #5 

Scheduling 

Scheme #6 

VHA Access 

Audit 

Identified 

Scheduling 

Issues 

entry and the desired date to the date of the appointment, thus reducing the 

reported wait time. 

Staff created patient appointments without notifying the patient. This is 

commonly referred to as blind scheduling and creates a high likelihood that 

the patient will be a no-show for their appointment. 

Facilities used paper wait lists or other manual systems to track veterans 

waiting for care instead of using the EWL. This action delayed adding the 

veteran to the EWL or scheduling their appointment, thus not capturing the 

veteran’s entire wait time in VA data. 

At the direction of the former Secretary, VHA conducted an Access Audit 

from May 12, 2014, through June 3, 2014. The audit was to determine 

whether allegations about inappropriate scheduling practices were isolated 

instances of improper practices or if broader, more systemic problems exist. 

VHA’s Access Audit had a number of audit limitations, such as independent 

verification of results, time limitations, and lack of establishing leadership 

and staff accountability. However, despite these and other limitations, 

VHA’s audit also found that inappropriate scheduling practices were a 

systemic problem nationwide. 

The audit was conducted in two phases. Phase One covered VA medical 

centers and large CBOCs serving at least 10,000 veterans. Phase Two 

covered additional VA facilities, including PVAHCS. Combined, the two 

phases covered 731 total facilities, including 140 parent facilities. 

Ultimately, VA chose to suspend Phase Two data collection after initial 

assessments restated high consistency with the findings of Phase One. The 

following are VHA’s Access Audit findings. 

	 Efforts to meet needs of veterans (and clinicians) led to an overly 

complicated scheduling process that resulted in a high potential to create 

confusion among scheduling clerks and front-line supervisors. 

	 Meeting a 14-day wait time performance target for new appointments 

was simply not attainable given the ongoing challenge of finding 

sufficient provider slots to accommodate a growing demand for services. 

Imposing this expectation on the field before ascertaining the resources 

required and its ensuing broad promulgation represented an 

organizational leadership failure. 

	 The concept of “desired date” is a scheduling practice unique to VA, and 

difficult to reconcile against more accepted practices such as negotiating 

a specific appointment date based on provider availability or using a 

“return to clinic” interval requested by providers. 

	 Thirteen percent of scheduling staff interviewed indicated they received 

instruction (from supervisors or others) to enter in the “desired date” field 

VA Office of Inspector General 67 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

White House 

Review of VA’s 

Access to 

Care 

a date different from the date the veteran had requested. At least one 

instance of such practices was identified in 76 percent of VA facilities. 

	 Eight percent of scheduling staff indicated they used alternatives to the 

EWL or VistA package. At least one of such instance was identified in 

70 percent of facilities. 

	 Findings indicate that in some cases, pressures were placed on schedulers 

to use inappropriate practices in order to make wait times (based on 

desired date and the wait lists) appear more favorable. Such practices are 

sufficiently pervasive to require VA to reexamine its entire performance 

management system and, in particular, whether current measures and 

targets for access are realistic or sufficient. 

	 Staffing challenges were identified in small CBOCs, especially where 

there were small counts of providers or administrative support. 

On June 27, 2014, the White House published its review of the issues 

affecting access to timely care at VA medical facilities. The review 

uncovered layers of problems that led to extended wait times for veterans to 

get medical care, including a “corrosive culture,” and little transparency or 

accountability. The report highlighted five significant issues that needed to 

be addressed by VA leadership. 

	 The 14-day scheduling standard is arbitrary, ill-defined, and 

misunderstood. The manner in which this unrealistic goal was developed 

and deployed has caused confusion in reporting and, in some cases, may 

have incentivized inappropriate actions. 

	 VHA needs to be restructured and reformed. It currently acts with little 

transparency or accountability with regard to its management of the VA 

medical structure. The VHA leadership structure often is unresponsive 

and unable to effectively manage or communicate to employees or 

veterans. 

	 A corrosive culture has led to personnel problems that are seriously 

affecting morale and by extension, the timeliness of health care. VHA’s 

extensive field structure is exacerbated by poor management and 

communication structures, a corrosive culture of distrust between some 

VA employees and management, a history of retaliation toward 

employees raising issues, and a lack of accountability. 

	 VA’s failures have generated a high level of oversight. It must be more 

agile and responsive in transparently addressing all legitimate oversight 

requirements. There have been a number of problems identified and 

recommendations made by the OIG, the Government Accountability 

Office (GAO), the Office of Special Counsel, Congress, and others. VA 

has not followed through on sufficiently addressing those problems or 

implementing those recommendations. 

VA Office of Inspector General 68 
 

 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

VHA 

Resistance to 

Change 

	 The technology underlying the basic scheduling system used by VA 

medical facilities is cumbersome and outdated. However, with regard to 

increasing access to care, the software of the scheduling system is 

secondary to the need for additional resources to actually schedule, such 

as physical space; appropriately trained administrative support personnel; 

and doctors, nurses, and other health professionals. 

VHA has resisted external review findings. Since July 2005, OIG published 

20 oversight reports on VA patient wait times and access to care, and VA has 

been resistant to change. For example, VHA did not concur with 

recommendations from the 2007 OIG report Audit of the Veterans Health 

Administration’s Outpatient Waiting Times to comply with its own policy to 

create appointments within 7 days or revert to calculating the wait times of 

new patients based on the desired date of care. VHA disagreed with OIG’s 

observations that VHA ignores the medical provider’s desired date for new 

patients, thereby understating actual wait times. In the 2008 OIG report 

Audit of Alleged Manipulation of Waiting Times in Veterans Integrated 

Service Network 3, VHA did not concur with the report’s conclusions and all 

nine recommendations. The Under Secretary at the time stated that the 

issues OIG reported reflected the need for policy solutions that VHA was 

already addressing. Therefore, singling out VISN 3 and holding it 

accountable was counterproductive. The 20 OIG reports are listed in 

Appendix F. 

Even when VHA concurred with our recommendations and submitted an 

action plan, medical facility directors did not always implement VHA’s 

program directives and policy changes. 

For example, VA’s recent Accelerating Access to Care Initiative is a critical 

part of increasing access to care through the use of Non-VA Care. In 

August 2009, OIG reported that VHA improperly paid 37 percent of 

outpatient fee claims, resulting in an estimated $225 million in overpayments 

and $52 million in underpayments in FY 2008 and an estimated $1.1 billion 

in overpayments and $260 million in underpayments over a 5-year period.12 

Also, serious weaknesses in the processes for authorizing outpatient fee care 

resulted in 80 percent of services lacking proper justification or 

authorization. We recommended that VHA revise and publish fee policies 

that establish clear requirements for how medical facilities should justify and 

authorize outpatient fee care. The then-Acting Under Secretary for Health 

concurred with the recommendation agreeing the current policies should be 

updated, with clarifying direction that better reflects current organizational 

responsibilities. 

12 Audit of Veterans Health Administration’s Non-VA Outpatient Fee Care Program (Report 

No. 08-02901-185, August 3, 2009) 

VA Office of Inspector General 69 
 

 

 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

VHA Waived 

Compliance

Certification 

However, nearly 21⁄2 years after our 2009 report on the Fee Care Program, we 

reported PVAHCS mismanaged fee care funds and experienced a budget 

shortfall of $11.4 million, which was 20 percent of the health care system’s 

FY 2010 fee care program funds.13 One cause of the shortfall was the lack of 

effective authorization procedures, the same problem we reported in 

2009. In fact, the facility processed about $56 million in fee claims without 

adequate review to ensure services were medically necessary. 

VHA’s awareness of scheduling issues provided it with an opportunity to 

abolish the systemic culture of inappropriate scheduling practices. However, 

as it did with prior audit recommendations, VHA did not hold senior field 

facility leaders responsible or accountable for ensuring compliance with 

scheduling procedures. 

VHA Directive 2010-027, dated June 9, 2010, required annual certification 

(through the VISN Director to the Director of Systems Redesign in the 

Office of the Deputy Under Secretary for Health for Operations and 

Management) of full compliance with the content of this directive. Initial 

certifications were due 6 months following issuance of the directive and then 

annually thereafter. 

As part of the directive, facilities are required to ensure completion, using 

VISN-approved processes and procedures, of a standardized yearly scheduler 

audit of the timeliness and appropriateness of scheduling actions and of the 

accuracy of desired dates. They are also required to ensure that identified 

deficiencies in competency or performance, identified by the annual 

scheduler audit, are effectively addressed. 

However, in May 2013, the Deputy Under Secretary for Health for 

Operations Management waived the FY 2013 annual requirement for facility 

directors to certify compliance with the VHA scheduling directive, further 

reducing accountability over wait time data integrity and compliance with 

appropriate scheduling practices. According to VHA’s Director of Systems 

Redesign, who was present when the decision was made, there was 

significant resistance from medical facility directors to certify compliance 

with the directive. The facility directors were concerned about certifying 

results that may be later found inaccurate by the OIG. VHA decided that 

medical facility directors would instead complete a self-review using a 

standardized scheduling process checklist. 

In total, there were 128 facility responses. There were 19 scheduling items 

on the checklist. The 19 items included identifying and avoiding 

inappropriate scheduling activities, checking the EWL daily and acting on 

13 Review of Alleged Mismanagement of Non-VA Fee Care Funds at the Phoenix VA Health 

Care System (Report No. 11-02280-23, November 8, 2011) 

VA Office of Inspector General 70 
Ethical Lapses 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

requests received, and creating appointments in response to consult requests 

using VistA to link the consult to the scheduled appointment. PVAHCS 

reported it was in compliance with these three items. The remaining 

127 facilities reported the following. 

	 Facilities (114) reported compliance with identifying and avoiding 

inappropriate scheduling activities. 

	 Facilities (110) reported compliance with checking the EWL daily and 

acting on requests received. 

	 Facilities (105) reported compliance with creating appointments in 

response to consult requests using VistA to link the consult to the 

scheduled appointment. 

VHA’s IntegratedEthics® model, implemented in VHA Handbook 1004.06, 

dated August 29, 2013, includes three core functions of integrated ethics: 

(1) ethics consultation, (2) preventative ethics (which is essentially training 

and issue awareness), and (3) ethical leadership. Although the current 

handbook is dated Summer 2013, these three core functions date back to at 

least 2007 in the primer discussed below as well as the earlier 

2009 handbook. The principles discussed in this section derive from VHA’s 

IntegratedEthics® program documents. A lapse in any of the three core 

functions of the ethics model, especially leadership as it influences the 

organization’s culture and the behavior of individuals, invites ethical failures. 

To help VA’s senior and middle management provide ethical leadership, 

VHA’s National Center for Ethics in Health Care published a primer entitled 

Ethical Leadership: Fostering an Ethical Environment & Culture in 2007. 

The primer provides this summary of an ethical leader’s responsibilities. 

Leaders in the VA health care system have unique obligations that 

flow from VA’s commitment to providing health care to veterans . . . 

born of the nation’s gratitude to those who have served in its armed 

services. 

	 As public servants, VA leaders are specifically responsible for 

maintaining the public trust, placing duty above self-interest, and 

managing resources responsibly. 

	 As health care providers, VA leaders have a fiduciary obligation 

to meet the health care needs of individual patients in the context 

of an equitable, safe, effective, accessible, and compassionate 

health care delivery system. 

	 As managers, leaders are responsible for creating a workplace 

culture based on integrity, accountability, fairness, and respect. 

VA Office of Inspector General 71 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

The primer also discusses the importance that leaders “understand their 

influence on the organization’s ethical environment and culture.” Leaders 

can “inadvertently encourage or endorse unethical behavior despite their best 

intentions and even without being aware they are doing so. This can happen 

in any of several ways, such as the following: 

	 “When leaders set unrealistic or unattainable goals they invite employees 

to game the system or misrepresent results. When leaders fail to take 

into account organizational barriers to achieving performance 

expectations, they may inadvertently set up situations in which the only 

way to “succeed” is by engaging in behavior that employees know is 

wrong. In such cases, employees are likely to become cynical, especially 

when they believe that those who are lauded for their performance have 

compromised their integrity in order to get there.” 

	 The failure “to link performance incentives to ethical practice” sets the 

stage for ethical lapses. “Lopsided incentives can leave employees 

feeling pressured to do whatever it takes to “make the measure” even 

when doing so raises ethical concerns. Leaders need to incentivize 

ethical practices just as they incentivize other behaviors.” 

	 “When leaders care more about good performance numbers than accurate 

performance numbers, focus on accreditation requirements as simply a 

compliance burden,” or “issue orders that are impossible to fulfill, . . . 

they send messages that have powerful effects in shaping the 

organization’s environment and how staff members perceive the 

organization, their place in it, and the behaviors that are valued.” 

	 “Many messages to employees focus on specific performance 

expectations. But leaders who have a personal commitment to ethics 

make it clear that they care not only that the results are achieved, but also 

how. If a leadership directive is expressed in absolute terms or too 

forcefully, it can create a strong incentive for staff to “game the system,” 

or to withhold or even misrepresent information, i.e., “fudge the 

numbers.” ” 

The systemic underreporting of wait times resulted from many causes, to 

include the lack of available staff and appointments, increased patient 

demand for services, and an antiquated scheduling system. The ethical 

lapses within VHA’s senior leaders and middle managers also contributed to 

the unreliability of reported access and wait time issues, which went 

unaddressed by those responsible. As one symptom of the ethics leadership 

problem, the Chief Ethics Officer for Health Care Ethics position, along with 

other positions, was removed from VHA’s National Leadership Board in a 

reorganization in 2011. 

