[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]


                    CRITICAL IMPACT: HOW BARRIERS TO
                  HIRING AT VA AFFECT PATIENT CARE AND
                                 ACCESS

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS

                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                     WEDNESDAY, SEPTEMBER 18, 2019

                               __________

                           Serial No. 116-33

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]       


                    Available via http://govinfo.gov
                    
                             __________

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
40-891                     WASHINGTON : 2022                     
          
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                     COMMITTEE ON VETERANS' AFFAIRS

                   MARK TAKANO, California, Chairman

JULIA BROWNLEY, California           DAVID P. ROE, Tennessee, Ranking 
KATHLEEN M. RICE, New York               Member
CONOR LAMB, Pennsylvania, Vice-      GUS M. BILIRAKIS, Florida
    Chairman                         AUMUA AMATA COLEMAN RADEWAGEN, 
MIKE LEVIN, California                   American Samoa
MAX ROSE, New York                   MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire          NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia            JACK BERGMAN, Michigan
SUSIE LEE, Nevada                    JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina       ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR.,           DANIEL MEUSER, Pennsylvania
    California                       STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota        CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN,      W. GREGORY STEUBE, Florida
    Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York

                 Ray Kelley, Democratic Staff Director
                 Jon Towers, Republican Staff Director

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                         
                         
                         C  O  N  T  E  N  T  S

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                     WEDNESDAY, SEPTEMBER 18, 2019

                                                                   Page

                           OPENING STATEMENTS

Honorable Mark Takano, Chairman..................................     1
Honorable David P. Roe, Ranking Member...........................     3
Honorable Neal P. Dunn...........................................    11
Honorable Julia Brownley.........................................    13
Honorable W. Gregory Steube......................................    14
Honorable Elaine G. Luria........................................    16
Honorable Jim Banks..............................................    18
Honorable Susie Lee..............................................    19
Honorable Steve Watkins..........................................    21
Honorable Kathleen M. Rice.......................................    22
Honorable Gregorio Kilili Camacho Sablan.........................    24
Honorable Conor Lamb.............................................    26
Honorable Gilbert Ray Cisneros, Jr...............................    28

                               WITNESSES

Mr. Daniel R. Sitterly, Assistant Secretary, Office of Human 
  Resources and Administration/Operations Security, and 
  Preparedness, U.S. Department of Veterans Affairs..............     5

        Accompanied by:

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

    Mr. John D. Oswalt, Deputy Chief Information Officer for 
        Information Technology Resource Management, Office of 
        Information and Technology, U.S. Department of Veterans 
        Affairs

The Honorable Michael Missal, Inspector General, VA Office of 
  Inspector General, U.S. Department of Veterans Affairs.........     7
Mr. Robert Goldenkoff, Director, Strategic Issues, U.S. Goverment 
  Accountability Office..........................................     8

                                APPENDIX
                     Prepared Statements of Witness

Mr. Daniel R. Sitterly Prepared Statement........................    35
The Honorable Michael Missal Prepared Statement..................    40
Mr. Robert Goldenkoff Prepared Statement.........................    48

                       Submission For The Record

The American Federation of Government Employees, AFL-CIO.........    65
Ms. Thelma Roach-Serry, President, Nurses Organization of 
  Veterans Affairs (NOVA)........................................    67
Ms. Kathryn Jansky, President, American Association of Nurse 
  Anesthetists (AANA)............................................    69

                   Question And Answer For The Record

Government Accountability Office (GAO)Responses to Questions for 
  the Record.....................................................    76

 
                    CRITICAL IMPACT: HOW BARRIERS TO
                  HIRING AT VA AFFECT PATIENT CARE AND
                                 ACCESS

                              ----------                              


                     WEDNESDAY, SEPTEMBER 18, 2019

                     Committee on Veterans' Affairs
                                   House of Representatives
                                                    Washington, DC.

    The committee met, pursuant to notice, at 2:13 p.m., in 
room 210, House Visitors Center, Hon. Mark Takano (chairman of 
the committee) presiding.
    Present: Representatives Takano, Brownley, Rice, Lamb, 
Levin, Brindisi, Pappas, Luria, Lee, Cunningham, Cisneros, 
Peterson, Sablan, Allred, Underwood, Roe, Bilirakis, Bost, 
Dunn, Banks, Watkins, Roy, and Steube.

           OPENING STATEMENT OF MARK TAKANO, CHAIRMAN

    The Chairman. Good afternoon. I now call the hearing to 
order. Today's hearing will be the first of several discussions 
this committee and its subcommittees will hold on how the 
Department of Veterans Affairs is addressing long-standing 
staffing challenges.
    Data reported last month indicates that there were more 
than 49,000 vacant positions across VA. Forty nine thousand, 
that is an astounding number, but there is more to it than just 
a number. And I want to look behind that number and understand 
what that number really means and how staff vacancies impact 
VA's ability to meet its mission.
    I am concerned that, if VA's vacancy rate continues to 
balloon unchecked, we will have no choice but to continue to 
send increasing numbers of veterans into the community for 
care, and community providers aren't ready to care for 
increasing numbers of veterans, according to a Rand Corporation 
study last year.
    This is the wrong path for VA and it is most assuredly the 
wrong path for veterans.
    First, we need to understand the scope of VA's staffing 
challenges. The MISSION Act required VA to report quarterly 
data on staffing and vacancies; however, VA's Office of 
Inspector General has found numerous problems with how VA 
reported those numbers over the first year. VA's data 
overstated the number of vacant positions for some medical 
facilities by as much as 20 percent and understated vacancies 
at other facilities by as much as 8 percent.
    Instead of reporting vacancies by occupation, as the law 
required, VA published its vacancy data as occupational groups.
    Finally, VA only posted the most recent quarter's data on 
its public face and website.
    We still have no idea where the critical needs really were 
or whether VA has made progress in filling critical vacancies. 
I am told that VA has attempted to correct these deficiencies 
since the IG published its report.
    Now, second, we also need to know what actions VA has taken 
to address long-standing staffing challenges and the extent to 
which VA has made full use of numerous new authorities Congress 
authorized in recent years. VA was given direct-hire authority 
to be able to bring on staff in areas of greatest need; 
however, data shows that VA is not using this authority to the 
fullest extent. For instance, in 2018, VA only hired 38 police 
officers under direct-hire authority, a rate far below than the 
pace of attrition. We need to understand why VA is struggling 
to use this and other tools Congress has provided.
    Now, third, while there is always concern with shortages 
among clinical staff, the ability to meet the highest standard 
of care to our veterans relies on more than just having the 
right number of physicians, nurses, and pharmacists. We also 
need qualified and well-trained housekeepers, IT technicians, 
human resources staff, and all of the other occupations that 
help VA achieve its mission of delivering high-quality and 
timely care.
    There are numerous identified barriers and challenges 
associated with hiring and retaining these staff, but we also 
need to hold VA accountable for identifying and implementing 
solutions. It is not enough to say that something is a barrier; 
we need to understand the extent of the problem, as well as 
develop an actionable and accountable plan to fix it.
    Fourth, leadership and governance in human capital has been 
a challenge. This is a common refrain in much of VA's 
operations. There has been a string of acting and interim 
leadership responsible for managing human capital for VA and 
the Veterans Health Administration since 2016.
    Now, I am very pleased to have Mr. Sitterly and Ms. 
Bonjorni here today. Welcome. I hope that VA will take the 
opportunity to address some long-standing recommendations from 
the IG and the Government Accountability Office. As we all 
know, it is hard to institute change when no one is responsible 
and no one is accountable.
    Fifth, there are thousands of dedicated VA employees doing 
their best every day to ensure that veterans have a positive 
experience and that they get the very best care and resources. 
I have had the privilege of meeting with some of these 
dedicated public servants and I thank them for all that they 
do.
    I also know that these same staff are overwhelmed and, 
while they have done more with less, at some point less is not 
enough. VA's mission also means doing the very best for its 
employees. GAO has reported on the need for training, 
performance management, and other improvements to ensure that 
VA can retain a highly qualified workforce.
    I hope to hear about progress on the recommendations from 
today's witnesses and what VA is doing to increase morale in 
the Department.
    Sixth, it is the concerning effects these vacancies have on 
the success or failure of billions of dollars' worth of 
technology modernization projects at VA. These projects have 
the potential to improve health care and benefits delivery, but 
they will also have major impacts on staff productivity. Those 
impacts will likely be more acutely felt at VA's facilities and 
in programs that are already understaffed. This is a particular 
concern for the Electronic Health Record Modernization project, 
as front-line staff members will have to be peeled away to 
complete countless hours of training, and some staff members 
will be removed from service for a month or more to act as 
super-users to help train and support other staff.
    Now, these are essential activities, but there are 
questions about how VA will be able to manage these complex IT 
implementations and training, and yet still meet its primary 
mission while not being fully staffed. There needs to be 
greater transparency into VA's staffing plan for these IT 
programs and I hope to hear about that today.
    It is my hope over the course of this hearing to gain a 
better understand of progress that has been made, barriers that 
remain, and what VA proposes to do next.
    Further, if VA really needs additional tools to address 
these challenges, I hope you will speak up. Please tell us if 
you need more resources.
    These challenges are not insurmountable. The committee is 
here to work with VA as a partner to ensure VA can meet these 
challenges now and in the future. To do that, we need 
transparency from VA, so we can have an open and honest dialog 
about the resource needs of the Department and how VA intends 
to use those resources to provide the highest level of service 
to our Nation's veterans.
    I thank the witnesses for being here and I look forward to 
their testimony.
    The Chairman. Dr. Roe, you are recognized for 5 minutes to 
give your opening statement.

       OPENING STATEMENT OF DAVID P. ROE, RANKING MEMBER

    Mr. Roe. Thank you, Mr. Chairman. And I think it was great 
that one of the constituents drove 2 and a half hours, but I 
have been in California traffic, that might not have been more 
than four or five miles.
    [Laughter.]
    Mr. Roe. They went through a great effort to get there.
    The Chairman. Yes, they did.
    Mr. Roe. One of the committee's longstanding priorities has 
been addressing recruitment and retention across the Department 
of Veterans Affairs. We have acted many times over the last 
several years to help VA hire the staff that it needs to 
provide high-quality care and timely benefits for our Nation's 
veterans. Because of those efforts, there is good news to 
share.
    While many headlines have been written about the number of 
vacancies that exist within VA, VA's workforce has grown by 
approximately 2 to 5 percent every year for the last 5 years. 
In fact, VA has more than 100,000 additional employees than 
when I came to Congress just a decade ago.
    In that time, VA has consistently maintained a turnover 
rate of about 9.5 percent or less, well outperforming both 
other large cabinet-level agencies, which average 11 percent 
turnover rate, and the private sector health care industry, 
which averages a turnover rate between 20 and 30 percent. Since 
the 2014 access and accountability crisis, VA has increased the 
number of annual appointments in VA facilities by a whopping 
five million visits. That leads to real-world consequences for 
veterans who rely on VA for care and benefits that they need to 
support themselves and their families; consequences such as 
better access to care, better patient satisfaction scores, 
quality ratings, and less time waiting for appointments, for 
disability claims to be processed and for appears to be heard.
    We should all be proud of those statistics; however, 
serious recruitment and retention challenges remain for the 
Department. The Association of American Medical Colleges 
projects that the United States will have a shortfall of more 
than 120,000 physicians by 2030. Given the approximately 90 
percent of VA's workforce is aligned under the Veterans Health 
Administration in support of the VA health care system, that 
will undoubtedly have significant consequences for VA, coupled 
with the numerous complexities inherent in VA's multiple and 
often-contradictory hiring authorities, and the burdensome and 
outdated Federal hiring practices that VA must abide by.
    That means that we must remain vigilant about helping VA to 
improve its ability to efficiently and effectively recruit and 
retain top-notch talent to serve our veterans. That includes 
continuing to provide the Department with the additional 
authorities it needs to attract prospective employees in an 
increasingly competitive labor market and to keep the 
hardworking employees already at their jobs at VA.
    It also means ensuring that VA utilizes the authorities 
that have been given to them to their fullest extent, as the 
chairman mentioned, which is something I would like to discuss 
in more detail today, to address its needs and fill gaps in 
care and services. It further includes touting not only the 
problems that VA is facing, but also the many benefits that are 
part of a VA career, the most important of which is the honor 
and privilege of caring for the men and women who have served.
    As chairman and now ranking member of this committee, I 
have had the unique pleasure of traveling across the country, 
from Long Island to Los Angeles and many points in between, to 
visit VA facilities and meet with veterans. While poor-
performing and outliers certainly exist, and they should be 
held accountable, they are being held accountability thanks to 
the passage of the Accountability and Whistleblower Protection 
Act last Congress. I have been impressed everywhere I go by the 
professionalism and the dedication of the vast majority of VA 
workforce, many of whom are veterans themselves. And I want to 
end my comments this afternoon by thanking all of them for the 
good work they do and the valuable services they provide for 
our heroes.
    I look forward to our discussion this afternoon. I thank 
the witnesses and the audience members for being here.
    With that, Mr. Chairman, I yield back.
    The Chairman. Thank you, Dr. Roe.
    Now I would like to welcome the witnesses on our first 
panel, first and only panel. First we have Dr. Daniel R. 
Sitterly, Assistant Secretary for Human Resources and 
Administration/Operations, Security, and Preparedness, from the 
U.S. Department of Veterans Affairs. Welcome, Dr. Sitterly.
    Accompanied by Ms. Jessica Bonjorni, Acting Assistant 
Deputy Under Secretary for Health for Workforce Service, also 
for the Veterans Health Administration. Welcome, Ms. Bonjorni.
    We also have with us Mr. John D. Oswalt, Deputy Chief 
Information Officer for Information Technology Resources 
Management from Veterans Admimistration.
    We also have with us Mr. Michael Missal, Inspector General, 
VA Office of Inspector General. Welcome, General Missal.
    We have, finally, Mr. Robert Goldenkoff, Director of 
Strategic Issues, the U.S. Government Accountability Office. 
Welcome, Mr. Goldenkoff.
    We will begin with Mr. Sitterly. I will recognize you for 5 
minutes for your opening statement.

                STATEMENT OF DANIEL R. SITTERLY

    Mr. Sitterly. Thank you, Mr. Chairman. I probably shouldn't 
start my comments correcting the chairman, but I am not a 
doctor. I admire all of the doctors in the VA that do great 
work. Mister is fine. Thank you, sir.
    The Chairman. My apologies.
    Mr. Sitterly. That is quite all right, sir.
    The Chairman. Mr. Sitterly.
    Mr. Sitterly. Yes. Chairman Takano, Ranking Member Roe, and 
members of the committee, thank you for the opportunity to 
discuss the Department of Veterans Affairs' views on ways to 
modernize and the hiring process, and also to retain our 
ability to be a competitive employer in the health care and 
information technology industries.
    As a 34-year veteran of the United States Air Force myself, 
I have both a personal and a professional interest in ensuring 
we get this right at the VA. And today just happens to be the 
72nd birthday of the United States Air Force, so happy 
birthday, U.S. Air Force.
    As the operator of the largest integrated health care 
delivery system in America, the VA successfully attracts and 
retains high-quality talent, and VA's overall workforce 
continues to grow. This growth, 81 percent in clinical 
occupations, directly responds to an increased demand for 
services based on improved access to care, reduced wait times, 
improved quality, enhanced veterans' satisfaction, and overall 
mission growth. VA appreciates the work Congress has done to 
provide the flexibilities to support the recruitment and the 
retention of talent to care for our Nation's veterans.
    That said, VA still contends with challenges presented by 
the complexities of multiple pay and personnel authorities. As 
health care demand has increased and shortages of health care 
and IT workers grow, private sector employers are quick to 
adjust to the changes in local labor markets, and modify 
starting salaries and total compensation packages to attract 
top talent. While VA recruits employees and applicants who are 
willing to accept lower compensation to be part of an 
organization with such a noble mission, VA faces challenges in 
our ability to attract and then to retain quality health care 
and information technology professionals.
    Despite challenges, VA employs a variety of tools to 
attract and retain quality talent. Those tools include a 
powerful mission of service to veterans and their families, a 
robust training pipeline for the majority of our Nation's 
physicians, strong employee engagement, direct-hiring 
authorities, as you mentioned, and strategic workforce planning 
for hard-to-fill occupations and medical center directors. VA 
strategically allocates monetary incentives to close skill gaps 
and to provide greater flexibility in the recruitment, 
relocation, and retention of highly qualified VA professionals. 
In Fiscal Year 2018, VA spent more than $50 million on these 
incentives.
    VA has also joined efforts with the Department of Defense 
to recruit transitioning servicemembers. We launched a direct 
marketing campaign to target medical professions in the 
military and IT professionals currently transitioning out of 
the military. VA has also partnered with the Department of 
Defense to hire military spouses through the Military Spouse 
Employment Partnership. We made significant progress in filling 
senior medical center director positions through a vigorous 
national recruitment strategy.
    Outcomes show that the VA is on the right track. Veterans 
are receiving the same or better care at VA medical centers 
than patients at private sector hospitals. For instance, 
veterans who are admitted for heart attacks, severe chronic 
lung disease, heart failure, and pneumonia have a greater 
chance of survival beyond 30 days after discharge from a VA 
hospital than non-VA hospitals.
    According to a study in the Journal of American Medical 
Association, VA average wait times are shorter than those in 
the private sector for primary care. VA reached a telehealth 
milestone, achieving more than one million video telehealth 
visits last year.
    Just this week, J.D. Power ranked the VA number 1 in the 
Nation for customer service satisfaction for mail order 
pharmacies. At the same time, almost 90 percent of the 3.3 
million veterans surveyed said they trust VA outpatient medical 
services.
    As one of the top 10 large Federal agencies, VA continues 
to enhance employee engagement. In April, the Secretary 
approved VA's first-ever employee engagement enterprise-wide 
plan, which emphasizes the principles of servant leadership. As 
I like to say, happy, engaged, empowered, innovative employees 
make for a positive veteran experience, and it also helps 
mightily with retention.
    We appreciate Congress' continued support to a high-quality 
workforce that provides the best possible care and benefits to 
veterans.
    The competition for talent in the health care and IT 
industries is increasingly competitive. Shortages abound around 
the Nation for both physicians and nurses, and they are 
projected to increase, and competition for IT talent is tight. 
Private hospitals use innovative and progressive solutions to 
address recruitment and retention challenges, and we in the VA 
must be creative in our approach to human capital. We want to 
be leaders or be very fast followers of the best human capital 
practices in the Federal Government and in the health care and 
IT space.
    We look forward to working with this committee on 
opportunities to enhance VA's ability to attract top talent. My 
colleagues and I are prepared to respond to any questions you 
may have.
    Thank you.

    [The Prepared Statement Of Daniel R. Sitterly Appears In 
The Appendix]

    The Chairman. Thank you, Mr. Sitterly.
    Now I would like to recognize our Inspector General, Mr. 
Missal.

                  STATEMENT OF MICHAEL MISSAL

    Mr. Missal. Thank you. Chairman Takano, Ranking Member Roe, 
and members of the committee, I appreciate the opportunity to 
discuss the Office of Inspector General's oversight of staffing 
issues with the Veterans Health Administration. In response to 
our congressional mandate, the OIG has examined and reported on 
staffing issues with VHA for the past 4 consecutive years. Our 
2019 report is expected to be released by September 30th.
    We also encounter staffing issues in connection with other 
work we conduct of VHA programs and processes. We have issued a 
number of reports with examples of areas where staffing 
shortages impacted the delivery of care, including at the Loma 
Linda, Memphis, and Northport Medical Centers. Although VHA has 
made some improvements, it continues to face a number of 
challenges in addressing its significant staffing needs. VA has 
experienced chronic health care professional shortages since at 
least 2015. The Department must enhance its ability to maintain 
a robust workforce in an increasingly competitive recruitment 
environment and with anticipated health care worker shortages 
in several practice areas. VA health care remains in sharp 
demand even as community care options are expanded.
    Since January 2015, the OIG has reported on VHA clinical 
staffing shortages as required by the 2014 Choice Act. Our 2018 
report was the first report that included facility-specific 
data reported by leaders at 140 VA medical centers. It was also 
the first report to include non-clinical positions, such as 
human resources, police, and custodial personnel. These non-
clinical occupations affect the ability of VHA facilities to 
provide quality and timely patient care in a safe and clean 
environment.
    The facility-specific results underscore how different the 
clinical and non-clinical needs are from one medical facility 
to another. We have therefore consistently recommended that VA 
develop and implement a staffing model that identifies and 
prioritizes staffing needs at the national level, while 
allowing flexibility at the facility level.
    The data in our 2018 report showed that 138 of the 140 
facilities listed the medical officer occupational series as 
experiencing a shortage, with psychiatry and primary care 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.
    Within non-clinical occupations, we found that human 
resources management and police occupations were among the most 
often cited as shortages. Our 2019 staffing report will have 
similar findings.
    Challenges to meeting staffing goals were also identified 
in our 2018 staffing report. Responses from medical center 
directors identified three frequently cited hiring challenges: 
first, lack of qualified applicants; second, non-competitive 
salaries; and, third, high staff turnover.
    Last year's MISSION Act created a mandate for VA to report 
annually on the steps taken to achieve full staffing capacity 
and any additional funds needed to achieve that mark. It also 
required VA to publish staffing and vacancy information, and 
update that information quarterly.
    The MISSION Act directed the OIG to report on how VA can 
improve its publication of this data. The first required OIG 
report found VA to be in partial compliance with MISSION Act 
Section 505's requirements.
    Generally, the OIG found that VA reported its current 
personnel levels and time-to-hire data as prescribed. However, 
staff vacancies were tracked in categories that were too broad 
to be meaningful and gains and losses were not tracked 
according to the law. OIG staff also found the information to 
not be transparent, because VA did not disclose that medical 
facility vacancy numbers were overstated.
    The OIG has made oversight of VA leadership and workforce 
management a priority. Although VA has taken important steps, 
for sustained improvement additional fundamental changes are 
needed.
    Mr. Chairman, this concludes my statement. I am happy to 
answer any questions that you or other members of the committee 
may have.

