This is the accessible text file for GAO report number GAO-04-949 entitled 'VA Health Care: VA Needs to Improve Accuracy of Reported Wait Times for Blind Rehabilitation Services' which was released on July 22, 2004. This text file was formatted by the U.S. General Accounting Office (GAO) to be accessible to users with visual impairments, as part of a longer term project to improve GAO products' accessibility. Every attempt has been made to maintain the structural and data integrity of the original printed product. Accessibility features, such as text descriptions of tables, consecutively numbered footnotes placed at the end of the file, and the text of agency comment letters, are provided but may not exactly duplicate the presentation or format of the printed version. The portable document format (PDF) file is an exact electronic replica of the printed version. We welcome your feedback. Please E-mail your comments regarding the contents or accessibility features of this document to Webmaster@gao.gov. This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. Because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Report to Congressional Requesters: United States Government Accountability Office: GAO: July 2004: VA Health Care: VA Needs to Improve Accuracy of Reported Wait Times for Blind Rehabilitation Services: GAO-04-949: GAO Highlights: Highlights of GAO-04-949, a report to congressional requesters. Why GAO Did This Study: The Department of Veterans Affairs (VA) provides rehabilitation services to legally blind veterans. These services are intended to help them acquire the skills necessary to become more independent. Almost all of VA’s rehabilitation services for legally blind veterans are provided at Blind Rehabilitation Centers (BRC), an inpatient program. VA reported that the average length of time a veteran waited to be admitted to a BRC increased from 168 to 210 days from fiscal years 1999 through 2003. GAO was asked to examine the accuracy of veterans’ wait times for admission to BRCs. GAO’s objective was to determine whether the average wait times for veterans seeking admission to BRCs reported by VA were accurate. GAO reviewed VA policies and procedures for determining the average length of time veterans wait to be admitted to a BRC. GAO also visited 5 of VA’s 10 BRCs to evaluate the reliability of the data used to calculate wait times. What GAO Found: GAO found that the average length of time VA reported that veterans wait for admission to BRCs was inaccurate. Some data used to calculate wait times were incomplete or incorrect. For example, at one BRC GAO found that one or more of the data elements used to calculate the wait times—the date the BRC received the application, the earliest admission date offered to the veteran, and the date the veteran was admitted to the BRC—were missing from 31 percent of the records and incorrect in 13 percent of the records. GAO also found missing or inaccurate data at two other BRCs. In addition, GAO found that BRCs used different procedures for their calculations, which also contributed to the inaccurate average wait times. For example, two BRCs correctly ended the wait times calculations on the earliest admission date offered to the veteran, while the other three BRCs ended the wait times calculations on the date the veteran was admitted to the BRC. To enable VA to accurately assess wait times, it is essential for VA to develop more comprehensive instructions to calculate average wait times and for BRCs to adhere to them. What GAO Recommends: GAO recommends that the Secretary of Veterans Affairs direct the Under Secretary for Health to instruct (1) the program office to develop more specific instructions for calculating wait times and (2) the BRCs to adhere to these instructions by developing procedures to compile complete and accurate information. VA concurred with GAO’s recommendations. www.gao.gov/cgi-bin/getrpt?GAO-04-949. To view the full product, including the scope and methodology, click on the link above. For more information, contact Cynthia A. Bascetta at (202) 512-7101. Contents: Letter: Results in Brief: Background: VA's Reported Wait Times for Accessing BRCs Were Inaccurate: Conclusions: Recommendations for Executive Action: Agency Comments: Appendix I: Scope and Methodology: Appendix II: Comments from the Department of Veterans Affairs: Table: Table 1: Location of VA's Blind Rehabilitation Centers and the Number of Authorized Beds: Abbreviations: BRC: Blind Rehabilitation Center VADepartment of Veterans Affairs VIST: Visual Impairment Service Team: United States Government Accountability Office: Washington, DC 20548: July 22, 2004: The Honorable Bob Graham: Ranking Minority Member: Committee on Veterans' Affairs: United States Senate: The Honorable Rob Simmons: Chairman: Subcommittee on Health: Committee on Veterans' Affairs: House of Representatives: The Department of Veterans Affairs (VA) provides rehabilitation training services for legally blind[Footnote 1] veterans