Department of Veterans Affairs
 

Office of Inspector General
 

Combined Assessment Program
 

Summary Report
 

Management of Test Results in
 

Veterans Health Administration Facilities
 

Report No. 11-02869-272 September 7, 2011
 VA Office of Inspector General
 

Washington, DC 20420
 
To Report Suspected Wrongdoing in VA Programs and Operations:
 

Telephone: 1-800-488-8244
 

E-Mail: vaoighotline@va.gov
 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
 
Management of Test Results in Veterans Health Administration Facilities 

Executive Summary
 

The VA Office of Inspector General Office of Healthcare Inspections evaluated the 

management of test results in Veterans Health Administration (VHA) facilities. The 

purposes of the evaluation were to follow up on a previous report Healthcare Inspection 

Summary Review – Evaluation of Veterans Health Administration Procedures for 

Communicating Abnormal Test Results (Report No. 01-01965-24, November 25, 2002) 

and to assess facilities’ compliance with The Joint Commission’s national patient safety 

goal regarding communicating critical test results. The objectives were to determine 

whether facilities: 

1. Complied	 with VHA policy and Joint Commission standards related to 

communicating critical clinical laboratory, radiology, and anatomic pathology test 

results. 

2. Periodically monitored communication of critical test results to evaluate effectiveness. 

3. Documented appropriate notification and follow-up actions in medical records when 

critical test results were generated. 

4. Notified patients of normal test results. 

Inspectors evaluated the management of test results at 25 facilities during Combined 

Assessment Program reviews conducted from October 1, 2010, through March 31, 2011. 

In response to our 2002 report, VHA provided system-wide guidance for management of 

test results. We identified significant improvements related to diagnostic clinician 

communication and documentation of critical results compared with our previous review. 

However, we identified three areas where compliance with VHA requirements needs to 

improve. We recommended that the Under Secretary for Health, in conjunction with 

Veterans Integrated Service Network and facility senior managers, ensures that: 

	 Facilities’ written policies are comprehensive and define the processes for monitoring 

the effectiveness of communicating critical results to practitioners and patients. 

 Ordering practitioners or designees notify patients of all critical results within the 

defined timeframe. 

 Practitioners notify patients of normal results and that managers monitor compliance. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS
 

Office of Inspector General
 

Washington, DC 20420
 

TO: Under Secretary for Health (10) 

SUBJECT: Combined Assessment Program Summary Report – Management of 

Test Results in Veterans Health Administration Facilities 

Purpose 

The VA Office of Inspector General Office of Healthcare Inspections evaluated the 

management of test results in Veterans Health Administration (VHA) facilities. The 

purposes of the evaluation were to follow up on a previous report Healthcare Inspection 

Summary Review – Evaluation of Veterans Health Administration Procedures for 

Communicating Abnormal Test Results (Report No. 01-01965-24, November 25, 2002) 

and to assess facilities’ compliance with The Joint Commission’s (JC’s) national patient 

safety goal regarding communicating critical test results. The objectives were to 

determine whether facilities: 

1. Complied with VHA policy and JC standards related to	 communicating critical 

clinical laboratory, radiology, and anatomic pathology (AP) test results. 

2. Periodically monitored communication of critical test results to evaluate effectiveness. 

3. Documented appropriate notification and follow-up actions in medical records when 

critical test results were generated. 

4. Notified patients of normal test results. 

Background 

U.S. health care facilities complete approximately 12 billion diagnostic (laboratory, 

radiology, and AP) tests every year. While most of the test results are negative, 

approximately 1 to 5 percent are abnormal or critical and require follow-up by the 

referring physician.1 Health care facilities have a legal, ethical, and moral obligation to 

ensure that these results are communicated to the responsible practitioner or care team for 

action. Diagnostic services’ clinicians are required to communicate critical results to 

1 Lisa Fratt, “Critical Test Results Management: The Human Touch,” Health Imaging & IT, Vol. 6, No. 3, 

March 2008, pp 14–15. 

VA Office of Inspector General 1 
Management of Test Results in Veterans Health Administration Facilities 

appropriate practitioners rapidly and effectively so that quality patient care can be 

rendered. 

