[Senate Hearing 116-466]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 116-466

                 RECRUITMENT, RETENTION AND BUILDING A 
                RESILIENT VETERANS HEALTH CARE WORKFORCE

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                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED SIXTEENTH CONGRESS

                             SECOND SESSION

                               __________

                              JULY 1, 2020

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
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        Available via the World Wide Web: http://www.govinfo.gov
        
                              __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
45-059 PDF                  WASHINGTON : 2021                     
          
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                     COMMITTEE ON VETERANS' AFFAIRS

                     Jerry Moran, Kansas, Chairman

John Boozman, Arkansas               Jon Tester, Montana, Ranking 
Bill Cassidy, Louisiana                  Member
Mike Rounds, South Dakota            Patty Murray, Washington
Thom Tillis, North Carolina          Bernard Sanders, (I) Vermont
Dan Sullivan, Alaska                 Sherrod Brown, Ohio
Marsha Blackburn, Tennessee          Richard Blumenthal, Connecticut
Kevin Cramer, North Dakota           Mazie K. Hirono, Hawaii
Kelly Loeffler, Georgia              Joe Manchin III, West Virginia
                                     Kyrsten Sinema, Arizona

                  Caroline R. Canfield, Staff Director
                Tony McClain, Democratic Staff Director


                            C O N T E N T S

                              ----------                              

                        Wednesday, July 1, 2020

                                SENATORS

                                                                   Page
Moran, Hon. Jerry, Chairman, U.S. Senator from Kansas............     1
Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana......     3
Boozman, Hon. John, U.S. Senator from Arkansas...................    10
Brown, Hon. Sherrod, U.S. Senator from Ohio......................    12
Cassidy, Hon. Bill, U.S. Senator from Louisiana..................    15
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    17
Rounds, Hon. Mike, U.S. Senator from South Dakota................    19
Tillis, Hon. Thom, U.S. Senator from North Carolina..............    21
Sinema, Hon. Kyrsten, U.S. Senator from Arizona..................    24

                               WITNESSES

Lieberman, Steven L., M.D., Acting Principal Deputy Under 
  Secretary for Health, Veterans Health Administration; 
  accompanied by Jessica Bonjorni, Chief, Human Capital 
  Management, VHA, and Victoria Brahm, Director, Veterans 
  Integrated Service Network 12, VHA.............................     5

                                APPENDIX

Moran, Hon. Jerry, Chairman, prepared statement..................    40
Lieberman, Steven L., M.D., Acting Principal Deputy Under 
  Secretary for Health, Veterans Health Administration, prepared 
  statement......................................................    42
American Federation of Government Employees, AFL-CIO, prepared 
  statement......................................................    45

Response to hearing questions submitted by:
  Hon. Jerry Moran...............................................    57
  Hon. Jon Tester................................................    64
  Hon. Sherrod Brown.............................................    76
  Hon. Mazie K. Hirono...........................................    82
  Hon. Kyrsten Sinema............................................    89

 
 RECRUITMENT, RETENTION AND BUILDING A RESILIENT VETERANS HEALTH CARE 
                               WORKFORCE

                              ----------                              


                        WEDNESDAY, JULY 1, 2020

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 3:07 p.m., in 
room 106, Dirksen Senate Office Building, Hon. Jerry Moran, 
Chairman of the Committee, presiding.
    Present: Senators Moran, Boozman, Cassidy, Rounds, Tillis, 
Sullivan, Blackburn, Tester, Brown, Blumenthal, and Sinema.

              OPENING STATEMENT OF CHAIRMAN MORAN

    Chairman Moran. Good afternoon. Thanks, everyone, for your 
patience waiting for my arrival. Perhaps you had no choice, but 
I appreciate the attitude that--I just came from the Indian 
Affairs Committee, where both Senator Tester and I are members. 
And before I came here, I wanted to make sure that I spoke.
    The Indian Affairs is having a hearing on COVID-19 pandemic 
and its consequences in Indian and Tribal Country, and I wanted 
to make certain that we made clear the role that the Department 
of Veterans Affairs is playing in trying to make certain that 
individual Tribal members and Tribe communities are cared for.
    Senator Tester and I have had weekly conversations by phone 
with the Secretary and often with Dr. Stone, and almost in 
every week's telephone conversation, we discuss what the 
Department of Veterans Affairs is doing to help assist in 
regard to the health care needs of Native Americans.
    Good afternoon, everyone. Thank you very much for joining 
us. The Committee will come to order.
    Here in this hearing, we are to discuss Veterans Health 
Administration's workforce and resources the VA uses in 
recruitment, in retention and resiliency----
    [Audio distortion.]
    Chairman Moran. I knew my words were important and would be 
repeated many times.
    First, I want to thank the 350,000 employees of VHA for the 
hard work they do day after day to care for our veterans. That 
occurs in easier times than this, but it occurs always. I have 
met a number of these professionals since being a Member of 
Congress and have always admired their dedication to the 
mission of helping veterans. In many cases, they are helping 
other veterans.
    We know that in many instances, these men and women who 
work at the Department of Veterans Affairs are going above and 
beyond to help provide our veterans with the services and 
health care needs that they deserve.
    This is especially true as our frontline VA health care 
workers fight against COVID-19. I was inspired by the story of 
Gary Kramer, an intensive care unit nurse at the Dole VA 
medical center in Wichita. Gary has gone the extra mile in 
caring for his patients suffering from COVID-19, offering up 
his own phone so patients could connect with loved ones unable 
to be by their side during their final days.
    VA health care workers serve our veterans because they 
believe in the mission, and that is exactly the kind of person 
that we want to have serving those veterans. But as we know, 
the VHA has a number of vacancies, including 27 occupations 
listed as critical shortages by the Office of the Inspector 
General. These shortages of critical positions strain the rest 
of the workforce and make it tougher for them as they care for 
our veterans.
    Reducing these vacancies must be a priority for the 
Department so that dedicated providers like Gary have the 
people and other resources around them to deliver the 
consistent, high-quality care that our veterans deserve.
    Recruiting providers is challenging for everyone in the 
health care industry, but I worry that the VA is limited in its 
ability to compete with the private sector due to salary 
restrictions and bureaucratic hiring practices.
    For health care providers, the VA does have authority to 
set pay based on market conditions in specific areas. One of 
the challenges, which we frequently see in rural areas, is that 
the qualified applicants are not in that market. The VA really 
needs to adjust the pay to attract doctors and nurses from 
other areas of the country.
    I hope to hear more from our witnesses today how VHA can 
accomplish that and what our Committee can do to help.
    Additionally, we often hear from hiring managers that it 
takes too long to hire good people. VHA's current hiring model 
for doctors and nurses allows for 34 days from closing a job 
announcement to issue a tentative offer of employment. It could 
take another 45 days from that initial offer to conduct the 
credentialing and privileging, background check, physical, and 
drug test before the new employee can actually start working. 
If another area hospital provides an offer sooner and has a 
quicker onboarding process, that doctor or nurse may not be 
able to wait for the VA process.
    I hope to hear more from our witnesses today on how this 
hiring model compares with practices in the private sector, 
including any additional requirements that the VHA faces.
    I also want to hear more about how VHA has been hiring 
during the pandemic because I know, I understand--the Secretary 
has indicated this many times--the VHA alone has hired over 
20,000 employees in the past 3 months. That appears to be more 
than double the number hired in the first 3 months of this 
year.
    In our Budget hearing last month, Secretary Wilkie noted 
that many of these new employees were hired much more quickly 
than traditional processes allow for, and I am very interested 
in what changes VHA has made during the pandemic and which of 
those changes can be used to improve the hiring process on a 
permanent basis.
    Again, I thank our witnesses for joining us.
    I now yield to the Ranking Member, Senator Tester, for his 
opening remarks.

              OPENING STATEMENT OF SENATOR TESTER

    Senator Tester. Well, thank you, Mr. Chairman, and I also 
want to thank the tech people in the room because the first 
part of your----
    Chairman Moran. Jon, just a suggestion. It seems odd for me 
asking to be able to hear you, but if you would speak into your 
microphone or turn up the volume.
    Senator Tester. I will get closer. I was just saying the 
same thing about you. I want to thank the tech people because 
they fixed it in the last couple minutes of your opening 
statement. I could hear it very well. The first part not so 
good, and I assume that it was a glorious statement as always. 
But I can hear you now, which is good.
    Dr. Lieberman, I want to start by thanking you and your 
team for being here today. I also want to thank the VA 
frontline employees for all they have done to care for veterans 
and nonveterans alike during this pandemic, especially now as, 
once again, the VA case count is surging and staff are being 
pushed to extremes.
    The staff, from providers to housekeepers to schedulers, 
are truly the backbone of the VA, and they work hard every day 
to make sure that veterans get the access to high-quality 
health care that they have earned.
    I want to commend the VA for its success in quickly and 
efficiently hiring thousands of new staff during COVID-19. It 
use to take 90 days to get a new employee in the door, and in 
the meantime, we lost some potential good employees because 
somebody else swept them up. So for the VA to bring on new 
staff not in 72 days but in 72 hours, 3 days, that shows what 
the agency is actually capable of when it sets itself to the 
task, but it should not take a pandemic for the VA to be able 
to fix some of its internal hiring processes, when many of the 
challenges, I think, could have been made years ago. And if 
they could not have, you can tell me why.
    Over the years, Congress has given the Department numerous 
hiring authorities, and my concern is that the VA is dragging 
its feet when it comes to implementing them. Some of these 
authorities are several years old, and the VA has yet to put 
them to use.
    Beyond that, the VA needs to make itself the employer of 
choice for health care professionals, and the first step of 
that is ensuring staff, current staff is feeling supportive. 
Think about it if you were out and going to go get a new job, 
and they offered you a job. The first people you would talk to, 
either before the interview or after, would be the people who 
work in that facility, and if they are not happy, we are not 
going to get the employees we need.
    Quite frankly, we have got great employees within the VA. 
We just need more of them, and we need to retain them. The good 
ones we have got because they are, like I said before, the 
backbone of the VA.
    One of the things about making the staff feel that they are 
wanted and supported is to guarantee they have access to PPE 
and testing that they need to be able to do their job safely, 
and VA leadership must recognize the sacrifices that staff are 
making by providing retention incentives and hazard pay when 
appropriate. I would also like to see the Department expand 
scholarship and training programs to help with recruitment and 
retention, especially in high-need areas like the rural parts 
of our country. We know that when a student trains at the VA, 
they are more likely to return and go to work at the VA. So 
recruiting and retaining staff also means treating the 
workforce with respect, listening to their concerns, and acting 
on them.
    So we need the management to understand that because, quite 
frankly, when it comes to health care issues, those folks that 
work for the VA, for the vast majority of them, they are the 
best, and quite frankly, if we treat them as they need to be 
treated, as this pandemic continues to look like it is going to 
expand in many parts of this country, we will be well set up to 
deal with it.
    Quite frankly, I look forward to your testimony, and I look 
forward to the questions that are going to come after that 
because we have got a number of things to talk about as this 
surge is upon this country.
    Thank you, Mr. Chairman. I appreciate the opportunity.
    Chairman Moran. Senator Tester, thank you very much.
    Now let me turn to our witnesses. Let me introduce the 
witnesses from the Department of Veterans Affairs. Dr. Steven 
Lieberman is the Acting Principal Deputy Under Secretary for 
Health at the Veterans Health Administration. He is accompanied 
by Ms. Jessica Bonjorni, the Chief of Human Capital Management 
at VHA. We also have Ms. Victoria Brahm, the Director of 
Veterans Integrated Services Network 12, joining us today. 
Thank you all very much, as I said earlier, for being with us. 
Thank you for the insight you can provide.
    Dr. Lieberman, you are recognized for your testimony.

