WGU D515 Assignment 1 | PVAHCS
Analysis Worksheet 2025 with
complete solutions
Strategic Questions for ERM Plan Development
1. According to the OIG report, how many serious violations
against PVAHCS were confirmed?
Correct Answer: Five serious violations.
Rationale: The VA OIG investigation confirmed five serious violations including clinically
significant delays in care, omission of patient names from EWL, organizational culture
emphasizing goals over patient care, noncompliance with scheduling procedures, and
systemic scheduling deficiencies throughout VHA.
,2. What is the most critical OIG violation identified at PVAHCS?
Correct Answer: Clinically significant delays in care resulting in adverse outcomes for
veterans.
Rationale: The OIG report identified clinically significant delays that led to deterioration
in health of several veterans, with instances linked to death—representing a failure to
meet the standard of care.
3. What adverse outcomes resulted from the clinically significant
delays in care?
Correct Answer: Deterioration in health and death of several veterans.
Rationale: The evidence of patient deaths linked to these delays suggests a failure to
meet the standard of care that a reasonably prudent provider would deliver under
similar circumstances.
4. What was the scheduling goal according to VHA Directive
1230?
Correct Answer: 30 days from the date the appointment is deemed clinically
appropriate.
Rationale: VHA Directive 1230 (Outpatient Scheduling Process and Procedures)
establishes policy that appointments must be scheduled timely and accurately with a
,scheduling goal of 30 days from the date the appointment is deemed clinically
appropriate by a VA provider.
5. How many veterans waited over 200 days for an appointment?
Correct Answer: 1,138 veterans.
Rationale: It was reported that 1,138 veterans waited over 200 days for an appointment.
However, this number is inaccurate because out of the 1,138, only 53 of those patients
were actually on the Electronic Waitlist (EWL), indicating significant data manipulation.
6. How many veterans were appropriately included on the EWL
but still did not have primary care appointments?
Correct Answer: 1,400 veterans.
Rationale: The OIG report identified 1,400 veterans who did not have primary care
appointments although they were appropriately included in the Phoenix Healthcare
Service electronic waitlist.
7. How many veterans were waiting for primary care
appointments but were NOT included in the EWL?
Correct Answer: 1,700 veterans.
, Rationale: The review identified about 1,700 veterans who were waiting for primary care
appointments but were not included in the electronic waitlist. These veterans had been
placed in an "imaginary" waitlist where their wait times had not officially started.
8. What specific practice did the Phoenix VA use to hide the true
scope of the access-to-care crisis?
Correct Answer: Omitting patients from the EWL and utilizing unofficial, private
waitlists.
Rationale: The Phoenix VA intentionally omitted patients from their EWL and utilized
unofficial, private waitlists. This practice violated VHA Policy 1230(5) and hid the true
scope of the access-to-care crisis from oversight bodies.
9. What unattainable scheduling goal were staff members
expected to meet "by any means necessary"?
Correct Answer: 14-day scheduling goal.
Rationale: Staff members were expected to meet the unattainable 14-day scheduling
goal by any means necessary to earn bonuses. This pressure led to fraudulent
scheduling practices including creation of secret waitlists and omission of patients from
the electronic system.
Analysis Worksheet 2025 with
complete solutions
Strategic Questions for ERM Plan Development
1. According to the OIG report, how many serious violations
against PVAHCS were confirmed?
Correct Answer: Five serious violations.
Rationale: The VA OIG investigation confirmed five serious violations including clinically
significant delays in care, omission of patient names from EWL, organizational culture
emphasizing goals over patient care, noncompliance with scheduling procedures, and
systemic scheduling deficiencies throughout VHA.
,2. What is the most critical OIG violation identified at PVAHCS?
Correct Answer: Clinically significant delays in care resulting in adverse outcomes for
veterans.
Rationale: The OIG report identified clinically significant delays that led to deterioration
in health of several veterans, with instances linked to death—representing a failure to
meet the standard of care.
3. What adverse outcomes resulted from the clinically significant
delays in care?
Correct Answer: Deterioration in health and death of several veterans.
Rationale: The evidence of patient deaths linked to these delays suggests a failure to
meet the standard of care that a reasonably prudent provider would deliver under
similar circumstances.
4. What was the scheduling goal according to VHA Directive
1230?
Correct Answer: 30 days from the date the appointment is deemed clinically
appropriate.
Rationale: VHA Directive 1230 (Outpatient Scheduling Process and Procedures)
establishes policy that appointments must be scheduled timely and accurately with a
,scheduling goal of 30 days from the date the appointment is deemed clinically
appropriate by a VA provider.
5. How many veterans waited over 200 days for an appointment?
Correct Answer: 1,138 veterans.
Rationale: It was reported that 1,138 veterans waited over 200 days for an appointment.
However, this number is inaccurate because out of the 1,138, only 53 of those patients
were actually on the Electronic Waitlist (EWL), indicating significant data manipulation.
6. How many veterans were appropriately included on the EWL
but still did not have primary care appointments?
Correct Answer: 1,400 veterans.
Rationale: The OIG report identified 1,400 veterans who did not have primary care
appointments although they were appropriately included in the Phoenix Healthcare
Service electronic waitlist.
7. How many veterans were waiting for primary care
appointments but were NOT included in the EWL?
Correct Answer: 1,700 veterans.
, Rationale: The review identified about 1,700 veterans who were waiting for primary care
appointments but were not included in the electronic waitlist. These veterans had been
placed in an "imaginary" waitlist where their wait times had not officially started.
8. What specific practice did the Phoenix VA use to hide the true
scope of the access-to-care crisis?
Correct Answer: Omitting patients from the EWL and utilizing unofficial, private
waitlists.
Rationale: The Phoenix VA intentionally omitted patients from their EWL and utilized
unofficial, private waitlists. This practice violated VHA Policy 1230(5) and hid the true
scope of the access-to-care crisis from oversight bodies.
9. What unattainable scheduling goal were staff members
expected to meet "by any means necessary"?
Correct Answer: 14-day scheduling goal.
Rationale: Staff members were expected to meet the unattainable 14-day scheduling
goal by any means necessary to earn bonuses. This pressure led to fraudulent
scheduling practices including creation of secret waitlists and omission of patients from
the electronic system.
