[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
HEALTHY HIRING: ENABLING VA TO RECRUIT AND RETAIN QUALITY PROVIDERS
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HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
WEDNESDAY, MARCH 22, 2017
__________
Serial No. 115-7
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
DAVID P. ROE, Tennessee, Chairman
GUS M. BILIRAKIS, Florida, Vice- TIM WALZ, Minnesota, Ranking
Chairman Member
MIKE COFFMAN, Colorado MARK TAKANO, California
BRAD R. WENSTRUP, Ohio JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American ANN M. KUSTER, New Hampshire
Samoa BETO O'ROURKE, Texas
MIKE BOST, Illinois KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine J. LUIS CORREA, California
NEAL DUNN, Florida KILILI SABLAN, Northern Mariana
JODEY ARRINGTON, Texas Islands
JOHN RUTHERFORD, Florida ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto
Rico
Jon Towers, Staff Director
Ray Kelley, Democratic Staff Director
SUBCOMMITTEE ON HEALTH
BRAD WENSTRUP, Ohio, Chairman
GUS BILIRAKIS, Florida JULIA BROWNLEY, California,
AMATA RADEWAGEN, American Samoa Ranking Member
NEAL DUNN, Florida MARK TAKANO, California
JOHN RUTHERFORD, Florida ANN MCLANE KUSTER, New Hampshire
CLAY HIGGINS, Louisiana BETO O'ROURKE, Texas
JENNIFER GONZALEZ-COLON, Puerto LUIS CORREA, California
Rico
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
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C O N T E N T S
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Wednesday, March 22, 2017
Page
Healthy Hiring: Enabling VA To Recruit and Retain Quality
Providers...................................................... 1
OPENING STATEMENTS
Honorable Brad Wenstrup, Chairman................................ 1
Honorable Julia Brownley, Ranking Member......................... 2
WITNESSES
Robert Goldenkoff, Director, Strategic Issues, U.S. Government
Accountability Office.......................................... 3
Prepared Statement........................................... 25
Accompanied by:
Debra A. Draper, Ph.D., Director, Health Care, U.S Government
Accountability Office
Max Stier, President and Chief Executive Officer, Partnership for
Public Service................................................. 5
Prepared Statement........................................... 37
Louis J. Celli Jr., Director, National Veterans Affairs and
Rehabilitation Division, The American Legion................... 7
Prepared Statement........................................... 45
Steve Young, Deputy Under Secretary for Health for Operations and
Management, Veterans Health Administration, U.S. Department of
Veterans Affairs............................................... 8
Prepared Statement........................................... 48
Accompanied by:
Paula Molloy Ph.D., Assistant Deputy Under Secretary for
Health for Workforce Services, Veterans Health
Administration, U.S. Department of Veterans Affairs
STATEMENTS FOR THE RECORD
Disabled American Veterans (DAV)................................. 50
Paralyzed Veterans of America (PAV).............................. 54
Veterans of Foreign Wars of the United States (VFW).............. 56
HEALTHY HIRING: ENABLING VA TO RECRUIT AND RETAIN QUALITY PROVIDERS
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Wednesday, March 22, 2017
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Disability Assistance
and Memorial Affairs,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 2:06 p.m., in
Room 334, Cannon House Office Building, Hon. Brad Wenstrup
[Chairman of the Subcommittee] presiding.
Present: Representatives Wenstrup, Bilirakis, Radewagen,
Dunn, Rutherford, Higgins, Brownley, Takano, Kuster, O'Rourke,
and Correa.
OPENING STATEMENT OF BRAD WENSTRUP, CHAIRMAN
Mr. Wenstrup. The Subcommittee will come to order. Good
afternoon and I thank you all for joining us. It is my pleasure
to welcome you to today's Subcommittee on Health Oversight
Hearing on the ability of the Department of Veterans Affairs,
Veterans Health Administration, to recruit and retain top notch
employees to serve our Nation's veterans.
Today's hearing comes as a timely follow up to legislation,
H.R. 1367, that was considered in the House last week to grant
VA expanded authorities to incentivize recruitment and
retention of highly qualified and motivated employees and
develop the next generation of VA leaders. H.R. 1367
unanimously passed the House last Friday morning by a vote of
412 to nothing and now is awaiting action in the Senate. You do
not see that very often.
I hope our colleagues in our upper chamber will take note
of the testimony discussed during today's hearing and act
swiftly to get this much needed bipartisan legislation to the
President's desk so that it can begin working for veteran
patients and VA employees across the country.
While I am proud of last week's effort and convinced that
if enacted H.R. 1367 will lead to improvements nationwide, I am
aware that it is just the tip of the iceberg. VA continues to
recruit new hires using a Federal hiring process that VA's own
testimony today calls outdated and unduly burdensome. The
Subcommittee continues to hear about prospective VA employees,
some of whom are themselves veterans, who want to work for VA
but accept other job offers because the VA on-boarding process
is too cumbersome and too lengthy.
In 2014 Congress appropriated billions of dollars to help
VA hire more medical staff. Three years later, it is unclear if
the department used that money for its intended purpose, or
hired any more clinicians with it than they would have without
it.
As if those challenges were not enough, during today's
hearing we will also be discussing the 2016 Government
Accountability Office report that resulted in some very
concerning conclusions about VA's human resources operations.
According to GAO, VHA human resource offices are struggling to
such an extent that they have undermined the department's most
sacred mission: the ability to improve the delivery of health
care services to veterans. What is more, the recent best places
to work in the Federal government survey ranked VA second to
last for large agencies in satisfaction among employees under
the age of 40. That finding contributes to ongoing concerns
that as the existing VA workforce becomes eligible to retire in
vast numbers, VA is not well positioned to recruit and retain
the young talent needed to guide the department into the
future.
The Commission on Care summed it up best in their final
report last year when the commissioners noted that VHA suffers
from staffing shortages and vacancies at every level of the
organization and across numerous critical positions. It lacks
competitive pay to aid recruitment and retention of highly
specialized positions and utilizes inflexible hiring processes,
a talent management approach from the last century, and a
confusing mix of personnel authorities and position standards.
Together, these findings are to say the very least troubling.
They clearly indicate a need for much further action to improve
VA's ability to recruit and retain high performing staff and
ensure that skilled candidates for open positions are quickly
identified, successfully recruited, and swiftly hired.
I appreciate our panelists from VA, GAO, and the
Partnership for Public Service, and the American Legion for
being here today as part of an ongoing conversation into how
together we can overcome the staffing challenges that VA
currently faces and in doing so improve the provision of care
and services to those veterans relying on VA to support and
heal them.
I am very much looking forward to today's discussion and
with that I will now yield to Ranking Member Brownley for any
opening statement that she may have.
OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER
Ms. Brownley. Thank you, Chairman Wenstrup. Thank you for
your leadership in passing your legislation and our bipartisan
legislation to improve the VA's ability to hire and retain
health care providers at the VA. I also thank you for allowing
my amendment to include the community based outpatient clinics,
nursing homes, and Vet Centers in the GAO succession planning
report. Thank you for supporting me on that. I look forward to
working with you to get this important legislation passed in
the Senate and to the President's desk as soon as we possibly,
possibly can.
We passed this legislation because our veterans deserve
timely, high quality health care, but that job is made so much
more difficult if we cannot hire the health care providers we
need. I know from talking to staff at the Oxnard CBOC in my
district in Ventura County, and with the director of the VA
medical facility in West Los Angeles, that both facilities
struggle to hire and retain health care providers and HR
professionals.
The VA continues to struggle to address staffing shortages
at the Oxnard CBOC. During my meeting with the West L.A. VA
Medical Center I have heard that HR is one of their biggest
challenges and last we spoke their HR Director position was
unfilled.
The GAO's testimony and its report on VA's longstanding
human capital challenges confirm what I have heard from the
veterans in my district and the staff at our local VA medical
centers. As the Chairman said, even though we have provided the
VA with an additional $2.2 billion in the Choice Act to hire
additional health care staff, VA continues to struggle with
recruiting and hiring of providers in the five clinical
occupations with the largest staffing shortages.
Today we will hear from witnesses who I hope will help us
understand the root causes of these staffing issues. I want to
learn about the challenges VA HR professionals face and how the
Federal hiring freeze affects the VA. As we know the hiring
freeze does not exempt HR staff and without HR personnel I am
concerned that the VA will not be able to bring on the health
care providers they need to serve our veterans. I want to know
if this is having a negative effect on VA's ability to fill the
45,000 vacancies in VHA.
I also welcome solutions to VA's human capital challenges
from the VA and our veterans service organizations. I believe
that more must be done to address the lengthy hiring process
for health care providers. VA must do a better job at hiring
and retaining the future health care workforce that they need
to care for our veterans. I look forward to continuing the
bipartisan work on this issue. And I yield back.
Mr. Wenstrup. Thank you, Ms. Brownley. Joining us this
afternoon on our first and only panel is Robert Goldenkoff, the
Director of Strategic Issues at the Government Accountability
Office; who is accompanied by Dr. Debra A. Draper, Ph.D., the
Director of the Health Care Team for the Government
Accountability Office; Max Stier, the Chief Executive Officer
for the Partnership for Public Service; Louis Celli, Jr., the
Director of National Veterans Affairs and Rehabilitation
Division for the American Legion; and Steven Young, the Deputy
Under Secretary for Health for Operations and Management for
the Department of Veterans Affairs; who is accompanied by Dr.
Paula Molloy, the Assistant Deputy Under Secretary for Health
for Workforce Services. I want to thank you all for being here
this afternoon. Mr. Goldenkoff, we will begin with you, and you
are now recognized for five minutes.
STATEMENT OF ROBERT GOLDENKOFF
Mr. Goldenkoff. Chairman Wenstrup, Ranking Member Brownley,
and Members of the Subcommittee, thank you for the opportunity
to participate in today's hearing on VHA's ability to recruit
and retain high quality clinical and administrative employees.
Joining me this afternoon is my colleague, Debra Draper, a
Director with GAO's health care team. The two of us are part of
a large GAO wide effort examining the various management
challenges facing VA.
As you know, in February, 2015, GAO added improving
veterans health care to its list of Federal high risk areas and
GAO's oversight is aimed at ensuring that VA's resources are
used to deliver cost effective health care to our Nation's
veterans.
With respect to the recruitment and retention of clinical
employees, to meet the growing demand for care, VHA has
implemented a number of targeted hiring initiatives.
Nevertheless, we and others have expressed concerns about
VHA's ability to ensure that it has the appropriate clinical
workforce to meet the current and future needs of veterans due
to such factors as national shortages and increased competition
for clinical employees in hard to fill occupations.
As one example, retention is problematic. Our 2016 report
found that attrition across the five clinical occupations at
VHA with the largest staffing shortages increased each year
from about 5,900 employees in fiscal year 2011 to about 7,700
employees in fiscal year 2015. Voluntary resignations were the
primary drivers of VHA's losses for these occupations, which
included physicians, registered nurses, physician assistants,
psychologists, and physical therapists.
We also found that VHA had not evaluated the training
resources provided to nurse recruiters at VA medical centers.
As a result, VHA is unable to determine the effectiveness of
its nurse recruitment and retention initiatives and whether VHA
has an adequate and qualified nurse workforce to meet veterans
health care needs.
The recruitment and retention challenges VHA is
experiencing with its clinical workforce are due in part to
VHA's limited HR capacity, including attrition among its HR
employees and weak HR related internal control functions. For
example, we found that between fiscal years 2011 and 2015 the
majority of medical centers fell short of VHA's staffing goals.
VHA determined that a ratio of one HR staff to 60 VHA employees
was needed to provide quality HR services. In fiscal year 2015,
however, about 116 of 139 medical centers fell short of this
target, and half of the 116 had a ratio of one HR staff to 80
employees or worse.
According to the HR staff we interviewed these staffing
levels reduced HR employees' ability to keep pace with work
demands and led to such issues as delays in the hiring
processes, problems with addressing important clinical hiring
initiatives, and an increased risk of personnel processing and
coding errors. To date VA has exempted 108 VHA occupations from
the current hiring freeze because they are necessary to meet
VHA's public safety responsibilities. However, the broad list
of exemptions, ranging from physicians to housekeeping staff,
did not include HR specialists even though VHA ranked human
resource management as third on a list of mission critical
occupations in its 2016 workforce succession plan.
Weaknesses in HR related internal control functions are
also reducing VHA's ability to deliver HR services. For
example, we found that central HR offices at VA and VHA have
inadequate oversight of medical center HR offices, thus
limiting VA's ability to hold the local offices accountable for
improving hiring processes, training HR staff, and implementing
consistent classification processes.
In summary, recruitment and retention challenges among the
ranks of VHA's clinical and HR employees are making it
difficult for VHA to meet the health care needs of our Nation's
veterans. GAO has recommended a number of actions to VA to
address those challenges. VA concurred with them and going
forward we will monitor VA's progress in implementing those
recommendations and report the results of those efforts to
Congress.
Chairman Wenstrup, Ranking Member Brownley, Members of the
Subcommittee, this completes my prepared statement. Debra and I
will be pleased to respond to any questions that you may have.
[The prepared statement of Robert Goldenkoff appears in the
Appendix]
Mr. Wenstrup. Thank you very much. We now go to Mr. Stier,
you are recognized for five minutes.
STATEMENT OF MAX STIER
Mr. Stier. Great. Well thank you very much for having me at
this hearing. It is a pleasure to be here. The first point I
would make is that you are focused on the right issue. No
organization can work well if it does not have the right talent
and there are real issues on the talent side for VA, and VHA in
particular. Ranking Member, you mentioned 45,000, my data says
48,000 vacancies. Under half of the VHA employees, only 44
percent, believe that their work unit is able to recruit the
talent that they need. And again under half of the staff
believes that they have the resources, the staff resources,
they need to succeed. So these are very, very concerning
figures.
Less than six percent of VHA is under the age of 30. And
the final stat, obviously that has improved over time but still
is not where it needs to be, is that you have 11 percent
vacancy rate at the center director level, which is
phenomenally important.
You mentioned earlier the great success you had and a
remarkable success in a unanimous piece of legislation.
Obviously getting it done, getting it passed by the Senate is
critical here. There are a number of elements of that
legislation that will make a difference. And I would highlight
the fact that you got the passport idea that qualified
individuals can come back into government at any level that
they now are justified to, which is terrific. The idea of a
talent exchange with the private sector I think is wonderful.
My favorite is holding political appointees accountable,
actually requiring them to have performance plans. I think that
if I might say the fish rots from the top and you need the
political appointees themselves to have, you know, performance
plans that are transparent and that include management and in
particular people management issues. There are, however, a
number of issues that I think would, you could surface still
today that would strengthen the VHA and VA's ability to get the
right talent in. And I would highlight three of them.
The first of it begins with the VISN and the medical center
directors. Your legislation included direct hire authority for
them. Initially you had included something around market pay
and had taken that out. I believe that was penny wise and pound
foolish. At the end of the day you are looking at the most
important element of success at VHA, which are the individuals
running the medical centers and they are being paid under
$200,000 in a market place where their peers for the private
sector are being paid $700,000 and plus. And I think unless you
are able to pay closer to market you are always going to have
too many vacancies and you are not going to be able to draw the
best talent in. It is a relatively small investment with high,
high impact. And so I strongly urge you to bring that back.
Number two, I think you need to make it easier more broadly
to recruit talent in. And there are several ways you can do
that. Again, on the young, or the younger talent, under age 30,
you should have direct hire authority for those that are coming
out of college or are recent graduates. And that would I think
deal with that imbalance in a very important way.
The standard for determining when you can have direct hire
authority to hire. Right now they have to show a shortage of
minimally qualified individuals. That is the wrong standard. It
should be a shortage of highly qualified individuals. And that
would then allow VA to actually recruit for mission critical
people that are in short supply that they actually need. They
do not need the minimally qualified. They need the highly
qualified. And if they cannot find them, the rules should be
easier for them to bring them in more easily.
And number three, it should be easier to hire executives
from the outside. And that means including a process in
recruiting executives that is akin to what all executives have
to do in every other organizations. They do not have to fill
out huge long essays in any other organization besides the
Federal government. We have to normalize the process inside the
government if we expect great talent from outside the
government to want to come in.
I would end with three concluding observations that I think
are important. And the first is that the talent issues that VA
is facing are not unique to VA. And in fact the changes that
are discussed here ought to be taking place across the entire
government and then some. We have a system that was largely
designed in 1949 for a world that is no longer. Work has
changed. The world has changed. The government systems have
not, and they are not going to be able to meet the talent needs
unless they are. And so I would urge all of you to think about
what can be done for VA but more broadly what can be done for
the larger government.
The second, the hiring freeze that has been raised here,
has been a real problem. Even when there are exceptions made,
you are sending a signal into the talent market that the
government cannot hire. You are confusing people. Clearly there
should be an exception made for the HR. But beyond that you do
not freeze in place something that you do not want. And we have
a system right now that we should not want.
Now I would argue for beyond that that the hiring freeze
only lasts another month and I would ask this Committee to
think about what happens next. Because there are plans that are
required from the executive branch. I am worried about that. I
am worried about the uncertainty. I am worried about the
choices. And I think this Committee should care about what
those choices are post the initial hiring freeze.
And then finally I think you need to think about how are
you going to know whether these changes are really making a
difference? How are you going to hold accountable the VA and
the rest of government that they are actually getting better?
There are so many opportunities that Congress has given to the
executive branch, new authorities that either do not get used
or do not scratch the real itch. And the real question is going
to be how are you going to know, how are you going to learn,
and how are you going to adapt and be agile to figure out how
to get better at it?
So thank you for your time and for your engagement.
[The prepared statement of Max Stier appears in the
Appendix]
Mr. Wenstrup. Thank you very much. Mr. Celli, you are now
recognized for five minutes.
STATEMENT OF LOUIS J. CELLI, JR.
Mr. Celli. Mayo Clinic, Cleveland Clinic, Mass General
Hospital, Johns Hopkins, billions of dollars in resources. They
can hire any doctor or medical team in the country if they want
them badly enough. Seemingly unlimited access to cash. Mayo has
4,000 doctors and half as many nurses. Cleveland Clinic has
3,000 doctors and 4,000 nurses. Mayo, a large rural hospital,
has 1,243 beds, and in Cleveland, a large metro hospital, they
have 1,278 beds. VA currently operates 1,233 health care
centers, all simultaneously at the same time.
Chairman Wenstrup, Ranking Member Brownley, and
distinguished, dedicated defenders of veterans who proudly
serve on this Committee, on behalf of Charles Schmidt, the
National Commander of the largest veterans service organization
in the United States of America, representing 2.2 million dues
paying, voting members, and combined with our American Legion
family whose numbers exceed 3.5 million voters living in every
district in America, it is my duty and honor to present the
American Legion's position on how to enable VA to recruit and
retain quality providers.
The top two hospitals in the country have two very
different strategies. One has 4,000 docs and 2,000 nurses,
while the other one has 43,000 nurses and 3,000 docs. Meanwhile
in 2015 VA lost over 2,000 medical officers alone. We have got
to do better. While VA may not have unlimited dollars to
attract, recruit, and retain medical teams, they do have a vast
sea of resources that they need to get more creative in using.
VA has been doing more with less for decades and with greater
demands on services and the striking increase in comorbidities
being presented at VA today, VHA is going to have to start
leveraging the resources they already have to attract and
retain medical talent and they are going to need your help.
VA has statutory missions that include research, training,
emergency preparedness, and all while providing world class
health care to nearly half of our veteran population. The
differences between VA and nearly every other hospital in
America is selectivity. VA is selective over who they serve,
which insurances they can accept, how much to charge patients,
and how they will accept payment, all while stretching to serve
veterans in every corner of the country and abroad. This is a
business model that no other hospital system in the country
suffers under nor would they be able to survive if they were
made to adhere to the regulatory guidance that VA has to
follow.
Comparing VA to other American business models is just
ridiculous. Here are five quick options to consider. One, open
VA to more patients. Two, make VA more competitive and allow
them to accept all forms of insurance, Medicare, Medicaid,
etcetera. Three, make VA a destination employer by offering
physicians rotations in research, emergency preparedness,
education. Next, call on VA to stand up a medical school. It is
within their statutory mission; they have the real estate; they
have the expertise; they have the reputation; and they have the
resources. Think service academies. Lastly, instruct VA to
engage in public-private partnerships with community hospitals
across the country by renting wings of existing hospitals.
These are just a few suggestions that the American Legion
continues to stand ready to work with this Committee and VA to
move innovation forward.
That said, the first thing that needs to happen, is VA
needs to start being treated fairly. The American Legion calls
on Congress and the American people to treat VA with fair and
balanced criticism, as well as praise. Stop taking cheap shots
at our health care system. It is hurting veterans. It is
hurting morale. And it is killing VA's recruiting efforts. We
all have a moral obligation to make it better and not to
torture it to death. Anyone that thinks that killing VA will
save taxpayer dollars is woefully misinformed and either
delusional or lying. Cost shifting to veterans has already
begun and we expect it to get progressively worse. I am afraid
that we may not be able to stem the tide.
VA can be more competitive if allowed to be, and the only
outcry that you will start hearing will be coming from the
private sector hospitals in the country who will accuse
government of unfair competition. You want solutions, you want
to reduce government's financial burden, you want to lower
taxes, and really step up to the plate, take the handcuffs off
of VA and let them really compete in the marketplace. Mayo,
Cleveland, Mass General, competitive. VA, a slave to Congress,
the media, and their own bureaucracy.
Only you have the power to fix what ails VA and it is not
by supporting the status quo.
[The prepared statement of Louis J. Celli, Jr. appears in
the Appendix]
Mr. Wenstrup. Mr. Young, you are recognized for five
minutes.
