VA Health Care: Management and Oversight of Consult Process Need Improvement to Help Ensure Veterans Receive Timely Outpatient Specialty Care
Published: 2014-09-30T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: There have been numerous reports of VAMCs failing to provide timely care to veterans, including specialty care. In some cases, delays have reportedly resulted in harm to patients. In 2012, VHA found that its consult data were not adequate to determine the extent to which veterans received timely outpatient specialty care. In May 2013, VHA launched an initiative to standardize aspects of the consult process at its 151 VAMCs and improve its ability to oversee consults.
GAO was asked to evaluate VHA's management of the consult process. This report evaluates (1) the extent to which VHA's consult process has ensured veterans' timely access to outpatient specialty care, and (2) how VHA oversees the consult process to ensure veterans are receiving outpatient specialty care in accordance with its timeliness guidelines. GAO reviewed documents and interviewed officials from VHA and from five VAMCs that varied based on size and location. GAO also reviewed a non-generalizeable sample of 150 consults requested across the five VAMCs.
section_title: What GAO Found
paragraphs: Based on its review of a non-generalizable sample of 150 consults requested from April 2013 through September 2013, GAO found that the Department of Veterans Affairs' (VA) Veterans Health Administration's (VHA) management of the consult process has not ensured that veterans always receive outpatient specialty care in a timely manner, if at all. Specifically, GAO found that for 122 of the 150 consults reviewed—requests for evaluation or management of a patient for a specific clinical concern—specialty care providers did not provide veterans with the requested care in accordance with VHA's 90-day timeliness guideline. For example, for 4 of the 10 physical therapy consults GAO reviewed for one VA medical center (VAMC), between 108 and 152 days elapsed with no apparent actions taken to schedule an appointment for the veteran. 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 timeliness guideline. Further, for all but 1 of the 28 consults for which VAMCs provided care within 90 days, an extended amount of time elapsed before specialty care providers properly documented in the consult system that the care was provided. As a result, the consults remained open in the system, making them appear as though the requested care was not provided within 90 days.
VHA's limited oversight of consults impedes its ability to ensure VAMCs provide timely access to specialty care. VHA officials reported overseeing the consult process primarily by reviewing data on the timeliness of consults; however, GAO found limitations in VHA's oversight, including oversight of its initiative designed to standardize aspects of the consult process. Specifically:
VHA does not routinely assess how VAMCs are managing their local consult processes, and thus is limited in its ability to identify systemic underlying causes of delays.
As part of its consult initiative, VHA required VAMCs to review a backlog of thousands of unresolved consults—those open more than 90 days—and if warranted to close them. However, VHA did not require VAMCs to document their rationales for closing them. As a result, questions remain about whether VAMCs appropriately closed these consults and if VHA's consult data accurately reflect whether veterans received the care needed in a timely manner, if at all.
VHA does not have a formal process by which VAMCs can share best practices for managing consults. As a result, VAMCs may not be benefitting from the challenges and solutions other VAMCs have discovered regarding managing the consult process.
VHA lacks a detailed system-wide policy for how VAMCs should manage patient no-shows and cancelled appointments for outpatient specialty care, making it difficult to compare timeliness in providing this care system-wide.
Consequently, concerns remain about the reliability of VHA's consult data, as well as VHA's oversight of the consult process.
section_title: What GAO Recommends
paragraphs: GAO recommends that VHA take actions to improve its oversight of consults, including (1) routinely assess VAMCs' local consult processes, (2) require VAMCs to document rationales for closing unresolved consults, (3) develop a formal process for VAMCs to share consult management best practices, and (4) develop a policy for managing patient no-shows and cancelled appointments. VA concurred with all of GAO's recommendations and identified actions it is taking to implement them.

section_title: Letter
paragraphs: The Veterans Health Administration (VHA), within the Department of  Veterans Affairs (VA), operates one of the nation’s largest health care  systems. Its medical facilities include 151 VA medical centers (VAMC),  which, in addition to providing inpatient care, also provide outpatient care  through primary and specialty care clinics. In recent years, VHA has  faced a growing demand for providing outpatient medical appointments.  From fiscal years 2005 through 2013, the number of annual outpatient  medical appointments VHA provided through its medical facilities  increased by approximately 50 percent, from 58 million to 86 million.
