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. 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. 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. 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. 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. 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.