PVAHCS Analysis Worksheet (Assignment 1) kx kx kx kx
Instructions:
This worksheet has two parts:
kx kx kx kx
1. A table to analyze each of the Office of Inspector General (OIG) allegations and justify corrective action solutions using IRAC
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
methodology.kx kx
2. A series of questions that will target the issues in the Phoenix Veterans Affairs Health Care System (PVAHCS) case most relevant
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
in the development of a new enterprise risk management (ERM) plan.
kx kx kx kx kx kx kx kx kx kx kx kx
Resources:
Use the following resources located in the course to complete this worksheet:
kx kx kx kx kx kx kx kx kx kx kx
Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
System
kx
Enterprise Risk Management: Issues and Cases kx kx kx kx kx
Note: This text investigates ERM case studies, both inside the healthcare industry and out. It also explores the key issues for
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
implementing ERM strategies.
kx kx kx
Impact Assessment Framework kx kx kx
Perform an internet search for the VHA Publications Index (policies = regulations and directives)
kx kx kx kx kx kx kx kx kx kx kx kx kx
Below are examples of directives. After reviewing the website, you may find more directives applicable to this case.
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
#1604: Data Entry Requirements for Administrative Data kx kx kx kx kx kx
#2011-002: Office of the Medical Inspector Reports kx kx kx kx kx kx
#1231: Outpatient Clinical Practice Management kx kx kx kx
#1230: Outpatient Scheduling Process and Procedures kx kx kx kx kx
#6300: Records Management kx kx
#1128: Timely Scheduling of Surgical Procedures in the Operating Room kx kx kx kx kx kx kx kx kx
#2006-041: Veterans Healthcare Service Standards kx kx kx kx
#1026: VHA Enterprise Framework for Quality, Safety, and Value kx kx kx kx kx kx kx kx
Go to the University of Washington Bioethical Principles site by copying and pasting the following link into your browser:
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
kx 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.
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
, Part 1. IRAC Table
kx kx kx
Formulate an IRAC (issue, rule, application, and conclusion) response for each of the five OIG violations that includes the following:
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
Issue: Summarize the relevant facts for each violation in the OIG report.
kx kx kx kx kx kx kx kx kx kx kx
Rule: Discuss the relevant ethical principles and legal or regulatory requirements for each violation.
kx kx kx kx kx kx kx kx kx kx kx kx kx
Application: Analyze how the violations deviated from the ethical principles and legal or regulatory requirements discussed.
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
Conclusion: Recommend appropriate ERM corrective actions or solutions for each of the violations.
kx kx kx kx kx kx kx kx kx kx kx kx
Clinically significant delays in care kx kx kx kx
A review identified 28 instances of harm linked to clinically significant delays in care resulting from scheduling
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
and access issues, with six of these patients deceased. Additionally, 17 patients received inadequate care
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
unrelated to scheduling, 14 of whom were also deceased. Complications were noted explicitly in access to
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
Summary of relevant kx kx
urology services. In total, 45 patients experienced clinically significant delays attributed to "unacceptable
facts:
kx kx kx kx kx kx kx kx kx kx kx kx kx
kx kx
and troubling lapses in follow-up, coordination, quality, and continuity of care" (Veterans Health
kx kx kx kx kx kx kx kx kx kx kx kx kx
Administration, 2014–b, p.1).
kx kx kx
Discussion and
The delays in care identified contravene two fundamental principles of medical ethics: nonmaleficence and
kx
analysis of deviation
kx kx kx kx kx kx kx kx kx kx kx kx kx
beneficence. Nonmaleficence involves avoiding harm, which can result from actions and omissions, such as
kx kx kx
from ethical principles
kx kx kx kx kx kx kx kx kx kx kx kx kx kx
failing to create an appointment. This negligence reflects carelessness. Beneficence emphasizes the
kx kx kx
and legal, or
kx kx kx kx kx kx kx kx kx kx kx kx
responsibility of healthcare providers to benefit patients. When patients request appointments, they trust
kx kx kx
regulatory
kx kx kx kx kx kx kx kx kx kx kx kx kx
the scheduling team as part of their care team, expecting timely access to necessary services (McCormick,
kx
requirements or
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
n.d.).
kx kx
standards:
kx kx
kx kx
It is recommended that the Veterans Health Administration review the cases mentioned in this report to
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
address potential patient injuries and allegations of poor care quality. For patients who experienced adverse
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
outcomes, the Phoenix VA Health Care System (PVAHCS) should consult with legal counsel about
ERM corrective action
kx kx kx kx kx kx kx kx kx kx kx kx kx kx
appropriate disclosures to patients and their families. Additionally, it is recommended that the PVAHCS
kx kx
or solution
kx kx kx kx kx kx kx kx kx kx kx kx kx kx
maintains continuity of health care, reduces delays in assigning dedicated providers, and expands access to
kx kx
recommendation:
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
services. Furthermore, they ensure timely and quality access to care and establish a process requiring facility
kx
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
directors to notify the Veterans Health Administration when their facilities cannot meet access or quality
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
standards (Veterans Health Administration, 2014–b).
