[Senate Hearing 110-767]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 110-767
 
 OVERSIGHT HEARING: MAKING VA THE WORKPLACE OF CHOICE FOR HEALTH CARE 
                               PROVIDERS

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                             APRIL 9, 2008

                               __________

       Printed for the use of the Committee on Veterans' Affairs


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 senate



                   U.S. GOVERNMENT PRINTING OFFICE
41-918 PDF                  WASHINGTON : 2009
----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing 
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC 
area (202) 512-1800 Fax: (202) 512-2104  Mail: Stop IDCC, 
Washington, DC 20402-0001



                     COMMITTEE ON VETERANS' AFFAIRS

                   Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Patty Murray, Washington             Arlen Specter, Pennsylvania
Barack Obama, Illinois               Larry E. Craig, Idaho
Bernard Sanders, (I) Vermont         Kay Bailey Hutchison, Texas
Sherrod Brown, Ohio                  Lindsey O. Graham, South Carolina
Jim Webb, Virginia                   Johnny Isakson, Georgia
Jon Tester, Montana                  Roger F. Wicker, Mississippi
                    William E. Brew, Staff Director
                 Lupe Wissel, Republican Staff Director


                            C O N T E N T S

                              ----------                              

                             April 9, 2008
                                SENATORS

                                                                   Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........     1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North 
  Carolina.......................................................     2
Craig, Hon. Larry E., U.S. Senator from Idaho....................     3
    Prepared statement...........................................     5
Murray, Hon. Patty, U.S. Senator from Washington.................     6
Rockefeller, Hon. John D., IV, U.S. Senator from West Virginia...    36
Tester, Hon. Jon, U.S. Senator from Montana......................     7
Wicker, Hon. Roger F., U.S. Senator from Mississippi.............    34

                               WITNESSES

Palkuti, Marisa W., M. Ed., Director, Health Care Retention and 
  Recruitment Office, Veterans Health Administration, Department 
  of Veterans Affairs............................................     7
    Prepared statement...........................................     9
    Response to written questions submitted by:
      Hon. Daniel K. Akaka.......................................    12
      Hon. Patty Murray..........................................    16
    Response to questions arising during hearing from Hon. John 
      D. Rockefeller IV..........................................    37
Cullen, Sheila M., Director, San Francisco VA Medical Center.....    16
    Prepared statement...........................................    18
    Response to written questions submitted by Hon. Daniel K. 
      Akaka......................................................    20
    Response to questions arising during hearing from:
      Hon. Daniel K. Akaka.......................................    32
      Hon. Roger F. Wicker.......................................    36
Kleinglass, Steven P., Director, Minneapolis VA Medical Center...    21
    Prepared statement...........................................    23
    Response to written questions submitted by Hon. Patty Murray.    24
Kanof, Marjorie, M.D., Managing Director, Health Care, U.S. 
  Government Accountability Office...............................    39
    Prepared statement...........................................    41
McDonald, John A., M.D., Ph.D., Vice President for Health 
  Sciences and Dean, University of Nevada School of Medicine, on 
  Behalf of the Association of American Medical Colleges.........    56
    Prepared statement...........................................    57
    Response to written questions submitted by Hon. Patty Murray.    63
O'Meara, Valerie, N.P., VA Puget Sound Health Care System, 
  Professional Vice President, American Federation of Government 
  Employees Local 3197...........................................    64
    Prepared statement...........................................    66
    Response to written questions submitted by Hon. Daniel K. 
      Akaka......................................................    71
Phelps, Randy, Ph.D., Deputy Executive Director, American 
  Psychological Association Practice Directorate.................    71
    Prepared statement...........................................    74
    Response to written questions submitted by:
      Hon. Daniel K. Akaka.......................................    77
      Hon. Patty Murray..........................................    80
Strauss, Jennifer L., Ph.D., Health Scientist, Center for Health 
  Services Research in Primary Care, Durham VA Medical Center, 
  and Assistant Professor, Department of Psychiatry and 
  Behavioral Sciences, Duke University Medical Center, on Behalf 
  of the Friends of VA Medical Care and Health Research (FOVA)...    81
    Prepared statement...........................................    82
    Response to written questions submitted by Hon. Patty Murray.    84

                                APPENDIX

Cohen, Harvey Jay, M.D., Walter Kempner Professor and Chair, 
  Department of Medicine, Director, Center for the Study of Aging 
  and Human Development, Duke University Medical Center..........    95
Converso, Ann, RN, President, United American Nurses, AFL-CIO....    96
Ingoglia, Charles, Vice President of Public Policy on Behalf of 
  the National Council for Community Behavioral Healthcare.......    98
Marberry, Sara, Executive Vice President, and Anjali Joseph, 
  Ph.D., Director of Research at The Center for Health Design....    99


 OVERSIGHT HEARING: MAKING VA THE WORKPLACE OF CHOICE FOR HEALTH CARE 
                               PROVIDERS

                              ----------                              


                        WEDNESDAY, APRIL 9, 2008

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:35 a.m., in 
room 418, Russell Senate Office Building, Hon. Daniel K. Akaka, 
Chairman of the Committee, presiding.
    Present: Senators Akaka, Rockefeller, Murray, Tester, Burr, 
Craig, and Wicker.

     OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, 
                    U.S. SENATOR FROM HAWAII

    Chairman Akaka. This hearing will come to order. Good 
morning. I welcome everyone to today's hearing.
    Health care matters affecting veterans are very important 
to this Committee and especially important to me. In recent 
years, the Committee has, by necessity, spent much time and 
effort delving into the health issues facing veterans today, 
including TBI and invisible wounds. The simple truth of VA 
health care is that its providers are the real backbone of the 
system. If the providers are not present or are there but 
unhappy in their jobs, it is likely that the veterans will not 
receive the quality care they need and deserve.
    The Department of Veterans Affairs faces a dangerous 
shortage of health care professionals around the country. 
Services for veterans at too many facilities are limited due to 
staffing shortages. From nurses to senior executives to 
psychologists, VA competes with other health care systems for 
employees and too often comes up short.
    In a recent publication by the Partnership for Public 
Service on employee satisfaction, the Veterans Health 
Administration ranked poorly in pay and benefits and in family 
support. VHA also rated very low among younger employees. 
However, a silver lining from this survey is that VHA has 
improved in almost all rankings. So, while there has been 
progress, clearly there is still much more to be done.
    The task of this Committee and of the Congress is to 
provide VA with the resources and tools necessary to enable VA 
facilities to attract health care professionals of the highest 
caliber. This fiscal year, Congress provided VA with a 
significant infusion of funds. It is my expectation that we 
will do so again this year for the next fiscal year.
    During today's hearing, we will have the opportunity to 
examine the tools VA now has and those it might need in the 
future to bring in top-notch health professionals. In my view, 
VA has the potential to recruit and retain the very best 
clinicians. Scholarship programs used effectively could 
alleviate student debt burdens. An effective pay system will 
allow VA to compete in every labor market. VA operates a world-
class research system that attracts clinicians who seek to push 
the boundaries of medical care. These are just a few examples 
of the effective recruitment and retention tools at VA's 
disposal. We must ensure that they are being fully utilized.
    It is my hope that this hearing may lead to more effective 
use of existing methods of recruiting the best and brightest 
health care professionals to VA and then making sure that they 
choose to stay. We also will seek to identify new approaches to 
attract health care professionals to VA. Over the past decade, 
VA has made tremendous strides in becoming the premier health 
care provider for veterans. We must now ensure that VA can 
employ premier employees.
    I offer a special thanks to our witnesses here today. We 
appreciate your taking the time to appear before the Committee 
and for your service to veterans.
    Now I will call on our Ranking Member, Senator Burr, for 
his opening remarks.

        STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, 
                U.S. SENATOR FROM NORTH CAROLINA

    Senator Burr. Aloha, Mr. Chairman. Thank you, and I thank 
all of our witnesses today for what I think will be some very, 
very important testimony.
    It goes without saying that if the VA is to continue to 
deliver top-notch health care to veterans, then it needs to be 
able to attract and retain qualified medical professionals. Of 
course, the challenge is that the VA competes for these 
professionals in a marketplace where they are high in demand 
and short in supply. The Health Resources Services 
Administration estimates that in 2020, the nationwide supply of 
primary care physicians will be around 270,000, but the need 
will be for nearly 340,000. For rural and inner-city areas, we 
can't wait until 2020. A shortage already exists today. In 
States with growing populations, the problem is particularly 
acute. In North Carolina, the provider-to-population ratio is 
expected to drop by 8 percent to 19 percent by 2030.
    With these numbers, Mr. Chairman, it is imperative that the 
VA have the tools it needs to attract and to keep quality 
doctors and nurses. This means that pay and benefits need to be 
competitive. It also means that scholarship and debt repayment 
programs in return for working at the VA need to be fully 
utilized. And, of course, it means that a robust research 
program at the VA, which has proven to be a powerful enticement 
for the brightest of medical minds, needs to be supported.
    I am pleased that we will hear today from Dr. Jennifer 
Strauss, an Assistant Professor at Duke University Medical 
Center's Department of Psychiatry and Behavioral Science, about 
how VA research can be strengthened. I think we all look 
forward to that testimony.
    In addition, Dr. Harvey Cohen, the head of Duke 
University's Department of Medicine and a career VA researcher, 
has submitted testimony for the record to give the Committee 
his thoughts on this subject.
    In addition to research, one of the greatest recruiting 
tools available to the VA is its noble mission. The job 
satisfaction that comes with serving America's veterans is one 
all of us on this Committee can attest to and it certainly 
exists for those who provide veterans with health care on a 
day-to-day basis.
    Before I conclude, Mr. Chairman, let me make an important 
point that is relevant to today's hearing. There are 
approximately 24 million veterans living in America today. 
Almost eight million of them are enrolled in the VA health 
system. Thus, 16 million veterans currently receive health care 
outside the VA system. The national shortage in medical 
providers is just as real for these veterans as it is for the 
VA patients. Although our primary focus for this hearing is on 
the recruitment and retention of VA medical professionals, we 
should also be aware of the impact that VA hiring has on the 
larger health care system.
    For example, VA has hired nearly 3,800 mental health 
workers since the year 2005 and may add an additional 500 in 
the near future. We need to ask the question, what impact does 
this have on the available supply of mental health workers in 
the communities both now and over the long term? Relevant to 
this point, testimony submitted for the record by Charles 
Ingoglia, Vice President of Public Policy for the National 
Council for Community Behavioral Healthcare, suggests that VA 
hiring is, and I quote, ``exacerbating an existing mental 
health workforce shortage and may not meet the long-term 
treatment and rehabilitation needs of returning veterans.''
    Mr. Chairman, I dare say, something we have talked about on 
this Committee is how we get the right amount of treatment as 
quickly as we can in the most intense way. In fact, if we have 
a medical professional shortage, we will be unable to do that 
and treat veterans at the most important time. Mr. Ingoglia 
suggests that rather than competing with the community-based 
mental health organizations for available workers, VA could, 
and I quote, ``pursue a targeted strategy of cooperation and 
collaboration through service partnerships,'' unquote. Such 
partnerships would have the added benefit of making care 
available for veterans in rural communities.
    What all this means is that we need to be prepared to take 
a comprehensive view of addressing the problems and be prepared 
to embrace the solutions that are in the best interest of the 
health care of our veterans, wherever they reside.
    Mr. Chairman, this is an extremely important hearing. Many 
of the decisions that we make from here on out have effects 
within the VA system on the direct care received by our 
veterans, but also outside the VA system on the care that this 
country's other veterans will receive, and the public at large.
    I thank the Chair for the time.
    Chairman Akaka. Thank you very much. By arrival time, let 
me call on Senator Craig for your statement.

               STATEMENT OF HON. LARRY E. CRAIG, 
                    U.S. SENATOR FROM IDAHO

    Senator Craig. Chairman Akaka, thank you very much, and 
Ranking Member Burr, thank you for this hearing today.
    I will submit my formal remarks for the record and react to 
what Senator Burr has just said. Mr. Chairman, because clearly 
we are headed into a time in health care--both for veterans and 
non-veteran civilian populations--that is having substantial 
stress on the resources available for a variety of reasons: 
from desirability of workplace and conditions to pay to lack of 
a Medicare system that stays sensitive to the constant needs of 
the patient--a combination of things.
    One of the things, though, that I find most fascinating 
that you have just mentioned, Senator Burr, is that really--
while we may not get there now, we must get there some day, and 
that is the idea that these are stand-alone systems and not 
effectively integrated. We are doing a little of that today, a 
little bit of that.
    Senator Murray and I--while I was up in the Lewiston area, 
and, of course, Lewiston, ID, and Clarkston and Asotin, WA, 
come together right there at a point in geography and 
transportation--we are standing up a CBOC that we are going to 
open up out there in mid-May. I met with the folks from over in 
Walla Walla and they had come over to walk me through it and 
show me the work that was being done. But, they are also 
contracting services with the local health care providers in 
the community for the things they cannot provide that aren't 
necessarily needed for travel on into Spokane or over to Walla 
Walla. And, of course, that CBOC will serve Clarkston and 
Asotin, WA, and Lewiston, ID.
    That is really the kind of integration that we have got to 
get at, the idea that we create bricks and mortar and walls, 
but we don't have a payment system that shows some flexibility. 
I have talked about that over time. Yesterday, I had a group of 
young veterans in my office. All of them have served in Iraq 
and Afghanistan and most of them live in rural Idaho. And they 
said, ``Senator Craig, why can't we have a VA health card? Why 
can't we have a card that allows us to go to our local 
providers to get the service we need instead of traveling the 
200 to 500 miles that you are now requiring us to travel to get 
the health care that we are entitled to have?''
    And again, I understand that, but as you know, as a Member 
of this Committee longstanding, I have also argued that in the 
dynamics of health care into the future, that the bricks and 
mortar and the walls and the structures we have created, while 
they have served us phenomenally well, may not serve us as well 
if our focus is service to the veteran, access to health care, 
period--access to health care--not the health care we define 
you are eligible for within that structure and that building.
    To me, that makes a great deal of sense, and when we talk 
about the problems that you and Senator Burr have talked about, 
we have got a marvelous system today. Again, VA gets top 
ratings. The New England Journal of Medicine has just put us on 
top again: access; quality; all of those kinds of things in 
general. And yet a million nurses are talked about now, a near 
shortage of a million nurses in the near future, 25,000 
physicians by 2020. Why should health care systems be 
competing? Should they not be complementing? I think that is 
going to be our greater challenge in the out years as we put 
money into this system to do so.
    And, of course, as you know, I have to get in my 
traditional punch. If we expand, if we are not focused on the 
disabled and the poor of the VA system and we go to Priority 8s 
and we add 1.4 million more to the system, from the standpoint 
of eligibility, then the numbers we are concerned about today 
simply go up. The demand goes up. And ought there not be a 
greater way for us to provide for our veterans in the out 
years, and looking at it in the modern sense that we may not be 
looking at it today. We are still dedicated--and I have no 
criticism of that--but to the bricks and mortar we have built 
down through the years. But it isn't serving our veterans 
across America as well as it should.
    So, yesterday, I had that reality when that veteran held up 
his hand and said, ``Senator, why can't I have a VA health card 
that allows me to get my services in Salmon, Idaho, or in 
Pocatello or somewhere in rural Idaho that provides quality 
health care that has an association with the VA system?'' I 
said to him, smile, work at it, become an advocate of it. Work 
with your service organizations, because they, too, are stuck 
in the tradition of supporting what we have instead of where we 
ought to go.
    Thank you very much.
    [The prepared statement of Senator Craig follows:]
   Prepared Statement of Hon. Larry E. Craig, U.S. Senator from Idaho
    Chairman Akaka, Thank you for calling this hearing today. I just 
want to make a few comments.
    One thing that I cannot do often enough is to commend VA for the 
excellent health care they provide for our veterans. In studies by 
various well-respected publications, including the New England Journal 
of Medicine, VA has outperformed Medicare and private insurance in 
quality of care.
    A key component of maintaining the high quality of VA health care 
is recruiting and retaining a dedicated staff. However, we are also 
facing a shortage across the country in many health care professions--
including physicians, nurses, and a variety of sub-specialties. A July 
2007 report from the Health Research Institute of 
PricewaterhouseCoopers found that the United States will be short 
nearly one million nurses and 24,000 physicians by 2020. Specifically, 
in my home State of Idaho we are grappling with a shortage of primary 
care physicians to treat individuals living in rural areas. In the 
midst of this nationwide shortage, VA must also continue to raise its 
profile among potential health care professionals to recruit a quality 
staff in order to maintain its stellar reputation as a health care 
system. This is no small challenge.
    I want to take this opportunity to point out that this is one of 
the reasons why I am opposed to allowing Priority 8 veterans into the 
VA health care system. While I think VA recognizes the need to 
aggressively recruit health care professionals, we also need to be 
realistic. We are being confronted with a nationwide shortage and if VA 
is having recruitment challenges now, adding upwards of 1.4 million 
individuals to the patient population would only exacerbate this 
problem.
    VA needs to continue to focus its health care delivery on our 
disabled veterans.
    With that being said, I want to commend VA on the excellent 
workplace environment it has created and I look forward to hearing from 
our witnesses about how they are addressing recruitment challenges.

    Chairman Akaka. Thank you, Senator Craig.
    Senator Murray?

                STATEMENT OF HON. PATTY MURRAY, 
                  U.S. SENATOR FROM WASHINGTON

    Senator Murray. Thank you, Chairman Akaka, Senator Burr, 
for holding this hearing on the recruitment and retention of 
health care professionals in the Veterans Health 
Administration. I look forward to the testimony from our 
distinguished members of both panels. I especially want to 
extend a welcome to Valerie O'Meara. She has traveled here 
across the country to testify in front of us today as a nurse 
practitioner from the Seattle VA Center. As I have said many 
times, Mr. Chairman, our VA staff are some of the most caring 
and compassionate people I know. They work hard. They are smart 
and very caring. They understand the needs of the veteran 
population that they serve; and they are critical as we see so 
many returning veterans coming home today, as well as veterans 
of previous wars. I appreciate the great job all of you and 
your coworkers do.
    Mr. Chairman, the doctors and nurses and mental health care 
providers and many health care professionals who work at the VA 
are the reason that the VA can stay true to its mission and to 
provide the best quality of care anywhere. But, as the topic of 
your hearing suggests today, the VA faces significant hurdles 
as it tries to recruit and retain the kind of high-quality 
health care professionals that the Department relies on to 
serve the veterans today. So, I am very pleased, Mr. Chairman, 
that we are holding this hearing to explore VA's workforce 
needs.
    I really think we have to get to the heart of this issue 
and explore our options, not only to improve working conditions 
for our current VA employees, but to ensure that the VA can 
compete with the private sector and recruit the best and 
brightest professionals. In order to do that, we have a lot of 
work ahead of us because there are a number of challenges to 
overcome.
    The VHA employment process is overly complicated and takes 
far too long. The VA doesn't pay health professionals as well 
as the private sector does. Education and training 
opportunities for workers have to be updated and revamped.
    So, Mr. Chairman, I emphasize this hearing is not only 
about the ways we can become more competitive as we recruit new 
people into the VHA system, it is about retaining our current 
employees, as well. And along that line, I am very concerned 
that a recent study by the Partnership for Public Service found 
that job satisfaction among VHA employees under the age of 40 
is very low. If the VA is going to continue to provide the best 
quality of care anywhere, that has to change.
    So, Mr. Chairman, I look forward to hearing from the 
witnesses today as we begin to address this issue. I do have 
another hearing at the same time as this hearing, so I am going 
to miss the first panel and their testimony, but my staff will 
be here and I will be back for the second panel. I think this 
is an extremely important topic, Mr. Chairman, and I thank you 
for exploring it today.
    Chairman Akaka. Thank you very much, Senator Murray. As you 
know, Senator Murray plays a huge role on Veterans' Affairs, 
and, of course, she is on the Appropriations Committee. We work 
very well together in trying to get things done for veterans. 
Thank you very much, Senator Murray.
    I want to now welcome our witnesses from the Department of 
Veterans Affairs. I appreciate your being here today and look 
forward to your testimony. Will you please be seated.
    First, I welcome Marisa Palkuti, Director of the VHA Health 
Care Retention and Recruitment Office. I also welcome Sheila 
Cullen, Director of the San Francisco VA Medical Center; and I 
also want to welcome Dr. Wiebe, who I see here in the room. 
Welcome and aloha, Dr. Wiebe, for being here today. Finally, I 
welcome Steven Kleinglass, Director of the Minneapolis VA 
Medical Center.
    I want to thank all of you for joining us today. Your full 
statements will appear in the record of this Committee.
    Ms. Palkuti, please begin after I ask Senator Tester 
whether he has any statement to make at this point in time.

                 STATEMENT OF HON. JON TESTER, 
                   U.S. SENATOR FROM MONTANA

    Senator Tester. Well, thank you, Mr. Chairman. That is very 
gracious of you. I am sorry about being late.
    I just want to tell you that from a Montana perspective, 
recruitment and retention of our health care officials and our 
support staff is really important. I have been around to most 
of the veterans' facilities in the State of Montana, done some 
public hearings and heard from veterans throughout the State 
and I can tell you the one comment that I hear repeatedly is a 
lack of staff.
    I look forward to your statements. I really want to hear 
what we are doing as far as recruitment and retention bonuses, 
those kind of things, to get people on board. I have been told 
by some of the health care professionals that the VA cannot pay 
what the private sector is paying for health care folks. I 
don't know what the thought process was there--whoever made 
that rule--but, it is wrong-headed thinking. I think if we are 
going to get the best people to take care of our veterans in 
this country, we have got to be competitive; and if we start 
out from a standpoint that we cannot meet basic wages, I think 
it reduces the employment pool right out of the chute. And our 
potential for keeping these people dwindles pretty quickly, 
because they see what the opportunities are out in the private 
sector.
    So, your statements today are going to be critically 
important. I will tell you that most of my questions are going 
to revolve around recruitment and retention and how we can do a 
better job and how I can help you do a better job in this 
process.
    So, with that, thank you, Mr. Chairman. I appreciate the 
opportunity.
    Chairman Akaka. Thank you very much, Senator Tester.
    At this time, we will hear from Ms. Palkuti.

 STATEMENT OF MARISA W. PALKUTI, M. ED., DIRECTOR, HEALTH CARE 
       RETENTION AND RECRUITMENT OFFICE, VETERANS HEALTH 
                         ADMINISTRATION

    Ms. Palkuti. Mr. Chairman and Members of the Committee, 
thank you for the invitation to appear before you. I am honored 
to be here today to share VA's ongoing efforts and challenges 
to develop innovative and aggressive approaches to addressing 
recruitment and retention of our health care workforce. My full 
testimony will be in the record, so I will highlight a few of 
the things that we are working on.
    An informal study conducted of all VA facilities in 2007 
revealed that 74 percent of the 800 psychologists hired over 
the past 3 years received some training in professional 
psychology at VA. This year, the office's academic affiliation 
and patient care services have significantly expanded VA's 
psychology training programs in anticipation of the ongoing 
need for VA psychologists as well as psychologists to practice 
in the community.
    In an effort to initiate proactive strategies and aid in 
the shortage of clinical faculty in nursing schools, VA has 
launched the VA Nursing Academy to address the nationwide 
shortage of nurses. Four partnerships were established in the 
2007-2008 school year and four additional partnerships will be 
selected each year in 2008 and 2009 for a total of 12 
partnerships.
    We have launched the VA Travel Nurse Corps, which is an 
exciting new program establishing an internal pool of 
registered nurses who can be available for short-term temporary 
travel assignments in VA and centers throughout the country, 
including rural care.
    We have a multitude of student programs that have been 
instrumental in helping VA meet its workforce needs. These 
programs include the VA Learning Opportunities Residency 
Program for baccalaureate prepared nurses and doctoral prepared 
pharmacists--student career experience programs. We have 
established a database for our interns and students so that we 
can track them and use them as a better applicant pool for our 
future needs.
    We have a Graduate Health Administration training program 
for practical work experiences for recent graduates of health 
care administrative master's programs for hospital leadership. 
We have a Technical Career Field Program. It is an entry-level 
program designed to fill vacancies in fields such as budget, 
finance, HR, engineering, and others where VA knows that there 
is a critical need and VA-specific knowledge is necessary.
    And we realize that our hiring process is cumbersome. This 
spring and summer, we will be training medical center 
leadership in human resources and systems redesign at a series 
of human resources cluster meetings around the country.
    My office works at the national level to promote 
recruitment branding and provide tools and resources and other 
materials to support both national and local recruiting 
efforts. Some of the features we have recently integrated, our 
VHA Internet Job Board with USA Jobs. We have done a complete 
revision of that tool. We use Public Service Announcements, 
online advertising, print advertising. We have a tool kit for 
recruiters across the country to tap into our resources. We 
have established National Recruitment Advisory Groups.
    As highlighted already, we developed a very comprehensive 
recruitment and marketing plan for mental health professionals 
using the strategies mentioned above as well as a number of 
financial incentives. Among the financial incentives, our 
Employee Incentive Scholarship Program will pay up to $35,900 
for academic and health care-related degree programs. We 
currently have authorized over 7,200 scholarships to VA 
employees and have over 4,000 graduates, closer to 4,300 at 
this point. It shows through analysis that we also have 
positive retention outcomes for that program.
    Our Education Debt Reduction Program provides a tax-free 
reimbursement of educational loans for clinical employees, and 
as of March 31, we had authorized over 6,400 awards under the 
Education Debt Reduction Program.
    There is routine use of other financial incentives--
recruitment incentives, retention incentives, relocation 
incentives, and special salary rates. And in fiscal year 2007, 
we spent over $24 million in recruitment incentives nationwide 
for over 3,150 employees in title 38 and hybrid occupations, 
and over $34 million in retention incentives to 5,300 of our 
clinical employees.
    Regarding the physician pay bill, we truly believe that 
this legislation has helped us to recruit and retain 
physicians.
    Our agency has one of the best and most comprehensive 
workforce strategic plans in government. We have been 
recognized by the Office of Personnel Management as a Federal 
best practice. We have a commitment, a strong commitment, to 
succession planning and ensuring that VA has a comprehensive 
recruitment, retention, and development strategy for the 
agency.
    I would like to thank the Committee for their interest and 
support in implementing legislation that allows us to compete 
in an aggressive health care market, and Mr. Chairman, that 
concludes my oral statement. I will be pleased to respond to 
any questions.
    [The prepared statement of Ms. Palkuti follows:]
Prepared Statement of Marisa W. Palkuti, M. Ed., Director, Health Care 
   Retention and Recruitment Office, Veterans Health Administration, 
                     Department of Veterans Affairs
    Mr. Chairman and Members of the Committee, Thank you for the 
invitation to appear before you today to discuss the Department of 
Veterans Affairs (VA), Veterans Health Administration (VHA) recruitment 
and retention programs, work schedules, and other issues related to 
creating a compassionate, qualified and diverse workforce of health 
care professionals. As the Nation's largest integrated health care 
delivery system, VHA's workforce challenges mirror those of the health 
care industry as a whole. This country is in the midst of a workforce 
crisis in health care and VHA experiences the same pressures as other 
health care organizations. VHA performs extensive national workforce 
planning and publishes a VHA Workforce Succession Strategic Plan 
annually. As part of this process, workforce analysis and planning is 
conducted in each Veterans Integrated Service Network (VISN) and 
national program office and then is rolled up to create a national 
plan. VHA's strategic direction addresses current and emerging 
initiatives including recruitment and retention, mental health care, 
polytrauma, Traumatic Brain Injury, and rural health to address 
workforce efforts. I am honored to be here today to share VHA's ongoing 
efforts and challenges to develop innovative and aggressive approaches 
to addressing recruitment and retention of our professional health care 
workforce.
              efforts to recruit health care professionals
    There is a growing realization that the supply of appropriately 
prepared health care workers in this country is inadequate to meet the 
needs of a growing and diverse population. This shortfall will grow 
exponentially over the next 20 years. This situation exists for various 
reasons. Enrollment in professional schools is not growing fast enough 
to meet the projected future demand for health care providers. The 
American Association of Colleges of Nursing has reported that more than 
42,000 qualified applicants were turned away from nursing schools in 
2006 because of insufficient numbers of faculty, clinical sites, 
classroom space and clinical mentors. The availability of academic 
programs to provide employees to meet qualification standards in other 
health care occupations is being experienced in many other health care 
occupations.
    More than 100,000 health professions 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 that, overall, 
following completion of VA learning experiences, trainees were twice as 
likely to consider VA employment as before the experience. This 
demonstrates that many trainees were not aware of VA employment 
opportunities or the quality of VA's health care environment prior to 
VA training but became considerably more interested after VA clinical 
experiences.
    An informal survey conducted of all VA facilities in 2007 revealed 
that 74 percent of the 800 psychologists hired over the last 3 years 
received some training in professional psychology through VA. This 
year, the 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.
    HRRO has produced a new recruitment brochure titled ``From 
Classroom to Career'' that is targeted at and distributed to VA 
trainees. The Office of Academic Affiliations in VA Central Office 
emphasizes recruitment of trainees in interactions with education 
leaders in the VA facilities. The Human Resource Committee of the VHA 
National Leadership Board has raised the trainee recruitment issue to a 
high priority and has included it as an important element of their 
strategic plan.
    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 purpose of the Academy 
is to expand the number of nursing faculty in the 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.
    VA Travel Nurse Corp is an exciting new program establishing an 
internal pool of registered nurses (RNs) who can be available for 
temporary, short-term assignments at VA medical centers throughout the 
country. The VA Travel Nurse Corps meets nurses' needs for travel and 
flexibility while meeting VA medical center needs for temporary top 
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 considering leaving 
the VA system; and to establish a potential pool of Registered Nurses 
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 have been instrumental helping meet VA workforce 
succession needs. These programs include the VA Learning Opportunities 
Residency (VALOR) Program, the Student Career Experience Program 
(SCEP), and the Hispanic Association of Colleges and Universities 
Internship Program (HACU). VALOR is designed to attract academically 
successful students of baccalaureate nursing programs and pharmacy 
doctorate programs to work at VA. 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, 
the pharmacy component was added in 2007 to address VA's need for 
pharmacists. 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 
Data base for Interns (VANDI) is a newly designed database developed to 
track students in VA internship/student programs to create a qualified 
applicant pool.
    The Graduate Health Administration Training Program (GHATP) 
provides practical work experience to students and recent graduates of 
health care administration masters programs. GHATP residents and 
fellows are competitively selected and upon successful completion of 
the programs are eligible for conversion to a VA health system 
management. The Technical Career Field (TCF) program is an entry level 
program designed to fill vacancies in technical career fields (Budget, 
Finance, Human Resources, Engineering, etc) 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 based on the changing needs of the workforce. Annually, the 
target positions and number of intern slots are determined based on 
projected workforce needs.
                    streamlining the hiring process
    It is well known that the Government hiring process is cumbersome. 
Last year, VA's Human Resource Committee chartered a workgroup to 
streamline the recruitment process for title 5 and title 38 positions 
within VHA. This included an analysis of the recruitment process and 
identification of barriers and lengthy processes. The recommendations 
were piloted in Network 4 (Pittsburgh, PA) with the implementation and 
results of the pilot rolled out nationwide. This spring and summer, 
training in systems redesign will be offered nationally at Human 
Resources Cluster meetings. At these sessions, we will focus on new 
strategies and systems redesign elements that can be used to help meet 
the daily challenges of attracting and retaining critical health care 
professionals.
    VA has direct appointment authority for several Title 38 
occupations, including physical therapists. We recognize that the 
physical therapist occupation is a key to the rehabilitation of 
returning veterans and VHA is working with the Office of Human 
Resources Management (OHRM) in the development of a new qualification 
standard. The new standard is in the final stages of approval and it is 
expected it will be implemented later this year.
            national recruitment/media marketing strategies
    VHA Health Care Retention & Recruitment Office (HRRO) administers 
national programs to promote national employment branding with VHA as 
the health care employer of choice. Established almost a decade ago, 
the brand ``Best Care--Best Careers'' reflects the care America's 
veterans receive from VA and the excellent career opportunities 
available to staff and prospective employees.
    Results of recent marketing studies for nursing and pharmacy have 
been the driving force to implementing many of our successful campaigns 
as I will discuss. HRRO works at the national level to promote 
recruitment branding and provide tools, resources, and other materials 
to support both national branding and local recruiting. Some of these 
features are:

     The recent integration of VHA recruitment Web site 
(www.VACareers.va.gov) with USAjobs (www.USAjobs.opm.gov) provides 
consolidated information on careers in VHA, job search capability, and 
information on Federal employment pay and benefits information.
     Public Service Announcements (PSA) promote the ``preferred 
health care employer'' image of VHA. PSA's emphasize the importance and 
advantage of careers with VA and focus on the personal and professional 
rewards of such a career.
     Online advertising through a comprehensive web advertising 
strategy, VA job postings are promoted on commercial employment sites 
(CareerBuilder, Healthecareers, Google, etc.) and online health 
information networks that expand our reach to over 5,000 discrete web 
sites. The strategy includes banner advertising that drives traffic to 
the VACareers web site for employment information. This advertising 
results in over 100,000 visits to the VA recruitment web site each 
month.
     Print advertising includes both direct classified 
advertising and national employment branding. The national program 
provides ongoing exposure of VA messaging to potential hires with the 
intent to promote VA as a leader in patient care. VHA print advertising 
reaches over 34 million potential candidates.
     VHA Health Care Recruiters' Toolkit, a unique virtual 
community internal to VHA is an online management program that 
coordinates national and local recruitment efforts for health care 
professionals. The toolkit serves as a resource by providing available 
recruitment tools, materials, ads, 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 embark address recruitment and retention.
     In fiscal year 2007, HRRO developed a comprehensive 
recruitment marketing plan for mental health professionals using 
strategies mentioned above as well as financial recruitment incentives. 
Funding was earmarked for Mental Health Enhancement Initiative (MHEI) 
Education Debt Reduction Program (EDRP) positions. As of March 31, 
2008, awards were made to over 100 participants. The total payout for 
these participants is $4,394,671 over the 5-year service obligation 
period. The average total award is $35,157.
           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 health care-
related degree programs. Since the program began in 1999, approximately 
7,200 VA employees have received scholarship awards for academic 
education programs related to title 38 and Hybrid title 38 occupations. 
Approximately 4,000 employees have graduated from their academic 
programs. Scholarship recipients include registered nurses (93 
percent), pharmacists, and many other allied health professionals. 
Focus group market research shows that staff education programs offered 
by VHA are considered a major factor in individuals selecting VA as 
their choice of employer. A 5-year analysis of program outcomes 
demonstrated 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 VA's equivalent to the Student Loan 
Repayment Program (SLRP) sponsored under Office of Personnel Management 
(OPM) regulations. The maximum award amount is capped at $48,000 due to 
the budget, but carries an added value because of the tax exempt status 
of the award. As of March 31, 2008, there were over 6,400 health care 
professionals participating in EDRP. The average amount authorized per 
student, for all years, is $18,392. The average award amount per 
employee has increased over the years from over $13,500 in fiscal year 
2002 to over $29,000 in fiscal year 2008 as education costs have 
increased. While employees from 34 occupations participate in the 
program, 75 percent are from three mission critical occupations--
registered nurse, pharmacist and physician. Resignation rates of EDRP 
recipients are significantly less than non-recipients as determined in 
a 2005 study.
    VHA routinely uses hiring and pay incentives established under 
Title 5, extended by the Secretary to title 38 employees. There is 
routine use of financial recruitment incentives, retention incentives 
(both individual and group), special salary rates, relocation 
incentives and other incentives as documented in VHA's Workforce 
Succession Strategic Plan. Recruitment and retention incentives are 
other strategies used to reduce turnover rates and help fill vacancies. 
In fiscal year 2007, nearly $24 million in recruitment bonuses were 
given to over 3,150 title 38 and title 38 Hybrid employees. Over $34 
million in retention bonuses were given to 5,300 title 38 and title 38 
Hybrid employees.
    The implementation of the physician pay legislation (Public Law 
108-445) has been very successful for VHA. The pay of VHA physicians 
and dentists consists of three elements: base pay, market pay, and 
performance pay. Since the implementation of the pay bill and the end 
of February 2008, we have increased the number of VA physicians by over 
1,430 FTEE. We believe the legislation has helped VHA's ability to 
recruit physicians and dentists. Also as a component of this 
legislation, the Chief Nurse of VHA has the discretionary ability to 
set Nurse Executive Pay to ensure we continue to successfully recruit 
and retain nursing leaders.
    VHA's workforce plan is one of the most comprehensive in government 
and has been recognized by OPM as a Federal best practice. VA presented 
at other Federal agencies and the OPM Conference, ``A Best Practice 
Leadership Form on Succession Management'' as well as being featured on 
the February 2008 edition of Government Executive, in the article ``VHA 
Grooms a Younger Generation to Ride out the Retirement Wave.''
    This year, VHA will benchmark its succession planning/developmental 
programs against private industry health care and other organizations. 
This will ensure that VHA is being as proactive as possible to meet the 
Administration's future needs and ensure that we have the right people 
in place at the right time. VHA has made a commitment to succession 
planning and ensuring VHA has a comprehensive recruitment, retention, 
development and succession strategy. This is a continuous process which 
requires on-going modifications and enhancements to our current 
programs.
    We want to thank the Committee for their interest and support in 
implementing legislation that allows us to compete in the aggressive 
health care market.

