Whistleblower Discloses More Than 1,000 Veterans Deprived of Timely Endoscopy Procedures by VA
March 29, 2019
For the second time in as many months, OSC has alerted the President and Congress to unacceptable wait times associated with endoscopy procedures at two different VA medical centers.
For the second time in as many months, the U.S. Office of Special Counsel (OSC) has alerted the President and Congress to unacceptable wait times associated with endoscopy procedures at two different Department of Veterans Affairs Medical Centers (VAMCs). A whistleblower alerted OSC to the lengthy backlog of patients who did not receive timely follow-up endoscopy procedures at two medical centers within the Eastern Kansas Health Care System (Eastern Kansas HCS). The resulting VA investigation follows a similar agency inquiry into a whistleblower disclosure involving a backlog of hundreds of veterans awaiting endoscopies at an Orlando, Florida VAMC that was closed by OSC in February 2019.
“These disclosures reveal that the VA continues to struggle with unacceptable delays in providing vital medical care for our veterans,” said Special Counsel Henry J. Kerner. “Endoscopy procedures are critical to early cancer detection, which can lower mortality rates for certain types of cancer. But to be effective, these procedures must be performed regularly and with timely follow-up appointments. It is incumbent on the VA to ensure adequate medical staffing at its facilities, or utilize Community Care to fill the gaps so that our veterans have access to these lifesaving procedures.”
The VA’s investigation found that as of February 2018, the Eastern Kansas HCS was woefully understaffed, with only one full-time gastroenterologist (GI) along with one other GI performing procedures at the Eisenhower VAMC only on Tuesday afternoons, and one GI performing procedures on Mondays at the O'Neil VAMC. The report found that GI clinics did not notify patients of their endoscopy results within 14 days of receiving them, as required. The clinics also failed to consistently remind patients to schedule follow-up appointments and neglected to monitor the quality of colonoscopies.
The VA’s report made several recommendations, including continuing to refer new consults to Community Care while decreasing the backlog; an audit of all GI schedulers’ training files; monitoring of colonoscopy quality, per VA policy; reeducating staff on updated policies; and ensuring appropriately staffed GI clinics.
Since the VA issued its report, the National GI Program Office conducted an onsite review of the Eastern Kansas GI and provided preliminary feedback, finding that in the last 12 months GI consult wait times have decreased from 128 days to 55 days, and all GI schedulers have completed needed training. Colonoscopy cases are now reviewed daily and quarterly for quality metrics, and thus far, the metrics have been met at 100 percent. The relevant local policies were revised and renewed, and leadership expects all GI staff training on the revised policies to be completed by May 3, 2019.