VA Health Care:

Management and Oversight of Consult Process Need Improvement to Help Ensure Veterans Receive Timely Outpatient Specialty Care

GAO-14-808: Published: Sep 30, 2014. Publicly Released: Oct 30, 2014.

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

 

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What GAO Found

Based on its review of a non-generalizable sample of 150 consults requested from April 2013 through September 2013, GAO found that the Department of Veterans Affairs' (VA) Veterans Health Administration's (VHA) management of the consult process has not ensured that veterans always receive outpatient specialty care in a timely manner, if at all. Specifically, GAO found that for 122 of the 150 consults reviewed—requests for evaluation or management of a patient for a specific clinical concern—specialty care providers did not provide veterans with the requested care in accordance with VHA's 90-day timeliness guideline. For example, for 4 of the 10 physical therapy consults GAO reviewed for one VA medical center (VAMC), between 108 and 152 days elapsed with no apparent actions taken to schedule an appointment for the veteran. VAMC officials cited increased demand for services, and patient no-shows and cancelled appointments among the factors that lead to delays and hinder their ability to meet VHA's timeliness guideline. Further, for all but 1 of the 28 consults for which VAMCs provided care within 90 days, an extended amount of time elapsed before specialty care providers properly documented in the consult system that the care was provided. As a result, the consults remained open in the system, making them appear as though the requested care was not provided within 90 days.

VHA's limited oversight of consults impedes its ability to ensure VAMCs provide timely access to specialty care. VHA officials reported overseeing the consult process primarily by reviewing data on the timeliness of consults; however, GAO found limitations in VHA's oversight, including oversight of its initiative designed to standardize aspects of the consult process. Specifically:

VHA does not routinely assess how VAMCs are managing their local consult processes, and thus is limited in its ability to identify systemic underlying causes of delays.

As part of its consult initiative, VHA required VAMCs to review a backlog of thousands of unresolved consults—those open more than 90 days—and if warranted to close them. However, VHA did not require VAMCs to document their rationales for closing them. As a result, questions remain about whether VAMCs appropriately closed these consults and if VHA's consult data accurately reflect whether veterans received the care needed in a timely manner, if at all.

VHA does not have a formal process by which VAMCs can share best practices for managing consults. As a result, VAMCs may not be benefitting from the challenges and solutions other VAMCs have discovered regarding managing the consult process.

VHA lacks a detailed system-wide policy for how VAMCs should manage patient no-shows and cancelled appointments for outpatient specialty care, making it difficult to compare timeliness in providing this care system-wide.

Consequently, concerns remain about the reliability of VHA's consult data, as well as VHA's oversight of the consult process.

Why GAO Did This Study

There have been numerous reports of VAMCs failing to provide timely care to veterans, including specialty care. In some cases, delays have reportedly resulted in harm to patients. In 2012, VHA found that its consult data were not adequate to determine the extent to which veterans received timely outpatient specialty care. In May 2013, VHA launched an initiative to standardize aspects of the consult process at its 151 VAMCs and improve its ability to oversee consults.

GAO was asked to evaluate VHA's management of the consult process. This report evaluates (1) the extent to which VHA's consult process has ensured veterans' timely access to outpatient specialty care, and (2) how VHA oversees the consult process to ensure veterans are receiving outpatient specialty care in accordance with its timeliness guidelines. GAO reviewed documents and interviewed officials from VHA and from five VAMCs that varied based on size and location. GAO also reviewed a non-generalizeable sample of 150 consults requested across the five VAMCs.

What GAO Recommends

GAO recommends that VHA take actions to improve its oversight of consults, including (1) routinely assess VAMCs' local consult processes, (2) require VAMCs to document rationales for closing unresolved consults, (3) develop a formal process for VAMCs to share consult management best practices, and (4) develop a policy for managing patient no-shows and cancelled appointments. VA concurred with all of GAO's recommendations and identified actions it is taking to implement them.

