VA Health Care: More National Action Needed to Reduce Waiting	 
Times, but Some Clinics Have Made Progress (31-AUG-01,		 
GAO-01-953).							 
								 
The Department of Veterans Affairs (VA) operates one of the	 
nation's largest health care systems. In fiscal year 2000,	 
roughly four million patients made about 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 in 1995, 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 ten 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 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. While two-thirds of	 
the specialty clinics GAO visited continued to have long waiting 
times, some were making noteworthy 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 collaboratively  
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 has only recently
contracted with IHI to disseminate best practices agency-wide. VA
also has not developed other national guidance to help clinics	 
reduce waiting times. While 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 for long waiting times.	 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-01-953 					        
    ACCNO:   A01678						        
    TITLE:   VA Health Care: More National Action Needed to Reduce    
             Waiting Times, but Some Clinics Have Made Progress               
     DATE:   08/31/2001 
  SUBJECT:   Health centers					 
	     Health services administration			 
	     Veterans hospitals 				 
	     Managed health care				 
	     Veterans benefits					 
	     Patient care services				 
	     VA Veterans Health Information Systems		 
	     and Technology Architecture			 								 
	     VA Veterans Integrated Service Network		 

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GAO-01-953
     
Report to the Committee on Veterans' Affairs, House of Representatives

United States General Accounting Office

GAO

August 2001 VA HEALTH CARE More National Action Needed to Reduce Waiting
Times, but Some Clinics Have Made Progress

GAO- 01- 953

Page i GAO- 01- 953 VA Waiting Times Letter 1

Results in Brief 2 Background 3 Long Waits Are Often Due to Poor Scheduling
Procedures and

Inefficient Use of Staff 5 Some Clinics Have Made Progress in Their Efforts
to Reduce

Waiting Times 7 VA Lacks A Systemwide Approach to Reducing Waiting Times 13
Conclusions 16 Recommendations for Executive Action 16 Agency Comments 17

Appendix I Scope and Methodology 18

Appendix II Comments From The Department of Veterans Affairs 20

Appendix III GAO Contact and Staff Acknowledgments 21 GAO Contact 21
Acknowledgments 21

Related GAO Products 22

Tables

Table 1: National Waiting Times for Patients for VA Clinics in Areas
Measured for Network Performance Goals 15

Figures

Figure 1: Range of Waiting Times for Patient Care at the 54 VA Specialty
Clinics We Visited 5

Figure 2: VA Medical Centers Visited 18 Contents

Page ii GAO- 01- 953 VA Waiting Times Abbreviations

IHI Institute for Healthcare Improvement VA Department of Veterans Affairs
VISN Veterans Integrated Service Network VISTA Veterans Health Information
Systems and Technology

Architecture

Page 1 GAO- 01- 953 VA Waiting Times

August 31, 2001 The Honorable Lane Evans Ranking Democratic Member The
Honorable Christopher Smith Chairman Committee on Veterans? Affairs House of
Representatives

The Department of Veterans Affairs (VA) operates one of the nation?s largest
health care systems. In fiscal year 2000, roughly 4 million patients made
about 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. For example, in October 1993, we found
that veterans frequently waited 8 to 9 weeks to obtain appointments in
specialty clinics. 1 To ensure timely access to care, in 1995, 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. 2 Yet, 3 years later, reports of long waiting times
persist.

Concerned about these delays in access to care, you asked us to (1)
determine whether clinics in VA?s medical centers are meeting the 30- day
appointment standard for outpatient primary and specialty care, (2) describe
clinics? approaches for meeting VA?s waiting time standard, and (3) identify
VA headquarter?s efforts to help clinics meet this standard.

To conduct our work, we visited 17 primary care clinics and 54 clinics in
five specialty areas- dermatology, gastroenterology, eye care (ophthalmology
and optometry), orthopedics, and urology- within 10 VA medical centers.
During these site visits, we spoke with center and clinic management and
staff, including scheduling clerks and information resource management
staff. We also spoke with VA headquarters officials.

1 See VA Health Care: Restructuring Ambulatory Care System Would Improve
Services to Veterans (GAO/ HRD- 94- 4, Oct. 15, 1993). A list of related GAO
products is included in this report. 2 VA?s timeliness standard for urgent
care requires that veterans have access to such care 24 hours a day.

United States General Accounting Office Washington, DC 20548

Page 2 GAO- 01- 953 VA Waiting Times

In addition, we reviewed these clinics? and national waiting times data;
however, we did not verify these data. Except for this, we conducted our
work in accordance with generally accepted government auditing standards
from August 2000 through July 2001. (See appendix I for more detail on our
scope and methodology.)

