Review of the Availability of Community Care Breast Images and Impact to Surgical Care at the VA Eastern Colorado Health Care System in Aurora

Report Information

Issue Date
Report Number
25-02420-118
VISN
19
State
Colorado
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Community Care
Women’s Health
Major Management Challenges
Healthcare Services
Recommendations
9
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations regarding the availability of breast images from community providers and the potential impact on patient care at the VA Eastern Colorado Health Care System (facility) in Aurora. Following the departure of the facility’s sole mammographer in February 2024, the facility’s in-house mammography program closed, and all breast imaging was referred to community care.

The OIG substantiated that delayed receipt of images from community care providers, and delayed uploading of images by facility staff once the images were received, did not ensure timely availability of breast images for facility providers to coordinate patient care. The OIG found factors contributing to the delays included community providers not sending breast images with reports, facility staff not following medical request processes, and VA technology limitations.

The OIG found the facility lacked guidance and processes for required women’s health tracking of abnormal mammography results. The OIG also learned facility primary care staff did not fully implement processes to identify patients due for breast cancer screening. Additionally, the OIG identified deficiencies with the credentialing and privileging of a mammographer.

The OIG made nine recommendations. The Under Secretary for Health and the Veterans Integrated Service Network and Facility Directors concurred with eight recommendations and concurred in principle with one recommendation. Acceptable action plans were provided, including plans to communicate expectations of community care providers related to breast images; address the request, receipt, and uploading of breast images; take action to modernize image sharing technology; address processes for breast cancer screening and care coordination; and address processes for credentialing and privileging.
 

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 Under Secretary for Health ensures the third-party administrator and community care breast imaging providers are informed of the expectations and processes for provision of breast images to the referring VA facility, addresses any barriers identified, and follows up to ensure compliance.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Eastern Colorado Health Care System Director ensures that facility community care staff comply with Veterans Health Administration requirements for requesting medical records, including images, from community providers and documentation of the receipt of medical records, including images, and follows up to ensure compliance.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Eastern Colorado Health Care System Director reviews processes, to ensure community care images are uploaded timely; assesses identified barriers, including staffing; and follows up to ensure compliance.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2026

The Under Secretary for Health reviews limitations of current VA image sharing technologies, considers implementation of technologies to support timely sharing of images with community providers, and takes action as warranted.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Eastern Colorado Health Care System Director reviews facility policy and standard operating procedures to ensure sufficient guidance and resources for compliance with Veterans Health Administration requirements for breast cancer screening, follow-up, and care coordination, and takes action as warranted.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Eastern Colorado Health Care System Director assesses the scope of the lack of tracking of breast cancer screening and follow-up for patients with a BIRADS 0, 3, 4, 5, or 6 from at least February 2024 forward to ensure all patients receive appropriate notification and timely follow-up of findings, and takes action as indicated.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Eastern Colorado Health Care System Director ensures credentialing and privileging staff complete primary source verification of credentials, and monitors for compliance.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Eastern Colorado Health Care System Director makes certain that clinical service chiefs follow processes for review of supporting documentation during the credentialing and privileging process, and follows up to ensure compliance.

No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Eastern Colorado Health Care System Director ensures that the radiology service chief initiates focused professional practice evaluations timely, as required, and monitors for compliance.