VA OIG releases report on Montana VA consult delays - Montana VA Health Care System
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Montana VA Health Care System

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VA OIG releases report on Montana VA consult delays

March 13, 2017


Media contact(s): Mike Garcia, Public Affairs Officer,, 406-447-7303

Fort Harrison, Mont. - On March 10, 2017, the VA Office of the Inspector General (OIG) published a report regarding consult delays and management concerns at the Fort Harrison VA Medical Center.

The scope of this report focused exclusively on a backlog of system consults from June 2014 to July 2015 and found no evidence of willful wrongdoing or negligence.

Prior to June 2014, a severe lack of specialty care in rural Montana required an inordinate number of Veterans to be seen for specialty care by community providers through non-VA care. This was a relatively new effort without the appropriate infrastructure, prior to implementation, to monitor and manage. 

The varied requirements and rapid implementation of Choice in late 2014 and into 2015 further exacerbated consult tracking and contributed to this growing backlog.  The Montana VA leadership team at that time was made aware of these issues and began working continually with staff and local stakeholders to make immediate and long-term improvements. 

The report did find that delays in more than 25,000 consults during the time period covered may have resulted in the harm of as many as four patients. In September 2016, system leadership provided an institutional disclosure for one of these patients. More than 99.98 percent of the delayed consults were determined to not have had any adverse effect for the Veterans involved. 

A review of the three remaining cases cited in the OIG report was conducted internally by Montana VA staff. However, all three have been referred to an external, non-VA source for an independent review pursuant to the recommendations of this OIG report.

Should evidence of patient harm be found, these will be referred to the Office of Chief Counsel for institutional disclosure, as appropriate. 

Medical reviews are a standard practice among all healthcare organizations. It is a medical and technical review of all circumstances related to a patient’s care and what, if any, of those contributed to suspected or alleged harm. These reviews are conducted within national parameters as well as any additional requirements unique to that healthcare organization.

 “I have reviewed the OIG’s findings and recommendations and concur with all of them,” said Dr. Kathy Berger, permanent director of the Montana VA Health Care System since Dec. 2016. “We have a long-standing commitment to make certain timely care is provided to our Veterans and we will continue to make constant improvements to the delivery of that care.” 

Berger said the OIG report recognized several ongoing efforts by Montana VA staff since July 2015 to identify and address consult delays as well as proactively identify any potential for patient harm. 

Since July 2015, over a dozen initiatives have been implemented successfully at the Montana VA to improve consult timeliness and adequately address factors that contribute to delays. This has included realignment of staff & supervisors with a focus on a balance of administrative and clinical specialists, relevant training, and regular reporting to senior managers.