    [The Prepared Statement Of Michael Missal Appears In The 
Appendix]

    The Chairman. Thank you, Inspector General Missal.
    I now recognize Mr. Goldenkoff from the GAO for 5 minutes.

                 STATEMENT OF ROBERT GOLDENKOFF

    Mr. Goldenkoff. Thank you. Chairman Takano, Ranking Member 
Roe, and members of the committee, thank you for the 
opportunity to participate in today's hearing on VA's ability 
to recruit and retain a high-performing workforce.
    As you know, VA operates one of the largest health care 
delivery systems in the Nation, and provides billions of 
dollars in benefits and services to veterans and their 
families. As a result, a top-notch workforce is crucial to VA's 
mission. Nevertheless, over the past two decades, we and others 
have found that VA and its components face serious and long-
standing human capital management challenges that are impeding 
its ability to meet the needs of our Nation's veterans.
    In my remarks today, I will focus first on the various 
human capital management challenges facing VA and its 
components; second, the recommendations that GAO has made to 
address those challenges; and, third, how these challenges are 
related to a broader set of Government-wide human capital 
problems that need to be addressed.
    The bottom line is that while both VA-specific and 
Government-wide human capital issues are hampering VA from 
acquiring and retaining the talent it needs to fulfill its 
mission, VA can take and in some cases is already taking a 
number of steps to strengthen its human capital management 
efforts.
    With respect to VA staffing challenges, we have found them 
to be systemic, long-standing, and harmful to VA's mission. For 
example, in May 2019, we reported that leadership turnover 
impeded VA's ability to address a number of operational issues 
that we identified such as managing acquisitions, managing 
risk, and improving veterans' health care.
    Additionally, we found that VHA's medical centers have 
large staffing shortages in such positions as physicians, 
registered nurses, physician assistants, psychologists, 
physical therapists, as well as human resource specialists and 
assistants.
    And while effective succession planning can help VA ensure 
it has a pipeline of talent to meet current and future mission 
requirements, in a forthcoming report we will note that VA has 
not produced a Department-wide succession plan since 2009 due 
to leadership turnover. This could be particularly problematic 
as agency-wide around 30 percent of VA employees who were on 
board as of September 30th, 2017 will become eligible to retire 
by 2022.
    Of the hundreds of recommendations that GAO has made over 
the years aimed at improving the performance and accountability 
of VA, beginning in 2012, we designated 40 of these 
recommendations as priorities. Twelve of the recommendations 
are aimed at strengthening VA's human capital management 
efforts. To date, VA has addressed six of the recommendations, 
but still needs to take action on the others, such as 
developing a process to accurately count all physicians 
providing care at VA medical centers and developing a modern 
and effective performance management system.
    Beyond these specific recommendations, VA can use key 
talent management strategies that we identified for acquiring, 
incentivizing, and engaging employees, and thus be more 
competitive in a tight labor market.
    As one example, while Federal agencies may struggle to 
offer competitive pay in certain labor markets, they can 
leverage existing incentives that appeal to a worker's desire 
for schedules and locations that provide work-life balance. 
Likewise, improved performance management, professional 
development opportunities, and involving employees in decisions 
that affect them could lead to higher levels of employee 
engagement and retention.
    Some of the challenges that VA is facing are part of a 
larger set of human capital issues affecting government as a 
whole. Structural issues impede the ability of agencies to 
recruit, retain, and develop workers, and these include 
outmoded position classification and pay systems, ineffective 
recruiting and hiring processes, and challenges in dealing with 
poor performers.
    In closing, while VA faces a number of staffing challenges, 
the future is not dismal, and there are a number of steps that 
VA can take within existing authorities and flexibilities to 
better address these challenges.
    Chairman Takano and Ranking Member Roe, I would be pleased 
to respond to any questions that you may have at this time.

    [The Prepared Statement Of Robert Goldenkoff Appears In The 
Appendix]

