Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Mammography, Cardiology, and 

Colonoscopy Management 

Jack C. Montgomery VA Medical Center 

Muskogee, Oklahoma 

Report No. 08-01866-62 February 2, 2009

VA Office of Inspector General 

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

Telephone: 1-800-488-8244 between 8:30AM and 4PM Eastern Time, 

 Monday through Friday, excluding Federal holidays 

 E-Mail: vaoighotline@va.gov 

 
Mammography, Cardiology, and Colonoscopy Management, Jack C. Montgomery VAMC, Muskogee, OK 

Executive Summary 

The purpose of the review was to determine the validity of allegations regarding delays in 

mammography services, cardiology consult responses, and scheduling colonoscopy 

procedures at the Jack C. Montgomery VA Medical Center (medical center), Muskogee, 

OK.

We determined that in 2007 patients did not consistently receive mammograms in a 

timely manner as required by Veterans Health Administration (VHA) and local policy. 

We concluded that a subject cardiac patient had not been contacted regarding the results 

of his cardiac imaging, cardiac catheterization, and echocardiogram in a timely manner. 

We further concluded that cardiology consultation requests were not always scheduled 

within the required timeframe. 

We substantiated that a subject colonoscopy patient did not receive a screening 

colonoscopy as requested by the primary care provider (PCP) and that a diagnostic 

colonoscopy, ordered one year later, was not scheduled within 60 days of the request. 

We concluded waiting times for scheduling colonoscopies were excessive. 

We could not substantiate or refute whether PCPs were notified regarding the status of 

mammogram requests, cardiology consults, and colonoscopy appointments. 

Prior to our visit, management had already implemented initiatives to correct the issues 

regarding delays in mammography services, cardiology consults, and scheduling 

colonoscopy procedures. We confirmed that the number of delays to schedule 

consultations and procedures for the three services decreased in the last quarter of fiscal 

year 2008. 

We recommended that the Veteran Integrated Service Network Director ensure that the 

Medical Center Director discusses the subject patient colonoscopy concern with Regional 

Counsel to determine whether this case meets disclosure requirements, and if it does, the 

disclosure is communicated and documented in accordance with VHA standards. The 

Regional Counsel reviewed this case and concluded that it did not meet disclosure 

requirements. Therefore, we consider this case closed. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

TO: Director, Veterans Integrated Service Network (10N16) 

SUBJECT: Healthcare Inspection – Mammography, Cardiology, and Colonoscopy 

Management, Jack C. Montgomery VA Medical Center, Muskogee, 

Oklahoma 

Purpose 

The VA Office of Inspector General (OIG), Office of Healthcare Inspections conducted 

an inspection at the request of Senator James M. Inhofe to determine the validity of 

allegations regarding delays in mammography services, cardiology consult responses, 

and scheduling colonoscopy procedures at the Jack C. Montgomery VA Medical Center 

(medical center), Muskogee, OK.

Background 

The medical center provides primary and secondary levels of inpatient medical and 

surgical care, and primary and consultative care at three community based outpatient 

clinics that include medicine, surgery, and mental health. The medical center provides 

services for more than 45,000 enrolled veterans and operates an outpatient clinic in Tulsa, 

OK. Additional services are provided by fee basis specialists. The medical center is part 

of Veterans Integrated Service Network (VISN) 16. 

A confidential complainant contacted the VA OIG Hotline Division with allegations 

regarding mammography services, cardiology consults, and scheduling colonoscopies. 

Specifically the complainant alleged that: 

In 2007, the medical center failed to achieve a timely diagnosis for 219 

male and female patients who had mammograms ordered through primary 

care services. Forty-four of the requests were for diagnostic purposes to 

follow up on known cancers or previous suspicious mammograms, and the 

remaining 175 were for screening purposes. Some patients waited 14 

months or longer for mammograms. Further, PCPs [primary care 

providers] are not notified when mammogram requests are canceled. The 

Acting Chief of Staff was aware of this but did not take action. 

