Enterprise Risk Management Project ERM Project has 2 requirements. You will take on the role of a consulting risk manager for the Phoenix VA Health Care Sy

Enterprise Risk Management Project ERM Project has 2 requirements. You will take on the role of a consulting risk manager for the Phoenix VA Health Care System (PVAHCS) to address the Office of Inspector General’s report. You begin by identifying and analyzing risk issues embedded within a real-world scenario. You will use enterprise risk management (ERM) concepts to create and define implementation strategies for an ERM plan to mitigate and manage the risks identified. Finally, you will recommend a new system model. Instructions
This worksheet has two parts:
1. A table to collect each OIG allegation and compare to applicable legal, ethical, or
regulatory principles
2. A series of questions that will target the issues in the PVAHCS case most relevant in
the development of a new enterprise risk management (ERM) plan
The information that is gathered in this worksheet will be used to inform two components of the
final project: the interim ERM response and the new system challenge.
Resources
Use the following resources 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
● Impact Assessment Framework
Part 1. Relevant Legislation or Regulation Allegation analysis table
This table will be used to collect the allegations described in the OIG report of the PVAHCS
case. For each allegation:
● determine the applicable ethical principles, and legal, or regulatory requirements that may
have been violated, and
● consider the extent of these violations, what could have been done to prevent each, and
remedial steps that may need to be taken. Compile this information in the notes column.
Allegation from OIG Report
Ethical, Legal, or Regulatory Violations
Morally wrong on the grounds of violating
principles of truthfulness, justice, and
fairness.
Gross mismanagement of VA
resources
Federal Statutes:
Title 5 U.S.C. Section 1213, Provisions
Relating to Disclosures of Violations of
Law, Gross Mismanagement, and Certain
Other Matters.
Criminal misconduct by VA
senior leadership
Morally wrong on the grounds of violating
principles of beneficence, nonmaleficence
autonomy,
Systemic patient safety issues
Morally wrong on the grounds of violating
principles of beneficence and
nonmaleficence
Possible wrongful deaths
Morally wrong on the grounds of violating
principles of beneficence and
nonmaleficence
Notes
Part 2. Probing Questions for ERM Assessment
Answer the following questions about the PVAHCS case intended to inform development of the
ERM response.
1. Preventing risks through an ERM program. Consider the allegations included in
the OIG report. How might an ERM program at the PVAHCS have potentially prevented
or immediately mitigated some of these issues?
An ERM program at the PVAHCS might have potentially prevented or immediately mitigated some of the
issues through key structural elements such as governance (decision-making and authority on the exercise of
risks), education, coordination, communication, infrastructure (evidence based processes, determining
human capital, labor and technology capabilities), visibility, accountability, and sponsorship (administrative
activities). A program as such aims to identify, assess, effectively respond, and continually predict and
monitor for risks.
2. Patient safety issues at the Phoenix VA. What patient safety issues does the
PVAHCS case illustrate from an ERM, ethical, and legal perspective?
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▪
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▪
▪
▪
▪
▪
▪
▪
▪
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Patients waiting up to 8 mon ths for mental and physical health treatment
Continuity of care
Care transitions
Delay in assignment to dedicated providers
Impaired access to individual and specialized psychotherapies
Health-care association infections
Incomplete or postponed health evalutions
Poor documentation in HER
Scheduling delays for primary/follow-up care
Cancelliing of necessary appointments without medically indicated reason
Inappropriate treatment plans
Misdiagnosis
Undermanaged and untimely primary care
Poor coordination of specialty care
Delay in palliative care implementation
Poor consult management
Prolonged delays between lab test, diagnosis, and treatment
Delayed referrals
Misinformation regarding benefits
Excessive wait times
3. Increasing visibility to patient concerns. How might an ERM program at the
PVAHCS have helped give greater visibility to patient concerns about care?
An ERM program at the PVAHCS might have helped give greater visibility to patient concerns about care
through consciousness-raising, organization-wide communication, continuing education activities,
orientation, and in-services.
4. Risk identification. How could the patient concerns and safety issues have been
identified earlier? Which risk assessment processes or tools would have been most
appropriate?
Patient concerns and safety issues could have been identified earlier on had PVAHCS implemented a risk
management information system with “real time” data necessary for decision-making and customized
reports (near misses). Also, patient account representatives could have vetted some of those concerns as
they may come up in conversation during the billing and collection process. Appropriate risk assessment
processes or tools would include safety checklists, audits, flowcharts, failure mode evaluation and analysis
(FMEA), strength/weakness/opportunity/threat (SWOT) analysis, and