kx kx kx kx kx
Omission of the names of veterans waiting for care from its electronic wait list (EWL)
kx kx kx kx kx kx kx kx kx kx kx kx kx kx
Instructions:
This worksheet has two parts:
kx kx kx kx
1. A table to analyze each of the Office of Inspector General (OIG) allegations and justify corrective action solutions using IRAC
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
methodology.kx kx
2. A series of questions that will target the issues in the Phoenix Veterans Affairs Health Care System (PVAHCS) case most relevant
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
in the development of a new enterprise risk management (ERM) plan.
kx kx kx kx kx kx kx kx kx kx kx kx
Resources:
Use the following resources located in the course to complete this worksheet:
kx kx kx kx kx kx kx kx kx kx kx
Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
System
kx
Enterprise Risk Management: Issues and Cases kx kx kx kx kx
Note: This text investigates ERM case studies, both inside the healthcare industry and out. It also explores the key issues for
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
implementing ERM strategies.
kx kx kx
Impact Assessment Framework kx kx kx
Perform an internet search for the VHA Publications Index (policies = regulations and directives)
kx kx kx kx kx kx kx kx kx kx kx kx kx
Below are examples of directives. After reviewing the website, you may find more directives applicable to this case.
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
#1604: Data Entry Requirements for Administrative Data kx kx kx kx kx kx
#2011-002: Office of the Medical Inspector Reports kx kx kx kx kx kx
#1231: Outpatient Clinical Practice Management kx kx kx kx
#1230: Outpatient Scheduling Process and Procedures kx kx kx kx kx
#6300: Records Management kx kx
#1128: Timely Scheduling of Surgical Procedures in the Operating Room kx kx kx kx kx kx kx kx kx
#2006-041: Veterans Healthcare Service Standards kx kx kx kx
#1026: VHA Enterprise Framework for Quality, Safety, and Value kx kx kx kx kx kx kx kx
Go to the University of Washington Bioethical Principles site by copying and pasting the following link into your browser:
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
kx 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.
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
, Part 1. IRAC Table
kx kx kx
Formulate an IRAC (issue, rule, application, and conclusion) response for each of the five OIG violations that includes the following:
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
Issue: Summarize the relevant facts for each violation in the OIG report.
kx kx kx kx kx kx kx kx kx kx kx
Rule: Discuss the relevant ethical principles and legal or regulatory requirements for each violation.
kx kx kx kx kx kx kx kx kx kx kx kx kx
Application: Analyze how the violations deviated from the ethical principles and legal or regulatory requirements discussed.
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
Conclusion: Recommend appropriate ERM corrective actions or solutions for each of the violations.
kx kx kx kx kx kx kx kx kx kx kx kx
Clinically significant delays in care kx kx kx kx
A review identified 28 instances of harm linked to clinically significant delays in care resulting from scheduling
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
and access issues, with six of these patients deceased. Additionally, 17 patients received inadequate care
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
unrelated to scheduling, 14 of whom were also deceased. Complications were noted explicitly in access to
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
Summary of relevant kx kx
urology services. In total, 45 patients experienced clinically significant delays attributed to "unacceptable
facts:
kx kx kx kx kx kx kx kx kx kx kx kx kx
kx kx
and troubling lapses in follow-up, coordination, quality, and continuity of care" (Veterans Health
kx kx kx kx kx kx kx kx kx kx kx kx kx
Administration, 2014–b, p.1).
kx kx kx
Discussion and
The delays in care identified contravene two fundamental principles of medical ethics: nonmaleficence and
kx
analysis of deviation
kx kx kx kx kx kx kx kx kx kx kx kx kx
beneficence. Nonmaleficence involves avoiding harm, which can result from actions and omissions, such as
kx kx kx
from ethical principles
kx kx kx kx kx kx kx kx kx kx kx kx kx kx
failing to create an appointment. This negligence reflects carelessness. Beneficence emphasizes the
kx kx kx
and legal, or
kx kx kx kx kx kx kx kx kx kx kx kx
responsibility of healthcare providers to benefit patients. When patients request appointments, they trust
kx kx kx
regulatory
kx kx kx kx kx kx kx kx kx kx kx kx kx
the scheduling team as part of their care team, expecting timely access to necessary services (McCormick,
kx
requirements or
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
n.d.).
kx kx
standards:
kx kx
kx kx
It is recommended that the Veterans Health Administration review the cases mentioned in this report to
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
address potential patient injuries and allegations of poor care quality. For patients who experienced adverse
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
outcomes, the Phoenix VA Health Care System (PVAHCS) should consult with legal counsel about
ERM corrective action
kx kx kx kx kx kx kx kx kx kx kx kx kx kx
appropriate disclosures to patients and their families. Additionally, it is recommended that the PVAHCS
kx kx
or solution
kx kx kx kx kx kx kx kx kx kx kx kx kx kx
maintains continuity of health care, reduces delays in assigning dedicated providers, and expands access to
kx kx
recommendation:
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
services. Furthermore, they ensure timely and quality access to care and establish a process requiring facility
kx
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
directors to notify the Veterans Health Administration when their facilities cannot meet access or quality
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
standards (Veterans Health Administration, 2014–b).
kx kx kx kx kx
Omission of the names of veterans waiting for care from its electronic wait list (EWL)
kx kx kx kx kx kx kx kx kx kx kx kx kx kx