VA Office of Inspector General 1 
Mammography, Cardiology, and Colonoscopy Management, Jack C. Montgomery VAMC, Muskogee, OK 

VA Office of Inspector General 2 

A cardiologist ended his employment at the medical center in March 2008, 

and management did not initiate a plan to address pending consults. The 

PCPs who ordered cardiology consults were unaware of the status of their 

requests. The complainant cited a case where a patient underwent a cardiac 

imaging test without being notified of the results and plans for follow up. 

Colonoscopy requests are associated with delays in scheduling. Some 

colonoscopies are performed at the medical center and others are fee based 

to the community. PCPs who order colonoscopies are not aware when or if 

the test is performed. The complainant again cited a case where a screening 

colonoscopy was ordered based on age criteria and never completed. The 

patient returned with symptoms a year later, a diagnostic colonoscopy was 

completed, and colon cancer was identified. 

Scope and Methodology 

On August 18, 2008, we conducted a telephone interview with the complainant. On 

September 22–25, we conducted a site visit and interviewed medical center management 

and staff involved with mammography, cardiology, and colonoscopy services. We 

reviewed patient referrals, medical records, policies, and other relevant documents. We 

conducted the inspection in accordance with Quality Standards for Inspections published 

by the President’s Council on Integrity and Efficiency.

Inspection Results 

Issue 1: Delays in Scheduling Screening and Diagnostic Mammograms 

We substantiated that in calendar year 2007 the medical center failed to provide timely 

mammography services for several patients who had mammograms requested by their 

PCPs. We could not substantiate or refute that PCPs were not notified when 

mammography requests were canceled. 

Veterans Health Administration (VHA) policy1

 requires that veterans with serviceconnected ratings of 50 percent or greater and veterans with less than 50 percent 

requiring care for service-connected disabilities be scheduled within 30 days of desired 

appointment dates. All other veterans must be scheduled for care within 120 days of the 

desired dates. The directive requires that requests for appointments be acted on by the 

medical facility staff as soon as possible, but no later than 7 calendar days from the date 

of request. To act on appointment requests means to schedule, complete, cancel, 

discontinue, or place the veteran on the Electronic Wait List (EWL). The EWL provides 

medical facilities with a standard tool to capture and track information about veterans 

 

1

 VHA Directive 2006-055, VHA Outpatient Scheduling Processes and Procedures, October 11, 2006. 
Mammography, Cardiology, and Colonoscopy Management, Jack C. Montgomery VAMC, Muskogee, OK 

waiting for medical appointments and procedure requests. The scheduling coordinator is 

responsible for maintaining the EWL. 

Medical center managers provided a list of 865 patients for whom PCPs had requested 

mammography studies in 2007. Of these 865 patients, 141 patients never had their 

requested mammograms. 

By March 2008, when the Chief of Medicine was made aware of a backlog for 

mammography studies, the backlog list contained 200 requests. By April, 140 of the 200 

patients were scheduled and received mammograms on a fee basis. The remaining 60 

mammogram requests were closed out because patients did not respond to efforts to 

schedule the tests, patients failed to report for the scheduled appointments, or the requests 

were duplicate orders. 

We could not substantiate or refute whether PCPs were notified regarding the status of 

mammogram requests. When consults are initiated, it is the receiving service’s 

responsibility to act on the consult and to document the actions taken. The requesting 

provider is to be alerted of these actions. The Veterans Health Information System & 

Technological Architecture (VistA) scheduling software can be set to automatically alert 

the requesting providers when any actions are taken on consults. During our interviews, 

providers told us that the alert function in the VistA software had been disabled due to the 

high volume of inappropriate orders. However, managers told us that the alerts were 

working and demonstrated the alerts while we were onsite. Due to conflicting 

statements, we were unable to determine whether or not the alerts were active during 

calendar year 2007. 

Issue 2: Pending Cardiology Consults 

We substantiated that the subject patient had not been contacted in a timely manner 

regarding results of cardiac imaging, cardiac catheterization, and an echocardiogram. We 

also substantiated that cardiology consult requests were not always scheduled within the 

required timeframes. We did not substantiate that managers did not appropriately plan 

for cardiology consults after the departure of a staff cardiologist. We could not 

substantiate or refute that PCPs were unaware of the status of consult requests. 

