VA Health Care: Ongoing and Past Work Identified Access, Oversight, and Data Problems That Hinder Veterans' Ability to Obtain Timely Outpatient Medical Care
Published: 2014-06-09T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Access to timely medical appointments is critical to ensuring that veterans obtain needed medical care. Over the past few years, there have been numerous reports of VAMCs failing to provide timely care to veterans, and in some cases, these delays have reportedly resulted in harm to patients. As the number of these reports has grown, investigations have been launched by VA's Office of Inspector General and VA to examine VAMCs' medical appointment scheduling and other practices.
In December 2012, GAO reported that improvements were needed in the reliability of VHA's reported medical appointment wait times, as well as oversight of the scheduling process. In May 2013, VHA launched the Consult Management Business Rules Initiative to standardize aspects of the consults process and develop system-wide consult data for monitoring.
This testimony is based on GAO's ongoing work to update information previously provided to the Committee on April 9, 2014, including information on VHA's (1) process for managing consults; (2) oversight of consults; and (3) progress made implementing GAO's December 2012 recommendations. To conduct this work, GAO has reviewed documents and interviewed VHA officials. Additionally, GAO has interviewed officials from five VAMCs for the consults work and four VAMCs for the scheduling work that varied based on size, complexity, and location. GAO shared the information it used to prepare this statement with VA and incorporated its comments as appropriate.
section_title: What GAO Found
paragraphs: GAO's ongoing work examining the Department of Veterans Affairs' (VA) Veterans Health Administration's (VHA) process for managing outpatient specialty care consults has identified examples of delays in veterans receiving outpatient specialty care. GAO has found consults—requests for evaluation or management of a patient for a specific clinical concern—that were not processed in accordance with VHA timeliness guidelines. For example, consults were not reviewed within 7 days, or completed within 90 days. For 31 of the 150 consults GAO reviewed (21 percent), the consult records indicated that VA medical centers (VAMC) did not meet the 7-day review requirement. In addition, GAO found that veterans received care for 86 of the 150 consults (57 percent), but in only 28 of the consults (19 percent) was the care provided within 90 days. For the remaining 64 consults (43 percent), the patients did not receive the requested care. For 4 of the 10 physical therapy consults GAO reviewed for one VAMC, between 108 and 152 days elapsed with no apparent actions taken to schedule an appointment for the veteran. For 1 of these consults, several months passed before the veteran was referred for care to a non-VA health care facility. VAMC officials cited increased demand for services, and patient no-shows and cancelled appointments among the factors that lead to delays and hinder their ability to meet VHA's guideline of completing consults within 90 days of being requested. VA officials indicated that they may refer veterans to non-VA providers to help mitigate delays in care.
GAO's ongoing work also has identified limitations in VHA's implementation and oversight of its new consult business rules designed to standardize aspects of the clinical consult process. Specifically, GAO has identified variation in how the five VAMCs reviewed have implemented key aspects of the business rules, such as strategies for managing future care consults—requests for specialty care appointments that are not clinically needed for more than 90 days. However, it is not clear the extent to which VHA is aware of the various strategies that VAMCs are using to comply with this task. Furthermore, oversight of the implementation of the business rules has been limited and does not include independent verification of VAMC actions. Because this work is ongoing, GAO is not making recommendations on VHA's consult process at this time.
In December 2012, GAO reported that VHA's outpatient medical appointment wait times were unreliable and recommended that VA take actions to: (1) improve the reliability of its outpatient medical appointment wait time measures; (2) ensure VAMCs consistently implement VHA's scheduling policy, including the staff training requirements; (3) require VAMCs to routinely assess scheduling needs and allocate staffing resources accordingly; and (4) ensure that VAMCs provide oversight of telephone access, and implement best practices. As of June 2014, VA has reported ongoing actions to address these recommendations, but GAO found that continued work is needed to ensure these actions are fully implemented in a timely fashion. Ultimately, VHA's ability to ensure and accurately monitor access to timely medical appointments is critical to ensuring quality health care is provided to veterans, who may have medical conditions that worsen if care is delayed.