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

Recommendations for Executive Action

  1. Status: Open

    Comments: In September, 2014, we recommended that VA ensure clinical providers are using correct progress notes to complete consults in a timely manner. VA concurred with this recommendation, and in August 2016, reported that they had taken many actions to ensure providers understand the correct process to link progress notes to complete consults in a timely manner. For example, VA reported that the total number of clinical consults open > 90 days was reduced by 67 percent from 270,740 in December 2013 to 88,650 in June 2016. Progress in these measures is expected to continue over time. VA considered this recommendation fully implemented, but has not yet provided documentation needed for GAO to make an assessment of the actions. As such, this recommendation remains open until VA provided information needed for us to complete our review.

    Recommendation: To improve VHA's ability to effectively oversee the consult process, and help ensure VAMCs are providing veterans with timely access to outpatient specialty care, the Secretary of Veterans Affairs should direct the Interim Under Secretary for Health to assess the extent to which specialty care providers across all VAMCs, including residents who may be serving on a temporary basis, are using the correct clinical progress notes to complete consults in a timely manner, and, as warranted, develop and implement system-wide solutions such as technical enhancements, to ensure this is done appropriately.

    Agency Affected: Department of Veterans Affairs

  2. Status: Open

    Comments: In September, 2014, we recommended that VA enhance oversight of consults by routinely conducting independent assessments of how medical centers are managing the consults process. VA concurred with this recommendation, and in August 2016 provided an update indicating it has begun conducting audits of consults, and the first round of audits will be completed in September 2016. When VA provides GAO with additional information, we assess whether VA's actions are sufficient to warrant closure of the recommendation.

    Recommendation: To improve VHA's ability to effectively oversee the consult process, and help ensure VAMCs are providing veterans with timely access to outpatient specialty care, the Secretary of Veterans Affairs should direct the Interim Under Secretary for Health to enhance oversight of VAMCs by routinely conducting independent assessments of how VAMCs are managing the consult process, including whether they are appropriately resolving consults. This oversight could be accomplished, for example, by VISN officials periodically conducting reviews of a random sample of consults as we did in the review we conducted.

    Agency Affected: Department of Veterans Affairs

  3. Status: Open

    Comments: In September 2014, we recommended that VA require specialty care providers to clearly document in the electronic consult system their rationale for resolving a consult when care has not been provided. VA concurred with this recommendation, and August 2016 reported to GAO that it had developed a consult SOP in December 2014 which requires providers to clearly document in the electronic consult system their rationale for cancelling or discontinuing a consult. VA also reported that it in October and November 2014, national training was provided to facility level staff via webinars, and to 975 employees via VA eHealth University (VeHU) training. These training presentations have been made available in the Talent Management System (TMS). Training on this requirement was provided nationally on the weekly best practice/training calls, and through the national consult training module #24762 in TMS. VA further indicated that it required not just specialty care providers but all Licensed Independent Practitioners (LIPs) complete the TMS consult training module by August 2015. VA also stated that as of August 2015, 97 percent of assigned staff have completed the TMS training. An additional 12,740 staff who were not assigned the consult training module in TMS also completed the training. In its August response VA indicated that they had fully implemented the recommendation, but GAO is still waiting for documentation on the training VA provided. Once VA provides documentation, GAO can make a final assessment as to whether this recommendation should be closed.

    Recommendation: To improve VHA's ability to effectively oversee the consult process, and help ensure VAMCs are providing veterans with timely access to outpatient specialty care, the Secretary of Veterans Affairs should direct the Interim Under Secretary for Health to require specialty care providers to clearly document in the electronic consult system their rationale for resolving a consult when care has not been provided.

