Reported Medical Appointment Wait Times Are Unreliable; VHA Uses Additional Methods to Monitor Patients’ Access to Medical Appointments

Medical appointment wait times used for measuring and assessing  performance toward VHA’s wait time goals are unreliable due to problems  with recording the appointment desired date in the VistA scheduling  system. Consequently, the reliability of reported wait time performance is  dependent on the consistency with which schedulers record the desired  date in the VistA scheduling system. In addition, we found that some  schedulers at select VAMCs did not correctly implement other aspects of  VHA’s scheduling policy for recording the desired date. Aspects of VHA’s scheduling policy and related training documents on  how to determine and record the desired date are unclear and do not  ensure replicable and reliable recording of the desired date by the large  number of staff across VHA who can schedule medical appointments in  the VistA scheduling system. While the policy defines desired date as “the  date on which the patient or provider wants the patient to be seen,” it also  instructs that the “the desired date needs to be defined by the patient” for  new patient medical appointments, medical appointments scheduled in  response to consult requests, and established patient follow-up medical  appointments. Therefore, reported wait times for these appointments  may not have accurately reflected how long patients actually waited. However,  reported wait time data for the month we visited showed that the clinic  completed all new patient appointments on the desired date, resulting in  an unlikely high percentage of appointments with zero-day wait times that  was inconsistent with information gathered during our site visit, raising  questions about whether the desired date was recorded in accordance  with VHA’s scheduling policy. Inconsistent Implementation of VHA’s Scheduling Policy and Other Problems Impede VAMCs’ Ability to Schedule Timely Medical Appointments

The four VAMCs we reviewed did not consistently implement certain  elements of VHA’s scheduling policy, including oversight requirements,  which may result in increased wait time or delays in scheduling medical  appointments. VAMCs also described other problems with scheduling  timely medical appointments, including outdated technology, gaps in  staffing of schedulers and providers, and telephone access problems. Officials at all of the VAMCs we visited told us that high call volumes and  a lack of staff dedicated to answering the telephones impede the timely  scheduling of medical appointments. In January 2012, VHA distributed suggested best practices for improving  telephone design, service, and access in its Telephone Systems  Improvement Guide. VHA Is Implementing a Number of Initiatives to Improve Access to Medical Appointments

VHA is implementing several initiatives to improve veterans’ access to  medical appointments. Specifically, these initiatives focus on more  patient-centered care; using technology to provide care, through means  such as telehealth; and using care outside of VHA to reduce travel and  wait times for veterans who are unable to receive certain types of  outpatient care in a timely way through local VHA facilities. Secure  messaging allows veterans to communicate electronically with their health  care team. Without reliable measurement  of how long patients are waiting for medical appointments, VHA is less  equipped to identify and address factors that contribute to wait times, or  gauge the success of its initiatives to improve access to timely medical  appointments, including efforts to improve primary care medical  appointments. To better facilitate timely medical appointment scheduling and improve  the efficiency and oversight of the scheduling process, we recommend  that the Secretary of VA 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. To improve timely medical appointments and to address patient and staff  complaints about telephone access, we recommend that the Secretary of  VA 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 Health Care: Access for Chattanooga-Area Veterans Needs  Improvement.
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 VHAs scheduling of timely medical appointments. GAO examined (1) the extent to which VHAs 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 VHAs policies and processes for appointment scheduling, and any problems encountered in ensuring veterans access to timely medical appointments; and (3) VHAs 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 VHAs policies and data, and interviewed VHA officials.

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.

What GAO Recommends

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.