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


     MORE THAN JUST FILLING VACANCIES: A CLOSER LOOK AT VA HIRING 
                 AUTHORITIES, RECRUITING, AND RETENTION

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH


                                 OF THE

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                        THURSDAY, JUNE 21, 2018

                               __________

                           Serial No. 115-67

                               __________

       Printed for the use of the Committee on Veterans' Affairs

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

        Available via the World Wide Web: http://www.govinfo.gov
                     
                     
                               __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
35-730 PDF                  WASHINGTON : 2019                     
          
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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
BILL FLORES, Texas                   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                   CONOR LAMB, Pennsylvania
JODEY ARRINGTON, Texas               ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana              SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto 
    Rico
BRIAN MAST, Florida
                       Jon Towers, Staff Director
                 Ray Kelley, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

                      NEAL DUNN, Florida, Chairman

GUS BILIRAKIS, Florida               JULIA BROWNLEY, California, 
BILL FLORES, Texas                       Ranking Member
AMATA RADEWAGEN, American Samoa      MARK TAKANO, California
CLAY HIGGINS, Louisiana              ANN MCLANE KUSTER, New Hampshire
JENNIFER GONZALEZ-COLON, Puerto      BETO O'ROURKE, Texas
    Rico                             LUIS CORREA, California
BRIAN MAST, Florida

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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                        Thursday, June 21, 2018

                                                                   Page

More Than Just Filling Vacancies: A Closer Look At VA Hiring 
  Authorities, Recruiting, And Retention.........................     1

                           OPENING STATEMENTS

Honorable Neal Dunn, Chairman....................................     1
Honorable Julia Brownley, Ranking Member.........................     2

                               WITNESSES

Max Stier, President and Chief Executive Officer, Partnership for 
  Public Service.................................................     3
    Prepared Statement...........................................    30
Debra A. Draper, Director, Health Care, Government Accountability 
  Office.........................................................     5
    Prepared Statement...........................................    36
The Honorable Michael J. Missal, Inspector General, Office of the 
  Inspector General, U.S. Department of Veterans Affairs.........     7
    Prepared Statement...........................................    43
Peter Shelby, Assistant Secretary for the Office of Human 
  Resources and Administration, U.S. Department of Veterans 
  Affairs........................................................     8
    Prepared Statement...........................................    46

  Accompanied by:

    Jessica Bonjorni MBA, PMP, SPHR, Acting Assistant Deputy 
        Under Secretary for Health for Workforce Services, 
        Veterans Health Administration, U.S. Department of 
        Veterans Affairs

                       STATEMENTS FOR THE RECORD

American Federation of Government Employees(AFGE)................    49
Whistleblowers of America (WOA)..................................    52

 
     MORE THAN JUST FILLING VACANCIES: A CLOSER LOOK AT VA HIRING 
                 AUTHORITIES, RECRUITING, AND RETENTION

                              ----------                              


                        Thursday, June 21, 2018

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                     Subcommittee on Health
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 10:00 a.m., in 
Room 334, Cannon House Office Building, Hon. Neal Dunn 
presiding.
    Present: Representatives Dunn, Bilirakis, Higgins, Mast, 
Roe, Brownley, Takano, Kuster, O'Rourke, and Correa.

            OPENING STATEMENT OF NEAL DUNN, CHAIRMAN

    Mr. Dunn. This meeting will come to order. Thank you. Good 
afternoon, good morning. Thank you all for joining us today as 
we take a closer look at the staffing across the Department of 
Veterans Affairs and the health care system. Just last week the 
Inspector General released a fourth annual VA staffing shortage 
report, and for the first time the report included a staffing 
shortage information about each VA medical center. It also 
included information on shortages for clinical and non-clinical 
positions in recognition of the fact that many VA facilities 
struggle to hire custodians, and police officers, and human 
resource professionals, just as much as they struggle to hire 
doctors and nurses.
    To no one's surprise, the report found a wide variety of 
staffing needs on the ground. It also found persistent 
challenges to improve staffing, due primarily to a lack of 
qualified applications, and an inability to compete with the 
private sector, and some high turnover problems. The 
consequence of VA's failure to address these challenges are 
almost unparalleled as the VA cannot function on any level 
without high performing, appropriately staffed facilities.
    Last summer, the Committee passed the VA Choice and Quality 
Employment Act of 2017 which contained 14 provisions to improve 
the VA's ability to hire clinicians and support staff. The VA 
Mission Act which was signed into law just three weeks ago 
included an additional 11 provisions to further improve the 
VA's ability to attract those professionals to our medical 
facilities.
    During today's hearing, I want to examine how well the 
authorities that we have provided to the VA, how well those are 
working from last summer, and the additional authorities that 
we provided this summer, also what further actions need to be 
taken to overcome the Department's considerable barriers to 
better recruitment and retention.
    I am grateful to all of our witnesses for being with us 
this morning to discuss this important issue, and I do want to 
note that the American Federation of Government Employees was 
invited also to testified today and initially accepted that 
invitation, ultimately declined. I believe that hearing the 
perspective of the employee union would have been valuable to 
today's conversation. I regret that they were unable to send a 
representative here today.
    With that, I yield to Ranking Member Brownley for any 
opening statement that she may have.

      OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

    Ms. Brownley. Thank you, Mr. Chairman, and thank you for 
holding this hearing on VHA's efforts to recruit, hire, and 
retain quality staff in both clinical and non-clinical 
positions.
    Nearly a year ago, this Congress passed the VA Choice and 
Quality Employment Act which provided the VA with even more 
tools to aid medical center directors as they attempt to hire 
quality employees. However, neither these tools nor previously 
authorized hiring authorities have been coupled with the 
resources and leadership necessary to ensure the mission is 
actually carried out.
    For instance, GAO found that VHA has failed to execute a 
comprehensive review of the authorities granted to it over the 
years. The failure to complete this review means that when this 
Committee discusses these incentives, such as increased salary 
caps or expanded physician training opportunities, we have no 
clue what actually works and what doesn't. When we are talking 
about an agency responsible for translating limited tax dollars 
into the unlimited commitment that this country owes veterans, 
every dollar counts.So efficiency, effectiveness, and 
transparency are paramount.
    As this Committee considers the staffing shortages of VHA 
today, it would be irresponsible to ignore VA's vacant 
executive suite. It has been nearly five weeks since the 
President announced his nominee for Secretary of VA. However, 
it took until yesterday to formally submit this nomination to 
the Senate. It has been 16 months since VA had a permanent 
Under Secretary of Health. There are no less than nine deputies 
Under Secretary and assistant deputy Under Secretary positions 
without permanent appointees.
    How can VA be expected to deliver timely, quality health 
care to over nine million veterans when this administration 
refuses to prioritize the need for stable, qualified, fully 
vetted leaders within the agency? How can we truly expect VHA 
to prioritize recruitment, hiring, and retention efforts at the 
local level when this administration and President Trump show 
no desire to do the same? This administration needs to lead by 
example, and that means putting the leadership in place who 
will get the job done.
    I also ask medical facility directors and VHA frontline 
employees to hold strong as we do our best to hold this vacant 
VA accountable. I believe today's hearing is a first step 
towards a fully staffed VHA. However, I have concerns regarding 
the VA's central office commitment to this process, a process 
that must include communication, data collection, and analysis, 
and fully supported and informed decision making.
    I hope to hear today how we can ensure the VA has the 
focus, dedication, and resources to carry out this process. I 
appreciate the majority and the witnesses for their willingness 
to engage in today's discussion, and I thank you, and I yield 
back.
    Mr. Dunn. Thank you very much, Ranking Member Brownley. I 
would like to also thank the Chairman of the overall Committee 
for coming in, Chairman Phil Roe. Thank you, sir.
    Joining us this afternoon on our first and only panel is 
Max Stier, the President Chief Executive Officer of the 
Partnership for Public Service. Welcome.
    Ms. Debra Draper, Health Care Director for the Government 
Accounting Office for Health. Great to have you here.
    The Honorable Michael J. Missal, the VA Inspector General, 
and a fellow graduate of Washington and Lee University. Go 
General.
    And also, Peter Shelby, the VA Assistant Secretary for the 
Office of Human Resources and Administration. And he is joined 
by Ms. Bonjorni, the VA Acting Assistant Deputy Under Secretary 
for Health for Workforce Services who was on a panel here just 
last week, if I remember you. So it is welcome back.
    Thank you all for being here today, and Mr. Stier, we are 
going to begin with you, and you are now recognized for five 
minutes for your opening statement.

                     STATEMENT OF MAX STIER

    Mr. Stier. Thank you very much, Mr. Chairman, Ranking 
Member Brownley, and the Members of the Committee. I just want 
to start by saying how exceptional it is that you are holding 
this hearing. Typically, we see legislation done, then the 
Committee moves on and doesn't come back to see whether it is 
actually working. The engagement you have had in trying to make 
the VA better on a bipartisan basis is really model performance 
in Congress in my view. So thank you for all the work that you 
are doing. I also want to thank the folks from VA itself who 
are doing really hard work and making some progress.
    So I want to start by putting us in a larger context here 
about what is happening, and I think you have to begin, again, 
with the people of the agency who are the fundamental resource 
that the organization has to produce results, and there is a 
real issue here because morale at the VA is not good and it is 
getting worse. VHA ranks 292 out of 339 agency subcomponents 
that we measure in the Partnership's Best Places to Work 
rankings, and that number went down last year whereas the rest 
of government went up.
    Morale is very important because it is directly related to 
the performance of the agency. It is related to customer 
experience, and much more relevant to us today, right here, it 
is related to retention, and there are real retention issues at 
the VA. Over the past six years, the VA has seen nearly a third 
of its medical personnel leave. That is double the attrition 
average of the Federal government. So again, the hiring is 
important, but you have got to hold on to your talent. They are 
intimately related, and morale is fundamental to making that 
work right.
    And then, Ranking Member Brownley, I think you hit on a 
very critical issue. You have no permanent secretary, no 
permanent deputy secretary, no Under Secretary, and you have a 
lot of acting folks underneath, and no organization can work 
effectively, certainly not take on the really big challenges 
that need to be done here, without that leadership in place.
    So I am going to offer nine recommendations in three 
buckets: oversight, short-term legislative fixes, and some 
long-term legislative issues that I think will make a big 
difference if you can get them done.
    Two ideas on the oversight issue, first. Number one, back 
to the leadership issue. It is the most important, and we need 
leaders to own the actual health of the organization. In the 
legislation you provided last year, there is a requirement for 
a performance plan for political appointees. I think the new 
secretary should be held accountable in implementing that. You 
can hold them accountable by using that performance plan, and 
employee morale ought to be one of the core issues that is 
included. So I would press on that.
    Secondly, I think it is very important that we look to the 
folks that are on this panel on the oversight side to help. 
They have done great work here. Two ideas that might actually 
help even further, one of which is that in every report that 
the IG and GAO does, it would be very helpful, where possible, 
to put promising practices in. The tendency in government is to 
find problems and not to find where there are bright spots that 
you can learn from, and I think the IG and GAO could do a lot 
if you asked them to find promising practices for every issue 
that they identify.
    Secondly, it would be really helpful if they also found 
things that the VA should stop doing. One of the big 
challenges, and one of the reasons why implementation is so 
hard, is the folks at the VA are being asked to do more and 
more and more and more. It builds on top of each other. No one 
goes back and says, ``Is that really important? Is that the 
priority?'' And the cost means that the important things don't 
get done, and I think if you directed the VA and the oversight 
folks to find the things that they shouldn't be doing, the 
reports they should not be giving you, that would be a huge 
benefit.
    Alright, let me move to some legislative opportunities. 
First, Congress should authorize market pay for medical center 
directors. This is the most important group in terms of 
performance at the VA. They are the folks that are leading the 
hospital centers and the VISNs, and right now they are being 
paid by and large under the SES system which was not designed 
for medical center directors. There are only about 170 of them, 
and if you provided market-base pay, or market-sensitive pay, 
for them that would be hugely important. You gave VA a direct 
hire authority already, but that authority is coming in even 
underneath the SES pay. That is a big problem. Fixing that 
would make a big change.
    Number two, give the VA the authority to certify senior 
executives. We have a process right now where everything goes 
through OPM at the front end. It slows everything down. You 
need to reverse this. Allow the VA to make its own SES 
appointments, and then have oversight after the fact so that 
the process doesn't become overwhelming and then chase away a 
lot of candidates. That is also true around critical pay 
authority, and I would also advocate that you codify the 
authority to make conditional offers to job candidates.
    I am going to jump to two long-term suggestions, here. The 
VA staff right now in HR has to operate with three personnel 
systems: Title 38, Title 5, and a hybrid Title 38. That makes 
no sense. It is a waste of time. You should create one system 
for VA. That would enable them, bluntly, to do their work much 
better. next, Congress should also get rid of the current 
classification system. I recognize that it is a big lift. It 
was a system that was created long ago for a world that doesn't 
exist anymore and the nature of work has changed. This reform 
should be made for all of government, but certainly here at VA.
    And I am happy to talk slower and offer a few more of those 
ideas, but I don't want to take more than my five minutes. 
Thank you.

    [The prepared statement of Max Stier appears in the 
Appendix]

    Mr. Dunn. Thank you very much, Mr. Stier. We appreciate you 
squeezing so much information into five minutes. I know how 
hard it can be.
    Ms. Draper, you are now recognized for five minutes.

                  STATEMENT OF DEBRA A. DRAPER

    Ms. Draper. Chairman Dunn, Ranking Member Brownley, and 
Members of the Subcommittee, thank you for the opportunity to 
be here today to discuss VA's ability to recruit, retain an 
onboard high-quality clinicians and support staff to care for 
our Nation's veterans.
    Physicians provide and supervise a broad range of care, 
including primary and specialty care, and are vital to VA's 
mission of providing quality and timely health care to 
veterans. Factors such as VA's lengthy hiring process, a 
limited supply of candidates, and a highly competitive 
recruitment environment have resulted in physicians occupying a 
top spot on VA's annual list of mission-critical occupations.
    Over the past two decades, we and others have expressed 
concern about VA's ability to ensure that it has the 
appropriate clinical workforce to meet the current and future 
needs of veterans. For example, a 2015 independent assessment 
found that VA may be unable to meet the projected demand for 
services if it doesn't increase the number of clinical staff, 
including physicians. In 2016, we found that physician losses 
steadily increased over the previous five years, due primarily 
to voluntary resignations and retirements.
    Additionally, the Health Resources and Services 
Administration projects that by 2025 the national demand for 
physician services will exceed supply. These shortages are 
expected to be considerably worse in rural areas where 
communities struggle to attract and keep well-trained 
providers. This is particularly concerning given that 
approximately one in four VA medical centers is located in a 
rural community.
    In October, we reported the VA's information on the number 
of physicians providing care at its medical centers was 
incomplete because it lacked data on the number of contract 
physicians and only had limited data on the number of physician 
trainees, two types of physicians that augment the care 
provided by VA employed physicians. As a result, the VA does 
not know how many physicians it has, impeding not only its 
ability to determine current needs, but also to appropriately 
plan for the future.
    In our October report, we recommended that VA implement a 
systematic process to count all of its physicians which would 
result in complete and accurate information. VA did not concur 
with this recommendation and recently reiterated its 
nonconcurrence. Although VA has implemented a new personnel 
database, HRsmart, that could help provide an accurate count, 
it does not plan to use the system to track physicians it does 
not directly employ. This is despite VA officials acknowledging 
that their workforce planning processes do not include data on 
all physicians. We continue to believe that it is imperative 
for VA to have an accurate count of all of its physicians.
    Also in October, we reported that although VA provides its 
medical centers with some guidance on how to determine the 
number of physicians and support staff it needs, there is 
insufficient guidance for the medical and surgical specialties. 
As a result, medical center officials told us that they are 
often unsure if their staffing is adequate.
    We recommended the VA issue guidance to its medical centers 
on determining appropriate physician staffing levels and VA 
concurred. VA recently told us it has taken steps to address 
this recommendation. For example, it established a work group 
to develop a staffing model for specialty care. VA anticipates 
that the work--will issue guidance in December.
    Additionally in October, we found that VA uses a number of 
strategies to recruit and retain physicians, but has not 
evaluated them to determine their effectiveness. These 
strategies include, for example, a national physician training 
program and financial incentives. We recommended that VA 
conduct a comprehensive evaluation of its physician recruitment 
and retention efforts, and establish an ongoing monitoring 
program, and establish a system-wide process to share 
information about physician trainees to help fill vacancies 
across medical centers.
    VA concurred with our recommendations and has taken steps 
to address them. For example, VA recently told us that they are 
in the process of completing a review of its physician 
recruitment and retention incentives, including an effort to 
evaluate and recommend a systematic approach for allocating 
resources, such as those for their education debt reduction 
program. This review is expected to be completed later this 
year.
    In conclusion, our October report identified a number of 
weaknesses with regards to VA's ability to recruit, retain an 
onboard high-quality physicians, and we made a number of 
recommendations. It is critical for VA to fully implement all 
of our recommendations to ensure its ability to attract and 
retain physicians, particularly given the continuing growth and 
demand for VA health care, an increasingly competitive 
recruitment environment, and looming shortages.
    Mr. Chairman, this concludes my opening remarks. I would be 
happy to answer any questions.

    [The prepared statement of Debra Draper appears in the 
Appendix]

    Mr. Dunn. Thank you very much, Ms. Draper. We now yield to 
Inspector General Missal five minutes.

                 STATEMENT OF MICHAEL J. MISSAL

    Mr. Missal. Chairman Dunn, Ranking Member Brownley, 
Chairman Roe, and other Members of the Subcommittee, thank you 
for the opportunity to discuss my office's recent report, OIG 
Determination of Veterans Health Administration's Occupational 
Staffing Shortages for Fiscal Year 2018.
    Although this is the fifth OIG report on staffing shortages 
within VA's health care system, it is the first report that 
includes facility specific data reported by leaders at 140 VA 
medical centers. Since January 2015, the OIG has reported on VA 
clinical staffing shortages as required by the Veterans Access 
Choice and Accountability Act of 2014. In our prior reports, we 
recommended that VHA develop and implement staffing models for 
critical occupations. We recognize that VHA has implemented 
staffing models in specific areas, such as primary care and in-
patient nursing. However, operational staffing models that 
comprehensively cover critical occupations are still needed.
    The VA Choice and Quality Employment Act of 2017 expanded 
the reporting requirements to include both clinical and non-
clinical positions, as well as requiring information for each 
VA medical center. Consequently, the OIG conducted a facility-
specific survey to determine current local staffing levels and 
identify shortages. The OIG requested that VA medical center 
directors designate and rank each occupation for which there is 
a shortage at their facility. This shortage information should 
assist VHA in determining how to best meet facility-specific 
needs and improve the quality of health care.
    Recent OIG reports have demonstrated the importance of 
including non-clinical positions in our reports of staffing 
shortages. For example, in our March 2018 report, critical 
deficiencies at the Washington D.C. VA Medical Center, we 
detail how excessive vacancies in key departments can impact 
patient care. In that report, we found an inadequately staffed 
human resources function that contributed to key vacancies 
throughout the facility, including shortages in logistics, 
prosthetic ordering, sterile processing, and environmental 
management services.
    In our 2018 survey, medical center directors most commonly 
cited the need for medical officers and nurses, which is 
consistent with the OIG's four previous VHA staffing reports. 
Our analysis showed that 138 of 140 facilities listed the 
medical officer occupational series as experiencing a shortage, 
with psychiatry and primary care positions being the most 
frequently reported. Of the 140 facilities, 108 listed the 
nurse occupational series as experiencing a shortage, with 
practical nurse and staff nurse as the most frequently 
reported. With non-clinical occupations, the OIG found that 
human resources management and police occupations were among 
the most often cited as shortages.
    The results of our survey demonstrate that although there 
are clusters of commonalities, there is also wide variability 
and occupational shortages reported by individual medical 
centers. This is critically important to recognize because 
facilities have distinct staffing needs that must considered. 
For example, a rural facility that specializes in the treatment 
of mental health will need to be staffed differently than an 
urban facility that provides a broad array of services.
    The report also identified challenges to meeting staffing 
goals. The three most frequently cited challenges were lack of 
qualified applicants, non-competitive salaries, and high staff 
turnover.
    Our 2018 report repeats the OIG's previous calls for VHA to 
develop a new staffing model that identifies and prioritizes 
staffing needs at the national level, while supporting 
flexibility at the facility level, to ensure taxpayer dollars 
are invested in delivering the highest quality care to 
veterans. VA's focus on developing a comprehensive staffing 
model will lead to more efficient hiring practices, and result 
in fewer recruitment challenges, and an increased capacity to 
serve veterans' needs.
    In conclusion, for VA to meets its mission of providing 
high quality health care to veterans, VA must have a better 
understanding of each facility's staffing needs. Our 2018 
report should provide prompt and meaningful discussions at both 
the local and national levels about how to implement, support, 
and oversee staffing in VA medical centers.
    Mr. Chairman, this concludes my statement. I would be 
pleased to answer any questions that you or other Members of 
the Committee may have. Thank you.

    [The prepared statement of Michael Missal appears in the 
Appendix]

    Mr. Dunn. Thank you very much, Mr. Missal. Assistant 
Secretary Shelby, we now recognize you for five minutes.

