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Research Highlight

The Evolution of Veteran-Centric Access Metrics

In 2014, VA underwent a widely publicized crisis in confidence as Congress and the public questioned whether appointment wait time metrics used by VA accurately reflected patient experience.1 Our work validating VA access metrics has found a consistent relationship between longer waits for VA care and decreased self-reported satisfaction. Our research findings also highlight the importance of using diverse metrics when assessing self-reported satisfaction for different populations.2

Historical Context

Congress requested that VA begin systematically measuring wait times for outpatient care over a decade ago when concerns first surfaced regarding excessive wait times experienced by Veterans for VA care. VA initially measured access by calculating the number of days between an appointment request and the first next available appointment in the scheduling system. Despite similar measures being extensively used in the private sector, VA recognized that these metrics measured overall supply but did not take actual Veteran experience into account. For example, a Veteran may not want or need the next available appointment but, rather, may want to schedule a follow-up appointment months from today. The metric did not take such preferences into consideration, assuming every Veteran wanted the next available appointment. Consequently, when the Veteran actually scheduled and completed the appointment was not captured.

Beginning in 2004, VA policymakers moved away from this 'first next available' appointment metric and developed several different access metrics. One such metric used the initial appointment request date as the starting point and then calculated the number of days until the appointment was scheduled or completed. Another metric used the ideal date that a patient wants to be seen—as interpreted by the scheduler—as the starting point (desired date). This metric was revamped in the Veterans Access Choice and Accountability Act of 2014 (Choice Act) that was passed in response to the VA access crisis.3 The clinically indicated date, also known as the patient preferred date, is now captured and used as the starting point. This date is the date that a provider requests to see a patient.

Past work has found new patients may want to be seen as soon as possible due to emerging health concerns. Returning patients may prioritize convenience of appointment times or continuity of care over how long they are waiting for appointments. Our work supports these conclusions. New patients who visited facilities with longer wait times using the 'appointment request' metric reported lower satisfaction with both their ability to access VA care and more generally with VA care. In fact, our research found no relationship between the 'desired date' metric and satisfaction for new patients. In contrast, there was no relationship between the 'appointment request' date metric and selfreported satisfaction for returning patients. We did find a consistent relationship between the 'longer desired' date metric and lower satisfaction for these patients.

Access to Specialty Consult Appointments

Preliminary recent work focusing on wait times for specialty consult appointments further supports these findings and expands the definition of Veteran-centric metrics. Patients referred to specialty care are likely to have new concerns and want to be seen as soon as possible after the need for a referral is identified. Veterans visiting facilities with longer wait times for specialty consults report lower satisfaction when assessed using a metric with consult 'appointment request' date as the starting point. Notably, a metric that measured the time it took to complete behind the scenes administrative processes (e.g., transferring the consult) had no relationship with satisfaction. As VA continues to put a greater emphasis on the experiences of patients, these findings suggest that metrics should focus on measuring tangible processes that patients easily understand as action being taken on their behalf, such as scheduling appointments.

Our work confirms that appointment wait times are an important issue for Veterans. When there is not an emerging health concern, Veterans may prefer to wait longer and prioritize other aspect of their health care. Ongoing work is examining whether the new access metrics that measure wait times and were required by the Choice Act reliably predict patient satisfaction. As VA continues to reorganize and provide comprehensive services outside of traditional appointments, more comprehensive access metrics that reflect patient experiences with non-traditional encounters—such as telephone contacts and secure messages with members of their care team—will also be needed. Researchers will need to validate these new metrics by demonstrating that better reported performance is associated with increased patient satisfaction.

References

1. Department of Veterans Affairs Access Audit. System- Wide Review of Access Results of Access Audit Conducted May 12, 2014 through June 3, 2014. Washington DC: U.S. Department of Veterans Affairs.

2. Prentice JC, Davies ML, SD Pizer. "Which Outpatient Wait-time Measures are Related to Patient Satisfaction?" American Journal of Medical Quality May-Jun 2014; 29(3):227-3.

3. Veterans Access, Choice and Accountability Act of 2014 ("Choice Act") http://www.va.gov/opa/choiceact/documents/Choice-Act-Summary.pdf