The OIG conducted a review at the William Jennings Bryan Dorn VAMC (facility) in Columbia, SC to determine whether deficient practices contributed to or caused delays in care, and whether facility leaders appropriately addressed clinical managers’ concerns. OIG substantiated the allegations and found additional factors that contributed to the events. In July 2011 VISN and facility leaders became aware of the GI consult backlog involving 2,500 delayed consults, 700 “critical”. The VISN awarded the facility $1.02M for fee colonoscopies in September 2011. Because facility leaders did not assure a structure for tracking and accountability by December 2011, the backlog stood at 3,800. The facility developed an action plan in January 2012 but had difficulty making progress in reducing the backlog. An adverse event in May 2012 prompted facility, VISN, and VHA leaders to re-evaluate the GI situation and essentially eliminated the backlog by late October 2012. During the review “look-back”, 280 patients were diagnosed with GI malignancies, 52 were associated with a delay in diagnosis and treatment. Several factors contributed to the GI backlog and hampered efforts to improve the condition. Specifically, the facility’s Planning Council did not have a supportive structure; Nursing Service did not include GI nurses on their priority hiring list; Fee Basis care had been reduced; low-risk patients were being referred for screening colonoscopies, thus increasing demand; staff members did not consistently and correctly use the consult management reporting and tracking systems; critical VISN and facility leadership positions were filled by a series of managers who often had collateral duties and differing priorities; and Quality Management was not included in discussions about the GI backlogs.