VA HEALTH CARE

Ongoing and Past Work 

Identified Access Problems 

That May Delay Needed 

Medical Care for Veterans

Statement of Debra A. Draper

Director, Health Care

Testimony 

Before the Committee on Veterans’ 

Affairs, House of Representatives

For Release on Delivery 

Expected at 10:00 a.m. EDT

Wednesday, April 9, 2014

GAO-14-509T

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-509T, a testimony 

before the Committee on Veterans’ Affairs, 

House of Representatives

April 9, 2014

VA HEALTH CARE

Ongoing and Past Work Identified Access Problems 

That May Delay Needed Medical Care for Veterans

Why GAO Did This Study

Access to timely medical appointments 

is critical to ensuring that veterans 

obtain needed medical care. Over the 

past few years there have been 

numerous reports of VAMCs failing to 

provide timely care to patients, 

including specialty care, and in some 

cases, these delays have resulted in 

harm to patients. 

In December 2012, GAO reported that 

improvements were needed in the 

reliability of VHA’s reported medical 

appointment wait times, as well as 

oversight of the appointment 

scheduling process. Also in 2012, VHA 

found that systemwide consult data 

could not be adequately used to 

determine the extent to which veterans 

experienced delays in receiving 

outpatient specialty care. In May 2013, 

VHA launched the Consult 

Management Business Rules Initiative 

with the aim of standardizing aspects 

of the consults process.

This testimony highlights 

(1) preliminary observations from 

GAO’s ongoing work related to VHA’s 

management of outpatient specialty 

care consults, and (2) concerns GAO 

raised in its December 2012 report 

regarding VHA’s outpatient medical 

appointment scheduling, and progress 

made implementing GAO’s

recommendations. To conduct this 

work, GAO reviewed documents and 

interviewed officials from VHA’s central 

office. Additionally, GAO interviewed 

officials from five VAMCs for the 

consults work and four VAMCs for the 

scheduling work that varied based on 

size, complexity, and location. GAO 

shared the information it used to 

prepare this statement with VA and 

incorporated its comments as 

appropriate.

What GAO Found

GAO’s ongoing work examining VHA’s management of outpatient specialty care 

consults identified examples of delays in veterans receiving outpatient specialty 

care, as well as limitations in the Department of Veterans Affairs’ (VA), Veterans 

Health Administration’s (VHA) implementation of new consult business rules 

designed to standardize aspects of the clinical consult process. For example, for 

4 of the 10 physical therapy consults GAO reviewed for one VAMC, between 108 

and 152 days elapsed with no apparent actions taken to schedule an 

appointment for the veteran. For 1 of these consults, several months passed 

before the veteran was referred for care to a non-VA health care facility. VA 

medical center (VAMC) officials cited increased demand for services, and patient 

no-shows and cancelled appointments among the factors that lead to delays and 

hinder their ability to meet VHA’s guideline of completing consults within 90 days 

of being requested. GAO’s ongoing work also identified variation in how the five 

VAMCs reviewed have implemented key aspects of VHA’s business rules, such 

as strategies for managing future care consults—requests for specialty care 

appointments that are not clinically needed for more than 90 days. Such variation 

may limit the usefulness of VHA’s data in monitoring and overseeing consults 

systemwide. Furthermore, oversight of the implementation of the business rules 

has been limited and did not include independent verification of VAMC actions. 

Because this work is ongoing, we are not making recommendations on VHA’s 

consult process at this time.

In December 2012, GAO reported that VHA’s outpatient medical appointment 

wait times were unreliable. The reliability of reported wait time performance 

measures was dependent in part on the consistency with which schedulers 

recorded desired date—defined as the date on which the patient or health care 

provider wants the patient to be seen—in the scheduling system. However, 

VHA’s scheduling policy and training documents were unclear and did not ensure 

consistent use of the desired date. GAO also reported that inconsistent 

implementation of VHA’s scheduling policy may have resulted in increased wait 

times or delays in scheduling timely medical appointments. For example, GAO 

identified clinics that did not use the electronic wait list to track new patients in 