Waiting times at the clinics in the 10 medical centers we visited indicate
that meeting VA?s 30- day standard is a continuing challenge for many
clinics. Although most of the primary care clinics we visited (15 of 17)
reported meeting VA?s standard for nonurgent, outpatient appointments, only
one- third of the specialty care clinics we 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. Many of these
delays- both in primary and specialty care- were the result of poor
scheduling procedures and inefficient use of staff. For example, some
clinics automatically rescheduled patients who missed appointments without
determining why the original appointment was missed or without notifying
patients of their new appointment. In some clinics, patients also continued
to be scheduled for specialty care appointments although they no longer
needed such care. Clinics also reported that they had too few staff, such as
technicians, scheduling clerks, and providers, to meet patient demand for
care. However, given the inefficiencies that we found, it was difficult to
determine the extent to which clinics would have benefited from additional
staff.

While two- thirds of the specialty clinics we visited continued to have long
waiting times, some were making noteworthy 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 collaboratively with the Institute for Healthcare
Improvement (IHI)- a private contractor VA retained in July 1999- to develop
strategies to reduce patient waiting times. One medical center essentially
restructured its health care delivery system, implementing multiple
strategies facilitywide. Specifically, this medical center assigned all
patients to a primary care provider for all routine, nonurgent care,
established a triage system for walk- in patients, and implemented a
centralized scheduling system for all of its clinics. As a result of these
and other changes, the primary care clinics and all but one of the five
specialty care clinics we reviewed at this medical center were meeting the
30- day standard. Results in Brief

Page 3 GAO- 01- 953 VA 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?s strategies, and has only recently contracted with IHI to
disseminate best practices agencywide. VA also has not developed other
national guidance to help clinics reduce waiting times. For example, half of
the specialty clinics we visited had referral guidelines for primary care
providers to follow when referring patients to specialists. These clinics?
waiting times were 25 percent shorter than the half that did not have
referral guidelines. While clinics that did not have guidelines could have
benefited from headquarters assistance, VA has not established a national
set of referral guidelines. Moreover, the Department lacks an analytic
framework for its medical centers and clinics to use in determining the root
causes of their long waiting times. Because VA is measuring patient waiting
times for nearly 17,500 clinics nationally- and has recently determined that
half of these clinics are not meeting its 30- day standard- it is especially
important for headquarters to promote a more systematic way to determine the
causes of long waiting times and address this problem quickly. As a result,
we have recommended that VA create a national set of referral guidelines and
take actions to strengthen its oversight of waiting times problems. In
commenting on a draft of our report, VA agreed with our findings and
concurred with our recommendations.

VA?s health care system is divided into 22 regional Veterans Integrated
Service Networks (VISN), which serve as the basic budgetary and decision-
making units for determining how best to provide services to veterans at
medical centers and community- based outpatient clinics located within their
geographic boundaries. Spread throughout the 22 VISNs are 172 medical
centers, each headed by a director who manages administrative functions,
along with a chief of staff who manages clinical functions for the entire
medical center. VA medical centers also have designated managers for each
area of care, such as primary and specialty care. Within each area of care,
there may be many clinics, which can vary in purpose and size. 3 For
example, VA has clinics that manage the care of patients who are taking
prescription medication for blood clots, and, due

3 VA defines a ?clinic? as an entity for dividing provider workload and
scheduling different types of patient care appointments. For example, the
gastroenterology specialty in one medical center we visited had 28
individual clinics, such as colonoscopy, endoscopy, flexible sigmoidoscopy,
hepatitis C, liver biopsy, and general gastroenterology. Background

Page 4 GAO- 01- 953 VA Waiting Times

to their more limited scope, these clinics might have a small number of
providers and staff. On the other hand, VA?s primary care clinics- where
physicians are responsible for the routine health needs of a caseload of
patients- tend to have a relatively larger number of providers and staff. In
addition, specialty care clinics, such as gastroenterology and urology,
could provide patients with specific care within that specialty, such as
treatment for hepatitis C and prostate cancer.

In 1996, the Congress required VA to ensure that veterans enrolled in its
health care system receive timely care. 4 For outpatient care, VA
established its ?30- 30- 20? goals: routine primary care appointments are to
be scheduled within 30 days from the date of request, as are specialty care
appointments, and patients are to be seen within 20 minutes of their
scheduled appointment time. 5 Following reports of long waiting times from
VA?s medical centers and clinics, veterans? service organizations, veterans,
the Inspector General, and us- VA began two initiatives to help identify and
address waiting times problems.

First, VA contracted with IHI, a Boston- based contractor, to help develop
strategies to reduce waiting times. As part of this project, 134 teams from
VA medical centers across the nation worked on reducing waiting times for
appointments in selected primary or specialty care clinics. Over half of
these teams focused on primary care. Second, VA began collecting patient
waiting times data from its outpatient scheduling system- the Veterans
Health Information Systems and Technology Architecture (VISTA), one of VA?s
main computer systems for clinical, management, and administrative
functions. Over the past few years, VA made several modifications to its
appointment scheduling software to develop more reliable data on waiting
times. In March 2001, VA began using these waiting times data to identify
clinics that failed to meet its 30- day standard.

