D.7 Standard Operating Procedure 1234-08 - Incomplete Exam Management.pdf

STANDARD OPERATING PROCEDURE

INCOMPLETE EXAM MANAGEMENT

SOP 1234-08

Signatory Authority:

Executive Director, National Radiology Program

Responsible Owner:

Executive Director, National Radiology Program

Effective Date:

July 25, 2023

Recertification Date:

July 25, 2028

1. PURPOSE AND AUTHORITY

a. The purpose of this standard operating procedure (SOP) is to establish procedures for managing incomplete exams in the VistA Radiology Package. Unread exams on the Incomplete Exam Report may cause delays in care and have the potential to harm Veterans; they need to be managed. The goal is to interpret at least 90 percent of exams within 48 hours and 100% of exams within 72 hours. This SOP must be followed by VA medical facility employees who are assigned this function.

b. This SOP sets forth mandatory procedures and processes to ensure compliance with VHA Directive 1234, Radiology Outpatient Scheduling and Orders Management, dated July 25, 2023

2. PROCEDURES

(1) VistA Radiology Package Incomplete Exam Report. At a minimum, this report must be run every business day for the time period of January 1, 2009, to the current date minus 1 day.

(a) All exams on the report will be reviewed to determine the appropriate disposition. When there are many incomplete exams, the process for reviewing is in reverse chronological order; that is, start the review with the oldest and work to the most recent exams. Exams on this report may include but are not limited to:

1. Unread exams that need to be interpreted and reported.

2. Registered exams with no associated images that need to be cancelled or rescheduled.

3. Registered exams with images and no report performed by non-Radiology providers (i.e. OR fluoroscopy exams, speech pathology exams).

July 25, 2023 SOP 1234-08

4. Interpreted exams with reports that did not go to the ‘Complete’ status due to ‘case editing’ or other technical issues.

5. Community care exams inappropriately registered prior to receiving images.

6. Exams with preliminary reports that were not verified by a radiologist.

7. Exams with or without images (Parent/Descendant exams) that need to be linked/associated with a finalized report.

(b) All unread exams with a registration date/accession number on or after January 1, 2009, and with associated images in electronic format (VistA Imaging or Picture Archiving Communication System (PACS)) must be interpreted with a final report. This includes any exams in draft, problem draft, released/not verified, transcribed, and other preliminary report statuses, all of which must be interpreted with finalized reports.

(c) Any incidents of harm or potential harm resulting from a delay in care related to the management of incomplete/unread exams will be reported to the facility Quality Manager (or appropriate leadership representative) to determine whether Clinical Disclosure or Institutional Disclosure is appropriate. These incidents should be locally tracked and reported through submission of an Issue Brief as determined by facility leadership.

3. ASSIGNMENT OF RESPONSIBILITIES

Refer to VHA Directive 1234 – Radiology Outpatient Scheduling and Orders Management.

4. DEFINITIONS

Incomplete Exam Report. The Incomplete Exam Report is a VistA Radiology Package option [INCOMPLETE EXAM REPORT] that generates a list of all registered exams that are not in the ‘Completed’ or ‘Canceled’ status.

5. REFERENCES

a. VHA Directive 1234, Radiology Outpatient Scheduling and Orders Management.

b. VHA Directive, 1004.08, Disclosure of Adverse Events to Patients.

c. VHA Radiology and Mammography SharePoint site, National Radiology Program (NRP) - VHA Directive 1234 SOP Directory - All Documents (sharepoint.com). NOTE:

This is an internal VA Web site that is not available to the public.

d. VA internal Web site VA Software Document Library Radiology/Nuclear Medicine User Manual https://www.va.gov/vdl/documents/Clinical/Radiology_Nuclear_Med/ra5_0um.pdf https://dvagov.sharepoint.com/sites/VHADiagnosticservices/NRP2/Scheduling%20Guidance/Forms/AllItems.aspx?id=%2Fsites%2FVHADiagnosticservices%2FNRP2%2FScheduling%20Guidance%2FVHA%20Directive%201234%20SOP%20Directory&viewid=39dee479%2D5d49%2D42d9%2D94ec%2D2ae372ee2243 https://dvagov.sharepoint.com/sites/VHADiagnosticservices/NRP2/Scheduling%20Guidance/Forms/AllItems.aspx?id=%2Fsites%2FVHADiagnosticservices%2FNRP2%2FScheduling%20Guidance%2FVHA%20Directive%201234%20SOP%20Directory&viewid=39dee479%2D5d49%2D42d9%2D94ec%2D2ae372ee2243 https://www.va.gov/vdl/documents/Clinical/Radiology_Nuclear_Med/ra5_0um.pdf

July 25, 2023 SOP 1234-08

6. REVIEW

This SOP must be reviewed, at a minimum annually, at recertification, when there are changes to the governing document and any regulatory requirement for more frequent review.

7. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of July 25, 2028. In the event of contradiction with national policy, the national policy supersedes and controls.

8. SIGNATORY AUTHORITY The signatory authority includes all affected service line chiefs.

Patrick C. Malloy, M.D.

Executive Director, National Radiology Program Date Approved:

DISTRIBUTION: Emailed to the VISN Directors, VISN Chief Medical Officers, VHA Group Practice Managers, VISN Diagnostics ICC Clinical Leads, VISN Diagnostics HSSs, VISN Lead Radiologists, Radiology Chiefs, Radiology Chief Technologists and Administrative Officers, VHA Radiology Supervisory Managers, Nuclear Medicine Service Chiefs, Nuclear Medicine Supervisors email distribution lists. SOPs are available at: National Radiology Program (NRP) - VHA Directive 1234 SOP Directory - All Documents (sharepoint.com) NOTE: This is an internal VA Web site that is not available to the public.

https://dvagov.sharepoint.com/sites/VHADiagnosticservices/NRP2/Scheduling%20Guidance/Forms/AllItems.aspx?id=%2Fsites%2FVHADiagnosticservices%2FNRP2%2FScheduling%20Guidance%2FVHA%20Directive%201234%20SOP%20Directory&viewid=39dee479%2D5d49%2D42d9%2D94ec%2D2ae372ee2243 https://dvagov.sharepoint.com/sites/VHADiagnosticservices/NRP2/Scheduling%20Guidance/Forms/AllItems.aspx?id=%2Fsites%2FVHADiagnosticservices%2FNRP2%2FScheduling%20Guidance%2FVHA%20Directive%201234%20SOP%20Directory&viewid=39dee479%2D5d49%2D42d9%2D94ec%2D2ae372ee2243