need of medical appointments as required by VHA policy, putting these patients 

at risk for not receiving timely care. VA concurred with the four recommendations 

included in the report and, in April 2014, reported continued actions to address 

them. For example, in response to GAO’s recommendation for VA to take actions 

to improve the reliability of its medical appointment wait time measures, officials 

stated the department has implemented new patient wait time measures that no 

longer rely on desired date recorded by a scheduler. VHA officials stated that the 

department also is continuing to address GAO’s three additional 

recommendations. Although VA has initiated actions to address GAO’s

recommendations, continued work is needed to ensure these actions are fully 

implemented in a timely fashion. 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. View GAO-14-509T. For more information, 

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

draperd@gao.gov.
 

Page 1 GAO-14-509T

Chairman Miller, Ranking Member Michaud, and Members of the 

Committee:

I am pleased to be here today as you examine issues related to delays in 

medical care provided by the Department of Veterans Affairs’ (VA), 

Veterans Health Administration (VHA). In fiscal year 2012, VHA provided 

nearly 84 million outpatient medical appointments to veterans through its 

primary and specialty care clinics, which are managed by VA medical 

centers (VAMC).1 Although access to timely medical appointments is 

critical to ensuring that veterans obtain needed medical care, problems 

with VHA’s scheduling and management of outpatient medical 

appointments may contribute to delays in care, or care not being provided 

at all. Over the past few years there have been numerous reports of 

VAMCs failing to provide timely care to patients, including specialty care, 

and in some cases, the delays have resulted in harm to patients.2

Nonetheless, VHA has reported continued improvements in achieving 

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

2011, VA reported that VHA completed 89 percent of medical 

appointments for new patients within its goal; in fiscal year 2012, VA 

reported that VHA completed 90 percent of primary and specialty care 

new patient appointments within the goal.3

 

1

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 cardiology or gastroenterology.

However, in December 2012, 

we reported that VHA’s medical appointment wait times were unreliable 

and VHA’s inadequate oversight of the outpatient medical appointment 

2

See, for example, Department of Veterans Affairs, Office of Inspector General, 

Healthcare Inspection Gastroenterology Consult Delays William Jennings Bryan Dorn VA 

Medical Center Columbia, South Carolina, Report No. 12-04631-313. (Washington D.C.: 

September 6, 2013), and Department of Veterans Affairs, Office of Inspector General, 

Healthcare Inspection Consultation Mismanagement and Care Delays Spokane VA 

Medical Center Spokane, Washington, Report No. 12-01731-284. (Washington D.C.: 

September 25, 2012). 

3

In fiscal year 2012, VHA’s appointment wait time goal for primary and specialty care 

appointments was 14 days from the patient’s or provider’s desired appointment date. 

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 2 GAO-14-509T

scheduling processes contributed to VHA’s problems with scheduling 

timely medical appointments.4

When a physician or other provider determines that a veteran needs 

outpatient specialty care, the provider refers the veteran to a specialist for 

a clinical consult—a request for evaluation or management of a patient for 

a specific clinical concern, or for a specialty procedure such as a

colonoscopy. VAMCs request and manage outpatient consults through an 

electronic system that retains information about each consult request and 

is part of VHA’s Veterans Health Information Systems and Technology 

Architecture (VistA).

 

5

Appointments resulting from outpatient consults, like other outpatient 

medical appointments, are subject to VHA’s scheduling policy.

Ideally, the consult system would contain timely and 

reliable information on the status and outcomes of consults, and would 

provide VHA information it needs to help effectively manage the process.

In 2012, however, VHA found that systemwide consult data could not be 

adequately used to determine the extent to which veterans experienced 

delays in receiving outpatient specialty care. As a result, in May 2013, 

VHA launched an initiative to standardize aspects of the consult process, 

with the goal of developing consistent and reliable information on consults 

across all VAMCs.

6

 

4

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

Times and Scheduling Oversight Need Improvement, 

This 

policy is designed to help VAMCs meet their commitment to scheduling 

medical appointments with no undue waits or delays for patients. It 

establishes processes and procedures for scheduling medical 

appointments and ensuring the competency of staff directly or indirectly 

involved in the scheduling process. Additionally, it includes several 

requirements that affect timely appointment scheduling, as well as 

accurate wait time measurement. For example, the policy requires 

schedulers to record appointments in VHA’s VistA medical appointment 

scheduling system.

