Tag Archives: healthcare

Root Cause Analysis

Multiple Factors Contributing to Health Care Crisis in Venezuela

By ThinkReliability Staff

Venezuela is facing a health care crisis of massive proportions. Since 2012, the infant mortality rate has skyrocketed from 0.02% to more than 2%. (The latest numbers are from 2015, so this is a hundred-fold increase within 3 years.) The mortality rate for new mothers increased almost 5 times over the same period. Everyone else isn’t doing too well either. Says Dr. Yamila Battaglini, a surgeon at J. M. de los Ríos Children’s Hospital, “There are people dying for lack of medicine, children dying of malnutrition and others dying because there are no medical personnel.” That doesn’t even cover all of the problems facing Venezuela right now, which include:

Rolling blackouts: The government has announced official “rolling” blackouts of at least 40 days. That includes hospitals and other medical facilities. (Doctors are reporting having to work in the dark.) At least one hospital has a generator that doesn’t work. One reason electricity is being rationed is that even though money has been allocated to building new power plants, the plants aren’t online, and the money hasn’t been accounted for. (Unfortunately this kind of potential theft/ corruption is much too common in Venezuela). Another reason is . . .

Drought: The Guri hydroelectric dam provides 75% of the nation’s electricity, and currently has extremely low levels due to drought. The drought, caused by El Niño, has also resulted in a general lack of water, which is now being rationed. The combination means that the hospital doesn’t have adequate water supplies, resulting in . . .

Lack of sanitation: Without water, sanitation suffers. Doctors have reported performing surgery after a quick rinse from a water bottle, and no rinsing down of surgical beds or instruments before the next surgery, or procedure. But the people who are getting surgery or procedures are lucky, because many hospitals are also suffering from . . .

Shortages of medical personnel: Many medical professionals have left Venezuela during the severe ongoing economic issues (such as inflation, currently pegged at 700%) due to both the decreasing price of oil (Venezuela’s main export) and what have been called “disastrous” government policies. Says Ricardo Hausmann, Professor at the Kennedy School of Government (and Venezuela native), “Venezuela’s problems are a consequence of the craziest economic policy ever in a country or in the world. It’s a country that has gone through its longest and highest oil boom in its history, and ended that period over-indebted, with a destroyed productive capacity, and now it cannot face the reduction in the price of oil.” Doctors that remain face exhaustion – without water and power, many are attempting to save lives by manually operating equipment (such as respirators for newborns). Even this can’t save lives with . . .

Shortages of drugs and equipment: The Pharmaceutical Federal of Venezuela estimates that the country is lacking ~80% of needed basic medical supplies. Price controls in Venezuela resulted in official selling prices lower than manufacturing costs. This made it financially infeasible to provide many products. The government can’t afford to import drugs, and individuals have difficulty doing so because official currency exchange isn’t available. (Even if it was, Venezuelan money is virtually worthless at this point, as the government keeps printing more.) Theft and corruption have also resulted in the loss of some equipment. And as if this all weren’t enough, the country is also suffering from . . .

Zika outbreak: To a country that lacks almost all ability to provide health care, add an ongoing outbreak (see our previous blog) for which there is currently no cure, and you end up with a situation where “some come here healthy, and they leave dead.” (Dr. Leandro Pérez, Luis Razetti Hospital)

With this many (and this severe) problems, there are no easy answers. Making the situation even worse is the government’s denial that there IS a problem. Says President Nicolás Maduro, “I doubt that anywhere in the world, except in Cuba, there exists a better health system than this one.” This is preventing other countries from providing aid, sometimes because they are unaware the extent of the need. At least one country, India, is offering drugs for oil, though that may be mainly to recoup funds they are already owed, not for providing new medication.

In order to see the multitude of causes that have resulted in the health care crisis in Venezuela laid out in a visual cause-and-effect format, click on “Download PDF” above. Or click here to read more.

Hospital Acquired Condition

16 patients infected with hepatitis C; thousands potentially exposed

By Kim Smiley

At least 16 patients were infected with hepatitis C after receiving treatment at two hospitals in Utah. Additionally, officials have stated that an estimated 7,200 patients may have potentially been exposed to hepatitis C.  Investigators are working to determine exactly what happened and to test patients who were potentially exposed.

