[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
       
       
       
       
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                             ______

             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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