                   STATEMENT OF PETER SHELBY

    Mr. Shelby. Thank you, sir. Morning Chairman Dunn, Ranking 
Member Brownley, Chairman Roe, and distinguished Members of the 
Committee. Thank you for this opportunity to discuss staffing 
at the Department of Veterans Affairs. I am accompanied by Ms. 
Jessica Bonjorni, our acting Assistant Deputy Under Secretary 
for Health.
    The Department of Veterans Affairs, and I personally as a 
24-year veteran of the Marine Corps, appreciate your steadfast 
commitment to America's veterans with your recent passage of 
several legislative acts, including the VA Mission Act and last 
year's VA Choice and Quality Employment Act. These bills enable 
the department's comprehensive efforts to recruit, develop, and 
retain the high-quality professionals who provide health care, 
benefits assistance, and memorial services to our veterans.
    Last week, the Office of Inspector General released its 
report on VHA occupational staffing shortages. Their findings 
are consistent with prior annual reviews of VHA staffing, with 
physicians and nurses topping the list. For the first time, 
non-clinical shortages were also identified, which consist of 
HR specialists, police officers, and custodial staff.
    VA continues to develop strategies to address shortages in 
these critical areas. Every occupation is critical to our 
ability to successfully deliver the highest quality care to our 
veterans. Inclusion of non-clinical positions in the GAO study 
is recognition of this reality.
    Strong HR is paramount to VA's ability to serve our 
veterans. The complexity of VA's three personnel system 
exacerbates our inability to fill HR vacancies and meet 
critical requirements. The only non-clinical occupation 
consistently in VHA's top mission-critical occupations, year 
after year, is HR. Despite this challenge, our HR capabilities 
and services continue to improve.
    Last year's GAO report on VHA human capital provided 
numerous recommendations to clarify lines of authority and 
provide comprehensive training and competency assessments to 
improve HR services. We are implementing these and many other 
changes to address our customers' needs. I am committed to 
exploring every option, technology, and innovation to develop 
and sustain highly effective human resources capabilities 
across the Department of Veterans Affairs.
    VA appreciates the legislative support of this Committee. 
Enhanced accountability and hiring authorities help us deliver 
critical recruitment and staffing services to sustain a vast 
department. VA is the second largest Federal agency with over 
380,000 employees distributed across all 50 states and all U.S. 
territories. The scope and scale make vacancies numbers often 
quoted in the media seem very high. Taken in context, VA's 
vacancy and turnover rates are very low. We fluctuate between 
nine and ten percent, which compares very favorably with the 
private sector. Since March 2018, we have filled more than 
16,000 vacancies and increased our end strength by nearly 
3,000.
    To meet key performance indicators, VA, like Kaiser, 
Cleveland Clinic, and DoD, approach staffing holistically by 
addressing the entire employee life cycle; recruitment, 
onboarding, development, and retention. Our staffing strategy 
targets one key performance indication: How well we meet the 
needs of the veterans we serve. Staffing issues in certain 
areas of our health care system impede our ability to provide 
optimal care to veterans. We are working diligently to correct 
those issues and continuously strive to improve.
    Recent events in some of our health care facilities raised 
concerns about VA staffing capabilities, and our processes for 
assessing and monitoring adequate staffing levels. Congress, 
GAO, and OIG have provided recommendations to improve staffing 
and to proactively identify occupational shortages.
    VA has established a manpower management office, and we 
have upgraded our HR system of record to enhance our talent 
acquisition capabilities. VHA has developed new staffing 
models. They now benchmark access, quality, and staffing 
against similar health care systems, and they can identify 
facilities at risk of critical staffing shortfalls. These 
efforts, combined with longstanding clinical staffing models, 
and non-clinical models being developed, validated, and 
refined, will provide VA's holistic staffing capability.
    VA is also making progress in implementing provisions of 
the VA Choice and Quality Employment Act of 2017. The 
Accountability Act provided direct higher authority to fill 
medical center and network director positions. However, it does 
not include authority to provide pay commensurate with other 
senior executives.
    In conclusion, we thank Congress for your continued support 
of the Department of Veterans Affairs. We serve and honor the 
men and women who have served this country, America's veterans. 
I personally welcome every opportunity to engage the Committee 
in dialogue and explore how we best work together to meet the 
needs of our veterans.
    Mr. Chairman, Jessica and I are prepared to answer any 
questions you and Members of the Committee may have.

    [The prepared statement of Peter Shelby appears in the 
Appendix]

