[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]


  HEALTHY HIRING: ENABLING VA TO RECRUIT AND RETAIN QUALITY PROVIDERS

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

                                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 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                             
                             C O N T E N T S

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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

                              ----------                              


                       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

                              ----------                              

                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.
---------------------------------------------------------------------------
    \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\
---------------------------------------------------------------------------
    \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.''
---------------------------------------------------------------------------
      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\
---------------------------------------------------------------------------
    \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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Washington, DC 20548

                                 
                    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \12\ Office of Healthcare Inspections, p. 27.
    \13\ Government Accountability Office, p. 24, 28.
    \14\ Government Accountability Office, p. 645.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \18\ Partnership for Public Service. ``Veterans Health 
Administration.'' Best Places to Work, January 2017, http://
bestplacestowork.org/BPTW/rankings/detail/vata.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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).
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \21\ ``Commission on Care: Final Report,'' p. 110.

Allow VHA to Use Direct Hire Authority for Any Position with a Shortage 
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \24\ ``Senior Executive Service: Selection Process.'' OPM.GOV, 
https://www.opm.gov/policy-data-oversight/senior-executive-service/
selection-process/#url=Qualifications-Review-Board.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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 
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \29\ ``Commission on Care: Final Report,'' p. 139.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.

---------------------------------------------------------------------------
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\
---------------------------------------------------------------------------
    \1\ Resolution 311: The American Legion Policy on VA Physicians and 
Medical Specialists Staffing Guidelines
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \2\ Resolution No. 237: The American Legion Policy on VA Nurse 
Recruitment and Retention
---------------------------------------------------------------------------
    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:
---------------------------------------------------------------------------
    \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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \5\ https://www.va.gov/oig/pubs/VAOIG-15-00430-103.pdf
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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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