Leaders Failed to Address Community Care Consult Delays Despite Staff’s Advocacy Efforts at VA Western New York Healthcare System in Buffalo

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations regarding community care consult appointment scheduling practices and delays for patients with serious health conditions who received community care at the VA Western New York Healthcare System (system) in Buffalo.

The OIG substantiated community care staff’s delays in scheduling patients’ radiation therapy and neurosurgery appointments resulted in delays in patient care, and in some cases caused or increased the risk of patient harm. The OIG found that a delay in scheduling, and eventual cancellation of, community care radiation therapy to treat a patient’s cancer-related pain resulted in progressive, debilitative pain. Although late in the course of the disease, receiving radiation therapy may have decreased the pain and improved the quality of life in the patient’s final months. System leaders failed to conduct an institutional disclosure to the patient’s family.

The OIG determined system and community care leaders failed to resolve significant community care scheduling delays for patients with serious health conditions, despite patient advocacy by providers and community care staff. The OIG found leaders relied on inaccurate assurances from system community care leaders that urgent, high-risk patient care consults were reviewed and prioritized, even when alerts to patient concerns continued. System and community care leaders’ lack of action was contrary to high reliability organization principles and values, as they failed to consistently focus on patients, get to the root cause of concerns, and predict and eliminate risk before causing patient harm.

The OIG made two recommendations to the VISN Director related to system leaders’ response to patient concerns, and oversight of community care practices; and two recommendations to the System Director related to the establishment of community care policies in alignment with VHA community care standards, and the disclosure of an adverse event.