View Alert Process Failures and the Impact on Patient Care at the Central Alabama Veterans Health Care System in Montgomery

The VA Office of Inspector General (OIG) conducted an inspection in response to allegations that significant failures related to the management of view alert notifications placed patients at risk. Unaddressed view alerts do not necessarily correlate to unmanaged clinical results or administrative consults; however, they will continue to accumulate until they are addressed. The OIG conducted reviews of patients with unaddressed view alerts and referred a total of 33 patients who had clinical or treatment issues that had not been adequately managed by the system for follow-up. The OIG reviewed the system’s action plans and found all plans to be acceptable. The OIG did not substantiate that at least 12 providers had each accumulated more than 5,000 view alerts, or that the system excluded teleradiologists from the requirement to communicate abnormal and critical test results to ordering providers or their designees. However, the OIG confirmed that nine providers each had more than 5,000 view alerts at some point between July 23 and December 2, 2019. The OIG substantiated that of the patients reviewed, some patient care was being compromised because abnormal laboratory and imaging results were either not managed or not managed within the required timeframe. Some patients were at risk for delayed cancer diagnoses because of the lack of timely provider follow-up. The OIG also found that the ordering providers did not consistently take appropriate actions to edit and resubmit canceled consults. The OIG determined that system leaders did not give providers clear instructions or adequate training on the prioritization of view alerts for review and disposition, documentation of actions when clearing unaddressed view alerts, and designation of surrogates. The OIG made one recommendation to the Under Secretary for Health, one recommendation to the VA Southeast Network Director, and nine recommendations to the System Director.