VA HEALTH CARE

Appointment Scheduling 

Oversight and Wait Time 

Measures Need 

Improvement

Statement of Debra A. Draper

Director, Health Care

Testimony 

Before the Subcommittee on Oversight 

and Investigations, Committee on 

Veterans’ Affairs, House of 

Representatives

For Release on Delivery 

Expected at 1:30 p.m. EDT

Thursday, March 14, 2013

GAO-13-372T

United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-13-372T, a testimony 

before the Subcommittee on Oversight and 

Investigations, Committee on Veterans’ 

Affairs, House of Representatives

March 14, 2013

VA HEALTH CARE

Appointment Scheduling Oversight and Wait Time 

Measures Need Improvement

Why GAO Did This Study

VHA provided nearly 80 million 

outpatient medical appointments to 

veterans in fiscal year 2011. Although 

access to timely medical appointments 

is important to ensuring veterans 

obtain needed care, long wait times 

and inadequate scheduling processes 

have been persistent problems. 

This testimony is based on a 

December 2012 report, VA Health 

Care: Reliability of Reported Outpatient 

Medical Appointment Wait Times and 

Scheduling Oversight Need 

Improvement (GAO-13-130), that

described 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. To conduct that work, 

GAO made site visits to 23 clinics at 

four VAMCs, the latter selected for 

variation in size, complexity, and 

location. GAO also reviewed VHA’s 

policies and interviewed VHA officials.

What GAO Recommends

In its December 2012 report, GAO 

recommended that VHA 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 allocate staffing 

resources based on scheduling needs, 

and (4) ensure that VAMCs provide 

oversight of telephone access and 

implement best practices to improve 

telephone access for clinical care. VA 

concurred with GAO’s 

recommendations.

What GAO Found

Outpatient medical appointment wait times reported by the Veterans Health 

Administration (VHA), within the Department of Veterans Affairs (VA), are 

unreliable. Wait times for outpatient medical appointments—referred to as 

medical appointments—are calculated as the number of days elapsed from the 

desired date, which is defined as the date on which the patient or health care 

provider wants the patient to be seen. The reliability of reported wait time 

performance measures is dependent on the consistency with which schedulers 

record the desired date in the scheduling system. However, aspects of VHA’s 

scheduling policy and training documents for recording desired date are unclear 

and do not ensure consistent use of the desired date. Some schedulers at VA

medical centers (VAMC) that GAO visited 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. VHA 

officials acknowledged limitations of measuring wait times based on desired date, 

and described additional information used to monitor veterans’ access to medical 

appointments; however, reliable measurement of how long patients are waiting 

for medical appointments is essential for identifying and mitigating problems that 

contribute to wait times.

While visiting VAMCs, GAO also found inconsistent implementation of certain 

elements of VHA’s scheduling policy that impedes VAMCs from 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 scheduling policy, putting these clinics at risk 

for losing track of these patients. Furthermore, VAMCs’ oversight of compliance 

with VHA’s scheduling policy, such as ensuring the completion of required 

scheduler training, was inconsistent across facilities. VAMCs also described 

other problems with scheduling timely medical appointments, including VHA’s 

outdated and inefficient scheduling system, gaps in scheduler staffing, and 

issues with telephone access. For example, officials at all VAMCs GAO visited 

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

telephones impede scheduling of timely medical appointments.

VHA is implementing a number of initiatives to improve veterans’ access to 

medical appointments such as use of technology to interact with patients and 

provide care, which includes the use of secure messaging between patients and 

their health care providers. VHA also 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 

within VHA in a timely way.

View GAO-13-372T. For more information, 

contact Debra A. Draper at (202) 512-7114 or 

draperd@gao.gov.
Page 1 GAO-13-372T

United States Government Accountability Office

Washington, DC 20548

Chairman Coffman, Ranking Member Kirkpatrick, and Members of the 

Subcommittee:

I am pleased to be here today to discuss improvements needed in the

Department of Veterans Affairs’ (VA) outpatient medical appointment 

scheduling oversight and wait time measurement.1 In fiscal year 2011, 

the Veterans Health Administration (VHA), within VA, provided nearly 

80 million medical appointments to veterans through its primary and 

specialty care clinics, which are managed by VA medical centers 

(VAMC).2 Although access to timely medical appointments is critical to 

ensuring that veterans obtain needed medical care, long wait times and 

inadequate scheduling processes at VAMCs have been persistent 

problems, as we and the VA Office of Inspector General have reported.3

Most recently, in December 2012, we reported that VHA’s medical 

appointment wait times are unreliable and problems with VHA’s oversight 

of outpatient medical appointment scheduling processes impede VHA’s 

ability to schedule timely medical appointments.4

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

commitment to scheduling medical appointments with no undue waits or 

delays.5

 

1

Throughout this statement, we will use the term “medical appointments” to refer to 

outpatient medical appointments.

The policy establishes processes and procedures for scheduling 

2

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. 

3

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

Some Clinics Have Made Progress, GAO-01-953 (Washington, D.C.: Aug. 31, 2001). See 

also 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). Finally, see 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). 

4

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).

5

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.

 
 

Page 2 GAO-13-372T

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.6 For example, the policy requires 

schedulers to record appointments in VHA’s Veterans Health Information 

Systems and Technology Architecture (VistA) medical appointment 

scheduling system; schedulers also are to record the date on which the 

patient or provider wants the patient to be seen—known as the desired 

date.7

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.8 VHA established these goals based on its performance 

reported in previous years.9

 

6

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).

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 

7

VistA 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. 

8

In 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.

9

In 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.
 

Page 3 GAO-13-372T

(VISN) directors’ and VAMC directors’ performance contracts10 and VA 

includes measures in its budget submissions and performance reports to 

Congress and stakeholders.11

My statement today 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.12 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.13

 

10Each 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.

We also visited 23 highvolume 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 

11VA 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.

12GAO-13-130. 

13We 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.
 

Page 4 GAO-13-372T

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.

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 

certain elements 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 
 

Page 5 GAO-13-372T

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 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.14

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.

 

14In October 2012, VA announced a contest seeking proposals for a new medical 

appointment scheduling system from commercial software developers. 
 

Page 6 GAO-13-372T

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 

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.

Chairman Coffman, Ranking Member Kirkpatrick, and Members of the 

Subcommittee, this concludes my prepared remarks. I would be pleased 

to respond to any questions you or other members of the subcommittee

may have at this time.

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 

testimony include Bonnie Anderson, Assistant Director; Rebecca Abela; 

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

(291127)
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