section_title: Letter
paragraphs: I am pleased to be here today as you examine ongoing concerns related  to the Department of Veterans Affairs’ (VA) delivery of health care to our  nation’s veterans. In recent years, VA’s Veterans Health Administration  (VHA) has faced a growing demand for providing outpatient medical  appointments. From fiscal years 2005 through 2012, the number of  annual outpatient medical appointments VHA provided increased by  approximately 45 percent, from 58 million to 84 million. VHA provided  this care through its primary and specialty care outpatient clinics, which  are managed by VA’s 151 medical centers (VAMC). Although access to  timely medical appointments is critical to ensuring that veterans obtain  needed medical care, problems with VHA’s scheduling and management  of outpatient medical appointments may contribute to delays in care, or  care not being provided at all. Over the past few years there have been  numerous reports of VAMCs failing to provide timely care, including  specialty care, and in some cases, the delays have reportedly resulted in  harm to veterans.
Nonetheless, VHA has reported continued improvements in achieving  timely access to medical appointments. For example, in fiscal year 2011,  VA reported that VHA completed 89 percent of medical appointments for  new patients within its goal; in fiscal year 2012, VA reported that VHA  completed 90 percent of primary and specialty care new patient  appointments within the goal. However, in December 2012, we reported  that VHA’s medical appointment wait times were unreliable and VHA’s  inadequate oversight of the outpatient medical appointment scheduling  processes contributed to VHA’s problems with scheduling timely medical  appointments. More recently, a report by VA’s Office of Inspector  General, as well as hearings on VA’s delivery of medical care have  discussed delays in care and improper scheduling practices resulting in  lengthy wait times at VA facilities, and in some cases, care not being  provided at all. Additionally, VA has initiated a system-wide audit to  identify the scope and magnitude of these issues. Initial results of the  audit confirmed questionable scheduling practices and other problems at  many VA facilities.
The problems that have been identified include VA’s scheduling and  delivery of outpatient specialty care. When a physician or other provider  determines that a veteran needs outpatient specialty care, the provider  refers the veteran to a specialist for a clinical consult—a request for  evaluation or management of a patient for a specific clinical concern, or  for a specialty procedure such as a colonoscopy. VAMCs request, review,  and manage consults using VHA’s clinical consult process and electronic  consult system, which retains information about each consult request and  is part of VHA’s Veterans Health Information Systems and Technology  Architecture (VistA). VHA’s timeliness guideline is that consults should  be completed within 90 days of being requested.
Appointments resulting from outpatient consults, like other outpatient  medical appointments, are subject to VHA’s scheduling policy. This  policy is designed to help VAMCs meet their commitment to scheduling  medical appointments with no undue waits or delays for patients. It  establishes processes and procedures for scheduling medical  appointments and ensuring the competency of staff directly or indirectly  involved in the scheduling process. Additionally, it includes several  requirements that affect timely appointment scheduling, as well as  accurate wait time measurement. For example, the policy requires  schedulers to record appointments in VHA’s VistA medical appointment  scheduling system.
Ideally, the consult system would contain timely and reliable information  on the status and outcomes of consults, and would provide VHA  information it needs to help effectively manage the process. In 2012,  however, VHA found that system-wide consult data could not be  adequately used to determine the extent to which veterans experienced  delays in receiving outpatient specialty care. VHA found that  approximately 2 million consults were unresolved in its system for more  than 90 days. Additionally, VHA determined that the data were  inadequate to identify whether care had been provided for these consults,  or provided in a timely manner. In response, in May 2013, VHA launched  the Consult Management Business Rules Initiative (referred to as “consult  business rules”) to standardize aspects of the consult process, with the  goal of developing consistent and reliable data on consults across all  VAMCs.
My statement today will draw from our ongoing work examining the  management of outpatient specialty care consult processes at five  selected VAMCs, and our December 2012 report examining the reliability  of VHA’s reported outpatient medical appointment wait times data and   In particular, this statement updates information  scheduling oversight.provided in our April 9, 2014 testimony before the Committee regarding  (1) the extent to which VHA’s process for conducting outpatient consults  at five selected VAMCs ensured veterans timely access to specialty care,  (2) the extent to which VHA monitors and oversees consults to ensure  veterans are receiving outpatient specialty care in accordance with its  timeliness standards; and (3) key findings and recommendations from our  December 2012 report, as well as the progress VHA has made in  implementing those recommendations.