political/economic/social/techonological/legal/environmental (PESTLE) analysis.
5. Preventing inaccurate data reporting. Given the allegation that managers were
directing staff to report inaccurate data, what oversight and accountability practices
measures could be put in place to guard against similar occurrences in the future?
Who should be responsible for implementing these practices?
Given the allegation that managers were directing staff to report inaccurate data, implementation of both
an error disclosure and error reporting policy is a good oversight and accountability practice. The reporting
error policy would mandate written and verbal account of unanticipated outcomes to medical staff, senior
management, quality control, risk management, board of trurtees, federal and local regulatory compliance
agencies, the community, and or professional organizations; while the disclosure policy would suggest
voluntary disclosure of medical negligence to patients and families only. Reporting/disclosing errors in this
fashion provides opportunity to reduce the errors effects and mitigate the likelihood of future occurences.
6. Assessing the impact of inaccurate data reporting. Using the Impact Assessment
Framework, perform an analysis scan of the impact dimensions specifically focused
on the Leadership and Culture outcome under the Organization and Workforce
dimension. In particular, what impact does the allegation of management directing
staff to report inaccurate data have on operations at the PVAHCS?
7. Determining responsibility. Who is ultimately responsible for the allegations in the
PVAHCS case? Summarize what leadership principles and practices should have
been followed.
8. Identifying impact on VHA patients. According to the OIG Report, up to 40 deaths
may have been caused by alleged improper practices at the PVAHCS. What other
impacts to patients are anticipated if the current practices continue?
9. Potential risk effects on VHA staff. Describe potential impacts on VHA staff, both
those employed in the PVAHCS and throughout the rest of the VHA system. What
risks do those effects pose to the VHA system?
10. Impact of allegations on reputational risk. How have these allegations harmed
the reputation of the PVAHCS? Is reputational risk a legitimate concern of an ERM
program? If so, what should be addressed in the development of an ERM program to
proactively anticipate and mitigate this risk?
Instructions
Use this worksheet to complete Assignment 2. It will be used to analyze effective strategies for
risk management and ethical leadership in the VHA Medical Home case and will be used for the
first half of the final project, the ERM plan.
Resources
Use the following resources to complete this worksheet:
● The Veterans Health Administration: Implementing Patient-Centered Medical Homes in
the Nation’s Largest Integrated Delivery System
● Enterprise Risk Management: Issues and Cases
VHA Medical Home Case Questions
1. Addressing risks. Consider the risks from the case study concerning the implementation of
the patient-aligned care team (PACT) model. How could these risks be addressed as part of
an ERM plan?
Risks from the case study concerning the implementation of the patient-aligned care team (PACT)
model could be addressed as part of an ERM plan with a proper framework that easily examines risks,
considers interrelation between individual risks, and
2. Identifying strategies. What risk management strategies were used? At what level and how
was leadership engaged in implementing those strategies?
3. Risks for implementation. What risks were involved in implementing those strategies
(legal, regulatory, ethical, leadership, operational, etc.)?
4. Leadership measures in the VHA Medical Home case. In contrast to the PVAHCS case,
what leadership oversight and accountability measures are present in the team-based
models in the VHA Medical Home case? How appropriate would the identical measures be
for monitoring performance in the PVAHCS case?
Leadership measures in the VHA Medical Home case are not benchmarked, instead, they are used only
as an evaluation tool, with no accountability. These measures are then focused on patient experience
moreso than on cost savings.
5. Increasing visibility to patient concerns. In what ways has the enterprise-wide teambased approach to care management in the VHA Medical Home case helped give greater
visibility to patient concerns about care?
An ERM program at the PVAHCS might have helped give greater visibility to patient concerns about
care through consciousness-raising, organization-wide communication, continuing education activities,
orientation, and in-services.
6. Patient safety issues in the VHA Medical Home. What patient safety issues are inherent
or explicitly identified in the VHA Medical Home case? Describe what might be the
implications of these safety concerns from an ERM, ethical, or legal perspective?
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
Patients waiting up to 8 mon ths for mental and physical health treatment
Continuity of care
Care transitions
Delay in assignment to dedicated providers
Impaired access to individual and specialized psychotherapies
Health-care association infections
Incomplete or postponed health evalutions
Poor documentation in HER
Scheduling delays for primary/follow-up care
Cancelliing of necessary appointments without medically indicated reason
Inappropriate treatment plans
Misdiagnosis
Undermanaged and untimely primary care
Poor coordination of specialty care
