GAO Has Cited VA for 'Unnecessary Deaths,' Incompetence for More than 20 Years

Tyler McNally
By Tyler McNally | May 20, 2014 | 2:39 PM EDT

As the Obama Administration scrambles to respond to the Department of Veteran's Affairs (VA) scandal, it's worth noting that the Government Accountability Office (GAO) has been citing the agency for incompetence, mismanagement and abuse for more than twenty years now.

It's had problems ever since the Department of Veterans Affairs Act of 1989 turned the Veterans Administration into a Cabinet-level department under Pres. George Bush, who declared: "There is only one place for the veterans of America, in the Cabinet Room, at the table with the President of the United States of America."

Since that time, the GAO has cited the VA for problems with structure, planning, practices, coordination, organization, and efforts to employ corrective measures.

In a Government Accountability Office (GAO) report in 1991, the congressional watchdog group reported that the VA had no structure to manage information technology and that the chief information resources officer (CIRO) had no control over the resources at hand.

What's more, the reorganization effort put forth by the VA in July 1990 "did not provide a solid foundation for [the Office of Information Resources Management], resulting in less responsibilities for the IRM office and a weakened CIRO."

The three different moving parts of the VA - the Veterans Health Administration, the Veterans Benefits Administration, and the National Cemetery System - were, up until that point, working autonomously from each other.  The creation of the CIRO was meant to fix the problem of autonomous administrations, but the effort did not prove successful.

In a July 1994 statement, the GAO found that the VA "has no plan that addresses how the modernization program will be redirected or how VA will improve oversight and overall coordination."  Also, the GAO found that "although VA's current and past Secretary have repeatedly agreed to strengthen CIRO oversight, VA's actions to date have not substantially changed or improved the CIRO role."

GAO investigation into VA psychiatric hospitals in 1992 blamed VA medical staff for "unnecessary deaths":

None of the four VA psychiatric hospitals visited are effectively collecting and using the kind of quality assurance data needed to demonstrate that their psychiatric programs fully meet patients' psychiatric needs, primarily because VA has not defined requirements for evaluating psychiatric programs, and nurses and physicians in two hospitals are not documenting the reasons why they place patients under restraints and seclusion; hospital staff in two VA hospitals were not timely correcting quality assurance problems identified through patient incident reports; unnecessary deaths occur in VA hospitals because medical staff do not use available quality assurance data to correct identified problems.

It's also worth noting that the GAO found that "VA and non-VA hospitals' quality assurance programs are similar; and quality-of-care problems resulting in complications or death occurred in both VA and non-VA hospitals."

The wait times that are plaguing the administration now are not a recent problem, either.  The VA "established a goal that all nonurgent primary and specialty care appointments be scheduled within 30 days of request and that clinics meet this goal by 1998."  But, in a GAO report in 2001, "only one-third of the specialty care clinics visited," 18 out of the 54 visited clinics, passed the 30-day standard.  Meanwhile, 15 out of the 17 primary care clinics met the standard.

"Although clinics that did not have guidelines could have benefited from headquarters' assistance, VA has not established a national set of referral guidelines. Moreover, VA lacks an analytic framework for its medical centers and clinics to use in determining the root causes of lengthy waits," summarizes the GAO.

Recently, the GAO put out a report in April 2014 saying, "[Veterans Health Administration's] scheduling policy and training documents were unclear and did not ensure consistent use of the desired date," and that, "inconsistent implementation of VHA's scheduling policy may have resulted in increased wait times or delays in scheduling timely medical appointments."

The GAO found "clinics that did not use the electronic wait list to track new patients in need of medical appointments as required by VHA policy, putting these patients at risk for not receiving timely care."

The GAO, in 2012, says that "VHA found that systemwide consult data could not be adequately used to determine the extent to which veterans experienced delays in receiving outpatient specialty care."

This problem is not one from this administration, but rather a systemic issue that has never been fixed within the Department of Veterans Affairs.