2 PATIENT-SAFETY RECOMMENDATIONS AT MARION VA: FACILITY SERVING ABOUT 42,300 VETERANS LACKED UPDATED TEST-RESULT POLICY
By VA Headlines staff - Published Nov 6, 2026 - Source dated November 6, 2026 (VA Office of Inspector General)
The VA Office of Inspector General (OIG) made 2 patient-safety recommendations after inspecting the VA Marion Healthcare System in Illinois from April 21 through 23, 2026. OIG found the facility did not have an updated policy for communicating test results, and leaders had not developed service-level workflows that designate the roles of providers and staff in communicating test results to patients, as required by VHA Directive 1088(1). The facility is rated medium complexity and, in fiscal year 2025, provided direct care to about 42,300 patients. OIG published report 26-00049-163 on November 6, 2026.
What OIG found
Policy not updated: OIG found an established process for communicating test results to providers and patients, but the facility policy had not been updated to match the directive.
No service-level workflows: Leaders had not developed written workflows describing staff roles in communicating test results to patients.
Missed chances to act: VHA published Directive 1088 on July 11, 2023, requiring a local policy and service-level workflows within 6 to 12 months. VHA amended it on September 20, 2024. OIG requested the facility's policies and workflows in March 2026.
Why it matters: OIG says outdated policies and missing workflows can lead to delayed or missed communication of abnormal test results and follow-up actions, which could compromise safety and quality of care.
Leaders' response: During interviews, the Chief of Staff and the Associate Director for Patient Care Services acknowledged the workflows were missing and said they would update their policy.
The two recommendations
Recommendation 1: The Director updates the facility policy for communicating test results in accordance with VHA Directive 1088(1).
Recommendation 2: The Chief of Staff and the Associate Director for Patient Care Services develop service-level written workflows in accordance with VHA Directive 1088(1).
The VISN Director and facility Director concurred with both recommendations and provided action plans with a target completion date of February 28, 2027. OIG says it will follow up on the planned actions until they are completed.
The other four areas
OIG made no recommendations in the other four areas it reviewed: culture, environment of care, integrated veteran care, and the veteran-centered safety net. This is a facility-level finding; the report does not allege wrongdoing by any individual employee.
Related: Middleton VA (Madison, WI) inspection: test-result communication policy and workflows cited. Big Spring VA: how often patients were told of abnormal PSA results on time. Department of Veterans Affairs (VA) News. More: all VA Headlines reports. How we report: Methodology & Corrections.
Healthcare Facility Inspection of the VA Marion Healthcare System in Illinois - Report 26-00049-163, November 6, 2026
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