VA Office of Inspector General 72 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Replacing 

VHA’s 

Scheduling 

System 

Since approximately 2000, VA has made a number of unsuccessful efforts to 

replace VHA’s VistA scheduling system. In 2009, for example, VA 

canceled the Replacement Scheduling Application (RSA) project. A 

March 2009 memo from the Under Secretary for Health to the Acting 

Assistant Secretary for Information and Technology stated that the RSA 

project had not developed a single scheduling capability it could provide to 

the field nor was there any expectation of delivering a capability in the near 

future. The memo also stated that after more than 5 years and a cost of more 

than $75 million, the RSA failed to deliver a useable product because of 

ineffective planning and oversight. 

In August 2009, we published the OIG report, Review of the Award and 

Administration of Task Orders Issued by the Department of Veterans Affairs 

for the Replacement Scheduling Application Development Program (RSA) 

(Report No. 09-01926-207, August 26, 2009). RSA was a multiyear project 

to replace the system VHA used to schedule medical appointments for VA 

patients. Lacking defined requirements, an information technology 

architecture, and a properly executed acquisition plan, RSA was at 

significant risk of failure from the start. We suggested that VA needed 

experienced personnel to plan and manage the development and 

implementation of complex information technology projects effectively. We 

also suggested that a system to monitor and identify problems affecting the 

progress of projects could support VA’s leadership in making effective and 

timely decisions to either redirect or terminate troubled projects. 

Since the cancelation of the RSA project, VA has continued to seek solutions 

to replace its current scheduling system. In December 2011, VA posted a 

Request for Information for market research purposes to help VA develop 

requirements and an acquisition strategy. Throughout 2012, VHA and VA’s 

Technology Acquisition Center reviewed responses from industry and 

determined it needed more information. In May 2013, VA decided to 

conduct an America Competes Act Prize Competition. The winners were 

notified in November 2013 (four prizes at a cost of $3 million). In FY 2013, 

VA awarded a $5 million contract to assist the VA project manager, a 

$1.06 million acquisition support contract, and a $5 million Test and 

Evaluation Contract to create test environments for the prize competition. 

To date, no solicitations have been issued for a replacement scheduling 

system. 

While VHA’s VistA scheduling system is old and cumbersome, the culture 

of staff manipulating data is VHA’s primary scheduling issue. If managed 

effectively, a replacement scheduling system may enhance patient scheduling 

operations. 

VA Office of Inspector General 73 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Management 

Comments 

Recommendations 

15.	 We recommended 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. We provided this recommendation 

to the former VA Secretary in the Interim Report. 

16.	 We recommended 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 Wait List. We provided this recommendation to 

the former VA Secretary in the Interim Report. 

17.	 We recommended the VA Secretary establish veteran-centric goals and 

eliminate current goals that divert focus away from providing timely 

quality care to all eligible veterans. 

18.	 We recommended the VA Secretary take measures to ensure use of 

“desired date” is appropriately applied. 

19.	 We recommended the VA Secretary provide veterans needed care in a 

timely manner and minimize the use of the Electronic Wait Lists. 

20.	 We recommended the VA Secretary require facilities to perform 

internal routine quality assurance reviews of scheduling accuracy of 

randomly selected appointments and schedulers. 

21.	 We recommended the VA Secretary initiate a process to selectively 

monitor calls from veterans to schedulers and then incorporate lessons 

learned into training or performance plans. 

22.	 We recommended the VA Secretary conduct a review of the Veterans 

Health Administration’s Ethics Program to ensure the Program’s 

operational effectiveness, integrity, and accountability. 

23.	 We recommended the VA Secretary initiate actions to update the 

Veterans Health Administration’s current electronic scheduling system 

and ensure milestones and costs are monitored. 

24.	 We recommended the VA Secretary ensure that the Veterans Health 

Administration establishes a mechanism to ensure data representing 

VA’s national performance are validated by an internal group that has 

direct access to the Under Secretary for Health. 

The VA Secretary concurred with our findings and recommendations and 

stated that VHA would implement Recommendations 17–23 by 

September 2015, and that VHA had already implemented 

Recommendations 15, 16, and 24. The Secretary’s entire verbatim response 

is located in Appendix K. 

VA Office of Inspector General 74 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

OIG Response The VA Secretary’s planned corrective actions are acceptable. We will 

monitor VA’s progress and follow up on the implementation of our 

recommendations until all proposed actions are completed. We will not 

close Recommendation 15 until VHA provides us national data on the 

number of veterans currently on wait lists to include data on how long the 

veterans have been on the wait lists. We will not close 

Recommendation 16 until the OIG completes our ongoing audit of the 

Health Eligibility Center to ensure the data put forth by the Health Eligibility 

Center are valid. We consider Recommendation 24 closed based on VA’s 

actions. 

VA Office of Inspector General 75 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Appendix A Background 

Phoenix VA PVAHCS serves veterans in central Arizona through its main medical Health Care facility, the Carl T. Hayden VA Medical Center in Phoenix, AZ. Veterans System can be seen at one of the medical center’s four primary care clinics. 

PVAHCS 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 VA 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 VA Health Care Clinic in Payson is a contract clinic offered 

to veterans through a partnership with Health Net Federal Services. The 

clinic serves veterans in the greater Payson area. 

	 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 Globe-Miami VA Health Care Clinic in Globe serves veterans in the 

surrounding area. 

VA Office of Inspector General 76 
‐    

Northwest Clinic

(Surprise)

Show Low Clinic

(Show Low)

       

   

 

Review of Alleged Patient Deaths, Patient Wait Times, and 

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Figure 5 is a map of the locations of the PVAHCS clinics. 

Figure 5. PVAHCS Community Clinics 

PVAHCS COMMUNITY CLINICS

Globe Miami Clinic

(Globe)

Payson Clinic

(Payson) Thunderbird Clinic

(Phoenix)

Southeast Clinic

(Gilbert)

Tracking Wait 

Time Data 

Source: Google Maps 

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

to the VHA Deputy Chief Information Officer for Health requesting the 

development of an EWL to track the demand for services at VA medical 

facilities. The memo indicated that existing wait time measures reflected the 

experience of veterans already in the system but did not capture the wait time 

experience of new veteran enrollees or patients without a scheduled 

appointment. At the time, “ad hoc” written lists of new veteran enrollees 

waiting 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 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 PCP assignments. The EWL was intended to assist VA 

VA Office of Inspector General 77 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

medical facilities in managing veterans’ access to outpatient health care and 

assist clinics in identifying patients in need of appointments. 

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 VistA. When a patient cannot be assigned to a 

primary care team or position, the software asks if the patient should be 

placed on the EWL. 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 

	 Records and updates patient eligibility information and service-connected 

status 

	 Runs background programs to determine changes in the veteran’s 

service-connected percentage and service-connected priority, as well as 

changes to appointments, clinics, and personnel that affect EWL patients 

	 Sends messages to assigned mail groups to notify them of such changes 

	 Produces reports on demand regarding EWL-related activities 

VA Office of Inspector General 78 
 

 

Review of Alleged Patient Deaths, Patient Wait Times, and 

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Appendix B 

Scope 

Methodology 

Scope and Methodology 

We conducted this review from April through July 2014. We reviewed 

allegations at PVAHCS that included gross mismanagement of VA 

resources, criminal misconduct by VA senior hospital leadership, systemic 

patient safety issues, and possible wrongful deaths. We initiated this review 

in response to allegations first reported to the VA OIG Hotline. We 

expanded our work at the request of the former VA Secretary and the 

Chairman of the HVAC following an HVAC hearing on April 9, 2014, on 

delays in VA medical care and preventable veteran deaths. 

Due to the multitude and broad range of issues, we assembled a 

multidisciplinary team comprising board-certified physicians, special agents, 

auditors, and health care inspectors. To address our review objectives, we 

reviewed applicable laws, regulations, policies, procedures, guidelines, and 

studies. Our review at PVAHCS included the following actions. 

	 We interviewed over 200 staff, most with direct knowledge of patient 

scheduling practices and policies. This included scheduling staff, data 

analysts, supervisors, patient care providers, management staff, and 

whistleblowers who reported allegations of wrongdoing. 

	 We interviewed the principal complainants, including Dr. Samuel Foote 

(retired PVAHCS physician) and Dr. Katherine Mitchell (Medical 

Director of the PVAHCS OEF/OIF/OND clinic). 

	 We collected and analyzed voluminous reports and documents from 

VHA information technology systems related to patient scheduling and 

enrollment. 

	 We obtained and reviewed VA and non-VA medical records of patients 

who died while on a wait list or whose deaths were alleged to be related 

to delays in care. 

	 We reviewed performance standards, ratings, and awards of senior 

PVAHCS staff. 

	 We reviewed 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. 

	 We reviewed prior reports relevant to these allegations, including 

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

the Medical Inspector. 

	 We reviewed over 1 million email messages, approximately 190,000 files 

from 11 encrypted computers and/or devices, and over 80,000 converted 

messages from VistA email. 

VA Office of Inspector General 79 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

During the review, we visited the PVAHCS main campus and three large 

primary care clinics located at the community-based outpatient sites. The 

review teams used interviews to determine whether PVAHCS personnel 

followed established scheduling procedures. 

Since the PVAHCS story first appeared in the national media, we received 

approximately 225 allegations regarding PVAHCS and approximately 

445 allegations of similar issues regarding manipulated wait times at other 

VA medical facilities through the OIG Hotline. We received additional 

allegations from Members of Congress, VA employees, veterans and their 

families, and the media. The VA OIG Office of Investigations opened 

investigations at 93 sites of care in response to allegations of wait time 

manipulations. In particular, we focused on whether management ordered 

schedulers to falsify wait times and EWL records, or attempted to obstruct 

OIG or other investigative efforts. Investigations continue, in coordination 

with the Department of Justice and the Federal Bureau of 

Investigation. These investigations, while some are still ongoing, confirmed 

that wait time manipulations are prevalent throughout VHA. Among the 

variations of wait time manipulations, our ongoing investigations, as of 

August 2014, at the 93 sites have thus far found many medical facilities 

were: 

	 Using the next available date as the desired date to “0-out” appointment 

wait times. 

	 Canceling appointments and rescheduling them to make wait times 

appear to be less than they actually were. We substantiated that 

management at one facility directed schedulers to do this. 

	 Using paper wait lists rather than the EWL. 

	 Canceling consults without appropriate clinical review. 

	 Altering clinic utilization rates to make it appear the clinic was meeting 

utilization goals. 

Wherever we confirm potential criminal violations, we will present our 

findings to the appropriate Federal prosecutor. If prosecution is declined, we 

will provide documented results of our investigation to VA for whatever 

administrative action they deem appropriate. We will do the same if our 

investigations substantiate manipulation of wait times but do not find 

evidence of any possible criminal intent. Finally, we have also kept the 

U.S. Office of Special Counsel apprised of our active criminal investigations 

as they relate to U.S. Office of Special Counsel’s numerous referrals to VA 

of whistleblower disclosures of allegations relating to wait times and 

scheduling issues. 

VA Office of Inspector General 80 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Patient Lists 

Case Reviews: 

EWL, PVAHCS 

Physician List, 

HVAC List, 

Hotline List, 

Media List, 

Institutional 

Disclosure List, 

NEAR List, and 

Suicides 

Case Reviews: 

Schedule an 

Appointment 

Consult List and 

Paper Wait List 

During this review, OIG was provided with numerous lists of PVAHCS 

patients. These patient lists were retrieved by OIG staff while onsite at 

PVAHCS; obtained from the PVAHCS Quality Management office and 

related activities; and obtained from external sources such as OIG’s Hotline, 

the HVAC, other Congressional sources, and media reports. Furthermore, 

late in the course of this inspection, we found problems with access to care 

for patients requiring Urology Services. As a result, Urology Services at 

PVAHCS will be the subject of a subsequent report. In all, OIG examined 

the EHRs and other information for 3,409 veteran patients identified from 

the various lists. 

OIG physicians reviewed the care provided to patients identified on the 

following lists. 

 EWL—deceased patients between April 2013 and April 2014

 Former PVAHCS physician list

 HVAC list

 Hotline referrals up to June 1, 2014

 Media list

 Institutional Disclosure List for disclosures made in calendar years

2012 and 2013

 Deceased patients on the NEAR list after January 1, 2012

 Suicides after January 1, 2012

Institutional disclosures include discussions of events not associated with 

substantial harm. For example, PVAHCS would disclose that a patient’s 

temperature was taken using an oral probe without a protective cover, a 

minor surgical procedure had to be interrupted because of a power failure, or 

an X-ray was performed on the wrong patient. 

Providers at PVAHCS used the Schedule an Appointment consult 

mechanism to refer patients for care to other providers, usually in Primary 

Care. For this purpose, a Schedule an Appointment consult was often used. 

OIG staff performed preliminary reviews for the 2,426 patients on both 

the Schedule an Appointment consult list and the “Paper Wait” list 

using a review tool developed by senior physicians. 

When a delay in patient care was identified, an in-depth EHR review was 

conducted. This review included researching previous inpatient admissions, 

reviewing ED visits, admissions at other VA facilities, VA registration data, 

and correspondence between a patient and PVAHCS. Reviewers used 

clinical judgment to determine whether, in their opinion, an identified delay 

could have translated into a harmful outcome or a potentially harmful 

outcome. When such a situation was identified, the EHR was flagged for an 

in-depth physician review (“second-level physician review”). 

VA Office of Inspector General 81 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Case Reviews 

for Mental 

Health 

Records 

Overall, 13 reviewers, selected based on their medical training and patient 

care experience, performed this initial screening. The reviewers were 

supervised by a physician. 

