An IG audit has found that the VA’s Patient Advocacy Program, intended to identify patterns and causes of unsatisfactory service, has “material weaknesses in internal control areas, such as policies, quality control, information technology, and human capital.”

A report said that the Veterans Health Administration “did not adequately capture patient complaint information and identify complaint trends” and that “lapses in collecting, monitoring, and trending patient complaints reduced the potential effectiveness of the Patient Advocacy Program and affected VA’s progress in becoming more veteran-centric, including identifying systemic issues for improving the quality of veterans’ health care.”

The auditors projected more than a third of the 135,000 of VHA’s serious patient complaints in the Patient Advocate Tracking System lacked key information and were closed erroneously. “Serious” complaints include issues such as delays in accessing care or services, problems with clinical care and pain management.

“In addition, we estimated about 11,000 patient complaints at five of the eight sites we visited were not recorded in PATS, and VA medical facilities and Veterans Integrated Service Networks in our fieldwork performed limited or no formal complaint trending,” a report said.

The system further lacked key security controls, it said, with about half of the nearly 8,000 users having inappropriate access and the system failing to track significant user actions. “As a result, PATS data were vulnerable to unauthorized access and alteration, and records were not available to monitor modifications to sensitive patient information,” it said.

It said the VA concurred with its recommendations to ensure the reliability of the data, including through tightening controls over access.