Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah.

Book/Report

Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah.

August 25, 2021

Washington, DC: Department of Veterans Affairs, Office of Inspector General. July 29, 2021. Report No. 21-00657-197.

Care coordination effectiveness is tested by time, hierarchy, and practice silos. This report examines allegations affecting medication access enabled by poor communication, workforce absences, and the built environment challenges. While care coordination challenges in this case were unsubstantiated, the report highlights lack of clinical review and inaccurate analysis of patient death as concerns.

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