1
Guidelines for Case Analysis
PAD 705
 This assignment is due by Wednesday, December 9th at 11:59 PM.
 Write a case study report that identifies a key problem(s) and suggests a solution(s) to the
problem(s). The written report must include the following sections (i.e., headings): Abstract
(max 150 words), Introduction, Background, Alternatives, Proposed Solution, and
Recommendations. For detailed information about each section, please refer to the
“Guidelines for Writing a Case Study Analysis” attached to the assignment submission tab.
 Your report will be evaluated under the following four categories: (1) Identification of
Problems/Issues; (2) Identification and Analysis of Alternatives; (3) Proposed Solutions and
Recommendations; and (4) Organization, Grammar, Spelling & Formatting. For detailed
information, please refer to the “Rubric for Case Study” attached to the assignment
submission tab.
 The written report must be theory-based; among the theories we learn in this class, pick 2-3
theories to identify and analyze alternatives and to develop solutions. In the Introduction
section, you must clearly indicate what theories you chose to analyze the case.
 The written paper must be 6-8 pages (min 6 pages, and max 8 pages), including a
reference list, double-spaced, 12-point font size in Word Document. The Abstract must not
exceed 150 words.
 Any questions about this assignment are welcome! Please do not send your draft to the
instructor for personal review. Students who need assistance with their work should reach out
to the writing coach, Prof. Mantovani at amantovani@jjay.cuny.edu. Please be advised that
the writing coach will not edit your work. She will review your work and give you tips
customized for your work, focusing on how to improve the quality of your work.
 If you have any questions about this assignment, please feel free to post it to the Q&A board
or, if your question is personal, let me know via email, and I will be happy to assist you. The
more specific your question is, the more you are likely to receive helpful answers and
comments from the instructor.
2
The Crisis of Phoenix VA Hospital
In early 2012, Dr. Katherine Mitchell, a Department of Veterans Affairs (VA) emergency-room
physician, warned Sharon Helman, the incoming Director of the Phoenix VA Health Care
System, that the Emergency Room at the Carl T. Hayden Veterans Affairs Medical Center (here
after, the Phoenix VA hospital) in Phoenix, Arizona was overwhelmed and dangerous,
particularly the considerable number of patients dying waiting for consultative appointments. To
tackle this problem, in later 2012, the U.S. Department of Veterans Affairs ordered the Phoenix
VA hospital to implement electronic wait-time tracking and to make improved patient access a
top priority. However, the problem was not fixed. On the speech at a subcommittee of the House
VA Committee held in March 2013, the GAO’s Debra Draper told that “[a]lthough access to
timely medical appointments is critical to ensuring that veterans obtain needed medical care,
long wait times and inadequate scheduling processes at VAMCs (Veterans Affairs Medical
Centers) have been persistent problems, as we and the VA’s Office of Inspector General have
reported”.
In October 2013, Dr. Sam Foote, a former clinic director for the Phoenix VA hospital, finally
filed a complaint with the VA’s Office of Inspector General alleging that purported successes in
reducing wait times stemmed from manipulation of data, not improved service, and that vets
were dying while awaiting appointments for medical care. Meeting with Arizona Republic
reporter, Dennis Wagner in December 2013, he detailed allegations that patients had died while
awaiting care at the Phoenix VA hospital and that wait times had been falsified. The same
month, inspector general’s investigators visited Phoenix to look into whistle-blowers’
complaints.
The VA’s Office of Inspector General released a scathing interim report on March 28, 2014 that
confirmed whistle-blower allegations of mismanagement and the manipulation of data related to
patient wait times. Two years later, after investigating the 11 medical facilities in the Phoenix
VA Health Care System (PVAHCS)―which is comprised of the Phoenix VA hospital and 10
community care clinics, the VA’s Office of Inspector General reported their findings below:
 In 2015, PVAHCS staff inappropriately discontinued consults. Staff inappropriately
discontinued 74 of the 309 specialty care consults (24 percent) the office reviewed. This
occurred because staff were generally unclear about specific consult management
procedures, and services varied in their procedures and consult management
responsibilities. As a result, patients did not receive the requested care or they
encountered delays in care. Of the 74 inappropriately discontinued consults, 53 patients
had not received the requested care at PVAHCS.