Access to timely medical appointments is critical to ensuring that veterans  obtain needed medical care, and 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 reportedly   In December 2012, we reported that  have resulted in harm to veterans.
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 congressional hearings on VHA’s delivery of medical  care, have focused on delays in care and improper scheduling practices  resulting in lengthy wait times at VHA facilities. Furthermore, a recent VA  system-wide audit to identify the scope and magnitude of these issues  confirmed questionable scheduling practices and other problems at many  VHA facilities, and identified strategies, such as expanding outpatient  clinic hours, VHA needed to implement to address immediate health care  access issues for veterans.
The problems identified in these reports include issues regarding VHA’s  management of consults for outpatient specialty care. When a physician  or other provider determines that a veteran needs outpatient specialty  care, the provider refers the veteran to a specialty care provider for an  outpatient 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). One of VHA’s timeliness guidelines is that consults should generally be  completed—care provided and documented in the consult system—within  90 days of being requested.
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 VAMCs effectively manage the process. In  2012, however, VHA found that these system-wide consult data were not  adequate to determine the extent to which veterans received timely  outpatient specialty care. Specifically, VHA found at the time,  approximately 2 million consults in its system were “unresolved” for more  than 90 days—that is, for those consults, care had not been provided,  care had been provided but not documented, or it had yet to be  determined if care was still needed. consult data were inadequate to identify whether care had been provided  in a timely manner or at all. In response, in May 2013, VHA launched the  Consult Management Business Rules Initiative (referred to in this report  as the “consult business rules initiative”) to standardize aspects of the  consult process, with the goal of developing consistent and reliable  consult data across all 151 VAMCs.
Additionally, VHA determined that its  In light of the findings and conclusions raised in recent reports, including  our December 2012 report on outpatient medical appointment wait times,  you asked us to evaluate VHA’s management of the consult process. This  report evaluates (1) the extent to which VHA’s consult process has  ensured veterans’ timely access to outpatient specialty care, and (2) how  VHA oversees the consult process to ensure veterans are receiving  outpatient specialty care in accordance with its timeliness guidelines.
Consults may be resolved in VHA’s electronic system by either providing the requested  care and completing the consult in the electronic system, or by determining the consult is  no longer needed (e.g., care is not needed, the patient refuses care, or the patient is  deceased) and closing the consult in the electronic system. policies and guidance for VAMCs to send, receive, and complete  outpatient consults. We also reviewed VHA’s policies for scheduling  outpatient specialty care medical appointments, including VHA’s  timeliness guidelines for managing consults. As part of our review, we  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. At each VAMC, we  interviewed leadership, specialty care service chiefs, administrative staff,  and providers from three high-volume, specialty care services— cardiology, gastroenterology, and physical therapy—regarding how they  implemented the consult process at their respective VAMCs. Although  VHA found that its consult data could not be used to determine the  timeliness of outpatient specialty care system-wide, through interviews  with VHA officials knowledgeable about the data, we determined that the  data were sufficiently reliable for our use in selecting individual VAMCs  and specialties to include in our review. We also obtained and reviewed  any local policies or procedures governing the consult process.
Additionally, for each of the five VAMCs, we obtained data on outpatient  consults that were requested by providers for the three specialties  included in our review during the period April 1, 2013, through   September 30, 2013. From these data, we identified those consults that  took more than 90 days to complete or had been in process for more than  90 days at the time of our review, and selected a random sample of 150  outpatient consults, 30 from each VAMC included in our review (10 from  each of the three specialties). We selected our sample of consults from  those open for more than 90 days to identify factors that affected VAMCs’  ability to meet VHA’s timeliness guideline for consults to be completed  within 90 days. For each of the 150 consults, we examined veterans’  medical records to determine the history of actions taken on each of the  outpatient consults included in our sample. From the consults data VHA  originally provided, we asked VHA to identify those that were requested  for veterans who were deceased as of March 2014. We then selected a  separate random sample of 50 of these consults (10 from each VAMC  included in our review) to determine if veterans experienced any delays in  care, and to identify the reported causes of their deaths. For all 200 of the  consults we examined, we reviewed key data elements from the patients’  medical records—such as dates the consults were requested, and dates  they were completed, if applicable. Due to the small sample size and  focus on consults open for more than 90 days, the results from our  examination cannot be generalized to all consults at the VAMCs in our  review, or to other VAMCs.
To determine how VHA oversees the consult process to ensure veterans  are receiving outpatient specialty care in accordance with its timeliness  guidelines, we reviewed documents and interviewed VHA central office  officials about their efforts to oversee implementation of VHA’s consult  policies system-wide. We focused our review on VHA’s oversight of the  consult business rules initiative, as this initiative was specifically intended  to help improve VHA’s ability to oversee the consult process. We also  interviewed officials at each of the five VAMCs we selected to identify the  processes and mechanisms they have used to oversee consults at their  facilities, and the extent to which they have implemented the tasks  outlined in the consult business rules initiative. Further, we interviewed  officials from each of the five Veterans Integrated Service Networks  (VISN) responsible for overseeing the VAMCs included in our review  about the processes they have used to oversee consults and VAMCs’  implementation of the consult business rules initiative. Finally, we  assessed VHA’s efforts to oversee consults within the context of federal  internal control standards.
We conducted this performance audit from July 2013 to September 2014  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: VHA’s outpatient consult process is governed by a national policyoutlines the use of an electronic system for requesting and managing  consults and delineates oversight responsibilities at the national, VISN,  and VAMC level.
subsections: section_title: Outpatient Consult Process
paragraphs: Outpatient 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  request is for a specialty care procedure, such as a colonoscopy. The  consult process—displayed in figure 1—is governed by VHA’s national  consult policy, which requires VAMCs to manage consults using a  national electronic consult system, and to provide timely and appropriate  care to veterans.
Outpatient consults typically are requested by a veteran’s primary care  provider using VHA’s electronic consult system. To send a consult  request, providers log on to the system and complete an electronic  consult request template that may be customized by the VAMC’s  applicable specialty care clinic. The template requires the requesting  provider to provide specific information, such as a diagnosis and a reason  why the specialty care is needed, and may require additional information  as determined by the specialty care clinic. For example, a gastroenterology template for abdominal pain used at one VAMC asked  the requesting provider whether the treatment should be provided in  person, reminded the provider about specific lab tests to be completed,  and asked the provider to provide a brief history of the patient’s  symptoms. (See fig. 2.) This specialty care clinic had specific templates  depending on the patient’s symptoms. (See appendix I for examples of  other templates used by the gastroenterology clinic at this VAMC.) After  completing the template, the requesting provider electronically submits  the consult for the specialty care provider to review.
According to VHA’s guideline, the specialty care provider is to review and  determine whether to accept a consult within 7 days of the request.  Typically, the provider’s review involves determining whether to accept  the consult—that the consult is needed and appropriate—and if the  consult is accepted, determining its relative urgency—a process known  as triaging. When reviewing a consult request, a specialty care provider  may decide not to accept it, and will send the consult back to the  requesting provider. This is referred to as discontinuing the consult, which  a specialty care provider may decide to do for several reasons, including  that 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 before accepting the consult; in such  cases, the specialty care provider will send the consult back to the  requesting provider, who can resubmit it with the needed information.
If the provider accepts the consult, an attempt is made to contact the  patient and schedule an appointment. 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 of scheduling medical appointments with  no undue waits or delays for patients. According to VHA officials, the  scheduler is to take into account the relative urgency of the consult, that  is, the result of the reviewing specialty provider’s triage decision, when  attempting to schedule the appointment.
If an appointment resulting from a consult is scheduled and held, VHA’s  policy requires the specialty care provider to appropriately document the  results in the consult system, which would then close out the consult as  completed. To do so, the provider updates the consult with the results of  the appointment by entering a clinical progress note in the consult  system. If the provider does not perform this step, or does not perform it  appropriately, the consult remains open in the consult system. If an  appointment is not held, specialty care clinic staff members are to  document why they were unable to complete the consult.
section_title: VHA National Consult Policy and Initiative to Improve Consult Data
paragraphs: According to VHA’s national consult policy, VHA central office officials  have overall oversight responsibility for the consult process, including the  measurement and monitoring of ongoing performance. The policy also  requires VISN leadership to oversee the consult processes for VAMCs in  their networks, and requires each VAMC to manage individual consults  consistent with VHA’s timeliness guidelines.
