1

!""#$$ !&'() *#$&+)$ ,&--./0

12.$# 34# !""#$$ !&'() 5/6- 78 9.0 8:7; < 7= 9.0 8:7;

1hls Access AudlL and Lhe lmmedlaLe and longer Lerm acLlon plans address Lhe SecreLary of
ueparLmenL of veLerans Affalrs dlrecLlve LhaL Lhe veLerans PealLh AdmlnlsLraLlon conducL a
sysLem-wlde audlL of schedullng and access managemenL pracLlces. 1hls audlL assesses Lhe
lnLegrlLy of Lhese pracLlces, makes recommendaLlons abouL pollcles, and seLs a course for
sysLem wlde lmprovemenL.
!&'() ,"6>#
hase Cne of Lhe Access AudlL covered ueparLmenL of veLerans Affalrs (vA) Medlcal CenLers
(vAMC)
1
and large CommunlLy 8ased CuLpaLlenL Cllnlcs (C8CC) servlng aL leasL 10,000
veLerans. 1aken LogeLher, hase Cne covered 138 parenL vAMCs encompasslng 216 dlvlslons
or slLes, a LoLal of 238 separaLe polnLs of access, and over 2,100 schedullng sLaff. hase 1wo of
Lhe Access AudlL wlll cover all remalnlng vA faclllLles.

!&'() ?(4'(4@$
Cf Lhe 216 slLe audlL reporLs, many were flagged for furLher revlew because of concerns
ldenLlfled by Lhe slLe audlL Leam abouL quesLlonable schedullng pracLlces, slgnallng a sysLemlc
lack of lnLegrlLy wlLhln some veLerans PealLh AdmlnlsLraLlon faclllLles. 1hese flagged slLes wlll
be revlewed and, where necessary, addlLlonal daLa wlll be gaLhered. SuspecLed wlllful
mlsconducL wlll be reporLed prompLly Lo Lhe Cfflce of lnspecLor Ceneral (ClC). Where Lhe ClC
chooses noL Lo lmmedlaLely lnvesLlgaLe, managemenL wlll launch elLher a formal facL flndlng or
admlnlsLraLlve lnvesLlgaLlon. Where mlsconducL ls conflrmed, approprlaLe personnel acLlons
wlll be pursued prompLly.

8esulLs presenLed ln Lhls summary cover hase Cne of Lhe naLlonal Access AudlL only. 1he
Access AudlL was a rapldly deployed, sysLem-wlde assessmenL of schedullng pracLlces across
vA, and was noL lnLended as a formal lnvesLlgaLlon of lndlvldual sLaff or managers. SlLe survey
Leams were noL able Lo lnLervlew all employees, and Llme dld noL allow assessmenL of lnLenL or
poLenLlal culpablllLy. All of Lhe lnformaLlon collecLed from audlL slLe vlslLs has been shared wlLh
Lhe ClC. hase 1wo of Lhe audlL wlll lnclude smaller cllnlc slLes, anonymous web surveys, and
addlLlonal managemenL perspecLlves conLlnue Lo be collecLed.
2
1he hase Cne flndlngs are a
sLrong basls for lmmedlaLe acLlon. 1he flndlngs from Lhese addlLlonal assessmenLs and surveys
wlll be added Lo Lhe reporL as appendlces Lo Lhls reporL when avallable.

1he Access AudlL was sub[ecL Lo cerLaln llmlLaLlons LhaL were unavoldable glven Lhe scope and
acceleraLed Llmeframe. noLwlLhsLandlng Lhese llmlLaLlons, flndlngs from hase Cne lnclude:


1
noLe: LoglsLlcs challenges prevenLed audlL sLaff from Lravellng Lo Lhe vA Medlcal CenLer ln Pawall, however, slLe
audlLs were conducLed ln uerLo 8lco and Alaska

