Healthcare Inspection Alleged Delay in Diagnosis and Communication Issues, Chattanooga Community Based Outpatient Clinic, Tennessee Valley Healthcare System Nashville, Tennessee

The VA Office of Inspector General, Office of Healthcare Inspections, conducted an inspection in response to allegations of a delay in diagnosis and communication issues at the community based outpatient clinic (CBOC) located in Chattanooga, TN. The CBOC is part of the Tennessee Valley Healthcare System (the system), Nashville, TN. We also reviewed an additional allegation that the patient had difficulty getting an appointment at the CBOC. We substantiated the allegation of a delay in diagnosis. We found no evidence that the patient’s CBOC primary care physician (PCP) reviewed the magnetic resonance imaging results, notified the patient of the abnormal results, or ensured follow-up care. We determined that current local policy does not delineate responsibility for the follow up of fee basis provider recommendations to ensure continuity of care. We could not confirm or refute the allegations that the PCP did not communicate adequately with the TRICARE provider, that the CBOC staff did not allow the patient to change providers, or that the patient had difficulty getting appointments at the CBOC. We recommended that the Facility Director: Require that ordering providers inform patients of abnormal test results and arrange for appropriate follow up according to local policy. Conduct a peer review of this case, and if care is determined to be deficient, consult with Regional Counsel to determine if disclosure is warranted. Review the local consult policy for fee basis care and make changes, as appropriate, to ensure continuity of care. The VISN and Facility Directors concurred with the findings and recommendations and provided acceptable action plans.