VA HEALTH CARE

Ongoing and Past Work 

Identified Access, 

Oversight, and Data 

Problems That Hinder 

Veterans’ Ability to Obtain 

Timely Outpatient Medical 

Care

Statement of Debra A. Draper 

Director, Health Care

Testimony 

Before the Committee on Veterans’ 

Affairs, House of Representatives

For Release on Delivery 

Expected at 7:30 p.m. ET

Monday, June 9, 2014

GAO-14-679T

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-679T, a testimony 

before the Committee on Veterans’ Affairs, 

House of Representatives

June 9, 2014

VA HEALTH CARE

Ongoing and Past Work Identified Access, Oversight, 

and Data Problems That Hinder Veterans’ Ability to 

Obtain Timely Outpatient Medical Care

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 veterans, and in 

some cases, these delays have 

reportedly resulted in harm to patients. 

As the number of these reports has 

grown, investigations have been 

launched by VA’s Office of Inspector 

General and VA to examine VAMCs’ 

medical appointment scheduling and 

other practices.

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 scheduling process. In 

May 2013, VHA launched the Consult 

Management Business Rules Initiative 

to standardize aspects of the consults 

process and develop system-wide 

consult data for monitoring.

This testimony is based on GAO’s 

ongoing work to update information 

previously provided to the Committee 

on April 9, 2014, including information 

on VHA’s (1) process for managing 

consults; (2) oversight of consults; and 

(3) progress made implementing 

GAO’s December 2012 

recommendations. To conduct this 

work, GAO has reviewed documents 

and interviewed VHA officials. 

Additionally, GAO has 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 the Department of Veterans Affairs’ (VA) 

Veterans Health Administration’s (VHA) process for managing outpatient 

specialty care consults has identified examples of delays in veterans receiving 

outpatient specialty care. GAO has found consults—requests for evaluation or 

management of a patient for a specific clinical concern—that were not processed 

in accordance with VHA timeliness guidelines. For example, consults were not 

reviewed within 7 days, or completed within 90 days. For 31 of the 150 consults 

GAO reviewed (21 percent), the consult records indicated that VA medical 

centers (VAMC) did not meet the 7-day review requirement. In addition, GAO 

found that veterans received care for 86 of the 150 consults (57 percent), but in 

only 28 of the consults (19 percent) was the care provided within 90 days. For 

the remaining 64 consults (43 percent), the patients did not receive the requested 

care. 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. 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. VA officials indicated that they may refer veterans to non-VA 

providers to help mitigate delays in care.

GAO’s ongoing work also has identified limitations in VHA’s implementation and 

oversight of its new consult business rules designed to standardize aspects of 

the clinical consult process. Specifically, GAO has identified variation in how the 

five VAMCs reviewed have implemented key aspects of the 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. However, it is 

not clear the extent to which VHA is aware of the various strategies that VAMCs 

are using to comply with this task. Furthermore, oversight of the implementation 

of the business rules has been limited and does not include independent 

verification of VAMC actions. Because this work is ongoing, GAO is 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 and recommended that VA take actions to: 

(1) improve the reliability of its outpatient medical appointment wait time 

measures; (2) ensure VAMCs consistently implement VHA’s scheduling policy, 

including the staff training requirements; (3) require VAMCs to routinely assess 

scheduling needs and allocate staffing resources accordingly; and (4) ensure that 

VAMCs provide oversight of telephone access, and implement best practices. As 

of June 2014, VA has reported ongoing actions to address these 

recommendations, but GAO found that 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 is provided to veterans, who may have medical 

conditions that worsen if care is delayed. View GAO-14-679T. For more information, 

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

draperd@gao.gov.
 

