GAO

United States General Accounting Office

Report to the Ranking Democratic

Member, Committee on Veterans’ Affairs,

House of Representatives

May 2000 VETERANS’ HEALTH

CARE

VA Needs Better Data

on Extent and Causes

of Waiting Times

GAO/HEHS-00-90

Page 1 GAO/HEHS-00-90 VA Waiting Times

Contents

Letter 3

Appendixes Appendix I: Scope and Methodology 20

Appendix II: Comments From the Department of Veterans Affairs 21

Appendix III: Staff Acknowledgments 24

Tables Table 1: Comparison of Scheduling Clerk Data and VISTA Data on

Number of Days Patients Wait for an Appointment at

Syracuse VA Medical Center Clinics, October 1999 10

Table 2: Clinics Chosen by VA Teams Participating in the IHI Project 13

Table 3: VA’s Proposed Initiatives and Funds Requested to Help

Achieve Its 30-30-20 Timeliness Goals 15

Abbreviations

IHI Institute for Healthcare Improvement

VA Department of Veterans Affairs

VISN Veterans Integrated Service Network

VISTA Veterans Health Information Systems and Technology

Architecture
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United States General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

B-284876 Letr

May 31, 2000

The Honorable Lane Evans

Ranking Democratic Member

Committee on Veterans’ Affairs

House of Representatives

Dear Congressman Evans:

Information on how long veterans must wait for outpatient health care—

and the locations and clinics where veterans must wait the longest—has

been largely anecdotal. While officials from the Department of Veterans

Affairs (VA) and representatives from veteran service organizations believe

these waiting times are often too long, VA lacks national data on the

number of days veterans must wait to get outpatient appointments at VA

health care facilities, as we have previously reported.1 Nonetheless, data

gathered by one facility show that, in January 2000, veterans at the facility

had to wait as many as 118 days to see an ophthalmologist. Similarly, a

representative from one veteran service organization reported that, in May

1999, patients were waiting over 190 days for an appointment in another

facility’s cardiology clinic. Concerned about such reports of waiting time

problems, you asked us to describe the initiatives VA has under way to (1)

improve its waiting time data and (2) address its waiting time problems.

Results in Brief Although VA has begun to collect data systematically on waiting times for

outpatient care, it has yet to develop reliable national waiting time data.

Over the past 10 months, VA has initiated two separate efforts for gathering

comprehensive outpatient waiting time data from its facilities. The first

effort, initiated in June 1999, produced data that were incomplete and

inaccurate, in part because of the differences in facilities’ scheduling of

appointments. VA’s second effort, initiated in December 1999, was designed

to improve the data’s reliability by measuring the average time taken to

schedule an appointment for an entire month. VA officials believe and we

agree that the new method is significantly better and should provide VA

1

See VA Health Care: Progress and Challenges in Providing Care to Veterans (GAO/T-HEHS99-158, July 15, 1999).
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with more complete and accurate data. To ensure this, however, VA will

need to overcome some problems identified during implementation, such

as inaccurate appointment codes being entered into the system.

In addition to taking steps to improve its waiting time data, VA has initiated

actions to reduce the time veterans must wait for outpatient appointments.

First, VA hired a private contractor to develop and implement techniques to

reduce waiting times at selected clinics in VA facilities nationwide. In

addition, VA plans to spend $400 million in fiscal year 2001 to make

improvements in the timeliness of service, patient access to telephone care,

and timely access to clinical information. However, VA’s lack of reliable

national waiting time data raises concerns about whether VA has an

adequate basis upon which to design these initiatives. Specifically, without

accurate data on the extent of waiting time problems and analyses of the

causes of long waits, VA cannot assess whether its proposed expenditures

would reduce waiting times or determine how best to allocate funds to

reduce waiting times. Further, without reliable baseline waiting time data

and a mechanism to track the funds used to improve timeliness of care, VA

will not be able to objectively measure whether these funds have actually

resulted in reduced waiting times. We recommended that VA take actions

to identify the extent and causes of waiting time problems and to monitor

and track expenditures for addressing these problems. VA agreed with our

recommendations.