that are intended to enable them to acquire the skills necessary to develop personal independence, such as using magnification devices for reading. Almost all of VA's rehabilitation services for legally blind veterans are provided at Blind Rehabilitation Centers (BRC), a residential inpatient program. VA reported that the average length of time a veteran waited to be admitted to a BRC increased from 168 to 210 days from fiscal years 1999 through 2003. In 2003, VA reported that approximately 2,100 legally blind veterans received care in BRCs, with average wait times ranging from 77 to 343 days. Congress has been concerned for more than 10 years about the length of time veterans wait to receive training at BRCs. In 1993 and again in 1995, Congress noted that veterans were unable to access services at BRCs in a timely manner and encouraged VA to provide more services. You expressed concern about the accuracy of the length of time VA reports that veterans wait for admission to BRCs. Our objective was to determine whether the average wait times for veterans seeking admission to BRCs reported by VA were accurate. To assess the accuracy of VA's reported wait times, we visited 5 of VA's 10 BRCs that we selected based on differences in geographical location and the number of beds available at the BRC. We met with BRC officials and other VA employees who manage the health care provided to legally blind veterans. We reviewed the procedures they followed to calculate veterans' wait times and analyzed documents[Footnote 2] to evaluate the reliability of the data used to calculate wait times at 3 of the BRCs. We were unable to assess the data at the other 2 BRCs because application packages were not available. After veterans were discharged, 1 BRC required that the application packages be destroyed and the other BRC returned the packages to the medical facility that referred the veteran. We also met with officials from VA's Blind Rehabilitation Service Program Office (program office), which has responsibility for blindness-related services, to review its policies and procedures regarding wait times calculations. Our review was conducted from September 2003 through July 2004 in accordance with generally accepted government auditing standards. (See app. I for additional information on our scope and methodology.) Results in Brief: The average length of time VA reported that veterans wait for admission to BRCs was inaccurate. Some data used to calculate wait times--the date the BRC received the application, the earliest admission date offered to the veteran, and the date of admission--were incomplete or incorrect. In addition, we found that BRCs used different procedures for their calculations, which also contributed to the inaccurate average wait times. We are making two recommendations to improve the accuracy of VA's reported BRC wait times. VA agreed with our findings and recommendations and indicated that it will provide a detailed action plan. Background: In 2003, VA estimated that about 157,000 veterans were legally blind, about 44,000 of them were enrolled in its health care system, and about 2,100 received rehabilitation training in BRCs. The blind rehabilitation program is designed to improve the quality of life for veterans who are legally blind. VA's Visual Impairment Service Team (VIST) coordinators are responsible for managing legally blind veterans' access to rehabilitation services, including reaching a decision with the veteran about appropriate training and other services. VIST coordinators prepare the veteran's application to a BRC and ensure that the veteran has the medical examinations required for admission, such as hearing examinations and low vision testing. VA's 10 BRCs provide training to legally blind veterans on an inpatient residential basis. Table 1 lists the location of the BRCs and the number of beds authorized for blind rehabilitation services. Table 1: Location of VA's Blind Rehabilitation Centers and the Number of Authorized Beds: Location: American Lake, Washington[B]; Authorized beds[A]: 15. Location: Augusta, Georgia[B]; Authorized beds[A]: 15. Location: Birmingham, Alabama; Authorized beds[A]: 32. Location: Hines, Illinois[B]; Authorized beds[A]: 34. Location: Palo Alto, California; Authorized beds[A]: 32. Location: San Juan, Puerto Rico; Authorized beds[A]: 12. Location: Tucson, Arizona[B]; Authorized beds[A]: 34. Location: Waco, Texas; Authorized beds[A]: 15. Location: West Haven, Connecticut; Authorized beds[A]: 34. Location: West Palm Beach, Florida[B]; Authorized beds[A]: 18. Location: Total; Authorized beds[A]: 241. Source: VA. [A] As of May 2004. [B] BRCs evaluated by GAO. [End of table] The training BRCs offer is comprehensive and individualized with the goal of helping legally blind veterans meet their personal goals and achieve a realistic level of independence. They offer a basic rehabilitation program and computer training. The basic program trains veterans in such areas as orientation and mobility (e.g., moving around the home or using a cane to travel through different environments) or visual skills (e.g., using closed circuit television or magnification devices to read or write checks). Computer training teaches veterans how to operate a computer; search the Internet; and send, receive, and read e-mail messages. Each month, BRCs are required to submit a report to the program office that includes their calculation of the average number of days veterans waited to be admitted to a BRC for training during the past 6 months. VA defines an applicant's wait time as the number of days that elapse from the date the BRC receives the application to the earliest admission date offered to the veteran. VA's Reported Wait Times for Accessing BRCs Were Inaccurate: Wait times reported by the program office were not accurate for two reasons. First, we found that some data VA used to calculate wait times were missing and some that it used were incorrect. Second, VA did not use consistent procedures to calculate wait times. Data Used to Report Wait Times Were Missing or Inaccurate: We determined that data elements BRCs used for calculating wait times for both basic and computer training--the date the BRC received the application, the earliest admission date offered to the veteran, and the date the veteran was admitted to the BRC--were missing or inaccurate. For example, during our review of data at one BRC, we found that one or more of the data elements used to calculate the wait times were missing from 31 percent of the records and incorrect in 13 percent of the records. We also noted missing or incorrect data elements during our review of records at two other BRCs. Specifically, at one BRC we reviewed 30 records and found missing or inaccurate data in 24 of them. At the other BRC, we found inaccurate data in 8 of 16 records. At the remaining two BRCs, we could not validate the completeness or accuracy of records used to calculate wait times because application packages were not available. After veterans completed their training, one BRC required that the application packages be destroyed and the other BRC returned the packages to the medical facility that referred the veteran. In addition, we found weaknesses in the way the BRCs ensured complete and accurate data. For example, none of the BRCs stated they validated data entry. Also, none of them checked their databases for completeness (Is the data element filled in or has it been left blank?) and reasonableness (Is the date the BRC received the application earlier than the first admission date offered to the veteran?). Further, one of them did not check for format accuracy (If the data element is a date, is it formatted as a date, such as 5/24/2004?). Procedures Used to Calculate Wait Times Were Inconsistent: We found that the five BRCs we visited followed different procedures for determining the average time a veteran must wait for admission to a BRC. According to VA instructions, the BRC is to average the number of days that elapsed from the date the application was received to the earliest admission date offered to the veteran for veterans admitted during the past 6 months. However, the instructions do not stipulate whether the application package must be complete before putting the veteran on the wait list or the length of time BRCs allow VIST coordinators to submit the missing information. This lack of specificity resulted in BRCs using different procedures to calculate their wait times. Although all five BRCs began their calculations when they received the veteran's application--even if it was not complete--they allowed VIST coordinators different lengths of time to provide the missing information. According to the BRC officials at these locations, the BRCs accepted incomplete packages as long as the basic information needed to process the application was present, including documents to prove eligibility, a recent physical examination, and an eye examination proving legal blindness. For example, one BRC official stated that the results of hearing examinations were not essential to approve applications but were needed before veterans were admitted for training. VIST coordinators who submitted incomplete applications could get their veterans on the wait list earlier than VIST coordinators who waited to submit complete applications. BRCs allowed different lengths of time for VIST coordinators to provide missing information before removing veterans from the wait list. For example, one BRC removed veterans with incomplete applications from the wait list after 30 days, while another waited at least 6 months. Not all BRCs used the same procedures to stop the wait times calculation. The program office instructs BRCs to stop the wait times calculation on the earliest admission date offered to the veteran. Two BRCs correctly ended the wait times calculation on that date, while the other three ended the wait times on the date the veteran was actually admitted, even if the veteran had refused