By Stephen Spotswood

SAN DIEGO — Inadequate training and mismanagement at the San Diego VA Healthcare System’s Primary Care Call Center (PCCC) has put patients at risk, according to an investigation conducted by the VA Office of the Inspector General.

In 2001, San Diego established the PCCC at a central location in Mission Valley, CA, where agents answer calls from patients seeking to contact VA for a variety of reasons, including to renew medications, leave messages for primary-care providers, discuss symptoms with a nurse, schedule primary-care appointments, obtain lab results and request a transfer of care. 

PCCC staff consists of a supervisory administration specialist and 20 PCCC agents who provide telephone services, handle the veterans’ requests or forward them to VA employees who can assist them.

In May, a complaint was made that patients calling the PCCC line and reporting emergency symptoms were at risk for delays in care and poor clinical outcomes.

OIG investigated the allegation and found that poorly-trained PCCC agents and mismanagement by supervisors had placed veterans’ health at risk.

The investigation also showed that PCCC agents did not follow established procedures for referring emergency calls for triage. Of 27 patients who called PCCC between November 2010 and August 2011 and complained of emergency symptoms, none were referred to the advice nurse’s emergency line, as required by policy. The PCCC agents either sent computer messages to primary-care teams or transferred the calls to a nonemergency advice line.

Investigators also found that the majority of the PCCC agents were inexperienced and did not have an understanding of basic medical terminology, even though they were responsible for managing clinical calls. Fifteen of the 20 PCCC agents had been hired within the year prior to the investigation. The agents who were interviewed described their training as two weeks of on-the-job training on how to receive calls, transfer calls and schedule appointments.

Although the job description states medical terminology is required for PCCC agents, only one agent had documentation of any medical-terminology training. While there was evidence that VA San Diego had discussed a training program for PCCC agents that would cover medical terminology, there was no indication the program was initiated.

PCCC agents also told investigators they were not properly trained in the use of the emergent-symptoms list, even though emergency-call documentation and routing were listed as core competencies of the position.

Problems Lead to Close Calls

The investigation revealed that, while patient event reports (PERs) were filed, San Diego VA health leaders did nothing to evaluate the root causes of the recurring problems.

An OIG study of PERs found 18 events that qualified as “close calls.”

For example, one patient called the PCCC line to complain of chest pain. The agent did not refer the patient to the emergency line. A clinic nurse was unable to reach the patient again on the phone until the following day, at which time the patient was advised to go to the emergency room. The patient was admitted to the coronary intensive-care unit and discharged 14 days later in stable condition.

The event reports were forwarded to PCCC management, who made recommendations for retraining of personnel. However, OIG found no evidence that such retraining occurred.

The IG report recommended that the San Diego VA Healthcare System director — in this case, Acting Director Robert Smith, MD — ensure that managers monitor PCCC agents for compliance, agents receive initial training and that competencies are evaluated and confirmed annually. It also called for root-cause analyses in response to PERs actions to address any problems revealed by those analyses.

San Diego VA officials concurred with all of OIG’s findings and stated that all three major recommendations have been incorporated into practice at the PCCC.

Each week, the nursing service will select two symptomatic calls for review to examine patient-reported symptoms, timeliness of call transfer and the appropriateness of transfer and interaction between staff.

According to Smith, PCCC-agent competencies have been added to staff evaluations, and ongoing assessments will be completed annually. Also, a root-cause analysis looking at the routing of symptom-based calls has been completed, and actions are being taken to ensure that calls are transferred to the appropriate emergency lines.

OIG will track San Diego VA’s compliance with the recommendations during the coming year to ensure the hospital is following up with the changes it has promised to make.

Department of Veterans Affairs: Office of Inspector General

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