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: Closed - Implemented

    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 to GAO that many actions were taken 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. VA noted that progress in these measures was expected to continue over time. In May 2017, VA provided documentation for a consult closure tool, which is a system-wide enhancement intended to further assist facilities with ensuring that consults are appropriately resolved. This tool identifies patients with pending consults who meet certain criteria, such as having been seen with a completed, clinically relevant note, despite having the consult show as unresolved. This tool helps resolve consults that were not closed at the time of service due to the use of an incorrect progress note title. VA officials have indicated that they considered this recommendation fully implemented.

    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: Closed - Implemented

    Priority recommendation

    Comments: In September, 2014, we recommended that the Department of Veterans Affairs (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, reported to GAO that it had begun conducting audits of consults. In January 2017, VA provided a copy of the official protocols that guided these audits, which included information on the scope of the audit and required documentation of audit results, among other things. In September 2017, VA provided the final report for its audit. According to the report, the Veterans Health Administration's (VHA) Office of Compliance and Business Integrity (CBI) reviewed a total of 18,330 randomly selected closed consults during two audit cycles in fiscal years 2016 and 2017. Based on its review, CBI identified two main causes of delays in processing consults as well as errors in consult documentation. As a result, CBI made several recommendations to the VHA Office of Veteran Access to Care, Veterans Integrated Service Network (VISN) Directors, and VISN Compliance and Business Integrity Officers. VA reported plans to continue conducting these audits at least twice annually to assess compliance with its consult policy.

    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: Closed - Implemented

    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 in August 2016, reported to GAO that it had developed a consult SOP in December 2014 requiring providers to clearly document in the electronic consult system their rationale for cancelling or discontinuing a consult when care had not been provided. 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 training. These training presentations have been made available in the Talent Management System (TMS). Training on this requirement also was provided nationally on the weekly consult performance improvement calls, and through a national consult training module in TMS. VA further indicated that it required specialty care providers and all Licensed Independent Practitioners to complete the TMS consult training module by August 2015 and that 97 percent of assigned staff had done so by the deadline. An additional 12,740 staff who were not assigned the consult training module in TMS also completed the training. In January 2017, VA provided documentation for its consult training module, which included instructions for discontinuing or cancelling consults and noted the requirement to document the rationale for doing so in VA's electronic system. VA officials have indicated that they considered this recommendation fully implemented.

    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: Closed - Implemented

    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 to GAO numerous actions taken to improve and standardize processes to manage future care consults. Specifically, VA reported that as a result of its assessment of various strategies VA medical centers 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 Electronic Waiting Lists) 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. In addition, 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 Veterans Integrated Service Networks, weekly national consult best practice/training calls, and a national consult training module in the TMS. According to VA's response, as of August 2015, 97 percent of specialty care providers and Licensed Independent Practitioners 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. In January 2017, VA provided documentation for the steps it previously reported taking, including the results from its future care consult poll and its national consult training module, which covered several topics regarding future care consults, including the requirement that this type of consult be used to manage care needed beyond 90 days from the date that the consult is created. VA officials expect that standardizing the use of the future care consult will improve the consistency and reliability of future care consult data and allow better oversight. VA officials have indicated that they considered this recommendation fully implemented.

    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: Closed - Implemented

    Comments: : In September, 2014, we recommended that VA should establish a system-wide process for identifying and sharing VA medical centers' best practices for managing consults. VA concurred with this recommendation, and in August 2016, reported to GAO that VHA established a system-wide process for identifying and sharing best practices for managing consults. First, VHA identified a list of about 475 VISN and facility consult points of contact (POC) and developed a mail group to facilitate communication with the POCs. Additionally, VHA established facility-level consult steering committees. The POCs and steering committee members participate in weekly national consult performance improvement calls, which began in November 2014. Each week, close to 400 attendees participate in these calls, which may include training on consult policies and processes, reviews of consult performance data, and presentations on best practices. In addition, VHA has created a means for its facilities to electronically access consult data as well as a SharePoint page, which serves as a repository for all consult policy documents, including training materials, frequently asked questions, and contact information for VISN and facility consult experts. On May 24, 2017, VHA officials provided a demonstration of VHA's consult SharePoint page, which all of its employees may access. The SharePoint page had tabs containing information from VHA's weekly consult performance improvement calls, policies, and key VISN and facility points of contact, among other things. VA officials have indicated that they considered this recommendation fully implemented.

    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: Closed - Implemented

    Comments: In September, 2014, we recommended that the 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 to GAO that it had developed national guidance for management of patient no-shows and cancelled appointments outlined in the VHA Consult SOP. This SOP had been distributed nationally and posted to VHA?s 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 a national consult training module in the TMS. In January 2017, VA provided a copy of its VHA Consult SOP and its related consult training. The SOP and its associated training clarified circumstances under which a facility may discontinue consults due to patient no-shows and cancellations, as recommended in our report. VA officials have indicated that they considered this recommendation fully implemented.

    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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