Consult Delays at the Atlanta VA Health Care System in Decatur, Georgia

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Atlanta VA Health Care System in Decatur, Georgia (facility), to review allegations and concerns of delays in care related to three patients’ non-VA community care (NVCC) consult appointments. The OIG confirmed these three patients experienced delays in the scheduling of their consults but did not identify an increase in risk of or an adverse clinical outcome for these patients. The OIG performed an expanded review of 221 consults and found that delays occurred. The OIG determined two patients had increased risks of an adverse clinical outcome due to delays in scheduling their appointments. Although the delays placed patients at increased risk, both patients received care and neither patient experienced an adverse clinical outcome. The OIG did not identify risks of or adverse clinical outcomes for the other patients. The facility had a backlog of open NVCC consults, and the OIG found deficiencies in processing, scheduling, and timeliness of these consults. Contributory factors also included, but were not limited to, inconsistent scheduling processes, inconsistent oversight, and deficiencies with third-party administrator scheduling oversight; shortages of facility NVCC staff; and lack of training and supervision for facility NVCC scheduling staff. The facility did not consistently meet facility process requirements for scheduling audits and lacked a process to identify consults that were missing documentation after administrative closure. The OIG made six recommendations to the Facility Director related to consult performance measurements, backlog and monitoring of open NVCC consults, hiring and training of NVCC staff, patient case reviews, and NVCC policy.