2

Lfforts to meet needs of Veterans (and c||n|c|ans) |ed to an over|y comp||cated
schedu||ng process LhaL resulLed ln hlgh poLenLlal Lo creaLe confuslon among schedullng
clerks and fronL-llne supervlsors.
Meet|ng a 14 day wa|t-t|me performance target for new appo|ntments was s|mp|y not
atta|nab|e glven Lhe ongolng challenge of flndlng sufflclenL provlder sloLs Lo
accommodaLe a growlng demand for servlces. lmposlng Lhls expecLaLlon on Lhe fleld
before ascerLalnlng requlred resources and lLs ensulng broad promulgaLlon represent an
organ|zat|ona| |eadersh|p fa||ure.
The concept of Desired Date is a practice unique to VA, and difficult to reconcile
agalnsL more accepLed pracLlces, such as negoLlaLlng a speclflc appolnLmenL daLe based
on provlder avallablllLy, or uslng a return to clinic interval requested by providers.
Cvera||, 13 of schedu||ng staff |nterv|ewed |nd|cated they rece|ved |nstruct|on to
enter in the Desired Date field a date different from that the Veteran had requested.
AL leasL one lnsLance of such pracLlces was ldenLlfled ln 64 of hase Cne vA faclllLles.
ln cerLaln lnsLances Lhls may be approprlaLe (e.g., provlder-dlrecLed daLes can, under
pollcy, overrlde daLes speclfled by paLlenLs). 1he survey dld noL deLermlne wheLher Lhls
was done Lhrough lack of undersLandlng or mal-lnLenL unless lL was clearly apparenL.
7-8 of schedu||ng staff |nd|cated they used a|ternat|ves to the L|ectron|c Wa|t L|st
(LWL) or VIS1A package. AL leasL one of such lnsLance was ldenLlfled ln 62 of faclllLles.
As wlLh ueslred uaLe pracLlces, we dld noL probe Lhe exLenL Lo whlch alLernaLlves mlghL
have been [usLlfled under pollcy. 1he quesLlonnalre employed dld noL lsolaLe
approprlaLe uses of exLernal llsLs.
Informat|on |nd|cates that |n some cases, pressures were p|aced on schedu|ers to
ut|||ze |nappropr|ate pract|ces |n order to make Wa|t|ng 1|mes appear more favorab|e.
Such pracLlces are sufflclenLly pervaslve Lo requlre vA re-examlne lLs !"#$%! erformance
ManagemenL sysLem and, ln parLlcular, wheLher currenL measures and LargeLs for
access are reallsLlc or sufflclenL.

3A$)."+#$ )6 B(-#+0 !""#$$
CrlLlcal lnslghLs came from asklng fronL-llne sLaff members Lo raLe Lhe degree Lo whlch cerLaln
facLors lnLerfered wlLh Llmely access Lo care. 1he &$'&!(# scored slngle barrler or challenge was
lack of provlder sloLs, closely followed by Lhe pecullarlLles of Lhe fourLeen day goal
3
. LlmlLed
clerlcal sLafflng was also deemed a slgnlflcanL obsLacle.

CbsLacles LhaL have been poslLed as slgnlflcanL lnhlblLors Lo schedullng Llmely appolnLmenLs,
such as lnadequaLe Lralnlng of schedulers, or Lhe lnflexlblllLy of Lhe legacy vlS1A schedullng
sofLware sysLem, were clLed much less ofLen durlng Lhls Access AudlL.

We also hlghllghL LhaL Lhere were many poLenLlal opporLunlLles ldenLlfled LhaL could lmprove
Lhe conslsLency of deslrable pracLlces among schedulers, such as calllng veLerans abouL
upcomlng appolnLmenLs, addresslng oLher obsLacles, maklng performance lmprovemenL

3
lor example, a veLeran mlghL have been enLlrely saLlsfled wlLh a negoLlaLed appolnLmenL Llme Lhe followlng
month, but that could have been viewed as failing the 14 day standard.
3

acLlvlLles more rouLlne, and ensurlng
LhaL cllnlc operaLlons daLa are regularly
revlewed aL Leam and managemenL
meeLlngs.

