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Unit 8 Assignment Case Study: Problems at the VA Health System

In 2009, President Barack Obama appointed retired Army Chief of Staff, General Eric Shinseki, to the position of secretary of Veterans Affairs (VA), the federal department responsible for providing healthcare and federal benefits to U.S. veterans and dependents. As part of its strategic plan, Secretary Shinseki was tasked with implementing 16 major initiatives to bring the VA into the 21st century. One of the 16 initiatives was the enhancement of the veteran’s experience with and access to healthcare. 

In 2013, CNN was among the news outlets reporting that veterans were experiencing delayed care at the Williams Jennings Bryan Dorn Veterans Medical Center in Columbia, SC. In fact, the delays were so serious that six veterans died while waiting for months to receive necessary diagnostic procedures. The VA launched an investigation into the GI clinic at Dorn and found several issues, including low staff census; leadership turnover that resulted in a lack of understanding of roles, responsibilities and system processes; and ineffective program coordination. Allegations of long wait times also emerged from VA facilities in Arizona, Pittsburgh, and the Phoenix VA Health Care System. Delays, however, were not the only shortcomings alleged. In the Phoenix VA Health Care System, for instance, there were claims of manipulated patient wait times, bad scheduling practices, and patient deaths.  

In 2014, the Office of the Inspector General (OIG) launched an investigation into these allegations. Two questions were addressed in this review: 

1. Did the facility’s electronic wait list (EWL) purposely omit the names of veterans waiting for care and, if so, at whose direction?
2. Were the deaths of any of these veterans related to delays in care?  

The investigators confirmed “inappropriate scheduling issues throughout the VA and health care system” (VA 2014, iii). 

In the Phoenix VA, specifically, investigators found that 1,400 veterans did not have a primary care

appointment but were listed on the EWL. It was also determined that 1,700 veterans were waiting for a primary care appointment but were not listed on the EWL. Because veterans were not on the EWL system, the Phoenix leadership significantly understated the time new patients waited for the appointments. The investigators found that the average wait time was 115 days for the first primary care appointment and about 84 percent of these patients waited more than 14 days. 

The Office of Inspector General (OIG) identified multiple types of scheduling practices that were not in compliance with Veterans Health Administration policy. Since the multiple lists found were something other than the official EWL, the additional lists may be the basis for allegations of “secret” wait lists. 

Case Study Questions  

1. From a leadership perspective, analyze the problems at the VA relative to ethical decision-making practices.
2. Discuss the ethical issue of having 1,700 veterans, who were not listed on the EWL, wait for a primary care appointment at the Phoenix VA. Create at least two (2) policies/standards to ensure ethical leadership practices with respect to improving coordination of the EWL and primary care appointments.
3. Explain why Secretary Eric Shinseki resigned his position. Identify at least two (2) alternative options that Secretary Shinseki could have taken to resolve the unethical decision-making practices in this case study.
4. Apply the American College of Healthcare Executives (ACHE) Code of Ethics to the VA Health System case study. 

Secretary Shinseki called the findings “reprehensible” and resigned from his post on May 30, 2014.