GAO-13-130 (Washington, D.C.: 

Dec. 21, 2012).

5

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

health care settings. It contains patients’ electronic health records.

6

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

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

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

Page 3 GAO-14-509T

My statement today will draw from ongoing work examining the 

management of outpatient specialty care consult processes at five 

selected VAMCs, and our December 2012 report examining the reliability 

of VHA’s reported outpatient medical appointment wait times data and 

scheduling oversight.7

For our ongoing outpatient specialty care consults work,

In particular, this statement highlights 

(1) preliminary observations from our ongoing work, and (2) key findings 

and recommendations from our December 2012 report, as well as the 

progress VHA has made in implementing those recommendations.

8 we reviewed 

documents and interviewed VHA central office officials about VHA’s 

policies and guidance for VAMCs to send, receive, and complete 

consults, and VHA’s procedures for VAMCs to schedule outpatient 

medical appointments, which include those for specialty care. We also 

reviewed documents and interviewed VHA central office officials about 

their efforts to oversee VAMCs’ implementation of VHA’s consult policies, 

including VHA’s Consult Management Business Rules Initiative, launched 

in May 2013. Additionally, we interviewed officials from five VAMCs 

selected for variation in volume of outpatient consults, complexity,9

 

7

and 

location. These five VAMCs were located in Augusta, Maine; Denver, 

Colorado; Gainesville, Florida; Oklahoma City, Oklahoma; and Palo Alto, 

California. For each VAMC included in our review, we interviewed 

leadership about how VHA’s consult policies and any local policies or 

procedures for managing consults are implemented at their facility. We 

also interviewed specialty care service chiefs, administrative staff, and 

providers of three high-volume specialty services—cardiology, 

gastroenterology, and physical therapy. Additionally, for each of the five 

medical centers, we reviewed the history of actions taken on a random 

sample of 30 outpatient consults (10 from each of the three specialties 

included in our review) that were requested during the period April 1, 

2013, through September 30, 2013, that either took more than 90 days to 

complete or had been in process for more than 90 days. The results of 

our review of outpatient consults are not generalizable across all VAMCs.

GAO-13-130. 

8

The scope of our work is limited to outpatient consults; however, providers may also 

request consults for inpatient care and administrative needs, among other things.

9

VHA categorizes VAMCs according to complexity level, which is determined on the basis 

of the characteristics of the patient population, clinical services offered, educational and 

research missions, and administrative complexity.
 

Page 4 GAO-14-509T

For our December 2012 report, we reviewed VHA’s scheduling policy and 

methods for measuring medical appointment wait times, and interviewed 

VHA central office officials responsible for developing them. We also 

visited 23 high-volume outpatient clinics at four VAMCs selected for 

variation in size, complexity, and location. These four VAMCs were 

located in Dayton, Ohio; Fort Harrison, Montana; Los Angeles, California; 

and Washington, D.C. At each VAMC we interviewed leadership and 

other officials about how they managed and improved medical 

appointment timeliness, their oversight to ensure accuracy of scheduling 

data and compliance with VHA’s scheduling policy, and problems staff 

experienced in scheduling timely appointments. Additionally, in April 

2014, in preparation for this statement, we reviewed documentation and 

interviewed officials from VHA’s central office about the extent to which 

they have addressed the recommendations we made in the 2012 report.

We are conducting our ongoing work on specialty care outpatient 

consults, which began in July 2013, in accordance with generally 

accepted government auditing standards. Because this work is ongoing, 

we are not making recommendations on VHA’s consult process at this 

time. We conducted our prior work on VHA’s outpatient appointment 

scheduling and oversight from February 2012 through December 2012, 

as well as an update on that work in April 2014, 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.

We shared information we used to prepare this statement with VA. After 

reviewing this information, VA provided us with technical comments, 

which we incorporated as appropriate.