STATEMENT OF STEVE YOUNG
Mr. Young. Good afternoon, Chairman Wenstrup, Ranking
Member Brownley, and Members of the Subcommittee. Thank you for
the opportunity to discuss VHA's ability to recruit and retain
high quality employees. I am accompanied today by Dr. Paula
Molloy, Assistant Deputy Under Secretary for Health for
Workforce Services.
VHA is the largest health care system in the United States,
with 170 VA medical centers, over 1,000 community based
outpatient clinics, and more than 320,000 employees. I want to
take a moment to recognize the HR employees who might be
listening right now. They work with a variety of complex HR
systems and I want to acknowledge that they are a talented,
hardworking group who are focused on doing their job so that
VHA can accomplish our mission to provide the health care our
veterans have earned.
But this mission is hampered by outdated Federal HR
processes. Furthermore, there is a national shortage of health
care providers and VHA is competing with the commercial sector
for these scarce resources. Consequently we are striving to
update not only internal hiring practices, but also open to
legislative assistance to reform VHA's recruitment,
compensation, and accountability practices to stay competitive.
The Government Accountability Office released a report in
December, 2016, management attention is needed to address
systemic, longstanding human capital challenges. In this report
GAO detailed how limited HR capacity combined with weak
internal control practices undermine VHA's operations and its
ability to improve delivery of health care services to
veterans.
I am working closely with Dr. Molloy to ensure that HR
operations teams in the field and the central office are
aligned to address the issues identified in this GAO report.
VHA concurs with GAO's assessment that high performing
organizations seek to create effective incentive and reward
systems that clearly link employee knowledge, skills, and
contributions to organizational results. VA has been faced with
significant caps on awards for several years, resulting in a
limited pool of funds for employee recognition. While these
caps were well intentioned to increase accountability, they
also result in significant impediments to recruitment and
retention in VHA. The cap for fiscal years 2017 and 2018
represents a significant decrease in available funding during a
time when the market for clinicians is growing increasingly
competitive.
VHA is entering into the next phase of an automated
performance management system, called ePerformance. This system
allows the development and sharing of consistent performance
standards, goals, and competencies in a schedule to be
completed in October of 2018. All employee survey results show
that employees are eager for us to hold accountable those who
do not meet our standards in respect for veterans and for one
another. Employees want all staff to be held to uniform
expectations, including being adjudicated fairly. We also know
that employee engagement is the most effective at the work
group level. We can monitor at the national level, but where it
really happens is between employees and their immediate
supervisors.
To achieve VHA's mission of providing exceptional patient
centered care to America's veterans, it is essential to recruit
and retain highly skilled and dedicated employees functioning
at the top of their competency level, as well as to develop a
talented succession pipeline. VA's national health care
recruitment service provides a centralized in house team of
skilled professional recruiters employing best practices to
fill agencies' top clinical and executive positions. The
national recruiters, nearly all of whom are veterans, work
directly with clinical leadership and local HR departments in
the development of comprehensive, client centered recruitment
strategies that address both current and future critical
staffing needs.
Over the last year VHA's business process improvement
efforts under the My VA critical staffing breakthrough
initiative have resulted in a more efficient hiring process. As
we continue our work to improve HR capacity across VHA, we are
engaged with a department wide effort to improve employee
experience through a complete overhaul of the on-boarding
process. As Secretary Shulkin has expressed previously, we need
all the tools that other health care organizations have: the
ability to recruit the best employees, the ability to reward
our top performers, and the ability to take meaningful actions
when employees do not perform up to our standards. VA's primary
concern during the hiring freeze is to ensure the health and
safety of our veterans. Positions deemed necessary to meet
national security or public safety responsibilities are exempt
from the hiring freeze. And although HR positions are not
exempt from the hiring freeze, we recognize that a well-trained
and adequately resources HR staff is essential to recruit,
hire, and retain high quality employees. Therefore we have
processes in place to address case by case circumstances.
Mr. Chairman, I am proud of the health care our employees
provide to our Nation's veterans. Together with Congress I look
forward to making sure that VA can attract and retain the best
medical providers and support staff to give our veterans the
care they have earned and deserve. Thank you for the
opportunity to testify before this Subcommittee. Paula and I
look forward to your questions.
[The prepared statement of Steve Young appears in the
Appendix]
Mr. Wenstrup. I want to thank you all very much for your
testimonies here today. It is greatly appreciated. You know, we
talk about some of the systems within the VA or processes have
never changed in 30 or 40 years. And I think that highlights to
me the importance of bringing people in from outside the VA
because when you stay in the same system forever, you do not
know what you do not know. And so that effort to reach out to
people who come from other walks of life in the same fields can
bring a lot to the table. And I appreciate that in the
testimony today that we engage that further and continue down
that line.
And I agree, Mr. Celli, competition drives excellence. And
this is not a competitive arena, if you will, in so many ways.
And I think that we have opportunities to change that. And I
will say this, that there is a great desire, as a doctor and
many doctor friends and even one last night coming up to me, he
said I really want to treat veterans. But I want the process to
be simpler. And one even said, maybe I just can come into VA,
he is an anesthesiologist who does pain management. This is who
you want treating pain, by the way, pain specialists. Too often
we have doctors that do not specialize in pain management
writing a lot of prescriptions. And we know what that has led
to. So you know, we have people that want to come in. Would be
willing to come in to the VA if the process was easier, or if
they could just lease a space in the VA and take care of
patients through something like the Choice program. So we have
opportunities here to bring excellent doctors in if we are
open-minded about how we go about what we are doing.
And with that I am going to yield myself five minutes now
for questions. And I want to start with you, Mr. Young, if I
could, and hoping you can outline for me some of the hiring
processes that you believe are outdated and burdensome, and
maybe even provide us with a list of processes that you would
like to see changed. Not necessarily this minute, but if you
could provide us with a list at some point of things that you
would like to see changed and what people at the VA would like
to see changed so that they can do their job better. And one
other thing in relation to that, do you track the number of
prospective hires that are lost during the hiring process? And
I will let you take all that in if you would. Thank you.
Mr. Young. I think the first reaction would be some of the
other items that have already been addressed in the opening
comments, would be the direct hire authority and the ability to
make it easier to come into government service. As was
referenced, the, I do not think there are any other executives
that are required to write a thesis to demonstrate what their
competencies are related to the positions for which they are
applying. And that is one of the things that we require for
people coming into government service as a health care
executive.
I would also defer to Dr. Molloy to talk a little bit more
about some of those challenges.
Ms. Molloy. Certainly. So I think some of the work that we
have done with our medical center director hiring, for example,
provides a nice illustration of what some of these processes
are. So for example with our medical center director hiring the
way we used to do it in order to be compliant with OPM rules we
would issue these single announcements for each individual
location for which a medical center director was needed. The
problem with that is we might get great candidates interested
in one location, but if they did not apply to the other
location we could not consider them for that. So what we have
done to change that process internally is to do national
announcements that cover all of the locations that are open. So
what this illustrates is that there are a number of HR hiring
rules under the regulations from OPM, this is just one example,
where there are opportunities to streamline and make those
processes easier and more common sense.
Mr. Wenstrup. Well, if you could highlight those for us, I
would appreciate hearing back from you on your ideas, and then
how we can help assist in making that process possible. Mr.
Young, in your written testimony you mentioned the local
facilities employ nurse recruiters. Are there recruiters in
place for other specific clinical positions that are needed? Or
do we just kind of post it out there? Is there active
recruitment for some of the specialties that you may need?
Mr. Young. Each medical center has nurse recruiters. But at
each network level we have recruiters that work on bringing in
medical specialties. And they all actually work directly under
central office but they are located out in the field for the
explicit purpose of trying to recruit in hard to recruit
medical specialties.
Mr. Wenstrup. Is that effective in that way? Or would it be
better at the local facility, do you think? Like you do for the
nursing?
Mr. Young. I believe that it is a nice blend, that they
have the support and the guidance from VA central office but
they are physically located out in the field and they are
working to support the individual medical centers in that
region of the country where they are.
Mr. Wenstrup. So they do approach it at a local level?
Mr. Young. Absolutely.
Mr. Wenstrup. And if you could just in the time I have left
elaborate a little bit on the VA's striving to update internal
hiring practices? When will that effort be complete? And when
can we expect to hear back from you on what you think is
working or not working?
Ms. Molloy. So we just completed a process where we went
out to all of our field locations and conducted a series of
rapid process improvement work groups. And I would be happy to
take for the record summarizing what those findings are,
because those are really guiding our practices. What we found
is that we, we have not come up with sort of a one size fits
all model. But it is sort of a multiple set of models. So for
example, one approach for nurses, another approach for
physicians because of both local hiring conditions and also the
professionals that we are trying to reach. You know, there are
different hiring pools that we are looking at.
Mr. Wenstrup. Is it within the realm to be able to reach
out to places like the Cleveland Clinic and ask them what their
process looks like?
Ms. Molloy. Absolutely.
Mr. Wenstrup. And bring that in? Because it would be good
to maybe get some comparisons of places that are highly
successful in many ways and see if that outside advice could be
helpful to us. With that, I now yield to Ranking Member
Brownley for her questions.
Ms. Brownley. Thank you, Mr. Chairman. So it has been
stated that, you know, voluntary resignations are a big part of
the reason for some of these empty positions, training,
particularly within HR. So what is, why are we having all of
these voluntary resignations? Is it just, they are aging out of
the system? Or is it they are overtaxed and cannot take it
anymore? Or what is the reason?
Ms. Molloy. So for HR, the information that we have seen
from our exit survey data is, it is a combination of factors.
In some cases it is career advancement, perhaps with another
Federal agency. In other cases it might be family or personal
reasons that is driving that attrition. But we are acutely
aware that there is a lot of work that is placed on our HR
professionals and it is something that I feel deeply personally
about and want to make sure that we are providing the
opportunities to expand the capabilities of our HR
professionals through training to make their lives easier
everyday on the job. And that we are also looking, in addition
to being able to increase our ranks through things like our
technical career field program, that we are also looking for
efficiencies that can help make the work go smoother and more
easily for folks.
Mr. Young. And I would add that we do know that among our
HR professionals that we see a fair amount of turnover for
those leaving VA to go to other Federal agencies because,
candidly, the job is easier. In the VA we have three HR
systems, Title 5, Title 38, Title 38 hybrid. It makes the HR
professionals' jobs very complex. And frankly, the jobs can be
easier elsewhere.
Ms. Brownley. So, you know, in terms of all of the--well,
let me back up. So, you know, the GAO has made some
recommendations. It sounds like you are going to comply to
those recommendations. Mr. Stier just gave a list of
recommendations from his perspective. From what Mr. Stier
suggested today, is there anything there that turns a lightbulb
on for you of things that we should be looking at and doing?
Mr. Young. I was particularly struck by a conversation we
were actually having before the hearing started about the
disparity in salaries. And I think that one of the, a mechanism
that can be used to try to close that disparity is moving
toward greater latitude with Title 38 as the hiring authority
versus Title 5 for a range of positions within VA.
Mr. Stier. So might I just jump in for a second, too, on
your attrition note. And what we do see at VA, again it was
noted earlier that VA is the second lowest major agency in the
government with respect to employee morale. It is quite
interesting if you look at the HR workforce in particular, VA
has actually made some progress in the last few years moving
up, even though they are still in relative terms fairly low.
That is not true for the HR workforce, which is going in the
opposite direction. And I think there is tons of data that
shows, you know, low morale, increased, you know, attrition.
And the morale question is going to be complicated and I think
you heard some of the reasons why in terms of complexity of
task.
One of the things that we see consistently across the
government is extremely high mission commitment clearly true at
VA, and extremely low views about their leadership. And I think
one thing again that is generic but extremely important across
government and at VA is we do not invest enough in the leaders
in the government and the managers in government. And this
comes back to the broader civil service reform needs. We ought
to have a system that allows great subject matter experts to
stay on a track of improving as a subject matter expert and not
be kicked into management as a way to be promoted. So we need
to separate those two things. We need to have an improved
investment in the supervisor and management capability of those
that do go into management and we need leaders that see this as
one of their core and primary responsibilities. These are
basics and there is a lot more that can be done on that.
Ms. Brownley. So are there, I see this as really an urgent,
it is an urgent problem. We are only as good as the employees
that we hire and can fulfill the mission. Are there strike
teams when you look at positions across the country and we look
at medical centers across the country and we know that there
are empty seats, there are unfilled positions, these are the
management teams, the leadership teams. Do we have a strike
force that goes out and says, we have got to make sure that at
least the management teams here are up to speed and running
these hospitals effectively and efficiently. Is there any
measure like that?
Mr. Young. We certainly just recently sent in a team at a
medical center that was having turnover in the leadership to do
a baseline assessment of the organization, to basically give a
gift to the new team coming in that says, these are the
challenges that you are facing, these are some of our
recommendations for how you approach it. We do also
occasionally send in teams to assist in places where there are
difficulties. As you commented in your opening comments,
Congresswoman, about GLA and their HR team. We are sending in a
team now to supplement the GLA human resources team to help
them get back on their feet because they have had such turnover
lately.
Ms. Brownley. Thank you. I apologize. I yield back.
Mr. Wenstrup. Mr. Bilirakis, you are recognized for five
minutes.
Mr. Bilirakis. Thank you. Thank you, doctor, I appreciate
it very much. Well I have got some urgent questions here. But I
want to ask what are some of the roadblocks? I mean, I know you
all talked about, for the panel, of hiring, recruiting
physicians specifically here? I know about the salary
disparity. Tell me how much that is. Maybe use the example of a
primary care physician in this case. And then additional
roadblocks. I know the General mentioned his friends that want
to work for the VA. I had a doctor that came to me recently and
said he applied to work as a volunteer for the VA, after hours
or what have you, on his days off. And he said it took about 12
months to get approved. And so I mean where are the roadblocks
here? What are we facing here? And how can we help? Who wants
to go first? Yes.
Ms. Draper. So some of the issues, the challenges that we
have heard in addition to things, the nationwide shortage of
physicians and it is always difficult to recruit in rural
areas. So those are common to every health care system. But I
think specifically for VA, and we have heard this related to
work that we have done recruiting mental health professionals
and nurse recruitment and retention, some of the issues that
are specific to VA are the lengthy on-boarding process. So we
have heard that it can take from three months to a year, and
during that time they lose a lot of candidates because they are
not willing to wait that long. So that is a big issue.
Mr. Bilirakis. You mentioned the mental health, excuse me,
is that because there are a lack of psychiatrists,
psychologists, mental health counselors? Or is it the salary
issue?
Ms. Draper. Well we have heard about the pay disparity as
well. We have also heard about that VA lacks some flexibility.
And some of the common recruitment and retention tools, like
relocation bonuses, retention bonuses, or signing, retention
bonuses and signing bonuses that, you know, are more prevalent
in the private sector and they have a lot more flexibility in
the private sector. I think some of the other things that we
have heard about is for clinical positions a lot of times they
are doing administrative functions, so it really takes away
from their clinical duties. For example, we have seen
physicians often having to schedule their own appointments. So
that is a real detriment to I think retaining and recruiting
professionals.
Mr. Bilirakis. So physicians have to schedule their own
appointments?
Ms. Draper. Sometimes, in some cases--
Mr. Bilirakis [continued]. In some cases they have to go
back, I mean I am sure this is true in the private sector as
well, but they have to go back and do the paperwork after they
see the patient and they do not have the help that they need
with regard to that?
Ms. Draper. They do not always have the administrative
support that they need, that they may have in the private
sector. That is what we have heard.
Mr. Bilirakis. Thank you. Anyone else?
Mr. Stier. Can I just jump in real quick and offer one
other, and I think it is a great thematic, which is, you know,
what is best in class being done elsewhere? So certainly at the
senior leadership positions by and large in government and in
the VA, they do not use executive search. And there is a whole,
you know, industry that is designed to find best talent and
that is what any, you know, large, well run organization is
going to be using. And that is not a tool that is funded or
used in any real way inside the government. And that means that
you are certainly, you know, fighting with one hand tied behind
your back.
Mr. Bilirakis. Okay. Question for Mr. Young, do you know in
absolute numbers how many medical officers and in what
specialties VA needs on a national level?
Mr. Young. I do not have that information with me today but
we could certainly take that for the record and bring that
back.
Mr. Bilirakis. And if you could break that down to maybe
regionally, and as far as facility, that level as well, we
would appreciate that very much. Given that 27 percent of the
medical officers left VA due to retirement, I think this was
covered, do you know the average age of medical officers in VA?
And how many are currently or will be at retirement age in the
next decade? How are you planning to compensate for the loss of
these retirees? So this is again for Mr. Young.
Mr. Young. I don't have the average age right now, but I
can say that we recruit on an ongoing basis to bring in new
talent to take advantage, frankly, of the academic
relationships that we have. As you know, VA trains--70 percent
of the physicians in America have had some part of their
training inside of VA. We try to take advantage of that when
they are inside the building and work with them about joining
VA whenever they have completed their training.
So we look for that--those, you know, people coming out of
their training programs and having them come into VA as part of
their career.
Mr. Bilirakis. Thank you very much. I appreciate it.
I yield back, Mr. Chairman.
Mr. Wenstrup. Mr. Takano, you are now recognized for five
minutes.
Mr. Takano. Thank you, Mr. Chairman. This is either for the
GAO or for the VA. I have heard a story, I mean, two years ago,
it was directly related to me by--I can't remember if the
graduate was from USC or UCLA--a gastroenterologist, a young
one, interested in working for the VA. They spotted a vacancy,
applied through, I guess, the Web site, and never heard back,
never got an acknowledgment that they even applied. I see a
nodding head over there, is that a kind of experience that you
have heard about?
Mr. Goldenkoff. Yeah. Anecdotally those are the kinds of
stories that we have been hearing, and it doesn't do much
either for the individual who applied or just for the agency's
brand itself when you apply and you never hear back, you don't
know where your application is, it falls into a black hole, it
sends the impression that Uncle Sam doesn't want you.
Mr. Takano. Well, is it typical for someone who is a
gastroenterologist, is the first step for such medical
professionals applications to the Web site?
Ms. Molloy. So we do announce all of our positions via the
USA Jobs Web site.
Mr. Takano. USA Jobs Web site?
Ms. Molloy. Yes. So in this case that is where that
particular person found that. But we actually do have a very
high-touch approach as well. So we--it is not exclusively that
we work through the Web site. So we do have a national
physician recruiter that really does a high-touch approach and
will reach out directly to candidates of whom they have some
awareness. So it is a combination.
Mr. Takano. High-touch in the way that, is it Mr.--from
the--I can't see your name for the--
Ms. Molloy. Mr. Stier.
Mr. Takano [continued]. Mr. Stier. Mr. Stier referred to as
executive recruiting?
Ms. Molloy. It operates like a commercial headhunter except
it is inside our walls inside the VA.
Mr. Takano. There is a question I had about the GMEs. As I
understand it, support staff to manage GME expansion and
administer the VA's GME programs, Graduate Medical School
Education Program, such as the Education Department Debt
Reduction Program, the Employee Incentive Scholarship Program,
Health Professional Scholarship Program, and the increase in
residency positions to 1,500 GMEs under the Choice Act, the
support administrative staff for these programs are not exempt
from the hiring freeze; is that right?
Ms. Molloy. That would depend on the occupational series,
but in general, I would say they are likely not the
administrative support, that would be correct.
Mr. Takano. And I know that we have had trouble. I mean,
this is kind of frustrating. Mr. O'Rourke's bill that I was
on--actually it was Ms. Titus, and Mr. O'Rourke, and I were
also a co-sponsor of that bill--pretty remarkable. New
mandatory spending that got us 1,500 new GMEs and we have only
been able to actually, I guess, deploy about 300 out of the
1,500, and we just passed an extension to give more time for
those GMEs to be used. But now you are telling me this hiring
freeze is going to impede by virtue of the fact we don't have
administrative support positions to actually look at that.
Ms. Molloy. So it may be impacting the administrative
support positions, I would like to take that for the record,
but it will not be impacting the ability to actually bring GMEs
into the program. So our clinical trainee programs are still
moving forward, and we are able to bring those folks in.
Mr. Takano. So with regard to the other program--well, I
will try and get down--you know, under-served and rural areas
often rely on doctors from foreign countries to practice in the
United States in their communities. In fact, I have a New York
Times article which highlights an Iranian oncologist who was
prevented from traveling to San Bernardino--which is right near
my community, near Loma Linda, with Loma Linda VA--earlier this
year.
Has the VHA been affected by the President's travel ban?
And has VHA been affected by the visa processing slow down?
Ms. Molloy. With regard to the travel ban, I would need to
take that for the record. Also regarding any issues related to
processing of visas.
Mr. Takano. And what are VHA's efforts to recruit
internationally and to recruit providers to serve in rural and
under-served areas?
Ms. Molloy. So we do utilize the J-1 visa program, which
allows us to hire those folks under that program if we have
been unable to find either a U.S. citizen or a resident to
serve that area after we have announced the position, and I
would be happy to come back to you with additional detailed
information as part of a response for the record.
Mr. Takano. And what are VHA's efforts to recruit foreign
providers participating in residencies and training programs
with its affiliates?
Ms. Molloy. So as Mr. Young mentioned, we are very
interested in being able to bring in any provider who is going
through our training program. So I will provide you with more
details on that.
Mr. Takano. All right. Thank you.
Mr. Chairman, I yield back.
Mr. Wenstrup. Ms. Radewagen, you are now recognized for
five minutes.
Ms. Radewagen. Thank you, Mr. Chairman, Talofa, and I want
to thank the panel for being here today.
Veterans' health concerns are an issue I hold close to my
heart. I represent the territory of American Samoa, and from
the Army's own Web site our recruitment depot has the highest
recruitment rate out of all 885 recruitment depots.
Samoa's sons and daughters enlist in the armed forces at a
rate ten times greater than areas here on the mainland. I find
it quite distressful then that my constituents who greater rely
on the services of the Department of Veterans Affairs often
have to travel to Hawaii for medical care. That is over 2,500
miles. Now, the onus of the blame cannot solely be placed on
the Department of Veterans Affairs; it is failure of action
here in Congress as well that punishes veterans.
