[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]



 
                      HEALTHCARE PROFESSIONALS --
                       RECRUITMENT AND RETENTION

=======================================================================

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                            OCTOBER 18, 2007

                               __________

                           Serial No. 110-55

                               __________

       Printed for the use of the Committee on Veterans' Affairs


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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     RICHARD H. BAKER, Louisiana
Dakota                               HENRY E. BROWN, Jr., South 
HARRY E. MITCHELL, Arizona           Carolina
JOHN J. HALL, New York               JEFF MILLER, Florida
PHIL HARE, Illinois                  JOHN BOOZMAN, Arkansas
MICHAEL F. DOYLE, Pennsylvania       GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada              MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado            BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas             DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana                GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California           VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota

                   Malcom A. Shorter, Staff Director

                                 ______

                         SUBCOMMITTEE ON HEALTH

                  MICHAEL H. MICHAUD, Maine, Chairman

CORRINE BROWN, Florida               JEFF MILLER, Florida, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
PHIL HARE, Illinois                  JERRY MORAN, Kansas
MICHAEL F. DOYLE, Pennsylvania       RICHARD H. BAKER, Louisiana
SHELLEY BERKLEY, Nevada              HENRY E. BROWN, Jr., South 
JOHN T. SALAZAR, Colorado            Carolina

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.


                            C O N T E N T S

                               __________

                            October 18, 2007

                                                                   Page
Healthcare Professionals--Recruitment and Retention..............     1

                           OPENING STATEMENTS

Chairman Michael Michaud.........................................     1
    Prepared statement of Chairman Michaud.......................    35
Hon. Shelley Berkley.............................................     9

                               WITNESSES

U.S. Department of Veterans Affairs, William J. Feeley, MSW, 
  FACHE, Deputy Under Secretary for Health for Operations and 
  Management, Veterans Health Administration.....................    24
    Prepared statement of Mr. Feeley.............................    59

                                 ______

American Federation of Government Employees, AFL-CIO, J. David 
  Cox, R.N., National Secretary-Treasurer........................    18
    Prepared statement of Mr. Cox................................    56
American Legion, Joseph L. Wilson, Assistant Director for Health 
  Policy, Veterans Affairs and Rehabilitation Commission.........    14
    Prepared statement of Mr. Wilson.............................    49
American Physical Therapy Association, Jeffrey L. Newman, PT, 
  Member, and Chief, Physical Therapy Department, Minneapolis 
  Veterans Affairs Medical Center, Minneapolis, MN...............     2
    Prepared statement of Mr. Newman.............................    35
Association of American Medical Colleges, Richard D. Krugman, 
  M.D., Chair, Executive Council, and Dean and Vice Chancellor 
  for Health Affairs, University of Colorado School of Medicine..     4
    Prepared statement of Dr. Krugman............................    38
CACI Strategic Communications, Jim Bender, Communications 
  Services Manager...............................................     7
    Prepared statement of Mr. Bender.............................    47
Disabled American Veterans, Joy J. Ilem, Assistant National 
  Legislative Director...........................................    16
    Prepared statement of Ms. Ilem...............................    51
National Board for Certified Counselors, Inc. and Affiliates, 
  Kristi McCaskill, M.Ed., NCC, NCSC, Counseling Advocacy 
  Coordinator....................................................     6
    Prepared statement of Ms. McCaskill..........................    43

                       SUBMISSIONS FOR THE RECORD

American Academy of Physician Assistants, statement..............    63
Miller, Hon. Jeff, Ranking Republican Member, and a 
  Representative in Congress from the State of Florida, statement    65
Nurses Organization of Veterans Affairs, statement...............    65
Salazar, Hon. John T., a Representative in Congress from the 
  State of Colorado, statement...................................    67

                   MATERIAL SUBMITTED FOR THE RECORD

``The Best Places to Work in the Federal Government--2007 
  Rankings,'' Veterans Health Administration Ranking Index Score, 
  from the Partnership for Public Service and American 
  University's Institute for the Study of Public Policy 
  Implementation.................................................    68
Break down of the healthcare professionals hired within the last 
  9 months (particularly licensed professional counselors) 
  (Monthly Distinct Employee for Non-Med Resident, GAIN, VHA 
  (Occupation Name) January-September 2007), requested by 
  Chairman Michaud during the hearing............................    70

Post Hearing Questions and Responses for the Record:
    Hon. Michael Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs, to Jeffrey L. Newman PT, 
      Chief Physical Therapy Department, Minneapolis VA Medical 
      Center, and Member, American Physical Therapy Association, 
      letter dated October 19, 2007, and response letter dated 
      December 3, 2007...........................................    73
    Hon. Michael Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs, to Richard D. Krugman, 
      M.D., Dean, University of Colorado Health Science Center 
      School of Medicine, letter dated October 19, 2007, and 
      response letter dated December 4, 2007.....................    75
    Hon. Michael Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs, to Jim Bender, 
      Communications Services Manager, CACI Strategic 
      Communications, letter October 19, 2007, and response from 
      Deborah Lee, Project Manager, CACI, Inc., Strategic 
      Communications Division, dated December 4, 2007............    78
    Hon. Michael Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs, to Joseph L. Wilson, 
      Assistant Director for Health Policy, Veterans Affairs and 
      Rehabilitation Commission, American Legion, letter dated 
      October 19, 2007, and response from Steve Robertson, 
      Director, National Legislative Commission, American Legion, 
      letter dated December 4, 2007..............................    81
    Hon. Michael Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs, to Joy J. Ilem, Assistant 
      National Legislative Director, Disabled American Veterans, 
      letter dated October 19, 2007..............................    83
    Hon. Michael Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs, to J. David Cox, National 
      Secretary-Treasurer, American Federation of Government 
      Employees, AFL-CIO, letter dated October 19, 2007..........    86
    Hon. Michael Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs, to Hon. Gordon H. 
      Mansfield, Acting Secretary, U.S. Department of Veterans 
      Affairs, letter dated October 19, 2007.....................    89
    Hon. Jeff Miller, Ranking Republican Member, Subcommittee on 
      Health, Committee on Veterans' Affairs, to Hon. Gordon H. 
      Mansfield, Acting Secretary, U.S. Department of Veterans 
      Affairs, letter dated October 31, 2007                         95


          HEALTHCARE PROFESSIONALS --RECRUITMENT AND RETENTION

                              ----------                              


                       THURSDAY, OCTOBER 18, 2007

             U.S. House of Representatives,
                            Subcommittee on Health,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice, at 10:00 a.m., in 
Room 334, Cannon House Office Building, Hon. Michael Michaud 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Michaud, Brown of Florida, and 
Berkley.

             OPENING STATEMENT OF CHAIRMAN MICHAUD

    Mr. Michaud. I would like to call the Subcommittee to 
order. Members will be here throughout the hearing. We will 
actually be having votes, as well as a journal vote, early, so 
we will try to start on time and recess if we are not done at 
that time.
    Today, the Subcommittee hearing will be on issues regarding 
recruitment and retention of healthcare professionals within 
the Veterans Health Administration (VHA) system. Healthcare 
professionals are VHA's most important resources in delivering 
high-quality healthcare for our Nation's veterans.
    So without further ado, I request unanimous consent to have 
my full statement submitted for the record and any other 
Members when they return or come.
    [The prepared statement of Chairman Michaud appears on p. 
35.]
    Mr. Michaud. On the first panel today we have Jeffrey 
Newman, Chief Physical Therapist from the Minneapolis Veterans 
Affairs (VA) Medical Center, who is here on behalf of the 
American Physical Therapy Association (APTA).
    I want to thank you very much, Mr. Newman. It is great to 
see you. Once again, I did have a great opportunity to visit 
Minneapolis VA facility and was extremely impressed.
    Also on panel one is Dr. Krugman, Chair of the Executive 
Council for the Association of American Medical Colleges 
(AAMC), and Dean of the University of Colorado School of 
Medicine. I would like to welcome you, Doctor.
    And also Kristi McCaskill, Counseling Advocacy Coordinator 
for the National Board for Certified Counselors (NBCC), Inc. 
and Affiliates. I welcome you as well.
    And fourth on panel one is Jim Bender, Communications 
Services Manager for CACI Strategic Communications. I would 
also like to welcome you, Jim, today and look forward to all of 
your testimony.
    And we will start off with Mr. Newman and work down the 
table. So, Mr. Newman.

STATEMENTS OF JEFFREY L. NEWMAN, PT, MEMBER, AMERICAN PHYSICAL 
 THERAPY ASSOCIATION, AND CHIEF, PHYSICAL THERAPY DEPARTMENT, 
 MINNEAPOLIS VETERANS AFFAIRS MEDICAL CENTER, MINNEAPOLIS, MN; 
RICHARD D. KRUGMAN, M.D., CHAIR, EXECUTIVE COUNCIL, ASSOCIATION 
OF AMERICAN MEDICAL COLLEGES, AND DEAN AND VICE CHANCELLOR FOR 
  HEALTH AFFAIRS, UNIVERSITY OF COLORADO SCHOOL OF MEDICINE; 
    KRISTI McCASKILL, M.ED., NCC, NCSC, COUNSELING ADVOCACY 
COORDINATOR, NATIONAL BOARD FOR CERTIFIED COUNSELORS, INC. AND 
 AFFILIATES; AND JIM BENDER, COMMUNICATIONS SERVICES MANAGER, 
                 CACI STRATEGIC COMMUNICATIONS

                 STATEMENT OF JEFFREY L. NEWMAN

    Mr. Newman. Mr. Chairman, Members of the Subcommittee, 
thank you for the opportunity to testify on the recruitment and 
retention of healthcare professionals who work in the U.S. 
Department of Veterans Affairs (VA).
    I have practiced as a physical therapist in the VA system 
for more than 30 years and for 20 of those years, I have served 
as Chief of Physical Therapy at the Minneapolis VA Medical 
Center in Minneapolis, Minnesota.
    I come before you today as a member of the American 
Physical Therapy Association. In my experience, I have seen the 
physical therapy profession advance to meet the changing 
rehabilitation needs of our patients.
    The primary challenge to meet the rehabilitation needs of 
veterans is the recruitment and retention of physical 
therapists. This challenge is compounded by two trends that 
increase the need for physical therapists, chronic conditions 
associated with an aging veteran population and the complex 
impairments associated with returning veterans from the 
conflicts in Afghanistan and Iraq.
    In my remarks today, I will discuss the increased need for 
physical therapists in the VA, highlight current challenges 
with recruitment and retention, and make two specific 
recommendations to help meet these challenges and ensure our 
Nation's veterans the accessibility and availability to the 
physical therapist services they need.
    These recommendations include the immediate approval and 
implementation of pending qualification standards and 
enhancements to current VA scholarship programs.
    With more than 1,000 physical therapists on staff, the VA 
is one of the largest employers of physical therapists 
nationwide. Physical therapists have a long history of 
providing care to our Nation's veterans. In fact, our 
professional roots started by rehabilitating soldiers as they 
began returning from World War I.
    Today physical therapists in the VA render evidence-based, 
culturally sensitive care and have been recognized leaders in 
clinical research and education. The need for high-quality 
rehabilitation provided by physical therapists has never been 
greater with the dual challenges of caring for the chronic 
diseases faced by aging veterans and the multifaceted profile 
of many of today's wounded warriors.
    According to the VA, 9.2 million veterans are age 65 or 
older. Among this aging veteran population, many have diabetes. 
Physical therapists assist patients in regaining mobility and 
function lost due to diabetes and its complications as well as 
its prevention strategies.
    Many of our Nation's recent veterans are facing unique 
injuries that require complex rehabilitation including spinal 
cord injury, amputee rehabilitation, and Traumatic Brain Injury 
(TBI).
    Physical therapists are a key part of the VA's polytrauma 
rehabilitation centers caring for TBI patients in Tampa, Palo 
Alto, Richmond, and at my facility in Minneapolis.
    Minneapolis has had a TBI program with dedicated staff and 
TBI rehabilitation for over 10 years. We have physical 
therapists on staff who have received specialist certification 
in neurological, geriatric, and orthopedic physical therapy.
    My specific clinical background is in amputation 
rehabilitation. I have had the honor of caring for a generation 
of veterans and have been able to see the growing need for 
physical therapist services through the years.
    The number one obstacle to both the recruitment and the 
retention of physical therapists to serve in the VA is the 
severely outdated qualification standards that currently govern 
the salary and advancement opportunities for physical 
therapists employed by the VA.
    These standards have not been updated for nearly 25 years. 
For example, the current minimal requirement to become a 
physical therapist is to graduate with a Master's Degree. 
Approximately 80 percent of programs now are graduating at the 
doctoral level and pass a licensure test.
    The current VA qualification standards have a minimal 
requirement of obtaining a Bachelor's Degree but do not 
recognize the Doctor of Physical Therapy Degree or DPT Degree 
programs.
    The need for immediate approval of these revised standards 
is due to several factors. First, the demand for physical 
therapy services is on the rise.
    Second, the increased need for services provided by 
qualified physical therapists in the VA due to aging veterans 
and meeting the complex needs of our soldiers returning from 
Iraq and Afghanistan.
    Third, the outdated qualification standards also limit the 
ability of a physical therapist to advance within the VA system 
once they have joined. The current standards do not recognize 
physical therapists that achieve specialty certification such 
as those needed in the polytrauma centers.
    Fourth, it has been at least 6\1/2\ years since the VA 
first recognized that the standards needed to be updated, yet 
no revisions have been implemented.
    In addition to the immediate approval and implementation of 
revised qualification standards, I recommend enhancements to 
the current VA scholarship programs to help in both recruitment 
and retention. Many new graduates are concerned with a high 
amount of student loan debt.
    I had the opportunity to serve on the Committee to review 
scholarship program applicants in the early nineties when the 
VA had a very successful scholarship program to attract new 
graduates. That scholarship program provided an incentive to 
serve right out of school, whereas the new program is poorly 
advertised and cumbersome. We are in need of better incentives 
to pull more graduates into the VA system.
    In closing, APTA recommends the immediate approval and 
implementation of the qualification standards for physical 
therapists and the investigation of options to enhance current 
programs offering scholarships, loan support, and debt 
retirement for physical therapists choosing to serve in the VA. 
This will assist in both the recruitment and retention of 
physical therapists to meet the needs of our veterans of today 
and tomorrow.
    Thank you, Mr. Chairman, for this opportunity. I would be 
happy to answer any questions from you or other Committee 
Members at this time.
    [The prepared statement of Mr. Newman appears on p. 35.]
    Mr. Michaud. Thank you very much, Mr. Newman.
    Doctor.

             STATEMENT OF RICHARD D. KRUGMAN, M.D.

    Dr. Krugman. Good morning. And thank you, Mr. Chairman, for 
the opportunity to testify this morning on the retention and 
recruitment of health professionals at the VA.
    My name is Richard Krugman. I am Dean of the University of 
Colorado School of Medicine and Vice Chancellor for Health 
Affairs there. We are affiliated with the Denver VA Medical 
Center and the Rocky Mountain Veteran Integrated Services 
Network (VISN) Network 19.
    I am also Chair of the Association of American Medical 
Colleges and member of the VA Dean's Liaison Committee of the 
AAMC which is a not-for-profit representing 126 accredited 
medical schools, 107 of which are affiliated with VAs and 
nearly 400 major teaching hospitals and health systems 
including 68 medical centers.
    We would like to thank the Committee for your support of 
the VA appropriation in 2008. Your leadership resulted in the 
House's passage of $36.6 billion for VA medical care and $480 
million for VA medical and prosthetics research. This funding 
is crucial to the continued success of the primary sources of 
VA physician recruitment and retention, namely academic 
affiliations, graduate medical education (GME), and VA 
research.
    While the VHA has made substantial improvements in quality 
and efficiency, the veteran service organizations cite 
excessive waiting times, delays as the primary problem in 
veterans' healthcare.
    Without increases in clinical staff, the demand for 
healthcare will continue to outpace the VA's ability to supply 
timely healthcare services and will erode the world-renowned 
quality of VA medical care.
    Concerns about physician staffing at the VA come at a time 
when the Nation faces a pending shortage of physicians. Recent 
analysis by the AAMC's Center for Workforce Studies indicates 
the United States will face a serious physician shortage in the 
next few decades.
    Our Nation's rapidly growing population, increasing number 
of elderly Americans, an aging physician workforce, and a 
rising demand for healthcare services all point to this 
conclusion.
    The VA has been the first to respond with plans to increase 
its support for graduate medical education. Under the GME 
Enhancement Initiative, the VA plans to add an additional 2,000 
physicians for residency training over 5 years. This will 
restore VA funded physicians to approximately 11 percent of the 
total GME physicians in the United States. The expansion began 
in 2007 when the VA added 342 physicians.
    The smooth operation at the VA's academic affiliations is 
crucial to preserving the health professions workforce needed 
to care for our Nation's veterans. The VA's AAMC Dean's 
Committee meets regularly to maintain an open dialog and 
provide advice on how better to manage our joint affiliations.
    The VA has consistently recognized that there is room for 
improvement. As such, the AAMC looks forward to working on 
other matters of concern.
    As medical care shifts to more satellite-based outpatient 
approaches, graduate medical education needs to follow suit. 
This strong shift to ambulatory care at multiple sites requires 
a similar locus of change in medical training.
    The dispersion of patients to multiple sites of care makes 
more difficult the volume of patient contact crucial to medical 
training. Similarly, faculty diffusion makes it more difficult 
as well.
    This is not exclusively a VA problem. And one of the key 
points I would like to make is that the issues faced by VA 
physicians are precisely the same that we as deans of medical 
schools face in recruiting and retaining faculty in the current 
economic environment in this country.
    Another concern at both VA and non-VA teaching hospitals is 
the growing salary discrepancy. This discrepancy continues to 
be a concern and it is increasingly difficult to recruit 
residents and students to our programs.
    In recent years, the funding for VA medical and prosthetics 
research has failed to provide the resources needed to 
maintain, upgrade, and replace aging facilities. Many VA 
facilities have run out of adequate research space. And, again, 
the recruitment of physicians who are interested in research 
and education and the support of those interests will be 
critical to retaining a VA workforce.
    The AAMC recommends an annual appropriation of $45 million 
in the VA's minor construction budget dedicated to renovating 
existing research facilities to try to replace at least one 
outdated facility per year.
    Mr. Chairman, Members of the Committee, thank you for the 
opportunity to testify on this important issue. I hope my 
testimony today has demonstrated that the recruitment and 
retention of an adequate physician workforce is central to the 
success of the VA's mission.
    The extraordinary partnership between the VA and its 
medical school affiliates coupled with the excellence of the VA 
medical and prosthetics research program allows the VA to 
attract the Nation's best physicians.
    Over the last 60 years, we have made great strides toward 
preserving the success of these affiliations and with our hard 
work, I am confident that this success will continue.
    Thank you. I would be happy to answer any questions at the 
appropriate time.
    [The prepared statement of Dr. Krugman appears on p. 38.]
    Mr. Michaud. Thank you very much, Doctor.
    Ms. McCaskill.

        STATEMENT OF KRISTI McCASKILL, M.ED., NCC, NCSC

    Ms. McCaskill. Mr. Chairman and Honorable Members of the 
Veterans' Affairs Committee, I appreciate the opportunity to 
present testimony regarding the need for additional mental 
healthcare providers in the VA.
    My name is Kristi McCaskill and I am the Counseling 
Advocacy Coordinator at the National Board for Certified 
Counselors. I possess a Master's Degree in Counseling from the 
University of North Carolina at Chapel Hill.
    For the past few years, I have worked with professionals 
who have been certified by NBCC as they explain their 
qualifications to prospective employers, public, and 
legislators. I, too, am certified by the NBCC and understand 
the value of counseling and counseling credentials.
    NBCC is the Nation's premier and largest professional 
certification board devoted to the credentialing of counselors 
holding Master's level or higher degrees. These counselors must 
meet standards for the general and specialty practices of 
professional counseling.
    Founded in 1982 as an independent, nonprofit credentialing 
body, NBCC provides a national certification system for those 
counselors and administers the Ethics Code for those 
counselors. Currently we have more than 42,000 active 
certificates living and working in the United States and in 
over 40 countries.
    NBCC and licensed professional counselors are pleased with 
the passage of Public Law 109-461. This legislation explicitly 
recognizes licensed professional counselors as healthcare 
providers within the Veterans Healthcare Administration.
    Unfortunately, it appears to us that despite the passage of 
this law, licensed professional counselors still have a very 
limited role as mental health providers in the VA in the nearly 
10 months since the law was enacted.
    Our veterans have unprecedented needs and these needs 
deserve to be met. Nationwide there are over 100,000 
professional counselors licensed to practice independently and 
this number is growing.
    In addition to completing rigorous degree programs, 
professional counselors must document supervised, professional 
practice, pass a national counselor examination, submit a 
professional disclosure statement, and keep current their 
professional education.
    Following licensure, these individuals provide quality 
mental health services to citizens. Counseling treatment comes 
in many forms and deals with problems such as stress, anxiety, 
depression, divorce, death, post traumatic stress disorder 
(PTSD), and other psychological or behavioral disorders common 
among our veterans.
    Congress has passed a law recognizing counselors as 
eligible to provide mental health services within the VA. In 
addition, a sufficient number of skilled professionals are 
available to provide these services. The VA and Congressional 
leaders must find a way to ensure that skills offered by 
counselors are readily available to meet the increasing mental 
health needs of our citizen heroes.
    NBCC stands ready, willing, and able to assist in this 
effort. Thank you for your time to speak on such an important 
subject.
    [The prepared statement of Ms. McCaskill appears on p. 43.]
    Mr. Michaud. Thank you.
    Mr. Bender.

                    STATEMENT OF JIM BENDER

    Mr. Bender. Mr. Chairman and Members of the Subcommittee, 
thank you for inviting CACI to contribute to the discussion on 
healthcare recruitment and retention.
    CACI has been instrumental in the advancement of 
recruitment marketing, research, and strategy and practice for 
more than 15 years. Our clientele include the National Security 
Agency, the National Guard Bureau, the Corporation for National 
and Community Service, and the Veterans Health Administration.
    My name is Jim Bender and I am one of the architects of the 
VA Nurse Recruitment Pilot Study I will address today.
    In February of 2006, in response to the ``Veterans Health 
Programs Improvement Act of 2004,'' VHA's Healthcare Retention 
and Recruitment Office (HRRO) contracted with CACI to conduct a 
pilot program to test and recommend innovative recruitment 
methods for hard-to-fill healthcare positions.
    From a pool of 17 pilot site applicants, the North Florida/
South Georgia Veterans Health System was chosen as the pilot 
location. The system's unique recruitment challenge was finding 
nurses with enough experience to fill higher level nursing 
positions.
    Our objective going into the North Florida/South Georgia 
System was to test methods to enhance effectiveness in four key 
areas. Number one, employer branding and interactive 
advertising strategies; number two, Internet technologies and 
automated staffing systems; number three, the use of 
recruitment, advertising, and communications agencies; and, 
number four, streamlining the hiring process.
    Subsequently the study was divided into two distinct 
operations. One was focused on recruitment marketing with a 
goal of increasing the number of qualified applications coming 
into the system. The second was business process reengineering 
with the goal of decreasing the administrative time between 
application receipt and job offer.
    An abundance of anecdotal evidence suggests that VA loses 
good candidates because of the lengthy boarding process.
    The program was conducted over 60 days beginning February 
5th, 2006. All activities were monitored and measured to 
evaluate the results.
    On the recruitment marketing side of the operation, the 
findings were exceptionally optimistic. The recruitment 
marketing campaign generated 10,261 inquiries into nursing 
positions for experienced nurses. An inquiry was defined as a 
response to recruitment advertising or similar communications 
outreach.
    Of those inquiries, 115 candidates submitted applications. 
Most impressive was the percentage of applicants uniquely 
qualified to fill the advertised positions.
    During March of 2006, the only full calendar month of the 
study, the number of applicants for nursing services who passed 
the initial screening process increased by 83 percent over the 
month prior from 12 applications to 22 and 300 percent over the 
trailing 5-month average from 7.4 applicants to 22.
    The recruitment methods that garnered these results 
included a strategy based on the principles of employer 
branding and market segmentation in addition to vigorous use of 
interactive media and Internet technologies which delivered the 
highest return on investment of any media in the study.
    The pilot program recommendations embraced these methods 
and further suggested the use of database marketing, 
relationship building, especially with the student population, 
employee referral programs, budget modifications, and 
improvements to organizational communications.
    On the business process side, the results were equally 
optimistic. A comparison of current hiring processes to what-if 
scenarios revealed that a small number of process changes could 
significantly accelerate the time to hire.
    The process changes that would actualize these what-if 
scenarios include the delegation of approval authority for 
routine recruitment activities, the implementation of an 
automated recruitment and management work-flow system to 
eliminate delays in paper-based, mail-in processing, and 
several modifications to standard processes that build delays 
into the system.
    We at CACI believe healthcare recruitment at VHA is both 
strong and spirited. HRRO, in addition to the exceptional staff 
and leadership at the North Florida/South Georgia System, 
embraced this project with enthusiasm and sustained 
intellectual vigor.
    Since the pilot's conclusion, we have seen continued 
movement toward the methods tested in the pilot project 
including increased use of targeted e-mail communications, 
expanded use of online job postings, and greater promotion of 
employee referral programs as well as a persistent hunger for 
new, progressive ways of engaging healthcare professionals.
    In closing, thank you once again for the opportunity to 
present CACI's conclusions on the Nurse Recruitment Pilot Study 
and thank you for the opportunity to contribute to the 
continued health and welfare of our country's veteran 
population. I look forward to your questions.
    [The prepared statement of Mr. Bender appears on p. 47.]
    Mr. Michaud. Thank you.
    I would like to thank once again all four panelists. Great 
testimony. And I will have a lot of questions. But at this 
time, because of the vote, we will recess. We should be back 
shortly. As I understand it, there is only one vote. So if you 
can hold your thoughts and get ready for the questions, I will 
try to drum up more Members to be here so that they can ask 
questions.
    Do you have a question right now, Ms. Berkley?

           OPENING STATEMENT OF HON. SHELLEY BERKLEY

    Ms. Berkley. I am not going to be able to come back. We 
also have the swearing in of the new Member afterward and I 
think many people are going to be down. I was requested by the 
Speaker to be there. Can I just very quickly?
    I want to thank you for being here and providing us with 
your testimony. I represent Las Vegas and that is the fastest 
growing area in the United States with the fastest growing 
veterans' population.
    We are in the process of building at the very early stages 
a huge VA facility, hospital, long-term care facility and 
outpatient clinic. We have trouble recruiting as it is 
healthcare professionals. I do not know what we are going to do 
to staff those buildings, particularly with the influx of new 
veterans coming to the Las Vegas Valley. So it is a tremendous 
challenge for me and that is why I especially appreciate your 
thoughts on this issue.
    Mr. Michaud. And there is no Member of the Committee that 
fights more diligently for VA facilities as well as VA 
employees than Congresswoman Berkley. I really appreciate your 
efforts.
    So with that, we will recess for the votes. Thank you.
    [Recess.]
    Mr. Michaud. I would like to call the hearing back to 
order. Once again, I apologize for the interruption because of 
the journal vote.
    Once again, I want to thank each of you for your testimony 
this morning and have several questions.
    If you look at last year, Congress passed the ``VA Benefits 
Healthcare and Information Technology Act of 2006'' (P.L. 109-
461) authorizing the recognition of licensed professional 
counselors within the VA system.
    What specifically can licensed professional counselors 
offer the VA? And my second question: Are licensed professional 
counselors capable of taking care of patients with severe 
problems such as PTSD and psychiatric disorders?
    Ms. McCaskill. Thank you.
    Licensed counselors are specifically trained in the 
provision of mental health services and they are experienced in 
dealing with people that are going through crisis. They can 
provide services from screening all the way through individual 
work, group work. They can do assessments.
    We do these kinds of things for private citizens in the 
States where they are licensed and we are just looking to be 
able to do it for the veterans, for our returning heroes.
    As far as those dealing with the very severe things like 
psychosis, we do not do medicine. We are not medical doctors, 
but we have worked cooperatively with other professions like 
psychiatrists or general physicians as they provide the medical 
treatment and we provide the counseling.
    In fact, research has shown that when you do the two of 
them together, they are very effective in providing help for 
people going through severe difficulties.
    Mr. Michaud. And do professional counselors receive 
evidence-based training?
    Ms. McCaskill. Yes, they do. The core coursework is what I 
mentioned a moment ago. They also have to have supervised 
experience before anybody becomes licensed. And in all 49 
States that license counselors, the only one that does not is 
California. That State has legislation pending at this time.
    But all 49 States use NBCC examinations. These examinations 
are based on research done in the field of counseling on a 
routine basis so that the exam does accurately reflect the 
profession and the current developments.
    Mr. Michaud. Great. Thank you.
    And as we heard in testimony earlier as far as recruitment 
and retention and the healthcare professionals shortage that we 
currently have not only within the VA system but in private 
sector as well, what type of tools do you think would be most 
effective in recruiting and retaining a high-quality workforce, 
particularly in rural areas? Do you see more of a problem in 
rural areas versus urban areas? I guess I would turn it over to 
Dr. Krugman.
    Dr. Krugman. Interestingly, Mr. Chairman, we are facing in 
this country now what we faced back in the late 1960s, early 
1970s when I started my faculty career and that is a real 
workforce shortage, particularly in rural and under-served 
areas.
    And in the Rocky Mountain region, we have VA facilities in 
rural areas. Grand Junction, Colorado, is one hospital--and 
others.
    There is good evidence that the recruitment and retention 
of professionals to under-served areas can exist if we provide 
portions of their training in those institutions, in those 
areas; if we work to develop loan repayment and other types of 
programs that can attract people to those areas; and to go to 
the head of the pipeline, if we recruit people from rural and 
under-served areas to come into our health profession training 
programs.
    There is 30 years of work done by the Area Health Education 
Center's programs in this country and in Colorado, we have one. 
And it works. The VA in Grand Junction as well as a VA facility 
in southeastern Colorado are part of our Area Health Education 
Network.
    We send students on rotations. We have them trained there. 
After we have taken them from those areas, we try to give them 
incentives to go back. And we keep them engaged in teaching 
because we know that is the best form of continuing education 
for any professional.
    If you have a student who wants to be like you, they will 
push you to keep learning and, in fact, will help you learn 
more.
    So I think the tools are there. The question is, can we get 
it done at a time when these programs, most of which were 
funded on the public health service side under title 7 are 
under severe budget pressure?
    I think we do not have to reinvent the wheel. We just need 
to pay attention to what we had to do 30 years ago and do it 
again better.
    Mr. Michaud. You had mentioned, Doctor, that part of the 
problem, and it is true, that when you look at higher ed, they 
do not have the slots available for students who want to go in 
the healthcare field.
    What do you recommend that we do to encourage people to go 
into the field, as far as helping higher ed out, specifically 
in rural areas? Do you think a grant program or more 
collaboration between the VA and higher ed facilities in the 
rural areas would help?
    Dr. Krugman. I think clearly recruitment and retention and 
scholarship and loan deferment programs targeted toward 
students from rural and under-served areas who want careers in 
medicine can work.
    It is similar to what the National Health Service Corps has 
done again on the public health service side, similar to what 
the Armed Forces has done with its scholarship program that 
pays students to come into health professional training in 
return for which they are expected to provide 4 to 8 years of 
service.
    I think if students can be attracted into a VA model 
program that will pay for their higher education and health 
professional training in return for which they do their 
graduate medical education and then serve in VA facilities for 
a particular period of time.
    The experience in the Armed Forces is that once you have 
put in 8 to 10 years, the retirement benefits are such that 
your retention is far more likely than if you do not have any 
hook at all.
    So I think there are models out there that the VA can take 
advantage of. And the AAMC and academic medical centers which 
already have these networks around the country would be 
delighted to collaborate in that effort.
    Mr. Michaud. And, Mr. Newman, do you want to add anything 
to that?
    Mr. Newman. Thank you, Mr. Chairman. I do.
    Within the VA system, within the VA system network, we have 
community based outpatient clinics in rural communities in 
Minnesota and I would think that this same situation applies in 
your home State.
    We have plans underway in Minneapolis to add physical 
therapy clinics to some of those community based outpatient 
clinics or CBOCs as they are called within the system. I think 
that is a great way to get the rural communities involved, to 
get the care to those veteran patients that can stay closer to 
home. They do not have to travel miles to come to our facility 
in Minneapolis and they can get that quality of care locally.
    To do that, recruitment and retention standards and the 
passage of those would go a long way in attracting qualified 
physical therapists to come to the va to work in those 
community based outpatient clinics.
    Mr. Michaud. And I would like each of you to comment. When 
you look at the healthcare professionals shortage we currently 
have nationwide and when you look at what is happening with the 
war in Iraq and Afghanistan, particularly men and women who are 
coming back to their home State that might not have a job 
waiting for them, or they lost their job, or just cannot make 
ends meet because the job does not pay enough, do you think 
this is a great opportunity where we can help address the 
healthcare professionals shortage we currently have in the 
system by focusing maybe first on providing slots for the men 
and women who served this country in the healthcare area?
    We will start with Mr. Newman and work down.
    Mr. Newman. Mr. Chairman, great question.
    Two good stories for you on that particular issue. This 
past summer, we had a decorated Iraqi veteran come back to 
Minnesota, come back to going back to school at the University 
of Minnesota, and has a great interest in physical therapy.
    He has come to me. He has come to our facility as a 
volunteer and has performed admirably within the clinic setting 
working with our polytrauma patients, working with our other 
veterans who are coming to our clinic for physical therapy.
    Just Tuesday, before I came on to Washington, D.C., I had 
another Guardsman from Minnesota who served 2 years in Iraq who 
has a degree in biochemistry. He has an interest in physical 
therapy. He is going to begin volunteering for us in our clinic 
with hopes in going back to school using his benefits as an 
active-duty soldier to become a physical therapist.
    I think that is a tremendous asset for our physical therapy 
clinic and for our VA setting. It goes a long way in working 
with our polytrauma patients and our polytrauma patient 
families. They have been there. They have served. They can be 
in the clinic answering questions, working with our young 
veteran population. It goes a long way in rehabilitating these 
veterans.
    Mr. Michaud. Those are great stories.
    Dr. Krugman.
    Dr. Krugman. I would concur that any individuals who have 
experienced healthcare on the side of being a patient who then 
want to come into any of our professions are likely to have a 
perspective and an empathy that would be welcome in the health 
professions provided they have had a good experience 
themselves.
    Mr. Michaud. Great.
    Ms. McCaskill. I would also echo the same comments. NBCC 
has been looking and is planning on trying to do an institute 
where we work with people to develop a specialty certification 
for those people who want to provide services to military 
personnel and returning veterans.
    We know that the military life is somewhat different. We 
know that there is some stigma attached to getting help, 
especially mental health service help. So that is part of the 
reason why we have been looking at additional things that we 
can do to help people.
    So people that have gone through it and have that awareness 
and understand the life of military and what they have gone 
through, I think, have a very deep respect and can help those 
who are having a hard time when they come back.
    Mr. Bender. Mr. Chairman, the question is really beyond the 
scope of my expertise. I will say we have engaged in a number 
of communication campaigns reaching out to those transitioning 
out of the military on behalf of VA, those transitioning out of 
the military to encourage them and to tell them about the 
opportunities of employment at VA.
    Mr. Michaud. Let us focus a little bit on what your 
expertise is. I have a question on your organization which 
conducted a nurse recruitment pilot study. What would you say 
were the biggest lessons learned from this pilot study? I 
believe it was in an urban area? Have you done any studies in 
rural areas, and, if so, what were the differences, if any?
    Mr. Bender. The area is the Gainesville, Lake City area in 
Florida. The difference between conducting the type of 
recruitment marketing that we do from an urban area to a rural 
area is not at this point going to be extreme. In other words, 
the difficulty level is not going to go up a number of notches.
    Prior to the Internet, it was a little bit different 
because of the penetration of media within certain areas. 
Obviously, you know, in a city, you have a large number of 
options and other places, you do not. So the difficulty of 
taking the message, the good message about VA to the people is 
not a tremendous concern right now.
    Getting back to the study, and there is a relationship 
between the two here, the method that works the best, 
especially with the young crowd now is Internet communication. 
People live on the Internet. It also happens to be the most 
cost-effective mode of communication. This study identified 
things such as e-mail campaigns and e-mail banners and so 
forth.
    Among all the media used, the most effective in reaching 
the number of candidates we had to reach and the most cost 
effective in having the lowest cost per lead, and obviously 
that is a medium that we can use in any part of the country.
    Mr. Michaud. Do you think VA should continue using private 
sector strategies in recruitment and retention efforts?
    Mr. Bender. Yeah. It depends what those strategies are. 
When you bring a marketing mindset, marketing best practices to 
the process, what happens is you start to improve the quality 
of the communication going out to the nurses. In the pilot 
study, we mentioned methods such as targeted marketing, you 
know.
    When we are going out and we are hiring nurses or we are 
hiring psychiatrists, we make sure that we have the research 
about this particular market, about what this market's cares 
are, how they feel about working for not only VA but also for 
the government at large. And then in the communication to these 
individuals, we make sure we address their specific concerns.
    So taking best practices within the marketing field and 
applying it to recruitment, I think, are one of the ways in 
which we can encourage a higher number of qualified applicants 
into the field.
    Mr. Michaud. Great. Thank you.
    In 2004, Congress passed the Physician Pay Bill, which 
established an improved and simplified pay structure for VA 
physicians that would increase salaries and make VA more 
competitive with the private sector.
    Do you think that legislation has been effective in 
retaining VA physicians?
    Dr. Krugman. Mr. Chairman, I think it has helped, but my 
understanding is that in each VISN and in each part of the 
country where that Pay Bill was implemented, the dollars went 
primarily to surgeons--and let me speak to our VISN. It 
primarily went to surgeons and radiologists and did not go to 
some of those in internal medicine, particularly 
gastroenterology where there is still a huge gradient left 
between the private community and the VA physicians.
    So it was a good start. But, unfortunately, the community 
sectors in many parts of the country, particularly in ours, the 
ability of physicians in the private community to garner 
technical fees in their own imaging centers and their own 
ambulatory surgery centers and other ways to supplement their 
professional fee income have made the salary gap more than 
double even with the Pay Bill.
    So retention is still going to be an issue. And I think it 
was a good start, but it has been variable in its penetrance.
    Mr. Michaud. Thank you.
    Any questions? There will be additional questions that will 
be submitted for the record and hopefully you will be able to 
respond in a timely manner.
    So once again, I would like to thank the four panelists. It 
has been very enlightening and look forward to working with you 
as we move forward on this very important issue. So once again, 
thank you very much.
    Dr. Krugman. Thank you.
    Mr. Newman. Thank you.
    Mr. Michaud. I would like to ask the second panel to come 
forward.
    On the second panel we have Joseph Wilson, Assistant 
Director for Health Policy, Veterans Affairs and Rehabilitation 
Commission for the American Legion; Joy Ilem, Assistant 
National Legislative Director for the Disabled American 
Veterans (DAV); and David Cox, National Secretary-Treasurer of 
the American Federation of Government Employees (AFGE), AFL-
CIO.
    So I want to welcome the three panelists, and we will start 
off with you, Mr. Wilson, and work down. Thank you.