Case Study 

This is a patient in his late 40s with a history of dyslipidemia, hypertension, rheumatoid 

arthritis, and chest pain with exertion. The patient underwent a stress myocardial scan in 

mid-March 2008, indicative of positive multi-vessel myocardial ischemia (coronary 

artery disease). The PCP prescribed isosorbide mononitrate and nitroglycerin sublingual 

(under the tongue) for chest pain management. 

The following day, a Nuclear Imaging Service staff requested a cardiology consult for the 

patient. The request was placed on the EWL and was noted, “semi-urgent (within two 

VA Office of Inspector General 3 
Mammography, Cardiology, and Colonoscopy Management, Jack C. Montgomery VAMC, Muskogee, OK 

weeks).” Approximately 5 weeks later, the patient was seen by a rheumatologist who 

documented in the electronic medical record that the patient continued to experience 

chest pain with exertion. The rheumatologist also documented that the patient was not 

aware of his mid-March cardiac stress test results, and was waiting to see a cardiologist. 

That same day, the rheumatologist consulted with the Chief of Medicine about the case, 

and shortly thereafter, the Chief of Medicine instructed the PCP to contact the patient. 

The patient was notified to continue isosorbide mononitrate daily and wait for 

notification of a cardiology appointment. Later that day, the patient was notified that a 

heart catheterization had been scheduled for early May and the cardiology consult request 

had been canceled. 

In early May, the patient had a cardiac catheterization at the Oklahoma City VA Medical 

Center (VAMC). The test revealed a normal heart catheterization with borderline slow 

flow. Documentation in the electronic medical record shows that discharge instructions, 

including follow up with the PCP, were discussed with the patient. However, there is no 

indication that the results of the heart catheterization were discussed with the patient. 

In late August, the patient was seen by the PCP with complaints of chest pain without 

shortness of breath. The patient told the PCP that he had been non-compliant with his 

medication regime since April. The patient stated his chest pain increased with activity, 

but said he could walk half a mile without stopping. The treatment plan was to restart his 

current cardiac medications, add metoprolol to manage his blood pressure, add a daily 

‘baby’ aspirin, and he was given a return appointment. 

Two days later, an echocardiogram was performed that revealed no evidence of 

significant pericardial effusion. Comparison with a previous 2007 study indicated only 

minor changes. Documentation in the electronic medical record shows that the patient 

called the medical center in mid-September and asked about the results of the study 

which were then provided over the phone. 

Finding 

The patient was not told the results of his mid-March cardiac stress test until late April 

when he asked about the results during a clinic appointment. There is no indication in the 

medical record that the patient was ever given the results of his early May heart 

catheterization. Further, the patient was not aware of his late August echocardiogram 

results until mid-September when he called the medical center and requested the results. 

Between March and June 2008, the medical center had only one full-time cardiologist on 

staff. To manage the workload during that period, managers made arrangements to send 

complicated and urgent consult requests to the Oklahoma City VAMC. While some 

routine consult appointments were less timely (ranging from 30 to 120 days of the 

requests) during this period, cardiology service continued to provide all requested 

VA Office of Inspector General 4 
Mammography, Cardiology, and Colonoscopy Management, Jack C. Montgomery VAMC, Muskogee, OK 

VA Office of Inspector General 5 

services. In June managers hired a full-time contract cardiologist and are currently 

recruiting for full-time staff cardiologists. 

As discussed in Issue 1, due to conflicting statements regarding the VistA software alert 

function, we could not substantiate or refute whether PCPs were notified when cardiac 

consults were completed or canceled. 

Issue 3: Delays in Scheduling Colonoscopies 

We substantiated that a patient did not receive a requested age criteria screening 

colonoscopy, returned a year later with blood in his stool, and was diagnosed with cancer. 

We also substantiated excessive waiting times for requested colonoscopies. We could 

not substantiate or refute that the PCPs did not receive notification when colonoscopies 

were completed. 

Case Study 

This is a patient in his early 60s with a history of hypertension, depression, osteoarthritis, 

and a benign tumor of the salivary gland. In mid-September 2006, the patient presented 

to the clinic for a yearly follow up with a chief complaint of leg cramps after walking. 