earlier admission dates. For example, one veteran was offered an admission date of October 27th. The veteran declined that date and two subsequently offered dates and was finally admitted on June 7th of the following year. Because the veteran's first offer date was October 27th, according to the program office instructions the wait times should have stopped on that date. Instead, the BRC included the additional time between October 27th and June 7th in its wait times calculation. In this example, the BRC calculation overstated the veteran's wait times by over 7 months. Conclusions: While VA reports BRC wait times for veterans, the information does not accurately reflect the time veterans wait for admission. Data used for calculations are often incomplete or inaccurate. In addition, BRCs followed different procedures for calculating wait times because VA's instructions do not specify whether application packages must be complete before putting the veteran on the wait list or the length of time BRCs allow VIST coordinators to submit the missing information. For VA to accurately assess wait times, it is essential for VA to develop a consistent process for determining average wait times and for BRCs to adhere to it. Recommendations for Executive Action: To improve VA's ability to effectively manage care for legally blind veterans, we recommend that the Secretary of Veterans Affairs direct the Under Secretary for Health to instruct (1) the program office to develop more specific instructions for calculating wait times and (2) the BRCs to adhere to these instructions by developing procedures to compile complete and accurate information on the length of time veterans wait for admission to BRCs. Agency Comments: In commenting on the draft of this report, VA agreed with our findings and conclusions. VA stated that the report accurately conveyed the variability and complexity of reporting wait times for admission to BRCs. VA concurred with our recommendations and indicated that it will provide a detailed action plan. VA's written comments are reprinted in appendix II. We are sending copies of this report to the Secretary of Veterans Affairs and other interested parties. We also will make copies available to others upon request. In addition, the report will be available at no charge at the GAO Web site at http://www.gao.gov. If you or your staff have any questions about this report, please call me at (202) 512-7101 or Michael T. Blair, Jr. at (404) 679-1944. Cherie Starck, Cynthia Forbes, and Janet Overton were key contributors to this report. Sincerely, Signed by: Cynthia A. Bascetta Director, Health Care--Veterans' Health and Benefits Issues: [End of section] Appendix I: Scope and Methodology: To determine whether VA accurately reports average wait times for veterans seeking admission to Blind Rehabilitation Centers (BRC), we examined the policies and procedures VA used to calculate the length of time veterans wait for admission. We met with and obtained documentation from officials at the Blind Rehabilitation Service Program Office and from the five BRCs we visited. We selected the five BRCs located in Tucson, Arizona; West Palm Beach, Florida; Augusta, Georgia; Hines, Illinois; and American Lake, Washington, based on differences in geographical location and the number of beds available at the BRC. We met with BRC officials and veterans' case managers. We reviewed documentation on the procedures BRC staff followed to calculate veterans' wait times to assess the quality of the data the five BRCs maintained. We also reviewed veterans' paper application packages for BRC admission, printouts from the BRC's electronic database used to manage the wait list, and veteran's computerized medical records. At the first BRC we visited, we compared the date the application was received at the BRC in the electronic and paper files for a judgmentally selected sample of 16 applicants. We identified data elements that were inaccurate in either the paper or electronic records in 8 of the 16 records. At the second BRC, we chose a random sample of 100 veterans, stratified by fiscal year, from the 578 that were admitted in fiscal years 2000 through 2003. A BRC official then provided printed copies of the data from the electronic file used to calculate the wait times and the folders containing the paper application packages. We reviewed the selected files to compare the data elements used for calculating wait times--the date the BRC received the application, the earliest admission date offered to the veteran, and the date the veteran was admitted to the BRC--from the two sources. We determined that one or more of these data elements were missing from 31 percent of the records with a margin of error of plus or minus 8 percent. Additionally, we found that one or more of these data elements were inaccurate in 13 percent of the records with a margin of error of plus or minus 6 percent.