Delay in Diagnosis and Treatment for a Patient with a New Lung Mass at the Hampton VA Medical Center in Virginia

The VA Office of Inspector General conducted a healthcare inspection at the Hampton VA Medical Center (facility) in Virginia to assess allegations related to the delay in diagnosis and treatment of a patient with a newly found lung mass. The OIG substantiated that there was a delay in diagnosis and treatment for a patient with a new lung mass, highly suspicious for cancer. The OIG found multiple care coordination deficiencies in scheduling and communication that led to the delay. As the patient likely had metastatic disease at initial presentation, the OIG could not determine if the delay in care coordination contributed to the patient’s death. The OIG determined the facility did not have an operational cancer committee, tumor board, or a certified cancer registrar at the time of the inspection. The lack of administrative oversight, and programmatic development, directly impacts the quality of patient cancer care. The lack of the programs did not contribute to the patient’s death, but may have impacted the quality of oncology services provided by the facility. The OIG determined that the facility submitted a Joint Patient Safety Report after being notified of the OIG inspection. Although a root cause analysis was conducted, the facility failed to identify care coordination deficiencies, such as scheduling delays, as contributing factors to the patient’s death. An institutional disclosure was conducted but lacked documented evidence that facility leaders provided the patient’s family member the required information about potential compensation. The OIG made seven recommendations to the Facility Director related to care coordination agreements, compliance with Veterans Health Administration (VHA) Patient Aligned Care Team policies and VHA cancer registry requirements, and a review of both the root cause analysis and institutional disclosure to ensure alignment with VHA policies.