A new report finds widespread problems; a second report is to be published this summer.

A new U.S. Department of Veterans Affairs (VA) Office of Inspector General (OIG) report has found widespread problems related to delayed treatment at a VA hospital in Phoenix, adding credibility to a growing list of complaints by whistle-blowers, patients, and their families claiming that treatment delays resulted in substandard or undelivered care and many deaths.

U.S. Secretary of Veterans Affairs Eric Shinseki stepped down this morning, following this latest review and calls from lawmakers for his resignation.

The VA health system comprises 151 medical centers and 800 community-based outpatient clinics, as well as additional points of care.

The report sampled 226 appointments and found that patients had an average wait time of 115 days before their first appointment. About 84 percent of veterans waited more than the 14-day goal set by the VA, according to the report.

The wait time the hospital reported to the department in 2013 was, on average, 24 days.

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Debra Draper, the director of Health Care Issues for the Government Accountability Office (GAO), told Healthline, “We’ve done work on appointment scheduling and wait times. We are also currently looking at specialty care consults, which is a type of medical appointment. These are both access-to-VA-care topic areas. We found a couple of common themes. One of these is ambiguous policies and processes, and these are often subject to interpretation. What we’ve seen is variation and confusion at the local level,” said Draper.

Pointing out that some of the scheduling is performed on antiquated software systems, Draper said these systems “don’t really facilitate good practices, and that’s another common theme that we’ve seen.”

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The GAO’s review took place in Dayton, Ohio; Washington, D.C.; Los Angeles; and Fort Harrison, Mont. “We found unclear staffing needs and staffing allocation priorities, as well as inadequate oversight that relies largely on facility self-certification without independent verification and use of unreliable data for monitoring,” said Draper. “We looked at four facilities and we found that not everyone who is supposed to have received training received it. This was a system-wide review. We usually include some of the facilities in our review so we can better understand how these central office policies play out at the local level.”

The GAO has provided some preliminary observations to Congress. It has found care delays and care not being provided at all at each of the medical centers it reviewed. “We found the specialty care consult data was unreliable, and there was a system-wide closure of about a million and a half consults over the 90 days—and there was no documentation as to why they were closed,” said Draper.

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What should the public take away from the investigations into misconduct within the VA health system? “In our first report, we did make recommendations,” said Draper. “The VA reported to us they are making some progress, but much more work needs to be done. It’s really important because delays in care can result in harm to people and harm to veterans.”

She went on to say that the GAO has been looking at this issue for more than a decade. “We have found the same problems. It’s an ongoing issue concerning medical appointment wait times being unreliable and the medical appointment scheduling.”

The GAO plans to publish its next report in July or August.

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Former U.S. Representative John Linder told Heathline that, in his experience, “these systems are huge bureaucracies that serve the system more than the patient.”

Linder recalled that when he served as a dentist in the U.S. Air Force, he was reprimanded by senior dentists and the colonel for spending too much time treating patients. “They told me I didn’t need to do all that much at one appointment. You are only expected to do so much. If you do more than that, then the rest of us will be blamed for something.”

Pointing out that veterans have to drive long distances to find a VA hospital, Linder said, “The hospitals are situated not in keeping with the VA population as much as where powerful politicians have lived or represented and the money went to their areas.”

“The VA health system should treat veterans for unique war-related injuries and disabilities, such as post-traumatic stress and prosthetics,” said Linder, adding, “We should spend more time and money on these things. Ordinary health care things should be taken care of by the hospital and doctor that you choose, and we should pay for that. We need to get back to a patient-centered system and this is clearly not that.”