    [Senate Hearing 117-615]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 117-615

                      THE VA WORKFORCE: ASSESSING WAYS TO
                       BOLSTER RECRUITMENT AND RETENTION

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

                                    HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS
                              UNITED STATES SENATE

                        ONE HUNDRED SEVENTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                  MAY 3, 2022

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

         [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

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

                                 ______

                 U.S. GOVERNMENT PUBLISHING OFFICE
     51-397             WASHINGTON : 2023

                         COMMITTEE ON VETERANS' AFFAIRS

                         Jon Tester, Montana, Chairman
    Patty Murray, Washington             Jerry Moran, Kansas, Ranking
    Bernard Sanders, Vermont                 Member
    Sherrod Brown, Ohio                  John Boozman, Arkansas
    Richard Blumenthal, Connecticut      Bill Cassidy, Louisiana
    Mazie K. Hirono, Hawaii              Mike Rounds, South Dakota
    Joe Manchin III, West Virginia       Thom Tillis, North Carolina
    Kyrsten Sinema, Arizona              Dan Sullivan, Alaska
    Margaret Wood Hassan, New Hampshire  Marsha Blackburn, Tennessee
                                         Kevin Cramer, North Dakota
                                         Tommy Tuberville, Alabama
                          Tony McClain, Staff Director
                     Jon Towers, Republican Staff Director
                                C O N T E N T S

                                  ----------

                                  May 3, 2022

                                    SENATORS

                                                                       Page
    Tester, Hon. Jon, Chairman, U.S. Senator from Montana............     1
    Tillis, Hon. Thom, U.S. Senator from North Carolina..............     5
    Hassan, Hon. Margaret Wood, U.S. Senator from New Hampshire......     8
    Brown, Hon. Sherrod, U.S. Senator from Ohio......................    10
    Boozman, Hon. John, U.S. Senator from Arkansas...................    12
    Murray, Hon. Patty, U.S. Senator from Washington.................    14
    Blackburn, Hon. Marsha, U.S. Senator from Tennessee..............    16
    Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    21

                                   WITNESSES

    Gina Grosso, Assistant Secretary for Human Resources and
      Administration/Operations, Security and Preparedness,
      Department of Veterans Affairs; accompanied by Carolyn Clancy,
      MD, Assistant Under Secretary for Health for Discovery,
      Education and Affiliate Networks, Veterans Health
      Administration; Jessica Bonjorni, Chief, Human Capital
      Management; and Ralph T. Gigliotti, FACHE, Network Director,
      VISN 19: VA Rocky Mountain Network.............................     2

                                    APPENDIX
                               Prepared Statement

    Gina Grosso, Assistant Secretary for Human Resources and
      Administration/Operations, Security and Preparedness,
      Department of Veterans Affairs.................................    29

                            Questions for the Record

    Department of Veterans Affairs response to questions submitted
      by:
      Hon. Jon Tester................................................    37
      Hon. Jerry Moran...............................................    44
      Hon. Kyrsten Sinema............................................    47
      Hon. Tommy Tuberville..........................................    51
      Hon. Richard Blumenthal........................................    54
      Hon. Thom Tillis...............................................    57
      Hon. John Boozman..............................................    59

                           Statements for the Record

    United Nurses Associations of California/Union of Health Care
      Professionals (UNAC/UHCP)......................................    63
    American Federation of Government Employees (AFGE), AFL-CIO......    65

                      THE VA WORKFORCE: ASSESSING WAYS TO

                       BOLSTER RECRUITMENT AND RETENTION

                                  ----------

                              TUESDAY, MAY 3, 2022

                                           U.S. Senate,
                                Committee on Veterans' Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 3:34 p.m., via
    Webex and in Room SR-418, Russell Senate Office Building, Hon.
    Jon Tester, Chairman of the Committee, presiding.
        Present: Senators Tester, Murray, Brown, Blumenthal,
    Hassan, Boozman, Tillis, and Blackburn.

                  OPENING STATEMENT OF CHAIRMAN TESTER

        Chairman Tester. I am calling this meeting to order.
        Good afternoon. Thank you for joining us today to discuss
    the VA workforce and ways to bolster recruitment and retention.
        First, I want to thank VA employees for all that they have
    done and continue to do for veterans, especially during this
    pandemic. Everybody knows the employees are the backbone of the
    VA, and I know that you work every day very hard to ensure that
    veterans get high quality health care and benefits.
        The VA was able to hire thousands of new staff last year
    thanks in part to the authorities and funding included in the
    CARES Act and the American Rescue Plan. VA needs to continue
    that momentum to address its growing turnover rate and
    retention challenges, including employee burnout during this
    pandemic.
        We all know there is a high demand for health care workers,
    but we also know VA puts potential health care employees
    through a long and burdensome hiring process, and I hear from
    VA employees in Montana and around the country that VA has not
    been maximizing bonuses and retention incentives for current
    employees. I would also like to see VA expand scholarship and
    training programs, particularly in rural areas. We know that
    when students train at the VA they are more likely to work at
    the VA.
        To that end, I am introducing the VA Workforce Improvement
    Support and Expansion Act this week. We will just call it WISE,
    which is pretty creative actually, and I am introducing that
    with Senator Boozman. This legislation would provide increased
    pay and benefits for VA workforce and expand opportunities in
    rural VA facilities. It will also support training for current
    and future clinicians and provide additional oversight of VA
    human resource operations and its usage of hiring authorities.
    I look forward to working with everybody on this Committee and
    everybody in the Senate to get this bill signed into law before
    the end of this Congress.
        On the VBA side of things, we know there is a backlog of
    disability compensation claims, and we know we need to ensure
    VBA has the support and staff that it needs to process these
    claims as well as future claims related to toxic exposure.
        Does anybody else have an opening statement they would like
    to give?
        [No audible response.]
        Chairman Tester. Good. With that, we will start with you.
    Oh, by the way, I have got to introduce some folks here. I
    would like to welcome Gina Grosso, VA Assistant Secretary for
    Human Resources and Administration/Operations, Security and
    Preparedness. That is a long title. It is good to have you
    here.
        She is accompanied by Dr. Carolyn Clancy, who has been
    before this Committee many times, Assistant Under Secretary for
    Health for Discovery, Education, and Affiliate Networks, and
    Jessica Bonjorni? Close enough. Chief of VHA Human Capital
    Management. I think, virtually, we have somebody that I saw
    just last weekend, Ralph Gigliotti, who is VISN 19 Director.
        I want to thank you all for being here in person and
    virtually.
        Ms. Grosso, you may begin with your opening statement, and
    please know that your entire written statement will be a part
    of the record.

                        STATEMENT OF GINA GROSSO

                     ACCOMPANIED BY CAROLYN CLANCY;

