VA Health Care: Veterans' Concerns About Services at Wilmington, Delaware, Center

Published by the Government Accountability Office on 1990-02-08.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                      United   States   General   Accounting   Office
                      Briefing Report to the Ranking
    GAO               Minority Member, Committee on
                      Governmental Affairs, U.S. Senate

    February   1990
                      VA HEALTH CARE,
                      Veterans’ Concerns
                      About Services at
                      Wilmington, Delaware,
             United States
GAO          General Accounting  Office
             Washington, D.C. 20548

             Human Resources         Division


             February 8,199O

             The Honorable William V. Roth, Jr.
             Ranking Minority Member
             Committee on Governmental Affairs
             IJnited States Senate

             Dear Senator Roth:

             Your October 21, 1988, letter requested that we review veterans’ con-
             cerns about health care services at the Department of Veterans Affairs’
             (VA) Wilmington, Delaware, Medical Center.’ The concerns focused pri-
             marily on delays in obtaining care in the following areas: outpatient,
             orthopedics, pharmacy, prosthetics, cardiology, speech therapy, and
             diagnostic testing.’ Concerns were also expressed about the cleanliness
             of some areas of the center. As agreed with your office, we determined
             whether (1) the medical center was aware of the veterans’ concerns and
             (2) corrective actions, if warranted, were taken to address the concerns.

             On November 27, 1989, we briefed your office on the results of our
             work. We reported that the medical center director was aware of the
             veterans’ concerns and had taken actions that adequately addressed two
             areas (cardiology and diagnostic testing). Waiting times for speech ther-
             apy and prosthetics did not appear to be problems. Additional corrective
             steps were needed to correct orthopedic, pharmacy, outpatient care, and
             housekeeping problems. This letter highlights the four service areas we
             found needing additional actions. After our discussions with the center
             director and VA headquarters officials, they agreed to take actions to
             improve conditions in these four areas. Appendixes I through VIII pro-
             vide a more detailed discussion of the veterans’ concerns about each of
             the eight service areas.

             In recent years, the medical center director made changes in many of the
Background   service areas of concern to veterans including (1) discontinuing orthope-
             dic services and (2) reducing the number of staff assigned to some other

             ‘Concerns about the adjodicatwn of compensation claims is discussed in Veterans’ Benefits: Allega-
             tmns Concerning Claims Adjudication at Wilmington, Delaware, Center (GO A /
             Aug. 31, 1989).

              ‘Wr rcvirwed the three pnmary diagnostic testing areas: radiology, nuclear medicine, and laboratory

             Page 1                         GAO/HRD90-SSBR Veterans’ Concerns About Wilmington Center

                    residents from the Wilmington center in order to locate them in a hospi-
                    tal closer to the college. Subsequently, the center’s orthopedic work load
                    decreased significantly, at least partly because other medical centers
                    discontinued referring veterans to Wilmington for orthopedic care. In
                    March 1988, the center’s director decided to discontinue providing these
                    services. The last orthopedic service was provided in February 1989.

                    Although we did not find any veterans who had to wait 6 months for
                    service, we found that some veterans’ care was delayed because of poor
                    coordination between the Wilmington and Philadelphia centers. Our
                    review of 27 referrals; showed that veterans had to wait an average of
                    45 days for an appointment in Philadelphia-ranging      from 26 to 67
                    days. These veterans were generally referred to Philadelphia for evalua-
                    tion of chronic conditions, after first being examined by a Wilmington
                    center physician.

                    When 13 of the 27 veterans arrived at the Philadelphia center, they
                    encountered delays in completing treatment. These delays resulted
                    because X-rays (1) could not be located, (2) were not completed before
                    the referral, or (3) were not properly coded to show the veterans’ identi-
                    fication numbers. The attending physicians at the Philadelphia center
                    examined these veterans and had them schedule a follow-up visit so
                    that X-rays could be taken and reviewed. The follow-up appointments
                    orcurrcd an average of 57 days later and ranged from 27 to 128 days
                    after the vet,erans’ initial visits to Philadelphia.

                    Although Philadelphia physicians were aware of the above problems
                    with X-rays, they did not communicate them to Wilmington officials.
                    When we told Wilmington officials about these problems in August
                    1989, they agreed to establish a formal log to track each orthopedic
                    referral through the actual visit in Philadelphia and to hold meetings
                    with Philadelphia staff to improve communications and eliminate as
                    many delays as possible.

                    Veterans alleged that the waiting times for prescriptions to be filled at
Pharmacy Services   the Wilmington center were excessive. Medical center records showed
                    that as of February 28, 1988, veterans had to wait over 2 hours for a
                    prescription to be filled. \A’S director of pharmacy services considers

                    Page 3                 GAO/HRDYOQ5BR   Veterans’   Concrms   About Wilmington   Center
                        The center took two steps to reduce waiting times. First, in January
                        1989 veterans with appointments were allowed to report directly to the
                        appropriate specialty clinic. Second, the center staff encouraged veter-
                        ans without appointments to call 3 days before their planned visit so
                        that medical records could he retrieved from storage before the veterans
                        arrived, thus saving time.

                        In .July 1989, the center studied waiting times in the general medical
                        clinic and found that they had increased rather than decreased for those
                        without appointments. When we discussed this situation with the center
                        director and M headquarters officials, they agreed to take additional
                        actions to reduce the delays. First, the assistant chief of staff for ambu-
                        latory care will routinely monitor delays and personally treat walk-in
                        pat icnts when a backlog exists. Second, center staff will conduct a study
                        to identify ways that t hc flow of patients through the outpatient area
                        can he improved.

                        \‘ctcrans alleged that bathrooms and floors in some wards were unsani-
Housekeeping Services   tary or dirty. Although the center has made efforts to correct this situa-
                        t ion. some cleanliness problems continue to exist because of staff

                        During a tour of the center with representatives of veterans’ service
                        organizations. we noted heavy dust on ventilation ducts and light fix-
                        tures in pat,ient treatment areas. The Joint Commission on Accreditation
                        of IIcalthcarc Organizations, veterans’ organizations, and the center’s
                        housekeeping staff had reported cleanliness problems, such as dirty
                        floors. at, t,hc center during the last, 3 years,

                        Center officials made significant changes in housekeeping services over
                        the iast 6 years that contributed to the center’s cleanliness problems.
                        Staffing levels were reduced from 42 in 1983 to 32 in 1989 in an effort
                        to reduce costs. As a result, administrative areas were cleaned less fre-
                        quently because housekeeping staff were used to perform daily mainte-
                        nance in patient arcas. Further, heavy-duty cleaning, such as washing
                        walls and air vents. was done less frequently throughout the center.