   STATEMENT OF STEVEN L. LIEBERMAN; ACCOMPANIED BY JESSICA 
                  BONJORNI, AND VICTORIA BRAHM

    Dr. Lieberman. Good afternoon, Chairman Moran, Ranking 
Member Tester, and Members of the Committee. I appreciate the 
opportunity to discuss the Veterans Health Administration 
recruitment, retention, and hiring efforts during the COVID-19 
pandemic. During this unprecedented challenge and 
transformational time in U.S. health care, VA is proud of the 
unparalleled dedication and resilience of our workforce.
    From the front line to senior leadership, we are unified in 
our mission to deliver excellence for the more than 9 million 
veterans who entrust us with their care. We are also honored to 
serve as the backstop to the Nation's health care system, 
responding beside our Federal partners.
    Having served Americans in 46 States and the District of 
Columbia through our Fourth Mission, we have provided expert 
consultation, testing, personal protective equipment and 
ventilators to community entities. Over 2,000 VA personnel 
raised their hand to deploy into areas of the Nation severely 
affected by COVID-19.
    Recruiting and retaining top professionals has been our 
priority for the duration of the response. We hired more than 
23,000 staff, 85 percent of whom are permanent employees, while 
decreasing the onboarding time from several months to as little 
as 3 days. We stayed ahead of increasing demand for care by 
quickly launching national hiring campaigns through amplified 
use of social media, targeting positions in highest demand. 
More than 4,700 nurses, 800 physicians, and 1,400 housekeepers 
joined our ranks.
    VA has long been a leader in interdisciplinary team- based 
care. We enhanced the COVID-19 readiness of our clinical teams 
by empowering clinical staff to work to the top of their 
licenses, by augmenting role-based training, and by rapidly and 
exponentially expanding telehealth across the enterprise.
    As in other VISNs, while COVID-19 cases were surging in the 
community, an inpatient bed capacity was in high demand. Ms. 
Brahm in VISN-12 led the cross-training of ambulatory care 
nurses and the construction of extra negative-pressure rooms. 
VISN-12 also activated a mobile medical unit for contingency 
purposes. These efforts exemplify our principles as a high-
reliability and learning organization, where newly identified 
models of care are rapidly and effectively implemented across 
our health care system.
    To recognize exceptional efforts of staff, VISN leaders 
offered retention incentive awards and special contribution 
awards. Our successful surge hiring was built in a foundation 
of human resources modernization achieved before the pandemic, 
whereby VHA consolidated more than 140 facility human resources 
offices into 18 VISN-level shared services, eliminating 
bottlenecks.
    With the pandemic onset, we employed our existing 
flexibilities to reduce the hiring timeline and leveraged our 
capacity across the enterprise to optimize resources. We 
established an integrated staffing command cell to drive 
accelerated hiring and manage deployments of staff to affected 
areas of the country.
    The Office of Personnel Management offered tremendous 
support enabling us to expedite our onboarding model by 
expanding our ability to hire noncompetitively and encouraging 
retired Federal employees to return to service using pay 
flexibilities.
    While we are just passing the 90-day mark for many of these 
processes, our hope is to continue building on these 
improvements as we define the new normal. Congress' continued 
support for the recruitment and retention of talent to care for 
our Nation's veterans is vital.
    VA being granted additional flexibility with the CARES Act 
allowed us to waive pay limitations for employees during the 
national emergency. The unique challenges and impacts of this 
can weigh heavily on even the most altruistic and dedicated of 
individuals.
    We have been committed to support our employees' needs to 
face these times with resilience, and leaders at all levels of 
the organization have been working hard to support their teams 
emotionally and spiritually. We are succeeding.
    Absenteeism rates have stayed consistently lower than 
average, and our retention rates remain stable. During these 
unique times, we are committed to providing excellence for 
those in our care. Our greatest asset is our talented mission-
driven workforce.
    We look forward to working with this Committee to maintain 
VA's ability to hire quickly and eliminate barriers to 
attracting and retaining top talent.
    This concludes my testimony. My colleagues and I are 
prepared to answer any questions you may have. Thank you.
    Chairman Moran. Dr. Lieberman, thank you very much, and 
thank you and your colleagues for being here, as I said 
earlier, but especially for your care and concern evidenced by 
your statement, by your testimony for those who served our 
Nation. I appreciate your willingness to do so.
    Let me start with a question for you, Dr. Lieberman. So my 
understanding is that VHA's goal for 2020 in the budget was to 
increase its workforce by 13,000 employees. I understand that 
VHA has hired over 20,000 employees since the end of March. 
Would you tell me how these two things fit together? How much 
of that increase in hiring is due to meeting the needs during a 
pandemic, and how much of that hiring is just more routine? 
Additionally, how does the 13,000 than fit into the 20,000 that 
you have for the goal, and how is the retention at least to 
date?
    Dr. Lieberman. Thank you, Mr. Chairman, for that question.
    It is very important for us right now with COVID to 
continue to build that workforce to care for our veterans with 
their ongoing medical issues. Certainly, our veterans have 31 
percent more diagnoses, more complications from those 
diagnoses, and we feel it is really important to continue to 
stay focused on staffing up as we continue to meet the surges 
from COVID.
    We also continue to focus on replacing our priorities in 
areas such as mental health and women's health and a variety of 
other topics.
    I will turn to Ms. Bonjorni to provide more details related 
to your question.
    Chairman Moran. Ms. Bonjorni?
    Ms. Bonjorni. Yes, sir. So that hiring activity that you 
mentioned earlier is a great accomplishment, but we also have 
to keep in mind that we still have people who leave on a 
regular basis as normal turnover. So we did see a net increase 
in onboards for the fiscal year of upwards of 8,000 staff, and 
about two-thirds of that net increase happened since the end of 
March. So that expedited hiring and real focus made a big 
difference in our increases, and we do anticipate seeing 
continued increases for the rest of the year.
    Chairman Moran. I mentioned in my opening statement about 
the expedited hiring, the process. How much of that can 
continue on actions of the VA, or are there legislative changes 
required to allow the VA to continue to hire on an expedited 
process?
    Dr. Lieberman. So we are committed to moving forward to 
maintain as many of these improvements as we can. We have been 
so pleased with how we showed that this organization could 
literally turn a ship rapidly when we needed to, to stay ahead 
of this COVID wave.
    We are still just 3 months into this process, and so we 
will be paying close attention to this, making sure there are 
no unintended consequences to some of these improvements we 
have made, and we certainly are prepared to come back if we 
need any support from the Committee to share with you what that 
is as we do this assessment moving forward. We are just not 
ready to ask for that today.
    Chairman Moran. Ms. Bonjorni, I want to understand how the 
VA matches its patient needs.
    Dr. Lieberman, I can address this question to you, and you 
can pass it around, if you would like.
    But the MISSION Act was, in part, designed because of a 
strategic planning portion to try to get the VA to match its 
hiring practices with what the strategic plan showed the 
professionals needed by the patient, to match the patient's 
needs for their care with who we are hiring. Is that yet 
ongoing? The MISSION Act is relatively new. Is there sufficient 
strategic planning to make certain we are hiring based upon the 
needs of veterans?
    Dr. Lieberman. So we are continuing to pay attention, even 
with COVID going on, to every aspect of the MISSION Act and 
keeping track of where things are moving.
    Certainly, with COVID coming along, it does make us want to 
take a step back and just make sure that nothing has changed as 
a result of this, as a result of how we are serving our 
veterans and what the priorities are as a part of our Fourth 
Mission. So we are continuing to look at that, but we 
definitely want to look even closer if there needs to be any 
changes in our strategy moving forward.
    Chairman Moran. I will turn to Senator Tester following 
this follow-up.
    Is there sufficient implementation of a strategic plan that 
now would allow the VA to make decisions, hiring decisions 
based upon a plan, or is that something we would expect in the 
future? And if so, what kind of timeframe?
    Dr. Lieberman. So it would be sometime in the future, and 
it would be hard to commit to a timeframe today because of the 
uncertainty of COVID and the influence that that will have on 
our health care system and the national health care system.
    Chairman Moran. The follow-up to my follow-up is you did 
express the importance of strategic plan and following the 
MISSION Act, and I appreciate that. I share that view, and I 
was pleased to hear you say it.
    Senator Tester?
    Senator Tester. Thank you, Mr. Chairman.
    Dr. Lieberman, thank you for being here to talk about VHA 
workforce issues.
    Obviously, the number 1 thing that is on everybody's mind 
right now is COVID-19, including the VA's, as we see cases 
surge nationally.
    In April, the VA had to move to PPE austerity measures due 
to global shortages and could not guarantee that every VHA 
employee had a mask. Tell me right now who gets a mask?
    Dr. Lieberman. We currently have adequate PPE--and, 
certainly, this is something, as you know, is just of critical 
importance to us as we move forward with the COVID, and we 
maintain a focus on the number of PPE. We even have every 
different type. We look across the country. We talk about it 
every day.
    Senator Tester. My question is, though, Dr. Lieberman, who 
gets a mask and how often right now?
    Dr. Lieberman. We are still following the CDC guidelines. 
It has not changed. For anybody who is working where there is a 
potential for aerosolization of COVID, they would get the N95 
mask. Other employees would be eligible to get the surgical 
mask, depending on where they work.
    Senator Tester. Do you anticipate with this surge that the 
VA will have to bring back any of the austerity measures that 
they had brought back earlier in April?
    Dr. Lieberman. We have really had a laser focus on this and 
continue to acquire PPE, and we believe that we will have 
adequate PPE moving forward.
    As of today, we have enough PPE to last us at least 30 
days, and that number continues to grow.
    Senator Tester. OK. That was my next question. So you are 
at 30 days right now. I am sure that you guys have run some 
projections on the surge because in parts of this country, it 
has gotten pretty crazy, quite frankly. You feel confident that 
you are going to be able to grow that PPE stockpile even while 
the surge is going on?
    Dr. Lieberman. We are focused on many different avenues for 
how to procure it, whether through the Federal Government, on 
our own, manufacturing of PPE. We are looking at opportunities 
with DOD, and so, yes, we believe we will stay ahead of it.
    The beauty of the VA, as you know, is if there is a 
location of the country that is feeling pressure because of 
increased COVID, we can rapidly adjust and move our PPE around 
the country. That is one of the benefits of our health care 
system.
    Senator Tester. OK. As the Chairman pointed out earlier, he 
and I have conversations with the Secretary and Dr. Stone with 
some regularity, and they have talked about they are going to 
be reopening different regions, different VA facilities, at 
different moments of time. Has the surge impacted the reopening 
plants?
    Dr. Lieberman. Yes, it has. Just as in the private sector, 
we focus on what is called the ``gating criteria,'' and 
basically, we are keeping a close eye. So, certainly, if there 
is a surge, that leadership in that area will take a close look 
at that of what they have increased and certainly decide 
whether they should continue along the pathway, hold, or move 
backwards.
    Senator Tester. So what I would ask is this. If it has 
changed your plans for reopening--the surge, I am talking 
about--could you inform the Chairman and myself and anybody 
else on this Committee that wants it what those changes are?
    The reason I ask that--and the Chairman will ask it from a 
Kansas perspective--is Montana was going to be opened up. We 
have seen cases increase greatly in Montana. We have not seen 
hospitalizations increase greatly, which is bad and good news, 
I guess, but if you could keep us informed on how the surge is 
impacting your reopening plans, we would very much appreciate 
that. Is that a possibility?
    Dr. Lieberman. Absolutely. Just again to reiterate, we will 
see a veteran if they have an urgent issue, if they have a 
time-sensitive issue.
    Senator Tester. I gotcha. But overall from a planning 
standpoint, it would be great to know what is going on and 
where you guys see the hotspots impacting the VA, only for the 
reason that we are here to help. I mean, this Committee is here 
to help you do your job. So more information is better.
    I have got a few seconds left, but I will kick it back to 
you, Mr. Chairman.
    Chairman Moran. Thank you, Senator Tester.
    Senator Boozman?

