VA Health Care: Reliability of Reported Outpatient Medical Appointment Wait Times and Scheduling Oversight Need Improvement

GAO-13-130 Published: Dec 21, 2012. Publicly Released: Jan 18, 2013.
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What GAO Found

Outpatient medical appointment wait times reported by the Veterans Health Administration (VHA), within the Department of Veterans Affairs (VA), are unreliable. Wait times for outpatient medical appointments--referred to as medical appointments--are calculated as the number of days elapsed from the desired date, which is defined as the date on which the patient or health care provider wants the patient to be seen. The reliability of reported wait time performance measures is dependent on the consistency with which schedulers record the desired date in the scheduling system in accordance with VHA's scheduling policy. However, VHA's scheduling policy and training documents for recording desired date are unclear and do not ensure consistent use of the desired date. Some schedulers at Veterans Affairs medical centers (VAMC) that GAO visited did not record the desired date correctly. For example, three schedulers changed the desired date based on appointment availability; this would have resulted in a reported wait time that was shorter than the patient actually experienced. VHA officials acknowledged limitations of measuring wait times based on desired date, and described additional information used to monitor veterans' access to medical appointments, including patient satisfaction survey results. Without reliable measurement of how long patients are waiting for medical appointments, however, VHA is less equipped to identify areas that need improvement and mitigate problems that contribute to wait times.

While visiting VAMCs, GAO also found inconsistent implementation of VHA's scheduling policy that impedes VAMCs from scheduling timely medical appointments. For example, four clinics across three VAMCs did not use the electronic wait list to track new patients that needed medical appointments as required by VHA scheduling policy, putting these clinics at risk for losing track of these patients. Furthermore, VAMCs' oversight of compliance with VHA's scheduling policy, such as ensuring the completion of required scheduler training, was inconsistent across facilities. VAMCs also described other problems with scheduling timely medical appointments, including VHA's outdated and inefficient scheduling system, gaps in scheduler and provider staffing, and issues with telephone access. For example, officials at all VAMCs GAO visited reported that high call volumes and a lack of staff dedicated to answering the telephones impede scheduling of timely medical appointments. In January 2012, VHA distributed telephone access best practices that, if implemented, could help improve telephone access to clinical care.

VHA is implementing a number of initiatives to improve veterans' access to medical appointments such as expanded use of technology to interact with patients and provide care, which includes the use of secure messaging between patients and their health care providers. VHA also is piloting a new initiative to provide health care services through contracts with community providers that aims to reduce travel and wait times for veterans who are unable to receive certain types of care within VHA in a timely way.

Why GAO Did This Study

VHA provided nearly 80 million outpatient medical appointments to veterans in fiscal year 2011. While VHA has reported continued improvements in achieving access to timely medical appointments, patient complaints and media reports about long wait times persist.

GAO was asked to evaluate VHA’s scheduling of timely medical appointments. GAO examined (1) the extent to which VHA’s approach for measuring and monitoring medical appointment wait times reflects how long veterans are waiting for appointments; (2) the extent to which VAMCs are implementing VHA’s policies and processes for appointment scheduling, and any problems encountered in ensuring veterans’ access to timely medical appointments; and (3) VHA’s initiatives to improve veterans’ access to medical appointments. To conduct this work, GAO made site visits to 23 clinics at four VAMCs, the latter selected for variation in size, complexity, and location. GAO also reviewed VHA’s policies and data, and interviewed VHA officials.

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GAO recommends that VHA take actions to (1) improve the reliability of its medical appointment wait time measures, (2) ensure VAMCs consistently implement VHA's scheduling policy, (3) require VAMCs to allocate staffing resources based on scheduling needs, and (4) ensure that VAMCs provide oversight of telephone access and implement best practices to improve telephone access for clinical care. VA concurred with GAO's recommendations.

