The investigation into the Veterans Affairs patient scheduling scandal that began in Phoenix has expanded to nearly 100 separate facilities.

Even at the early stages of what has become a nationwide probe, investigators have concluded that many of the same practices that kept veterans waiting for care in Arizona were a matter of routine in dozens of facilities across the country.

The VA inspector general’s office concluded local administrators at 13 separate facilities lied to its investigators during the course of the investigation.

Despite those obstructions, the IG found a pattern of practices that appeared to mirror many of the same techniques the IG condemned last month when it found that officials in Phoenix were using numerous workarounds to conceal exactly how long veterans were waiting for health care.

At 42 different medical facilities nationwide, patient schedulers were falsifying wait times by claiming that the next available appointment date was actually the date the patient wanted in the first place — making it appear that there was no waiting involved.

In a similar maneuver, at least 19 facilities routinely canceled their patients’ appointments and then rescheduled them for the exact same time so that they would disappear from wait time tallies. The IG found 16 facilities that kept their own off-the-books waiting lists, to make sure the actual waits weren’t visible to VA headquarters.

The findings so far represent only the initial stages of an ongoing investigation. Richard Griffin, the acting VA inspector general, told the Senate Veterans Affairs Committee Tuesday that the majority of the 93 cases the IG launched in conjunction with the Phoenix investigation remain active. Only 12 have been closed and sent to VA management for administrative action.

Who’s in charge?

Griffin said the results to date reinforce his office’s earlier conclusions that the improper scheduling practices were not a problem that was isolated to Phoenix, where the IG concluded that at least 45 veterans suffered from “clinically significant” shortfalls in medical care.

“Frankly, when something is going on for many years at a number of facilities, it almost becomes the accepted way of doing scheduling,” he said. “It’s a combination of factors. The bottom line is, who’s in charge?”

Griffin stopped short of saying that VA’s headquarters staff were aware of the depth of the deceptive scheduling practices. But he suggested that top officials knew, or should have known, that something was amiss.

Earlier VA guidance required local managers to certify that they were in full compliance with department policies that were designed to make sure the department’s top officials had an accurate view of true patient waiting times, in part, by banning local practices that did not use VA’s centralized electronic wait list.

But in May 2013, VA decided to waive that certification requirement for the entire fiscal year in an apparent recognition that its field staff either couldn’t or wouldn’t comply.

“That happens when there’s a failure of leadership,” Griffin said. “We’re not just talking about Phoenix. We have reported on this problem for nine years. Excellent policies were, in fact, published and sent out, but you have to follow through. Wait times is not the only issue that we’ve reported on where VHA has promulgated policies to address our recommendations and sent them out, and they were supposed to certify that they were being followed, but they weren’t. It’s hard to explain why, but when people do not follow the directive from their headquarters leadership and mislead them about it, there has to be a consequence.”

Staff not trained adequately

Until this summer, VA evaluated the performance of its local executives, in part, based on whether or not they were meeting the department’s goal of making sure that veterans waited no longer than 14 days for care.

VA has since abolished that performance measurement for its senior staff in field offices, acknowledging that the metric created a perverse incentive for local officials to game the system.

In Phoenix, emails between senior VA staff members made clear that the 14-day objective was not achievable given the number of doctors and nurses who were working in the system at the time and emphasized the need to report good statistics to VA headquarters, all the while acknowledging that those statistics were “smoke and mirrors.”

But Griffin said the schemes local officials used were abetted by the fact that the staff who actually operate the scheduling system on a day-to-day basis are at the bottom end of the General Schedule and don’t have the training necessary to decide which patients need to be seen most quickly.

“When you look at the initial point where a veteran has contact at the medical center, very often, you have the lowest graded employees who might not be equipped to be able to triage whether a patient really needs to get in within 14 days, or seven days, or tomorrow or today,” he said. “In the private sector, you would probably have somebody with a little more clinical background to try and make that evaluation, so you know who really does need to come in and who doesn’t.”

Robert McDonald, the new VA secretary, said one of the first things he wants to change in the department he now leads is that the staff members who have the most one-on-one contact with veterans are also the ones who occupy the lowest rungs of the GS system.

He told reporters Sept. 8 that the problem worsened when the Office of Personnel Management downgraded several of VA’s job descriptions into lower grades then they’d had before, cutting the pay rate of those positions by tens of thousands of dollars per year.

“So I’ve told all of our operations that we need to take a look at those,” McDonald said. “If those people are our front line, we need to seek exceptions from OPM for those jobs. I don’t think we’ve done a great job of making the case about the value of these positions. We’re going back and looking at that.”

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