                JESSICA BONJORNI; AND RALPH T. GIGLIOTTI

        Ms. Grosso. Good afternoon, Chairman Tester, Ranking Member
    Moran, and the members of the Committee. Thank you for the
    opportunity to discuss the state of the Department of Veterans
    Affairs' workforce.
        I am joined today by Dr. Carolyn Clancy, Assistant Under
    Secretary for Health for Discovery, Education, and Affiliate
    Networks, Veterans Health Administration; Ms. Jessica Bonjorni,
    Chief, Human Capital Management, Veterans Health
    Administration; and Mr. Ralph Gigliotti, Director, Veterans
    Integrated Service Network 19.
        As we look back on the COVID-19 challenges of the past two
    years and reflect on the 21,000 families in the United States
    that lost a veteran to COVID-19, in addition to the 273 VA
    employees that we lost to COVID-19, we believe it is important
    to acknowledge the accomplishments our employees achieved,
    working around the clock to battle this terrible virus. This
    required teamwork, agility, and planning on a unique scale. We
    could not be more proud of our VA employees for their hard
    work, passion, and dedication in responding to this difficult
    and heartbreaking global crisis.
        I am thankful to be here today to share with you the steps
    we are taking to continue to attract and retain VA's most
    precious resource, our amazing employees. We know that an
    investment in our employees is an investment in the Nation's
    veterans. Secretary McDonough recently spoke about 10 steps VA
    is taking to invest in its incredible workforce, and I would
    like to take a moment to highlight those steps as well as
    present updates on actions VA is taking to attract and retain
    new talent by leveraging investments and improvements in VA's
    human capital infrastructure.
        First, we appreciate the work Congress has done on
    legislation such as the Retention and Income Security
    Enhancement Act, more commonly known as the RAISE Act, to
    invest in employee wages. We look forward to continuing to work
    with Congress on legislation that enables VA to be competitive
    in the health care environment.
        The VA has more than 400,000 employees and continues to
    grow each year. Health care is the largest part of VA's
    mission, representing nearly 90 percent of VA's workforce. As
    the largest integrated health care delivery system in the
    United States, VA's workforce challenges mirror those faced in
    the private health care industry.
        Across the private health care sector, hospitals and
    ambulatory care centers have reported higher turnover,
    increased labor costs, and increased reliance on travel nurses.
    While VA's turnover rate has historically been extremely
    competitive, at or below 9.6 percent annually, the rate
    increased to 9.9 percent in fiscal year 2021. This is due in
    part to higher wages and bonuses offered by private health care
    systems coupled with COVID-19 pressures and burnout. The
    Secretary's 10-point plan is intended to combat these
    challenges.
        Despite these challenges, VA's unique mission attracts new
    employees each year. Nearly 30 percent of VA's workforce are
    veterans themselves, who identify closely with our mission.
        VA continues to lead the way in using telehealth and mobile
    deployment clinics to reach veterans living in areas defined as
    health professional shortage areas. VA is a leader in virtual
    health care delivery and is well positioned to expand in this
    area.
        In VHA, efforts are underway with the goal of standardizing
    processes to increase efficiency in HR processing. While
    national policies have long existed for HR functions,
    variability in local processes has led to inefficiencies. This
    variability also makes it difficult to automate processes with
    modern information technology systems. HR modernization shift
    to shared services was a key factor in VHA's ability to
    accomplish significant surge hiring during the pandemic.
        VA acknowledges the concerns raised by customers and other
    stakeholders about delays in the hiring and onboarding process,
    and we are actively working to address it. In VHA, an
    onboarding optimization team recently met to standardize and
    reduce the steps in the pre-employment and onboarding process.
        We continue to develop staffing models across VA and have
    just started the work to develop staffing models for all VA
    Medical Centers (VAMC). The staffing model will contain
    sufficient detail to inform VAMC requirements and will help
    each VHA network allocate resources that will produce the best
    outcomes.
        It is an honor and privilege to be part of this noble
    mission to care for our veterans, our Nation's heroes, whose
    service and sacrifice is so inspiring.
        I look forward to working with each of you on the state of
    the VA workforce with respect to recruiting, hiring, and
    staffing opportunities across VA as well as investing in our
    current employees so they can continue to provide the best care
    and service to our veterans and their families.
        This concludes my testimony. We look forward to your
    questions.

        [The prepared statement of Ms. Grosso appears on page 29 of
    the Appendix.]

        Chairman Tester. Thank you for your testimony, Ms. Grosso,
    and feel free to pass the question on to somebody in your team
    if you want.
        Before we get started, I want to give you the opportunity
    to clear up some misunderstandings about the use of VA
    employees at the border. So the question is this: Have you or
    any VA representatives had conversations, or plan to have
    conversations, with the Department of Homeland Security to
    deploy VA personnel at the border to address issues resulting
    from the repeal of Title 42?
        Ms. Grosso. I thank you for that question, Senator. No, we
    have not been in any direct discussion with DHS on sending our
    employees to the border.
        However, I would like to share that we are very proud of
    the work we have done helping other Federal agencies that are
    on the border, in particular, giving vaccinations, to include
    border--Customs and Border Protection and Immigration and
    Customs Enforcement. And we also help our Federal partners
    across the Nation. We have helped the D.C. Police. So that
    mission we are very proud of, and we hope to be able to serve
    our other Federal partners.
        Chairman Tester. Okay. Thank you. More of VA's funding is
    being directed into community care in part because the
    Department cannot hire enough of the right staff to execute in-
    house dollars. The second budget request calls for $4.3 billion
    more in community care funding than last year's projection. So
    the question is: What is the VA actively doing to fix the
    staffing shortage in the administrative positions, primarily in
    HR and scheduling, to remove those as barriers to veterans
    accessing in-house care?
        Ms. Grosso. Sir, we are very fortunate for many of the
    authorities you have given us and some of the authorities that
    we are seeking. Certainly, being able to implement the minimum
    wage was tremendously helpful. We are very cognizant that we
    have a shortage of skills, and we are using the tools that you
    have given us to hire more HR talent. And I think Ms. Bonjorni
    could add more to this response.
        Ms. Bonjorni. Sir, thank you. We actually are doing very
    well in hiring medical support assistants. That is an
    occupation where we continue to see growth, but it is an entry
    level occupation, so we anticipate continued turnover and a
    need to keep hiring there.
        For Human Resources, we have many plans for the coming
    year, and you will see that in our budget request, where we are
    working to invest in training and development of HR staff and
    seeking the ability to staff up our HR personnel to the
    appropriate staffing ratio so we can recruit more of our
    clinicians.
        Chairman Tester. So I assume you have numbers in mind as
    what you need in HR in scheduling if you are fully staffed?
        Ms. Bonjorni. For HR, yes, and we could get back to you on
    scheduling.

        [For VA response to Chairman Tester, see Questions 1-4 on
    pages 37-40 of the Appendix.]

        Chairman Tester. Yes, I am just curious to know where you
    have been and where you are at now and what your projections
    are moving forward, if you could do that. You can get it to me.
    That would be great. I appreciate that.
        Ms. Grosso, we have seen the latest data from VHA that puts
    vacancies at 57,000 in the last quarter; that is VHA. This is a
    much higher vacancy rate than in recent years even though VA
    recently stopped including vacancies more than six months old
    in its reporting. So what that statement just said is it is
    probably higher than 57,000.
        In addition, VHA has seen a higher employee turnover rate
    than usual. Many staff on the ground, especially hiring
    managers, are frustrated the same level of support for hiring
    is not exercised on keeping existing staff.
        So the question is: What is VA doing about the vacancies
    and the high turnover rate?
        Ms. Grosso. Sir, I would share with you first that a
    vacancy does not necessarily mean we do not have a person in a
    position that we need. Vacancies can often reflect requirements
    that we need now, and some of them we fill, and some of them we
    fill when we get funding.
        Chairman Tester. So what you are saying is that if you have
    a position and the person in that position has not got the
    required education or experience that that position is
    classified as vacant even though there is a person working in
    that position?
        Ms. Grosso. Oh, no, sir. I did not mean to imply that.
        Chairman Tester. Okay.
        Ms. Grosso. So the 59,000 vacancies do not all have funding
    against them. Some have funding, and we are actively recruiting
    for them, and some do not. But it is like a position library.
    We do not want to delete it because at some point we might want
    to use it in the future.
        Chairman Tester. Oh, Okay, Okay. Yes, Okay. So how many of
    the 50,000 are funded? 57,000 are funded?
        Ms. Grosso. The current data shows about 55 percent are
    funded and about 45 percent are not funded. And one of the
    things we are working very hard on, honestly, is to have a more
    accurate picture in the future of what a vacancy is, and we are
    working that very hard to have a better understanding of what
    vacancies we need to hire for and what vacancies we are not
    hiring for and actually mark them funded and unfunded.
        Chairman Tester. I am going to come back to this question
    because I am afraid if I keep asking questions we will be here
    five more minutes from now. I will turn it over to you, Senator
    Tillis.

