Healthcare Inspection – Consultation Mismanagement and Care Delays, Spokane VA Medical Center, Spokane, WA

OIG reviewed allegations of inappropriate consultation cancellation causing delays in care and potential harm to patients, poor communication between consultants and primary care providers (PCPs) and patients, and inappropriate requests for PCPs to order tests for consultants at the Spokane VA Medical Center, Spokane, WA. We substantiated that requests for consultations were inappropriately cancelled or discontinued, and that patients consequently had unnecessary delays in the amelioration of symptoms. We substantiated that there was poor communication between consultants and PCPs that resulted in requests for consultations being discontinued or cancelled. We did not substantiate that consultants inappropriately asked PCPs to order tests. However, we noted opportunities for improvement, such as the use of service agreements to define workflow processes and expedite efficient patient care. We recommended that the Medical Center Director: (1) ensure that there is a comprehensive consultation process in place and that staff are educated on the process, (2) ensure that all requests for consultations be appropriately generated, tracked to completion, and that consultation completion data is shared with clinical staff, and (3) ensure that persistent staff conflicts and communication issues are appropriately addressed and resolved. The Veterans Integrated Service Network and System Directors agreed with the findings and recommendations and provided acceptable action plans.