 STATEMENTS OF JOSEPH L. WILSON, ASSISTANT DIRECTOR FOR HEALTH 
    POLICY, VETERANS AFFAIRS AND REHABILITATION COMMISSION, 
 AMERICAN LEGION; JOY J. ILEM, ASSISTANT NATIONAL LEGISLATIVE 
 DIRECTOR, DISABLED AMERICAN VETERANS; AND J. DAVID COX, R.N., 
NATIONAL SECRETARY-TREASURER, AMERICAN FEDERATION OF GOVERNMENT 
                       EMPLOYEES, AFL-CIO

                 STATEMENT OF JOSEPH L. WILSON

    Mr. Wilson. Mr. Chairman and Members of the Subcommittee, 
thank you for this opportunity to present the American Legion's 
views on recruitment and retention of VA's healthcare----
    Mr. Michaud. Is your microphone on?
    Mr. Wilson. What about now?
    Mr. Michaud. Okay. Yes. We can hear you now.
    Mr. Wilson. Mr. Chairman and Members of the Subcommittee, 
thank you for this opportunity to present the American Legion's 
views on recruitment and retention of VA's healthcare 
professionals.
    The Nation is facing an unprecedented healthcare shortage 
that could potentially have a profound impact on the care given 
to this Nation's veterans.
    The American Legion supports comprehensive efforts to 
establish and maintain the Department of Veterans Affairs as a 
competitive force in attracting and retaining healthcare 
personnel, especially nurses, essential to the mission of VA 
healthcare and commends the Subcommittee for holding a hearing 
to discuss this very important and urgent issue.
    The Federal Government estimates that by 2020, nurse and 
physician retirements will create a shortage of about 24,000 
physicians and almost one million nurses nationwide. The 
American Legion strongly believes that what happens at the 
Department of Veterans Affairs medical centers often reflects 
the general state of affairs within the healthcare community as 
a whole.
    Shortages in healthcare staff threaten the Veterans Health 
Administration's ability to provide quality care and treatment 
to veterans.
    During the American Legion's recent site visits to 
polytrauma centers throughout the Nation, some facilities 
identified uncertainty of existing staff's ability to handle an 
expected influx of patients as a challenge to providing care.
    One major polytrauma center which serves as a frontline 
medical center to those returning from Iraq and Afghanistan 
reported recruitment and retention as part of their major 
budgetary challenge.
    Although the utilization of a variety of tools to include 
relocation, recruitment, and retention bonuses to attract new 
employees and retain existing employees is a step in the right 
direction, the locality pay is insufficient to keep pace with 
respective surrounding healthcare employers.
    VA nurses are one of the most important resources in 
delivering high-quality, compassionate care to veterans. 
Currently, there are challenges in attracting nursing personnel 
to VA due to both the shortage of people entering the career 
field and VA's inability to remain competitive in salary and 
benefits.
    The American Legion urges the VA and Congress to provide 
adequate resources to implement the Commission's 
recommendations and urges VA to continue to strive to develop 
an effective strategy to recruit, train, and retain advanced 
practice nurses, registered nurses, licensed practical nurses, 
and medicine assistants to meet the inpatient and outpatient 
healthcare needs of its growing patient population.
    VA recently established a Nursing Academy to address the 
nationwide nursing shortage issue. The Nursing Academy has 
embarked on a 5-year pilot program that will establish 
partnerships with a total of 12 nursing schools. This pilot 
program will train nurses to understand the healthcare needs of 
veterans and increase the availability of nurses, thereby 
allowing VA to continue to provide veterans with the quality of 
care they deserve.
    The American Legion affirms its strong commitment and 
support for the mutually beneficial affiliations between VHA 
and the medical and nursing schools of this Nation.
    The American Legion is also appreciative of the many 
contributions of VHA nursing personnel and recognizes their 
dedication to veterans who rely on VHA healthcare. Every effort 
must be made to recognize, reward, and maximize their 
contributions to the VHA healthcare system because veterans 
deserve nothing less.
    VHA currently conducts the largest coordinated education 
and training program for healthcare professions in the Nation. 
Their recent and newest recognitions as a leader providing 
safe, high-quality healthcare to the Nation's veterans can be 
directly attributed to the relationship that has been fostered 
through medical school affiliations which allows VA to train 
new healthcare professionals to meet the healthcare needs of 
veterans and the Nation.
    Mr. Chairman and Members of the Subcommittee, the American 
Legion sincerely appreciates the opportunity to present 
testimony and looks forward to working with you, your 
colleagues, and staff to resolve this critical issue.
    Thank you for your continued leadership on behalf of 
America's veterans.
    [The prepared statement of Mr. Wilson appears on p. 49.]
    Mr. Michaud. Thank you very much, Mr. Wilson.
    Ms. Ilem.

                    STATEMENT OF JOY J. ILEM

    Ms. Ilem. Mr. Chairman and Members of the Subcommittee, 
thank you for inviting the DAV to testify today.
    Without question, recruitment and retention of high-caliber 
healthcare professionals is critical to VHA's mission and 
essential to providing safe, high-quality healthcare services 
to sick and disabled veterans.
    Since 2000, VA has been working to address the ever-
increasing demand for medical services while coping with the 
impact of a rising national nursing shortage.
    In 2004, VA's Office of Nursing released its strategic plan 
to guide national efforts to advance nursing practice within 
VHA and to improve VA's abilities to recruit and retain 
sufficient nursing staff.
    One of VA's greatest challenges today is effective 
succession planning. VA faces significant anticipated workforce 
supply and demand gaps in the near future along with an aging 
workforce and an increasing percentage of VHA employees who 
become eligible for retirement each year.
    In a recent succession planning and workforce development 
conference, VHA identified registered nurses as its top 
occupational challenge. Over the past several years, VHA has 
been trying to attract younger nurses and create incentives to 
keep them in the VA healthcare system.
    To address this problem, VA created a Nursing Academy Pilot 
Program in which it plans to partner with four universities. 
Academy students will be offered VA funded scholarships in 
exchange for defined periods of VA employment following 
graduation.
    VA notes that in order for this program to move forward, 
legislation will be required to reactivate VA's Health 
Professions Education Assistance Program authority.
    Although the Nursing Academy offers an innovative solution 
to recruitment and retention challenges, we would like to bring 
to your attention a number of reports dealing with VA nursing 
workplace issues.
    We continue to hear complaints about marginal nursing staff 
levels, overuse of mandatory overtime, unofficial hiring 
freezes and delays in hiring for critical positions, reduced 
flexibility in tours of duty, limiting of nurse locality pay, 
and shortages of ward secretaries and other key support 
personnel.
    Many of these difficult working conditions continue to 
exist today for nursing staff despite VA's efforts to make 
positive changes. We hope that VA will place greater emphasis 
on improving the work environment for nurses, to increase staff 
satisfaction, ensure the provision of safe, high-quality 
patient care.
    Likewise, DAV is concerned about the stressful working 
environment also confronting VA physician workforce. Recently 
DAV received a copy of a letter written by a group of VA 
physicians. I will mention only a few of the concerns it 
expresses.
    Complaints focused on the negative impact of provider 
shortages including understaffing of both nurses and doctors, 
increased panel size for doctors, increased turnover rates, 
difficulty in recruiting for key positions, and a lack of an 
adequate number of support staff.
    The following statement sums up the heavy burden these 
providers are shouldering, and I quote, ``We state we must not 
compromise quality of care, access, and patient and provider 
satisfaction in the quest for increasing panel size. Providers 
who are already struggling will not be able to provide high-
quality care and ultimately you will have fewer providers to 
provide that care. We have not been able to recruit new 
providers in the current climate. Our ability to recruit will 
be further hampered by the unbearable workload that would be 
created by an increased panel size. Preventing panel size 
increases is critical to the future quality of primary care 
within VA.''
    If the general situation in clinical care across the VA is 
anything like this report suggests, VA has a serious and rising 
morale problem that eventually may interfere with recruitment 
and retention as well as healthcare quality, safety, 
efficiency, and effectiveness.
    For these reasons, we ask that the Subcommittee consider 
conducting a survey of VA facilities to gauge conditions of 
employment and the current morale of the VA physician and 
nursing workforce.
    Mr. Chairman, in summary, we believe VA should establish 
innovative recruitment programs to remain competitive with 
private sector healthcare marketing and advertising strategies 
to attract high-caliber nurses and doctors to VA careers.
    While we applaud what VA is trying to do in improving its 
incentive programs, we believe these competitive strategies are 
yet to be fully developed or deployed in VA.
    Finally, we hope the Subcommittee will provide oversight to 
ensure sufficient provider staff levels and to regulate and 
reduce to a minimum VA's use of mandatory overtime for nurses. 
We believe this practice endangers the quality of care and 
safety of veteran patients.
    Again, we thank you for this opportunity to testify and I 
will be happy to answer any questions you may have. Thank you.
    [The prepared statement of Ms. Ilem appears on p. 51.]
    Mr. Michaud. Thank you.
    Mr. Cox.

                   STATEMENT OF J. DAVID COX

    Mr. Cox. Mr. Chairman and the Subcommittee, thank you for 
inviting AFGE to testify today. AFGE greatly appreciates the 
opportunity to share the views of our members working on the 
front lines of VA healthcare.
    I spent 23 years working as a registered nurse at the 
Salisbury VA Medical Center prior to becoming AFGE's National 
Secretary-Treasurer. It was tremendously rewarding to care for 
these unique patient populations in a highly regarded 
healthcare system on the cutting edge of new treatments while 
regularly collaborating with management on patient care issues.
    The VHA workforce is a highly skilled professional and 
dedicated workforce that takes great pride in caring for our 
veterans. Many of these employees are covered by title 38 rules 
designed to expeditiously recruit and retain personnel. So why 
is this great healthcare system in a retention crisis?
    Seventy-seven percent of all nurses who resign from the VA 
do so within the first 5 years on the job. And on the other end 
of the spectrum, because 63 percent of VA's registered nurses 
will be eligible to retire in 2010, the VHA will face a 
staffing shortage.
    I commend the VA for its efforts to address this impending 
crisis. And I represented AFGE on the National Commission on VA 
Nursing that focused on growing nurse shortages. However, AFGE 
believes many of the findings of the Commission have not been 
addressed by the VA.
    Congress has passed critical legislation over the past 
several years to address VHA recruitment and retention, but I 
fear that as long as VA's funding is so uncertain, 
Congressional intent to place meaningful incentives will be 
frustrated by cash strapped facility directors reluctant to 
offer retention bonuses and competitive schedules.
    Recent legislation could achieve its potential if the VA 
Central Office exerted more control over local facility 
workforce policies. Nurse locality pay legislation has achieved 
mixed success because local management has complete discretion 
to decide when and how to conduct pay surveys and how to 
distribute pay increases. We have yet to see any evidence that 
nurse pay policies have reduced the VA's reliance on agency 
nurses.
    Local discretion has also been a real impediment to 
implementing physician and dentist pay legislation. Many 
facilities excluded practitioners from groups setting market 
pay and performance pay criteria. Hereto, we still do not know 
if this legislation has been effective in reducing the VA's 
reliance on fee-based care.
    Local discretion and underfunding have also frustrated 
Congressional intent to limit mandatory nurse overtime and 
promote compressed work schedules. Local facilities have 
complete discretion to determine when an emergency exists to 
justify mandatory overtime. We urge Congress to define 
emergency by statute as many States have done and limit local 
discretion which deprives VA nurses of compressed work week 
schedules.
    AFGE is skeptical of new fixes such as the Nursing Academy 
that promise to bring more nurses to the VA. It would be far 
more effective to invest more funds in oversight and the VA's 
Employee Debt Reduction Program that offers loans assistance in 
exchange for a commitment to work at the VA.
    In my career, I was able to spend much time serving on 
medical center Committees addressing patient care and workforce 
issues. But for the past 7 years, AFGE members and 
representatives have been shut out of such opportunities.
    If the VA once again permits meaningful labor management 
cooperation, we will achieve the same or greater goal of 
employee empowerment that the Magnet Program promises but has 
yet failed to demonstrate. And we could do this without 
diverting precious dollars away from patient care for Magnet 
applications and certification fees.
    I also note that we have not seen any evidence that VA 
medical centers with Magnet status have higher nurse retention 
or satisfaction rates.
    Another useful retention tool would be to allow title 38 
employees under FERS Retirement System to apply unused sick 
leave toward their retirement benefit. More equal treatment for 
part-time nurses would be beneficial. They should have the 
right to earn permanent status and receive premium overtime and 
shift differential pay.
    Finally, recruitment and retention efforts should not be 
overlooked for other VHA employees who play a crucial role in 
the delivery of care including physician assistants, 
podiatrists, optometrists, and personnel supporting VHA 
information technology.
    Thank you, Mr. Chairman, for inviting us and we do look 
forward to working with you and the Committee and Members of 
the Subcommittee and VA management to tackle these many 
pressing workforce issues.
    [The prepared statement of Mr. Cox appears on p. 56.]
    Mr. Michaud. Once again, I would like to thank the three 
panelists for your testimony this morning.
    All of you discussed the fact that VA currently has 
difficulty in recruiting and retaining qualified healthcare 
providers. What effect has recruitment and retention had on, or 
has on, patient care? Has it affected patient care at all? And 
we will start with Mr. Wilson.
    Mr. Wilson. Mr. Chairman, I speak on my experience from 
visiting over 30 VA medical centers within the past year; and I 
would say it was fear of becoming complacent. I think 
healthcare employees were fearful because of the shortage 
within their respective VA Medical Center. Although cordial to 
patients, it had an effect on them, mainly physically.
    We are talking waiting lists and waiting time issues, which 
also frustrated healthcare employees because they were spending 
unexpected time at the VA Medical Center and putting off family 
duties, which really frustrated them, and also affected morale.
    Ms. Ilem. I think in speaking with both doctors and nurses, 
but one particular doctor that, you know, we had a conversation 
with, I mean, I think the stresses that they have had to absorb 
when they lose somebody in a primary care clinic and the other 
doctors have to absorb their patient panel which is sometimes 
in the thousands and the pressure that that puts on them that 
limit, the time limited that they can spend with their patients 
for each visit because they have a full caseload all day with 
very little time in between and they have to keep moving, you 
know, they feel frustrated.
    They had said because many of our patients have such 
chronic disabilities, they have a number of things they want to 
come in. And there is just not the time for them to spend with 
that patient, so they will say give me the top two things I can 
help you with today versus what they really want to do is to 
spend the appropriate time with the patient based on the needs 
of that patient.
    And so I think that would be an example of a direct impact 
on care. And all of us as patients, you know, how we would want 
to be treated, we do not want to know they have exactly 7 
minutes to spend with us because they have to do some charting. 
They have to see, you know, a number of patients each day.
    And I think that is reflective throughout the VA healthcare 
system, the pressure they are under because of the limited 
number of people they have. And then when they lose someone, 
they are generally not replaced right away.
    The other one is in a women veterans clinic, we often hear 
about--a provider leaves. VA knows they are leaving ahead of 
time and suddenly they are gone. They are trying to recruit 
someone. It is a difficult position to recruit for. And what 
happens to those patients, those women veteran patients who 
expect high-quality care from a provider that really is 
proficient in women's health? So I would think that is another 
example.
    Mr. Michaud. Thank you.
    Mr. Cox. Mr. Chairman, I have worked for the VA for 23 
years. There were many times we were short staffed. Now, one 
thing I believe nurses always do, they get work accomplished 
and they take care of their patients because they are 
dedicated.
    But the frustration level of saying when is help going to 
come, when are you going to hire more staff, and more recently, 
you know, can you hire staff because there are not applicants 
or the pay is inadequate or the staffing levels.
    I think the biggest issue that I hear from VA nurses is the 
patient ratios that a VA nurse has to what nurses have in the 
private sector is much greater and that the VA does not staff 
its facilities as adequately as private sector.
    So, therefore, yes, I think patient care suffers. I believe 
staff is very dedicated to try to meet the needs of every 
veteran, but, yes, there is a frustration level. If we could 
get staffing ratios that Congress would set as to how many 
nurses needs to be to take care of so many veterans, I believe 
it would certainly improve patient care in the VA.
    Mr. Michaud. My last question actually deals with staffing 
ratios. Have there been any studies done on the appropriate 
staff versus patient ratios? And if so, do they take into 
consideration where you might have one patient that might not 
need as much time as another patient? Do staff take nurse and 
patient ratio into consideration?
    Mr. Cox. There is a lot of research that has been done on 
nurse-to-patient ratios. I think the State of California has 
actually adopted State law that mandates various ratios. And 
you take into consideration, yes, this is a patient that may be 
in for observation or this is a patient that has had surgery or 
one that has just had a heart attack or stroke.
    There are different levels and there are mechanisms that 
you use in nursing to evaluate the levels of care and the 
amount of time that it is going to take and also the level. Do 
you need the registered nurse, the licensed practical nurse, or 
the nursing assistant to provide the care? There is a lot of 
information, a lot of research out there.
    VA operates pretty much on a very fluid process. AFGE has 
never been able to find that staffing ratio in the VA. We asked 
about that. It is talked about a lot, but it is a moving target 
that can never be pinned down.
    Mr. Michaud. Thank you.
    Ms. Brown.
    Ms. Brown of Florida. Thank you and thank you for holding 
this hearing.
    I am sorry. You know, as always, we have two or three 
meetings at the very same time and I wanted to be here when 
Panel Two was making the presentation. They did a study in the 
Gainesville area and I think they are still here in the room. 
And could one of the parties come and sit at the table because 
my question goes to Panel Two and Panel Three?
    Mr. Michaud. Yes. You are making reference to Panel One?
    Ms. Brown of Florida. Panel One. I am sorry.
    Mr. Michaud. Mr. Bender, would you please come back.
    Ms. Brown of Florida. As I listened to the discussion, I 
guess I am a little perplexed because I understand there are a 
lot of patients that need care. And it may be frustrating, but 
sometimes I do not know whether in the private sector it is 
realistic as far as the ratio.
    And how is the pay in comparison with other segments as far 
as nursing is concerned?
    Mr. Cox. Are you speaking to me, Congresswoman?
    Ms. Brown of Florida. Yes, sir, Mr. Cox.
    Mr. Cox. Nurse pay in the VA, by law, the VA cannot be a 
leader in the community. What has happened, Congress tried to 
fix nurse pay, said that the VA had to give at least the GS 
cost of living raise, that is minus the locality pay, as a 
floor, that VA could go further and do locality pay studies.
    VA very rarely does those locality pay studies because 
there is an expense and time to do them. And usually we will 
give the floor what we are required by law to nurses. We do not 
give the cost of living plus the locality pay or even give 
greater amounts that surveys would show.
    Ms. Brown of Florida. Uh-huh. So I guess my question to you 
is that, if we add additional financial incentives, do you 
think that would help as far as more satisfaction with the job?
    Mr. Cox. I think additional financial incentive would 
definitely help. Younger nurses do not think as much about 
retirement as they do money up front. But I think getting some 
Congressional mandate on nurse-patient ratios because I believe 
Congress is going to have to establish those mandates and those 
numbers for the VA to be able to live by them just as Congress 
had to mandate that you would give nurses a raise every year 
because the VA was not giving nurses a raise.
    Ms. Brown of Florida. I guess right now I would not be 
comfortable doing that at this time.
    Mr. Cox. I understand.
    Ms. Brown of Florida. But, you know, as we move forward 
with discussion, I would want more information about that.
    Mr. Bender, would you like to respond as far as what you 
think we can do as far as recruitment is concerned? I think if 
we could expand on the pool of nurses, of course, the paperwork 
is another thing. There should be some way we could expedite 
the amount of time it takes to get a person that wants to work 
with the VA qualified and on the job.
    Mr. Bender. Yes. Our study, we had to look at what the 
biggest challenge for the area was. The biggest challenge for 
the area was attracting experienced nurses which means we had 
to reach into the private sector and pull nurses from the 
private sector to ask them to come into VA. It can be a 
challenge.
    So what we did is when we looked back at the research, we 
found that because of the nursing shortage and because of the 
difficulties being experienced in all hospitals with patient 
overload and burnout and so forth, nurses in the private sector 
are also experiencing a large degree of burnout, but maybe to a 
greater extent than possibly the nurses at VA because they see 
the healthcare institution being run as a business. They see 
managed care doing things that they perhaps would not agree 
with, maybe the doctors, because I do not know. But they are 
frustrated by that attitude.
    So what we were able to do is through the communications 
campaign, open up a dialog about that particular point about 
the frustration that can be experienced within the midst of 
this nursing shortage and in the private sector and say it may 
be a little bit different at VA for a number of reasons. We 
think that is one of the reasons. And when I talk about the 
communication campaign, I am talking about the messages that 
were going through the media.
    That particular point we think in the Gainesville, Lake 
City area had a lot to do with opening the experienced private 
practice nurses' eyes to what options are available and why 
they decided to check it out.
    I am sorry. Could you repeat the second----
    Ms. Brown of Florida. And just how successful is this 
program?
    Mr. Bender. Oh, yes. And as we mentioned, it was a very 
successful program. The numbers of qualified nurses, those 
experienced nurses who anecdotally were coming from the private 
sector into the VA increased by, as I say, 80 some percent 
month over month and more than 300 percent over a trailing 5-
month average. So the approach was very, very successful.
    In the business process side as has been noted, the length 
of time it takes to get through that entire application process 
from the time I hand it in until the time I am ultimately hired 
is a deterrent. And there are a number of things that can be 
done to expedite that process including the automation of the 
paperwork. The automation of the paperwork alone and the 
mailing either through the Postal Service or through internal 
VA mail adds a number of days onto that entire practice.
    We have heard anecdotally through the years that this is a 
problem, the length of time. In other words, while a nurse, for 
instance, is considering a VA job, that length of time can have 
a negative impact because a private sector hospital can maybe 
get to that nurse first.
    So the automation of the paperwork, the elimination of some 
of the paper-based mail processing can have a large effect in 
bringing that time period down and making it more reasonable.
    Ms. Brown of Florida. Can I continue?
    Mr. Wilson, I was concerned about your comment because you 
mentioned that a lot of the nurses, I guess the nurse's 
profession was most frustrated with their job?
    Mr. Wilson. Yes.
    Ms. Brown of Florida. I do not understand that.
    Mr. Wilson. Actually, I do not know if it was rumored 
through the employees' respective division or mandated, but 
they were expecting an influx of employees to arrive; I guess 
the expected arrival date passed.
    I am speaking from a more tangible experience. In visiting 
these various VA Medical Centers, it was mainly sidebar 
conversations. A more accurate account is compiled in a report 
the American Legion publishes annually, which is also 
distributed to Congressional Members. Although I cannot be as 
definitive as in my reports, the overall subject matter here is 
that they spoke of issues affecting them.
    And part of the frustration also, there was no raise in 
pay. The pay was not so bad because it was used to attract them 
and even mentioning like in a whisper on the side that the 
locality pay was a challenge.
    For example, in one of the locales visited in California, 
the cost of living was pretty challenging. The average home was 
$750,000; it was an issue of locality pay, which employees, who 
reported to me that it would force them to relocate because of 
affordability. While they loved it there and loved the VA 
Medical Center, they could not afford to live there.
    Ms. Brown of Florida. I see. I think this is something that 
we probably need to address. But, I feel like the allied health 
is like teachers and we do not pay these people enough. I 
agree. But it is rewarding to do what you really like to do.
    And hopefully maybe we could recruit differently and maybe 
we could work with scholarships early on like we do in some 
critical needs areas that you could get some kind of support as 
far as the college loans and other kinds of programs like that 
because we need people that are committed to the profession and 
really want to work with these veterans.
    Mr. Michaud. Thank you very much, Congresswoman, and I 
agree a hundred percent.
    Once again, I would like to thank this panel and Mr. Bender 
for coming back up for your excellent testimony and answering 
questions. So thank you very much.
    The last panel that we have is Mr. William Feeley, who is 
Deputy Under Secretary for Health for Operations and Management 
in VHA. And he is accompanied by Nevin Weaver, who is the Chief 
Management Support Officer in VHA, and Joleen Clark, who is the 
Deputy Chief Management Support Officer in VHA.
    So I would like to welcome you, Mr. Feeley, and look 
forward to hearing your testimony.

   STATEMENT OF WILLIAM F. FEELEY, MSW, FACHE, DEPUTY UNDER 
 SECRETARY FOR HEALTH FOR OPERATIONS AND MANAGEMENT, VETERANS 
  HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
ACCOMPANIED BY NEVIN WEAVER, CHIEF MANAGEMENT SUPPORT OFFICER, 
  VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
  AFFAIRS; AND JOLEEN CLARK, DEPUTY CHIEF MANAGEMENT SUPPORT 
  OFFICER, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 
                        VETERANS AFFAIRS

    Mr. Feeley. Good morning, Mr. Chairman and Members of the 
Committee. I want to thank you for the opportunity to discuss 
VHA's Recruitment and Retention Program for Healthcare 
Professionals.
    One of the most critical obligations leaders in any 
organization have is taking steps to ensure that the 
organization has a solid workforce in the future.
    I am proud that the VHA's workforce plan has been 
recognized by Office of Personnel Management as a Federal best 
practice and look forward to sharing with you some of the 
strategies that have gotten us to this point.
    I am joined today by Mr. Nevin Weaver, Chief Management 
Support Officer, and Joleen Clark, Deputy Chief Management 
Support Officer.
    I will begin my testimony by outlining a number of the key 
programs that VHA has implemented to improve recruitment and 
retention. My oral comments will be a reduced version of the 
written testimony to best use time.
    In April of 2007, VA launched a Nursing Academy to address 
the nationwide shortage of nurses. The purpose is to expand 
nursing faculty in schools and promote nursing education 
through clinical rotations in the VA. VA will assign its 
nursing staff to serve as faculty roles and will fund school 
faculty when they are not in the VA.
    This initiative is rolling out at four locations, in 
Gainesville, Salt Lake City, San Diego, and West Haven, 
Connecticut VA, and will expand to 8 other facilities over the 
next several years allowing us to impact on recruiting about 
1,000 new nurses into the VA.
    The VA Learning Opportunities Residency Program is another 
program designed to attract students of baccalaureate nursing 
and pharmacy doctorate programs. Students are paid internship 
development competencies in the VA facility under the guidance 
of a preceptor. In 2006, VHA hired 89 nurses who graduated from 
this program.
    The Graduate Health Administration Training Program is a 
year-long paid training experience offering the graduates of a 
healthcare administration master's program brought to our 
system and we have recruited 35 of these positions on an annual 
basis.
    The technical career field is intended to create a talent 
pool in critical occupations such as financial management, 
human resources, contracting, prosthetics, logistics, bio-med, 
and general engineering. In the past 5 years, 226 interns have 
completed the program and accepted positions in the VHA.
    The Student Career Experience Program offers students work 
experience related to their field of study by providing periods 
of work and study while attending school. It focuses on 
recruiting students from minority colleges and universities in 
mission-critical occupations for permanent employment following 
graduation.
    The VA Cadet Program targets high school students who come 
to us as volunteers. It introduces high school students to 
healthcare occupations and encourages them to pursue education 
and training in nursing and other allied health professions.
    We have some very interesting recruitment and retention 
tools. The Employee Incentive Scholarship Program pays up to 
$32,000 for healthcare related degree programs. Since 1999, 
approximately 4,000 employees have graduated from these 
programs. Recipients include registered nurses, 93 percent of 
the graduates, pharmacists, and other allied health 
professionals.
    The Education Debt Reduction Program provides tax-free 
reimbursement of educational loans to recently hired title 38 
and hybrid title 38 employees. As of August 2007, there were 
5,600 healthcare professionals in the program. Seventy-seven 
percent of these professionals were from three mission-critical 
occupations, nursing, pharmacy, and physician.
    The Physician Pay legislation has proven to be very 
successful. VA is committed to ensuring that the levels of 
annual pay for VA physicians and dentists are at the levels 
regionally comparable with the income of non-VA physicians and 
dentists. Since this legislation has gone into effect, 
physician employment has increased by 430 doctors.
    VHA also pays close attention to employee entrance and exit 
surveys. The entrance survey is an excellent tool to examine 
why individuals come to work for us in the first place. And as 
Congresswoman Brown has indicated, people need to have passion 
in their belly to do the job in wanting to serve veterans. In 
contrast, the exit survey tracks the reason why VHA staff 
leave.
    Results from the 2006 show the top reasons to work for the 
VA were advancement, career development opportunities, benefits 
package, and job stability. The mission of serving VA and pay 
were also highly admitted.
    The exit survey shows the top reasons for leaving VHA were 
normal retirement as we face an aging workforce, advancement, 
and other healthcare organizations, and family matters 
including relocation and people being in childbearing years.
    We want to thank the Committee for their interest and 
support for VHA's succession planning. This concludes my 
statement and I look forward to responding to any questions you 
might have.
    [The prepared statement of Mr. Feeley appears on p. 59.]
    Mr. Michaud. Thank you very much, Mr. Feeley.
    You mentioned VA has been working on the pilot project for 
universities and colleges and the academic world. It sounded 
like all four of those were in urban areas. And as we know, 
that if you tend to get trained in a certain area, if it is a 
rural area, you tend to stay there.
    What is VA doing, and you mentioned additional sites, to 
make sure that rural areas are taken care of, particularly when 
you look at the veterans' population? Forty percent of our 
military are in rural areas. Rural areas are definitely going 
to need the help. So what are you doing to help recruit or 
retain healthcare professions and working with higher ed in the 
rural areas?
    Mr. Feeley. I think this is a pilot initiative. It is going 
to have eight more schools enrolled in it. That is something I 
will take back.
    [The following was subsequently received:]

          Question: What plans does VA have in place to ensure that 
        rural areas also have the opportunity to participate in the VA 
        Nursing Academy Pilot Project? The four initial sites selected 
        seem to be primarily in urban areas.

          Response: On April 16, 2007, the VA announced the VA Nursing 
        Academy: Enhancing Academic Partnerships program by sending the 
        Request for Proposals to every VA healthcare facility and VISN 
        and to 609 schools of nursing with baccalaureate degree 
        programs. VA received 62 Letters of Intent (LOI) to submit 
        proposals involving 59 VA facilities and 68 schools. Each 
        proposal was evaluated by a panel of VA and other Federal nurse 
        experts with clinical, educational and faculty backgrounds, 
        using a standard process in routine use by VA's Office of 
        Academic Affiliations, VA's Office of Research Development, the 
        National Institutes for Health and Non-Profit Foundations. The 
        four sites selected received the highest scores.

        The following review criteria were used:

                 1.  Commitment by VA and Nursing School Leadership
                 2.  Commitment by Nursing School to increase 
                enrollment
                 3.  Current/past relationships and activities between 
                VA and Nursing School
                 4.  Experience of VA and Nursing School Program 
                Directors to implement educational programs and 
                innovations
                 5.  Ability to implement proposed partnership model
                 6.  Activities/learning opportunities included in the 
                proposed program
                 7.  Availability/experience/interest of VA and School 
                Faculty
                 8.  Proposed faculty development plan
                 9.  Proposed evaluation plan
                10.  Agreement to fund travel for program planning and 
                evaluation

          For the second year of the pilot, the applying sites will be 
        classified by: (1) VA complexity level, which is an overall 
        measure of size, complexity of healthcare services provided and 
        research intensity; (2) rural-urban location; (3) inclusion of 
        multiple schools and/or VA facilities in the proposed 
        partnership; and (4) intensity and duration of relationships 
        between VA(s) and school(s) in the proposed partnership. This 
        will allow the peer review panel to take additional factors 
        into account when scoring the applications.

    Mr. Feeley. As a New Englander and as someone who spent 
some time in Damariscotta, Boothbay Harbor, and the Rangeley 
area, I know exactly what you are talking about. And I think we 
are going to have to find ways to incentivize it via tuition 
reimbursement, loan reduction. And I guess my preferred 
location at some point in my life would be a Cabot Cove type of 
environment.
    Mr. Michaud. That is good to hear.
    To date, has VA taken any steps to hire licensed 
professional counselors to provide the mental health services 
to our veterans?
    Mr. Feeley. We have recruited in the last 15 months 3,500 
additional mental health professionals over the base that we 
already had in 2005. This recruitment is with the benevolent 
generosity of Congress giving us additional money to prepare 
for the influx of mental health patients we are anticipating 
from the war.
    I think that those are competed for at a local level and 
people have to reply. We actually used USA Today as an 
advertisement source. Got a very good response to that as we 
were trying to accelerate the recruitment process.
    I do not have a breakdown of how many counselors were 
hired. A historical pattern has been psychologists, Master's 
trained social workers, and advanced nurse professionals. But 
counselors who are trained and certified can apply. They have 
to win the competition in a competitive interview process to 
get the job.
    [The following was subsequently received:]

        Question: Please provide a breakdown of the healthcare 
        professionals hired within the last 9 months (particularly 
        licensed professional counselors).

        Response: The breakdown (Monthly Distinct Employee for Non-Med 
        Resident, GAIN, VHA (Occupation Name), January-September 2007) 
        appears on p. 70.

    Mr. Michaud. You mentioned hiring dentists. I am not sure 
of the breakdown within the VA system as far as how many 
veterans actually need dentures. Often in the private sector, 
if you go to a dentist, it is a lot more expensive to get 
dentures than if you went to a denturist. And a lot of times 
dentists actually go to denturists to get the dentures which 
are much more expensive than going through a dentist.
    Have you looked at or evaluated cost efficiencies when you 
look at hiring denturists versus dentists?
    Mr. Feeley. I think you are raising a very interesting 
question. We had a considerable challenge in meeting dental 
needs. About 18 months ago, invested a fair amount of money to 
meet that backlogged need. And that included fee basis in rural 
areas to make sure people did not have to travel long 
distances.
    The question you are raising related to using another type 
of provider to do denture work, I am frankly just not up on 
what the proper answer to that would be. But we certainly can 
get back to you. And it is an interesting idea, unless Mr. 
Weaver or Ms. Clark have a thought on that.
    [The following was subsequently received:]

        Question: Has VA considered employment of denturists as opposed 
        to dentists? Denturists prepare and fit dentures at much lower 
        costs than dentists.

        Response: VA does not employ denturists at any of its 
        facilities as the independent practice by denturists is not 
        legal in most States. Denturists are dental laboratory 
        technicians with additional training to provide denture 
        services directly to patients. Denture services are provided to 
        eligible veterans by VA dentists at a cost less than can be 
        obtained through fee basis contract with dentists in private 
        practice.

    Mr. Michaud. I appreciate you looking at it because you 
will hear from the dentist that they are the only ones that can 
do it. But, quite frankly, a lot of them go to denturists to 
get that care, which is a lot less expensive by far. And I 
think that is something that we ought to look at how we can 
best utilize our funding.
    When you look at providing healthcare providers within the 
VA, if you look at what is happening, particularly in the war 
in Iraq and Afghanistan, we had a panel a couple of weeks ago 
that said, I believe, 13 percent of our men and women who are 
coming back have some form of eye injury.
    Is there a shortage currently within VA to deal with those 
types of issues and, if so, how are you addressing that 
shortage?
    Mr. Feeley. We measure wait in a number of specialty areas. 
We actually measure waits in 50 clinics and 8 specialty areas. 
I believe the eye clinic is one of those areas that we measure.
    And I am not seeing in our data systems backlog or people 
waiting long periods of time for ophthalmology care, keeping in 
mind that a person who needs stat right-away care is going to 
get it immediately. Just like when you go to the emergency 
room, that is a different situation than going for your routine 
primary care. So an eye injury that occurs and is requiring 
active care is going to be seen right away.
    Mr. Michaud. Great. Thank you.
    Ms. Brown.
    Ms. Brown of Florida. Thank you.
    I have a couple of questions. One, when you were giving 
those schools, you said Gainesville. Is that the University of 
Florida at Gainesville?
    Mr. Feeley. Yes.
    Ms. Brown of Florida. All right. Well, you know, there is 
another Gainesville somewhere.
    Mr. Feeley. Okay. Yes. I am sorry.
    Ms. Brown of Florida. What were those three other areas did 
you say? You said Gainesville, Florida, and what were the 
others?
    Mr. Feeley. Salt Lake City, San Diego, and West Haven.
    Ms. Brown of Florida. Okay.
    Mr. Feeley. And we will expand to eight other schools in 
the next several years.
    Ms. Brown of Florida. Yes. Well, some of those places sound 
pretty rural to me including Gainesville because Gainesville 
serves Gainesville, Lake City, you know, a lot of the rural 
areas. So the school will be serving the local communities, I 
assume.
    And now, the programs that you have at those schools, would 
you tell us quickly what the pilot programs encompass?
    Mr. Feeley. I could not give a detailed explanation of that 
curriculum other than the over-arching objective is we are 
going to provide faculty for these schools because the schools 
actually have a shortage of teachers and that is a piece of 
what is leaving them unable to take applicants in.
    So we are moving our well-educated nursing staff into being 
faculty in those schools and they would get, these students 
would get the exact same curriculum that they would have gotten 
in the nursing school.
    Ms. Brown of Florida. Okay. I guess the next question I am 
asking is, what kind of scholarship programs do you have to 
encourage internships or co-ops? What kind of program do you 
have working with young people because one of the problems now 
is the cost of education? And if you were providing some kind 
of a grants program to assist kids as they go to school, I 
mean, that is an incentive in itself.
    Mr. Feeley. I am going to make a try at that and then ask 
my colleagues to help me. The Education Debt Reduction Program 
is a huge----
    Ms. Brown of Florida. Oh, it is a great program. And we are 
not real sure how it is working with the VA. But I know I use 
it on my staff and basically even though your salary may be one 
thing, but if we are giving you a thousand dollars a month to 
pay off your loan, that is a big incentive.
    Mr. Feeley. And we do that up to the tune of, I believe, 
$34,000?
    Ms. Clark. It's 38 funded centrally and $48,000----
    Mr. Feeley. Thirty-eight dollars funded centrally and----
    Ms. Brown of Florida. Okay.
    Ms. Clark. Forty-eight thousand is the total amount that 
can be paid so the medical center can supplement if they want 
to pay off or give a provider additional funds.
    Ms. Brown of Florida. Are you saying that a nursing student 
that is working for the VA, you will pay up to how much money?
    Ms. Clark. Forty-eight thousand dollars.
    Ms. Brown of Florida. For one student?
    Ms. Clark. Yes.
    Ms. Brown of Florida. Well, I mean, I think that is good.
    And so they have to be working there in order to get that?
    Ms. Clark. For that program, yes, they do.
    [The following was subsequently received:]

        They received loan repayment at the end of each year up to a 
        maximum of 5 years.

    Ms. Brown of Florida. So how many people do you have 
enrolled in that program?
    Mr. Michaud. And could you turn your microphone on as well? 
Thank you.
    Ms. Clark. Sorry. I thought it was on.
    Well, registered nurses, we had a total of 2,300, a little 
over 2,300 that went through using the Education Debt Reduction 
since----
    Ms. Brown of Florida. That is a small percentage. Is it a 
limited amount of money in the program?
    Mr. Feeley. It is 5,600 nationally, 2,300 nurses, but there 
is not a limitation, I think, that I am aware of. We are going 
to come forward and fund whoever we can.
    The other thing I would mention along the lines you are 
talking about, if someone comes to work for us as a nursing 
assistant or as an LPN, we will also pay their education to go 
on to a baccalaureate degree which is another good recruitment 
tool.
    Ms. Brown of Florida. Oh, it has got to be. And it would 
help us get the people in the profession with that fire in the 
belly that we want, that want to help and work.
    My question is, what kind of programs do you have with the 
minority institutions? Florida A&M has one of the best pharmacy 
programs in the country. I was involved in helping to expand 
that program when I was a State representative in Florida. Do 
you all do recruitment at the black colleges and do you have, 
like you said, co-op programs working with these black 
institutions of higher education, the HBCV's----
    Ms. Clark. Historically black colleges and universities 
(HBCV).
    Ms. Brown of Florida. Yes, uh-huh.
    Mr. Weaver. Yes, we do. In fact, with nursing, we have 
approximately 650 affiliations with nursing schools and I think 
it is about 30 to 35 percent of all nursing students do a 
rotation through the VA.
    Ms. Brown of Florida. Do you pay those students while they 
are going through that program?
    Mr. Weaver. Well, only if they are an employee. And if a 
person is going to school and they are not an employee of the 
VA, they do rotations through the VA. We have employees who 
work for the VA who go to these schools that we do provide 
tuition support if they have requested it.
    Ms. Brown of Florida. Well, we should encourage that. And 
do you have the co-op type program?
    Mr. Weaver. Yes, we do. We have co-op programs not only for 
nurses but other allied health and also technical career 
fields.
    Ms. Brown of Florida. And my last question is, I was with 
someone Sunday and they had just received a Master's in Mental 
Health. And I was talking to them about the VA and they 
indicated that you do not hire people with a Master's Degree in 
mental health, VA, that you have to have it in social work. I 
am just kind of confused.
    I asked her to send me the curriculum because if that is 
the case, we need to take a look at it because, in fact, they 
have had more training working with people with, you know, 
problems directly related to mental health as opposed to a 
person with a Master's in Social Work because that could be 
School of Social Work or, you know, it is very broad.
    Mr. Feeley. I think that was what the first panel witness 
was pointing out. And, again, I think people need to apply and 
compete for these positions. And under the Public Law, they are 
able to do that. And I would encourage that person to make an 
application at their local VA.
    There is never a better time now----
    Ms. Brown of Florida. Oh, I told her that.
    Mr. Feeley. Yeah.
    Ms. Brown of Florida. And she is in Orlando, an excellent 
area, so I am definitely going to follow through with that 
person.
    But I am just wondering is it any kind of system in VA that 
does not encourage a person with a Master's Degree in Mental 
Health to apply?
    Mr. Feeley. Not that I am aware of. And I think the 
classification of what a person's pay may be is going to be 
based on their educational experience. But I think my message 
would be there are a variety of jobs in mental health, please 
go knock on the door and put the application in.
    I would just share with you one unique experience related 
to an approach I have seen a number of facilities take. Some 
medical centers actually have seniors in high school who are 
the best and brightest attending their senior year at the VA 
Medical Center 3 days a week. And they are getting preceptored 
by our clinical staff and they are walking around in doctor's 
coats and x-ray coats. And I actually saw the graduation 
ceremony. These young people were going to very prestigious 
schools and all of them were going into healthcare.
    So we are trying to reach down very deeply. I think grammar 
school is next, but I am pleased to see high school doing as 
well as it is doing.
    Ms. Brown of Florida. High school is great. And, you know, 
junior high school is critical because that is when those are 
really areas that, you know, we want to put them on the right 
track.
    Thank you very much.
    And thank you, Mr. Chairman.
    Mr. Michaud. Thank you very much.
    I just have one additional question. It deals with a study 
that was sponsored by the Partnership for Public Service that 
recently came out that showed a large discrepancy in the 
workplace satisfaction in the Veterans Health Administration 
between workers who are over 40 and workers who are under 40. 
VHA workers who are over 40 reported a high satisfaction as far 
as their work; those under 40 reported a low satisfaction.
    What factors do you think account for that discrepancy and 
what are you doing to try to attract younger workers?
    Mr. Feeley. We do an all employee survey each year and that 
all employee survey is done throughout the country with an 80 
percent completion rate. Most of it is online, but if someone 
is unable to do it online, we will help them get it done in 
writing.
    We have it broken down by job category and by age. And so 
you can see it actually from 30 and under to 30 to 45, 45 and 
over, and even 60 and over.
    And clearly the trend you are describing is very prevalent. 
Part of what I think we have to do is find a way to engage the 
younger generation in, I think, the point Congresswoman Brown 
made, about the meaning that comes with this work. It is an 
honor to do this work.
    And we also have to work on workforce after five o'clock 
life balance. I want to be careful how I say this, but people 
of different eras were brought up differently related to work. 
And so what is a 60-hour-a-week standard in one era is now a 
40-hour-a-week standard in another.
    So we have to find ways to adapt our workforce employment 
to take this all into consideration because I just turned 60 
and I am concerned about how healthy it is going to be in the 
next 5 years. We want to make sure we are bringing young people 
in.
    Mr. Michaud. Great.
    Ms. Brown.
    Ms. Brown of Florida. Mr. Chairman, in that survey, I am 
finding that even across fields, money is more of an incentive 
to young people and the amount of time they work and how much 
free time they have as to people that are over 40 because, you 
know, it is just a different mentality as far as the work is 
concerned.
    And I think money can be an incentive. I hate to keep 
talking about money, but it is a factor for a lot of young 
people.
    Mr. Feeley. And we are trying to use all types of tools 
including relocation bonuses, retention bonuses. And as Mr. Cox 
said, if we are able to keep an employee beyond 5 years, they 
are going to be with us. It is that first five-year period to 
get them ignited and excited about working for the VA that is 
critical.
    Ms. Brown of Florida. And I think if you all could look 
seriously at expanding that student loan program and that 
repayment program because that is a great incentive if you all 
are paying a thousand dollars a month, I mean, because we use 
that in other offices and it makes a difference because we 
cannot compete with, you know, a lot of the jobs in the private 
sector. But when people have these huge loans they have to pay 
back, that is a bonus in itself.
    Mr. Michaud. Great.
    Ms. Brown of Florida. So I would like to get an update on 
the program and exactly how many people you have and how are we 
advertising it to the employees.
    Thank you, Mr. Chairman.
    [The following was subsequently received:]

        Question: Please provide an update on the different student 
        loan/scholarship/debt reduction programs.