Hepatitis C is a blood-borne illness and cannot be spread by casual contact, including through saliva or sharing food and water. It is not an illness that should typically be at risk of transmission from healthcare professional to patient. A nurse who tested positive for a rare form of hepatitis C worked at the two hospitals that have each had at least one patient who tested positive for the same rare form of hepatitis C. Officials have not released detailed information on how the hepatitis C outbreak occurred, but there are some suspicious circumstances.

The nurse in question was fired in November 2014 after a hospital found evidence that she had diverted medications, which means she was tampering with syringes or other injectable equipment to steal medication.  The nurse pled guilty to the offense and her license was suspended in December of 2015.

It can be very difficult to identify medication tampering by medical personnel, but one of the most alarming facets of this case is that the nurse had been reprimanded and fined by a previous employee for similar misbehavior.  It seems like it should be possible to identify whether a prospective employee has a history of issues with medication diversion during the hiring process. Investigators have not commented on what type of background checks were done prior to her employment at the second hospital, but it seems like an area where hard questions should be asked.

The immediate risk of this particular nurse exposing more patients has been addressed since she is no longer working at a healthcare facility.  The hospitals are offering free testing to anybody who was potentially exposed and are working on a case-by-case basis to determine how to pay for any necessary treatment of those who were infected.  No longer-term solutions have been identified yet, but the investigation is still underway so it is not clear if any lessons learned will result in changes to overall work processes.

Click on “Download PDF” to view an initial Cause Map of this incident.  A Cause Map visually lays out cause-and-effect relationships and can help identify a wider range of causes that contributed to an issue.  Identifying more than a single root cause can promote a wider range of solutions to be considered and can aid in reducing the risk that a problem may reoccur.

Root Cause Analysis

Do you know how an MRI works?

By Kim Smiley

About 30 million magnetic resonance imaging (MRI) scans are performed in the United States each year. They are most frequently used to create images of the brain and spinal cord, but can also help diagnose aneurysms, eye and inner ear disorders, strokes, tumors and other medical issues. MRIs are painless and do not expose a patient to potentially harmful radiation, making them one of the safest medical procedures available.

MRIs are fairly common and most people have heard of them, but do you have any idea how they work?  A Process Map is used to document how a work process is performed, which can be useful when explaining how a process works to somebody who is unfamiliar with it.  To view a high level Process Map of how an MRI is used to create an image, click on “Download PDF”.

The high level Process Map is very basic and would not be useful to somebody trying to learn how to perform an MRI, but it might be helpful in explaining to a patient what to expect during the procedure and how an MRI image is produced.  A more detailed Process Map that included information on each step that needs to be done to perform an MRI could be built for use as a training aid or as a way to document best work practices, but sometimes a basic high level Process Map can also be helpful.

So how does an MRI create detailed images of the inside of a human body? An MRI uses a strong magnet to create a large, steady magnetic field around the patient’s body.  Many atoms, such as hydrogen atoms, have strong magnetic moments that cause them to align in the same direction when exposed to a magnetic field.  Once atoms in the patient’s body are aligned along the field lines of the large magnet, the MRI machine produces a pulse of radio frequency current.  During the pulse of energy (which is extremely brief), atoms in the patient’s body absorb this energy and rotate to align with the radio frequency current.  Once the pulse is over, the atoms will rotate back to their original position, emitting energy.  Atoms in different types of body tissue return to their original positions at different rates and release different energy signals. The body is pulsed many times by different frequencies at different locations to target the specific type of issue being looked at by the MRI. All of the energy emitted by the atoms during these pulses is collected by antennas and a computer uses a mathematical formula to convert the data into images.

Obviously this is a very high level explanation that leaves out a lot of detail, but the basic idea is that an MRI uses changing magnetic fields and the body’s natural magnetic properties to produce detailed images of the human body.  The patient’s role during an MRI is simple (if maybe a little claustrophobic), but the process by which the MRI image is produced is fairly complicated to understand.  Having a simple, visible explanation of what is going on may help make a patient feel more comfortable with their experience.

Can you think of a time when it would be useful to explain the big picture of a work process to somebody, whether a manager or a customer? Creating a simple high Level Process Map to help explain a process to people that aren’t directly involved in the work is something that can be useful across many industries.

