A year ago, the Department of Veterans Affairs was in turmoil. A scandal had erupted that April with news reports that at least 40 patients died while waiting for care at VA health facilities in Phoenix.
Soon, similar problems with “secret waiting lists” and patients denied care were being uncovered at other VA hospitals nationwide. And at the Kansas City VA Medical Center, officials revealed that several dozen heart patients in need of care had been left waiting for appointments.
They blamed that lapse on a “serious clerical mistake.”
Behind the scenes, officials were blaming a single scheduling clerk, NaNette Chaney.
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Several days after reports about the missing appointments surfaced in The Kansas City Star and other news media, Chaney was put on administrative leave. A month later, she was fired.
Now the Army veteran, who worked for the VA for eight years, is fighting to get her job back.
Experts say the problems Chaney says she faced were typical of the systemwide dysfunction exposed at the VA last year — inadequate staffing, unattainable goals and a bureaucracy that heaped demands on workers at the lowest levels while keeping those in the highest echelons in the dark.
“The problems don’t necessarily reside at the top or at the bottom,” said David Gai of Amvets, a national veterans service organization. “It’s usually at a leadership management level and trickles up and down from there.”
Chaney says she was given an impossible job. She was assigned to schedule patients attending two clinics, told to ignore VA rules and doctors’ orders, and given ever-changing rosters of physicians available to see patients, as well as conflicting orders left on sticky notes, emails and voice messages.
Chaney complained frequently about being told to bend the rules for the convenience of nurses and to game the system to make it appear that patients were being seen within the VA’s time limits.
She has appealed her dismissal through the federal civil service system, has gone through a hearing and is awaiting a judge’s ruling that will most likely come after the first of the year. She also has filed a complaint with the VA’s Office of Inspector General about how the hospital handled scheduling.
She said she’s eager to return to work at the VA.
“I’d just rather go to a different department. Not all people at the VA are bad,” Chaney said in an interview.
“I love patient care. I’m not trying to hide nothing, to deny nothing. I just want the truth out.”
That truth lies somewhere under a pile of about 1,000 “yellow sheets” — appointment requests doctors write for their patients — that VA officials say they found in Chaney’s desk drawer and file cabinet.
Most of the sheets either didn’t require any action or were for appointments Chaney already had scheduled, but 39 were for patients whose appointments apparently were overdue. About 330 more were for patients whose appointments weren’t overdue, but hadn’t been scheduled.
In hearing testimony, VA officials said Chaney was “removed” for failure to perform her duties and for improperly disclosing patient information. Chaney said she was unaware that the person to whom she sent an email mentioning a patient’s name was no longer employed at the hospital.
“It’s unacceptable” for clerks to not schedule patients, said Kent Hill, the hospital’s director, now retired. “It goes to the heart of what they do.”
Hill said the “egregious nature of the offense” played a role in his decision to sign off on Chaney’s dismissal. “Especially in light of all the attention” the VA was getting at the time.
Citing the ongoing legal issues, the Kansas City VA Medical Center declined to comment on Chaney’s case or to make any of the employees she worked with available for interviews.
“We are committed to ensuring wait times are reasonable and within the scope of care,” hospital spokesman Joseph Burks said in a written statement. Burks referred to a website that provides current wait times of VA hospitals; it shows that in June, 97.87 percent of patient appointments at the Kansas City hospital were completed within 30 days, similar to the national rate.
Chaney’s attorney, Dale Ingram, says Chaney’s constant complaints to her supervisors made her a burr in the side of the hospital’s management. And when VA scheduling irregularities became a national scandal, she became a serious liability.
“Everybody in the bureaucracy is above her. Everybody was giving her different guidelines. That was the untenable position she was in,” Ingram said.
“She wanted to do things by the book. She was a sticking point.”
Chaney, 54, trained as a medical specialist in the Army. She served three years at Fort Sam Houston in San Antonio, doing work similar to that of a licensed practical nurse.