To evaluate the timeliness of resolving consults across VAMCs, in  September 2012, VHA created a national consult database from the  information contained in its electronic consult system. After reviewing  these data, VHA determined that they were inadequate for monitoring  consults, because they had not been entered in the consult system in a  consistent, standard manner, among other issues. For example, in  addition to requesting consults for clinical concerns, VHA found that  VAMCs also were using the consult system to request and manage a  variety of administrative tasks, such as arranging 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. VHA found that this was due, in part, to the fact  that data in the consult system included consults for both care that was  clinically appropriate to be open for more than 90 days—known as future  care consults—as well as those for care that was needed within   90 days. At the time of the database’s creation, according to VHA  officials, approximately 2 million consults (both clinical and administrative)  were unresolved for more than 90 days.
Subsequently, in October 2012, a task force convened by VA’s Under  Secretary for Health began addressing several issues, including those  regarding VHA’s consult system. In response to the task force  recommendations, in May 2013, VHA launched the consult business rules  initiative to standardize aspects of the consult process and develop  consistent and reliable information on consults across all VAMCs. For  example, the consult business rules initiative required that VAMCs limit  their use of the consult system to requesting consults for care expected  within 90 days, and distinguish between administrative and clinical  consults in the consult system. As part of this initiative, VAMCs were  required to complete four 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 managing requests for future  care consults that are not needed within 90 days.
Conduct a clinical review, as warranted, to determine if care has been  provided or is still needed for unresolved consults—those open more  than 90 days.
After the initial implementation of these tasks, VHA required VAMCs to  maintain adherence to the consult business rules initiative when  processing consults. VHA was updating its national consult policy to  incorporate aspects of the consult business rules initiative and expected  to have a draft policy by September 2014.
section_title: VHA’s Consult Process Has Not Ensured Veterans Always Receive Outpatient Specialty Care in a Timely Manner, or at All
paragraphs: Our review of a sample of consults at five VAMCs found that veterans did  not always receive outpatient specialty care in a timely manner, if at all.  We found consults that were not processed in accordance with VHA  timeliness guidelines—for example, consults that were not reviewed  within 7 days or not completed within 90 days. We also found consults for  which veterans did not receive the outpatient specialty care requested— 64 of the 150 consults in our sample (43 percent)—and those for which  the requested specialty care was provided, but the consults were not  properly closed in the consult system.
We found that specialty care providers at the five VAMCs we examined  were not always able to make their initial consult reviews within VHA’s   7-day guideline. Specifically, we found that for 31 of the150 consults in  our sample (21 percent), specialty care providers did not meet the 7-day  guideline, but they were able to meet the guideline for 119 of the consults  (79 percent). (See table 1.) For one VAMC, nearly half the consults were  not reviewed and triaged within 7 days, and for some consults, we found  it took several weeks before the specialty care providers took action.  Officials at this VAMC cited a shortage of providers needed to review and  triage the consults in a timely manner.
We also found that for the majority of the 150 consults in our sample,  veterans did not receive care within 90 days of the date the consult was  requested, in accordance with VHA’s guideline. Specifically, veterans did  not receive care within 90 days for 122 of the 150 consults we examined  (81 percent). (See table 2.)
We also found that for the 28 consults in our sample for which VAMCs  provided care to veterans within 90 days, an extended amount of time  elapsed before specialty care providers completed all but 1 of them in the  consult system. As a result, the consults remained open in the system,  making them appear as though the requested care was not provided  within 90 days. Although 1 consult remained open for only 8 days from  when the care was provided, for the remaining 27 consults, it took  between 29 and 149 days from the time care was provided until the  consults were completed in the system. In addition, of the 28 consults, we  found that specialty care providers at one VAMC did not properly  document the results of all 10 cardiology consults we reviewed, in order  to close them in the system.
Officials from four of the five VAMCs told us that specialty care providers  often do not properly document that consults are complete, which  requires the selection of the correct clinical progress note that  corresponds to the patient’s consult. Officials attributed this ongoing issue  in part to the use of medical 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 such rotations require VAMC  leadership to ensure new residents are continually trained on how to  properly complete consults. To help ensure that specialty care providers  consistently choose the correct clinical progress note, this VAMC  activated a technical solution consisting of a prompt in its consult system  that instructs providers to choose the correct clinical progress note  needed to complete consults. Officials stated that this has resulted in  providers more frequently choosing the correct notes needed to complete  consults.
