Dennis Wagner

The Republic | azcentral.com

Southwestern VA officials knew in 2012 that inaccurate data on patient wait times was a problem.

A former VA official said untrustworthy statistics made it impossible to know if goals were met.

Appointments routinely were canceled in blocks by VA clinics%2C then blamed on patient cancellations.

The Department of Veterans Affairs has consistently ignored whistle-blower warnings about dangerous practices that jeopardize patient safety, according to a scathing letter sent to President Barack Obama by the Office of Special Counsel.

The letter sent Monday by the independent federal investigative agency says the failure of Phoenix VA officials to heed alerts about fraudulent appointment scheduling is part of a "troubling pattern" nationally where the VA investigated and verified complaints but did nothing to correct problems.

"The VA, and particularly the VA's Office of the Medical Inspector, has consistently used a 'harmless error' defense, where the department acknowledges problems but claims patient care is unaffected," says the letter. "This approach has prevented the VA from acknowledging the severity of systemic problems and from taking the necessary steps to provide quality care to veterans."

The letter goes on to say that assertion of "harmless error" in many cases was "unsupportable." It listed numerous instances where employees reported unlawful prescriptions, delayed care, medical negligence and other issues, yet the complaints were simply cast aside after they were confirmed.

Acting VA Secretary Sloan Gibson immediately ordered a review of the department's response system for dealing with whistle-blower complaints.

"I respect and welcome the letter and the insights from the Office of Special Counsel. I am deeply disappointed not only in the substantiation of allegations raised by whistle-blowers, but also in the failures within VA to take the whistle-blower complaints seriously."

The Office of Special Counsel is an investigative and prosecutorial agency that focuses on federal agency abuses and failures. In her letter to Obama, Special Counsel Carolyn Lerner said the agency has 50 pending cases involving VA whistle-blowers that alleged threats to patient health or safety. Of those, 29 have been referred to the VA for investigation — more than a quarter of all referrals by the office.

The OSC letter cited Phoenix as one example, but also described egregious conditions in other VA medical centers.

In Jackson, Miss., numerous employees filed complaints about unsterile equipment, flawed chemotherapy drugs and other issues. In an attempt to work around staffing shortages, the letters says, patients were assigned to appointments in "ghost clinics" that had no doctors, so no appointments was possible.

In Fort Collins, Colo., whistle-blowers raised a red flag last year about bogus scheduling methods and prolonged delays in care similar to those in Phoenix. The letter says staffers were directed to falsify wait times and those who did not comply "were put on a 'bad boy' list" and transferred to Wyoming.

In a mental health facility in Brockton, Mass., one patient went eight years without a psychiatric evaluation and another went seven years without a single note in his chart. Nevertheless, the Office of Medical Inspector declared the negligence "harmless." The OSC letter says such findings are "a serious disservice to the veterans."

The letter says whistle-blowers at other facilities exposed a pulmonologist who falsified records on more than 1,200 patients, the contamination of drinking water with Legionella bacteria, and unsanitary practices with surgical instruments — all confirmed and ignored.

Lerner urged Gibson to carry out corrective actions, including the discipline of culpable employees.

Gibson immediately ordered a comprehensive review of all aspects of the Office of Medical Inspector (OMI) operations within 14 days, with "consideration of personnel actions."

Rep. Ann Kirkpatrick, D-Ariz., a member of the House Committee on Veterans' Affairs, called on the VA to end a "culture of retaliation and reprisal" against whistle-blowers.

"As a former prosecutor, I would add that if anyone is hiding information, retaliating against whistle-blowers, or impeding an investigation, they will be exposed and held accountable," Kirkpatrick added. "It is against the law for VA leadership to prevent a VA employee from providing information to Congress. The VA must take immediate steps to protect whistle-blowers under the law, and it must end a culture of tolerating retaliation against whistle-blowers."

The Office of the Medical Inspector is an internal VA department that reviews complaints to determine whether misconduct or systemic failures have endangered patient lives. The VA has come under intense congressional criticism because those investigations are confidential, so politicians and the public cannot learn whether dysfunction in the VA may be killing or maiming veterans.

Congressional scrutiny continued Monday as the House Veterans' Affairs Committee grilled Dr. Thomas Lynch, VA assistant deputy under secretary for health for clinical operations, about the agency's ability to quickly treat patients left off waiting lists.

Lynch told the committee the VA is aggressively looking to add doctors to cut wait times and will go outside the system to hire private doctors if appointment wait times exceed 30 days. Committee members, however, were skeptical. Kirkpatrick questioned why the VA wasn't prepared to handle a surge in patients and why it has been slow to respond to Congress' questions.

Lynch acknowledged VA data provided in the past "was not honest," and the agency plans to hire an independent third-party consultant to verify that records are accurate.

Rep. Mike Coffman, R-Colo., asked Lynch why he continued to defend the system and why VA executives did not listen to whistle-blowers, including those at the Phoenix VA. He also ripped the VA for handing out large bonuses to executives at hospitals that were found to have manipulated records.

"I'm stunned with all the information that has come out that you would call this a good system," Coffman said. "I think the ... (VA) is the most mismanaged agency in the federal government. It has not been there to serve those who serve our country. The leadership has been there to serve itself ... The only thing you are effective at is writing checks to one another."

The House and Senate Veterans' Affairs Conference Committee, which is trying to craft a bipartisan VA reform bill, will hold its first meeting Tuesday in Washington, D.C. The meeting begins at 11 a.m. Arizona time. The committee's goal is to get legislation to Obama for his signature by Independence Day.

Sen. Jerry Moran R-Kan., a member of the Senate Veterans' Affairs Committee, on Monday 6/23 repeated a call for the release of OMI reports, declaring that publication "will allow Americans, the press, Congress and veterans to see what the VA knew, when they knew it and what they did about it."

The latest criticism hits an agency reeling from scandal that originated with Phoenix disclosures that thousands of patients who sought appointments were delayed and sidetracked by improper scheduling practices. Whistle-blowers said up to 40 patients may have died awaiting care as a result of data manipulation that allowed employees to collect bonuses for meeting wait-time goals.

Since April, the VA Office of Inspector General has launched investigations in at least 42 VA locations.

Former VA Secretary Eric Shinseki and a top deputy resigned. The top VA health care officials in Arizona have been removed.

Ten days ago, Gibson sent a letter to all of the VA's 341,000 employees urging them to report mismanagement, misconduct and systemic flaws. He also vowed to protect from retaliation those who come forward .

Dennis Wagner has been a beat reporter, columnist and investigative journalist at The Republic for 31 years. He focuses on watchdog stories involving public money, corruption and misconduct. He broke the first story in the VA scandal by writing April 10 about allegations of falsified wait times in Phoenix.

How to reach him

dennis.wagner@arizonarepublic.com

Phone: 602-444-8874

Twitter: @azrover