Delays and Deficiencies in Obtaining and Documenting Mammography Services at the Atlanta VA Health Care System, Decatur, Georgia

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review a complaint alleging a delay in care, including surgery, after a non-VA imaging center reported mammogram results as normal for a patient with known breast cancer at the Atlanta VA Health Care System in Decatur, Georgia. The OIG found that the patient’s mammograms were stable for six years. The OIG confirmed that the spring 2016 mammogram results at issue were reported as “normal,” which was reasonable, and did not substantiate allegations that this delayed surgery. The patient had repeatedly declined surgery since 2005. Based on information developed during the course of the inspection, the OIG broadened the scope of the inspection to include 4,727 mammography orders and consults ordered from October 1, 2014, to June 22, 2017. The OIG identified 42 patients whose diagnostic mammograms were not completed and referred them to the facility for follow-up. The OIG also identified concerns related to a lack of a streamlined mammography process, delays in scheduling and retrieving results, physician review for clinical appropriateness, unscanned documents, and oversight of the Women Veterans Program, among others. The OIG made seven recommendations to the facility director to ensure patients who were transitioned from the mammography contract provider in October 2015 to other non-VA providers received care, that facility policy and practice are consistent, non-VA mammograms are scheduled timely and undergo consistent clinical review of the mammogram request, the availability of mammogram results improves, gender-specific care is provided by Women’s Health Primary Care Providers, and the facility provides executive oversight of its Women Veterans Program.