Findings of Veterans Healthcare System Review Called for by Kilmer Released to the Public
Washington, D.C. – Today, U.S. Representative Derek Kilmer (D-WA) noted the release of the first of a series of comprehensive studies that uncovered management problems at the Veterans Health Administration (VHA). In a new report, originally called for by Kilmer, the Government Accountability Office (GAO) found that following scandals related to manipulated wait times and management failures the VA did not follow through on internal and Congressional recommendations to fix the problems.
In 2014 news reports came out about patient delays at the Phoenix VA and other facilities across the country. A national audit of the VA was conducted and it was found at the time that the VA Puget Sound hospital facilities had new patients waiting 59 days – on average – for an appointment. Nearly 100,000 veterans use the VA Puget Sound system. Nationally, the audit found that 13 percent of VA schedulers reported that supervisors told them to manipulate appointments to make wait times look shorter.
“This report is needed to help us ensure we can take care of veterans who have sacrificed so much to protect us,” said Kilmer. “After stories and reports about manipulated wait times and mismanagement in our VA system, it became clear systemic reforms were needed. Now we can move forward with increased oversight and improve care at the VA to get veterans the services they deserve.”
The GAO report evaluated how well the VHA followed through on recommendations to change management practices from internal and outside reviews of the organization. It also looked at how well a realignment of Veterans Integrated Service Networks (VISN) from 21 to 18 was being carried out. Each VISN oversees all VA facilities and personnel in separate regions of the country.
The GAO found:
- Recommendations not carried out: A number of different recommendations from the internal and outside reviews were given to the VHA central offices to more effectively detail what roles and responsibilities need to be carried out at local and national facilities, better measure how core VHA duties are completed, and the best ways to improve services, planning, and communications throughout the entire system. The GAO found that despite spending more than $68 million on these efforts, the majority of these recommendations were not agreed to or implemented by leadership at the VHA.
- No guidance on realignment: The GAO discovered that the VHA did not create a plan to guide the reduction of the VISN networks from 21 to 18. Instead, they allowed each to move forward independently without any guidance or direction. That created problems at the regional level as VISN officials tried to figure out on their own how to incorporate new VA facilities of different sizes and patient populations and matching up electronic records correctly.
The GAO management review studies were included in the Veterans Health Administration Management Improvement Act Kilmer reintroduced last year. Kilmer has worked with Veteran Service Organizations, his Veterans Council, and the Government Accountability Office (GAO) to come up with proposals to effectively address long-term challenges in the VA system. Though the House of Representatives passed a package to address several issues affecting veterans’ healthcare in 2014, Kilmer’s legislation is intended to address and change the underlying culture that caused manipulated wait times.
The Veterans Health Administration Management Improvement Act seeks to supplement and enhance the changes that Congress already made by passing the Veterans Access, Choice and Accountability Act of 2014. The bill takes additional steps to address leadership failures by management, and to make it easier for employees to report mismanagement. Specifically the legislation:
- Directs the GAO to conduct a study to determine what management problems exist at the VA, and establishes a pilot program to provide an opportunity for management to improve;
- Establishes a VHA Management and Accountability Ombudsman to provide a safe avenue for employees to report issues they observe. The Ombudsman would be responsible for keeping the Secretary of Veterans Affairs appraised of employee concerns; and
- Establishes a patients’ bill of rights to create basic rights for VHA beneficiaries, so that veterans have a clear sense of what they are entitled to in their healthcare. The bill of rights was written after consulting multiple stakeholders to ensure it meets industry best practices.
During his time in Congress, Kilmer has sought to address issues facing the nation’s veterans. In both of his terms Kilmer has introduced a bill to add anti-discrimination laws for housing and employment to ensure that military status isn’t used against any veteran looking for a home or a job. Kilmer first announced his VHA reform bill in Tacoma with representatives from local veterans’ organizations. He has also formed a Veterans Advisory Group to identify the challenges that veterans face.