The PCP requested a consult for a screening colonoscopy for age specific criteria. 

A year later, in mid-September 2007, the patient presented to the clinic with indigestion, 

melena (blood in the stool), and wrist pain. The PCP requested a diagnostic colonoscopy. 

A month later, in mid-October, the nurse educated the patient on the procedure and 

provided a colon cleansing kit with instructions. The procedure was scheduled for late 

December and later canceled by the clinic due to physician absence. In early January 

2008, the colonoscopy was completed with pathology results consistent with a grade II 

adenocarcinoma extending through the muscular wall into the overlying serosa (the outer 

lining). 

In early February 2008, the patient underwent a low anterior rectal resection with 

pathology results identifying 2 of 32 positive nodes for metastatic disease. He was 

discharged home on a week later. The patient completed radiation and chemotherapy 

regimens in September and a follow-up colonoscopy was requested in early November. 

Findings 

The patient never had the screening colonoscopy the PCP requested during a September 

2006 appointment. A year later, the patient complained of bloody stools during a clinic 

appointment. A diagnostic colonoscopy ordered in mid-September 2007, the day of the 

appointment, was scheduled for late December, more than 90 days after the request was 

submitted. VHA policy2

 states a veteran of any age with signs or symptoms must be 

 

2

 VHA Directive 2007-004, Colorectal Cancer Screening, January 12, 2007. 
Mammography, Cardiology, and Colonoscopy Management, Jack C. Montgomery VAMC, Muskogee, OK 

immediately offered an appropriate diagnostic evaluation. The directive also states a 

diagnostic colonoscopy must be performed within 60 calendar days of the request. 

We received a patient list of colonoscopies scheduled from August 2007 through August 

2008. Due to the large volume of data provided, we selected 3 months for our review. 

Of the 522 colonoscopies completed during that 3 month period, 287 were diagnostic and 

235 were for screening. We found 112 (39 percent) of 287 diagnostic colonoscopies 

were not completed within 60 days of the request as required. Of the screening 

colonoscopies, 71 (30 percent) of 235 were not completed within required timeframes. 

As discussed in Issue 1 and 2, due to conflicting statements regarding the VistA software 

alert function, we could not substantiate or refute whether PCPs were notified when 

colonoscopies were completed or canceled. 

Conclusions 

We determined that in 2007 patients did not consistently receive mammograms in a 

timely manner as required by VHA and local policy. 

We concluded that the subject cardiac patient had not been contacted regarding the 

results of his cardiac imaging, cardiac catheterization, and echocardiogram in a timely 

manner. We further concluded that cardiology consultation requests were not always 

scheduled within the required timeframe. 

We substantiated that the subject colonoscopy patient did not receive a screening 

colonoscopy as requested by the PCP and that a diagnostic colonoscopy, ordered one year 

later, was not scheduled within 60 days of the request. We concluded waiting times for 

scheduling colonoscopies was excessive. 

We could not substantiate or refute that PCPs were notified regarding the status of 

mammogram requests, cardiology consults, and colonoscopy appointments. 

Management Actions 

Management agreed there were delays in mammography services, cardiology consults, 

and scheduling colonoscopies. We were informed of initiatives that management had 

implemented, such as clearing the EWL for mammograms by fee basing to more 

providers and replacing the cardiologist with another full-time contract cardiologist in 

addition to recruiting for two more cardiologists. Further, they created a Performance 

Improvement Team to review and improve the colonoscopy ordering process. We 

confirmed during our site visit that the number of delays to schedule consultations and 

procedures for the three services decreased in the last quarter of FY 2008. 

VA Office of Inspector General 6 
Mammography, Cardiology, and Colonoscopy Management, Jack C. Montgomery VAMC, Muskogee, OK 

VA Office of Inspector General 7 

Recommendation: 

Recommendation. We recommended that the VISN Director ensure that the Medical 

Center Director discusses the patient case in issue 3 with Regional Counsel to determine 

whether it meets disclosure requirements, and if it does, the disclosure be communicated 

and documented in accordance with VHA and local policy.3

Comments 

The VISN and Medical Center Directors concurred with the finding and recommendation 

of this inspection and appropriate actions have to been taken. (See Appendixes A and B, 

pages 8−10, for the full text of the Directors’ comments.) We consider the 

recommendation closed. 