    Mr. Chairman, that concludes my statement. I am pleased to respond 
to any questions you or the Subcommittee members may have.
                                 ______
                                 
  Response to Written Questions Submitted by Hon. Daniel K. Akaka to 
    Marisa W. Palkuti, M. Ed., Director, Health Care Retention and 
           Recruitment Office, Department of Veterans Affairs
    Question 1. Committee oversight activities have made clear the 
challenges in providing nurses with sufficient pay. How does VA deal 
with compression of nurse salary grades?
    Response. The Department of Veterans Affairs (VA) is experiencing 
the kinds of workforce challenges every other health care organization 
faces. VA's Nursing Service has implemented a number of provisions to 
offset the challenges salary compression creates, including the 
following:

     Nurse locality pay schedules have been adjusted to 
minimize the impact of salary grade compression by establishing pay 
schedules with up to 26 steps, instead of the usual 12 steps.
     Special pay bands have been established by facilities for 
each nursing specialty, including clinical nurse specialists, certified 
registered nurse anesthetists, nurse practitioners, and administrative 
nurses.
     Nurse managers are given two additional pay steps when 
they assume clinical leadership roles.
     Public Law (Pub. L.) 108-445, Physician Pay, provided VA a 
comprehensive way to offer flexible compensation packages to nurse 
executives. VA is authorized to grant special pay rates of $10,000 to 
$25,000 per year to the nurse executive at each VA medical center, and 
to nurse executives in VA Central Office Nursing Service based on the 
scope and complexity of the nurse position; the nurse executive's 
personal qualifications; the characteristics of the health care 
facility, and demonstrated recruitment and retention difficulties.
     Facilities have the discretion to use other tools, 
including recruitment and retention incentives, relocation assistance, 
educational support, and student loan reimbursement to relieve pay 
compression.

    Question 2. GAO has suggested that VA managers need better training 
in the conduct of locality pay surveys. VA concurred with this 
recommendation. What action has VA taken as of this time?
    Response. Public Law 106-419 enabled VA facilities to use third 
party salary surveys rather than VA-conducted surveys whenever 
practicable. The use of third party survey data is VA's preference in 
administering the locality pay system.
    As a result, VA's Office of Human Resources Management (OHRM) has 
focused on training managers in accessing the appropriate salary data 
for a particular situation. When current data is unavailable from the 
Bureau of Labor Statistics, facilities must use available third-party 
data. When third party data is not available then VA-conducted surveys 
are used, but only as a last resort. To assist facilities in conducting 
surveys, a Web-based training module on VA-conducted surveys is 
expected to be available by late summer 2008.
    On-going training and education on administering the nurse locality 
pay system includes a monthly national conference call targeted to 
nurse executives and human resource managers. Topics of discussion 
included how to obtain salary data; how to expand the local labor 
market to capture effective survey data; additional pay authorities 
available to facility directors; and sharing of ``best practices'' used 
throughout the country. OHRM worked with the Veterans Health 
Administration (VHA) to provide nurse locality pay training to more 
than 80 interns in 2007.
    OHRM will conduct a training session at a VA Health care Recruiters 
Conference, to be held in the summer of 2008. The session will be 
titled, Obtaining Salary Survey Data to Develop an Effective 
Recruitment/Retention Program. Participants in the conference include 
VA human resources management community, nurses, and other health care 
recruiters. In addition, OHRM conducts technical review of all Locality 
Pay Schedules (LPS) and special salary rate schedules at the Central 
Office level, and provides appropriate direction and guidance.
    VHA's Workforce Management and Consulting Office and the 
Department's Strategic Human Resource Advisory Council are holding 
cluster conferences in the summer of 2008, at which pay, flexibilities, 
salary data, and special schedules will be discussed.
    OHRM is also conducting market research to determine if a 
contractor could provide a single source of third party salary survey 
data for each VA facility. A request for information will solicit 
contractors to submit information regarding their salary survey 
products, processes and availability; a statement of work will be 
created and posted for contract bidding if market research reveals a 
potential salary survey product. If a contractor is available, VA would 
be able to centrally identify appropriate job matches and ensure 
consistency in the interpretation of salary data.

    Question 3. Which VA medical centers, if any, do not conduct 
locality pay surveys, and what is the rational for such inaction?
    Response. There is a mandatory requirement for VA facilities to 
collect salary survey data whenever the facility director determines a 
significant pay-related staffing problem exists or is likely to exist. 
Only when current Bureau of Labor Statistics or third party data is 
unavailable may a facility conduct its own salary survey.
    Facility directors have the discretion to collect appropriate 
survey data at any time, and as often as necessary, to maintain 
competitive rates of pay.
    Title 38 U.S.C. 7451(e)(4) requires each facility director to 
provide the Secretary an annual report on staffing for covered nurse 
positions. This report is sent to the Senate and House Committees on 
Veterans' Affairs. OHRM reviews each report to ensure salary survey 
data is collected when specific criteria indicates that a pay-related 
staffing problem exists, or is likely to exist. In the most recent 
report dated October 2, 2007, only 24 (3.3 percent) of VA's 717 
locality pay schedules met the criteria for the mandatory collection of 
survey data. The 24 schedules required mandatory review at 21 different 
VA facilities. As required by policy, those 21 facilities initiated the 
appropriate collection of salary survey data within the required 90-day 
timeframe, and those results were included in our report to Congress.

    Question 4. There are over 700 locality pay schedules used by VHA. 
While locality pay surveys and policies are set at the local level, the 
VA Central Office is charged with overseeing the system. Do you believe 
the current system is an efficient and effective method to address 
geographically-related pay issues?
    Response. VA's nurse locality pay system is unique. Unlike other 
pay systems in the Federal Government, the nurse locality pay system 
enables VA officials throughout the country to establish and adjust 
nurse pay rates based on local survey data. This authority enables 
facility directors to quickly respond to compensation trends within 
specific local labor markets in order to maintain competitive rates 
needed to recruit and retain high quality nursing staff. Nurse locality 
pay continues to be an effective pay system to address geographically-
related pay issues.

    Question 5. Education incentive programs have the potential to 
improve recruitment and retention, but current average awards are out 
of step with the cost of education. Can this program be adjusted to 
better reflect the cost of education, and to better match the goals of 
VHA and individual employees?
    Response. VHA's educational incentive programs have statutory 
limitations that are adjusted annually by the amount of the General 
Schedule pay increase. The newly adjusted statutory award cap for the 
Education Debt Reduction program (EDRP) is just over $50,000, based on 
the General Schedule increase in January 2008. While the program is 
generously funded at $15 million per year, there is not enough funding 
to provide EDRP awards to every new hire with student loans. Priorities 
and funding amounts are therefore established to enable VHA to make 
awards to the largest number of individuals possible given budget 
constraints and mission requirements. The average award is not entirely 
reflective of the actual awards authorized to employees. Many 
participants are authorized to receive reimbursement for their entire 
loan. If the award is small, it can reduce the average of the total 
award amounts. From fiscal year 2006 to fiscal year 2008, 40 percent of 
the participants were authorized the maximum award. For fiscal year 
2006 and fiscal year 2007 the maximum award was capped within VHA at 
$38,000. In fiscal year 2008 the award cap was increased to $48,000. 
This fiscal year, EDRP awards range from a low of $621 to the VHA 
budgetary cap of $48,000.
    We are seeing increases in the levels of debt new hires have 
accumulated when they enter on duty. Many of these individuals have 
educational loans in excess of $100,000. While the EDRP program doesn't 
retire the complete debt, it makes a substantial contribution to 
retiring student loans. Because EDRP awards are tax free, the financial 
benefit to the individual extends beyond the actual value of the award.
    In addition to EDRP, employees may participate in an additional 
Federal program designed to retire student educational debt. Through 
Section 401 of the College Cost Reduction and Access Act, (Pub. L. 110-
84), public service employees are eligible to have their student loans 
forgiven after 10 years of service. This program can be used in 
addition to an EDRP award.

    Question 6. How are funds distributed for EDRP--at the national 
level, or through each facility, or by another modality?
    Response. Funds for EDRP are established through VHA's National 
Leadership Board and allocated by the national VHA Health care 
Retention and Recruitment Office (HRRO) to all Veterans Integrated 
Service Networks (VISNs). Allocations are made proportionately based on 
each VISN's total number of title 38 and Hybrid title 38 employees; the 
previous year's usage, and other special need programs such as the 
mental health enhancement initiative and the polytrauma rehabilitation 
center start-up. Funds are allocated at the beginning of the fiscal 
year to the VISNs. VISNs in turn allocate resources to the facilities 
in its networks. HRRO staff monitors the funding on a weekly basis to 
ensure that award funding can be redistributed between VISNs as 
necessary throughout the year.

    Question 7. Almost 4 years ago, Congress enacted sweeping reforms 
of the physician and dentist pay system. At the time, VA was spending 
huge sums on high-cost specialty care contracts. How much is VA still 
spending on specialty care contracts, and have more physicians and 
dentists been attracted to VA?
    Response. The annual report to Congress on the pay of physicians 
and dentists in VA (Pub. L. 108-445) delivered December 2007, provides 
an in-depth analysis of VA's reduction in physician and dentist 
contracts. From fiscal year 2006 to fiscal year 2007, $5.6 million in 
contract dollars were saved for physician services. Since the new pay 
system has been implemented, VA has seen a 10 percent increase in the 
number of physicians it has hired.

    Question 8. The quality of workplace facilities plays a significant 
role in patient and staff satisfaction, from lighting to sound 
abatement. What steps has VA taken to modify facilities to improve 
patient and staff quality-of-life?
    Response. Transforming Care at the Bedside (TCAB) is a national 
project designed to transform care processes for ongoing improvement in 
medical/surgical units. These transformations are accomplished by 
engaging and empowering nurses and managers to identify needed changes; 
rapidly conducting small tests of potential solutions or improvements 
and determining whether changes should be implemented. As a result, 
nurses on TCAB units report measurable improvements in work unit 
vitality, patient safety and the efficiency with which the unit 
delivers care, and the patient centeredness of the care delivered.
    Some results of what TCAB has accomplished include:

     Nine TCAB pilots units have gone 5 successive months or 
more without a need for a full resuscitation code;
     Three TCAB pilot units have gone 6 successive months 
without patients having moderate or severe harm resulting from falls;
     Average turnover rates for registered nurses on the TCAB 
pilots units at all TCAB sites dropped from 5.8 percent in 2003 to 3.4 
percent in 2006 (58 percent 
decrease);
     The percentage of time registered nurses spent in direct 
patient care at TCAB hospitals increased from approximately 40 percent 
in 2004 to greater than 50 percent in 2006;
     Improved patient satisfaction with nursing care and with 
all care;
     Increased percentage of licensed nurse time in direct 
patient care;
     More self-accountability tools for patients to take 
control of their own health; and,
     More interdisciplinary focus on care planning.

    TCAB projects were funded by the Robert Wood Johnson Foundation. 
The work was initiated by the Institute for Health care Improvement and 
involved 13 U.S. hospitals, including the Tampa VA Medical Center 
(VAMC). The project has been expanded by the American Organization of 
Nurse Executives to work with 68 hospitals nationwide, including 
Central Arkansas Veterans Health Care System, Greater Los Angeles 
Health care System, San Francisco VAMC and Zablocki VAMC in Milwaukee.
    VA facilities have accomplished ward renovation projects to ensure 
patient satisfaction. Doors, floors, and ceilings have been replaced as 
a result of environment of care inspections. Complaints from staff and 
patients about parking are being addressed at some facilities by 
leasing additional parking or initiating parking garage projects.
    Other strategies for workplace improvement include ongoing 
supervisory, managerial, and executive training; educational and 
mentoring programs for staff throughout the system, and initiatives to 
improve workplace culture.
    VHA managers and employees formulate action plans based on 
information gathered in the annual Patient Survey and the All Employee 
Survey. This analysis is a proactive approach to improve worker and 
patient quality-of-life at facility and work unit level.
    These projects provide an excellent opportunity for nurses within 
VA to redesign care processes emphasizing nurse empowerment and process 
improvement. Information and lessons from these projects can improve 
the process and outcomes of delivering care for veterans.

    Question 9. VA has the authority to assign a range of personnel to 
alternative work schedules. Alternative work schedules have been 
demonstrated to improve employee satisfaction. How does VA use these 
schedules to improve recruitment, retention, and employee satisfaction?
    Response. VA encourages facility managers to use alternate work 
schedules for all eligible employees whenever feasible. This includes 
compressed and flexible work schedules as well as alternate work 
schedules that pertain only to registered nurses. As authorized by Pub. 
L. 108-445, the use of the 36/40 work schedule and the 9-month/3-month 
work schedule are available for registered nurses when managers 
determine that such schedules are needed to be competitive in the local 
markets. The use of alternate work schedules increases VA's visibility 
as the employer of choice.
                                 ______
                                 
  Response to Written Questions Submitted by Hon. Patty Murray to Ms. 
                 Palkuti, Mr. Kleinglass and Ms. Cullen
                       alternative work schedule
    Question. Can you all please explain why the VA is not using 
Alternative Work Schedules more often?
    Response from Ms. Palkuti on behalf of all. VA encourages facility 
managers to use alternate work schedules for all eligible employees 
whenever feasible. However, this legislation is discretionary; the law 
provides the direction for establishing alternate work schedules. 
Facilities are not mandated to use the alternate work schedules. There 
are multiple types of alternate work schedules and many VA facilities 
use at least one option of alternate work schedules for nursing staff 
in order to provide attractive and competitive work hours and, to meet 
staffing requirements. Individual facilities may choose to offer the 
alternate work schedules if they believe these schedules would benefit 
their posture of retaining well-qualified staff as an employer of 
choice.
    Alternate work schedules can be an expensive alternative to 
staffing challenges, and is implemented judicially as appropriate in a 
particular competitive marketplace.
    Challenges in payroll, timekeeping, and tracking are being 
addressed through modification of the time and attendance tracking 
software. The Office of Human Resources Management, Work Life and 
Benefits Service are currently researching and considering solutions 
that can be implemented to address these systems issues.

    Chairman Akaka. Thank you very much, Ms. Palkuti.
    Ms. Cullen?

           STATEMENT OF SHEILA M. CULLEN, DIRECTOR, 
                SAN FRANCISCO VA MEDICAL CENTER

    Ms. Cullen. Mr. Chairman, Mr. Tester, thank you for the 
invitation to appear before you today to discuss recruitment 
and retention challenges faced by the San Francisco VA Medical 
Center. I appreciate the opportunity to discuss our ongoing 
efforts to recruit some of the finest employees in the VA 
system and the challenges we face to retain those employees in 
one of the most expensive areas of the country.
    The San Francisco VA Medical Center has an outstanding 
workforce of more than 1,900 dedicated staff. We are proud that 
our medical center has had consistently high patient and 
employee satisfaction scores. In a recent inpatient 
satisfaction survey, we scored better than the national average 
in several areas, including the categories of courtesy 
exhibited by doctors, confidence and trust patients have with 
their doctor, and the dignity and respect given to patients 
during their stay.
    In the recently conducted all-employee survey, nearly 76 
percent of our employees responded and our scores were better 
than the VHA national average in all areas except for 
categories related to pay. Last year, our nurses participated 
in the National R.N. Satisfaction Survey and we rated in the 
top ten nationally for highest employee satisfaction scores.
    We believe employee satisfaction and dedication to the 
mission of serving veterans leads directly to good patient 
care. To ensure that we maintain a highly talented and 
motivated workforce, we have implemented several programs to 
aid in our retention and recruitment efforts. We have a very 
successful grow-our-own program for specialized occupations, 
such as surgical technicians, nuclear medicine technologists, 
and diagnostic radiology technicians. This program provides 
educational and career advancement opportunities for staff in 
specialized fields that are difficult to recruit and retain due 
to the competitive health care market.
    We have a very successful program in place to hire new 
nurse graduates. Through this program, graduates are hired as 
temporary nurses without benefits. They are assigned a 
preceptor and they work 40 hours per week gaining experience in 
clinical areas. After a 12-week rotation, they can compete for 
permanent jobs. This program has an 88 percent retention rate. 
Our overall vacancy rate is 3.5 to 4.5 percent, with a turnover 
rate of just under 12 percent, and the primary reason for 
turnover at our medical center is attributed to retirements.
    Our success in physician recruitment and retention is 
directly credited to our strong affiliation with the University 
of California, San Francisco. In addition, our unique mission 
of providing health care to veterans as well as our excellent 
research and teaching programs play key roles. San Francisco 
does have the largest research program in the VA nationally. 
The physician pay bill has also clearly been instrumental in 
helping us to maintain our top-notch medical staff.
    We believe much of our success is due to our efforts to 
provide a good work environment, which includes adequate 
support staff, educational opportunities, state-of-the-art 
equipment, and ongoing support of leadership.
    Our recruitment and retention efforts are continually 
challenged as a result of the high cost of living and non-
competitive salaries in the Bay area. According to the National 
Association of Realtors, the median home price in the nine-
county Bay area is $720,000. That is three times as expensive 
as the national average, and that is greatly reduced from what 
it was last year and the year before that as a result of 
national declining real estate values.
    We fully utilize the authority to offer recruitment and 
relocation bonuses. Last year, we paid out over $200,000 in 
recruitment bonuses, $129,000 for relocation bonuses, and over 
$1.8 million for retention pay.
    In an effort to stay competitive, we use the special salary 
rate authority as much as possible. This has been somewhat 
successful for clinical support staff. Our medical center has 
13.5 percent of our employees on special salary rates. 
Excluding nurses, the annual additional cost to our medical 
center budget is $5.7 million. We also have the highest 
geographical pay in the country, which includes a 33.5 percent 
locality pay adjustment for those on the General Schedule.
    In order to keep our retention rates above the 80th 
percentile, we have attempted to keep pace with community 
hospitals by approving salary increases for our registered 
nurses, which have ranged from five to 8 percent annually. The 
2008 annual salary increases for all professional nurses was 
nearly $3 million.
    Another emerging pay situation is with our Certified 
Registered Nurse Anesthetists, or CRNAs, who are compensated 
under the Nurse Locality Pay System. Our CRNA pay schedule has 
reached the statutory pay limit, so staff can only receive the 
mandated annual cost-of-living increase. What this means is 
that we cannot offer a salary any higher than the statutory 
limit of $139,600, even though our local labor market shows 
that salaries for a CRNA is at a median salary of over 
$170,000. If we are unable to recruit or retain CRNAs, we will 
be forced to use expensive contracts whose annual rate would be 
approximately $300,000.
    VA has many effective training programs that serve to 
support our recruitment efforts and have proven their efficacy. 
We are currently exploring possibilities for expanding these 
programs to other professional areas.
    In summary, the San Francisco VA Medical Center has made 
great efforts to recruit and retain qualified personnel through 
our innovative training programs, financial incentives, and 
commitment to the advancement in growth of our staff. We are 
committed to facing the challenges of the future and will 
continue to look for innovative ways to enhance our workforce.
    Mr. Chairman, this concludes my statement. I have a 
slightly longer statement that was submitted for the record and 
I am pleased to answer any questions that you may have.
    [The prepared statement of Ms. Cullen follows:]
   Prepared Statement of Sheila M. Cullen, Medical Center Director, 
                    San Francisco VA Medical Center
    Mr. Chairman and Members of the Committee, thank you for the 
invitation to appear before you today to discuss recruitment and 
retention challenges faced by the San Francisco VA Medical Center. I 
appreciate the opportunity to discuss our ongoing efforts to recruit 
some of the finest employees in the VA system and the challenges we 
face to retain these employees in one of the most expensive cities in 
the country.
    The San Francisco VA Medical Center provides a full range of 
primary and tertiary health care services. We are proud to have five 
National Centers of Excellence, as well as the largest funded research 
program in VA.
    Our Medical Center has had consistently high patient satisfaction 
scores. In our recent VA Office of the Inspector General (OIG) Combined 
Assessment Program Review, we were very proud that the patient 
interviews documented an impressive level of patient satisfaction with 
care at our facility. In our recent inpatient satisfaction survey, we 
scored better then the national average in several areas including the 
categories of ``courtesy exhibited by doctors,'' ``confidence and trust 
patients have with their doctor,'' and the ``dignity and respect given 
to patients during their stay.''
    We have also had consistently high employee satisfaction scores. In 
the recently conducted VHA All Employee Survey, nearly 76 percent of 
our employees responded to the survey and our scores were better than 
the VHA national average in all areas except for categories related to 
pay. In fiscal year 2007, our nurses participated in a national nurse 
satisfaction survey. Our Medical Center rated in the top ten nationally 
for highest employee satisfaction scores. Our nurses also had the 
highest scores for our Network, VISN 21, in quality of care and overall 
job satisfaction. These high levels of satisfaction are noteworthy 
given our high cost of living and the challenges we face with 
recruitment and retention. We believe employee satisfaction and 
dedication to the mission of serving veterans directly leads to good 
patient care.
                            accomplishments
    In our ongoing efforts to ensure that we maintain a highly talented 
and motivated workforce, we have implemented several programs to aid in 
our retention efforts, as well as assist us in meeting the mission and 
organizational needs of the Medical Center. Our upward mobility program 
provides employees with an opportunity to obtain career positions 
through on-the-job and formal training.
    We have a very successful ``Grow Our Own'' program for specialized 
occupations such as surgical technicians, nuclear medicine 
technologists, and diagnostic radiology technicians. This program 
provides educational and career advancement opportunities for staff in 
specialized fields that are difficult to recruit and retain due to the 
competitive health care market. Without these efforts, we would have to 
rely on costly registry or contract staff to fill these vacancies.
    We have a very successful program in place to hire new nurse 
graduates. Through this program, graduates are hired as temporary 
nurses without benefits. They are assigned a preceptor and work 40 
hours per week gaining experience in clinical areas. After they 
complete a 12-week rotation, they have the opportunity to compete for 
permanent jobs. This program has an 88 percent retention rate. Our 
overall vacancy rate for nurses is 3.5-4.5 percent with a turnover rate 
of 11.95 percent. VA's national turnover rate is 10.55 percent, so we 
consider this is be excellent, in spite of the high cost of living in 
our area. The primary reason for turnover is attributed to retirements.
    Our success in physician recruitment and retention can be credited 
to our strong affiliation with the University of California San 
Francisco. In addition, our unique mission of providing health care to 
veterans, as well as our excellent research and teaching programs, play 
key roles. The physician pay bill has also been instrumental in helping 
us to maintain our top notch medical staff.
    We believe much of our success is due to our efforts to provide a 
good work environment, which includes adequate support staff, 
educational opportunities, state-of-the-art equipment and ongoing 
support of leadership.
                               challenges
    While we have been successful in developing effective and 
innovative programs to supplement our recruitment and retention 
efforts, we are continually challenged as a result of the high cost of 
living and non-competitive salaries in the Bay Area--specifically, we 
note that Federal salaries across the board in the Bay Area are often 
not competitive with local providers. According to the National 
Association of Realtors, the median home price in the 9-county Bay Area 
is $720,000--three times as expensive as the national average. The 
median home price in San Francisco has increased by nearly 96 percent 
since the early 1990's. We fully utilize the authority to offer 
recruitment and relocation bonuses. Last year we paid out over $200,000 
in recruitment bonuses, $129,000 for relocation bonuses and over $1.8 
million for retention pay.
    A large percentage of employees in many services are approaching 
retirement age, while other services have a relatively young staff. 
Both present unique challenges either in recruiting qualified 
replacements for highly skilled retiring employees or retaining younger 
staff in highly specialized areas in a very competitive job market. 
Currently, more than 29 percent of our employees are eligible to 
retire.
    In an effort to stay competitive we use the special salary rate 
authority, as much as possible. This has been somewhat successful for 
clinical support staff. Our Medical Center has 13.5 percent of our 
employees on special salary rates. Excluding nurses, the annual 
additional cost to our Medical Center budget is $5.7 million. This is 
on top of the fact that we already have the highest geographical pay in 
the country which includes a 32.53 percent locality pay adjustment. In 
order to keep our retention rates above the 80th percentile, we have 
approved salary increases for our Registered Nurses which have ranged 
from 5-8 percent annually. The 2008 annual salary increase for all 
professional nursing categories was nearly $3 million.
    Another challenge is the limitation in developing special salary 
charts for difficult-to-fill occupations. Current law only allows the 
General Schedule salary chart to be extended out an additional 18 
steps. In our high cost economy we have reached our maximum 
effectiveness with many of our GS direct patient care occupations. Due 
to the 18-step limitation, our special salary charts for these 
occupations has become severely compressed. Since most of these 
employees are hired in difficult to recruit clinical specialties, their 
salary is often set at the higher end of the pay range. This limits 
their opportunities for future step increases.
    Another emerging pay situation is with our Certified Registered 
Nurse Anesthetists (CRNA), who are compensated under the Nurse Locality 
Pay System. Our CRNA pay schedule has reached the statutory pay limit, 
so staff can only receive the mandated annual cost of living increase. 
What this means is that we cannot offer a salary any higher than the 
statutory limit of $139,600 even though our local labor market shows 
that salaries for a CRNA is at a median salary of $171,334. Therefore, 
we have had to maximize the 25 percent retention incentive for this 
occupation.
    VA has many effective training programs that serve to support our 
recruitment efforts and have proven their efficacy. We are currently 
exploring possibilities for expanding these programs to other 
professional areas.
    The recent mental health initiative has given us the opportunity to 
increase our mental health capacity. However, since so many facilities 
nationwide are competing for limited numbers of psychiatrists and 
psychologists it has been a challenge to fill all of our positions, 
particularly in rural areas. In addition, recruitment of primary care 
providers in rural areas proves to be increasingly difficult.
    In summary, the San Francisco VA Medical Center has made great 
efforts to recruit and retain qualified personnel through our 
innovative training programs, financial incentives, and commitment to 
the advancement and growth of our staff. As our work force ages, the 
recruitment and retention of highly qualified employees will be even 
more important and our challenges greater. We are committed to facing 
these challenges head on and will continue to look for new and 
innovative ways to maintain and enhance our workforce.

    Mr. Chairman, this concludes my statement. I am pleased to answer 
any questions you or the Committee members may have.
                                 ______
                                 
  Response to Written Questions Submitted by Hon. Daniel K. Akaka to 
  Sheila M. Cullen, Medical Center Director, San Francisco VA Medical 
  Center; and Steven P. Kleinglass, FACHE, Director, Veterans Affairs 
                 Medical Center, Minneapolis, Minnesota
    Question 1. How many nurses under your direction work an 
alternative work schedule, and how do you use these schedules to 
improve recruitment, retention, and employee satisfaction?
    Response. At the Minneapolis VAMC there are approximately 424 
registered nurses, 79 licensed practical nurses, 46 nurse assistants 
and 54 health technicians on compressed or non-traditional tours of 
duty. Alternative work schedules improve recruitment, retention and 
employee satisfaction. Allowing staff the option to choose non-
traditional tours of duty hours gives them the chance to find balance 
between their work and home lives as they feel best suits their 
individual needs. Many nurses go to compressed tours to attend school 
for advanced educational purposes.
    In general, alternative schedules are used for staff who work on 
non-traditional tour hours, 9, 10 or 12 hour tours.
    There are 100 San Francisco VAMC staff nurses who work under an 
alternate work schedule/compressed work tour. In the past year, we have 
seen considerable improvement in our vacancy rates, particularly in the 
critical care units, because we offer these alternative tours of duty.


------------------------------------------------------------------------
               Vacancy Rates                    10/1/2007     4/7/2008
------------------------------------------------------------------------
Intensive care unit..........................   6.4 percent  3.4 percent
Transitional care unit.......................   8.1 percent  1.0 percent
Hemodialysis unit............................  14.5 percent  1.2 percent
------------------------------------------------------------------------

    We have assessed through our new graduate nurse training program 
that most new hires are highly interested in an alternative work 
schedule. In addition, critical care unit staff have taken an interest 
in expanding their nursing leadership roles, including furthering their 
education. Alternative work schedules are effective in allowing staff 
this opportunity. We believe that offering an alternative work schedule 
improves recruitment, retention and employee satisfaction.

    Question 2. Please detail each step you take in conducting locality 
pay surveys.
    Response. The local process at the VAMC Minneapolis starts with the 
establishment of a Committee with representatives from:

  Management (deputy nurse executive)
  Technical advisor (human resources specialist)
  Subject matter experts such as:
    Registered nurse
    Nurse practitioner
    Certified registered nurse anesthetist (CRNA)
    Operative room registered nurse (ORRN)

    A survey team that consists of registered nurses, labor 
representatives, and a technical advisor is formed to collect salary 
databased on matching job duties with like positions in the private 
sector. The teams identify local labor market areas and medical 
facilities to contact that are similar to the VAMC. The team sends out 
letters to private sector agencies requesting their participation then 
schedules a time for interview at their location. The team requests 
information on minimum, midpoint and maximum rates actually paid in a 
given job category. Copies of job descriptions are requested to ensure 
job matches and numbers of employees are the same. Once this process is 
complete, a statistical analysis of this data is done to create a 
summary of the results.
    The human resources officer and human resources technical advisor 
present options to the medical center director, nurse executive, fiscal 
officer and chief nurse anesthetist for review and discussion. After 
discussion, the medical center director approves pay scales and the 
information is then sent to VA Central Office for final review, 
approval, and input into the paid system.
    Over the past years the medical center has consistently provided an 
equitable pay increase to the nursing staff based on the data from the 
locality pay survey.
    The San Francisco VAMC partners with the Allied for Health Survey 
Program to conduct the annual locality pay surveys. Once the survey 
results are received, we use this information to set the beginning rate 
for each grade. In choosing the beginning rate of pay, we consider the 
geographic relationship of our facility to major establishments in the 
survey area, the severity of recruitment or retention problems, local 
non-VA employee benefit packages, and other factors, which affect our 
ability to recruit and retain nurses. Normally, we set the beginning 
rate for each grade at, or within 5 percent of, the average beginning 
rate for comparable non-VA positions in the survey area. By law, we 
cannot set a beginning rate above the highest beginning rate in the 
community for corresponding positions. In order to keep our retention 
rates above the 80th percentile, we have attempted to keep pace with 
community hospitals by approving salary increases for our registered 
nurses, which have ranged from 5-8 percent annually.

    Question 3. Emergency situations in hospitals often create staffing 
challenges. Under what emergency circumstances are nurses required to 
work mandatory overtime?
    Response. Since our nursing staff at the Minneapolis VAMC is 
required to be on duty 24 hours per day, 7 days a week, there are 
infrequent times when mandated overtime is needed to satisfy patient 
care demands. It is medical center policy to avoid the use of mandates. 
If there is a mandated situation, the medical center director is 
informed of the reason for its occurrence. Some instances in which 
nurses are required to work mandatory overtime are to cover unplanned 
leave, sick leave, emergency annual leave, absenteeism, and tardiness 
for duty by nursing staff.
    Patient's safety and staffing levels at the San Francisco VAMC 
would mandate an emergency situation. In the last 3 years, the San 
Francisco VA Medical Center has implemented a mandatory overtime on ONE 
occasion, and it was with the concurrence of the local bargaining 
union.

    Chairman Akaka. And I repeat that your full statements will 
be included in the record.
    Mr. Kleinglass?