Never Event, Root Cause Analysis

Healthy kidney removed by mistake

By Kim Smiley

The Patient Safety Network presented a case study where a patient with suspected kidney cancer had the wrong kidney removed.  Instead of the right kidney that showed suspected renal cell carcinoma in a CT scan, the healthy left kidney was removed. A second surgery was then performed to remove the right kidney and the patient was left dependent on dialysis after losing both kidneys.  The patient wasn’t a candidate for a kidney transplant because of the cancer.

Reviewing and understanding case studies such as this one is important because wrong-site surgeries are one of the more common serious medical errors.  A Cause Map, a visual root cause analysis, can be used to better understand the many causes that contributed to this wrong-site surgery, and better understanding the causes of an incident leads to development of better solutions.  The first step in building a Cause Map is to fill in an Outline with the basic background information.  These details are often not published for medical errors to protect patient privacy, but the information should be recorded if available.  The bottom of the Outline also includes space to list how the issue impacts the overall organizational goals. The Cause Map itself is built by starting at one of the impacted goals and asking “why” questions.

Focusing on the patient safety goal as a starting point, the investigation could be started by asking “why was a healthy left kidney removed instead of the right?” The surgeon who performed the surgery believed the tumor was in the left kidney because all patient information readily available stated the tumor was in the left kidney.  The case study didn’t include details on how this error in the patient’s record occurred, but it is known that a CT scan was initially performed at a different hospital than the one that performed the surgery.  The patient sought treatment at the first hospital after suffering from abdominal pain and hematuria and a CT scan was performed.  He was transferred to a second hospital for the surgery after the CT scan revealed suspected renal cell carcinoma.  An image of the CT scan was not included with the patient records at the time of transfer and the records noted that there was a tumor in the incorrect (left) kidney.

The stage was essentially set for a wrong-site surgery and the surgeon missed the opportunity to prevent it.  The surgeon chose to perform the surgery based on the records without either verifying the original CT (because it was not available) or requesting an additional CT scan to be performed to confirm the diagnosis.  It does not appear that the surgeon was required to review the CT scan, but the decision on whether to do so was left up to the surgeon’s judgement. The error was only identified after the pathologist who examined the left kidney found no evidence of cancer and informed the surgeon who then reviewed the original CT scan and realized the wrong kidney had been removed.

Once the causes that contributed to an issue have been identified, the final step in the Cause Mapping process is to identify and implement solutions to prevent a problem from reoccurring.  One way to prevent similar errors is to require labeled radiology images to be available to the surgeon prior to any surgery.  Requiring a review of images prior to the surgery would build in a double check to ensure the surgery is performed at the correct site.  Building in a double check of medical records may also reduce errors like the wrong kidney being listed as potentially cancerous or a patient being transferred with medical files missing important radiology images.

Root Cause Analysis

FDA’s Wish List: Regulatory Authority for Lab-Developed Tests

By ThinkReliability Staff

Laboratory testing is incredibly important to health care – it is thought to be an influence in about 70% of health decisions. Results of testing will often be used to diagnose a patient, or select a treatment plan. Thus, inaccurate testing results can lead to inappropriate, sometimes even dangerous, treatments. However, diagnostic tests manufactured and used within a single laboratory, known as laboratory developed tests, or LDTs, are not subject to regulation by the FDA.

This has led to significant concern by the FDA, outlined in a report making the case for FDA oversight for these tests. Their concerns can be diagrammed in a Cause Map, or visual root cause analysis, allowing us to see how the specific concerns are related and impact patient safety and other regulatory goals.

The first step in any problem solving method is to determine the problem that is to be solved. Using the Cause Mapping method, the “problem” is defined as an impact to an organization’s goals. In this case, patient safety is impacted because of the possibility for insufficient treatment of life-threatening disease and the potential for patients to undergo unnecessary dangerous procedures. Additionally, patient services are impacted because of the threat to the scientific integrity of clinical trials using these tests.

The second step in the Cause Mapping method is the analysis. Beginning with one of the impacted goals and asking ‘why’ questions develops the cause-and-effect relationships involved in the issue. In this case, we begin with the patient safety goal that is impacted due to insufficient treatment for life-threatening disease. This is due to either a failure to detect the disease and/or to patients choosing to undergo unproven therapies. We address each cause in turn.