                          SENATOR THOM TILLIS

        Senator Tillis. Thank you, Mr. Chairman. Thank you all for
    being here.
        Ms. Grosso, thank you for your prior service in the Air
    Force. I think I overheard you say your husband went to the Air
    Force Academy and also served.
        Ms. Grosso. Yes, sir.
        Senator Tillis. So thanks to you and your family.
        I was glad that Senator Tester asked the question about the
    potential deployment of VA personnel down to the border if we
    were to experience the removal of Title 42. So that is good
    news. I think that we would need to know if--and hopefully,
    that was just an unsubstantiated rumor. That would make me very
    happy.
        But I think we do have to understand that why some people
    reacted to it as we are talking about vacancies. We are talking
    about headwinds on recruiting to complete the core mission. And
    I think it is very important for that word to get out because I
    know that many people who come to serve in the VA may be
    turning away from a more lucrative opportunity because their
    goal is to serve veterans, and so I am glad that Chairman
    Tester made that a priority from the outset.
        Tell me a little bit about the vacancies that are legit.
    How many positions do we have open that without them being
    filled are diminishing the level of care that we can provide
    today, or the quantity of care we can provide today, not the
    level?
        Ms. Grosso. Let me pass to Ms. Bonjorni. I think she is
    better capable of answering that.
        Ms. Bonjorni. Well, we do believe that we are providing the
    care we need to be providing right now. I can tell you that----
        Senator Tillis. But we can get to burnout here in a minute.
        Ms. Bonjorni. Sure. Within VHA, we have about 31,000
    candidates that are in our hiring pipeline right now. So we
    have made a selection, and we are working to onboard them.
        So one of the things we are trying to do to really get them
    on quicker is moving toward onboarding surge events. We will be
    having those across the country between now and May 14th. We
    would welcome your help publicizing those, to get both hiring
    fairs and surge events, to get people in the door, to get
    positions filled.
        Senator Tillis. Good. I mean, just rough numbers, what kind
    of overtime are we experiencing right now that would be reduced
    with additional capacity?
        Ms. Bonjorni. Overtime? I am going to have to take that for
    the record.

        [VA response to Senator Tillis appears on page 57 of the
    Appendix.]

        Senator Tillis. Yes, I would like to know that because that
    is what I am speaking to in terms of--I mean, you are doing a
    great job. Most of you all know--I know Dr. Clancy knows--I try
    to be a cheerleader for everything you are doing, but I also
    think people are going above and beyond. We have got a lot of
    stressors at home with COVID, everything else. So I just want
    to really focus on some of the critical onboarding that we need
    to do and the help that we can provide.
        I did want to ask, Secretary Grosso, I believe that you
    stood up a task force specifically focused on burnout, how you
    are addressing some of the challenges with the workforce. How
    is that going? Have there been any recommendations that have
    come out of the task force?
        Ms. Grosso. Actually, the task force was set up by VHA. I
    would say when you look across the VA we do collect data on
    burnout from our all-employee survey, and interestingly, it has
    not really changed much since 2013, but we did find that 49
    percent of our workforce has experienced at least one factor of
    burnout. So we are very grateful for the work VHA is doing in
    leading the way on that.
        And, Jessica, please give them more.
        Ms. Bonjorni. Sure. I am one of the co-chairs of that task
    force in VHA, and we are just near the end of our time,
    wrapping up, gathering recommendations from front-line
    employees. And we are putting those forward for leadership's
    consideration, and we will have some recommendations coming out
    soon.
        We may need some help from the Committee depending on what
    recommendations are finalized, but they will include things we
    can do ourselves like creating chief well-being officer
    positions in many facilities, moving toward more flexibility in
    work hours and scheduling, which is what employees have asked
    for, but in other cases they are looking for things like pay
    increases where we might need some other relief.
        Senator Tillis. Okay. And since the Chair did not ask a
    question of his VISN Director, I thought I would. Mr.
    Gigliotti, a quick question for you. One, what unique
    challenges--if you take a look at the geography of your VISN,
    you are pretty spread apart. So what sort of unique challenges
    are you having in the hiring process?
        And also, to what extent do you want to continue to rely on
    telemedicine as we move forward? Many of the provisions we put
    into place in response to COVID.
        And then, finally, how much of your workforce right now is
    still virtual versus back in facilities?
        Mr. Gigliotti. Thank you, Senator, for those questions. As
    far as challenged positions, given the reality of the
    frontierism of VISN 19, it is nursing positions, physician
    positions, social work positions are our top three vacancies.
    We are, obviously, working closely on that.
        During the pandemic, we had some relief from some of the
    hiring requirements that allowed us to be really agile in
    bringing employees on. So that is one thing we would look for
    the Committee to do, and working closely with Ms. Grosso and
    Ms. Bonjorni, is some kind of relief in terms of the
    requirements to be able to bring staff on in certain manners
    because it worked really well during the pandemic.
        As far as tele goes, telework, we have a very good
    telehealth program in the VISN, and we are really proud of
    that. We were able, during the pandemic, to--before the
    pandemic, we were very aggressive in telemedicine given our
    situation. During the pandemic, we really ramped it up.
        We were able to get veterans seen, and these hubs have been
    really positive. And once a veteran gets exposure to
    telehealth, they tend to like it. It does not always replace
    face to face, and in some cases veterans prefer face to face,
    but they really prefer a combination of both. And so we have
    seen that increase, which we are really, really pleased with.
        And then I think the last thing I want to say is some of
    the hiring authority that we have been able to use, Senators,
    on some of the legislation, in terms of training programs that
    have allowed us to be able to bring on staff, as the Chair,
    Senator Tester said. One of the programs is the Specialty
    Education Loan Repayment Program for physicians and nurses,
    where we are able to pay back tuition loan repayment to recent
    graduates. We have been able to hire three, and we are working
    on a fourth physician or nurse in Sheridan, Wyoming, and we
    have some on the line for Montana. And as the Chair said, once
    they get exposure to VA, they tend to want to work for VA, and
    so a program like this of loan repayment has been very
    positive. Thank you.
        Senator Tillis. Mr. Chair, thank you. I just also wanted to
    tell you I think you have a great VISN director, and that is
    largely due to his time as the Durham VA Medical Center
    Director before he took the post in 2012. Thank you.
        Chairman Tester. You just used your second round, Tillis.
        Senator Hassan.