Reviewers referred 341 of the 2,426 patient EHRs for physician 

review. This second-level review involved reexamination of the 

available information in the VA EHR, along with a review of any 

pertinent non-VA treatment records that would help in making an 

informed assessment regarding the effect of the delay on the veteran’s 

health care. For many of these secondary evaluations, case review 

meetings were conducted with senior physician staff to present complex 

cases and formulate a consensus. 

OIG inspectors obtained a list from the PVAHCS’s former SPC of all patient 

suicides from May 23, 2010, through May 6, 2014, known to the facility and 

reported to the VA’s Center of Excellence for Suicide Prevention in 

Canandaigua, NY. OIG physicians (including two psychiatrists) reviewed 

the EHRs of 77 patients on the list who committed suicide between 

January 1, 2012, and May 6, 2014. Thirty of the 77 suicides initially were 

not known to the SPC but later came to the attention of the SPC from the 

PVAHCS Quality Management office. 

OIG inspectors also obtained a spreadsheet of 171 PVAHCS patients on a 

wait list for psychotherapy services from the Director of Psychology at the 

PVAHCS. PVAHCS reported that most of the patients on the list were 

referred for psychotherapy to non-VA providers. These referrals were made 

in early May 2014 through the TriWest contract. OIG clinician inspectors 

and an OIG psychiatrist reviewed the EHRs for all patients on the list in 

order to ascertain an updated status for pending psychotherapy consults. For 

patients authorized for Non-VA Care through TriWest but still awaiting an 

appointment per the EHR, we obtained updates as of July 9, 2014. 

We interviewed the Director of the VA Center of Excellence for Suicide 

Prevention, the PVAHCS’ former SPC, a facility suicide prevention case 

manager, the Chief of Primary Care at the PVAHCS, the Chief of the 

Psychiatry Department, the Director of Psychology Services, the Section 

Chief for Outpatient Psychiatry, nine psychiatric providers in the Jade/Opal 

clinic, three psychologist providers in the Jade/Opal clinic, a clinical social 

worker in the Jade/Opal clinic, five of the clinic’s registered nurses, two 

nursing assistants, a home telehealth nurse, and three of the Jade/Opal 

clinic’s medical support assistants. 

Patient records were reviewed in VA’s Compensation and Pension Record 

Interchange database that includes the EHR. Also, as needed, images and 

additional data were downloaded from VA’s Computerized Patient Record 

System (CPRS). 

VA Office of Inspector General 82 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Government 

Standards 

Several patients in cases reviewed herein opted for Non-VA Care at critical 

junctures. As needed, we obtained the relevant private sector medical 

records and interviewed caregivers and family members. For all deceased 

patients reviewed in a second-level physician review, we obtained death 

certificates from Maricopa County and the State of Arizona, whom we would 

like to acknowledge for their cooperation and expedience in meeting our 

request. 

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 completed this 

independent, joint review in accordance with the Council of the Inspectors 

General on Integrity and Efficiency’s Quality Standards for Inspection and 

Evaluation (January 2012). 

VA Office of Inspector General 83 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Appendix C Statistical Sampling Methodology 

We selected two random samples of primary care appointments completed at 

PVAHCS. Both samples were evaluated to determine the reported wait 

times based on our assessment of the earliest indication a patient desired 

care. 

Populations	 We sampled two populations. The first sample’s population consisted of 

26,382 primary care appointments for new and established patients that were 

completed during June through August 2013. The second population 

consisted of 12,341 primary care appointments for new patients during 

FY 2013 including 1,352 completed in August 2013. 

Sampling We selected a simple random sample of 80 appointments from the first 

Design population described above. We stratified the second population into eight 

strata and reviewed a sample of 226 appointments. We stratified the sample 

based on the month the appointment was completed (August or not August) 

and based on whether the veteran was ever on the EWL, received a Schedule 

an Appointment consult, or both. 

Weights	 We calculated estimates in this report using weighted sample data. Sampling 

weights were computed by taking the product of the inverse of the 

probabilities of selection at each stage of sampling. 

Projections We used a 90 percent confidence interval and the midpoint of our estimates and Margins for our projections. The margins of error and confidence intervals are of Error indicators of the precision of the estimates. If we repeated this audit with 

multiple samples, the confidence intervals would differ for each sample, but 

would include the true population value 90 percent of the time. 

VA Office of Inspector General 84 
 

Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Table 3 provides our projections and margins of error. 

Table 3. Projections and Margins of Error 

Category 

Sample 

Estimate 

(Percent) 

Margin 

of Error 

(Percent) 

90% 

Confidence 

Interval 

Lower 

90% 

90% 

Confidence 

Interval 

Upper 90% 

Sample 

Size 

New/Established 

Patient Appointments 

Completed in 7 Days 

of Desired Date 

58.8 9.2 49.5 68.0 80 

New Patient 

Appointments 

Completed in 14 Days 

of Create Date 

(FY 2013) 

13.4 8.7 4.8 22.1 226 

New Patient 

Appointments 

Completed in 14 Days 

of Create Date (August 

2013) 

16.1 7.9 8.3 24.0 107 

Source: OIG Analysis 

VA Office of Inspector General 85 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Review of Alleged Patient Deaths, Patient Wait Times, and 

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Appendix D Phoenix Outreach Campaign, Health Resource Center 

Revised 06/24/2014 12:30 PM CST 

DEPARTMENT OF VETERANS AFFAIRS 

Health Resource Center 

3401 SW 21st St., Building 9 

Topeka, KS 66604 

June 30, 2014 

In Reply Refer To: Director/00 

Mr. Steven Young 

650 E Indian School Road 

Phoenix, AZ 85012 

Mr. YoungWe were proud to support your facility in identifying Veteran’s needs for potential care. 

Our outbound call campaign has completed, however, there is a chance the data may 

change due to inbound phone calls received by the Health Resource Center (HRC). In 

addition, we understand Phoenix VAMC staff continue to contact the Veterans we were 

unsuccessful in reaching. Please find below a summary of HRC’s efforts. 

Phoenix Outreach Campaign 

Executive Overview – The Phoenix VAMC requested the HRC to contact Veterans 

identified by the Phoenix VAMC regarding scheduling appointments for health care. 

The Phoenix VAMC identified 3091 Veterans requiring contact 19 of which were 

duplicated. The list of unique records included 169 records with no phone number 

listed and 41 deceased Veterans leaving a total of 2862 total available records for the 

HRC to contact. In campaign 1 the HRC Contact Representatives (CRs) were able to 

locate an extra 19 Veteran’s phone numbers out of the list of those that did not have a 

phone number listed on the original report increasing the total of available contacts to 

2881. Out of the 2881 contacts 11 of the calls resulted in an urgent priority, 146 of the 

calls were high priority, 722 of the calls were medium priority, and 2002 of the calls 

were low priority. The first campaign began on 5/29/14 and the last campaign ended 

6/10/14. The Health Resource Center was tasked to make three attempts for each 

identified Veteran. All outbound calls were documented according to our internal 

procedures (a service request created for each attempt and a documented disposition). 

The snapshot below is related to a fixed point in time. The reported numbers may 

change due to inbound calls associated with voicemails left by the HRC and inbound 

calls related to mailings by the Phoenix VAMC. 

VA Office of Inspector General 86 
 

 

 

 

 

 

 

 

 

Review of Alleged Patient Deaths, Patient Wait Times, and 

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Campaign 1 – The Phoenix VAMC originally provided a list of 1704 Veterans to the 

HEC. The list included 19 entries that were determined to be duplicated leaving 

1685 unique Veteran records. The list of unique records included 108 records with no 

phone number listed and 14 deceased Veterans leaving a total of 1563 total available 

records for the HRC to contact. Through the effort of the HRC CRs making the phone 

calls an extra 19 Veteran’s phone numbers were located to be contacted raising the 

number of records to be attempted to 1582. Out of the 1582 contacts 9 of the calls 

resulted in an urgent priority, 112 of the calls were high priority, 529 of the calls were 

medium priority, and 932 of the calls were low priority. 

Phoenix NEAR Outreach Campaign 1 

Veterans on original NEAR list 1704 

Duplicate Entries Found 19 

Total Records Received by HRC (excluding duplicates) 1685 

Total No Phone Number or Deceased Records 122 

No Phone Number 108 

Deceased 14 

Net Veterans requiring Contact 1563 

Campaign 1 Metrics 

Veterans Contacted (PRM Referral Sent)* 1582 

Urgent (Crisis Call or Emergency Services) 9 

High (Request Appt. within 7 Days) 112 

Medium (Request Appt. within 30 Days) 529 

Low (Request Appt. within 90 Days, 

wrong/disconnected number, or unsuccessful 3rd 

attempt) 932 

Requesting Appointment within 90 Days 8 

Veteran already has appointment 218 

Unsuccessful in 3 Attempts 508 

Transferred to another VAMC 27 

Requesting not to be contacted 164 

Deceased (Discovered by HRC outbound call) 7 

Current as of June 4, 2014 10:00 AM CST 

* Defined as: Veterans Verbally Contacted, 3 attempted calls with message left, or wrong/disconnected number 

Revised 06/24/2014 12:30 PM CST 

VA Office of Inspector General 87 
 

 

 

 

 

 

 

 

Review of Alleged Patient Deaths, Patient Wait Times, and 

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Campaign 2 – The Phoenix VAMC identified an additional 823 Veterans requiring 

contact. The list of unique records included 55 records with no phone number listed and 

23 deceased Veterans leaving a total of 745 total available records for the HRC to 

contact. Out of the 745 contacts 1 of the calls resulted in an urgent priority, 9 of the 

calls were high priority, 127 of the calls were medium priority, and 608 of the calls 

were low priority. 

Phoenix NEAR Outreach Campaign 2 

Veterans on original NEAR list 823 

Duplicate Entries Found 0 

Total Records Received by HRC (excluding duplicates) 823 

Total No Phone Number or Deceased Records 78 

No Phone Number 55 

Deceased 23 

Net Veterans requiring Contact 745 

Campaign 2 Metrics 

Veterans Contacted (PRM Referral Sent)* 745 

Urgent (Crisis Call or Emergency Services) 1 

High (Request Appt. within 7 Days) 9 

Medium (Request Appt. within 30 Days) 127 

Low (Request Appt. within 90 Days, 

wrong/disconnected number, or unsuccessful 3rd 

attempt) 608 

Requesting Appointment within 90 Days 13 

Veteran already has appointment 16 

Unsuccessful in 3 Attempts 347 

Does not want an appointment 164 

Requesting not to be contacted 57 

Deceased (Discovered by HRC outbound call) 11 

Current as of June 6, 2014 8:40 AM CST 

* Defined as: Veterans Verbally Contacted, 3 attempted calls with message left, or wrong/disconnected number 

Revised 06/24/2014 12:30 PM CST 

VA Office of Inspector General 88 
 

 

 

 

 

Review of Alleged Patient Deaths, Patient Wait Times, and 

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Campaign 3 – The Phoenix VAMC identified an additional 564 Veterans requiring 

contact. The additional Veterans requiring contact were identified after a comparison 

review was completed between the Veteran contacts received in the previous two 

campaigns and the official Office of Inspector General (OIG) report. The list of unique 

records included 6 records with no phone number listed and 4 deceased Veterans 

leaving a total of 554 total available records for the HRC to contact. Out of the 

554 contacts 1 of the calls resulted in an urgent priority, 25 of the calls were high 

priority, 66 of the calls were medium priority, and 462 of the calls were low priority. 

Phoenix NEAR Outreach Campaign 3 

Veterans on original NEAR list 564 

Duplicate 0 

List Received by HRC (excluding duplicates) 564 

Veterans (No Phone Number or Deceased) 10 

No Phone Number 6 

Deceased 4 

Net Veterans requiring Contact 554 

Campaign 3 Metrics 

Veterans Contacted (PRM Referral Sent)* 544 

Urgent (Crisis Call or Emergency Services) 1 

High (Request Appt. within 7 Days) 25 

Medium (Request Appt. within 30 Days) 66 

Low (Request Appt. within 90 Days, 

wrong/disconnected number, or unsuccessful 3rd 

attempt) 462 

Requesting Appointment within 90 Days 11 

Veteran already has appointment 170 

Unsuccessful in 3 Attempts 153 

Does not want/need an appointment 45 

Requesting not to be contacted 5 

Deceased (Discovered by HRC outbound call) 1 

Wrong Phone # 51 

Disconnected Phone 17 

Transferred to another VAMC 9 

Current as of June 11, 2014 11:00 AM CST 

* Defined as: Veterans Verbally Contacted, 3 attempted calls with message left, or wrong/disconnected number 

Matthew Eitutis 

Director, Health Resource Center; (785)350-3742 Revised 06/24/2014 12:30 PM CST 

Cc: Linda Halliday, Assistant IG for Audits; VA Office of Inspector General 

VA Office of Inspector General 89 
Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

Appendix E Chronology of OIG Oversight of Patient Wait Times 

For almost a decade, OIG and GAO reviews identified that VHA managers 

needed to improve efforts for collecting, trending, and analyzing clinical 

data. 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 reported, in the Audit of Veterans Health Administration’s Outpatient 

Scheduling Procedures, July 2005, that VHA did not follow established 

procedures when scheduling appointments, resulting in inaccurate wait times and 

lists. OIG found: 

 Nationwide electronic wait lists could be understated by as many as

10,000 veterans.

 VHA lacks standardized training programs for scheduling.

 VHA had insufficient oversight.

2006 

OIG reported in the Review of Access to Care in the Veterans Health 

Administration, May 2006, 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. Nor did it have 

effective controls to ensure 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.

