[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
HUMAN RESOURCES CHALLENGES WITH
THE VETERANS HEALTH ADMINISTRATION
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
MAY 22, 2008
__________
Serial No. 110-88
__________
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 HENRY E. BROWN, Jr., South
Dakota Carolina
HARRY E. MITCHELL, Arizona JEFF MILLER, Florida
JOHN J. HALL, New York JOHN BOOZMAN, Arkansas
PHIL HARE, Illinois GINNY BROWN-WAITE, Florida
MICHAEL F. DOYLE, Pennsylvania MICHAEL R. TURNER, Ohio
SHELLEY BERKLEY, Nevada BRIAN P. BILBRAY, California
JOHN T. SALAZAR, Colorado DOUG LAMBORN, Colorado
CIRO D. RODRIGUEZ, Texas GUS M. BILIRAKIS, Florida
JOE DONNELLY, Indiana VERN BUCHANAN, Florida
JERRY McNERNEY, California STEVE SCALISE, Louisiana
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 HENRY E. BROWN, Jr., South
SHELLEY BERKLEY, Nevada Carolina
JOHN T. SALAZAR, Colorado VACANT
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
__________
May 22, 2008
Page
Human Resources Challenges with the Veterans Health
Administration................................................. 1
OPENING STATEMENTS
Chairman Michael Michaud......................................... 1
Prepared statement of Chairman Michaud....................... 33
Hon. Jeff Miller, Ranking Republican Member...................... 2
Prepared statement of Congressman Miller..................... 33
Hon. Phil Hare................................................... 2
WITNESSES
U.S. Department of Veterans Affairs, Joleen Clark, Chief Officer,
Workforce Management and Consulting, Veterans Health
Administration................................................. 26
Prepared statement Ms. Clark................................. 56
______
American Association of Nurse Anesthetists, Angela Mund, CRNA,
MS, Clinical Director, University of Minnesota Nurse Anesthesia
Area of Study, Minneapolis Veterans Affairs Medical Center,
Veterans Health Administration, U.S. Department of Veterans
Affairs........................................................ 6
Prepared statement of Ms. Mund............................... 42
American Federation of Government Employees, AFL-CIO, J. David
Cox, RN, National Secretary-Treasurer.......................... 3
Prepared statement Mr. Cox................................... 34
American Psychological Association, Randy Phelps, Ph.D., Deputy
Executive Director for Professional Practice................... 4
Prepared statement of Dr. Phelps............................. 38
Disabled American Veterans, Adrian M. Atizado, Assistant National
Legislative Director........................................... 19
Prepared statement of Mr. Atizado............................ 54
Paralyzed Veterans of America, Fred Cowell, Senior Associate
Director for Health Analysis................................... 16
Prepared statement of Mr. Cowell............................. 48
Nurses Organization of Veterans Affairs, Cecilia McVey, BSN, MHA,
RN, Immediate Past President, and Associate Director for
Patient Care/Nursing, Veterans Affairs Boston Healthcare
System, Veterans Health Administration, U.S. Department of
Veterans Affairs............................................... 18
Prepared statement of Ms. McVey.............................. 52
Vertical Alliance Group, Inc., Texarkana, TX, Jay W. Wommack,
Founder, President and Chief Executive Officer................. 8
Prepared statement of Mr. Wommack............................ 46
MATERIAL SUBMITTED FOR THE RECORD
Post Hearing Questions and Responses for the Record:
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Hon. James B. Peake,
M.D., Secretary, U.S. Department of Veterans Affairs,
letter dated June 5, 2008, including questions from Hon.
Vic Snyder, and VA responses............................... 60
HUMAN RESOURCES CHALLENGES WITH THE VETERANS HEALTH ADMINISTRATION
----------
THURSDAY, MAY 22, 2008
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:05 a.m., in
Room 334, Cannon House Office Building, Hon. Michael Michaud
[Chairman of the Subcommittee] presiding.
Present: Representatives Michaud, Snyder, Hare, and Miller.
OPENING STATEMENT OF CHAIRMAN MICHAUD
Mr. Michaud. The hearing will come to order, and I will ask
the first panel to come forward.
I would like to thank everyone for coming today.
The Veterans Health Administration's (VHA's) mission is to
provide patient-centered healthcare that is comparable to or
better than care available in the non-U.S. Department of
Veterans Affairs (VA) sector. To do this, VHA must have a
viable healthcare workforce that is competent, well-trained and
happy.
Over the past 5 years, the VA has built a reputation of
delivering healthcare efficiently and effectively. VA has been
touted as the ``best care anywhere,'' and the Department has
been recognized on numerous occasions for healthcare quality
and patient satisfaction.
However, in order to carry that banner forward, careful
planning and efficient processes must be put into the system to
ensure continued success.
We know that VA's workforce is aging, with an average age
of 48.6 years. We know that at the end of 2012 a significant
percentage of the employees will be eligible to retire.
This Subcommittee has held many hearings that have examined
the appropriateness and quality of care and treatment that
veterans receive within the healthcare system. This hearing
today will focus on the human resource challenges that VHA must
address in order to ensure that there will not be a gap in
expertise and quality of care provided to our veterans.
The Subcommittee realizes that this is a complex issue, but
we also recognize that it is an important one that deserves
serious thought and consideration as well.
I would like to recognize Mr. Miller for any opening
statement that he might have.
[The prepared statement of Chairman Michaud appears on
p. 33.]
OPENING STATEMENT OF HON. JEFF MILLER
Mr. Miller. Thank you very much, Mr. Chairman. I do
appreciate you holding this hearing today to examine all those
challenges the VA faces in regards to keeping the high-quality
healthcare workers that are currently in the system. They are
on the frontline of the healthcare issue every single day.
Our servicemembers who have honorably served our country
deserve high-quality healthcare, and we must do what we can to
keep those professionals retained and recruit them as well. One
of the most pressing problems we face as a Nation is a marked
shortage in virtually all areas of the healthcare worker
industry, including nurses, physicians, physicians' assistants,
psychologists, pharmacists, and physical and occupational
therapists.
The VA system has been recognized for the significant
benefit of its use of electronic medical records and focus on
preventative care. To make sure that our veterans continue to
receive the best care, it is critical that we see the VA as a
workplace of choice. So I appreciate you putting this hearing
together to focus and see what we can do better.
I yield back the balance of my time.
[The prepared statement of Congressman Miller appears on
p. 33.]
Mr. Michaud. Thank you.
Mr. Hare.
OPENING STATEMENT OF HON. PHIL HARE
Mr. Hare. Thank you, Mr. Chairman. I want to thank you and
Ranking Member Miller for holding this hearing today.
The Veterans Health Administration is one of the most
impressive healthcare delivery systems in the entire world, and
that is in large part due to the dedicated medical
professionals who make up the system. From doctors to nurses to
technicians to psychologists, these are the men and women who
are on the ground every day taking care of our Nation's
veterans.
The veterans population will undergo significant changes
over the next two decades. And as such, the leadership at the
VHA will have to be prepared to handle these challenges.
One of the biggest challenges is the recruitment and
retention of highly qualified medical personnel at a time when
the overall health industry is facing massive shortages. The VA
must be able to compete with the private sector for medical
staff. And we must ensure that, as the VHA continues forward,
that they have the tools and the funds necessary to guarantee
adequate numbers of staff in order to continue the care of our
veterans.
Once again, Mr. Chairman, I want to thank you for holding
the hearing today. I look forward to hearing from our panels.
And thank you very much, Mr. Chairman. I yield back.
Mr. Michaud. Thank you very much, Mr. Hare.
Our first panel includes David Cox, a Registered Nurse (RN)
who is the National Secretary-Treasurer for American Federation
of Government Employees (AFGE) of the AFL-CIO.
I want to welcome you, David, here this morning.
And Dr. Randy Phelps, who is the Deputy Executive Director
of the American Psychological Association (APA); and Angela
Mund, who is a CRNA, the Clinical Director for Minneapolis VA
Medical Center, who is here on behalf of the American
Association of Nurse Anesthetists (AANA); and then Jay Wommack,
President of Vertical Alliance Group, Inc.
So I want to welcome our four panelists this morning and am
looking forward to hearing your testimony.
We will start off with Mr. Cox.
STATEMENTS OF J. DAVID COX, RN, NATIONAL SECRETARY-TREASURER,
AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, AFL-CIO; RANDY
PHELPS, PH.D., DEPUTY EXECUTIVE DIRECTOR FOR PROFESSIONAL
PRACTICE, AMERICAN PSYCHOLOGICAL ASSOCIATION; ANGELA MUND,
CRNA, MS, CLINICAL DIRECTOR, UNIVERSITY OF MINNESOTA NURSE
ANESTHESIA AREA OF STUDY, MINNEAPOLIS VETERANS AFFAIRS MEDICAL
CENTER, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF
VETERANS AFFAIRS, ON BEHALF OF AMERICAN ASSOCIATION OF NURSE
ANESTHETISTS; AND JAY W. WOMMACK, FOUNDER, PRESIDENT AND CHIEF
EXECUTIVE OFFICER, VERTICAL ALLIANCE GROUP, INC., TEXARKANA, TX
STATEMENT OF J. DAVID COX
Mr. Cox. Chairman Michaud and Ranking Member Miller and
distinguished Members of the Subcommittee--it seems like I am
getting off to a bad start here. I am tying my tongue up this
morning. I have never been first on a panel; maybe that is what
it is. Thank you for the opportunity to testify today. AFGE
greatly appreciates the Subcommittee's continued attention to
the impact of VA healthcare workforce problems on patient care.
Veterans want to get their care from the VA because VA
healthcare professionals are extremely dedicated to their
patients and committed to the mission of the VA. In the
eighties, labor management collaboration helped transform the
VA into a healthcare leader in best practices, patient safety
and healthcare information technology.
AFGE believes the greatest human resources challenge facing
VHA today is the continuing erosion of title 38 collective
bargaining rights, as I will discuss shortly. First, I would
like to address several other human resources issues of concern
to AFGE.
The hybrid title 38 process, which covers psychologists,
social workers, pharmacists and licensed practical nurses
(LPNs), among others, has become severely backlogged. It is
also troubling that VHA employees lose their veterans'
preference when they are converted to title 38 from title 5.
Therefore, AFGE urges this Subcommittee to reject proposals
to add more positions to title 38 and instead conduct a pilot
project using a streamlined title 5 hiring process to compare
the two systems. We would be pleased to work with you to
develop this pilot project and believe it can provide valuable
lessons for other Federal employers.
AFGE also urges the Subcommittee to conduct oversight into
the many implementation problems surrounding the 2004 physician
pay law, such as secretive process for setting market pay and
use of improper performance measures. Since Congress is still
waiting for the VA's long-overdue report on how well the pay
law is working and whether it is has reduced the VA's reliance
on costly contract physicians, we urge the Subcommittee to
conduct its own study on this important law instead.
Nurse alternative work schedules provide full-time pay for
working 3 12-hour days per week or 9 months per year. These
schedules are very popular in the private sector and could be a
valuable VHA recruitment and retention tool. Unfortunately, VHA
refuses to offer this schedule option to its nurses, even
though they were given this authority by Congress 4 years ago.
AFGE recommends that Congress amend the law to require the VA
to offer alternate work schedules based on a fixed formula that
aligns facilities with their local labor markets.
Turning to title 38 collective bargaining rights, we are
very grateful to Chairman Michaud and Subcommittee Members
Berkley, Brown and Doyle for cosponsoring H.R. 4089. This bill
is an essential enforcement tool for past and future VHA
recruitment and retention legislation.
In 1991, Congress provided RNs, physicians and other pure
title 38 providers with rights to challenge improper personnel
policies through grievances, arbitrations and the court.
Providers lost these rights because the VA began using an
arbitrary interpretation of the three exceptions in section
7422 of title 38: professional conduct and competency, peer
review, and compensation.
Management's section 7422 policy directly contradicts
Congressional intent, as is evident by the plain language of
the law and the legislative history. Management's section 7422
policy is also inconsistent with its own position that it took
in 1996 with a labor management agreement to allow grievances
over indirect patient care matters, scheduling, and rights to
pay survey data.
The VA contends that amending section 7422 will allow labor
to disrupt patient care. But management's rights to determine
the agency's mission under title 5 already protect against
that. And the VA cannot point to a single case where a
grievance involved a challenge to medical procedures. VHA
employees who have full grievance rights, such as LPNs,
psychologists, and pharmacists, never use these rights to
disrupt patient care.
The VA also contends that current law gives title 38
providers fair process for deciding when a grievance can be
filed, pointing to a review by the Under Secretary for Health.
We asked, fair to whom? In the past 3 years, 100 percent of
these decisions have been in favor of management. Shouldn't VA
healthcare dollars be spent on caring for veterans, not looking
for ways to block legitimate concerns of hard-working,
dedicated nurses and physicians?
Thank you, Mr. Chairman. I would be glad to entertain any
questions from the Committee.
[The prepared statement of Mr. Cox appears on p. 34.]
Mr. Michaud. Thank you very much.
Doctor.
STATEMENT OF RANDY PHELPS, PH.D.
Dr. Phelps. Thank you, Mr. Chairman, Ranking Member Miller
and distinguished Members of the Subcommittee. I am Dr. Randy
Phelps, Deputy Executive Director for Professional Practice of
the American Psychological Association.
We are the largest association of psychologists, with
approximately 90,000 full doctoral psychology members and
another 50,000 graduate students in the pipeline. Our folks are
engaged in the study, research and practice of psychology.
I am currently a licensed clinical psychologist but
formerly a practitioner myself, a clinical researcher and
educator. And for the last 15 years, I have been on the APA
Executive Staff and have served as APA's liaison to
Professional Psychology in the Department of Veterans Affairs.
We really appreciate the opportunity to testify today about
human resources challenges within VHA.
I should note at the outset that VHA is the workplace of
choice for many of our members. There are over 2,400
psychologists working nationwide in the system. And, in fact,
VA is the largest single employer of psychologists in this
country.
Professional psychology was born as a result of the needs
of returning soldiers from previous wars, particularly World
War II. So we owe a great debt to the brave men and women who
have served this country.
I will shorten the remarks, obviously, for the oral
testimony. There is a considerable amount of detail in the
written testimony.
But psychologists are very actively involved, particularly
in the mental health side, of treatment of veterans in VA. The
architects of the two evidence-based practice treatments for
post traumatic stress disorder (PTSD) are psychologists.
Psychologists are serving a very critical role in understanding
diagnosis and treatment of traumatic brain injury (TBI), which
is the other signature wound of the war, alongside nursing,
neurologists and other folks.
Recruitment of psychologists in the VA is actually in a
good place at this point. It has not been until the last year
and a half. And we applaud VHA's efforts to add 800 new
positions for doctoral psychologists since 2005, bringing us up
to that 2,400 psychologists in the system. Most of those folks,
I should add, are young psychologists entering the system at
GS-11.
I should emphasize that every psychologist who comes out of
a clinical or counseling program already knows how to treat
PTSD, depression and so forth.
The thing that I wanted to emphasize, though, about
recruitment is that the staffing levels are a very recent
developments. It was only 2 years ago where we reached the
staffing levels of psychologists in the VA of the 1995 years.
So the curve has been going down until just very recently with
the hiring of this new cadre of psychologists.
Additionally--and this gets to the issue of retention that
I would like to spend a little bit more time on--additionally,
the number of GS-14 and GS-15 psychologists in the system at
the higher leadership levels are actually not increasing
similarly. The GS-15 level is lower than it was in 1995.
The VA has done a good job of recruiting new psychologists
coming into the system because it is hiring its own. We have
approximately 600 psychology training positions within VA, and
75 percent of the new hires are past VA psychology trainees.
There are three major problems, however, that affect
retention of the workforce that I can elaborate on later if you
have questions.
One is a lack of uniform psychology leadership positions.
We are the only mental health position without an officially
designated leader at medical centers. There is a very
inequitable access to key leadership positions throughout VA.
And there are, as you have heard some from a colleague, very
serious implementation issues with the hybrid title 38. In
fact, I would describe the implementation of the hybrid title
38 system as an absolute boondoggle, bureaucratically and
otherwise, for the system.
These problems--which, again, we can elaborate on later--
have led to a number of very chilling situations for
psychologists throughout the country, where folks are leaving
the VA to go to the private sector, losing their positions,
inability to get advancement and so forth.
And we consider those kinds of problems as the most serious
obstacles to making VA the workplace of choice for
psychologists now and in the future, because without clear
advancement systems in place, VA faces critical long-term
recruitment and retention problems. As psychologists come to
believe that there is little possibility for advancement in the
system, regardless of the level of complexity of their
responsibilities, fewer VA psychologists will be willing to
accept positions of greater responsibility.
And, in addition, high-potential trainees coming into the
system the VA would like to recruit for the future will
increasingly, and are increasingly, seeing VA as a dead-end for
their careers and will be attracted to other career options
with more potential for advancement.
And we thank you very much for this opportunity to testify
today. Thank you.
[The prepared statement of Dr. Phelps appears on p. 38.]
Mr. Michaud. Thank you.
Ms. Mund.
STATEMENT OF ANGELA MUND, CRNA, MS
Ms. Mund. Chairman Michaud, Ranking Member Miller and
Members of the Subcommittee, good morning. My name is Angela
Mund. I am a Certified Registered Nurse Anesthetist, or a CRNA,
at the Minneapolis VA. I also serve as President of the
Association of VA Nurse Anesthetists. And I am pleased to
appear before you on behalf of my profession, the American
Association of Nurse Anesthetists and its 39,000 members in the
United States.
You have my written statement, and I ask unanimous consent
for it to be entered into the record.
Mr. Michaud. Without objection.
Ms. Mund. America's CRNAs provide some 30 million
anesthetics annually in every healthcare setting requiring
anesthesia care, and we provide that safely. The Institute of
Medicine reported in 2000 that anesthesia is 50 times safer now
than it was in the 1980s. For over 125 years, nurse
anesthetists have met the mission of caring for our veterans,
caring for those who have borne the battle, their widows and
orphans.
Nurse anesthetists are the predominant provider of
anesthesia services in the VA and are the sole anesthesia
provider in 12 percent of VA facilities. In the days before I
left for this hearing, I personally provided anesthesia for our
veterans. Any of the more than 500 CRNAs in the Veterans Health
Administration could say the same.
But the average VA CRNA is 53 years old, 7 years older than
the profession's average, and is approaching retirement. In any
recent year, nearly one in five VA CRNAs leaves or retires from
the VA. Twenty-four VA facilities report CRNA vacancies. We
believe that actual number is closer to 40, and the U.S.
Government Accountability Office (GAO), in their report, used
70 as the number. Contract personnel also fill about 150 of the
VA CRNA posts.
We are increasingly concerned that without a sufficient
number of CRNAs in the VA system, our veterans won't get the
care they need and deserve. They may have to wait too long for
that care, which ultimately may increase cost to the U.S.
Treasury.
A report last December from the GAO confirmed what we, in
the VA, have long known. The GAO found 54 percent of VA
facilities have had to close operating rooms, and 74 percent
have had to delay surgeries for lack of CRNAs. Twenty-six
percent of VA CRNAs plan to retire within the next 5 years, and
the agency has struggled to both recruit and retain nurse
anesthetists. Seventy-four percent of VA respondents to the GAO
survey said they had difficulty recruiting CRNAs.
The VA's struggle has not been for lack of CRNAs in the
marketplace. In 2007, accredited nurse anesthesia educational
programs produced over 2,000 graduates, an 88 percent increase
in just 5 years, in order to meet the growing demand for
anesthesia services. Rather, the GAO found, and we agree, that
the VA CRNA compensation is far below market levels in many
localities.
The issue of below-market compensation was cited by 90
percent of chief anesthesiologists reporting difficulty
recruiting CRNAs and by 77 percent of chief anesthesiologists
reporting difficulty retaining CRNAs. In some facilities, bad
working conditions also sent good CRNAs elsewhere.
We have three recommendations to close this gap and to
ensure American veterans have the necessary anesthesia care for
the surgical and invasive diagnostic procedures they require.
First is to enhance the VA relationship with the nurse
anesthesia educational programs. Already some 70 VA hospitals
serve as clinical practice education sites for nurse anesthesia
schools. Many hospitals find serving these clinical practice
sites helps them recruit new CRNAs.
Second is to continue nurturing the VA's joint relationship
with the U.S. Army Nurse anesthesia educational program at Fort
Sam Houston, Texas, which educates CRNAs for VA service. The
current program uses the VA Employee Incentive Scholarship
Program, or EISP, to fund tuition, fees and salary
reimbursement for nurse anesthesia students who then fulfill a
service commitment to the VA.
Third is to bring VA's CRNA compensation closer to local
market rates. The GAO recommends VA facilities take advantage
of VA locality pay policies. But that will not be enough to
close the gap. In addition, Congress should act to lift the
statutory cap on VA CRNA pay so that local facilities can set
compensation at rates closer to market levels.
Of all the options available to close the VA's CRNA
workforce gap and ensure veterans gets the high quality of care
they deserve, these three suggestions are the most cost-
effective and the easiest to carry out.
Thank you, and I would be happy to take your questions.
[The prepared statement of Ms. Mund appears on p. 42.]
Mr. Michaud. Thank you very much.
Mr. Wommack.
STATEMENT OF JAY W. WOMMACK
Mr. Wommack. I would like to start with a quote. ``In times
of change, learners inherit the Earth, while the learned find
themselves beautifully equipped to deal with a world that no
longer exists''--Eric Hoffer.
I don't need to repeat the nursing shortage; everybody up
here knows that. The baby boomers are about to retire. We, 2
years ago, entered the first baby boomer turning age 60. This
year, the first baby boomer started to retire at 62. And this
generation looks like a basketball going through the belly of a
snake, and behind it we do not have enough people to fill the
needs in the healthcare industry.
On top of that, we have a declining dollar. A declining
dollar causes devaluation of the currency, which means the
Canadian dollar is more powerful. We are seeing nurses leave
the United States, to go back up north.
We see all these things and we see the nursing shortage is
in quite a state, but I think there is a worse shortage than
that out there, and the worst shortage is the shortage of
qualified, well-trained, recruiting personnel, not just to
recruit nurses and medical personnel, but also to go out and
actively recruit people to teach in the schools, because we are
short on educators. We had to turn down 38,000-plus, in the
last few years, going to schools to learn how to be medical
personnel.
Each month, millions of dollars are spent on advertising to
draw people into not just the private sector, but into the
public sector, both sectors, to draw them into the medical
community, to recruit them for institutions. Millions of
dollars are spent to generate leads and phone calls. And guess
what happens? We have dealt with the private sector, and 82
percent of the phone calls for people that would like to have
jobs go unanswered. I cannot speak for the VA system; I haven't
worked with them. But in the private sector, that is an
astounding number, and that number is shocking.
Mr. Chairman, Members of Subcommittee, my name is Jay
Wommack. I am the Chief Executive Officer of a company called
Vertical Alliance Group. We are an Internet-based training,
recruiting company. We were founded in 1999. We have 80 Web
sites, sub-domains and domains, of which a couple of them
represent the medical community, one called NurseUniverse, one
called MedVotech. Obviously, the names imply they are out to
recruit nurses and people for the medical vo-tech schools. We
operate those Web sites.
And I have to tell you, I am honored to be here to make
this presentation. It is a wonderful experience and wonderful
opportunity, and I appreciate you all taking the time to hear
us and our testimony.
I don't make any claim to be a professional in the
healthcare services area. However, we do know quite a bit. In
the last 9 years, we have developed quite a bit about the
process of recruiting and retaining good employees. Now, we do
this with boot camps. And let me address that issue real quick.
