Assessment E (Workflow Scheduling) E (Workflow – Scheduling) ... This report describes the results of assessing workflow processes for ... scheduling best practices,

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  • Prepared by:

    McKinsey & Company, Inc.

    A Product of the CMS Alliance to Modernize Healthcare Federally Funded Research and Development Center Centers for Medicare & Medicaid Services (CMS)

    Prepared For: U.S. Department of Veterans Affairs At the Request of: Veterans Access, Choice, and Accountability Act of 2014 Section 201: Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs

    Assessment E (Workflow Scheduling)

    September 1, 2015

    Prepared for CAMH under:

    Prime Contract No. HHS-M500-2012-00008I

    Prime Task Order No. VA118A14F0373

    This document was prepared for authorized distribution only. It has not been approved for public release.

  • Assessment E (Workflow Scheduling)

    The views, opinions, and/or findings contained in this report are those of the assessment team and should not be construed as an official government position, policy, or decision.

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  • Assessment E (Workflow Scheduling)

    The views, opinions, and/or findings contained in this report are those of the assessment team and should not be construed as an official government position, policy, or decision.

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    Preface Congress enacted and President Obama signed into law the Veterans Access, Choice, and Accountability Act of 2014 (Public Law 113-146) (Veterans Choice Act), as amended by the Department of Veterans Affairs (VA) Expiring Authorities Act of 2014 (Public Law 113-175), to improve access to timely, high-quality health care for Veterans. Under Title II Health Care Administrative Matters, Section 201 calls for an independent assessment of 12 facets of VAs health care delivery systems and management processes.

    VA engaged the Institute of Medicine of the National Academies to prepare an assessment of access standards and engaged the Centers for Medicare & Medicaid Services (CMS) Alliance to Modernize Healthcare (CAMH)1 to serve as the program integrator and as primary developer of the remaining 11 Veterans Choice Act independent assessments. CAMH coordinated the assessments and is furnishing a complete set of reports of individual assessment findings and recommendations to the VA Secretary, the House and Senate Veterans Affairs Committees, and the Commission on Care. This report describes the results of assessing workflow processes for scheduling appointments for Veterans at VA medical facilities.

    The research addressed in this report was conducted by McKinsey & Company, Inc., and Atlas Research under a subcontract with The MITRE Corporation.

    1 The CMS Alliance to Modernize Healthcare (CAMH), sponsored by the Centers for Medicare & Medicaid Services (CMS), is a federally funded research and development center (FFRDC) operated by The MITRE Corporation, a not-for-profit company chartered to work in the public interest. For additional information, see the CMS Alliance to Modernize Healthcare (CAMH) website (http://www.mitre.org/centers/cms-alliances-to-modernize-healthcare/who-we-are/the-camh-difference).

    http://www.mitre.org/centers/cms-alliances-to-modernize-healthcare/who-we-are/the-camh-differencehttp://www.mitre.org/centers/cms-alliances-to-modernize-healthcare/who-we-are/the-camh-difference

  • Assessment E (Workflow Scheduling)

    The views, opinions, and/or findings contained in this report are those of the assessment team and should not be construed as an official government position, policy, or decision.

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  • Assessment E (Workflow Scheduling)

    The views, opinions, and/or findings contained in this report are those of the assessment team and should not be construed as an official government position, policy, or decision.

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    Executive Summary Health systems across the U.S. have struggled with ensuring optimal patient access to the services they provide, and Veterans Health Administration (VHA) is no exception. Although VHA has faced public concerns about access to outpatient care for several decades, many factors that influence access have been only partially analyzed to date at VHA and were called out in the Choice Act as areas for independent assessment. The Choice Act tasked Assessment E with assessing the workflow process at each medical facility of the Department for scheduling appointments for Veterans to receive care, medical services, or other health care from the Department. The assessment was also asked to address several supplemental areas related to provider scheduling templates, scheduler training, the use of call centers and the appointment scheduling system. All of these factors as well as others explored in Choice Act assessments such as overall health care capabilities (Assessment B) and clinical staffing (Assessment G) are critical to ensuring that our Veterans receive improved access to care.

    In this assessment, we have reviewed VHA performance in the scheduling workflow areas against best practices from both within VHA and across the private sector. The major finding of this assessment is that VHA is not fully leveraging provider resources, scheduling best practices, or scale to deliver the best possible scheduling experience and access for Veterans. These shortcomings have a negative impact on both patient access to outpatient appointments (in terms of total number of appointments available and the matching of patients to those available appointments) and the patient experience of scheduling an appointment with VHA. It is likely that, with improved data visibility, more streamlined processes and performance management, VHA could expand the supply of appointments even with its existing provider base, as well as improve overall utilization of appointment supply and patient experience.

    More specifically, we observed the following challenges that reduce the overall effectiveness of VHA scheduling today:

    System limitations prevent accurate visibility into the supply of available appointments, inhibiting VHAs ability to understand the gap between total appointment supply and demand and to effectively manage current performance and plan for the future. Due to system design limitations, some providers operate across multiple, potentially overlapping, booking templates or clinic profiles for any given day or session. As a result, these profiles, when aggregated, provide an inaccurate picture of total available appointment supply and make it challenging to easily understand whether appointment supply matches the quantity VHA should expect given the number of providers. The issue of overlapping profiles not only affects centralized calculations of overall and provider-level appointment supply, but also makes it challenging to calculate provider utilization rate, which is an essential metric for managing access to care. These limitations mean VHA cannot determine how much patient demand its current provider capacity can meet in a timely manner.

    Imbalance between supply and demand has led to policies that add responsibilities for schedulers and administrators. Because VHA has a persistent backlog of patient demand, VHA created additional policies that do not exist in the private sector, such as the capture

  • Assessment E (Workflow Scheduling)

    The views, opinions, and/or findings contained in this report are those of the assessment team and should not be construed as an official government position, policy, or decision.

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    of patient desired date and the use of the Electronic Wait List (EWL). These policies for measuring wait times and managing waitlists have resulted in a significant number of additional activities required within the schedulers day-to-day workflow. Further, the implementation of these policies is left largely to frontline interpretation, which may also result in inconsistent experience for patients across clinics or facilities. For example, use of the EWL varies across clinics; some clinics use it solely to measure backlog while others use it to highlight patients who may be willing to take an appointment that becomes available at the last minute (Choice Act site visits, interviews 2015). Veterans may then experience variation in when they are removed from the waitlist depending on how their clinic has implemented EWL.

    Clinics do not consistently employ standard industry practices related to schedule setup and other scheduling processes. VHA clinics are inconsistent in their use of industry and VHA best practices in scheduling, resulting in a fewer appointment slots available than may be possible within existing provider capacity and a significant number of booked appointments not being completed as originally scheduled. On schedule setup, examples of these practices in common use in industry and within certain services (such as Primary Care) within VHA include using standard appointment lengths within a sub-specialty and determining appointment mix (for example, number of new patient slots) based on patient demand (Institute for Healthcare Improvement (IHI), Reduce Scheduling Complexity, n.d.; Primary Care Clinic Profile Standardization Guide, 2014). Similarly, inconsistent scheduling practices, such as the ways in which appointment reminders are used, exist across facilities and clinics. For example, a patient could expect a reminder from a clinic and not receive it (and potentially not go to the appointment as a result). Ultimately, the variability in these practices may result in reduced appointment availability and utilization as well as inconsistent patient experience.

    Facility-level differences in performance management and accountability limit system-wide improvements in access. VHA facilities lack consistent organizational st

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