4 Veterans? Health Care Eligibility Reform Act of 1996, P. L. 104- 262, Sec.
104( b)( 1). 5 VA?s performance in meeting the 20- minute waiting time goal
was beyond the scope of this review.

Page 5 GAO- 01- 953 VA Waiting Times

While most veterans using the primary care clinics we visited were able to
get an appointment within 30 days, many seeking specialty care often had to
wait longer than 30 days for a referral. Clinics with long waiting times
often had poor scheduling procedures or did not use their staff efficiently.

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. The other two clinics reported waiting times of 56
and 61 days. 6 However, chiefs of specialty care at the clinics we visited
reported that patients with nonurgent needs often wait in excess of VA?s 30-
day standard (see fig. 1). The longest reported waiting times were in
gastroenterology and optometry. At one location, veterans had to wait 282
days- more than 9 months- for an optometry appointment.

Figure 1: Range of Waiting Times for Patient Care at the 54 VA Specialty
Clinics We Visited

Source: Clinic data provided by VA officials during site visits from
November 2000 through March 2001.

6 According to several clinic chiefs, some veterans continue to see
specialists for primary care services- potentially decreasing the demand for
primary care appointments. Long Waits Are Often

Due to Poor Scheduling Procedures and Inefficient Use of Staff

0 30 60 90 120 150 180 210 240 270 300 Dermatology

Gastroenterology Ophthalmology

Optometry Orthopedics

Urology Days Clinic met waiting times standards. Clinic did not meet waiting
times standards. 0 30 60 90 120 150 180 210 240 270 300

Days

Page 6 GAO- 01- 953 VA Waiting Times

These long waiting times were often the result of high percentages of
patients not showing up for appointments, poor scheduling procedures, and
inefficient use of staff. When veterans do not keep their appointments, some
of the limited appointment slots are lost and are unavailable for other
veterans. This could extend waiting times overall. Almost 60 percent of the
71 primary and specialty care clinics we visited had a no- show rate of 20
percent or greater. Gastroenterology had the highest average noshow rate at
29 percent. At one gastroenterology clinic, half of the scheduled patients
did not show up for their appointments. Urology had the lowest average no-
show rate at 18 percent. According to one clinic chief, patients failed to
keep appointments because their health condition improved or they forgot
about the appointment because it was scheduled so far into the future.

Some clinics? scheduling procedures may actually encourage no- shows. For
example, some clinics schedule appointments several months in advance.
Although most clinics remind patients of their appointments- by mail or
telephone- we found that some reminder systems were not sufficient to ensure
that patients kept their appointments. For example, over 30 percent of the
clinics we visited automatically rescheduled noshows, and some did not
follow up with the veterans to determine why they had missed the original
appointments. In addition, in one clinic, staff told us that the patient
often was not informed of this new appointment, making it likely that the
patient would miss the new appointment as well.

We found that inefficient use of staff could also limit the number of
available appointment slots, contributing to long waiting times. For
example, some specialists told us that they were treating patients who could
be seen in primary care. 7 Specifically, one chief of dermatology told us
that she receives new patient referrals for conditions that could easily be
treated in primary care, such as dry skin. In addition, several chiefs of
orthopedics told us that they continue to see patients with conditions such
as rheumatoid arthritis and back pain because the patients request
appointments, even after their conditions have stabilized. Furthermore,
shortages of nonprovider staff at some clinics also resulted in the
inefficient use of physician time. For example, one orthopedic clinic did
not have a cast technician, so an orthopedic surgeon had to apply and

7 VA?s ?1998 Guidelines for Implementation of Primary Care? states that
primary care providers should serve as the point of entry for nonemergency
care and should refer patients to specialists only when appropriate.

Page 7 GAO- 01- 953 VA Waiting Times

remove patient casts. At another clinic, a shortage of clerks resulted in
nurses? assuming clerical duties- such as scheduling, admitting, and
discharging patients- and physicians? assuming tasks that nurses would
otherwise have handled, such as escorting patients to the examination room.
As physicians assumed duties that could more appropriately have been
fulfilled by nonphysician personnel, the number of appointments that could
have been scheduled each day might have been reduced.

When one appointment is linked to or dependent on another, scheduling and
staffing problems can further compound delays. For example, two chiefs of
orthopedics told us that patients who are scheduled for an x- ray prior to
their orthopedic appointment sometimes arrive late to the orthopedic clinic
or without an x- ray as a result of delays in the x- ray clinic. Because
orthopedic surgeons typically must have x- rays to properly assess the
severity of a patient?s condition, patients who do not have xrays often must
reschedule their orthopedic appointments, wasting the original appointment
and filling another future appointment slot on the schedule.

