VA’s health care system is divided into 22 regional Veterans Integrated Service Networks (VISN), which serve as the basic budgetary and decision-making units for determining how best to provide services to veterans at medical centers and community-based outpatient clinics located within their geographic boundaries. Spread throughout the 22 VISNs are 172 medical centers, each headed by a director who manages administrative functions, along with a chief of staff who manages clinical functions for the entire medical center. VA medical centers also have designated managers for each area of care, such as primary and specialty care. Within each area of care, there may be many clinics, which can vary in purpose and size. For example, VA has clinics that manage the care of patients who are taking prescription medication for blood clots, and, due to their more limited scope, these clinics might have a small number of providers and staff. On the other hand, VA’s primary care clinics—where physicians are responsible for the routine health needs of a caseload of patients—tend to have a relatively larger number of providers and staff. In addition, specialty care clinics, such as gastroenterology and urology, could provide patients with specific care within that specialty, such as treatment for hepatitis C and prostate cancer. In 1996, the Congress required VA to ensure that veterans enrolled in its health care system receive timely care. For outpatient care, VA established its “30-30-20” goals: routine primary care appointments are to be scheduled within 30 days from the date of request, as are specialty care appointments, and patients are to be seen within 20 minutes of their scheduled appointment time. Following reports of long waiting times from VA’s medical centers and clinics, veterans’ service organizations, veterans, the Inspector General, and us—VA began two initiatives to help identify and address waiting times problems. First, VA contracted with IHI, a Boston-based contractor, to help develop strategies to reduce waiting times. As part of this project, 134 teams from VA medical centers across the nation worked on reducing waiting times for appointments in selected primary or specialty care clinics. Over half of these teams focused on primary care. Second, VA began collecting patient waiting times data from its outpatient scheduling system—the Veterans Health Information Systems and Technology Architecture (VISTA), one of VA’s main computer systems for clinical, management, and administrative functions. Over the past few years, VA made several modifications to its appointment scheduling software to develop more reliable data on waiting times. In March 2001, VA began using these waiting times data to identify clinics that failed to meet its 30-day standard. While most veterans using the primary care clinics we visited were able to get an appointment within 30 days, many seeking specialty care often had to wait longer than 30 days for a referral. Clinics with long waiting times often had poor scheduling procedures or did not use their staff efficiently. The chiefs of primary care at the 10 VA medical centers we visited reported that 15 of their 17 primary care clinics—or about 88 percent— met VA’s 30-day timeliness standard. The other two clinics reported waiting times of 56 and 61 days. However, chiefs of specialty care at the clinics we visited reported that patients with nonurgent needs often wait in excess of VA’s 30-day standard (see fig. 1). The longest reported waiting times were in gastroenterology and optometry. At one location, veterans had to wait 282 days—more than 9 months—for an optometry appointment. These long waiting times were often the result of high percentages of patients not showing up for appointments, poor scheduling procedures, and inefficient use of staff. When veterans do not keep their appointments, some of the limited appointment slots are lost and are unavailable for other veterans. This could extend waiting times overall. Almost 60 percent of the 71 primary and specialty care clinics we visited had a no-show rate of 20 percent or greater. Gastroenterology had the highest average no- show rate at 29 percent. At one gastroenterology clinic, half of the scheduled patients did not show up for their appointments. Urology had the lowest average no-show rate at 18 percent. According to one clinic chief, patients failed to keep appointments because their health condition improved or they forgot about the appointment because it was scheduled so far into the future. Some clinics’ scheduling procedures may actually encourage no-shows. For example, some clinics schedule appointments several months in advance. Although most clinics remind patients of their appointments—by mail or telephone—we found that some reminder systems were not sufficient to ensure that patients kept their appointments. For example, over 30 percent of the clinics we visited automatically rescheduled no- shows, and some did not follow up with the veterans to determine why they had missed the original appointments. In addition, in one clinic, staff told us that the patient often was not informed of this new appointment, making it likely that the patient would miss the new appointment as well. We found that inefficient use of staff could also limit the number