                      SENATOR JOHN BOOZMAN

    Senator Boozman. Thank you, Mr. Chairman and Senator 
Tester, again for having this hearing. I want to commend you 
all and your staffs that have worked so, so very hard in such a 
difficult time to make it such that you are able to come up 
with some flexibility and really do a great job of hiring 
people, as was desperately needed.
    The VA, the bureaucracy--not only the VA. Just the 
government in general makes those things very, very difficult, 
as we all know, but working with OPM, what you did was 
remarkable.
    Ms. Bonjorni, the VHA was able to reduce the hiring 
timeline for over 90 days down to, in some instances, 3 days. 
Again, I want to commend you in doing that.
    During a recent interview on May 19th, you stated that you 
were able to do this by delaying the verification of new hires' 
education, medical license, medical references, drug testing, 
and other verification requirements. Some verification steps 
were given 3 months to be completed after being hired.
    While I understand the need for hiring people quickly, as 
is done in the private sector, during the pandemic, we also 
want to ensure patient safety. So can you reassure us the steps 
that were taken are being taken to make sure that those 
expedited hires are qualified?
    Dr. Lieberman. Thank you, Senator.
    So this is something we are paying close attention to.
    First of all, let me assure you that we have not seen any 
untoward events occurring in our health care system to date. We 
also have not had to remove any clinical staff that we have 
hired under this expedited process.
    We are following the Joint Commission processes for urgent 
privileging, and we do check three items right up front. And we 
make sure they have an active license. We check a reference, 
and one that I think is particularly helpful is we go to what 
is called the National Practitioner Data bank. And there, we 
can see if an applicant has had a payment with a malpractice 
suit, if they have a history of criminal activity or civil 
action against them related to health care, whether they have 
been denied an appointment to a health care program, State or 
Federal, whether there has been an action taken against their 
license by, again, State or Federal. So this is something we 
are paying attention to.
    If we were to see any warning signs either during the 
application process or even following, we would take a very 
immediate look at what was going on with that individual and 
pull them away from patient care while we do a further 
investigation. This is really important to us, so we are taking 
a close look at this.
    Senator Boozman. Oh, good. Well, we appreciate that 
reassurance very much.
    Under the CARES Act, Congress granted the Secretary a great 
pay flexibility. In your testimony, you highlight how helpful 
this pay flexibility was to recruit and retain your health care 
professionals. We understand VHA is utilizing existing pay 
authorities to provide recruitment and retention incentives for 
providers as well as examining additional potential 
authorities. What flexibilities does VA need, if any, that they 
currently do not have, that currently do not exist? How can we 
be helpful?
    Dr. Lieberman. Thank you.
    Ms. Bonjorni?
    Ms. Bonjorni. Sure. So the CARES Act has allowed us to 
waive a variety of pay limitations. The one that is most 
frequently been used thus far is the waiver of the biweekly 
premium pay limit, and I will just remind everyone that we are 
still in the middle of the year. And so most people are not 
going to come close to hitting up against their aggregate or 
annual pay limits, but we do expect that we are going to use 
more of those waivers as the year goes on while we are 
responding to not just the COVID pandemic but other 
simultaneous emergencies such as weather events and fires. So 
as we proceed down this, we expect that number of waivers will 
increase.
    There are some flexibilities around our ability to offer 
incentives that are still somewhat restricted, and that is 
something we are exploring now to make sure that we have all 
the flexibilities we need for future emergencies.
    Senator Boozman. Good. We appreciate that.
    Again, follow up if we need to do something in that regard.
    Thank you, Mr. Chairman.
    Chairman Moran. Thank you, Mr. Chairman.
    Senator Brown is recognized.

                     SENATOR SHERROD BROWN

    Senator Brown. Great. Thank you, Mr. Chairman. Thank you, 
Chairman Moran and Senator Tester. I appreciate that.
    Yes, we know we are here to discuss the VA's workforce, 
those on the front lines. The workers at VA facilities caring 
for veterans are so important. We always thank them, but we do 
not pay them like we thank them.
    A grocery store worker in southwest Ohio said to me, ``You 
know, they call me essential, but I am really expendable 
because they do not pay me a decent wage. And they do not 
protect me on the workforce.'' And I just want that never to be 
said about the Veterans Administration.
    Last month when Secretary Wilkie testified, I will say it 
again to you all that I urged VA to find a way to negotiate in 
good faith for VA employee unions. Veterans know they get 
better care if employees know their concerns are addressed when 
union representation is at the table. So I will urge you again 
to do that.
    Building off earlier comments from the previous 
questioners, Chairman Moran and Ranking Member Tester and 
Senator Boozman, I want to talk for a second about vacancies 
and hiring.
    Dr. Lieberman and Ms. Bonjorni, VA has shortened time to 
hire from about 90 days to 3 days, as we talked. During the 
pandemic, that is obviously amazing and should be commended.
    As of the last vacancy report, VHA had about 47,000 
vacancies. Walk me through, putting aside as much as you can, 
the pandemic, what you are going to do to fill those vacancies 
going forward, if you would walk through that.
    Dr. Lieberman. First, I just want to point out that an 
empty position does not mean a gap in care. We have ways to 
provide care via contingency plans. We have resource hubs 
around the country that provide care, can fill in if there is a 
gap, either face-to-face or via telehealth. Many of these 
positions are predictable, where somebody moves to a different 
position within their own organization or moves to a different 
facility, retirements, and so we are always planning for these 
with contingencies. Certainly in rare occasions, there are gaps 
in coverage, but those are actually unusual.
    We also have vacancies from growth in positions. So we 
have--for example, right now we are planning to open a 
precision oncology program, and that requires new positions. So 
that gets added to this number.
    Ms. Bonjorni, do you want to add to that?
    Ms. Bonjorni. Sure. I will add that in the hiring that we 
have done so far in response to the pandemic, we have seen a 
higher number of temporary employees hired. We do anticipate 
that we will convert over a large number of those into full-
time hires.
    But we are also seeing some trends across the broader 
health care industry that will certainly impact the VA. As you 
are aware, other health care systems are laying off staff, are 
furloughing them, and so that may make us easier to convince 
people that we are an employer of choice, where we can offer 
greater job security and they might turn to look at VA as an 
employer.
    So we do anticipate we will continue that hiring surge as 
we go forward using all the flexibilities we have already been 
granted.
    You may be aware also that we are using incentives to 
retain the staff that we have on board in many areas where 
there is fierce competition. So we can target that at our key 
occupations and in our high cost-of-living areas.
    Ms. Brahm. If I could add, from the field perspective, we 
have been aggressively hiring because we want to make sure that 
no matter what the future holds for us, we are going to be able 
to support our veterans and give them the care that they 
deserve as well as support the Fourth Mission in the community.
    Having Chicago in my VISN, we have gone through an initial 
pandemic. We had high rates of the COVID virus and were able to 
proudly not only serve our veterans but help the community at 
large.
    We were able since March to increase our workforce by 9 
percent, about 1,600 employees. Now we really not only want to 
continue aggressively hiring but also retain those employees. 
So we have implemented a program where we have already shown 
over the course of a year, we were able to decrease RN--we had 
a turnover rate of about 16 percent in our RNs by instituting 
what we call ``Stay in the VA'' and stay interviews at 
incremental times during the RN, the new RN stay, 30, 60, 90 
days. We have different levels of management meeting with them. 
How can we do better? What are we doing right? What makes you 
want to stay? Why are you here to serve? And we found that in 
the course of a year, we were able to reduce the turnover rate 
by 50 percent. So not only are we aggressively hiring, but we 
want to retain and make sure that we do have the staff that we 
need.
    Senator Brown. I wanted to ask one more question, if I 
could, to Ms. Brahm.
    A lot of us, Senator Tester especially and I, are 
interested in pandemic premium pay for workers, and that is 
obviously people that work directly with patients. But it is 
also custodians and security guards. It is grocery store 
workers. It is bus drivers. They are not government employees, 
not VA. We are trying in the package that Senator McConnell has 
shown little interest in so far and the President seems to be 
mostly unaware of to provide premium pay paid by government up 
to $10,000 through the course of a year.
    Talk, Ms. Brahm, if you would, about how many medical 
center directors are providing any kind of incentive pay or 
premium pay where they limit it to RNs and doctors. Do they 
include screeners and janitorial staff and others? What are you 
thinking, and what have you done so far, Ms. Brahm, about that?
    Ms. Brahm. Thank you so much for raising that question, 
Senator. I would love to answer that.
    We are very much focusing on housekeeping, medical support 
assistance, all of the other employees that really make our 
care happen. We realize this is not just nurses and doctors, 
even though they are integral to what we do for our patients. 
It is the whole team.
    So, in fact, we are not only using incentive retention 
awards across the board for both--all levels of employees but 
also special contribution awards across the board for those 
employees as well. VISN-12, every single hospital in VISN-12 is 
using that type of reimbursement at this time.
    Dr. Lieberman. And that is our approach across the country, 
Senator.
    Senator Brown. Thank you. Thank you all.
    Senator Moran, thank you for your indulgence there.
    Chairman Moran. Senator Cassidy?