Page 1 GAO-14-679T

Chairman Miller, Ranking Member Michaud, and Members of the 

Committee:

I am pleased to be here today as you examine ongoing concerns related 

to the Department of Veterans Affairs’ (VA) delivery of health care to our 

nation’s veterans. In recent years, VA’s Veterans Health Administration 

(VHA) has faced a growing demand for providing outpatient medical 

appointments. From fiscal years 2005 through 2012, the number of 

annual outpatient medical appointments VHA provided increased by 

approximately 45 percent, from 58 million to 84 million.1 VHA provided 

this care through its primary and specialty care outpatient clinics, which 

are managed by VA’s 151 medical centers (VAMC).2 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, including 

specialty care, and in some cases, the delays have reportedly resulted in 

harm to veterans.3

Nonetheless, VHA has reported continued improvements in achieving 

timely 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 

 

1

In addition, the number of patients VHA served increased from fiscal years 2005 to 2012 

by approximately 19 percent, from 5.3 million to 6.3 million patients.

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 cardiology or gastroenterology.

3

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).
 

Page 2 GAO-14-679T

appointments within the goal.4 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 scheduling 

processes contributed to VHA’s problems with scheduling timely medical 

appointments.5 More recently, a report by VA’s Office of Inspector 

General, as well as hearings on VA’s delivery of medical care have 

discussed delays in care and improper scheduling practices resulting in 

lengthy wait times at VA facilities, and in some cases, care not being 

provided at all. Additionally, VA has initiated a system-wide audit to 

identify the scope and magnitude of these issues. Initial results of the 

audit confirmed questionable scheduling practices and other problems at 

many VA facilities.6

The problems that have been identified include VA’s scheduling and 

delivery of outpatient specialty care. 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, review, 

and manage consults using VHA’s clinical consult process and electronic 

consult system, which retains information about each consult request and 

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

Architecture (VistA).7 VHA’s timeliness guideline is that consults should 

be completed within 90 days of being requested.8

 

4

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.

5

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

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

Dec. 21, 2012).

6

U.S. Department of Veterans Affairs, Access Audit Results Summary: Phase One Access 

Audit from 12 May 2014 – 16 May 2014, accessed June 3, 2014, 

http://www.blogs.va.gov/VAntage/wp-content/uploads/2014/05/VHA-Access-Audit-Phase1-Findings-Report-ExSum-05-30-2014.pdf. 

7

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

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

8

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

90 days; consults for urgent needs are completed sooner.
 

Page 3 GAO-14-679T

Appointments resulting from outpatient consults, like other outpatient 

medical appointments, are subject to VHA’s scheduling policy.9

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 system-wide consult data could not be 

adequately used to determine the extent to which veterans experienced 

delays in receiving outpatient specialty care. VHA found that 

approximately 2 million consults were unresolved in its system for more 

than 90 days. Additionally, VHA determined that the data were 

inadequate to identify whether care had been provided for these consults, 

or provided in a timely manner. In response, in May 2013, VHA launched 

the Consult Management Business Rules Initiative (referred to as “consult 

business rules”) to standardize aspects of the consult process, with the 

goal of developing consistent and reliable data on consults across all 

VAMCs.

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.

My statement today will draw from our 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.10

 

9

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.

In particular, this statement updates information 

provided in our April 9, 2014 testimony before the Committee regarding 

(1) the extent to which VHA’s process for conducting outpatient consults 

at five selected VAMCs ensured veterans timely access to specialty care,

10GAO-13-130. 
 

Page 4 GAO-14-679T

(2) the extent to which VHA monitors and oversees consults to ensure 

veterans are receiving outpatient specialty care in accordance with its 

timeliness standards; and (3) key findings and recommendations from our 

December 2012 report, as well as the progress VHA has made in 

implementing those recommendations.11

For our ongoing outpatient specialty care consults work,12 we have 

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 

have 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 have interviewed officials from 

five VAMCs selected for variation in volume of outpatient consults, 

complexity,13 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 ongoing work, 

we have interviewed leadership about how VHA’s consult policies and 

any local policies or procedures for managing consults are implemented 

at their facility. We also have interviewed specialty care service chiefs, 

administrative staff, and providers of three high-volume specialty 

services—cardiology, gastroenterology, and physical therapy. Further, we 

have interviewed officials at the five regional Veterans Integrated Service 

Networks (VISN) responsible for overseeing consults for the VAMCs 

included in our review.14

 

11GAO, VA Health Care: Ongoing and Past Work Identified Access Problems That May 

Delay Needed Medical Care for Veterans, GAO-14-509T (Washington, D.C.: Apr. 9, 

2014). 