Background VA operates one of the nation’s largest health care systems, providing

services in over 600 patient care facilities in all 50 states, Guam, and Puerto

Rico. These facilities include 172 medical centers as well as numerous

community-based outpatient clinics and domiciliaries.2 Twenty-two

regional Veterans Integrated Service Networks (VISN) manage the facilities

and serve as the basic budgetary and decisionmaking units for determining

how best to provide services to veterans within their geographic

boundaries. Over the past several years, VA has begun to adopt managed

care practices, treating more of its patients in outpatient settings and

reducing its heavy reliance on inpatient care. VA reports that, during fiscal

year 1999, it provided care to about 3.5 million veterans, resulting in almost

38 million outpatient visits.

2

Domiciliaries are residential rehabilitation and health maintenance centers for veterans

who do not require hospital or nursing home care but are unable to live independently

because of medical or psychiatric disabilities.
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To serve veterans appropriately, the Veterans’ Health Care Eligibility

Reform Act of 1996 required VA to ensure that veterans enrolled in VA’s

health care system receive timely care. For outpatient care, VA’s goals are

that patients (1) receive an initial, nonurgent3 appointments with their

primary care or other appropriate provider within 30 days of requesting

one; (2) receive specialty appointments within 30 days when referred by a

primary care provider; and (3) be seen within 20 minutes of their scheduled

appointments.4 VA refers to these goals as the “30-30-20” goals.

To schedule outpatient appointments, VA relies on the Veterans Health

Information Systems and Technology Architecture (VISTA). VISTA

automates major clinical, management, and administrative functions and

includes a scheduling component. The scheduling component has been

upgraded several times since VA developed it about 2 decades.

VA Does Not Have

Reliable Systemwide

Waiting Time Data

In June 1999, VA began for the first time—in response to a congressional

request for information on outpatient waiting times—to systematically

collect data on the length of time veterans must wait for outpatient health

care appointments.5 According to VA officials, collecting these data

required software modifications to VISTA’s appointment-scheduling

component because the system was not designed to collect information on

waiting times. However, because VA clinics used this scheduling

component in varying and often inconsistent ways, the data generated from

the first data collection effort were not comparable from facility to facility.

In an effort to address this problem, VA implemented in December 1999 a

new data collection method that it plans to use to evaluate VISN directors’

performance in improving waiting times, beginning in September 2000.

Although VA officials told us they believe the new method is a better one,

implementation problems—such as inaccurate appointment types being

entered into the system—could reduce data reliability.

3

VA’s timeliness standard for urgent care requires that veterans have access to such care 24

hours a day.

4

For purposes of this review, we focused on how long it takes veterans to obtain a scheduled

appointment for outpatient health care, not the length of time spent in the waiting room to

see a provider.

5

According to an official from VA’s Office of Primary and Ambulatory Care, from 1993 to

1998, VA required facilities to self-report waiting time data for several specialty clinics.

However, VA recognized that self-reported data were not reliable and that such data did not

capture waiting time information on a national basis.
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Initial Data Collection Effort

Produced Unreliable Data

In its first attempt to collect outpatient waiting time information, VA

designed a software program to extract data from VISTA’s appointmentscheduling component once a month at every VA outpatient clinic

nationwide. The program, run on the last day of each month, determined

for each clinic the number of days veterans had to wait for a scheduled

primary care appointment from that 1 day. For primary care appointments,

the third available appointment was used because, according to VA, the

first and second appointments are often held open for urgent care and

would not be given to veterans calling for routine care. Waiting times for all

clinics of the same type—such as orthopedics or primary care—were then

averaged within a facility. For example, if a facility had 10 primary care

clinics, the number of days to the third available appointment for each

clinic was gathered, summed, and the total divided by 10 to establish the

facility average waiting time for primary care appointments.

However, clinics varied in how they used the appointment-scheduling

component, and data generated for the third available appointment could

not be aggregated to obtain an overall picture of waiting times. Several

other problems with this first data collection effort resulted in VA not being

able to determine whether waiting times in a given clinic were understated

or overstated.

• Some clinics showed a higher number of available appointment slots

than could actually be staffed and relied on the scheduling clerks to

know which slots were available and which slots should not be filled—a

distinction the software program could not make. Therefore, by

averaging “available” slots, the software program probably understated

the time a veteran would wait for an appointment.

• Conversely, some clinics scheduled more patients than the number of

appointment slots shown in the scheduling component—perhaps to

account for patients who fail to appear for their appointments or

because the number of appointment slots shown were fewer than the

number of patients that the clinic could actually accommodate during

that time. In such cases, the software program probably overstated

waiting times.

