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Healthcare Inspection – Alleged Delays in Notifying Patients of Biopsy Results, W.G. (Bill) Hefner VA Medical Center, Salisbury, NC

Report Information

Issue Date
Report Number
13-00940-193
VISN
State
North Carolina
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
3
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG conducted an inspection in response to a complaint concerning delays in reporting biopsy test results to patients and possible delays in treatment at the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC. We substantiated the allegation that the facility was not timely in notifying patients of biopsy test results. However, we did not substantiate that resulting treatments were delayed. In addition, we identified that notification procedures for new malignancies found during outpatient test biopsies were not included in the facility’s critical biopsy policy. We recommended that procedures be implemented to ensure that patients receive timely notification of biopsy test results, notifications be documented in patients’ electronic health records, performance improvement procedures be adjusted to include periodic monitoring of test result communication to patients, and the facility’s written policy for critical test results be revised to include outpatient biopsy test results. Management agreed with the findings and recommendations and provided an acceptable improvement plan.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director implement procedures to ensure that patient notifications are timely and documented in patients' electronic health records.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that performance improvement processes be strengthened to include periodic monitoring of test result communication to patients.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that the facility's written policy on critical test results addresses critical biopsy test results from outpatient procedures.