    Agency Affected: Department of Veterans Affairs

  4. Status: Open

    Comments: In September 2014 we recommended that VA should identify and assess various strategies that all medical centers have implemented to manage future care consults, and take measures to ensure consistency of consults data. VA concurred with this recommendation, and in August 2016 VA reported that it had taken numerous actions to improve and standardize processes to manage future care consults. Specifically, VA reported that as a result of VHA's assessment of various strategies VAMCs used to manage future care consults, VHA made a decision to standardize the procedures by authorizing future care consults (rather than recall reminders or non-count EWLs) as the only approved method for managing consult requests for care intended to take place beyond 90 days from the date the consult is created. Standardized processes improved the consistency and reliability of future care consult data allowing better oversight. National guidance on future care consults was published on April 8, 2015. Training on future care consults was provided via individualized consult training with all VISNs, weekly national consult best practice/training calls, and national consult training module #24762 in the Talent Management System (TMS). According to VA's response, as of August 2015, 97 percent of Licensed Independent Practitioners (LIPs) assigned the TMS training have completed it. An additional 12,740 staff who were not assigned the consult training module in TMS also completed the training. VA indicated that it considers this recommendation implemented, but has not yet provided the documentation supporting the actions it reported taking. Once VA provides this documentation to GAO, we can make an assessment whether VA's actions warrant closing this recommendation.

    Recommendation: To improve VHA's ability to effectively oversee the consult process, and help ensure VAMCs are providing veterans with timely access to outpatient specialty care, the Secretary of Veterans Affairs should direct the Interim Under Secretary for Health to identify and assess the various strategies that all VAMCs have implemented for managing future care consults; including determining the potential effects these strategies may have on the reliability of consult data; and identifying and implementing measures for managing future care consults that will ensure the consistency of consult data.

    Agency Affected: Department of Veterans Affairs

  5. Status: Open

    Comments: In September, 2014, we recommended that VA should establish a system-wide process for identifying and sharing medical centers' best practices managing consults. VA concurred with this recommendation, and in August 2016 reported that to promote nationwide communication, VHA established a system-wide process for identifying and sharing best practices for managing consults. VHA first identified a list of about 475 VISN and facility consult POCs and developed a mail group to facilitate communication with the POCs. Facility level consult steering committees were established and are represented on weekly national consult performance improvement calls. VHA began holding national calls with these POCs on November 14, 2014. Each week, close to 400 attendees participate in these calls, which include training on consult policies and processes, review of consult performance data, and presentations on best practices. In its response VHA indicated that it considered this recommendation fully implemented. Once VA provides GAO with documentation supporting its reported actions, we can make an assessment whether or not VA's actions warrant closing this recommendation.

    Recommendation: To improve VHA's ability to effectively oversee the consult process, and help ensure VAMCs are providing veterans with timely access to outpatient specialty care, the Secretary of Veterans Affairs should direct the Interim Under Secretary for Health to establish a system-wide process for identifying and sharing VAMCs' best practices for managing consults that may have broader applicability throughout VHA, including future care consults.

    Agency Affected: Department of Veterans Affairs

  6. Status: Open

    Comments: In September, 2014, we recommended that VA should develop a national policy for medical centers in order to manage patient no-shows and cancelled appointments, and ensure it enables VHA to develop standardized data needed for effective oversight of consults. VA concurred with this recommendation, and in August 2016 reported that it had developed national guidance for management of patient no-shows and cancelled appointments outlined in the VHA Consult SOP, which has been distributed nationally and posted to the Consult SharePoint site. Training on the no-show guidance was provided via individualized consult training with all VISNs, weekly national consult best practice/training calls, and national consult training module #24762 in the Talent Management System (TMS). In its response, VA indicated it considered this recommendation fully implemented. Once VA provides documentation on the training in provided staff, GAO can assess whether VA's actions warrant closing this recommendation.

    Recommendation: To improve VHA's ability to effectively oversee the consult process, and help ensure VAMCs are providing veterans with timely access to outpatient specialty care, the Secretary of Veterans Affairs should direct the Interim Under Secretary for Health to develop a national policy for VAMCs to manage patient no-shows and cancelled appointments that will ensure standardized data needed for effective oversight of consults.

    Agency Affected: Department of Veterans Affairs

 

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