12The scope of our work is limited to outpatient consults; however, providers may also 

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

13VHA 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.

14VHA’s health care system is divided into 21 areas called VISNs, each responsible for 

managing and overseeing medical facilities within a defined geographic area.
 

Page 5 GAO-14-679T

Additionally, for each of the five medical centers, we have 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. We also asked VHA to identify those consults that 

were requested during this time period for veterans who are now 

deceased. We randomly selected 50 of these consults (10 from each 

VAMC included in our review) to determine the extent to which these 

veterans may have experienced any delays in care. The preliminary 

findings from our ongoing review of outpatient consults are not 

generalizable across all VAMCs.

For our December 2012 report examining the reliability of VHA’s reported 

outpatient medical appointment wait times and scheduling oversight,15 we 

reviewed VHA’s scheduling policy and methods for measuring medical 

appointment wait times and interviewed VHA central office officials 

responsible for developing them.16

 

15

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 scheduling 

policy, and problems staff experienced in scheduling timely medical 

appointments. We examined each VAMC’s and clinic’s implementation of 

elements of VHA’s scheduling policy and obtained documentation of 

scheduler training completion. In addition, we interviewed schedulers 

from 19 of the 23 clinics visited, and also reviewed patient complaints 

about telephone responsiveness, which is integral to timely medical 

appointment scheduling. We interviewed the directors and relevant staff 

of the four regional VISNs for the VAMCs we visited. We also interviewed 

VHA central office officials and officials at the VAMCs we visited about 

selected initiatives to improve veterans’ access to timely medical 

appointments. Additionally, in April and June 2014, we reviewed 

documentation and interviewed officials from VHA’s central office about 

GAO-13-130. 

16We did not include mental health appointments in the scope of our work, because this 

issue was already being reviewed by VA’s Office of Inspector General.
 

Page 6 GAO-14-679T

the extent to which they have addressed the recommendations we made 

in the 2012 report.17

The work upon which this statement is based was conducted 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 are not making 

recommendations on VHA’s consult process at this time because some of 

this work is ongoing. 

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. The consult 

process is governed by VHA’s national consult policy.18 The policy 

requires VAMCs to manage consults using a national electronic consult 

system,19

Once a 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 

and requires VAMC staff to provide timely and appropriate care 

to veterans.

 

17GAO-14-509T. 

18VHA Directive 2008-056, VHA Consult Policy (Sept. 16, 2008).

19The electronic consult system retains information about each consult request and is part 

of VHA’s VistA. 

Background
 

Page 7 GAO-14-679T

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

to receive the consultation or procedure.20 In some cases, a provider may 

discontinue a consult for reasons such as the care is not needed, the 

patient refuses care, or the patient is deceased.21 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.22

According to VHA’s consult policy, VHA central office officials have 

oversight responsibility for the consult process, including the 

measurement and monitoring of ongoing performance.

VHA’s current 

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

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

were unable to complete the consult.

23

 

20Some 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.

In 2012, VHA

created a database to capture all consults system-wide and, after 

reviewing these data, determined that the data were inadequate for 

monitoring purposes. 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 also was 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 

21When 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. 

22The results of consults are documented in the consult system, and are contained in the 

patient’s electronic health record. 

23The policy also requires VISN leadership to oversee the consult processes for VAMCs in 

their networks. 
 

Page 8 GAO-14-679T

consult system, among other things. In response to the 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 required 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;24

• 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;25

• 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.26

 

24These 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 budget submissions and 

25According 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 component of the VistA scheduling system designed for recording, tracking, 

and reporting veterans waiting for medical appointments.