She started working as a health tech — drawing blood, taking vital signs — at the VA Medical Center in 2006 through a temp agency. In 2008, the hospital hired her full time.
As a VA employee, Chaney scheduled patients, checking them in and out of primary care and specialty clinics. At times, she said, she was assigned to clean up the scheduling at various clinics to bring them up to date.
Chaney said she enjoyed working for the VA, and her supervisors gave her work positive reviews.
She was rated “excellent” in an annual performance review in 2013. “NaNette is a stalwart employee,” the review said, “a model of dependability.”
“I was really good. I still am really good,” Chaney said. “It was lovely up until October” 2013.
That was when the hospital assigned Chaney to the Patient Aligned Care Team, or PACT, serving cardiology patients.
Chaney was the PACT’s advanced medical support assistant. It was her job to serve as a receptionist, take phone calls, schedule patients and coordinate their appointments throughout the hospital.
Some patients might require another visit to the clinic. Others might need lab work. Some of the follow-ups were urgent — stress tests, echocardiograms, surgery to implant a pacemaker.
Chaney had expected to receive some training her first day. Instead, she said, she was told to clean up several hundred “yellow sheets” dating back to September.
“Yellow sheets didn’t just get backed up when I came there. They were already backed up,” Chaney said.
From the beginning, Chaney received instructions that seemed hard to follow.
“Please do not ever overbook (a clinic) without checking. You will see us ask you to overbook often and that is OK,” Shari Engert, the cardiology clinic’s nurse coordinator, told her in an October 2013 email.
“Even if there is an opening, please ask … prior to adding anyone to these spots. And you will have lots of doc(s) asking you to do so. Just yes them in your awesome way and let us know.”
In other words, Chaney said, “if a doctor tells you to book a patient, don’t do it.”
Chaney found that some cardiology nurses were making phone calls to follow up on patients who had undergone cardiac catheterization procedures instead of bringing them back to the hospital, as required.
This was done at Engert’s direction, for her convenience, Chaney said. “This was her own list she created for herself. It was a Shari Engert list, not a VA list.”
During the hearing, Engert said she never kept her own patient list or scheduled patients on her own.
Chaney was stationed in the hospital’s Silver Clinic, a specialty clinic that saw patients with ailments including cancer, diabetes and heart disease. She was responsible for the heart patients, but also was assigned to serve other patients. She didn’t get the heart patients’ yellow sheets until the next morning and then had to reach them by phone.
Chaney’s task was further complicated because she wasn’t allowed to have her cardiology calls forwarded to her while she was on general duty. She would only be allowed to check her voice mail from time to time.
Because her calls to heart patients involved confidential medical information, Chaney said she had to wait until she was back in her cardiology clinic office on the seventh floor to return phone messages and arrange appointments. The Silver Clinic is on the first floor.
“All it was doing was making me look bad,” Chaney testified during her hearing.
‘Not working out’
At the time Chaney was scheduling patients, the VA’s ambitious goal was to schedule appointments within 14 days. The agency was tracking hospitals’ performance. Peoples’ bonuses were riding on how well they did, Chaney said.
She claimed that the clinic was gaming the system to make sure that appointments appeared to have been made within the two-week deadline.
When patients were called to schedule appointments, no attempt would be made to schedule them within 14 days if VA doctors weren’t available to see them, Chaney said.
Instead, patients would be told when appointments were available and asked to pick a day convenient to them. That day would be when the 14-day clock would start ticking.
Journalists and federal investigators found similar techniques to “zero out” the 14-day waiting period were being used at other VA hospitals across the country, including those in Fort Collins, Colo., and Austin, Texas.
Chaney complained frequently to her supervisors about her difficulties scheduling patients. Cardiology clinics would be booked months in advance, but the availability of doctors and nurse practitioners would change from day to day.
Canceling a clinic would mean patients who had been waiting several months to see a doctor might get bumped to the back of the line and have to wait months longer.
Her immediate supervisor, Elizabeth Dial, told her “I have to learn to be a team player,” Chaney said.