• Finally, the software program only extracted information on clinic

availability on the last day of the month for which it was run. Because of

day-to-day variations in scheduling, the data collected for that 1 day

might not have been representative of general clinic availability on the

other days of the month.
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We attempted to validate VISTA’s automated data by comparing it with data

collected manually at one location in VISN 2—Syracuse, New York. To

measure adherence to VA’s 30-day waiting time standard, scheduling clerks

at facilities in VISN 2 check appointment availability for 1 day during the

second week of every month, counting the number of days to the third

available appointment using VISTA scheduling package information.

Although this technique parallels that used by VA’s software program, the

manual collection of waiting time data allows clerks in VISN 2 facilities to

identify nuances associated with a particular location or clinic. For

example, one doctor out of several in a clinic may not be accepting new

patients, so when a new patient asks for an appointment, the clerk would

not check that doctor’s availability for appointments but instead would

check the availability of others. In this situation, VISTA’s count of available

appointments would be overstated because it would count all doctors.

Comparing data from both approaches for 12 clinics located at the

Syracuse VA medical center, we noted large differences between waiting

time data reported by clerks and data extracted from VISTA. For five

clinics, clerks reported waiting times ranging from 17 to 56 days shorter

than the computer-extracted data; for seven clinics, waiting times reported

by clerks ranged from 2 to 47 days longer. Waiting times were closest for

neurology and farthest apart for orthopedics and cardiology (see table 1).
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Table 1: Comparison of Scheduling Clerk Data and VISTA Data on Number of Days Patients Wait for an Appointment at Syracuse

VA Medical Center Clinics, October 1999

Some variations may be attributable to the data’s being collected on

different days in October. However, even in the unlikely event that all

variations could be attributed to different collection days, the variations

still serve to illustrate the problems inherent in collecting data for only 1

day of the month.

Second Data Collection

Effort Designed to

Overcome Earlier Problems

Recognizing the shortcomings of its initial data collection effort, VA

introduced in December 1999 a new method of collecting data on

outpatient appointment waiting times. While this new method also uses

information from the VISTA scheduling package, it measures the average

number of days between the date that an appointment was requested and

the scheduled date of the appointment. These data are collected on a

monthly basis for every patient, not just for 1 day. VA most recently

extracted data on the average time from request to appointment for the

entire month of April 2000. VA now has 4 months of data to monitor waiting

times for the next available appointment—January, February, March, and

April—since the new software program was initiated in December 1999.

The amount of time between the day an appointment was requested and

the date for which it was scheduled is then summed for all patients and a

per-patient average is calculated. This calculation is performed once a

Clinic

Days as reported by

clerks

Days as extracted by software

program

Difference in days

reported

Cardiology 10 66 -56

Ear, nose, and throat 47 69 -22

Gastroenterology 3 30 -27

General surgery 56 22 +34

Gynecology 38 10 +28

Neurology 15 13 +2

Ophthalmology 70 41 +29

Optometry 99 61 +38

Orthopedics 81 34 +47

Podiatry 37 54 -17

Primary care 5 36 -31

Urology 44 29 +15
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month for all clinics within each VA facility, then summed for all clinics of

the same type in each facility. By examining only actual scheduled

appointments, the new method is designed to overcome the problems

posed by the variations in clinic scheduling practices. Similarly, obtaining

data on all appointments scheduled in a month provides VA with complete

information.

This second approach also takes into account the possibility that patients

may not want or need the next available appointment. For example, some

patients may schedule a follow-up visit in 6 months at their physicians’

direction or may choose an appointment further in the future rather than

the next available appointment because of their work or personal demands.

VA has chosen to omit scheduled appointments such as these from its

calculations because it is interested only in determining the time that

patients have no choice but to wait for the next available appointment.

To exclude these types of appointments from its calculations, VA

introduced with this second effort a procedure under which scheduling

clerks must enter in a particular field on the computer whether an

appointment is (1) the next available (indicated by an “N”), (2) other than

the next available at the request of the clinician (indicated by a “C”), or (3)

other than the next available at the request of the patient (indicated by a

“P”). In calculating the average time to appointment, only those

appointments marked with an “N” are considered.