                      SENATOR BILL CASSIDY

    Senator Cassidy. Great. Hey, thank you all. Thank you for 
your service to our veterans and to our country.
    I want to continue on this. I am looking at a spreadsheet. 
I wish I could show it to you, but one of my staff did 
excellent work pulling this up. And it is from some of the 
reporting requirements required for the MISSION Act.
    It shows the average amount of turnover from Q3 2018 to Q2 
2020, and it looks like the average turnover is probably about 
33 percent. Walla Walla, Washington, is like 49 percent. I am 
not looking at it, but I remember seeing that was near 50. Big 
Spring, Texas, is at 50 percent turnover. New Orleans, 
Alexandria, Shreveport, my home state, those have anywhere from 
25 to 30 percent turnover.
    And that is not really the picture I had gotten from your 
testimony, but if you are having 25 to 50 percent turnover in 
an institution, that is incredible. Can you just kind of 
comment on those numbers from that MISSION Act reporting?
    Dr. Lieberman. Ms. Bonjorni?
    Ms. Bonjorni. Sure. I would be happy to speak with you 
about the numbers in particular, but not having that massive 
spreadsheet in front of me, I cannot say to those specific 
locations.
    Across our system, however, our turnover rate has stayed 
consistent for the past decade at around 9.5 percent----
    Senator Cassidy. Now, that is not what this--this is, by 
the way--this is VHA medical facilities, and this is something 
you provided. I apologize. If I had forethought, I would have 
had it posted for everybody to look at. But there is like no 
place with lower than 20 percent.
    Now, this is all personnel. This is not just professionals, 
and I have another document which shows that for professionals, 
it is reported all the way from the physician down to the x-ray 
tech, not to diminish the x-ray techs, but just to say the 
range of education required, that that is lower.
    On the other hand, it seems a little counterintuitive 
because it seems like professionals have more options than 
folks who might not have professional degrees.
    So are you speaking, ma'am, just of the professionals, or 
are you speaking across the board?
    Ms. Bonjorni. I am speaking across the board. Our average 
turnover is 9.5 percent. When we look at specific occupational 
areas, we see slightly higher numbers in certain areas. So 
housekeepers, for example, or medical support assistants or 
other food service workers, entry- level occupations, generally 
have higher turnover.
    Our physicians and nurses, though, tend to trend--
physicians stay around that 9.5 or 10 percent, and nurses 
lower, more closer to 8 percent turnover.
    Senator Cassidy. OK. Well, this is from your quarterly 
report, the MISSION Act reporting requirements in a table, the 
questions for the 2020 annual document. So maybe that should be 
a question for the record because it really seems to be a 
disconnect between that which is reported and that is what you 
are telling us. OK.
    Dr. Lieberman. Senator, we would be happy to get back to 
you about that.
    Senator Cassidy. Yeah. OK, that is fine.
    Now, the other thing, the last time when we had a 
conversation, the statement was made that the time from the job 
offer to the onboarding has been greatly compressed.
    But a couple years ago--so I am going to explain this and 
see if you can give me--if this is still the case. A friend who 
is a physician told me, ``You know, I knew my nurse 
practitioner was leaving in 6 months, but I was not allowed to 
advertise for the position until she had left. So then when I 
advertised, it took me a process of hiring. We had to 
advertise. We knew she was leaving. She left. Then we had to 
advertise for a certain period of time, and then we had to 
onboard.'' So I think he said it was a year and a half between 
the time which he knew she was leaving until she was actually 
replaced.
    So I guess my question is there are three segments to that. 
You know she is leaving. Then you advertise the position, and 
then you onboard once you make an offer.
    I think I heard you specifically speak of the onboarding 
process. What about those previous two segments? You know they 
are leaving, and then the position is open. And you are now 
advertising for that.
    Ms. Bonjorni. Yes, sir. So the data that we have been 
reporting, when previously it was referenced that our average 
time to hire was upwards of 90 days, that is a measurement from 
the time that you validate the need to make a hire. So that 
should have been from when you were notified a person was 
leaving until they actually come on board. So that encompasses 
all the steps of the hiring process.
    The individual case you referenced, that sounds like they 
were not pulling that process, and we have certainly made clear 
as we have improved our time to hire that that is not a process 
we are following across the system.
    Senator Cassidy. So one more time, because I am almost 
out--I am out--on forbearance. If I know that--I am a 
physician, so I am going to speak as if I am the physician--
that my nurse practitioner is leaving in 6 months, I can begin 
to advertise to fill that position before she has actually 
left?
    Ms. Bonjorni. Yes.
    Senator Cassidy. OK. Well, thank you very much.
    I yield.
    Chairman Moran. Doctor, thank you.
    Senator Blumenthal?
    Senator Tester. Mr. Chairman?
    Chairman Moran. Senator Tester?
    Senator Tester. With Senator Cassidy's consent, of course, 
could we get that spreadsheet, and then could we get the 
Department's response to that spreadsheet? I think this is 
really an important point, and I would love to see it. And I 
would love to see the Department's response to find out what is 
going on.
    Senator Cassidy. My staff member who did the great work on 
this is watching. I am going to ask him to send it to SVAC 
staff right now, and maybe it can be shown to folks now. And 
please send to Senator Tester's staff as well, speaking to my 
folks who are listening.
    Chairman Moran. We will accept that offer, and our staff 
looks forward to getting the report that you were describing.
    Senator Tester, that is a very good idea. Thank you.
    Senator Tester. Thank you.
    Senator Cassidy. Thanks, Mr. Chairman.
    Chairman Moran. Senator Blumenthal?

                   SENATOR RICHARD BLUMENTHAL

    Senator Blumenthal. I am deeply concerned along with my 
colleagues about the spread of COVID-19 among veterans. I 
understand that the number of active cases has doubled in the 
last month, and that 1,574 patients have died along with 39 VA 
employees. Over 50 percent of VA acute care and ICU beds are 
occupied at present. I think those numbers are right. They are 
alarming, and what they indicate as well is the need for proper 
protection, PPE, which is financed in the CARES Act.
    I am hearing from employees of the VA all over the country, 
my colleagues and I are, about the need for more PPE. I know 
these complaints are not new to you.
    I am also hearing about the number of hours worked by VA 
employees, and I join Senator Tester and Senator Brown in 
expressing the view that these employees, all of them, deserve 
hazard pay.
    The CARES Act waived the pay caps to allow frontline VA 
workers to work overtime, as you know, but I think more has to 
be done. I am in favor of the hazard pay provisions under the 
CARES Act for VA frontline workers. The kinds of hazardous duty 
pay that it contemplates are well deserved. VA employees are 
putting themselves at risk every day to fight this virus.
    So my question is, Dr. Lieberman, do you have data on which 
VA employees have exceeded the pay limitations provided under 
the CARES Act, and how many have?
    Dr. Lieberman. Ms. Bonjorni?
    Ms. Bonjorni. Certainly. Looking at just the data for the 
first month that we were able to use the authority, we had 
upwards of 150 employees who exceeded the biweekly caps, and we 
are still waiting for the most recent month's data. So, again, 
that is a biweekly cap because we are early in the year. We 
anticipate more people will start to hit the cap as the year 
goes on.
    Senator Blumenthal. 150?
    Ms. Bonjorni. Yes, sir.
    Senator Blumenthal. And you said for the first month?
    Ms. Bonjorni. Yes.
    Senator Blumenthal. What dates does that----
    Ms. Bonjorni. That is from mid April to mid May.
    Senator Blumenthal. Mid-April to mid-May. So presumably, 
you have more data from mid-May to mid-June?
    Ms. Bonjorni. Yes, that I do not have yet.
    Senator Blumenthal. When will it be available?
    Ms. Bonjorni. It should be within the next week or so.
    Senator Blumenthal. 150 sounds low, does it not?
    Ms. Bonjorni. Yes.
    Senator Blumenthal. OK. Well, I would appreciate you 
providing that data as soon as it is available.
    The second area I would like to ask about, the Office of 
Accountability and Whistleblower Protection. You know that the 
VA Office of Inspector General released a report at the end of 
last year that found systematic problems within the Office of 
Accountability and Whistleblower Protection. These issues 
concern the failure to hold senior-level executives 
accountable, the failure to conduct unbiased investigations, 
lack of transparency, failing to protect whistleblowers from 
retaliation.
    A number of us wrote to Secretary Wilkie, and in response, 
he said, quote, `` quality control team would review all 
whistleblower retaliation cases that were closed without action 
during OAWP's first 2 years.''
    Now, there are about 175 whistleblower retaliation cases 
that need to be reviewed. Can you provide an update as to the 
review of those cases?
    Dr. Lieberman. I do not have an update today, but I 
certainly can ask the agency to get that for you.
    Senator Blumenthal. Can you tell us how the VA decides 
whether or not to implement a recommendation action by OAWP?
    Dr. Lieberman. I can just speak on behalf of VHA. 
Certainly, we review closely what they recommend, consider it. 
It goes up to senior levels and take it under serious 
consideration and then make a determination if we believe what 
they recommend is consistent with what the facts show from our 
standpoint.
    Senator Blumenthal. My understanding is that the VA has 
closed only 3 of the 22 recommendations from the OIG report. I 
do not know whether you have an update on those 
recommendations.
    Dr. Lieberman. I do not today.
    Senator Blumenthal. Could you provide that update along 
with the 175-case status?
    Dr. Lieberman. Certainly.
    Senator Blumenthal. To the extent you can. Thank you.
    Thanks, Mr. Chairman.
    Chairman Moran. You are welcome, Senator Blumenthal.
    Senator Rounds?