        Response:

        Scholarship Programs

        Implemented in 2000 the Employee Incentive Scholarship Program 
        (EISP) authorizes VA to award scholarships to employees 
        pursuing degrees or training in healthcare disciplines for 
        which recruitment and retention of qualified personnel is 
        difficult. EISP awards cover tuition and related expenses such 
        as registration, fees, and books. The academic curricula 
        covered under this initiative include education and training 
        programs in fields leading to appointments or retention in 
        Title 38 or Hybrid Title 38 positions listed in 38 U.S.C. 
        section 7401. The following data reflects the total employee 
        participants through fiscal year 2007:

                  Total number of awards: 7,127
                  Total number of employees completing the 
                program (graduates): 3,988
                  Total amount of funding for awards through FY 
                2012: $88,315,696
                  Average amount of award per participant 
                $12,392

        The chart below identifies the total number of scholarships 
        awarded to VHA employees since 2000, the number of employees 
        who have completed their programs and the average amount of the 
        scholarship awarded by occupation.

----------------------------------------------------------------------------------------------------------------
                                                                                Total #        Average Amount of
                       Occupation                          Total # Awards      Completed          Each Award
----------------------------------------------------------------------------------------------------------------
Registered Nurse                                                    6,595            3,634              $12,416
----------------------------------------------------------------------------------------------------------------
Pharmacist                                                            188               96              $17,601
----------------------------------------------------------------------------------------------------------------
Licensed Practical Nurse                                              134               66               $7,196
----------------------------------------------------------------------------------------------------------------
Physical Therapist                                                     55               21               $9,593
----------------------------------------------------------------------------------------------------------------
Physician Assistant                                                    34               26               $6,388
----------------------------------------------------------------------------------------------------------------
Registered Respiratory Therapist                                       34               16               $5,995
----------------------------------------------------------------------------------------------------------------
Certified Registered Nurse Anesthetist                                 33                7              $15,920
----------------------------------------------------------------------------------------------------------------
Audiologist                                                            12                3               $5,949
----------------------------------------------------------------------------------------------------------------
Occupational Therapist                                                 12                6              $14,677
----------------------------------------------------------------------------------------------------------------
All other                                                              30               16                   --
----------------------------------------------------------------------------------------------------------------
TOTAL                                                               7,127            3,988              $12,392
----------------------------------------------------------------------------------------------------------------


        An analysis of the average cost per award reveals that the 
        average award ($12,329) is substantially less than the maximum 
        amount allowed ($35,024 in FY 2007) by statue. Additionally, 
        the average number of credit hours funded per employee (45 
        credits for undergraduate and for 36 credit hours graduate) is 
        substantially less than the hours allowed by statue (90 credits 
        for undergraduate and 54 for graduate). This demonstrates that 
        the employees are selecting academic institutions with 
        reasonable costs and the employees have self-funded a 
        substantial part of the degree prior to applying for the 
        scholarship award.

        Education Debt Reduction Program

        The chart below provides a snap shot of the number of employees 
        who have participated in the Education Debt Reduction Program 
        (EDRP) since its implementation in May 2002. The program is 
        authorized in Chapter 76 of Title 38 of the United States Code. 
        Designed to assist VA with recruitment and retention of hard-
        to-fill healthcare professions, it applies to Title 38 and 
        hybrid Title 38 occupations. Total expenditures for EDRP awards 
        from the programs inception and continuing with award 
        obligations authorized through FY 2012 are $96,870.402.


----------------------------------------------------------------------------------------------------------------
                                                            Total # EDRP        Total #        Average Amount of
                       Occupation                              Awards          Completed            Award
----------------------------------------------------------------------------------------------------------------
Registered Nurse                                                    2,704            1,475              $13,451
----------------------------------------------------------------------------------------------------------------
Pharmacist                                                            876              429              $23,595
----------------------------------------------------------------------------------------------------------------
Physician                                                             715              345              $24,790
----------------------------------------------------------------------------------------------------------------
Licensed Practical/                                                   285              173               $5,499
  Vocational Nurse
----------------------------------------------------------------------------------------------------------------
Physical Therapist                                                    231              128              $21,522
----------------------------------------------------------------------------------------------------------------
Physician Assistant                                                   204              116              $21,254
----------------------------------------------------------------------------------------------------------------
Occupational Therapist                                                105               75              $16,381
----------------------------------------------------------------------------------------------------------------
Medical Technologist                                                   97               38              $16,135
----------------------------------------------------------------------------------------------------------------
Diagnostic Radiologic Technologist                                     80               34              $11,223
----------------------------------------------------------------------------------------------------------------
Registered Respiratory Therapist                                       50               33              $11,860
----------------------------------------------------------------------------------------------------------------
All other 23 occupations                                              309              138
----------------------------------------------------------------------------------------------------------------
Total                                                               5,656            2,984              $16,571
----------------------------------------------------------------------------------------------------------------


        VALOR--VA Learning Opportunity Residency Program

        Initiated in 1990, for students (junior class level) enrolled 
        in schools of nursing with baccalaureate degree programs VALOR 
        has provided opportunities for students to develop competencies 
        in clinical nursing while at an approved VA healthcare 
        facility. In FY 2007 there were 398 new VALOR nursing students 
        and 193 continuing students. Outcomes of the program have 
        demonstrated that it is an excellent method of recruiting 
        students when those students are retained into the senior year 
        (over 50 percent of this group are hired). With the success of 
        the nursing VALOR program, in 2007 the VALOR program for 
        pharmacy students began. In this inaugural year 14 students 
        were selected. Additional sites and students will be approved 
        as the program evolves and develops.

    Mr. Michaud. Thank you very much, Ms. Brown.
    And there will be additional questions for the record as 
well.
    So once again, I want to thank this panel for your 
outstanding testimony. As we move forward on this very 
important issue, I look forward to working with you as well.
    And I want to thank all the employees at VA. I know a lot 
of times, they get criticized. But, quite frankly, part of the 
blame belongs to the Administration and Congress for not 
providing adequate timely funding.
    So I do appreciate all the hard work that the VA employees 
do and we will continue to work with you.
    So this hearing is adjourned. Thank you.
    [Whereupon, at 11:57 a.m., the Subcommittee was adjourned.]



                            A P P E N D I X

                              ----------                              

             Prepared Statement of Hon. Michael H. Michaud,
                    Chairman, Subcommittee on Health
    I would like to thank the members of the Subcommittee, our 
witnesses and all those in the audience for being here today.
    We are here to address the very important issue of recruitment and 
retention of health care professionals in the Veterans Health 
Administration. Health care professionals are the Veterans Health 
Administration's most important resource in delivering high-quality 
health care to our Nation's veterans. The VA must recruit and retain 
doctors, nurses, mental health providers, physical therapists, and many 
other health care professionals in order to stay true to their motto of 
``Best Quality of Care Anywhere.'' Quality care can only come from 
quality care providers--but recruiting and retaining quality health 
care professionals is becoming increasingly difficult. Health care 
professionals often choose to work in the private sector because it 
offers more attractive pay and benefits packages than the VA offers.
    Not only does the VA need to maintain its current workforce, but 
the VA also needs to look to the future to ensure that its staffing 
needs can be met. Operation Enduring Freedom and Operation Iraqi 
Freedom veterans are returning and becoming eligible for VA services in 
record numbers. Additionally, a recent study by the Partnership for 
Public Service found that VHA employees under the age of 40 have very 
low job satisfaction. The VA needs to pay particular attention not only 
to its future workforce needs, but also to the work environment so that 
they will be able to retain younger workers.
    In our first panel this morning we will hear from representatives 
of health care providers. These organizations work closely with the VA 
to provide the best service possible to our Nation's veterans. I want 
to send a special welcome to Kristi McCaskill representing the National 
Board of Certified Counselors. Last year, Congress passed the Veterans 
Benefits, Health Care, and Information Technology Act of 2006 which 
explicitly recognizes licensed counselors as health care providers 
within the Veterans Health Administration. As part of their recruitment 
plan moving forward, I would encourage the VA to use Licensed 
Professional Counselors as mental health treatment providers. Licensed 
Professional Counselors are qualified and eager to provide services to 
America's Veterans.
    I look forward to hearing about the VA's current recruitment and 
retention system as well as some ideas about how this system can be 
improved in the future to meet VA's health care needs.

                                 
 Prepared Statement of Jeffrey L. Newman, PT, Member, American Physical
      Therapy Association, and Chief, Physical Therapy Department,
      Minneapolis Veterans Affairs Medical Center, Minneapolis, MN
    Chairman Michaud, and members of the Subcommittee on Health, thank 
you for the opportunity to testify on the recruitment and retention of 
qualified healthcare professionals to work in the Department of 
Veterans Affairs' (VA) Veterans Health Administration (VHA). These 
professionals, such as physical therapists, are vital to meet the 
rehabilitation needs of our Nation's veterans today and tomorrow.
    I am proud to say I have practiced as a physical therapist in the 
VA system for more than 30 years, and for 20 of those years I have 
served as Chief of the Physical Therapy Department at the VA Medical 
Center in Minneapolis, Minnesota. As you may know, this facility is 
also one of the four designated Polytrauma Rehabilitation Centers (PRC) 
providing care to patients with a wide spectrum of rehabilitation needs 
including those with Traumatic Brain Injury (TBI). I come before you 
today as a member of the American Physical Therapy Association (APTA) 
which represents over 70,000 physical therapists, physical therapist 
assistants and students of physical therapy nationwide. I have served 
in several leadership posts within the Association including past 
President of the APTA's Veterans Affairs' section.
    In my experience providing physical therapist services and managing 
a team to provide rehabilitation services, I have seen the physical 
therapy profession advance to meet the changing rehabilitation needs of 
our patients. The primary challenge to continue to meet the 
rehabilitation needs of veterans is the recruitment and retention of 
physical therapists. This challenge is compounded by two trends that 
increase the need for physical therapist services: chronic conditions 
associated with an aging veteran population and the complex impairments 
associated with returning veterans from Operation Enduring Freedom 
(OEF) in Afghanistan and Operation Iraqi Freedom (OIF) in Iraq.
    In my remarks today, I will discuss the increased need for physical 
therapists in the VA system, highlighting current challenges with 
recruitment and retention of physical therapists within a changing 
environment that only increases the need for rehabilitation led by 
these professionals. I will make two specific recommendations to help 
meet these challenges and ensure our Nation's veterans the 
accessibility and availability to the physical therapists services they 
need to regain mobility and function to ensure they achieve the highest 
degree of independence and quality of life in their homes and 
communities. These recommendations are the immediate approval and 
implementation of pending qualification standards and focused 
enhancements to current VA scholarship programs for physical 
therapists.
Physical Therapists in the VA: An Increasing Need For Rehabilitation 
        Services
    Physical therapists (PTs) are health care professionals who 
diagnose and manage individuals of all ages, from newborns to elders, 
who have medical problems or other health-related conditions that limit 
their abilities to move and perform functional activities in their 
daily lives. Physical therapists examine and develop an individualized 
plan of care using treatment interventions to promote the ability to 
move, reduce pain, restore function, and prevent disability. Physical 
therapists also work with individuals to prevent the loss of mobility 
by developing fitness- and wellness-oriented programs for healthier and 
more active lifestyles.
    With more than 1,000 \1\ physical therapists on staff, the VA is 
one of the largest employers of physical therapists nationwide. 
Physical therapists have a long history of providing care to our active 
duty military and to our Nation's veterans. In fact, our professional 
roots started by rehabilitating soldiers as they began returning from 
World War I. Back then, physical therapists were known as 
``reconstruction aides.'' Today, physical therapists in the VA render 
evidence-based, culturally sensitive care and many have been recognized 
leaders in clinical research and education. Physical therapists in the 
VA practice across the continuum of care, from primary care and 
wellness programs to disease prevention and post-trauma rehabilitation. 
Clinical care practice settings that include physical therapists 
include inpatient acute care, primary care, comprehensive inpatient and 
outpatient rehabilitation programs, spinal cord injury centers and 
geriatric/extended care.
---------------------------------------------------------------------------
    \1\ At the end of fiscal year 2006, 1,024 physical therapists were 
employed by the VA Department of Veterans Affairs.
---------------------------------------------------------------------------
    The need for high quality rehabilitation provided by physical 
therapists has never been greater with the dual challenges of caring 
for the chronic diseases faced by aging veterans and the multifaceted 
profile of many of today's wounded warriors. According to the VA, 9.2 
million veterans are age 65 or older, representing 38% of the total 
veteran population. By 2033, the proportion of older veterans will 
increase to 45% of the total.\2\ Among this aging veteran population, a 
high prevalence of diabetes is a critical chronic disease challenge for 
health care providers. Physical therapists are specialists in 
facilitating or regaining mobility and function lost due to diabetes 
and its complications as well as its prevention strategies.
---------------------------------------------------------------------------
    \2\ ``Research in VA Geriatrics Centers of Excellence'' Fact Sheet 
May 2006. Department of Veterans Affairs website. Accessed October 15, 
2007.
---------------------------------------------------------------------------
    The second trend that highlights the need to recruit and retain 
physical therapists in the VA is the changing profile of injuries and 
impairments of our returning service personnel. Enhancements in 
battlefield medicine have helped a larger portion of soldiers survive 
their injuries, compared to previous wars our Nation has fought.\3\ 
Many of our Nation's recent veterans are facing unique injuries that 
require complex rehabilitation including spinal cord injury, amputee 
rehabilitation and traumatic brain injury. Physical therapists are a 
key part of the VA's Polytrauma Rehabilitation Centers (PRCs) caring 
for TBI patients in Tampa, Palo Alto, Richmond, and at my facility in 
Minneapolis. PRCs have clinical expertise and include an 
interdisciplinary team to provide care for complex patterns of 
injuries, including TBI, traumatic or partial limb amputation, nerve 
damage, burns, wounds, fractures, vision and hearing loss, pain, mental 
health and readjustment problems. Physical therapists are also part of 
the specialized amputee rehabilitation center at the Brooke Army 
Medical Center at Fort Sam Houston, Texas.
---------------------------------------------------------------------------
    \3\ Atul Gawande, ``Casualties of War-Military Care for the Wounded 
from Iraq and Afghanistan,'' The New England Journal of Medicine, vol. 
351, issue 24 (December 2004) p. 2471.
---------------------------------------------------------------------------
    Physical therapists at the Minneapolis VA facility--and at other 
facilities--have been at the forefront in developing programs to care 
for our wounded warriors prior to the creation of the PRC designation. 
Minneapolis has had a TBI program with dedicated staff in TBI 
rehabilitation for over 10 years. We have physical therapists on staff 
who have received American Board of Physical Therapy Specialties 
(ABPTS) specialist certification in neurological, clinic specialists in 
geriatric, and orthopedic physical therapy. My specific clinical 
background is in amputation rehabilitation. I have had the honor of 
caring for a generation of veterans and have been able to see the 
growing need for physical therapist services through the years.
Current Recruitment and Retention Challenges for Physical Therapists in 
        the VA
    Given the increasing number of aging veterans and the number of 
OEF/OIF veterans needing physical therapist services, recruitment and 
retention of qualified physical therapists is vital to ensuring our 
veterans have access to the physical therapist services they need in a 
timely fashion. The number one obstacle to both the recruitment and 
retention of physical therapists to serve in the VA is the severely 
outdated qualification standards that currently govern the salary and 
advancement opportunities for physical therapists employed by the VA. 
These standards have not been updated for nearly 25 years.
    The physical therapy profession has evolved as the need for our 
services has expanded. Unfortunately the VA has not kept pace with 
current professional practice standards and is quickly falling behind 
clinical areas outside of the VA and other health care professionals 
with similar or lesser qualifications within the VA. The current 
minimal requirement to become a physical therapist is to graduate with 
a master's degree (approximately 80% of programs now are graduating at 
the doctoral level \4\ and pass a licensure test. The current VA 
qualification standards still only require a physical therapist to 
obtain a bachelor's degree and do not recognize the doctorate of 
physical therapy or DPT degree. Not only is this severely out of date 
with current minimal education requirements but it is not competitive 
with clinical settings outside of the VA system.
---------------------------------------------------------------------------
    \4\ ``2005-2006 Fact Sheet, Physical Therapy Education Programs.'' 
Pg 4. American Physical Therapy Association. January 2007.
---------------------------------------------------------------------------
    I recommend the immediate approval of revised qualification 
standards for physical therapists to establish a consistency between 
the VA and the current professional practice of physical therapy and to 
achieve equity with healthcare professionals of similar education, 
experience and expertise currently practicing in the VA. The APTA in 
representing physical therapists practicing in the VA, strongly 
supports the immediate approval of these qualification standards.
    APTA began working with the VA to update the qualification 
standards over six years ago and supports the following changes to 
establish consistency between the VA and the current professional 
practice of physical therapy as defined by the Guide to Physical 
Therapist Practice:

      Recognition of Educational and Clinical Training of the 
Physical Therapist,
      Clarification of a career ladder in the Department of 
Veterans Affairs for Physical Therapists,
      Recognition of the Doctoral Degree in Physical Therapy, 
and
      Expanded opportunities for career advancement for 
physical therapists.

    Unfortunately while the APTA has received feedback from the VA that 
changes need to be made to update the qualification standards, these 
recommendations have not been implemented. Establishing appropriate and 
up to date qualification standards will make it easier to both recruit 
and retain physical therapists to serve our Nation's veterans.
    The need for immediate approval of these revised standards is due 
to several factors. First, the demand for physical therapist services 
is on the rise, and the outdated qualification standards have made it 
difficult to recruit physical therapists to the VA system. Second, the 
increased need for services provided by qualified physical therapists 
in the VA due to the two trends outlined above--providing services for 
our aging veterans and meeting the complex rehabilitation needs of our 
returning soldiers. Third, the outdated qualification standards also 
limit the ability of a physical therapist to advance within the VA 
system once they have joined. The current standards do not recognize 
physical therapists that achieve specialty certification such as those 
needed in the polytrauma centers. Fourth, it has been at least 6\1/2\ 
years since the VA first recognized that the standards needed to be 
updated. These pending regulations should be implemented immediately.
    In addition to the immediate approval and implementation across the 
board--not just in select facilities--of the revised qualification 
standards, I recommend enhancements to the current VA scholarship 
programs for physical therapists to help in both recruitment and 
retention. Many new graduates are concerned with a high amount of 
student loan debt when leaving school, scholarship and loan repayment 
programs are an important tool in recruiting additional physical 
therapists to meet the VA's need.
    I had the opportunity to serve on the Committee to review 
scholarship program applicants in the early 1990s when the VA had--in 
my opinion--a very successful scholarship incentive program to attract 
new graduates. Over the course of that particular program, my facility 
in Minneapolis had five recipients. One of those original recipients is 
still in my facility, two of the other stayed for several years with 
only two leaving directly after their required service was complete. 
The previous scholarship program provided an incentive to serve right 
out of school whereas the new incentive program including the debt 
reduction program is poorly advertised and cumbersome for the potential 
applicants. In 2007, only 19 physical therapists have participated in 
the Education Debt Reduction Program and only 14 physical therapists 
have participated in the Employee Incentive Scholarship Program.\5\
---------------------------------------------------------------------------
    \5\ According to information on physical therapists from the HRRO 
Education Database provided to APTA by the Department of Veterans 
Affairs on October 15, 2007.
---------------------------------------------------------------------------
    In closing, APTA recommends the immediate approval and 
implementation of the qualification standards for physical therapists 
in the VA and the investigation of options to enhance current programs 
offering scholarships, loan support and debt retirement for physical 
therapists choosing to serve in the VA. This will assist in both the 
recruitment and retention of qualified physical therapists to meet the 
needs of our veterans today and tomorrow.
    Physical therapists are a vital part of the healthcare network that 
provides services to our Nation's veterans. Ensuring that the 
qualification standards that govern the salary and advancement 
opportunities for physical therapists in the VA are up to date and 
reflective of the current professional practice of physical therapy as 
well as enhancing current scholarship opportunities will help recruit 
and retain more physical therapists to the VA system.
    Thank you for this opportunity Mr. Chairman, I would be happy to 
answer any questions you or the other committee members may have.

                                 
    Prepared Statement of Richard D. Krugman, M.D., Chair, Executive
    Council, Association of American Medical Colleges, and Dean, and
 Vice Chancellor for Health Affairs, University of Colorado School of 
                                Medicine

    Good morning and thank you for this opportunity to testify on the 
recruitment and retention of health professionals at the Department of 
Veterans Affairs (VA). I am Dr. Richard Krugman, Dean of the University 
of Colorado School of Medicine and Vice Chancellor for Health Affairs, 
Chair of the Association of American Medical Colleges (AAMC) Executive 
Council, and a member of the AAMC VA-Deans Liaison Committee. The 
University of Colorado is affiliated with the Denver VA Medical Center 
of the Rocky Mountain Veterans Integrated Services Network (VISN 19).
    The AAMC is a nonprofit association representing all 126 accredited 
U.S. and 17 accredited Canadian medical schools; nearly 400 major 
teaching hospitals and health systems, including 68 VA medical centers; 
and 94 academic and scientific societies. Through these institutions 
and organizations, the AAMC represents 109,000 faculty members, 67,000 
medical students, and 104,000 resident physicians.
    I would like to thank the committee for your support of the 
Veterans Health Administration (VHA) fiscal year (FY) 2008 
appropriations. Your leadership resulted in the House's passage of 
$36.6 billion for VA Medical Care and $480 million for VA Medical and 
Prosthetics Research. This funding is crucial to the continued success 
of the primary sources of VA's physician recruitment and retention: 
academic affiliations, graduate medical education, and research.
VA Medical Care
    The mission of the Veterans Healthcare System is ``to serve the 
needs of America's veterans by providing primary care, specialized 
care, and related medical and social support services.'' The VHA 
operates the largest comprehensive, integrated healthcare delivery 
systems in the United States. Organized around 21 Veteran Integrated 
Services Networks (VISNs), VA's health care system includes 154 medical 
centers and operates more than 1,300 sites of care, including 875 
ambulatory care and community based outpatient clinics, 136 nursing 
homes, 43 residential rehabilitation treatment programs, 206 Veterans 
Centers, and 88 comprehensive home-care programs.
    VHA has experienced unprecedented growth in the health care system 
workload over the past few years. The number of unique patients treated 
in VA health care facilities increased by 34 percent from 4.1 million 
in 2001 to more than 5.5 million in 2006. That same year, VA inpatient 
facilities treated 587,000 patients and VA's outpatient clinics 
registered nearly 57.5 million visits.
    The VA healthcare system had 7.7 million veterans enrolled to 
receive VA health care benefits in 2006. To help VA manage health care 
services within budgetary constraints, enrolled veterans are placed in 
priority groups or categories. Unfortunately, with limited resources, 
VA has had to restrict the number of priority 8 veterans, higher-income 
veterans suffering from conditions not related to their service, who 
can receive VA care.
    Despite limiting access of this category of veterans, a significant 
backlog of delayed appointments has resulted from an inadequate supply 
of physicians. While the VHA has made substantial improvements in 
quality and efficiency, the Independent Budget veterans service 
organizations cite excessive waiting times and delays as the primary 
problem in veterans' health care. Without increases in clinical staff, 
veterans' demand for health care will continue to outpace the VHA's 
ability to supply timely health-care services and will erode the world-
renowned quality of VA medical care.
Physician Shortage
    Concerns about physician staffing at the VA come at a time when the 
Nation faces a pending shortage of physicians. Recent analysis by the 
AAMC's Center for Workforce Studies indicates the United States will 
face a serious doctor shortage in the next few decades. Our Nation's 
rapidly growing population, increasing numbers of elderly Americans, an 
aging physician workforce, and a rising demand for health care services 
all point to this conclusion.
    Many areas of the country and a number of medical specialties are 
already reporting a scarcity of physicians. Approximately 30 million 
people now live in a federally designated shortage of physicians area. 
An acute national physician shortage would have a profound effect on 
access to health care, including longer waits for appointments and the 
need to travel farther to see a doctor. The elderly, the poor, rural 
residents, and the 20 percent of Americans who are already medically 
underserved would face even greater challenges as a result.
    Between 1980 and 2005, the Nation's population grew by 70 million 
people--a 31-percent increase. As baby boomers age, the number of 
Americans over age 65 will grow as well. By 2030, the number of people 
over 65 will double from 35 million to 71 million. Patients age 65 and 
older typically average six to seven visits to a physician per year 
compared with two to four visits annually for those under 65. As the 
population ages, the AAMC projects that Americans will make 53 percent 
more trips to the doctor in 2020 than in 2000. As medical advances 
extend longevity and improve the quality of life for those with chronic 
conditions, the need for chronic health care services will increase.
    Currently, 744,000 doctors practice medicine in the United States. 
But 250,000--one in three of these doctors--are over age 55 and are 
likely to retire during the next 20 years, just when the baby boom 
generation begins to turn 70. The annual number of physician retirees 
is predicted to increase from more than 9,000 in 2000 to almost 23,000 
in 2025. Meanwhile, since 1980, the number of first-year enrollees in 
U.S. medical schools per 100,000 population has declined annually. 
Consequently, America is producing fewer and fewer doctors each year 
relative to our continually growing population.
    Because it can take up to 14 years from the time new doctors begin 
their education until they enter practice, the AAMC believes that we 
must begin to act now to avert a physician shortage. Specifically:

      The AAMC has called for a 30 percent increase in U.S. 
medical school enrollment by 2015, which will result in an additional 
5,000 new M.D.s annually.
      To accommodate more M.D. graduates, the AAMC supports a 
corresponding increase in the number of federally supported residency 
training positions in the Nation's teaching hospitals.

Academic Affiliations
    The affiliations between VA medical centers and the Nation's 
medical schools have provided a critical link that brings expert 
clinicians and researchers to the VA health system. The affiliations 
began shortly after World War II when the VA faced the challenge of an 
unprecedented number of veterans needing medical care and a shortage of 
qualified VA physicians to provide these services. As stated in seminal 
VA Policy Memorandum No. 2 published in 1946, the affiliations allow VA 
to provide veterans ``a much higher standard of medical care than could 
be given [them] with a wholly full-time medical service.''
    Over six decades, these affiliations have proven to be mutually 
beneficial by affording each party access to resources that would 
otherwise be unavailable. It would be difficult for VA to deliver its 
high quality patient care without the physician faculty and medical 
residents who are available through these affiliations. In return, the 
medical schools gain access to invaluable undergraduate and graduate 
medical education opportunities through medical student rotations and 
residency positions at the VA hospitals. Faculty with joint VA 
appointments are afforded opportunities for research funding that are 
restricted to individuals designated as VA employees.
    These faculty physicians represent the full spectrum of generalists 
and specialists required to provide high quality medical care to 
veterans, and, importantly, they include accomplished sub-specialists 
who would be very difficult and expensive, if not impossible, for the 
VA to obtain regularly and dependably in the absence of the 
affiliations. According to a 1996 VA OIG report, about 70 percent of VA 
physicians hold joint medical school faculty positions. These jointly 
appointed clinicians are typically attracted to the affiliated VA 
Medical Center both by the challenges of providing care to the veteran 
population and by the opportunity to conduct disease-related research 
under VA auspices.
    At present, 130 VA medical centers have affiliations with 107 of 
the 126 allopathic medical schools. Physician education represents half 
of the over 100,000 VA health professions trainees. The VA estimates 
that medical residents contribute approximately \1/3\ of the VA 
physician workforce. In a 2007 Learners Perceptions Survey, the VA 
examined the impact of training at the VA on physician recruitment. 
Before training, 21 percent of medical students and 27 percent of 
medical residents indicated they were very or somewhat likely to 
consider VA employment after VA training. After training at the VA, 
these numbers grew to 57 percent of medical students and 49 percent of 
medical residents.
VA Graduate Medical Education
    Today, the VA manages the largest graduate medical education (GME) 
training program in the United States. The VA system accounts for 
approximately 9 percent of all GME in the country, supporting more than 
2,000 ACGME-accredited programs and 9,000 full-time medical residency 
training positions. Each year approximately 34,000 medical residents 
(30 percent of U.S. residents) rotate through the VA and more than half 
the Nation's physicians receive some part of their medical training in 
VA hospitals.
    As our Nation faces a critical shortage of physicians, the VA has 
been the first to respond. The VA plans to increase its support for GME 
training, adding an additional 2,000 positions for residency training 
over five years, restoring VA-funded medical resident positions to 10 
to 11 percent of the total GME in the United States. The expansion 
began in July 2007 when the VA added 342 new positions. These training 
positions address the VA's critical needs and provide skilled health 
care professionals for the entire Nation. The additional residency 
positions also encourage innovation in education that will improve 
patient care, enable physicians in different disciplines to work 
together, and incorporate state-of-the-art models of clinical care--
including VA's renowned quality and patient safety programs and 
electronic medical record system. Phase 2 of the GME enhancement 
initiative has received applications requesting 411 new resident 
positions to be created in July 2008.
VA-AAMC Deans Liaison Committee
    The smooth operation of VA's academic affiliations is crucial to 
preserving the health professions workforce needed to care for our 
Nation's veterans. The VA-AAMC Deans Liaison Committee meets regularly 
to maintain an open dialogue between the VA and medical school 
affiliates and to provide advice on how to better manage their joint 
affiliations. The committee consists of medical school deans and VA 
officials, including the VA Chief Academic Affiliations Officer, the VA 
Chief Research and Development Officer, and three Veteran Integrated 
Services Network (VISN) directors. The committee's agendas usually 
cover a variety of issues raised by both parties and range from 
ensuring information technology security to the integrity of solesource 
contracting directives.
    Recently, the VA-Deans Liaison Committee has reviewed the 
remarkable progress being made on several VA initiatives. These 
include:

    Establishment of the Blue-Ribbon Panel on Veterans Affairs Medical 
School Affiliations--This panel will provide advice and consultation on 
matters related to the VA's strategic planning initiative to assure 
equitable, harmonious, and synergistic academic affiliations. During 
the panel's deliberations, those affiliations will be broadly assessed 
in light of changes in medical education, research priorities, and the 
health care needs of veterans.

    Survey of Medical School Affiliations--The AAMC has worked with VA 
staff to develop criteria to evaluate the ``health'' of individual 
affiliation relationships. The ``Affiliation Governance Survey'' will 
survey the leadership at both the VA medical centers and their 
affiliated schools of medicine on a range of topics including:

      Overall satisfaction and level of integration;
      Affiliation Effectiveness Factors (such as education, 
research, VA clinical practice environment, and faculty affairs);
      Overall commitment to the affiliation relationship;
      Academic affiliations partnership councils (Dean's 
committees); and
      Direction and value of school of medicine-VA medical 
center affiliations.

    Development of VA Handbook on VHA Chief of Staff Academic 
Appointments--To prevent conflicts of interest or the appearance 
thereof, the VA has determined that limits on receiving remuneration 
from affiliated institutions are necessary for VHA employees at levels 
higher than chief of staff. While it is important to ensure that 
remuneration agreements do not create bias in the actions of VHA staff, 
prohibition of certain compensation from previous academic appointments 
(e.g., honoraria, tuition waivers, and contributions to retirement 
funds) could significantly hinder the VA's ability to recruit staff 
from their academic affiliates. The AAMC has worked with VA staff to 
develop a mutually acceptable agreement that considers this balance.

    Piloting the VA physician time and attendance/hours bank--
Monitoring physician time and attendance for the many medical faculty 
holding joint appointments with VA medical centers has been complicated 
and inefficient. The VHA has accepted the ``hours bank'' concept to 
improve the tracking of part-time physician attendance. Under the hours 
bank, participating physicians will be paid a level amount over a time 
period agreed to in a signed Memorandum of Service Level Expectations 
(MSLE). This agreement will allow the supervisor and participating 
physician to negotiate and develop a schedule for the upcoming pay 
period. A subsidiary record will track the number of hours actually 
worked, and a reconciliation will be performed at the end of the MSLE 
period to adjust for any discrepancies. A pilot for this program has 
been successfully completed and plans for nationwide implementation are 
underway.

    The VA has consistently recognized that there is always room for 
improvement. As such, the AAMC looks forward to working on other items 
of concern as the VA continues to evaluate its affiliation policies and 
processes. As medical care shifts to a more satellite-based outpatient 
approach, graduate medical education needs to follow suit. This strong 
shift to ambulatory care at multiple sites requires a similar change in 
the locus of medical training. A dispersion of patients to multiple 
sites of care makes more difficult the volume of patient contact that 
is crucial to medical training. Similarly, faculty diffusion to 
multiple sites also makes more difficult the development of a culture 
of education and training. This is not exclusively a VA problem and all 
of our Nation's medical schools and teaching hospitals are struggling 
to cope with this shift.
    Another concern at both VA and non-VA teaching hospitals is the 
growing salary discrepancy between more specialized fields of medicine 
and the other disciplines. With the ``Department of Veterans Affairs 
Health Care Personnel Enhancement Act of 2003'' (P.L. 108-445, dubbed 
the ``VA-Pay bill''), the VA made significant strides beyond its 
private-hospital counterparts. However, this discrepancy continues to 
be an issue of concern. Once again, this is not exclusively a VA 
problem, but one faced by all medical schools and teaching hospitals.
VA Medical and Prosthetic Research Program
    To accomplish its aforementioned mission, VHA acknowledges that it 
needs to provide ``excellence in research,'' and must be an 
organization characterized as an ``employer of choice.'' The VA Medical 
and Prosthetic Research program is one of the Nation's premier research 
endeavors and attracts high-caliber clinicians to deliver care and 
conduct research in VA health care facilities. The VA research program 
is exclusively intramural; that is, only VA employees holding at least 
a five-eighths salaried appointment are eligible to receive VA awards. 
Unlike other federal research agencies, VA does not make grants to any 
non-VA entities. As such, the program offers a dedicated funding source 
to attract and retain high-quality physicians and clinical 
investigators to the VA health care system.
    VA currently supports 5,143 researchers, of which nearly 83 percent 
are practicing physicians who provide direct patient care to veteran 
patients. As a result, the VHA has a unique ability to translate 
progress in medical science directly to improvements in clinical care.
    The VA Research Career Development Program attracts, develops, and 
retains talented VA clinician scientists who become leaders in both 
research and VA health care. For VA clinical investigators, the awards 
(normally 3-5 years) provided protected time for young investigators to 
develop their research careers. Awardees are expected to devote 75 
percent time to research as well as to apply for additional VA Merit-
Reviewed funding and non-VA research support. The remainder of their 
time is devoted to non-research activities such as VA clinical care or 
teaching. The program is designed to attract, develop, and retain 
talented VA researchers in areas of particular importance to VA. The 
Office of Research and Development supports approximately 458 awardees, 
at a cost of $55 million in FY 2006, in all areas of medical research 
including basic science, clinical medicine, health services and 
rehabilitation research. The VA retains approximately 56 percent of 
participants as VA principal investigators. Ths research program, as 
well as the opportunity to teach, is a major factor in the ability of 
VA to attract first class physician talent.
Earmarks and Designation of VA Research Funds
    The AAMC opposes earmarks because they jeopardize the strengths of 
the VA Research program. VA has well-established and highly refined 
policies and procedures for peer review and national management of the 
entire VA research portfolio. Peer review of proposals ensures that 
VA's limited resources support the most meritorious research. 
Additionally, centralized VA administration provides coordination of 
VA's national research priorities, aids in moving new discoveries into 
clinical practice, and instills confidence in overall oversight of VA 
research, including human subject protections, while preventing costly 
duplication of effort and infrastructure.
    VA research encompasses a wide range of types of research. 
Designated amounts for specific areas of research compromise VA's 
ability to fund ongoing programs in other areas and force VA to delay 
or even cancel plans for new initiatives. While Congress certainly 
should provide direction to assist VA in setting its research 
priorities, earmarked funding exacerbates resource allocation problems. 
AAMC urges the Committee to continue preserving the integrity of the VA 
research program as an intramural program firmly grounded in scientific 
peer review. These are principles under which it has functioned so 
successfully and with such positive benefits to veterans and the Nation 
since its inception.
VA Research Infrastructure
    State-of-the-art research requires state-of-the-art technology, 
equipment, and facilities. Such an environment promotes excellence in 
teaching and patient care as well as research. It also helps VA recruit 
and retain the best and brightest clinician scientists. In recent 
years, funding for the VA medical and prosthetics research program has 
failed to provide the resources needed to maintain, upgrade, and 
replace aging research facilities. Many VA facilities have run out of 
adequate research space. Ventilation, electrical supply, and plumbing 
appear frequently on lists of needed upgrades along with space 
reconfiguration. Under the current system, research must compete with 
other facility needs for basic infrastructure and physical plant 
support that are funded through the minor construction appropriation.
    To ensure that funding is adequate to meet both immediate and long 
term needs, the AAMC recommends an annual appropriation of $45 million 
in the VA's minor construction budget dedicated to renovating existing 
research facilities and additional major construction funding 
sufficient to replace at least one outdated facility per year to 
address this critical shortage of research space.
    Mr. Chairman and Members of the Committee, thank you for the 
opportunity to testify on this important issue. I hope my testimony 
today has demonstrated that the recruitment and retention of an 
adequate physician workforce is central to the success of VA's mission. 
The extraordinary partnership between the VA and its medical school 
affiliates, coupled with the excellence of the VA Medical and 
Prosthetics Research program, allows VA to attract the Nation's best 
physicians. Over the last 60 years, we have made great strides toward 
preserving the success of our affiliations. With the hard work of VA-
AAMC Deans Liaison Committee and the VA's Blue Ribbon Panel on Medical 
School Affiliations, I am confident that this success will continue.

