Nurse Diane Birmingham offered her resignation to the Cheyenne Veterans Affairs Medical Center last Monday with great relief. She was tired and demoralized and no longer able to fight for the patients.
Birmingham is the second medical practitioner in two years to resign from Cheyenne. Both she and Dr. Cephus Allin lodged grievances with the VA about scheduling practices and resource problems that they say impacted their ability to care for patients at the Fort Collins clinic. Both say they were then transferred to Cheyenne and harassed out of their jobs for speaking up.
“There’s a point at which you just cannot go against your own sense of what is right,” Birmingham said of her resignation. “I love the patients. I still do miss them. Some of these guys were like old friends.”
The Veterans Administration hospitals have received high marks in recent years for installing new bar-code technology to ensure patients receive the correct medication, and implementing electronic prescription orders and electronic medical records. The Cheyenne center’s patient satisfaction data ranks 87.7 out of 100, above the 78.1 rating of national VA hospitals.
Yet, Birmingham and Allin say that VA policies and data collection are catered toward creating a positive face for the organization, instead of improving care for the country’s most revered patients.
Few resources, many patients
Birmingham came to the clinic six years ago with a master’s degree in public health. She enjoyed the fast-paced workload, her coworkers and her patients, but it wasn’t long before she had questions about the resources and policies at the clinic.
Birmingham said the small Fort Collins building lacks the infrastructure to serve the large number of patients with complex problems who come there. Fort Collins staffs 1.5 doctors, a nurse practitioner, a registered nurse, a licensed practical nurse and a phlebotemist with a rotating set of specialists using only four exam rooms and one patient room. In fiscal year 2006, 2,776 patients came through the doors.
Birmingham also noted that the average veteran comes to the clinic with far more problems than a regular doctor’s office would see. “We have the oldest and we have the sickest (patients),” she said.
Due to the space constraints, nurses were routinely forced to assess patients in the hallway, performing blood pressure checks and asking routine questions when no rooms were available, Birmingham said. Although this was a violation of the Health Insurance Portability and Accountability Act, the nurses were also under pressure not to reschedule appointments and to see as many patients as possible.
The Fort Collins clinic is under the auspice of the Cheyenne Veterans Affairs Medical Center. Spokesman Andrew Ruben said that the center does the best it can with the resources available and is constantly assessing whether outpatient clinics need more space or staff. Ruben recognized that the clinics are busy, but said a committee is due to make recommendations about needs by October.
“The clinics are pretty much approaching their full capacity. That’s why we’ve got that committee in place now to make sure we are aware of the workload data,” Ruben said.
Dan Frantz, clinical specialist in psychiatric nursing in Greeley, lauds the care veterans receive at his clinic, but said of course he’d like more resources. “More days than not, every room is double booked,” he said. “Expanding this clinic would make a difference in terms of waits.”
Appointments not by the books
Allin worked at the veterans administration for three years. As a doctor in Fort Collins, he consistently served a higher number of patients than many other doctors in the Cheyenne network. He also helped implement the emergency medical record system there.
As a self-professed computer geek and passionate doctor, Allin said he noticed that the VA’s patient appointment policy was causing the sickest patients to fall through the cracks.
The administration created its scheduling policy to free up the doctors and get patients in the door as quickly as possible. To do that, the computer only allows schedulers to make appointments for the next 30 days. Patients who come out of the doctor’s office with instructions to return in five weeks are put into a reminder system, which sends them a letter telling them to call and make an appointment.
Birmingham said the aging, ill patients who come to the VA aren’t good at rescheduling. “That population doesn’t do a lot to follow up on anything” that isn’t done the time they leave, she said.
Allin found the data to back up his claims. Using the VA system when he worked there in 2005, he determined that 24.7 percent of the people receiving letters didn’t actually schedule appointments. “People who are going to have the greatest problems getting around to making appointments are probably the most vulnerable patients,” Allin said.
Nurse Mary Walton of the Greeley clinic, who speaks highly of the veterans administration as an employer, agreed that patients can fall through the cracks in the system.