When providers at VAMCs determine that a veteran needs outpatient 

specialty care, they request and manage consults using VHA’s clinical 

consult process. Clinical consults include requests by physicians or other 

providers for both clinical consultations and procedures. A clinical 

consultation is a request seeking an opinion, advice, or expertise 

regarding evaluation or management of a patient’s specific clinical 

concern, whereas a procedure is a request for a specialty procedure such 

as a colonoscopy. Clinical consults are typically requested by a veteran’s 

primary care provider using VHA’s electronic consult system. Once a 

Background
 

Page 5 GAO-14-509T

provider sends a request, VHA requires specialty care providers to review 

it within 7 days and determine whether to accept the consult. If the 

specialty care provider accepts the consult—determines the consult is 

needed and is appropriate—an appointment is made for the patient to 

receive the consultation or procedure.10 In some cases, a provider may 

discontinue a consult for several reasons, including that the care is not 

needed, the patient refuses care, or the patient is deceased.11 In other 

cases the specialty care provider may determine that additional 

information is needed, and will send the consult back to the requesting 

provider, who can resubmit the consult with the needed information. Once 

the appointment is held, VHA’s policy requires the specialty care provider 

to appropriately document the results of the consult, which would then 

close out the consult as completed in the electronic system.12 VHA’s 

current guideline is that consults should be completed within 90 days of 

the request.13

In 2012, VHA created a database to capture all consults systemwide and, 

after reviewing these data, determined that the data were inadequate for 

monitoring consults. One issue identified was the lack of standard

processes and uses of the electronic consult system across VHA. For 

example, in addition to requesting consults for clinical concerns, the 

system was also being used to request and manage a variety of 

administrative tasks, such as requesting patient travel to appointments. 

Additionally, VHA could not accurately determine whether patients 

actually received the care they needed or if they received the care in a 

timely fashion. According to VHA officials, approximately 2 million 

consults (both clinical and administrative consults) were unresolved for 

more than 90 days. Subsequently, VA’s Under Secretary for Health 

convened a task force to address these and other issues regarding VHA’s 

If an appointment is not held, staff are to document why 

they were unable to complete the consult.

 

10Some consults, referred to as “e-consults,” do not require an in-person appointment with 

the patient and may be addressed electronically through the consult system.

11When a provider discontinues a consult, action on the consult is stopped, and a new 

consult request must be initiated by the requesting provider for the veteran to obtain the 

specialty care—whether that care is for a clinical consultation or procedure.

12The results of consults are documented in the consult system and are contained in the 

patient’s electronic health record.

13VHA officials noted that although VHA’s guideline is for consults to be completed within 

90 days, consults for urgent needs are completed sooner.
 

Page 6 GAO-14-509T

consult system, among other things. In response to task force 

recommendations, in May 2013, VHA launched the Consult Management 

Business Rules Initiative to standardize aspects of the consult process, 

with the goal of developing consistent and reliable information on consults 

across all VAMCs. This initiative requires VAMCs to complete four 

specific tasks between July 1, 2013, and May 1, 2014:

• Review and properly assign codes to consistently record consult 

requests in the consult system;14

• Assign distinct identifiers in the electronic consult system to 

differentiate between clinical and administrative consults;

• Develop and implement strategies for requesting and managing 

requests for consults that are not needed within 90 days—known as 

“future care” consults;15

• Conduct a clinical review as warranted, and as appropriate, close all 

unresolved consults—those open more than 90 days.

and

At the time of our December 2012 review, VHA measured outpatient 

medical appointment wait times as the number of days elapsed from the 

patient’s or provider’s desired date, as recorded in the VistA scheduling 

system by VAMCs’ schedulers. In fiscal year 2012, VHA had a goal of 

completing new and established patient specialty care appointments 

within 14 days of the desired date. VHA established this goal based on its 

performance reported in previous years.16

 

14These codes identify the type of care requested in the consult (e.g., dermatology or 

cardiology) and are used by VHA to run reports that assist with managing its services.

