Report No. 07-00616-199 September 10, 2007

VA Office of Inspector General 

Washington, DC 20420 

Department of Veterans Affairs 

Office of Inspector General 

 

Audit of the Veterans 

Health Administration's 

Outpatient Waiting Times 
To Report Suspected Wrongdoing in VA Programs and Operations 

Call the OIG Hotline – (800) 488-8244 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

Contents 

Page 

Executive Summary ..............................................................................................i

Introduction ..........................................................................................................1

Purpose............................................................................................................................. 1

Background...................................................................................................................... 1

Scope and Methodology .................................................................................................. 2

Results and Conclusions ....................................................................................5

Issue 1: Differences In Outpatient Waiting Times ......................................................... 5

Issue 2: Consult Referrals Not Included On Electronic Waiting Lists........................... 9 

Issue 3: Prior OIG Recommendations Were Not Implemented ................................... 13 

Appendixes 

A. Under Secretary for Health Comments.................................................................... 19

B. OIG Contact and Staff Acknowledgments............................................................... 26

C. Report Distribution................................................................................................... 27

VA Office of Inspector General 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

Executive Summary 

Introduction 

At the request of the U.S. Senate Committee on Veterans’ Affairs, the VA Office of 

Inspector General (OIG) audited the Veterans Health Administration’s (VHA) outpatient 

waiting times. The purpose of this audit was to follow up on our Audit of the Veterans 

Health Administration’s Outpatient Scheduling Procedures (Report No. 04-02887, 

July 8, 2005), which reported that VHA did not follow established procedures when 

scheduling medical appointments for veterans seeking outpatient care. As a result, 

reported waiting times and electronic waiting lists were not accurate. The report made 

eight recommendations for corrective action. VHA agreed with the reported findings and 

recommendations. 

The objectives of this follow-up audit were to determine whether (1) established 

scheduling procedures were followed and outpatient waiting times reported by VHA 

were accurate, (2) electronic waiting lists were complete, and (3) prior OIG 

recommendations were fully implemented. 

Background 

VHA policy requires that all veterans with service-connected disability ratings of 50 

percent or greater and all other veterans requiring care for service-connected disabilities 

be scheduled for care within 30 days of desired appointment dates. All other veterans 

must be scheduled for care within 120 days of the desired dates. VHA policy also 

requires that requests for appointments be acted on by the medical facility as soon as 

possible, but no later than 7 calendar days from the date of request. 

To determine if schedulers followed established procedures when making medical 

appointments for veterans and to determine whether reported waiting times were 

accurate, we reviewed a non-random sample of 700 appointments with VHA reported 

waiting times of 30 days or less that were scheduled for October 2006 at 10 medical 

facilities in 4 Veterans Integrated Service Networks (VISN). Our universe included 14 of 

VHA’s 50 high-volume clinics and represented only 1 month of appointments. VHA 

designates a clinic as a high-volume clinic if the total nation-wide workload (patient 

visits) of that clinic ranks in the top 50 clinics. Our sample included 70 appointments at 

each medical facility, with 60 of the appointments being for established patients and 10 

appointments for new patients. For measuring waiting times, VHA defines established 

patients as those who have received care in a specific clinic in the previous 2 years; new 

patients represent all others. For example, a veteran who has been receiving primary care 

at a facility within the previous 2 years would be considered an established patient in the 

primary care clinic. However, if that same veteran was referred to the facility’s 

VA Office of Inspector General i 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

Cardiology clinic, that veteran would now be classified as a new patient to the 

Cardiology clinic. 

VHA uses Veterans Health Information Systems and Technology Architecture (VistA) 

scheduling software to collect all outpatient appointments in 50 high-volume clinics and 

then calculates the waiting time. For established patients, (representing 90 percent of 

VHA’s total outpatient appointments), waiting times are calculated from the desired date 

of care, which is the earliest date requested by either the veteran or the medical provider, 

to the date of the scheduled appointment. For new patients, VHA calculates waiting 

times from the date that the scheduler creates the appointment. In the Department of 

Veteran Affairs Fiscal Year 2006 Performance and Accountability Report, issued 

November 15, 2006, VHA reported that 96 percent of all veterans seeking primary 

medical care and 95 percent of all veterans seeking specialty medical care were seen 

within 30 days of their desired dates. 

VHA implemented the electronic waiting list in December 2002 to provide medical 

facilities with a standard tool to capture and track information about veterans’ waiting for 

medical appointments. Veterans who receive appointments within the required 

timeframe are not placed on the electronic waiting list. However, veterans who cannot be 

scheduled for appointments within the 30- or 120-day requirement should be placed on 

the electronic waiting list immediately. If cancellations occur and veterans are scheduled 

for appointments within the required timeframes, the veterans are removed from the 

electronic waiting list. 

Results 

Schedulers were still not following established procedures for making and recording 

medical appointments. We found unexplained differences between the desired dates as 

shown in VistA and used by VHA to calculate waiting times and the desired dates shown 

in the related medical records. As a result, the accuracy of VHA’s reported waiting times 

could not be relied on and the electronic waiting lists at those medical facilities were not 

complete. Also, VHA has not fully implemented five of the eight recommendations in 

the July 8, 2005, report. 

Differences in Reported Waiting Times 

Of the 700 veterans reported by VHA to have been seen within 30 days, 600 were 

established patients and 100 were new patients. Overall, we found sufficient evidence to 

support that 524 (75 percent) of the 700 had been seen within 30 days of the desired date. 

This includes 229 (78 percent) veterans seeking primary care and 295 (73 percent) 

veterans seeking specialty care. However, 176 (25 percent) of the appointments we 

reviewed had waiting times over 30 days when we used the desired date of care that was 

established and documented by the medical providers in the medical records. 

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Audit of the Veterans Health Administration's Outpatient Waiting Times 

For example, on December 20, 2005, a veteran who was 50 percent service-connected 

was seen in the Eye Clinic. The medical provider wrote in the progress notes that the 

veteran should return to the clinic in 6 weeks (January 31, 2006). However, over 7 

months later, on September 6, 2006, the scheduler created an appointment for the veteran 

for October 17, 2006. The scheduler entered a desired date of October 2, 2006, which 

resulted in a reported waiting time of 15 days. Based on the provider requested date of 

January 31, 2006, the veteran actually waited 259 days, and was never placed on the 

electronic waiting list. We saw no documentation to explain the delay and medical 

facility personnel said it “fell through the cracks.” Although this particular examination 

was delayed, the veteran received medical care from other clinics during this time. 

In total, 429 (72 percent) of the 600 appointments for established patients had 

unexplained differences between the desired date of care documented in medical records 

and the desired date of care the schedulers recorded in VistA. If schedulers had used the 

desired date of care documented in medical records: 

• The waiting time of 148 (25 percent) of the 600 established appointments would have 

been less than the waiting time actually reported by VHA. 

• The waiting time of 281 (47 percent) of the 600 established appointments would have 

been more than the waiting time actually reported by VHA. Of the 281 appointments, 

the waiting time would have exceeded 30 days for 176 of the appointments. 

VHA’s method of calculating the waiting times of new patients understates the actual 

waiting times. Because of past problems associated with schedulers not entering the 

correct desired date when creating appointments, VHA uses the appointment creation 

date as the starting point for measuring the waiting times for new appointments. VHA 

acknowledges that this method could understate the actual waiting times for new patients 

by the number of days schedulers take to create the appointment. VHA uses this method 

for new appointments because VHA assumes the new patient needs to be seen at the next 

available appointment. This is true for patients that are absolutely new to the system. 

However, the problem is that VHA’s definition of new patients also includes patients that 

have already seen a provider and have a recommended desired date. In our opinion, 

while these veterans might be new to a specialty clinic, they are established patients 

because they have already seen a medical provider who has recommended a desired date. 

For VHA to ignore the medical providers desired date for this group of new patients 

understates actual waiting times. For example, we reviewed 100 new patients that VHA 

reported had waiting times of less than 30 days. Out of the 100, 86 had already seen a 

medical provider and were being referred to a new clinic. The other 14 were either new 

to the VA or had not been to the VA in over 2 years; therefore they had no desired date. 

The results of reviewing these two categories are listed below: 

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Audit of the Veterans Health Administration's Outpatient Waiting Times 

• Eighty-six were currently receiving care at the facility but were classified as a new 

patient because they were referred to a specialty clinic in that same facility and had 

not received care in that clinic within the previous 2 years. For those 86 patients, we 

calculated the waiting time by identifying the desired date of care as documented in 

the medical records (date of the consult referral) to the date of the appointment. We 

found that 68 (79 percent) of the 86 new patients were seen within 30 days. For 15 of 

the 18 patients not seen within 30 days, schedulers did not create the appointment 

within the 7-day requirement and the scheduling records contained no explanation of 

the scheduling delay. The actual waiting time for the 18 patients ranged from 32 to 

112 days. 

• Fourteen were either new to the VA, new to the facility, or had not received care in 

the facility within the previous 2 years. For those 14, we reviewed the VistA 

scheduling package and identified the date the veteran initiated the request for care 

(telephone or walk-in) and used that as the desired date for calculating the waiting 

time. Based on available documentation, all 14 veterans were seen within 30 days of 

the desired date. 

VHA needs to either ensure schedulers comply with the policy to create appointments 

within 7 days or revert back to calculating the waiting time of new patients based on the 

desired date of care. The results included in this section are limited by the fact that 

schedulers may not have recorded the veterans’ preferences for an appointment date in 

VistA as discussed below. 

