VA Hospital Taught Employees to Game Wait Times

Inspector general: More evidence of appointment manipulation in Arizona after Phoenix scandal

Philadelphia VA hospital / AP
November 11, 2016

Employees at a Department of Veterans Affairs hospital in southern Arizona were instructed to manipulate veterans' wait times so they appeared shorter, a newly released investigation shows.

The agency's inspector general substantiated allegations that managers at the Tuscon-based VA medical system told schedulers to "zero out" patient wait times, a scheduling practice that persisted in 2016 despite whistleblower reports of wait-time manipulation at the Phoenix VA that drew national outrage more than two years ago.

The VA inspector general report, publicly released on Wednesday, provides more evidence of bad scheduling practices that stretched beyond the Phoenix VA hospital.

The watchdog launched the investigation into the Ocotillo primary care clinic in the Southern Arizona VA System in response to allegations from a former employee in October 2014. The inspector general substantiated claims that employees were instructed to record zero-day wait times for patients by making the desired date the same as the appointment date, in violation of VA policy.

Seventy-six percent of appointments had a zero-date wait time, according to a review of a sample of appointments scheduled between December 2013 and August 2014. Auditors also found that 46 percent of appointments between October 2015 and March displayed a zero-day wait time.

The VA measures wait times by counting the number of days between the date the veteran wants to be seen or needs to be seen—the so-called "preferred" or "desired" date—and the actual date of the appointment. Employees at VA facilities across the country have been found improperly recording this data, resulting in inaccurate patient wait times.

The inspector general found evidence from interviews and training materials that nurses at the Southern Arizona VA were trained to record the next available appointment date as a patient's desired date, thereby understating the amount of time a veteran waited for care.

"VA OIG staff reviewed [Southern Arizona VA] scheduling training materials from early 2014 and found that the practice of recording the next available date for an appointment as the patient's desired date was included in the training provided to schedulers within the medical facility," the report states.

For example, the training materials displayed one "mock scenario" in which "the scheduler offers the veteran an appointment and the veteran accepts the appointment. The veteran is not requested to state a specific date he/she wishes to be seen. In this scenario, the training material indicated that the 'agreed upon date becomes the desired date.'"

The inspector general also found evidence that senior executives at the hospital put pressure on employees to meet internal goals of 92 percent of veterans seen within seven days of their "desired date" for care. One nurse told auditors that "she was told to 'fix it' if she fell short of the performance goal without explicitly requesting scheduling records to be altered," according to the report.

In fiscal 2013, four physicians at the facility were given performance-based bonuses totaling over $28,500 that were based in part on meeting wait-time goals.

Managers at the facility only altered training to comply with VA policy after wait-time manipulation at the Phoenix hospital became widely covered by national media outlets. Employees continued to "zero out" patient wait times into 2016, although to a lesser extent than previous years, according to the data reviewed by auditors.

Thirteen veterans who were waiting for appointments at the Southern Arizona VA for more than 30 days between 2013 and 2014 died before their scheduled appointments. However, investigators reviewed each case and concluded that the patients did not die as a result of delays in care.

The audit found that one patient may have died as a result of "poor communication" regarding the need to schedule a procedure to implant a cardiac device.

The VA inspector general also conducted a separate investigation into the allegations to determine whether there was any criminal activity surrounding the scheduling practices at the hospital. The investigation has been sent to the Office of Accountability and Review.

The local VA director agreed with the findings of the investigation released on Wednesday and submitted plans to make sure that schedulers do not violate VA policies in the future.

The VA has been widely criticized by lawmakers and others for mismanagement at its hospitals and persisting waits. The inspector general launched separate probes into a number of VA hospitals over allegations of wait-time manipulation following the 2014 controversy, including the flagship Tuscon VA hospital in the Southern Arizona VA system.

"The results of these VA OIG reports are deeply disturbing, and confirm that the problems plaguing our VA health care system nationwide extend to Southern Arizona," Arizona's Republican Sens. John McCain and Jeff Flake said in a statement. "A separate investigation found employees failed to properly schedule approximately 400 Orthopedic appointment requests, as well as an additional 600 Urology appointment requests. Moreover, the OIG confirmed widespread scheduling misconduct, including in some cases cancelling appointments if wait times exceeded 30 days."

"The gross mismanagement by employees at the Southern Arizona VA Health Care System and at our VA hospitals in Arizona and across the country are unacceptable," they said. "We urge the new administration and Congress to take this issue very seriously, and finally deliver accountability and real reform at the VA that our veterans deserve."

"It is well known throughout the VA that veterans continue to die and languish on electronic wait lists trying to get the health care they have earned in service to this nation. Tucson is no different," Brandon Coleman, a VA employee who exposed poor mental healthcare at the agency's hospital system in Phoenix, told the Washington Free Beacon in an email Thursday.

A separate inspector general wait-time investigation, which was publicly released on Tuesday, found evidence that employees were concerned about "gaming activities" with appointment scheduling as far back as 2010. The investigation found evidence of bad scheduling practices across several departments of the hospital.

According to the VA's internal data, more than 530,000 veterans were waiting more than 30 days for appointments at agency facilities across the country as of mid-October.