Administrative Summary of Investigation

ADMINISTRATIVE SUMMARY OF INVESTIGATION
BY THE VA OFFICE OF INSPECTOR GENERAL
IN RESPONSE TO ALLEGATIONS
REGARDING PATIENT WAIT TIMES
VA Medical Center in Tucson, Arizona

November 8, 2016
1. Summary of Why the Investigation Was Initiated

This investigation was initiated following the receipt of information from the Department of
Veterans Affairs (VA) Office of Inspector General (OIG) Hotline. The complainant, a
former Southern Arizona VA Health Care System (SAVAHCS) employee, alleged that she
became aware of a number of game playing techniques by SAVAHCS to improve the
appearance of appointment access. The complainant alleged: (a) that in 2012, more than
400 Orthopedic appointment requests were on individual pieces of paper instead of being
placed on the Electronic Wait List (EWL); (b) that, between 2008 and 2009, approximately
600 Urology appointments were on individual pieces of paper instead of the EWL; (c) that
Palliative Care consults were placed in Veterans Health Information Systems and
Technology Architecture (VistA) with the statements, This consult placed for performance
measures only. Do not take action on this consult; and (d) that consults were discontinued
with the comments, Consult being discontinued because 30-day metric could not be met.
Please resubmit consult. The complainant further alleged that she had reported these
concerns to SAVAHCS management, but senior leader 1 dismissed her findings. The
complainant also alleged that she reported the matters in 2010 to two senior leaders, who
substantiated her complaints. The complainant added that she wanted to make the OIG
aware of the ways SAVAHCS gamed the system and was concerned patient care may have
been delayed and patient harm may have occurred.
In May 2014, an anonymous source also contacted the OIG Hotline and alleged that the
Veterans Affairs Medical Center (VAMC) in Tucson had been under investigation 6 years
ago for instructing scheduling clerks to falsify veteran desired dates in order to meet
requirements. The anonymous source alleged that schedulers were now receiving training,
but managers who previously told them to falsify desired dates were denying they instructed
scheduling clerks to falsify the appointment dates. The anonymous source stated that
managers were once again throwing the clerks under the bus as if they came up with this
idea [to falsify the desired dates] themselves. The anonymous source further stated that
senior leader 1 created a culture where he doesnt communicate with most of the hospital
staff, remains very isolated, rarely if ever leaves his office during weekdays and has created a
culture of intimidation where employees are deathly afraid to bring him bad news or tell him
the truth.
In July 2014, VA OIG received a copy of an anonymous complaint routed from U.S.
Representative Ron Barbers office. The anonymous complainant stated that he/she was an
employee at the Tucson VA and that the clinical nurse manager (CNM) praised nurses who
entered a patients appointment dates as being 14 days or less. The anonymous complainant
also stated that the CNM instructed him/her how to misrepresent the patients desired date to
achieve the 14-day metric.
VA OIG Administrative Summary 14-02890-353
Administrative Summary of Investigation by VA OIG in Response to Allegations

Regarding Patient Wait Times at the VAMC in Tucson, AZ
2. Description of the Conduct of the Investigation

Interviews Conducted: VA OIG interviewed the complainant and 23 VA employees
from both Veterans Integrated Service Network (VISN) 18 and VAMC Tucson.
Records Reviewed: VA OIG reviewed VA emails, a report of contact, a report regarding
the 2010 VISN Unannounced Site Visit, the facilitys response to the unannounced site
visit, VA memos, training materials, pending consults, Electrophysiology documentation,
monthly appointment and consult audit reports, as well as a Veterans Health
Administration (VHA) issue brief.
3. Summary of the Evidence Obtained From the Investigation
Complainant Interview
Interviews Conducted
The complainant stated that she believed the issues she referred to the VA OIG were
criminal and added that the SAVAHCS staff were directed by [senior leader 1] and his
underlings to do exactly what they did and game the system. The complainant stated
that, in February 2010, she went to multiple SAVAHCS employees, including two senior
leaders, in an effort to address her concerns of SAVAHCS employees gaming the system.
The complainant stated that in her discussion with a specific senior leader about gaming,
it was her impression that he wanted her to lie to the VA OIG and that he disregarded the
information she had. After that meeting, she went to VISN management.
The complainant explained that, at about the time of her reporting to VISN management
that gaming activities were taking place, SAVAHCS senior leader 2 and senior
leader 3 had asked her if she had called the VISN. She had reportedly replied that in fact
she had called the VISN. The complainant further explained that senior leader 2 had told
her that she should have come back to me, and that, in response to her affirmative
statement, senior leader 3 had lit into me. The complainant said she believed senior
leader 1 and others retaliated against her for bringing the issues to VISN managements
attention and that she planned to file a retaliation complaint with the Office of Special
Counsel.
2010 Unannounced Site Visit
Records Reviewed
We reviewed a VISN report, dated March 1, 2010, in which an employee of the
SAVAHCS reported her concerns about gaming activities to VISN senior leader 1. The
report stated that the employee was concerned about appointment scheduling and
consults. The report further stated that the employee wanted someone to review facility
data to determine if any adverse patient events had occurred as a result of these practices.
The report indicated that VISN senior official 1 and senior official 2 reviewed the issues
at SAVAHCS on February 25, 2010, calling it the 2010 VISN Unannounced Site Visit.
The report stated that VISN senior official 1 and senior official 2 concluded, Some

SAVAHCS staff members were practicing in a way that placed a higher priority on the
achievement of performance measures versus the achievement of high quality care for
patients. The report also stated, Additionally, findings confirm that scheduling and
consult practices did misrepresent facility performance on some performance measures.
The report stated that, as a result of the VISN review, SAVAHCS leadership was
required to perform a number of tasks, including a full review of all canceled consults
entered on or after April 1, 2008, to the present (March 2010). The report specifically
identified the following:
o A practice existed whereby Cardiology staff members, for example, Fellows,
canceled pre-surgery Cardiology consults and notated that only an EKG
[electrocardiogram] was performed and as such was not a risk stratified assessment
for surgical purposes.
o A practice existed whereby a Dermatologist responded to consults without actually
seeing the patients in question. Occasionally the Dermatologist recommended topical
chemotherapeutic agents for patients based only on a description of a lesion and not
based on an actual face-to-face evaluation of the patient.
o A practice existed whereby Womens Clinic staff members told consulting staff that
Pap smear consults were not needed; that a telephone call requesting a consult was all
that is needed. Patients had been lost to follow-up as a result of canceled consults.
o A practice existed whereby administrative clerks routinely, and presumably without
clinical oversight, canceled consults for patients if the patients had been seen by the
consulted service within the last 24 months.
o Evidence existed that consults were being canceled and then rescheduled after the
30-day mark had been reached in order to prevent the consults from showing up as
not completed within the 30-day goal.
o Evidence existed indicating that administrative clerks were determining desired dates
for next appointments rather than patients and providers.
o Service agreements between Primary Care and Specialty Care Services did not exist
in all areas.
o The SAVAHCS leadership recently learned that Palliative Care consults were being
placed and the consulting service was documenting that, in essence, the consult was
not a true consult, but instead was a consult written to meet a performance measure.
Leadership took immediate action ordering that this practice cease and desist.
o No direct harm to a patient was identified in this initial review.
The facility provided a copy of a memo dated October 1, 2010, that addressed senior
leader 1s Final Response to Staff Member Allegation and Subsequent VISN
Unannounced Site Visit. The memo and attachment stated that a review of more than
21,000 consults canceled from April 1, 2008, to March 1, 2010, identified one potential

