May 31, 2014

Unanswered VA Scandal Question: Why Is Even a 14-Day Wait For an Appointment Acceptable?

An item which appears to be overlooked in the Department of Veterans Affairs scandal is the press’s and presumably the public’s blind acceptance of the department’s goal to reduce its average wait times to 14 days as supposedly “aggressive.”

My reaction is that the goal doesn’t seem “aggressive” at all, or even borderline acceptable, based on both personal experience and some admittedly limited research I’ve done on best practices. It seems to me that the average consumer, and for that matter the average journalist, would have a hard time accepting the idea of an average 14-day wait time for a personal appointment involving real urgency. So why should the expectations of or for those who served our country be any lower?


A trade article on medical appointment scheduling has the following narrative (paragraph breaks added by me; bolds are mine throughout this post):

Appointment scheduling is a key part of medical practice management. While it may sound easy, it is deceptively challenging.

The scheduler must estimate how long an appointment will take, be able to cancel and rearrange appointments as patients or physicians dictate, and constantly stay on top of emerging and ever-changing scheduling software. It is a position that takes the patience of a saint, the people skills of a politician, and extreme organizational skills.

When a patient calls for an appointment the scheduler must determine the urgency of the problem and approximate length of time the medical personnel will require to asses and treat the patient’s situation. This is typically done based on just one or two sentences from the patient describing the problem.

If the problem is urgent, but the scheduler misinterprets the patient’s complaints and sets the appointment for several days away, the problem may become exacerbated and worsen into a serious condition. 

Moreover, an appointment that sounds routine and is scheduled for a short time slot but turns out to be complex in nature will run over its allotted time, resulting in long waits for other patients and late hours for the office staff. However, only a certain number of appointments that can fit into each day, so the scheduler must be judicious in scheduling and not overload the caregivers or patient care quality may suffer.

Note that this practice management guidance sets the bar at “several days,” which is a heck of a lot fewer than 14 — and that it often can take only several days before a condition can become serious.

At the extreme, there are those in the private sector who claim to be able to pull off same-day scheduling, including someone who wrote an article on the topic with a list of alleged succesfull results — 14 years ago:

Same-Day Appointments: Exploding the Access Paradigm

… in the early 1990s, we were managing a large primary care department for Kaiser Permanente in northern California. We had roughly a quarter of a million adult primary care patients, more than 100 physicians and 400 support staff. The one thing all of us had in common was that no one was happy, with much of the discontent centered around this issue of long waits and delays, or bottlenecks, in our system. The average wait for an appointment was 55 days, and when our patients were lucky enough to get an appointment, the likelihood that they would see their own personal physician was less than 47 percent.

Not only was the system inefficient and frustrating, but it was also costly. For example, our large backlog of appointments nearly convinced us we needed to hire additional physicians and staff that we didn’t actually need. Long wait lists created a high rate of missed appointments, meaning lost income and lost opportunity. Staff resources that should have been channeled toward patient care were being wasted on triage, phone calls and managing our large backlog of appointments. In addition, the longer care was delayed, the greater the threat to quality.

The access model we created is often called “open access,” “advanced access” or “same-day scheduling.” It has one very simple yet challenging rule: Do today’s work today. Doing so enables patients to see their own personal physician on the day they call for any problem, whether urgent, routine or preventive. In less than one year, it reduced our 55-day wait to just one day, it increased dramatically the odds of patients seeing their own personal physician, and it improved physician, patient and staff satisfaction. We are even gathering evidence that it improves clinical outcomes as well. (See “Success stories.”)

When we first embarked on advanced access, we believed the model would work only in managed care environments. But as we have worked with organizations throughout the United States, Canada and Europe testing and refining these principles, we have discovered that advanced access works equally as well, if not better, in fee-for-service environments. These principles have incredibly broad applications and hold tremendous promise for physician practices of all shapes and sizes.

Read the whole thing.

The point here is that it sure seems that the VA is setting the bar far too low, and that the press isn’t nearly as skeptical as it should be about that supposedly “aggressive” 14-day goal. There certainly isn’t any reason to believe that a veteran’s wait of anything beyond several days is any less dangerous than it would be for the average adult.

If it really doesn’t believe that the same-day model described at the link is realistic —though I’d sure like to hear someone explain why not, given that the system outlined is 14 years old and was developed when scheduling systems had far less firepower — I would think that the government needs to set the bar at “several” days, which I’m taking to mean “three or four, tops.” If they can’t get that done, the government needs to be honest with itself and find private entities which can and will meet best practice standards.

Cross-posted at


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