On November 6, 2026, the VA’s Office of the Inspector General released another report on the Marion VA Healthcare System in Illinois. In 2025, the Marion VA hospital system cares for over 42,000 patients drawing from southern Illinois, southwestern Indiana, and northwestern Kentucky. It has a budget of over $363 million annually.
As part of this inspection, the IG reviewed patient safety concerns at the VA. Similar to previous reports concerning VA facilities noted by National Trial Law in Illinois, the VA Inspector General found that the policies for communicating test results to patients “had not been updated, and leaders did not develop service-level workflows that describe staff’s roles in communicating test results to patients” as required by VA policy.
Are other VAs missing policies to make sure their patients get test results?
National Trial Law has noted previous instances in Illinois, but there are also similar problems discovered at a Georgia VA and a Virginia VA system. As noted by the Inspector General, systemic problems like this can compromise patient safety. Notably, the IG report stated: “Outdated policies and lack of service-level workflows can result in delayed or missed communication of abnormal test results and follow-up actions, which could compromise safety and the quality of care provided to veterans.”
What is a VA workflow and how does it impact patient safety?
A workflow is a part of the system of checks that makes sure that someone has responsibility for communicating important information to patients. Without a workflow, no one has primary responsibility for communicating test results to patients. So, if the patient’s PCP or family doctor happens to find the test results and communicate those results to the patient, then there may be no harm done. But a robust hospital system that is looking out for the safety of its patients does not rely on luck to make sure veterans know their health. Instead, the VA should develop processes (sometimes called workflows) to make sure that test results are timely delivered each time to vets and their families.