Healthcare Inspection – Delayed Access to Primary Care, Contaminated Reusable Medical Equipment, and Follow-Up of Registered Nurse Staffing Concerns, Southern Arizona VA Health Care System, Tucson, Arizona

The VA Office of Inspector General conducted a healthcare inspection at the request of Senator John McCain, Senator Jeff Flake, Congresswoman Martha McSally, former Congresswoman Ann Kirkpatrick, and Congressman Raúl M. Grijalva to assess the merits of allegations regarding patients’ delayed access to primary care and contaminated reusable medical equipment at the Southern Arizona VA Health Care System (system), Tucson, AZ. We also followed up on registered nurse staffing concerns identified in the fiscal year (FY) 2014 Employee Assessment Review survey. We substantiated that the number of primary care patient appointments taking 30 days or more to schedule from FY 2015 to FY 2016 had increased. We also found an increase in the number of new and established patients waiting more than 30 days from the preferred to the appointment date. We determined that primary care wait times were affected by complex scheduling templates containing different appointment types and provider vacancies. System leaders increased physician recruitment by offering financial incentives to attract providers to a rural clinic. While we substantiated that reusable medical equipment (endoscopes) were contaminated and reused on two patients, we did not substantiate it was due to reduced staffing. We found this was a process issue. System staff notified the patients, who were tested, and we found no related adverse patient outcomes. System managers modified the process and trained staff. We found that since FY 2014, registered nurse staffing improved in the inpatient medical/surgical and mental health units, the community living center, the special procedures unit, and the Emergency Department. We made one recommendation.