VA field officials, who have oversight responsibilities for appointment

scheduling, told us that the new data collection method is conceptually

superior to VA’s initial approach because the data collected is more

accurate. However, these officials raised concerns that early problems in

implementing the method could reduce the data’s reliability. For example,

if a patient initially requests the next available appointment but then

decides to select an appointment further in the future, the clerk must exit

and then reenter the system and rekey all of the appointment information—

simply to change the appointment code from “N” to “P.” According to these

field officials, requiring scheduling clerks to exit and then reenter the

scheduling system in such events is cumbersome and may cause busy

clerks to leave the “N” they initially entered rather than changing it to a “P.”

As a result, the appointment would be inappropriately included in the

clinic’s waiting time data and would overstate the actual waiting time at the

clinic.
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In addition, VA’s ability to collect comparable waiting time data for all

facilities may be limited because some clinics schedule appointments only

2 months into the future. In such cases, patients would be asked to call

back if no appointments were available during that 2-month time period. As

a result, data collected from these clinics would always show average

waiting times of 2 months or less. To the extent patients in the clinics must

wait longer than 2 months to obtain an appointment, data collected from

these clinics would understate waiting times.

Believing its new approach will provide adequate and accurate data on

waiting times, VA intends to use this information to evaluate VISN

directors’ performance in their efforts to reach waiting time goals,

beginning in September 2000. According to VA’s “Fiscal Year 2000 Network

Performance Plan,” VISN directors’ performance will be measured on their

ability to provide patient appointments within 30 and 45 days for six clinics:

audiology, cardiology, ophthalmology, orthopedics, primary care, and

urology. According to an official in VA’s Chief Network Office, VA identified

these six clinics by asking clinical managers from each of the 22 VISNs to

survey their facilities on what clinics had the most problems with waiting

times. VA plans to collect waiting time data for all clinics and might replace

one or more of the six clinics with different clinics if the data show that

their waiting times are worse.

VA Has Waiting Time

Initiatives Under Way,

but More Data Are

Needed

VA has begun several initiatives to reduce its waiting times. For example, in

June 1999, VA retained a private contractor to help it develop and

implement techniques to reduce waiting times in selected VA clinics

nationwide. Recognizing that this project will not completely solve its

waiting time problems, VA plans to spend $400 million in fiscal year 2001 to

help it achieve its timeliness goals. However, VA currently has little detailed

knowledge of the extent or causes of outpatient waiting times systemwide.

Further, without baseline waiting time data and a method for tracking and

monitoring funds, VA will not be able to objectively measure whether any

funds spent to reduce waiting times have produced the desired

improvements. Given VA’s lack of reliable national waiting time data and

lack of detailed plans specifying which facilities or clinics would

implement the improvements, we cannot assess whether VA’s proposed

expenditures would reduce waiting times.
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VA Launches Project to

Reduce Waiting Times

In July 1999, VA contracted with the Boston-based Institute for Healthcare

Improvement (IHI) to develop ways to reduce waiting times in specific

clinics selected by VA facilities nationwide. As part of this project, 134

teams from VA facilities across the nation developed strategies to reduce

waiting times for appointments in 160 primary or specialty care clinics.

While some teams worked to reduce waiting times in only one clinic,

several chose two or more clinics. Table 2 summarizes the clinics that the

VA teams chose for their IHI projects.

Table 2: Clinics Chosen by VA Teams Participating in the IHI Project

Source: Institute for Healthcare Improvement.

Since the project began in July 1999, some VA clinics have reported notable

successes in reducing waiting times, often by increasing provider

availability and office efficiency. One VA facility, for example, reports that it

has reduced the number of days veterans must wait for a primary care

appointment from 240 days to about 14 days—that is, veterans who once

had to wait almost 8 months for primary care are now able to obtain

appointments within 2 weeks. VA staff attribute this success, in part, to

scheduling changes, such as reducing the number of unnecessary return

Clinic Number of clinics

Primary care 88

Orthopedics 11

Eye (including ophthalmology and optometry) 9

Urology 9

Gastrointestinal 8

General medicine/surgery 6

Neurology 5

Cardiology 3

Dermatology 3

Mental health/psychiatry 3

Rheumatology 3

Endocrinology 2

Physical therapy 1

Women’s health 1

Other specialty care (specialty not identified) 8

Total 160
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visits scheduled for veterans and no longer automatically rescheduling new

patients who do not show up for their appointment.

Other improvements reported to us include an orthopedic clinic’s having

reduced its waiting time for consultations from 130 days to 7 days, and an

eye clinic’s having reduced its waiting time from 120 days to 50 days. Some

teams, however, have struggled with reducing waiting times, citing barriers

such as physician and team member resistance to the changes and

difficulties in sustaining improvements made to reduce waiting times.