    The Chairman. Thank you, Mr. Goldenkoff.
    At this point, I will begin the questioning, recognizing 
myself for 5 minutes. I would like to begin with Mr. Sitterly 
and Ms. Bonjorni regarding housekeeping staff, recruiting and 
retention of housekeeping staff.
    This past June, the IG published a report that 
substantiated concerns I raised in early 2018 about facility 
cleanliness and infection control at the VA Loma Linda Health 
Care System. Low pay and staff turnover among housekeeping 
staff were among the root causes the IG identified as 
contributing to the lack of cleanliness inside the medical 
center. When I visited the facility in early July to followup 
on the IG recommendations, there were 45 vacant housekeeping 
positions out of the roughly 150 authorized positions.
    In March 2019, Loma Linda requested special pay rates for 
its housekeeping staff and I am told that these must be 
approved at the department level.
    What is the status of that request, if you have that 
information, and have you approved these special pay rates for 
housekeepers at Loma Linda?
    Mr. Sitterly. Mr. Chairman, let me start by answering the 
question, then I'll let Ms. Bonjorni address Loma Linda 
specifically. But one of the challenges that we have and we are 
working very closely with OPM is delegations of the authorities 
to allow us in the Department to make the changes for special 
salary rates and hiring re-employed annuitants in some of 
those. Right now, the position is that we have to go to OPM to 
provide the data on any occupational series, including 
housekeepers, to show that the local wages are not where they 
should be according to the pay tables that we use.
    Yes, we are working on that specific request for Loma Linda 
with OPM, but every time there is a rate change we have to go 
back and do that. And so, as I mentioned, we are working very 
closely with OPM and they are very receptive to giving us 
delegations to allow those special salary rates.
    The Chairman. Ms. Bonjorni, do you have something to add to 
this at all?
    Ms. Bonjorni. Yes, just that we are also working to improve 
our recruitment abilities for housekeeping aides using the 
flexibilities we created for medical support assistant hiring 
under Hire Right/Hire Fast approach, where we have hiring fairs 
and have a standing register of applicants to come through the 
process.
    The Chairman. Do you recommend any change in authorities 
for you in order to make this less cumbersome? Because this is 
a common refrain across the country. I am asking every medical 
facility I go to and they all indicate they have issues with 
housecleaning staff.
    Mr. Sitterly. I don't know that it requires legislation. It 
is a Title 5 under CFR. It may be an interpretation or it may 
be the statute, but the more authorities that we have in the 
Department that we don't have to go to OPM for, the more 
flexible that we can be. That is not just for housekeepers, 
that is for everything. I will give you an example. At the 
senior executive level, we have to go to OPM to get the 
standards approved by other Government agencies----
    The Chairman. Well, can you tell me how many locations you 
have approved special pay rates for housekeeping staff? If you 
don't have that information, you can get back to me with it.
    Mr. Sitterly. Yes, I don't have that information with me, 
Mr. Chairman.
    The Chairman. I understand that the wages for VA 
housekeeping staff are set through the Federal prevailing rate 
system through OPM, which may not adequately account for 
differences in pay between custodial staff working in a health 
care environment versus staff working in an office environment. 
To what extent has VA studied whether reclassification for this 
occupation is needed?
    Mr. Sitterly. We have studied it and we agree it is needed.
    The Chairman. OK. Also, an interesting proposal that I 
heard from the Brooklyn VA recently, pay rates are part of the 
issue, but really the set-aside for veterans is--they are not 
proposing to get rid of the set-aside, but maybe if we have a 
system in place where if they could show they have done due 
diligence in trying to recruit veterans for the set-aside that 
that requirement after that point may become more flexible, so 
they can hire from the general population more easily. What do 
you think about that?
    Mr. Sitterly. We have 120 different hiring authorities, I 
would like very much to work with you and this committee and 
others to streamline those authorities to something simpler 
than that. We have 60 different pay tables in the VA that every 
time we make a change to a local salary we have to update the 
IT systems to be able to accommodate that.
    I would be willing to work with you to have a simpler H.R. 
system in the VA and across the Federal Government.
    The Chairman. All right, thank you very much. My time is 
up. I am going to recognize Dr. Roe for 5 minutes.
    Mr. Roe. Mr. Chairman, I am going to wait until the end. I 
will need to be here for the whole hearing, so I am going to 
wait to ask questions until it is over, just so the other 
members may have somewhere they need to be.
    The Chairman. All right. Thank you, Dr. Roe. I should have 
done that.
    All right, go ahead, Dr. Dunn.
    Mr. Dunn. Thank you very much, Mr. Chairman.
    Mr. Sitterly, Secretary Sitterly, the committee has 
received reports and they are confirmed by the VA's Office of 
Labor-Management Relations and General Counsel, that VA 
employees are offered $100 cash during new employment 
orientation to join AFGE on the spot. Are you aware of this 
practice and what is your opinion of this practice that appears 
to be a handout or a bribe to get new employees to join the 
union?
    Mr. Sitterly. Dr. Dunn, I have heard of that, I have not 
verified that, my opinion is our employees ought to be making 
their own decisions.
    Mr. Dunn. You are the Assistant Secretary for HR, so that 
is kind of in your wheelhouse to know what is going on there?
    Mr. Sitterly. Yes, sir, it is. That was just recently 
brought to my attention as well. My opinion is that our 
employees ought to be able to decide on their own.
    Mr. Dunn. I look forward to hearing back from you.
    Mr. Sitterly. Yes, sir.
    Mr. Dunn. Also, Secretary Sitterly, what, if any, is there 
a practical reason for the provision in the current collective 
bargaining agreement with AFGE that only allows an employee to 
leave the union and stop paying dues in a very narrow window of 
time each year that is unannounced and has automatic re-
enrollment if they miss that, is there a practical reason for 
that?
    Mr. Sitterly. Doctor, not that I am aware of, and that 
collective bargaining agreement is currently under 
negotiations.
    Mr. Dunn. I am so glad to hear that. It does seem to fly in 
the face of choice for your employees.
    Once again, Secretary Sitterly, can you please provide an 
update on the VA's efforts to implement the President's 
executive order to ensure that clinicians who are hired to care 
for veteran patients are focused on patient care and not 
spending any significant percentage of their time on--their 
official time on union activities?
    Mr. Sitterly. Sir, you asked the question about physicians, 
which are under Title 38, so we have different authorities 
which are not covered under the executive order for Title 38 
employees. So we have repudiated that time already and we are 
waiting for the courts to decide on the other three EOs.
    Mr. Dunn. So does that occur to--does that apply then to 
the other group, the Title 5?
    Mr. Sitterly. No, sir, that does not. We are waiting for 
the courts to make a decision on those executive orders.
    Mr. Dunn. So, hypothetically, how much money would it save 
the taxpayers if we did have full implementation of that 
executive order? You would have clinicians that were doing 
clinical work or you wouldn't have to hire so many clinicians 
in that case, I assume there is some savings, have we 
calculated that number?
    Mr. Sitterly. We have done some sort of back-of-the-
envelope math on that, Dr. Dunn. So----
    Mr. Dunn. You have----
    Mr. Sitterly.--it is several millions of dollars.
    Mr. Dunn. Several million, excellent.
    Finally, let me say I am fully in support of Dr. Stone's 
efforts to prohibit smoking in the VA medical facility 
campuses. It is clearly aligned with best medical practices, it 
aligns the VA with the rest of the health care footing in the 
country. However, I understand that there is still debate in 
these same negotiations that are going on right now and the 
union is continuing to push for the VA to provide smoking areas 
on VA campuses for the employees. Can you give us an update on 
the VA negotiations with the unions on that front?
    Mr. Sitterly. I cannot give you an update on the 
negotiations, sir, but we have implemented no smoking across 
our medical campuses currently.
    Mr. Dunn. So it is currently the rule that there is no 
smoking on the VA campuses?
    Mr. Sitterly. Yes, sir that is correct.
    Mr. Dunn. That is good. That is a lot like all the 
hospitals that I ever worked in.
    I appreciate your time. Thank you very much, General, for 
the service to our VAs, they certainly deserve our very best 
efforts.
    Mr. Chairman, I yield back.
    The Chairman. Thank you, Dr. Dunn.
    I now recognize Ms. Brownley for 5 minutes.
    Ms. Brownley. Thank you, Mr. Chair. Thank you all for being 
here and, Mr. Sitterly, you have been with the VA now for maybe 
9 months or so?
    Mr. Sitterly. Yes, ma'am, that is correct.
    Ms. Brownley. And you came from the Air Force?
    Mr. Sitterly. I did.
    Ms. Brownley. No previous jobs with the VA other than this 
one. When you arrived, can you just explain to me or describe 
to me your assessment of the Department, where you thought 
where immediate improvements have been, and then talk a little 
bit about some of your successes in your short tenure.
    Mr. Sitterly. Yes, ma'am. Thank you for the question, I 
appreciate that. I think that my immediate assessment was I was 
shocked to find out how many folks, how many veterans were 
enrolling in the VA today, despite the fact that we have the 
smallest military that we have had since World War II, with the 
exception of the last couple of years where the end strength 
has increased. So my immediate question was, why do we have so 
many people enrolling?
    The answer is that access standards are better than they 
have been, care standards are high, people want to come to the 
VA now to receive their care, present company included. When I 
retired several years ago now, I didn't have a disability or I 
didn't apply for a disability, so there was no reason for me to 
be at the VA. Since I have been at the VA, they have some 
wonderful services for me, for veterans, outreach, that I was 
not aware of. And so that was my fist ah-ha moment is that we 
need to do outreach and we are doing, under the leadership of 
Dr. Linda Davis, a tremendous job outreaching to our veterans 
who we haven't had enrolled in our facilities before.
    Ms. Brownley. I was thinking more along the lines----
    Mr. Sitterly. Yes, ma'am.
    Ms. Brownley.--of HR.
    Mr. Sitterly. OK. The thing that sort of shocked me and the 
thing that Secretary Wilkie asked me to look at as my No. 1 
priority, and the thing that best addresses the reports of the 
IG and of the GAO, is that we don't have a manpower position 
management model by which to assess our current vacancies. I 
have been engaged for the last 9 months and the chairman asked, 
who is accountable for this, and I will tell you, ma'am, I am 
accountable for this, in putting together a position management 
system in which we can track the vacancies across the VA.
    When we talk about 50,000 vacancies, we have to qualify 
that number many different ways to assure that we know what we 
are talking about. For instance, with a 9.5 percent turnover 
rate across, let's just use 400,000 employees for simple math, 
that is about 9500 positions that we have turnover every year 
times four and, if it takes 90 days to hire, that is 10,000 
vacancies or so that will always be vacant because of the 
turnover rates that we have.
    When we look at the growth of the VA, 2 to 5 percent, as 
Dr. Roe indicated, 100,000 people in a decade. Over the last 5 
years, we have gone from 315,000 to 387,000 and, if Congress 
approves the President's budget this time, we will be to 
393,000. So we continue to grow our capacity, our capability in 
all of the services that we provide our veterans, it is growing 
exponentially every day----
    Ms. Brownley. But we can't count the number vacancies we 
have?
    Mr. Sitterly. We started by looking at our as-is by 
facility when we started this journey just before I got here. 
We have an IT system that we have to get on track to allow us 
to put the right data----
    Ms. Brownley. Just--and I understand there is a lot to 
get----
    Mr. Sitterly. Yes, ma'am.
    Ms. Brownley.--to improve upon these things, but just the 
real problem from your perspective, first 9 months, is we have 
no way of counting the number of vacancies?
    Mr. Sitterly. We have no way of verifying the exact 
requirements and then keeping a person tied to a position 
versus a person tied to a personnel system. And so it is my 
responsibility and I will put into place business rules where 
6,000 H.R. professionals across the VA have certain things they 
can change in a position and certain things that they can't. 
And I----
    Ms. Brownley. OK, thanks.
    Mr. Sitterly. Yes, ma'am.
    Ms. Brownley. I have limited time. So I just want to ask 
either Mr. Missal or Mr. Goldenkoff, I am not sure which one of 
you can answer this, but I know in the Inspector General report 
you talked about there are portions--there were reporting 
mechanisms required within the MISSION Act, you talked about 
the fact that that was partially executed or executed in a way 
that was in larger categories, so therefore you couldn't kind 
of get the exact count; am I correct on that?
    Mr. Missal. That is correct.
    Ms. Brownley. OK. So there was something that was required 
in the MISSION Act to address this issue that you are raising, 
but yet the VA is not doing that.
    So my time has run out, but, you know, I would certainly 
like to have an answer.
    The Chairman. Is Mr. Bilirakis here?
    The Chairman. Mr. Steube.
    Mr. Steube. Thank you, Mr. Chair.
    Mr. Secretary, I represent--just to kind of orient you, I 
represent Southwest Florida, I have nine counties in Southwest 
Florida, and one of the clinics that I have in my district is 
in Port Charlotte. We have had limited and overwhelmed doctors 
seeing too many patients at the Port Charlotte clinic in my 
district. The veterans who go to this clinic rarely see the 
same doctor twice, many are referred to nurse practitioners 
instead of seeing a doctor. They are also letting go of 
employees that should not have been let go with an already 
short staff.
    I have one veteran in my district who just got out of a 
private hospital and was told to see a cardiologist within a 
week. The VA hospital cannot provide him with a referral to see 
a cardiologist without him seeing a VA doctor first. The 
soonest he would see that doctor was after 30 days, which I 
know falls within the time lines, but I don't view that as 
acceptable.
    Bay Pines, to give you an idea, most of the people in my 
district, including myself, who get services through the VA go 
to Bay Pines, Bay Pines is 2 hours from Charlotte County. It is 
an hour and a half, hour and 45 from my house. If veterans in 
my district who live in Hardee, Desoto, Highlands, or 
Okeechobee, they are having to also drive, that is another 
probably 45 minutes, so you are probably talking 3, three and a 
half hours to get to Bay Pines.
    Like I said, the VA hospital couldn't provide him with a 
referral within the time line and, because Bay Pines is 2 hours 
away from his home, he called an ambulance, went to the closest 
ER down the street. It turns out it was a life-or-death matter 
and he could not have waited the 30 days.
    This is a situation for many of the veterans in my 
district, it is a situation that I have faced personally. The 
clinic that I am assigned to is in Manatee County, which is not 
in my district, but it happens to be the closest clinic to my 
residence, and same scenario. I need a hernia repair. You go to 
a doc, you see your primary care guy, which, you know, maybe 
you can get in within a 30-day period of time to see your 
primary care guy, which it may be the same guy you saw a year 
ago, probably not, to then get a referral to go to Bay Pines, 
which is then going to take you another 30 to 60 days to get 
somebody that you don't know who you are going to see for the 
first time.
    This is a situation that I have personally experienced, 
many veterans in my district have experienced. We have a very 
large veteran population in my district. It is Florida, 
everybody likes to come and retire to Florida, especially 
Southwest Florida, so we have a very large veteran population. 
The clinic in Port Charlotte is understaffed, which is the one 
in my district. What do you suggest to these veterans in 
critical conditions do in the meantime and is there any plans 
to fully staff at least the Charlotte clinic?
    Mr. Sitterly. Thank you for your service. I am not familiar 
with the staffing issues that you have there, and I am also not 
the expert on MISSION Act and the decision support tools and 
community service opportunities that our veterans have, but I 
would gladly like to visit there with you to talk about the 
staffing issues that we have and to get our arms around exactly 
what it is that we need to do to take care of our veterans.
    Mr. Steube. How soon would you be able to meet to discuss 
these issues?
    Mr. Sitterly. The week after next.
    Mr. Steube. I have a staff person here, she will followup 
with your office, because I was supposed to meet with Secretary 
Wilkie, was it next--tomorrow, and he canceled, to discuss 
these issues and many others. So if----
    Mr. Sitterly. I am happy to come over and talk----
    Mr. Steube.--I could meet with you----
    Mr. Sitterly.--yes, sir.
    Mr. Steube.--in a reasonable amount of time, I would like 
to do that.
    Mr. Sitterly. I am going to visit some facilities next week 
and I would be happy to come over when I get back and meet with 
you, and Ms. Bonjorni as well.
    Mr. Steube. Yes. I mean, I can't speak for other rural 
districts, but my district is considerably rural. I go from--if 
anybody is familiar with Florida, I go from almost one coast to 
the other, and so it is a real challenge for those in Southwest 
Florida because your closest hospital is Bay Pines. So that, 
obviously, with the timeframes and the referrals that are 
necessary to see a specialist, causes lots of challenges for 
the veterans in my district.
    I will have my staff today reach out to yours and hopefully 
we can arrange that.
    Mr. Sitterly. I am happy to do that, sir.
    Mr. Steube. All right, thank you.
    Mr. Sitterly. Thank you.
    The Chairman. The gentleman yields back.
    We now have Miss Rice--are you here? She is not here.
    Mr. Brindisi? Ms. Luria?
    Ms. Luria, you are recognized for 5 minutes.
    Ms. Luria. Well, thank you for being here today as part of 
the panel. I represent a large portion of Hampton Roads, which 
has a very large veterans concentration, and I have had the 
opportunity three times this year to visit the Hampton VA 
Medical Center. And I have heard each time from different 
groups, both from employees and from leadership and management, 
we are now on the third director since I have been in office 
less than a year. One moved to Richmond, then we had an interim 
director, and starting just, I believe, yesterday the new 
director was installed. So I look forward to sitting down with 
him and going over some of my concerns. But what I hear each 
time is the length and the complexity of the hiring process.
    And each time that I have heard this I have tried to get at 
what is the reason that it takes so long. And one thing that is 
highlighted is the fact that the process must recertify the 
person's credentials every time, back to their degree, to their 
licensing, to their medical board certification, which I 
understand it is very important to confirm these things before 
employing an individual, but I also understand that this 
happens even if the person is already employed with the VA at a 
different VA medical center and then moves to the Hampton VA, 
even if the person is already employed as a physician or a 
nurse, for example, within DOD health system. And I have yet to 
understand if this is a statutory requirement or if it is just 
within the VA policy for hiring that this is required, even if 
the person is already employed by the Government, doing the 
same job with the same credentials.
    Do you have any insight onto that and how we can help 
smooth and quicken that process?
    Ms. Bonjorni. Sure, I am happy to try to address your 
question, Congresswoman.
    It is not statutory that we have to re-credential people as 
they move across facilities, it is not even policy right now. 
So if that is occurring, then we will move to correct that. It 
has historically been happening. Unfortunately, right now there 
is not a direct linkage between the DOD system and the VA 
system that we use to track credentialing, so we have some 
opportunities there.
    Ms. Luria. OK, we are limited on time. So I would love a 
followup, and specifically a followup with regards to the new 
director at the Hampton VA Medical Center to understand if just 
within their practices locally they have been doing something 
that is actually hampering the time line to hire people.
    And then also I serve on the Mil-Per subcommittee as well, 
so I think that we have a good relationship between the VA and 
DOD policies, if there is a way to write something in that 
allows that streamlining, because it happens incredibly 
frequently within our region that people find job opportunities 
and move back and forth between these facilities.
    I did see in the material that was presented prior to the 
hearing today the data about attrition or turnover. What I find 
is that, you know, it is taking so long to get someone on 
board, yet once we have them there, we are not keeping them. 
And statistically I wasn't aware of, you know, throughout the 
health care industry that there is a relatively higher 
turnover. In most professions it seemed that the VA nationally 
is below that threshold, but I do find that, you know, 
specifically within our VA medical center that I have had the 
opportunity to visit, that there are a lot of morale problems 
and challenges for employees, a lot of employees who feel like 
their concerns are not being adequately adjudicated. What do 
you have in mind to just improve retention? It could nationally 
meet a threshold that is better than the rest of the industry, 
but certain VA medical centers--and ours does rank in the 
bottom 30 in the country statistically--do you have any 
programs to improve that and to retain good professionals who 
we have already on board?
    Mr. Sitterly. Thank you for that question. Actually, you 
know, as you look across the entire VA enterprise, there are 
different issues that we have at different facilities based on 
where you are and it is not all monetary incentives, as you 
know.
    One example is, in our all-employees survey we determined 
that for physicians who have trainees and residents, that they 
are more likely to stay than those that don't. We are looking 
at our program to make sure that we have teaching 
opportunities, because that will directly impact retention.
    A non-monetary incentive, ma'am, since you are on the Armed 
Services Committee, you understand that the DOD has the very 
best parental leave policy in the entire Federal Government for 
those in uniform. For Federal employees, we get zero parental 
leave for Federal employees. I would like very much for the VA 
to be a pilot to have the same authorities that the Department 
of Defense has for parental leave, paid parental leave. I think 
with 85,000 nurses, most of whom start their careers, if they 
are in our intern programs, young, that would be a great 
incentive for retention as well.
    As we look across some of our other authorities that we 
have, retention obviously is important to us, but the 
statistics you have to look a little closer at. When we look at 
the quit rate, we are at 3.3 percent for nurses this year and 
over 4 years that quit rate has been decreasing. Same thing for 
physicians. So when you look at the turnover rate, a lot of 
those are voluntary retirements, those are voluntarily going to 
another facility, but our quit rates are actually extremely low 
and they are at a 4-year low.
    So our retention, frankly, is doing well, but, again, as 
you go across the enterprise, it does vary greatly location to 
location.
    The Chairman. We need to move on. Thank you.
    Mr. Banks, you are recognized for 5 minutes.
    Mr. Banks. Thank you, Mr. Chairman.
    Ms. Bonjorni or Mr. Sitterly, how many different hiring 
authorities does VHA have for Title 38 positions, meaning 
medical positions?
    Ms. Bonjorni. Well, underneath Title 38, we have pure Title 
38 for a smaller number of occupations, then we have hybrid 
Title 38, which has elements of Title 38 and Title 5. So two 
primary hiring authorities, but then we have a variety of other 
special authorities and carveouts within that that allow us to 
follow different rules.
    Mr. Banks. The answer is several?
    Ms. Bonjorni. Yes.
    Mr. Banks. But there is not a specific answer, but several. 
Maybe you could provide the committee with a chart of what 
those----
    Ms. Bonjorni. Sure.
    Mr. Banks.--authorities are.
    Mr. Sitterly, how many of those hiring authorities do human 
resource officers use on a regular basis?
    Mr. Sitterly. 7306, 7401-1, 7401-3, 7405 are the four 
primary ones that we use on a regular basis.
    I would also mention, if I may, another area that you can 
help us with is our market pay for medical center directors, 
going back to the issue that we have. Regrettably, when we look 
at the complexity of systems between Title 5 and Title 38, and 
when we add additional appointment authorities, sometimes we 
don't dot the Is and cross the Ts. While I have direct-hire 
authority for medical center directors, I can only pay them at 
$156,000 a year if they are not Title 38.
    By fixing that, it will improve our ability to hire senior 
level directors at our medical centers that are other than 
Title 38----
    Mr. Banks. Then we also----
    Mr. Sitterly.--and then we also have hybrid Title 38----
    Mr. Banks. So follow on that line of thinking for a moment. 
How many Title 38 hiring authorities would you say you need in 
order to hire effectively?
    Mr. Sitterly. Four.
    Mr. Banks. OK. Mr. Sitterly or Mr. Oswalt, your testimony 
refers to an OIT vacancy rate that was historically high, but 
is now lower. What were the vacancy and attrition rates 
historically and what are they now? Mr. Oswalt.
    Mr. Oswalt. Thank you for the question. Historically, it 
has been in the 5 to 6 percent range. I think right now it is 
currently approximately 8 and a half percent, so we have seen 
an up tick with that. I guess, given the overall aging of the 
workforce, that is not totally unexpected. But we have made a 
concerted effort over the past 18 months to broaden our 
recruitment net where we are actually, right now, we are pretty 
much maxed out on our hiring with the available funding we 
have.
    Mr. Banks. OK. Mr. Oswalt as well. In today's testimony and 
in recent meetings with the staff, OIT gives the impression 
that it does not have a significant staffing problem. You seem 
to be saying the staffing situation is comparable to that of 
other chief information officer organizations at Federal 
agencies; would you say that is accurate?
    Mr. Oswalt. Well, getting back to what Mr. Sitterly had 
said about our projecting the requirements versus what we have 
funding to hire, that would be the demarcation. I mean, if we 
use the staffing model now that is currently in its final 
stages of development, we can project that there is additional 
resources, IT resources needed, but given the realities of the 
appropriation that we have, we are at full capacity in that 
regard.
    Mr. Banks. OK. I understand that you have prioritized 
hiring for cyber-security positions. What other positions does 
OIT consider important and difficult to staff?
    Mr. Oswalt. Anything in the information--or in the IT job 
series we consider to be a high priority, information security 
being the most critical one, but we also have enterprise 
architectures, and primarily I would think the next below 
cyber-security would be project managers.
    Mr. Banks. OK. How do you plan to use the direct-hire and 
retention pay authorities that Congress granted the VA for 
those positions?
    Mr. Oswalt. For the cyber-security, we have been--we are in 
the second year of offering cyber retention pay and we have 
seen a considerable drop in the turnover, the attrition of 
these information security specialists. For direct-hire 
authority, we are using that, when we said earlier that we are 
casting a wider net, that is one of the things we are doing is 
we are going out with standing open announcements where there 
is continually a pipeline of folks coming in and applying that 
we are able to select from or interview based on that open and 
continuous announcement, and then exercise our hiring 
authority.
    Mr. Banks. OK, thank you very much.
    I yield back.
    The Chairman. The gentleman yields back. I now recognize 
Ms. Lee for 5 minutes.
    Ms. Lee. Thank you, Mr. Chairman. Thank you all for being 
here.
    I wanted to touch on governance within VA. It seems to be 
challenge with all facets of VA management, but really comes 
down to leadership and accountability, and human capital 
governance has complicated VA's decentralized management. What 
part of--for Mr. Sitterly--what part of VA is ultimately 
accountable for addressing the human capital challenges?
    Mr. Sitterly. I am.
    Ms. Lee. You are? OK.
    Mr. Sitterly. Yes, ma'am.
    Ms. Lee. How do you coordinate with VISNs, individual 
facilities?
    Mr. Sitterly. Ms. Bonjorni is the Chief Human Capital 
Officer for VHA, Ms. Beers for the Veterans Benefits 
Association, and Dr. Lisa Thomas for the National Cemetery 
Administration. I see those three people more than I see my 
family. There is not anything that we put in policy and 
governance that we haven't discussed, that we don't collaborate 
on, that we don't talk about.
    Ms. Lee. Mr. Goldenkoff, I wanted to ask you, there has 
been some leadership turnover, and how has that--and 
challenges--how has that affected the VA's ability to make 
sustainable improvements in human capital management?
    Mr. Goldenkoff. It has been extremely problematic. 
Leadership continuity is so important because, you know, if you 
have a plan in place, if you have a strategy in place, leaders 
set the tone. As long as there is that consistent turnover, a 
lot of that just never happens or it is just much more 
difficult to happen when essentially the people at the top are 
temporary employees.
    Ms. Lee. Thank you, thank you.
    I want to turn now--as you know, I am the chairwoman of the 
Electronic Health Record Modernization. A GAO 2018 report cited 
having quality, experienced program staff as a critical factor 
in the success of major IT acquisitions, also noted the 
importance of consistency and stability of government and staff 
in achieving these goals.
    Mr. Oswalt, what specific steps has the VA and the Office 
of OEHRM taken in furtherance of these critical factors?
    Mr. Oswalt. Well, there is a standing Integration Office in 
the Office of Information Technology headed up by one of our IT 
senior executives, who happens to be a clinician as well, so 
there is a constant, ongoing dialog there. The individuals who 
are at the initial operating capacity sites, the IOC sites, are 
working, what we call, shoulder-to-shoulder with the VA/VHA 
folks to develop the clinical workflows and to respond to their 
needs as our customers. In conjunction to with the EHRM staff, 
my staff in particular, we provide a great deal of logistical 
support to the EHRM folks in terms of budget space and H.R. 
support.
    Ms. Lee. What percentage of the OIT staff is assigned or 
tasked with the EHRM project, do you have a percentage?
    Mr. Oswalt. No, ma'am, I don't, but I will be able to get 
that back for you.
    Ms. Lee. Can you get that for me? You know, I am just sort 
of--obviously, the concern with supporting your ongoing IT, as 
well as this enormous oncoming project and the stress that it 
puts on your IT personnel, and obviously with your vacancy rate 
as well, it is a big concern as we move into the implementation 
to make sure that we are moving forward to that.
    Do you know what the turnover rate for your OIT personnel 
is and in what--do you have any idea about the turnover rate 
