Federal Reports

The VA OIG is required to report to Congress on the accuracy of VA’s annual special disabilities capacity report, which documents the department’s capacity to provide specialized treatment for veterans with spinal cord injuries and disorders, traumatic brain injuries, blindness, prosthetics and sensory aids, or mental health issues. 

Regarding the FY 2023 capacity report, the OIG team identified data inaccuracies and omissions. VA reported the wrong spending data for traumatic brain injury when it included obligations instead of expenditures data. VA also did not report traumatic brain injury spending data at the geographic service area and national levels as required. Further, the OIG found that blind rehabilitation bed data were not reported by geographic service area as required but were reported nationally. The capacity report also did not capture data on the services that veterans received through community care or the extent to which bed capacity was used at VA’s centers for spinal cord injuries and disorders.

As the OIG reported previously, VA cannot meet the requirement to compare its mental health capacity with 1996 levels as federal law requires because of changes in defining and tracking treatment outcomes of veterans with mental illness. The OIG continues to believe that such reporting would not provide Congress with assurances that VA’s capacity is adequate to provide care to these high-risk veterans. Finally, some medical facilities’ transitions to VA’s new electronic health record system have affected the completeness of some reported data elements at facility, regional, and national levels. The OIG notes that VA could give Congress insight into annual trends by correcting the data differences to define the measures consistently for comparability across facilities or by reporting capacity data separately for facilities using the new system.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Oklahoma City VA Medical Center (system) in response to an allegation that patients awaiting possible cancer diagnoses experienced delays in receiving pathology testing results. 

The OIG reviewed nine specimens from five patients and substantiated delays in four specimens from four patients. The chief of Pathology and Laboratory Medicine Service (P&LMS), who processed all four, attributed the delays to competing administrative duties. The OIG found that P&LMS quality staff did not conduct a comprehensive review of the delays and assess for patient harm, limiting leaders’ ability to evaluate risk and improve care.

The OIG also found that routine turnaround time (TAT) metrics for non-gynecological cytopathology reports were not met for 8 of 12 months in 2024. Although comments in quality reports noted plans to improve TAT, corrective actions and improvement plans were not documented, limiting facility leaders’ ability to identify effective interventions.

The chief of P&LMS consistently did not meet the two-day TAT benchmark. In 2024, the chief met the benchmark in 25 percent of cases from January through June and none from July through December. While facility leaders initiated actions to address performance, they did not assess the chief’s non-cytopathology cases to assess patient safety risks.

The OIG identified concerns in laboratory and patient safety event reporting. P&LMS staff did not report variance events or enter patient safety events in the Joint Patient Safety Reporting system despite completing required training.

The System Director concurred with the OIG’s five recommendations and shared plans and actions taken to review potential patient harm, improve documentation and monitoring of TAT metrics, address the chief’s performance, and train staff on event reporting processes.