The story sounds familiar. Perhaps a little too familiar. Manipulated wait times. Erroneous appointment cancellations. Veterans not receiving quality, timely care. Veterans dying. Media attention. Scandal. Crisis. Congressional outrage. Office of Inspector General investigations.
And … repeat.
This article has been updated with additional information and state summaries on June 21, 2016
Up to 40 veterans reportedly placed on secret appointment wait lists died before getting care, according to whistleblowers in 2014. VA investigations revealed a systemic issue with delays in care and rampant use of unofficial wait lists. Some folks defended the VA. Others stood by the whistleblowers. Families grieved for their loved ones. The media frenzy began, and Congressional outrage was sparked. More than 70 facilities across the country were investigated. And people waited for the results. Fast forward nearly two years, to late February when USA Today reported the VA Office of Inspector General found scheduling problems in 51 cases of the 73 facilities investigated. Rep. Tammy Duckworth (D-Ill.), a disabled combat veteran, called for an investigative hearing:
“After the abhorrent wait-time abuses that took place in [VA hospitals] across the country, it is absolutely vital that we carefully study the misconduct and act on lessons learned to ensure we never repeat such disgraceful mistakes,” Duckworth said in a letter Thursday to Rep. Jason Chaffetz (R-Utah), who chairs the House Oversight and Government Reform Committee.
The VA released a statement in advance of the release of the OIG reports, relating expectations of all 77 completed investigation summaries to be released.
“It is important to note that OIG has not substantiated any case in which a VHA Senior Executive or other senior leader intentionally manipulated scheduling data. In 25 of the 77 OIG completed investigations, OIG found no scheduling irregularity. In 18 of the remaining 52 reports, OIG substantiated intentional misuse of scheduling systems and provided this information to OAR. In 12 of those reports, OAR substantiated individual misconduct warranting discipline. From those 12 reports, 29 employees have been disciplined with actions ranging from admonishment to removal. This includes three employees who retired or resigned with discipline pending.”
On February 29, the VA OIG released 15 administrative summaries of wait time investigations — 11 in Florida, 1 in Iowa, and 3 in Minnesota. A quick assessment of the issues/conclusions of the newly released administrative summaries concluded that about half of the issues reported were substantiated, and half were not.
Update (March 7, 2016): The VA Office of Inspector General released additional administrative summaries regarding appointment wait times for Delaware, Illinois, Louisiana and Hawaii. Generally, the audits showed the appointment scheduling system being used inappropriately, resulting in inaccurate wait times. There appears to be no public acknowledgement of patient harm or death resulting in the manipulations. The investigation summary for one location, the VA Medical Center in Hines, Illinois appears to show more egregious activities. The OIG investigation hinged on public allegations of “secret backlog lists” and tales of manipulated wait times ensuring staff large bonuses that reportedly resulted in harm to patients. The VA OIG’s investigation included interviews of the claimant and 20 witnesses at all levels of the organization. There was also an extensive review of available records, including 245,000 official emails and complaints registered with the Patient Advocate office. The desired date/appointment date wait time metrics were analyzed, and data analysis reports were reviewed.
- For the issue of secret waiting lists, this complaint was not substantiated. However, the investigation did reveal delays in access to care.
- For the issue of bonuses, this complaint was not substantiated. “Upper management whose performance appraisals might have been influenced by wait time metrics did not receive a five-figure bonus”. … “Overall ratings drive performance awards and access measures alone are not large enough to significantly influence overall awards.”
Of note, a similar complaint from Senator Mark Kirk (R., IL) alleged $16.6 million paid in bonuses since 2011. Of the alleged $16.6 million, $9.5 million was in “salary incentives and retention bonuses (which are widely known and deemed necessary by the VA)”.
- For the issue of intentional and/or malicious falsification of wait times – the VHA Outpatient Scheduling Process and Procedures Directive was violated.
So what happened? “The OIG referred the Report of Investigation to VA’s Office of Accountability Review on January 26, 2015.”
The reported allegations and the OIG conclusions are summarized below:
VA Medical Center – Tuscaloosa
• Allegation: Primary Care Clinic schedulers were instructed to cancel and reschedule appointments to improve appearance of access to care.
• Conclusion: A paper list was maintained of established patients being transferred from one clinic to another after the Mental Health clinic and the PTSD clinic merged. When questioned, the involved employee was not truthful about the list. Supervisors, service line chiefs or managers did not appear to have provided guidance to schedulers regarding VA scheduling policies. Supervisors could not clearly articulate scheduling procedures in the VHA Directive. Senior leaders did not appear to be aware of inappropriate scheduling practices.
VA Community Based Outpatient Clinic – Lake Havasu City
• Allegation: Medical, administrative, and clerical violations, including “paper scheduled appointments” were alleged in a letter to Senator John McCain.
• Conclusion: Violations were not substantiated. The “paper scheduling” was an encounter form that showed current and next appointment information. No separate scheduling lists were kept. “Clerical violations” were actually a misunderstanding with other employees at the clinic.
VA Medical Center – Little Rock
• Allegation: Whistleblower complaint alleging inappropriate scheduling practices.
• Conclusion: Schedulers were trained in the appropriate methods for scheduling appointments, but several supervisors had instructed staff to schedule appointments inconsistent with training or VA policy. Appointment dates were manipulated in the system, giving the appearance of lower wait times. “Testimonial evidence and a review of email” revealed that two supervisory employees “displayed a lack of candor” regarding their knowledge and/or participation in the patient wait time manipulations.