  STATEMENT OF STEVEN P. KLEINGLASS, DIRECTOR, MINNEAPOLIS VA 
                         MEDICAL CENTER

    Mr. Kleinglass. Thanks. Mr. Chairman and Mr. Tester, thank 
you for the invitation to appear before you today to present 
testimony on recruitment and retention issues at the 
Minneapolis VA Medical Center. I am honored to be here today to 
share some thoughts with you on these important issues.
    In the greater Twin Cities geographic area, there are 
numerous highly respected health care systems, hospitals, 
outpatient clinics, nursing facilities, and pharmaceutical 
branches that the Minneapolis VA competes with for the health 
care worker. In the March 20 Sunday edition of the local 
newspaper, the jobs section had four pages seeking applicants 
for health care careers and all claimed that they were 
exceptional places to be employed. So, from the very start, we 
are competing for a limited number of applicants in a highly 
competitive environment.
    In addition, while pay is not the only driving factor, we 
are in an area where our locality pay is higher than it is in 
Washington, DC.
    I would like to share with you some of our successes 
regarding recruitment and retention and how they have impacted 
our ability to maintain some of our stability within our 
organization.
    Without reservation, the physician and dentist pay 
legislation is a major factor in our ability to attract 
providers in our competitive area. Unlike most highly 
affiliated teaching and research VA medical centers, we at 
Minneapolis employ more than 160 full-time physicians and 
dentists. We are able to do this because we have taken full 
advantage of the pay legislation. While we still struggle to 
employ physicians in the highly competitive sub-specialty 
categories, we contract with our local affiliate for these 
providers.
    In the nursing profession, we have taken several proactive 
measures to both attract and retain these highly-valued 
employees. Each year, we do a nurse locality pay survey and 
make necessary adjustments to nurse pay to stay competitive 
with our community. During fiscal year 2007, 19 registered 
nurse hires were former student nurse technicians from within 
our own facility. Also, we use finders fees and other programs 
and attend various health fairs throughout the State to attract 
individuals.
    In the pharmacy profession, we see keen competition for 
both pharmacists and pharmacy technicians and the private 
sector recruitment bonuses and starting salaries are highly 
attractive to new graduates. Our competitive edge has been 
starting these individuals above the minimum salary rates. We 
then involve these individuals on the treatment team so they 
work directly with physicians in prescribing appropriate drugs 
for better patient outcomes. In addition, since we believe we 
operate the largest single pharmacy in the State of Minnesota 
with more than 5,000 outpatient prescriptions being processed 
daily through our pharmacy, the volume, pace, and work affords 
our staff an exciting work environment.
    In the areas of other patient care support personnel, such 
as diagnostic radiology technicians, medical record coders, 
medical supply technicians, physical therapists, and Certified 
Registered Nurse Anesthetists, there are numbers of issues that 
we face both in recruitment and retention. Again, while pay is 
an issue, the competition for these scarce employees is highly 
competitive and our community has been willing to offer some 
very interesting perks to both entice new grads and our current 
employees. Some of our recruitment successes in these areas 
have come from our having an onsite radiology technician and 
CRNA school within the medical center, and this gives us a pool 
to be able to recruit new graduates to work within our 
facility.
    Let me share some other approaches in general that we have 
taken at the Minneapolis VA Medical Center in an effort to 
maintain our workforce. As part of our annual budget process, 
we have focused on identifying several departments where 
succession planning would be a benefit for the medical center 
and then we provide appropriate resources to these departments. 
As a medical center, we strive to be an employer of choice and 
we have done several things to reinforce this including the 
following.
    Between fiscal year 2006 and 2007, we have increased the 
number of employees who receive performance awards by 750. We 
have two major all-employee recognition functions each year to 
recognize and thank our employees for the work they do. We 
promote wellness in many ways and have a fitness center that is 
available to our employees at no cost. We have an onsite day 
care center where many of our employees' children receive their 
day care each day, and employees can venture there during their 
lunch hour to be with their children. We have a farmers' market 
on site in the summer where employees and our patients can buy 
produce. Finally, we believe that employee engagement is a key 
to morale and retention. To this end, we have annual employee 
forums, regular lunch-and-learn sessions with leaders, and 
ongoing communications with our staff through a daily e-mail 
message, a monthly newsletter, and walk-arounds from the 
executive team as they dialog with employees.
    In closing, while we do have issues with employee 
recruitment and retention, I am pleased to report that during 
fiscal year 2007 our overall employee turnover rate was less 
than 10 percent. This is amongst the lowest when compared with 
other similar VA medical centers in our system and lower than a 
recent health care entity that was a Malcolm Baldridge award 
winner.
    Mr. Chairman, this concludes my statement. I would be 
pleased to answer any questions that you or Mr. Tester may 
have.
    [The prepared statement of Mr. Kleinglass follows:]
     Prepared Statement of Steven P. Kleinglass, FACHE, Director, 
        Veterans Affairs Medical Center, Minneapolis, Minnesota
    Mr. Chairman and Members of the Committee. Thank you for the 
invitation to appear before you today to present testimony on 
recruitment and retention efforts at the Minneapolis, Minnesota VA 
Medical Center. I am honored to be here today and to share with you 
some thoughts on these important issues.
    In the greater Twin Cities geographical area there are numerous 
highly respected health care systems, hospitals, outpatient clinics, 
nursing facilities and pharmaceutical branches that the Minneapolis VA 
competes with for the health care worker. In the March 30th Sunday 
edition of the local newspaper the ``Jobs'' section had four pages 
seeking applicants for health care careers and all claimed that they 
were exceptional places to be employed. So, from the very start, we are 
competing for a limited number of applicants in a highly competitive 
environment. In addition, while pay is not the driving factor, we are 
in an area where our locality pay is higher than it is in Washington, 
DC.
    I would like to share some of our successes related to recruitment 
and retention and how they have impacted our ability to maintain some 
stability within our workforce.

     Without reservation the physician and dentist pay 
legislation is a major factor in our ability to attract providers in 
our competitive area with few exceptions. Unlike most highly 
affiliated, teaching and research VA medical centers, we employ more 
than 160 full-time physicians and dentists. We are able to do this 
because we have taken full advantage of the pay legislation. We still 
struggle to employ physicians in the highly competitive sub-specialty 
categories and so we contract for those services with our affiliated 
medical school.
     In the nursing profession we have taken several proactive 
measures to both attract and retain these highly valued employees. Each 
year we do a nurse locality pay survey, and make necessary adjustments 
to nurse pay, to stay competitive within our community. During fiscal 
year 2007, 19 Registered Nurse hires were former student nurse 
technicians from our facility. Also, we use a finder's fee program and 
attend various recruitment fairs.
     In the pharmacy profession we see keen competition for 
both pharmacists and pharmacy technicians and the private sector 
recruitment bonuses and starting salary rates are highly attractive to 
new graduates who are impressionable. Our competitive edge has been 
starting these individuals above the minimum salary rates. We then 
involve these skilled individuals on the treatment teams so that they 
work directly with physicians in prescribing appropriate drugs for 
better patient outcomes. In addition, since we believe we operate the 
largest single pharmacy in the State of Minnesota with more than 5000 
outpatient prescriptions being processed daily through our pharmacy the 
volume and pace of work affords our staff an exciting work environment.
     In the areas of other patient care support personnel such 
as diagnostic radiology technicians, medical record coders, medical 
supply technicians, physical therapists and certified registered nurse 
anesthetists (CRNA) there are a number of issues that we face in both 
recruitment and retention. Again, while pay is an issue, the 
competition for these scarce employees is highly competitive and our 
community has been willing to offer some very interesting ``perks'' to 
entice both new grads and our current employees. Some of our 
recruitment successes in these areas have come from having a radiology 
technician and CRNA school on-site which provides a pool of new 
graduates to recruit from every year.

    Let me share with you some approaches in general we have taken at 
the Minneapolis VAMC toward maintaining a workforce that meets our 
needs.

     As part of our annual budget process we have focused on 
identifying several departments where succession planning would be a 
benefit to the Medical Center and we then provide the appropriate 
resources.
     As a Medical Center we strive to be an employer of choice 
and we have done several things to reinforce this including:
    - Between fiscal year 2006 and fiscal year 2007, we increased the 
    number of employees who received performance awards by 750.
    - We have two major all-employee recognition functions.
    - We promote wellness in many ways and have a fitness center 
    available to employees without cost.
    - We have an on-site daycare center where many employees' children 
    receive daycare.
    - We have an on-site farmers market during the summer months.
    - Finally, we believe that ``employee engagement'' is a key to 
    morale and retention. To this end, we have annual employee forums, 
    regular ``lunch and learn'' sessions with leaders and ongoing 
    communications with our staff through a daily e-mail, a monthly 
    newsletter and ``walk-a-rounds'' through the medical center by the 
    Executive Team.

    In closing, while we do have issues with employee recruitment and 
retention, I am pleased to report that during fiscal year 2007 our 
overall employee turnover rate was less than 10 percent. This level is 
amongst the lowest when compared with other similar VA medical centers 
and lower than a recent health care entity that was a Malcolm Baldridge 
winner.

    Mr. Chairman, that concludes my statement. Thank you for allowing 
me to provide these comments and I would be pleased to respond to any 
questions.
                                 ______
                                 
Response to Written Questions Submitted by Hon. Patty Murray to Steven 
   P. Kleinglass, FACHE, Director, Veterans Affairs Medical Center, 
                         Minneapolis, Minnesota
                         retention bonus issues
    Question 1. Mr. Kleinglass, you mentioned during the hearing that 
there are problems associated with the use of retention bonuses. Can 
you please expand on what you mean by that statement?
    Response. A recent request to provide retention bonuses across the 
board to a particular group of nursing staff was not approved. A review 
of the request found that approving this request would cause disparity 
among other employees. At the Minneapolis VAMC, our government pay 
scale falls behind the medical community as a whole, therefore, in 
theory, we should have most of our employees on a retention bonus. The 
Minneapolis VAMC has allowed bonuses in a limited fashion and mainly 
for recruitment purposes with time pay back provisions. The Minneapolis 
VAMC does have some retention bonuses in place, which are reviewed 
annually and adjusted appropriately. In an effort to deal with the pay 
and retention issues for the certified registered nurse anesthetist 
(CRNA) staff, the Director has requested a site visit by the Chief, 
Anesthesia and CRNA services within VHA. This site visit is scheduled 
for June 10, 2008. During this consultative visit pay, performance, 
scheduling and other associated issues related to CRNA staff will be 
addressed.

    Chairman Akaka. Thank you very much, Mr. Kleinglass.
    Ms. Palkuti, thank you for your statement. You laid out 
everything that your office is doing and I must tell you it is 
impressive.
    Ms. Palkuti. Thank you.
    Chairman Akaka. But my simple question to you is, even with 
that impressive service that you provide, is that enough? Are 
there some other things that you can suggest?
    Ms. Palkuti. What we do at the central level is to try to 
help support the local facilities and their individual 
recruitment needs and implementing the legislation as fully as 
we can. We realize that continuing to work with individual 
facilities to help them improve their recruitment planning, to 
help them improve how they use the scholarships or strategize 
how they can better use education debt reduction programs is 
part of our mission and something that we work on consistently. 
We are a very large system and so we are consistently working 
in that endeavor.
    I think the work that we are doing in expanding our 
clinical programs and our training programs in psychology, what 
we are doing with the expansion of the nursing academy, will 
probably be the strongest direction that we go in in terms of 
helping not only VA in the future, but communities, as well. We 
do very closely monitor student satisfaction with their 
clinical assignments and find that that is a very strong area 
that helps improve our performance. This year, we are going to 
be taking additional efforts to focus more intently, both my 
office and the Office of Academic Affiliations and others, on 
improving our recruitment from our student corps.
    Chairman Akaka. Ms. Cullen, I would note that nurses at 
your facilities have told us that they really believe you are 
using all of the authorities bestowed upon you to ensure that 
their pay is fair. You mentioned all the good things you have 
done and did admit that pay was one of the areas that you are 
looking at. My question to you is, knowing that your area is a 
high cost-of-living area, what would you tell other directors 
about how to achieve a similar level of success?
    Ms. Cullen. Thank you, Mr. Chairman. It is all about 
creating a positive work environment, and I think that that is 
reflected in the results of the all-employee survey, not only 
at the San Francisco VA Medical Center, but actually throughout 
VISN 21, and that is under Dr. Wiebe's leadership. All of the 
facilities in Northern California, Hawaii, and Northern Nevada 
have consistently expressed satisfaction at levels higher than 
the national average.
    The strong commitment to veteran patient care and world-
class research are a key at San Francisco. The quality of staff 
who come and stay do that because of the strong demonstrated 
support for those dual missions. I believe that even non-
academicians, nurses included, are positively affected and 
influenced by that high level of research and academic pride.
    We have a viable partnership with our professional union, 
the NFFE IAM Local 1 and President Patricia La Sala, who is 
also a registered nurse and who keeps me on my toes and makes 
sure I utilize every possible authority that can benefit our 
nursing staff. We have a transparent and cooperative 
relationship committed to the goals of the organization.
    The positive press for VHA and the confidence that VHA 
employees have that they work for one of the most successful 
health care systems in the world absolutely helps recruitment 
and retention. We certainly try to publicize the positive media 
acclaim that VA has received wherever possible in employee 
forums.
    Of course, maintaining our success requires supportive 
budgets, not to mention market-level health care clinical and 
administrative salaries. I referenced earlier in my testimony 
that we are absolutely bound to provide our staff with state-
of-the-art equipment, adequate support staff, educational 
opportunities, and ongoing support of leadership.
    Chairman Akaka. Going back to pay, do you feel that in 
those high cost-of-living areas the pay is fair in your region?
    Ms. Cullen. Well, I feel that we maximally utilize the 
authorities that we have available to us. I feel that a much 
broader issue, which is the OPM-set salaries, are woefully 
inadequate for administrative staff. I think that goes beyond--
it is an issue beyond VA--however, despite the 33 and one-half 
percent geographic COLA. We are able to keep pace with our 
competitive institutions through special salary rates, and 
while we are not allowed to be the pay leader, we are allowed 
to catch up to pay in the surrounding area, and we take 
advantage of that with annual adjustments for all of our 
professions that have special salary rates.
    Chairman Akaka. Thank you. Mr. Kleinglass, we will hear 
from GAO in a bit about how difficult it is to recruit and 
retain nurse anesthetists. Have you used the retention bonuses 
for these professionals, and have you used them for temporary 
hires to fill vacant spots?
    Mr. Kleinglass. Mr. Chairman, as you state, it is difficult 
to recruit these individuals. We have not used retention 
bonuses in this field for our current employees because I 
believe there are some overall issues with doing that, and I 
can elaborate on that if you would like me to. When we do 
recruit new hires, we do use that authority, and just recently 
I did sign some recruitment bonuses for some new hires. We have 
on occasion used some locum tenens in this area to be able to 
maintain the level of staffing that we need for these 
individuals.
    Chairman Akaka. Thank you. Let me at this time call on 
Senator Burr for his questions, and that will be followed by 
Senator Tester.
    Senator Burr. Mr. Chairman, I will be very brief. I have 
only one question and it is to some degree off topic. I want to 
take the opportunity to ask Ms. Palkuti, Federal Recovery 
Coordinators were recently put in place to assist severely 
injured servicemembers and their families in navigating 
confusing layers of support that exist from rehabilitation and 
recovery case managers. It took several months to hire eight. 
One has died. One has quit. How long would it take to fill the 
vacancies so that we get what I think most Members on this 
Committee agree is an absolute necessity, and that is these 
Recovery Coordinators, in place?
    Ms. Palkuti. I am not personally involved with that 
particular process, with that particular occupation, so I 
didn't realize that it had--one had passed and one had not. But 
the general process of recruiting for that occupation would 
require announcing the position for whatever period of time and 
then interviewing to find the best candidate. It could take as 
short a period of time as 30 days. I would be more than happy 
to take that question for the record and find out precisely 
what is going rather than offering you just a theoretical time 
line.
    Senator Burr. I will save you the responsibility, but we 
will follow through with the VA.
    I just want to encourage all of you. There is a system in 
place. You could tell me better than I could tell you whether 
the system works as prescribed. It has been very frustrating to 
me as to how long it is taking to get these Recovery 
Coordinators in place. Now, if we have a process in place that 
is cumbersome and duplicative and does not allow us to 
aggressively go out and surge to an area that there is total 
agreement we need to do--and this is in the best interest of 
our veterans coming back--then tell us to change this; and we, 
collectively, I think, can get our heads together and figure 
out whether we can provide some legislative remedy to it, or, 
at least we will review it to determine whether it needs to 
stay in place.
    But, I would say this to all three of you, just because 
things are in statute certain ways, if they don't work, for 
God's sake, tell us so that we can change them, so that we can 
facilitate what it is you need in the positions that you hold 
to make sure that recruitment and retention are much easier. I 
think there is a tendency, Mr. Chairman, and I believe it is 
probably very appropriate, that the pay challenges are probably 
the number one thing. But if it was pay alone, then I think we 
would be looking at a different universe of health care 
professionals within VA.
    There is more to it, and I really want you to reach in and 
share with the Committee at some point those things that really 
do make a difference in us being able to develop that delivery 
system that reflects what the private sector does for the 21st 
century. I dare say I am not sure that there is a private 
sector entity that goes very long with a space unfilled because 
that is a service they can't deliver, and it is hard for me to 
believe how the best health care system in the world with the 
most vulnerable population could go for so long with positions 
unfilled. Because the net result to me is somebody is not 
serviced to the degree that the commitment was made. We are 
here to try to facilitate that and I encourage you.
    I thank the Chair.
    Chairman Akaka. Thank you very much, Senator Burr.
    Senator Tester?
    Senator Tester. Thank you, Mr. Chairman. I want to thank 
the participants on this panel very much for the work you do. I 
appreciate the pride that is exhibited by all of you in your 
specific institutions, or medical facilities, I should say; and 
I want to thank you for the work that you do. I think that it 
is very important.
    A couple of things. Again, it spins off of what Senator 
Burr said about more to it than pay and things that make a 
difference, and I think that the San Francisco VA Center and 
Minneapolis VA Center did talk about some things--the fitness 
center, the day care, the farmers' market on site. I applaud 
that. Those kind of things are important, but then also from a 
professional standpoint, Ms. Cullen, you talked about a nurse 
rotation of 12 weeks. Eighty-eight percent of the folks who 
went through that program that you hired stay on, 88 percent of 
the time----
    Ms. Cullen. That is correct. Those were new hires, new 
nursing graduates.
    Senator Tester. How long has that been in place?
    Ms. Cullen. Over the last 2 years.
    Senator Tester. Good.
    Ms. Cullen. We are in our second year.
    Senator Tester. And then, I think, if I recall, you both 
talked about the physician pay bill and how that was important 
to your success.
    I don't know if you know this because you work in a pretty 
urban setting, especially if you compare it to a place like 
Montana--I don't know if any of you have been to Montana----
    [Nodding heads.]
    Senator Tester. That is good. You have all been there. 
Good. Come back again. But it is a very rural State and your 
boss, Secretary Peake, was out a few months ago and got a sense 
of it. But some of the issues that bother me about what is 
going on right now for veteran health care is the fact that 
veterans who live in rural areas don't live as long, and I 
don't think it is because the air is dirty or the water is 
dirty or we get worse food there. I really do think it revolves 
around health care. And it is not the VA's exclusive problem. I 
mean, every small hospital in the State of Montana, every big 
hospital in the State of Montana, has a hard time recruiting 
and keeping people for a number of reasons.
    But, one of the things that I think works pretty darn well 
is that if you can have people do their intern programs in a VA 
hospital or in a rural part of America if you are trying to 
recruit, it really does work. So, the question I have for you, 
Ms. Palkuti, is the bigger places have it. I mean, there are, 
what, 100,000 health care professionals that you train at VA 
facilities every year, and you need to be applauded for that.
    Ms. Palkuti. Thank you.
    Senator Tester. How many of those are in rural areas? How 
many are trained in rural areas to really meet the needs of 
veterans living in rural America? And if it is zero, that is 
fine. We can fix it.
    Ms. Palkuti. You know, personally, I don't have that number 
for you at this point in time. I know that a number of places--
there was someone I was speaking to in Arizona, actually, and 
they were designing part of their clinical process so that they 
would have that particular set of residents rotate through 
their more remote outpatient clinics. It is becoming something 
that was actually a popular rotation among clinicians in that 
area. So, they are looking at getting people out to some of 
those CBOCs that are further out in the country.
    Senator Tester. Good. My daughter happens to be a 
registered nurse. She graduated from college--a 4-year program 
in 2002, I believe--and she did do part of her--I forget what 
the term is, but part of----
    Ms. Palkuti. Clinical rotation?
    Senator Tester. That is it--in a VA hospital in Helena, 
Montana, and she liked it a lot. I guess I am wondering, does 
the VA aggressively approach--there are a lot of nursing 
schools in Montana.
    Ms. Palkuti. Right.
    Senator Tester. Do they aggressively approach these folks 
to do their--it is not internship, but you know what I mean----
    Ms. Palkuti. Rotation.
    Senator Tester. Yes, rotation--there?
    Ms. Palkuti. VA has academic affiliations with numerous 
nursing schools around the country and encourages people to do 
academic rotations. I think, through the project that we have 
right now with the expanding in the VA nursing academy and 
because of all the learner surveys that we do with all of the 
clinicians who come through our organizations, we realize that 
in-place rotation at a VA facility is critical to improving our 
chance of hiring those people afterwards.
    Senator Tester. So, what you are saying is they do reach 
out to the colleges and technical schools to----
    Ms. Palkuti. Yes.
    Senator Tester. Pretty aggressively, in your opinion? I 
mean----
    Ms. Palkuti. From my knowledge, yes.
    Senator Tester. OK. It needs to be very aggressive, I 
think, from my perspective. And you have got to know that my 
focus is on rural. We have got 930,000, 950,000 people in a 
State that is pretty good-sized, and so it is really important.
    You talked about $24 million in recruitment bonuses and you 
had a figure of people that that impacted, and $34 million in 
retention bonuses. Can you give me any idea on how much of that 
money went to rural areas?
    Ms. Palkuti. I can go back and have the data run that way.
    Senator Tester. Could you, I mean, because the issue--could 
you just run it for Montana? I am not going to pick up the 
sheet and say, gosh, we are--I am not going to do that. I am 
just curious, because burn-out is a big problem amongst our 
professional folks and we have got some great people working in 
these clinics and these hospitals. I am not kidding you. They 
are incredibly committed to the health care system and to 
veterans throughout the State and I am incredibly impressed by 
them. But, they are burning out and so that is why I wonder, 
because I think that if there were some dollars for incentives, 
we could get them in. There might not be a lot of people there, 
but there is some pretty good fishing and hunting and hiking 
and those kinds of things.
    Ms. Palkuti. My brother went out there for the antelope.
    Senator Tester. There you go.
    Ms. Palkuti. And never went back to Kentucky.
    Senator Tester. Have him come to my house; I have too many.
    At any rate, I wanted to ask--and you guys may or may not 
know this, Ms. Cullen and Mr. Kleinglass--if a person is 
sitting in a waiting room, are there limits of time that the 
doctor spends with a client; and what is that?
    Mr. Kleinglass. Well, I would like to respond for you.
    Senator Tester. Sure.
    Mr. Kleinglass. We do have standards that we look at to 
measure this and I often talk with patients in the morning as I 
come into the medical center and ask them. And what I am 
realizing now is that patients are getting upset with us 
because they are moving through the medical center so quickly, 
and that is a very good thing. So, our waiting times now in our 
primary care areas and our non-specialty areas are really quite 
good. We have done a lot to help that by putting in more 
support staff so that our professional staff can have more time 
to do the professional things that they need to do.
    We still have some longer waits in some of the sub-
specialties. In our eye clinic, in particular in orthopedics, 
there are longer waits there and we see times that we don't 
like and our patients don't like.
    Senator Tester. There are actually two issues here and the 
first one deals with the time in the waiting room, which I 
applaud your efforts in minimizing that as much as possible. 
The other one applies to the amount of time that the person 
spends with the doctor in the examination room. Are there 
limits on that time?
    Mr. Kleinglass. There are set appointment times, but I 
would hope and I feel fairly confident telling you that the 
physicians will spend whatever time is necessary if there is an 
issue with a patient, and that is going to complicate back-up.
    Senator Tester. Yes, exactly; and it will complicate the 
amount of time you spend in the waiting room. So, if your 
physicians were told that they needed to funnel these folks 
through, 15 minutes is the most they can spend with them, would 
you object vigorously to that? You can answer, too, Ms. Cullen.
    Ms. Cullen. Our appointments are for one-half hour for 
routine appointments, 1 hour for a first-time appointment in 
primary care. We do not schedule 15-minute appointments.
    Senator Tester. Good.
    Ms. Cullen. In some areas, there are 20-minute 
appointments, but no shorter than that.
    Senator Tester. Well, I think the problem is--because I 
have heard this in Montana--I think the problem is lack of 
staff. I think that they have to get them through because we 
have got more people that need help than we have staff to take 
care of them. I think that contributes, in a great part, to the 
burn-out. Because there is nothing more frustrating than coming 
to a Committee meeting and not being able to spend as much time 
as you want asking you folks questions; and compound that 
exponentially if you are a doctor or a nurse and you are trying 
to give health care that you were trained to give and you don't 
have enough time to give it.
    So, I think you get my drift here. Like I said, it is not 
just VA in rural America, but we are really in crisis when it 
comes to health care. And I am on this Committee, and I think 
that we need to do our best to make sure we live up to our 
obligation to veterans, make no mistake about it.
    I would love to work with all three of you individually to 
figure out ways we can address health care in rural/frontier 
America. I have got some ideas. I know you guys have more ideas 
than I have. We have just got to figure out--as Senator Burr 
said, it isn't all about money. I think a lot of it has to do 
about training. I think a lot of it has to do about telling 
folks the opportunities. I think a lot of it has to do about 
stuff like on-site day care and fitness centers and farmers' 
markets for availability. I mean, that is good stuff.
    Go ahead.
    Mr. Kleinglass. We will do anything that is innovative and 
creative to help manage this. These are small things that we 
do, but I think that when you measure these across, they mean a 
lot to employees.
    Senator Tester. Yes, in the end. I appreciate you guys' 
work, but I am telling you, we do have a problem in rural 
America. Because, number one, it is tough to get them, it is 
tough to keep them, and we are burning out the ones we are 
getting. So, it just compounds itself.
    So, thank you.
    Chairman Akaka. Thank you, Senator Tester.
    Mr. Kleinglass, I understand from my staff that you have 
been using Maxim Health Care Services to fill some of your 
vacancies. Why have you resorted to temporary staffing of VA 
with an outside entity? Have you not been able to recruit 
professionals through the normal channels?
    Mr. Kleinglass. Mr. Chairman, I am not familiar with Maxim 
staffing. Is that an agency?
    Chairman Akaka. Health Care Services, yes.
    Mr. Kleinglass. There are times where we do use temporary 
agencies to help supplement some of our staff. I personally 
don't think that is a bad thing. It gives us some flexibility 
in some areas where we flex up and flex down according to the 
needs of what is going on. So, it depends specifically in what 
area we are using those temporaries. We have used some 
temporaries in some of our Community-Based Outpatient Clinics 
because, quite honestly, it is a rural area, and as Senator 
Tester said, it is sometimes difficult to recruit staff for 
those areas. So, we do use temporaries--locum tenentes--in 
those areas.
    Chairman Akaka. Yes. Mr. Kleinglass and Ms. Cullen, could 
you both please tell us what types of physician specialties you 
still must contract for despite the success of physician pay 
reform, and please give us an example of the sub-specialty 
contract at your facility and how much you are currently paying 
them. Ms. Cullen?
    Ms. Cullen. We still have anesthesiologists on contract, 
neuroradiologists, and those are the only two that come to 
mind. Most of our physician staff are on staff. 
Neuroradiologists remain out of our price range and 
anesthesiologists are very difficult to recruit, and we have 
some salary concerns there, as well. But truly, our affiliation 
with UC San Francisco has been our strength for recruiting and 
retaining staff.
    Chairman Akaka. Mr. Kleinglass?
    Mr. Kleinglass. Mr. Chairman, in our case, the physician 
and dentist pay bill has been an outstanding tool that we have 
and we have; used that pay bill to help us in lots of areas. We 
struggle in the areas of therapeutic radiology, diagnostic 
radiology, and cardiovascular surgeons, in particular. These 
sub-specialties are both in high demand in the community and 
command salaries that would exceed the limitations that we 
have.
    Chairman Akaka. Ms. Cullen, how much are you paying for 
your anesthesiologist contract, for example?
    Ms. Cullen. I don't have that dollar amount. I can 
certainly get you that, specifically. But, we are currently 
exceeding the amounts that are identified for 
anesthesiologists. I will have to follow up and provide that.
    [The response from Ms. Cullen follows:]

    Response. The cost of an anesthesiologist on contract is $472,160 
at VA Medical Center San Francisco.

    Chairman Akaka. My final question is to Mr. Kleinglass and 
Ms. Cullen. I am aware that some facilities give nurse managers 
and supervisors greater locality pay than other nurses versus 
increases for the staff nurses. Based on the results of the 
locality pay surveys, how do you assign locality pay and how do 
you justify higher locality pay for nurse managers and 
supervisors?
    Ms. Cullen. For our nurse managers, and particularly for 
our nurse managers on inpatient units, we have two additional 
steps of salary for that additional supervisory role. For the 
most part, our larger geographic salary is allocated to the 
nurses who work on inpatient units; and we find that we can 
adequately recruit nurses in outpatient settings. It remains 
difficult to recruit them for inpatient settings and for off-
hour shifts, as well. So, they are on a higher salary range, 
not our nurse managers, but the nurses who work on inpatient 
units.
    Chairman Akaka. Mr. Kleinglass?
    Mr. Kleinglass. Mr. Chairman, in fiscal year 2006, our 
annualized RN locality pay survey resulted in an $850,000 
annualized cost. In fiscal year 2007, it was $1.1 million in 
annualized cost. We take the locality pay survey work extremely 
seriously. We put a lot of effort into doing that and we do 
want to match up as best we can, albeit staying below the 
community rates, and over the many, many years that I have been 
at Minneapolis, each year, we have provided a raise for these 
individuals.
    We do provide some extra money to our nurse managers and we 
started that several years ago. We did that because of the 
demands on those individuals, our expectations of them, and the 
roles they play each day in managing patient care. So, they do 
get some extra money. It is not a lot, and I don't have the 
exact figures with me, but, in fact, they do get some extra 
money.
    Chairman Akaka. We are into our second round. Senator 
Tester, do you have any questions?
    Senator Tester. I do have just a couple of real quick ones. 
I talked about the medical professionals in the first round. I 
want to talk more about administrative folks, folks who answer 
the phone, folks who do the schedules. A little less pressure 
on the pool there, but I hear a lot of things about the length 
of time it takes to hire somebody to answer the phone. Is the 
bureaucracy that bulky? Do we need to do some things to change 
it? Tell me the process and why it should take a long time to 
hire somebody to----
    Ms. Palkuti. Well----
    Senator Tester. No, go ahead.
    Ms. Palkuti. The process, depending on which hiring 
authority you use, there is something called delegated 
examining, which is commonly used to bring in people in 
administrative positions because we don't have a direct hire 
authority for most of those occupations. And so we are 
delegated by OPM with the authority to hire and examine for 
those positions.
    Starting actually last summer, we did a total evaluation of 
delegated hiring within the Veterans Health Administration and 
we had 19 units around the country. Effective October 1 of 
2007, we have completely reorganized that function, centralized 
it under my office. We now have eight of the most high-
performing centers that have now been totally automated and are 
performing the delegated examining function for the agency.
    From the time that a complete package is received in those 
examining units until a certificate is delivered to an H.R. 
manager is--our March numbers showed that it was around 14 
days. So, it depends on how long the position is open. If it is 
open for 2 weeks, then--but generally, within 7 days of the 
position closing, we actually do have the certificate back to 
the hiring manager. And we have been monitoring our numbers in 
that regard since the reorganization----
    Senator Tester. And do you track it after the certificate 
goes? Is there some tracking on that human resource person as 
to when they hire the person?
    Ms. Palkuti. Yes, we do. We track the process well beyond 
the date that we produce the certificate----
    Senator Tester. And there isn't a glitch there?
    Ms. Palkuti. There is the timing that it takes a manager to 
schedule interviews, do interviews, make a selection, check 
credentials, and those kinds of things----
    Senator Tester. OK. Are we understaffed in the human 
resource end of things so that is holding up the process?
    Ms. Palkuti. We have identified the human resources 
occupation as one of our top ten priority occupations for the 
agency. We have increased the number of folks that we are 
hiring in new internships for developmental purposes to 42 this 
year.
    Senator Tester. OK.
    Ms. Palkuti. We are looking at that.
    Senator Tester. I mean, one of the things that really gets 
the VA off to a bad start is if the first person they talk to 
is a machine.
    Ms. Palkuti. Correct.
    Senator Tester. With the press the last couple days 
reporting on credit cards, I'm inclined to ask this question to 
both Ms. Cullen and Mr. Kleinglass. Are there people that you 
have oversight over, yourselves included, that have VA credit 
cards; and are there rules as to how those cards can be used?
    Mr. Kleinglass. Please.
    Ms. Cullen. Yes, I have a government credit card. Mine is 
just for travel; and yes, we have a number of government credit 
cards throughout our organization; and there are, indeed, rules 
for how they are to be utilized.
    Senator Tester. And I assume it is the same for you, Mr. 
Kleinglass?
    Mr. Kleinglass. Yes, Senator Tester. I have a government 
credit card. We have many staff that have them. There are 
rules. We have an Ethics Committee at our institution. We talk 
about this regularly.
    Senator Tester. I am not making any implications on your 
particular facilities, let the record be clear on that. But do 
you have any oversight of those credit cards within your 
facilities or is it all done from this end?
    Mr. Kleinglass. In our institution, our Chief Financial 
Officer and his staff manage that for us and they regularly put 
out guidance on the use of these cards and I know of no 
problems at our institution.
    Senator Tester. OK.
    Ms. Cullen. Also, we do internal audits on the use of 
purchase cards, and we occasionally have the benefit of visits 
from our colleagues in central office who do the same, and from 
the IG. They just--within this fiscal year, we had a random 
audit of credit cards by the IG, as well.
    Senator Tester. Thank you very much. Sorry I had to bring 
up the messy subject, but I had to do it. Thank you.
    Ms. Cullen. No problem.
    Chairman Akaka. Thank you very much.
    Before I dismiss the first panel, I want to call on Senator 
Wicker for any statement or questions you may have.

              STATEMENT OF HON. ROGER F. WICKER, 
                 U.S. SENATOR FROM MISSISSIPPI

    Senator Wicker. Thank you, and I would ask a few questions. 
I do want to thank Senator Tester for asking about the credit 
cards. Some things we sometimes feel go without saying, or some 
questions go without asking, and then we learn that, lo and 
behold, the very obvious questions need to be asked. So, I 
appreciated the question and appreciate the answer.
    Let me just follow up, first of all, Mr. Kleinglass, with 
your testimony about extra pay or incentive pay for nurse 
managers and certain specialty areas among the nurses. Do you 
find that your civilian counterparts are doing the same, or are 
there differences in that particular area? Or do you have 
conversations with your civilian counterparts?
    Mr. Kleinglass. I do. I sit on the Minnesota Hospital 
Association Board and I asked various questions of my 
colleagues in town. What I would say to you is it is very 
difficult to match up exactly, for lots of reasons. It is my 
understanding when our nurse executive at our institution asked 
me about doing this, she was interested in it because the 
community in which we reside does this. She felt passionately 
that in order to maintain the staff that we want, this would be 
a good incentive for our nurse managers.
    I didn't bring the numbers with me, but I am fairly 
confident when I tell you the amount of money that we have 
given to these nurse managers is really very small in the realm 
of what we are asking them to do. They are really the backbone 
to the nursing units and have responsibilities 24 hours-a-day/7 
days-a-week, with a very large responsibility.
    Senator Wicker. Well, I think, certainly, we can 
acknowledge that the shortage across the board affects the 
government health care providers and private and community-
based health care providers.
    Let me just back up and see if someone on the panel can 
give us an overview of the profile of physicians and nurses in 
the VA. Do you get most of them straight from school, or do 
they work a while in the private sector typically? And at what 
point do we tend to lose them, both the doctors and the nurses, 
to the private sector? Is there anything that we can learn 
along those lines that might be helpful to the Committee?
    Mr. Kleinglass. I would be pleased to answer that for you. 
In our institution, and I am speaking only for the Minneapolis 
VA, we have a combination of reasons why physicians come to us 
and we get a mix from our affiliate through the medical school, 
through the training programs, and then individuals that are 
mid-career that have gone out and done some other things come 
back to us.
    When I talk to new physicians that come to work for us, 
they come because of the affinity for taking care of veterans; 
for the teaching opportunities; for the research opportunities; 
and for the way we do our business--particularly with the 
computerized patient medical record. That is a real bonus. They 
also like the way we practice medicine within the VA. They are 
getting very frustrated with what is going on in the private 
sector--their inability to order tests or inability to really 
practice--and so, they see the VA as a model of very high level 
practice availability.
    Senator Wicker. And why do you lose them at a certain 
point?
    Mr. Kleinglass. Well, I can give you one specific example. 
We are losing a physician that we value greatly and he was kind 
enough to tell me he was going to be leaving us. So, I asked 
him to come up to my office and we spoke quite a bit. His words 
to me were, ``I am leaving because of a family lifestyle 
change, a location--that is, going back home--and not because I 
am unhappy here in any way, and it is not because of pay.'' So, 
I think there are those reasons.
    Quite honestly, in some of the sub-specialties, particular 
cardiology, diagnostic radiology, interventional cardiology, we 
lose some physicians because of pay, and predominately pay. And 
I have some examples of those that I could share with you where 
we have tried to entice these people to stay. And it is very, 
very difficult to compete with the pay that these people are 
getting. I was successful a couple of years ago convincing one 
of our valued cardiologists not to leave, and a year and one-
half later the offer just was way out of control from the 
private sector.
    Ms. Cullen. At San Francisco, our situation is similar to 
what Mr. Kleinglass describes. We hire physicians at all 
levels. Experienced, tenured physicians from other areas will 
come to our medical center. The affiliation with our medical 
school is the primary draw for recruitment and retention of 
physicians. Our research program, which is the largest in the 
VA, is an enormous magnet for recruitment and retention. We 
lose physicians because they can get an academic promotion 
elsewhere. Infrequently, but it does happen, we lose them due 
to very attractive salary offers, sometimes outside academia.
    Most recently, we have two pending physician losses that 
will be very painful to us, one, an interventional cardiologist 
who is leaving for an over $600,000 salary. The second is an 
anesthesiologist who will be leaving us for a $300,000 sign-on 
bonus and who will yet get to stay in the area. But, for the 
most part, our physicians remain in an academic setting.
    With nurses, we hire them as new grads and we try to 
attract new nursing graduates, but the largest number of nurses 
that we lose are through retirement, so they are people who 
have had an extensive career with the VA--extensive and 
successful career with VA. Sometimes we lose people because 
families move elsewhere, but that is to be expected. Again, as 
I think I mentioned in my testimony, our largest nursing loss 
is due to retirements.
    Senator Wicker. Well, thank you. And I guess this is a 
question for the record, but if anyone on the panel could let 
us know the percentage of people--nurses or doctors--who stick 
with you the whole time. I realize that is not what we do in 
society anymore. People have a number of careers nowadays, 
whereas in my father's day, you picked one and that is what you 
retired from. But, it would be interesting if you could supply 
me--if you know off the top of your head or can supply for the 
record--how many people make a total career out of it.
    Thank you; and thank you, Mr. Chairman.
    [The response from Ms. Cullen follows:]

    Response. VA does not keep data on staff who remain with VA for 
their entire careers.