But by spring 2014, it was clear that Chaney was no longer welcome in cardiology.
“NaNette Chaney is not working out as the Cardiology PACT clerk,” Dial wrote in an email April 1 to Laura Kochenower, another supervisor at the hospital. “We need supporting documentation — such as not following instructions, etc., ASAP.”
Chaney was written up on April 11 for unacceptable customer service involving her treatment of a woman who arrived on the wrong day for an appointment.
Then came news of the Phoenix scandal. It had the Kansas City VA hospital buzzing.
In an April 24 email to all supervisors, Glenna Greer, the hospital’s public information officer at the time, sent a link to CNN’s exposé.
“If you haven’t been following this story — the report describes how lengthy wait times contributed to the deaths of 40 Veterans,” Greer wrote. “Plus a report on ‘secret’ list being kept to hide over 1400 Veterans being forced to wait for an appointment. Please review and share with your staff.”
That day, Chaney emailed Dial: “I saw that on the news today.”
“What you’ll have me doing is making it look like the patient is being seen within the guidelines, when they are actually being seen 40 or more days out,” Chaney wrote.
“I prayed about it and God knows my heart. So now every time I take a gamble with a patient’s life I say a silent prayer, ‘Lord, keep this person safe until we can see them.’”
In an interview with The Star, Chaney said she also told Dial, “just wait until the office of inspector general comes here.”
On April 28, Dial emailed several hospital administrators and mentioned the possibility that Chaney’s complaining might lead to an investigation by the inspector general’s office:
“I was informed by the union on Friday that this employee is communicating that we are having staff incorrectly schedule patients. … Here lies the concern: This employee’s incorrect assessment of the scheduling process could place the KCVA in a negative light. (OIG?)”
One administrator, Stanley Utley, emailed her back: “As you know, this whole story is a huge issue for VHA (Veterans Health Administration) and we’re getting requests from Central Office daily about access, (electronic waiting lists), etc. This needs to be addressed and we must ensure that we have accurate scheduling procedures in place.”
“We have accurate scheduling procedures in place,” Dial replied. “She was not ignored.”
That day, Chaney received a reprimand for failure to follow instructions.
Several weeks later, Engert told hospital managers about Chaney’s cache of yellow sheets. An investigation ensued, as hospital staff went through the sheets to determine whether the patients had received appointments.
On June 9, 2014, Utley proposed Chaney’s “removal.” It became official a month later.
“I’m very sympathetic. The person at the bottom gets hit,” said Paul Light, a professor of public service at New York University who has studied the breakdown of the VA and other public institutions.
“It sounds exactly like a failure of management and not a failure of the employee.”
At the VA, “unmeetable goals” were passed down from level to level, Light said. “Nobody ever said, ‘Gee, we can’t do this.’ They passed it down like a hot potato and it’s the person at the bottom who gets the order who can’t do it.”
The VA scandal did lead to some swift actions.
On May 21, 2014, the VA began a nationwide search for patients who had been waiting too long to see a doctor, and scheduled them into VA clinics or to treatment outside the VA system.
By early June 2014, the VA had eliminated its 14-day scheduling goal.
Meeting that performance target “was simply not attainable given the ongoing challenge of finding sufficient provider slots to accommodate a growing demand for services,” a VA audit said.
Imposing that expectation without determining what resources were required represented “an organizational leadership failure.”
In July 2014, Congress voted the VA an extra $16 billion to hire more staff and provide some veterans private medical care outside the VA system. The VA secretary also received greater authority to fire poorly performing managers.
The VA has improved its ways of doing business, such as how it schedules patients, said Gai of Amvets.
“There is a measurable difference compared to a year ago, but there’s still a lot of work to be done because the health care need hasn’t changed.”
Critics point out that the VA still doled out performance bonuses last year to administrators at some of its most troubled hospitals and few hospital executives have lost their jobs.
Reforming a bureaucracy as vast as that of the VA is proving to be a monumental task, Gai said. “It’s like trying to eat an elephant. You can’t swallow it whole.”