                                 
       Prepared Statement of Kristi McCaskill, M.Ed., NCC, NCSC,
     Counseling Advocacy Coordinator, National Board for Certified 
                    Counselors, Inc. and Affiliates

INTRODUCTION AND EXECUTIVE SUMMARY
    Mr. Chairman and Honorable Members of the Veterans' Affairs 
Committee, I thank you for the opportunity to present testimony 
regarding the need for additional mental health care providers in the 
Department of Veterans Affairs (VA). As a representative of the 
National Board for Certified Counselors (NBCC), I believe that 
counselors play an important role in assisting the VA with health care 
recruitment and retention.
    By way of background, I am the Counseling Advocacy Coordinator at 
the NBCC. For the past two years, I have worked with certificants as 
they explain their certification and qualifications to prospective 
employers, to the public, and to legislators. As a certificant of NBCC, 
I understand the value of counseling and counseling credentials. I was 
trained as a school counselor at the University of North Carolina at 
Chapel Hill. Shortly after graduation and beginning work as a counselor 
in the schools, I completed my certification as a National Certified 
Counselor (NCC). The NCC is the flagship certification offered by the 
NBCC. I also possess the NBCC specialty certification for school 
counseling, the National Certified School Counselor (NCSC).
    NBCC is the Nation's premiere professional certification board 
devoted to credentialing counselors who meet standards for the general 
and specialty practices of professional counseling. Founded in 1982 as 
an independent, non-profit credentialing body, NBCC provides a national 
certification system for professional counselors, identifies those 
counselors who have obtained certification, and maintains a registry of 
those counselors.
    NBCC is the largest certification agency for professional 
counselors in the United States, certifying more than 42,000 
practitioners, living and working in the U.S. and over 40 countries. We 
also create and distribute all licensure examinations for 49 states, 
District of Columbia and Puerto Rico. NBCC works closely with over 300 
universities offering master's level education in counseling throughout 
the United States as well as around the world.
    The practice of professional counseling involves the application of 
mental health, psychological, and human development principles, through 
cognitive, affective, behavioral or systematic strategies, that address 
wellness, personal growth, or career development, as well as pathology. 
Working with individuals, groups, families and organizations in a 
variety of settings, professional counselors are trained to address a 
wide range of issues including anxiety, depression, bereavement, 
addiction, coping with illness and disability, adjustments in living 
situations, family and relationship issues and job stress. Professional 
counselors also provide emergency services in times of catastrophic 
events, such as acts of terror and natural disasters, which can 
severely traumatize survivors. NBCC has established an enforceable Code 
of Ethics to foster ethical practices for all clients of NBCC 
credentialed counselors.
    Counselors certified by NBCC meet predetermined standards in 
education, training, and experience. For 25 years, NBCC has offered the 
NCC, the first general practice counseling credential with nationwide 
recognition. NBCC also offers specialty credentials for mental health 
counselors, addictions counselors, and school counselors. These 
specialized credentials require advanced knowledge and experience in 
these respective counseling fields.
    As a non-profit 501(C)(3) organization, NBCC continues to promote 
leadership, accountability and quality assurance within the counseling 
profession.
    NBCC and licensed professional counselors are pleased with the 
passage of the Veterans Benefits, Health Care, and Information 
Technology Act of 2006 (Public Law 109-461), which was signed into law 
on December 22, 2006, and we thank this Committee for working so hard 
to pass this legislation during the last session of Congress. This 
groundbreaking legislation paved the way for licensed counselors to 
utilize their training and skills to meet the increasing needs of 
veterans.
    This legislation explicitly recognizes licensed professional 
counselors as health care providers within the Veterans Health Care 
Administration (VHA) (including licensed marriage and family 
therapists). It also delineates the qualifications mental health 
counselors need to be appointed to a position in the VA. This 
legislation is the result of years of work by the counseling profession 
and Congress to gain recognition of licensed counselors within the VA. 
Although rehabilitation counselors are recognized within the VA, 
licensed professional counselors have had only a limited role as mental 
health providers. Prior to passage of this law, the VA could not hire 
counselors for mental health professional positions at the same pay 
grade as clinical social workers, nor could licensed professional 
counselors apply for supervisory positions open to clinical social 
workers and others.
    Passage of this law will allow counselors access to better paying 
jobs as mental health specialists, with the potential for promotion 
into supervisory positions. This will increase the pool of mental 
health specialists the VA is able to draw upon in attempting to meet 
the growing health care needs of veterans. With enactment of the 
provision, the federal Office of Personnel Management (OPM) will be 
required to create a General Schedule (GS) occupational classification 
for mental health counselors, which is necessary for a counselor to be 
employed by the U.S. Government.
    In my position with NBCC, I understand the frustration that some 
counselors have experienced in their attempts to work within the VA 
health system. In the past, licensed professional counselors faced 
significant employment obstacles within the Veterans Health 
Administration (VHA) and its hospitals, clinics, and programs across 
the country. While some counselors have found positions within the 
agency, either on a contract or full-time basis, there continue to be 
barriers to independent practice, advancement, and hiring.
    While licensed clinical social workers were able to practice 
independently and serve as clinical supervisors in the VA, counselors 
found themselves struggling to achieve similar recognition. The VA 
remains the largest employer of clinical social workers in the country, 
and the VA employs very few counselors on a full-time basis. According 
to the VHA, most supervisory positions at Department hospitals and 
clinics are filled by psychiatrists, psychologists, and social workers. 
Many VHA positions in mental health services are developed by social 
workers on staff, and therefore the agency is most likely to hire 
social workers first. Psychiatrists, psychologists, and clinical social 
workers are specifically named in VA statutes. While VHA says there is 
no formal policy excluding licensed professional counselors from being 
hired, some have found that the VA does not recognize their licensure, 
and therefore refuses to hire them or relegates them to non-clinical 
positions. The lack of recognition of licensed professional counselors 
by OPM exacerbates this problem.
    We commend the United States Congress for recognizing the need for 
mental health counseling within the VA and thank you for passing such 
meaningful legislation. The inclusion of licensed counselors by the VA 
and the quality of the services they provide will make it easier for 
those who served our Nation and in need of mental health services to 
get the health care they need. This issue is especially important given 
the increasing number of veterans returning from Iraq and Afghanistan 
with symptoms of mental illness.
    I believe we are all familiar with the mental health needs of our 
returning service men and women and veterans from Iraq and Afghanistan. 
According to a report by the United Press (UP) in June of 2005, the 
Army's first study of the mental health of our troops who fought in 
Iraq, found that about one in eight reported symptoms of post-traumatic 
stress disorder (PTSD), which can cause flashbacks of traumatic combat 
experiences and other severe reactions. By mid-2006, more than one in 
three soldiers and Marines returning from the wars in Iraq, Afghanistan 
and other locations later sought help for mental health problems. About 
35 percent of soldiers are seeking some kind of mental health treatment 
a year after returning home under a program that screens returning 
troops for physical and mental health. I need not elaborate more to 
convey the immense impact PTSD and other mental health issues has on 
our soldiers, especially those with repeated and extended deployment to 
battle zones. PTSD and other effects of war linger and will require 
ongoing care for many years to come.
    The VA and the Pentagon have acknowledged a need to improve access 
to mental health treatment. NBCC is encouraged by the recent 
announcements of VA's intention of hiring suicide prevention counselors 
at VA medical centers, providing readjustment counseling at VA 
community based Vets Centers, and increasing outreach and advocacy 
efforts for veterans of the Global War on Terror. However, NBCC is 
concerned that little has been accomplished in the 10 months that have 
passed since legislation was signed into law recognizing licensed 
professional counselors as health care providers within the VHA. VA now 
has the statutory authority to make these changes, and we are concerned 
that licensed professional counselors are not being utilized to serve 
in the VA health system.
    There is a practical solution to the shortage of mental health care 
professionals available to veterans. By fully implementing Public Law 
109-461 and creating a counselor job classification within the GS 
schedule, more than 100,000 clinically trained counselors would be 
added to the pool of possible candidates to these positions.
           THE NATIONAL BOARD FOR CERTIFIED COUNSELORS (NBCC)
    NBCC has created and maintained standards for professional 
counselors for 25 years. These standards include specifications 
regarding education, experience, and required examinations for initial 
certification. Continuing education in the mental health field and 
adherence to NBCC's Code of Ethics are required in order to maintain 
certification. Any applicant or certificant violating the Code of 
Ethics is subject to sanctions determined by a well-developed 
adjudication process.
    The initial, fundamental designation awarded by the NBCC is the 
National Certified Counselor (NCC) certification. To become certified 
as a NCC, the applicant must document graduation from (at least) a 
master's-level CACREP-accredited program (or an equivalent curriculum), 
complete a specified minimum number of hours of supervised experience 
as a counselor, and pass a national counselor examination. Qualified 
NCCs who work as school counselors, clinical mental health counselors, 
or addictions counselors may apply for specialized credentials through 
NBCC. In order to obtain a specialized credential, additional 
education, experience, and assessment requirements must be met. NBCC 
also creates and distributes the licensure examinations for the 49 
states that regulate the practice of counseling, District of Columbia 
and Puerto Rico.
    NBCC's educational requirement and assessments are based on 
educational standards developed by the Council for the Accreditation of 
Counseling and Related Educational Programs (CACREP). In addition, NBCC 
adheres to the Standards for Educational and Psychological Testing 
(1999) and the U.S Federal Uniform Guidelines on Employee Selection 
Procedures (1978) in its commitment to providing assessments that test 
examinees' ability to apply knowledge in ways that define safe and 
effective professional practice, with public protection as the ultimate 
goal. The Uniform Guidelines identify job analysis as the sine qua non 
of procedures for amassing content-related validity evidence for 
licensure testing. NBCC utilizes the job analysis framework, developing 
a detailed list of responsibilities that counselors routinely perform, 
as well as responsibilities that are essential to safe and effective 
practice of counseling. The validity of NBCC's assessment development 
process, maintenance, and security processes is acknowledged nationwide 
as the standard for the counseling profession. Both the National 
Certified Counselor Certification and the Master's Addiction Counselor 
Certification are accredited by the National Commission for Certifying 
Agencies (NCCA). Utilizing an assessment based on a national analysis 
of the work performed by professional counselors helps assure that 
NBCC's certificants and the states' licensees possess the knowledge 
essential to providing excellent service.
                          LICENSED COUNSELORS
    In June 2007, Nevada passed counselor licensure legislation 
bringing the total number of states regulating the practice of 
counseling to 49. The only state without such provision is California 
where similar legislation is pending. Nationwide, there is a growing 
body of about 100,000 professional counselors licensed to practice 
independently. Under state laws, credentialed counselors have the 
authority to practice independently and increasing numbers may bill 
insurance companies for reimbursement of services provided.
    Professional counselors possess a master's degree or higher from an 
accredited college or university. The degree program must cover 
specific coursework including counseling theories, group counseling, 
social/cultural foundations, human growth and development, appraisal/
assessment techniques, etc. Additionally, professional counselors must 
document a supervised professional practice, pass a national counselor 
examination, submit a professional disclosure statement, and must keep 
current their professional education.
    Licensed counselors are well qualified professionals that assist 
people of all ages and abilities to develop life-enhancing skills. They 
utilize their skills to identify and treat emotional, psychological or 
behavioral disorders which may interfere with daily activities. While 
counselors are trained to understand mental illnesses, counselors 
approach issues from a developmental perspective. This perspective of 
strength building encourages those who are struggling to seek help and 
reduces stigma.
         THE NEED FOR INCREASED MENTAL HEALTH SERVICE PROVIDERS
    In February 2007, a Presidential Task Force conducted an 
investigation on the psychological needs of U.S. Military Members and 
their families identified three main barriers to effective military 
mental health treatment:

    1.  a shortage of professionals experienced in military life,
    2.  the stigma of receiving mental health services, and
    3.  difficulties assessing help due to long waiting lists, limited 
clinic hours, location, etc.

    Other important statistics found in this study include:

      Over 23,000 have returned with physical wounds and 
permanent disabilities including traumatic brain injury.
      As many as one-fourth of returning servicemen and women 
are struggling with psychological injuries.
      There has been a 22% decrease of licensed clinical 
psychologists serving servicemen and women.
      There are approximately 1,839 psychologists employed by 
the VA to serve more than 24.3 million veterans from previous wars as 
well as the rapidly growing number from the current conflict.

    The VA acknowledges the need for increased mental health providers. 
A tour of the VA website in the mental health section provides the 
following information:

      ``Suicide is the 11th most frequent cause of death in the 
U.S.: someone dies from suicide every 16 minutes.''
      ``The newest patients to the VA have been returning 
combat soldiers, men and women who served in Operations Enduring 
Freedom and Iraqi Freedom (OEF/OIF).''
      ``In a recent study, Dr. Karen Seal and colleagues at the 
San Francisco Veterans Affairs Medical Center and USC, reviewed records 
for over 100,000 veterans, who separated from active duty between 2001-
2005 and sought care from VA medical facilities.''
      ``The most common combination of diagnoses found was post 
traumatic stress disorder (PTSD) and depression.''
      ``Young soldiers were three times as likely as those over 
40 to be diagnosed with PTSD and/or another mental health disorder.''
      ``VA is expanding counseling and mental health services 
to meet the needs of the returning veterans and provide early 
treatment.''

    In recent testimony provided to the President's Commission on the 
Care of Wounded Warriors, Dr. Thomas Clawson, the President and CEO of 
NBCC, illustrated the connection between PTSD and the witnessing of 
traumatic events. His testimony included information regarding the 
occurrence rates of other disorders within the military--anxiety 
disorder (24%), adjustment disorder (24%), depression (20%) and 
substance abuse disorder (20%). Despite these numbers, Dr. Clawson 
noted that less than half with problems sought help because they were 
worried that it would have an adverse affect on their status within the 
military. Dr. Clawson also referenced a report from the Office of the 
Surgeon General of the U.S. Army Medical Command which stated the 
conditions under which our service men and women currently serve are 
unprecedented and have a significant influence upon them.
    This information is consistent with a statement by Vice Admiral 
Donald C. Arthur, MC, CSN, cochairman of the Department of Defense Task 
Force on Mental Health. According to Admiral Arthur, ``Not since 
Vietnam have we seen this level of combat. With this increase in 
psychological need, we now find that we have not enough providers in 
our system.''
    Furthermore, in recent testimony, Dr. Antoinette Zeiss, Ph.D., 
Deputy Chief Consultant, Office of Mental Health Services, Department 
of Veterans Affairs, stated that the VA has seen many returning 
veterans with ``injuries of the mind and spirit.'' Recognizing the 
increasing need for mental health services, Dr. Zeiss's testimony 
included a plan to expand the number of Vet Centers from 209 to 232 
over the next two years. She elaborated that these centers are staffed 
by psychologists, nurses, and social workers. Dr. Zeiss projected that 
686,306 servicemembers have been discharged since the end of the first 
quarter of FY 2007, and that of those, nearly 33% have sought care. Of 
the group that sought care, she reports that mental health problems are 
the second most common.
    The implementation of licensed counselors in the VA system is one 
method of helping to address this increasing and apparent need for 
providers. Implementation will increase access to returning veterans 
and address the issue of long wait times for care and treatment by 
veterans. Furthermore, it is cost-effective to utilize licensed 
professional counselors who work at different pay grades than to 
psychiatrists and psychologists.
       THE DEPARTMENT OF VETERAN'S AFFAIRS (VA) AND P.L. 109-461
    With the passage of PL 109-461 in December 2006, licensed mental 
health counselors were recognized as mental health specialists by the 
Department of Veteran's Affairs (VA). NBCC is concerned that in the ten 
months following the passage of PL 109-461, the VA has not made any 
visible progress and there still is not a General Schedule (GS) 
occupational classification for counselors, paving the way for licensed 
counselors to become recognized as service providers.
    The VA website references the U.S. Office of Personnel Management 
(OPM) as the primary method of determining basic qualifications for 
every job within the Federal Government. VA vacancy announcements 
provide additional qualifications needed for specific positions. 
Potential applicants are encouraged not to apply if they do not meet 
both the required minimum qualifications and any selective factors 
described. Without a new GS schedule specifically designed for 
counselors, it is difficult, if not impossible, for counselors to 
become employed at the VA, despite the passage of PL 109-461.
                            RECOMMENDATIONS
    NBCC would like to offer itself as a resource to military and 
government leaders, including the VA and the OPM, and we remain 
committed to developing long term solutions to the current and future 
mental health needs of our servicemembers and their families. As an 
organization with over 25 years experience, NBCC maintains close 
associations with other professional counseling organizations including 
the American Association of State Counseling Boards (AASCB), the 
organization representing state licensure boards. We are prepared and 
capable of connecting licensed counselors with the VA so that together 
we can provide services for the increasing mental health needs of 
veterans. Licensed counselors are well qualified professionals with 
training and experience in helping those who are struggling with 
depression, post-traumatic stress disorder (PTSD), stress/anxiety, and 
other mental health issues. P.L. 109-461 was an important step in 
adding qualified mental health service providers. We are 
enthusiastically poised for the next steps which would allow counselors 
to work for the VA.
    As a demonstration of our eagerness, we have compiled information 
which could be helpful to OPM in the creation of a job classification. 
By working together, NBCC and licensed counselors in the United States 
can help the VA in its mission to serve America's veterans and their 
families with dignity and compassion and to help ensure that they 
receive appropriate services and support in recognition of their 
service to this Nation.
    On behalf of NBCC, I want to again express my appreciation to the 
members of the Subcommittee on Heath of the U.S. House of 
Representatives Committee on Veteran's Affairs for their dedication to 
the provision of quality mental health services to our veterans. It 
would be our pleasure and an honor to work with you to establish a 
mechanism to allow licensed counselors to serve veterans who not only 
have given of themselves to protect our country, but who now need our 
help.
    NBCC stands ready, willing, and able to work cooperatively, 
effectively, and professionally with VA and Congressional leaders 
interested in developing a lasting solution to current and future 
mental health needs of our active duty servicemembers, veterans, and 
their families.

                                 
    Statement of Jim Bender, Communications Services Manager, CACI 
                        Strategic Communications
    Mr. Chairman and Members of the Subcommittee:
    Thank you for inviting CACI to contribute to the discussion on 
health care recruitment and retention. CACI has been instrumental in 
the advancement of recruitment marketing research, strategy and 
practice for more than 15 years. Our clientele include the National 
Security Agency, the National Guard Bureau, the Corporation for 
National and Community Service, and the Veterans Health Administration. 
My name is Jim Bender, and I am one of the architects of the VA Nurse 
Recruitment Pilot Study I will address today.
    Given the impending retirement of the Baby Boom generation, in 
addition to severe shortages in certain health care occupations, we at 
CACI support efforts by the Federal Government and affected industries 
to advance recruitment marketing and retention. These efforts will help 
neutralize the competitive market pressures that would otherwise 
undermine the effectiveness of all but the highest paying health care 
systems in the country.
    The national supply of health care professionals in certain 
fields--especially nursing--is not keeping pace with demand. In April 
of 2006, the American Hospital Association reported 118,000 registered 
nurse vacancies nationwide, a vacancy rate of 8.5 percent. The Health 
Resources and Services Administration projects a shortage of 1 million 
nurses by year 2020. As the Nation's largest health care system, the 
VHA has a major stake in this game.
    In February of 2006, in response to the Veterans Health Programs 
Improvement Act of 2004, VHA's Health Care Retention & Recruitment 
Office contracted with CACI to conduct a pilot program to test and 
recommend innovative recruitment methods for hard-to-fill health care 
positions.
    From a pool of 17 pilot site applicants, the North Florida/South 
Georgia Veterans Health System was chosen as the pilot location. The 
system's unique recruitment challenge was finding nurses with enough 
experience to fill higher-level nursing positions.
    Our objective going into the North Florida/South Georgia system was 
to test methods to enhance effectiveness in four key areas:

      Employer branding and interactive advertising strategies
      Internet technologies and automated staffing systems
      The use of recruitment, advertising and communications 
agencies
      Streamlining the hiring process

    Subsequently, the study was divided into two distinct operations. 
One was focused on recruitment marketing, with the goal of increasing 
the number of qualified applications coming into the system. The second 
was business process reengineering, with the goal of decreasing the 
administrative time between application receipt and job offer. An 
abundance of anecdotal evidence suggests that VA loses good candidates 
because of the lengthy boarding process.
    The program was conducted over 60 days, beginning Feb. 5, 2006. All 
activities were monitored and measured to evaluate results.
    On the recruitment marketing side of the operation, the findings 
were exceptionally optimistic.

      The recruitment marketing campaign generated 10,261 
inquiries into nursing positions for experienced nurses. An inquiry was 
defined as a response to recruitment advertising or similar 
communications outreach.
      Of those inquiries, 115 candidates submitted 
applications.
      Most impressive was the percentage of applicants uniquely 
qualified to fill the advertised positions. During March of 2006, the 
only full calendar month of the study, the number of applicants for 
Nursing Services who passed the initial screening process increased by 
83 percent over the month prior (from 12 applications to 22) and 300 
percent over the trailing five-month average (from 7.4 applicants to 22 
applicants).

    The recruitment methods that garnered these results include a 
strategy based on the principles of employer branding and market 
segmentation, in addition to vigorous use of interactive media and 
Internet technologies, which delivered the highest return on investment 
of any media in the study.
    The pilot program recommendations embraced these methods and 
further suggested the use of database marketing, relationship building 
(especially with the student population), employee referral programs, 
budget modifications and improvements to organizational communications.
    On the business process side, the results were equally optimistic. 
A comparison of current hiring processes to what-if scenarios revealed 
that a small number of process changes could significantly accelerate 
the time-to-hire:

      The average time-to-fill for new hires can be reduced 
from 72 days to 25 days.
      The average time-to-fill for employee transfers can be 
reduced from 33 days to 13 days.

    The process changes that would actualize these what-if scenarios 
include the delegation of approval authority for routine recruitment 
activities, the implementation of an automated recruitment management 
workflow system to eliminate delays in paper-based mail and processing, 
a change in the timing of the VetPro credential verification process, 
and several modifications to standard processes that build delays into 
the system.
    We at CACI believe healthcare recruitment at VHA is both strong and 
spirited. HRRO, in addition to the exceptional staff and leadership at 
the North Florida/South Georgia system, embraced this project with 
enthusiasm and sustained intellectual vigor. Since the pilot's 
conclusion, we have seen continued movement toward the methods tested 
in the pilot project--including increased use of targeted email 
communications, expanded use of online job postings and greater 
promotion of employee referral programs--as well as a persistent hunger 
for new, progressive ways of engaging health care professionals.
    In closing, thank you once again for the opportunity to present 
CACI's conclusions from the Nurse Recruitment Pilot Study, and thank 
you for the opportunity to contribute to the continued health and 
welfare of our country's veteran population. I look forward to your 
questions.

                                 
 Prepared Statement of Joseph L. Wilson, Assistant Director for Health 
Policy, Veterans Affairs and Rehabilitation Commission, American Legion
    Mr. Chairman and Members of the Subcommittee:
    Thank you for this opportunity to present The American Legion's 
views on recruitment and retention of VA's Health Care Professionals. 
The Nation is facing an unprecedented health care shortage that could 
potentially have a profound impact on the care given to this Nation's 
veterans. The American Legion supports comprehensive efforts to 
establish and maintain the Department of Veterans Affairs (VA) as a 
competitive force in attracting and retaining health care personnel, 
especially nurses, essential to the mission of VA health care and 
commends the Subcommittee for holding a hearing to discuss this very 
important and urgent issue.
    The Federal Government estimates that, by 2020, nurse and physician 
retirements will create a shortage of about 24,000 physicians and 
almost 1 million nurses nationwide. The American Legion strongly 
believes that what happens at the Department of Veterans Affairs 
Medical Centers (VAMCs) often reflects the general state of affairs 
within the health care community as a whole.
    Shortages in health care staff threaten the Veterans Health 
Administration's (VHA's) ability to provide quality care and treatment 
to veterans. Shortages in health care staffing also influence VHA's 
ability to provide timely access to quality care and, in some 
instances, its ability to provide certain types of care.
    During The American Legion's recent site visits to Polytrauma 
Centers throughout the Nation, some facilities identified uncertainty 
of existing staff's ability to handle an expected influx of patients as 
a challenge to providing care. Another challenge was acquiring staff 
trained in certain specialty fields. These specialties include: 
physical medicine and rehabilitation, blind rehabilitation, speech and 
language pathology, physical therapy, and certified rehabilitation 
nursing. Given the special rehabilitative and long-term care needs of 
combat wounded veterans returning from Iraq and Afghanistan--especially 
those residing in rural areas--shortages in these specialty fields will 
have a lasting impact on these veterans as they attempt to resume 
independent functioning.
    One major Polytrauma Center, which serves as a frontline medical 
center to those returning from Iraq and Afghanistan, reported 
recruitment and retention as part of their major budgetary challenge. 
Although the utilization of a variety of tools, to include relocation, 
recruitment, and retention bonuses, to attract new employees and retain 
existing employees is a step in the right direction, the locality pay 
is insufficient to keep pace with respective surrounding health care 
employers.
VA Nurses
    VA nurses are one of the most important resources in delivering 
high-quality, compassionate care to veterans. Nursing personnel are the 
backbone of direct patient care in the VA health delivery system. There 
have been challenges in attracting nursing personnel to VA due to both 
the shortage of people entering the career field and VA's inability to 
remain competitive in salary and benefits.
    VA nurses are consistently reporting that their staffing levels are 
inadequate to provide safe and effective care. A study published in The 
New England Journal of Medicine found there were shorter inpatient 
stays and lower complication rates in hospitals with higher staffing 
levels, while there were longer inpatient stays and increased urinary 
infections, gastrointestinal bleeding, pneumonia and shock or cardiac 
arrest in hospitals with lower staffing levels.
    A study by the Center for Health Economics and Policy at the 
University of Texas Health Science Center in San Antonio, Texas 
identified three essential factors that affect the retention of nurses:

      Work environment practices that may contribute to stress 
and burnout;
      The aging of the Registered Nurse (RN) workforce combined 
with the shrinking applicant pool for nursing schools; and
      The availability of other career choices that makes the 
nursing profession less attractive.

    Other factors cited most frequently for attrition of nurses 
included:

      Lack of time with patients;
      Concern with personal safety in the health care setting;
      Better hours outside of nursing; and
      Relocating.

    It should also be noted that 63 percent of those surveyed said that 
RN staffing is inadequate and that current working conditions 
jeopardize their ability to deliver safe patient care.
    VA nursing workforce data support the conclusion that it is likely 
that the number of current VA nurses in the workforce will decline 
sharply and rapidly. This decline is attributed to an aging workforce 
wherein a large number of nursing personnel will be eligible for 
retirement.
    VA must be able to retain and recruit well-qualified nurses in 
order to maintain the quality of care provided to veterans. A 
significant part of this recruitment and retention effort is VA-
administered initiatives to enhance the educational preparation of 
nursing personnel, including scholarship and loan repayment programs.
    In its report, Caring for America's Veterans: Attracting and 
Retaining a Quality VHA Nursing Workforce, the National Commission on 
VA Nursing (the Commission) addresses recruitment and retention tactics 
that VA could implement to attract more nursing staff. The Commission 
provided recommendations in areas of the profession that impact nurses' 
satisfaction with their careers. These areas include leadership 
participation, professional development, work environment, respect and 
recognition, fair compensation, technology, and research/innovation. 
The Commission noted the importance of adequate resources from VA and 
Congress to implementing the recommendations should improve retention 
and recruitment. Recruitment and retention efforts should concentrate 
on these identified areas, which nurses consider key factors in their 
career satisfaction.
    The American Legion urges VA and Congress to provide adequate 
resources to implement the Commission's recommendations and urges VA to 
continue to strive to develop an effective strategy to recruit, train, 
and retain advanced practice nurses, registered nurses, licensed 
practical nurses, and nursing assistants to meet the inpatient and 
outpatient health care needs of its growing patient population.
    VA's Chiefs of Nursing have said that one of the most effective 
recruitment tools is to capture student nurses while they are in 
training or as they graduate. VA recently established a Nursing Academy 
to address the nationwide nursing shortage issue. The Nursing Academy 
has embarked on a 5-year pilot program that will establish partnerships 
with a total of 12 nursing schools. The initial set of partnerships 
implemented this year includes nursing schools in Florida, California, 
Utah and Connecticut. More partnerships will be selected over the next 
two years. This pilot program will train nurses to understand the 
health care needs of veterans and make more nurses available to allow 
VA to continue to provide veterans with the quality care they deserve.
    The American Legion affirms its strong commitment and support for 
the mutually beneficial affiliations between VHA and the medical and 
nursing schools of this Nation.
    The American Legion is appreciative of the many contributions of 
VHA nursing personnel and recognizes their dedication to veterans who 
rely on VHA health care. Every effort must be made to recognize, reward 
and maximize their contributions to the VHA health care system because 
veterans deserve nothing less.
Medical School Affiliations
    VHA conducts the largest coordinated education and training program 
for health care professions in the Nation. The medical school 
affiliations allow VA to train new health professionals to meet the 
health care needs of veterans and the Nation. Medical school 
affiliations have been a major factor in VA's ability to recruit and 
retain high quality physicians. It also affords veterans access to the 
some of the most advanced medical technology and cutting-edge research. 
VHA research continues to make meaningful contributions to improve the 
quality of life for veterans and the general population. VHA's recent 
and numerous recognitions as a leader in providing safe, high-quality 
health care to the Nation's veterans can be directly attributed to the 
relationship that has been fostered through the affiliates.
    Mr. Chairman and members of the Subcommittee, The American Legion 
sincerely appreciates the opportunity to present testimony and looks 
forward to working with you, your colleagues and staff to resolve this 
critical issue. Thank you for your continued leadership on behalf of 
America's veterans.
    This concludes my testimony.

                                 
   Prepared Statement of Joy J. Ilem, Assistant National Legislative 
                  Director, Disabled American Veterans
    Mr. Chairman and Members of the Subcommittee:
    Thank you for inviting the Disabled American Veterans (DAV) to 
testify on recruitment and retention of healthcare professionals by the 
Department of Veterans Affairs' (VA) Veterans Health Administration 
(VHA). Without question, recruitment and retention of high caliber 
healthcare professionals is critical to VHA's mission and essential to 
providing safe, high quality healthcare services to sick and disabled 
veterans. Given the impact of the nationwide nursing shortage and 
reports of continued difficulty in filling nursing, specialty physician 
and other key positions in VHA, this is an important and timely 
hearing.
NATIONAL COMMISSION ON VA NURSING
    The environment of VHA, like America's health care enterprise in 
general, is ever-changing and confronted with new challenges at every 
turn. Since 2000, VA has been working to address the ever-increasing 
demand for medical services while coping with the impact of a rising 
national nursing shortage. In 2001, VHA's Nursing Strategic Healthcare 
Group released
    A Call to Action--VA's Response to the National Nursing Shortage. 
Since that time, health manpower shortages, and plans to address them, 
have been dominant themes of numerous conferences, reports by the 
Government Accountability Office (GAO) and other reviewers, and 
Congressional hearings.
    One part of the equation that has remained paramount in the 
discussion, concerns VA's ability to compete in local labor markets, 
given the barriers that impede nursing recruitment and retention in 
general. Based on work in this Subcommittee, in 2002 the National 
Commission on VA Nursing (hereinafter the Commission), was established 
by Public Law 107-135. The Commission was charged to examine and 
consider VA programs, and to recommend legislative, organizational and 
policy changes to enhance the recruitment and retention of nurses and 
other nursing personnel, and to address the future of the nursing 
profession within VHA. The Commission members were a group of 
distinguished leaders in nursing, medicine, labor, academic management, 
veterans' affairs and other relevant fields, including DAV's Washington 
Headquarters Executive Director, David W. Gorman. The Commission 
envisioned a desired ``future state'' for VHA nursing, and made 
recommendations to achieve that vision. In May 2004, the Commission 
published its final report to Congress--Caring for America's Veterans: 
Attracting and Retaining a Quality VHA Nursing Workforce.
    Illustrative of the Commission's findings and recommendations is 
this synopsis in its final report:

    ``Recruiting and retaining nursing personnel are priority issues 
for every healthcare system in America. VHA is no exception. With the 
aging of the population, including veterans, and the U.S. involvement 
in military activity around the world, VHA will experience increasing 
numbers of enrolled veterans. Consequently, as the demand for nursing 
care increases, the Nation will grapple with a shortage of nurses that 
is likely to worsen as baby boomer nurses retire. VHA must attract and 
retain nurses who can help assure that VHA continues to deliver the 
highest quality care to veterans. Further, VHA must envision, develop, 
and test new roles for nurses and nursing as biotechnologies and 
innovations change the way healthcare is delivered.''

    The Office of Nursing Service in VA Central Office developed a 
strategic plan to guide national efforts to advance nursing practice 
within VHA, and engage nurses across the system to participate in 
shaping the future of VA nursing practice. This strategic plan embraces 
six patient-centered goals that encompass and address a number of the 
recommendations of the Commission.

      Leadership Development: supporting and developing new 
nurse leaders, and creating a pipeline to continuously ``grow'' nursing 
leaders throughout the organization;
      Technology and System Design: creating mechanisms to 
obtain and manage clinical and administrative data to empower 
decisionmaking. The objective is to develop and enhance systems and 
technology to support nursing roles. The Commission report highlighted 
the importance of nursing input in the development stage of new 
technologies for patient care;
      Care Coordination and Patient Self-Management: promoting 
and recognizing innovations in care delivery and facilitating care 
coordination and patient self-management. The objectives are to 
strengthen nursing practice for the provision of high-quality, 
reliable, timely, and efficient care in all settings and to enhance the 
use of evidence-based nursing practice. This goal also encompasses 
recommendations from the Commission related to the work environment of 
VA nurses;
      Workforce Development: improving the recognition of, and 
opportunities for, the VA nursing workforce. Areas of emphasis are (1) 
utilization: to maximize the effective use of the available workforce; 
(2) retention: to retain a qualified and highly skilled nursing 
workforce; (3) recruitment: to recruit a highly qualified and diverse 
nursing staff into VHA; and (4) outreach: to improve the image of 
nursing and promote nursing as a career choice through increased 
collaboration with external partners. The Commission report addresses 
all of these areas as critical to the future of VA nursing;
      Collaboration: forging relationships with professional 
partners within VA, across the Federal community, and in public and 
private sectors. The objective is to strengthen collaborations in order 
to leverage resources, contribute to the knowledge base, offer 
consultation, and lead the advancement of the profession of nursing for 
the broader community. The priorities of this goal align with VHA's 
Vision 2020 and the Commission recommendations related to collaboration 
and professional development; and,
      Evidence-Based Nursing Practice: identifying and 
measuring key indicators to support evidence-based nursing practice. 
The objective is to develop a standardized methodology to collect data 
related to nursing-sensitive indicators of quality, workload and 
performance within VHA facilities.

    DAV believes the Commission's legislative and organizational 
recommendations served as a blueprint for the reinvention of VA 
nursing. Having followed that blueprint, the VHA's strategic plan 
serves as a solid foundation for the creation of a delivery system that 
meets the needs of our Nation's sick and disabled veterans while 
supporting those who provide their care. Therefore, we urge Congress to 
continue to provide appropriations for, and oversight of, VA health 
care to enable VHA to invest more resources--human, financial and 
technological--to carry out an aggressive agenda to improve VA's 
abilities to recruit and retain sufficient nursing manpower while 
proactively testing new and emerging nursing roles in VA healthcare.
CURRENT WORKFORCE--FUTURE NEEDS
    One of VA's most significant challenges is dealing effectively with 
succession--especially in the health sciences and technical fields that 
so characterize contemporary American medicine and healthcare delivery. 
DAV believes the Subcommittee and Full Committee should be particularly 
mindful of VA's progress in gaining a greater foothold on succession 
planning.
    VHA's Succession Strategic Plan for Fiscal Year (FY) 2006-2010 
reports: ``VHA faces significant challenges in ensuring it has the 
appropriate workforce to meet current and future needs. These 
challenges include continuing to compete for talent as the national 
economy changes over time, and recruiting and retaining health care 
workers in the face of significant anticipated workforce supply and 
demand gaps in the health care sector in the near future. These 
challenges are further exacerbated by an aging federal workforce and an 
increasing percentage of VHA employees who receive retirement 
eligibility each year.''
    In April 2007 VHA conducted a national conference, titled, VHA 
Succession Planning and Workforce Development. The conference report 
indicated the average age of all VHA employees in 2006 to be 48 years. 
It estimated that by the end of 2012, approximately 91,700 VHA 
employees, or 44% of current full time and part time staff, would be 
eligible for full civil service retirement. The report also indicated 
approximately 46,300 VHA employees are projected to retire during that 
same period. Additionally, a significant number of healthcare 
professionals in leadership positions would also be eligible to retire 
by the end of 2012. In a startling finding the report concluded that 
97% of VA nurses in pay band ``V'' positions would be eligible to 
retire, and that 56% were expected to retire; and, that 81% of VA 
physicians in pay category 16--including many current Chiefs of Staff, 
would be eligible to retire, with 44% projected to actually retire from 
Federal service.
    In its assessment of current and future workforce needs, VHA 
identified registered nurses (RN) as its top occupational challenge, 
with licensed practical/vocational nurses and nursing assistants also 
among the top ten occupations with critical recruitment needs. 
Currently, VA employs over 62,000 nursing personnel, including about 
42,000 registered nurses (RN), 11,400 licensed vocational or practical 
nurses, and 9,100 nursing assistants. According to VA in fiscal year 
2005 (most recent data available), 77.7% of all VHA RN resignations 
occurred within the first five years of employment. Nurse turnover for 
that same period was 9.1%. Vacancy and turnover rates continue to be 
reported as lower than the national rates for all nurses, but did rise 
in 2004.
    Over the past several years VHA has been searching to attract 
younger nurses into VA healthcare, and to create incentives to keep 
them in the VA system. DAV is pleased that VHA continues its positive 
trend as an employer of choice for men and ethnic minorities in nursing 
careers. According to the Health Resources and Services Administration, 
by 2015 all 50 States will experience a shortage of nurses to varying 
degrees. However, the American Association of Colleges of Nursing has 
reported that three-fourths of the Nation's schools of nursing 
acknowledge faculty shortages along with insufficient clinical 
practicum sites, lack of classroom space, and budget constraints as 
reasons for denying admission to qualified applicants. In 2005 (most 
recent data available) schools and colleges of nursing turned away 
41,683 qualified applicants.
    Earlier this year, to address this problem and attain a more stable 
nursing corps, VA initiated a ``Nursing Academy'' pilot program. VA 
reports its Nursing Academy will be committed to nursing education and 
practice, and will address the nursing shortages in VA while aiding the 
Nation's needs for nurses as well. VA's pilot program for fiscal years 
2007-2012 will partner with the University of Florida, San Diego State 
University, the University of Utah, and Connecticut's Fairfield 
University, with their respective VA affiliates at Gainesville, San 
Diego, Salt Lake City and West Haven. The curriculum and the practicum 
policies of these affiliations will be developed jointly by the 
partners. Similar to VA's longstanding relationships with schools of 
medicine nationwide, VA nurses with qualified expertise will be 
appointed as faculty members at the affiliated schools of nursing. 
Academy students will be offered VA-funded scholarships in exchange for 
defined periods of VA employment subsequent to graduation and 
successful State licensure. VA notes that in order for this program to 
move forward, legislation will be required to reactivate the VA's 
Health Professions Educational Assistance Program (38 U.S.C. 7601-
7636), an authority that expired December 31, 1998.
    We urge Congress to reauthorize and fund these provisions to aid VA 
in establishing the Nursing Academy. According to VA, funding for the 
five-year pilot program, (with a total five-year cost of $85 million), 
will be provided from available VA Medical Services funds, but to 
extend the pilot or expand it further will require new appropriations. 
VA is hopeful that the investment made in helping to educate a new 
generation of nurses, coupled with the requirement that scholarship 
recipients serve a period of obligated service in VA health care 
following graduation, will help VA cultivate and retain quality 
healthcare staff, even during a time of nationwide shortage.
VA NURSING WORKPLACE ISSUES
    Mr. Chairman, DAV continues to hear reports that VHA staffing 
levels are frequently so marginal that any loss of staff--even one 
individual in some cases, can result in a critical staffing shortage 
and present significant local clinical challenges. Additionally, 
inadequate funding has resulted in ``unofficial'' hiring freezes in 
some locations. These freezes and delays in hiring have had a negative 
impact on the VA nursing workforce as some nurses have been forced to 
assume non-nursing duties due to shortages of ward secretaries and 
other key support personnel. These staffing deficiencies impact both 
patient programs and VA's ability to retain an adequate nursing 
workforce. Staffing shortages or freezes on hiring can result in the 
cancelation or delay of elective surgeries and closure of intensive 
care unit beds. It can also cause unavoidable referrals of veterans to 
private facilities--ultimately at greater overall cost to VA. This 
situation is complicated by the fact that VHA has downsized inpatient 
capacity in an effort to provide more services on a primary care basis. 
The remainder inpatient population is generally more acute, often with 
co-morbid conditions, lengthier inpatient episodes, complications, and 
needing more skilled care and staff-intensive aftercare. It has also 
been reported to us that in some locations, VA is overusing overtime, 
including ``mandatory overtime;'' reducing flexibility in tours of duty 
for nurses; and, limiting nurse locality pay. These actions, driven by 
short financing and extremely tight local budgets, including the 
current situation of a Continuing Resolution that restricts overall 
management discretion nationwide, creates a working environment that 
compromises patient safety with staff burnout, creates morale problems, 
produces inadequate staffing levels, and requires the use of older, 
inferior technology in some VA facilities. Given that VA has made so 
much progress in establishing the current national standard of 
excellence in providing care to its large veteran population, these 
reports.
    Mr. Chairman, in testimony to this Committee in 2003, VA's top 
nurse executive stated the following: ``Published findings underscore 
the need to focus on improving the work environment for nurses in order 
to increase staff satisfaction and to ensure the provision of safe, 
high quality patient care.'' We believe many of those difficult 
conditions in VHA continue to exist today for VA's nursing staff, 
despite the best efforts and intentions of those involved. Therefore, 
we hope this Subcommittee will provide additional oversight to ensure a 
safe environment for both patients and staff.
    Like other health care employers, VHA must actively address those 
factors known to affect recruitment and retention of all health care 
providers and nursing staff, and take proactive measures to stem crises 
before they occur. We encourage VHA to continue its quest to deal with 
shortages of health manpower in ways that keep VHA at the top of the 
standards of care in this country. We are very encouraged with the 
Nursing Academy proposal, endorsed by the Nursing Commission and hope 
that it proves its worth early so that it can be expanded beyond the 
four pilot sites. We ask the Subcommittee to pay special attention to 
the development of that Academy and to encourage its expansion.
PAY REFORM ISSUES FOR VA PHYSICIANS AND DENTISTS
    In 2004, as reported by this Committee, Congress passed the 
Department of Veterans Affairs Personnel Enhancement Act, Public Law 
108-445. This new law reformed the pay and performance system used by 
VA in employment of physicians and dentists. This proposal was one of 
VA's top legislative goals in the 108th Congress. Enactment of this 
proposal was supported by DAV and other organizations that expressed 
concern that VA needed new authority to attract and retain the best 
physicians and dentists for the care of sick and disabled veterans--
particularly at a time of ongoing military engagements in Iraq and 
Afghanistan. VA implemented this new authority as required by the Act 
in January 2006, and began to announce new pay plans for VA physicians 
under its terms. This Act is the most significant reform of pay systems 
for VA employees since the enactment of the Civil Service Reform Act in 
1978, and represents the first real reform in VA physician pay since 
1991.
    We believe the Committee should use its oversight authority to 
study the impact of Public Law 108-445 on recruitment and retention of 
VA physicians and dentists--especially those who practice in some of 
the more scarce specialties, including anesthesiology, orthopedics, and 
various surgical specialties. These subspecialties are very scarce and 
VA has historically had great challenges recruiting these practitioners 
to full-time employment. VA's motivation to secure this new authority 
was driven by the exorbitant cost of procuring contract services of 
scarce medical specialists. One of the purposes of the Act was to give 
VA the tools to enable it to attract even these specialists to VA 
employment on a full-time basis. Also, the crafting of the bill was 
designed to attract to VA young physicians first entering their 
professional practices after residencies, and to provide them 
meaningful incentives that pointed them to full careers in the VA 
health care system.
    We believe the Committee should investigate whether the Act is 
resulting in VA's improving its ability to achieve these goals. 
Physicians are essential caregivers, educators, and key biomedical 
researchers in the VA health care system. This Act was intended for 
their benefit, to attract them to VA careers and to keep them providing 
outstanding care to veterans. We would hope these purposes would be 
transparent and that VA would have moved implementation toward these 
goals, but we believe the Committee should confirm those intended 
results.
VA PHYSICIAN WORKPLACE ISSUES
    Mr. Chairman, DAV is concerned about the stressful working 
environment now confronting the VA physician workforce. While the 
matters brought to our attention over the past few years as VA clinical 
workloads have grown might be dismissed as anecdotal and not indicative 
of the general national environment, they are no less disturbing. We 
have been told by numerous sources that many VA medical center 
directors have established arbitrary ``caps'' on the total bonus a VA 
physician may receive under the performance element of pay. While the 
Act gave the VA Secretary discretion by regulation to determine 
appropriate pay levels, it allowed for annual performance pay up to 
$15,000 or not to exceed 7.5 percent of combined base and market pay 
amounts. Directors should not, given those limitations, be permitted to 
establish arbitrary performance pay amounts of as little as $1,000 (we 
have been told this to be the case in some facilities), thereby 
frustrating the purposes of the Act. Also, we are in possession of a 
letter written by a group of VA physicians. This was a signed letter to 
the clinical manager of a VA network. Let me excerpt only a few of the 
concerns it expresses, which we fear may be suggestive of the workplace 
situation across the VA system:

    ``First, we are understaffed. Over the past 1\1/2\ years, we have 
lost a net of three physicians and one nurse practitioner at the _____ 
site. We all have had to absorb those provider panels into our own, at 
a rapid pace. You stated that we had grown by fewer than 200 new 
patients since January; however, that statistic misses how we have 
added literally thousands of our former colleagues' patients into our 
own panels. Our CBOC colleagues are suffering from similar provider 
shortages and turnover; in a single month this spring the Bangor CBOC 
lost two out of seven providers. At ______, half of us are at or above 
full panel, and the other half of us are virtually at full panel. We 
have had no success so far at recruiting new providers, and we do not 
see evidence of strong administration commitment to recruitment. 
Further, it was known many, many months in advance that we would be 
losing a Women's Clinic provider to her deployment to Iraq, yet there 
was no leadership in making sure a temporary provider was ready to step 
into her place. In fact, there seemed to be obstruction to an on-site 
willing provider starting work in Women's Clinic. Again, current 
providers have had to absorb the workload of the absent provider.''
    ``We are not only understaffed in terms of providers; we are also 
working without adequate numbers of support staff. Specifically, within 
the past year, we at _____ lost two pharmacists who used to work 
directly with us in the clinic; to date these positions have not been 
filled. Our CBOC colleagues are overwhelmed by the extra work that an 
understaffed pharmacy creates. At the CBOCs, the providers spend 
inordinate amounts of time writing and documenting prescriptions for 
veterans to fill locally, when our pharmacy does not fill the 
medications in a timely fashion. At both _____ and the CBOCs we now 
have fewer nurses as well.''

