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The Department of Veterans Affairs (VA) runs one of the nation's largest health care systems. In fiscal year 2000, roughly four million patients made 39 million outpatient visits to more than 700 VA health care facilities nationwide. However, excessive waiting times for outpatient care have been a long-standing problem. To ensure timely access to care, VA established a goal that all nonurgent primary and specialty care appointments be scheduled within 30 days of request and that clinics meet this goal by 1998. Yet, three years later, reports of long waiting times persist. Waiting times at the clinics in the 10 medical centers GAO visited indicate that meeting VA's 30-day standard is a continuing challenge for many clinics. Although most of the primary care clinics GAO visited (15 of 17) reported meeting VA's standard for nonurgent, outpatient appointments, only one-third of the specialty care clinics visited (18 of 54) met VA's 30-day standard. For the remaining two-thirds, waiting times ranged from 33 days at one urology clinic to 282 days at an optometry clinic. Although two-thirds of the specialty clinics GAO visited continued to have long waiting times, some were making progress in reducing waiting times, primarily by improving their scheduling processes and making better use of their staff. These successes were often the result of medical centers' and clinics' working with the Institute for Healthcare Improvement (IHI)--a private contractor VA retained in July 1999--to develop strategies to reduce patient waiting times. Medical centers and clinics participating in VA's IHI project have received valuable information and strategies for successfully reducing waiting times. However, VA has not provided guidance to its medical centers on how to implement IHI strategies, and VA has only recently contracted with IHI to disseminate best practices agency-wide. VA has not developed other national guidance to help clinics reduce waiting times. Although clinics that did not have guidelines could have benefited from headquarters' assistance, VA has not established a national set of referral guidelines. Moreover, VA lacks an analytic framework for its medical centers and clinics to use in determining the root causes of lengthy waits.

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Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Veterans Affairs 1. To help ensure that clinics meet VA's 30-day waiting times standard, the Secretary of Veterans Affairs should direct the Under Secretary for Health to create a national set of referral guidelines for medical centers to use when referring patients from primary care to specialty care as well as guidelines for specialty clinics to follow in returning patients to primary care when they no longer need specialty care.
Closed - Implemented
VA has developed a national set of referral guidelines and disseminated them to clinicians. VA discusses the use of these guidelines with clinicians during regularly scheduled conference calls, as well as with network directors during their performance reviews.
Department of Veterans Affairs 2. To help ensure that clinics meet VA's 30-day waiting times standard the Secretary of Veterans Affairs should direct the Under Secretary for Health to strengthen oversight by developing an agencywide process for determining the causes of waiting times problems; implementing corrective actions, where needed; and requiring periodic progress reports from clinics with long waiting times until they meet VA's national standards.
Closed - Implemented
VA officials have identified prescription drug procedures as a significant factor that contributes to waiting times for primary care appointments. VA plans to initiate a transitional pharmacy benefit on September 22, 2003, which is expected to decrease demand for primary care appointments, while meeting veterans' medical needs. VA will monitor the utilization, cost, and demand associated with this initiative. Also, network directors will continue to submit quarterly status reports on their network and individual facilities and discuss ways to remedy the backlog problem.

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