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. One VA medical center combined these and other strategies, and as a
result, all but one of its clinics that we reviewed had reduced their
waiting times to less than 30 days.

According to the chiefs of several clinics we visited, their improved
waiting times were, in part, the result of their increasing the number of
available patient appointments. To make more appointments available, these
clinics reduced the number of no- shows and reduced physician involvement in
certain services. Some clinics also added more providers.

To increase the likelihood that patients would show up for their
appointments, the clinics we visited used various strategies, such as the
following.

 One ophthalmology and optometry clinic reduced its no- show rate from 45
percent to 22 percent by having scheduling clerks call patients a few days
in advance to remind them of their appointments. When making these calls,
clerks found that some patients had forgotten their appointments and would
likely have missed them had they not received the reminder Some Clinics Have

Made Progress in Their Efforts to Reduce Waiting Times

Improved Scheduling Helped Clinics Increase Their Available Appointments

Page 8 GAO- 01- 953 VA Waiting Times

call. Some patients, however, said that they did not plan to keep the
appointments. In these cases, clerks were typically able to schedule another
patient into the time slot and thus increase the number of patients that the
provider could see each day and thereby reduce the number of days it took
veterans to get appointments.

 A primary care clinic at another medical center reduced its no- show rate
from 22 percent to about 12 percent through two actions. First, it changed
its medical resident rotation rate to once every 3 years, allowing patients
to develop relationships with the residents assigned to their care. The
chief of this clinic told us that she believes that the patients are more
comfortable knowing that they will see the same provider on each visit and
so are more likely to keep their appointments. Second, this primary care
clinic also used open access scheduling- an IHI technique- to reduce its no-
show rate. 8 The basic premise of open access scheduling is to schedule
nonurgent appointments within 30 days to reduce the likelihood that patients
would miss their appointments. For those patients needing appointments past
the 30- day time frame, the center sends reminder notices near the time the
patient needs to call in to schedule the appointment. According to this
center?s director of ambulatory care, lower no- show rates have helped to
reduce patient waiting times for primary care. Further, to accommodate
urgent patients who need same- day appointments, the medical center holds
open the last two appointment slots for each provider in each clinic day.

Clinics also freed up appointments by reducing provider involvement in
services that do not require one- on- one physician- patient interaction.

 Providers in one medical center?s primary care clinic now use an automated
telephone system to convey the results of blood and other lab tests to
patients when the test results are normal. The system automatically calls
patients and instructs them to call the system back and enter a preassigned
password to retrieve messages from their providers about the results of
their tests- which patients can access at any time.

 The gastroenterology clinic at another medical center initiated group
education classes for patients diagnosed with hepatitis C. In these classes,
patients can receive information and ask questions about the virus. A

8 Open access scheduling typically can only occur in health care systems
that have eliminated or greatly reduced the backlog of patients who are
waiting for nonurgent appointments. Under the open access system at this
medical center, clinics are encouraged to use a reminder system to contact
patients within 30 days of the time they need to make appointments.

Page 9 GAO- 01- 953 VA Waiting Times

primary care clinic at another medical center developed an innovative
approach to educating patients newly diagnosed with chronic diseases, such
as diabetes. Once diagnosed, each patient is given a ?prescription? to take
to the clinic?s medical library, where the patient receives medical
literature and other media on the disease. Providers at this clinic told us
that patients who fill their library prescriptions know more about managing
their own conditions and thus need less time with a physician.

Chiefs of 12 clinics told us that they hired more providers- both physician
and nonphysician- to increase the number of available appointments, thereby
reducing waiting times.

 A urology clinic at one medical center hired a full- time urologist, and,
according to the clinic?s chief, this action- along with others such as
providing education seminars for primary care physicians-- helped reduce the
clinic?s waiting time from over 1 year to 30 days, over a period of several
years.

 Another urology clinic hired a full- time physician?s assistant to help in
its general and procedure clinic. According to the chief of the clinic,
clinic efficiency and the number of patients seen each day have increased
because the physician?s assistant can independently see patients.

 One eye care clinic hired a part- time optometrist, which helped to reduce
the waiting times for patients requiring nonurgent appointments.

Some clinic chiefs told us that, through the use of referral guidelines,
they were able to increase the number of available specialty appointments by
reducing the number of scheduled patients whose medical needs could more
appropriately be met by a primary care provider. 9 Some clinics have
computerized their referral guidelines, which provides easy access to the
guidelines, expedites referrals, and helps ensure that needed tests and
exams are completed in advance. Efficiencies such as these enable clinics to
increase the number of daily appointments available and help reduce waiting
times.

