Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations that surgical pathology specimen processing delays in the pathology and laboratory medicine service (P&LMS) resulted in multiple patients’ harm and possibly death, and follow-up on the facility’s response. Patients experienced no adverse clinical outcomes related to specimen delays. Actions developed by facility leaders improved turnaround times for surgical pathology specimens processed onsite; however, the OIG was unable to determine if offsite pathology turnaround times improved because of incomplete evidence. In 2018, approximately 39 percent of P&LMS positions were vacant. The pathologists’ shortage contributed to inconsistent surgical pathology quality assurance and prolonged specimen turnaround times. Facility leaders had plans in place to ensure compliance with quality management program requirements, but the plans were not fully implemented at the time of the OIG visit. Facility leaders did not conduct a formal quality review to systematically determine the causes that contributed to the delays. The OIG identified deficiencies in initial training and annual competency documentation. Without these measures, facility leaders were unable to ensure staff readiness to provide quality services for patients. The OIG did not find that facility leaders attempted to conceal deficiencies discovered in P&LMS. However, an issue brief to the Veterans Integrated Service Network dated approximately two months after the discovery of the delayed surgical pathology specimens only listed problems in P&LMS related to environment of care and staffing. As a result, the OIG had concerns about Veterans Health Administration senior leaders’ oversight of the specimen processing delays and evaluation of the need for a large-scale disclosure. The OIG made eight recommendations related to P&LMS staffing improvement strategies, specimen tracking process, identification of areas of future risk, P&LMS quality management program, staff competencies and training, and the issue brief process.

The objective of this limited scope follow-up review was to determine if the agreed upon corrective actions taken in response to three findings from the Final Report on the Program Evaluation of Peace Corps/Nepal (IG-15-05-E) were fully implemented and had the intended effects. We found that, overall, Peace Corps/Nepal had improved regarding all three findings selected for review. We found 2 areas of concern related to the post's site selection criteria and whereabouts tracking. This report included 2 recommendations for management's consideration.

IHS provides comprehensive Federal health services to approximately 2.6 million American Indians and Alaska Natives. OIG and others have found significant problems in the quality of care and oversight of IHS hospitals. This study identifies underlying organizational challenges that may hamper IHS's ability to address critical longstanding problems. At times these issues have had serious consequences, including difficulty maintaining compliance with Federal quality-of-care requirements. IHS has made important new plans for improving the quality of care that it provides in its hospitals. However, if underlying organizational challenges are not addressed, they may prevent IHS from bringing its full organizational strength to these efforts.

This report is not publicly available due to concerns with information protected under the Freedom of Information Act.