Breadcrumb

Delay in Diagnosis and Treatment for a Patient with a New Lung Mass at the Hampton VA Medical Center in Virginia

Report Information

Issue Date
Report Number
22-02800-225
VISN
1
State
Virginia
District
Continental
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Major Management Challenges
Benefits for Veterans
Recommendations
7
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General conducted a healthcare inspection at the Hampton VA Medical Center (facility) in Virginia to assess allegations related to the delay in diagnosis and treatment of a patient with a newly found lung mass. The OIG substantiated that there was a delay in diagnosis and treatment for a patient with a new lung mass, highly suspicious for cancer. The OIG found multiple care coordination deficiencies in scheduling and communication that led to the delay. As the patient likely had metastatic disease at initial presentation, the OIG could not determine if the delay in care coordination contributed to the patient’s death. The OIG determined the facility did not have an operational cancer committee, tumor board, or a certified cancer registrar at the time of the inspection. The lack of administrative oversight, and programmatic development, directly impacts the quality of patient cancer care. The lack of the programs did not contribute to the patient’s death, but may have impacted the quality of oncology services provided by the facility. The OIG determined that the facility submitted a Joint Patient Safety Report after being notified of the OIG inspection. Although a root cause analysis was conducted, the facility failed to identify care coordination deficiencies, such as scheduling delays, as contributing factors to the patient’s death. An institutional disclosure was conducted but lacked documented evidence that facility leaders provided the patient’s family member the required information about potential compensation. The OIG made seven recommendations to the Facility Director related to care coordination agreements, compliance with Veterans Health Administration (VHA) Patient Aligned Care Team policies and VHA cancer registry requirements, and a review of both the root cause analysis and institutional disclosure to ensure alignment with VHA policies.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Hampton VA Medical Center Director assesses the current use of care coordination agreements between the Patient Aligned Care Team and specialty care services, and determines if there would be benefit in developing agreements where they do not currently exist.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Hampton VA Medical Center Director, in conjunction with the Radiology Department chief, reviews the Radiology Department standard operating procedures and scheduling processes, identifies deficiencies, and ensures compliance with Veterans Health Administration policies.
No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Hampton VA Medical Center Director, in conjunction with the Primary Care Service chief, reviews the Patient Aligned Care Team processes, identifies deficiencies, and ensures compliance with Veterans Health Administration Patient Aligned Care Team requirements, including scheduling huddles, follow-up of Emergency Department patient discharges, and communication with and coordination of specialty care.
No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Hampton VA Medical Center Director, in conjunction with the Primary Care Service chief, reviews the Patient Aligned Care Team pain management and referral processes, identifies deficiencies, and takes action as warranted.
No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Hampton VA Medical Center Director, in consultation with a subject matter expert from the National Program Office for Oncology, reviews the facility cancer registry program, identifies deficiencies, and ensures compliance with Veterans Health Administration requirements, including the need for a qualified cancer registrar and entry of all cancer cases in the registry.
No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Hampton VA Medical Center Director reviews the completed root cause analysis in order to ensure its completeness, and take action if warranted.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Hampton VA Medical Center Director reviews the institutional disclosure made to the patient’s family and completes any required items not addressed, including providing the patient’s family with information about potential compensation from the Veterans Benefits Administration and under the Federal Tort Claims Act.