First, VA contracted with IHI, a Boston-based contractor, to help develop strategies to reduce waiting times. The chiefs of primary care at the 10 VA medical centers we visited reported that 15 of their 17 primary care clinics—or about 88 percent— met VA’s 30-day timeliness standard. At one location, veterans had to wait 282 days—more than 9 months—for an optometry appointment. At one gastroenterology clinic, half of the scheduled patients did not show up for their appointments. Some Clinics Have Made Progress in Their Efforts to Reduce Waiting Times

While most of the clinics we visited continue to experience waiting times problems, several have reported success in reducing their waiting times— primarily by improving their scheduling processes or making better use of staff. VA also lacks a systematic process for determining the causes of long waiting times, for monitoring clinics’ progress in reducing waiting times, and for helping those centers and clinics that continue to have long waiting times. However, as of July 2001, none of the 134 teams’ findings have been summarized and publicized, leaving the medical centers and clinics nationwide to independently determine how to implement IHI’s strategies for reducing waiting times. VA Has Identified Clinics With Excessive Waiting Times but Has Not Developed a Process to Analyze Their Root Causes

When VA established its 30-day waiting times standard for primary and specialty care over 5 years ago, it also established the objective that clinics meet this standard by 1998. Conclusions

Some of the 71 clinics in the 10 medical centers we visited have successfully begun to address their waiting times problems for patients— often by implementing IHI’s strategies—and several are meeting VA’s 30- day goal to provide nonurgent, outpatient primary and specialty care. In addition, VA has not provided medical centers and clinics with an analytic framework for identifying the root causes of their long waiting times. Recommendations for Executive Action

To help ensure that clinics meet VA’s 30-day waiting times standard, we recommend that the Secretary of Veterans Affairs direct the Under Secretary for Health to take the following actions:   Create a national set of referral guidelines for medical centers to use when referring patients from primary care to specialty care as well as guidelines for specialty clinics to follow in returning patients to primary care when they no longer need specialty care.
What GAO Found

The Department of Veterans Affairs (VA) runs one of the nation's largest health care systems. In fiscal year 2000, roughly four million patients made 39 million outpatient visits to more than 700 VA health care facilities nationwide. However, excessive waiting times for outpatient care have been a long-standing problem. To ensure timely access to care, VA established a goal that all nonurgent primary and specialty care appointments be scheduled within 30 days of request and that clinics meet this goal by 1998. Yet, three years later, reports of long waiting times persist. Waiting times at the clinics in the 10 medical centers GAO visited indicate that meeting VA's 30-day standard is a continuing challenge for many clinics. Although most of the primary care clinics GAO visited (15 of 17) reported meeting VA's standard for nonurgent, outpatient appointments, only one-third of the specialty care clinics visited (18 of 54) met VA's 30-day standard. For the remaining two-thirds, waiting times ranged from 33 days at one urology clinic to 282 days at an optometry clinic. Although two-thirds of the specialty clinics GAO visited continued to have long waiting times, some were making progress in reducing waiting times, primarily by improving their scheduling processes and making better use of their staff. These successes were often the result of medical centers' and clinics' working with the Institute for Healthcare Improvement (IHI)--a private contractor VA retained in July 1999--to develop strategies to reduce patient waiting times. Medical centers and clinics participating in VA's IHI project have received valuable information and strategies for successfully reducing waiting times. However, VA has not provided guidance to its medical centers on how to implement IHI strategies, and VA has only recently contracted with IHI to disseminate best practices agency-wide. VA has not developed other national guidance to help clinics reduce waiting times. Although clinics that did not have guidelines could have benefited from headquarters' assistance, VA has not established a national set of referral guidelines. Moreover, VA lacks an analytic framework for its medical centers and clinics to use in determining the root causes of lengthy waits.