Healthcare Inspection – Lack of Follow-Up Care for Positive Colorectal Cancer Screening, New Mexico VA Health Care System, Albuquerque, New Mexico

OIG conducted an inspection in response to allegations concerning the lack of follow-up care for patients with positive colorectal cancer screening at the New Mexico VA Health Care System (facility), Albuquerque, NM. We did not substantiate that laboratory staff had a list of 300 patients who had tested positive for fecal occult blood, but no follow-up had been done. We determined that laboratory personnel do not keep lists of patients with positive fecal occult results. However, we found that laboratory staff flagged positive results in patients’ electronic health records which generated a “view alert” to providers and that providers did not consistently notify patients of positive fecal immunochemical tests (used to determine presence of occult blood) in fiscal years (FYs) 2013 and 2014. As a result, some patients did not receive timely follow-up care. We identified nine patients diagnosed with colorectal cancer who experienced delays and, in some instances, significant delays that may have affected the patients’ clinical outcomes. Such delays placed patients at unnecessary risk for adverse outcomes. We determined that during FY 2013 and FY 2014, the facility did not have a process in place to monitor provider compliance with colorectal cancer screening. In 2012, facility leaders assigned a registered nurse to follow up on positive fecal immunochemical tests and report to the Chief of Staff monthly. However, the employee transferred from the facility, and the position had been vacant for over 2 years. We found that facility leaders did not institute processes for monitoring provider compliance with colorectal cancer screening and reporting to ensure that patients received timely notification of results and appropriate follow-up care. We made four recommendations.