My question is, and all of you can answer, and Mr. Takano
brought up part of it. I noticed that some of you mentioned the
difficulty of retaining VA employees in rural areas, and that
is also a problem for us in remote islands, say, the
territories. What would you recommend to keep VA employees in
remote and rural areas?
Mr. Celli. Can I get one?
Ms. Radewagen. Yes.
Mr. Celli. Thanks.
Ms. Radewagen. Mr. Celli.
Mr. Celli. So VA employees, and VA physicians specifically,
have a very high burnout rate. And one of the reasons that they
are stressed to the degree that they are and they have the high
burnout rate is because they lack a lot of the support
mechanisms, as you have heard here from some of the other
panelists, that other hospitals and other physicians have. One
of the reasons that they lack that support mechanism is because
VA, historically, has done a horrible job in succession
planning.
At any number of facilities at any time you will find an
acting director, an acting deputy director, an acting--or
transitional leadership who are afraid to make decisions, who
feel that once that permanent placement is made, then they will
just go back to being a regular employee without the leadership
that they are exhibiting now, and it really--it causes huge
problems.
Hospitals, again, civilian hospitals don't work that way,
they don't have that struggle. They have leadership development
and they have succession planning, and VA needs to get on the--
get onboard with succession planning.
Ms. Radewagen. Thank you. Anyone else? Mr. Stier? Mr.
Steer?
Mr. Stier. Stier.
Ms. Radewagen. Stier.
Mr. Stier. You have forced me to answer the question now by
giving me two choices of the name.
Look, I don't have a lot to add, but, clearly, you know,
the opportunity to increase the flexibilities of the
organization, part of the challenge in Government is so much--
becomes a--it is a rule based culture where everything is
treated the same across the whole organization when, as you
suggest, there are some substantial differences in different
areas that may require different kinds of encouragement to get
the right talent.
So I think, in my view, the most important thing you could
do is to provide, you know, real tools and flexibilities to the
leadership at VA so that they can design the right kind of
retention programs for, you know, the different areas in our
country. And rather than trying to pick out, you know,
individual tools and say this is going to work for everybody,
at the end of the day you need good leaders and good managers
that are going to be able to figure out the problems like this
one in an effective way. So I would invest in your leadership
and give them, you know, more flexibility, which, by and large,
they don't have a lot of.
Mr. Young. And I would add to just go to the issue of
health care in more rural areas or difficult to get to places.
I came to this job after seven years as a medical center
director in a western state where it wasn't quite 2,500 miles
to get to the health care, but we had some pretty remote areas
that we were responsible for, and we utilized telehealth
technologies.
And I think that that is one of the areas that we need to
do more of, especially in areas such as American Somoa, to be
able to link people with these--the emerging technologies to
provide health care in more remote areas with wherever
clinicians may be to be able to link them better together. So I
think that is one of the areas that we need to work even harder
at. We have been doing a decent job of it, but we have got more
that we can do.
Ms. Radewagen. Thank you.
Mr. Chairman, I yield back.
Mr. Wenstrup. Thank you.
Mr. O'Rourke, you are now recognized for five minutes.
Mr. O'Rourke. Thank you, Mr. Chairman. And I would like to
add my thanks to the others for your work on the hiring reform
bill that passed last week, and I am also looking forward to
that being speedily passed by the Senate, and signed into law,
and being able to see the positive effects of that soon.
And, Mr. Young, before the hearing started, you kindly
offered to assist us in El Paso as we strive to hire our full
complement of mental health care staff in a community that has
had a real struggle with mental health care access. So I want
to thank you. Samantha O'Guerra, who is sitting behind me, is
going to call you right after this hearing to follow up on
that. We want to get working on it, and so thank you.
And I will tell you a couple things. One, part of our
struggle is that for two years in El Paso--getting back to, I
believe, the 11 percent number that Mr. Stier gave us--we have
not had a permanent director, and it is really hard to hire
into a poorly performing medical center that doesn't have a
coach.
Like, how do you recruit the player to play for a temporary
coach. We finally had someone. Thank you, Colonel Amaral, who
was the chief of staff at the William Beaumont Army Medical
Treatment Facility. And even though he was a chief of staff at
a medical treatment facility, and even though, I think, we, the
VA, recruited him, it took a year to bring him onboard and he
had to do these ridiculous essays, some of which got rejected
and he had to rework.
So just real quickly, is that within the administrations'
purview to change through OPM or is it an act of Congress? Can
we do away with the essay tomorrow?
Mr. Young. I am going to break a cardinal rule and
speculate when testifying. I believe that that is not within
our purview to--
Mr. O'Rourke. You need an act of Congress? Mr. Stier, you
have an answer?
Mr. Stier [continued]. I do, and I am not speculating, but
I can still be wrong.
Mr. O'Rourke. Okay. Let's hear it.
Mr. Stier. Hopefully that is not the case. But the answer
is, yes. You know, VA could actually simply require a resume
for hiring. They are not required to get all those essays.
However, there is a process, it is called the QRB, in which the
office's quality review board, in which the office of personnel
management then reviews all the choices that the agencies make.
And in our view, that is an unnecessary process.
Mr. O'Rourke. Is that an act of Congress?
Mr. Stier. And that would require--yeah, I don't--unless
you got OPM to change things, which they probably could, you
probably--ultimately to make it happen you would need some
congressional legislation on that.
Mr. O'Rourke. Okay. So you are going to get back to us and
tell us if you will--if we believe Mr. Stier is correct, you
will forego the essay requirement going forward for directors?
Ms. Molloy. So the answer is yes. And to be clear, we do
not require that essay as part of the initial application, we
do use a resume only--
Mr. O'Rourke. This guy had to fill out an essay--
Ms. Molloy [continued]. --for the initial application.
Mr. O'Rourke [continued]. --and that was part of the hold
up, so--
Ms. Molloy. Correct.
Mr. O'Rourke [continued]. --something--
Ms. Molloy [continued]. But it is--
Mr. O'Rourke [continued]. You know what I am asking--
Ms. Molloy. Yes.
Mr. O'Rourke [continued]. --and what I want.
Ms. Molloy. It is required on the back end. Yeah.
Mr. O'Rourke. Yeah. Okay. I want to ask you, Mr. Young, so
when we were first selected and were sworn in in 2013, we had
68 full-time equivalent mental health staff, and that was part
of the problem, and we had a real hard time hiring in.
We put some pressure, we asked for help, VA gave it and we
are grateful for it, and I also have become part of the
recruiting staff. And with the permission of the applicant, the
recruiter gives me their name, I call them, I am making a call
to Guam tomorrow for a husband and wife team that we are trying
to recruit to El Paso.
We started with 68 FTE, we are at 98. We have 120
authorized and appropriated for. What are the consequences for
the recruiter not making it to 120? Can the recruiter come back
to you and say, you know, it is El Paso, it is the VA, we have
45,000 or 47,000 clinical positions, we are short, life is
tough, we just can't make it, or are there defined goals they
have to hit or else? Where is the urgency, in other words? But
I want to hear what the accountability is.
Ms. Molloy. Understood. So let me take that back for the
record, I want to see what--actually what is in the performance
plans for the recruiter.
Mr. O'Rourke. I think it is very telling that you don't
have an answer for that. And, you know, I think it is telling
that you have got Members of Congress who are making the
recruitment phone calls to get people hired in, and Members of
Congress who are having to call OPM to ask why the heck
somebody's filling out an essay when we desperately need their
leadership.
And it also makes me sometimes question--although I like
Colonel Amaral a lot, I just got off the phone with him, we are
very lucky to have his service, but after a year waiting, I am
kind of thinking, who is the guy that wants to work at the VA
after being jerked around for a year. I mean, you know, is that
who we are trying to attract here? It just turns out this guy
is--got a heart for public service, and is willing to do it,
and really wants to help out veterans. But, I mean, it almost
begs the question.
So really I am looking for your responses that you have
promised me for the record including the consequences for
recruiters not meeting a quota, if there is, in fact, a quota,
which there should be.
Mr. Chairman, thank you.
Mr. Wenstrup. Thank you. I have had the same experience
where I have had doctors that I know for years, and they call
me and say, I am waiting, waiting, waiting, I want to go work
at the VA. So we have got work to do.
Mr. Rutherford, you are now recognized.
Mr. Rutherford. Thank you, Mr. Chairman, I will keep this
very brief, I know we have votes coming up.
I just want to ask very quickly of the GAO. We have heard
lots of testimony in other Committees about official time, and
during those discussions I can tell you I begin to wonder
sometimes who is running the zoo because I can't figure out who
is actually in charge, whether it is management or the unions.
Can you tell me your perception of the union/management
relationship and how well that is actually working? Because I
think it goes back to something that Mr. Celli said, that I
agree with wholeheartedly, I know that people join
organizations, they quit people. And they quit people because
of lack of leadership and lack of organization, because
leadership is your organization, and lack of training. And
those are the two things that Mr. Celli brought up that really
struck me as a former CEO.
So can you talk about the relationship between management
and their ability to do their job, to lead the organization,
and the union?
Mr. Goldenkoff. Sure. Well, not so much the union because
our work has not addressed that, but in terms of just the
broader issue about leadership and their ability to engage the
workforce. I mean, that is one of the single largest morale
busters is that leadership turnover.
It prevents a lack of strategic vision, you have people
coming and going, it is a revolving door. Just when the
employees start getting on board with one leader and their
priorities, a new leader comes in, it is a whole new set of
priorities, and it is hard to keep up with that, and it does
affect morale and engagement.
And we actually--you can see it in some of the numbers, for
example, GAO, we have identified six drivers of employee
engagement. And these are efforts or attributes, things that
basically make you go the extra mile within an organization,
really make you passionate about the work. And they are things
like constructive performance conversations, career development
and training, work/life balance, developing inclusive work/life
environment.
VHA employees, they were less satisfied on all six drivers
of employee engagement than the government wide average. And so
you can see that this is having an impact--
Mr. Rutherford. Right.
Mr. Goldenkoff [continued]. --when the leadership and the
turnover, it really does affect people's desire to stay in an
organization and how they feel about it.
Mr. Rutherford. Thank you.
Dr. Draper, do you have anything real quick so I can turn
this over to my colleagues?
Ms. Draper. Only thing I would add is in--the VA does do
exit surveys of exiting employees, and of those that
voluntarily have quit, the two common drivers were lack of
advancement, but the other piece was dissatisfaction with
elements of the work, including management. So I think there
is--it sort of reiterates what Robert said.
Mr. Rutherford. Yeah, I think that is coming through in
these Committee meetings. Thank you very much. And I yield
back, Mr. Chairman.
Mr. Wenstrup. Thank you.
Votes have been called, it is a 15 minute vote. I would
like to try to give these other gentlemen the opportunity. Mr.
Higgins, you are now recognized.
Mr. Higgins. Thank you, Mr. Chairman.
Mr. Young, I am sure you are aware that during his
confirmation hearing last month, Secretary Shulkin testified
that there are 45,000 vacancies across the VHA. Can you provide
a breakdown of those vacancies by location and by occupation
for the record for us because of the 1,000--I believe you
stated 1,223 facilities--but we have 320,000 employees listed,
that is quite a large number of employees for that number of
facilities. So who are these? What are the occupations and job
descriptions of these 45,000?
Mr. Young. We can certainly bring that information back for
the record.
Mr. Higgins. All right.
Mr. Young. I think it is important to--
Mr. Higgins. And of the 320,000, does that include the
45,000 vacancies, or is that to be added?
Mr. Young [continued]. The 320,000 is the current number of
on-board.
Mr. Higgins. So we are talking about 360,000 employees for
1,223 facilities? Just to be clear.
Mr. Young. Yeah.
Mr. Higgins. All right.
Mr. Young. And it is important to note that the 45,000 are
the number that are in recruitment. There is nuance in that as
to whether those are one-to-one relationships because you might
be recruiting for a psychiatrist, a psychologist, a social
worker, and a nurse practitioner for only one vacancy, but that
is nuance. But largely that figure is true.
Mr. Celli. Hold on. To be clear, and I am not sure that Mr.
Young completely understood your question. That 360,000
employees is VA wide, not VHA.
Mr. Higgins. All right.
Mr. Celli. You are talking about VHA?
Mr. Higgins. Yes. Is the states' VHA.
Mr. Young. Yeah. Three hundred and eleven thousand.
Mr. Celli. Right.
Mr. Young. Three hundred and eleven thousand, three hundred
and twelve thousand for VHA.
Mr. Higgins. So VHA employees has 300 and--
Mr. Young. Twelve.
Mr. Higgins [continued]. --12,000. That is close to 320.
Thank you very much, Mr. Chairman. I yield back.
Mr. Wenstrup. Dr. Dunn, you are now recognized.
Mr. Dunn. Recognizing that we are very short on time, let
me ask you--let me just task you with a few questions to come
back with some information that we all would like. And it is
reflective of Captain Higgins' comments as well, which is, you
know, we want to get our arms around this and get a feeling for
how big this thing is, and how, you know, measure the problem,
but also let's measure the size of the VA.
So what we would like to have you do is share with the
Committee information regarding--so their MOS. You know, how
many docs, how many surgeons, how many primary care, how many
total employees? Again, where they are located. And that is
something I think that you could pull together pretty quickly
for us, and save us the Google search and all these things.
Also, I would like to have a sense of exactly what the
budget is for the VHA as well as the VA, so we are separating
those two, the budget, how much money is actually flows through
those? So we can do some apportioning and figure out what we
are doing.
Then the very hard number to come by, and I have asked the
CRS to generate it for me, but they failed, and that is what is
the cost of a patient encounter in the VA? I mean, and I am
talking health now, not when they get a call for to schedule an
appointment, or they get six calls to schedule the same
appointment, I want to know, you know, I am talking--I am a
doctor-- a real, honest to god, health encounter whether it is
surgery, or visit in the office, and if you can break those
things out. That is the kind of information that allows us to
sort of, you know, assess--understand what you are dealing with
there.
And I guess the final thing I would like to do is, also we
have talked a lot about highly paid employees here, I would
like to get a sense of what the pay scale is for the physicians
and mid-levels that are in the VA, and, you know, I have a
pretty good sense of what that costs on the outside. I have
never actually been employed by the VA, though like every other
doctor, I have worked there.
So those are just requests that I know that you don't have
those numbers on the tip of your fingers, but I think those
would be very helpful to a number of Members of the Committee.
And, finally, I just want to say, Ms. Radewagen is gone,
but she is right, the Samoans participate to an incredible
degree in, you know, volunteering for our armed services, and
they deserve to be recognized for that. And I have served with
them in Samoa, so I--she is right, they are a great group.
Thank you. I yield back.
Mr. Wenstrup. Thank you. Thank you all. I am sorry we are
cutting this short, but I want to thank you again. Before
today's hearing adjourns, on behalf of Chairman Roe and myself,
I would like to extend a very special congratulations, and the
Committee's most sincere gratitude, to the chief clerk of the
Committee on Veterans Affairs, Jessica Eggimann, who is
clerking her final hearing for the Committee this afternoon.
Thank you very much, Jessica.
After six years as the committee's chief clerk, legislative
coordinator, and office manager, Jessica has been presented
with a very exciting opportunity to work at her alma mater,
Converse College in Spartanburg, South Carolina. So on behalf
of all Members of this Committee, thank you, Jessica, best
wishes on your next chapter, and we will miss you.
And if there are no further questions, this panel is now
excused. And I ask unanimous consent that all Members have five
legislative days to revise and extend their remarks, and
include extraneous material.
Without objection, so ordered.
The hearing is now adjourned.
[Whereupon, at 3:41 p.m., the Committee and Subcommittee
was adjourned.]
A P P E N D I X
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Prepared Statement of Robert Goldenkoff
Actions Needed to Better Recruit and Retain Clinical and Administrative
Staff
Thank you for the opportunity to participate in today's hearing on
the ability of the Department of Veterans Affairs' (VA) Veterans Health
Administration (VHA) to recruit and retain high-quality clinical and
administrative employees.
VHA operates one of the largest health care systems in the country.
As of fiscal year 2015, it included about 317,000 employees in Veterans
Integrated Service Networks (VISN) overseeing 168 medical centers and
more than 1,000 outpatient facilities. \1\ VHA provided care to about
6.7 million veterans in fiscal year 2015 and the demand for its
services is expected to grow in the coming years due, in part, to
service members returning from the United States' military operations
in Afghanistan and Iraq and the growing needs of an aging veteran
population. Attracting, hiring, and retaining top talent is critical to
VHA's mission to provide quality and timely care for our nation's
veterans.
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\1\ VHA organizes its system of care into regional networks called
VISNs. Each VISN is responsible for managing and overseeing VA medical
centers within a defined geographic area and reporting to the Deputy
Under Secretary for Health for Operations and Management within VHA's
central office. In October 2015, VHA began realigning its VISN network,
which included merging several VISNs; when complete, this realignment
will decrease the number of VISNs from 21 to 18. See GAO, VA Health
Care: Processes to Evaluate, Implement, and Monitor Organizational
Structure Changes Needed, GAO 16 803 (Washington, D.C.: Sept. 27,
2016).
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According to a June 2016 evaluation by the Commission on Care, VHA
provides health care that is, in many ways, comparable or better in
clinical quality to that generally available in the private sector. \2\
Still, the care is inconsistent from facility to facility. Our prior
work has described the human capital challenges facing VHA, including
difficulties ensuring it has the appropriate clinical and
administrative workforce to meet the current and future needs of
veterans \3\. In February 2015, we added managing risks and improving
veterans' health care to our list of federal high-risk areas, and we
continue to be concerned about VA's ability to ensure its resources are
being used cost-effectively and efficiently to improve veterans' timely
access to health care and to ensure the quality and safety of that
care. \4\
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\2\ In an effort to help VA address various management weaknesses,
Congress enacted the Veterans Access, Choice, and Accountability Act of
2014, also known as the Choice Act (Pub. L. No. 113-146, 128 Stat. 1754
(August 7, 2014)) (hereafter, Choice Act), as amended by Pub. L. No.
113-175, 128 Stat. 1901 (Sept. 26, 2014) (Department of Veterans
Affairs Expiring Authorities Act of 2014). Among other things, the
Choice Act established the Commission on Care. This independent entity
evaluated veterans' access to VA health care and assessed how veterans'
care should be organized and delivered during the next 20 years.
\3\ See, for example, GAO, Veterans Health Administration:
Management Attention Is Needed to Address Systemic, Long-standing Human
Capital Challenges, GAO 17 30 (Washington, D.C.: Dec. 23, 2016);
Veterans Health Administration: Personnel Data Show Losses Increased
for Clinical Occupations from Fiscal Year 2011 through 2015, Driven by
Voluntary Resignations and Retirements, GAO 16 666R (Washington, D.C.:
July 29, 2016); and VA Health Care: Oversight Improvements Needed for
Nurse Recruitment and Retention Initiatives, GAO 15 794 (Washington,
D.C.: Sept. 30, 2015).
\4\ GAO, High-Risk Series: An Update, GAO 15 290 (Washington, D.C.:
Feb. 11, 2015).
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Our remarks today will focus on (1) the difficulties VHA is facing
in recruiting and retaining staff for key clinical positions, and (2)
VHA's capacity to perform key human resources (HR) functions needed to
address those difficulties. As requested, we will also discuss the
implications of the recently imposed federal hiring freeze on VHA's
staffing levels and ability to meet its mission.
Our bottom line is that recruitment challenges and turnover among
clinical and HR employees are threatening VHA's ability to meet the
health care needs of our nation's veterans. In addition, VHA's weak HR-
related internal control practices have undermined its HR operations
and its ability to effectively support its mission. Going forward,
management attention-beginning with the recently confirmed VA
Secretary-and continued strong congressional oversight will be needed
to address those challenges.
This testimony is based on our recent work. \5\ For those studies,
among other things, we reviewed key documents such as VHA directives,
policies, and guidance; analyzed VHA employment and attitudinal data;
reviewed applicable federal internal control standards; and interviewed
knowledgeable officials from VHA and VA in both headquarters offices,
as well as in eight VA medical centers across the country selected for
such attributes as facility complexity and rural versus urban location.
Our reports provide further details on our scope and methodology.
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\5\ GAO 17 30, GAO 16 666R, and GAO 15 794.
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The work on which this statement is based was conducted in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Background
VHA's health care mission is broad in that it provides veterans
with a wide range of health care services. These services include
primary care and surgery and unique specialized care, such as treatment
for post-traumatic stress disorder, traumatic brain injury, and
readjustment counseling. VHA is also a leader in medical research and
the largest provider of health care training in the United States. \6\
As such, each medical center hires employees in a wide range of
clinical and administrative professions, from nurses and physicians to
hospital administrators, police, and housekeepers. \7\ These employees
are covered by three types of personnel systems: \8\
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\6\ According to VHA, the department provides clinical traineeships
and fellowships to more than 100,000 students in more than 40
professions each year.
\7\ In 2015, VHA had about 54,000 registered nurses, 19,000
physicians, 1,000 dentists, and 81,000 other staff including, among
others, medical support assistants, administrative staff, and police.
\8\ In this testimony, for ease of comprehension, we refer to the
respective personnel systems by the terms that VA uses, which loosely
correspond to the applicable codification in the U.S. Code which
authorizes those personnel systems.
Title 5 of the U.S. Code (Title 5): The majority of
federal employees across the government are hired under the authority
of Title 5; at VHA, employees under this personnel system hold
positions such as police officers, accountants, and HR management. \9\
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\9\ Title 5 of the U.S. Code provides the authority for government
organization and employees.
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Title 38 of the U.S. Code (Title 38): VA's separate
personnel system for appointing medical staff including physicians,
dentists, and registered nurses. These appointments are made based on
an individual's qualifications and professional attainments in
accordance with standards established by VA's Secretary. \10\
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\10\ Title 38 of the U.S. Code provides the authority for veterans'
benefits and includes provisions which cover certain employees of the
VA.