We further reviewed the 176 cases where veterans’ waiting times were more than 30 

days, and identified 64 veterans that were given an appointment past the 30- or 120-day 

requirement and should have been on the electronic waiting lists. This represented 9 

percent of the 700 appointments reviewed. The 64 cases consisted of 36 veterans with 

service-connected ratings of 50 percent or greater, 12 veterans being treated for serviceconnected conditions, and 16 veterans with waiting times more than 120 days. 

Use of Patient Preferences When Scheduling Appointments 

VHA told us that the unexplained differences we found between the desired dates of care 

shown in the medical record and the desired date of care the schedulers recorded in VistA 

can generally be attributed to patient preference for specific appointment dates that differ 

from the date recommended by medical providers. VHA policy requires schedulers to 

include a comment in VistA if the patient requests an appointment date that is different 

than the date requested by the provider. We reviewed all comments in VistA and 

accepted any evidence that supported a patient’s request for a different date. VHA 

personnel told us that schedulers often do not document patient preferences due to high 

workload. Without documentation in the system or contacting the patients, neither we 

nor VHA can be sure whether the patient’s preference or the scheduler’s use of 

inappropriate scheduling procedures caused the differences we found. 

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Audit of the Veterans Health Administration's Outpatient Waiting Times 

Some VHA clinics use recall or reminder clinics to emphasize patient-driven scheduling. 

If a veteran is entered in a recall or reminder clinic, the scheduler will notify the veteran 

either by letter or phone about 30 days before the expected appointment date and ask the 

veteran to call the clinic to set up their appointment. VHA personnel said that some 

veterans may not call for their appointment or, in some cases, may wait several months 

before calling. If the scheduler does not document this situation, then the veterans 

waiting time may appear to be longer than it actually was. If a patient fails to call in, 

VHA policy requires the facility to send a follow-up letter and to document failures to 

contact the veteran. 

VHA personnel told us that some providers are not specific when they document the 

veterans’ desired date of care. For example, some providers will request the veteran to 

return to the clinic in 3 to 6 months. If a provider uses a date range, VHA policy requires 

schedulers to use the first date of the date range as the desired date of care or obtain 

clarification from the provider. When we found appointments with date ranges and no 

clarifying comments from the provider, we followed VHA policy and considered the first 

date of the range as the desired date. 

Appointments for Consult Referrals Not Scheduled Within Required Timeframe 

None of the 10 medical facilities we reviewed consistently included veterans with 

pending and active consults (referrals to see a medical specialist), that were not acted on 

within the 7-day requirement, on the electronic waiting list. Pending consults are those 

that have been sent to the specialty clinic, but have not yet been acknowledged by the 

clinic as being received. Active consults have been acknowledged by the receiving 

clinic, but an appointment date has either not been scheduled or the appointment was 

cancelled by the veteran or the clinic. 

According to the consult tracking reports, the 10 medical facilities listed 70,144 veterans 

with consult referrals over 7 days old. In accordance with VHA policy, the medical 

facilities should have included these veterans on the electronic waiting lists. The 70,144 

does not include veterans with referrals for prosthetics or inpatient procedures. VHA 

personnel told us that the 70,144 includes some referrals for procedures (such as cardiac 

catheters) and alternative care (such as contracted care) that should not have been 

identified on the consult tracking reports. VHA personnel also acknowledged to us that 

VHA policy does not exempt those referrals from the 7-day requirement. At the time of 

our review, the total number of veterans on the electronic waiting lists for specialty care 

was only 2,658. 

To substantiate the data in the consult tracking reports, we reviewed 300 consults; 20 

active consults and 10 pending consults from each of the 10 medical facilities. Based on 

our review of the 200 active consults we found that 105 (53 percent) were not acted on 

within 7 days, and these veterans were not on the electronic waiting lists. Of this 

number, 55 veterans had been waiting over 30 days without action on the consult request. 

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Audit of the Veterans Health Administration's Outpatient Waiting Times 

Of the 100 pending consults, 79 (79 percent) were not acted on within the 7-day 

requirement and were not placed on the electronic waiting list. Of this number, 50 

veterans had been waiting over 30 days without action on the consult request. Also, 

medical facilities did not establish effective procedures to ensure that veterans received 

timely care if the veteran did not show up for their initial appointment or the appointment 

was cancelled. For 116 (39 percent) of the 300 consults we reviewed, subsequent actions 

such as a patient no-show placed the 116 consults back into active status. We identified 

60 of the 116 consult referrals where the facility either did not follow up with the patient 

in a timely manner or did not follow up with the patient at all when the patient missed 

their appointment. 

Schedulers Lack Necessary Training 

We interviewed 113 schedulers at 6 medical facilities and found that 53 (47 percent) had 

no training on consults within the last year, and that 9 (17 percent) of the 53 had been 

employed as a scheduler for less than 1 year. We also discovered that 60 (53 percent) of 

the 113 schedulers had no training on the electronic waiting list within the last year, and 

that 10 (17 percent) of the 60 had been employed as schedulers for less than 1 year. 

Schedulers and managers told us that, although training is readily available, they were 

short of staff and did not have time to take the training. The lack of training is a 

contributing factor to schedulers not understanding the proper procedures for scheduling 

appointments, which led to inaccuracies in reported waiting times by VHA. 

While waiting time inaccuracies and omissions from electronic waiting lists can be 

caused by a lack of training and data entry errors, we also found that schedulers at some 

facilities were interpreting the guidance from their managers to reduce waiting times as 

instruction to never put patients on the electronic waiting list. This seems to have 

resulted in some “gaming” of the scheduling process. Medical center directors told us 

their guidance is intended to get the patients their appointments in a timely manner so 

that there are no waiting lists. 

Prior Recommendations Not Implemented 

At the start of this audit, five of the eight recommendations in our July 8, 2005, report 

remained unimplemented. During the course of this audit, VHA submitted 

documentation to support closing three additional recommendations. We closed one 

recommendation; the other two remain open due to insufficient action taken by VHA. 

Also, as evidenced by the findings of this report, actions taken by VHA with respect to 

one of the previously closed recommendations proved ineffective in monitoring 

schedulers’ use of correct procedures when making appointments so we are reinstituting 

that recommendation in this report. Therefore, five of the eight recommendations from 

our 2005 report remain unimplemented. 

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Audit of the Veterans Health Administration's Outpatient Waiting Times 

Conclusion 

The conditions we identified in our previous report still exist. VHA has established 

detailed procedures for schedulers to use when creating outpatient appointments but has 

not implemented effective mechanisms to ensure scheduling procedures are followed. 

The accuracy of outpatient waiting times is dependent on documenting the correct desired 

date in the system. 

Our audit results are not comparable to VHA’s reported waiting times contained in its 

Performance and Accountability Report because we used a different set of clinics and 

timeframe of appointments. Further, our audit results cannot be extrapolated to project 

the extent that waiting times exceed 30 days on a national level because the medical 

facilities and appointments selected for review were based on non-random samples. 

Nevertheless, the findings of this report do support the fact that the data recorded in 

VistA and used to calculate veteran outpatient waiting times is not reliable. VHA states 

that our results overstate waiting times because patients requested a different appointment 

date. We agree that patient preference could change the desired date of care; however, if 

schedulers did not document the patient preference our testing would not disclose this 

fact. We believe that VHA’s calculations of waiting times are subject to a greater 

uncertainty than our numbers because we cannot assume that differences are due to 

patient preference, especially when our review took into account medical provider 

desired dates that were also not accurately recorded in VistA. Until VHA establishes 

procedures to ensure that schedulers comply with policy and document the correct 

desired dates of care, whether recommended by medical providers or requested by 

veterans, calculations of waiting time from the current system will remain inaccurate. 

We recommended that the Under Secretary for Health take action to: 

• Establish procedures to routinely test the accuracy of reported waiting times and 

completeness of electronic waiting lists, and take corrective action when testing 

shows questionable differences between the desired dates of care shown in medical 

records and documented in the VistA scheduling package. 

• Take action to ensure schedulers comply with the policy to create appointments 

within 7 days or revert back to calculating the waiting time of new patients based on 

the desired date of care. 

• Amend VHA Directive 2006-055 to clarify specialty clinic procedures and 

requirements for receiving and processing pending and active consults to ensure they 

are acted on in a timely manner and, if not, are placed on the electronic waiting lists. 

• Ensure all schedulers receive required annual training. 

• Identify and assess alternatives to the current process of scheduling appointments and 

recording and reporting waiting times, and develop a plan to implement any changes 

to the current process. 

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Audit of the Veterans Health Administration's Outpatient Waiting Times 

Under Secretary for Health Comments 

The Under Secretary stated that the report correctly identifies areas VHA needs to 

address to improve outpatient waiting time accuracy but non-concurs with the findings in 

Issue 1 because of the limitations of the methodology used in the study and 

Recommendation 2, relating to the calculation of waiting times for new patients. The 

Under Secretary agreed with Recommendations 1, 3, 4, and 5. See Appendix A for the 

full text of the Under Secretary’s comments. 

OIG Response 

In paragraph 2 of the Under Secretary’s response, he attempts to discredit the audit 

findings by comparing the audit results with the results of VA’s national patient 

satisfaction survey. The survey showed that 85 percent of the veterans who completed 

the survey reported that they had access to primary care appointments when they needed 

them and that 81 percent of the veterans reported satisfaction with timely access to 

specialty care. Notwithstanding the Under Secretary’s comment that the national patient 

satisfaction survey is one of the most valid measurements of access efficiency and that 

the patient satisfaction survey varies significantly with OIG report results, there is no 

valid basis for a comparison between the results of the patient satisfaction survey and the 

results of the OIG audit. 

The purpose of the audit was to determine whether established scheduling procedures 

were followed and whether outpatient waiting times reported by VHA were accurate. 