    Chairman Akaka. Thank you, Senator Wicker.
    Senator Rockefeller, any statement or questions to the 
first panel?

  STATEMENT OF HON. JOHN D. ROCKEFELLER IV, U.S. SENATOR FROM 
                         WEST VIRGINIA

    Senator Rockefeller. Mr. Chairman, I am just interested in 
the fact that in this question, and in response to what the 
Senator previously said, my understanding was that the average 
VA nurse has been there for 27 years. VA has also hired a lot 
of people--specialists and general people--in the last 2 years 
because you have had more money to do so--thanks to Patty 
Murray--and that you plan on hiring some 500 more this year, if 
that is correct. So, the question is sort of regarding the 
people leaving for higher pay versus the 27 years tradition, if 
that is still correct, and then the hiring on of new people 
means that they are coming already knowing that there is higher 
pay elsewhere, and that would make sense to me simply because 
of the centrality of the veterans. The last several years have 
really highlighted it. This Congress will never be the same, I 
hope, as it has been in the past, unfortunately.
    One thing that caught my attention was the question of 
nurses seeking sort of overtime and the 3-day/12-hour-a-day 
pattern, and that that seemed to make sense to them--and 
obviously does to you because it probably wouldn't have been 
suggested if that had not been the case. But then I am 
confused, because you have the sole authority to decide which 
workplace disputes can be grieved. Since 2002--I am just saying 
``you'' generically--has ruled in favor of management and 
against the employees' right to grieve in 100 percent of the 
cases that have come before him, which couldn't be you, and 
that interests me.
    Ms. Palkuti. Sir, I am probably not the expert in the 
employee relations arena. Can I take that question for the 
record and respond to that?
    Senator Rockefeller. Yes, if you could let me know. It is 
just sort of a phenomenon that doesn't take place if they are 
satisfied with it; and you are satisfied with it, but then 
those who don't always lose. So, if you could take that for the 
record, I would be very grateful.
    Ms. Palkuti. Yes, sir. I would be glad to. Thank you.
    Senator Rockefeller. That will be my only question for the 
moment, Mr. Chairman.
    [The response from Ms. Palkuti follows:]

    Response. VA provided this information directly to Senator 
Rockefeller's office.

    Chairman Akaka. Thank you very much, Senator Rockefeller.
    Senator Murray?
    Senator Murray. Mr. Chairman, I had an opportunity to speak 
earlier and I know the panel has been up here and you have got 
a second panel. I will pass on my questions and submit them for 
the record on this panel.
    Chairman Akaka. Thank you very much.
    I want to then thank our first panel. The kind of questions 
we have had really were seeking to find out more of what you 
are doing. You have been doing an incredible job and we want 
others to learn from your experiences, as well. So, thank you 
very much for being here today.
    Senator Rockefeller. Can I----
    Chairman Akaka. Just a second. Senator Rockefeller?
    Senator Rockefeller. I didn't use all my time, did I? Let 
me go back to the earlier part of that question. Is the 27-year 
thing still fundamentally accurate?
    Ms. Palkuti. Are you asking if----
    Senator Rockefeller. That the average length of the VA 
nurse's stay. I have used it all over my State, so I am hoping 
that it is----
    Ms. Palkuti. You are hoping it is correct.
    [Laughter.]
    Ms. Palkuti. I can confirm or determine whether that----
    Senator Rockefeller. It is in that area.
    Ms. Palkuti [continuing]. That average is----
    Senator Rockefeller. I believe it is in that area, which 
shows the dedication.
    Ms. Palkuti. Yes.
    Senator Rockefeller. But then you use the example of people 
being attracted by higher salaries elsewhere, and, of course, 
we all face that, particularly those of us who are surrounded 
by much richer States. And you have hired a lot of people, 
which meant they had to go through that calculus in their mind, 
because they know what is being offered. Is there an 
explanation for that?
    Ms. Palkuti. Well, I guess we can refer back to some of our 
workforce planning initiatives. We have turnover because of 
retirement and other types of attrition, so we are continuously 
hiring new employees. Many of them are coming from the private 
sector at mid-career because they appreciate the way VA 
practices medicine. There is a focus on the patient and less of 
a focus on just decisions that are bottom-line business 
decisions. We have a phenomenal health record that draws 
people. And so, some people do make a decision and calculate 
the differences in terms of salary to make a choice to come and 
work for VA. Many people come to us because of the mission, and 
some who don't come to us because they are mission-bound become 
very attached to our mission very shortly after arriving.
    We have some very good incentives. We have scholarship 
incentives that draw people, especially associate and 
baccalaureate degree nurses. We have a scholarship program 
which is exceptional across the agency, so we draw them in for 
their educational benefits. Our Education Debt Reduction 
Program, which is offered to new hires, gives them an incentive 
to stay for 5 years to collect all of those funds, and we found 
very clearly that employees who stay in years three, four, and 
five remain with the agency when those benefits expire.
    So, we have some very good benefits that draw people into 
the agency and help them see what a fine place it is to 
practice and serve the country.
    Senator Rockefeller. Has the intensity of these two wars 
that are going on and the trauma of the wounded and injured--
physically, psychologically, both--has that, do you think, 
helped the whole sense of mission?
    Ms. Palkuti. To some degree, I would like to defer to my 
colleagues who are more on the front lines and may be able to 
speak to that even more.
    Mr. Kleinglass. Mr. Rockefeller, the Minneapolis VA Medical 
Center is one of VHA's five polytrauma centers, and so we have 
a lot of experience with your question. I would say, 
undoubtedly, the new staff that is coming in have this notion 
of serving veterans is just a noble thing. They thoroughly 
enjoy working with the returning soldiers. We have a 
tremendously dedicated staff that work day-in and day-out with 
the returning soldiers and thoroughly, thoroughly enjoy it. And 
so, I think that in our case, at least, that has contributed to 
some of our successes with the new people coming in.
    Senator Rockefeller. Good. I have over-used my time and I 
apologize, but I am glad to hear those answers.
    Chairman Akaka. Thank you, Senator Rockefeller.
    Let me say that speaking of dedication, there is a nurse at 
the Albany VA Hospital who has just celebrated her 50th 
anniversary as a nurse. That is something to shoot for, and I 
want Senator Rockefeller and Senator Wicker to know that. There 
is a 50-year-career at the Albany VA Hospital.
    With that, again, thank you very much to our first panel 
for being here and sharing your experiences.
    Let me now welcome our second panel. I would like to thank 
our second panel for being here today.
    First, I welcome Marjorie Kanof, Managing Director for 
Health Care in the Government Accountability Office.
    Second, I welcome Dr. John McDonald, Vice President for 
Health Sciences and Dean of the University of Nevada School of 
Medicine.
    I also welcome Valerie O'Meara, a nurse practitioner in the 
VA Puget Sound Health Care System and Professional Vice 
President of the American Federation of Government Employees 
Local 3197.
    Next, I welcome Randy Phelps, Deputy Executive Director of 
the American Psychological Association Practice Directorate.
    Finally, I welcome Dr. Jennifer Strauss, Assistant 
Professor in the Department of Psychiatry and Behavioral 
Sciences of Duke University Medical Center.
    Again, I want to thank all of you for being here today and 
let you know that your full statements will appear in the 
record. We will begin with Dr. Kanof and your testimony.

 STATEMENT OF MARJORIE KANOF, M.D., MANAGING DIRECTOR, HEALTH 
          CARE, U.S. GOVERNMENT ACCOUNTABILITY OFFICE

    Dr. Kanof. Mr. Chairman, Mr. Rockefeller, and Ms. Murray, I 
am pleased to be here today as you discuss personnel issues at 
the Department of Veterans Affairs.
    One such issue VA faces is an increased demand for the 
services provided by Certified Registered Nurse Anesthetists 
(CRNAs), who provide the majority of anesthesia care veterans 
receive in VA medical facilities. The VA employs approximately 
500 CRNAs and many of these CRNAs are nearing retirement 
eligibility age. Given the increased demand for CRNAs, concerns 
have been raised about the challenges VA may face in making 
salaries competitive to maintain the CRNA workforce, 
particularly in the areas where the local market can be highly 
competitive.
    In December 2007, GAO issued a report that examined the 
challenges VA faces recruiting and retaining CRNAs. Based on 
this report, I will discuss both the CRNA workforce challenges 
and the key mechanisms VA facilities have to make CRNA salaries 
competitive.
    We reported that VA medical facilities have challenges both 
recruiting and retaining CRNAs. Seventy-four percent of the VA 
chief anesthesiologists that responded to our survey reported 
that they had difficulty recruiting CRNAs. VA medical facility 
officials responding to our survey reported that it took VA 
facilities a long time, on average about 15 months, to fill a 
CRNA vacancy. Based on fiscal year 2005 data, nationally, VA 
had a 13 percent CRNA vacancy, or 70 unfilled positions at 43 
medical facilities.
    According to our survey, the CRNA vacancy impacted the 
delivery of care to the veterans. For example, 54 percent of 
our chief anesthesiologists reported that they temporarily 
closed their operating rooms.
    In addition to the challenge of recruiting CRNAs, we also 
reported that VA medical facilities were likely to face a 
challenge in retaining CRNAs. On the basis of the response to 
our survey, we projected a CRNA attrition rate of 26 percent 
across VA in the next 5 years. Overall, 93 CRNAs at 53 
facilities reported that they plan to either leave or retire 
from the VA in 5 years. VA medical facilities reported in our 
survey that recruitment and retention challenges were caused 
primarily by the level of VA's CRNA salaries when compared to 
salaries in the local market area.
    In December 2007, we also reported that VA's Locality Pay 
System, known as LPS, is a key mechanism that facilities use to 
determine whether to address salaries. The LPS provides 
information on salaries paid to CRNAs in the facility's local 
market area. We reported that the majority of VA facilities use 
the LPS, but at the eight VA medical facilities we visited, 
five did not use the LPS in accordance with VA's LPS policy. At 
these five facilities, officials with oversight responsibility 
for the LPS were not knowledgeable about the changes in the 
policy. For example, one official told us that third-party 
salary survey data wasn't available, so they used salary data 
from the Hot Jobs Web site, which doesn't match the data 
accuracy that is required by the VA protocol.
    The problem some VA medical facilities had fully 
understanding the LPS policy indicated that VA training had 
been inadequate. Actually, VA had changed its policy in 2001, 
but it had not conducted nationwide training since 1995. As a 
result, VA medical facility officials cannot ensure that the 
CRNA salaries have been adjusted as needed to be competitive in 
local market areas. Training on the LPS is necessary to help 
ensure that VA medical facilities are competitive as an 
employer.
    And so, to improve VA's ability to recruit and retain 
CRNAs, in our December report, we recommended that VA expedite 
the development and implementation of training; and VA agreed 
with our recommendation and stated that it had developed a 
draft action plan and they hope to complete online training by 
the end of this fiscal year.
    Mr. Chairman and Members, this concludes my opening 
statement.
    [The prepared statement of Dr. Kanof follows:]
 Prepared Statement of Marjorie Kanor, Managing Director, Health Care, 
                 U.S. Government Accountability Office

































    Chairman Akaka. Thank you very much, Dr. Kanof.
    Dr. McDonald?

STATEMENT OF JOHN A. McDONALD, M.D., PH.D., VICE PRESIDENT FOR 
   HEALTH SCIENCES AND DEAN, UNIVERSITY OF NEVADA SCHOOL OF 
  MEDICINE, ON BEHALF OF THE ASSOCIATION OF AMERICAN MEDICAL 
                            COLLEGES

    Dr. McDonald. Thank you, Mr. Chairman, Mr. Rockefeller, Ms. 
Murray. I appreciate the opportunity to speak on behalf of the 
American Association of Medical Colleges and myself. I bring 
somewhat a different perspective to this dialog. Prior to 
assuming my current position in the State of Nevada, I was the 
Chief of the Medical Service at the Utah Veterans 
Administration Medical Center in Salt Lake City and was 
responsible there for the care of veterans and also practiced 
as a pulmonary physician and internal medicine specialist. Now, 
I am seeing this dialog through a different set of eyes and 
hope to share with you briefly some of my observations and 
those of the AAMC.
    This is about recruiting the very best and brightest to 
serve those who have served the country, as Abraham Lincoln put 
it so well. Unfortunately, we are all facing a major workforce 
shortage in physicians as well as in nurses and other health 
care professionals. Our workforce is aging, just as America is 
aging. We also have a smaller pipeline to train health care 
professionals, specifically with regard to physicians. Medical 
school has not kept up with the growing population of the 
United States.
    In addition, residency training, and every physician in 
order to become a licensed practitioner must train a minimum of 
3 years and sometimes as many as 7 or 8 in order to practice a 
specialty or sub-specialty, is capped in existing hospitals, 
civilian hospitals that already have residency programs. This 
does not make allowances for rapidly-growing States in the 
West. One example of that: we are 47th out of 50 States with 
respect to physicians in the workforce; and 50th out of 50 with 
respect to nurses, and we have the lowest number of physicians-
in-training and residencies of any State in the Union with the 
medical school. So, we are particularly aware, keenly aware, of 
these problems with the pipeline.
    The VA has taken a leadership role in trying to address 
these issues. It has increased its residency training, as I 
note in my written testimony, and has increased each year and 
is trying to go from 9 percent to 11 percent of the total 
training opportunities for medical residents in this country.
    This is extremely important. Residents who train at the VA 
are much more likely to have a favorable perception of working 
in the VA, and I would like to add for the record that my own 
perception of working in the VA, both in a leadership position 
and as a practicing physician, was entirely positive. I left 
the institution with great regard for the staff, the nurses, 
the physicians, the leadership; particularly high regard for 
the veterans who served our country; and for many reasons, it 
can be a very attractive work environment for a physician. But 
if you are not exposed to that environment, you won't learn the 
benefits of working in it.
    We heard in earlier testimony some of the challenges in 
obtaining specialists to work in the VA, and I think that there 
are a number of issues that could help in this regard. The 
average medical student graduates with a debt of approximately 
$140,000. That is before they enter their residency training. 
Loan repayment, we think, and the legislation sponsored by 
Senator Durbin is an important step forward in this regard--
would be a very attractive incentive. It has worked well to 
recruit physicians to rural locations that are underserved in 
the National Health Service Corps and I believe it would be a 
very positive enhancement for the VA.
    A robust academic affiliate is absolutely essential. You 
heard from two of the best Veterans Administration hospitals 
with respect to their relationships with their peer academic 
institutions--from Ms. Cullen, the Director of the San 
Francisco VA, and Mr. Kleinglass, the Director of the 
Minneapolis VA. These are paradigms of what can be achieved 
when there is a successful partnership between academia and a 
Veterans Administration hospital. This standard is one we all 
strive for. It is not always met because of challenges within 
the local environment.
    A critical part of this is Veterans Administration research 
and development. One of the attractive lures for young 
physicians to join the VA is access to a separate pot of money 
which is restricted to VA physicians and researchers. 
Unfortunately, over the past several years, despite this 
Committee's great efforts in the past year to secure more 
funding, the VA research infrastructure and the research budget 
have suffered, and I believe that this is well worth the 
attention of the Committee in terms of being a very positive 
incentive for attracting promising young physician scientists 
into the VA system. It is a crisis nationally.
    Our young physicians, physician scientists like myself, are 
simply not choosing an academic path because of the 
difficulties in funding. The first independent research award, 
for example, granted to M.D.s does not occur until the mid-
40's, which is an astonishing figure to me, and the VA research 
environment can do a lot to reverse this trend and to recruit 
the best and brightest into the VA hospitals.
    That concludes my spoken testimony, Mr. Chairman. Thank 
you.
    [The prepared statement of Dr. McDonald follows:]
Prepared Statement of John A. McDonald, M.D., Ph.D., Vice President for 
    Health Sciences and Dean of the University of Nevada School of 
 Medicine; and Member of the Association of American Medical Colleges, 
                Veterans Affairs-Deans Liaison Committee
    Good morning and thank you for this opportunity to testify on the 
recruitment and retention of health professionals at the Department of 
Veterans Affairs (VA). I am Dr. John McDonald, Vice President for 
Health Sciences and Dean of the University of Nevada School of Medicine 
and a member of the Association of American Medical Colleges (AAMC) VA-
Deans Liaison Committee. I also recently served as the Chief of 
Medicine at the Salt Lake City VA Medical Center. The University of 
Nevada is affiliated with the Reno and Las Vegas VA medical centers of 
the Sierra Pacific and Desert Pacific Veterans Integrated Service 
Networks (VISNs 21 and 22, respectively).
    The AAMC is a not-for-profit association representing all 129 
accredited U.S. medical schools; nearly 400 major teaching hospitals 
and health systems, including 68 Department of Veterans Affairs medical 
centers; and 94 academic and scientific societies. Through these 
institutions and organizations, the AAMC represents 109,000 faculty 
members, 67,000 medical students, and 104,000 resident physicians.
    I would like to thank the committee for your support of the 
Veterans Health Administration (VHA) in the fiscal year 2009 budget 
resolution. Your leadership resulted in the Senate's passage of $48.2 
billion for fiscal year 2009 discretionary veterans programs, including 
medical care.
    For the Veterans Health Administration programs in fiscal year 
2009, the AAMC recommends $42.8 billion for VA medical care, $55 
million for VA Medical and Prosthetic Research, and $45 million for VA 
research facilities improvement. This funding is crucial to the 
continued success of the primary sources of VA's physician recruitment 
and retention: academic affiliations, graduate medical education, and 
research.
                           physician shortage
    Concerns about physician staffing at the VA come at the same time 
the Nation faces a pending shortage of physicians. Recent analysis by 
the AAMC's Center for Workforce Studies indicates the United States 
will face a serious doctor shortage in the next few decades. Our 
Nation's rapidly growing population, increasing numbers of elderly 
Americans, an aging physician workforce, and a rising demand for health 
care services all point to this conclusion.
    Many areas of the country and a number of medical specialties are 
already reporting a scarcity of physicians. Approximately 30 million 
people now live in federally designated physician shortage areas. An 
acute national physician shortage would have a profound effect on 
access to VA health care, including longer waits for appointments and 
the need to travel farther to see a doctor.
    Currently, 744,000 doctors practice medicine in the United States. 
But 250,000--one in three of these doctors--are over age 55 and are 
likely to retire during the next 20 years, just when the baby boom 
generation begins to turn 70. The annual number of physician retirees 
is predicted to increase from more than 9,000 in 2000 to almost 23,000 
in 2025. Meanwhile, since 1980, the number of first-year enrollees in 
U.S. medical schools per 100,000 population has declined annually. 
Consequently, America is producing fewer and fewer doctors each year 
relative to our continually growing population.
    Because it can take as many as 7 to 10 years after college 
graduation until new doctors enter practice, the AAMC believes that we 
must begin to act now to avert a physician shortage. Specifically:

     The AAMC has called for a 30 percent increase in U.S. 
medical school enrollment by 2015, which will result in an additional 
5,000 new M.D.s annually.
     To accommodate more M.D. graduates, the AAMC supports a 
corresponding increase in the number of federally supported residency 
training positions in the Nation's teaching hospitals.
                         recruitment incentives
    With difficulty recruiting health professions, the VA in some cases 
has similar characteristics to certain rural and urban areas, 
population groups, or medical facilities designated as ``underserved'' 
by the U.S. Department of Health and Human Services. The National 
Health Service Corps (NHSC) has a proven track record of expanding 
access for underserved populations by supplying physicians to federally 
designated shortage areas. The NHSC provides scholarship and loan 
forgiveness awards in exchange for service in qualifying ``health 
professions shortage areas'' (HPSAs). After 5 years of service, the 
majority of physicians are able to forgive their entire educational 
debt.
    Similarly, the VA's Education Debt Reduction Program (EDRP) 
provides newly appointed VA health care professionals with educational 
loan repayment awards. However, the EDRP is limited to $49,000 spread 
out over 5 years of service. As the average medical education 
indebtedness has climbed to over $140,000 in 2007, the limited EDRP 
awards fail to provide an adequate incentive for most physicians.
    The AAMC has had initial discussions with Senator Dick Durbin's 
office regarding the ``Veterans Health Care Quality Improvement Act of 
2007'' (S. 2377), which has been referred to the Senate Committee on 
Veterans Affairs for consideration. The AAMC is strongly supportive of 
the bill's proposed increases for VA physician educational loan 
repayment in exchange for at least 3 years of service in ``hard-to-fill 
positions,'' as determined by the VA. Under this program, VA physicians 
would be eligible for up to $30,000 in loan forgiveness per year until 
their medical education debt had been repaid.
                         academic affiliations
    The affiliations between VA medical centers and the Nation's 
medical schools have provided a critical link that brings expert 
clinicians and researchers to the VA health system. The affiliations 
began shortly after World War II when the VA faced the challenge of an 
unprecedented number of veterans needing medical care and a shortage of 
qualified VA physicians to provide these services. As stated in seminal 
VA Policy Memorandum No. 2 published in 1946, the affiliations allow VA 
to provide veterans ``a much higher standard of medical care than could 
be given [them] with a wholly full-time medical service.''
    Over six decades, these affiliations have proven to be mutually 
beneficial by affording each party access to resources that would 
otherwise be unavailable. It would be difficult for VA to deliver its 
high quality patient care without the physician faculty and medical 
residents who are available through these affiliations. In return, the 
medical schools gain access to invaluable undergraduate and graduate 
medical education opportunities through medical student rotations and 
residency positions at the VA hospitals. Faculty with joint VA 
appointments are also afforded opportunities for research funding that 
are restricted to individuals designated as VA employees.
    These faculty physicians represent the full spectrum of generalists 
and specialists required to provide high quality medical care to 
veterans, and, importantly, they include accomplished sub-specialists 
who would be very difficult and expensive, if not impossible, for the 
VA to obtain regularly and dependably in the absence of the 
affiliations. According to a 1996 VA OIG report, about 70 percent of VA 
physicians hold joint medical school faculty positions. These jointly 
appointed clinicians are typically attracted to the affiliated VA 
Medical Center both by the challenges of providing care to the veteran 
population and by the opportunity to conduct disease-related research 
under VA auspices.
    At present, 130 VA medical centers have affiliations with 107 of 
the 129 allopathic medical schools. Physician education represents half 
of the over 100,000 VA health professions trainees. In a 2007 Learners 
Perceptions Survey, the VA examined the impact of training at the VA on 
physician recruitment. Before training, 21 percent of medical students 
and 27 percent of medical residents indicated they were very or 
somewhat likely to consider VA employment after VA training. After 
training at the VA, these numbers grew to 57 percent of medical 
students and 49 percent of medical residents.
                     va graduate medical education
    Today, the VA manages the largest graduate medical education (GME) 
training program in the United States. The VA system accounts for 
approximately 9 percent of all GME positions in the country, supporting 
more than 2,000 ACGME-accredited programs and 9,000 full-time medical 
residency training positions. Each year approximately 34,000 medical 
residents (30 percent of U.S. residents) rotate through the VA and more 
than half the Nation's physicians receive some part of their medical 
training in VA hospitals.
    As our Nation faces a critical shortage of physicians, the VA has 
been the first to respond. The VA plans to increase its support for GME 
training, adding an additional 2,000 positions for residency training 
over 5 years, restoring VA-funded medical resident positions to 10 to 
11 percent of the total GME in the United States. The expansion began 
in July 2007 when the VA added 342 new positions. These training 
positions address the VA's critical needs and provide skilled health 
care professionals for the entire Nation. The additional residency 
positions also encourage innovation in education that will improve 
patient care, enable physicians in different disciplines to work 
together, and incorporate state-of-the-art models of clinical care--
including VA's renowned quality and patient safety programs and 
electronic medical record system. Phase 2 of the GME enhancement 
initiative has received applications requesting 411 new resident 
positions to be created in July 2008.
                    va-aamc deans liaison committee
    The smooth operation of VA's academic affiliations is crucial to 
preserving the health professions workforce needed to care for our 
Nation's veterans. The VA-AAMC Deans Liaison Committee meets regularly 
to maintain an open dialog between the VA and medical school affiliates 
and to provide advice on how to better manage their joint affiliations. 
The committee consists of medical school deans and VA officials, 
including the VA Chief Academic Affiliations Officer, the VA Chief 
Research and Development Officer, and three Veterans Integrated Service 
Network (VISN) directors. The committee's agendas usually cover a 
variety of issues raised by both parties and range from ensuring 
information technology security to the integrity of sole-source 
contracting directives.
    Recently, the VA-Deans Liaison Committee has reviewed the 
remarkable progress being made on several VA initiatives. These 
include:

    Establishment of the Blue-Ribbon Panel on Veterans Affairs Medical 
    School Affiliations--This panel will provide advice and 
    consultation on matters related to the VA's strategic planning 
    initiative to assure equitable, harmonious, and synergistic 
    academic affiliations. During the panel's deliberations, those 
    affiliations will be broadly assessed in light of changes in 
    medical education, research priorities, and the health care needs 
    of veterans.
    Survey of Medical School Affiliations--The AAMC has worked with VA 
    staff to develop criteria to evaluate the ``health'' of individual 
    affiliation relationships. The ``Affiliation Governance Survey'' 
    will survey the leadership at both the VA medical centers and their 
    affiliated schools of medicine on a range of topics including:

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

    Development of VA Handbook on VHA Chief of Staff Academic 
    Appointments--To prevent conflicts of interest or the appearance 
    thereof, the VA has determined that limits on receiving 
    remuneration from affiliated institutions are necessary for VHA 
    chiefs of staff and higher levels. While it is important to ensure 
    that remuneration agreements do not create bias in the actions of 
    VHA staff, prohibition of certain compensation from previous 
    academic appointments (e.g., honoraria, tuition waivers, and 
    contributions to retirement funds) could significantly hinder the 
    VA's ability to recruit staff from their academic affiliates. The 
    AAMC has worked with VA staff to develop a mutually acceptable 
    agreement that considers this balance.
    Piloting the VA physician time and attendance/hours bank--
    Monitoring physician time and attendance for the many medical 
    faculty holding joint appointments with VA medical centers has been 
    complicated and inefficient. The VHA has accepted the ``hours 
    bank'' concept to improve the tracking of part-time physician 
    attendance. Under the hours bank, participating physicians will be 
    paid a level amount over a time period agreed to in a signed 
    Memorandum of Service Level Expectations (MSLE). This agreement 
    will allow the supervisor and participating physician to negotiate 
    and develop a schedule for the upcoming pay period. A subsidiary 
    record will track the number of hours actually worked, and a 
    reconciliation will be performed at the end of the MLSE period to 
    adjust for any discrepancies. A pilot for this program has been 
    successfully completed and plans for nationwide implementation are 
    underway.

    The VA has consistently recognized that there is always room for 
improvement. As such, the AAMC looks forward to working on other items 
of concern as the VA continues to evaluate its affiliation policies and 
processes. As medical care shifts to a more satellite-based outpatient 
approach, graduate medical education needs to follow suit. This strong 
shift to ambulatory care at multiple sites requires a similar change in 
the locus of medical training. A dispersion of patients to multiple 
sites of care makes more difficult the volume of patient contact that 
is crucial to medical training. Similarly, faculty diffusion to 
multiple sites also makes more difficult the development of a culture 
of education and training. This is not exclusively a VA problem and all 
of our Nation's medical schools and teaching hospitals are working to 
cope with this shift.
    Another concern at both VA and non-VA teaching hospitals is the 
growing salary discrepancy between more specialized fields of medicine 
and the other disciplines. With the ``Department of Veterans Affairs 
Health Care Personnel Enhancement Act of 2003'' (Pub. L. 108-445, 
dubbed the ``VA-Pay bill''), the VA made significant strides beyond its 
private-hospital counterparts. However, this discrepancy continues to 
be an issue of concern. Once again, this is not exclusively a VA 
problem, but one faced by all medical schools and teaching hospitals.
               va medical and prosthetic research program
    To accomplish its aforementioned mission, VHA acknowledges that it 
needs to provide ``excellence in research,'' and must be an 
organization characterized as an ``employer of choice.'' The VA Medical 
and Prosthetic Research program is one of the Nation's premier research 
endeavors and attracts high-caliber clinicians to deliver care and 
conduct research in VA health care facilities. The VA research program 
is exclusively intramural; that is, only VA employees holding at least 
a five-eighths salaried appointment are eligible to receive VA awards. 
Unlike other Federal research agencies, VA does not make grants to any 
non-VA entities. As such, the program offers a dedicated funding source 
to attract and retain high-quality physicians and clinical 
investigators to the VA health care system.
    VA currently supports 5,143 researchers, of which nearly 83 percent 
are practicing physicians who provide direct patient care to veteran 
patients. As a result, the VHA has a unique ability to translate 
progress in medical science directly to improvements in clinical care.
    The VA Research Career Development Program attracts, develops, and 
retains talented VA clinician scientists who become leaders in both 
research and VA health care. For VA clinical investigators, the awards 
(normally 3-5 years) provide protected time for young investigators to 
develop their research careers. Awardees are expected to devote 75 
percent time to research as well as to apply for additional VA Merit-
Reviewed funding and non-VA research support. The remainder of their 
time is devoted to non-research activities such as VA clinical care or 
teaching. The program is designed to attract, develop, and retain 
talented VA researchers in areas of particular importance to VA. The 
Office of Research and Development supports approximately 458 awardees, 
at a cost of $55 million in fiscal year 2006, in all areas of medical 
research including basic science, clinical medicine, health services 
and rehabilitation research. The VA retains approximately 56 percent of 
participants as VA principal investigators. This research program, as 
well as the opportunity to teach, is a major factor in the ability of 
VA to attract first class physician talent.
    Since 2005, inadequate funding for VA research has forced the 
Department to cap many VA merit-review awards at a mere $125,000 
annually. The current cap fails to keep pace with biomedical inflation 
and VA's commitment to scientific innovation. The cap--which is 
significantly lower than the average award at comparable Federal 
research programs--is a tradeoff that VA leadership has had to make to 
continue funding the same number of grants it has historically 
supported. To compete with its private counterparts, funding for VA 
research must be steady and sustainable while allowing for innovative 
scientific growth to address critical emerging needs. For fiscal year 
2009, the AAMC recommends an appropriation of $555 million for the VA 
Medical and Prosthetic Research program.
             earmarks and designation of va research funds
    The AAMC opposes earmarks because they jeopardize the strengths of 
the VA Research program. VA has well-established and highly refined 
policies and procedures for peer review and national management of the 
entire VA research portfolio. Peer review of proposals ensures that 
VA's limited resources support the most meritorious research. 
Additionally, centralized VA administration provides coordination of 
VA's national research priorities, aids in moving new discoveries into 
clinical practice, and instills confidence in overall oversight of VA 
research, including human subject protections, while preventing costly 
duplication of effort and infrastructure.
    VA research encompasses a wide range of types of research. 
Designated amounts for specific areas of research compromise VA's 
ability to fund ongoing programs in other areas and force VA to delay 
or even cancel plans for new initiatives. While Congress certainly 
should provide direction to assist VA in setting its research 
priorities, earmarked funding exacerbates resource allocation problems. 
AAMC urges the Committee to continue preserving the integrity of the VA 
research program as an intramural program firmly grounded in scientific 
peer review. These are principles under which it has functioned so 
successfully and with such positive benefits to veterans and the Nation 
since its inception.
                       va research infrastructure
    State-of-the-art research requires state-of-the-art technology, 
equipment, and facilities. Such an environment promotes excellence in 
teaching and patient care as well as research. It also helps VA recruit 
and retain the best and brightest clinician scientists. In recent 
years, funding for the VA medical and prosthetics research program has 
failed to provide the resources needed to maintain, upgrade, and 
replace aging research facilities. Many VA facilities have run out of 
adequate research space. Ventilation, electrical supply, and plumbing 
appear frequently on lists of needed upgrades along with space 
reconfiguration. Under the current system, research must compete with 
other facility needs for basic infrastructure and physical plant 
support that are funded through the minor construction appropriation.
    To ensure that funding is adequate to meet both immediate and long 
term needs, the AAMC recommends an annual appropriation of $45 million 
in the VA's minor construction budget dedicated to renovating existing 
research facilities and additional major construction funding 
sufficient to replace at least one outdated facility per year to 
address this critical shortage of research space.
    Mr. Chairman and Members of the Committee, thank you for the 
opportunity to testify on this important issue. I hope my testimony 
today has demonstrated that the recruitment and retention of an 
adequate physician workforce is central to the success of VA's mission. 
The extraordinary partnership between the VA and its medical school 
affiliates, coupled with the excellence of the VA Medical and 
Prosthetics Research program, allows VA to attract the Nation's best 
physicians. Over the last 60 years, we have made great strides toward 
preserving the success of our affiliations. With the hard work of VA-
AAMC Deans Liaison Committee and the VA's Blue Ribbon Panel on Medical 
School Affiliations, I am confident that this success will continue.
                                 ______
                                 
Response to Written Questions Submitted by Hon. Patty Murray to John A. 
  McDonald, M.D., Ph.D., Vice President for Health Sciences and Dean, 
University of Nevada School of Medicine on Behalf of the Association of 
  American Medical Colleges, Veterans Affairs-Deans Liaison Committee
    Dear Senator Murray: Thank you for your inquiry regarding my 
testimony before the Senate Committee on Veterans' Affairs. Here are my 
responses.
                       incentives for recruitment
    Question 1. Dr. McDonald, I know that many questions have been 
discussed to deal with the VHA's workforce issues. Things such as 
signing bonuses, loan repayment, relocation expenses, and retention 
bonuses for those already employed.
    What are some of the other things that we can do to attract people 
to the VHA, particularly with regard to rural areas?
    Response. Several possible strategies are worth considering, 
including:

     Providing medical student scholarships with forgiveness 
for service clauses, emphasizing students from rural areas. Our own 
students who come from rural Nevada are more comfortable there, and 
more likely to relocate to rural areas upon completion of training.
     Create robust telemedicine links between rural practices 
and VA medical centers, to create a more supportive virtual environment 
for the solo or small group clinic.
     Set up a formal mentorship/partnership between rural 
providers and VA facilities the rural provider will be referring 
patients to.
     Work with the AAMC, ACGME and schools of medicine to 
encourage residency training in VA rural sites as part of their 
outpatient experience. As I noted in my testimony, exposure to the VA 
medical environment is key in altering perceptions of caregivers.
                            va research cuts
    Question 2. Dr. McDonald, in your testimony you mentioned that the 
VA Medical and Prosthetic Research program ``attracts high-caliber 
clinicians to deliver care and conduct research in VA health care 
facilities.'' As you know, the President cut funding for this critical 
program in his fiscal year 2009 budget request.
    Can you discuss in more detail what budget cuts to the VA's 
research budget does to the morale of VA's current workforce and how it 
impacts the department's ability to recruit high quality health care 
professionals?
    Response. My experience includes serving as chief of medicine in a 
VA facility, NIH funded investigator within the VA system, brief tenure 
as ACOS for Research and Development, and meetings with central VA 
administration. Based on this and discussions with fellow deans of 
medicine, I believe that the diminishing VA research budget, combined 
with aging and inadequate research facilities at many stations, has a 
very deleterious effect upon morale, recruitment and retention. 
Historically, the VA has been seen as an environment fostering the 
development of young physician investigators and Ph.D. scientists. It 
was this atmosphere of inquiry and scholarship that attracted and kept 
the best and brightest investigators and physicians within the VA. Now, 
more than ever, the VA and those it serves will benefit from the 
development and application of new diagnostic and therapeutic 
modalities, driven by these highly motivated individuals.
                        dod and va collaboration
    Question 3. Over the past couple of years, there has been a lot of 
attention focused on the seamless transition between the VA and the DOD 
when it comes to information sharing.
    Thinking along those lines, is there any way that the VHA and the 
DOD could pool together and share some of their resources to fill in 
some of the gaps in clinical coverage?
    Response. I have read the testimony presented for the Record by the 
Honorable Gordon England, Deputy Secretary of Defense, and the 
Honorable Gordon Mansfield, Deputy Secretary of Veterans Affairs before 
the Senate Committee on Armed Services on 13 February 2008. I have 
little to add to this report, as this specific topic is not one that I 
have experience in. It would appear as you point out that the move 
toward seamless sharing of medical information between DOD and VA is of 
particular benefit in facilitating the care of our wounded veterans. In 
addition, where possible, sharing physicians and other care givers 
between VA and DOD facilities could be used to extend services of 
scarce specialties or ameliorate local shortages in care givers.

