Healthcare Inspection – Non-VA Colonoscopy Follow-Up Concerns, Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana

OIG conducted a healthcare inspection to assess allegations regarding the management of follow-up care for patients who had colonoscopies from 2006 through 2012 via Non-VA Care Coordination (NVCC) at the Southeast Louisiana Veterans Health Care System (system), New Orleans, LA. Specific allegations were: System leadership failed to provide appropriate follow-up for approximately 16,000 to 18,000 patients who received colonoscopies through NVCC; System leadership failed to notify patients who had been potentially harmed; System clinicians did not timely receive and review the results of colonoscopies completed for seven patients through NVCC referrals; The System Director had knowledge of the issue and did nothing about it. At the time of our inspection, system managers had completed a review of the patients and taken action. We chose to examine the adequacy of the review conducted by the system. We could not substantiate that then-system leaders failed to provide appropriate follow-up for patients because we determined that system managers did not reliably identify all potentially affected patients. We identified patients who had developed colorectal cancer and were not on the system’s list. We also found that then-system leaders did not take appropriate steps to ensure the validity of case reviews of patients who were identified. We did not substantiate that system managers failed to notify a patient who had suffered harm. A certified letter was sent to the family member. We substantiated that the system did not timely receive results for two of seven identified patients who underwent NVCC colonoscopy procedures. We did not substantiate that the then-System Director had knowledge of the issue and did nothing about it. While developing a more flexible clinical reminder for colorectal cancer screening, then-system leaders discovered delays in scheduling the procedure when recommended. The then-System Director became aware of this and initiated a protected quality review for patients. We recommended that the System Director (1) ensure that all potentially affected patients be reviewed by an external source to ensure those patients received follow-up care and (2) confer with the Office of Chief Counsel about possible institutional disclosure and appropriate action regarding two patients. OIG UPDATE: After our review was completed, the system was able to generate a report reflecting evidence of the system’s 2014 colonoscopy lookback and confirmed that 12,964 patient’s colonoscopy reports were reviewed and clinical reminders were updated to reflect the appropriate return timeframe for procedures performed between September 1, 2005 and December 30, 2013.