                        ‘I’hc director agreed that reduced housekeeping staff levels have
                        resulted in the center not being as clean as when staffing levels were
                        higher. IIc stated, ho\vevcr, that the rate of infections developed by vet-
                        crans at the center has not increased. When we discussed this situation
                        with M headqtmrtcrs officials in November 1989, they stated that

                        Page 5                 GAO/HRD-90.55BR Veterans’ Conccms About Wilmington Center
Page 7   GAO/HRD-90.55BR Veterans’ Concerns About Wilmingtm, Center
Appendix IX
Major Contributors to
This Report
Table                   Table VI. 1: Special Pay Rates                                               27


                        VA        Department of Veterans Affairs

                        Page 9                 GAO/HRD~SSBR   Veterans’ Concerns About Wilmington Center
                      Appendix I
                      Orthopedic Care

                      In June 1986, the Jefferson Medical College’ withdrew its two orthope-
Orthopedic Services   die residents from the Wilmington Medical Center. According to the dean
Canceled              of the college, the new chief of orthopedics at Jefferson requested the
                      transfer of the residents to a hospital closer to the college. The Wilming-
                      ton center attempted to establish affiliation agreements with other med-
                      ical schools and hospitals in the area but was unsuccessful. It is the
                      center director’s view that without an orthopedic residency program,
                      the facility will not he able to attract physicians willing to work the long
                      hours necessary to provide orthopedic services.

                      The center director decided to stop providing orthopedic services
                      because the inpatient work load decreased after the residents left and
                      staff reductions were required to meet authorized staffing levels. After
                      the residency affiliation was canceled, the number of full-time orthope-
                      dic staff at the center fluctuated, and the chief of staff said the inpa-
                      tient work load did not justify continuing the orthopedic service. The
                      inpatient work load decreased by 65 percent from 1986 to 1988. When
                      management decided in March 1988 to eliminate orthopedics, one physi-
                      cian transferred to another medical center, leaving one part-time ortho-
                      pedic physician who staffed a limited orthopedic outpatient clinic until
                      he retired in March 1989. At that time, all orthopedic services were ter-
                      minated, and veterans needing orthopedic care were referred to Phila-
                      delphia. Most veterans were referred to Philadelphia for evaluation of
                      chronic conditions, after first being examined by a Wilmington center
                      physician. Wilmington has no plans to restore orthopedic services.

                      The Philadelphia center orthopedic clinic scheduled those veterans
Referral Process      included in our medical record review, an average of 45 days after Wil-
Functions but Some    mington physicians saw them. Although we did not find a B-month delay
Delays Occur          in waiting for the initial appointment, delays averaging 57 days did
                      occur when the Philadelphia physicians ordered X-rays and the veter-
                      ans had to either return to Wilmington for them or have them taken
                      when they returned to Philadelphia for further treatment.

                      The Wilmington center scheduled appointments for veterans referred to
                      Philadelphia, but did not monitor the process or keep a list of every vet-
                      eran referred. We wcr(’ able to document 62 referrals made between
                      mid-November 1988 and February 1989. From these 62 referrals, we

                       A part of Thomas .Jefferson I lnwvrsity in Philadelphia. Pennsylvania. The hchml has an affiliation
                      ;~~rcementwth VA.

                      Page 11                         GAO/HRDS@55BR        Veterans’   Concerns   About Wilmingtm    Center
Appendix II

Pharmacy Services

              l   Veterans alleged excessive
                  waits for prescriptions
              l   2- to 2-l/2 hour wait in
                  February 1988
                  *Wait reduced to 60-80
                   minutes in December 1988, but
                   some waited 2 hours
              l   VA taking steps to overcome
                  personnel, staffing, and
                  inventory problems
                          Veterans alleged that the waiting times for prescriptions at the Wilming-
                          ton center were excessive. As of February 28, 1988, veterans had to
                          wait over 2 hours for prescriptions to be filled. Such delays were due to
                          (1) shortage of personnel, (2) inadequate space, and (3) inefficient
                          inventory practices. Management actions, such as the hiring of a new
                          pharmacy chief and improving inventory practices, have reduced wait-
                          ing times, but many veterans must still wait more than 1 hour.

                          viz’s director of pharmacy services considers waiting times of more than
Excessive Waiting         1 hour for prescriptions to be excessive, but \:t has no formal criteria for
Times                     acaceptable waiting times. The Wilmington center reported an average

                          Page 13                 GAO/HRD-90.BBBR   Veterans’   Concerns   About Wilmington   Center
                        Appendix   I1
                        Pharmacy   Services

                        pharmacy space and the way the space was laid out limited Wilming-
                        ton’s ability to fill mail-out prescriptions and to reduce the number of
                        veterans waiting at the pharmacy for prescriptions to be filled. Wilming-
                        ton’s mail-out prescriptions totaled 35 percent of the outpatient work
                        load in February 1988 and 41 percent in the first 9 months of fiscal year
                         1989 (compared with a VA-wide average of 60 percent). Overall, the
                        pharmacy filled almost 154,000 prescriptions in fiscal year 1988, a 150-
                        percent increase over 1984.

                        The medical center planned a pharmacy expansion in fiscal year 1986 at
                        an estimated cost of $56,000, but this project has been repeatedly
                        delayed.’ The regional medical director funded the project in fiscal year
                        1988 but the center’s director used the funds for routine operating
                        expenses. At the time we were performing our work, the director
                        planned to implement the project in fiscal year 1991.