For our ongoing outpatient specialty care consults work, reviewed documents and interviewed VHA central office officials about  VHA’s policies and guidance for VAMCs to send, receive, and complete  consults, and VHA’s procedures for VAMCs to schedule outpatient  medical appointments, which include those for specialty care. We also  have reviewed documents and interviewed VHA central office officials  about their efforts to oversee VAMCs’ implementation of VHA’s consult  policies, including VHA’s Consult Management Business Rules Initiative,  launched in May 2013. Additionally, we have interviewed officials from  five VAMCs selected for variation in volume of outpatient consults,  complexity, and location. These five VAMCs were located in Augusta,  Maine; Denver, Colorado; Gainesville, Florida; Oklahoma City, Oklahoma;  and Palo Alto, California. For each VAMC included in our ongoing work,  we have interviewed leadership about how VHA’s consult policies and  any local policies or procedures for managing consults are implemented  at their facility. We also have interviewed specialty care service chiefs,  administrative staff, and providers of three high-volume specialty  services—cardiology, gastroenterology, and physical therapy. Further, we  have interviewed officials at the five regional Veterans Integrated Service  Networks (VISN) responsible for overseeing consults for the VAMCs  included in our review.
The scope of our work is limited to outpatient consults; however, providers may also  request consults for inpatient care and administrative needs, among other things.
Additionally, for each of the five medical centers, we have reviewed the  history of actions taken on a random sample of 30 outpatient consults   (10 from each of the three specialties included in our review) that were  requested during the period April 1, 2013, through September 30, 2013,  that either took more than 90 days to complete or had been in process for  more than 90 days. We also asked VHA to identify those consults that  were requested during this time period for veterans who are now  deceased. We randomly selected 50 of these consults (10 from each  VAMC included in our review) to determine the extent to which these  veterans may have experienced any delays in care. The preliminary  findings from our ongoing review of outpatient consults are not  generalizable across all VAMCs.
For our December 2012 report examining the reliability of VHA’s reported  outpatient medical appointment wait times and scheduling oversight, we  reviewed VHA’s scheduling policy and methods for measuring medical  appointment wait times and interviewed VHA central office officials   We also visited 23 high-volume  responsible for developing them.outpatient clinics at four VAMCs selected for variation in size, complexity,  and location; these four VAMCs were located in Dayton, Ohio; Fort  Harrison, Montana; Los Angeles, California; and Washington, D.C. At  each VAMC we interviewed leadership and other officials about how they  managed and improved medical appointment timeliness, their oversight to  ensure accuracy of scheduling data and compliance with scheduling  policy, and problems staff experienced in scheduling timely medical  appointments. We examined each VAMC’s and clinic’s implementation of  elements of VHA’s scheduling policy and obtained documentation of  scheduler training completion. In addition, we interviewed schedulers  from 19 of the 23 clinics visited, and also reviewed patient complaints  about telephone responsiveness, which is integral to timely medical  appointment scheduling. We interviewed the directors and relevant staff  of the four regional VISNs for the VAMCs we visited. We also interviewed  VHA central office officials and officials at the VAMCs we visited about  selected initiatives to improve veterans’ access to timely medical  appointments. Additionally, in April and June 2014, we reviewed  documentation and interviewed officials from VHA’s central office about  the extent to which they have addressed the recommendations we made  in the 2012 report.
The work upon which this statement is based was conducted in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives. We are not making  recommendations on VHA’s consult process at this time because some of  this work is ongoing.
We shared information we used to prepare this statement with VA. After  reviewing this information, VA provided us with technical comments,  which we incorporated as appropriate.
