Federal investigation: Salisbury VA staff falsified wait time information

Published 3:11 pm Wednesday, October 5, 2016

By Josh Bergeron


SALISBURY — Two scathing reports by federal investigators have found that 15 Salisbury VA patients died while awaiting care and that employees were trained to manipulate data to make it appear appointments had been scheduled to avoid long wait times.

One report started as a criminal investigation. The other came as a result of an anonymous tip. The details of both were swiftly condemned as “unacceptable” and “profoundly disturbing.”

In one investigation, the Department of Veteran Affairs Inspector General’s Office found a backlog of about 3,300 pending requests for radiology exams at a specific point in 2014. The average backlog for the period investigated — Jan. 1, 2014 to March 31, 2016 — was 1,358. A total of 15 patients died while waiting for care. However, the inspector general’s report didn’t directly attribute the deaths to practices at the Salisbury VA.

In another investigation, federal investigators found that employees were trained and later instructed to alter data to show that patient appointments fell within the 14-day period requested by patients. More than half of the VA’s schedulers were routinely “fixing” patient appointment dates so they appeared to fall in the 14-day window, according to the investigation’s summary released Tuesday.

At a women’s health clinic, an employee told investigators that some patients had been waiting over 500 days for an appointment to be scheduled.

“The findings of today’s report are profoundly disturbing,” said U.S. Sen. Thom Tillis, R-N.C. “This is not the way the VA should be treating the men and women who risked everything in service to our country. My office has assisted many veterans in the Charlotte area who have had difficulty getting timely appointments at the Salisbury VA Medical Center, and the IG report confirms the worst of our suspicions.”

In response to the report, Salisbury VA Director Kaye Green said the facility has and will continue to work to make improvements.

“We will provide continuous training to ensure our staff understand and are in compliance with our scheduling policy, and we will continue to audit and improve our work to provide the highest quality of care to the veterans we serve,” Green said in a news release.

The news release said supervisory staff who instructed staff to manipulate data are either no longer employed at the Salisbury VA or are no longer supervisors.

When investigators asked Green about wait times at the Salisbury VA, she told them she had implemented a plan to improve access in May 2013, according to the summary released Tuesday. Green said she took other steps after learning of a wait time scandal at a VA facility in Phoenix.

The problems noted in the federal investigation, however, allegedly began before Green became director in 2012.

In their report, investigators didn’t find any patients who had been waiting for care since 2007. Pending orders for care, however, may not have been effectively managed, the report said

In her interview with investigators, Green said previous management teams had focused on “meeting the metrics” or hitting the numbers rather than achieving the intent behind the metrics. In fact, investigators found that meeting the desired 14-day window was included on employees’ performance reviews.

One VA employee told investigators that an appointment with a wait time greater than 14 days was considered “a scheduling error that needed to be corrected,” Tuesday’s report states. In order to correct it, the employee said she would change patients’ desired date so it fell within 14 days of the actual appointment date.

Investigators presented the report on wait times to the VA’s Office of Accountability Review on September 24, 2015.

When asked about the delay between the referral to another government agency and the report’s release, a spokesman for the Inspector General’s office said his office didn’t want to interfere with any administrative actions the VA may have considered.

Investigators made a number of recommendations to avoid findings similar to those outlined in the report on radiology. Those suggestions included reviewing all unscheduled radiology exam orders that are 30 days past the clinically indicated date, ensuring that staff determine whether harm has occurred to patients because of delays, and developing a plan to ensure patients receive timely access to radiology exams.

An attachment to investigators’ findings says all of the recommendations have been implemented.

A news release from the Salisbury VA says it’s in the midst of hiring two full-time scheduling auditors.

In response to the investigators, U.S. Sen. Richard Burr, R-NC, said it’s unacceptable that veterans are waiting for medical care. No veteran should have to wait for care with the Veterans Choice Program, which allows patients to see private providers instead of Salisbury VA doctors.

“It’s clear that the VA was not effectively using the Choice program to help veterans receive radiological exams in an acceptable time frame and that wait time data was being falsified,” Burr said. “I’m committed to doing whatever it takes to ensure that our veterans get the care they need. I will keep fighting for my legislation to improve the Veterans Choice Program.”

Contact reporter Josh Bergeron at 704-797-4246.