Exhibit 1206 · Inspector general report
Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System (14-02603-267)
PVAHCS’s emphasis on goals resulted in a misleading portrayal of veterans’ access to patient care.
Final OIG report. Confirms unofficial wait lists, scheduler manipulation of desired dates, and a facility emphasis on goals that produced a misleading picture of access. Reports that OIG had warned of the same data problems since 2005 and that VA reported high performance regardless. States OIG could not conclusively assert that delays caused the deaths of the veterans whose cases it reviewed.
- Source
- VA Office of Inspector General
- Date
- 26 August 2014
- Quoted from
- Conclusion to the performance-goals section, p. 63 (printed report page)
- Grade
- Primary record
- Document
- https://www.vaoig.gov/sites/default/files/reports/2014-08/VAOIG-14-02603-267.pdf
- Accessed
- 2026-11-10
- Cited by
- Findings citing this exhibit
- Note
- Same report, p. 91: "Contrary to OIG reports, VA reported high performance in the VA Performance and Accountability Reports, even after we had twice reported the scheduling system contained inaccurate, incomplete, and unreliable data." P. 92: for the 2008 VISN 3 report "VHA disagreed with the report's conclusions and all nine recommendations." P. 72 quotes VHA ethics guidance that "When leaders set unrealistic or unattainable goals they invite employees to game the system or misrepresent results." The report attributes underreporting to staffing, demand and an antiquated scheduling system as well as ethical lapses (p. 72). Summary text states that OIG was "unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans."