VA Health Care:

Restructuring Ambulatory Care System Would Improve Services to Veterans

HRD-94-4: Published: Oct 15, 1993. Publicly Released: Oct 15, 1993.

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Pursuant to a congressional request, GAO reviewed the Department of Veterans Affairs' (VA) ambulatory care system, focusing on: (1) the factors that cause service delays; and (2) ways to improve efficiency and shorten veterans' waiting times in ambulatory care facilities.

GAO found that: (1) the VA ambulatory care system forces veterans with nonurgent conditions to use VA emergency screening clinics regardless of their medical needs; (2) veterans with nonurgent conditions are treated on a first-come, first-served basis; (3) most VA facilities have taken some steps to reduce veterans' waiting times; (4) long delays frequently occur in specialty clinics because many veterans receive routine follow-up care in these clinics after their conditions are stabilized; (5) VA headquarters has not provided guidance on how veterans' waiting times should be measured; (6) VA headquarters has not established performance goals to evaluate the timeliness of services; and (7) facilities have no benchmarks to compare performance, since systemwide goals have not been set.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: VA has developed several directives aimed at addressing the potential opportunities to reduce the number of no-shows, thereby reducing the need to overbook. VA plans to advise veterans of the importance of keeping appointments, instruct veterans to contact VA if they are unable to keep an appointment, and contact veterans by mail and computerized telephone calls to remind them of appointments.

    Recommendation: The Secretary of Veterans Affairs should require the Under Secretary for Health to revise operating policies and procedures for treating veterans in specialty clinics in order to improve the timeliness of services, especially for those veterans needing specialty evaluation of new medical conditions. Specifically the Under Secretary for Health should require all facilities to survey veterans to determine why they missed appointments and develop steps to counteract these no-shows and, thereby, reduce clinics' reliance on overbooking. VA should then disseminate to all facilities the best practices that are being used to reduce adverse effects of no-shows on waiting times and incorporate these best practices into existing policies and procedures.

    Agency Affected: Department of Veterans Affairs

  2. Status: Closed - Implemented

    Comments: VA has issued a directive that provides guidance for the implementation of primary care. VA medical centers are to ensure that veterans are treated in primary clinics instead of specialty clinics, when appropriate.

    Recommendation: The Secretary of Veterans Affairs should require the Under Secretary for Health to revise operating policies and procedures for treating veterans in specialty clinics in order to improve the timeliness of services, especially for those veterans needing specialty evaluation of new medical conditions. Specifically, the Under Secretary for Health should require all facilities to develop treatment-monitoring systems that ensure that all veterans subsequently referred to specialty clinics are transferred to general medicine or primary care clinics in a timely manner after their conditions are stabilized such that only general medical services are needed.

    Agency Affected: Department of Veterans Affairs

  3. Status: Closed - Implemented

    Comments: VA has issued a directive that calls for a review of existing specialty clinics and identifying patients who can be more appropriately treated in primary care clinics. The directive identifies examples of the types of services that could appropriately be managed in a primary care clinic.

    Recommendation: The Secretary of Veterans Affairs should require the Under Secretary for Health to revise operating policies and procedures for treating veterans in specialty clinics in order to improve the timeliness of services, especially for those veterans needing specialty evaluation of new medical conditions. Specifically, the Under Secretary for Health should require all facilities to review the medical needs of veterans currently being served in specialty clinics and transfer those veterans needing only general medical care to general medicine or primary care clinics for necessary service.

    Agency Affected: Department of Veterans Affairs

  4. Status: Closed - Implemented

    Comments: VA has issued a directive that sets goals for timeliness of medical care. The goals state that new patients will be scheduled for an appointment with a primary care provider within 30 days, and established patients will be scheduled for an appointment with a primary care provider within 7 days and with a specialist within 30 days. Patients will be seen within 30 minutes of scheduled appointments. VA assessed the timeliness goals in May 1995. Medical facilities were advised of the findings and have been instructed to improve timeliness where necessary. VA has also disseminated a number of strategies that have proven useful in reducing waiting times. Facilities that have difficulties in meeting the timeliness goals are encouraged to consider implementation of one or more of these strategies.