for the personnel responsible for the OEHRM?
    Mr. Oswalt. No, ma'am, I don't. Given that this is within 
just the last 18 months, I don't think we have the metrics on 
that. A number of OIT employees have moved over and been hired 
by the EHRM staff. So, in effect, we are fully embedded with 
them based on the relationships that exist between people and 
we are backfilling the positions that, you know, were vacated 
by that.
    So I don't have any metrics on turnover, but, again, I will 
be able to provide that to you.
    Ms. Lee. Great. Thank you very much. My time is up.
    The Chairman. The gentlelady yields back.
    I now recognize Mr. Watkins for 5 minutes.
    Mr. Watkins. Thank you, Mr. Chairman. Thanks for being 
here.
    There is a lot of discussion on the challenges that the VA 
and the rest of the health care community has with regards to 
recruiting and retaining good staff and clinical support staff, 
but the VA has a lot of benefits that they offer potential 
employees. Why should potential employees, who could be 
listening, or those with whom I speak with, why should they 
consider a career in VA? This is open to anybody.
    Mr. Sitterly. I will start. It is a noble mission taking 
care of America's heroes, our veterans. When you look at, 
beyond that, the research that our doctors get to do in our 
facilities, that our clinicians get to do in our facilities, 
they are on the cutting edge in many, many areas of making 
discoveries in modern medicine. The same thing can be said for 
all of our employees.
    I don't know if you have visited a national cemetery 
lately, sir, but the most honorable place, they are clean, they 
are respectful. It is just a wonderful way to serve your 
country.
    Mr. Watkins. Excellent. Thank you. And then the followup to 
that, how can the VA better articulate these advantages of 
working with the VA beyond just the salary?
    Ms. Bonjorni. I would say that we have a lot of great 
resources out there that we use in our marketing materials to 
candidates, when we are reaching out directly to providers to 
try to convince them to make the switch to come over to VA. So 
we offer such things as our better quality of life. They don't 
have to worry about spending all their time on billing and 
racing to get through their patients in a day, it is a much 
different model of care that we provide in the VA, and that 
attracts a lot of our providers to come work for us where they 
can provide more of a whole health approach rather than 
cranking out patients every day. Our website, VA Careers, 
offers a lot of information about our monetary and non-monetary 
benefits as well.
    Mr. Oswalt. I would add, sir, that approximately 60 percent 
of IT employees are veterans. So, to echo what Mr. Sitterly was 
saying, veterans serving veterans is a belief, core belief we 
have.
    I would think too--and this is just pure speculation on my 
part--that increased outreach for transitioning servicemembers 
is a noble and lofty goal that I think, you know--I mean, you 
have people who from day one are dedicated and ready to work.
    Mr. Watkins. Excellent. Thank you.
    The Association of American Medical Colleges projects that 
the U.S. will have a shortfall of some 120,000 physicians by 
2030. What can Congress do today to ensure that the VA can 
effectively recruit highly qualified doctors despite this 
shortfall?
    Mr. Sitterly. Sir, I will start with that. Give the VA the 
authority to provide salary support, enable us to send medical 
students to the Uniformed Services University. As the 
Department of Defense moves their Defense Health Agency model 
around, I think you will find, and we have spoken to the Dean 
of the Uniformed Services University, that they have excess 
capacity and we would love to be able to grow our own doctors.
    We are using some authorities that Congress gave us in the 
Choice in Quality Employment Act to do more scholarship 
programs in other facilities, we are trying to--Dr. Roe has 
been a coach for us in getting our own doctors to help recruit 
our doctors. One hundred and 20 two thousand students and 
residents come through VA hospitals every year. Last year, we 
increased the number of psychiatrists and health care providers 
by a net 1,000 by having a very targeted recruitment toward 
those students. We still have 2,000 more vacancies to go that 
we know of with current requirements, so we are targeting those 
folks as well.
    Mr. Watkins. Well, thank you very much. Thanks for being 
here, to the panel, thanks for what you do for our veterans and 
our country.
    I yield back the remainder of my time.
    The Chairman. The gentleman yields back.
    Miss Rice, you are recognized for 5 minutes.
    Miss Rice. Thank you, Mr. Chairman.
    Staffing challenges have been an ongoing concern at the 
Northport VA Medical Center, which serves veterans in my 
district and throughout Long Island. Within the past 2 years, 
Northport faced considerable turnover in virtually all of its 
key administrative roles, including 4 medical center directors, 
3 chiefs of staff, 3 nursing department directors, and a heads 
of the human resources department who all left the facility.
    Last year an OIG investigation shed some light on nursing 
shortages at the medical center that led to quality of care 
issues and the highest number of vacancies continues to be for 
nursing staff positions.
    To improve recruitment of retention of nursing staff, the 
facility has proposed new salary levels to address the 
significant pay differentials that exist between VA and private 
sector salaries. I just met in my district with the head of 
the--I guess--I don't know if he is real or acting director. It 
is my understanding that the new salary levels must be approved 
at the VISN level.
    So, Mr. Sitterly, I guess this question would be for you. 
Can you provide any details about the approval process at the 
VISN level, what that entails, and how long it usually takes, 
and what authority do VISN leadership officials have to either 
effect or weigh in on facility level staffing,whether it is 
authorized staffing levels or the actual hiring process?
    Mr. Sitterly. I will start the conversation and ask Ms. 
Bonjorni to help me with her experience. But there are a couple 
of issues that you have brought up I would like to address. And 
the first one is authorizing market pay for our medical center 
directors themselves, depending on whether they are Title 5 or 
Title 38, and to allow us the flexibility to establish those 
market pays.
    The other issues is just in general. We do market salary 
surveys, and then we come back and determine what is the right 
rate to pay the folks based on that particular market. I don't 
mean to sound flippant, but I would say that every VA facility 
is a handmade wooden shoe when it comes to the human capital 
dynamics of that particular area.
    For instance, in San Francisco a neurosurgeon can get paid 
downtown close to a million dollars, 800 and some thousand. We 
can only pay them up to the aggregate $400,000. I can never 
compete with that.
    When you get to more rural areas in America, the average 
salary is less than it is nationwide and I can't compete 
because when I do the survey of market data they are already 
getting lower pay. So I can't raise that pay above market rate.
    To give us more--and your particular facility I haven't 
done the research on exactly. But I suspect that it is probably 
a high area.
    Miss Rice. Yes.
    Mr. Sitterly. We don't have to have any additional 
authorities in order to set those pay rates. But what we have 
to do is continuously do the market surveys to determine what 
the local pay rates are, and then they have to be approved 
through the chain to offer those salary rates.
    I will let Ms. Bonjorni add to that if she wishes.
    Ms. Bonjorni. For nurse salary rates in particular, those 
go through the VISN, from the facility to the VISN and then 
from the VISN up to my office. For Northport in particular, we 
are working with them to make sure that those get processed in 
a timely fashion. We have moved to a model of having 
compensation managed at the network level to make sure that we 
are looking across the entire market and setting pay 
appropriately.
    We do still have some challenges in that, even when we look 
at the market and see that we need to make a change. There are 
caps within statute that we cannot go over, even if the market 
indicates it.
    Miss Rice. Well, I mean, I think we have to address this 
issue because I agree with you that we are not going to--the 
Federal Government is not going to be able to compensate people 
at the level that they get in the private sector. If it means 
us acting to raise those caps, if that is where the 
authorization comes from, that is what we have to do because 
this is not just a morale issue, although it certainly affects 
the morale of the employees. This is, are the veterans getting 
the kind of healthcare that they deserve, and the answer is in 
some instances, no. And it should never be because we are not 
paying people enough money to, you know, you to get them to 
come.
    So, Mr. Missal, this question is for you. There has been, 
you know, well documented significant leadership turnover and 
vacancies at VA over the last few years. We see this happening 
not only at the facility level as I just talked about, but 
department-wide.
    In your view, how has this affected VA's ability to make 
more meaningful progress toward addressing outstanding 
recommendations from OIG and GAO? And I think it is important 
to kind of frame this by mentioning a comment that the 
president made himself that he actually likes the flexibility 
that keeping people in acting positions gives him.
    But we all know that that is not--first of all, I don't 
agree with that. I mean, you should have--they should be 
approved through the process and you shouldn't have an agency 
like the VA being constantly run by someone in an acting 
position.
    In your opinion, how has that affected the ability to get 
the kind of changes that we are talking about done with people 
who are actual employees who are doing the grunt work?
    Mr. Missal. I have had the privilege to be the inspector 
general for 3 years, 4 months and 16 days, and in that time I 
have served with 5 different individuals who have been the 
secretary----
    Miss Rice. Yes.
    Mr. Missal.--and an almost equal number for other 
secretaries of health and other senior positions. It is very 
difficult for those people, if they are in an acting position, 
to present their vision for what they want to do to get the 
respect of the staff as to following what they do, and almost 
as importantly, having a leadership group who work together 
well, who communicate because in any large organization it is 
not going to be 1 person or 2 people. It is going to be a 
number of different people who are leading. And if they don't 
have experience working together, it makes it that much more 
challenging.
    Miss Rice. I think this is an issue that we--my time is up, 
but I think this is, you know, we need to communicate that 
acting positions and this kind of turnover are not helpful to 
the efficient running of an agency as important as the VA and 
helping our veterans.
    Thank you, Mr. Chairman. I yield back.
    The Chairman. All right. Thank you, Miss Rice.
    Mr. Sablan, you are recognized for 5 minutes.
    Mr. Sablan. Thank you very much, Mr. Chairman. And good 
afternoon, everyone.
    The VA acquired HR*Smart, this new software for human 
resources management in 2016, and in December 2017 VA began 
working on a department-wide position management cleanup in 
HR*Smart. But according to the inspector general, VA has yet to 
complete this position management cleanup nearly 2 years later. 
Therefore, discrepancies exist between this number of full-time 
employee equivalents authorized at VA medical facilities and 
the number of positions appearing in HR*Smart.
    For some facilities the IT found that HR*Smart overstated 
the number of positions by as much as 20 percent, while at 
other facilities the number of positions for were unaccounted 
by as much as 8 percent.
    So, Mr. Sitterly and Ms. Bonjorni, why is VA's position 
management cleanup taking so long? Shouldn't this be finished 
by now?
    Mr. Sitterly. Thank you for the question, Congressman. It 
is a complicated answer and I will try to make it as simple as 
I possibly can.
    But HR*Smart is our personnel data base system. We never 
had a manpower requirements piece of that in the system. And so 
the data cleanup is in the personnel actions as we went in 2016 
from one system to another. When we started our manpower 
position management journey, we started with the as is, if you 
will, on what positions were currently across the VA, input 
them in.
    Now what we are cleaning up is we have positions where 
let's say you have a requirement for a left-handed monkey 
wrench turner and a right-handed monkey wrench turner, but you 
can only find two left-handed ones. So is that good enough to 
put into this position, yes or no.
    You know, that's probably a simplistic answer, but when you 
start talking about specialties across the entire VA, you may 
have a physician's assistant that you have hired because you 
couldn't hire an RN, or you may have a food service worker you 
hired instead of an RN.
    As we get to the position management across the entire VA, 
understanding the metric that we need to be able to assess and 
then to surgically input where we need recruiting, retention, 
and relocation bonuses, that will better help us define where 
those requirements are.
    Mr. Sablan. That still doesn't answer my question of why it 
is taking so long.
    Mr. Sitterly. So HR*Smart, sir----
    Mr. Sablan. Yes. Who----
    Mr. Sitterly.--will require----
    Mr. Sablan.--who decided to acquire this software or 
whatever it is?
    Mr. Sitterly. I cannot speak. That decision was made 
probably in 2015. It came on board in 2016. But we are adding 
new capability to the system every day. Not all of it is rolled 
out as I would like it, but we are adding the opportunity for 
us to track our residents and our students, and we will be able 
to do that soon so that we can better recruit them. We will 
have them in a data base system, our employee relations. So we 
are continuing to build out that system.
    I also have to tell you that productivity standards for the 
VA is not something new. We have always had them, and we have 
about 40 percent of everybody now that meets some sort of a 
manpower determinant. To put the business rules in place and to 
get each of those positions into the IT system is what we are 
working on now.
    Mr. Sablan. Well, I don't think it is easy, but I think it 
is necessary that it must be done because, you know, you need 
the data to make good decisions.
    Mr. Sitterly. Yes, sir.
    Mr. Sablan. And so, Mr. Missal, does the Department's 
explanation seem reasonable to you, what was just answered? 
Should it take 2 years for VA to complete this position 
management cleanup?
    Mr. Missal. It is hard for me to say since it is their 
system. We have reported that they need to continue to work to 
improve HR*Smart. We have identified some issues, and they have 
committed to doing so.
    Mr. Sablan. Is HR*Smart the right program, the right 
software for what the VA is faced with?
    Mr. Missal. I think it can be. There are a lot of different 
products out there. It's their decision as to which one they 
want to use, which one they think is going to be the most 
effective for their needs.
    Mr. Sablan. So you can't say for sure?
    Mr. Missal. I can't say for sure.
    Mr. Sablan. You think there could be maybe a better system 
out there? I mean, we don't want to be back here 2 years from 
now and still be talking about, you know, all of these issues.
    Mr. Missal. I agree with you. IT is----
    Mr. Sablan. It's unfair to our veterans.
    Mr. Missal.--an issue that comes up in a lot of different 
matters we work on.
    Mr. Sablan. All right. So let me ask one more question. 
Actually, my time is up, Thank you.
    The Chairman. Thank you.
    Mr. Sablan. Thank you.
    The Chairman. I appreciate that, Mr. Sablan.
    Mr. Sablan. Thank you very much.
    The Chairman. I do.
    Mr. Lamb, you have 5 minutes.
    Mr. Lamb. Thank you, Mr. Chairman, and thank you to all the 
witnesses for being here with us. This is such an important 
issue. We hear about it at every VA that we visit. I just think 
the VA employees themselves are kind of crying out for some 
extra help in a lot of cases, and we want to make sure we get 
it to them, and for the patients, too.
    I know a lot of our conversation today has probably been 
about doctors, and I apologize. I just came in. I wanted to 
talk to you about non-doctor jobs, particularly the medical 
technician and other types of jobs that require training cycles 
that are a little bit shorter and cheaper maybe from a 
community college or even from some non-college programs.
    I know we have--in Pittsburgh there is a great program 
called the Manchester Craftsman Guild and there are similar 
programs in different places around the country that are really 
good at training medical technicians.
    We have such a strong healthcare economy in Western 
Pennsylvania that those people get jobs and they are good-
paying jobs, 40, 50, 60 grand a year. They are competed for 
actually because these programs are so good at them. But when I 
met with some folks there the VA wasn't really even on their 
radar screen. They weren't thinking of it as a destination for 
their students.
    I was just curious, do any of the VA witnesses know, do we 
have formal partnership programs with kind of community 
organizations like this or with community colleges?
    Ms. Bonjorni. Sure. Thank you for the question. And that is 
an important one because medical technologists are a key part 
of our workforce, and they are on our list of shortages.
    Our national recruiters have been primarily focused on 
physician recruitment since that is where our focus needs to be 
in many cases. We also need to focus on these other 
occupations.
    We do have relationships with many schools across the 
country. Our health professional trainee programs allow us to 
bring in folks through different local schools. It sounds like 
we have at least one that we haven't reached out with to 
partner with, and we would be happy to meet with you to figure 
out how to do that.
    Mr. Lamb. Just so I know, where does the hiring authority 
exist for folks like that? Is it at the individual hospital 
level?
    Ms. Bonjorni. Yes.
    Mr. Lamb. OK.
    OK, now to doctors, again, for any of the VA witnesses, 
since MISSION Act has increased the amount of debt repayment, I 
know it has been a pretty short period of time, but do you have 
any data or feedback yet showing if that makes a difference or 
are you getting that impression?
    Ms. Bonjorni. Yes. Already we have seen a significant 
uptick in the usage among our physicians. The average award 
amount has gone up significantly since the MISSION Act passed 
and we were given more authority.
    Mr. Lamb. That's great. And did it go overall from, what, 
140 to $200, was that it or----
    Ms. Bonjorni. $1500, yes. And so our average award amount 
was around $77,000 prior to MISSION Act passing, and now it is 
up to 113,000--$115,000 on average.
    Mr. Lamb. OK. And what commitment are we asking people to 
get the full reward, how many years?
    Ms. Bonjorni. Well, each year that you are a part of the 
EDRP program, essentially it is paid in arrears. So it goes up 
to 5 years and it is paid out after you have completed the 
year.
    Mr. Lamb. OK. So you have to do 5 years to get the full 
benefit?
    Ms. Bonjorni. To get all the way to the $200,000.
    Mr. Lamb. Yes. Then in this program if you leave before the 
5 years are up, do you have to repay what was already given to 
you or----
    Ms. Bonjorni. No, because it is paid in arrears. You have 
done the time----
    Mr. Lamb. It is paid in arrears. That's good.
    Ms. Bonjorni.--once you get it.
    Mr. Lamb. See, when I was at the Department of Justice we 
had a similar thing, but if you left before the 3 years was up, 
you had to pay it back which I had to do when I ran for 
Congress.
    [Laughter.]
    Mr. Lamb. Yes. I like the way yours is structured. That is 
good for talent.
    On the issue of the geographic disparities, I have visited 
a few VA facilities in Pennsylvania, not in my district, that 
have a hard time keeping and attracting mental health, 
especially which I know is a system-wide problem, just kind of 
based on where they are, a little isolated.
    Has anyone talked about whether you could use loan 
repayment to give even an additional benefit to people that are 
willing to go to the areas where we really need people the 
most? Maine is another example I hear of a lot. Have we talked 
about increasing the rewards even further for those 
specifically targeted people?
    Ms. Bonjorni. Yes. Absolutely. We have a group right now 
that is looking at how to enhance our trainee recruitment among 
physicians and health profession trainees. As part of that 
review they have identified we need to have a more strategic 
approach to putting together our compensation packages so that 
facilities that are in those harder to reach areas understand 
exactly what kind of package they should put together to offer 
people to come on board.
    We are also focusing on recruiting those trainees and 
trying to find ways to match them across the country so that 
they can't confine positions not just where they are training, 
but also elsewhere. If they would like to, for example, move 
home to Maine or elsewhere.
    Mr. Lamb. OK. Yes. Great. Thank you for that. I mean, it 
strikes me that with the lower cost of living in a lot of these 
placements, and enhanced debt repayment or enhanced salary or 
all 3 could combine to a really nice, you know, incentive for 
somebody. But we might have to put our thumb on the scales a 
little bit more.
    Thank you, Mr. Chairman. I yield back.
    The Chairman. Thank you, Mr. Lamb.
    Mr. Cisneros, you are recognized for 5 minutes.
    Mr. Cisneros. Thank you, Mr. Chairman. Thank you all for 
being here today.
    The VA Office of Inspector General found that 3 frequently 
cited categories for reasons of VA staff shortages is due to a 
lack of applicants, non-competitive salaries and high staff 
turnover.
    Mr. Missal, in your opinion what more needs to be done to 
address the issues of high staff turnover and retention?
    Mr. Missal. A number of things should be done. First, I 
would like to emphasize that leadership at different facilities 
is so important. That really sets the tone of the facility. 
People want to work at a place where not only they feel like 
they are fulfilling the noble mission of VA, but that working 
with people who have the highest integrity. So working 
leadership is very important.
    Also, VA has a number of different recruitment tools that 
they can use and they do use. And there could be opportunities 
for them to use them more aggressively and more effectively.
    Mr. Cisneros. One of the recommendations you provided for 
was to engage employees as engaged employees are more 
productive and less likely to leave.
    Can you elaborate on that, please?
    Mr. Missal. Sure. It goes back to my previous answer, which 
is if employees feel that they own the mission, that they are 
part of helping veterans get the services and benefits that 
they so richly earn and deserve, then they are going to feel 
more committed to their job. If they feel like the job is not 
meeting those goals, then it is going to be much harder for 
them to want to stay.
    Mr. Cisneros. Thank you.
    Now the VA cannot accomplish this mission without dedicated 
people behind it. For at least 2 decades the Government 
Accountability Office has documented how the VA has fallen 
short with its management of human capital. In 2019, GAO 
provided 8 priority recommendations to VA for addressing human 
capital, which includes accurate counting of positions, 
assessing the effectiveness of recruitment, developing 
effective performance management systems, and addressing 
retaliation.
    Mr. Goldenkoff, for those outstanding priority 
recommendations what has been the VA's progress in implementing 
solutions?
    Mr. Goldenkoff. Well, it has been mixed. VA certainly 
recognizes and has embraced most of those recommendations. And 
we have been working with them on a regular basis to share some 
leading practices with them. But it has been taking time.
    For example, in the area of performance management systems, 
we would like to see more progress because that is so important 
to the transformation of the whole organization. It often 
starts with the performance management system, what you hold 
people accountable for.
    It is taking steps in the right direction. We are 
encouraged by that. It was interesting to hear about the 
engagement plan at the enterprise level. That can address some 
of these issues. You just mentioned the importance of 
engagement.
    We will continue to work with them.
    Mr. Cisneros. There has also been significant human capital 
leadership turnover at the VA over the last few years, 
including at VHA.
    In your view, how has this affected VA's ability to make 
significant strides in addressing outstanding recommendations?
    Mr. Goldenkoff. It has been an absolute impediment. What we 
have seen, both at VA and at all Federal agencies, is a direct 
connection between the human resource staff and the leadership 
within the human resource function and the mission side of the 
agency.
    Within the human resource area we found 2 significant 
issues. One was just a lack of internal control procedures that 
are so important to execute the human resource function. But 
then also in the capacity of the human resource specialists, 
there were shortcomings there as well. It's a perfect storm of 
problems there is a lot of the human resources offices not 
fully staffed. So that increases the workload. That creates 
burnout and engagement problems which increases turnover, which 
increases workload. And so you can see it is a non-virtuous 
cycle.
    It is so important to start with the human resource office 
because what they do is so important to everything else that 
the agency does.
    Mr. Cisneros. Thank you all for your testimony today.
    I yield back the balance of my time.
    The Chairman. Dr. Roe, I recognize you for 5 minutes.
    Mr. Roe. Thank you.
    Mr. Sitterly, I was having a really good day today until 
you mentioned the birthday of the Air Force and I realized I 
was older than the Air Force.
    [Laughter.]
    Mr. Roe. It messed up my whole day.
    Mr. Sitterly. Sorry, Doctor.
    Mr. Roe. A couple of things.
    One, the VA is out competing in a market across the country 
for very skilled people. There is a hospital in my region that 
has 100 openings right now. Every single police officer, I mean 
police chief and sheriff I have talked to in my district cannot 
find enough people to work in the police area, in law 
enforcement.
    The challenge you face is a nationwide challenge, both in 
and outside the VA. And I think you all in H.R. are in a unique 
position, one of the most important positions that is 
unrecognized in the VA to recruit these talented people. You 
have an incredible challenge in front of you to do that.
    As it was mentioned, Mr. Watkins has some great advantages. 
One, the physician management, we talked about it yesterday in 
the office, may be changing how the loan scholarships like the 
DOD uses to recruit doctors have a very effective to do. 80 
percent of us at some point in our career go through a VA, 
spend some time at a VA hospital during our medical training. 
So you have a chance to interact and show them that the VA, how 
this would be a great place to work.
    We mentioned our local hospital system, in the last 2 years 
of nursing school, paid the tuition, books and fees, and a 
small stipend. We were able to retain nurses. They stopped that 
program and low and behold we didn't have enough nurses.
    Those things are huge for young people now because of the 
student loan debt that they are facing across the country, $1.6 
trillion in student loan debt.
    We have advantages. And there are obviously some 
challenges. Geographic were mentioned. I think you mentioned 
some things that we are absolutely going to look at. The DOD 
paid family leave, and that is for young families that are 
raising children. I know I was--you know, matter of fact, we 
mentioned this yesterday in this office, but I volunteered my 
wife to be the one that stayed home with the kids. I go to work 
because that was a lot easier than taking care of babies.
    We mentioned some successes. What I would like for you all 
to do, and I want to just any of you take this question. If you 
had a magic wand, what would you do right now to streamline the 
hiring practices to make your job easier? What can we do to 
help is what I am asking?
    Mr. Missal, any of you all can jump on that and take it.
    Mr. Sitterly. I guess I will start that, Dr. Roe.
    I would ask Congress to do a little less in terms of 
additional authorities for hiring. I spent 43 years doing H.R. 
work and I never seen as complex an H.R. system as I see facing 
us right now, not just in the VA, across the entire Federal 
Government. There are 120 that we can count specific 
appointment authorities. And several people come under more 
than one authority. Veterans have 6 different appointment 
authorities, for instance.
    And I think the best characteristic or the best talent an 
H.R. specialist has to have is a law degree. It is so complex. 
It is very difficult.
    Thank you to this Congress. You asked us to stand up an 
H.R. academy and we did that in Baltimore. I attended it 
personally where we did nurse pay setting. It took me an entire 
day to learn how to do one nurse pay setting. It is very, very 
complex.
    So I would ask that we work together, sir, to simplify. We 
are working with OPM as well to simplify all of the authorities 
that we have.
    Mr. Roe. Well, we don't know those. And so we have to have 
you all to help us with that because I think we could help not 
only the VA, that's what our committee is, but we could help a 
lot of other agencies if we could do just that. But we need 
your expertise to tell us where the road blocks are.
    Mr. Missal. Yes, sir.
    Mr. Roe. Before we go, because we haven't got time to go 
through all that today. But, I mean, that is maybe a round 
table that we do to get this hammered down so we can make your 
job more efficient and easier.
    The Choice Act we passed in 2014 increased the number of 
GME slots, about 1,500 positions, for primary care, mental 
health and others.
    Do you know how many of those have been created, how many 
of those 1,500 slots are out there available now?
    Ms. Bonjorni. Right now it just over 1,300, so we have 
about 200 to go.
    Mr. Roe. And so we are close. That is very good. And how do 
you decide where they are positioned, where they are located?
    Ms. Bonjorni. Well, I believe the language in the law did 
ask us to try to move those toward more rural areas.
    Mr. Roe. Yes.
    Ms. Bonjorni. And so that has been a bit of the delay in 
getting them up and running because it requires us to create 
the infrastructure to get out to those rural areas. So we look 
at where the most need is.
    Mr. Roe. And which states have had the most GME positions? 
I hope it is Tennessee.
    [Laughter.]
    Ms. Bonjorni. I can't answer that one off the top of my 
head, sir.
    Mr. Roe. OK. And I guess the last question on this very 
quickly is just most of these are probably with pre-existing 
programs that already had GME slots, or were these programs 
that did not have any GME slots and it started? That is much 
harder.
    Ms. Bonjorni. It is. And our academic affiliate office has 
worked to create a grant program to actually help build out 
that infrastructure in the places where they don't have 
programs.
    Mr. Roe. So if we could get that, Mr. Chairman. I know you 
are interested in that----
    The Chairman. Yes.
    Mr. Roe.--because that was one of your great ideas in 2014. 
So if we could get all that sort of compiled up, we would like 
to see that.
    Thank you, all. My time is expired. I yield back.
    Mr. Chairman. Dr. Roe, and I am especially also interested 
in that, the idea. We have been talking offline here about the, 
is it USU?
    Mr. Missal. Yes, sir, that's correct. USU. Uniformed 
Services University.
    The Chairman. Uniformed services, they have capacity there. 
I am intrigued with that idea as well. That is wonderful.
    Well, I would like to thank the witnesses for their 
appearances and their testimony today. Thank you all for what 
you do for our country and for our veterans.
    All members will have 5 legislative days to revise and 
extend their remarks, and include extraneous material.
    Again, thank you for appearing before us today. This 
hearing is now adjourned.
    [Whereupon, at 3:51 p.m., the committee was adjourned.]