                        A third factor contributing to delays in filling prescriptions was drug
Inefficient Inventory   inventory management practices, which made it difficult for the phar-
Practices               macy to track and maintain a sufficient supply of medications. The
                        center’s current pharmacy chief established a computerized inventory
                        system to monitor medication supply levels and track procurement
                        requests that was activated in the late summer of 1989. Another action
                        to improve inventory management was the revision of the hospital’s for-
                        mulary list (a list of medications that should be stocked and/or readily
                        available for patient care when needed). The new hospital formulary
                        reduces the number of drugs that must be carried in the inventory,
                        thereby reducing costs.

                        The Wilmington center began experiencing difficulties in hiring and
Staffing Problems       retaining pharmacists in October 1988. The new pharmacy chief cited
                        personnel-related problems and noncompetitive pay rates as the major
                        reasons for staff turnover. Three pharmacists resigned between October
                        and December 1988 because, in the pharmacy chief’s opinion, they dis-
                        agreed with the changes he had implemented (e.g., extended hours, tem-
                        porary leave restrictions). The pharmacy chief also stated that he was
                        unable to recruit new pharmacists because the starting salary ($13.87
                        per hour) was too low. As a result, the medical center requested and

                         ‘A clinical addition and renrn~~twn project including a new pharnucy was planned in 1983. This
                         project has been repeatedly delayed, however, and no funds for construdinn were authorized m the
                         medical center’s fiscal year 1989 hudget.

                         Page 15                       GAO/HRD90-55BR       Veterans’   Concerns   About Wilmington   Center
Appendix III

Outpatient Care

               l   Veterans alleged excessive
                   waits for outpatient care
               l   I- to 1-l/2-hour wait in April
                   1988 for nonemergency care
                   @Primarilydue to walk-ins
               l   Process streamlined but
                   waiting times increased
               WA taking additional steps to
                serve walk-ins
                            Veterans alleged that there were excessive waiting times for services at
                            the outpatient facilities. Veterans without appointments (walk-ins) fre-
                            quently had to wait 1 l/2 to 2 hours before seeing a doctor for non-
                            emergency care in fiscsal years 1988 and 1989. Medical center actions to
                            revise the intake process and decrease the unpredictable work load have
                            been unsuccessful.

                            The Wilmington center had 73,679 outpatient visits in fiscal year 1988,
Intake Processing           an increase of 28,160 visits since 1984. Medical center officials said
Is Cumbersome               thcrcb has been an increase in the number of veterans using the center
                            and a shift t,oward outpatient treatment of many illnesses. Almost half

                            Page 17               GAO/HRD-90.MBR Vrterans’ Concrms About Wilmington Center
                      Appendix Ill
                      Outpatient  Care

                      VA has no criteria for acceptable waiting times. The chief of ambulatory
                      care at the medical center considered these delays undesirable but not

                      Medical center officials believed that the problem of delays in the
                      center’s ability to serve outpatients was caused primarily by the large
                      number of unscheduled visits made to the center by veterans. The medi-
                      cal center has the equivalent of 3.5 full-time physicians assigned to see
                      outpatients in the general medical clinic. These physicians see both
                      scheduled and unscheduled patients. No physician is assigned to handle
                      only walk-ins because the work load is unpredictable and all physicians
                      have full appointment, schedules. A physician working part time saw
                      walk-in patients 2 or 3 days a week during part, of 1988, but he retired
                      and VA did not fill this position.

                      Center officials have taken several actions to streamline intake process-
    ^^      Actions   ing. The assistant chief of medical administration services established a
ineffective           “scheduled walk-in” procedure to help manage the unscheduled work
                      load and eliminate the wait associated with retrieving medical records.
                      The new procedure cnc>ouragesveterans to call 3 days before “walking
                      in,” thus giving staf’f an opportunity to retrieve medical records before
                      the veteran’s arrival.

                      Medical center officials expected that these changes would alleviate
                      some of the delays. Ilowever, a July 1989 study by center staff of wait-
                      ing times for unscheduled veterans showed a 32-percent increase in the
                      average waiting time to see a physician. The assistant chief of medical
                      administration services stated that, as a result of this study, in August
                       1989 he recommended to medical center management that an additional
                      staff physician be assigned to handle unscheduled veterans in the outpa-
                      tient clinic.

                      After we discussed t.hc waiting times for outpatient care with center
                      officials, they advised us that another study will be done by the center
                      to determine the effectiveness of changes made in the flow of patients
                      through the outpatient clinic. In the meantime, the assistant chief of
                      staff for ambulatory care will see walk-in patients when backlogs exist.
                      11~and the ambulatory care coordinating committee are also considering
                      other options to impro\,e timeliness within current budgetary

                      Page 19                GAO: HRD-9055BR   Veterans   Concerns   About Wilmington   Cmtrr
                     Appendix IV
                     Housekeeping   Services

                     center is not up to standards of sanitation expected in a hospital set-
                     ting.” The Veterans of Foreign Wars also conducts periodic reviews at VA
                     medical centers, and the local representative requested a review at Wil-
                     mington, in part because of his concern over sanitary conditions. The
                     October 1988 report on this review stated there were unsanitary condi-
                     tions in several patient units. For example, ventilation ducts and light
                     fixtures in some bathrooms had heavy dust, as did furnishings in
                     patient rooms. During our March 1989 inspection of the medical center
                     with representatives of veterans’ organizations, we noted similar

                     The medical center management decreased cleaning staff from 42 in
Staff Reductions     1983 to 32 in 1989 in an effort to reduce the center’s costs. In response
Result in Reduced    to these staff reductions, the chief of building management reduced
Cleaning Schedules   cleaning schedules in administrative areas and had staff concentrate on
                     patient care areas. For example, administrative offices are now cleaned
                     weekly instead of daily. Periodic, heavy cleaning jobs, such as washing
                     walls and cleaning air vents, were delayed so that housekeeping staff
                     could concentrate on routine daily cleaning.

                     The medical center hired six temporary staff for 3 months in 1988 to
                     strip and refinish floors and five temporary employees in the summer of
                     1989 to do heavy cleaning. Representatives of the veterans’ organiza-
                     tions believed that sanitary conditions in some areas of the center had
                     improved but that current conditions are still not satisfactory.

                     The director agrees that the reduced schedules mean the center is not as
                     clean as it was when staffing levels were higher. He stated, however,
                     that the rate of infections incurred by veterans during their stays at the
                     center has not increased.

                     We discussed the cleanliness issue with VA headquarters officials who
                     agreed to request regional staff to assess the cleanliness of the Wilming-
                     ton center and, if warranted, propose solutions to the center director.

                     Page 21                   GAO/HRDSO56BR   Veterans’   Concerns   About   Wilmington   Center
                       Appendix V
                       Cardiology Services

                       used in an emergency. Communication problems between the two cen-
                       ters created some delays in obtaining diagnostic tests. The Philadelphia
                       center has now designated specific contact points for Wilmington cardi-
                       ologists to use. This should resolve the communication problems
                       between the centers and reduce the time veterans have to wait for

                       Two cardiologists provided services to veterans at the Wilmington
Delays in              center before June 1988. At that time, one cardiologist resigned, which
Appointments           resulted in delays for routine cardiology clinic appointments. The
                       remaining cardiologist could see only about half as many veterans as
                       had previously been seen and appointment waiting times were thus
                       extended. For example, as of March 1989, the next open routine out-
                       patient cardiology appointment was in November 1989,8 months away.
                       However, the cardiologist would see veterans with acute cardiac prob-
                       lems promptly if they were referred by their general medical physician.

                       We reviewed 10 cases randomly selected from a list of veterans with
                       cardiology clinic appointments from January through March 1989 to
                       determine waiting times for appointments. The cardiology clinic was fol-
                       lowing four of the cases for such conditions as coronary artery disease.
                       Six cases were newly referred from the general medical clinic with such
                       problems as chest pain or irregular heartbeats. Waiting times for
                       appointments in the cardiology clinic ranged from l-l/2 to 12 months
                       after a referral, based on our medical record review. When a second car-
                       diologist joined the staff in April 1989, waiting times for appointments
                       in the clinic decreased to from 1 to 3 weeks.

                       The Wilmington center began recruiting a second cardiologist in June
Inability to Attract   1988. However, 10 months passed before the vacancy was filled. A med-
Cardiologist           ical center official explained that a noncompetitive VA salary and the
                       t.iming of their effort hindered their recruitment efforts. An experienced
                       board-certified cardiologist would start at no more than $74,303, which
                       is much lower than the national private salary average of $162,000 for
                       1987. In addition, the Wilmington recruitment efform started at a time
                       when recent graduates from physician training programs had already
                       obtained other positions.

                       Page 23                GAO/HRD-9055BR   Veterans’   Concerns   About Wihington   Center
Diagnostic Testing

       l   Veterans alleged insufficient
           staff to operate special
       l   Salaries hampered recruitment
       l   Staff not available to perform
           needed tests
       l   Special pay authorized/
           contract staff used

                    Veterans alleged that insufficient staff were available at the Wilmington
                    center to administer and operate specialized equipment.’ Our analysis
                    showed that there was insufficient staff to operate specialized diagnos-
                    tic equipment. As a result (1) there were delays in obtaining tests, (2)
                    some tests were performed outside of VA, and (3) inpatient stays were
                    extended. Staff shortages in radiology, nuclear medicine, and laboratory
                    services were due to a decrease in the number of authorized staff and
                    the medical center’s inability to recruit and retain qualified

                    ‘We revnwed the three primary diagnostic testing areas: radiology, nuclear medicine, and laboratory

                    Page 25                        GAO/HRD806SBR        Veterans’   Concern   About Wilmington   Center
                  Appendix VI
                  Diagnostic Testing

                  In dollars    per hour
                                                            Regular             Special rates                   Approved
                  Service                                    rate9          Requested      Approved              increase
                     1988                                      $637                $8.28            -$a.06            $1.69
                     1989                                       8.06                8.06              8.79             0.73
                  Nuclear      medIcme
                     1988                                           6.50           11.01              8.79              229
                     1988                                           7.24           1208               944               2.20
                   Starting salaries before rate wrease requested     Radiology and nuclear medlclne technologists   start at
                  E-4, laboratory technologMs start at GS~5

                  Center officials requested special pay rates for radiology in June 1987,
                  for laboratory in July 1988, and for nuclear medicine in December 1988.
                  Office of Personnel Management approval took 7,3, and 4 months,
                  respectively. Center officials requested an additional radiology rate
                  increase in August 1988, and the Office of Personnel Management took 7
                  months to approve the increase. In addition, Wilmington’s inability to
                  recruit a chief of nuclear medicine delayed submission of a special sal-
                  ary request for nuclear medicine technologists. Laboratory services had
                  high staff turnover rat,es in fiscal year 1987, yet the center did not
                  request special salary rates until July 1988.

                  Since the special salary rates went into effect for nuclear medicine and
                  laboratory services, the center has recruited additional technologists.
                  Radiology, however, continues to experience recruitment and retention
                  problems, in part because of the heavy night and weekend on-call
                  requirement shared by six technologists. Also, salaries in the private
                  sector are expected to soon rise again because of technologist shortages
                  in the area. The chief of laboratory services told us that when this hap-
                  pens the salaries paid by the Wilmington center will again be non-
                  competitive without another adjustment.

                  Staff shortages in radiology, nuclear medicine, and laboratory services
Impact of Staff   have the potential to affect quality of care and increase lengths of inpa-
Shortages         tient stays. The VA headquarters chief of nuclear medicine reviewed
                  patient, test results at the Wilmington center in January 1988. He noted
                  six deficiencies, such as poor quality test results and a backlog of
                  patients waiting for laboratory tests. He said that these deficiencies
                  could ,jeopardize the‘ welfare of patients. In addition, the pharmacy

                   Page 27                         GAO/HRD9@55BR Veterans’ Concerns About Wilmington Center
Appendix VII


               l   Veterans alleged cutback in
                   speech therapy
               *Services not cut back, but
                delivery under contract
                for 2 months
               l   Services now delivered by
                   a VA employee

