Veteranclaims’s Blog

June 9, 2014

VA’s System Wide Audit of Wait Times, May 12, 2014, through June 3, 2014

Full VA Report, pdf file at:

http://www.va.gov/health/docs/VAAccessAuditFindingsReport.pdf

Excerpt from Department of Veterans Affairs report:

System-Wide Review of Access Results of Access Audit Conducted May 12, 2014, through June 3, 2014

OVERVIEW
These Access Audit findings address the Secretary of The Department of Veterans Affairs directive that the Veterans Health Administration conduct a system-wide audit of scheduling and access management practices. This audit assesses the integrity of these practices and recommends next steps to improve service to Veterans.

Access Audit Results
At the direction of the Secretary of the Department of Veterans Affairs (VA), the Veterans Health Administration (VHA) conducted an Access Audit to determine if allegations about inappropriate scheduling practices are isolated instances of improper practices or if broader, more systemic problems exist. The audit was designed to:
1. Gauge front-line staff understanding of proper scheduling processes;
2. Assess the frequency and pervasiveness of both desired and undesirable practices employed to record Veteran preferences for appointment dates, manage waiting lists, and process requests for specialty consultation; and
3. Identify factors that interfere with schedulers’ ability to facilitate timely care for Veterans.
The Access Audit was by necessity a rapidly deployed, system-wide assessment of scheduling practices across VA, and was not intended as a formal investigation of individual staff or managers. Site survey teams were not able to interview all employees, and time did not allow assessment of intent or potential culpability. All of the information collected from audit site visits has been shared with VA’s Office of Inspector General (OIG).

Audit Scope
The audit was conducted in two phases. Phase One covered VA medical centers (VAMC) and large Community-Based Outpatient Clinics (CBOC) serving at least 10,000 Veterans. Phase Two covered additional VA facilities, including Hawaii VA and Phoenix VA Health Care Systems. Combined, the two phases covered 731 total facilities, including 140 parent facilities and all VAMCs. During the course of the audit, over 3,772 staff were interviewed.

Audit Findings
The Phase One findings were a strong basis to commence immediate action, even while Phase Two data were being collected. Ultimately, VA chose to limit Phase Two data collection after initial assessments restated high consistency with the findings of Phase One.
The Access Audit was subject to certain limitations (emphasized in later sections of this report) that were unavoidable given the scope and accelerated timeframe. Notwithstanding these limitations, findings include:
1. Efforts to meet needs of Veterans (and clinicians) led to an overly complicated scheduling process that resulted in high potential to create confusion among scheduling clerks and front-line supervisors.
2. Meeting a 14-day wait-time performance target for new appointments was simply not attainable given the ongoing challenge of finding sufficient provider slots to accommodate a growing demand for services. Imposing this expectation on the field before ascertaining the resources required and its ensuing broad promulgation represent an organizational leadership failure.
3. The concept of “desired date” is a scheduling practice unique to VA, and difficult to reconcile against more accepted practices such as negotiating a specific appointment date based on provider availability, or using a “return to clinic” interval requested by providers.
4. Overall, 13 percent of scheduling staff interviewed indicated they received instruction (from supervisors or others) to enter in the “desired date” field a date different from the date the Veteran had requested. At least one instance of such practices was identified in 76 percent of VA facilities. In certain instances this may be appropriate (e.g., a provider-directed date can, under VA policy, override a date specified by a patient), but the survey did not distinguish this, nor did it determine whether this was done through lack of understanding or malintent unless it was clearly apparent.
5. Eight percent of scheduling staff indicated they used alternatives to the Electronic Wait List (EWL) or Veterans Health Information Systems and Technology Architecture (VistA) package. At least one of such instance was identified in 70 percent of facilities. As with desired date practices, we did not probe the extent to which some of these alternatives might have been justified under VA policy. The questionnaire employed did not isolate appropriate uses of external lists.
6. Findings indicate that in some cases, pressures were placed on schedulers to utilize inappropriate practices in order to make waiting times (based on desired date, and the waiting lists), appear more favorable. Such practices are sufficiently pervasive to require VA re-examine its entire performance management system and, in particular, whether current measures and targets for access are realistic or sufficient.
7. Staffing challenges were identified in small CBOCs, especially where there were small counts of providers or administrative support.

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