    Chairman Akaka. Thank you very much, Dr. McDonald.
    Ms. O'Meara?

STATEMENT OF VALERIE O'MEARA, N.P., VA PUGET SOUND HEALTH CARE 
  SYSTEM, PROFESSIONAL VICE PRESIDENT, AMERICAN FEDERATION OF 
                GOVERNMENT EMPLOYEES LOCAL 3197

    Ms. O'Meara. Chairman Akaka, Mr. Rockefeller, and Ms. 
Murray, thank you for inviting me here to testify today. My 
name is Valerie O'Meara. I am from Seattle, Washington. I have 
worked as a primary care and emergency room nurse practitioner 
at the VA Puget Sound Health Care System for the past 13 years, 
which is my entire career as a nurse practitioner. I am also a 
union representative for the nurses, physicians, and other 
health care professionals at my facility.
    In 1993, the VA paid all of my tuition plus a stipend so I 
could attend the University of Pennsylvania to pursue my 
master's degree in nursing. In exchange, I had to work at the 
VA for 2 years. Obviously, I am still there, and why is that? 
It is because I love working with the veterans and taking care 
of the veterans. I get so much professional fulfillment from 
helping them and knowing that they really need the care that we 
provide. My own father is a Korean War veteran, and I can think 
of no better place to gain valuable experience than as a front-
line health care provider in the VA. We get exposed to such a 
wide range of medical issues. The VA is a terrific learning 
environment, as has been attested to, as well.
    At Puget Sound, we get to consult often with the medical 
faculty of the University of Washington. We have regular in-
services where we discuss ongoing research and how to apply it 
to our practice. The VA is a true culture of learning.
    So, why am I seeing so many nurses quit the VA after a few 
years, especially ward nurses or staff nurses? First, it is so 
difficult for them to get the type of pay they see nurses 
getting in private hospitals right nearby. Our nurses are not 
getting the flexible work schedules that are so popular in 
nursing today. And with too little staff to care for the 
veterans, the work environment becomes highly stressful and low 
on respect for the employees' ability to make good decisions.
    When it comes to getting educational help, not everyone has 
had as good of an experience as I had. For example, right now, 
I am battling a case for a nurse practitioner in which the VA 
is trying to withhold the remaining 3 years of her promised 
EDRP, or Education Debt Reduction Program payments, because 
they are insisting--incorrectly, we believe--that she 
transferred to an ineligible nursing position. Management is 
not only reading the law wrong, they are letting this drag on 
for over 3 years. Both the local and the central office EDRP 
managers, each are denying that they have authority for 
declaring that nurse ineligible.
    We fought another battle over educational assistance that 
shows how often management doesn't understand these programs. 
An R.N. at Puget Sound got her master's degree to become a 
nurse practitioner with the help from the NNEI Program, but 
human resources and nursing refused to hire her when an NP 
vacancy came up in the area she was already working in as a 
nurse, claiming she didn't have enough experience as a nurse 
practitioner. In the meantime, we had to fight just to get her 
enough hours to maintain her new license, because you do have 
to practice in the State of Washington to maintain your 
licensure. She finally quit out of frustration and got hired 
immediately as a nurse practitioner at the University of 
Washington.
    EDRP and other education assistance programs are clearly a 
win-win for management, veterans, and employees carrying large 
school debts. But, managers need to understand them and 
facilities need enough sense so applicants are no longer turned 
away, especially when funds are lying around unused in other VA 
facilities.
    We all know how expensive education is these days, and as a 
parent, I certainly worry about it. It would also be helpful to 
increase the amount of assistance that can be given to each 
employee in the program to keep up with today's tuition costs.
    A few years ago, we learned that the VA was no longer 
offering EDRP for continuous open announcements. Instead, 
rather, it was linking EDRP offers to specific position 
announcements and I think this is short-sighted. EDRP should be 
offered throughout nursing and throughout other professional 
jobs. I also think it could be a great retention tool if it 
were offered not to just new employees, because it would help 
hold on to the nurses the VA has already invested in.
    I also don't understand why management is so resistant to 
conducting nurse locality pay surveys to keep us competitive--
and we have to stay competitive. In Seattle, the private sector 
lures our nurses away with huge pay increases all the time. 
When management does these surveys, we, as employees and union, 
are kept in the dark. They don't tell us when they conduct 
third-party surveys at my facility, for example; and when we 
tried to access the survey data--data that we need to be sure 
that our pay is being correctly set--we are turned down and 
told we can't challenge it through the grievance process.
    We recently had to go through a long and difficult process 
to get more pay for advanced practice nurses. First, we asked 
for a one-time retention pay increase from our nurse executive. 
And the reason we did that is because she had declared us 
officially ``difficult to recruit and retain'' about 6 months 
prior. She insisted on tying the retention bonus or pay to a 
performance standard, even though that is not what the law 
says. We submitted a petition with approximately 20 signatures 
of advance practice nurses, and only after the new director had 
recently arrived, he saw the petition and that is when we 
learned that, in fact, a locality pay survey had recently been 
done. He looked at it again and decided to give us a raise, and 
we do want to give him kudos for that. He acted very quickly 
and we got a substantial raise.
    The Locality Pay System definitely needs to be more 
transparent and conducted with a better understanding of the 
survey process. so nurses don't have to go through such 
frustration and delays.
    I am fortunate that the VA lets me work part-time so I can 
spend more time with my 4- and 6-year-old boys. But I only 
learned recently, after the fact, that there is a real cost to 
being a part-time nurse at the VA. I worked full-time for 
approximately 5 years before switching to part-time, and as a 
full-time nurse, I went through my two-year probationary period 
and became a permanent employee with grievance rights, 
reduction-in-force rights, and other appeal rights. No one ever 
explained to me that I would lose all of these rights and 
essentially had become an ``employee at will'' when I became 
part-time.
    And parents are not the only ones who may need to work 
part-time. Since I started at Puget Sound, the nursing 
workforce has gotten noticeably older. There are nurses who 
have worked at the VA for a very long time who want to switch 
to part-time because, out of many reasons, one is that they are 
caregivers for their elderly parents or they need to reduce the 
stress of this very demanding job.
    It seems only fair that full-time nurses become permanent 
employees with appeal rights and job security after 2 years, 
that part-timers should earn the same rights when they work the 
equivalent of 2 years. And for nurses like me who already went 
through a 2-year probationary period, we should not have to go 
through it again just because we now fall under a different 
section of the law. One thing is certain. I am going to make 
top priority to educate our nurses about the tradeoffs of part-
time employment.
    I want to close by expressing my hope that we can go back 
to the labor-management partnerships that used to be in place 
at the VA, to work together to improve patient care and working 
conditions. Nurses at Puget Sound who are part of these 
partnerships tell me how great it was to have their opinions 
valued and to feel like they had an equal voice in making VA 
health care even better for the veterans. Isn't it easier to 
work together than to be at odds, after all?
    Thank you again for the great honor of testifying before 
this Committee.
    [The prepared statement of Ms. O'Meara follows:]
    Prepared Statement of Valerie O'Meara, N.P., Professional Vice 
President, AFGE Local 3197, VA Puget Sound Health Care System, Seattle, 
 Washington, on Behalf of American Federation of Government Employees, 
                                AFL-CIO
    Dear Chairman and Members of the Committee: On behalf of the 
American Federation of Government Employees (AFGE), I thank you for the 
opportunity to testify regarding recruitment and retention of 
Department of Veterans' Affairs (VA) health care professionals.
    Throughout my thirteen-year career as a Nurse Practitioner (NP), I 
have worked at the VA Puget Sound Health care System in Seattle, 
Washington. As the Professional Vice President of AFGE Local 3197 at 
Puget Sound, I am also in regular communication with other nurses and 
health care professionals at my facility. Through my participation in 
the VISN 20 Advanced Practice Nurse (APN) Advisory Group to the Office 
of Nursing Service and AFGE National VA Council discussion forums, I 
also hear a great deal about what health professionals at other 
facilities are experiencing.
    We feel as if we have to fight harder each year for the pay and 
working conditions that we should be entitled to by law. The VA is 
losing nurses to private sector jobs where the pay is more competitive, 
shifts are more flexible and their input into hospital matters are more 
valued. In my facility, I see many RNs and NPs leave in frustration 
after only a few years with the VA. This turnover is very expensive. As 
I recently pointed out to management in an effort to secure APN 
retention pay, nursing research shows that the replacement cost of a 
nurse in an acute care facility is at least twice that nurse's regular 
salary. By the VA's own estimates, it costs $100,000 to bring on a new 
nurse.
    At the same time, our older nurses retire as soon as they can, and 
many go on to work in the private sector. Nationwide, nearly two-thirds 
of VA's registered nurses will be eligible to retire in 2010. Since I 
have gotten there, the average age of nurses at Puget Sound has 
increased noticeably.
    It is especially frustrating for us to see Congress take steps to 
address this impending crisis with good pay and scheduling laws, only 
to have VA management undermine Congress' intent through loopholes, 
delay, and inaction.
    Our facility is less short staffed than some others, but we have 
still seen an impact on veterans' care. Whenever our ICU is full, we 
cannot take ambulance calls and veterans must be diverted elsewhere. 
This seems to happen each winter, especially. As a result of huge 
backlogs for outpatient care in urology, podiatry, and other 
subspecialty clinics, patients with chronic illnesses such as diabetes 
are not getting monitored as frequently as they should. Puget Sound has 
massively increased its use of fee basis, non-VA providers to address 
these backlogs. Better recruitment and retention policies would be a 
preferable and less expensive alternative in the long run.
                           nurse locality pay
    Nurse locality pay is a big source of frustration for VA nurses. In 
my facility, we were facing a serious recruitment and retention problem 
for APNs. We asked for retention bonuses and the Chief Nurse did 
declare us ``hard to recruit.'' But instead of just giving us the 
bonuses, she wanted to tie our bonuses to our performance and require 
us to ``highly perform'' based on new criteria. We tried to explain to 
her and Human Resources what the law said and submitted a petition 
signed by almost 20 people. When the director arrived, he looked at a 
locality pay survey (LPS) that we did not even know existed, and 
decided to give us additional pay instead to address recruitment and 
retention.
    I believe that if management received more training on LPS, there 
were be fewer problems across the country. Locality pay should be 
provided based on local labor market conditions, and be paid according 
to consistent rules, not on how hard employees fight for it or whether 
a particular manager decides to pay it.
    I hear many stories from other facilities about delays in 
conducting surveys and management's unwillingness to share survey 
information. It is also very troubling that in many facilities, nurse 
managers receive their locality pay through separate, more favorable 
survey data.
    The 2000 law also requires the VA to report annually on turnover 
rates, vacancies, staffing problems, and survey information from each 
facility. I have never seen this data and would find it very valuable. 
Therefore, I urge the Committee to strengthen these reporting 
requirements.
Nurse Premium and Overtime Pay
    RNs have expressed frustration at the inconsistent application of 
premium pay (weekend pay and night shift differential pay) and overtime 
pay. At Puget Sound, management attempted to deny overtime pay for work 
above 8 hours because it involved charting, which management contended 
was not direct patient care. Here, too, it was only after the union 
contested this policy did they pay overtime according to the law. 
Perhaps additional training on these pay provisions would also be 
helpful.
    Another problem is that nurses working on a part-time schedule are 
not consistently receiving overtime pay for shifts longer than 8 hours 
when the shift spans two calendar days.
    More generally, we believe that the VA's premium and overtime pay 
policies must be competitive with those of other workplaces. We urge 
the Committee to take steps to ensure that premium pay is available to 
all RNs who perform services on weekends or off shifts, work overtime 
on a voluntary or mandatory basis, or work during on call duty, and 
that overtime rules are applied properly.
Other Needed Pay Adjustments
    CRNA Pay: Facilities around the country are finding it increasingly 
difficult to recruit CRNAs. To ensure that VA's CRNAs can receive 
locality pay increases needed to keep the VA competitive with local 
market conditions, AFGE recommends lifting the current statutory pay 
cap that prohibits any RN pay to exceed that of the facility's chief 
nurse.
    LPN Pay: Under current law (39 U.S.C. 7455), VA health care 
personnel who are not covered by specific pay legislation can receive 
special pay increases at the discretion of their directors to achieve 
competitive pay levels. This provision sets a cap on the size of this 
increase. Congress has exempted other professions (CRNAs, physical 
therapists, and pharmacists) from this in order to keep their pay 
competitive. LPNs are now facing similar problems receiving needed 
special pay. Therefore, we urge this Committee to add LPNs to the 
exempted group.
              i. competitive nurse work schedule policies
    In 2004, Congress provided VHA with two additional tools for 
recruitment and retention of RNs: alternative work schedules (AWS) and 
restrictions on mandatory overtime. As a result of delay and resistance 
by the VA at the national and local levels, both tools have failed to 
meet their potential for addressing VA nurse recruitment and retention 
problems.
    Currently, local directors have complete discretion as to whether 
to offer AWS In my facility. The AWS schedule (either three 12-hour 
days or 9 month schedules) are not offered, even though they are 
available to nurses at other Seattle hospitals. Other VA nurses around 
the country report the same problem. If we attempt to challenge this, 
management says AWS is a nongrievable patient care issue under 39 
U.S.C. 7422 (to be discussed.) It seems as if the law was never passed.
    AFGE urges this Committee to hold the VA more accountable for 
proper implementation of the AWS law. An important first step would be 
to require the VA to provide data to Congress comparing the prevalence 
of AWS in the VA as compared to private employers, by each local labor 
market, in order to determine whether and to what extent the VA needs 
to offer AWS to its nurses to remain a competitive nurse employer.
Restrictions on Mandatory Overtime
    We are fortunate at Puget Sound that voluntary nurse overtime meets 
the current need. However, I am aware of widespread problems in other 
facilities, where nurses are forced to work overtime on a frequent 
basis.
    Once again, Congress' attempt to make VA hospitals safer and lessen 
nurse burnout has been thwarted. The law permits the VA to require 
overtime in cases of emergency. AFGE filed a national grievance to 
require the VA apply a nationally uniform definition of emergency 
consistent with common usage even though nine States (including 
Washington) have passed such laws, VA successfully blocked our 
challenge to the policy on emergencies based on ``7422.'' As a result, 
facility directors continue to invoke the emergency exception when 
staffing shortages are the result of easily anticipated scheduling and 
hiring problems. AFGE urges the Committee to protect VA nurses and the 
safety of their patients by enacting a statutory, workable definition 
of emergency.
    AFGE also supports expansion of overtime protections to LPNs and 
Nursing Assistants.
    Finally, AFGE urges the Committee to strengthen the requirement in 
the overtime provision that VHA provide a report to Congress certifying 
that facilities have implemented nurse overtime policies. Reports 
issued to date appear to grant, without explanation, a large number of 
waivers to facilities that have not developed overtime policies.
                          ii. part-time nurses
    During my first 5 years at Puget Sound, I was full-time which meant 
I had job security in the event of a RIF and grievance and arbitration 
rights. When I switched to part-time to raise a family, I lost these 
rights--but no one made me aware of this at the time. I have seen the 
same thing happen to older nurses who have worked a decade or more for 
the VA who switch to part-time because of the stress of their job or to 
care for their aging parents. Now that I understand this two-tier 
system, it is a top priority for me as a union representative to 
educate our nurses about the tradeoffs of becoming part-time.
    Part-time RNs represent a valuable resource for the VA. They should 
be able to accrue the rights of permanent employees after they work the 
equivalent of 2 years, just like their full-time colleagues. This will 
be a valuable recruitment and retention tool for the VA. We urge the 
Committee to take action to address this inequity.
                       iii. educational programs
    The VA has excellent educational programs to use as recruitment and 
retention tools, including the Education Debt Reduction Program (EDRP) 
and National Nursing Education Initiative (NNEI). With adequate 
funding, better resource allocation, and more national direction, these 
programs could be even more effective. VA has a long tradition of 
``growing its own'', i.e., training employees in lower level positions 
to become registered nurses, and training RNs to become NPs.
    One of the problems we are seeing is that once the employee 
completes his or her training, the VA does not provide a suitable 
position. At Puget Sound, one of our RNs got assistance through the 
NNEI program to become an NP but management refused to hire her when an 
opening came up so she quit.
    Nurses at other facilities report problems with EDRP, a highly 
effective program that ties tuition loan repayment to a commitment to 
work at the VA. Applicants are being turned away at some facilities 
because EDRP funds have been exhausted, while EDRP funds in other 
facilities remain unused. In addition, the EDRP grant amounts need to 
be raised to better match current educational costs.
                      iv. nurses need to be heard
    I am proud that VA nurses have played such an essential role in the 
past in transforming its health care system into a world leader in 
health care quality and cost effectiveness.
    According to a January 2008 VA national RN satisfaction survey, for 
the past 2 years, ``Participation in Hospital Affairs'' was one of two 
areas (along with staffing) where RNs were the least satisfied. Yet, VA 
increasingly deprives front line nurses of meaningful opportunities for 
input into groups shaping policies on key issues such as patient safety 
and qualification standards. This hurts the veteran and the taxpayer as 
well.
    The VA keeps saying that magnet status is its most effective nurse 
recruitment and retention tool because it is said to offer nurses a 
voice in organizational decisionmaking. I hear reports from nurses in a 
number of facilities that patient care dollars and substantial staff 
time are being diverted to the process of preparing magnet applications 
and paying large certification fees.
    I find this very troubling and wasteful. VA has a long and 
successful track record in soliciting and using input from front-line 
nurses. The Department simply needs to return to a more collaborative 
approach and bring the nurses back into policy setting groups where 
they were once welcome, not use an expensive third party to hear from 
its nurses.
           v. recruitment and retention challenges in other 
                       va health care professions
    AFGE also urges the Committee to examine obstacles to VA's ability 
to recruit and retain physicians and other professionals. In a health 
care system of this magnitude that encompasses three different 
personnel systems (Title 38, Title 5, and Hybrid Title 38) and hundreds 
of local labor markets, one size will surely not fit all, but swift 
action is needed nonetheless.
Physicians
    VA physicians are facing great pressures to meet current patient 
demand without additional resources. In my facility, management wants 
to require physicians who take sick leave or vacation leave to make up 
the clinics they canceled, either on the weekends, evenings or during 
their administrative days that they need for other duties. If there 
were enough physicians in the VA workforce, others could cover when 
someone takes leave he or she has earned and needs.
    At Puget Sound, we just lost our ER Director who was growing more 
and more frustrated at management for refusing to provide extra staff. 
Instead, ER doctors are required to work longer shifts. The ER has to 
draw from other pools on an ad hoc basis to find physicians to fill the 
gap. Clearly, a longer range staffing plan would be preferable.
    Here too, the VA is undermining a valuable retention tool: the 2004 
physician pay law (Pub. L. 108-445). Reduced reliance on contract 
physician services was at the top of Congress' agenda when this 
legislation. Based on our members' very mixed experiences with market 
pay and performance pay awarded under the new law, we are very doubtful 
that Congressional intent has been well served to date.
    Unfortunately, the VA has not been forthcoming with its own data on 
recruitment, retention, and contract care. Although the pay bill has 
been in effect for 27 months, we have still not seen the 18 month 
report that Congress required the VA to provide. We believe veterans 
and the taxpayers deserve to see the evidence of whether contract care 
is the best solution to current VA physician shortages. More 
transparency in the pay process is greatly needed. In the market pay 
process that was first conducted 2 years ago, management excluded 
employee representatives from national groups that set pay ranges and 
selected survey. Front line practitioners were largely excluded at the 
local level from compensation panels setting individual pay, despite 
requirements in the law to include them. AFGE's own attempts to obtain 
information through the Freedom of Information Act were denied.
    Annual physician performance pay awards under this law have been 
inconsistent and unjustifiably lower than the maximum amounts set by 
Congress. At many facilities, management has imposed improper 
performance criteria that determine bonuses based on factors beyond the 
practitioner's control, such as missed appointments. In very rare 
instances have front line physicians been allowed to have input in the 
selection of these critical criteria.
    Unreasonable panel sizes are also causing severe morale problems 
among VA physicians, particularly in primary care and psychiatry. Many 
facilities keep raising their panel sizes, while others have simply 
lifted the ceiling altogether! As a result, practitioners do not have 
adequate time to assess the medical needs of new patients (e.g., no 
additional time is allowed for a first time exam of veterans with 
Traumatic Brain Injury) or enough patient openings to schedule needed 
follow up for veterans with chronic illnesses that require frequent 
monitoring. Management is also requiring them to work more weekend and 
evening hours without compensation to meet growing demand.
Other VA Health Care Professionals
    AFGE members report significant recruitment retention problems in 
other VA professions due to pay policies and other factors. For 
example:
    Physician Assistants: Like physicians, physician assistants (PAs) 
are also trying to deliver care in the face of unreasonable panel 
sizes. In addition, PAs lack an effective voice for their profession at 
the facility and national levels because the PA Advisor is only a part-
time position. AFGE supports pending House legislation (H.R. 2790) to 
establish a full-time PA Advisor. AFGE also urges legislative action to 
more closely align PA pay and benefits, including professional 
education assistance, with the private sector.
    Podiatrists: The demand for podiatry services is rising among 
elderly veterans with chronic illnesses and injured OEF/OIF veterans. 
Unfortunately, the VA's compensation package for podiatrists has been 
largely unchanged since 1976. As a result, the pay gap between the VA 
and private sector is widening, causing severe recruitment and 
retention problems.
    Psychologists and the Hybrid Boarding Process: As part of the 
``hybrid Title 38'' group of VA health care professionals, 
psychologists are required to go through a one-time boarding process to 
secure hybrid status and obtain promotions. Delays in the boarding 
process have been especially long and demoralizing: some psychologists 
have still not received their promotions 2 years after issuance of the 
board's recommendation. At a time when the VA is significantly 
increasing its mental health capacity, it is especially important that 
oversight from Congress and VA Central Office is increased to ensure 
that local facilities are carrying out the hybrid boarding process 
properly. More generally, AFGE is concerned about widespread delays in 
the hybrid boarding process that in some cases, are greater than hiring 
under Title 5. As a result, applicants awaiting credentialing and 
salary offers end up leaving for other positions because of long 
delays.
               vi. other recruitment and retention issues
    FERS Sick Leave: Currently, most Federal employees covered by the 
FERS retirement system cannot apply unused sick leave toward 
retirement, while their counterparts under the older CSRS system can. 
Congress carved out an exception under Title 38 for RNs several years 
ago. We urge that this benefit be extended to all VHA personnel as an 
added incentive for staying with the VA.
    Disincentives in the Current Funding Process: Recruitment and 
retention strategies depend on a workable funding process. So long as 
VA health care relies on discretionary dollars, the system will suffer 
from unpredictable and inadequate funding. In turn, facility directors 
will continue to be rewarded for keeping a lid on their spending 
through fewer pay increases, promotions, and less hiring.
    Title 38 Collective Bargaining Rights: As noted, VA's health care 
professionals are unable to challenge workplace policies on pay, 
scheduling, and other policies that hurt recruitment and retention, 
even when these policies are directly inconsistent with Congressional 
intent. Management asserts ``nongrievability'' under 38 USC 7422 in 
more and more instances. We greatly appreciate the important step that 
Senator Rockefeller and cosponsors Senators Webb, Brown, and Mikulski 
have taken by introducing S. 2824 to restore these critical rights.

    Thank you.
                                 ______
                                 
  Response to Written Questions Submitted by Hon. Daniel K. Akaka to 
Valerie O'Meara, N.P., VA Puget Sound Health Care System, Professional 
 Vice President, American Federation of Government Employees Local 3197
    Question 1. How effective is the locality pay system at your 
facility? Does your facility employ temporary health workers, 
particularly in the area of nursing?
    Response. The locality pay system could be improved at our 
facility. There is no transparency so it is impossible for me to state 
how effective it is. The most disturbing example of this occurred in 
the summer of 2007. Several of my Nurse Practitioner (NP) colleagues 
had commented to me that they felt they were not being competitively 
paid. In response, as the unit professional vice president, I drafted a 
memo to this effect to management that was signed by many of the NP 
staff. At this time the facility had a relatively new Director. Within 
approximately 2 weeks the Chief Nurse Executive and the Director met 
with the NPs and told them they had decided to take another look at a 
recent salary survey and in doing so had decided that an approximately 
13% salary raise was in order. Staff believed this confirmed that 
salary survey data was only acted upon via staff complaints and has led 
to mistrust of the locality pay system.
    My facility does employ temporary health workers. For example, 
there is only one staff emergency room physician. All the rest are fee 
basis or locum tenens. There are temporary nursing staff throughout the 
hospital.

    Question 2. Multiple alternative work schedules are available at 
facilities around the country, from condensed work weeks to intensive 9 
month schedules. How prevalent is use of the various alternative work 
schedules at your facility, and how could VA make better use of these 
schedules while maintaining quality of care for veterans?
    Response. The use of alternate work schedules is concentrated in 
the areas of intensive care and emergency room, where compressed 
schedules are used. However, there is no use of the schedules 
authorized by Public Law 108-445. One reason given by Management why 
these alternate work schedules are not used is that there is no patch 
in the pay system to allow them. The other reason that the alternate 
schedules cannot be used is because there are not enough nursing staff 
overall to fill the staffing need created by the schedules. The reason 
given for not enough staff is that nurses are not applying for the 
jobs. VA needs to create an attractive work environment to compete for 
nursing personnel, which may mean spending a little more money.

    Question 3. What role have VA education incentive programs played 
in your careers, and how do you think these programs could be improved 
to encourage further education and improve recruitment and retention?
    Response. VA education incentive programs have been very popular at 
my medical center. I am a good example. I received a Health 
Professional Scholarship which paid for my Master's Degree in Nursing 
that included tuition, books, and a stipend.
    The program required a 2-year work commitment and I have been with 
VA for 14 years. The Health Professional Scholarship program should be 
re-instated. It was a very simple process, with tuition paid directly 
to the school. This is a powerful incentive to recruitment and 
retention. There also needs to be a guarantee that the participant will 
be offered an appropriate assignment upon graduation that is the 
responsibility of management rather than the participant. One problem 
currently is that Nurse Practitioners are graduated but then not 
offered an assignment as a NP, so are forced to leave VA in order to be 
able to maintain their state licensure and board certification. This 
defeats the purpose of the programs.

    Chairman Akaka. Thank you, Ms. O'Meara.
    Dr. Phelps?

 STATEMENT OF RANDY PHELPS, PH.D., DEPUTY EXECUTIVE DIRECTOR, 
    AMERICAN PSYCHOLOGICAL ASSOCIATION PRACTICE DIRECTORATE

