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Witness Testimony of Mr. William Schoenhard, FACHE, Deputy Under Secretary for Health for Operations and Management Veterans Health Administration U.S. Department of Veterans Affairs

Good afternoon, Chairman Coffman, Ranking Member Kirkpatrick, and Members of the Subcommittee.  Thank you for the opportunity to discuss an important topic that impacts every Veteran’s experience with Department of Veterans Affairs (VA) health care services - the reliability and timeliness of outpatient medical appointments.  I am accompanied today by Thomas Lynch, M.D., Assistant Deputy Under Secretary for Health for Clinical Operations; Philip Matkovsky, Assistant Deputy Under Secretary for Health for Administrative Operations; and, Michael Davies, M.D., National Director of Systems Redesign

The Veterans Health Administration’s (VHA) mission is to honor America’s Veterans by providing exceptional healthcare that improves their health and well-being.  Providing timely access to that care is a critical aspect of our mission.  Access enables VHA to provide personalized, proactive, patient-driven health care; achieve measurable improvements in health outcomes; and, align resources to deliver sustained value to Veterans. VHA is continually assessing wait times and making adjustments as needed to ensure that Veterans have access to the best care anywhere.

VHA Wait Time Determination: Early Efforts

VHA has been transforming its health care delivery system for two decades, moving from a hospital-based system to an ambulatory care model.   The ability of Veterans to access health care at the right time and in the right place is at the heart of keeping our promise to America’s Veterans.  For this reason, VA’s effort to manage timely access is critically important.  

We know timeliness of appointments has improved since we began tracking it, but determining a reliable and valid way to measure timeliness has been difficult. In the 1990s, VHA started measuring wait times using capacity measures, such as next available appointment date that are widely used in the health care industry today.  VHA found that capacity measures proved inadequate to portray each individual patient’s experience because they showed clinic availability rather than what occurred for the individual patient.  In the absence of an effective industry standard, VHA has had to develop, test, and refine new methods for measuring wait time that align with our goal to provide patient-centered care. Much of this work has been iterative and is reflected by the numerous wait time measures VHA has developed over the past ten years.

In retrospect, we now know that some of our reporting on wait times was not as reliable as our Veteran patient and stakeholders deserve.  For instance, while the information VHA submitted for the President’s annual Performance and Accountability Reports did provide the current level of performance against the existing measures, these measures did not accurately capture the experience of Veterans.  Measuring outpatient medical appointment wait times was uncharted territory and we relied on the best information and experience available at the time.  

In 1999, Veterans waited an average of 60-90 days for a primary care appointment.  In 2011, VHA established a wait time goal of 14 days, rather than 30 days, for both primary and specialty care appointments. VHA challenged itself to provide more timely care to increase patient satisfaction since most patients were being seen within the earlier established 30 day goal.  Currently, approximately 40% of new patients and 90% of established patients meet this 14 day goal.  

Over the past few years, the U.S. Government Accountability Office (GAO) and VA’s Office of Inspector General (OIG) have assessed VHA’s outpatient medical appointment wait times.  OIG made multiple recommendations to improve scheduler accuracy and “establish procedures to test the accuracy of reported wait times.”  VHA acknowledges the shortcomings in our past approaches and appreciates these findings and recommendations. Through these analyses, we are better able to understand the gaps in our processes and incorporate best practices into future policy and operations.

VHA’s Wait Times Study

In 2009, VA commissioned a retrospective study partly in response to concerns raised by GAO and OIG to assess the association between multiple measures of timeliness and patient satisfaction.  Using data from 2005 – 2010, researchers obtained and analyzed information from nearly 400 million VHA appointments and over 220,000 patient satisfaction surveys. VHA received the study’s results in 2012.

The study showed that new and established patients have different needs and require different approaches for capturing wait times.  Also, the data identified that the Create Date, the date that an appointment is made is the optimal method for new patients, since most new patients want their visit or clinical evaluation to occur as close to the time they make the appointment as possible.  For established patients, VHA has determined that using the Desired Date is the most reliable and patient-centered approach. Desired Date is the ideal time a patient or provider wants the patient to be seen.  Although not perfect, this measure provides the best association with patient satisfaction for established patients.  VHA’s Wait Time Study, consistent with the literature in this area, shows that shorter wait times are associated with better clinical care and positive health outcomes.  Armed with evidence that the Create Date and the Desired Date best predict patient satisfaction and health outcomes for new and established patients respectively, VHA adopted these methods on October 1, 2012.

In December 2012, GAO issued its report urging VA to improve oversight of the reliability of reported outpatient medical appointment wait times and scheduling for outpatient appointments.  VA concurred with GAO’s findings and their four recommendations that are important to improving VHA’s wait time measures.  We will discuss in more detail VHA’s action plan to address GAO’s recommendations below.  

The Way Forward

With the recent evidence from our wait time study, ongoing VHA performance measures, as well as findings and recommendation from oversight entities, VHA believes it now has reliable and valid wait time measures that allow VHA to accurately measure how long a patient waits for an outpatient appointment.  VHA’s action plan is aimed at ensuring the integrity of wait time measurement data so that VHA has the most reliable information to ensure Veterans have timely access to care and high satisfaction.  

VHA is focused on implementing new wait time measurement practices, policies, and technologies along with aggressive monitoring of reliability through oversight and audits.  VHA is working to implement the action plan and expects to have the majority of the efforts in place in the next 12 months.  Following is a discussion of VHA’s efforts to implement reliable measures so that we can ensure that Veterans receive the care they need when they need it.
    