Based on the evidence available in VistA, patient medical records, and discussions with 

the schedulers, the audit demonstrated that scheduling procedures were not followed and 

that the waiting time information reported by VA was not accurate. There is no 

comparison between overall patient satisfaction and VA’s compliance with specific 

policy requirements, or the accuracy of the waiting time information reported by VHA. 

We note that waiting time information reported by VHA was obtained from the same data 

system that the OIG used to conduct the audit, not from the patient satisfaction survey. 

To support any level of comparison, the patient satisfaction survey would have had to ask 

veterans whether they were seen within the 30-day requirement. Because this question 

was not posed in the survey, the survey results cannot be construed as an indicator of 

compliance with established scheduling procedures or the accuracy of reported waiting 

times. 

Even assuming, for the sake of argument, that the patient satisfaction results could be 

used as an indicator of VHA’s reported waiting times, the results of the patient 

satisfaction survey do not support the results VHA reported to Congress in November 

2006. VHA reported that 96 percent of all veterans seeking primary care and 95 percent 

seeking specialty care were seen within the 30-day standard. Only 85 percent of the 

veterans who responded to the survey reported satisfaction with access to primary care 

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Audit of the Veterans Health Administration's Outpatient Waiting Times 

and only 81 percent were satisfied with timely access to specialty care. These 

percentages are closer to the results of the OIG audit, which were 78 percent and 73 

percent respectively. Although we agree with the Under Secretary that the patient 

satisfaction survey results do vary from the results of our report, there is a more 

significant variance between the survey results and the information VHA reported. Also, 

the results reported by the OIG are accurate, well-documented, and based on all available 

VA information. 

In paragraph 3, the Under Secretary disagrees with our conclusions concerning 

scheduling and the definition of new patients. With respect to scheduling, VHA asserts 

that this is a hard number to game because the dates are automatically selected by the 

software program when the scheduler makes the appointment. The problem with this 

logic is that the system can be gamed if schedulers delay in entering the information in 

the system to schedule the appointment. For example, if a physician requests an 

appointment be scheduled within 30 days but the scheduler waits 90 days before trying to 

schedule the appointment, the system could show that the patient was seen within 30 days 

of the date the appointment was scheduled but, in reality, the patient would not have been 

seen within 30 days of the date requested by the physician. Although the OIG did not 

investigate whether schedulers were intentionally “gaming” the system, the type of 

conduct described in the above example is exactly what occurred in 18 of the 100 new 

patient appointments that were audited. 

Although the Under Secretary disagreed in general with our definition of new patients, 

his response did not include any discussion as to the basis of the disagreement other than 

to state that the software logic determines which appointments are new. While this may 

be true, the software makes this determination based on the data put into the system by 

the scheduler. Part of the problem may be in the definition of a “new patient.” In our 

view, a “new patient” is one who was not previously enrolled in the VA health care 

system. However, VHA considers new patients to also include patients who have been 

seen by a VA physician and have been referred to a specialty clinic for the first time. 

These are established patients, not new VA patients. The definition of a “new patient” is 

important because many patients who have been referred by a VA physician have a 

medical provider desired date and, therefore, should be considered as established patients, 

not new VA patients. 

In paragraph 4, the Under Secretary expresses concern that the methodology used by the 

OIG resulted in a flawed conclusion about the magnitude of the inaccuracy in patient 

waiting times. VHA’s assertion that the OIG computed waiting time error rates by using 

the date that VA providers specified for the patient without considering the possibility 

that the veteran could have changed the date, unless the patient’s preferred date was 

clearly documented in the scheduling package, is not accurate. The issue is not whether 

the patient preferences were clearly documented, but whether there was any 

documentation at all to support the apparent delays in scheduling patients. To assess 

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Audit of the Veterans Health Administration's Outpatient Waiting Times 

VHA’s compliance with scheduling procedures, the OIG used procedures contained in 

VHA Directive 2006-055 that requires schedulers to add a comment into the scheduling 

package when the patient requests an appointment date that is different than the 

provider’s requested date. To accept an assumption that the patient requested a desired 

date different than the documented desired date shown in the medical records would be 

irresponsible on our part and contrary to VHA’s own directives. During the OIG review, 

managers at each facility were given the opportunity to provide any evidence available 

that would indicate a change in veteran preference for a new appointment date. Absent 

any documentation, the OIG relied on the data in the scheduling system and the medical 

provider desired date in the patient’s medical record. Since the Under Secretary provided 

no evidence to support his position that veterans were changing their appointments, we 

found his contention that the OIG reported magnitude of the inaccuracy of patient waiting 

times was somehow flawed to be illogical and unpersuasive. 

The Under Secretary also asserts that the OIG used the most conservative desired 

appointment date whenever the patient’s preferred appointment date was not clearly 

documented, which essentially provided a worse-case scenario analysis. This assertion is 

not entirely inaccurate in that we did use the most conservative date. However, it was not 

done to provide a worse-case scenario analysis; we used the most conservative date to be 

consistent with VHA policy. In cases where the provider’s desired date was a range of 

time, such as 3-6 months, VHA Directive 2006-055 requires schedulers to use the first 

date of the date range as the desired date of care or obtain clarification from the medical 

provider. 

In paragraph 4.a. and 4.b., the Under Secretary points out that many VHA facilities use 

the recall/reminder system to allow patients to negotiate their appointment dates based on 

personal priorities, and to also ensure the patient is seen within the time period specified 

by the provider. We agree that the recall/reminder system is beneficial to both the 

veteran and VA. In those cases where a recall/reminder system was used, the OIG 

followed VHA policy in reviewing scheduler’s compliance with scheduling procedures 

and relied on the information recorded in the scheduling system. 

In paragraph 4.c., the Under Secretary concedes that the failure of scheduling clerks to 

adequately document patient preferences in appointment dates contributed to the OIG 

findings and states that it is unrealistic to expect schedulers to maintain such a high level 

of documentation. While the OIG recognizes the workload associated with millions of 

appointments made every year, documenting changes in veteran desired dates is required 

by VHA’s own policy. The Under Secretary also comments that this documentation is 

solely to support audit requirements and does little, if anything, to support the actual 

scheduling of the appointment. Contrary to this position, the OIG maintains that full 

compliance with established scheduling procedures is critical to ensuring patients are 

seen in a timely manner and no one falls through the cracks. Compliance is also critical 

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Audit of the Veterans Health Administration's Outpatient Waiting Times 

to ensure data integrity. VA and Congress must have accurate, reliable, and timely 

information for budgeting and other decision making purposes. 

In paragraph 5, the Under Secretary points out that the OIG incorrectly cited VHA for 

errors where veterans cancelled appointments and VHA did not follow up to reschedule 

new appointments when it was the patient’s responsibility to reschedule the appointment. 

This is not accurate. The OIG reported error rate did not include any of the follow-up 

appointments. This was addressed in a separate part of the report. The OIG reported that 

VHA did not have effective follow up procedures to ensure patients received the desired 

care when patients missed their appointments. VHA’s Directive 2006-055 requires that 

the responsible facility personnel must ensure that when a clinic cancels an appointment, 

patients are rescheduled and when a patient no shows, the patient is contacted to 

determine the reason for the no show and assist the patient in rescheduling a new 

appointment acceptable to the patient. We identified 60 consult referrals where the 

facility either did not follow up with the patient in a timely manner or did not follow up 

with the patient at all when the patient missed their appointment. For 11 of the 60 

appointments, the clinic cancelled the patient’s appointment but did not follow up with 

the patient in a timely manner or did not follow up with the patient at all to ensure the 

patient received the desired care. In some cases, the patient cancelled and requested the 

appointment be rescheduled. For example, a veteran had an appointment in the 

neurology clinic on January 25, 2007. Two days before the appointment, a comment was 

added in VistA stating that the patient cancelled the appointment. Included in the 

comment was instruction to reschedule and notify the veteran. We found no evidence 

that the medical facility made any further attempt to reschedule the appointment. The 

consult was eventually discontinued without any explanation in VistA. 

In paragraph 6, the Under Secretary opines that any attempt at accurate reporting using 

the current scheduling software package is a formidable, if not impossible, task. We 

disagree that this is an impossible task. VHA needs to dedicate the necessary resources 

and training to ensure compliance with their own policies and procedures. 

In paragraph 7, the Under Secretary states that to obtain “a more objective, professional 

analysis” of all components of VHA’s scheduling process, he plans to obtain the services 

of a contractor who will thoroughly assess the factors that contribute to the complexity of 

the scheduling process and offer suggestions on ways that VHA can improve scheduling 

processes and demonstrate accurate waiting times. We take issue with any implication 

that the OIG audit was not an objective or professional analysis of the scheduling 

process. We briefed VHA representatives on our proposed methodology and approach 

during the entrance conference and made adjustments to incorporate all of their concerns. 

The audit was conducted in accordance with Government Auditing Standards, which are 

the professional standards established by the Comptroller General to ensure 

independence, due professional care, and quality control. Although VHA concurred with 

all the findings and recommendations in the 2005 report, five of the eight 

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Audit of the Veterans Health Administration's Outpatient Waiting Times 

recommendations from that report remain unimplemented, which accounts, in part, why 

the problems still exist, as shown by the most recent audit. While we do not disagree 

with the Under Secretary’s plan of action, we believe any long-term fixes or changes to 

the current system may take years to implement. In the meantime, VHA needs to ensure 

accuracy in the current system. 

In closing, the OIG remains encouraged that VHA is willing to accept responsibility for 

the problems reported and has concurred with four of the five recommendations made. 

We will follow up on the planned actions in this report, and those that remain 

unimplemented from the 2005 report, until they are completed. 