                           Veterans alleged cutbacks in a specialized speech therapy program. We
                           found that despite program changes, the Wilmington center’s speech
                           therapy program continued uninterrupted. Because of anticipated
                           budget constraints in fiscal year 1989, center management reviewed the
                           speech therapy program work load to determine whether a full-time
                           speech therapist was required. Based on this work load analysis and
                           consideration of other needs, the center decided to reassign its full-time
                           speech therapist to other duties beginning in September 1988, while con-
                           tracting out speech therapy services on a part-time basis. However, an
                           agreement was reached between the center’s associate director and the

                           Page 29                GAO/HRDS@55BR Veterans’ Concerns About Wihington   Center
Appendix VIII


                l   Veterans alleged excessive
                    waiting times-
                * Waiting times genera .Ily did
                  not exceed 3 weeks
                l   Veterans and service
                    organizations agree waiting
                    times for prosthetics not a

                            Veterans alleged that there were excessive waiting times for prosthetic
                            services,’ but we did not find this allegation to be valid. Although
                            records were not available to determine the waiting times for prosthetics
                            at the Wilmington center, the chief of prosthetics told us that waiting
                            times generally did not exceed 3 weeks. Veterans’ service organizations
                            and medical center officials agreed that delays in obtaining prosthetics
                            at the center have been kept to a minimum. The center provided pros-
                            thetic services for 4,253 disabilities in fiscal year 1988, up from 3,625 in
                            fiscal year 1986. Some delays in processing orders for this increased
                            work load occurred in fiscal year 1988 and early 1989, taking up to 3 to

                            Page 31                 GAO/HRDSO-55BR Veterans’ Concerns About Wilmington Center
Appendix IX

Major Contributors to This Report

                   Paul R. Reynolds, Assistant Director, (202) 233-5281
Human Resources    Frank C. Ackley. Assignment Manager
Washington, D.C.

                   Robert W. Lewandowski, Evaluator-in-Charge
Philadelphia       Dorothy M. Barrett, Site Senior
Regional Office    Al-Hashar Abdullah. Evaluator

                   Page 33                GAO/HRD-SO-55BR Veterans’   Concerns   About Wilmington   (:ent~r

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Appendix Vm

4 weeks to send orders out to suppliers. The use of overtime and part-
time staff resolved the backlog. In addition, we were advised by the
chief of prosthetics that, whenever possible, the medical center main-
tains an inventory of prosthetics items needed by veterans, which
decreases waiting time.

page 32                GAO/HRDSOdBBR   Veterans   Concm~s   About Wilmington   Cmtrr
Appendix VII
Speech Therapy

therapist to continue providing “specialized” speech therapy to two vet-
erans. About 2 months after the therapist was reassigned, he was rein-
stated as the full-time speech therapist because, according to medical
center management. the inpatient work load was greater than previ-
ously reported.

Page 30                GAO/HRL%9966BR   Veterans’   Concerns   About Wilmington   Center
Appendix VI
Diagnostic Testing

reported higher usage of broad spectrum antibiotics. These were used
because the tests needed to identify the specific bacteria could not be
obtained because of a shortage of laboratory technologists. A standing
medical center committee (Utilization Review) also reported lengths of
inpatient stay increased during a 5-month period (Nov. 1988 through
Mar. 1989) because the laboratory did not provide test results on a
timely basis.

In addition to requesting special pay rates for technologists and the use
of overtime, the center contracted for technologists to provide 24-hour
coverage. In some cases, the medical center sent the veterans to a local
hospital to have tests performed.

Page 28                GAO/HRD@M6BR   Veterans’   Concerns   About Wihhgton   Center
                         Appendix   M
                         Diagnostic Testing

                         Because of these problems, the medical center requested special pay
                         rates for technologists in the above services, but the time required to
                         process the requests, coupled with recruitment and retention problems,
                         required the center to rely on staff on overtime or contract personnel to
                         operate the equipment. The subsequent approval of special pay rates
                         and the use of contract personnel has enabled the center to reduce the
                         delays in obtaining medical tests.

                         In response to overall reductions in its authorized staffing levels during
Authorized Staff         the last 3 years, the medical center reduced the staffing level of each
Reduced                  medical center service. i As a result:

                     l Radiology technologists decreased from nine in fiscal year 1986 to six in
                       fiscal year 1989.
                     . Nuclear medicine technologists were cut from four to three in fiscal year
                     . Authorized laboratory technologists decreased from 23 in fiscal year
                       1986 to 20 in fiscal year 1989.

                         The Wilmington center has experienced difficulties recruiting and
Recruitment and          retaining technical staff because VA salary rates are not competitive
Retention Problems       with local private sector hospitals and laboratories as shown in docu-
                         ments supporting requests for special pay rates. As a result, staff vacan-
                         cies have occurred in radiology, nuclear medicine, and laboratory
                         services. For example, in January 1989, all three nuclear medicine tech-
                         nologist positions were’ vacant; nuclear medicine was unsuccessful in
                         recruiting technologists for a year and was without a chief for 16
                         months-from      October 1987 to February 1989; and laboratory services
                         had 7 of 20 medical technologist positions vacant in July 1988. In addi-
                         tion, the laboratory technologist turnover rate was 37 and 47 percent
                         for fiscal years 1987 and 1988, respectively.

                         In order to overcome the problem of noncompetitive pay rates, medical
                         center officials requested permission from VA headquarters and the
                         Office of Personnel Management to pay special rates. Table VI.1 shows
                         the special salary rates in effect as of June 1989 for these services.

                         ‘\!4 does not havr critena fur staffing levels m radiology, nuclear medicmc, or laboratory services.
                         Each service cluef estmuttd staffung needs based on experience

                         Page 26                         GAO/HRD-90.55BR      Veterans’   Concerns   About Wilmington   Center
                   Appendix V
                   Cardiology Servicrs

                   The Wilmington Medical Center does not have the work load to support
Communication      a cardiac catheterization and surgery unit; therefore, it refers veterans
Problems Between   needing cardiac catheterization or surgery to the Philadelphia Medical
Facilities         Center or a local hospital. The Philadelphia center acts as the referral
                   center for other VA medical centers in the area whose patients need car-
                   diac catheterization. Philadelphia has a contract with a nearby medical
                   center for cardiac catheterization and surgery at, a reduced cost. Wil-
                   mington prefers to use this Philadelphia arrangement because of the
                   high cost of using other private hospitals.

