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Healthcare Inspection – Delay in Care of a Lung Cancer Patient, Phoenix VA Health Care System, Phoenix, Arizona

Report Information

Issue Date
Report Number
14-00875-325
VISN
State
Arizona
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
7
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
At the request of Senator Jeff Flake, OIG conducted an inspection to determine the merit of allegations regarding a delay in treating a patient diagnosed with lung cancer at the Phoenix VA Health Care System, Phoenix, AZ. We substantiated a delay between the diagnosis of the lung cancer and treatment. We could not determine whether this delay impacted the final outcome. We substantiated a delay in identification of symptoms of cancer metastasis; however, we did not substantiate a delay in treatment once the brain metastasis was discovered. We identified lack of patient education and primary care provider involvement in the coordination of subsequent cancer-related specialty appointments as factors contributing to delays in care. We did not substantiate the allegation that following his craniotomy there was a failure to communicate the patient’s status to the patient and family. The patient and his family received accurate information regarding his status and the plan to transition the patient to a non-VA nursing home and place him in hospice. We did not substantiate a failure to adequately manage the patient’s pain. Pain management monitoring, decisions, and education were documented in the electronic health record. We identified several additional issues during our review. The patient’s risk for depression was not fully assessed following the new diagnosis of lung cancer. Although the EHR contained evidence that system providers were aware of results of non-VA testing, non-VA medical records were not consistently available in the electronic health record. Service agreements were not active for the oncology and neurology services. Consults placed during the course of the patient’s treatment were designated with routine urgency even though the clinical expectation and actual need was for a more urgent response. We made seven recommendations.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that primary care providers are notified of specialty evaluations and treatment plans so they can be involved in care coordination.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that staff assesses patient learning needs, barriers, abilities and readiness to learn, and that related education is provided as required by local policy, and monitor for compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that all patients are annually screened for depression, or more frequently as indicated by existing or newly identified risks, and that system manager’s monitor for compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that documentation from non-VA clinical care, including radiology reports, are obtained and available in the electronic health record for review in a timely and consistent manner.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that system staff place consults with urgency based on the needed response time.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director review facility service agreements and care coordination in order to better care for patients with complex diseases that require multi-specialty intervention.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director review this case and consult with the Office of Chief Counsel (formerly Regional Counsel) regarding the care provided and take action if appropriate.