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 indicated that to address variation in clinical progress note use, the Veterans Health Administration (VHA) Deputy Under Secretary for Health for Operations and Management (DUSHOM) will charter a workgroup to assess and develop a single set of clear standard operating procedures for requesting and completing consults. VA indicated that the standard operating procedures will specifically address rules related to the cancellation and denial of consults, as well as the appropriate process for completing and closing consults. Specifically, VA indicated actions will provide for: Clarification of the standard operating procedures for requesting and completing consults; development of TMS programs to educate physicians, mid-levels providers, and resident trainees. Target Completion Date: December 31, 2014. Completion of training for all providers. Target Completion Date: March 31, 2015. Validation of ongoing training, including assurance that all new residents and providers are trained. Target Completion Date: December 31, 2015. As of September 2015 we are awaiting an update from VA on the status of this recommendation, and we will update the status of this recommendation when we receive additional information.

    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 indicated that a workgroup will develop a clear set of standard operating procedures for tracking and monitoring consults at the provider, clinic, service line, facility, and Veterans Integrated Service Network (VISN) level. As part of the standard operating procedures, the workgroup will develop recommendations and instructions for generating a standard set of management tools. The facility will be responsible for using these tools to manage the consult process at the requestor and consultant level. Oversight of these processes will occur at the VA medical center (VAMC), VISN, and VHA levels. Clinical leadership at VAMCs will regularly review and monitor the consult process. In addition, VISNs will be responsible for reviewing the facility audit process. Lastly, VHA's Office of Compliance and Business Integrity will routinely audit facilities to ensure use of VHA's standardized consultation process and to identify causes of delays. VA specifically indicated that: Development of standard operating procedures for tracking and monitoring consults. Target Completion Date: December 31, 2014. Implementation of facility/VISN auditing process. Target Completion Date: March 31, 2015. As of September 2015 we are awaiting an update from VA on the status of this recommendation, and we will update the status of this recommendation when we receive additional information.

    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 indicated that a workgroup will develop a clear set of standard operating procedures for the management of consults. The workgroup will develop an educational tool to provide proper orientation for physicians, mid-level providers, and resident trainees on the use of the consult package. These tools will specifically address rules related to the cancellation and denial of consults, as well as exploring options for the development of a template to indicate and track the reasons for cancellation and denial of consults. VA further indicated that: Clarification of the standard operating procedures for the cancellation and denial of consults; development of TMS programs to educate physicians, mid-level providers, and resident trainees; explore options for development of a template to standardize indications for cancellation and denial of consults. Target Completion Date: December 31, 2014. Completion of training for all providers; implementation and use of template for cancellation and denial of consults. Target Completion Date: March 31, 2015. Validation of ongoing training. Target Completion Date: December 31, 2015. As of September 2015 we are awaiting an update from VA on the status of this recommendation, and we will update the status of this recommendation when we receive additional information.

    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 indicated that a workgroup will assess local strategies for managing future care consults, including the effects of the reliability of consult data. It also indicated that that VHA,through the National Consult Steering Committee, will review workgroup findings and recommendations to reassess policy and practices for management of future consults. The VHA will determine whether modifications to current measures are needed and will implement necessary changes. Target Completion Date: December 31, 2014. As of September 2015 we are awaiting an update from VA on the status of this recommendation, and we will update the status of this recommendation when we receive additional information.

    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 indicated that VHA will establish a system-wide process that facilitates the identification and dissemination of best practices for managing consults. Regular conference calls will be scheduled between representatives of local consult steering committees. The calls will include identification and discussion of best practices, including management of future care consults. Best practices that have broader applicability will be shared through posting on VHA's existing electronic consults switchboard and communicated to appropriate groups. The electronic consults switchboard is a system-wide tool that VISNs and facilities currently use to review national data on consults. This switchboard will be VHA's depository for best practices for managing consults. Target Completion Date: December 31, 2014. As of September 2015 we are awaiting an update from VA on the status of this recommendation, and we will update the status of this recommendation when we receive additional information.

    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 indicated that in the short term, VHA will issue clarification to all VISNs and facilities regarding management of no-shows and cancellations while developing national policy documents. Target Completion Date: December 31, 2014. In the long term, VHA will establish requirements for managing no-shows and canceled appointments in national policy. Target Completion Date: March 31, 2015. As of September 2015 we are awaiting an update from VA on the status of this recommendation, and we will update the status of this recommendation when we receive additional information.

    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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