The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess the coordination and scheduling of community care for a patient with a lung mass suspicious for cancer at the VA Fayetteville Coastal Healthcare System (system) in North Carolina. The inspection followed a complaint that the patient experienced delays in diagnosis and treatment between December 2023 and May 2024. The OIG substantiated delays in ordering diagnostic imaging and scheduling community care, which may have reduced the opportunity for earlier diagnosis and treatment of lung cancer.
The patient’s primary care provider did not act on a radiologist’s recommendation for a chest computed tomography (CT) scan for over 15 months after an abnormal chest x-ray in March 2022. After a CT scan confirmed a lung mass, a pulmonologist requested expedited community care, but staff delayed scheduling the appointment for more than five months. The OIG found no explanation for the delay, despite documented handoffs and reminders.
Contributing factors included leadership turnover, lack of a community care oversight council, and absence of procedures to prioritize high-risk consults for serious conditions.
System leaders also missed opportunities to address the patient’s delayed care and broader programmatic deficiencies. Leaders did not follow VA policy for investigating the complaint, initiate timely peer reviews, or complete an institutional disclosure. Efforts to address a backlog of unscheduled consults were fragmented and ineffective. The OIG concluded system leaders did not ensure timely care and oversight.
The OIG made eight recommendations. In response, VA leaders shared plans to review consult management practices and the system’s backlog, ensure implementation of a community care oversight council, management of high-priority consults, quality management tracking processes, staff training, and attempts to disclose the adverse event.
Fayetteville, NC
United States