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OIG performed a follow-up audit, Audit of Veterans Health Administration’s 

Outpatient Waiting Times, September 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 wait list, but should have been. In 

addition, 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 its position. 

Contrary to OIG reports, VA reported high performance in the VA Performance 2007 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 wait 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 wait times, and delays remain in obtaining sub-specialty 

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

times and patient wait lists, a problem about which OIG has reported and sought 

corrective action since 2005. OIG will continue to review medical outcomes and 

quality of care issues. 

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

progress in addressing the longstanding and underlying causes of problems with 

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

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

quality procedures necessary to ensure the reliability of wait times and wait lists. 

The May 2008 OIG report on VISN 3 wait times determined scheduling 

procedures were not followed, which affected the reliability of reported wait times 2008 

and caused inaccuracies in the electronic wait lists. OIG recommended VHA 

establish procedures to routinely test the accuracy of reported wait times and the 

completeness of electronic wait lists, as well as take corrective action when its 

testing shows questionable differences between the desired dates of care and those 

documented in the scheduling system. 

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2008 

(cont’d) 

OIG reported that the problems and the causes associated with scheduling, wait 

times, and wait lists are systemic throughout VHA. 

VHA disagreed with the report’s conclusions and all nine recommendations. The 

Under Secretary stated that the issues OIG reported reflected the need for policy 

solutions that VHA was already addressing. Therefore, singling out VISN 3 and 

holding them accountable was counterproductive. 

OIG investigated an allegation that VA employees at PVAHCS altered patient 

wait times in an effort to improve their performance measures. OIG found that it 

was an accepted past practice at the medical center to alter appointments to avoid 

wait times greater than 30 days and that some employees still continued that 

practice. 

2009 

OIG reported longstanding problems with outpatient scheduling delays, accuracy 

of reported wait times, and incomplete electronic wait 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, wait times, and EWL data integrity issues as 

OIG’s first “hot issues” paper in Administration transition briefing materials. 

2010 

OIG reported VHA lacked the management controls needed to ensure CBOCs 

provided with veterans consistent, quality care. OIG noted that CBOC primary 

care data were inaccurate. VA responded with new directives providing more 

detailed instruction for schedules on correct entry of the desired date and other 

essentials to improve the scheduling of veterans’ appointments. 

2012 

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

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

measures do not adequately reflect critical dimensions of mental health care 

access. 

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

 Establishment of mental health staffing and productivity standards

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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 PVAHCS 

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 

2012  Fee staff obligated sufficient funds for fee care

(cont’d) As a result, PVAHCS had to obtain additional funds from the National Fee 

Program and VISN 18, and it had to 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 PVAHCS 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 its 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. 

OIG, in the Review of Patient Wait Times, Scheduling Practices, and Alleged 

Patient Deaths at the Phoenix Health Care System - Interim Report, 

May 2014, substantiated serious conditions at PVAHCS. We identified about 

1,400 veterans who did not have a Primary Care appointment but were 

appropriately included on PVAHCS’s 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 

2014 veterans has not started. Most importantly, these veterans were and continue to be 

at risk of being forgotten or lost in PVAHCS’s convoluted scheduling process. 

Our reviews at additional VA medical facilities 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. 

OIG testified on VA Data Manipulation and Access to VA health care before the 

HVAC, Subcommittee on Oversight and Investigations. 

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Appendix F 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.	 Review of Access to Care in the Veterans Health Administration 

(5/17/2006) 

3.	 Audit of the Veterans Health Administration’s Outpatient Waiting 

Times (9/10/2007) 

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

Service Network 3 (5/19/2008) 

5.	 Audit of Veterans Health Administration’s Efforts to Reduce Unused 

Outpatient Appointments (12/4/2008) 

6.	 Healthcare Inspection – Mammography, Cardiology, and Colonoscopy 

Management Jack C. Montgomery VA Medical Center Muskogee, 

Oklahoma (2/2/2009) 

7.	 Audit of Veterans Health Administration’s Non-VA Outpatient Fee 

Care Program (8/3/2009) 

8.	 Veterans Health Administration Review of Alleged Use of 

Unauthorized Wait Lists at the Portland VA Medical Center 

(8/17/2010) 

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

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

10.	 Healthcare Inspection – Electronic Waiting List Management for 

Mental Health Clinics Atlanta VA Medical Center Atlanta, Georgia 

(7/12/2011) 

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

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

12.	 Healthcare Inspection – Select Patient Care Delays and Reusable 

Medical Equipment Review Central Texas Veterans Health Care 

System Temple, Texas (1/6/2012) 

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

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14.	 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) 

15.	 Healthcare Inspection – Consultation Mismanagement and Care 

Delays Spokane VA Medical Center, Spokane, Washington (9/25/2012) 

16.	 Healthcare Inspection – Delays for Outpatient Specialty Procedures 

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

17.	 Audit of VHA’s Physician Staffing Levels for Specialty Care Services 

(12/27/2012) 

18.	 Healthcare Inspection – Patient Care Issues and Contract Mental 

Health Program Mismanagement Atlanta VA Medical Center Decatur, 

Georgia (4/17/2013) 

19.	 Healthcare Inspection – Gastroenterology Consult Delays William 

Jennings Bryan Dorn VA Medical Center Columbia, South Carolina 

(9/6/2013) 

20.	 Review of Patient Wait Times, Scheduling Practices, and Alleged 

Patient Deaths at the Phoenix Health Care System - Interim Report 

(5/28/2014) 

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Appendix G VHA Directive 2010-027: VHA Outpatient Scheduling 

Processes and Procedures, June 9, 2010 

DEPARTMENT OF VETERANS AFFAIRS VHA DIRECTIVE 2010-027 

VETERANS HEALTH ADMINISTRATION 

WASHINGTON, DC 20420 JUNE 9, 2010 

VHA OUTPATIENT SCHEDULING PROCESSES AND PROCEDURES 

1. PURPOSE: This Veterans Health Administration (VHA) Directive provides policy for 

implementing processes and procedures for the scheduling of outpatient clinic appointments and 

for ensuring the competency of staff directly or indirectly involved in any, or all, components of 

the scheduling process. 

2. BACKGROUND 

a. It is VHA’s commitment to provide clinically appropriate quality care for eligible 

Veterans when they want and need it. This requires the ability to create appointments that meet 

the patient’s needs with no undue waits or delays. Wait times for patients to be seen through 

scheduled appointments in primary care and specialty care clinics are monitored. In addition, 

patients (both new and established) are surveyed to determine if they received an appointment 

when they wanted one. 

b. VHA is mandated to provide priority care for non-emergent outpatient medical services 

for any condition of a service-connected (SC) Veteran rated 50 percent or greater or for a 

Veteran’s SC disability. Priority scheduling of any SC Veteran must not impact the medical care 

of any other previously scheduled Veteran. Veterans with SC disabilities are not to be prioritized 

over other Veterans with more acute health care needs. Emergent or urgent care is provided on an 

expedient basis. Emergent and urgent care needs take precedence over a priority of service 

connection. 

c. The assurance of timely access to care requires consistent and efficient use of Veterans 

Health Information Systems and Technology Architecture (VistA) in the scheduling of outpatient 

clinic appointments. 

d. Tracking and assessing the utilization and resource needs for specialty care also require 

use of the Computerized Patient Record System (CPRS) electronic consult request package. 

e. Definitions 

(1) Desired Date. The desired appointment date is the date on which the patient or provider 

wants the patient to be seen. Schedulers are responsible for recording the desired date correctly. 

(2) Emergent and Urgent Care 

(a) Urgent Care is care for an acute medical or psychiatric illness or for minor injuries for 

which there is a pressing need for treatment to manage pain or to prevent deterioration of a 

condition where delay might impair recovery. For example, urgent care includes the follow-up 

appointment for a patient discharged from a Department of Veterans Affairs (VA) medical facility 

if the discharging physician directs the patient to return on a specified day for the appointment. 

THIS VHA DIRECTIVE EXPIRES JUNE 30, 2015 

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(b) Emergency care is the resuscitative or stabilizing treatment needed for any acute medical 

or psychiatric illness or condition that poses a threat of serious jeopardy to life, serious impairment 

of bodily functions, or serious dysfunction of any bodily organ or part. 

(3) Provider. A provider is an individual licensed to deliver health care and services to 

patients. 

(4) Service-Connected (SC). Service connection or “service-connected” means that VA 

has determined that a condition or disability was incurred in, or has been aggravated by, military 

service. 

(5) Non-Service Connected (NSC). NSC refers to a condition or disability VA has not 

determined was incurred in, or has been aggravated by, military service. 

(6) New Enrollee. A new enrollee is a previously non-enrolled Veteran who applies for VA 

health care benefits and enrollment by submitting VA Form 10-10EZ, Application for Health 

Benefits, is determined to be eligible, and is enrolled. 

(7) New Enrollee Appointment Request (NEAR) Call List. The NEAR Call List is a tool 

to be used by enrollment staff to communicate to Primary Care Management Module (PCMM) 

Coordinators or schedulers, at the Veteran’s designated preferred location, that a newly enrolled 

Veteran has requested an appointment during the enrollment process. 

(8) Appointment Type. Using VistA, an outpatient appointment requires the selection of at 

least one appointment type, which combined with the “Purpose of Visit” code creates one of 40 

unique appointment types. Appointment types can be critical when scheduling different types of 

appointments. Examples of appointment types include: regular, employee, collateral of Veteran, 

sharing agreement, etc. For a complete list of appointment types, see the Patient Appointment 

Information Transmission (PAIT) Release Notes and Installation Guide Patch SD*5.3*333 at 

http://www.va.gov/vdl/documents/Clinical/Patient_Appointment_Info_Transmission/sd_53_p33 

3_rn.doc. 

(9) Newly registered Patient to the Facility. A newly registered patient to the facility is a 

Veteran who is enrolled with VHA, but who has not been registered at a specific facility. 

(10) New Patient as Defined for VHA Wait Time Measurement Purposes. For VHA 

Wait Time Measurement purposes, a “new patient” is any patient not seen by a qualifying 

provider type within a defined stop code or stop code group at that facility, within the past 24 

months. 

NOTE: See data definitions at http://vssc.med.va.gov/WaitTime/New_Patient_Monitor.asp# . This 

is an internal VA Web site not available to the public. In order to access this site, VA staff may 

need to go first to http://vssc.med.va.gov and accept the VHA Support Service Center Data Use 

Agreement. 

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(11) Electronic Wait List (EWL). The EWL is the official VHA wait list. The EWL is 

used to list patients waiting to be scheduled, or waiting for a panel assignment. In general, the 

EWL is used to keep track of patients with whom the clinic does not have an established 

relationship (e.g., the patient has not been seen before in the clinic). 

(12) Service Agreement. A service agreement is a written agreement defining the work 

flow rules between any two or more services that send work to one another. Ideally, this 

document is developed based on discussion and consensus between the two or more involved 

services. The document is signed by service chiefs from involved services. If the agreement is 

between services at separate facilities, as with inter-facility consult service agreements, it needs to 

be signed by the Chiefs of Staff of each involved facility. 

(13) Encounter. An encounter is a professional contact between a patient and a provider 

vested with responsibility for diagnosing, evaluating, and treating the patient’s condition. 

(a) Contact can include face-to-face interactions or those accomplished using 

telecommunications technology. 

(b) Encounters are neither occasions of service nor activities incidental to an encounter for a 

provider visit. For example, the following activities are considered part of the encounter itself and 

do not constitute encounters on their own: taking vital signs, documenting chief complaint, 

giving injections, pulse oximetry, etc. 

(c) Use of e-mail is limited and does not constitute an encounter. E-mail communications 

are not secure and e-mails must not contain patient specific information. NOTE: Secure 

messaging communication is available through the My HealtheVet (MHV) personal health record 

(PHR). These communications may meet the definition of an encounter, based on type of message 

and content. 

(d) A telephone contact between a practitioner and a patient is only considered an encounter 

if the telephone contact is documented and that documentation includes the appropriate elements 

of a face to face encounter, namely, history and clinical decision-making. Telephone encounters 

must be associated with a clinic that is assigned one of the Decision Support System (DSS) 

Identifier telephone codes and are designated as count clinics. 

(14) Occasion of Service. Formerly known as ancillary service, an “occasion of service” is 

a specified identifiable instance of an act of technical and administrative service involved in the 

care of a patient or consumer, which is not an encounter and does not require independent clinical 

judgment in the overall diagnosing, evaluating, and treating the patient's condition(s). 

(a) Occasions of service are the result of an encounter. Clinical laboratory tests, 

radiological studies, physical medicine interventions, medication administration, and vital sign 

monitoring are all examples of occasions of service. 

(b) Some occasions of service, such as clinical laboratory and radiology studies and tests, 

are automatically loaded to the Patient Care Encounter (PCE) database from other VistA 

packages. 

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(15) Count. The term “count” refers to workload that meets the definition of an encounter 

or occasion of service. 

(16) Count versus Non-Count Clinics. In the creation of Clinic Profiles, clinics are 

designated as either Count Clinics or Non-Count Clinics. Count Clinics are transmitted to PCE as 

encounters. Non-Count Clinics are not transmitted to PCE. There are generally two reasons why 

a clinic might be designated as non-count: if the clinic is administrative in nature and therefore 

not providing patient care; and if the workload associated with the clinic is transmitted to PCE 

automatically through another means (a VistA package other than Scheduling) then the clinic is 

setup as non-count to avoid sending duplicate workload to PCE (for example, occasions of 

service.) 