1. VA Medical Center – Los Angeles
• Allegation: A supervisor is alleged to have printed a list of patient appointments and rescheduling any appointment that exceeded a 14 day wait, resulting in wait times appearing lower. The review discovered in part that approximately 680 out of 750 appointments reviewed had been changed. The cause was found to be “improper training” rather than trying to manipulate wait times. Of note: Employees persevered in getting this complaint heard, including emails to the VA Under Secretary of Health, The WLA Director, VISN 22 Director, Assistant Deputy Under Secretary for Health Clinical Operations, the Director, Network Support and “other officials”.
• Conclusion: The allegation was substantiated. An intentional deviation from VA policy, it was not substantiated the actions were done specifically to manipulate wait time data. Prior investigation of the allegations and corrective action was taken before this OIG investigation.
2. VA Medical Center – Palo Alto
• Allegation: California members of the House Committee on Veterans’ Affairs alleged multiple listed for scheduling patient appointments in the Gastroenteroligy (GI) Clinic:
- List 1: “legal” list of patients waiting for appointments
- List 2: “illegal” list of patients designed to make wait times consistent with required performance measures
- List 3: List of patients scheduled to have “substandard test or care in order to make the first list meeting the performance measures”
The allegation for List 3 was reviewed separately by the OIG’s Office of Healthcare Inspections. The findings were published in their report Healthcare Inspection: Alleged Colorectal Cancer Screening and Administrative Issues VA Palo Alto Health Care System Palo Alto, California.
• Conclusion: The allegations were not substantiated. “All employees interviewed during the investigation stated that they were not aware of any secondary or hidden patient wait lists.
3. VA Medical Center – San Diego
• Allegation: “Misconduct and manipulation” of desired dates. Of note:
- The complaint was also made to the VA Secretary’s office
- In the investigation, the Mental Health department scheduled more than 700 appointments with a 98 – 100 percent rate of zero wait time.
- One Veteran reported his appointments were canceled by the clinic four times in a row, which triggered a suicide attempt.
- This Veteran’s provider canceled almost 14 percent of appointments with less than a day’s notice in FY13, and almost 27 percent of appointments in FY14.
- Manipulations for desired dates in the Mental Health clinic were also investigated in 2013.
• Conclusion: Interviews substantiated the allegation. Data analysis substantiated the allegation. Emails substantiated the allegation. The Medical Administrative Officer denied responsibility of directing manipulation of wait times.
4. VA Medical Center – San Diego
• Allegation: Four supervisors pressured employees to “fudge the desired date”. Of note:
- Interviews were conducted with 3 schedulers and a current supervisor.
- Of the 3 schedulers reviewed, 1 showed 99 percent appointments with zero wait time, and the other 2 showed 70 percent appointments with no wait time.
• Conclusion: Allegation was not substantiated.
1. VA Medical Center (Dental Clinic) – Denver
• Allegation: Manager instructed an employee to “destroy/dispose of all information and charts related to patients on the waiting list”.
• Conclusion: Allegation not substantiated.
2. VA Medical Center (Endoscopy Clinic) – Grand Junction
• Allegation: An employee reported that a spreadsheet was being used to track appointments.
• Conclusion: A spreadsheet was being used, but not to schedule appointments. The spreadsheet was for data tracking only as part of a VHA national collaborative, and may be considered for use elsewhere as a national benchmark.
3. Multi-Specialty Outpatient Clinic – Fort Collins
This investigation was initiated based on information from “media reports, congressional staff, and other sources”.
• Allegation: Manipulation of appointments and wait times at the Fort Collins Multi-Specialty Outpatient Clinic. The Fort Collins Multi-Specialty Outpatient Clinic is administered by the VAMC, Cheyenne Wyoming. Of concern – an email on how to “game” the scheduling system to show appointments were being scheduled within 14 days of the desired date. The initial investigation uncovered additional information that implicated a supervisor in VAMC Cheyenne in cancelling and rescheduling appointments to reduce the reported wait time.
• Conclusion: Allegations were substantiated – about 2,700 appointments in approximately 18 months (2011 to 2013)
- Manager deliberately manipulated appointments to show reduce wait times
- The clinic utilization rate was manipulated to show the VA Central Office “85 percent” goal was met
- The manager directed the email sent to explain a method of “gaming” the system in appointment wait time manipulation to “address the 14-day policy requirement”
- No Veterans were harmed by the wait time manipulation practice (Veteran appointments were the same as originally scheduled)
- Employee performance reviews and bonuses for involved employees “were not based on meeting standards for scheduling”
VA Medical Center – Wilmington, Delaware
• Allegation: Scheduling procedures issues
• Conclusion: There were several scheduling errors:
- The patient’s desired date to be seen and the appointment creation date were the same date in the system
- Practice of negotiating the patient’s desired date based on clinic availability, resulting in a zero wait time appointment
- Paper list of patients requesting appointments at CBOC Dover
- Paper list of behavioral health patients for the CBOC at Dover
- Paper slips for the recall list at CBOC Dover
- List of orthopedic patients requesting joint replacement surgery
1. VA Medical Center – Lake City, Fla.
• Allegation: Paper scheduling list discovered
• Conclusion: A health care provider had requested that the paper list be used in addition to (not in lieu of) the VA’s online system for scheduling patients. No evidence was found to show the use of list had any negative effect on patient care; the list was not a “secret” wait list.
2. VA Medical Center – Bay Pines, Fla.
• Allegations: (1) “Changing and destroying records and appointments” at the Outpatient Clinic Lakeside to cover up mistakes; (2) More than 500, possibly more than 1,000 Gastroenterology (GI) Clinic consults and procedures reported cancelled.
• Conclusion: Allegations were not substantiated. However, staff had used the “next available” appointment dates in the online system as patients’ desired dates for the medical treatment.
