VA 2008 Patient Wait Times Memo

Department of Veterans Affairs memo from Sept. 2, 2008, in which officials said they found workers at the Phoenix VA Health Care System altered records of patient wait times to improve their performance measures.
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   epartment or Veterans ffairs -... Memc~randum ·f, · ate: eptemb~r 2 2 8 . ,_. ; ~ , From: Assistant Inspector General for nvestlg~tlons (51) Subj: Administrative Investigation -Improper Altering of Patient ~ It Times and Failure to Use the electronic d List, Phoenix VA Heal· h Care System, Arizona (2007.()311 1'-IQ-0190) To: Ofreclor, Phoenix VA Health Care System 1. The VA Office of Inspector General (OIG), Administrative lnve ti~ ations Division, lnvestigEIIted an allegation thQt VA employees altered ·patient wait tin 1es In an effort to Improve tf1elr performance measures at the Phoenix VA Health Cant System. Employees allegedly cancelled and resched1,11ed appointments for tl.e same date and time . tnu& oreating a O d<av wait time. To assess thl& &lleoatJon, nterviewed and Patient Service ~ssistants, also known as schedulers. We reviewed VHA Outpatient Scheduling Pn IC8Sses and Procedures, scheduler performance plans, V policies, and other n levant documents. We lnvHtlgated and did not sc.~bstantiate allegati ons of a mismanag ment of ~ources abuse of authority or improper hiring, and they will not b1, discussed further in this memorandum. ·. 2. We found that It was an 'coepted past practice at the medical nter to etlter appointments to avoid wait times greater than 30 days and that $0 e employees $1111 continue this practice. We also found that some schedulers did not understand their perfonnance standards and that the medical center did not use the ,lectronfc wait list (EWL) In aeooraance with policy. We suggest, in nght of a May 200 3 OIG report titled Audit o Alleged Manipuletlon o ~fting Tlmes In Vefaf8ns lnttlgrst nJ Serv ciJ Network 3, that ensure all HAS steff, from management to schedulers, U~Je the VistA scheduling pacl<age In compliance with policy to properly mar age appolntmfiJllt:o; provide chJrificatlon on performance standtãrds to schedulers and th l'ir supeNisors to ensur$ that schedulers are not penalized for following VA poticy; an~ eneure v~terans are placed on tl'le EWL when appointmente, cannot be scheduled W :hll'l th 3 or 120.(1ay r~quirement. We are providing this memorandum to·_ fc r _ information and of'ficial use and any 81etion deem appropriate. No responsE is necessary. Improper Altering o Patient Wait Times 3. VHA policy states that all outpatient clinic appointments must be soheduled using Veterans Health Information Systems and Tschnology Arcnltecture :VIstA) Scheduling options. It requlre6 that all veterans with service connected ratings ~5 per~nt or greater to be seen within 30 deys of the d0 lred date for im: conditl m; wherea& It requires veterans with service oonnected ratings of less than 50 pe1 ~ent to be seen  '  ; . · ã within 30 days of the deeired date only f9r a service connected dis< t bility   AJI other veterans must be scheduled tor care within 120 days of the deslrec dete. Polley defines desired dateã as the earliest date on which the patient or clinician specifies the patient needs to be seen. Veteran6 who cannot be scheduled ' or appointments within the 30- or 120-day requirement ehould be Immediately placEd on the EWL . VHA Olrectlve 2008-0SS. 4. The following exempl .. clarffy how the VistA pacl<age calculttte 1 patient walt times: ã When a patient asks to see a doctor as soon as possible or a doctor asks that a patient be s.een at the next available appointment, the ap ltolntrnent should be tehectuled as a Next Available appointment, and the desl ·ed date '' defaults to the date it is created. Thus, if an appointment Is made o l June 1 and the ~next available appointment ~ Auguat 1, the desired date' defaults to June 1, creating a 6<>-day patient walt time. ã When a patient asl<e for a epecific date or a doctor provlda4 only a at~ range, such as 2 to 3 months from today, ~ appointment Is sch lduled as a Not - Next Available appointment, and the desired date becom ~s the speci fic date requested by the patient or the fir&t date of the date ranger aquested by the doctor. Therefore, If today Is June 1 and the patient asks o and is given an appointment on August 1 or a doctor rovld~ a 2- to J..m01 1 h date range, the desired date defaults to August 1 creating e 0-day watt til ile. 5. Two medical center schedulers told us that it was common prac lloe to alter appointment$ to obtaln a ).day walt time to avoid w it times greah r than 30 d.