In response to the first GAO recommendation, identifying weaknesses in scheduler procedures for accurately and reliably establishing the patient’s desired appointment date, VHA is both establishing more accurate wait time measures and revising its scheduling policy.  The old scheduling policy relied on the scheduler to ascertain and correctly record the Desired Date for established patients.  The new policy requires the provider to record the patient-provider decision on the projected next appointment date. This ‘Agreed-Upon-Date’ (AUD) process provides clear documentation and will improve the reliability of the recorded desired appointment date. AUD also includes the patient actively in the decision-making process and more accurately portrays the patient expectation. VHA piloted these new procedures and found them to be feasible to implement.

In order to improve the accuracy of wait time measures, VHA is using methodology that relies on recorded time stamps.  For new patients, VHA will report the length of time that elapses between appointment creation and completion.  For established patients, VHA will report the time between the AUD and the scheduled appointment.  The VA’s wait time study that began in 2009 demonstrated that of all possible measure combinations, these particular methods best reflect patient satisfaction.

Regarding GAO’s second recommendation to improve scheduling policy and procedures for the use of the Electronic Wait List (EWL), VHA is updating policy and training.  Also, VHA is ensuring all staff with access to the Veterans Health Information Systems and Technology Architecture (VistA) appointment scheduling system completes required training.  The EWL is used to keep track of patients waiting to be scheduled with a provider in Primary Care, Specialty Care, or Mental Health.  When the new process goes into effect within the next year, only new patients will be placed on an EWL if they cannot be scheduled within 90 days.  In the past, VHA did not specify the 90-day standard.  Patients on the EWL will continue to have their wait times tracked from the time they are entered on the list.  Standardizing all clinics to this procedure will allow managers to better understand clinic operations and resource needs.  

VHA has updated its training program for the more than 50,000 staff that uses the VistA scheduling system.  Schedulers are trained on how to properly record the AUD in VistA.  VHA acknowledges that the VistA scheduling system is outdated and inefficient.  Schedulers must open and close multiple screens to check a providers’ availability.  It can take a scheduler between 30 seconds and five minutes and many keystrokes to make an appointment in VistA, compared to a point and click process in modern scheduling programs.  This cumbersome process leads to user error.  To optimize scheduler efficiency, VHA requires training of schedulers making appointments.  VA medical centers are able to track schedulers’ compliance with training requirements.

While training ensures that staff know the proper scheduling procedures, VHA also requires audits to ensure compliance with these procedures.  The implementation of new AUD procedures enables more comprehensive auditing capabilities.  In the future, supervisors will have the capability to electronically audit proper entry of the AUD by the scheduler.  For a typical Patient Aligned Care Team (PACT) practice, this could range from 1,000 to 2,000 appointments per year for every provider.  Supervisors will not need to pull and review charts, but rather more efficiently retrieve reports from central databases.  This process will audit appointment requests generated internally from health care providers, where the majority of appointments are made.  These procedures do not apply to patients who call-in or walk-in from “outside” the practice.  VHA will continue to require manual audits of these cases.

Complying with GAO’s third recommendation, to ensure adequate scheduling staff is present in VHA facilities, VHA is working to ensure that each medical center has adequate scheduling staff.  Schedulers are entry-level positions with high turnover rates and may have multiple responsibilities.  VHA has launched efforts to study and select the best way to track staff occupying these positions.  In addition, VHA has made progress in developing analytical tools that will help schedulers and managers select the best methods to manage access based on individual clinic patterns of operation.  For instance, clinics have differing amounts of no-shows, cancellations, and different utilization and revisit rates.  

GAO’s fourth recommendation to VHA is to improve responsiveness to Veterans accessing services by phone. To improve telephone service for Veterans calling into health care facilities for appointments, VHA will require facilities to complete a standardized telephone assessment and implement improvements.  VHA will monitor the progress quarterly and align resources as needed.

In addition to actions taken to comply with GAO’s recommendations, VHA continues to develop technology for improving the scheduling system.  VHA has completed programming for version 1.0 of the Veteran Appointment Request Application that is currently being pilot tested.  This “App” resides on a Veteran’s handheld device or desktop computer and accepts up to three preferences for each appointment request.  VHA databases will capture the Veteran-entered first choice as the Desired Date.  VHA has also contracted for the development of a Scheduler Calendar View.  This “overlay” to the VistA scheduling system is envisioned as a way to decrease user error that can occur during the scheduling process.  The Scheduler Calendar View will be a more user-friendly, point-and-click interface.  VHA continues to pursue efforts to replace VistA scheduling with a commercial off-the-shelf product.  The Department has issued a challenge on Challenge.gov for a medical patient scheduling solution.

Conclusion

In conclusion, VHA is aggressively addressing access for patients in many ways. In 2011, VHA raised the bar for the industry by setting a wait time goal of 14 days for both primary and specialty care appointments.  Last year, VHA added a goal of completing primary care appointments within 7 days of the Desired Date.  The intent is to come as close as possible to providing just-in-time care for patients.  The ultimate goal is same day access. VHA is making improvements in delivering timely care to our Veterans and in the reliability of reporting wait time information. We have identified the issues and are taking steps to address them. We recognize that there is more to do, and we will continue to make this a priority.

VA is committed to honoring America’s Veterans by providing them the health care they have earned and deserve. Thank you for the opportunity to speak to you about this issue.  My colleagues and I are ready to respond to any questions you might have.