If the  specialty care provider accepts the consult—determines the consult is  needed and is appropriate—an appointment is made for the patient to  receive the consultation or procedure. In response to 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. Officials at VHA’s central office, VISNs, and VAMCs all have oversight  responsibilities for the implementation of VHA’s scheduling policy. GAO’s Preliminary Work Identified Examples of Delays in Specialty Care, and Limitations in VHA’s Implementation of Its Business Rules Impede Its Ability to Assess Delays

As we reported in our April 9, 2014, testimony statement, our preliminary  work identified examples of delays in veterans receiving requested   VAMC officials  outpatient specialty care at the five VAMCs we reviewed.cited increased demand for services, and patient no-shows and cancelled  appointments, among the factors that hinder their ability to meet VHA’s  guideline for completing consults within 90 days. 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. In 1 of these cases, several months passed before the  veteran was referred to non-VA care, and he was seen 252 days after  the initial consult request. As we also reported, our preliminary work identified variation in how the  five VAMCs we reviewed have implemented key aspects of VHA’s  business rules, which limits the usefulness of the data in monitoring and  overseeing consults systemwide. 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. In addition, oversight of the implementation of VHA’s business rules has  been limited and has not included independent verification of VAMC  actions. If the patient fails to do  so within this time frame, the specialty care provider may discontinue the  consult. 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. Since, at the time of our review, VHA  measured medical appointment wait times as the number of days elapsed  from the desired date, the reliability of reported wait time performance  was dependent on the consistency with which VAMC schedulers  recorded the desired date in the VistA scheduling system. However,  VHA’s scheduling policy and training documents were unclear and did not  ensure consistent use of the desired date. For example, we found the electronic wait  list was not always used to track new patients that needed medical  appointments as required by VHA scheduling policy, putting these  patients at risk for delays in care. VA concurred with the four recommendations included in our December  2012 report and reported continuing actions to address them. First, we recommended that the Secretary of VA direct the Under  Secretary for Health to take actions to improve the reliability of its  outpatient medical appointment wait time measures. In response, VHA officials stated that the  department is in the process of revising the VHA scheduling policy to  include changes, such as the new methodology for measuring wait  times, and improvements and standardization of the use of the  electronic wait list. In April 2014,  VHA officials stated that they expected to receive the first report in  approximately 2 months. 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 patients, including specialty care, and in some cases, these delays have resulted in harm to patients.
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 appointment scheduling process. Also in 2012, VHA found that systemwide consult data could not be adequately used to determine the extent to which veterans experienced delays in receiving outpatient specialty care. In May 2013, VHA launched the Consult Management Business Rules Initiative with the aim of standardizing aspects of the consults process.
This statement highlights (1) preliminary observations GAO made in an April 9, 2014, testimony statement regarding VHA's management of outpatient specialty care consults, and (2) concerns GAO raised in its December 2012 report regarding VHA's outpatient medical appointment scheduling, and progress made implementing GAO's recommendations. To conduct this work, GAO reviewed documents and interviewed officials from VHA's central office. Additionally, GAO interviewed officials from five VAMCs for the consults work and four VAMCs for the scheduling work that varied based on size, complexity, and location.

What GAO Found

As GAO previously reported in its testimony on April 9, 2014, its preliminary work examining the Department of Veterans Affairs' (VA), Veterans Health Administration's (VHA) management of outpatient specialty care consults identified examples of delays in veterans receiving outpatient specialty care, as well as limitations in the implementation of new consult business rules designed to standardize aspects of the clinical consult process. 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. 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. GAO's preliminary work also identified variation in how the five VAMCs reviewed have implemented key aspects of VHA's 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. Such variation may limit the usefulness of VHA's data in monitoring and overseeing consults systemwide. Furthermore, oversight of the implementation of the business rules has been limited and has not included independent verification of VAMC actions. Because of the preliminary nature of this work, GAO is not making recommendations on VHA's consult process at this time.
In its December 2012 report, GAO found that VHA's outpatient medical appointment wait times were unreliable. The reliability of reported wait time performance measures was dependent in part on the consistency with which schedulers recorded desired date—defined as the date on which the patient or health care provider wants the patient to be seen—in the scheduling system. However, VHA's scheduling policy and training documents were unclear and did not ensure consistent use of the desired date. GAO also found that inconsistent implementation of VHA's scheduling policy may have resulted in increased wait times or delays in scheduling timely medical appointments. For example, GAO identified clinics that did not use the electronic wait list to track new patients in need of medical appointments as required by VHA policy, putting these patients at risk for not receiving timely care. VA concurred with the four recommendations included in the report and, in April 2014, reported continued actions to address them. For example, in response to GAO's recommendation for VA to take actions to improve the reliability of its medical appointment wait time measures, officials stated the department has implemented new patient wait time measures that no longer rely on desired date recorded by a scheduler. VHA officials stated that the department also is continuing to address GAO's three additional recommendations. Although VA has initiated actions to address GAO's recommendations, 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.