Mammography Program Deficiencies and Patient Results Communication at the Washington DC VA Medical Center

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Washington DC VA Medical Center (facility) pursuant to a request by several members of Congress. The members had learned that the facility was not in compliance with the Veterans Health Administration (VHA) policy on communicating exam results and letters had not been appropriately mailed to patients who had breast imaging studies. After discovery of the unsent letters, facility staff completed reviews and all patients were notified of abnormal findings. The OIG identified nine additional mammography exams not included in the facility’s reviews due to errors in diagnostic coding. The facility reviewed and determined the exams were not abnormal. The facility identified two patients and the OIG identified two additional patients who had clinically significant mammography exams (breast cancer). Though the four patients did not receive timely letters, all four breast cancer patients received timely notification by the ordering provider. The OIG found that ordering providers did not consistently document patient notification of abnormal mammography results as required. At the time of the OIG review, the facility did not have a functional mammography program due to loss of staff. The facility had not fully implemented the September 2019 National Radiology Program Office (NRPO) site visit recommendations. The NRPO did not cite the facility for lack of a program standard operating procedure manual. The facility did not fully implement program procedural changes including oversight of staff duties and training, appropriate oversight and quality controls in delegating the task of mailing patient lay summary letters, and development of a formalized training program for mammography staff to ensure monitoring and tracking of patients. The OIG made seven recommendations related to documentation and notification processes, action plans, standard operating procedures, staff training, and NRPO reviews and requirements.