3. VA Medical Center – Tallahassee, Fla.
• Allegation: Clerks at the VA outpatient clinic (OPC) were purposely manipulating scheduling data in the VA scheduling system.
• Conclusion: Two employees were not determining the patient’s desired date. In addition, a pharmacy employee was maintaining a paper file system for 23 patients waiting to be scheduled for treatment instead of entering the patients into the system.
4. VA Medical Center – Gainesville, Fla.
• Allegation: A reporter inquired about a “secret waiting list” found at the Malcolm Randall Veterans Affairs Medical Center (VAMC).
• Conclusion: On May 13, 2014 at Malcolm Randall VAMC, a paper wait list of 219 patients awaiting recall for future appointments was found at the VA Medical Center’s Mental Health Clinic. None of the patients were denied treatment. Clerks did not have access to, or training on the appropriate online scheduling system.
5. Community Based Outpatient Clinic – Marianna, Fla.
• Allegations: (1) a psychiatrist provided the clerks scheduling notices for patient follow-up visits via a paper list instead of using the online system; (2) a telehealth nurse who was maintaining a list of patients requiring scheduling for telehealth services.
• Conclusion: The investigation into both issues revealed that the paper lists were maintained in a secure environment. Relevant information on the lists was entered into the online system.
6. VA Outpatient Clinic – Jacksonville, Fla.
• Allegation: The Prosthetics Department created a new consult for prescription eyeglasses in the online scheduling system if the patient acted on an eyeglass prescription more than 30 days after receiving the prescription.
• Conclusion: The investigation confirmed that the Prosthetic staff recreated consults in lieu of cloning. The Prosthetics managers made the decision to have employees create new consults in lieu of cloning them, against business practice guidelines.
7. VA Outpatient Clinic – Tallahassee, Fla.
• Allegations: (1) Clerks were purposely manipulating the patient “desired date” for an appointment in the online scheduling system to reflect the actual date of the appointment, versus the desired date, when the two dates were greater than 14 days apart; (2) A dietician self-reported a paper waiting list for a program called “Be Active and Move.”
• Conclusion: The investigation confirmed that several employees made unintentional errors by improperly entering scheduled appointments and improperly inputting the desired dates. The dietician maintained a paper waiting list until the program class was 3 weeks away, then verified participants still wanted to attend the class before they were entered into the online scheduling system.
8. Community Based Outpatient Clinic – St. Augustine, Fla.
• Allegation: An employee self-reported that she was maintaining a paper waiting list.
• Conclusion: The employee did not violate any Veterans Health Administration directives. The list contained names of fifteen interested caregivers in a program that did not yet exist.
9. VA Medical Center – Orlando, FL; VA Outpatient Clinic – Daytona Beach, Fla.
• Allegations: (1) Clerks deleted consults without checking with physicians, resulting in patients not being seen; (2) New patients experienced excessive wait times; (3) Performance objectives linked to leaders’ compensation could lead to potential misconduct.
• Conclusion: Employees did not delete consults without first discussing the situation with a physician. Employees did manipulate the electronic waiting list to show a reduced wait time for veterans consults. Excessive wait times were not found at the VAMC Orlando; however, there were access to care issues identified at the Outpatient Clinic at Daytona Beach. The mental health clinic was keeping a list of patients who might benefit from a new treatment should it become available.
10. VA Medical Center – West Palm Beach, Fla.
• Allegations: (1) “Gaming” veterans’ desired dates for appointments; (2) Scheduling staff using the “next available date” as a veteran’s “desired date” for an appointment; (3) Management pressured staff to adjust the patients’ desired appointments for gastrointestinal (GI) test consults.
• Conclusion: The clinic’s next available date was used as a veteran’s desired date. Appointments that were outside the 14-day desired date policy were changed. Staff “did not understand the overall effect of gaming access on department resource allocations.” Management was not found to direct staff to “game” appointment times or change GI appointments. Management bonuses and appraisal ratings do not solely rely on facility access.
11. VA Medical Center – Miami, Fla.
• Allegations: (1) Double patient scheduling lists were maintained; (2) Patient wait times were manipulated to meet the 14-day scheduling policy.
• Conclusion: Schedulers were using the next available clinic date instead of the veteran’s desired date to meet the 14-day goal. “The allegation regarding double lists was a misunderstanding, as the double lists were the active and access lists maintained by the facility.”
VA Medical Center – Dublin
• Allegation: According to a referral from Congressman Jack Kingston, more than 2,000 non-VA care coordination consults were closed via a “batch closure”. As a result, Veterans did not receive care they were entitled to receive. Of note: A VA OIG Office of Healthcare Inspections (OHI) Report Improper Closure of Non-VA Care Consults Carl Vinson VA Medical Center Dublin, Georgia, Report No. 14-03010-251, dated August 12, 2014 concluded that staff “improperly batch-closed 1,546 consults on April 25, 2014 in order to meet organizational goals”.
• Conclusion: The “batch closure” option was improperly used to close 1,546 Non-VA care consults at the request of the Director. The facility appeared to meet a “consult cleanup goal” in a timely manner. An analysis by the Office of Healthcare Inspections found that 648 patients whose consults were closed had not been seen by a provider. “The Director’s omission of key information he possessed regarding improper closures he directed demonstrated a lack of candor.”
Matasunaga VA Medical Center – Honolulu
• Allegations: Schedulers were instructed to (1) not schedule appointments more than 30 days in advance, and (2) not to input the patient’s desired date into the system; to offer an available appointment. These instructions were “contrary to VA policy at the time”.