adverse outcome involving a delay in diagnosis and treatment that resulted in a patients
death from advanced lung cancer. The memo stated that because of the VISN review,
senior leader 1 implemented the following:
o One hundred percent retraining of the scheduling clerks and supervisors to ensure
compliance with VHA directives on scheduling and consult practices;
o Inappropriate handling of consults addressed through development of procedures,
process improvements, and training;
o Adverse events discovered disclosed to patients; and
o Consult monitoring established to ensure appropriate practices were sustained
Orthopedics
The complainant stated that SAVAHCS participated in a national collaboration effort
regarding Orthopedics services, and that during this initiative, she had learned that
schedulers were scheduling patients desired date incorrectly. She explained that she told
service chief 2 that he needed to retrain the schedulers. The complainant said that is
when she learned that Orthopedics had a backlog of more than 400 cases. The
complainant added that when she tried to identify where the patients were in the process,
she discovered that they werent on a wait list of any sort. They were on little pieces of
paper on the techs desk, who is responsible for trying to get them scheduled according to
the orthopedists prioritization.
VISN senior official 1 stated that she was aware of the 400 Orthopedic appointments on
individual pieces of paper that someone found in a cast technicians desk. She further
stated that she believed the scheduler simply printed the consult and placed the paper in a
drawer. She added, Especially if its a cast tech, because sometimes theyll send a
consult to prosthetics for the casting, and thats how they actually order the cast to be
done. So if that persons getting them on the printer and just putting them in a drawer,
ideally they wouldnt do that.
Service chief 3 stated that Orthopedics had 400 handwritten consults on paper that were
not in the electronic scheduling system. He added that he was aware of the backlog for
some time and knew that people were working with paper. He also said that now they
scan paper into the electronic charts and then destroy the paper copy.
Medical staff assistant (MSA) 1 stated that she had worked as an advanced MSA at
VAMC Tucson for approximately 10 years. MSA1 stated that after someone determined
that 400 Orthopedic cases were not on a wait list, this might have started the surgical wait
list. MSA1 stated that about 2 years prior to the interview, Orthopedics was very, very
far behind. They created an Excel work list to work from and it was only to make sure
that the patient still wanted the surgery or they had the surgery and for some reason the
request was still there. I did help on that for a little bit.

A manager for a specialty service stated that he was aware the Orthopedics Department
had several hundred scheduling requests that piled up about a year prior to the interview.
He said he believed it was very difficult to manage patients by papers. He added that he
and others decided to start placing the patients into a Microsoft Excel spreadsheet so the
department could track its patients. He said he was not aware of any patient harm due to
delays in care. He stated that Orthopedics now used the EWL, but they also used a
Microsoft Outlook calendar for scheduling.
Service chief 2 stated that he recalled 400 Orthopedic appointment requests on individual
pieces of paper placed in a desk; however, he could not recall any details.
Senior leader 3 stated that she did not have any knowledge of 400 Orthopedic requests on
individual pieces of paper that someone placed in a desk.
Service chief 1 said she was not aware of 400 Orthopedic appointment requests on
individual pieces of paper found in a desk.
Based on the aforementioned interviews, we established a timeline and attempted to
interview a former VAMC employee in connection with the 400 Orthopedic appointment
requests found in the desk. When approached by OIG, the former VAMC employee
declined to be interviewed.
Records Reviewed
We reviewed an email provided by the complainant regarding Orthopedic collaborative
meeting minutes from August 17, 2012. One email discussion item stated:
Wait List for Patients: Since these patients are backlogged for procedures and
not visits, [name removed] stated the Electronic Wait List does not need to be
used. Rather, there is a backlog package within the surgery scheduling package
that will be used. This package is managed jointly between SCL [Surgical Care
Line] and BSL [Business Service Line].
Urology
The complainant stated that, in the late summer of 2012, the Urology clinic found shoved
into a drawer more than 600 paper Urology consults that were not scheduled. The
complainant said the urologists used paper forms to identify patients who needed
follow-up appointments as well as their diagnoses.
VISN senior official 1 stated she believed the 600 Urology consults that were stuffed into
a drawer might have been printouts of patients who were already scheduled.
Service chief 3 stated that Urology had been chronically understaffed for a long time and
SAVAHCS had difficulty recruiting urologists. He said they had some problems seeing

patients within the 14-day requirement. He further stated that at one point Urology had
around 600 handwritten consults on paper that were not in the scheduling system. He
stated that he was aware of the backlog for some time and knew that people were
working with paper and even now its an issue because we still have some bit of paper
around, but we try to be more electronic. He said he received complaints about delays
for surgeries, but that most patients were seen within a month.
MSA 1 stated the Urology Department at VAMC Tucson was currently very
understaffed. She further stated that another employee had placed 600 Urology
appointments into a drawer but did not recall any names. She added that she addressed
the stack of appointments four times by scheduling an appointment for each patient. She
stated that at one point employees had to come in on Saturdays to do flow studies for
patients. She said she remembered a former VAMC Tucson employee, whose name she
did not recall, who was scheduling patients by service-connected disability and not by
diagnosis. For example, she learned that the former employee would schedule a veteran
who only had urinary issues, but was service-connected, before a veteran who had
bladder cancer, but was not service-connected. She stated that the service chief was very
upset when he learned about this. She added that another former VA employee, whose
name she did not recall, contributed to the same problem, because thats how she was
being trained. She stated that three former employees were involved with the Urology
backlog and this occurred about 5 or 6 years before the June 2014 interview.
Licensed Practical Nurse (LPN) 1 stated that she once had more than 400 unscheduled
Urology appointments; a fact she brought to the attention of management. She said that,
at that time, Urology did not have enough staff; there were no appointments available;
and management did not allow non-VA care as an option.
A manager of a specialty service stated that he was aware of Urology having
600 scheduling requests pile up 4 or 5 years ago (prior to 2014). He added that he
continued to have an ongoing concern about urologists using paperwork to schedule
patients.
A Business Service Line (BSL) employee stated that a scheduling backlog of a couple
hundred patients in Urology was discovered after an MSA resigned. The BSL employee
said the MSA placed the names of veterans who needed consults on paper scheduling
sheets. She stated that when a patient checked into the clinic, the clinic created the paper
scheduling sheets. She added that she reported this to her supervisor. She said they
worked on the backlog and got the patients into the system as quickly as possible. She
stated that MSA1 helped in scheduling the patients. She said she did not recall any
patient harm due to the MSA not properly scheduling patients. She stated that she was
unaware of any gaming of the metrics at SAVAHCS.
Service chief 2 said he recalled Urology appointments being in a drawer of a BSL clerk,
but was not sure there were 600 appointments. He stated that an MSA resigned and a
new MSA was moved in and discovered the Urology orders that needed to be scheduled.
He said the MSA who left VA was supposed to schedule the Urology appointments but
did not.