    Recommendation: The Secretary of Veterans Affairs should require the Under Secretary for Health to restructure the ambulatory care system to improve timeliness of customer service and facilitate veterans' access to services. Specifically, the Under Secretary for Health should establish performance goals for timely service delivery and gather systemwide data that will allow facilities' performance to be measured against the established goals. When performance does not meet or exceed goals, facilities should be required to evaluate the cause(s) and implement corrective actions to improve timeliness of service delivery.

    Agency Affected: Department of Veterans Affairs

  5. Status: Closed - Implemented

    Comments: In January 1995, VA published "Sharing Innovations Among VA Clinicians." This document is a collection of innovations in clinical practice, including reducing waiting times, from various VA medical centers. Innovations and their benefits are described along with a contact person from whom more detailed information can be obtained. VA plans to publish additional innovations in the future.

    Recommendation: The Secretary of Veterans Affairs should require the Under Secretary for Health to restructure the ambulatory care system to improve timeliness of customer service and facilitate veterans' access to services. Specifically, the Under Secretary for Health should survey VA facilities to identify innovative practices that are used to effectively reduce waiting times and incorporate the best practices into existing operating policies and procedures.

    Agency Affected: Department of Veterans Affairs

  6. Status: Closed - Implemented

    Comments: VA issued a directive that established a Telephone Liaison Care Program. The program requires that VA medical facilities allow veterans to schedule appointments at general medicine or primary care clinics. The directive establishes a policy that every VA medical facility will develop and institute, the goal of which will be to allow veterans to contact VA by telephone to discuss concerns such as eligibility for care and scheduling appointments. Each medical facility must have a mechanism for making patients aware of its Telephone Liaison Care Program, including the phone number, services available, and hours of operation. VA believes the program can improve access to care providers, reduce unnecessary clinic visits, and decrease waiting times.

    Recommendation: The Secretary of Veterans Affairs should require the Under Secretary for Health to restructure the ambulatory care system to improve timeliness of customer service and facilitate veterans' access to services. Specifically, the Under Secretary for Health should allow veterans to schedule appointments to receive care at general medicine or primary care clinics, to the maximum extent possible.

    Agency Affected: Department of Veterans Affairs

  7. Status: Closed - Implemented

    Comments: On March 18, 1994, VA issued VHA Directive 10-94-022. The stated VA policy in this directive is that every VA medical facility will develop and institute a Telephone Liaison Care Program, the goal of which would be to allow patients and families to contact the facility by telephone to discuss any concerns relevant to access of care (eligibility and scheduling), medical concerns (treatment and followup), and questions about medications.

    Recommendation: The Secretary of Veterans Affairs should require the Under Secretary for Health to restructure the ambulatory care system to improve timeliness of customer service and facilitate veterans' access to services. Specifically, the Under Secretary for Health should establish telephone assistance networks at each facility, so that veterans' access to medical care can be better facilitated.

    Agency Affected: Department of Veterans Affairs

  8. Status: Closed - Implemented

    Comments: VA has issued directives addressing customer service standards and reduction of excessive waiting times including those for specialty clinics. These directives require VA medical centers to meet, by 1998, national standards for timely health care delivery to veterans. Both VA central office and medical facilities are required to review actual experience against the standards and report annually the facilities' performance along with plans for improvements where necessary.

    Recommendation: The Secretary of Veterans Affairs should require the Under Secretary for Health to revise operating policies and procedures for treating veterans in specialty clinics in order to improve the timeliness of services, especially for those veterans needing specialty evaluation of new medical conditions. Specifically, the Under Secretary for Health should establish performance goals for timely service delivery and gather systemwide data that will allow facilities' performance to be measured against the established goals. When performance of specialty clinics does not meet the goals, facilities should be required to evaluate the cause(s) and implement corrective actions to improve timeliness of services.

    Agency Affected: Department of Veterans Affairs

 

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