Half of the 54 specialty care clinics we visited had referral guidelines for
primary care providers to use when determining whether to refer a patient to
a specialist. For example, an orthopedics clinic at one medical center

9 The use of referral guidelines is supported by the IHI. Use of Referral
Guidelines

Helped Some Clinics Make Better Use of Staff

Page 10 GAO- 01- 953 VA Waiting Times

we visited implemented referral guidelines in September 1999 to encourage
orthopedists to refer patients back to primary care after their orthopedic
needs have been met. Seventeen months after the guidelines were implemented,
the clinic?s waiting times dropped from 200 days to 54 days. Referral
guidelines also often indicate which laboratory tests need to be ordered by
the primary care provider before a patient is referred to the specialist.
According to the director of ambulatory care at another medical center-
which established facilitywide referral guidelines- before the guidelines
were implemented, primary care providers would notify specialists that
patients were being referred. However, these referrals often did not include
the primary care provider?s assessment of the patient?s condition. As a
result, the specialists were required to spend time performing routine tests
to assess patients? conditions.

This same medical center requires its primary care providers to use a
computerized checklist program, which prompts them to complete specific
steps for each referral to a specialist. The referral is then reviewed for
completeness and accuracy by a medical center team, and, if it meets the
criteria, is sent forward to the specialist within a 24- hour period or
less. According to medical center officials, this process has greatly
reduced the number of unnecessary patient referrals and has helped to make
the time that specialists spend with patients more productive.

While the use of patient referral guidelines at the sites we visited varied
from clinic to clinic and from one medical center to another, many officials
told us that clearly defined and strictly adhered- to guidelines would help
reduce the number of specialty referrals for conditions that could more
appropriately be handled by a primary care provider and would maximize the
time that specialists spend with patients. Yet half of the 54 specialty
clinics we visited did not have any form of referral guidelines, and waiting
times at these clinics were 25 percent longer than those clinics that had
referral guidelines. Some chiefs of specialty and primary care told us that
while they believe that referral guidelines could help them better manage
their workload and increase the number of available appointment slots, they
did not have time to establish such guidelines.

Page 11 GAO- 01- 953 VA Waiting Times

One medical center significantly reduced its waiting times by using multiple
strategies, phased in over a 4- year period, that completely restructured
its health care delivery system. According to the medical center?s director
of ambulatory care, because of these changes, along with the hiring of a
modest number of primary care providers, 10 waiting times for primary care
appointments have been reduced from an average of 35 days to an average of
20 days. In addition, waiting times for specialty care met the 30- day
standard in all but one of the specialties we reviewed. 11 For example,
waiting times in urology were reduced from 3 months to 7 days, and waiting
times in ophthalmology were reduced from more than a year to about 7 days.

Before these strategies were implemented, the medical center operated under
a ?traditional? health care delivery model within VA- screening new patients
in the emergency room and compensating for high no- show rates by
overbooking appointments and allowing patients to walk in for care,
regardless of the level of urgency. Based on information received during the
VA- sponsored national collaborative with IHI, the medical center adopted
several strategies to more effectively manage its patient workload. In
addition to increasing available appointments and implementing referral
guidelines, 12 the medical center adopted three key features: the primary
care model, walk- in triage, and centralized appointment scheduling.

 The primary care model. Almost all of the medical center?s nonurgent
patient care workload was shifted into primary care. Until 4 years ago, none
of the veterans seeking care at this medical center were assigned to a
primary care provider; now, about 97 percent are. Primary care providers are
now expected to provide comprehensive, ongoing medical care and preventive
health measures. They are also expected to coordinate patients? other health
care needs, doing more diagnosis and treatment themselves before referring
patients to specialists. For example, if a patient makes a request to see an
orthopedist for a knee problem or a urologist for suspected prostate cancer,
the primary care provider is expected to review the patient?s records, order
and review the results of needed tests, refer

10 Over the past 4 years, the medical center has hired three full- time
primary care providers and now has a total of 15 full- time equivalent
primary care physicians. 11 At the time of our visit, dermatology had a
waiting time of 45 days.

12 The facility?s guidelines are based on those developed by InterQual, a
private medical consulting firm. One VA Medical Center

Used Multiple Strategies to Reduce Waiting Times

Page 12 GAO- 01- 953 VA Waiting Times

the patient to a specialist only when needed, and oversee and coordinate the
patient?s care.

 Walk- in triage. According to officials at the medical center, delivering
nonurgent care on a walk- in basis (without a scheduled appointment)- a
practice common at many VA medical centers- limits the number of
appointments that can be scheduled because providers spend time on
unscheduled walk- in patients instead of scheduled patients. They also said
that treating walk- in patients is not in the best interest of the patients
or providers because the treatment is episodic and lacks continuity of care;
consequently, providers do not get to know the patients and are less
involved in their overall health. 13 The medical center now triages walk- in
patients, with a nurse assessing them to determine whether they need
emergency, urgent, or nonurgent care. If their conditions require care in
the emergency room or urgent care clinic, they are seen immediately.
However, if their conditions require nonurgent care, they are referred to a
scheduling clerk, who schedules an appointment for them within 30 days.
According to the medical center?s director of ambulatory care, this approach
helps to better ensure that patients are seen in the appropriate setting,
maximizing the delivery of primary care and ensuring that patients with
urgent symptoms, such as blurred vision, loss of breath, or acute pain,
still receive the most timely care possible.