26In 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 9 GAO-14-679T

performance reports to Congress and stakeholders.27

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 all 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.

28 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.

 

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 performance report—the performance and 

accountability report—which contains performance targets and results achieved compared 

with those targets in the previous year.

28Specifically, 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 10 GAO-14-679T

Our ongoing work has identified examples of delays in veterans receiving 

requested outpatient specialty care at the five VAMCs we reviewed. We 

found consults that were not processed in accordance with VHA 

timeliness guidelines—for example, consults were not reviewed within 

7 days, or completed within 90 days. We also found consults for which 

veterans did not receive the requested outpatient specialty care, and 

those for which the requested specialty care was provided, but were not 

properly closed in the consult system.

VHA requires specialty care providers to review consults within 7 days 

and determine whether to accept the consult. Of the 150 consults we 

reviewed, the consult records indicated that VAMCs did not meet the 

7-day requirement for 31 consults (21 percent). For one VAMC, nearly 

half the consults were not reviewed and triaged within 7 days. Officials at 

this VAMC cited a shortage of providers needed to review and triage the 

consults in a timely manner.

Our ongoing work also has identified that for the majority of the 150 

consults we reviewed, VAMCs did not meet VHA’s timeliness guideline 

that care be provided and consults completed within 90 days. We found 

that veterans received care for 86 of the 150 consults we reviewed 

(57 percent), but in only 28 of the consults (19 percent) veterans received 

care within 90 days of the date the consult was requested. For the 

remaining 64 consults (43 percent), the patients did not receive the 

requested care. Specific examples of consults that were not completed in 

90 days, or were closed without the patients being seen, 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 patients received care. For the 

consult that took 210 days, an appointment was not available within 

90 days 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 

GAO’s Ongoing Work 

Indicates That 

Veterans Did Not 

Always Receive 

Outpatient Specialty 

Care in Accordance 

with VHA Timeliness 

Standards, and in 

Some Cases, Did Not 

Receive Care at All
 

Page 11 GAO-14-679T

evaluations.29

• 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 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.

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.

30

VAMC officials cited increased demand for services, patient no-shows, 

and cancelled appointments, among the factors that hinder their ability to 

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

VAMC officials also noted a growing demand for both gastroenterology 

procedures, such as colonoscopies, as well as consultations for physical 

therapy evaluations, combined with a difficulty in hiring and retaining 

specialists for these two clinical areas, as causes of periodic backlogs in 

providing these services. Officials at these facilities indicated that they try 

to mitigate backlogs by referring veterans to non-VA providers for care.

While officials indicated that use of non-VA care can help mitigate 

backlogs, several officials indicated that non-VA care requires more 

coordination between the VAMC, the patient, and the non-VA provider; 

can require additional approvals for the care; and also may delay 

obtaining the results of medical appointments or procedures. In addition, 

wait times are generally not tracked for non-VA care. As such, officials 

acknowledged that this strategy does not always prevent delays in 

veterans receiving timely care or in completing consults.

 

29A non-service-connected disability is an injury or illness that was not incurred or 

aggravated during active military service.

30As 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 GAO-13-130. 
 

Page 12 GAO-14-679T

Our ongoing review also has identified one consult for which the patient 

experienced delays in obtaining non-VA care and died prior to obtaining 

needed care. In this case, the patient needed endovascular surgery to 

repair two aneurysms – abdominal aortic and an iliac. According to the 

patient’s medical record, the timeline of events surrounding this consult 

was as follows:

• September 2013 – Patient was diagnosed with two aneurysms.

• October 2013 – VAMC scheduled patient for surgery in November, 

but subsequently cancelled the scheduled surgery due to staffing 

issues.31

• December 2013 – VAMC approved non-VA care and referred the 

patient to a local hospital for surgery.

• Late December 2013 – After the patient followed up with the VAMC, it 

was discovered that the non-VA provider lost the patient’s information. 

The VAMC resubmitted the patient’s information to the non-VA 

provider.

