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, Center United States GAO General Accounting Office Washington, D.C. 20548 Human Resources Division B-238225 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 senwes Page 1 GAO/HRD90-SSBR Veterans’ Concerns About Wilmington Center B-238225 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 reductions. 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 Abbreviations 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 excessive. 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- Corrective ^^ 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 constraints. 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 conditions. 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 appointments. 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 equipment 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 technologists. ‘We revnwed the three primary diagnostic testing areas: radiology, nuclear medicine, and laboratory wrvkcs. 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 Radtology. 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 Laboratory. 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 SpeechTherapy 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 Prosthetics 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 problem 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 Division, 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 . Requests for copies of GAO reports should be sent to: U.S. General Accounting Office Post Office Box 6015 Gaithersburg, Maryland 20877 Telephone 202-275-6241 The first five copies of each report are free. Additional copies are $2.00 each. There is a 25% discount on orders for 100 or more copies mailed to a single address. Appendix Vm Prosthetics 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 1986. . 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 problems. Page 24 GAO/HRD-90.55BR Veterans’ Concerns About Wilmington Center Appendix V Cardiology Services l Excessive waiting times alleged 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 HousekeepingServices l Veterans alleged unsanitary conditions at medical center l Staff reduced and cleaning schedules cut back l Studies identified cleanliness issues 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 doctor. 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 outpatients. 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 appointments. . 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 times l Service stopped at Wilmington in Feb. 1989 l 45-day wait for service at Philadelphia 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 Contents 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 Prosthetics Page 8 GAO/HRIKW65BR Veterans’ Concerns About Win Center B-238226 regional staff would be asked to visit the center to review the house- keeping situation and propose whatever corrective actions are warranted. 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 B-238225 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 --~ B-238225 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
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)