Report Summary

Title: Healthcare Inspection – Echocardiography Scheduling and Quality of Care Concerns, Edward Hines, Jr. VA Hospital, Hines, Illinois
Report Number: 15-01900-142 Download
Issue Date: 2/2/2017
City/State: Hines, IL
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted

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.