VA HEALTH CARE

Reliability of Reported 

Outpatient Medical 

Appointment Wait 

Times and Scheduling 

Oversight Need 

Improvement

Report to Congressional Requesters

December 2012

GAO-13-130

United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-13-130, a report to 

congressional requesters

December 2012

VA HEALTH CARE

Reliability of Reported Outpatient Medical 

Appointment Wait Times and Scheduling Oversight 

Need Improvement

Why GAO Did This Study

VHA provided nearly 80 million 

outpatient medical appointments to 

veterans in fiscal year 2011. While 

VHA has reported continued 

improvements in achieving access to 

timely medical appointments, patient 

complaints and media reports about 

long wait times persist.

GAO was asked to evaluate VHA’s 

scheduling of timely medical 

appointments. GAO examined (1) the 

extent to which VHA’s approach for 

measuring and monitoring medical 

appointment wait times reflects how 

long veterans are waiting for 

appointments; (2) the extent to which 

VAMCs are implementing VHA’s 

policies and processes for appointment 

scheduling, and any problems 

encountered in ensuring veterans’ 

access to timely medical appointments; 

and (3) VHA’s initiatives to improve 

veterans’ access to medical 

appointments. To conduct this 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 data, and interviewed VHA 

officials.

What GAO Recommends

GAO recommends 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 in accordance with VHA’s 

scheduling policy. However, 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 Veterans Affairs medical centers (VAMC) that 

GAO visited did not record the desired date correctly. For example, three 

schedulers changed the desired date based on appointment availability; this 

would have resulted in a reported wait time that was shorter than the patient 

actually experienced. VHA officials acknowledged limitations of measuring wait 

times based on desired date, and described additional information used to 

monitor veterans’ access to medical appointments, including patient satisfaction 

survey results. Without reliable measurement of how long patients are waiting for 

medical appointments, however, VHA is less equipped to identify areas that need 

improvement and mitigate problems that contribute to wait times.

While visiting VAMCs, GAO also found inconsistent implementation 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 and provider 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. In January 2012, VHA 

distributed telephone access best practices that, if implemented, could help 

improve telephone access to clinical care. 

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

medical appointments such as expanded 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-13-130. For more information, 

contact Debra Draper at (202) 512-7114 or 

draperd@gao.gov.
Page i GAO-13-130 VA Scheduling and Wait Times

Letter 1 

Background 5

Reported Medical Appointment Wait Times Are Unreliable; VHA 

Uses Additional Methods to Monitor Patients’ Access to Medical 

Appointments 11

Inconsistent Implementation of VHA’s Scheduling Policy and Other 

Problems Impede VAMCs’ Ability to Schedule Timely Medical 

Appointments 19

VHA Is Implementing a Number of Initiatives to Improve Access to 

Medical Appointments 29

Conclusions 34

Recommendations for Executive Action 35

Agency Comments and Our Evaluation 35

Appendix I Comments from the Department of Veterans Affairs 41

Appendix II GAO Contact and Staff Acknowledgments 45

Related GAO Products 46

Tables

Table 1: Selected Fiscal Year 2012 VHA Medical Appointment Wait 

Time Performance Measures 10

Table 2: Number of Schedulers at Each VAMC Visited Who 

Incorrectly Recorded the Medical Appointment Desired 

Date, by Error Type 15

Table 3: Number of Clinics That Did Not Implement Selected 

Elements of the VHA’s Scheduling Policy, by VAMC Visited 20

Contents 
Page ii GAO-13-130 VA Scheduling and Wait Times

Abbreviations

CBOC community-based outpatient clinic

FDPP Facility Director Performance Plan

NDPP Network Director Performance Plan

OIG Office of Inspector General

PACT Patient-Aligned Care Team

PAR Performance and Accountability Report

Project ARCH Access Reached Closer to Home

VA Department of Veterans Affairs

VAMC VA Medical Center

VHA Veterans Health Administration

VISN Veterans Integrated Service Network 

VistA Veterans Health Information Systems and 

 Technology Architecture

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Page 1 GAO-13-130 VA Scheduling and Wait Times

United States Government Accountability Office

Washington, DC 20548

December 21, 2012 

Congressional Requesters

The Veterans Health Administration (VHA), within the Department of 

Veterans Affairs (VA), operates one of the nation’s largest health care 

systems. Its medical facilities include 152 VA medical centers (VAMC), as 

well as more than 800 community-based outpatient clinics (CBOC) and 

ambulatory care centers that operate under supervision of the VAMCs.1

At these facilities, VHA provides outpatient care through primary and 

specialty care clinics.2 In fiscal year 2011, there were more than 8 million 

veterans enrolled in VHA’s health system, and VHA provided nearly 

80 million outpatient medical appointments to veterans for primary and 

specialty care.3

Although access to timely medical appointments is critical to ensuring that 

veterans obtain needed medical care, long wait times and inadequate 

scheduling processes at VHA medical facilities have been long-standing 

problems. For example, in 2001, GAO reviewed the timeliness of medical 

appointments and found that two-thirds of the specialty care clinics visited 

had wait times longer than 30 days, although some clinics had made 

progress in reducing wait times, primarily by improving their scheduling 

processes and making better use of their staff.4

 

1

Generally a CBOC or ambulatory care center is defined as a fixed health care site that is 

geographically distinct or separate from its parent VAMC. All CBOCs and ambulatory care

centers generally provide primary care, and some may provide specialty care; services 

can vary by individual CBOC or ambulatory care center.

Later, in 2007, the VA 

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 or dermatology. A “clinic” may be defined as an 

entity for dividing provider workload and scheduling different types of patient care 

appointments. A particular area of care, such as primary care or specialty care may have 

multiple clinics that vary in purpose and size. A VAMC can provide care in each area at 

the VAMC or its affiliated CBOCs and ambulatory care centers; for example, primary care 

could be provided through multiple primary care clinics at a VAMC’s different locations. 

Throughout the report we refer to a specific area of care at a specific location as a “clinic.” 

3

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

medical appointments.

4

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).

 
 

Page 2 GAO-13-130 VA Scheduling and Wait Times

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.5 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.6

VHA has reported continued improvements in measuring and achieving 

timely access to medical appointments. For example, in fiscal year 2011, 

VHA had a goal of scheduling medical appointments within 14 days of the 

patient’s or provider’s desired medical appointment date,7

To address all three objectives, we interviewed VHA central office officials 

responsible for medical appointment scheduling policy, medical 

appointment wait time measurement, and initiatives to improve access to 

timely medical appointments. We also conducted site visits to four 

VAMCs selected for variation in size and complexity, geographic location, 

and in that 

year, VA reported that it completed 95 percent of specialty care medical 

appointments and 94 percent of primary care medical appointments 

within this time frame. However, patient complaints and media reports 

about long wait times have persisted, prompting renewed concerns about 

excessive medical appointment wait times. You asked us to evaluate 

VHA’s scheduling of timely medical appointments. We examined (1) the 

extent to which VHA’s approach for measuring and monitoring medical 

appointment wait times reflects how long veterans are waiting; (2) the 

extent to which VAMCs are implementing VHA’s policies and processes 

for medical appointment scheduling, and any problems encountered in 

ensuring veterans’ access to timely medical appointments as identified by 

VAMCs; and (3) VHA’s initiatives to improve veterans’ access to medical 

appointments.

 

5

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).

6

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). 

7

According to VHA’s scheduling policy, the desired appointment date, referred to as the 

“desired date,” is the date on which the patient or provider wants the patient to be seen.
 

Page 3 GAO-13-130 VA Scheduling and Wait Times

or role as a pilot site for a VHA initiative to improve access to timely 

medical appointments.8 These four VAMCs were located in Dayton, Ohio; 

Fort Harrison, Montana; Los Angeles, California; and Washington, D.C. At 

each site, we visited the VAMC as well as the affiliated CBOCs that had 

among the highest volume of medical appointments.9 We also visited the 

highest volume ambulatory care center at one VAMC that had such 

facilities.10 At each VAMC, CBOC, and ambulatory care center, we visited 

an outpatient primary care clinic, and where available, one or more 

outpatient specialty care clinics for a total of 23 clinics—9 primary care 

and 14 specialty care clinics—the clinics were among those with the 

highest medical appointment volume.11 Results from our site visits cannot 

be generalized to other VAMCs. We also interviewed the directors and 

relevant staff of the four Veterans Integrated Service Networks (VISN), or 

regional networks of care, for the sites we visited.12

To examine the extent to which VHA’s approach for measuring and 

monitoring medical appointment wait times reflects how long veterans are 

waiting, we reviewed VHA’s outpatient medical appointment scheduling 

policy and processes and training documents based on the policy, as well 

as documents related to performance accountability that include wait time 

measures.13

 

8

VA assigns each VAMC a complexity score derived from multiple variables to measure 

facility complexity arrayed along four categories, namely patient population served, clinical 

services offered, education and research complexity, and administrative complexity.

At each of the four VAMCs we visited, we interviewed the 

leadership team, scheduling managers, and managers from all of our 

9

We visited the highest volume CBOC for three VAMCs and the second highest volume 

for the fourth VAMC.

10CBOCs and ambulatory care centers provide outpatient primary care and may provide 

specialty care services. Oversight for facility functions—including scheduling—occurs at 

the VAMC level. CBOCs and ambulatory care centers generally are geographically distinct 

from, but operate under the supervision of a parent VAMC, which maintains administrative 

responsibility. 

11During our site visits, we visited only outpatient clinics. Some CBOCs did not have 

specialty care clinics. From this point forward, we use VAMC to refer collectively to the 

VAMC and all of its affiliated CBOCs and ambulatory care centers.

12Each of VA’s 21 VISNs is responsible for managing and overseeing medical facilities 

within a defined geographic area.