?&/)2#/ !")(64$
vA ls now conducLlng surveys aL all
remalnlng slLes, whlch ls scheduled Lo
compleLe ln early !une 2014.
AddlLlonally, vA ls aggregaLlng faclllLy
managements perspective of access challenges, also due to conclude ln early !une.

vA wlll Lake follow-up accounLablllLy acLlons based on resulLs of Lhe Access AudlL. Senlor
leaders wlll be held accounLable Lo lmplemenL pollcy, process, and performance managemenL
recommendaLlons sLemmlng from Lhls AudlL and oLher revlews. Where audlLed slLes ldenLlfy
concerns wlLhln Lhe parenL faclllLy or lLs afflllaLed cllnlcs, Lhe vA wlll Lrlgger admlnlsLraLlve
procedures Lo ascerLaln Lhe approprlaLe follow-on acLlons for speclflc lndlvlduals.

8ased on Lhe flndlngs of hase Cne of Lhe Access AudlL, vA wlll crlLlcally revlew lLs performance
managemenL, educaLlon, and communlcaLlon sysLems Lo deLermlne how performance goals
were conveyed across Lhe chaln of command such LhaL some fronL-llne, mlddle, and senlor
managers felL compelled Lo manlpulaLe vA schedullng processes. 1hls behavlor runs counLer Lo
our Core values, Lhe overarchlng envlronmenL and culLure whlch allowed Lhls sLaLe of pracLlce
Lo Lake rooL musL be confronLed head-on lf vA ls Lo evolve Lo be more capable of ad[usLlng
sysLems, leadershlp, and resources Lo meeL Lhe needs of veLerans and famllles. lL musL also be
confronLed ln order Lo regaln Lhe LrusL of Lhe veLerans vA serves.
C--#'(.)# !")(64$ )6 ,)/&")&/#$ .4' 1/6"#$$#$ 56/ 9.4.@(4@ !""#$$ B(-#+(4#$$
Whlle vPA musL assess and learn from Lhe Access AudlL, we are lmmedlaLely redoubllng our
efforLs Lo qulckly address delays ln Veterans health care. vPA ls ldenLlfylng where veLerans are
walLlng for care and ensurlng LhaL Llmely, quallLy care ls made avallable as qulckly as posslble.

lurLher, vPA ls maklng rapid and definitive changes to ensure integrity in managing Veterans
access Lo care so Lhe agency can malnLaln lLs focus on provldlng veLerans Llmely care. vPA
musL provlde hands-on aLLenLlon Lo all sLaff engaged ln provldlng veLerans healLh care and
managlng access ln a fashlon LhaL ls Lrue Lo our Core values. 1he acLlons/lnlLlaLlves below are
belng coordlnaLed Lhrough a near Lerm plan LhaL commenced 23 May 2014:
AcceleraLe Care for veLerans CurrenLly WalLlng for Care
Assess Care uellvery CapaclLy vs. PealLh Care uemand Lo Lnsure 8esource Levels
8emove 14-uay erformance Coal from erformance ConLracLs
8evlse and/or 8esclnd Schedullng ulrecLlve
Suspend vPA LxecuLlve erformance Awards for l?14
lace-Lo-lace LngagemenL wlLh Medlcal SupporL AsslsLanLs, Cllnlc Managers and CLher
CrlLlcal lronL-llne SLaff
4