-.y$. A supervisory scheduler explained that, In the past, schedulers cone itloned themselves to ffx appointments so that they reflected zero. She sa id that the:· dld this to avoid making appointment& that showed up on a ãnegative list'' generate J by supervisors that listed appointments with more than a 30-<fay walt tlme. She e :plal ned that, In the paat, to avoid having her name on the list, she scheduled appointn tents twice. She 6ald she first entered t e appointment in the next avf ilable functi· >n to find the next available date; &he backed out of that function: and she then re-en .ered that same appointment date as a desired date, resutting in a ~ay walt tlmt ·. She further to ld us that her managers previously told her to never use the next avr 1ilable function and to only enter acDointment:s with a ãdesi red date. She said that in 1 >ecember 2007 , he Jave her a ll~t o appointments with more · han a 30-day wall time, and she, in turn, gave the list to two ~;chedulers Instructing t em to fix the appointments. However, she told us that ~ince that time , she believed that schedulers entered all appointment$ correctly In the VistA package. 6. On the contraty, one scheduler told us that canceling and rema dn9 appointments for the same date to get a 0-<lay wait time was a current practi ce . She said that She changed one 9 recent ae 1.hour prior to he r Interview with ue and that they (supervisors) will ding the heek out of yov If they see a number on t he bottom of their report. She said that management recently sent her a fi st of appolltments with more 2  ã ã than a 30-day wait time, along with Instructions to remake those a~ polntments. Further, another 6Cheduler told us that when he Initially made appc lntments, he immediately remade the seme- appointment, If It reflected more tha , a 30-day wait tlme. He further said that every morning, his supervisor ran a repo t of appointments made tor servic& oormeoted veterans and that anything with more ·h an a 30.(fay welt time we& chF;~nged. As a result, he said thl t the schedulers tralne·t themselves'' to change the lnltl1l sppointmenta automatloally'to avoid ehowing up m his list. 7. Another supervisory schedul er told us that the ins1ructed sche<futers , In the past, to keep walt times at :z:ero, so th t schedulers automatically chetnged or cancelled appolntmenf$ to avoid hO'Iving ã my walt times greater than 30 days. He also said thet schedulers were lnstructe< to flx any appointments listed on their reports that reflected more than a 30-< ay walt time. He said that he did as l ns1ruoted , because he had ãa wife and ki Js anc needed his job. He said that sometime in 2007, the to d the schedyters to stop fudging~ the numbers, and the supervtsor sa1d that sinoe thai time, he believed schedulers made entries oorr~ly. However, one scheduler told u ã that it was soi'T'Ietlme In 2 oa when the· ins1ructet them to fix only those appoln1ments which aehedulers made imoroperly when lnltle lly scheduling the appointments. The said that, as an e· ample, if a scheduler did not enter the proper ãdesired date when the provide s note clearly gave one, It would be an improperly sched   ~ ied appointment that l 'o ~e to be fiXed. 8. also told us that he reviewed t ervlce oonnected patient appointments with more than a 30-day wait time to see If th gy were made correctly, and If they were not, he asked that they be corrected. Ht, explained that if a schvduler did not enter a desired date when the provider gave or , It would be an Incorrect entry and that appointments made the proper way were lr t ft untouched. He told us that he stressed at meetings that he wanted schedulers to 1 nake appointments the way they were trained, and tt was ill gross misunderstanding lãy the schedule~ to zero out appointments with more than a 30·day wait time. 9. A scheduler at the medfcal oenter'e told us th~ I in the p~st, managers Instructed him to zero out apPomtments reflecting over :: o day$, He sa id that when he arrived