 Centralized appointment scheduling. Prior to centralized scheduling,
clerks in each of the medical center?s clinics scheduled patient
appointments, resulting in a wide variety of scheduling practices. With
centralized scheduling, patient appointments for all clinics are now
scheduled from one administrative office. According to the center?s director
of ambulatory care, implementing a centralized scheduling system also
allowed the individual clinic clerks more time to focus on other functions,
including patient intake at appointment time and patient discharge
activities such as recording patient visit information into encounter forms.

According to the center?s director of ambulatory care, implementing any of
these strategies could result in reduced waiting times, but she believed
that combining all of the strategies had the most significant effect.

13 VA?s primary care directive, dated April 1998, requires that VA provide
continuity of care to its patients, which it defines as follows: the primary
care provider must be backed by a team that knows the patient well and
effective and appropriate communication will facilitate continuity of care
and ensure that the primary care provider is notified of patient encounters
other than scheduled visits.

Page 13 GAO- 01- 953 VA Waiting Times

Although VA has set a performance goal for network directors and has
contracted with IHI, it has generally relied on its medical centers
nationwide to develop and implement strategies to reduce their own waiting
times. However, clinic officials we talked to noted that more guidance and
direction from VA on implementing and using referral guidelines could help
them in their efforts to reduce waiting times. In addition, some chiefs of
specialty and primary care clinics were unaware of the successes that other
medical centers have had in reducing waiting times and told us that they
would find such information useful in developing their own strategies.
However, VA has not provided clinics with referral guidelines, nor has it
assessed or disseminated ways to improve patient waiting times that have
worked at some clinics. 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.

Clinic officials told us that while IHI?s strategies for reducing waiting
times have been useful, they could benefit from more guidance and direction
from VA- including referral guidelines and information on best practices- to
help them implement these strategies.

In April 1998, VA established a requirement that all medical centers and
community- based outpatient clinics adopt a primary care model- a system in
which patients use primary care providers to manage their care. In
implementing a primary care model, VA strongly suggested that its health
care facilities establish guidelines for primary care providers to follow in
deciding when to refer patients to specialty care. According to the chief of
primary care at one medical center we visited, the center?s guidelines for
referrals to urology and gastroenterology have resulted in improved
communication between these specialists and primary care providers, fewer
inappropriate referrals, more complete information on patients who have been
referred, and ultimately shorter waiting times for patients in these two
specialty clinics.

However, the chief of primary care also told us that the medical center had
not developed referral guidelines for the three other specialty care areas
that we reviewed. Overall, we found that half of the 54 specialty care
clinics we visited have implemented referral guidelines. Further, the
existence and use of referral guidelines varied within a medical center and
even within a specialty. For example, in one medical center, only the
urology clinic had developed referral guidelines. In another medical center,
referral guidelines were not available for two of the five specialty VA
Lacks A

Systemwide Approach to Reducing Waiting Times

Referral Guidelines and Information on Best Practices Could Help

Page 14 GAO- 01- 953 VA Waiting Times

care areas that we reviewed. Several of the chiefs of primary and specialty
care we spoke to indicated that implementing referral guidelines would help
reduce the number of inappropriate referrals and the time specialists spend
with patients, but they did not have the time to develop such guidelines and
would like headquarters to do so. Although headquarters officials told us
that they believe that providing minimum guidelines could serve as a
framework for medical centers and clinics to build on and could help
standardize the referral process, VA has not yet developed a national set of
referral guidelines for its medical centers and clinics to use.

Clinic officials also told us that they could benefit from learning about
other clinics? successes- especially those achieved through VA?s initial
project with IHI. In July1999, IHI began working with 134 teams from various
medical centers across the nation, representing 160 different clinics. Nine
of the 10 medical centers we visited had teams that participated in the IHI
project- including the medical center that had reduced waiting times by
implementing a primary care model, referral guidelines, centralized
appointment scheduling, and a system for triaging walk- ins. 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. In March 2001, VA entered into a second contract with IHI to
identify and disseminate information on clinics? best practices for reducing
waiting times. According to an official from VA headquarters, this second
contract should help VA communicate and share, nationwide, the results of
medical centers and clinics that have had success in reducing waiting times.