To facilitate accountability for 

achieving its wait time goals, VHA includes wait time measures—referred 

to as performance measures—in its Veterans Integrated Service Network 

15According to VHA guidance, the consult system should only be used for services 

needed within 90 days. VAMCs were given the option to track future care consults either 

by developing markers so they could be identified in the consult system, or using existing 

mechanisms outside of the consult system such as electronic wait lists. The electronic 

wait list is a type of computer software application designed for recording, tracking, and 

reporting veterans waiting for medical appointments.

16In 1995, VHA established a goal of scheduling primary and specialty care medical 

appointments within 30 days to ensure veterans’ timely access to care. VA’s reported wait 

times for fiscal year 2010 showed that nearly all primary and specialty care medical 

appointments were scheduled within 30 days of desired date. In fiscal year 2011, VHA 

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

appointments.
 

Page 7 GAO-14-509T

(VISN)17 directors’ and VAMC directors’ performance contracts, and VA 

includes measures in its budget submissions and performance reports to 

Congress and stakeholders.18

Officials at VHA’s central office, VISNs, and VAMCs all have oversight 

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

example, each VAMC director, or designee, is responsible for ensuring 

that clinics’ scheduling of medical appointments complies with VHA’s 

scheduling policy and for ensuring that any staff who can schedule 

medical appointments in the VistA scheduling system have completed the 

required VHA scheduler training.

The performance measures, like wait time 

goals, have changed over time.

19 In addition to the scheduling policy, 

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.

 

17VHA’s health care system is divided into 21 areas called VISNs. Each of VA’s 21 VISNs 

is responsible for managing and overseeing medical facilities within a defined geographic 

area.

18VA prepares a congressional budget justification that provides details supporting the 

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

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

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

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

accountability report—which contains performance targets and results achieved compared 

with those targets in the previous year.

19Specifically, 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.
 

Page 8 GAO-14-509T

Our ongoing work identified examples of delays in veterans receiving 

requested outpatient specialty care at the five VAMCs we reviewed. 

VAMC officials cited increased demand for services, and patient noshows and cancelled appointments, among the factors that hinder their 

ability to meet VHA’s guideline for completing consults within 90 days. 

Specifically, several VAMC officials discussed a growing demand for both 

gastroenterology procedures, such as colonoscopies, as well as 

consultations for physical therapy evaluations. Additionally, officials noted 

that due to difficulty in hiring and retaining specialists for these two clinical 

areas, they have developed periodic backlogs in providing services. 

Officials at these facilities indicated that they try to mitigate backlogs by 

referring veterans for care with non-VA providers. However, this strategy 

does not always prevent delays in veterans receiving timely care. For 

example, officials from two VAMCs told us that non-VA providers are not 

always available. Examples of consults that were not completed in 

90 days include:

• For 3 of 10 gastroenterology consults we reviewed for one VAMC, we 

found that between 140 and 210 days elapsed from the dates the 

consults were requested to when the patient received care. For the 

consult that took 210 days, an appointment was not available and the 

patient was placed on a waiting list before having a screening 

colonoscopy.

• For 4 of the 10 physical therapy consults we reviewed for one VAMC, 

we found that between 108 and 152 days elapsed, with no apparent 

actions taken to schedule an appointment for the veteran. The 

patients’ files indicated that due to resource constraints, the clinic was 

not accepting consults for non-service-connected physical therapy 

evaluations.20

• For all 10 of the cardiology consults we reviewed for one VAMC, we 

found that staff initially scheduled patients for appointments between 

33 and 90 days after the request, but medical files indicated that 

patients either cancelled or did not show for their initial appointments. 

In 1 of these cases, several months passed before the 

veteran was referred to non-VA care, and he was seen 252 days after 

the initial consult request. In the other 3 cases, the physical therapy 

clinic sent the consults back to the requesting provider, and the 

veterans did not receive care for that consult.

 

20A non-service-connected disability is an injury or illness that was not incurred or 

aggravated during active military service.

