CEO SUMMARY: Last year, Veterans Administration officials received an anonymous complaint about delays in laboratory specimen processing and results at the Memphis VA Medical Center may have harmed patients and led to a patient death. Following an investigation, the VA’s Office of Inspector General issued a report last month. It determined that a staff shortage contributed to the delays and that only 62% of the full-time positions authorized for the pathology lab were filled.
A VETERANS ADMINISTRATION REPORT showed delays of as long as 120 days or more in the processing of histology tissue specimens in the Pathology and Laboratory Medicine Service (PLMS) at the Memphis VA Medical Center.
Late last month, the federal Veterans Administration’s Office of Inspector General (OIG) found that the PLMS was responsible for delays in laboratory specimen processing which affected 123 cases. However, after assessing the electronic health records of 136 patients, the report found no evidence of patient harm.
10-Day TAT in 2017
Turnaround times in the pathology laboratory were as long as 10 to 12 days in January and February of 2017. This was far from the facility’s goal of two-day turnaround for surgical pathology cases.
The delays resulted from severe staffing shortages among pathologists, histotechs, medical technicians, and other positions, and that the service had almost two vacant positions (1.8 full-time equivalents) for pathologists during the period under review. There were also deficiencies in the PLMS’ quality management and surgical pathology quality assessment.
The OIG team could not confirm a consistent process was in place for quality management. In addition, documentation was missing for initial employee orientation, six-month competency assessments, and annual competency reviews.
The OIG concluded that a shortage of staff was a contributing factor. This development follows closely after a peer-reviewed medical journal published a study that showed the number of pathologists in the United States had declined by 17.5% from 2007 through 2017. (See “JAMA Study: 17% Fewer Pathologists in U.S. Since 2007,” TDR, June 10, 2019.)
The OIG’s report is remarkably understated in its assessment of the problems in the PLMS. In several places, for example, the report showed that the PLMS could not produce reports the OIG needed to assess reasons for the pathology lab’s delays.
The report’s conclusion showed that, for example, “facility leaders were unable to produce evidence that processes to prevent delays had been incorporated into a PLMS policy.”
It also included this statement: “Because the OIG team could not verify the methodology used to identify patients affected by surgical pathology processing delays, the OIG was unable to determine if facility leaders completed a comprehensive assessment of the processing delays and any impact on affected patients.”
Staff shortage was one reason for the delays. When the OIG team visited the Memphis VA in November 2018, the PLMS was approved to have almost 80 (79.8 full-time equivalent) employees. But at the time, PLMS had almost 30 (29.8) vacant full-time positions. To fill the gap, PLMS used contract employees for frontline staff positions, including medical technicians and histopathologists, the chief of staff said.
38% Vacancy Rate
Of the 30 full-time positions vacant in October 2018, the PLMS staff at the Memphis VA Medical Center was short 1.8 pathologists, 10 medical technicians, eight medical technologists, two lead medical technicians, and two transcription program assistants—some of the most important staff in a pathology lab.
Also, there was one vacancy in each of the following positions: pathologist specialist, program assistant, lab information manager, supervisory medical technician, supervisory histopathology technician, and histopathology technician.
It’s no surprise then that the OIG found that inadequate staffing affected the ability of the PLMS to deliver specimens for processing in a timely manner. The pathology laboratory at the Memphis VA was operating with just 62% of the authorized and budgeted staff positions.
The report concluded by saying that in January and February 2017, surgical pathology processing delays were attributed to a transcription software issue, shortages of facility pathologists, and relying on pathology residents from the University of Tennessee for initial processing of tissue specimens.
The report also concluded that while PLMS staff improved TAT for surgical pathology specimens done onsite, the laboratory’s leaders were unable to show that that processes to prevent delays had been implemented.
An Anonymous Complaint
Last year, the VA OIG got an anonymous complaint alleging that the previous chief of the PLMS service at the Memphis VA was responsible for delays in laboratory specimen processing that resulted in patient harm and possibly death due to delayed reporting of pathology results.
For the report issued last month, the OIG said it reviewed the electronic health records of 136 patients and found no adverse clinical outcomes from the delays in processing pathology specimens. The OIG did, however, recommend eight steps the lab and pathology service could implement to improve operations.
To assess the timeliness of specimen TAT, the OIG team reviewed surgical pathology reports for the period from January 2017 through September 2018 and found that the facility decreased TAT in that time from 10 days in January 2017 and 12 days in February 2017 to two delays from March through September 2018.
Inadequate Lab Staffing
Although OIG investigators did not uncover an example of patient harm attributable to specimen processing delays, the report did not comment on the consequences of the lab’s staffing shortage. Most experienced pathologists and clinical lab administrators know that, with just 62% of authorized staff positions filled, there is the potential for many essential tasks to either not be performed, or to be performed poorly. They would assess the inadequate staffing at this lab site to be a risk factor that could contribute to patient harm in the future.