A Year to Write a Policy
On July 11, 2023, the Veterans Health Administration reissued Directive 1088(1), its national rule for getting test results to the providers who order them and then to the patients they belong to. Results that require action must reach the patient within seven days. Results that do not must reach the patient within fourteen. The original text also did something bureaucracies rarely do, which is hand out a grace period. Every medical center had six to twelve months to write a local policy and service-level workflows, meaning written documents that say who on each team does what.
The rule is not decorative. The directive’s own background section concedes that delayed follow-up of abnormal results has contributed to poor outcomes. The VA inspector general has documented what that looks like, in a review of a patient whose abnormal results were not acted on or communicated, where the OIG also noted that VHA’s electronic health record has no process to ensure results are communicated and acted upon. The clock on the fix started in July 2023. It was supposed to stop by July 2024 at the latest.
Policy by Inspection
The Central Virginia VA Health Care System in Richmond treats about 92,000 veterans a year on a medical care budget of roughly $1.4 billion, according to the inspector general’s new report. Inspectors visited April 22 through 24, 2025, nine months after the outer edge of the deadline window had closed. Leaders did not update the local policy until April 2025, and staff acknowledged they did so only after learning the OIG would review it. The chief of quality management said the facility knew it needed a policy and offered no reason for the delay.
The policy they produced did not meet the directive. It said nothing about abnormal results that may be life-changing, such as a test suggestive of cancer, for patients at high risk for suicide, and it lacked written workflows for each service. The directive treats the first omission as serious. It says some veterans may be at increased risk of suicide after receiving such news, and it requires the ordering provider to coordinate the conversation with mental health staff, leaving the modality and timeline to the facility’s own policy. No policy means no defined process, and no defined process means the national rule has nothing local to attach to.
The directive itself notes that patients can see results in online portals in fewer than seven days, which means the clinician’s phone call and the patient’s screen may not arrive in the order anyone planned. For a veteran at high risk, the order matters.
Nor can anyone plead that the requirement was new. The suicide-risk provisions and the workflow requirement are in the July 2023 original, and the September 2024 amendment added only a sentence about alert recipients and a definition of the term service-level workflow.
The OIG asked again in June 2026. The Chief of Staff supplied a copy, and the OIG found it still did not meet the directive. A revision signed on September 1, 2026 was enough for the OIG to close the first recommendation before publication, more than two years after the far end of the window.
Concurrence Is Not Closure
Both recommendations drew the same response, which was agreement. The facility director and the health service area director concurred. The first recommendation, updating the policy to cover patients at high risk for suicide, is closed. The second, developing workflows that describe each team member’s role, remains open, with a target completion date of September 30, 2026, the same day the report was published.
The facility’s answer on workflows is that a single standardized workflow will serve every service line, and that the Richmond On-Call system is now the principal pathway for notifying staff of test results. The health service area director’s memo, dated September 15, goes further and asks that both recommendations be closed, declaring the policy actions fully implemented. The inspector general declined, and says it is keeping the second open until leaders submit supporting documents. The directive requires workflows for each unit of service, though it also lets services adapt them from one another. Whether one workflow for everyone is the adaptation or the shortcut is a question the report does not answer.
To be fair, the facility was not watching nothing. Quality management told inspectors it reviews national external peer review measures on test-result communication quarterly and, beginning in January 2025, pulled 50 additional laboratory and radiology records a month to check. The OIG found no test-result communication issues in the oversight and accreditation reports of the prior three years. The gap the OIG documented is in the paperwork that assigns responsibility, and the report does not claim that results went missing.
Workflows matter most where teams are thin. The directive names medical support assistants among the team members whose roles a workflow should define. The OIG reports that those positions at Richmond have a high turnover rate, and that as of June 2026 the facility still relied on contracted staff to cover patient scheduling. A document that assigns a role to a seat is only as good as the person in it.
Then there is the matter of who answers for it. The report notes that the facility’s most tenured leader was the director, in place since March 2019. VA’s own profile dates J. Ronald Johnson’s appointment to that month, and he was still quoted as director in a May 2026 news release. VA’s Atlanta page says he was named interim head of that system in August 2026. The September 4 response to the OIG was signed by James W. Dudley Jr. as acting executive director. The director who presided over the delay was not the one who answered for it.
One Facility or the Whole Fleet
Richmond is not obviously alone. An August 2026 OIG inspection of the Mountain Home system in Tennessee cited the same directive, finding the facility fell short because it lacked service-level workflows, and made a recommendation. When inspectors visited VA Central Western Massachusetts in July 2024, by contrast, leaders were still developing local policies and were within the time frame VHA had allowed. The window was open, then it closed, and inspections are how anyone finds out who climbed through it in time.
Nothing in the published inspection reports tells the public when each facility adopted its policy, so the inspection cycle, which the OIG describes as roughly three years per facility, is the only window. A rule that depends on an inspector’s arrival to be obeyed is less a directive than a suggestion with a calendar. The open question is how many other medical centers wrote theirs when the inspectors’ schedule did.
The second recommendation is the one to watch. If the inspector general closes it on a single workflow for every service line, that becomes the model. If it does not, Richmond has more paperwork ahead.
