VA HEALTH CARE

Reported Outpatient 

Medical Appointment Wait 

Times Are Unreliable

Statement for the Record by

Debra A. Draper

Director, Health Care

Statement for the Record to the 

Committee on Veterans’ Affairs, 

U.S. House of Representatives

For Release on Delivery 

Expected at 10:00 a.m., EST

Wednesday, February 13, 2013

GAO-13-363T

United States Government Accountability Office

GAO
Page 1 GAO-13-363T

United States Government Accountability Office

Washington, DC 20548

Chairman Miller, Ranking Member Michaud, and Members of the 

Committee:

I am pleased to have the opportunity to comment on overcoming barriers 

for quality mental health care for veterans—particularly those who are 

returning from deployment. In 2011, we reported that the number of 

veterans receiving mental health care had increased each year from fiscal 

year 2006 to 2010, and veterans who served in Afghanistan and Iraq 

accounted for an increasing proportion of veterans receiving mental 

health care during this period.

1 We also reported on the key barriers that 

may hinder veterans from accessing mental health care from the 

Department of Veterans Affairs (VA), which included difficulty scheduling 

appointments.

2 More recently, in December 2012, we reported on 

problems with VA’s oversight of outpatient medical appointment 

scheduling processes and measurement of outpatient medical 

appointment wait times.3

In fiscal year 2011, there were more than 8 million veterans enrolled in 

VA’s health system, which is operated by the Veterans Health 

Administration (VHA). VHA provided nearly 80 million outpatient medical 

appointments to veterans through its primary and specialty care clinics.4

 

1

GAO, VA Mental Health: Number of Veterans Receiving Care, Barriers Faced, and 

Efforts to Increase Access, 

Although access to timely medical appointments is critical to ensuring that 

veterans obtain needed medical care, long wait times and inadequate 

scheduling processes at VA medical centers (VAMC) have been longstanding problems that persist today. For example, in 2001, we reported 

on the timeliness of medical appointments and found that two-thirds of the 

specialty care clinics visited had wait times longer than 30 days, although 

GAO-12-12 (Washington, D.C.: Oct. 14, 2011).

2

We identified key barriers from the literature, and corroborated the barriers through 

interviews with VA officials.

3

GAO, VA Health Care: Reliability of Reported Outpatient Medical Appointment Wait 

Times and Scheduling Oversight Need Improvement, GAO-13-130 (Washington, D.C.: 

Dec. 21, 2012).

4

Outpatient clinics offer services to patients that do not require a hospital stay. Primary 

care addresses patients’ routine health needs and specialty care is focused on a specific 

specialty service such as orthopedics, dermatology, or psychiatry. Throughout this 

statement we will use the term “medical appointments” to refer to outpatient medical 

appointments.

 
 

Page 2 GAO-13-363T

some clinics had made progress in reducing wait times, primarily by 

improving their scheduling processes and making better use of their 

staff.5 Later, in 2007, the VA Office of Inspector General (OIG) reported 

that VHA facilities did not always follow VHA’s scheduling policies and 

processes and that the accuracy of VHA’s reported wait times for medical 

appointments was unreliable.6 Most recently, in 2012, the VA OIG 

reported that VHA was not providing all new veterans with timely access 

to full mental health evaluations, and had overstated its success in 

providing veterans with timely new and follow-up appointments for mental 

health treatment.7

VHA has a scheduling policy intended to help its VAMCs meet its 

commitment to scheduling medical appointments with no undue waits or 

delays.

Although VHA has reported continued improvements in 

measuring and achieving timely access to medical appointments, patient 

complaints and media reports about long wait times have persisted, 

prompting renewed concerns about excessive medical appointment wait 

times.

8 The policy establishes processes and procedures for scheduling 

medical appointments and ensuring the competency of staff directly or 

indirectly involved in the scheduling process. It includes several 

requirements that affect timely appointment scheduling, as well as 

accurate wait time measurement.9

 

5

GAO, VA Health Care: More National Action Needed to Reduce Waiting Times, but 

Some Clinics Have Made Progress, 

For example, the policy requires 

schedulers to record appointments in VHA’s Veterans Health Information 

Systems and Technology Architecture (VistA) medical appointment 

GAO-01-953 (Washington, D.C.: Aug. 31, 2001).

6

Department of Veterans Affairs, Office of Inspector General, Audit of the Veterans Health 

Administration’s Outpatient Waiting Times, Report No. 07-00616-199, (Washington, D.C.: 

Sept. 10, 2007).

7

Department of Veterans Affairs, Office of Inspector General, Veterans Health 

Administration: Review of Veterans’ Access to Mental Health Care, Report No. 12-00900-

168, (Washington, D.C.: Apr. 23, 2012).

8

VHA medical appointment scheduling policy is documented in VHA Directive 2010-027, 

VHA Outpatient Scheduling Processes and Procedures (June 9, 2010). We refer to the 

directive as “VHA’s scheduling policy” from this point forward.

9

VHA has a separate directive that establishes policy on the provision of telephone 

service related to clinical care, including facilitating telephone access for medical 

appointment management. VHA Directive 2007-033, Telephone Service for Clinical Care 

(Oct. 11, 2007).
 