• February 2014 – The consult was closed because the patient died 

prior to the surgery scheduled by the non-VA provider.32

According to VAMC officials, they conducted an investigation of this case. 

They found that the non-VA provider planned to perform the surgery on 

February 14, 2014, but the patient died the previous day. Additionally, 

they stated that according to the coroner, the patient died of cardiac 

disease and hypertension and that the aneurysms remained intact.

Furthermore, our ongoing work shows that for nearly all of the consults 

where care had been provided within 90 days, an extended amount of 

time elapsed before specialty care providers completed them in the 

consult system.33

 

31Officials indicated that in October 2013, the VAMC temporarily suspended the 

endovascular surgeon that conducts these surgeries.

Specifically, for 28 of the 29 consults, even though care 

was provided, the consult remained open in the system, making it appear 

as though the requested care was not provided within 90 days. For one 

32We have referred this case to VA’s Office of Inspector General for further review.

33According to VAMC officials, in order to successfully complete a consult, the specialty 

care provider must select a specific note title that links the results to the consult. 
 

Page 13 GAO-14-679T

VAMC, we found that for all 10 cardiology consults we reviewed, specialty 

care providers did not properly document the results of the consults in 

order to close them in the system. In some cases, it took over 100 days 

from the time care was provided until the consults were completed in the 

system. 

Officials from several VAMCs told us that often specialty care providers 

do not choose the correct notes needed to document that the consults are 

complete. Officials attributed this ongoing issue in part to the use of 

residents, who rotate in and out of specialty care clinics after a few 

months and lack experience with completing consults. Officials from one 

VAMC told us that this requires VAMC leadership to continually train new 

residents on how to properly complete consults. To ensure that specialty 

care providers consistently choose the correct notes, this VAMC activated 

a prompt in its consult system asking each provider if the note the 

provider is entering is in response to a consult. Officials stated that this 

has resulted in providers more frequently choosing the correct note title to 

complete consults.

Our ongoing work has identified variation in how the five VAMCs in our 

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

limits the usefulness of the data in monitoring and overseeing consults 

system-wide. 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, we have found variation in 

how VAMCs 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.

One task of the consult business rules required VAMCs to develop and 

implement strategies for requesting and managing requests for future 

care consults.34 Based on our ongoing work, we have identified that 

VAMCs are adopting various strategies when implementing this task,35

 

34VHA provided VAMCs with options for managing future care consults—namely that they 

could develop markers to identify them in the consult system, or use existing mechanisms 

outside of the consult system such as electronic wait lists.

35Information on the strategies used by VAMCs to implement this consult business rule 

task was included in our April 2014 testimony. See GAO-14-509T. 

Limitations in VHA’s 

Implementation of the 

Consult Business 

Rules Impedes Its 

Ability to Assess 

Delays in Care
 

Page 14 GAO-14-679T

such as piloting an electronic system for providers to manage future care 

consults outside of the consult system and entering the consult 

regardless of whether the care was needed beyond 90 days.36

Overall, our ongoing work indicates that oversight of the implementation 

of VHA’s consult business rules has been limited and has not included 

independent verification of VAMC actions. VAMCs were required to selfcertify 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, 

however, VHA cannot be assured that VAMCs implemented the tasks 

correctly.

However, 

during the course of our ongoing work, several VAMCs told us they are 

changing their strategies for requesting and managing future care 

consults. For example, officials from a VAMC that was piloting an 

electronic system stated that, after evaluating the pilot, they decided not 

to use this approach, and are instead planning to implement markers to 

identify future care consults. These consults will appear in the consult 

data, but will be identified as future care consults and remain

appropriately open until care is provided. Officials from two other VAMCs 

that were entering consults regardless of whether the care was needed 

beyond 90 days told us they are no longer doing this. According to 

officials, instead they are implementing a separate electronic system to 

track needed future care outside of the consult system, and these future 

care needs will not appear in consult data until they are entered in the 

consult system closer to the date the care is needed. Based on our 

discussions with VHA officials, it is not clear the extent to which they are 

aware of the various strategies that VAMCs are using to comply with this 

task. According to VHA officials, they have not conducted a system-wide 

review of the future care strategies and did not have detailed information 

on the various strategies specific VAMCs have implemented.