GAO’s Ongoing Work 

Identified Examples 

of Delays in Specialty 

Care, and Limitations 

in VHA’s 

Implementation of Its 

Business Rules 

Impede Its Ability to 

Assess Delays
 

Page 9 GAO-14-509T

In several instances patients cancelled multiple times. In 4 of the 

cases VAMC staff closed the consults without the patients being seen; 

in the other 6 cases VAMC staff rescheduled the appointments for 

times that exceeded the 90-day timeframe.21

Our ongoing work also identified variation in how the five VAMCs we 

reviewed have implemented key aspects of VHA’s business rules, which 

limits the usefulness of the data in monitoring and overseeing consults

systemwide. As previously noted, VHA’s business rules were designed to 

standardize aspects of the consult process, thus creating consistency in 

VAMCs’ management of consults. However, VAMCs have reported 

variation in how they are implementing certain tasks required by the 

business rules. For example, VAMCs have developed different strategies 

for managing future care consults—requests for specialty care 

appointments that are not clinically needed for more than 90 days.

• At one VAMC, officials reported that specialty care providers have 

been instructed to discontinue consults for appointments that are not 

needed within 90 days and requesting providers are to track these 

consults outside of the electronic consult system and resubmit them 

closer to the date the appointment is needed. These consults would 

not appear in VHA’s systemwide data once they have been 

discontinued.

• At another VAMC, officials stated that appointments for specialty care 

consults are scheduled regardless of whether the appointments are 

needed beyond 90 days. These future care consults would appear in 

VHA consult data and would eventually appear on a timeliness report 

as consults open greater than 90 days. Officials from this VAMC 

stated that they continually have to explain to VISN officials who 

monitor the VAMC’s consult timeliness that these open consults do 

not necessarily mean that care has been delayed.

• Officials from another VAMC reported piloting a strategy in its 

gastroenterology clinic where future care consults are entered in an 

electronic system separate from the consult and appointment 

scheduling systems. Approximately 30 to 60 days before the care is 

needed the requesting provider is notified to enter the consult request 

 

21According to VHA consult policy, when a patient fails to keep a scheduled appointment, 

the specialty care provider must reassess the need for service and either reschedule the 

appointment or cancel the consult request, as appropriate. VHA Directive 2008-056, VHA 

Consult Policy (Sept. 16, 2008). 
 

Page 10 GAO-14-509T

in the electronic consult system for the specialty care provider to 

complete.

In addition, oversight of the implementation of VHA’s business rules has 

been limited and has not included independent verification of VAMC 

actions. VAMCs were required to self-certify completion of each of the 

four tasks outlined in the business rules. VISNs were not required to 

independently verify that VAMCs appropriately completed the tasks. 

Without independent verification, VHA cannot be assured that VAMCs 

implemented the tasks correctly.

Furthermore, VHA did not require that VAMCs document how they 

addressed unresolved consults that were open greater than 90 days, and 

none of the five VAMCs in our review were able to provide us with 

specific documentation in this regard. VHA officials estimated that as of 

April 2014, about 450,000 of the approximately 2 million consults (both 

clinical and administrative consults) remained unresolved systemwide. 

VAMC officials noted several reasons that consults were either completed 

or discontinued in this process of addressing unresolved consults, 

including improper recording of consult notes, patient cancellations, and 

patient deaths. At one of the VAMCs we reviewed, a specialty care clinic 

discontinued 18 consults the same day that a task for addressing 

unresolved consults was due. Three of these 18 consults were part of our 

random sample, and our review found no indication that a clinical review 

was conducted prior to the consults being discontinued. Ultimately, the 

lack of independent verification and documentation of how VAMCs 

addressed these unresolved consults may have resulted in VHA consult

data that inaccurately reflected whether patients received the care 

needed or received it in a timely manner.

Although VHA’s business rules were intended to create consistency in 

VAMCs’ consult data, our preliminary observations identified variation in 

managing key aspects of consult management that are not addressed by 

the business rules. For example, there are no detailed systemwide VHA 

policies on how to handle patient no-shows and cancelled appointments, 

particularly when patients repeatedly miss appointments, which may 

make VAMCs’ consult data difficult to assess.22

 

22As we previously reported, scheduling practices at some VAMCs could result in 

miscommunication with patients and cause them not to make medical appointments. In 

addition, outdated or incorrect patient contact information may also affect patient noshows and cancelled appointments. See 

For example, if a patient 

GAO-13-130. 
 