Page 3 GAO-13-363T

scheduling system, including the date on which the patient or provider 

wants the patient to be seen—known as the desired date.10

At the time of our review, VHA measured medical appointment wait times 

as the number of days elapsed from the patient’s or provider’s desired 

date, as recorded in the VistA scheduling system by VAMCs’ schedulers. 

According to VHA central office officials, VHA measures wait times based 

on desired date in order to capture the patient’s experience waiting and to 

reflect the patient’s or provider’s wishes. In fiscal year 2012, VHA had a 

goal of completing primary care appointments within 7 days of the desired 

date, and scheduling specialty care appointments within 14 days of the 

desired date.

11 VHA established these goals based on its performance 

reported in previous years.12 To help facilitate accountability for achieving 

its wait time goals, VHA includes wait time measures—referred to as 

performance measures—in its Veterans Integrated Service Network 

(VISN) directors’ and VAMC directors’ performance contracts,13

 

10VistA is the single integrated health information system used throughout VHA in all of its 

health care settings. There are many different VistA applications for clinical, 

administrative, and financial functions, including the scheduling system. 

and VA 

11In 2012, VA also had several additional goals related to measuring access to mental 

health appointments specifically, such as screening eligible patients for depression, posttraumatic stress disorder, and alcohol misuse at required intervals; and documenting that 

all first-time patients referred for or requesting mental health services receive a full mental 

health evaluation within 14 days of their initial encounter. As noted earlier, in its Report 

No. 12-00900-168, the VA OIG found that some of the mental health performance data 

were not reliable. VA is dropping several of these mental health measures in 2013.

12In 1995, VHA established a goal of scheduling primary and specialty care medical 

appointments within 30 days to ensure veterans’ timely access to care. In fiscal year 2011, 

VHA shortened the wait time goal to 14 days for both primary and specialty care medical 

appointments. In fiscal year 2012, VHA added a goal of completing primary care medical 

appointments within 7 days of the desired date.

13Each of VA’s 21 VISNs is responsible for managing and overseeing medical facilities 

within a defined geographic area. VISN and VAMC directors’ performance contracts 

include measures against which directors are rated at the end of the fiscal year, which 

determine their performance pay.
 

Page 4 GAO-13-363T

includes measures in its budget submissions and performance reports to 

Congress and stakeholders.14

This statement highlights key findings from our December 2012 report 

that describes needed improvements in the reliability of VHA’s reported 

medical appointment wait times, scheduling oversight, and VHA initiatives 

to improve access to timely medical appointments.15

 

14VA prepares a congressional budget justification that provides details supporting the 

policy and funding decisions in the President’s budget request submitted to Congress prior 

to the beginning of each fiscal year. The budget justification articulates what VA plans to 

achieve with the resources requested; it includes performance measures by program 

area. VA also publishes an annual performance report—the performance and 

accountability report— which contains performance targets and results achieved 

compared with those targets in the previous year.

For that report, we 

reviewed VHA’s scheduling policy and methods for measuring medical 

appointment wait times and interviewed VHA central office officials 

responsible for developing them. We did not include mental health 

appointments in the scope of our work, because this issue was already 

being reviewed by VA’s Office of Inspector General. We also visited 

23 high-volume outpatient clinics at four VAMCs selected for variation in 

size, complexity, and location; these four VAMCs were located in Dayton, 

Ohio; Fort Harrison, Montana; Los Angeles, California; and Washington, 

D.C. At each VAMC we interviewed leadership and other officials about 

how they manage and improve medical appointment timeliness, their 

oversight to ensure accuracy of scheduling data and compliance with 

scheduling policy, and problems staff experience in scheduling timely 

medical appointments. We examined each VAMC’s and clinic’s 

implementation of elements of VHA’s scheduling policy and obtained 

documentation of scheduler training completion. In addition, we 

interviewed schedulers from 19 of the 23 clinics visited, and also 

reviewed patient complaints about telephone responsiveness, which is 

integral to timely medical appointment scheduling. We interviewed the 

directors and relevant staff of the four VISNs for the sites we visited. We 

also interviewed VHA central office officials and officials at the VAMCs we 

visited about selected initiatives to improve veterans’ access to timely 

medical appointments. We performed this work from February 2012 

through December 2012 in accordance with generally accepted 

government auditing standards.

15GAO-13-130. 
 

Page 5 GAO-13-363T

In brief, we found that (1) VHA’s reported outpatient medical appointment 

wait times are unreliable, (2) there was inconsistent implementation of 

certain elements of VHA’s scheduling policy that could result in increased 

wait times or delays in scheduling timely medical appointments, and 

(3) VHA is implementing or piloting a number of initiatives to improve 

veterans’ access to medical appointments. Specifically, VHA’s reported 

outpatient medical appointment wait times are unreliable because of 

problems with correctly recording the appointment desired date—the date 

on which the patient or provider would like the appointment to be 

scheduled—in the VistA scheduling system. Since, at the time of our 

review, VHA measured medical appointment wait times as the number of 

days elapsed from the desired date, the reliability of reported wait time 

performance is dependent on the consistency with which VAMC 

schedulers record the desired date in the VistA scheduling system. 

