2.) The policy also  requires VISN leadership to oversee the consult processes for VAMCs in  their networks, and requires each VAMC to manage individual consults  consistent with VHA’s timeliness guidelines. Conduct a clinical review, as warranted, to determine if care has been  provided or is still needed for unresolved consults—those open more  than 90 days. VHA’s Consult Process Has Not Ensured Veterans Always Receive Outpatient Specialty Care in a Timely Manner, or at All

Our review of a sample of consults at five VAMCs found that veterans did  not always receive outpatient specialty care in a timely manner, if at all. We also found consults for  which veterans did not receive the outpatient specialty care requested— 64 of the 150 consults in our sample (43 percent)—and those for which  the requested specialty care was provided, but the consults were not  properly closed in the consult system. We also found that for the 28 consults in our sample for which VAMCs  provided care to veterans within 90 days, an extended amount of time  elapsed before specialty care providers completed all but 1 of them in the  consult system. As a result, the consults remained open in the system,  making them appear as though the requested care was not provided  within 90 days. For 4 of the 10 physical therapy consults we examined for one VAMC,  we found that between 108 and 152 days elapsed, with no apparent  actions taken to schedule appointments for the veterans for whom  consults were requested. VAMC officials cited increased demand for services, patient no-shows,  and cancelled appointments, among the factors that hinder specialty care  providers’ ability to meet VHA’s guideline for completing consults within  90 days. VHA’s Limited Oversight of Consults Impedes Its Ability to Ensure VAMCs Provide Timely Access to Specialty Care

Since launching the consult business rules initiative in May 2013, VHA  officials reported overseeing the consult process system-wide primarily by  reviewing consult reports created from its national database to monitor  VAMCs’ progress in meeting VHA’s timeliness guidelines. VHA and VISNs do not routinely assess VAMCs’ management of  consults. For example, one VAMC found that its process for  managing consults requested from other VAMCs was not clear to  providers and needed to be improved to mitigate delays in processing  such consults. By primarily relying on  reviewing data and not routinely conducting an assessment of VAMCs’  management of consults, VHA and VISN officials may be limited in  identifying systemic issues affecting VAMCs’ ability to provide veterans  with timely access to care. VHA lacks documentation of how VAMCs addressed unresolved  consults. Given the thousands of consults that have been closed by  VAMCs, the lack of documentation and independent verification of how  VAMCs addressed these unresolved consults raises questions about the  reliability of VHA consult data and whether the data accurately reflects  whether patients received the care needed in a timely manner, if at all. Furthermore, VHA does not have a formal process by which VAMCs  could share best practices system-wide. We found that  VAMCs may not be benefiting from the challenges and solutions other  VAMCs discovered when implementing strategies for managing future  care consults. However, we found that VHA has not developed a detailed, system-wide  policy on how to address patient no-shows and cancelled appointments,  two frequently noted causes of delays in providing care. Limitations in VHA’s oversight of the consult process have affected the  reliability of VHA’s consult data and its usefulness for oversight. Further, VHA’s decentralized approach for handling patient no-shows and  cancelled appointments, as well as other issues, makes it difficult to  compare timeliness of providing outpatient specialty care system-wide. Recommendations for Executive Action

To improve VHA’s ability to effectively oversee the consult process, and  help ensure VAMCs are providing veterans with timely access to  outpatient specialty care, we recommend that the Secretary of Veterans  Affairs direct the Interim Under Secretary for Health to take the following  six actions:
Assess the extent to which specialty care providers across all VAMCs,  including residents who may be serving on a temporary basis, are  using the correct clinical progress notes to complete consults in a  timely manner, and, as warranted, develop and implement system- wide solutions such as technical enhancements, to ensure this is  done appropriately. In its  written comments, VA concurred with all six of the report’s  recommendations.
Why GAO Did This Study

There have been numerous reports of VAMCs failing to provide timely care to veterans, including specialty care. In some cases, delays have reportedly resulted in harm to patients. In 2012, VHA found that its consult data were not adequate to determine the extent to which veterans received timely outpatient specialty care. In May 2013, VHA launched an initiative to standardize aspects of the consult process at its 151 VAMCs and improve its ability to oversee consults.
GAO was asked to evaluate VHA's management of the consult process. This report evaluates (1) the extent to which VHA's consult process has ensured veterans' timely access to outpatient specialty care, and (2) how VHA oversees the consult process to ensure veterans are receiving outpatient specialty care in accordance with its timeliness guidelines. GAO reviewed documents and interviewed officials from VHA and from five VAMCs that varied based on size and location. GAO also reviewed a non-generalizeable sample of 150 consults requested across the five VAMCs.

What GAO Found

Based on its review of a non-generalizable sample of 150 consults requested from April 2013 through September 2013, GAO found that the Department of Veterans Affairs' (VA) Veterans Health Administration's (VHA) management of the consult process has not ensured that veterans always receive outpatient specialty care in a timely manner, if at all. Specifically, GAO found that for 122 of the 150 consults reviewed—requests for evaluation or management of a patient for a specific clinical concern—specialty care providers did not provide veterans with the requested care in accordance with VHA's 90-day timeliness guideline. For example, for 4 of the 10 physical therapy consults GAO reviewed for one VA medical center (VAMC), 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, and patient no-shows and cancelled appointments among the factors that lead to delays and hinder their ability to meet VHA's timeliness guideline. Further, for all but 1 of the 28 consults for which VAMCs provided care within 90 days, an extended amount of time elapsed before specialty care providers properly documented in the consult system that the care was provided. As a result, the consults remained open in the system, making them appear as though the requested care was not provided within 90 days.
VHA's limited oversight of consults impedes its ability to ensure VAMCs provide timely access to specialty care. VHA officials reported overseeing the consult process primarily by reviewing data on the timeliness of consults; however, GAO found limitations in VHA's oversight, including oversight of its initiative designed to standardize aspects of the consult process. Specifically:
VHA does not routinely assess how VAMCs are managing their local consult processes, and thus is limited in its ability to identify systemic underlying causes of delays.
As part of its consult initiative, VHA required VAMCs to review a backlog of thousands of unresolved consults—those open more than 90 days—and if warranted to close them. However, VHA did not require VAMCs to document their rationales for closing them. As a result, questions remain about whether VAMCs appropriately closed these consults and if VHA's consult data accurately reflect whether veterans received the care needed in a timely manner, if at all.
VHA does not have a formal process by which VAMCs can share best practices for managing consults. As a result, VAMCs may not be benefitting from the challenges and solutions other VAMCs have discovered regarding managing the consult process.
VHA lacks a detailed system-wide policy for how VAMCs should manage patient no-shows and cancelled appointments for outpatient specialty care, making it difficult to compare timeliness in providing this care system-wide.
Consequently, concerns remain about the reliability of VHA's consult data, as well as VHA's oversight of the consult process.

What GAO Recommends

GAO recommends that VHA take actions to improve its oversight of consults, including (1) routinely assess VAMCs' local consult processes, (2) require VAMCs to document rationales for closing unresolved consults, (3) develop a formal process for VAMCs to share consult management best practices, and (4) develop a policy for managing patient no-shows and cancelled appointments. VA concurred with all of GAO's recommendations and identified actions it is taking to implement them.