subsections: section_title: Background
paragraphs: When providers at VAMCs determine that a veteran needs outpatient  specialty care, they request and manage consults using VHA’s clinical  consult process. Clinical consults include requests by physicians or other  providers for both clinical consultations and procedures. A clinical  consultation is a request seeking an opinion, advice, or expertise  regarding evaluation or management of a patient’s specific clinical  concern, whereas a procedure is a request for a specialty procedure such  as a colonoscopy. Clinical consults are typically requested by a veteran’s  primary care provider using VHA’s electronic consult system. The consult  process is governed by VHA’s national consult policy. The policy  requires VAMCs to manage consults using a national electronic consult  system,to veterans.   and requires VAMC staff to provide timely and appropriate care  Once a provider sends a request, VHA requires specialty care providers  to review it within 7 days and determine whether to accept the consult. If  the specialty care provider accepts the consult—determines the consult is  needed and is appropriate—an appointment is to be made for the patient  to receive the consultation or procedure. In some cases, a provider may  discontinue a consult for reasons such as the care is not needed, the  patient refuses care, or the patient is deceased. In other cases the  specialty care provider may determine that additional information is  needed, and will send the consult back to the requesting provider, who  can resubmit the consult with the needed information. Once the  appointment is held, VHA’s policy requires the specialty care provider to  appropriately document the results of the consult, which would then close  out the consult as completed in the electronic system. VHA’s current  guideline is that consults should be completed within 90 days of the  request. If an appointment is not held, staff are to document why they  were unable to complete the consult.
According to VHA’s consult policy, VHA central office officials have  oversight responsibility for the consult process, including the  measurement and monitoring of ongoing performance. In 2012, VHA  created a database to capture all consults system-wide and, after  reviewing these data, determined that the data were inadequate for  monitoring purposes. One issue identified was the lack of standard  processes and uses of the electronic consult system across VHA. For  example, in addition to requesting consults for clinical concerns, the  system also was being used to request and manage a variety of  administrative tasks, such as requesting patient travel to appointments.  Additionally, VHA could not accurately determine whether patients  actually received the care they needed, or if they received the care in a  timely fashion. According to VHA officials, approximately 2 million  consults (both clinical and administrative consults) were unresolved for  more than 90 days. Subsequently, VA’s Under Secretary for Health  convened a task force to address these and other issues regarding VHA’s  consult system, among other things. In response to the task force  recommendations, in May 2013, VHA launched the Consult Management  Business Rules Initiative to standardize aspects of the consult process,  with the goal of developing consistent and reliable information on consults  across all VAMCs. This initiative required VAMCs to complete four  specific tasks between July 1, 2013, and May 1, 2014:
Review and properly assign codes to consistently record consult  requests in the consult system;
Assign distinct identifiers in the electronic consult system to  differentiate between clinical and administrative consults;
Develop and implement strategies for requesting and managing  requests for consults that are not needed within 90 days—known as  “future care” consults; and
Conduct a clinical review as warranted, and as appropriate, close all  unresolved consults—those open more than 90 days.
At the time of our December 2012 review, VHA measured outpatient  medical appointment wait times as the number of days elapsed from the  patient’s or provider’s desired date, as recorded in the VistA scheduling  system by VAMCs’ schedulers. In fiscal year 2012, VHA had a goal of  completing new and established patient specialty care appointments  within 14 days of the desired date. VHA established this goal based on its  performance reported in previous years.achieving its wait time goals, VHA includes wait time measures—referred  to as performance measures—in its budget submissions and   To facilitate accountability for  performance reports to Congress and stakeholders.measures, like wait time goals, have changed over time.
Officials at VHA’s central office, VISNs, and VAMCs all have oversight  responsibilities for the implementation of VHA’s scheduling policy. For  example, each VAMC director, or designee, is responsible for ensuring  that clinics’ scheduling of medical appointments complies with VHA’s  scheduling policy and for ensuring that all staff who can schedule medical  appointments in the VistA scheduling system have completed the  required VHA scheduler training. In addition to the scheduling policy, VHA has a separate directive that establishes policy on the provision of  telephone service related to clinical care, including facilitating telephone  access for medical appointment management.
section_title: GAO’s Ongoing Work Indicates That Veterans Did Not Always Receive Outpatient Specialty Care in Accordance with VHA Timeliness Standards, and in Some Cases, Did Not Receive Care at All
paragraphs: Our ongoing work has identified examples of delays in veterans receiving  requested outpatient specialty care at the five VAMCs we reviewed. We  found consults that were not processed in accordance with VHA  timeliness guidelines—for example, consults were not reviewed within   7 days, or completed within 90 days. We also found consults for which  veterans did not receive the requested outpatient specialty care, and  those for which the requested specialty care was provided, but were not  properly closed in the consult system.
VHA requires specialty care providers to review consults within 7 days  and determine whether to accept the consult. Of the 150 consults we  reviewed, the consult records indicated that VAMCs did not meet the   7-day requirement for 31 consults (21 percent). For one VAMC, nearly  half the consults were not reviewed and triaged within 7 days. Officials at  this VAMC cited a shortage of providers needed to review and triage the  consults in a timely manner.