    We at DAV certainly hope these are isolated matters but we believe 
we could obtain similar responses from many other VA physician groups, 
in primary care and elsewhere, now shouldering a very heavy burden in 
caring for veterans. If the general situation in clinical care across 
the VA is anything like this report suggests, VA has a very serious and 
rising morale problem that eventually may interfere with health care 
quality, safety, efficiency and effectiveness. We ask the Subcommittee 
to consider conducting a survey of VA facilities to gauge conditions of 
employment and the current morale of the VA physician workforce. We 
believe this examination could be very informative to the Subcommittee, 
to VA Central Office, and to the VSO community that is so concerned 
about sustaining quality VA health care.
SUMMARY AND CLOSING
    Mr. Chairman, in summary, DAV believes that VA must devote 
sufficient resources to avert the national shortage of nurses from 
creeping into and potentially overwhelming VA's critical healthcare 
programs, and to minimize the impact that the nursing shortage on the 
care VA provides to sick and disabled veterans. In that regard, DAV 
supports VA's strategic goals for nursing, including establishment of 
the innovative VHA Nursing Academy, and urges the Committee to act on 
legislation that would reauthorize the scholarship program. Also, we 
ask that you use your oversight powers to ensure the intent of Public 
Law 108-445 is fully realized.
    This Subcommittee should provide oversight to ensure sufficient 
physicians and nursing staffing levels, and to regulate, and reduce to 
a minimum, VA's use of mandatory overtime for VA registered nurses. We 
believe this practice of mandatory overtime endangers the quality of 
care and safety of veterans in VA health care. We believe VA should 
establish innovative recruitment programs to remain competitive with 
private-sector health care marketing and advertising strategies, to 
attract nurses and doctors to VA careers. While we applaud what VA is 
trying to do in improving its nursing programs, these competitive 
strategies are yet to be fully developed or deployed in VA. Also, 
Congress must provide sufficient funding through regular appropriations 
that are provided on time, to support programs to recruit and retain 
critical nursing staff to VA. The routine annual Continuing Resolution 
process negatively impacts not only VA nursing but all of VHA. We also 
believe the VA workplace situation with respect to both nurses and 
physicians deserves greater oversight by the Subcommittee, and we hope 
you will take our recommendations in that regard into consideration.
    Again, we thank you for this opportunity to testify. We ask the 
Committee to consider these situations as it deals with its legislative 
plans for this year. This concludes my testimony, and I will happy to 
address any questions from the Chairman or other Members of the 
Subcommittee.

                                 
Prepared Statement of J. David Cox, R.N., National Secretary-Treasurer, 
          American Federation of Government Employees, AFL-CIO
    Dear Chairman and Members of the Subcommittee:
    The American Federation of Government Employees (AFGE) appreciates 
the opportunity to present its views on recruitment and retention tools 
for the Veterans Health Administration (VHA) workforce. AFGE represents 
more than 150,000 employees in the Department of Veterans Affairs (VA), 
more than two-thirds of whom are VHA professionals on the front lines 
treating the physical and mental health needs of our veteran 
population.
    The vast majority of VHA's workforce is covered by ``pure Title 
38'' or ``hybrid Title 38'' personnel rules that were designed to 
recruit and retain personnel through a more flexible, shorter process. 
A small number of direct patient care positions remain under Title 5, 
e.g., Nursing Assistants and Medical Technicians. In practice, hiring 
and promotion under Title 38 have turned out to be anything but quick 
and streamlined processes, further contributing to VHA's inability to 
adequately recruit and retain needed personnel. Applicants awaiting 
credentialing and salary offers leave for other positions because of 
long delays. Current VHA employees are demoralized by delays and 
inequities in the Title 38 promotion process. The current credentialing 
system and boarding process for Title 38 should be evaluated to 
identify ways to eliminate these harmful disincentives.
    Congress has enacted a wide array of VHA recruitment and retention 
tools over the years that rely on educational assistance, pay, work 
schedules, and other workplace benefits to enable the VA medical 
facilities to compete with other health care systems for quality 
personnel. These tools complement VA's most effective recruiting and 
retention tool: itself. Caring for our Nation's veterans in this world 
class health care system offers a professional opportunity like no 
other.
    So why is the VA reporting such alarming workforce shortage 
statistics? 2007 VA data shows that new employees are practically 
fleeing VHA: 77% of all RN resignations occur within the first five 
years, and other professions have equally high attrition rates (71% of 
physicians, 77% of pharmacists and 79% of Licensed Practical Nurses 
(LPN.)) As a result, VHA's workforce is steadily aging: the average age 
is now at 48.3 years. In five years, 44% of the current workforce will 
be eligible for full retirement. By 2010, 22,000 of VA's 35,000 
registered nurses will be eligible to retire.
    The VA pays dearly for its flawed retention and recruitment 
policies. The average VA-wide cost of turnover is $47 million for 
nurses, $90 million for physicians, and $9.6 million for pharmacists.
    Chronic staffing shortages result in other significant costs. Since 
injured veterans cannot wait for replacements to come on board, VA 
medical facilities are increasingly relying on contract nurses and 
physicians as a stopgap solution--a very costly one at that. AFGE 
anxiously awaits the findings of the pending GAO study of the impact of 
contract nurses on VA health care quality and cost. The use of contract 
nurses also hurts morale: agency nurses are given more desirable shifts 
than senior staff nurses (in part because they lack the specialized 
skills to function independently on evening and night shifts). Agency 
nurses also lack familiarity with the VA's unique health care IT 
systems and patient safety policies.
    We also anxiously await the VA's first report to Congress on how 
effective the 2004 Physicians and Dentists pay bill (PL 108-445) has 
been at achieving its top objective: reducing spending on costly fee 
basis physicians. Based on our members' very mixed experiences with 
market pay and performance pay awards coming out of the new law, we are 
doubtful that the VA has achieved the law's objectives.
    While an urgent response to VHA's growing workforce shortage is 
warranted, we urge Congress to be wary of new fixes that promise 
success under old conditions, such as the Nursing Academy and Magnet 
hospitals, as will be discussed. Such approaches divert precious health 
care dollars away from direct patient care and hiring of needed health 
care professionals. The same dollars can be put to better use investing 
in the excellent array of recruitment and retention tools that Congress 
has already created. AFGE firmly believes that these tools can meet 
current staffing needs, if properly funded and managed.
    Funding is inextricably tied to recruitment and retention. As the 
Independent Budget points out, when VHA fails to receive its funding in 
a timely manner under a discretionary funding process, budget-strapped 
medical center directors are unable to adequately meet anticipated 
hiring needs.
    The effectiveness of the current tools also depends on adequate 
guidance from VA Central Office and regular Congressional oversight. 
VA's implementation of recent nurse and physician legislation has been 
largely decentralized, leaving great discretion to directors to decide 
what incentives to offer to their staff and whether to allocate needed 
funds to achieve success.

    Pay Incentives: VHA's success with using pay to recruit and retain 
professionals has been mixed. Title 38 has always permitted management 
to offer hiring and retention bonuses and special pay increases to 
employees hired under this authority that are underutilized. Congress 
recently augmented this authority with two profession specific pay 
laws: 2001 nurse locality pay legislation and 2004 physician/dentist 
pay legislation.
    The nurse locality pay law had two primary objectives: provide VA 
registered nurses with the National Employment Cost Index (ECI) based 
portion of the annual federal pay raise, and give hospital directors 
the authority to conduct third party locality pay surveys in order to 
set competitive pay rates for VA nurses. Unlike other federal 
employees, nurse locality pay portion is still at the discretion of 
their facility directors. Directors regularly refuse, especially in 
competitive markets, to conduct equitable pay surveys, even in the face 
of serious recruitment and retention problems. Or they conduct separate 
surveys for rank-and-file and nurse supervisors and provide higher 
percentage increases to the latter.
    The key test of whether the nurse locality pay law is working is 
whether the VA is able to recruit and retain nurses, reduce reliance on 
costly agency nurses, mandate less overtime and properly match staffing 
with patient acuity. The VA has yet to provide evidence of success in 
these indicators.
    The 2004 law (PL 108-445) to provide more competitive pay to VA 
physicians and dentists has also had its share of roadblocks. Employee 
representatives were excluded from national level groups that set the 
pay ranges for market pay. Local compensation panels setting market pay 
for individual providers at each facility largely excluded the 
frontline practitioners, despite requirements in the law to include 
them. In some cases, management excluded them overtly, in other cases; 
they ``accidentally'' forget to inform them when the panels were 
meeting. AFGE's requests for the survey data used by facilities to set 
market pay were denied without basis and after great delay. In short, 
AFGE and the physicians and dentists at the frontline do not know which 
surveys were used to set their pay or whether their pay is comparable 
to that of their peers. Anecdotally, we are aware of many examples 
where individual providers were denied market pay increases, and 
facilities that used questionable survey data to set pay.
    The performance pay provisions in the 2004 law have been severely 
weakened, first by VA's blanket reduction of the maximum award from 
$15,000 to $5,000 in the first year, and similar blanket caps of a few 
thousand dollars that continue to be imposed by many facility 
directors. Providers are also frustrated by the great delay in issuing 
criteria for receiving performance pay, the inability to have input 
into the development of these criteria, and the fact that many of the 
criteria were improper or unrealistic. Clearly, Congressional intent to 
use performance pay as a retention tool for physicians and dentists has 
been frustrated.
    Again, the key test of whether the physician and dentist pay bill 
has fulfilled Congressional intent is whether the VA has been able to 
reduce the use of expensive fee basis physicians and dentists and fill 
vacancies at medical facilities. Hopefully, VA's report to Congress 
will be released in the near future and shed some light on whether 
these objectives have been at least partially met.
    We also urge Congress to consider other nurse pay fixes that will 
aid in recruitment and retention. The VA cannot offer competitive pay 
to Certified Registered Nurse Anesthetists because under current law, 
they cannot earn more than facility nurse executives. In addition, we 
urge Congress to amend 38 USC Sec. 7455 to remove the current cap on 
locality pay for Licensed Practical Nurses, as Congress previously did 
for physical therapists and pharmacists.

    Educational Assistance: The Nursing Academy, the VA's newest 
education-based recruitment tool, carries a $40 million price tag for 
an initial five year pilot project. This initiative does not guarantee 
that the VA will be able to recruit any graduates of the Academy. VA 
already has an effective education-based tool in place that requires an 
employment commitment, and its effectiveness can be increased through 
better funding and management. The Employee Debt Reduction Program 
(EDRP) provides new graduates with educational loan repayments in 
exchange for a fixed period of employment at a VHA facility. Our 
members report that nurses in hard-to-recruit geographic areas have 
been turned away because EDRP funds have been exhausted, while excess 
EDRP funds remain unused in other locations. The Federal Government 
also has longstanding upward mobility programs that could be used to 
recruit health care professionals from within the VA but they appear to 
be woefully underutilized.

    Scheduling Incentives:
    The nurse alternative work schedule provisions that Congress 
enacted in 2004 were intended to make the VA workplace a more desirable 
place to work by offering VA registered nurses the same popular 
compressed work schedule (CWS) (full-time pay for three 12 hour days) 
that private nurses are offered. Again, funding problems and local 
discretion have frustrated Congressional intent. Local directors are 
reluctant to offer CWS in part because it requires them to hire 
additional staff and in part because of a reluctance to make change. 
Since they can't afford to hire, they lose prospective nurses but 
cannot attract others to replace them so they end up spending far more 
on agency nurses. We urge Congress to end this vicious cycle by 
ensuring that adequate funds are available for the VA to offer CWS and 
require the VA to conduct more oversight at the local level.
    The second scheduling incentive that Congress included in the 2004 
law (P.L. 108-445) was to reduce the VA's reliance on mandatory 
overtime. The law prohibits the use of mandatory overtime except in 
cases of emergencies. To be competitive with other employers, all VA 
facilities should use the same, widely accepted, narrowly drawn 
definition of emergency adopted by a number of states to protect their 
nurses from excessive overtime. Instead, each facility is permitted to 
invoke the emergency exception to mandate overtime, even when staffing 
shortages are a result of their own mismanagement and could have been 
easily anticipated. AFGE urges Congress to adopt a statutory definition 
of emergency consistent with state law. In addition, the current 
overtime provision should also apply to Licensed Practical Nurses and 
Nursing Assistants. Finally, we urge Congress to strengthen and extend 
the current requirement that VHA certify as to status of overtime 
policies in all facilities.

    Other Recruitment and Retention Tools:
    Greater employee voice: Magnet certification is regularly touted as 
a highly effective recruitment and retention tool for VHA, because 
among other alleged benefits, it provides greater involvement by front 
line nurses. Long before magnets came on the scene, VHA endorsed 
employee involvement. That is why AFGE nurses regularly served on key 
committees such as patient safety, nurse innovation, qualification 
standards, and workforce planning. Sadly, we have been virtually 
excluded from such groups as of late. We doubt that magnet status will 
make VA management more open to frontline employee participation. What 
we are sure of is that many, many medical dollars are being diverted 
from patient care and nurse hiring in order to go to magnet 
certification fees and staff time to prepare magnet applications. This 
appears to be a questionable use of appropriated dollars as well as a 
questionable use of patient care dollars.
    Retirement benefits: Currently, most federal employees covered by 
the FERS retirement system cannot apply unused sick leave toward 
retirement, while their counterparts under the older CSRS system can. 
Congress carved out an exception under Title 38 for RNs several years 
ago. We urge that this benefit be extended to all VHA personnel as an 
added incentive for staying with the VA.
    Equality for Part-Time Nurses: Part-time nurses represent a 
valuable untapped source of personnel for VHA, but they face two 
disincentives. First, even if they were previously full-time nurses 
with permanent status, they enter probationary status with no employee 
rights for an indefinite period if they become part-time. We urge 
Congress to give part-time nurses permanent status after working at the 
VA for the equivalent of two years full-time. Part-time nurses are also 
denied most of the overtime, shift differential, and weekend premium 
pay earned by full-time nurses. To remain competitive with other 
employers who recognize the importance of flexible work schedules for 
nurses, the VA should update its policies for part-timers.
    Other professionals appointed under 38 USC Sec. 7401(1): AFGE 
supports H.R. 2790 to provide a full-time physician assistant advisor 
so that valuable role of physician assistants in VA health care can be 
better utilized. We also encourage a renewed look at the status of the 
other professionals appointed under this authority as chiropractors, 
podiatrists, and optometrists who are increasingly playing a key role 
in the treatment of OIF/OEF veterans.
CONCLUSION
    VHA clearly recognizes the recruitment and retention challenges 
that lie ahead. AFGE participated in the National Commission on VA 
Nursing several years ago that acknowledged that the ``current and 
emerging gap between the supply of and demand for nurses may adversely 
affect the VA's ability to meet the healthcare needs of those who have 
served our Nation.'' We commend VHA for other efforts undertaken to 
address VHA workforce succession planning in recent years. We urge 
Congress to give the VA the financial support and direction it needs to 
address short and long term health care workforce needs in a cost 
effective manner that ensures that veterans receive high quality care.
    Thank you.

                                 
          Prepared Statement of William J. Feeley, MSW, FACHE,
    Deputy Under Secretary for Health for Operations and Management,
  Veterans Health Administration, U.S. Department of Veterans Affairs
    Mr. Chairman and members of the Committee, thank you for the 
invitation to appear before you today to discuss the Department of 
Veterans Affairs (VA), Veterans Health Administration (VHA) recruitment 
and retention program for health care professionals. I appreciate the 
opportunity to discuss our ongoing efforts in workforce and succession 
planning as they relate to recruitment and retention. As the Nation's 
largest integrated health care delivery system, VHA's workforce 
challenges mirror those of the health care industry as a whole. The 
Nation is in the midst of a workforce crisis in health care and VHA 
experiences the same pressures. I am pleased to be here today to share 
VHA's innovative approaches to addressing recruitment and retention of 
our professional health care workforce.
Efforts to Increase the Pipeline of Health Care Workers
    There is a growing realization that the supply of appropriately 
prepared health care workers in the Nation is inadequate to meet the 
needs of a growing and diverse population. This shortfall will grow 
more serious over the next 20 years. Enrollment in schools of nursing 
is not growing fast enough to meet the projected future demand. The 
American Association of Colleges of Nursing has reported that more than 
42,000 qualified applicants were turned away from nursing schools in 
2006 because of insufficient numbers of faculty, clinical sites, 
classroom space and clinical mentors.
    In April 2007, VA launched the VA Nursing Academy to address the 
nationwide shortage of nurses. The purpose of the Academy is to expand 
the number of nursing faculty in the schools, increase student nursing 
enrollment by 1,000 students and promote innovations in nursing 
education through enhanced clinical rotations in the VA. VHA research 
shows that students who perform clinical rotations at a VA facility are 
more likely to consider VA as an employer following graduation.
    The pilot program known as ``Enhancing Academic Partnerships'', 
selected four sites from among 42 applicants. The first year begins in 
conjunction with the 2007-2008 academic school years. The four VA 
facilities and nursing schools selected include: the North Florida/
South Georgia Veterans Health System and the University of Florida in 
Gainesville; the VA San Diego Healthcare System and San Diego State 
University; the VA Salt Lake City Health Care System and the University 
of Utah in Salt Lake City; and the VA Connecticut Healthcare System and 
Fairfield University in Fairfield, CT. Another four partnership sites 
will be selected in 2008 and 2009, for a total of 12 partnership sites 
in the five-year pilot program.
    Another program designed to attract academically successful 
students of baccalaureate nursing programs and pharmacy doctorate 
programs to work at VA is the VA Learning Opportunities Residency 
(VALOR) Program. The purpose of this intern program is to develop a 
candidate pool of qualified and highly motivated candidates for 
employment. The VALOR program, offering a paid internship, gives the 
selected students the opportunity to develop competencies in their 
clinical practice in a VA facility under the guidance of a preceptor. 
In 2006, VHA hired 89 of the VALOR nurses who had graduated. In 
response to the success of the VALOR program for nurses, the pharmacy 
component was added in 2007 to address VA's need for pharmacists. VHA 
hopes to mirror this success through the pharmacy program.
    The Student Career Experience Program (SCEP) offers students work 
experience directly related to their academic field of study by 
providing formal periods of work and study while the student is 
attending school. This program focuses on recruiting students from 
minority colleges and universities and in mission critical occupations. 
Mission critical occupations are those that may exhibit such things as 
an increasing demand, high turnover, or a high volume position in VHA. 
VHA's goal is to actively recruit these students for permanent 
employment following graduation. VA National Database for Interns 
(VANDI) is a newly designed database developed to track those 
individuals who participate in specific VA recognized internship/
student programs. The strategy is to use the database to identify 
potential qualified applicant pool. VANDI will also assist with 
workforce development, diversity management and succession planning. 
The database will include: demographic data on interns, various 
educational information for interns and management officials (i.e. 
resume writing, Special Hiring Authorities, list of colleges and 
universities, links to various VA Offices, etc.), and statistical data 
for reports and evaluations.
    The VA Cadet program is a collaborative effort between VHA's 
Healthcare Retention and Recruitment Office, the Office of Nursing 
Service and Voluntary Service. The program targets high school students 
who initially come to VHA as volunteers and later convert to student 
employment. The goal of the program is to introduce high school 
students to health care occupations and encourage the pursuit of 
education and training in nursing or other allied health professions. 
Students attending allied health programs may be appointed under the 
student career experience program and hired into vacant positions upon 
graduation. Once in a permanent position for one year, they are then 
eligible for Employee Incentive Scholarship Program (EISP) scholarships 
to advance their careers.
    The Graduate Health Administration Training Program (GHATP) 
provides practical work experience to students and recent graduates of 
health care administration masters programs. GHATP residents and 
fellows are competitively selected and upon successful completion of 
the programs are eligible for conversion to a VA health systems 
specialist position in hospital management.
    The Technical Career Field (TCF) program is an internship created 
to recruit journeyman level staff to fill vacancies in technical career 
fields where current and future shortages are predicted and knowledge 
of VA-related issues is critical to success. Recruitment is focused on 
local colleges and universities. Each intern is placed with an 
experienced trained preceptor in a VHA facility. Interns convene for an 
annual conference with their peers and the program is evaluated at the 
national level. The program is designed to be flexible based on the 
changing needs of the workforce. Annually, the target positions and 
number of intern slots are determined based on current and projected 
workforce needs and program evaluation data.
Streamlining the Hiring Process
    It is well known that the Government hiring process is cumbersome. 
In May 2007, the Human Resource Committee chartered a process redesign 
workgroup to streamline the recruitment process for Title 5 and Title 
38 positions within VHA. This included an analysis of the recruitment 
process and identification of barriers and lengthy processes. In August 
2007, the workgroup presented their findings and recommendations for 
short, intermediate and long-term improvements intended to streamline 
processes at the facility level and facilitate change at the national 
level.
    VA has direct appointment authority for several occupations, 
including physical therapists. We recognize that the physical therapist 
occupation is a key to the rehabilitation of returning veterans and VHA 
is working with the Office of Human Resources Management (OHRM) to 
develop a new qualification standard. OHRM expects the revised standard 
to advance to collaboration with the labor unions in January 2008 and 
be approved for implementation in mid-summer of that year. During the 
interim, the existing qualification standard is being used for 
appointments.
National Recruitment/Media Marketing Strategies
    VHA Health Care Retention & Recruitment Office (HRRO) administers 
national programs to promote national employment branding with VHA as 
the health care employer of choice. Established almost a decade ago, 
the brand ``Best Care--Best Careers'' reflects the care America's 
veterans receive from VA and the excellent career opportunities 
available to staff and prospective employees. The brand has been 
reflected in the popular press in the January/February 2005 edition 
Washington Monthly magazine article ``Best Care Anywhere'' and in the 
recently published book Best Care Anywhere: Why VA Health Care is 
Better than Yours by Phillip Longman.
    HRRO works at the national level to promote recruitment branding 
and provide tools, resources, and other materials to support both 
national branding and local recruiting. Some of these features are:

          VHA recruitment Web site (www.VACareers.va.gov) 
        provides extensive information on careers in VHA, job search 
        capability, and information on Federal employment pay and 
        benefits information.
          Public Service Announcements (PSA) promote the 
        ``preferred health care employer'' image of VHA. PSA's 
        emphasize the importance and advantage of careers with VA and 
        focus on the personal and professional rewards of such a 
        career.
          Online advertising through a comprehensive web 
        advertising strategy, VA job postings are promoted on 
        commercial employment sites and online health information 
        networks that expand our reach to over 5,000 discrete Web 
        sites. The strategy includes banner advertising that drives 
        traffic to the VACareers Web site for employment information. 
        This advertising program generates millions of ad impressions 
        and accounts for more than 100,000 visits to the VA recruitment 
        Web site each month.
          Print advertising includes both direct classified 
        advertising and national employment branding. Local classified 
        advertising plans are built around single job announcements and 
        using journals, newspapers, and the web to promote positions. 
        The national program provides ongoing exposure of VA messaging 
        to potential hires with the intent to promote VA as a leader in 
        patient care and to clearly state the benefits of VA 
        employment. With advertising placed in more than 35 health 
        professional magazines and peer review journals, VHA targets 
        readership of over 34 million potential candidates.
          VHA Health Care Recruiters' Toolkit, a unique virtual 
        community internal to VHA is an online management program that 
        coordinates national and local recruitment efforts for health 
        care professionals. The toolkit helps recruiters combat the 
        national recruitment shortage by placing all available 
        recruitment tools, materials, ads, and information at their 
        fingertips.
          National Recruitment Advisory Groups, the VHA Nurse 
        Recruiters Advisory Board and the National Nurse Recruiters 
        group established in the early 90's is a collaborative network 
        of nurse recruiters from VHA facilities across the country. The 
        group holds membership as a subchapter of the National 
        Association of Healthcare Recruiters and works to educate and 
        develop nurse recruiters in VHA and to share best practices.
          National Pharmacy Recruitment Advisory Board and 
        regional network of Pharmacy Recruiters was established in 
        2007.
          In 2004, VHA conducted the Nursing Recruitment and 
        Retention Study to examine attitudes toward careers in nursing 
        and to develop and test recruitment marketing materials and 
        messaging for development of ads, PSA's, and brochures. In 
        2006, VHA conducted the Pilot Program to Study Innovative 
        Recruitment Tools to Address Nursing Shortages at Department of 
        Veterans Affairs. This study further developed recruitment and 
        marketing approaches using online methods and refined 
        recruitment marketing messages and recruitment materials for 
        nursing occupations (e.g. brochures).
          In July 2007, following qualitative research to 
        determine why pharmacists are drawn to work at VA, the VHA 
        Pharmacy Marketing Plan was developed. This research was 
        supplemented by quantitative research performed by the Office 
        of Academic Affiliations of both nurses and pharmacists in the 
        first three and five years of employment respectively. These 
        studies quantified the impact of student clinical experiences 
        in VA on the decision to work at a VA facility as well as the 
        impact of the work environment and work assignments on 
        retention.
          In fiscal year (FY) 2007, HRRO developed a 
        comprehensive recruitment marketing plan for recruitment in 
        mental health occupations that used strategies listed above as 
        well as recruitment incentives to assist with quick recruitment 
        of these providers nationally.

Financial Incentives for Recruitment and Retention
    Both a recruitment and retention tool, the Employee Incentive 
Scholarship Program (EISP) pays up to $32,000 for academic health care 
related degree programs with an average of $12,000 paid per 
scholarship. Since the program began in 1999, approximately 7,000 VA 
employees have received scholarship awards for academic education 
programs related to Title 38 and Hybrid 38 occupations. Approximately 
4,000 employees have graduated from their academic programs. 
Scholarship recipients include registered nurses (93 percent), 
pharmacists, and many other allied health professionals. Focus group 
market research shows that staff education programs offered by VHA are 
considered a major factor in individuals selecting VA as their choice 
of employer. A 5-year analysis of program outcomes demonstrated the 
impact on employee retention. For example, turnover of nurse 
scholarship participants is 7.5 percent compared to a non-scholarship 
nurse turnover rate of 8.5 percent. Less than one percent of nurses 
leave VHA during their service obligation period (from one to three 
years after completion of degree).
    The Education Debt Reduction Program (EDRP) provides tax free 
reimbursement of education loans/debt to recently hired Title 38 and 
Hybrid Title 38 employees. EDRP is the Title 38 equivalent to the 
Student Loan Repayment Program (SLRP) sponsored under Office of 
Personnel Management (OPM) regulations for Title 5 employees. As of 
August 9, 2007, there were over 5,600 health care professionals 
participating in EDRP. The average amount authorized per student for 
all years since the program's inception is $17,000. The average award 
amount per employee has increased over the years from over $13,500 in 
FY 2002 to over $27,000 in FY 2007 as education costs have increased. 
While employees from 33 occupations participate in the program, 77 
percent are from three mission critical occupations--registered nurse, 
pharmacist and physician. Resignation rates of EDRP recipients are 
significantly less than non-recipients as determined in a 2005 study. 
For physicians, the study found the resignation rate for EDRP 
recipients was 15.9 percent compared to 34.8 percent for non-EDRP 
recipients.
    VHA routinely uses hiring and pay incentives established under 
Title 5, extended by the Secretary to Title 38 employees. There is 
routine use of financial recruitment incentives, retention incentives 
(both individual and group), special salary rates, relocation 
incentives and other incentives as documented in VHA's Workforce 
Succession Strategic Plan.
Innovative Retention Strategies
    One retention strategy that has been very successful for VHA was 
the approval of the physician pay legislation (Public Law 108-445, 
dated December 3, 2004) effective January 8, 2006. The pay of VHA 
physicians and dentists consists of three elements: base pay, market 
pay, and performance pay. The change was intended to make possible the 
recruitment and retention of the best qualified workforce capable of 
providing high quality care for eligible veterans. VA is committed to 
ensuring that the levels of annual pay (base pay plus market pay) for 
VHA physicians and dentists are fixed at levels reasonably comparable 
with the income of non-VA physicians and dentists performing like 
services. Since the physician pay legislation went into effect, 
physician employment has increased by 430 physicians.
    An overarching mission of VHA is to develop and retain our most 
valuable asset--those who provide quality care to our veterans and 
their families. VHA invests resources to nurture and maintain an 
exceptionally competent workforce that is committed to providing ``the 
best quality care anywhere.''
    There is a direct impact in the relationship of organization 
culture and employee and patient satisfaction. For example, researchers 
demonstrated a positive relationship between group culture and patient 
satisfaction among inpatients and ambulatory care patients, such that 
the higher the group/teamwork culture the higher the patient 
satisfaction (Meterko, Mohr, & Young, Medical Care, 42(5), May 2004, 
492-498).
    VHA believes maintaining the health of the organization improves 
retention of employees in hard to recruit occupations and will continue 
to invest in the All Employee Survey, the Civility Respect and 
Engagement in the Workforce (CREW) program as well as others designed 
to improve organizational health. We strongly believe a healthy 
organizational culture ensures improved patient satisfaction and care 
for our veterans.
Employee Entrance and Exit Survey Analysis
    In 2000, VA implemented the use of an electronic database to 
capture survey information from employees entering and exiting VA 
Service. The entrance survey is an excellent tool to compare and 
contrast reasons the new workforce has come to work for VHA and is an 
excellent tool to determine recruitment sources used by candidates 
(e.g. newspaper ads, employee referral, online job postings). In 
contrast, the exit survey tracks the reasons why staff leave VHA 
employment.
    Survey results of 2006 and the first half of 2007 show the top 
reasons to work for VA were advancement/development opportunities, 
benefits package and job stability. The mission of serving veterans and 
pay were also highly rated. The exit survey shows the top reasons for 
leaving VHA in FY 2006 and the first half of 2007 were normal 
retirement, advancement elsewhere, and family matters (marriage, 
pregnancy, etc.). These findings provide valuable insight for 
developing recruitment marketing messages and establishing programs to 
improve retention.
Workforce Succession Planning
    VHA performs extensive national workforce planning and updates and 
publishes a VHA Workforce Succession Strategic Plan annually. As part 
of this process, workforce analysis and planning is conducted in each 
Veterans Integrated Services Network (VISN) and national program office 
and then is rolled up to create a national plan. The plan addresses 
VHA's strategic direction and emerging initiatives such as mental 
health care, polytrauma, TBI, and rural health. Mission critical 
occupations, which are considered shortage categories, are identified 
and initiatives are established at local, regional and national levels 
to address recruitment and retention. For each of the nationally ranked 
mission critical occupations a thorough historical and projected 
workforce analysis is conducted. Plans are established at every level 
to address turnover, the succession pipeline, developmental 
opportunities, and diversity issues. For each of the critical 
occupations, as well as the workforce nationwide, equal employment 
opportunity (EEO) comparison data is provided to ensure that VHA 
maintains a diverse workforce.
    VHA's workforce plan is one of the most comprehensive in government 
and has been recognized by OPM as a Federal best practice. VA presented 
at other Federal agencies and the OPM Conference, ``A Best Practice 
Leadership Forum On Succession Management.''
    The Under Secretary for Health has made a personal commitment to 
succession planning and ensuring VHA has a comprehensive recruitment, 
retention, development and succession strategy. This is a continuous 
process which requires on-going modifications and enhancements to our 
current programs.
    We want to thank the Committee for their interest and support in 
implementing legislation that allows us to compete in the aggressive 
health care market.
    Mr. Chairman, that concludes my statement. I am pleased to respond 
to any questions you or the Subcommittee members may have.
    Thank you.

                                 
         Statement of American Academy of Physician Assistants
    On behalf of the nearly 65,000 clinically practicing physician 
assistants (PAs) in the United States, the American Academy of 
Physician Assistants (AAPA) is pleased to submit comments in support of 
H.R. 2790, a bill to amend title 38, United States Code, to establish 
the position of Director of Physician Assistant Services within the 
office of the Under Secretary of Veterans Affairs for Health. The AAPA 
is very appreciative of Representatives Phil Hare and Jerry Moran for 
their leadership in introducing this important legislation. AAPA 
believes that enactment of H.R. 2790 is essential to improving patient 
care for our Nation's veterans, ensuring that the 1,600 PAs employed by 
the VA are fully utilized and removing unnecessary restrictions on the 
ability of PAs to provide medical care in VA facilities. Additionally, 
the Academy believes that enactment of H.R. 2790 is necessary to 
advance recruitment and retention of PAs within the Department of 
Veterans Affairs.
    Physician assistants are licensed health professionals, or in the 
case of those employed by the Federal Government, credentialed health 
professionals, who--

      practice medicine as a team with their supervising 
physicians
      exercise autonomy in medical decisionmaking
      provide a comprehensive range of diagnostic and 
therapeutic services, including performing physical exams, taking 
patient histories, ordering and interpreting laboratory tests, 
diagnosing and treating illnesses, suturing lacerations, assisting in 
surgery, writing prescriptions, and providing patient education and 
counseling
      may also work in educational, research, and 
administrative settings.

    Physician assistants' educational preparation is based on the 
medical model. PAs practice medicine as delegated by and with the 
supervision of a physician. Physicians may delegate to PAs those 
medical duties that are within the physician's scope of practice and 
the PA's training and experience, and are allowed by law. A physician 
assistant provides health care services that were traditionally only 
performed by a physician. All states, the District of Columbia, and 
Guam authorize physicians to delegate prescriptive privileges to the 
PAs they supervise. AAPA estimates that in 2006, approximately 231 
million patient visits were made to PAs and approximately 286 million 
medications were prescribed or recommended by PAs.
    The PA profession has a unique relationship with veterans. The 
first physician assistants to graduate from PA educational programs 
were veterans, former medical corpsmen who had served in Vietnam and 
wanted to use their medical knowledge and experience in civilian life. 
Dr. Eugene Stead of the Duke University Medical Center in North 
Carolina put together the first class of PAs in 1965, selecting Navy 
corpsmen who had considerable medical training during their military 
experience as his students. Dr. Stead based the curriculum of the PA 
program in part on his knowledge of the fast track training of doctors 
during World War II. Today, there are 139 accredited PA educational 
programs across the United States. Approximately 1,600 PAs are employed 
by the Department of Veterans Affairs, making the VA the largest single 
employer of physician assistants. These PAs work in a wide variety of 
medical centers and outpatient clinics, providing medical care to 
thousands of veterans each year. Many are veterans themselves.
    Physician assistants (PAs) are fully integrated into the health 
care systems of the Armed Services and virtually all other public and 
private health care systems. PAs are on the front line in Iraq and 
Afghanistan, providing immediate medical care for wounded men and women 
of the Armed Forces. Within each branch of the Armed Services, a Chief 
Consultant for PAs is assigned to the Surgeon General. PAs are covered 
providers in Tri-Care. In the civilian world, PAs work in virtually 
every area of medicine and surgery and are covered providers within the 
overwhelming majority of public and private health insurance plans. PAs 
play a key role in providing medical care in medically underserved 
communities. In some rural communities, a PA is the only health care 
professional available.
    The current position of Physician Assistant (PA) Advisor to the 
Under Secretary for Health was authorized through section 206 of P.L. 
106-419 and has been filled as a part-time, field position. Prior to 
that time, the VA had never had a representative within the Veterans 
Health Administration with sufficient knowledge of the PA profession to 
advise the administration on the optimal utilization of PAs. This lack 
of knowledge resulted in an inconsistent approach toward PA practice, 
unnecessary restrictions on the ability of VA physicians to effectively 
utilize PAs, and an under-utilization of PA skills and abilities. The 
PA profession's scope of practice was not uniformly understood in all 
VA medical facilities and clinics, and unnecessary confusion existed 
regarding such issues as privileging, supervision, and physician 
countersignature.
    Although the PAs who have served as the VA's part-time, field-based 
PA Advisor have made progress on the utilization of PAs within the 
agency, there continues to be inconsistency in the way that local 
medical facilities use PAs. In one case, a local facility decided that 
a PA could not write outpatient prescriptions, despite licensure in the 
state allowing prescriptive authority. In other facilities, PAs are 
told that the VA facility cannot use PAs and will not hire PAs. These 
restrictions hinder PA employment within the VA, as well as deprive 
veterans of the skills and medical care PAs have to offer.
    The AAPA believes that a full-time Director of PA Services within 
the VA Central Office is necessary to recruit and retain PAs in the 
Department of Veterans Affairs. PAs are in high demand in the private 
marketplace.

