Review of Community Care Consult Management at the VA Fayetteville Coastal Healthcare System in North Carolina

Report Information

Issue Date
Report Number
24-03186-99
VISN
6
State
North Carolina
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Care Coordination
Community Care
Patient Safety
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
8
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 assess the coordination and scheduling of community care for a patient with a lung mass suspicious for cancer at the VA Fayetteville Coastal Healthcare System (system) in North Carolina. The inspection followed a complaint that the patient experienced delays in diagnosis and treatment between December 2023 and May 2024. The OIG substantiated delays in ordering diagnostic imaging and scheduling community care, which may have reduced the opportunity for earlier diagnosis and treatment of lung cancer.

The patient’s primary care provider did not act on a radiologist’s recommendation for a chest computed tomography (CT) scan for over 15 months after an abnormal chest x-ray in March 2022. After a CT scan confirmed a lung mass, a pulmonologist requested expedited community care, but staff delayed scheduling the appointment for more than five months. The OIG found no explanation for the delay, despite documented handoffs and reminders. 

Contributing factors included leadership turnover, lack of a community care oversight council, and absence of procedures to prioritize high-risk consults for serious conditions.

System leaders also missed opportunities to address the patient’s delayed care and broader programmatic deficiencies. Leaders did not follow VA policy for investigating the complaint, initiate timely peer reviews, or complete an institutional disclosure. Efforts to address a backlog of unscheduled consults were fragmented and ineffective. The OIG concluded system leaders did not ensure timely care and oversight. 

The OIG made eight recommendations. In response, VA leaders shared plans to review consult management practices and the system’s backlog, ensure implementation of a community care oversight council, management of high-priority consults, quality management tracking processes, staff training, and attempts to disclose the adverse event.
 

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 VA Fayetteville Coastal Healthcare System Director confirms full implementation of the VA Community Care Oversight and Consult Management Council.

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

The Under Secretary for Health reviews practices and procedures for managing consults to identify and prioritize appointment scheduling for patients with serious health conditions (high‑priority consults), such as cancer, and provide direction to the field on the process to use to make this determination.

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

The VA Fayetteville Coastal Healthcare System Director directs the development and implementation of community care service standard operating procedures to address identification and management of high-priority consults, timeliness of consult processing, and care coordination that aligns with direction provided by Veterans Health Administration’s Integrated Veterans Care program.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Fayetteville Coastal Healthcare System Director ensures staff are trained in all newly developed community care standard operating procedures and that adherence to policy and practice is monitored.

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

The VA Fayetteville Coastal Healthcare System Director confirms completion of a review of quality management processes to ensure quality management staff, when reviewing patient safety events, consider potential system issues and, if present, recommend they be addressed using other quality management reviews.

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

The VA Fayetteville Coastal Healthcare System Director ensures local processes are in place, including assigned roles and responsibilities, to manage Office of Inspector General case referrals in compliance with VA Directive 0701, Office of Inspector General Hotline Complaint Referrals.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/8/2026

The VA Fayetteville Coastal Healthcare System Director confirms reasonable efforts to conduct an institutional disclosure with the patient regarding circumstances that led to the delay in the diagnosis of and treatment for lung cancer are made and, if a disclosure is completed, that it is documented in the electronic health record.

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

The Under Secretary for Health assesses the electronic health record reviews completed by the system in response to the community care backlog to determine if a more comprehensive review is warranted with appropriate disclosure to patients placed at risk or harmed as a result of a delay in action on their community care consult, and takes action accordingly.