VA OIG report and the Legion response

 
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VA OIG report and the Legion response

Unless you live somewhere without TV or internet, you are no doubt tracking that the VA Office of Inspector General issued their long-awaited report yesterday titled:  Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System.  If you want to read the full 143 page report, click the title of it in the preceding sentence and it will take you to it, but I did want to point out some of the highlights from their summary.

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.

That paragraph could have been easier to nutshell:  everything that could go wrong *did* go wrong.

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.

There's really no telling if they even identified everything.  I'm not insinuating the VA OIG didn't look hard, I am sure they did, but how many vets just gave up and went away?  I don't think we'll ever know.

This conclusion paragraph here is just brutal:

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.

Pretty hard hitting right there.

At initial glance though the VA saying that they found no deaths directly attributable is difficult to digest, and that is something National Commander Dellinger noted in a statement just released:

“VA’s internal investigation of patient deaths in Phoenix may not have proven conclusively those deaths occurred through negligence, but VA needs to do more than investigate itself on this matter. The American Legion wants a non-VA authority to determine whether negligence was involved in the deaths of those veterans. In fact, we want an independent authority to investigate all the VA facilities where patients died while waiting for medical care.
 
“Secretary McDonald said at our national convention yesterday that this is a critical time for VA, and we agree. This is a time when fundamental changes can be made in a system wracked by scandal. I met with the Secretary and assured him that The American Legion intends to stand alongside VA to make sure those changes take place.”
 
The VA doing the investigating does strike me a bit like the uncle of an accused murderer doing the autopsy on the deceased.  There may be nothing to it, but can anyone truly accept the findings? 
 
Hopefully Secretary McDonald moves on this quickly.  I think we're cautiously optimistic now, but bold action is certainly needed.
Posted in the burner | 7 comments
 
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Has no one yet noticed that as of March 2014, a Veteran's eligibility for Healthcare at a VA Hospital is now determined by the IRS and SS Administration?
This is per letter to me from VA in April 2014.
Veteran, Korean Conflict.

AND WHO IN THE HELL DETERMINES THE HEALTHCARE ELIGIBILITY OF THESE SO CALLED GOVERNMENT EMPLOYEE'S??!! WHO DETERMINES IT FOR THE IRS, SS ADMINISTRATION REF'S? 40=+ BY COUNT? WERE MURDERED BY THESE CLERKS, SUPERVISORS, MANAGERS ETC., YA THEY KNEW WHAT WAS GOING ON!! NO ONE HAD THE BALLS TO BLOW THE WHISTLE . SOMEBODY NEEDS TO GO TO PRISON FOR MANY , MANY YEARS , IF NOT LIFE. WHO IN GOD'S NAME IS WATCHING THE HEN HOUSE? WHY OF COURSE IT'S THE FOX'S !! MOST OF MY EXPERIENCE'S WITH THE VA , IS NOT WITH THE MEDICAL TEAM, BUT THESE BIG ASSED CLERKS WITH AN ATTITUDE, THEY ARE SO BORED OR THINK WE VETERAN'S ARE STUPID, AND HAVE ALL THE TIME IN THE WORLD FOR THEM TO GET OFF THE PHONE, OR GET DONE B.S.ing WITH EACH OTHER. I AM RETIRED, COMBAT MEDIC, AND HAVE TO PAY THE VA FOR MY CARE. BUT SOMEONE NEEDS TO PAY FOR KILLING THESE VET'S, AND HURTING THEIR FAMILY'S. I GUESS THE VA HAS FUN INVESTIGATION THEMSELVES HUH!! .

AND I MEAN IT!!

LOOK OUT FOR BIG BROTHER !!

DITO TO IT ALL

Not that it matters with regard to how the deceased vets were treated, which is damnable. Just a little point that seems to have gotten mixed up in this article.

The VA Office of Inspector General is not part of the VA. It is a separate independent agency. The Inspector General is appointed by the President with the consent of Congress. The IG has direct access to Congress and can by-pass the agency secretary any time it is warranted. So, it isn't accurate to say that the VA was investigating itself.

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News from the World of Military and Veterans Issues. Iraq and A-Stan in parenthesis reflects that the author is currently deployed to that theater.