There is a dire lack of training for people that know how
to go out and deal with the society today. The Internet changed
everything. It made us an immediate-gratification society.
Things happen fast. I mean, when I go to Amazon and I go and
order a book, I want it, I want it now. I don't like waiting
till tomorrow. And this is how people are when they are looking
for jobs. They go fill out an application or make a phone call.
These people are hanging up before 1 minute when no one is
answering the telephone. They are sending in applications, and
you have seen the medical applications. It takes time to fill
out an application. They send those in, and they get no
response.
So what we did as a company is we started to develop
processes that basically said we are going to train people from
being paper processors, the old style of human resource, into
active, proactive salespeople. Because that is what it takes to
compete in this environment.
We train them to be salespeople through our boot camps. We
empower people and teach the salespeople--we call them
salespeople--we teach them sales training. We teach them
direct-response marketing. We teach them what it costs to
actually recruit a nurse. Many people don't know. Advertising
cost per hire is $10,000 to recruit a nurse, according to AMA.
It costs between $35,000 and $70,000 to recruit a nurse, not to
mention a nurse anesthetist. So we are training these people,
we are empowering them, teaching them what it takes to go out
and be a proactive recruiter.
Have we had success? The standard average of a recruiting
department gets between 1 and 2 percent closing on the people
that apply for a job. Our companies, on a bell curve, at the
top of it, get an average of 12 percent closing. Some,
obviously, have gotten much more than that, some less, but on
the average, on the bell curve. That is significant savings to
the bottom line. The process lends itself to the lowest cost
per hire.
But you have to inspect what you train, and you have to
continue to teach what you train. So we developed a process, an
online, Internet, databased program that basically teaches,
tracks, trains and follows up on all the education we provide
at the boot camps. We do it daily, weekly, monthly. It is
available 24/7.
It doesn't just happen, though. In order for a program to
be successful, it must have buy-in from the top. Obviously, we
wouldn't be sitting here if there wasn't buy-in from the top.
I visit with a number of VA healthcare facilities. The
executives at those facilities, they absolutely care. They
would like to push forward, and they have put together great
programs, but they like to push forward and get their hiring in
order.
I am excited to be here. I appreciate the opportunity to
speak, and I will be glad to answer any questions.
[The prepared statement of Mr. Wommack appears on p. 46.]
Mr. Michaud. Thank you very much. I appreciate it.
My first question will be for Mr. Cox.
You talked about H.R. 4089, the bill that is pending. If
that is passed, what impact will that really have on
recruitment and retention, in your opinion?
Mr. Cox. We believe that it would give the registered
nurses and physicians the same rights that other employees have
in the VA; that if there are workplace disputes, that they
would have an avenue to resolve those disputes and to seek
relief in that arena.
It is a message we hear from our membership and the VA
employees over and over, and we believe that it would certainly
make for a better workplace.
Mr. Michaud. But as far as the recruitment or retention, do
you think it will have a positive effect?
Mr. Cox. I think it will definitely have a positive effect
on the recruitment and retention, because, again, when you are
able to resolve problems in the workplace through a negotiated
agreement to resolve those issues, that makes people feel
better. There is a way to seek relief if you believe things are
wrong.
I believe, also, the fact that the pay data, that we have
all the locality pay systems, but now if a request is made to
the VA, ``Share this data with us, show us what you are paying,
give us information,'' it is, ``No, we do not have to provide
that to you, because that is a section 7422 issue.'' I believe
it would bring more light to the issue of pay and the
recruitment process. But it would definitely be a positive
impact.
Mr. Michaud. Thank you.
Dr. Phelps, you had mentioned the impact of the hybrid
title 38. What impact would moving psychologists to title 38
from the hybrid title 38 have on recruitment and retention of
these professionals?
Dr. Phelps. Mr. Chairman, that is an issue that we are--
because we are so frustrated with the difficulties and the
implementation problems with the hybrid system, that is an
issue that we are looking at very seriously right now.
Preliminarily, we think it would be the way to go for
psychologists. We are the only doctoral-level professionals in
the VA system that are not in the title 38 system. So we are
very much in favor of that direction.
Mr. Michaud. Thank you.
Ms. Mund, how many CRNA candidates rotate through the 70 VA
training sites annually?
And my second question is, out of that, how many of those
candidates actually choose the VA upon completion of their
training?
Ms. Mund. I don't have those numbers with me, but I can
have my staff look at that.
However, what I can speak to is--I am clinical director of
a nurse anesthesia program through the University of Minnesota.
And the VA in Minneapolis is our primary clinical site. We have
had a relationship with them 25 years, I believe, recently. And
we send 10 students per year through the VA. We get some
support from Central Office, which we appreciate. In previous
years, as much as 75 percent of the graduating class have
stayed at the VA. However, in the last 2 years, we have had one
person out of 20.
And a lot of that is due to low pay, is the main thing. I
mean, they come out with student loans and are unable to have a
salary that makes it easier to pay those student loans off.
And the other big piece of it is the employee debt-
reduction program that the VA has, it is not entirely, through
issues with human resources, lack of understanding of the
program. Not everybody who has been eligible has been able to
take advantage of that as a student loan payback. So they have
chosen to go to places where they can see exactly, when they
apply, HR can tell them, ``This is what you will make, this is
what we will give you, and this is what your loan payback is.''
The VA is a little bit hazy on that, so students elect to go
elsewhere.
Mr. Michaud. I believe it was in your written testimony,
you recommended $400,000 in fiscal year 2009 appropriations to
expand the joint education program. How many additional CRNAs
would this funding affect?
Ms. Mund. What they have right now is they have had seven
graduates and are working. They have three who are in what we
call phase II, which a clinical portion, three that are in the
first-year portion, and three that are starting.
I believe that they would like to increase that number, and
the Army is available with slots, with seats for those, but
they need additional funding to have the students come.
The benefit of going there is that you get your tuition,
salary and your education paid for. And then they have a three-
year commitment after completing the program.
Mr. Michaud. Thank you.
My last question is for Mr. Wommack.
What immediate action should the VA take to modernize their
hiring system so that it is competitive with the private
sector?
Mr. Wommack. That is a very good question.
The first thing I would do is I would start training the
personnel on being very proactive. You have to train these
people. They have the tools in place. The VA has done a great
job of putting together a package of information, kits like
that. But they have to be brought into the 21st century via the
technology, the platforms of technology that they have at their
disposal and that we offer.
They have to be trained, and they have to be trained in the
value of what they are doing, the lead. The half-life of a
lead, when someone picks up that phone to call or when someone
sends in an application, the half-life of that lead is probably
less than 4 hours. In other words, if you don't touch it in 4
hours, they are gone. That is what we found; it may be even
shorter than that.
So the first thing I would do is set up training for them.
And then you have to follow up and monitor exactly what you
have taught. You have to inspect it every single week. We do
that with our existing clients. We train them, and then we
follow up every single week, and we make them respond to us,
because that is where you ferret out what the real problems
are. You find out what is working, what is not working, and
then you adjust it and you change it. And then you continue the
education process.
Mr. Michaud. Great. Thank you.
Mr. Miller.
Mr. Miller. Thank you, Mr. Chairman.
Mr. Cox, can you give me a little feel for the difference
between title 5 and title 38 in regards to the hiring process?
How would title 5 be more or less stringent than title 38?
Mr. Cox. Title 5 employees get on registers. They go
through, as you know, the various places throughout the
country. They apply with USAJOBS, those type things. They get
on registries. They are hired. From that, they get veterans'
preference, things of that nature.
Title 38, like registered nurses and physicians, they can
go to a VA medical center, fill out an application and be
hired. There is a boarding process that title 38s have to go
through, the credentialing process, things of that nature,
which takes a very lengthy period of time. And that is what
really holds up a lot of the hiring process at the VA in the
title 38 arena.
With the hybrid title 38s, again, the VA has not developed
a lot of the qualification standards, so there is not the
boarding processes to promote these people and to move them
through the proper grades. It is a very, very complex hiring
system.
Mr. Miller. Well, you recommended establishing a pilot
program streamlining title 5. I would like to know a little
more in detail about, what that plan would--or how it would
differ from the current title 5? Wouldn't it be just as useful
to streamline or do a pilot program to streamline the hybrid
title 38 hiring process?
Mr. Cox. We believe that you can go to Office of Personnel
Management (OPM) and the agency, VA, can work with OPM, do a
demonstration project to--like, nursing assistants is one group
that, if people are certified, that you could hire them through
a title 5 process that would actually be easier than the hybrid
title 38. Because with that, you have to develop the
qualification standards, the boards that would then have to
evaluate the people, determine their promotions and
appointments and things of that nature.
So we believe that there are procedures with OPM that could
actually streamline title 5 and make it easier than hybrid
title 38. And one thing that we believe that that would also
help, it would maintain the veteran preference for the
employees.
Mr. Miller. Give me a little indication of how the
retirement benefits differ from the Federal worker and the
private sector right now.
Mr. Cox. The difference in the retirement benefits?
Mr. Miller. Yes.
Mr. Cox. I am not sure that I could give you a total
picture on that.
Mr. Miller. More, less, better, worse?
Mr. Cox. I retired from the Federal Government myself 2
years ago, and I have friends that are in the private sector.
And I would say, with the current FERS employees, it is about
comparable to the private sector. Most employees in the private
sector have some type of matching 401(k) plan and some other
defined benefit plan, such as--available with that. But I would
say this, we're fairly comparable in that arena.
And, in some areas, I believe the private-sector retirement
may be better; in others, obviously, the Federal Government. I
am not sure that I am----
Mr. Miller. What about health insurance?
Mr. Cox. Health insurance, private sector, in many cases,
is better than the Federal employee health insurance.
Mr. Miller. Dr. Phelps, what benefits do you see in
bringing psychologists fully into the title 38 program?
Dr. Phelps. As I said, Mr. Miller, we are looking more
closely at that. We have tried to be good citizens with the
hybrid system. So the benefits would be to eliminate some of
these kinds of problems with the hybrid system.
Let me give you a couple of examples. As Mr. Cox said, that
with the hybrid title 38 system there is required the creation
of professional standards boards for each of those disciplines.
Psychology has a national professional standards board, and it
also has developed its quality standards. And so that process
is under way.
But what has been happening for the last year or so is that
psychologists with additional scope of responsibility--running
huge treatment programs, 60 psychology staff under them and so
forth--who have submitted to the professional standard boards
and have then been recommended nationally for a grade increase
have then been stymied at the level of the local medical
center, in most cases. Some cases, it is at division level.
And the VA itself is issuing, in some cases certainly,
informational missteps about who is qualified, who is not
qualified, what do you have to submit and so forth.
So moving into a system that is based on the title 38
system, that is based simply on the professional is hired,
promoted and retained based solely on their qualifications, as
opposed to going through these very complex processes that VA
has been unable to implement over the past 5 years. It has been
5 years since the Congress changed the hybrid statutorily.
So we believe that it would very much not only simplify the
system for psychologists, but certainly improve the recruitment
of new psychologists and, clearly, the retention of
psychologists, the leadership. We have a lot of psychologists
in the system who have been in 20 and 30 years that are
operating at the GS-13 level. They are not there for the money.
They are there because of the dedication to veterans. And they
need to be the folks training the new cadre of professionals.
Mr. Miller. Thank you very much.
I apologize to Ms. Mund and Mr. Wommack. My time for
questions has expired.
Mr. Michaud. Mr. Hare.
Mr. Hare. Thank you, Mr. Chairman.
Ms. Mund, I was wondering, could you please compare the
differences between hiring, retention or educational benefits
packages offered by the VA and the private sector for CRNAs?
And does the VA excel in any of those areas more than the
private sector?
Ms. Mund. Well, the main difference, I think, between the
two is other places, what I have heard from my students,
especially recent grads, are they can call up the University of
Minnesota hospital and say, ``I am a new grad. What am I going
to start at for salary? What kind of bonus am I going to get?
What can I see for loan paybacks?'' And they can get that
number from human resources immediately.
The problem with the VA is often they will call human
resources and they will get a range just like it is posted on
VA Jobs. So the student does not know where they are starting
until they sign on. Often they are not going to take that
chance when the range is anywhere from $89,000 to $139,000. It
is difficult to see where you would fit on that scale.
The other thing is the employee debt-reduction program,
which I spoke to before, which I think is a great recruitment
tool. The problems is there is a 6-month window that, if you
don't apply for it within that time, you are no longer
eligible. Well, if for some reason paperwork has been lost, the
human resources person covering that student has some lack of
information, all of a sudden that 6-month window is gone and
the debt-reduction program they are no longer eligible for.
Other things related to that is human resources also, if it
does not say on the Web site that you are eligible for the
Education Debt Reduction Program (EDRP), they cannot offer that
to you once you sign on.
So I think a lot of it is the transparency for when
students apply for jobs. They need to see that in the VA. They
need to know that these things are going to be available and
rather than getting lost in the shuffle of paperwork and time.
Mr. Hare. Because it would seem to me, somebody graduates
and they know at one hospital what their bonus is going to be,
their salary is going to be, their compensation is going to be,
almost to the penny----
Ms. Mund. Right.
Mr. Hare [continuing]. And then you have the VA who gives
them a range. So if you are getting out of school with a lot of
debt load, and I am sure the debt load is significant, it has
got to really put us at a disadvantage, I am assuming.
I can't blame the student, I mean, obviously, because they
have spent this time and, as I said, built up a lot of debt.
Ms. Mund. And I think the unfortunate thing is they
primarily had their training site in the VA, and they loved
taking care of veterans. There really is not another population
that is like that. But after having the time and expense of
school, sometimes you have to weigh those things. And I think
that if we did a better job of a transparent benefit package, I
think the VA could be very comparable.
Mr. Hare. Mr. Cox, can you talk a little bit more about the
hybrid hiring process and what makes it so long and complicated
for prospective applicants?
Mr. Cox. The hybrid--again, the VA has to develop
qualification standards. The way that it is sold to everyone in
the beginning is that, okay, hybrid, you can just walk in, fill
out an application and apply for a job. That is fine; that
process is simplified. But then there is the qualifications
standards, the professional standards boards. These people have
to be brought in. The boards have to meet. They have to review
the qualifications of the people, then establish their grade,
those type things.
That is what really complicates the process. While it is
not the actual application process, it is the professional
standards boards, the qualifications standards that create the
problems in it.
Mr. Hare. And my last question here. Dr. Phelps, outside of
fair compensation, how else would uniformed leadership in the
VA facilities benefit recruitment and retention of
psychologists?
Dr. Phelps. The issue of uniformed leadership is this. In
the mid-nineties, when Dr. Kaiser came in, regionalized the
system, got rid of discipline-based services, what happened
was, not just to psychology but with other professions as well,
social work--I am most familiar with the mental health side--is
we had staffs reporting to other disciplines who had no
understanding of what the standards of practice are within that
particular discipline.
What has happened since then is a recognition by the system
that the ability to certify the qualifications, the skill sets
and so forth of psychologists in the system requires somebody
in psychology. So we have a system where there is no
uniformity. Facilities appoint a lead psychologist or a senior
psychologist; there are many different terms. And this gets
back to the issue of, sort of, fair pay for a fair day's work,
Mr. Hare. Those folks operate in those positions in addition to
their regular job description.
And part of our issue with the hybrid is national standards
boards and the quality standards have recognized that those are
additional responsibilities that should bring additional pay,
but there is no uniformity even at the level of what those
types of positions are.
Mr. Hare. Thank you.
Thank you, Mr. Chairman.
Mr. Michaud. Thank you, Mr. Hare.
Once again, I would like to thank our panelists. We will
have some additional questions for the record, so if you could
answer the questions for the record, we would appreciate it
very much. Once again, thank each and every one of you for
coming out this morning.
Our second panel is comprised of Fred Cowell, who works for
the Paralyzed Veterans of America (PVA); Adrian Atizado, of the
Disabled American Veterans (DAV); and Cecilia McVey, who is the
Associate Director of Patient Care and Nursing in the VA Boston
Healthcare System, and Immediate Past President of the Nurses
Organization of Veterans Affairs (NOVA).
I would like to welcome our second panel. I am looking
forward to your testimony here this morning.
And we will start off with Mr. Cowell.
STATEMENTS OF FRED COWELL, SENIOR ASSOCIATE DIRECTOR FOR HEALTH
ANALYSIS, PARALYZED VETERANS OF AMERICA; CECILIA McVEY, BSN,
MHA, RN, ASSOCIATE DIRECTOR FOR PATIENT CARE/NURSING, VETERANS
AFFAIRS BOSTON HEALTHCARE SYSTEM, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS, AND
IMMEDIATE PAST PRESIDENT, NURSES ORGANIZATION OF VETERANS
AFFAIRS; AND ADRIAN M. ATIZADO, ASSISTANT NATIONAL LEGISLATIVE
DIRECTOR, DISABLED AMERICAN VETERANS
STATEMENT OF FRED COWELL
Mr. Cowell. Chairman Michaud, Ranking Member Miller and
Members of the Subcommittee, on behalf of the Paralyzed
Veterans of America, I am pleased to offer our views concerning
the human resource challenges within the Department of Veterans
Affairs.
Mr. Chairman, the Subcommittee's interest in the issues
concerning VA healthcare personnel is well-placed and timely.
Congress must assist VA's efforts to recruit and retain its
corps of healthcare professionals as the demand for healthcare
increases because of today's wars and the aging of veteran
population from previous wars.
Currently, the Nation is experiencing serious shortfalls in
its supply of physicians, nurses, pharmacists, therapists and
psychologists. Competition for experienced medical personnel
and newly licensed professionals is keen.
PVA believes that Congress must take the lead in revamping
outdated personnel policies and procedures, that includes
salaries, benefits and working conditions, that may place VA at
a disadvantage in today's labor market and will prevent VA from
becoming a medical care employer of choice in the future.
PVA also believes that the broken VA appropriation process,
which delays VA funding, is a major barrier to VA's healthcare
professional recruitment processes.
VA nurse recruitment and retention efforts: As has been
stated earlier, the United States is currently in the 10th year
of a critical nursing shortage which is expected to continue
through 2020. The current and emerging gap between the supply
of and the demand for nurses may adversely affect the VA's
ability to meet the healthcare needs of those who have served
our Nation.
The VA must be able to recruit the best nurses and retain a
cadre of experienced, competent nurses. Providing high-quality
nursing care to the Nation's veterans is integral to VA's
healthcare mission.
VA physician recruitment and retention: PVA is concerned
about VA's current ability to maintain appropriate and adequate
levels of physician staffing at a time when the Nation faces a
pending shortage of physicians. Recent analysis by the
Association of American Medical Colleges indicates the United
States will face a serious doctor shortage over the next few
decades. The subsequent increasing demand for doctors as many
enter retirement will increase challenges to VA's recruitment
and the retention efforts.
VA's psychologist recruitment, retention and appropriate
promotions: According to the American Psychological
Association, VA is the largest single employer of psychologists
in the Nation. Congress and VA have recognized the need to
increase the number of psychologists and have added more than
800 new psychologists since 2005, thereby raising the number of
the psychologists in the VA system to approximately 2,400.
VA must also strive to retain and promote its more
experienced psychologists in order to meet new training and
supervision requirements. Since the vast majority of new
psychologist hires in VA are less experienced professionals, VA
must ensure they are properly trained and supervised. VA must
also strive to retain and promote its more experienced
psychologists in order to meet new training and supervision
requirements.
Recommendations to enhance VA's recruitment retention
efforts: Congress must revamp outdated VA personnel policies
and procedures to streamline the VA hiring process and avoid
recruitment delays that become barriers to employment.
Conduct Congressional oversight hearings to determine the
extent of problems regarding national standardization and
availability of VA locality pay.
Congress should implement a title 38 specialty pay
provision for VA nurses providing care in VA specialized
service areas, such as spinal cord injury, blind
rehabilitation, mental health, and traumatic brain injury.
Review and adopt the recommendations developed by the VA's
National Commission on VA Nursing. PVA believes these
recommendations have broad application and can serve as a
template for improvements that can assist VA's human resource
management recruitment and retention efforts.
Congress should improve the provisions of VA's Education
Debt Reduction Program, the EDRP. Currently, the EDRP is
limited to not more than $49,000 spread out over 5 years of
service. This program has not kept pace with the soaring costs
of medical specialty education. Expanding benefit levels in
EDRP will make VA more competitive than the national healthcare
professional marketplace.
VA must also become more flexible with its work schedules
to meet the needs of today's healthcare professionals.
Other benefits, such as child care, and a less stringent
policy regarding mandatory overtime will make VA employment
more attractive.
Congress should also consider reinstating the VA Health
Professional Education Assistance Scholarship Program. This
program was sunset in 1998, and the program would be an
excellent medical care student incentive to future VA
employment.
Finally, Mr. Chairman, PVA believes that Congress must find
a solution to delays with the VA appropriation process. Delays
in VA appropriations hamstring VA managers' recruitment efforts
all across the country.
Mr. Chairman, this concludes my remarks. I will be happy to
answer any questions you may have.
[The prepared statement of Mr. Cowell appears on p. 48.]
Mr. Michaud. Thank you very much.
Ms. McVey.
STATEMENT OF CECILIA McVEY, BSN, MHA, RN
Ms. McVey. Mr. Chairman and Members of the Committee on
Veterans Affairs' Subcommittee on Health, the Nurses
Organization of Veterans Affairs, NOVA, would like to thank you
for inviting us to present testimony on human resource issues
in VA.
I am Cecilia McVey, Associate Director for Patient Care/
Nursing at the VA Boston Healthcare System, and I am here today
as the Immediate Past President of NOVA. NOVA is the
professional organization for registered nurses employed by the
Department of Veteran Affairs.
NOVA respects and appreciates what our labor organizations,
such as AFGE and the National Association of Government
Employees (NAGE), do for VA nurses. NOVA clearly deals with VA
on RN professional matters, not working conditions, for which
VHA RNs have the union representative. Because this Committee
has invited NOVA to share its views on this bill however, I am
here to offer the following observations.
Nursing and other medical center workforce members are
dependent on timely and efficient recruiting. Human resource
departments across VHA are not able to function optimally due
to systems that have not kept pace with our private-sector
recruitment abilities. Although there are numerous barriers to
timely and efficient recruiting, the following are the top
three.
Although certain pay flexibilities do exist, such as
recruitment bonuses, retention allowances and the special rate
authority, additional pay flexibilities are needed in order for
VA to be able to successfully compete for the best candidates
in the marketplace. The current general schedule and locality
pay system, which works hand in hand with the classification
system, is antiquated and cannot respond quickly enough and has
a number of major barriers.
For example, retention allowances are not considered base
pay for benefits such as retirement and life insurance. And
candidates have declined positions based on this limitation.
VA's special pay rates--there are restrictions on how far the
table can be expanded, and the approval process for special
rates is too slow to address the current market conditions.
Above-the-minimum rates allow a manager to appoint an applicant
above the minimum step, but there is no mechanism, for example,
to increase the pay of existing staff to maintain pay parity.
The application process, how to apply, is very cumbersome
and confusing to those in the private sector who are used to a
much faster and simpler process. Staffing specialists must help
many of the would-be applicants to navigate through the maze of
the Federal application process.
A consistent theme across the country is that applicants
are looking for money for professional development, not just in
clinical occupations but in administrative as well. Tuition
reimbursement is limited to a few select occupations at this
time, such as nurses, that still require expansion.
Some suggested policy changes recommended are as follows:
More pay flexibility should be provided. Pay reform similar to
the physician pay reform, where there is a market pay
component, would provide the needed flexibility for VA
facilities at the local level.
Classification standards are in need of review and
revision. Many of them are too old and no longer reflective of
the types of duties and responsibilities that are typically
performed. Given that these are used to determine the pay, they
can often serve as a barrier to appropriate and effective pay
setting.