of available appointment slots, contributing to long waiting times. For example, some specialists told us that they were treating patients who could be seen in primary care. Specifically, one chief of dermatology told us that she receives new patient referrals for conditions that could easily be treated in primary care, such as dry skin. In addition, several chiefs of orthopedics told us that they continue to see patients with conditions such as rheumatoid arthritis and back pain because the patients request appointments, even after their conditions have stabilized. Furthermore, shortages of nonprovider staff at some clinics also resulted in the inefficient use of physician time. For example, one orthopedic clinic did not have a cast technician, so an orthopedic surgeon had to apply and remove patient casts. At another clinic, a shortage of clerks resulted in nurses’ assuming clerical duties—such as scheduling, admitting, and discharging patients—and physicians’ assuming tasks that nurses would otherwise have handled, such as escorting patients to the examination room. As physicians assumed duties that could more appropriately have been fulfilled by nonphysician personnel, the number of appointments that could have been scheduled each day might have been reduced. When one appointment is linked to or dependent on another, scheduling and staffing problems can further compound delays. For example, two chiefs of orthopedics told us that patients who are scheduled for an x-ray prior to their orthopedic appointment sometimes arrive late to the orthopedic clinic or without an x-ray as a result of delays in the x-ray clinic. Because orthopedic surgeons typically must have x-rays to properly assess the severity of a patient’s condition, patients who do not have x- rays often must reschedule their orthopedic appointments, wasting the original appointment and filling another future appointment slot on the schedule. While most of the clinics we visited continue to experience waiting times problems, several have reported success in reducing their waiting times— primarily by improving their scheduling processes or making better use of staff. One VA medical center combined these and other strategies, and as a result, all but one of its clinics that we reviewed had reduced their waiting times to less than 30 days. According to the chiefs of several clinics we visited, their improved waiting times were, in part, the result of their increasing the number of available patient appointments. To make more appointments available, these clinics reduced the number of no-shows and reduced physician involvement in certain services. Some clinics also added more providers. To increase the likelihood that patients would show up for their appointments, the clinics we visited used various strategies, such as the following. One ophthalmology and optometry clinic reduced its no-show rate from 45 percent to 22 percent by having scheduling clerks call patients a few days in advance to remind them of their appointments. When making these calls, clerks found that some patients had forgotten their appointments and would likely have missed them had they not received the reminder call. Some patients, however, said that they did not plan to keep the appointments. In these cases, clerks were typically able to schedule another patient into the time slot and thus increase the number of patients that the provider could see each day and thereby reduce the number of days it took veterans to get appointments. A primary care clinic at another medical center reduced its no-show rate from 22 percent to about 12 percent through two actions. First, it changed its medical resident rotation rate to once every 3 years, allowing patients to develop relationships with the residents assigned to their care. The chief of this clinic told us that she believes that the patients are more comfortable knowing that they will see the same provider on each visit and so are more likely to keep their appointments. Second, this primary care clinic also used open access scheduling—an IHI technique—to reduce its no-show rate. The basic premise of open access scheduling is to schedule nonurgent appointments within 30 days to reduce the likelihood that patients would miss their appointments. For those patients needing appointments past the 30-day time frame, the center sends reminder notices near the time the patient needs to call in to schedule the appointment. According to this center’s director of ambulatory care, lower no-show rates have helped to reduce patient waiting times for primary care. Further, to accommodate urgent patients who need same-day appointments, the medical center holds open the last two appointment slots for each provider in each clinic day. Clinics also freed up appointments by reducing provider involvement in services that do not require one-on-one physician-patient interaction. Providers in one medical center’s primary care clinic now use an automated telephone system to convey the results of blood and other lab tests to patients when the test results are normal. The system automatically calls patients and instructs them to call the system back and enter a preassigned password to retrieve messages from their providers about the results of their tests—which patients can access at any time.