                      SENATOR MIKE ROUNDS

    Senator Rounds. Thank you, Mr. Chairman.
    First, let me begin by saying thank you for the work that 
you are doing. Thanks for working through some real difficult 
challenges during this pandemic time.
    I would like to focus on a couple of specific issues with 
regard to South Dakota, and I would like to use them as an 
example of some concerns I would have elsewhere within the 
United States as well.
    At the Fort Meade VA in Sturgis, which is in the western 
part of South Dakota near the Black Hills, there is a Title 38 
recruiter who works in an office down the hall from the Black 
Hills health care system director.
    Now, we are a small State. We have small facilities. It is 
not very far from one office to the next.
    He used to report to that director, and they worked 
together to identify local needs and staff critical positions 
successfully.
    But last October, the recruiter got rolled up under the 
VISN. So even though he knows South Dakota, knows our veterans, 
and has brought quality providers to some of the most rural 
parts of our State, I am told that now his hands are tied by 
red VISN tape. He cannot even walk down the hall anymore to 
discuss recruitment with the health care system director. 
Instead, he has to go through the VISN.
    Am I missing something here? How does adding a layer of 
bureaucracy help anyone in the VA working on recruitment and 
retention to close the gap in filling critical vacancies or to 
meet a time to hire metric?
    If you would like to refer to either one of your team 
members, that would be fine.
    Ms. Bonjorni. Sure. I could speak to the overall setup of 
our VISN H.R. modernization.
    The concern that you raised, thank you for raising it, and 
it is not one that should actually occur. There is nothing that 
would prevent a recruiter from speaking directly to the medical 
center director that they work with. It is certainly possible 
that the situation you are referencing involves someone who has 
been assigned to support the broader VISN overall, and there 
might be someone else assigned to do local work for South 
Dakota. But we would continue to encourage that strong 
relationship with the recruiter and the medical center director 
leader. It just might be different people.
    Senator Rounds. We are not a real big facility. If you have 
got a facility as small as that, I doubt there are multiple 
recruiters in one facility. If you are sitting in the facility 
and now you are going to go through VISN 23 which is basically 
out of Minneapolis, that would be, what, 7-, 750 miles away? So 
you are now working your way through another facility. I do not 
know exactly how large the Minneapolis facility is, but I can 
guarantee it is a whole lot bigger than what we have got in 
Sturgis.
    And then to be able to somehow work through that to get 
back down to do what you were doing successfully before, it 
seems to me that you have added a layer of bureaucracy, which 
is not necessarily defensible, particularly when if the 
suggestion is that you are using a recruiter that is not at 
that location now, that somehow they are supposed to do a 
better job than someone who is already there and has successful 
done it, it seems to me that there is something missing in it.
    And the reason why I am bringing it up is not just because 
it is one location, but because if the reorganization of this 
is to provide an efficiency, it seems to me that there may be 
some lacking oversight with regard to whether or not that 
efficiency would actually be working. And if it is not working 
in a small facility like that, I wonder what is actually going 
on, on the job, at other locations throughout the country.
    And I would simply ask, can you follow up and find out 
whether or not the statements as I have shared with you are 
accurate, and second of all, if they are accurate, why we would 
not get back down to allowing a normal, more reasonable 
approach in a local region to exist?
    Ms. Bonjorni. Yes, sir. I can absolutely commit to looking 
into that specific situation you reference, and then when we 
look at the way the model is set up, there are some staff who 
are doing shared services work for the whole network. And then 
there are staff who are strategic business partners who are 
dedicated to that facility. So that did not actually change in 
the model. It sounds like we need to look into your specific 
case to figure out where the disconnect may have occurred.
    Senator Rounds. And I thank you for that because it seems 
since fiscal year 2015, this Congress has literally authorized 
funding for about 35 percent more in terms of FTE to meet 
demand from 295,000 up to and authorized 357,500 fully funded 
for fiscal year 2021. And if we are going to do that, we need 
the most efficient and reasonable approach to actually getting 
these folks in place. If we have got a system that has been 
designed, but it may not be working as hoped for, I just hope 
there would be a reasonable expectation that modifications 
could be made to actually get the results we are after.
    Ms. Bonjorni. Yes, sir. We share the same goals of making 
sure we have the most efficient and effective H.R. processes we 
can.
    Senator Rounds. OK. And when would you be able to get back 
to us with this?
    Ms. Bonjorni. Within the next couple of weeks, I 
anticipate, once we speak with the network.
    Senator Rounds. Five, 6 weeks should be more than adequate?
    Ms. Bonjorni. Yes, sir.
    Senator Rounds. OK. Thank you very much.
    Thank you, Mr. Chairman.
    Chairman Moran. Senator Rounds, thank you.
    Senator Sinema?
    [No response.]
    Chairman Moran. Senator Sinema, if you are there or join 
us, we will come back.
    Senator Tillis?

                      SENATOR THOM TILLIS

    Senator Tillis. Thank you, Mr. Chairman. Thank you all for 
being here.
    I want to go back and just do a quick mental math exercise. 
How many total employees do we have in VA health?
    Dr. Lieberman. About 352,000.
    Senator Tillis. OK. 350,000. And the average attrition 
rate, you said is 9 among documents? So it is 9 right on the 
average? Among nurses, it is 8? So I am looking forward to 
getting the spreadsheet, but I do not see how the math works. 
It would mean for non-doctors and non- health officials, you 
had an attrition rate of--if you extrapolated beyond these 
facilities of 40 or 50 percent. My guess is if you had that, it 
would be something you would be well aware of. So I will be 
interested in seeing how we normalize those numbers for the 
benefit of the Committee.
    I did have a question for Ms. Brahm. You cover Great Lakes, 
right? That is VISN-12?
    Ms. Brahm. Correct.
    Senator Tillis. OK. So that is a portion of Michigan, 
northwest portion of Indiana, Illinois, Wisconsin. You have got 
a good mix of rural and urban areas.
    Tell me a little bit about how well you all have done with 
the COVID response specifically for any of the veterans that 
you are serving and, comparatively, if you know this, against 
your peer group in the private sector.
    Ms. Brahm. Yes. And thank you for the opportunity.
    It has been really beneficial for us to have both regions 
because, as we were struggling with Chicago area, the Illinois 
area going through a massive surge, we were able to leverage 
from the Wisconsin side, the northern tier, to help us. So we 
were able to flex very quickly staff, PPEs, supplies, 
ventilators.
    And when we did even come up to a point where we needed 
additional help, where not only was the private sector 
occupying ICU beds at a rate of 87 percent, we were able to get 
the region, so the entire Midcon region to help support us very 
quickly on the ground. That was amazing.
    We also were able to very closely collaborate with our 
private-sector partners. We created triage systems, whereby 
when Mission Four was activated, even though we were under a 
surge ourselves, we were able to support the private sector in 
moving civilians into our hospitals and taking care of them.
    The great thing about having both the remote and the urban 
hospitals are that you can activate in one hospital that is not 
suffering. For instance, Iron Mountain, Michigan, was able to 
help support us in the Chicago area. Madison, Wisconsin, at one 
point was able to support us in the----
    Senator Tillis. So you were able to do a lot of load 
leveling because there were clearly hotspots in other areas 
that were not.
    At any point during the peak or do you fore see any--so 
looking back, at any point during the peak, were you out of 
beds, out of ventilators?
    Ms. Brahm. No.
    Senator Tillis. Out of PPEs?
    Ms. Brahm. We were able to create surge plans, and some of 
that was due to the ability of our engineers, our biomed people 
to create negative-pressure rooms.
    Senator Tillis. Were you ever out of PPEs?
    Ms. Brahm. No, we did not. We were able to cross- leverage 
and predicted. That was ongoing. Of course, we set up incident 
command, and we have had up to five meetings a day, consistent 
communications.
    Senator Tillis. Were there any instances where you were 
actually providing care to private sector logistically or 
through PPEs?
    Ms. Brahm. We did help. We were in daily communication with 
our State veterans homes and the contract nursing homes that 
take care of our veterans. We did supply----
    Senator Tillis. How well have the State veterans homes 
done? We have done a lot of work with North Carolina, with the 
State-run veterans homes, co-resident with some of our VA 
facilities. How well did they do compared to the facilities 
that you have with seniors?
    Senator Tillis. We had one that did phenomenally well, with 
no cases to date, and then others that needed not only PPE 
support, but some consultation in terms of how to set up COVID, 
non-COVID, and emergency response, especially of nursing 
personnel. So we were able to go into those homes and help them 
to help themselves. It was very much appreciated.
    Senator Tillis. Do you have any peer-level review of how 
well you all did within VISN-12 and how well that rough 
geography did within the private-sector health care response 
for seniors, congregate facilities, other ones?
    Ms. Brahm. I do not think I understand the question.
    Senator Tillis. So you have got congregate care facilities 
outside the VA system.
    Ms. Brahm. Yes.
    Senator Tillis. They had a crisis. It looks like they were 
a little bit later or behind the VA in implementing protocols. 
So I was kind of curious as to how well you all did as a health 
care facility for the VISN-6 as compared to the elderly and 
congregate care facilities in the private sector.
    Ms. Brahm. I think comparatively, subjectively, knowing we 
did open a Mission Four to take community care, nursing home 
patients from the private sector. So we did take those type of 
patients. We did, and we implemented our protocol very early. 
And we are very protective of our nursing home patients. So I 
think we did extremely well, comparatively.
    Senator Tillis. Mr. Chair, just in closing, I have done a 
little looking into this in VISN-6. I work very closely with my 
VISN director, the VA facility directors, and everything I see 
there, obviously we could always improve. But everything I see 
there is most likely a best practice for how to handle 
congregate care facilities in the private sector.
    So I hope after we get through this, we share some of those 
best practices because I believe what we are going to find, by 
and large--there could be some exceptions in certain areas, but 
by and large, you as a national health care system probably 
performed more admirably than any other major health care 
system in the yesterday. And I thank you all for the work you 
did.
    Thank you, Mr. Chairman.
    Chairman Moran. Thank you, Senator Tillis.
    Now Senator Sinema?

