Report Summary

Title: Healthcare Inspection – Consult Management Concerns, VA Greater Los Angeles Healthcare System, Los Angeles, California
Report Number: 15-04681-228 Download
Issue Date: 5/4/2017
City/State: Los Angeles, CA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Hotline Healthcare Inspection
Release Type: Unrestricted

OIG conducted an inspection at the request of former Chairman Jeff Miller, Committee on Veterans' Affairs, US House of Representatives, to determine the validity of the allegation that 74 deceased patients had open consults at the VA Greater Los Angeles Healthcare System (facility), Los Angeles, CA.

We identified 225 deceased patients who had 371 open or pending consults at the time of their deaths or had discontinued consults after their deaths. Of the 225 patients, we found 117 patients with 158 consults who experienced delays in obtaining requested consults. We substantiated that 43 percent (158/371) of consults were not timely because providers and scheduling staff did not consistently follow consult policy or procedures. We did not substantiate the allegation that patients experienced serious or severe impact with long-term consequences or organ dysfunctions or that patients died as a result of delayed consults. However, we identified two patients who experienced minor or intermediate clinical impacts. We found that providers entered incorrect inpatient/outpatient setting and/or urgency for 14 percent (52/371) of the reviewed consults. While not an allegation, we observed deficiencies in consult management practices contributing to the delays. Of the 158 delayed consults, we noted that facility staff did not: (a) timely act on clinical consult requests, (b) close completed consults or discontinue duplicate requests or consults no longer indicated, or (c) monitor the electronic wait list for Homemaker/Home Health Aide services.

We recommended that the Facility Director ensure that providers assign the proper consult setting and urgency, staff take action within 7 days of a consult request or sooner if clinically indicated, staff timely close or discontinue consults, staff review the quality and timeliness of the cardiology care for one of the two patients who experienced intermediate clinical impact and take action if appropriate, and staff monitor and address the care needs of patients on the Homemaker/Home Health Aide services electronic wait list.