(original signed by:) 

 BELINDA J. FINN 

 Assistant Inspector General 

 for Auditing 

VA Office of Inspector General xii 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

Introduction 

Purpose 

The purpose of this audit was to follow up on our Audit of the Veterans Health 

Administration’s Outpatient Scheduling Procedures (Report No. 04-02887, July 8, 2005), 

which reported that VHA did not follow established procedures when scheduling medical 

appointments for veterans seeking outpatient care. The objectives of the follow-up audit 

were to determine whether (1) established scheduling procedures were followed and 

outpatient waiting times reported by VHA were accurate, (2) electronic waiting lists were 

complete, and (3) prior OIG recommendations were fully implemented. 

Background 

VHA policy requires that all veterans with service-connected ratings of 50 percent or 

greater and all other veterans requiring care for service-connected disabilities be 

scheduled for care within 30 days of desired appointment dates.1

 All other veterans must 

be scheduled for care within 120 days of the desired dates. In the Department of 

Veterans Affairs Fiscal Year 2006 Performance and Accountability Report, issued 

November 15, 2006, VHA reported that 96 percent of all veterans seeking primary 

medical care and 95 percent of all veterans seeking specialty medical care were seen 

within 30 days of their desired dates. VHA uses VistA scheduling software to collect all 

outpatient appointments in 50 high-volume clinics and uses that data to calculate the 

percent of appointments scheduled within 30 days. VHA designates a clinic as a highvolume clinic if the total nation-wide workload (patient visits) of that clinic ranks in the 

top 50 clinics. Examples of two high-volume clinics would be Ophthalmology and 

Optometry—both are part of the Eye Care Specialty. Additionally, VHA uses patient 

surveys to determine whether the patient received an appointment for primary care when 

they wanted one. 

VHA prescribes the following two methods to calculate the waiting times for outpatient 

appointments. 

• For established patients (about 90 percent of outpatient appointments), VHA 

measures the elapsed days from the desired dates of care contained in the VistA 

scheduling package to the dates of the appointments. Schedulers must enter the 

correct desired dates of care in the system to ensure the accuracy of this measurement. 

The desired dates of care are usually established by the providers but can be adjusted 

based on veterans’ requests. 

1

 VHA Directive 2006-028, “Process For Ensuring Timely Access To Outpatient Clinical Care” (May 8, 2006). 

VA Office of Inspector General 1 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

• For new patients, VHA calculates waiting times from the date that the scheduler 

creates the appointment. Since schedulers have 7 days to create appointments, VHA 

acknowledges that the actual waiting time for new patients could be understated by 

the number of days schedulers take to create the appointment. 

For measuring waiting times, VHA defines established patients as those who have 

received care in a specific clinic in the previous 2 years; new patients represent all others. 

For example, a veteran who has been receiving primary care at a facility within the 

previous 2 years would be considered an established patient in the primary care clinic. 

However, if that same veteran was referred to the facility’s Cardiology clinic, that veteran 

would now be classified as a new patient to the Cardiology clinic. 

VHA implemented the electronic waiting list in December 2002 to provide medical 

facilities with a standard tool to capture and track information about veterans’ waiting for 

medical appointments. Veterans who receive appointments within the required 

timeframe are not placed on the electronic waiting list. However, veterans who cannot be 

scheduled for appointments within the 30- or 120-day requirement should be placed on 

the electronic waiting list immediately. If cancellations occur and veterans are scheduled 

for appointments within the required timeframes, the veterans are removed from the 

electronic waiting list. VHA tracks the number of veterans who are on the electronic 

waiting list for more than 30 days. 

VHA policy also requires that requests for appointments (including consults) be acted on 

by the medical facility as soon as possible, but no later than 7 calendar days from the date 

of request.2

 To act on the consult is to complete or deny the consult, schedule the 

consult, or place the veteran on the electronic waiting list. The policy also requires each 

facility employee involved directly or indirectly in the outpatient scheduling process, and 

the employee’s supervisor to successfully complete VHA’s Comprehensive Scheduler’s 

Training Program. No employee will be granted access to the VistA scheduling package 

until this training program is completed. 

Scope and Methodology 

We reviewed applicable laws, regulations, policies, procedures, and guidelines and 

interviewed employees at VA Central Office and 10 medical facilities in 4 VISNs. We 

also reviewed scheduling and consult records contained in VistA and the Computerized 

Patient Records System (CPRS). The 10 medical facilities reviewed were: 

• VISN 7—Atlanta VA Medical Center (VAMC), Birmingham VAMC, and the 

William Jennings Bryan Dorn VAMC (Columbia, SC). 

• VISN 10—Chillicothe VAMC and the Cincinnati VAMC. 

2

 VHA Directive 2006-055, “VHA Outpatient Scheduling Processes And Procedures” (October 11, 2006). 

VA Office of Inspector General 2 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

• VISN 11—John D. Dingell VAMC (Detroit, MI) and the Richard L. Roudebush 

VAMC (Indianapolis, IN). 

• VISN 17— VA North Texas Health Care System (HCS) (Dallas, TX), South Texas 

Veterans HCS (San Antonio, TX); and the Central Texas Veterans HCS (Temple, 

TX). 

Two of VHA’s key performance measures are the percent of primary care appointments 

and the percent of specialty care appointments scheduled within 30 days of the desired 

dates of care. VHA uses VistA scheduling software to collect all outpatient appointments 

in 50 high-volume clinics and uses that data to calculate the percent of appointments 

scheduled within 30 days. Our universe included 14 of VHA’s 50 high-volume clinics 

and represented only 1 month of appointments. 

From VHA’s data, we determined that the 10 medical facilities we reviewed scheduled 

249,981 outpatient appointments for October 2006 in 14 of the 50 clinics representing 8 

specialties—Audiology, Cardiology, Eye Care, Gastroenterology, Mental Health, 

Orthopedics, Primary Care, and Urology. To determine if schedulers followed 

established procedures when selecting the types of appointments and veterans’ desired 

dates of care, we: 

• Reviewed a non-random sample of 700 appointments from 14 high-volume clinics 

that were scheduled for October 2006—60 appointments for established patients and 

10 appointments for new patients at each of the 10 medical facilities. The 60 

appointments for established patients consisted of 20 appointments with VHAreported waiting times of 30 days, 20 with waiting times of 15 days and 20 with 

waiting times of 0 days. We selected a smaller sample of new patient appointments 

because VHA eliminated the use of desired dates when calculating the waiting times 

of new patients. We did not review any appointments with VHA-reported waiting 

times of more than 30 days. 

• Reviewed the desired date of care requested by the provider and documented in 

medical records or the veteran’s desired date of care as recorded in the VistA 

scheduling and consult packages by the scheduler to determine if the waiting times of 

established patients were calculated correctly. 

• Determined if schedulers created appointments for new patients within the 7-day 

requirement prescribed by VHA policy to determine if the reported waiting time was 

accurate. 

• Presented the results of our reviews to each of the 10 medical facilities and, where 

appropriate, made changes to our results based on information the medical facilities 

provided to us. Subsequently, we provided the detailed results of all 700 

appointments to VHA central office personnel for their review and comment. 

VA Office of Inspector General 3 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

• Interviewed 113 schedulers to capture their experiences related to training, 

supervision, and scheduling practices. 

At the time of our review, the 10 medical facilities had 70,144 consult referrals 

(excluding prosthetic and inpatient referrals) with either an active or pending status that 

were over 7 days old. To determine if medical facilities used effective procedures to 

ensure all veterans either had appointments or were identified on the electronic waiting 

list, we reviewed a non-random sample of 300 consult referrals that were requested 

during May 2006 through March 2007. 

To determine whether VHA and medical facilities implemented the recommendations we 

made in our July 2005 report, we interviewed personnel responsible for monitoring 

outpatient waiting times and scheduling appointments. We also tested new procedures to 

determine if the accuracy of outpatient waiting times and electronic waiting lists 

improved for new patient appointments. 

We assessed the reliability of automated data by comparing selected data elements—date 

appointment was created, desired date of care, date of completed appointment—to the 

electronic medical records. We concluded that the data used to accomplish the audit 

objective was sufficiently reliable. 

Our assessment of internal controls focused only on those controls related to the accuracy 

of veterans’ waiting times and facility waiting lists. The audit was conducted in 

accordance with Generally Accepted Government Auditing Standards. 

VA Office of Inspector General 4 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

Results and Conclusions 

Issue 1: Differences in Outpatient Waiting Times 

Findings 

Schedulers were still not following established procedures for making and recording 

medical appointments. We found unexplained differences between the desired dates as 

shown in VistA and used by VHA to calculate waiting times and the desired dates shown 

in the related medical records. As a result, the accuracy of VHA’s reported waiting times 

could not be relied on. 

Differences in Reported Waiting Times 

Of the 700 veterans reported by VHA to have been seen within 30 days, 600 were 

established patients and 100 were new patients. Overall, we found sufficient evidence to 

support that 524 (75 percent) of the 700 had been seen within 30 days of the desired date. 

As shown in Table 1, this includes 229 (78 percent) veterans seeking primary care and 

295 (73 percent) veterans seeking specialty care. However, 176 (25 percent) of the 

appointments we reviewed had waiting times over 30 days when we used the desired date 

of care that was established and documented by the medical providers in the medical 

records. 