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. However, until several months ago, VA
had problems collecting accurate and reliable patient waiting times data.
The deficiencies in the data limited its ability to identify clinics that
were not meeting its 30- day timeliness standard. After several
modifications to its national data collection software package, VA can now
identify those clinics that exceed the 30- day standard systemwide. In
September 1999, VA began holding its network directors responsible for
meeting the 30- day VA Has Identified Clinics

With Excessive Waiting Times but Has Not Developed a Process to Analyze
Their Root Causes

Page 15 GAO- 01- 953 VA Waiting Times

waiting times standard for six clinic types. 14 As of March 2001, VA data
showed that about half of VA?s nearly 17,500 clinics for these six clinic
types were meeting VA?s 30- day standard (see table 1).

Table 1: National Waiting Times for Patients for VA Clinics in Areas
Measured for Network Performance Goals Clinic Total clinics

Percentage of clinics with waiting times of

30 days or less Percentage of

clinics with waiting times of

31 to 45 days Percentage of

clinics with waiting times of

46 to 90 days Percentage of

clinics with waiting times of

91 to 120 days Percentage of

clinics with waiting times of

more than 120 days

Primary care 11,586 49 16 24 6 5 Audiology 920 66 15 11 5 3 Cardiology 1,440
49 16 23 7 5 Eye care 1,961 42 14 24 9 11 Orthopedics 717 59 12 21 4 4
Urology 854 51 16 21 6 6

Total a 17,478 50 15 23 6 5

a Due to rounding, percentages do not add to 100. Source: GAO calculations
using VA March 2001 VISTA waiting times data.

According to a headquarters? official, VA is planning to notify, in several
phases, clinics whose waiting times have not met the 30- day standard. VA
has begun by notifying clinics whose waiting times exceed 120 days and, in
the next phase, plans to notify clinics whose waiting times exceed 90 days.
In March 2001, VA reported that 948 of its clinics had waiting times of 120
days or more in the six medical care areas that VA is using to measure VISN
director performance. VA has also developed new waiting time performance
objectives to be met by 2003: 90 percent of nonurgent primary care patients
and 90 percent of patients with nonurgent specialty care referrals are to be
seen within 30 days.

However, VA has not developed an analytic framework for identifying root
causes and tracking progress for solving these clinics? waiting times
problems. Consequently, over 8,700 clinics for the six areas in which
waiting times are longer than 30 days are left to independently develop a
process for identifying these root causes. Moreover, while VA distributed a
report showing waiting times data to each of its networks, it did not

14 VA identified the six specialties to measure VISN director performance by
asking clinical managers from the 22 VISNs to survey their facilities on
what clinics had the most problems with waiting times.

Page 16 GAO- 01- 953 VA Waiting Times

require networks to develop corrective actions for medical centers and
clinics that failed to meet the 30- day waiting times standard. As a result,
VA cannot be sure that medical center management is making progress to meet
this standard.

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 30day
goal to provide nonurgent, outpatient primary and specialty care. However,
many veterans continue to experience long waits for appointments, especially
for certain types of care- despite VA?s initial objective to have its
medical centers and clinics meet the 30- day standard by 1998.

While VA?s two contracts with IHI are important first steps needed to
expedite solving its waiting times problems systemwide, the Department could
provide more guidance and direction to medical centers and clinics to reduce
patient waiting times. In particular, VA has not established national
referral guidelines- with local discretion, as appropriate- even though many
centers and clinics told us that they need such guidelines but do not have
the time to develop them. In addition, VA has not provided medical centers
and clinics with an analytic framework for identifying the root causes of
their long waiting times. Such a framework could greatly help those centers
and clinics that need assistance. Until VA develops a systematic approach
for identifying, analyzing, and monitoring waiting times problems, veterans
will continue to be at risk of experiencing long waits in their access to
nonurgent primary and specialty care.

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.

 Strengthen oversight by developing an agencywide process for determining
the causes of waiting times problems; implementing corrective actions, where
needed; and requiring periodic progress reports from clinics with long
waiting times until they meet VA?s national standards. Conclusions

Recommendations for Executive Action

Page 17 GAO- 01- 953 VA Waiting Times

We provided VA a draft of our report for its review. In its comments, VA
agreed with our findings and concurred with both of our recommendations (see
appendix II). In response to our first recommendation, VA acknowledged the
need to develop national referral guidelines for specialty care and has
charged its newly formed National Waiting Time Steering Committee to address
this issue. In response to our second recommendation, VA stated that its
ongoing collaboration with IHI should provide an analytic roadmap for
facilities to use in analyzing their waiting time problems. In addition, VA
is working with IHI to develop a reporting instrument for clinics to use in
monitoring waiting time progress.

As arranged with your office, unless you announce its contents earlier, we
plan no further distribution of this report until 30 days after its date. At
that time, we will send copies to the Secretary of Veterans Affairs,
appropriate congressional committees, and other interested parties. We will
make copies available to others upon request.

Please contact me at (202) 512- 7101 if you or your staffs have any
questions. Another contact and key contributors to this report are listed in
appendix III.