Service chief 1 stated that she was unaware of the existence of 600 Urology appointments
being stuffed into a drawer by a BSL clerk at SAVAHCS.
Senior leader 3 said she did not know anything about 600 unscheduled Urology
appointments found stuffed into a BSL clerks drawer.
Records Reviewed
We reviewed an email provided by a complainant. The email was from service chief 3,
who wrote, It seems that BSL had been taking the paper request and squirreling the
paperwork in various spots. We investigated and there were more than 600 actionable
requests for services unattended.
Palliative Care
A complainant stated that, in February 2010, she learned about Palliative Care consults
that employees entered into VistA with the explanation that they were for performance
measures only and that no one should take action. The complainant said she identified
17 patient consults with these notes and met with a senior leader and told him it was
criminal at best. She said senior leader 2 appeared shocked that this was occurring and
issued a cease and desist order.
VISN senior official 1 said she recalled the Palliative Care consult issue, adding that
Somebody was putting in consults, because they thought it was the right thing to do.
They said well, were supposed to have consults on all these people. But they knew that
the family didnt necessarily want palliative care, and they would put the consult in
anyway, because they felt they were required to have the consult in for the metric. So to
not offend the family, they would put that in, which I find offensive. She also said that
it appeared that SAVAHCS was totally gaming, because youre talking about a metric.
However, she stated that she understood it was one employee who believed he or she was
supposed to put the consult in for metric purposes, even though the patients family may
not have wanted palliative care. She said, This was a localized finding that we saw no
direction from leadership to do. It was stopped when leadership in the facility was made
aware. She stated that this was an old issue, which had already been addressed during a
2010 consult lookback.
Service chief 2 said he did not know about consults that stated the consult was placed for
performance measures only and not to take action on the consults.
Service chief 1 said she did not know anything about consults being placed for
performance measures only.
Records Reviewed
A complainant provided a Report of Contact (ROC) she authored in February 2010.

Review of the ROC showed it recorded the timeline of events surrounding the Palliative
Care consult manipulation. The ROC indicated that a physician identified a Palliative
Care consult as something created solely for the purpose of a performance measure. The
ROC showed that, on February 5, 2010, the complainant reviewed the records of
19 patients assigned to the intensive care unit (ICU) and found that three of the patients
had these inappropriate consults placed in their records. The ROC showed the
complainant then reviewed 150 Palliative Care consults and found a significant number
of them to be placed solely for purposes of meeting the performance measures.
We reviewed a February 2010 email string between senior leader 2, senior leader 3, and
the complainant about 3 ICU patients out of 19 consults placed to meet a performance
measure. Senior leader 2 and senior leader 3 supported the cease and desist order and
believed social workers were responsible.
Consult Discontinuations
The complainant stated that she believed there was at least one patient that died due to
the gaming of the consults that involved a pulmonary embolism. The complainant said
she did not think senior leader 1 was aware of the deceased veteran until an unidentified
VISN employee informed the front office staff.
VISN senior official 1 said that in 2012 (approximately), a review of Gastroenterology
consults determined that a patient died while there was an open consult. She said
SAVAHCS had contacted the family of the veteran and the veterans family explained
that the veteran did not want the carewhich is the reason he did not go to VA. She
stated that in either 2009 or 2010, SAVAHCS conducted a 100 percent review of consults
at VAMC Tucson as the result of concerns brought forward by a VAMC Tucson
employee, later identified as the complainant. When she was requested to provide copies
of the consults that were discontinued because they did not meet the 30-day metric, she
said she could not locate the source documents or a list of the patients. She stated, I
observed CPRS (Computerized Patient Record System) records where a consult was
canceled with a statement saying the reason was that it was going to extend beyond the
30-days target. The care would be delivered despite that. I observed that this didnt
change the delivery of care to the veteran, but changed the assessment of the timeliness of
that care in some cases. This was immediately halted when leadership in the facility was
made aware. This also was the evidence for our statement that staff were valuing
performance on a metric more than the accurate reflection of the delivery of care. We did
not find any evidence that leadership directed this to happen and it only appeared to have
been at a very front line level in certain areas that it happened.
A BSL employee said she was aware employees canceled consults because they did not
meet the metric. She stated that she could recall one instance in cardiology when the
consult was closed, even though it should have remained open; however, she could not
remember specifics regarding this consult. She further stated that although she could
only think of that one consult, she believed there were probably various ones throughout

the facility. She said she was aware a 30-day metric had to be met because it was a
national metric. She said she never received counseling by management regarding not
meeting a metric. She stated that she thought Neurosurgery had consults canceled after
30 days, which made the provider resubmit the consult. She added, its like the
provider, they didnt follow the service agreements and I know that Neurosurgery had
done that and said resubmit when everything is completed.
Service chief 2 stated that he recalled hearing in 2009 or 2010 about consults that
contained a comment about the consult being discontinued because a 30-day metric could
not be met. He explained that he was in a different role at that time. He said there could
be several reasons to close a consult: a clinical reason, which meant the care was
completed; or an administrative closure, which meant there was no need to see the
patient. He stated that a consult could also be discontinued, which meant you were
unable to resurrect the consult.
Service chief 1 said she was not aware of consults being discontinued because a 30-day
metric could not be met.
Senior leader 3 stated that she had no knowledge of someone discontinuing a consult
because a 30-day metric could not be met.
Records Reviewed
A complainant provided an email from a Compliance and Business Integrity Office
employee, dated March 2, 2010, in which the employee stated that he reviewed
1,301 Dermatology consults between October 1, 2009, and January 31, 2010. The email
showed the employee found that 45.27 percent of all consults were canceled. The
employee had written, The number of cancelled consultations seems excessively high.
VISN senior official 1 provided an email that stated that one result of the consult review
included prohibiting SAVAHCS clerks from canceling consults for any reason, effective
March 4, 2010.
Scheduling
VISN senior official 1 stated that VA recently completed an internal audit of scheduling
in facilities. She said the auditors identified a problem with a clerks supervisor; she did
not know this persons name, but indicated a review of VAMC Tucson concerning the
desired date and other issues determined that clerks felt a general pressure from their
supervisor - that they should use the next available date instead of the [patients]
desired date. She further stated, So the best I can tell is that there was an educational
document that had gotten into the National Systems Redesign Web site, that talked about
how you book the desired date, and it erroneously had in there that you use the next
available. Thats part of the confusion in this, is if I were a clerk, entry level position
here to a clinic, and I went to a National System Redesign site, that are supposed to be the

experts, and I download this thing and it says this, I can understand how they do it wrong.
Thats been taken down. We made sure of that. But there was misinformation, and it
could have been that the supervisor was looking at this and saying no, this is what youre
supposed to do, and that they felt pressure.
Service chief 3 stated that he recognized there were problems seeing patients within the
14-day requirement. He said he had complaints about delays for surgeries, but providers
saw most patients usually within a month. He added, You have to see a new patient
within 14 days; but nobody has gone beyond that.
MSA1 stated that the only game-playing technique that she knew about involved the
desired date. She said there was an instance in Orthopedics about 2 years ago. She also
said that scheduling for operating rooms was so far behind, they created a Microsoft
Excel spreadsheet to determine whether each patient still wanted the surgery or whether
the veterans had the surgery and for some reason the surgery request was still in the
system. She stated, I do know that we have been told to tell the patient when our next
available is and use that as a desired date.
LPN1 stated that she was previously an MSA in a specialty clinic, where she experienced
problems getting veterans care. She said she met with the manager of the specialty clinic
and Urology staff because Urology was behind about 150 appointments in scheduling and
the appointments were on paper forms. She stated that she recalled veterans would
come up to the front desk and say, you know, am I going to die before I get this exam
done? She added that she kept Urology staff up to date about the backlog of paper
schedules. When asked if the paper list was a copy of what would be considered the
EWL, she said the Business Service Line was very careful never to call it a wait list []
We dont have a wait list. We dont have a reminder list. We dont have anything like
that. She stated that no one trained her on the EWL and BSL management told her and
others that there was no such thing as the EWL.
She added that patients would ask her to call them if someone canceled, but she had to
tell the patients she was not allowed to do that. She explained that she could not write
down patient names and numbers because management did not want any lists around
with patient names. She stated that, just before this interview, she heard a patient say he
was supposed to come back for an appointment in 6 months, the patient forgot, and it was
10 months later before the patient had his appointment. She said there was no list or
anything to remind the patient. She added that she recognized that many of the veterans
suffered from memory problems and putting the responsibility on them to remember to
call back months later to make an appointment was a systemic problem. She stated that
some patients would complain about their appointment being canceled by patient when
the veteran claimed that to be untrue. She said that recently she had had a patient who
said he needed to see the hematologist-oncologist because he found out his platelet count
was still low. She stated that no one had told the veteran his platelet count was low; he
had learned about it by reviewing his own test results.
A nurse manager stated that the 14-day metric involving the desired date was
manipulated by going in the system, learning the next available appointment date,
10

