Discontinued Consults Led to Patient Care Delays at the Oklahoma City VA Medical Center in Oklahoma

Report Information

Issue Date
Report Number
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Appointment Scheduling and Wait Times
Mental Health
Major Management Challenges
Healthcare Services
Questioned Costs
Better Use of Funds
Congressionally Mandated



The VA Office of Inspector General (OIG) conducted a healthcare inspection to review an allegation that the Behavioral Health Service program manager denied 32 patients behavioral health community care services at the Oklahoma City VA Medical Center in Oklahoma (facility).

During the review, the OIG substantiated that the program manager did not follow the consult management process and discontinued behavioral health community care consults for 29 patients. The OIG did not substantiate that the behavioral health patients were denied care but determined that the discontinued consults resulted in a delay of care for seven patients. The OIG determined that when the discontinued consults were identified, facility leaders initiated reviews and took timely action to ensure patients received the requested care.

The OIG found that the program manager reviewed each community care consult and used an availability tool to identify open internal appointments, then incorrectly commented to schedule patients in specific internal openings and discontinued the consults. Despite completing required trainings, the program manager reported not recognizing that comments to schedule a patient into a specific opening could be considered a prohibited practice called blind scheduling, and incorrectly identified that the discontinue consult status allows further action to be taken. The OIG concluded that the program manager had poor knowledge of the consult management scheduling processes and failed to follow requirements for behavioral health community care consults that led to delayed care for seven patients. 

The Behavioral Health Service leaders and the patient safety manager reported concerns to facility leaders after identifying that the program manager was discontinuing consults. Facility leaders took actions, including investigating the reports and conducting quality reviews that showed no adverse events from the delays.

The OIG made one recommendation to the Facility Director related to community care consult management and appointment scheduling processes.

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 Oklahoma City VA Health Care System Director, in conjunction with Behavioral Health Service leaders, reviews the community care consult management and appointment scheduling processes, identifies deficiencies, and takes action as warranted.