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Healthcare Inspection – Echocardiography Scheduling and Quality of Care Concerns, Edward Hines, Jr. VA Hospital, Hines, Illinois

Report Information

Issue Date
Report Number
15-01900-142
VISN
State
Illinois
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
4
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG conducted an inspection in response to allegations concerning echocardiography scheduling and quality of care concerns at the Edwards Hines, Jr. VA Hospital (facility) in Hines, IL. We substantiated the allegation of scheduling delays for 1,226 echocardiography studies during 2014. We found that 1,176 requests were performed between 31–120 days, and 50 requests were performed greater than 121 days from requests. For one of the patients whose imaging study was performed greater than 121 days, the scheduling delay resulted in a delay in diagnosing a condition requiring surgery. This scheduling delay had the potential to cause harm, but no apparent adverse effects occurred. To assess the quality of the echocardiography images, we reviewed 50 routine echocardiography studies randomly selected from 1,122 studies completed July 1, 2014 through January 12, 2015. In all 50 studies, our findings were consistent with, or had only minor deviations from, the final written reports documented in each patient’s electronic health record and none of the deviations were clinically significant. All of the studies were sufficient for clinical decision making. However, we found the quality of the majority of the images reviewed was poor and may have been due to the technicians’ competency. We found no documented evidence of performance improvement activities for the echocardiography technicians. The Chief of Cardiology informed us that a formal performance improvement process was not in place for the echocardiography technicians. We recommended that the Facility Director ensure routine echocardiographic studies are scheduled according to VHA policy; confer with counsel about a possible patient disclosure and take appropriate action, if any; ensure echocardiography technicians are provided training and continuing education opportunities; and that managers establish performance improvement activities for echocardiography technicians.

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 Facility Director ensure that routine, outpatient echocardiography studies are scheduled in accordance with Veterans Health Administration policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director confer with the Office of Chief Counsel (formerly known as Regional Counsel) for possible disclosure to the patient with delayed echocardiography described in this report and take appropriate action, if any.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that echocardiography technicians are offered opportunities for re-training and continuing education to improve the quality of the echocardiography image acquisition.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that cardiology managers establish performance improvement activities for the echocardiography technicians in accordance with facility policy.