Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation that facility leaders failed to complete clinical and institutional disclosures for three identified patients. The OIG substantiated that one of the three patients received a delayed institutional disclosure and did not receive a clinical disclosure. The OIG found that the delay in the institutional disclosure occurred because the Chief of Staff established a process to have a peer review conducted prior to determining if an institutional disclosure was warranted. The other two patients received clinical disclosures. During the inspection, the OIG identified concerns related to deficiencies in quality management and safety processes, including failure to enter events into the Joint Patient Safety Reporting system and review adverse events, failure to initiate a required root cause analysis, and insufficient documentation and explanation of decision-making within Peer Review Committee meeting minutes. Additionally, the OIG determined that facility providers failed to properly communicate abnormal imaging and laboratory test results to patients as required by policy. The OIG made five recommendations to the Facility Director related to conducting and documenting clinical disclosures; evaluating quality management processes that impede the timeliness of conducting institutional disclosures; adhering to Peer Review Committee documentation standards; ensuring adverse events or close calls are entered into the system, reviewed, and required actions are conducted per policy; and evaluating the process for the communication of abnormal test results to patients.