VA Health Care:

Reliability of Reported Outpatient Medical Appointment Wait Times and Scheduling Oversight Need Improvement

GAO-13-130: Published: Dec 21, 2012. Publicly Released: Jan 18, 2013.

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Debra A. Draper
(202) 512-7114
DraperD@gao.gov

 

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What GAO Found

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.

Why GAO Did This Study

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.

What GAO Recommends

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.

For more information, contact Debra Draper at (202) 512-7114 or draperd@gao.gov.

Recommendations for Executive Action

  1. Status: Open

    Comments: VA concurred with this recommendation and stated that it would revise its scheduling policy to implement more reliable wait time measures and new processes to better define desired date. As of March 2015, VA reported that The Veterans Access, Choice, and Accountability Act (VACA), signed August 7, 2014, defines wait-time goals for VA as not more than 30 days from the date on which the Veteran requests an appointment for hospital care or medical services. On October 17, 2014, VA further specified in the Federal Register a definition of the term "wait-time goals", which means not more than 30 days from either the date that an appointment is deemed clinically appropriate by a VA health care provider, or, if no such clinical determination has been made, the date a Veteran prefers to be seen for hospital care or medical services. In response, VHA drafted an updated scheduling memorandum containing instructions that further clarify scheduling procedures to align with VACA.

    Recommendation: To ensure reliable measurement of veterans' wait times for medical appointments, the Secretary of VA should 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.

    Agency Affected: Department of Veterans Affairs

  2. Status: Open

    Comments: VA concurred with this recommendation and stated that it would require all VISNs to update and verify each VA facility's Scheduler Master List (the list of staff who have completed required scheduler training)and require all schedulers to complete a standardized training update on the revised scheduling policy. As of March 2015, VHA reported it had drafted updated scheduling instructions, which are pending publication. Once published, supplemental virtual training will be provided. Additionally, VHA created, implemented and trained staff to use the "Scheduling Trigger Tool", which is a database that identifies facilities and specialty areas within facilities that are not following the scheduling policy, including use of the electronic wait list. Low performers are flagged for further action by local facility leadership.

    Recommendation: To better facilitate timely medical appointment scheduling and improve the efficiency and oversight of the scheduling process,the Secretary of VA should 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.

    Agency Affected: Department of Veterans Affairs

  3. Status: Open

    Comments: VA concurred with this recommendation and noted that it would ask VA facilities to routinely assess clinics' availability and ensure staff are distributed to meet access standards for clinics, as well as revising and implementing improved clinic management tools. In March 2015, VHA reported that in February 2015, the Scheduling Resource Assessment report was finalized for online testing. This report identifies the number of appointments scheduled for each stop code and clinic during a one month period at a selected facility. A drill-down is available with the information on the staff making the appointments to include position and volume of appointments made.

    Recommendation: To improve timely medical appointment scheduling, the Secretary of VA should 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.

    Agency Affected: Department of Veterans Affairs

  4. Status: Open

    Comments: VA concurred with this recommendation and stated that VISN and VA Medical Center leadership would use best practices to develop and implement improved telephone service plans. As of March 2015, VHA had developed a standardized telephone assessment tool and requested that facilities that care for 5,000 or more veterans complete the assessment and select actions for improvement based on its existing telephone systems improvement guide. Based on this request, VHA received telephone assessment and improvement plans from 286 facilities that care for 5,000 or more veterans. VHA is monitoring the facilities' telephone performance and is re-baselining call center infrastructure at each facility with a survey and new performance goals. In September 2015, VHA issued an updated Telephone Access and Contact Management Improvement Guide. VHA has also drafted an update to its directive on telephone access, which is currently undergoing internal review with publication anticipated in July 2016.

    Recommendation: To improve timely medical appointments and to address patient and staff complaints about telephone access,the Secretary of VA should 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.

    Agency Affected: Department of Veterans Affairs

 

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