 The allegation that the Acting Chief of Health Administration Service (HAS) at the
Phoenix VA hospital instructed administrative staff to discontinue inappropriately the
consults of patients before a provider reviewed the consult was not substantiated. The
VA’s Office of Inspector General determined that some staff believed the guidance was
not clear, and that leadership, clinicians, and schedulers had a different understanding of
3
the various consult management responsibilities. The VA’s Office of Inspector General
interviewed 58 schedulers in the Phoenix VA hospital, clinicians, and other
administrative staff, including the complainant. The complainant told the investigators
that discontinuing consults required a medical decision and did not agree that
administrative staff should be involved in this action. Veterans Health Administration
(VHA)’s National Guidance for Discontinuing or Cancelling Consults (June 2015) stated
that non-clinicians can discontinue consults under certain circumstances, including
instances when the patient has died, the consult was a duplicate request, the patient
refused care, or the patient opted for non-VA care. Although some of the remaining 57
interviewees also stated that only clinicians should discontinue consults, none of them
told the investigators that the Phoenix VA hospital management instructed them to
discontinue or cancel consults improperly. Two interviewees told the investigators that
they received unclear guidance, which the VA’s Office of Inspector General determined
resulted in inappropriate consult management. Two providers stated that facility
leadership applied pressure to services to ensure consults did not exceed 90 days, and
further stated that services had to provide justification for those consults that exceeded 90
days.
 The allegation that PVAHCS management removed a scheduler from Vascular Service
because the scheduler identified and reported problems was not substantiated. In an effort
to reduce a scheduling backlog, HAS temporarily reassigned two medical support
assistants (MSAs) from Cardiology Service to schedule consults in the Vascular Lab at
the Phoenix VA hospital. Based on interviews with staff, the VA’s Office of Inspector
General determined that differences in consult management responsibilities between the
services may have led the incoming staff to believe that the program support assistant
(PSA) in the Vascular Lab at the Phoenix VA hospital was inappropriately discontinuing
consults since the Cardiology Service section chief did not allow MSAs to discontinue
consults. The VA’s Office of Inspector General found that because of poor cooperation
among staff, Vascular Service and HAS decided to assign a different scheduler to assist
Vascular Service with scheduling.
 The allegation that a paper list of patients waiting for chiropractic care, reported to the
VA’s Office of Inspector General by the complainant and PVAHCS leadership, was an
unofficial wait list was not substantiated. PVAHCS staff printed the list from the
Veterans Health Information Systems and Technology Architecture (VistA) and used the
list to record their attempts to contact the patients. The VA’s Office of Inspector General
determined that the consults were electronically tracked in VHA’s consult package.
However, the VA’s Office of Inspector General also determined that the PVAHCS
Chiropractic Service inappropriately canceled consults. The VA’s Office of Inspector
General analyzed 30 consults canceled from January through March 2015, and found that
the Chiropractic Service staff responsible for scheduling inappropriately canceled all 30
consults. This occurred because the Chiropractic Service did not make adequate attempts
to contact patients to schedule appointments and did not maintain sufficient resources to
4
manage and schedule consults. Canceled consults resulted in patients not receiving a
scheduled appointment and, therefore, not receiving the requested chiropractic care.
Within the 30 canceled consults the VA’s Office of Inspector General reviewed, 28
patients had not received the requested chiropractic care at PVAHCS.
 The OIG’s Office of Healthcare Inspections (OHI) reviewed a total of 294 facility
consults for 215 individual patients who had open consult requests at the time of their
deaths, or had consults discontinued after the date of their deaths. Of the 215 individual
patients’ records reviewed, OHI determined that untimely care from PVAHCS may have
contributed to the death of 1 patient. OHI found that this patient never received an
appointment for a cardiology exam that could have prompted further definitive testing
and interventions that could have forestalled his death. OHI determined that the
remaining patients’ records reviewed did not die because they did not receive the
requested consult in a timely fashion before they died. The VA’s Office of Inspector
General did not substantiate that the facility was having non-clinical staff discontinue
consults for vascular patients to hide the fact that a patient died while waiting for care. In
regard to the consults reviewed of patients who died while they had open consults, the
VA’s Office of Inspector General found that PVAHCS closed these consults because
VHA and PVAHCS business rules and policy both required that a consult be
discontinued if the patient is deceased. However, facility staff did not consistently
comply with this policy and some consults remained open long after patients’ deaths.