However, aspects of VHA’s scheduling policy and related training 

documents on how to determine and record the desired date are unclear 

and do not ensure replicable and reliable recording of the desired date by 

the large number of staff across VHA who can schedule medical 

appointments, which at the time of our review was estimated to be more 

than 50,000. During our site visits, we found that at least one scheduler at 

each VAMC did not record the desired date correctly, which, in certain 

cases, would have resulted in a reported wait time that was shorter than 

the patient actually experienced for that appointment. Moreover, staff at 

some clinics told us they change medical appointment desired dates to 

show clinic wait times within VHA’s performance goals. Although VHA 

officials acknowledged limitations of measuring wait times based on 

desired date, and told us that they use additional information, such as 

patient satisfaction survey results, to monitor veterans’ access to medical 

appointments, reliable measurement of how long veterans wait for 

appointments is essential for identifying and mitigating problems that 

contribute to wait times.

At the VAMCs we visited, we also found inconsistent implementation of 

VHA’s scheduling policy, which can result in increased wait times or 

delays in scheduling timely medical appointments. For example, four 

clinics across three VAMCs did not use the electronic wait list to track 

new patients that needed medical appointments as required by VHA’s 

scheduling policy, putting these clinics at risk for losing track of these 

patients. Furthermore, VAMCs’ oversight of compliance with VHA’s 

scheduling policy was inconsistent across the facilities we visited. 

Specifically, certain VAMCs did not ensure the completion of scheduler 

training by all staff required to complete it even though officials stressed 

the importance of the training for ensuring correct implementation of 
 

Page 6 GAO-13-363T

VHA’s scheduling policy. VAMCs also described other problems that 

impede the timely scheduling of medical appointments, including VA’s 

outdated and inefficient VistA scheduling system, gaps in scheduler 

staffing, and issues with telephone access. The current VistA scheduling 

system is more than 25 years old, and VAMC officials reported that using 

the system is cumbersome and can lead to errors.16

VHA is implementing or piloting a number of initiatives to improve 

veterans’ access to medical appointments that focus on more patientcentered care; using technology to provide care, through means such as 

telehealth and secure messaging between patients and their health care 

providers; and using care outside of VHA to reduce travel and wait times 

for veterans who are unable to receive certain types of outpatient care in 

a timely way through local VHA facilities. For example, VHA is piloting a 

new initiative to provide health care services through contracts with 

community providers that aims to reduce travel and wait times for 

veterans who are unable to receive certain types of care from VHA in a 

timely way. Although VHA collects information on wait times for medical 

appointments provided through this initiative, these wait times may not 

accurately reflect how long patients are waiting for appointments because 

they are counted from the time the contracted provider receives an 

authorization from VA, rather than from the time the patient or provider 

first requests an appointment from VHA.

In addition, 

shortages or turnover of scheduling staff, identified as a problem by all of 

the VAMCs we visited, can result in appointment scheduling delays and 

incorrect scheduling practices. Officials at all VAMCs we visited also 

reported that high call volumes and a lack of staff dedicated to answering 

the telephones impede the scheduling of timely medical appointments. 

Although we did not specifically review mental health clinic wait times, 

some of the problems we identified were pervasive, and may also affect 

clinics other than those we visited.

In conclusion, VHA officials have expressed an ongoing commitment to 

providing veterans with timely access to medical appointments and have 

reported continued improvements in achieving this goal. However, 

unreliable wait time measurement has resulted in a discrepancy between 

the positive wait time performance VA has reported and veterans’ actual 

 

16In October 2012, VA announced a contest seeking proposals for a new medical 

appointment scheduling system from commercial software developers. 
 

Page 7 GAO-13-363T

experiences. More consistent adherence to VHA’s scheduling policy and 

oversight of the scheduling process, allocation of staff resources to match 

clinics’ scheduling demands, and resolution of problems with telephone 

access would potentially reduce medical appointment wait times. VHA’s 

ability to ensure and accurately monitor access to timely medical 

appointments is critical to ensuring quality health care to veterans, who 

may have medical conditions that worsen if access is delayed.

To ensure reliable measurement of how long veterans are waiting for 

appointments and improve timely medical appointment scheduling, we 

recommended that the Secretary of VA direct the Under Secretary for 

Health to take actions to (1) improve the reliability of its medical 

appointment wait time measures, (2) ensure VAMCs consistently 

implement VHA’s scheduling policy, (3) require VAMCs to routinely 

assess scheduling needs for purposes of allocation of staffing resources, 

and (4) ensure that VAMCs provide oversight of telephone access and 

implement best practices to improve telephone access for clinical care. 

VA concurred with our recommendations and identified actions planned 

or underway to address them.

This concludes my statement for the record.

For questions about this statement, please contact Debra A. Draper at 

(202) 512-7114 or draperd@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last 

page of this statement. Individuals making key contributions to this 

statement include Bonnie Anderson, Assistant Director; Rebecca Abela; 

Jennie Apter; Lisa Motley; Sara Rudow; and Ann Tynan.

GAO Contacts and 

Staff 

Acknowledgments 

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