The IHI project ended in March 2000, and the final report summarizing the

results of this project is due in July 2000. According to VA officials, reduced

waiting times in other clinics could be expected to follow from the success

of these initial projects as VA facilities implement the techniques they

learned by participating in IHI.

Concerns About Basis for

Waiting Time Initiatives

In its fiscal year 2001 budget submission to the Congress, VA is proposing

to spend $400 million toward meeting its 30-30-20 timeliness goal (that is,

appointments within 30 days for initial primary care and specialty care

referrals and patients seen by providers within 20 minutes of scheduled

appointments). VA plans to spend these funds to improve the timeliness of

service, patient access to telephone care, and timely access to clinical

information.6 VA expects that these improvements will help it achieve its

30-30-20 goal by fiscal year 2003. Table 3 shows the fiscal year 2001 funds

VA plans to spend on each of these improvements.7

6

According to VA’s Acting Director for Resource Formulation, VA identified these initiatives

by summarizing and reviewing proposals from each of VA’s 22 VISNs and from headquarters

program officials. Although the estimated funding needed to accomplish these goals by

fiscal year 2003 exceeds the $400 million, VA determined that it was a reasonable investment

in fiscal year 2001 to help reach this future goal.

7

Of this $400 million, VA plans to obtain $77 million through new appropriated dollars from

the Congress. The remaining $323 million is expected to come from fiscal year 2000

activities. Specifically, $200 million is expected to come from management savings and $123

million is expected to be available as a result of a reduction in staff through retirement

incentives.
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Table 3: VA’s Proposed Initiatives and Funds Requested to Help Achieve Its 30-30-20

Timeliness Goals

Source: VA Acting Director for Resource Formulation.

To meet its timeliness of service initiative, VA plans to spend a total of $223

million to implement the following three efforts:

• Scheduling package: VA plans to spend $34.7 million to redesign or

replace its outpatient appointment-scheduling package. VA believes that

difficulties with the current system reduce both access to and timeliness

of service because it does not allow flexibility in appointment length or

scheduling across different facilities. VA officials told us that they

recently formed a team to review whether it should redesign or replace

the scheduling package. After its review, the team is expected to provide

a detailed proposal of project costs, time frames, and implementation

strategies. VA anticipates this project to be a multiyear effort and

expects the $34.7 million to help fund the project for about 2 years.

• Contract physicians: VA plans to use additional contract specialist

physicians to reduce the backlog of patients waiting for specialty care

and, as a result, reduce the amount of time patients must wait to receive

such care. According to VA budget officials, VA has not yet determined

how much of the fiscal year 2001 funds it will use for this purpose, nor

which facilities will receive additional specialists. VA hopes to contract

for specialists based on patient needs and facility capabilities. Because

VA does not know at this time which facilities or clinics will contract

with physicians, what specialties are experiencing the longest waiting

times, and how much it intends to spend on this initiative, it is unclear to

what extent using contract physicians will reduce patient waiting times.

Proposed initiative

Projected

expenditure

(in millions)

Timeliness of service $223

Patient access to telephone care 21

Timely access to clinical information 156

Total $400
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• Outpatient clinics: VA plans to improve timeliness by establishing 63

additional community-based outpatient clinics. VA believes that by

offering patients more convenient access to care—and possibly

alleviating workload at other clinics—these patients might receive more

timely initial and subsequent appointments for their primary care.8

However, VA has not yet determined the cost or locations of these new

clinics or to what extent they would reduce waiting times. Further, it is

unclear whether this initiative would reduce waiting times at all.

Specifically, in 1999, 12 of the 22 VISN directors we surveyed told us that

by increasing veterans’ access to VA health care, community-based

outpatient clinics could stimulate demand. If this occurs, waiting times

could actually lengthen. VA is currently studying whether existing

community-based outpatient clinics have resulted in shorter waiting

times.

VA also believes that telephone care will help it achieve its timeliness goals.

