Report Summary

Title: Healthcare Inspection - Alleged Chemotherapy Delay and Excessive Emergency Department Length of Stay, Jesse Brown VA Medical Center, Chicago, Illinois
Report Number: 13-00488-26
Issue Date: 12/9/2013
City/State: Chicago, IL
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
Summary: OIG conducted an inspection in response to a complainant’s allegations of a delay in chemotherapy treatment, excessive length of stay (LOS) in the Emergency Department (ED), and failure to perform a kidney ultrasound at the Jesse Brown VA Medical Center in Chicago, IL. We substantiated a delay in chemotherapy treatment, that the patient experienced excessive LOS in the ED on two occasions while awaiting admission, and that an inpatient kidney ultrasound was ordered but not performed. However, on both ED visits, the patient was promptly triaged and treated. We could not substantiate that the patient suffered adverse medical outcomes as a result of these delays. We found that there was no clearly defined process for monitoring oncology clinic patients awaiting inpatient beds after hours and that there was inconsistent patient handoff communication between oncology clinic staff and the ED triage nurses. We also identified problems in the Patient Flow Committee structure, membership, and communication of patient flow initiatives to the frontline staff.
We made three recommendations.