(17) DSS Identifiers. DSS Identifiers are used to measure workload for all outpatient 

encounters. They are the single designation by which VHA defines clinical work units for costing 

purposes. In some, but not all cases, DSS Identifiers are defined to be used only for specific NonCount Clinics assigned to a clinic profile. In these cases, DSS rules must be followed. As a 

specific example: when a clinic’s Primary Stop Code is 674, that clinic is explicitly defined to be a 

Non-Count Clinic and that is the only way it should be used. 

(a) Primary Stop Code. The first three numbers of the DSS Identifier represent the primary 

stop code. The primary stop code designates the main clinical group responsible for the care. 

Three numbers must always be in the first three characters of a DSS Identifier for it to be valid. 

(b) Secondary Stop Code. The last three numbers of the DSS Identifier contain the 

secondary or credit stop code, which the VA medical center may use as a modifier to further 

define the primary work group. For example, a flu vaccination given in Primary Care is 

designated by 323710. The secondary stop code modifier may also represent the type of provider 

or team. For example, a Mental Health Clinic run by a social worker can be designated 502125. 

(c) Credit Pair. A DSS Identifier Credit Pair is the common term used when two DSS 

Identifiers, a primary code and a secondary code, are utilized when establishing a clinic in the 

VistA software. Some specific credit pairs are listed in the DSS Identifier References. 

3. POLICY. It is VHA policy that all outpatient clinic appointments, meeting the definition of 

an encounter, are made in Count Clinics using the VistA Scheduling software in a fashion that 

best suits patients’ clinical needs and preferences; this includes, but is not limited to: appointments 

made for clinic visits; VA provided home care; consultations; and medical, surgical, dental, 

rehabilitation, dietetic, nursing, social work, and mental health services and procedures. 

NOTE: The Count Clinic requirement does not include: non-VA care paid through VistA Fee; 

procedures performed in the operating room and recorded in the VistA Surgery Software; 

instances where encounters are generated based on unscheduled telecommunication; and 

occasions of service, such as clinical laboratory, radiology studies, and tests that are 

automatically loaded to the PCE database. An exception from the requirement of using VistA 

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Scheduling software is also extended to providers and programs such as Care Coordination 

Home Telehealth when encounters are generated based on unscheduled communication. 

4. ACTION 

a. Director of Systems Redesign. The Director, VHA Systems Redesign, within the 

Office of the Deputy Under Secretary for Health for Operations and Management (10N), is 

responsible for oversight of implementation of requirements of this Directive, to include 

measurement and monitoring of ongoing performance. 

b. Veterans Integrated Service Network (VISN) Director. The VISN Director, or 

designee, is responsible for the oversight of enrollment, scheduling, processing, consult 

management, and wait lists for eligible Veterans. 

c. Facility Director. The facility Director, or designee, is responsible for: 

(1) Ensuring that when outpatients are seen for what constitutes an encounter on a “walk-in” 

basis without an already scheduled appointment, an appointment is recorded in a Count Clinic 

with the “Purpose of Visit” entered in the VistA Scheduling Software as “unscheduled.” NOTE: 

Since unscheduled visits include no entry of “desired date” for wait time measurement, desired 

date is equated to appointment creation date. In addition, applicable profiles need to be designed 

to ensure sufficient capacity to accommodate unscheduled “walk-in” patients. Unscheduled 

encounters that occur via telephone will not be used in the VistA Scheduling Software. 

(2) Ensuring outpatient appointments for diagnostic laboratory and imaging services are not 

made using count clinics. Non-Count clinics may be used to schedule laboratory and imaging 

appointments. Requests for laboratory and imaging services must be made by provider orders 

(not consult requests). Orders transmit directly to the laboratory or radiology software 

applications. Work performed in response to such orders triggers transmission of encounter data 

via the VHA PCE software application. NOTE: The use of Count Clinics for diagnostic services 

is inappropriate in part because it would generate duplicate workload reports. 

(3) Defining “standard work” for the clinic teams to most efficiently operate the clinic. This 

work includes: 

(a) Ensuring clinic flow occurs in a standardized manner including patient check-in with 

scheduling staff, nurse interview, provider visit, and check-out. 

(b) Ensuring providers document orders in CPRS and explain rationale and timeframes for 

medications, diagnostic tests, laboratory studies, return appointments, consultations, and 

procedures before the patient leaves the examination room. 

(c) Ensuring a check out process occurs following each clinic visit. The check-out process may 

consist of: nurse-administered patient education; clinical pharmacist education and review of 

prescription orders; collection of patient feedback; scheduling of diagnostic studies; consultations; 

and follow-up visits. The check-out process must also include verifying that the 

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disposition of the appointment in the VistA Appointment Management system has been 

completed. 

(d) Ensuring standardized systems are in place to balance supply and demand for outpatient 

services including continuous forecasting and contingency planning. 

(e) Ensuring each clinic follows these additional business rules for standardizing work. 

1. Schedules must be open and available for the patient to make appointments at least 

three to four months into the future. Permissions may be given to schedulers to make 

appointments beyond these limits when doing so is appropriate and consistent with patient or 

provider requests. Blocking the scheduling of future appointments by limiting the maximum days 

into the future an appointment can be scheduled is inappropriate and is disallowed. 

2. Synchronize internal provider leave notification practices with clinic slot availability to 

minimize patient appointment cancellations. 

3. Strive to make follow-up appointments “on the spot” for patients returning within the 3 

to 4 month window. 

4. Use the Recall/Reminder Software application to manage appointments scheduled 

beyond the 3 to 4 month scheduling window. 

NOTE: Backlog must be eliminated and demand and supply balanced for the above suggestions 

to be successful. 

(f) Using the preferred strategy for initiating scheduling which involves: 

1. Having the referring providers’ team schedule clinical consultation appointments as 

soon as possible on the day the consult is ordered, before the patient leaves the referring provider 

team area. 

2. Having the treating provider’s team either schedule an appointment or, if the timeframe 

specified by the provider is several months into the future, record in the Recall/Reminder 

Software application the need for the patient to return to clinic, before the patient leaves the 

treating provider team area. 

a. When a patient needs a follow-up appointment but cannot be immediately scheduled, 

this need is to be recorded in the Recall/Reminder Software application. 

b. The patient must be advised to expect to receive a reminder to contact the clinic to 

actually schedule an appointment a few weeks prior to the return to clinic timeframe that the 

provider has specified. 

c. The patient needs to be provided information for contacting the clinic at the 

appropriate time to make the appointment. 

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3. Having registration or enrollment staff obtain contact information and initiate 

scheduling action while in direct contact with a newly enrolled or newly registered patient. 

(4) Ensuring correct entry of “desired date” for an appointment. The goal is to schedule an 

appointment on, or as close to the desired date as possible. 

(a) For New Patients 

1. The scheduler needs to ask the patient: "What is the first day you would like to be 

seen?" The date the patient provides is the desired date. 

2. The desired date is defined by the patient without regard to schedule capacity. Once the 

desired date has been established, it must not be altered to reflect an appointment date the patient 

acquiesces to accept for lack of appointment availability on the desired date. 

3. The third step is to offer and schedule an appointment on or as close to the desired date 

as possible. 

(b) For Established Patients’ Return Appointments: A specific or a general timeframe is 

communicated by the provider and the actual desired date is established by the patient. 

1. In order for the provider and scheduler to have a clear understanding of the intent for a 

return appointment, the provider must document the return date in CPRS, preferably through an 

order. The provider must specify if the return appointment request is for a specific day, or a 

general timeframe. 

2. In order to establish the actual desired date correctly, the scheduler needs to tell the 

patient that the provider wants to see them again, giving the patient either the provider’s specified 

date or general timeframe, and asking when the patient would like to be seen. The date the patient 

provides is the desired date. 

3. The desired date needs to be defined by the patient without regard to schedule capacity. 

Once the desired date has been established, it must not be altered to reflect an appointment date 

the patient acquiesces to accept for lack of appointment availability on the desired date. 

4. The scheduler is to offer and schedule an appointment on or as close to the desired date 

as possible. If there is a discrepancy between the patient and provider desired date, the scheduler 

must contact the provider for a decision on the return appointment timeframe. 

(c) For Patients Scheduled in Response to Intra and Inter Facility Consults 

1. The provider specified timeframe for the appointment needs to be the date of the 

provider request, unless otherwise specified by the provider. 

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2. In order to establish the actual desired date correctly, the scheduler informs the patient 

of the provider's specified date or general timeframe and asks the patient "What day would you 

like to be seen?" The date the patient provides is the desired date. 

3. The desired date needs to be defined by the patient without regard to schedule capacity. 

Once the desired date has been established, it must not be altered to reflect an appointment date 

the patient acquiesces to accept for lack of appointment availability on the desired date. 

4. The scheduler offers and schedules an appointment on or as close to the desired date as 

possible. If the provider has specified a desired date (or “soonest appropriate date”) and there is a 

discrepancy between the patient and provider specified desired date, the scheduler must contact 

the provider for a decision on the appointment timeframe. 

5. In creating an appointment in response to a CPRS consult request, the scheduler must 

use VistA menu options to link the CPRS consult request to the scheduled appointment. 

(5) Ensuring that when an appointment is cancelled and rescheduled by the clinic, the 

scheduler enters as the desired date for the new appointment the desired date for the original 

appointment. 

(6) Ensuring that if the patient must be contacted to create an appointment, policies are in 

place that outline actions to be taken to make contact, the number of attempts necessary, and 

documentation required. 

(7) Monitoring telephone access and taking action, as needed, to minimize patient problems 

in accessing providers, teams, and schedulers by phone. 

(8) Implementing standardized processes for enrollment, and the scheduling, processing, and 

management of appointments, consults, and wait lists for eligible Veterans. 

(9) The creation and maintenance of a Master List of all staff members that have any of the 

VistA Scheduling options that may be used for scheduling patients: PCMM menu options for 

primary care team or for provider assignments, menu options for entries onto the EWL, and the 

direct supervisors of all such individuals. 

(10) Ensuring successful completion of VHA Scheduler Training by all individuals on the 

Master List. Menu options for creating outpatient appointments are not to be provided to new 

schedulers without proof of their successful completion of this training. To retain these menu 

options, all individuals must complete newly released training for schedulers within 120 days of it 

being announced. NOTE: Details regarding the availability of this training will be posted on the 

Mandatory Training Web page located at: http://vaww.ees.lrn.va.gov/mandatorytraining . This is 

an internal Web site and is not available to the public. 

(11) Ensuring all individuals on the Master List have their position description or functional 

statement include specific responsibilities relative to scheduling, PCMM assignments, and entries 

into EWL. 

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(12) Ensuring all individuals on the Master List have, on file with their supervisor, an annual 

competency assessment that includes their responsibilities relative to scheduling, PCMM 

assignments, and entries into EWL. 

(13) Ensuring completion, using VISN-approved processes and procedures, of a 

standardized yearly scheduler audit of the timeliness and appropriateness of scheduling actions, 

and of the accuracy of desired dates. 

(14) Ensuring that identified deficiencies in competency or performance, identified by the 

annual scheduler audit, are effectively addressed. 

(15) Ensuring that all clinic profiles are current at all times and subject to an annual review. 

This review must include compliance in requirements for use of Count versus Non-Count clinics. 

(16) Ensuring full compliance by all involved services with Service Agreements. Service 

agreements must be reviewed and, if necessary, re-negotiated regularly (at least annually). 

(17) Measuring and tracking all unused outpatient appointments in count clinics including 

those from no shows, patient cancellations, and unscheduled appointment slots. 

(18) Ensuring that when appointments become available and the facility has at least 3 days to 

give patients notice, scheduling personnel offer appointments to patients who are either on the 

EWL waiting for appointments, or currently have appointments more than 30 days past the 

desired dates of care. NOTE: This applies to management of scheduling in Count Clinics. 

(19) Ensuring that the following Business Rules for Scheduling Outpatient Clinic 

Appointments are followed. 

(a) Patients with emergent or urgent medical needs must be provided care, or be scheduled to 

receive care, as soon as practicable, independent of SC status and whether care is purchased or 

provided directly by VA. 

(b) Generally, patients with whom the provider does not yet have an established relationship 

and cannot be scheduled in target timeframes must be put on electronic waiting lists (EWL). 

VHA’s EWL software is used to manage these requests, which usually consist of newly 

registered, newly enrolled, or new consult requests for patients waiting for their first scheduled 

appointment. No other wait list formats (paper, electronic spreadsheets) are to be used for 

tracking requests for outpatient appointments. When patients are removed from the EWL, except 

for medical emergencies or urgent medical needs, Veterans who are SC 50 percent or greater, or 

Veterans less than 50 percent SC requiring care for a SC disability must be given priority over 

other Veterans. 

(c) Facilities are required to provide initial triage evaluations within 24 hours for all 

Veterans either self-requesting or being referred for mental health or substance abuse treatment. 

Additionally, when follow-up is needed, it must include a full diagnostic and treatment 

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evaluation within 14 days. NOTE: VHA leadership may mandate specific timeframes for special 

categories of appointments. 

(d) PCMM Coordinators or Scheduling Coordinators must check the Primary Care EWL 

daily and act on requests received. Schedulers in all clinics at all locations (substations) must 

review the EWL daily to determine if newly enrolled or newly registered patients are requesting 

care in their clinic at their location. 

(e) A wait list for hospice or palliative care will not be maintained as VHA must offer to 

provide or purchase needed hospice or palliative care services without delay. 

(f) A patient currently or formerly in treatment for a mental health condition, who requests 

to be seen outside of the clinician desired date range, needs to be seen or contacted within 1 

working day by the treatment team for evaluation of the patient's concern. 

