Healthcare Inspection – Quality of Care Concerns in a Diagnostic Evaluation, Jesse Brown VA Medical Center, Chicago, Illinois

OIG conducted an inspection to assess the merit of allegations made by a confidential complainant relating to quality of care concerns in a diagnostic evaluation at the Jesse Brown VA Medical Center, Chicago, Illinois. We substantiated a delay in scheduling and completing the lower extremity arterial study. We could not substantiate the allegation that the patient’s requirement for limb amputation would have been different had he received the vascular laboratory lower extremity arterial study sooner. Although not an allegation, we identified an additional quality of care issue with this patient’s care. During three providers’ visits, the patient did not receive complete pain assessments. We recommended that the Facility Director: (1) evaluate the scheduling process for vascular consultations and diagnostic tests, and take action if factors potentially impacting quality of care are identified; (2) evaluate the practice of vascular laboratory technicians interpreting the urgency of providers’ consult requests and whether providers are notified when consult requests are not scheduled within the providers’ timeframe, and take action if needed; (3) ensure that managers develop a policy defining who is responsible for provider and patient notification of consults ordered through the Emergency Department or Urgent Care Clinic that are not completed timely according to VHA policy; (4) ensure that providers perform comprehensive pain assessments according to VHA policy, and monitor compliance; (5) ensure that managers conduct an internal evaluation of the case discussed in this report; and, (6) consult with Regional Counsel regarding possible institutional disclosure.