Table 1.

Themes and subthemes with representative quotes

Description of access issues
Difficulty getting an individual to answer	The only glitch is sometimes it's hard getting them on the phone. Sometimes… you can't even get through at all.
Lack of communication about office closures	Yesterday… I was trying to get a hold of the VA… and I finally get through to the VA, I must have started in the morning, and made 10 or 15 calls… it wasn't until I [reached] emergency [that I] finally heard, the VA is closed today for [a holiday]… I wasted a whole morning just playing with the phone.
Changing extensions	It happened to me today before we came in [to the focus group]. The doctor wasn't at [his usual] extension. If I didn't go and try to find him… I would never have known he had a new extension, [and] new office.
Out‐dated phone directories	You get the phone listing one time at enrollment and eligibility, and it's outdated within four months.
Frequent disconnections	Sometimes you'll push a number and you'll get hung up on. And it's like, ‘Wait a minute, I pushed the right number.’ Now I got to call back… and then you hit the number again and maybe get through.
	I [try to] bypass the option carousel if I just hit zero… Every time I've tried that, I got disconnected.
Incorrect transfers	They transfer you. That's the worst thing, when they transfer you.
	I never get transferred to the right [place]… you ask for clinic six, and it's not clinic six, it's in the labs.
Responses to access issues
Do nothing	Just give up, basically. Hopefully whatever the problem is isn't going to kill me.
Wait	I usually leave him a message and [wait]… You don't want to just run to the emergency room.
Visit emergency department	If I'm in a real need and cannot get it resolved over the phone… I'm in the emergency room next.
	Sometimes the only way I get in here is going to the emergency room.
Travel to facility and speak with provider in‐person	I haven't got a half an hour to waste to hang on the phone… I'm not going to call, I mean, I can walk to [the clinic] before I get through on the phone.
Use an alternate contact	Usually I don't call [my primary care] team… These others, like the psychiatrist and the occupational therapist, that's [who] I'm in contact with.
	I had a, a problem with the doctor, and I ended up having to come to [the] patient advocate and get switched to a [different] team.
Use another form of communication	Find another avenue to go through. … If you can't make it in person, you know, try to find another way. Email [for example].
Seek non‐VA care	You go to another hospital… If it's a real health‐care problem… Then worry about it [later].
Participants' recommendations for improvement
Share directory and keep up‐to‐date	Give us a directory… quit changing all the numbers in other words.
	The numbers that are given for different departments or whatever, they need to go to that department, and that department needs to pick it up… What would improve it is if I'm given a number and I call that number, it goes to team A, and team A picks up. And that doesn't happen.
Create telephone triage line (for facilities that do not have one)	I would love something if a department would take a nurse or a series of nurses and put them on the phone. Have them sit down for two hours a day, an hour a day, whatever, and their responsibility is to answer those calls, whatever calls come in, for that day. I think that whole problem could be resolved. The problem is no one is around to answer the phone.
Increase staff for telephone triage line (for facilities that already have one in place)	The waiting period to get a hold of a triage nurse is terrible. You know, you could actually die before the nurse gets on the phone. It's too long a period, something has to be done about that.
Increased monitoring by operators	When they see a certain department is overloaded with … people holding on, they should divert those calls to an open [line]… instead of just 80 people just sitting on the line.
	If someone won't pick it up within a certain amount of time, the operator needs to get back to you and say, ‘I'm sorry, there's no answer.’ It's got to be monitored.
Voice recognition in menu	I would like to see… the automated [menu] with the voice recognition… instead of listening to all ten prompts, I just say ‘pharmacy.’
Announce approximate hold time and ‘place in line’	Knowing how long… I [have] to wait… If I've already waited 10 minutes, and I only got to wait two more, then I'm going to stay on the line… But if I [have] to wait 10 more minutes I'm hanging up.
	The system could be upgraded, to determine how many people in line, and how much time… you have to wait… [Such as,] ‘You're number five in line, and you have 3 minutes to wait.’