The failure to detect a disease is caused by inaccurate test results and/or insufficient interpretation of test results. Inaccurate test results can be caused by tests not being clinically valid (one of the FDA’s prime concerns) because the test is not regulated by the FDA. The test is not required to be regulated by the FDA, which is the addressed in the FDA’s report. The argument against requiring FDA regulation for tests is that the laboratories that create and use the tests are regulated under the Clinical Laboratory Improvement Amendments (CLIA). However, according to the FDA, CLIA is intended to regulate the operators of laboratories, not diagnostic devices. The report provides multiple case studies of problematic LDTs, which were offered from laboratories “following the minimum requirements of CLIA.”

Inaccurate test results are also caused by not identifying adverse events, which are not systematically reported for these tests (another of the FDA’s prime concerns). An additional prime concern of the FDA is that performance data is not required to be reviewed prior to marketing these devices. Not only is FDA approval not required, but there is an incentive for companies not to seek FDA approval of LDTs, leading to an uneven playing field (another of the FDA’s prime concerns) for companies who do seek FDA approval of laboratory tests. Insufficient interpretation of test results occurs because testing labels do not provide adequate information on interpretation (another of the FDA’s prime concerns).   Again, these causes are due to not requiring regulation by the FDA.

The FDA is concerned that results from unapproved testing may result in patients choosing to undergo unproven therapies. Misleading manufacturer’s claims and/or lack of transparency can mean patients are unaware that the tests have not been cleared or approved by the FDA. These causes are both listed as prime concerns of the FDA. Patients are unable to assess tests available because there is no comprehensive listing of tests currently being used (the last prime concern of the FDA).

Because of these reasons (causes), the FDA is requesting oversight of LDTs. The oversight provided by the FDA would ideally provide solutions to these issues by addressing each of the concerns (causes) listed in the report. To learn more, click here to read the report. Or, click on “Download PDF” above to view the cause-and-effect relationships including the FDA’s concerns about LDTs.

Root Cause Analysis

Equipment, procedural failure lead to resident scalding

By ThinkReliability Staff

While equipment and procedures were both in place to prevent resident scalding from too-hot baths, failures of both resulted in a resident receiving serious burns on August 13, 2013. The Health and Safety Executive (HSE) report was recently released on the incident, which resulted in prosecution for the care home and the employee responsible for the bath.

This incident illustrates the limitation in looking for the “one” root cause. There wasn’t just one thing that resulted in this incident; rather multiple failures were required to result in the tragic scalding. We can show these causes by performing a visual root cause analysis, known as a Cause Map. Note that the term “root cause” refers to a system of causes, much like the root of a plant is a system.

We begin the analysis by looking at the impact to the goals. Resident safety was impacted due to the very serious burning of a resident. The burning was so severe it resulted in the amputation of ten toes and the resident will never walk again. In addition, employee safety is impacted because of the emotional impact to the employee (known as the second victim). The employee safety is also impacted due to a risk of burns. The environmental goal is impacted due to the lack of temperature control and the compliance goal is impacted due to the prosecution of both the employee and the care home. Resident services are impacted from a resident being placed in a scalding bath. The failure of a thermostat is an impact to the property goal and the time required for response and investigation is an impact to the labor and time goal.

Beginning with one of the impacted goals (in this case we’ll begin with the resident safety goal) and asking “why” questions develops the cause-and-effect relationships that caused the incident. In this case, the resident’s injuries resulted from being placed in a scalding bath and being unable to exit due to physical and communication limitations. The resident was placed in the too-hot bath because the water in the bath was too hot, and the caregiver placed the resident in the bath. Both of these things (the water temperature being too high, and the caregiver placing the resident in the bath) had to occur in order for the injury to occur.

The water temperature was too high because of the failure of the immersion heater thermostat. The reason for the failure, as well as how long it was not working, is unknown. The caregiver placed the resident in the bath because she did not check the water temperature and failed to realize it was too hot. The caregiver appears to have been unaware of the thermostat failure, or certainly there would have been other safeguards in check. Additionally, there were inadequate thermometers provided to check the water temperature. (A manual check for comfort was still possible, though in this case could have resulted in a burn to the employee.) Although it was “required” to test the water temperature and record that the check had been done, there were no written instructions to that effect.