Furthermore, our ongoing work shows that 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 ongoing

review were able to provide us with specific documentation in this regard. 

 

36Two VAMCs included in our review reported entering the consults regardless of whether 

the care was needed beyond 90 days. One of these VAMCs further stated that providers 

discontinued consults for future care appointments when the 90-day threshold was 

reached.
 

Page 15 GAO-14-679T

VHA officials estimated that as of June 2014, about 278,000 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 ongoing review has 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 consult business rules were intended to create 

consistency in VAMCs’ consult data, our preliminary work has identified 

variation in managing key aspects of the consult process that are not 

addressed by the business rules. For example, there are no detailed 

system-wide 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.37

For example, if a patient 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.38

 

37As 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 

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 

GAO-13-130. 

38According to VAMC officials, the 1-1-30 rule provides a minimum standard for specialty 

care providers to follow in scheduling patient appointments.
 

Page 16 GAO-14-679T

been in place at the time.39 Furthermore, all of the VAMCs included in our 

ongoing review had some type of policy addressing patient no-shows and 

cancelled appointments, each of which varied in its requirements.40 VHA 

officials indicated that they allow each VAMC to develop their own 

approach to addressing patient no-shows and cancelled appointments. 

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

cancelled appointments, however, VHA consult data may reflect 

numerous variations of how VAMCs handle patient no-shows and 

cancelled appointments.

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 2012 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 in our 2012 review, we also found inconsistent 

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

 

39The VAMC issued its updated consult policy, which included the 1-1-30 rule, in 

December 2013 after our request for consults data.

40One 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. Another VAMC 

allowed for two no-shows for all specialty care appointments before a consult could be 

discontinued, but provided no limit for patient cancellations. Two other VAMCs’ policies 

stated that specialty providers should reassess the patient’s needs after one no-show and 

may or may not reschedule the appointment. Finally, the remaining VAMC’s policy did not 

include a limit to the number of no shows allowed for specialty appointments.

Reliability of Reported 

Outpatient Medical 

Appointment Wait 

Times and 

Scheduling Oversight 

Need Improvement, 

and VA Has Initiated 

Actions to Address 

Related GAO 

Recommendations
 

Page 17 GAO-14-679T

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. At that time, 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 in 2012 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 has 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 

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.41

 

41Prentice, 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 June 4, 2014, 

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

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 
 

Page 18 GAO-14-679T

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. In a June 5, 2014 statement from the Acting Secretary, 

VA indicated that it is removing measures related to the 14-day 

performance goal from VISN and VAMC directors’ performance 

contracts.

• 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 was 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 March 2013, VHA distributed guidance, via 

memo, to VAMCs describing this information and also offered 

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

2014, VHA officials told us that they were in the process of further 

revising the scheduling policy, in part to reflect findings from VA’s 

system-wide access audit, and planned to issue a memo regarding 

new scheduling procedures at a future date. 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 by each; VAMC staff can then 

compare this information to the list of staff that have completed the 

required training. However, as of June 2014, 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. As of June 

2014, VHA officials stated that they are continuing to address this 
 

Page 19 GAO-14-679T

recommendation including through internal and external discussions 

taking place in May and June 2014 regarding VHA scheduling policy. 

• 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 contracted with an outside vendor to assess VHA’s 

telephone infrastructure and business process and was reviewing the 

findings from the first vendor report in June 2014. 

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. Our findings regarding incorrect use of 

the desired date in the scheduling system and the electronic wait list are 

consistent with VHA’s recent findings from its system-wide access audit, 

indicating continued system-wide problems that could be addressed, in 

part, by implementing our recommendations. 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.

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.
 

Page 20 GAO-14-679T

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 Contacts and 

Staff 

Acknowledgments

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