Page 11 GAO-14-509T

cancels multiple specialty care appointments, the associated consult 

would remain open and could inappropriately suggest delays in care. To 

manage this type of situation, one VAMC developed a local consult policy 

referred to as the “1-1-30” rule. The rule states that a patient must receive 

at least 1 letter and 1 phone call, and be granted 30 days to contact the 

VAMC to schedule a specialty care appointment.23 If the patient fails to do 

so within this time frame, the specialty care provider may discontinue the 

consult. According to VAMC officials, several of the consults we reviewed 

would have been discontinued before reaching the 90-day threshold if the 

1-1-30 rule had been in place at the time.24 Three VAMCs included in our 

review also noted some type of policy addressing patient no-shows and 

cancelled appointments, each of which varied in its requirements.25

Without a standard policy across VHA addressing patient no-shows and 

cancelled appointments, VHA consult data may reflect numerous 

variations of how VAMCs handle patient no-shows and cancelled 

appointments.

 

23According to VAMC officials, the 1-1-30 rule provides a minimum standard for specialty 

care providers to follow in scheduling patient appointments.

24The VAMC issued its updated consult policy, which included the 1-1-30 rule, in 

December 2013 after our request for consults data.

25One of the VAMCs allowed for a maximum number of two no-shows for all specialty 

appointments, with consideration given to the patient’s medical needs. The other two 

VAMCs policies stated that specialty providers should reassess the patient’s needs after 

one no-show and may or may not reschedule the appointment.
 

Page 12 GAO-14-509T

In December 2012, we reported that VHA’s reported outpatient medical 

appointment wait times were unreliable and that inconsistent 

implementation of VHA’s scheduling policy may have resulted in 

increased wait times or delays in scheduling timely outpatient medical 

appointments. Specifically, we found that VHA’s reported wait times were 

unreliable because of problems with recording the appointment desired 

date in the scheduling system. Since, at the time of our review, VHA 

measured medical appointment wait times as the number of days elapsed 

from the desired date, the reliability of reported wait time performance 

was dependent on the consistency with which VAMC schedulers 

recorded the desired date in the VistA scheduling system. However, 

VHA’s scheduling policy and training documents were unclear and did not 

ensure consistent use of the desired date. Some schedulers at VAMCs 

that we visited did not record the desired date correctly. For example, the 

desired date was recorded based on appointment availability, which 

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

patient actually experienced.

At each of the four VAMCs we visited, we also found inconsistent 

implementation of VHA’s scheduling policy, which impeded scheduling of 

timely medical appointments. For example, we found the electronic wait 

list was not always used to track new patients that needed medical 

appointments as required by VHA scheduling policy, putting these 

patients at risk for delays in care. 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 we visited 

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

the telephones affected their ability to schedule timely medical 

appointments.

VA concurred with the four recommendations included in our December 

2012 report and reported continuing actions to address them.

• First, we recommended that the Secretary of VA direct the Under 

Secretary for Health to take actions to improve the reliability of its 

outpatient medical appointment wait time measures. In response, 

VHA officials stated that they implemented more reliable measures of 

patient wait times for primary and specialty care. In fiscal years 2013 

and 2014, primary and specialty care appointments for new patients 

Reliability of Reported 

Outpatient Medical 

Appointment Wait 

Times and 

Scheduling Oversight 

Need Improvement, 

and VA Has Initiated 

Actions to Address 

Related GAO 

Recommendations
 

Page 13 GAO-14-509T

have been measured using time stamps from the VistA scheduling 

system to report the time elapsed between the date the appointment 

was created—instead of the desired date—and the date the 

appointment was completed. VHA officials stated that they made the 

change from using desired date to creation date based on a study that 

showed a significant association between new patient wait times 

using the date the appointment was created and self-reported patient 

satisfaction with the timeliness of VHA appointments.26

• Second, we recommended that the Secretary of VA direct the Under 

Secretary for Health to take actions to ensure VAMCs consistently 

implement VHA’s scheduling policy and ensure that all staff complete 

required training. In response, VHA officials stated that the 

department is in the process of revising the VHA scheduling policy to 

include changes, such as the new methodology for measuring wait 

times, and improvements and standardization of the use of the 

electronic wait list. In the interim, VHA distributed guidance, via 

memo, to VAMCs in March 2013 describing this information and also 

offered webinars to VHA staff on eight dates in April and May of 2013. 