(g) The VHA Class I Recall/Reminder Software application is used for patients with whom 

the service has an established relationship. This software application is typically used when the 

requested follow-up appointment date is more than 3 to 4 months into the future. These patients 

include those that have either been seen initially in a given VA clinic and need to return in the 

future; or those who have been seen initially through purchased non-VA care with a plan to be 

seen in follow-up at the VA clinic. NOTE: Even though a patient seen initially through 

purchased non-VA care may be new to a facility clinic, the organization has committed to this 

relationship, so Recall/Reminder scheduling may be appropriate. 

(h) Non-VA care may be utilized in accordance with regulatory authority when service is 

not available in a timely manner within VHA due to capability, capacity, or accessibility. 

Availability of non-VA care and access to VA care must be taken into account before non-VA 

care is authorized. An analysis of costs of care needs to be undertaken at appropriate intervals to 

determine if services could be more efficiently provided within VA facilities. Use of purchased 

care may only be considered when the patient can be treated sooner than at a VA facility and the 

service is clinically appropriate and of high quality. Purchased care must only be considered when 

the request for care can be resolved efficiently, including having results available to the referring 

facility in a timely manner. 

(i) Patients provided authorization for continued non-VA care need to be tracked and 

brought back within VHA as capacity becomes available. This needs to be from the oldest 

authorization moving forward, as clinically indicated. 

(j) Clinic cancellations, particularly when done on short notice, are to be avoided whenever 

possible. If a clinic must be canceled or a patient fails to appear for a scheduled appointment, the 

medical records need to be reviewed to ensure that urgent medical problems are addressed in a 

timely fashion. Provisions need to be made for necessary medication renewals and patients need 

to be rescheduled as soon as possible, if clinically appropriate. 

(k) When a patient does not report (“no-show”) for a scheduled appointment, the 

responsible provider, surrogate, or designated team representative needs to review the patient’s 

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VHA DIRECTIVE 2010-027 

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medical record, including any consult or procedure request received or associated with the 

appointment and then determine and initiate appropriate follow-up action. NOTE: It may be 

useful for the facility to assign a case manager to the patient with multiple “no-shows” to 

determine the best method to manage the patient’s pattern of repetitive “no-shows.” 

(l) Facility leadership must be vigilant in the identification and avoidance of inappropriate 

scheduling activities. NOTE: For further guidance, please see the Systems Redesign 

Consultation Team Guidebook available on the Systems Redesign Web site at Systems Redesign 

Consultation Team Guide 2008 (https://srd.vssc.med.va.gov/Pages/default.aspx). This is an 

internal VA Web site not available to the public. 

(20) Providing annual certification through the VISN Director to the Director, Systems 

Redesign, in the Office of the Deputy Under Secretary for Health for Operations and Management, 

of full compliance with the content of this Directive. Initial certifications are due 6 months 

following issuance of this Directive and then annually thereafter. 

5. REFERENCES 

a. Public Law 104-262. 

b. Title 38 United States Code (U.S.C.) Sections 1710, and 1703, 1705. 

c. Code of Federal Regulations, § 17.52, 17.100, 17.36, 17.37, 17.38, and 17.49. 

6. FOLLOW-UP RESPONSIBILITY: The Deputy Under Secretary for Health for Operations and 

Management (10N) is responsible for the contents of this Directive. Questions may be directed to 

the Director, Systems Redesign Program at 605-720-7174. 

7. RESCISSIONS: VHA Directive 2009-070 is rescinded. This VHA Directive expires 

June 30, 2015. 

Robert A. Petzel, M.D. 

Under Secretary for Health 

DISTRIBUTION: E-mailed to the VHA Publications Distribution List 6/9/2010 

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Appendix H Memorandum From the Deputy Under Secretary for 

Health for Operations and Management, 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 

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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 

several ways this has been observed: 

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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. 

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

VA Office of Inspector General 109 
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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 

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

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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 111 
 

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	 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 wait 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 112 
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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 113 
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Appendix I OIG Testimony on VA Patient Wait Times 

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

reporting to Congress on patient wait times. 

Congressional Testimony - 6/9/2014 - Statement of Richard J. Griffin, 

Acting Inspector General, Office of Inspector General, Department of 

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

House of Representatives, Hearing on “Data Manipulation and Access to 

VA Healthcare” 

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

Inspector General, Department of Veterans Affairs, 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 

VA Office of Inspector General 114 
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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” 

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, 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, 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, Department of Veterans Affairs, 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” 

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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, 

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 116 
 

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Appendix J Congressional Requests 

House Committee on Veterans’ Affairs 

Hon. Jeff Miller, Chairman 

Hon. Mike Michaud, Ranking Member 

Subcommittee on Oversight and Investigations, House Committee on 

Veterans’ Affairs 

Hon. Mike Coffman, Chairman 

Hon. Ann Kirkpatrick, Ranking Member 

House Committee on Appropriations 

Hon. Harold Rogers, Chairman 

Hon. Nita Lowey, Ranking Member
 

Subcommittee on Military Construction, Veterans Affairs, and Related 

Agencies, House Committee on Appropriations 

Hon. John Culberson, Chairman 

Hon. Sanford D. Bishop, Jr., Ranking Member 

Senate Committee on Appropriations 

Hon. Barbara Mikulski, Chairwoman 

Hon. Richard Shelby, Ranking Member 

Subcommittee on Military Construction, Veterans Affairs, and Related 

Agencies, Senate Committee on Appropriations 

Hon. Tim Johnson, Chairman 

Hon. Mark Kirk, Ranking Member
 

US Senate	 Hon. Kelly Ayotte Hon. Amy Klobuchar 

Hon. Michael Bennet Hon. John McCain 

Hon. Richard Blumenthal Hon. Lisa Murkowski 

Hon. Dianne Feinstein Hon. Brian Schatz 

Hon. Jeff Flake Hon. Jeanne Shaheen 

Hon. Charles Grassley Hon. Tom Udall 

Hon. Dean Heller Hon. Mark Udall 

Hon. Mazie Hirono Hon. David Vitter 

Hon. Mark Kirk 

VA Office of Inspector General 117 
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US House of 

Representatives 

Hon. Joe Barton 

Hon. Jaime Herrera Beutler 

Hon. Kevin Brady 

Hon. Michael Burgess 

Hon. John Carter 

Hon. Mike Conaway 

Hon. John Culberson 

Hon. Mike Doyle 

Hon. Tammy Duckworth 

Hon. Blake Farenthold 

Hon. Bill Flores 

Hon. Pete Gallego 

Hon. Louie Gohmert 

Hon. Paul Gosar 

Hon. Kay Granger 

Hon. Al Green 

Hon. Ralph Hall 

Hon. Jeb Hensarling 

Hon. Sam Johnson 

Hon. Jack Kingston 

Hon. Ann Kirkpatrick 

Hon. Kenny Marchant 

Hon. Michael McCaul 

Hon. Tim Murphy 

Hon. Randy Neugebauer 

Hon. Pete Olson 

Hon. Ted Poe 

Hon. Pete Sessions 

Hon. Kyrsten Sinema 

Hon. Lamar Smith 

Hon. Mac Thornberry 

Hon. Dina Titus 

Hon. Randy Weber 

Hon. Ed Whitfield 

Hon. Roger Williams 

VA Office of Inspector General 118 
 

 

 

 

 

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Appendix K VA Secretary Comments 

Department of Memorandum 

Veterans Affairs 

Date: August 18, 2014 

From: Secretary of Veterans Affairs (00) 

Subj: OIG Draft Report, Review of Alleged Patient Deaths, Patient Wait Times, and 

Scheduling Practices at the Phoenix VA Health Care System 

To: Acting Inspector General (50) 

1. VA is in the midst of a very serious crisis. As we now tackle nationwide challenges 

to timely Veteran access to health care while also fixing our scheduling system, our 

priorities are clear: 1) to get Veterans off wait lists and into clinics; 2) to address 

VA’s cultural issues, which includes holding people accountable for willful 

misconduct or management negligence, and creating an environment of openness 

and transparency; and 3) to use our resources to consistently deliver timely, highquality health care to our Nation’s Veterans. 

2. We sincerely apologize to all Veterans and we will continue to listen to Veterans, 

their families, Veterans Service Organizations and our VA employees to improve 

access to the care and benefits Veterans earned and deserve. 

3. We concur with all the recommendations in the draft final report and will use them to 

hone the focus of VA’s actions moving forward. 

4. We appreciate OIG’s in-depth investigation into a whistleblower’s allegation that 

40 Veterans died waiting for an appointment. OIG pursued this allegation, but the 

whistleblower was unable to provide OIG with a list of 40 patient names. It is 

important to note that while OIG’s case reviews in the report document substantial 

delays in care, and quality of care concerns, OIG was unable to conclusively assert 

that the absence of timely quality care caused the death of these Veterans. 

5. VA took immediate and ongoing actions to address the deficiencies identified in the 

Interim Report. Attached are our specific responses to address the 

24 recommendations contained in the OIG report. If you have any concerns 

regarding this memorandum, please email Karen Rasmussen, M.D., Director, 

Management Review Service (10AR) at VHA10ARMRS2@va.gov. 

Carolyn Clancy, M.D. Robert A. McDonald 

Interim Under Secretary for Health Secretary of Veterans Affairs 

Attachment 

VA Office of Inspector General 119 
____________________________________________________________________________________ 

 

 

Review of Alleged Patient Deaths, Patient Wait Times, and 

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VETERANS HEALTH ADMINISTRATION (VHA)
 

Action Plan 

OIG Draft Report, Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices

at the Phoenix VA Health Care System 

Date of Draft Report: July 28, 2014 

Recommendations/ Status Completion Date 

Actions 

Recommendation 1. We recommended the VA Secretary direct the Veterans Health 

Administration to review the cases identified in this report to determine the appropriate response 

to possible patient injury and allegations of poor quality of care. For patients who suffered 

adverse outcomes, Phoenix VA Health Care System should confer with Regional Counsel 

regarding the appropriateness of disclosures to patients and families. 

VHA Comments: Concur. 

The Phoenix VA Health Care System (PVAHCS) has reviewed all cases identified in the OIG Report. 

Final determinations regarding the appropriate responses, including disclosures to patients and families, 

is underway. Over 70 clinical staff have been formally trained to conduct disclosure discussions, which 

consistently involve clinical leadership, such as the Chief of Staff or Nurse Executive. These discussions 

and this process are used to develop opportunities for improvement for the facility. Regional Counsel will 

be included in these discussions. In response to identified issues, the PVAHCS reviewed the records of 

over 1,200 patients who were determined to be waiting for an appointment. When issues were identified 

relating to quality of care, those individual cases were referred for additional review and action, when 

appropriate. PVAHCS completed five protected peer reviews and one institutional disclosure prior to the 

release of this report. If additional Disclosures are warranted, they will be completed as quickly as 

possible taking into account the needs and preferences of Veterans and their family members. 

Status: Target Completion Date: 

In progress November 30, 2014 

Recommendation 2. We recommended the VA Secretary require the Phoenix VA Health Care 

System to ensure continuity of mental health care, improve delays in assignments to a dedicated 

provider, and expand access to psychotherapy services. 

VHA Comments: Concur. 

The (PVAHCS) has taken action to address this recommendation as outlined below and in the draft OIG 

report. 

PVAHCS leadership began making significant changes in Mental Health services in the past year. In 

October 2013, there were 13 Psychiatry vacancies and limited Mental Health services in the Emergency 

Department. A new Chief of Psychiatry was hired and all but 3 of the Psychiatry vacancies are filled. 

Four additional Social Workers were hired to support the Emergency Department and six of the seven 

vacant Psychology positions have now been selected. 

Prior to the release of the Interim OIG Report, PVAHCS Mental Health leadership began to convert the 

urgent walk-in Mental Health clinic (CSTAT) into a multi-disciplinary, team –based clinic (Behavioral 

Health Interdisciplinary Program team model) that significantly improved provider assignments for 

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Veterans as well as continuity and coordination of care. Not only are these changes already showing a 

considerable improvement in patient access, but they have improved the process by which Veterans are 

assigned a Mental Health Treatment Coordinator (MHTC). Since the release of the Interim OIG Report, 

Mental Health leadership has reached out to over 2,000 mental health patients who did not have MHTCs 

assigned to ensure that they were reassigned a MHTC and given an appointment in Mental Health if they 

desired. Patients who could not be seen within 30 days in Mental Health were offered the option of 

obtaining Mental Health care in the community via purchased care. PVAHCS will conduct audits to 

evaluate the new Behavioral Health Interdisciplinary Program model to ensure continuity of care occurs 

as intended. Results from these audits will be reported to Medical Center leadership on a quarterly basis 

for one year. 

PVAHCS conducted a Community Summit with 25 community partners and 18 PVAHCS staff. Mental 

Health Summits help build and sustain collaborative efforts to enhance mental health well-being for 

Veterans and their families. 

PVAHCS is working to obtain an emergency bridge lease to provide an additional 30,000 square feet of 

clinical space to support mental health and primary care operations, until a new Health Care Clinic is 

built. The major lease for the Health Care Clinic is pending Congressional approval. 

In addition, we will hire additional staff to enhance access to psychotherapy, including services for Military 

Sexual Trauma, recovery model programming, addiction services and marriage and family therapy 

services. Additional VHA Human Resources support has been dedicated to support and streamline the 

hiring process. 

Status: Target Completion Date: 

In progress August 15, 2015 

Recommendation 3. We recommended the VA Secretary require the Phoenix VA Health Care 

System to reevaluate and make the appropriate changes to its method of providing veterans 

primary care to ensure they provide veterans timely and quality access to care. 

VHA Comments: Concur. 

