BUFFALO, N.Y. — We are learning more about the issues concerning the VA Western New York Healthcare System in Buffalo.
The VA Office of the Inspector General (OIG) conducted an investigation following allegations that the community care consult appointment scheduling practices, as well as delays in patients who had serious health issues and received community care at the VA hospital.
According to the OIG report, they found the community care staff's delays in scheduling a patient's radiation therapy and neurosurgery appointments "caused delays in the patient's care and in some cases caused or increased the risk of patient harm."
They found one case in which a patient with cancer was supposed to receive radiation therapy to treat cancer-related pain, but that appointment was delayed and ultimately canceled. The report noted that if the patient received the radiation therapy, it might have decreased the pain and improved the quality of life in that patient's final days.
The OIG says VA Western New York Healthcare System and community care leaders failed to resolve the scheduling delays for patients with serious health progress
In August, the VA transferred out Western New York Veterans Healthcare System Director Michael Schwartz and his chief of staff with various misconduct allegations and claims of delayed outside-the-system cancer referrals for veteran patients.
Congressman Tim Kennedy (D-NY26), who is a member of the House Committee on Veterans’ Affairs, said in a release, “The egregious neglect and failure of the Buffalo VA leadership outlined in this report is infuriating and inexcusable. Their repeated inattention to provider and patient outcries has led to American heroes being abandoned by a system meant to serve and protect them. This is a complete disgrace and a betrayal to the women and men who have made incredible sacrifices to safeguard our nation.
“Immediate reforms are necessary to ensure that Western New York veterans receive the care, support, and respect they have earned and deserve. Implementing the recommendations in the report is a first step. I am calling for further Congressional oversight, up to and including an investigation, to ensure this failure in care never happens again."
The OIG made four recommendations:
- The New York/New Jersey VA Health Care Network Director conducts a review of system leaders’ responses to repeated concerns regarding delayed community care consult scheduling for patients with serious health conditions to determine whether leaders’ actions were in alignment with patient safety and high reliability organizational principles, and take action as warranted.
- The New York/New Jersey VA Health Care Network Director ensures VA Western New York Health Care System Director develops community care consult practices and procedures for managing consults deemed high-risk or complex, implements an effective process to ensure consistency with processing consults within Veterans Health Administration timeliness requirements, and audits for compliance.
- The VA Western New York Health Care System Director ensures system community care leaders develop and implement standardized operating procedures for consult management consistent with Veterans Health Administration standards, provide training to community care staff, monitor compliance, and evaluate effectiveness.
- The VA Western New York Health Care System Director ensures all efforts to conduct an institutional disclosure to Patient A’s family are made and that the disclosure is documented in the patient’s electronic health record, as required. (This recommendation has been implemented)
Congressman Nick Langworthy (R) had raised concerns about the care veterans with cancer were receiving.
“This report reveals a horrifying level of negligence that resulted in veterans experiencing significant delays in the care they desperately needed,” said Congressman Langworthy. “This is not about a lack of resources—this is about sheer incompetence from leadership at the Buffalo VA that left veterans to suffer and, in some cases, lose their lives. I spoke with VA Undersecretary Dr. Shereef Elnahal, who confirmed there will be a disciplinary hearing for those responsible, and I have confidence in his ability to get the Buffalo VA back on the right track. Above all else, we must follow up on real reforms to put veterans first, so they get the timely, quality care they deserve.”
You can read the full report here: Leaders Failed to Address Community Care Consult Delays Despite Staff’s Advocacy Efforts at VA Western New York Healthcare System in Buffalo