    Mr. Phelps. Thank you, Mr. Chairman. Chairman Akaka, 
Senator Murray, and Senator Rockefeller, I am Randy Phelps, 
Deputy Executive Director for Professional Practice at the 
American Psychological Association. We are the largest 
association of psychologists, with approximately 90,000 
doctoral members and another 50,000 graduate student members in 
the pipeline to become psychologists, 75 percent of whom will 
become practitioners and a great number of whom we hope will 
serve this Nation's veterans. I am also a licensed clinical 
psychologist and former practitioner, but for the past 15 
years, on APA's executive staff. I have also served as APA's 
liaison to professional psychology in the Department of 
Veterans Affairs.
    We at APA appreciate the opportunity to testify on making 
VA the workplace of choice for psychologists. I should note, 
unlike some of the other testimony today, bring to your 
attention that VA is already the workplace of choice for many 
psychologists. There are about 2,400 psychologists in the 
system currently and, in fact, VA is the single largest 
employer of psychologists in the Nation. We at APA applaud VA's 
recent and very aggressive attempts, successful attempts, to 
recruit new psychologists, but we have many concerns, less so 
on the recruitment side and more so on the retention side, and 
I will skip most of this oral statement in the interest of time 
and focus in on those retention issues.
    With regard to the current staffing pattern, however, this 
is a very recent development. It was only until about 2006, 
mid-2006 that VA began hiring additional psychologists as a 
result of influx and needs, mental health needs and TBI needs 
and so forth due to the War on Terror. In 2006, we finally 
achieved the psychology, doctoral psychology staffing levels 
that we had in 1995, so it was on the decline. Again, most 
recently, VA has been very aggressive to bring new 
psychologists into the system.
    You should be aware that the vast majority of those new 
psychologists hired, and new FTEs hired, in the last year and 
one-half are functioning as GS-11 and 13 levels. With regard to 
leadership of psychology across the system nationally, we are 
still at essentially the 1995 levels in GS-14s. There are 
approximately 130 GS-14s in the Nation, psychologists; and only 
approximately 50 GS-15 leaders nationally currently, which is 
actually below the level in 1995.
    We think that VA's success in recruiting new psychologists 
has to do in many cases with the outstanding efforts to bring 
its own trainees into the system, and as you have heard, VA has 
increased the psychology training slots. Seventy-five percent 
of all new psychologist hires in the system have been prior VA 
trainees. So, we applaud those efforts.
    With regard to retention, however, the VA needs to not only 
recruit new and young staffers for careers at VA, but to retain 
those existing staff who have many years, as we have heard with 
regard to other disciplines, of dedication to service to this 
Nation's veterans. Like the other staff in VA, psychologists 
are not drawn to the money. They are drawn to the work and to 
the honor in providing care for the heroes of this country.
    There are three basic issues that are covered in great 
detail in our extended remarks for the record with regard to 
processes that we feel are working against retention of 
psychologists. One is, there is a lack of uniform psychology 
leadership positions in the VA system. Senior psychologists--
20, 30 years' experience--range from, in some cases, chief 
psychologist designations to, in most others, lead 
psychologists, manager psychologists, and so forth.
    There is also inequitable access across the VHA system for 
psychologists to achieve the highest levels of leadership 
positions in the VA. The under secretary--two under secretaries 
now--have reaffirmed a VHA directive that states that it is 
important that the most qualified individuals be selected for 
leadership positions in mental health programs regardless of 
their professional discipline. That directive has had very 
little practical impact in terms of the appointment of highly-
qualified psychologists to VA senior leadership positions.
    Most recently, and of great concern to us currently at the 
VA is the Congress's and the VA's attempt to address 
recruitment and retention problems through the inclusion of an 
expansion of the Hybrid 38 program. It has led to very variable 
and chaotic processes across the system. Many, many 
psychologist leaders from facilities throughout the country 
report to us that in their facilities and in their Veterans 
Integrated Service Networks, that psychologists who have been 
qualified by the National Professional Standards Boards to 
advance to GS-14s and 15 levels, for example, and have been 
recommended to do so, have been stopped at the local level. 
There are also tremendous informational missteps and technical 
problems that have plagued the National Psychology Boarding 
process in this system.
    I will just give but two examples that are not in the 
written testimony--they just crossed my desk, literally, in the 
last 48 hours--of how problems affect not only the retention of 
senior psychologists and journey psychologists in the system, 
but also the new psychologists coming into the system.
    One regards a new hire. I just spoke with him this weekend 
at our board meeting. He happens to be a former--young but very 
bright star--State Psychological Association president and he 
happens to be a representative to APA's National Committee on 
Early Career Psychologists. He told me a story of being 
dismissed a few months ago in his probationary year after he 
was unable to effectively discharge what ended up being a dual 
leadership position thrust upon him in the medical center as 
the Local Recovery Coordinator, as was discussed earlier, and 
also in the role of Acting Supervisory Psychologist. This kind 
of thing has a very chilling effect on our young psychologists' 
interests.
    In another facility, a psychologist who was approved by the 
National Standards Boards as qualifying for a GS upgrade was 
denied locally her position as Psychology Program Manager in 
her facility, and as a result, she tendered her resignation on 
April 1.
    APA considers these problems the most serious obstacle 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 our psychologists come 
to believe that there is little possibility for advancement in 
the system regardless of the level or the complexity of their 
responsibilities, fewer VA psychologists will be willing to 
accept those positions of greater responsibility; and in 
addition, high-potential trainees whom the VA would like to 
attract will increasingly see VA as dead ends--the VA as a dead 
end for their careers--and will certainly be attracted to other 
career options that offer more potential for advancement 
outside the system.
    I thank you very much for the opportunity today.
    [The prepared statement of Mr. Phelps follows:]
 Prepared Statement of Randy Phelps, Ph.D., Deputy Executive Director 
     for Professional Practice, American Psychological Association
    Chairman Akaka and distinguished Members of the Committee, I am Dr. 
Randy Phelps, Deputy Director for Professional Practice of the American 
Psychological Association (``APA''), the largest association of 
psychologists, with more than 148,000 members and affiliates engaged in 
the study, research, and practice of psychology. The APA appreciates 
the opportunity of testifying before you today on behalf of our member 
psychologists who are dedicated to serving the very pressing needs of 
our country's veterans. VA's need for the health and mental health, 
primary care, research, and other, often unique, services that 
psychologists provide has perhaps never been greater.
                             growing needs
    Over 200,000 homeless veterans will be sleeping on America's 
streets tonight. Worse yet, Operation Iraqi Freedom (OIF) and Operation 
Enduring Freedom (OEF) veterans are becoming homeless faster than their 
predecessors. After Vietnam, it took 9 to 12 years for veterans' 
circumstances to deteriorate to the point of homelessness. Today, the 
high incidence of Post Traumatic Stress Disorder (PTSD) and Traumatic 
Brain Injury (TBI) will contribute to increased homelessness unless 
dramatic measures are taken to mitigate this trend. Other issues for 
servicemembers and their families are repeated deployment, National 
Guard and Reserve deployment, women in combat and the extended duration 
of the Global War on Terrorism (GWOT).
    More than one million servicemembers in the Active and Reserve 
components of the military have been deployed in OEF/OIF; more than 
449,000 of those have been deployed more than once. Of the troops 
returning from deployment, 31% of Marines, 38% of Soldiers, and 49% of 
National Guardsmen report psychological symptoms. This doesn't take 
into account those making multiple deployments or the psychological 
needs of their families.
    There were 686,306 OIF and OEF veterans who separated from active 
duty service between 2002 and December 2006 who were eligible for 
Department of Veterans Affairs (DVA) care; 229,015 (33%) of those 
accessed care at a DVA facility. Of those 229,015 veterans who accessed 
care since 2002, 83,889 (37%) received a diagnosis of or were evaluated 
for a mental disorder, including PTSD (39,243 or 17%), non-dependent 
abuse of drugs (33,099 or 14%), and depressive disorder (27,023 or 
12%).
            psychologists' roles within health care systems
    Psychologists are unique professionals in terms of their training 
and skill sets. No other mental health profession requires as high a 
degree of education and training in mental health as psychology. 
Accredited doctoral programs in clinical, counseling and other health 
services psychology involve a median of 7 years of training beyond an 
undergraduate degree. Psychologists are licensed, independent 
practitioners with specialized clinical and research skills.
    Psychologists provide a holistic approach to mental health care 
with their keen understanding of how the mind and the body interact. 
Our members include the specially trained neuropsychologists who 
understand those disorders of perception, memory, language, and 
behavior that result from brain injury, an essential skill in dealing 
with the new generation of veterans returning from theater in large 
numbers with Traumatic Brain Injuries (TBI).
    Psychologists' skills in program development, team building, 
research/outcome and program evaluation, and in assessment and 
treatment interventions equip psychologists to be leaders in planning 
and providing a coordinated service approach. This includes models and 
practices of care that encompass inpatient, partial hospitalization and 
outpatient services including Community Based Outpatient Clinics 
(CBOC), psychosocial rehabilitation programs, homeless programs, 
geriatric services in the community, residencies and the home.
    Psychologists initiate and evaluate innovative programs, such as 
tele-mental health services. They go beyond the provision of service to 
initiate, plan and evaluate the efficacy of such services and their 
clinical and cost benefits.
                  recruitment of psychologists in vha
    It is critical to note that VA is already the single largest 
employer of psychologists in the Nation, and has been for many years. 
However, VA continues to recognize the need to increase its psychology 
staffing numbers in response to ever-increasing needs for services to 
veterans. For example, the Veterans Health Administration's (VHA) 
provision of mental health services to veterans has skyrocketed from 
1996 to 2006, going from 565,529 veterans served to 934,925 and rising. 
In response, VHA has hired more than 800 new psychologists since 2005; 
thereby, increasing the number of GS-11 through 15 psychologists and 
surpassing its 1995 high of approximately 1,800 psychologists.
    The APA applauds VA for its tremendous and serious recent efforts 
to increase psychology staffing levels, such that there are now 
approximately 2,400 psychologists employed by VA nationwide across the 
GS-11 to GS-15 levels. However, that is a very recent accomplishment. 
It was not until 2006 that psychology staffing levels exceeded those of 
1995 levels. Moreover, the vast majority on new psychologist hires in 
VHA are younger, lesser experienced psychologists who have come into 
the system at the GS-13 level or below. In contrast, as of the end of 
2007, the number of GS-14s in the entire system nationally was 
essentially the same as it was in 1995, at approximately 130 GS-14 
psychologists. Of additional concern to the APA is that the number of 
GS-15 psychologists nationally as of the end of 2007 (approximately 50) 
was still considerably lower than the number of GS-15s in 1995.
    VA has also recognized and capitalized on the fact that the best 
source of recruiting new psychologists has been the Department's own 
training system. Over the past 2 years, approximately 75% 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
    Here is the dilemma: while the VA is employing more psychologists 
than ever, 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 are 
already institutionalized within the system. These psychologists are 
vital to service provision because of their professional expertise and 
knowledge of the system and its resources. However, there are several 
glaring obstacles to retention, covered in some detail below.
                  lack of uniform 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. Interdisciplinary management 
within mental health services can have advantages in terms of cross-
discipline coordination of care and clearer accountability at the 
individual program level. However, 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. For Psychology, this problem is 
further complicated by the fact that the lack of recognized psychology 
discipline leadership at many facilities translates into a significant 
lack of oversight, structure and support for the growing number of 
psychologists working in non-mental health areas such as primary care, 
geriatrics, and Home & Community Based Care (HBPC), among others.
    In 2002, the VA remedied this situation for Social Work with the 
appointment of a Social Work Executive at each facility that lacked an 
independent Social Work Service (VHA Directive 2002-029). The creation 
of the Social Work Executive position has been highly effective in 
ensuring the integrity of Social Work practice and training within an 
inter-disciplinary management structure. Since 2003 there have been 
efforts to create an analogous Psychologist Executive role. However, at 
present, Psychology remains the only major mental health discipline 
without an officially designated leader in every medical center. While 
the number of ``Chief Psychologists'' is now increasing, a far more 
prevalent position is the ``Lead Psychologist,'' a position which is 
all too frequently unrecognized at the level of additional pay for 
additional responsibilities.
             inequitable access to key leadership positions
    Nor are psychologists represented equitably in the all levels of 
leadership in the VA's health care 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.
               implementation problems in hybrid 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 Title 38 Hybrid is a combination of Title 
38 and Title 5 provisions for non-physician health care professionals 
at the VA.
    Historically, Title 38 was created to alleviate severe shortages of 
health care personnel, especially for physicians in VA, by reducing the 
bureaucratic red tape of the civil service recruiting and hiring system 
and the restrictive compensation practices inherent in Title 5.
    Psychologists remain the only health care providers requiring the 
doctorate who are not included in Title 38. The Title 38 Hybrid was 
created to provide a middle ground solution for health care 
professionals that needed some of the same 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 on 
the number of GS-14 and 15 psychologists is currently very mixed. Many 
Psychologist leaders from facilities throughout the country have 
reported that their facilities and Veterans Integrated Service Networks 
(VISN) 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. This leaves the psychologists in question 
with considerable leadership responsibilities, but with little or no 
recourse regarding their boarding status and consequent grade level.
    Informational missteps and technical problems have also plagued the 
national psychology boarding process. An unknown, but apparently 
significant, number of boarding packets have been adversely affected by 
incorrect information provided by local human resource (HR) officials 
regarding the required format and content of the packets. This has 
resulted in the submission of a number of packets that may have 
described GS-14 or above responsibilities, but that were unable to be 
boarded at that level due to packet content errors.
    Of particular concern are reports that a number of psychologists 
throughout the country were instructed by their facilities to only 
submit special achievements occurring during the previous 3 years, 
despite the fact that Psychology Boards were authorized to consider 
achievements throughout the psychologists' VA careers for the one-time 
Special Advancement for Achievement. This meant that significant and 
creditable achievements occurring earlier in the psychologists' VA 
careers would never have an opportunity to be considered for a Special 
Advancement for Achievement (SAA).
    On March 7, 2007, instructions were sent from the VA Central Office 
(VACO) to the field that eliminated the national cap on GS-14 
psychologists. This was a beneficial step that has removed one of the 
reasons often cited by local and VISN management for failure to approve 
justified grade increases to the GS-14 level.
    However, the same set of instructions tied the award of GS-15 
psychology positions to the facility's level of complexity. Per these 
instructions, only psychologists at complexity level 1A facilities are 
eligible for promotion to GS-15. Senior psychologist leaders at non-1A 
facilities, regardless of the scope and complexity of their actual 
duties and regardless of the question of whether they meet the VA's own 
qualification standards for GS-15 would be ineligible for promotion to 
that grade level. In addition, complexity 1A facilities without current 
GS-15 psychologists would need to petition VACO for an increase in 
their GS-15 ceiling should the boarding process recommend, and the 
facility management concur, in moving a psychologist manager to the GS-
15 level.
    These new field instructions will accelerate the already steep 
decline in the number of GS-15 level psychologists. They will also 
create equity problems in that psychologists from non-1a facilities who 
supervise many programs and individuals will be ineligible for a GS-15, 
whereas facility complexity 1a psychologists with more limited 
supervisory responsibility will be eligible for the grade as long as 
they meet the minimum GS-15 requirements of the VA's Qualification 
Standard.
    Part of the difficulty with these new instructions is that they 
treat psychologist promotion in a manner that is characteristic of 
Title 5. Dissimilar positions are compared against one another 
according to some overarching standard of complexity. Typically, in the 
case of psychologists, the comparison is made to the grade level of the 
Associate Director.
    As doctoral level Title 38 Hybrid clinicians, it would be more 
appropriate to treat the issue of psychologist promotion as being 
similar to the Title 38 process. In this approach, the full performance 
level (GS-13) is defined by the journeyperson clinical 
responsibilities. Additional administrative and program management 
responsibilities warrant higher grade levels, provided that these 
additional responsibilities meet established scope and complexity 
requirements for those levels. This is essentially the approach that 
was taken in the VA's own Qualification Standard for Psychology.
    The decline in the availability of upper grade level positions 
presents VA with a serious recruitment and retention issue. As 
psychologists come to believe that there is little possibility for 
advancement, regardless of the level or complexity of responsibilities, 
fewer high potential 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.
                                 ______
                                 
Response to Written Questions Submitted by Hon. Daniel K. Akaka to Dr. 
    Randy Phelps, Deputy Executive Director, American Psychological 
                    Association Practice Directorate
    Question 1. The number of veterans rolling into the VA mental 
health care system is significantly growing each year of the Global War 
on Terror. The VA system is already stretched with a need for trained 
mental health professionals to deal with the unique needs of the 
veteran population and their families. Additionally, veterans in rural 
areas remain underserved due to the lack of VA access in non-
metropolitan areas. The Committee is aware that the Department of 
Defense successfully conducted a demo project giving prescribing 
authority to psychologists. In your opinion, would giving VA 
psychologists the authority to prescribe psychotropic drugs ease the 
strain on the system; especially in rural areas?
    Response. APA continues to look for ways to extend services to 
veterans in rural areas where existing VA and DOD facilities are simply 
beyond the reach of patients. We continue to advocate for prescriptive 
authority for appropriately trained doctoral psychologists, 
particularly in those rural areas where providers are few and far 
between.
    For Americans living in rural areas, the problem of access to care 
is particularly acute. The Final Report of the President's New Freedom 
Commission on Mental Health states that the ``vast majority of all 
Americans living in underserved, rural, and remote areas also 
experience disparities in mental health services . . . . In rural and 
other geographically remote areas, many people with mental illnesses 
have inadequate access to care, limited availability of skilled care 
providers, lower family incomes, and greater social stigma for seeking 
mental health treatment than their urban counterparts'' which is 
compounded by ``the fact that rural Americans have lower family incomes 
and are less likely to have private health insurance benefits for 
mental health care than their urban counterparts.''
    VA data shows that 19% of the Nation lives in rural America, and 
that 44% of U.S. military recruits come from those rural areas. This 
disproportionate number of OEF/OIF rural veterans has created a crisis 
in which they do not have sufficient access to VA healthcare. Having 
psychologists ready to accept the challenge of serving these rural 
veterans, including through psychotherapy, prescribing or unprescribing 
medication as needed, carrying out medication management and compliance 
tasks, and any combination of these services, via telehealth or through 
placement in a Community-Based Outpatient Clinic or satellite clinic in 
a rural or remote area, would serve well our Nation's veterans from 
rural and frontier areas.
    With a focus on psychologist prescription privileges, the private 
healthcare sector and states are also grappling with how to ensure 
access to health and mental health services in rural areas. To address 
pressing mental health needs, 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, allow 
appropriately trained and certified psychologists 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) 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 its report on the 
PDP. Both reports repeatedly stressed how well the PDP psychologists 
had performed. According to the 1999 GAO report, ``an outside panel of 
psychiatrists and psychologists who evaluated each of the graduates 
rated the graduates' quality of care as good to excellent.'' The 1998 
ACNP review stated that ``they had performed safely and effectively as 
prescribing psychologists, and that no adverse outcomes had been 
associated with their performance.''
    Psychologists are highly trained mental health specialists, many of 
whom have acquired this additional post-doctoral training in 
psychopharmacology in order to collaborate with physicians about their 
patients' medications. With prescriptive authority, they can offer a 
holistic, integrative model of 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 PDP. 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.

    Question 2. In written testimony, APA discussed the challenges of 
recruiting psychologists in light of a growing national shortage. How 
can VA recruit more mental health providers to work in rural locations 
in particular? Could partnerships with community providers be 
effective, without compromising quality of care?
    Response. As the Committee is aware, the VA is not alone in the 
need to recruit psychologists and other practitioners to provide 
services in the rural areas of our country. Many private and public 
employers are working to ensure services in these areas as well. The 
issue of psychologist recruitment has its own unique aspect, since 
psychologists are far more numerous than psychiatrists and therefore 
available to provide services in rural areas, while at the same time, 
social workers, though relatively more numerous and available, simply 
do not have the training to deliver the range of psychotherapeutic and 
testing services that psychologists provide to patients.
    The testimony provided by various panelists during the hearing 
demonstrate that the VA is finding innovative ways to recruit health 
care professionals into VA service, including in rural areas. The APA 
would return to our testimony, however, in emphasizing the need to hire 
and promote psychologists beyond the GS-13 level, particularly through 
a more effective use of the Title 38 Hybrid process. Pay and promotion 
must be competitive for psychologists in the VA if the department hopes 
to be effective in recruiting and retaining psychologists for service 
in rural areas.
    Beyond the fundamental issue of pay and promotion, the APA strongly 
suggests that the VA look to its current authority to provide mental 
health services to veterans outside of the VA system. It is now clearly 
apparent that with the influx of returning OEF/OIF veterans on top of 
the current mental health needs of the aging veteran population, that 
the need for mental health services has reached a crisis situation. The 
recent RAND Corporation study is telling:

     300,000 returning U.S. troops are suffering symptoms of 
PTSD or depression but only about half are receiving care. We cannot 
emphasize strongly enough, the importance of treating these conditions 
early for effective treatment.
     320,000 returning troops have suffered possible TBI during 
deployment. Psychologists are key providers in treating TBI.
     18.5% of the more than 1.5 million deployed troops in the 
two war zones are suffering stress disorder and depression. 
Undoubtedly, many of these soldiers will need psychological care when 
they separate from service.

    As our answer to the first question indicates, a relatively large 
proportion of veterans are from rural areas, therefore the need for 
mental health services in rural areas is going to tremendously 
increase, considering the mental health needs indicated in the RAND 
study. The VA has authority to contract with non-VA facilities and 
individual providers, including community providers, for the provision 
of mental health services. Some of this authority is specific to the 
provision of mental health services in current statute, such as for the 
provision of readjustment counseling 
and related mental health services by a physician or psychologist (see 
38 U.S.C. Sec. 1712A(b)(1)).
    While we do not have sufficient knowledge or information on how the 
VA has used this contracting authority for fee-basis care to ensure 
adequate mental health services in rural areas in the past, we would 
assume that given the current situation, the VA should utilize its 
authority more expansively in this time of crisis. Therefore, the APA 
respectfully suggests that the Committee strongly urge the VA to use 
this authority now.
    The Committee could also approve S. 38, a bill that would establish 
a program for the provision of readjustment counseling and other mental 
health services for 
OEF/OIF veterans. The House already has passed a measure, the Veterans' 
Health Care Improvement Act, H.R. 2874, which has similar provisions. 
Certainly, enactment of S. 38 would help address the Committee's query 
concerning partnering with community providers for care, since the bill 
would promote these services through ``qualified entities,'' including 
community mental health providers. We would further suggest that the 
term ``qualified entity'' be made more clear so as to include 
psychologists and other mental health providers whether in facilities 
or in private or group practice.
    Beyond encouraging the VA to use its current authority to contract 
with psychologists for fee-basis care, the Committee should commend and 
encourage the VA to continue its efforts to recruit more psychologists 
into service and urge the VA to contract with psychologists to provide 
services within VA facilities as needed, particularly for VISNs with 
large rural populations. All of these initiatives should go a long way 
in addressing the tremendous need for mental health services for 
veterans at this time.

    Question 3. What effect do VA's hiring processes have on 
recruitment, and how do you believe it can be improved and accelerated 
while still ensuring quality care for veterans?
    Response. VA is already the single largest employer of 
psychologists in the Nation, and has been for many years. VA continues 
to acknowledge the need to increase its psychology staffing numbers in 
response to ever-increasing needs for services to veterans.
    VA has capitalized on the fact that the best source of recruiting 
new psychologists has been the Department's own training system. Over 
the past 2 years, approximately 75% 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 post-
doctoral fellowship positions, spending approximately $5 million to do 
so. This will bring the total psychology training positions to 
approximately 620 per year nationwide.
    VA has also recently made tremendous efforts to increase psychology 
staffing levels, so that there are now approximately 2,400 
psychologists employed by VA nationwide across the GS-11 to GS-15 
levels. However, that is a very recent accomplishment. It was not until 
2006 that psychology staffing levels exceeded those of 1995 levels. 
Moreover, the vast majority of new psychologist hires in VHA are 
younger, lesser experienced psychologists who have come into the system 
at the GS-13 level or below.
    In contrast, at the end of 2007, the number of GS-14s in the entire 
system nationally was essentially the same as it was in 1995, at 
approximately 130 GS-14 psychologists. Of additional concern to the APA 
is that the number of GS-15 psychologists nationally at the end of 2007 
(approximately 50) was still considerably lower than the number of GS-
15s in 1995.
    In 2007 a VA instruction lifted the cap on GS-14 psychologists. The 
numbers are slowly increasing, but not enough to keep up with the 
growing demand on the system. On the other hand, promotions of GS-15 
psychologists remain incredibly low with the cap remaining firmly in 
place. In fact, the same VA instruction that lifted the cap on GS-14's 
also tied the promotion to GS-15 for psychologists to the facility's 
level of complexity. In short, a psychologist must work at a level 1A 
facility to have a serious chance at promotion to GS-15.
    The new promotion process created as a result of the Title 38 
Hybrid legislation has been chaotically and unevenly implemented across 
facilities. There are common reports of medical centers sitting on 
promotion packages, denying promotion after the national board's review 
and approval, or misinformation regarding what is to be submitted as 
part of a board package resulting in the denial of a submitter's 
package.
    Also, there remains a lack of uniform psychology leadership 
positions in the VA. Psychology is the only major mental health 
discipline without an officially designated leader in every medical 
center. Such a position is critical for purposes of professional 
practice within a facility and as a representative of the facility 
without. In addition, psychologists are not represented equitably at 
all levels of leadership in the VA healthcare delivery system. There 
have been some attempts by the VA to address this but with little 
practical impact at this time.
    In sum, the VA has been making progress in its psychologist 
recruitment efforts, partly by taking advantage of recruitment from its 
own psychology training structure. Psychology staffing levels are 
improving but promotions to the GS-14 and 
GS-15 levels must be accelerated. Serious implementation problems with 
the Hybrid Title 38 system should be addressed, as well as the lack of 
uniform psychology leadership positions and the current inequitable 
access to key leadership positions within the VA in general that 
psychologists face.
                                 ______
                                 
 Response to Written Questions for the Record Submitted by Hon. Patty 
    Murray to Dr. Randy Phelps, Deputy Executive Director, American 
             Psychological Association Practice Directorate
    Question 1. Over the past couple of years, there has been a lot of 
attention focused on the seamless transition between the VA and the DOD 
when it comes to information sharing.
    Thinking along those lines, is there any way that the VHA and the 
DOD could pool together and share some of their resources to fill in 
some of the gaps in clinical coverage?
    Response. The APA greatly appreciates the Committee's active 
interest and work toward addressing mental health issues as they relate 
to efforts for a seamless transition between VA and DOD, particularly 
at a time when so many returning 
OEF/OIF soldiers are returning with PTSD, TBI, and many other mental 
health and substance use issues. We further appreciate that the VA and 
DOD have made concerted efforts to address mental health issues through 
the work of the Senior Oversight Committee, as reflected in the April 
23rd joint testimony before the Committee by The Honorable Gordon 
England, Deputy Secretary of Defense and The Honorable Gordon 
Mansfield, Deputy Secretary for Veterans Affairs.
    We believe that the Committee should continue to oversee and 
encourage the current DOD and VA transition activities with regard to 
mental health and substance use services. These activities and 
initiatives include: the improvement to the Disability Evaluation 
System, the DOD Center of Excellence for Psychological Health and 
Traumatic Brain Injury, and the widespread dissemination and 
implementation of standard clinical practice guidelines for PTSD and 
other serious mental and substance use disorders. In addition, the 
departments should be further encouraged in improving TBI screening and 
health information sharing, as well as collaborative efforts to address 
PTSD and PTSD research.
    In addition, the APA urges the Committee to encourage the DOD and 
VA to fully implement the Wounded Warrior title in the recently enacted 
National Defense Authorization Act, particularly those that relate to 
the mental health needs of returning soldiers. We share the belief with 
the Committee and the departments that these needs are extremely 
pressing at this time, and full and timely implementation is critical 
to ensure that services are fully available now.

    Chairman Akaka. Thank you, Dr. Phelps.
    Dr. Strauss?

  STATEMENT OF JENNIFER L. STRAUSS, PH.D., HEALTH SCIENTIST, 
CENTER FOR HEALTH SERVICES RESEARCH IN PRIMARY CARE, DURHAM VA 
    MEDICAL CENTER, AND ASSISTANT PROFESSOR, DEPARTMENT OF 
  PSYCHIATRY AND BEHAVIORAL SCIENCES, DUKE UNIVERSITY MEDICAL 
CENTER, ON BEHALF OF THE FRIENDS OF VA MEDICAL CARE AND HEALTH 
                            RESEARCH

    Ms. Strauss. Hello, Chairman Akaka, Ranking Member Burr, 
Members of the Committee. On behalf of the Friends of Medical 
Care and Health Research, I thank you very much for this 
opportunity to testify.
    I am a clinical psychologist and a health scientist at the 
Durham VA Medical Center and a recipient of a VA Research 
Career Development Award. The primary focus of my research is 
the treatment of Post Traumatic Stress Disorder in women 
survivors of military sexual trauma. Today, I have been asked 
to share my reasons for choosing a career as a VA clinician 
researcher and specifically how research opportunities impact 
the Department of Veterans Affairs's ability to recruit and 
retain clinicians.
    Let me say at the outset that I love my job. The 
opportunity to conduct research greatly enhances my job 
satisfaction and has played a large role in my decision to 
remain at VA.
    VA is not the only venue in which a clinician can conduct 
research, but understand that I have come of age professionally 
in the post-9/11 era. The opportunity to apply my clinical and 
research training in support of veterans traumatized by their 
war experiences continues to resonate very strongly with me.
    This war has presented numerous clinical challenges, and in 
many ways, we are still learning as we go. To make progress, VA 
must foster partnerships between research and clinical services 
and must recruit clinician investigators to guide these 
efforts.
    Towards this end, VA offers exceptional research and 
training opportunities for clinicians like me who are 
interested in research careers. Among these is the Research 
Career Development Program. This is a highly competitive 
mentored award that typically provides 3 to 5 years of 
structured research training. Clinicians who receive these 
awards are relieved of 75 percent of their clinical duties, 
allowing for dedicated time to focus on training and developing 
an individual program of research.
    Despite the many advantages VA offers, it is not 
necessarily easy to build a career as a clinician investigator 
at VA and I would like to highlight several ways in which I 
believe VA can improve recruitment and retention of clinicians 
such as me, who are interested in integrating research into 
their careers.
    To date, the VA has invested in 5 years of my research 
training. Yet what happens when my Career Development Award, 
and the dedicated research time it affords, expires in 2 years 
is an open question. Unlike clinicians at most academic medical 
centers, VA clinicians may not fund a portion of their salaries 
through research grant support. If a non-clinician VA 
researcher is awarded research funds, those funds can be used 
to pay salary for time devoted to the research project. But VA 
clinicians often perform research duties early in the morning 
or very late into the night after a long day of seeing 
patients.
    I recommend that VA consider a model that is more in line 
with what is available to clinician researchers working in 
other academic medical settings, namely to foster recruitment 
of the best care providers and to encourage clinicians to 
conduct research by ensuring dedicated research time.
    Current space constraints are an additional obstacle to the 
clinician researcher career path. Space is at such a premium at 
our facility that some of our researchers may soon be moving 
offsite. A geographic divide between research labs and clinics 
will do little to enhance the type of collaborations that I 
believe are essential to move VA research forward in a manner 
that will best inform the clinical care of veterans. Continued 
investment in the Durham research infrastructure and similar 
investments at other VA facilities are imperative.
    The last obstacle I want to mention is data security in the 
context of research. Absolutely, veterans' privacy and research 
data must be safeguarded. That is paramount. However, while I 
know it is not intentional, it has become extremely difficult 
to share data even among VA facilities, and collaborating with 
non-VA organizations can be even more problematic. I urge VA to 
ensure that its security policies guarantee the safety of data 
but still allow shared research to continue. With improvements 
in security technology, I hope the current situation will get 
better. But right now, managing research data in compliance 
with VA policies is a significant challenge.
    Serving veterans is what I do, and I am filled with pride 
by the opportunity to do so. That feeling is considerably 
deepened by the opportunity to combine clinical care with 
research, to compete for Career Development Awards, and to be 
linked with mentors willing to nurture my research interests. 
These are significant factors in why I came to and remain at 
VA; and apparently many of my colleagues also feel this way. 
When surveyed by VA in 2002, 61 percent of clinician 
respondents indicated that they would not work at VA without 
research opportunities.
    Mr. Chairman, thank you again for inviting me today and I 
am happy to answer any questions. Thank you.
    [The prepared statement of Ms. Strauss follows:]
    Prepared Statement of The Friends of VA Medical Care and Health 
    Research (FOVA) presented by Jennifer L. Strauss, Ph.D., Health 
Scientist, Center for Health Services Research in Primary Care, Durham 
VA Medical Center and Assistant Professor in Psychiatry and Behavioral 
                Sciences, Duke University Medical Center
    Chairman Akaka, Ranking Member Burr, and Members of the Committee, 
on behalf of the Friends of VA Medical Care and Health Research, thank 
you for the opportunity to testify. FOVA is a coalition of over 90 
national academic, medical and scientific societies; voluntary health 
and patient advocacy groups; and veteran service organizations 
committed to ensuring high-quality health care for our Nation's 
veterans.
    I am a clinical psychologist and health scientist at the Durham VA 
Medical Center and a recipient of a VA Research Career Development 
Award. The primary focus of my research is the treatment of Post 
Traumatic Stress Disorder in women survivors of military sexual trauma. 
Today I have been asked to share my reasons for choosing a career as a 
VA clinician-researcher, and specifically, how VA research 
opportunities impact the Department of Veteran Affairs' ability to 
recruit and retain talented clinicians.
    Let me say at the outset that I love my job. The opportunity to 
conduct research greatly enhances my job satisfaction and has played a 
large role in my decision to remain at the VA for 7 years. From the 
time I applied to graduate school, my goal was to pursue training and 
professional opportunities that would allow me to blend my clinical and 
research interests. And VA provides an environment to do just that.
    VA is not the only venue in which a clinician can conduct research. 
Academic medical centers are frequently the landing pad for individuals 
like me. But understand that I have come of age professionally in the 
post-9/11 era. I earned my doctorate in June of 2001. Shortly 
thereafter we were at war. I wanted to help and I had a specific skill 
set that could allow me to do so quite directly. The opportunity to 
apply my clinical and research training in support of veterans 
traumatized by their war experiences continues to resonate very 
strongly with me, as I believe it does with many of my VA colleagues.
    I treat women survivors of military sexual trauma while also 
conducting research to make those treatments more effective. I am a 
small piece of a shared vision to provide the best possible care to our 
Nation's veterans. And I am well aware of how lucky I am to be able to 
say that. This war has presented numerous clinical challenges and, in 
many ways, we are still learning as we go. To make progress, VA must 
foster partnerships between research and clinical services, and must 
recruit clinician investigators to guide these efforts.
    Towards this end, VA offers exceptional research and training 
opportunities for clinicians like me who are interested in research 
careers. Among these is the Research Career Development Program. This 
is a highly competitive mentored award that typically provides 3-5 
years of structured research training. Clinicians who receive these 
awards are relieved of 75% of their clinical duties, allowing for 
protected time to focus on training and developing an individual 
program of research.
    This award is specifically designed to attract, develop, and retain 
talented researchers in areas of particular importance to VA, and it is 
a powerful recruitment tool. I am currently in the second year of my 
Research Career Development award. For this privileged opportunity, I 
aim to repay VA and our Nation's veterans hefty dividends on their 
investment in me, in the currency of high quality care and clinically-
informed research to improve the care of veterans.
    As a VA research career development awardee, I am in a unique and 
fortunate position. I benefit from truly exceptional research mentoring 
and training, and I have the luxury of devoting a substantial portion 
of my time to developing a research program at VA. At the Durham VA's 
Center for Health Services Research in Primary Care, I am one of 31 
core investigators, half of whom are clinicians and many of whom are 
young investigators, who jointly attract over $10 million of research 
grant support annually. The Center's success is a reflection of 
exceptional leadership, a sophisticated research infrastructure, and a 
talented, collegial, multidisciplinary faculty who are unusually 
invested in fostering the careers of junior faculty. The common thread 
is a deep respect for our nations' veterans and a drive to provide them 
with the highest quality care and to constantly seek improved 
treatments. I believe my success to date is largely a reflection of the 
exceptional opportunities afforded to me in this environment and it is 
these opportunities that give me such professional satisfaction and 
keep me at the VA.
    Despite the many advantages VA offers, it is not necessarily easy 
to build a career as a clinician investigator at VA. I would like to 
highlight several ways in which I believe VA can improve recruitment 
and retention of clinicians such as myself, who are interested in 
integrating research into their careers. I offer what follows from the 
perspective of a field worker. I know there are numerous constraints on 
implementing the ideal in the short run. But I also firmly believe that 
longer-term goals should be kept in mind for the good of the veterans 
we are all committed to serve.
    To date, VA has invested in 7 years of my research training. Yet 
what happens when my Career Development award, and the protected 
research time it affords, expires in 2 years is an open question. 
Unlike clinicians at most academic medical centers, VA clinicians may 
not fund a portion of their salaries through research grant support. If 
a non-clinician VA researcher is awarded research funds, those funds 
can be used to pay salary for time devoted to the research project. But 
VA clinicians cannot do this and typically must donate their time, 
often performing research duties early in the morning or very late into 
the night after a long day of seeing patients. I do not think this is 
in the best interest of VA or the veterans we serve. I strongly 
recommend that VA adopt a model that is more in line with what is 
available to clinician researchers working in academic medical 
settings. Namely, to foster recruitment of the best care providers and 
to encourage clinicians to conduct research by providing protected 
research time. The objective, of course, is to hasten development of 
the new and more effective treatments that are urgently needed.
    There are several other ways in which I believe VA could better 
facilitate clinicians' involvement in research. Currently, the primary 
research funding mechanism for VA investigators is a merit review 
award. For health services researchers like myself, these are typically 
3-5 year studies with relatively large budgets. Understandably, these 
studies are generally awarded to mature investigators who have already 
completed a substantial body of work in the research area. Currently 
missing from the VA research funding portfolio in my area of health 
services research is a grant mechanism that would allow individuals to 
conduct research on a smaller scale. I believe this type of funding 
mechanism, akin to the R03 program offered by the National Institutes 
of Health, would be particularly attractive to VA clinicians interested 
in taking on research without the commitment of time and resources that 
large scale studies demand.
    Current space constraints are an additional obstacle to the 
clinician-researcher career path. Space is at such a premium at our 
facility that some of our researchers may soon be moving off-site. A 
geographic divide between research labs and clinics will do little to 
enhance the type of collaborations that I believe are essential to move 
VA research forward in a manner that will best inform the clinical care 
of veterans. Continued investment by VA in the Durham research 
infrastructure and a similar investment at other facilities are 
imperative.
    The last obstacle I want to mention is data security in the context 
of research. Absolutely, veterans' privacy and research data must be 
safeguarded; that is paramount. However, while I know it is not 
intentional, it has become extremely difficult to share data even among 
VA facilities, and collaborating with non-VA organizations can be even 
more problematic. I urge VA to ensure that its security policies 
guarantee the safety of data, but still allow shared research to 
continue. With improvements in security technology I hope the current 
situation will get better. But right now, managing research data in 
compliance with VA policies is a significant challenge. The reasoning 
behind some of the obstacles is understandable; the consequences can be 
severe.
    Finally, I think the career opportunities available at VA remain a 
too well-kept secret. A VA career never occurred to me until a trusted 
graduate school mentor encouraged me to take a closer look. Coming from 
a traditional academic training environment, VA simply wasn't on my 
radar. It is time to let this secret out of the bag. For the reasons I 
have described, VA is an elite venue for clinicians and researchers 
alike and should recruit accordingly.
    Serving those who have served our country is what my colleagues and 
I do. And we are filled with pride by the opportunity to do so. That 
feeling--that attachment--is considerably deepened because of the 
opportunity to combine clinical care with research, to compete for 
Career Development awards, and to be linked with mentors willing to 
nurture our research interests. These are significant factors in why I 
came to and remain at the VA. And apparently many of my colleagues feel 
similarly. When surveyed by VA in 2002, 79% judged that research 
opportunities and support were very or extremely important for 
recruiting and retaining high quality clinicians in VA, and 61% of 
clinician respondents indicated that they would not work in VA without 
research opportunities.