PVAHCS has already initiated action to address this recommendation as outlined below: 

PVAHCS leadership received approval to increase Primary Care staffing by 53 additional full-time 

equivalent employees. All services – Physicians, Nursing and Clerks – have increased staffing in primary 

care clinics and Community Based Outpatient Clinics. Aggressive recruitment and hiring processes have 

been implemented to speed this process. Local contracts are being secured to utilize Primary Care 

physicians through locum tenens agencies. 

Mobile medical units were deployed from three other VA facilities to provide additional space. PVAHCS 

leadership requested permission to delay a minor construction project to remodel the Community Living 

Center, which was approved. This delay provided additional swing space in the facility to create an 

additional 27 examination rooms to temporarily accommodate new staff. This space has provided relief 

until an emergency bridge lease can be secured. PVAHCS is expediting procurement of two new 

Community Based Outpatient Clinics as well as obtain an emergency bridge lease to provide an 

additional 30,000 square feet of clinical space to support mental health and primary care operations. 

This additional space will allow expanded clinical operations until a new Health Care Clinic is built. 

Other modalities of care, such as tele-health and extended clinic hours are being utilized to help expand 

capacity. These will be further expanded once the new additional Primary Care staff has been hired. 

VA Office of Inspector General 121 
 

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Ongoing training and education is provided to scheduling staff regarding proper scheduling processes 

and compliance with the VHA scheduling directive. 

PVAHCS leadership has been working with the Arizona Congressional delegation and Veterans Service 

Organizations to increase outreach efforts in the community. Since May 1, 2014, PVAHCS has 

participated in three community outreach events focused on Veteran’s access to care. 

Status: Target Completion Date: 

In progress August 15, 2015 

Recommendation 4. We recommended the VA Secretary direct the Veterans Health 

Administration to establish a process that requires facility directors to notify, through their chain 

of command, the Under Secretary of Health when their facility cannot meet access or quality of 

care standards. 

VHA Comments: Concur. 

Issues related to access no longer solely depend on local leadership raising the concern up through a 

chain of command. VHA is transparent by making these data available and easily accessible to the 

public and the entire organization. Transparency of data facilitates timely, honest, and open discussion 

throughout the organization, among leadership peers, among employees, and among Veterans. 

Twice monthly, VHA publishes data on access to care on a public website 

(http://www.va.gov/health/access-audit.asp). Leadership at all levels use the same data to determine 

trends, foretell access shortfalls, and address underlying issues that impede Veterans’ access. This data 

includes: the number of appointments scheduled at each facility; the number of requested appointments 

that are on each facility’s Electronic Wait List; the number of newly enrolled patients who have not yet 

been scheduled by facility; and average wait times for mental health, primary care, and specialty care at 

each facility, for both new and established patients. 

Additionally, VHA publishes a scorecard model for internal quality of care benchmarking. Strategic 

Analytics for Improvement and Learning (SAIL) Value Model assesses 25 quality measures in areas such 

as mortality, complications, and customer satisfaction, as well as overall efficiency. SAIL benchmark 

tables can be found at http://www.hospitalcompare.va.gov/docs/SAILData.pdf 

Status: Target Completion Date:

 Completed Implemented 

Recommendation 5. We recommended the VA Secretary review all existing wait lists at the 

Phoenix VA Health Care System to identify veterans who may be at risk because of a delay in the 

delivery of health care and provide the appropriate medical care. We provided this 

recommendation to the former VA Secretary in the Interim Report. 

VHA Comments: Concur. 

PVAHCS – with support from VHA’s Health Resource Center (HRC) – has reached out to all Veterans 

identified as being on unofficial lists or the facility Electronic Waiting List (EWL). Those Veterans, in 

addition to the new daily Veteran enrollments, have resulted in over 7,300 new patients being addressed 

by PVAHCS. Over 3,200 appointments have been made in Primary Care for new patients since this 

initiative began. As of August 5, 2014, there were 87 Veterans on the EWL at PVAHCS, of which 60 had 

received three telephone calls and a certified letter, leaving only 27 Veterans remaining on the EWL. 

VA Office of Inspector General 122 
 

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PVAHCS is now scheduling the vast majority of patients directly into a Primary Care appointment when 

enrollment/registration occurs. 

This has been accomplished by leveraging VISN 18 and VHA resources to support PVAHCS. An 

Incident Command Center was established and lead by the facility Chief of Staff. The Disaster 

Emergency Medical Personnel System was activated to mobilize VHA staff nationally to Phoenix. In 

addition, the VHA Interim Staff Program was utilized to mobilize additional nurses and providers to 

Phoenix. To date, over 70 staff have arrived on station to assist and many more (Human Resources, 

Patient Advocates, etc.) have helped through virtual means. 

Status: Target Completion Date:

 Implemented Completed 

Recommendation 6. We recommended the VA Secretary take immediate action to ensure the 

Phoenix VA Health Care System reviews and provides appropriate health care to all veterans 

identified as being on unofficial wait lists. We provided this recommendation to the former VA 

Secretary in the Interim Report. 

VHA Comments: Concur. 

PVAHCS took immediate actions to contact all Veterans identified by OIG as being on unofficial waitlists; 

they were all contacted by June 4, 2014. This was accomplished by leveraging resources provided by 

the VHA Health Resources Center (HRC) located in Topeka, KS, in conjunction with PVAHCS scheduling 

staff. The campaign was later expanded to include all Veterans remaining on the PVAHCS New 

Enrollees Appointment Request (NEAR) list, and resulted in 1,057 scheduled appointments. Of the 

Veterans not scheduled, all had been contacted and either indicated they did not want an appointment or 

did not respond to at least three telephone calls and a certified letter offering the opportunity to schedule 

an appointment. This aggressive campaign concluded on June 10, 2014. PVAHCS now monitors all 

new Veterans to ensure timely access to care. 

Status: Target Completion Date:

 Implemented Completed 

Recommendation 7. We recommended the VA Secretary ensure all new enrollees seeking care at

the Phoenix VA Health Care System receive an appointment within the time frames directed by 

VHA policy. 

VHA Comments: Concur. 

Nationally, VHA expeditiously mobilized staff and resources from around the country to help PVAHCS 

identify patients waiting for care, and cleared the way for them to get the care they needed. We have 

completed the immediate and urgent work and are publicly publishing data on our progress. 

Locally, PVAHCS implemented process changes to ensure all new enrollees seeking care receive an 

appointment when desired. In May of 2014, the New Enrollee Appointment Request (NEAR) list reached 

levels of over 1,900 Veterans potentially waiting for care. As of July 2014, fewer than 10 Veterans were 

in a pending status on the NEAR list. To ensure continued success, the Electronic Wait List (EWL) and 

NEAR List are reviewed daily and reported to facility and VISN leadership. 

Status: Target Completion Date: 

In progress December 2014 

VA Office of Inspector General 123 
 

 

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Recommendation 8. We recommended the VA Secretary ensure the Phoenix VA Health Care 

System timely process enrollment applications. 

VHA Comments: Concur. 

Nationally, VHA is developing an automated system for monitoring enrollment processing at every VA 

facility. 

Locally, PVAHCS is hiring dedicated staff to complete on-line enrollment processing and are 

implementing an ongoing review of the NEAR list with daily reports of Veteran status to medical center 

leadership. Tele-health enrollment was implemented at all Community Based Outpatient Clinics to 

provide patients with an enrollment option close to their home. At the VISN-level, the Network Director is 

evaluating trends at PVAHCS on a monthly basis. 

Status: Target Completion Date: 

In progress August 2015 

Recommendation 9. We recommended the VA Secretary ensure the Phoenix VA Health Care 

System follows VA consultation guidance and appropriately reviews consultations prior to 

closing them to ensure veterans receive necessary medical care. 

VHA Comments: Concur. 

PVAHCS established a consult management committee to ensure appropriate processes follow VA 

consultation policy. The initial focus of their work was to address aging consults to ensure Veterans 

received care in a timely manner. This initiative lead to the PVAHCS having less than 1 percent of all 

submitted consults being open greater than 90 days as of May 1, 2014. The facility continues to report 

weekly consult status reports to Medical Center Leadership. 

Since the Accelerating Care Initiative (ACI) began, resources have been provided to continue to work 

down the number of open consults even further. Since the beginning of the ACI, over $16.9 million has 

been used to obtain care for over 3,100 unique Veterans in the community via purchased care. 

Consults are reviewed prior to closing to ensure Veterans receive necessary medical care. The facility is 

following nationally established standards, making telephone contacts and sending letters when 

telephone contacts are not successful. However, additional education for providers is needed to come 

into full compliance. The Chief of Staff will provide leadership oversight of this educational effort in the 

next 90 days. 

Over the past year, PVAHCS lost several Urology providers. An action team was established to address 

this crisis which ultimately determined that no additional new consults could be seen by Urology Service. 

A decision was made to discontinue all of the active or pending status Urology consults (approximately 

280 Veterans). These consults were sent back to their Primary Care providers for review and referral to 

Non-VA Care if Urology care was still warranted. Instructions were provided to the Primary Care 

providers by the Chief of Staff as well as the Chief of Primary Care prior to these consults being 

discontinued. PVAHCS has hired two new Urologists, a Nurse Practitioner and two Physician Assistants 

to support future Urology needs for patients. An offer has been extended to another Urologist. 

Status: Target Completion Date: 

In process December 31, 2014 

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Recommendation 10. We recommended the VA Secretary ensure the Phoenix VA Health Care 

System staff timely verify and record veteran deaths in Veterans Health Information Systems and 

Technology Architecture. 

VHA Comments: Concur. 

To address timeliness of acting on notifications of death by the Decedent Affairs Office, PVAHCS trained 

two additional staff members to serve as Decedent Affairs Clerks to provide cross-coverage to the 

Decedent Affairs Office, as needed. This additional resource has proven sufficient to provide timely 

processing of death notifications. In addition, VA will address the technical issues that have caused 

delays in sharing information about Veteran deaths across different information systems. 

Status: Target Completion Date: 

In progress October 30, 2014 

Recommendation 11. We recommended the VA Secretary ensure the Phoenix VA Health Care 

System establish an internal mechanism to perform routine quality assurance reviews of

scheduling accuracy. 

VHA Comments: Concur. 

Locally, the PVAHCS Acting Medical Center Director visited all facility and CBOCs in July, 2014. During 

these visits, the facility Director emphasized to scheduling staff that everyone needs to follow scheduling 

policies and procedures to ensure we are delivering timely care to Veterans. All front line supervisors 

received training on auditing schedulers’ work. The monthly audit process includes a mechanism to 

randomly identify appointments for review. Over 10 items per appointment are reviewed. Results are 

used in regular feedback for schedulers and in performance reviews. 

Nationally, VHA is developing a “Scheduling accuracy” database to compliment front line audits. The 

national database consists of 4 measures that audit elements of appointments available in centralized 

data sets. The national audits will provide insight into scheduling accuracy and process reliability. 

Status: Target Completion Date: 

In progress August 2015 

Recommendation 12. We recommended the VA Secretary ensure all Phoenix VA Health Care 

System staff with scheduling privileges satisfactorily complete the mandatory Veterans Health 

Administration scheduler training. 

VHA Comments: Concur. 

Nationally, between May 27, 2014 and June 6, 2014, the Access and Clinic Administration Program 

Office and the Employee Education System held individual training sessions for all 21 VISNs. Each 

session trained on a number of elements related to patient access including: new patient definitions, 

EWL, recall reminder, and the NEAR list. To date, 8,248 employees across the VHA System have been 

trained including 764 at Phoenix. 

PVAHCS now requires review by the Health Administration Service (HAS) to ensure all staff requesting 

scheduling privileges have taken the mandatory scheduling training. All staff members that have any of 

the VistA scheduling options are also now identified on a Master List required by the VHA Scheduling 

Directive. In addition to the monitoring of the mandatory training and adherence to maintaining a Master 

List, PVAHCS offered face-to-face refresher training that was attended by more than 450 staff members 

VA Office of Inspector General 125 
 

 

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in July 2014. Finally, to ensure staff members are fully trained and compliant with scheduling policies 

and procedures moving forward, the PVAHCS began an intensive, week-long scheduling training for all 

new dedicated schedulers, as well as those individuals requesting remedial training. This training 

includes hands-on experience for staff members and results in a local certification of scheduling 

competency. 

Status: Target Completion Date: 

In progress August 2015 

Recommendation 13. We recommended that upon the completion of the investigation the VA 

Secretary confer with appropriate VA staff and determine whether administrative action should be 

taken against management officials at the Phoenix VA Health Care System and ensure that action 

is taken where appropriate. 

VHA Comments: Concur. 

Following completion of all external reviews, VA will charge an internal group to convene an 

Administrative Investigation Board (AIB) responsible for conducting a focused review of Phoenix VA 

Health Care System managers’ culpability for the deficiencies identified in the OIG report. Additionally, 

the internal group will coordinate the issuance of appropriate proposals or actions should the AIB report 

determine that management accountability actions are warranted. 

Status: Target Completion Date: 

In progress To be determined after completion 

of all external reviews 

Recommendation 14. We recommended the VA Secretary ensure Phoenix VA Health Care System 

include an employee satisfaction measure and a veteran satisfaction measure in Phoenix VA 

Health Care System management’s performance plans and facility goals. 

VHA Comments: Concur. 

VHA Senior Executive performance plans communicate the priorities of VA and VHA. The Executive 

plans are used to inform the performance expectations for subordinate leaders and workforce. 

The lessons of Phoenix have provided a major impetus for VHA to reexamine its entire process of setting 

performance expectations for its leaders and managers. We are taking vigorous action to ensure that a 

“data driven” approach does not have the unintended impact of diverting attention from our primary goal 

of providing Veterans with personalized, proactive, patient-driven health care. To ensure that 

operational indicators of access promote the correct behaviors, we are committed to having all 

performance plans emphasize an ethical organizational culture that promotes constructive and engaged 

relationships between Veterans and their health care teams. The performance plans will align the entire 

staff of our health care system to support that goal. 