13VHA outpatient 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 4 GAO-13-130 VA Scheduling and Wait Times

selected clinics about oversight activities to ensure the accuracy of 

scheduling data, and about what data and measures they use to manage 

clinics and improve medical appointment timeliness. In addition, we 

interviewed schedulers from the 9 primary care clinics and 10 of the 

14 specialty care clinics we visited using a structured protocol to 

determine the accuracy with which schedulers determined and recorded 

medical appointment data for hypothetical patient medical appointments 

into the scheduling system in accordance with VHA’s scheduling policy.14

We also compared reported medical appointment wait times for the clinics 

we visited to information gathered during our site visits.15

To determine the extent to which VAMCs are implementing VHA’s 

scheduling policy and processes, and to gather information on problems 

encountered in scheduling timely medical appointments, we reviewed 

VHA’s scheduling policy, interviewed VHA central office officials 

responsible for the scheduling policy, and obtained information about 

scheduling practices from officials at each of the four VAMCs we visited. 

Specifically, for each of the VAMCs, we interviewed leadership, 

scheduling managers, clinic managers, patient advocates, and case 

managers. We obtained information about the VAMCs’ oversight to 

ensure compliance with policy, and about problems staff at these facilities 

say they experience in scheduling timely medical appointments. We 

reviewed the implementation of selected elements of VHA’s scheduling 

policy at both the VAMC and individual clinic level. These elements 

included the use of VHA’s scheduling software to schedule medical 

appointments, the use of the electronic wait list16

 

14We refer to clerical or administrative support staff with scheduling responsibilities as 

“schedulers.” We did not complete a scheduler interview for 4 of the 14 specialty clinics 

that we visited because either the clinic did not have a scheduler or it would have caused 

delays in patient care to take a scheduler off duty for an interview.

for tracking patients new 

to a clinic that are waiting for medical appointments, and the use of the 

recall/reminder software to facilitate reminders for patients that need to 

return to the clinic for follow-up medical appointments. We also obtained 

from VHA and reviewed VAMCs’ fiscal year 2011 certifications of 

compliance with VHA’s scheduling policy—a required annual self15VHA Support Services Center maintains an internal VHA website that allows central 

office-, VISN-, and VAMC-level staff to access reports on a variety of topics including 

medical appointment data. 

16The electronic wait list is a type of computer software application designed for recording, 

tracking, and reporting veterans waiting for medical appointments.
 

Page 5 GAO-13-130 VA Scheduling and Wait Times

certification—as well as documentation of scheduler training completion 

obtained from the four VAMCs visited. Finally, we reviewed patient 

complaints about telephone responsiveness collected by each VAMC’s 

Office of the Patient Advocate.

To examine VHA’s initiatives to improve veterans’ access to timely 

medical appointments, we interviewed VHA central office officials to 

obtain information about selected initiatives and reviewed relevant VHA 

documents outlining these initiatives. We also interviewed officials at the 

VAMCs we visited about the implementation of these initiatives and 

officials at the Billings Clinic, a non-VA health care facility involved in the 

implementation of one of the initiatives.17

We conducted this performance audit from February 2012 to December

2012 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.

VHA’s health care system is geographically divided into 21 VISNs, each 

of which is headed by a VISN director. Each VISN is comprised of a 

network of VAMCs, and the VISN office serves as the basic budgetary 

and decision-making unit for providing health care services to veterans 

within that geographical area. Each VAMC and its affiliated CBOCs and 

ambulatory care centers are headed by a VAMC director who manages 

administrative functions, and a chief of staff who manages clinical 

functions for these facilities. VHA’s Central Office establishes systemwide scheduling policy.

VHA’s scheduling policy establishes processes and procedures for 

scheduling medical appointments, and for ensuring the competency of 

staff directly or indirectly involved in the scheduling process. This policy is 

designed to help VAMCs meet VHA’s commitment to scheduling medical 

 

17VHA uses non-VA care to reduce wait times and backlogs and to provide veterans 

access to specialists not available through VHA.

Background 

VHA Medical Appointment 

Scheduling Policy
 

Page 6 GAO-13-130 VA Scheduling and Wait Times

appointments with no undue waits or delays. Specifically, VHA’s 

scheduling policy includes, but is not limited to, the following 

requirements:

• Requires VAMCs to use VHA’s Veterans Health Information Systems 

and Technology Architecture (VistA) medical appointment scheduling 

system to schedule medical appointments.18

• Requires VAMCs to keep appointment schedules open and available 

for patients to make medical appointments at least 3 to 4 months into 

the future.

• Requires schedulers to record in the VistA scheduling system the date 

on which the patient or provider wants the patient to be seen as the 

desired date. To determine the desired date, schedulers should be in 

communication with the patient when scheduling the medical 

appointment.

• Requires schedulers to record the desired date correctly and 

describes how to determine and record the desired date for new 

patients—patients who haven’t been seen by a health care provider in 

a clinic within the past 2 years, including those scheduled in response 

to a consult request—as well as specifying how to determine the 

desired date for established patients’ follow-up medical 

appointments—patients who have been seen within the past two 

years.19

• Requires VAMCs to track new patients waiting for medical 

appointments using the electronic wait list within VistA and to remind 

established patients of follow-up medical appointments using the 

recall/reminder software within VistA, which enables clinics to create a 

list of established patients who need follow-up medical appointments 

more than 3 or 4 months in the future.

 

18From this point forward, the VistA medical appointment scheduling system will be 

referred to as the VistA scheduling system.

19Consults—generally requests for specialty care appointments—are most often 

communicated electronically through an application in the electronic medical record within 

VistA. 
 

Page 7 GAO-13-130 VA Scheduling and Wait Times

Additionally, 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.20

Officials at the VHA central office, VISN, and VAMC all have oversight 

responsibilities for the implementation of VHA’s scheduling policy. In the 

VHA central office, the Director of Systems Redesign, through the Office 

of the Deputy Undersecretary for Health for Operations and Management, 

is responsible for the oversight and implementation of medical 

appointment scheduling requirements. This oversight includes 

measurement and monitoring of ongoing performance. Each VISN 

director, or designee, is responsible for oversight of enrollment and 

medical appointment scheduling for eligible veterans.21 Each VAMC 

director, or designee, is responsible for ensuring that clinics’ scheduling of 

medical appointments complies with VHA’s scheduling policy, including 

clinics in affiliated CBOCs and ambulatory care centers. In addition, the 

VAMC director is responsible for ensuring that any staff who can 

schedule medical appointments in the VistA scheduling system has 

completed VHA scheduler training.22

Starting in fiscal year 2007, VHA required every VAMC to annually selfcertify compliance with VHA’s scheduling policy.23

 

20VHA Directive 2007-033, Telephone Service for Clinical Care (Oct. 11, 2007). 

This certification is 

signed by the VAMC director and also encompasses scheduling 

compliance in affiliated CBOCs and ambulatory care centers. For fiscal 

year 2011, the certification required VAMCs to self-certify compliance, 

partial compliance, or noncompliance with more than 30 individual 

21To obtain VHA healthcare services, veterans generally must enroll with VHA and 

register at a specific VAMC.

22Specifically, VAMCs are required to maintain a list of all staff who can schedule medical 

appointments in the VistA scheduling system and VAMC directors are required to ensure 

successful completion of required training by all staff on the list. Schedulers are not to be 

allowed to schedule medical appointments in the VistA scheduling system without proof of 

their successful completion of this training.

23For fiscal year 2011, the most recent certification available at the time of our review, 

VHA Systems Redesign collected VAMC directors’ certification through a web-based 

template. As part of the certification, VAMC directors certify that they have completed, 

using VISN-approved processes and procedures, a yearly standardized audit of 

schedulers on the timeliness and appropriateness of scheduling actions and the accuracy 

of desired dates.
 

Page 8 GAO-13-130 VA Scheduling and Wait Times

aspects of VHA’s scheduling policy as well as overall compliance, partial 

compliance, or noncompliance with VHA’s scheduling policy as a whole. 

According to officials, VHA’s central office does not penalize 

noncompliance with the certification and expects oversight to be 

managed locally. VHA’s central office uses this certification of compliance 

as a tool for VAMCs to identify and improve performance on important 

aspects of the policy.

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 

VHA’s electronic medical record, known as the Computerized Patient 

Record System, and the scheduling system. As we reported in May 2010, 

the VistA scheduling system is more than 25 years old and inefficient in 

facilitating care coordination between different sites.24 In 2000, VHA 

began an initiative to modernize the scheduling system, but VA 

terminated the project in 2009. We also reported that VA’s efforts to 

successfully replace the scheduling system were hindered by 

weaknesses in its project management processes and lack of effective 

oversight.

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

medical appointments within 30 days to ensure veterans’ timely access to 

care.25

 

24GAO, Information Technology: Management Improvements Are Essential to VA’s 

Second Effort to Replace Its Outpatient Scheduling System, 

In fiscal year 2011, VHA shortened the wait time goal to 14 days 

for both primary and specialty care medical appointments based on 

improved performance reported in previous years. Specifically, VA’s 

reported wait times for fiscal year 2010 showed that nearly all primary 

care and specialty care medical appointments were scheduled within 

30 days of desired date. In fiscal year 2012, VHA added a goal of 

completing primary care medical appointments within 7 days of the 

desired date.

GAO-10-579 (Washington, 

D.C.: May 27, 2010).

25VHA also has a goal of scheduling compensation and pension examinations within 

30 days. Compensation and pension examinations may be provided to veterans to 

establish a claim for disability compensation; appointment wait times for these 

appointments are outside the scope of this report. 

VistA Information 

Technology System

Wait Time Measurement 

and Performance
 

Page 9 GAO-13-130 VA Scheduling and Wait Times

To facilitate accountability for achieving its wait time goals, VHA includes 

wait time measures—referred to as performance measures—in its VISN 

and VAMC directors’ performance contracts known as Network Director

Performance Plans (NDPP) and Facility Director Performance Plans 

(FDPP), respectively.26 Wait time performance measures also are 

included in VA’s budget submissions and performance reports to 

Congress and stakeholders; the performance reports are published

annually in VA’s Performance and Accountability Report (PAR).27

However, the medical appointment wait time performance measures 

included in the NDPPs and FDPPs differ from the measures that are 

reported in the PAR. (See table 1.) For example, in fiscal year 2012, 

VHA’s wait time goal of 7 days for primary care medical appointments 

was reflected in the NDPP and FDPP performance measures, but the 

fiscal year 2012 PAR reported primary care wait time performance using 

a 14-day standard.28 The performance measures have also changed over 

time.29

 

26Directors’ performance contracts include measures against which directors are rated at 

the end of the fiscal year, which determine their performance pay. The contracts include 

system-wide performance measures, as well as individualized performance measures that 

are selected based on specific problems or needs of the respective VISN or VAMC.