backing out of the scheduling system, and changing the desired date so it looked like the
date the veteran wanted to have the appointment. She further stated that if she and others
did not do that, the system would show a 60-day wait list. When asked who gave her the
instructions to do the scheduling that way, she said the chief over her Patient Aligned
Care Team (PACT) passed down all the metrics and that they received training from BSL
leadership. She stated that senior leader 1 put pressure to meet metrics down the chain of
command. She added that they were trained to alter desired dates by making the desired
date the date of the next available appointment, not the patients actual desired date.
MSA2 stated MSA3 sent daily emails to MSAs in Primary Care that listed each
providers next available date, which was no more than 2 weeks away. She added that
the emails were never accurate and believed it was an effort to try to make the
appointment access numbers look good. She stated that the next available appointments
were at least 2 months away and that she was currently scheduling patients for
appointments between 60 and 90 days in the future. She said, They want to make it
seem like were actually scheduling the patients in a timely manner, but its not really
accurate. She stated that she placed a patients desired date in the system as the desired
date; however, she was trained to tell the veteran the next available appointment date, ask
the veteran if that is when he would like to be seen, and use the appointment date as the
desired date. She added, The desired date is the date that were actually scheduling their
appointment. She said the desired date was whatever the veteran was requesting and if
the veteran wanted to be seen today, that would be the desired date. She further stated
that if the veteran asked for one appointment date and she gave him the next available
date and the veteran acquiesced to that date, the desired date would match the next
available appointment date.
MSA3 stated that approximately 2 months ago (from June 2014), physician 2 told him to
switch from looking at a Primary Care doctors next available appointment, to also look
at triage appointments with nurses as the next available appointment for patients. He said
this change improved the appointment access numbers dramatically but required some
patients to seen by a nurse instead of a doctor, in some cases. He stated that only a few
doctors used the recall reminder. He estimated that 8 out of 10 patients forgot to call and
make their appointment. He said most physicians he worked with have next available
appointments about 60 to 90 days out. He stated that he used the date the patient wanted
to be seen as the desired date and felt no pressure to change it; however, he told the
patient when the next available date was and would massage the patient in order to find
a common date, which was used as the official desired date.
MSA4 stated that the desired date was the date the veteran wanted to see the provider.
She said that before SAVAHCS implemented PACT in 2011, she would change the
desired date to match the next available date. She said with PACT, the veterans
requested date was the desired date. She stated that, in some cases, veterans called in
every single day to see if there was a cancellation.
Physician 3 stated that her MSA was reprimanded several times because she did not go
back into medical records and change the desired date to the date of the scheduled
appointment.
11

A business manager stated that he and others performed audits of desired dates and talked
to MSAs when the MSAs did not enter the desired dates correctly. He explained that
after discussion with the MSAs, he found that the MSAs often believed they were
supposed to make the desired date the same day as the appointment date. He said he
thought desired date was not complicated and stated if the patient agreed with the next
available appointment, then that would be the desired date. He said schedulers should not
be using T1 as the desired date. He said he never heard about the desired date being
blank or skipped over.
A business manager reported that he had seen consults as old as 180 days, 200 days, and
300 days. He stated that a long time ago, someone had patient information in a drawer
that needed to be scheduled for follow-up appointments, but he was not aware of any
patient harm involved in that incident.
A manager in a specialty service stated the desired dates had always been a concern. He
said he acquired reports to see if schedulers complied with the 14-day rule. He said he
and other schedulers were trained not to guide the patient to where there were
appointments available, but instead tried to ask the veteran first when the veteran wanted
an appointment. He said there was negotiation between the scheduler and the patient. He
said he counseled schedulers when they used T for desired date. He stated that if they
used T, that was an error. He said he was aware of the problem with paper scheduling in
Orthopedics in the past and initially stated that he had created a Microsoft Excel
spreadsheet to keep track of the patients. He later stated that Orthopedics never used a
spreadsheet. He said General Surgery, ENT [Ear, Nose, and Throat], Cardiology, and
Thoracic used a spreadsheet to schedule patients. He stated that he and others decided to
start placing the patients into a Microsoft Excel spreadsheet so the departments could
track their patients. He said that at the time of the interview, Orthopedics used the EWL,
in addition to a Microsoft Outlook calendar for scheduling.
MSA5 said that other than a 2-week orientation, she did not receive much training on
how to do her job. She stated that when she scheduled patients, she entered the date the
patient wanted to be seen as the desired date and then offered the patient the next
available date. She said that on multiple occasions, her supervisor reprimanded her orally
and via email for not meeting the 7-day access-to-care rule. She stated that she got into
the habit of going into the system, finding the next available date the patient could be
seen, backing out of the system, and then going back into the system to make the
patients desired date on the same date that she made the appointment. She explained, I
asked why we were gaming the system and I was told that numbers went up to
Washington D.C. and we needed to show that we were in compliance as far as seeing
veterans in a timely manner. She stated that she asked why they didnt tell the truth so
that they would be given more help, and she was told that she needed to continue
scheduling patients within the 7-day window rule. She said her last performance
1
MSA(s) use VHAs VistA computerized health care management system to schedule appointments. Several date
input fields are used when scheduling an appointment to include date of contact, desired date, and appointment
date. MSA(s) can input the current date into the system by striking the T (Today) key.
12