                     SENATOR KYRSTEN SINEMA

    Senator Sinema. Thank you, Chairman Moran, and thank you, 
Ranking Member Tester, for holding this hearing today.
    I also want to thank our witnesses for being here today.
    In Arizona, the VA health system covers a lot of rural 
areas, and this represents an additional challenge to 
recruiting and retaining VA employees, and now with COVID-19 
cases rising dramatically across our State, we are struggling 
to ensure we have enough staff to support the need. And, of 
course, that is critical.
    So my question for Ms. Bonjorni is last week, I served as 
Ranking Member for a Homeland Security and Government Affairs 
Subcommittee hearing on the National Commission on Military, 
National, and Public Services' final report. This report 
identified agency culture as strongly contributing to hiring 
challenges.
    In recent years, stakeholders and Congress have worried 
that many of those hiring barriers have prevented the VA from 
fully addressing its vacancy challenges, yet in the midst of a 
pandemic, the VA has hired nearly 20,000 new employees very 
quickly.
    So what has this surge taught you about the culture of the 
VA around hiring? And how will you continue to build on this 
recent momentum?
    Ms. Bonjorni. Thank you for the question, Senator.
    Certainly, we have learned a great deal from our surge 
hiring efforts. I have not read the specific report that you 
reference, but certainly, when you look at any process, there 
are people who may be resistant to changing it. And sometimes 
the complexity of our hiring process makes it feel to the 
average user of the process that it cannot be changed.
    I think what the pandemic showed us on our lofty goal that 
we push toward to get to a 3-day onboarding timeline was it 
made us very creative to think through what were the things 
that we could change and what help did we need.
    It is unusual to have the level of support that we have had 
just among each other and from other Federal agencies. So we 
are really grateful to see the amount of collaboration that we 
had from OPM and other partners to help us really think through 
how we could break down those barriers, and now we are starting 
to evaluate each one of those changes that we made and figure 
out how many days it shaved off of the process and how we can 
retain many of those changes.
    I will note that we will not probably be able to retain all 
of them without additional support, either through legislative 
change or regulatory change.
    Senator Sinema. Thank you.
    My next question is for Dr. Lieberman. The Commission 
report also noted specific challenges at the VA in filling open 
positions for health care professionals. The report recommended 
streamlining the hiring process by implementing a single 
personnel system, Title 38, for all health care providers and 
support staff at the VA, but stakeholders have expressed 
concern regarding moving away from the competitive service 
hiring system of Title 5. So what are the challenges and 
benefits of this recommendation for the VA?
    Dr. Lieberman. Senator, thank you for that question.
    I would defer to Ms. Bonjorni, who really is the greatest 
expert here on this topic.
    Ms. Bonjorni. Sure. Thank you.
    When you look at perhaps prior testimony that we have 
given, we have expressed some of the challenges we have with 
having upwards of 120 different appointment authorities for new 
hires. It makes it very complex for H.R. professionals and for 
managers to understand how the hiring process works due to 
those complexities.
    Having a streamlined process where there were fewer laws to 
learn, I think would be helpful for our staff, and having more 
flexibility all the time in our pay-setting policies would also 
be extremely helpful for us to continue to meet the needs of 
our hiring managers.
    As we can see right now, the market is changing 
significantly. We do not know what the pay flexibilities might 
look like a year from now, given what the private sector is 
doing. We just need to be agile.
    So if we had a system that was consistently agile, that 
would be something we would certainly be happy to discuss with 
you.
    Senator Sinema. Thanks.
    My last question for you is how does the VA ensure local 
facilities have the flexibility they need to meet specific 
hiring challenges they face, like adjusting incentives and pay 
rates based on the high cost of living in certain areas?
    So, for example, the Prescott area in Arizona has a high 
cost of living, but it does not qualify for the locality pay 
that Phoenix does. So this has led to problems hiring and 
retaining positions such as housekeepers.
    Ms. Bonjorni. Yes. We share that concern, and I think the 
way that pay setting works for both Title 5 GS employees and 
for wage grade employees, the pay-setting considerations are 
not the same across those different groups. An area like 
Prescott, in particular, faces a challenge just based on the 
number of people there and the number of people who work for 
the Federal Government and how those calculations occur.
    What is within our control in the VA is to look at the use 
of incentives, so recruitment, relocation, and retention 
incentives, which we can use at any facility, regardless of 
geography, and so that is what we focus on.
    In the future, if there are changes to how pay setting 
works for those different occupations, we definitely would be 
interested in talking about that.
    Senator Sinema. Thank you.
    Thank you, Mr. Chairman. I yield back.
    Chairman Moran. Thank you, Senator.
    All right. I think that may conclude those we think are 
with us remotely or certainly I can tell those who are not with 
us present, in person.
    Let me see. Senator Tester, I have a series of questions I 
want to ask. Let me give you the opportunity to go first for a 
second round.
    Senator Tester. I appreciate that, although Senator 
Blackburn is on my screen. I do not know if she is out there or 
not.
    Chairman Moran. She is not, and I think if she was, we 
would hear from her.
    Senator Tester. OK. That is true.
    Chairman Moran. Thank you.
    Senator Tester. So, Dr. Lieberman, there have been plenty 
of examples in the private sector. There have been plenty of 
examples at VA. In times of health care crises, medical, 
mental, and physical well-being is important. How is the VHA 
addressing the issue of mental and physical well- being, and 
what resources are out there for our staff?
    Dr. Lieberman. Senator, I just want to make sure I 
understood. You are asking of our staff?
    Senator Tester. Yep, of your staff.
    Dr. Lieberman. Thank you.
    Senator Tester. Mental and physical well-being of your 
staff. Are there resources available to them? How are you 
addressing to make sure that you are----
    Dr. Lieberman. So thank you for that question. This is a 
really important issue at a time like this, and we have been 
focused on this really since the beginning of starting to see 
the numbers of COVID increase in certain parts of the country.
    By definition, VA staff are resilient. They come to VA to 
work because of the special mission we have, and yet we have to 
pay attention to this.
    One of the things is focusing on certainly our leadership. 
We expect them to--and we know that they are--following the 
principles of servant leadership where they really are there 
for the success of the employees, and a big part of that is the 
well-being of the employee. That is what we are hearing of what 
is going on in the field about being out there, getting out 
there, talking to employees, hearing what their experiences 
are.
    We also early on focused on some of our national experts in 
mental health, in whole health, and the National Center for 
Organizational Development to give us ideas on how we could 
focus to make sure that our frontline staff as well as our 
leadership, which were truly also working 24/7, to making sure 
that every aspect of care was taken care of, had what they 
needed to be successful.
    So we did provide a number of resources for them and tools 
and also had people available to talk to them, whether it was a 
chaplain or employee assistance program or the National Center 
for Organizational Development certainly would meet with 
leadership who really just wanted to have a confidential 
conversation with someone about the stress that they were 
experiencing and what they were going through as a leader.
    I would ask if either of my----
    Senator Tester. I was going to redirect it to Victoria 
Brahm, anyway----
    Dr. Lieberman. Sorry. OK.
    Senator Tester [continuing]. Because I wanted to hear what 
her perspective is as being a director of VISN-12. What are you 
seeing as far as burnout, and do you think you have adequate 
resources to deal with the issue?
    Ms. Brahm. Thank you for that question. That is a very 
extremely important priority for us.
    I am a big proponent of whole health, especially for--it is 
for our veterans and our employees. We have done multiple--we 
have implemented multiple strategies in that area. We have 
virtual stress relief. We have tai chi. We have yoga. We have 
created areas in the hospitals where our staff can go to 
rejuvenate, relax.
    We have created areas where staff can come to vent, speak, 
either in listening sessions that are larger and 
psychologically safe or in private practice like Dr. Lieberman 
has suggested with our mental health professionals.
    We are moving forward also with increased communication. It 
is very important because a lot of anxiety is caused when you 
do not communicate. So we do virtual discussions very 
frequently with the staff not only across the VISN, but the 
directors do it in the hospital. And we share mantras and share 
stories about what is going on in the COVID epidemic, because 
what staff do not know tends to be sometimes worse than it 
really is, so really sharing what is going on, what are we 
doing as leaders, how are we helping you, and what do you think 
we need to be doing.
    So actually with the implementation of whole health, with 
the activation of all of our mental health professionals, in 
looking for stress relief, and then in creating environments 
for psychological, safety, and listening sessions and constant 
communication, I think we have been able to manage.
    I would just tell you that this staff is awesome. They have 
the resilience. I am shocked. We have very little coli strain, 
an epidemic that is very scary.
    We have had--people come back that were retired. I have a 
nurse that came back after retiring after 40 years of service. 
She was an infection control person and came back over the age 
of 60. I can say that because I am too, but over the age of 60 
that came right back into an epidemic and helped do intensive 
infection control surveillance.
    I have a retired respiratory therapist who came back to 
activate a medical hospital on one of my hospital campuses. In 
case we ran out of room for ICU beds, we would be ready to 
activate a mobile hospital.
    They are just awesome. Every day, I am amazed at the 
resilience.
    And I have also worked with the military to do resilience 
training for our staff. So we have done quite a bit of military 
culturation and resilience training, which has seemed to have 
been very effective for the staff as well.
    Senator Tester. Thank you.
    Mr. Chairman, I have one more question, if you will give me 
that flexibility.
    Chairman Moran. Please proceed.
    Senator Tester. OK. This is for Victoria Brahm again as 
director of VISN-12. Are you collecting from your frontline 
staff--are you collecting information on sufficient PPE and 
testing, both for the vets and for staff themselves? Are you 
collecting that information?
    Ms. Brahm. Absolutely. Twice a day. In an ongoing manner, 
we are looking at testing capacity. We want to make sure and 
guarantee that every employee that wants to be tested can be 
tested, and we have been able to achieve that. We want to make 
sure that if there are any PPE issues, we address them quickly, 
and as I stated before, we were able to leverage across the 
VISN. If we are not, we look at the regional level, and if we 
are not, we have had great support for the Central Office 
level.
    At this point, since we have been able to lower the curve 