Cynthia A. Bascetta Director, Health Care- Veterans?

Health and Benefits Issues Agency Comments

Appendix I: Scope and Methodology Page 18 GAO- 01- 953 VA Waiting Times

To determine the extent to which clinics are meeting VA?s 30- day
appointment standard for outpatient primary and specialty care and to learn
about approaches some clinics have used to improve waiting times, we visited
10 medical centers 1 selected to include a variety of different- size
medical centers, with relatively high, medium, and low numbers of patient
visits, located across the United States. 2 The results of the site
selection are reflected in figure 2.

Figure 2: VA Medical Centers Visited

At these locations, we visited in total 71 clinics- 17 primary care clinics
and 54 clinics in five specialty areas: dermatology, gastroenterology, eye
care (ophthalmology and optometry), orthopedics, and urology- within 10 VA
medical centers. We selected these specialties, using data from VA?s
national VISTA database for April, May and June 2000, because the data
showed that these areas had some of the highest waiting times for scheduled
outpatient clinic appointments compared to other VA specialty

1 These 10 medical centers were Cheyenne, WY; Chicago, IL; Clarksburg, WV;
Dallas, TX; Los Angeles, CA; Minneapolis, MN; New Orleans, LA; Seattle, WA;
Tampa, FL; and Washington, DC.

2 VA also has a goal for patients to be seen within 20 minutes of their
scheduled appointment, but this goal was beyond the scope of our review.
Appendix I: Scope and Methodology

Seattle Dallas

New Orleans Cheyenne

Los Angeles Washington DC

Chicago Clarksburg Minneapolis

Tampa

Appendix I: Scope and Methodology Page 19 GAO- 01- 953 VA Waiting Times

areas. During these site visits, we interviewed the medical center directors
and chiefs of staff, when available, and clinic management and staff,
including scheduling clerks and information resource managers. We also
reviewed documents that these medical centers and clinics provided, such as
examples of referral guidelines that primary care providers use before
referring patients to specialists. We also spoke with VA headquarters
officials.

To identify VA?s efforts to help medical centers and clinics deliver timely
care, we interviewed VA headquarters, medical center, and clinic officials
and reviewed documents relating to VA?s past and current projects with IHI.
We also reviewed VA?s Annual Performance Report Fiscal Year 2000 and other
documents detailing VA?s goals to reduce its waiting times for appointments.
To assess VA?s progress in improving the accuracy of waiting times data, we
reviewed VA?s VISTA waiting time data for July 2000 through March 2001 and
reviewed documentation of VA?s changes to the VISTA scheduling software, but
we did not verify these data. We also interviewed chiefs of primary and
specialty care clinics at the 10 medical centers we visited and obtained
clinic waiting times data from these officials.

Apart from data verification, we conducted our work from August 2000 through
July 2001 in accordance with generally accepted government auditing
standards.

Appendix II: Comments From The Department of Veterans Affairs

Page 20 GAO- 01- 953 VA Waiting Times

Appendix II: Comments From The Department of Veterans Affairs

Appendix III: GAO Contact and Staff Acknowledgments

Page 21 GAO- 01- 953 VA Waiting Times

Ronald J. Guthrie, (303) 572- 7332 In addition to the contact named above,
James Espinoza, Lisa Gardner, Sigrid McGinty, Karen Sloan, Bradley Terry,
and Alan Wernz made key contributions to this report. Appendix III: GAO
Contact and Staff

Acknowledgments GAO Contact Acknowledgments

Related GAO Products Page 22 GAO- 01- 953 VA Waiting Times

Major Management Challenges and Program Risks: Department of Veterans
Affairs (GAO- 01- 255, Jan. 1, 2001).

Veterans? Health Care: VA Needs Better Data on Extent and Causes of Waiting
Times (GAO/ HEHS- 00- 90, May 31, 2000).

VA Health Care: Progress and Challenges in Providing Care to Veterans (GAO/
T- HEHS- 99- 158, July 15, 1999).

Veterans? Affairs: Progress and Challenges in Transforming Health Care (GAO/
T- HEHS- 99- 109, Apr. 15, 1999).

VA Health Care: More Veterans Are Being Served, but Better Oversight Is
Needed (GAO/ HEHS- 98- 226, Aug. 28, 1998).

VA Health Care: Status of Efforts to Improve Efficiency and Access (GAO/
HEHS- 98- 48, Feb. 6, 1998).

Veterans? Health Care: Veterans? Perceptions of VA Services and VA?s Role in
Health Care Reform (GAO/ HEHS- 95- 14, Dec. 23, 1994).

VA Health Care: Restructuring Ambulatory Care System Would Improve Services
to Veterans (GAO/ HRD- 94- 4, Oct. 15, 1993). Related GAO Products

(406198)

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