Our ongoing work also has identified that for the majority of the 150  consults we reviewed, VAMCs did not meet VHA’s timeliness guideline  that care be provided and consults completed within 90 days. We found  that veterans received care for 86 of the 150 consults we reviewed   (57 percent), but in only 28 of the consults (19 percent) veterans received  care within 90 days of the date the consult was requested. For the  remaining 64 consults (43 percent), the patients did not receive the  requested care. Specific examples of consults that were not completed in  90 days, or were closed without the patients being seen, include:
For 3 of 10 gastroenterology consults we reviewed for one VAMC, we  found that between 140 and 210 days elapsed from the dates the  consults were requested to when the patients received care. For the  consult that took 210 days, an appointment was not available within  90 days and the patient was placed on a waiting list before having a  screening colonoscopy.
For 4 of the 10 physical therapy consults we reviewed for one VAMC,  we found that between 108 and 152 days elapsed, with no apparent  actions taken to schedule an appointment for the veteran. The  patients’ files indicated that due to resource constraints, the clinic was  not accepting consults for non-service-connected physical therapy  evaluations.veteran was referred to non-VA care, and he was seen 252 days after  the initial consult request. In the other 3 cases, the physical therapy  clinic sent the consults back to the requesting provider, and the  veterans did not receive care for that consult.
In 1 of these cases, several months passed before the
For all 10 of the cardiology consults we reviewed for one VAMC, we  found that staff initially scheduled patients for appointments between  33 and 90 days after the request, but medical files indicated that  patients either cancelled or did not show for their initial appointments.  In several instances patients cancelled multiple times. In 4 of the  cases VAMC staff closed the consults without the patients being seen;  in the other 6 cases VAMC staff rescheduled the appointments for  times that exceeded the 90-day timeframe.
VAMC officials cited increased demand for services, patient no-shows,  and cancelled appointments, among the factors that hinder their ability to  meet VHA’s guideline for completing consults within 90 days. Several  VAMC officials also noted a growing demand for both gastroenterology  procedures, such as colonoscopies, as well as consultations for physical  therapy evaluations, combined with a difficulty in hiring and retaining  specialists for these two clinical areas, as causes of periodic backlogs in  providing these services. Officials at these facilities indicated that they try  to mitigate backlogs by referring veterans to non-VA providers for care.
While officials indicated that use of non-VA care can help mitigate  backlogs, several officials indicated that non-VA care requires more  coordination between the VAMC, the patient, and the non-VA provider;  can require additional approvals for the care; and also may delay  obtaining the results of medical appointments or procedures. In addition,  wait times are generally not tracked for non-VA care. As such, officials  acknowledged that this strategy does not always prevent delays in  veterans receiving timely care or in completing consults.
Our ongoing review also has identified one consult for which the patient  experienced delays in obtaining non-VA care and died prior to obtaining  needed care. In this case, the patient needed endovascular surgery to  repair two aneurysms – abdominal aortic and an iliac. According to the  patient’s medical record, the timeline of events surrounding this consult  was as follows:
September 2013 – Patient was diagnosed with two aneurysms.
October 2013 – VAMC scheduled patient for surgery in November,  but subsequently cancelled the scheduled surgery due to staffing  issues.
December 2013 – VAMC approved non-VA care and referred the  patient to a local hospital for surgery.
Late December 2013 – After the patient followed up with the VAMC, it  was discovered that the non-VA provider lost the patient’s information.  The VAMC resubmitted the patient’s information to the non-VA  provider.
February 2014 – The consult was closed because the patient died  prior to the surgery scheduled by the non-VA provider.
According to VAMC officials, they conducted an investigation of this case.  They found that the non-VA provider planned to perform the surgery on  February 14, 2014, but the patient died the previous day. Additionally,  they stated that according to the coroner, the patient died of cardiac  disease and hypertension and that the aneurysms remained intact.
