WGU D515 Assignment 1 | PVAHCS Analysis Worksheet 2 0 2 5
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 f or
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
In February 2014, the Office of Inspector General (OIG) received a whistleblower’s allegation that 40
veterans had died while waiting for appointments at the Phoenix VA Health Care System (PVAHCS)
(Veterans Health Administration, 2014). In response, the OIG investigated, examining the electronic
health records (EHRs) and other documentation for 3,409 veteran patients. In its analysis, the OIG
identified delays in care that were clinically significant in medical, surgical, or mental health care in 28
instances (with 6 of these patients deceased), and care deficiencies in 17 cases unrelated to access or
scheduling (with 14 of these patients deceased), 4 patients with conditions newly diagnosed, and 1
patient that was considered to be a risk to the public.
The majority of the patients reviewed were on wait lists, both official and unofficial, and had
experienced delays with primary care access (Veterans Health Administration, 2014). The investigation
Summary of relevant
found over 3,500 veterans on an unofficial wait list for appointments; because they were not on the
facts:
PVAHCS’s official electronic wait list (EWL), they were at risk of never receiving their necessary
appointments. PVAHCS executives were aware of the inappropriate scheduling practices.
The OIG concluded that veterans utilizing the PVAHCS experienced barriers to care access that
negatively affected the quality of primary and specialty care provided (Veterans Health Administration,
2014). There were frequent obstacles for patients to establish care, obtain an ou tpatient appointment
after discharge from the hospital or emergency department, and seek care when visiting Phoenix.
Problems were also identified with mental health care continuity and transitions, as well as issues with
limited access to psychotherapy. Additionally, there were significant issues found with patient access to
Urology Services. The OIG stated that lapses in follow-up, coordination of care, quality, and continuity of
care are unacceptable and troubling.
Discussion and
analysis of deviation
from ethical Deviation from legal/regulatory requirements: The Veterans Health Administration’s (VHA)
, directive 1230: Outpatient Scheduling Management states that the Patient Indicated Date (PID) is the
veteran’s preferred date, and this cannot be changed due to capacity or access reasons (U.S.
Department of Veterans Affairs, n.d.). Scheduling staff who use the wrong date of care desired by the
veteran or reschedule an appointment with a later desired date to show an improved wait time are in
clear violation of this directive.
Directive 1230 requires that the VA facility’s director monitors compliance with this directive and
reports non-compliance to the Veterans Integrated Service Network (VISN) Director (Veterans Health
principles and legal,
Administration, 2014). PVAHCS executives and senior clinical staff were aware of the inappropriate
or regulatory
scheduling practices but failed to comply with this policy, so they are in violation of this directive.
requirements or
standards:
Deviation from ethical principles: An ethical violation committed through inappropriate scheduling
practices is that of nonmaleficence, which requires that one does not intentionally cause harm or injury
to the patient, whether through acts performed or omitted (McCormick, n.d.). The deviation from
scheduling standards constitutes nonmaleficence in preventing the veterans from receiving
appointments that are managed safely, timely, and accurately, based on clinical need and the veteran’s
preference according to VHA policy (U.S. Department of Veterans Affairs, n.d.). This resulted in care
that was significantly delayed which may have resulted in adverse health outcomes to include further
worsening of a chronic condition, up to and including death.
-Review VHA policy with the PVAHCS facility director and charge this individual with ensuring that all
staff, from senior executives to scheduling staff, are educated and trained on appropriate practices to
comply with all VHA directives.
-Continued annual refresher training for staff regarding scheduling directives to ensure that all
veterans’ appointments are managed safely, timely, and accurately per VHA policy.
ERM corrective action
or solution -Conduct regular internal audits to ensure policy compliance moving forward.
recommendation: -Establish a process that requires the facility director to notify, through appropriate channels, the VISN
Director when the facility cannot meet access or quality of care standards.
-Ensure continuity of care for mental health services, including the accessibility of psychotherapy for
those veterans in need.
-Establish and monitor improved access to care for patients who require Urology Services.