    Mr. Dunn. Thank you very much, Mr. Shelby. We will turn to 
the question portion of the panel, and I am going to ask the 
panelists if you can keep your answers, sort of, succinct. I 
know that is hard sometimes, but we are constrained by time. So 
appreciate your efforts on behalf of that.
    I will now yield myself five minutes for questions and 
begin, if I may, with Inspector General Missal.
    We have pretty--the same recommendations year after year, 
at least since 2015. I am going to ask you, you know, it feels 
like we are stuck. Are we stuck, and if we are not stuck--well, 
if we are stuck, why? Where?
    Mr. Missal. We agree with you that we have been making the 
same recommendation on a staffing model, first to develop, then 
to implement. That still hasn't been closed out by us. We 
believe VA is making progress on it, but not as quickly as we 
would like.
    Mr. Dunn. So on the implementation, the model is there?
    Mr. Missal. Implementation, right. They do have some 
staffing models, as I said, in primary care and some nursing 
positions, but they need a comprehensive staffing model, so 
they really understand where they need positions, how to spend 
the dollars, and how to budget.
    Mr. Dunn. Do you think that is the biggest barrier? The VA, 
is that the biggest barrier to meeting staffing shortages, is 
the lack of implementation of model, or is it shortage of--
    Mr. Dunn [continued]. --adequate personnel?
    Mr. Missal. That is a significant issue. If they can get a 
staffing model where they really understand what they need. I 
think that goes a long way towards improving the staffing.--
    Mr. Dunn. So that is a start. All right.
    Mr. Shelby, thank you for your service. How many 
vacancies--let's see--no, how--you said this. This is great, 
you addressed the vacancy rate is not that different from other 
large health care systems, but it--clearly, we have shortages. 
So I am guessing, that is all specialty specific. Does it match 
up to the gaps we have in the staffing models?
    Mr. Shelby. Yes, sir. What is critically important to focus 
on is our critical shortfalls. Overall vacancy rate doesn't 
tell me where we are not meeting the needs of veterans. 
Focusing on critical shortfalls does, and noted in the IG, you 
saw a great difference in the types of shortages they have 
across. We have several that are common, and they will parallel 
the private sector health care. All right? There is a shortage 
of psychiatrists across--
    Mr. Dunn. Across the Nation.
    Mr. Shelby [continued]. --the Nation. So we compete for 
that limited--
    Mr. Dunn. I remember, we are always looking for nurses. 
That is--so, a great, great profession.
    Let me--do you have any direct authority over the HR 
functions at VA?
    Mr. Shelby. Yes, sir. You have full authority over all HR 
functions at the VA.
    Mr. Dunn. Okay. So, this sort of sounds like HR is in your 
wheelhouse to implement these models that we have talked about: 
can you give us any good news here?
    Mr. Shelby. We have--in the past, it has been three or four 
different HR organizations, very decentralized. We are 
consolidating that into a single HR authority. We work as a 
single executive HR team now and we are figuring out how to 
consolidate official and effective HR.
    If I have 182 people doing a single HR function and divide 
them over 182 organizations, any one of those that goes on 
vacation, that particular facility loses 100 percent of their 
capability. If I start consolidating those capabilities into 
regional support centers, they meet the needs.
    Mr. Dunn. We like that. In terms of consolidations, I 
notice you have 19 physician recruiters for the entire system; 
is that roughly a correct number, 19 physician recruiters?
    Mr. Shelby. Yes.
    Mr. Dunn. Yes? Okay. So, do they have a lot of staff? Each 
of them has staff, because--no? That is just 19 people, total, 
front to back.
    Okay. Have you been using civilian recruitment--physician 
recruitment forms--vendors?
    Mr. Shelby. Yes, Jessica can speak specifically to the ones 
we use, but we use all resources at our disposal to meet the 
recruiting and staffing needs of the VA.
    Mr. Dunn. So, what feedback do we get from our vendors, you 
go asking them for fine doctors and they come back empty-
handed, what feedback are they giving us?
    Mr. Shelby. Jessica?
    Ms. Bonjorni. Sure. So, similar challenges that you might 
see across any health care system. I think the challenge that 
we have is by using those private sector recruiters, it is 
significantly more expensive than using the ones that we have 
in-house, who are extremely effective. We just need more of the 
in-house recruiters.
    Mr. Dunn. So, I have used recruiters over the years, and I 
agree, it can be expensive, but I also think we can negotiate 
those fees. You are the largest health care system in the 
country. I think you can negotiate a break on that. And there 
is expertise involved in recruiting physicians and expertise in 
getting each specialty.
    I think I will yield back at this point to Ms. Brownley, 
the Ranking Member.
    Ms. Brownley. Thank you, Mr. Chairman.
    This Committee has heard time and time again that hiring 
medical center directors has had its own specific challenges 
and that is why vacancies remain open for long periods of time. 
So, I was happy when we passed the VA Choice and Quality 
Employment Act, which mandated the VA to develop a plan to 
address hiring medical center directors.
    And, recently, I became aware that there was a plan 
submitted. It was roughly three months late. It was four pages 
long and, basically, the gist of the whole report is to say 
that VHA will utilize the current recruitment process to select 
candidates. So, we asked to do a plan to overcome challenges. 
We got a plan that says we should just use the regular 
recruitment process.
    So, Ms. Draper, based on your experience, what constitutes 
a good plan to address this issue around hiring, in a timely 
way, medical center directors?
    Ms. Draper. Well, I think a lot of lessons can be learned 
from us on VA high-risk, but a good plan has a number of 
different elements. I think the very first thing that needs to 
be done is a root cause analysis, because there obviously was 
some issue with hiring medical center directors. There is some 
problem that either there is not enough candidates or qualified 
candidates or not able to retain them. So, I think 
understanding the issues that are leading to that issue is 
really critical. So, that is really a first plan in developing 
the first action in developing a good plan.
    And there needs to be corrective actions; those need to be 
clearly identified. Resources need to be identified and 
allocated looking at timelines, looking at metrics--how are you 
going to measure this--and looking at what are your expected 
outcomes.
    And one key thing is that you need to assign will 
accountability: who is going to be responsible for making sure 
that this plan is carried out?
    Ms. Brownley. Have you seen this plan?
    Ms. Draper. It was on the table here, so ...
    Ms. Brownley. So, have you had a chance to review it a 
little?
    Ms. Draper. I reviewed a really quickly. I mean, I think 
the thing that struck me was that they are going to continue to 
use the same process that they have done and to me that was a 
little surprising.
    Ms. Brownley. So, you feel that is a valid concern, that 
they--the plan says to just use the existing recruitment 
process?
    Ms. Draper. Well, to me, if you look at the elements of a 
good plan, it really didn't contain many of those elements, so 
...
    Ms. Brownley. Thank you.
    Mr. Shelby, first, let me thank you for your 24 years of 
service with the Marine Corps. And so, you know, what is your 
response for that? If you think that, you know, our recruitment 
efforts are fully adequate, what evaluations do you have to 
confirm that?
    Mr. Shelby. I don't particularly think all of our 
recruitment efforts are fully adequate and I am working on 
getting more diagnostic capabilities. One of the biggest things 
that jumped out in the changes we made is we were way too 
decentralized. So, you have individual organizations trying to 
meet all of their needs on a local level and we have 
commonalities; in particular, medical center directors, nurses, 
certain physicians. We have raised that to a national 
capability, rather than a lower capability so we can target a 
broader audience, have targeted teams that focus on the 
onboarding and hiring of these critical shortfalls. And so, we 
actually did change that.
    Ms. Brownley. Well, let's get back to what Ms. Draper said 
in terms of root causes. Do you think a plan to mitigate 
challenges with regards to recruiting medical directors, do you 
think we need to get down total root causes, in order to have a 
positive, effective plan?
    Mr. Shelby. Yes, ma'am.
    Ms. Brownley. And do you think the VA is going to initiate 
that or, you know, how are we going to get to that place where 
we can understand what the root causes are?
    Mr. Shelby. Yes, the VA is absolutely doing that, and it is 
across the board. We found several reasons why it varies why we 
don't have strong retention in certain positions. Medical 
center directors, it is the demand and the pay. It is an 
extremely demanding job. The counterparts in the private 
sector, in some cases, make four or five times what we are 
capable of paying in certain markets. And so, you combine that 
with the workload, it is very difficult to retain them. And 
then recruiting them, like we alluded to at the beginning, we 
got Direct-Hire Authority. We moved to use that, and we are 
capped on salary at $153,000.
    We tried Direct-Hire on two medical centers. We got through 
the entire process, made the offer, and they rejected the offer 
just because we could not meet their salary demands.
    Ms. Brownley. My time is over. I yield back.
    Mr. Dunn. Thank you, Ms. Brownley.
    We have been joined by the Chairman of the Full Committee, 
Dr. Phil Roe. I now yield to you 5 minutes, sir.
    Mr. Roe. Thank you, Mr. Chairman and Ranking Member.
    Medical staffing is something I know a lot about and spent 
a career dealing with it. And we have at VA, some incredible 
challenges going forward, I can tell you that. We had a 
roundtable in this room a week ago that the AAMC, the American 
Academy of Medical Colleges said that we would have a forty to 
a hundred-thousand-dollar doctor shortage by 2030. That is not 
very far away.
    I mean military--folks that have served in the military, 
like you, Mr. Shelby--and, again, thank you for your service in 
the Marine Corps--who are just starting; that is going to 
affect them.
    So, I think we do need to have a long-term strategy, but 
all health care is local, as you all pointed out. I mean, what 
Mr. Missal said was if you are doing maybe it is mental health 
in one place, those needs are different in a rural area than 
they are and the challenges--and you can't do that centrally. I 
think you have to recruit locally. That is where a lot of your 
people are from, and it is hard to move and up people into a 
place.
    So, one of the things that we have done in our Committee is 
we have sent people out to various VA hospitals and--you know, 
with just one-hours' notice just to sort of see what was going 
on at that medical center and one of the things that struck me 
was that one of the material weaknesses I think I found was HR, 
is recruiting. You have someone who is--has this position as 
the HR director trying to recruit a professional person and 
they don't know how to recruit to these people, and it was 
amazing to me to see the disconnect.
    I totally agree with you that, as I help run a hospital, 
you are no better than the weakest link in that hospital and 
that may be the environmental services, food services, staff in 
the ORs to make sure the instruments are clean; all those are 
critically important. They are just as important as I was as a 
physician in the operating room. If they didn't do their job 
well, I couldn't do my job well.
    So, I think you have got a huge challenge ahead of you. And 
one of the things, Mr. Shelby, you said, was if we are meeting 
the needs of the veterans, I would disagree with that, because 
if we were, we wouldn't need the Choice Program or the Mission 
Act we just passed. So, I think we have huge challenges ahead 
and I think HR, believe it or not is one of the critical ones. 
And I don't know how you are going to recruit all of these 
people.
    I know my hospital at home recruits nationwide. We had a 
huge nursing shortage, so what did they do? They provided 
scholarships for nursing students, their third and fourth years 
of school, and for that, when you ended up with no debt when 
you left, you had a time obligation to serve at that hospital. 
It is worked incredibly well. They stopped it for a while and 
learned their lesson. They started over again.
    So, if you could bring us ideas like that, we want to help. 
We want to be--we are not here fussing; we want to be part of 
the solution in trying to help.
    And Ms. Draper, I think you mentioned something that 
shocked me a little bit, but it was that a third of the medical 
personnel turned over in what length of time was that orb 
someone said there was that much turnover with the physicians 
and nurses and so forth or maybe it was--
    Mr. Stier. That was in six years, so 2011 to 2017
    Mr. Roe. That is amazing.
    Mr. Stier. So, it is double the attrition rate for the rest 
of the Federal government.
    Mr. Roe. Yeah, that is--why is that?
    Mr. Stier. I think that is a good question that I am not 
likely to offer you real insight on. I do think that 
fundamentally it begins with the question that the Chairman 
asked before: What are the big issues here? It starts at the 
top and making sure that you have medical center directors in 
place and that they are going to be there for a long period of 
time, which requires a different funding model than you have 
right now.
    If you think about it, you offer Direct-Hire, but at a 
lower pay than what you were able to do before. You are paying 
the medical center directors less than you are paying the 
individual physicians in a marketplace in which those folks, as 
you heard earlier, can make four, five, six times that amount.
    You asked for real concrete things Congress can do, like 
the scholarship issue. Offer market-sensitive pay for medical 
center directors to those folks. As you say, it is all local; 
they are going to figure out a lot of the answers that they 
need to in their own hospital or hospital system.
    Mr. Roe. Now, I agree with you. We have a hospital--a 
private hospital and VA campuses that meet each other, and I 
can assure you that the hospital director at the private 
hospital is not compensated the same as the one at the VA is; I 
agree with that 100 percent.
    Any other suggestions that you all have of how we can be of 
help to you all in making think job easier for you in getting 
those personnel that you need?
    Mr. Shelby. Yes, sir. I think Max alluded to it; having 
three pay systems does not give us the agility that we need. 
And as you saw in the IG report, it is very unique and local 
and having a market rate-based personnel system will give the 
agility we need in each market to target the town and compete 
with the local competition there. And then you have a national 
strategy for implementing all of your HR strategies, but you 
have the flexibility at the local level for them to meet the 
needs there.
    Mr. Roe. Just--thank you--just one other comment before I 
yield back is that in my opinion, all the years I worked in 
health care, I don't--the personnel, the people who work in the 
systems are the most important. That is the engine. I don't 
care if you have got a shiny outside--brand new hospital at 
Denver, Colorado--if you don't have great people working in it, 
you will not have a good facility. So, the people are the most 
important part of a health care system, more so than buildings; 
they are the engine that drive it. They are the face of it who 
provide the care.
    So, anything that we can do to help you all do your job, we 
are here to do. I yield back.
    Mr. Dunn. Thank you, very much, Chairman Roe.
    Now, I yield 5 minutes to Representative Takano from 
California.
    Mr. Takano. Thank you, Mr. Chairman.
    You know, as Members of this Committee, we can't find 
solutions to problems until we understand the full scope of the 
problems that we are facing. We saw over the last few years, 
the staffing reports mandate under the Choice Act weren't 
giving us all the details that we needed. I am pleased to see 
that this latest report by the IG breaks down the staffing 
shortages into more specific occupations and also includes non-
clinical positions.
    Of all the employees at our medical centers, all of our 
employees play a vital in ensuring veterans receive the highest 
quality of care that they deserve. And I know from visiting 
Loma Linda in my own--near my own district, one of the 
challenges they face is hiring custodial staff and I see that 
reflected in the IG's findings.
    I want to get right into my questions. This Committee has 
long been raising the issue of VA's lack of staffing models. At 
present, VA only has three staffing models: primary care, 
mental health, and nursing.
    Mr. Shelby, when can we expect to see additional clinical 
staffing models?
    Mr. Shelby. Sir, I would like to yield that to Jessica, 
because she's been working on several staffing models.
    Mr. Takano. Of course, yes.
    Ms. Bonjorni. Sure. Thank you, sir.
    As Ms. Draper mentioned, I think, and Mr. Missal, we have 
been working on those staffing models for some time, for some 
time. We have a specialty care workgroup that is working on 
developing multiple staffing models for clinical occupations 
that will be done by the end of this year.
    Mr. Takano. By the end of this year?
    Ms. Bonjorni. Yes.
    Mr. Takano. By the end of this calendar year?
    Ms. Bonjorni. Yes.
    Mr. Takano. Okay. Mr. Stier, as I look over the findings 
from the GAO and IG, both make recommendations for the under 
secretary of health to improve hiring at the VA; unfortunately, 
that position is currently vacant, and we still don't have a 
nominee. There has been uncertainty about who would lead the 
Department as secretary for nearly two months.
    Based on your organization's mission, can you speak to the 
importance of having stable leadership in key positions and 
what impact these vacancies may have on the VA's success.
    Mr. Stier. So, I think that is a question that you have 
answered already. Anyone who has been involved in any 
organization knows that stable leadership is fundamental to the 
success of that organization. It is one of the unique 
challenges we have in our own government that you have so many 
political appointees--4,000 of them. No other democracy has 
anything else like that. By its very nature, these folks aren't 
sticking around for a long period of time.
    What we are seeing right now at the VA is particularly 
problematic and it has massive impact. It is very difficult to 
run an organization when people are in short-term positions. My 
analogy is the substitute teacher: they may be wonderful 
educators, but the reality is that they don't get a lot of 
respect from the people in the classroom or they don't take on 
the long-term challenges.
    So, if we want to see VA succeeding, we need to see long-
term, capable, stable leadership.
    Mr. Takano. So, I am really concerned about our move toward 
the electronic medical records and our attempt to get them 
interoperable with the Department of Defense and our non-VA 
providers. Are you concerned at all that lack--you know, these 
vacancies are going to set us up for some sort of failure or 
boondoggle down the road?
    Mr. Stier. I think the reality is that these are incredibly 
challenging issues, whether it is staffing medical professions 
where there is a shortage, or changing electronic medical 
systems which are phenomenally complex systems. You want 
everything aligned right to make it work and right now we don't 
have that, so for sure, this adds another risk factor.
    Mr. Takano. As you know, the commission on--you might 
have--are you familiar with the Commission on Care report? All 
of you are nodding your head.
    Mr. Stier. Yes.
    Mr. Takano. You know, I recall those hearings very, very 
vividly about--we had them about accountability and they said 
you can't have accountability--we know done an accountability 
bill and we spent a lot of time on that, but I don't believe--I 
don't think the Commission on Care, the bipartisan co-chairs 
believe that accountability will be achieved without a robust 
HR Department which does the hiring, but also the kind of 
training with progressive discipline that our managers need to 
implement to be able to really--they said you can't fire your 
way to excellence and you can't discipline your way to--you 
need trained personnel.
    I understand that through April 2018, VA has hired 4222 
human resource specialists. We also know that from work that 
GAO has done that attrition rates among HR specialist rose 7.88 
percent in 2013 to 12.1 percent in 2015.
    How many vacancies are there currently for these positions?
    Mr. Stier. That is not a question that I would be able to 
answer.
    Mr. Takano. Mr. Shelby?
    Ms. Bonjorni. We have--we still have several hundred 
vacancies for HR specialist, however our turnover rate did go 
down over the last year, but that was primarily because of the 
Federal hiring freeze, so they couldn't leave for other 
agencies.
    Mr. Takano. Do you collect exit surveys for these 
positions?
    Ms. Bonjorni. I'm sorry?
    Mr. Takano. Do you collect exit surveys for these 
positions?
    Ms. Bonjorni. Yes, we do.
    Mr. Takano. And if so, why are the general reasons listed 
for why they are exiting and what are you doing to address 
them?
    Ms. Bonjorni. For HR specialists our exit-survey data shows 
that they are leaving for advancement at other organizations or 
concerns about the volume and nature of the work, due to the 
complexity of the work.
    Mr. Takano. Okay. Thank you.
    I yield back, Mr. Chairman.
    Mr. Dunn. Thank you, Mr. Takano.
    And we now recognize Mr. Bilirakis from Florida for 5 
minutes.
    Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it 
very much.
    Mr. Shelby, thank you for your service. I have a question 
for you. The testimony mentions 422 new HR specialists hired 
into the VA and that is good. While this is--again, it is 
progress--one of the last year's--one of last year's GAO 
reports express concerns about the attrition rate amongst the 
HR staff. I understand 13 and a half percent in fiscal year 
2015; significantly higher than the VA employees in general.
    What does VA plan on doing to help continue the progress 
and retain those 422 new specialists that you have hired in 
2018?
    Mr. Shelby. Part of what we are doing is developing them. 
We have re-implemented a development program to make them more 
effective and efficient at their jobs. The other things are we 
are way too decentralized, so there is too much demand at local 
level. We are consolidating into centers of excellence so you 
have depth at any given organization, and they can shift their 
resources to the demand signal rather than have a full burden 
on a single one and you miss capacity where there is capacity. 
So, we are consolidating those.
    And we also have to get operations much more involved in 
HR. The supervisors and managers have to get involved in talent 
management. They own their organizations. HR is a consultant to 
make sure we hire it legally. They are the experts that run 
their organizations and understand the talent they need, and so 
they have to be more involved and so we are working towards 
that model where HR is a consultant and a business partner, and 
we have operations supporting every effort to find the right 
talent to bring into those organizations.
    Mr. Bilirakis. Very good.
    Ms. Draper, do you have any suggestions? Does GAO have any 
suggestions, additional suggestions, recommendations for VA in 
order to reduce the attrition rate?
    Ms. Draper. Yeah, in our report that we issued in 2017, we 
made a number of recommendations and it wasn't just about the 
hiring. The hiring--the attrition was very high, but it is also 
about training the HR specialist and making sure that they are 
adequately trained to do their jobs.
    There are other issues that we identified. One was 
problematic information technology systems that really did not 
support good practices. So, that was a--so that is another big 
issue, is our multiple systems that HR has to use.
    The other thing is that there is just poor performance 
management system that really does not provide clear 
distinctions amongst staff and their abilities and, also, it 
limits employee accountability.
    And I think the other thing we identified is that weak 
internal control. So, the overall oversight of HR functions was 
inadequate. So, those were all in that 2017 report.
    Mr. Bilirakis. Okay. Mr. Shelby, I mean, can you respond to 
that--
    Mr. Shelby. Yes, sir. We have addressed--
    Mr. Bilirakis [continued]. --with regard to inadequately 
training--
    Mr. Shelby. We have implemented training. So, there is no 
organization or school outside of government that is going to 
create an HR professional to work in the government and, in 
particular, in the VA. We are the only education around Title 
38, hybrid Title 38. And so we are implementing a robust 
development program to give those HR professionals that we 
bring in, the education they need.
    Mr. Bilirakis. Okay.
    Mr. Shelby. But we absolutely need systems, right. When all 
the demand is on individuals, rather than systems to support, 
and self-service of our customers, there is always going to be 
too much tactical demand in non-HR professionals. We have 
upgraded our HR SMART system. Are cleaning up data corruption. 
I inherited a system that they told me was going to cost $120 
million to clean up. We have spent nothing. We have gotten to 
the 70 percent solution. We are able to give accurate data on 
vacancies now.
    In the next few weeks, I anticipate us cleaning up enough 
where we can launch individual self-service and manage-self-
service. So, as I alluded to, more and more onus upon 
operations to lead and manage their people where HR can be 
consultants and we can move them from the tactical day-to-day 
personnel actions up to the talent-management, recruiting, and 
getting the people onboard they need to run their 
organizations.
    Mr. Bilirakis. Very good. I have a second question, again, 
for you Mr.--VA is currently expanding residency training and 
has recently offered scholarships to those currently in school. 
You say in your testimony that the VA is in the process of 
completing a review of physician- recruitment strategies. When 
will the review be complete and what is VA doing for the 
current employees to ensure retention, such as educational--
education reduction programs, which are very important?
    Mr. Shelby. We are using every resource at our disposal to 
retain those that we have. I personally don't think we tapped 
into enough. Almost every doctor in America, about 80 percent, 
come through our systems and we don't--we haven't been 
proactive enough in recruiting those.
    Nurses, same thing--offering scholarships--we have to catch 
them early. We are exposed to them early in their educational 
career and we haven't taken advantage of that. I want to start 
bringing in interns between their sophomore and junior years 
and vet them then, and then at the end, between their junior 
and senior year, vet them again and if they are meeting the 
standards of the VA and if they are somebody we want to bring 
onboard, I want to start offering tentative job offers, so we 
get a whole year ahead of them. So, a year before they are 
graduating, they have a tentative offer from the VA and then 
using the resources that you have giving us with debt reduction 
and debt repayment in order to entice them to come.
    Mr. Bilirakis. Okay. Can we help you with that? Do you need 
legislation for anything like that?
    Mr. Shelby. Where we run into problems is caps, you know, 
current caps--
    Mr. Bilirakis. Yeah.
    Mr. Shelby [continued]. --the recruiting, retention, and 
relocation bonuses, we have caps. We appreciate the bump in 
that cap that we just had, but we have the resources there. We 
have already burned through that bump in the cap. So, we 
absolutely need to flexibility. It is market-based. Somewhere 
we are going to have offer more than in other markets and if we 
have caps on it, we are always going to run into that.
    Mr. Bilirakis. Thank you very much for bringing that up. I 
appreciate it. Thank you.
    I yield back, Mr. Chairman.
    Mr. Dunn. Thank you, Mr. Bilirakis.
    Now, recognized for 5 minutes, Mr. O'Rourke from El Paso, 
Texas.
    Mr. O'Rourke. Thank you, Mr. Chairman.
    Mr. Stier, I appreciate your points about the need to 
ensure that we have leadership and we, in El Paso, saw 
firsthand the consequence of not having that leadership. We 
were out a medical center director for two years, had a series 
of interim directors. There was no captain setting the course 
and holding everybody else accountable and we, at one point, 
had the worst performance in mental health care wait times in 
the country; out of 141 measured systems, we ranked 141st.
    We--the veterans there, their families understood that care 
delayed became care denied. It led to really tragic outcomes.
    With the director that we now have, permanent director, we 
now sometimes match and are better than the national wait time 
average for mental health care. We are better than the national 
wait time for primary health care. We have consistency in 
recruitment and retention. So, it really makes a difference.
    One of the challenges that you laid out to hiring all of 
these directors is the pay. And I just heard Mr. Shelby say 
that he has capped out at 153,000. What does market pay look 
like?
    Mr. Stier. Well, it is going to be dependent on the market, 
so--
    Mr. O'Rourke. Give me a ballpark. Give me a range.
    Mr. Stier [continued]. --I mean, there are--and it depends 
on the nature of the medical center, but there are medical 
center directors that are paid in excess of a million dollars.
    I don't think you have to do that. One of the incredible 
advantages VA has is the mission. The mission is powerful, but 
you can't pay a tenth or, you know, a fifth and then expect 
that you are either going to be able to recruit people in or 
retain them. Right now, I think the average is under three 
years that you have medical center directors in place. It is 
essential to ensure that VA can offer more flexibility in terms 
of salary, surely more than you are going to offer just with an 
individual doctor and making sure that the Direct-Hire 
Authority you provided doesn't actually require a lower level 
of pay than the standard SES pay scale. I am confident if you 
do that, you have great folks at the VA who will use that 
authority to great impact. That is the point of highest 
leverage.
    The last thing I want to say is I was very impressed the 
last time I was in here when you described how you personally 
recruited the medical center director. It matters when you hear 
from a Member of Congress that they want you, that it is 
important that they take this job. That kind of engagement is 
phenomenal.
    Mr. O'Rourke. Let me ask Mr. Shelby, 153,000 is the cap 
right now. What would the cap need to be for you to have the 
flexibility necessary to hire the directors that you are 
missing?
    Mr. Shelby. The cap has to be flexible. It is market-based.
    Mr. O'Rourke. Unlimited?
    Mr. Shelby. No.
    Mr. O'Rourke. To the moon?
    Mr. Shelby. So--
    Mr. O'Rourke. So, what should the cap be?
    Mr. Shelby. So, if you combine our mission--
    Mr. O'Rourke. Okay. I am just looking for a number.
    Mr. Shelby. Six-hundred-thousand dollars.
    Mr. O'Rourke. Okay. How many medical center directors are 
you missing right now, permanent medical center directors?
    Mr. Shelby. We have 20 vacancies right now. I think we have 
five impending vacancies. I believe we are recruiting right now 
for 15.
    And what we have changed is we do national recruiting 
efforts, rather than individual requisitions, so we are being 
much more proactive in finding those vacancies and putting 
several of them out at the at the same time every single month. 
So, we are trying to stay ahead of that turnover.
    Mr. O'Rourke. How many clinical positions are you short?
    Mr. Shelby. I can't tell you specifically how many clinical 
positions we are short.
    Mr. O'Rourke. Is that to Ms. Draper's point, that the VA 
doesn't know?
    Mr. Shelby. It is a--
    Mr. O'Rourke. If you don't have an accurate count of the 
physicians that you have, do you agree with that assessment?
    Mr. Shelby. I agree.
    Mr. O'Rourke. Okay. And is that why you can't answer our 
question?
    Mr. Shelby. No, I can't specifically answer the question 
because it is such a large system and it is changing every 
single day.
    Mr. O'Rourke. It is a pretty important question.
    Mr. Shelby. And if you look on the IG report, on every 
single day--
    Mr. O'Rourke. Yeah.
    Mr. Shelby [continued]. --it is different and in every 
single market it is different.
    Mr. O'Rourke. Give me a ballpark. Thirty thousand is the 
number that I have heard; that is the most recent number that I 
have heard. I have heard as high as 40,000 from the secretary 
of the VA. Where--are we in the ballpark, 30,000 clinical?
    Mr. Shelby. Yes. So, a 10 percent rate in 385,000 is 38,000 
on any given day.
    Mr. O'Rourke. Okay.
    Mr. Shelby. So, I can give you that. But, specific--maybe I 
understand--you wanted specific clinical vacancies, and it 
fluctuates so much--
    Mr. O'Rourke. And do you have a ballpark of how many of 
those are mental health care positions?
    Mr. Shelby. I know we are very short. So, in mental health, 
we have targeted that. Our goal is to increase it by 1,000 by 
the end of the year. We have already increased it, net gain, of 
over 400, and we are targeting by January of this year, to 
reach that thousand.
    Mr. O'Rourke. Last question. Mr. Stier was talking about 
some of the morale challenges within the VA. Talked about 
double the attrition rate. One of the lowest morale rankings in 
the Federal government. That doesn't seem to match your 
description of what is going on in the VA. You offered a far 
rosier picture.
    Is he wrong? Are you right? Do you see what he has seeing? 
Do you acknowledge the attrition rate and the morale challenge?
    Mr. Shelby. I absolutely acknowledge the attrition rate. It 
is very difficult in a system where we are competing for 
limited talent, you have a high demand, and we are working 
people a lot. So we have to get better at that.
    But I can tell you this, I have been out to medical 
centers. I have been out to benefits offices. I have been out 
to cemeteries. And the VA workforce is the most amazing, 
dedicated workforce I have ever seen, and their morale is high. 
And we have to help them be successful because of us and not in 
spite of us. We have removed impediments--and a lot of these 
are hiring impediments--and the market--and our inability to 
compete in the markets that they work in for the talent we 
need.
    Mr. O'Rourke. The last thing, and I am going to yield back 
to the chair, but you say morale is high and I think morale is 
something that can be measured and maybe imperfectly, and it 
seems to be measured low. I would love to understand, maybe for 
the record, maybe for a future conversation, why the 
discrepancy between what we are measuring and hearing from VA 
employees and what you are telling Members of the Oversight 
Committee right now.
    Mr. Shelby. I have our own employee survey out now. It goes 
to 100 percent of our employees. We expect a 65 percent return 
rate on that. So, that is nearly 300,000 employees. I will have 
a clearer picture and I would welcome the opportunity to come 
back and share that information with you.
    Mr. O'Rourke. Thank you. Appreciate it.
    Mr. Dunn. Thank you, Mr. O'Rourke.
    And I wouldn't wait to come back. If you would share that 
report when you get it, I know we would all be interested in 
it.
    I now recognize Captain Clay Higgins from St. Landry's 
Parish, Louisiana, for 5 minutes.
    Mr. Higgins. Thank you, Mr. Chairman.
    Mr. Shelby, you gave us a number of $600,000. I think that 
is probably a good estimation on your part regarding the 
disparity between the pay for directors of our medical centers 
and our VISNs, compared to the hundred-and-fifty- three-
thousand-dollar cap that you are currently working with. And we 
can certainly understand the challenge of maintaining those 
positions and filling those slots and retaining qualified 
personnel in those positions because of the disparity of pay 
that is available in the civilian world, but at the same time 
can you imagine how a regular American veteran, you know, 
coming from a middle-class family, earning $34,000 a year would 
feel when they can't get an postponement for weeks and weeks 
and weeks at a medical center, knowing that the director is 
getting paid 600 grand?
    As a marine, give me your feelings on that, sir.
    Mr. Shelby. Yes, sir. I am the checking account person you 
described. I am the eighth of nine kids. Joined the Marines 
when I was 17. My father was a police officer, retired. And 
that type of pay is mind-boggling to me. I never anticipated my 
father would make a hundred thousand dollars so--
    Mr. Higgins. Exactly. We talk about numbers in this body 
like it is--like we are operating in a vacuum and in many ways, 
DC is a vacuum; it is certainly a bubble that is in far too 
many instances, is disassociated from the reality of American 
struggle.
    So, I would hope--I am very glad that we are focused on 
directors and filling these positions. Mr. Chairman, Madam 
Ranking Member, my colleagues have brought up these challenges 
that we face, and I would hope that we have a spirit of being 
able to do more with less and tapping into the patriotic 
service of the Americans and medical professions across the 
country that have a desire to serve their country.
    So, I am going to shift to what you had stated, sir, 
regarding recruitment out of our universities' medical schools. 
I am very encouraged by what you stated regarding offering jobs 
to pending graduates coming out of medical schools. How is that 
process going? Have you had any success with it? Because I 
think that is certainly an answer.
    For a graduate, a medical school graduate to have a job 
waiting for them when they graduate is important and the VA has 
not been participating in recruiting during that internship of 
their medical training in the past and you are telling us they 
are now. How is that working? Have you had success? Is anybody 
in place right now, based upon that level of recruitment?
    Mr. Shelby. They are not. This is a disrupter. This is a 
complete change in the mindset of how we do government hiring.
    Mr. Higgins. Congratulations. That is a damn good change 
and I encourage you to pursue it aggressively.
    Is there anything this body can do, that this Committee can 
do legislatively to help your clear any obstacles to that 
mission, because I think that is key.
    Mr. Shelby. I think part of it is the caps. We need to be 
able to offer scholarships and debt reduction and that is going 
to fluctuate. And so, working with Congress to identify what 
the demand is going to be on that, but I promise you this, I 
will do a cost-benefit analysis in losing that talent and not 
being able to bring them in and how that impacts wait times and 
our ability to serve veterans.
    To me, it is a no-brainer, right; the costs far outweigh 
not doing it. And I am working closely with OPM. I am hoping to 
get policies and process in place. You know, we are in the 
midst of civil-service reform with them, as well. We need them 
to facilitate the ability to do our job and not be an 
impediment to that and I am confident that we are going to get 
to that with working with OPM.
    Mr. Higgins. And, quickly, with regard to filling the slots 
to directors' positions, is there a way to incorporate a 
similar policy of recruiting out of the collegiate level? Do 
they just not have the life experience?
    Mr. Shelby. We could put them into an intern program, like 
a management intern program--
    Mr. Higgins. Yes, sir.
    Mr. Shelby [continued]. --but it is going to take, you 
know, 10, 12, 15 years in my estimation, to develop to the 
point where you can run a facility.
    Mr. Higgins. Understood. Thank you for your candid 
response, sir, and thank you for your service to our country.
    Mr. Chairman, I now yield back.
    Mr. Dunn. Thank you, Mr. Higgins.
    I now recognize Representative Correa from California for 5 
minutes.
    Mr. Correa. Thank you, Mr. Chairman.
    First of all, I want to thank the Members on the panel for 
your good work and, of course, thank our veterans that are here 
today with us, thank you for your service for our great 
country.
    And I wanted to start out by following up with some of the 
comments that Mr. Higgins made, which are, you know, our 
priorities should be--is and should be taking care of veterans 
in a timely manner, best quality health care. And as I listen 
to the testimony, not only of you here, but of our Members here 
of this Committee, I was thinking to myself, what are the 
impediments that we, as a legislature, legal impediments, 
regulatory impediments that we putting upon you, because we 
are, again, addressing a set of issues that have been with us 
5, 10 years, maybe longer and we keep doing the same thing over 
and over again.
    I am not pointing the fingers at you. What are we not doing 
up here to help you do your job? Dr. Roe talked about some of 
the things that he was doing when he was practicing medicine, 
scholarships, how do you recruit nurses, how do you recruit 
folks, do you need more flexibility?
    Dr. Roe, my wife is also a doctor and she will come home 
and tell me we have got a doctor shortage in this area of the 
organization and they go out and they have to raise salaries to 
bring in folks.
    You talked about decentralization and then you talk about 
centralization. I don't think that is really the issue. What I 
am hearing is you don't have the flexibility to respond to the 
market forces in your area. If it is West LA, I don't care who 
you are hiring in West LA, you are going pay that person more 
than you are somebody in the Midwest; that is just the way it 
is.
    And I guess I am asking--and maybe you don't answer it 
today--but what can we do to give you that flexibility? And it 
is going to cost more, but maybe we can get innovative and make 
it less costly by some of the ideas that you are talking about 
already--some scholarships, some debt forgiveness. There are a 
lot of patriots that are graduating from medical school, from 
nursing school that maybe do want to come to the VA to learn 
things and also to give back.
    Can we help them with scholarships with debt forgiveness? 
Can we legislate a good program to move ahead in this 
direction, so the VA becomes a place that everybody wants to go 
to, to learn and to serve America? What can we do to move in 
that direction?
    Again, we keep doing the same thing over and over again 
expecting different outcomes. And I think we are really tying 
you up, because, again, you are moving from decentralized to 
centralized, but I don't think that is the issue. I think the 
issue is you don't have the ability to move to react to recruit 
people that you need.
    Mr. Shelby. Exactly, sir. We need the agility in each of 
our markets to compete with the local market there for talent. 
And so, I want to build a pipeline of youth--youth nurses, 
youth doctors. And so, having the flexibility and the funding 
to have those scholarships and debt-reduction programs to 
entice them as they are going through school would be huge for 
us.
    Mr. Correa. Do you need a legislative act by this body to 
help you go through?
    Mr. Shelby. I would like the opportunity to come back and 
see what flexibilities we have. I want to explore everything--
you have already been generous with and given us--and make sure 
that we are taking advantage of those and if there are still 
gaps in that, I would like the opportunity to bring that back.
    I think the most glaring is the market pay, as you alluded 
to. West LA is going to pay much differently than Louisiana. I 
want the flexibility within that market to compete with the 
local talent there and I won't have to pay as high. The 
benefits packages that the Federal Government provides are 
better than most private-sector benefits packages. That 
combined with the mission of serving veterans, we can compete, 
and we won't have to pay as high, but we can't pay as set, 5 
percent, 10 percent, 15 percent of what their market value is. 
We have to be able to compete at that 80 percent level.
    Mr. Correa. You know, I keep hearing about these wonderful, 
brilliant people graduating from high school, graduating from 
college wanting to go to the Peace Corps, wanting to serve 
somewhere in that world, wanting to give back. I am just trying 
to figure out, is there a place for them at the VA where they 
can come and spend a few years moving in another direction and 
fulfilling their life's dream and help our veterans help our 
country do some real good work with you.
    Mr. Shelby. Absolutely. You know, I was a chief learning 
officer for 10 years and I think we need to target them in 
middle school, right. So, they are getting the grades. They see 
that they have an opportunity. There are Federal programs that 
will help them pay for their bachelor's degree, their master's 
degree, even all the way up to their Ph.D.--
    Mr. Correa. I have got 7 seconds, so my question is, I 
presume you also have programs that hire our veterans that are 
coming out of the service to get to the next level of life?
    Mr. Shelby. Absolutely.
    Mr. Correa. Thank you, very much.
    To the Chair, I yield.
    Mr. Dunn. Thank you, Mr. Correa.
    Now recognized for 5 minutes, Representative and Army Major 
Brian Mast.
    Mr. Mast. Thank you, Mr. Dunn.
    I want to start with one of the comments my friend, 
Representative Higgins, made about the ability to do more with 
less and this is an opinion question for you, Mr. Shelby. It is 
your opinion that those that are VA directors are willing to 
take on the job by doing more with less or are we hiring people 
at a certain pay scale amount that we are bringing in somebody 
who is unqualified? If they are willing to do more than less, 
are you saying that there is a fuse on that and at a certain 
point, they are just saying, we are going to turn this over.
    Mr. Shelby. I have always called it ``more with different'' 
rather than ``more with less.'' You have got to change the way 
you think about your business model and I think we absolutely 
bring in people that are capable of that.
    What I am doing now is developing them to be able to engage 
their staffs and their teams. Great ideas come from everywhere 
and the diversity of thought and thinking of different ways of 
doing business have to be a team effort. And so, engaging the 
entire team to figure out how to do things better, faster, 
cheaper, is the way to go and we can absolutely get there.
    Mr. Mast. Thank you. Mr. Missal, I would like to go to some 
of the questions--it hasn't really been touched yet--but the VA 
inspector general's fiscal year 2018 report dismiss also talk 
about staffing shortages, as it related to police officers 
within the VA. I have gone to the headquarters here in DC, 
spoke to the focus that run everything as it relates to the VA 
police force.
    The report said in the state of Florida that the State of 
Florida is 18 officers shy of the number they need; that is 14 
in Orlando and 4 in Tampa. I was wondering if you could 
elaborate a little bit on that. What are the metrics that are 
used to determine VA police staffing for facilities? Does it go 
by what the VA medical center director wants? Does it go by 
what is determined here in Washington? How is that number 
determined and what level of security is needed at a facility 
when we do know in the past, groups like ISIS have called and 
said, Let's go to a VA medical center, there is a bunch of 
veterans there, let's go target them. How do you determine 
that?
    Mr. Missal. The VA police actually report to the medical 
center director, so it is up to the medical center director to 
determine what is an appropriate level of staffing at the 
police. So, in our staffing report a number of the medical 
center directors did identify critical shortages with police.
    I do also want to note that we are coming out with an audit 
report in the near term with respect to looking at the whole 
governance structure of the police force and other issues 
because we have been concerned about some of the issues related 
to the police force.
    Mr. Mast. Okay. So, if a security need is not reported by a 
hospital director, then there is an assumption here by DC that 
there is no security shortfall if it doesn't make it from the 
security force through the director to DC?
    Mr. Missal. It was up to the medical center director to 
determine what they believed were the critical shortages. We 
didn't verify that or look behind it; we relied on what they 
told us.
    Mr. Mast. Okay. I appreciate your answers on this. I want 
to continue on this track a little bit. What is the stance, 
when it comes to the VA, on who should have access to the 
grounds of a VA hospital? What is the stance of the VA on who 
should have access to the grounds of a VA hospital?
    Mr. Missal. In terms of, are we talking about the police or 
are we talking just in general?
    Mr. Mast. Any individual that wants to enter the premises 
of a VA hospital, what is the stance of who should have access 
to get on, walk in the doors? Who should be allowed to walk in 
the doors?
    Mr. Missal. I don't know if there is a set policy--in a 
number of the facilities, I think it is up to the director to 
determine the level of security within a particular facility.
    Mr. Mast. And I have to believe that you are right in 
saying that. In my VA hospital, it feels to me like we have on 
and off policies of enforcing, okay, we are going to check 
people's ID at the door and an hour later there is not going to 
be somebody there to check somebody's ID at the door and then 
an hour later there is going to be somebody there.
    So, it is as though they want to make sure that the right 
people are entering the VA, but there is not a priority that is 
necessarily put on. It is not a paid position, I believe. I 
believe it is volunteers that check these IDs at the door. And 
that is something that also plays into the security of our 
veterans on this facility. So, I would appreciate it if you 
would take a look into that as you are looking at metrics on 
what is needed for VA facility security. What is the stance of 
who you believe should have access to the VA medical centers 
and what are you doing to actually ensure that that is enforced 
by the VA police force and that might have an impact on the 
numbers that you determine you need in terms of a VA police 
force and their presence in each state.
    And that, I will yield back any additional time Mr. Dunn. 
Thank you.
    Mr. Dunn. Thank you very much, Representative Mast.
    I now recognize for 5 minutes, Representative Anne Kuster 
from Concord, New Hampshire.
    Ms. Kuster. Thank you very much, Mr. Chairman, and thank 
you to our panel.
    I am going to move quickly because I have a number of 
issues to cover, but--oh, I was hoping Dr. Roe had--would stay. 
I agree with his assessment and one of the most effective 
recruitment measures would be loan forgiveness for the 
incredible public service of people working within the VA, but 
I need his help in convincing the speaker not to bring to the 
floor the Prosper Act because one of the greatest concerns is 
that bill H.R. 4508 eliminates the Public Service Loan 
Forgiveness Program; it is completely contrary to the whole 
purpose of this hearing. And so, I will work with Dr. Roe and 
my Republican colleagues to make sure that that Prosper Act 
does not come to the floor.
    And, in fact, what I would prefer to do is to increase the 
incentives for people to join public service at the VA. And to 
that end, I have sponsored a bill that has been passed in the 
House, the Grow Our Own Act. This is with regard to medics and 
other health care professionals coming out of their military 
service who have the skills to serve the needs of our VA 
population. It gives them competitive pay and it also--the 
House version recognizes the skills that they gained in the 
field during their military service.
    I am just wondering if you have considered that for any 
other types of medical credentials. Ours was focused on 
physician assistants, but is that something that is under 
consideration and would you need legislation to do that? And 
that is for the VA.
    Mr. Shelby. I am going to have Jessica respond to that to 
see if we need legislation.
    Ms. Bonjorni. Thank you. We would welcome the opportunity 
to work with you on that. I know that we have been focused 
quite recently on hiring corpsman and medics to come into our 
Intermediate Care Technician Program and we are really trying 
to grow that program because it gets rave reviews from our 
veterans. They appreciate being seen by those who have also 
served. So, we would welcome the opportunity to work with you 
on that.
    Ms. Kuster. Absolutely. And the other issue, I just think 
it is a waste of people power. They have fantastic skills and 
they're coming back, and it is making for a very difficult 
transition when they are told they have to go back to school 
for two years to get a specific credential. So, we would love 
to work with you.
    I am going to switch gears entirely to a March 2018 Merit 
Systems Protection Board release report on the incidents of 
sexual harassment across the Federal government. The VA was the 
worst offender with 22 percent of the employees reporting 
sexual harassment. And I just would like everyone on this panel 
to consider the impact on morale and certainly on retention 
when 1 in 5 employees in the VA has experienced sexual 
harassment, it is no wonder that we have very high turnover and 
we lose valuable and qualified employees and it is no wonder 
that it would be difficult to recruit and retain qualified 
employees.
    So, one very specific question: With the rate of our human 
resources officers being so low with the shortage, where are 
employees expected to go if they have a sexual harassment 
complaint and if you could also comment on sexual harassment 
training and how we are going to lower this abominable rate. I 
am embarrassed that it is the VA that has the very worst rate 
across the Federal government. Thank you.
    Mr. Shelby. Yes, thank you for allowing me to respond to 
that. I took a look at the study. It was done--the data was 
collected between 2014 and 2016 and they only interviewed 1100 
people so, about .003 percent of the VA population--
    Ms. Kuster. That is quite a big sample, 1100 people.
    Mr. Shelby. And since 2016, we have implemented a very 
robust civility in the workforce program. We have continuous 
training. We have an office of resolution management with 
several hundred people--you have a difference between 201s and 
ORM. They are embedded throughout the organization.
    Ms. Kuster. To you have a statistic on the number of VA 
employees that have received this sexual harassment training?
    Mr. Shelby. One hundred percent. It is required learning--
everybody, including supervisors and managers. We have six and 
a half hours of training for supervisors and managers and three 
and a half hours for general employees. Our statistics--in 
2017, there were only 17 reports of sexual harassment and only 
3 total in 385,000 were validated as a problem--
    Ms. Kuster. Well, sir, I apologize for interrupting--my 
time is up--I have requested of Chairman Bergman that we have 
an oversight and investigation Subcommittee hearing on this 
topic, and we would be very interested in hearing the progress 
that has been made since that original statistic was gathered.
    So, I yield back.
    Mr. Shelby. We look forward to that.
    Mr. Dunn. Thank you, Representative Kuster.
    If there are no other questions, the panel is now excused. 
And I ask unanimous consent that all Members have 5 legislative 
days to revise and extend their remarks and include extraneous 
materials.
    Without objection, that is ordered, and the hearing is now 
adjourned. Thank you very much.