To assist VISNs and VAMCs in the task of verifying that all staff have 

completed required scheduler training, VHA has developed a 

database that will allow a VAMC to identify all staff that have 

scheduled appointments and the volume of appointments scheduled 

VA, in its FY 

2013 Performance and Accountability Report, reported that VHA 

completed 40 percent of new patient specialty care appointments 

within 14 days of the date the appointment was created in fiscal year 

2013; in contrast, VHA completed 90 percent of new patient specialty 

care appointments within 14 days of the desired date in fiscal year 

2012. VHA also modified its measurement of wait times for 

established patients, keeping the appointment desired date as the 

starting point, and using the date of the pending scheduled 

appointment, instead of the date of the completed appointment, as the 

end date for both primary and specialty care. VHA officials stated that 

they decided to use the pending appointment date instead of the 

completed appointment date because the pending appointment date

does not include the time accrued by patient no-shows and cancelled 

appointments.

 

26Prentice, Julia C., Michael L. Davies, and Steven D. Pizer, “Which Outpatient Wait-Time 

Measures Are Related to Patient Satisfaction?” American Journal of Medical Quality, 

(Aug. 12, 2013), accessed April 4, 2014, 

http://ajm.sagepub.com/content/early/2013/07/31/1062860613494750.abstract.
 

Page 14 GAO-14-509T

by each; VAMC staff can then compare this information to the list of 

staff that have completed the required training. However, VHA officials 

have not established a target date for when this database would be 

made available for use by VAMCs.

• Third, we recommended that the Secretary of VA direct the Under 

Secretary for Health to take actions to require VAMCs to routinely 

assess scheduling needs for purposes of allocation of staffing 

resources. VHA officials stated that they are continuing to work on 

identifying the best methodology to carry out this recommendation, 

but stated that the database that tracks the volume of appointments 

scheduled by individual staff also may prove to be a viable tool to 

assess staffing needs and the allocation of resources. VHA officials 

stated that they needed to discuss further how VAMCs could use this 

tool, and that they had not established a targeted completion date for 

actions to address this recommendation. 

• Finally, we recommended that the Secretary of VA direct the Under 

Secretary for Health to take actions to ensure that VAMCs provide 

oversight of telephone access, and implement best practices to 

improve telephone access for clinical care. In response, VHA required 

each VISN director to require VAMCs to assess their current 

telephone service against the VHA telephone improvement guide and 

to electronically post an improvement plan with quarterly updates. 

VAMCs are required to routinely update progress on the improvement 

plan. VHA officials cited improvement in telephone response and call 

abandonment rates since VAMCs were required to implement 

improvement plans. Additionally, VHA officials said that the 

department has also contracted with an outside vendor to assess 

VHA’s telephone infrastructure and business process. VHA expects to 

receive the first report in approximately 2 months.

Although VA has initiated actions to address our recommendations, we 

believe that continued work is needed to ensure these actions are fully 

implemented in a timely fashion. Furthermore, it is important that VA 

assess the extent to which these actions are achieving improvements in 

medical appointment wait times and scheduling oversight as intended. 

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.
 

Page 15 GAO-14-509T

Chairman Miller, Ranking Member Michaud, and Members of the 

Committee, this concludes my statement. I would be pleased to respond 

to any questions you may have.

For further information about this statement, please contact 

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

points for our Offices of Congressional Relations and Public Affairs may 

be found on the last page of this testimony. Key contributors to this 

statement were Bonnie Anderson, Assistant Director; Janina Austin, 

Assistant Director; Rebecca Abela; Jennie Apter; Jacquelyn Hamilton; 

David Lichtenfeld; Brienne Tierney; and Ann Tynan.

GAO Contact and 

Staff 

Acknowledgments

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