phoenix hcs report on patient deaths and wait times

Why is there a death error in Phoenix VA health system?

8 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.

What is the wait time for primary care in Phoenix VA?

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.

What is the report number for the Phoenix VA Office of Inspector General?

Department of Veterans Affairs Office of Inspector General Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System, Report #14-02603-267 Author VA Office of Inspector General Subject

How many veterans have died waiting for medical appointments in Phoenix?

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.

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

A previous report by the Veterans Affairs (VA) Office of the Inspector General found that many veterans at the Phoenix VA facility endured months-long waits for primary care appointments, due in part to inappropriate manipulation of the scheduling process so that the facility could appear to meet VA quality metrics. This follow-up report examined whether these delays led to patients ...

Timeline: The Phoenix VA Scandal That Never Ended

Phoenix, AZ – Last week, the Office of Inspector General (OIG) confirmed that veterans are still dying while they are waiting for care at the Phoenix VA Medical Center, the hospital known as "ground zero" for VA’s secret wait list scandal which emerged in 2014. Despite tens of billions of dollars in additional funding for the VA, a rotation of seven directors during the past three years ...

IG Report: 300,000 Veterans Died While Waiting for Health Care at VA

WASHINGTON -- More than 300,000 American military veterans likely died while waiting for health care -- and nearly twice as many are still waiting -- according to a new Department of Veterans ...

How many allegations of VA wait time manipulation?

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:

What are inappropriate scheduling practices?

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 .

What is the VA OIG hotline?

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

Does the VA investigate wait times?

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.

Did PVAHCS comply with VHA?

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.

Does Phoenix VA have access barriers?

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.

How many allegations of VA wait time manipulation?from va.gov

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:

What are inappropriate scheduling practices?from va.gov

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 .

What is the VA OIG hotline?from va.gov

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

Does the VA investigate wait times?from va.gov

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.

Did PVAHCS comply with VHA?from va.gov

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.

Does Phoenix VA have access barriers?from va.gov

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.