    [Whereupon, at 11:23 a.m., the Subcommittee was adjourned.]

                            A P P E N D I X

                              ----------                              

                    Prepared Statement of Max Stier
    Chairman Dunn, Ranking Member Brownley, members of the Subcommittee 
on Health, thank you for the opportunity to appear before you today to 
discuss the implementation of the VA Choice and Quality Employment Act 
of 2017 (P.L. 115-46). I am Max Stier, President and CEO of the 
Partnership for Public Service. The Partnership is a nonpartisan, 
nonprofit organization that works to revitalize our federal government 
by inspiring a new generation of Americans to enter public service and 
by transforming the way our government works.
    The success of the Department of Veterans Affairs depends upon a 
highly qualified, engaged and accountable workforce operating at full 
capacity and equipped with the knowledge and resources it needs to 
achieve its mission. Congress is an essential partner to the department 
in building and sustaining this workforce, and I commend this committee 
for its continuing focus on how best to do so, including by holding 
this hearing and passing laws like the one we are discussing today. The 
Partnership strongly supports this legislation and believes that, if it 
can be fully realized, it will reduce critical vacancies in key 
mission-critical occupations and, more importantly, ensure that 
veterans receive the care they have earned through their service.
    But this law, though helpful, represents just a first step. To the 
department's credit, it has continued to add employees-its total 
medical workforce grew by 2.9 percent in 2017. \1\ The department has 
also reduced wait times overall and maintained satisfaction levels 
equal to or above those of the private sector. \2\ However, over the 
next decade, our nation will face potential shortages of between 42,600 
and 121,300 physicians, and this will be the environment in which VHA 
must recruit. \3\ More action needs to be taken to modernize the VA, 
including smart implementation of the tools provided by the VA Choice 
and Quality Employment Act, better data about the agency's workforce, 
talent needs and applicant pools, additional legislation to address 
fundamental problems with the VHA's complex and burdensome personnel 
systems, leaders at the VA who are focused on and committed to these 
issues, and sustained oversight by this committee.
---------------------------------------------------------------------------
    \1\ ``U.S. Office of Personnel Management - Ensuring the Federal 
Government Has an Effective Civilian Workforce.'' FedScope - Diversity 
Cubes (Enhanced Interface). Accessed June 18, 2018. https://
www.fedscope.opm.gov/employment.asp.
    \2\ Sisk, Richard. ``VA Wait Times As Good or Better Than Private 
Sector: Report.'' Military.com. Accessed June 18, 2018. https://
www.military.com/daily-news/2017/09/20/va-wait-times-good-better-
private-sector-report.html.
    \3\ ``New Research Shows Increasing Physician Shortages in Both 
Primary and Specialty Care.'' AAMCNews. April 11, 2018. Accessed June 
18, 2018. https://news.aamc.org/press-releases/article/workforce--
report--shortage--04112018/.

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State of VA Choice and Quality Employment Act Implementation

    When Congress passed the VA Choice and Quality Employment Act last 
summer, it provided VA with several new authorities and tools to 
streamline the hiring of mission-critical talent. These included an 
expanded direct hire authority, unique promotional tracks for technical 
experts, better sharing of information regarding applicants for 
shortage positions, and new training for human resources staff. 
Collectively, this legislation and the personnel authorities granted by 
the VA Accountability and Whistleblower Protection Act of 2017 (P.L. 
115-41) empower VA to recruit, hire and retain the talent it needs to 
serve veterans.
    Our understanding is that the VHA is working hard to implement the 
bill and has already made progress on several fronts. The agency is 
working with the Department of Defense to stand up joint programs that 
will bring more transitioning service members into the VHA, as directed 
by Section 207 of the Act. The agency as a whole is continuing efforts 
begun in the prior administration to improve collaboration and 
coordination with the DOD. Next, the VHA is beginning to make use of 
the direct hire authority authorized under Section 213. \4\ The Office 
of Personnel Management has approved a set of fourteen positions, both 
clinical and non-clinical, which the VA can fill through the use of 
this authority. \5\ Our understanding is that the VHA has already begun 
to use the authority to fill vacancies. We also understand that the VHA 
is looking at how to use the authority granted under Section 206, which 
speeds the hiring of students and recent graduates, to fill vacancies 
on the business side of the agency.
---------------------------------------------------------------------------
    \4\ Statement of the Honorable David J. Shulkin, M.D. Secretary of 
Veterans Affairs for Presentation before the Senate Committee on 
Veterans Affairs, 10 (January 17, 2018). 115th Congress
    \5\ United States of America. Department of Veterans Affairs. 
Office of Inspector General. OIG Determination of Veterans Health 
Administration's Occupational Staffing Shortages FY2018. Washington, 
DC, 2018. 2
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    For an agency the size of the Veterans Health Administration, any 
change, however small, will take time to implement. And because the 
authorities and programs enacted by this legislation did not come with 
significant new funding, implementation will be slower as a result. In 
this case, the example of the 2015 Enhanced Physician Recruiting and 
Onboarding Model (EPROM) is instructive: the VHA issued a set of 
recommendations to VAMCs designed to improve physician recruitment and 
speed hiring. However, GAO found that a lack of resourcing and capacity 
at the facility HR level led many VAMCs to ignore the EPROM or 
implement it in only a limited fashion, resulting in minimal impact 
overall. \6\ Turnover among HR specialists in facilities across the VHA 
system is also contributing to lagging action on various provisions of 
the legislation. A large number of relatively new HR specialists means 
more preparation and work required to make sure the agency implements 
new rules and programs effectively. Long-term under-resourcing of the 
agency's HR function is acting as a drag on the agency's ability to 
implement the new law as quickly as the committee and stakeholders 
might prefer. For example, in 2015 more than 80 percent of VAMCs failed 
to meet target staffing ratios of one HR specialist to 60 employees and 
it is our understanding that this remains an issue today. \7\ These 
challenges underscore the importance of focusing the committee's 
oversight on how to ensure the VHA can implement the law and seeking 
additional ways to improve its personnel system.
---------------------------------------------------------------------------
    \6\ United States of America. Government Accountability Office. 
Veterans Health Administration: Better Data and Evaluation Could Help 
Improve Physician Staffing, Recruitment, and Retention Strategies. 
Washington, DC, 2018. 27.
    \7\ Ibid. 13

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Enabling More Effective Implementation

More and Better Data

    An organization cannot manage what it cannot or does not measure. 
For the Department of Veterans Affairs and the Veterans Health 
Administration, a failure to effectively combine and scale strategic 
priorities with data about the composition and commitment of its 
workforce hinders effective hiring and talent management. More broadly, 
a risk-averse culture which resists change makes the task of using data 
and building a performance culture even more difficult. Research by the 
Partnership has found that while many agencies have ``taken the first 
step toward creating a performance management culture'' by regularly 
and systematically collecting data, few are processing it in a 
meaningful way. \8\ John Kamensky of the IBM Center for the Business of 
Government has similarly noted that agencies have plenty of data but 
are ``information poor.'' \9\ Like other agencies, the VHA has plenty 
of data, particularly at the facility level, but fails to make full use 
of it. The decentralized nature of the organization means data is not 
aggregated to provide a complete picture of the state of the 
organization. This lack of data is especially true in the workforce 
space, where GAO has found that VHA lacks detailed information about 
the overall composition of its workforce and use of hiring incentives. 
\10\ Better data about the composition of the workforce and more 
sophisticated dashboards that offer real-time views of the critical 
information that enables better management decisions would greatly 
enhance the department's talent management and use of workforce 
flexibilities such as those authorized by the Act.
---------------------------------------------------------------------------
    \8\ Taking Measure: Moving from Process to Practice in Performance 
Management. Report. Washington, DC: Partnership for Public Service, 
2013. 8
    \9\ Kamensky, John. ``Government Is Data Rich, But Information 
Poor.'' Editorial. Government Executive, June 12, 2018.
    \10\ United States of America. Government Accountability Office. 
Veterans Health Administration: Better Data and Evaluation Could Help 
Improve Physician Staffing, Recruitment, and Retention Strategies. 
Washington, DC, 2018. 12
---------------------------------------------------------------------------
    An effective hiring process makes use of data both at the front end 
to determine needs and at the back end to evaluate results, and it also 
provides a means of holding leaders accountable for the state of talent 
in the organization. The Act took positive steps towards providing more 
and better data by requiring GAO to examine the department's succession 
planning practices, mandating the creation of a comprehensive list of 
vacant positions across VA, and codifying the department's current exit 
survey. Moving forward, the Partnership believes the VHA should look at 
ways to align this workforce data with the organization's strategic and 
service priorities. Better integrating employee satisfaction and 
commitment data already available to the agency through the VA All-
Employee Survey (AES) and the Federal Employee Viewpoint Survey (FEVS), 
which the Partnership uses to produce its Best Places to Work in the 
Federal Government Rankingsr, will be key to this integration. In 
looking at ways to fill mission-critical vacancies, the department and 
this committee should not lose sight of the fact that employee 
engagement is a necessary ingredient for developing a high-performing 
workforce and attracting top talent. The committee should also look at 
ways it can use its oversight to track key metrics of the hiring 
process and agency outcomes, perhaps on a quarterly basis, to work with 
the department to adjust in real time.
    Better use of all of these types of data will be particularly 
critical because of the troubling quit rates at VHA. Between 2011 and 
2017, employees with less than two years of service quit at a rate of 
nearly 32 percent. \11\ This attrition rate is especially problematic 
because less than one-quarter of VHA employees in clinical roles is 
under the age of 40. \12\ Each of these statistics highlights serious 
retention issues at the VHA. The department's Office of Inspector 
General noted in September 2017 that, despite some hiring gains, ``the 
percentage of regrettable losses to total onboard staff in many 
critical need occupations was high relative to overall increases in 
onboard staff.'' \13\ Minimizing regrettable losses and retaining 
talent will require the department not just to understand the size and 
composition of its workforce, but combining it with insights pulled 
from surveys like the AES to design national retention strategies. The 
next step for VHA will be to create an integrated, comprehensive 
process for gathering and distributing critical workforce data across 
VAMCs to encourage learning and best practice sharing in the use of 
various hiring authorities and flexibilities and to get leaders at the 
facility level to act on it. To its credit, the VHA Office of Workforce 
Management and Consulting has begun looking at how it can collect and 
share data better. I strongly encourage the committee to follow up on 
this work.
---------------------------------------------------------------------------
    \11\ ``U.S. Office of Personnel Management - Ensuring the Federal 
Government Has an Effective Civilian Workforce.'' FedScope - Diversity 
Cubes (Enhanced Interface). Accessed June 18, 2018. https://
www.fedscope.opm.gov/employment.asp.
    \12\ Ibid.
    \13\ United States of America. Department of Veterans Affairs. 
Office of Inspector General. OIG Determination of VHA Occupational 
Staffing Shortages FY 2017. Washington, DC, 2017. I.

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Modernizing the Department's Personnel System

    The challenges faced by the Veterans Health Administration in 
recruiting, hiring and retaining mission-critical talent are by no 
means unique. Agencies across the federal government struggle to 
function within a system that is ``stuck in the past, serving as a 
barrier rather than an aid in attracting, hiring and retaining highly 
skilled and educated employees.'' \14\ Much of the Title 5 civilian 
personnel system dates back to 1949 and has not been revisited by 
Congress since 1978. Title 38 was created in 1946 at a time when the 
state of healthcare was far different than it is today. \15\ The 
accretion of new laws, regulations, and court rulings has also added 
significant complexity to the process. The VHA faces a particular 
challenge in that it operates three different personnel systems: Title 
5, Title 38 and Title 38 Hybrid, each with unique rules and processes. 
Organizations from GAO to the VA Office of Inspector General and VHA 
Commission on Care, created by Congress as part of the Veterans Access, 
Choice, and Accountability Act of 2014, have cited the challenge 
presented by the department's multiple personnel systems for 
recruitment \16\ and \17\ retention \18\. Fixing the department's 
broken personnel management will ultimately require significant reform 
and, ideally, consolidation of the personnel systems under which it 
operates.
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    \14\ Building the Enterprise: A New Civil Service Framework. 
Publication. Washington, DC: Partnership for Public Service, 2014. 7.
    \15\ United States of America. Merit Systems Protection Board. 
Office of Policy and Evaluation. The Title 38 Personnel System in the 
Department of Veterans Affairs: An Alternative Approach. Washington, 
DC, 1991.
    \16\ United States of America. Government Accountability Office. 
Veterans Health Administration: Management Attention Is Needed to 
Address Systemic, Long-standing Human Capital Challenges. Washington, 
DC, 2016.
    \17\ United States of America. Department of Veterans Affairs. 
Office of Inspector General. OIG Determination of Veterans Health 
Administration's Occupational Staffing Shortages FY2018. Washington, 
DC, 2018.
    \18\ United States of America. Veterans Health Administration. 
Commission on Care. Commission on Care: Final Report. Washington, DC, 
2016.
---------------------------------------------------------------------------
    Perhaps the clearest example of the way in which outdated and 
inflexible personnel systems limit the department's ability to recruit 
and hire is in the area of classification. A June 2018 report by the VA 
OIG stated that ``many facilities noted that...outdated OPM 
classifications affected their ability to offer competitive salaries 
and advance opportunities within the organization'' with the result 
that facilities were ``less competitive in attracting new staff and 
retaining highly skilled staff.'' \19\ The link between classifications 
and uncompetitive salaries is long-standing and critical. GAO noted in 
its October 2017 report that one VAMC reported losing its chief of 
cardiac surgery to a nearby hospital, which increased the individual's 
salary from $395,000 to $700,000. \20\ The VHA has attempted to tackle 
some issues piecemeal, by working to consolidate classification 
procedures at the VISN level for example. \21\ However, this reform is 
unlikely to address many of these long-standing challenges on its own. 
Unfortunately for the VA, it is operating in an environment in which it 
competes not just with the private sector for talent, but with other 
federal agencies as well. Regrettable losses caused by the resignation 
of medical professionals is a symptom of the broader problem.
---------------------------------------------------------------------------
    \19\ United States of America. Department of Veterans Affairs. 
Office of Inspector General. OIG Determination of Veterans Health 
Administration's Occupational Staffing Shortages FY2018. Washington, 
DC, 2018.
    \20\ United States of America. Government Accountability Office. 
Veterans Health Administration: Better Data and Evaluation Could Help 
Improve Physician Staffing, Recruitment, and Retention Strategies. 
Washington, DC, 2018. 28
    \21\ United States of America. Government Accountability Office. 
Veterans Health Administration: Management Attention Is Needed to 
Address Systemic, Long-standing Human Capital Challenges. Washington, 
DC, 2016.
---------------------------------------------------------------------------
    Operating multiple different systems also hurts the effective 
functioning and retention of the department's human resources staff. 
The VHA struggles to hold on to HR talent-the VA OIG's FY2018 
determination of staffing shortages report noted that HR has ranked 
among the top ten shortage occupations since 2011. \22\ Attrition among 
HR specialists is a significant challenge as well, as three-quarters of 
HR assistants who left VHA in 2015 did so in their first two years. 
Overall attrition rates for the position rose from 7.8 percent in 2013 
to 12.1 percent in 2015, where they have roughly held. \23\ 
Unfortunately, there is little reason to think this trend has abated; 
in recent testimony to this committee on May 22, 2018, VA Inspector 
General Michael Missal stated that vacancies in mission-critical 
positions at the Washington, DC VAMC were caused in part by turnover in 
the facility's HR office. \24\ There is plenty of evidence to suggest 
that HR specialists are leaving VHA due to their dissatisfaction with 
understaffing and complexity of the work. \25\ The result is 
administrative delays that further lengthen the time needed to recruit, 
hire and onboard badly-needed talent.
---------------------------------------------------------------------------
    \22\ United States of America. Department of Veterans Affairs. 
Office of Inspector General. OIG Determination of Veterans Health 
Administration's Occupational Staffing Shortages FY2018. Washington, 
DC, 2018. 6
    \23\ United States of America. Government Accountability Office. 
Veterans Health Administration: Management Attention Is Needed to 
Address Systemic, Long-standing Human Capital Challenges. Washington, 
DC, 2016. 10
    \24\ Statement of The Honorable Michael J. Missal Inspector General 
of the Department of Veterans Affairs Before the Committee on Veterans' 
Affairs U.S. House of Representatives Hearing on ``The Curious Case of 
the VISN Takeover: Assessing VA's Governance Structure'', 115th Cong., 
13 (2018).
    \25\ United States of America. Government Accountability Office. 
Veterans Health Administration: Management Attention Is Needed to 
Address Systemic, Long-standing Human Capital Challenges. Washington, 
DC, 2016.
---------------------------------------------------------------------------
    In the short term, there are several actions the committee might 
consider to strengthen further the department's ability to fill 
mission-critical vacancies and improve service to veterans. I describe 
these actions in greater detail in the recommendations below. The 
committee should address the technical issue artificially limiting pay 
for VAMC and VISN directors created by the VA Accountability and 
Whistleblower Protection Act that serves as a significant disincentive 
to recruitment and retention of these essential leaders. The 
Partnership also believes the delegation of authority to assess 
candidates for senior executive roles without advance OPM permission 
and to make direct hire determinations at the agency level would be 
highly beneficial. Finally, using provisions authorized by the VA 
Choice and Quality Employment Act, we recommend the committee work with 
the department to build a scorecard or other assessment mechanism that 
can be used to hold VA leaders accountable for their organization's 
health, including talent management practices.
    Beyond small-bore changes to the department's current personnel 
operating authorities, however, the Partnership strongly encourages the 
committee to work with the administration to move towards a unified 
personnel system for the department that will allow the VHA to fully 
address its hiring, classification, pay and accountability issues. The 
system should be the product of strong leadership across the branches, 
employee buy-in, and investment in agency HR and other implementation 
functions, and should reflect a commitment to the Merit System 
Principles that serve as the bedrock of the civil service system. The 
VHA Commission on Care came to this same conclusion. The panel stated 
that VHA uses ``talent management approach from the last century'' and 
that Congress should ``create a simple-to-administer alternative 
personnel system, in law and regulation, which governs all VHA 
employees, applies best practices from the private sector to human 
capital management, and supports pay and benefits that are competitive 
with the private sector.'' \26\ Fortunately, the provisions of the VA 
Choice and Quality Employment Act offer a blueprint for how other 
committees might jumpstart the process. \27\ While the Partnership 
would prefer that Congress apply this system to all of government, the 
Veterans Health Administration, with its massive scale, specialized 
workforce, and complex mission, represents a good place to start.
---------------------------------------------------------------------------
    \26\ United States of America. Veterans Health Administration. 
Commission on Care. Commission on Care: Final Report. Washington, DC, 
2016.
    \27\ Neal, Jeff. ``How the VA Choice and Quality Employment Act of 
2017 May Drive Civil Service Reform.'' Editorial. Federal News Radio, 
August 15, 2017. Accessed June 18, 2018. https://federalnewsradio.com/
commentary/2017/08/how-the-va-choice-and-quality-employment-act-of-
2017-may-drive-civil-service-reform/.