Given the sizable number of employees at or near retirement
age, succession planning is becoming increasingly important,
especially for those critical positions.
One other critical area of concern relates to the impact on
patient care if 38 U.S.C. 7422 exclusions were to be repealed.
Some of the issues that I foresee would have a negative impact
on the care of our veterans include the following: RN
reassignment decisions made on the basis of clinical
competence, performance appraisals, and proficiency reports;
fitness for duty issues as determined by a professional
standard board; clinical competence issues as determined by a
professional standard board; and disciplinary and major adverse
actions based on patient care or clinical competence issues.
Determination of clinical competence is best reserved for those
responsible for ensuring that quality care is delivered.
VA has been a leader in healthcare and has earned an
excellent reputation as one of the best healthcare providers in
the country. In order to continue this reputation, VHA's staff
will need to have new skills and competencies to treat this new
generation of veterans. Nimble and flexible human resource
processes are critical to VA's future success.
Thank you, Mr. Chairman and Members of this Subcommittee,
for this opportunity to testify here about these important
personnel issues. And I would be happy to answer any questions.
[The prepared statement of Ms. McVey appears on p. 52.]
Mr. Michaud. Thank you very much.
Mr. Atizado.
STATEMENT OF ADRIAN M. ATIZADO
Mr. Atizado. Mr. Chairman, Members of the Subcommittee, I
thank you for inviting the Disabled American Veterans to
testify on human resource challenges within the Department of
Veterans Affairs' Veterans Health Administration.
As you have been made aware by this panel, as well as the
previous panel, the human capital needs of VHA are quite a
concern. There are a few factors I think that we must talk
about before I can fully deliver my oral testimony. We have to
understand that the workforce shortage in the Nation is
primarily defined in three factors: supply, demand and,
obviously, the compensation package.
Congress has seen fit to address compensation package with
regards to the physician pay bill reform as well as VA changing
the nurses' compensation package.
Also, VA has been creating some new initiatives with
regards to the supply end of the issue. You just heard the
concern about not enough trainers and preceptors for the
healthcare fields. And I think that should also be addressed,
not only by VA, but by this Committee as well.
I would like to highlight a few factors within VHA that
drive the human capital needs of VHA. There is a distinct
variation in demographics and behavior of the newest generation
of VA's patient population compared to the veterans of previous
conflicts.
On the attrition of its workforce, by 2012, nearly 92,000
VHA employees who would be eligible for full civil service
retirement. Over 46,000 of those are projected to retire. In
fact, the health resources and services administration division
of the Department of Health and Human Services projected a
national shortage of nearly 500,000 nurses by 2010 and over 1
million by 2020.
Moreover, the unbalanced matriculants and supply of
prepared healthcare workers, as well as the maldistribution of
these workers across the U.S., will demand much more of VHA's
human resource program.
Without question, recruitment management and providing
direction for VA employees on such issues as hiring
compensation, performance management, and organizational
development are critical to the success of VHA's mission to
provide high-quality care to sick and disabled veterans.
While, as I have mentioned, most recent actions by Congress
to affect the compensation package of VHA to offer to
prospective employees necessitates additional implementation
oversight, as mentioned by the previous panel.
We believe an equally important problem within the realm of
recruitment that requires additional attention is the Federal
hiring process itself. This was touched upon by the previous
panel. Hiring a new wave of Federal employees to succeed those
that leave is paramount, given the frequent civil service
hiring freezes of the past 2 decades and the inadequate funding
levels in the unpredictable nature of the discretionary budget
process.
Fortunately, there is a perennial and widely acknowledged
complaint by applicants for Federal employment about cumbersome
Federal hiring procedures and practices which require too much
time and excessive paperwork. Of those who submit applications,
many say they never received feedback from agencies of
interest.
The most recent Merit Systems Protection Board's survey of
entry-level hires and upper-level hires showed that substantial
numbers had to wait 5 months or longer before being hired. This
is much, much too long to expect a high-quality applicant to
wait, particularly in the healthcare arena, which is extremely
competitive.
As the Subcommittee is aware, VHA's workforce is covered
under title 5, title 38 and title 38 hybrid. The greater
majority of VHA employees fall in title 38 as well as the title
38 hybrid. Personnel rules under both were designed to allow
greater flexibility and expedite VHA's hiring and promotion
processes. However, the reality of hiring and promotion
processes are facing extraordinary delays, particularly in the
boarding process across health disciplines from nurses to
psychologists, as well as background searches. The Federal
hiring process is so daunting that it often reinforces
applicants' worst fears of government as an ineffective,
unresponsive and incomprehensible bureaucracy.
In addition, at times there is often poor communication
between Federal managers and Human Resource professionals on
the qualities and skills needed in a candidate. Attrition of
experienced VHA human resources employees has a direct impact
on the quality of recruitment and retention efforts, as well as
providing needed assistance to train new and inexperienced
staff to successfully hire needed VHA employees. Only by
insisting that VHA make recruiting talent a top priority, that
both agency leaders and managers are held responsible for
results, and that the individuals involved in the hiring
process be held more accountable can we ensure that VHA
recruits the talent needs to meet the challenges ahead.
Mr. Chairman, this concludes my testimony. I will attempt
to answer any questions you may have.
[The prepared statement of Mr. Atizado appears on p. 54.]
Mr. Michaud. Once again, I would like to thank all three of
you for your testimony this morning. Just a couple of quick
questions.
You all touched upon retention and talked a lot more about
recruitment. What additional programs or tools do you feel that
the VA can use in trying to retain the employees that they
currently have?
I'll start with Mr. Atizado.
Mr. Atizado. Well, the retention package of VA should first
be seen in a different light than the recruitment package. As
previously mentioned, there are certain things that current
employees, direct healthcare providers in VHA, look to when
they make a decision whether to stay in VA or not, whether it
be the education reimbursement package which, by the way, my
colleague has mentioned, has expired back in 1998. We believe
and we actually recommended that be addressed in a previous
testimony last year before the House Veterans' Affairs
Committee.
In addition, I believe there is a great concern in the
Nurse Corps with regards to the pay bands. A lot of the well
experienced nurses in VA are very much at the top tier of the
pay band and have nowhere to go. They are, to look across the
street at a private healthcare system, which will offer more;
and obviously there is an unequal footing.
Ms. McVey. The pay band cap is an issue for nurses and for
nurses anesthetists as was testified early. That is one thing.
Ongoing educational benefits are critical for retention and
not just for nursing. I think it is very important for the
succession planning for other deliverers of healthcare, such as
human resource departments that support the work for nursing,
and the workforce.
To have educational moneys for these people for succession
planning would also be very valuable support for the VA Nursing
Academy program. This is a program I am not sure you are
familiar with where the VA has funded last year four pilot
programs with a VA and an adjoining university, to help bring
more nurses into the workforce for VA. But it is also an
opportunity for VA staff to become educators in these
universities and give them additional opportunities, while
still remaining a VA employee, to deliver care and also expand
our workforce and give that workforce another opportunity to
expand their horizon. And that would indeed also help
retention.
Mr. Cowell. Mr. Chairman, just to build on what has been
said, I think VA needs to look at doing a better job with its
internal scholarship programs. These are great incentives for
people to improve their skills, get higher education, and
remain loyal employees of the VA.
We mentioned earlier the EDRP, the Education Debt Reduction
Program, the cost, especially of medical education, is soaring.
For people who want to improve their position, improve their
skills and seek higher educational opportunities, these types
of programs can help reduce some of that debt that goes with
higher medical education. We think that would be an excellent
incentive.
Locality pay is certainly an issue. It needs to be more
fairly distributed and available across the system.
We think flexible schedules are important. It was testified
about earlier. And in addition, you know, bonuses are not just
a recruitment tool, but they are also a retention tool; and we
think that pot of money needs to be more fairly distributed and
available across the system. Even, perhaps, a set-aside pool of
money in the VA for bonuses would be a good idea. Currently, we
hear that local facility managers have to take that available
money out of their existing FTEE budget, so when they do that
and they have bonus money available, then they are not as able
to hire the additional staff they really need.
So it is a lot of issues out there and a lot of personnel
issues. We think a review of section chapter 74 and 76, both
the personnel and the educational benefits, to take a good
look.
Mr. Michaud. Thank you very much.
Mr. Miller.
Mr. Miller. Thank you, Mr. Chairman.
Mr. Cowell, in your testimony--excuse me, I am sorry. I
have this about the nurse organization.
Ms. McVey, in your testimony you raise concerns about
including matters relating to direct patient care and clinical
competence in collective bargaining rights.
Please explain in more detail your concerns.
Ms. McVey. I think--if section 7422 were to be repealed, I
think that it would cause perhaps some delays because inherent
in the bargaining process itself is the element of time; and if
certain issues needed to be negotiated, such as mandatory
training on traumatic brain injury, as an example, it may
delay--not always, but in some cases. The implementation of
being able to effect that training might be one example.
I also think there is some inconsistent application of
section 7422 across the United States, and this may also be an
issue. Perhaps it is invoked not appropriately when it should
not have been or should have been; and I think that is some of
the concern right now.
Mr. Miller. Mr. Cowell, you reiterated in your testimony
several recommendations for improving VA's recruitment process
from the National Commission on VA Nursing.
Can you give me an idea of what you think may be the top
one, two, or three of those recommendations?
Mr. Cowell. Yes.
We had a meeting with Cathy Rick, who is the head of VA
nursing, and we talked a lot about the Commission's
recommendations. She told us that many aspects of that have
been implemented, and it is becoming good policy. But she
talked about some of the problems that VA nurses, even though
they are in--somewhat always in need of more compensation; but
there is a lack of organizational sharing responsibility that
they feel would be a great incentive to make them feel more
important and more a part of the healthcare team.
That was something that really came through in our
discussion with nurses across the system, that they just think
they could share a greater responsibility in unit planning and
unit organization and have a greater responsibility in the
administration of those areas.
Mr. Miller. What effect do you think specialty pay rates
for certain nursing professions would have on the recruitment
and retention of nurses and physicians that don't have
specialty pay?
Mr. Cowell. Well, we have--our analysis of the data of the
spinal cord injury system, and that is our expertise, there is
an agreement and a rule that the nursing service that works in
the spinal cord injury service, 50 percent of those are
supposed to be RNs. Our data reveals that very few of the 22
SCI centers in the four long-term care facilities meet those
requirements. So there is a dearth of RNs available to veterans
with spinal cord injury. We think that is true in the other
specialized services as well.
One of the issues that happens, particularly in the spinal
cord injury service, is that patients have high acuity needs,
and it is labor-intensive work. Many of the nurses that work in
spinal cord injury centers suffer personal injuries. They are
on light duty. There is a lot of lifting to meet the needs of
these veterans that are in these hospitals and centers. So it
works as a disincentive to stay on board those services.
We think specialty pay will help attract nurses to that
type of labor-intensive work and help to fulfill that RN
requirement.
Mr. Miller. The VA has established a Travel Nurse Corps.
Can you talk a little about that? Do you think it is----
Ms. McVey. Yes. It is a pilot for the VA to have its,
really what could be considered its own agency nurses, but
these are VA employees; and the goal is to have a trained
workforce of VA employees that could theoretically go anywhere
in the country and serve in the VA in times of need. So there
is a pilot project which is under way.
I am not as familiar with it as perhaps Cathy Rick would be
at this time, but I am aware of it and everyone is very pleased
and seems to think it is a very good thing.
Mr. Michaud. Mr. Hare.
Mr. Hare. Thank you, Mr. Chairman. I just have one question
for the panel. Maybe you could just each take a shot at this.
Does the VHA coordinate in any capacity with Veterans
Service Organizations (VSOs) as a resource or recruitment tool,
to find veterans who could be hired here? And if not, how do
you think that could be useful, if they are, you know, A, to
what degree and how effective have you found that to be?
Mr. Cowell. I would just say, in my experience, there
hasn't been a great deal of collaboration between human
resources people across the country and the VSOs that PVA has.
As you know, PVA has started an employment program. It is
in Minneapolis and in Richmond, Virginia, and it seems like the
emphasis is on our end to try to discover what local physicians
might feel available and how we can place a veteran in that
kind of a position.
But we haven't had much contact from the VA toward us.
Mr. Hare. Would that be helpful to you? Do you think that
is something that----
Mr. Cowell. I think anything that can help get certainly
our members employed and other veterans is a good idea. And I
don't think it would be a real tough step to implement. I think
it is a matter of communication.
Ms. McVey. I also think it is a very excellent idea.
We have collaborated with the PVA on local open houses at
our facility in Boston, and it has worked very well. And as you
said, any extension on collaboration and the ability to bring
in more staff into the VA workforce is an excellent idea.
Mr. Atizado. I agree, Mr. Hare. We, DAV, does not have a
very established relationship with VA's human resources. It is
not one of our fortes as more--as it would be for PVA, because
it does affect directly on their membership, although we do
work very closely with the ancillary organizations like NOVA
and APA and those organizations to try and highlight VHA as a
place to work.
I do believe we would more than welcome in any kind of
collaboration we can make with VHA to increase their exposure
on that end.
Mr. Hare. I am not sure how we would go about doing that,
but it would seem to me that if the VHA would coordinate with
the VSOs, you probably could give them a number of people, or
at least it would be a resource for them.
So that, given the need--I want to get the numbers again.
The shortage of nurses that we are going to see is what? I am
sorry; I forget who testified about that, but somebody
mentioned the shortages now or what we are looking at down the
road.
What were those numbers again?
Mr. Atizado. Half a million by 2010.
Mr. Hare. Half a million.
Mr. Atizado. One million through 2020. This is through
Health Resources and Services Administration Division of the
U.S. Department of Health and Human Services.
Mr. Hare. We are going to have to get rolling, it would
seem to me, because that is a huge, huge hole that we are going
to have to try to fill.
So, again, I think anything that would work, Mr. Chairman,
getting the VHA to talk to the VSOs, would be great, because
again you are great resources. You have the people, you know
them; and when you are looking at that kind of shortages down
the road, that just seems to me to be a natural thing to do.
So I thank you, Mr. Chairman.
Mr. Michaud. Thank you.
Mr. Snyder.
Mr. Snyder. Thank you, Mr. Chairman. I am sorry I was late
getting here.
Ms. McVey, before I started in this, I made my living as a
family doctor, and I generally found if I did what the nurses
say, I would stay out of trouble. So I am going to ask my
question to you.
I met with Mr. Wommack yesterday and did not hear his
testimony today, but it seems like, as far as the veterans
healthcare system--in order to get healthcare professionals on
board it seems like there are two basic things. Number one, you
can flood the input with such great numbers that sooner or
later enough will float through and fill the positions; or you
can deal with the input that is coming in in such a way that
you can increase the percentage of those you end up hiring to
fill your positions.
And my question is, have you--have you done--do you do any
kind of formal testing, your organization, where you either
sample people, folks who are making application to the VA
system? Or do you ever go online yourself or make the phone
calls yourself just to see what the process is like?
Do you have any formal way that you judge how people are
treated when they actually are interested in working for the VA
healthcare system?
Ms. McVey. That is a excellent point.
I chair our local succession planning Committee and we have
not done that although we have discussed that. What we have
done is, we have done some research; and we found that many VA
employees, and nurses in particular, are vulnerable to leaving
the system between the third and seventh year of employment.
So what we did through our succession planning Committee
was go out and survey a random group of these employee nurses,
and other employees as well, that are thought to be at the
point at which they may consider leaving VA employment, and
tabulated the results to see why they stayed, with the thought
being that if we could tap into those things and incentives to
make them stay, we could have a better retention rate for all
of our VA employees in the Boston VA Healthcare System.
I am happy to say, for nursing RNs in particular, we have
now a 5 percent turnover rate, which is extraordinarily low.
Nine years ago it was 18 percent, so I think things are going
well in that particular group.
But we are also concerned about turnover, though we haven't
had as much in the RN group; but that is not necessarily true
across the country. There have been no other departments that
support the work of nursing; there are challenges, and many of
them--some of which I stated in my testimony--had to do with
recognition, the ability for a career ladder for non-nursing
personnel, the moneys for education, et cetera. So we have been
trying to tackle those on a local level, and it has been very
interesting.
But I also like the thought of serving a group that has not
yet come. We do hear informal feedback from our staff who are
friends of the staff that have applied for positions, and that
feedback is, they are very concerned about the very long and
excessive timeline between when they apply for employment and
when we are actually able to bring them in.
And so they do tend to get discouraged, and that is a
concern of ours.
Mr. Snyder. You did bring up--in my simplistic analysis,
the third component is, if you can cut down on people quitting,
then you don't have so many openings that you need to fill.
But the issue of--I have actually done this before in
different things, where I get an internist, say, Here, call
this help line, and here is the story I want you to read; see
what kind of information.
I would think that a group like yours could get some nurses
and kind of test how quickly--once you make an inquiry, how
quickly do you get responded to.
As you know, the market is such out there, if somebody
applies for a job or goes online and makes an initial inquiry,
the nurses market being what it is, if it is a week or 2 or 3
days before they hear back from somebody, they will have other
job offers if they are very aggressive and have a reasonable-
to-average work record.
That might be helpful information both for you and this
Committee if you, with your--you probably have the ability to
do something that we don't have, which is, you can do those
kinds of test cases to different VAs around the country, and
because I think that would be helpful.
I know Mr. Wommack is concerned about streamlining. And the
streamlining basically is, we need to have a description of
what the current process is. And I don't know that we have that
yet, but----
Thank you for you all's participation today.
Thank you, Mr. Chairman.
Mr. Michaud. Thank you.
Once again, I would like to thank our panelists for coming
out and for your testimony as well. Thank you very much.
Our last panel is Joleen Clark, who is the Chief Officer of
Workforce Management and Consulting with the VHA.
I want to thank you, Joleen, for your willingness to come
here this morning as well. We probably will be having votes
shortly, so if you can, summarize your written testimony and
the complete copy will be submitted for the record.
STATEMENT OF JOLEEN CLARK, CHIEF OFFICER, WORKFORCE MANAGEMENT
AND CONSULTING, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT
OF VETERANS AFFAIRS
Ms. Clark. Thank you, Mr. Chairman and Members of the
Subcommittee. Thank you for the invitation to appear before you
to discuss human resource challenges within the Department of
Veterans Affairs, Veterans Health Administration. As the
Nation's largest integrated healthcare delivery system, VHA's
workforce challenges mirror those of the healthcare industry as
a whole.
VHA performs extensive national workforce planning and
annually publishes a workforce succession strategic plan. VHA's
strategic plan addresses current and emerging initiatives, the
areas of including, but not limited to, recruitment and
retention, mental healthcare, polytrauma traumatic brain injury
and rural health to address workforce efforts.
VHA's workforce plan is one of the most comprehensive in
government and has been recognized by OPM as a Federal best
practice. It is important that the supply of appropriately
prepared healthcare workers meets the need of a growing and
diverse population. Enrollment in nursing schools needs to grow
to meet the projected future demand for healthcare providers.
In an effort to initiate proactive strategies to aid in the
shortage of clinical faculty, VA launched the VA Nursing
Academy to address the nationwide shortage of nurses. The VA
Travel Nurse Corps is an exciting new program that establishes
a pool of registered nurses in VA who can be available for
temporary short-term assignments at VA medical centers
throughout the country. This program is being piloted at two
sites, Phoenix and San Diego.
Student programs such as the VA Learning Opportunities
Residency Program, the Student Career Experience Program and
the Hispanic Association of Colleges and Universities
Internship Program have helped VA meet the workforce succession
needs. The Graduate Health Administration Training Program
provides practical work experience to students and recent
graduates of healthcare administration Master's programs.
VA recognizes that rural communities face additional
healthcare workforce challenges. VA is working to develop an
effective rural workforce strategy to recruit locally for a
broad range of healthcare professionals.
Experiential training opportunities for young medical
students are important investments for creating a veteran and
rural friendly physician workforce. Last year VHA's Human
Resource Committee chartered a work group to streamline the
recruitment process for title 5 and for title 38 physicians
within VHA. The work group initially analyzed the recruitment
process and identified barriers and lengthy processes for
registered nurses. The work group recommendations were then
piloted and are now in the process of being implemented
nationally.
One retention strategy that has proven very successful for
VHA was approved in Public Law 108-445. The public law improves
VA's ability to recruit and retain the best qualified workforce
capable of providing high-quality care for eligible veterans.
The VHA Healthcare Recruitment and Retention Office administers
national programs to promote employment branding within VHA as
a healthcare employer of choice.
Both a recruitment and retention tool, the Employee
Incentive Scholarship Program pays up to $35,900 for academic
healthcare-related degree programs. Between 1999 and May of
2008, over 7,500 VA employees have received scholarship awards
for academic education programs related to title 38 and hybrid
title 38 occupations. And more than 4,200 employees have
graduated from those programs.
The Education Debt Reduction Program provides tax-free
reimbursement of education loans debt to recently hired
employees, both title 5 and hybrid title 38. EDRP is similar to
the student loan repayment programs for title 5 employees. VHA
routinely uses hiring and pay incentives established under
title 5 and title 38. Recruitment and retention incentives are
used to reduce turnover rates and help fill vacancies.
In 2000, VA began to use an electronic database to capture
survey information from employees entering and exiting VA's
service. The entrance survey is an excellent tool for comparing
and contrasting reasons new employees have come to work for
VHA.
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 ongoing modifications and enhancements to our current
programs.
I would like to thank the Subcommittee for your interest
and support in implementing legislation that allows us to
compete in the healthcare market. Thank you.
Mr. Michaud. Thank you very much for that enlightening
testimony.
[The prepared statement of Ms. Clark appears on p. 56.]
Mr. Michaud. Mr. Miller.
Mr. Miller. Thank you, Mr. Chairman. I have several
questions that I am going to submit for the record in view of
time.
[No questions were submitted.]
Mr. Miller. But how does VA use the tools that it currently
has at its disposal to help recruit staff that have been hard
to recruit and retain?
Ms. Clark. The Education Debt Reduction Program is one of
the most successful tools that we do have, and that, as
mentioned, has been used to recruit healthcare professionals in
both title 38 and hybrid title 38. So far, over 6,500
participants have received funding with an average award of
$29,000. Right now, the cap is at just over $50,000 for those
awards. And, yes, some students are coming out of school with
higher debt than that, but it has been very effective in
recruiting healthcare professionals.
We also use recruitment incentives extensively in areas
where they have felt that they are needed to recruit staff. We
draw people in with our scholarship program, our Employee
Incentive Scholarship Program that we have for both title 38
and hybrid title 38 occupations.
Mr. Miller. Talk to me about that just a little bit, the
scholarship program.
Ms. Clark. The scholarship program is available to
employees after they have had 1 year of employment. We have had
7,500 that have entered into the program. It is open to all
occupations that fall under title 38 and hybrid title 38. It is
up to 3 years of schooling, up to 35--it is over $35,000 that
it pays out for scholarships in those occupations.
Mr. Miller. Thank you.
Ms. Clark. You are welcome.
Mr. Michaud. Mr. Hare
Mr. Hare. Thank you, Mr. Chairman.
The RAND Corporation recently released reports stating that
about 300,000 soldiers report symptoms of PTSD or major
depression, and only half of those are seeking treatment. This
conflict in particular has put a new focus on the importance of
treating mental health problems.
Should the VA be reexamining if psychologists should
continue to be in the hybrid title 38 program, do you think?
Ms. Clark. The difference between hybrid title 38 and title
38 doesn't reside in how the person is boarded. It resides in--
the two things that are covered by hybrid title 38 are pay and
appointments, and they are covered under title 5 for everything
else.
