Although the report found no evidence that care delays within the Phoenix VA were directly responsible for 40 veterans' deaths, it did determine access barriers adversely affected veterans' primary and specialty care, according to the report. VA patients encountered these barriers when they or their providers "attempted to establish care, when they needed outpatient appointments after hospitalizations or emergency department visits, and when seeking care while traveling or temporarily living in Phoenix," the OIG wrote in a Q&A accompanying the report.
OIG reviewed 45 patient cases and, in addition to the access barriers, found "unacceptable and troubling" negligence in terms of care coordination, follow-up, continuity of care and quality. The review included both 28 patients directly affected by care delays and 17 patients whose care did not meet expected standards independent of delays.
OIG made 24 recommendations for improvement of the Phoenix VA, including:
Establishing a process requiring the Veterans Health Administration to notify the Under Secretary of Health when they are unable to meet standards for access or quality
Ensuring new enrollees obtain an appointment "within the time frames directed by Veterans Health Administration policy"
Establishing internal mechanisms for regular scheduling quality reviews
Adding measures of both employee and veteran satisfaction to the Phoenix VA's performance plans and facility goals
"The VA Secretary [Robert McDonald] acknowledged that VA is in the midst of a very serious crisis and will use the OIG's recommendations to hone the focus of VA's actions moving forward," the report summary states." The VA Secretary also apologized to all veterans and stated the VA will continue to listen to veterans, their families, Veterans Service Organizations, and VA employees to improve access to the care and benefits veterans earned and deserve."