Since 2006, The JC has identified timely communication of critical results as one of its 

national patient safety goals. The JC requires health care organizations to develop 

written procedures for managing the critical results of tests and diagnostic procedures that 

address the following: 

 The definition of critical results of tests and diagnostic procedures. 

 By whom and to whom critical results of tests and diagnostic procedures are to be 

reported. 

 The acceptable length of time between the availability of and the reporting of 

critical results of tests and diagnostic procedures. 

In addition, health care organizations are required to implement procedures for managing 

and evaluating the timeliness of critical results of tests and diagnostic procedures. 

In our 2002 report, we made recommendations for the Under Secretary for Health, in 

conjunction with VHA managers, to: 

	 Develop system-wide policies requiring timely communication of abnormal test 

and procedure results to providers and patients and the documentation of these 

notifications in medical records. 

	 Ensure that diagnostic clinicians document on their test reports when they notify 

providers of abnormal results. 

	 Emphasize to treatment providers the importance of complete documentation, 

including documentation of any follow-up action, when they notify patients of 

abnormal test results. 

	 Ensure that managers evaluate the effectiveness of their view alert systems. 

In response to our report, VHA issued a directive delineating the procedures for 

communicating test results to practitioners and patients.2 On March 24, 2009, the 

directive was renewed and reissued as VHA Directive 2009-019. 

Scope and Methodology 

Inspectors evaluated the management of test results at 25 facilities during Combined 

Assessment Program reviews conducted from October 1, 2010, through March 31, 2011. 

The facilities reviewed represented a mix of size, affiliation, geographic location, and 

Veterans Integrated Service Networks (VISNs). Reviews focused on fiscal year 2010 

outpatient test results generated from the laboratory, radiology, and AP. We interviewed 

2 VHA Directive 2003-043, Ordering and Reporting Test Results, August 6, 2003. 

VA Office of Inspector General 2 
Management of Test Results in Veterans Health Administration Facilities 

selected program managers and reviewed policies, medical records, facility 

self-assessments, and other applicable documents. 

We generated an individual Combined Assessment Program report for each facility. For 

this report, we analyzed and summarized the data from the individual facility Combined 

Assessment Program reviews. Some of the areas reviewed did not apply to all VHA 

facilities; therefore, denominators differ in our reported results. For those review 

elements not mentioned further in this report, we generally found acceptable compliance. 

Inspectors conducted the reviews in accordance with Quality Standards for Inspection 

and Evaluation published by the Council of the Inspectors General on Integrity and 

Efficiency. 

Inspection Results 

Issue 1: Facility and Diagnostic Services’ Policies 

VHA requires facilities to develop written policies regarding communication of results 

from diagnostic clinicians to ordering practitioners.3 Policies need to describe the 

reporting process and timeframes for results that require prompt clinical attention. 

Facilities must monitor that communication of results to practitioners and patients occurs 

according to policy and requirements. Additionally, facilities need to monitor these 

communication processes to ensure that they are effective. 

We reviewed 21 facility, 24 laboratory, 24 radiology, and 20 AP policies. Table 1 below 

summarizes review elements. 

Table 1 

Element Facility Policy 

 Policies did not describe a process for 

monitoring the effectiveness of 

communicating critical results to patients. 

10/21 (48%) 

Element Laboratory Radiology AP 

 Policies did not specify timeframes for 

reporting critical results to practitioners. 

No problems 

identified 

No problems 

identified 

4/20 (20%) 

 Policies did not describe a process for 

monitoring the effectiveness of 

communicating critical results to 

practitioners. 

4/24 (17%) 5/24 (21%) 2/20 (10%) 

3 VHA Directive 2009-019, Ordering and Reporting Test Results, March 24, 2009. 

VA Office of Inspector General 3 
Management of Test Results in Veterans Health Administration Facilities 

We concluded that facilities’ (and their diagnostic services’) written policies needed to be 

more comprehensive and needed to define the processes for monitoring the effectiveness 

of communicating critical results to practitioners and patients. 

Issue 2: Patient Critical Results Notification 

VHA requires facilities to communicate critical results to patients within defined 

timeframes.4 We reviewed 710 outpatient medical records to determine whether ordering 

practitioners or designees documented in the medical record when they notified patients 

of critical results and whether the notifications were timely. Table 2 below summarizes 

medical record review results. 

