Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation of delays in diagnosis of a patient’s cancer at a Veterans Integrated Service Network 15 medical facility. The OIG substantiated a delay in the patient’s diagnosis. The patient’s initial complaint and abnormal computed tomography scan were in summer 2016, but a complete evaluation did not occur until spring 2018 when the patient was diagnosed with cancer. The patient completed suicide prior to treatment. The OIG identified multiple deficiencies in the coordination of the patient’s care between and among several primary and specialty care providers, changes in providers or assignments of surrogate providers, receipt of automated electronic notifications (view alerts) for imaging study abnormalities, and communication of abnormal test results to the patient that contributed to the delayed diagnosis. Facility leaders did not perform an institutional disclosure and conducted a prospective internal review rather than a retrospective analysis for adverse clinical events as required by the Veterans Health Administration. The OIG made eleven recommendations related to the planning and implementation of the new electronic health record, review of the patient’s clinical care, Patient Centered Management Module and provider assignments, designation of surrogates, view alerts, secure messaging communication, patient notification of test results, disclosures, and quality management activities related to internal reviews.

The VA Office of Inspector General (OIG) performed this review as required by the VA MISSION Act of 2018. VA has experienced chronic healthcare professional shortages since at least 2015, and the law requires annual reporting on steps taken to achieve full staffing and the additional funds needed to achieve that level. The law also requires VA to publicly release quarterly staffing and vacancy data. The OIG found VA partially complied with the law’s requirements, reporting current personnel and time-to-hire data as prescribed. However, VA’s initial reporting of staff vacancies and employee gains and losses was not transparent enough to allow stakeholders to track VA’s progress toward full staffing. This lack of compliance, if not corrected, may impact the transparency of VA’s future staffing and vacancy reporting. VA also did not follow specifications for reporting gains and losses quarterly as required, instead reporting annually without public explanation. VA should adjust its methodology for aggregating gains and losses to ensure data are reported appropriately and transparently. The OIG team identified opportunities for VA to improve its data reporting. VA’s public website only reported data for the current quarter and did not maintain historical versions of the published data. The overall transparency of VA’s staffing and recruitment website would be improved by maintaining historical data for public review. The OIG also found labeling errors in the reported information, indicating opportunities to improve the review process before publication. However, the OIG noted VA’s improvements in its administration of the reporting process which allowed for more precise quality reviews and greater assurance that the published data were accurate. The OIG recommended the Assistant Secretary for Human Resources and Administration ensure that staffing and vacancy data are reported as required, disclose limitations in the data, maintain historical data publicly, and update the methodology.