The care home has purchased portable thermometers for caregivers’ use, but the HSE also recommends the use of a secondary thermostatic cut-out, which would prevent boiling of the water tank even if the thermostat failed. The HSE has also provided a white paper “Managing the risks from hot water and surfaces in health and social care“, that discusses appropriate risk assessments and control measures to prevent burns of vulnerable care home residents.

To view the Cause Map of this incident, click “Download PDF” above.

Or, click here to read the HSE report of the incident.

Root Cause

Care Home Residents Unable to Escape Fire

By ThinkReliability Staff

A tragic fire at a care home for residents dependent on caregivers occurred in Pingdingshan, China on the night of May 25, 2015. Of the 51 residents housed at the 130-bed care home, 38 were killed and 6 injured.

It is tempting to declare the fire as the “root cause” of the tragedy. However, doing so limits the analysis (and thus potential solutions) to only prevention of fires. While many potential improvements in fire prevention at this and other structures with high-risk occupants can be identified, it’s also important to identify solutions that increase the probability of occupants being able to successfully escape a fire.

To ensure that the investigation develops the broadest possible range of solutions, begin with the impact to the goals. In this case, the primary goal impacted was that of resident safety – 38 residents died and 6 were injured. Most residents were unable to escape, impacting the resident services goal. The care home was completely destroyed, impacting the property goal, and it was found to not meet standards, impacting the compliance goal.

Once we’ve determined the impact to the goals, we can develop a Cause Map, or a visual diagram of cause-and-effect relationships that led to the impacted goals. Beginning with one of the impacted goals (in this case the deaths and injuries), and asking “Why” questions develops the cause-and-effect relationships. In this case, the deaths were due to the severe fire at the care home. But that isn’t the only cause. After all, the fire occurred in a facility where 51 residents were (presumably) sleeping, and there were a few residents who were able to escape with their lives.

This means that the cause-and-effect relationship of “fire kills resident” is accurate, but not complete. The effect of the deaths resulted not only from the fire, but from the residents being unable to escape. This gives us two different lines of questioning and possible solutions.

A severe fire results from a fire being initiated and spreading. Heat, fuel and oxygen are required in order to initiate a fire. Oxygen is present in the atmosphere. As in most fires due to destruction of evidence, the heat (or ignition) source has not been identified, but the national work safety agency investigation did find “irregularities” in the electrical system, which could be a potential source. While the initial fuel source is not clear, the care home was constructed with highly flammable materials, which allowed the spread of the fire.

The residents in the care home were dependent on caregivers and so were generally unable to escape without help. Unfortunately help was in short supply. Although residents complained of a shortage of caregivers, it’s not clear how many caregivers were on duty at the time of the fire. Shortage of caregivers is a huge problem in China due to the large percentage of the population that is older, which resulted from the one child policy of previous generations. It’s estimated there are 200,000 caregivers for the elderly in China, and 10 million are needed. In addition, the national work safety agency investigation found that the escape routes in the care home were poorly designed, making it difficult for anyone to escape.

After the tragedy, Chinese Premier Li Keqiang called on others to “draw lessons from the accident, checking all potential safety hazards to avoid similar incidents.” To avoid deaths from fire, that involves not only reducing the risk of fire, but making sure all people, regardless of ability, are able to escape.

To view the analysis of this issue, click on “Download PDF” above. To read about an arson at a care home in Australia that killed 11 and spurred a law requiring installation of automatic sprinkler systems, click here.

 

Root Cause

Identifying and Preventing Causes of Lab Errors

By ThinkReliability Staff

A man was mistakenly told he had HIV. A baby who died from a blood disorder that could have been treated during pregnancy, but wasn’t because the routine blood screen came back clear. A little girl who had to receive a second transplant after the test to verify her acceptance of a new organ was run incorrectly. These are just some of the cases mentioned in a watchdog report about how laboratory errors and weak oversight put patients at risk.

There are 7 to 10 billion medical laboratory tests run in the US every year. Lab tests influence about 70% of medical decisions. Having the wrong information from these tests can be deadly, and there is no good data about how many lab tests may be inaccurate, or may be negitively impacting patient safety. Laboratories are generally overseen by accrediting organizations but the results are almost always private, and there have been recent cases where federal regulators have had to step in because serious deficiencies in lab processes were identified.

