Report Summary

Title: Healthcare Inspection – Evaluation of the Veterans Health Administration’s National Consult Delay Review and Associated Fact Sheet
Report Number: 14-04705-62 Download
Issue Date: 12/15/2014
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: National Healthcare Review
Release Type: Unrestricted

OIG evaluated Veterans Health Administration’s (VHA’s) review of “unresolved” consults and the accuracy of VA’s summary, the National Consult Delay Review Fact Sheet (Fact Sheet), as requested by the Chairman of the House Veterans’ Affairs Committee (HVAC). Unresolved consults are requests for consultations that are open or active in patients’ electronic health records. In September 2012, VHA initiated a multi-phased review of consults that were unresolved for more than 90 days. By May 2014, the number of unresolved consults had decreased considerably. However, because VHA did not implement appropriate controls, we found it lacks reasonable assurance that facilities appropriately reviewed and resolved consults; closed consults only after ensuring veterans had received the requested services, when appropriate; and, where consult delays contributed to patient harm, notified patients as required by VHA policy. Our review of the Fact Sheet found several key statements related to the scope and results of VHA’s review of unresolved consults were misleading or incorrect. These statements were repeated by VHA leaders at meetings with congressional staff and during media events. In July 2014, VHA issued a letter to the Chairman of the HVAC that included information intended to clarify statements in the Fact Sheet. We recommended that the Interim Under Secretary for Health (1) conduct a systematic assessment of the processes each VA medical facility used to address unresolved consults during VHA's system-wide consult review; (2) ensure that if a medical facility's processes are found to have been inconsistent with VHA guidance on addressing unresolved consults, action is taken to confirm that patients have received appropriate care; and (3) after reviewing the circumstances of any inappropriate resolution of consults, confer with the Office of Human Resources and the Office of General Counsel or other relevant agency to determine the appropriate administrative action to take, if any.

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