Report Summary

Title: Healthcare Inspection – Alleged Pathology and Laboratory Medicine Service Quality of Care Issues, Wilmington, VA Medical Center, Wilmington, Delaware
Report Number: 14-04524-224 Download
Issue Date: 5/16/2017
City/State: Wilmington, DE
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Healthcare Inspection Report
Release Type: Unrestricted

OIG conducted a healthcare inspection to evaluate allegations that a pathologist misread oncology test results, did not complete pathology tests timely, inappropriately sent some tests outside the facility on a fee for service basis, and altered pathology reports from alternate Veterans Health Administration (VHA) and non-VHA laboratories to make it appear as though he performed the tests at the facility laboratory. We could not substantiate that the pathologist misread oncology tests. We reviewed electronic health record data, and found that the pathologist replaced preliminary pathology results with final results; therefore initial test results were not available for comparison to final test results or to the facility’s data. We interviewed oncology staff who could not recall any instances of misread tests. We substantiated that the pathologist did not always have pathology test results available to ordering providers within required timeframes and had, with facility leadership approval, sent specimens to Fee Basis vendors for processing. We did not substantiate that the pathologist altered reports of pathology tests. However, we discovered inconsistent documentation identifying non-VHA pathologists on final pathology reports and incomplete documentation for specimens sent to alternate VHA and non-VHA laboratories.

We found that the pathologist utilized a non-VHA laboratory to process pathology tests without a required VHA contractual arrangement and inappropriately revised a facility laboratory standard operating procedure. In addition, oversight services and committees did not consistently report accurate statistical and performance information to facility leadership, and did not complete and monitor internal review action plans and ongoing professional performance evaluations using current facility performance data. We recommended that the Facility Director ensure the use of acceptable processing procedures for pathology testing; that staff follow facility documentation requirements for non-Veterans Health Administration laboratory pathology reports; that the pathology tests performed at the unofficial non-Veterans Health Administration laboratory are reviewed; that oversight service and committees review current performance data and follow VHA and facility quality assurance policies and practices; and that facility managers complete ongoing professional performance evaluations and other internal reviews as required by VHA and facility policies.