                      SENATOR MARGARET WOOD HASSAN

        Senator Hassan. Thank you, Mr. Chair. I want to thank you
    and the Ranking Member for this hearing.
        I want to thank all three of our panelists today, and four,
    our virtual panelist, for being here and for your service.
        Ms. Grosso, I echo the concerns of my colleagues on the
    need to fill Veterans Health Administration vacancies. I was
    glad to see the Hire Veteran Health Heroes Act that Senator
    Braun and I introduced signed into law. It directs the VA to
    recruit and hire Department of Defense medical personnel who
    are transitioning out of military service for open positions at
    the VA by referring them to the appropriate hiring authority.
    Can you please speak to how the VA and DOD are working together
    to recruit and hire DOD medical personnel?
        Ms. Grosso. I will pass that off to Jessica, who
    understands this, but I would like to share since you were
    talking about hiring. Since the beginning of this FY, we have
    hired 59,000 employees.
        Senator Hassan. Wow.
        Ms. Grosso. So we are hiring a lot of people.
        Senator Hassan. Good. Thank you.
        Ms. Bonjorni. Yes, Senator, thank you for that authority.
    We have continued our partnership with DOD to try to convince
    more people who are separating to come join us. We have also
    been working with them on things like the SkillBridge program--
    --
        Senator Hassan. Yes.
        Ms. Bonjorni [continuing]. To train people as they are
    transitioning out to come work with us. We have a lot of
    success with our intermediate care technician program, bringing
    them in as former medics and corpsmen----
        Senator Hassan. Right.
        Ms. Bonjorni [continuing]. To come in and work for us. So
    we are expanding that, continuing to expand it across the
    country. So, well underway on that program.
        Senator Hassan. Okay. That is good to hear also just
    because I hear from veterans all the time that nobody
    understand them like another veteran. So it is a really
    important thing for us to be able to work on.
        Ms. Grosso, I want to talk to you a little bit about
    whistleblowers because the VA has routinely dismissed
    whistleblower claims, including whistleblowers at VA facilities
    that Granite State veterans rely on for their care. Last March,
    the Office of Special Counsel again found a VA response to a
    whistleblower complaint to be unreasonable, this time regarding
    allegations at the White River Junction Medical Center. This
    case is just one example where the VA failed to treat
    allegations seriously and failed to safeguard whistleblowers.
        Ensuring the appropriate management of whistleblower claims
    and addressing VA workplace culture is really critical to
    veterans and VA personnel. So how is the VA addressing the
    culture of silence and whistleblower retaliation at VHA
    facilities in its strategy to bolster its workforce?
        Ms. Grosso. Well, of course, we take these allegations very
    seriously, and we need to address them appropriately.
        Dr. Clancy, I think you are in a better position to speak
    for the VHA on this.
        Dr. Clancy. So the one aspect that we emphasize all the
    time and, frankly, check through our all-employee survey is are
    we creating a psychologically safe culture where people know
    that if they raise their hands and report a problem, whether
    that is an actual harm event or something that is not working,
    what we sometimes call a near miss----
        Senator Hassan. Yes.
        Dr. Clancy [continuing]. That that will be welcomed. Some
    of our directors even celebrate that and will announce great
    catches of the previous, week, month or whatever.
        But I would agree with Assistant Secretary Grosso. When
    someone reports that they have raised issues then and have not
    been taken seriously, that is egregious, and we need to deal
    with it.
        Senator Hassan. Well, I thank you for that. It is not just
    whether they are taken seriously. It is also whether they are
    retaliated against.
        Dr. Clancy. Exactly.
        Senator Hassan. And that takes leadership from the very top
    to really make clear that retaliation is never acceptable. So
    you know, I am grateful for the tone of these answers. I think
    you all have more work to do.
        Dr. Clancy. Yes.
        Senator Hassan. So let me also just turn to a different
    issue I have been hearing about from Granite State veterans
    because our veterans also depend on volunteers to access their
    VA services. Veterans receive free transportation to VA health
    care appointments from volunteer drivers, most who serve
    through Disabled American Veterans. Unfortunately, Granite
    State veterans who want to be volunteer drivers often wait up
    to six months for exams through VA's occupational health
    services before they are allowed to drive.
        Can you please speak to how streamlining the process for
    volunteer drivers would help both veterans and the VA and what
    other efforts VA is making to remedy these issues that
    volunteers are facing?
        Ms. Grosso. Well, thank you for sharing that information
    with us. This is the first time I have heard this. So
    obviously, our volunteers are critical to our success, and we
    will pledge to you to get you an answer and also look at the
    process to see what is the cog in the wheel.
        Senator Hassan. Right. I mean, I have veterans who say,
    look, I could go to a community occupational health screener if
    I needed to, and we have got, you know, especially with
    increasing fuel prices, fewer and fewer people volunteering to
    be drivers. So it really, really is a barrier for a lot of
    people, and I would really appreciate working with all of you
    on that.
        And I will follow up with a question to the record on the
    cyber workforce and what we can do to be helping with cyber
    workforce by training up veterans. Thanks.
        Dr. Clancy. And if I could add just very, very quickly.
        Senator Hassan. Yes.
        Dr. Clancy. And this should not be counted against you for
    your time, I hope. We actually have a rideshare program to help
    homeless veterans. This uses Uber, Lyft, and other kinds of
    services, and we have actually been able to save money doing
    this. And during the peak of the pandemic, when we were all on
    lockdown, one of our employees in Boston figured out that we
    could repurpose the contracts to send Uber and Lyft to food
    banks to bring food to veterans who were isolated at home and
    otherwise could not go out and get it. But this something,
    again, that we take very, very seriously.
        Senator Hassan. Well, and again, in a State like mine,
    where we rely on volunteers a lot and people are very eager to
    volunteer, having this kind of barrier is really an issue.
    Thanks.
        Thank you, Mr. Chair.
        Chairman Tester. Senator Brown.

                         SENATOR SHERROD BROWN

        Senator Brown. Thank you, Mr. Chairman. I just want to
    remind Senator Hassan they volunteer in my State, too. It is
    not just New Hampshire they do that. So just . . .
        Senator Hassan. You are kidding.
        Senator Brown. You are kidding, yes. Nice try.
        Mr. Chairman, thank you. Before I begin my questions, I
    would like to submit a letter from the United Nurses
    Association of California/Union of Health Care Professionals
    affiliated with AFSCME into the record.
        I would like to quote from the letter just briefly: ``An
    overwhelming majority of RNs and other crucial health care
    professionals are stressed out, burned out, anxious, exhausted,
    depressed, traumatized, unable to get a good night's sleep.
    Despite years of investment, education, and certification,
    these workers have found themselves forced to think about
    leaving the profession they love for their own preservation.
    The looming exodus of nurses has accelerated the pre-pandemic
    nurse shortage. Thirty-six percent of nurses have considered,
    or are considering, leaving the bedside.'' If I could enter
    that.
        Chairman Tester. The letter will be entered into the
    record, without objection.
        Senator Brown. Thank you, Mr. Chairman.

        [The letter submitted by Senator Brown appears on page 63
    of the Appendix.]