   
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                         A  P  P  E  N  D  I  X

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                    Prepared Statements of Witnesses

                              ----------                              


                 Prepared Statement of Daniel Sitterly

    Chairman Takano, Ranking Member Roe, and Members of the Committee. 
Thank you for the opportunity to discuss the Department of Veterans 
Affairs' (VA) ability to be a competitive employer in the health care 
and information technology industries, including any impacts of rising 
labor costs, provider pay structure, and the impact of previous hiring 
and retention related efforts. I am joined today by Ms. Jessica 
Bonjorni, the Acting Assistant Deputy Undersecretary for Health for 
Workforce Services, Veterans Health Administration (VHA), and Mr. John 
Oswalt, the Deputy Chief Information Officer for Information Technology 
Resource Management, Office of Information Technology (OIT).
            competitive employer in the health care industry
    As the operator of the largest integrated health care delivery 
system in America, VA successfully attracts and retains high quality 
talent and VA's overall workforce has consistently grown by 
approximately two to 5 percent annually over the last 5 years. This 
growth is responsive to an increased demand for services, which is the 
result of improved access, reduced wait times, improved quality, 
enhanced Veteran satisfaction, and overall mission growth. As of June 
30, 2019, VA has 386,000 employees with over 89 percent of VA employees 
serving in VHA. Most of the additional staffing capacity needed in VA 
in the past 5 years has been in clinical occupations, which accounts 
for 81 percent of overall growth in VA. VA has consistently maintained 
turnover rates at or below 9.5 percent for the past decade, which is 
low when compared with other large Cabinet-level agencies that average 
11 percent (as published by the Office of Personnel Management's (OPM), 
FedScope), or with health care industry turnover rates of 20-30 percent 
(per the United States (U.S.) Bureau of Labor Statistics). VA has also 
ranked quite favorably on the list of Best Places to Work in the 
Federal Government, as compiled by the Partnership for Public Service, 
reflecting improvements in employee engagement.
    Despite the foregoing successes in staffing growth, the ability for 
VA to remain competitive for some occupations is challenged by 
compensation inflexibilities faced in the Federal pay system. For 
example, the San Francisco medical center is in one of the highest 
cost-of-living markets. Highly specialized surgeons in that market 
average nearly eight hundred thousand dollars in compensation, while VA 
is capped at about 50 percent of that rate. Statutory limits on total 
compensation mean that VA must spend considerably more to contract out 
critical healthcare services such as cardiothoracic surgery and 
interventional radiology, as a lower cost alternative.
                   impacts of the rising labor costs
    VA is extremely appreciative of the work Congress has done and 
continues to do in providing flexibilities to support the recruitment 
and retention of talent to care for our Nation's Veterans. However, VA 
still contends with ongoing pay challenges presented by the limitations 
of multiple pay systems and compounded by rising labor costs. While VA 
utilizes many incentives available under statute to recruit and retain 
talent successfully, these incentives provide only a short-term 
solution. In many situations, existing flexibilities are insufficient 
to support a strategic approach to attracting and retaining talent. 
Incentives do not necessarily eliminate salary disparities with 
competing employers and therefore, do not address long-term gaps in 
pay. As the demand for healthcare providers continues to outstrip 
supply (BLS Healthcare Occupation Outlook; American Association of 
Medical Colleges report, 2019), private sector employers are nimble 
enough to adjust quickly to changes in local labor markets by modifying 
starting salaries and total compensation packages, as needed, to 
attract top talent. Meanwhile, VHA and other Federal employers are 
restricted by Federal statutes and regulations regarding the 
establishment of pay rates, and often require years of pay disparities 
to exist before lengthy processes can respond to market changes. This 
leaves Federal agencies at a disadvantage when competing for talented 
employees. While VA has employees and applicants who are willing to 
accept a lower salary to be part of an organization with such an 
important mission, VHA faces increasing challenges in its ability to 
attract or retain quality health care professionals when the salary gap 
continues to increase.
    The General Schedule (GS) is the predominant pay scale for Federal 
employees and is based on the level of difficulty, responsibility, and 
qualifications required for the position. By law, GS base rates are 
adjusted annually based on average increases in private sector salaries 
as measured by the Employment Cost Index, except as otherwise provided 
under a Presidential alternative plan. Annual locality pay adjustments 
for GS employees are also provided by law but are subject to a 
Presidential alternative plan. As part of the Fiscal Year (FY) 2020 
budget, the President has proposed that no increases in GS base rates 
or locality rates be made in January 2020. The Administration supports 
reforming the GS pay system so that it is more performance-based and so 
pay levels and adjustments are targeted to address occupation-specific 
pay disparities. As a first step, the Administration has proposed 
legislative changes that would slow the frequency of GS longevity-based 
step increases and make funding available to provide targeted 
performance-based pay increases for mission-critical occupations. To 
request Special Salary Rates or adjustments to these scales, VA must 
prepare comprehensive documentation on market conditions and submit the 
request to OPM, which coordinates special rate requests with other 
agencies employing the same type of employees, for approval. The 
Federal Wage System (FWS) is a uniform pay-setting structure that 
covers Federal blue-collar hourly employees. OPM oversees this pay 
system, with the support of the Department of Defense (DoD), which has 
responsibility for conducting wage surveys and coordinating special 
rate requests. These existing pay systems do not meet the fluid and 
dynamic nature of today's market. VHA's volume of positions to hire is 
tremendous, reaching more than 45,000 new hires in Fiscal Year 2018 to 
replace workers due to turnover and grow the workforce to meet Veteran 
demand. As of the end of the third quarter Fiscal Year 2019, VHA has 
more than 28,000 new hires for the year and hiring for Fiscal Year 2019 
has continued to outpace separations. The constant need for new hiring 
due to mission growth and turnover is reflected in more than 43,000 VHA 
vacancies. As a result, it is necessary for the pay structure to 
support VHA's ability to hire qualified candidates as quickly as 
possible to support access to care for Veterans.
    In addition to the limited flexibility in establishing new locality 
areas and the overall pay structure, the GS pay system and the FWS 
require the use of antiquated rules and formulas that do not provide 
for market driven pay-setting latitude. Most GS employees are entitled 
to locality pay, which is a geographic-based percentage rate that 
reflects pay levels for non-Federal workers in certain geographic areas 
as determined by surveys the U.S. Bureau of Labor Statistics conducts. 
Those localities that do not fall under a specified locality pay 
schedule are placed on the Rest of United States (RUS) schedule 
covering all other localities not otherwise having a specified 
schedule. VHA facilities serve multiple local labor markets, to include 
heavily populated cities, suburban towns, and low populated rural 
areas. Many of these areas receive locality pay under the RUS schedule 
because they do not meet the criteria: for a separate locality pay 
area; as an area of application to a locality pay area by being 
adjacent to the metropolitan statistical area; or as a combined 
statistical area comprising the basic locality pay area and having 
2,500 or more GS employees. VHA facilities in smaller counties and 
rural towns generally offer salaries significantly lower than the local 
labor market because they do not have enough GS employees to be 
considered for their own locality pay schedule. It is important to also 
note that, wherever VA facilities are located, there is a need for a 
robust and fully capable IT workforce. OIT faces some of the same 
challenges VHA does to include outdated position classification 
guidance that inhibits OIT's ability to attract and retain top tier IT 
talent in highly competitive job markets.
                         provider pay structure
    VHA currently functions under multiple personnel systems (title 38, 
Hybrid title 38, and title 5), each with multiple pay systems that 
contain distinctive variations and complexities. VHA hires health care 
providers under title 38 and associated health professionals under 
Hybrid title 38 (i.e., employees are covered under title 38 for 
appointment, advancement, and some pay structures, but for all other 
purposes are covered under title 5). Both authorities allow the 
Secretary of VA broad flexibility in setting pay based on both the 
individual's qualifications and conditions in the local market. VHA 
hires non-clinical employees under Government-wide title 5 authorities, 
with pay set under the GS and FWS.
    VHA needs the ability to offer competitive salaries to recruit and 
retain employees in various occupations that have much higher rates of 
pay in the private sector, particularly in larger cities and rural 
areas. VHA is in the process of developing a comprehensive legislative 
package that would provide additional flexibilities for its workforce.
  impact and success of previous hiring and retention related efforts
    Despite the above challenges, VA employs a variety of tools to 
attract and retain quality talent. Those tools include direct hiring 
authorities, recruitment and retention flexibilities, hiring 
initiatives, improved employee engagement, workforce planning, targeted 
recruitment of Servicemembers transitioning from DoD, national 
recruitment programs for hard-to-fill occupations and specialties, and 
strategies for filling medical center director positions.
    VA has successfully used direct hire authority for more than 71 
percent Cyber Security / Information Security (Cyber / IT) of its 
hiring actions for 12 months, ending June 2019.
    The VA Maintaining Internal Systems and Strengthening Integrated 
Outside Networks (MISSION) Act of 2018 authorized or expanded several 
programs intended to recruit and retain health care providers in VHA, 
to include an increase in the maximum amount of student loan debt that 
may be reimbursed under the VHA Education Debt Reduction Program 
(EDRP); authorizing designated scholarships for physicians and dentists 
under the VA Health Professional Scholarship Program (HPSP); 
establishing the VA specialty education loan repayment program to 
incentivize VHA employees to pursue education and training in medical 
specialties for which VA determines there is a shortage; and 
establishing a pilot program for the Veterans Healing Veterans Medical 
Access and Scholarship program.
    The new OIT Office of Human Capital Management developed and 
implemented a robust Recruitment and Talent Acquisition Strategy to 
reduce the time to hire, attract, and brand OIT as an employer of 
choice. OIT has simultaneously created a first-ever comprehensive 
staffing model that identifies all existing workload drivers and 
associated workforce profiles giving OIT the necessary analytical tools 
to determine actual staffing requirements as they emerge alongside new 
technologies.
    During this past fiscal year, OIT rolled out many new and expanded 
recruitment and talent acquisition strategies to include: resume mining 
via USAJOBS; gaining access to critical talent identification platforms 
like LinkedIn; providing opportunities for students, recent graduates, 
Presidential Management Fellows, military spouses; and offering 
noncompetitive appointments designed to attract disabled Veterans and 
non-Veterans. OIT continues to educate hiring managers on the vast 
number of recruitment and hiring flexibilities available to them.
    VA strategically allocates recruitment, retention, and relocation 
(3R) incentives to close skills gaps and provide greater flexibility in 
the recruitment, relocation, and retention of highly qualified VA 
professionals. In Fiscal Year 2018, VA spent $52.4 million on 3R 
incentives. Of that total, $41.2 million (78.6 percent) was directed 
toward VHA shortage occupations (i.e., the 10 clinical and 8 non-
clinical occupations identified by facilities as shortage occupations 
via the VHA workforce planning cycle).
    For the second year in a row, OIT has offered Cyber-Retention pay 
incentives to IT specialists, which has been beneficial in keeping 
prized cyber talent within VA.
    VA uses EDRP to secure health care providers in specific, difficult 
to fill positions for up to 5 years by providing student loan payment 
reimbursements. Positions eligible for EDRP are prioritized based on 
local recruitment and retention requirements to meet specific staffing 
needs. In Fiscal Year 2018, VA spent $44 million on EDRP. Section 302 
of the MISSION Act enhanced EDRP by increasing the maximum award amount 
from $120,000 to $200,000, not to exceed $40,000 per year. 
Additionally, section 306 ensures clinical staff working at Vet Centers 
are eligible to participate in EDRP.
    During Fiscal Year 2018, VA awarded 1,071 new scholarships in the 
Employee Incentive Scholarship Program and supported 3,133 employees 
actively participating in the educational phase of their scholarship 
with funding totaling $29 million. The top five scholarship-funded 
occupations were: Registered Nurse, Licensed Practical/Vocational 
Nurse, Social Worker, Physical Therapist, and Medical Technologist/
Medical Records Technician. The VA Learning Opportunity Residency 
program allows nursing, pharmacy, and medical technology students who 
have completed their junior year in an accredited clinical program to 
gain valuable clinical experience at a VA health care facility for up 
to 800 hours, with pay. From Fiscal Year 2015 through Fiscal Year 2018, 
VA funded 339 student salaries for nurses, pharmacists, and medical 
technology students for a total of $4.2 million. VA also awarded $5.2 
million for new and continuing awards to 201 nursing, physical therapy, 
and physician assistant participants in the HPSP. HPSP awards 
scholarships to students receiving education or training in a direct or 
indirect health care services discipline to assist in providing an 
adequate supply of such personnel for VA and the U.S.
    Targeted hiring initiatives have proven to be an extremely 
effective way of hiring talent where it is needed most. In 2017, VA 
introduced a Mental Health Hiring Initiative, committing to hiring 
1,000 new mental health providers by June 30, 2019, as part of VA's No. 
1 clinical priority to eliminate Veteran suicide. By January 31, 2019, 
VA surpassed its goal by hiring 3,956 mental health providers resulting 
in a net gain of 1,045 additional mental health providers. This 
initiative included VA's inaugural virtual trainee hiring fair where 85 
facilities participated to connect, match, and place interested 
candidates into mental health positions across VHA. Through the trainee 
hiring fair, 74 mental health trainees accepted job offers at a matched 
location after completion of their training. This initiative laid the 
groundwork for a permanent trainee hiring capability in VHA.
    Hire Right Hire Fast (HRHF) is a hiring model initiated in 2017 for 
the medical support assistance occupation. The goal for HRHF was to 
reduce the time it takes to hire and fill open positions within this 
occupation. This was achieved by developing applicant registers and 
implementing specific actions integral to hiring success. This program 
drove time-to-hire to under 60 days (formerly 180 days) and reduced 
open positions to 9.4 percent. Based on the preliminary results, HRHF 
will also be extended to the Housekeeping Aid occupation. The HRHF 
model was found to be most impactful in occupations that exhibit few 
requirements to entry (e.g., no licenses, no certifications, etc.); 
high loss rates; and large onboard full-time employee equivalent 
requirements.
    VHA's Workforce Planning Cycle places direct emphasis on optimizing 
VA's most vulnerable professions. During this process, VHA identifies 
staffing shortage occupations; assists with current and future 
workforce planning efforts and challenges; and conducts other workforce 
planning activities. In response to requirements in the VA Choice and 
Quality Employment Act of 2017, the workforce planning cycle was 
redesigned to provide a structured, data-driven approach for 
identifying clinical and non-clinical shortage occupations at the 
health care system level. Each year, VHA publishes a staffing shortage 
report that identifies the results from the Workforce Planning Cycle. 
During the Fiscal Year 202018 cycle, recruitment challenges were 
selected as the primary drivers for 64 percent of the shortage 
occupations and specialties, while the remaining 36 percent were 
primarily associated with retention challenges. The most commonly cited 
root causes for shortage occupations included competition with other 
health care employers and a limited supply of candidates. The most 
commonly cited strategies to address staffing challenges included non-
competitive hiring flexibilities and utilization of recruitment and 
retention incentives.
    As a subset of the military to civilian transition, DoD and VA have 
combined efforts to recruit transitioning Servicemembers into vacant 
positions within VA. In a 2015 study of over 8,500 Veterans, active 
duty Servicemembers, National Guard and Reserve members, and military 
dependents, 55 percent of the participants identified ``finding a job'' 
as their most significant transition challenge. The goal of this effort 
is to create an additional candidate pipeline for entry level job 
opportunities. Beginning in Fiscal Year 2018, VHA launched a direct 
marketing campaign to target military medical professionals currently 
enrolled in the transition process for recruitment into VHA employment. 
VHA uses the VA-DoD Identity Repository data to identify 
Servicemembers, their discharge date, and their military occupational 
specialty or specialty codes. In Fiscal Year 2018, VHA's total Veteran 
hires increased by 36 percent, totaling over 17,000. VA is also 
partnering with DoD to support hiring military spouses for mission-
critical and hard to fill positions. Military spouses represent a 
robust pipeline of talent for health care and science, technology, 
engineering, and mathematics occupations nationwide. Through the 
Military Spouse Employment Partnership, VA will have direct access to 
points of contact at military installations where we are able to share 
job opportunities and access resumes of qualified candidates for 
noncompetitive employment.
    The VHA National Recruitment Program (NRP) provides a small in-
house team of skilled professional recruiters employing private sector 
best practices to the Agency's most critical clinical and executive 
positions. The VHA-NRP works directly with VHA's Office of Rural 
Health, other national program offices, Veterans Integrated Service 
Network Directors, VA Medical Center (VAMC) Directors, clinical 
leadership, and local VAMC Facility Recruitment Liaisons to develop a 
comprehensive, client-centered recruitment strategy that addresses both 
current and future critical needs.
    VHA has made significant progress in efficiently filling medical 
center director (MCD) positions through the implementation of a 
vigorous national recruitment strategy which includes using existing 
legal authorities to fill MCD positions and leveraging critical pay 
authority to adjust the rate of pay up to $201,900 (as of January 2019) 
for 39 Complexity Level 1A MCD positions. In addition, the Agency has 
adopted a 120-day time-to-fill standard for MCD positions. The result 
has been a significant reduction in the MCD opening positions from as 
high as 25 percent in Fiscal Year 2015 to 11 percent in Fiscal Year 
2018.
    The historically high vacancy rate in OIT resulted from an increase 
in attrition rates due to retirements, transfers, and losses to other 
Federal agencies in highly competitive job markets. As mentioned above, 
OIT has expanded its recruitment efforts beyond the normal USAJOBS 
announcement and has been very successful in reducing its vacancy rate. 
One area where OIT has made great strides is hiring from outside of 
OIT. While developing and promoting existing staff is a key component 
of any human capital strategy, internal hiring creates a new vacancy 
elsewhere in the organization. By encouraging hiring managers to 
consider a wider catchment area outside of OIT to fill positions, OIT 
has increased its net number of new hires lowering the overall vacancy 
rate.
    Improved outcomes show that VA is on the right track and that 
Veterans are being well served. Recent studies have reported that 
Veterans are receiving the same or better care at VAMCs as patients at 
private sector hospitals. Since 2014, the number of annual appointments 
for VA care is up by almost 5.0 million, with more than 58 million 
appointments scheduled in VA facilities last Fiscal Year and 1.5 
million extra appointments expected by the end of this fiscal year. 
According to a study in the Journal of the American Medical 
Association, VA average wait times are shorter than those in the 
private sector for primary care, as well as two out of three specialty 
care areas. VA recently reached a telehealth milestone, achieving more 
than 1 million video telehealth visits in Fiscal Year 2018, a 19 
percent increase in video telehealth visits over the prior year. This 
technology gives Veterans access to the timely, quality care they 
deserve, without having to travel great distances to a VA facility. As 
published in a March 2019 article in the Annals of Internal Medicine, 
Veterans who choose VA for their health care have a greater chance of 
survival beyond 30 days after hospital discharge, if they were admitted 
for heart attacks, severe chronic lung disease, heart failure and 
pneumonia as compared with non-VA hospitals.
    In the second quarter of Fiscal Year 2019, 87.6 percent of 3.3 
million Veterans surveyed said they trust VHA outpatient services, with 
an overwhelming majority (92.1 percent) of VAMCs improving in that 
trust score from fall of 2017. In December 2018, the Partnership for 
Public Service released its Best Places to Work in the Federal 
Government rankings where VA ranked sixth out of large Federal 
agencies. As one of the top ten large agencies to work for in the 
Federal Government, VA continues to enhance employee engagement, 
focusing on multiple touchpoints to receive employee feedback. VA's 
Employee Engagement Council periodically meets to address and implement 
solutions. In April, the Secretary approved VA's first ever Employee 
Engagement Enterprise-Wide Plan which emphasizes principles of servant 
leadership. Leaders at all levels seek feedback year-round, in person 
and online, to ensure the Agency continues making progress. High 
employee engagement at VA will positively impact the customer service 
Veterans receive daily.
    In summary, VA is very appreciative of the numerous recruitment and 
retention authorities granted by Congress to help support a high-
quality workforce providing the best possible care to Veterans. 
However, the competition for talent in the health care industry is 
increasingly competitive. Shortages of physicians and nurses abound 
nationwide. Medical schools and private hospitals are implementing 
innovative and progressive solutions to address these deficits both in 
the short and long term. Our ever-expanding reliance on IT to 
accomplish VA's mission requires us to remain competitive in the IT job 
market and adopt new ways of thinking about recruitment and retention 
of IT talent.
    VHA has fallen significantly behind private sector health care 
recruitment and compensation practices, which are aggressive and 
effective at targeting an array of new employees from entry levels to 
experienced professional staff. VHA has struggled with staying 
competitive and being an employer of choice with the limitations placed 
on the Agency under the current pay systems and with the increased 
demands to hire additional staff quickly to meet patient needs and 
support our Veterans. Additionally, to position ourselves for success 
we must have the right level of IT and support. Mission success depends 
on IT success. We look forward to working with this Committee on 
opportunities to enhance VA's ability to attract top talent. This 
concludes my testimony. My colleagues and I are prepared to respond to 
any questions you may have.
                                 ______
                                 

                Prepared Statement of Michael J. Missal

    Chairman Takano, Ranking Member Roe, and members of the Committee, 
thank you for the opportunity to discuss the Office of Inspector 
General's (OIG's) oversight of how ongoing recruitment and hiring 
challenges within the Department of Veterans Affairs (VA) can affect 
patient access to quality care. The mission of the OIG is to oversee 
the efficiency and effectiveness of VA's programs and operations 
through independent audits, inspections, reviews, and investigations. 
In response to Congressional mandate, the OIG has examined and reported 
on staffing concerns within the Veterans Health Administration (VHA) 
for the past four consecutive years (with the 2019 report expected to 
be released by September 30), and has raised issues with shortages or 
related issues whenever appropriate in the context of its other routine 
examinations of programs and processes. While it has made some 
significant strides, VHA continues to face a number of challenges to 
reaching full staffing.
    This statement focuses on the barriers and challenges the OIG has 
identified in VA's efforts to recruit and retain a highly qualified 
workforce that delivers health care to millions of veterans. The OIG 
also acknowledges areas in which VA has made some laudable progress. 
The OIG has identified frequent changes (and lapses) in leadership and 
workforce issues as major management challenges for VA and consistently 
found staffing shortages as a root cause for many of the problems in 
veterans' care and access identified in oversight reports. VA's 
inability to adequately recruit, onboard, and retain clinicians and 
support staff, particularly within specific service areas, reflects 
problems with competitive pay, field-wide shortages with some 
professions or positions, leadership and climate, planning, and other 
factors. Efforts to remediate these problems are hampered by VA's 
inability to maintain accurate medical facility vacancy numbers.
    VA has experienced chronic healthcare professional shortages since 
at least 2015. It is critical for VA to move forward with developing 
staffing models calculated from defined requirements based on accurate 
data and implementing OIG recommendations related to hiring and 
retention. VA must enhance its ability to maintain a full workforce 
given the demand for VA health care, even as community care options are 
expanded. This is particularly important given an increasingly 
competitive recruitment environment and anticipated healthcare worker 
shortages in several practice areas. The OIG reports highlighted in 
this statement provide stakeholders with examples of areas where the 
results of OIG reviews found instances of staffing shortages impacting 
the delivery of care.
               congressionally mandated staffing reports
    Congress has passed at least three laws since 2014 requiring a 
periodic accounting of vacancies within VHA, all of which have related 
OIG reporting requirements on VA's occupational shortages.\1\
---------------------------------------------------------------------------
    \1\ Veterans Access, Choice, and Accountability Act of 2014, 
Section 301; VA Choice and Quality Employment Act of 2017, Section 201; 
and VA MISSION Act of 2018, Section 505.
---------------------------------------------------------------------------
  oig determination of veterans health administration's occupational 
                staffing shortages for fiscal year 2018
    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\ Although the 2018 report 
was the fifth OIG report on staffing shortages within VHA, it was the 
first report that included facility-specific data reported by leaders 
at 140 VA medical centers.\3\ Users can examine the particular self-
reported needs of an individual facility as opposed to only national 
data. It was also the first report to include nonclinical positions 
(such as human resources, police, and custodial personnel) as required 
by the VA Choice and Quality Employment Act of 2017 (PL 115-46).\4\ 
These nonclinical occupations ultimately affect the ability of VHA 
facilities to provide quality and timely patient care in a safe and 
clean environment. The facility-specific results underscore for readers 
how variable the clinical and nonclinical needs are from one medical 
facility to another.
---------------------------------------------------------------------------
    \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.
    \3\ OIG Determination of Veterans Health Administration's 
Occupational Staffing Shortages for Fiscal Year 2018, June 14, 2018.
    \4\ VHA's own rankings in previous reports included Human Resources 
Officer as a position with shortages, but because the statute had 
excluded administrative positions, OIG did not include Human Resources 
Officer in the ranking methodology.