[Footnote 3] For the remaining three BRCs, we attempted to verify that the problems we found at the first two BRCs were also found at the other facilities. At the third BRC we randomly sampled 10 admissions each from fiscal years 2001 through 2003.[Footnote 4] A BRC official provided printed copies of the data from the electronic file used to calculate the wait times and the folders containing the paper application packages. We reviewed the two sources to compare the data elements used for calculating wait times. To determine if similar data problems also existed at this BRC, we compared the percentage of inaccurate or missing data elements to a tolerable level of 10 percent--that is, not less than 10 percent of the records at this BRC had one or more inaccurate or missing data elements. We found that 24 of the 30 records had inaccurate or missing data elements. We confirmed that the percent of inaccurate and incomplete data elements was not less than 10 percent by performing a one-sided significance test at the 95-percent confidence level. We were unable to assess the data at the other two BRCs because application packages were not available. After veterans completed their training, one BRC required that the application packages be destroyed and the other BRC returned the packages to the medical facility that referred the veteran. Our results from these five BRCs cannot be generalized to other facilities. Appendix II: Comments from the Department of Veterans Affairs: THE SECRETARY OF VETERANS AFFAIRS WASHINGTON July 9, 2004: Ms. Cynthia A. Bascetta Director: Health Care Team: U. S. General Accounting Office 441 G Street, NW Washington, DC 20548: Dear Ms. Bascetta: The Department of Veterans Affairs (VA) has reviewed the General Accounting Office's (GAO) draft report, VA HEALTH CARE: VA Needs to Improve Accuracy of Reported Wait Times for Blind Rehabilitation Services (GAO-04-949) and agrees with your conclusions. The report accurately conveys the variability and complexity of reporting wait times for admission to the Veterans Health Administration's (VHA) Blind Rehabilitation Centers based on data from 3 of its 10 centers. GAO addresses the need for a systems approach to data management leading to less variability and more consistency in reporting wait times. Compliance from all the Blind Rehabilitation Centers is an important component to the systems change and will provide consistency in VA's data collection and reporting. VA concurs with GAO's recommendations. The Blind Rehabilitation Program Office recognized the need for consistency and standardization and is developing an electronic system for reporting wait times. Implementation is part of the Information Technology (IT) update of the Blind Rehabilitation IT package Version 5.0. VA anticipates completing implementation in the fourth quarter of Fiscal Year 2005. The program office, in conjunction with the Office of the Deputy Under Secretary for Health for Operations and Management, will develop compliance reporting requirements for Blind Rehabilitation Centers. VA believes this will ensure accountability for accurate data calculation through medical center and network directors. In the interim, VHA will clarify the current policy so that the BRCS will report wait times data more accurately and consistently. The Department will provide a detailed action plan in its response to GAO's final report. VA appreciates the opportunity to comment on your draft report. Sincerely yours, Signed by: Anthony J. Principi: [End of section] FOOTNOTES [1] VA defines legal blindness as when the patient's best-corrected central visual acuity with ordinary eyeglasses or contacts is 20/200 or less in the better eye (as measured by the Snellen Visual Acuity Chart) or when the field of useful vision is 20 degrees or less in the better eye. People who are legally blind can only at best read the big "E" on the eye chart or see as if they are looking through a paper towel tube, according to VA. [2] These documents included veterans' applications for BRC admission, printouts from the BRC's electronic database used to manage the wait list, and veterans' computerized medical records. [3] The categories of records with missing data elements and those with inaccurate data elements are not mutually exclusive. [4] We had planned to sample from fiscal years 2000 through 2003 but records from fiscal year 2000 had been destroyed. GAO's Mission: The General Accounting Office, the audit, evaluation and investigative arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. GAO examines the use of public funds; evaluates federal programs and policies; and provides analyses, recommendations, and other assistance to help Congress make informed oversight, policy, and funding decisions. GAO's commitment to good government is reflected in its core values of accountability, integrity, and reliability. Obtaining Copies of GAO Reports and Testimony: The fastest and easiest way to obtain copies of GAO documents at no cost is through the Internet. 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