The setting of the pay and the grade that they go to is the
same under title 38 and hybrid title 38, so that would not make
a difference; and I don't know how it would make a difference
in how care is provided.
Mr. Hare. Do you think that VA should diversify its loan
repayment or scholarship programs? For certain medical
professions, a physician can accrue about $150,000 in debt in
medical school costs, yet they are only eligible for about $46
to $50,000 from the VA.
Ms. Clark. Yes. We have found that many of the doctorate
programs, along with the physicians, are coming out of school
with debt in excess of $100,000. And although the Education
Debt Reduction Program certainly helps with $50,000, you know,
many of them would benefit from larger loan repayment.
Mr. Hare. One last question I had asked the last panel
because it seemed to make a little sense about the working
with--the VA working with different VSOs to try to find some
folks who might be interested in going into the field.
I was, candidly, very alarmed when I asked the question
about, you know, the half-million or 500,000 nurse shortage and
then up to 1 million; and it just seemed to me that anything
and everything that the VA can do, or that we can do, or
whoever can go do to try to fill that hole, because we are
going to see more veterans coming back. Obviously, the need is
going to be greater.
So I wonder if you had a thought or two on that.
Ms. Clark. That was a great suggestion. There are new
positions that have been added to the organization called
Veterans Employment Coordinators, that are placed strategically
through the country; and that will be a great opportunity for
them to contact the local VSOs and try to coordinate with them
and get information out on any of the recruitment activities
that we have going on in the local areas.
Mr. Hare. I appreciate that because, again, I think it
would be--I think we have to have all hands on deck to try to
help the program out here.
Mr. Michaud. Ms. Clark, you had mentioned the VA's working
to integrate rural areas into the residency rotation.
How far along are you with that program and who are you
working with to accomplish that.
Ms. Clark. The Office of Academic Affiliations is working
closely with the medical schools in the local areas to address
that. I don't know how far they are along in that. I can get
that information back to you.
[The VA response is included in the response to Question
#4(b) in the post-hearing questions for the record, which
appears on p. 63.]
Ms. Clark. But that is something that we have been really
concerned about and thought, if we get those students, trainees
and residents into those rural areas and have them do their
training programs and residencies there, the likelihood that
they would return and stay in that area for employment is much
higher.
So that was the thought behind doing that and increasing
the employment in those areas in our critical occupations.
Mr. Michaud. Do you have programs doing that and how many
States are involved in that?
Ms. Clark. There is not a pilot program yet. I am sure we
will have pilot programs that we will have doing the rural
health, the residencies in the rural areas.
Mr. Michaud. You heard the other two previous panels talk
about the hiring process and dealing with hybrid title 38,
which is onerous and potentially actually could cause VA to
lose good employees.
What is the number one reason that candidates are turned
down for employment within the VA system?
Ms. Clark. We are aware of the problem, and as I mentioned
we have done a redesign look and see at the whole process and
our end process of implementing numerous changes.
It is not just one thing. It is our paperwork; we have way
too much paperwork. It is some of our internal policies that we
are finding are really obsolete with some of the things we have
to do with the credentialing process. Our credentialing process
is very onerous, but very necessary to make sure that our staff
have the appropriate credentials for patient care.
But we are looking at a process that we can do
simultaneously, so it doesn't take as long, eliminating steps
that don't need to be taken.
The background investigations that we have to do take some
time, but also looking at combining processes and trying to
eliminate unnecessary steps is helping tremendously. I think,
just looking internally, we can probably, without changing
regulation or statute, improve the process tremendously; and we
are working toward that.
In the pilot they showed that it can be done in 30 days to
bring somebody on and going through all these credentialing
processes and background investigations, et cetera; and we are
rolling that out throughout the country, having targeted Human
Resource cluster meetings so that word can get out, they can
understand what we are looking for and assist them in getting
there.
Mr. Michaud. What do you believe VHA's number one challenge
is in filling the shortage in the positions that you have? Is
it more prominent in any one region of the country than
another?
Ms. Clark. I can't say that it is more prominent in any
region, but there are specific areas, certain rural areas,
certain demographic areas that might not have schools in the
area that have greater challenges in certain occupations.
Through our succession and workforce planning, we look at those
things and try to build recruitment and marketing strategies to
address those areas where we are having the recruitment
problems.
We have--throughout the Nation, when the workforce planners
do their plans, we come up with a list of what we consider our
critical occupations in VA; and we target those occupations for
additional recruitment strategies to look and ensure that we
have the appropriate workforce.
Mr. Michaud. What are the top three critical occupations it
needs?
Ms. Clark. Medical doctor positions and pharmacists, are
always our top three.
Mr. Michaud. When you look at pharmacists, you are looking
at working in the academic world as well? I know pharmacy
schools are pretty expensive to have. Are you looking in that
area as well--in the rural areas?
Ms. Clark. We haven't looked at the rural areas yet.
What they have just recently started, last year in 2007, is
the VALOR program, VA Learning Opportunity Residency, for
pharmacists; and they have increased the number this year. And
some of those are in--I don't know if I would call them rural,
but in less-populated areas, and they are continuing to expand.
The pharmacy leadership has been really excited about how
the program has taken off and is looking to expand it; and this
is with the pharmacy doctorate programs. And it is working
really well, and we are hoping that they stay in the VA after
they finish their residency program.
So we think this will be a great recruitment tool.
Mr. Michaud. Is there anything that we can do to help deal
with the shortage that you foresee?
Ms. Clark. Thank you for the offer.
Right now, what we are trying to do is work through some of
the issues internally to see how we can improve the hiring and
on boarding process; and if there is something you can do to
help, we certainly will let you know. Thank you.
Mr. Michaud. And how long is that internal review going to
take? As you heard earlier, there is a severe problem out
there, and the longer we wait, the less likely we are able to
get these good, qualified healthcare providers in the VA
system.
Ms. Clark. We certainly understand that.
We have already implemented it in several of our networks,
and it is going to be a performance measure for all of the
network and medical center directors for 2009 to have it down
to the 30-day hiring process. We anticipate that it will be
happening by the time 2009 gets here; though, you know, there
are a lot of challenges. A lot of people are at really long
timeframes, so will they get down to the 30. But we are hoping
at least they can cut their timeframes in half.
Mr. Michaud. What Veterans Integrated Services Network
(VISN)?
Ms. Clark. VISN 4 is the one that piloted the recruitment
redesign, but several other networks have already implemented
it as well.
Mr. Michaud. What are you doing to work with the Office of
Rural Health, as well, to look at some of these needs,
realizing that the office is, in my opinion, adequately
understaffed.
Ms. Clark. We are working hand in hand with them in the
recruitment issues to try to come up with a recruitment plan so
that we can--they can identify some of the things and then we
can work with them on how, trying to meet those challenges. And
I think that is how Academic Affiliations came up with the plan
for working with the schools to try to get some of those
residents into those under-served areas.
Mr. Michaud. My other question involves rural areas where
there is a healthcare shortage, not only within the VA system.
If you look at the Capital Asset Realignment for Enhanced
Services (CARES) Process, 2004, when their report came out,
they recommended a lot of access points, particularly in rural
areas, and they haven't moved as aggressively as a lot of us
would like to see.
My question is, what are you, the VA, doing to work with
local healthcare providers in States to deal with the
healthcare shortage, and are there ways that you can partner
with the healthcare providers currently out there, keeping in
mind the CARES Process, might recommend to provide access
points in rural areas?
Ms. Clark. I am not sure what they are doing. I know that
some local facilities do contract with those in areas where
they have the clinics, et cetera, but I can take that question
back for the record.
[The VA response is included in the response to Questions
#4(a) in the post-hearing questions for the record, which
appears on p. 62.]
Mr. Michaud. Do you have any additional questions?
Once again there will probably be additional questions,
later on, in writing.
Mr. Michaud. We really appreciate your willingness to come
today. It has been very helpful. This is an extremely important
issue, one that we are going to have to deal with soon if we
are going to make sure that our veterans have adequate
healthcare here. Once again, thank you very much for your
testimony today. We look forward to working with you as we move
forward in this Congress.
So if there are no other questions, this hearing is
adjourned. Thank you.
[Whereupon, at 11:40 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
Thank you everyone for coming today.
The Veterans Health Administration's mission is to provide patient
centered healthcare that is comparable with or better than care
available in the non-VA sector. To do this, VHA must have a viable
healthcare workforce that is competent, well trained and happy.
Over the past 5 years, VA has built a reputation of delivering
healthcare efficiently and effectively. VA has been touted as the
``best care anywhere'' and the Department has been recognized on
numerous occasions for healthcare quality and patient satisfaction.
However, in order to carry that banner forward, careful planning
and efficient processes must be put into the system to ensure continued
success.
We know that VA's workforce is aging, with an average age of 48.6
years. We know that at the end of 2012 a significant percentage of the
employees will be eligible to retire.
This Subcommittee has held many hearings that examined the
appropriateness and quality of care and treatment that veterans receive
within the healthcare system.
This hearing today will focus on the human resource challenges that
VHA must address in order to ensure there will not be a gap in the
expertise and quality of care provided to veterans.
The Committee realizes that this is a complex issue. But we also
recognize that it is an important one that deserves serious thought and
consideration.
Thank you again for coming today.
Prepared Statement of Hon. Jeff Miller, Ranking Republican Member,
Subcommittee on Health
Thank you, Mr. Chairman.
I appreciate your holding this hearing today to examine the many
challenges VA faces in hiring and keeping healthcare workers.
Healthcare workers are the frontline of VA healthcare. Every day
they care for our servicemembers who have honorably served our country.
And the high quality of healthcare available to our veterans is
dependent on the ability of VA to recruit and retain qualified
healthcare personnel.
One of the most pressing problems we face as a Nation is the marked
shortage of virtually all healthcare workers. This includes, among
others, nurses, physicians, physician assistants, psychologists,
pharmacists, and physical and occupational therapists.
Competition for these and other healthcare personnel is intense and
VA must aggressively vie with the private sector to bring the very best
staff into the VA system.
To do that, VA must effectively use innovative recruitment tools
and offer a good work environment with educational opportunities.
The VA healthcare system has been recognized for the significant
benefit of its use of electronic medical records and focus on
preventative care. And, to make sure that our veterans continue to
receive the best care, it is critical that it is also seen as the
workplace of choice.
I look forward to hearing from our witnesses today to learn about
issues they see and ideas they have for improving VA's ability to
recruit and retain a first-class healthcare workforce.
Thank you, Mr. Chairman, and I yield back the balance of my time.
Prepared Statement of J. David Cox, RN, National Secretary-Treasurer,
American Federation of Government Employees, AFL-CIO
The American Federation of Government Employees (AFGE) appreciates
the opportunity to present its views on human resources challenges
within the Veterans Health Administration (VHA). AFGE represents nearly
160,000 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 personnel rules
known as ``pure Title 38'' providers (e.g. registered nurses (RN),
physicians and physician assistants (PA)) or ``hybrid Title 38'' (e.g.
licensed practical nurses (LPN), pharmacists, psychologists and social
workers). The Title 38 boarding process for appointment and promotion
of these two groups of VHA professionals was designed to be more
flexible and expeditious than Title 5, but as will be discussed, the
process faces extreme delays and backlogs. A small number of VHA direct
patient care positions remain under Title 5, e.g., Nursing Assistants
and Medical Technicians.
AFGE's testimony focuses primarily on two significant human
resource challenges facing VHA today:
Loss of grievance rights for ``pure Title 38'' employees;
Extreme delays in the ``hybrid Title 38'' boarding
process;
In my nearly 25 years as a registered nurse and union official at
the Salisbury, North Carolina VA Medical Center, I have seen the impact
of many Veterans Health Administration (VHA) personnel policies on
recruitment and retention of healthcare professionals. In the eighties,
I saw first hand how regular collaboration between frontline providers
and management helped transform the VA into a world-class healthcare
system, becoming a model in patient safety, healthcare information
technology, and best practices.
Sadly, what I have seen over the past 7 years is a sea change in
VA's personnel practices that now hurt, rather than help, recruitment
and retention, and exclude frontline providers from medical affairs.
The current culture of exclusion is very demoralizing to these
dedicated providers who are extremely committed to the mission of the
VA and work so hard to care for our veterans. For example, according to
a January 2008 VA national RN satisfaction survey, for the past 2
years, ``Participation in Hospital Affairs'' was one of two areas where
RNs at VA medical facilities were the least satisfied.
Loss of grievance rights for ``pure Title 38'' employees
The most harmful, far-reaching VHA personnel policy in place today
is the severe erosion of collective bargaining rights (hereinafter
``grievance rights'') of RNs, physicians, PAs and other pure Title 38
providers (``providers''.) These rights include the right to challenge
management personnel actions through grievances, arbitrations, labor-
management negotiations, unfair labor practices (ULPs) and litigation
before the Federal Labor Relations Authority (FLRA) and courts.
VHA denies these rights by asserting an arbitrary and unsupported
interpretation of 38 USC Sec. 77422 (``7422''), the law that provides
collective bargaining rights to these providers. VA's 7422 policy
blocks virtually every provider grievance on the basis of three narrow
exceptions in the law: professional conduct and competence (defined as
direct patient care or clinical competence); peer review; and
compensation.
VHA's 7422 policy has undermined Congress' attempts to improve VHA
recruitment and retention through rights to better pay and schedules.
The effect, to quote the old adage, is ``rights without remedies''
which ``are no rights at all.''
AFGE greatly appreciates the support of Chairman Michaud and
Subcommittee Members Berkley, Brown and Doyle for H.R. 4089,
legislation introduced by Committee Chairman Filner to amend section
7422 and restore these critical rights. This bill is an essential
enforcement tool for all past and future legislation that addresses VHA
recruitment and retention of pure Title 38 providers, as well as
Federal statutes that provide rights to information and prohibit
employment discrimination.
VHA's 7422 policy directly contradicts Congressional intent as to
the scope of these three exceptions. Specifically:
Congress viewed Title 38 and Title 5 employees as having
the same collective bargaining rights when it enacted the Civil Service
Reform Act (CSRA) in 1978.
Congress enacted section 7422 in direct response to a
1988 Federal appeals court decision involving annual nurse
``comparability pay'' increases. The Court held that the VA could not
be compelled by the CSRA to engage in collective bargaining over
conditions of employment for Title 38 providers. Colorado Nurses Ass'n
v. FLRA, 851 F.2d 1486 (D.C. Cir. 1988).
The plain language of the 1991 law narrows the scope of
the exceptions by specifying that the matter must relate to ``direct
patient care'' or clinical competence.''
The 1990 House Committee report on the underlying bill
defined the ``direct patient care'' exception as ``medical procedures
physicians follow in treating patients.'' This report also cited
guidelines for RNs wishing to trade vacation days as falling outside
the exception. (H. Rep. No. 101-466 on H.R. 4557, 101st Cong., 2d
Sess., 29 (1990)).
VHA's 7422 policy also contradicts its own 1996 agreement with
labor to clarify the scope of the law and resolve remaining disputes in
a less adversarial manner. Sadly, the VA unilaterally abandoned this
useful, inclusive agreement in 2003. More specifically, in that
agreement:
The VA committed to a new process for resolving 7422
disputes that departed from the ``adversarial, litigious, dilatory . .
. nature of past labor-management relations.''
The VA acknowledged that providers provide valuable input
into medical affairs: ``We recognize that the employees have a deep
stake in the quality and efficiency of the work performed by the
agency.''; ``The purpose of labor-management partnership is to get the
frontline employees directly involved in identifying problems and
crafting solutions to better serve the agency's customers and
mission.''
The VA recognized the narrow scope of the direct patient
care exception, i.e., it does not extend to ``many matters affecting
the working conditions of Title 38 employees [that] affect patient care
only indirectly'' (emphasis provided).
The VA agreed that scheduling matters may be grievable:
``For example, scheduling shifts substantially in advance so that
employees can plan family and civic activities may make it more
expensive to meet patient care standards under certain circumstances.
That does not relieve management of either the responsibility to assure
proper patient care or to bargain over employee working conditions.''
The VA agreed that pay matters other than setting pay
scales are grievable: ``Under Title 38, pay scales are set by the
agency, outside of collective bargaining and arbitration. Left within
the scope of bargaining and arbitrations over such matters as:
procedures for collecting and analyzing data used in determining
scales, alleged failures to pay in accordance with the applicable
scale, rules for earning overtime and for earning and using
compensatory time, and alternative work schedules.''
The 7422 appeals process:
Section 7422 gives the Undersecretary of Health (USH) the sole
authority to determine what matters are grievable. USH decisions are
posted on the VA Web site (http://www1.va.gov/lmr/page.cfm?pg=28). The
VA does not keep AFGE apprised of unpublished decisions or pending
cases.
AFGE is very concerned by the lack of meaningful, balanced review
by the USH and by failure of local facilities to comply with the USH
review process.
A review of posted decisions and member reports received by AFGE
reveals how VA's 7422 policies directly undermine recruitment and
retention legislation passed over the past decade and deprive providers
of a fair appeals process.
For example:
No right to grieve over denial of request to review nurse
locality pay survey data
Background: Congress enacted legislation in 2000 to
authorize directors to conduct third party surveys to set competitive
nurse pay (P.L. 106-419).
USH Ruling: ``Compensation'' exception blocks
employees' access to third party survey data. (Decision dated 1/06/05)
No right to grieve over VA nurse mandatory overtime
policy
Background: Congress enacted legislation in 2004
requiring facilities to establish policies limiting mandatory overtime
except in cases of ``emergency'' (P.L. 108-445).
USH Ruling: National grievance over definition of
``emergency'' for requiring overtime is barred by the ``professional
conduct or competence'' exception. (Decision dated 10/22/07).
No right to grieve over composition of panels setting
physician pay
Background: Congress enacted legislation in 2004 to use
local panels of physicians to set market pay that would be competitive
with local markets (P.L. 108-445). AFGE contended that management
unfairly excluded practicing clinicians and employee representatives
from the panels.
USH Ruling: Grievance barred by ``compensation''
exception. (Decision dated 3/2/07).
Other grievances blocked by VA's 7422 policy (based on
member reports of pending disputes or unpublished USH decisions)
No right to challenge intimidation of arbitration
witnesses: After two VA nurses testified for the union at arbitration,
management sent them letters questioning their conduct and suggesting
that they could be subject to discipline. The union filed an unfair
labor practice with the FLRA which initiated steps to file charges
against management. Management invoked the ``professional conduct or
competence'' exception to suspend FLRA action pending an USH ruling.
No right to challenge performance rating based on use
of approved leave: Management invoked 7422 when a nurse tried to grieve
the lowering of her performance rating that was based on her authorized
absences using earned sick leave and annual leave, and carried out
without any written justification.
No right to challenge error in pay computation:
Management invoked 7422 when a nurse was incorrectly denied a within-
grade pay increase because of lost time arising out of a work-related
injury covered by workers compensation.
No right to challenge low reimbursement for costs of
required training: Management invoked 7422 when a nurse tried to grieve
the amount of reimbursement she received for attending required
training to maintain her Advanced Practice RN certification.
Exclusion from hospital affairs: Management invoked
7422 to block a local union's efforts to have input into the drafting
of medical staff bylaws that impact personnel policies.
No right to challenge unfair bonus policies: VA
physicians are unable to challenge policies that are not in compliance
with the 2004 physician pay law because managers set arbitrarily low
bonuses and impose unfair performance measures based on factors beyond
the physician's control.
Recent court decisions confirm the need for Congressional action on
7422:
AFGE Local 446 v. Nicholson, 475 F.3d 341 (D.C. Cir.
2007). The Federal court held that the VA operating room nurses could
not file a grievance over denial of premium pay weekend and evening
shifts.
AFGE Local 2152 v. Principi, 464 F.3d 1049 (9th Cir.
2006).
A VA physician was removed from his surgical duties at age
76 and his specialty pay was discontinued. The court held that
the physician's grievance alleging unlawful age and gender
discrimination was barred by the ``professional conduct or
competence'' exception in 7422.
The court rejected the union's contention that management's
7422 assertion was a mere pretext for unlawful discrimination.
Similarly, in a posted USH decision dated 6/1/07, a nurse
alleging that management's denial of specialized skills pay was
racially motivated was not allowed to pursue a grievance.
Amending 7422 will not hurt patient care. Those defending VA's
current 7422 policy are likely to suggest that labor will try to
disrupt patient care if 7422 is amended. In fact, Title 5 makes the
three exceptions in 7422 redundant and unnecessary. Federal sector
unions are only authorized to negotiate on ``conditions of employment''
as that term is defined in 5 USC 7103(a)(14). In contrast, 5 USC
7106(a)(1) makes it a management right (i.e., not to be modified at the
bargaining table) for an agency to determine its ``mission.''
Furthermore, a review of published cases that have come before the
USH did not reveal even one attempt to interfere with medical
procedures or other direct patient care matters.
Finally, if grievance rights can interfere with VHA operations,
then why do hybrid Title 38 providers hired under Title 5 and working
side by side with ``pure'' Title 38 providers have rights to grieve
over these prohibited matters? For example, psychologists have full
grievance rights while psychiatrists do not; licensed practical nurses
have full grievance rights while RNs do not.
The current dispute resolution process for 7422 is broken and
biased against employees. Those defending VA's current 7422 policy are
also likely to argue that employees already have a fair process though
the USH for resolving 7422 disputes. Numbers tell a very different
story: Of the 25 published USH decisions over the past 3 years, the USH
ruled in favor of management one hundred percent of the time. Opponents
are unlikely to mention that many, many more cases never get to the USH
even though the law clearly states that he has sole authority to make
these rulings. Across the country, human resource departments with no
authority regularly make 7422 determinations and refuse to go through
the proper USH channels.
The current 7422 process wastes taxpayer dollars. Finally, the VA's
7422 policies result in a great waste of taxpayer dollars that would be
much better spent on patient care. The Asheville case previously
discussed was pending for seven years. HR departments in facilities
around the country regularly block or delay the section 7422 review
process, draining resources and staff time away from the VA's mission
of caring for veterans.
Extreme delays in the hybrid Title 38 boarding process
Congress' primary objective in establishing hybrid Title 38
positions (i.e., employees are hired under Title 5 but appointed and
promoted at the facility level under Title 38) was to expedite the
appointment and promotion of more VHA employees involved in direct
patient care. Unfortunately, the hybrid boarding process has been
anything but expeditious. Employees involved in medical care and mental
health treatment, including the large numbers of psychologists and
social workers the VA is trying to bring on board, are facing extreme
delays in appointment and promotion
A second concern is the impact of this process on veterans'
preference in employment. OIF/OEF veterans experience great difficulty
in securing and retaining employment, including reservists and members
of the National Guard who return to Federal service following active
duty. VA employees lose veterans' preference protections when they are
converted from Title 5 to Title 38 status. All veterans, whether they
are covered by Title 38 or Title 5, should have equal employment
opportunities in the VA, which strives to be a model employer of
veterans.
We urge the Subcommittee to reject proposals to convert additional
Title 5 employees to hybrid status. A substantial increase in the
number of covered employees would be disastrous. Rather, we recommend
the suspension of all hybrid boarding pending completion of a pilot
project using a streamlined Title 5 hiring process and comparative
study of the two systems. AFGE would like to work with the Subcommittee
to develop this pilot project. A pilot project using an alternative
Title 5 process can also provide valuable lessons for other Federal
agencies.
Other human resources challenges
Physician Pay Law:
AFGE urges this Subcommittee to conduct oversight into the many
problems surrounding the implementation of the physician and dentist
pay provisions in P.L. 108-445, Department of Veterans Affairs Health
Care Personnel Enhancement Act of 2004.