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Title 38-Hybrid: Employees under this personnel system
hold positions such as respiratory, occupational, or physical
therapists; social workers; and pharmacists. This system combines
elements of both Title 5 (such as for performance appraisal, leave, and
duty hours) and Title 38 (such as for appointment, advancement, and
pay). \11\
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\11\ The appointing authority for employees under Title 38 and
Title 38-Hybrid differ. Title 38 employees are appointed under the
authority of 38 U.S.C. Sec. 7401 and Title 38-Hybrid employees are
appointed under the authority of 38 U.S.C. Sec. Sec. 7403 or 7405.
Each of these personnel systems has different requirements (and
flexibilities) related to recruitment and hiring, performance
management, and other areas served by VHA's HR staff.
VHA's HR functions are decentralized. Each of VHA's VISNs has an HR
office that oversees the medical center-level HR offices within its
network. In general, each VA medical center has its own HR office led
by an HR officer. Individual HR offices are responsible for managing
employee recruitment and staffing, employee benefits, compensation,
employee and labor relations, and overseeing the annual employee
performance appraisal process. Medical center HR offices also provide
HR services to employees at VHA's community-based living centers,
rehabilitation centers, and outpatient centers. VHA's HR staff are
classified as either an HR specialist, who manages, supervises, and
delivers HR products and services; or an HR assistant, who provides
administrative support to HR specialists.
Attrition in Clinical Positions Driven by Voluntary Resignations and
Retirements
VHA Losses for the 5 Occupations with the Largest Shortages Increased
from Fiscal Year 2011 through 2015
In our 2016 report on VHA clinical employee retention, \12\ we
noted that in 2015 VHA had about 195,900 clinical employees in 45 types
of occupations. \13\ To meet the growing demand for care, VHA
implemented a number of targeted hiring initiatives, such as a mental
health hiring initiative, which brought on about 5,300 staff nationwide
from 2012 to 2013.
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\12\ GAO 16 666R.
\13\ The 195,000 clinical employees are employed specifically in
the VHA occupations covered by 38 U.S.C Sec. 7401-a specific section
of law that provides VHA with the authority to hire clinical employees.
This number does not include employees of the veteran canteen service,
the VHA central office, health care providers who provided services
through contracts, or medical residents or trainees that were
intermittently employed or in non-pay status. This number does include
some types of trainees, such as interns and post-doctoral fellows. For
fiscal year 2016, VHA changed the occupations counted as clinical
employees to not include occupations that were in the process of being
moved to Title 38 positions, but had not completed that transition. If
VHA had used this method to estimate clinical employees in fiscal year
2015, the number would have been reduced by about 4,200 employees.
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Despite these hiring efforts, we and others have expressed concerns
about VHA's ability to ensure that it has the appropriate clinical
workforce to meet the current and future needs of veterans, due to
factors such as national shortages and increased competition for
clinical employees in hard-to-fill occupations. \14\ VHA officials have
expressed concern with their hiring capabilities since 2014, when a
well-publicized series of events called into question the ability of
veterans to gain timely access to care from VHA. \15\
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\14\ See GAO, VA Primary Care: Improved Oversight Needed to Better
Ensure Timely Access and Efficient Delivery of Care, GAO 16 83
(Washington, D.C.: Oct. 8, 2015); VA Mental Health: Clearer Guidance on
Access Policies and Wait-Time Data Needed, GAO 16 24 (Washington, D.C.:
Oct. 28, 2015); VA Health Care: Oversight Improvements Needed for Nurse
Recruitment and Retention Initiatives, GAO 15 794 (Washington, D.C.:
Sept. 30, 2015); VA Health Care: Actions Needed to Ensure Adequate and
Qualified Nurse Staffing, GAO 15 61 (Washington, D.C.: Oct. 16, 2014);
Department of Veterans Affairs Office of the Inspector General,
Veterans Health Administration, Audit of Physician Staffing Levels for
Specialty Care Services, 11-01827-36 (Washington, D.C.: Dec. 27, 2012),
and Department of Veterans Affairs Office of the Inspector General, OIG
Determination of Veterans Health Administration's Occupational Staffing
Shortages, 15-00430-103 (Washington, D.C.: Jan. 30, 2015).
\15\ In 2014, news outlets began reporting about extended wait
times for veteran appointments at VHA medical facilities. Subsequent
investigations by us, the VA Office of Inspector General (OIG), and
others substantiated allegations of extended wait times and we found
that VHA employees responsible for scheduling appointments at certain
facilities engaged in inappropriate practices to make wait times appear
more favorable.
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Our 2016 report found that for the 5 VHA clinical occupations with
the largest staffing shortages (as identified by the VA Office of
Inspector General in January 2015), the number of employees that VHA
lost increased each year, from about 5,900 employees in fiscal year
2011 to about 7,700 in fiscal year 2015 (the 5 occupations were
physicians, registered nurses, physician assistants, psychologists, and
physical therapists). \16\ This attrition accounted for about 50
percent of VHA's total losses across all clinical occupations during
this period. We found a similar trend for all clinical occupations
across VHA-losses increased annually during this period. (See table 1).
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\16\ The VA OIG reviewed VHA data on occupational attrition rates
and vacancies and facilities' rankings of occupations for which they
have a critical need. The VA OIG then weighted these rankings based on
additional factors, such as the total number of facilities that ranked
an occupation as a critical need.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
From fiscal year 2011 through 2015, occupation loss rates for each
of the 5 shortage occupations varied annually, though most saw an
overall increase in losses during this period (see figure 1). Physician
assistants consistently had the highest loss rate among the 5 shortage
occupations. The loss rate for physician assistants increased from 9.3
to 10.9 percent during this period. The loss rate for physical
therapists decreased from fiscal year 2011 to 2012 (from 8.3 to 6.4
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percent), but then increased to 8.0 percent in fiscal year 2015.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
In addition to our review of VHA's 5 shortage occupations, we also
identified the 10 clinical occupations within VHA with the highest loss
rates as of fiscal year 2015 (they were physician assistant, medical
support assistant, medical supply aide and technician, optometrist,
nursing assistant, medical records technician, health technician
(optometry), physician, practical nurse, and medical records
administration). The loss rates for these 10 occupations also varied
(ranging from 5.3 percent to 10.9 percent each year from fiscal years
2011 through 2015). We found that 2 of the 5 shortage occupations-
physician assistants and physicians-were among this group of the 10
highest loss-rate occupations each year from fiscal year 2011 through
2015.
Additionally, 2 other occupations-medical support assistants and
nursing assistants-were also consistently among this group of the 10
highest loss-rate occupations each year during this period. \17\ The 6
remaining occupations were technical positions that were generally
small in overall number, such as medical supply aides and technicians.
According to VHA HR officials, employees in these occupations generally
do not require specialized education or licensing; thus, they tend to
be more easily replaced than those in the 5 shortage occupations.
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\17\ Medical support assistants schedule veterans' appointments and
thus play a critical role in ensuring veterans' access to care and
nursing assistants attend to basic patient needs and support other
nursing staff.
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Voluntary Resignations and Retirements Were the Primary Drivers of
VHA Losses, though Reasons Differed for Some Occupations
According to VHA's personnel data, voluntary resignations and
retirements accounted for about 90 percent of VHA's losses from the 5
shortage occupations annually from fiscal year 2011 through fiscal year
2015 (see figure 2). \18\
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\18\ Resignations include employees who quit and voluntarily
transferred to other government agencies. Retirement includes voluntary
retirements and retirements due to disability or special situations,
such as voluntary early retirement.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Notes: Resignations include employees who quit and voluntarily
transferred to other government agencies. Retirement includes voluntary
retirements and retirements due to disability or special situations,
such as voluntary early retirement. Removals include terminations that
occurred during a probationary period and removals due to adverse
actions. Other reasons employees may depart VHA include death;
separations due to a reduction in force (layoffs) or an employee
entering into a uniformed service; and expirations of nonpermanent,
time-limited appointments, including trainees, such as interns or post-
doctoral fellows.
Totals may exceed 100 percent due to rounding.
The percent of losses due to voluntary resignations from the 5
shortage occupations averaged 54 percent during this period, and
retirements averaged 36 percent. However, for some occupations,
voluntary resignations and retirements accounted for a smaller
proportion of employee losses. For example, for physical therapists and
psychologists, the resignation rate averaged about 44 percent and
retirement averaged about 19 percent during the 5-year period. In these
occupations, other reasons-primarily expiration of their appointments-
averaged about 35 and 33 percent of losses, respectively. According to
VHA officials, expirations of appointments occur when a nonpermanent,
time-limited appointment ends due to the expiration of the work or the
funds available for the position. For physical therapists and
psychologists, the use of trainees, such as interns or post-doctoral
fellows, accounted for the majority of losses due to expirations of
appointments. Removals accounted for a small proportion (5 percent or
less, on average) of losses in each of these 5 occupations. \19\
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\19\ Removals include terminations that occurred during a
probationary period and removals due to adverse actions.
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Voluntary resignations and retirements accounted for 84 percent of
VHA's losses from the 10 occupations with the highest loss rates
annually from fiscal year 2011 through fiscal year 2015. The percentage
of losses due to voluntary resignations from these 10 occupations
averaged about 55 percent during this period and retirements averaged
30 percent.
The following summarizes the reasons for leaving VHA cited by exit
survey respondents in the 5 shortage occupations: \20\
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\20\ VHA's exit survey is offered to employees who voluntarily
resign or retire. The response rate for the 5 shortage occupations
averaged about 30 percent over the past 5 years. For each question,
some respondents may have opted not to respond or provided a response
other than what is summarized here. Percentages are approximate.
28 percent said opportunities to advance and 21 percent
said that dissatisfaction with certain aspects of the work, such as
concerns about management and obstacles to getting the work done, was
the primary reason they were leaving. Other than retirement, these were
the most commonly cited reasons. \21\
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\21\ We grouped like responses together to create these categories.
For example, we aggregated the number of responses for ```advancement-
lack of opportunity within VHA'' and ``advancement-unique opportunity
elsewhere'' into a single category, ``advancement.''
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71 percent said that a single event generally did not
cause them to think about leaving, while 28 percent reported that it
did.
65 percent were generally satisfied with their jobs over
the past year, while 25 percent reported that they were not.
50 percent indicated that they were generally satisfied
with the quality of senior management, while 31 percent were not.
69 percent said that their supervisors did not try to
change their minds about leaving, while 30 percent reported that they
did.
73 percent felt that their immediate supervisors treated
them fairly at work, while 15 percent reported that they did not.
67 percent felt that they were treated with respect at
work, while 19 percent reported they were not.
50 percent reported that one or more benefits would have
encouraged them to stay, such as alternative or part-time schedules (25
percent) or student loan repayment or tuition assistance (12 percent),
among others. \22\
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\22\ Exit survey respondents were instructed to either select all
benefits that may have encouraged them to stay or to select ``no
benefits would have helped.'' Of the 9,623 employees from the 5
shortage occupations who completed an exit survey from fiscal years
2011 through 2015, about 60 percent (5,830) reported that no benefits
would have helped encourage them to stay. Because respondents who did
not select ``no benefit would have helped'' could select more than one
response, the responses by the different benefit categories are not
mutually exclusive.
VHA's exit survey results were similar for respondents from the 10
occupations with the highest loss rates to those in the 5 shortage
occupations. For example, respondents from these 10 occupations also
said that advancement issues (34 percent) and dissatisfaction with
certain aspects of the work (20 percent) were among their primary
reasons for leaving. Additionally, the majority said that a single
event generally did not cause them to think about leaving (71 percent)
and about 47 percent reported that one or more benefits would have
encouraged them to stay, such as an alternative or part-time schedule
(22 percent) or student loan repayment or tuition assistance (12
---------------------------------------------------------------------------
percent), among others.
Oversight Improvements Needed for Nurse Recruitment and Retention
Initiatives
We and others have highlighted the need for an adequate and
qualified nurse workforce to provide quality and timely care to
veterans. As we have previously reported, it is particularly difficult
to recruit and retain nurses with advanced professional skills,
knowledge, and experience, which is critical given veterans' needs for
more complex specialized services.
In our 2015 report-which included staff interviews at four medical
centers-we found that VHA had multiple system-wide initiatives to
recruit and retain its nurse workforce, but three of the four VA
medical centers in our review faced challenges offering them. \23\ VHA
identified a number of key initiatives it offered to help medical
centers recruit and retain nurses, which focused primarily on providing
(1) education and training, and (2) financial benefits and incentives.
VA medical centers generally had discretion in offering these
initiatives.
---------------------------------------------------------------------------
\23\ GAO 15 794.
---------------------------------------------------------------------------
The four medical centers in our review varied in the number of
initiatives they offered, and three of these medical centers developed
local recruitment and retention initiatives in addition to those
offered by VHA. While three of the four medical centers reported VHA's
initiatives improved their ability to recruit and retain nurses, they
also reported challenges. The challenges included insufficient HR
support for medical centers, competition with private sector medical
facilities, a reduced pool of advanced training nurses in rural
locations, and employee dissatisfaction.
In our 2015 report we also found that VHA provided limited
oversight of its key system-wide nurse recruitment and retention
initiatives. Specifically, VHA conducted limited monitoring of medical
centers' compliance with its initiatives. For example, in the past, VHA
conducted site visits in response to a medical center reporting
difficulty with implementation of one of its initiatives and to assess
compliance with program policies, but VHA stopped conducting these
visits. Consistent with federal internal control standards, monitoring
should be ongoing and should identify performance gaps in a policy or
procedure. With limited monitoring, VHA lacks assurance that its
medical centers are complying with its nurse recruitment and retention
initiatives, and that any problems are identified and resolved in a
timely and appropriate manner.
In addition, VHA has not evaluated the training resources provided
to nurse recruiters at VA medical centers or the overall effectiveness
of the initiatives in meeting its nurse recruitment and retention
goals, or whether any changes are needed. Consistent with federal
internal control standards, measuring performance tracks progress
toward program goals and objectives and provides important information
to make management decisions and resolve any problems or program
weaknesses. For example, we found that VHA did not know whether medical
centers had sufficient training to support nurse recruitment and
retention initiatives. In particular, VHA did not provide face-to-face
training specifically for nurse recruiters, but regular training was
available to those assigned to a HR office as part of training
available to all HR staff.
Representatives from a national nursing organization reported that
clinical nurse recruiters at VA medical centers often feel less
prepared for the position than those assigned to HR offices, but VHA
has not evaluated this disparity or its effects. Without evaluations of
its collective system-wide initiatives, VHA is unable to determine how
effectively the initiatives are meeting VHA policies and the provisions
of the Veterans Access, Choice, and Accountability Act. Nor can VHA
ultimately determine whether it has an adequate and qualified nurse
workforce at its medical centers that is sufficient to meet veterans'
health care needs.
VA Has Exempted 108 VHA Occupations from the Hiring Freeze
On January 23, 2017, the administration issued an across-the-board
90-day hiring freeze applicable to federal civilian employees in the
executive branch. \24\ As of January 22, 2017, no existing vacant
positions could be filled and no new positions could be created. The
memorandum stated that the head of any executive department or agency
may exempt from the hiring freeze positions that it deems necessary to
meet national security or public safety responsibilities.
---------------------------------------------------------------------------
\24\ The White House, Memorandum of January 23, 2017 on the Federal
Civilian Employee Hiring Freeze, Daily Comp. Pres. Docs. 2017 No.
00062, p.1, 82 Fed. Reg. 8493 (Jan. 25, 2017). Within 90 days of the
date of the memorandum, the Director of the Office of Management and
Budget, in consultation with the Director of the Office of Personnel
Management, are to recommend a long-term plan to reduce the size of the
of the federal workforce through attrition.
---------------------------------------------------------------------------
In accordance with the memorandum, as of mid-March, VA has exempted
108 VHA occupations from the freeze because they were necessary to meet
VA's public safety responsibilities. They included the 5 shortage
occupations noted earlier (physician, registered nurse, physician
assistant, psychologist, and physical therapist), as well as, for
example, pharmacist, medical records technician, chaplain, and security
guard.
VHA Needs to Strengthen Its HR Capacity to Better Serve Veterans
The recruitment and retention challenges VHA is experiencing with
its clinical workforce are due, in part, to VHA's limited HR capacity,
including (1) attrition among its HR employees and unmet staffing
targets, and (2) weak HR-related internal control functions. Until VHA
strengthens its HR capacity, it will not be positioned to effectively
support its mission.
Attrition of VHA's HR Staff and Unmet Staffing Targets Undermine VHA's
HR Capacity
In our December 2016 report on VHA's HR capacity, we found that
attrition of HR staff grew from 7.8 percent (312 employees) at the end
of fiscal year 2013 to 12.1 percent (536 employees) at the end of
fiscal year 2015. \25\ In comparison, attrition for all VHA employees
was generally consistent during the same period, from 8.4 percent in
fiscal year 2013 to 9 percent at the end of fiscal year 2015 (see
figure 3).
---------------------------------------------------------------------------
\25\ GAO 17 30.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Note: Veterans Health Administration (VHA) data include permanent,
temporary, full-time, and part-time employees in pay status. Data
exclude medical residents and intermittent employees. Between fiscal
years 2011 and 2015, the average total N=4,000 VHA human resources (HR)
staff, and total average N=295,912 VHA employees in all occupations.
Government-wide data include permanent, temporary, full-time, and part-
time executive branch HR staff in pay status. Data do not cover the
U.S. Postal Service, intelligence agencies, or judicial branch
employees. Between fiscal years 2011 and 2015, the average total
---------------------------------------------------------------------------
N=39,917 HR staff.
Most of the turnover is due to transfers to other federal agencies,
followed by resignations and voluntary retirement. In fiscal year 2015
HR specialists transferred to other federal agencies at a rate six
times higher than all VHA employees.
We found that between fiscal years 2011 and 2015, the majority of
medical centers fell short of VHA's HR staffing goals, even with new
hires to partially offset annual attrition (see figure 4). VHA
established a target HR staffing ratio of 1 HR staff to 60 VHA
employees to manage consistent, accurate, and timely delivery of HR
services. However, in fiscal year 2015 about 83 percent (116 of 139) of
medical centers did not meet this target. \26\ Of these 116 medical
centers, about half had a staffing ratio of 1 HR staff to 80 VHA
employees or worse. In other words, each HR employee at those medical
centers was serving 20 to 80 more employees than recommended by VHA's
target staffing ratio. According to the HR staff we interviewed, this
has reduced HR employees' ability to keep pace with work demands and
has led to such issues as delays in the hiring process, problems with
addressing important clinical hiring initiatives, and an increased risk
of personnel processing and coding errors.
---------------------------------------------------------------------------
\26\ Although VHA has 168 individual medical centers, it reports
data at the ``parent'' medical center level. There are 140 parent
medical centers. However, one medical center did not have sufficient
data to be included in our analysis.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Note: N - 139 VA medical centers. Ratios reflect all Veterans
Health Administration employees on board in both pay and non-pay
---------------------------------------------------------------------------
status.
In addition, VHA's All Employee Survey results from 2015 indicate
that HR staff reported feeling more burned out and less satisfied with
their amount of work compared to the VHA-wide average in these areas.
\27\ Specifically, about 48.1 percent of those who identified as HR
specialists reported being satisfied with the amount of work compared
to about 62.5 percent of employees VHA-wide.
---------------------------------------------------------------------------
\27\ VHA's National Center for Organization Development develops
and administers the All Employee Survey, an annual census survey that
is intended to gauge employees' experiences at VA. Among other things,
the survey captures the extent to which employees feel burned out on
their job on a scale from 0 to 6, with 0 meaning never, and 6 meaning
every day.
---------------------------------------------------------------------------
As noted above, as of mid-March 2017, VA has exempted 108
occupations from the current hiring freeze because VHA maintained they
were necessary to meet VA's public safety responsibilities. However,
the broad list of exemptions, ranging from physicians to housekeeping
staff, did not include HR specialists, even though VHA ranked HR
management as third on a list of mission critical occupations in its
2016 Workforce and Succession Strategic Plan. \28\ Given the attrition
rate that we identified among HR specialists and the HR staffing
shortfalls at many VA medical centers, a prolonged hiring freeze could
further erode VHA's capacity to provide needed HR functions.
---------------------------------------------------------------------------
\28\ Veterans Health Administration, VHA Workforce and Succession
Strategic Plan, 2016 (2016).
---------------------------------------------------------------------------
In our 1982 report on hiring freezes under prior administrations,
we concluded that government-wide freezes are not an effective means of
controlling federal employment because they ignored individual
agencies' missions, workload, and staffing requirements and could thus
disrupt agency operations. We noted that improved workforce planning,
rather than arbitrary across-the-board hiring freezes, is a more
effective way to ensure that the level of personnel resources is
consistent with program requirements. \29\
---------------------------------------------------------------------------
\29\ GAO, Recent Government-Wide Hiring Freezes Prove Ineffective
In Managing Federal Employment, FPCD-82-21 (Washington D.C.: March 10,
1982).
---------------------------------------------------------------------------
Weak Internal Control Practices Adversely Affect Key HR Functions
In our December 2016 report, we noted that weaknesses in HR-related
internal control functions reduce VHA's ability to deliver HR services.
Federal standards for internal controls require agencies to (1)
establish an organizational structure that includes appropriate lines
of accountability and authority, (2) evaluate the competencies of HR
staff and ensure they have been appropriately trained to do their jobs,
and (3) design information systems to meet operational needs and use
valid and reliable data to support the agency's mission. \30\ We found
shortfalls in each of these practices at VHA. Moreover, as shown in
figure 5, the twin challenges of weak internal controls and limited HR
capacity have had a compounding effect, creating an environment that
undermines VHA's HR operations and impedes its ability to improve
delivery of health care services to veterans.