appraisal did not include a reference to meeting or failing to meet performance metrics.
A BSL employee said the expectation was that schedulers would hopefully make the
desired date within 14 days or 30 days or whatever the case may be within that desired
date. She stated that she was not aware of a former BSL chief giving any guidance to
schedulers to manipulate numbers. She said she was not aware of patients having the
need to call back daily to try to get an appointment. She said she never gamed the system
or told anyone to game the system to meet metrics. She said she recalled that MSA2 had
a list of patients who were not scheduled. She stated that the list went back about 1 week
for appointments waiting to be scheduled. She said that when MSA2 scheduled all the
patients, she told MSA2 that she (MSA2) was not to keep any lists and told MSA2 to
destroy the old list. She stated that she was not aware of anybody else destroying,
manipulating, or shredding any type of paperwork related to EWL or scheduling. She
said she was not aware of any issues at VAMC Tucson similar to what was occurring at
VAMC Phoenix.2
Service chief 1 stated that when VA first provided its facilities with guidance regarding
the EWL, a scheduler was expected to place a new patient on the EWL if the patient
could not be seen within 120 days. She said VA eventually changed this guidance to
90 days. She said she had not seen anything showing a deliberate pattern of someone
trying to circumvent the system or work the numbers in regard to scheduling
patients. She stated that supervisors conducted monthly audits and identified errors. She
said veterans provided schedulers the dates and times they wanted particular
appointments, which were the desired dates. She stated that currently new patients at
SAVAHCS waited about 10 days to see a provider from the time they first called to
schedule appointments. She said she was not aware of any metric gaming occurring at
SAVAHCS. She said she was not aware of any scheduling clerks going in and out of the
scheduling system to manipulate data. She stated that she was aware that the chief of a
specialty service received permission from senior leader 2 to keep paper copies of
everything. She said the specialty service chief kept the copies in a secure cabinet and
the copies represented what he had entered into CPRS. She added that metrics were
never part of an MSAs performance review. She said she was not aware of patient harm
because of schedulers not using the EWL, inappropriate scheduling practices, or a focus
on meeting metrics.
Service chief 1 stated that VA Central Office (VACO) conducted the VA Access Audit
review from May 12, 2014, through June 3, 2014. She explained that there was
confusion with the schedulers at the time of rescheduling when a clinic canceled
appointments. She stated that when clerks called veterans to inform them of a clinic
cancellation, they were sometimes changing the desired date to the new desired date
instead of holding the original desired date. She said that VA did not clearly define how
to handle clinic cancellations in the standard operating procedure.
Any reference to Phoenix in this summary refers to wait time allegations that surfaced at VAMC Phoenix in early
2014.
13

Service chief 2 stated that, as of May 2014, the average wait time for a veteran at VAMC
Tucson was from 20 through 30 days. He further stated that he held training sessions as
recently as October 2013 and even February 2014 to ensure employees understood how
to schedule veterans, identify the desired date, properly identify what the patient wanted,
and how to identify what information VACO looked at nationally. He declared, We
wanted to make sure that people understood how to select the desired date and that the
veteran determines the desired date every time. He said he had no knowledge of metric
gaming at VAMC Tucson, adding, We do not want to fudge anything, we dont want to
game anything, we dont want to present something thats not true. He said he did not
feel any unnecessary pressure from his supervisor to meet a certain metric or goal.
Senior leader 3 said she had no knowledge of any metric gaming occurring at
SAVAHCS. She stated that the desired date was the patients requested date to be seen
by a provider. She also stated that the veteran should be the one to initiate the desired
date, not the scheduler. She stated that service chief 1 was ultimately responsible for
ensuring schedulers received proper training. She continued that she would not know
about an MSA changing a desired date to meet a metric. She stated that the 14-day
metric was not realistic. She said she was not aware of any patients harmed because of
inappropriate scheduling practices or of a focus on meeting metrics at SAVAHCS. She
added that she was not aware of any destruction of documents or falsification of data
related to metric gaming.
Records Reviewed
A complainant forwarded an email, dated December 16, 2009, from a BSL employee,
who stated that there was a new performance measure: appointments are measured
14 days from desired date. The BSL employee went on to state, WE control the
desired date, keeping within the time frame requested by the provider.
The facility provided a copy of the VISN 18 Appointment Scheduling Audit Report,
V18-022011, dated January 7, 2012. The audit identified the following:
o VISN-completed appointments averaged 60-percent where desired date equaled
appointment date and VISN 18 believed this was artificially high;
o Big Spring and Prescott were the only two VISN facilities that routinely used the
EWL while the three largest facilities had the lowest volume use of the EWL;
o Tucson was identified as having the appearance of appointments showing canceled by
patient when it appeared they were canceled by clinic, noting the frequency and
back-to-back occurrences of these events indicated that the appropriate status should
have been cancelled by clinic and not cancelled by patient;
o Sixteen percent of Tucsons clinics scheduled appointments without desired dates;
o Fifty-seven percent of Tucsons appointments had desired dates that equaled the
appointment date; and
14

o It appears Tucson was not appropriately placing patients on the EWL.

We reviewed a June 7, 2010 memo from an MSA supervisor involving a Scheduling
Practices Assessment in which a SAVAHCS workgroup found that, in most clinics, the
schedulers were basing the desired date on clinic availability and not including the patient
in the scheduling process. The memo stated that SAVAHCS also found that other
prohibited scheduling practices were occurring.
We reviewed the 2010 to 2014 monthly appointment and consult audit reports from BSL
management. The audits revealed schedulers appeared to be making a multitude of errors
each month. Examples of the comments on the errors included, >14 days past desired
date, no justification and 15 days from desired date.
MSA1 provided a copy of her appointment management training materials. A review of
the documents disclosed that a veteran could state his/her desired date and this date
should be used in VistA or if the veteran asked when the next available date was, the date
the scheduler found was then the desired date.
We reviewed an email string from the business manager to a BSL employee in which the
business manager asked, With the lack of access in Audiology and Dermatology do you
think patients that no-show their consults appointment could be completed after
1 no-show? The BSL employee responded, My concern is an audit of
appointments/consults that could reveal cx [cancel] after 1 NS which is not in accordance
with VHA policy. We would be up a creek.
We reviewed a VHA Issue Brief dated May 14, 2014. The review disclosed that many
MSAs did not use the EWL and could not articulate the use of the EWL; some staff
members were not asking the veteran for his/her desired date, and some scheduling staff
felt pressured by their supervisor to have the desired date closest to the first available
appointment date.
EWL
VISN senior official 3 said her only concern with VAMC Tucson was that they were
underutilized and they did not have many patients on the EWL, when compared with
others in the same network. She stated that she was not aware of any gaming in
SAVAHCS. She added that VAMC Tucson had been one of the better performers.
MSA2 said supervisors prohibited her and other MSAs from keeping a waiting list or
setting a reminder to call a patient if they had a cancellation. She said MSAs in Primary
Care use the recall reminder, but many veterans do not remember to call VA to make the
appointment. She said she had never seen the EWL. She stated that there had been times
she had to reschedule patient appointments at least four times because a provider was not
available. She said cancellations by clinic were frequent.
15

Service chief 3 said he was not aware of any metric gaming, but said the rules for
appointments had been difficult to understand and had been changing. He said they had a
couple of issues a few years ago because they kept their wait list on paper and the paper
logs should be electronic because of HIPAA3 issues and the possibility of losing the
papers. He stated that he did not understand the wait list because he just considered it a
backlog.
A nurse manager said Primary Care had never used the EWL, but that there was enough
demand to use it. She said Primary Care previously used the callback list, but did not use
it anymore. She stated that patients have had to call in every day to try to get an
appointment. She said management disciplined providers for sending patients to the
Emergency Department (ED). She said management wanted primary care to see all
patients, even when the patient was ED-appropriate. She stated that if the patients went
to the ED, a metric went down and someone got into trouble.
MSA4 stated that she had never seen or used the EWL. She said that when VAMC
Phoenix received media attention, a business manager told her that if she had any
unofficial wait list that she must get rid of it.
MSA3 said that when issues with VAMC Phoenix became a media headline, the BSL
employee went to each scheduler and asked each whether they had any unofficial wait
lists and if the scheduler had one, to throw it away.
An administrative employee said his duties included being in charge of the scheduling
keys and the scheduling application. He said he believed all clinics used the EWL. He
stated that he ensured all schedulers completed the three modules of online training. He
said supervisors decided who needed access to the EWL. He also stated that he was not
aware of any scheduling manipulation or other metric gaming.
The manager of a specialty service stated he was aware of Orthopedics having scheduling
issues about a year ago. He said it was very difficult to manage patients by papers. He
stated that he was not aware of any patient harm because of delays in care. He said that
today (July 2014), Orthopedics used the EWL, but they also used a Microsoft Outlook
calendar for scheduling. He said Urology might have used something other than the
EWL. He stated that the EWL or surgical wait list showed names primarily, but the
Microsoft Outlook calendar showed more details about the patient, doctor, and procedure.
He said that there were times when a doctor had notes on a piece of paper for dictation
purposes and later brought the paper back to the scheduler and asked the scheduler to
give the patient a follow-up appointment. He said Vascular Clinic and sometimes
Neurosurgery used paper copies with patient information for scheduling. He stated that
this methodology could cause patients to fall through the cracks. He added that
SAVAHCS had not used the EWL, but recently started using it for colonoscopies and a
couple of other areas.
Health Insurance Portability and Accountability Act
16

