Radiology Concerns at the VA Illiana Health Care System in Danville, Illinois
Veterans Affairs Office of Inspector General (OIG) sent this bulletin at 05/05/2020 01:16 PM EDT
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Given VA’s need to focus on the COVID-19 response, the OIG has developed interim measures for releasing oversight reports. Accordingly, at this time, the OIG is generally releasing only those reports that are relevant to the COVID-19 pandemic, statutorily required, or that involve compelling circumstances related to the welfare of veterans, the safety of patients and VA personnel, or pose significant risks to VA resources.
This report is compelling because it discusses significant patient safety issues including a radiologist’s error rate, the facility’s radiology quality assurance program, and a recommendation to the Under Secretary for Health regarding adopting national radiology guidelines. As the report addresses compelling patient safety concerns and VHA was able to propose or initiate action plans in early and mid-March, publication of the report at this time is warranted and would not pose an undue burden on VHA.
The OIG conducted a healthcare inspection in response to a congressional request to assess concerns regarding the appropriateness of facility leaders’ response to a radiologist’s alleged four radiologic errors. The OIG determined that the facility should have considered making an institutional disclosure (notification of a possible adverse event) to one patient’s family. Alerted to the radiologist’s potential errors, facility leaders conducted an expanded review, with Veterans Integrated Service Network (VISN) and National Teleradiology Program assistance and found a high error rate in the radiologist’s exams. A second expanded review ensued.
The OIG concluded that the Radiology Service lacked an effective early detection and identification process for radiologic errors. Once errors were identified, VISN and facility leaders took appropriate actions. The Radiology Service Chief, however, inadequately assessed the radiologist’s performance due to a small exam sample size and did not fully consider the modalities and complexities of the exams. VA’s National Guidelines for Radiology Professional Competency provide facility leaders with direction to assess radiologists’ clinical competence. Because radiologic exams vary in complexity and risk to patients, a risk stratification methodology would better inform professional practice evaluations.
The OIG made six recommendations including one to the Under Secretary for Health regarding guidelines to better inform radiologists’ professional practice evaluations. A second recommendation was made to the VISN Director on continued oversight of the facility’s response to National Teleradiology Program findings. The remaining four recommended the Facility Director take action on (1) disclosures to patients or families as warranted, (2) Radiology Service improvements in quality assurance and performance plans, (3) radiologist competency reviews based on VA’s National Guidelines for Radiology Professional Competency, and (4) evaluation of National Teleradiology Program final findings to determine what additional steps are required.
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