Omission of the names of veterans waiting for care from its electronic wait list (EWL)
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 f or
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
In February 2014, the Office of Inspector General (OIG) received a whistleblower’s allegation that 40
veterans had died while waiting for appointments at the Phoenix VA Health Care System (PVAHCS)
(Veterans Health Administration, 2014). In response, the OIG investigated, examining the electronic
health records (EHRs) and other documentation for 3,409 veteran patients. In its analysis, the OIG
identified delays in care that were clinically significant in medical, surgical, or mental health care in 28
instances (with 6 of these patients deceased), and care deficiencies in 17 cases unrelated to access or
scheduling (with 14 of these patients deceased), 4 patients with conditions newly diagnosed, and 1
patient that was considered to be a risk to the public.
The majority of the patients reviewed were on wait lists, both official and unofficial, and had
experienced delays with primary care access (Veterans Health Administration, 2014). The investigation
Summary of relevant
found over 3,500 veterans on an unofficial wait list for appointments; because they were not on the
facts:
PVAHCS’s official electronic wait list (EWL), they were at risk of never receiving their necessary
appointments. PVAHCS executives were aware of the inappropriate scheduling practices.
The OIG concluded that veterans utilizing the PVAHCS experienced barriers to care access that
negatively affected the quality of primary and specialty care provided (Veterans Health Administration,
2014). There were frequent obstacles for patients to establish care, obtain an ou tpatient appointment
after discharge from the hospital or emergency department, and seek care when visiting Phoenix.
Problems were also identified with mental health care continuity and transitions, as well as issues with
limited access to psychotherapy. Additionally, there were significant issues found with patient access to
Urology Services. The OIG stated that lapses in follow-up, coordination of care, quality, and continuity of
care are unacceptable and troubling.
Discussion and
analysis of deviation
from ethical Deviation from legal/regulatory requirements: The Veterans Health Administration’s (VHA)
, directive 1230: Outpatient Scheduling Management states that the Patient Indicated Date (PID) is the
veteran’s preferred date, and this cannot be changed due to capacity or access reasons (U.S.
Department of Veterans Affairs, n.d.). Scheduling staff who use the wrong date of care desired by the
veteran or reschedule an appointment with a later desired date to show an improved wait time are in
clear violation of this directive.
Directive 1230 requires that the VA facility’s director monitors compliance with this directive and
reports non-compliance to the Veterans Integrated Service Network (VISN) Director (Veterans Health
principles and legal,
Administration, 2014). PVAHCS executives and senior clinical staff were aware of the inappropriate
or regulatory
scheduling practices but failed to comply with this policy, so they are in violation of this directive.
requirements or
standards:
Deviation from ethical principles: An ethical violation committed through inappropriate scheduling
practices is that of nonmaleficence, which requires that one does not intentionally cause harm or injury
to the patient, whether through acts performed or omitted (McCormick, n.d.). The deviation from
scheduling standards constitutes nonmaleficence in preventing the veterans from receiving
appointments that are managed safely, timely, and accurately, based on clinical need and the veteran’s
preference according to VHA policy (U.S. Department of Veterans Affairs, n.d.). This resulted in care
that was significantly delayed which may have resulted in adverse health outcomes to include further
worsening of a chronic condition, up to and including death.
-Review VHA policy with the PVAHCS facility director and charge this individual with ensuring that all
staff, from senior executives to scheduling staff, are educated and trained on appropriate practices to
comply with all VHA directives.
-Continued annual refresher training for staff regarding scheduling directives to ensure that all
veterans’ appointments are managed safely, timely, and accurately per VHA policy.
ERM corrective action
or solution -Conduct regular internal audits to ensure policy compliance moving forward.
recommendation: -Establish a process that requires the facility director to notify, through appropriate channels, the VISN
Director when the facility cannot meet access or quality of care standards.
-Ensure continuity of care for mental health services, including the accessibility of psychotherapy for
those veterans in need.
-Establish and monitor improved access to care for patients who require Urology Services.
Omission of the names of veterans waiting for care from its electronic wait list (EWL)
