On September 5, 2014, a tragic story was released of a man who lost most of his nose due to spreading cancer. When diagnosing cancer, it’s generally acknowledged that the earlier the cancer is caught, the less the risk of the cancer spreading. In this case, the veteran waited over two years for a biopsy. He is one of thousands of patients who have had to wait unreasonable amounts of time for care through the Veterans Administration (VA) system.
Although the issues with delay of veterans care appear to be nationwide, looking at one particular incident can help shed some light on not only what went wrong, but possibilities for reducing the risk of it happening in the future. The Inspector General examined dozens of cases of patients who died while waiting for care at the Phoenix VA hospital in order to determine the impacts of the delayed care, the causes related to it, and recommendations for fixing the problem. We can also examine the impact, causes and potential solutions for the care issue by performing a root cause analysis based on the story of this particular patient. (His case was not covered in the IG report, which primarily examined deaths of veterans while waiting to be seen at VA facilities.)
We can capture the analysis in a Cause Map, which visually lays out the cause-and-effect relationships that resulted in an incident in order to provide the maximum opportunities for improvement. After the what, when and where of the incident are captured, it’s important to determine the impacts to the goals resulting from a particular issue. In this case, the patient’s safety was endangered because of the spread of cancer. The patient services goal was impacted because the patient lost most of his nose as a result of inadequate treatment at the healthcare facility. The schedule/operations goal is impacted due to the delay in treatment of the patient. In order to better quantify the effects of an overarching issue such as this one, a frequency of events is essential. In this case, the Inspector General found that delayed treatment was clinically significant for at least 28 other veterans at the same VA hospital. (The Inspector General also found that 40 veterans died while waiting for appointments but was unable to determine if the deaths were due to the delays.)
Beginning with an impacted goal, asking “Why” questions adds detail to the Cause Map. The spread of the patient’s cancer was caused by a delay of treatment. Treatment was delayed due to the exceptionally long wait for a biopsy (two and a half years) as well as the wait between the diagnosis and treatment (surgical removal). Insufficient capacity and large numbers of veterans seeking care at the VA hospital resulted in veterans waiting months or even years for care. Because (as described by a whistleblower physician from the site) the site used “secret” waiting lists (where patients were effectively put on a non-official waiting list for the waiting list so that the reported wait was within an acceptable time frame), oversight of the facility was minimal. As in this case, many veterans prefer to get care at a VA facility and/or don’t have another type of insurance that would cover the costs incurred for healthcare needs.
As expected, the results of these investigations have resulted in a number of personnel being removed from their positions in the VA. The “secret” waiting lists were used to hide the fact that the VA hospitals don’t appear to have the capacity for the number of veterans that need treatment. Significant additional funding is being directed towards the VA in order to build more hospitals and hire additional medical staff. In the meantime (and possibly continuing into the future if capacity continues to be inadequate), arrangements for veterans to receive covered care at other facilities are being made.
In light of these highly publicized issues, hopefully the VA will receive the funding and oversight it needs so that the nation’s veterans can receive the care they deserve.