• Conclusion: (1) patients were scheduled further than 30 days in advance; (2) management was not found to have instructed staff to disregard patient’s desired appointment dates. Situations were identified in which the patient accepted the next available appointment and that date was listed as the patient’s desired date in order to clear the system wait list.
VA Medical Center – Boise
• Allegation: Manager directed staff to cancel non-VA medical consultations that “had not been scheduled from 14 to 90 days”.
• Conclusion: Delays in ophthalmology and orthopedic care were primarily due to lack of medical providers. Patients were placed on the online wait list if a consult could not be scheduled. When funds became available, patients were referred into the community (non-VA coordinated care). A records review showed that consults were being closed per policy. When the accelerated care initiative (ACI) became effective in May 2014, additional funding was available for the consults; the number of open consults decreased significantly.
VA Medical Center – Danville, Illinois
• Allegation: An employee understood the next available appointment date is the same as the patient’s desired date. Another employee was instructed to make the desired date the same as the appointment date (next available appointment date is the same as the patient’s desired date).
• Conclusion: Schedulers received a weekly list of patients whose appointment wait times were greater than 14 or 30 days between the patient desired date and the appointment date. The system dates were changed to zero out wait times greater than 14 days. There is disagreement as to whether these actions were a result of poor training, or a management mandate. There was agreement that schedulers did not want to receive “nasty-grams” or be on a “black list”.
Psychotherapy Service, VA Medical Center – Des Moines
• Allegation: A “secret waiting list” in a spreadsheet that was destroyed prior to a 2014 VA audit.
• Conclusion: No evidence of a “secret” wait list found. The spreadsheet was in fact two spreadsheets created to track wait times for initial consults and later for the more specific treatment of psychotherapy.
1. VA Medical Centers – Leavenworth and Topeka
• Allegation: Improper cancelling of appointments by reporting appointments “cancelled by patient” instead of “cancelled by clinic”. This practice is being used for funding purposes – the facility is paid for provider time for patient cancellations, but not for provider cancellations.
• Conclusion: Allegation not substantiated. Funding is not based on types of appointment cancellations. There is no indication of an increase in appointment cancellations “over the past year”.[from the date of the OIG investigation]. The OIG report was given to the VA Office of Accountability Review on January 30, 2015.
2. VA Medical Center – Wichita, and the Community Based Outpatient Clinic (CBOC) – Salina
• Allegation: Deletion of an unauthorized Home Based Primary Care(HBPC) patient consult list after a “litigation hold memo” was sent to all VA employees in May 2014. Incorrect scheduler training was provided to CBOC-Salina staff.
• Conclusion: Two HBPC patient lists existed, and were stored on the internal SharePoint drive. All HBPC patients were in the online scheduling system; no “intentional and/or malicious falsification” of wait time data was found. One list was deleted by an employee who was unaware of the litigation hold memo. Allegation not substantiated of an employee “fraudulently” providing incorrect scheduling instructions to CBOC-Salina staff.
1. VA Medical Center (Community Based Outpatient Clinic) – Louisville
• Allegation: Improper appointment scheduling and falsification of audit data.
• Conclusion: Improper appointment scheduling was not substantiated. Audit data was changed on a tracking sheet – two supervisors disagreed on a matter of interpretation of the information. There was no effect on appointment scheduling, wait times, or desired dates.
2. VA Medical Center – Louisville
• Allegation: Wait time manipulation
• Conclusion: Allegation not substantiated. Appointments were scheduled correctly; schedulers were not found to be told to use anything other than the correct date by supervisors.
1. VA Medical Center – New Orleans/Baton Rouge
• Allegation: Schedulers at the VA Outpatient Clinic (OPC) New Orleans and the Community Based Outpatient Clinic (CBOC) Baton Rouge were manipulating patient appointment information to show more timely care.
• Conclusion: The patient’s desired dates were not used properly – the agreed-upon date or the next available date were used as the patient desired date, so accurate wait-times were not measured.
2. VA Medical Center – Shreveport
• Allegation: Secret list being used instead of the system wait list function. The investigation initially centered on the Mental Health Clinic, but was expanded into other departments.
• Conclusion: The Mental Health department used a spreadsheet to track approximately 2,700 patients who needed to be assigned to a provider. The list was not used for scheduling appointments or in lieu of the system wait list function. Schedulers outside the Mental Health Clinic were inputting appointments into the electronic system in a way that manipulated the wait time between the patient’s desired date and the appointment date.
VA Medical Center (Mental Health and Primary Care Services) – Northampton
• Allegation: Management was “gaming” access numbers in Mental Health through inaccurate desired dates and creating and cancelling appointments to make a desired date closer to the actual appointment date. The OIG investigation expanded to Primary Care based on new allegations regarding failure to use the online system wait list and lack of responsiveness to consults.
• Conclusion: Schedulers in the Mental Health clinic did not use the desired date correctly; evidence shows it was through a lack of understanding the system. The online system wait list could have been used, but wasn’t. Allegation of “gaming” the numbers to improve performance measures was not substantiated.
VA Medical Center (Healthcare for Homeless Veterans|HCHV Program) – Battle Creek
• Allegation: HCHV employees retroactively scheduled appointments for Veterans seen through the outreach program. This practice is considered unethical since the Veterans did not have scheduled appointments.
• Conclusion: HCHV Program employees did not demonstrate irregularities with their scheduling practices, which was “best practice” regarding social workers’ time. No Veterans waited for program services; Veterans who presented at the office for the walk-in program were provided services at that time. Social workers entered appointments and progress notes at the end of the day before leaving work. This allowed the data entry to be done accurately and only once.
