Communication of Test Results and Oncology Scheduling Concerns at the Beckley VA Medical Center in West Virginia

The VA Office of Inspector General (OIG) conducted an inspection at the request of Representative Carol Miller in response to allegations related to timeliness and quality of care in the Emergency Department and scheduling concerns in the Oncology Clinic of a patient at the Beckley VA Medical Center (facility) in West Virginia. The OIG did not substantiate that the patient received untimely or poor-quality care in the facility’s Emergency Department. On six occasions over four months in 2019, the patient presented to the Emergency Department, was assessed, treated for the presenting complaints, and received coordinated care between the primary care provider and other providers. On two occasions, there was no documented evidence that the primary care provider communicated abnormal and critical laboratory test results with the patient. While it appears that the failure to document communication of test results did not negatively affect this patient’s care, the lack of timely follow-up of abnormal test results could contribute to poor patient outcomes. The OIG found deficits in an oncologist’s use of scheduling orders and adherence to the Primary Care and Oncology Service Agreement wait times. Although the oncologist agreed to see the patient earlier than a scheduled appointment, it was not until a second oncology e-consult was entered that an earlier appointment was scheduled. The OIG was unable to determine whether compliance with the return-to-clinic policy would have altered the patient’s course. The OIG found that facility leaders performed comprehensive reviews of the patient’s care. The OIG made two recommendations to the Facility Director related to primary care providers’ communication and documentation of laboratory results and the oncologist’s compliance with scheduling and ordering policies.