The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations concerning delays in interpreting electrocardiograms (ECGs) and event monitor tracings, failure to schedule cardiac procedures for over one year, failure to scan pacemaker data into the electronic health record (EHR), high cardiologist turnover, and the lack of proper supervision in the Device Clinic at the Richard L. Roudebush VA Medical Center (facility). The OIG reviewed an additional allegation that Surgery Service maintained an unauthorized wait list for an electrophysiology procedure. The OIG did not substantiate that ECG or cardiac event tracings reports were not interpreted timely, patients requiring cardiac surgery procedures were not scheduled for over a year, or improper supervision of the Device Clinic. Pacemaker tracings were not scanned into the EHR; however, the facility’s practice of entering tracing information as EHR notes was acceptable according to the VA Director of the National Cardiology Program. After the OIG’s site visit, the Cardiology Department initiated a process to scan pacemaker tracings into the EHR despite the lack of a requirement. The OIG substantiated that cardiologist turnover has been high at the facility but did not find evidence of adverse clinical outcomes resulting from staff turnover. The OIG substantiated that Cardiology and Surgery Services staff did not utilize the required consult process and maintained an unauthorized wait list for the electrophysiology procedure. The OIG found electrophysiology providers were not using the Veterans Health Administration consult process for electrophysiology procedures prior to February 2019. The OIG did not find evidence of adverse clinical outcomes related to the use of wait lists or failure to use the consult process. The OIG made four recommendations related to cardiologist turnover, staff understanding of authorized and unauthorized patient wait lists, and the training of staff on consult process and wait list policies.
Indianapolis, IN
United States