Examples of consults that were not completed in 90 days, or were closed  without the veterans being seen, included:
For 3 of 10 gastroenterology consults we examined for one VAMC, we  found that between 140 and 210 days elapsed from the dates the  consults were requested to when the veterans received care. For the  consult that took 210 days, an appointment was not available and the  veteran was placed on a waiting list before having a screening  colonoscopy.
For 4 of the 10 physical therapy consults we examined for one VAMC,  we found that between 108 and 152 days elapsed, with no apparent  actions taken to schedule appointments for the veterans for whom  consults were requested. The veterans’ medical records indicated that  due to resource constraints, the clinic was not accepting consults for   For 1 of these  non-service-connected physical therapy evaluations.consults, several months passed before the veteran was referred to  non-VA care, and was seen 252 days after the initial consult request.  The other 3 consults were sent back to the requesting providers  without the veterans receiving care.
For all 10 of the cardiology consults we examined for one VAMC, we  found that staff initially scheduled veterans for appointments between  33 and 90 days after the request, but medical records for those  patients indicated that the veterans either cancelled or did not show  for their initial appointments. In several instances, medical records  indicated the veterans cancelled multiple times. For 4 of the consults,  VAMC staff closed the consults without the veterans being seen; for  the other 6 consults, VAMC staff rescheduled the appointments for  times that exceeded VHA’s 90-day guideline.
VAMC officials cited increased demand for services, patient no-shows,  and cancelled appointments, among the factors that hinder specialty care  providers’ 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 specialty care providers for these two clinical areas,  as causes of periodic backlogs in providing these services. Officials at  these VAMCs indicated that they try to mitigate backlogs by referring  veterans to non-VA providers for care.
Although officials indicated that use of non-VA care can help mitigate  backlogs, several officials also indicated that this requires more  coordination between the VAMC, the patient, and the non-VA provider;  can require additional approvals for the care; and also may increase the  amount of time it takes a VAMC specialty care provider to obtain the  results (such as diagnoses, clinical findings and treatment plans) of  medical appointments or procedures. Officials acknowledged that using  non-VA care does not always prevent delays in veterans receiving timely  care or in specialty care providers completing consults.
Additionally, we 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—an abdominal aortic aneurysm and an iliac aneurysm.  According to the patient’s medical record, the timeline of events  surrounding this consult was:
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 specialty  care clinic, it was discovered that the non-VA provider lost the  patient’s information. The specialty care clinic staff 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.
section_title: VHA’s Limited Oversight of Consults Impedes Its Ability to Ensure VAMCs Provide Timely Access to Specialty Care
paragraphs: Since launching the consult business rules initiative in May 2013, VHA  officials reported overseeing the consult process system-wide primarily by  reviewing consult reports created from its national database to monitor  VAMCs’ progress in meeting VHA’s timeliness guidelines. However, we  found limitations in VHA’s system-wide oversight, as well as in the  oversight provided by the five VISNs included in our review. These  limitations have affected the reliability of VHA’s consult data and  consequently VHA’s ability to effectively assess VAMC performance in  managing consults.
VHA and VISNs do not routinely assess VAMCs’ management of  consults. Although VHA officials reported using system-wide consult  data to help ensure that VAMCs are meeting VHA timeliness guidelines,  and the five VISNs included in our review reported using consult data to  monitor VAMCs they oversee, neither routinely assesses how VAMCs are  actually managing consults. According to federal internal control  standards, managers should perform ongoing monitoring, including  independent assessments of performance.important to help VHA identify the underlying causes of delays and to  help ensure that its consult data reliably reflects the number of, and  length of time, veterans are waiting for care. VHA and VISN officials  reported that they do not routinely audit consults to assess whether  VAMC providers have been appropriately requesting, reviewing, and  resolving consults in accordance with VHA’s consult policy. Instead, VHA  and VISN officials reported their oversight primarily relies on monitoring  reports that track VAMCs’ progress in reducing the number of consults  unresolved for more than 90 days. VHA officials stated that they delegate  oversight of unresolved consults to VAMCs and as such, do not conduct  assessments of individual consults. Further, several VISN officials stated  that they did not see the need for such assessments and that ongoing  monitoring of consult data has been sufficient.