    Mr. Chairman, thank you again for inviting me today. I am happy to 
answer any questions that you or the other committee members may have.
                                 ______
                                 
    Response to Written Questions Submitted by Hon. Patty Murray to 
    Jennifer L. Strauss, Ph.D., Health Scientist, Center for Health 
    Services Research in Primary Care, Durham VA Medical Center and 
    Assistant Professor in Psychiatry and Behavioral Sciences, Duke 
                       University Medical Center
              balance between research and clinical duties
    Question 1. Given the need for the VA to do research in areas 
critical to the health and well being of our veterans, how do we strike 
a balance between protecting research time for present and prospective 
VA employees, while still keeping enough clinicians on the ``front 
line'' to meet the acute needs of our veterans, given an urgent 
shortage in this area?
    Response. This is a very good question and I think the concept of 
``balance'' between front line clinical care and investment in research 
is a critical point. In my opinion, one step in this direction would be 
to allow clinicians to fund a portion of their salary (e.g., 1/8th-2/
8th) through VA funding and to allow the medical center to use the 
salary support offset to backfill the clinicians' time. This would be 
analogous to the NIH model which provides salary support commensurate 
with the investigator's level of effort on the project, in addition to 
the amounts provided for the direct and indirect costs of the grant. 
This approach would allow clinician researchers to devote a specific 
portion of their time to research without disrupting the availability 
of clinical care to veterans.
    In contrast, the current method of providing ``protected'' time for 
researchers is to use VERA dollars to backfill clinical positions. The 
concern, which I have heard voiced loudly and repeatedly at the annual 
VA HSR&D meeting, is that VERA dollars are used by medical center 
directors to fund many competing demands. Additionally, the VERA 
research allocation is based on prior year funds and the amounts 
provided to each medical center are not tied to specific projects. With 
the caveat that I am not a subject matter expert on VA budgets, VERA or 
the allocation process, what I am suggesting is a more direct means of 
ensuring the support of clinicians conducting research and the 
continued provision of front line clinical care to veterans.
    Bear in mind that the vast majority of clinicians do not want to 
conduct research. But I think those who do will play a critical role in 
improving VHA's ability to provide the best possible care to our 
veterans, for decades to come. It is arguably short-sighted to not 
invest in both our ability to provide timely, high quality care today, 
and to advance the standard and improve the quality of care provided by 
tomorrow's VHA. In other words, we must strike a balance between VHA's 
investment in front line clinical care and research.
                        dod and va collaboration
    Question 2. Over the past couple of years, there has been a lot of 
attention focused on the seamless transition between the VA and the DOD 
when it comes to information sharing.
    Thinking along those lines, is there any way that the VHA and the 
DOD could pool together and share some of their resources to fill in 
some of the gaps in clinical coverage?
    Response. Broadly speaking, I am certainly in favor of greater 
collaboration between these agencies, but it is not within my scope of 
expertise to suggest how best to achieve this goal. That said, one 
promising idea that has been suggested by others is a common electronic 
medical record, accessible by both DOD and VHA personnel. If tenable, I 
believe a shared medical record system would help to smooth transitions 
between DOD and VA care. From a health services research perspective, a 
shared electronic medical record would also foster our ability to 
conduct research on veterans' functioning before and after active duty 
and deployments, as well as after their transition to veteran status. 
An additional means of strengthening ties between agencies may be to 
assign some VHA staff to DOD, to facilitate transitions and access.

    Chairman Akaka. Thank you very much, Dr. Strauss.
    I understand that the opportunity to conduct research at VA 
has influenced the course of your career.
    Ms. Strauss. Yes, it has.
    Chairman Akaka. In your view, how could the hiring system 
be modified to attract and retain more researchers like 
yourself? What was it about VA research that made it an 
attractive option to you as a clinician? I would just like to 
note per Dr. McDonald's comments that Congress provided the VA 
research program with a $69 million increase this year and we 
are pushing for yet another substantial increase.
    Ms. Strauss. Which is much appreciated. You know, there are 
several factors that I think brought me to this career. One 
really is a specific interest in serving veterans and in 
conducting the type of research that I think is necessary to 
increase the quality of care that we are providing over time. 
So, the mission of that resonates very strongly with me.
    I am very fortunate to be at a facility, the Durham VA, 
that has a very strong research infrastructure and is highly 
supportive of research and of young clinical investigators like 
myself, and I am also really blessed with tremendous 
mentorship.
    Looking forward, I think a concern that is on everybody's 
minds who is in a position like myself, or certainly on my own 
mind, is some assurance that we will be allowed to continue to 
conduct research while also providing patient care. What that 
means is some mechanism, and I am not the individual, I don't 
think, to speak to what that mechanism should be or how it 
should be organized, but some allowance that there can be some 
dedicated time for us to continue research activities while 
also taking care of patients.
    Chairman Akaka. Thank you, Dr. Strauss.
    Dr. McDonald, over the course of your career, you have both 
hired contractors in your capacity as a VA administrator and 
clinician and you have been hired to work in VA as a 
contractor, so you have been through both of those systems. 
Does VA have the authority and resources to fully staff its 
facilities on its own, or do you believe VA will be required to 
expand contractor agreements?
    Dr. McDonald. Chairman Akaka, I believe that the answer to 
that is a qualified yes, and it really depends upon the size of 
the station or the VA hospital and the relationship with the 
affiliate medical school. In the case of Durham, San Francisco, 
Minneapolis, these are tight affiliations. I trained as a 
medical student at Duke, in fact, in the old Durham VA, and so 
that relationship goes back many, many years. So, except for 
some very highly remunerated specialties, such as 
neuroradiology, interventional radiology, interventional 
cardiology, for the most part, I believe that the VA will be 
able to.
    I think the current pay scale, although it is a great 
improvement, is still not adequate to recruit scarce 
specialties to a VA hospital. It takes--and it is not money, it 
is really the other elements of working in the VA system. It is 
the integrated medical record, it is caring for veterans, it is 
the team approach to health care, it is being in a vertically-
integrated health care system. If these appeal to physicians 
and we expose our medical students and our residents to these 
environments, then I believe the VA will be successful if it 
can offer a career path for investigation and scholarship as 
well as simply seeing patients. If you are simply doing the 
same thing as a VA physician that all other physicians in the 
community are doing and getting paid half as much, then it is 
going to be very difficult to rationalize on pure economic 
means why you should work at the VA.
    Where I believe the Veterans Administration faces 
particular challenges is in marketplaces like the one in which 
I serve. Our school has the largest group practice in the State 
of Nevada. We run two campuses 450 miles apart. For Easterners, 
that is the distance between Boston and Washington, DC. It is a 
very competitive health care market. So, our Reno VA, which is 
not a tertiary care referral VA, often has to refer patients, 
as we say, across the hill, across the Sierra Nevada to San 
Francisco, and similarly, Las Vegas is the largest metropolitan 
area without a dedicated VA hospital. There is an integrated 
VA-DOD facility, but as you are keenly aware, they are building 
a new VA hospital.
    In those circumstances, it is imperative, I believe, for 
the VA to really reach out to the academic affiliates to build 
these strong lasting ties so that there is a mutual 
interdependence, because I believe that our missions and vision 
and values are really very similar to the VA. In fact, most of 
those, particularly those who have served within the VA, hold 
it up as a paradigm of health care for this country. Thank you.
    Chairman Akaka. Thank you so much, Dr. McDonald.
    This question is for the entire panel. What effect does 
VA's hiring process have on recruitment, and how do you believe 
it can be improved and accelerated while still ensuring quality 
care for veterans? This is for the GAO as well as the 
providers. Dr. Kanof?
    Dr. Kanof. I don't have the answer, but at least I can give 
you some data. I mean, when we did our surveys--and, granted, 
this was in 2005 and 2006--we surveyed VA officials that were 
responsible for H.R. activity and the average took 15 months. 
In one case, it was as short as 3 months, and this is for the 
CRNAs. But in another case, it was as long as 60 months. So, 
clearly, wherever you are, either 15 months or 60 months, that 
is too long.
    The previous panel went through some of the steps, but it 
really takes a concerted effort to, as soon as you have made 
the decision to hire someone, to the posting, to the 
interviewing, to the job offering, to knowing are you going to 
be offering retentions? Are you going to be doing relocation 
bonuses? All that needs to be known from step one so that the 
timeframe could be significantly shortened.
    Chairman Akaka. Dr. McDonald?
    Dr. McDonald. Yes, sir, Chairman Akaka. There is one piece 
of the VA hiring puzzle which is not broken and I would urge 
the Committee to consider this when thinking about changes. 
That is that currently the VA--and I don't know the situation 
with nursing, I am sure we can hear about that--but currently, 
the VA is allowed to hire an employee, a physician, who is 
licensed in any State in the Union to practice exclusively in a 
VA facility. That is extremely important, because it may take--
in our case, in Nevada--it takes a minimum of 6 months to 
obtain a medical license and an additional 3 to 6 months before 
a physician in the civilian sector is fully credentialed with 
payers. So, essentially, the VA is treating licensure in any 
State as a national medical license, which I think that is a 
piece that works very well.
    I used to think, until I joined the State of Nevada, that 
the VA had a cumbersome bureaucracy. I am now disillusioned. I 
think that we can probably match the Federal system for hiring 
any day, and I think there probably are some streamlining steps 
we can take. But, on the other hand, I also realize, as a 
leader who recruits a lot of other leaders, that it is very 
important to cast a broad net when you are looking for the most 
qualified individual. And so, some of the things that seem to 
be ponderous and slow, hopefully, as long as we get rid of the 
unnecessary steps, are, I think, very important parts of 
ensuring a quality workforce. Thank you.
    Chairman Akaka. Thank you, Dr. McDonald.
    Ms. O'Meara?
    Ms. O'Meara. Thank you, Chairman Akaka. From what I have 
seen, one thing, I keep track of the newspaper ads for the VA 
and they are pretty few and far between. I always wonder why 
they don't advertise more just in the Sunday paper, which a lot 
of people get the Sunday paper.
    Another issue, from experience, I think that H.R. needs to 
be fully staffed at my facility and better trained in the 
process, especially for title 38, because it seems there are 
many, many people with roles to play in hiring the title 38 
professional staff--from the nurse recruiter to the chief nurse 
executive, then to HR, then to the staffing director. It 
appeared to me that there wasn't a whole lot of working 
together. It is like they are working separately and have their 
own piece. But, if no one is really overseeing the whole 
process, it can just be slow. Personal experience.
    Chairman Akaka. Thank you. Dr. Phelps?
    Mr. Phelps. I would echo what is being said about human 
resources policies and procedures, but I wonder if I could also 
add--and it is on the recruitment side but it is also the 
retention side--about research. Psychologists are kind of a 
unique discipline. We are trained at the doctoral level to not 
only be service delivery providers, but also as researchers, 
and so Dr. Strauss is a great example of our best and 
brightest. If we are recruiting psychologists to one or the 
other role in the system, we are missing the skills and the 
expertise that psychologists like Dr. Strauss bring to the 
system.
    So, the point that she made about release time to do 
research--because psychologists, again, are not bench 
researchers as you see in medicine and other places. We 
research clinical processes, the delivery of service and how 
best to do that. For example, the two evidence-based practices 
that VA cites for the treatment of PTSD, those were developed 
by clinical researchers in VA, those are people who live in the 
delivery system as well as do research.
    The way the system is configured currently, and this is my 
experience at a number of facilities around the country, is in 
many cases, psychologists have 5 percent release time to do 
research. What they do is get together and pool their 5 percent 
time across eight people and hand it to somebody in the 
psychology staff to do research. That is a very foolish waste 
of research and clinical activity, in my opinion. So, a system 
that recruits people at their skill level and expertise to fill 
real needs in the system, I think would go a long way.
    Chairman Akaka. Thank you very much, Dr. Phelps.
    Dr. Strauss?
    Ms. Strauss. Let me see. What can I add to this? Probably 
distinct from other members of the panel, I am on the early 
side of my career and I have a very fortunate position in VA 
right now. My hiring was not through the normal course, because 
I was able to pursue a research path through a grant award 
early on.
    It is not that long ago, though, that I graduated, and I 
have to say that if I were on the market looking for a job and 
I understood that it might take 6 months or so for a position 
at VA to become available or for the offer to come through, I 
don't know that I would have been able to afford to wait that 
long. I don't know if I would have felt terribly welcome or 
wanted.
    Because I haven't been in this position, I am not sure if 
such things are clarified up front. But, I think it would be 
really important to express clearly up front to new hires what 
the package is. So, obviously, for a psychologist like myself 
interested in research, that would be a piece of the puzzle. 
The potential for other benefits, like loan repayment programs, 
would also factor in, and I think would actually be crucially 
important for people just coming out of school. I think that 
that is a real factor.
    I guess the upshot is, when one graduates, one knows one 
needs to get a job and wants to land someplace where they are 
going to feel welcome and really want to build a career. And 
some of the timelines that I am hearing about, I think could be 
problematic in recruiting people at the highest level, because 
hopefully you are talking about people who also have options 
elsewhere.
    Chairman Akaka. Thank you all so much. Let me call on 
Senator Burr for his questions.
    Senator Burr. Thank you, Mr. Chairman, and I would 
appreciate it if nobody would take it personally that I missed 
the first four and got back for Dr. Strauss. It is a scheduling 
problem.
    Dr. McDonald, let me assure you, coming from a guy that 
represents a State that is over 600-plus miles from one end to 
the other, I understand what 450 can be and how challenging it 
can be.
    I wanted to just make an observation on your remark about 
the national licensure process. It does make it easier for the 
VA to access, in a timely fashion, health professionals. It 
comes with a tremendous amount of responsibility on the part of 
VA to make sure that we have gone through the review of these 
individuals thoroughly. So, I just caution us that speed is not 
the lone objective, it is the quality of the individuals, and 
we have had incidences of late where we have gone back and 
realized that we had a breakdown in our system. I don't think 
there are any of us that are proponents that we change 
something in that national licensure, but I think we constantly 
are reminded that we need to remind the entire system of the 
responsibility to proceed with caution as we go through it.
    Ms. O'Meara, your statement mentioned several bills signed 
into law that have failed to be fully implemented by the VA 
through either inaction or delay. Specifically, you mentioned 
provisions involving contract physicians, provisions to enhance 
recruitment, retention, and pay improvements. Would you just 
briefly tell me where you think this disconnect is occurring?
    Ms. O'Meara. Well, the first area is with alternative work 
schedules for nurses. I do not know of any facility where the 
36-hour week paid as full-time 40-hour week has actually been 
implemented. Neither has a 9-month work year been offered. So, 
it was as if the bill was never written, the law was never 
passed. That is the first area.
    I think the EDRP program is not fully--the amounts that are 
even authorized now are not being fully given to individuals 
and the amounts could be higher, given the cost of education. 
Those are the two areas I have the most familiarity with.
    Senator Burr. Great. Thank you very much.
    Dr. Phelps, you highlighted several problems, as well, that 
are obstacles to retention of VA psychologists. Let me ask you 
what the normal turnover rate among VA psychologists is and if 
you have identified any problems that contributed directly to 
an accelerated departure by psychologists.
    Mr. Phelps. Senator Burr, I do not have the data on 
turnover rate for psychologists in VA. Anecdotally, having 
worked with psychologists for a long time in the system, 
psychologists tend to stay for a long time. We just have had 
retirement parties for at least four senior psychologists there 
30 years, and I am sure those data would be available from the 
VA system.
    My experience, though, is once you are in, you are in. That 
has changed of late, though, with the promise of advancement 
through the Hybrid 38 system for many psychologists who have 
operated--I know many psychologists who have been in senior 
leadership positions across the country for 20 years who are 
still at a GS-13 level, which is the journeyman level in the 
system. The statute was passed to expand that system in 2003. 
Here we are 5 years later with what we consider very 
complicated red tape, bureaucratic systems, that essentially 
are holding our psychologists at bay, continuing to ask them to 
perform far above the duties of just service delivery or 
research but rather leadership position of teams, treatment 
units, whole components of VA and not being able to advance in 
the system despite qualifying for advancement through the new 
National Professional Standards----
    Senator Burr. If I made the statement that I personally 
don't think that the VA delivery system responds the same way 
that the private delivery system does to technology, to 
research and the findings from that research, would you agree 
with that?
    Mr. Phelps. I would agree with it mostly, Senator. The 
issue of the electronic medical record, however, in the VA is 
one at least we at the APA--we are studying and participating 
in national efforts for a national medical record--we see that 
as a world-class system. Now, this is not to say there are not 
problems with the system, but with regard to personnel and 
staffing patterns--and I am really not attempting to introduce 
turf into this hearing, because I have great respect for our 
physician colleagues, our nurse colleagues, our occupational 
therapist colleagues, and so forth--but VA, to simplify, VA's 
hiring procedures and personnel procedures, at least with 
regard to health care delivery professionals, are ones that 
were born out of the days when health care in this country was 
really driven by what we call the doctors' workshop.
    And sir, what that means, the doctors' workshop is the 
hospital. People don't talk about that much anymore. We have 
seen radical improvements, and I think this Committee has a 
large responsibility here; over the last 10 years in a great 
deal of new and modern thinking in the VA's delivery system so 
that it has moved out of the hospital, into the community. It 
still needs to go further. The real frontier is the rural 
frontier, as we heard earlier. But many, many, the development 
of the electronic record and so forth. But the personnel system 
is one that was rooted about 40 years ago, back to the doctors' 
workshop.
    Senator Burr. Let me add to something that you said and 
that is that we might agree that it doesn't happen naturally 
within the VA and there is a progression that happens naturally 
in the private health system.
    Mr. Phelps. Yes.
    Senator Burr. You are right. It has been prodded by 
Congress. It has been prodded by you. It has been prodded by 
associations that might represent veterans. I think it is safe 
to say that with the exponential change that health care is 
seeing in the future, we can't wait for the VA to be prodded to 
do something if we expect it to be on the cutting edge of 
research and development. And I think most of us on the 
Committee believe that as it relates to Traumatic Brain Injury, 
PTSD, to other mental health challenges, that the data is 
sufficient in the system to say the faster you can get people 
in, the more intense the treatment and the rehabilitation can 
be, the more you can affect the outcome on the other end.
    I am sure at some point we will prod to a point that we 
will actually believe that not only do we have a system that is 
conducive to that, but we also have the right incentives on the 
patient side to make sure that, in fact, they are accessing 
that treatment at an early point in an intense way with their 
expectations being, ``I am going to get better.''
    I have got to move to Jennifer just real quick, if I can, 
because you talked about a number of things. You talked about 
the need to have the right type of facilities. Here is the 
challenge for this Committee and for the VA as a whole. If you 
look at the veterans' population, it continues to age, though 
we have an infusion now, the result of the War on Terror. How 
much of our responsibility is it to make sure that our 
investment in facilities reflects where our veterans are 
living?
    It is pretty easy to look at Nevada and see the growth 
numbers and say, this is a good place to put a VA facility. It 
is easy to look at North Carolina and the growth projections, 
but more importantly, the retiring military families and say, 
gee, we could start building today and we probably couldn't 
meet the need.
    I think we have to go further, and I believe that we have 
got to get it even closer than just a couple places in a State, 
and I think Senator Tester said this. Even though you are not 
going to look at Montana and find a growth pattern that would 
say, this requires a tremendous investment right now, it still 
requires us to look at where the population is and decide 
whether we can restructure the delivery system in a way that we 
can provide the services in a fashion that more people take 
advantage of it.
    The Chairman and I have exchanged thoughts as it relates to 
our ability to not dislocate a veteran from his family, not 
dislocate a veteran and his family from his community to access 
care. That is how the private system begins to set up. So, I 
think we have got to think of new efforts in the future.
    I am curious to know how much of the research that is done 
at the Duke VA is driven based upon the tightness of the 
affiliation with Duke University and the understanding of 
today's academic institutions about the need to perfect and to 
focus on research?
    Ms. Strauss. Let me make sure I am understanding your 
question. How much of----
    Senator Burr. If Duke University wasn't next door and had 
the tight affiliation with the Durham VA, do you believe the 
Durham VA would be involved in the degree of research that they 
are currently involved in?
    Ms. Strauss. I am actually not sure, but I think that the 
Duke academic community is a tremendous resource.
    Senator Burr. I agree with you totally. My answer would be, 
probably not. It would probably not be involved in research to 
the degree that they are, and I think somebody alluded to it 
earlier--Dr. McDonald or Dr. Phelps--that it really is 
leveraging knowledge learned from a standpoint of research from 
the academic world into the clinical world, and understanding 
where it is appropriate within the Veterans Administration for 
us to really drive research that, quite frankly, we can't get 
anywhere else. This is a gold mine if you pick the right types 
of things.
    In Wilmington, North Carolina, we have one of the largest 
diabetes research studies being done in a community health 
center. Now, most people around the world would never believe 
that that would be a beneficial pool to do a study on diabetes. 
In fact, it is probably the richest pool, and outside of a 
community health center, I am not sure that you could find the 
cross-section like you could there.
    I think we are going to be challenged in the future as to 
how we take more of the VA facilities and have that tight 
relationship with an academic institution, even if it is not 
right there on the same footprint like Durham exists. I don't 
think there is any question that we will continue to be 
challenged to find new ways to market the VA, and this is my 
last question.
    You made a statement that if it hadn't have been for an 
academic mentor, you might not have gone to the VA and worked. 
Let me just say----
    Ms. Strauss. I think my statement was the quality of 
mentorship available at my facility----
    Senator Burr. OK.
    Ms. Strauss [continuing]. Was a very strong attraction to 
me.
    Senator Burr. My question is, how does the VA change its 
marketing strategy to market itself to these unbelievable 
academic institutions and begin to cultivate in these medical 
students a desire to work at the VA? Is that something we 
should be doing that we are not doing today?
    Ms. Strauss. Probably. In my written testimony, one of the 
things I mentioned is that I was coming from a very traditional 
academic medical environment, and honestly, VA wasn't on my 
radar when I first started looking for positions. It was a very 
trusted graduate school mentor to whom I am quite grateful who 
suggested to me that given my research interests, this would be 
a really good fit. On my own, I am not sure I would have 
considered it, just because in the ivory tower that is academic 
research, it wasn't on my radar.
    Senator Burr. I look at a nurse with a 4-year degree who is 
being recruited by people from six different States 6 months 
before she graduates based upon the market today and the need 
for nurses. The same is true for every health care 
professional, and I guess the point I was beginning to make is 
that VA can no longer silently sit by, waiting until people 
graduate, and hope that VA is in the mix of consideration.
    Do we not have to reprogram to where we proactively go out 
into the community and begin to pull students in; because there 
is a story to tell, and the story, as Dr. McDonald said, it is 
not always the highest pay. It is not always the most 
responsive system. But the mission that they carry out is a 
mission that is more fulfilling than anywhere else somebody in 
the health profession can work.
    Listen, we have gone well over the time that I know the 
Chairman allotted and asked you to be here. And again, I 
apologize that I have been out and in. I can't thank all of you 
enough for the value of the information. And Mr. Chairman, I 
look forward to trying to figure out exactly how we use this in 
a very positive way with you.
    Chairman Akaka. Thank you. Thank you very much, Senator 
Burr.
    As you know, this hearing is focusing on making VA the 
workplace of choice and what we are finding out are many facts 
here, directly from you, the providers. Before we adjourn, I 
want to ask the panel on your own to say a few last words about 
making VA the workplace of choice for health care providers. 
Thinking about that, thinking about what Senator Burr has 
asked, what can you add to this about making VA the workplace 
of choice?
    Dr. Kanof. Well, I will start. I am going to echo some of 
the comments that other members have said, and it is not in our 
statement, but it goes back to our report. Interesting enough, 
when we did a survey--and again, this was just the CRNAs--
salary, while important, was not one of the drivers for what 
the CRNAs were looking for in terms of improvement. I mean, 
they really did want the flexibility in their work schedule. We 
didn't know to ask them about a market as they do in San 
Francisco, but they wanted flexibility. They wanted child care. 
They wanted those elements of quality-of-life that actually the 
Federal Government and many private sector hospitals are 
providing.
    Chairman Akaka. Dr. McDonald?
    Dr. McDonald. Thank you, Mr. Chairman. From the AAMC's 
perspective and from my own personal perspective, I would say 
that it is to continue to grow graduate medical education, to 
carefully consider more robust loan repayment schedules for VA 
physicians, and to ensure that the tradition and importance of 
a strong affiliate relationship with the VA is true not just at 
the large premier institutions, but at some of the smaller 
institutions, such as the two that I am responsible for 
affiliates with. Thank you.
    Chairman Akaka. Ms. O'Meara?
    Ms. O'Meara. Thank you, Chairman. I think there are several 
convergence areas for this to make it the workplace of choice. 
The pay issues, we have discussed all of those and all of them 
are important, retention pay, recruitment incentives. I think 
the VA could definitely start a marketing campaign. I don't 
think I really see that, you know, what Mr. Burr was talking 
about, to attract people to the mission. I think that sounds 
wonderful.
    One other area that shows up in nursing research a lot is 
the workplace environment is very important to nurses 
particularly, and I am sure other health care professionals. 
The work environment, which has to do with collegiality, with 
being treated with respect, having a say in your workplace, 
things like staffing, things like flexible work schedules, if 
those things aren't implemented, they will be going other 
places, and for the newer generation coming in, the Gen X-ers, 
VA has been shown that they will move along. They will not stay 
in an environment that they don't enjoy. And so, as opposed to 
the older generation where we have the 27-year tenures, I don't 
think we will see that, unless the VA changes. Thank you.
    Chairman Akaka. Thank you. Dr. Phelps?
    Mr. Phelps. Yes. I think the VA's--this is a little beyond 
the personnel systems--the VA's continued innovation and 
modernization of the health care system toward more integrated 
care models, team-based care, all of these are the modern 
approach to treatment; world class electronic recordkeeping; 
and that sort of thing; continued innovation in VA so that it 
is truly seen as the world class health care delivery system 
that it can be is probably the strongest marketing point, shall 
we say, not only for veterans seeking care in the system but 
for health care professionals to come in. And finally, of 
course, fair pay for a fair day's work for health care 
professionals.
    Chairman Akaka. Thank you. Dr. Strauss?
    Ms. Strauss. Thank you. I guess what I can add or at least 
reiterate from what already has been said, salary, of course, 
is an issue--fair pay for what we are doing. I will also say 
that if salary were the driving issue, I wouldn't be here 
because I could be paid better elsewhere. And so that is not 
the thing that keeps me here, although I certainly appreciate 
the opportunity to be paid fairly.
    One of the big driving things that attracted me and keeps 
me here is truly the mission of what we do and how it makes me 
feel about myself and the time that I am spending doing it, 
which is quite a bit of time. And I think that once people 
enter the system, their commitment and attachment to what we 
are doing only grows.
    I think VA could do a better job, potentially, of marketing 
the quality of training that is offered in this environment. As 
I mentioned, when I was in graduate school, it really wasn't on 
my radar. I had no idea, truly, what the resources were and 
what a tremendous environment this is to grow a career. So, it 
is a bit of a kept secret and I wish that weren't the case.
    And for the record, I plan to be here for many years to 
come, so I have every intention and very much hope to continue 
to build a career at VA.
    Chairman Akaka. Thank you very much, Dr. Strauss.
    In closing, I again want to thank this panel for appearing 
today. Your input on these issues is valuable to this Committee 
as we work to make VA the employer of choice in our country, 
and especially for health care professionals in the years to 
come.
    I want you to know that we will be submitting additional 
questions to you for the record, and again, I want to say 
thanks so much for your responses today.
    This hearing is adjourned.
    [Whereupon, at 12:20 p.m., the Committee was adjourned.]
                            A P P E N D I X

                              ----------                              


                            Duke University Medical Center,
                                         Durham, NC, April 7, 2008.
Hon. Daniel K. Akaka,
Chairman,
Senate Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.

    Dear Chairman Akaka: My name is Harvey Jay Cohen, MD. I am the 
Professor and Chairman of Department of Medicine at Duke University 
Medical Center, having recently retired from the Department of Veterans 
Affairs after 35 years of service. I am extremely sorry that I cannot 
accept the invitation to appear in person before your Committee to 
offer testimony regarding the VA Research Service. Unfortunately, 
unavoidable prior scheduling conflicts preclude my doing so. However, I 
am delighted to respond to the opportunity to write today to express my 
strongest support for the VA Research Service. I do so because it is my 
belief that my own career mirrors many others in the VA, and can offer 
an example of how the VA can be a pivotal driving force in the 
recruitment and retention of physicians for the Department of Veterans 
Affairs. In many respects I owe the greatest debt of gratitude to the 
VA Research Service for offering me the opportunity to initiate and 
develop essentially my whole career within the VA and in affiliation 
with Duke University. I believe this a model replicated many times over 
across this country.
    Let me illustrate. In 1971 I was a young faculty member, just 
having joined the faculty at Duke University one year before. As you 
may know, our institution is closely affiliated with the VA Medical 
Center in Durham, located just across the street. I had done part of my 
residency training and fellowship training at the VA, and had an 
excellent experience. When asked if I would consider spending my 
clinical time in hematology and oncology at the VA, I initially 
hesitated because in addition to my commitment to clinical and 
educational activities, I was interested in developing my research 
career as well. When I learned that I could compete for an opportunity 
to receive a Research Career Development Award, I seized that 
opportunity immediately. I was fortunate enough to compete successfully 
and became a VA Research Clinical Investigator the following year. I 
set up my laboratory at the VA, and became a full time VA investigator 
and clinician. In ensuing years, I became the Chief of the Hematology/
Oncology section at the VA, and then Chief of the Medical Service from 
1976 through 1982. Throughout that period I remained funded by 
competitive grants under the VA merit review program. I also held 
funding through the NIH, but based that entire activity at the VA.
    In subsequent years I became interested in the new discipline of 
geriatrics and led the effort at our institution to secure a Geriatric 
Research Education and Clinical Center in the early 1980's, and from 
that point forward concentrated my efforts on geriatrics with an 
emphasis on cancer in the older individual. This further cemented my 
ties with the VA as we continued to expand and develop our programs. 
Those programs became the basis for the development of the entire 
geriatrics program at Duke University as well as the VA, a program that 
has for the last several years been consistently ranked in the top five 
in the country. Over those years, as my research interests evolved, the 
VA Research Service offered me the opportunity not only to compete for 
more basic research, but subsequently for more health services-oriented 
research and cooperative studies. Each of these, I hope, made 
contributions to our ability to care for our patients better, but also 
offered me wonderful opportunities which further cemented my 
relationship with the VA. This is just one example of how the broad 
spectrum of the portfolio of VA research can accommodate and encourage 
physicians with many different interests to serve within the VA system. 
Personally the VA Research Service allowed me the opportunity to take 
on clinical and administrative roles which kept me within the system 
for virtually my entire career. I could not be more enthusiastic about 
the potential of the VA Research Service.
    However, currently there are great challenges despite the 
tremendous opportunities that continue to exist. Among these challenges 
is that over the years, the clinical load has increased for many of the 
physicians within the VA, and this has had consequences in the ability 
to devote time to research. This is not a problem for people in the 
career development program. However, for those who are in the clinical 
service, despite having funding for merit review grants, the time to do 
the research is difficult to carve out. While it is my understanding 
that accommodations have been made for this through the VERA modeling, 
and funding is supposed to be provided to support these investigators' 
research time, it would appear that because of tight budgetary 
constraints and other priorities, these dollars do not end up 
supporting that time directly. It seems to me that the VA might 
consider an option somewhat like one that the NIH uses when money is 
awarded to the VA Research Service, such that when physician 
investigators apply for research grants a portion of their time and FTE 
could be budgeted directly on the grant, and thus will directly protect 
that time for the research activity. A second challenge is that science 
has evolved. In past years, when I was beginning my career the 
individual investigator working in his laboratory, perhaps with some 
collaborations, could be successful. Currently, however, with the 
evolution of scientific technology, it is rare that this situation 
occurs. Rather, science has become a team game. One needs an 
environment that is supportive both in terms of infrastructure and in 
terms of colleagues with complementary scientific expertise. This is 
sometimes difficult to achieve within a given VA institution's walls, 
although at some of the more complex tertiary care medical centers with 
substantial affiliations this can be done. However, even in those 
circumstances, a flexible and fluid approach to location and activities 
for any budding investigator must be encouraged, to allow the best of 
translational science to bring the best of care for the future, to the 
VA.
    Despite these challenges I believe that the VA research system 
still has great potential. In particular, it has substantial advantages 
related to the patient population. This is a national system with 
national databases and the potential to provide accurate patient 
descriptions (sometimes referred to as the phenotype) which can inform 
research in many different areas, in particular genomics research. This 
would allow the VA to participate actively in the coming revolution in 
the approach to personalized medicine. The databases within the VA are 
a natural for large-scale epidemiologic work, and the patient 
population is a natural for cooperative studies. Moreover, as the 
proportion of women now being cared for by the VA has increased, the 
patient population becomes even more representative for such studies.
    Finally, let me say a bit about the critical role that VA research 
has played in supporting the growth of certain areas and disciplines. 
Perhaps the best example of this is geriatrics. My own career parallels 
the growth of geriatrics in this country, a growth largely initiated 
and sustained by funding of centers such as the Geriatrics Research 
Education and Clinical Centers, and subsequently MIRECs and others. 
These have been able to focus activity through groups of investigators 
with similar interests to work together and have made great advances, 
both for the VA and the country at large. Such centers, especially the 
GRECCS, are under substantial budgetary threats. I would urge the 
Committee, as it looks at VA research, to find ways to protect these 
jewels in the VA's crown.
    As you can tell, I am most enthusiastic about the VA and its 
research. Why should I not be? It has afforded me the ability to grow 
my career while being able to be of service to the veterans in this 
country to whom we owe so much. Thank you for the opportunity to 
provide this testimony.
            Sincerely,
                            Harvey Jay Cohen, M.D.,
        Walter Kempner Professor and Chair, Department of Medicine,
     Director, Center for the Study of Aging and Human Development,
                                    Duke University Medical Center.
                                 ______
                                 
          Prepared Statement by Ann Converso, RN, President, 
                    United American Nurses, AFL-CIO
    I would like to thank the Chairman, Ranking Republican Member, and 
Members of the Committee for the opportunity to provide testimony for 
the hearing on ``Making the VA the Workplace of Choice for Health Care 
Providers.'' My name is Ann Converso and I have been a registered nurse 
in acute medical/surgical units and later I.V. therapy at the VA 
Western New York Health Care in New York's VISN 2 region for more than 
30 years. I have also been an active member of my union, the United 
American Nurses (UAN), AFL-CIO, during that time. I am testifying today 
as the President of the United American Nurses, a union representing 
registered nurses--6,000 of whom are VA nurses.
    There exists a health care crisis in our country regarding the 
shortage of registered nurses. A 2002 report by the Health Resources 
and Services Administration states that by 2020, hospitals will be 
short 808,416 RNs. In a 2002 survey by the United American Nurses, 
three out of every ten nurses said it was unlikely they would be a 
hospital staff nurse in 5 years. The VA health care system has by no 
means been immune to the shortage.
    As nurses leave the VA system, new nurses are not joining the VA at 
comparable rates, and patient load is increasing. In its own report, 
``A Call to Action,'' the VA states that it must replace up to 5.3 
percent of its RN workforce per year to keep up with RNs retiring. By 
all accounts, that is not happening. In its Web site documentation of 
system-wide capacities, VA statistics show that between 1996 and 2002 
the number of full-time-equivalent RNs went down by 8.4 percent. During 
that same time period, the number of ``unique patients'' treated at the 
VA went up by 55 percent.
    In my years as a VA nurse, I have experienced several nursing 
shortages firsthand. I believe I speak for other VA nurses when I say 
that we love our jobs and the important work we do in caring for our 
Nation's veterans. With that said, registered nurses are leaving the 
bedside in favor of the many other job options now available to us, 
from clinic jobs, outpatient jobs, computer jobs, quality management, 
doctors' offices, pharmaceutical jobs or leaving nursing entirely. A 
contributing factor causing registered nurse to leave the VA is 
problems they are experiencing with section 7422 of title 38.
    Congress amended Title 38 to provide medical professionals who work 
at VA facilities with collective bargaining rights, which include the 
rights to use the negotiated grievance procedure and arbitration. Under 
38 U.S.C., section 7422, covered employees can negotiate, file 
grievances and arbitrate disputes over working conditions except ``any 
matter or question concerning or arising out of:''

     professional conduct or competence (defined as direct 
patient care or clinical competence;
     peer review; or
     the establishment, determination, or adjustment of 
employee compensation.