    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. The data 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.
    These results demonstrated that there are some clear commonalities, 
but the results also revealed wide variability in occupational 
shortages reported by individual medical centers. This was critically 
important to recognize because facilities have distinct staffing needs 
that must be considered in light of the facility's mission and its 
local resources. For example, a rural facility specializing in treating 
mental health needs may be staffed differently than an urban facility 
providing a broad array of services. Moreover, the rural facility may 
have a much smaller pool of qualified behavioral health professionals 
from which to recruit than VA facilities in urban areas.
    The OIG's 2018 report also identified challenges to meeting 
staffing goals. Although hiring has increased, in 4 years of publishing 
the determination of VHA occupational shortages, the OIG has repeatedly 
noted the relatively long onboarding process and difficulty in finding 
suitable candidates. Medical center directors were able to use free 
text to explain the reasons for shortages, which varied significantly. 
OIG staffs' thematic analysis of the responses resulted in three 
frequently cited categories: (1) lack of qualified applicants, (2) 
noncompetitive salaries, and (3) high staff turnover.\5\ Facilities 
reported recruitment challenges because of tough competition for 
quality healthcare professionals, and were using various recruitment 
tools such as special salary rates; recruitment, relocation, and 
retention incentives; and the education debt reduction program. The 
noncompetitive salaries were noted as a particular issue with 
recruitment of nonclinical staff, such as police officers. The survey 
responses noted that high turnover amongst high-performing staff had 
follow-on impacts as remaining staff became burned out from working 
overtime to cover existing vacancies. Additionally, facilities noted 
that both OPM classification appeal downgrade decisions and outdated 
OPM classifications affected their ability to offer competitive 
salaries and advancement opportunities within the organization, 
resulting in VHA being a less competitive employer for new staff and 
less likely to retain highly skilled staff. An additional challenge for 
managers is navigating the recruiting and on-boarding process. In a 
separate OIG report, one manager described the recruitment process at 
their facility as being ``exquisitely problematic.'' \6\
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    \5\ The thematic analysis categories were developed after reading 
all the responses. Responses that fell outside of the developed 
categories were classified as ``other.''
    \6\ Leadership, Clinical, and Administrative Concerns at the 
Charlie Norwood VA Medical Center Augusta, Georgia, November 2, 2017.
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                        va's corrective actions
    Staffing for future needs requires hiring in anticipation of future 
losses, as well as ongoing and projected changes in clinical demand, 
staffing productivity, and allocation of personnel. The OIG recognizes 
that VHA has made progress in implemented staffing models in specific 
areas such as primary care and inpatient nursing. However, operational 
staffing models that comprehensively cover other critical occupations 
are still needed. Well-developed predictive staffing models would allow 
VHA to better assess and implement effective measures to address 
staffing shortage concerns. It is not enough, for example, to address 
doctor and nurse positions if the staffing model also does not provide 
for staff to schedule those providers' appointments, handle lab 
capacity for their testing, for sterile processing staff to clean their 
instruments, or the custodial staff to clean additional rooms.
    The Fiscal Year 2018 report's recommendations repeat the OIG's 
previous calls for VHA to develop additional comprehensive staffing 
models that address national needs, while supporting flexibility at the 
facility level. This approach would help ensure taxpayer dollars are 
invested in delivering the highest quality of care to veterans as 
promptly as possible. These staffing models, however, cannot be 
completed without accurate data. As detailed below, in a recent report 
examining VA's self-reported staffing data, the OIG found that VA and 
some of its medical facilities were unable to provide accurate data on 
the numbers of vacancies. Focusing on serving the individual and 
aggregate needs of veterans in different geographic areas and using 
that understanding to develop comprehensive staffing models will help 
VA achieve more efficient and targeted hiring and retention practices. 
Both of the Fiscal Year 2018 report's recommendations are open as of 
September 18, 2019, despite the Executive in Charge for VHA providing a 
target date for completion of May 2019. The recommendations call on VHA 
to refine and formalize its position categories for clinical and non-
clinical staff across all facilities.
    In September 2017, the OIG made the following four recommendations 
to the Acting Under Secretary for Health in the Fiscal Year 2017 
report.

        1. We recommended that the Acting Under Secretary for Health 
        ensure that the Veterans Health Administration implements 
        staffing models for critical need occupations. VA's self-
        determined Targeted Completion Date: September 2018.

        2. We recommended that the Acting Under Secretary for Health 
        review the Veterans Health Administration report on regrettable 
        losses and implement effective measures to reduce such losses. 
        Closed on August 2, 2018.

        3. We recommended that the Acting Under Secretary for Health 
        continue incorporating data that predict changes in veteran 
        demand for health care into its staffing model. VA's self-
        determined Targeted Completion Date: September 2018.

        4. We recommended that the Acting Under Secretary for Health 
        continue assessing the Veterans Health Administration's 
        resources and expertise in developing staffing models and 
        determine whether exploration of external options to develop 
        the above staffing model is necessary. VA's self-determined 
        Targeted Completion Date: June 2018.

    VHA has provided information on the progress they have made in 
addressing the recommendations, and OIG staff will continue to review 
VHA's future work.
      staffing and vacancy reporting under the mission act of 2018
    The OIG now reports on how VA can improve its administration of a 
website that publishes staffing and vacancy information in accordance 
with the MISSION Act.\7\ Specifically, Section 505 of the MISSION Act 
requires VA to publish by departmental component, such as the Veterans 
Benefits Administration, National Cemetery Administration, and staff 
offices, or by medical facility for VHA, the following information:
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    \7\ Under the John S. McCain III, Daniel K. Akaka, and Samuel R. 
Johnson VA Maintaining Internal Systems and Strengthening Integrated 
Outside Networks Act of 2018 or VA MISSION Act of 2018, VA's Office of 
HR&A coordinates the quarterly retrieval, aggregation, validation, and 
publication of the data (PL 115-182).

      The number of current personnel
      The number of employment gains and losses processed 
during the previous quarter
      The number of staff vacancies by occupation
      The percentage of new staff who were hired within the 
Office of Personnel Management's (OPM) time-to-hire target of 80 days

    The MISSION Act also requires VA to report annually on the steps 
taken to achieve full staffing capacity and any additional funds needed 
to achieve that mark. The first required OIG report assessing how VA is 
meeting this mandate found VA to be in partial compliance with the 
Section 505 requirements of the MISSION Act.\8\ Generally, OIG found 
that VA reported its current personnel levels and time-to-hire data as 
prescribed. However, the staff vacancy, as well as the gains and 
losses, used alternative aggregation methods and were not sufficiently 
transparent for stakeholders to use the information reliably to track 
VA's progress toward meeting its full staffing capacity.
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    \8\ Staffing and Vacancy Reporting under the MISSION Act of 2018, 
June 25, 2019.
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                   vacancy information lacked detail
    Section 505 of the MISSION Act requires that VA publish the number 
of vacancies by occupation.\9\ Instead, in each quarterly release, VA 
presented its vacancy data by occupational groups and job families, 
which are broad categories covering a set of related job functions. 
Most of the reported vacancies were generalized under the Medical, 
Hospital, Dental, and Public Health Group, referred to as the 0600-
occupational group. However, this group includes clinical positions, 
such as doctors, nurses, and pharmacists, as well as nonclinical 
positions in medical records administration, housekeeping management, 
and consumer safety. The lack of specificity is significant because, as 
currently reported by VA, vacancy numbers for the 0600-occupational 
group do not sufficiently identify position-specific staffing needs in 
VHA. For example, VA reported in November 2018 that the North Florida/
South Georgia Veterans Health System had approximately 347 full-time 
equivalent (FTE) vacancies within the 0600-occupational group. That 
number is too broad to provide meaningful insight on specific 
vacancies, such as nurses versus physicians. VA's Office of Human 
Resources and Administration (HR&A) staff stated they did not list 
vacancies by series because it would reduce the readability of the 
report and because they lacked enough staff to break down the data by 
series. While these concerns may have merit, the OIG maintains that 
reporting the data by specific job or position would improve the value 
to VA and the public.
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    \9\ In implementing 5 U.S.C. Sec.  51, OPM identified 676 
occupational series (or occupations) divided into 59 occupational 
groups and job families as of September 2018.
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               gains and losses not reported as required
    The MISSION Act requires VA to publish the number of employment 
gains and losses that were processed during the quarter preceding the 
data's publication date. However, VA did not follow these 
specifications and, instead, published data on all actions that took 
place during all four quarters of Fiscal Year 2018, instead of only the 
fourth quarter as required. VA maintained that a report covering a 
single quarter would not capture losses that were initiated but not 
processed until after the quarter concluded. However, the MISSION Act 
does not require a complete accounting of all gains and losses, only 
those that were processed during the quarter. VA should adjust this 
methodology to ensure that data are reported in compliance with the 
MISSION Act.
        published staffing and vacancy data lacked transparency
    The OIG team identified opportunities for VA to improve the 
administration of posted personnel data by clearly articulating any 
caveats or context required to understand published figures. For 
example, VA did not disclose in their Section 505 staffing reports that 
it was aware the medical facility vacancy numbers were overstated. HR&A 
and VHA officials told the OIG team that inconsistencies and how the 
human resources software, H.R. Smart, was used created problems in 
counting vacant positions. Since December 2017, VA has been undergoing 
a process to correct this issue. Nevertheless, to improve the value and 
utility of the data, VA should inform the public of any known facility-
level inaccuracies.
    HR Smart is a position-based software, which means records are tied 
to the particular job position--not to the individual filling that 
position. The position, once established, exists regardless of whether 
it is filled. VA policy requires human resources staff to reuse an 
existing HR Smart position when an employee leaves a job. However, the 
OIG team was informed that human resources staff were creating new 
positions in HR Smart after employees left without deleting the 
existing job position, which was inflating the vacancy numbers to show 
two vacancies for the facility's single position--the original slot and 
the newly created position.
    From October to November 2018, VHA's calculations for the 
discrepancy between the number of FTE in H.R. Smart and the authorized 
FTE level grew from 1 percent to 2.4 percent nationwide. In December 3, 
2018, an internal VHA memo indicated some individual VA medical 
facilities had H.R. Smart position counts that were overstated by as 
much as 20.7 percent or understated by as much as 8.1 percent.\10\
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    \10\ OIG staff did not receive definitive explanations from VA 
regarding the causes of understated position counts.
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    Any variance between H.R. Smart and the authorized FTE for each 
location means that VA cannot precisely report on vacancies by facility 
as the MISSION Act requires. Also, VA medical facilities risk reporting 
vacancy numbers that do not accurately reflect their needs. VA's three 
administrations recognized that their position counts were inaccurate 
and began efforts to correct these figures before the initial release 
in August 2018. In general, this involved reconciling approved 
organizational charts with FTE counts in H.R. Smart. As of February 
2019, the efforts to clean up H.R. Smart position counts and correct VA 
vacancy numbers were ongoing.
    At the time the OIG published its report, VA's public website did 
not maintain each iteration of its published data, which further 
undermined its value as it limited the public's ability to compare data 
over time. For example, on November 14, 2018, and again on February 15, 
2019, VA released the quarterly staffing and vacancy information, but 
replaced the prior publication rather than posting it as an additional 
release. Initially, VA staff claimed that historical releases were not 
maintained due to concern that data could be manipulated. For 
comparison, VA proposed that it has maintained its annual budget 
submission for public use dating back to Fiscal Year 2008, and 
preserved public reports detailing veteran population and expenditures 
for compensation and pension benefits, medical care, construction, and 
readjustment and vocational rehabilitation for each State, 
congressional district, and municipality dating back to Fiscal Year 
1996. Subsequently, VA changed its position and is presently 
maintaining historical data.
    va established a methodology for data reporting, but additional 
                        improvements are needed
    The OIG report identified several errors in VA's reported data that 
should be corrected to ensure accurate representation to the public. VA 
misreported time-to-hire information in two instances. VA's website 
incorrectly reported figures in November 2018 as pertaining to the 
fourth quarter of Fiscal Year 2018 only, when in fact it represented 
time-to-hire data for all of Fiscal Year 2018. Similar mislabeling 
occurred in February 2019, when VA's time-to-hire data noted that 
several occupational groups and Senior Executive Service positions were 
excluded.\11\ These occupational groups support critical, mission-
oriented work for the department. While HR&A leaders explained the 
exclusions were in error, VA should have verified that labels were 
accurate. In order to boost stakeholder trust in the validity of the 
data, VA's methodology needed to be updated to include quality control 
steps to verify the accuracy of its data labeling.
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    \11\  The excluded 0600-occupational family includes physicians and 
nurses, who would be providing direct care to veterans. The excluded 
0900-occupational family includes veterans claims examiners and 
veterans service representatives, who would be processing veterans' 
benefits. The excluded 4754-occupational series is for cemetery 
caretakers, who would be providing burial for veterans and maintaining 
the cemeteries.
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    VA lacked a documented methodology for implementing the MISSION 
Act's requirements until February 7, 2019.\12\ The methodology VA 
established in February described how to compile the information 
supporting the MISSION Act's four requirements. The guidance ensures 
the work is not dependent on a single individual, allows for 
consistency across quarterly reporting, and provides an opportunity for 
VA to review each step of the process.
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    \12\ VA did not have a documented methodology for the initial two 
postings of staffing and vacancy data in August and November 2018. VA's 
process to aggregate data was undocumented and the responsibility 
rested with one HR&A data analyst. HR&A staff told the OIG team that 
standardized processes were necessary for staffing and vacancy 
collection.
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    The OIG team noted that VA did alter its method for sharing data 
with its different administrations and staff offices to improve the 
accuracy of internal quality assurance checks.
                            recommendations
    In May 2019, the OIG made the following five recommendations to the 
Assistant Secretary for HR&A to improve the administration of VA's 
staffing and vacancy reporting. VA concurred with the recommendations 
and provided acceptable implementation plans.
    1. Ensure VA vacancy data are reported by occupation as required by 
Section 505(a)(1)(C) of the MISSION Act. Targeted Completion Date: VA's 
self-determined Before publishing Fiscal Year 2020 Quarter 1 MISSION 
Act Report, which will occur in February 2020.
    2. Make certain that VA staffing gains and losses data are reported 
by quarter as required by Section 505(a)(1)(B) of the MISSION Act. VA's 
self-determined Targeted Completion Date: Before publishing Fiscal Year 
202019 Quarter 3 MISSION Act Report, which will occur in August 2019.
    3. Annotate limitations clearly within the staffing and vacancy 
data to improve transparency and usability of the data, to include 
changes from H.R. Smart data-cleansing efforts. VA's self-determined 
Targeted Completion Date: Before publishing Fiscal Year 202019 Quarter 
3 MISSION Act Report, which will occur in August 2019.
    4. Ensure that the staffing and vacancy reporting website maintains 
historical information on the data elements required by the MISSION 
Act. VA's self-determined Targeted Completion Date: Before publishing 
Fiscal Year 202019 Quarter 3 MISSION Act Report, which will occur in 
August 2019.
    5. Update the methodology for collecting and reporting on VA 
staffing and vacancy data to ensure consistency in future quarters. 
VA's self-determined Targeted Completion Date: Before publishing Fiscal 
Year 2019 Q3 MISSION Act Report, which will occur in August 2019.
    VA has begun implementing the changes in Recommendations 1, 2, and 
4, but all recommendations remain open. OIG staff will monitor VA's 
progress until all proposed actions are complete.
          prior reports identifying staffing-related problems
    Each year, the OIG provides Congress with an update summarizing the 
most serious management and performance challenges identified by OIG 
work as well as an assessment of VA's progress in addressing them.\13\ 
These challenges are aligned with the OIG's six areas of focus outlined 
in its strategic plan: (1) leadership and workforce investment, (2) 
healthcare delivery, (3) benefits delivery, (4) financial management, 
(5) procurement practices, and (6) information management.
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    \13\ U.S. Department of Veterans Affairs Office of Inspector 
General Management and Performance Challenges, November 2018.
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    The following OIG reports are highlighted to demonstrate how OIG 
staff have identified staffing and workforce concerns over the past 
several years that can affect the quality and timeliness of patient 
care. In particular, these reports highlight how shortages of non-
clinical personnel, such as human resources, logistics, scheduling, and 
custodial, can have impacts in the timeliness of care delivered across 
VA medical facilities.
    Health Care Inspection: Evaluation of System-Wide Clinical, 
Supervisory, and Administrative Practice, Oklahoma City VA Health Care 
System, Oklahoma. In early 2016, the OIG became aware of concerns 
regarding clinical and administrative operations at the system, 
subsequently expanding to other provider-related issues.\14\ The report 
describes how underlying causes for shortcomings within multiple 
program areas, processes, and operations were, in part, the result of 
leadership turnover and vacancies at multiple levels, most notably the 
medical director position, prior to May 2016. System data indicated 
that full-time employee-equivalent staff levels were often below 
authorized levels, despite the use of incentives and direct-hire 
authorities. At the same time, the system experienced serious front-
line patient care staffing shortages, particularly in primary care, 
mental health, specialty care, nursing, and non-VA care coordination, 
which has clinical and non-clinical components. The system director 
took action on the OIG recommendation, including establishing a process 
to automatically recruit for clinical and medical support assistant 
positions.
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    \14\  Health Care Inspection: Evaluation of System-Wide Clinical, 
Supervisory, and Administrative Practices, Oklahoma City VA Health Care 
System, November 2, 2017.
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    Critical Deficiencies at the Washington DC VA Medical Center. In 
March 2017, the OIG received a confidential complaint and additional 
subsequent allegations that the medical center had equipment and supply 
issues that could be putting patients at risk for harm. The OIG 
conducted an inspection, issuing an interim report in April 2017, and a 
final report in March 2018.\15\ The final report provided findings in 
four areas: (1) risk of harm to patients, (2) hospital service 
deficiencies affecting patient care, (3) lack of financial controls, 
and (4) failures in leadership. These deficiencies spanned many years, 
impacting the core medical center functions that healthcare providers 
need to effectively provide quality care. In particular, the report 
detailed the failure to inventory and to ensure supplies and equipment 
reached patient care areas when needed. 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. The OIG made 
40 recommendations, to which VA concurred. While VA provided detailed 
action plans on how the recommendations would be implemented and 
identified progress made, of the 40 recommendations, 9 are still open 
as of September 18, 2019. One open recommendation calls on the VISN 5 
Director to ensure the timely completion of hiring actions at the 
facility until staffing deficiencies in the Logistics Service and 
Sterile Processing Service are fully resolved.
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    \15\  Interim Summary Report, April 17, 2017; Critical Deficiencies 
at the Washington DC VA Medical Center, March 7, 2018.
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    Delays in Processing Community-Based Patient Care at the Orlando VA 
Medical Center, Florida. In January 2018, the OIG initiated a 
healthcare inspection of the medical center at the request of 
Congressman Bill Posey. The allegations included that a patient died 
while experiencing a delay in obtaining approval for aortic valve 
surgery outside VA.\16\ It was additionally alleged that the facility 
failed to timely approve, process, and coordinate non-VA care 
coordination (NVCC) consults, and these delays were causing adverse 
clinical outcomes. The OIG substantiated delays in the processing of 
other thoracic surgery NVCC consults entered during a 10-month period 
in 2017 related to an increase in the number of consults and limited 
staff available to process consults. However, the OIG did not identify 
adverse clinical outcomes associated with the delays. The OIG concluded 
the absence of a fully implemented tool to assist with care 
coordination increased the possibility of disruptions in the care 
coordination for the NVCC patients. The OIG made six recommendations, 
including that the medical center director conduct a review of 
Integrated Health Services workload demand and available staff, and 
takes appropriate action to ensure staffing allows for consults to be 
acted upon within VHA timeliness standards. All recommendations are now 
closed.
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    \16\  Delays in Processing Community-Based Patient Care at the 
Orlando VA Medical Center, February 20, 2019.
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    Alleged Inadequate Nurse Staffing Led to Quality of Care Issues in 
the Community Living Centers at the Northport VA Medical Center, New 
York. Following allegations from several sources, the OIG conducted a 
healthcare inspection to assess long-term care nurse staffing and 
quality of care issues in the Community Living Centers (CLC).\17\ Among 
other findings in the September 2018 report, OIG staff substantiated 
that nursing leaders were aware of staffing shortages; administrative 
registered nurses provided CLC nursing care; facility leaders pressured 
CLC managers to accept admissions despite inadequate staffing. The OIG 
was unable to substantiate that the use of float staff and overtime 
placed residents at a higher risk for adverse events. The OIG found the 
facility failed to use alternative staffing. There was also a delay in 
filling vacant positions and a lack of approval for increased staff. 
Also, overtime funding exceeded the cost of filling vacant positions. 
The OIG made three recommendations related to CLC nurse staffing and 
recruitment, alternative staffing, and overtime management. The 
recommendations related to nurse staffing and overtime management 
remain open.
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    \17\  Alleged Inadequate Nurse Staffing Led to Quality of Care 
Issues in the Community Living Centers at the Northport VA Medical 
Center, September 18, 2018. That same day, the OIG released two other 
reports regarding allegations of poor quality of care at the CLC: 
Alleged Poor Quality of Care in a Community Living Center at the 
Northport VA Medical Center and Alleged Quality of Care Issues in the 
Community Living Centers, Northport VA Medical Center.
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    Review of Environment of Care, Infection Control Practices, 
Provider Availability, and Leadership VA Loma Linda Healthcare System, 
California. In March 2018, the OIG conducted an inspection at the 
request of Congressmen Pete Aguilar and Mark Takano related to a series 
of concerns regarding the environment of care (EOC), infection control 
(including Legionella), care provider availability, leadership 
responsiveness, and the dental clinic at the VA Loma Linda Healthcare 
System.\18\ The OIG substantiated many of the identified concerns 
related to inconsistent levels of cleanliness and repair through the 
EOC, including the dental clinic, as well as inadequate staff training 
and ineffective facility leader corrective actions. OIG also found high 
staff turnover, necessitating contracting for cleaning work and 
borrowing staff from other VA medical facilities. The OIG found 
inconsistent water temperatures to deter Legionella and in the 
notification of water testing results. The Sterile Processing Service's 
storage room was not consistently within temperature and humidity 
parameters, and the facility's healthcare-associated infection rates 
underperformed VHA's national averages. There were high hospitalist and 
mental health staff vacancy rates and recruiting challenges. The OIG 
made 14 recommendations regarding staff recruitment, EOC, infection 
control, Legionella inhibition, training, and documentation. OIG staff 
will monitor VA's progress until all proposed actions are complete.
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    \18\  Review of Environment of Care, Infection Control Practices, 
Provider Availability, and Leadership VA Loma Linda Healthcare System, 
June 18, 2019.
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    Pathology Processing Delays at the Memphis VA Medical Center, 
Tennessee. In July 2018, the OIG initiated a healthcare inspection at 
the medical center following allegations of patient harm and death due 
to delays in processing laboratory specimens and reporting pathology 
results in the Pathology and Laboratory Medicine Service (P&LMS).\19\ 
The OIG learned of delays in processing the reports, and found that in 
2018, nearly 40 percent of P&LMS positions were vacant, and recruitment 
incentives for these critical staff vacancies were not being used. The 
OIG also found that Veterans Integrated Service Network (VISN) and 
national P&LMS leaders were aware of the vacancies but took no 
mitigating action. Facility leaders cited lengthy recruiting processes 
and lower pay leading to continued vacancies, as well as limited 
promotional opportunities leading to retention challenges. 
Additionally, turnover among human resources staff impacted P&LMS 
hiring efforts. The OIG made a recommendation to the VISN director to 
ensure that the medical center director and leadership team properly 
assess staffing needs in pathology and laboratory services and develop 
plans to recruit and retain those staff. The VISN director concurred 
with the recommendation, with a projected completion date of September 
27, 2019. OIG staff will monitor VA's progress until all proposed 
actions are complete.
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    \19\  Pathology Processing Delays at the Memphis VA Medical Center, 
Tennessee, August 27, 2019.
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    Although these are just a few examples, it should be clear that 
staffing deficiencies occur throughout VHA with far-reaching 
implications. Last month, the OIG reported how staffing shortages have 
created extensive backlogs in scanning electronic health records from 
community providers with the potential to undermine coordinated patient 
care and well-reasoned medical decisions.\20\
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    \20\  Health Information Management Medical Documentation Backlog, 
August 21, 2019.
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                               conclusion
    The OIG has prioritized oversight of VA leadership and workforce 
management, particularly adequate staffing by qualified professionals--
recognizing that deficiencies in these areas are the root cause for 
many issues identified during OIG oversight reviews. Although VA has 
made important improvements, additional fundamental changes are needed 
for significant and sustained improvement, such as accurately tracking 
VHA's vacancy numbers; considering the implications for support staff 
and other team members in staffing models for particular positions; 
reliable and transparent reporting; recruiting and retention oversight 
that includes consideration of both individual facility and veterans' 
needs within a community; and strong and consistent leadership to 
create a stable and welcoming environment. To more efficiently utilize 
its resources, VHA must identify needed staff positions based upon 
comprehensive staffing models that are completely implemented.
    The OIG thanks Congress for its commitment to ensuring VA has the 
resources to provide veterans with timely access to quality care that 
can be provided by caring and qualified staff.
    Mr. Chairman, this concludes my statement. I would be happy to 
answer any questions you or other members of the Committee may have.
                                 ______
                                 