Congress' primary objective in enacting these provisions was to
reduce the use of expensive fee basis physicians and dentists and fill
vacancies at medical facilities has clearly not been achieved. The law
required the VA to provide an initial report on progress toward this
goal to Congress followed by five annual reports. AFGE is not aware of
a single report having been published to date. Meanwhile, many
facilities face severe recruitment problems and the VA continues to
spend substantial sums on costly contract care, including Project HERO,
a pilot project impacting 23 States.
Problems are evident both in the law's market pay and performance
pay systems for physicians and dentists, specifically:
Improper composition of local compensation panels setting
market pay for individual providers;
Management's refusal to share market pay survey data;
The VA's unilateral reduction of the maximum performance
pay award set by Congress;
In many facilities, there have been severe delays in
developing performance pay criteria;
Most criteria were developed without any input from
frontline provider or employee representatives;
Many of the criteria are improper, for example penalizing
missed patient appointments, which is clearly beyond the provider's
control.
AFGE urges the Subcommittee to conduct its own study of the law's
effectiveness, including the following criteria including in the law's
reporting requirement: rates of pay by facility and specialty; rates of
attrition; number of unfilled positions in each specialty and length of
time positions have been unfilled; and, a yearly comparison of staffing
levels, contract expenditures, and average salaries.
Nurse Alternative Work Schedules: In 2004, Congress authorized
facility directors to offer nurse alternative work schedules (AWS) in
the form of full-time pay for three 12-hour work days. This schedule
option is widely available in the private sector. AFGE is not aware of
a single VA facility that has offered AWS to date. We urge the
Subcommittee to stop relying on the discretion of facility directors
who are resistant to implementing AWS, and mandate by law that
facilities offer this option consistent with their prevalence in the
local labor market.
Equality for Part-Time Nurses: Part-time nurses represent a
valuable resource to VHA. We recommend that Title 38 be amended to
enable part-time nurses to earn the same rights and job security as
their full-time colleagues. Also, many full-time nurses convert to
part-time status for family and other personal reasons after they
acquire permanent status. Changing to a part-time schedule should not
result in a loss of permanent status.
Thank you.
Prepared Statement of Randy Phelps, Ph.D., Deputy Executive Director
for Professional Practice, American Psychological Association
Chairman Michaud, Ranking Member Miller, and distinguished Members
of the Committee, I am Dr. Randy Phelps, Deputy Executive Director for
Professional Practice of the American Psychological Association
(``APA''), the largest association of psychologists, with approximately
90,000 full members and 50,000 graduate student members engaged in the
study, research, and practice of psychology. I am a licensed clinical
psychologist, a former practitioner, clinical researcher and educator,
and for the past 15 years on the APA executive staff, have served as
APA's liaison to professional psychology in the Department of Veterans
Affairs (VA).
APA appreciates the opportunity to testify today about human
resource challenges within the Veterans Health Administration (VHA)
that have a direct impact on the recruitment and retention of doctoral
psychologists to provide care to this Nation's heroes. I should note at
the outset that VHA is the workplace of choice for many of our members,
with about 2,400 psychologists currently in the system. VA is, in fact,
the largest single employer of psychologists in the country. APA
supports VA's recent and aggressive efforts to recruit new
psychologists but has concerns about a number of policies and
procedures which are negatively affecting both recruitment and
retention.
APA's Contribution to Growing Needs
Professional psychology as a discipline was ``born'' as a result of
the needs of this Nation's returning World War II heroes, and
psychologists are acutely aware of the debt we owe to those veterans
and to the brave men and women who have followed in their footsteps, as
well as to the system of care this country has evolved to minister to
their healthcare needs.
And, APA is acutely aware that there are over 200,000 homeless
veterans on America's streets today; that the risks of Post Traumatic
Stress Disorder (PTSD) and traumatic brain injury (TBI) appear to be at
unprecedented levels in the population of 1.7 million servicemembers
who have been deployed in the War on Terror; that there has been a
resulting influx of veterans from previous theaters of war who are
increasingly seeking VA services; and that the healthcare needs of
aging veterans continue to grow.
To assist with those needs, APA has many initiatives currently
underway, including two Presidential Task Forces on the Needs of
Military Servicemembers and Their Families, and the recently adopted
``Blueprint for Change: Achieving Integrated Healthcare for an Aging
Population'', which is consonant with VA's groundbreaking work on
primary care integration.
APA's Committee on Rural Health is addressing ways for
psychologists to help extend services to veterans in rural areas where
existing VA and Department of Defense (DoD) facilities are simply
beyond the reach of patients. As well, APA's public interest component
works on issues of direct concern to VA, such as homelessness, military
sexual trauma, and family violence. In education, we are creating
training pipelines for specialty training of psychologists and other
mental health professionals regarding soldiers' pre and post deployment
needs, through both the Center for Deployment Psychology (with the DoD)
and in proposing expansion of our Graduate Psychology Education
program. We also have recently provided testimony proposing funding
increases over the Administration's FY '09 VA Medical and Prosthetic
Research Account funding levels.
Recruitment and the Psychology Workforce Within VHA
As I indicated, VHA is the single largest employer of psychologists
in the Nation, and has been for many years. Yet, VA continues to
recognize the need to increase its psychology staffing levels in
response to ever-increasing needs for services to veterans.
As a result, VHA has added more than 800 new positions for
psychologists since 2005; thereby rapidly increasing the number of
psychologists in the system to a current high of approximately 2,400,
now surpassing the previous 1995 high of approximately 1,800
psychologists nationally. The 2,400 psychologists now employed by VA
range from the GS-11 to GS-15 levels.
The APA applauds VA for these tremendous and serious recent efforts
to recruit additional psychologists into the system, and we have
actively partnered with VA to promote the news of these openings, have
attempted to assist with recruiting neuropsychologists (who are needed
in increasing numbers due to TBI), and have worked to promote VA career
choices by the newer generations of psychologists.
I need to emphasize, however, that these increased psychology
staffing levels are a very recent development over approximately the
last year and a half only. Psychology staff levels were actually
significantly BELOW 1995 levels until 2006. Moreover, the vast majority
of new psychologist hires in VHA are younger, lesser experienced
psychologists who have come into the system at the GS-11 to GS-13
levels.
However, the contrast between the VA's success in recruiting new
professionals into the system versus VA's retention and promotion of
those existing VA psychologists with years of experience treating
veterans is dramatic.
For example, at the end of 2007, the number of GS-14s in the entire
system nationally was no different than it was 12 years prior in 1995
(at 130 GS-14s total). Of additional concern to the APA is that the
number of GS-15 psychologists nationally as of the end of 2007
(approximately 50) was actually considerably lower than the number of
GS-15s in 1995.
To the system's credit, VA has also recognized and capitalized on
the fact that the best source of recruiting new psychologists has been
the Department's own training systems. Over the past 2 years,
approximately 75 percent of all new psychologist hires have been prior
VA trainees. And, VA is rapidly increasing its funding of psychology
training. In the 2008-2009 training year, VA has added approximately 60
new psychology internship positions and 100 new postdoctoral fellowship
positions, spending approximately $5 million to do so. This will bring
the total psychology training positions to approximately 620 per year
nationwide.
Retention of the Psychology Workforce
Despite positive developments in recruitment, VA's advancement and
retention policies continue to be driven by outdated and overly rigid
personnel and retention systems. In addition to hiring new staff, the
VA needs to retain those existing psychologists who are qualified,
possess specialized skills, and who are already acculturated within
VHA. These psychologists are vital to service provision because of both
their professional expertise and their knowledge of the system and its
resources for veterans.
1. Lack of Uniform Psychology Leadership Positions
Since 1995, independent mental health discipline services at most
facilities have been replaced with interdisciplinary Mental Health
Service Lines. As a result, there has been a decrease in the number of
discipline chiefs across the system. The dissolution of discipline
specific services has left a clear leadership gap in terms of
professional practice accountability, guidance on the proper use of
professional skills, and promotion and oversight of profession-specific
staff and pre-licensure training.
Psychology remains the only major mental health discipline without
an officially designated leader in every medical center, analogous to
the Social Work Executive. While there are a small number of ``Chief
Psychologists'' remaining, the far more prevalent positions of
discipline-based professional leadership are those such as
``Supervisory Psychologist'', ``Lead Psychologist'', or ``Psychology
Director''. Notably, these positions are all too frequently
unrecognized at the level of additional pay for the additional
professional leadership responsibilities they entail.
2. Inequitable Access to Key Leadership Positions
Psychologists are also not represented equitably in all levels of
leadership in the VA's healthcare delivery system. In 1998, the Under
Secretary for Health (USH) attempted to correct this situation with the
issuance of VHA Directive 98-018, later reissued in 2004 as VHA
Directive 2004-004, which stated that ``it is important that the most
qualified individuals be selected for leadership positions in mental
health programs regardless of their professional discipline.''
Unfortunately, the only requirement within the Directive was that
announcements of VA mental health leadership positions not contain
language that restricts recruitment to a specific discipline. As a
result, this Directive has had little practical impact on the
appointment of highly qualified psychologists to VA mental health
senior leadership roles, particularly at medical school affiliated VA
facilities.
3. Serious Implementation Problems in Hybrid Title 38
Psychologists remain the only doctoral healthcare providers in VA
who are not included in Title 38. In late 2003, the Hybrid Title 38
system was statutorily expanded to provide psychologists (and a wide
range of other non-physician disciplines) some of the same personnel
and pay considerations as their physician counterparts. The hybrid
model requires Professional Standards Boards to make recommendations on
employment, promotion and grade for psychologists, and is still more
subjective than a pure Title 38 program; unlike Title 38 where
professionals are hired, promoted and retained based solely on their
qualifications.
The implementation of the new Title 38 Hybrid boarding process has
been extremely variable and chaotic across the system. Many
Psychologist leaders from facilities throughout the country have
reported that their facilities and Veterans Integrated Service Networks
(VISNs) have denied GS-14 and 15 promotions that have been recommended
by the national boarding process. Even more frequent are reports of
facilities and VISNs that have delayed or refused to forward boarding
packets to the national board and/or have refused to reveal the results
of the national board action.
Informational missteps and technical problems have also plagued the
national psychology boarding process. Just last month, VA Central
Office (VACO) sent instructions to the field that eliminated the
national cap on GS-14 levels for psychologists. However, these same
instructions tied the award of GS-15 psychology positions to the
facility's level of complexity, making many senior psychologist leaders
ineligible for grade increases commensurate with the scope and
complexity of their actual duties.
APA was optimistic that the Hybrid Title 38 system would modernize
the pay system and foster greater retention of senior psychologists
within the VHA system. Given that 5 years after its passage,
implementation continues to be such a boondoggle, we are now seriously
reconsidering our support for the Hybrid system, and considering
instead a policy change to bring psychologists fully into the Title 38
system. The basic concept of Title 38 is ``rank-in-person'' rather than
rank in position, basing rank and pay on one's qualifications brought
to the job rather than on some of the duties of the position. Hybrid 5/
38 uses the procedures of Title 38 for recruitment, but not for rank
and pay boards, preferring a mixture of Title 5 types of position
descriptions, now re-titled in Title 38 language as ``functional
statements''. The functional statements are used with Title 5 kinds of
considerations, including scope of supervisory or managerial
responsibilities, leaving no room for advancement in rank for senior
psychology clinicians who are not part of medical staff.
For example, efforts to make it easier for outstanding research
clinicians to advance in rank have been virtually unsuccessful because
in many cases it is written into their jobs as clinicians that research
is part of their function; they are denied any special advancement for
published papers, grants awarded from merit review bodies, etc. Indeed
the bar of publications has been set so high that few of them have been
able to advance in rank, again based on the kinds of measures one would
have used under Title 5.
Most physicians, under this rank in person concept, used to achieve
a base pay equivalent to a GS-15, step 10. More recent changes to
physician pay have resulted in psychiatric physicians being paid a
minimum of $91,500 to a maximum of $225,000, with four levels of pay
grade, each with a minimum and maximum, incorporating other elements
such as ``market pay'' and ``performance pay.'' The result is that the
typical psychologist, depending upon locality tops out at about
$101,000 after 15-20 years of service (GS-13, step 10), while a senior
physician typically may make 30 to 125 percent higher salary.
Also, physicians have long had an annual bonus for board
certification. Psychologists are now eligible for a one-time step
increase, but only if they were to become newly board certified within
a narrow window prior to, or since the inception of hybrid Title 5/38.
Senior psychologists who have topped out in their grade (GS-13) are not
eligible for anything other than a one-time award.
Additional Factors Affecting Recruitment and Retention of Psychologists
1. Medical Staff (Clinical) Privileges vs. Full Medical Staff
Membership
VA is based on a medical model, and doctoral psychologists are
excluded from the decisionmaking process by being denied full medical
staff privileges in many facilities, particularly those that are not
affiliated with medical schools. Not being a member of the medical
staff is to be a second class citizen. Psychologists are most typically
``clinically privileged'' practitioners, i.e., those who are not full
members of the medical staff, and who are called ``Licensed Independent
Practitioners''. But they have no formal say in hospital policy, and
may not sit on the governing body of the medical staff in those
facilities where they are not members.
There are a number of important reasons to support psychologists
having full medical staff membership throughout the VHA healthcare
system. In recent years there has been a significant increase in the
number of psychologists who have assumed leadership roles in important
medical center programs. These include many of the new post traumatic
stress disorder (PTSD), Recovery, Pain, Substance Abuse programs, and
so forth. These psychologists are responsible for the supervision of
various disciplines and provide direct clinical care for the medical
center. These are certainly responsibilities that are consistent with
full membership on the medical staff. In addition, many of the new Home
Based Primary Care (HBPC) psychologists are working independently and
away from the physical umbrella of the VA medical centers. They are
doing important and demanding work in the veteran's homes. Again, the
level and complexity of work is what one would expect from a full
member of the staff. Without membership, there is restricted input into
many important decisions that impact programming and ultimately on
patient care.
2. Prescriptive Authority
One of the most difficult current challenges for VHA is how to
extend care into those areas, particularly in rural America, where VA
facilities do not exist or are at great distance from the veteran. One
option that VHA has long resisted, but should more carefully consider,
is granting expanded authority for appropriately trained psychologists
to provide both psychological and psychopharmacological care to
veterans in these under-served rural areas. Experience in both States
where licensed psychologists have this expanded statutory authority to
prescribe (New Mexico and Louisiana), as well as a decade of data from
the original DoD psychopharmacology program, have shown these practices
to be safe and effective for the public.
Both New Mexico and Louisiana, States with large rural populations,
have passed laws to allow psychologists to prescribe. New Mexico, which
passed its prescriptive authority law in 2002, and Louisiana, which
passed its law in 2005, permit appropriately trained licensed
psychologists with additional postdoctoral training in
psychopharmacology to prescribe. These laws have been very successful,
and to date nearly 50 psychologists prescribing in these States have
written more than 40,000 prescriptions without adverse incident.
Furthermore, a Federal demonstration project set up nearly two
decades ago has set a clear precedent that psychologists can
successfully prescribe in a large Federal health system. The Department
of Defense Psychopharmacology Demonstration Project (PDP) also proved
that psychologists can be trained to prescribe safely and effectively.
Begun in 1991, ten psychologists participated in the PDP, which was
designed to train and use psychologists to prescribe psychotropic
medications. These psychologists treated a wide variety of patients,
including active duty military, their dependents and military retirees,
with ages ranging from 18 to 65.
The PDP was highly scrutinized. The American College of
Neuropsychopharmacology (ACNP) conducted its own independent, external
review of the PDP and in 1998 presented its final report to the DoD.
Likewise, the General Accounting Office (GAO) issued a positive report
on the PDP. Both reports repeatedly stressed how well the PDP
psychologists had performed, and noted that with prescriptive
authority, psychologists were able to offer holistic, integrative
treatment, which includes psychotherapy and medication, where
appropriate.
It is clear that already licensed doctoral psychologists are being
trained to prescribe safely and effectively. The precedent for the VA
system to recognize psychologist prescriptive authority is clear both
from State action and the DoD's program. In addition, APA Division 18
psychologists--Psychologists in Public Service--including those who
serve in the VA, are already supporting training of a cadre of public
service psychologists to be able to prescribe as recognition expands
along with the need for services. The VA should begin to utilize such
professionals to the full extent of their licensure and training.
Psychologists are willing and able to help fill the gap and ease the
strain on the VA health system particularly in rural areas.
Summary and Examples
Two dramatic, but not apparently unusual examples of how these
problems are affecting services have recently crossed my desk. In one,
a new hire, who happens to be a former State Psychological Association
President and representative to APA's Committee on Early Career
Psychologists, was dismissed during his probationary year after being
hampered in his abilities to effectively discharge his dual leadership
duties as the facility's new Local Recovery Coordinator as well as the
Acting Supervisory Psychologist. In another facility, a more senior
psychologist who was approved by the National Standards Board was
denied locally for a GS-14 upgrade for her position as Psychology
Program Manager and tendered her resignation on April 1st.
APA considers the issues and problems addressed in this testimony
as serious obstacles to making VA the workplace of choice for
psychologists. Without clear advancement systems in place, VA faces
critical long term recruitment and retention problems. As psychologists
come to believe that there is little possibility for advancement,
regardless of the level or complexity of responsibilities, fewer VA
psychologists will be willing to accept positions of greater
responsibility. In addition, high potential trainees whom the VA would
like to recruit will increasingly see VA as a ``dead end'' for their
careers, and will be attracted to other career options that offer more
potential for advancement.
Thank you for this opportunity to provide testimony today on behalf
of the American Psychological Association. We stand ready to assist
with the Committee's work to further improve recruitment and retention
of psychologists to assist in providing care to this Nation's honored
veterans.
Prepared Statement of Angela Mund, CRNA, MS, Clinical Director,
University of Minnesota Nurse Anesthesia Area of Study,
Minneapolis Veterans Affairs Medical Center, Veterans Health
Administration, U.S. Department of Veterans Affairs, on behalf of
American Association of Nurse Anesthetists
Chairman Michaud, Ranking Member Miller, and Members of the
Subcommittee:
The American Association of Nurse Anesthetists (AANA) is the
professional association that represents over 39,000 Certified
Registered Nurse Anesthetists (CRNAs) across the United States. Over
500 CRNAs are employed by the Department of Veterans Affairs (DVA)
healthcare system. We appreciate the opportunity to present our
testimony to the Subcommittee. With our military personnel and
Veterans' access to safe and high quality healthcare our first
priority, we want you to know that the profession of nurse anesthesia
is working creatively and effectively with the Department of Veterans
Affairs (DVA), in partnership with the U.S. Army, to improve its
retention and recruitment of CRNAs, so that high quality anesthesia
services remain available and accessible for our Nation's Veterans.
This work is crucial for several reasons; most importantly, because the
anesthesia workforce needs in the DVA are increasing. Our request of
the Committee is to understand these needs and to examine more closely
the VA anesthesia workforce to ensure the safest, most cost-effective
anesthesia services for our Veterans.
CRNAs AND THE VA: A TRADITION OF SERVICE
Let us begin by describing the profession of nurse anesthesia, and
its history and role with the Veterans Administration health system.
In the administration of anesthesia, CRNAs perform the same
functions as anesthesiologists and work in every setting in which
anesthesia is delivered including hospital surgical suites and
obstetrical delivery rooms, ambulatory surgical centers, health
maintenance organizations, and the offices of dentists, podiatrists,
ophthalmologists, and plastic surgeons. Today, CRNAs administer some 30
million anesthetics given to patients each year in the United States.
Nurse anesthetists are also the sole anesthesia providers in the vast
majority of rural hospitals, assuring access to surgical, obstetrical
and other healthcare services for millions of rural Americans.
Since the mid-19th Century, our profession of nurse anesthesia has
been proud and honored to provide anesthesia care for our past and
present military personnel and their families. From the Civil War to
the present day, nurse anesthetists have been the principal anesthesia
providers in combat areas of every war in which the United States has
been engaged. In May 2003, at the beginning of ``Operation Iraqi
Freedom,'' 364 CRNAs had been deployed to the Middle East to ensure
military medical readiness capabilities. For decades CRNAs have staffed
ships, remote U.S. military bases, and forward surgical teams, often
without physician anesthesiologist support. The U.S. Army Joint Special
Operations Command Medical Team and Army Forward Surgical Teams are
staffed by CRNAs.
As our military personnel advance from active service to retired
and Veteran status, their anesthesia care in VA facilities is provided
predominantly by nurse anesthetists. In 12 percent of VA healthcare
facilities, the necessary anesthesia services are provided solely by
CRNAs, ensuring our Veterans the safe anesthesia care that they deserve
and have earned.
Our tradition of service to the military and our Veterans is
buttressed by our personal, professional commitment to patient safety,
made evident through research into our practice. In our professional
associations, we state emphatically ``our members' only business is
patient safety.'' Safety is assured through education, high standards
of professional practice, and commitment to continuing education.
Having first practiced as registered nurses (RNs), CRNAs are educated
to the master's degree level, and some to the doctoral level, and meet
the most stringent continuing education and recertification standards
in the field. Thanks to this tradition of advanced education and
clinical practice excellence, we are humbled and honored to note that
anesthesia is 50 times safer now than in the early eighties (National
Academy of Sciences, 2000). Research further demonstrates that the care
delivered by CRNAs, physician anesthesiologists, or by both working
together yields similar patient safety outcomes. In addition to studies
performed by the National Academy of Sciences in 1977, Forrest in 1980,
Bechtoldt in 1981, the Minnesota Department of Health in 1994, and
others, Dr. Michael Pine, MD, MBA, recently concluded once again that
among CRNAs and physician anesthesiologists, ``the type of anesthesia
provider does not affect inpatient surgical mortality'' (Pine, 2003).
Thus, the practice of anesthesia is a recognized specialty in nursing
and medicine. Most recently, a study published in Nursing Research
confirmed obstetrical anesthesia services are extremely safe, and that
there is no difference in safety between hospitals that use only CRNAs
compared with those that use only anesthesiologists (Simonson et al,
2007). Both CRNAs and anesthesiologists administer anesthesia for all
types of surgical procedures from the simplest to the most complex,
either as single providers or together.
NURSE ANESTHESIA PROVIDER SUPPLY AND DEMAND: SOLUTIONS FOR RECRUITMENT
AND RETENTION IN THE DVA
While both types of health professionals can provide the same high
quality anesthesia care, CRNAs provide the DVA an additional advantage
of cost-effectiveness. Consequently, both our Veterans and our VA
health system are best served by policies and initiatives that secure
adequate numbers of CRNA employees in the DVA. We believe that this
Committee can help accomplish this objective by supporting nurse
anesthesia education programs, both within the VA itself and in
partnership with military and civilian schools of nurse anesthesia.
It is essential to understand that while there is strong demand for
CRNA services in the public and private healthcare sectors, the
profession of nurse anesthesia is working effectively to meet this
workforce challenge. The AANA anticipates growing demand for CRNAs. Our
evidence suggests that while vacancies exist, the demand for anesthesia
professionals can be met if appropriate actions are taken. As of
January 2008, there are 108 accredited CRNA schools to support the
profession of nurse anesthesia. The number of qualified registered
nurses applying to CRNA schools continues to climb. The growth in the
number of schools, the number of applicants, and in production
capacity, has yielded significant growth in the number of nurse
anesthetists graduating and being certified into the profession. The
Council on Certification of Nurse Anesthetists reports that in 2007,
our schools produced 2,021 graduates, an 88 percent increase since
2002, and 1,869 nurse anesthetists were certified. The growth is
expected to continue. The Council on Accreditation of Nurse Anesthesia
Educational Programs (COA) projects the 108 CRNA schools to produce
over 2,300 nurse anesthetists in 2008.