at that clinic in January 2008, he found th~ tt e schedul ers there were also zeroing-out any appointments reflect in g more than a 3· ã·day walt tlmei therefore, he con11nued to ~r out appointments up through Marclr 2008. He said th Jt he received a dally report Ut le d Service Connected Vetarsns f waiting ppointments to find those with a walt time beyond 30 days, end I . a e~ve the report to the schedulers, ins1ructing them to fix theirs and then pass It to tt e next scheduler. He also told us that ã though he rnetMged new patient appolntmer Is , he entered all appointments usln~ onlv (fesired dates· reg rdle~ of the type of 1 ppoinlment made. because the nstructed him to go strictly by desired· dates. He said that his only exception to those Instructions was that he u ed the next available~ function when rescheduling patients that cancelled appc lntments.  ã r ã ã 10. told us that when she f1rst arrived ; t the medical center In 2004, it was standard practlca to alter appointments, and employees readily admitted to her that it ~e gaming the system. She said that prlo ·to the VA Scheduling Directive, schedulers changed or cancelled appolntme 1ts to avoid any Indication that they made appotntments with mont than a 30-day w Jlt ttme. and she said that old habits were hard to break. She told us that since she became a supeJVisor, she Instructed her staff to schedule correctly and that s 1e rel~d on her front llne managers to make sure they followed her instructions. S 'e said that she ran reports to monitor a no compare the appointmentz with the physlcJE ns' not~. She said that a report she ran 3 weeks ago reflected more than 400 appoint nents with walt times greater than 30 days and that about 10 percent of those werãl done Incorrectly. She told us that ell schedulers took scheduling training, along with one-on·one training for 3 weeks when oriented to their Individual positions. and tha1 sC i edUiers were aware of the new VA SCheduling Directive. Records reflected that the employees we in1ei'Viewed took the required scheduler training in 2007 or 2008. 11. ·  ã told us th t he supervised all sc 1edulers n primary care and specialty cllnies and that he was ultlmate v resDonslble fc ~their ~cheduling practices. H'i' said that the previous enc ouraged fixing appointments, but since anc' came onboard, the pn ctlce no longer existed. He said that he was not aware that schedulers were maki 1g appointments, cancelling them, end rebooking them to zero out the walt times. F1rrther, he $aid that employees were instructed to correct only improperly scheduled a11POintments and that they ran a dally report to check for appointments with a wait til ne of more than 30 days, correcllng only those that were rnade Incorrectly. 12. gave us the following example of an incorrectly madf ' appointment: A physician's note said to give a patient the next available appointr 1ent. The scheduler went Into the scheduling program on May 1, found the next avallat le appointment wes on August 1, or 90 days from then. If the scheduler put In May 1 as the desired date, they were Incorrect, as that created a wait time of 90 days · said thBt the scheduler should instead put In a desired'' date o August 1 to ave ld a 90-day walt time. He told us that schedulel' 3 were not supposed to use the ne ct available'' function in the VistA package, e5 it skewed the numbers. Howe'v :tr, example was contrary to VHA Directive 2006-055, Attachment o, thlch states that when an appointment Is scheduled as a ''Next Available, the d~l·ed dale defaults to the date the appointment is created and that this is proper when a patient asks to see a clinician as soon as possible or the cl'nic la n requests the patient be scheduled for the next available appointment. In ã ã example, the proper way to schedule the August 1 appointment would be to use the Next Available rurction, which defaults the desired date to May ~ thus creating a 90-day walt ti fie. 13. Records reflected that the 2005 Performance Plan for schedu ~rs listed the use of the scheduling package as a critical element and that for a fully su ~oessfuJ rating, the sehArilll~r should have no more than four substantiated instances )f non-compliance. told ue that schedulers were not permi :ted more than four 4
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