Birmingham said that the system makes the VA look like there is a smaller waiting list to get into the clinic, instead of showing concern for patients. “We’ve got to look good, whether it’s real or not. And isn’t that what politics is all about?” she said of the VA policy.
Allin: Managers lie to improve statistics
Allin also noticed in his clinic that schedulers weren’t following the correct appointment procedures. His suspicion was that the divergent scheduling was a strategy to make the patient wait times look better. Only six months before he left the clinic, an audit verified his complaints.
A report by the Department of Veterans Affairs Office of the Inspector General on outpatient scheduling found that 41 percent of the schedulers in the eight facilities scrutinized were directed by supervisors to enter information incorrectly. Because of this, the VA numbers looked far better than reality when the statistical sample was applied nationally. While only 65 percent of patients were truly seen in 30 days, the VA reported 81 percent. Further, the average waiting time was actually 44 percent higher than reported by the VA when errors were corrected, according to the audit.
Using the model from the sample, the office determined that the error rate applied to as many as 24,463, veterans nationwide.
Both Allin and Birmingham said that doctors and nurses were constantly under pressure to keep waits down and serve an increasing number of patients. This, Allin said, resulted in a culture where managers would lie to make their facilities look better.
The Veterans Health Administration uses scheduling data to measure performance and plan budgets. The report concluded that the inaccurate data compromised the VA’s ability to assess and manage demand for medical care.
Laurie Tranter, a spokeswoman for the Department of Veterans Affairs, said the administration is currently rolling out new policies and training in response to the audit. She said the VA did a thorough review of the situation and issued two directives to rectify the scheduling problems.
Allin worked for the VA for six months after the report was released and saw no changes in policy at the clinic. During that time he testified before a U.S. Senate committee hearing on rural veterans and discussed the scheduling errors. Despite the new policies being rolled out, Allin said that until the VA fires the 41 percent of managers instructing their employees to fraud the system, the problem would likely continue.
A gold standard
While Allin and Birmingham had bad experiences as VA employees, Frantz and Walton tell a different story about the organization.
Frantz has worked at the VA for 20 years and lauds the organization’s integrity. Walton also loves her job and praises the incredible patients, who she says share their lives with her. She has a room full of fishing antiques given to her by veterans.
Both Frantz and Walton see room for improvement at the clinic, which is also run by the Cheyenne Medical Center, but believe the clinic is the “gold standard for medical care.”
Ruben would not offer specific employee satisfaction data for the Cheyenne Medical Center, except to comment that the data tracks along the same profiles that are generated nationally. “The raw data is intended for internal analysis, program development and employee recruitment and retention and I am happy to have summarized it for you,” he said.
Allin is now a private consultant helping medical facilities implement electronic medical record systems, which he also did at the Veterans Administration. The day after Birmingham filed her resignation, she received a job offer in public health.
VA whistleblowers nationwide unite
Dr. Jeffrey Fudin formed the VA Whistleblowers Coalition in 2005 to lobby Congress to prevent retaliation against those who report abuses in the U.S. Department of Veterans Affairs. Fudin underwent a long and much-publicized battle for his job as a pharmacist at the Stratton VA Hospital in Albany, N.Y., after he disclosed cancer research violations and patient abuse. The whistleblowers group has 20 signing members in 13 states and about 40 anonymous members who fear for their jobs and pensions.
Salazar announces rural clinic for Craig, introduces bill for rural vets
U.S. Sen. Ken Salazar announced last Wednesday that the U.S. Department of Veterans Affairs is planning to open a community based outpatient clinic in Craig. An organized group of veterans in Craig have fought for the clinic for decades, Salazar said. Approximately 4,200 veterans, who currently must drive to either Grand Junction or Denver for service, could use the clinic. The VA plans to open the clinic this fall.
Salazar also announced that he introduced the Rural Veterans Healthcare Improvement Act last week. The measure aims to address the disparity in treatment between rural and urban veterans, expand options by partnering with local clinics and provide additional transportation options.