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Veterans Affairs
Priority Rec.
This is a priority recommendation.
To ensure reliable measurement of veterans' wait times for medical appointments, the Secretary of VA should direct the Under Secretary for Health to take actions to improve the reliability of wait time measures either by clarifying the scheduling policy to better define the desired date, or by identifying clearer wait time measures that are not subject to interpretation and prone to scheduler error.
VA agreed with our recommendation. VA has taken actions intended to address the reliability of appointment wait times through improvements in appointment scheduling, including issuing a revised scheduling policy, providing and documenting scheduler training, and improving oversight through scheduler audits. While the revised scheduling policy and subsequent guidance changed the terminology of wait-time measures, they did not substantively clarify or define the desired date. Therefore, we continue to believe that the desired date field is still subject to interpretation and prone to scheduler error, which poses concerns for the reliability of wait times measured using patients' desired dates. Furthermore, VA's first internal audit in February 2019 was unable to evaluate the accuracy and reliability of its wait-time data due to the lack of business rules for calculating them, indicating that additional efforts are needed to address this issue. Further, the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020 requires VA to establish a process and requirements for scheduling appointments, including the maximum number of days allowed to complete the scheduling process. GAO is to report no later than December 2022 on VA's compliance with its new processes and requirements for appointment scheduling that are mandated in the same law. According to VA officials, the department is in the process of implementing a new scheduling system (integral to its new electronic health record system), with a targeted national completion date of 2027 for implementation across all VA health care facilities. Given our continued concerns about VA's ability to ensure the reliability of the wait-time data, we have requested additional information from VA about how the new scheduling system will address GAO's concerns about wait time reliability and whether the new scheduling system will be adapted to accommodate the scheduling process and requirements VA established under the recent law.
Department of Veterans Affairs
Priority Rec.
This is a priority recommendation.
To better facilitate timely medical appointment scheduling and improve the efficiency and oversight of the scheduling process,the Secretary of VA should direct the Under Secretary for Health to take actions to ensure that VAMCs consistently and accurately implement VHA's scheduling policy, including use of the electronic wait list, as well as ensuring that all staff with access to the VistA scheduling system complete the required training.
Closed – Implemented
VA concurred with our recommendations to revise its scheduling policy to implement more reliable wait time measures and required all schedulers to complete standardized training on a revised scheduling policy. In July 2016, VA published VHA Directive 1230-Outpatient Scheduling Processes and Procedures, which updated and replaced the prior policy. Although the updated directive provides new instructions for scheduling appointments, the new instructions, which form the basis for measuring wait times, are still subject to scheduler interpretation, making training vital to consistent and accurate implementation of the policy. According to VHA, Directive 1230 was developed to correspond with a technical enhancement to the scheduling system, known as the Vista Scheduling Enhancement (VSE), which also required training. From 2017 through 2019, VA developed training methods and programs and implemented training on the revised scheduling policy and VSE for all schedulers. VA reported that, as of July 2019, 97 percent of all staff who scheduled an appointment within the previous 30 days completed the required scheduler training for new staff or the refresher training for current staff. Also as of July 2019, VA completed its effort to reconcile national training completion records with local facility documentation.VA identified several facilities that have not completed scheduler training and/or reconciled training documentation. VA stated that these remaining sites will be monitored monthly by their facility compliance committee through the Office of Compliance and Business Integrity. VA made available to all staff a reporting tool that continually refreshes training data, comparing training completion against staff who schedule appointments The Office of Compliance and Business Integrity will continue to monitor compliance with the training requirement through local medical center reporting on a monthly basis. As a result of these actions, we are closing this recommendation as implemented.
Department of Veterans Affairs To improve timely medical appointment scheduling, the Secretary of VA should direct the Under Secretary for Health to develop a policy that requires VAMCs to routinely assess clinics' scheduling needs and resources to ensure that the allocation of staffing resources is responsive to the demand for scheduling medical appointments.
Closed – Implemented
VA concurred with this recommendation and noted that it would ask VA facilities to routinely assess clinics' availability and ensure staff are distributed to meet access standards for clinics, as well as revising and implementing improved clinic management tools. In February 2015, VA noted that it had finalized a Scheduling Resource Assessment report to address this recommendation. In December 2016, VA noted that the Scheduling Resource Assessment tool had been further enhanced and clarified that the training for this tool is not mandatory and use of the tool is optional. As of July 2019, VA amended VHA Directive 1230-Outpatient Scheduling Process and Procedures to require VA medical center directors to assess clinics' scheduling needs and allocation of resources no less than yearly and recommended monthly monitoring. The amended directive also included a link to the Scheduling Resource Assessment tool. As a result of these actions, we are closing this recommendation as implemented.
Department of Veterans Affairs To improve timely medical appointments and to address patient and staff complaints about telephone access,the Secretary of VA should direct the Under Secretary for Health to ensure that all VAMCs provide oversight of telephone access and implement best practices outlined in its telephone systems improvement guide.
VA concurred with this recommendation. In December 2019, VA hosted a two-day meeting to support the development of the major sections of the replacement telephone policy. The meeting included participation from critical stakeholders, such as the clinical service line offices and the Office of Veterans Access to Care. Following the meeting, a VA team drafted a policy for clinical contact center communications. In May 2020, VA held a meeting of key stakeholders and subject matter experts to develop a plan to modernize, standardize and centralize clinical contact center operations using updated software and technology platforms. According to VA, the clinical contact center policy was updated and submitted for internal review. VA anticipates that the policy will be published and disseminated in October 2021. To close this recommendation, VA should provide GAO with a copy of the finalized policy and documentation of its dissemination across VHA.

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