VA Health Care: Reliability of Reported Outpatient Medical Appointment Wait Times and Scheduling Oversight Need Improvement
Published: 2012-12-21T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: VHA provided nearly 80 million outpatient medical appointments to veterans in fiscal year 2011. While VHA has reported continued improvements in achieving access to timely medical appointments, patient complaints and media reports about long wait times persist.
GAO was asked to evaluate VHAs scheduling of timely medical appointments. GAO examined (1) the extent to which VHAs approach for measuring and monitoring medical appointment wait times reflects how long veterans are waiting for appointments; (2) the extent to which VAMCs are implementing VHAs policies and processes for appointment scheduling, and any problems encountered in ensuring veterans access to timely medical appointments; and (3) VHAs initiatives to improve veterans access to medical appointments. To conduct this work, GAO made site visits to 23 clinics at four VAMCs, the latter selected for variation in size, complexity, and location. GAO also reviewed VHAs policies and data, and interviewed VHA officials.
section_title: What GAO Found
paragraphs: Outpatient medical appointment wait times reported by the Veterans Health Administration (VHA), within the Department of Veterans Affairs (VA), are unreliable. Wait times for outpatient medical appointments--referred to as medical appointments--are calculated as the number of days elapsed from the desired date, which is defined as the date on which the patient or health care provider wants the patient to be seen. The reliability of reported wait time performance measures is dependent on the consistency with which schedulers record the desired date in the scheduling system in accordance with VHA's scheduling policy. However, VHA's scheduling policy and training documents for recording desired date are unclear and do not ensure consistent use of the desired date. Some schedulers at Veterans Affairs medical centers (VAMC) that GAO visited did not record the desired date correctly. For example, three schedulers changed the desired date based on appointment availability; this would have resulted in a reported wait time that was shorter than the patient actually experienced. VHA officials acknowledged limitations of measuring wait times based on desired date, and described additional information used to monitor veterans' access to medical appointments, including patient satisfaction survey results. Without reliable measurement of how long patients are waiting for medical appointments, however, VHA is less equipped to identify areas that need improvement and mitigate problems that contribute to wait times.
While visiting VAMCs, GAO also found inconsistent implementation of VHA's scheduling policy that impedes VAMCs from scheduling timely medical appointments. For example, four clinics across three VAMCs did not use the electronic wait list to track new patients that needed medical appointments as required by VHA scheduling policy, putting these clinics at risk for losing track of these patients. Furthermore, VAMCs' oversight of compliance with VHA's scheduling policy, such as ensuring the completion of required scheduler training, was inconsistent across facilities. VAMCs also described other problems with scheduling timely medical appointments, including VHA's outdated and inefficient scheduling system, gaps in scheduler and provider staffing, and issues with telephone access. For example, officials at all VAMCs GAO visited reported that high call volumes and a lack of staff dedicated to answering the telephones impede scheduling of timely medical appointments. In January 2012, VHA distributed telephone access best practices that, if implemented, could help improve telephone access to clinical care.
VHA is implementing a number of initiatives to improve veterans' access to medical appointments such as expanded use of technology to interact with patients and provide care, which includes the use of secure messaging between patients and their health care providers. VHA also is piloting a new initiative to provide health care services through contracts with community providers that aims to reduce travel and wait times for veterans who are unable to receive certain types of care within VHA in a timely way.
section_title: What GAO Recommends
paragraphs: GAO recommends that VHA take actions to (1) improve the reliability of its medical appointment wait time measures, (2) ensure VAMCs consistently implement VHA's scheduling policy, (3) require VAMCs to allocate staffing resources based on scheduling needs, and (4) ensure that VAMCs provide oversight of telephone access and implement best practices to improve telephone access for clinical care. VA concurred with GAO's recommendations.

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 152 VA medical centers (VAMC), as  well as more than 800 community-based outpatient clinics (CBOC) and  ambulatory care centers that operate under supervision of the VAMCs.  At these facilities, VHA provides outpatient care through primary and  specialty care clinics. In fiscal year 2011, there were more than 8 million  veterans enrolled in VHA’s health system, and VHA provided nearly   80 million outpatient medical appointments to veterans for primary and  specialty care.
Although access to timely medical appointments is critical to ensuring that  veterans obtain needed medical care, long wait times and inadequate  scheduling processes at VHA medical facilities have been long-standing  problems. For example, in 2001, GAO reviewed the timeliness of medical  appointments and found that two-thirds of the specialty care clinics visited  had wait times longer than 30 days, although some clinics had made  progress in reducing wait times, primarily by improving their scheduling  processes and making better use of their staff. Later, in 2007, the VA Office of Inspector General (OIG) reported that VHA facilities did not  always follow VHA’s scheduling policies and processes and that the  accuracy of VHA’s reported wait times for medical appointments was  unreliable. Most recently, in 2012, the VA OIG reported that VHA was  not providing all new veterans with timely access to full mental health  evaluations, and had overstated its success in providing veterans with  timely new and follow-up appointments for mental health treatment.
VHA has reported continued improvements in measuring and achieving  timely access to medical appointments. For example, in fiscal year 2011,  VHA had a goal of scheduling medical appointments within 14 days of the  patient’s or provider’s desired medical appointment date, and in that  year, VA reported that it completed 95 percent of specialty care medical  appointments and 94 percent of primary care medical appointments  within this time frame. However, patient complaints and media reports  about long wait times have persisted, prompting renewed concerns about  excessive medical appointment wait times. You asked us to evaluate  VHA’s scheduling of timely medical appointments. We examined (1) the  extent to which VHA’s approach for measuring and monitoring medical  appointment wait times reflects how long veterans are waiting; (2) the  extent to which VAMCs are implementing VHA’s policies and processes  for medical appointment scheduling, and any problems encountered in  ensuring veterans’ access to timely medical appointments as identified by  VAMCs; and (3) VHA’s initiatives to improve veterans’ access to medical  appointments.
To address all three objectives, we interviewed VHA central office officials  responsible for medical appointment scheduling policy, medical  appointment wait time measurement, and initiatives to improve access to  timely medical appointments. We also conducted site visits to four  VAMCs selected for variation in size and complexity, geographic location,  or role as a pilot site for a VHA initiative to improve access to timely  medical appointments. These four VAMCs were located in Dayton, Ohio;  Fort Harrison, Montana; Los Angeles, California; and Washington, D.C. At  each site, we visited the VAMC as well as the affiliated CBOCs that had  among the highest volume of medical appointments. We also visited the  highest volume ambulatory care center at one VAMC that had such  facilities. At each VAMC, CBOC, and ambulatory care center, we visited  an outpatient primary care clinic, and where available, one or more  outpatient specialty care clinics for a total of 23 clinics—9 primary care  and 14 specialty care clinics—the clinics were among those with the  highest medical appointment volume. Results from our site visits cannot  be generalized to other VAMCs. We also interviewed the directors and  relevant staff of the four Veterans Integrated Service Networks (VISN), or  regional networks of care, for the sites we visited.
To examine the extent to which VHA’s approach for measuring and  monitoring medical appointment wait times reflects how long veterans are  waiting, we reviewed VHA’s outpatient medical appointment scheduling  policy and processes and training documents based on the policy, as well  as documents related to performance accountability that include wait time  measures. At each of the four VAMCs we visited, we interviewed the leadership team, scheduling managers, and managers from all of our  selected clinics about oversight activities to ensure the accuracy of  scheduling data, and about what data and measures they use to manage  clinics and improve medical appointment timeliness. In addition, we  interviewed schedulers from the 9 primary care clinics and 10 of the   14 specialty care clinics we visited using a structured protocol to  determine the accuracy with which schedulers determined and recorded  medical appointment data for hypothetical patient medical appointments  into the scheduling system in accordance with VHA’s scheduling policy.  We also compared reported medical appointment wait times for the clinics  we visited to information gathered during our site visits.
To determine the extent to which VAMCs are implementing VHA’s  scheduling policy and processes, and to gather information on problems  encountered in scheduling timely medical appointments, we reviewed  VHA’s scheduling policy, interviewed VHA central office officials  responsible for the scheduling policy, and obtained information about  scheduling practices from officials at each of the four VAMCs we visited.  Specifically, for each of the VAMCs, we interviewed leadership,  scheduling managers, clinic managers, patient advocates, and case  managers. We obtained information about the VAMCs’ oversight to  ensure compliance with policy, and about problems staff at these facilities  say they experience in scheduling timely medical appointments. We  reviewed the implementation of selected elements of VHA’s scheduling  policy at both the VAMC and individual clinic level. These elements  included the use of VHA’s scheduling software to schedule medical  appointments, the use of the electronic wait list for tracking patients new to a clinic that are waiting for medical appointments, and the use of the  recall/reminder software to facilitate reminders for patients that need to  return to the clinic for follow-up medical appointments. We also obtained  from VHA and reviewed VAMCs’ fiscal year 2011 certifications of  compliance with VHA’s scheduling policy—a required annual self- certification—as well as documentation of scheduler training completion  obtained from the four VAMCs visited. Finally, we reviewed patient  complaints about telephone responsiveness collected by each VAMC’s  Office of the Patient Advocate.
To examine VHA’s initiatives to improve veterans’ access to timely  medical appointments, we interviewed VHA central office officials to  obtain information about selected initiatives and reviewed relevant VHA  documents outlining these initiatives. We also interviewed officials at the  VAMCs we visited about the implementation of these initiatives and  officials at the Billings Clinic, a non-VA health care facility involved in the  implementation of one of the initiatives.
We conducted this performance audit from February 2012 to December  2012 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 health care system is geographically divided into 21 VISNs, each  of which is headed by a VISN director. Each VISN is comprised of a  network of VAMCs, and the VISN office serves as the basic budgetary  and decision-making unit for providing health care services to veterans  within that geographical area. Each VAMC and its affiliated CBOCs and  ambulatory care centers are headed by a VAMC director who manages  administrative functions, and a chief of staff who manages clinical  functions for these facilities. VHA’s Central Office establishes system- wide scheduling policy.
subsections: section_title: VHA Medical Appointment Scheduling Policy
paragraphs: VHA’s scheduling policy establishes processes and procedures for  scheduling medical appointments, and for ensuring the competency of  staff directly or indirectly involved in the scheduling process. This policy is  designed to help VAMCs meet VHA’s commitment to scheduling medical  appointments with no undue waits or delays. Specifically, VHA’s  scheduling policy includes, but is not limited to, the following  requirements:
Requires VAMCs to use VHA’s Veterans Health Information Systems  and Technology Architecture (VistA) medical appointment scheduling  system to schedule medical appointments.
Requires VAMCs to keep appointment schedules open and available  for patients to make medical appointments at least 3 to 4 months into  the future.
Requires schedulers to record in the VistA scheduling system the date  on which the patient or provider wants the patient to be seen as the  desired date. To determine the desired date, schedulers should be in  communication with the patient when scheduling the medical  appointment.
Requires schedulers to record the desired date correctly and  describes how to determine and record the desired date for new  patients—patients who haven’t been seen by a health care provider in  a clinic within the past 2 years, including those scheduled in response  to a consult request—as well as specifying how to determine the  desired date for established patients’ follow-up medical  appointments—patients who have been seen within the past two  years.
Requires VAMCs to track new patients waiting for medical  appointments using the electronic wait list within VistA and to remind  established patients of follow-up medical appointments using the  recall/reminder software within VistA, which enables clinics to create a  list of established patients who need follow-up medical appointments  more than 3 or 4 months in the future.
Additionally, 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.
Officials at the VHA central office, VISN, and VAMC all have oversight  responsibilities for the implementation of VHA’s scheduling policy. In the  VHA central office, the Director of Systems Redesign, through the Office  of the Deputy Undersecretary for Health for Operations and Management,  is responsible for the oversight and implementation of medical  appointment scheduling requirements. This oversight includes  measurement and monitoring of ongoing performance. Each VISN  director, or designee, is responsible for oversight of enrollment and  medical appointment scheduling for eligible veterans. director, or designee, is responsible for ensuring that clinics’ scheduling of  medical appointments complies with VHA’s scheduling policy, including  clinics in affiliated CBOCs and ambulatory care centers. In addition, the  VAMC director is responsible for ensuring that any staff who can  schedule medical appointments in the VistA scheduling system has  completed VHA scheduler training.
To obtain VHA healthcare services, veterans generally must enroll with VHA and  register at a specific VAMC. aspects of VHA’s scheduling policy as well as overall compliance, partial  compliance, or noncompliance with VHA’s scheduling policy as a whole.  According to officials, VHA’s central office does not penalize  noncompliance with the certification and expects oversight to be  managed locally. VHA’s central office uses this certification of compliance  as a tool for VAMCs to identify and improve performance on important  aspects of the policy.
section_title: VistA Information Technology System
paragraphs: VistA is the single integrated health information system used throughout  VHA in all of its health care settings. There are many different VistA  applications for clinical, administrative, and financial functions, including  VHA’s electronic medical record, known as the Computerized Patient  Record System, and the scheduling system. As we reported in May 2010,  the VistA scheduling system is more than 25 years old and inefficient in  facilitating care coordination between different sites. In 2000, VHA  began an initiative to modernize the scheduling system, but VA  terminated the project in 2009. We also reported that VA’s efforts to  successfully replace the scheduling system were hindered by  weaknesses in its project management processes and lack of effective  oversight.
section_title: Wait Time Measurement and Performance
paragraphs: In 1995, VHA established a goal of scheduling primary and specialty care  medical appointments within 30 days to ensure veterans’ timely access to  care.for both primary and specialty care medical appointments based on  improved performance reported in previous years. Specifically, VA’s  reported wait times for fiscal year 2010 showed that nearly all primary  care and specialty care medical appointments were scheduled within   30 days of desired date. In fiscal year 2012, VHA added a goal of  completing primary care medical appointments within 7 days of the  desired date.
In fiscal year 2011, VHA shortened the wait time goal to 14 days  To facilitate accountability for achieving its wait time goals, VHA includes  wait time measures—referred to as performance measures—in its VISN  and VAMC directors’ performance contracts known as Network Director  Performance Plans (NDPP) and Facility Director Performance Plans  (FDPP), respectively. Wait time performance measures also are  included in VA’s budget submissions and performance reports to  Congress and stakeholders; the performance reports are published  annually in VA’s Performance and Accountability Report (PAR).  However, the medical appointment wait time performance measures  included in the NDPPs and FDPPs differ from the measures that are  reported in the PAR. (See table 1.) For example, in fiscal year 2012,  VHA’s wait time goal of 7 days for primary care medical appointments  was reflected in the NDPP and FDPP performance measures, but the  fiscal year 2012 PAR reported primary care wait time performance using  a 14-day standard. The performance measures have also changed over  time.
At the time of our review, all of VHA’s medical appointment wait time  performance measures reflected the number of days elapsed from the  patient’s or provider’s desired date, which is recorded in the VistA  scheduling system by VAMCs’ schedulers. According to VHA central  office officials, VHA measures wait times based on desired date in order  to capture the patient’s experience waiting and to reflect the patient’s or  provider’s wishes; which is not reflected by other available wait time  measures.
section_title: Reported Medical Appointment Wait Times Are Unreliable; VHA Uses Additional Methods to Monitor Patients’ Access to Medical Appointments
paragraphs: Medical appointment wait times used for measuring and assessing  performance toward VHA’s wait time goals are unreliable due to problems  with recording the appointment desired date in the VistA scheduling  system. Acknowledging limitations of the wait time measures, VHA uses  additional information to monitor patients’ access to medical  appointments.
subsections: section_title: Reported Medical Appointment Wait Times Derived from Desired Date Are Unreliable
paragraphs: VHA measures its medical appointment wait times as the number of days  that have elapsed from the patient’s or provider’s desired date.  Consequently, the reliability of reported wait time performance is  dependent on the consistency with which schedulers record the desired  date in the VistA scheduling system. However, aspects of VHA’s  scheduling policy and training documents regarding how to determine and  record the desired date are unclear and do not ensure replicable and  reliable use of the desired date. In addition, we found that some  schedulers at select VAMCs did not correctly implement other aspects of  VHA’s scheduling policy for recording the desired date.
Aspects of VHA’s scheduling policy and related training documents on  how to determine and record the desired date are unclear and do not  ensure replicable and reliable recording of the desired date by the large  number of staff across VHA who can schedule medical appointments in  the VistA scheduling system. Specifically, VHA’s scheduling policy and  related scheduler training documents do not provide consistent guidance  about when or whether the desired date should be based on the patient’s  or provider’s preference. While the policy defines desired date as “the  date on which the patient or provider wants the patient to be seen,” it also  instructs that the “the desired date needs to be defined by the patient” for  new patient medical appointments, medical appointments scheduled in  response to consult requests, and established patient follow-up medical  appointments. When there is a conflict between the provider and patient  desired date, the scheduler is instructed to contact the provider for a  decision on the return time frame, but the policy and training documents  do not clearly describe under what circumstances the provider’s date  should be used as the desired date. Further, providers may designate a  desired appointment time frame for a follow-up medical appointment  rather than a specific date; in such cases, the policy is unclear as to  which date within the provider’s designated time frame the scheduler  should enter as the desired date. The scheduling policy and training do  not provide sufficient guidance to ensure consistent use of desired date in  these various scheduling scenarios.
VHA central office officials responsible for developing VHA’s scheduling  policy and related training documents told us that the desired date is  intentionally broad to account for all of the scheduling scenarios that may  exist. However, leadership officials from the four VAMCs we visited and  their corresponding VISNs reported problems with the unclear guidance  on the desired date definition, and difficulties achieving consistent and  correct use of the desired date by their schedulers. In addition, given the  ambiguity in the scheduling policy and related training documents, there  are different interpretations of the desired date between officials at  different levels. For example, a VISN director stated that if a provider  gives a desired time frame, the scheduler is to use the earliest date in that  range as the desired date; whereas a provider in a specialty care clinic at  the VAMC we visited within that VISN stated that the clinic uses the latest  date in the range to meet the 14-day specialty care medical appointment  scheduling goal.
Additionally, when presented with various scheduling scenarios,  schedulers at the VAMCs we visited determined and recorded the desired  date differently. For example, when posed with the question “What date  do you enter into the scheduling system as the desired date for an  established patient follow-up medical appointment?”, 12 schedulers said  they would enter the patient’s desired date, 4 said the provider’s date,  and the remaining 3 said they used the next available medical  appointment date. When posed with the question “If the patient’s stated  desired date conflicts with the provider’s designated desired date or time  frame, what date do you enter as the desired date?”, 1 scheduler said  that the patient’s desired date would be entered, while another said the  desired date has to come from the provider. The variation in schedulers’  interpretation of the desired date suggests confusion about its correct use  in different scheduling scenarios.
Although unclear about when to use the patient’s or provider’s desired  date, VHA’s scheduling policy clearly instructs that, in all circumstances,  the desired date should be defined without regard to schedule capacity,  and should not be altered once established to reflect a medical  appointment date the patient accepts because of lack of medical  appointment availability on the desired date. However, we found that at  least one scheduler from each of the VAMCs we visited did not correctly  implement these aspects of the policy when recording the desired date in  the VistA scheduling system for specific hypothetical scheduling  situations. As summarized in table 2, we identified the following three  types of errors, each of which would have resulted in desired dates that  did not accurately reflect the patients’ or providers’ desired date, as well  as potentially result in the reporting of more favorable wait times for those  medical appointments.
Determined appointment availability prior to establishing desired date:  Although VHA’s scheduling policy requires schedulers to establish the  desired date for a medical appointment without regard to the schedule  capacity, four schedulers from three VAMCs determined the clinic’s  next available medical appointment dates before establishing a  desired date. Therefore, reported wait times for these appointments  may not have accurately reflected how long patients actually waited.
Altered original desired date based on appointment availability: Three  schedulers from two VAMCs established a desired date that was  recorded in the VistA scheduling system independent of schedule  capacity, but later altered the desired date because of appointment  availability. Specifically, two of the three schedulers altered the  originally established desired date to match the agreed-upon  appointment date, which would have incorrectly resulted in no wait  time reported for the appointment. The third scheduler altered the  established desired date when there was no appointment availability  within 2 weeks of that date; which would have resulted in an  incorrectly reported wait time that was shorter than the patient actually  waited from his or her original desired date.
Recorded a new desired date when rescheduling appointment:  Additionally, eight schedulers from three VAMCs incorrectly recorded  a new desired date when rescheduling an appointment cancelled by  the clinic rather than keeping the original desired date as required by  VHA’s scheduling policy. Changing the desired date in this way would  incorrectly decrease the reported wait times for the rescheduled  appointments; veterans actually would wait longer than the reported  wait times indicated.
During our site visits, staff at some clinics told us they change medical  appointment desired dates to show clinic wait times within VHA’s  performance goals. A scheduler at one primary care clinic specifically  stated that she changes the recorded desired date to the patient’s  agreed-upon appointment date in order to show shorter wait times for the  clinic. A provider at a specialty care clinic at another VAMC said providers  in that clinic change the desired dates of their follow-up appointments if a  patient cannot be scheduled within the 14-day performance goal.
In addition, the reported wait times, derived from desired date, for one of  the specialty care clinics we visited were inconsistent with the VAMC’s  account of appointment scheduling backlogs and scheduling challenges,  indicating reported wait time inaccuracies. At the time of our site visit,  officials from this clinic indicated that long waits for new patient  appointments had existed prior to our visit and told us that the next  available appointment for a new patient was in 6 to 8 weeks. However,  reported wait time data for the month we visited showed that the clinic  completed all new patient appointments on the desired date, resulting in  an unlikely high percentage of appointments with zero-day wait times that  was inconsistent with information gathered during our site visit, raising  questions about whether the desired date was recorded in accordance  with VHA’s scheduling policy. Furthermore, according to reported wait  times for the VAMC, this clinic completed nearly all new patient  appointments within 14 days of the desired date for the 2 months prior to  our visit; and, similarly, in the 2 months after our visit, reported wait times  for this clinic show completion of all new patient appointments within the  14-day time frame.
section_title: VHA Officials Cited Importance of Desired Date in Capturing Patient Preference and Supplement Wait Time Measures with Other Information to Monitor Patient Access to Appointments
paragraphs: VHA central office officials told us that they recognized the potential  reliability issues of using the desired date for measuring wait times, but  stated that use of the desired date is the best approach for capturing  patient experience and preference. Officials told us that there is no single  industry standard for measuring how long patients wait for appointments  and commonly used measures—such as capacity measures—do not  account for patient preference or reflect how long the patient actually   In addition, officials told us that the VistA  waited for an appointment.scheduling system was not designed to capture data for management  purposes, which has limited VHA’s options for developing wait time  measures. Over the years, VHA has tried using many different  approaches to measuring wait times, such as capacity measures and  using the date the appointment was created rather than the desired date  to determine wait times.used for performance accountability or reported on the PAR or NDPP and  FDPP in fiscal year 2012, data on these measures are available to VISNs  and VAMCs for performance monitoring. Officials told us that improving  how wait times are measured is an ongoing effort, and they have  conducted research to identify wait time measures that most closely  correlate with patient satisfaction and positive outcomes. At the time of  our review, VHA had not implemented changes to wait time performance  measures based on the results of this research.
Although these measures were not officially  In addition to measuring medical appointment wait times, VHA central  office officials reported that VHA also uses other information to monitor  patients’ access to medical appointments and to assist VISNs and  VAMCs in managing clinics.
Patient Satisfaction Measures: VHA central office and VISN officials with  whom we spoke identified patient satisfaction as another important  indicator of patient access to medical appointments and VA has  incorporated measures of self-reported patient satisfaction in its  performance assessments. Specifically, the annual PAR includes a  measure of overall patient satisfaction with VHA inpatient and outpatient  healthcare in addition to the wait time measures derived from desired  date. Separate measures related to patient satisfaction with obtaining  outpatient care were also among the measures available for VISN and  VAMC directors to include in their fiscal years 2011 and 2012  performance plans (NDPP and FDPP).
VHA also makes the satisfaction  measures available to VISNs and VAMCs for continuous performance  monitoring as well as available to the public. One of the four VAMCs we  visited included the satisfaction measures in their performance plan for  fiscal year 2012, and officials cited monitoring these measures on a  regular basis. Officials from one VISN also specifically cited comparing its  VAMCs’ patient satisfaction scores to reported wait times to identify  inconsistencies. However, the director of another VAMC said he does not  rely on the satisfaction measures to monitor access because the data are  dated by the time the VAMC sees the results, and instead, he relies on  the scheduling data derived from wait time measures.
Clinic Management Information: In addition to wait time measures, VHA  has other information available for VISNs and VAMCs to manage clinics  and monitor and improve clinic access, such as no-show rates and  consult lists. Several clinic officials reported monitoring no-show rates— the rate at which patients do not appear for their scheduled  appointment—in order to reduce unused appointments, for example, by  identifying and providing additional appointment reminders to patients  with frequent no-shows. Officials from multiple specialty clinics said they  monitor lists of consults—requests for specialty care appointments—to  ensure they are acted upon in a timely manner. Although the time  between when the provider requests a consult and when the specialty  clinic reviews the consult can affect the total time a patient waits for a  specialty appointment, this time is not reflected in current wait time  performance measures.
section_title: Inconsistent Implementation of VHA’s Scheduling Policy and Other Problems Impede VAMCs’ Ability to Schedule Timely Medical Appointments
paragraphs: The four VAMCs we reviewed did not consistently implement certain  elements of VHA’s scheduling policy, including oversight requirements,  which may result in increased wait time or delays in scheduling medical  appointments. VAMCs also described other problems with scheduling  timely medical appointments, including outdated technology, gaps in  staffing of schedulers and providers, and telephone access problems.
subsections: section_title: Inconsistent Implementation of VHA’s Scheduling Policy Hinders VAMCs’ Ability to Schedule Timely Medical Appointments
paragraphs: The four VAMCs we visited did not consistently implement VHA’s  scheduling policy, which is intended to facilitate the creation of medical  appointments that meet patients’ needs with no undue waits or delays.  This policy includes the use of the VistA scheduling system to schedule  medical appointments, and the use of the electronic wait list to track new  patients waiting for medical appointments. (See table 3 for information on  the number of clinics we visited that did not implement selected elements  of the VHA’s scheduling policy.) Inconsistent implementation of VHA’s  scheduling policy can result in increased wait time or delays in obtaining  medical appointments.
One of the clinics we visited did not use the VistA scheduling system to  determine available medical appointment dates and times, and to  schedule medical appointments, as required by VHA’s scheduling policy.  Officials noted that this clinic lacked a full-time staff person dedicated to  scheduling, and therefore, the providers called their patients to schedule  their own medical appointments. Clinic staff reported that providers  recorded medical appointments on sheets of paper and gave those  sheets to a scheduler, who maintained a paper calendar of all medical  appointments; this scheduler later recorded the appointment into the  VistA scheduling system. Failing to use VistA to schedule medical  appointments could create additional backlogs or scheduling errors  because the schedule in VistA may not accurately reflect providers’  availability. According to one provider in this clinic, for example, “staff  from other departments look in VistA  and it looks like  the clinic is not booked, so they’ll send their patients as walk-in  appointments. However, the clinic is really fully booked and patients are  waiting.”
Officials from six clinics across two different VAMCs reported that staff  scheduled new patient or established patient follow-up medical  appointments without speaking to patients, and then notified patients of  the scheduled medical appointment by letter, if the appointment was at  least a few weeks away. This method of scheduling—referred to as  “blind” scheduling by one official —is not in accordance with VHA’s  scheduling policy and could result in missed medical appointments for  patients who do not receive the letters, or are not available at the  scheduled time because patients are not involved in the scheduling  process. One scheduler noted that he sent medical appointment letters  because he didn’t have time to call all patients to schedule appointments  as he performs scheduling duties for 27 different clinics. Furthermore,  outdated or incorrect patient contact information is an impediment to  scheduling appointments via letters; an official in one of the six clinics told  us that the databases containing patient contact information used to send  such letters often do not have veterans’ correct or up-to-date contact  information.
Officials in four clinics across three VAMCs that had backlogs of patients  waiting for medical appointments stated that they do not use the  electronic wait list, the official VHA wait list used to track patients with  whom a clinic does not have an established relationship. Clinics that do  not use the electronic wait list may be at risk of losing track of new  patients waiting for medical appointments. For example, at one specialty  clinic with a backlog of consult requests, medical appointments for new  patients were backed up almost 3 months; VAMC officials reported  tracking patients waiting for medical appointments by printing paper  copies of the consult requests from the electronic medical record. A  provider at this clinic expressed concern that the clinic manager “has a  tall stack of unscreened consult referrals just sitting on her desk, and no  one is addressing them.”
Officials from one VAMC stated that it did not have the required  recall/reminder software to facilitate reminders for patients who need to  return to the clinic for follow-up medical appointments more than 3 to   4 months into the future; therefore, none of its clinics, including the five  clinics that we visited, were able to use it as intended. Instead clinics at  this VAMC use a work-around in the scheduling system to remind clerks  to print and send letters reminding patients to call and schedule their  follow-up medical appointments. However, this work-around is not  automated and relies on schedulers to remember to generate a list of  patients who need follow-up medical appointments, and print and send  those letters. The VAMC is in the process of implementing recall/reminder  software, according to officials.
One clinic in each of the four VAMCs visited did not keep their medical  appointment schedules open 3 to 4 months into the future as required by  VHA’s scheduling policy. appointments to be booked only 1 to 2 months into the future. Limiting the  future medical appointment schedule may limit patients’ ability to  schedule a follow-up medical appointment before leaving the clinic, as  recommended by the policy, and also may result in additional work for  clinic staff to send recall/reminder letters to patients for medical  appointments less than 3 to 4 months away.
VHA’s scheduling policy states that for clinics to most efficiently operate, “schedules  must be open and available for the patient to make  appointments at least three  to four months into the future. Permissions may be given to schedulers to make  appointments beyond these limits when doing so is appropriate and consistent with patient  or provider requests. Blocking the scheduling of future  appointments by limiting  the maximum days into the future an appointment can be scheduled is inappropriate and  is disallowed.” completion of the training by all staff who were required to complete it.Although all VAMCs we visited provided a list of staff who can schedule  appointments, three VAMCs did not provide documentation that all staff  on the list had successfully completed the required training. For example,  officials from one VAMC stated that it maintained a list of staff who can  schedule appointments, and a separate list of staff who had completed  the training, but only in response to GAO’s request for documentation did  the VAMC identify staff with scheduling access who needed to complete  the training. Further, three of the 19 schedulers we interviewed said they  completed training other than the required VHA scheduler training.  Completion of required VHA scheduler training and maintaining up-to- date documentation of schedulers’ completion of the training is  particularly important for ensuring consistent implementation of VHA’s  scheduling policy, given the high rates of scheduler turnover described by  officials.
All four of the VAMCs we visited completed the required self-certification  of compliance with the VHA’s scheduling policy for fiscal year 2011, three  of which certified overall compliance, and one certified overall  noncompliance.including the only one of the four that certified overall noncompliance,  were initially uncertain who completed the certification or the steps taken  to complete it, indicating that VAMCs are not always using the self- certification process to identify and improve problems with compliance  with VHA’s scheduling policy.
section_title: VAMCs Identified Other Problems with Scheduling Medical Appointments, Including Issues with Outdated Technology, Staffing Gaps, and Telephone Access
paragraphs: VAMCs identified several problems that can impede the timely scheduling  of medical appointments, which also may impact their compliance with  VHA’s scheduling policy.
VHA central office officials and officials from all of the VAMCs we visited  said the VistA scheduling system is outdated and inefficient, which  hinders the timely scheduling of medical appointments. In particular,  officials said the scheduling system requires schedulers to use  commands requiring many keystrokes and does not allow them to view  multiple screens at once. Schedulers must open and close multiple  screens to check a provider’s or clinic’s full availability when scheduling a  medical appointment, which is time-consuming and can lead to errors.  For example, providers have separate schedules within VistA to  accommodate the various types of services they provide. Because the  scheduling system cannot display multiple schedules on the same  screen, schedulers have to enter and exit multiple screens to check a  provider’s full daily schedule when scheduling a medical appointment. If  schedulers do not open all of the necessary screens, they may  unknowingly create scheduling errors such as booking two medical  appointments at the same time in different sections of a provider’s  schedule. Further, staff at one VAMC told us the problem of not being  able to easily view a provider’s full schedule can result in the failure to  ensure that appointments are cancelled when a provider requests it. This  error could cause patients to come to the VAMC unnecessarily or a failure  to reschedule cancelled appointments in a timely way, both of which  might lead to increased wait times for those patients.
Officials from all the VAMCs we visited also noted that the VistA  scheduling system is not easily adapted to meet clinic needs. For  example, staff cannot create a provider schedule in the scheduling  system that is longer than 8 hours. If a provider wants to extend his or her  schedule on certain days, staff must create additional clinic schedules in  the scheduling system for that provider, which can result in more delays  and possible errors because schedulers have to check additional screens  for medical appointment availability. Furthermore, officials told us that the  scheduling system does not automatically interface with VHA’s electronic  medical record, which makes the scheduling process more time- consuming as schedulers alternate between the two software applications  to ensure medical appointments are made in accordance with providers’  guidance.
VAMC officials described steps they take to ensure schedulers use VistA  in accordance with the scheduling directive, including ongoing scheduler  training and supervisory reviews of scheduler performance. However, as  noted above, a lack of clarity in the desired date training documents and a  lack of documentation of scheduler training at certain facilities may limit  the effectiveness of these interventions. One VAMC provides schedulers  with dual monitors to enable them to open multiple screens at once.  Another VAMC told us they considered this solution in their primary care  clinic, but found that limited physical space in the clinic did not  accommodate additional monitors.
In response to ongoing problems with the VistA scheduling system, VHA  undertook an initiative to replace it in 2000, but VA abandoned the  replacement due to weaknesses in project management and a lack of  effective oversight. VA released a new request for information in  December 2011 to gather information about vendors and possible  software packages that could replace the current scheduling system. In  September 2012, VHA told us that vendors’ responses to the request for  information indicated that VHA will be able to choose among several  viable software packages. According to officials, VA’s next step is to  compare different vendors’ software packages through the summer of  2013, and subsequently issue a request for vendor proposals.
VHA central office officials and officials from all of the VAMCs we visited  stated that shortages or turnover of schedulers also creates problems for  the timely scheduling of medical appointments. Officials said that  schedulers perform many important roles, including greeting patients,  checking patients in and out of clinics, answering telephone calls,  scheduling medical appointments for primary care, as well as specialty  care consults, and performing other administrative support functions on  behalf of the clinical staff. Officials explained, however, that high stress  and a demanding workload as well as the entry-level pay grade of the  scheduler position leads to high turnover. Further, officials told us that  high-performing schedulers often are quickly promoted to other positions  within VA. According to VHA officials, most scheduler positions are  classified as a low grade within the government general schedule pay  scale with little room for upward movement within the grade. Officials at  two of the VAMCs we visited told us they are working to raise the pay  level for schedulers; for example, one VAMC has begun to assess  scheduler position descriptions to determine whether they can be  reclassified to allow for more flexibility in determining scheduler salaries  based on the variation in their assigned duties.
Given the important role of schedulers in the scheduling process, officials  said that even temporary staffing gaps or shortages can cause medical  appointment delays or wait times. Staff with whom we spoke in several  clinics said that when scheduler staffing is lacking, including when a  scheduler is on short-term leave, it is difficult to cover all the scheduler’s  duties, and that such gaps can cause delays for patients. Further, we  were told that scheduler staffing gaps resulted in inefficient use of clinical  staff time. For example, at one specialty clinic that lacked its own  scheduler, providers routinely scheduled their own medical appointments,  which took away from time seeing patients, and also resulted in incorrect  scheduling practices. Given the training needs associated with using the  VistA scheduling system, following VHA’s scheduling policy, and ensuring  the correct use of desired date, high rates of scheduler turnover could  contribute to inconsistent use of desired date in the scheduling process or  other appointment scheduling problems.
Officials at two VAMCs noted that scheduler staffing gaps are  compounded by recent changes in their roles and responsibilities as VHA  implements a new team-based model of primary care, which calls for one  scheduler to be assigned to each primary care team. Officials told us that  these changes generally increase the administrative demands placed on  schedulers, as they are asked to respond to team duties while continuing  to answer phones, greet patients, and register new patients, among other  responsibilities. Officials from two VAMCs told us they had requested  approval to hire additional staff to meet these added administrative  needs.
Scheduler staffing gaps may also create problems managing patient flow  through clinics, which can impede scheduling of follow-up appointments,  according to officials at two of the VAMCs we visited. Staff at these  VAMCs told us that they sometimes do not have sufficient schedulers  available to staff check-out desks, and staff at one VAMC added that as a  result patients might “fall through the cracks,” leaving follow-up medical  appointments unscheduled unless the patient remembers to call in to  schedule the appointment. In addition, when patients do not check out,  schedulers are responsible for tracking patients needing follow-up  medical appointments. This situation may be exacerbated in clinics that  do not use the required recall/reminder software to facilitate the  scheduling of follow-up medical appointments more than 3 to 4 months in  the future, adding further to the backlog of patients in need of follow-up  medical appointments.
Officials from all of the VAMCs we visited told us that provider shortages  also contribute to scheduling backlogs in certain locations and specialties.  Recruitment and retention of providers was a particular challenge for  VAMCs in rural areas, areas with high costs of living, and for certain  provider specialties. All of the VAMCs we visited described gaps in  provider staffing in certain specialty care clinics. Officials at all VAMCs  also stated that a lack of salary competitiveness or the length of time to  hire new providers into the VA system also contributed to gaps in provider  staffing and scheduling backlogs.
Gaps in provider staffing also can result from providers being on  extended or unexpected leave, including vacation time, sick leave, or  military deployments. These absences may result in longer wait times for  patients. For example, officials at one VAMC told us that even a brief  absence of one provider on leave can cause significant wait times, and  that it is difficult to catch up and eliminate the backlog.
Staff from some clinics described steps they take to reduce backlogs  caused by gaps in provider staffing, including overbooking provider  schedules and scheduling temporary Saturday hours. Officials at one  VAMC told us that they employ a “floater” primary care physician to  provide coverage for providers on leave, but an official at another clinic  told us that they were unable to hire additional providers to meet the  demand for medical appointments.
Officials at all of the VAMCs we visited told us that high call volumes and  a lack of staff dedicated to answering the telephones impede the timely  scheduling of medical appointments. Despite VHA’s telephone policy  requiring the provision of continuous telephone service for clinical care  and medical appointment management, VAMC officials noted that  schedulers are frequently overwhelmed by high call volumes and are  unable to respond to calls in a timely way. In addition, officials at one  VAMC told us that outdated telephone technology, and the lack of a  dedicated VAMC-wide call center, limited their ability to improve their  telephone responsiveness. VHA has reported that telephone access to  VHA health services has historically been a frustrating experience for  veterans, including dropped calls, multiple transfers, and long waits to  reach a staff person able to resolve their inquiries. Further, patients at  all of the VAMCs we visited registered complaints about the difficulty of  reaching outpatient clinic staff by telephone and unreturned telephone  calls. According to information on patient complaints provided by the four  VAMCs we visited, patient complaints about unreturned telephone calls  ranked among the top two categories of complaints in fiscal year 2012 at  all four VAMCs. Further, staff at two of the VAMCs reported that their  telephone calls to outpatient clinics within their own VAMC went  unanswered, and one added that their inability to reach staff in their own  clinics also was an obstacle to timely medical appointment scheduling.
In January 2012, VHA distributed suggested best practices for improving  telephone design, service, and access in its Telephone Systems  Improvement Guide. This guide outlines steps VHA found to be effective  means of improving telephone service and maintaining health care  access, including regularly monitoring the purpose and volume of  telephone calls; establishing dedicated staff to answering calls, especially  at times of peak call volume; and training staff responsible for answering  telephones in call centers. To address telephone issues, officials at one  VAMC we visited told us they were developing a proposal to establish a  call center with a new telephone system, to be staffed by schedulers  dedicated to answering the telephones. Officials at a different VAMC  stated that a scheduling supervisor periodically checks schedulers’  telephones to ensure that voice mail messages are listened to and that  calls are returned.
section_title: VHA Is Implementing a Number of Initiatives to Improve Access to Medical Appointments
paragraphs: VHA is implementing several initiatives to improve veterans’ access to  medical appointments. Specifically, these initiatives focus on more  patient-centered care; using technology to provide care, through means  such as telehealth; and using care outside of VHA to reduce travel and  wait times for veterans who are unable to receive certain types of  outpatient care in a timely way through local VHA facilities. VHA officials  told us they are monitoring the implementation of these initiatives;  however, in some cases, more information is needed to determine their  impact on timely access to care over time.
subsections: section_title: Patient-Centered Care Initiatives
paragraphs: VHA’s patient-centered medical home model for primary care, Patient  Aligned Care Teams (PACT), is intended, in part, to improve access to  medical appointments and care coordination through the use of  interdisciplinary care teams and technology to communicate with patients.  Implementation of PACT began in 2010, and is an ongoing effort,  according to VHA officials. PACT differs from how primary care was  previously delivered by assigning each patient to an interdisciplinary  team. The PACT team is intended to be comprised of a primary care  provider, registered nurse care manager, a clinical support staff member   These teams offer  such as a licensed practical nurse, and a scheduler.patients a centralized way to get questions answered by nurses or other  clinical support staff and aim to reduce the need for face-to-face medical  appointments, thereby enabling more efficient use of providers’ time. For  example, at one of the VAMCs we visited, patients are given a direct  telephone number to contact their PACT team and leave a voice mail  message to be returned by the team’s registered nurse. Encouraging  PACT teams’ use of telephone communication and telephone  appointments is intended to enable patients to more quickly obtain  answers to some of their administrative and medical questions, such as  requests for prescription refills, without having to schedule a face-to-face  medical appointment. VHA officials told us that they expect PACT teams’  use of telephone communication and telephone appointments will open  up face-to-face medical appointment slots for patients who need them  and might enable clinics to reduce backlogs and improve access to same- day primary care medical appointments.
Officials at two VAMCs we visited told us that the transition to the PACT  model has created some initial scheduling and staffing difficulties. For  example, officials at these VAMCs noted that it is difficult for scheduling  staff to respond to their PACT team duties in addition to meeting other  responsibilities such as answering phones, checking in patients,  registering new patients, and scheduling for more than one clinic. This is  compounded by the fact that not all PACT teams have been assigned  their own scheduler, as prescribed by the PACT model, so an individual  scheduler is sometimes serving multiple PACT teams. Officials at these  two VAMCs explained that they would need to hire more schedulers to  meet the goal of assigning one to each PACT team.
To measure the progress of PACT implementation and its impact on  access to quality care, VHA is collecting data and tracking a series of  measures in a monthly internal data report. Five of the PACT measures  are (1) primary care medical appointments completed within 7 days of the  desired date; (2) same day access with primary care provider, or the  percentage of appointments completed within 1 day; (3) telephone  utilization, or the percentage of total encounters that occur by telephone;  (4) continuity of care, or the percentage of primary care appointments  with the patient’s assigned primary care provider; and (5) post-hospital  discharge contact, or percentage of patients discharged from the hospital  who were contacted by their primary care provider within 2 days. As  described earlier, accurate measurement of medical appointment wait  times—including the first two PACT measures—is dependent upon the  correct recording of the desired date in the VistA scheduling system. In  fiscal year 2012, PACT measures were also included in the NDPP and  FDPP.
section_title: Initiatives Using Technology
paragraphs: Part of VHA’s goal of achieving improved access to medical appointments  is the increased use of technology such as telehealth and secure  messaging. Use of these tools is intended to improve communication  between patients and providers and open up providers’ schedules for  needed face-to-face medical appointments, thereby improving access to  face-to-face appointments. home telehealth for chronic disease management such as diabetes; real-time clinic-based video telehealth, in which patients at a local  CBOC may connect with a VHA provider at a different location to  receive services that are unavailable at the CBOC, such as mental  health or speech pathology; and store-and-forward telehealth, in which digital images such as   x-rays or images of skin problems, are taken, stored, and sent to an  expert for review and consultation.
VHA officials told us that the use of telehealth can reduce both travel and  wait times for medical appointments and help meet the needs of patients  with chronic conditions. All VAMCs we visited told us they were using  telehealth to improve access to care.
Another initiative that uses technology to reduce unnecessary face-to- face medical appointments is VHA’s My HealtheVet, a web-based  program that enables veterans to create and maintain a web-based  personal health record with secure access to health information; services  such as prescription refill requests; and secure messaging. Secure  messaging allows veterans to communicate electronically with their health  care team. According to VHA, of the more than 8 million veterans enrolled  in VHA, 1.4 million are registered in My HealtheVet as of August 2012,  and more than 437,000 have created secure messaging accounts. A  recent VA study reports that secure messaging may improve access,  patient perceptions about access, and provides for better  communication.
section_title: Non-VA Care Initiative
paragraphs: VHA uses non-VA care to reduce wait times and backlogs and to provide  veterans’ access to specialists not available through VHA.statutory requirement to help veterans receive care closer to home, VHA  is piloting a new model of non-VA care known as Project ARCH (Access   Under a  Received Closer to Home). Project ARCH is a five-site, 3-year pilot  program administered by the VHA Office of Rural Health to provide health  care services through contracts with local community providers.According to VHA officials, Project ARCH might help alleviate wait times  for specialty care services with high demand, or for which there is a  shortage of local providers.
At the Montana Project ARCH pilot site, which we visited as part of our  site visit to the Montana VAMC, staff from the VAMC and the Billings  Clinic, a non-VA provider delivering services to veterans through Project  ARCH, identified both benefits and obstacles for patients enrolled in  Project ARCH. For example, though VAMC and Billings Clinic staff noted  that Project ARCH reduced both travel and wait times for Montana  veterans in need of orthopedic care, Billings Clinic staff also noted that  difficulties in coordinating care for veterans moving between VHA and  non-VA providers at times resulted in delays in providing care to those  and other veterans. Additionally, problems with processing authorizations  for certain services were among the concerns raised in an April 2012  evaluation of the Montana Project ARCH program.
Project ARCH contractors must submit monthly reports, including  information on medical appointment scheduling timeliness, wait times,  and other topics. For example, the contractor for the Project ARCH  Program in Montana is required to report on the extent to which it is  meeting VHA’s 14-day wait time goal for medical appointments— according to VHA officials, the contractor must meet a 90 percent target.  These wait times may not accurately reflect how long patients are waiting  for a medical appointment, however, because the wait time is counted  from the time the contractor receives the authorization from VA, rather  than from the time the patient or provider requests a medical  appointment.
section_title: Conclusions
paragraphs: VHA officials have expressed an ongoing commitment to providing  veterans with timely access to medical appointments and have reported  continued improvements in achieving this goal. However, unreliable wait  time measurement has resulted in a discrepancy between the positive  wait time performance VA has reported and veterans’ actual experiences.  Ambiguity in what constitutes the medical appointment desired date—the  date VHA uses as the basis for measuring wait time—as well as  manipulation of the desired date to meet goals have contributed to these  inaccuracies. With more than 50,000 schedulers making approximately  80 million medical appointments in fiscal year 2011, establishing a clear  definition of the desired date or finding and reporting another acceptable  measure of wait time is key to understanding how long veterans are  actually waiting for medical appointments. Without reliable measurement  of how long patients are waiting for medical appointments, VHA is less  equipped to identify and address factors that contribute to wait times, or  gauge the success of its initiatives to improve access to timely medical  appointments, including efforts to improve primary care medical  appointments.
More consistent adherence to VHA’s scheduling policy and oversight of  the scheduling process, as well as the allocation of staffing resources in  accordance with clinics’ demands for scheduling of medical  appointments, would potentially reduce medical appointment wait times.  Furthermore, persistent problems with telephone access must be  resolved to assure veterans’ ability to schedule timely medical  appointments. 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.
section_title: Recommendations for Executive Action
paragraphs: To ensure reliable measurement of veterans’ wait times for medical  appointments, we recommend that the Secretary of VA direct the Under  Secretary for Health to take actions to improve the reliability of wait time  measures either by clarifying the scheduling policy to better define the  desired date, or by identifying clearer wait time measures that are not  subject to interpretation and prone to scheduler error.
To better facilitate timely medical appointment scheduling and improve  the efficiency and oversight of the scheduling process, we recommend  that the Secretary of VA direct the Under Secretary for Health to take  actions to ensure that VAMCs consistently and accurately implement  VHA’s scheduling policy, including use of the electronic wait list, as well  as ensuring that all staff with access to the VistA scheduling system  complete the required training.
To improve timely medical appointment scheduling, we recommend that  the Secretary of VA direct the Under Secretary for Health to develop a  policy that requires VAMCs to routinely assess clinics’ scheduling needs  and resources to ensure that the allocation of staffing resources is  responsive to the demand for scheduling medical appointments.
To improve timely medical appointments and to address patient and staff  complaints about telephone access, we recommend that the Secretary of  VA direct the Under Secretary for Health to ensure that all VAMCs  provide oversight of telephone access and implement best practices  outlined in its telephone systems improvement guide.
section_title: Agency Comments and Our Evaluation
paragraphs: In reviewing a draft of this report, VA generally agreed with our  conclusions and concurred with our recommendations. (VA’s comments  are reprinted in app. I.) In summary, VA stated that VHA officials have  closely followed our review and proactively taken steps in response to our  findings. Specifically, VHA is revising and improving directives, policies,  training, clinic management tools, and oversight related to scheduling  practices. VA further stated that VHA is committed to routinely assessing  clinics’ scheduling needs and resources and developing practices and  guidelines to ensure adequate staffing resources for scheduling medical  appointments.
VA described its plans to address each recommendation as follows:   In response to our recommendation that VA take actions to improve  the reliability of wait time measures, VA concurred and stated that  VHA will revise its scheduling policy to implement more reliable wait  time measures and new processes to better define desired date with a  targeted completion date of November 1, 2013.
In response to our recommendation that VA take actions to ensure  that VAMCs consistently and accurately implement VHA’s scheduling  policy and ensure that all staff complete required training, VA  concurred and stated that the revised scheduling policy will include  improvements and standardization of the use of the electronic wait  list. Additionally, VHA will require VISNs to update each VAMC’s  scheduler master list and verify that all schedulers on the list have  completed required training, and will require schedulers to complete a  standardized training update on the revised scheduling policy. The  targeted completion date for these activities is November 1, 2013.
In response to our recommendation that VA develop a policy that  requires VAMCs to routinely assess clinics’ scheduling needs and  resources, VA concurred and stated that VHA will ask VAMCs to  routinely assess clinics’ availability and ensure staff is distributed to  meet access standards in clinics. However, VA has not specified  requirements for VAMCs to complete these assessments nor has the  agency provided a timeline for this process. Because schedulers are  key to ensuring timely appointment scheduling, we believe that VA  should establish a targeted completion date for requiring these  assessments in policy or guidance.
In response to our recommendation that VA ensure that all VAMCs  provide oversight of telephone access and implement best practices  outlined in its telephone improvement guide, VA concurred and stated  that VHA will require each VISN director to assess current phone  service and develop strategic improvement telephone service plans to  improve service. Additionally, VHA will identify a process to monitor  performance on a quarterly basis for at least 1 year after the  assessment. The targeted completion date for the telephone service  assessments and plans is March 30, 2013.
As arranged with your offices, unless you publicly announce the contents  of this report earlier, we plan no further distribution until 28 days after its  issuance date. At that time, we will send copies of this report to  appropriate congressional committees, the Secretary of Veterans Affairs  and other interested parties. In addition, the report is 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 II.
section_title: Appendix I: Comments from the Department of Veterans Affairs
section_title: Appendix II: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Bonnie Anderson, Assistant  Director; Rebecca Abela; Jennie Apter; Rich Lipinski; Sara Rudow; and  Ann Tynan made key contributions to this report.
section_title: Related GAO Products
paragraphs: VA Mental Health: Number of Veterans Receiving Care, Barriers Faces,  and Efforts to Increase Access. GAO-12-12. Washington, D.C.:   October 14, 2011.
Information Technology: Department of Veterans Affairs Faces Ongoing  Management Challenges. GAO-11-663T. Washington, D.C.:   May 11, 2011.
Information Technology: Management Improvements Are Essential to  VA’s Second Effort to Replace Its Outpatient Scheduling System.   GAO-10-579. Washington, D.C.: May 27, 2010.
VA Health Care: Access for Chattanooga-Area Veterans Needs  Improvement. GAO-04-162. Washington, D.C.: January 30, 2004.
VA Health Care: More National Action Needed to Reduce Waiting Times,  but Some Clinics Have Made Progress. GAO-01-953. Washington, D.C.:  August 31, 2001.
Veterans’ Health Care: VA Needs Better Data on Extent and Causes of  Waiting Times. GAO/HEHS-00-90. Washington, D.C.: May 31, 2000.