Table 2 

Element Laboratory Radiology AP 

 Patients not informed of critical results. 10/255 (4%) 26/239(11%) 8/219 (4%) 

 Patients not notified of critical results 

within the defined timeframe. 

6/245(2%) 22/213 (10%) 26/211 (12%) 

Although compliance is fairly high, we concluded that ordering practitioners (or their 

designees) needed to consistently notify their patients of all critical results within the 

defined timeframes. 

Issue 3: Patient Normal Results Notification 

VHA requires practitioners to communicate outpatient test results, including normal 

results, no later than 14 calendar days from the date on which the results are available to 

the ordering practitioner.5 We reviewed the medical records of 547 outpatients who had 

normal laboratory or radiology results to determine whether practitioners notified patients 

of the results and whether communication occurred within the required timeframe. 

Table 3 below summarizes medical record review results. 

Table 3 

Element Total 

Records 

Reviewed 

Laboratory Radiology 

 Patients not informed of normal results. 178/547 

(33%) 

54/270 

(20%) 

124/277 

(45%) 

 For those patients notified of normal 

results, communication did not occur 

within the required timeframe. 

25/369 (7%) 13/216 (6%) 12/153 (8%) 

4 VHA Directive 2009-019. 

5 VHA Directive 2009-019. 

VA Office of Inspector General 4 
Management of Test Results in Veterans Health Administration Facilities 

We concluded that practitioners needed to improve considerably in notifying their 

patients of normal results and that facility managers needed to monitor compliance. 

Conclusions 

In response to our 2002 report, VHA developed system-wide guidance for management 

of test results. We identified significant improvements related to diagnostic clinician 

communication and documentation of critical results compared with our previous review. 

However, compliance with VHA requirements needs to improve in the areas of written 

policies, monitoring the effectiveness of communication processes, and patient 

notification of critical and normal results. 

Recommendations 

Recommendation 1. We recommended that the Under Secretary for Health, in 

conjunction with VISN and facility senior managers, ensures that facilities’ written 

policies are comprehensive and define the processes for monitoring the effectiveness of 

communicating critical results to practitioners and patients. 

Recommendation 2. We recommended that the Under Secretary for Health, in 

conjunction with VISN and facility senior managers, ensures that ordering practitioners 

notify patients of all critical results within the defined timeframes. 

Recommendation 3. We recommended that the Under Secretary for Health, in 

conjunction with VISN and facility senior managers, ensures that practitioners notify 

patients of normal results and that managers monitor compliance. 

Comments 

The Under Secretary for Health concurred with the findings and recommendations. The 

implementation plan is acceptable, and we will follow up until all actions are completed. 

JOHN D. DAIGH, JR., M.D.
 

Assistant Inspector General for
 

Healthcare Inspections
 

VA Office of Inspector General 5 
Management of Test Results in Veterans Health Administration Facilities 

Appendix A 

Under Secretary for Health Comments 

Department of 

Veterans Affairs Memorandum 

Date: August 5, 2011 

From: Under Secretary for Health (10) 

Subject: OIG Combined Assessment Program Summary 

Report – Management of Test Results in Veterans Health 

Administration Facilities (VAIQ 7134066) 

To: Assistant Inspector General for Healthcare Inspections (54) 

1. I have reviewed the draft report and concur with the report’s 

recommendations. Attached is the Veterans Health Administration (VHA) 

corrective action plan for the report’s recommendations. 

2. Thank you for the opportunity to review the draft report. If you have 

any questions, please contact Linda H. Lutes, Director, Management 

Review Service (10A4A4) at (202) 461-7014. 

(original signed by:) 

Robert A. Petzel, M.D.
 

Attachment
 

VA Office of Inspector General 6 
Management of Test Results in Veterans Health Administration Facilities 

VETERANS HEALTH ADMINISTRATION (VHA)
 

Action Plan
 

OIG Combined Assessment Program Summary Report: Management 

of Test Results in Veterans Health Administration Facilities 

(VAIQ 7134066) 

Date of Draft Report: July 10, 2011 

Recommendations/ Status Completion 

Actions Date 

Recommendation 1. We recommended that the Under Secretary for 

Health, in conjunction with VISN and facility senior managers, ensures that 

facilities’ written policies are comprehensive and define the processes for 

monitoring the effectiveness of communicating critical results to 

practitioners and patients. 