Table 1. Appointments With Waiting Times of 30 Days or Less 

(70 Reviewed at Each Facility) 

Medical Facility 

Location 

Total Primary Care Specialty Care 

Number Percent Number Percent Number Percent 

Atlanta, GA 54 77% 26 76% 28 78% 

Birmingham, AL 56 80% 18 75% 38 83% 

Columbia, SC 45 64% 21 72% 24 59% 

Chillicothe, OH 45 64% 19 76% 26 58% 

Cincinnati, OH 56 80% 14 70% 42 84% 

Detroit, MI 59 84% 28 93% 31 78% 

Indianapolis, IN 51 73% 24 73% 27 73% 

Dallas, TX 53 76% 29 83% 24 69% 

San Antonio, TX 47 67% 28 76% 19 58% 

Temple, TX 58 83% 22 79% 36 86% 

Total Within 30 Days 524 75% 229 78% 295 73% 

Total Reviewed 700 295 405 

VA Office of Inspector General 5 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

Veterans waited more than 30 days for the remaining 176 appointments as shown below 

in Table 2. 

Table 2. Appointments With Waiting times of More Than 30 Days 

OIG Calculated Waiting 

Time 

Total 

Appointments 

Primary Care 

Appointments 

Specialty Care 

Appointments 

31 to 50 Days 79 32 47 

51 to 100 Days 63 23 40 

101 to 150 Days 21 8 13 

More Than 150 Days 13 3 10 

Total Over 30 Days 176 66 110 

Number of Appointments 

Reviewed 700 295 405 

Percent Over 30 Days 25% 22% 27% 

Of the 176 appointments, 48 (27 percent) were for veterans with service-connected 

ratings of 50 percent or greater or veterans requiring care for service-connected 

disabilities. For example: 

• On December 20, 2005, a veteran who was 50 percent service-connected was seen in 

the Eye Clinic. The provider wrote in the progress note that the veteran should return 

to the clinic in 6 weeks (January 31, 2006). On September 6, the scheduler created an 

appointment for the veteran for October 17. The scheduler entered a desired date of 

October 2, which resulted in a reported waiting time of 15 days. However, based on 

the provider’s desired date of January 31, the veteran actually waited 259 days for his 

appointment. The scheduling records did not contain any explanation for the delay. 

Medical facility personnel told us the reason this appointment took so long to 

schedule was because it “fell through the cracks.” 

• On April 18, 2006, a veteran who was 80 percent service-connected, including service 

connection for hearing impairment, was referred to the Audiology Clinic. Because 

this was a consult referral, the veteran should have received the next available 

appointment. On September 20 (155 days after the referral), the scheduler created an 

appointment for the veteran for October 20 and entered a desired date of September 

20, which resulted in a reported waiting time of 30 days. However, based on the 

provider’s desired date of April 18, the veteran actually waited 185 days for his 

appointment. The scheduling records did not contain any explanation for the delay. 

Medical facility personnel agreed with our recalculated waiting time. 

Although these particular examinations were delayed, the veterans received medical care 

from other clinics during this time. 

VA Office of Inspector General 6 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

Of the 700 veterans reported by VHA to have been seen within 30 days, 600 were 

established patients and 100 were new patients. In total, 429 (72 percent) of the 600 

appointments for established patients had unexplained differences between the desired 

dates of care documented in medical records and the desired dates of care the schedulers 

recorded in VistA. If schedulers had used the desired dates of care documented in 

medical records: 

• The waiting time of 148 (25 percent) of the 600 established appointments would have 

been less than the waiting time actually reported by VHA. 

• The waiting time of 281 (47 percent) of the 600 established appointments would have 

been more than the waiting time actually reported by VHA. Of the 281 appointments, 

the waiting time would have exceeded 30 days for 176 of the appointments. 

VHA’s method of calculating the waiting times of new patients understates the actual 

waiting times. Because of past problems associated with schedulers not entering the 

correct desired date when creating appointments, VHA uses the appointment creation 

date as the starting point for measuring the waiting times for new appointments. VHA 

acknowledges that this method could understate the actual waiting times for new patients 

by the number of days schedulers take to create the appointment. VHA only uses this 

method for new appointments because VHA assumes the new patient needs to be seen at 

the next available appointment. This is true for patients that are absolutely new to the 

system. However, the problem is that VHA’s definition of new patients also includes 

patients that have already seen a provider and have a recommended desired date. In our 

opinion, while these veterans might be new to a specialty clinic, they are established 

patients because they have already seen medical providers who have recommended 

desired dates. 

For VHA to ignore the medical providers’ desired dates for this group of new patients 

understates actual waiting times. For example, we reviewed 100 new patients that VHA 

reported had waiting times of less than 30 days. Out of the 100, 86 had already seen a 

medical provider and were being referred to a new clinic. The other 14 were either new 

to the VA or had not been to the VA in over 2 years; therefore they had no desired date. 

The results of reviewing these two categories are listed below: 

• Eighty-six were currently receiving care at the facility but were classified as a new 

patient because they were referred to a specialty clinic in that same facility and had 

not received care in that clinic within the previous 2 years. For those 86 patients, we 

calculated the waiting time by identifying the desired dates of care as documented in 

the medical records (date of the consult referral) to the dates of the appointment. We 

found that 68 (79 percent) of the 86 new patients were seen within 30 days. For 15 of 

the 18 patients not seen within 30 days, schedulers did not create the appointment 

within the 7-day requirement and the scheduling records contained no explanation of 

VA Office of Inspector General 7 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

the scheduling delay. The actual waiting time for the 18 patients ranged from 32 to 

112 days. 

• Fourteen were either new to the VA, new to the facility, or had not received care in 

the facility within the previous 2 years. For those 14 we reviewed the VistA 

scheduling package and identified the date the veteran initiated the request for care 

(telephone or walk-in) and used that as the desired date for calculating the waiting 

time. Based on available documentation, all 14 veterans were seen within 30 days of 

the desired date. 

VHA needs to either ensure schedulers comply with the policy to create appointments 

within 7 days or revert back to calculating the waiting time of new patients based on the 

desired dates of care. The results included in this section are limited by the fact that 

schedulers may not have recorded the veterans’ preferences for appointment dates in 

VistA as discussed below. 

Impact on the Electronic Waiting List 

We further reviewed the 176 cases where veterans’ waiting times were more than 30 

days, and identified 64 veterans that were given appointments past the 30- or 120-day 

requirement and should have been on the electronic waiting lists. This represented 9 

percent of the 700 appointments reviewed. The 64 cases consisted of 36 veterans with 

service-connected ratings of 50 percent or greater, 12 veterans being treated for serviceconnected conditions, and 16 veterans with waiting times more than 120 days. 

Use of Patient Preferences When Scheduling Appointments 

VHA told us that the unexplained differences we found between the desired dates of care 

shown in the medical records and the desired date of care the schedulers recorded in 

VistA can generally be attributed to patient preference for specific appointment dates that 

differ from the date recommended by medical providers. VHA Directive 2006-055 

requires schedulers to include a comment in VistA if the patient requests an appointment 

date that is different than the date requested by the provider. We reviewed all comments 

in VistA and accepted any evidence that supported a patient’s request for a different date. 

VHA personnel told us that schedulers often do not document patient preferences due to 

high workload. Without documentation in the system or contacting the patients, neither 

we nor VHA can be sure whether the patient’s preference or the scheduler’s use of 

inappropriate scheduling procedures caused the differences we found. 

Some VHA clinics use recall or reminder clinics to emphasize patient-driven scheduling. 

If a veteran is entered in a recall or reminder clinic, the scheduler will notify the veteran 

either by letter or phone about 30 days before the expected appointment date and ask the 

veteran to call the clinic to set up their appointment. VHA personnel said that some 

veterans may not call for their appointment or, in some cases, may wait several months 

VA Office of Inspector General 8 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

before calling. If the scheduler does not document this situation, then the veterans 

waiting time may appear to be longer than it actually was. If a patient fails to call in, 

VHA Directive 2006-055 requires the facility to send a follow-up letter and to document 

failures to contact the veteran. 

VHA personnel told us that some providers need to be more specific when they document 

the veterans’ desired dates of care. For example, some providers will request the veterans 

to return to the clinic in 3 to 6 months. If a provider uses a date range, VHA Directive 

2006-055 requires schedulers to use the first date of the date range as the desired date of 

care or obtain clarification from the provider. When we found appointments with date 

ranges and no clarifying comments from the provider, we followed VHA policy and 

considered the first date of the range as the desired date. 

Conclusion 

We found that the conditions we identified in our previous report still exist. VHA has 

established detailed procedures for schedulers to use when creating outpatient 

appointments but has not implemented effective mechanisms to ensure scheduling 

procedures are followed. The accuracy of outpatient waiting times is dependent on 

documenting the correct desired date in the system. 

Issue 2: Consult Referrals Not Included On Electronic 

Waiting Lists 

Findings 

Schedulers did not always create appointments for consult referrals within 7 calendar 

days and as a result, VHA’s electronic waiting lists were understated. Electronic waiting 

lists are a key tool used in determining how well medical facilities are meeting their 

patient care requirements and are instrumental in making sure no veterans go untreated or 

are not treated timely. Incomplete electronic waiting lists compromise VHA’s ability to 

assess and manage demand for medical care. 

Appointments for Consult Referrals Were Not Scheduled Within Required Timeframe 

None of the 10 medical facilities we reviewed consistently included veterans with 

pending and active consults (referrals to see a medical specialist), that were not acted on 

within the 7-day requirement, on the electronic waiting list. Pending consults are those 

that have been sent to the specialty clinic, but have not yet been acknowledged by the 

clinic as being received. Active consults have been acknowledged by the receiving 

VA Office of Inspector General 9 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

clinic, but an appointment date has either not been scheduled or the appointment was 

cancelled by either the veteran or the clinic. To act on the consult is to complete or deny 

the consult, schedule an appointment for the veteran to be seen timely, or place the 

veteran on an electronic waiting list. 