1. Dental Service, VA Medical Center – Minneapolis
• Allegation: Wait time manipulation
• Conclusion: No indication data was manipulated to hide wait times.
2. Gastroenterology Clinic, VA Medical Center – Minneapolis
• Allegation: Former employees alleged they were instructed to alter appointment and scheduling records, cancel appointments without informing vets while marking vets had been informed. Employees had been previously removed from Federal service but said concerns were brought to management prior to removal.
• Conclusion: Investigation determined allegations made by complainants were not substantiated.
3. VA Medical Centers in Minneapolis and St. Cloud
• Allegation: Investigation based off news media report that the VA Medical Center had manipulated the date an appointment was canceled. Media reported VA computer system showed veteran called to cancel appointment on the date in question, but veteran had died prior to date indicated in VA system.
• Conclusion: Allegations not substantiated
VA Medical Center – Kansas City
• Allegation: Scheduling practices in the Cardiology Clinic were “erratic and potentially unreliable”. Some providers used “yellow sheets” to document return appointments; over 1,000 of these “yellow sheets” were found in a drawer and file cabinet in May 2014 and appears not to have been processed by the scheduler.
• Conclusion: The allegation was substantiated. “Yellow sheets” relating to follow up cardiology appointments were not processed; 37 of the 1,032 yellow appointment sheets were delayed appointments. A clinical review found no specific harm to patients.
1. VAMC – Manchester
• Allegation: The Pain Management Clinic had secret waiting lists and excessive wait time. In addition, unidentified administrators secretly installed cameras in office and patient areas and only worked 4 days a week. Review highlights:
- “Next available new patient appointments” were reported with wait times of 53 days, 67 days, and 84 days. Appointments for injections were reported to be booked 9 to 12 months out.
- In a records review, new patient wait times were substantiated as being almost 3 months; one patient experienced an average wait time of 7 to 8 months for injections or procedures.
- The wait time performance measure being tracked was for new patients; established patient wait times were not tracked. The 14-day wait time goal was removed from VA performance plans in June 2014.
- The Director explained the installed “devices” did not contain cameras or microphones. The purpose was “asset management, cath lab supply management, sterile processing workflow, and automated temperature monitoring.” Staff were notified of the installation and given an opportunity to attend an information session about the equipment.
- The allegation that the Pain Clinic had secret wait lists was unsubstantiated.
- The allegation of excessive wait times at the Pain Clinic was substantiated, but positive changes had been implemented prior to the investigation to alleviate the problem.
- The allegation regarding cameras being secretly installed in the Pain Clinic was unsubstantiated.
- The allegation that management worked only 4-day weeks was unsubstantiated.
- The allegation that the Pain Clinic might have manipulated wait time data that resulted in bonuses being paid to VAMC administrators was unsubstantiated.
2. VAMC – Manchester
• Allegation: Wait time manipulation; using “next available” as the “desired date”. New allegations of manipulation of the “create date” were received during the investigation. Of note: this case was initiated in part due to information provided by a congressional staff for the House Committee on Veterans’ Affairs.
- It was a “well-known and acceptable” practice to use the “next available” date as the “desired date”. The timeframe was unspecified, but could have gone through early 2012.
- Wait time manipulation was substantiated into 2011 or 2012 through standard practice and conversation with the patient by asking if the next available appointment date “would work”, then making it the desired date. There were instances found of pressure to improve wait times.
- In 2013, the Dermatology Clinic instructed a consult be resubmitted if the patient didn’t want to be seen within 14 days of that initial request.
- As recently as 2014, the Cardiology Clinic “discontinued consults so they could be resubmitted later within the 14-day time frame to meet the then-current 14-day access performance measure”.
- The electronic wait list was not consistently used until around September 2013.
No patient harm was identified.
1. VA Medical Center – Brooklyn
• Allegation: The Radiology Department manipulated patient scheduling and misrepresented wait times for medical scans.
• Conclusion: Allegation was not substantiated. The Radiology Department is following the 2008 policy regarding “no show” appointments. With some exceptions, the order for testing is cancelled for any “no-show”, and the physician’s office is notified. The test must be re-ordered [and rescheduled].
2. Community Based Outpatient Clinic – Rochester
• Allegation: A supervisor instructed a scheduler to verify with Veterans that they wanted to keep a currently scheduled appointment date. If confirmed, the scheduler should alter the desired date to reflect the date of the appointment. It would appear that the clinic was providing appointments on the desired date.
• Conclusion: An employee was told to contact nine patients via telephone. This task was reported to be completed, though the patients had not been called. The employee “lied about it to management and OIG special agents”. Changes to the desired dates by this employee were blamed on misunderstanding supervisory instruction.
3. Community Based Outpatient Clinic – Rochester
• Allegation: Former supervisor instructed Primary Care Clinic schedulers to make the desired date the same as the first available appointment or the actual scheduled appointment date. This created the perception of adequate staffing at the clinic due to zero-day wait times.
• Conclusion: The allegation was substantiated. Several schedulers were using the first available appointment date as the desired date, due to erroneous information provided by supervisors. Corrective action taken by management included additional guidance and oversight.
VA Medical Center — Portland
• Allegation: A fictitious patient “ZZ Test Patients” or (ZZTP) was being used to occupy appointment times for the Neurosurgery Clinic in the online scheduling system.
• Conclusion: Schedulers outside the Neurosurgery Clinic were allowed to schedule appointments, many times inappropriately. The issue was self-reported and corrected by allowing only Neurosurgery Clinic schedulers access to the clinic’s online appointment schedule. ZZTP appointments are acceptable in several specific circumstances, though not for use as a placeholder for future patient appointments. Corrective action was completed prior to the complaint to the VA OIG.