Furthermore, our ongoing work shows that for nearly all of the consults  where care had been provided within 90 days, an extended amount of  time elapsed before specialty care providers completed them in the   Specifically, for 28 of the 29 consults, even though care  consult system.was provided, the consult remained open in the system, making it appear  as though the requested care was not provided within 90 days. For one  VAMC, we found that for all 10 cardiology consults we reviewed, specialty  care providers did not properly document the results of the consults in  order to close them in the system. In some cases, it took over 100 days  from the time care was provided until the consults were completed in the  system.
Officials from several VAMCs told us that often specialty care providers  do not choose the correct notes needed to document that the consults are  complete. Officials attributed this ongoing issue in part to the use of  residents, who rotate in and out of specialty care clinics after a few  months and lack experience with completing consults. Officials from one  VAMC told us that this requires VAMC leadership to continually train new  residents on how to properly complete consults. To ensure that specialty  care providers consistently choose the correct notes, this VAMC activated  a prompt in its consult system asking each provider if the note the  provider is entering is in response to a consult. Officials stated that this  has resulted in providers more frequently choosing the correct note title to  complete consults.
section_title: Limitations in VHA’s Implementation of the Consult Business Rules Impedes Its Ability to Assess Delays in Care
paragraphs: Our ongoing work has identified variation in how the five VAMCs in our  review have implemented key aspects of VHA’s business rules, which  limits the usefulness of the data in monitoring and overseeing consults  system-wide. As previously noted, VHA’s business rules were designed  to standardize aspects of the consult process, thus creating consistency  in VAMCs’ management of consults. However, we have found variation in  how VAMCs are implementing certain tasks required by the business  rules. For example, VAMCs have developed different strategies for  managing future care consults—requests for specialty care appointments  that are not clinically needed for more than 90 days.
One task of the consult business rules required VAMCs to develop and  implement strategies for requesting and managing requests for future  care consults. Based on our ongoing work, we have identified that  VAMCs are adopting various strategies when implementing this task,such as piloting an electronic system for providers to manage future care  consults outside of the consult system and entering the consult  regardless of whether the care was needed beyond 90 days. However,  during the course of our ongoing work, several VAMCs told us they are  changing their strategies for requesting and managing future care  consults. For example, officials from a VAMC that was piloting an  electronic system stated that, after evaluating the pilot, they decided not  to use this approach, and are instead planning to implement markers to  identify future care consults. These consults will appear in the consult  data, but will be identified as future care consults and remain  appropriately open until care is provided. Officials from two other VAMCs  that were entering consults regardless of whether the care was needed  beyond 90 days told us they are no longer doing this. According to  officials, instead they are implementing a separate electronic system to  track needed future care outside of the consult system, and these future  care needs will not appear in consult data until they are entered in the  consult system closer to the date the care is needed. Based on our  discussions with VHA officials, it is not clear the extent to which they are  aware of the various strategies that VAMCs are using to comply with this  task. According to VHA officials, they have not conducted a system-wide  review of the future care strategies and did not have detailed information  on the various strategies specific VAMCs have implemented.
Overall, our ongoing work indicates that oversight of the implementation  of VHA’s consult business rules has been limited and has not included  independent verification of VAMC actions. VAMCs were required to self- certify completion of each of the four tasks outlined in the business rules.  VISNs were not required to independently verify that VAMCs  appropriately completed the tasks. Without independent verification,  however, VHA cannot be assured that VAMCs implemented the tasks  correctly.
Furthermore, our ongoing work shows that VHA did not require that  VAMCs document how they addressed unresolved consults that were  open greater than 90 days, and none of the five VAMCs in our ongoing  review were able to provide us with specific documentation in this regard.
VHA officials estimated that as of June 2014, about 278,000 consults  (both clinical and administrative consults) remained unresolved system- wide. VAMC officials noted several reasons that consults were either  completed or discontinued in this process of addressing unresolved  consults, including improper recording of consult notes, patient  cancellations, and patient deaths. At one of the VAMCs we reviewed, a  specialty care clinic discontinued 18 consults the same day that a task for  addressing unresolved consults was due. Three of these 18 consults  were part of our random sample, and ongoing review has found no  indication that a clinical review was conducted prior to the consults being  discontinued. Ultimately, the lack of independent verification and  documentation of how VAMCs addressed these unresolved consults may  have resulted in VHA consult data that inaccurately reflected whether  patients received the care needed or received it in a timely manner.
