[Joint House and Senate Hearing, 118 Congress]
[From the U.S. Government Publishing Office]






 
                     VHA RECRUITMENT AND RETENTION:


                         IS BUREAUCRACY HOLDING


                       BACK A QUALITY WORKFORCE?

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

                             JOINT HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                and the

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 of the

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

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                        WEDNESDAY, MAY 17, 2023

                               __________

                           Serial No. 118-14

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
       [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] 
       
       


                    Available via http://govinfo.gov
                    
                    
                    
                          ______                       


             U.S. GOVERNMENT PUBLISHING OFFICE 
 52-536             WASHINGTON : 2023 
                    
                    
                    
                    
                    
                    
                     COMMITTEE ON VETERANS' AFFAIRS

                     MIKE BOST, Illinois, Chairman

AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking 
    American Samoa, Vice-Chairwoman      Member
JACK BERGMAN, Michigan               JULIA BROWNLEY, California
NANCY MACE, South Carolina           MIKE LEVIN, California
MATTHEW M. ROSENDALE, SR., Montana   CHRIS PAPPAS, New Hampshire
MARIANNETTE MILLER-MEEKS, Iowa       FRANK J. MRVAN, Indiana
GREGORY F. MURPHY, North Carolina    SHEILA CHERFILUS-MCCORMICK, 
C. SCOTT FRANKLIN, Florida               Florida
DERRICK VAN ORDEN, Wisconsin         CHRISTOPHER R. DELUZIO, 
MORGAN LUTTRELL, Texas                   Pennsylvania
JUAN CISCOMANI, Arizona              MORGAN MCGARVEY, Kentucky
ELIJAH CRANE, Arizona                DELIA C. RAMIREZ, Illinois
KEITH SELF, Texas                    GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia        NIKKI BUDZINSKI, Illinois

                       Jon Clark, Staff Director
                  Matt Reel, Democratic Staff Director
                                 ------                                

                         SUBCOMMITTEE ON HEALTH

               MARIANNETTE MILLER-MEEKS, Iowa, Chairwoman

AUMUA AMATA COLEMAN RADEWAGEN,       JULIA BROWNLEY, California, 
    American Samoa                       Ranking Member
JACK BERGMAN, Michigan               MIKE LEVIN, California
GREGORY F. MURPHY, North Carolina    CHRISTOPHER R. DELUZIO, 
DERRICK VAN ORDEN, Wisconsin             Pennsylvania
MORGAN LUTTRELL, Texas               GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia        NIKKI BUDZINSKI, Illinois
                                 ------                                

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

               JENNIFER A. KIGGANS, Virginia, Chairwoman

AUMUA AMATA COLEMAN RADEWAGEN,       FRANK J. MRVAN, Indiana, Ranking 
    American Samoa                       Member
JACK BERGMAN, Michigan               CHRIS PAPPAS, New Hampshire
MATTHEW M. ROSENDALE, SR., Montana   SHEILA CHERFILUS-MCCORMICK, 
                                         Florida

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

                              ----------                              

                        WEDNESDAY, MAY 17, 2023

                                                                   Page

                           OPENING STATEMENTS

Honorable Jennifer A. Kiggans, Chairwoman, Subcommittee on 
  Oversight and Investigations...................................     1
Honorable Julia Brownley, Ranking Member, Subcommittee on Health.     2
Honorable Frank J. Mrvan, Ranking Member, Subcommittee on 
  Oversight and Investigations...................................     4

                               WITNESSES
                                Panel 1

Ms. Tracey Therit, Chief Human Capital Officer, U.S. Department 
  of Veterans Affairs............................................     5

        Accompanied by:

    Ms. Jessica Bonjorni, MBA, PMP, SPHR, Chief of Human Capital 
        Management, Veterans Health Administration, U.S. 
        Department of Veterans Affairs

Ms. Sharon Silas, Director of Health Care Team, Government 
  Accountability Office..........................................     7

                                Panel 2

Ms. Kelley Saindon, DNP, RN, NE-BC, CHPN, Chairman of the 
  Legislative Committee, Nurses Organization of Veterans Affairs.    23

Mr. Will Morse, Corporate Vice President of Solution Design and 
  Sales, AMN Healthcare..........................................    24

Dr. Robyn Begley, DNP, RN, NEA-BC, FAAN, Senior Vice President of 
  Workforce, American Hospital Association.......................    26

Ms. Mary Jane "MJ" Burke, First Executive Vice President, AFGE 
  National VA Council............................................    28

                                APPENDIX
                    Prepared Statements Of Witnesses

Ms. Tracey Therit Prepared Statement.............................    45
Ms. Sharon Silas Prepared Statement..............................    48
Ms. Kelley Saindon Prepared Statement............................    66
Mr. Will Morse Prepared Statement................................    69
Dr. Robyn Begley Prepared Statement..............................    78
Ms. Mary Jane "MJ" Burke Prepared Statement......................    83

                       Statements For The Record

American Medical Association.....................................    87
National Nurses United...........................................    91
American Association of Nurse Anesthesiology.....................    94


                     VHA RECRUITMENT AND RETENTION:



                         IS BUREAUCRACY HOLDING



                       BACK A QUALITY WORKFORCE?

                              ----------                              


                        WEDNESDAY, MAY 17, 2023

             U.S. House of Representatives,
                            Subcommittee on Health,
      Subcommittee on Oversight and Investigations,
                            Committee on Veterans' Affairs,
                                                   Washington, D.C.
    The subcommittees met, pursuant to notice, at 10:32 a.m., 
in room 360, Cannon House Office Building, Hon. Jen Kiggans 
[chairwoman of the subcommittee on Oversight and 
Investigations] presiding.
    Present from the Subcommittee on Health: Representatives 
Kiggans, Radewagen, Bergman, Murphy, Brownley, Deluzio, 
Landsman, and Budzinski.
    Present from the Subcommittee on Oversight and 
Investigations: Representatives Mrvan, Kiggans, Radewagen, 
Bergman, Rosendale, Pappas, and Cherfilus-McCormick.

     OPENING STATEMENT OF JENNIFER A. KIGGANS, CHAIRWOMAN, 
          SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

    Ms. Kiggans. Good morning. This joint Oversight hearing for 
the Subcommittee on Oversight and Investigations and the 
Subcommittee on Health will now come to order.
    As a geriatric nurse practitioner, I am no stranger to the 
challenge of hiring and staffing medical professionals. I would 
like to wish a belated happy Nursing Week to the nurses out 
there. The VA has its work cut out for them. Having worked in 
both VA and the private sector, I know how crucial it is for 
patients to be supported by adequately staffed healthcare 
teams. Unfortunately, we are experiencing a workforce shortage 
nationwide, which can lead to higher risks and poor health 
outcomes for our patients. This crisis, which has been 
exacerbated by COVID-19 pandemic and aging population, provider 
burnout, demographic shifts, and higher education faculty 
shortages, is negatively impacting all healthcare 
professionals. Unfortunately, VA healthcare facilities are not 
immune.
    The passage of The Sergeant First Class Heath Robinson 
Honoring our Promise to Address Comprehensive Toxics Act of 
2022 (PACT) Act last Congress, which largely expanded 
healthcare eligibility at the VA, makes a seamless hiring 
process and a robust workforce that much more important. The 
PACT Act also included many hiring provisions to help make VA 
more attractive to prospective employees and added incentives 
to help increase retention rates. I look forward to hearing 
from the VA on whether they are fully implementing these hiring 
authorities to address the health and resiliency of their 
workforce. Veterans Health Administration (VHA) has told the 
committee that it is setting a record pace for hiring and is 
minimizing their turnover rates. In 2023, VHA's workforce grew 
by 9,590 employees, which is the highest growth rate we have 
seen in more than 20 years. This is encouraging news, but I 
remain concerned about the VA's lengthy and resource intensive 
hearing and relocation process. Delays in hiring or relocating 
staff across its own system has led to well-trained and high 
quality staff ending up accepting other jobs outside of the VA.
    I am also worried about numerous concerns expressed by VA 
employees and their support organizations across the country 
about indifferent management, discrepancies, and pay driven by 
poor processing and inadequate staffing models and vacancy 
tracking. This is not confined to just medical staff. Medical 
center police forces have been struggling with staffing issues 
as well, and with it being National Police Week, I want to say 
thank you to our VA police officers who work so hard each day 
to provide a safe and supportive health care environment to our 
veterans. VA police are often understaffed and must manage very 
difficult situations in sensitive health care settings. I am 
introducing a bill to get to the bottom of police staffing 
issues and security weaknesses, which are impacting medical 
centers across the country, like the Hampton Medical Center 
next to my district.
    In closing, the VA appears to be making some progress, but 
there is still much to do, and we need to ensure the burdensome 
bureaucracy of VA is not reducing the quality of the workforce 
because it takes too long to hire, promote or support talented 
employees. I hope this hearing brings clarity to what the VA is 
doing to minimize overlapping bureaucratic processes and what 
resources VA is currently applying, as the title of this 
hearing mentions, to ensure a quality workforce.
    I look forward to hearing from all of our witnesses today 
about the obstacles, the opportunities they face, and the 
effort to ensure veterans get the care that they deserve. I 
especially look forward to hearing from the American Hospital 
Association on panel two to understand the lessons learned from 
the private sector on how they are handling recruitment and 
retention issues.
    Thank you all for being here, and I look forward to our 
discussion on both panels today.
    With that, I yield to Ranking Member Brownley for her 
opening statement.

     OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER, 
                     SUBCOMMITTEE ON HEALTH

    Ms. Brownley. Thank you, Chairwoman Kiggans, for convening 
this morning's hearing. I will aim to keep my remarks brief as 
I know we have a lot of witnesses to hear from today, and I am 
eager to hear their perspectives.
    Last week marked the end of the COVID-19 public health 
emergency in the United States. This is an opportune time to 
reflect on how the pandemic affected the healthcare workforce 
in this country and renew our focus on addressing long standing 
human capital challenges at VA.
    One such challenge is the complexity of VA's personnel 
systems. In 1946, Congress recognized the need to expedite 
hiring of certain VA healthcare professionals and created a new 
hiring authority unique to VA under Title 38. Other occupations 
which exist at VA and other Federal agencies continue to be 
administered under Title Five. In 1983, Congress developed a 
hybrid category of personnel, making certain clinical 
occupations subject to Title Five for the purposes of leave, 
hours of duty, and performance appraisal, but subject to Title 
38 for appointment, advancement and pay. Thus, we have three 
different personnel systems under which VA occupations are 
categorized, each with its own set of rules and requirements. 
This makes the job of a human resources professional at VA a 
very difficult one, and VA has struggled to retain Human 
Resources (HR) professionals with the skills and knowledge 
necessary to operate within these three complex systems.
    Another long-standing challenge has been VA's ability to 
offer salaries and financial incentives that are on par with 
those available to clinicians in the private sector. The COVID-
19 emergency has caused many healthcare workers to leave their 
professions, contributing to even greater competition for an 
even smaller pool of potential applicants. At the same time, 
salaries and financial incentives in the private sector 
continue to rise, and VA is having difficulty keeping up.
    Finally, VA staffing shortages have led to increased 
workloads for employees who may be asked to work additional 
shifts or longer shifts, which contributes to burnout, low 
morale, and staff turnover.
    This is my eleventh year on the Veterans' Affairs 
Committee, and I have probably participated in at least a half 
a dozen hearings examining these very challenges. What I am 
going to say next is not directed exactly to the witnesses 
here, but it is frustrating that the VA has not made more 
progress addressing these challenges, most of which long 
predate the COVID-19 pandemic. While I am pleased that VA 
submitted its written testimony on time for this hearing, for 
the first time in a long time for the Health Subcommittee 
hearing, I might add, but I must say I was very disappointed in 
the quality of the written testimony. These are major 
challenges which directly affect veterans' access to their 
earned health care benefits. VA's testimony, all three and a 
half pages of it, provides almost no detail on the Department's 
path forward.
    However, I do not believe these challenges are 
insurmountable. That is why I especially look forward to the 
testimony of today's second panel witnesses, who represent a 
wide array of healthcare professional organizations, providing 
perspectives from both the existing VA workforce as well as 
from the private sector. Together, I hope we can explore new 
ways in which VA can more competitively attract and retain 
clinical professionals. We must work together to ensure VA's 
healthcare system will be prepared to care for those who have 
borne the battle for generations to come.
    With that chairwoman. I yield back.
    Ms. Kiggans. Thank you, Ranking Member Brownley. I will now 
yield to Ranking Member Mrvan for his opening remarks.

     OPENING STATEMENT OF FRANK J. MRVAN, RANKING MEMBER, 
         SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS 

    Mr. Mrvan. Thank you, Chairwoman.
    First, I would like to recognize that it is National Police 
Week as the chairwoman had also. I am proud to co-sponsor, 
along with Ranking Member Brownley, of H.R. 1322, the 
Bipartisan Law Enforcement Officers Equity Act, which will 
provide equal pay and retirement benefits for all Federal law 
enforcement officers. Our hearing today is highlighting issues 
of recruitment and retention, and this bill will help us 
recruit and retain VA police officers who often leave these 
positions to acquire retirement benefits.
    With more than 400,000 employees nationwide, and the second 
largest budget in the federal government, VA employees are the 
lifeblood of the healthcare and benefits that we provide our 
veterans. Congress has provided VA with many authorities to 
improve recruitment and retention of healthcare professionals. 
As we are currently seeing, at VA as well as in the private 
sector, recruitment and retention of clinical staff is a 
significant issue. Even with the enactment of the PACT Act, 
which has provided VA with a broad range of new authorities to 
aid in recruiting and retaining staff, we continue to hear that 
VA is experiencing issues. One major issue I have been made 
aware of that impacts recruitment and retention, is errors in 
compensation. Specifically, I am aware of issues with offers 
being made to employees which are later changed when they 
accepted the job. This bait and switch in salary, job 
description, and schedule do not imbue a sense of confidence 
among employees who are looking to take new positions at VA. We 
have also heard of VA employees receiving debt letters to 
recoup money they were paid due to HR coding mistakes. New VA 
employees are often taking positions that offer lower 
compensation than they would in the private sector, and these 
errors are a significant financial burden. I hope to address 
these compensation errors today. Paying our employees what they 
are owed should not be this difficult. VA employees provide 
excellent care for our Nation's veterans. The least we can do 
is pay them what they are owed.
    While implementation of these hiring authorities and 
compensation issues have proven challenging, I would also like 
to highlight the effect that IT modernization delays and 
failures have had on recruitment and retention. VA's delays 
with competing and awarding a new HR modernization system, 
along with the other administrative challenges, is a hindrance 
to progress. Last Congress, I cosponsored and we passed the IT 
Reform Act to require better program management and acquisition 
controls for large IT projects at VA, and I expect to continue 
that oversight of this program. Veterans and employees have had 
enough of ineffective IT solutions, and they deserve better.
    I look forward to hearing from our witnesses today and 
discussing these and other ways to improve our ability to 
recruit and retain healthcare professionals at VHA.
    With that, I yield back.
    Ms. Kiggans. Thank you very much, Ranking Member Mrvan.
    I would now like to introduce the witnesses.
    Joining us today from the Department of Veteran Affairs is 
Ms. Tracey Therit, the chief human capital officer at the 
Department. Accompanying Ms. Therit today is Ms. Jessica 
Bonjorni, the chief of Human Capital Management at Veteran 
Health Administration. We also have Ms. Sharon Silas, the 
director of healthcare at Government Accountability Office 
(GAO).
    Ms. Therit, you are now recognized for 5 minutes to deliver 
your opening statement.

                   STATEMENT OF TRACEY THERIT

    Ms. Therit. Good morning, Chairman Kiggans, Ranking Members 
Brownley and Mrvan and members of the Committee. Thank you for 
inviting us here today to discuss the Department's hiring 
efforts and staffing opportunities. Joining me today is the 
Veterans Health Administration's Jessica Bonjorni, chief of 
Human Capital Management.
    VA has dramatically increased hiring, holding surge events 
to onboard staff more quickly and increasing incentives for 
recruitment and retention. We are proud to report that our 
emphasis on hiring more competitively led to a record of more 
than 48,500 hires in VHA last year and we are well on our way 
to exceeding that number this year. VHA's total workforce grew 
by 13,627 employees, 3.6 percent in the first 7 months of 
Fiscal Year 2023. This represents VHA's highest growth rate in 
more than 20 years. These efforts well position us to meet our 
goal of 52,000 new VHA employees this fiscal year, which would 
result in a growth of over 3 percent in the overall size of the 
VHA workforce. Veterans Benefits Administration (VBA) was also 
able to increase its workforce by more than 10 percent, more 
than 2,700 employees in the first 7 months of Fiscal Year 2023, 
compared to last year with a growth rate of 3 percent for the 
same period in Fiscal Year 2022.
    VA currently stands at 439,415 employees and continues to 
grow each year in response to increased demand for its 
services, improved access and benefits, reduced wait times, 
improved quality, enhanced veteran satisfaction, and overall 
mission growth. VHA accounts for approximately 89 percent of VA 
employees and most of the additional staffing needed in the VA 
in the past 5 years has been in our clinical occupations, which 
account for approximately 63 percent of VA employees.
    At the largest integrated healthcare delivery system in 
America, VA's workforce challenges mirror those faced in 
private healthcare industry. Across the private healthcare 
sector, hospitals and ambulatory care centers have reported 
high turnover, increased labor costs, and increased reliance on 
travel nurses. While VA's turnover rate has historically been 
extremely competitive at below 10 percent annually, the rate 
did increase to 10.1 percent in Fiscal Year 2022, due in part 
to improved economy, greater competition with private sector, 
and the pressures and burnout of COVID-19.
    VA's aggressive hiring and retention efforts, together with 
leveraging the PACT Act authorities, have resulted in 
significantly improved retention so far this Fiscal Year and 
growth leading us to a point where we are currently providing 
more care, more benefits to more veterans at any time in our 
Nation's history.
    Despite challenges, VA's unique mission attracts new 
employees yearly, and nearly 30 percent of our workforce are 
veterans themselves who identify closely with our mission. 
Other unique benefits attracting employees include working for 
a nationwide healthcare organization that provides flexibility 
to move to facilities in other parts of the country without 
leaving VA employment while maintaining a single professional 
license or credential. VA benefits also include scholarships 
for employees to gain education in critical shortage 
occupations, loan repayment to help those who have already 
completed their education, liability protection, work schedule 
flexibilities, telework options, and opportunity to participate 
in cutting edge medical research.
    VA is responding to concerns raised by customers and 
stakeholders about delays in hiring and onboarding processes 
through our Candidate Care Model. The Candidate Care Model is a 
framework and set of tools supported by customer experience 
principles that will assist VHA hiring managers and candidates 
and human resources professionals in providing a better 
onboarding experience. VHA has spearheaded initiatives to 
standardize and improve the onboarding process, including work 
done by VHA HR standardization teams, we have conducted an 
onboarding deep dive by our Veterans Experience Office and 
onboarding rapid process improvement workshops conducted by VHA 
Human Capital Management. The result is a new, modernized and 
interactive onboarding experience that redesigns candidate 
touch points to fewer people across fewer systems infused with 
consistent candidate friendly messaging.
    To mitigate some of the hiring challenges in clinical 
occupations, VA continues to lead the way using telehealth and 
mobile deployment clinics to reach veterans living in areas 
defined as health professional shortage areas. VA is a leader 
in virtual healthcare delivery and is well positioned to expand 
in this area.
    Additionally, VA continues to use direct hire authority, 
recruitment and retention flexibilities and incentives, hiring 
initiatives, virtual trainee recruitment events, improved 
employee engagement, HR modernization, workforce planning, 
targeted recruitment of military spouses and service members, 
transitioning from the Department of Defense, National 
recruiter programs for hard to fill occupations and 
specialties, and including historically underserved communities 
and regions.
    We also appreciate the close collaboration with the 
committee staff and look forward to continuing future 
legislative efforts centered specially around pay and hiring 
flexibilities in those critical and hard to fill positions.
    This concludes my statement. My colleague and I would be 
happy to answer any questions that you or members of the 
committee may have.