      The U.S. Bureau of Labor Statistics (BLS) projects that 
the number of PA jobs will increase by 50 percent between 2004 and 2014 
and has ranked the profession as the fourth fastest growing profession 
in the country.
      US News & World Report named the PA profession within its 
2007 list of 25 best careers.
      Money magazine ranked the PA profession number five in 
its 2006 list of top careers; CNN listed the PA profession as number 
four in its 2006 list of top U.S. careers.

    The growth in PA jobs is in the private sector, not the Federal 
Government. AAPA believes that the Federal Government, including the 
Department of Veterans Affairs, will not be able to compete with the 
private market unless special efforts are made to recruit and retain 
PAs. According to the AAPA's 2006 Census Report, an estimated 3,545 PAs 
are employed by the Federal Government to provide medical care. 
Unfortunately, AAPA's Annual Census Reports of the PA Profession from 
1997 to 2006 document an overall decline in the number of PAs who 
report Federal Government employment. In 1991, nearly 13.4% of the 
total profession was employed by the Federal Government. This 
percentage dropped to 6% in 2006.
    The Academy also believes that the elevation of the PA Advisor to a 
full-time Director of Physician Assistant Services, located in the VA 
central office, is necessary to increase veterans' access to quality 
medical care by ensuring efficient utilization of the VA's PA workforce 
in the Veterans Health Administration's patient care programs and 
initiatives. PAs are key members of the Armed Services' medical teams 
but are an underutilized resource in the transition from active duty to 
veterans' health care. As health care professionals with a longstanding 
history of providing care in medically underserved communities, PAs may 
also provide an invaluable link in enabling veterans who live in 
underserved communities to receive timely access to quality medical 
care.
    Thank you for the opportunity to submit a statement for the hearing 
record in support of H.R. 2790. AAPA is eager to work with the House 
Committee on Veterans' Affairs Subcommittee on Health to improve the 
availability and quality of medical care to our Nation's veteran 
population.

                                 
Statement By Hon. Jeff Miller, Ranking Republican Member, Subcommittee 
 on Health, and a Representative in Congress from the State of Florida
    VA physicians, nurses, physical therapists, mental health and other 
health care professionals are at the side of every veteran patient. 
They are the front line of VA health care. They use their expertise, 
experience, and compassion to provide a continuum of care that our 
veterans need and deserve.
    As a large employer of health care providers, VA must compete with 
the private sector to attract qualified personnel into the VA system.
    One of the major challenges VA faces is the recruitment of 
Registered Nurses (RNs). The rising demand for nursing care, with an 
aging RN workforce and fewer new nurses entering the profession is 
creating a shortage of RNs. It poses a problem to maintaining RN 
staffing levels across the United States.
    For the past four years, VA has reported an increase in the average 
nurse vacancy rate. In an effort to mitigate this situation, VA 
recently created a new multi-campus Nursing Academy through 
partnerships with baccalaureate nursing schools. While I am pleased 
with VA's actions, it is my hope that VA will expand its partnerships 
to include associate degree nursing schools. Expanding the program will 
help increase the number of nurses that will see VA as a desirable 
employer.
    VA's ability to recruit and retain a first-class health care 
workforce is critical to addressing the dynamic healthcare needs of our 
veterans.

                                 
          Statement of Nurses Organization of Veterans Affairs

      Retention & Recruitment

    The Nurses Organization of Veterans Affairs (NOVA) has identified 
retention and recruitment of healthcare staff members as a critically 
important issue in providing high quality health care to veterans. 
Shorter lengths of stay, higher patient acuity, more sophisticated 
technologies and procedures, and increasing care complexity place 
greater demands on health care workers today. For VHA to provide high 
quality health care, there must be a dramatic increase in retention and 
recruitment efforts.
    As VHA executives face growing vacancies, elevated turnover due to 
retirements is imposing an additional tremendous burden on VHA 
facilities, especially in a time of shortage. The result is lost 
productivity, increased use of premium labor, escalating recruiting 
expenditures, and damage to employee morale.
    There are several key issues that impact the ability of VHA to 
provide excellent health care.

      Nurse Executive Pay and Pay Cap

    Another important issue for retention and recruitment involves 
Nurse Executive pay. Recent changes in pay for non-SES leaders in VHA 
have worsened the issue of pay inequity. Nurse Executives do not 
receive pay comparable with their peers. Due to the recently 
implemented Physician Pay Bill, Medical Center Chiefs of Staff received 
substantial pay increases averaging 8% to an average level of $210,000 
and reaching $250,000 at the most complex (Tier 1) VA medical centers.
    The mean salary for Nurse Executives is $129,000. Many Nurse 
Executives did not receive additional pay in the form of a bonus that 
is included in retirement computation under Public Law 108-445, because 
the bonus was not mandatory. This underscores the need for VA to move 
quickly to remedy a problem that is already manifesting itself in 
turnover and in recruitment problems for key upper level positions in 
the organization.
    Currently, individuals appointed under section 7306 of Title 38 
serve in executive level positions that are equivalent in scope and 
responsibility to positions in the Senior Executive Service. Examples 
of such positions are the Director, Pharmacy Benefits Management 
Strategic Health Group; Director of Optometry; Director of Podiatry; 
and Director of Dietetics. The pay schedule for section 7306 appointees 
is adjusted each year by Executive Order and is capped at the pay rate 
for Level V of the Executive Schedule (currently $136,200). Locality 
pay is also paid up to the rate for Level III of the Executive Schedule 
(currently $154,600).
    In addition there is a need to increase the pay limitation 
contained in 38 U.S.C. 7451(c)(2) for VA nurses from Level V (currently 
$136,200) to Level IV (currently $145,400) of the Executive Schedule to 
address the pay disparity between the Nurse V maximum rate and the GS-
15 maximum rate in some geographic areas.
    A change to 38 USC 7451 is needed to increase the pay cap under the 
nurse locality pay system. With an increase to EL-IV, each nurse pay 
schedule that is currently limited by the EL-V cap would be 
recalculated based upon the existing beginning rate for the grade.

      CRNAs

    This change will also address a growing recruitment and retention 
problem with Certified Registered Nurse Anesthetists (CRNA). Presently, 
the pay of 286 of the 531 CRNAs (54%) in VA is frozen at the ELV level 
($136,200). A search of a commercial website that lists job openings 
for CRNAs revealed that in 66.8% of the listings, the potential pay 
rates advertised exceed the EL-V salary cap.
    We see this as a potential challenge for the VA in terms of 
retaining our skilled CRNA workforce and attracting new candidates.
    The alternative to hiring CRNAs is utilizing more, higher priced 
Anesthesiologists (currently a scarce medical specialty that commands 
high market pay rates).

      Lack of Human Resources Support

    The loss of experienced human resources staff throughout VHA has 
had a significant impact on nursing retention and recruitment. 
Inexperienced staff members do not have the expertise to provide needed 
assistance to medical center staff to assist them to successfully 
recruit and retain qualified healthcare staff. The VA has developed a 
succession plan to address this but the loss of experienced staff is an 
issue.

      Delays in Background Investigations

    Delays related to security and background checks have significantly 
impacted VHA's ability to hire. The increased security requirements 
cause several months' delay in bringing staff into VHA facilities. The 
delays are so extensive that facilities are losing valuable staff 
members who cannot wait for long lengths of time for the background 
checks to be completed. These delays are particularly frustrating due 
to poor communication of reasons for delays. In addition, background 
checks for students are creating an additional burden for schools and 
universities. For example, most students have already had background 
checks and fingerprints completed but must complete another set for 
VHA. The delays these cause are so severe in some areas that VHA 
facilities are losing students, a valuable source of future employees.

      Information Technology Issues

    The VA, as the Nation's largest healthcare organization, has the 
potential to be the leader in defining 21st century evidence-based 
quality nursing care. Evidence-Based Practice (EBP) is a national 
nursing strategic goal, which will help to ensure that patients have 
the best possible outcomes and that resources are allocated 
appropriately. The Office of Nursing Services (ONS) and the National 
Nurse Executive Council (NNEC) selected a program team to develop the 
VA Nursing Outcomes Database--VANOD.
    CPRS re-engineering and redesign to focus on nursing software 
improvements necessary for VANOD have not occurred in a timely manner. 
Plans for a new and improved CPRS that will allow for ICU equipment 
connectivity; customization to reflect clinical care and safety; and 
documentation designed to match clinical workflow have not met 
implementation schedules. These critical changes will result in 
increased patient safety, software usability, and data standardization 
for integrated, consistent, comparable, longitudinal patient health 
records across the system and must be supported.

      Performance of Non Nursing Tasks

    The National Commission on VA Nursing's Work Environment 
recommendation #1 was to eliminate performance of non nursing tasks by 
nursing staff. The top five issues were: clerical tasks, finding 
patient care equipment and supplies, housekeeping tasks, 
troubleshooting technology, and transporting patients. It remains 
challenging in many parts of the country to recruit and retain these 
valuable workers.

      VA Nursing Academy

    The VA Nursing Academy is a collaborative program established 
between the Office of Academic Affiliations (OAA) and the Office of 
Nursing Services (ONS). Through an expansive network of affiliate 
partnerships between local VA Medical Centers (VAMC) and schools of 
nursing, the VA Nursing Academy will meet nurse recruitment/retention 
and nurse faculty needs for the VA and may ultimately impact the 
nursing shortage nationwide.

      Health Professions Scholarship Program

    As part of the Academy, financial assistance will be provided to 
competitively selected VA and non-VA nursing students in exchange for 
VA service obligations upon graduation and licensing. The authority to 
provide this financial assistance will be established by extending the 
expiration date of the Department of Veterans Affairs Health 
Professional Scholarship Program (HPSP) described in 38 USC 7611-7618 
and 38 CFR 17.600-17.612.
    The scholarship program will pay tuition, fees, miscellaneous 
expenses and a monthly stipend to competitively selected participants. 
There is no other scholarship program available to non-VA employees at 
this time.

      Patient and Staff Safety

    VA Nursing has prioritized the prevention of musculoskeletal 
injuries to nursing staff in collaboration with national nursing and 
specialty organizations. The American Nurses Association launched the 
``Handle with Care'' campaign in 2003 to focus education and research 
efforts on this topic. The VA Patient Safety Center of Inquiry (Tampa, 
FL) has created and tested a series of activities known as the Safe 
Patient Handling and Movement (SPHM) program, and ONS is supporting 
this program as a top initiative for FY2006.
    These SPHM programs have been found to decrease the number and 
severity of nursing injuries, while improving job satisfaction and 
patient quality of care and quality of life. Funding to support full 
implementation of both of these programs will contribute significantly 
to recruitment and retention of health care staff.

      Clinical Nurse Leader

    The Clinical Nurse Leader (CNL) initiative was launched in 2004 to 
deliver clinical leadership at the microsystem level (individual 
patient care units). The CNL is an advanced generalist that delivers 
and directs practice, evaluates outcomes, assesses risks and works to 
improve the overall coordination and delivery of care for an 
individual/group of patients at the unit level in all VA health care 
settings. Evidence suggests that a positive relationship exists between 
the numbers and educational level of professional nurses involved in 
direct patient care and the quality of the care outcomes. Support for 
this innovative role is critical for retention.

      Succession Planning

    The Office of Nursing Services has placed emphasis on succession 
planning for nurse executives. There is a program manager dedicated to 
implementing a program providing support for new nurse executives. In 
addition, there is a need for formal succession planning for nurse 
managers, with the development of an assistant nurse manager role. This 
is in progress through the Office of Nursing Services.

      Magnet Hospital Environment

    The magnet characteristic was used in the 1981 study of hospitals 
conducted by Margaret McClure and colleagues of the American Academy of 
Nursing. The study determined that a hospital that successfully 
attracted and retained nurses possessed certain characteristics. In the 
early 1990s the American Nurses Credentialing Center launched the 
Magnet Recognition Program which was based on hospitals (and other 
health care organizations which were added later) demonstrating these 
magnet characteristics.
    Magnet environments provide supports for the work of nursing--
autonomy, maximized participation in Medical Center governance, 
adequate support personnel, are just some tenets of the Magnet 
environment.
    It is critical that VHA support the environment necessary to 
provide a model that results in professional satisfaction for the 
nurse. Although not necessarily magnet status, the support of the 
Magnet environment is critical.

                                 
 Statement of Hon. John T. Salazar, a Representative in Congress from 
                         the State of Colorado
    Thank you, Mr. Chairman.
    I would like to also thank our panel today and give a special 
welcome to Dr. Richard Krugman, Dean of the University of Colorado 
School of Medicine.
    The issue of recruitment and retention is one of great importance 
to me.
    As you know, Dr. Krugman, my congressional district encompasses 
almost 60% of the State of Colorado; much of it is very rural.
    Presently, it's not uncommon for a veteran to drive five hours of 
mountainous terrain to reach a VA medical facility; with a predicted 
nationwide shortage of healthcare professionals it can only get worse 
for veterans living in rural areas.
    In Colorado we have a great opportunity for the VA to work with the 
University of Colorado medical school.
    The medical school has relocated to the old Fitz-Simmons campus and 
if the VA is able to negotiate a land purchase they will also build a 
new state of the art medical facility adjacent to the medical school.
    This will give medical students the opportunity to work directly 
with the VA on rotation and give VA additional opportunities to recruit 
new healthcare professionals.
    Again, thank you for your testimony today and I look forward to 
working together to tackle this tough issue.
    Ultimately, the answers we find to address the shortage of 
healthcare professionals within the VA could translate to addressing 
these shortages in communities across America.

                                 

                     PARTNERSHIP FOR PUBLIC SERVICE

                        The Best Places to Work
                In The Federal Government--2007 Rankings

    The Partnership for Public Service and American University's 
Institute for the Study of Public Policy Implementation use data from 
the Office of Personnel Management's Federal Human Capital Survey to 
rank federal agencies and subcomponents. These organizations are ranked 
according to a Best Places to Work index score, which measures overall 
employee engagement. In addition to this employee engagement rating, 
agencies and subcomponents are also scored in 10 workplace environment 
(``best in class'') categories.\1\
---------------------------------------------------------------------------
    \1\ The ten ``best in class'' categories: employee skills/mission 
match, strategic management, teamwork, effective leadership, 
performance based rewards and advancement, training and development, 
support for diversity, pay and benefits, family friendly culture and 
benefits, and work/life balance. The categories that have the highest 
impact on VHA's index score are effective leadership, employee skills/
mission match, and strategic management.
---------------------------------------------------------------------------
Veterans Health Administration (VHA)

Mission: To provide primary care, specialized care, and related medical 
and social support services to U.S. veterans.

Overall Rank: 18 of 222 agency subcomponents.

Key Agency Findings:

      In 2007, VHA's index score was 12 percentage points above 
total government. This shows dramatic improvement for the agency from 
2005, when it was 4 percentage points above government.
      VHA improved in almost every workplace category since 
2005, and had substantial increases in performance based rewards and 
advancement (+24 percent change), teamwork (+16.8 percent change) and 
effective leadership (+8.7 percent change).
      Although VHA ranks well, the Department of Veterans 
Affairs (VA) as a whole is declining VA's score has decreased 6.5 
percent since 2005. VA has also declined in every single workplace 
category.
      Although the highest-ranking subcomponent within the V A, 
VHA ranks in the lowest quartile for both pay and benefits and family 
friendly culture and benefits. VHA also has high satisfaction among 
employees 40 and over, but very low satisfaction among its younger 
cohort.

Additional Information:
    According to the Partnership for Public Service's 2007 Where the 
Jobs Are report, the VA will hire 22,000 nurses, physicians, and 
pharmacists by 2009.

------------------------------------------------------------------------
                        Category                               Rank
------------------------------------------------------------------------
Overall Index Score                                              18/222
------------------------------------------------------------------------
Best in Class scores                                               Rank
------------------------------------------------------------------------
Employee Skills/Mission Match                                     2/222
------------------------------------------------------------------------
Strategic Management                                             26/222
------------------------------------------------------------------------
Teamwork                                                         42/222
------------------------------------------------------------------------
Effective Leadership                                             37/222
------------------------------------------------------------------------
Performance Based Rewards and Advancement                        36/222
------------------------------------------------------------------------
Training and Development                                         44/222
------------------------------------------------------------------------
Support for Diversity                                            68/222
------------------------------------------------------------------------
Pay and Benefits                                                185/222
------------------------------------------------------------------------
Family Friendly Culture and Benefits                            182/222
------------------------------------------------------------------------
Work/Life Balance                                                70/222
------------------------------------------------------------------------
Score by Demographic                                             Rank 2
------------------------------------------------------------------------
Female                                                      No data/222
------------------------------------------------------------------------
Male                                                        No data/222
------------------------------------------------------------------------
40 and Over                                                      12/222
------------------------------------------------------------------------
Under 40                                                        112/222
------------------------------------------------------------------------
American Indian                                                 No data
------------------------------------------------------------------------
Asian                                                           No data
------------------------------------------------------------------------
Black and African-American                                        5/222
------------------------------------------------------------------------
Hispanic or Latino                                              No data
------------------------------------------------------------------------
Multi-racial                                                    No data
------------------------------------------------------------------------
White                                                            26/222
------------------------------------------------------------------------

      \2\
---------------------------------------------------------------------------
    \2\ The total number of agencies included in each ranking varies. 
Some agencies did not participate in every category.


                           Monthly Distinct Employee for Non-Med Resident, GAIN, VHA (Occupation Name), January-September 2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                            All
                                           Grade    0      1      2     3    4    5    6    7    8    9   10   11   12   13  14    15         Notes
--------------------------------------------------------------------------------------------------------------------------------------------------------

0101  Social Science-------------------------162-----  -----  -----  ---  ---  ---  ---  ---11---  --102--  ---42----3----4--  -----  ---------------  -
--------------------------------------------------------------------------------------------------------------------------------------------------------
0102  Social Science Aid and                  45                              2   15   11    9    1    6        1
  Technician
--------------------------------------------------------------------------------------------------------------------------------------------------------
0180  Psychology                             815    458                                                        70   64  223               Trainees: 394
--------------------------------------------------------------------------------------------------------------------------------------------------------
0181  Psychology Aid and                     103                         3    3   10   12   38    4   33
  Technician
--------------------------------------------------------------------------------------------------------------------------------------------------------
0185  Social Work                           1464    512                                              210      644   99    8   2           Trainees: 470
--------------------------------------------------------------------------------------------------------------------------------------------------------
0186  Social Services Aid                     13                              2    4    3    2         2
  and Assistant
--------------------------------------------------------------------------------------------------------------------------------------------------------
0187  Social Services                         11                                             5    5    1
--------------------------------------------------------------------------------------------------------------------------------------------------------
0188  Recreation Specialist                    1                                   1
--------------------------------------------------------------------------------------------------------------------------------------------------------
0189  Recreation Aid and                      11             4                2    4    1
  Assistant
--------------------------------------------------------------------------------------------------------------------------------------------------------
0601  General Health Science                 435     46                       1   33    1   55  105   68   2   60   34   27   3            Trainees: 39
--------------------------------------------------------------------------------------------------------------------------------------------------------
0602  Medical Officer                       1977     71                                                                           1907          Medical
                                                                                                                                         Residents: 367
--------------------------------------------------------------------------------------------------------------------------------------------------------
0603  Physician's Assistant                  245     80                       1                   7   18       26   88   25                Trainees: 74
--------------------------------------------------------------------------------------------------------------------------------------------------------
0604  Chiropractor                             3                                                                     2               1
--------------------------------------------------------------------------------------------------------------------------------------------------------
0605  Nurse Anesthetist                       78     27      7     13   31
--------------------------------------------------------------------------------------------------------------------------------------------------------
0610  Nurse                                 4619     99   2666   1430  397   21    5    1                       1             1            Trainees: 65
--------------------------------------------------------------------------------------------------------------------------------------------------------
0620  Practical Nurse                       1494     86                187  298  635  285    3
--------------------------------------------------------------------------------------------------------------------------------------------------------
0621  Nursing Assistant                     1338     23     16     15  125  521  614   25
--------------------------------------------------------------------------------------------------------------------------------------------------------
0622  Medical Supply Aide and                203      3      6      2   10   39   86   51    4    2
  Technician
--------------------------------------------------------------------------------------------------------------------------------------------------------
0625  Autopsy Assistant                        2                                   2
--------------------------------------------------------------------------------------------------------------------------------------------------------
0630  Dietitian and Nutritionist             226    131                       1             13        15       60    4    1   1           Trainees: 125
--------------------------------------------------------------------------------------------------------------------------------------------------------


                     Monthly Distinct Employee for Non-Med Resident, GAIN, VHA (Occupation Name), January-September 2007--Continued
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                            All
                                           Grade    0      1      2     3    4    5    6    7    8    9   10   11   12   13  14    15         Notes
--------------------------------------------------------------------------------------------------------------------------------------------------------
0631  Occupational Therapist                 142     85                                      4        10  26   18    1                     Trainees: 65
--------------------------------------------------------------------------------------------------------------------------------------------------------
0633  Physical Therapist                     210     99                                      5        16  45   46    1    1                Trainees: 79
--------------------------------------------------------------------------------------------------------------------------------------------------------
0635  Corrective Therapist                     8                                             5         3
--------------------------------------------------------------------------------------------------------------------------------------------------------
0636  Rehabilitation Therapy                  58      1                       6   11   10   22    6    1   1
  Assistant
--------------------------------------------------------------------------------------------------------------------------------------------------------
0638  Recreation/Creative Arts                68      1                            2         7        18  41
  Therapist
--------------------------------------------------------------------------------------------------------------------------------------------------------
0639  Educational Therapist                    1      1
--------------------------------------------------------------------------------------------------------------------------------------------------------
0640  Health Aid and                         772     41      2      7   40  107  252  170  136   11    4             1    1
  Technician
--------------------------------------------------------------------------------------------------------------------------------------------------------
0642  Nuclear Medicine                         4                                   2                            2
  Technician
--------------------------------------------------------------------------------------------------------------------------------------------------------
0644  Medical Technologist                   273      2                       2    2    1   50       188   8   14    5    1
--------------------------------------------------------------------------------------------------------------------------------------------------------
0645  Medical Technician                     200      1      3      5   20  100   52    7   12
--------------------------------------------------------------------------------------------------------------------------------------------------------
0646  Pathology Technician                    30                              1    1        17    5    4        2
--------------------------------------------------------------------------------------------------------------------------------------------------------
0647  Diagnostic Radiologic                  277                         5   15   73   33   45   57   36   5    6    2
  Technologist
--------------------------------------------------------------------------------------------------------------------------------------------------------
0648  Therapeutic Radiologic                  10                                   1    3    1    1    1   2         1
  Technologist
--------------------------------------------------------------------------------------------------------------------------------------------------------
0649  Medical Instrument Technician          168                             10    9   28   29   57   27   8
--------------------------------------------------------------------------------------------------------------------------------------------------------
0651  Respiratory Therapist                   12                             10              1         1
--------------------------------------------------------------------------------------------------------------------------------------------------------
0660  Pharmacist                             800    831                                      2         3      255  147   12               Trainees: 272
--------------------------------------------------------------------------------------------------------------------------------------------------------
0661  Pharmacy Technician                    483     12            15   66   71  192  123    3    1
--------------------------------------------------------------------------------------------------------------------------------------------------------
0662  Optometrist                            190    134                                                             24   26   4      2    Trainees: 127
--------------------------------------------------------------------------------------------------------------------------------------------------------
0664  Restoration Technician                   2      1                                                1
--------------------------------------------------------------------------------------------------------------------------------------------------------


                     Monthly Distinct Employee for Non-Med Resident, GAIN, VHA (Occupation Name), January-September 2007--Continued
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                            All
                                           Grade    0      1      2     3    4    5    6    7    8    9   10   11   12   13  14    15         Notes
--------------------------------------------------------------------------------------------------------------------------------------------------------

0665  Speech Pathology and-------------------245----158-----  -----  ---  ---  ---  ---  ---  ---  ---12--  ---15---58----1--  ------1----Trainees: 135-
  Audiology
--------------------------------------------------------------------------------------------------------------------------------------------------------
0667  Orthotist and Prosthetist               29      6                            2         3         2       12    3    1
--------------------------------------------------------------------------------------------------------------------------------------------------------
0668  Podiatrist                             110     63                                                              1   18  12     16     Trainees: 52
--------------------------------------------------------------------------------------------------------------------------------------------------------
0669  Medical Records                         33      8             1         1    1         7         8        3    3    1
  Administration
--------------------------------------------------------------------------------------------------------------------------------------------------------
0670  Health System Administration            87     32                       1    6    1   16        28                  1   1      1
--------------------------------------------------------------------------------------------------------------------------------------------------------
0671  Health System Specialist                49                                             2        11        9   16    7   4
--------------------------------------------------------------------------------------------------------------------------------------------------------
0672  Prosthetic Representative                7                                   1         2         2        2
--------------------------------------------------------------------------------------------------------------------------------------------------------
0673  Hospital Housekeeping                    9                                   2                            1    4    2
  Management
--------------------------------------------------------------------------------------------------------------------------------------------------------
0675  Medical Records Technician             140                         1    9   28   22   48   30    2
--------------------------------------------------------------------------------------------------------------------------------------------------------
0679  Medical Support                        906      1      2      4    4  183  683   26    1    2
  Assistance
--------------------------------------------------------------------------------------------------------------------------------------------------------
0680  Dental Officer                          76                                                                                    76          Medical
                                                                                                                                         Residents: 188
--------------------------------------------------------------------------------------------------------------------------------------------------------
0681  Dental Assistant                       139                         5    7   93   32    2
--------------------------------------------------------------------------------------------------------------------------------------------------------
0682  Dental Hygiene                          14                                   1             10    3
--------------------------------------------------------------------------------------------------------------------------------------------------------
0683  Dental Laboratory Aid                   17                              1    3         2    7    4        4    9    5
  and Technician
--------------------------------------------------------------------------------------------------------------------------------------------------------
0690  Industrial Hygiene                      22
--------------------------------------------------------------------------------------------------------------------------------------------------------
0699  Medical and Health Student            1262   1069            22   33  120   10    1    6         1                                   Trainees: 42
  Trainee
--------------------------------------------------------------------------------------------------------------------------------------------------------
TOTAL                                      20098
--------------------------------------------------------------------------------------------------------------------------------------------------------

                        QUESTIONS FOR THE RECORD

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                   October 19, 2007
Jeffrey L. Newman, PT
Chief, Physical Therapy Department
Minneapolis VA Medical Center
117 D One Veterans Drive
Minneapolis, MN 55417

Dear Mr. Newman:

    Thank you for testifying before the U.S. House of Representatives 
Committee on Veterans' Affairs Subcommittee on Health at the hearing on 
``Healthcare Professionals--Recruitment and Retention'' held on October 
18, 2007.
    Please provide answers to the following questions to Chris Austin, 
Executive Assistant to the Subcommittee on Health, by December 4, 2007.

General Challenges--There is currently a shortage of medical 
professionals in the United States. As new graduates enter the 
workforce, they are making choices about where they want to work.

      What types of tools do you think would be most effective 
in recruiting and retaining a high-quality workforce?
      We know that many healthcare professionals under age 40 
are ``very unsatisfied'' with working at the VA. Why do you think this 
is? What can the VA do to improve this situation?

    Again, thank you for your testimony. The Subcommittee looks forward 
to receiving your responses by December 4, 2007.

            Sincerely,
                                                 MICHAEL H. MICHAUD
                                                           Chairman

                               __________
                              American Physical Therapy Association
                                                    Alexandria, VA.
                                                   December 3, 2007
Hon. Michael H. Michaud
Chairman, Subcommittee on Health
House Veterans' Affairs Committee
335 Cannon House Office Building
Washington, DC 20515

Dear Chairman Michaud and Members of the Subcommittee on Health:

    Thank you for the opportunity to present testimony at the House 
Veterans' Affairs Committee, Subcommittee on Health's hearing on 
``Healthcare Professionals--Recruitment and Retention'' held on October 
18, 2007. I appreciated the opportunity to answer your questions during 
the hearing and am happy to respond to your additional written 
questions. As I mentioned during the hearing, I hope that physical 
therapists in the future have the opportunity to have a long, 
fulfilling career serving our Nation's veterans as I have had over the 
past 30 years as a physical therapist in the Department of Veterans 
Affairs (VA). As you know from testimony at the hearing, there are many 
challenges to meet in order for that to be possible.

Question 1: What types of tools do you think would be most effective in 
recruiting and retaining a high-quality workforce?

    Our number one obstacle to recruiting and retaining physical 
therapists to serve in the Veterans Administration are the severely 
outdated qualification standards. I appreciate your leadership in 
supporting the revision of these standards to make them more in line 
and competitive with settings outside of the VA. The immediate approval 
of qualification standards for physical therapist would be the most 
effective tool to ensuring that the VA retains and is able to recruit 
physical therapists to meet the increasing demand for physical therapy 
in the VA. In addition to the immediate revision of the qualification 
standards (which currently hinder recruitment and retention by not 
recognizing the current minimal education standards and restricting the 
career ladder of physical therapists in the VA), the following tools or 
initiatives would be helpful in recruiting and retaining a high quality 
physical therapist workforce:
Recruitment & Retention

Initiatives to encourage young returning veterans to become healthcare 
providers in the VA system

    As you noted in a question during the hearing, young returning 
veterans who have an interest in healthcare offer us a huge opportunity 
to help meet the current and future need for healthcare professionals 
to serve in the VA. I have personally witnessed several young men and 
women who have volunteered at my facility in Minneapolis and who have 
been moved by the experience of helping their fellow veterans and have 
then chosen to go on and get their degree in physical therapy. As you 
know, many of today's returning veterans are young--some are Reservists 
or National Guard members who may have joined to help pay for college. 
Offering veterans scholarships, finance assistance or loan repayment to 
pursue a physical therapist degree program would provide an opportunity 
to enhance healthcare in the VA. These initiatives would provide 
veterans the opportunity to serve as healthcare providers who have a 
unique understanding of the battlefield and the ability to relate to a 
fellow veteran. An initiative to specifically recruit returning 
veterans into healthcare careers has the potential to be an untapped 
resource for the VA and provide a great incentive for returning 
veterans to make an impact in improving healthcare for their 
colleagues.

Improving current VA scholarship programs

    As noted in my testimony, enhancements to the current VA 
scholarship programs for physical therapists will help recruitment and 
retention. Many new graduates are concerned with a high amount of 
student loan debt when leaving school, and scholarship and loan 
repayment programs are an important tool in recruiting physical 
therapists to meet the VA's need. A specific program for physical 
therapists is needed to meet the growing demand for rehabilitation 
among our aging veterans and those returning from current conflicts.
    I had the opportunity to serve on the Committee to review 
scholarship program applicants in the early nineties when the VA had--
in my opinion--a very successful scholarship incentive program to 
attract new graduates. I had several recipients at my facility--several 
of whom chose to stay beyond their required amount of service. The 
previous scholarship program provided an incentive to serve right out 
of school, whereas the new incentive program including the Education 
Debt Reduction Program and the Employee Incentive Scholarship Program 
are poorly advertised and cumbersome for the potential applicants. A 
targeted program to promote the current programs and a specific 
strategy to enhance scholarship programs would assist in recruiting and 
retaining physical therapists in the VA.
    Another prominent reason physical therapists leave the VA is to 
pursue a higher degree. Unfortunately the current structure does not 
recognize the physical therapists who have achieved their doctor of 
physical therapy (DPT) or advanced degree. Revising the physical 
therapist qualification standards to recognize the DPT would help the 
VA keep pace with the physical therapy field and other employers. 
Another tool would be incentives to allow physical therapists to seek 
advanced degrees while employed in the VA. Programs to assist 
financially or with flexible work arrangements to encourage advanced 
study would be an asset to physical therapists employed in the VA.

Improving VA Employee Benefits Packages
Continuing education credits
    It is also important for recruitment initiatives to include easily 
accessible funds for continuing education credits. Jobs that freely and 
openly offer support for employees to attend continuing education 
classes and strongly encourage their employees to attend these courses 
will attract and retain physical therapists. The VA had a program that 
ended in 2003 that allowed continuing education funds to be allocated 
to professions that had documented recruitment and retention problems, 
such as physical therapy. The current funding is not distributed in 
this way and is allocated to each VA service line, therefore putting 
professions who are experiencing recruitment and retention challenges 
in the same category as other professions competing for continuing 
education funding.
Promote immediate implementation of on-call float pools
    Clinic managers should be able to cover unplanned leave with an on-
call pool of qualified therapists/assistants. The current system 
burdens staff to absorb workload of those individuals on emergency 
absence. When we are already facing a shortage of physical therapists, 
asking those currently employed to just keep ``doing more with less'' 
is not an acceptable scenario for either the provider or the patients 
we serve.
Flex tours and other benefits
    Allow staff to determine a schedule that best suits the agency 
mission and personal need. VHA is not and should not be an 8:00 am to 
4:30 pm operation any longer. To be competitive with the private 
sector, it is also important to offer VA employees benefit packages 
that can compete with options such as maternity leave and healthcare 
benefit packages for employees.

Question 2:

    We know that many healthcare professionals under age 40 are ``very 
unsatisfied'' with working at the VA. Why do you think this is? What 
can the VA do to improve this situation?
    For physical therapists, I believe part of this could be due to the 
qualification standards for physical therapists being severely out of 
date. They do not currently allow experienced physical therapist 
clinicians enough of an opportunity to move up the career ladder. It is 
also understandable for an employee who has gone on to receive 
specialist certification or their Doctorate of Physical Therapy (DPT) 
degree to be disappointed not to be recognized for their additional 
investment in their education. Physical therapy, like many other 
healthcare professions, is a dynamic field and it is vital for 
practitioners to continue to seek the best evidence and training to 
meet their patients' needs. Recognizing those physical therapists who 
have received additional training is especially critical considering 
the veteran population, some who have complex impairments such as 
amputations and traumatic brain injuries. The VA can immediately 
implement revised qualification standards for physical therapists to 
improve this situation. Revising the qualification standards would 
provide opportunities for advancement and help make salaries 
competitive with other professions with equal educational requirements. 
This would be the best strategy to reverse the current job satisfaction 
rating among professionals under 40 years of age.
    Other factors important to many employees--especially younger 
employees--are mentorship programs. Formal mentoring programs that pair 
a younger healthcare professional with an experienced leader in the 
field could improve satisfaction and also provide prospective employees 
the opportunity to practice in clinical centers of excellence.
    Thank you again for the opportunity to testify at the hearing. I 
look forward to continuing to be a resource for you, your staff and the 
entire Committee on issues impacting physical therapists and the 
veterans we have the opportunity to care for. If you need additional 
information or have further questions, please feel free to contact me 
at [email protected] or 612-467-3071 or Rachel Reiter in the 
Congressional Affairs department at the American Physical Therapy 
Association at [email protected] or 703-706-8548.

            Sincerely,
                                              Jeffrey L. Newman, PT
                      Member, American Physical Therapy Association
  Chief, Physical Therapy Department, Minneapolis VA Medical Center

                                 
                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                   October 19, 2007
Richard D. Krugman, M.D.
Dean
University of Colorado
Health Science Center School of Medicine
4200 East Ninth Avenue, Box C-290
Denver, CO 80262

Dear Dr. Krugman:

    Thank you for testifying before the U.S. House of Representatives 
Committee on Veterans' Affairs Subcommittee on Health at the hearing on 
``Healthcare Professionals--Recruitment and Retention'' held on October 
18, 2007.
    Please provide answers to the following questions to Chris Austin, 
Executive Assistant to the Subcommittee on Health, by December 4, 2007.

General Challenges--There is currently a shortage of medical 
professionals in the United States. As new graduates enter the 
workforce, they are making choices about where they want to work.

      What types of tools do you think would be most effective 
in recruiting and retaining a high-quality workforce?
      We know that many healthcare professionals under age 40 
are ``very unsatisfied'' with working at the VA. Why do you think this 
is? What can the VA do to improve this situation?

    Again, thank you for your testimony. The Subcommittee looks forward 
to receiving your responses by December 4, 2007.

            Sincerely,
                                                 MICHAEL H. MICHAUD
                                                           Chairman

                               __________
                                             University of Colorado
                           Health Science Center School of Medicine
                                                        Denver, CO.
                                                   December 4, 2007
The Honorable Michael Michaud
Chair, Subcommittee on Health
Committee on Veterans' Affairs
United States House of Representatives
335 Cannon House Office Building
Washington, DC 20515

Dear Mr. Chairman:

    The following is in response to your questions regarding my October 
18, 2007, testimony on ``Healthcare Recruitment and Retention at the 
U.S. Department of Veterans Affairs'' before the House Veterans' 
Affairs Subcommittee on Health.

General Challenges--There is currently a shortage of medical 
professionals in the United States. As new graduates enter the 
workforce they are making choices about where they want to work.

    What types of tools do you think would be most effective in 
recruiting and retaining a high-quality workforce?

    The United States will face a serious doctor shortage in the next 
few decades. As this shortage comes to fruition, the VA will likely 
have an even more difficult time competing with their private 
counterparts for both new and more tenured physicians. With difficulty 
recruiting health professions, the VA can be likened to the rural and 
urban areas, population groups, or medical facilities designated as 
``underserved'' by the U.S. Department of Health and Human Services. 
Programs under the Health Resources and Services Administration (HRSA) 
are effective tools in recruiting and retaining a high-quality health 
professions workforce.
    HRSA manages several programs authorized by Title VII of the Public 
Health Service Act that recruit students to careers in health 
professions and subsequently direct health professionals to underserved 
areas. There could be an opportunity for the VA to collaborate with 
HRSA programs such as the Title VII Centers of Excellence (COE), Health 
Career Opportunities Program (HCOP), and Area Health Education Centers 
(AHECs) to increase recruitment of health professions to the VA. 
However, a dramatic 50 percent cut of the Title VII appropriations in 
FY 2006 continues to threaten the ability of these programs to fulfill 
their missions.
    The National Health Service Corps (NHSC) has a proven track record 
of expanding access for underserved populations by supplying physicians 
to federally designated shortage areas. The NHSC provides scholarship 
and loan forgiveness awards in exchange for service in qualifying 
``health professions shortage areas'' (HPSAs). After five years of 
service, the majority of physicians are able to forgive their entire 
educational debt. Similarly, the VA's Education Debt Reduction Program 
(EDRP) provides newly appointed VA healthcare professionals with 
educational loan repayment awards. However, the EDRP is limited to 
$44,000 spread out over five years of service. As the average medical 
education indebtedness has climbed to over $140,000 in 2007, the 
limited EDRP awards fail to provide an adequate incentive for most 
physicians.
    The VA Medical and Prosthetic Research Program plays an integral 
role in recruiting physicians to the VA. The VA research program is 
exclusively intramural; that is, only VA employees holding at least a 
five-eighths salaried appointment are eligible to receive VA awards. 
Unlike other federal research agencies, VA does not make grants to any 
non-VA entities. As such, the program offers a dedicated funding source 
to attract and retain high-quality physicians and clinical 
investigators to the VA healthcare system.
    State-of-the-art research requires state-of-the-art technology, 
equipment, and facilities. Such an environment promotes excellence in 
teaching and patient care as well as research. It also helps VA recruit 
and retain the best and brightest clinician scientists. In recent 
years, funding for the VA medical and prosthetics research program has 
failed to provide the resources needed to maintain, upgrade, and 
replace aging research facilities. Many VA facilities have run out of 
adequate research space. Ventilation, electrical supply, and plumbing 
appear frequently on lists of needed upgrades along with space 
reconfiguration. Under the current system, research must compete with 
other facility needs for basic infrastructure and physical plant 
support that are funded through the minor construction appropriation.
    To ensure that funding is adequate to meet both immediate and long 
term needs, the AAMC recommends an annual appropriation of $45 million 
in the VA's minor construction budget dedicated to renovating existing 
research facilities and additional major construction funding 
sufficient to replace at least one outdated facility per year to 
address this critical shortage of research space.

    We know that many healthcare professionals under age 40 are ``very 
unsatisfied'' with working at the VA. Why do you think this is? What 
can VA do to improve the situation?