                   Wilmington experienced delays in transferring cardiac patients to Phila-
                   delphia because neither center established a policy on how patients
                   requiring acute cardiac care were to be referred from one medical center
                   to the other. As a result, Wilmington medical staff had problems in con-
                   tacting appropriate Philadelphia staff and getting needed approvals.
                   Several patients were advised to seek care elsewhere. A Wilmington
                   center cardiologist told us that, within a 2-month period in the spring of
                   1989, he advised one patient to seek cardiac care at a military hospital
                   and another at a private hospital because of referral delays. Wilmington
                   and Philadelphia officials have met and discussed steps to improve com-
                   munication, and Philadelphia has designated specific persons for the
                   Wilmington cardiologists to contact when making referrals. These offi-
                   cials plan to continue meeting to discuss any unresolved communication

                    Page 24               GAO/HRD-90.55BR   Veterans’   Concerns   About Wilmington   Center
Appendix V

Cardiology Services

             l   Excessive waiting times
             l   Veterans experienced 8-month
                 delays for routine care as of
                 March 1989
             l   Cardiologist hired after 1O-
                 month vacancy
             l   Waiting period reduced to less
                 than 1 month
                          Veterans alleged that there were excessive waiting times for appoint-
                          ments in special medical areas. We reviewed the medical area of cardiol-
                          ogy’ based on a complaint received in Senator Roth’s office. We found
                          that as of March 1989, veterans had to wait 8 months for a routine (non-
                          emergency) scheduled cardiology clinic appointment at the Wilmington
                          center. This wait, however, decreased to 1 to 3 weeks after a second
                          cardiologist was hired in April 1989 to fill a long-standing vacancy.

                          The Wilmington center refers veterans needing cardiac catheterization
                          and surgery to the Philadelphia center, although a local hospital can be

                          ‘The branch of medicine mvolving the diagnosis and treatment of heart and blood vessel diseases,
                          such as heart attack, high blood pressure, and stroke.

                          Page 22                        GAO/HRD9066BR       Veterans’ Concerns About Wilmington Center
Appendix IV


              l   Veterans alleged unsanitary
                  conditions at medical center
              l   Staff reduced and cleaning
                  schedules cut back
              l   Studies identified cleanliness
              l   VA headquarters agreed to
                  request regional staff to
                  assess cleanliness
                           Veterans alleged bathrooms were unsanitary and floors were dirty in
                           some wards. Cleanliness problems have existed periodically at the Wil-
                           mington center. Although center officials attempted to address these
                           problems, some persisted because of reductions in the number of clean-
                           ing staff.

                           Two studies in the past 3 years identified cleanliness problems at the
Periodic Cleanliness       Wilmington center. i\n October 1986 review by the .Joint Commission on
Issues                     Accreditation of Hcalthcare Organizations identified several cleanliness
                           problems at the center. In April 1987, a medical center building manage-
                           ment service review concluded that the “appearance of this medical

                           Page 20               GAO/HRDW-55BR Veterans’ Concerns About Wilmington Center
                    Appendix III
                    Outpatient  Care

                    of the outpatient visits (35,774) were to the general medical clinic in
                    fiscal year 1988; the other visits were to specialty clinics, such as cardi-
                    ology or mental hygiene.

                    lJnti1 .January 1989, vrterans with and without appointments went
                    through basically the same intake process. On arrival, veterans reported
                    to the registration area where center staff determined their eligibility
                    and retrieved their medical records. Veterans with appointments were
                    then referred to the appropriate clinic, while walk-ins saw a general
                    medical clinic nurse who made a preliminary medical observation while
                    waiting for their medical records. After the records were retrieved,
                    walk-ins were seen by the next available physician in the general medi-
                    cal clinic.

                    Outpatient clinic staff decided that having both scheduled and
                    unscheduled veterans report to the same place was causing long waiting
                    times. In January 1989. the process was changed. Veterans with sched-
                    uled appointments began reporting directly to the appropriate clinic,
                    while the procedure for unscheduled veterans did not change. Also, vet-
                    erans wanting to visit the mental hygiene clinics no longer had t,o go
                    through the general medical clinic.

                    About 54 percent of the veterans seen in the general medical clinic have
Delays Created by   scheduled appointments. 40 percent. arrive as walk-ins, and 6 percent,
Unpredictable       are emergencies. ITnschcduled patients tend to show up in greater num-
Work Load           bers on Mondays and Tuesdays. From .June through November 1988, an
                    average of 37 unsc,lrcaduledveterans arrived on Mondays and 32 arrived
                    on Tuesdays. Act,ual numbers ranged from 21 to 49. An average of 27
                    veterans arrived on t.h~ other 3 days without appointments, ranging
                    from 12 to 35. This work flow complicat,es the staffing process and con-
                    tributes to waiting t imcls.

                    A time study conducted in April 1988 by medical center staff deter-
                    mined that it took an average of 54 minutes to process walk-in veterans
                    through t,hc administrative steps, including the recovery of medical
                    records. After the rcc.ords wore retrieved, it took an average of 32 min-
                    utcls before the vctchrans wcrc called by the physician. This amounted to
                    a total waiting timesof 1 hour and 26 minutes before the veteran saw a

                    Page 1x                 GAO/HRD-W-55BR   Veterans’   Concwns   About Wilmington   Center
                 Appendix   II
                 Pharmacy   Services

                 received authorization from VA headquarters to use special salary rates’
                 for pharmacists ($16.18 per hour) effective in April 1989. Wilmington
                 was able to hire an additional pharmacist in June 1989.

                 After we discussed the waiting times and the need to expedite the
Agency Actions   expansion of the pharmacy with center officials, they awarded a con-
                 tract to expand the pharmacy. Construction is scheduled for completion
                 in February 1990. This expansion will provide space to increase the
                 number of mail-out prescriptions. The pharmacy chief said that further
                 increasing mail-outs and decreasing prescriptions filled at the window
                 should decrease the pharmacy’s waiting times.

                 ‘VA can request special salary rates to assist in the recruiting and retention of specialized staff by
                 enabling it to compete with salaries in the local labor market.

