After 17 years working as a registered nurse in the Tucson VA system, Diane Suter says she was taken aback when a manager first pressured her to falsely record patient wait times in 2014.
Suter, 62, had just started a new job scheduling patients at a Southern Arizona VA Health Care System primary care clinic on South Sixth Avenue. Wait times were often one to three months long, but revealing the true wait times in the computer system meant the doctor missed out on bonus pay, Suter's nurse manager told her.
"She said, 'Your appointments are over two weeks out and you're costing your doctor money,'" Suter said. The manager showed her how to "zero out" wait times on their computerized scheduling system: Suter was told to input a patient's desired appointment date as the same day as the scheduled appointment date, so it would appear there was no wait time, she said.
Suter complied after her manager strongly implied she'd be fired if she refused. But her dogged whistleblower complaints to VA regulators and legislators contributed to the Department of Veterans Affairs Office of Inspector General's decision to investigate the Tucson VA starting in April.
The resulting Office of Inspector General report substantiated much of what Suter alleged about wait-time manipulation and misconduct at the Southern Arizona VA Health Care System.
The report, released Nov. 9, recommended disciplinary action for staff who encouraged the falsifications. The report found:
* Between December 2013 and August 2014, 76 percent of appointments in the Ocotillo Primary Care Clinic -- where Suter worked -- had a zero-day wait time.
* In fiscal year 2013, Ocotillo clinic physicians got bonuses based in part on the percentage of patients with appointments scheduled within 14 days of their requested date. Doctor pay did not appear to be based on wait times in the following three fiscal years.
* Training materials from 2014 advised staff workers to mark the patient's desired appointment date as the same as the actual appointment date in some scenarios, in violation of VA policy. Some time after the fallout from the Phoenix VA wait-time scandal in mid-2014, the training materials were updated to align with VA scheduling policy.
Tucson VA spokesman Luke Johnson said in an email the practices described in the report "are inappropriate and are not consistent with our ... core values of integrity, commitment, advocacy, respect and excellence."
The OIG also issued a separate report on Nov. 8 summarizing allegations about the Tucson VA dating to 2012, and subsequent investigations. Among the report's conclusions: Tucson's VA staff kept 400 orthopedic and 600 urologic appointment requests on pieces of paper, instead of in the electronic scheduling system.
A staff member who told senior leaders about these practices said that her concerns were dismissed, the report said.
Johnson said the VA apologizes to veterans for these practices, which are no longer occurring.
"These reports are related to practices dating as far back as 2008, and we have made significant changes since then," he said.
Two years ago the Phoenix VA Health Care System was at the center of the scandal over dishonest scheduling practices and dangerously long wait times for veterans seeking care.
An OIG report found 1,700 patients at the Phoenix VA hospital were put on unofficial waiting lists. Veterans there waited an average of 115 days for their first appointment, but the facility reported an average wait time of 24 days, which could have led to bonuses for Phoenix VA leadership, the report said.
At the time, an OIG review did not identify problems at the Southern Arizona VA Health Care System.
Doctors' and nurses' performance pay is no longer tied to wait times, Johnson said.
Even before the recent OIG report was released, the Southern Arizona VA Health Care System reviewed scheduling practices and has trained staff to be in compliance with federal VA procedures. Johnson encourages VA staff to speak up if unethical practices are still happening.
"If there are any scheduling issues or concerns, leadership wants to know about them so they can be addressed," he said.
An underlying systemic problem is physician staffing issues at VA hospitals, including difficulty recruiting specialists, Johnson said. In the past couple of years, the Southern Arizona VA Health Care System has hired 100 new staff members and is reviewing physician compensation to improve recruitment and retention, he said.
"These initiatives have helped enhance access to care for our veterans," he said.
Johnson said that in September, wait times for primary care appointments at the Tucson VA averaged less than four days; specialty care wait times were about six days; and mental health appointments were less than three days.
Vietnam War veteran Ray Murphy, 67, said Friday he was "a little shocked" by the news of the wait-time fraud at Tucson's VA. He's had only positive experiences there getting treatment for hearing problems, and his wait times are usually less than 30 days, he said. But Murphy said he has a couple of friends who have experienced very long wait times to see specialists.
"I think personally that the Tucson VA is really good," said Murphy, who served three tours in Vietnam as a member of the U.S. Navy and still deals with the effects of exposure to Agent Orange. But for veterans in need of timely urgent care, he said, "if they're not getting it, that's not good."
Rep. Ann Kirkpatrick, D-Ariz., said in a Friday email that she asked the OIG to investigate the Tucson VA after hearing from Suter. In a statement, she called the results of the OIG report "infuriating and unacceptable."
"I don't see how the VA can earn back the trust of our veterans until these systemic problems are fixed once and for all," she said.
After Suter objected to unethical scheduling practices, she suffered retaliation and a hostile work environment, leading her to leave the VA in August 2014 and seek treatment for post-traumatic stress disorder, she said.
The nurse manager who compelled her to falsify wait times still works at the Tucson VA, Suter said.
Johnson said the Southern Arizona VA Health Care System has appointed an "administrative investigative board" to review the practices identified in the OIG report.
"The scope and level of necessary personnel actions will be determined based upon the findings of this board," he said.