The number of VA anesthesia vacancies is causing us concern. We
believe that they can be filled through creative partnership between
the VA system and the profession of nurse anesthesia, and commitment by
the DVA to effectively recruit and retain CRNAs. More than half of the
VA nurse anesthesia workforce is over the age of 53, an age some years
above the mean for all CRNAs nationally. The annual turnover and
retirement rate among CRNAs within the VA has risen to about 19 percent
over the past few years and continues to rise as the workforce ages,
more lucrative employment is offered in the private sector, and new
graduates from CRNA educational programs find the VA employment and
practice package comparatively uncompetitive. Currently, 24 stations
show vacancies on public Federal job posting sites. However, we have
reason to believe that the numbers of stations with actual vacancies is
closer to 40, with staff vacancies either being left vacant for
extended periods of time, or filled by contract personnel.
Approximately 150 CRNA slots in the DVA are being filled by contract
personnel.
As the nurse anesthesia profession is working to meet the demand
for CRNAs generally, we believe that the DVA specifically can meet its
CRNA recruitment needs by pursuing three strategies. First, DVA should
expand its relationships with existing CRNA schools. Second, the DVA
should expand its joint CRNA educational program together with the
Department of Defense (DOD) health system. Third, the DVA should
upgrade its recruitment, retention, and practice environment factors to
make VA service more competitive with the private market for anesthesia
services, within the context of the DVA's mission.
To a degree, some of these strategies are already under way and
achieving results for the VA health system. A recent AANA survey shows
our nurse education programs use some 70 VA hospitals and healthcare
facilities as clinical practice education sites, helping to educate
CRNAs, provide superior patient care, and aid the VA in recruiting
nurse anesthetists. In addition, we recommend that the DVA pursue nurse
anesthesia resource sharing programs with civilian CRNA schools through
faculty exchange initiatives.
Because nurse anesthesia is a safe and highly cost-effective means
to secure anesthesia services for our Veterans, we have expressed
concern that the DVA has introduced ``anesthesiologist assistants''
(AAs) to the VA health system, through new qualifications standards
that do not require them to be licensed in any State, or subject to any
State's oversight or discipline, or to have graduated from an
accredited educational program, or to have secured certification, or to
be appropriately supervised by anesthesiologists in a manner consistent
with AAs' training as assistants. Though the DVA handbook VHA-1123
updated March 2007 authorizes anesthesiologists to delegate anesthesia
care to unqualified, uncredentialed individuals, the VHA has not yet
hired such individuals. There are other substantive concerns with the
handbook. Our Veterans deserve better. We have requested the policy be
withdrawn, and have met with the agency to promote our shared interest
in ensuring our Veterans access to safe, high quality anesthesia care.
U.S. ARMY-VA JOINT PROGRAM IN NURSE ANESTHESIA, FT. SAM HOUSTON, SAN
ANTONIO, TX
The establishment of the joint U.S. Army-VA program in nurse
anesthesia education at the U.S. Army Graduate Program in Anesthesia
Nursing, Ft. Sam Houston, in San Antonio, TX holds the promise of
making significant improvements in the VA CRNA workforce, as well as
improving retention of VA registered nurses in a cost effective manner.
The current program utilizes existing resources from both the
Department of Veterans Affairs Employee Incentive Scholarship Program
(EISP) and VA hospitals to fund tuition, books, and salary
reimbursement for student registered nurse anesthetists (SRNAs).
This VA nurse anesthesia program started in June 2004 with three
openings for VA registered nurses to apply to and earn a Master of
Science in Nursing (MSN) in anesthesia granted through the University
of Texas Houston Health Science Center. In the future, the program is
granting degrees through the Northeastern University Bouve College of
Health Sciences nurse anesthesia educational program in Boston, Mass.
Due to continued success and interest by VA registered nurses for the
school, the program increased to five openings for the June 2005 and
2006 classes. This program continues to attract registered nurses into
VA service, by sending RNs the strong message that the VA is committed
to their professional and educational advancement. In order to achieve
the goal of expanding the program further, it is necessary for full
funding of the current and future EISP to cover tuition, books, and
salary reimbursement.
The 30-month program is broken down into two phases. Phase I, 12
months, is the didactic portion of the anesthesia training at the U.S.
AMEDD Center and School (U.S. Army Graduate Program in Anesthesia
Nursing). Phase II, 18 months, is clinical practice education, in which
VA facilities and their affiliates would serve as clinical practice
sites. In addition to the education taking place in Texas, the agency
will use VA hospitals in Augusta, Georgia, increasing Phase II sites as
necessary. Similar to military CRNAs who repay their educational
investment through a service obligation to the U.S. Armed Forces,
graduating VA CRNAs would serve a 3-year obligation to the VA health
system. Through this kind of Department of Defense--DVA resource
sharing, the VA will have an additional source of qualified CRNAs to
meet anesthesia care staffing requirements.
At a time of increased deployments in medical military personnel,
VA-DOD partnerships are a cost-effective model to fill these gaps in
the military healthcare system. At Ft. Sam Houston nurse anesthesia
school, the VA faculty director has covered her Army colleagues'
didactic classes when they are deployed at a moment's notice. This
benefits both the VA and the DOD to ensure the nurse anesthesia
students are trained and certified in a timely manner to meet their
workforce obligation to the Federal Government as anesthesia providers.
We are pleased to note that the Department of Veterans Affairs
Acting Deputy Under Secretary for Health and the U.S. Army Surgeon
General approved funding to start this VA nurse anesthesia school in
2004. In addition, the VA director has been pleased to work under the
direction of the Army program director LTC Thomas Ceremuga, CRNA, PhD
to further the continued success of this U.S. Army-VA partnership. With
modest levels of additional funding in the EISP, this joint U.S. Army-
VA nurse anesthesia education initiative can grow and thrive, and serve
as a model for meeting other VA workforce needs, particularly in
nursing.
We recently recommended that $400,000 be included in the FY 2009
appropriations to expand this joint educational program.
LOCALITY PAY
In order to meet demand for nurse anesthetists, each VA facility's
administrator may make use of existing locality pay structures as
authorized and funded by Congress. Competitive salaries assist the DVA
with retention of CRNAs to provide anesthesia services for our Nation's
veterans. Though providing competitive salaries for excellent employees
is an ongoing challenge, using locality pay to keep personnel is most
cost-effective. This is where Congress can help, by providing adequate
funding for personnel through locality pay adjustments where base
salaries are not sufficiently competitive with the local private
market. Further, this Subcommittee should examine whether the 2004
authorization to expand incentive professional pays for physicians and
nurse executives should also be applied to the recruitment and
retention of nurse anesthetists, or, alternatively, whether other means
should be pursued to lift the statutory cap that keeps VA nurse
anesthetist compensation below local market levels.
For several reasons, ensuring sufficient locality pay flexibility
is in the interest of both our VA and our Veterans. The DVA faced a
severe shortage of CRNAs in the early nineties, which was moderately
corrected with the implementation of a locality pay system in 1991. In
1992, Congress expanded the authority to the local medical directors
and allowed them to survey an expanded area to determine more
competitive average salaries for CRNAs, which boosted pay and morale.
Implementation of this expanded authority helped assist the DVA in
making great leaps in retention and recruitment of CRNAs at that time.
However, times and the local labor markets for healthcare professionals
have continued to change. In the past few years CRNAs' salaries have
increased in the private sector, while the VA has not adjusted to these
new salary rates. This means that in some markets the DVA locality pay
system is no longer competitive with the private sector, and new nurse
anesthetist graduates are choosing not to work in the VA health system.
We believe that the VA would benefit by providing CRNAs competitive
salaries in VA facilities and making use of effective locality pay
adjustments, which reduces VA hospital administrators' requirements for
contracted-out services at higher rates.
Though nurse anesthetists provide the lion's share of anesthesia
services to U.S. Department of Veterans Affairs (VA) healthcare
facilities, the agency is facing a wave of retirements and having
challenges recruiting CRNAs because the compensation it offers is below
local market levels, a Government Accountability Office (GAO) report
highlighted (``Many Medical Facilities Have Challenges in Recruiting
and Retaining Nurse Anesthetists,'' GAO-08-56, 12/13/2007) The GAO
recommended that the VA apply its locality pay system more vigorously
to recruit and retain nurse anesthetists.
At the time the report was issued, the AANA issued a statement,
saying, ``The profession of nurse anesthesia is committed to caring for
our Nation's Veterans. Nurse Anesthesia continues to be a safe,
flexible and highly cost-effective means for the VA to ensure our
Veterans the healthcare that they need and deserve. We look forward to
continuing work with the Department of Veterans Affairs, the Congress,
and the members of the Association of Veterans Affairs Nurse
Anesthetists (AVANA) to help carry out the recommendations of this
report.''
The GAO found that VA medical facilities have had to temporarily
close operating rooms or delay elective surgeries due to a shortage of
CRNAs. While demand for CRNA services is increasing, the report says 26
percent of the VA's CRNAs are projected to retire or leave the
department in the next 5 years. The GAO said that the VA's CRNA
recruitment and retention challenges are caused primarily by the
agency's below-market compensation compared with local market
conditions around the country. The GAO made its findings based on
surveys of VA CRNAs, VA managing personnel in local VA facilities and
at VA headquarters, and through other data sources. The report says the
nurse anesthesia profession has been working effectively to meet high
U.S. demand for anesthesia workforce by increasing the number of
qualified practitioners graduating from accredited nurse anesthesia
programs.
The report recommended that the agency deploy and carry out its
existing locality pay system to adjust salaries so that they are more
competitive. Any locality pay system should be structured to set
competitive salary levels for nurse anesthetists working in VA
healthcare facilities. The DVA could implement a system that guarantees
accurate surveys on pay are being conducted in a timely manner. This
salary data will be used to adjust Nurse 1 (Step 1) to be competitive
within the local market to assist VA facilities in hiring new nurse
anesthesia graduates.
Finally, with adjustments in the pay structure to include
professional pays for recruitment and retention of CRNAs, VA facilities
may well realize cost savings by contrast with other arrangements for
securing anesthesia services.
Recently, Senator Daniel Akaka (D-HI) introduced the Veterans'
Medical Personnel Recruitment and Retention Act of 2008 (S. 2969), and
several of its provisions are intended to help the VA recruit and
retain CRNAs to the VA healthcare system. We applaud Senator Akaka's
efforts to bring VA healthcare professionals' pay closer to the private
sector. Our first priority remains ensuring our Veterans' access to a
high quality of healthcare. The quality of healthcare services, and the
qualifications expected of healthcare professionals, and the numbers of
healthcare professionals, all together have bearing on the quality of
life of our Veterans, and should be kept in mind in equal measure.
CONCLUSION
In conclusion, we recognize that the VA has nurse anesthesia
staffing needs. Through an effective partnership with the nurse
anesthesia profession, the DVA can help meet its future CRNA workforce
requirements through three cost-effective models, which exist today and
can be expanded. Our VA hospitals can serve as clinical practice sites
for CRNA schools. Going one step further, the VA health system can
pursue resource sharing and faculty exchange agreements with nurse
anesthesia schools. Further still, the VA and DOD can share resources
outright to educate nurse anesthetists for the Veterans and military
settings alike, particularly with modest additional funding. This VA
commitment to CRNA education helps secure the nurse anesthesia
workforce our Veterans need, and attracts registered nurses into VA
service, by sending the strong message that the VA is committed to RNs'
professional and educational advancement. Last, the VA should examine
and improve the effectiveness of its recruitment, retention and
practice environment for CRNAs.
Thank you. If you have further questions, please contact the AANA
Federal Government Affairs Office at 202-484-8400.
Prepared Statement of Jay W. Wommack, Founder, President and
Chief Executive Officer, Vertical Alliance Group, Inc., Texarkana, TX
Mr. Chairman and Members of the Committee, I am Jay Wommack,
Founder, President and Chief Executive Officer of Vertical Alliance
Group, Texarkana, TX. Thank you for the opportunity to express our
views on the important issues relating to ``Human Resources Challenges
within the Veterans Health Administration.''
As the Nation's largest integrated healthcare system, the Veterans
Health Administration (VHA), due in large to the efforts of this
Committee has made impressive strides in improving the quality of care
for our Nation's Veterans. VHA has established itself as the
``Trendsetter'' in healthcare reform with programs such as the
electronic medical records innovation. You are to be applauded.
In the way of introduction, I make no claim to being an expert in
the Health Service arena; rather, over the past 9 years, I have been
involved in the development, evaluation, and evolution of a
comprehensive recruiting process for businesses that include health
services. If I were to provide a title for my testimony today it would
be ``How to convert 40 percent of the applicants that come through
VHA's door into employees.''
I recall shortly after college when I applied for my first ``real''
job, taking an hour or more filling out an application, turning it in
and waiting patiently by the mailbox for weeks for a response that
never came. And you can probably recall the excitement of receiving
that four-inch thick mail order catalog. How you thumbed through every
page, in my case mostly the toy section, and the anticipation and
anxiety as you waited the 4 to 6 weeks for delivery--now I order online
and it is at my door by the next day. Paper applications are fast going
the way of the Pony Express and the new Sheriff in town is the
Internet. Fundamental changes to the way we perceive and process
applications must emerge if we are to meet the demands of tomorrow's
career markets. In today's world, instant gratification is the norm.
Not only do employers want quality employees, they want them now.
Potential employees want the job of their dreams and they want it now.
Applicants are all too often greeted with outdated processes that might
have worked well in the sixties but fail to meet the demands of our
high tech, Internet savvy society. A dramatic paradigm shift must take
place to allow the conversion of new technologies into our recruiting
process. We must consider how we merge today's technology with this
paperwork world. Applicants don't want to wait for the hiring process
to find the job of their dreams while their application is subjected to
the confines of an electronic maze, they want immediate, personalized
attention. With just a few changes in how we view and respond to these
applicants our process can become more effective and efficient
providing a lower cost per hire ratio.
In 1999 Vertical Alliance Group, Inc. (VAG) began a long and
thorough process to find out what works ``BEST'' in attracting and
recruiting employees. With great efficiencies come great rewards.
Operating on the premise that the Internet provides the most efficient/
effective venue to attract and recruit quality employees VAG has
created some proven processes that advance recruit productivity.
Current statistics indicate the recruiting closing rate of U.S.
businesses to be approximately 2 percent of all applications received.
A forty percent (40 percent) closing rate doesn't constitute the norm,
however, these results can and have been attained utilizing the process
we developed. Recruiting, training and retaining quality employees is
paramount to the success of any business and directly affect it's
bottom-line. The amount of time, money and effort dedicated to
recruiting/replacing staff can be reduced with just a few changes in
our attitude and processes about how we recruit and what efforts are
being made to retain quality employees.
Our efforts have produced the following conclusions:
All levels of management must buy into and participate in
the recruiting process.
Training of current personnel at all levels is an
essential element if we are to change the dynamic of how we respond to
leads and become more proactive in streamlining the hiring process.
Conversion of Human Resource personnel from the world of paper
processor to high tech ``Sales Ambassadors'' is essential to provide
the immediate gratification demanded by today's society.
We must provide timely follow-up to closure that
ensure(s) prompt attention is given each lead.
We must improve the ``quality'' of prospective
applications received. A success rate of 2 percent of ``spammed'' or
database derived leads cost money and wastes time.
Training is the essential element to a quality recruiting process.
All levels of management must understand and value the recruiting
process and recognize their role not only in recruiting but also the
retention of highly qualified personnel. Understanding the direct
response marketing strategy that includes an industry overview, how to
rate/rank leads, selling skills, technique to close, selling points,
the hiring cycle, are all necessary skills in providing a quality
recruiting process. Knowledge of the current ``shelf life'' of
applications is essential. In this competitive market, often the first
quality response, usually within minutes not hours, days or weeks wins
the deal. Human Resource personnel who are properly trained, highly
motivated and who understand the value of this process provide the
largest ``bang for the buck'' in recruiting and maintaining a strong
workforce.
Understanding the benefits and limitations of modern technology and
the balance between them can also improve your odds in closing the
deal. The ``human'' element is still one of vital importance in the
process. First impressions still count. Potential employees still want
a response from a real person, not a computer. In the words of Walt
Disney, ``There is no magic in magic, just details.'' Timely, polite,
professional communication will work magic in the recruiting process.
Massed, unranked or inappropriately filtered leads provide
``volume'' but lack ``quality'' and generate large amounts of paperwork
generally resulting in minimal success. Quality leads, appropriately
ranked by source first allow Human Resource personnel to come out of
the paper processor role and become more proactive in the recruiting
process. Targeted leads focused on essential hiring criteria provide
optimal potential for successful closure and lower cost for hire rates.
In an agency the size of VHA arguments can be made pro and con
between centralized and decentralized recruiting processes. Each has
its own unique values and barriers. Training of all personnel in their
respective roles in the recruiting and retention process will provide a
more prolific recruiting effort on behalf of the VHA.
There are a number of issues and complexities that challenge our
Human Resource efforts . . . But the good news is, there are solutions.
Amy Gruver, Call Center Team Leader for Swift Transportation Company,
one of the largest trucking companies in America, has stated that the
VAG process has resulted in their lowest cost per hire rate. Small
businesses to Fortune 500 companies have effectively implemented and
assimilated this process with phenomenal success saving valuable
resources.
Mr. Chairman, this concludes my remarks. I would be happy to answer
any questions that you or other Members of the Subcommittee may have at
the appropriate time.
Prepared Statement of Fred Cowell, Senior Associate Director
for Health Analysis, Paralyzed Veterans of America
Chairman Michaud, Ranking Member Miller, and Members of the
Subcommittee, on behalf of the Paralyzed Veterans of America (PVA), I
am pleased to be here today to offer our views concerning the ``Human
Resource Challenges within the Department of Veterans Affairs.''
PVA's primary concern, and the basic reason for our existence, is
the health and welfare of our members and of our fellow veterans. The
thousands of VA healthcare professionals and all of those individuals
necessary to support their efforts are at the core of VA's primary
mission. These individuals serve on the front line every day, caring
for America's wounded veterans from Iraq and Afghanistan and seeing to
the complex medical needs of our countries older veterans from previous
wars. PVA believes thatVA's most important asset is the people it
employs to care for those who have served our Nation.
Mr. Chairman, the Subcommittee's interest in the issues concerning
VA healthcare personnel is well placed and timely. Congress must assist
VA' efforts to recruit and retain its corps of healthcare professionals
as the demand for healthcare increases because of today's wars and the
aging of the veteran population from previous wars. Currently, the
Nation is experiencing serious short falls in its supply of physicians,
nurses, pharmacists, therapists and psychologists. Competition for
experienced medical personnel and newly licensed professionals is keen.
PVA believes that Congress must take the lead in revamping outdated
personnel policies and procedures (salaries, benefits, and working
conditions) that may place VA at a disadvantage in today's labor market
and will prevent VA from becoming the medical-care employer of choice
in the future. PVA also believes that the broken VA appropriation
process, which delays VA funding, is a major barrier to VA's healthcare
professional recruitment process.
America's National Nurse Shortage
The United States is currently in the tenth year of a critical
nursing shortage which is expected to continue through 2020. The
shortage of registered bed-side nurses and registered nurse specialists
is having an impact on all aspects of acute and long-term care.
America's nursing shortage has created nurse recruitment and retention
challenges for medical-care employers nationwide and is making access
to quality care difficult for consumers.
Three national issues are directly contributing to America's
national nursing shortage. First, the number of new nursing students
entering nursing education programs is insufficient to meet rising
medical care demand. Second, the number of nursing students seeking
admission to nursing schools is restricted because of a lack of
qualified nursing educators. According to the American Association of
Colleges of Nursing, 38,400 nursing school applicants were turned away
because of a lack of faculty. Third, a large percentage of the Nation's
nurse workforce is nearing retirement and will soon need to be
replaced.
The current and emerging gap between the supply of and the demand
for nurses may adversely affect the VA's ability to meet the healthcare
needs of those who have served our Nation. According to VA, it employs
more than 64,000 nursing professionals, and has one of the largest
nursing staffs of any healthcare system in the world. Of that 64,000,
VA has 43,000 registered nurses, 12,000 licensed practical nurses, and
9,000 nursing assistants. VA also says that approximately 4,300 nurses
retire or leave each year. VA must be able to recruit the best nurses,
and retain a cadre of experienced, competent nurses. Providing high
quality nursing care to the Nation's veterans is integral to the
healthcare mission of VA.
Like other healthcare employers, VA must actively address those
factors known to affect recruitment and retention of nursing personnel
such as: fair compensation, professional development, work environment,
respect and recognition, underlying issues of sucessful VA nurse
recruitment and retention. Failure to do so will undermine the quality
of VA care and will jeopardize the health of our veterans.
Mr. Chairman, The National Commission on VA Nursing submitted its
final report to then VA Secretary, Anthony J. Principi on March 18th,
2004.\1\ The report titled, Caring for America's Veterans: Attracting
and Retaining a Quality VHA Nursing Workforce is as vital today as it
was then.
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\1\ National Commission on VA Nursing 2002-2004, Final Report,
Caring for America's Veterans: Attracting and Retaining a Quality VHA
Nursing Workforce.
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PVA supports the following recommendations contained in that report
and believes they serve as a sound template for improvements to VA's
policies and procedures that govern its healthcare workforce. The
recommendations of the National Commission on VA Nursing were:
Leadership
The facility nurse executive should have line authority,
responsibility, and accountability for nursing practice and personnel.
The facility nurse executive should be a member of the
executive body at VISN and facility levels.
The facility nurse executive should be accountable for
(a) the effective performance of nurse managers, (b) leadership
development of all nursing staff, (c) development and implementation of
clinical leadership roles at the point of care, and (d) compliance with
standardized Nurse Professional Standards Boards (NPSB) protocols.
VHA should clearly define Nurse Qualification Standards
to facilitate consistent interpretation across VA's system of care.
Professional Development
VHA should structure career development opportunities to
assure that every nurse in VHA can actualize his/her goals within one
or more career paths with the opportunity for professional growth and
advancement.
VHA should establish policy guidelines for schools of
nursing comparable to the medical school model and actively promote
nursing school affiliations.
VHA should assure that VA's Health Professionals
Educational Assistance Program is funded and available nationwide.
Work Environment
VHA should develop, test, and adopt nationwide staffing
standards that assure adequate nursing resources and support services
to achieve excellence in patient care.
NOTE: PVA believes that nurse staffing standards must consider
the acuity level of patients for these standards to be meaningful.
VHA should review and adopt appropriate recommendations
outlined in the Institute of Medicine report , Keeping Patients Safe:
Transforming the Work Environment of Nurses, to determine specific
strategies for implementation across VHA.
Respect and Recognition
VHA should expand recognition of achievement and
performance in its nursing service.
VHA should create a sense of value and culture of mutual
respect for nursing through all levels of VHA to include physicians and
other colleagues, management, and stakeholders.
Fair Compensation
VHA should amend Title 38 to establish procedures for
assuring that RN locality pay policies are competitive with local RN
employer markets.
NOTE: PVA supports specialty nurse pay for VA nurses working in
VA's specialty care areas such as: spinal cord injury rehabilitation
and sustaining care, blind rehabilitation, mental illness and traumatic
brain injury.
VHA should change hiring and compensation policies to
promote recruitment and retention of licensed practical nurses and
nursing assistants.
VHA should strengthen its human resources systems and
departments to develop an active hiring and recruiting process for
nursing staff that is consistent, to the extent possible, across
facilities and VISN's.
Technology
VHA should give priority to the continued rollout of the
VA Nursing Outcomes Database (VANOD) as the repository for nursing
performance standards and the evaluation of effective patient care
delivery models.
VHA should engage experts to evaluate and redesign
nursing work processes to enhance patient care quality, improve
efficiency, and decrease nurse turnover through the use of technology.