Although VHA and the five VISNs included in our review do not routinely  conduct such assessments, our work at five VAMCs found such reviews  may help provide insights into the underlying causes of delays. Our  examination of a sample of consults revealed several issues with VAMCs’  specialty care clinics’ management of consults, including delays in  reviewing and scheduling consults, incorrectly discontinuing consults, and  in some cases incorrectly closing a consult as complete even though care  had not been provided. We discussed these issues with officials at the  five VAMCs included in our review. Officials from two VAMCs stated that  in responding to our questions, they researched the actions taken on  each consult and learned about some of the root causes contributing to  consult delays. For example, one VAMC found that its process for  managing consults requested from other VAMCs was not clear to  providers and needed to be improved to mitigate delays in processing  such consults. Additionally, for a few of the consults for which we  identified that care had not been provided, VAMC officials stated that, as  a result of our findings, they contacted the veterans to schedule  appointments when care was still needed. In addition, VHA officials stated  that independent assessments of consults may be helpful and that they  would consider conducting them in the future. By primarily relying on  reviewing data and not routinely conducting an assessment of VAMCs’  management of consults, VHA and VISN officials may be limited in  identifying systemic issues affecting VAMCs’ ability to provide veterans  with timely access to care.
VHA lacks documentation of how VAMCs addressed unresolved  consults. One task under the consult business rules initiative required  VAMCs to resolve consults that had been open for more than 90 days.  VHA provided system-wide guidance outlining how to appropriately  complete this task. VAMCs were to conduct clinical reviews of all non- administrative consults and determine whether the consult should be  completed or discontinued—thus closing them in the consult system.  However, VHA did not require VAMCs to document these decisions or the  processes by which they were made, only to self-certify the task had been  completed. Further, VHA did not require VISNs to independently verify  that the task was completed appropriately. VAMC officials told us their  reviews indicated that for many of the consults, care had been provided,  but an incorrect clinical progress note was used. Therefore, officials had  to select the correct note that corresponded to each consult, which  completed the consult in the system. In addition, officials also told us that  they discontinued many other consults because they found that patients  were deceased or that patients had repeatedly cancelled appointments  and thus, they determined that care was no longer needed. However,  none of the five VAMCs in our review were able to provide us with  specific documentation of these decisions and rationales. At one VAMC,  for example, we found that 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 we  found no indication that a clinical review was conducted prior to the  consults being discontinued. The lack of documentation is not consistent  with federal internal control standards, which indicate that all transactions  and other significant events need to be clearly documented and stress the  importance of the creation and maintenance of related records, which  provide evidence of execution of these activities.
In addition to monitoring VAMC performance in completing the consult  business rules initiative tasks, VHA officials told us they are continuing to  monitor VAMCs’ performance in addressing unresolved consults. In 2012,  VHA estimated that approximately 2 million consults in its system were  unresolved for more than 90 days. According to a VHA June 2014 consult  tracking report, 285,877 consults were unresolved. attributed this reduction in the number of unresolved consults to  implementation of the consult business rules initiative and their continued  monitoring of VAMC performance in meeting VHA’s consult timeliness  guideline. Given the thousands of consults that have been closed by  VAMCs, the lack of documentation and independent verification of how  VAMCs addressed these unresolved consults raises questions about the  reliability of VHA consult data and whether the data accurately reflects  whether patients received the care needed in a timely manner, if at all.
VHA officials told us that this number changes daily and expects it to continue to decline  as VAMCs continue to resolve consults open more than 90 days.