        Senator Brown. Ms. Grosso and Ms. Bonjorni, please keep us
    updated on what you are doing to provide these professionals--
    helping them work through this workplace trauma and burnout, if
    you would, and I know you are very aware of it. I know you are
    making efforts. I was at Chillicothe last week, been there
    three times in the last month, and just have those
    conversations regularly with all kinds of professional staff.
    So, thank you.
        I have three, or at least two, pretty quick questions. Ms.
    Grosso, across the country, VHA needs to fill critical
    vacancies. Almost 20 medical centers, VA medical centers, as
    you know, have been recommended for closure to the Air
    Commission. In Chillicothe, veterans and VA employees are
    concerned that medical professionals will not apply for
    vacancies because they think the hospital will close. What do
    you say to them?
        How does VA work to make sure that prospective employees
    understand these are just recommendations, this hospital will
    operate, at worst, it will operate for several more years
    before closure if we cannot prevent the closure, but it needs
    to continue to operate, that it is not a done deal? How do you
    deal with that?
        Ms. Grosso. Well, sir, you have hit on a point that we are
    very cognizant of, and we have been very clear to message to
    our workforce that you are critical now and you are going to be
    critical in the future and that there will be a place for you
    and that anything that happens is not going to happen soon. So
    there is many steps along the way, as I know--I am sure you
    understand, and we have tried to make sure that our employees
    understand that so that they know that there is a place for
    them.
        Ms. Bonjorni, please expand.
        Ms. Bonjorni. Sure. You hit the nail on the head. We also
    are looking to continue to retain every single employee we
    have. Our goal is for all of them to stick with us, and so we
    are exploring a variety of potential asks we may have, that we
    might need some flexibilities to help us keep people if they
    need to perhaps relocate to another facility if their facility
    is closing. So we will keep you informed.
        Senator Brown. That is mostly satisfactory, Ms. Grosso, and
    I do not want--you do not need to respond again. But my concern
    is Chillicothe, like hospitals in Senator Boozman's and Senator
    Tester's States in a very rural area, and they come to
    Chillicothe--you talk them into coming to Chillicothe for two
    years. They do not know what is going to be next, if it closes,
    they are a long way from an area--another VA without moving. It
    is too long a commute. The Louisville hospital does not provide
    the benefits. It is a good--the Adena system is good.
        But, I mean, just keep that in mind that saying there will
    be a place for you later is not always satisfactory to every
    potential employee, but I get what you are saying.
        Ms. Grosso, I want to expand a bit on the Chairman's
    question about turnover and employee shortage. When I was at
    the VA in Chillicothe, the leadership team raised the nursing
    shortage, as I think they do everywhere we talk. And they need
    to find and hire more nurses, but they focused on LPNs in a
    number of these discussions. As important as RNs are and as
    much of a shortage there, there was an even greater shortage of
    LPNs, a national shortage, the tight labor market.
        I know that VA is doing everything it can to review local
    pay scales to address any discrepancy. I asked the question
    about different pay scales. My staff has heard that an LPN
    working at the Chillicothe's VA--and I confirmed this, not that
    I do not always trust my staff on these questions, but--in
    these conversations, makes about $6 an hour less than one
    working across town at a private, not-for-profit, but in a
    community hospital.
        How often do VAMCs conduct--how often do you conduct local
    pay surveys? In a facility that has not done a survey, what
    action does your office take to ensure that VA employees are
    afforded the pay increases that might have been justified by
    the survey that you have not taken frequently enough? Could any
    of you--I think that is a Ms. Grosso question, but it may be
    the other two of you.
        Ms. Bonjorni. Sure. In the case of LPNs, we have the
    flexibility to adjust salaries based on salary surveys that we
    conduct within VHA, and we also buy national survey data
    annually. So we are always looking at the data. We would be
    happy to take a look at that facility in particular to see if
    there is a challenge there, but our shift to regional human
    resources structures is really helping us see the entire market
    so we can make those adjustments on a more swift basis.
        We anticipate continued increases. We have seen an increase
    of about 50 percent in the total number of requests of
    adjustments to salary across the Nation. We will take a close
    look at Chillicothe.
        Senator Brown. Okay. Well, thank you. And one comment,
    Chair, if I could go another 30 seconds. We heard more about
    the 2018 HR modernization efforts started under the Trump
    administration. It moved HR to the VISN level, as you know.
    There seems to be pretty strong pushback or disagreement with
    that.
        I will submit a question for the record but would like to--
    and again, we will work directly with you. I would like to
    understand that better. What is the right move there? Local
    people seem to think it should be determined at the local
    level. That seems to be more common sense to me, but I am not
    sure we know enough on that.
        So, thanks, Mr. Chairman.
        Chairman Tester. Senator Boozman.

                          SENATOR JOHN BOOZMAN

        Senator Boozman. Thank you, Mr. Chairman, and thank you for
    holding this very important hearing.
        We appreciate all of you. We enjoy working with you very,
    very closely and appreciate all you represent.
        It is clear that we are experiencing significant challenges
    regarding staffing, and that is true. I think in every
    community I am in, you know, whether it is the biggest
    community or the smallest, you know, that is a real problem
    throughout society in general right now with the labor force,
    but I know it is particularly hard with, you know, people that
    you are looking for regarding health professionals and all that
    you are searching for.
        I was very concerned--I know it is being discussed--about
    the possibility of deploying personnel to the border. We
    introduced legislation to prevent that from happening, so not
    going to go into detail about that. Like I say, I think it has
    been discussed. But I would be very much opposed to that, and I
    think in talking to my colleagues that there is a number that
    would also be in that camp.
        So it is imperative that we hire and retain the best and
    brightest talent that this country has because our veterans and
    their families deserve the highest levels of care and support
    for the sacrifices they have made in protecting our country,
    and I know you are working very, very hard to do that in a
    difficult time.
        Ms. Grosso, if you had to rate on a scale from 1 to 10, how
    would you currently rate the severity of staffing shortages
    facing the VHA?
        Ms. Grosso. Sir, I really cannot speak to the shortages at
    VHA. I will let Ms. Bonjorni characterize that.
        Senator Boozman. Well, we will let her do that then.
        Ms. Bonjorni. Well, having not given a rating previous to
    the pandemic, I am going to say I would rate it at a 7 right
    now.
        Senator Boozman. What would you say before the pandemic?
        Ms. Bonjorni. Probably close to a 4 or a 5. We have areas
    where we isolated concerns, but now we are seeing concerns
    across the country.
        Senator Boozman. Very good. What are the areas where you
    have the highest shortages?
        Ms. Bonjorni. Our biggest concerns right now are at the
    higher end of the pay scale and the lower end. So our entry
    level occupations are really where we are having some
    difficulty, in addition to nurses, as was previously mentioned,
    but we are seeing the most labor pressure for positions like
    housekeeping aides, health technicians, food service workers,
    where we are competing directly with private sector offering
    higher hourly wages.
        Senator Boozman. I know you are working really hard to
    prevent it from happening, but is it affecting your ability to
    deliver care?
        Ms. Bonjorni. I do not think it is affecting our ability to
    deliver care at this point. We still have some flexibility to
    do some contracted staff if needed, but we are seeing
    continued, sustained, higher turnover and less success rates in
    each of our hiring attempts.
        Senator Boozman. So hiring is difficult, and retention is
    difficult also.
        Ms. Bonjorni. Yes.
        Senator Boozman. Right?
        Ms. Bonjorni. Yes.
        Senator Boozman. Why do employees stay at the VHA?
        Ms. Bonjorni. I think they like the work environment. We
    continue to be rated as a very solid employer and score well in
    Best Places to Work. When we look at our exit survey data,
    about three-quarters of employees would still recommend VA as a
    place to work and they would plan to come back.
        We do see, however, that only about a quarter of
    supervisors right now are asking their employees to stay, so
    that is what the employees report. So right now, we are working
    on an initiative called ``Stay in VA,'' where we work with
    managers to have them not wait until someone is going to leave
    to ask them what would keep them there but to talk to them
    throughout their employment, to encourage them to stay and
    build a job that they want to stay in for the long term.
        Senator Boozman. My next question was that it is estimated
    that roughly three million rural veterans are enrolled in the
    VHA. More than half of these veterans are over the age of 65.
    These members often have more complex medical conditions
    requiring specialty care. What initiatives and strategies are
    being discussed to improve recruitment or retention to ensure
    proper staffing in those areas? I know it is difficult in the
    private sector also.
        Ms. Bonjorni. I think we are looking especially at our--for
    specialty care providers, we have challenges on the higher end
    of the pay scale, where it is very difficult for us to compete
    with specialty providers. There is also a national shortage of
    occupations, people who are geriatricians, for example, which
    is an occupation that is very important for us to fill. So we
    need to continue to offer scholarships and encourage people to
    go into those fields through our training programs.
        Senator Boozman. The importance of the partnerships with
    our medical schools and those kinds of things, we are doing all
    we can to strengthen those, Dr. Clancy?
        Dr. Clancy. Yes, we are affiliated, I think, with 99
    percent of the Nation's medical schools. So as new medical
    schools come online and all of the osteopathic schools as well,
    this has been a 75-plus-year partnership.
        Senator Boozman. Right.
        Dr. Clancy. So after Medicare, we have the biggest impact
    on the future health care workforce, and it is something that
    we relish and are very thrilled about.
        Senator Boozman. Good. Thank you. Thank you all very much.
    Appreciate it.
        Chairman Tester. Senator Murray.