---------------------------------------------------------------------------
\30\ GAO, Standards for Internal Control in the Federal Government,
GAO 14 704G (Washington, D.C.: September 2014).
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
---------------------------------------------------------------------------
We reported that key areas for improvement include the following:
Strengthen oversight of HR offices. VHA is structured so that the
central HR offices at VA and VHA have inadequate oversight of medical
center HR offices in order to hold them accountable. This lack of
oversight contributes to issues with VHA's capacity to provide HR
functions and limits VHA's ability to monitor HR improvement efforts
and ensure that HR offices apply policies consistently. Our Standards
for Internal Control requires an agency's organizational structure to
provide a framework for planning, directing, and controlling operations
to achieve agency objectives. \31\ VA and VHA's central HR offices are
primarily responsible for developing HR policy, guidance, and training,
while VISN and medical center HR offices are responsible for
implementing HR policies and managing daily HR operations. However, as
shown in figure 6, there is not a direct line of authority between the
VISN and medical center HR offices and the central HR offices in VA and
VHA.
---------------------------------------------------------------------------
\31\ GAO 14 704G.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Note: In addition to the Deputy and Assistant Deputy Under
Secretary positions shown in this figure, the following positions also
report to the Under Secretary for Health: Chief of Staff, Chief Officer
of Readjustment Counseling Service, Executive Director of Research
---------------------------------------------------------------------------
Oversight, and Chief of Nursing.
According to the director of VA's Office of Oversight and
Effectiveness, the department's organizational structure enables
medical center directors to effectively respond to the needs of
veterans and other clients using available resources. However, VA and
VHA HR officials with whom we spoke said that the organizational
structure limits the department's ability to oversee individual HR
offices, improve hiring processes, train HR staff, and implement
consistent classification processes.
Identify and address critical competency gaps. Federal standards
for internal control require an agency to ensure that its workforce is
competent to carry out assigned responsibilities in order to achieve
the agency's mission. Additionally, our prior work has identified
principles for human capital planning that recommend an agency identify
skills gaps within its workforce, implement strategies to address these
gaps, and monitor its progress. \32\ However, VA and VHA's model for
assessing the competencies of HR staff is incomplete and fragmented. As
one example, VHA's internal human capital reviews have consistently
found that HR staff competencies are not being assessed and HR staff
lack the necessary skills to deliver high-quality services. Further,
although both VA and VHA provide a variety of training programs, HR
staff with whom we spoke described barriers to completing them,
including a lack of time to take training and train new hires, limited
course offerings, and lengthy waiting lists for courses.
---------------------------------------------------------------------------
\32\ GAO, Human Capital: Key Principles for Effective Strategic
Workforce Planning, GAO 04 39 (Washington, D.C.: Dec. 11, 2003).
---------------------------------------------------------------------------
Address long-standing information technology challenges. To have an
effective internal control system, agencies should design their
information systems to obtain and process information to meet
operational needs. \33\ Likewise, our prior work on strategic human
capital management notes that high-performing organizations leverage
modern technology to automate and streamline personnel processes to
meet customer needs. \34\ Data that are valid and reliable are critical
to assessing an agency's workforce requirements. However, VA faces
long-standing, significant information technology (IT) challenges that
include outdated, inefficient IT systems and fragmented systems that
are not interoperable. \35\ With respect to HR IT systems, in May 2016
we reported that VA's department-wide HR system, Personnel and
Accounting Integrated Data (PAID), is one of the federal government's
oldest IT systems and that VA is in the process of replacing it. \36\
---------------------------------------------------------------------------
\33\ GAO 14 704G.
\34\ GAO, A Model of Strategic Human Capital Management, GAO 02
373SP (Washington, D.C.: Mar. 15, 2002).
\35\ GAO 15 290. Interoperability is the ability of two or more IT
systems or components to exchange information and to use the
information that has been exchanged.
\36\ GAO, Information Technology: Federal Agencies Need to Address
Aging Legacy Systems, GAO 16 468 (Washington, D.C.: May 25, 2016).
---------------------------------------------------------------------------
As part of efforts to replace PAID, VA is developing and
implementing an enterprise-wide, modern web-based system called HR
Smart. \37\ VA officials told us that HR Smart will be implemented in
phases across the department. According to agency documentation, HR
Smart will enable HR staff to better manage information on employee
benefits and compensation; electronically initiate, route, and receive
approval for personnel actions; monitor workforce planning efforts and
vacancies by medical center and across the department; and generate
reports and queries.
---------------------------------------------------------------------------
\37\ Note that we did not undertake a comprehensive assessment of
HR Smart's system development and implementation as part of this
review.
---------------------------------------------------------------------------
As VA continues to develop and implement its new HR system, VHA HR
staff must rely on several separate enterprise-wide IT systems to
handle core HR activities such as managing personnel actions and hiring
and recruiting efforts. HR staff with whom we spoke stated that the
amount of time they spent entering duplicate data into four or more
non-interoperable systems and reconciling data between the systems has
made their jobs more difficult and has taken time away from performing
other critical HR duties. According to VA officials, once HR Smart is
fully implemented, it should reduce HR offices' reliance on multiple HR
systems and local tools and help to streamline HR processes. For
example, according to program documentation, VA plans to implement
functionality in HR Smart that will allow managers to initiate, review,
and approve basic personnel actions independently. In these cases, HR
staff would no longer be responsible for data entry.
In conclusion, VHA's challenges recruiting and retaining clinical
and HR employees are making it difficult for VHA to meet the health
care needs of our nation's veterans. The prior reports on which this
testimony is based made three recommendations to VA aimed at improving
the oversight of nurse recruitment and retention initiatives and seven
recommendations directed at strengthening VHA's HR capacity. Key
recommendations included developing a process to help monitor medical
centers' compliance with key nurse recruitment and retention
initiatives and establishing clear lines of authority between VA and
VHA's central personnel offices and those offices in individual medical
centers to hold them accountable for improving HR functions. VA
concurred with our recommendations and said they are taking steps to
implement them. We will monitor VA's progress in addressing our
recommendations and report the results of those efforts to Congress.
Chairman Wenstrup, Ranking Member Brownley, and Members of the
Subcommittee, this completes our prepared statement. We would be
pleased to respond to any questions that you may have.
GAO Contacts and Staff Acknowledgments
If you have any questions on matters discussed in this statement,
please contact Robert Goldenkoff at (202) 512-2757 or by e-mail at
[email protected], or Debra Draper at (202) 512-7114 or by email at
[email protected]. Contact points for our Offices of Congressional
Relations and Public Affairs may be found on the last page of this
statement. Other key contributors to this testimony include Lori
Achman, Assistant Director, Janina Austin, Assistant Director, Tom
Gilbert, Assistant Director, Heather Collins, Analyst-in-Charge, Dewi
Djunaidy, Sarah Harvey, Meredith Moles, Steven Putansu, Susan Sato, and
Jennifer Stratton.
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Prepared Statement of Max Stier
Chairman Wenstrup, Ranking Member Brownley, Members of the
Subcommittee on Health, thank you for the opportunity to appear before
you today to discuss the ability of the Veterans Health Administration
(VHA) to recruit and retain high quality clinical and administrative
employees.
I am Max Stier, President and CEO of the Partnership for Public
Service. The Partnership is a nonpartisan, nonprofit organization that
seeks to transform our federal government by inspiring a new generation
of Americans to enter public service and to improve the way our
government works. I have been privileged to appear before this
subcommittee before to discuss the Veterans Health Administration's
workforce, and welcome the opportunity to do so again. I commend the
Subcommittee for its thoughtful efforts to address the challenges VHA
faces in recruiting and retaining world-class clinicians and support
personnel.
The Veterans Health Administration has a critical mission - to
provide medical care to our veterans - and as the nation's largest
integrated healthcare system, its ability to get the talent it needs is
essential to accomplishing that mission. Recruiting, hiring, and
retaining that talent will require addressing three key challenges: an
inability to compete effectively for talent, a failure to build a
strategic and integrated talent function, and a lack of strong
leadership.
The Veterans Health Administration is making real progress towards
becoming an employer of choice, with employees reporting rising job
engagement each of the last two years, but data tells us there is still
more to be done. According to the Partnership's 2016 Best Places to
Work in the Federal Government Rankingsr, VHA ranks just 235th out of
305 agency subcomponents in overall employee engagement. In the
category of ``Strategic Management,'' which measures the extent to
which employees have the necessary skills and abilities to do their
jobs and management is successful at hiring new employees with the
necessary skills to help the organization, VHA ranked 210 of our 305
subcomponents with a score of 53.1. \1\ Further, a Partnership analysis
of the Office of Personnel Management's (OPM) Federal Employee
Viewpoint Survey (FEVS) found that under half of VHA employees believe
their work unit can recruit people with the right skills (44.4
percent).
---------------------------------------------------------------------------
\1\ By way of comparison, the highest rated agency subcomponent in
this category was the Tennessee Valley Authority Office of the
Inspector General with a score of 87.5. A more accurate comparison by
size might be another large agency - NASA - which led all large
agencies with a ``Strategic Management'' score of 66.2.
---------------------------------------------------------------------------
VHA Struggles to Compete Effectively For Talent
The VHA contends for talent in a highly competitive labor pool for
medical professionals that already faces serious shortages, with
predictions of a shortfall of between 60,000 and 90,000 physicians by
2025. \2\ Unfortunately, both VHA and government as a whole are at a
disadvantage in the battle for talent as a result of self-imposed
barriers that lengthen and complicate the hiring process, and make it
difficult to recruit executive- and entry-level talent, and talent from
the private sector.
---------------------------------------------------------------------------
\2\ Dall, Tim, et. al. ``The Complexities of Physician Supply and
Demand: Projections from 2014 to 2025.'' IHS Inc., April 2016, p. 4,
https://www.aamc.org/download/458082/data/2016--complexities --of--sup
ply--and--demand--projections.pdf.
---------------------------------------------------------------------------
Perhaps most critical is the need for top executive talent, which
means focusing on vacancies among the medical center and Veterans
Integrated Service Network (VISN) leaders. Analysis of medical center
leadership showed that roughly thirteen percent of VA medical centers
lack permanent leadership, a number that has been on the decline but is
still too high. The key to this is the pay disparity between medical
center directors in VHA and the private sector. The Partnership has
long advocated for expanding the use of market-sensitive pay within
government to improve recruitment and retention and to ensure that
government is not paying too much or too little for essential talent.
In a memo to Congress, VA noted that ``individuals holding the position
of Chief Executive Officer (CEO) in private sector health care systems
received on average $731,800 annual cash compensation. CEOs of a single
facility within an overall system received an average of $393,100. In
that same year, SES pay rates capped annual compensation for senior
executives at $181,500.'' \3\ Simply put, while VHA will never pay
salaries equal to private sector medical facilities, market-sensitive
pay is essential for making VHA a more attractive destination for the
executive talent needed to lead medical facilities. There was
legislation in the previous Congress to expand more market-sensitive
pay to this group, but our understanding is that it was not acted on by
the committee due to cost concerns. Such concerns are, frankly, penny
wise but pound foolish - if Congress wants to push for greater
accountability, it must be willing to compensate the executives who
take on these demanding and complex jobs.
---------------------------------------------------------------------------
\3\ ``Title 38 Appointment, Compensation, Performance Management,
and Accountability System for Senior Executive Leaders in the
Department of Veterans Affairs.'' Government Executive, p. 3, https://
www.govexec.com/media/gbc/docs/pdfs--edit/022315kl1.pdf.
---------------------------------------------------------------------------
Even beyond pay, Congress can do more to bring private sector and
entry-level talent into VHA. Direct hire authority, which allows
managers to make job offers without going through the full Title 5
hiring procedure, is a useful tool for agencies to hire for specific
mission-critical jobs. Chairman Roe's recent legislation, the VA
Accountability First Act of 2017 (H.R. 1259), which would grant VA the
authority to directly hire medical center and VISN directors, is a step
in the right direction. Other talent pools could also benefit from this
authority, such as students and recent graduates who are disadvantaged
by a hiring process that overvalues government experience, and
positions under Title 5 where VA faces personnel shortages. Finally,
Congress should modify the standard for granting direct hire. The
current standard requires agencies to demonstrate a severe shortage of
talent, which has been interpreted to mean a shortage of ``minimally-
qualified'' candidates. The Partnership believes this standard should
be clarified to require that agencies demonstrate only a shortage of
``highly-qualified'' talent - a more realistic and appropriate
standard. In recruiting for any position, but especially mission-
critical positions, agencies like VHA should only be seeking the most
highly-qualified applicants.
Facilitating greater movement between the private sector and VHA is
another way that Congress could encourage more individuals to consider
government service. The Partnership has long supported greater mobility
in government, and the Commission on Care has agreed, stating that ``To
expand the perspectives and management experience in its leadership
pipeline, VHA must develop explicit strategies to on-ramp diverse
candidates at critical midcareer transition points.'' \4\ Chairman
Wenstrup's bill, H.R. 1367, already includes some improvements in this
area, such as creating an executive management exchange program to
develop leaders within VHA and allowing former employees who left the
Department in good standing to rejoin the organization more easily.
Congress should also consider additional reforms to the process by
which VA selects and certifies its senior executives, as a way to
remove barriers to executive-level private sector talent joining VHA
and other government agencies. In 2013, the Partnership found that just
six percent of VA career senior executives came from outside government
- lower than the government-wide average of 7.3 percent, a number
which, in our view, is already too low. \5\ I offer several
recommendations on this topic below.
---------------------------------------------------------------------------
\4\ Schlichting, Nancy M., et. al. ``Commission on Care: Final
Report.'' Commission on Care, June 2016, p. 117, https://
s3.amazonaws.com/sitesusa/wp-content/uploads/sites/912/2016/07/
Commission-on-Care--Final-Report--063016--FOR-WEB.pdf.
\5\ ``Building the Leadership Bench: Developing a Talent Pipeline
for the Senior Executive Service.'' Partnership for Public Service with
McKinsey & Company, July 2013, p. 31, http://www.govexec.com /media /
gbc/docs/pdfs--edit/071913cc1.pdf.
---------------------------------------------------------------------------
Finally, it is worth noting that the administration's hiring freeze
is likely to exacerbate talent challenges. While VHA exempted some
critical jobs from the freeze, positions such as human resources
specialists, who play a crucial role in the recruitment, hiring, and
onboarding process for medical professionals who provide care to
veterans, were not. The freeze also sends a message that government is
not looking for talent, which deters individuals who would otherwise
pursue public service and damages the ability of government to reach
the highly trained, high-performing people that it most needs to
recruit.
VHA Lacks a Strategic and Integrated Talent Function
VHA must have a single-minded strategic focus on talent that
informs every decision the organization makes if it is to fill the
roughly 48,000 vacancies across the organization. \6\ Hiring quality
talent for these roles will require investment in the agency's talent
function - the human resources (HR) workforce. The organization's HR
professionals must have the skills, knowledge, and resources necessary
to support the recruitment and retention of great talent and be a
strategic partner to the medical center and network leaders.
Unfortunately, VHA's HR systems are disjointed and poorly integrated,
while the HR workforce faces challenges in the form of low morale,
staff shortages, and ineffective training.
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\6\ Katz, Eric. ``VA Hearing Spurs Divide Over Hiring Freeze, Bonus
Abuse.'' Government Executive, 1 March 2017, http://www.govexec.com/
pay-benefits/2017/03/va-reform-hearing-divides-along-partisan-lines/
135820/?oref=govexec--today--nl.
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Low morale is perhaps the most measurable symptom of a VHA HR
workforce in trouble. A recent GAO report found that attrition for HR
staff at VHA has risen from 7.8 percent in 2013 to 12.1 percent in
2015. Responses to VA's All-Employee Survey showed that ``HR staff
report feeling more burned out and are less satisfied with their amount
of work compared to the VHA-wide average in these areas.'' \7\ The
Partnership's 2016 Best Places to Work rankings bear this out: HR
specialists at VHA posted a satisfaction and engagement score of 54.3
out of 100, 2.4 points below VHA as a whole. More troubling is the fact
that this group's score declined by 5.4 points from 2015, even though
the agency as a whole improved. \8\ The agency is also not building an
HR talent pipeline for the future: just five percent of VHA's HR
specialists are under the age of 30. This number falls below the
government-wide average and well short of comparable private sector
benchmarks, while three out of four HR assistants who leave VA do so
within their first two years of \9\employment. \10\ A report from the
Department's Inspector General noted that VHA identified human
resources officers as its third largest staffing shortage. \11\
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\7\ Government Accountability Office. ``Veterans Health
Administration: Management Attention is Needed to Address Systemic,
Long-standing Human Capital Challenges.'' GAO Publication No. 17-30,
December 2016, p. 13, 15, http://www.gao.gov/assets/690/681805.pdf.
\8\ Partnership for Public Service. ``Veterans Health
Administration.'' Best Places to Work, January 2017, http://
bestplacestowork.org/BPTW/rankings/detail/vata.
\9\ U.S. Office of Personnel Management. FedScope: Federal Human
Resources Data, 2017, https://www.fedscope.opm.gov/.
\10\ Government Accountability Office, p. 12.
\11\ Office of Healthcare Inspections. ``OIG Determination of VHA
Occupational Staffing Shortages.'' Report No. 16-00351-453, September
2016, p. 5, https://www.va.gov/oig/pubs/VAOIG-16-00351-453.pdf.
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Inadequate and poorly-designed training is one contributing issue.
Reports from the Partnership, GAO, and others have reinforced the need
for more and better training for HR specialists both across government
and within VA. Training is especially critical because of the
complexity of the VHA's personnel system, which operates under three
different titles (Title 5, Title 38, and Title 38-Hybrid). GAO reported
that VA offers several HR training programs and resources (e.g., VA HR
Academy), but limited course openings and heavy workloads prevent HR
specialists from participating. \12\ Especially troubling is the fact
at least two medical centers shut down developmental programs for HR
staff and limit the number of intern slots for entry-level HR trainees
due to high workloads. Such cuts are a short-sighted approach that will
only make training deficiencies and personnel shortages more acute.
\13\ The result has been ``technical competency gaps in the areas of
labor relations, position classification and management, and
recruitment and staffing.'' Too often, training at VHA does not give
employees what they need, focusing rather on individual procedures that
have accumulated over time without thought to the overarching skills,
knowledge, and strategies needed for HR staff to be effective. VA
apparently concurs and has noted, according to GAO, that ``an outdated
2002 policy and a decentralized approach to training'' serve as
``potential root causes of the lack of effective training management
and oversight.'' \14\
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\12\ Office of Healthcare Inspections, p. 27.
\13\ Government Accountability Office, p. 24, 28.
\14\ Government Accountability Office, p. 645.
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Finally, investing in VHA's HR capacity is critical to addressing
the organization's talent gaps. The Department struggles to bring in
top talent, particularly young talent and has had mixed success in
retaining that talent. The Department's Inspector General has found
that while ``VHA continued to increase the absolute number of staff in
critical need occupations...the net gains are still significantly
reduced by high loss rates''. \15\ Much of this loss is
``regrettable,'' or among employees who could have stayed on at VA but
chose to leave. \16\ Further, the Independent Assessment found that
time-to-hire ``significantly exceed private-sector benchmarks,
affecting VHA's ability to fill vacancies on patient care teams'' and
that hiring consistently exceeds the agency's 60-day hiring target,
``reaching approximately six months for most clinical occupations.''
\17\ Top HR talent is not just ``nice to have'' - it is essential for
addressing the VHA's workforce challenges.
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\15\ Office of Healthcare Inspections, p. 10.
\16\ Office of Healthcare Inspections, p. 10.
\17\ Independent assessment report pg. 32
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VHA Struggles To Fill Vacancies and Empower Leaders
The third key challenge for the Department is leadership, from
filling vacancies in critical leadership roles to empowering leaders
throughout the organization to focus on talent, effectively manage
people, and deal with poor performers. The Veterans Health
Administration ranks just 273 out of 305 (48.5 out of 100) federal
agency subcomponents in employee satisfaction with leadership. It ranks
similarly poorly in employee views of senior leaders and empowerment.
\18\ Research by the Partnership has shown that leadership is the
single biggest factor driving employee satisfaction and commitment in
the workplace. Accomplishing the mission of the VHA will depend on the
ability of the organization's leaders to build an engaged workplace
culture.
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\18\ Partnership for Public Service. ``Veterans Health
Administration.'' Best Places to Work, January 2017, http://
bestplacestowork.org/BPTW/rankings/detail/vata.
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Unfortunately, that is difficult to do when many leaders are not
even in place. In 2015, nearly half of VISN director positions were
vacant while roughly a quarter of medical center director positions
were empty. \19\ As noted above, the vacancy rate has declined since,
but is still high; further, VA still struggles to recruit these top
leaders. Dr. Carolyn Clancy, in a hearing before this subcommittee last
year, noted that it takes over six months for VISN and medical center
director positions to get filled, with many being re-announced multiple
times due to a lack of candidates. \20\ These empty slots have a
negative impact on performance - hospitals will not function
effectively without the right leadership in place. Filling these
positions must continue to be a priority. Addressing some of the
challenges I have noted above regarding the barriers deterring
applicants for senior jobs, such as low pay and an onerous hiring
process, would help.
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\19\ Maucione, Scott. ``VA's Top Health Official's Five Ways to
Transform Access to Care.'' Federal News Radio, September 2015, http://
federalnewsradio.com/management/2015/09/vas-top-health-official-
rethinking-healthcare-goals/.
\20\ H.R. 1367, 115th Cong. (2017).
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Once permanent leaders are in place, Congress must hold both them
and the Department's political leaders accountable for managing well.