VAMCs were instructed to track future care consults either by developing markers so  such consults could be identified in the consult system, or by using existing mechanisms  outside of the consult system such as an electronic wait list. The electronic wait list is a  component of the VistA scheduling system designed for recording, tracking, and reporting  veterans waiting for medical appointments. completing this task, we found that each of the five VAMCs initially  implemented strategies for managing future care consults that were,  wholly or in part, non-approved VHA options. For example, one VAMC  reported to us that initially its staff entered consult requests for future care  into the consult system without the use of a future care flag, and  subsequently discontinued these consults if they reached the 90-day  threshold. Discontinuing future care consults closed them in the consult  system, and thus prevented the consults from being monitored, which  may have increased the risk of the VAMC losing track of these requests  for specialty care. Further, during the course of our work, officials from  three VAMCs reported revising their initial strategies for managing future  care consults. (See table 3.) Some of these VAMCs continued to  implement strategies that were non-approved VHA options and could  have resulted in consult data that failed to distinguish future care consults  from those that were truly delayed.
According to federal internal control standards, managers should perform  ongoing monitoring, including independent assessments of  performance. However, because VHA officials relied on self- certifications submitted by VAMCs, they were not aware of the extent to  which VAMCs implemented strategies that were not one of VHA’s  approved options, nor would they be aware of the extent to which VAMCs  have since changed their strategies. As of June 2014, VHA officials told  us they did not have detailed information on the various strategies  VAMCs have implemented to manage future care consults, and they  acknowledged that they had not conducted a system-wide review of  VAMCs’ strategies.
Furthermore, VHA does not have a formal process by which VAMCs  could share best practices system-wide. control standards, identifying and sharing information is an essential part  of ensuring effective and efficient use of resources. We found that  VAMCs may not be benefiting from the challenges and solutions other  VAMCs discovered when implementing strategies for managing future  care consults. For example, during our review, we found that one VAMC  revised its initial strategy in a way that another VAMC had already found  ineffective. Officials at that VAMC stated that they were implementing a  new strategy to manage future care consults in a separate electronic  system. However, another VAMC opted not to use a similar electronic  system it piloted after finding that it confused providers and required  extensive training; that VAMC opted instead to use future care markers in  its consult system. A more systematic identification and sharing of best  practices for managing future care consults would enable VAMCs to more  efficiently implement effective strategies for managing specialty care  consults.
Officials from VAMCs in our review described sharing best practices with colleagues at  other VAMCs in their VISN on an ad hoc basis. standardized data needed for conducting oversight. Additionally,  according to federal internal control standards, management is  responsible for developing the detailed policies, procedures, and  practices to fit their agency’s operations and to ensure that they are built  into, and an integral part of, operations.
However, we found that VHA has not developed a detailed, system-wide  policy on how to address patient no-shows and cancelled appointments,  two frequently noted causes of delays in providing care. Instead, VHA  policies provide general guidance that state that after a patient does not  show for or cancels an appointment, the specialty care clinic staff should  review the consult and determine whether or not to reschedule the   VHA officials told us that they allow each VAMC to  appointment. determine its own approach to managing these occurrences. However,  such variations in no-show and cancellation policies are reflected in the  consult data, and as a result, this variation may make it difficult to assess  and compare VAMCs’ performance. For example, if a specialty care clinic  allows a patient to cancel multiple specialty care appointments, the  consult would remain open and could inaccurately suggest delays in care  where none might exist. In contrast, if the specialty care clinic limited the  number of patient cancellations, the consult would be closed after the  allowed number and would not appear as a delay in care, even if a delay  had occurred.
See VHA Directive 2010-027, VHA Outpatient Scheduling Processes and Procedures  (June 9, 2010) and VHA Directive 2008-056, VHA Consult Policy (Sept. 16, 2008). varied in its requirements.we found that specialty care providers had scheduled appointments for  127 of the consults, and that patient no-shows and cancelled  appointments were among the factors contributing to delays in providing  timely care for 66 of these consults (52 percent).
section_title: Conclusions
paragraphs: Providing our nation’s veterans with timely access to medical care,  including outpatient specialty care, is a crucial responsibility of VHA. We  and others have identified problems with VHA’s consult process used to  manage the outpatient specialty care needs of veterans. Our review of a  sample of consults found that VAMCs did not always provide veterans  with requested specialty care in a timely manner, if at all. In other cases,  VAMCs were able to provide the needed care on a timely basis, but  specialty care providers failed to properly complete or document the  consults, making it appear as though care for veterans was delayed, even  when it was not.