The BSL employee stated that she was unaware of patient harm because of the lack of
EWL use at SAVAHCS.
Service chief 2 stated that there were no issues with the EWL. He added that wait lists
were currently in use in Electrophysiology, Home-Based Primary Care, and the Pain
Clinic. He said that recently there was an EWL established in Sleep Study. He said he
was not aware of any patient harm because of delays in care. He stated that several years
ago (from 2014), the pain clinic at VAMC Tucson created a list other than the EWL. He
explained: we sounded the alarm, we said no, thats not going to happen, we created a
wait list, they got in, they were able to clean everybody, clean the wait list out by
scheduling them appropriately and we were able to eliminate the wait list.
Service chief 1 stated that she was aware that a clerk in the Electrophysiology section at
VAMC Tucson kept a list of patients, whom he had not placed on the EWL. She said the
patients were now on the EWL. She further stated that Home-Based Primary Care was
also maintaining a list of patients who needed an appointment scheduled. She stated that
some of the patients were on the list, but many patients were not appropriately scheduled
for Home-Based Primary Care.
Senior leader 3 said the Pain Clinic, Home-Based Primary Care, and Electrophysiology
currently (at the time of the interview) used the EWL. She said there were daily meetings
to discuss the EWL. She stated that she was not aware of other areas that needed to use
the EWL at VAMC Tucson.
Records Reviewed
VISN senior official 1 provided an email (May 2014) with an EWL chart that revealed
VAMC Tucson currently had 34 electrophysiology patients on the EWL with 18 days as
the average wait time; home-based primary care had 59 patients waiting an average of
59 days for an appointment; and Sleep Study had 13 veterans on the EWL, waiting an
average of 30 days.
We reviewed emails that the BSL employee sent to supervisors on October 11, 2013,
February 12, 2014, and April 23, 2014. These emails revealed that there were many
EWL entries entered in error and EWL entries had to be approved.
Electrophysiology
Physician 4 and a nurse practitioner (NP) were interviewed together. The NP stated that
electrophysiology involved implanting pacemakers, defibrillators, and ablation
procedures for cardiac rhythm problems, and that SAVAHCS had only one cardiologist
that specialized in electrophysiology. The NP said Cardiology never had an official
electronic waitlist until a few weeks ago [prior to June 2014] when all the stuff [about
VAMC Phoenix] started coming out in the press. The NP stated that there were many
complaints from patients, unhappy patients, and referring providers. The NP also stated
17

that there was only one scheduler and that there was no official list or anything to track
patients until a few weeks prior. The NP said there had been delays and SAVAHCS may
have compromised care. The NP said she was aware of two patient deaths (Patient 1 and
Patient 2) that she associated with delays in care before Electrophysiology began using
the EWL and she identified those patients. The NP stated both patients died while on the
paper waiting list for their electrophysiology procedures. The NP stated that the
electrophysiology scheduler scheduled patients 3 to 4 months out based on paper lists.
Physician 4 said Cardiology was an in-demand service and received very little support or
increase in providers, even though management knew of the need.
The NP stated that 3 to 4 weeks ago [prior to June 2014], management allowed patients
waiting for electrophysiology procedures to be sent outside VA to a private provider for
fee based medical treatment because the lack of access to these procedures could
adversely affect a patients life. The NP stated that of the recent patients sent outside
VA for care, one was seen by the outside provider within 4 days, another saw the outside
provider within approximately 1 week, and the third patient waited 2 weeks. The NP
stated that when the program support assistant (PSA) recently attempted to call two
patients, he learned they had died. Physician 4 stated, I think its fair for us to say that
patients on a waitlist for a device, these patients are old, they have a lot of comorbidities,
and its very difficult for somebody to assume or to figure out whether they died because
they didnt get the device. The NP stated that one of the two patients who died, and who
had been on the paper wait list for 3 months, had a stroke, died from complications of the
stroke, and the defibrillator would not have prevented the stroke. The NP added that the
other patient died of congestive heart failure and the device for which he was referred to
was a treatment for congestive heart failure.
The NP stated that Electrophysiology used a one-page worksheet that the clinicians wrote
on and provided to the scheduler. The NP further stated that clinicians gave this
handwritten page to the PSA in order to schedule the patients. The NP added that she had
performed this work for 15 years and that multiple times she and others had raised their
concern to upper management about getting behind.
The PSA in Cardiology stated that he scheduled patients for electrophysiology
procedures. He stated, [The NP] does the work-up for me and I have a folder of the
cases to be scheduled and so when I get a new case I just put them on the bottom of the
pile because, uh, I schedule the cases in the order in which they come in to me. He
further stated that he used the paper for each patient and scheduled a month or two in
advance. He said he always had a stack of patients waiting to be scheduled their
procedures in Electrophysiology; at one point, he had 40 to 50 patients on his paper wait
list. He said, If I were to go down the pile and get them all scheduled right away, I
would be scheduling out 4 months in advance. He added that there were times when
someone misplaced one of the paper schedule requests because it was accidentally
paper-clipped to another case. He also stated that there were a couple cases for which he
should have received a paper to schedule a patient, but did not and the patient began
calling him, asking about the procedure.
The PSA said he believed a patient was harmed due to the delay in care and had to show
18

up in the ED while waiting for the electrophysiology procedure to be scheduled. He did