in my VISN, we are now trying very much to help other VISNs as 
well in the need for PPE, employees--I mean PPE, staffing, and 
equipment.
    We are also working at the Milwaukee VA to start 
production. We have been working on laser cut shields, 
controlled air purifying respirators, and swabs, and we are in 
production now, not only to guarantee enough for our VISN but 
to share across the Nation.
    Senator Tester. I will yield back now, Mr. Chairman. Thank 
you.
    Chairman Moran. Thank you, Senator Tester.
    I have a few questions, and then maybe we can conclude.
    First of all, let me ask about funding. The hiring that has 
occurred in the last several months during the COVID pandemic 
was funded by Congress, by the American taxpayers with 
increases through the various phases, but particularly the 
CARES Act. When that money is gone--is that money being--what 
money is still available for hiring from the CARES Act? As we 
look at the next phase of spending on the pandemic, are there 
going to be needs for dollars for hiring to address COVID?
    Dr. Lieberman. Thank you for that question.
    We thank Congress for the generosity to the Veterans Health 
Administration at VA from the CARES Act, and between that and 
our regular funding and our request for 2021, we expect to have 
enough funding.
    Certainly, COVID is unpredictable in some ways, and so we 
may come back and ask to have the monies moved from one account 
to another. But at this point, we expect to be fine.
    Chairman Moran. So let me put that in, I think, the same 
words that you just said but make sure that I understand it. 
The money that was appropriated both in the regular 
appropriations process and in the various phases, the four 
phases of legislation that we have passed to date that provided 
money to the Department of Veterans Affairs for payment, of 
costs associated with COVID-19 and the pandemic, those dollars 
are sufficient? And unless things change, you would not expect 
a request for additional dollars?
    Dr. Lieberman. That is correct, Senator.
    Chairman Moran. Thank you.
    Let me raise the topic of discrimination, particularly 
racial. What can you do to assure me that both in the hiring 
practices and in the daily work of the VA workforce that there 
is not discrimination based upon race or other factors?
    Dr. Lieberman. Thank you for that question, Mr. Chairman. 
This is something that is a very important topic to Dr. Stone 
and myself as well as the Secretary. Certainly, we have been 
hearing about concerns voiced at the VA in your home state.
    We are taking a variety of different approaches to this. 
Number 1, for the facility in your State, we are planning to 
really listen a lot and find out about experiences that staff 
are having, and we certainly are doing this at other places 
across the country.
    We also have developed a survey that will go out to staff, 
starting again at a facility in Kansas, to hear from staff, 
first line, what do they think is going on and what do we need 
to do to change.
    Sometimes we in leadership just think we have all the 
answers that we know from reading textbooks, and I think at a 
time like this, we really need to make sure we take the time to 
listen to frontline staff what they have to stay. So that is 
what we are going through right now.
    Additionally, even before the events of recent months, we 
felt that this was such an important topic in the Veterans 
Health Administration that we wanted to make sure that our 
workforce, both frontline, mid-level, and top-level staff truly 
reflected as much as possible the population of veterans that 
we cared for.
    So we, Dr. Stone and I, had set up a group, advisory group 
involving a lot of people from the field, more people from the 
field than headquarters, and looking what are best practices 
out there with diversity and inclusion.
    We spoke to health care systems such as the Cleveland 
Clinic and the University of Pennsylvania, non-health care 
systems such as Google, and based upon feedback from all these 
different organizations, this group advised Dr. Stone and I, 
gave us almost 50 recommendations on what we need to do to move 
forward.
    So we have agreed to make this a priority and set up a new 
improved diversity inclusion office that will report directly 
to myself and Dr. Stone, and we are in the process of beginning 
the search for the individual that will head up that office.
    This is really just the beginning of a journey we are on to 
make sure that we get this right moving forward.
    Chairman Moran. Thank you for your answer, and I appreciate 
the intentions of additional efforts in regard to this.
    Ms. Brahm, something that I should know from your 
perspective as a medical center director on this topic?
    Ms. Brahm. Yes. Well, we also take this very seriously in 
the field, and as you know, there has been a lot of civil 
unrest. I feel like one of the major things that we are doing 
is working with our leaders and to develop resources on how to 
have these conversations, not only how to listen to what is 
actually the feelings that are out in the frontline workers, 
but how do you respond when it is a difficult conversation. So 
we have been working very much with our leadership on those 
kinds of things as well, as well as putting out mechanisms for 
our staff at the local level to be able to address their 
leadership when they feel there is this kind of behavior.
    I have personally at the VISN level been receiving 
information from the staff at the hospital level. So we take it 
all very seriously, and anytime we do receive some kinds of 
concerns, we follow up on that. But mostly at this point, it is 
education. It is communication. It is the toolbox and how do 
you handle these kinds of situations.
    And in addition, we have set up committees at the VISN 
level to monitor and look at this and to look if we do not have 
appropriate representation in our diverse workforce and what 
can we do about that. So we also are in a learning phase to do 
better.
    Chairman Moran. Thank you for your answer.
    Perhaps Ms. Brahm, but it could be you, Dr. Lieberman. My 
experience has been that generally when we talk about 
employment at the VA, we think of those who are caring for 
patients. But I want to highlight the importance of the 
leadership, Ms. Brahm, your position, but others within the 
various VISNs.
    The medical center director is hugely important in the way 
that a hospital cares for our veterans, and we have had--what 
is it that needs to take place to make certain that there is 
long-term stability in that position, in the position who is 
the medical center director in our medical hospitals across the 
country?
    I do not know which direction to look. Dr. Lieberman is 
looking at you, Ms. Brahm.
    Ms. Brahm. OK. Here I am. Thank you for that question.
    Having been a medical center director and now a new network 
director and been with the VA as a nurse for 39 years, I can 
tell you that our succession planning for these positions is 
critical, and we do a wonderful job of that.
    But I think it is developing enough confidence of the 
leaders that we do have within the VA system to step up and 
take the role. I think they hear negative publicity sometimes. 
I think the job, it is very stressful. It is a senior 
leadership position. It has a lot of accountability.
    But I think talking to people, as I mentor multiple people 
in the field that are leaders, part of what I do is try and 
develop their confidence to step up and take the role.
    Chairman Moran. I thank you for that answer.
    Dr. Lieberman, I would tell you that at one of our 
hospitals, the medical center director, it is now filled by an 
interim, and it seemed like for a decade, we had the same 
medical center director. And then it has been a series of 
changes ever since then.
    I just want to express to you the importance of having 
stability in that position, certainly stability with somebody 
who is good at their job, somebody that performs well, but they 
are seemingly--and I do not know how prevalent that is across 
the country, but my experience in Kansas, at least in one of 
our hospitals, is the directors seem to come and go. And that 
certainly diminishes my ability to develop the relationship 
that I think is helpful to me and hopefully to the center 
director but also, more importantly, to the patients and to the 
staff that work in that hospital. Am I missing something?
    Dr. Lieberman. We agree on everything there, Senator. This 
is so important, and certainly, it is important to hire right, 
to make sure we get the right person. A part of that is making 
sure you have the right network director who is also keeping an 
eye on this.
    Sometimes we have to give incentives if we do not get the 
right applicant in a particular location, but we are aiming for 
somebody not to be there for a short time but to be there a 
significant amount of time, to develop the relationships with 
the veterans there, with the veterans service organizations, 
with the staff and their leadership. And that stability is 
critical to the success of any organization. So I agree with 
you.
    Chairman Moran. Thank you.
    Let me raise the issue of the MISSION Act and maybe then a 
couple categories of people who do and could work more at the 
VA.
    So the Choice Act, not the MISSION Act, but the Choice Act 
was originally passed for a number of reasons. There was a 
crisis going on within the VA it was intended to address, but 
one of the reasons that we supported and passed the Choice Act 
was to fulfill the ability for veterans to more quickly access 
care as a result of a shortage of health care professionals 
within the VA.
    So at least from a congressional point of view and 
certainly from my perspective, a reason the Choice Act made 
some sense was the VA does not have the capability because of 
lack of professionals, employees, to meet all the needs of 
veterans, meet the demand, and therefore, let us bring in the 
community providers and give them the opportunity to meet those 
needs.
    There were other reasons associated with the Choice Act, 
and in my world, the distance of travel for a veteran in rural 
Kansas is significant. So Choice became a significant 
opportunity to reduce that travel time.
    Now we have the MISSION Act. How do you see the role of the 
VA and its hiring practices in determining--it goes back 
perhaps to the strategic plan that I was asking about earlier. 
How do we make certain that we are pursuing community care in 
the appropriate level at a time in which we are hiring more 
people in the VA? How do we know where the demand for those 
services is going to be, back related to that strategic plan 
that the VA is still developing?
    Dr. Lieberman. Certainly--and thank you for that question. 
Certainly, a big part of that are the market assessments, which 
unfortunately because of COVID, we have had to stop the face-
to-face part of it. A lot of useful information, a lot of data 
was being reviewed. A lot of analyses were ongoing, and so that 
certainly was an important process. We hope to continue that as 
long as COVID does not escalate----
    Chairman Moran. Well, I understand that the implementation 
of the MISSION Act may not fall directly to you. The point I 
want to make is as we utilize community care to the level for 
which it is determined to be in the best interest of veterans, 
it has a consequence on what professionals and how many are 
needed inside the VA, internal employees, and how many 
contracts, how many opportunities we utilize community care. 
There is a relationship between the two. Does that make sense 
to you? Am I missing something or something I should know about 
that?
    Dr. Lieberman. No, it makes sense.
    Chairman Moran. OK. I want to mention a couple of 
professions specifically. One of them, of course, is mental 
health. It would be a mistake on my part if I did not raise the 
continued need for an increase in number of mental health 
providers in this country and the private sector, within the 
VA. They are in short supply.
    One of the things that we have--let me start with a 
different example first. So even before the Choice Act, I was 
advocating back in my days of chairing the House Subcommittee 