Specifically, VA officials cited studies that found that a significant

percentage of visits to emergency departments, urgent care, and doctors’

offices bring no medical benefits, and a percentage of unnecessary visits

could be avoided by providing patients the option to speak to a nurse over

the telephone. To improve patient access to telephone care, VA plans to

spend $21 million to begin providing nurse advice lines nationwide, 24

hours a day, 7 days a week. According to an official in VA’s Office of Primary

and Ambulatory Care, VA plans to identify basic systemwide standards and

measures as part of this nationwide initiative. To ensure that the advice

provided over the phone is standardized at all locations, for example, this

official explained that VA will need to purchase a license for automated

medical and legal protocols. Along with this telephone care program, VA is

also considering using a portion of the $21 million to purchase self-care

manuals to provide to patients to improve their medical knowledge and

possibly reduce unnecessary visits. VA expects the program to be fully

implemented at the end of fiscal year 2002.

To improve timely access to clinical information, VA plans to spend $156

million to primarily provide the information technology support it believes

is necessary to ensure timely and quality care. VA officials believe that

8

According to VA, it determines the need for community-based outpatient clinics based on a

demographic analysis that includes an evaluation of the proposed area, its proximity to the

parent facility, the existing and projected veteran population, and the characteristics of the

population to be served.
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improvements such as access to clinical information across sites of care

will help ensure prompt service and improve continuity of quality care. For

example, to improve access to clinical information across sites of care, VA

plans to improve software capabilities so that facilities can access and

exchange patient health summary information across sites of care. In

addition, VA also plans to expand several national telemedicine pilot

programs and study the results of these programs to establish best

practices for new telemedicine programs. Further, VA plans to purchase

software and hardware—such as personal computers, network servers,

and X-ray equipment—and hire additional technical staff to support these

functions. VA has not yet determined how much of the $156 million it will

spend on each of these initiatives or which locations will receive these

improvements. According to VA’s Acting Director for Resource

Formulation, these determinations will be based on individual needs and

the capabilities of the facilities within the 22 VISNs.

Given VA’s lack of reliable national waiting time data, VA cannot reasonably

allocate its proposed $400 million to facilities that have the worst

problems. VA also cannot measure program progress, as it currently does

not have a baseline of reliable national data from which to measure such

progress. Moreover, without a thorough, data-driven analysis of the cause

of the long waits and a method for tracking and monitoring funds, VA

cannot objectively measure whether funds appropriated to reduce waiting

times would produce these desired reductions.

VA’s lack of reliable national waiting time data not only limits its ability to

identify which facilities and clinics have the longest waiting times but also

limits VA’s ability to know whether waiting time problems are systemwide

or isolated to particular facilities. VA officials explained that they hope to

collect more reliable appointment waiting time data in the near future but,

in the interim, are encouraging VISN directors to monitor their facilities’

waiting times by reviewing the data extracted from the VISTA software

program for the facilities within their VISN. According to a VA official, VISN

directors are also encouraged to take appropriate actions to reduce waiting

times, including implementing techniques learned through the IHI project,

such as targeting resources to clinics where they are most needed and

improving office efficiencies.

Although VA has budgeted funds expressly to help it achieve its timeliness

goals, it does not plan to track these funds by project and thus will be

unable to monitor whether the funds have contributed to reduced waiting

times. Specifically, VISN directors have the authority to allocate funds to
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the facilities within their VISNs. VA officials told us that, for this reason, VA

does not have detailed spending plans for much of the $400 million of

planned obligations. For example, while VA has proposed spending $223

million on three initiatives to improve the timeliness of service, it could

only provide funding estimates for one: the $34.7 million to redesign or

replace its scheduling package.

Because VA will not be designating the exact uses for most of the $400

million, each VISN director has discretion over how the funds will be used.

Consequently, VA will not be able to track whether these funds were

actually spent on improving timeliness or whether their use had the

intended effect on reducing waiting times.

Conclusions Anecdotal information has led to the perception that VA is not meeting its

30-30-20 timeliness goals and that veterans in different locations do not

have equal access to timely care. In order to correct these perceived

problems, VA managers must make decisions about where and how to

apply the agency’s finite resources in order to have the greatest effect. To

make such decisions, we believe that VA managers must have reliable data

on the extent and causes of waiting times in different locations and in

different clinics.

Although VA has made significant strides in collecting waiting time data

systemwide, some problems must be overcome before the data can be

reliably used. Once improvements are made, we believe the data can be

used to give VA managers an estimate of national waiting times and those

for every individual VA clinic. However, VA has not analyzed the causes of

waiting times and is still waiting for final data from the IHI project.

Consequently, it does not have an adequate basis for determining which

initiatives could best improve the timeliness of care. Further, VA does not

plan to ensure that its initiatives for improving timeliness will result in

decreased waiting times or even if these funds will be spent on timeliness

initiatives.