    [The Prepared Statement Of Tracey Therit Appears In The 
Appendix]

    Ms. Kiggans. Thank you. Thank you, Ms. Therit.
    Ms. Silas, you are now recognized for 5 minutes to deliver 
your opening statement.

                   STATEMENT OF SHARON SILAS

    Ms. Silas. Chairwomen Miller-Meeks and Kiggans, Ranking 
members Brownley and Mrvan, and members of the subcommittees, I 
am pleased to be here today to discuss our work on staffing 
challenges at the Veterans Health Administration.
    My testimony today covers recent GAO report findings and 
recommendations that illustrate program staffing, recruiting, 
and retention challenges, and their impact on VHA's ability to 
meet its program objectives, but also opportunities for VHA to 
help ensure it can quickly onboard staff needed to effectively 
meet its mission of delivering quality, timely care to 
veterans.
    VHA operates the Nation's largest healthcare system, 
employing more than 371,000 clinical and support staff and 
serving over 9 million enrolled veterans. Implementation of the 
PACT Act and an increasing demand for certain healthcare 
services, such as mental health, highlight the need for VHA to 
implement effective strategies for staffing, recruiting, and 
retaining staff. Further, it is important that VHA have the 
processes, data, and systems in place to ensure the agency is 
able to effectively expedite, track, and monitor the hiring and 
onboarding processes for new staff.
    My statement today highlights three recent reports, 
however, our findings are only examples of, in some instances, 
long standing issues VHA has had in ensuring that it has enough 
staff to effectively meet program needs. For example, in 
reviews of the Community Care Program, we cite challenges with 
recruitment and retention, vacancies, and the program not 
having enough staff to process consults to ensure timely access 
to care through the program. Specifically, we have an open 
recommendation from 2020 that leadership should assess staffing 
and resource needs, including strategies to adjust staff levels 
and address recruitment and retention challenges.
    In our December 2022 report on VHA's program that 
integrates mental health care in primary care settings, 
facilities often reported staffing as one of their most 
significant challenges to implementing or sustaining program 
services. Facilities cited, for example, insufficient staffing 
levels for providers such as psychologists and psychiatrists, 
turnover, and recruiting staff as affecting the implementation 
of these programs since at least 2016 and peaking in 2022. VA 
Medical Center officials told us that several factors may 
contribute to the program staffing issues, including a national 
shortage of mental health providers, salary discrepancies with 
the private sector, and a slow and complicated hiring process. 
In our report, we made a recommendation that VHA evaluate and 
implement strategies to help mitigate staffing challenges that 
affect medical centers' abilities to integrate mental health 
care within those primary care settings.
    Last, I wanted to discuss VHA's hiring and onboarding 
processes for new hires. Although VA has undertaken a number of 
major modernization initiatives, including consolidating human 
resources within each regional network, concerns have been 
raised that the hiring and onboarding process can be long and 
complicated, creating barriers to hiring highly qualified staff 
to fill positions. According to VHA, the hiring process for new 
staff can take upwards of 3 months. In our January 2023 report, 
we reviewed VHA's onboarding process for new hires. We found 
that VHA lacked reliable data to monitor the completion of key 
onboarding tasks, such as credentialing and background checks 
that were expedited or deferred during the COVID-19 pandemic. 
Consequently, VHA could not tell us the number of clinical 
staff hires during COVID-19 using USA Staffing, the U.S. Office 
of Personnel Management (OPM) data system that VA customized to 
track its new employee onboarding tasks. Specifically, we found 
that the onboarding data was incomplete, inaccurate, and not 
timely because VHA lacked a comprehensive policy requiring all 
staff to use USA Staffing to manage key onboarding tasks and 
guidance to ensure consistent data entry.
    We made two recommendations to address these findings. 
Reliable onboarding data is important to ensuring effective 
monitoring of timely hiring. It allows VHA to set baselines, 
track trends, and measure timeliness across facilities to 
target where there may be pain points in the onboarding 
process. VHA's workforce plays a central role in transforming 
the agency into a high performing organization.
    We placed Veterans Healthcare on GAO's high risk list in 
2015, in part based on our concern that the Agency was not 
clear on its resource needs and allocation priorities, 
including the recruiting and retention of staff. VHA is taking 
steps to implement our recommendations, however, without 
continued attention to staffing challenges, including those 
related to its human resources modernization effort, VHA may 
not be best positioned to address ongoing and future demand for 
its healthcare services.
    This concludes my statement and I am happy to take any 
questions that you have today.

    [The Prepared Statement Of Sharon Silas Appears In The 
Appendix]

