IG Recommendations On How to Fix the VA

The Office of Inspector General’s report on the substandard care veterans received at the Phoenix VA Health Care System details 24 recommendations on how to fix the VA.

• Veterans Health Administration should 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• Ensure all new enrollees seeking care at the Phoenix VA Health Care System receive an appointment within the time frames directed by Veterans Health Administration policy.
• Ensure the Phoenix VA Health Care System timely process enrollment applications.
• 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.
• Ensure the Phoenix VA Health Care System staff timely verify and record veteran deaths in the Veterans Health Information Systems and Technology Architecture.
• Ensure the Phoenix VA Health Care System establish an internal mechanism to perform routine quality assurance reviews of scheduling accuracy.
• Ensure all Phoenix VA Health Care System staff with scheduling privileges satisfactorily complete the mandatory Veterans Health Administration scheduler training.
• Upon the completion of the investigation the VA Secretary should 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.
• 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.
• 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.
• 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.
• Establish veteran-centric goals and eliminate current goals that divert focus away from providing timely quality care to all eligible veterans.
• Take measures to ensure use of “desired date” is appropriately applied.
• Provide veterans needed care in a timely manner and minimize the use of the Electronic Wait Lists.
• Require facilities to perform internal routine quality assurance reviews of scheduling accuracy of randomly selected appointments and schedulers.
• Initiate a process to selectively monitor calls from veterans to schedulers and then incorporate lessons learned into training or performance plans.
• Conduct a review of the Veterans Health Administration’s Ethics Program to ensure the Program’s operational effectiveness, integrity, and accountability.
• Initiate actions to update the Veterans Health Administration’s current electronic scheduling system and ensure milestones and costs are monitored.
• 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.

What do you think of these recommendations? Will they make a difference?