                          SENATOR PATTY MURRAY

        Senator Murray. Thank you, Mr. Chairman.
        Assistant Secretary Grosso, in Washington State, our VA
    employees have spent the last couple of years navigating COVID-
    19 pandemic and the implementation of this new electronic
    health care record system that has really been plagued with
    numerous issues. And on top of their responsibilities at work,
    we all know that they have had to balance child care, school
    closures, taking care of family members who are ill, and
    finding ways to stay connected with their communities.
        Tell us what lessons the VA has learned and is taking from
    the past few years to make meaningful improvements to the
    employee experience.
        Ms. Grosso. We certainly collect data on employee
    engagement and how we are doing and certainly addressing
    concerns that they have. I think the adoption of the new
    technology was a unique perturbation. We have learned
    significantly from that experience and have been able to have
    more successes as we have implemented it at a couple of other
    locations.
        And, Dr. Clancy?
        Dr. Clancy. Yes. So I know that you are fully aware of the
    challenges experienced by our colleagues at Mann-Grandstaff in
    Spokane.
        Senator Murray. Yep.
        Dr. Clancy. All reports are that Walla Walla went more
    smoothly, and to be quite honest, Cerner had a lot more people
    on the ground and under less stressful circumstances. During
    the Spokane deployment, some of the trainers as well as the
    employees got COVID because the things were sort of surging up
    as the deployment unfolded. But it is something that we are
    literally following daily, right up to the Deputy Secretary.
        Senator Murray. Are there additional authorities or
    resources the Department needs to meet the needs of these
    workers?
        Dr. Clancy. Well, we certainly need--and I will pass this
    to Jessica in just a moment--I think, more flexibility with
    retention and recruitment incentives. We have not quite hit our
    ceiling, but we are coming very, very close. And given that the
    entire health care system is facing workforce shortages and,
    frankly, having higher turnover rates than we are and often
    deeper pockets to, you know, entice some of our employees to
    leave, that is an area of worry.
        We are also expanding training opportunities so that we can
    grow more of our own, as you will see in our fiscal year '23
    budget, doubling the--requesting that we can double the amount
    of health profession scholarships both to increase the volume
    particularly of doctors and nurses but also the diversity of
    that pipeline as well, with very special attention to our rural
    areas.
        Senator Murray. Well, thank you. Let me turn to another
    question. Having enough providers, we know, is really critical
    for access to care, especially in rural parts of our country. I
    have heard some concerning things about VA's hiring practices,
    for example, positions disappearing from the HR system after
    not being filled and facilities not using the recruitment and
    retention incentives that are available to them, and that is
    just unacceptable.
        Congress provided the VA with the authority and the
    resources to recruit and retain staff, but there seems to be a
    lack of consistency in human resources management and lengthy
    wait times to fill these positions, which means we lose out on
    building a strong workforce and our veterans lose out on the
    potential to get care from these talented providers across a
    range of really important services: mental health care, women's
    health care, programs supporting homelessness. So I wanted to
    ask you, what plans does the Department have to improve
    recruitment and retention?
        Ms. Grosso. Well, we are aware that there are authorities
    that we have been given that are not being systematically used
    across the system, and that is obviously a leadership issue
    that we are working.
        Ms. Bonjorni. Sure. I would also add that we are investing
    in human resources. So you mentioned that there is a lack of
    standardization. We recognize that as we move to a shared
    services structure. We are still in the middle of doing that
    transition because we have not yet fully standardized our
    operations. While we all use the same policies, we do not all
    use the same procedures. So right now, we are in the middle of
    that standardization process.
        In addition, we are investing in training our HR
    professionals. So you will see, I think, quite a bit of
    improvement over the next couple of years in that as we are
    investing in the entry-level part of the HR workforce so that
    we can get everyone following the same procedures at the same
    time, and that will ultimately improve our recruitment and
    retention.
        Senator Murray. Okay. Thank you very much and thank you,
    Mr. Chairman.
        Chairman Tester. Senator Blackburn.