    Ms. Kiggans. Thank you, Ms. Silas.
    We will now proceed to questioning, and I will yield 5 
minutes to myself first.
    Ms. Therit, earlier this year, I visited the Hampton VA 
Medical Center, which is just outside my district. While 
Hampton has made progress with medical staffing, we were 
shocked at the time of visit that they had many months that 
they were unable to hire a police chief or deputy, which is--
since it is National Police Week, it is very fitting just to 
start with a law enforcement question. Is this a common 
occurrence that the police chief and deputy positions are open? 
Is there anything that the VA is currently doing to improve 
police recruitment and retention? I know several members, 
including myself, are working on ways to try to incentivize 
that. Is there anything that the VA can do specifically before 
we get through the legislative process, with some things we are 
working on?
    Ms. Therit. Chairwoman Kiggans, I am going to offer a few 
things that we are actively doing to support our police officer 
hiring processes and then ask Ms. Bonjorni for any additional 
information she has.
    Over the last year, we have standardized a lot of our 
position descriptions for police officer positions. Sometimes 
the process for classifying a position and announcing a 
position and recruiting to fill it can be timely. We are 
looking at every part of the process and where we can 
streamline, consolidate, and reduce the time it takes to engage 
in those efforts.
    We also have direct hire authority from the Office of 
Personnel Management for filling police officer positions. We 
use our non competitive hiring authorities to bring police 
officers in at a faster rate than our 80 day time to hire model 
that the Office of Personnel Management has. We are also 
exploring the special salary rates for police officers to have 
competitive pay in the VA when they are looking at other 
occupations in that hard to fill community.
    The last thing that I will mention is we very much support 
the Law Enforcement Officer Equity Act. We look forward to 
being able to provide our police officers with those enhanced 
benefits as well to make us more attractive and to fill those 
positions.
    Ms. Bonjorni, if there is anything specific to VHA that you 
want to add.
    Ms. Bonjorni. Thanks, Tracey.
    I concur with your statements and I think we have new 
flexibilities with the PACT Act that are going to make it 
easier for us to assist on those chief positions where we did 
not have those same flexibilities prior to that law. We will 
look at using the full scope of flexibilities with special 
salary rates and potentially critical skills incentives for 
that population.
    Ms. Kiggans. Great. Thank you.
    Ms. Bonjorni, I believe that Dr. Miller-Meeks, and I are 
some of the only people in Congress who have been through the 
VA hiring process as providers. Although I did not work at the 
VA long, one of my primary reasons for leaving was just that it 
was not a good match. I wanted to work in a clinical setting 
and I was placed in a clinic that was very administrative, so I 
felt like my clinical skills were really being set aside, so I 
decided to find different employment. How does the VA work with 
current employees to match opportunities of the VA with some of 
their career goals? I know that especially for our nurses, we 
have nurses, we want to keep our nurses in all capacities, 
right. The reasons that nurses leave jobs is because they are 
overworked and underpaid and that they are not using the skills 
that they studied so hard and trained so hard to use.
    I want to make their lives easier by making sure we have 
enough health care providers, but keeping the ones we have by 
just incorporating them in the best capacity. Is there anything 
that we are doing to make sure that the ones that want to keep 
their clinical skills current can do that? There are so many of 
them in different administrative roles. Is there any good 
matching programs where we feel like we could just do a better 
job at keeping them current in some of their certifications? I 
know that for myself as a geriatric nurse practitioner, we had 
such a small geriatric clinic at the Hampton VA, which is a 
whole other issue. We really should be expanding geriatrics in 
general for focused part of care. But how are we doing this to 
just incentivize and keeping nurses especially so that we can 
have our hands on patients and be able to do that daily care 
that we love so much, but what are we doing to incentivize 
that?
    Ms. Bonjorni. Well, first, thank you for giving VA a shot. 
When you are done with this gig, maybe you will consider us 
again.
    We have a lot of options to try to make sure that our 
providers are getting diversity of experience. One of the 
things that we are about to test out internally is to take some 
of the detailed opportunities that often are filled with people 
without maybe wide competition and posting those in one central 
location so that people have access to know that there are 
other opportunities out there that they could test out. We are 
also looking to expand our continuing professional education 
reimbursement process beyond what we currently offer. There is 
some legislation pending that would help us do that, but we are 
going to do that internally as well. We are very interested in 
making sure all of our providers have the chance to continue to 
improve on their education and skills.
    Ms. Kiggans. Thank you very much.
    One last question. Ms. Therit, during the pandemic the VA 
was able to expedite the hiring process to weeks instead of 
months with quicker onboarding. While there were several risks 
inherent to this emergency process, there had been some lessons 
learned on what improvements in the hiring process were you 
able to identify and have you been able to incorporate any into 
your current hiring models.
    Just as a side note, I have a brother who is a nurse who 
works at the VA hospital in Maine, and I just randomly--calling 
him, and I chair this VA committee, is there anything, any 
complaints you have that we should be addressing? He says, 
well, if you want to talk about anything at your oversight 
committee meeting, we have lost many physician providers just 
because of the length of time it is taken. We have gotten 
excited about new providers--he is in pain management clinic--
and then it is taken 6 plus months, so we have lost them. That 
was literally the only complaint that my nurse brother at the 
VA hospital had. What are we doing to ensure that we are 
cutting that hiring time in half and not losing those 
providers?
    Ms. Therit. Ms. Bonjorni and I are looking very closely at 
shifting from a time to hire model to a time to fill because 
there are a lot of steps that need to be taken from the time a 
position is vacated until that next person arrives. We are 
looking at what can be delayed or deferred, which is some of 
the approaches that we took during COVID to get folks on board 
faster. Re-engineering that hiring process from vacancy 
incurred until the next person arrives. We are looking at what 
we can delay, what we can defer, what we can re-purpose in 
terms of steps in the process and where we can save time and 
streamline more of those activities.
    I think the ultimate goal is to be able to look at the 
experience that employee has. I know one idea that we have 
explored is instead of a tentative job offer letter and a final 
job offer letter, one contingent letter that tells the 
individual when they are going to be able to start, the things 
that they need to complete before they start the position, and 
making sure that we are working closely as a team to get all of 
those items completed.
    I think we are looking at everything. We welcome both the 
ideas of this committee as well as those on the second panel, 
and what we can learn from private sector.
    Jessica, if there is other things that you are doing to 
streamline the process or that would be responsive to the 
question, feel free to add.
    Ms. Bonjorni. Sure.
    Well, I think we all share the same concerns. Our hiring 
process is more complex and lengthy than we would like it to 
be. I think we have shared with this committee a detailed 
explanation of all the steps that have to happen in our hiring 
process. Now, there are 83 total steps that happen in that 
process, 27 of them are things that we are working on doing, 
doing process redesign right now. There are also a handful, I 
believe eight, that require regulatory or OPM changes to make a 
difference, and then there are 12 that would require a 
legislative change.
    We would love to work with the committee to figure out how 
we can tackle each one of those that would make the most 
difference.
    Ms. Kiggans. That would be great. Thank you. Thank you very 
much.
    Now I would like to recognize Ranking Member Brownley for 
any questions she may have.
    Ms. Brownley. Thank you, Madam Chair.
    The first thing I wanted to just point out, or get your 
feedback on, is you in your opening statements and in your 
testimony, you talked about dramatically increasing hiring at 
record amounts. I guess my question to you is, and this lies 
some of my frustration, is that the net net increase in 
hiring--and I presume it is not--but you let me--tell me one 
way or the other, is it net net?
    Ms. Therit. The growth rate is the net increase. I think 
the numbers that were provided were about 30,000 external 
hires, of which we have 13,000 net growth. That is the net 
amount in terms of growth and hires.
    Ms. Brownley. Okay. Do you have any kind of timelines in 
terms of where you are trying to get to in these various 
categories? The chairwoman talked about public safety and 
police, and you talked about all these different categories.
    Ms. Therit. As part of the PACT Act implementation we have 
developed a workforce dashboard. We will be releasing that and 
you should see it later this month. We do have targets for this 
Fiscal Year for our mission critical occupations, which include 
physicians, nurses, housekeeping aides, social workers. We do 
have those targets and we are looking each pay period at how we 
are doing and working toward those targets. We are seeing 
trends up in virtually all of those mission critical 
occupations. Then VHA has also identified specialty 
occupations.
    We are tracking that information, making sure that we are 
growing to the levels that we had set as targets for the end of 
this Fiscal Year and making sure that we are on track. I know 
VHA is looking at 52,000 hires, external hires, so that they 
can meet that over 3 percent projected growth that they have 
for this fiscal year. VBA is nearing 29,000 employees, and that 
is about 8 percent growth so far this fiscal year.
    Ms. Brownley. I would like to see your timelines and 
objectives for what you talked about the mission critical 
places.
    I applaud the VA in terms of their strong focus on 
implementation of the PACT Act, but we can not forget the rest 
of the VA and all the other missions that we have here. I just 
want to get that on the record.
    The next question I wanted to ask is in one of the panel 
two witnesses, Mr. Morse of AMN Healthcare, observed in his 
testimony that VHA typically offers many of the job 
characteristics healthcare professionals seek. We talk about 
this all the time, set hours, generous vacation times, the 
security of government employment, freedom from the stress of 
malpractice claims and personal financial liabilities, and most 
importantly, a rewarding sense of mission. My question is, what 
is VA doing to market these non financial benefits of a VA 
career to clinical professionals? Do your offices have a 
marketing budget? Do the VA medical facilities have a marketing 
budget? I never see any marketing. I do not see it. Tell me 
what you are doing.
    Ms. Bonjorni. We are doing a lot. We will connect you with 
all of our social media pages and make sure you are following 
all the VA recruitment marketing pages. We do have a national 
program that my office manages. VAcareers.va.gov is our central 
hub for all of our recruitment activities, where you can see 
information like our total rewards information that describes 
exactly what you are mentioning, the non financial benefits of 
working at the VA.
    Ms. Brownley. That is great and I am aware of those things. 
The problem area that I see is one has to seek that information 
out. They are not just going to turn on a television set or 
open up a magazine and see all the different possibilities, 
they have to seek it out. I think that is part of the challenge 
is how are we recruiting, how are we bringing very qualified 
candidates into the VA?
    Is there any marketing that you do that one does not have 
to seek the information to find it?
    Ms. Bonjorni. We do. We also advertise our positions in 
places that are specifically targeted where providers are 
looking for jobs. Specific job boards where they might be on 
the hunt. We also right now are standing up a national sourcing 
office that will help us look for passive candidates, so people 
who are not looking for jobs. Instead we are going out and 
looking for them in a more proactive fashion.
    Ms. Brownley. Does this marketing include these benefits 
like generous leave and liability protections and opportunities 
to participate in medical research? All of those things that I 
think a lot of people do not know that the VA offers.
    Ms. Bonjorni. Absolutely. We do have commercials and public 
service announcements that are on television, but perhaps not 
enough saturation. We will continue to invest in that.
    Ms. Brownley. Okay.
    I just last wanted to address The Reforming American 
Immigration for Strong Employment (RAISE) Act, the nurses and 
the Physician Assistants (PAs). The nurses have spoken to me 
and have told me that VA largely only implemented pay increases 
for employees who were already at or near the pay cap. 
Certainly it was Congress intent with the RAISE Act that it 
would be a tide that would raise all boats. We envisioned it to 
not only as a raise for those who are already maxed out, but as 
an opportunity for VA to reassess nurse and physician 
assistants pay across the board.
    What are you doing to ensure that all VA medical facilities 
are continually--and continually as a keyword--reassessing 
whether their nurse and PA salaries are keeping pace with local 
markets?
    Ms. Bonjorni. Thank you. We have received similar feedback 
and concerns raised from our nurses and our PAs.
    The initial round of adjustments was exactly that, was 
adjusting those that were at the cap already. Then we did a 
review of those that were within 10 percent of the cap, and now 
we are doing ongoing reviews for those positions. We have 
processed hundreds and hundreds of increases in nurse locality 
pay schedule changes. There are changes being made across the 
system. We are working through some issues with our systems, 
our IT systems, to make sure that we can process them timely. 
We are seeing hundreds and hundreds of schedules increase 
across the enterprise. We are happy to provide you with that 
data.
    Ms. Brownley. Very good. It is just I feel as though we 
have given--this committee has given the VA a lot of tools and 
sometimes those tools are underutilized to get to the goals 
that we are trying to get to.
    Thank you. I yield back.
    Ms. Kiggans. Thank you, Ranking Member Brownley.
    I now recognize Ranking Member Mrvan for any questions he 
may have.
    Mr. Mrvan. Thank you chairwoman.
    Ms. Therit mentioned in her opening statement that the VA 
has increased utilization of recruitment and retention 
incentives. Can you qualify this in some way, either in terms 
of dollars or numbers of employees receiving incentives? 
Congress provided many new authorities under the Choice Act, 
the VA Accountability Act and the Mission Act and the PACT Act, 
but we have not seen any data on the extent of which the VA is 
using all these authorities.
    Ms. Therit. Ranking Member Mrvan, I mentioned the dashboard 
that we are developing, which you will see at the end of the 
month.
    In terms of recruitment and retention incentive 
utilization, the latest report that I had seen is that we have 
tripled our use of recruitment incentives from last year, same 
time last year to this time this year, which is about 2,000 
compared to about 6,000 at this point in time.
    With respect to the retention incentives, we have been 
using them, about 10,000, I think, last year and over 20,000 
this year.
    We can get you that data, but we are seeing changes and 
increases by those authorities that we have been given and how 
we have been able to utilize them.
    Mr. Mrvan. Thank you.
    Ms. Bonjorni, Ranking Member Browning asked a specific 
question about marketing. In my simple terms, very often when I 
have been out and about, people collect data on how they hear 
about them on social platforms or TV advertisements, as you 
mentioned. Do you have the data of the new hirees and how they 
hear about it? What is the most impactful platform you are 
using in order to get to the most qualified candidates and 
those that have longevity?
    Ms. Bonjorni. Sure. We do collect that data in our entrance 
surveys, which we are currently revising to try to get more 
robust information. People do hear about us through 
advertising, but they are more likely to hear about us through 
word of mouth, or that they trained at some point in a VA 
facility. That is the more likely path that we have people 
coming.
    Mr. Mrvan. If someone trains in a VA facility, what 
processes are in place to recruit them for permanent 
employment?
    Ms. Bonjorni. At local facilities they are able to go ahead 
and make offers to people. One of the things that we have found 
is that there is often confusion about the ability to make an 
offer to someone who is not quite done with their training yet. 
We have embarked upon a comprehensive training program for HR 
staff and others to make sure they understand they can make an 
offer that is contingent upon someone completing their full 
professional training. We also host trainee recruitment events 
that match people across the country to opportunities. If they 
trained at one facility but might want to work elsewhere, we 
match them across clinical specialties to help them find those 
opportunities.
    Mr. Mrvan. What is the contributing factor that leads to 
that confusion?
    Ms. Bonjorni. The complexity of our personnel systems.
    Mr. Mrvan. Please expand upon that.
    Ms. Bonjorni. Sure. It is because people often normally 
when you post a job for federal employment, you have to meet 
all of the qualifications for that job before you can be 
considered eligible. In the case of a clinical provider who has 
not fully completed their education, we can make them an offer 
contingent on them getting all of their licensure finalized. We 
are able to do it it is just not what is typical in when we are 
doing other hiring.
    Mr. Mrvan. Is that legislative or is that procedural that 
is causing that confusion about when they can make the offer?
    Ms. Bonjorni. I think it is procedural. It is a practice 
confusion, yes.
    Mr. Mrvan. Is there a way to change that practice?
    Ms. Bonjorni. Through training and education, we are trying 
to clarify for folks that they can make the offer.
    Mr. Mrvan. Has the policy changed to make the procedure 
easier?
    Ms. Bonjorni. There is no policy change that is required to 
do it. It is more of an internal practice. There is another 
factor that impacts this, which is that holding a position 
open, for example, making a job offer to someone who will not 
start for 1 year from now is not typically how people make 
offers. As part of our hire, faster, and more competitively 
priority action that we are working on in VHA, we are working 
to improve the frequency with which we recruit proactively. 
Before we have a vacancy, we are trying to recruit for 
positions before they actually are vacant and unencumbered. 
This is an education effort again to get us there.
    Mr. Mrvan. Okay, If there is a HR shortage, or not a lot of 
HR employees or a reduction in that workforce, as you are 
bringing people on, are they being trained on that new policy 
in order to recruit people a year out?
    Ms. Bonjorni. Yes. There has been a shortage in the past of 
HR professionals. I would not characterize it as a shortage now 
in VHA. We grew the HR workforce by 17 percent last fiscal 
year. This year we are investing in our HR Star Recruitment and 
Internship program where we are hiring 1,000 new HR 
professionals and putting them through a year-long training 
program to make sure when they start in their new roles, they 
know exactly what they need to be doing.
    Mr. Mrvan. I think what we discovered just through our 
dialog is there are policies and internal practices that are in 
place that are contradicting the easiness in order to offer 
jobs to medical providers who are interning, which you had said 
is the major source or pipeline. If we can eliminate that, you 
would think logically then we would increase the number of 
individuals who may be enticed to work for us.
    If there is any way legislatively we can work with you to 
do that, please let us know.
    Ms. Bonjorni. Absolutely. Will do.
    Mr. Mrvan. With that, I yield back.
    Ms. Kiggans. Thank you, Ranking Member Mrvan. I now 
recognize Dr. Murphy for 5 minutes.
    Mr. Murphy. Thank you, Madam Chairman. Thanks, guys, for 
coming today.
    This is a big issue. It is not only a big issue for the VA, 
it is a national issue. One in seven of my constituents are 
veterans. It is a really big number in that particular 
district. PACT Act, I was going to say, did not make anything 
any easier on anybody. It sure made it harder, for good 
reasons. Again, thinking ahead, knowing this big huge influx 
would occur, I think we honestly could have done a better--
little bit better job anticipating that, but anticipation is 
not one of the things that Congress does very, very well.
    Major competition today for doctors and nurses. We saw 
during the pandemic that travel nurses became a disrupter, as 
it were. I always want people to earn as much as they can, but 
the fact they did this so much in the private world, it 
absolutely disrupted how people pay structures. I want to go 
down that alley. I think Representative Brownley really brought 
up some good parts about marketing, and I am going to get to 
those in just a second. Can someone answer to me how travel 
nurses were dealt with during that era? If they have to be 
federally employed and you have to go through this many hoops 
just to get them in the private world, how was that dealt with 
during the pandemic.
    Ms. Bonjorni. Specifically us recruiting for travel nurses?
    Mr. Murphy. No, I mean, if you need nurses, you want to 
recruit travel nurses. If we are talking about this absolute 
ridiculous bureaucracy that people have to go through to get 
hired by the VA, how did you guys do it during the pandemic?
    Ms. Bonjorni. A couple of different pathways. We have our 
own internal travel nurse group that follows the normal hiring 
process that we use in VHA, but we had a focused attention on 
bringing them on board, especially at the beginning of the 
pandemic, so that we could source them out to different 
locations. We were tracking what was going on with those hires 
every single day. We also are able to use clinical staffing 
contracts at the local level if we need to have a contracted 
nurse to provide some temporary relief when we can not staff.
    Mr. Murphy. This is where I am just trying to get to. We 
did things well during the pandemic in cutting down the 
bureaucracy. There is absolutely no reason we have to go 
backward and go back into the--embrace the bureaucracy.
    I am told that it is 9 months to hire somebody.
    Ms. Silas, did you say something about 3 months?
    Ms. Silas. Yes.
    Mr. Murphy. What is the discrepancy here? I am not sure I 
understood.
    Ms. Silas. It could be that the data that I am citing is 
from a report that has been, like, 6 months since has been 
released.
    Mr. Murphy. Okay.
    Ms. Silas. I do not know if they have made some updates.
    Mr. Murphy. I will tell you at my institution where I work, 
if I hire a physician or something, getting them in the door, 
getting all their licensure, and all that other stuff is 4 
months. Why on earth would it take the VA 9 months? Why does 
government always have to be so much more bureaucratic?
    I know you pointed out to 83 of those things. It sounds 
like we need to get rid of, like, 82 of them.
    Ms. Bonjorni. We would like to get rid of a solid number of 
them. There are things that we did during the early days of the 
pandemic that we would like to be able to replicate. Some of 
those will require legislative change or continued work with 
our partners at other agencies to get some of the pre-
employment tasks shifted to later in the process. Then there 
are, of course, expedited or emergency authorities we have that 
we always have related to credentialing, for example, but you 
have to be in an emergency situation to use that.
    Mr. Murphy. Right. Well, I am sorry, I think taking care of 
people, especially with mental health patients, is an 
emergency. We are seeing an absolute explosion with mental 
health needs from things that occur because of the pandemic and 
occurred during the pandemic. That is not getting any better 
whatsoever. The private sector is bleeding for people to come 
in and do mental health, especially in our kids, which has not 
affected quite the VA quite yet.
    I will just reiterate Representative Brownley's comments 
about marketing. Do not be a passive marketer, because when 
there is such a dearth of individuals, you have to be an active 
marketer. I have got a lot of gray hair. I still practice, but 
all I hear is burnout, burnout, burnout from my fellow 
physicians. With the regulation, what--this government loves to 
pour on regulation in medicine, we are the most highly 
regulated industry. If you guys could reach out to the 55 and 
older group of physicians, do not let them retire. Do not let 
them go off into the blue yonder because doctors do not do very 
well in retirement. Seek them out. Go into the American 
Neurologic Society, go into these other societies. Putting 
something on a board for people to seek out, it is just like 
checking a box. It is not being in active pursuit of people.
    I think there is also a patriotic duty of physicians that 
want to serve veterans and want to do it well. But there is 
also just after 55, 60 years of standing up in the operating 
room, we get old. Going out for a VA and when trying to 
actively pursue individuals for all these different fields, can 
not be passive. That is what government bureaucracy does, it is 
passive. You have got to be active to get those individuals.
    Thank you, Mr. Chairman. I will yield back.
    Ms. Kiggans. Thank you, Dr. Murphy.
    Now, Mr. Deluzio, you have 5 minutes for your questions.
    Mr. Deluzio. Thank you, Madam Chair.
    Good morning, everyone. Thank you for being here.
    I will pick up on many of the good comments from my 
colleagues about this being Police Week and the importance to 
focus on law enforcement within the VA as well. My 
understanding of the thousands of VA police officers, roughly 
90 percent of them are veterans themselves.
    In July 2021, before this subcommittee, before my time, VA 
testified that granting 6C benefits, including early retirement 
for officers and enhanced law enforcement pension, would help 
with some of the VA police officer retention problems. While 
not within the jurisdiction here, many of us, including myself, 
Chair Bost, Ranking Member Takano, my colleagues here today, 
support the Law Enforcement Officers Equity Act. Ms. Therit, I 
appreciate you sharing today VA's support there as well. I 
would ask if the VA's looked at granting some of these benefits 
to these officers administratively rather than waiting on a 
legislative fix?
    Ms. Therit. Congressman, thank you for that question.
    Up until this point, we have had to follow the Office of 
Personnel Management regulations to be able to grant 6C 
retirement benefits. Typically that is classifying a rigorous 
Police Department (PD), which is often our 1811 series criminal 
investigator positions, and then having law enforcement as a 
secondary. We have individuals within the Department of 
Veterans Affairs today currently receiving 6C retirement 
benefits. It is a very small scale in terms of the numbers 
because of the way we have to follow the regulation to provide 
those benefits to our workforce.
    Mr. Deluzio. You think there is not additional room for you 
to maneuver administratively short of action from Congress?
    Ms. Therit. That is correct.
    Mr. Deluzio. Okay.
    Was hoping you could talk a bit about the specialized, 
unique nature of the work these VA police officers undertake 
related--I am thinking about crisis intervention training, the 
importance of having a special understanding of how to interact 
well with veterans. Again, since so many, roughly 90 percent or 
so are veterans themselves, I would think that would be a great 
benefit they bring to this work. I am curious how you see it.
    Ms. Therit. I will offer two thoughts and then ask Ms. 
Bonjorni for any input that she has.
    We have our law enforcement training center in Little Rock, 
Arkansas, and we have a very rigorous curriculum that is 
focused on the type of work our police officers experience in 
the medical centers. I think that is one thing that helps us to 
stand out and focus on the types of skills and training that 
our officers need.
    The other thing that we have talked about internally, and I 
know Ranking Member Brownley mentioned this, are three 
personnel systems. Currently, police officers fall under that 
Title 5 system. When you are working at a VHA medical facility, 
you need some of that healthcare background, you need some of 
that knowledge of clinical skills. Looking at better ways to 
both recruit and retain, if we are able to use some of those 
Title 38 authorities for our police officers for things that we 
are exploring.
    Ms. Bonjorni. Sure. The only other thing I would add is I 
think you are right on point. We do provide additional training 
to all of our staff about suicide prevention and their role in 
that. I think that is maybe also a unique thing that our police 
officers need to be aware of, given how they oversee our VA 
campuses and the challenges that we have on them.
    Mr. Deluzio. Thank you.
    Changing topics here for the last little bit of time I 
have, thinking about some of the new PACT Act authorities that 
VA has. My understanding now is there is additional authority 
to buy out service contracts in rural facilities, essentially 
in non-VA facilities, physicians, nurse, anesthetists, nurse 
practitioners, and others in exchange for employment at VA 
facilities. What has the VA been doing? Has this been an 
effective tool? Are we utilizing it? Could more be done? Where 
are things within the VA there?
    Ms. Bonjorni. Well, we are excited to use the tool. We were 
just able to work out all the details in publishing the policy 
within the last 6 weeks or so. It is rolled out to facilities. 
They are asking a lot of questions about how it should work. We 
will be able to report back, I think, in a few months how 
effective it is been. It is just rolled out.
    Mr. Deluzio. Great. Okay. Thank you.
    Madam Chair, I yield back.
    Ms. Kiggans. Thank you very much, Mr. Deluzio.
    I now recognize Mr. Bergman for 5 minutes.
    Mr. Bergman. Thank you, Madam Chairwoman.
    Anybody in a leadership role and you are tasked with 
leading an organization, making decisions, those decisions are 
only going to be as good as the data you have. Anybody, any of 
you on the panel want to say, are you confident that the data 
that you have in making everything from the hiring process to 
the accreditation process to all of the different processes--
again, this is--I would like a personal opinion from each of 
you--is the data that you are working from accurate?
    Ms. Bonjorni. I will offer a personal opinion. The answer 
is it depends. Some of our data we feel very comfortable with. 
Data that we report on, what is going on, with the number of 
hires and the number of employees that we have on board, we 
feel comfortable with. Our hiring process. Data needs to be 
improved. As GAO has found, we have many opportunities to have 
better tracking of what is going on in each stage of the 
process.
    Mr. Bergman. Okay, so good. I do not want to cut you short 
here, because time does move on, but I appreciate your answer, 
because I was listening in your opening statement, this is 83 
steps. I think Dr. Murphy already mentioned that, 83 steps in 
the VA hiring process, 12 of which are legislatively imposed. 
Did I get that number right?
    Ms. Bonjorni. Twelve of which that we think need to be 
changed with legislation. They are more than that were 
legislatively imposed.
    Mr. Bergman. How many would you say of those 83 steps are 
currently legislatively imposed?
    Ms. Bonjorni. I would have to get back to you with that 
number.
    Mr. Bergman. I mean is it a big number, little--just say 
big, little, medium.
    Ms. Bonjorni. Probably half, because some of them are 
broadly legislative or----
    Mr. Bergman. We as legislators are part of the problem?
    Ms. Bonjorni. I think we have opportunities to work 
together to improve.
    Mr. Bergman. Well, the point is, is that you are trying to 
do the right thing, we are trying to do the right thing, but if 
we, as legislators are providing too much input, tell us. Okay? 
We are going to tell you. We are trying to do the best we can, 
but we need the accuracy of the data so that we can say, you 
know what, we should not be dealing with this issue because the 
VA leadership under Secretary McDonough is trying very hard, 
from what I see. Okay, but again, we are all in the same 
symphony here. One is the drum section, one is the woodwinds, 
one is the whatever it is, but we all have to play our part to 
get this right.
    If you could take the list of requirements for a Federal 
job, to apply for a Federal job, all the requirements that you 
have, could you take that list and X out some of them? Okay. I 
would like you all to just take a list of the requirements and 
just take a line and put them through them and give us a copy. 
Okay? They are imposed by one of two areas, they are imposed by 
us legislatively, or they are imposed by some good idea within 
the bureaucracy.
    Oh, by the way, I have studied and worked in and created 
and dismantled bureaucracies for a 50 plus year timeframe. 
There is a need for a good bureaucracy, but not a bureaucracy 
that makes its own decisions on its own criteria. You in the 
leadership role, us in the leadership role up here, we are the 
leaders. I appreciate everything that you all are trying to do, 
but again, you are dealing with a Marine. My other service 
members, service applauded and accepted, we tend to get to the 
heart of the matter quickly because we want to put steel on 
target. In this case, we want to put people in jobs, so 
qualified people to serve our veterans.
    With that, madam, I yield back.
    Ms. Kiggans. Thank you so much.
    I now recognize Ms. Budzinski for 5 minutes.
    Ms. Budzinski. Thank you, Madam Chair and ranking member.
    Maybe just adding on a little bit about these 80 steps and 
the possibility of maybe eliminating some of them. Just one of 
the questions. When you talk about re-engineering the hiring 
process, you mentioned delaying or deferring certain of these 
tasks. Could not some of the tasks actually just happen 
concurrently, i.e., some of those 80 steps of the process that 
Ms. Bonjorni mentioned. It seems like delaying or deferring 
those would probably do little to actually shortening the 
process.
    Ms. Bonjorni. Yes. There are many tasks that are happening 
concurrently. I think some of the challenges we have is there 
are a variety of checks that have to happen and vetting steps 
that have to occur that have to go through different places, 
different people have to do them, and they are not centrally 
managed in one IT system. That is where, in the hand off of 
those processes, we lose some time.
    I do not know, Tracey, if you want to add to that.
    Ms. Therit. I was going to amplify that concurrently is a 
challenge because of the different offices that are involved 
and trying to make sure that we are all connected through the 
same IT system to be able to see that everything was done by 
that point in time.
    Absolutely, I think it goes to General Bergman's comment 
that we really need to look at what is happening at each step 
in the process and where we have increased the bureaucracy. The 
title of this hearing, reduce that bureaucracy or eliminate it 
completely where possible.
    Ms. Budzinski. Okay, great.
    I am going to shift gears a little bit. A question 
specifically more related to my district, which is a pretty 
rural district in central Illinois. I share a lot of the 
concerns that my colleagues on this committee have talked about 
related to workforce. I am though happy to see that the VHA has 
experienced the highest growth rate in workforce in more than 
20 years. I am specifically wondering if this growth has been 
really realized in rural communities from an access standpoint. 
The VA often struggles to hire and retain qualified clinicians 
in rural areas to work in specialized specializations such as 
emergency care. We talk a lot about mental health, obviously, 
Intensive Care Units (ICUs). For this reason I have actually 
helped to lead on a bipartisan initiative called the Rural 
Health Care Act, which is really an attempt to help not just 
when we are training medical professionals, but we have trained 
them, but then get them to stay in our rural communities. If 
they stay for 5 years, then we help them with some of their 
student loan, provide some debt relief.
    I understand the VHA is also working on student loan 
forgiveness incentives. In February 2022, Secretary McDonough 
unveiled funding for scholarship programs and loan forgiveness 
as a part of his ten major steps in supporting VA's workforce. 
Additionally, the PACT Act included a provision that increased 
loan repayment limits, but the VA has been able to really fully 
utilize this provision due to insufficient HR support and 
paperwork processing issues.
    I guess my question, maybe for Ms. Therit and then open it 
up to Ms. Bonjorni too, is two parts. What are some of the 
steps VHA is taking to recruit and retain top talent, 
specifically in rural areas? Then second, how will VHA improve 
HR support to allow for the full use of retention initiatives 
such as student loan forgiveness programs?
    Ms. Bonjorni. Thank you for the question.
    I do think this is a really critical area for us to focus 
on. I can say historically we know that our turnover in rural 
facilities is slightly higher than it is across the rest of the 
country. We saw that change during the pandemic. While our 
turnover continued to go up across the Nation, it actually 
stayed pretty flat in rural areas. We did see 3.6 percent 
growth this year so far. In rural areas, it is slightly higher 
3.8 percent. That is because our turnover has stayed pretty 
steady. We are improving there. We are allocating additional 
dollars for our recruitment marketing budget, an additional 
million dollars directly targeted at rural areas this year so 
that we can make sure we get more information out there, more 
imprint, so people see what we are recruiting for. Then of 
course, implementing the two sections of the PACT Act that 
really are focused on rural recruitment, the contract buyout 
and then the national plan is in development right now. We 
expect we will have a draft early this summer. It is not due 
for a while, but we are working on that to make sure we are 
really having strategies for HR staff and hiring managers on 
what they really should focus on in rural areas.
    Ms. Budzinski. Thank you. I appreciate that focus on those 
rural parts of our country for our veterans.
    I will go ahead and yield back. Thank you.
    Ms. Kiggans. Thank you, Ms. Budzinski.
    The chair now recognizes Ms. Radewagen for 5 minutes.
    Ms. Radewagen. I want to thank Chairwomen Kiggans and 
Miller-Meeks, Ranking Members Brownley and Mrvan for holding 
this hearing today. I want to thank you, the witnesses, for 
being here to testify.
    I do appreciate joint hearings like this, and today's 
hearing covers a very important issue. Staffing and retention 
are particularly difficult in rural and remote areas like my 
home district, as my colleague has just mentioned. I appreciate 
my colleagues for coming together to address the problem.
    Ms. Therit, in 2020, a GAO report mentioned that most VA 
facilities did not have recommended administrative and clinical 
staff needed to support the Community Care program. What has VA 
since then done to address the recruitments and retention 
challenges for this critical function? Do you believe that 
veterans access to timely care has been impacted by the 
staffing challenge?
    Ms. Therit. Congresswoman Radewagen, I am going to ask Ms. 
Bonjorni to speak on the VHA question.
    Ms. Bonjorni. Sure. Based on the feedback from the GAO 
report and our own review, we recognize that we need to enhance 
our staffing projections and models for the Community Care 
program. In particular, the position that gets the most 
attention is the medical support assistant. We have seen 
continued year over year, positive growth in that position, 
however, challenges remain in trying to recruit for a role that 
really comes in at the entry level. Our salaries are not as 
competitive as they need to be for those key positions. That is 
the first person veterans see when they come into a facility 
and the first person, usually, they talk to on the phone, and 
so we are exploring new options for strengthening that 
position. I think a long term solution for us is going to be a 
revision to our personnel system in order to make those 
positions more competitive.
    Ms. Radewagen. Ms. Silas, would you care to comment on VA's 
response?
    Ms. Silas. I am really very pleased to hear Ms. Bonjorni's 
response. As I mentioned in my statement, we have been looking 
at the Community Care program for a number of years now, and 
even when we are not focused on the staffing resource issues, 
it still comes up as an issue and a concern, especially how it 
impacts facilities' ability to meet timeliness standards. We 
think it is a very important recommendation. It has been open 
since 2020, and so I am very happy to hear VA's response to 
your question.
    Ms. Radewagen. Ms. Silas, has GAO done any work on HR Smart 
and the reliability of VA's data systems that the Agency uses 
to manage its hiring and onboarding processes?
    Ms. Silas. We have not conducted a specific audit on HR 
Smart. However, as part of our work on high risk, we just 
issued our high risk report last month, and that included 
information on veterans' health care. One of the things that 
the VA has done in terms of their action plan to address their 
high risk status is to create some goals that are related to 
the implementation and kind of oversight of HR Smart.
    One of the examples I can provide you is that they had set 
up a goal to develop internal controls to ensure the accuracy 
of HR Smart, and then they have also developed some metrics to 
measure that. I mean, one of the things that we noted, the 
Comptroller General noted in testifying about high risk last 
month, was that we still are looking to see some more details 
and more specific metrics related to the goals in the action 
plan. I think this overall would be very helpful in us being 
able to kind of oversee and understand the progress that VA is 
making with not only using HR Smart for their human resources 
management, but also with their HR modernization.
    Ms. Radewagen. I have a couple of tiny questions here I 
want to just squeeze in.
    Based on your work, does VA have sufficient and reliable 
data to determine whether its staffing efforts are sufficient? 
Does GAO have prior work evaluating VA's HR modernization 
efforts? If not, would GAO consider conducting an evaluation on 
this topic if the subcommittee requested it?
    Ms. Silas. We are always happy to do additional work for 
the committee. We have not looked at HR modernization 
comprehensively, but I did in my statement, talk about VA's 
onboarding staffing module, the USA Staffing, which is part of 
their HR modernization effort, to try to have consistent and 
standardized information to monitor onboarding staff. Based on 
that review, as I noted in my statement, we found that the data 
was unreliable. That was because there was not a comprehensive 
policy that required all staff to use USA Staffing to input 
information about onboarding tasks and when they were 
completed, and also that there was not guidance for staff in 
terms of inputting the information and the data accurately.
    Ms. Radewagen. Thank you, Madam Chair.
    I yield.
    Ms. Kiggans. Thank you, Ms. Radewagen.
    On behalf of both subcommittees, I thank you all for your 
testimony today and for joining us. You three are now excused, 
and we will wait for a moment as the second panel comes to the 
witness table.
    Thank you so much.
    Ms. Kiggans. Welcome, everyone. Thank you for your 
participation today. We have our second panel in place. On our 
second panel, we have Ms. Kelley Saindon, the chairman of the 
Legislative Committee of the Nurses Organization of Veteran 
Affairs (NOVA), we have Dr. Robyn Begley, the chief executive 
officer of the American Association for Nursing Leadership and 
the chief nursing officer, senior vice president of Workforce 
for the American Hospital Association (AHA), we have Ms. Mary 
Jane Burke, the first executive vice president of American 
Federation of Government Employees (AFGE), National Veterans 
Affairs Council, and we have Ms. Cary Grace, the president and 
chief executive officer of AMN Healthcare Services.
    Ms. Saindon, you are now recognized for 5 minutes to 
deliver your opening statement.

