Assessment of Cytopathology Processing at the Oklahoma City VA Medical Center in Oklahoma

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Oklahoma City VA Medical Center (system) in response to an allegation that patients awaiting possible cancer diagnoses experienced delays in receiving pathology testing results. 

The OIG reviewed nine specimens from five patients and substantiated delays in four specimens from four patients. The chief of Pathology and Laboratory Medicine Service (P&LMS), who processed all four, attributed the delays to competing administrative duties. The OIG found that P&LMS quality staff did not conduct a comprehensive review of the delays and assess for patient harm, limiting leaders’ ability to evaluate risk and improve care.

The OIG also found that routine turnaround time (TAT) metrics for non-gynecological cytopathology reports were not met for 8 of 12 months in 2024. Although comments in quality reports noted plans to improve TAT, corrective actions and improvement plans were not documented, limiting facility leaders’ ability to identify effective interventions.

The chief of P&LMS consistently did not meet the two-day TAT benchmark. In 2024, the chief met the benchmark in 25 percent of cases from January through June and none from July through December. While facility leaders initiated actions to address performance, they did not assess the chief’s non-cytopathology cases to assess patient safety risks.

The OIG identified concerns in laboratory and patient safety event reporting. P&LMS staff did not report variance events or enter patient safety events in the Joint Patient Safety Reporting system despite completing required training.

The System Director concurred with the OIG’s five recommendations and shared plans and actions taken to review potential patient harm, improve documentation and monitoring of TAT metrics, address the chief’s performance, and train staff on event reporting processes.