                Prepared Statement of Robert Goldenkoff
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
   
=======================================================================


                 Additional Submissions for the Record

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


                       Submissions for the Record

                              ----------                              


Prepared Statement of the American Federation of Government Employees, 
                                AFL-CIO

    Chairman Takano, Ranking Member Roe, and Members of the Committee,
    The American Federation of Government Employees, AFL-CIO and its 
National Veterans Affairs Council (AFGE) appreciate the opportunity to 
provide our views on how hiring barriers at the Department of Veterans 
Affairs (VA) affect patient care and access to VA's exemplary, 
comprehensive and veteran-centric medical and mental health services.
    AFGE represents more than 700,000 Federal and District of Columbia 
government employees, 260,000 of whom are dedicated VA employees. AFGE 
is the largest labor representative of Veterans Health Administration 
(VHA) providers and support personnel, and represents employees at 
nearly every VA medical center.
front-line employees and their labor representatives: critical ``change 
                      agents'' for vha innovations
    AFGE shares the Committee's concerns about the corrosive effect 
that chronic VHA short staffing has on patient care and access. We 
applaud the Committee's commitment to spotlight VHA staffing shortages 
on the eve of the rollout of the new electronic health record (EHR) 
that will place additional demands on staff.
    During most of the past fifty years, AFGE had a front row seat at 
many of VHA's major information technology (IT) transformations. We are 
grateful to former Under Secretary of Health, Dr. Ken Kizer for 
providing AFGE with a meaningful seat at the table when both the first 
EHR and bar code medication systems were implemented in the 1970's. We 
feel proud of our essential role in the success of these earlier IT 
systems. As the primary users of these systems and recipients of 
training, the employees we represent must be true partners in all such 
endeavors.
    Sadly, reports by local AFGE officers at VA medical centers 
indicate that the agency has made little or no effort to include the 
union in efforts to implement the new EHR.
    Therefore, we urge the Committee and VA leadership to work with 
front-line employees and their labor representatives to implement and 
improve new technology initiatives. VA asserted in its September 16th 
press release that the VA Innovative Technology Advancement Lab (VITAL) 
Program selected ``key clinical and frontline staff'' for end user 
advanced training. We request that that Committee look into whether any 
labor representatives were actually among those selected. The agency 
description of VITAL participants aligns closely with the beneficial 
role that AFGE represented employees have played in the past, i.e. to 
``directly influence a successful EHRM introduction at their facilities 
by performing as `change agents' who can capitalize on and advance the 
capabilities and value of EHRM's transformational innovation.'' 
(https://www.va.gov/opa/pressrel/pressrelease.cfm?id=5314)
                              compensation
    Provider compensation is a significant barrier to VHA's ability to 
recruit and retain a strong health care workforce. The VA does not 
fully or correctly utilize the many recruitment and retention tools 
enacted by Congress to make the VA competitive with pay provided by 
other employers in local markets. The problem is exacerbated for 
providers covered completely by the Title 38 personnel system, 
including physicians, dentists, registered nurses, physician assistants 
and podiatrists. Due to broad Secretary discretion over Title 38 
providers, and the absence of collective bargaining rights, they cannot 
challenge management violations of pay laws or pay rules. This also 
prevents pay from being consistent among providers, causing favoritism 
and unequal application of pay laws that greatly undermine recruitment 
and retention. However, some VHA facilities have successfully applied 
existing pay laws to make provider pay more competitive. Therefore, the 
VA already has the tools it needs to make pay competitive for VHA 
personnel. The root cause continues to be overly broad Secretary 
discretion over the pay and working conditions of Title 38 clinicians. 
Adequate training of managers and human resources (HR) personnel will 
help ensure that they make proper pay decisions and face greater 
accountability when they make bad pay decisions. More congressional 
oversight of pay setting processes and pay decisions will ensure use of 
best practices across all VHA facilities.
    For physicians, dentists and podiatrists, Secretary discretion over 
their market pay has resulted in long delays in updating pay, arbitrary 
decisions over which comparative pay data is relevant and how much to 
adjust market pay. In 2004, Congress passed the physician-dentist pay 
law to make the process more transparent. However, in 2016, Congress 
eliminated the requirement that VA set market pay through compensation 
panels comprised of providers working in the relevant practice area. As 
a result, management now makes market pay decisions without any 
accountability or transparency and it has become much more difficult 
for providers to know whether they or their colleagues are receiving 
the proper amount of market pay. We regularly hear reports from the 
field that senior physicians are paid significantly less than new 
hires, and that many providers are making far below market rate. The 
adverse impact of these poor pay practices is especially felt among 
specialty physicians and providers in high cost of living areas.
    Podiatrists were added to the physician-dentist pay system by the 
VA MISSION Act. AFGE has received many reports that they are widely 
disappointed by the market pay determinations they have received. Their 
frustrating experiences to date further illustrate how a lack of 
competency and accountability cause good pay tools to be poorly 
utilized. Many facilities delayed implementation of this pay change; 
others began implementing the fix, but miscalculated market pay and 
failed to take into consideration the greater pay needs of podiatrists 
performing rear-foot surgeries.
    Broad Title 38 discretion and a lack of transparency have also 
limited the ability of registered nurses (RNs) and physician assistants 
(PAs) (who were added to the RN third party locality pay system in 
2017) to challenge improper pay determinations and resulted in delays 
in making needed pay updates.
    RNs also express frustration with the pay determinations made by 
the nurse professional standards boards (PSB) for new hires and RNs 
seeking promotions. Many front-line nurses feel that the PSB is plagued 
by favoritism, denying promotions to many deserving RNs. Our members 
express frustration that many in the position of Nurse II with 
extensive experience never get promoted to Nurse III. Similarly, 
individuals in the position of Nurse I with valuable experience never 
get promoted to Nurse II because they do not have 4-year degrees and 
the PSBs fails to properly credit their years of service with the VA.
    VA physician assistants (PA) report that it is extremely difficult 
to be promoted beyond a GS-11, leaving their pay well below the PA pay 
offered outside the VA. Similarly, PA Leads also have difficulty moving 
from GS-13 to GS 14. The VA Choice and Quality Employment Act of 2017 
required that the VA apply the RN third party locality pay process to 
PAs but to date, the legislation has been applied very unevenly across 
facilities.
    As previously mentioned, the lack of full bargaining rights among 
Title 38 providers causes an additional barrier to receiving 
competitive pay. The VA's Title 38 collective bargaining rights policy, 
which is based on an extremely narrow reading of Section 7422 of Title 
38, prohibits these providers from challenging VHA's violation of pay 
laws and its own policies. AFGE has fought a long battle to amend 
Section 7422 to eliminate the compensation exclusion and other 
exclusions to bargaining. We are very grateful to Chairman Takano for 
introducing H.R. 1133, the ``VA Employee Fairness Act'', which will 
rectify this problem. Without this change, the VA's ``7422'' policy 
will continue to undermine the pay laws Congress enacts to keep the VA 
provider workforce strong.
    Hybrid Title 38 providers, including psychologists, social workers 
and pharmacists are also frustrated by the Hybrid Title 38 Professional 
Standards Board and the fact that special pay increases are within the 
discretion of the Medical Center Director. However, they can use their 
full collective bargaining rights and to grieve over improper 
applications of pay laws and policies. That is why AFGE strongly 
opposes efforts to move VHA psychologists from Hybrid to full Title 38 
through Section 501 of S. 785, the ``Commander John Scott Hannon 
Veterans Mental Health Care Improvement Act of 2019''. One of the 
reasons offered by proponents for this change is the ability to get 
higher pay for psychologists under the physician three-tier pay system. 
In addition to losing full bargaining rights, and the right to use the 
grievance and arbitration process, or Merit Systems Protection Board to 
challenge unfair terminations and discipline, or incorrect pay 
determinations, it is far from certain whether front-line VHA 
psychologists would receive higher pay under the market pay system.
                      va mission act vacancy data
    Adequate data on vacancies within the Department is crucial to 
fully assessing the true State of VA staffing. When Congress began the 
process of overhauling the CHOICE program, AFGE was adamant that 
language be included to provide transparency on staffing levels. As the 
VA MISSION Act began to develop Section 505 was added, which requires 
the Department to post data every quarter outlining where vacancies 
exist. This data is intended to provide the public with information -- 
both at the national and facility levels. This data should be used as 
an indicator of how the Department is doing with hiring and retaining 
talented professionals to care for our veterans.
    Pushing for vacancy transparency is not a new notion. When Congress 
passed the CHOICE Act, they included language directing the VA Office 
of Inspector General (OIG) to provide an annual update on the five 
occupations with the largest vacancy rates. Congress further amended 
this part of statute in 2017 with the passage of the VA Choice and 
Quality Employment Act, which required reporting on the top five 
clinical and nonclinical occupations with the largest staff shortages. 
Making this data publicly available is important so that patients and 
other stakeholders are able to fully assess the State of their local 
VA. Looking at wait times only does not tell the full story.
    In the CHOICE-mandated reports the OIG routinely found vacancies in 
mental health and primary care. These two components are the bedrock of 
VA care, and it certainly raises red flags that the Department is 
routinely coming up short in these areas. What is also interesting is 
high number of nonclinical vacancies the Department has, for example in 
the June 14, 2018, OIG report occupations such as police officer, 
general engineer, and custodial worker were all in the top 11 (11) of 
positions that need to be filled.
    Section 505 of the MISSION Act was intended to take this 
occupational data and narrow it down even further. Ideally, this 
language was drafted to require the department to report by facility 
how many vacancies exist for each occupation. On June 25, 2019, the OIG 
released its first report based on the new MISSION Act requirement. 
While the OIG did not accuse the VA of not complying with the law, they 
did call into question the extent of VA's reporting. According to the 
OIG, ``VA's initial reporting of staff vacancies and employee gains and 
losses used alternative aggregation methods and lacked sufficient 
transparency to permit stakeholders to use this information to track 
VA's progress toward meeting full staffing capacity.''
    When Section 505 was included it was clear that the intent of the 
provision was to provide stakeholders with adequate data to assess VA 
hiring. We all agree that veterans have earned the world-class care and 
services provided by the Department, and AFGE stands ready to help the 
VA bring more fulltime Federal employees on board who want to make a 
career out of serving veterans. Instead, though, it appears that the We 
hope that the Committee will continue to force the VA to be transparent 
and put forth a serious effort to address staffing challenges.
    AFGE thanks the Committee for the opportunity to share our views on 
VHA hiring practices and vacancy data collection. We welcome the 
opportunity to share the perspective of AFGE and the front-line 
employees we represent to ensure increased competency, accountability 
and transparency in management's application of all VHA pay processes. 
The VA's refusal to fill the nearly 50,000 positions that remain vacant 
is a disservice to veterans. We look forward to working with the 
Committee to ensure that all stakeholders have access to adequate data 
to assess VA hiring.
                                 ______
                                 