                  STATEMENT OF KELLEY SAINDON

    Ms. Saindon. Chairmen Miller-Meeks and Kiggans, Ranking and 
Members Brownley and Mrvan, and members of the subcommittees, 
on behalf of nearly 3,000 members of the Nurses Organization of 
Veteran Affairs, thank you for allowing us an opportunity to 
present our views on today's topics, ``VHA Recruitment and 
Retention: Is Bureaucracy Holding Back a Quality Workforce?''
    My name is Kelley Saindon. I am a member of NOVA's board of 
directors, chairman of the legislative committee, and the nurse 
executive of White River Junction VA Healthcare System in 
Vermont. Our written statement has been provided. I will 
discuss a few critical issues that need attention.
    NOVA is a professional organization for nurses employed by 
the Department of Veteran Affairs. The opinions provided here 
are not that of the VA, but of that of our members, who are 
nurse managers, frontline, and specialty healthcare 
professionals taking care of our veterans at facilities around 
the country.
    I want to begin by thanking the committee for its support 
of the VA workforce and its work on several legislative 
packages that have provided the VA with various tools needed to 
address hiring and retention. Congressional authorities, like 
those found in the RAISE Act, Title 9 of the PACT Act, provide 
a broad range of pay flexibility to help VHA recruit and retain 
quality candidates. It may be too soon to see if these will be 
effective and help in recruitment and retention efforts, 
however, we believe they can and will help.
    Although these authorities are generous, challenges remain 
as hearing delays and length of time to onboard new staff 
remains high. If there is one major bureaucratic challenge to 
emphasize it is the VHA hiring process is antiquated and 
noncompetitive. One issue that NOVA has highlighted in its 2023 
legislative priority goals is HR modernization. It remains a 
centralized system that separates the staffing specialists from 
their customers. Without knowledge of the facility and its 
needs, hiring managers and others are left to do the legwork, 
which pulls them away from their more critical clinical duties. 
It is our understanding that there are supposed to be HR 
leaders working at every facility that help serve as a liaison 
between the virtual or centralized HR and the medical center. 
Severe shortages among HR staff, particularly HR specialists, 
who are responsible for helping recruit, retain, and onboard 
employees, has led to an inability to provide quick responses 
or timely turnaround in many aspects of the hiring process. 
This leads to qualified candidates taking other positions 
outside of the VHA system.
    The private sector can tender an offer on the day of an 
interview. VA takes months to extend offers. They will not and 
cannot begin to compete when the hiring goal is 120 days. 
During the pandemic, VA employed expedited hiring practices 
which allowed for more timely application and quicker 
onboarding. VA was able to hire within weeks rather than 
months. NOVA believes a comprehensive review of these processes 
should be considered, studied, and used to increase efficacy 
and speed of hiring process.
    The VHA workforce needs major reform regarding pay. In many 
areas of the country, VA cannot compete with private sector 
wages. VA must be able to compete with the private sector to 
maintain safe staffing levels and provide the highest quality 
of care for veterans. NOVA members report that a balance of 
competitive pay and scheduling flexibility is necessary in 
hiring strong, committed nursing staff. As the only 
professional organization for nurses in the VA, we continue to 
monitor the Department's progress in developing staffing models 
and position descriptions for each VHA occupation.
    We want to advise that an expedited VA concurrence process 
for handbooks and policies that require approval takes too 
long. Average turnaround time is approximately 18 months from 
initiation to concurrence. VA must be able to recruit and 
retain a valuable workforce without barriers to hiring that 
impede their ability to compete with other healthcare systems.
    A strong workforce is at the heart of ensuring that our 
Nation's veterans can continue to receive the highest quality 
of care that they have earned and deserve. NOVA remains 
committed to providing that care.
    Thank you again for inviting us to present our views on VHA 
recruitment and retention. I am happy to answer any questions 
that you may have.

    [The Prepared Statement Of Kelley Saindon Appears In The 
Appendix]

    Ms. Kiggans. Thank you very much. First, I want to 
apologize to Mr. Morse. You are certainly not Ms. Carrie Grace.
    Mr. Morse. It is quite a compliment, though, it is quite a 
compliment, I might add.
    Ms. Kiggans. Mr. Morse is the corporate vice president----
    Mr. Morse. I am sure I will be getting a text later.
    Ms. Kiggans. Sorry about that.
    Mr. Morse. No worries.
    Ms. Kiggans. The corporate vice president of Solution, 
Design, and Sales for AMN Healthcare.
    Mr. Morse, if you would like to, you are recognized for 
your 5 minutes to deliver your opening statement.

                    STATEMENT OF WILL MORSE

    Mr. Morse. Thank you so much. It is such an honor, true 
honor to be here today.
    I would first like to thank Dr. Miller-Meeks, chairwoman of 
the Committee on Veterans; Affairs, the Subcommittee of Health, 
and of course, Honorable Jen Kiggans, chairwoman of the 
Subcommittee of Oversight and Investigation. Thank you for this 
opportunity to submit our statement of record.
    Established in 1985, AMN Healthcare is the largest publicly 
traded workforce management staffing and technology 
organization in the United States. We have had the honor of 
partnering with thousands of private sector, not for profit, 
and community hospitals around the country, as well as numerous 
VHA facilities.
    Before I start to comment on the VHA recruiting retention 
process, I would like to briefly talk a little bit about the 
healthcare staffing market conditions. Today, the healthcare 
workforce staffing takes place within the context of a worker 
shortage, and this has been endemic for us in the industry for 
years now. What is new is the spiking volatility in the 
existing workforce. The COVID-19 pandemic saw a societal shift 
in how workers view their relationship with employment and 
reassessing how and when and where they work. The resulting 
great resignation has seen hundreds of thousands of healthcare 
workers leave their jobs, and those worker shortages and 
turnover and increased competition has created one of the most 
competitive healthcare recruiting environments we have seen in 
recent memory.
    Many healthcare organizations are now reassessing the 
staffing practices to better align with the evolving market 
realities. The VHA is certainly not alone in self evaluating 
its ability to recruit and retain a quality workforce, and it 
should be commended for doing so.
    That said, in our work with VHA facilities, AMN healthcare 
in our divisions has encountered several reoccurring challenges 
that have been impeded our ability to recruit medical 
professionals. The first and most important is the recruiting 
process itself. Given the current market conditions there is a 
need for a sense of urgency and agility to make recruitment a 
success. Healthcare professionals that are recruited into the 
VHA are oftentimes getting multiple offers from multiple 
organizations. Without a really accelerated, standard, timely 
method of screening, interviewing, credentialing, and 
responding to candidates, the VHA is losing qualified 
candidates to more efficient systems that are in place. 
Furthermore, the majority of VHA facilities that we have worked 
with still remain hindered, as mentioned in the earlier panel, 
from a long process that candidates who have actually already 
been selected for employment go through in terms of laborious 
security and bureaucratic requirement gathering. That hiring 
process time for VHA facilities often runs as long as 6 months 
compared to 4 weeks in the private sector.
    We have also noticed strategic staffing challenges. For 
example, the VHA uses temporary physicians known as locum 
tenens, which is a great service, but sometimes it can be 
overutilized and become expensive and therefore distract from 
actually important recruitment of perm physicians. We have 
noticed that sometimes the Request for Proposal (RFP) and 
contracting process can be an additional impediment to the 
efficient recruiting, and once the solicitation closes, it 
often takes months for the contract to be awarded, and it 
results in candidates losing interest or the candidate pipeline 
evaporating.
    That said, healthcare facilities nationwide are adapting 
new technologies and methods to really streamline their 
recruiting process, and we know the VHA is working very hard on 
adopting some of those. Some of those examples we have seen in 
the marketplace are predictive analytics and technologies and 
proactive workforce planning. Advances in technology allow 
healthcare facilities to actually accurately project the right 
staffing mix between permanent and contingent labor based on 
patient care, demand and analytics, and this helps produce a 
more balanced scheduling system, improved retention, integrated 
staffing plans, while lowering labor cost. We have also seen 
the advent of mobile digital staffing apps such as AMN's 
Passport apps, which actually take artificial intelligence to 
automatically connect candidates to open positions to allow 
them to leave their application and submit to a job within 
minutes, if not under a day. Online automation in the form of 
virtual credentialing wallets and onboarding have also 
standardized and streamlined and reduced the credentialing and 
onboarding times from months to days.
    Ultimately, what are the employment flexibility offerings 
to medical professionals? The growing number of hospitals are 
now offering flexible arrangements such as internal agencies 
and internal float pools to give medical personnel a more 
choice and more employment options.
    The one important positive note, which I know Ms. Brownley 
indicated earlier, is that the VHA typically does have job 
characteristics that are really compelling to medical 
professionals, including the set hours, the generous vacation 
time, security in government employment, and the rewarding 
sense of mission that comes with helping our Nation's veterans. 
In our experience, these features attract numerous mission 
driven candidates. They are out there. The challenge for VHA is 
to make their value proposition better known and to evangelize 
their culture to candidates.
    In closing, the entire healthcare industry is putting 
renewed priority on addressing personnel shortages, and 
therefore, it is a really opportune time for the VHA to respond 
to these pervasive challenges.
    Thank you for the time. I welcome questions.