1. VA Community based Outpatient clinic – Horsham
• Allegation: Scheduling staff were instructed “by upper health administration management” to use the next available date as the desired date. They were given lists of scheduled appointments and were instructed to change the desired date to the next available date. They also reported being instructed to sign a letter indicating the desired date was not changed or manipulated, which they refused to do.
• Conclusion: The desired date creation violated VHA policy. Staff appears to have misunderstandings about correction of desired dates in an error report. Management did not make sure any corrections were done properly. No one could provide a letter that schedulers were reportedly instructed to sign.
2. VA Medical Center – Philadelphia
• Allegations: (1) a spreadsheet was being used to track patients who required consults for non-VA care at the Pennsylvania Ear Institute (PEI); (2) appointments were not properly made during a long absence of a clerk; (3) the Eye Clinic was manipulating consults – other issues discovered by investigators – (4) Physical Medicine and Rehabilitation consults (PMR) were being cancelled and rebooked in the online scheduling system for unknown reasons.
• Conclusions: (1) a spreadsheet was used to track patients referred to the PEI – approximately 900 patients were on the list; (2) no wrongdoing was found to be related to scheduling responsibilities of the clerk who was on a long absence; (3) the Eye Clinic consult manipulation was due to diagnostic equipment’s limited ability to interface with the online scheduling system and (4) there was no wrongdoing with PMR consult cancellation – clinic review determined that patients had received care and the consults were “old” and had been left open.
VA Medical Center – San Juan
• Allegation: “Gaming” wait lists in primary care and specialty clinics as directed by management.
• Conclusions: Wait times were manipulated by using the next available appointment as the desired date. There was no evidence that senior management directed the manipulation, but first level supervisory pressure was evident. The investigation found no evidence of:
- Inappropriate destruction of records related to appointment scheduling
- No senior management bonuses or appraisals were solely tied to patient access levels
1. VA Community Based Outpatient Clinic in Chattanooga
• Allegation: 2 VA employees alleged took home personnel records in order to conceal them from a Veterans Health Administration inspection team in May 2014.
• Conclusion: Allegations that any records were taken home by VA employees were not substantiated.
2. VA Community Based Outpatient Clinic in Chattanooga
• Allegation: Schedulers were being directed to change patient desired dates to actual appointment dates, even if the provider wanted the patients to be seen sooner. If they did not comply, there were placed on a “bad boy” list.
• Conclusion: Not substantiated: (1) a “bad boy” list; (2) schedulers were “written up” for entering correct desired date; (3) manipulation of wait times intended to “game the system.
• Discovered: A need for standardized training for schedulers.
• Substantiated: Possibility of schedule manipulation prior to June 2014, when scheduler training began.
3. VA Medical Center – Memphis
• Allegations: (1) senior management employees changed consultation times to conceal delayed treatment for pulmonary function exams; and (2) missed required deadlines were covered up by “bogus scheduling” and “secret lists”.
• Conclusion: Allegations were not substantiated – no bogus scheduling, no secret list, no consultation changes to hide treatment delays for pulmonary function exams.
• Other discoveries: The next available date was used as the desired date in 2011-2012. A list of patients needing mammograms was being used by the Business Office outside the required process – this issue was resolved prior to this OIG investigation.
4. VA Medical Center – Murfreesboro
• Allegation: Four schedulers concerned they were inappropriately scheduling appointments by following supervisory direction. The desired date was manipulated to show the actual appointment date.
• Conclusion: Appointments were not scheduled properly, but there was no evidence of manipulation to “game the system”. A corrective training program was implemented to ensure policy compliance.
5. VA Medical Center – Mountain Home
• Allegation: Non-VA care coordination consult status was changed without clinical review or eligibility verification of the patient. Consults were also marked “complete” after the patient’s first treatment even though follow-up care was required.
• Conclusion: In a review conducted in 2014, the allegations were substantiated. Staff followed instructions from the Service Chief. The instructions and practice were inconsistent with VA policy. Fortunately, patient care was found to be timely in 97 percent of the reviewed cases. The Service Chief retired unexpectedly in January 2015.
1A. Endoscopy Clinic Amarillo – VA Medical Center Texas
1B. Outpatient Clinic Lubbock – VA Medical Center Texas
• Allegation: Congressman Mac Thornberry expressed concerns over “negligent employee performance”:
- Endoscopy Clinic Amarillo used a paper wait list for a “huge backlog”; when a slot opened up, the information was taken from the paper wait list and input into the online scheduling system. Patient may have been on the paper wait list for more than 150 days.
- Endoscopy Clinic Amarillo changed or shredded paper lists and other documents
- Outpatient Clinic (OPC) Lubbock changed or shredded documents relating to paper wait time lists. Additional concerns included staff not using the online system due to lack of training and shortage of nurses and providers.
• Conclusions: Allegations of wrongdoing regarding manipulation of patient wait times or scheduling, or destruction of paper lists at the Endoscopy Clinic Amarillo was not substantiated. At the OPC Lubbock, one employee reported the next available appointment date was used as the patient’s desired date. Interviews of four other staff members did not support the allegations.
2. Central and South Texas Veterans Affairs Health Care Systems – San Antonio and Austin facilities
• Allegation: Patient desired dates were made the same date as the first available date to avoid the online waiting list. Additional allegations required the investigators to expand the investigation and interviews of seven facilities were interviewed.
• Conclusion: The allegations were substantiated, and found to be systemic. Schedulers were using the first available date as the patient’s desired date. Many employees credited the improper scheduling to inadequate training, lack of supervision and lack of non-centralized scheduling.
