In response to the task force  recommendations, in May 2013, VHA launched the Consult Management  Business Rules Initiative to standardize aspects of the consult process,  with the goal of developing consistent and reliable information on consults  across all VAMCs. This initiative required VAMCs to complete four  specific tasks between July 1, 2013, and May 1, 2014:
Review and properly assign codes to consistently record consult  requests in the consult system;
Assign distinct identifiers in the electronic consult system to  differentiate between clinical and administrative consults;
Develop and implement strategies for requesting and managing  requests for consults that are not needed within 90 days—known as  “future care” consults; and
Conduct a clinical review as warranted, and as appropriate, close all  unresolved consults—those open more than 90 days. At the time of our December 2012 review, VHA measured outpatient  medical appointment wait times as the number of days elapsed from the  patient’s or provider’s desired date, as recorded in the VistA scheduling  system by VAMCs’ schedulers. GAO’s Ongoing Work Indicates That Veterans Did Not Always Receive Outpatient Specialty Care in Accordance with VHA Timeliness Standards, and in Some Cases, Did Not Receive Care at All

Our ongoing work has identified examples of delays in veterans receiving  requested outpatient specialty care at the five VAMCs we reviewed. We  found consults that were not processed in accordance with VHA  timeliness guidelines—for example, consults were not reviewed within   7 days, or completed within 90 days. Of the 150 consults we  reviewed, the consult records indicated that VAMCs did not meet the   7-day requirement for 31 consults (21 percent). We found  that veterans received care for 86 of the 150 consults we reviewed   (57 percent), but in only 28 of the consults (19 percent) veterans received  care within 90 days of the date the consult was requested. For the  remaining 64 consults (43 percent), the patients did not receive the  requested care. For 4 of the 10 physical therapy consults we reviewed for one VAMC,  we found that 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, patient no-shows,  and cancelled appointments, among the factors that hinder their ability to  meet VHA’s guideline for completing consults within 90 days. Officials at these facilities indicated that they try  to mitigate backlogs by referring veterans to non-VA providers for care. December 2013 – VAMC approved non-VA care and referred the  patient to a local hospital for surgery. Limitations in VHA’s Implementation of the Consult Business Rules Impedes Its Ability to Assess Delays in Care

Our ongoing work has identified variation in how the five VAMCs in our  review have implemented key aspects of VHA’s business rules, which  limits the usefulness of the data in monitoring and overseeing consults  system-wide. As previously noted, VHA’s business rules were designed  to standardize aspects of the consult process, thus creating consistency  in VAMCs’ management of consults. For example, VAMCs have developed different strategies for  managing future care consults—requests for specialty care appointments  that are not clinically needed for more than 90 days. Based on our  discussions with VHA officials, it is not clear the extent to which they are  aware of the various strategies that VAMCs are using to comply with this  task. Overall, our ongoing work indicates that oversight of the implementation  of VHA’s consult business rules has been limited and has not included  independent verification of VAMC actions. Reliability of Reported Outpatient Medical Appointment Wait Times and Scheduling Oversight Need Improvement, and VA Has Initiated Actions to Address Related GAO Recommendations

In December 2012, we reported that VHA’s reported outpatient medical  appointment wait times were unreliable and that inconsistent  implementation of VHA’s scheduling policy may have resulted in  increased wait times or delays in scheduling timely outpatient medical  appointments. Finally, we recommended that the Secretary of VA direct the Under  Secretary for Health to take actions to ensure that VAMCs provide  oversight of telephone access, and implement best practices to  improve telephone access for clinical care. Although VA has initiated actions to address our recommendations, we  believe that continued work is needed to ensure these actions are fully  implemented in a timely fashion. Ultimately, VHA’s ability to ensure and accurately  monitor access to timely medical appointments is critical to ensuring  quality health care to veterans, who may have medical conditions that  worsen if access is delayed.
Why GAO Did This Study

Access to timely medical appointments is critical to ensuring that veterans obtain needed medical care. Over the past few years, there have been numerous reports of VAMCs failing to provide timely care to veterans, and in some cases, these delays have reportedly resulted in harm to patients. As the number of these reports has grown, investigations have been launched by VA's Office of Inspector General and VA to examine VAMCs' medical appointment scheduling and other practices.
In December 2012, GAO reported that improvements were needed in the reliability of VHA's reported medical appointment wait times, as well as oversight of the scheduling process. In May 2013, VHA launched the Consult Management Business Rules Initiative to standardize aspects of the consults process and develop system-wide consult data for monitoring.
This testimony is based on GAO's ongoing work to update information previously provided to the Committee on April 9, 2014, including information on VHA's (1) process for managing consults; (2) oversight of consults; and (3) progress made implementing GAO's December 2012 recommendations. To conduct this work, GAO has reviewed documents and interviewed VHA officials. Additionally, GAO has interviewed officials from five VAMCs for the consults work and four VAMCs for the scheduling work that varied based on size, complexity, and location. GAO shared the information it used to prepare this statement with VA and incorporated its comments as appropriate.

What GAO Found

GAO's ongoing work examining the Department of Veterans Affairs' (VA) Veterans Health Administration's (VHA) process for managing outpatient specialty care consults has identified examples of delays in veterans receiving outpatient specialty care. GAO has found consults—requests for evaluation or management of a patient for a specific clinical concern—that were not processed in accordance with VHA timeliness guidelines. For example, consults were not reviewed within 7 days, or completed within 90 days. For 31 of the 150 consults GAO reviewed (21 percent), the consult records indicated that VA medical centers (VAMC) did not meet the 7-day review requirement. In addition, GAO found that veterans received care for 86 of the 150 consults (57 percent), but in only 28 of the consults (19 percent) was the care provided within 90 days. For the remaining 64 consults (43 percent), the patients did not receive the requested care. For 4 of the 10 physical therapy consults GAO reviewed for one VAMC, between 108 and 152 days elapsed with no apparent actions taken to schedule an appointment for the veteran. For 1 of these consults, several months passed before the veteran was referred for care to a non-VA health care facility. 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 guideline of completing consults within 90 days of being requested. VA officials indicated that they may refer veterans to non-VA providers to help mitigate delays in care.
GAO's ongoing work also has identified limitations in VHA's implementation and oversight of its new consult business rules designed to standardize aspects of the clinical consult process. Specifically, GAO has identified variation in how the five VAMCs reviewed have implemented key aspects of the business rules, such as strategies for managing future care consults—requests for specialty care appointments that are not clinically needed for more than 90 days. However, it is not clear the extent to which VHA is aware of the various strategies that VAMCs are using to comply with this task. Furthermore, oversight of the implementation of the business rules has been limited and does not include independent verification of VAMC actions. Because this work is ongoing, GAO is not making recommendations on VHA's consult process at this time.
In December 2012, GAO reported that VHA's outpatient medical appointment wait times were unreliable and recommended that VA take actions to: (1) improve the reliability of its outpatient medical appointment wait time measures; (2) ensure VAMCs consistently implement VHA's scheduling policy, including the staff training requirements; (3) require VAMCs to routinely assess scheduling needs and allocate staffing resources accordingly; and (4) ensure that VAMCs provide oversight of telephone access, and implement best practices. As of June 2014, VA has reported ongoing actions to address these recommendations, but GAO found that continued work is needed to ensure these actions are fully implemented in a timely fashion. Ultimately, VHA's ability to ensure and accurately monitor access to timely medical appointments is critical to ensuring quality health care is provided to veterans, who may have medical conditions that worsen if care is delayed.