    [The Prepared Statement Of Will Morse Appears In The 
Appendix]

    Ms. Kiggans. Thank you very much, Mr. Morse.
    Ms. Begley, you are now recognized for 5 minutes to deliver 
your opening statement.

                   STATEMENT OF ROBYN BEGLEY

    Ms. Begley. Chairwoman Kiggans, Ranking Members Brownley 
and Mrvan, and distinguished members of the subcommittee, I am 
Robyn Begley, senior vice president of workforce and Chief 
Nursing Officer at the American Hospital Association. I also 
serve as Chief Executive Officer (CEO) of the American 
Organization for Nursing Leadership, and I am proud to say that 
this week I celebrate my 46th anniversary as a nurse.
    On behalf of the AHA's, nearly 5,000 member hospitals and 
health systems, I appreciate the opportunity to testify today.
    A qualified and engaged and diverse workforce is at the 
heart of America's healthcare system. Healthcare workers often 
say that they feel a calling to serve patients, families, and 
communities. We see their dedication, selflessness, bravery, 
and compassion every day, whether it is taking care of the sick 
and injured or keeping people healthy. That has never been more 
evident than during the past 3 years battling COVID-19. 
However, long building structural changes in the healthcare 
workforce, combined with the profound toll of the pandemic, 
have left hospitals and health systems facing a national 
staffing emergency that could jeopardize access to quality 
equitable care for patients and communities. Simply put, our 
Nation cannot maintain access to high quality care without a 
strong healthcare workforce.
    A recent study estimated that 100,000 nurses left the 
workforce during the pandemic. In addition, this study showed 
that nearly 900,000 nurses, or 20 percent of the 4.5 million 
total registered nurses, intend or are considering leaving the 
workforce due to stress, burnout, and retirement. Hospitals 
also face similarly troubling trends for physicians and other 
healthcare providers and clinicians. Meanwhile, nurses, 
physicians and other staff on the front lines of healthcare are 
experiencing deeply troubling increases in violence.
    To address these challenges, hospitals and health systems 
across the country have taken many actions. These include 
collaborating to expand training opportunities, launching nurse 
and allied health professional education programs, re-imagining 
workforce models, investing in upskilling workers, and 
providing nontraditional support for healthcare workers. And I 
would like to give you a few examples.
    Mary Washington Healthcare in Virginia partners with 
Germanna Community College in an Earn While you Learn program. 
Mary Washington onboards groups of 60 nursing students, 2 
groups per year, who work 12 to 20 hours a week using a 
clinical rotation model. The program includes an additional 
nursing school as well as mentor models for nursing assistants, 
and they are exploring an apprenticeship model for other 
clinical roles as well. Pittsburgh based Allegheny Health 
Network launched Work Your Way, a mobile internal staffing 
model to provide flexible work life solutions for nurses, 
surgical techs, and others. This unique program allows health 
professionals the freedom and flexibility to choose how and 
when they can work. To fill the scores of medical assistant 
openings, Vanderbilt University Medical Center partnered with 
Nashville State Community College to train current employees, 
including truck drivers and environmental service staff. During 
training, workers continued to receive their full salary plus 
tuition reimbursement.
    Advances in technology also are driving creative solutions 
to workflows, workplaces, and teams. The broad adoption of 
telehealth is just one example how we improved where and how 
patients can access care. The innovative approaches that 
emerged during the pandemic provide an avenue to rethink care 
delivery, but these advances require continued regulatory 
flexibility and funding to continue.
    Finally, it is clear that our workforce challenges need 
immediate attention from all levels of government. Among other 
actions, Congress should protect healthcare workers from 
violence by passing the bipartisan Safety from Violence for 
Healthcare Employees or SAVE Act, which would provide Federal 
protections for healthcare workers against violence and 
intimidation. It would also would authorize much needed funding 
for additional staff training, security, technology, and other 
resources hospitals need to prevent violence and protect 
caregivers more effectively.
    Congress also should address nursing shortages by investing 
in nursing education and faculty, provide scholarships and loan 
repayment, re-authorize and increase funding for the National 
Health Service Corps, and increase graduate medical education 
slots.
    Thank you for this opportunity to testify. I look forward 
to your questions.

    [The Prepared Statement Of Robyn Begley Appears In The 
Appendix]

    Ms. Kiggans. Thank you very much, Dr. Begley.
    Now, Ms. Burke, you are recognized for 5 minutes for your 
opening statement.

                  STATEMENT OF MARY JANE BURKE

    Ms. Burke. Thank you, Chairman Miller-Meeks, Ranking Member 
Brownley, Chairwoman Kiggans, and Ranking Member Mrvan, and 
members of the Health and Oversight and Investigation 
Subcommittees. Thank you for inviting AFGE to participate in 
today's hearing.
    I am MJ Burke. I am the first vice president of AFGE's 
National VA Council, proudly representing 291,000 of our VA 
employees. I am also a practicing Physical Therapist (PT) at 
the Indianapolis VA in Indiana, and I consider my decision to 
work at VA as one of the best decisions I have made 
professionally.
    VA staffing shortages remain an ongoing concern. Pay and 
benefits that are comparable to what competing employers 
provide, improved HR processes, and a reasonable workload are 
all necessary to attract and retain a high caliber VA 
workforce.
    VHA has been inconsistent and nontransparent about 
implementing pay laws and policies designed to make clinicians 
pay competitive with the private sector. Physician market pay 
data is no longer required to be publicly reported in the 
Federal Register. This has facilitated a lack of transparency 
for medical directors. Our members report an indefensible level 
of variation in market pay for physicians. Performance pay 
distribution has also been inconsistent. In some facilities, 
physician performance pay functions as an optional retention 
bonus or award rather than what it is, it is salary for those 
who meet the requirements. Third-party locality surveys for 
registered nurses and physician assistants are not being 
executed transparently. Locality pay surveys should be 
triggered by factors such as turnover rates, resignations, and 
vacancies, but the inability to obtain information needed to 
calculate timely turnover vacancy rates makes it hard to 
determine whether the Agency is being compliant. Widespread 
human resource errors create further barriers to retention or 
recruitment and tarnish VA's reputation as a good faith 
employer.
    People accept job offers based on salaries, job duties, and 
schedules outlined in offer letters. When these differ from 
offer letters in reality, it is an injustice. These individuals 
may have given notice at previous job, declined competing 
offers, relocated, based on erroneous HR offers. To make 
matters worse, these employees can be hit with debt letters, 
meaning the Department will claw back money. Congressional 
oversight is needed.
    VA needs better training and HR coding within the 
Department, 38 U.S.C. 7422, which disallows employees from 
using grievance procedures from a collective bargaining 
agreement for issues related to compensations limits redress 
for many of these problems. Citing the inability to grieve 
compensation under 7422 as a complete bar for obtaining 
information about locality pay surveys mandated under 38 U.S.C. 
7451 is not helpful.
    Finally, VA staffing shortages are driving longer hours for 
clinicians. Unworkable bookable hour standards, too many 
patients, and unpredictable shifts and days off will not help 
recruitment and retention efforts. To fix these problems, AFGE 
recommends VHA provide HR officials with proper training to 
code VHA personnel records and mandate after action plans for 
errors. VHA should make third-party locality pay surveys more 
accessible to employee representatives. Employee 
representatives should receive the same training and locality 
pay survey as managers receive. Congress should enact H.R. 543, 
Continuing Professional Education (CPE) Modernization Act, 
which passed the committee last Congress in a bipartisan vote, 
would increase the eligibility for clinicians to receive CPE, 
increase the reimbursement amount, and adjust the amount for 
inflation.
    Employee representatives needs access to routine 
information about nursing hours per patient day, turnover 
rates, vacancy, and the maximum number of people to be allowed 
for a specific unit. We should not have to file grievances or 
information requests to get this critical information. VA 
should regularly report information about VA specialties that 
conduct physician market pay evaluations and include whether 
the adjustment was made. VHA should change scheduling policies 
so that they are sustainable. VHA should develop staffing 
requirement for high risk individuals with service-connected 
mental health problems. The length of time and frequency for 
follow up visits needs congressional oversight.
    Congress should amend 7422 to allow full collective 
bargaining rights for Title 38, including the ability to grieve 
VA's own violation of pay policies. Congress should have passed 
H.R. 1322, the Law Enforcement Officer (LEO) Act, to give VA 
police full law enforcement benefits.
    Thank you for giving me the opportunity to testify at 
today's hearing, and I look forward to answering any of the 
questions you may have.

    [The Prepared Statement Of Mary Jane Burke Appears In The 
Appendix]