The Agency for Healthcare Research and Quality (AHRQ) and
VHA should partner in applying findings from information systems and
technology research projects into patient care delivery.
Research and Innovation
VHA should establish a Center for Excellence in Quality
Nursing Care to create and implement a research agenda consistent with
VHA mission.
Mr. Chairman, while these recommendations for VA improvement were
directed toward VA's Nursing Service PVA believes that they have broad
application to VA's entire healthcare workforce.
Specialty Pay for VA's Specialized Services Nurses
PVA would very much appreciate the committee's consideration of
providing specialty pay for nurses providing care in VA's specialized
service programs such as: spinal cord injury/disease (SCI/D), blind
rehabilitation, mental health and brain injury.
Mr. Chairman, veterans who suffer spinal cord injury and disease
require a cadre of specialty trained registered nurses to meet their
complex initial rehabilitation and life-long sustaining medical care
needs. PVA's data reveals a critical shortage of registered nurses who
are providing care in VA's SCI/D center system of care. The complex
medical and acuity needs of these veterans, makes care for them
extremely difficult and demanding. These difficult care conditions
become barriers to quality registered nurse recruitment and retention.
Many of VA's SCI/D nurses are often placed on light duty status because
of injuries they sustain in their daily tasks. When this happens it
becomes a significant problem because it places additional patient care
responsibility on those SCI/D nurses not on light duty. PVA believes
SCI/D specialty pay is absolutely necessary if nurse shortages are to
be overcome in this VA critical care area.
We strongly encourage your committee to create a Title 38 specialty
pay provision that will assist VA's efforts to recruit and retain
nurses in these specialized areas. PVA is eager to assist Committee
staff in developing legislative language that will create specialty pay
for VA nurses working in these critical care areas.
Nurse Anesthetists
VA is currently facing serious challenges to the recruitment and
retention of Certified Registered Nurse Anesthetists (CRNA) who provide
the majority of anesthesia care for veterans receiving care in VA
medical facilities. GAO has reported that VA medical facilities have
current challenges recruiting and retaining VA CRNAs and that these
facilities will likely face challenges in retaining CRNAs over the next
5 years due to the number of VA CRNAs projected to retire from or leave
VA.\2\ The GAO further reported that their surveys of VA officials
indicated that low VA salaries were the major barrier to VA's
recruitment and retention efforts for this critical nursing skill.
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\2\ GAO Report April 9, 2008, VA Health Care: Recruitment and
Retention Challenges and Efforts to Make Salaries Competitive for Nurse
Anesthetists, GAO-08-647T.
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VA Physicians
PVA is concerned about the VA's current ability to maintain
appropriate and adequate levels of physician staffing at a time when
the Nation faces a pending shortage of physicians. Recent analysis by
the Association of American Medical Colleges (AAMC) indicates the
United States will face a serious doctor shortage in the next few
decades.\3\ The AAMC goes on to say that currently, ``744,000 doctors
practice medicine in the United States, but 250,000--one in three are
over the age of 55 and are likely to retire during the next 20 years.''
The subsequent increasing demand for doctors, as many enter retirement,
will increase challenges to VA's recruitment and retention efforts.
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\3\ Statement before the Senate Committee on Veterans Affairs,
April 9, 2008, Making VA the Workplace of Choice for Health Care
Providers, by John A. McDonald, M.D., Ph.D. Vice President for Health
Services and Dean of the University of Nevada Medical School and member
of the Association of American Medical Colleges, Veterans Affairs--
Deans Liaison Committee.
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Mr. Chairman PVA has serious concerns regarding VA's current and
future ability to match or exceed private sector physician salaries.
Additionally, PVA believes that VA's recruitment efforts are hampered
because VA's Education Debt Reduction Program (EDRP) is limited to
$49,000 spread out over 5 years of service. The average medical
education indebtedness has climbed to over $140,000 in 2007, therefore
the limited VA EDRP awards fail to provide an adequate incentive for VA
recruitment.
PVA is also concerned that the P.L. 108-445, the Department of
Veterans Affairs Personnel Enhancement Act, is being manipulated by
facility management to reduce operation costs. The American Federation
of Government Employees (AFGE), AFL-CIO testified before the Senate
Committee on Veterans Affairs that, ``At many VA facilities, management
has imposed improper performance criteria that determine bonuses based
on factors beyond the practitioners control, such as missed
appointments.''\4\ The AFGE goes on to say that annual physician
performance pay awards under this law have been inconsistent and
unjustifiably lower than the maximum amounts set by Congress.
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\4\ Statement before the Senate Committee on Veterans Affairs,
April 9, 2008, Making VA the Workplace of Choice for Health Care
Providers by Valerie O. Meara, N.P. Professional Vice President, AFGE
Local 3197 VA Puget Sound Health Care System, Seattle, Washington.
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The Independent Budget veterans service organizations (IBVSOs)
believe that appropriate committees should use their oversight
authority to study the impact of P.L. 108-445 on recruitment and
retention of VA physicians and dentists.
VA Psychologists
According to the American Psychological Association (AAPA), VA is
the largest single employer of psychologists in the Nation. Congress
and VA have recognized the need to increase the number of psychologists
and have added more than 800 new psychologists since 2005, thereby
raising the number of psychologists in the VA system to approximately
2,400. The demands placed on VA's mental health service have increased
dramatically because of the wars in Iraq and Afghanistan (OIF/OEF).
However, it should be noted that these increased psychology staffing
levels are a recent development. Since the vast majority of new
psychologist hires in VA are less experienced professionals, VA must
ensure they are properly trained and supervised. VA must also strive to
retain and promote its more experienced psychologists in order to meet
new training and supervision requirements.
Despite VA's positive recruitment efforts, VA's advancement and
retention policies continue to be driven by outdated and overly-rigid
personnel and retention mandates. PVA urges the Subcommittee to utilize
its oversight authority to investigate VA's on-going psychologists
recruitment efforts to determine if VA is providing adequate levels of
mental healthcare to meet the demands imposed by OIF and OEF while
ensuring that adequate treatment opportunities continue to exist for
veterans with prior service.
Summary
Mr. Chairman, the Veterans Health Administration has made great
strides over the last decade to improve the quality of care it provides
to our Nation's veterans. Despite these gains, VA now finds itself in a
precarious situation if it expects to retain its position as a vastly
improved healthcare system. Challenges associated with maintaining a
highly qualified medical care workforce are a major issue for VA.
Competition to hire medical care professionals, during a national
period of low supply, is making it more-and-more difficult for VA to
successfully recruit and retain qualified personnel.
If VA is to succeed it must have the resources required to offer
competitive salaries and benefits and to make improvements to its work
environment. VA must better utilize existing policy provisions that
provide locality pay, premium and overtime pay, create flexible work
schedules, relieve restrictions on mandatory overtime, and fully fund
its excellent educational programs such as the Education Debt Reduction
Program and the National Nursing Education Initiative.
Mr. Chairman, PVA believes that Congress must assist VA's
employment efforts by up-dating provisions of Title 38 that will
enhance VA's competitive position as it vies to attract healthcare
professionals to its ranks. Additionally, Congress must embrace a VA
appropriation process that promptly funds the VA healthcare system so
VA management can be confident that resources are available to support
a health-care workforce that can meet the medical care demand of a
growing veteran population.
Mr. Chairman, this concludes my remarks. I will be happy to attempt
to answer any questions you or Members of the Subcommittee may have.
Prepared Statement of Cecilia McVey, BSN, MHA, RN, Associate Director
for Patient Care/Nursing, Veterans Affairs Boston Healthcare System,
Veterans Health Administration, U.S. Department of Veterans Affairs,
and Immediate Past President, Nurses Organization of Veterans Affairs
Mr. Chairman and Members of the Committee on Veterans' Affairs
Subcommittee on Health, the Nurses Organization of Veterans Affairs
(NOVA) would like to thank you for inviting us to present testimony on
Human Resource issues in the VA.
I am Cecilia McVey, BSN, MHA, RN, Associate Director for Patient
Care/Nursing at the VA Boston Healthcare System and am here today as
the Immediate Past President of NOVA. NOVA is the professional
organization for registered nurses employed by the Department of
Veterans Affairs.
NOVA respects and appreciates what our labor organizations, such as
AFGE and NAGE, do for VA nurses. NOVA clearly deals with VA on RN
professional matters, not working conditions for which VHA RNs have
their union representatives. Because this Committee has invited NOVA to
share its views on this bill, however, I am here to offer the following
observations.
The Veterans Health Administration (VHA) is the third largest
civilian employer in the Federal Government and one of the largest
healthcare providers in the world. VHA is facing significant challenges
in ensuring it has the appropriate workforce to meet both current and
future workforce needs. This workforce is critical to ensure we are
able to provide the care our Nation's heroes deserve. These challenges
are further exacerbated by an aging workforce in general and in nursing
specifically and the high number of employees' retirement eligible each
year.
Nursing and other Medical Center workforce members are dependent on
timely and efficient recruiting. Human Resources Departments across VHA
are not able to function optimally due to systems that have not kept
pace with private sector recruitment abilities.
Although there are numerous barriers to timely and efficient
recruiting the following three are the top three:
1. Although certain pay setting flexibilities do exist, such as
recruitment bonuses/retention allowances, above minimum entry rates,
and the special rate authority, additional pay flexibilities are needed
in order for VA to be able to successfully compete for the best
candidates in the marketplace. The current general schedule and
locality pay system which works hand in hand with the classification
system is antiquated, cannot respond quickly enough and has a number of
major barriers. For example:
a. Retention allowances.
1. They are not considered base pay for benefits such as
retirement and life insurance. Candidates declined positions based on
this limitation.
b. Special pay rates.
1. There are restrictions on how far the pay table can be
expanded.
2. You cannot use special rates to address recruitment/
retention issues of a subgroup within an occupation
3. Approval process for special rates is too slow to address
current market conditions.
4. The major focus of the criteria is whether you are getting
qualified candidates to apply and not whether the candidates are highly
qualified.
c. Above minimum rates.
1. Allows manager to appoint the applicant above the minimum
step. There are many situations where the manager needs to offer a
highly qualified candidate more money than the existing experienced
staff. There is no mechanism to increase the pay of the existing staff
to maintain pay parity.
2. The application process (how to apply) is too cumbersome
and very confusing for those in the private sector who are used to a
much faster and simpler process. Staffing Specialists must help many of
the would-be applicants to navigate through the maze of the Federal
application process. Applicants are frustrated by the duplication of
information that they are required to provide, such as the information
on Federal application for employment, information for background
investigations, and credentialing. The enormous amount of paperwork,
data base entries, and checklists associated with fulfilling all of the
hiring requirements further delays the process. This leads to hiring
additional FTEs to manage the processes.
3. A consistent theme across the country is that applicants
are looking for money for professional development not just in clinical
occupations but administrative as well. Tuition reimbursement is
limited to a few select occupations at this time such as Nurses.
Some suggested policy changes recommended are as follows:
1. More positions should be converted to Excepted Service, i.e.,
hybrid Title 38 such as Nursing Assistants, Health Technicians, Medical
Support Assistants, Radiation Safety Officers, and Information
Technology Specialists, for example. Due to the constraints associated
with recruiting through the Delegated Examining Units, the process is
often too difficult and generally does not provide a list of ``highly
qualified candidates'' and discourages potential hires.
2. More pay flexibilities should be provided. Pay reform similar
to the Physician pay reform where there is a market pay component would
provide the needed flexibility for VA facilities at the local level.
Another option would be to provide legislation that would address the
barriers in paragraph 1 above.
3. Classification Standards are in need of review and revision.
Many of them are too old and no longer reflective of the types of
duties and responsibilities that are typically performed. Given that
these are used to determine the pay, they often serve as a barrier to
appropriate and effective pay setting.
4. Given the sizeable numbers of employees at or near retirement
age, succession planning is becoming increasingly more important,
especially for critically important positions. In order to successfully
transition workload from retirees who possess a wealth of experience to
their successors; transitional recruitment is required, which can take
up 3 to 6 months of addition FTE per situation.
One other critical issue of concern relates to the impact on
patient care if 38 U.S.C. 7422(b) exclusions were to be repealed. Some
of the issues that I foresee would have a negative impact on the care
of our Veterans include the following:
RN reassignment decisions made on the basis of clinical
competence.
Performance appraisals/proficiency reports.
Fitness for duty issues as determined by Professional
Standards Boards.
Clinical competence issues as determined by Professional
Standards Boards.
Disciplinary and major adverse actions based on patient
care or clinical competence issues.
Determination of clinical competence is best reserved for those
responsible in ensuring that quality patient care is delivered. Our
veterans deserve the best that VA has to offer, and although the
majority of our employees are excellent, there are a few marginal
performers who put patient safety at risk. Moreover, clinical
supervisors and managers must retain the authority to make clinical
decisions such as which personnel are best suited for particular
assignments and the appropriate staff mix for a given clinical setting.
Inherent in bargaining is the element of timeliness. If an employee
needs to be removed from direct patient care or if providers' hours
must be extended to meet growing patient care needs, those changes must
be made immediately and cannot wait for the completion of protracted
negotiation. National Level bargaining on policy or program changes is
currently taking 120 days or longer. Local bargaining usually takes
less time but still can result in delays, despite the best of
intentions. If clinical matters were subject to bargaining, critical
clinical programs such as extending the hours of mental health clinics
or mandating traumatic brain injury training for all providers could
not be implemented for months, which would unacceptably put patients at
risk.
VHA has been a leader in healthcare and has earned an excellent
reputation as one of the best healthcare providers in the country. In
order to continue this reputation, VHA staff will need to have new
skills and competencies to treat this new generation of Veterans.
Nimble and flexible HR processes are critical to VA's future success.
Thank you, Mr. Chairman and Members of the Subcommittee, for the
opportunity to testify here today about these important personnel
issues.
Prepared Statement of Adrian M. Atizado,
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 human resources challenges within the Department of Veterans
Affairs' (VA) Veterans Health Administration (VHA).
The human capital needs of VHA are driven by needs of the
population VA serves. VA is experiencing a gradual slowdown in the
growth of its enrollees due to declining veteran population, mortality
in the Priority 8 enrollee population since the suspension of
enrollment, and deaths in the pre-enrollee population. New enrollments
of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF)
veterans do not reverse the trend. Further, the reliance and
utilization rates of veteran enrollees from prior conflicts are more
established and better defined than the medical care consumerism of the
OEF/OIF enrollee population.
A number of undefined variables, such as duration of the conflict,
demobilization requirements, and impact of outreach efforts, will
influence the number and types of services that VA will need to provide
OEF/OIF veterans. What is known today is that the current OEF/OIF
veterans appear to have different utilization patterns than the rest of
the VA enrollee population, needs that will demand greater flexibility
in human resource management within the VA. Specifically, initial
findings indicate OEF/OIF enrollees use half as much inpatient surgery
and acute medicine, but it is expected that they will need three times
the number of PTSD residential rehabilitation services, and have
greater needs for physical medicine, prosthetics and outpatient
psychiatric and substance abuse services. Correspondingly, enrollees
from previous wars making up the vast majority of the population
continue transitioning to higher enrollment priorities, and the aging
morbidity of this population are driving the type and intensity of
healthcare needs--even with the acknowledged declining reliance on VA
once they qualify for Medicare.
In the general civil service arena, the Office of Personnel
Management (OPM) estimates about one-third of full-time government
workers will retire by 2012, but some occupations are more sensitive to
external forces and agency initiatives than others. 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 was 48 years. It estimated that by the end
of 2012, approximately 91,700 VHA employees, or 44 percent 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. In addition,
a significant number of healthcare professionals in leadership
positions would also be eligible to retire by the end of 2012. With
regard to the three mission critical occupations--registered nurse,
pharmacist and physician, a startling finding in the report concluded
that 97 percent of VA nurses in pay band ``V'' positions would be
eligible to retire, and that 56 percent were expected to retire; and,
that 81 percent of VA physicians in pay category 16--including many
current Chiefs of Staff, would be eligible to retire, with 44 percent
projected to actually retire from Federal service.
Furthermore, the supply of healthcare providers poses an added
hurdle for VA to be a patient-centered and integrated healthcare
organization for veterans providing excellence in healthcare, research,
and education; an organization where people choose to work; an active
community partner and a back-up for national emergencies. In
recognition, VA's more recent commonly used description is that,
``[t]here is a growing realization that the supply of appropriately
prepared healthcare 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 professional schools
is not growing fast enough to meet the projected future demand for
healthcare providers.''
Without question, recruitment, management, and providing direction
for VA employees on such issues as compensation, hiring, performance
management, and organizational development are critical to the success
of VHA's mission to provide safe, high quality healthcare services to
sick and disabled veterans. While the most recent actions by Congress
to affect the compensation package VHA may offer to prospective
employees necessitates additional implementation oversight, an equally
important problem within the realm of recruitment that requires
attention is the Federal hiring process itself.
Hiring a new wave of Federal employees to succeed those that leave
is paramount given the frequent civil-service hiring freezes of the
past 2 decades due to cross-government rescissions and dictated
``management efficiency'' savings, inadequate funding levels, and the
unpredictable nature of the discretionary appropriations process.
Moreover, the passive approach to recruiting applicants by Federal
agencies including VA puts themselves on unequal footing compared to
the recruitment and retention programs used by many competitive private
employers. With over 100,000 healthcare trainees receiving clinical
learning experiences annually in VA facilities, hiring from this pool
should provide VHA with an increased advantage over private healthcare
facilities. Unfortunately, there is the perennial and widely
acknowledged complaint by applicants for Federal employment about
cumbersome Federal hiring procedures and practices, which require too
much time and excessive paperwork. Of those who do submit applications,
many say they never receive feedback from agencies of interest.
According to a survey conducted by the Merit Systems Protection
Board (MSPB), supervisors and upper-level new employees reported that
the hiring process is complex and takes too long. The most recent MSPB
survey of entry-level hires and upper-level hires showed that
substantial numbers had to wait 5 months or longer before being hired--
much too long to expect a high-quality applicant to wait. These
findings harken back to the 2002 survey indicating an average of about
3 months are required for the government to hire anyone, while 70
percent of college students say that they are unwilling to wait more
than 4 weeks for a job offer.
OPM has publicly acknowledged this problem in Federal hiring and
has agreed that the process has become cumbersome. To address this, it
has urged Federal agencies to take advantage of recent laws that
encourage quick hiring decisions and permit the use of bonuses to
recruit and retain Federal employees. Unfortunately, a myriad of rules
and procedures are still in place to restrict the use of these tools.
These restrictions in Federal hiring decisions were designed to ensure
equity, consistency, and accountability, while also protecting against
fraud, waste and abuse. This design does not compete well with private
sector recruitment practices.
While Federal job applications are only the first tedious part of
the process, agencies require approval from their personnel
departments, which in turn cannot go beyond the level of appropriated
or designated funds. If the agency, department, or facility does get
approval, its managers must produce a proper position description, get
the vacancy announcement approved and posted, rate the applicants,
interview the candidates, get higher-level approval for the hire, then
conduct boarding, and finally complete any required background checks,
(and for professionals, complete credentialing and privileging). Each
step adds more time to the process. In some cases security and
background checks have caused several months delay due to increased
security requirements. Candidates for the top tier career appointments
to the Senior Executive Service (SES must pass yet another review
board, composed of SES members. The 5-month average for the government
to hire anyone is infeasible for many applicants--especially younger
job-seekers.
VA recently testified on streamlining its cumbersome hiring
process, stating the Human Resource Committee of the VHA National
Leadership Board chartered a workgroup last year 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 that could be streamlined. The
recommendations were piloted in Veterans Integrated Service Network
(VISN) 4 (generally, Pennsylvania) with the implementation and results
of the pilot rolled out nationwide. During the spring and summer of
2008, training in systems redesign will be offered nationally at Human
Resources Cluster meetings. At these sessions, VA testified it will
focus on new strategies and systems redesign elements that can be used
to help meet the daily challenges of attracting and retaining critical
healthcare professionals.
In addition to time, there is often poor communication between
Federal managers and HR professionals on the qualities and skills
needed in a candidate. Attrition of experienced VHA human resources
employees has had a direct impact on the quality of recruitment and
retention efforts as well as providing needed assistance to train new
and inexperienced staff to successfully hire needed VA healthcare
providers. In the end, those individuals who make it to the end of this
process are often not the optimum candidates, nor the best qualified
for the position. In fact, in the 2006 Federal Human Capital Survey,
less than half of government workers said that their work unit is able
to hire people with the right skills.
VHA's workforce is covered under Title 5, Title 38, and Congress
has provided VHA a unique Title 38 ``hybrid'' authority, combining
elements of both titles. As the greater majority of VHA employees fall
under Title 38 and Title 38 hybrid systems, personnel rules under both
were designed to allow greater flexibility and expedite VHA's hiring
and promotion processes. The Title 38 hybrid model requires
Professional Standards Boards to make recommendations on employment,
promotion and grade. This model is viewed as more subjective due to the
level of transparency than Title 38, where professionals are hired,
promoted and retained based solely on their professional
qualifications. Moreover, the reality of the hiring and promotion
processes under Title 38 hybrid is facing extraordinary delays
particularly in the boarding process across healthcare disciplines from
nurses to psychologists.
The Federal hiring process is so daunting that it often reinforces
applicants' worst fears of government as an ineffective, unresponsive
and incomprehensible bureaucracy. Only by insisting that agencies make
recruiting talent a top priority and that both agency leaders and
managers be held responsible for results, can we ensure that the
government recruits the talent it needs to meet the challenges ahead. A
simple practice (but time consuming due to inadequate VHA human
resources staffing) that could be employed is to ensure that the human
resources staffs responsible for recruiting applicants provide some
meaningful and timely feedback to job applicants. Feedback, which puts
some personal touch to an impersonal process, can help maintain
applicants' interest in the agency as well as throughout a hiring
process that can be lengthy as I have indicated.
Again, we thank you for this opportunity to testify. This concludes
my testimony, and I will be happy to address any questions from the
Chairman or other Members of the Subcommittee.
Prepared Statement of Joleen Clark, Chief Officer,
Workforce Management and Consulting, 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 to discuss ``Human Resources
Challenges'' within the Department of Veterans Affairs (VA) Veterans
Health Administration (VHA). Our challenges cover recruitment and
retention programs, improving and streamlining the recruitment process,
and other issues related to developing and maintaining a qualified and
diverse workforce of healthcare professionals.
As the Nation's largest integrated healthcare delivery system,
VHA's workforce challenges mirror those of the healthcare industry as a
whole. VHA experiences pressures equal to or greater than other
healthcare organizations. VHA performs extensive national workforce
planning and annually publishes a Workforce Succession Strategic Plan
that includes workforce analysis and planning for each Veterans
Integrated Service Network (VISN) and national program office. VHA's
Strategic Plan addresses current and emerging initiatives in areas
including, but not limited to, recruitment and retention, mental
healthcare, polytrauma, traumatic brain injury, and rural health to
address workforce efforts.
VHA's Strategic Plan identifies mission-critical occupations which
are considered shortage categories, as well as recruitment and
retention initiatives at the local, regional and national levels. For
each of the nationally ranked mission critical occupations, VA conducts
a thorough historical and projected workforce analysis. Plans are
established at every level to address turnover, succession planning,
developmental opportunities, and diversity issues. VHA uses equal
employment opportunity comparison data for each of the critical
occupations, as well as the workforce nationwide, 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 has
presented it to other Federal agencies as well as by means of OPM's ``A
Best Practice Leadership Forum On Succession Management'' conference.
Efforts to Recruit Health Care Professionals
It is important that the supply of appropriately prepared
healthcare workers meet the needs of a growing and diverse population.
