In June 2013, an administrative assistant at the Phoenix VA Health Care System noticed a chart. It hung, very large, on the wall of Room D641, and it showed a steady decline in the number of days new patients waited for an appointment. The latest figure, for April 2013, was 36.8 days.
He had been asking why a veteran who requested a primary care doctor in mid-May still had no appointment in June. One veteran he named in his email had been waiting more than 60 days. “Why the variance?” he wrote to a group of colleagues, and he suggested someone check how the numbers were calculated before the director reported them outside Phoenix.
The number on the wall had a long history. In 1995 the Veterans Health Administration set a goal of scheduling appointments within 30 days. In fiscal year 2011, according to the Government Accountability Office, it shortened the goal to 14 days, based on improved performance reported in previous years. Wait-time measures were written into the performance contracts of regional network directors and medical center directors, contracts that determine their performance pay.
In the measures the GAO reviewed in 2012, each wait was counted from a “desired date,” the day the patient or provider wanted the appointment, typed in by a scheduler. In December 2012 the GAO called VA’s reported wait times unreliable: three schedulers it observed had changed the desired date based on appointment availability.
In 2013 the Phoenix director made access to primary care her “Wildly Important Goal.” At first it used a local measure, not the national 14-day one: every primary care doctor was to have a third-next available appointment within 7 days. Posters around the facility showed each clinic’s success or failure against it. After July 2013 she changed the goal to match regional and national metrics: by September 30, more than 40 percent of new primary care patients would be seen within 14 days of the date their appointment was created. In her self-assessment for the year, she reported that the share of new patients getting an appointment within 14 days had risen from 32 percent to 50 percent. She received a performance award of $8,495.
In 2014, after allegations about Phoenix, the VA inspector general went through a statistical sample of 226 new-patient appointments there from fiscal year 2013. VA’s national data said those veterans had waited 24 days on average and that 43 percent had waited more than 14 days. The inspector general found an average of 115 days, with about 84 percent waiting more than 14 days. Investigators also found about 1,700 veterans waiting for a primary care appointment who were not on the official electronic wait list at all, so for them the clock had not started.
Schedulers described how the numbers were made. Thirty Phoenix staff said they had used the wrong desired date, producing a false wait of zero days. At one VA location, a scheduler told investigators, each supervisor received a list of schedulers who had exceeded the 14-day goal; to stay off it, schedulers changed the desired date to the next available appointment.
A system-wide VA audit that spring interviewed more than 3,700 staff across 731 facilities. Thirteen percent of schedulers said they had been told to enter a desired date different from the one the veteran asked for. Some such changes can be proper, the audit noted, since under VA policy a date set by a doctor can override the patient’s; the survey did not separate those from improper ones. The audit concluded that the 14-day target “was simply not attainable” given the shortage of provider appointment slots, and that imposing it “before ascertaining the resources required” was “an organizational leadership failure.”
After the inspector general’s interim report, the Acting VA Secretary removed the 14-day goal from employee performance contracts. VA rescinded the Phoenix director’s award.