The risk isn’t just for patients. An employee was infected with HIV and hepatitis C after a machine malfunctioned, splashing contaminated blood product onto her face. The employee had warned her boss previously that the machine was broken and cross-contaminating samples. Patients can also receive wrong information that isn’t harmful to their physical health but causes all sorts of other problems, such as incorrectly run paternity tests that improperly rule out a man as the father of a child.

The process involved in laboratory testing – from taking a specimen from a patient to delivering the results – is complex, and there are potential issues at each step that can lead to inaccurate results. These causes can be visually diagrammed in a Cause Map, or a visual cause-and-effect diagram. (To view the Cause Map, click “Download PDF” above.) In this case, potential causes of lab errors are captured and analyzed for potential solutions. These causes include labeling of samples, time and storage conditions of the samples, use of proper (and non-expired) products to treat the samples, and calibration of the machines used for the testing.

Actions that reduce the risk of inaccurate lab results should be in place at all labs, but even with a well-planned process, mistakes can happen. That makes the addition of checks and oversight into the process incredibly important. Says Michael Baird, the chief science officer and laboratory director at DNA Diagnostics Center, “I will agree that mistakes are something that can happen whatever you do. You just need to have the appropriate controls in place for when a mistake happens, (so) you can catch it before it goes out the door.”

For example, at the lab Baird runs, samples used for DNA checks are run independently by two different technicians and when a man is ruled out as the father of a child, there is a double-check in place. Other labs have incorporated alert systems for time-sensitive specimens and have hired technical directors responsible for overseeing the labs.

There are also steps patients themselves can take to minimize the impact on their safety from potential lab testing errors. First, ensure that any samples taken are labeled immediately and with accurate information. If you’re at all unsure about a test result, get a second opinion at a different lab. Complaints about a lab should be directed to state health officials.

To view the Cause Map addressing potential causes of laboratory errors, click “Download PDF”. To learn more, read the watchdog report.

Root Cause

Safely using a treadmill is not quite as simple as it seems

By Kim Smiley

Did you know that treadmills are the riskiest exercise machines?  I sure didn’t, but I have to admit that I have fallen off one before.  (Based on conversations with my coworkers, this isn’t all that uncommon.)  As recent headlines have made clear, using a treadmill safely may not be quite as simple as it seems.

According to data from the National Electronic Injury Surveillance System, about 19,000 people went to the emergency room (ER) because of treadmill injuries in 2009, which is about triple the number of injuries reported in 1991.  More and more people are using treadmills and the number of accidents has increased as well. Although only a small percentage of the injuries are serious, about 30 deaths related to treadmill use were reported between 2003 and 2011.

Understandably, the details surrounding Dave Goldberg’s death have not been released to the public, but it is believed that he slipped while using a treadmill and hit his head when he fell.  Falls off treadmills that result in serious injury are rare, but they have the potential to cause significant injury and even death. More common injuries associated with treadmill use are less serious overuse injuries, such as strains and sprains.

Children are at particular risk of being injured by treadmills.  A motor propels the belt on treadmills and children can get their extremities caught in the moving belt or suffer burns if they accidently turn a treadmill on or one is left running while unattended.  Of the 19,000 ER visits associated with treadmills in 2009, nearly a third were for children under age 9.

So how do you stay safe while using a treadmill?  The number one rule is to limit distractions.  Using a phone or watching TV puts you at a much higher risk of accidently misplacing a foot and falling.  (Trying to write an email while I walked on a treadmill is what resulted in my own fall.  Luckily, only my pride was injured, but I have learned my lesson.)

Treadmills have also risen in complexity and all the buttons and options can be distracting, especially if you are unfamiliar with the specific equipment.  Make sure you understand how to use the treadmill prior to starting the belt.  If you have balance issues or are elderly, you should also check with a doctor prior to using a treadmill.  And lastly, start by walking slowly and gradually increase the pace of the treadmill so that you aren’t caught unaware by how quickly the belt is moving.

To view a Cause Map of this issue, click on “Download PDF” above.

Root Cause

With $16.3B, Why Are Veterans Still Waiting for Care?