    Until the early 1990s, the VA healthcare system was seen as 
substandard and physicians that worked there were viewed as second 
rate. Today, VA healthcare is touted for its remarkable transformation 
and has been rated higher by the American Customer Satisfaction Index 
than its private counterparts. Unfortunately, an unjustified stigma of 
VA employment remains in the physician community, if only at a 
subconscious level. While this may only be prevalent in more seasoned 
physicians, under their mentorship this impression still manages to 
trickle down to new physicians as they enter the field.
    A crucial tool in reversing the negative impression of VA 
employment is exposing young physicians to the new quality associated 
with VA healthcare. In a 2007 Learners Perceptions Survey, the VA 
examined the impact of training at the VA on physician recruitment. 
Before training at the VA, 21 percent of medical students and 27 
percent of medical residents indicated they were very or somewhat 
likely to consider VA employment after VA training. After training at 
the VA, these numbers grew to 57 percent of medical students and 49 
percent of medical residents.
    The VA plans to increase its support for GME training, adding an 
additional 2,000 positions for residency training over five years, 
restoring VA-funded medical resident positions to 10 to 11 percent of 
the total GME in the United States. The expansion began in July 2007 
when the VA added 342 new positions. These training positions address 
the VA's critical needs and provide skilled healthcare professionals 
for the entire Nation. The additional residency positions also 
encourage innovation in education that will improve patient care, 
enable physicians in different disciplines to work together, and 
incorporate state-of-the-art models of clinical care--including VA's 
renowned quality and patient safety programs and electronic medical 
record system. Phase 2 of the GME enhancement initiative has generated 
applications for 411 new resident positions to be created in July 2008.
    There is some evidence that the VA will become a more competitive 
employer with future generations of physicians. Initial research into 
the practice decisionmaking of new physicians indicates that new 
physicians favor ``employee settings'' to traditional practice 
settings. However, VA will have to overcome difficulties inherent in 
government agencies to compete with other sectors. The draw of 
``employee'' practice settings is spurred by new physicians' desire for 
having fewer nights and weekends on call, a decrease in administrative 
work (particularly dealing with insurance companies), access to state-
of-the-art medical care resources and an electronic medical record and 
linkages to academia and research. These factors can outweigh the draw 
of the large salaries available in the private practice setting. This 
is an area in which hopefully the Veterans Health Administration and 
the academic medical education community through the AAMC can work 
together and make some progress.
    Thank you again for the opportunity to testify on this important 
issue.

            Sincerely,
                                           Richard D. Krugman, M.D.
                                                               Dean

                                 

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                   October 19, 2007
Jim Bender
CACI
650 Washington Road
6th Floor
Pittsburgh, PA 15228

Dear Mr. Bender:

    Thank you for testifying before the U.S. House of Representatives 
Committee on Veterans' Affairs Subcommittee on Health at the hearing on 
``Healthcare Professionals--Recruitment and Retention'' held on October 
18, 2007.
    Please provide answers to the following questions to Chris Austin, 
Executive Assistant to the Subcommittee on Health, by December 4, 2007.

General Challenges--There is currently a shortage of medical 
professionals in the United States. As new graduates enter the 
workforce, they are making choices about where they want to work.

      What types of tools do you think would be most effective 
in recruiting and retaining a high-quality workforce?
      We know that many healthcare professionals under age 40 
are ``very unsatisfied'' with working at the VA. Why do you think this 
is? What can the VA do to improve this situation?

    Again, thank you for your testimony. The Subcommittee looks forward 
to receiving your responses by December 4, 2007.

            Sincerely,
                                                 MICHAEL H. MICHAUD
                                                           Chairman
                               __________
                       CACI Response to Questions
                     from Oct. 18, 2007 Hearing on
          Healthcare Professionals--Recruitment and Retention
                CACI, Strategic Communications Division

                            December 4, 2007

             Point of Contact: Deborah Lee, Project Manager
QUESTION 1 & 2 CONTEXT

    There is currently a shortage of medical professionals in the 
United States. As new graduates enter the workforce, they are making 
choices about where they want to work.

QUESTION 1

    What types of tools do you think would be most effective in 
recruiting and retaining a high-quality workforce?

RESPONSE 1

    CACI's recommendations for recruiting healthcare professionals are 
outlined in detail in the July 2006 study titled ``Pilot Program to 
Study Innovative Recruitment Tools to Address Nursing Shortages at 
Department of Veterans Affairs.'' The report identified 18 
recommendations within seven major recruitment marketing categories. A 
subset of those recommendations is listed below:

        1.  Interactive Media

                a.  Implement regular email communication of open 
                positions: More than 5,000 individuals responded to an 
                email blast promoting the availability of hard-to-fill 
                nursing positions, the highest response of all pilot 
                program advertising tactics. The high number of 
                responses and the reasonable cost of email also 
                resulted in the lowest cost-per-lead. Automated email 
                communications were also used to send alerts of new job 
                postings to 333 people who signed up for this service 
                on the pilot program Web page. Seventy people also 
                chose to send the pilot program Web page address to a 
                friend via the automated email link provided on the 
                site. VA is pursuing this recommendation with multiple 
                email campaigns over the past year that promote hard-
                to-fill occupations and include send-to-a-friend 
                functionality.
                b.  Use Internet job postings: Internet job sites have 
                replaced newspapers as the preferred source of job 
                leads. The pilot study's Internet job postings resulted 
                in the second highest number of trackable leads and the 
                second lowest cost-per-lead. VA actively uses Internet 
                job postings for hard-to-fill job openings, and it is 
                augmenting this effort by integrating USAJOBS search 
                functionality into the VACareers job site.
                c.  Design and launch an automated system to allow all 
                VACareers visitors to register for notification when 
                new jobs are posted: The pilot program gave all 
                visitors who responded to pilot program media the 
                opportunity to register to be notified of new job 
                postings. A total of 333 registered, indicating a 
                market preference for automated email alerts. This 
                recommendation is being pursued through a redesign of 
                VACareers and integration of USAJOBS email notification 
                functionality.
                d.  Provide ``send to a friend'' email functionality on 
                all job postings: Seventy visitors took advantage of 
                the ``send to a friend'' button to alert friends or 
                relatives of jobs available at VA. The cost of the 
                functionality is nominal, resulting in a very strong 
                return on investment. The redesign of VACareers and the 
                partnership with USAJOBS are addressing this 
                recommendation.
                e.  Promote the most difficult-to-fill positions with a 
                graphic logo on the VACareers home page: About 10 
                percent of the people who viewed the VACareers home 
                page, regardless of place of residence or visiting 
                intent, clicked on a graphically designed logo 
                promoting positions in the pilot area, North Florida/
                South Georgia (NF/SG). Difficult-to-fill positions are 
                promoted on the new VACareers site in a section 
                entitled Careers in Demand. This section will be 
                promoted on the home page of VACareers when Phase 2 
                upgrades go live.

        2.  Employer Branding

                a.  Continue to focus on employee benefits and quality 
                care: Focus groups have demonstrated that the decision 
                criteria used most by non-VA employees are employee 
                benefits (e.g., child care, education support, and paid 
                days off) and quality care. The current tagline (The 
                Best Care/The Best Careers) reflects those messages. VA 
                actively abides by these principles in all current 
                recruitment marketing.
                b.  Segment market and speak directly to the unique 
                needs and concerns of each segment (e.g., student 
                nurses, military nurses, male and minority nurses, 
                clinical specialties, etc.): This pilot program focused 
                its attention on experienced nurses. Previous focus 
                group research revealed that experienced private sector 
                nurses suffer a great deal of dissatisfaction from the 
                private sector's ``big business'' approach to 
                healthcare. The primary advertisements in the pilot 
                program communicated VA's answer to the nurses' 
                concern. The headline read, ``Patient Care Is Not a 
                Business Decision.'' The response to the message, 
                10,261 direct visits to VACareers, confirms the 
                research and underscores the importance of talking to 
                each segment's unique needs and concerns. VA is 
                implementing this recommendation. Each of VA's 
                strategic recruitment marketing plans over the past two 
                years has incorporated focus group research and a 
                market segmentation strategy based on that research, to 
                include segmented email blasts, print ads, and Web 
                content.
                c.  Raise community awareness with Public Relations 
                efforts: Public Relations efforts focused on ``The Best 
                Care/The Best Careers'' message can help reverse old, 
                negative stereotypes that may exist concerning VA's 
                career opportunities and quality of care. These efforts 
                have resulted in numerous positive press articles about 
                VA over the last couple of years.
                d.  Establish employer branding at the national level: 
                In order to keep the employer branding message 
                consistent across all VA facilities nationwide, every 
                facility should adopt the national VHA brand (The Best 
                Care/The Best Careers) in all recruitment promotional 
                activities. VA has pursued this recommendation by 
                making all recruitment ads, brochures, and exhibit 
                displays available to local recruiters via the VHA 
                Healthcare Recruiters' Toolkit Web site.

        3.  Database Marketing

                a.  Nurture relationships with applicants who are 
                qualified but not appointed: Qualified applicants who 
                have already shown an interest in VA remain strong 
                candidates for future employment. The pilot program 
                originally included a direct mail campaign to reengage 
                qualified job applicants who were not offered the first 
                position for which they applied. However, the campaign 
                was not executed due to the lack of a database with 
                pertinent applicant data.

        4.  Relationship Building

                a.  Build relationships with nursing schools: NF/SG 
                does not have difficulty hiring student nurses. This is 
                because the Malcom Randall VA Medical Center is located 
                in very close proximity to the University of Florida. 
                Student nurses from the university are well aware of 
                the opportunities at VA and many complete their 
                training through VA. Although the health system has a 
                distinct geographic advantage over other VA health 
                systems, its relationship with nursing students and its 
                full quota of young nurses testifies to the importance 
                of nurturing relationships with nursing schools. VA 
                currently has hundreds of academic affiliations with 
                nursing, pharmacy, medical, and allied health schools 
                around the country, with more than 100,000 students 
                rotating through the VA system every year. Programmatic 
                relationship-building activities include the VA Nursing 
                Academy (now in pilot stage) and the VA Learning 
                Opportunities Residency (VALOR) Program.
                b.  Conduct regular Open House events: An Open House 
                event was conducted during the pilot program that 
                allowed visiting nurses the opportunity to meet and 
                talk with VA RNs at several dedicated discussion 
                booths, including: VA Benefits, Current Opportunities, 
                Applications, and VA Technology. Interested attendees 
                were also invited to take a guided personal tour of the 
                facilities and interview with a hiring manager. The 
                promotion for the Open House event attracted 65 
                experienced nurses to the doorstep of the Malcom 
                Randall VA Medical Center. From these 65 candidates, 13 
                people were selected at the conclusion of the pilot 
                (20% of attendees and 20.3% of all new hires during the 
                pilot period), with more applications pending. These 
                numbers illustrate the importance of having interested 
                candidates visit VA facilities and meet with recruiters 
                to learn more about what VA has to offer. Names and 
                other information were collected from attendees so that 
                NF/SG recruiters may use this information to follow up 
                or to use for future marketing initiatives. Open houses 
                are happening regularly at VA facilities nationwide. 
                HRRO is supporting these efforts via an event planner 
                on the VHA Healthcare Recruiters' Toolkit, as well as 
                with national recruitment brochures and banner stands.

        5.  Employee Referral Program

                a.  Create and promote employee referral programs: 
                According to VA Entrance Survey results for FY04 
                through First Quarter FY06, more new employees (34.9 
                percent of females and 32.5 percent of males) learned 
                about VA through current employees than through any 
                other source. The original pilot design included the 
                creation and promotion of a referral program to test 
                the ability of such a program to increase the number of 
                referrals from employees. However, the program was not 
                approved until the last week of the pilot program and 
                therefore could not be implemented at that time. VA 
                facilities should continue efforts to revamp employee 
                referral programs and look for innovative, creative 
                ways to compensate employees for referring friends and 
                colleagues, such as offering Employee of the Month 
                recognition, a special parking place, or paid 
                enrollment in a CEU activity. VA has taken steps over 
                the past two years to promote employee referrals via 
                facility posters, banner stands, and other promotional 
                material.

        6.  Recruitment Budgeting

                a.  Create a funding source for recruitment marketing 
                that is linked to an approved recruitment plan and 
                managed at the recruiter level: Before the pilot study, 
                nurse recruiters at NF/SG did not have a budget for 
                nurse recruiting. Each expenditure, from single 
                newspaper advertisements to recruitment functions, 
                required approval obtained through a cumbersome, slow 
                process. The result was that nurse recruiters were 
                unable to execute their mission with the speed and 
                agility required to compete in a very competitive 
                recruitment market. Since the pilot study, a request 
                for a dedicated nurse recruitment budget has been 
                approved. Outside of NF/SG, the availability of a 
                dedicated recruitment budget is mixed.

QUESTION 2

    We know that many healthcare professionals under age 40 are ``very 
unsatisfied'' with working at VA. Why do you think this is? What can VA 
do to improve this situation?

RESPONSE 2

    CACI is unaware of the conditions addressed in this question. 
Furthermore, the improvement of employee moral is an interdepartmental 
activity that goes beyond the boundaries of CACI's specialty, which is 
recruitment marketing.

                                 

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                   October 19, 2007
Joseph L. Wilson
Assistant Director for Health Policy
Veterans Affairs and Rehabilitation Commission
American Legion
1608 K Street, N.W.
Washington, D.C. 20006

Dear Mr. Wilson:

    Thank you for testifying before the U.S. House of Representatives 
Committee on Veterans' Affairs Subcommittee on Health at the hearing on 
``Healthcare Professionals--Recruitment and Retention'' held on October 
18, 2007.
    Please provide answers to the following questions to Chris Austin, 
Executive Assistant to the Subcommittee on Health, by December 4, 2007.

1. Academic Affiliations--Several witnesses stated that one of the most 
effective recruitment tools the VA has is its academic affiliations 
because they capture students while they are still training.

      What can the VA do to strengthen their academic 
affiliations?
      What other tools can the VA use to recruit newly trained 
healthcare providers?

2. Future Needs--Recently the VA has had difficulty recruiting and 
retaining healthcare professionals such as nurses and pharmacists.

      What is the greatest recruitment challenge facing the VA 
right now? What healthcare professions are in the shortest supply?
      Looking into the future, what challenges does the VA 
anticipate facing in 10 years? 20 years?

    Again, thank you for your testimony. The Subcommittee looks forward 
to receiving your responses by December 4, 2007.

            Sincerely,
                                                 MICHAEL H. MICHAUD
                                                           Chairman

                               __________
                                                The American Legion
                                                    Washington, DC.
                                                   December 4, 2007
Honorable Michael Michaud, Chairman
Subcommittee on Health
U.S. House of Representatives
335 Cannon House Office Building
Washington, DC 20515-6335

Dear Mr. Congressman Michaud:

    Thank you for allowing The American Legion to participate in the 
Committee hearing on the ``Health Care Professionals--Recruitment and 
Retention'' on October 18, 2007. I am pleased to respond to your 
specific questions concerning that hearing:

1. Academic Affiliations. Several witnesses stated that one of the most 
effective recruitment tools the VA has its academic affiliations 
because they capture students while they are training.

                a.  What can the VA do to strengthen their academic 
                affiliations?

    The American Legion believes that VA medical school affiliates 
should be appropriately represented as a stakeholder on any national 
Task Force, Commission, or Committee established to deliberate on 
veterans health care.

                b.  What other tools can the VA use to recruit newly 
                trained health care providers?

    The American Legion concurs that other effective tools the VA can 
utilize to recruit newly trained health care providers, to include the 
continuous effort in striving to develop an effective strategy, such as 
competitive benefits, to retain quality health care providers.

2. Future Needs. Recently the VA has had difficulty recruiting and 
retaining health care professionals such as nurses and pharmacists.

                a.  What is the greatest recruitment challenge facing 
                the VA right now? What health care professions are in 
                the shortest supply?

    The American Legion believes the greatest recruitment challenge 
currently facing the VA is adequate funding which would allow VA to 
offer employee benefits comparable to the private sector.
    Currently, there is a physician and nursing shortage within the VA.

                b.  Looking into the future, what challenges does the 
                VA anticipate facing in 10 years? 20 years?

    The American Legion believes the greatest challenge faced by the VA 
in 10 years include a shortage of physicians and nurses nationwide, 
which would stagnate quality care and treatment to veterans. Due to a 
shortage, there would be the probability of complacency amongst 
physicians and nurses, which would be due in part to working 
overwhelming hours, in addition to an increase in patients.
    Due to the declination of medical school enrollment and anticipated 
increase in retirement of physicians (250,000) by 2025, the shortage 
would obviously become worse in 20 years, which would continue to 
affect quality care and treatment to veterans.
    Thank you once again for all of the courtesies provided by you and 
your capable staff. The American Legion welcomes the opportunity to 
work with you and your colleagues on many issues facing veterans and 
their families throughout this Congress.

            Sincerely,
                                          Steve Robertson, Director
                                    National Legislative Commission

                                 
                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                   October 19, 2007
Joy J. Ilem
Assistant National Legislative Director
Disabled American Veterans
807 Maine Avenue, S.W.
Washington, DC 20024-2410

Dear Ms. Ilem:

    Thank you for testifying before the U.S. House of Representatives 
Committee on Veterans' Affairs Subcommittee on Health at the hearing on 
``Healthcare Professionals--Recruitment and Retention'' held on October 
18, 2007.
    Please provide answers to the following questions to Chris Austin, 
Executive Assistant to the Subcommittee on Health, by December 4, 2007.

1. Academic Affiliations--Several witnesses stated that one of the most 
effective recruitment tools the VA has is its academic affiliations 
because they capture students while they are still training.

      What can the VA do to strengthen their academic 
affiliations?
      What other tools can the VA use to recruit newly trained 
healthcare providers?

2. Future Needs--Recently the VA has had difficulty recruiting and 
retaining healthcare professionals such as nurses and pharmacists.

      What is the greatest recruitment challenge facing the VA 
right now? What healthcare professions are in the shortest supply?
     Looking into the future, what challenges does the VA 
anticipate facing in 10 years? 20 years?

    Again, thank you for your testimony. The Subcommittee looks forward 
to receiving your responses by December 4, 2007.

            Sincerely,
                                                 MICHAEL H. MICHAUD
                                                           Chairman

                               __________
  POST-HEARING QUESTIONS FOR JOY ILEM, ASSISTANT NATIONAL LEGISLATIVE 
              DIRECTOR OF THE DISABLED AMERICAN VETERANS,
           TO THE U.S. HOUSE OF REPRESENTATIVES COMMITTEE ON
               VETERANS' AFFAIRS, SUBCOMMITTEE ON HEALTH,
  AT THE HEARING ON HEALTHCARE PROFESSIONALS RECRUITMENT AND RETENTION
QUESTION: Academic Affiliations--several witnesses stated that one of 
the most effective recruitment tools the VA has is its academic 
affiliations because they capture students while they are still 
training.

      What can the VA do to strengthen their academic 
affiliations?
      What other tools can the VA use to recruit newly trained 
healthcare providers?

RESPONSE:

    DAV is pleased to provide our perspective on these questions. The 
VA's affiliations programs were inaugurated after World War II by 
visionary VA leaders. They foresaw the wisdom and value in linking 
post-war VA hospitals to State schools of medicine through affiliation 
agreements. That model of mutual cooperation has served VA and veterans 
well for over 50 years, and it helped to train several new generations 
of physicians for the whole Nation. In the mid-nineties, VA shifted its 
healthcare delivery system from hospitalization to primary care, and 
simultaneously VA created and empowered its Network management to 
coordinate nearly all functions except national policies. Until the 
advent of the Veteran Integrated Services Networks (VISNs), VA 
hospitals (now called VA medical centers [VAMCs]) and their affiliated 
medical schools were the locus of actions, decisions and relationship 
building, through their firmly established Dean's Committees under 
title 38 United States Code Sec. 7313.
    Through the Dean's Committee relationship both VA and affiliates 
benefited from the conjoined missions of caring for sick and disabled 
veterans and educating America's health professions. However, an 
unintended consequence of the advent of the VISNs was to have distilled 
that classic one-to-one relationship of a VA hospital to a school of 
medicine. This metamorphosis contributed to a shifting of the schools' 
focus away from the Dean's Committee system at the local level, to the 
Network office, since the key decisions affecting the medical centers 
are made at the Network level--not by the individual medical center 
director. As a result, the Dean's Committees no longer function as 
originally designed: As a result, they are not powerful advisory bodies 
governing two close affiliates, each aimed at a common purpose. Most of 
VA's affiliates are components of State universities, but Network 
offices are often located in different States from those of the 
schools, or in distant cities. Decision makers in those offices are 
often remote and uninvolved in local VAMC activities. Negotiations 
important to the affiliates (and to their VAMCs) are made much more 
problematic in this kind of environment. Today there is more 
variability in VA affiliations throughout the healthcare system than 
ever before. Most of the original spirit of affiliation ``agreements'' 
has devolved into a form of contract management. The Networks face 
challenges at a global level, involving major allocation of resources 
among competing programs and facilities, human resource, strategic 
planning, construction management, planning issues, and other large 
scale matters. At times they do not fully appreciate the environment of 
an associated VA facility and its affiliate.
    The VA has adopted a broad system of performance measures and 
quality indicators. These techniques are used within the system for 
management, and serve as one of the bases for VA's major quality 
improvements seen over the past dozen years. While VA has established a 
large number of measures in the clinical arena, what performance 
measures have been established for its academic and research missions? 
Do we know today on any measureable basis what VA locally, regionally 
or nationally expects from its academic affiliations, and how that 
expectation relates to VA's needs and plans? What are the metrics VA 
would use to determine those needs? How are they evaluating the 
experiences of medical students and residents who progress through 
those affiliations and may consider VA as a career option? Without some 
benchmark or measurement system, VA cannot position itself to take full 
advantage of its affiliations as a basis for staff recruitment. We 
believe that VA could strengthen relationships with the affiliates by 
applying the successful performance measurement policy to these 
programs. VA could create real and measurable metrics in conjunction 
with its academic partners, and thereby improve both the immediate 
relations and promote a better future for the affiliations and for VA.
    VA has a number of qualities that attract newly trained healthcare 
providers--one opportunity that is especially attractive to young 
physicians completing residency training is VA's well-established and 
proven Research Career Awards program. Unfortunately that program is 
highly dependent on available, state-of-the-art research space, 
laboratory facilities and ample equipment for use by these inquisitive 
clinician-investigators. Maintaining these programs and infrastructure 
could prove to be especially crucial to attracting future VA career 
practitioners in cardiology, gastroenterology, hematology, surgery, 
anesthesiology, and numerous other specialty fields that are otherwise 
extremely difficult for VA to recruit.
    Also, we believe that the highly stressful environment of VA 
healthcare delivery has contributed to deterioration in affiliation 
relationships. For example, we know of at least one school that has 
pulled all of its residents from VA primary care clinics because VA 
could not arrange a setting where male and female patients were 
available in sufficient numbers to support training requirements of the 
school. Also, some VA operational requirements for its physician 
workforce are difficult for residents to meet due to their other 
training and clinical responsibilities. VA facilities that are truly 
committed to affiliations should be more sensitive to their partner 
schools' needs when designing and managing clinical programs. At the 
same time, the schools need to consider VA's operating needs in 
designing the clinical practice to be observed by their students and 
residents. In absence of a more balanced relationship, sick and 
disabled veterans suffer the consequence of a lack of cooperation by a 
VA facility and its academic affiliate.
    We understand that the Veterans Health Administration (VHA) has 
established a Blue Ribbon Panel on Veterans Affairs Medical School 
Affiliations, and that the Association of American Medical Colleges 
(AAMC) has established and will be conducting a national survey of VA's 
medical school affiliations. We hope these efforts will serve to 
identify ways to further improve the relationship between VA and its 
academic affiliates, and point the way to a better future for these 
relationships. Information from those efforts could be very helpful to 
the Subcommittee as well, especially if academic affiliates fully 
participate in the process.
    Academic affiliations have played an integral role in VA healthcare 
over the years, contributing major elements to VA's noted rise in 
quality and recognition as America's best healthcare system. A current 
assessment of the needs of both the VA and its academic partners is 
timely and warranted by the Subcommittee to continue and improve these 
successful and symbiotic relationships.

QUESTION: Future Needs--Recently the VA has had difficulty recruiting 
healthcare professionals such as nurses and pharmacists.

      What is the greatest recruitment challenge facing the VA 
right now? What healthcare professions are in the shortest supply?
      Looking into the future, what challenges does the VA 
anticipate facing in 10 years? 20 years?

RESPONSE:

    VA's greatest recruitment challenge is likely the shortage the 
Nation faces as a whole for both nurses and specialty physicians. We 
often hear from VA facility sources that VA has the authority to hire 
for particular positions but are unable to identify qualified 
applicants. Additionally, VA's ability to compete with attractive 
hiring bonuses and other incentives offered routinely by private sector 
providers create unique challenges for VA. The top five ``key 
occupation challenges'' identified at a VHA Succession Planning and 
Workforce Development Nursing Conference held April 18, 2007, are:

      Registered Nurse
      Physician
      Pharmacist
      Practical Nurse
      Diagnostic Radiology Technologist

    To answer the last question about future challenges we refer the 
Subcommittee to VHA's Succession Strategic Plan for Fiscal Year (FY) 
2006-2010 which states: ``VHA faces significant challenges in ensuring 
it has the appropriate workforce to meet current and future needs. 
These challenges include continuing to compete for talent as the 
national economy changes over time, and recruiting and retaining 
healthcare workers in the face of significant anticipated workforce 
supply and demand gaps in the healthcare sector in the near future. 
These challenges are further exacerbated by an aging federal workforce 
and an increasing percentage of VHA employees who receive retirement 
eligibility each year.''
    Additionally, we continue to hear reports that use of VA's website 
for employment opportunities is cumbersome and that interested and 
qualified applicants often get bogged down in hiring practice delays 
and by other VA human resources requirements. It is our observation of 
VA that the hiring for all types of positions are treated relatively 
co-equally by human resources management. If VA's overall human 
resources management performance were judged without regard to the 
distinctions among differing elements of its workforce, VA could be 
judged to be doing a good job. However, the maintenance of a committed 
clinical workforce requires more nuanced policies, especially given the 
competitiveness of the local labor markets for experienced healthcare 
providers, and in this respect, VA's performance needs significant 
improvement. The reforms discussed earlier that were put in place by a 
former VA Under Secretary were correct in establishing performance 
metrics, but clinicians complain that in the succeeding years 
performance metrics have become additive, so that it is difficult to 
judge which performance elements are the most important. VA has issued 
a significant number of these measurements but only a minority may be 
truly meaningful to healthcare outcomes. This form of ``piling on'' has 
had a corrosive effect on VA physician morale. In a similar vein, the 
establishment of clinical reminders and so-called ``prompts'' in the 
VistA computerized patient care record system was a novel and essential 
development in improving VA quality of care; however, this, too, has 
become an additive system. Apparently no reminder or prompt is ever 
dropped from VistA. All must be responded to, whether the particular 
issue or variance from norms is significant or not. Given VA's 
tremendous primary care caseload, these kinds of tedious requirements 
are draining for both the physician and nurse workforces.
    We believe one of the biggest challenges VA faces in the next 
decade or more relates to the continuing deterioration of its capital 
infrastructure. Within that overall deficit but often overlooked are 
VA's research laboratories. The research laboratories at the 60 most 
active VA affiliations struggle to meet basic requirements for 
electrical and other energy needs, sanitation, negative-positive air 
flow separation, and other essential regulations, including human 
protections and safety regulations. Neither VA nor Congress have made 
this a priority and dedicated resources to keep these laboratories up 
to par. In recent years, several potential serious hazards in VA 
laboratories have been averted--but only on an emergency basis when 
further delay could not be tolerated. As time goes on, these 
laboratories will likely see more crisis conditions develop. This is 
reminiscent of the conditions that led to the recent Minneapolis 
interstate bridge collapse. That bridge safely and routinely supported 
heavy vehicle traffic for decades, and because it ``worked,'' its 
structural problems and known, documented deterioration hazards were 
ignored by public officials--until it collapsed. Therefore, not only 
for purposes of improving VA's prospects for recruiting career-minded 
physicians and others as clinician-investigators, but also to protect 
the general safety of staff and patients, a major initiative should be 
funded to bring VA's research laboratory and related research space up 
to contemporary standards of practice in American medicine. Without 
these contributions, VA will not be able to attract or keep top-flight 
providers and clinical investigators. In turn VA will not be able to 
continue to provide a system of quality healthcare for veterans, and VA 
will lose its role as a provider of future physicians and other 
caregivers to the Nation.
    We hope the Subcommittee will provide strong oversight to address 
these key issues, and will support funding to ensure VA's research 
infrastructure receives the resources it needs to both assure safety 
and sustain an important tool to recruit new generations of caregivers 
to VA healthcare careers.
    Again, DAV appreciates the opportunity to provide these comments as 
an addendum to our testimony during the October 18th hearing.

                                 

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                   October 19, 2007
J. David Cox
National Secretary-Treasurer
American Federation of Government Employees, AFL-CIO
80 F Street, N.W.
Washington, D.C. 20001

Dear Mr. Cox:

    Thank you for testifying before the U.S. House of Representatives 
Committee on Veterans' Affairs Subcommittee on Health at the hearing on 
``Healthcare Professionals--Recruitment and Retention'' held on October 
18, 2007.
    Please provide answers to the following questions to Chris Austin, 
Executive Assistant to the Subcommittee on Health, by December 4, 2007.

1. Academic Affiliations--Several witnesses stated that one of the most 
effective recruitment tools the VA has is its academic affiliations 
because they capture students while they are still training.

      What can the VA do to strengthen their academic 
affiliations?
      What other tools can the VA use to recruit newly trained 
healthcare providers?

2. Future Needs--Recently the VA has had difficulty recruiting and 
retaining healthcare professionals such as nurses and pharmacists.

      What is the greatest recruitment challenge facing the VA 
right now? What healthcare professions are in the shortest supply?
      Looking into the future, what challenges does the VA 
anticipate facing in 10 years? 20 years?

    Again, thank you for your testimony. The Subcommittee looks forward 
to receiving your responses by December 4, 2007.

            Sincerely,
                                                 MICHAEL H. MICHAUD
                                                           Chairman

                               __________
       AFGE RESPONSES TO QUESTIONS FOLLOWING THE OCTOBER 16, 2007
                 HVAC SUBCOMMITTEE ON HEALTH HEARING ON
        ``HEALTHCARE PROFESSIONALS--RECRUITMENT AND RETENTION''

1.

Academic Affiliations

      What can the VA do to strengthen their academic 
affiliations?

i.

Provide incentives to include performance pay to encourage VA healthcare 
professionals to pursue teaching and other academic activities.

ii.

Strengthen the current link between the VA and state physician residency 
programs to increase the exposure of residents to VA job opportunities. 
(For example, there is no link between the Togus, ME VAMC and the state's 
only Internal Medicine Program at the Maine Medical Center in Portland.)

iii.

The VA should get more involved in sponsoring or cosponsoring medical 
education activities. This will have the double benefit of providing VA 
medical professionals with more CME opportunities while exposing non-VA 
professionals to the VA. Many professionals outside the VA are very 
interested in working with OIF/OEF veterans.

iv.

More VA clinicians should give lectures at community hospitals where 
residents will be in attendance.

v.

The VA should strengthen ties with local scientific organizations, thereby 
increasing the VA's position as a scientific, research oriented workplace.

      What other tools can the VA use to recruit newly trained 
healthcare providers?

i.

Enact HR 4089 to restore the grievance rights and other workplace rights of 
frontline clinicians that are afforded to other federal employees and 
private sector clinicians who have a voice in scheduling, assignment, 
staffing and other patient care and clinical competence issues.

ii.

Make all P/T employees appointed under Title 38 permanent after the 
equivalent of two years of employment.

iii.

Offer the same alternative work schedules that are available to nurses in 
the private sector.

iv.

Limit mandatory overtime consistent state laws that have clear definitions 
of ``emergency'' to justify mandatory O/T.

v.

Expand scholarship programs for internal promotion, e.g. promoting physical 
therapy assistants to physical therapists, and nursing assistants to RNs 
and Nurse Practitioners. Also, ensure that positions are available to 
graduates of these programs. More generally, increase upward mobility 
opportunities for current VA employees, for example, nurse training for 
employees in administrative positions. Ensure that RNs with two year 
degrees have the same employment opportunities as BSN nurses.

vi.

Increase assistance with student loans for all VA healthcare professionals. 
More specifically, improve allocation of EDRP funds to ensure that 
applicants in areas with greater demand are able to receive funding. 
Currently, funds are evenly distributed across facilities regardless of the 
number of applications received at each medical center. An AFGE Nurse 
Leader in Seattle reports due to scarce EDRP funds, EDRP offers have gone 
from continuous open announcements to attaching an EDRP offer to specific 
positions, presumably because of poor funding.

vii.

Encourage residents who train at the VA to stay on as staff physicians 
through fair market pay and performance pay policies, fair annual leave 
policies, rights to grieve and arbitrate over indirect patient care issues 
and other workplace issues, compensatory time for evening and weekend 
duties and a greater voice in the workplace through inclusion in medical 
director meetings, input into medical by-laws, and other medical center 
policy setting groups.

viii.

Too often, there is only one clinical instructor trying to cover more than 
one nursing unit. If there were more instructors, nursing students would 
have a better experience and feel more positive about seeking employment 
with the VA.

ix.

Expand the funding for VALOR students within the VA. This will provide 
nursing students with summer jobs that enable them to learn the VA system 
and get hands on experience, which, in turn, will encourage more of them to 
seek VA employment upon completion of their education.

x.

Expand use of the VA nurse awards program (both the number and size of the 
awards).

xi.

Ensure that supervisors issue fair performance ratings for front line 
clinicians.

xii.

Expand the use of recruitment and retention bonuses.

xiii.

Ensure fair locality pay adjustments through greater oversight of local 
survey processes.

xiv.

The VA needs to be careful that their recruitment efforts do not alienate 
the employees already on staff. There needs to be some retention efforts 
done simultaneously or otherwise this will just create animosity amongst 
employees--new and old.

xv.

Improve retirement benefits for Title 38 professionals under FERS, i.e. 
afford them the same rights to use accrued sick leave toward retirement as 
their counterparts under Title 5. (Only VA RNs can currently do so, while 
physicians, PAs or other Title 38ers still cannot.)

xvi.

Increased continuing education opportunities for nurses: Currently, RNs at 
the VA do not have time to pursue education. The VA now relies on computer 
assisted mandatory reviews where there is no opportunity for human 
interaction or to have discussions or ask questions, even though there are 
documents embedded into these classes such as Station or VISN policies that 
employees are held accountable as knowing. Often, employees do not have the 
time to go through the actual module but test out due to lack of time.

xvii.

CME: Management does not comply with the current statutory requirement to 
reimburse physicians annually for CME expenses. More generally, all VHA 
healthcare professionals should have more definite rights to annual CME 
reimbursement, rather than leaving it to the discretion of management and 
budget uncertainties.

2.

Future Needs

      What is the greatest recruitment challenge facing the VA 
right now?

    (This comes from an AFGE nurse leader in Seattle) Recruitment of 
Registered Nurses (RNs) is the greatest recruitment challenge for VHA. 
The average RN in VHA is approximately 48 years old. Registered Nurses 
are the most numerous direct caregivers in the healthcare setting. As 
the baby boom population ages, so do RNs. Nursing is a physically as 
well as emotionally demanding occupation. Most RNs are women who also 
bear the majority of the care giving burden for dependent children and 
aging parents/relatives. They are being stretched thin. Despite 
numerous policies in place to help VHA with recruitment and retention, 
they are underutilized by VHA. The culture of top-down management and 
the restrictions of Title 38 USC 7422(b) do not allow RNs the 
appropriate level of involvement in decisions about care delivery and 
quality or the ability to challenge poor managers in a meaningful way. 
Our Renal Dialysis unit went 2 years before finding an RN to manage the 
clinic. Retention bonuses are rarely used. Our Nurse Executive told a 
group of Nurse Practitioners that she had a hard time getting locality 
pay information from area hospitals, due to a fear that we would 
``poach'' their RNs.

      What healthcare professions are in the shortest supply? 
RNs are in very short supply, as well as pharmacists. As noted below, 
we are facing an imminent, substantial shortage of mental health 
clinicians.
      Looking to the future, what challenges does the VA 
anticipate facing in 10 years? 20 years?

i.

UNPRECEDENTED DEMAND FOR LONG TERM MENTAL HEALTHCARE FOR OIF/OEF VETS: We 
are going to face a vast shortage of providers to meet this future need if 
current weak recruitment and retention policies continue.

ii.

AGING PATIENT POPULATIONS: In the next 10-20 years the aging of the 
population across the board is going to be the biggest challenge for VHA 
and the Nation as a whole. As people age, they acquire multiple chronic 
conditions that are management-labor intensive and require costly 
medications to remain alive and out of the hospital. In particular, the VA 
needs to increase its focus on diabetes; it is a lifestyle disease that is 
associated with a metabolic syndrome that also increases the risk of heart 
disease, high blood pressure, kidney failure, blindness, amputation, and 
stroke.

iii.

AGING WORKFORCE: The VA has historically relied on employees who stayed 
with the system until normal retirement. This is no longer the case. Even 
though the VA is facing a workforce crisis due to an imminent wave of 
retirements, many older employees feel that there is a concerted effort to 
go after them, forcing them to retire early with a reduced annuity, rather 
than stay employed at the VA. The VA needs to increase retention incentives 
for older employees including better pay and benefits for P/T employees, 
permanent status, and more flexible schedules.

iv.

SHORT STAFFING: The VA is adding more and more clinical reminders, lengthy 
and cumbersome referral forms on the computer that help them with keeping 
track of numbers, but staffing is the same or less with a lot more 
documentation. The turnover and the acuity of inpatients have been immense. 
Yet the nurses are tied down with all the documentation rather than patient 
care.

v.

SUPERVISOR PROBLEMS: There is inadequate support from supervisors and all 
the way up in the organization. Even if the staff is overwhelmed, the 
supervisors say just do it while they go off to their meetings or are away 
at VISN/National Meetings. They have not touched a patient in years yet 
they are quick to criticize or discipline. The Supervisors and upper 
Managers do not have a finger on the pulse of what is happening at their 
work site. They are too busy looking at overall numbers that get reported 
to VACO.

                                 

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                   October 19, 2007
The Honorable Gordon H. Mansfield
Acting Secretary
U.S. Department of Veterans Affairs
810 Vermont Ave., NW
Washington, D.C. 20420

Dear Secretary Mansfield:

    Thank you for testifying before the U.S. House of Representatives 
Committee on Veterans' Affairs Subcommittee on Health at the hearing on 
``Healthcare Professionals--Recruitment and Retention'' held on October 
18, 2007.
    Please provide answers to the following questions to Chris Austin, 
Executive Assistant to the Subcommittee on Health, by December 4, 2007.

    1.  Workplace satisfaction--A study sponsored by the Partnership 
for Public Service recently came out that showed a large discrepancy in 
workplace satisfaction in the Veterans Health Administration between 
workers over 40 and workers under 40. VHA workers over 40 report ``high 
satisfaction'' and those under 40 report ``very low satisfaction.''

        What does the VA plan to do to attract and keep younger 
workers?

    2.  Future Needs--Recently the VA has had difficulty recruiting and 
retaining healthcare professionals such as nurses and pharmacists.

        What is the greatest recruitment challenge facing the 
VA right now? What healthcare professions are in the shortest supply?
        Looking into the future, what challenges does the VA 
anticipate facing in 10 years? 20 years?

    3.  Current programs--The VA has several current programs for 
recruitment and retention of healthcare professionals.

        How many people are currently in these programs?
        How much do these programs cost?
        Are these programs successful? How is success measured?

    4.  Physicians Pay Bill--In 2004 Congress passed the Physicians' 
Pay Bill which established an improved and simplified pay structure for 
VA physicians that would increase salaries and make VA more competitive 
with the private sector.

        How effective has the Physicians Pay Bill been in 
retaining VA physicians?
        When will VA be delivering the report to Congress on 
the 2004 Physicians Pay Bill?

    Again, thank you for your testimony. The Subcommittee looks forward 
to receiving your responses by December 4, 2007.

            Sincerely,
                                                 MICHAEL H. MICHAUD
                                                           Chairman

                               __________
                        Questions for the Record

                The Honorable Michael Michaud, Chairman
                         Subcommittee on Health
                  House Committee on Veterans' Affairs
      Healthcare Professionals--Recruitment and Retention Hearing
Question 1: Workplace satisfaction--A study sponsored by the 
Partnership for Public Service recently came out that showed a large 
discrepancy in workplace satisfaction in the Veterans Health 
Administration between workers over 40 and workers under 40. VHA 
workers over 40 report ``high satisfaction'' and those under 40 report 
``very low satisfaction.''

Question 1a: What does the VA plan to do to attract and keep younger 
workers?