              The Prepared Statement of Thelma Roach-Serry

    Chairman Takano, Ranking Member Roe, and Members of the Committee, 
on behalf of the nearly 3,000 members of the Nurses Organization of 
Veterans Affairs (NOVA), I would like to thank you for the opportunity 
to submit testimony on today's hearing ``Critical Impact: How Barriers 
to Hiring at VA Affect Patient Care and Access.''
    NOVA is a professional organization for nurses employed by the 
Department of Veterans Affairs (VA).
    NOVA appreciates the opportunity to provide our input; as nurses 
who make up one third of the VA workforce, we will discuss the critical 
areas that affect hiring, recruitment and retention and how staffing 
shortages affect the delivery of care around the country.
    Staffing vacancies within the Veterans Health Administration (VHA) 
have continued to plaque the Department and remain at over 45,000. NOVA 
believes that filling critical vacancies is one of the most pressing 
issues for VA.
    Studies have shown that better care is provided when facilities 
have both an adequate number of nurses, and nurses that are qualified 
for the jobs to which they are assigned.
    The number of Veterans receiving care within VHA facilities has 
steadily climbed from 6.8 million in Fiscal Year 2002 to 9.0 million in 
Fiscal Year 2015, with many who require more intensive nursing care 
especially those returning from Afghanistan and Iraq, and the aging 
population of Veterans from prior service.
    The need to have an adequate and qualified nursing staff to care 
for those with more complex injuries led to legislation (PL 107-135) 
passed by Congress requiring VA to develop a nationwide policy on 
staffing levels for operation at all VAMCs. VA's Office of Nursing 
Services (ONS) oversees the implementation of the Staffing Methodology 
for VHA Nursing Personnel as outlined in VA Directive 2017-1351.\1\
---------------------------------------------------------------------------
    \1\ VHA Directive 2017-1351https://www.va.gov/vhapublications/
publications.cfm?pub=1
---------------------------------------------------------------------------
    The Directive provides a nationally standardized method of 
determining appropriate direct care staffing for VA nursing personnel, 
with nurse staffing in Patient Aligned Care Teams (PACTs) following the 
VHA Handbook 1101.10 (PACT). The Directive noted that staffing 
decisions require the use of research and non-research sources of 
evidence, professional judgment, critical thinking, and flexibility. 
While also using available evidence with staffing standards of nursing 
professional organizations, established VHA team staffing models and 
facility strategic directions to ensure safe and effective nursing care 
for Veterans.
    Staffing needs are individualized to specific clinical settings and 
cannot rely solely on ranges and fixed staffing models, staff-to-
patient ratios, or prescribed patient formulas. The staffing 
methodology described in the VA Directive requires the systematic 
collection of a minimum set of core data and unit-based operations 
assessment to support staffing decisions. Professional nursing 
organizations' staffing standards and recommendations, where they 
exist, provide the basis for the ONS-developed tools.
    While the methodology uses a variety of tools to determine staffing 
levels within VHA, it also accounts for changes in each unit/facility 
to include high staff turnover and vacancies throughout the system.
    Several recent reports published by the VA Office of Inspector 
General (VAOIG) found a significant variation in the number and types 
of shortages reported. According to a June 14 report, (June 14, 2018/VA 
OIG 18-01693-196) \2\, ``reasons for the shortages varied significantly 
and not all facilities provided a reason for each designated 
shortage.'' The number of vacancies within the Department remains high 
and the most commonly cited challenges to staffing fell into three 
categories:
---------------------------------------------------------------------------
    \2\ VAOIG 18-01693-196, June 14, 2018
---------------------------------------------------------------------------
      Lack of qualified applicants
      Non-competitive salary
      High staff turnover
    NOVA remains concerned about the inconsistencies in how data is 
collected on where shortages exist. As noted in the VA OIG report 
mandated under the MISSION Act, Section 505, (June 25, 2019 /VA OIG 19-
00266-141) the VA's vacancy data is organized by broad position 
categories--clinical and nonclinical--rather than specific 
occupations.\3\ Without the required specificity, i.e. nurses, doctors 
and other clinical staff shortages, those using the data to identify 
needs to hire within facilities are spending valuable time on another 
step impeding the process.
---------------------------------------------------------------------------
    \3\ VAOIG 19-00266-141, June 25, 2019
---------------------------------------------------------------------------
    Identifying shortages where patient centered care and access is 
affected should be a priority. Simplified data that provides 
information on how many nurses (at all levels), doctors, mental health 
providers, etc. are needed at each facility would be far more effective 
and transparent.
    The OIG noted in its recommendations, that VA should identify 
specific jobs or positions so that the public can better understand its 
staffing needs. VA should also adjust its methodology for aggregating 
gains and losses to ensure that data is reported appropriately and 
transparently.
    As nurses who provide direct patient care, having adequate staff 
goes hand in hand in determining access and delivering high quality 
health care to all Veterans.
    Budgets that are sufficient in allowing VISN and Medical Center 
Directors to hire staff is critical. With the passage of the MISSION 
Act and expanded access to community care, VHA leaders must make 
decisions on how funding will be used and disbursed throughout its 
Veteran population. Medical Center Directors are constantly challenged 
to weigh the cost of funding staff as opposed to funding other critical 
needs. Funding mechanisms and congressional appropriations have not 
always contained priorities which consider the internal needs of the 
VHA system.
    NOVA reminds the Committee that requiring VA to do more with less 
puts unnecessary pressure on leadership at VA facilities to manage 
funding by borrowing from one account to pay for another. We have noted 
in the past that we do not agree with any plan that would include 
diverting staff (i.e. to non-clinical VCCP administrative referrals), 
and other funding from clinical care needs. Adequate and appropriate 
funding is critical if the system is to remain competitive within the 
health care industry.
    Recruitment and Retention remains one of NOVA's top priority goals. 
This includes ensuring Human Resources has sufficiently trained staff 
in order to review and streamline policies and procedures to improve 
the efficiency and speed of the hiring process; supporting competitive 
wages for all levels of nursing; undertaking a thorough review of 
downgrades, reclassification of critical positions and implementing 
salary surveys annually with corrective steps for all nursing staff 
across VA. As well as, revising the cap on nurse pay structures and RN 
pay schedules and reclassification of critical positions so that VA can 
provide acceptable salaries especially in highly competitive employment 
regions.
    We also stand by our commitment to a more inclusive use of APRN's, 
NP's, and PA's within the system. Allowing health care professionals to 
practice to their full scope and authority will provide higher access 
to care for Veterans enrolled in VA, while encouraging those eligible 
to come into a system that provides the highest access to timely 
quality care.
    Thank you for allowing us to submit our views today. As nurses, who 
are often the first face a patient sees, we are reminded that it is VA 
care that Veterans overwhelmingly prefer and deserve. We are committed 
to enhancing access and improving health care at VA and stand ready to 
work with this Committee and its staff on this important mission.
                                 ______
                                 

                  Prepared Statement of Kathryn Jansky

                              introduction
    Chairman Takano, Ranking Member Roe, and Members of the Committee, 
thank you for the opportunity to offer this statement for the record. 
The American Association of Nurse Anesthetists (AANA) is the 
professional association for Certified Registered Nurse Anesthetists 
(CRNAs) and student registered nurse anesthetists, with membership that 
includes more than 53,000 CRNAs and student nurse anesthetists 
representing over 90 percent of the nurse anesthetists in the United 
States. CRNAs are advanced practice registered nurses (APRNs) who 
personally administer more than 45 million anesthetics to patients each 
year in the United States. CRNAs provide acute, chronic, and 
interventional pain management services. In some states, CRNAs are the 
sole anesthesia providers in nearly 100 percent of rural hospitals, 
affording these medical facilities obstetrical, surgical, trauma 
stabilization, and pain management capabilities.
    The House Committee on Veterans' Affairs' hearing, entitled 
``Critical Impact: How Barriers to Hiring at VA Affect Patient Care and 
Access'' comes at an important time, as the largest barrier CRNAs face 
is not being able to practice to their full scope of education and 
training. On December 14, 2016, the U.S. Department of Veterans Affairs 
(VA) issued a final rule granting three of the four APRN specialties 
full practice authority, excluding CRNAs. In the final APRN rule, the 
VA indicated that CRNAs are highly qualified for full practice 
authority, but were not included with the other three APRN specialties 
because the VA believes there currently is not a problem with access to 
anesthesia care in Veterans Health Administration (VHA) facilities. 
Granting CRNAs full practice authority would go a long way in terms of 
recruitment and retention.
   assessment of current and future access to anesthesia care issues
    The AANA advocates on numerous issues to help improve healthcare, 
patient safety and practice excellence by working to increase access to 
healthcare, make healthcare more affordable, and improve the quality of 
the care available to all patients, including our Nation's veterans. 
The AANA supports full practice authority for CRNAs, working in 
Veterans Health Administration (VHA) facilities, who help care for our 
Nation's veterans to the full scope of their education, training and 
licensure to help ensure that veterans have access to the timely 
anesthesia and related healthcare services they deserve.
    On December 14, 2016, the VA published its final rule granting full 
practice authority to three of the four APRN specialties, illogically 
excluding CRNAs from the rule ``due to VA's lack of access problems in 
the area of anesthesiology.''\1\ This is an inaccurate statement that 
is clearly refuted by evidence, as will be illustrated below. In order 
to help expand veterans' access to quality anesthesia care, we urge you 
to do what is right for our veterans by using the evidence clearly 
demonstrated in this statement to reconsider this action. Permitting 
full practice authority for CRNAs will ensure veterans receive the full 
scope of timely, high-quality anesthesia and pain management care they 
so rightfully deserve within VHA facilities.
---------------------------------------------------------------------------
    \1\ 81 Fed. Reg. 90198. https://www.gpo.gov/fdsys/pkg/FR-2016-12-
14/pdf/2016-29950.pdf
---------------------------------------------------------------------------
  the va's own studies and data confirm an access to anesthesia care 
                                 issue
    Recent data from VA commissioned studies show a clear access to 
care issue in VHA facilities. We are troubled as to why these objective 
findings weren't considered to be sufficient evidence for granting full 
practice authority to CRNAs in the final rule. As you know, the VA 
sponsored the congressionally mandated 2015 RAND Corporation 
Independent Assessment of the VHA, which reported that wait times for 
VA care are getting longer and current VA workforce capacity may not be 
sufficient to provide timely care to veterans across a number of key 
specialties, as well as primary care.\2\ The VA's Enrollee Health Care 
Projection Model (EHCPM), a healthcare demand projection model, 
forecasts a ``19-percent increase in demand for VA health care services 
nationally from Fiscal Year 2014 to Fiscal Year 2019, due to a 
projected 5.1-percent increase in enrollment and the aging of 
enrollees.'' \3\ The VA Independent Assessment stated that one of the 
most important changes in VA policy to help meet increases in demand 
for healthcare over the next 5 years and ensure continued access to 
care for veterans would be formalizing full practice authority for all 
APRNs, including CRNAs.
---------------------------------------------------------------------------
    \2\ RAND Health. ``Resources and Capabilities of the Department of 
Veterans Affairs to Provide Timely and Accessible Care to Veterans,'' 
(2015). http://www.rand.org/content/dam/rand/pubs/research_reports/
RR1100/RR1165z2/RAND_RR1165z2.pdf
    \3\ Ibid.
---------------------------------------------------------------------------
    Instead, the VA has chosen to exclude CRNAs from full practice 
authority, which means many veterans will continue to endure 
dangerously long wait times for needed healthcare requiring anesthesia 
services. A report released by the VA in December 2016 showed there are 
150 VHA facilities reporting that more than 10 percent of their 
appointments have a wait time of more than 30 days, meaning that 
veterans have to wait more than a month to get an appointment.\4\
---------------------------------------------------------------------------
    \4\ Department of Veterans Affairs Report ``Pending appointments 
and Electronic Wait List Summary -- National, Facility, and Division 
Level Summaries Wait Time Calculated from Prefed Date'' (December 
2016). http://www.va.gov/HEALTH/docs/
DR60_122016_Pending_and_EWL_Biweekly_Desired_Date_Division.pdf
---------------------------------------------------------------------------
    The VA Independent Assessment reported access to care challenges 
due to anesthesia delays. Specifically, the VA Independent Assessment 
identified delays in cardiovascular surgery for lack of anesthesia 
support, rapidly increasing demand for procedures requiring anesthesia 
outside of the operating room, and slow production of colonoscopy 
services in comparison with the private sector.\5\ This speaks to the 
underutilization of existing anesthesia providers such as CRNAs, who 
are not allowed to practice to the full scope of their education, 
experience, and licensure. It remains unclear why the Independent 
Assessment's impartial findings are not sufficient evidence to allow 
full practice authority for CRNAs in VHA facilities.
---------------------------------------------------------------------------
    \5\ VA Independent Assessment, Appendices E -- I, http://
www.va.gov/opa/choiceact/documents/assessments/
Assessment_B_Health_Care_Capabilities_Appendices_E-I.pdf
---------------------------------------------------------------------------
    A logical solution to reducing or preventing delays in veterans' 
access to anesthesia care in VHA facilities would be to promptly allow 
CRNAs to practice to the full extent of their education, training, and 
licensure.
unrequired, unnecessary crna supervision reduces access to care in vha 
                               facilities
    Concerns over anesthesia delays in VHA facilities stem from the 
underutilization of CRNAs who are not allowed to practice to the full 
scope of their education, experience, and licensure, as well as 
anesthesiologists who spend more time supervising CRNAs than actually 
providing hands-on patient care, even though the VA does not require 
CRNAs to be supervised by anesthesiologists or by any other physicians. 
CRNAs are appropriately educated and trained to handle every aspect of 
the delivery of anesthesia services including general and regional 
anesthesia and acute, chronic, and interventional pain management 
services. Forty states plus the District of Columbia have no 
supervision requirement concerning nurse anesthetists in nurse practice 
acts, board of nursing rules/regulations, medical practice acts, board 
of medicine rules/regulations, or their generic equivalents, allowing 
CRNAs to practice autonomously consistent with their education, 
training, and licensure. (This does not take into account hospital 
statutes or regulations.) Furthermore, no State or Federal laws require 
CRNAs to be supervised by anesthesiologists. CRNA supervision leads to 
increased costs and reduced access to timely care, but does not lead to 
better healthcare outcomes as confirmed by scientific research data 
time and time again.
    However, observations within the VHA have found that some 
supervising anesthesiologists prohibit CRNAs from providing regional 
anesthesia services to veterans undergoing certain procedures, such as 
orthopedic, urological, and vascular, for which regional anesthesia may 
be the preferred choice. Further, many of these patients suffer from 
multiple chronic conditions such as lung disease, obstructive sleep 
apnea, and obesity. In these instances, regional anesthesia services 
are frequently the best option. Administering large amounts of 
narcotics to these patients, as in general anesthesia, introduces risks 
beyond those of regional anesthesia care. Instead of the surgeon 
authorizing the CRNA to provide regional anesthesia, anesthesiologists 
are ordering CRNAs to administer general anesthesia which requires a 
higher dosage of narcotic medications and inhalational agents and puts 
the patient at greater risk of postoperative pulmonary problems, slower 
recovery times, and greater postoperative pain, and also contributes to 
delays in physical therapy services. All of these factors compromise 
the patient's ability to recover as promptly and safely as possible and 
leads to additional costs due to longer hospital stays.
    Additional observations within the VHA find CRNAs are commonly 
supervised by anesthesiologists at 1:1 and 1:2 ratios not generally 
found in the commercial healthcare delivery marketplace, and which do 
not correlate with improved outcomes.\6\ Because these arrangements are 
so costly compared with alternatives, they divert resources from VHA 
delivery of other priority services such as primary care, women's 
healthcare or mental healthcare. Anesthesia services provided by CRNAs 
and anesthesiologists are considered extremely safe and except in rare 
instances a single anesthesia provider is sufficient to administer an 
excellent anesthetic. CRNAs administer anesthesia in all settings 
working in collaboration with surgeons, anesthesiologists, and other 
healthcare professionals as part of the patient care team. A Lewin 
Group peer-reviewed economic analysis noted, ``There are no 
circumstances examined in which a 1:1 direction model is cost effective 
or financially viable.'' \7\ The Lewin Group analysis concludes that 
allowing CRNAs to practice to the full extent of their education and 
training would ``both ensure patient safety and result in substantial 
cost savings, allowing the VHA to allocate scarce resources toward 
other Veteran healthcare needs.'' \8\
---------------------------------------------------------------------------
    \6\ Dulisse, op cit., http://content.healthaffairs.org/content/29/
8/1469.full.pdf and Negrusa op cit., http://journals.lww.com/lww-
medicalcare/Abstract/publishahead/
Scope_of_Practice_Laws_and_Anesthesia.98905.aspx
    \7\ Hogan op cit., http://www.aana.com/resources2/research/
Documents/nec_mj_10_hogan.pdf
    \8\ Ibid.
---------------------------------------------------------------------------
    By granting full practice authority to CRNAs, the VHA would make 
full use of more than 900 CRNAs already practicing in VHA facilities. 
Many more veterans could be cared for if start times for surgical and 
other types of cases requiring anesthesia were no longer delayed 
unnecessarily while waiting for supervising anesthesiologists to become 
available. This would ensure that our Nation's veterans have access to 
essential surgical, emergency, obstetric, and pain management 
healthcare services without needless delays or having to travel long 
distances for care. It would also correspond with VA Secretary David 
Shulkin's May 31, 2017 address on the ``State of the VA'' where he 
remarked that the goal was to ``turn the VA into the organization 
veterans and their families deserve, and one that America can take 
pride in,'' which includes, ``reducing burdensome regulations that do 
not make sense and launching new tools that make it easier for veterans 
to engage with VA.'' \9\
---------------------------------------------------------------------------
    \9\ Secretary David Shulkin ``State of the VA'' Address (May 31, 
2017), http://www.blogs.va.gov/VAntage/wp-content/uploads/2017/05/
StateofVA_FactSheet_5-31-2017.pdf
---------------------------------------------------------------------------
   recruitment and retention of crnas will increase productivity and 
                               efficiency
    The AANA fails to understand how the VA concluded that the current 
anesthesia workforce is sufficient to meet the healthcare needs of 
veterans in the VA health system. The VA stated in their final APRN 
rule, ``VA understands that there are difficulties hiring and retaining 
anesthesia providers.'' We agree with this statement, since a major VHA 
workforce evaluation published in January 2015 reported that CRNAs have 
been among the VHA's most difficult to recruit specialties over four of 
the past 5 years.\10\
---------------------------------------------------------------------------
    \10\ VA Office of the Inspector General, OIG Determination of 
Veterans Health Administration's Occupational Staffing Shortages 
(January 30, 2015)
---------------------------------------------------------------------------
    In the final APRN rule, the VA provided data on CRNAs and 
anesthesiologists that is inaccurate, troubling and does not justify 
the assertion that current staffing levels can meet the anesthesia 
needs of veterans. As stated in the final APRN rule, as of August 31, 
2016, the VA had 940 anesthesiologists and 937 CRNAs. In addition, data 
from the VA's Center for Veterans Analysis and Statistics show a growth 
in total Veteran enrollees (6.8 million in 2002 to 9.1 million in 
2014), outpatient visits (46.5 million to 92.4 million) and inpatient 
admissions (565,000 to 707,000) in the VA healthcare system over the 
last 12 years.\11\ The final APRN rule also stated that the 2015 
independent survey of VA general facility Chief of Staffs conducted by 
the RAND Corporation showed that about 38 percent reported problems 
recruiting or hiring advanced practice providers and 30 percent 
reported problems retaining advanced practice providers.\12\
---------------------------------------------------------------------------
    \11\ http://www.va.gov/oig/publications/report-summary.asp?id=3276.
    \12\ https://www.va.gov/vetdata/Utilization.asp.
---------------------------------------------------------------------------
    Looking at these numbers alone, it is clear that the VA is 
suffering from APRN recruitment and retention issues. With the 
substantial increases in the number of veterans using the VA system for 
healthcare over the last 10 years, it is unclear to us how only 940 
anesthesiologists and 937 CRNAs are sufficient to meet the anesthesia 
care needs of more than 9 million veterans across the country.
    Moreover, we feel that CRNAs are being held to a different and 
unfair standard regarding recruitment and retention data than the other 
categories of APRNs who were granted full practice authority in the 
final APRN rule. For example, the VA states that the lack of 
advancement opportunities and practice autonomy were not cited as 
reasons for recruitment and retention challenges for CRNAs, and that it 
would consider future rulemaking if there's evidence linking full 
practice authority to CRNA recruitment and retention. However, the VA 
fails to show that this same linkage was established for the other APRN 
categories that were granted full practice authority. The final APRN 
rule also provides data on critical staffing shortages and states that 
CRNAs and physician anesthesiologists are not high on the list of hard 
to recruit and retain specialties. The VA again fails to present 
compelling data that reveals shortages in the other APRN categories or 
of their respective physician counterparts. Again, CRNAs are being held 
to a different and inconsistent set of rules than the other categories 
of APRNs. Also, in the VA's Economic Impact Analysis for RIN-2900-AP44, 
the VA reports in the description of current APRN practice a net gain 
of 88 CRNA FTEs as a reason to exclude them from the rule, while the VA 
noted a net gain of 620 NP FTEs, which is far greater than the net gain 
for CRNAs.\13\
---------------------------------------------------------------------------
    \13\ 81 Fed. Reg. 90198. https://www.gpo.gov/fdsys/pkg/FR-2016-12-
14/pdf/2016-29950.pdf.
---------------------------------------------------------------------------
    The VA's final APRN rule also references current and future 
recruitment and retention of CRNAs, stating that it is possible 
resources might be available to address some of these underlying issues 
if efficiencies were realized as a result of advanced practice nursing 
authority.\14\ The AANA recently surveyed its membership, which 
includes more than 90 percent of the Nation's nurse anesthetists, and 
found that over 90 percent of respondents indicated that the decision 
to not grant full practice authority to CRNAs would deter them from 
seeking employment in the VHA in the future. This chilling effect on 
the ability of the VHA to hire skilled CRNAs will have a lasting impact 
on its ability to meet the healthcare needs of veterans. Conversely, 98 
percent of the survey respondents said they would be more inclined to 
work for the VHA if it took the appropriate steps to grant full 
practice authority to CRNAs.
---------------------------------------------------------------------------
    \14\ VA Impact Analysis for RIN 2900-APxx/WP 2013-036, Advanced 
Practice Registered Nurses. ``APRN Gains and Losses for FY-12 to FY-16 
(Source: 2015 VHA Workforce Planning Report): The number of Nurse 
Anesthetist gains and losses for FY-12 to FY-16: Total Gains 314 / 
Total Losses 226 for a net gain of 88. The number of Nurse Practitioner 
gains and losses for FY-12 to FY-14: Total Gains 1499 / Total Losses 
879 for a net gain of 620.''
---------------------------------------------------------------------------
                               conclusion
    By granting full practice authority to CRNAs, the VA would become a 
more desirable place for CRNAs to work. It would maximize productivity 
and efficiency, making full use of more than 900 CRNAs already 
practicing in VHA facilities and also make working in VHA facilities 
more attractive to future CRNAs. Allowing CRNA full practice authority 
in the VA would only help to increase the number of CRNAs who can 
provide safe, high quality and cost effective anesthesia care for our 
Nation's veterans. This would ensure that our Nation's veterans have 
access to essential surgical, emergency, obstetric, and pain management 
healthcare services without needless delays or having to travel long 
distances for care.
   
      
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                   Question and Answer for the Record

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