Limitations in VHA’s oversight of the consult process have affected the  reliability of VHA’s consult data and its usefulness for oversight. Although  VHA officials cited VAMCs’ progress in reducing the backlog of consults  unresolved for more than 90 days, they have not independently verified  that VAMCs appropriately closed these consults, calling into question the  accuracy of these data. Due to their lack of oversight, VHA officials are  not aware of the various strategies VAMCs implemented to manage  future care consults, and thus when monitoring consult data, cannot  adequately determine if future care consults are distinguishable from  those that are truly delayed. Additionally, VHA has not developed a  system-wide process for identifying and sharing VAMCs’ best practices  for managing future care and other types of consults; thus, VAMCs may  be implementing strategies that others already have found ineffective or  may be unaware of strategies that others have successfully implemented.  Further, VHA’s decentralized approach for handling patient no-shows and  cancelled appointments, as well as other issues, makes it difficult to  compare timeliness of providing outpatient specialty care system-wide.
Ultimately, this decentralized approach may further limit the usefulness of  the data and VHA’s and VISNs’ ability to assess VAMCs’ performance in  managing consults and providing timely care to our nation’s veterans.
section_title: Recommendations for Executive Action
paragraphs: To improve VHA’s ability to effectively oversee the consult process, and  help ensure VAMCs are providing veterans with timely access to  outpatient specialty care, we recommend that the Secretary of Veterans  Affairs direct the Interim Under Secretary for Health to take the following  six actions:
Assess the extent to which specialty care providers across all VAMCs,  including residents who may be serving on a temporary basis, are  using the correct clinical progress notes to complete consults in a  timely manner, and, as warranted, develop and implement system- wide solutions such as technical enhancements, to ensure this is  done appropriately.
Enhance oversight of VAMCs by routinely conducting independent  assessments of how VAMCs are managing the consult process,  including whether they are appropriately resolving consults. This  oversight could be accomplished, for example, by VISN officials  periodically conducting reviews of a random sample of consults as we  did in the review we conducted.
Require specialty care providers to clearly document in the electronic  consult system their rationale for resolving a consult when care has  not been provided.
Identify and assess the various strategies that all VAMCs have  implemented for managing future care consults; including determining  the potential effects these strategies may have on the reliability of  consult data; and identifying and implementing measures for  managing future care consults that will ensure the consistency of  consult data.
Establish a system-wide process for identifying and sharing VAMCs’  best practices for managing consults that may have broader  applicability throughout VHA, including future care consults.
Develop a national policy for VAMCs to manage patient no-shows and  cancelled appointments that will ensure standardized data needed for  effective oversight of consults.
section_title: Agency Comments
paragraphs: We provided VA with a draft of this report for its review and comment. VA  provided written comments, which are reprinted in appendix II. In its  written comments, VA concurred with all six of the report’s  recommendations. To implement five of the recommendations, VA  indicated that the VHA Deputy Under Secretary for Health for Operations  and Management will take a number of actions, such as chartering a  workgroup to develop clear standard operating procedures for completing  and managing consults. VA indicated that target completion dates for  implementing these recommendations range from December 2014  through December 2015. For the sixth recommendation, VA indicated  that, by December 2014, VHA will establish a system-wide process that  facilitates identifying and disseminating VAMC best practices for  managing consults. VA also provided technical comments, which we have  incorporated as appropriate.
As arranged with your office, unless you publicly disclose the contents  earlier, we plan no further distribution of this report until 30 days after the  date of this letter. At that time, we will send copies of this report to the  Secretary of Veterans Affairs and interested congressional committees. In  addition, the report will be available at no charge on the GAO website at  http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or draperd@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff who made key contributions to this report  are listed in appendix III.
section_title: Appendix I: Examples of Gastroenterology Consult Request Templates
paragraphs: To send a consult request, providers log on to the consult system and  complete an electronic consult request template developed by the VA  medical center's specialty care clinic. As shown in figures 3 and 4 below,  the information requested in these templates may vary depending on the  patient’s symptoms. After completing the template, the requesting  provider electronically submits the consult for the specialty care provider  to review.
section_title: Appendix II: Comments from the Department of Veterans Affairs
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Janina Austin, Assistant Director;  Jennie F. Apter; Jacquelyn Hamilton; David Lichtenfeld; Brienne Tierney;  and Ann Tynan made key contributions to this report.