---------------------------------------------------------------------------
Promoting Leader Ownership

    The next secretary of the Department of Veterans Affairs and his 
leadership team will have a big job ahead of them and relatively little 
time to do it. History suggests that the department's political 
appointees, once confirmed by the Senate, are unlikely to stay in their 
jobs more than two years. They will be in charge of managing an 
organization with over 300,000 employees, 145 medical facilities, and 9 
million veteran patients. \28\ The secretary and his team will also be 
operating in a complex environment in which the White House, Congress, 
veterans' service organizations, employee groups and the private sector 
will all be demanding action. The incentives faced by the department's 
incoming political appointees will be to focus on policy and headlines, 
rather than the sometimes invisible work of strengthening the VA's 
management systems and structure. It is this work that has some of the 
most lasting impacts on improving services for America's veterans, even 
if the sheer size of the department means that achieving results may 
take years. In other words, the incoming leaders of the department need 
to take ownership of the health of the organization they run and leave 
it in a state that is better than the one it was in when they arrived.
---------------------------------------------------------------------------
    \28\ Statement of The Honorable Michael J. Missal Inspector General 
of the Department of Veterans Affairs beforethe Committee on Veterans' 
Affairs U.S. House of Representatives Hearing on ``The Curious Case of 
the VISN Takeover: Assessing VA's Governance Structure'', 115th Cong., 
13 (2018).
---------------------------------------------------------------------------
    Section 203 of the VA Choice and Quality Employment Act included 
important language to this effect, specifically requiring that the 
Secretary and other political appointees of the department have annual 
performance plans which hold them accountable for talent management, 
employee engagement and development, and promoting effective 
performance management practices. This provision provides an excellent 
opportunity both to the department and to Congress. The Partnership's 
Best Places to Work in the Federal Government Rankings have 
consistently found that quality of leadership is a key driver of 
employee satisfaction, but views of senior leadership in the department 
do not provide much reason for optimism. In 2017 VA ranked 17th out of 
18 agencies in employee satisfaction with the effectiveness of agency 
leadership, declining slightly from 2016. \29\ Further, FEVS data 
showed that fewer than half of VA employees had a high level of respect 
for senior leaders and just 36.1 percent of employees were satisfied 
with the policies and practices of these leaders (the number rose 
slightly to 36.3 percent at the Veterans Health Administration). \30\ 
And, as noted above, data on talent management at the department shows 
similar problems and, while removals have gone up, there are concerns 
that new accountability procedures are being weaponized to retaliate 
against rank-and-file employees. \31\
---------------------------------------------------------------------------
    \29\ Partnership for Public Service. ``Department of Veterans 
Affairs.'' Best Places to Work in the Federal Government. Accessed June 
18, 2018. http://bestplacestowork.org/BPTW/rankings/detail/VA00#tab--
category--tbl.
    \30\ Partnership analysis of the 2017 Federal Employee Viewpoint 
Survey
    \31\ Arnsdorf, Isaac. ``Trump's VA Is Purging Civil Servants.'' 
Politico Magazine, March 12, 2018. https://www.politico.com/magazine/
story/2018/03/12/trump-is-trying-to-fix-the-vabut-its-backfiring-
217348.
---------------------------------------------------------------------------
    These data reinforce the importance of the role of Congress and 
this committee in particular. Congress is itself an ``owner'' of the 
Department of Veterans Affairs and has an important stake in its 
success or failure. To its great credit, this committee has recognized 
its stewardship role and done excellent bipartisan work elevating 
important issues of talent management and performance. There is more 
the committee can do to build on its work to date. Asking for more 
real-time data on vacancies and leadership, utilizing a scorecard to 
measure and assess the department's leadership, and encouraging system-
wide learning by highlighting best-in-class practices would reinforce 
important norms around leader ownership. These additional reforms would 
create the lasting expectation that those appointees who answer the 
call to serve our nation's veterans are capable of and accountable for 
effectively leading the agency. Many of the provisions of the VA Choice 
and Quality Employment Act, including Section 203, provide the 
committee with precisely these tools.
    As of the date of this hearing, the Department of Veterans Affairs 
lacks a confirmed secretary, deputy secretary, under secretary for 
health and assistant secretary for information and technology. \32\ The 
effect of these vacancies should not be understated. The Under 
Secretary for Health leads the largest healthcare system in the U.S., 
with a budget of $65 billion, hundreds of thousands of employees, and 
hundreds of facilities. \33\ The Assistant Secretary for Information 
and Technology oversees a staff of over 8,000 employees and a $4 
billion budget that is comparable in scope to the largest private 
sector IT operations. Further, the VA Central Office (VACO) has a 
significant number of acting officials, which further hampers policy 
and management execution within the department. The changes that this 
committee and the VA's many stakeholders want to see, including filling 
mission-critical vacancies, require permanent leadership. The 
administration and Senate must, therefore, take swift action to 
nominate and confirm candidates for these critical positions. I 
strongly urge the members of this committee to speak up for the need 
for qualified, confirmed leadership in the agency.
---------------------------------------------------------------------------
    \32\ ``Trump Nominations Tracker''. The Washington Post. Accessed 
June 18, 2018. https://www.washingtonpost.com/graphics/politics/trump-
administration-appointee-tracker/database/?utm--term=.af6b57628757.
    \33\ Ibid.

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Recommendations

Short-Term

Authorize Market Pay for VAMC and VISN Directors

    While medical professionals are the individuals on the front line 
delivering care, the effective functioning of the VHA enterprise is 
dependent on experienced and capable VAMC and VISN directors. I commend 
this committee for authorizing direct hire authority for this cohort, 
and the department deserves credit for maintaining low vacancy rates 
among this group. But retention of these leaders remains an issue, and 
a sure way of improving retention is increasing pay, as the SES pay 
scale was simply never designed for positions like medical facility 
directors. Individuals in these positions and other similar highly 
skilled federal employees-those with a professional degree or 
doctorate-tend to earn far less than their private sector counterparts. 
Toward this end, the Partnership recommends enacting market pay for 
this select group of leaders who are so essential to ensuring quality 
care for veterans. Additionally, we urge the committee to address 
limitations on the current direct hire authority for this cohort that 
prevents the VA from paying even at the top of the SES pay scale, 
hampering successful recruitment.

    Use the performance plan required under Section 203 to hold leaders 
accountable for successfully managing the organization

    As noted above, VA lacks critical data to manage its talent or link 
personnel and resources to strategic priorities and does little to make 
political leaders take ownership of the organization's success or 
failure. The VA Choice and Quality Employment Act of 2017 provides new 
performance planning and data collection requirements that can provide 
this accountability and give Congress greater visibility into how the 
VA's leaders are managing the organization. The Partnership recommends 
the committee work with the department to conduct regular oversight of 
the extent to which leaders are truly taking ownership and moving the 
department in the right direction.

Delegate authority to conduct Qualifications Review Boards to VA

    The Partnership has previously stated in testimony to this 
committee that the VA would benefit from the ability to make final 
selections for SES positions with appropriate OPM oversight. Today, the 
VA is still forced to ask applicants for senior executive roles, 
including VAMC directors, to write lengthy essays explaining their 
qualifications and then to put those individuals before a 
Qualifications Review Board (QRB) assembled and led by OPM. The QRB 
serves as the last step in the SES selection process, extending the 
hiring process but adding limited value. Today, we reiterate our view 
that Congress should remove this requirement from VA and increase the 
department's flexibility to recruit the leadership talent it needs to 
strengthen the VHA healthcare system. The Senate's Fiscal Year 2019 
National Defense Authorization Act proposes granting this authority to 
the Defense Department.

Delegate direct hire authority from OPM to the department

    Direct hire authority is an important tool for filling mission-
critical vacancies, as this committee has recognized through recent 
legislative actions to expand its use across the department. However, 
the current statute still requires the department to receive approval 
from OPM before finalizing and utilizing this authority. This step adds 
months to implementation and creates an extra layer of process and 
complexity. The Partnership recommends addressing this issue by 
granting the Secretary of Veterans Affairs the ability to designate 
positions eligible for direct hire authority, with appropriate OPM 
oversight on the back end and metrics to ensure that it VA uses it 
responsibly and fairly.

Develop, collect and report more comprehensive measures of hiring 
    effectiveness

    The Partnership has previously advocated for expanded collection 
and reporting requirements for aggregated applicant and hiring data. 
Given the ongoing concerns about shortages of workforce data raised by 
GAO and others, the Partnership believes this recommendation remains 
relevant. Beyond simply looking at vacancies in specific clinical or 
non-clinical positions, these data would also examine applicant pools, 
recruiting efforts and manager satisfaction with candidates. In fact, 
data on applicant pools such as physician trainees would be especially 
important given GAO's finding that VHA does not currently track the 
number of trainees hired following graduation, even though this group 
represents a valuable recruiting source. \34\ The Federal Hiring 
Process Improvement Act of 2010, introduced by former Senators Daniel 
Akaka and George Voinovich, includes several measures of hiring 
effectiveness that could be instructive. \35\ Providing such detailed 
information would make it easier for the committee to target future 
reforms to the VHA's talent management process.
---------------------------------------------------------------------------
    \34\ United States of America. Government Accountability Office. 
Veterans Health Administration: Better Data and Evaluation Could Help 
Improve Physician Staffing, Recruitment, and Retention Strategies. 
Washington, DC, 2018.
    \35\ Federal Hiring Process Improvement Act, S. S.736, 111th Cong. 
(2010).

Authorize VHA to make conditional offers to employees on the strengths 
---------------------------------------------------------------------------
    of their qualifications

    It is common in the private sector for hospitals and other entities 
competing for medical talent to make conditional offers, pending the 
individual's completion of their training or educational program. The 
federal government, however, tends to bias the hiring process against 
individuals without significant professional experience, even if they 
possess the skills to succeed. While VHA can technically make these 
offers now, GAO has found that many VAMC officials believe otherwise. 
\36\ A congressional imprimatur in favor of early offers could give VHA 
officials more cover to promote contingent offers and increase the 
amount of younger talent.
---------------------------------------------------------------------------
    \36\ United States of America. Government Accountability Office. 
Veterans Health Administration: Better Data and Evaluation Could Help 
Improve Physician Staffing, Recruitment, and Retention Strategies. 
Washington, DC, 2018. 29

---------------------------------------------------------------------------
Long-Term

Create a unified personnel system for VHA

    As discussed above, the unruly tangle of personnel systems is a 
weight around the neck of the Veterans Health Administration. 
Classification under these systems forces employees to accept salaries 
below those of both the private sector and comparable federal 
positions. The complexity of administering three separate systems 
drives human resources specialists into other federal agencies. The 
need to understand the unique rules and processes for each adds 
unnecessary time to the hiring process. The Partnership believes it is 
time, and well worth the investment of energy and political capital, to 
create a unified personnel system for the VHA. While there are 
legitimate concerns about the further balkanization of the federal 
civil service system, the uniqueness of the agency's mission and the 
pressing challenges it faces in recruitment, hiring and retention 
demand action sooner rather than later.

Reform the classification system

    The General Schedule classification system, which determines pay 
for the vast majority of the federal workforce, is nearly seventy years 
old and hopelessly out of step with modern compensation practices. \37\ 
Many facilities cite uncompetitive salaries stemming from 
administration of the classification system specifically as a key 
barrier to effective recruitment and retention. \38\ Modernizing this 
system in a way which gives the department flexibility to craft 
competitive compensation packages will go a long way towards allowing 
the VHA to bring in the talent it needs and better serve veterans.
---------------------------------------------------------------------------
    \37\ Building the Enterprise: A New Civil Service Framework. 
Publication. Washington, DC: Partnership for Public Service, 2014. 16.
    \38\ United States of America. Department of Veterans Affairs. 
Office of Inspector General. OIG Determination of Veterans Health 
Administration's Occupational Staffing Shortages FY2018. Washington, 
DC, 2018. 13.

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Conclusion

    Chairman Dunn, Ranking Member Brownley, members of the Subcommittee 
on Health, thank you for the opportunity to present the Partnership's 
views on the implementation of the VA Choice and Quality Employment Act 
of 2017 and the continuing mission-critical hiring challenges of the 
Veterans Health Administration. I applaud the committee for its 
ongoing, bipartisan commitment to ensuring America's veterans receive 
the care they have earned. I look forward to continuing to work with 
you and the department to help it meet its goals and am happy to answer 
any questions you may have.

                                 
                 Prepared Statement of Debra A. Draper
Steps Taken to Improve Physician Staffing, Recruitment, and Retention, 
    but Challenges Remain

    Chairman Dunn, Ranking Member Brownley, and Members of the 
Subcommittee:

    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 physicians. A 
strong clinical workforce capable of providing quality and timely care 
to our nation's veterans is critical to the success of VHA, which 
operates one of the largest health care systems in the United States, 
providing care at 1,252 facilities, including 170 VA medical centers 
(VAMC). \1\ As the demand for VHA's services grows-due in part to 
increasing demand from servicemembers 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 high-quality and timely 
health care for our nation's veterans.
---------------------------------------------------------------------------
    \1\ In addition to the 170 VAMCs, VHA also operates 1,082 
outpatient sites of care, such as health care centers and community-
based outpatient clinics.
---------------------------------------------------------------------------
    Physicians-who provide and supervise a broad range of care, 
including primary and specialty care-serve an integral role in VHA's 
mission. VHA indicated that physicians occupy a top spot on its annual 
list of mission-critical occupations, as a result of factors including 
the time frames needed for VHA's hiring process, a limited supply of 
candidates, and competition for candidates. \2\ Within the physician 
category, VHA has also identified the top five physician occupations 
that are the hardest to recruit and retain. We use the term ``mission-
critical physician occupations'' to refer to the top five physician 
occupations VHA identified in fiscal year 2016 as most in need of 
staffing: primary care, mental health, gastroenterology, orthopedic 
surgery, and emergency medicine. VHA hires more than 2,800 mission-
critical physicians annually. Yet, physicians have consistently been 
identified by VHA as a critical staffing priority due to recruitment 
and retention concerns.
---------------------------------------------------------------------------
    \2\ VHA obtains data from its Veterans Integrated Service Networks 
and VAMCs on which occupations are the highest priority for recruitment 
and retention based on known recruitment and retention concerns, among 
other factors. See U.S. Department of Veterans Affairs, Veterans Health 
Administration, Mission-Critical Occupation Report (2016).
---------------------------------------------------------------------------
    Over the past two decades, 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. \3\ A 2015 
independent assessment found that if VHA does not increase its total 
number of clinical employees, including physicians, it will be 
difficult for it to meet the projected demand for services. \4\ 
Further, in July 2016, we found that the number of physicians who leave 
VHA had steadily increased from fiscal years 2011 through 2015. During 
this time, physicians were among the 10 occupations with the highest 
rates of attrition each year. \5\ The attrition was primarily due to 
voluntary resignations and retirements.
---------------------------------------------------------------------------
    \3\ We and the VA Office of the Inspector General have issued at 
least 16 reports between 1981 and 2017 that raised a variety of 
concerns about VHA's workforce. Recent GAO reports include, GAO, 
Veterans Health Administration: Better Data and Evaluation Could Help 
Improve Physician Staffing, Recruitment and Retention Strategies, GAO 
18 124 (Washington, D.C.: Oct. 19, 2017); Veterans Health 
Administration: Management Attention Is Needed to Address Systemic, 
Long-standing Human Capital Challenges, GAO 17 30 (Washington, D.C.: 
Dec. 23, 2016); and 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).
    \4\ See RAND Corporation, Assessment B (Health Care Capabilities), 
(Santa Monica, Calif: Sept. 1, 2015).
    \5\ See GAO 16 666R.
---------------------------------------------------------------------------
    My statement today is based on our October 2017 report examining 
VHA physician staffing, recruitment, and retention strategies. \6\ In 
particular, my statement focuses on (1) VHA information on how many 
mission-critical physicians provided care at VAMCs; (2) VHA guidance 
for determining its physician staffing needs; and (3) the strategies 
VHA used to support the recruitment and retention of physicians at 
VAMCs, and the extent to which it has evaluated these strategies to 
determine their effectiveness. As part of that work, we made several 
recommendations for VHA to improve staffing, recruitment, and retention 
strategies for physicians.
---------------------------------------------------------------------------
    \6\ See GAO 18 124.
---------------------------------------------------------------------------
    To do the work for our October 2017 report, we reviewed key 
documents and interviewed knowledgeable officials from VHA in 
headquarters offices, as well as in six VAMCs across the country. More 
detailed information on the objectives, scope, and methodology for our 
2017 report can be found in that report. For this statement, we 
obtained information from VHA officials in June 2018 about any steps 
they have taken to implement our 2017 recommendations.
    This statement is based on work 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

    The attrition among VHA physicians has been of particular concern 
given that the Health Resources and Services Administration (HRSA) 
anticipates that by 2025 the national demand for physician services 
will exceed supply. HRSA's Office of Rural Health Policy reported, in 
2017, that physician shortages were exacerbated in rural areas, where 
communities struggle to attract and keep well-trained providers. \7\ 
This difficulty has posed a particular challenge for VHA, as 
approximately one in four VAMCs is located in a rural area.
---------------------------------------------------------------------------
    \7\ Department of Health and Human Services, Health Resources and 
Services Administration, Designated Health Professional Shortage Areas 
Statistic, HRSA Data Warehouse, accessed May 31, 2017.
---------------------------------------------------------------------------
    Most physicians providing care at VAMCs are employed by VHA. VHA 
also supplements the capacity of its employed physician staff by 
acquiring additional physician services through fee-basis arrangements 
or contracts. Under fee-basis arrangements, providers are paid a pre-
agreed-upon amount for each service provided. Under contracts, 
physician services may be obtained on a short-term basis; for example, 
through sole-source contracts with academic affiliates. \8\ VAMCs may 
also use physicians who volunteer their time, who are referred to as 
work-without-compensation providers.
---------------------------------------------------------------------------
    \8\ The term academic affiliate describes any of the following 
three entities in a partnership with a VAMC: (1) a university medical 
school, (2) a university hospital, or (3) a university affiliated 
physician practice group. If VA requires heath care resources-such as 
physician services, medical equipment usage, or clinical space-and 
intends to acquire these resources from its affiliate due to its 
connection with a residency program, VA can enter into a non-
competitive contract with that affiliate. See 38 U.S.C. Sec.  
8153(a)(3)(A).These sole source contracts are available only to VAMCs 
and their affiliates, and allow a VAMC to obtain physician services 
directly from the affiliate without competition if those services are 
necessary to support learning opportunities for physicians during their 
residency training in VAMCs. See Department of Veterans Affairs, Health 
Care Resources Contracting-Buying, Title 38 U.S.C. 8153, VA Directive 
1663 (Aug. 10, 2006).
---------------------------------------------------------------------------
    In addition to VHA-employed, contract, and fee-basis physicians, 
VAMCs often supplement their capacity by using physician trainees, who 
include medical residents and advanced fellows. \9\ In 2016, 135 of the 
170 VAMCs had active physician training programs. According to VHA 
officials, there were 43,768 medical residents who trained at a VAMC in 
2016. VHA has been expanding its physician training program, as 
directed by the Veterans Access, Choice, and Accountability Act of 
2014, as amended. \10\ In 2017, VHA added 175 physician trainee 
positions across VAMCs nationwide, including 3 VAMCs that did not have 
physician trainees prior to this expansion. VHA's objective is to add 
953 additional physician trainee positions to its VAMCs by 2025 in 
order to improve access and hire additional physicians. Further, VHA 
officials told us they want to continue to add new positions that would 
eventually allow all VAMCs access to physician trainees.
---------------------------------------------------------------------------
    \9\ A medical resident or fellow is a physician who practices 
medicine under the direct or indirect supervision of an attending 
physician. Successful completion of a residency program is a 
requirement to obtaining an unrestricted license to practice medicine. 
Advanced fellows are individuals who have completed all desired 
residency training (including fellowships) and have stayed in VHA for 
additional training.
    \10\ Pub. L. No, 113-146, Sec.  301(b)(2), 128 Stat. 1754, 1785 
(2014), as amended by Pub. L. No. 114-315, Sec.  617(a), 113 Stat. 
1536, 1577 (2016) (codified at 38 U.S.C. Sec.  7302 note).

