OIG conducted a healthcare inspection at the request of Senators Jon Tester and Steve Daines to assess whether patients experienced delays in obtaining consults, and the impact of any consult delays on patient outcomes, at the VA Montana Health Care System (system), Fort Harrison, MT. We also evaluated the adequacy of internal feedback mechanisms related to consults. For consults ordered in fiscal year (FY) 2015, we found apparent delays for: 11,073 of 26,293 patients (42 percent) with at least one in-house consult; 11,863 of 21,221 patients (56 percent) with at least one non-VA care consult; and, 2,683 of 4,427 patients (61 percent) with at least one Choice consult. Among the VA facilities reviewed for comparison, the system had the lowest or among the lowest percentage of patients with delayed in-house and Choice consults and the highest percentage of patients with delayed non-VA care consults. We found that delays among consults ordered in FY 2015 may have harmed four patients. In July 2015, system leadership initiated a focused effort to identify and resolve factors contributing to consult delays. Despite this effort, we found evidence of persistent issues with completing consults timely in FY 2016. System leadership initiated ongoing reviews to determine if patient harm occurred due to delays in care. We found the system had several mechanisms in place for staff to communicate concerns about consult delays to system leadership. Despite available mechanisms, staff expressed concerns about communication with system leadership. We recommended the System Director ensure the care of the potentially harmed patients be reviewed by an external source, confer with the Office of Chief Counsel as necessary regarding the potentially harmed patients and take action as appropriate, and continue efforts to improve consult timeliness.