not recall the patients name. He stated that at some point, he began considering patient
prioritization instead of first come, first served. He said he recently discovered that a
patient died while waiting for a defibrillator implant. He thought that occurred about a
year ago [prior to July 2014] and he may not have scheduled the patient for his
procedure. He stated that the NP told him a patient died while waiting for a procedure
and the procedure could have prevented the death. He said there were a couple patients
that died waiting for a defibrillator device [] within the last 3 months, 2 months or so.
He could not recall the patients names. He stated this caused Cardiology to start looking
at prioritizing more and getting defibrillator cases accomplished within 6 weeks. The
PSA recalled a time when he attempted to contact a patient approximately 5 years ago to
schedule his procedure and while talking to the patients wife, the wife discovered that
her husband had died.
The PSA said that after the findings came out about VAMC Phoenix, in approximately
May 2014, his supervisor came and told him he needed to put the Electrophysiology
patients on the EWL. He stated that from 2007 until recently, he never used the EWL
and there was always a paper waiting list for Electrophysiology because VAMC Tucson
had only one provider. The PSA said he received a briefing on the EWL when he first
started, but he never received training to use it and never had the scheduling key needed
to access the EWL. He further stated that he recently began using the EWL; however,
none of the patients received their care any sooner.
The PSA said he did not use the desired date function in scheduling and always skipped
over it. He said he always offered the patient the next available date and left the desired
date blank. He stated that a couple months before the OIG interview, senior leader 1 met
with all the schedulers and told them, We ask the patient, Whats your desired date?
and if they say, Well, I would like to go in tomorrow for my appointment, and if we
dont have any appointments for them for the next month or two, he said its a
negotiation. He said he did not know what senior leader 1 meant by negotiation. He
said, even if I enter them into the electronic waiting list, they stay, you know, somebody
may still have harm waiting for his position, his case.
A business manager stated that right after the public became aware of problems at
VAMC Phoenix, he told the PSA that nobody should have wait lists in which patients
were not scheduled. He said that statement prompted the PSA to tell him about a folder
he had of patients waiting for electrophysiology procedures. The business manager said
that about 3 weeks later, he placed the patients, about 25 or 26, on the EWL. He stated
that he was not aware of any patient harm that may have occurred.
The BSL employee stated that Electrophysiology started using the EWL a few months
prior to the OIG interview. She said that one of her supervisors discovered
Electrophysiology had a patient list that was in the queue to be scheduled. She said she
and others instructed Electrophysiology to create an EWL to get the patients on the list.
She said she informed service chief 2 that Electrophysiology was keeping a wait list other
than the EWL.
19

Service chief 2 said there was an employee assigned to the Cardiology Department at
VAMC Tucson who held orders for electrophysiology studies in his desk. He stated that
when he and others discovered the issue, all the patients concerned were placed on the
EWL.
Senior leader 3 stated Electrophysiology began to use the EWL within the last few
months [prior to July 2014]. She said the cardiac electrophysiologist went on leave and
the consult numbers began to increase. She said she was not aware of any patients who
died awaiting an Electrophysiology consult.
Records Reviewed
We reviewed an email, dated May 8, 2014, from the PSA in Cardiology to a VA
employee and the business manager indicating that BSL had told him that he needed the
EWL option in VistA so he could enter Electrophysiology patients into the EWL.
We reviewed pending consults for the specialty service. The review disclosed that on
May 12, 2014, consult review notes indicated that Electrophysiology needed to have
46 patients on the EWL. On May 16, 2014, consult review notes showed
Electrophysiology had 44 patients on the EWL.
The NP provided examples of one-page forms with handwritten notes for
electrophysiology procedure scheduling. Review of these forms disclosed that they listed
cases in the queue to be scheduled. The NP also provided the electrophysiology cases
that involved deaths, scheduled cases, and fee-based cases. Review of these documents
disclosed the names of the two veterans who had died.
The VA OIG Office of Healthcare Inspections (OHI) sent an email confirming that
someone at SAVAHCS should have placed Patient 1, who had died, on the EWL.
Sleep Study
The business manager stated that if the facility could not get the patient in within 90 days,
the scheduler should place the patient on the EWL. He said that even though the Sleep
Study Department has had patients scheduled over 90 days, they did not place the
patients on the EWL.
Records Reviewed
We reviewed an email string from April 2014 that identified a 10-month backlog of
126 Sleep Study patients. One of the physicians wanted to send these patients for fee
basis, starting with the old ones from June 2013. Our review also disclosed that Sleep
Study began using the EWL on or about February 6, 2014.
20

Analysis of Alleged Patient Harm

Interviews of Cardiology staff identified two patients (Patient 1 and Patient 2) who died
while waiting for electrophysiology procedures. Another inquiry conducted by OHI (VA
OIG Report 14-02603-267), identified an additional patient. None of the three patients
were on the EWL because the scheduler did not have access to the EWL and used paper
wait lists for scheduling purposes. During the 2010 consult look-back, SAVAHCS
reviewers identified one more patient whose death they determined was attributed to a
delay in care and diagnosis associated with his canceled consult.
Records Reviewed
OHI conducted an initial review of the medical records associated with Patient 1 and
Patient 2. The OHI employee who conducted the initial review stated, I did not see any
evidence of a delay in care or concerns with the Cardiology consult for either patient.
He further stated, The consult for Patient 1 was acted upon within 5 days of it being
placed; however the procedure [w]as canceled because the veteran was hospitalized.
Patient 2 had only one consult and one note in the electronic health record. The consult
was completed within 12 days.
Additional review conducted by another OHI employee of the medical records of
Patient 1, Patient 2, and the third patient identified by OHI, found that all three were
critically ill patients with multiple chronic medical problems, and that all three met
criteria for the implantable cardiac devices that were recommended by their cardiologists.
The review found that Patient 1 had such significant cardiac disease and was in such an
acutely decompensated stateas a result of a stroke requiring urgent vascular surgery
that it is unclear if an implantable cardiac device would have affected the final outcome.
The review found that Patient 2 also suffered from severe cardiac disease, but evidence
within the electronic health record suggested that the delay in scheduling his device
implantation was likely due to noncompliance and/or altered metabolism of his blood
thinning medication. The review found that the third patient initially declined an
evaluation for the recommended device, but after allergy testing and eventual consent for
the procedure, his cardiologist failed to communicate with SAVAHCS providers to
coordinate scheduling for the device implantation. The OHI employee also reviewed the
medical records of the patient identified during the 2010 consult look-back and
concluded, This unfortunate outcome appears to be the result of an oversight by the
Primary Care provider, and not the result of the cancellation of the Inpatient Pulmonary
consult.
Senior Leader Interviews
VISN senior leader 1 stated that she did not have any knowledge of gaming the
scheduling system at VAMC Tucson to avoid or alter the EWL in order to maintain a
good metric. She said VISN 18 had a serious issue with wait times for a very long
time, and that she had seen the wait times of VAMC Tucson go up and down. She
21

stated that the patient scheduling process was a very difficult and error-prone task. She
added that there was a complaint from a staff member at VAMC Tucson regarding
consult closures. She stated that the complaint was about employees closing outstanding
consults and that there were patients falling through the cracks. She also stated that
about 2 to 2 1/2 years before the OIG interview, she had instructed VAMC Tucson
management to conduct a 100 percent consult review. She said the review substantiated
the complainants allegations.
VISN senior leader 1 said Community Based Outpatient Clinic provider losses have had
a drastic effect on wait times at each of the clinics. She stated that staff turnover at
VAMC Tucson resulted in increased wait times for veterans. She further stated that the
desired date is probably the thing that gets most easily manipulated. She said that she
did not know that a BSL clerk at SAVAHCS had been placing 600 requests for Urology
appointments into a drawer. When asked about the 400 Orthopedic cases that VAMC
Tucson staff did not place on the EWL, she said that was at a time when we started
doing centralized Ortho out of Phoenix.
VISN senior leader 1 stated that in 2012 one of the issues her office identified was that
many facilities were not using the EWL throughout the network. She stated VAMC
Tucson did not have an EWL and needed to get one up and operational. She could not
tell whether VAMC Tucson worked down the backlog without getting the EWL in place.
She explained that the VISN looked at the consults and performance measures, which
were the goals for the network. She stated that VISN 18 required facilities to use the
EWL for consults that exceeded 90 days. She said she tasked a network team to work
with the facilities to establish EWLs in facilities in which EWLs were not used. She
stated, I think that people try very hard to do the best they can for the veteran. And
sometimes that means that theyre going to do something thats a little bit not following
directive, thinking that thats going to help the veteran, or theyre going to, you know,
take some administrative thing and not do it because they want to focus on the veteran.
Well, of course that administrative thing is the way we measure. She said metrics could
affect two of five elements in SES performance plans. These include Results Driven
and Business Acumen. She stated that she does not always accept what each director
says in their self-assessments and narratives. She added that senior leader 1 was highly
regarded and that VAMC Tucson was a closely managed organization.
When re-interviewed, VISN senior leader 1 stated that she did not instruct or suggest to
anyone that they should manipulate data or metrics. She said she had no knowledge of
senior leader 1 being involved in data manipulation. She stated that a SAVAHCS
employee in the Quality Department reported an incident wherein the employee felt
patients had fallen through the cracks because of a cancellation process at SAVAHCS.
She further stated that she ordered senior leader 1 to review each canceled consult,
regardless of the area, and that he had to look to see what the status location was, get a
patient in for follow-up care if it were needed, and then report back to the network.
About senior leader 1, she said, I think that there are times in the organization where his
enthusiasm may result in people doing stuff that he would not approve of. She also
stated, So its more like hes got a firmly controlled ship compared to Phoenix chaos,
22