VHA Lacked Information on the Total Number of Mission-Critical 
    Physicians Who Provided Care at VAMCs and Does Not Plan to Collect 
---------------------------------------------------------------------------
    this Information

    In our October 2017 report, we found that VHA's data on physicians 
who provided care at VAMCs were incomplete. Specifically, we found that 
VHA had data on the number of mission-critical physicians it employed 
(more than 11,000) and who provided services on a fee-basis (about 
2,800), but lacked data on the number of contract physicians and 
physician trainees. As a result, VHA did not have data on the extent to 
which VAMCs used these arrangements and thus, underestimated its 
physician use overall. Therefore, VHA was unable to ensure that its 
workforce planning processes sufficiently addressed any gaps in 
staffing.
    All six VAMCs included in our review used at least one type of 
arrangement other than employment for physicians, and five of the six 
used contract physicians or physician trainees. (See fig. 1.) On 
average, contract and fee-basis physicians made up 5 to 40 percent of 
the physicians in a given mission-critical physician occupation at each 
VAMC in our review. \11\ For example, officials from a large, highly 
complex VAMC told us that, in March 2017, they augmented the 86 
employed primary care physicians with eight contract and three fee-
basis physicians, which represented about 16 percent of their primary 
care physician workforce. \12\ Further, this VAMC also had about 64 
primary care physician trainees providing certain medical services 
under the supervision of a senior physician.
---------------------------------------------------------------------------
    \11\ Officials from one of the six VAMCs we reviewed told us that 
they used both contract and fee-basis physicians, but they were not 
able to determine if these physicians worked in mission-critical 
physician occupations. Also, because physicians who are compensated on 
a fee-basis do not have an assigned full-time equivalent (FTE), we were 
unable to calculate the percentage of FTEs that contract and fee-basis 
physicians contribute to a VAMC. VAMC officials told us that, in order 
to ensure a physician is on-call 24 hours a day, 7 days a week, they 
may have a number of physicians on contract that only provide a limited 
amount of care.
    \12\ The contract and fee-basis physicians constituted 
approximately 6 percent of the VAMC's primary care FTE positions, which 
is lower because contract primary care physicians were often used on a 
part-time basis. Officials from this VAMC told us that employed primary 
care physicians filled 85 FTE positions, while contract physicians 
filled 3, and fee-basis physicians filled about 1 FTE.
[GRAPHIC] [TIFF OMITTED] T5730.001


    During the course of our work for the October 2017 report, VHA 
officials told us that its personnel databases were designed to manage 
VHA's payroll systems, but that these databases did not contain 
information on contract physicians or physician trainees. VHA officials 
told us they were working to include information on physician trainees 
in a new human resources (HR) database-HR Smart-which at the time of 
our review, was scheduled to be implemented in 2017. However, these 
officials were not aware of plans to add information to the database on 
contract physicians. Instead, VAMC leaders used locally devised methods 
to identify and track contract physicians, fee-basis physicians, and 
physician trainees. For example, one VAMC in our October 2017 review 
used a locally maintained spreadsheet to track its physicians under 
arrangements other than employment, while another VAMC asked department 
leaders to identify how many of these provided care within their 
respective departments. At each of the six VAMCs in our review, we 
found that department leaders were generally knowledgeable about the 
total number of physicians that provided care within the departments 
they managed. However, this locally maintained information was not 
readily accessible by VHA officials.
    To address the limitations in VHA's data, we recommended in our 
October 2017 report that VHA develop and implement a process to 
accurately count all physicians providing care at each of its VAMCs, 
including physicians not employed by VHA. VHA did not concur with this 
recommendation, stating that it uses other tools for workforce 
planning. However, a VHA official acknowledged that data sources used 
for workforce planning may not include all types of contract physicians 
or work-without-compensation physicians.
    As we discussed in our prior report, implementing such a systematic 
process would eliminate the need for individual VAMCs to use their own 
mechanisms, such as a locally developed and maintained spreadsheet to 
track its physician workforce, as was done by one VAMC in our prior 
review. Further, local mechanisms may not be readily accessible to VHA 
officials engaged in workforce planning, resulting in incomplete 
information for decision-making purposes.
    Since our report, VHA officials told us that they have completed 
implementation of HR Smart, which provides the capability to track 
every position with a unique position number, and each employee's full 
employment history. However, VHA officials told us they do not plan to 
enhance the capability of HR Smart to track contractors.
    We continue to believe that having a systematic and consistent 
process to account for all physicians who provide care across VAMCs, 
including physicians not employed by VHA, would help address concerns 
that VHA is unable to identify all physicians providing care at its 
VAMCs.

VHA Has Begun to Develop Guidance for Determining Its Staffing Needs 
    for All Physicians

    In our October 2017 report, we found that VHA gave responsibility 
for determining staffing needs to its VAMCs and provided its facilities 
with guidance, through policies and directives, on how to determine the 
number of physicians and support staff needed for some physician 
occupations. Specifically, VHA provided this guidance for primary care, 
mental health, and emergency medicine, but lacked sufficient guidance 
for its medical and surgical specialties, including occupations such as 
gastroenterology and orthopedic surgery. For these occupations, VHA 
provided guidance on the minimum number of physicians, but did not 
provide information on how to determine appropriate staffing levels for 
physicians or support staff based on the need for care.
    Specifically, the VHA guidance available at the time set a minimum 
requirement that VAMCs of a certain complexity level have at least one 
gastroenterologist and one orthopedic surgeon that is available within 
15 minutes by phone or 60 minutes in person 24 hours a day, 7 days a 
week. \13\ VHA guidance did not include information on how to use data, 
such as workload data, to manage the demand for care or help inform 
staffing levels for these physician occupations beyond this minimum 
requirement. Officials from four of the six VAMCs we reviewed for our 
October 2017 report told us that because they lacked (1) guidance on 
how to determine the number of physicians and support staff needed, and 
(2) data on how their staffing levels compared with those of similar 
VAMCs, they were sometimes unsure whether their staffing levels were 
adequate.
---------------------------------------------------------------------------
    \13\ VHA categorizes VAMCs according to complexity level, which is 
determined on the basis of the characteristics of the patient 
population, clinical services offered, educational and research 
missions, and administrative complexity. There are three complexity 
levels with level 1 representing the most complex facilities and level 
3 the least complex. Level 1 is further subdivided into categories 1a, 
1b, and 1c. Therefore, VAMCs that are categorized as level 1a would 
offer the most advanced and complex medical treatment within VHA's 
medical care system.
---------------------------------------------------------------------------
    In our October 2017 report, we discussed that VHA had previously 
established, in 2016, a specialty physician staffing workgroup that 
examined the relationships between staffing levels, provider workload 
and productivity, veterans' access, and cost across VAMCs for its 
medical and surgical specialties, including gastroenterology and 
orthopedic surgery. This group's work culminated in a January 2017 
report that found VHA was unable to assess and report on the staffing 
at each VAMC, as required by the Veterans Access, Choice, and 
Accountability Act of 2014, because a staffing model for specialty care 
had not been established and applied across VAMCs. This report made a 
number of recommendations, including that VHA provide guidance to its 
VAMCs on what level of staffing is appropriate for its mission-critical 
physician occupations. However, as we noted in our October 2017 report, 
VHA leadership had not yet taken steps to develop such staffing 
guidance. We reported that, according to a VHA official, other 
priorities were taking precedence and continued work in this area had 
not yet been approved by VHA leadership. Although VHA officials agreed 
that further steps should be taken, they did not indicate when these 
would occur. In our report, we concluded that until VHA issues guidance 
on staffing levels for certain physician occupations that provide 
specialty care to veterans, there would continue to be ambiguity for 
VAMCs on how to determine appropriate staffing levels.
    To address this, we recommended that VHA develop and issue guidance 
to VAMCs on determining appropriate staffing levels for all mission-
critical physician occupations. VHA concurred with our recommendation 
and reported it would evaluate and develop staffing guidance for its 
medical and surgical specialties.
    Since our report, VHA officials told us that on November 27, 2017, 
the Executive-in-Charge for VHA signed the specialty care workgroup 
charter. The primary goal of the workgroup is to develop a specialty 
care staffing model that will include staffing information for all 
specialty care. VHA anticipates completing its work and issuing 
staffing guidance by December 2018.

VHA Used Multiple Strategies for Physician Recruitment and Retention, 
    but Has Not Comprehensively Evaluated Them to Assess Effectiveness

    In our October 2017 report, we found that VHA used various 
strategies to recruit and retain its physician workforce, including 
providing assistance recruiting for mission-critical physician 
occupations through the National Recruitment Program; policies and 
guidance; financial incentives to enhance hiring and retention offers; 
and a national physician training program. (See table 1.)

                           Table 1: VHA Physician Recruitment and Retention Strategies
 
 
 
 Providing assistance recruiting for        VHA operates the National Recruitment Program that provides direct
           mission-critical physician       physician recruitment services to Veterans Affairs medical centers
                          occupations         (VAMC) for hard-to-recruit positions, including physicians. This
                                        program, which had 19 physician recruiters as of May 2017, according to
                                        officials, represents VHA at medical conferences, screens resumes, and
                                        develops marketing materials, among other things, to identify and refer
                                                                                physician candidates to VAMCs.
----------------------------------------------------------------------------------------------------------------
               Policies and guidance    VHA administers the policies and guidance developed by VA that provide
                                              the basic framework for hiring, paying, promoting, and retaining
                                           physicians. Using in-person and webcast sessions, VHA also provides
                                               basic and advanced training to VHA staff on personnel policies.
----------------------------------------------------------------------------------------------------------------
                Financial incentives    VHA provides financial incentives to strengthen efforts to recruit and
                                        retain physicians and help to narrow the differences between VHA salary
                                        offers and those of private sector employers. VAMCs adjust market pay,
                                             one component of physician compensation, to reflect a physician's
                                          training, experience, and prevailing pay levels in the local medical
                                               community. Additionally, VHA may offer other types of financial
                                                incentives such as the Education Debt Reduction Program, which
                                            reimburses qualifying education loan debt for employees, including
                                                                     physicians, in hard-to-recruit positions.
----------------------------------------------------------------------------------------------------------------
          Physician training program         VHA's physician training program provides VAMC officials with the
                                        ability to regularly interact with trainees and identify top-performing
                                              physicians who would be a ``good fit'' for permanent employment.
                                        According to officials, access to this pool of potential hires serves as
                                                                            an important recruitment resource.
 
Source: Veterans Health Administration (VHA) / GAO 18 623T


    In our October 2017 report, we found that VHA faced challenges 
using its strategies for recruiting and retaining physicians. For 
example, according to VHA officials, budget shortfalls in the Education 
Debt Reduction Program-which reimburses qualifying education loan debt 
for employees, including physicians, in hard-to-recruit positions-
reduced VAMCs' ability to offer this recruitment incentive to physician 
candidates. In addition, the relatively small number of physician 
recruiters in VHA's National Recruitment Program-19 recruiters for the 
170 VAMCs at the time of our report-limited their ability to understand 
the particular nuances of some markets, particularly in rural areas.
    Further, despite VHA's large and expanding graduate medical 
training program, VAMCs experienced difficulties hiring physicians who 
received training through its residency and fellowship programs. VHA 
did not track the number of physician trainees who were hired following 
graduation, but officials told us that the number was small in 
comparison to the almost 44,000 physician trainees educated at VAMCs 
each year.
    We found that VAMCs faced challenges hiring physician trainees, in 
part, because VHA did not share information on graduating physician 
trainees for recruitment purposes with VAMCs across the system. VHA 
officials told us that recruitment efforts could be improved by 
developing and maintaining a database of physician trainees, but said 
that VHA had no such database. According to VHA officials, information 
sharing could help both VAMCs in geographically remote locations that 
do not have a residency program and help identify trainees who want to 
work at VHA after graduating, but who received no offers from the VAMC 
they trained at due to the lack of vacancies in their specialty.
    We also reported in October 2017 that VHA did not have complete 
information on whether its recruitment and retention strategies were 
meeting its needs. VHA had gathered feedback on barriers VAMCs face 
when offering financial incentives to physician candidates through its 
Education Debt Reduction Program and created a workgroup to look at its 
overall use of physician retention strategies, although it had not 
completed a comprehensive review of its recruitment and retention 
strategies to identify any areas for improvement. As a result, VHA did 
not have complete information on the underlying causes of the 
difficulties VAMCs faced or whether its recruitment and retention 
strategies met its objective of having a robust physician workforce to 
meet the health care needs of veterans.
    To address these issues, we recommended that VHA (1) establish a 
system-wide method to share information about physician trainees to 
help fill vacancies across VAMCs, and (2) conduct a comprehensive, 
system-wide evaluation of its physician recruitment and retention 
efforts, and establish an ongoing monitoring program. VHA concurred 
with our recommendations, and reported it planned to enhance its 
personnel database, HR Smart, to include physician trainees. 
Additionally, VHA said it planned to complete a comprehensive, system-
wide evaluation of the physician recruitment and retention strategies.
    Since our report, VHA reported taking some steps to address these 
recommendations. Specifically, officials told us they are working to 
include information in the newly implemented HR Smart database on work-
without-compensation employees, such as physician trainees, and 
anticipate conducting pilot projects at various sites before fully 
implementing this capability by September 30, 2019. Additionally, 
officials said that they are in the process of completing a review of 
physician recruitment and retention incentives. Furthermore, according 
to VHA officials, beginning in October 2017, VHA's Office of Workforce 
Management and Consulting partnered with the Partnered Evidence-based 
Policy Resource Center-an internal VHA resource center-to evaluate and 
recommend a systematic approach for allocating workforce management 
resources, such as the Education Debt Reduction Program. VHA expects to 
complete its efforts by September 2018.
    Chairman Dunn, Ranking Member Brownley, and Members of the 
Subcommittee, this concludes my statement. I would be pleased to 
respond to any questions you may have.

GAO Contact and Staff Acknowledgments

    For further information about this statement, please contact Debra 
A. Draper at (202) 512-7114 or [email protected]. Contact points for our 
Offices of Congressional Relations and Public Affairs may be found on 
the last page of this testimony. Key contributors to this statement 
were Janina Austin (Assistant Director), Sarah Harvey (Analyst-in-
Charge), Jennie Apter, Frederick Caison, Alexander Cattran, and Krister 
Friday.

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                Prepared Statement of Michael J. Missal
    Mr. Chairman, Ranking Member Brownley, and members of the 
Subcommittee, thank you for the opportunity to discuss my office's 
recent report, OIG Determination of Veterans Health Administration's 
Occupational Staffing Shortages for Fiscal Year 2018. \1\ Although this 
is the fifth Office of Inspector General (OIG) report on staffing 
shortages within VA's healthcare system, it is the first report that 
includes facility-specific data reported by leaders at 140 VA medical 
centers.
---------------------------------------------------------------------------
    \1\  The report was published on June 14, 2018.
---------------------------------------------------------------------------
    Previous OIG reports examined Veterans Health Administration (VHA) 
national staffing shortages for clinical staff only. The report 
released last week, in contrast, allows users to examine the particular 
self-reported needs of an individual facility as opposed to only 
national data. In keeping with statutory changes, this report also 
includes nonclinical occupations (such as human resources and custodial 
personnel) that ultimately affect the ability of VHA facilities to 
provide quality and timely patient care in a safe environment. This 
shift to facility-specific data reveals the staffing gaps in both 
clinical and nonclinical occupations identified by each VA medical 
center, which have not been apparent in previous reports containing 
only aggregate data. The results underscore how variable the needs are 
from one medical facility to another.

BACKGROUND

    Since January 2015, the OIG has reported on VHA clinical staffing 
shortages as required by the Veterans Access, Choice, and 
Accountability Act of 2014 (PL 113-146). \2\
---------------------------------------------------------------------------
    \2\ OIG Determination of Veterans Health Administration's 
Occupational Staffing Shortages reports were previously published on 
September 27, 2017; September 26, 2016; September 1, 2015; and January 
30, 2015.
---------------------------------------------------------------------------
    Our past reports have described the following aspects of staffing:

      Mission critical occupations - Medical officer, nurse, 
psychologist, and physician assistant were occupations consistently 
included in our top five determinations of occupational staffing 
shortages. Physical therapist was initially in the top five, but was 
replaced by medical technologist in our 2017 report.
      Gains and losses - We reported that overall hiring at VHA 
is increasing. Our analysis of staffing gains and losses shows that for 
mission critical occupations, a significant percentage of total gains 
were offset by losses. We made recommendations regarding reducing the 
number of regrettable losses and voluntary departures. \3\
---------------------------------------------------------------------------
    \3\ Regrettable losses are defined as those individuals who resign 
from VA or who transfer to other government agencies. Regrettable 
losses are staff who potentially could have continued employment in VA 
and represent an opportunity for VA to retain staff.
---------------------------------------------------------------------------
      Staffing models - The OIG has recommended that VHA 
develop and implement staffing models for critical occupations. We 
recognize that VHA has implemented staffing models in specific areas 
such as primary care and inpatient nursing. VHA has also expanded the 
occupations covered by such models. However, operational staffing 
models that comprehensively cover critical occupations are still 
needed. The OIG 2017 report states that, ``In the absence of facility-
specific staffing targets or an operational staffing model, determining 
whether facilities are making meaningful progress in filling critical 
staffing shortages is challenging.''

    The 2017 report also notes that despite having staffing models for 
some occupations, many medical centers reported relying on additional 
data when evaluating their staffing needs. An overwhelming majority 
specified they continued to use a locally developed process as opposed 
to a formal staffing model. Even when they have a methodology, 
additional data is desired and greater refinement is needed.

VHA'S OCCUPATIONAL STAFFING SHORTAGES FOR FISCAL YEAR 2018

    The VA Choice and Quality Employment Act of 2017 (PL 115-46) 
expanded the reporting requirement to include both clinical and 
nonclinical positions as well as requiring information for each VA 
medical center. Consequently, the OIG conducted a facility-specific 
survey to determine current local staffing levels and identify 
shortages. The OIG requested that VA medical center directors designate 
and rank each occupation for which there is a shortage at their 
facility. This shortage information should spur discussions about how 
best to meet facility-specific needs.
    As in previous years, the OIG analyzed staffing data using the 
Office of Personnel Management's (OPM) occupational series. We 
augmented our analysis this year by including VHA assignment codes to 
provide additional detail about the shortages in the medical officer 
and nurse occupational series. For example, these codes help 
distinguish a psychiatrist from a neurosurgeon-two physicians that 
would fall under the umbrella OPM occupation series of ``medical 
officer'' but provide significantly different types of care.
    Recent OIG reports have demonstrated the importance of including 
nonclinical positions in reports of staffing shortages. For example in 
our March 2018 report, Critical Deficiencies at the Washington DC VA 
Medical Center, we detail how excessive vacancies in key departments 
can affect patient care. An inadequately staffed human resources 
function contributed to key vacancies throughout that facility, 
including shortages in logistics, prosthetics ordering, sterile 
processing, and environmental management services. Without properly 
cleaned instruments, clinical areas, and storage rooms, the risk of 
infection increases to patients. Failing to have enough staff to order 
prosthetics and supplies, and track them, also can impact patient care.

Clinical and Nonclinical Results

    Medical center directors most commonly cited the need for medical 
officers and nurses, which is consistent with the OIG's four previous 
VHA staffing reports. Our analysis showed that 138 of 140 facilities 
listed the medical officer occupational series (or a related VHA 
assignment code) as experiencing a shortage, with the psychiatry and 
primary care positions being the most frequently reported. Of the 140 
facilities, 108 listed the nurse occupational series (or a related VHA 
assignment code) as experiencing a shortage, with practical nurse and 
staff nurse as the most frequently reported.
    Within nonclinical occupations, the OIG found that human resources 
management and police occupations were among the most often cited as 
shortages. Included in Appendix A is a table with the frequency of 
facility-designated occupational shortages.
    The results demonstrate that although there are clusters of 
commonality, there is also wide variability in occupational shortages 
reported by individual medical centers. This is critically important to 
recognize because facilities have distinct staffing needs that must be 
considered. For example, a rural facility that specializes in the 
treatment of mental health will need to be staffed differently than an 
urban facility in downtown Manhattan that provides a broad array of 
services.

Reasons for Shortages

    The report also identified challenges to meeting staffing goals. 
Because VHA utilizes OPM's criteria for supporting evidence that must 
be submitted to claim a ``severe shortage of candidates'' in generating 
its Mission Critical Occupation Report, we applied the same criteria. 
We provided the directors being surveyed with information from Title 5 
of the Code of Federal Regulations regarding OPM's Direct Hire 
Authority Severe Shortage of Candidates. The directors were able to use 
free text for providing information on the reasons for shortages, and 
the reasons varied significantly. OIG staff's thematic analysis of the 
responses resulted in three frequently cited categories: (1) lack of 
qualified applicants, (2) non-competitive salaries, and (3) high staff 
turnover. \4\
---------------------------------------------------------------------------
    \4\ The thematic analysis categories were developed after reading 
all the responses. Responses that fell outside of the developed 
categories were classified as ``other.''
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

---------------------------------------------------------------------------
Recommendations

    Our 2018 report repeats the OIG's previous calls for VHA to develop 
a new staffing model that identifies and prioritizes staffing needs at 
the national level while supporting flexibility at the facility level 
to ensure taxpayer dollars are invested in delivering the highest 
quality of care to veterans. Without the ability to analyze accurate 
data, VHA risks spending significant dollars without any measurable 
improvement in the quality of health care. VA's focus on developing a 
comprehensive staffing model will lead to more efficient hiring 
practices and result in fewer recruitment challenges and an increased 
capacity to serve veterans' needs.

CONCLUSION

    The OIG's 2018 survey provides facility specific data on staffing 
shortages reported by the leaders of the 140 VA medical centers and 
highlights the need for a model that identifies and prioritizes 
staffing needs allowing flexibility at the facility level. This report 
should prompt meaningful discussions at both the local and national 
levels about how to implement, support, and oversee staffing in VA 
medical centers that will result in the best possible care for 
veterans.
    Mr. Chairman, this concludes my statement, and I would be pleased 
to answer any questions you or other members of the Subcommittee have.