27VA 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 PAR, which contains performance targets and results 

achieved against those targets in the previous year.

28VHA officials told us the department is working to better coordinate consistency of the 

performance measures.

29For example, the fiscal year 2011 NDPP and FDPP included a measure “percent of 

patients waiting for a primary care appointment longer than 14 days from the desired date” 

instead of the primary care measures included in fiscal year 2012.The fiscal year 2010 

NDPP and FDPP included the measure “percent of patients waiting for a primary care 

appointment longer than 30 days from the desired date.” In addition, the fiscal year 2011 

PAR included three rather than four wait time measures that did not break out the new 

and established patients for primary and specialty care; the fiscal year 2012 PAR included 

separate measures for new and established patients. The fiscal year 2010 PAR also 

included three measures, one of which measured the “percent of new patient 

appointments completed within 30 days of the appointment create date.” 
 

Page 10 GAO-13-130 VA Scheduling and Wait Times

At the time of our review, all of VHA’s medical appointment wait time 

performance measures reflected the number of days elapsed from the 

patient’s or provider’s desired date, which is 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; which is not reflected by other available wait time 

measures.

Table 1: Selected Fiscal Year 2012 VHA Medical Appointment Wait Time Performance Measures 

Performance plan or report Wait time performance measure

Network Director’s Performance Plans 

and Facility Director’s Performance 

Plans (NDPP, FDPP)

Percent of patients waiting for a specialty care appointment longer than 14 days from the 

desired date a

Percent of primary care appointments completed within 7 days of the desired date

b

Same day access with primary care provider (percent of requested same day primary care 

appointments completed within one day)

c

VA Budget Submission and Performance 

and Accountability Report (PAR)

c

Percent of new patient primary care appointments completed within 14 days of the desired 

date d

Percent of established patient primary care appointments completed within 14 days of the 

desired date

e

Percent of new patient specialty care appointments completed within 14 days of the 

desired date

Percent of established patient specialty care appointments completed within 14 days of 

the desired date

e

Source: VA.

Notes: New and established patient appointments, and primary care and specialty care appointments 

refer to outpatient medical appointments.

a

The NDPP and FDPP are the network (VISN) and facility (VAMC) directors’ contracts that include 

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

monitored throughout the year.

b

For fiscal year 2012, the specialty care medical appointment wait time measure represents the 

percent of patients waiting for at least one appointment longer than 14 days from the desired date at 

a given point in time. The measure was collected twice a month and VISN and VAMC directors were 

rated against the average of these scores at the end of the year. The plans also included additional 

performance measures specifically for mental health appointment timeliness that are outside the 

scope of this report.

c

For fiscal year 2012, the plans included five individual measures related to primary care and a sixth 

measure that was a composite of the five individual measures. Two of the five individual primary care 

measures pertained to primary care medical appointment wait times; these two wait time measures 

represent the percent of appointments completed in the specified time frame. The three other 

individual measures were percentage of total encounters that occur by telephone (telephone 

utilization), percentage of primary care appointments with patient’s assigned primary care provider 

(continuity of care), and percentage of patients discharged from hospital who were contacted by their 

primary care provider within 2 days (post-hospital discharge contact). At the end of the year, VISN 

and VAMC directors were scored for each of the five individual primary care measures and rated 

against the single composite measure. They were rated as meeting the composite measure if they 

met targets for at least three of the five individual primary care measures.
 

Page 11 GAO-13-130 VA Scheduling and Wait Times

d

VA prepares a congressional budget justification that provides details supporting the policy and 

funding decisions in the President’s budget request that is submitted to Congress prior to the 

beginning of each fiscal year. VA also publishes an annual PAR, which contains performance targets 

and results achieved against those targets in the previous year. For fiscal year 2012, the four PAR 

wait time measures represent the percent of each type of appointment completed within 14 days of 

the desired date. The cumulative year-to-date scores were reported on the PAR.

e

Generally, for wait time measurement purposes, VA defines new patients as those who have not 

been seen in a particular clinic at that facility within the last 2 years. This includes appointments for 

newly enrolled patients as well as those scheduled in response to a consult request.

Medical appointment wait times used for measuring and assessing 

performance toward VHA’s wait time goals are unreliable due to problems 

with recording the appointment desired date in the VistA scheduling 

system. Acknowledging limitations of the wait time measures, VHA uses 

additional information to monitor patients’ access to medical 

appointments.

VHA measures its medical appointment wait times as the number of days 

that have elapsed from the patient’s or provider’s desired date. 

Consequently, the reliability of reported wait time performance is 

dependent on the consistency with which schedulers record the desired 

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

scheduling policy and training documents regarding how to determine and 

record the desired date are unclear and do not ensure replicable and 

reliable use of the desired date. In addition, we found that some 

schedulers at select VAMCs did not correctly implement other aspects of 

VHA’s scheduling policy for recording the desired date.

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 in 

the VistA scheduling system.30

 

30According to a VHA official, there were more than 50,000 staff across VHA who could 

schedule appointments at the time of our review.

Specifically, VHA’s scheduling policy and 

Reported Medical 

Appointment Wait 

Times Are Unreliable; 

VHA Uses Additional 

Methods to Monitor 

Patients’ Access to 

Medical 

Appointments 

Reported Medical 

Appointment Wait Times 

Derived from Desired Date 

Are Unreliable

Unclear Desired Date Policy 
 

Page 12 GAO-13-130 VA Scheduling and Wait Times

related scheduler training documents do not provide consistent guidance 

about when or whether the desired date should be based on the patient’s 

or provider’s preference. While the policy defines desired date as “the 

date on which the patient or provider wants the patient to be seen,” it also 

instructs that the “the desired date needs to be defined by the patient” for 

new patient medical appointments, medical appointments scheduled in 

response to consult requests, and established patient follow-up medical 

appointments. When there is a conflict between the provider and patient 

desired date, the scheduler is instructed to contact the provider for a 

decision on the return time frame, but the policy and training documents 

do not clearly describe under what circumstances the provider’s date 

should be used as the desired date. Further, providers may designate a 

desired appointment time frame for a follow-up medical appointment 

rather than a specific date; in such cases, the policy is unclear as to 

which date within the provider’s designated time frame the scheduler 

should enter as the desired date. The scheduling policy and training do 

not provide sufficient guidance to ensure consistent use of desired date in 

these various scheduling scenarios.

VHA central office officials responsible for developing VHA’s scheduling 

policy and related training documents told us that the desired date is 

intentionally broad to account for all of the scheduling scenarios that may 

exist. However, leadership officials from the four VAMCs we visited and 

their corresponding VISNs reported problems with the unclear guidance 

on the desired date definition, and difficulties achieving consistent and 

correct use of the desired date by their schedulers. In addition, given the 

ambiguity in the scheduling policy and related training documents, there 

are different interpretations of the desired date between officials at 

different levels. For example, a VISN director stated that if a provider 

gives a desired time frame, the scheduler is to use the earliest date in that 

range as the desired date; whereas a provider in a specialty care clinic at 

the VAMC we visited within that VISN stated that the clinic uses the latest 

date in the range to meet the 14-day specialty care medical appointment 

scheduling goal.

Additionally, when presented with various scheduling scenarios, 

schedulers at the VAMCs we visited determined and recorded the desired 

date differently. For example, when posed with the question “What date 

do you enter into the scheduling system as the desired date for an 

established patient follow-up medical appointment?”, 12 schedulers said 

they would enter the patient’s desired date, 4 said the provider’s date, 

and the remaining 3 said they used the next available medical 

appointment date. When posed with the question “If the patient’s stated 
 

Page 13 GAO-13-130 VA Scheduling and Wait Times

desired date conflicts with the provider’s designated desired date or time 

frame, what date do you enter as the desired date?”, 1 scheduler said 

that the patient’s desired date would be entered, while another said the 

desired date has to come from the provider. The variation in schedulers’ 

interpretation of the desired date suggests confusion about its correct use 

in different scheduling scenarios.

Although unclear about when to use the patient’s or provider’s desired 

date, VHA’s scheduling policy clearly instructs that, in all circumstances, 

the desired date should be defined without regard to schedule capacity, 

and should not be altered once established to reflect a medical 

appointment date the patient accepts because of lack of medical 

appointment availability on the desired date. However, we found that at 

least one scheduler from each of the VAMCs we visited did not correctly 

implement these aspects of the policy when recording the desired date in 

the VistA scheduling system for specific hypothetical scheduling 

situations.31 As summarized in table 2, we identified the following three 

types of errors, each of which would have resulted in desired dates that 

did not accurately reflect the patients’ or providers’ desired date, as well 

as potentially result in the reporting of more favorable wait times for those 

medical appointments.32

• Determined appointment availability prior to establishing desired date: 

Although VHA’s scheduling policy requires schedulers to establish the 

desired date for a medical appointment without regard to the schedule 

capacity, four schedulers from three VAMCs determined the clinic’s 

next available medical appointment dates before establishing a 

desired date. Therefore, reported wait times for these appointments 

may not have accurately reflected how long patients actually waited.

• Altered original desired date based on appointment availability: Three 

schedulers from two VAMCs established a desired date that was 

recorded in the VistA scheduling system independent of schedule 

capacity, but later altered the desired date because of appointment 

 

31Because the policy and training documents are unclear about when the desired date is 

defined by the patient or defined by the provider, we only identified errors related to 

aspects of the policy and training regarding how to determine and record the desired date 

that hold true despite the ambiguity.

32For reporting on the PAR, VHA measures medical appointment wait times as the 

number of days between the desired date and appointment date.