3. VA Medical Center – Dallas
• Allegation: Congresswoman Eddie Bernice Johnson’s office was only one of several sources of allegations of “conduct that resulted in inaccurate wait times for patient appointments and possible destruction of records to conceal such activities”. Multiple clinics and departments were reported to be involved in these alleged practices. An alleged altercation was reported when one employee refused to destroy some black binders.
• Conclusion: Allegations of destroyed records, intentional wait time manipulation or altercation over binder destruction were not substantiated. It was determined that schedulers received inadequate training that did not match current VHA Directives at the time, using the next available date as the desired date.
4. VA Health Care System – El Paso
Note: The VA OIG partnered with the FBI/El Paso by request; Congressman Robert Francis (Beto) O’Rourke wanted the FBI to investigate patient wait time manipulation in El Paso.
• Allegation: Patient wait time manipulation
• Conclusion: Policy violations were substantiated. Schedulers violated VHA Directives by incorrectly capturing (or not capturing) veterans’ desired dates when scheduling appointments.
• Of Interest:
- A former supervisory scheduler was aware the next available date was used as the desired date by some schedulers, and felt it was “either a learned practice because it was easier or was done out of ignorance”.
- Some schedulers were not aware the patient’s desired appointment date was supposed to be captured in the system.
- The former EL Paso Director, newly appointed as the VISN 20 Deputy Network Director, opined that the scheduling clerks misunderstood the process. He also stated that “Wait time was a factor on his performance plan prior to 2012, as it was built into access measures. Access was so bad in El Paso that he negotiated the number that the VISN wanted him to reach into something a little more attainable.”
5. Outpatient Clinic – Fort Worth
• Allegation: Staff was previously instructed to use the next available date as the desired date, but had received new instruction to use the “find next available appointment” function. “One employee reported being threatened with a reprimand for noncompliance due to not using this function.” One staff member stated in an interview that “the clinics were booked so far back, and the patients had to wait so long, it was pointless to ask for a desired date from the patient.”
• Conclusion: Employees violated VHA Directive by using the next available date as the patient’s desired date when scheduling appointments. “No evidence was obtained to suggest these employees intentionally manipulated patient times…”
6. Outpatient Clinic – Harlingen
• Allegation: A management official threatened the employment of an employee for not falsifying VA patient scheduling numbers. The OIG also proactively investigated the issue of manipulated appointment wait times. One supervisor reported in an interview that clinic standards were attained 99.9 percent of the time, though patients were being scheduled on a 120-day grid. This was during the time of the 14-day wait time standard.
• Conclusion: Allegation of the management official threatening employment was not corroborated. No evidence was found that management “directly instructed” staff to manipulate appointment wait times; however, there was evidence that staff felt pressure from the management official which led them to manipulate the online scheduling system information to keep scheduling numbers within standard. Evidence of inappropriate training in the past was also found.
7. VA Medical Center – Houston
• Allegation: The OIG Hotline was contacted by a complainant that “had information” regarding a “hidden list” of patient names; and that some Veterans had been waiting on primary care appointments since 2006. Investigators were requested to speak with personnel regarding “GI consults fraud”.
• Conclusion: Schedulers in multiple clinics were trained to base the patient’s desired date with the next available date, zeroing out the reported wait time. The original allegations of patients waiting for years for a primary care appointment and improper discontinuation of GI consults were not substantiated. While the New Enrollee Appointment Request (NEAR) list showed nine Veterans who appeared to have waited for more than 100 days from the appointment request date documented on the VA Form 10-10EZ application, this was found to be a result of the online scheduling system programming. The program showed the wait time started when the Veteran first applied for health benefits (2009), though he was found ineligible at that time. The Veteran reapplied in 2014 and was approved.
7A. VA Medical Center – Houston and associated outpatient clinics
• Allegation: Leadership instructed staff at the Michael E. DeBakey VA Medical Center and associated Community Based Outpatient Clinics (CBOC’s) to incorrectly record appointment cancellations by the clinic as “patient cancellations”.
Why this matters: Appointment wait times are counted from the number of days from clinically indicated appointment date or the preferred appointment date to the actual appointment. Clinic appointment cancellations and patient cancellations are counted differently.
For an appointment canceled by the clinic, the “wait time clock” doesn’t stop. For an appointment canceled by the patient, the clock restarts. One example: because a patient cancellation was entered into the system, the appointment wait time was recorded as 3 days. However, the wait time clock doesn’t stop on clinic cancellations, so in reality, veterans waited an average of 81 days for an appointment.
In the investigation, of the 373 appointments reviewed that were recorded as patient cancellations, 223 were incorrectly recorded. Those 223 appointments were canceled by the clinic. Thirty-eight of fifty appointments that understated the veteran wait times showed a zero-day wait time.
• Conclusion: Two previous scheduling supervisors and a current director of two CBOCs instructed staff to record clinic cancellations incorrectly as canceled by the patient. This occurred despite a system-wide review in May and June 2014 and subsequent changes to scheduling practices.
Management comments on this investigation and report:
- Software is complex to navigate and limited due to outdated technology
- Inexperienced, entry-level employees
- Nearly a 25 percent scheduling staff turnover annually
- The investigation was done during “an isolated peak period”, which does not reflect “Houston’s baseline data”
- No administrative action was taken because “The CBOC Director was using their best judgement to reflect the scheduling transaction, and did not engage in malicious or ethically unjustifiable conduct or deliberately manipulate scheduling data.”