This kind of accountability means defining leaders' performance in a
way that emphasizes their role as managers and focusing attention on
leadership activities like recruiting and retaining top talent,
engaging employees, investing in professional development, and holding
poor performers accountable. Chairman Wenstrup's legislation drives
towards this goal in two key ways: by requiring that the Department
create separate promotional tracks for technical experts who are not
right for or do not want to take on management roles, and by mandating
performance plans for political appointees that would assess their work
towards these goals. The short tenure of many appointees tends to
disincentivize attention to management, so it is important for Congress
to create an expectation that the long-term health of the organization
receives the attention it deserves from the department's political
leaders.
Building the workforce the Veterans Health Administration needs to
achieve its mission will require both short-term improvements to
policies and processes as well as longer-term reforms of the systems
that support or, in this case, inhibit the effective management of the
agency's workforce. Below, I offer five recommendations for how
Congress can address these challenges.
Recommendations
Congress Should Pass Legislation to Improve the Authority of the
Secretary of Veterans Affairs to Hire and Retain Physicians and
Administrative Support Personnel
The House took an important step last week towards addressing many
of the challenges I outlined above when it passed H.R. 1367,
legislation to provide additional authorities to the Department to
improve recruitment, hiring, leadership, and performance, which has
since passed the House. The Partnership, which endorses this
legislation and endorsed similar legislation introduced in the 114th
Congress, believes it will offer some important flexibilities that will
better enable VA to recruit, hire, and retain talent. These include the
ability to noncompetitively rehire former employees at any grade for
which they quality, the creation of a recruiting database that will
enable VA to review applicants for vacant mission-critical positions at
an enterprise level without jeopardizing local talent pipelines, and
the expansion of Pathways intern conversion authority, among other
reforms. While the Partnership continues to believe that the department
must collect more and better data on the quality of its hiring process
and pipelines, this legislation represents an important reform. I thank
you, Chairman Wenstrup, for your attention to this critical issue, and
urge the Senate to take similar action.
Implement Reforms to Make the VHA Hiring Process More Competitive With
the Private Sector
The Veterans Health Administration does not just compete with other
federal agencies for talent, but it does compete with the private
sector, which in many cases can offer prospective employees higher pay
and other benefits beyond what is available to the government. On the
other hand, VHA offers a uniquely challenging, meaningful, and
rewarding mission, to which the agency's employees are deeply
committed. But a hiring process which takes six months or longer to
complete and is complex and unresponsive to applicants will deter even
the most eager job seekers. To this end, Congress should:
Make Compensation for VA Executives More Comparable With the Private
Sector
Senior executives at VHA take on exceptionally difficult jobs which
entail a great deal of professional risk. If VHA is to attract and
retain the type of talent needed to fill these positions, it must be
able to pay them a salary that is more in line with what the private
sector offers. Unfortunately, Title 5 does not allow for the kind of
flexibility that VHA, or other agencies for that matter, need. Senior
executives do not even receive locality pay as other federal employees
do. Ideally, Congress would revamp the federal pay system to enable all
federal agencies to attract the best and brightest. As a first step,
though, Congress should look for ways to close the gap between VA
senior executives and the private sector, for example, by reconsidering
language from a bill introduced in the previous Congress by Chairman
Wenstrup, H.R. 5526, which expanded market-pay to include VISN and
medical center directors.
Grant the VA direct hire authority for post-secondary students and
recent graduates
With under six percent of the VA workforce below the age of 30,
more needs to be done to bring in the entry-level employees who will
serve as the organization's talent pipeline. However, the current
federal hiring process tends to underemphasize qualifications and
potential, disadvantaging younger job applicants. This authority would
allow VA to make on-the-spot conditional job offers to students and
quickly fill entry-level positions - common practice in the private
sector. The National Defense Authorization Act for Fiscal Year 2017
(P.L. 114-328) granted this authority to the Department of Defense, and
the Partnership believes Congress should expand it across government,
including to VA.
Authorize a Public-Private Talent Exchange for VA employees
The Partnership has long supported greater mobility in government.
Job rotations offer a rich professional development opportunity in
management and policy for current and aspiring leaders and allow
agencies to build managerial skills, strategically fill vacancies, and
infuse new thinking into their organizations. The Commission on Care
endorsed the need for more rotation between VHA and the private sector,
noting that ``VHA field leaders are cultivated from within VHA with
about 98 percent advancing from lower-level field positions.As a
result, field senior executives often lack outside experience and
first-hand knowledge of alternative management methods.'' \21\ There
are many forms this exchange could take, from amending the
Intergovernmental Personnel Act to allow for rotations to the private
sector, to a formal exchange program, such as the Executive Management
Fellowship Program authorized by H.R. 1367. Regardless of the type of
program, rotations should be a minimum of six months in length, offer
meaningful work assignments and leadership opportunities, and serve as
an essential part of an executive's career path.
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\21\ ``Commission on Care: Final Report,'' p. 110.
Allow VHA to Use Direct Hire Authority for Any Position with a Shortage
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of ``Highly-Qualified'' Talent
As I noted above, use of direct hire authority requires that an
agency demonstrates a severe shortage of qualified candidates,
generally interpreted as a shortage of candidates who are ``minimally
qualified.'' The minimal standard is not just the wrong one to use but
is extremely difficult to demonstrate in practice, as there are some
positions and geographic locations for which it is simply difficult to
recruit and hire. Demonstrating a lack of minimally qualified
candidates requires an agency to go through the full hiring process
before applying to OPM for such authority, adding a minimum of six
months to the process. Congress should grant VHA expanded direct hire
authority under the ``highly-qualified'' standard so that it can
quickly recruit and hire top talent. The agency would not require OPM
approval, but OPM or another oversight body could be required to
conduct audits after the fact to ensure that VA uses this authority
properly.
Require applicants for Senior Executive Service (SES) positions to
apply with a resume in the initial stage of the hiring process rather
than submit lengthy Executive Core Qualification narratives. Allow
agencies, including VA, to make final selections for SES positions,
with OPM oversight.
No private sector employer asks applicants for executive-level
positions to write lengthy essays to demonstrate their qualifications,
yet this is what the government asks of most applicants for its
executive positions. Aspiring federal executives must complete long
narratives explaining how they have demonstrated the Executive Core
Qualifications (ECQs), which compose the set of competencies against
which agencies and OPM evaluate senior executives. A report by the
Partnership, A Pivotal Moment for the Senior Executive Service:
Measures, Aspirational Practices and Stories of Success, pointed out
that the application process ``discourages many potential candidates
from applying, particularly if they come from the private sector.''
\22\ The Commission on Care also recommended exempting VHA from the
ECQs narratives. \23\ A resume should provide sufficient information
for VA to do an initial screening of applicants. Should additional
information be needed later in the process, the agency can collect it.
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\22\ A Pivotal Moment for the Senior Executive Service: Measures,
Aspirational Practices and Stories of Success.'' Partnership for Public
Service with McKinsey & Company, June 2016, p. 15, https://
ourpublicservice.org/issues/government-reform/SES-report.php.
\23\ ``Commission on Care: Final Report,'' p. 134.
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Also, agencies are required to submit the materials of their SES
applicants for review by an OPM-administered Qualifications Review
Board (QRB). The board is the last step in the SES selection process,
and its purpose is to certify that an SES candidate possesses broad
leadership skills. \24\ The QRB process extends the length of the
hiring process even though nearly all applicants are ultimately
approved.
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\24\ ``Senior Executive Service: Selection Process.'' OPM.GOV,
https://www.opm.gov/policy-data-oversight/senior-executive-service/
selection-process/#url=Qualifications-Review-Board.
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The Partnership recommends addressing these interconnected
challenges by authorizing agencies, including VA, to certify their
executives, with appropriate oversight from OPM, and require
individuals to apply for executive positions, at least in the early
stages, with a resume. Several agencies, including the General Services
Administration and Customs and Border Protection, currently use resume-
based hiring. \25\ We understand that VA has tried resume-based hiring
in the past with mixed success because the agency had to assume
additional work in putting together the applicant's package for the
QRB. If VA were exempted from the QRB, the department could determine
an application and assessment process that would enable them to screen
for top talent without burdening the applicant or human resources
office.
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\25\ ``Senior Executive Service: Selection Process,'' p. 16.
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Invest in the HR Workforce
The Veterans Health Administration, with Congress' assistance, must
do far more to support and expand the HR workforce. The Defense
Department's acquisition workforce reforms may serve as a model. \26\
The Department of Defense has instituted new qualifications standards
for acquisition specialists, created training opportunities, and
requested direct hire authority to bring in needed acquisition talent.
I applaud you, Chairman Wenstrup, for addressing the need for
additional HR training in your legislation. However, measures to expand
the capabilities of the HR workforce should accompany measures to
expand its capacity and integrate it across the organization. Exempting
HR specialists from the federal hiring freeze would be a good first
step. VHA's central HR office, which is responsible for developing
agency-wide HR policies and training, must also think more
strategically about what training it currently offers, what it should
start or stop offering, how best to deliver training, and how to
provide the resources on the ground to make it happen. \27\ More
thoughtful evaluation of required training could both increase the
skill level of the current HR workforce and free up time now spent on
unnecessary or unhelpful training.
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\26\ United States. Cong. House. Committee on Homeland Security and
Governmental Affairs, Subcommittee on the Oversight of Government
Management. Hearing on Building and Maintaining an Effective Human
Resource Workforce in the Federal Workforce. May 9, 2012. 112th Cong.
2nd sess. Washington: GPO, 2012 (statement of John Palguta, Vice
President for Policy, Partnership for Public Service).
\27\ For the purpose of full disclosure, the Partnership operates
the Emerging HR Leaders (EHRL) training program. The Emerging HR
Leaders Forum is a professional development program for HR employees
early in their federal careers. Through monthly education sessions
featuring group discussions, facilitated activities and guest speakers,
participants will develop the knowledge, network and perspective
necessary to lead in the federal human capital community.
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In my testimony last year, I recommended that the subcommittee
request more information on the status of VA HR training programs and
how training offerings can be streamlined and updated to meet the
Department's most pressing talent needs. \28\ I also recommended that
training includes best practices for HR staff in effectively engaging
with hiring managers to maximize the success of the hiring process and
satisfaction with new hires and to expand the availability of training
to all VA employees engaged in recruitment activities. Because the need
for a strengthened VHA HR workforce remains as acute as ever, I believe
these recommendations remain relevant.
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\28\ United States. Cong. House. Committee on Veterans' Affairs,
Subcommittee on Economic Opportunity and Subcommittee on Health.
Hearing on Draft Legislation to Improve the Authority of the Secretary
of Veterans Affairs to Hire and Retain Physicians and Other Employees
of the Department of Veterans Affairs. March 16, 2016. 114th Cong. 2nd
sess. Washington: GPO, 2016 (statement of Max Stier, President and CEO,
Partnership for Public Service).
Think About the Veterans Health Administration in the Context of
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Broader Civil Service Reform
Many of the challenges experienced by the Veterans Health
Administration in recruiting, hiring, and retaining top talent are the
result of the flaws of the civil service system. The Commission on Care
made the case well: ``VHA lacks competitive pay, must use inflexible
hiring processes and continues to use a talent management approach from
the last century. A confusing mix of personnel authorities and position
standards make staffing and management a struggle for both supervisors
and human resources personnel.'' \29\ The Partnership, in its 2014
report, Building the Enterprise: A New Civil Service Framework, decried
the balkanization that has resulted from agencies seeking one-off
exemptions from personnel laws and offered a blueprint for reforming
the outdated and overly complex civil service system. The report
suggested reforms to hiring, pay, job classification, accountability,
and leadership.
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\29\ ``Commission on Care: Final Report,'' p. 139.
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In our view, solving the problems at VHA will require reforms at
the enterprise level. And, as a sprawling organization with a mission
that demands highly specialized talent, VHA could serve as a potential
model for broader civil service reform. Though this committee does not
have jurisdiction over the broad civil service system, it can push for
the broader changes needed to give VHA the high-performing personnel
system it needs to accomplish its mission. This type of government-wide
reform would have the added benefit of helping other agencies that
provide services to veterans and their families, such as the Veterans
Benefits Administration and the National Cemetery Administration.
Shine a Spotlight on What Is Going Right
The Department of Veterans Affairs, and the Veterans Health
Administration specifically, face challenges as a result of a small
number of employees' poor performance and misconduct. But this should
not overshadow the incredible work done by dedicated VA employees every
day. Focusing simply on firing risks negatively impacting recruitment
and hiring without any improvement in performance. Instead, I urge the
Committee to focus on what is going right in the Department and to
highlight the incredible, life-changing work that happens in VHA
facilities across the country.
The Partnership's Service to America Medals program, which
highlights excellence in our federal workforce, brings attention to
just a few of these inspiring stories. For example, in the James J.
Peters VA Medical Center in New York City, medal winners Drs. William
Bauman and Ann Spungen greatly improved the health care and the quality
of life of paralyzed veterans by developing new ways to treat long-
overlooked medical problems. Dr. Thomas O'Toole, director of the VA's
National Center on Homelessness Among Veterans, created two nationwide
programs to help high-risk, high-need homeless veterans receive
comprehensive medical care, housing assistance, and social services to
reclaim their lives. A third VA leader, Ronald Walters, currently the
Acting Under Secretary for Memorial Affairs, honored veterans by
delivering the pinnacle of care and service at their final resting
place, while increasing availability and access to burial sites
throughout the country. The National Cemetery Administration has placed
first among public and private sector organizations in customer service
for the last six years and places a high priority on providing
excellent service to veterans and their families. \30\ This kind of
accomplishments occur across the Department every day, and I urge the
Committee to use its platform to share them with the public.
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\30\ ``VA's National Cementeries Lead Nation in Satisfaction
Survey.'' U.S. Department of Veterans Affairs, February 2017, https://
www.cem.va.gov/CEM/pressreleases/VA--National--Cemeteries--Lead --
Nation--in--Satisfaction--Survey.asp.
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Conclusion
Chairman Wenstrup, Ranking Member Brownley, Members of the
Subcommittee on Health, thank you again for the opportunity to offer
the Partnership's views on the challenges faced by the Veterans Health
Administration in recruiting and retaining a world-class clinical and
administrative workforce. The work and continued oversight of this
Subcommittee are critical to ensuring that VHA can meet its talent need
both today and in the future, and I look forward to supporting this
subcommittee's work in the new Congress. I am now happy to answer any
questions you may have.
Prepared Statement of Louis J. Celli, Jr.
The American Legion has been concerned about the dangers of
physician and medical specialists staffing shortages at the Veterans
Health Administration (VHA) since 1998. In 2003 we established our
System Worth Saving (SWS) Program in 2003, and have continued to track
and report staffing shortages at VA medical facility across the
country. Our SWS report is submitted to Congress, VA, and the President
of the United States. For more than 98 years The American Legion has
dedicated considerable resources to monitoring the healthcare system
established to care for America's returning veterans. \1\
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\1\ Resolution 311: The American Legion Policy on VA Physicians and
Medical Specialists Staffing Guidelines
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Chairman Wenstrup, Ranking Member Brownley and distinguished
members of the Subcommittee on Health; on behalf of more than 2.2
million members of The American Legion and our National Commander
Charles E. Schmidt; The American Legion, the largest patriotic service
organization for veterans serving every man and woman who has worn the
uniform for this country, we thank you for the opportunity to testify
regarding The American Legion's position on ``Healthy hiring: Enabling
VA to recruit and retain quality providers.''
Unfortunately, there are no easy solutions for VHA when it comes to
effectively and efficiently recruiting and retaining staff at VA
healthcare facilities. The American Legion believes that access to
basic health care services offered by qualified primary care providers
should be available locally as often as possible at all times.
In 2004, The American Legion urged VHA to develop an aggressive
strategy to recruit, train, and retain advanced practice nurses
(APN's), registered nurses (RN's), licensed practical nurses (LPN's),
and nursing assistants (NA's) to meet the inpatient and outpatient
health care needs of veterans. The Legion fully supports VA's
education-assistance programs for APNs, RNs, LPNs, and NA's. We also
urged VA to provide equitable and competitive wages for Advanced
Practice Nurses (APNs), Registered Nurses (RNs), Licensed Practical
Nurses (LPNs), and nursing assistants. \2\
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\2\ Resolution No. 237: The American Legion Policy on VA Nurse
Recruitment and Retention
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A full one-third of all veterans treated by the VA live in a rural
area \3\, and The American echoes VA's concern, supports their efforts
and the efforts of this committee, to increase access to quality health
care for veterans living in these communities. As the number of
veterans residing in rural communities continues to grow veterans will
continue struggling to find timely and quality VA health care that
meets our community's health care needs. VA medical centers in rural
areas face ongoing challenges recruiting and retaining qualified
medical and clinical providers due to their inability to compete with
medical centers in large metropolitan areas. In The American Legion's
2012 SWS Report on Rural Healthcare, American Legion research found:
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\3\ https://www.ruralhealth.va.gov/docs/ORH--Infosheet--
WorkforceAndFacilities--FINAL--508.pdf
``Department of Veteran Affairs Medical Centers (VAMC) in rural
America, recruitment, and retention of primary and specialty care
providers has been a constant challenge. Some clinicians prefer to
practice in more urban settings with more research opportunities and
quality of life that urban settings provide.'' \4\
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\4\ The American Legion: 2012 System Worth Saving Report on Rural
Health Care
During our 2013 site visit to the Huntington VA Medical Center in
Huntington, West Virginia we recommended, ``VHA conduct a rural
analysis for hard to recruit areas and look into different options to
support VAMCs in getting the talent they need to serve veterans
better.'' VHA needs to ensure that veteran health care is consistent
across each Veterans Integrated Service Network (VISN).
In 2014, The American Legion published an SWS report titled ``Past,
Present, and Future of VA Healthcare'', which noted several challenges
VA still faced regarding recruiting and retention such as:
Several VAMCs continue to struggle to fill critical
leadership positions across multiple departments.
These gaps have caused communication breakdowns between
medical center leadership and staff that work within these departments.
In 2015, during our SWS site visit to the VA Medical Center in St.
Cloud, Minnesota, providers were openly upset about the number of
physician vacancies, and how the additional workload is impacting
morale at the medical centers. During the same visit, one veteran told
us ``every time [I] visit the medical center, [I am] assigned a new
primary care provider because [my] last provider either quit or
transferred to another VA.''
There have been numerous reports citing VA's staffing issues, for
example in January 2015 the VA's Office of Inspector General (VAOIG)
released the report Determination of Veterans Health Administration's
Occupational Staffing Shortages \5\, that performed a rules-based
analysis on VHA data to identify these occupations. The VAOIG
determined that the five occupations with the ``largest staffing
shortages'' were Medical Officer, Nurse, Physician Assistant, Physical
Therapist, and Psychologist.
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\5\ https://www.va.gov/oig/pubs/VAOIG-15-00430-103.pdf
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In 2015, The American Legion appeared before members of the House
Veterans' Affairs Subcommittee on Health and testified again that VA
physicians and medical specialists staffing shortages within the
Veterans Health Administration (VHA) were dangerously low and required
immediate attention \6\. Two years later we are here again to discuss
this very important issue, which has now escalated to a level that is
creating physician burnout and degradation of employee morale within
VHA. Through our SWS site visits The American Legion has heard first
hand from VA clinicians, non-clinical employees, and veterans, how the
staffing crisis is impacting the VA healthcare system and the patients
they serve.
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\6\ https://www.legion.org/legislative/testimony/227163/va-
staffing-medical-professional
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From December 2015 through February 2017, The SWS Program visited
more than twenty-five VA health care facilities nationwide. When we
asked to describe their number one challenge; directors, human resource
officers, and VA managers unanimously responded ``staffing.'' Medical
center vacancies ranged from as low as 44 positions at smaller medical
centers to over 300 at the larger medical centers. Critical vacancies
exist across all occupations, clinical as well as administrative.
Directors are being rotated from one VA medical center to another to
cover critical shortages, which was the case in over 50 percent of the
medical centers we visited during that time frame.
As an example, at the time of our December 2016 visit to the
Pacific Island Health Care System, the director, and chief of human
resource position were both vacant. At the time of our January 2017
visit to the Greater Los Angeles VA Health Care System, the medical
center director had been in his position for less than a year, and the
associate director, chief, and assistant chief, human resource
positions were ALL vacant. During a follow-up call last month, the VA
Pacific Island Health Care System told us that all their top management
positions, except for the Director position have now been filled and
that the chief of human resources position has been filled with a
permanent manager who is highly experienced in human resources.
These staffing shortages are contributing to physician and staff
burnout which was reinforced during our Saint Cloud, Minnesota visit.
As The American Legion continues to conduct System Worth Saving Site
visits across the VA health care system, we see the trend of VA
staffing shortages declining rather than improving.
Things that are working well include the significant contribution
of the VA's Academic Residency Program. As one of the VA's statutory
missions, the VA conducts an education and training program for health
profession students and residents to enhance the quality of care
provided to veterans within the VHA healthcare system. For almost sixty
years, in accordance with VA's 1946 Policy Memorandum No. 2, the VA has
worked in partnership with this country's medical and associated health
profession schools to provide high quality health care to America's
veterans and to train new health professionals to meet the patient
health care needs within VA and the nation. This partnership has grown
into the most comprehensive academic health system partnership in
American history.
While the VA's Academic Residency Program has made significant
contributions in training VA health care professionals, upon
graduation, many of these health care professionals choose a career
outside the VA health care system. The VA will never be in a position
to compete with the private sector. To this end, The American Legion
feels strongly that VA should begin looking into establishing its own
VA Health Professional University and begin training their medical
health care professionals to serve as a supplement to VA's current
medical residency program. \7\ Conceivably, medical students accepted
into VA's Health Professional University would have their tuition paid
in full by VA and upon graduation, the graduate would be required to
accept an appointment at a federal health facility at a starting salary
comparable to what a new medical graduate would be paid by VA based on
their experience and specialty. Similar to a military service academy,
a VA medical school will be highly selective, competitive, and well
respected. Applicants can be nominated by their congressional
representative, teaching staff can be sourced organically as well as
nationally, and real estate is plentiful. This will help ensure the VA
will have an adequate number of healthcare professionals to meet the
growing number of veterans and their healthcare needs.
