Long Beach-VA, VAOIG Documents Poor Quality of Care in Radiation Therapy

We substantiated the allegation of poor care for 1 of the 10 patients reported and identified medical record documentation deficiencies for 9 of the 10 patients. We also substantiated that facility leaders were not aware of adverse patient outcomes in RT and found that action was not taken to correct deficiencies identified in peer reviews.

VAOIG Report atHealthcare Inspection Alleged Poor Quality of Care in Radiation Therapy VA Long Beach Healthcare System, Long Beach, California

Report Number 10-03861-119, 3/9/2011 | Full Report (PDF)

The VA Office of Inspector General conducted an inspection to determine the validity of allegations regarding radiation therapy (RT) at the VA Long Beach Healthcare System (the facility) in Long Beach, CA. Allegations included inappropriate care, lack of competence of radiation oncologists, lack of communication with facility leadership, and a hostile work environment. We substantiated the allegation of poor care for 1 of the 10 patients reported and identified medical record documentation deficiencies for 9 of the 10 patients. We also substantiated that facility leaders were not aware of adverse patient outcomes in RT and found that action was not taken to correct deficiencies identified in peer reviews. We did not substantiate the allegation that radiation oncologists lacked competence and did not address the allegation of a hostile work environment in this report. We recommended that the facility Director (1) ensures that an external peer review assessment of the treatment provided by radiation oncologists for Patient 1 is performed; (2) evaluates the care of Patient 1 with Regional Counsel for possible disclosure to the patient; (3) ensures that RT medical record documentation complies with VHA policy and ACR guidelines; and (4) ensures that RT patient outcomes are monitored by the Quality Management program and others external to the RT department to oversee the implementation of corrective actions for all adverse patient outcomes.