 (original signed by:)

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

Assistant Inspector General for 

Healthcare Inspections 

 

3

 VHA Directive 2008-002, Disclosure of Adverse Events to Patients, January 18, 2008. 
Mammography, Cardiology, and Colonoscopy Management, Jack C. Montgomery VAMC, Muskogee, OK 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 8 

Department of 

Veterans Affairs Memorandum

Date: January 8, 2009 

From: Director, Veterans Integrated Service Network (10N16) 

Subject: Mammography, Cardiology, and Colonoscopy 

Management, Jack C. Montgomery VAMC, Muskogee, 

OK 

To: Director, Dallas Office of Healthcare Inspections (54DA) 

 Director, Management Review Office (10B5) 

I have reviewed the report and concur with the response to the 

recommendation. 

(original signed by:) 

George H. Gray, Jr. 
Mammography, Cardiology, and Colonoscopy Management, Jack C. Montgomery VAMC, Muskogee, OK 

Appendix B 

Medical Center Director Comments 

VA Office of Inspector General 9 

Department of 

Veterans Affairs Memorandum

Date: January 8, 2009 

From: Director, Jack C. Montgomery VA Medical Center (623/00) 

Subject: Mammography, Cardiology, and Colonoscopy 

Management, Jack C. Montgomery VAMC, Muskogee, 

OK 

To: Director, Veterans Integrated Service Network (10N16) 

In response to the OIG Draft Report, the Jack C. Montgomery 

VA Medical Center concurs with the report. Response to the 

recommendation is also submitted. 

 

(original signed by:) 

Adam C. Walmus, 

 Medical Center Director 
Mammography, Cardiology, and Colonoscopy Management, Jack C. Montgomery VAMC, Muskogee, OK 

VA Office of Inspector General 10 

Director’s Comments 

to Office of Inspector General’s Report 

The following Director’s comments are submitted in response 

to the recommendation(s) in the Office of Inspector General’s 

report: 

OIG Recommendation(s)

Recommendation. We recommended that the VISN 

Director ensure that the Medical Center Director discusses the 

patient case in issue 3 with Regional Counsel to determine 

whether it meets disclosure requirements, and if it does, the 

disclosure be communicated and documented in accordance 

with VHA and local policy. 

Concur Target Completion Date: December 19, 2008 

Action taken: On 12/19/08 this review was completed by 

COS and Regional Counsel. They concluded: “This patient 

was screened appropriately for colorectal cancer by annual 

fecal occult blood testing from June 2002 through September 

2006. All tests were negative. The request for screening 

colonoscopy submitted in September, 2006 was not acted 

upon timely, but did not result in lack of screening. Regional 

counsel agrees that this does not meet criteria for either 

clinical or institutional disclosure.” Laboratory medical 

record documentation shows the patient was screened on 

06/02/02, 10/21/03, 10/8/04, 10/12/05, and 9/25/06. 

Recommend this recommendation be closed. 
Mammography, Cardiology, and Colonoscopy Management, Jack C. Montgomery VAMC, Muskogee, OK 

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Marilyn Walls, Healthcare Inspector 

Dallas Office of Healthcare Inspections 

(214) 253-3335 

Acknowledgments Shirley Carlile 

Wilma I. Reyes 

George Wesley, M.D. 

VA Office of Inspector General 11 
Mammography, Cardiology, and Colonoscopy Management, Jack C. Montgomery VAMC, Muskogee, OK

Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans Integrated Service Network (10N16) 

Director, Jack C. Montgomery VA Medical Center (623/00) 

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 

U.S. Senators: Tom Coburn, James M. Inhofe 

U.S. House of Representatives: Dan Boren, Tom Cole, Mary Fallin, Frank Lucas, John 

Sullivan 

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

VA Office of Inspector General 12