Enrollment in nursing schools needs to grow to meet the projected
future demand for healthcare providers.
More than 100,000 health professional trainees come to VA
facilities each year for clinical learning experiences. Many of these
trainees are near the end of their education or training programs and
become a substantial recruitment pool for VA employment as health
professionals. The annual VHA Learners' Perceptions Survey shows
trainees were twice as likely to consider VA employment after
completing their VA learning experiences than they were before. This
demonstrates many trainees were not aware of VA employment
opportunities or the quality of VA's healthcare environment prior to VA
training, but became considerably more interested after their VA
clinical experiences.
An informal survey of all VA facilities in 2007 found that 74
percent of the 800 psychologists hired over the last 3 years received
some training in professional psychology through VA. This year, VHA's
Offices of Academic Affiliations (OAA) and Patient Care Services
significantly expanded VA's psychology training programs in
anticipation of the ongoing need for additional VA psychologists.
The Healthcare Retention and Recruitment Office (HRRO) is
distributing a new recruitment brochure titled ``From Classroom to
Career'' to VA trainees. The Office of Academic Affiliations in VA
Central Office emphasizes trainee recruitment to education leaders in
VA facilities. The VHA leadership has raised the trainee recruitment
issue to a higher priority.
In an effort to initiate proactive strategies to aid in the
shortage of clinical faculty, VA launched the VA Nursing Academy
(Academy) to address the nationwide shortage of nurses. The purpose of
the Academy is to expand the number of nursing faculty in schools,
increase student nursing enrollment by 1,000 students, increase the
number of students who come to VA for their clinical learning
experience, and promote innovations in nursing education and clinical
practice. Four partnerships were established for the 2007--2008 school
year. Four additional partnerships will be selected each year in 2008
and 2009 for a total of twelve partnerships.
The VA Travel Nurse Corps is an exciting new program that
established a pool of registered nurses (RNs) in VA who can be
available for temporary, short-term assignments at VA medical centers
throughout the country; this program is being piloted at two sites, San
Diego and Phoenix. The VA Travel Nurse Corps meets nurses' needs for
travel and flexibility while meeting VA medical center needs for
temporary, high quality nurses. The goals of the program are to
maintain high standards of patient care quality and safety; reduce the
use of outside supplemental staffing; improve recruitment of new nurses
into the VA system; improve retention by decreasing turnover of newly
recruited nurses; provide alternatives for experienced nurses who may
leave the VA system; and establish a potential pool of RNs for national
emergency preparedness efforts. The VA Travel Nurse Corps program may
also serve as a model for an expanded multidisciplinary VA Travel Corps
in the future.
Student programs, such as the VA Learning Opportunities Residency
(VALOR) Program, the Student Career Experience Program (SCEP), and the
Hispanic Association of Colleges and Universities (HACU) Internship
Program, have helped VA meet its workforce succession needs. VALOR is
designed to attract academically successful students of baccalaureate
nursing programs and pharmacy doctorate programs. VALOR offers a paid
internship and gives the honor students the opportunity to develop
competencies in their clinical practice in a VA facility under the
guidance of a preceptor. In response to the success of the VALOR
program for nurses, VA added a pharmacy component in 2007. SCEP and
HACU offer students work experience related to their academic field of
study. VHA's goal is to actively recruit these students for permanent
employment following graduation. VA National Database for Interns is a
newly designed database developed to track students in VA internship/
student programs and to create a qualified applicant pool.
The Graduate Health Administration Training Program (GHATP)
provides practical work experience to students and recent graduates of
healthcare administration masters programs. On an annual basis, 40-45
GHATP residents and fellows are competitively selected and, upon
successful completion of the programs, are eligible for conversion to a
permanent position. The Technical Career Field program is designed to
fill entry level vacancies in areas like Budget, Finance, Human
Resources, and Engineering, where shortages are predicted and VA-
specific knowledge is critical to success. Recruitment is focused on
colleges and universities. Each intern is placed with an experienced
preceptor in a VHA facility. The program is designed to be flexible and
responsive to the changing needs of the workforce, as the target
positions and the number of intern slots are determined based on
projected needs.
Challenges Hiring Health Professional in Rural Areas
VA recognizes that rural communities face additional healthcare
workforce challenges. Many of the access and quality challenges rural
patients face begin with a shortage of healthcare providers. VA is
working to develop an effective rural workforce strategy to recruit
locally for a broad range of health-related professions.
Experiential training opportunities for young medical students are
important investments for creating a veteran- and rural-friendly
physician workforce. VA is working to integrate rural areas into
residency rotations, since evidence shows those who serve residencies
in rural areas are more likely to practice in rural areas.
Streamlining the Hiring Process
Last year, VHA's Human Resource Committee chartered a workgroup to
streamline the recruitment process for Title 5 and Title 38 positions
within VHA. The workgroup initially analyzed the recruitment process
and identified barriers and lengthy processes for Registered Nurses.
VHA conducted a pilot program in VISN 4 (Pittsburgh, PA) where the
group's recommendations were put into practice. The recommendations
were piloted there with the implementation and results of the pilot
rolled out nationwide using information from this pilot. This spring
and summer, VA is offering training in systems redesign nationally at
Human Resources Cluster meetings. These sessions will focus on new
strategies and systems redesign elements that can be used to help meet
the daily challenges of attracting and retaining critical healthcare
professionals.
VA has direct appointment authority for several Title 38
occupations, including physical therapists. We recognize that physical
therapists are essential to the rehabilitation of injured veterans, and
VHA is in the final stages of working with the Office of Human
Resources Management to develop a new qualification standard, which
should be implemented later this year.
In October 2007, VHA consolidated the Delegated Examining Units
from 19 decentralized units to eight centralized units, fully automated
offices which process all VHA requests for external Title 5 job
applicants. The centralization, consolidation and automation of this
function have helped VHA achieve reductions in the timeframes for
announcing Title 5 positions to the general public; qualifying
candidates and generating certificates of eligible candidates for
hiring managers. Metrics have been established and tracking implemented
to measure the competitive hiring process within VHA. Improvements in
timelines for processing are expected to continue throughout the year.
Innovative Retention Strategies
One retention strategy that has proven very successful for VHA was
approved in Public Law 108-445 (dated December 3, 2004 and effective
January 8, 2006). VHA physician and dentist pay consists of three
elements: base pay, market pay, and performance pay. P.L. 108-445
improves VA's ability to recruit and retain the best qualified
workforce capable of providing high quality care for eligible veterans.
VA is committed to ensuring 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 similar services. Between the time the pay bill went into
effect and the end of February 2008, we have increased the number of VA
physicians by over 1,430 FTE. Also as a component of this legislation,
VA has the discretionary ability to set Nurse Executive Pay to ensure
we continue to successfully recruit and retain nursing leaders.
National Recruitment/Media Marketing Strategies
The VHA Healthcare Retention & Recruitment Office (HRRO)
administers national programs to promote employment branding with VHA
as the healthcare 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.
Recent marketing studies for nursing and pharmacy have been the
driving force for many of our successful campaigns. HRRO works at the
national level to promote recruitment branding and to provide tools,
resources, and other materials to support both national branding and
local recruiting. The current annual recruitment advertising budget is
$1.8 million. Some of the features of this program are:
Integration of VHA's recruitment website search engine
(www.VACareers.va.gov) with the USA Jobs (www.USAjobs.opm.gov) search
engine. This combined resource provides consolidated information on
careers in VHA, job search capability, and information on Federal
employment pay and benefits information. This integration was completed
in March 2008.
Public Service Announcements (PSAs) promote the
``preferred healthcare employer'' image of VHA. PSAs emphasize the
importance and advantage of careers with VA and focus on the personal
and professional rewards of such a career.
A comprehensive online advertising strategy where VA
positions are promoted on commercial employment websites like Career
Builder, Healthcareers, and others. Advertising on online health
information networks expands our reach to over 5,000 discrete websites
at a cost of just over $500,000 annually. VA's strategy includes banner
advertising directing traffic to the VACareers website for employment
information and adding keyword searches to Google and Yahoo! to elevate
VA jobs to the top of the list of search results on these sites. This
advertising results in over 100,000 visits to the VA recruitment
website each month.
Print advertising includes both direct classified
advertising and national employment branding. The national program
provides ongoing exposure of VA messaging to potential employees and
promotes VA as a leader in patient care. VHA print advertising reaches
over 34 million potential candidates.
VHA Health Care Recruiters' Toolkit is a unique virtual
community internal to VHA. This toolkit is an online management program
coordinating national and local recruitment efforts for healthcare
professionals and serves as a resource by providing available
recruitment tools, materials, advertisements, and other related
information at recruiters' fingertips.
VHA's National Recruitment Advisory Groups represent top
mission critical occupations that collaborate on an interdisciplinary
approach to address recruitment and retention.
In Fiscal Year 2007, HRRO developed a comprehensive recruitment
marketing plan for mental health professionals using some of the
strategies mentioned earlier, as well as financial recruitment
incentives. Funding was dedicated for Mental Health Enhancement
Initiative Education Debt Reduction Program (EDRP) positions. As of May
1, 2008, awards had been made to 144 participants. The total payout for
these participants is over $5,235,000 over a 5-year service period. The
average total award is $36,355.
Financial Incentives for Recruitment and Retention
Both a recruitment and retention tool, the Employee Incentive
Scholarship Program (EISP) pays up to $35,900 for academic healthcare-
related degree programs. Between 1999 and May 1, 2008, 7,524 VA
employees have received scholarship awards for academic education
programs related to Title 38 and Hybrid Title 38 occupations, and more
than 4,200 employees have graduated. Scholarship recipients include RNs
(93 percent), pharmacists, and many other allied health professionals.
Focus group market research shows 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
positive employee retention. Less than 1 percent of nurses leave VHA
during their service obligation period, from one to 3 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 similar to the Student Loan
Repayment Program, under Office of Personnel Management (OPM)
regulations. VA has the authority to award up to $50,824. Currently,
the maximum award amount is capped at $48,000 and is tax free. The
maximum award amount is usually increased each fiscal year. As of May
1, 2008, 6,467 healthcare professionals were participating in EDRP. The
average amount authorized per student, since the inception of EDRP, is
$18,394. The average award amount per employee has increased each
fiscal year from over $13,500 in FY 2002 to over $29,000 in FY 2008 as
education costs have increased. While employees from 34 occupations
participate in the program, 75 percent are from three mission critical
occupations: registered nurses, pharmacists and physicians. These
figures include the mental health initiative EDRP awards discussed
previously.
Resignation rates of EDRP recipients are significantly less than
non-recipients as determined in a 2005 study that showed:
The resignation rate for nursing EDRP recipients was 14.3
percent while the resignation rate for non-EDRP recipients was 28
percent--a 13.7-percent difference. The resignation rate for physician
EDRP recipients was 15.9 percent while the resignation rate for non-
EDRP recipients was 34.8 percent--an 18.9-percent difference. The
resignation rate for pharmacy EDRP recipients was 13.4 percent while
the resignation rate for non-EDRP recipients was 27.6 percent--a 14.2-
percent difference.
A study of the EDRP program retention rates in 2007 showed 75
percent of pharmacists and nurses who received EDRP awards in 2002 were
still employed by VA at the end of the initial 5-year period of the
program's operation. Among physicians, 65 percent were still employed.
Although a smaller percentage, it represents a substantial retention
level.
VHA routinely uses hiring and pay incentives established under
Title 5 and Title 38. Financial recruitment incentives, retention
incentives (both individual and group), special salary rates,
relocation incentives and other incentives are routinely used and
documented in VHA's Workforce Succession Strategic Plan. Recruitment
and retention incentives are used to reduce turnover rates and help
fill vacancies. In Fiscal Year 2007, nearly $24 million in recruitment
incentives were provided to over 3,150 Title 38 and Title 38 Hybrid
employees, while more than $34 million in retention incentives were
given to 5,300 Title 38 and Title 38 Hybrid employees.
Employee Entrance and Exit Survey Analysis
In 2000, VA began using an electronic database to capture survey
information from employees entering and exiting VA service. The
entrance survey is an excellent tool for comparing and contrasting
reasons the new workforce has come to work for VHA and for determining
recruitment sources used by candidates (for example, newspaper
advertisements, employee referrals, online job postings, etc.). The
exit survey tracks the reasons why staff leaves VHA employment.
Survey results of 2006 and the first half of 2007 show advancement
and development opportunities, benefits, and job stability were the top
reasons to work for VA. VA's 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 opportunities elsewhere, and family matters (marriage,
pregnancy, etc.). These findings provide valuable insight for
developing recruitment marketing messages and establishing programs to
improve retention.
Conclusion
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.
I would like to thank the Committee for your interest and support
in implementing legislation that allows us to compete in the healthcare
market.
MATERIAL SUBMITTED FOR THE RECORD
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
June 5, 2008
Honorable James B. Peake, M.D.
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Secretary Peake:
Thank you for the testimony of Joleen Clark, Chief Officer,
Workforce Management and Consulting, Veterans Health Administration, at
the U.S. House of Representatives Committee on Veterans' Affairs
Subcommittee on Health hearing that took place on May 22, 2008 on
``Human Resources Challenges Within the Veterans Health
Administration.''
Please provide answers to the following questions by July 17, 2008,
to Chris Austin, Executive Assistant to the Subcommittee on Health.
1. In your statement you reference the VHA's Strategic Plan and
that it identifies mission-critical occupations which are considered
shortage categories.
Could you tell this Subcommittee what are the top three
mission-critical occupations?
What initiatives have been undertaken in the past year
to help alleviate the shortages of these three critical occupations?
How successful have the initiatives been?
2. Let's talk about the hiring process. We know that the
application process is extremely onerous to a potential employee, not
to mention it takes months to fill a position.
For the mission-critical occupations, what is the
average length of time it takes to fill a position?
What is the number one reason a potential candidate
turns down employment with VA?
What has VHA done to help expedite the hiring process?
3. What do you believe is VHA's number one challenge in filling
shortage positions?
4. Regarding the challenges facing VHA with hiring in rural areas.
You state in your testimony that ``VA is working to integrate rural
areas into residency rotations, since evidence shows those who serve
residencies in rural areas are more likely to practice in rural
areas.''
How does that program work and who are you working with
to accomplish that?
Please tell me how far along VHA is with ``working to
integrate rural areas into residency rotations?
Additionally, please answer the following questions for Congressman
Vic Snyder:
1. For each category (i.e. Title 38, Title 5 and hybrid), what is
the current total cost per hire?
2. What are the existing advertising costs?
What are the total advertising costs per hire?
3. What is the total volume of generated leads by source per
month?
What is the average hire rate based on that source?
4. What are the projected staffing requirements (RN nurse
positions only) considering existing vacancies, losses due to
anticipated turnover, and anticipated retirement losses through 2015?
5. What is the current cycle timeframe from a commitment to hire
an application and to actual hire date?
6. Would you please rank in descending order the percentage of
closing of each source (i.e., walk-ins, Internet, phone inquiries,
billboard, radio, etc.)?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers by July 17, 2008.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
Questions for the Record
The Honorable Michael H. Michaud, Chairman
Subcommittee on Health
House Committee on Veterans' Affairs
May 22, 2008
Human Resources Challenges within the Veterans Health Administration
Question 1(a): In your statement you reference VHA's Strategic Plan
and that it identifies mission-critical occupations which are
considered shortage categories. Could you tell this Subcommittee what
are the top three mission-critical occupations?
Response: The top three mission-critical occupations within the
Veterans Health Administration (VHA) are registered nurses, physicians,
and pharmacists.
Question 1(b): What initiatives have been undertaken in the past
year to help alleviate the shortages of these three critical
occupations?
Response: The Department of Veterans Affairs (VA) has undertaken
several initiatives to help reduce the shortages of mission-critical
occupations:
Offering student loan repayment
Tuition support/scholarship programs
Special salary rates may be authorized for hybrid, title
38 and title 5 positions when:
hiring or retention efforts are likely to become
significantly handicapped due to factors such as higher rates of pay
being offered by private sector employers
the duty station is in a remote location
the nature of the work or working condition is
unfavorable (i.e., exposure to occupational or health hazards)
Retention/Recruitment Incentives (recruitment and
retention payments provide monetary incentives for individuals to
accept employment or remain employed in Federal Service) and
Developmental/promotional opportunities
Question 1(c): How successful have the initiatives been?
Response: The initiatives have been successful in reducing turnover
rates in the top three mission-critical occupations. Since 2002, these
initiatives have been successful in reducing turnover rates in the top
three mission-critical occupations. VA has also brought on board more
employees in these occupations in fiscal year (FY) 2007 than any time
in the last 10 years and increased the end-of-year onboard head count
by an additional 968 physicians (6.3-percent increase), 2,449
registered nurses (6.2-percent increase), and 238 pharmacists (4.8-
percent increase). This is more than double the increase seen in most
of the previous 10 years for these occupations. VA expects to see a
larger increase in each of these occupations this year. VA is
projecting 7.2 percent, 8.7 percent, and 6.2 percent increases for the
end of FY 2008. This means that our recruiting efforts have been
phenomenal and our human resources shops have been working incredibly
hard to bring on the additional physicians, nurses, and pharmacists VA
needs to fulfill the mission.
Question 2(a): Let's talk about the hiring process. We know that
the application process is extremely onerous to a potential employee,
not to mention it takes months to fill a position. For the mission-
critical occupations, what is the average length of time it takes to
fill a position?
Response: After identifying a candidate, the average length of time
to fill a mission-critical occupation is approximately 10 days (if
being hired as temporary) to 180 days. There are a number of steps in
the hiring process that must be completed before a candidate can be
appointed on a permanent basis. VA performs reference checks and
credentials are verified through the necessary sources. Title 38 and
hybrid title 38 candidates must be evaluated by a Professional
Standards Board, and compensation panels need to recommend pay for
physicians and dentists. Additionally, preemployment physicals have to
be performed and candidates have to give proper notice to their
previous employer.
Question 2(b): What is the number one reason a potential candidate
turns down employment with VA?
Response: Non-competitive salary with the local market is the
number one reason why a potential candidate turns down employment with
VA.
Question 2(c): What has VHA done to help expedite the hiring
process?
Response: VHA has several initiatives underway to shorten the
hiring and review process. The initiatives involve: policy revisions,
software development, retooling and focusing on streamlining the hiring
process. VHA is looking at credentialing timelines and background
investigations. In addition, facilities are undertaking a systems
redesign process that will focus on improving the staffing process.
Question 3: What do you believe is VHA's number one challenge in
filling shortage positions?
Response: VHA's number one challenge in filling shortage positions
is the limited supply of medical professions, particularly in
specialized areas. Private and Federal sectors are competing for hard-
to-fill positions with a limited pool of professionals in certain
specialties. This makes recruiting and retaining medical professionals
in these core professions a challenge.
Question 4(a): Regarding the challenges facing VHA with hiring in
rural areas. You state in your testimony that ``VA is working to
integrate rural areas into residency rotations, since evidence shows
those who serve residencies in rural areas are more likely to practice
in rural areas.'' How does that program work and who are you working
with to accomplish that?
Response: The VHA Office of Academic Affiliations (OAA) oversees an
extensive portfolio of training programs around the country,
encompassing over 100,000 trainees per year having clinical experiences
at VA sites. In recent years, OAA has encouraged and incentivized
training in rural areas. Over 400 paid trainees (including 125
physician residents) and over 4,000 unpaid trainees participate in
training at rural sites. Training programs exist at 22 out of 31
medical centers that support rural or highly rural markets.
Through an initiative known as the graduate medical education (GME)
enhancement program, OAA has funded medical training experiences in
more remote VA sites. One specific component, New Affiliations and New
Sites of Care, encourages trainee rotations at community based
outpatient clinics (CBOC), as well as at other new sites of care. To
date, OAA has funded over 80 new physician resident positions in 21
sites through this program; over 13 of these positions have been
allocated to officially designated rural sites. More than 10 additional
positions have been awarded to rural locations not officially
designated as such (Boise, Idaho; Northampton, Massachusetts; and the
CBOC in Pine Bluff, Arkansas).
VHA also recognizes the need for more infrastructure support at
rural sites in order to ensure that residents have an excellent
educational experience--without which they are unlikely to view rural
practice in a favorable light. Thus, OAA and the Office of Rural Health
are currently discussing the feasibility of partnering in order to
further expand OAA's GME enhancement initiative to include more
resource support for rural and highly rural hospitals and CBOCs as
training locations.
Question 4(b): Please tell me how far along VHA is with ``working
to integrate rural areas into residency rotations.''
Response: VHA's efforts to integrate rural sites into training
programs are still evolving. VA's care initiatives, including new
affiliations and new sites, are only in the second year of
implementation. The Office of Rural Health is in the process of
collaboration with OAA to pursue these initiatives.
Questions for the Record
Hon. Vic Snyder
Question 1: For each category (i.e. Title 38, Title 5, and hybrid),
what is the current total cost per hire?
Response: VHA does not track the total cost per hire due to the
complexities of allocating direct and indirect costs of multiple
staffers involved in the hiring process.
Question 2: What are the existing advertising costs? What are the
total advertising costs per hire?
Response: The Healthcare Recruitment and Retention Office (HRRO), a
part of the Workforce Management Office, spends approximately $2.5
million per year on print advertising, collateral materials (brochures,
flyers, and promotional items), web design and promotion and by
participating in career fairs, conferences, trade shows and other
events annually. HRRO also provides local and national VA recruiters
with valuable tools through its toolkit of developed ads, banners, and
event displays to promote consistent branding in support of recruitment
efforts.
VA does not track the total advertising cost per hire due to
complexities of properly allocating funds VHA may have expended at the
local and national level to fill a position.
Question 3(a): What is the total volume of generated leads by
source per month?
Response: VA does not collect data that provides the total volume
of generated leads by source per month or data that provides the
average hire rate based on that source; however, based on entrance
surveys, we know that the number one method applicants find out about
open positions is through the Internet--employee referral is the second
source.
Question 3(b): What is the average hire rate based on that source?
Response: VA does not track the data that gives the exact breakdown
as multiple sources could have influenced a new employee to accept a
position within VA.
Question 4: What are the projected staffing requirements (RN nurse
positions only) considering existing vacancies, losses due to
anticipated turnover, and anticipated retirement losses through 2015?
Response: Currently, there are an estimated 1,700 vacancies (which
equate to 10.7 percent vacancy rate) for registered nurses. The
turnover rate for this fiscal year 2008 has been approximately 5
percent. Projections for future hires through 2013 are projected at an
increase of 19 percent from approximately 42,000 to 50,000.
There is projected to be a loss of 7,600 registered nurses due to
retirement by the year 2013 or approximately 15 percent over that same
time period.
Question 5: What is the current cycle timeframe from a commitment
to hire an applicant and to actual hire date?
Response: Generally, it takes approximately 30 to 180 days from a
commitment to hire an applicant to the actual hire date. Many
facilities are moving closer to the 30-day timeframe as a result of
ongoing initiatives.
Question 6: Would you please rank in descending order the
percentage of closing of each source (i.e. walk-ins, Internet, phone
inquiries, billboard, radio, etc.)?
Response: Based on the 2007 Entrance Survey Results, the following
sources in descending order represent how a new hire heard about job
opportunities within VA.
a.
(33.25 percent) VA Internet Job Opportunities Site--www.vacareers.va.gov
b.
(32.38 percent) VA Employee Referrals
c.
(15.34 percent) Other (i.e. friend, veteran, colleague, conference)
d.
(7.92 percent) College or University
e.
(5.71 percent) Newspapers & Magazines
f.
(4.58 percent) Office of Personnel Management Job Notice
g.
(0.68 percent) Career Counselor
h.
(0.13 percent) No Response