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\7\ American Legion Resolution No. 377: Support for Veteran Quality
of Life: (Sept. 2016)
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Lastly, there are too many vacancies in VHA, and the recent action
by the President to freeze federal hiring will only add to delays in
performing life-saving surgeries, patient wait times, and claims
backlogs. The American Legion believes the president was correct in
exempting national security, public safety, and our armed forces from
the federal hiring freeze and looks forward to ensuring VA remains
properly staffed to serve the veterans we have an obligation to
support. According to Acting Undersecretary for Benefits Tom Murphy,
The Veterans Benefits Administration alone loses more than 25 of its
staff each pay period and equals an attrition deficit of more than
1,300 claims processors, adjudicators, customer support staff, and
more.
``The American Legion believes that the president is correct in
exempting national security, public safety and our armed forces from
the federal hiring freeze,'' National Commander Charles E. Schmidt
said. ``We fully support his promise to rebuild our military and
eliminate the scourge of radical Islamic terrorism from the face of the
earth. Acting VA Secretary Rob Snyder has assured us that frontline
caregivers will be exempted. We have strong concerns, however, about
how this will impact the veterans who have been waiting too long to
have their claims processed. The sacrifices that these veterans have
made must not be forgotten. VA has made progress in this area, and it
must continue to do so.'' \8\
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\8\ https://www.legion.org/pressrelease/235742/american-legion-
offers-praise-concerns-about-white-house-executive-orders
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The American Legion calls on the administration to exempt all VA
employees from the hiring freeze. All health care employees are
essential and critical to the health and safety of all patients
entrusted to their care. When a patient's room is not properly cleaned,
the safety and health of the patient are at risk of acquiring life-
threatening illnesses such as Methicillin-resistant Staphylococcus
Aureus (MRSA) or any other hospital-acquired infections.
Health care provider positions that remain unfilled due to a lack
of HR resources impacts the health and safety of patients. For this
reason, The American Legion immediately calls for all HR staff to be
exempt from this hiring freeze.
Conclusion
The American Legion understands that filling highly skilled
vacancies at premiere VA hospitals around the country is challenging.
We also expect VA to do whatever is legally permissible to ensure that
veterans have access to the level of quality healthcare they have come
to expect from VA. VA leadership needs to do more to work with
community members and stakeholders. VA has a variety of creative
solutions available to them without the need for additional legislative
action. One such idea could involve the creation of a medical school,
another would be to aggressively seek out public private partnerships
with all local area hospitals. VA could expand both footprint market
penetration by renting space in existing hospitals where they would
also be able to leverage existing resources and foster comprehensive
partnerships with the community. Finally, VA could research the
feasibility of incentivizing recruitment at level 3 hospitals by
orchestrating a skills sharing program that might entice physicians to
work at level 3 facilities if they were eligible to engage in a program
where they could train at a level 1 facility for a year every 5 years
while requiring level 1 facility physicians to spend some time at level
3 facilities to share best practices. Currently, medical staff are
primarily detailed to temporarily fill vacancies. This practice fails
to incentivize the detailed professional to share best practices and
teach, merely hold down the position until it can be filled by a
permanent hire.
In addition to what is presented in this testimony, there is a
large amount of proposed legislation that would have a positive effect
on transforming VA to a more effective healthcare delivery system, most
of which The American Legion strongly supports.
As always, The American Legion thanks the Subcommittee on Health
for the opportunity to present the position of our 2.2 million veteran
members. For additional information regarding this testimony, please
contact Mr. Warren J. Goldstein at The American Legion's Legislative
Division at (202) 861-2700 or [email protected]
Prepared Statement of Steve Young
Good afternoon, Chairman Wenstrup, Ranking Member Brownley, and
Members of the Subcommittee. Thank you for the opportunity to discuss
the Department of Veterans Affairs (VA) Veterans Health
Administration's (VHA) ability to recruit and retain high-quality
employees. I am accompanied today by Dr. Paula Molloy, Assistant Deputy
Under Secretary for Health for Workforce Services.
Introduction
VHA is the largest health care system in the United States, with
170 VA medical centers, over 1,000 community-based outpatient clinics
and more than 320,000 employees. VHA recognizes that our mission to
provide healthcare to Veterans is impacted by outdated Federal human
resources (HR) processes. As you are aware, there is a national
shortage of health care providers; and VHA is competing with the
commercial sector for these scarce resources. Consequently, we are
striving to update internal hiring practices, but also open to
legislative assistance to reform VHA's recruitment, compensation, and
accountability practices to stay competitive.
GAO Report
The Government Accountability Office (GAO) released a report in
December 2016 entitled Management Attention Is Needed to Address
Systemic, Long-standing Human Capital Challenges. In this report, GAO
detailed how limited HR capacity, combined with weak internal control
practices, undermined VHA's HR operations and its ability to improve
delivery of health care services to Veterans.
GAO made 12 recommendations to improve the HR capacity and
oversight of HR functions at its medical centers; develop a modern,
credible employee performance management system; and establish clear
accountability for efforts to improve employee engagement. VA concurred
with 9 recommendations and partially concurred with 3 recommendations
to improve VHA's performance management system.
First, I would like to note that many of the HR challenges revealed
by this report are not unique to VA, and are experienced across the
Federal sector. VHA is impacted more acutely due to our unique health
care mission, which has resulted in our using three different personnel
systems: the government-wide Title 5 statute; the two systems outlined
in Title 38, for physicians, dentists, and nurses; and the Hybrid Title
38 system for allied health professions. Operating with three distinct
personnel systems means our HR professionals have one of the toughest
jobs in the Federal HR workforce, which partly explains the high
turnover and reduced HR capacity within VHA. We agree with GAO's
assessment that VA needs to improve HR capacity and oversight of HR
functions at our medical centers.
To that end, I am working closely with Dr. Molloy to ensure that HR
operations teams in the field and the central office are aligned to
address the issues identified in this GAO report. For example, Dr.
Molloy's staff is administering a competency assessment of HR staff in
Title 5, and is expanding the competency assessment tool to include
Title 38 and Hybrid Title 38. I am working with the Veterans integrated
Service Network (VISN) leadership to ensure that HR staff takes the
competency assessment tool and uses the results to work towards closing
identified knowledge gaps through further training and development.
VHA concurs with GAO's assessment that high-performing
organizations seek to create effective incentive and reward systems
that clearly link employee knowledge, skills, and contributions to
organizational results. VA has been faced with significant caps on
awards for several years, resulting in a limited pool of funds for
employee recognition. Congress recently established new, VA-specific
performance award and incentive spending limitations in Section 951 of
the Comprehensive Addiction and Recovery Act of 2016 (CARA). CARA
amended Section 705 of the Veterans Access, Choice, and Accountability
Act of 2014 to cap VA's spending on employee awards and incentives.
Given these caps, VA will pursue ways to maximize effective use of both
monetary and non-monetary awards to promote employee performance, as
well as maximize existing flexibilities under Title 38 to set market-
based compensation. CARA caps on funding for employee performance
awards and incentives for recruitment, retention and relocation, while
well-intentioned to increase accountability, will result in significant
impediments to recruitment and retention in VHA. The $230 million cap
for fiscal years 2017 and 2018 represents a significant decrease in
available funding during a time when the market for clinicians is
growing increasingly competitive and VHA already faces challenges
competing directly with the commercial sector for top talent.
VHA is entering into the next phase of an automated performance
management system, called ePerformance. This system allows the
development and sharing of consistent performance standards, goals, and
competencies. ePerformance is a government off-the-shelf product that
is used in several Federal agencies. The product was evaluated by a
cross-disciplinary group of subject-matter experts that represented all
three VA administrations, the VA Central Office, and the National
Unions. VHA continues to use this product in a pilot environment, while
all of VHA's performance plan types are configured and tested. Feedback
from the previous pilots has been overwhelmingly positive. VHA's
expanded use of the ePerformance system ensures procedures are in place
to support effective conversations between supervisors and employees,
including electronic certification of those conversations. Broad
implementation of this technology, as well as any future system, will
require adequate IT funding. The target completion date for this
project is October 2018.
VHA agrees with the GAO recommendation that better monitoring of
employee engagement efforts is needed and a formal governance structure
to monitor employee engagement at the workgroup level is being
developed. Employee engagement has been shown to be strongly tied to
patient satisfaction; and engaged staff are critical to VHA's
commitment to rebuilding Veteran trust.
VA Response/60 Day Plan
To achieve VHA's mission of providing exceptional patient-centered
care to America's Veterans, it is essential to recruit and retain
highly skilled and dedicated employees functioning at the top of their
competency level, as well to develop a talented succession pipeline.
VHA has a robust and multi-pronged approach to recruitment. Local
facilities have in-house HR departments, as well as nurse recruiters -
who reach out to and coordinate with applicants at the local level.
This includes outreach to nearby training programs and hosting open
houses when needed to facilitate hiring. VHA successfully used this
recruitment strategy during the Mental Health, Peer Support, Homeless
Program Office, and Intermediate Care Technician national hiring
initiatives.
Facilities also produce job and station-specific advertisements in
local, state and national publications, journals, newspapers, radio
advertisements, and attend local and regional career and job fairs. VA
also promotes opportunities for employment on www.vacareers.va.gov and
leading recruitment websites. The Internet is our number one lead
source; leads also are gained though promotion online with social
media, job boards, and banner advertisements. VA has access to and
routinely utilizes a variety of Web-based sourcing platforms that the
private industry uses to attract and recruit top clinical talent. These
advertisements are placed where targeted clinical providers are most
likely to visit to explore practice opportunities.
At the national level, VHA provides programs, services, and tools
that enhance recruitment and retention of clinicians, allied health,
and support staff. VA's National Healthcare Recruitment Service (NHRS)
provides a centralized in-house team of skilled professional recruiters
employing best practices to fill the agency's top clinical and
executive positions. The national recruiters, nearly all of whom are
Veterans, work directly with VISN Directors, Medical Center Directors,
clinical leadership, and local HR departments in the development of
comprehensive, client-centered recruitment strategies that address both
current and future critical staffing needs. NHRS has increased its
targeted recruitment efforts for mission-critical clinical vacancies
that directly impact patient care and, once filled, will improve
Veterans access to care. These specialties include primary care, mental
health, women's health and critical medical subspecialties. This fiscal
year, NHRS restructured to stand up a dedicated nurse recruitment team,
which works in close concert with nurse recruiters at each facility to
recruit and streamline the hiring process for this vital component of
VHA's workforce.
Historically, VHA has followed hiring practices that have proven to
be unduly burdensome. Over the last year, VHA's business process
improvement efforts, under the MyVA Critical Staffing Breakthrough
Initiative, have resulted in a more efficient hiring process. Rapid
Process Improvement Workshops were conducted at each VISN to identify
barriers to hiring and other HR practices that could be addressed
locally, while issues that required national intervention were
escalated and addressed by Dr. Molloy's team. As part of this effort,
we were able to reduce the time to hire Medical Center Directors by 40
percent, eliminate use of Professional Standards Boards for hiring
medical support assistants as part of the Hire Right Hire Fast
initiative, and obtain the authority from OPM to provide critical pay
to many of our senior healthcare leaders. As we continue our work to
improve HR capacity across VHA, we are engaged with the Department-wide
effort to improve the employee experience through a complete overhaul
of the onboarding process.
Hiring Freeze
VA's primary concern during the hiring freeze is to ensure the
health and safety of our Veterans. Positions deemed necessary to meet
national security or public safety responsibilities are exempt from the
hiring freeze. VA exemptions cover a range of occupations that are
located in various Medical Centers, Outpatient Clinics, Community Based
Outpatient Clinics, and Health Centers that provide direct patient care
or which are in direct support to augment care, without which the
safety of human lives is at stake. Although HR positions are not
exempted from the hiring freeze, we recognize that a well-trained and
adequately resourced HR staff is essential to recruit, hire and retain
high-quality employees. In addition, we have processes in place to
address case by case circumstances should the hiring freeze continue
for an indefinite period of time.
Conclusion
Mr. Chairman, I am proud of the health care our employees provide
to our Nation's Veterans. Together with Congress, I look forward to
making sure that VA can attract and retain the best medical providers
and support staff to give our Veterans the care they have earned and
deserve. Thank you for the opportunity to testify before this
subcommittee. I look forward to your questions.
Statements For The Record
DISABLED AMERICAN VETERANS (DAV)
STATEMENT OF ADRIAN ATIZADO
Mr. Chairman and Members of the Committee:
Thank you for inviting DAV (Disabled American Veterans) to testify
on the recruitment and retention of high quality clinical and
administrative Department of Veterans Affairs (VA) employees. As you
know, DAV is a non-profit veterans service organization comprised of
1.3 million wartime service-disabled veterans that is dedicated to a
single purpose: empowering veterans to lead high-quality lives with
respect and dignity.
Virtually all of our members rely on the VA health care system for
some or all of their health care, particularly for specialized
treatment related to injuries and illnesses they incurred in service to
the nation. To overcome the size and scope of barriers to effective
recruiting and retention of VA health care personnel, Congress and VA
must to work in concert. In reviewing this issue, we highlight those
areas where VA lacks control, requiring Congressional action. VA must
be empowered to hire the right people, have them in the right places,
and empower these dedicated employees to care for our nation's ill and
injured veterans.
As the largest integrated health care system in the country, VA is
the proverbial "canary in the coal mine" for identifying physician
shortages in America's health care workforce. While the exact need has
yet to be determined, the Association of American Medical Colleges
estimates that the United States is facing a shortage of between
61,700-94,700 physicians by 2025, with specialty shortages particularly
acute. The most vulnerable patient populations are in underserved
areas, many of which have large veteran populations. With more than 60
percent of United States trained physicians receiving VA training prior
to employment, the VA health care system plays an important role in
training the next generation of physicians and filling such shortages.
NEEDED CHANGES IN EXISTING AUTHORITIES
VA's effective recruitment and retention strategies must include
the coordination of other resources such as physical space issues. All
too often we hear of the VA facilities built recently in areas
struggling with long waits because planning and building these
facilities take so long that they are often immediately over capacity
when the doors are opened. Changes in the local health care market
occur constantly, but significant changes likely occur during long
building timeframes. Certainly, such changes can be addressed in part
with last minute but costly changes in the initial design, but VA must
identify strategies to truncate this process or better estimate future
demand. In addition, Congress should assist VA to be more nimble with
its physical footprint by enacting legislation to allow VA to lease
facilities.
Leasing Authority
Under current law, Congress must enact legislation authorizing VA
to lease medical facilities with average annual rental payments in
excess of $1 million. Since 2012 however, Congress has not approved VA
leases for its health care employees to work in, hampering the ability
of the Department to provide much-needed health care and services to
veterans around the country.
The Congressional Budget Office (CBO) changed the way it scores
these leases in 2012. Previously, VA major medical facility leases were
designated as operating leases and recorded the obligations on an
annual basis in an amount equal to the lease payments due in that year,
which was the amount used to score the legislation for such leases. In
2012, CBO determined that budget authority for these leases must be
recorded up front when the leases are initiated and the acquisition
occurs-not when the debt is being repaid. This change significantly
increased the scoring of leasing legislation even though actual
spending would not increase and the leases are ultimately subject to
annual appropriations.
Starting with this Subcommittee, Congress must allow leases to go
forward while working on a more permanent resolution on the scoring
challenges facing these leases. Without Congressional action, VA will
remain unable to effectively manage its physical footprint and its
health care workforce to meet the changing health care demands of
veterans across the nation.
Telemedicine Authority
Physical capacity constraints can be mitigated, however. Telehealth
is one of the VA's major transformational initiatives, and the number
of veterans utilizing telehealth services continues to climb. More than
12 percent of VA patients receive elements of their care through
telehealth services. Nearly 90 percent of veterans who utilized the
VA's effective telehealth services were satisfied with the care they
received and telehealth services save on average $2,000 per year in
health care related costs, including travel to a VA medical facility.
Yet under current law, the VA may only waive the state license
requirement for telehealth services if both the patient and physician
are located in a federally owned facility. In addition, the VA may only
perform in-home telehealth care when the patient and physician are
located in the same state.
Legislation is required to address these barriers, which prevent
ill and injured veterans from being seen by a VA physician in another
state. Rural veterans are particularly affected by this lack of
authority and in some cases force them to travel great lengths to a
federal facility before receiving telehealth services.
Graduate Medical Education
VA's participation in graduate medical education (GME) programs
assists the Department in the recruitment and retention of high quality
clinical staff. GME residency programs occur after medical school
graduation, which require three to seven years of additional training
and allow physicians to gain specialty knowledge and judgment. Medical
residents directly contribute to the clinical care of veterans in their
role as supervised trainees who are granted clinical responsibility.
Congress took an important first step towards addressing these
shortages and expanding VA's training mission by increasing VA GME
slots up to 1,500 residency positions authorized under section 302(b)
of Public Law 113-146, the Veterans Access, Choice and Accountability
Act of 2014 (VACAA). We applaud VA for including in its effort to
successfully utilize this new authority additional funds for such
things as the salary of VA staff who are instructors for or supervise
residents and trainees; overhead/administrative costs associated with
maintaining a GME program, and; minor construction projects, or augment
major construction projects, that will allow for necessary expansions
of space.
Notably, VA's expanded support for residencies to help address
physician workforce shortages must be leveraged using the synergy
between a VA hospital and its affiliated academic medical center.
Academic partnerships facilitate the joint recruitment of faculty to
provide care at both VA and academic medical facilities. VA GME
programs also educate new physicians on cultural competencies for
treating veteran patients (inside and outside the VA), and help recruit
residents physicians to the VA after they complete their residency
training. According to results from the VA's Learners' Perception
Survey, residents that rotate through the VA are nearly twice as likely
to consider employment at VA institutions.
However, VA residency programs are sponsored by an affiliated
medical school or teaching hospital. While programs and specialties at
VA medical centers vary considerably, on average medical residents
rotating through VA spend approximately three months of a residency
year at VA. To successfully expand VA GME, VA estimates that affiliated
teaching hospitals need two to three positions for every VA position to
meet all program requirements.
In addition, VA is limiting additional appointments of residents
when fulfilling the requirements of section 302(b) of VACAA. Existing
law established in 1997, under title 42, United States Code, imposes a
ceiling on hospital residency positions for cost-reporting purposes in
the federal graduate medical education program (which reimburses
residency costs from federal funds). Congress must address this primary
barrier to increasing residency training at medical schools and
teaching hospitals.
VA'S PATIENT POPULATION
To improve and strengthen VA's ability to recruit and retain
employees, we assume the providers hired by the Department have the
requisite training and expertise. VA's patient population resides in
rural and highly rural settings to a greater degree than the general
population as a whole. The median age of veterans is nearly 60 years
old and over half of veterans using VA outpatient care are older than
65.
Nearly half of veterans enrolled in VA are age 65 and older, nearly
a third are over 75, and over a million veterans are over 85. A
September 2011 study of the VHA funded by Commonwealth Fund found that
VA patients (primarily older men) had much higher rates of many chronic
health problems-such as high blood pressure, diabetes, and depression-
than the U.S. patient population as a whole. That is, we can expect the
average age of enrolled veterans to continue to rise and use VA
services at an increasing rate as they age. It should be alarming to
this Subcommittee that most VA providers are not Geriatricians.
VA needs physicians trained to meet the special health issues of
older veterans. As veterans age, it becomes more common to have a
number of health issues and to take several medications at the same
time to deal with those problems. Moreover, diseases and medications
can have a different effect on older veterans. Geriatricians are
trained in the specialty of medicine that focuses the diseases and
disabilities of advanced age supported by extensive and decisive
literature demonstrating that care of elder patients by non-specialists
substantially deviates from established medical recommendations.
Mr. Chairman, if children are best seen by Pediatricians, complex
aging patients should be seen by Geriatricians who know how to manage
all their health issues and design care plans to deal with the whole
person.
The supply of providers best able to meet the type of demand is
lacking with interest in practicing this type of medicine in severe
decline. Just as it is with Primary Care, practitioners of geriatric
medicine are reimbursed at a lower level than other physicians. Who
would want to incur additional debt to specialize in a field of
medicine and be paid less? Practitioners specializing in the care of
elderly patients may need to move from practicing to teaching future
providers to increase the supply of clinicians with this advanced
knowledge. We urge VA to address this critical need if it is to deliver
effective high quality care to our nation's ill and injured veterans.
There are a number of available options to influence the workforce
that can be initiated at any time: Congress can target geriatricians
using the VA/Medicare GME program; VA can grow the number of providers
with advanced training in caring for this challenging population; VA
can increase geriatric competencies across the entire workforce,
including physicians, nurses, social workers, mental health providers,
pharmacists, and; VA can increased provider-to-provider consultation
might serve as a partial strategy while building the necessary
workforce.
RURAL AREAS
The DAV believes VA is working in good faith to address its
shortcomings in rural areas but still faces major challenges.
Shortages, recruitment and retention of health care personnel are key
challenges to rural veterans' access to VA care and to the quality of
that care. The Future of Rural Health report recommended that the
federal government initiate a renewed, vigorous, and comprehensive
effort to enhance the supply of health care professionals working in
rural areas. \1\
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\1\ Quality Through Collaboration: The Future of Rural Health,
Committee on the Future of Rural Health Care, Board on Health Care
Services, Institute of Medicine of the National Academies, the National
Academies Press, Washington, D.C., 2005.
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Through VA's existing partnerships with 165 medical schools, over
43,000 medical residents and 24,000 medical students receive some of
their training in VA facilities every year. In addition, nearly 54,000
associated health sciences students from over 1,000 schools-including
future nurses, pharmacists, dentists, audiologists, social workers,
psychologists, physical therapists, optometrists, respiratory
therapists, physician assistants, and nurse practitioners-receive
training in VA facilities.