on Health Care what we have in Kansas is community mental 
health centers, and they are groups of counties that generally 
at the local level, with some State support, provide mental 
health services across the State. But they are probably the 
only provider in most of rural Kansas. Many veterans in Kansas 
live in the rural parts of our State, and access to health 
care, particularly mental health care, particularly at a time 
in which suicide is so prevalent, timeliness matters greatly.
    I just would again use this opportunity to express my 
belief in the value of what we call community health centers, 
which now should be contracted with. In the days in which I 
started this conversation, there was not the formal--there was 
not the MISSION Act, and there was not the Choice Act. But 
please make certain that those community mental health 
centers--I know this may be the third-party administrator issue 
as well. But please do not forget, at least in a State like 
ours, the folks in the community who provide mental health 
services can be of great value to the veterans who live in 
those communities.
    Then I would highlight once again, as we have done before, 
about the importance of some of the professions, licensed 
professional mental health counselors and marriage and family 
therapists. There are opportunities for the VA to further hire 
outside the psychologist, the social worker, the psychiatrist, 
and there are other professions that the VA is not able to 
hire.
    We have encouraged that to occur, particularly at a time in 
which there is such a shortage. There are those professions who 
are ready, willing, and capable licensed to provide mental 
health services that could be of value to our veterans. I am 
encouraging the VA to continue to pursue the hiring of those 
individuals, those professions.
    Dr. Lieberman. If I may respond, we see the value in this 
as a member of our mental health team. Actually, our Office of 
Academic Affiliation is offering, I believe, 55 stipends for 
the upcoming year for individuals, for both of those job 
series, to undergo training. We actually have been growing in 
both of those jobs, 20 percent for the licensed professional 
mental health counselors and 10 percent for the marital and 
family therapist over this fiscal year compared to last fiscal 
year so far this year. So we do see the value in that.
    Chairman Moran. Thank you for that answer, and thanks for 
that action.
    Musculoskeletal disabilities, which generally, I think, 
mean back pain, is a significant complaint, symptom of 
veterans, and I would ask how do you see chiropractic care 
fitting in the VHA's staffing model for rehabilitation and 
other medical services. I would indicate to you that it has 
always seemed to me that the VA is slow in implementing 
programs to include chiropractic care within the VA.
    Dr. Lieberman. There certainly is a value of chiropractic 
care as a part of a whole variety of therapies for including 
whole health, for musculoskeletal pain, and certainly 
chiropractic care is among the options to help in that area.
    Chairman Moran. Nothing that you know from a structural, 
from an attitude point of view that is diminishing the 
opportunity for chiropractic care to be utilized within the VA 
or within community care?
    Dr. Lieberman. Certainly, it is on the list of items to 
consider. There are many different options. You have to speak 
to the veteran to see what it is that they are interested in 
participating in.
    Ms. Brahm, did you have something to add?
    Ms. Brahm. Yes. If I could add, from the VISN perspective, 
we are encouraging the hiring of chiropractic, acupuncture, and 
massage therapy as alternative methods versus opioids.
    Chairman Moran. Is there a problem in hiring more of those 
individuals? Are they not available?
    Ms. Brahm. No. Actually, we are doing very well with that. 
Right. When you look at the kinds of services that veterans are 
looking for when we do refer to the community, at least in my 
VISN, acupuncture was very high, chiropractic. So we are 
investing in that.
    Chairman Moran. Thank you, Ms. Brahm.
    I have a number of other questions, but for the sake of my 
colleagues, I will submit a couple in writing.
    I think that Senator Cassidy has rejoined us. Senator 
Cassidy, do you have questions or comments?
    Senator Cassidy. Yeah, a couple things. One, I have sent 
the spreadsheet, but the spreadsheet is actually a compilation 
of other spreadsheets. So I will give you time to look at it 
and make my staff available to discuss it.
    But we were speaking about mental health, and I know mental 
health provision has been difficult. I also know that from 
speaking to patients and physicians that there is a relatively 
high no-show rate in many places, just if people are having to 
drive an hour and a half to an appointment, and somebody begins 
with mental illness, it may be difficult to pull off.
    We spoke last time about tele-mental health, and I know--I 
think I know there are some private providers providing tele-
mental health, which seems appropriate seeing that there is a 
shortage of mental health providers within the VA. Can you give 
me a status of tele-mental health and maybe how we are going to 
continue to provide these services and whether or not this is 
going to be an enduring change after COVID, the tele-mental 
health aspect?
    Dr. Lieberman. So I will start, and then Ms. Brahm will 
add, I am sure.
    Even before COVID, all the evidence out there was that the 
consumer, including the veteran, would--and this is not 100 
percent, but certainly the veteran's preference would be ``I do 
not want to drive into the hospital. I would like to do it from 
my home or from my place of work.'' So the prediction was 
always there would be more telehealth--and that was what we 
were working toward, to give the veteran the choice. Certainly, 
if they want to come in, they can come in, but if not, we would 
provide the services at the location of their choosing. And 
that is what our program is, VA Video Connect. That is exactly 
what it is about.
    So one of the things that has occurred during COVID is that 
we have just rapidly accelerated and grown our VA Video 
Connect.
    At the same time, we have been encouraging through our 
community partners, through our third-party administrators, 
that they grow the same telehealth, so that for the veteran who 
is already getting therapy in the community, they should not 
have to--even if it is driving 5 or 10 minutes, if they can be 
in the safety of their home and the comfort of their home, why 
should that not happen? So, to us, that is really important for 
the future.
    Ms. Brahm. I can tell you from the VISN perspective, we 
have been doing telehealth, mental telehealth for quite a 
while. We are finding that we have a great satisfaction rate, 
around 86 or 87 percent satisfaction rate. Our providers like 
it. We are doing it not in a local Walmart. We are doing it in 
a VSO office. We have increased since COVID about 200 percent 
actually and finding that it works very well. Providers are 
happy with it, and it seems that at an 86 percent satisfaction, 
many of our veterans like it as well.
    Senator Cassidy. So can you give me metrics as in if we ask 
people to come in, this is our no-show rate; if we have tele-
mental health, this is our no-show rate? Are the average 
times----
    Chairman Moran. Dr. Cassidy, could you get closer to the 
mic?
    Senator Cassidy. I am sorry.
    DO you have metrics that you can give, for example, this is 
the no-show rate within office versus this is the no-show rate 
via telehealth or this is the average time to next appointment 
in office, average time via telehealth, those sorts of metrics, 
which are intuitive as to how you would assess compliance with 
the program?
    Dr. Lieberman. So, as you pointed out, we know the no-show 
rate is high for face-to-face mental health appointments. I 
have not seen data yet during the COVID months. So, certainly, 
we are going to be taking a look at that.
    One would predict that, as I believe you are surmising, the 
no-show rate would go up, and one of the things that we have 
been talking about, even before----
    Senator Cassidy. Would go up or go down?
    Dr. Lieberman. Would go down, would be better.
    So one of the things that we want to work toward--and we 
even were talking about this before COVID--would be that if a 
veteran calls to cancel their mental health appointment or does 
not appear for their mental health appointment, that someone on 
the staff would call the veteran and offer them on the spot, 
``We see you are not here today or you could not make your 
appointment. Would you like to have a video appointment? We can 
help walk you through that appointment for the first time, give 
it a try.'' So that is something that more and more, we will be 
working toward.
    But, again, I think during the COVID era, we kind of have 
gotten there anyway for a lot of our appointments.
    Senator Cassidy. Would you allow somebody to do it over 
Facetime or Skype, or do they have to have something which is 
more fancy than that?
    Dr. Lieberman. We have a system that is just literally a 
link is sent to the veteran, and the veteran clicks the link. 
As long as they have a smartphone or a programmable computer, 
that works.
    There are some security issues with some of the different--
information security issues, and so they do not all work for 
that.
    But, actually, sir, during COVID, we are utilizing whatever 
modality is available while we work in the long term the 
security issues that you raised.
    Senator Cassidy. Thank you.
    Thank you, Mr. Chairman. I yield back.
    Chairman Moran. Thank you, Senator Cassidy.
    Senator Tester, anything to conclude with?
    Senator Tester. No, Mr. Chairman. You have done a masterful 
job of having this hearing, and I look forward to hearing the 
responses back from the panelists. So thank you.
    Chairman Moran. That is a nice conclusion. Thank you.
    I always have the practice of allowing our witnesses to 
tell us anything they wish they had said or wish they had not 
have said, they can correct, or something you wished we had 
asked that we did not. Anything you would like for us to know, 
Doctor?
    Dr. Lieberman. Just that we are, all of us, so proud of our 
350,000 employees. They are true American heroes for what they 
do every day, particularly during this COVID crisis, and we are 
just so proud of them and thank them, and also for our 
veterans, this is certainly a scary time for many. We in VA, we 
are here for you. You do not have to come in. You can just 
call, and we will take care of you. So thank you for giving us 
this opportunity to make some comments.
    Chairman Moran. Thank you for sincerely expressing both of 
those sentiments.
    Ms. Brahm or Ms. Bonjorni?
    Ms. Brahm. Boy, I could not have said it any better. Thank 
you, Dr. Lieberman.
    It is all about the staff, and I just cannot tell you about 
how passionate and dedicated, as I said before, these staff are 
to the veterans. And I am so thankful, after being with the VA 
for as long as I have, about that mission that we are all 
driven by. So I just really do want to extend my thanks to the 
staff. Thank you to the veterans, and we are here for you. 
Thank you.
    Dr. Lieberman. Thank you.
    Chairman Moran. We will begin to wrap up our hearing, then. 
I thank our witnesses for what they had to tell us and for 
joining us today. I think this is an important discussion that 
this Committee will continue to pursue answers. How well we 
treat our veterans is determined in part by how well we treat 
our staff and those who care for our veterans, and we want to 
make certain that the VA has the tools necessary to hire the 
appropriate number of people with the right kind of 
opportunities for them to care for those who served our Nation.
    Our hearing record will remain open, so that any Member of 
the Committee can submit a question in the next 5 days, and 
then we would ask that you submit your answers for the record 
as quickly thereafter as you can.
    With that, our hearing is adjourned.
    [Whereupon, at 4:50 p.m., the Committee was adjourned.]

                                APPENDIX

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