Errors in Recording Desired 

Date
 

Page 14 GAO-13-130 VA Scheduling and Wait Times

availability. Specifically, two of the three schedulers altered the 

originally established desired date to match the agreed-upon 

appointment date, which would have incorrectly resulted in no wait 

time reported for the appointment. The third scheduler altered the 

established desired date when there was no appointment availability 

within 2 weeks of that date; which would have resulted in an 

incorrectly reported wait time that was shorter than the patient actually 

waited from his or her original desired date.

• Recorded a new desired date when rescheduling appointment: 

Additionally, eight schedulers from three VAMCs incorrectly recorded 

a new desired date when rescheduling an appointment cancelled by 

the clinic rather than keeping the original desired date as required by 

VHA’s scheduling policy. Changing the desired date in this way would 

incorrectly decrease the reported wait times for the rescheduled 

appointments; veterans actually would wait longer than the reported 

wait times indicated.
 

Page 15 GAO-13-130 VA Scheduling and Wait Times

Table 2: Number of Schedulers at Each VAMC Visited Who Incorrectly Recorded the Medical Appointment Desired Date, by 

Error Type

Number of schedulers who demonstrated error 

(number of schedulers interviewed at each VAMC)

Desired date recording error VAMC A (3) VAMC B (7) VAMC C (4) VAMC D (5)

Total 

schedulers who 

demonstrated error

Determined medical appointment availability prior 

to establishing desired datea 1  

2 1 0 4 

Altered original desired date based on medical 

appointment availabilitya 0  

2 1 0 3 

Recorded a new desired date when rescheduling a 

medical appointment

0 b 3 3 2 8 

Total number of errors 1 7 5 2 15

Total number of schedulers who demonstrated 

at least one error 1 6 3 2 12

Source: GAO analysis of scheduler interviews.

Notes: This table presents the results of our interviews with 19 schedulers from the four VAMCs 

visited. We used structured questions to test how schedulers would determine and enter the desired 

date for specific medical appointment types using hypothetical patients. We identified three types of 

desired date scheduling errors which, for actual patient medical appointments, would have resulted in 

a desired date that would not accurately reflect the patient or provider’s desired date, as well as 

potentially result in reporting of more favorable wait times for those medical appointments. A 

scheduler could have demonstrated more than one error.

a

According to VHA’s scheduling policy, when scheduling new patient medical appointments—

including medical appointments in response to a consult request—and established patient follow-up 

medical appointments, the medical appointment desired date needs to be defined by the patient 

without regard to schedule capacity. Once the patient’s desired date has been established, it must not 

be altered to reflect a medical appointment date patients agree to accept due to lack of medical 

appointment availability on the original desired date.

b

During our site visits, staff at some clinics told us they change medical 

appointment desired dates to show clinic wait times within VHA’s 

performance goals. A scheduler at one primary care clinic specifically 

stated that she changes the recorded desired date to the patient’s 

agreed-upon appointment date in order to show shorter wait times for the 

clinic. A provider at a specialty care clinic at another VAMC said providers 

in that clinic change the desired dates of their follow-up appointments if a 

patient cannot be scheduled within the 14-day performance goal.

According to VHA’s scheduling policy, when a medical appointment is cancelled and rescheduled by 

the clinic, the scheduler must record as the desired date for the new medical appointment, the 

desired date for the original medical appointment. Three of the 19 schedulers did not respond to 

questions about rescheduling medical appointments.

In addition, the reported wait times, derived from desired date, for one of 

the specialty care clinics we visited were inconsistent with the VAMC’s 

account of appointment scheduling backlogs and scheduling challenges, 
 

Page 16 GAO-13-130 VA Scheduling and Wait Times

indicating reported wait time inaccuracies. At the time of our site visit, 

officials from this clinic indicated that long waits for new patient 

appointments had existed prior to our visit and told us that the next 

available appointment for a new patient was in 6 to 8 weeks. However, 

reported wait time data for the month we visited showed that the clinic 

completed all new patient appointments on the desired date, resulting in 

an unlikely high percentage of appointments with zero-day wait times that 

was inconsistent with information gathered during our site visit, raising 

questions about whether the desired date was recorded in accordance 

with VHA’s scheduling policy. Furthermore, according to reported wait 

times for the VAMC, this clinic completed nearly all new patient 

appointments within 14 days of the desired date for the 2 months prior to 

our visit; and, similarly, in the 2 months after our visit, reported wait times 

for this clinic show completion of all new patient appointments within the 

14-day time frame.33

VHA central office officials told us that they recognized the potential 

reliability issues of using the desired date for measuring wait times, but 

stated that use of the desired date is the best approach for capturing 

patient experience and preference. Officials told us that there is no single 

industry standard for measuring how long patients wait for appointments 

and commonly used measures—such as capacity measures—do not 

account for patient preference or reflect how long the patient actually 

waited for an appointment.34

 

33This is based on a measure similar to the performance measure “percent of new patient 

specialty care medical appointments completed within 14 days of the desired date,” 

reported on the PAR.

In addition, officials told us that the VistA 

scheduling system was not designed to capture data for management 

purposes, which has limited VHA’s options for developing wait time 

measures. Over the years, VHA has tried using many different 

approaches to measuring wait times, such as capacity measures and 

using the date the appointment was created rather than the desired date 

34Clinic capacity is the supply of available future appointments. Capacity measures 

typically count the number of days between the day the measure is taken and the day the 

first or third next available appointment occurs.

VHA Officials Cited 

Importance of Desired 

Date in Capturing Patient 

Preference and 

Supplement Wait Time 

Measures with Other 

Information to Monitor 

Patient Access to 

Appointments 
 

Page 17 GAO-13-130 VA Scheduling and Wait Times

to determine wait times.35

In addition to measuring medical appointment wait times, VHA central 

office officials reported that VHA also uses other information to monitor 

patients’ access to medical appointments and to assist VISNs and 

VAMCs in managing clinics.

Although these measures were not officially 

used for performance accountability or reported on the PAR or NDPP and 

FDPP in fiscal year 2012, data on these measures are available to VISNs 

and VAMCs for performance monitoring. Officials told us that improving 

how wait times are measured is an ongoing effort, and they have 

conducted research to identify wait time measures that most closely 

correlate with patient satisfaction and positive outcomes. At the time of 

our review, VHA had not implemented changes to wait time performance 

measures based on the results of this research.

Patient Satisfaction Measures: VHA central office and VISN officials with 

whom we spoke identified patient satisfaction as another important 

indicator of patient access to medical appointments and VA has 

incorporated measures of self-reported patient satisfaction in its 

performance assessments.36 Specifically, the annual PAR includes a 

measure of overall patient satisfaction with VHA inpatient and outpatient 

healthcare in addition to the wait time measures derived from desired 

date. Separate measures related to patient satisfaction with obtaining 

outpatient care were also among the measures available for VISN and 

VAMC directors to include in their fiscal years 2011 and 2012 

performance plans (NDPP and FDPP).37

 

35For example, in the 2010 PAR, VA reported a wait time performance measure for new 

patient medical appointments based on days from the date the appointment was created. 

The appointment create date is automatically generated in the VistA scheduling system 

and therefore not prone to scheduler error. VHA officials told us that wait time measures 

based on create date do not reflect patient preference and therefore can incorrectly 

characterize wait times, particularly for established patient follow-up appointments which 

may be scheduled months before they are completed.

VHA also makes the satisfaction 

36Since 2002, VHA has measured veterans’ perceived access through a monthly Survey 

of Health Experiences of Patients —a survey of satisfaction with inpatient and outpatient 

care similar to the Department of Health and Human Services Consumer Assessment of 

Healthcare Providers Survey. 

37Specifically, those measures were: Getting Needed Care—combines responses from 

questions regarding how much of a problem, if any, patients had with various aspects of 

getting needed care; and Getting Care Quickly—combines responses from questions 

regarding how often patients received various types of care in a timely manner.
 

Page 18 GAO-13-130 VA Scheduling and Wait Times

measures available to VISNs and VAMCs for continuous performance 

monitoring as well as available to the public. One of the four VAMCs we 

visited included the satisfaction measures in their performance plan for 

fiscal year 2012, and officials cited monitoring these measures on a 

regular basis. Officials from one VISN also specifically cited comparing its 

VAMCs’ patient satisfaction scores to reported wait times to identify 

inconsistencies. However, the director of another VAMC said he does not 

rely on the satisfaction measures to monitor access because the data are

dated by the time the VAMC sees the results, and instead, he relies on 

the scheduling data derived from wait time measures.

Clinic Management Information: In addition to wait time measures, VHA 

has other information available for VISNs and VAMCs to manage clinics 

and monitor and improve clinic access, such as no-show rates and 

consult lists. Several clinic officials reported monitoring no-show rates—

the rate at which patients do not appear for their scheduled 

appointment—in order to reduce unused appointments, for example, by 

identifying and providing additional appointment reminders to patients 

with frequent no-shows. Officials from multiple specialty clinics said they 

monitor lists of consults—requests for specialty care appointments—to 

ensure they are acted upon in a timely manner.38 Although the time 

between when the provider requests a consult and when the specialty 

clinic reviews the consult can affect the total time a patient waits for a 

specialty appointment, this time is not reflected in current wait time 

performance measures.

 

38Consults are most often communicated electronically through an application in the 

electronic medical record within VistA. The electronic medical record is separate from the 

scheduling system.
 

Page 19 GAO-13-130 VA Scheduling and Wait Times

The four VAMCs we reviewed did not consistently implement certain 

elements of VHA’s scheduling policy, including oversight requirements, 

which may result in increased wait time or delays in scheduling medical 

appointments. VAMCs also described other problems with scheduling 

timely medical appointments, including outdated technology, gaps in 

staffing of schedulers and providers, and telephone access problems.

The four VAMCs we visited did not consistently implement VHA’s 

scheduling policy, which is intended to facilitate the creation of medical 

appointments that meet patients’ needs with no undue waits or delays. 

This policy includes the use of the VistA scheduling system to schedule 

medical appointments, and the use of the electronic wait list to track new 

patients waiting for medical appointments. (See table 3 for information on 

the number of clinics we visited that did not implement selected elements 

of the VHA’s scheduling policy.) Inconsistent implementation of VHA’s 

scheduling policy can result in increased wait time or delays in obtaining 

medical appointments.