VA is in the unique position of employing individuals within the
same profession under two differing hiring authorities, title 5 and
title 38 of the United States Code. VA also has been given the
authority to classify employees in a "hybrid" employee status, which
removes employees from a Title 5 competitive service system and
empowers VA to offer competitive salaries as well as create and
interpret rules for hiring and promoting certain health care employees
exclusively under its own unique authority.
Whether in health, benefits or other services, VA invests a
significant amount of effort and resources into training its workforce
to meet the specific needs of veterans. Maintaining the wealth of
experience, skills and knowledge needed by VA employees is essential to
carry out the VA mission. To retain quality employees, VA needs to
provide employee incentives and programs that include child care
benefits, flexible scheduling, and adequate continuing education
allowances to expand skills and underwrite board certification.
COMPETITION IN RECRUITING
The bureaucratic and lengthy process VA requires for candidates to
receive employment commitments and onboarding continues to hinder the
VA ability to recruit and officially appoint physicians, nurses, and
most commonly, new graduates, who are often in debt from student loans.
VA must reduce the amount of time it consumes to bring these new
employees on board, and provide its human resources (HR) management
staff adequate support through updated, streamlined hiring systems, new
procedures, and better training, to maintain the VA ability as a
provider of health care, benefits, and other services to veterans.
DAV is aware that more seasoned recruiters are able to streamline
and compress VA's lengthy process using current authority in aggressive
and novel ways. VA should encourage these local innovators to self-
identify, test the feasibility of their practice, and disseminate this
information through dedicated times for education and training.
While VA has statutory authority to directly hire physicians, it is
not authorized to offer them employment until after they complete their
residency program. Since private health care systems often offer
residents employment a year or two before completing their residency
programs, VA is at a disadvantage when hiring health care professional
who complete their residency at VA medical facilities. This statutory
limitation hinders VA's ability to hire and retain physicians who
complete their residency program at VA and would like to continue to
work at VA.
Also, VA leadership must ensure recruitment strategies and goals
are shared by local HR staff across the system as they carry out their
duties. VA administrations produce annual Workforce and Succession
Strategic Plans that establish VA-wide HR recruitment and retention
goals. VA must create and adopt performance measures and standards that
systematically identify when these recruitment goals are achieved, and
when they are not.
To this end, we are appreciative of the report by the Government
Accountability Office on its findings of high attrition among VA's HR
staff and an increasing workload to fulfill HR functions have made it
difficult to implement is Workforce and Succession Strategic Plans. VA
must fully address challenges with its workforce identified by GAO
before HR staff can be held accountable to performance measures and
goals for recruitment and retention. The failure to fill critical
vacancies across VA in a timely manner directly impacts the
Department's ability to provide services to veterans.
BURNOUTS
VA's Center for the Study of Healthcare Innovation, Implementation
and Policy (formerly the VA HSR&D Center of Excellence for the Study of
Healthcare Provider Behavior) has been studying VA provider burnout-a
syndrome characterized by specifically work-related emotional
exhaustion, otherwise known as cynicism, depersonalization and a
reduced sense of personal accomplishment.
As this Subcommittee is aware, VA launched the patient-aligned care
team (PACT) initiative in 2010 to implement a medical home model in
more than 900 primary care clinics nationwide. Two years later in 2012,
a survey showed that about 39 percent of primary care employees
participating in PACT transformation screened positive for burnout and
includes 45 percent of all providers that were surveyed.
A more recent study published in the Journal of Internal Medicine
looking at burnout among VA Primary Care team members, the overall
prevalence of burnout was 41 percent for fully staffed teams with team
turnover and overcapacity patient panel. There was a lower but
significant burnout prevalence of 30 percent for fully staffed teams
with no turnover and caring for a patient panel within capacity. DAV
believes the burnout rate in VA health care teams needs to be addressed
by VA and deserves strong oversight by the Subcommittee.
In closing, we thank you for this opportunity to provide testimony
for the record. We ask the Committee to consider these situations as it
deals with its legislative plans for this year. This concludes my
testimony, and I will be happy to address any questions from the
Chairman or other Members of the Subcommittee.
PARALYZED VETERANS OF AMERICA (PVA)
Chairman Wenstrup, Ranking Member Brownley, and members of the
subcommittee, Paralyzed Veterans of America (PVA) would like to thank
you for the opportunity to offer our views on recruiting and retaining
quality providers at VA. The degree to which this issue impacts our
members, veterans with a spinal cord injury or disease (SCI/D), cannot
be overstated. We are grateful to be part of this discussion.
The access to care issues plaguing Department of Veterans Affairs
(VA) can almost always be traced back to staff shortages, and the
systemic consequences of those shortages, within the health care
system. These staffing shortages are a result of improper staffing
decisions, a lack of sufficient resources, and the misallocation of
existing resources. No reformation of staffing or capital
infrastructure processes will increase access without appropriate
resources. Despite the increase in resources provided to VA in the
past, there is still a significant need for increase in resources to
serve an impending demand from aging veterans.
PVA, as well our partners in The Independent Budget (IB), DAV and
VFW, believe in a holistic approach to workforce development for VA-one
that allows for the recruitment, training and retention of a high
quality workforce, while at the same time granting VA the authority to
hold employees accountable. In order to transform the culture and
timeliness of care, Congress must enable VA to quickly hire a competent
workforce with competitive compensation that ensures VA is a first-
choice employer among providers.
No one is more affected by provider shortages than those veterans
with complex injuries who rely on VA to treat their specialized needs.
Unfortunately, VA has not maintained its capacity to provide for the
unique health care needs of severely disabled veterans-veterans with
spinal cord injury/disorder, blindness, amputations, and mental
illness-as mandated by P.L. 104-262, the "Veterans' Health Care
Eligibility Reform Act of 1996." As a result of this law, VA developed
policy that required the baseline of capacity for Spinal Cord Injury/
Disease System of Care to be measured by the number of available beds
and the number of full-time equivalent employees assigned to provide
care.VA was also required to provide Congress with an annual "capacity"
report to be reviewed by the Office of the Inspector General. This
reporting requirement expired in 2008, and was reinstated in last
year's "Continuing Appropriations and Military Construction and
Veterans Affairs Appropriations Act for FY 2017." This report, a
critical tool of oversight, should be made available to Congress by
September 30 of this year. However, we have serious concerns about VA's
plan to re-implement this requirement.
It is worth noting that the SCI/D System of Care is the only
specialty service line with its own staffing mandate, implemented in
2000, as a standardized method of determining the number of nursing
staff needed to fulfill all points of patient care. VA has not met this
statutory mandate. For years, PVA has identified chronic staff
shortages, resulting bed closures, and denied admissions. Since 2010,
VA has operated at only 60% of the capacity mandate. Further still, the
mandate itself is 17 years old, and in need of an update to reflect the
aging population of veterans. Such an update would provide a starker
picture of unmet need for the most vulnerable population of veterans.
When there is a shortage of nurses in a specialty care setting,
veterans will be denied admission to that facility, because there
aren't the hands to provide care. The unused beds are then either
closed, or used for other specialties-further denying access. To
complicate the matter, leadership uses a facility's average daily
census to substantiate its staff and budget requests. The average daily
census only captures that day's utilization, it does not capture that
day's denied admissions. Since SCI/D centers are funded based on
utilization, refusing care to veterans does not accurately depict the
growing needs of aging and newly separated veterans. This dynamic is
inherently compromising to patient safety and is the clearest evidence
for the need to provide resources to quickly improve provider
recruitment and retention.
PVA strongly advocates for Congress to provide sufficient funding
for VA to hire physicians, nurses, psychologists, social workers, and
rehabilitation therapists to meet the true demand for services in the
SCI/D system of care. In 2015, SCI/D nurses worked more than 105,000
combined hours of overtime due to understaffing. Such a trend is
unnecessary and dangerous, and has led to an inevitable staff burnout,
low morale and in some circumstances, jeopardized the health care of
patients. Left to their own devices, too many facility directors have
staffed spinal cord injury centers like non-specialty/general
rehabilitation or geriatric units. VA's staffing decisions do not
properly account for the unique skills required of the nursing staff in
an SCI/D unit. This leads to floating nurses who are not properly
trained to handle SCI patients or overworking the existing nursing
staff, which in turn leads to burn out, injury, and staff departure.
Veterans are then left without the responsive bedside care they need.
Considering SCI/D Veterans are the most vulnerable patient population,
the reluctance to meet legally mandated staffing levels is tantamount
to willful dereliction of duty.
Additionally, it is no surprise to suggest VA's administrative
bureaucracy has ballooned in recent years. Arguably, resources devoted
to expanding administrative staff have significantly jeopardized the
clinical operations of VA. We believe serious consideration needs to be
given to rightsizing the administrative functions of VA to free
critical resources and dedicate them to building clinical capacity.
Congress must use its oversight authority to ensure VA is using its own
range of authorities to recruit and compensate providers in critical
health care positions.
Mid-level management at the VISN level seems to have obfuscated all
responsibility for clinical staff shortages, while maintaining
themselves handsomely. The 21 VISNs, managed by directors and senior
managers control the funding for all 1,233 VA health facilities, and
are required to oversee the performance for their VA facilities and
providers. Currently a nominal appointment, this structure was intended
to decentralize decision-making authority and integrate the facilities
to develop an interdependent system of care.
In 1995 the total number of VISN staff was 220. In fiscal year
2011, the total number of VISN employees had climbed to 1,340, a 509%
increase, while bedside clinician and nurse staffing in specialized VA
services plateaued, then fell behind demand. Meanwhile, the VA failed
to request from Congress the resources to meet health care demand,
particularly in specialized services such as spinal cord injury and
disorder care and inpatient mental health.
A modernized and effective human resources operation is vital to
any organization, especially one as large as VA. The multiple
authorities governing the VHA personnel system are incompatible with a
high-performing health care system. Hiring managers and their employees
must attempt to understand the end-to-end hiring process under four
separate rules systems. This unnecessarily adds complexity to the
hiring system which is difficult for both the potential employee and
the human resources staff to navigate. The unnaturally slow hiring
process also ensures VA loses talented applicants. It is not reasonable
to expect a quality provider to wait up to six months for VA to process
an application. Similarly, when an employee announces his or her
forthcoming retirement or departure from VA, HR is unable to begin the
recruiting or hiring process for that position until it is actually
vacated. This not only causes an unnecessary vacancy, exacerbated by
the lengthy hiring time, but it also prevents a warm handoff between
employees and any chance for training or shadowing.
PVA believes that veterans have suffered from VA's inability to be
competitive with its private sector health care counterparts who do not
face the same restrictions on pay and benefits. In the face of a
nationwide provider shortage, and an aging generation of baby boomers,
VA must be competitive now in order to have any chance of meeting the
needs of veterans.
While the personnel challenges facing VA, are numerous, and often
frustrating, it is important to remember these staffing issues and how
they are resolved will have an immediate impact on the life and well-
being of catastrophically injured veterans. For the thousands with
complex needs, there is no private sector alternative where they can
seek care until VA's access problems are solved.
Thank you for the opportunity to present our views on these issues.
VETERANS OF FOREIGN WARS OF THE UNITED STATES (VFW)
CARLOS FUENTES, DIRECTOR
Chairman Wenstrup, Ranking Member Brownley and members of the
Subcommittee, on behalf of the men and women of the Veterans of Foreign
Wars of the United States (VFW) and its Auxiliary, I want to thank you
for the opportunity to present the VFW's views on ways the Department
of Veterans Affairs (VA) can improve recruitment and retention of high
quality health care professionals.
When the VFW asked veterans how they would improve the VA health
care system in our latest survey of VA health care entitled "Our Care
2017," the most common suggestion was to hire more health care staff to
reduce wait times. The VFW thanks this subcommittee for recognizing
that VA's ability to hire and retain high quality employees is equally
as important as its ability to fire or demote wrongdoers. Considering
that more than 30 percent of VA employees will be eligible for
retirement by 2020, it is important that Congress focuses on ways to
improve VA's hiring and retention authorities to ensure veterans have
timely access to the care they have earned.
If VA is not able to quickly hire high quality employees, it will
lack the staff needed to accomplish its mission. In its report, "Hurry
Up and Wait," the VFW highlighted deficiencies in VA Human Resources
practices. The VFW recommended Congress ease federal hiring protocols
for VA health care professionals to ensure VA can compete with private
industry to hire and retain the best health care providers in a timely
manner.
In their review of VA's scheduling system and software development
as required by the Veterans Access, Choice and Accountability Act of
2014 (VACAA), the Northern Virginia Technology Council (NVTC)
reinforced the VFW's concerns that VA's hiring process moves too
slowly. NVTC suggested that for VA to be successful, it must
aggressively redesign its human resources processes by prioritizing
efforts to recruit, train, and retain clerical and support staff.
That is why the VFW is glad the House of Representatives
unanimously passed H.R. 1367, which would improve the authority of the
Secretary of Veterans Affairs to hire and retain physicians and other
employees. This important bill would make many needed improvements to
the way VA hires and retains high quality employees.
The VFW would like to thank this subcommittee for incorporating a
suggestion from one of this year's VFW-Student Veterans of America
(SVA) fellows into a proposed Executive Management Fellowship Program.
In his proposal, "Connecting America's Best to Serve America's Best,"
Karthik A. Venkatraj highlighted how a private-public partnership
program such as the Executive Management Fellowship -- where VA leaders
are detailed to a private sector company and vice versa -- can infuse
private sector expertise and disciplines into VA governance and
management. The proposed fellowship would also grant private, non-
profit and academic institutions the ability to immerse its leadership
in the highest levels of our nation's public policy to better
understand how the public and private sector can learn from each other
and work together to improve the lives of America's veterans.
The VFW also lauds this subcommittee for taking steps towards
improving veterans preference to ensure veterans who served in the
Guard and Reserve are afforded the same hiring preferences as their
active duty counterparts. Currently, veterans who served after
September 11, 2001, are required to have served at least 180
consecutive days on active duty. Due to our all-volunteer military and
the nature of the wars in Iraq and Afghanistan, the Guard and Reserve
have been utilized much more than they have during past conflicts.
However, not all Guard and Reserve service members receive active duty
orders for more than 180 days. Thus, many veterans that deployed into
harm's way in support of the wars in Iraq and Afghanistan are not
eligible for veterans hiring preferences. Changing the eligibility for
veterans preference from "180 consecutive days" to "180 cumulative
days," ensures Guardsmen and Reservists are afforded the same
opportunity to obtain meaningful civilian employment after military
service as their active duty brothers and sisters.
H.R. 1367 also included other ideas the VFW has suggested and
supported in the past, such as expedited hiring authority for students
enrolled in a VA residency or internship program and recent graduates
who are being poached by private sector health care systems because
VA's hiring process is to too long and cumbersome. It also includes a
requirement for VA to conduct and use exit surveys to determine why its
medical professionals are leaving. Doing so would ensure VA is able to
address retention issues, which is one of the biggest reasons behind VA
staff shortages. While H.R. 1367 included a number of important
provisions to improve VA's hiring and retention authorities, there are
more steps Congress and VA can take.
VA must conduct periodic demand and capacity analyses in each
health care market to properly size its footprint in each community and
leverage the capabilities of community care partners. Doing so would
enable VA to adjust to changes in the veteran population and develop
staffing models based on actual medical need and function level. The
VFW applauds Secretary of Veterans Affairs David J. Shulkin for
announcing in a recent House Committee on Veterans' Affairs hearing
that he would ask his staff to conduct demand and capacity analyses.
The VFW urges Congress to ensure Secretary Shulkin has the authority
and resources to do so.
Another program that needs congressional attention and proper
resources is the VA Health Professionals Education Assistant Program
(HPEAP). VA operates a number of programs as part of HPEAP to
incentivize health care professionals to join VA. The most popular
incentive is the Debt Reduction Program which enables VA to provide
certain employees up to $120,000 over five years to repay student debt.
This program serves as an important recruitment and retention tool and
has seen a major increase in usage mainly due to increased funding from
VACAA. Thanks to VACAA, VA was able to enroll 696 new participants in
this program in 2015 -- a 250 percent increase in new awards compared
to 2013.
However, the infusion of resources from VACAA are set to be
exhausted soon and VA will have to rely on its annual appropriations to
fund this important program. Before VACAA, medical facilities were not
given the resources needed to properly use this program. Facilities
were only given enough resources to reimburse two or three employees
the max amount or provide a small reimbursement to all the medical
center's hard to recruit and retain occupations. Lack of proper funding
would erode this program and diminish its impact on VA's ability to
recruit and retain high quality health care providers. Congress must
ensure the VA Debt Reduction Program continues to be properly funded to
ensure it remains a powerful recruitment and retention tool for VA.
A recent VA Office of Inspector General (OIG) report entitled
"Audit of Recruitment, Relocation, and Retention Incentives" found that
VA -- particularly the Veterans Health Administration (VHA) -- has
misused certain incentives or failed to follow proper steps before
using such incentives. H.R. 1367 would require VA to establish a Human
Resources Academy to train Veterans Health Administration human
resources professionals on how to best recruit and retain employees. As
indicated by this VAOIG report, such training must also include how to
properly use recruitment, relocation and retention incentives.
Another onboarding process that has needed attention for far too
long is VA's licensing and credentialing process, which is excessively
long and should be modified to make certain VA is able hire high
quality doctors on a timely basis. The VFW has heard from countless
would-be VA doctors who elected to seek employment elsewhere because
the onboarding process for VA was too time consuming and strenuous. As
mentioned above, VFW's surveys indicate that veterans want more doctors
at their VA medical facilities. Requiring doctors who want to serve
veterans to jump through hoops deters them from doing so. Congress must
require VA to streamline its licensing and credentialing process.
Congress must also ensure VA has the authority to quickly hire
frontline staff. Due to the lack of support staff, many VA providers
are required to spend time on administrative tasks instead of treating
patients or spending more time with their patients. VA is in the
process of streamlining its hiring process for medical scheduling
assistants (MSAs) and has set the goal of hiring MSAs within 30 days,
which is half the time it takes, on average, to hire support staff
today. The VFW commends VA for its efforts, but it is time Congress
expands direct hire authorities to all Veterans Health Administration
staff, not just doctors and nurses.
During our site visits of VA medical facilities, the VFW has
noticed one constant struggle facilities face -- hiring and retaining
entry level clerks who help with answering phones, greeting patients,
scheduling appointments, and other administrative tasks. During our
visits, we often hear providers and facility leadership say that the
lack of administrative support staff limits their ability to deliver
health care to veterans, particularly when operating in a patient
aligned care team (PACT) where team members are often left to backfill
the duties of vacant positions. This contributes to attrition of
existing employees who are overworked and underpaid because of
vacancies that take too long to fill. Non-clinical VA employees,
including frontline staff, are typically hired under title 5, United
States Code (U.S.C.) authorities. Unfortunately, such authorities
preclude VA from expeditiously hiring qualified candidates to fill
vacancies.
Under section 7802 of title 38, U.S.C., the VA Canteen Service is
exempted from title 5, U.S.C., competitive service, general schedule
pay rates and classification requirements to ensure it is able to
provide veterans reasonably priced merchandise and services essential
to their comfort and well-being. Similar to VA medical facilities, the
Canteen Service relies on entry level employees to operate and maintain
its services. However, the VA Canteen Service would not be able to
operate its retail stores, cafes, and quality of life programs in VA
medical facilities around the country without exemptions from title 5,
U.S.C., competitive service requirements.
The VA Canteen Service has the authority to bypass the USA Jobs
process and hire employees through referral and traditional job search
engines. When it finds qualified candidates, the VA Canteen Service
hires employees as contractors while they undergo the 30-60 day process
to become a federal employee. This process provides the VA Canteen
Service the latitude it needs to ensure its retail stores remain fully
staffed despite high turnover rates. The VFW urges Congress to provide
VHA similar authorities to quickly fill high turnover vacancies at VA
medical facilities.
VA's ability to effectively build, lease and maintain its capital
infrastructure has a direct impact on delivery of care. Regardless if
VA is able to quickly or efficiently hire health care professionals, VA
may still lack the ability to keep pace with increased demand for care
due to outdated exams rooms or insufficient space. That is why the VFW
strongly urges this subcommittee to consider and pass legislation to
reform VA's capital leasing process.
Current congressional rules require the Veterans' Affairs
Committees to offset the full ten-year cost of leases in the first
year. This makes authorizing leases nearly impossible. There are
currently 24 major medical leases from fiscal years 2016 and 2017 that
Congress has yet to authorize. Delays in authorization of these leases
have a direct impact on VA's ability to provide timely care to
veterans. Congress must authorize pending leases and reform the
authorization process.
The VFW believes VA must also improve its process for major
construction projects. To ensure VA is able to complete major
construction projects on time and on budget, the VFW believes VA must
move its construction process entirely to an Integrated Design Bid
Build (IDBB) model. This will allow VA to shorten the overall length of
major construction projects by overlapping the three phases of the
project. Additionally, using the IDBB process would allow state of the
art medical technology to be in use during its prime years, meaning VA
would get more use out of expensive medical equipment.
The largest added benefit of the IDBB process is it saves time over
the entire length of the project. Currently, the three phases of
building -- the design, the bidding, and the building -- happen
sequentially. Integrating the three phases allows for some overlap of
the different phases and shortens the entire length of the project,
sometimes by years.
The other added benefit of the IDBB is bringing the contractors on
board during the design phase of the project, which allows the builders
and the designers to interact as a team and helps prevent future
conflicts during the building phase. Teamwork in the design phase
alleviates problems up front, which saves time and ultimately money.
In closing, I would like to thank the Subcommittee for advancing
accountability and workforce reform legislation, which would have a
significant impact on VA's ability to deliver the timely, high quality,
and veteran-centric care our nation's veterans have earned. However,
those are only the first steps towards building a quality VA workforce.
We look forward to working with this subcommittee to identify and
advance meaningful reforms to ensure VA is able to recruit and retain
top-performing health care providers.
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