CommunlcaLe vAs Core Values Applicability to Day-Lo-uay erformance
8evlew and Modlfy erformance lans for WalL 1lme AccounLablllLles
Modlfy ManagemenL uashboards ueslgned for CrganlzaLlonal and CperaLlonal Levels
Lnhance aLlenL SaLlsfacLlon MonlLorlng Lo Assess SaLlsfacLlon wlLh Access and
Lxperlence
lmplemenL Medlcal CenLer Access AudlLs, Cngolng MonlLorlng, LlevaLlon 1rlggers, and
Clear Llne AccounLablllLy lncludlng Speclflc 8equlremenLs for 8egular lnspecLlon and
8eporLlng
Lnhance vPA naLlonal rogram Cfflce wlLh locus on Access Lo Care
lmplemenL vPA-Wlde SlLe lnspecLlon rocess
Cross-CrganlzaLlon Surveylng of Schedullng and Access 8esL racLlces
8evlew Medlcal SupporL AsslsLanL ClasslflcaLlon Lo Lnsure CorrecL Cradlng
8evlse, Lnhance and ueploy Schedullng 1ralnlng
Assess oslLlon ManagemenL racLlces and SLafflng 8equlred Lo lully SupporL vA
Medlcal CenLers
LsLabllsh WalL-1lme 8ased Culdance for non-vA Care 8eferral
Assess lmplemenLaLlon of SysLem-Wlde ConLracLs for rlmary Care
D64@#/<B#/-E F6->/#2#4$(G# *#$#)
vPA has rlgorously used measuremenL of processes and ouLcomes Lo gauge performance of our
healLh care sysLem, lncluslon of such measures has been Lhe foundaLlon of vPAs performance
lmprovemenL program. Powever, when Lled Lo rewards, measuremenL of sysLem performance
runs Lhe rlsk of engenderlng a culLure where Lhe appearance of success becomes Lhe drlvlng
force. 1he valldlLy and preclslon of measuremenL ls Lhe foundaLlon for all lmprovemenL, and
Lherefore lL musL never be lnLerpreLed as punlLlve or rewardlng. 8aLher, performance needs Lo
be llnked Lo capablllLy, capaclLy, processes and resources. 1oward Lhls end, vPA musL dlrecLly
address Lhe pollcy, process, personnel and sysLem challenges LhaL adversely affecL our ablllLy Lo
give Veterans reliable, quality and #$)!*+ care.

Scheduling is the initial touch point where Veterans access to care is managed, and lL ls also
Lhe polnL of greaLesL rlsk ln provldlng Llmely access Lo care. vPA ),(# geL Lhls process rlghL as
all downsLream funcLlons derlve from Lhls fronL-llne Louch polnL. Lnsurlng lnLegrlLy ln Lhls
process and uslng valld assessmenLs of acLual Llmellness Lo accesslng care ls a leadershlp lssue.

1he acLlons below wlll be coordlnaLed Lhrough an overarchlng access lmprovemenL plan LhaL ls
lncluslve of vPA and vA sLakeholders and sLaff:
8eassess Access 1lmellness Coals Lo Lnsure AllgnmenL beLween Access and CuLcome
Coals
Cverhaul Lhe Schedullng and Access ManagemenL ulrecLlve
8oll-CuL near 1erm Changes Lo Lhe Legacy Schedullng SysLem
Acqulre and ueploy Long 1erm SofLware SoluLlon LhaL lnLegraLes 8esource
ManagemenL, 1elehealLh and 1lme ManagemenL CapablllLles
Ad[usL Medlcal SupporL AsslsLanL ClasslflcaLlon SLrucLure
LsLabllsh SLrong laclllLy 8uslness and PealLh AdmlnlsLraLlve Servlces
3

SLrengLhen AccounLablllLy for lnLegrlLy ln Schedullng and Access ManagemenL

vPA wlll commlL Lo a renewed and aggresslve preparaLlon, Leachlng, Lralnlng and coachlng of
our people.

1hroughouL Lhe lmmedlaLe and longer Lerm changes we wlll emphaslze accounLablllLy. ln Lhe
near Lerm, as we assess slLes for furLher revlew, we wlll ensure LhaL managers and sLaff
engaglng ln undeslred pracLlces are held accounLable. As we lmplemenL lmmedlaLe and longer-
Lerm changes, accounLablllLy for lnLegrlLy wlll resL squarely wlLh faclllLy, neLwork and naLlonal
execuLlves.