Inconsistent 

Implementation of 

VHA’s Scheduling 

Policy and Other 

Problems Impede 

VAMCs’ Ability to 

Schedule Timely 

Medical 

Appointments 

Inconsistent 

Implementation of VHA’s 

Scheduling Policy Hinders 

VAMCs’ Ability to Schedule 

Timely Medical 

Appointments 
 

Page 20 GAO-13-130 VA Scheduling and Wait Times

Table 3: Number of Clinics That Did Not Implement Selected Elements of the VHA’s Scheduling Policy, by VAMC Visited 

Number of clinics at each VAMC that did not implement the 

element of VHA’s scheduling policy 

(clinics visited at each VAMC)

Element of VHA’s scheduling policy

(number of clinic responses) VAMC A (4) VAMC B (9) VAMC C (5) VAMC D (5) 

Using VistA in scheduling of medical appointments (23) 0 1 0 0 

Scheduling medical appointments while in direct communication 

with the patient (20) 0 1 5 0 

Using the electronic wait list for patients who have not been seen 

before in the clinic and are waiting to be scheduleda (21) 0 1 2 1 

Using recall/reminder software for medical appointments needed 

more than 3 to 4 months into future (22) 0 0 5 0 

Keeping medical appointment schedules open at least 3 to 

4 months into future (19) 1 1 1 1 

Total number instances in which elements of VHA’s 

scheduling policy were not implemented 1 4 13 2 

Total number of clinics that did not implement at least one 

element of VHA’s scheduling policy 1 2 5 2 

Source: GAO analysis of interviews at 23 clinics.

Notes: Except for the element “using VistA in scheduling of medical appointments,” we did not report 

responses for all 23 clinics we visited because interview responses were incomplete for some 

elements of the VHA’s scheduling policy as depicted in the table.

a

One of the clinics we visited did not use the VistA scheduling system to 

determine available medical appointment dates and times, and to 

schedule medical appointments, as required by VHA’s scheduling policy. 

Officials noted that this clinic lacked a full-time staff person dedicated to 

scheduling, and therefore, the providers called their patients to schedule 

their own medical appointments. Clinic staff reported that providers 

recorded medical appointments on sheets of paper and gave those 

sheets to a scheduler, who maintained a paper calendar of all medical 

appointments; this scheduler later recorded the appointment into the 

VistA scheduling system. Failing to use VistA to schedule medical 

appointments could create additional backlogs or scheduling errors 

because the schedule in VistA may not accurately reflect providers’ 

availability. According to one provider in this clinic, for example, “staff 

from other departments look in VistA [scheduling system] and it looks like 

the clinic is not booked, so they’ll send their patients as walk-in 

appointments. However, the clinic is really fully booked and patients are 

waiting.” 

Officials from 12 clinics told us that they do not use the electronic wait list because their clinic did not 

have new patients waiting for appointments or their clinic schedules patients for appointments with 

long wait times.

Use of VistA Scheduling System
 

Page 21 GAO-13-130 VA Scheduling and Wait Times

Officials from six clinics across two different VAMCs reported that staff 

scheduled new patient or established patient follow-up medical 

appointments without speaking to patients, and then notified patients of 

the scheduled medical appointment by letter, if the appointment was at 

least a few weeks away. This method of scheduling—referred to as 

“blind” scheduling by one official —is not in accordance with VHA’s 

scheduling policy and could result in missed medical appointments for 

patients who do not receive the letters, or are not available at the 

scheduled time because patients are not involved in the scheduling 

process. One scheduler noted that he sent medical appointment letters

because he didn’t have time to call all patients to schedule appointments 

as he performs scheduling duties for 27 different clinics. Furthermore, 

outdated or incorrect patient contact information is an impediment to 

scheduling appointments via letters; an official in one of the six clinics told 

us that the databases containing patient contact information used to send 

such letters often do not have veterans’ correct or up-to-date contact 

information.

Officials in four clinics across three VAMCs that had backlogs of patients 

waiting for medical appointments stated that they do not use the 

electronic wait list, the official VHA wait list used to track patients with 

whom a clinic does not have an established relationship.39 Clinics that do 

not use the electronic wait list may be at risk of losing track of new 

patients waiting for medical appointments. For example, at one specialty 

clinic with a backlog of consult requests, medical appointments for new 

patients were backed up almost 3 months; VAMC officials reported 

tracking patients waiting for medical appointments by printing paper 

copies of the consult requests from the electronic medical record. A 

provider at this clinic expressed concern that the clinic manager “has a 

tall stack of unscreened consult referrals just sitting on her desk, and no 

one is addressing them.” 

 

39According to VHA’s scheduling policy, the electronic wait list is used to keep track of 

patients with whom the provider does not yet have an established relationship and who 

cannot be scheduled for appointments in target time frames. No other wait list formats 

(such as paper or electronic spreadsheets) are to be used for tracking requests for 

medical appointments.

Communication with Patients

Use of the Electronic Wait List 
 

Page 22 GAO-13-130 VA Scheduling and Wait Times

Officials from one VAMC stated that it did not have the required 

recall/reminder software to facilitate reminders for patients who need to 

return to the clinic for follow-up medical appointments more than 3 to 

4 months into the future; therefore, none of its clinics, including the five 

clinics that we visited, were able to use it as intended.40

One clinic in each of the four VAMCs visited did not keep their medical 

appointment schedules open 3 to 4 months into the future as required by 

VHA’s scheduling policy.

Instead clinics at 

this VAMC use a work-around in the scheduling system to remind clerks 

to print and send letters reminding patients to call and schedule their 

follow-up medical appointments. However, this work-around is not 

automated and relies on schedulers to remember to generate a list of 

patients who need follow-up medical appointments, and print and send 

those letters. The VAMC is in the process of implementing recall/reminder 

software, according to officials.

41

The VAMCs we visited inconsistently implemented certain oversight 

requirements in VHA’s scheduling policy—specifically, completion of 

training and certification of compliance. VAMC officials stressed the 

importance of scheduler training for ensuring correct implementation of 

VHA’s scheduling policy; however, certain VAMCs did not ensure 

Instead, these four clinics allowed medical 

appointments to be booked only 1 to 2 months into the future. Limiting the 

future medical appointment schedule may limit patients’ ability to 

schedule a follow-up medical appointment before leaving the clinic, as 

recommended by the policy, and also may result in additional work for 

clinic staff to send recall/reminder letters to patients for medical 

appointments less than 3 to 4 months away.

 

40Patients are entered into the recall/reminder software for the date they are to return to 

the clinic—which should be identified by the provider—and VistA automatically generates 

correspondence to the patient (post card or letter) a week or 2 prior to that date to remind 

the patient to call the clinic and schedule a medical appointment.

41VHA’s scheduling policy states that for clinics to most efficiently operate, “schedules 

must be open and available for the patient to make [medical] appointments at least three 

to four months into the future. Permissions may be given to schedulers to make 

appointments beyond these limits when doing so is appropriate and consistent with patient 

or provider requests. Blocking the scheduling of future [medical] appointments by limiting 

the maximum days into the future an appointment can be scheduled is inappropriate and 

is disallowed.” 

Use of Recall/reminder 

Software

Medical Appointment Schedule 

Availability

Oversight of VHA’s Scheduling 

Policy
 

Page 23 GAO-13-130 VA Scheduling and Wait Times

completion of the training by all staff who were required to complete it.42

All four of the VAMCs we visited completed the required self-certification 

of compliance with the VHA’s scheduling policy for fiscal year 2011, three 

of which certified overall compliance, and one certified overall

noncompliance.

Although all VAMCs we visited provided a list of staff who can schedule 

appointments, three VAMCs did not provide documentation that all staff 

on the list had successfully completed the required training. For example, 

officials from one VAMC stated that it maintained a list of staff who can 

schedule appointments, and a separate list of staff who had completed 

the training, but only in response to GAO’s request for documentation did 

the VAMC identify staff with scheduling access who needed to complete 

the training. Further, three of the 19 schedulers we interviewed said they 

completed training other than the required VHA scheduler training. 

Completion of required VHA scheduler training and maintaining up-todate documentation of schedulers’ completion of the training is 

particularly important for ensuring consistent implementation of VHA’s 

scheduling policy, given the high rates of scheduler turnover described by 

officials.

43 However, leadership officials from two VAMCs, 

including the only one of the four that certified overall noncompliance, 

were initially uncertain who completed the certification or the steps taken 

to complete it, indicating that VAMCs are not always using the selfcertification process to identify and improve problems with compliance 

with VHA’s scheduling policy.

 

42VAMCs are required to maintain a list of all staff who can schedule medical 

appointments in the VistA scheduling system, and are required to ensure successful 

completion of required VHA scheduler training by all staff on that list. Schedulers are not 

to be allowed to schedule medical appointments in the VistA scheduling system without 

proof of their successful completion of this training.

43Of the 144 VAMCs that completed the certification for fiscal year 2011, 109 certified 

overall compliance, 27 certified partial compliance, and 8 certified noncompliance.
 

Page 24 GAO-13-130 VA Scheduling and Wait Times

VAMCs identified several problems that can impede the timely scheduling 

of medical appointments, which also may impact their compliance with 

VHA’s scheduling policy.

VHA central office officials and officials from all of the VAMCs we visited 

said the VistA scheduling system is outdated and inefficient, which 

hinders the timely scheduling of medical appointments. In particular, 

officials said the scheduling system requires schedulers to use 

commands requiring many keystrokes and does not allow them to view 

multiple screens at once. Schedulers must open and close multiple 

screens to check a provider’s or clinic’s full availability when scheduling a 

medical appointment, which is time-consuming and can lead to errors. 

