VA - Another home run! Untimely care from PVAHCS may have contributed to the death
Oversight Reports for Veterans Affairs Office of
Inspector General (OIG). This information has recently been updated, and is
now available.
10/03/2016 08:00 PM EDT
The
Department of Veterans Affairs (VA) Office of Inspector General (OIG)
initiated this review of alleged consult management issues at the Phoenix VA
Health Care System (PVAHCS) in response to allegations reported to the OIG by
the House Committee on Veterans’ Affairs in July 2015. These allegations,
communicated by a confidential complainant, were received about one year
after the OIG published a report confirming allegations of patient care
delays, wait times, and problematic scheduling practices at PVAHCS. We
reviewed these more recent allegations that PVAHCS staff inappropriately
discontinued and canceled consults, management provided staff inappropriate
direction, patients died waiting for consultative appointments, more than
35,000 patients were waiting for consults, and other allegations received
during our review, to assess the adequacy of managing patient consults at
PVAHCS. We substantiated that in 2015, PVAHCS staff inappropriately
discontinued consults. We determined that staff inappropriately discontinued
74 of the 309 specialty care consults (24 percent) we reviewed. This occurred
because staff were generally unclear about specific consult management
procedures, and services varied in their procedures and consult management
responsibilities. As a result, patients did not receive the requested care or
they encountered delays in care. Of the 74 inappropriately discontinued
consults, 53 patients never received the requested care at PVAHCS. We did not
substantiate that the Acting Chief of Health Administration Service (HAS)
instructed administrative staff to discontinue inappropriately the consults
of patients before a provider reviewed the consult. We also did not
substantiate that PVAHCS management removed a scheduler from Vascular Service
because the scheduler identified and reported problems. We did not
substantiate that a paper list of patients waiting for chiropractic care,
reported to us by the complainant and PVAHCS leadership, was an unofficial
wait list. However, we also determined that the PVAHCS Chiropractic Service
had inappropriately canceled consults. Canceled consults resulted in patients
not receiving a scheduled appointment and, therefore, not receiving the
requested chiropractic care. Within the 30 canceled consults we reviewed, 28
patients had not received the requested chiropractic care at PVAHCS. The
OIG’s Office of Healthcare Inspections (OHI) reviewed a total of 294 facility
consults for 215 individual patients who had open consult requests at the
time of their deaths, or had consults discontinued after the date of their
deaths. In addition, OHI reviewed nine deceased patients’ records with nine
discontinued consults from a list of discontinued vascular consults provided
by the complainant. Of the 215 individual patients’ records reviewed, OHI
determined that untimely care from PVAHCS may have contributed to the death
of 1 patient. OHI also determined that the records reviewed of the remaining
patients indicated the patient had not died because they did not receive the
requested consult in a timely fashion before they died. We did not
substantiate that the facility was having non clinical staff discontinue
consults for vascular patients to hide the fact that a patient died while
waiting for care. In regard to the consults reviewed of patients who died
while they had open consults, we found that PVAHCS closed these consults
because VHA and PVAHCS business rules and policy both required that a consult
be discontinued if the patient is deceased. However, facility staff did not
consistently comply with this policy and some consults remained open long
after patients’ deaths.
We
determined that, as of August 12, 2015, more than 22,000 individual patients
had 34,769 open consults at PVAHCS. The total open consults included all
categories, statuses, and ages of consults. Of all the open consults at that
time, about 4,800 patients had nearly 5,500 consults for appointments within
PVAHCS that exceeded 30 days from their clinically indicated appointment
date. In addition, more than 10,000 patients had nearly 12,000 community care
consults exceeding 30 days. Consults for care in the community included traditional
non VA care and Choice. The remaining approximately 17,000 open consults were
for prosthetics, administrative purposes, and/or did not exceed 30 days. VHA
does not require staff to complete prosthetics consults immediately. We
substantiated that one patient waited in excess of 300 days for vascular
care. A patient received vascular care in October 2015 following a consult
request from a clinician in Vascular Surgery in June 2013. As of August 12,
2015, we identified 13 open consults of patients waiting for Vascular Lab
more than 30 days beyond the clinically indicated date of the provider,
ranging from 32 to 157 days. We also found that the PVAHCS Vascular Service
staff did not properly link clinicians’ notes for the completed appointments
to the corresponding consults, which meant consults remained open even though
the patient received the care. During the past two years, the OIG has
reviewed a myriad of allegations at PVAHCS and issued six reports involving
policy, access to care, scheduling and canceling of appointments, staffing,
and consult management. Although VHA has made efforts to improve the care
provided at PVAHCS, these issues remain. This report contains 14
recommendations. The Under Secretary for Health concurred with the
recommendation to update VHA’s consult policy, and VHA published a new
directive on August 23, 2016. The VISN 22 Director also concurred with the
remaining recommendations to improve consult management at PVAHCS and
submitted acceptable corrective action plans.
All other inquiries can be directed to vaoig.reportsstaff@va.gov.
This service is provided to you at no charge by Veterans
Affairs Office of Inspector General (OIG).
|
Comments
Post a Comment