By ThinkReliability Staff

Concerns regarding the timeliness of treatment within the Veterans Administration (VA)’s network of hospitals and clinics have been around nearly as long as the VA itself. In 1995, a goal was set to have veterans seen for appointments within 30 days. VA doctors’ and executives’ bonuses are based at least in part on meeting timeliness targets. Many believe this is a key reason that waiting lists were doctored (by being kept on a separate “secret” waiting list, before being moved onto the real, computerized waiting list within 14 days of their scheduled appointment). The scandal, which is believed to have contributed to the deaths of dozens of veterans while they waited for appointments, led to much consternation and a call for significant reform to improve the waiting time of veterans.

It was found that veterans were waiting too long for appointments not only in Phoenix (where the “secret waiting list” scandal was discovered) but at many VA sites around the country. This was determined to have significant (though not always easily quantifiable) impact on patient safety as well as patient services to the large numbers of veterans who were unable to get timely appointments. (Read our previous blog about a veteran who lost much of his nose after waiting more than 2 years for a biopsy.)

In order to lessen the waiting times, $16.3 billion in spending to hire more doctors, open more clinics, and create a program that allows veterans to seek private-sector care was approved July 31, 2014. However, a study by the Associated Press has found that from August 1, 2014 to February 28, 2015, over 890,000 appointments failed to meet the timeliness goal. More than 230,000 appointments were delayed more than 60 days. While the number of vets waiting more than 30 and more than 60 days has stayed about flat, the number of appointments that take more than 90 days has nearly doubled. Some specific problem areas have been identified.

Challenges remain with the “Choice Program”: The Choice Program began to cover non-VA care for eligible veterans November 5, 2014. However, eligibility remains limited to those who have to wait more than 30 days from their “preferred date” or a date medically determined by their doctor or those who are more than 40 miles (straight line) from the nearest VA facility or face an unusual travel burden to access it.   Only some private physicians participate. The program is being expanded so that the 40 miles is based on driving distance rather than a straight line calculation, and telephone lines and other programs are being implemented to assist veterans using the program to seek care.

Medically underserved areas have the worst delays: During the government’s investigation, it was found that many VA facilities have inadequate providers for the number of veterans in their care. These areas tend to be areas that are medically underserved, which compounds the problem because civilian options in the area are also limited, limiting the effectiveness of the program that allows veterans to seek private-sector care. Says Dr. Kevin Dellsperger, chief medical officer at Georgia Regents Medical Center and former chief of staff at the VA medical center in Iowa City, Iowa, “Not a lot of medical students want to go work for the VA in a rural community medical clinic.” While 8,000 employees were added to the VA between April and December 2014, it’s hoped that increasing salaries in the underserved areas will attract more providers.

Physical space is also an issue: Any government contracting and building process can be cumbersome, and the VA has been identified as having particular difficulty managing the contracting process. When buildings are (finally) constructed, they’re usually already too small.

Enrollment is increasing: Enrollment in VA programs has been expanding rapidly. From 2002 to 2013, enrollment increased from 6.8 million to 8.9 million and spending increased from $19.9B to $44.8B.   Says Robert McDonald, Secretary of Veterans Affairs, “Today, we serve a population that is older, with more chronic conditions, and less able to afford private sector care.” It’s hoped that the increased enrollment is actually a positive, buoyed by the efforts made to increase access and shorten waiting times. “I think what we are seeing is that as we improve access, more veterans are coming, ” says Sloan Gibson, the Deputy Secretary of Veterans Affairs.

It may get worse: “The cost of fulfilling those obligations to our veterans grows and we expect it will continue to grow for the foreseeable future. We know that services and benefits for veterans do not peak until roughly four decades after conflict ends . . . we project the benefits for recent veterans in recent conflicts will peak around 2055,” testified VA Secretary McDonald.

The VA administration is asking for patience. Deputy Secretary Gibson says “We are doing a whole series of things – the right things, I believe – to deal with the immediate issue. But we need an intermediate term plan that moves us ahead a quantum leap, so that we don’t continue over the next three or four years just trying to stay up. We’ve got to get ahead of demand.”

To view an overview of these issues in a visual cause-and-effect diagram (or Cause Map), as well as some of the associated solutions, click on “Download PDF” above. To read more about the AP’s analysis, click here.