For example, providers have separate schedules within VistA to 

accommodate the various types of services they provide.44

Officials from all the VAMCs we visited also noted that the VistA 

scheduling system is not easily adapted to meet clinic needs. For 

example, staff cannot create a provider schedule in the scheduling 

system that is longer than 8 hours. If a provider wants to extend his or her 

schedule on certain days, staff must create additional clinic schedules in 

Because the 

scheduling system cannot display multiple schedules on the same 

screen, schedulers have to enter and exit multiple screens to check a 

provider’s full daily schedule when scheduling a medical appointment. If 

schedulers do not open all of the necessary screens, they may 

unknowingly create scheduling errors such as booking two medical 

appointments at the same time in different sections of a provider’s 

schedule. Further, staff at one VAMC told us the problem of not being 

able to easily view a provider’s full schedule can result in the failure to 

ensure that appointments are cancelled when a provider requests it. This 

error could cause patients to come to the VAMC unnecessarily or a failure 

to reschedule cancelled appointments in a timely way, both of which 

might lead to increased wait times for those patients.

 

44For example, a physical therapist may have a separate schedule for amputee clinic, 

general physical therapy, or other types of services.

VAMCs Identified Other 

Problems with Scheduling 

Medical Appointments, 

Including Issues with 

Outdated Technology, 

Staffing Gaps, and 

Telephone Access

Problems with Outdated VistA 

Scheduling System
 

Page 25 GAO-13-130 VA Scheduling and Wait Times

the scheduling system for that provider, which can result in more delays 

and possible errors because schedulers have to check additional screens 

for medical appointment availability. Furthermore, officials told us that the 

scheduling system does not automatically interface with VHA’s electronic 

medical record,45

VAMC officials described steps they take to ensure schedulers use VistA 

in accordance with the scheduling directive, including ongoing scheduler 

training and supervisory reviews of scheduler performance. However, as 

noted above, a lack of clarity in the desired date training documents and a 

lack of documentation of scheduler training at certain facilities may limit 

the effectiveness of these interventions. One VAMC provides schedulers 

with dual monitors to enable them to open multiple screens at once. 

Another VAMC told us they considered this solution in their primary care 

clinic, but found that limited physical space in the clinic did not 

accommodate additional monitors.

which makes the scheduling process more timeconsuming as schedulers alternate between the two software applications 

to ensure medical appointments are made in accordance with providers’ 

guidance.

In response to ongoing problems with the VistA scheduling system, VHA 

undertook an initiative to replace it in 2000, but VA abandoned the 

replacement due to weaknesses in project management and a lack of 

effective oversight. VA released a new request for information in 

December 2011 to gather information about vendors and possible 

software packages that could replace the current scheduling system. In 

September 2012, VHA told us that vendors’ responses to the request for 

information indicated that VHA will be able to choose among several 

viable software packages. According to officials, VA’s next step is to 

compare different vendors’ software packages through the summer of 

2013, and subsequently issue a request for vendor proposals.46

 

45The electronic medical record is a component of the VistA system that includes patient 

health information and enables providers to record notes, such as when the provider 

would like to see the patient for a follow-up appointment, and place orders for procedures, 

x-rays, and laboratory tests, among other things.

46In October 2012, VA announced a contest seeking proposals for a new medical 

appointment scheduling system from commercial software developers. The contest is 

intended to reduce risks in the future procurement and implementation of a new 

scheduling system.
 

Page 26 GAO-13-130 VA Scheduling and Wait Times

VHA central office officials and officials from all of the VAMCs we visited 

stated that shortages or turnover of schedulers also creates problems for 

the timely scheduling of medical appointments. Officials said that 

schedulers perform many important roles, including greeting patients, 

checking patients in and out of clinics, answering telephone calls, 

scheduling medical appointments for primary care, as well as specialty 

care consults, and performing other administrative support functions on 

behalf of the clinical staff. Officials explained, however, that high stress 

and a demanding workload as well as the entry-level pay grade of the 

scheduler position leads to high turnover. Further, officials told us that 

high-performing schedulers often are quickly promoted to other positions 

within VA. According to VHA officials, most scheduler positions are 

classified as a low grade within the government general schedule pay 

scale with little room for upward movement within the grade. Officials at 

two of the VAMCs we visited told us they are working to raise the pay 

level for schedulers; for example, one VAMC has begun to assess 

scheduler position descriptions to determine whether they can be 

reclassified to allow for more flexibility in determining scheduler salaries 

based on the variation in their assigned duties.

Given the important role of schedulers in the scheduling process, officials 

said that even temporary staffing gaps or shortages can cause medical 

appointment delays or wait times. Staff with whom we spoke in several 

clinics said that when scheduler staffing is lacking, including when a 

scheduler is on short-term leave, it is difficult to cover all the scheduler’s 

duties, and that such gaps can cause delays for patients. Further, we 

were told that scheduler staffing gaps resulted in inefficient use of clinical 

staff time. For example, at one specialty clinic that lacked its own 

scheduler, providers routinely scheduled their own medical appointments, 

which took away from time seeing patients, and also resulted in incorrect 

scheduling practices. Given the training needs associated with using the 

VistA scheduling system, following VHA’s scheduling policy, and ensuring 

the correct use of desired date, high rates of scheduler turnover could 

contribute to inconsistent use of desired date in the scheduling process or 

other appointment scheduling problems.

Officials at two VAMCs noted that scheduler staffing gaps are 

compounded by recent changes in their roles and responsibilities as VHA 

implements a new team-based model of primary care, which calls for one 

scheduler to be assigned to each primary care team. Officials told us that 

these changes generally increase the administrative demands placed on 

schedulers, as they are asked to respond to team duties while continuing 

to answer phones, greet patients, and register new patients, among other 

Problems with Scheduler 

Turnover and Provider Staffing 

Gaps
 

Page 27 GAO-13-130 VA Scheduling and Wait Times

responsibilities. Officials from two VAMCs told us they had requested 

approval to hire additional staff to meet these added administrative 

needs.

Scheduler staffing gaps may also create problems managing patient flow 

through clinics, which can impede scheduling of follow-up appointments, 

according to officials at two of the VAMCs we visited. Staff at these 

VAMCs told us that they sometimes do not have sufficient schedulers 

available to staff check-out desks, and staff at one VAMC added that as a 

result patients might “fall through the cracks,” leaving follow-up medical 

appointments unscheduled unless the patient remembers to call in to 

schedule the appointment. In addition, when patients do not check out, 

schedulers are responsible for tracking patients needing follow-up 

medical appointments. This situation may be exacerbated in clinics that 

do not use the required recall/reminder software to facilitate the 

scheduling of follow-up medical appointments more than 3 to 4 months in 

the future, adding further to the backlog of patients in need of follow-up 

medical appointments.

Officials from all of the VAMCs we visited told us that provider shortages 

also contribute to scheduling backlogs in certain locations and specialties. 

Recruitment and retention of providers was a particular challenge for

VAMCs in rural areas, areas with high costs of living, and for certain 

provider specialties. All of the VAMCs we visited described gaps in 

provider staffing in certain specialty care clinics. Officials at all VAMCs 

also stated that a lack of salary competitiveness or the length of time to 

hire new providers into the VA system also contributed to gaps in provider 

staffing and scheduling backlogs.

Gaps in provider staffing also can result from providers being on 

extended or unexpected leave, including vacation time, sick leave, or 

military deployments. These absences may result in longer wait times for 

patients. For example, officials at one VAMC told us that even a brief 

absence of one provider on leave can cause significant wait times, and 

that it is difficult to catch up and eliminate the backlog.

Staff from some clinics described steps they take to reduce backlogs 

caused by gaps in provider staffing, including overbooking provider 

schedules and scheduling temporary Saturday hours. Officials at one 

VAMC told us that they employ a “floater” primary care physician to 

provide coverage for providers on leave, but an official at another clinic 

told us that they were unable to hire additional providers to meet the 

demand for medical appointments.
 

Page 28 GAO-13-130 VA Scheduling and Wait Times

Officials at all of the VAMCs we visited told us that high call volumes and 

a lack of staff dedicated to answering the telephones impede the timely 

scheduling of medical appointments.47 Despite VHA’s telephone policy 

requiring the provision of continuous telephone service for clinical care 

and medical appointment management, VAMC officials noted that 

schedulers are frequently overwhelmed by high call volumes and are 

unable to respond to calls in a timely way. In addition, officials at one 

VAMC told us that outdated telephone technology, and the lack of a 

dedicated VAMC-wide call center, limited their ability to improve their 

telephone responsiveness. VHA has reported that telephone access to 

VHA health services has historically been a frustrating experience for 

veterans, including dropped calls, multiple transfers, and long waits to 

reach a staff person able to resolve their inquiries.48 Further, patients at 

all of the VAMCs we visited registered complaints about the difficulty of 

reaching outpatient clinic staff by telephone and unreturned telephone 

calls. According to information on patient complaints provided by the four 

VAMCs we visited, patient complaints about unreturned telephone calls 

ranked among the top two categories of complaints in fiscal year 2012 at 

all four VAMCs.49 Further, staff at two of the VAMCs reported that their 

telephone calls to outpatient clinics within their own VAMC went 

unanswered, and one added that their inability to reach staff in their own 

clinics also was an obstacle to timely medical appointment scheduling.

 

47VHA’s policy on telephone service for clinical care, VHA Directive 2007-033, establishes 

VHA’s policy of providing telephone access for appointment management and continuous 

access to health care advice. The telephone directive also establishes recommended 

benchmarks for telephone service at VA facilities. VAMCs differ in how they manage the 

telephones; for example, some VAMCs establish VAMC-wide call centers to answer and 

direct incoming calls. VAMC telephone systems generally serve the VAMC including its 

affiliated CBOCs and ambulatory care centers.

48Veterans Health Administration, Telephone Systems Improvement Guide, Second 

Edition (December 2011). 

49Each VAMC has a patient advocate who accepts and addresses patient complaints. The 

patient advocate records complaints in the patient advocate tracking system and tracks 

complaints in various categories, including “phone calls not returned, letters not 

answered.” Two of the four VAMCs provided information on patient complaints for fiscal 

year 2012 from October 1, 2011, through May 31, 2012. One VAMC provided information 

for fiscal year 2012 through June 25, 2012, and the other provided information for fiscal 

year 2012 through August 31, 2012.

