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Healthcare Inspection – Administrative Summary Non-VA Care Consult Program Concerns, Charles George VA Medical Center, Asheville, North Carolina

Report Information

Issue Date
Report Number
15-05578-294
VISN
State
North Carolina
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
0
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG conducted an inspection in 2016 to assess concerns made regarding the clinical and administrative systems and practices within the non-VA care program at the Charles George VA Medical Center (facility), Asheville, NC. In 2015, we conducted a survey in advance of a Combined Assessment Program review and multiple respondents raised concerns about the non-VA care program. We did not find that non-VA care consult staff inappropriately discontinued or cancelled consults. Based on our random sample of 147 non-VA care consults, we found that staff discontinued or cancelled 33 consults. Of the 33 consults, we found 32 (97 percent) had appropriate reasoning documented within the consult. We did not find that the facility’s non-VA care program lacked clinical oversight. We found that approving officials reviewed and documented approval for the 147 randomly sampled consults. We found that telephone calls to the non-VA care program went unanswered. Beginning in October 2015, non-VA care leadership changed and then implemented a reorganization. In addition, the non-VA care program increased the number of phone lines, implemented teams, clarified roles and responsibilities, and increased staffing. With these efforts, the facility’s telephone metrics improved by the end of March 2016. We found apparent delays in processing non-VA care consults in FY 2015 and FY 2016. We focused our findings on the results from our review of the non-VA care consults ordered in FY 2016. We found apparent delays for 3,294 of 6,800 patients (48.4 percent) with at least one non-VA care consult. We reviewed the 863 EHRs of patients who experienced either a hospital admission or death following an apparent delay. We did not identify that the delays in care clinically impacted the patients reviewed. We made no recommendations.
Recommendations (0)