IG Report Examines Impact of Care Delays at Phoenix VA

WASHINGTON—A VA IG report has found that access barriers adversely affected the quality of care at the Phoenix VA Healthcare System, but could not “conclusively assert” that patients died as a result of waiting for care.

The IG conducted a review of 3,409 veteran patients at the Phoenix VA, including 40 patients who died while on the waitlist that it identified from April 2013 through April 2014.The VA IG report explained that investigators identified 28 instances of “clinically significant delays in care associated with access to care or patient scheduling” and of these 28 patients, 6 were deceased. In addition, the report noted that it identified “17 care deficiencies that were unrelated to access or scheduling” and that of these 17 patients, 14 patients had died.

“Our analysis found that the majority of the veteran patients we reviewed were on official or unofficial wait lists and experienced delays accessing primary care—in some cases, pressing clinical issues required specialty care, which some patients were already receiving through VA or non-VA providers. For example, a patient may have been seeing a VA cardiologist, but he was on the wait list to see a primary care provider at the time of his death. While the case reviews in this report document poor quality of care, we are unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans,” Acting IG Richard Griffin wrote in the report.

Griffin wrote that the 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.”

The release of the VA IG report this week follows a preliminary VA IG report released in May that found veterans waiting for a primary care appointment, but were not included on the Phoenix VA Health Care System’s electronic wait list as they should have been.

In a written statement on the new report, VA Secretary Robert A. McDonald said that they “sincerely apologize to all veterans who experienced unacceptable delays in receiving care.”

“We will continue to listen to veterans, our VA employees, and Veterans Service Organizations to improve access to quality care in Phoenix and across the country and we will work hard to rebuild trust with veterans and the American public,” he said.

Meanwhile, House Committee on Veterans’ Affairs Chairman Rep. Jeff Miller (R-FL) said in a written statement that the report “paints a very disturbing picture.”

“Delays in care that VA officials tried to hide caused harm to veterans. Even though the IG says it can’t conclusively assert that deaths were caused by VA negligence, the report does link 20 deaths to substandard care,” he wrote.




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