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.”