Palo Alto VA head called to lead controversial Arizona network

Lisa Freeman on temporary assignment for up to four months

The director of the VA Palo Alto Health Care System has been called to temporarily head the VA Southwest Health Care Network in Arizona, the epicenter of this year's national scandal over VA wait times and standard of care.

Lisa Freeman, who has been Palo Alto's director since 2001 and with the VA since 1983, left to serve as the Southwest VA's acting director in early July. She's replacing former director Susan Bowers, who retired in May. Her assignment is set to last between 90 and 120 days, according to VA Palo Alto spokesman Michael Hill-Jackson.

Deputy director Tony Fitzgerald is serving as Freeman's replacement, Hill-Jackson said.

Though she's now based in Arizona, the Southwest VA network is made up of seven sub-health care systems, five hospitals, six VA nursing home care units, three domiciliaries, and 46 outpatient clinics. The network stretches from Arizona to Texas, New Mexico, Colorado and Oklahoma.

It was the network's Phoenix facility where allegations of secret wait lists – designed by local VA management to hide appointment delays for thousands of veterans – first cropped up, sparking highly publicized inquiries into 42 facilities across the nation. A 35-page independent report conducted by the VA's inspector general released May 28 found that 1,700 veterans using the Phoenix VA hospital were kept on these unofficial, secret wait lists. The report drew from reports of 226 veterans who had sought appointments at the hospital in 2013, finding that 84 percent had to wait more than two weeks to be seen. At least 40 veterans died waiting for appointments in Phoenix, according to CNN.

Hill-Jackson said Freeman was called to Arizona "to make sure all procedures are being followed properly, to correct any mistakes that are being made and to just create better processes.

"That's one of the things that she does here a lot, is working on a lot of process improvement. That's the driving force here now."

In order to position itself within – and above – the national scandal, the Palo Alto VA in June boasted shorter-than-average wait times: an 18-day average for new patients seeking primary care and one week for those seeking mental health care.

As of July 31, the Palo Alto VA scheduled 89.77 percent of its appointments in 30 days or less and 10.23 percent in more than 10 days, according to U.S. Department of Veteran's Affairs data. The department recently started posting online twice-monthly updates in the middle and end of each month to show the current status of wait times at all VA's.

The average wait for new patients seeking to schedule primary-care appointments within the Palo Alto system was 51 days as of July 31, compared to 73 in mid-June. The average wait for new patients seeking specialized care is about 41 days (barely down from 43 in mid-June), according to government data. The average wait time for established patients seeking primary or specialized care is much lower, at around six days.

U.S. Rep. Anna Eshoo, D-Palo Alto, in June condemned what she called "longstanding and widespread" failure within the Veterans Administration but lauded the Palo Alto's VA's "level of excellence."

"Veterans surveyed on their satisfaction with the Palo Alto VA consistently score it above the national average for all VA medical centers and in the top 25 percent in the region for access to outpatient care," she said in a statement at the time. "More VA systems should be striving for this level of excellence."

But about two weeks later, an inpatient pharmacy technician supervisor at the VA Palo Alto Health Care System's Palo Alto facility publicly decried his employer, claiming he experienced retaliation and a gag order from his superiors after speaking up about errors and delays in delivery of medication to patients. Stuart Kallio, a veteran who served nine years in the Navy, was among 800 current and former VA employees and veterans who responded to a call from the Project on Government Oversight (POGO), a nonpartisan, independent watchdog group that champions good government reforms. POGO teamed up with the Iraq and Afghanistan Veterans of America to put out a call for the stories following recent disclosures of sometimes fatal delays in treatment at VA facilities across the country. Kallio's story was one among those detailed in a July 21 POGO report titled "Fear and Retaliation at the VA."

Kallio shared with POGO a series of critical emails from February and April that he sent up the VA chain of command, eventually as high as Freeman.

On Feb. 26, he wrote: "In essence, after all these years of suffering under gross mismanagement and wonton (sic) violation of VHA regulations, the processes utilized by the Pharmacy Service have steadily deteriorated and atrophied to the point that the Inpatient Pharmacy is in reality in a perpetual state of failure, failing to provide timely, quality care to veterans."

Kallio also wrote in emails to leadership that patients were suffering "missed doses, late doses, wrong doses," quoting hospital records of medication errors and copying Congressional overseers.

In May, the chief of pharmacy service informed Kallio he would be suspended from June 8 through June 21.

On the first day of his suspension, Kallio reiterated his complaints and accused the VA of retaliation in an email to Freeman.

"For almost two years now I have been communicating my concerns regarding the VAPAHCS Palo Alto Division Inpatient Pharmacy up the chain of command up to and including your office," he wrote. "Your response has been to unlawfully retaliate against me."

On July 22, Freeman responded in a lengthy statement defending the Palo Alto VA's pharmacy services.

"I want to assure our veterans, staff and other stakeholders the VAPAHCS Pharmacy Service is committed to providing care of the highest quality," the statement reads. "It has been a leader in its approach to medication safety. VAPAHCS Pharmacy Service is using state-of-the-art technology, collaborating with frontline providers, and applying evidence-based practices to improve the quality, safety, and efficiency of our medication practices."

She also cited a VAPAHCS's designated medication-safety officer, who is charged with ensuring "the safe use of medications throughout the organization through a robust system of continual review of internal safety data and application of best practices."

Related content:

Local vets laud, decry Palo Alto VA system

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