Although VHA’s consult business rules were intended to create  consistency in VAMCs’ consult data, our preliminary work has identified  variation in managing key aspects of the consult process that are not  addressed by the business rules. For example, there are no detailed  system-wide VHA policies on how to handle patient no-shows and  cancelled appointments, particularly when patients repeatedly miss  appointments, which may make VAMCs’ consult data difficult to assess.  For example, if a patient cancels multiple specialty care appointments,  the associated consult would remain open and could inappropriately  suggest delays in care. To manage this type of situation, one VAMC  developed a local consult policy referred to as the “1-1-30” rule. The rule  states that a patient must receive at least 1 letter and 1 phone call, and  be granted 30 days to contact the VAMC to schedule a specialty care  appointment. If the patient fails to do so within this time frame, the  specialty care provider may discontinue the consult. According to VAMC  officials, several of the consults we reviewed would have been  discontinued before reaching the 90-day threshold if the 1-1-30 rule had  been in place at the time. Furthermore, all of the VAMCs included in our  ongoing review had some type of policy addressing patient no-shows and  cancelled appointments, each of which varied in its requirements. VHA  officials indicated that they allow each VAMC to develop their own  approach to addressing patient no-shows and cancelled appointments.  Without a standard policy across VHA addressing patient no-shows and  cancelled appointments, however, VHA consult data may reflect  numerous variations of how VAMCs handle patient no-shows and  cancelled appointments.
section_title: Reliability of Reported Outpatient Medical Appointment Wait Times and Scheduling Oversight Need Improvement, and VA Has Initiated Actions to Address Related GAO Recommendations
paragraphs: In December 2012, we reported that VHA’s reported outpatient medical  appointment wait times were unreliable and that inconsistent  implementation of VHA’s scheduling policy may have resulted in  increased wait times or delays in scheduling timely outpatient medical  appointments. Specifically, we found that VHA’s reported wait times were  unreliable because of problems with recording the appointment desired  date in the scheduling system. Since, at the time of our 2012 review, VHA  measured medical appointment wait times as the number of days elapsed  from the desired date, the reliability of reported wait time performance  was dependent on the consistency with which VAMC schedulers  recorded the desired date in the VistA scheduling system. However,  VHA’s scheduling policy and training documents were unclear and did not  ensure consistent use of the desired date. Some schedulers at VAMCs  that we visited did not record the desired date correctly. For example, the  desired date was recorded based on appointment availability, which  would have resulted in a reported wait time that was shorter than the  patient actually experienced.
At each of the four VAMCs in our 2012 review, we also found inconsistent  implementation of VHA’s scheduling policy, which impeded scheduling of  timely medical appointments. For example, we found the electronic wait  list was not always used to track new patients that needed medical  appointments as required by VHA scheduling policy, putting these  patients at risk for delays in care. Furthermore, VAMCs’ oversight of  compliance with VHA’s scheduling policy, such as ensuring the  completion of required scheduler training, was inconsistent across  facilities. At that time, VAMCs also described other problems with  scheduling timely medical appointments, including VHA’s outdated and  inefficient scheduling system, gaps in scheduler and provider staffing, and  issues with telephone access. For example, officials at all VAMCs we  visited in 2012 reported that high call volumes and a lack of staff  dedicated to answering the telephones affected their ability to schedule  timely medical appointments.
VA concurred with the four recommendations included in our December  2012 report and has reported continuing actions to address them.
First, we recommended that the Secretary of VA direct the Under  Secretary for Health to take actions to improve the reliability of its  outpatient medical appointment wait time measures. In response,  VHA officials stated that they implemented more reliable measures of  patient wait times for primary and specialty care. In fiscal years 2013  and 2014, primary and specialty care appointments for new patients  have been measured using time stamps from the VistA scheduling  system to report the time elapsed between the date the appointment  was created—instead of the desired date—and the date the  appointment was completed. VHA officials stated that they made the  change from using desired date to creation date based on a study that  showed a significant association between new patient wait times  using the date the appointment was created and self-reported patient  satisfaction with the timeliness of VHA appointments.FY 2013 Performance and Accountability Report, reported that VHA  completed 40 percent of new patient specialty care appointments  within 14 days of the date the appointment was created in fiscal year  2013; in contrast, VHA completed 90 percent of new patient specialty  care appointments within 14 days of the desired date in fiscal year   VA, in its   2012. VHA also modified its measurement of wait times for  established patients, keeping the appointment desired date as the  starting point, and using the date of the pending scheduled  appointment, instead of the date of the completed appointment, as the  end date for both primary and specialty care. VHA officials stated that  they decided to use the pending appointment date instead of the  completed appointment date because the pending appointment date  does not include the time accrued by patient no-shows and cancelled  appointments. In a June 5, 2014 statement from the Acting Secretary,  VA indicated that it is removing measures related to the 14-day  performance goal from VISN and VAMC directors’ performance  contracts.