    Ms. Kiggans. Thank you so much, Ms. Burke
    I yield to myself for 5 minutes for questions.
    Mr. Morse, you mentioned things like flexibility for 
employees, and some of you talked about work life solutions. 
Just thinking back to when I was looking at jobs at the VA. I 
mean, are we offering those flexible solutions? I think of 
especially military spouses who want to work or veterans, any 
candidate, really. I mean, there are a lot of moms and dads 
that have children, they want part-time options, they want 
those flexible ways. There was not a lot. My job at the VA was 
the first time I worked full-time as a nurse practitioner. I 
had four children and a husband that was deployed a lot. For 
me, it was a real challenge, and that was a factor and a reason 
I did not stay with the VA. I would have loved to have switched 
to a part-time option. They were not out there, that work/life 
balance, those flexible options. From my limited experience, I 
do not feel like the VA is doing a great job.
    Ms. Saindon, can you speak on behalf of your organization 
and tell me if you think that the VA is doing a good job of 
offering those flexible solutions, or do we need to do 
something from our end to improve that?
    Ms. Saindon. Thank you for the question. It is an excellent 
question that we have discussed often as our membership.
    I would say that it is very inconsistent. Some reports 
where these flexibilities are well employed and then some other 
sites that are not necessarily using those flexibilities. That 
is, in a nutshell, it is just inconsistent across the Nation 
from our members perspective.
    Ms. Kiggans. What can we do or what types of flexibility 
solutions would improve our recruitment and retention of nurses 
specifically, but all employees?
    Ms. Saindon. Specific to nursing, we have really focused in 
on the 72 for 80. Essentially, nurses will work 72 hours and 
get paid for 80, which is what our competitors are doing in 
healthcare. This is something that we would definitely need 
some support for. It is in the written testimony that was 
submitted specific to making that be a standard pay mechanism. 
Right now, there is not one. There is many hoops that have to 
be jumped through in order to get that 72 for 80. It is not 
that it is not available to us, it is available to us 
currently, but it is just not well utilized across the Nation 
from our members perspective.
    Ms. Kiggans. Mr. Morse, do you have anything to add?
    Mr. Morse. Yes, it is a great question. I do not think the 
VA is alone in healthcare systems evaluating the different ways 
that employees are looking at working and wanting to work with 
healthcare systems. This question is being asked across all 
healthcare systems.
    Agree there is a need for more flexibility. I agree with 
the comment that there is inconsistencies in application of 
that. That said, we are seeing the advent of a lot of different 
sorts of both technologies and work arrangements that allow for 
health systems to identify different types of pools of talent 
that they may want to approach and look at working in a part-
time capacity. For example, I mentioned internal flow pools, 
and I think someone in the prior panel had mentioned internal 
travel agencies. There is a huge opportunity to take the skill 
sets, if they are standardized, and the requirements and allow 
workers to have the flexibility to move and mobilize across the 
different Veterans Integrated Services Networks (VISNs) and the 
different VA facilities. Those inconsistencies and lacks of 
standards can really demobilize that. That is speaking to a 
certain type of worker base that would like to do that.
    On the flexibility of part-time, we can curate flow pools 
that allow for things like you just said in terms of just part-
time work. Or maybe there are second medalists, people that 
interviewed that were great runners up but did not get the 
particular role, that we can curate or retiree groups that we 
can curate to the technology to keep them engaged and keep them 
active in thinking around that.
    There are different types of technologies and ways to 
curate that, but you have to have a consistent governance 
policy and kind of identified way of managing that and 
identifying those pools. I hope that helps.
    Ms. Kiggans. Great. Yes, it does. Thank you very much.
    Dr. Begley, in your testimony, you cited a survey conducted 
during the pandemic where 44 percent of nurses reported 
experiencing physical violence in the workplace, 68 percent 
reported verbal abuse. These statistics are appalling. In your 
view, do they reflect the experience of clinicians at VA 
hospitals today? You mentioned the SAVE Act, but what else can 
we do or what else can you recommend to address this increased 
hostility that medical providers, especially nurses, are 
facing?
    Ms. Begley. Thank you for your question.
    It really, truly is probably the number one comment that I 
receive from nurse leaders as I travel the country and interact 
with my colleagues. Hospitals and health systems are doing 
everything they can to mitigate violence. They have safety 
plans for their organizations. I think the need to really focus 
training for all employees, not just clinicians, is really 
important, and that is what we are seeing throughout the 
country.
    In addition, there are technologies in the way of safety 
panic buttons and metal detectors that are subtle and not very 
overt, but really help protect our patients and our staff.
    I mentioned the SAVE Act in my statement. I think it is 
really important that our public, our patients, know that we 
are here to serve them in their not so great times. They have 
real challenges. When people are in the hospital and receiving 
our services, we know that it is challenging for them, and we 
are trained for that. We are trained to de-escalate conditions. 
The SAVE Act would really recognize that our workers are here 
for the public trust. I mentioned that it is a calling to many 
of us in healthcare. And I think that that would be a really 
significant Federal statement that it is unacceptable to be 
violent against health care workers, whether it is verbal or 
physical.
    We are studying ways that will help mitigate intentional 
violence. I think that that is really something that there is 
future work to be done on to really evaluate why we are seeing 
the rise in violence across the country in our hospitals and 
health systems.
    Ms. Kiggans. Thank you. I appreciate that.
    Now I would like to yield to Ranking Member Brownley for 
her 5 minutes questions.
    Ms. Brownley. Thank you, Madam Chair.
    Ms. Burke, thank you for being here and your testimony 
today. Just to follow up on the conversation we are just having 
here, can you kind of reflect, do you hear from a lot of your 
members with regards to acts of violence toward women in the 
workplace?
    Ms. Burke. We do, but I want to say that VA is probably the 
most proactive in this regard. We have something called the 
DBRS, which is the Disruptive Behavior Reporting System. When 
there is an act of violence, patient against employee, or even 
employee perceived against employee, there is a group that gets 
together and they potentially flag that veteran's chart. 
Sometimes it is called behavioral restraint. For example, one 
of the challenges I think that we are really struggling as an 
organization is the vast outpatient situation where VA police, 
which if they were at what we call the mothership, the main 
medical campus, would be present and report some of those 
behavioral restraints.
    In Community Based Outpatient Clinics (CBOCs), that is not 
so much the case. Like in your district, California, where we 
have extremely large geographical regions, lots of CBOCs, we 
have heard complaints where the local municipality may not 
understand the grievance, the amount of concern there regarding 
safety. I think we need to do a little bit better in addressing 
safety plans, especially with our CBOCs and creating some 
policy around that.
    Ms. Brownley. Thank you.
    In your testimony, you talked about transparency or lack 
thereof, and you have talked about this omissions and errors 
that are occurring. We do not really have any data on that. 
That is frustrating that we do not have that data from the VA. 
Can you just give me a sense in terms of where you work and the 
members that you are representing, et cetera, how many of these 
emissions and errors are occurring?
    Ms. Burke. Yes, I think that is a great question, 
Congressman. Thank you for asking.
    A lot of times I consider, if I hear it in my location, in 
Indiana, that is kind of like the middle of the bell shaped 
curve as far as the population we serve. You can only imagine 
what is going on in California, Nevada, North Carolina, Texas, 
where we have growth of our population, very full panels, et 
cetera. Just like in the last 2 months in my location, I have 
had at least four job offers or four complaints where they are 
saying what they offered upon initial coming on hiring or an 
offer of potentially another job or assignment was not--ended 
up being like, oh, I am sorry, we made a mistake here.
    I think it goes to other people that have testified here. 
There are so few candidates. That has to be like 100 percent 
accurate. I mean, we are at that point where they just have to 
be accurate. We need job letters that are commitments to these 
tentative employees. Not only a timeliness thing, but we have 
issues where if you are not going to be the market play leader, 
you rely on your mission and rely on your conditions of 
employment. They have to know what those are. We have to be not 
tarnishing the VA reputations when those are wrong.
    Ms. Brownley. Are you saying that, just as an example, that 
the VA hires someone at $100,000, they move from one place to 
another, they arrive at their new job, they have moved, they 
have gotten an apartment, a place to live, and then the VA 
tells them, I am sorry, we made a mistake, you are actually 
getting paid $80,000? Is that----
    Ms. Burke. Yes, yes, exactly. That is it, exactly.
    Ms. Brownley. Then what happens?
    Ms. Burke. The HR person turns and said, I am sorry, it was 
a tentative offer. Therefore we----
    Ms. Brownley. Does the VA take responsibility and say, it 
is our error, so we are going to pay you 100?
    Ms. Burke. No, no. No.
    Ms. Brownley. No.
    Ms. Burke. No.
    Ms. Brownley. Do they say that you are going to have to 
give us, you know.
    Ms. Burke. Right. Even our ability to grieve that, because 
there is not like--you know, what we want is like a job offer 
and our ability to grieve those, like salary disturbances, 
those things that are not right, we can not do. The Agency 
often uses this exemption of 7422 from the Collective 
Bargaining Agreement. There is no way to adjudicate these 
problems either. That is why we are advocating, at least for 
these compensation rules and VA's policies, potentially a 
violation of VA policy or the law. We need to have some 
oversight with that through the Collective Bargaining 
Agreement.
    Ms. Brownley. Thank you. I see my time is up.
    I will yield back.
    Ms. Kiggans. Thank you, Ranking Member Brownley.
    Now I recognize Ranking member Mrvan for his questions.
    Mr. Mrvan. Ms. Burke, one of the most frequent frustrations 
expressed by VA Medical Center staff, whether we are speaking 
to facility leaders, service line managers, union leaders, or 
frontline staff, is they no longer have as much access to HR 
professionals as they once did as a result of the VA's ongoing 
HR modernization effort. What have been some of the negative 
effects of this reorganization, and do you think leaders at the 
VA Central office are doing enough to address the concerns 
about these unintended consequences?
    Ms. Burke. Thank you, Congressman, for the questions.
    I think the main problem is, if you can not get a human on 
the line, it creates frustration to answer anybody's questions. 
I guess I am a little bit old school. I am trying to figure out 
what problem HR Centralization is supposed to fix. As a result, 
when you have consistent HR shifting around, no one likes 
generic email boxes. I know the point of contacts are a share 
point somewhere, but every facility has a different intranet. 
You do not know necessarily how to get a hold of, who to get a 
hold of. When there are questions about pay, questions about 
childcare subsidy, the interpretation of HR policy, a lot of 
times these lower level people do not know who to turn to 
exactly.
    I do think the people that you heard from the first panel 
are working their issues, and they are hard workers, I will say 
that. I think at times the training programs specifically 
involved in HR coding, I do not see an after action loop 
connected to those coders, and I think that is a big problem.
    Mr. Mrvan. Ms. Burke, you discuss in your testimony a lack 
of transparency about whether VA medical facilities are 
appropriately assessing market pay for physicians and locality 
pay for nurses. From your perspective, what could Congress do 
to promote better transparency in setting market pay for 
locality pay?
    Ms. Burke. The VA needs to follow their own regulations and 
the law for sharing results with employee representatives 
regarding locality pay, survey data. 74551 of the law provides 
for timelines for directors and undersecretary of health to 
enact results for locality pay surveys, which are basically the 
Registered Nurse (RN) and PA piece. It is hard to see through 
that process when you are not given routine access to turnover, 
what authorized ceilings are for vacancies, what the vacancy 
rate is, what you are trying to recruit at the given time, 
unless you go to USA Staffing. Some of this is internal things 
on step one before you can get to step two of assuring that--
when they get the data back, they have 30 days to make a 
decision and within one pay period to enact. We have trouble 
getting to those points because we can not see through that 
process very well.
    The market pays for physicians, you know, I think the panel 
before that and our other panelists here have--it is just not a 
VA problem. It is a private sector. We have fewer candidates. 
We are not going to be the market pay leaders. Issues with VA 
following their own policies. When you have anesthesiologists 
complaining that I am a board certified person, I have been 
here for 10 years, and a resident that just came off his 
fellowship is making a lot more money than me, those are market 
pay policies that are not consistent. Especially in our areas 
of primary care and especially our areas of psychology and our 
psychiatrists, that needs oversight with, I think. I think we 
are at the point where we just need 7422 to allow us to have 
access to better data to assure that VA follows their own 
regulations in that regard, sir.
    Mr. Mrvan. With that, I yield back my time, chairwoman.
    Ms. Kiggans. Thank you, Ranking Member Mrvan.
    Now the chair recognizes Mr. Bergman for 5 minutes.
    Mr. Bergman. Thank you, Madam Chair.
    First of all, Dr. Begley, let me say congratulations. You 
noted this is your 46th anniversary as a nurse. Did I get that 
right?
    Ms. Begley. That is correct.
    Mr. Bergman. You kind of struck a very positive nerve for 
me because my oldest daughter, who was born on Father's Day in 
1971, announced at the ripe old age of 16 at one point that she 
was going to be a nurse. Now some 35 plus years later, she is 
still in nursing. She chose pediatrics rather than geriatrics. 
She told me I was out of luck for that. She said she was going 
to assign her younger sister to care for me in my older years.
    The point is, as we look at what you all do and what you 
are trying to do, you are to be commended. I am going to again, 
as a Marine, life is pretty simple for me, get a mission, get 
the training, get what you need, and then go do it. Were you 
all sitting in here during the first panel? Okay. We talked 
about the 80 some steps. Could you cross out some of those 
steps necessarily? Do you think--and I say this to all four of 
you sitting there, do you think if you had that same list of 
steps that you could kind of line out some of the things that 
would maybe make the interactions better across the board?
    Ms. Begley. Well, I would like to begin by saying. Thank 
you. My daughter is a nurse practitioner, and I am very proud 
of her, and she is the one who is stuck with me in my old age.
    I think in the private sector that we have the same 
challenges. Maybe not the numbers of steps, but every hospital 
and health system that I know are part of our membership are 
looking at ways to compress that timeframe. We need to hire 
more folks in a timely manner, but also, of course, very 
safely.
    Some of the challenges, I think, that we experience that 
are not perhaps something that the VA experiences, is that we 
have individual State boards of nursing, medicine, et cetera, 
that can vary in their requirements and even timelines for when 
we need to access information from them. But----
    Mr. Bergman. Can I interrupt for a sec?
    Ms. Begley. Sure.
    Mr. Bergman. You made a point there I want to piggyback on. 
What I heard you say is state boards of licensing play a role?
    Ms. Begley. Yes.
    Mr. Bergman. I just want to make sure.
    Ms. Begley. Yes.
    Mr. Bergman. The thing we have been dealing with--we in 
this case, I sit on Armed Services as well, and this is kind of 
back when I had my hat on as a military commander, the 
licensing across state lines when members of the military would 
get transferred from base to base, another spouse could not 
work, whatever it is, nursing assistant, registered nurse, 
whatever it happens to be. I guess I want to ask you just kind 
of dig into that a little more. Is there things out of our 
control here based on what the states do that no matter how 
hard we as Congress and the Veterans Administration do, that 
states can still screw it up for us?
    Ms. Begley. Well, from a private sector perspective, I 
would say there is definitely variation in sometimes even just 
the timing of information back and forth, the information flow 
from state to state. The states are responsible for the 
licensure for the individuals in their state. Now, we know that 
in nursing, for example, we have what is called the Compact 
Licensure, which allows a nurse from New Jersey, like me, who 
has my license in New Jersey to go to Philadelphia, for 
example, and work or other states that participate in the 
compact. I do not know if that was a great example because I am 
not 100 percent sure that Pennsylvania participates. There are 
now about 40 states that have this compact agreement, which 
really helps because if you live close to another state--it is 
an economic issue if you have to maintain licensure in a number 
of states. It is also a convenience factor. If I live in New 
Jersey but live by the border and want to travel across state 
lines to work in other places, it reduces red tape for sure.
    Mr. Bergman. Well, you know--and I know my time is running 
out here, but again that is something--that is why we have 
these hearings, so we can see what are we missing, if you will, 
when we get thinking about a certain issue, whatever. Just 
thank you for that perspective. You gave me something to work 
on.
    Now, Madam Chairman, I yield back.
    Ms. Kiggans. Thank you very much.
    The chair now recognizes Ms. Budzinski for 5 minutes.
    Ms. Budzinski. Thank you very much, Madam Chair, and thank 
you to the panelists.
    My first question is for Dr. Begley. As I know you are 
aware, we have been discussing our rural hospitals and 
facilities, including those in my district, are struggling to 
recruit and retain staff. Many factors contribute to this, 
including staff burnout, inadequate pay and burnout many 
experience due to the pandemic itself.
    My first question is really to address this problem I know 
AHA has supported several recruitment initiatives such as the 
National Health Service Corps, which I think you have 
referenced, which is similar to the efforts I am also pursuing 
with my rural--that I am co-leading on the Rural America Health 
Corps Act. Could you talk about how robust funding of workforce 
development initiatives, such as loan forgiveness, could make a 
difference in rural veteran spaces?
    Ms. Begley. Well, it is a little bit hard for me to comment 
on veteran spaces. From a rural perspective, loan forgiveness, 
we know we have frontline employees in hospitals working in 
more entry level positions that would make fabulous clinicians 
and wonderful nurses, but they do not have the resources to not 
work while pursuing their nursing degree or even a nursing tech 
degree or a certification. The funding that would allow the 
education and training to occur would go, I think, just light 
years ahead, to be able to take these very competent 
individuals that have real potential and help them realize 
their dreams, in particular rural folks. In the AHA we have the 
Rural Committee, we also in nursing have the Rural Nursing 
Leadership Group. We know rural folks tend to stay in their 
home district but we have to really enable that. I think that 
the funding would be very helpful.
    I just want to add a note that partnerships, academic 
practice partnerships, so hospitals are actively reaching out 
to their community colleges, to their local universities, and 
not just the once a year conversation about how many clinical 
spots do you have and how can we fill that, but really doing 
planning for the future and saying that in this year we will 
need approximately X amount of nurses and other clinicians. 
What we have been seeing across the country is that hospitals 
are saying, I have masters doctorally prepared nurses and other 
clinicians, and we are going to loan them to the education 
program--it will be a joint faculty agreement so that we will 
pay our nurses to go and teach in your facilities. This is--for 
your organizations, your colleges, a really wonderful model for 
the future as well.
    Ms. Budzinski. Okay, thank you very much.
    I just had another question more related to competitive 
compensation for healthcare professionals. I really appreciate 
Mrs. Burke's testimony and you kind of outlined, I think, a lot 
of different steps that we could be taking. Maybe I could open 
this up to Ms. Saindon as well, regarding competitive 
compensation. Just from your perspective, what would you maybe 
highlight are some steps that VHA can take to improve 
competitiveness and transparency and pay to attract talent to 
our rural VA hospitals?
    Ms. Saindon. Thank you for the question.
    Our members have voiced that we feel more transparency, as 
one of my colleagues over here had just previously mentioned, 
regarding the annual market assessments, the third-party 
process, which seems to be time intense. Then the 
implementation of said evaluations and changes in pay salaries 
are two time intense and we end up lagging our competitors, so 
we lose qualified candidates. Becoming a more competitive 
agency, keeping up with our salaries, is one good strategy to 
really employ. That is really what we feel would be the best 
bang for our buck. Yes, so.
    Ms. Budzinski. Okay, thank you. Thank you so much.
    I will yield back. Thank you.
    Ms. Kiggans. Thank you very much.
    The chair now recognizes Mr. Rosendale for 5 minutes.
    Mr. Rosendale. Thank you very much, Madam Chair.
    Ms. Begley, I appreciate your talking about the compacts. I 
represent Montana, we have a very large veterans population, 10 
percent of our population, and we started working on compacts 
and the reciprocity 10 years ago. I am glad to hear that there 
is 40 states. It makes the family easier to relocate and much 
happier once they get there. It is a good thing. I would say 
that if there is any states out there listening that have not 
joined in, that they should do so.
    My questions, though, are for Ms. Burke. Ms. Burke, thank 
you for testifying today. You state in your testimony, and I 
quote,''prospective employees accept VA offers based on 
salaries, duties, and schedules outlined in tentative offer 
letters. When they report to the job, they are informed by HR 
or their manager that their salary, job description, or 
schedule differs from the offer made by the VA.'' This is 
unacceptable. There is no one in the private world that would 
be exposed to that and expect to keep any kind of a labor force 
in place. Employees should know what their job description will 
be when they accept a position.
    How common is this practice?
    Ms. Burke. Well, thank you for your question, Congressman.
    I can only give you anecdotal references. At the beginning 
of the pandemic, when it was just like fast and furious 
retention allowances being given to everywhere, a lot of our 
nurses, especially in those 24/7 operations, being picked up 
and moved because it was just such a turbulent time for hiring. 
We had--the ones I am aware of, we had locally, like 21 
retention service agreements that were in error. Basically, 
those service agreements were lengthened as a result of that. 
That was fixed by the PACT Act. To give reference, I believe 
all 20 of those people have left that situation.
    Mr. Rosendale. Which leads me to my next question. How does 
that hurt employee morale and/or retention?
    Ms. Burke. I think it creates--I always look at things kind 
of very simply, and if you can not be a market pay leader, what 
you are dealing with is the mission of what we do and the 
conditions of employment and the predictability of what we have 
to offer. Consequently, it erodes trust at the bottom line. It 
is not really I think sometimes the trust of that frontline 
supervisor as much as if it is potentially the offer was made 
and it was based on a specialty schedule that was not right, 
and they thought they were coming to get that specialty 
schedule and it was----
    Mr. Rosendale. What ideas do you have to prevent this in 
the future?
    Ms. Burke. My ideas are pretty simple. You have to have a 
written job offer, and it has to outline maybe the functional 
statement that is attached to it, a salary not a range and not 
a salary range, a salary offer, your hours of work, and any 
variability that may occur as a result.
    Mr. Rosendale. Much like much what we do or do not do up 
here. That is, to be more precise, about exactly what you 
expect?
    Ms. Burke. Yes.
    Mr. Rosendale. Okay.
    We have heard a lot in this hearing about hiring and 
onboarding timeliness issues at the VA. There is a legitimate 
concern that the VA is taking much too long to hire and onboard 
employees, resulting in the VA losing good employees who have 
other offers. It is unacceptable as it results in worse care 
for veterans who visit the VA.
    How long, on average, from your experience, does the hiring 
and onboarding process take for a VA job?
    Ms. Burke. I think the ideal scenario is I think they are 
down to 80 days. I think the question really is, when do you 
start? For me, from my perspective, when do you start the 
stopwatch for that 80 days? I do not think it is just merely, 
sir--and this is my perspective--an issue with a timeliness. It 
is when they are allowed to fund those positions. This gets 
back to the Mission Act 502 requirements. Specifically, if 
the--Congressman Bergman was here--what you hear from 
Department of Defense (DoD) and HR, particularly, is they are 
used to manning documents to execute the mission.
    Mr. Rosendale. Right.
    Ms. Burke. Okay. We do not really have that. We are not----
    Mr. Rosendale. How does that compare them with--if it is 80 
days, how does that compare with other agencies, and how does 
that compare with the private sector outside?
    Ms. Burke. I do not think it is where we should be yet. We 
need better processes altogether. I think we need staffing 
requirements to be outlined kind of transparent. If you have X 
amount--I can only tell you what I think, which is if you have 
X amount of high risk suicidal patients, how many psychologists 
or mental health professionals you need to execute that 
treatment plan for those patients? That is what I feel. And----
    Mr. Rosendale. Madam Chair, I see that I have run out of 
time, so I would thank you for your answers.
    Ms. Burke. Yes, sure. Thank you.
    Mr. Rosendale. I yield back.
    Ms. Kiggans. Thank you, Mr. Rosendale.
    The chair now recognizes Mr. Pappas for 5 minutes.
    Mr. Pappas. Thanks very much, Madam Chair. Thank you to our 
panel. Dr. Begley, I want to congratulate you as well on 46 
years in nursing. Thanks to everyone here for their 
professional accomplishments and their contributions to the 
discussion here today about how we can support our healthcare 
workforce at VA and writ large across the country.
    I want to delve into an issue that has become readily 
apparent. In New Hampshire, where I am from, we have been 
talking about a nursing crunch for more than a decade now and 
working to expand programs and to ease the burden as we know 
that so many are at or near retirement age. Obviously, COVID-19 
has accelerated many trends that we have seen and challenges to 
our workforce, both at VA and in the private sector.
    Dr. Begley, if I could ask this question of you. A 2021 
survey from the Kaiser Foundation found that nearly 60 percent 
of healthcare workers experienced a decline in their mental 
health due to stressors that they encountered in the course of 
their work during the pandemic. I heard about it firsthand from 
so many tours that I took of facilities in my district. I 
remember one nurse telling me we were cheered as healthcare 
heroes at the beginning of this pandemic, but now I do not feel 
like I am getting the support that I need. In one tour of a 
local hospital just over a year ago, I remember nurses on the 
floor pulling me aside and telling me about how they were 
struggling, how they were seeking help for their mental health. 
Nearly 30 percent have considered leaving their profession 
altogether in that 2021 survey. Another survey by AHA's 
American Organization for Nursing Leadership found that one of 
the top challenges and reasons for healthcare staffing 
shortages was emotional health and well being of staff.
    I am wondering, you talked about violence in the workplace 
and an important bill that we can support to help address that 
at the federal level. Could you expand on the findings of AONL 
survey and what we should be thinking about as it pertains to 
the mental health of our health care workers?
    Ms. Begley. Sure. Thank you very much for that question, 
Congressman.
    That is actually my organization's study that you last 
referenced. It is a longitudinal study of all of our members--
nursing leadership across the country. We had four different 
surveys over the past 3 years. Some of those questions were the 
same, hence longitudinal, and others we added as new issues 
came up over the course of the pandemic. The last survey was 
published in August.
    Our nurse leaders, we surveyed managers, directors, and 
also nurse executives, validated what you just said. Mental 
health and well-being for their staff was really their top 
challenge. This continues to be--and I am going to say that 
nursing is a proxy for the entire healthcare workforce. We 
learned that some of the best practices in connecting with our 
nursing staff, and again, I am using nurses as a proxy was 
really to communicate. There is no one size fits all. What 
wellness programs work for one unit or one person may look 
different than another organization. That communication with 
your staff about what they need is really critically important.
    Last year--and thank you, Congress, for passing the Dr. 
Lorna Breen Act. That was an act and now law that provides 
Federal funding for mental health education and awareness aimed 
at protecting well-being for healthcare workers. The important 
component from my perspective of that bill, in addition to the 
financial support, is really the idea that there should not be 
stigma in healthcare for seeking mental health. That is 
something that when we look at all of our nursing leaders and 
leaders in healthcare, they talk very openly about. When you 
ask someone how they are doing, it is not just a cursory 
question, it is really, how are you, and in some cases sharing 
their feelings and challenges with what the last 3 years has 
presented. There is different--mental health programs are 
critically important. We also need to increase access for 
behavioral health services, not only to our patients for sure, 
but also for our clinicians and our health care workers.
    Part of it is also reducing job stressors. Those again can 
be very--you know, we could probably take way more than our 
time here--but when we look at what are some of the job 
stressors, staffing numbers are certainly part of it. It is 
things like schedules that do not fit with your work life 
balance. We talked earlier about moms and childcare and elder 
care and how a 12 hour shift that has been pretty constant 
across our country for many, many years now may not be the way 
that I can continue to be a nurse and practice my profession, 
serve our country, and still take care of my work life balance 
issues, my children.
    Mr. Pappas. Well, thanks very much for those comments and 
just what the reflections on what our nurses are facing right 
now. If I had more time, I would certainly ask the rest of the 
panel their thoughts. We know VA is working to address some of 
these issues and we are hopeful to get additional feedback from 
you all.
    Thank you. I yield back.
    Ms. Kiggans. Thank you so much Mr. Papas.
    Then Ranking Member Brownley, would you like to make any 
closing remarks?
    Ms. Brownley. I will just be very, very brief.
    I think it has been a good hearing. I think we have raised 
most of the important issues and challenges. I will just say to 
the VA and to the management of the VA that we all know that 
this is a crisis situation. It was a crisis before COVID, it is 
a bigger crisis now and we have to treat it accordingly and 
work on this in a way that we can really expedite.
    As the VA said, they have hired more people than they have 
historically in a long, long time. We just have to even do 
better than that. I believe that we need the timelines and 
metrics so that we can do our proper oversight, but work with 
you to help us collectively get there.
    Thank you.
    Ms. Kiggans. Thank you very much.
    Then I would like to thank everyone for their participation 
in today's hearing and for this productive, insightful 
conversation.
    One of my main priorities in Congress is to ensure Nation's 
veterans have high quality and timely access to care, as I am 
sure my colleagues share that same sentiment. I took pages of 
notes. I want to just personally thank all of you for the job 
you all do every day in taking care of our veterans and our 
patients. There is so much room for improvement. I wish I could 
snap my fingers and make some of these changes that seem so 
easy. In my short time in Congress, I have learned that is not 
quite how it works. We will work together and see what we can 
do to implement some of the many changes that you all 
mentioned.
    I go back to my original sentiment of the reasons that 
nurses, but probably all healthcare professionals, leave jobs. 
They are overworked and underpaid. I think if we can work on, 
how can we not--take away some of that stress that so many of 
you mentioned and not make you feel overworked, and then making 
sure we are properly compensating our professionals who take 
care of our veterans. I think those two things will go a long 
way.
    I look forward to working on these issues with the 
Department stakeholders and my colleagues on the committee.
    The complete written statement of today's witnesses will be 
entered into the hearing record, and I ask unanimous consent 
that all members have 5 legislative days to revise and extend 
their remarks and include extraneous material hearing.
    Hearing, no objection, so ordered.
    I thank the members and the witnesses for their attendance 
and participation today, and the hearing is now adjourned.
    Thank you.
    [Whereupon, at 12:46 p.m., the subcommittees were 
adjourned.]