but it can result in the same misinterpretation and outcome. She stated that senior
leader 1 was a man who has a lot of control over things. I mean, he is a controller. She
also stated, He is also a very brilliant man when it comes to things like numbers, and
planning and all of that kind of stuff. But typically, we would see, he would say, boy, my
wait times are getting bad. And we would see the same thing happen in our data. So I
never got the same feeling he was showing manipulated data. She said she felt senior
leader 1 would distance himself, but not retaliate against people he felt had been
disloyal. She recalled one incident: And I went, [Senior Leader 1], they thought they
did come to you. And you didnt respond the way they thought you should. She came
once and talked to me once. She never said anything else. And I said, well, [Senior
Leader 1], she felt she was turned off, and she needed to come to me. And you cannot
hold her [responsible], you know, in any way, for doing it. Well, but she should have
trusted me. [Senior Leader 1], you should have listened more.
Senior leader 1 stated that he was not aware of more than 400 Orthopedic appointment
requests placed on individual pieces of paper and put inside a desk instead of on the
EWL. He added that he was not aware of 600 Urology appointments placed into a BSL
clerks desk drawer. He recalled consults in the system this way: This consult is placed
for performance measures only. Do not take action. He said that when someone
discovered that issue, his staff took care of it immediately. He stated that he was not
aware of consults that staff discontinued from 2009 to 2010 at VAMC Tucson because
they could not achieve a 30-day metric. He said he never felt any pressure from VISN
senior leader 1 to manipulate any data. He stated, [VISN Senior Leader 1] was
absolutely, you know, very clear, we dont game.
Senior leader 1 said the Pain Clinic, Home-Based Primary Care, and Electrophysiology
currently used the EWL. He stated that EWL use fluctuated among areas at VAMC
Tucson. He said he recalled Electrophysiology not using the EWL at one point and
someone telling him the electrophysiologist went on leave for 2 or 3 weeks and
apparently had some appointments in the desk or something. He added, The
supervisor became aware of it, went and got them, put them in the system, and we moved
on it. He said he was not aware of patient harm in Electrophysiology because of a delay
in scheduling patients.
Senior leader 1 stated that he was not aware of any patient harm due to employees not
using the EWL, inappropriate scheduling practices, delays in care, or because of a focus
on meeting metrics. He said he was not aware of any paper list or Microsoft Outlook
calendar usage to schedule veterans at VAMC Tucson. He said he was not aware of any
gaming that occurred at VAMC Tucson. He stated there was a shortage of Primary Care
physicians and that there had always been enough funds for SAVAHCS to send patients
to get non-VA care when needed.
Senior leader 1 explained the use of the word negotiation to SAVAHCS employees
during a May 2014 training session. He stated, You record the desired date and then
you say to them, in essence, heres what I have available. So I dont know about the
word negotiation, but what Im saying is heres what I have available. Will that work?
But you always record the desired date first and you try to give them some idea of what
23

you have available and ask is that acceptable. Thats all that was meant by it and thats
normal. He stated that he and others were responsible in making sure schedulers
received adequate training. He said VAMC Tucson did not place its awards before
employee needs. He stated that the facility held annual focus groups with employees and
that there was an all-employee survey. He added, Whether I like it or not, Im
responsible for everything here.
4. Conclusion
This investigation confirmed the allegation that approximately 400 Orthopedic appointment
requests were on individual pieces of paper in an employees desk instead of on the EWL.
Because of the operating room backlog, the former scheduler, who was identified based on
the timeline provided by other interviewees as a former VAMC employee and who also
declined to be interviewed, had each unscheduled patient on a piece of paper. The former
scheduler did not use the EWL, but had only paper copies of schedule requests, which were
later destroyed.
This investigation confirmed the allegation that 600 Urology appointments on pieces of paper
were in a clerks desk drawer and had not been scheduled before the departure of an MSA.
The appointments were handwritten consults doctors filled out and provided to an MSA to
schedule. The patients to whom these consults applied were not placed on the EWL.
This investigation confirmed the allegation that one or more SAVAHCS employees entered
Palliative Care consults into VistA with notes stating that the employee placed the consults
for performance measures only and that no action should be taken. The investigation did not
identify any managers who knew about, or directed, the gaming of the metrics in this
instance. This investigation confirmed the allegation that there were consults that one or
more employees discontinued because the 30-day metric could not be met. VISN senior
official 1 said she corroborated the allegations when the VISN audited SAVAHCS in 2010.
The investigation did not identify any managers who knew about, or directed, the gaming of
the metrics in this instance.
In 2010, VISN 18 required SAVAHCS leadership to conduct a consult review based on the
complainants allegation of consult gaming. SAVAHCSs review found that one patients
death was attributed to a delay in care and diagnosis associated with his canceled consult.
VA OIG OHI reviewed the patients records and concluded that the death was the result of
oversight by the Primary Care provider, not because of the consult cancellation.
This investigation found the Electrophysiology Section did not use the EWL until
approximately May 16, 2014. On May 12, 2014, SAVAHCS identified 46 patients who
needed to be placed on the EWL for electrophysiology procedures. We also learned that the
Sleep Study/Sleep Clinic did not use the EWL until February 6, 2014. In April 2014, Sleep
Study had a 10-month backlog of 126 patients. This investigation discovered that other
clinics within SAVAHCS (Orthopedic, General Surgery, ENT, Cardiology, Thoracic, and
Urology) also used other scheduling methods, as opposed to only using the approved
electronic VistA and EWL tools. Scheduling supervisors condoned these other scheduling
methods. In addition, several employees disclosed they scheduled veterans desired date by
24

using the next available appointment date. Two scheduling supervisors made statements
during our investigation that suggested they trained schedulers to control the desired date in a
way that was contrary to VA policy.
VA OIG referred the Report of Investigation to VAs Office of Accountability Review on
August 10, 2016.
QUENTIN G. AUCOIN
Assistant Inspector General
for Investigations
For more information about this summary, please contact the

Office of Inspector General at (202) 461-4720.
25

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ADMINISTRATIVE SUMMARY OF INVESTIGATION

BY THE VA OFFICE OF INSPECTOR GENERAL

REGARDING PATIENT WAIT TIMES

VA Medical Center in Tucson, Arizona

1. Summary of Why the Investigation Was Initiated

VA OIG Administrative Summary 14-02890-353