                  Page 16                         GAO/HRDM-55BR         Veterans’   Concerns   About Wilmington    Center
                     Appendix   II
                     Pharmacy   Scrvicrs

                     waiting time at the pharmacy of over 2 hours as of February 28, 1988.
                     Subsequent changes in the pharmacy’s operations have reduced the
                     waiting times to 60 to 80 minutes but waits still exceed 2 hours at times.

                     During a February 1988 site visit requested by the medical center direc-
Personnel Problems   tor, VAheadquarters officials identified two personnel issues as major
                     reasons for excessive waiting times at the pharmacy. The first issue
                     related to a personality conflict that resulted in a lack of communication
                     between the pharmacy chief and the chief of staff. Since the chief of
                     pharmacy was not a member of key hospital committees, such issues as
                     staff, space, and fiscal management arose without being addressed. The
                     medical center director responded to this situation by hiring a new chief
                     of pharmacy in September 1988, assigning him to key hospital commit-
                     tees, and organizationally realigning the pharmacy service (i.e., the chief
                     began reporting to the center’s associate director rather than the chief
                     of staff).

                     The second issue concerned insufficient staffing for the pharmacy work
                     load. According to vt\ guidelines, the pharmacy should have a staff of 20,
                     but as of February 1988, it had a staff of 10. The VA headquarters report
                     stated that “staffing is very lean” and recommended that if a pharma-
                     cist vacancy occurred, the medical center hire two technicians instead.
                     The medical center implemented this recommendation when a pharma-
                     cist resigned in October 1988. In addition, the chief of pharmacy
                     requested three additional staff. The center director approved an
                     increase of one permanent staff, but said that he did not have the funds
                     to hire the other two. Additional part-time staff and reassignments
                     increased the staff to 14 as of May 1989.

                     Inadequate space in the pharmacy, coupled with the distribution of out-
Inadequate Space     patient work load, also contributed to delays in filling prescriptions.
                     According to the chief of pharmacy, the space problems were docu-
                     mented by VA headquarters 15 years ago and again in February 1988.
                     The 1988 review concluded that the lack of overall space, plus the lay-
                     out of that space, hindered pharmacy services for both inpatients and

                     The VA encourages veterans to get prescriptions refilled by mail, Head-
                     quarters officials’ follow-up visits conducted in March and May 1988 to
                     review the efficiency of the mail-out program concluded that the lack of

                     Page 14                GAO/HRD-YO-55BR   Vrterans’   Concerns   About Wilmington   Center
    Appendix I
    Orthopedic Care

    selected 27 for review 1.0determine how long veterans waited for treat-
    ment We selected 11 because conditions appeared to require immediate
    medical care, 4 because Wilmington’s records indicated a waiting time in
    excess of 4 months. and another 12 randomly.

    Our review of the 27 medical records showed that 2 veterans with bro-
    ken bones i were treated immediately at the Wilmington center and seen
    within 2 days at the Philadelphia facility. Of the 25 veterans with rou-
    tine appointments:

. 6 did not come for their appointments. The medical centers did not know
  why these veterans missed their appointments.
l 2 came for their first appointment but did not return for their follow-up
. 4 received care at Philadelphia as scheduled.
. 13 encountered delays in treatment because X-rays could not be located,
  were not completed before the referral, or had to be reordered because
  the initial X-rays were not properly coded to show the veterans’ identifi-
  cation numbers. The attending physician examined these veterans and
  had them schedule a follow-up visit so that X-rays could be taken and
  reviewed. First appointments occurred an average of 49 days after the
  referral, and the second ones averaged 57 days and ranged from 27 to
   128 days after the initial visit to Philadelphia.

    Although Philadelphia physicians were aware of the problem with
    X-rays for referred vctcrans, they did not communicate this problem to
    Wilmington officials. When we told Wilmington officials about these
    problems, they established a formal log within the Medical Administra-
    tion Service to track each referral from t,hc time of the referral through
    the actual visit to Philadelphia. They also began meetings with Philadel-
    phia staff to improve communications and to eliminate as many delays
    as possible. They are also considering the use of a toll-free number for
    patients to use for such things as changing appointments.

    Pag? 12                GAO:HRD-9@55HK Vrtrrans’ Concerns About WiImingtnn Center
Orthopedic Care

       l   Veterans alleged long waiting
      l    Service stopped at Wilmington
           in Feb. 1989
      l    45-day wait for service at
      OVA working to reduce waiting
       times for referred veterans

                    Veterans alleged there were severe restrictions in orthopedic care’
                    because they were referred to the Philadelphia Medical Center, where
                    the waiting time for appointments was about 6 months. In March 1988,
                    the Wilmington Medical Center decided to discontinue orthopedic ser-
                    vices and began referring veterans needing such services to the Philadel-
                    phia Medical Center. This change was made because of work load
                    reductions and staff shortages. Although poor coordination between the
                    two centers was causing delays in some cases, veterans received care in
                    an average of 45 days after their initial visits to Wilmington.

                    ‘The treatment of deformile   of the musculoskeletal system. such as broken bones.

                    Page 10                        GAO,‘HRDSO-SSBR Veterans’ Concerns About Wilmington Center

Letter                                                                                               1

Appendix I
Orthopedic Care            Orthopedic Services Canceled
                           Referral Process Functions but Some Delays Occur

Appendix II
Pharmacy Services          Excessive Waiting Times                                                  13
                           Personnel Problems                                                       14
                           Inadequate Space                                                         14
                           Inefficient Inventory Practices                                          15
                           Staffing Problems                                                        15
                           Agency Actions                                                           16

Appendix III                                                                                        17
Outpatient Care            Intake Processing Is Cumbersome                                          17
                           Delays Created by Unpredictable Work Load                                18
                           Corrective Actions Ineffective                                           19

Appendix IV                                                                                         20
Housekeeping    Services   Periodic Cleanliness Issues                                              20
                           Staff Reductions Result in Reduced Cleaning Schedules                    21

Appendix V                                                                                          22
Cardiology Services        Delays in Appointments                                                   23
                           Inability to Attract Cardiologist                                        23
                           Communication Problems Between Facilities                                24

Appendix VI                                                                                         25
Diagnostic Testing         Authorized Staff Reduced                                                 26
                           Recruitment and Retention Problems                                       26
                           Impact of Staff Shortages                                                27

Appendix VII
Speech Therapy
Appendix VIII

                           Page 8                 GAO/HRIKW65BR   Veterans’ Concerns About Win   Center

              regional staff would be asked to visit the center to review the house-
              keeping situation and propose whatever corrective actions are

              We believe that the medical center and headquarters officials have initi-
Conclusions   ated reasonable actions to address the veterans’ concerns in these four
              areas. If implemented fully, these actions should result in improved ser-
              vices t,o veterans.