?

      
      
      
      
      
      
      
      
      
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                         A  P  P  E  N  D  I  X

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                    Prepared Statement of Witnesses

                              ----------                              


                  Prepared Statement of Tracey Therit

    Good afternoon, Chairwoman Miller-Meeks, Chairwoman Kiggans, 
Ranking Members Brownley and Mrvan, and members of the Committees. 
Thank you for the opportunity to discuss the Department of Veterans 
Affairs' (VA) health care hiring and staffing opportunities, as well as 
the State of VA's human capital management programs. I am joined today 
by Ms. Jessica Bonjorni, Chief, Human Capital Management, Veterans 
Health Administration (VHA).
    We are here today to discuss the steps we are taking to recruit and 
retain VA's number one asset, our employees. We know that an investment 
in our employees is an investment in Veterans.
    The Sergeant First Class Heath Robinson Honoring our Promise to 
Address Comprehensive Toxics Act of 2022 (PACT Act), which was signed 
into law on August 10, 2022, marked the largest and most significant 
expansion of Veteran care and benefits in decades, empowering VA to 
deliver additional care and benefits to millions of Veterans and their 
survivors. We are grateful for this opportunity, and now that the bill 
has become law, it is our job to implement it in a way that is 
seamless, efficient and timely for the Veterans we serve--and most 
importantly, ensure that eligible Veterans can receive the care and 
benefits they deserve.
    VA has taken steps to implement the priorities within title IX of 
the PACT Act. Title IX reflects the investment needed in VA's workforce 
to successfully implement all other titles in this important law. The 
Act provides a broad range of flexibilities for recruiting and 
retaining staff to serve Veterans, their caregivers and survivors. VA 
is grateful to Congress for including these tools in the PACT Act and 
for supporting investments in its workforce to address ongoing 
challenges with recruitment, hiring and retention. VA quickly 
established an integrated project team (IPT) with internal and external 
stakeholders to identify the policies, procedures, systems and training 
required to implement each section of title IX. IPT meets on a weekly 
basis to address any issues that arise during implementation and track 
progress. Implementation has resulted in the following several new 
tools to help with recruitment and retention:

      Removing restrictions on hiring housekeeping aides;

      Establishing a program to buy out service contracts in 
rural facilities;

      Modifying statutory limitations on awards and bonuses;

      Enhancing systems to improve hiring;

      Increasing limits on expedited hiring of post-secondary 
students and college graduates;

      Increasing student loan repayment limits;

      Increasing the cap on special contribution awards;

      Increasing the limits for recruitment, relocation and 
retention incentives and payment of retention incentives as a lump sum 
upfront;

      Increasing the limits for and the number of critical pay 
positions; and

      Increasing the limits for special salary rates.

    Ensuring that VA has the appropriate mechanisms in place to track, 
measure and provide oversight of PACT Act title IX implementation is a 
VA priority. We will continue to develop and refine metrics ensuring we 
can measure the effectiveness of these authorities and the impact on 
VA's recruitment and retention efforts. VA is tracking progress through 
recurring reports and dashboards with oversight by VA governance 
processes.
    VA is hiring more staff across the Department to ensure that care 
and benefits are delivered in a timely manner. VA is also focused on 
improving employee experience to achieve better outcomes for Veterans, 
their families, caregivers and survivors, which makes sure that we keep 
the Veteran at the center of everything we do. VA is implementing new 
hiring authorities and new retention authorities to grow and maintain a 
diverse, talented workforce with a shared mission to provide more care 
and benefits to Veterans. VBA is using the recently approved Direct 
Hire Authority for its mission critical occupations. VBA was able to 
increase its total workforce by more than 10 percent (more than 2,700) 
employees in the first 7 months of fiscal year (FY) 2023, compared to 
less than 3 percent growth in the workforce over the same period in FY 
2022.
    We are proud to report that our emphasis on hiring more 
competitively led to a record number of more than 48,500 hires in VHA 
last year, and we are well on our way to exceeding that number this 
year. VHA's total workforce grew by 11,628 employees (3.1 percent) in 
the first 6 months of FY 2023. This represents VHA's highest growth 
rate in more than 20 years.
    VA currently stands at 439,415 employees and continues to grow each 
year in response to increased demand for its services, improved access 
to care and benefits, reduced wait times, improved quality, enhanced 
Veteran satisfaction and overall mission growth. VHA accounts for 
approximately 89 percent of VA employees, and most of the additional 
staffing needed at VA in the past 5 years has been in clinical 
occupations, which account for approximately 63 percent of VA 
employees. As the largest integrated health care delivery system in 
America, 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 
10 percent annually, that rate increased to 10.1 percent in fiscal year 
2022, due in part to an improved economy and greater competition with 
the private sector coupled with Coronavirus Disease 2019 pressures and 
burnout. VA's aggressive hiring and retention efforts together with 
leveraging PACT Act authorities have resulted in significantly improved 
retention so far in FY 2023 and growth, leading us to the point where 
we are currently providing more care, and more benefits, to more 
Veterans than at any time in our Nation's history.
    Despite challenges, VA's unique mission attracts new employees 
yearly, and nearly 30 percent of VA's workforce are Veterans 
themselves, who identify closely with our mission. Other unique 
benefits attracting employees include working for a nationwide health 
care organization that provides flexibility to move to facilities in 
other parts of the country without leaving VA employment, while 
maintaining a single professional license or credential. VA benefits 
also include scholarships for employees to gain education in a critical 
shortage occupation, loan repayment to help those who already completed 
their education, liability protection, work schedule flexibilities, 
telework options and the opportunity to participate in cutting-edge 
medical research.
    VA is responding to concerns raised by customers and other 
stakeholders about delays in the hiring and onboarding process through 
rollout of its Candidate Care Model. The Candidate Care Model is a 
framework and set of tools supported by customer experience principles 
that will assist VHA hiring managers and Human Resources (HR) 
specialists in providing an outstanding onboarding experience for 
candidates. VHA has spearheaded initiatives to standardize and improve 
the onboarding process, including work done by VHA HR standardization 
teams, an onboarding deep dive conducted by the Veterans Experience 
Office and an onboarding rapid process improvement workshop conducted 
by VHA Human Capital Management. The result is a new modernized and 
interactive onboarding experience that redesigns candidate touchpoints 
with fewer people across fewer systems, infused with consistent, 
candidate-friendly messaging.
    To mitigate some of the hiring challenges in clinical occupations, 
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. Additionally, 
VA continues to use direct hiring authorities; recruitment and 
retention flexibilities and incentives; hiring initiatives; virtual 
trainee recruitment events; improved employee engagement; HR 
modernization; workforce planning; targeted recruitment of military 
spouses and Service members transitioning from the Department of 
Defense; national recruiter programs for hard-to-fill occupations and 
specialties including in historically underserved communities and 
regions; and strategies for filling Medical Center Director positions 
throughout VA.
    We also appreciate the close collaboration of Committee staff and 
look forwarding to continuing future legislative efforts centered 
especially around more pay flexibilities and hiring provisions that are 
critical to recruiting and retaining health care professionals in an 
increasingly competitive labor market.

Conclusion

    I am proud to be part of this noble mission to care for the 
Nation's Veterans. I look forward to working with each of you on this 
Committee on health care 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 deserving Veterans and their 
families. This concludes my testimony. My colleague and I are prepared 
to respond to any questions you may have.
                                 ______
                                 

                   Prepared Statement of Sharon Silas
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                  Prepared Statement of Kelley Saindon

    Chairman Miller-Meeks, and Kiggans, Ranking Members Brownley and 
Mrvan and Members of the Subcommittees; on behalf of the nearly 3,000 
members of the Nurses Organization of Veterans Affairs (NOVA), thank 
you for allowing us an opportunity to present our views on today's 
topic--VHA Recruitment and Retention: Is Bureaucracy Holding Back a 
Quality Workforce?
    NOVA is a professional organization for nurses employed by the 
Department of Veterans' Affairs (VA). The opinions provided here are 
not that of the VA, but of our members who are nurse managers, 
frontline and specialty healthcare professionals taking care of 
Veterans at facilities around the country.
    I want to begin by thanking the Committee for its support of the VA 
workforce and its work on several legislative packages that have 
provided the VA with various tools needed to address hiring and 
retention. Congressional authorities like those found in the RAISE Act 
which removed the executive level caps on pay and mandated salary 
surveys at each VA facility to ensure pay is competitive with local 
private sector healthcare professionals.
    We also applaud Title IX of the PACT Act which included provisions 
that provide a broad range of pay flexibility to help VHA to recruit 
and retain quality candidates. New authorities include modification on 
pay caps for certain employees, expansion of recruitment and retention 
bonuses, awards, special rates of pay, and student loan repayment - our 
understanding is that VHA has encouraged use of these incentives which 
will help improve hiring in rural areas and other critical clinical 
operations staff.
    It may be too soon to see if these will be effective in aiding 
recruitment and retention efforts, we believe they can and will help. 
We would also like to note that although the authorities are generous, 
challenges remain as hiring delays and length of time to onboard 
remains high.
    If there is one major bureaucratic challenge to emphasize, it is 
that the VHA hiring process is antiquated and non-competitive. The 
Office of Personnel Management rules are constrictive and not 
reflective of today's labor market.
    Most importantly, an issue that NOVA has highlighted in its 2023 
Legislative Priority Goals is HR Modernization - which reorganized and 
centralized Human Resources away from the facility level. It remains a 
system that separates the staffing specialists from their customers. 
Without knowledge of the facility and its needs, hiring managers and 
others are left to do the legwork which pulls them away from their more 
critical clinical duties. Our members have reported that nurse leaders 
are being required to assume the duties of HR to fill vacancies, 
leaving gaps in clinical care.
    It is our understanding that there is supposed to be a HR leader 
working at every facility that helps serve as a liaison between the 
virtual (centralized) HR and medical center, but severe shortages among 
HR staff, particularly HR Specialists who are responsible for helping 
recruit/retain, and onboard employees has led to an inability to 
provide quick responses or timely turnaround in many aspects of the 
hiring process.
    The time it takes to hire and onboard often leads to qualified 
candidates taking other positions outside the VHA system.
    As of May 2023--national vacancy rates for HR positions are 20.1 
percent.

    One of NOVA's members is a nurse recruiter and offered this - ``HR 
is turning over their HR specialists at an alarming rate resulting in 
HR staff who are inexperienced and handling workload amounts that are 
far beyond their ability due to staffing shortages. Bottlenecks in 
hiring occur during transitional periods between hiring more staffing 
specialists, realigning workload, and the frequent change on hiring 
processes. Due to this, oftentimes tentative job offers do not get out 
to the selected candidates for weeks or months causing a stall in the 
entire hiring process.''

    VA continues to struggle to hire robust HR staff that are trained 
in all phases of the hiring process, to include the use of locality 
pay, and all congressional authorities. To be able to manage its hiring 
needs, VA must combat the high vacancy and turnover of HR specialists 
and ensure they have the proper training and FTE to be able to 
anticipate hiring increases of its healthcare workforce.
    The private sector can often tender an offer on the day of an 
interview. VA takes months to extend offers. They will not and cannot 
begin to compete when the hiring goal is 120 days.
    During the pandemic, VA employed expedited hiring practices which 
allowed for more timely application and quicker onboarding - VA was 
able to hire within weeks rather than months.
    NOVA believes a comprehensive review of these processes should be 
considered, studied, and used to increase efficiency and speed of the 
hiring process.
    Additionally, the VHA workforce needs major reform regarding pay. 
In many areas of the country, VA cannot compete with private sector 
wages. Again, we acknowledge the RAISE Act, but it did little to 
alleviate compressed pay for frontline nurses. The immediate pay 
affected only APRNs, PAs and RNs whose salaries were at the prior pay 
cap of $173,300. Fair and equitable pay is mandatory in the current 
market of healthcare shortages that is predicted to be a global health 
emergency by 2030. VA must be able to compete with the private sector 
to maintain safe staffing levels and provide the highest quality of 
care for Veterans.
    Licensed Practical Nurses (LPNs) and Nursing Assistants (NAs) 
remain one of the highest challenges to recruit as salaries in the 
community have increased in part due to the demand for staff during and 
after the pandemic. They are utilized in an increased variety of 
settings to include nursing homes, CBOCs, and medical centers. VHA 
continues to live within qualification standards that prohibit the 
hiring of qualified NAs - change is needed to allow individuals who 
have been NAs for years but because they lack a college level education 
cannot be hired.
    Nationally (May 2023) NAs are showing the highest vacancy levels, 
sitting at 22.7 percent with LPNs right behind at 18.3 percent. RNs are 
at a 15.5 vacancy rate (VHA vacancy rate trend 5/1/23.)
    NOVA members report that a balance of competitive pay and 
scheduling flexibility is necessary for work-life balance and in 
recruiting top candidates. The pandemic highlighted elevated levels of 
burnout and mental stress--more nurses are asking for schedules that 
accommodate their home needs. To accommodate some of these needs, VA 
could provide staff the ability to work as a 0.9 FTE and receive full 
time benefits, which aligns with how many private sector systems pay 
their nurses, 36 hours = FT; working 36 hours per week will reduce 
burnout, retain nurses, and allow the flexibility needed for work-life 
balance.
    Having the flexibility of 72/80 hours in a pay period could be a 
great tool to use for recruitment and retention and give VA a tool 
often offered in private sector healthcare systems. This would require 
a legislative change to VA Payroll regulations.