    Increasingly, VA management has interpreted these exceptions very 
broadly, and has refused to bargain over significant workplace issues 
affecting medical professionals. Recent court decisions are upholding 
VA's broad reading of Section 7422, even when management raises it 
after completion of the arbitration process.
    Congress passed this law in 1991 to strengthen the bargaining 
rights of VA medical professionals. By its own admission, the VA 
recognizes the critical role that health care professionals play in 
improving quality of care. According to the VA Office of Nursing, ``VA 
nurses have been widely recognized for their instrumental work in 
initiating, developing, implementing, and monitoring the practices and 
policies that made VHA one of the world's foremost authorities in 
patient safety and quality outcomes evidenced by performance measures--
an exceptional achievement by any assessment.'' (DVA Web site, April 
30, 2007)
    In practice, VA health care professionals have a shrinking role in 
quality assurance and patient safety. Too often, the Human Resource 
staff is making health care decisions instead. The VA's current 7422 
policy goes directly against good medicine and Congressional intent. 
Employees leave the VA for other public and private health care systems 
where they have more rights, which in turn pose's a threat on 
recruitment and retention at the VA. Congress needs to amend section 
7422 of Title 38 to ensure that the VA complies with Congressional 
intent and that registered nurses are able to care for veterans with 
dignity, respect and the basic bargaining rights they were intended to 
have.
    To address this problem, Senator Rockefeller, along with Senators 
Webb, Brown, and Mikulski introduced S. 2824, a bill that would improve 
collective bargaining rights of registered nurses in the Department of 
Veterans Affairs. The UAN is pleased by the introduction of this 
legislation and strongly endorses it. The UAN strongly urges Members of 
the Committee to support and work for the passage of this important 
legislation.

    Thank you again for opportunity to provide testimony regarding this 
important issue. The UAN looks forward to working with the Committee to 
protect registered nurses and the veterans they take care of.
                                 ______
                                 
  Prepared Statement Submitted by Charles Ingoglia, Vice President of 
     Public Policy on Behalf of the National Council for Community 
                         Behavioral Healthcare
    The National Council for Community Behavioral Healthcare 
appreciates the opportunity to submit testimony on behalf of its 1,400 
member agencies who provide medical and rehabilitative treatment and 
support services to nearly six million adults, children, and families 
with mental and addiction disorders in every community across America.
    We appreciate the Committee's interest in meeting the physical and 
behavioral health needs of our Nation's veterans. Since the initiation 
of OEF and OIF, nearly 800,000 servicemembers have been discharged and 
are eligible for VA care. Of those, more than one-third sought medical 
care within the VA. The Department has also acknowledged that mental 
disorders are the second most commonly reported health concern by 
veterans seeking care.
    A June 2007 Army study found that 49% of Army National Guard 
soldiers and 43% of Marine reservists reported symptoms of PTSD, 
anxiety and depression. At the end of their tours of duty, these 
citizen soldiers return to their families and communities, oftentimes 
miles away from a VA facility.
    To meet this need, the VA has hired nearly 3,800 mental health 
workers, including physicians, nurses, pharmacists, social workers, and 
clinical psychologists, since 2005. Most of these professionals have 
been hired in the past 18 months. The Department has expressed interest 
in hiring at least an additional 500 mental health workers in the near 
future.
    The VA's interest in hiring permanent full time staff to meet this 
need is based on a stated desire to assure sustainable, evidence-based 
programs. This approach, however, is exacerbating an existing mental 
health workforce shortage, and may not meet the long-term treatment and 
rehabilitation needs of returning veterans.
    Most Americans with serious mental illnesses receive their 
treatment from government sponsored or not-for-profit community-based 
mental health organizations. From California to Maine, and in every 
State in between, there is currently a shortage of qualified mental 
health workers. While the shortage of psychiatrists and nurses is the 
most severe, there are shortages in all areas, including social 
workers, mental health counselors, and psychologists.
    The VA's recent efforts to increase its mental health workforce 
have exacerbated this shortage. Community-based mental health 
organizations around the country report that staff are being recruited 
away by the VA, leaving them unable to serve current clients and 
looking once again for qualified replacements in a market with few to 
choose from. This situation is even more acute in rural areas of the 
country.
    While it is clear that many returning servicemembers are currently 
seeking care for mental disorders, it is less than clear what their 
long-term treatment needs will be. Instead of providing for a ``surge 
capacity'' to meet the current need, the VA is hiring permanent, full 
time staff in a system where the average employee remains until 
retirement. Such as approach would also provide the Department, and 
Congress, time to understand the long-term treatment needs of Veterans 
and to develop effective programs to meet them, as opposed to building 
a system that may not be relevant to what veterans need or want.
    In our view, rather than competing with, or recruiting from, 
existing community-based mental organizations, the VA could pursue a 
targeted strategy of cooperation and collaboration through service 
partnerships. Such a course of action would provide immediate treatment 
capacity, as well as ameliorate the ongoing damage to the private 
sector inflicted by VA recruitment of mental health professionals.
    Further, the establishment of service partnerships with existing 
community-based organizations would also extend the ability of the VA 
to provide needed treatment services in rural areas of the country 
where many returning National Guard and Reserve component veterans 
live. The stigma associated with mental illnesses already serves as a 
barrier to care, veterans do not need the further barrier of long 
travel times to access care.
    Effective service partnership would be characterized by VA control 
of the referral process, as well as minimum standards for clinical 
training. Community organizations participating in such arrangements 
would be required to hire veterans as peer outreach workers, and to be 
competent in understanding the military culture and mindset. 
Additionally, all treatment records would be transmitted to the VA for 
inclusion in the veteran's electronic medical record to assure 
continuity of care.
    Such models of cooperation exist, albeit in short supply. It is 
recognized that any such arrangements would be in existence only as 
long as the need existed and are not intended to replace the existing 
network of VA controlled care.
    We would welcome the opportunity to work with the Committee to 
further develop these issues in support of our troops, and I would be 
pleased to answer any questions you might have. Please feel free to 
contact me by telephone at 301.984.6200, ext. 249, or via email--
[email protected].
                                 ______
                                 
  Prepared Statement of Sara Marberry, Executive Vice President, and 
  Anjali Joseph, Ph.D., Director of Research at The Center for Health 
                                 Design
    Chairman Akaka and distinguished Members of the Committee, I am 
Sara Marberry with The Center for Health Design, along with my 
colleague Anjali Joseph. Thank you for the opportunity to present our 
thoughts on how the design of the physical environment of health care 
can help increase patient and staff safety and satisfaction, and worker 
efficiency.
    The Center for Health Design, which was founded in 1993, is a 
nonprofit research, education, and advocacy organization of forward-
thinking health care, elder care, design, and construction 
professionals who are leading the quest to improve the quality of 
health care facilities and create new environments for healthy aging. 
Our mission is to transform health care settings into healing 
environments that improve outcomes through the creative use of 
evidence-based design.
    Traditionally, health care environments have been organized to 
support the individual work efforts of practitioners in various roles 
and disciplines (doctors, nurses, therapists, dieticians, and many 
others) who work primarily in their areas of expertise and attempt to 
coordinate with others by orders, notes, phone calls, pages and other 
methods of individual communication. Patients and families have 
traditionally been viewed as passive recipients of care rather than as 
active experts in their own life and health conditions.
    In contrast, a growing body of evidence compiled by The Center for 
Health Design and others demonstrates that health care work happens 
most effectively when practitioners work highly interdependently in 
well-functioning teams, with active participation by patients and 
families (McCarthy & Blumenthal, 2006; Uhlig, Brown, Nason, Camelio, & 
Kendall, 2002). As care moves from simply ``treating disease'' to 
healing the individual in a holistic sense--physically, emotionally and 
psychologically--health care teams must increasingly work seamlessly 
together and include the patient and family as integral team members.
    A disconnect has arisen between the traditional, individual-centric 
health care organizational and physical infrastructure of the workplace 
and the way that health care practitioners, patients, and families 
optimally must work together. This manifests itself in the form of 
inefficiencies, communication breakdowns, occupational stress, medical 
errors, and other operational failures that are alarmingly common in 
health care today.
    Further, the physical environment of the health care workplace, 
along with other factors such as culture and work processes, also 
impacts the health and safety of the health care workforce. According 
to the Peter D. Hart Research Associates' (2001) survey of registered 
nurses (RN), the primary reason why nurses leave health care other than 
for retirement reasons is to find a job that is less stressful and 
physically demanding. In a survey of nurses conducted by the American 
Nurses Association (2001), 76% of the nurses stated that unsafe working 
conditions interfered with their ability to provide quality care.
    In order to understand and address these problems, it is necessary 
to consider the health care workplace as an interdependent system 
comprised of the physical environment, work processes, organizational 
culture (e.g. formal and informal values, norms, expectations and 
policies, etc.), workforce demographics, and information technology 
(Becker, 2006). It is important to consider the interdependencies and 
patterns of interaction between these elements, rather than focusing on 
individual elements alone.
    While several studies indicate that the physical environment 
impacts staff outcomes in health care settings, it is clear that a 
well-designed environment alone is unlikely to achieve its intent 
without a supportive work culture and the technology in place. 
Likewise, a supportive work culture such as one that promotes family 
and patient participation in care processes is unlikely to function 
successfully without the presence of design features (such as space for 
families in patient rooms) that make this possible.
    Hospital redesign and renovation projects provide the opportunity 
to consider how these different elements might interact. The challenge 
is to create settings where the physical environment, technology and 
organizational culture together support ways of working that ensure 
health, safety and effectiveness for all in health care.
                 hospitals are dangerous places to work
    Of the 14 industries with the highest numbers of occupational 
injuries and illnesses, three are in health care, with the top two 
being hospitals and nursing and residential care facilities. Health 
care workers are exposed to various occupational hazards on a daily 
basis. They are exposed to airborne infections in the hospital as well 
as those acquired through direct contact with patients. Taking care of 
patients in the hospital is often back breaking work with nurses 
required to manually lift heavy patient loads. This is an issue of 
great concern today with the increasing bariatric population in US 
hospitals.
    For night shift nurses, poorly entrained circadian rhythms and lack 
of sleep contribute to stress, fatigue and health deterioration. In 
addition, other environmental stressors such as high noise levels, 
inadequate light and poorly designed workspaces impact staff health and 
safety. Proper design of health care settings along with a culture that 
prioritizes the health and safety of the care team through its policies 
and values can reduce the risk of disease and injury to hospital staff 
and provide the necessary support needed to perform critical tasks.
    Health care employees are at serious risk of contracting infectious 
diseases from patients due to airborne and surface contamination 
(Clarke, Sloane, & Aiken, 2002; Jiang et al., 2003; Kromhout et al., 
2000; Kumari et al., 1998; Smedbold et al., 2002). Factors such as poor 
ventilation and fungal contamination of the ventilation system that 
have been linked to the spread of nosocomial infections among patients 
may also impact staff. For example, one study that examined the 
relationship between indoor environmental factors and nasal 
inflammation among nursing personnel found the contamination of air 
ducts with Aspergillus fumigatus to be the source of infection 
(Smedbold et al., 2002). A recent study conducted in the wake of the 
SARS epidemic in China found that isolating SARS cases in wards with 
good ventilation could reduce the viral load of the ward and might be 
the key to preventing outbreaks of SARS among health care workers, 
along with strict personal protection measures in isolation units 
(Jiang et al., 2003).
    While ventilation system design and maintenance is critical to 
controlling the spread of airborne infections, infections are often 
spread through direct and indirect contact with patients. Ulrich and 
colleagues (2004) in their extensive literature review concluded that 
poor handwashing compliance among staff is the primary cause of contact 
transmission of infections. They suggest that providing environmental 
supports to increase handwashing including visible, conveniently placed 
sinks, handwashing liquid dispensers, and alcohol rubs might be more 
successful in improving and sustaining handwashing compliance than 
education programs alone (Ulrich, Zimring, Joseph, Quan, & Choudhary, 
2004). They also document several studies that clearly show that 
nosocomial infection rates are lower in single patient rooms as 
compared to semiprivate rooms (Ulrich, Zimring, Joseph, Quan, & 
Choudhary, 2004). These environmental measures that are linked to 
increased patient safety are also likely to protect staff from 
infection.
44% of injuries to staff are strains & sprains
    Nursing work has become increasingly complex with changing 
technology, changing work practices, and increasing documentation 
requirements. Further, nurses are growing older and the patient 
demographics are changing as well. Lower back pain is a pervasive 
problem among nursing staff and is a result of poor fitness, long 
periods of standing and efforts far exceeding workers' strengths 
(Brophy, Achimore, & Moore-Dawson, 2001; Camerino et al., 2001; Miller, 
Engst, Tate, & Yassi, 2006). Patient lifting in particular is a major 
cause of injury to health care workers. According to Fragala and Bailey 
(2003), 44% of injuries to nursing staff in hospitals that result in 
lost workdays are strains and sprains (mostly of the back), and 10.5% 
of back injuries in the United States are associated with moving and 
assisting patients. Reducing injuries that result from patient-lifting 
tasks cannot only result in significant economic benefit (reduced cost 
of claims, staff lost workdays), but also reduce pain and suffering 
among workers.
    Ergonomic programs, staff education, a no-manual lift policy, and 
use of mechanical lifts have been successful in reducing back injuries 
that result from patient-handling tasks (Engst, Chhokar, Miller, Tate, 
& Yassi, 2005; Garg & Owen, 1992; Garg, Owen, Beller, & Banaag, 1991; 
Joseph & Fritz, 2006; Miller, Engst, Tate, & Yassi, 2006). When 
PeaceHealth in Oregon installed ceiling lifts in most patient rooms in 
their intensive care unit and neurology unit, they found that the 
number of staff injuries related to patient handling came down from 10 
in the 2 years preceding lift installation to two in the 3 years after 
lift installation (Joseph & Fritz, 2006). The annual cost of patient 
handling injuries in these units reduced by 83% after the lifts were 
installed (Joseph & Fritz, 2006).
    This study, as well as others, has emphasized the importance of 
instituting a no-manual lift policy (along with the installation of 
mechanical lifts) in hospitals to prevent such injuries from occurring. 
Another environmental design feature that has been linked to reduced 
discomfort (particularly for the lower extremities and lower back) for 
workers who spend large amounts of time on their feet, is using softer 
floors (such as rubber floors) (Redfern & Cham, 2000).
    Ergonomic evaluations of the work area of different types of 
nursing staff might provide solutions to problems that are specific to 
different groups. For example, based on an ergonomic evaluation of the 
work area of scrub nurses in the operating room, Gerbrands and 
colleagues (2004) provided short term solutions for reducing the neck 
and back problems experienced by this group as well as suggested 
guidelines for operating room design.
Noise levels in hospitals are louder than a jackhammer
    The effects of noise on patients are well known. However, few 
studies have examined the impact of noise on health care staff. Ulrich 
and colleagues (2004) analyzed several studies that measured noise 
levels in hospitals and found that background noise levels in hospitals 
were typically in the range of 45 dB to 68 dB, with peaks frequently 
exceeding 85 dB to 90 dB, which is as loud as a jackhammer. This is 
well above the values (35 dB) recommended by the World Health 
Organization guidelines (Berglund, Lindvall, & Schwela, 1999).
    Staff perceive higher sounds levels as interfering with their work 
(Bayo, Garcia, & Garcia, 1995) and higher sounds levels are also 
related to greater stress and annoyance among nursing staff (Morrison, 
Haas, Shaffner, Garrett, & Fackler, 2003). Importantly, noise-induced 
stress in nurses correlates with reported emotional exhaustion or 
burnout (Topf & Dillon, 1988). Blomkvist and colleagues (2005) examined 
the effects of changing the acoustic conditions on a coronary 
intensive-care unit (using sound absorbing versus sound reflecting 
ceiling tiles) on the same group of nurses over a period of months. 
During the periods of lower noise, many positive outcomes were observed 
among staff including improved speech intelligibility, reduced 
perceived work demands and perceived pressure and strain (Blomkvist, 
Eriksen, Theorell, Ulrich, & Rasmanis, 2005).
  designing better workplaces can reduce errors & increase efficiency
    The tasks performed by the health care team involve a complex 
choreography of multiple activities including direct patient care, 
indirect care such as filling meds, coordination with care team 
members, accessing and communicating information, documentation of 
patient records and other housekeeping tasks (Lundgren & Segesten, 
2001; Tucker & Spear, 2006). Studies have shown that increased nursing 
time per patient results in better patient outcomes (Institute for 
Health care Improvement, 2004; Tucker & Spear, 2006).
    However, the fact remains that nurses spend less than half their 
time delivering direct patient care (Institute for Health care 
Improvement, 2004). Nurses spend a lot of their time searching for 
other staff, materials, missing meds and supplies and also are 
frequently interrupted during their work to address these problems 
(Tucker & Spear, 2006). In one study, a hospital nurse was interrupted 
43 times during a 10-hour period, including 10 instances when necessary 
materials, equipment and personnel were unavailable (Potter et al., 
2004).
    At the root of the inefficiencies in health care is a physical and 
organizational infrastructure that is completely out of sync with the 
optimal practice of health care. It is becoming increasingly clear that 
poorly designed physical environments along with other factors such as 
lack of social support and an unsupportive work culture, reduces the 
effectiveness of staff in providing care and potentially leads to 
medical errors.
Nurses spend a lot of time walking
    According to an unpublished time and motion study by Hendrich and 
colleagues (cited in the 2004 Institute of Medicine Report, Keeping 
patients safe: Transforming the work environment of nurses, pp. 251), 
most of nurses' time is spent walking between patient rooms, the 
nursing unit core and the nurses' station. Most older existing hospital 
units have centralized nursing stations with different configurations 
such as radial, racetrack, single or double corridor where the nursing 
station is located centrally and patient rooms are located around the 
perimeter. This kind of arrangement necessitates frequent trips between 
patient rooms and the nurses' station to look for supplies, charting, 
filling meds, and so on. According to one study, almost 28.9 percent of 
nursing staff time was spent walking (Burgio, Engel, Hawkins, McCorick, 
& Scheve, 1990). This came second only to patient-care activities, 
which accounted for 56.9 percent of observed behavior.
    A few studies have examined the impact of unit layout on the amount 
of time spent walking (Shepley, 2002; Shepley & Davies, 2003; 
Sturdavant, 1960; Trites, Galbraith, Sturdavant, & Leckwart, 1970) and 
two studies showed that time saved walking was translated into more 
time spent on patient-care activities and interaction with family 
members. Shepley and colleagues (2003) found that nursing staff in a 
radial unit walked significantly less than staff in a rectangular unit 
(4.7 steps per minute versus 7.9 steps per minute). Two other studies 
also found that time spent walking was lower in radial units as 
compared to rectangular units (Sturdavant, 1960; Trites, Galbraith, 
Sturdavant, & Leckwart, 1970). It must be noted that in the units 
examined in these studies, the nursing station was centralized with 
rooms arrayed around it.
    These studies seem to suggest that bringing staff and supplies 
physically and visually closer to the patients helps in reducing the 
time spent walking. Centralized location of supplies, however, could 
double staff walking and substantially reduce care time irrespective of 
whether nurses stations were decentralized (Hendrich, 2003). There is 
also anecdotal evidence that staff members who move from a centralized 
nursing unit to a decentralized unit often feel isolated and miss the 
camaraderie and support of the centralized unit. The social 
interactions that occur within the care team are critical for 
information sharing and effective communication. While the 
decentralized unit potentially has many benefits, it is important to 
consider how the design might impact staff interactions.
98,000 needless deaths a year
    According to the IOM report, ``To err is human: Building a safer 
health care system'', more than 98,000 people die each year in U.S. 
hospitals due to medical errors (Kohn, Corrigan, & Donaldson, 1999). 
According to Reiling and colleagues (2004) while some errors (active 
failures) occur at the point of service (for example, a nurse 
administering the wrong drug), most occur due to flaws in the health 
care system or facility design--such as due to high noise levels or 
inadequate communication systems.
    Inadequate lighting and a disorganized chaotic environment are 
likely to compound the burden of stress for nurses and lead to errors. 
A few studies have shown that lighting levels and workplace design can 
impact errors in dispensing medication in pharmacies. One study 
examined the effect of different illumination levels on pharmacists' 
prescription-dispensing error rate (Buchanan, Barker, Gibson, Jiang, & 
Pearson, 1991). They found that error rates were reduced when work-
surface light levels were relatively high (Buchanan et al., 1991). In 
this study, three different illumination levels were evaluated (450 
lux; 1,100 lux; 1,500 lux). Medication-dispensing error rates were 
significantly lower (2.6%) at an illumination level of 1,500 lux 
(highest level), compared to an error rate of 3.8% at 450 lux.
    This is consistent with findings from other settings that show that 
task performance improves with increased light levels (Boyce, Hunter, & 
Howlett, 2003). Two investigations of medication dispensing errors by 
hospital pharmacists found that error rates increased sharply for 
prescriptions when an interruption or distraction occurred, such as a 
telephone call (Flynn et al., 1999; Kistner, Keith, Sergeant, & 
Hokanson, 1994). Thus, lighting levels, frequent interruptions or 
distractions during work, and inadequate private space for performing 
work can be expected to worsen medication errors.
       physical environment impacts staff & patient satisfaction
    There is evidence that a supportive physical work environment, 
along with other factors such as high autonomy, low work pressure and 
supervisor support, positively impacts job satisfaction and burnout 
among nurses (Constable & Russell, 1986; Mroczek, Mikitarian, Vieira, & 
Rotarius, 2005; Tumulty, Jernigan, & Kohut, 1994; Tyson, Lambert, & 
Beattie, 2002). Further, studies show that environments (i.e. physical 
environment, culture and work processes) that include patients and 
families as active participants in the care process (as opposed to 
passive recipients of care) result in higher levels of satisfaction 
among patients and families (Sallstrom, Sandman, & Norberg, 1987; 
Uhlig, Brown, Nason, Camelio, & Kendall, 2002).
    Studies show that physical design changes in long-term care 
settings such as interior design modifications, natural elements, 
furniture repositioning to support social interaction, design supports 
for resident independence (such as large clocks, handrails, additional 
mirrors) and orientation (large, clear signposts and reality 
orientation boards), and artwork were related to improved morale and 
satisfaction among staff (Christenfeld, Wagner, Pastva, & Acrish, 1989; 
Cohen-Mansfield & Werner, 1999; Jones, 1988; Loeb, Wilcox, Thornley, 
Gun-Munro, & Richardson, 1995; Parker et al., 2004). Tumulty and 
colleagues (1994) suggest that if staff were allowed to make small 
design modifications to their existing environments, their satisfaction 
with their jobs might increase.
    Other studies, primarily conducted in long-term-care settings, 
suggest that smaller units contribute to reduced stress and increased 
staff satisfaction. A cross-sectional survey of 1,194 employees and 
1,079 relatives of residents in 107 residential-home units and health-
center bed wards found that large unit size was related to increased 
time pressure among employees and reduced quality-of-life for residents 
(Pekkarinen, Sinervo, Perala, & Elovainio, 2004). Other studies found 
that small unit sizes were positively associated with increased 
supervision and interaction between staff and residents in a special-
care unit for residents with dementia (McCracken & Fitzwater, 1989). 
However, no consistent numbers are offered on what makes a unit large 
or small (Day, Carreon, & Stump, 2000) and it is also not clear how 
these findings translate to acute care settings. Further, even in small 
units, it is important to consider how the design impacts staff ability 
to monitor residents. Morgan and Stewart (Morgan & Stewart, 1998) found 
that in a newly designed, low-density special-care unit with private 
rooms, enclosed charting spaces, and secluded outdoor areas and 
activity areas, staff spent increased time monitoring and locating 
residents.
    An important point that is emphasized in many of these studies is 
that design changes alone are not likely to impact staff behavior, 
satisfaction and stress. They must be accompanied by a supportive 
culture and progressive work practices to result in overall beneficial 
outcomes for patients and staff.
                            now is the time
    We believe there is an urgent need to address the inherent problems 
in the health care workplace that lead to staff injuries, medical 
errors, and waste. The physical environment plays an important role in 
improving the health and safety for staff, increasing effectiveness in 
providing care, reducing errors and increasing job satisfaction. By 
utilizing available evidence to plan and design new facilities, VA 
hospitals can create work environments that help reduce staff turnover 
and increase retention, two key factors related to providing quality 
care.
    However, it has become increasingly clear to us that efforts to 
improve the physical environment alone are not likely to help any 
health care organization achieve its goals without a complementary 
shift in work culture and work practices. While the studies we cited in 
this testimony demonstrate that well designed physical workplaces can 
support staff in their work and increase health and safety for both 
staff and patients, there is a definite need for more research 
examining the effectiveness of new design innovations such as acuity 
adaptability, standardized patient rooms, and decentralized nursing 
stations within the larger context of any health care organization's 
culture, technology changes, and work practices.
            Respectfully submitted,
                             Sara Marberry & Anjali Joseph,
                                      The Center for Health Design,
                                1850 Gateway Boulevard, Suite 1083,
                                                 Concord, CA 94520,
                           Tel. 925.521.9404; www.healthdesign.org.

References Cited

American Nurses Association. 2001. American Nurses Association/ 
            NursingWorld.org online health and safety survey: Key 
            findings (Survey results). Washington, DC: American Nurses 
            Association.
Bayo, M. V., Garcia, A. M., & Garcia, A. (1995). Noise levels in an 
            urban hospital and workers' subjective responses. Archives 
            of Environmental Health, 50(3), 247-251.
Becker, F. 2006. Organizational ecology and knowledge networks. 
            California Management Review.
Berglund, B., Lindvall, T., & Schwela, D. H. (1999). Guidelines for 
            community noise.
Blomkvist, V., Eriksen, C. A., Theorell, T., Ulrich, R. S., & Rasmanis, 
            G. (2005). Acoustics and psychosocial environment in 
            coronary intensive care. Occupational and Environmental 
            Medicine, 62, 1-8.
Boyce, P., Hunter, C., & Howlett, O. (2003). The benefits of daylight 
            through windows. Troy, New York: Rensselaer Polytechnic 
            Institute.
Brophy, M. O. R., Achimore, L., & Moore-Dawson, J. (2001). Reducing 
            incidence of low-back injuries reduces cost. American 
            Industrial Hygiene Association journal, 62(4), 508-511.
Buchanan, T. L., Barker, K. N., Gibson, J. T., Jiang, B. C., & Pearson, 
            R. E. (1991). Illumination and errors in dispensing. 
            American Journal of Hospital Pharmacy, 48(10), 2137-2145.
Burgio, L., Engel, B., Hawkins, A., McCorick, K., & Scheve, A. (1990). 
            A descriptive analysis of nursing staff behaviors in a 
            teaching nursing home: Differences among NAs, LPNs and RNs. 
            The Gerontologist, 30, 107-112.
Camerino, D., Cesana, G. C., Molteni, G., Vito, G. D., Evaristi, C., & 
            Latocca, R. (2001). Job strain and musculoskeletal 
            disorders of Italian nurses, Occupational Ergonomics (Vol. 
            2, pp. 215): IOS Press.
Clarke, S., Sloane, D., & Aiken, L. (2002). Effects of hospital 
            staffing and organizational climate on needlestick injuries 
            to nurses. American Journal of Public Health, 92(7), 1115-
            1119.
Constable, J., & Russell, D. (1986). The effect of social support and 
            the work environment upon burnout among nurses. Journal of 
            Human Stress, 12(1), 20-26.
Engst, C., Chhokar, R., Miller, A., Tate, R. B., & Yassi, A. (2005). 
            Effectiveness of overhead lifting devices in reducing the 
            risk of injury to care staff in extended care facilities. 
            Ergonomics, 48(2), 187-199.
Flynn, E. A., Barker, K. N., Gibson, J. T., Pearson, R. E., Berger, B. 
            A., & Smith, L. A. (1999). Impact of interruptions and 
            distractions on dispensing errors in an ambulatory care 
            pharmacy. American Journal of Health Systems Pharmacy, 
            56(13), 1319-1325.
Garg, A., & Owen, B. (1992). Reducing back stress to nursing personnel: 
            An ergonomic intervention in a nursing home. Ergonomics, 
            35(11), 1353-1375.
Garg, A., Owen, B., Beller, D., & Banaag, J. (1991). A biomechanical 
            and ergonomic evaluation of patient transferring tasks: Bed 
            to wheelchair and wheelchair to bed. Ergonomics, 34, 289-
            312.
Gerbrands, A., Albayrak, A., & Kazemier, G. (2004). Ergonomic 
            evaluation of the work area of the scrub nurse. Minimally 
            Invasive Therapy & Allied Technology, 13(3), 142-146.
Institute for Health care Improvement. (2004). Transforming care at the 
            bedside. Cambridge, MA: Institute for Health care 
            Improvement.
Institute of Medicine. (2004). Work and workspace design to prevent and 
            mitigate errors. In A. Page (Ed.), Keeping patients safe: 
            Transforming the work environment of nurses (pp. 226-285). 
            Washington, DC: National Academies Press.
Jiang, S., Huang, L., Chen, X., Wang, J., Wu, W., Yin, S., et al. 
            (2003). Ventilation of wards and nosocomial outbreak of 
            severe acute respiratory syndrome among health care 
            workers. Chinese Medical Journal, 116(9), 1293-1297.
Joseph, A., & Fritz, L. (2006, March). Ceiling lifts reduce patient-
            handling injuries. Healthcare Design, 6, 10-13.
Kistner, U. A., Keith, M. R., Sergeant, K. A., & Hokanson, J. A. 
            (1994). Accuracy of dispensing in a high-volume, hospital-
            based outpatient pharmacy. American Journal of Hospital 
            Pharmacy, 51(22), 2793-2797.
Kohn, L., Corrigan, J., & Donaldson, M. (Eds.). (1999). To err is 
            human: Building a safer health system. Washington, DC: 
            National Academy Press.
Kromhout, H., Hoek, F., Uitterhoeve, R., Huijbers, R., Overmars, R. F., 
            Anzion, R., et al. (2000). Postulating a dermal pathway for 
            exposure to anti-neoplastic drugs among hospital workers: 
            Applying a conceptual model to the results of three 
            workplace surveys. The Annals of Occupational Hygiene, 
            44(7), 551-560.
Lundgren, S., & Segesten, K. (2001). Nurses' use of time in a medical-
            surgical ward with all-RN staffing. Journal of Nursing 
            Management, 9, 13-20.
McCarthy, D., & Blumenthal, D. (2006). Committed to safety: Ten case 
            studies on reducing harm to patients (No. 923). New York, 
            NY: Commonwealth Fund.
Miller, A., Engst, C., Tate, R., & Yassi, A. (2006). Evaluation of the 
            effectiveness of portable ceiling lifts in a new long-term 
            care facility. Applied Ergonomics, 37, 377-385.
Morrison, W. E., Haas, E. C., Shaffner, D. H., Garrett, E. S., & 
            Fackler, J. C. (2003). Noise, stress, and annoyance in a 
            pediatric intensive care unit. Critical Care Medicine, 
            31(1), 113-119.
Mroczek, J., Mikitarian, G., Vieira, E. K., & Rotarius, T. (2005). 
            Hospital design and staff perceptions: An exploratory 
            analysis. The Health Care Manager, 24(3), 233-244.
Potter, P., Boxerman, S., Wolf, L., Marshall, J., Grayson, D., Sledge, 
            J., et al. (2004). Mapping the nursing process: A new 
            approach for understanding the work of nursing. Journal of 
            Nursing Administration, 34(2), 101-109.
Redfern, M., & Cham, R. (2000). The influence of flooring on standing 
            comfort and fatigue. American Industrial Hygiene 
            Association journal, 61, 700-708.
Reiling, J., Knutzen, B., Wallen, T., McCullough, S., Miller, R., & 
            Chernos, S. (2004). Enhancing the traditional hospital 
            design process: A focus on patient safety. Joint Commission 
            Journal on Quality and Safety, 30(3), 115-124.
Sallstrom, C., Sandman, P. O., & Norberg, A. (1987). Relatives' 
            experience of the terminal care of long-term geriatric 
            patients in open-plan rooms. Scandinavian Journal of Caring 
            Science, 1(3-4), 133-140.
Shepley, M. M. (2002). Predesign and postoccupancy analysis of staff 
            behavior in a neonatal intensive care unit. Children's 
            Health Care, 31(3), 237-253.
Shepley, M. M., & Davies, K. (2003). Nursing unit configuration and its 
            relationship to noise and nurse walking behavior: An AIDS/
            HIV unit case study. AIA Academy Journal Retrieved 5/26/
            2004, 2004, from http://www.aia.org/aah/journal/0401/
            article4.asp
Smedbold, H. T., Ahlen, C., Unimed, S., Nilsen, A. M., Norbaeck, D., & 
            Hilt, B. (2002). Relationships between indoor environments 
            and nasal inflammation in nursing personnel. Archives of 
            Environmental Health, 57(2), 155-161.
Sturdavant, M. (1960). Intensive nursing service in circular and 
            rectangular units. Hospitals, JAHA, 34, 46-48, 71-78.
Topf, M., & Dillon, E. (1988). Noise-induced stress as a predictor of 
            burnout in critical care nurses. Heart Lung, 17(5), 567-
            574.
Tucker, A., & Spear, S. (2006). Operational failures and interruptions 
            in hospital nursing. Health Services Research, 41(3), 643-
            662.
Tumulty, G., Jernigan, I. E., & Kohut, G. F. (1994). The impact of 
            perceived work environment on job satisfaction of hospital 
            staff nurses. Applied Nursing Research, 7(2), 84-90.
Tyson, G. A., Lambert, G., & Beattie, L. (2002). The impact of ward 
            design on the behavior, occupational satisfaction and well-
            being of psychiatric nurses. International Journal of 
            Mental Health Nursing, 11(2), 94-102.
Uhlig, P., Brown, J., Nason, A., Camelio, A., & Kendall, E. (2002). 
            System innovation: Concord Hospital. The Joint Commission 
            Journal on Quality Improvement, 28(12), 666-672.
Ulrich, R. S., Zimring, C., Joseph, A., Quan, X., & Choudhary, R. 
            (2004). The role of the physical environment in the 
            hospital of the 21st century: A once-in-a-lifetime 
            opportunity. Concord, CA: The Center for Health Design.
  

                                  