                        SENATOR MARSHA BLACKBURN

        Senator Blackburn. Thank you, Mr. Chairman, and thank you
    for being here. We appreciate your time.
        We have had so many issues with the VA. I represent
    Tennessee, and I appreciate that we just had a visit to the
    Memphis VA to address some of the issues that are there.
    Secretary McDonough was down just a couple of weeks or so ago
    to look at some of these issues.
        I know you all said earlier that you had not had
    conversations with DHS regarding the Title 42 issue. Do you
    intend to have conversations? Has anything been scheduled?
        Ms. Grosso. No, ma'am, not to my knowledge.
        Senator Blackburn. So the statements that have been made
    have been made without your awareness, knowledge, or
    participation?
        Ms. Grosso. That is correct.
        Senator Blackburn. Okay. I will tell you quite honestly to
    those of us who work on these issues, trying to meet the needs
    of our veteran, looking at the case backlog, it was astounding
    to hear that resources would be taken from the VA and moved to
    the southern border. I could not imagine that happening and
    telling a veteran, who was in line to have an appointment in a
    couple of weeks, after waiting four or five months, that they
    were going to have to wait longer. It is grossly unfair and is
    really misplaced.
        It seems that VA does not have enough employees. I think
    that when I looked you have got 60,000 job vacancies and 2,800
    funded vacancies and over 56,000 unfunded vacancies. So,
    Assistant Secretary Grosso, describe the differences that you
    have going on there between the funded and the unfunded, and
    then what do you do with the unused funds in those funded
    positions that are vacant? So, a little bit of clarity on that.
        Ms. Grosso. Thank you for the question. A vacancy does not
    necessarily represent that a position needs a human in it. So
    if you think about a big organization, we have all kinds of
    people needs, and there are some people--we have a system that
    puts position descriptions into our system of record, and
    because that takes time and effort that stays in there. And so
    that becomes a position library, and so there are positions in
    there that we do not have funding for but we do not want to
    take out because we may need to hire for it in the future.
        Senator Blackburn. Okay. So you are not 60,000 people
    short.
        Ms. Grosso. Yes, ma'am, that is correct.
        Senator Blackburn. And looking at your records, it would
    appear that you were 60,000 people short.
        Ms. Grosso. Yes, ma'am.
        Senator Blackburn. But you are not. You are closer to 2,800
    people short.
        Ms. Grosso. Yes, ma'am.
        Senator Blackburn. Is that fair?
        Ms. Grosso. Yes, ma'am.
        Senator Blackburn. Okay. I think a little bit of
    clarification on that would probably be helpful to the process.
        Let me ask you this. We have heard a good bit about the
    lengthy hiring and onboarding process that is required by VA.
    So how long does an average VA employment hire spend? How many
    months are they going through this process until they are
    onboarded and fully active in that job?
        Ms. Grosso. So across the VA, that averages 95 days, but I
    will share that VHA is doing tremendous work in the onboarding
    process to see where we have inefficiencies.
        And, Ms. Bonjorni, please expand.
        Ms. Bonjorni. Sure. So as you mentioned, the time that we
    are reflecting there is the time from when a position is filled
    to be recruited until the employee comes on board. So that 95
    day average can span all occupations, and there are some that
    are faster and some that are slower. The parts of that process
    that are taking the longest right now are the pre-employment
    steps, from once we have selected the candidate until they come
    on board, so all of the vetting processes. And so that is why
    we pulled together a team to look at what are the steps that we
    can take out of that process.
        Senator Blackburn. Okay. Let me ask you this, Ms. Grosso.
    When you look at that vetting process, how much of that can you
    utilize technology and move to an online platform as opposed to
    doing it manually? It sounds like you assemble teams and you
    are doing it more a manual process rather than doing it online.
    So how much time could you save if you achieved some efficiency
    there?
        Ms. Bonjorni. Well, I think the steps that we are taking
    still require people to do them. They cannot all be done in an
    automated fashion, but there are definitely technology
    improvements that we are looking at. But the steps we are
    talking about background investigations----
        Senator Blackburn. Why have you chosen not to use
    technology?
        Ms. Bonjorni. We have. I think we need to invest more in
    more modern technology to get to more automated steps, but some
    of the steps, like drug testing, physicals, et cetera, still
    will require interaction with a person to get done.
        Senator Blackburn. Well, absolutely, but there should be
    the ability to use technology just as saying we keep trying to
    move to electronic health records, which would speed up the
    process. And I know that some of these legacy systems and
    approaches in the VA have been a contributing factor to the
    delays, to the backlog, to the lack of service that has reached
    the veteran, which our goal, our shared goal, should be to get
    the resources to the veteran as quickly as we possibly can.
        Thank you, Mr. Chairman.
        Chairman Tester. Thank you, Senator Blackburn.
        I have got a couple more questions I want to ask since five
    minutes went way too fast the first time, so if you guys want--
    and part of this has to do with the question that Senator Brown
    asked about wages and wage surveys.
        And, Ms. Bonjorni, you had said that you can make a wage
    adjustment, but it was more a plural term. Who makes the wage
    adjustment? If you determine wages are too low in Ohio, in a
    sector of Ohio--I do not know how you do it. Do you do it VISN
    wide? Do you do it State? Do you do it region? Do you do it
    community by community? How do you make, and who makes, those
    determinations?
        Ms. Bonjorni. The full answer to that would take longer
    than five minutes, but I can tell you that it varies by
    occupation and our authority to make those adjustments vary by
    the type of appointment, the type of position, and who makes
    the decision also varies by the occupation.
        Chairman Tester. Okay. Let us say it is an RN. Say RN wages
    are--or LPN.
        Ms. Bonjorni. Yes.
        Chairman Tester. A nurse. They are six bucks too low. Who
    makes the decision whether to raise them or not?
        Ms. Bonjorni. It is different for an RN and an LPN, but the
    decision is made by the medical center director at the
    facility.
        Chairman Tester. Okay, Okay. That might be a place to
    simplify right there, to be honest with you.
        If I heard Senator Blackburn's answer or the answer to one
    of her questions, Ms. Grosso, did you say that you are 2,800
    people short, not 57,000 people short?
        Ms. Grosso. Sir, in fairness, it is very difficult to know
    how short we are. We are definitely not 50,000 short.
        Chairman Tester. But 2,800 with a staff the size of VA
    means you are fully staffed.
        Ms. Grosso. Right. So what we really need to do is work on
    what our requirements are, and we are putting a lot of effort
    into what actually is the requirement and how do we budget for
    that. When you look at the end of the fiscal year, the money
    that we budgeted for people, we have almost spent all of it.
    But we are working very hard to get to more of a requirements
    based system so we know what we need, and then we can give you
    a better, accurate number on what we are short.
        Chairman Tester. I think if you went around this table and
    talked to every Senator, regardless of party, where they are
    from, every one of them would say their staffing needs in their
    State. Okay? So there is some work to be done there. And I
    would just say that we are not here to be critical; we are here
    to help and do anything that needs to be done to be able to
    ensure accountability and make sure that we are getting the job
    done.
        One of you, I think it was Dr. Clancy, said that it is 95
    days across the VA to hire. Is that what you said? Somebody
    said that. Who said that?
        Ms. Grosso. Yes, sir, I did.
        Chairman Tester. You said that.
        Ms. Grosso. And if you look across the VA, that is the----
        Chairman Tester. Yes. Okay. So for Ralph Gigliotti, not to
    put you on the spot, Ralph, but to hire a nurse, how long does
    it take in VISN 19, on average?
        Mr. Gigliotti. So right now, we are at about 88 days across
    the VISN. The problem with that for us is the competition in
    the community is less than that, and so we are very dependent
    on that nurse wanting to come work for VA because of the
    mission. We have done everything we can, and we continue to do
    to make sure the pay is equitable and the work environment is
    equitable, but that speed of hire is an issue for us.
        Chairman Tester. So you gotta help me out here, Ralph.
    Eighty-eight days is three months. People gotta survive. They
    are coming out of college. A lot of them have debt. I know
    there is some debt forgiveness you guys can offer up as a
    possibility of bringing them on board. But, what can be done,
    what can you do or what can we do, to shorten that 88 days?
        My daughter happens to be a nurse. And I know there is
    different kinds of nurses, but in the end, if you need an RN,
    you need an RN. Why should it take 88 days to hire an RN?
        Mr. Gigliotti. I think that is what Jessica was referring
    to with the vetting pre-employment requirements and some of the
    work that is being done.
        Chairman Tester. Are those requirements--and, Jessica, you
    can answer this or Ralph can. Are those requirements put on you
    by us, or is that requirements you put on yourself? Who is
    putting the requirements on because if the private sector can
    do it quicker there really is no reason we cannot, too?
        Ms. Bonjorni. The requirements come from various sources.
    So we have temporary authority to waive some of these things
    due to the COVID emergency.
        Chairman Tester. Yes.
        Ms. Bonjorni. Once that expires, we will not have those
    authorities anymore, so we would need to document in some cases
    in legislation that we can use a different process than what is
    currently required.
        Chairman Tester. So you are saying during the pandemic it
    is shorter now, even though it is 95 days, than it was pre-
    pandemic?
        Ms. Bonjorni. Only for COVID hires. So early in the
    pandemic all of our hires were COVID-related hires.
        Chairman Tester. Okay.
        Ms. Bonjorni. Now we can only use it for a small subsection
    of our hires.
        Chairman Tester. So I am going to kick it over here to
    Tillis in a second, but we really do need to sit down and
    figure out what is the benefit and what is the cost to have all
    these regulations around hiring. Look, I do not want an inept
    person in the VA. You guys do not want an inept person in the
    VA. You want to make sure, but these are health care folks that
    you guys have thousands of. You have already hired thousands of
    them. It ought not be that tough.
        We really--I will tell you what I need from you. I need a
    list of things that we could do to make the hiring thing work.
    Okay?
        Senator Tillis.
        Senator Tillis. Thank you. I have got two follow-up
    questions, one of them related to I know that you all got the
    waivers through OPM.
        And, Mr. Gigliotti, what is the rough amount of time you
    believe that your competition for resources take to onboard
    somebody? They have decided they want to hire them. Then they
    get hired. Do you have a rough idea of what the private sector
    is doing right now?
        Mr. Gigliotti. Yes, thinking through my eight markets, I
    would say roughly half of our time.
        Senator Tillis. Okay, so about half the time. You know,
    these are--in my State, top tier hospitals, high standards for
    RNs, and my guess is the number is about the same. So I think
    we really do need to look at this. We need to find out to what
    extent we should codify some of the practices that we have
    seen.
        I know the Inspector General noted some risk associated
    with the vetting process, and you all are working through that.
        I feel strongly we should be able to compress the time, and
    my goodness, if we only compress it by 25 percent, we are still
    going to be 50 percent greater than the private sector
    competitors. But you can count me in to work with you if you
    can find specific things that we should take up as a matter of
    legislation.
        Last question I have really relates to the future of the
    VA. I know Secretary McDonough, a month or so ago, was before
    the Committee. He echoed the President's support for the PACT
    Act, and so I have got to believe that you all are at least in
    the preliminary stages of understanding the impact that that is
    going to have on resourcing.
        You are right now at about 222,000 claims backlog. That is
    up as a result of COVID, but COVID is going to be around for a
    while. So although it may be adjusted down, that is a part of
    the base. I think the estimates for the PACT Act is somewhere
    around 1.5 million claims.
        So you may not need all those 57,000 jobs filled, but some
    of them are going to need to be. Whether or not those jobs, as
    they have been posted now, are aligned with the needs of the
    provisions of the PACT Act is another question.
        So how are you now--making the assumption that the PACT Act
    would pass into law, what is your best estimate of how the
    Department deals with a quadrupling of the claims backlog?
        And I want to also put into that--I am a technology systems
    implementation person. We heard Senator Murray talk about the
    electronic health record. So keep in mind, if the PACT Act gets
    passed, you are also going through some major transformational
    implementations that while you are onboarding the other VISNs
    are going to slow down productivity. So how do you game out and
    give us feedback on the implementation of the PACT Act, the
    reality that you can get it done without actually disrupting
    the current run rate of care that you are providing and
    providing care to those who would be eligible under the PACT
    Act?
        Ms. Grosso. Well, thank you for that question. We have done
    a lot of work on the Veterans Benefits Administration side
    because that is where the process starts with the claims.
        Senator Tillis. Yes.
        Ms. Grosso. We have hired about almost 2,000 people, just
    shy of that now, to start working that. Probably need more, as
    you said. We think it would be 1.5 million more, and if
    hypertension is added it will be 2.5 million. So obviously, we
    are hiring more people, we are maximizing overtime, and we are
    also starting to use artificial intelligence to speed up
    looking at these many claims.
        Now it is very much a human-centered process, but we know
    technology can help us attack this. And I think we are still
    working the VHA side, to your point, so once the claims are
    approved, what human resources do we need to add to the VHA
    side.
        Senator Tillis. I just think as the discussions about the
    PACT Act, or anything that is substantially similar to the PACT
    Act goes through, I feel like we need your feedback on gaming
    out what the impact is going to be on the Department, what risk
    there will be to the current and anticipated flows before you
    add the increment. And you were talking about hypertension,
    going from 1.5 to 2.5. That means that your current struggles
    right now with a backlog of 222,000 is increased by 10 times.
    And we have already talked about hiring. We have talked about
    other challenges.
        So I feel like there is a risk, not debating the merits of
    the PACT Act, but a real risk. The good news is we have got new
    legislation passed. The bad news is about 18 or 24 months from
    now you could be in a real crisis in terms of people,
    technology, infrastructure to actually support the will of
    Congress.
        Ms. Grosso. Yes, sir, we agree. We need to be gaming that,
    and we are. Ironically, we do not have trouble hiring claims
    examiners, but it does take about six to seven months to train
    them.
        Senator Tillis. And then sooner or later, you are--either
    through community care or through additional medical resources,
    oncologists go through the very long list of presumptions that
    are in the PACT Act. You have also got to anticipate how much
    of that is going to be done by creating an organic capacity,
    which is going to ebb and flow based on where you are in the
    country, and how you are going to be able to address that
    through community care.
        Thank you.
        Chairman Tester. Before I get to Senator Blumenthal's first
    question, I would just say I think there is plenty of
    opportunity to speed things up. I like to talk about my kids
    because I am very proud of them. One of my daughters is a chief
    operating officer of a hospital, needed employees. HR director
    was not getting them on. She has got no HR director.
        So I think it is expectations here. And we have got to
    follow the law. We have got to make sure the law is there. But
    then the expectation is because you guys have an inherent
    hiring advantage, I think, over any hospital system in the
    Nation and that you are dealing with veterans and people want
    to work and deal with veterans in the VA. So we gotta take
    advantage of that.
        Senator Blumenthal.