8. VA Medical Center – San Antonio
• Allegation: Two employees at the Frank Tejeda VA Outpatient Clinic in San Antonio were reported to have provided patient information to the media, including a list of 161 patient names, the last 4 digits of their social security number and telephone numbers. The ABC affiliate, News 4 WOAI (News4) ran a story, which is when the privacy officer learned of the release of patient information. The patients were subsequently notified of the disclosure.
• Conclusion: The allegations against the two specific employees were not substantiated. The information was accessible by numerous VA employees.
9. VA Medical Center – San Antonio
• Allegation: Allegation that employees assigned to the home-based primary care program were not allowed to use the online waiting list. Additional information provided to the investigators included “an associate chief of Nursing and an associate chief of staff told the employee to “get rid of” the EWL”. [Electronic Waiting List] The employee began to use an Excel spreadsheet in lieu of the EWL for new patients. The spreadsheet was reportedly discussed and displayed at weekly meetings every Tuesday morning. No documentation was provided to support these allegations. Spreadsheets were used to track geographic workload, though not to track patients in lieu of the online wait list.
• Conclusion: The allegation was not substantiated.
10. VA Medical Center – Audie L. Murphy VA Hospital – San Antonio
• Allegation: Employees assigned to the sleep clinic were made to schedule appointments in order to make the “desired data report” reflect a shorter wait time.
• Conclusion: Between 2011 and 2013, the schedulers in the Sleep Medicine section zeroed outpatient wait times by basing the patient’s desired appointment date on clinic availability. Scheduling “errors” were resolved by canceling and rescheduling appointments with a different desired date than what the patient had originally selected. The patient was not notified, according to one interviewee, because the actual appointment date did not change.
11. VA Medical Center – Temple
• Allegation: A former employee witnessed radiology consult manipulation in order to show imaging procedures were completed within 30 days of the desired date listed on the original order. One urgent order for an ultrasound to be completed within 1 week took 2 or 3 weeks, directly affecting one patient. An email exchange regarding appointment manipulation was published by The Daily Beast that included an email sent by the Chief Technologist, which he acknowledged sending. The email advised physicians of the next available dates for annual screening mammograms for when the physicians were selecting a desired date of a procedure. This email practice was discontinued after receiving an email from the Chief of Staff stating “You cannot do this!!!!”
• Conclusion: Allegation was not substantiated, and “the medical records of the patient identified by the OIG Hotline complainant [were reviewed] and determined that, given the patient’s clinical history, all imaging procedures were performed within a reasonable period of time.”
12. VA Medical Center – Temple
• Allegation: The FBI received an allegation against the Prosthetics and Sensory Aids Service (PSAS) and contacted the VA OIG. The allegation included:
- Purchasing agents were not qualified to manage artificial limb consults
- Purchasing agents were closing consults under pressure due to consult performance management standards
- The Assistant Chief determined that the purchasing agents did not need to notify the Veteran by letter before closing a consult due to pressure to meet consult performance management standards
- Closing consults without notifying the Veteran by letter violates the Business Practice Guidelines for Prosthetics Consult Management
An excel file with 677 Orthotics & Prosthetics Laboratory closed consults for May and June 2014 were provided to investigators in support of the allegations.
• Conclusion: The inappropriate actions were reported to have since ceased, and as of September 17 2014, PSAS was appropriately managing consults in accordance with guidelines.
1. VA Medical Center – American Lake
• Allegation: Schedulers were instructed by a Supervisor to make up Veteran contact dates to “artificially lower the number of outstanding fee-based referrals. A former employee also alleged mistreatment by the supervisor. The supervisor was also alleged to be “borderline abusive” to other employees.
• Conclusion: The manager of the Non-VA Care Program instructed schedulers to re-create Veteran contact dates in order to capture contacts and attempted contacts that had not been properly entered in the internal Microsoft Access scheduling database system. A medical records review of a representative sample determined that Veterans had received their non-VA appointment, and documentation was proper except for one case. The lone case was missing scanned documentation of the visit. Allegation of abuse was not substantiated.
2. Community Based Outpatient Clinic (CBOC) – Chehalis
• Allegation: A former manager had pressured a scheduler to change patient desired dates several times. Of note: this CBOC is managed by a private VA contractor.
• Conclusion: Changes to patient desired dates in the VA’s online scheduling system had been made less than 10 times in the last 3 years. Some of the initial data had been input incorrectly; the VA Contracting Officer’s Technical Representative (COTR) emailed the CBOC manager to fix the data input errors.
3. VA Medical Center – Spokane
• Allegation: A former employee alleged “unauthorized methods to manually track Behavioral Health Services patient appointments. “ This alleged practice was due to low staffing and high provider turnover.
• Conclusion: Manually printed appointment slips were used when transitioning patients from one medical provider to another. The online scheduling system did not differentiate active from former patients of a clinician. The online system did not allow a future appointment to be scheduled when a provider was not assigned. A software update in late 2014 addressed this issue.
VA Medical Center – Huntington
• Allegation: A contract psychiatrist alleged Veterans committed suicide because they did not receive timely follow-up appointments. She asked follow-up appointments within 10 – 12 days, and discovered the appointments were scheduled several months out. “At least two of her patients committed suicide while waiting for follow up appointments.” The complaint by the contract psychiatrist was made in a national television interview with Fox News.
• Conclusion: The investigation did not substantiate the allegation. The contract psychiatrist did not submit any supporting documentation even after receiving a VA OIG subpoena. There is no indication that the psychiatrist requested follow up appointments within 10 – 12 days. None of the patients of this psychiatrist experienced delays as reported; no patients committed suicide while waiting for follow up appointments.
Read the entire group of Investigative Administrative Summaries released at the VA OIG website.