Review of Availability of On-Call Interventional Radiology Services and a Related Patient Transfer at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana

The VA Office of Inspector General (OIG) initiated a healthcare inspection at the Richard L. Roudebush VA Medical Center (facility) in Indianapolis, Indiana, to assess allegations and concerns related to the availability of on-call interventional radiology services. In May 2024, VA clarified that fee basis provider duties must be related to direct patient care activities, which prevented VA from paying providers for being on call and available to provide patient care services. In response, the facility halted on-call interventional radiology services, which were later resumed intermittently using facility providers.  

The OIG did not substantiate the allegation that a waiver request should have been submitted prior to the reduction in coverage. However, the OIG substantiated that confusion and deficient communication of intermittent on-call coverage led to a patient being unnecessarily transferred after developing a gastrointestinal bleed, despite services being available at the facility. The resumption of coverage on an intermittent basis was communicated to staff and leaders through emails and daily calls. However, the patient’s intensive care unit (ICU) attending physician and the ICU director were not included in the email communication and did not participate in the daily calls. Further, the ICU fellow who transferred the patient did not consult with the ICU attending physician and the gastroenterology fellow did not document assessing the patient as required. 

The OIG determined that a clinical or institutional disclosure was not conducted, facility leaders did not conduct a comprehensive review of the event to understand staff’s involvement, and quality management staff did not process a related patient safety report in accordance with VHA policy.

The Facility Director concurred with the six recommendations and shared plans and actions taken to address communication, documentation, disclosure, patient safety reporting, mitigation of risks that contributed to the transfer, and rejected patient safety reports.