Delay in palliative care implementation
Poor consult management
Prolonged delays between lab test, diagnosis, and treatment
Delayed referrals
Misinformation regarding benefits
Excessive wait times
7. Assessing the impact of the transition to team-based operations. Using the Impact
Assessment Framework, perform an assessment of all impact dimensions and the transition
towards a team-based operational model (e.g., PACT) within the VHA Medical Home cases.
8. Applying risk management principles to the PVAHCS. According to the OIG report, up to
40 deaths may be linked to ongoing practices at the PVAHCS. What practices, implemented
in the VHA Medical Home case, would be appropriate to address leadership accountability,
ethical, operational, and other risks specific to the PVAHCS case?
9. Risk impacts throughout the VHA. Describe and contrast potential effects on the VHA
clinical staff based on the events in the VHA Medical Home case, the PVAHCS system
case, and throughout the rest of the VHA system.
10. PACT model impact on reputational risk. Based on the VHA Medical Home case study,
describe the following topics:
● Impact the PACT model had on the reputation of the VHA clinics
● Significance of reputation risk within an ERM program
● A recommended measure of effectiveness of the PACT model in relation to reputation.
▪
The PACT model had a positive impact on the reputation of the VHA clinics, bringing
competitive advantage in attracting new members, new employees, and retaining of old
employees.
▪
The significance of reputation risk within an ERM program
▪
Recommended measures of effectiveness of the PACT model in relation to reputation include
o Turnover rate
o Dividends and market price per share
o Corporate Social Responsibility
o Quality awards
o Return on Investment
Note for Student
The worksheet for Assignment 2 is designed to help prepare you for the final project. As such, it helps
you achieve the following learning objectives defined for this project (numbers are WGU codes for each
objective):
● 3042.1.1-06 Interpret the effectiveness of leadership strategies used by a given organization
● 3042.1.1-08 Analyze ethical leadership principles in a given healthcare system
● 3044.1.2-05 Analyze state and federal risk management legislation and corporate laws in a
healthcare setting
● 3044.1.2-10 Identify the role of medical ethics in risk
VA Office of Inspector General
Veterans Health
Administration
Review of
Alleged Patient Deaths,
Patient Wait Times, and
Scheduling Practices at the
Phoenix VA Health Care System
August 26, 2014
14-02603-267
ACRONYMS
CBOC
CBT
COPD
CPRS
CSTAT
CT
DBT
ED
EHR
EWL
FY
GAO
HAS
HRC
HVAC
ICD
LPN
NEAR
OEF/OIF/OND
OIG
PCP
PDF
PET
PSA
PTSD
PVAHCS
RSA
SPC
VA
VAMC
VHA
VISN
VistA
VSSC
WIG
Community Based Outpatient Clinic
Cognitive Behavioral Therapy
Chronic Obstructive Pulmonary Disease
Computerized Patient Record System
Consultation Stabilization Triage Assessment Team
Computerized Tomography
Dialectical Behavioral Therapy
Emergency Department
Electronic Health Record
Electronic Wait List
Fiscal Year
Government Accountability Office
Health Administration Service
Health Resource Center
House Committee on Veterans’ Affairs
Implantable Cardioverter Defibrillator
Licensed Practical Nurse
New Enrollee Appointment Request
Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn
Office of Inspector General
Primary Care Provider
Portable Document Format
Positron Emission Tomography
Prostate-Specific Antigen
Post-Traumatic Stress Disorder
Phoenix VA Health Care System
Replacement Scheduling Application
Suicide Prevention Coordinator
Department of Veterans Affairs
Veterans Affairs Medical Center
Veterans Health Administration
Veterans Integrated Service Network
Veterans Health Information Systems and Technology Architecture
Veterans Health Administration Support Service Center
Wildly Important Goal
The VA OIG Hotline is the responsible office for complaints of fraud, waste,
abuse, and mismanagement within the Department of Veterans Affairs. Using the
VA OIG Web page, at www.va.gov/oig, will facilitate the processing of your input.
Federal regulations require that VA employees must report criminal matters
involving felonies to the OIG. Complainants are protected under the Inspector
General (IG) Act of 1978, which requires IGs to protect the identity of agency
employees who complain or provide other information to the IG. In addition, the
IG Act makes reprisal against an employee contacting the IG a prohibited
personnel practice.
————-To Report Suspected Wrongdoing in VA Programs and Operations:
Email: vaoighotline@va.gov
Telephone: 1-800-488-8244
(Hotline Information: www.va.gov/oig/hotline)
(This Page Left Intentionally Blank)
EXECUTIVE SUMMARY
The VA Office of Inspector General (OIG) reviewed allegations at the Phoenix VA Health Care
System (PVAHCS) that included gross mismanagement of VA resources, criminal misconduct
by VA senior hospital leadership, systemic patient safety issues, and possible wrongful deaths.
We initiated this review in response to allegations first reported to the VA OIG Hotline. We
expanded our work at the request of the former VA Secretary and the Chairman of the House
Committee on Veterans’ Affairs (HVAC) following an HVAC hearing on April 9, 2014, on
delays in VA medical care and preventable veteran deaths. Since receiving those requests, we
have received other Congressional requests including those submitted by the Chair and Ranking
Members of the following Committees and Subcommittees. A complete list of requestors is
located in Appendix J.