According to the VistA Consult Tracking Reports, the 10 medical facilities listed 70,144 

veterans with consult referrals over 7 days old. In accordance with VHA policy, the 

medical facilities should have included these veterans on the electronic waiting lists. The 

70,144 does not include veterans with referrals for prosthetics or inpatient procedures. 

VHA personnel told us that the 70,144 included some referrals for procedures (such as 

cardiac catheters) and alternative care (such as contracted care) that should not have been 

identified on the consult tracking reports. VHA personnel also acknowledged to us that 

VHA policy does not exempt those referrals from the 7-day requirement. At the time of 

our review, the total number of veterans on the electronic waiting lists for specialty care 

was only 2,658. Table 3 shows the number of consult referrals over 7 days old where, in 

accordance with VHA policy, the medical facilities should have included the veterans on 

the electronic waiting lists and the number of veterans medical facilities reported on their 

electronic waiting lists. 

Table 3. Consult Referrals Over 7 Days Old for All Services 

According to VistA Consult Tracking Reports 

Medical Facility 

Location Active Pending Total 

Total Veterans on 

the Electronic 

Waiting List For 

Specialty Services 

Atlanta, GA 1,598 416 2,014 323 

Birmingham, AL 169 109 278 0 

Columbia, SC 114 433 547 0 

Chillicothe, OH 1,326 3,356 4,682 188 

Cincinnati, OH 2,850 7,393 10,243 351 

Detroit, MI 4,561 28,819 33,380 5 

Indianapolis, IN 88 10,647 10,735 24 

Dallas, TX 145 116 261 378 

San Antonio, TX 1,991 2,954 4,945 501 

Temple, TX 1,095 1,964 3,059 888 

Total 13,937 56,207 70,144 2,658 

According to medical facility personnel, the consult tracking report did not always reflect 

the actual consult status because clinic personnel did not always update the consult after 

action was taken. To substantiate the data in the tracking report, we selected 300 consults 

(20 active consults and 10 pending consults from each medical facility) with consult 

request dates from May 2006 through March 2007. We found that: 

VA Office of Inspector General 10 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

• Of the 200 active consults, 105 (53 percent) were not acted on within 7 days and the 

veterans were not placed on the electronic waiting list. For 55 (28 percent) of the 200 

consults, no action had occurred for at least 30 days from the consult request date. 

• Of the 100 pending consults, 79 (79 percent) were not acted on within 7 days and the 

veterans were not placed on the electronic waiting list. For 50 (50 percent) of the 100 

consults, no action had occurred for at least 30 days from the consult request date. 

We reported this same condition in our July 2005 report and recommended that the Under 

Secretary for Health monitor consult referrals to ensure that all veterans with referrals 

either have scheduled appointments within 7 calendar days or be included on electronic 

waiting lists. In response to our recommendation, VHA published VHA Directive 2006-

055 (October 11, 2006) and included detailed instructions to follow when responding to 

consult referrals. The directive also requires that schedulers be monitored on an ongoing 

basis regarding their performance in scheduling. During our facility visits, we found that 

VHA managers had not implemented an effective process to monitor schedulers’ 

performance. We did however, identify clinics within some medical facilities that 

monitored all pending and active consults over 7 days old in an effort to ensure that 

veterans were either scheduled for their appointments or included on the electronic 

waiting lists. 

Schedulers Were Not Getting the Necessary Training 

Schedulers at the medical facilities we reviewed told us that, although training was 

readily available, they did not have time to take the training. Their managers agreed, 

saying that medical facilities were short of staff and training was not a high priority. We 

interviewed 113 schedulers at 6 medical facilities and found that: 

• Fifty-three (47 percent) told us they have had no training on consults within the last 

year. Nine (17 percent) of the 53 have been employed as schedulers for less than 1 

year. 

• Sixty (53 percent) told us they have had no training on the electronic waiting list 

within the last year. Ten (17 percent) of the 60 have been employed as schedulers for 

less than 1 year. 

Medical facilities need to implement mechanisms to ensure that all personnel involved in 

managing consult referrals understand the requirement to either act on the consult 

referrals within 7 calendar days from the date of request or to include the veterans on the 

electronic waiting list. 

VA Office of Inspector General 11 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

Facilities Did Not Have Effective Consult Follow-Up Procedures 

Medical facilities did not establish effective procedures to ensure that veterans received 

timely care if the veteran did not show up for their initial appointment or the appointment 

was cancelled. Facility personnel complied with VHA policy to schedule appointments 

within 7 days for 116 (39 percent) of the 300 consults we reviewed. However, 

subsequent actions such as a patient no show placed the 116 consults back in active 

status. For 26 (22 percent) of the 116 consults, we found no evidence in the medical 

records that the facilities followed up on the consults to ensure the veterans eventually 

received the desired care. For example: 

• A consult request was initiated on November 28, 2006, for a veteran to receive care in 

the Endocrinology Clinic. On November 30, the scheduler created the appointment 

for January 29, 2007. On January 30, a note was added in VistA stating that the 

veteran did not show up for the previous day’s appointment. We reviewed medical 

records and interviewed facility personnel and found no evidence that clinic personnel 

made any further attempt to contact the referring physician or veteran to determine 

whether the consult should be cancelled or rescheduled. 

• A consult request was initiated on December 12, 2006, for a veteran to receive care in 

the Neurology Clinic. On December 18, the scheduler created the appointment for 

January 25, 2007. Two days before the appointment, the veteran called to cancel. 

Remarks were added in VistA to reschedule and notify the veteran. We reviewed 

medical records and interviewed facility personnel and found no evidence that clinic 

personnel made any further attempt to contact the referring physician or veteran to 

determine whether the consult should be cancelled or rescheduled. 

For 90 of the 116 consults where we found evidence that the medical facilities did follow 

up with the veteran, the facilities took longer than 7 days to act on the appointment for 34 

(38 percent) of the consults and did not place the veterans on the electronic waiting list. 

For example: 

• A consult request was initiated on November 17, 2006, for a veteran to receive care in 

the Internal Medicine Clinic. On November 22, the scheduler created the 

appointment for December 28. On the day of the appointment, a note was added in 

VistA stating that the patient did not show and the appointment needed to be 

rescheduled. Another note to reschedule the appointment was added on 

February 8, 2007. Clinic personnel did not create a new appointment until February 

12—46 days after the veteran did not show up for the original appointment on 

December 28. The appointment was rescheduled for March 15. 

• A consult request was initiated on January 3, 2007, for a veteran to receive care in the 

Orthopedic Clinic. On January 4, the scheduler created the appointment for 

VA Office of Inspector General 12 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

February 15. On January 29, a note was added in VistA stating that the clinic 

cancelled the appointment because there was only one resident available and the 

appointment needed to be rescheduled. Clinic personnel did not create a new 

appointment until February 20—22 days after the clinic cancelled the veteran’s 

original appointment. The appointment was rescheduled for April 16. 

Facility personnel told us the requirement to act on consults within 7 calendar days 

applied only to the initial appointments. Although VHA Directive 2006-055 does not 

specifically address the required timeline for following up on consults, VHA personnel 

confirmed for us that the 7-day requirement also applied when consults were placed back 

in active status. 

Conclusion 

VHA needs to ensure that the electronic waiting lists are complete and accurate. 

Electronic waiting lists are used to gauge how well medical facilities are meeting their 

patient care requirements and are also instrumental in making sure no veterans go 

untreated. Underreported waiting lists compromise VHA’s ability to assess and manage 

demand for medical care. 

Issue 3: Prior OIG Recommendations Were Not 

Implemented 

Findings 

In July 2005, we reported that outpatient scheduling procedures were not adequate to 

ensure accurate reporting of veterans’ waiting times and facility waiting lists (Audit of the 

Veterans Health Administration’s Outpatient Scheduling Procedures, Report No. 04-

02887-169, July 8, 2005). The Under Secretary for Health agreed with all eight 

recommendations to correct the reported conditions; however, at the start of this audit 

five of the recommendations to improve the accuracy of waiting times and waiting lists 

remained unimplemented. They were as follows: 

• Ensure that medical facility managers require schedulers to create appointments 

following established procedures (recommendation 1a). 

• Monitor consult referrals to ensure that all veterans with referrals either have 

scheduled appointments within 7 business days or be included on electronic waiting 

lists (recommendation 2a). 

• Establish an automated link from the CPRS consult package to the VistA scheduling 

module (recommendation 2b). 

VA Office of Inspector General 13 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

• Develop a standard training package for medical facilities to train schedulers on the 

electronic waiting list and VistA scheduling module (recommendation 3a). 

• Make sure all schedulers receive annual training on the electronic waiting list and 

VistA scheduling module (recommendation 3c). 

In addition, as evidenced by the results of this review, VHA’s actions to monitor the 

schedulers’ use of correct procedures when creating appointments (one of the three 

implemented recommendations) were not effective (recommendation 1b). 

During the course of this audit, VHA submitted documentation to us stating that 

recommendations 1a, 2a, and 3a were implemented. We agreed that recommendation 3a 

was implemented. However, recommendations 1a and 2a were only partially 

implemented by VHA as neither implementation action sufficiently addressed the 

oversight needed to ensure the schedulers followed the procedures. We did not review 

VHA’s efforts to establish an automated link from the CPRS consult package to the 

VistA scheduling module (recommendation 2b). 

Conclusion 

VHA needs to take timely action to implement recommendations as five of the eight 

recommendations from our July 2005 report remain unimplemented. Timely action may 

have precluded the same conditions from occurring again. 

Our audit results are not comparable to VHA’s reported waiting times contained in its 

Performance and Accountability Report because we used a different set of clinics and 

timeframe of appointments. Further, our audit results cannot be extrapolated to project 

the extent that waiting times exceed 30 days on a national level because the medical 

facilities and appointments selected for review were based on non-random samples. 