Response: The Department of Veterans Affairs (VA) has an extensive 
array of recruitment and retention tools available to employees 
including scholarship programs, continuing education, student debt 
reduction, entry-level career training programs that offer promotion 
potential and residency and fellowship training programs. Recruitment 
strategies are targeting college students in Veteran Health 
Administration's (VHA) primary occupational categories to encourage 
them to consider VA as a career option. Additionally, to address 
employee satisfaction efforts, VHA requires action plans be developed 
at every organizational level to address issues with satisfaction which 
were identified in its annual All Employee Survey.

Question 2: Future Needs--Recently the VA has had difficulty recruiting 
and retaining healthcare professionals such as nurses and pharmacists.

Question 2a: What are the greatest recruitment challenges facing the VA 
right now? What healthcare professionals are in the shortest supply?

Response: The greatest recruitment challenge is retaining new hires in 
the VA system. While turnover decreased for VHA overall by a small 
amount (0.1 percent), turnover increased for physical therapists (4.3 
percent), pharmacists (0.5 percent), and physicians (0.1 percent) from 
fiscal year (FY) 2005 to FY 2006 and decreased for nurses in the same 
time period by 0.5 percent. New hires in each of the key positions have 
increased by a significant amount, with increases of 33 percent to 44 
percent among these occupations in FY 2007.

       All Loss Turnover for VHA FT/PT Employees (Excludes Medical Residents, Trainees, and Intermittent)
----------------------------------------------------------------------------------------------------------------
                                                             FY      FY             Gain FY   Gain FY    Gain FY
                                                            2005    2006   Change    2005       2006      2007
----------------------------------------------------------------------------------------------------------------
All VHA                                                    9.55%   9.45%   -0.10%   19,270     23,692    32,412
----------------------------------------------------------------------------------------------------------------
0602 Physician                                             9.70%   9.80%   0.10%     1,754      1,842     2,473
----------------------------------------------------------------------------------------------------------------
0610 Nurse                                                 9.00%   8.50%   -0.50%    3,196      3,872     5,553
----------------------------------------------------------------------------------------------------------------
0660 Pharmacist                                            6.50%   7.00%   0.50%       311        383       534
----------------------------------------------------------------------------------------------------------------
0633 Physical                                              6.39%   10.70%  4.31%       110        132       175
  Therapists
----------------------------------------------------------------------------------------------------------------

    On-board numbers for mental health positions in direct patient care 
are also increasing, with 387 more psychologists, 842 more social 
workers, and 157 more psychiatrists in FY 2007.

 On-Board for Mental Health Positions with Direct Care Cost Centers for
FT/PT Employees (Excludes Medical Residents, Trainees, and Intermittent)
------------------------------------------------------------------------
                                        FY 2005     FY 2006     FY 2007
------------------------------------------------------------------------
0180 Psychology                            1604        1768        2155
------------------------------------------------------------------------
0185 Social Work                           4263        4607        5449
------------------------------------------------------------------------
0602 Physician, Assignment Code 31,        1922        1977        2134
  Psychiatry
------------------------------------------------------------------------


    VHA develops a workforce succession strategic plan each year. The 
plan is developed with input from network and program offices 
throughout VHA. Identified in this plan are the ``top critical 
occupations'' within VHA for the current year. For the FY 2008-2012 
plan, the following occupations were identified: registered nurse, 
physician, pharmacist, practical nurse, diagnostic radiology 
technologist, medical technologist, physical therapist, nursing 
assistant and medical records technician.

Question 2b: Looking into the future, what challenges does the VA 
anticipate facing in 10 years? 20 years?

Response: The major workforce drivers within healthcare include an 
increasing demand for health services driven largely by an aging 
population that exhibits multiple chronic health conditions; and an 
aging healthcare workforce that is not being adequately replaced by 
younger workers. Two of the largest veteran cohorts, those who served 
in World War II and Vietnam, are aging and increasingly relying upon 
VHA for their healthcare needs. On the other hand, we have a growing 
population of younger veterans of Operation Enduring Freedom/Operation 
Iraqi Freedom (OEF/OIF). This generation has a greater expectation for 
state-of-the-art medical treatment options and many return from combat 
severely injured, arriving at VHA facilities with polytraumatic 
injuries that would have been fatal in previous conflict eras. These 
injuries require different types of rehabilitation as well as increased 
need for mental health treatment.
    While anticipating the needs of this next generation of veterans is 
of great importance to VHA, we also realize that equally important are 
the broad-based changes in the age and demographics of World War II, 
Korean, and Vietnam-era veterans. With the median age of all living 
veterans being approximately 60 years of age, the number of veterans 
aged 85 and older has grown from 164,000 in 1990 to 1,075,000 in 2005. 
By 2011, the number of veterans aged 85 and older will grow to more 
than 1.3 million. This large increase in the oldest segment of the 
veteran population has had, and will continue to have, significant 
ramifications on the demand for healthcare services, particularly in 
the areas of long-term care and home-based care.
    VHA's workforce is also aging and becoming eligible for retirement 
in greater numbers. At the end of FY 2007, 11.5 percent of VHA's 
218,000 full- and part-time employees were eligible for regular 
retirement. It is expected that within the next 10 years, approximately 
30 percent of VHA employees will need to be replaced as a result of 
regular retirements. In that same time period, VHA will need to replace 
approximately 85 percent of all senior leaders, including senior 
executives, medical center directors, nurse executives/directors of 
patient care services, associate/assistant and deputy network 
directors, and chiefs of staff. We anticipate that competition for 
workers will increase significantly over the next 20 years and that 
competition for healthcare workers will be especially strong.

Question 3. Current programs--The VA has several current programs for 
recruitment and retention of healthcare professionals.

Question 3a: How many people are currently in these programs?

Response: Scholarship Programs Implemented in 2000--the Employee 
Incentive Scholarship Program (EISP) authorizes VA to award 
scholarships to employees pursuing degrees or training in healthcare 
disciplines for which recruitment and retention of qualified personnel 
is difficult. EISP awards cover tuition and related expenses such as 
registration, fees, and books. The academic curricula covered under 
this initiative include education and training programs in fields 
leading to appointments or retention in title 38 or hybrid title 38 
positions listed in 38 U.S.C. Section 7401. The following data reflects 
the total employee participants through FY 2007:

      Total number of awards: 7,127
      Total number of employees completing the program 
(graduates): 3,988
      Total amount of funding for awards through FY 2012: 
$88,315,696
      Average amount of award per participant: $12,392

    The chart below identifies the total number of scholarships awarded 
to VHA employees since 2000, the number of employees who have completed 
their programs and the average amount of the scholarship awarded by 
occupation.


------------------------------------------------------------------------
                                 Total #      Total #     Average Amount
          Occupation             Awards      Completed    of Each Award
------------------------------------------------------------------------
Registered Nurse                   6,595         3,634          $12,416
------------------------------------------------------------------------
Pharmacist                           188            96          $17,601
------------------------------------------------------------------------
Licensed Practical Nurse             134            66           $7,196
------------------------------------------------------------------------
Physical Therapist                    55            21           $9,593
------------------------------------------------------------------------
Physician Assistant                   34            26           $6,388
------------------------------------------------------------------------
Registered Respiratory                34            16           $5,995
 Therapist
------------------------------------------------------------------------
Certified Registered Nurse            33             7          $15,920
 Anesthetist
------------------------------------------------------------------------
Audiologist                           12             3           $5,949
------------------------------------------------------------------------
Occupational Therapist                12             6          $14,677
------------------------------------------------------------------------
All other                             30            16               --
------------------------------------------------------------------------
TOTAL                              7,127         3,988          $12,392
------------------------------------------------------------------------


    An analysis of the average cost per award reveals that the average 
award ($12,329) is substantially less than the maximum amount allowed 
($35,024 in FY 2007) by statute. Additionally, the average number of 
credit hours funded per employee (45 credits for undergraduate and 36 
credit hours for graduate) is substantially less than the hours allowed 
by statute (90 credits for undergraduate and 54 for graduate). This 
demonstrates that the employees are selecting academic institutions 
with reasonable costs and the employees have self-funded a substantial 
part of the degree prior to applying for the scholarship award.

Question 3b: How much do these programs cost?

Question 3c: Are these programs successful? How is success measured?

Response: The scholarship program has graduated 423 new healthcare 
personnel in the following occupations: registered nurse anesthetists 
(4); certified respiratory therapy technicians (1); dental hygienist 
(1); licensed practical nurses (64); occupational therapist (2); 
pharmacist (5); physician assistants (4); registered nurses (331); 
registered respiratory therapist (11). The remaining scholarship 
participants are employees who pursued an advanced degree in their 
profession. Additionally, the scholarship program supports workforce 
succession planning by offering flexible use of the scholarship to 
achieve more than one academic degree. For example, 202 of the 3,886 
successful graduates through FY 2007 include 100 registered nurses who 
completed both a baccalaureate and a masters program and 1 registered 
nurse who completed a masters and a doctoral degree. As the 
organization identifies the competency and knowledge level, the 
employee can use the scholarship program to meet those needs as well as 
reinforcing VA as the preferred employer. The scholarship program was 
identified as one of the primary reasons for working for VA in all 
marketing materials.
    When considering impact of the scholarship program on employee 
retention, the first issue of significance is the program completion 
rate of participants. The U.S. Department of Education in its most 
recent report (2004) stated that the rates of college degree attainment 
have not changed over several decades despite an increase in the total 
number of college students. Approximately 6 out of 10 traditional 
students and 4 out of 10 nontraditional students who entered college in 
1995 had actually completed a degree by 2001 (Horn & Berger, 2004).\1\ 
All of the employee participants in this scholarship program would meet 
the criteria for the nontraditional student and would thus be in the 
highest risk category. However, the VA employee scholarship 
participants have had an overall attrition rate of 15 percent in 
contrast to the national norm of 60 percent. A review of the first time 
degree VA scholarship participants (which would be in the highest risk 
category for attrition) reveals that even their attrition rate 25 
percent remains substantially below the attrition national norm for all 
first time college attendees.
---------------------------------------------------------------------------
    \1\ Horn, & Berger. (2004). College persistence on the rise? 
Changes in 5-Year degree completion and postsecondary persistence rates 
between 1994 and 2000. (No. NCES 2005-156). Washington, DC: U.S. 
Department of Education, National Center for Education Statistics.
---------------------------------------------------------------------------
    The next criterion related to retention asks if scholarship 
participants have a higher VA employment retention rate when compared 
to non scholarship participants. A study (2005) of the 3844 registered 
nurse (RN) scholarship participants demonstrated that 7.4 percent of 
RNs enrolled in the scholarship program left VA employment compared to 
the 10.6 percent leave VA rate for all VA registered nurses. 
Additionally, of those scholarship participants who left VA less than 1 
percent (0.6 percent) left during their service obligation period. Thus 
in this study group which represents 95 percent of all awards, the 
scholarship program had a significant impact on employee retention in 
VHA.
    The final retention criterion addresses the impact of the required 
service obligation period relative to employee retention. The average 
service obligation period for all awards is 2.2 years following 
completion of the degree. A review of the 1172 employees who have 
breached their scholarship agreement reveals that only 102 (9 percent 
of breaches or 1 percent of all awards) breached during their service 
obligation period. Thus 99 percent of award recipients who complete 
their degree also complete the service obligation period. Additionally, 
an effective oversight program is in place and assures appropriate 
collection of all financial liabilities incurred as a result of 
breached agreements.
    The criterion for measuring success is the direct impact in our 
workforce of the recruitment and retention of title 38 and hybrid title 
38 occupations. The effectiveness of the scholarship programs in 
recruitment of healthcare professionals is measured primarily by 
determining if the programs impact on professionals' decisions to work 
at VA, if the programs are generating new first-time licensed 
healthcare personnel, and if the programs contribute to the workforce 
succession plan.
    The criteria for measuring retention efforts include comparing the 
student attrition rate using national benchmarking data from the 
Department of Education; comparing employee attrition rates of 
scholarship participants with that of the general VHA registered nurse 
population; and determining if the mandatory service obligation period 
contributes to employee retention.

    Education Debt Reduction Program The chart below provides the 
number of employees who have participated in the education debt 
reduction program (EDRP) since its implementation in May 2002. The 
program designed to assist VA with recruitment and retention of hard-
to-fill healthcare professions, applies to title 38 and hybrid title 38 
occupations. Total expenditures for EDRP awards from the programs 
inception and continuing with award obligations authorized through FY 
2012 are $96,870,402.


----------------------------------------------------------------------------------------------------------------
                                                                                                       Average
                            Occupation                                Total # EDRP       Total #      Amount of
                                                                         Awards         Completed       Award
----------------------------------------------------------------------------------------------------------------
Registered Nurse                                                              2,704         1,475       $13,451
----------------------------------------------------------------------------------------------------------------
Pharmacist                                                                      876           429       $23,595
----------------------------------------------------------------------------------------------------------------
Physician                                                                       715           345       $24,790
----------------------------------------------------------------------------------------------------------------
Licensed Practical/Vocational                                                   285           173        $5,499
  Nurse
----------------------------------------------------------------------------------------------------------------
Physical Therapist                                                              231           128       $21,522
----------------------------------------------------------------------------------------------------------------
Physician Assistant                                                             204           116       $21,254
----------------------------------------------------------------------------------------------------------------
Occupational Therapist                                                          105            75       $16,381
----------------------------------------------------------------------------------------------------------------
Medical Technologist                                                             97            38       $16,135
----------------------------------------------------------------------------------------------------------------
Diagnostic Radiologic                                                            80            34       $11,223
  Technologist
----------------------------------------------------------------------------------------------------------------
Registered Respiratory Therapist                                                 50            33       $11,860
----------------------------------------------------------------------------------------------------------------
All other 23 occupations                                                        309           138            --
----------------------------------------------------------------------------------------------------------------
Total                                                                         5,656          2984       $16,571
----------------------------------------------------------------------------------------------------------------

    VALOR--VA Learning Opportunity Residency Program Initiated in the 
Summer 1990, for students (junior class level) enrolled in bachelors 
degree nursing program, VALOR has provided opportunities for 
outstanding students to develop competencies in clinical nursing while 
at an approved VA healthcare facility. In FY 2007, there were 398 new 
VALOR nursing students and 193 continuing students from the 2006 
scholars. Outcomes of the program have demonstrated that it is an 
excellent method of recruiting students when those students are 
retained into the senior year (over 50 percent of this group are 
hired). The success of the nursing VALOR program led to the launching 
in 2007 of a VALOR program for pharmacy students. In this inaugural 
year there were 14 students selected. Additional sites and students 
will be approved as the program evolves and develops.

Question 4: Physicians Pay Bill--In 2004 Congress passed the 
Physicians' Pay Bill which established an improved and simplified pay 
structure for VA physicians that would increase salaries and make VA 
more competitive with the private sector

Question 4a: How effective has the Physicians Pay Bill been in 
retaining physicians?

Response: The new physician and dentist pay system has provided VA with 
a comprehensive way to offer flexible compensation packages making VA 
more competitive in the recruitment and retention of physicians and 
dentists. Through the use of the new pay flexibilities, VA has been 
able to increase the overall number of physicians and dentists employed 
by 574 additional staff. Many of the additional staff are in clinical 
specialties which had previously experienced significant difficulty 
attracting candidates.
    In addition to improvements in recruitment, VA has also benefited 
from improvements in the retention of physician and dentist staff. A 
comparison of the loss rates for 2006 (9.60 percent) and 2007 (4.18 
percent) show a more than 50 percent improvement in the retention of 
physicians and dentists. The significance of this improved rate of 
retention is most evident when compared against the historical loss 
rates for physicians and dentists.


------------------------------------------------------------------------
        Physicians Loss Rate                  Dentists Loss Rate
------------------------------------------------------------------------
2000 11.69%                          2000 8.48%
------------------------------------------------------------------------
2001 10.88%                          2001 4.23%
------------------------------------------------------------------------
2002 10.76%                          2002 6.92%
------------------------------------------------------------------------
2003 10.37%                          2003 6.82%
------------------------------------------------------------------------
2004 10.22%                          2004 4.91%
------------------------------------------------------------------------
2005 9.69%                           2005 9.15%
------------------------------------------------------------------------
2006 9.60%                           2006 9.68%
------------------------------------------------------------------------
2007 4.18%                           2007 4.32%
------------------------------------------------------------------------

    We believe the new pay system has significantly contributed to the 
overall decrease in physician and dentist separations.

Question 4b: When will VA be delivering the report to Congress on the 
2004 Physicians Pay Bill?

Response: The first annual report on the pay of physicians and dentists 
was delivered to the Congress on November 16, 2007, a copy of which is 
attached.

                                 

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                   October 31, 2007
Honorable Gordon H. Mansfield
Acting Secretary
U.S. Department of Veterans Affairs
810 Vermont Ave., NW
Washington, DC 20420

Dear Secretary Mansfield:

    On Thursday, October 18, 2007, William J. Feeley, MSW, FACHE, 
Deputy Under Secretary of Health for Operations and Management, 
Veterans Health Administration, U.S. Department of Veterans Affairs 
(VA), testified before the Subcommittee on Health on VA Healthcare--
Recruitment and Retention. As a followup to this hearing, I request 
that Mr. Feeley respond to the following questions in written form for 
the record. Each question should be listed on the page with the answers 
immediately following the question.

     1.  The American Physical Therapy Association (APTA) testified, 
``only 19 physical therapists have participated in the Education Debt 
Reduction Program and only 14 physical therapists have participated in 
the Employee Incentive Scholarship Program.''

                a.  Do you consider this a low level of participation?
                b.  What has VA been doing to promote and increase the 
                utilization of these programs?
                c.  How does VA plan to improve promotion of the 
                Education Debt Reduction Program and the Employee 
                Incentive Scholarship Program?

     2.  APTA testified that proposed updates to the VA qualification 
standards for Physical Therapists have been pending for six years.

                a.  Why is the process taking so long and when do you 
                anticipate issuing updated standards?
                b.  Are there other categories of healthcare employees 
                that have qualification standards under review? If so, 
                please list those categories of healthcare employees, 
                the date they were proposed, and the date you expect to 
                complete the review process.

     3.  How does VA monitor professional licensure criteria to ensure 
it employs the most up-to-date requirements?

     4.  The 2006 CACI pilot study evaluated innovative recruitment 
tools to address nursing shortages and made five recommendations to 
improve the hiring process: (1) delegate approval authority; (2) make 
greater use of recruitment advertising; (3) streamline and standardize 
the processes; (4) implement an automated recruitment management 
workflow system; and (5) adjust Vet Pro to coordinate with date of 
entry. Has VA implemented any of the CACI recommendations? If so, 
please provide a description of the steps VA has taken to implement 
each recommendation.

     5.  The CACI report found ``[t]he majority of current processes 
are manual processes in a paper-based system. One of the greatest 
opportunities for process improvement and reduced time-to-hire is the 
elimination of paper-based manual systems and the introduction of 
electronic document workflow'' (p. 28). Furthermore, the report noted, 
``VA's HR2020 Task Force has also chartered a National Automation 
workgroup to implement a national strategy for an integrated HR 
information system as well as establishment of outcome-based metrics 
specifically related to the timeliness of recruitment'' (p. 29).

                a.  Has VA implemented a plan for an integrated HR 
                information system?
                b.  How much progress has been made on the integrated 
                HR information system? If no progress has been made, 
                please explain why and provide a timeline for VA 
                action.

     6.  What is the average time it takes for VA to fill a vacant 
healthcare position? How does this timeline compare with that of the 
private sector?

     7.  Based on the CACI study, do you think VA could benefit from 
using an outside recruitment, advertising and communications agency to 
speed up the hiring process?

     8.  Public Law 108-445, the ``VA-Pay bill'' reformed the VA 
physician pay and performance system.

                a.  What difference has this legislation made on VA's 
                ability to recruit and retain the best physicians?
                b.  What effect has the ``VA-Pay bill'' had on VA's 
                reliance on part-time physicians?

     9.  The Partnership for Public Service and American University's 
Institute for the Study of Public Policy Implementation rankings from 
the Office of Personnel Management's (OPM) Federal Human Capital Survey 
rank VHA 18th out of 222 Federal agencies as the ``Best Places to 
Work''. Do you find that this survey is a valid representation of VHA 
staff?

    10.  The Partnership for Public Service analysis of the OPM survey 
shows a high satisfaction rate among employees 40 and over (12 of 222), 
but very low satisfaction among its younger cohort (112 out of 208)? 
How would you explain this difference?

    The attention to these questions by Mr. Feeley is much appreciated, 
and I request that they be returned to the Subcommittee on Health no 
later than close of business, 5:00 p.m., Friday, November 30, 2007. If 
you or your staff have any questions, please call Dolores Dunn, 
Republican Staff Director for the Subcommittee on Health, at 202-225-
3527.

            Sincerely,
                                                        Jeff Miller
                                                     Ranking Member

                               __________
                       The Honorable Jeff Miller
                        Ranking Minority Member
                         Subcommittee on Health
                   House Veterans' Affairs Committee

          Healthcare Professionals--Recruitment and Retention

Question 1: The American Physical Therapy Association testified, ``only 
19 physical therapists have participated in the Education Debt 
Reduction Program and only 14 physical therapists have participated in 
the Employee Incentive Scholarship Program?

Question 1(a): Do you consider this a low level of participation?

Response: It is true that 19 of 119 recently appointed physical 
therapists participated in the Education Debt Reduction Program. The 
data shows that 16 percent of physical therapists hired during fiscal 
year (FY) 2007 received EDRP awards. However, in spite of being a small 
component of the Veterans Heath Administration (VHA) workforce; 
physical therapist ranks fifth in the total number of EDRP awards 
allocated since the program inception in 2002. The total number of 
awards to physical therapists as of FY 2007 was 231. An analysis of the 
EDRP program for the first group of recipients (from 2002) shows that 
EDRP may be less effective as a retention tool for the physical therapy 
occupation (59 percent remained employed by VHA for the duration of the 
award) than nursing (75 percent) or pharmacy (75 percent) indicating 
there may be other market-based factors contributing to retention, 
including pay disparity with private sector. VHA will continue using 
EDRP as appropriate to recruit and retain physical therapists in 
addition to using other Title 5 recruitment and retention pay 
incentives.
    Fifty-five physical therapists have participated in the Employee 
Incentive Scholarship Program (EISP). The low number of physical 
therapists returning to college is not surprising as they are hired 
into VHA with the masters or doctorate degree as is required to 
practice in the occupation. By comparison nurses are often hired with 
associate degrees and use EISP extensively to advance to bachelor or 
masters degrees. However, as the occupation's academic preparation 
moves from the masters degree to the doctorate degree at the entry-
level, we anticipate more of VHA's masters prepared physical therapists 
will apply for EISP scholarships to obtain doctorate degrees.

Question 1(b): What has VA been doing to promote and increase the 
utilization of these programs?

Response: To promote and increase use of these program VHA conducts 
monthly conference calls for field liaisons and participates in 
discipline specific national conference calls to communicate 
information about these programs for field-based managers. National 
recruitment advertising materials contain information about scholarship 
and debt reduction programs. Strategies for using these programs are 
integrated into VHA Workforce Succession Planning conference curricula 
and regional presentation.

Question 1(c): How does VA plan to improve promotion of the Education 
Debt Reduction Program and the Employee Incentive Scholarship Program?

Response: The Healthcare Retention and Recruitment Office is working in 
concert with leadership in Patient Care Services to communicate 
availability of both EDRP and EISP scholarships to both field-based PT 
managers and practitioners. Of particular interest will be enhancing 
the academic credentials for existing staff and eliminating any reason 
for physical therapists to resign from VHA to return to school.

Question 2: APTA testified that the proposed updates to the VA 
qualification standards for Physical Therapists have been pending for 
six years.

Question 2(a): Why is the process taking so long and when do you 
anticipate issuing updated standards?

Response: The original request to revise the physical therapist 
qualification standard was received in the Office of Human Resources 
Management (OHRM) in March 2004. The passage of Public Law 108-170 (the 
Veterans Health Care, Capital Asset and Business Improvement Act of 
2003) on December 6, 2003, converted 22 occupations from Title 5 to the 
Title 38 employment system. Conversion required the development of new 
qualification standards for each of the 22 new hybrid occupations. 
Therefore, all work to revise existing qualification standards, 
including the physical therapist, was suspended until after completion 
of the new 22 standards, which included collaboration with bargaining 
unit representatives as required by PL 108-170.
    Work on the physical therapist standard resumed in February 2006 
following an eight-step process that ensures consistency with the 
Uniform Guidelines on Employee Selection Procedures and the principles 
of equal pay for equal work established in 5 United States Code 5104, 
the Equal Pay Act 1963, Title VII of Civil Rights Act 1964, Age 
Discrimination in Employment Act 1967, and Title I of Americans with 
Disabilities Act 1990. OHRM launched a new initiative and training was 
provided to the subject matter experts in March 2006. Since that time 
OHRM and VHA have been working together to produce the required 
supporting documentation. The new physical therapist qualification 
standard is in the final review stage, and in April 2008, will go 
through statutorily-mandated collaboration with bargaining unit 
representatives. By statute, collaboration requires a minimum of 90 
days, and in the past, it has taken 120 days including the preparation 
and issue of required reports to Congress. The qualification standard 
will move to the formal concurrence process, and can be expected to be 
available for implementation in early to late-summer/early-fall 2008.
    The revised qualification standards will address several concerns 
by:

    1.  Considering appropriate entry and full performance grade 
levels;
    2.  Recognizing the Doctor of Physical Therapy (DPT) degree, and;
    3.  Providing for many new assignments above the full performance 
level to allow for advancement.

Question 2(b): Are there other categories of healthcare employees that 
have qualification standards under review? If so, please list those 
categories of healthcare employees, the date they were proposed and the 
date you expect to complete the review process.

Response: We are currently revising or developing new qualification 
standards for these additional healthcare occupations:


------------------------------------------------------------------------
                                                           Anticipated
              Occupation                    Received        completion
------------------------------------------------------------------------
Blind Rehabilitation Specialist                11/2004      Winter 2008
------------------------------------------------------------------------
Nurse Anesthetist (CRNA)                        5/2006      Winter 2008
  (Certified Registered Nurse
 Anesthetist)
------------------------------------------------------------------------
Occupational Therapist                          3/2006      Spring 2008
------------------------------------------------------------------------
Pharmacist                                      1/2004      Summer 2008
------------------------------------------------------------------------
Social Worker                                   5/2004      Summer 2008
------------------------------------------------------------------------

Program Offices have inquired about revising the qualification 
standards for:

    Medical Instrument Technician
    Physician Assistant
    Respiratory Therapist
    Therapeutic Radiologic Technologist
    Veterinary Medical Officer

Question 3: How does VA monitor professional licensure to ensure it 
employs the most up-to-date requirements?

Response: VA requires all licensed healthcare professionals to practice 
within the scope of their licensure. When privileges or scopes of 
practice are granted, verification with the licensing board confirms 
that the practitioner's license allows for each element to be granted. 
Licensure is verified at the time of initial appoint and at expiration 
for all licensed healthcare practitioners. For privileged practitioners 
it is verified initially and at the time of reappraisal, which occurs 
at a minimum of every 2 years. As privileges or scopes of practice are 
reviewed, confirmation of the scope of practice allowed by licensure is 
also reviewed. The verifications are completed by local human resources 
staff.

Question 4: The 2006 CACI pilot study evaluated innovative recruitment 
tools to address nursing shortages and made five recommendations to 
improve the hiring process: (1) delegate approval authority; (2) make 
greater use of recruitment advertising; (3) streamline and standardize 
the processes; (4) implement an automated recruitment management 
workflow system; and (5) adjust VetPro to coordinate with the date of 
entry. Has VA implemented any of the CACI recommendations? If so, 
please provide a description of the steps VA has taken to implement 
each recommendation.

Response: The Veterans Health Administration (VHA) commissioned a task 
force in May 2007, VHA recruitment process redesign workgroup (RPRW), 
to consolidate findings from several VHA recruitment processing studies 
and make recommendations for action. This workgroup incorporated 
findings and recommendations from the CACI study (a study limited in 
geographical scope) and multiple other VHA recruitment and hiring 
timeline studies. The workgroup incorporated aspects of the CACI study 
into its final work product which was published on August 20, 2007. 
This study was presented to the VHA National Leadership Board in 
October 2007. A pilot project has been initiated at one facility to 
implement the approved recommendations. However, other networks/
facilities will simultaneously move forward with the recommendations. 
The workgroup recommendations identified recruitment barriers and 
recommendations for resolution that covered short-term, intermediate 
and long-term actions.
    As an example, the VA Medical Center in Alexandria, Louisiana, has 
implemented a number of changes in its hiring processes and achieved 
the ability to hire a nurse within 30 days of accepting the 
application. They have implemented a practice that uses the VetPro 
system as the nursing application and provide applicants with easy 
access by setting up convenient work stations. Modifications were made 
in the timing of preemployment physicals and performing process steps 
concurrently versus sequentially. These practices are being shared 
across the administration to improve hiring timelines.
    Building on the CACI recommendations, the RPRW further recommended 
complete automation of the application process, to include electronic 
integration with various human resource systems. Once these systems are 
electronically integrated, job applicants will only have to provide the 
necessary information once at the beginning of the recruitment process 
and the various systems will be automatically populated by this 
information. Accomplishment of this recommendation will eliminate what 
is presently a redundant, frustrating process which causes VHA to lose 
highly desirable applicants.
    Communication of new recruitment processes and expectations must be 
far-reaching to include human resources, credentialing and privileging, 
selecting officials, and job applicants. A recommendation presented by 
the RPRW was to have facility points of contact communicate early and 
often with applicants to ensure they have reasonable expectations of 
the timeframe for the process to unfold.

Question 5: The CACI report found ``[t]he majority of current processes 
in a paper-base system. One of the greatest opportunities for process 
improvement and reduced time-to-hire is the elimination of paper-based 
manual systems and the introduction of electronic document workflow'' 
(p. 28). Furthermore, the report noted, ``VA's HR 2020 Task Force has 
also chartered a National Automation workgroup to implement a national 
strategy for an integrated HR information system as well as 
establishment of outcome-based metrics specifically related to the 
timeliness of recruitment'' (p. 29).

    a.  Has VA implemented a plan for an integrated HR information 
system?
    b.  How much progress has been made on the integrated HR 
information system? If no progress has been made, please explain why 
and provide a timeline for VA action.

Response: The VHA Strategic Human Resources Advisory Council (SHRAC) 
established a 2020 goal for automating human resources. This goal was 
to have all human resources processes be highly automated, streamlined, 
efficient and consistent nationwide. The SHRAC formed a work group to 
examine the best means of meeting this goal. The work group endorsed a 
plan to pilot VA Greater Los Angeles, human resource automation efforts 
to include their automated request for personnel action (ARPA). Over 
the past 18 months pilots were initiated: in four Veteran Integrated 
Services Networks (VISN). The initial project moved beyond the first 
pilots and evolved to five major initiatives:

      Centurion--process for assigning permissions and rights
      PAID--Net--standardized reports for all human resources 
offices
      Web HR--standardized portal for all VHA staff
      ARPA--standardized process for automating requests for 
personnel actions.
      HR Forms--standardized employment forms

    To ensure consistent and integrated implementation with other 
technology, additional work groups have been added to the initial 
project:

      HR METRICS
      POLICIES/BUSINESS RULES
      DEFINITIONS-CENTURION
      DEPLOYMENT
      APPLICATIONS/DATABASES
      TRAINING
      REQUIREMENTS

TARGET ROLL OUT:

PAID Net--Available to all sites December 2007

Centurion and ARPA--Initiate roll-out for HR office sites March 
2008,Web HR--January 2008, HR Forms--March 2008

Question 6: What is the average time it takes for VA to fill a vacant 
healthcare position? How does this compare with that of the private 
sector?

Response: The average time to fill healthcare positions is highly 
variable depending on the labor market. In labor markets where there 
are adequate candidates, the timeframes for pre-employment processing 
(credential verifications, suitability clearance, medical clearance, 
etc.) range from 30 days to over 90 days after a selection is made. In 
many facilities, the timeframe has been much longer. With the 
implementation of recommendations from the process redesign workgroup, 
we anticipate the timeframes will be shortened significantly. Automated 
recruitment databases will be used to monitor and evaluate 
improvements. Considerable efforts are underway to reduce the time it 
takes to fill healthcare positions in VHA. We are closely monitoring 
these efforts as well as continually sharing best and most effective 
practices as they are identified.
    Data on private sector hiring times is not readily available for 
comparative purposes. However, private employers are required to 
perform many of the same screening procedures as VA, such as primary 
source verification of credentials; background and reference checks; 
and pre-employment physical examinations. Therefore, we believe the 
timeframes would be somewhat comparable. We recognize, however, that 
Federal employers are held to more stringent standards in many aspects 
of employee security and suitability.

Question 7: Based on the CACI study, do you think VA could benefit from 
using an outside recruitment, advertising and communications agency to 
speed up the hiring process?

Response: VHA has been actively using the services of external 
recruitment, advertising and communication agency for more than 17 
years and have found these services invaluable. We continue to 
advertise in professional journals, public service announcements, and 
newspapers but have expanded into extensive use of online advertising 
and use of commercial job boards as technologies have changed. Our 
recruitment Web site has undergone extensive redesign with CACI as our 
contractor and we are currently in phase 2 of the redesign process. 
Each step has been based on research into best practices for developing 
recruitment Web sites and marketing materials that are both attractive 
and designed to increase interest in job applications. Several 
recruitment marketing research studies have been completed and each has 
advanced both our approach to how we create the messages we use to 
target our recruitment to healthcare professionals. Our major 
recruitment campaigns are tested with focus groups to determine what 
messages are best received and likely to prompt actions on the part of 
the potential job candidate.

Question 8: Public Law 108-445, the ``VA-Pay bill'' reformed the VA 
physician pay and performance system.

Question 8(a): What difference has this legislation made on VA's 
ability to recruit and retain the best physicians?

Response: The new physician and dentist pay system has provided VA with 
a comprehensive way to offer flexible compensation packages making VA 
more competitive in the recruitment and retention of physicians and 
dentists. Through the use of the new pay flexibilities, VA has been 
able to increase the overall number of physicians and dentists employed 
by 574 additional staff. Many of the additional staff are in clinical 
specialties which had previously experienced significant difficulty 
attracting candidates.
    In addition to improvements in recruitment, VA has also benefited 
from improvements in the retention of physician and dentist staff. A 
comparison of the loss rates for 2006 (9.60 percent) and 2007 (4.18 
percent) show a more than 50 percent improvement in the retention of 
physicians and dentists. The significance of this improved rate of 
retention is most evident when compared against the historical loss 
rates for physicians and dentists.


------------------------------------------------------------------------
        Physicians Loss Rate                  Dentists Loss Rate
------------------------------------------------------------------------
   Year            Percentage           Year           Percentage
------------------------------------------------------------------------
2000       11.69                      2000      8.48
------------------------------------------------------------------------
2001       10.88                      2001      4.23
------------------------------------------------------------------------
2002       10.76                      2002      6.92
------------------------------------------------------------------------
2003       10.37                      2003      6.82
------------------------------------------------------------------------
2004       10.22                      2004      4.91
------------------------------------------------------------------------
2005        9.69                      2005      9.15
------------------------------------------------------------------------
2006        9.60                      2006      9.68
------------------------------------------------------------------------
2007        4.18                      2007      4.32
------------------------------------------------------------------------

    We believe the new pay system has significantly contributed to the 
overall decrease in physician and dentist separations.

Question 8(b): What effect has the ``VA-Pay bill'' had on VA's reliance 
on part-time physicians?

Response: The physician and dentist pay reform has improved the ability 
of our medical facilities to recruit both full-time and part-time 
physicians. In all of circumstances, there is not a need to hire a 
physician in a certain specialty on a full-time basis, so part-time 
employment is preferred over full time. In many instances, highly 
qualified academic physicians hold part-time appointments with both VA 
and affiliated medical schools. This arrangement is beneficial to VA in 
that it allows us to hire a higher quality physician than we would if 
we required that they work full-time with VA, where they would not be 
able to pursue the teaching and research opportunities available 
through a joint appointment. Certainly, the new pay system has improved 
facilities' ability to recruit full-time physicians when that is the 
preferred arrangement.

Question 9: The Partnership for Public Service and American 
University's Institute for the Study of Public Policy Implementation 
rankings from the Office of Personnel Management's (OPM) Federal Human 
Capital Survey rank VHA 18th out of 222 Federal agencies as the ``Best 
Places to Work.'' Do you find that this survey is a valid 
representation of VHA staff?

Response: VHA administers an All Employee Survey (AES) annually to all 
full-and part-time VHA employees. Response rates during in 2007 were as 
high as 76.2 percent, which is 164,905 employees. The AES can therefore 
be considered a census (as opposed to a sample) of VHA employees and a 
more reliable measure of employee satisfaction that the survey from the 
Partnership for Public Service. The AES includes Job Satisfaction 
Index:--a scale that consists of 13 questions and concerns related to 
the respondent's current level of job satisfaction. The rated aspects 
of job satisfaction include: type of work, amount of work, pay, 
coworker relationships, direct supervision, senior management, 
opportunities for promotion, working conditions, perceived customer 
satisfaction, amount of praise, quality of work, overall satisfaction, 
and overall satisfaction compared to 2 years ago.

Question 10: The Partnership for Public Service analysis of the OPM 
survey shows a high satisfaction rate among employees 40 and over (12 
of 222), but very low satisfaction among its younger cohort (112 out of 
208)? How would you explain the difference?

Response: The results of AES Job Satisfaction Index:--for the rated 
aspects of job satisfaction include: type of work, amount of work, pay, 
coworker relationships, direct supervision, senior management, 
opportunities for promotion, working conditions, perceived customer 
satisfaction, amount of praise, quality of work, overall satisfaction 
for these two age groups is presented below:.
    The first selection of the data discussed below includes ratings 
from all AES respondents in 2007. The second selection of the data 
included ratings from the AES respondents in the clinical occupations 
only (such as physicians, pharmacists, registered nurses, licensed 
practical nurses, clinical laboratory employees and others). For each 
data selection, respondents' ratings were examined separately for the 
following age groups: Younger than 20; 20-29; 30-39; 40-49; 50-59; and 
60 or older. The mean ratings of each aspect of job satisfaction were 
computed for each of these age groups. The following survey ratings 
were the basis for computing the means: 1=Not at all satisfied, 2=Not 
very satisfied, 3=Neither satisfied or dissatisfied, 4=Somewhat 
satisfied, 5=Very satisfied. Ratings above 4 are considered highly 
satisfied, ratings between 3.3 and 4 (including these values) are 
considered moderately satisfied, ratings between 2.8 and 3.2 (including 
these values) are considered neutral, and ratings below 2.8 are 
considered low in this report.
    In the all AES respondents' data, only one job aspect, 
opportunities for promotion, demonstrated low mean satisfaction ratings 
for some of the age groups: for 40-49, for 50-59, and for the 
respondents who did not indicate their age. Mean satisfaction ratings 
for all the other job aspects, including the most important summary 
score: the overall satisfaction, showed either neutral or better 
ratings for all of the age groups. Quality of work showed highly 
satisfied ratings, for all the age groups. Type of work showed highly 
satisfied ratings for all the age groups except younger than 20, where 
the ratings were moderately satisfied. Relationships with coworkers 
showed highly satisfied ratings for the age groups 20-29, 50-59, and 60 
or older, and moderately satisfied ratings for all of the other age 
groups. Customer satisfaction showed highly satisfied ratings for the 
age group of 60 or older, and moderately satisfied ratings for all of 
the other age groups.
    Overall satisfaction ratings were moderately satisfied only, for 
all of the age groups; and overall satisfaction compared to two years 
ago had neutral ratings for all of the age groups. Satisfaction with 
amount of work, direct supervision, and working conditions all showed 
moderately satisfied ratings, for all of the age groups.
    Data for the AES respondents in the clinical occupations only (the 
total of 58,151 individuals) showed a pattern that was overall 
consistent with the all AES respondents' data, with the exception of 
three low satisfaction ratings. Opportunities for promotion were rated 
low by respondents younger than 20 and those who did not indicate their 
age, and amount of praise was rated low by respondents younger than 20. 
Mean satisfaction ratings for all the other job aspects, including the 
most important summary score: the overall satisfaction, showed either 
neutral or better ratings for all of the age groups. Quality of work 
showed highly satisfied ratings only, for all the age groups. Type of 
work showed highly satisfied ratings for all the age groups except 
younger than 20. Relationships with coworkers showed highly satisfied 
ratings for all the age groups except younger than 20 and respondents 
who did not indicate their age: these two groups had moderately 
satisfied ratings. Customer satisfaction showed highly satisfied 
ratings for the age group of 60 or older and moderately satisfied 
ratings for all of the other age groups. Overall satisfaction ratings 
were moderately satisfied only, for all of the age groups; and overall 
satisfaction compared to 2 years ago had neutral ratings for all of the 
age groups. Satisfaction with amount of work, direct supervision, and 
working conditions all showed moderately satisfied ratings, for all of 
the age groups. Taken together, these data suggest overall acceptable 
(i.e. neutral or better) levels of satisfaction of VHA employees with 
the comprehensively assessed various aspects of their jobs.

                                 
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