Recommendations We recommend that the Secretary of Veterans Affairs direct the Under

Secretary for Health to first determine the extent of waiting times and their

causes and then develop a spending plan that will result in solving the

identified waiting time problems. In addition, VA should develop a
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mechanism for monitoring and tracking expenditures for improving

timeliness to evaluate how well targeted funds have reduced waiting times.

Agency Comments and

Our Evaluation

We provided VA a draft copy of our report for its review and comment.

Overall, VA agreed with the report’s conclusions and recommendations and

indicated that it will use it as a guide for developing a national plan for

addressing waiting time issues. As a result of our report, VA is also planning

to require VISNs to develop systematic spending plans for waiting time

expenditures and is planning to track projected goals for each waiting time

initiative, including a description of anticipated and measurable benefits in

meeting its goals.

VA said that it believes its February 2000 clinic appointment waiting time

data are adequate for use as a baseline to measure progress. While the

February 2000 data are better than that previously available, VA has not yet

tested the validity of each clinic’s data and, thus, cannot be assured that

these data can be used as an adequate baseline. As noted in the report, we

found errors at some locations—specifically, inaccurate appointment types

being entered into the system—that indicate the data may not be reliable.

Moreover, VA points out that it is continuing to collect and improve upon

its monthly data and that its understanding will increase as the data are

refined.

VA also noted that it is developing a systematic spending plan for

addressing identified waiting time problems. It also intends to integrate

existing and proposed initiatives—which have been fragmented—into a

cohesive national plan. VA appears to be committed to carrying out these

and other initiatives aimed at achieving its waiting time goals. However, we

cannot assess the effectiveness of these actions until they are completed.

The full text of VA’s comments is presented in appendix II.

As arranged with your office, unless you announce its contents earlier, we

plan no further distribution of this report until 30 days after the date of this

letter. At that time, we will send copies to the Honorable Togo D. West, Jr.,

Secretary of Veterans Affairs; appropriate congressional committees; and

other interested parties. We will also make copies available to others upon

request.
B-284876

Page 18 GAO/HEHS-00-90 VA Waiting Times

Please contact me at (202) 512-7101 or Ronald J. Guthrie at (303) 572-7332

if you or your staff have any questions. Other key contributors to this

report are listed in appendix III.

Sincerely,

Cynthia Bascetta, Associate Director

Veterans’ Affairs and Military

Health Care Issues
Page 19 GAO/HEHS-00-90 VA Waiting Times
Page 20 GAO/HEHS-00-90 VA Waiting Times

Appendix I

Scope and Methodology ApApenednxidexiIs

To determine what initiatives VA has under way to improve its waiting time

data, we reviewed and analyzed VA data extracted under both of its recent

approaches and VA supporting documentation for these approaches. We

interviewed VA headquarters and field officials to gain their perspectives

on these data extracts and whether they could be used as a reliable

measure of waiting times systemwide.

To determine what initiatives VA has under way to address its waiting time

problems, we reviewed VA’s fiscal year 2001 budget submission to the

Congress, VA’s Fiscal Year 2000 Network Performance Plan, and other

documents detailing VA’s goals to reduce its waiting times for

appointments. In addition, we interviewed VA headquarters and field

officials and IHI officials and faculty to gain their perspectives on the

project to reduce waiting times. To learn more about the VA/IHI project, we

also attended two of the three learning sessions and reviewed and analyzed

relevant documents obtained from these sessions. Finally, we interviewed

veteran service organization representatives and obtained data related to

their reports of waiting times in several clinics.

We conducted our work between January 2000 and May 2000 in accordance

with generally accepted government auditing standards.
Page 21 GAO/HEHS-00-90 VA Waiting Times

Appendix II

Comments From the Department of Veterans

Affairs ApendxiI
Appendix II

Comments From the Department of Veterans

Affairs

Page 22 GAO/HEHS-00-90 VA Waiting Times
Appendix II

Comments From the Department of Veterans

Affairs

Page 23 GAO/HEHS-00-90 VA Waiting Times
Page 24 GAO/HEHS-00-90 VA Waiting Times

Appendix III

Staff Acknowledgments ApendxiI

James Espinoza, Lisa Gardner, Steve Gaty, George Lorenzen, Karen Sloan,

and Alan Wernz also made key contributions to this report.

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