PVAHCS Analysis Worksheet (Assignment 1)
Instructions:
This worksheet has two parts:
1. A table to analyze each of the Office of Inspector General (OIG) allegations and justify corrective action solutions using
IRAC methodology.
2. A series of questions that will target the issues in the Phoenix Veterans Affairs Health Care System (PVAHCS) case most
relevant in the development of a new enterprise risk management (ERM) plan.
Resources:
Use the following resources located in the course to complete this worksheet:
Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care
System
Enterprise Risk Management: Issues and Cases
Note: This text investigates ERM case studies, both inside the healthcare industry and out. It also explores the key issues for
implementing ERM strategies.
Impact Assessment Framework
Perform an internet search for the VHA Publications Index (policies = regulations and directives)
Below are examples of directives. After reviewing the website, you may find more directives applicable to this case.
#1604: Data Entry Requirements for Administrative Data
#2011-002: Office of the Medical Inspector Reports
#1231: Outpatient Clinical Practice Management
#1230: Outpatient Scheduling Process and Procedures
#6300: Records Management
#1128: Timely Scheduling of Surgical Procedures in the Operating Room
#2006-041: Veterans Healthcare Service Standards
#1026: VHA Enterprise Framework for Quality, Safety, and Value
Go to the University of Washington Bioethical Principles site by copying and pasting the following link into your
browser: https://depts.washington.edu/bhdept/ethics-medicine/bioethics-topics/articles/principles-bioethics
Note: The site link above includes the ethical principles found in the C985: Analytical Methods of Health Leaders course.
, Part 1. IRAC Table
Formulate an IRAC (issue, rule, application, and conclusion) response for each of the five OIG violations that includes the
following:
* Issue: Summarize the relevant facts for each violation in the OIG report.
* Rule: Discuss the relevant ethical principles and legal or regulatory requirements for each violation.
* Application: Analyze how the violations deviated from the ethical principles and legal or regulatory requirements
discussed.
* Conclusion: Recommend appropriate ERM corrective actions or solutions for each of the violations.
Clinically significant delays in care
The Phoenix VA Health Care System (PVAHCS) had a significant backlog of veterans waiting for medical
appointments, which was exacerbated by manipulated scheduling practices. Some were homeless and
discharged from the ED without a plan in place for their medical treatment when they should have been
Summary of relevant admitted to the hospital. Many veterans were not placed on the Electronic Wait List (EWL), causing
facts: delays in care. The delayed access to care led to the deterioration in the health of some veterans. The
OIG report identified instances where delayed care was linked to adverse outcomes, including death
and the report highlighted the need for immediate corrective actions to prevent further harm (Veterans
Health Administration, 2014).
Discussion and The allegations of clinically significant delays in care at PVAHCS reveal critical deviations from both
analysis of deviation ethical principles and legal or regulatory standards. Healthcare providers are ethically bound to act in
from ethical the best interest of patients (beneficence) and to do no harm (non-maleficence) (McCormick, 2018).
principles and legal, Discharging a homeless patient requiring insulin to manage his hyperglycemia and not helping him
or regulatory establish a plan to care for him goes against beneficence and non-maleficence.
requirements or
The principle of justice requires that healthcare resources be distributed fairly and equitably. The
standards:
neglect of timely care undermined this principle, as some veterans were effectively denied access to
necessary medical services, leading to unequal treatment and outcomes.
According to #1230 from the VHA's policy for Outpatient Scheduling Process and Procedures, it is policy
that appointments are scheduled timely and accurately with a scheduling goal of 30 days from the date
the appointment is deemed clinically appropriate by a VA provider (Veterans Health Administration,
2022).
The delay in care may also constitute negligence or medical malpractice, as the failure to provide
timely care leg to adverse health outcomes. The evidence of patient deaths linked to these delays
suggests a failure to meet the standard of care that a reasonably sensible provider would under similar
Instructions:
This worksheet has two parts:
1. A table to analyze each of the Office of Inspector General (OIG) allegations and justify corrective action solutions using
IRAC methodology.
2. A series of questions that will target the issues in the Phoenix Veterans Affairs Health Care System (PVAHCS) case most
relevant in the development of a new enterprise risk management (ERM) plan.
Resources:
Use the following resources located in the course to complete this worksheet:
Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care
System
Enterprise Risk Management: Issues and Cases
Note: This text investigates ERM case studies, both inside the healthcare industry and out. It also explores the key issues for
implementing ERM strategies.
Impact Assessment Framework
Perform an internet search for the VHA Publications Index (policies = regulations and directives)
Below are examples of directives. After reviewing the website, you may find more directives applicable to this case.
#1604: Data Entry Requirements for Administrative Data
#2011-002: Office of the Medical Inspector Reports
#1231: Outpatient Clinical Practice Management
#1230: Outpatient Scheduling Process and Procedures
#6300: Records Management
#1128: Timely Scheduling of Surgical Procedures in the Operating Room
#2006-041: Veterans Healthcare Service Standards
#1026: VHA Enterprise Framework for Quality, Safety, and Value
Go to the University of Washington Bioethical Principles site by copying and pasting the following link into your
browser: https://depts.washington.edu/bhdept/ethics-medicine/bioethics-topics/articles/principles-bioethics
Note: The site link above includes the ethical principles found in the C985: Analytical Methods of Health Leaders course.
, Part 1. IRAC Table
Formulate an IRAC (issue, rule, application, and conclusion) response for each of the five OIG violations that includes the
following:
* Issue: Summarize the relevant facts for each violation in the OIG report.
* Rule: Discuss the relevant ethical principles and legal or regulatory requirements for each violation.
* Application: Analyze how the violations deviated from the ethical principles and legal or regulatory requirements
discussed.
* Conclusion: Recommend appropriate ERM corrective actions or solutions for each of the violations.
Clinically significant delays in care
The Phoenix VA Health Care System (PVAHCS) had a significant backlog of veterans waiting for medical
appointments, which was exacerbated by manipulated scheduling practices. Some were homeless and
discharged from the ED without a plan in place for their medical treatment when they should have been
Summary of relevant admitted to the hospital. Many veterans were not placed on the Electronic Wait List (EWL), causing
facts: delays in care. The delayed access to care led to the deterioration in the health of some veterans. The
OIG report identified instances where delayed care was linked to adverse outcomes, including death
and the report highlighted the need for immediate corrective actions to prevent further harm (Veterans
Health Administration, 2014).
Discussion and The allegations of clinically significant delays in care at PVAHCS reveal critical deviations from both
analysis of deviation ethical principles and legal or regulatory standards. Healthcare providers are ethically bound to act in
from ethical the best interest of patients (beneficence) and to do no harm (non-maleficence) (McCormick, 2018).
principles and legal, Discharging a homeless patient requiring insulin to manage his hyperglycemia and not helping him
or regulatory establish a plan to care for him goes against beneficence and non-maleficence.
requirements or
The principle of justice requires that healthcare resources be distributed fairly and equitably. The
standards:
neglect of timely care undermined this principle, as some veterans were effectively denied access to
necessary medical services, leading to unequal treatment and outcomes.
According to #1230 from the VHA's policy for Outpatient Scheduling Process and Procedures, it is policy
that appointments are scheduled timely and accurately with a scheduling goal of 30 days from the date
the appointment is deemed clinically appropriate by a VA provider (Veterans Health Administration,
2022).
The delay in care may also constitute negligence or medical malpractice, as the failure to provide
timely care leg to adverse health outcomes. The evidence of patient deaths linked to these delays
suggests a failure to meet the standard of care that a reasonably sensible provider would under similar