                        Table 1. Frequency of Facility-Designated Occupational Shortages
----------------------------------------------------------------------------------------------------------------
               Occupational Series or                                          Number of Facilities Marked the
                   Assignment Code                   Occupation                    Occupation as a Shortage
----------------------------------------------------------------------------------------------------------------
           1                       31                           Psychiatry                                   98
----------------------------------------------------------------------------------------------------------------
           2                     0201           Human Resources Management                                   92
----------------------------------------------------------------------------------------------------------------
           3                       P1                             Primary Care                               66
----------------------------------------------------------------------------------------------------------------
           4                     0180                           Psychology                                   58
----------------------------------------------------------------------------------------------------------------
           5                     0644                 Medical Technologist                                   56
----------------------------------------------------------------------------------------------------------------
           6                     0801                  General Engineering                                   55
----------------------------------------------------------------------------------------------------------------
           7                     0083                               Police                                   52
----------------------------------------------------------------------------------------------------------------
           8                       K6                          Hospitalist                                   49
----------------------------------------------------------------------------------------------------------------
           9                       16                   Emergency Medicine                                   48
----------------------------------------------------------------------------------------------------------------
          10                     0620                      Practical Nurse                                   46
----------------------------------------------------------------------------------------------------------------
          11                     3566                                     Custodial Worker                   46
----------------------------------------------------------------------------------------------------------------
          12                       25                     Gastroenterology                                   45
----------------------------------------------------------------------------------------------------------------
          13                       88                          Staff Nurse                                   44
----------------------------------------------------------------------------------------------------------------
          14                       12                              Urology                                   42
----------------------------------------------------------------------------------------------------------------
          15                        7                   Orthopedic Surgery                                   42
----------------------------------------------------------------------------------------------------------------
          16                     0603                Physician's Assistant                                   39
----------------------------------------------------------------------------------------------------------------
          17                     0622   Medical Supply Aide and Technician                                   39
----------------------------------------------------------------------------------------------------------------
          18                     0647   Diagnostic Radiologic Technologist                                   39
----------------------------------------------------------------------------------------------------------------
          19                       75                   Nurse Practitioner                                   39
----------------------------------------------------------------------------------------------------------------
          20                     0633                   Physical Therapist                                   37
----------------------------------------------------------------------------------------------------------------
          21                     0649        Medical Instrument Technician                                   37
----------------------------------------------------------------------------------------------------------------
          22                       20                          Dermatology                                   36
----------------------------------------------------------------------------------------------------------------
          23                       30                            Neurology                                   35
----------------------------------------------------------------------------------------------------------------
          24                       38                 Radiology-Diagnostic                                   33
----------------------------------------------------------------------------------------------------------------
          25                     0631               Occupational Therapist                                   31
----------------------------------------------------------------------------------------------------------------
          26                        1                       Anesthesiology                                   31
----------------------------------------------------------------------------------------------------------------
          27                     7408                  Food Service Worker                                   31
----------------------------------------------------------------------------------------------------------------
          28                     0858               Biomedical Engineering                                   30
----------------------------------------------------------------------------------------------------------------
          29                       21            General Internal Medicine                                   30
----------------------------------------------------------------------------------------------------------------
          30                       26                   Pulmonary Diseases                                   29
----------------------------------------------------------------------------------------------------------------
          31                       40                           Geriatrics                                   29
----------------------------------------------------------------------------------------------------------------
OIG Determinations of Veterans Health Administration's Occupational Staffing Shortages, June 14, 2018, page 11


                                 
                 Prepared Statement of Peter J. Shelby
    Good morning, Mr. Chairman, Ranking Member Brownley, and Members of 
the Committee. Thank you for the opportunity to discuss staffing for 
the Department of Veterans Affairs (VA). I am accompanied today by Ms. 
Jessica Bonjorni, Veterans Health Administration (VHA) Acting Assistant 
Deputy Under Secretary for Health for Workforce Services.
    We are excited to report to you the progress VA has made in the 
last year to support recruitment and retention for the professionals 
who provide healthcare, benefits assistance, and memorial services to 
our Veterans.

Leadership Training Plan

    VA is partnering with numerous private-sector organizations to 
strengthen the leadership and technical skills of VA executives, while 
at the same time leveraging the relationships to identify innovative 
strategies, best practices and technologies to drive transformational 
changes in VA healthcare management and delivery systems. The Executive 
Management Fellowship (EMF) program allows for reciprocal assignments 
of private-sector executives in VA facilities and VA executives in 
private sector healthcare organizations. VA is currently finalizing the 
hosting agreements and identifying the VA participants in this program, 
with the initial cohort to be selected by mid-July 2018. Once the 
fellowship agreements are in place, VA will extend reciprocal 
Fellowship opportunities to employees in the partner private-sector 
organizations. We anticipate having up to 20 EMFs in the year-long 
program in private-sector healthcare organizations across the country 
beginning this October, with private-sector EMFs being hosted in VA 
facilities shortly thereafter.

Military Transition

    VA has developed a three-pronged approach to encouraging 
transitioning Servicemembers to consider employment at the Veterans 
Health Administration. VA has partnered with Department of Defense 
(DoD) military installations in the National Capital Region on an 
initiative called Military Transition and Training Advancement Course 
(MTTAC). MTTAC is an entry-level training program for Servicemembers 
currently enrolled in the transition process, who anticipate being 
released from active duty within 90 to 120 days. This training program 
is modeled after VA's very successful Warrior Training Advancement 
program, which trains transitioning Servicemembers to serve as benefits 
claims examiners. VA's MTTAC program is currently set up to train 
Servicemembers to become medical support assistants, with the goal of 
hiring them into VA immediately upon separation from the military. As 
part of the course, Servicemembers are also provided with general 
Federal employment tips, including how to write a Federal resume and 
how to apply for Federal jobs. The first course was in May 2018, and 
the next class is scheduled for July 16-27, 2018 at Walter Reed 
National Military Medical Center. This course is expected to be offered 
at Fort Belvoir and Aberdeen Proving Ground in August 2018.
    VA is also using a direct marketing campaign to attract military 
medical professionals currently enrolled in the transition process. VA 
uses the VA-DoD Identity Repository data to identify Servicemembers, 
time of discharge, and military occupational specialty. The first 
campaign will launch on June 30, 2018.
    In addition, the Intermediate Care Technician (ICT) Program is an 
established VA program to recruit former military medics and corpsmen 
into positions in VA Medical Center (VAMC) emergency departments and 
other specialty areas. ICTs are aligned organizationally under licensed 
independent practitioners in the clinical setting to maximize their 
utility and value to Veteran care. This program has been piloted in VA 
and was deployed to 23 VA VAMCs at the start of fiscal year (FY) 2018. 
VA intends to expand this program to all 171 VAMCs.

System-wide Method to Share Information about Physician Trainees

    In close partnership with the Office of Personnel Management, VA 
has evaluated new requirements necessary to track physician trainees in 
HR-Smart and is developing requirements for VA's interface with the USA 
Staffing information system. The current USA Staffing interface design 
does not currently include ``without compensation'' employees. A 90-day 
pilot is currently underway to test the technical solution being 
proposed to track physician trainees to assess employment and retention 
of trainees. Afterward, additional pilot projects at various sites will 
be performed, including full application of the trainee onboarding 
initiative. The anticipated completion date for these pilot projects is 
the fourth quarter of FY 2019.

Physician Recruitment & Retention Strategies

    VA has taken steps to complete a comprehensive, system-wide 
evaluation of the physician recruitment and retention strategies. VA's 
Office of Workforce Management and Consulting (WMC) is in the process 
of completing a review of physician recruitment, relocation, and 
retention incentives by specialty as well as a comparison of salary 
data for local markets.
    VA's WMC is working with VA's Partnered Evidence-based Policy 
Resource Center to evaluate the impact of market trends and recruitment 
and retention incentives to target resources effectively. To date, 
analysis is conducted at the VAMC level. Targets for FY 2018, Q3 are 
focusing on analysis at the individual employee level to provide a 
richer variation and more statistical power to measure the impact of 
Federal-private wage differential, impact of incentives such as the 
Education Debt Reduction Program, recruitment, retention and relocation 
incentives on employees receiving such benefits and other variables of 
interest.
    WMC is also actively collaborating with Quality Enhancement 
Research Initiative partners to evaluate and refine strategic 
allocation of workforce resources for critical staffing needs within 
the top clinical staffing shortage occupations (physicians, registered 
nurses, physician assistants and psychologists). Ongoing activities 
include evaluation and development of existing recruitment and 
retention incentives, loan repayment and scholarship programs. 
Components of the recruitment and retention evaluation specific tasks 
include not only evaluating the effectiveness of these recruitment and 
retention programs, but also exploration of predictive turnover, 
retention profiling, and a pilot design for a strategic approach of 
workforce resources. The study is expected to conclude by the end of FY 
2018.

Staffing Models for Critical Need Occupations

    The VA Specialty Care Staffing Working Group continues its efforts. 
The team is building and establishing an integrated set of costing, 
forecasting and productivity tools based upon the latest 2016 and 2017 
information. Previous work by the team established a data baseline, 
demonstrating the relationship between Veteran demand for Specialty 
Care services with corresponding cost, complexity and productivity 
factors. The team is now evaluating the results and developing staffing 
models and decision matrices for medical facilities to use when setting 
Specialty Care staffing requirements. The anticipated completion date 
for initial delivery is September 2018.
    Meanwhile, VA continues to evolve its clinical staff modeling and 
workforce planning for other practice areas. VA is leveraging long-
standing staffing models for primary care, mental health, and nursing; 
and is developing, evaluating, and refining additional staffing models 
for other functional areas. VA provided technical support to the Office 
of the Inspector General (OIG) for an OIG independent assessment of 
field occupational staffing priorities in February 2018. VA OIG 
released their report to VA, the results will be incorporated into the 
next round of clinical staffing planning assessments. The anticipated 
completion date is September 2018. The Medical Center results will be 
published in the Federal Register by September 2018.
    VA is establishing a manpower capacity for the entire Department, 
with the creation of a permanent manpower office in the Office of 
Management, and is leveraging HR Smart as a technical solution-enabling 
position management. VHA is closely integrated with the Department's 
efforts and is committed to deploying a position management solution 
for both clinical and non-clinical requirements.
    An updated, efficiently aligned position categorization structure 
will enable VA facilities to more precisely define their clinical and 
non-clinical staffing requirements. Such a structure will also enable 
staffing predictive power on the part of VAMCs and Veterans Integrated 
Service Networks, and will simultaneously enable the flow of staffing 
requirements to the enterprise level, facilitating national recruitment 
efforts and budget formulation.

Predicting Staffing Changes

    The VA Enrollee Health Care Projection Model (EHCPM), developed in 
1998, is a sophisticated healthcare demand projection model and uses 
actuarial methods and approaches to project Veteran demand for VA 
healthcare. These approaches are consistent with the actuarial methods 
employed by the Nation's insurers and public providers, such as 
Medicare and Medicaid. The EHCPM projects enrollment, utilization, and 
expenditures for the enrolled Veteran population for more than 90 
categories of healthcare services 20 years into the future.
    A key component in of the EHCPM is ``reliance.'' A unique aspect of 
the enrolled Veteran population is that enrollees have many options for 
healthcare coverage in addition to VA: Medicare, Medicaid, TRICARE, and 
private insurance. Approximately 80 percent of enrollees have some type 
of public or private healthcare coverage in addition to VA. As a 
result, enrollees rely on VA for approximately one-third of their 
healthcare needs. Changes in enrollee reliance occur as a result of 
many factors, such as enrollee movement into service-connected 
priorities, changing economic conditions, VA's efforts to provide 
Veterans access to the services they need, VA's efforts to enhance its 
practice of healthcare, the opening of new or expanded facilities, and 
the availability of services and/or the cost sharing associated with 
services in the private sector.
    The VHA Office of Enrollment and Forecasting and the Specialty Care 
Delivery Network Model Work Group Co-Chairs (WMC and National Surgery 
Office) are incorporating EHCPM data into its staffing model 
development, including the Specialty Care Delivery Network Model. VA 
will continue to expand its capability to predict Veteran demand for 
care and to further enhance the ability of its staffing models to 
leverage demand prediction.
    This remains a critical activity, and as noted above is being 
conducted as a subset of the Specialty Care Services Staffing 
workgroup. The team is currently analyzing enrollee demand for all 
healthcare within a healthcare market (whether received in a public or 
private setting), not just within a framework of demand in the context 
of VA facilities. The anticipated completion date is the end of 2018.

Training Human Resource Specialists

    Through April 2018, there have been 422 new General Schedule (GS) 
201 Human Resources (HR) specialists hired into VA. At the start of FY 
2018, VA launched a course called 201 Jumpstart. This self-paced 
virtual course helps orient HR professionals to VA, and includes 
training on how to best recruit and retain employees. Following the 
completion of this course, new HR Specialists enroll in the New Talent 
Development Program (NTDP) which is a face-to-face training that 
provides comprehensive HR training on two tracks: (1) Staffing/
Classification and (2) Employee Relations/Labor Relations/Performance 
Management. After piloting NTDP in the first two quarters of FY 2018, 
the program is now expanding to enroll all newly hired HR Specialists, 
with annual throughput capacity of 900 employees. To date, 120 HR 
Specialists have completed the NTDP, with an additional 34 currently 
enrolled.

Mental Health Hiring

    VA has committed to achieving a net gain of 1,000 Mental Health 
(MH) Providers by the end of this calendar year. As of June 8, 2018, VA 
has achieved a net gain of 424 new MH clinicians. As part of this MH 
hiring initiative, VA used a new workforce planning approach that has 
proven to be a successful proof of concept for early VA manpower 
capabilities, including analysis of workforce and mitigation of 
regrettable losses. In addition, VA launched the first VA MH Trainee 
and Early Career Connection and Recruitment event, to help potential 
candidates connect, match, and interview with local VAMCs that are 
hiring. Approximately 2,000 matches have been made between participants 
and 75 VAMCs. The VA MH Trainee and Early Career Connection and 
Recruitment event will run through late July 2018.

Conclusion

    VA appreciates Congress's support, which allows us to train future 
healthcare professionals to care for Veterans and the Nation as a 
whole. Mr. Chairman, this concludes my testimony. My colleague and I 
are prepared to answer any questions you, Ranking Member Walz, or other 
members of the Committee may have.

                                 
                       Statements For The Record

      AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, AFL-CIO (AFGE)
    Chairman Dunn, Ranking Member Brownley, and Members of the 
Subcommittee:

    The American Federation of Government Employees, AFL-CIO (AFGE) and 
its National VA Council (NVAC) appreciate the opportunity to submit a 
statement for the record for the June 21, 2018 hearing titled, ``More 
Than Just Filling Vacancies: A Closer Look at VA Hiring Authorities, 
Recruiting and Retention.'' AFGE and NVAC represent more than 700,000 
employees in the federal and D.C. government, including 250,000 front 
line employees at the Department of Veterans Affairs (VA) providing 
comprehensive benefits, health care, and other critical services for 
veterans.
    As numerous studies, reports, and anecdotal evidence have shown, 
veterans receive the best care for their conditions in a system that is 
specifically designed for the treatment of veterans, the VA. In turn, 
it is not surprising that the preferred ``CHOICE'' of veterans 
regarding where to receive care is also the VA. Because of these 
preferences, and the nation's commitment to those and the families of 
those who have served, Congress must do all in its power to staff the 
VA to a point where capacity meets the VA's exceptional demand, and 
where veterans receive the VA care they have earned. If proper staffing 
is not accomplished and positions are not filled, the VA will continue 
down the path of privatization, and veterans will instead have a 
``CHOICE'' made for them by being sent to non-VA care.
    AFGE and NVAC welcomes the opportunity to comment on several 
components that have an impact on the future of VA staffing, including:

Office of Inspector General Report on Staffing

    For years AFGE and NVAC have urged Congress to take a real look at 
hiring at the VA. With over 33,000 unfilled positions currently on the 
books at the VA, this hearing is timely. It is impossible for us to 
keep the promise made to our veterans without adequately funding and 
staffing the VA. The VA provides world-class, comprehensive, veteran-
centric care and services that simply are unavailable elsewhere and 
that is a system which must be preserved. We hope that the end result 
of the hearing today is with an even greater interest in staffing and a 
desire to fill all 33,000 vacant VA positions.
    Additional data on nonclinical staffing needs: Last week the VA 
Office of Inspector General (OIG) released its annual report on 
staffing at the VA. Unlike past years, Congress directed the OIG to now 
include the top five clinical and non-clinical occupations which are 
the most short staffed. To comply, the OIG released data from 140 VA 
facilities nationwide and rank ordered the data based on how frequently 
the facilities cited an occupation as short staffed.
    AFGE and NVAC were pleased to see the OIG provide a more thorough 
and complete review of facility staffing deficiencies including 
additional data on nonclinical staffing needs. This information will be 
useful to all stakeholders as we attempt to identify how to best staff 
the VA and fill these vacancies with fulltime federal employees who 
will make a career out of serving our veterans.
    AFGE and NVAC are pleased to see an increased spotlight on the need 
for adequate staffing of nonclinical positions. Staffing levels for VA 
police ensure the safety of patients and employees, and staffing the VA 
with an appropriate number of custodial workers reduces the risk of 
hospital-acquired infections. These are life and death issues.
    Given the enormous burden that Choice and other non-VA private care 
programs have placed on VA's own support staff who are handling 
consults, medical records and requests for assistance from patients 
trying to navigate the private care maze, AFGE and NVAC strongly 
recommend that additional staffing data be collected to reflect 
staffing needs for these support positions as the Mission Act is rolled 
out.
    Mental health staffing needs: Sadly, once again mental health 
topped the list of difficult to fill positions in the OIG report. Of 
the 140 facilities surveyed, 98 facilities listed psychiatrist as the 
position which is most difficult to fill. This made mental health the 
top category of those reported in the surveys. At a time when private 
sector entities are hoping to carve out mental health care as a primary 
avenue for privatization, this finding is particularly disturbing. The 
VA does veteran-centric mental health care better than any comparable 
entity in the private sector, and those professionals work every day to 
make sure our veterans get the help that they need.
    AFGE and NVAC urge Congress to work to increase internal capacity 
within the VA's mental health practices instead of supplementing this 
care with the private sector. AFGE and NVAC are very troubled by field 
reports from our locals who have observed that there appears to be 
widespread noncompliance with VA's own mental health staffing ratios. 
Chronic short staffing of clinicians providing mental health treatment 
to our wounded warriors will directly undermine VA's continued ability 
to provide the exemplary specialty mental health care and Primary Care 
Mental Health Integration that are a national model.

Direct Hire Authority

    The VA has long called for, and the Congress has consistently 
provided, direct hiring authority to bypass the regular civil service 
process and fill positions within the VA. Less than a year ago, in 
August of 2017, the ``VA Choice and Quality Employment Act of 2017'' 
was enacted into law. This law goes beyond traditional direct hiring 
authority, and exclusively grants the VA additional direct authority 
when ``there exists a severe shortage of highly qualified candidates'' 
(Sec. 213). Furthermore, just as recently as last month, the VA MISSION 
ACT was signed into law, making two distinct references to how the VA 
should use direct hiring authority. Specifically, it says it should be 
used as a part of the remediation of closed medical service lines (Sec. 
109), as well as for addressing the problems facing underserved 
facilities (Sec. 401).
    Currently, tens of thousands of vacancies exist throughout the VA, 
and short staffing requires some veterans to receive non-VA care 
despite their preference to be treated within the VA. While the 
aforementioned laws address VA's direct hire authority, we must ask how 
the VA is using these hiring tools to address staffing challenges.

Accountability Act

    Since the day of its introduction, AFGE and NVAC have vociferously 
opposed the ``Department of Veterans Affairs Accountability and 
Whistleblower Protection Act of 2017.'' AFGE opposed this law with the 
belief that it would lead to a purge of frontline employees at the VA, 
including many veterans continuing their service to the nation within 
the VA, while failing to address managers who have failed in their 
ability to lead staff and serve the mission of the VA. While the VA has 
made collection of data related to terminations under the powers 
granted by the Accountability Act difficult to say the least, AFGE and 
NVAC have worked to compile and analyze data from these terminations. 
Through February 2018, 1646 individuals were removed under the 
Accountability Act, including 44 physicians, 100 Registered Nurses, 51 
Licensed Practical Nurses, 40 Nurses, and eight Physicians Assistants, 
while only 18 Supervisors were terminated. With so many veterans 
requiring care, it is counterproductive to arbitrarily terminate 
medical personnel in short supply, while simultaneously failing to hold 
supervisors accountable. AFGE and NVAC are very pleased that a 
bipartisan bill, the VA Personnel Equity Act of 2018 (HR 6101) has just 
been introduced to restore critical workplace rights that the 2017 law 
severely weakened or eliminated. Regarding staffing, passage of this 
legislation will enable the VA to restore a more just and fair 
workplace that will enable it to be on a more level playing field in 
competing with other health care employers,

Transparency

    AFGE and NVAC have urged Congress to seriously address VA staffing 
in a way that is transparent to patients, workers, and job seekers. We 
were pleased to see Congress include new transparency language in the 
VA MISSION Act, which is now law. Specifically, Sec. 505 of the new law 
requires the VA to submit a report to Congress outlining how many 
unfilled positions exist by occupation and by facility. This 
information will be posted on a publicly available website so that all 
interested parties will have access to the information. This section of 
the new law is an important step forward in staffing transparency at 
the Department. For entirely too long we have allowed the public to 
only see one side of the VA story: wait times. Now the public will be 
able to see how many unfilled positions exist at these facilities and 
ask questions about why those positions are going unfilled. We were 
also pleased to see Sec. 505 include a reporting requirement so that 
the Department will have to face Congress and explain what steps it is 
taking to fully staff every VA facility across the country. This new 
transparency requirement is important, and we ask that Congress make 
certain that the VA complies with this section of the new law.

Other comments: Physician Assistant Pay

    As the OIG noted in its June 14, 2018 report, VHA has consistently 
faced a shortage of physician assistants (PA) in its workforce. Section 
212 of the VA Choice and Quality Employment Act of 2017 (VCQEA) added 
the requirement that physician assistants employed by VHA receive 
competitive pay through the same locality pay setting process already 
in place for registered nurses.
    AFGE and NVAC have monitored the implementation of this new PA pay 
requirement. Our locals in multiple locations report problems with the 
types of surveys used. Management at some facilities are using 2016 
contract wage surveys and they appear unwilling to consider any other 
options. Given that the Medical Center Director has total discretion 
over the salary levelswhen converting to the new salary schedule and is 
only required to notify the Secretary of his decision, this leaves 
little recourse for the PAs adversely affected by the choice of survey, 
or their employee representatives to challenge unfair salary schedules.
    As a result, despite these new provisions in the law, PAs working 
for the VA are paid significantly less than other PAs in the same local 
market; some report a $20,000 pay gap. PAs with longstanding tenure 
with the VA are facing some of the worst pay gaps due to the VA's 
current pay ceilings for PAs.
    PAs also report that their years of experience are undervalued 
relatives to VA advanced practice registered nurses (APRNs). For APRNs 
working at the VA, nursing years of experience are counted as years of 
experience towards their APRN salary determination. This practice 
results in APRN's receiving higher salaries than PAs with the same or 
less APRN experience.
    AFGE and NVAC appreciate the opportunity to comment on these 
important staffing issues.

                                 
                       WHISTLEBLOWERS OF AMERICA
    Mr. Chairman and Ranking Member:

    Whistleblowers of America (WoA) was established as a nonprofit in 
2017 to provide peer support and advocacy to whistleblowers suffering 
the ill-effects of retaliation. Although it receives contacts from 
various sectors and communities, whistleblowers from the Department of 
Veterans Affairs (VA) is the clear majority. When similar concerns were 
raised by VA employees about their retention, reprisal, demotion, 
termination, and constructive dismissal WoA wanted to learn more, so we 
asked for feedback. We were hearing multiple concerns from employees 
(and veterans) about the new Office of Accountability and Whistleblower 
Protection (OAWP), WoA wanted to develop a more comprehensive 
understanding of interactions people were having with the OAWP. WoA has 
included the Findings section upfront and actual comments for VA 
whistleblowers in Background.
    In previous testimony to this Committee, WoA has cited its concerns 
for high turnover rates and vacant positions in the neighborhood of 
40,000. WoA believes some of this turnover and difficultness to fill 
position is due to the retaliation, discrimination, harassment, and 
hostile work environment that VA employees find themselves subject to. 
This reputation does not make VA an organization of choice. The Federal 
Employees Viewpoints Survey (FEVS) of all government employees shows VA 
to be amongst the less favorable places to work. If we want to hire 
qualified, competent providers, we must give them a positive work 
environment.