                       SENATOR RICHARD BLUMENTHAL

        Senator Blumenthal. Thank you, Mr. Chairman. I know there
    has been some conversation about mental health care, and I know
    there has been conversation as well about nursing. In
    Connecticut, we face a real shortage of nurses. The nurses'
    shortage exceeds 10 percent, and it is characterized as severe,
    but of course, this issue prevails across the entire system. Is
    there something that we as a Committee, we as Congress, can do
    about it?
        Ms. Grosso. Well, we certainly thank you for the
    authorities that you have given us and would very much like to
    continue to work with you on helping us meet some of these
    challenges.
        Ms. Bonjorni, please.
        Ms. Bonjorni. Well, I would echo that. We continue to
    receive great support from the Committee to invest in things
    like scholarships and education debt reduction programs that
    help us hire and retain mental health professionals. Upwards of
    40 percent of our participants in the debt reduction program
    are in mental health occupations, and most of our scholarship
    recipients under some of our new programs are in mental health.
    We would welcome the chance to continue to invest in those
    programs.
        Senator Blumenthal. Should we change the programs apart
    from putting more money into them?
        Ms. Bonjorni. A couple of our programs I think we would
    benefit from the opportunity to allow people, for example, for
    education debt reduction, to essentially have another round at
    it. So prior to the MISSION Act, we had lower caps. And so some
    people have a lot of loans, and they might benefit from being
    able to go back to that again, additional investments in the
    Specialty Education Loan Repayment Program to let people
    participate in it further along in their training program so
    that we can allow more people to enter it.
        But right now we are anticipating awarding upwards of 25 of
    those scholarships to psychiatrists this year. So we are making
    use of it, just would like to do more.
        Dr. Clancy. If I could just add, we have requested in the
    '23 budget the opportunity to double the number of health
    profession scholarships with a strong focus on mental health,
    diversity, and attention to rural.
        If there is one--we have expanded nurse residencies. We
    will probably be coming to you with a potential request that we
    might be able to offer nurse residents accepting one of these
    specialties the opportunity to get a recruitment incentive at
    the start if they make a commitment. That, I am pretty sure,
    would require legislation.
        Mental health, I think, is probably the biggest challenge.
    Not enough people are choosing that as a field. So I think we
    have got to add growing our own, you know, our own employees
    who might be interested in making a career change and making
    those opportunities. We have some opportunities available but
    making them widely known. But mental health we need as a nation
    to really step up to, and that is a huge challenge.
        Senator Blumenthal. Chairman Tester, I think, rightly made
    the point that a lot of professionals want to go to work in the
    VA system because they are dealing with veterans. So I am
    wondering is this shortage of mental health professionals one
    that prevails throughout society or is it more common in the VA
    system.
        Dr. Clancy. No, I would--my best estimate is the VA is
    doing a lot better than most systems. For one thing, mental
    health tends to be sort of segregated and outsourced, if you
    will, in much of private U.S. health care, but in general, we
    have a strong national shortage of just about every occupation
    in mental health.
        Senator Blumenthal. Why do you think that is?
        Dr. Clancy. Some of it on the physician side is probably
    pay, and the rest I am not 100 percent sure. I mean, because if
    you think about it, neuroscience, I believe, is one of the most
    exciting fields because it is so new and so forth, but I simply
    do not know. And some of it, I think, is that we still have a
    stigma around mental health.
        Senator Blumenthal. Yes, it is hard to do something about
    it if you do not know what the cause.
        Dr. Clancy. Yes.
        Senator Blumenthal. You can just kind of try things out.
    And I agree with you that there may be some enduring stigma,
    but I am hoping that we are overcoming it. In the VA system,
    where I think the military, which was once behind the curve on
    mental health, now because of a very enlightened leadership in
    all of the Services and in the VA, is trying to remove the
    stigma.
        Dr. Clancy. I think that is right, and I think the other
    big opportunity and advantage we have in recruiting is the
    telemental health, which will not necessarily go away depending
    on what CMS decides to do about reimbursement and so forth. We
    are not hemmed in that. And thanks to all of you and the
    Anywhere to Anywhere Act, which may not be the official name,
    but we are not, you know, hamstrung by the State scope of
    practice laws either.
        Senator Blumenthal. Great. Well, thank you very much, Mr.
    Chairman.
        Chairman Tester. Thank you, Senator Blumenthal.
        I want to thank all three of you for the work you do, and
    the people that work with you, thank them, too. Appreciate you
    being here today. I look forward to continuing to work with the
    VA and the members of this Committee to ensure we provide the
    necessary resources and support to our VA employees.
        We will keep the record open for a week.
        Thank you for being here.
        This hearing is adjourned.
        [Whereupon, at 4:42 p.m., the Committee was adjourned.]

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