[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.