Summary of Findings:

    Although whistleblowers are bringing forward a variety of different 
issues related to disclosing wrongdoing, the retaliation occurs along 
similar lines. Whistleblowers report to WoA that they experience 
further reprisal in the form of harassment/violence, gaslighting, 
mobbing, ostracizing, marginalizing and devaluing, double-binding, 
blackballing and counter accusing. \1\ They describe these conditions 
as evidence of retaliation in hopes that OAWP will be able to protect 
and assist them quickly. However, that is often not the case. The OAWP 
is plagued with deficiencies related to timeliness, process and 
staffing further effecting outcomes.
---------------------------------------------------------------------------
    \1\ Garrick Inventory: Whistleblower Retaliation Checklistc. I 
developed this checklist with indicators to help assess whistleblower 
retaliation.
---------------------------------------------------------------------------
    Timeliness - The OAWP, which employees perceive as having been 
created to help them, has caused most of them more harm as evident by 
some of the comments. Across the board, OAWP does not provide timely 
responses. When a whistleblower contacts the OAWP, they are assigned a 
case manager who asks them to fill out the VA Form 10177. 
Whistleblowers wait several months and are then given ``boilerplate'' 
answers. They are told that they will hear back, but then they never 
do.
    Process - Another consistent issue with OAWP is that it appears 
limited in its protocol for engagement. Because of the language in the 
VA Form 10177, attorneys have advised clients not to sign it because it 
creates some conflicts of interest and may be interpreted to waiving 
certain rights. However, once signed and a case manager assigned, the 
process entails a report to the OAWP Director, but then the information 
goes back to the VISN or RO Director, the hospital director and then to 
the supervisor, who is usually the person reported in the first place. 
Retaliation increases.
    This process seems to also involve hospital chiefs of staff sending 
letters of investigation to license boards and professional association 
that have career ending implications. Doctors are reported to the 
National Practitioner Data Bank (NPDB) even when no charges have been 
substantiated but once identified to the NPDB a medical career is 
virtually over. Living under this threat is causing some practitioners 
to leave the VA out of fear. A Readjustment Counseling Services 
conference in June 2018 reportedly ended with Vet Center employees 
being reminded that Trump has curtailed your due process rights and 
that they can be fired at any time.
    OAWP engagement seems limited to ``trafficking'' the paperwork and 
monitoring the whistleblowers, but not a lot of advocacy or assistance. 
They do not appear to have the capability to investigate, mediate, or 
arbitrate an outcome. They should also be required to provide case 
management updates and disclose an outcome. Although privacy of all 
parties must be respected, the whistleblower should at least be able to 
receive notice on the section(s) of law reviewed and how it was 
applied.
    Staffing - The one whistleblower who identified the job series 
issue appears to have hit a key element that is challenging engagement 
effectiveness. Since the OAWP was created by overtaking the former OAR 
- an HR function, the staff tends to have that background. Therefore, 
there is a shortage of the right staffing mix of HR specialists, 
investigators, mediators/arbitrators and decision makers. The office 
would benefit from being authorized to engage independent consultants 
to conduct these investigations and issue reports. This would increase 
transparency, accountability and confidence in the system.
    When employees leave the VA (regardless if they are terminated, 
resign or retire), they should be required to participate in an exit 
interview process that captures information related to their employment 
experience and reasons for leaving. This information should be reported 
to Congress annually.
    Performance - The OAWP is reporting accountability and disclosures 
on their website. \2\ The accountability report (adverse actions) 
details demotions, suspensions and terminations while the disclosure 
report identifies the types of whistleblower reports made. However, 
almost half of those contacting the office were not found to be 
whistleblowers. This data point is concerning because it either means 
that employees are not being educated in accordance with the NO FEAR 
Act or whistleblowers are being unjustly denied. There is also a lack 
of data on how they are being assisted as described by the WoA 
respondents. The OAWP needs to open the aperture on how it is defining 
its whistleblower terms and capturing retaliation (in its many forms) 
and be able to account for the assistance provided. It should denote 
how many of the adverse actions they took involved any whistleblowers 
and who were veterans.
---------------------------------------------------------------------------
    \2\ https://www.va.gov/accountability/
---------------------------------------------------------------------------
    There is also very limited accountability for when the OIG makes 
recommendations related to disclosures. Those should be better tracked 
and reported. There are no mandates to implement an OIG recommendation. 
Those can literally, ``sit on the shelf.'' Only the OSC can mandate any 
corrective action and rarely do they because they do not have the 
resources to take cases to that level of litigation and the MSPB has 
not had a full panel of judges to hear cases in years. According to 
OSC, about 40% of its cases are VA, so an improved internal VA process 
could alleviate this burden and increase effectiveness for all federal 
employees. Respondents demonstrate their reliance on OIG and OSC 
investigations to support them. Furthermore, managers who were guilty 
of the wrongdoing or the retaliation are not held accountable - rarely 
are they even identified by the OIG. Most of the time, the OIG 
recommendation is for ``further training.'' There should be serious 
penalties for retaliation (fines, demotions, loss of retired pay, etc) 
to discourage the tactics related to it. Congress could create a fund 
that requires those identified as engaging in retaliation to contribute 
fines. Whistleblowers who must defend themselves against retaliation 
are out-of-pocket - sometimes upward of $100,000 while the wrongdoer is 
defended by the government, which wastes taxpayer money for veterans. 
This is antithetical to common sense, so this fund could be used to 
offset those costs by being used to retain private sector attorneys 
chosen by the whistleblower (similar to a risk pool created for 
insurance coverage) and reduce the burden on the taxpayer when damages 
are awarded. Plus, the lack of serious accountability furthers a 
corporate culture that allows retaliation to fester.

Suggested Next Steps:

    1.Host a roundtable with whistleblowers to hear firsthand about 
retaliation at VA and the career impacts it has had.

    2.Conduct a hearing on Whistleblower Retaliation and the 
effectiveness of the OAWP

    3.Draft legislative requirements for staffing (government and 
independent) and performance measures (to include timeliness and 
process outcomes) as described above

Background:

    WoA contacted 22 current and former VA employees for their feedback 
and insights into retaliation at the VA and the effectiveness of OAWP. 
Responses came from 13 current and former staff (some who are also 
veterans) at VA Central Office, the VA Medical Centers and the VA 
Regional Offices from around the country. They are medical doctors and 
other clinical providers, claims representatives, lawyers, law 
enforcement officers, contracting experts and senior officials. We are 
particularly concerned about disabled veterans who are hired and then 
terminated during their probationary period, especially after asking 
for reasonable accommodations.
    The following questions were sent out and their answers are 
imbedded below:

What did you ask OAWP to do on your behalf?

      My case was presented to OAWP for review because I was 
being retaliated against for disclosing fraud, waste, abuse and 
substandard care. My law firm on my behalf, requested OAWP to assist 
with getting the VA to immediately cease and desist reprisal against 
me. After my case was presented to OAWP, the retaliation intensified 
and became more frequent.
      I was removed in 2014. I think (co-worker \3\) had me 
talk to Brandon (OAWP staff) \4\ for some whistleblower Dept in VA that 
was new and supposedly for whistleblowers. I called him. Spoke more 
than once. He had me submit a form \5\ and then some. I tried to follow 
up a couple of times. I never heard back from him.
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    \3\ Parenthesis and italics denotes a person was named that is not 
a known VA senior official, so their identities are protected.
    \4\ Brandon Coleman was the addiction counselor at the VAMC in 
Phoenix who made headlines with his whistleblower retaliation case and 
was subsequently awarded a high-level position at VACO with the OAWP. 
Because of his notoriety, many VA whistleblowers reach out to him 
looking for help.
    \5\ VA Form 10177
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      They conducted a full board investigation of me in June 
2017 due to an anonymous complaint sent to OIG in 2015. Why it was sat 
on for 2 years is a mystery to all. Board ruled the complaint was not 
substantiated. However, they never closed the case with OIG though so 
I'm still under law enforcement review until they close it. We have 
members of Congress tying to help. OIG says 10N still has the same open 
complaint, but they haven't heard from them. I requested documents from 
OAWP to which the guy called me to complain and amend. I did. No 
response. FOIA appeal. No response. Requested new FOIA based on 
additional info. They haven't read it. Will file another FOIA appeal.
      I specifically asked the OAWP to investigate my loss of 
employment and to review my evidence the VA OIG refused to investigate 
on failed temperature monitoring systems at the Denver VA facility. I 
was the Manager since June 28, 2012. The only contact I ever received 
was from Mr. Brandon Coleman. Mr. Coleman informed me that Mr. Peter 
O'Rourke had received all of my information and that they (OAWP) would 
soon be contacting me. OAWP never requested any of my evidence. I even 
CC'd Dr. Shulkin, OIG Director Mr. Michael Missal, (private consultant) 
and sent letters of concern to the White House. Never once have I ever 
received a response. I even attempted to report the ``Double Billing of 
Windows Operating Systems'' VA purchases from Dell corporation. Nothing 
was done nor was I ever contacted. I can prove this is taking place in 
less than 10 minutes. This is literally hundreds of millions of dollars 
of waste taking place each and every year. These includes fabrications 
that VA Leadership provided to the OIG to cover up the abandonment of 
the VA Research facility that resulted in the dismantlement of my 
Management Position and our local research activities to the Academic 
Affiliate (3 HVAC hearing have been held on this topic). Evidence that 
supports a much greater level of corruption that the Denver VA has 
successfully been allowed to subvert and cover up. The reason I lost my 
job.
      Investigate the issue I reported of management cancelling 
Veteran orders for radiologic exams, fix the problem and protect me 
from reprisal.
      1. Give me unredacted audits (disclosures) of everyone 
who has accessed &/or queried my C-file, 2. make veterans a watchdog 
over the C-file by releasing unredacted audits whenever requested and 
immediately when requested, 3. make reporting privacy violations easy 
and efficient, 4. make those accountable for violating existing laws
      The Salt Lake City Fiduciary regarding elder abuse, I 
informed them that the SLC fiduciary hub was not helping (a veteran) 
who is being financially abused, and that VA officials gave the abuser 
permission to sell his home against his wishes. They said there was 
nothing that they could do except send a message to have SLC look into 
it.
      Investigate misconduct and intervene in retaliation. I 
filed two separate complaints in August 2017, and again in April 2018.
      Investigate misuse of funds by RO senior officials.
      I reached out to three arms of that office. HR and 
Brandon Coleman. He was useless. I am so dissatisfied and disappointed.
      On August 30, 2017; I submitted per their request an 
email with my recommendations to improve OAWP. This email was addressed 
to the [email protected]. Please be advised that at the time 
this email distribution was sent to everyone associated with the OAWP, 
which included every one of the former employees of OAR \6\. After 
waiting for Brendan Coleman to get settled in to his new position at 
OAWP, I submitted my Disclosure to him in his formal capacity as a OAWP 
employee. In summary, I asked them to look into the retaliation against 
me, allow me to detailed to another facility, request that OIG or OAWP 
look into the perjurious statements & manufactured documents made 
against me in order to obstruct any legitimate investigation, request 
that any denial of my request that justification be provided by Medical 
Center Director or higher, And since I had been detailed with nothing 
to do for 6 months pending the outcome of Northern Indiana's fact 
finding investigation, that OIG or OAWP conduct an investigation into 
criminal misconduct by management officials for wasting VA resources & 
taxpayer's monies based on allegations that they couldn't even prove.
---------------------------------------------------------------------------
    \6\ Office of Accountability Review
---------------------------------------------------------------------------
      I didn't go to OAWP. I went to EEO and MSPB. I was 
retaliated against and terminated by the VA in May '15 for reporting 
medication mishandling, sterile protocol breaches in surgery (surgeon 
operating while bleeding), failure to chart medications in the patient 
EMR, failure to encrypt sensitive patient data for  5 months, gender 
harassment & discrimination, and a hostile workplace (to name a few) 
all by the same physician/surgeon, which escalated into a smear 
campaign to retaliate against me by administrators. I was stalked and 
devastated financially. My family has been pushed to the brink. I am 
unemployed currently and just certified to work in the field of 
addiction medicine and aspire to help mitigate the opioid crisis. Still 
paying the price for speaking up.
      I have had no relief of whistle blower retaliation. I 
asked for them to hold those accountable. They assigned an inhouse 
investigator to gather some of my documents. I was not allowed to give 
him all the documents proving whistleblower retaliation due to being 
arrested \7\. I've been barred from the Cincinnati VAMC and several 
surrounding VA medical center's. I'm unable to get medical care due to 
the whistleblower retaliation. My only concern is that I have an 11-
month-old child and one on the way.
---------------------------------------------------------------------------
    \7\ I have contacted DepSec Tom Bowman about this case and Brendan 
Coleman. VA has charged him with ``harassment and menacing behavior'' 
after he filed EEOC complaint. He is an OIF disabled Marine Veteran. I 
contacted the Veterans Treatment Court, who are supporting him. VA 
continues to work on a reassignment for him while still holding charges 
against him. I've met with Rep. Brad Wenstrup staff on this case.
---------------------------------------------------------------------------
      I asked for assistance from the retaliation to stop and 
help to reassign for an investigation.

Did they help you?

      NO!
      The results of all my work with them was nothing. No one 
got back to me. No one.
      No Response
      I had a private conversation with Peter (O'Rourke) when 
he first arrived. Offered help with PR and strategic positioning to 
help develop the office further. Offered to assist on detail. Never 
heard back. We had a joint call with several WBs and Peter. He said 
they'd follow up. Never heard back.
      I have contacted the OAWP on repeated occasions since 
August 4, 2017. Never, not once have I received any correspondence. 
These including overlapping Whistleblower evidence that the VA OIG has 
since substantiated to be true. Substantiated evidence that I have 
further attempted to report to the OAWP.
      Not one bit. They have done nothing whatsoever.
      NO
      Never heard back on the privacy issue requests
      They said they could not in fiduciary cases, even when 
there is suspected foul play of government officials at the hub.
      No, they have taken no perceivable action.
      No, closed my case with no finding when I gave them ample 
evidence to have a huge finding related to $1.5 million in payoffs even 
though we already had a member of the region counsel confirm our 
allegations. It's a fake office and then they leaked my name to Diana 
Rubens who then sent harassing emails. You go to them in confidence and 
they send what you reported to the person you reported.
      There is zero support or outreach to whistleblowers. If 
you go to them then you are targeted and attacked. I feel the office is 
not about accountability but firing/targeting the dissidents/
whistleblowers. Taxpayers are funding ``monster-like'' tactics with 
that office.
      On September 4, 2017; I was contacted by Brendan Coleman 
asking me to participate in a OAWP listening session conference call on 
September 13, 2017. The purpose was twofold, first for Mr. Peter 
O'Rourke to hear from me, along with others, what was going on in our 
individual retaliation cases. This call also included (Several Others). 
The second, was to give my chain of command notice that I had the 
interest of the OAWP and provide me a breather from the retaliation. On 
December 11, 2017; the Northern Indiana VA issued me a proposed removal 
along with over 1,500 pages of documents that were never seen before & 
I was given seven days to respond. My attorneys weren't provided copies 
of this voluminous `justification' until almost a week later. I was 
advised on or about December 14, 2017 by Brendan Coleman that the OAWP 
was going to put a `delay' on any action against me. The purpose of 
calling it a `delay' rather than a hold, is because of legal 
ramifications & to avoid publicity. Which honestly didn't make any 
sense. On January 22, 2018; I was offered a 120-day detail to the Puget 
Sound VA Health Care System to be the Chief of Facilities Management. I 
contacted the OAWP after the management at Northern Indiana VA refused 
to release me for the detail. I was contacted by Brendan Coleman and 
Peter O'Rourke to provide information regarding the detail. In summary, 
in the most general sense ``yes'' they did help me.
      I did receive an email from the OAWP. However, 
(Consultant) advised me not to respond and forewarned me that they are 
an unethical entity. Since I trust his legal advisement, I did not 
respond. I did not reach out to them first, so I do not know how they 
got information on my case nor do I know the status on their end.
      They said they called my HR and told them to reassign me. 
(That did not happen.)

How did they help you?

      Not applicable.
      They did not. They have done nothing.
      They have not.
      N/A
      In September 2017, they tried to put my chain of command 
on notice that OAWP was watching. I'm sure it had the effect we hoped. 
In December 2017, they did `delay' any adverse personnel actions 
against me. And in January 2018, I believe Peter O'Rourke tried to get 
the Northern Indiana VA to release me to go on the detail to Puget 
Sound.
      The retaliation never stopped and only continued to get 
worse and my case worker from OAWP said she was a HR employee being 
assigned to help with case part time. How can the HR's properly help 
when they are the ones helping to retaliate?

How long did it take for them to respond to you? (If at all)

      Months
      They have not, ever responded.
      I was contacted after my initial disclosure, after 
supplying the OAWP with over 1600 pages of documentation of both 
canceled orders and retaliation paperwork. I NEVER heard from them 
again.
      I received an email after contacting them several times 
that was cryptic. I contacted Brandon Coleman who emailed me a form 
that was supposed to have been given to me several months prior. No 
response after I submitted the whistleblower form.
      I received only initial acknowledgements that they 
received the information.
      Because I had a relationship with Brendan Coleman before 
he started at the OAWP, they were responsive in pumping the breaks on 
the proposed termination that took Northern Indiana almost a year of me 
doing nothing before handing me a giant box of manufactured nonsense.
      They never called me, and when I contact them, they just 
said 45 more days...and then I resigned for constructive discharge and 
I was assigned new case manager, but they didn't inform me, and the new 
CM said she couldn't find any data I sent in.

Did they close your case without sharing information with you?

      Yes. I routinely contacted OAWP one time per month for an 
update. It required a lot of time and effort to get them to respond. 
And even after they did respond, OAWP refused to tell me what, if 
anything, they had done for me. Since my employment was eventually 
terminated, obviously, OAWP did not help me at all.
      I never heard from any individual at the OAWP regarding 
any aspect of my reporting to the OAWP (let alone opening a case). I 
have copies of every correspondence with OAWP. No reply, no response.
      Yes, I have made several attempts to gather more 
information, but was told due to privacy issues they are unable to give 
me any information.
      I have no idea what they did.
      Unknown, although their template email response indicates 
they will not share information.
      They did close my case without informing me. I have no I 
idea what the OAWP is doing. The only information that I received that 
the VA was still investigating my claims was while listening to the NPR 
story about me on April 27, 2018.
      I have no idea what they have or have not done, they 
don't let me know and Brandon Coleman stopped answering me.

What would you suggest be done to improve the OAWP?

      Immediately close the office. Please note, I did not make 
that comment to try and be funny. Whistleblowers are under the 
impression that by contacting OAWP will help stop the retaliation. I'm 
unsure if there is one whistleblower who has submitted a claim to that 
office who has actually had the reprisal stopped. In fact, the 
contrary. It appears as if VA prefers whistleblowers to report to OAWP 
as opposed to OSC. Furthermore, the VA is utilizing the office to 
collect information about whistleblowers, so the agency can use the 
shared information against the whistleblower. Whistleblowers would be 
better off if OAWP did not exist because it gives whistleblowers a 
false sense of security where none exists. And obviously, it wastes 
taxpayers' money because OAWP is ineffective.
      Feedback is...needs major work.
      Waste of resources in my opinion and likely more of the 
David Shulkin show. He did nothing except create shiny new things to 
brag about to the media.
      Respond to the Whistleblowers. Not ``Stone walling'' as 
VA does best.
      As far as I'm concerned, the OAWP is yet another 
``Whitewash machine'' that the VA has successfully constructed as a 
``False Accounting'' system the does not exist. I hope to talk 
Congressman Jeff Miller soon as he may become our new VA Secretary. He 
will get the OAWP working as intended.
      My view of the process and the concept does of course 
come with an understanding that they are a startup organization that 
may be struggling to find identity. They cannot organizationally depend 
on the Office of General Counsel (OGC) for legal. OGC is tasked with 
protecting the agency and defending it in litigation, therefore it is a 
conflict. They cannot be transparent with that relationship. I have 
looked at job postings for OAWP. They hire for job series 0201, Human 
Resource Specialist. That job series shouldn't be the occupational 
series for the Investigators in OAWP. Any qualified candidates under 
the 0201 series will qualify based on HR experience, not necessarily 
investigative technique skills.
      Find a different group to manage them. An HONEST group.
      Improve communication and actually do something.
      The office needs to purge the corrupt investigators that 
came from the OAR. I am one of numerous VA employees that have gotten 
copies of their reports only after the court forced the issue and found 
that the OAWP had intentionally ignored exculpatory evidence to provide 
findings that were favorable to the VA as cover in case news reporters 
started asking questions.
      Don't use VA employees for case workers and just shut 
down the VA all together. Give Whistle Blowers other Federal Jobs to be 
able to have our retirement. I'm a 10 year AF veteran and lost my 20 
year retirement by 5 years. No one will hire me in social work or any 
other field.

Did another entity act when the OAWP did not?

      OSC completed one investigation and ruled in my favor.
      OIG has been trying to help. And has responded timely to 
FOIA. GAP is reviewing my case for my defense.
      OSC is still investigating this issue.
      In all fairness, no one has helped me. VA OIG did not 
return communication and OSC wants me to develop my case, so we meet a 
threshold for them to ask for an investigation.
      VA OIG said they cannot help in fiduciary cases and 
referred me to OSC. I am acting as a family member to a veteran in this 
instance not as an employee. The Justice Department refers people to VA 
OIG on elder abuse fiduciary cases, but VA OIG refers to OSC or back to 
the hub.
      I am engaged with OSC for the issues I want to see 
corrected that affect care.
      I honestly believe that OIG Special Agent did try to help 
me. Unfortunately, because of how the rules are, only OSC can help me. 
After intense lobby by Tom Devine at GAP, the OSC reopened the 
investigation into my case. However, the Northern Indiana VA and the 
OGC Midwest Region keep delaying providing supporting documentation in 
order to move the investigation along. I do want to say that the OGC is 
as corrupt as the rest of the VA. The misconduct and obstruction by VA 
attorneys is criminal.
      I went all the way up the chain and OIG report, and not 
one agency or person was able to help at all. Not even EEO at the VISN 
level and higher. I continue to be retaliated against.

    Thank you for considering this information.

                                 [all]