 The VA’s Office of Inspector General determined that, as of August 12, 2015, more than
22,000 individual patients had 34,769 open consults at PVAHCS. The total open consults
included all categories, statuses, and ages of consults. One of all the open consults at that
time, about 4,800 patients had nearly 5,500 consults for appointments within PVAHCS
that exceeded 30 days from their clinically indicated appointment date. In addition, more
than 10,000 patients had nearly 12,000 community care consults exceeding 30 days.
Consults for care in the community included traditional non-VA care and Choice. 2 The
remaining approximately 17,000 open consults were for prosthetics, administrative
purposes, and/or did not exceed 30 days. VHA does not require staff to complete
prosthetics consults immediately.
 By March 2016, PVAHCS had just over 32,500 total open consults. As of July 2016,
according to PVAHCS, the facility had nearly 38,000 total open consults. PVAHCS
continues to have a high number of open consults because providers are not always
receiving and reviewing consults to their clinics timely, staff had not scheduled patients’
appointments in a timely manner (or had not rescheduled canceled appointments), a clinic
could not find lab results, and staff did not properly link completed appointment notes to
the corresponding consults. As a result, patients attempting to get care at PVAHCS
continued to encounter delays in obtaining such care.
 The VA’s Office of Inspector General substantiated that one patient waited in excess of
300 days for vascular care. A patient received vascular care in October 2015 following a
5
consult request from a clinician in Vascular Surgery in June 2013. The requesting
provider’s clinically indicated date for care was June 19, 2014. Vascular Lab staff
scheduled an appointment to which the patient did not go and the consult remained open.
Staff did not act on the consult again until July 2015. Facility staff then made multiple
attempts to contact the patient and provided care to the patient in October 2015. As of
August 12, 2015, the VA’s Office of Inspector General identified 13 open consults of
patients waiting for Vascular Lab more than 30 days beyond the clinically indicated date
of the provider, ranging from 32 to 157 days. The VA’s Office of Inspector General also
found that the PVAHCS Vascular Service staff did not properly link clinicians’ notes for
the completed appointments to the corresponding consults, which meant consults
remained open even though the patient received the care.
 This occurred, in part, because they could not find printed lab results of completed
appointments associated with open consults to input completed appointment results into
the electronic health records. The Vascular Service electronically sent, received, and
scheduled consults in VHA’s consult package. However, PVAHCS’s Vascular Lab
machines were not connected to the VA network, which meant the lab results of
completed appointments had to be printed and scanned into VistA after the provider
dictated the results. The VA’s Office of Inspector General found 29 consults in which
clinicians had not reviewed and dictated the consult results because they could not find
the lab results. Since 2008, the Chief of Vascular Service has been voicing concerns
about delays in scanning reports and lost appointment documents, and attempting to
improve Vascular Lab procedures by requesting that the Veterans Integrated Service
Network (VISN) and PVAHCS replace the Vascular Lab software. The Chief of Vascular
Service reported lost documents again in July and October 2013. During the course of
this review, PVAHCS took action to move appointment results for Vascular Labs to an
electronic process. However, the Vascular Service still printed results for some studies.
***NOTE. This case material is a collection of texts about the Phoenix VA hospital Scandal
that are sourced from the following three sources. To use any of phrases or sentences in the
case material in your paper, you must read and cite the original sources:
https://www.azcentral.com/story/news/arizona/politics/2014/05/10/timeline-road-va-wait-timescandal/8932493/
https://www.azcentral.com/story/news/local/arizona-investigations/2017/01/10/office-of-specialcounsel-warns-obama-congress-phoenix-va-woes-continue/96366462/
https://www.va.gov/oig/pubs/VAOIG-15-04672-342.pdf