House Committee on Veterans’ Affairs

HVAC Subcommittee on Oversight and Investigations

House Appropriations Committee

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and Related
Agencies

Senate Committee on Veterans’ Affairs

Senate Appropriations Committee

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and
Related Agencies
On May 28, 2014, we published a preliminary report, Review of Patient Wait Times, Scheduling
Practices, and Alleged Patient Deaths at the Phoenix Health Care System – Interim Report, to
ensure all veterans received appropriate care and to provide VA leadership with
recommendations for immediate implementation. This report updates the information previously
provided in the Interim Report to reflect the final results of our review. We focused this report
on the following five questions and identified serious conditions at the PVAHCS and throughout
the Veterans Health Administration (VHA).

Were there clinically significant delays in care?

Did PVAHCS omit the names of veterans waiting for care from its Electronic Wait List
(EWL)?

Were PVAHCS personnel following established scheduling procedures?

Did the PVAHCS culture emphasize goals at the expense of patient care?

Are scheduling deficiencies systemic throughout VHA?
i
Due to the multitude and broad range of issues, we assembled a multidisciplinary team
comprising board-certified physicians, special agents, auditors, and health care inspectors to
evaluate the many allegations, determine their validity, and assign individual accountability if
appropriate. The team interviewed numerous individuals to include the principal complainants,
Dr. Samuel Foote, a retired PVAHCS physician, and Dr. Katherine Mitchell, the Medical
Director of the PVAHCS Operation Enduring Freedom/Operation Iraqi Freedom/and Operation
New Dawn (OEF/OIF/OND) clinic. In addition:

We obtained and reviewed VA and non-VA medical records of patients who died while on a
wait list or whose deaths were alleged to be related to delays in care.

We reviewed two statistical samples of completed primary care appointments to determine
the accuracy of patient wait times based on our assessment of the earliest indication a patient
desired care.

We reviewed over 1 million email messages, approximately 190,000 files from 11 encrypted
computers and/or devices, and over 80,000 converted messages from Veterans Health
Information Systems and Technology Architecture emails.
The patient experiences described in this report revealed that access barriers adversely affected
the quality of primary and specialty care at the PVAHCS. In February 2014, a whistleblower
alleged that 40 veterans died waiting for an appointment. We pursued this allegation, but the
whistleblower did not provide us with a list of 40 patient names. From our review of PVAHCS
electronic records, we were able to identify 40 patients who died while on the EWL during the
period April 2013 through April 2014. However, we conducted a broader review of
3,409 patients identified from multiple sources, including the EWL, various paper wait lists, the
OIG Hotline, the HVAC and other Congressional sources, and media reports.
OIG examined the electronic health records (EHRs) and other information for the 3,409 veteran
patients, including the 40 patients reflected above in PVAHCS’s records, and identified
28 instances of clinically significant delays in care associated with access to care or patient
scheduling. Of these 28 patients, 6 were deceased. In addition, we identified 17 care
deficiencies that were unrelated to access or scheduling. Of these 17 patients, 14 were…
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