Second, we recommended that the Secretary of VA direct the Under  Secretary for Health to take actions to ensure VAMCs consistently  implement VHA’s scheduling policy and ensure that all staff complete  required training. In response, VHA officials stated that the  department was in the process of revising the VHA scheduling policy  to include changes, such as the new methodology for measuring wait  times, and improvements and standardization of the use of the  electronic wait list. In March 2013, VHA distributed guidance, via  memo, to VAMCs describing this information and also offered  webinars to VHA staff on eight dates in April and May of 2013. In June  2014, VHA officials told us that they were in the process of further  revising the scheduling policy, in part to reflect findings from VA’s  system-wide access audit, and planned to issue a memo regarding  new scheduling procedures at a future date. To assist VISNs and  VAMCs in the task of verifying that all staff have completed required  scheduler training, VHA has developed a database that will allow a  VAMC to identify all staff that have scheduled appointments and the  volume of appointments scheduled by each; VAMC staff can then  compare this information to the list of staff that have completed the  required training. However, as of June 2014, VHA officials have not  established a target date for when this database would be made  available for use by VAMCs.
Third, we recommended that the Secretary of VA direct the Under  Secretary for Health to take actions to require VAMCs to routinely  assess scheduling needs for purposes of allocation of staffing  resources. VHA officials stated that they are continuing to work on  identifying the best methodology to carry out this recommendation,  but stated that the database that tracks the volume of appointments  scheduled by individual staff also may prove to be a viable tool to  assess staffing needs and the allocation of resources. As of June  2014, VHA officials stated that they are continuing to address this  recommendation including through internal and external discussions  taking place in May and June 2014 regarding VHA scheduling policy.
Finally, we recommended that the Secretary of VA direct the Under  Secretary for Health to take actions to ensure that VAMCs provide  oversight of telephone access, and implement best practices to  improve telephone access for clinical care. In response, VHA required  each VISN director to require VAMCs to assess their current  telephone service against the VHA telephone improvement guide and  to electronically post an improvement plan with quarterly updates.  VAMCs are required to routinely update progress on the improvement  plan. VHA officials cited improvement in telephone response and call  abandonment rates since VAMCs were required to implement  improvement plans. Additionally, VHA officials said that the  department has contracted with an outside vendor to assess VHA’s  telephone infrastructure and business process and was reviewing the  findings from the first vendor report in June 2014.
Although VA has initiated actions to address our recommendations, we  believe that continued work is needed to ensure these actions are fully  implemented in a timely fashion. Our findings regarding incorrect use of  the desired date in the scheduling system and the electronic wait list are  consistent with VHA’s recent findings from its system-wide access audit,  indicating continued system-wide problems that could be addressed, in  part, by implementing our recommendations. Furthermore, it is important  that VA assess the extent to which these actions are achieving  improvements in medical appointment wait times and scheduling  oversight as intended. Ultimately, VHA’s ability to ensure and accurately  monitor access to timely medical appointments is critical to ensuring  quality health care to veterans, who may have medical conditions that  worsen if access is delayed.
Chairman Miller, Ranking Member Michaud, and Members of the  Committee, this concludes my statement. I would be pleased to respond  to any questions you may have.
section_title: GAO Contacts and Staff Acknowledgments
paragraphs: For further information about this statement, please contact   Debra A. Draper at (202) 512-7114 or draperd@gao.gov. Contact   points for our Offices of Congressional Relations and Public Affairs may  be found on the last page of this testimony. Key contributors to this  statement were Bonnie Anderson, Assistant Director; Janina Austin,  Assistant Director; Rebecca Abela; Jennie Apter; Jacquelyn Hamilton;  David Lichtenfeld; Brienne Tierney; and Ann Tynan.
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