Problems with Telephone 

Access 
 

Page 29 GAO-13-130 VA Scheduling and Wait Times

In January 2012, VHA distributed suggested best practices for improving 

telephone design, service, and access in its Telephone Systems 

Improvement Guide.50 This guide outlines steps VHA found to be effective 

means of improving telephone service and maintaining health care 

access, including regularly monitoring the purpose and volume of 

telephone calls; establishing dedicated staff to answering calls, especially 

at times of peak call volume; and training staff responsible for answering 

telephones in call centers. To address telephone issues, officials at one 

VAMC we visited told us they were developing a proposal to establish a 

call center with a new telephone system, to be staffed by schedulers 

dedicated to answering the telephones. Officials at a different VAMC 

stated that a scheduling supervisor periodically checks schedulers’ 

telephones to ensure that voice mail messages are listened to and that 

calls are returned.

VHA is implementing several initiatives to improve veterans’ access to 

medical appointments. Specifically, these initiatives focus on more 

patient-centered care; using technology to provide care, through means 

such as telehealth; 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. VHA officials 

told us they are monitoring the implementation of these initiatives; 

however, in some cases, more information is needed to determine their 

impact on timely access to care over time.

VHA’s patient-centered medical home model for primary care, Patient 

Aligned Care Teams (PACT), is intended, in part, to improve access to 

medical appointments and care coordination through the use of 

interdisciplinary care teams and technology to communicate with patients. 

Implementation of PACT began in 2010, and is an ongoing effort, 

according to VHA officials. PACT differs from how primary care was 

previously delivered by assigning each patient to an interdisciplinary 

team. The PACT team is intended to be comprised of a primary care 

provider, registered nurse care manager, a clinical support staff member 

such as a licensed practical nurse, and a scheduler.51

 

50Veterans Health Administration, Telephone Systems Improvement Guide. 

These teams offer 

51VHA officials noted that even in primary care clinics in which PACT implementation has 

begun, some PACT teams are not yet fully staffed in accordance with the model.

VHA Is Implementing 

a Number of 

Initiatives to Improve 

Access to Medical 

Appointments 

Patient-Centered Care 

Initiatives
 

Page 30 GAO-13-130 VA Scheduling and Wait Times

patients a centralized way to get questions answered by nurses or other 

clinical support staff and aim to reduce the need for face-to-face medical 

appointments, thereby enabling more efficient use of providers’ time. For 

example, at one of the VAMCs we visited, patients are given a direct 

telephone number to contact their PACT team and leave a voice mail 

message to be returned by the team’s registered nurse. Encouraging

PACT teams’ use of telephone communication and telephone 

appointments is intended to enable patients to more quickly obtain 

answers to some of their administrative and medical questions, such as 

requests for prescription refills, without having to schedule a face-to-face 

medical appointment. VHA officials told us that they expect PACT teams’ 

use of telephone communication and telephone appointments will open 

up face-to-face medical appointment slots for patients who need them 

and might enable clinics to reduce backlogs and improve access to sameday primary care medical appointments.

Officials at two VAMCs we visited told us that the transition to the PACT 

model has created some initial scheduling and staffing difficulties. For 

example, officials at these VAMCs noted that it is difficult for scheduling 

staff to respond to their PACT team duties in addition to meeting other 

responsibilities such as answering phones, checking in patients, 

registering new patients, and scheduling for more than one clinic. This is 

compounded by the fact that not all PACT teams have been assigned 

their own scheduler, as prescribed by the PACT model, so an individual 

scheduler is sometimes serving multiple PACT teams. Officials at these 

two VAMCs explained that they would need to hire more schedulers to 

meet the goal of assigning one to each PACT team.

To measure the progress of PACT implementation and its impact on 

access to quality care, VHA is collecting data and tracking a series of 

measures in a monthly internal data report. Five of the PACT measures 

are (1) primary care medical appointments completed within 7 days of the 

desired date;52

 

52In contrast to the PACT 7-day wait time measure reported in the NDPP and FDPP, VA 

reported primary care wait time performance as the completion of appointments within 

14 days of desired date in its fiscal year 2012 PAR.

(2) same day access with primary care provider, or the 

percentage of appointments completed within 1 day; (3) telephone 

utilization, or the percentage of total encounters that occur by telephone; 

(4) continuity of care, or the percentage of primary care appointments 

with the patient’s assigned primary care provider; and (5) post-hospital 
 

Page 31 GAO-13-130 VA Scheduling and Wait Times

discharge contact, or percentage of patients discharged from the hospital 

who were contacted by their primary care provider within 2 days.53 As 

described earlier, accurate measurement of medical appointment wait 

times—including the first two PACT measures—is dependent upon the 

correct recording of the desired date in the VistA scheduling system. In 

fiscal year 2012, PACT measures were also included in the NDPP and 

FDPP.54

Part of VHA’s goal of achieving improved access to medical appointments 

is the increased use of technology such as telehealth and secure 

messaging.55

VHA telehealth includes:

Use of these tools is intended to improve communication 

between patients and providers and open up providers’ schedules for 

needed face-to-face medical appointments, thereby improving access to 

face-to-face appointments.

• home telehealth for chronic disease management such as diabetes;

• real-time clinic-based video telehealth, in which patients at a local 

CBOC may connect with a VHA provider at a different location to 

receive services that are unavailable at the CBOC, such as mental 

health or speech pathology;

• and store-and-forward telehealth, in which digital images such as 

x-rays or images of skin problems, are taken, stored, and sent to an 

expert for review and consultation.

 

53There are additional measures in the monthly internal data report. 

54VISN and VAMC directors were scored for each of the five PACT measures listed and 

rated against a sixth composite PACT measure. They were rated as meeting the 

composite PACT measure if they met targets for three of the five individual PACT 

measures.

55Telehealth is the delivery of health care services using telecommunications technology. 

Using technology such as videoconferencing, telehealth changes the location where 

health care services are delivered. Secure messaging is VHA’s web-based message 

service that allows patients to communicate nonemergency health-related information with 

their health care team.

Initiatives Using 

Technology 
 

Page 32 GAO-13-130 VA Scheduling and Wait Times

VHA officials told us that the use of telehealth can reduce both travel and 

wait times for medical appointments and help meet the needs of patients 

with chronic conditions. All VAMCs we visited told us they were using 

telehealth to improve access to care.

Another initiative that uses technology to reduce unnecessary face-toface medical appointments is VHA’s My HealtheVet, a web-based 

program that enables veterans to create and maintain a web-based 

personal health record with secure access to health information; services 

such as prescription refill requests; and secure messaging. Secure 

messaging allows veterans to communicate electronically with their health 

care team. According to VHA, of the more than 8 million veterans enrolled 

in VHA, 1.4 million are registered in My HealtheVet as of August 2012, 

and more than 437,000 have created secure messaging accounts. A 

recent VA study reports that secure messaging may improve access, 

patient perceptions about access, and provides for better 

communication.56

VHA uses non-VA care to reduce wait times and backlogs and to provide 

veterans’ access to specialists not available through VHA.57

 

56Kim Nazi, Department of Veterans Affairs Experiences with System-wide Transformation 

Activities that Foster Continuous Learning and Improvement, Institute of Medicine 

Consensus Study on the Learning Healthcare System in America (May 2012). 

Under a 

statutory requirement to help veterans receive care closer to home, VHA 

is piloting a new model of non-VA care known as Project ARCH (Access 

57Non-VA care is medical care paid for by VA but provided to veterans outside of VA. 

Non-VA care may be offered on a temporary basis to a veteran when medical services are 

not available due to a lack of available VA specialists, long wait times, or when VA care is 

only available at extraordinary distances from a veteran’s home. VAMCs do not track wait 

times for patients using non-VA care.

Non-VA Care Initiative
 

Page 33 GAO-13-130 VA Scheduling and Wait Times

Received Closer to Home).58 Project ARCH is a five-site, 3-year pilot 

program administered by the VHA Office of Rural Health to provide health 

care services through contracts with local community providers.59

At the Montana Project ARCH pilot site, which we visited as part of our 

site visit to the Montana VAMC, staff from the VAMC and the Billings 

Clinic, a non-VA provider delivering services to veterans through Project 

ARCH, identified both benefits and obstacles for patients enrolled in 

Project ARCH. For example, though VAMC and Billings Clinic staff noted 

that Project ARCH reduced both travel and wait times for Montana 

veterans in need of orthopedic care, Billings Clinic staff also noted that 

difficulties in coordinating care for veterans moving between VHA and 

non-VA providers at times resulted in delays in providing care to those 

and other veterans. Additionally, problems with processing authorizations 

for certain services were among the concerns raised in an April 2012 

evaluation of the Montana Project ARCH program.

According to VHA officials, Project ARCH might help alleviate wait times 

for specialty care services with high demand, or for which there is a 

shortage of local providers.

60

Project ARCH contractors must submit monthly reports, including 

information on medical appointment scheduling timeliness, wait times, 

and other topics. For example, the contractor for the Project ARCH 

 

58See Pub. L. No. 110-387, § 403, 122 Stat. 4110, 4124 (2008). Veterans are eligible to 

participate in the program if they reside in a location where a pilot site is located and if 

they are enrolled in VA health care when the program starts, and meet any of the 

following criteria: live more than (1) 60 miles driving distance from the nearest VA health 

care facility providing primary care services, if the veteran is seeking such services; 

(2) 120 miles driving distance from the nearest VA health care facility providing acute 

hospital care, if the veteran is seeking such care; or (3) 240 miles driving distance from 

the nearest VA health care facility providing tertiary care, if the veteran is seeking such 

care. Nonenrolled veterans who are eligible to enroll in VA health care because they 

served in a combat theater after November 11, 1998, are also eligible to participate in the 

program. Health care delivery contracts for services covered under Project ARCH were 

awarded to Humana Veterans, a health services support contractor, in four pilot sites, and 

to a health care provider in the fifth pilot site. 

59Project ARCH services are currently being piloted at five sites, including Northern 

Maine; Farmville, Virginia; Pratt, Kansas; Flagstaff, Arizona; and Billings, Montana.