Nevertheless, the findings of this report do support the fact that the data recorded in 

VistA and used to calculate veteran outpatient waiting times is not reliable. VHA states 

that our results overstate waiting times because patients requested a different appointment 

date. We agree that patient preference could change the desired date of care; however, if 

schedulers did not document the patient preference our testing would not disclose this 

fact. We believe that VHA’s calculations of waiting times are subject to greater 

uncertainty than our numbers because we cannot assume that all differences are due to 

patient preference, especially when our review took into account medical provider 

desired dates that were also not accurately recorded in VistA. Until VHA establishes 

procedures to ensure that schedulers comply with policy and document the correct 

desired dates of care, whether recommended by medical providers or requested by 

veterans, calculations of waiting time from the current system will remain inaccurate. 

VA Office of Inspector General 14 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

Recommendations 

1. We recommended that the Under Secretary for Health establish procedures to 

routinely test the accuracy of reported waiting times and completeness of electronic 

waiting lists, and take corrective action when testing shows questionable differences 

between the desired dates of care shown in medical records and documented in the 

VistA scheduling package. 

Management Response 

The Under Secretary for Health agreed with the recommendation and stated that the 

Deputy Under Secretary for Health (DUSH) for Operations and Management will task 

a Work Group composed of knowledgeable clinical, administrative, and technical 

staff (including facility/VISN representation) to fully address all issues relating to 

electronic waiting list management that are addressed in this report. The group will 

develop comprehensive procedures, perhaps in the form of a checklist, which all 

facilities will be required to apply systematically in testing the completeness of their 

electronic waiting lists. As part of their task, the work group will also provide 

specific recommendations to the DUSH/Operations and Management for oversight 

monitoring and reporting tools that can be practically utilized to measure facility 

compliance in implementing the procedures. One action that will be considered by 

the work group is implementation of a new access performance monitor that will 

assist in identifying problem areas that need to be addressed. Before the end of this 

fiscal year, a new software patch will also be released that will automatically place 

patients on the electronic waiting list if the appointment is being scheduled more than 

120 days beyond the desired appointment date. It is anticipated that this software 

enhancement will significantly improve compliance with existing directives. 

VHA is also in the process of negotiating a national contract to analyze the full scope 

of scheduling processes, including electronic wait lists and waiting times reporting. 

Final actions approved in response to recommendations made by the work group will 

be implemented in conjunction with related actions addressed in the scheduling 

improvement study. The work group will be appointed and convened by the end of 

August 2007, with formal recommendations submitted to the DUSH/Operations and 

Management, by November 2007. 

OIG Response 

While we do not disagree with the Under Secretary’s plan of action, we believe any 

long-term fixes or changes to the current system may take years to implement. In the 

meantime, VHA needs to ensure accuracy in the current system. We will follow up 

on the planned actions until they are completed. 

VA Office of Inspector General 15 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

2. We recommended that the Under Secretary for Health take action to ensure schedulers 

comply with the policy to create appointments within 7 days or revert back to 

calculating the waiting time of new patients based on the desired date of care. 

Management Response 

The Under Secretary for Health did not agree with the recommendation and especially 

disagreed with our observation that VHA ignores the medical provider’s desired date 

for new patients, thereby understating actual waiting times. The Under Secretary 

stated that the OIG inaccurately stated that problems with using incorrect desired 

dates of care prompted VHA to stop using desired dates when calculating waiting 

times for new patients. Since 2001, VHA has calculated the waiting times for new 

patients as the number of days between the date the appointment was created and the 

appointment date. VHA considered it a number hard to game and more difficult to 

manipulate because the dates are automatically selected by our software when the 

scheduler makes the appointment. The Under Secretary stated that VHA must 

maintain a high level of flexibility in our scheduling practices for new patients, since 

provider/patient preferences and numerous other factors can obviously impact final 

appointment decisions. 

OIG Response 

Unless the desired date of care and the appointment creation date are the same, 

VHA’s decision to measure the waiting time for new patients as the number of days 

between the date the appointment was created and the appointment date ignores the 

desired date of care (whether established by the medical provider or the patient). Of 

the 100 new patient appointments we reviewed, only 41 of the appointments were 

created on the desired date of care. For the remaining 59 new appointments, the 

scheduler understated the reported waiting times by taking anywhere from 1 to 97 

days past the providers (or patients) desired date of care to create the appointment. 

Further, VHA’s intention to use software to make the new patient scheduling process 

harder to game and more difficult to manipulate actually reduces the flexibility the 

Under Secretary says is necessary because the software automatically selects the 

appointment creation date as the desired date of care. This process does not allow the 

scheduler to consider any patient preferences. Finally, during our entrance 

conference, the Under Secretary’s key representatives specifically stated that past 

problems with incorrect desired dates prompted the new process of measuring new 

patient waiting times by using the appointment creation dates instead of the desired 

dates. 

3. We recommended that the Under Secretary for Health amend VHA Directive 2006-

055 to clarify specialty clinic procedures and requirements for receiving and 

processing pending and active consults to ensure they are acted on in a timely manner 

and, if not, are placed on the electronic waiting lists. 

VA Office of Inspector General 16 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

Management Response 

The Under Secretary for Health agreed with the recommendation and stated that the 

Directive will be amended pending final determinations made by the Under Secretary 

for Health in response to recommendations made by the referenced work group and 

by the national scheduling improvement study that is currently under negotiation by 

VHA. 

OIG Response 

The improvement plans are acceptable and we will follow up on the planned actions 

until they are completed. 

4. We recommended that the Under Secretary for Health ensure all schedulers receive 

required annual training. 

Management Response 

The Under Secretary for Health agreed with the recommendation and stated that 

annual scheduler training, including certification of completion, is already mandated. 

All facilities have either completed or have nearly completed comprehensive annual 

training requirements for all schedulers, and VISNs are in the process of monitoring 

full completion via review of locally maintained training records. Annual scheduler 

refresher training will also be developed. Again, future training plans will be 

designed to reflect recommendations made by the pending work group and scheduling 

improvement study. 

OIG Response 

The improvement plans are acceptable and we will follow up on the planned actions 

until they are completed. 

5. We recommended that the Under Secretary for Health identify and assess alternatives 

to the current process of scheduling appointments and recording and reporting waiting 

times, and develop a plan to implement any changes to the current process. 

Management Response 

The Under Secretary for Health agreed with the recommendation and stated that VHA 

has released a Statement of Work to engage the services of a technical contracting 

firm to analyze the full scope of our scheduling processes, identify opportunities for 

improvement, and recommend viable alternative approaches for consideration. Based 

on submitted recommendations, decisions will be made about pursuing alternative 

directions in the scheduling design. 

VA Office of Inspector General 17 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

OIG Response The improvement plans are acceptable and we will follow up on the 

planned actions until they are completed. 

. 

VA Office of Inspector General 18 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

Appendix A 

Under Secretary for Health Comments 

Department of 

Veterans Affairs Memorandum 

Date: August 22, 2007 

From: Under Secretary for Health (10) 

Subject: OIG Draft Report: Audit of the Veterans Health 

Administration’s Outpatient Waiting Times (Project 

No. 2007-00616-R5-0068/WebCIMS 381450) 

To: Assistant Inspector General for Auditing (52) 

1. I have carefully reviewed your revised draft report on waiting 

times, and I appreciate your willingness to address several key VHA 

concerns with the audit methodology, particularly in relation to the 

contrasting methods used by VHA and OIG to calculate wait times, 

and your acknowledgment that the audit results cannot be 

extrapolated to project national trends. I also believe that the report 

correctly identifies areas VHA needs to address to improve

outpatient waiting time accuracy. Nevertheless, VHA continues to 

non-concur with the findings in Issue 1 because of the limitations of 

the methodology used in the study. I also do not concur with 

Recommendation 2, relating to the calculation of waiting times for 

new patients. We do, however, concur with Issue 2 and the

remaining recommendations, and include a plan of corrective actions 

as part of our response. 

2. As I am sure you will agree, scheduling processes in a system as 

massive as VA are often overwhelmingly complex, with so many 

variables involved that accurate reporting of national waiting times 

by any large organization is a daunting challenge. To my

knowledge, VHA’s efforts appear to be unprecedented, since no 

other system in the public or private sector has attempted to measure 

waiting times for almost 40 million appointments. Your report 

highlights many of the roadblocks we face. However, one of the 

most valid measurements we have of access efficiency is also the 

most vital, since it is generated directly from our veterans. VA’s

national patient satisfaction survey, completed in February and 

VA Office of Inspector General 19 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

March 2007, shows that 85 percent of the veterans who personally 

completed the survey reported that they had access to primary care 

appointments when they needed them. Eighty-one percent of those 

same veterans also reported satisfaction with timely access to 

specialty care. This positive reporting by actual veteran patients 

varies significantly with your report results. There are several 

factors which might account for this discrepancy. 

3. With respect to Issue 1: “Differences in Outpatient Waiting 

Times,” I am extremely concerned that the methodology OIG used 

resulted in a flawed conclusion about the magnitude of the 

inaccuracy in patient waiting times. I especially disagree with your 

conclusions about both the scheduling and definition of new 

patients, and the observation that VHA ignores the medical 

providers’ desired date for new patients, thereby understating actual 

waiting times. You inaccurately state that problems with using 

incorrect desired dates of care prompted VHA to stop using desired 

dates when calculating waiting times for new patients. VHA has 

calculated a new patient wait time since 2001. We have always 

calculated it as the number of days between the date the appointment 

was created and the appointment date. We considered it a number 

hard to game because the dates are automatically selected by our 

software when the scheduler makes the appointment. Thus, the 

software logic determines which appointments are new, not the 

scheduler, so it’s very difficult for the field to manipulate. We must 

maintain a high level of flexibility in our scheduling practices for 

new patients, since provider/patient preferences and numerous other 

factors can obviously impact final appointment decisions. It should 

also be emphasized that new patients who are in high priority 

categories, including Operation Iraqi Freedom/Operation Enduring 

Freedom (OIF/OEF) and service-connected veterans, are 

immediately provided with timely access to needed care either in the 

VA or in the private sector, if necessary. 