              As agreed with your office, we did not obtain written agency comments
              on this report, Unless you publicly announce its contents earlier, we
              plan no further distribution of this report for 30 days. At that time, we
              will send copies to the Secretary of Veterans Affairs and interested con-
              gressional committees. We will also make copies available to others upon
              request. If you have any questions on this report, please contact me at
              (202) 275-6207. Other major contributors to this report are listed in
              appendix IX.

              Sincerely yours,

              David P. Baine
              Director, Federal Health Care
                Delivery Issues

              Page 6                 GAO/HRD-90.55BR Veterans’ Concerns About Wilmington Center

                  waiting for over 1 hour to be excessive: but VA has no formal criteria for
                  acceptable waiting times. Changes in the pharmacy’s operations have
                  since reduced the waiting times to 60 to 80 minutes, but some waits still
                  exceed 2 hours.

                  The delays were due primarily to inadequate staffing, a personality con-
                  flict that resulted in a lack of communications between the pharmacy
                  chief and the chief of staff, and inadequate pharmacy space. Although
                  ~4 headquarters guidelines recommend a staff of 20, the pharmacy had
                   10 staff as of February 1988. The center also experienced difficulties
                  hiring and retaining pharmacist,s partly because of the v~ pay scale.
                  IIowever, with the approval of one additional permanent staff, the hir-
                  ing of part-time staff. and reassignments, the staffing level increased to
                   14 as of May 1989.

                  The pharmacy does not have sufficient space to provide for an efficient
                  and effective work flow. The director had approved the implementation
                  of a plan for using a room ad.jacent to the pharmacy so they could
                  increase the number of’ mail-out prescriptions and thus reduce the
                  number of veterans waiting for prescriptions to be filled. Although VA’S
                  regional medical director funded the project in fiscal year 1988, the
                  center director wed the funds to pay operating expenses and planned to
                  initiate the expansion m fiscal year 1991. We discussed the need for this
                  project with the director and other center officials in August 1989. Sub-
                  sequently, they awarded a contract for expansion of the pharmacy; corn
                  pletion is expected in February 1990.

                  Veterans alleged that 1here were excessive waiting times for services in
Outpatient Care   the outpatient clinics. The clinics reported over 73,000 visits in fiscal
                  year 1988-35.000 in the general medical clinic and the remainder in
                  specialty clinics, such as cardiology or mental hygiene. Veterans without
                  appointments (walk-ins) frequently had to wait between l-l/2 and 2
                  hours for nonemergcnc-y services in the general medical clinic during fis-
                  cal years 1988 and 19X0. Although the medical center has revised the
                  intake process, waiting times have not, decreased.

                  Medical center officials attribute the outpatient delays primarily to the
                  large member of walk-ins. which make up 40 percent of the general med-
                  ical clinic’s total annual work load; walk-ins are especially heavy on
                  Mondays and Tuesdays. linti *January 1989. veterans with appoint-
                  mcbnts and walk-ins wont through basically the same intake process at,
                  t h(>clinic.

                  Page 4                 GAO/HRD-90.55BR Vrtrrans’ Concerns About Wilmington Center

                  programs. He said that the changes were needed because of budget con-
                  straints and a shift in the center’s work load from inpatient to out-
                  patient care. The center has 296 hospital beds, but its average daily
                  occupancy had declined to about 150 over the last several years. During
                  this time, the number of veterans seeking outpatient care increased 62
                  percent-from     45,519 in fiscal year 1984 to 73,679 in fiscal year 1988.
                  Although the center’s expenditures have increased from $31.7 million in
                  fiscal year 1985 to about $37.1 million in fiscal year 1989, they have
                  decreased about 3 percent when calculated in 1985 dollars.

                  We clarified the veterans’ concerns through discussions with your office
Scope and         and a meeting with a group of about 25 veterans. This group included
Methodology       veterans who had expressed concerns to your office and others who rep-
                  resented veterans’ service organizations. They provided their views on
                  service delivery problems they had encountered at the center.

                  To address the veterans’ concerns we (1) interviewed both the former
                  and current medical center director and other center officials and
                  (2) reviewed administrative and medical records to examine such fac-
                  tors as work load, staffing levels, and waiting times for services. In addi-
                  tion, we accompanied representatives of veterans’ organizations on a
                  tour of the facility and made periodic spot checks to assess sanitary con-
                  ditions. Because some veterans who needed orthopedic care were
                  referred to the VA medical center in Philadelphia, we interviewed offi-
                  cials and reviewed selected medical records at that center to determine
                  how well the referral process was working.

                  Finally, we discussed the veterans’ concerns and the center’s actions
                  with the regional medical director in Durham, North Carolina, and head-
                  quarters officials in Washington, DC. This review was done between
                  January and November 1989 in accordance with generally accepted gov-
                  ernment auditing standards.

                  Veterans alleged that they had to wait 6 months for orthopedic services
Orthopedic Care   because they were being referred to the Philadelphia Medical Center for
                  services that had previously been available at the Wilmington center. In
                  June 1986, the Jefferson Medical College’ withdrew its two orthopedic

                  ‘A new medical center dirtaor began work in July 1989. The former center director served from
                  Apnl 1981 to April 1989. thts enter had an acting director between April and .July 1989.

                  ‘A part of Thomas .Jefferson I‘mversity in Philadelphia. Pennsylvania

                  Page 2                         GAO/HRD-9055BR       Veterans’   Conccms   About Wilmington   Center