60VA is required to evaluate the program and prepare an annual report to Congress for 

each of the 3 years of the pilot. VHA engaged a contractor to conduct site visits and 

provide VHA with quarterly progress reports on Project ARCH implementation. The first 

progress report for Montana VAMC’s Project ARCH program was produced in April 2012. 
 

Page 34 GAO-13-130 VA Scheduling and Wait Times

Program in Montana is required to report on the extent to which it is 

meeting VHA’s 14-day wait time goal for medical appointments—

according to VHA officials, the contractor must meet a 90 percent target. 

These wait times may not accurately reflect how long patients are waiting 

for a medical appointment, however, because the wait time is counted 

from the time the contractor receives the authorization from VA, rather 

than from the time the patient or provider requests a medical 

appointment.

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. 

Ambiguity in what constitutes the medical appointment desired date—the 

date VHA uses as the basis for measuring wait time—as well as 

manipulation of the desired date to meet goals have contributed to these 

inaccuracies. With more than 50,000 schedulers making approximately 

80 million medical appointments in fiscal year 2011, establishing a clear 

definition of the desired date or finding and reporting another acceptable 

measure of wait time is key to understanding how long veterans are 

actually waiting for medical appointments. Without reliable measurement 

of how long patients are waiting for medical appointments, VHA is less 

equipped to identify and address factors that contribute to wait times, or 

gauge the success of its initiatives to improve access to timely medical 

appointments, including efforts to improve primary care medical 

appointments.

More consistent adherence to VHA’s scheduling policy and oversight of 

the scheduling process, as well as the allocation of staffing resources in 

accordance with clinics’ demands for scheduling of medical 

appointments, would potentially reduce medical appointment wait times. 

Furthermore, persistent problems with telephone access must be 

resolved to assure veterans’ ability to schedule timely medical 

appointments. Ultimately, 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.

Conclusions 
 

Page 35 GAO-13-130 VA Scheduling and Wait Times

To ensure reliable measurement of veterans’ wait times for medical 

appointments, we recommend that the Secretary of VA direct the Under 

Secretary for Health to take actions to improve the reliability of wait time 

measures either by clarifying the scheduling policy to better define the 

desired date, or by identifying clearer wait time measures that are not 

subject to interpretation and prone to scheduler error.

To better facilitate timely medical appointment scheduling and improve 

the efficiency and oversight of the scheduling process, we recommend 

that the Secretary of VA direct the Under Secretary for Health to take 

actions to ensure that VAMCs consistently and accurately implement 

VHA’s scheduling policy, including use of the electronic wait list, as well 

as ensuring that all staff with access to the VistA scheduling system 

complete the required training.

To improve timely medical appointment scheduling, we recommend that 

the Secretary of VA direct the Under Secretary for Health to develop a 

policy that requires VAMCs to routinely assess clinics’ scheduling needs 

and resources to ensure that the allocation of staffing resources is 

responsive to the demand for scheduling medical appointments.

To improve timely medical appointments and to address patient and staff 

complaints about telephone access, we recommend that the Secretary of 

VA direct the Under Secretary for Health to ensure that all VAMCs 

provide oversight of telephone access and implement best practices 

outlined in its telephone systems improvement guide.

In reviewing a draft of this report, VA generally agreed with our 

conclusions and concurred with our recommendations. (VA’s comments 

are reprinted in app. I.) In summary, VA stated that VHA officials have 

closely followed our review and proactively taken steps in response to our 

findings. Specifically, VHA is revising and improving directives, policies, 

training, clinic management tools, and oversight related to scheduling 

practices. VA further stated that VHA is committed to routinely assessing 

clinics’ scheduling needs and resources and developing practices and 

guidelines to ensure adequate staffing resources for scheduling medical 

appointments.

Recommendations for 

Executive Action

Agency Comments 

and Our Evaluation 
 

Page 36 GAO-13-130 VA Scheduling and Wait Times

VA described its plans to address each recommendation as follows: 

• In response to our recommendation that VA take actions to improve 

the reliability of wait time measures, VA concurred and stated that 

VHA will revise its scheduling policy to implement more reliable wait 

time measures and new processes to better define desired date with a 

targeted completion date of November 1, 2013.

• In response to our recommendation that VA take actions to ensure 

that VAMCs consistently and accurately implement VHA’s scheduling 

policy and ensure that all staff complete required training, VA 

concurred and stated that the revised scheduling policy will include 

improvements and standardization of the use of the electronic wait 

list. Additionally, VHA will require VISNs to update each VAMC’s 

scheduler master list and verify that all schedulers on the list have 

completed required training, and will require schedulers to complete a 

standardized training update on the revised scheduling policy. The 

targeted completion date for these activities is November 1, 2013.

• In response to our recommendation that VA develop a policy that 

requires VAMCs to routinely assess clinics’ scheduling needs and 

resources, VA concurred and stated that VHA will ask VAMCs to 

routinely assess clinics’ availability and ensure staff is distributed to 

meet access standards in clinics. However, VA has not specified 

requirements for VAMCs to complete these assessments nor has the 

agency provided a timeline for this process. Because schedulers are 

key to ensuring timely appointment scheduling, we believe that VA 

should establish a targeted completion date for requiring these 

assessments in policy or guidance.

• In response to our recommendation that VA ensure that all VAMCs 

provide oversight of telephone access and implement best practices 

outlined in its telephone improvement guide, VA concurred and stated 

that VHA will require each VISN director to assess current phone 

service and develop strategic improvement telephone service plans to 

improve service. Additionally, VHA will identify a process to monitor 

performance on a quarterly basis for at least 1 year after the 

assessment. The targeted completion date for the telephone service 

assessments and plans is March 30, 2013. 
 

Page 37 GAO-13-130 VA Scheduling and Wait Times

As arranged with your offices, unless you publicly announce the contents 

of this report earlier, we plan no further distribution until 28 days after its 

issuance date. At that time, we will send copies of this report to 

appropriate congressional committees, the Secretary of Veterans Affairs 

and other interested parties. In addition, the report is available at no 

charge on the GAO website at http://www.gao.gov. 

If you or your staff have any questions about this report, please contact 

me 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 report. GAO staff who made key contributions to this report 

are listed in appendix II. 

Debra A. Draper

Director, Health Care
Page 38 GAO-13-130 VA Scheduling and Wait Times

List of Requesters

The Honorable Jeff Miller

Chairman

Committee on Veterans’ Affairs

House of Representatives

The Honorable Karen Bass

House of Representatives

The Honorable Shelley Berkley

House of Representatives

The Honorable Howard L. Berman

House of Representatives

The Honorable Brian P. Bilbray

House of Representatives

The Honorable Mary Bono Mack

House of Representatives

The Honorable Ken S. Calvert

House of Representatives

The Honorable John Campbell

House of Representatives

The Honorable Lois Capps

House of Representatives

The Honorable Judy Chu

House of Representatives

The Honorable Jim Costa

House of Representatives

The Honorable Susan Davis

House of Representatives

The Honorable David Dreier

House of Representatives
Page 39 GAO-13-130 VA Scheduling and Wait Times

The Honorable Elton Gallegly

House of Representatives

The Honorable Joe Heck

House of Representatives

The Honorable Duncan D. Hunter

House of Representatives

The Honorable Darrell Issa

House of Representatives

The Honorable Jerry Lewis

House of Representatives

The Honorable Kevin McCarthy

House of Representatives

The Honorable Howard P. McKeon

House of Representatives

The Honorable Gary Miller

House of Representatives

The Honorable Grace Napolitano

House of Representatives

The Honorable Laura Richardson

House of Representatives

The Honorable Dana Rohrabacher

House of Representatives

The Honorable Lucille Roybal-Allard

House of Representatives

The Honorable Ed Royce

House of Representatives

The Honorable Loretta Sanchez

House of Representatives
Page 40 GAO-13-130 VA Scheduling and Wait Times

The Honorable Adam Schiff

House of Representatives

The Honorable Brad Sherman

House of Representatives

The Honorable Henry A. Waxman

House of Representatives
Appendix I: Comments from the Department of 

Veterans Affairs

Page 41 GAO-13-130 VA Scheduling and Wait Times

Appendix I: Comments from the Department 

of Veterans Affairs
Appendix I: Comments from the Department of 

Veterans Affairs

Page 42 GAO-13-130 VA Scheduling and Wait Times
Appendix I: Comments from the Department of 

Veterans Affairs

Page 43 GAO-13-130 VA Scheduling and Wait Times
Appendix I: Comments from the Department of 

Veterans Affairs

Page 44 GAO-13-130 VA Scheduling and Wait Times
Appendix II: GAO Contact and Staff 

Acknowledgments

Page 45 GAO-13-130 VA Scheduling and Wait Times

Debra A. Draper, (202) 512-7114 or draperd@gao.gov

In addition to the contact named above, Bonnie Anderson, Assistant 

Director; Rebecca Abela; Jennie Apter; Rich Lipinski; Sara Rudow; and 

Ann Tynan made key contributions to this report.

Appendix II: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Staff 

Acknowledgments 
Related GAO Products

Page 46 GAO-13-130 VA Scheduling and Wait Times

VA Mental Health: Number of Veterans Receiving Care, Barriers Faces, 

and Efforts to Increase Access. GAO-12-12. Washington, D.C.: 

October 14, 2011.

Information Technology: Department of Veterans Affairs Faces Ongoing 

Management Challenges. GAO-11-663T. Washington, D.C.: 

May 11, 2011.

Information Technology: Management Improvements Are Essential to 

VA’s Second Effort to Replace Its Outpatient Scheduling System. 

GAO-10-579. Washington, D.C.: May 27, 2010.

VA Health Care: Access for Chattanooga-Area Veterans Needs 

Improvement. GAO-04-162. Washington, D.C.: January 30, 2004.

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

but Some Clinics Have Made Progress. GAO-01-953. Washington, D.C.: 

August 31, 2001.

Veterans’ Health Care: VA Needs Better Data on Extent and Causes of 

Waiting Times. GAO/HEHS-00-90. Washington, D.C.: May 31, 2000.

Related GAO Products

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