Delayed Diagnosis and Treatment for a Patient’s Lung Cancer and Deficiencies in the Lung Cancer Screening Program at the VA Eastern Kansas Healthcare System in Topeka and Leavenworth

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Date Issued

Thursday, April 17, 2025

Submitting OIG

Department of Veterans Affairs OIG

Agencies Reviewed/Investigated

Department of Veterans Affairs

Components

Veterans Health Administration

Report Number

24-00990-99

Report Description

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations related to a patient’s care and the lung cancer screening (LCS) program at the VA Eastern Kansas Healthcare System (system) in Topeka and Leavenworth.

The OIG substantiated that a patient experienced a delay in the diagnosis of and treatment for lung cancer. Neither the patient aligned care team (PACT) provider nor the system pulmonologist took the necessary steps to ensure a bronchoscopy was ordered and completed. The PACT provider ordered, but failed to track, a positron emission tomography (PET) scan completed by a community provider; and failed to communicate the abnormal results to the patient and initiate clinical actions as indicated. System leaders conducted an institutional disclosure to the patient; however, the institutional disclosure documentation did not include required details.

The OIG identified concerns related to the absence of an established process for community care providers to communicate abnormal test results directly to the system’s ordering providers.

Community care staff did not make timely, sufficient efforts to retrieve the patient’s PET scan results. The OIG found a broad system failure of community care staff not making three attempts to retrieve patient records within 90 days of completed appointments, which leaders partially attributed to metrics that prioritized receiving and scheduling community care appointments.

System and program leaders failed to develop the LCS program infrastructure prior to implementation. The LCS program lacked oversight, multidisciplinary engagement, policy, and adequate primary care training and engagement.

The OIG made one recommendation to the Under Secretary for Health related to the communication of patients’ abnormal test results and one recommendation to the Veterans Integrated Service Network Director regarding the system’s LCS program. The OIG made four recommendations to the System Director related to test results, institutional disclosures, and community care records.

Report Type

Inspection / Evaluation

Location

KS
United States

Number of Recommendations

Questioned Costs

Funds for Better Use

Report updated under NDAA 5274

External Link

https://www.vaoig.gov/reports/hotline-healthcare-inspection/delayed-diagnosis-a…

Open Recommendations

This report has 12 open recommendations.

Recommendation Number	Significant Recommendation	Recommended Questioned Costs	Recommended Funds for Better Use
01	No	$0	$0
The VA Eastern Kansas Healthcare System Director ensures the chief of primary care reviews, strengthens, and implements system Patient Aligned Care Team processes for tracking and following up on community care consults ordered, particularly diagnostic consults, to verify patients receive care and to review and act upon consult results, as clinically indicated.
02	No	$0	$0
The VA Eastern Kansas Healthcare System Director reviews institutional disclosures conducted by the system over the past 12 months, including the patient’s institutional disclosure, and ensures these disclosures fully adhere to Veterans Health Administration Directive 1004.08, Disclosure of Adverse Events to Patients, October 31, 2018, including documenting the details of the adverse event and discussion points of the disclosure, and takes action needed to remediate disclosures that do not meet these standards.
03	No	$0	$0
The VA Eastern Kansas Healthcare System Director ensures community care staff make the required three attempts to obtain patients’ community care records within 90 days of completed appointments, and monitors for compliance.
04	No	$0	$0
The VA Eastern Kansas Healthcare System Director collaborates with the Kansas City VA Medical Center Director to review the frequency and circumstances of community care records being sent to the incorrect VA facility, develops, and implements a process for ensuring community care records are delivered to the correct ordering VA facility, educates staff on the process, and monitors for compliance.
05	No	$0	$0
The Under Secretary for Health establishes and monitors compliance with a process that ensures the Veterans Health Administration ordering provider receives urgent non-life-threatening abnormal test results from care obtained in the community, such as the diagnostic positron emission tomography scan results described in this report, within a time frame that allows timely attention and appropriate action to be taken.
06	No	$0	$0
The Veterans Integrated Service Network Director, in conjunction with the Veterans Health Administration National Center for Lung Cancer Screening Program Office, evaluates the VA Eastern Kansas Healthcare System’s Lung Cancer Screening Program to ensure operational adherence to the Lung Cancer Screening Program requirements, and takes action as needed.
01	No	$0	$0
The VA Eastern Kansas Healthcare System Director ensures the chief of primary care reviews, strengthens, and implements system Patient Aligned Care Team processes for tracking and following up on community care consults ordered, particularly diagnostic consults, to verify patients receive care and to review and act upon consult results, as clinically indicated.
02	No	$0	$0
The VA Eastern Kansas Healthcare System Director reviews institutional disclosures conducted by the system over the past 12 months, including the patients institutional disclosure, and ensures these disclosures fully adhere to Veterans Health Administration Directive 1004.08, Disclosure of Adverse Events to Patients, October 31, 2018, including documenting the details of the adverse event and discussion points of the disclosure, and takes action needed to remediate disclosures that do not meet these standards.
03	No	$0	$0
The VA Eastern Kansas Healthcare System Director ensures community care staff make the required three attempts to obtain patients community care records within 90 days of completed appointments, and monitors for compliance.
04	No	$0	$0
The VA Eastern Kansas Healthcare System Director collaborates with the Kansas City VA Medical Center Director to review the frequency and circumstances of community care records being sent to the incorrect VA facility, develops, and implements a process for ensuring community care records are delivered to the correct ordering VA facility, educates staff on the process, and monitors for compliance.
05	No	$0	$0
The Under Secretary for Health establishes and monitors compliance with a process that ensures the Veterans Health Administration ordering provider receives urgent non-life-threatening abnormal test results from care obtained in the community, such as the diagnostic positron emission tomography scan results described in this report, within a time frame that allows timely attention and appropriate action to be taken.
06	No	$0	$0
The Veterans Integrated Service Network Director, in conjunction with the Veterans Health Administration National Center for Lung Cancer Screening Program Office, evaluates the VA Eastern Kansas Healthcare Systems Lung Cancer Screening Program to ensure operational adherence to the Lung Cancer Screening Program requirements, and takes action as needed.