Alleged Care Delays and Inadequate Instrument Precleaning at the New Mexico VA Health Care System, Albuquerque

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations regarding patient care concerns in the departments of ophthalmology and gastroenterology (GI) at the New Mexico VA Health Care System (facility) in Albuquerque. A patient’s CHOICE referral for cataract surgery was denied but the denial was supported by Veterans Health Administration (VHA) policy. The OIG did not substantiate a delay in scheduling of the patient’s cataract surgery but determined that the ophthalmology department failed to meet VHA consult management scheduling expectations and followed a standard operating procedure for cataract surgery intake evaluations that had not gone through an approval process. The OIG also found delays in the authorization of non-VA care consults for comprehensive eye appointments. While it was not determined that 500 or more consults for outpatient GI procedures were awaiting scheduling as alleged, significant delays in access to outpatient GI care were identified. Facility leaders attributed the delays to loss of staff. The facility did not monitor and conduct performance improvement efforts on known GI consult performance deficiencies, and GI providers did not consistently communicate test results to patients per facility policy. Possible factors contributing to the inconsistent communication included a lack of knowledge of test results notification requirements, an absence of a standardized process for delegating responsibility, and a failure of GI leaders to address known issues. The OIG did not substantiate a failure to train GI Fellows on endoscope precleaning but found a lack of documentation of the training. There was no evidence that patients underwent procedures with endoscopes that GI Fellows did not properly preclean. The OIG made 13 recommendations related to non-VA care appeals, consult management, the timeliness of eye appointments and surgery, test results issues, and precleaning of endoscopic instruments.