Accordingly, beginning in fiscal year (FY) 2015, the performance plans and goals for management at 

Phoenix, and across VHA, will emphasize the importance for all leaders to engage deeply with Veterans 

and staff. VHA currently has an ongoing Survey of Health Experiences of Patients (SHEP) and an 

annual All Employee Survey (AES) that elicit the perspectives of Veterans and staff, respectively, about 

the factors that promote or hinder a healing environment and a healthy organization. No later than the 

2nd quarter of FY 2015, VHA leadership will be expected to share the results of both surveys with all 

employees during town halls, staff meetings, and other venues. AES results will be made available at 

the workgroup level so that individual workgroups and departments can prioritize what changes are 

VA Office of Inspector General 126 
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needed, develop an action plan based on those priorities, and follow through with actions designed to 

improve the workplace. SHEP results, including an analysis of the key drivers of Veteran experience of 

Access, will similarly be provided at the level of facility, division, and CBOC as a reliable Veterangenerated indicator of progress towards meeting Veteran needs. 

The VHA 2015 Senior Executive Performance Plan is currently in development. Upon approval of the 

Senior Executive Performance Plan by VHA senior leadership, management performance plans and 

facility goals at Phoenix will include an expectation that senior executives demonstrate action to address 

the results identified by local AES and SHEP survey data. Facility, network, and national results will be 

published internally to document progress as well as ensure that appropriate technical support and 

resources are provided. Additionally, the agency will provide an annual summary report of progress for 

our stakeholders and the public upon completion of the performance period. 

Status: Target Completion Date: 

In progress March 2015 

Recommendation 15. We recommended 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. 

We provided this recommendation to the former VA Secretary in the Interim Report. 

VHA Comments: Concur. 

VHA has taken aggressive steps at the national and local levels to address recent reports of 

unacceptable delays in access to care. The Accelerating Care Initiative (ACI), a coordinated, systemwide initiative designed to increase timely access to care for Veteran patients; decrease the number of 

Veteran patients on the EWL longer than 30 days for their care; and standardize the process and tools for 

ongoing monitoring and access management at VA facilities was implemented in June 2014. The ACI is 

a process where network and health care facility leadership teams reviewed where Veterans were either 

waiting too long for care or where Veterans did not yet have appointments. ACI identified requirements 

for over $400 million to support care delivery requirements. These funds have been used to support 

overtime for clinical and administrative support and for acquiring health care services for Veterans in the 

community through non-VA care. As of August 6, 2014, VA has obligated $128 M in funding and 

authorized non-VA care for 83,000 Veterans. The success of ACI ensures it will be among the 

remediation options made available to medical center directors through this process. 

Status: Target Completion Date:

 Completed Implemented 

Recommendation 16. We recommended 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 wait list. We provided this recommendation to the former VA 

Secretary in the Interim Report. 

VHA Comments: Concur. 

The Health Eligibility Center, in connection with the Veterans Health Administration Support Services 

Center, developed a report to identify those individuals currently waiting on the NEAR list. 

As of May 15, 2014, approximately 64,000 Veterans were currently pending on the NEAR list. 

As of July 15, 2014, approximately 2,100 individuals remained on the NEAR list. 

VA Office of Inspector General 127 
 

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A preliminary analysis of the 61,900 Veterans removed from the NEAR list show: 

	 20 percent cancelled their request for an appointment 

	 11 percent scheduled an appointment 

	 2 percent were placed on the Electronic Wait List 

	 7 percent requested and were referred to other VA services 

	 7 percent were in the early stages of eligibility and verification 

	 VA has made several attempts to contact the remaining Veterans (52%) by phone. After 

verifying mailing addresses, VA sent certified letters to every Veteran who could not be reached 

by phone. 

Status: Target Completion Date:

 Completed Implemented 

Recommendation 17. We recommended the VA Secretary establish veteran-centric goals and 

eliminate current goals that divert focus away from providing timely quality care to all eligible 

veterans. 

VHA Comments: Concur. 

VHA will establish Veteran-centric goals for the agency as a whole as well as its operating executives. 

VHA will review and modify all current performance plans to remove measures related to waiting time 

goals. VA will work with the Office of Management and Budget to remove wait time goals from the FY15 

Agency Performance Plan. 

Status: Target Completion Date: 

In progress September 30, 2014 

VHA will develop additional Veteran-centric measures for access to care and responsiveness and have in 

place validated indicators and goals. 

Status: Target Completion Date: 

In progress September 30, 2015 

Recommendation 18. We recommended the VA Secretary take measures to ensure use of 

“desired date” is appropriately applied. 

VHA Comments: Concur. 

VA will take measures to ensure use of “desired date” is appropriately applied. VA has suspended the 

use of Desired Date performance metrics for the Agency Performance Accountability Report as well as in 

all individual performance plans. To date, over 8,200 employees have undergone additional scheduler 

training. Additionally, VISN and VA Medical Center Directors have conducted over 2,000 in-person site 

visits to review understanding of scheduling practices. As part of ongoing efforts to reinforce proper use 

of the “desired date,” the Acting Deputy Under Secretary for Health for Operations and Management 

issued a memorandum on August 15, 2014, to all VISN directors titled, “Clarification of Certain 

Scheduling Definitions.” 

Status: Target Completion Date: 

In progress August 2015 

VA Office of Inspector General 128 
 

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Recommendation 19. We recommended the VA Secretary provide veterans needed care in a 

timely manner that minimizes the use of the electronic wait list. 

VHA Comments: Concur 

VHA’s policy is that patients requesting new appointments in a clinic where they have not been seen in 

the last 24 months are placed on the EWL if an appointment cannot be made within 90 days. In some 

cases, appointments are made beyond 90 days rather than placed on an EWL (for example, patients 

without a phone). The value of the EWL is that it allows staff to see the volume of appointment request 

backlog, secure appointment supply or make a decision to use Non-VA care, and then make the 

appointment with the patient once (rather than cancel and reschedule). Since VA tracks waiting times for 

each appointment whether a patient is on the EWL or in a scheduled appointment, VA can track 

appointment backlog and wait times in either case. 

VHA seeks to provide care within 30 days. EWL volume in general signals clinics with waiting times of 

over 90 days for new appointments. To minimize wait times, VHA has created the Accelerating Care 

Initiative, which requires facilities to reach out to patients waiting more than 90 days and offer them more 

timely care within VA, or Non-VA care. As of August 6, 2014, VHA had contacted over 150,000 patients. 

In addition, VHA is expanding the number of providers in facilities and the use of Non-VA care to meet 

demand. VHA will report on effectiveness of the ACI in providing timely care to Veterans and appropriate 

minimal usage of the EWL. 

Status: Target Completion Date: 

In progress August 2015 

Recommendation 20. We recommended the VA Secretary require facilities to perform internal 

routine quality assurance reviews of scheduling accuracy of randomly selected appointments and 

schedulers. 

VHA Comments: Concur. 

VHA has developed and deployed a leadership scheduling audit process. VA medical center directors 

and VISN directors are completing face-to-face audits of their facilities’ scheduling practices. Additionally, 

VHA will seek independent external reviews by The Joint Commission at all facilities. These external 

reviews will assess VHA processes and accreditation standards directly related to timely access to care; 

identify processes that may potentially indicate delays in care and diagnosis; review continuity of care 

and patient flow; and review the environment of care and those standards that assess organizational 

leadership and culture. 

Status: Target Completion Date: 

In progress August 2015 

Recommendation 21. We recommended the VA Secretary initiate a process to selectively monitor 

calls from veterans to schedulers and then incorporate lessons learned into training or 

performance plans. 

VHA Comments: Concur 

VHA Telephone infrastructure is diverse. Some lines of the business are served by professional call 

centers that have up-to-date equipment, well trained staff, and the capability to selectively monitor calls 

and incorporate lessons learned into training and performance plans. Some facilities have established 

call centers at a facility or network level on a pilot basis. However, the majority of facilities have either 

VA Office of Inspector General 129 
 

 

 

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small or non-existent call centers and decentralized staff that answer calls in addition to their other duties. 

Many facilities have outdated telephone equipment and simply do not have the infrastructure to 

automatically distribute or monitor calls. In any case, VHA Scheduling Audit Training Materials currently 

include selective call monitoring as an option for scheduler performance review. Practically, compliance 

with the recommendation is most likely in selected facilities and services with the most up-to-date 

infrastructure. 

VHA will convene a workgroup to fully understand the complexities of the widely variable telephone 

systems used in each of the facilities and CBOCs across the country. This workgroup will also assess 

applicable regulation, statute, and labor management agreements regarding call monitoring. The 

workgroup will be charged with providing recommendations to the Under Secretary for Health regarding 

feasible options for auditing telephone systems for answered calls, dropped calls, and unanswered calls. 

Status: Target Completion Date: 

In progress August 2015 

Recommendation 22. We recommended the VA Secretary conduct a review of the Veterans 

Health Administration’s Ethics Program to ensure the Program’s operational effectiveness, 

integrity, and accountability. 

VHA Comments: Concur. 

VA strongly believes that the agency’s core values of integrity, commitment, advocacy, respect and 

excellence are critical elements in VA’s overall pledge to serve all Veteran’s and must be embodied by all 

employees and incorporated into all operational processes. Many factors promote effectiveness, 

integrity, and accountability for ethical behavior, and leadership commitment, human resource processes, 

staff engagement, and performance expectations must work in synergy to promote an ethical culture. To 

ensure the presence and alignment of the proper elements needed for an ethical culture, VHA will 

establish a work group, to include external experts and facilitation, to conduct a holistic review, including 

the proper role and functions of the National Center for Ethics in Health Care. VHA will expect the review 

to provide recommendations on essential structural elements necessary for reinforcing a strong ethical 

culture: such as how to select and hire ethical leadership and staff; how to communicate expectations 

around ethical behavior, and the proper organizational structures and processes for eliciting and 

responding to ethical concerns. 

Status: Target Completion Date: 

In progress January 15, 2015 

Recommendation 23. We recommended the VA Secretary initiate actions to update the Veterans 

Health Administration’s current electronic scheduling system and ensure milestones and costs 

are monitored. 

VHA Comments: Concur. 

VA Office of Information and Technology and VHA will implement incremental changes to the VISTA 

Scheduling Package via the VistA Scheduling Enhancement Project. These Milestones are identified 

below: 

Planning 7/21/2014 – 9/15/2014 

Development & Testing 9/15/2014 – 1/16/2015 

Initial Operating Capability 1/20/2015 – 5/19/2015 

Integration/Deployment 5/20/2015 – 8/18/2015 

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Status: Target Completion Date: 

In progress August 2015 

Recommendation 24. We recommended the VA Secretary ensure that the Veterans Health 

Administration establishes a mechanism to ensure data representing VA’s national performance 

are validated by an internal group that has direct access to the Under Secretary for Health. 

VHA Comments: Concur. 

VA has created SAIL, the Strategic Analytics for Improvement and Learning Value Model, to distill salient 

information from a large number of individual metrics. SAIL is a web-based, balanced scorecard model 

that the Department of Veterans Affairs (VA) is developing and continuously improving to measure, 

evaluate and benchmark quality and efficiency at medical centers. SAIL is designed to offer high-level 

views of health care quality and efficiency, enabling executives and managers to examine a wide breadth 

of existing VA measures. The underlying data on which SAIL is based are identical to those available 

through other Veterans Health Administration (VHA) sources such as: Linking Knowledge and Systems 

(LinKS), ASPIRE, VA Inpatient Evaluation Centers (IPEC), Performance Management, and Office of 

Productivity, Efficiency, and Staffing (OPES). 

SAIL assesses 25 Quality measures in areas such as mortality, complications, and customer satisfaction, 

which are organized within eight domains (See Appendix A for full list). In addition, SAIL includes 

another measure to assess overall efficiency (the Efficiency domain). SAIL draws data from existing 

measures prepared by VHA Program Offices and VA national databases for inpatient and outpatient 

encounters and facility characteristics. SAIL is VA-specific and intended to suggest areas of focus. While 

many of the measures are consistent with those reported in the private sector, others are unique to VA 

and have not been as thoroughly validated. SAIL allows individual VAMCs to assess their performance 

for each measure by comparing their results with those achieved by similar facilities by percentile ratings. 

The benchmark is the performance achieved by the top 10 percent of similar facilities. 

As part of the largest integrated health care system in the United States, each VAMC is organized slightly 

differently to best serve Veterans’ health care needs, and SAIL is designed accordingly. SAIL’s quality 

and efficiency measurements take into account the complexity level of each medical center (e.g., patient 

volume, number of residents, complex clinical programs, and research dollars) when assessing 

performance. Unlike most other health industry report cards which are updated annually, SAIL is 

updated quarterly to allow medical centers to more closely monitor the quality and efficiency of the care 

delivered to our Veterans. SAIL is produced by a unit of VHA that is independent of VHA operations 

(VISNs/Medical Centers) whose leader has direct access to the Under Secretary for Health and the 

Deputy Secretary of the Veterans Affairs. 

Status: Target Completion Date:

 Completed Implemented 

VA Office of Inspector General 131 
 

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Appendix L Office of Inspector General Contact 

OIG Contact For more information about this report, please 

contact the Office of Inspector General at 

(202) 461-4720. 

VA Office of Inspector General 132 
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Appendix M 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 

All Members of the United States Congress 

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

VA Office of Inspector General 133