VHA Comments 

Concur 

VHA Office of the Deputy Under Secretary for Health for Operations and 

Management (DUSHOM) will reinforce policy in VHA Directive 2009-19, 

Ordering and Reporting Test Results, on notification of critical results 

during the Network Director and Chief Medical Officer (CMO) conference 

call. 

In process September 30, 2011 

The DUSHOM will establish a national monitoring tool to determine if 

policies are comprehensive and include effective processes, documenting 

treatment actions in response to the results as required by VHA Directive 

2009-19, paragraph 4b(5)(d), for critical results notification to practitioners 

and patients. Veterans Integrated Service Networks (VISN) will be 

expected to provide leadership oversight and management to achieve 

compliance. The DUSHOM will follow-up with VISN leadership to ensure 

that corrections to local policies are in effect. 

In process September 30, 2011 

VA Office of Inspector General 7 
Management of Multidrug-resistant Organisms in Veterans Health Administration Facilities 

Recommendation 2. We recommended that the Under Secretary for 

Health, in conjunction with VISN and facility senior managers, ensures that 

ordering practitioners notify patients of all critical results within the defined 

timeframes. 

VHA Comments 

Concur 

The DUSHOM will reinforce VHA’s policy on notification of critical 

results during the Network Director and CMO conference call. 

In process September 30, 2011 

The DUSHOM will publish a memorandum highlighting policy 

expectations and tasking VISN Directors with developing effective critical 

results follow up systems to mitigate patient safety risks. The Test Results 

Communication Workgroup (see rec. 3 below) will provide standardized 

recommendations and tools to ensure timely reporting of all results. 

In process September 30, 2011 

Recommendation 3. We recommended that the Under Secretary for 

Health, in conjunction with VISN and facility senior managers, ensures that 

practitioners notify patients of normal results and that managers monitor 

compliance. 

VHA Comments 

Concur 

The DUSHOM will reinforce VHA’s policy on notification of results 

during the Network Director and CMO conference call. 

In process September 30, 2011 

The DUSHOM has already formed the Test Results Communication 

Workgroup to develop a standardized national approach for notification of 

results for all tests. The objectives of the workgroup are to develop: 

• toolkit and guidance 

• monitoring parameters and tracking methodology 

• implementation and communication plan 

VA Office of Inspector General 8 
Management of Multidrug-resistant Organisms in Veterans Health Administration Facilities 

The workgroup will also explore and recommend enterprise level 

technology solutions for patient notification and monitoring, tracking and 

trending. 

The toolkit will be available January 31, 2012, and monitoring in 

accordance with the recommendations of the Workgroup will be ongoing. 

In process	 Tool Kit will be 

available 

January 31, 2012 

VA Office of Inspector General 9 
Management of Test Results in Veterans Health Administration Facilities 

Appendix B 

OIG Contact and Staff Acknowledgments 

OIG Contact For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720. 

Contributors Daisy Arugay, MT, Project Coordinator 

Annette Acosta, RN 

Lisa Barnes, MSW 

Paula Chapman, CTRS 

Jennifer Christensen, DPM 

Myra Conway, RN 

Kathy Gudgell, RN, JD 

Elaine Kahigian, RN, JD 

Gayle Karamanos, PA 

Cathleen King, RN 

Sarah Lutter, RN, JD 

JoDean Marquez, RN 

Jeanne Martin, PharmD 

Claire McDonald, MPA 

Karen Moore, RN 

Reba Ransom, RN 

Kathleen Shimoda, RN 

Carol Torczon, ACNP 

Cheryl Walker, NP 

Susan Zarter, RN 

VA Office of Inspector General 10 
Management of Test Results in Veterans Health Administration Facilities 

Appendix C 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

National Center for Patient Safety 

Office of General Counsel 

Office of Medical Inspector 

Veterans Integrated Service Network Directors (1–23) 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 11