4. OIG auditors computed waiting times by using the date that our 

clinicians specified for a patient to return for a visit, without 

considering the date the patient wanted to return, unless that 

patient’s preferred date was clearly documented by the clerk in the 

scheduling package or the medical record. You also estimated the 

most conservative desired appointment date whenever the patient’s 

preferred appointment date was not clearly documented, essentially 

providing a worse-case scenario analysis. Strictly adhering to the 

physician desired date as an absolute nonnegotiable date rather than 

VA Office of Inspector General 20 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

as the preferred time frame it is used as in scheduling, and by not 

factoring in all patient preferences, the report overstates the delay in 

waiting times. 

a. VHA allows patients to negotiate their own appointment dates 

based on their own personal priorities. To accommodate this, many 

of our facilities use a “recall/reminder” system. As the time of the 

appointment scheduling nears, a postcard or other reminder is sent to 

the patient which reminds the patient to contact the facility to 

schedule their appointment. Patient involvement in this process 

decreases the likelihood that appointments will be cancelled if they 

are scheduled far in advance, and also reduces the possibility that the 

patient will be a “no show” for his or her appointment. 

b. For example, a veteran and his or her clinician agree that a followup appointment is needed in six months. Using the 

“recall/reminder” system, no appointment is made at the time of that 

agreement. Five months later, the facility sends the veteran a 

reminder that an appointment is needed, and that the veteran should 

contact the facility within a month. Many times, veterans take 

longer than a month to make that contact. In those situations, even if 

an appointment is made within 30 days of the call, OIG auditors 

would consider this an overdue appointment, which VHA believes it 

is not. 

c. I concede that scheduling clerks’ failures to adequately document 

patient preferences in appointment dates contributed to the audit 

findings - but it is unrealistic to expect VHA’s schedulers to 

maintain such a high level of documentation for the 37 million 

appointments scheduled annually when that documentation is solely 

to support audit requirements and does little, if anything, to support 

the actual scheduling of the appointment per se. 

5. OIG auditors also cited VHA for errors in cases where veterans 

cancelled appointments, and VHA did not follow-up to reschedule 

new appointments. Except in cases involving mental health 

diagnoses or other high-risk illnesses, our patients have the 

responsibility to reschedule appointments that they have cancelled. 

This expectation is the same as that in the private sector. VHA, of 

course, has the responsibility to follow-up when our staff initiate the 

cancellation. 

6. With respect to Issue 2: “Electronic Wait Lists Were Not 

Complete,” VHA concurs with the report findings and an action plan 

VA Office of Inspector General 21 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

to address the associated recommendations is attached. I would reemphasize, however, that any attempt at accurate reporting of 

waiting times, as an unintended byproduct of a scheduling software 

package, is a formidable, if not impossible, task in a health care 

system as vast and complex as VA. 

7. To obtain a more objective, professional analysis of all 

components of VHA’s scheduling process, including electronic wait 

lists and waiting times reporting, I plan to obtain the services of a 

contractor who will thoroughly assess the factors that contribute to 

the complexity of the scheduling process and offer suggestions on 

ways VHA can improve scheduling processes and demonstrate 

accurate waiting times. Included in the assessment will be 

information technology software support; levels of variability in the 

way departments are organized; scheduling rules and their 

implementation; demands on scheduling clerks and their 

organizational alignment; patient no-show rates; overbooking 

practices, and variability in provider supply and patient demand for 

specific types of appointments. VHA, working with the Office of 

Acquisition and Material Management, finalized a Statement of 

Work for this project and is now in the solicitation process. 

8. Along with this study, VHA will continue to take important steps 

towards implementing a proposed new scheduling software package; 

improving waiting time metrics; developing standardized tools to 

improve reporting accuracy systemwide; improving our 

documentation procedures; and addressing training and career 

development issues for our scheduling clerks. I am personally 

committed to making significant improvements in this area, and I 

look forward to working with you to ensure that these improvements 

fully benefit veterans and their families. 

9. If you require any additional information, please contact Margaret 

M. Seleski, Director, Management Review Service (10B5), at 565-

7638. 

(original signed by:) 

Michael J. Kussman, MD, MS, MACP 

Attachment 

VA Office of Inspector General 22 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

Under Secretary for Health Comments 

to Office of Inspector General’s Report 

The following comments are submitted in response to the 

recommendations in the Office of Inspector General’s report: 

1. We recommended that the Under Secretary for Health establish 

procedures to routinely test the accuracy of reported waiting times 

and completeness of electronic waiting lists, and take corrective 

action when testing shows questionable differences between the 

desired dates of care shown in medical records and documented in 

the VistA scheduling package. 

Concur 

Target Completion Date: November 2007 and Ongoing 

The Deputy Under Secretary for Health for Operations and 

Management (DUSH/Operations and Management) will task a Work 

Group composed of knowledgeable clinical, administrative and 

technical staff (including facility/VISN representation) to fully 

address all issues relating to electronic waiting list management that 

are addressed in this report. The group will develop comprehensive 

procedures, perhaps in the form of a checklist that all facilities will 

be required to apply systematically in testing the completeness of 

their electronic waiting lists. As part of their task, the work group 

will also provide specific recommendations to the DUSH/Operations 

and Management for oversight monitoring and reporting tools that 

can be practically utilized to measure facility compliance in 

implementing the procedures. One action that will be considered by 

the work group is implementation of a new access performance 

monitor that will assist in identifying problem areas that need to be 

addressed. Before the end of this fiscal year, a new software patch 

will also be released that will automatically place patients on the 

electronic waiting list if the appointment is being scheduled more 

than 120 days beyond the desired appointment date. It is anticipated 

that this software enhancement will significantly improve 

compliance with existing directives. 

VA Office of Inspector General 23 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

As noted in our response memo, VHA is also in the process of 

negotiating a national contract to analyze the full scope of 

scheduling processes, including electronic wait lists and waiting 

times reporting. Final actions approved in response to 

recommendations made by the work group will be implemented in 

conjunction with related actions addressed in the scheduling 

improvement study. 

The work group will be appointed and convened by the end of 

August 2007, with formal recommendations submitted to the 

DUSH/Operations and Management, by November 2007. 

2. We recommended that the Under Secretary for Health take action 

to ensure schedulers comply with the policy to create appointments 

within 7 days or revert back to calculating the waiting time of new 

patients based on the desired date of care. 

Non-Concur 

Non-Concur based on reasons cited in the response memo. VHA 

anticipates the contractor will include recommendations related to 

policy compliance as part of their review. 

3. We recommended that the Under Secretary for Health amend 

VHA Directive 2006-055 to clarify specialty clinic procedures and 

requirements for receiving and processing pending and active 

consults to ensure they are acted on in a timely manner and, if not, 

are placed on the electronic waiting lists. 

Concur 

Target Completion Date: December 2007 and Ongoing 

The Directive will be amended pending final determinations made 

by the Under Secretary for Health in response to recommendations 

made by the referenced work group and by the national scheduling 

improvement study that is currently under negotiation by VHA. 

4. We recommended that the Under Secretary for Health ensure all 

schedulers receive required annual training. 

Concur 

Target Completion Date: December 2007 and Ongoing 

VA Office of Inspector General 24 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

Annual scheduler training, including certification of completion, is 

already mandated. All facilities have either completed or have 

nearly completed comprehensive annual training requirements for all 

schedulers, and VISNs are in the process of monitoring full 

completion via review of locally maintained training records. 

Annual scheduler refresher training will also be developed. Again, 

future training plans will be designed to reflect recommendations 

made by the pending work group and scheduling improvement 

study. 

5. We recommended that the Under Secretary for Health identify 

and assess alternatives to the current process of scheduling 

appointments and recording and reporting waiting times, and 

develop a plan to implement any changes to the current process. 

Concur 

Target Completion Date: December 2007 and Ongoing 

As already noted, VHA has released a Statement of Work to engage 

the services of a technical contracting firm to analyze the full scope 

of our scheduling processes, identify opportunities for improvement 

and recommend viable alternative approaches for consideration. 

Based on submitted recommendations, decisions will be made about 

pursuing alternative directions in the scheduling design. 

VA Office of Inspector General 25 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

Appendix B 

OIG Contact and Staff Acknowledgments 

OIG Contact Larry Reinkemeyer (816) 426-7100 

Acknowledgments Robin Frazier 

Joseph Janasz 

Brad Lewis 

Daniel Morris 

Dao Pham 

Carla Reid 

Jason Schuenemann 

Marcia Schumacher 

Oscar Williams 

VA Office of Inspector General 26 
Audit of the Veterans Health Administration's Outpatient Waiting Times 

Appendix C 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Veterans Benefits Administration 

National Cemetery Administration 

Assistant Secretaries 

Office of General Counsel 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Committee on Appropriations, Subcommittee on Military Construction, Veterans 

Affairs, and Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Committee on Appropriations, Subcommittee on Military Construction, Veterans 

Affairs, and Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

This report will be available in the near future on the OIG’s Web site at 

http://www.va.gov/oig/publications/reports-list.asp. This report will remain on the OIG 

Web site for at least 2 fiscal years after it is issued. 

VA Office of Inspector General 27