Report Summary

Title: Pathology Processing Delays at the Memphis VA Medical Center, Tennessee
Report Number: 18-02988-198 Download
Issue Date: 8/27/2019
City/State: Memphis, TN
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection
Release Type: Unrestricted

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations that surgical pathology specimen processing delays in the pathology and laboratory medicine service (P&LMS) resulted in multiple patients’ harm and possibly death, and follow-up on the facility’s response.

Patients experienced no adverse clinical outcomes related to specimen delays. Actions developed by facility leaders improved turnaround times for surgical pathology specimens processed onsite; however, the OIG was unable to determine if offsite pathology turnaround times improved because of incomplete evidence.

In 2018, approximately 39 percent of P&LMS positions were vacant. The pathologists’ shortage contributed to inconsistent surgical pathology quality assurance and prolonged specimen turnaround times.

Facility leaders had plans in place to ensure compliance with quality management program requirements, but the plans were not fully implemented at the time of the OIG visit. Facility leaders did not conduct a formal quality review to systematically determine the causes that contributed to the delays.

The OIG identified deficiencies in initial training and annual competency documentation. Without these measures, facility leaders were unable to ensure staff readiness to provide quality services for patients.

The OIG did not find that facility leaders attempted to conceal deficiencies discovered in P&LMS. However, an issue brief to the Veterans Integrated Service Network dated approximately two months after the discovery of the delayed surgical pathology specimens only listed problems in P&LMS related to environment of care and staffing. As a result, the OIG had concerns about Veterans Health Administration senior leaders’ oversight of the specimen processing delays and evaluation of the need for a large-scale disclosure.

The OIG made eight recommendations related to P&LMS staffing improvement strategies, specimen tracking process, identification of areas of future risk, P&LMS quality management program, staff competencies and training, and the issue brief process.