    NOVA has made suggestions on other legislative fixes that may 
provide relief and a pathway to recruiting and retaining a stronger 
nursing workforce.
    Provide funding to allow for additional nursing residencies. VA has 
done a phenomenal job of implementing residency programs for RNs which 
has served as a pipeline to transition nursing students to independent 
practicing RNs to fill vacancies. It's vital that VA have dedicated 
funding to increase the number of new graduate RNs and expanded funding 
for specialty areas, many that are predicted to be particularly 
problematic in the future based on projected losses--for example if an 
Operating Room (OR) has all senior staff predicted to retire in the 
next 1-5 years it would be beneficial to start an OR specific residency 
for succession planning purposes at that facility. Dedicated funding 
would allow for hiring transition to practice (TTP) nurses outside of 
vacant funded positions; meaning they could cross-train and rotate 
throughout the facility during their residency program.
    Offer continuing education reimbursement for all nursing staff. 
NOVA thanks Subcommittee on Health Ranking Member Julia Brownley for 
reintroducing the Department of Veterans Affairs Continuing 
Professional Education Modernization Act. Our members strongly support 
providing continuing education reimbursement to all levels of nursing. 
Currently only Physicians receive a CE stipend to maintain their 
training and education requirements for licensure. The lack of parody 
hurts morale and harms recruitment and retention. We urge Congress to 
support and pass the bill as it would be another useful recruiting tool 
to offer those interested in working at VA.
    Require salary market analysis and transparent reporting annually 
to VHA leadership and Congress. This will ensure that every facility 
performs an annual market survey and acts on the results. It will allow 
for comparison to private sector salaries and encourage increases if 
funding is available, especially in high-cost areas where shortages of 
healthcare professionals remain.
    As the only professional nursing organization that supports the VA 
nursing workforce, we continue to monitor the Department's progress in 
developing staffing models and position descriptions for each VHA 
occupation. We want to advise that an expedited VA concurrence process 
for Handbooks and Policies that require approval takes too long--
average turnaround time is 18 months from initiation to concurrence. An 
example of this is the dissolution of the Nurse Professional Standard 
Boards (NPSB) which if concurred with, would require less documentation 
and the ability to hire in a more expedited fashion as the dimensions 
of practice would be eliminated. This speaks to the bigger problem of 
just how long change takes to occur and the hoops, like paperwork 
delays, that need to be jumped through at VA.
    VA must be able to recruit and retain a valuable workforce without 
barriers to hiring that impede their ability to compete with other 
healthcare systems. A strong workforce is at the heart of ensuring that 
our Nation's Veterans can continue to receive the highest quality of 
care they have earned and deserve. NOVA remains committed to providing 
that care.
    Thank you for allowing us to provide our thoughts on today's 
important topic. We look forward to working with the Committee to meet 
the challenges facing VA's workforce so that we can continue to provide 
timely, high quality compassionate care now and into the future.
    We are happy to answer any questions you may have now and as you 
continue to discuss VA's healthcare workforce recruitment and retention 
challenges.

    NOVA is a nationwide, nonprofit professional organization whose 
members are nurses working for the Department of Veterans' Affairs 
Medical Centers and Clinics. NOVA is not part of the VHA, nor is NOVA 
sanctioned or endorsed by the VHA.
                                 ______
                                 

                    Prepared Statement of Will Morse
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                   Prepared Statement of Robyn Begley

    Chairmen Miller-Meeks and Kiggans, Ranking Members Brownley and 
Mrvan, and members of the Subcommittees, I am Robyn Begley, senior vice 
president of workforce and chief nursing officer at the American 
Hospital Association (AHA), and chief executive officer of the American 
Organization for Nursing Leadership (AONL), an affiliate of the AHA. On 
behalf of the AHA's nearly 5,000 member hospitals and health systems, 
along with our clinician partners, I appreciate the opportunity to 
testify today on health care workforce challenges and successes, 
including recruitment and retention, outside of the Department of 
Veterans Affairs.

SUSTAINING THE HEALTH CARE WORKFORCE

    A qualified, engaged and diverse workforce is the cornerstone of 
America's health care system. Health care workers often say they feel 
called to serve patients, families and communities. However, long-
building structural changes in the health care workforce combined with 
the profound toll of the COVID-19 pandemic have left hospitals and 
health systems, including post-acute and behavioral health care 
providers, facing a national staffing emergency that could jeopardize 
access to quality, equitable care for the patients and communities they 
serve. Simply put, our Nation cannot maintain access to high quality 
care for patients and communities without health care workers.
    Prior to the COVID-19 pandemic, hospitals were already facing 
significant challenges making it difficult to sustain, build and retain 
the health care workforce. In 2017, the majority of the nursing 
workforce was close to retirement, with more than half aged 50 and 
older, and almost 30 percent aged 60 and older. Yet, nursing schools 
had to turn away over 78,000 qualified applications in 2022, according 
to the American Association of Colleges of Nursing (AACN), due to lack 
of faculty and training sites. Data released this month by AACN 
indicated that the number of students in entry-level baccalaureate 
nursing programs decreased by 1.4 percent in 2022, ending a 20-year 
period of enrollment growth in programs designed to prepare new 
registered nurses.
    The unprecedented scope, scale and severity of nursing workforce 
challenges also was reflected in the recently released results of a 
large-scale biennial survey conducted in 2022 by the National Council 
of State Boards of Nursing and National Forum of State Nursing 
Workforce Centers. Based on responses from over 53,000 registered 
nurses and licensed practical and vocational nurses from 45 states, the 
study estimates that 100,000 nurses left the workforce during the 
COVID-19 pandemic. In addition, nearly 900,000 nurses - or nearly one 
fifth of the 4.5 million total registered nurses - intend to leave the 
workforce due to stress, burnout and retirement. Of particular concern, 
the study estimated that nearly 189,000 registered nurses younger than 
age 40 reported an intent to leave the workforce. Large proportions of 
nurses also reported feeling emotionally drained (50.8 percent), burned 
out (45.1 percent) or at the ``end of their rope'' (29.4 percent) 
either a few times per week or daily.
    Hospitals faced similarly troubling trends for physicians and other 
health care providers. Data from the Association of American Medical 
Colleges indicates that one-third of practicing physicians will reach 
retirement age over the next decade. Hospitals also were reporting 
significant shortages of allied health and behavioral health 
professionals.

SUPPORTING THE WELL-BEING OF THE HEALTH CARE WORKFORCE

    The traumatic impact of COVID-19 has amplified the need for support 
to improve clinician well-being, destigmatize mental health and address 
overall wellness. Addressing well-being cannot be isolated from other 
efforts to improve the work lives and well-being of health care 
workers, including mitigating workplace violence and expanding access 
to behavioral health care.
    Nurses, physicians and other staff on the front lines of care in 
U.S. hospitals, emergency departments and health care systems 
experience high rates of violence. According to a survey of registered 
nurses working in hospitals during the pandemic, 44 percent of 
respondents reported experiencing physical violence and 68 percent 
reported experiencing verbal abuse.\1\ Despite the near-daily 
occurrence of abuse directed toward health care workers, there is no 
federal law that protects them by specifying consequences for acts of 
violence or intimidation. According to a 2022 American College of 
Emergency Physician (ACEP) survey, 85 percent of emergency physicians 
believe the rate of violence experienced in emergency departments has 
increased over the past five years.
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    \1\ https://journals.sagepub.com/doi/full/10.1177/21650799211031233
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    The AHA urges Congress to consider the following policies to 
support the well-being of the health care workforce:

      Protect health care workers from violence. Congress 
should enact H.R. 2584, the Safety from Violence for Healthcare 
Employees (SAVE) Act. This legislation would provide federal 
protections for health care workers against violence and intimidation, 
as well as provide grant funding to hospitals for violence prevention 
programs, coordination with state and local law enforcement, and 
physical plant improvements such as enhanced technology.

      Continue to provide grant funding support to well-being 
focused initiatives. Thanks to the Dr. Lorna Breen Health Care Provider 
Protection Act of 2022, the health care field received important 
funding for projects that help support well-being in their workplaces. 
We encourage Congress to provide additional support for projects and 
collaborative efforts to scale successful practices on well-being 
across the health care field, especially those efforts that link well-
being with hospital efforts to improve quality and the patient 
experience.

HOSPITALS AND HEALTH SYSTEMS SUPPORTING THEIR WORKFORCE

    Hospitals and health systems exist and can continually care for 
patients because of the physicians, nurses, technologists, supply chain 
professionals, facilities management specialists and the many other 
professionals who work in them. We cannot care for patients without 
these caregivers and team members. They are always there ready to care, 
and it is our job to support them.

    This is why hospitals and health systems are collaborating to 
expand training opportunities, ethically recruiting internationally, 
launching nurse and allied health professional education programs, 
reimagining workforce models, investing in upskilling and providing 
nontraditional support for health care workers.
    The following are examples of ways hospitals and health systems are 
supporting the workforce.

Collaborating

      Mary Washington Healthcare in Virginia partners with 
Germanna Community College on an Earn While You Learn program, 
onboarding two cohorts of as many as 60 nursing students each year, who 
work 12-20 hours a week using a clinical rotation model. The program 
includes an additional nursing school, as well as mentor models for 
nursing assistants and is exploring an apprenticeship model for other 
clinical roles, such as surgical technologists.

      Participants in the Jump Start program at MercyOne in 
Iowa receive a monthly stipend while they finish nursing school. 
MercyOne covers the cost of board exams and licensing fees, and 
provides employment upon RN licensure.

      Hospitals also are pursuing private-sector solutions to 
rapidly train nurses. For example, Galen College of Nursing, one of the 
Nation's largest nursing schools, includes an accelerated 3-year 
bachelors of nursing program and multiple educational advancement 
pathways for nurses at all levels.

      The Chicagoland Healthcare Workforce Collaborative, 
formed among four hospitals and health systems partnering with Malcolm 
X Community College and other community organizations, developed a 
program to fill high-demand jobs and increase retention. The Medical 
Assistant Pathway Program enables employees to complete a Medical 
Assistant certification program while still working. The program offers 
tuition coverage, transportation support and subsidy as well as 
internal and external mentoring and career coaching.

      The Workforce Readiness Institute is a workforce strategy 
partnership between Dartmouth Hitchcock Medical Center and Colby-Sawyer 
College to train licensed practical nurses, medical assistants, 
surgical techs, pharmacy techs and ophthalmic assistants. It also 
includes opportunities for existing RNs to complete a BSN and an option 
for an accelerated nursing degree. Through the program, more than 1,000 
people have joined the Dartmouth Hitchcock Medical Center.

      Norton Healthcare's Student Nurse Apprenticeship Program 
is a 12-to-18 month program that supports the accredited associate and 
baccalaureate student nurse. It pairs one student with an RN in acute 
care to increase a student nurse's readiness for nursing practice. 
Student nurses are competitively paid for their time in the program.

      Phoebe Putney Health System developed partnerships with 
secondary and post-secondary academic institutions to address the 
nursing faculty shortage. Each partnership is unique, including career 
exploration for middle and high school students, and funding part-time 
and full-time classroom and clinical instructors and faculty. They 
invested $35 million in creating a Living and Learning Community for 
student nurses, new graduate nurses and early career nursing 
professionals.

Recruiting Internationally

      Over the next 3 years, Sanford Health headquartered in 
Sioux Falls, S.D., plans to hire more than 700 internationally trained 
nurses to work in its health system. Sanford covers housing during the 
initial transition period and has instituted a program to acculturate 
nurses to their new communities.

Launching Nursing Programs

      Nearly 60 schools and hospitals across the country 
partnered to start or expand nursing programs in 2022. These programs 
range from accelerated BSN programs and virtual nursing programs to 
brand-new nursing schools and licensed practical nursing programs.

      Corewell Health System in Michigan is providing $20 
million to Oakland University--$10 million in grants for nursing 
students and $10 million to support infrastructure expansion and 
faculty hiring. Students who receive a grant commit to working for 
Corewell Health for 2 years following graduation.

Reimagining Workforce Models

      As part of its ongoing efforts to better recruit and 
retain talented health professionals amid the significant labor 
shortages, Pittsburgh-based Allegheny Health Network launched ``Work 
Your Way,'' a mobile internal staffing model to provide flexible work-
life solutions for nurses, surgical technologists and other team 
members. This unique program allows health professionals the freedom 
and flexibility to choose how and when they want to work.

      Jefferson Health's Nursing SEAL Team reimagines how to 
address variability in staffing needs by matching preferences of nurses 
to work in different settings and providing increased flexibility by 
deploying them to provide specialty nursing care across all of 
Jefferson's acute care locations.

Upskilling

      Colorado's UCHealth plans to invest $50 million in its 
Ascend leadership program to help current and prospective employees 
earn clinical certification, participate in foundational learning 
programs such as English language and college prep, and earn degrees in 
areas such as social work and behavioral health. Newly hired employees 
also will be able to earn a high school diploma or GED.

      Along with three educational partners, the University 
Medical Center of El Paso in Texas will pay up to $5,000 annually for 
two years for employees to earn a degree in nursing, respiratory, 
imaging or other hard-to-fill fields. Employees maintain full-time 
employment status and compensation while working part-time. Under 
another new program, the hospital is offering eligible employees 
pursuing a health care degree up to $5,250 a year in student loan-
repayment assistance.

      To fill the scores of medical assistant openings, 
Vanderbilt University Medical Center partnered with Nashville State 
Community College to train current employees, including truck drivers 
and environmental services staff. During training, workers continue to 
receive their full salary plus tuition reimbursement. They also train 
high school students to receive medical assistant certification.

      In Pennsylvania, Geisinger's Nursing Scholars Program 
awards $40,000 in financial support to each employee who is pursuing a 
nursing career and makes a five-year commitment to work as an inpatient 
nurse.

Nontraditional Support

      St. Luke's Wood River Medical Center, located in a 
popular Idaho tourist area, is building single-family homes that will 
be affordable long-term rentals for employees.

      Bozeman Health in Montana invested in a future workforce 
housing complex to provide employees with affordable rentals.

      Northwell Health, Johns Hopkins, Cleveland Clinic and BJC 
Healthcare are among employers offering grants or forgivable loans that 
can be used for employees' housing costs.

EXPLORING NEW CARE MODELS

    Severe workforce constraints have prompted hospitals and health 
systems to develop and evaluate innovative new team-based models to 
support staffing in their organizations. Hospitals have used 
technology-enabled virtual nursing models to help with remote patient 
monitoring in order to help provide an extra support to bedside nurses. 
Looking at their non-physician and non-nursing caregivers, some 
organizations are using these professionals to take on tasks that may 
not require a physician or nursing license. Enabling practice at top of 
one's education and license can lead to greater staff satisfaction but 
also better use of limited resources.
    Hospitals need flexibility to test, evaluate and - when the 
evidence supports it - implement new models. That is why we urge 
policymakers to avoid the use of restrictive staffing rules that limit 
innovation and threaten to exacerbate health care access challenges, 
such as nurse staffing ratios or levels. Nurse staffing is a decision 
based on complex variables under the purview of the nurse such as 
patient population, care delivery models, unit layout, patient acuity 
and the education and experience of the nurse. Mandated nurse staffing 
ratios imply a ``one size fits all'' approach and impedes the ability 
to respond to a patient's care needs in real time.
    The AHA and AONL believe mandated nurse staffing ratios are a 
static and ineffective tool that does not guarantee a safe health care 
environment, quality or optimum patient outcomes. Staffing ratios are 
usually informed by older nursing-only care models and do not consider 
advanced capabilities in technology or interprofessional team-care 
models. These newer models incorporate not only nurses at various 
levels of licensure, but also respiratory therapists, occupational 
therapists, speech-language pathologists, physical therapists and case 
managers.
    Hospitals and health systems across the country are working to 
advance safety, affordability and value by transforming health care 
delivery. Mandated approaches to staffing not only limit this 
innovation but also increase stress on a health care system already 
facing an escalating shortage of educated nurses. Mandated staffing 
does not create more nurses.

SUPPORTING ADVANCES IN TECHNOLOGY

    Health care workforce shortages have led to challenges but also 
creative solutions to workflows, workplaces and teams. The broad 
adoption of telehealth is just one example how we improved where and 
how patients can access care. Regulatory flexibilities available under 
the public health emergency allowed exploration of the most effective 
treatment modalities and locations to allow providers to care for their 
communities in the midst of surging illness and concerns. The 
innovative approaches that emerged during the pandemic provide an 
avenue to rethink care delivery in light of the current workforce 
capacity. These advances require continued regulatory flexibility and 
funding to continue. Organizations need additional funding to continue 
to pilot, test and scale those changes that can best support their 
current workforce in caring for their communities.
    Hospitals and health systems are exploring the use of technology by 
automating certain clinical documentation, as well as using artificial 
intelligence to help consolidate and trend large amounts of clinical 
information to provide insights for delivering care. Technology is not 
a substitute for caregivers, but it can enhance their ability to 
practice efficiently and reduce burden. Congress could consider 
providing support for pilot testing innovative technology solutions 
that support the health care workforce.

TRAVEL NURSES, TEMPORARY LABOR ISSUES

    To help offset the critical shortage of workers and maintain 
appropriate levels of care for patients, nearly every hospital in the 
country was forced to hire temporary staff at some point during the 
pandemic, including contract or travel nurses.\2\ Hospitals' reliance 
on travel nurses and the inflated associated costs to employ them have 
grown significantly since the start of the pandemic. The AHA has 
previously pointed out that the rates these staffing firms charge 
hospitals grew much faster than the rates the firms actually paid the 
staff,\3\ meaning the firms pocketed more at the time of greatest need.
---------------------------------------------------------------------------
    \2\ https://www.amnhealthcare.com/siteassets/amn-insights/surveys/
amn-survey-of-temporary-allied-healthcare-professional-staff-trends-
2021.pdf
    \3\ https://www.aha.org/costsofcaring
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    The AHA remains concerned that the conduct of some of these travel 
staffing agencies bears the hallmarks of collusion and perhaps other 
abuses. The AHA sent letters urging the Federal Trade Commission and 
the White House to use their authority to investigate these reports of 
anticompetitive behavior.

POLICY SOLUTIONS

    Our workforce challenges are a national emergency that demand 
immediate attention from all levels of government and workable 
solutions. These include recruiting, revitalizing and diversifying the 
health care workforce. Congress should consider the following policies 
to help sustain and support the Nation's workforce:

      Address nursing shortages by investing in nursing 
education and faculty. Schools of nursing continue to need more 
faculty, preceptors and clinical training sites to support students, 
new graduates and prospective students. The Future Advancement of 
Academic Nursing Act would provide those vital resources to support the 
needs of nursing students, help retain and hire diverse faculty, 
modernize nursing education infrastructure, and create and expand 
clinical education opportunities.

      Provide scholarships and loan repayment. Title VIII 
Nursing Workforce Development programs such as Nurse Corps help bolster 
the advanced practice and nursing workforce by addressing the shortage 
of nursing faculty and clinical sites, as well as funding nursing 
schools located in rural and underserved communities. The CARES Act 
reauthorized these critical programs through 2024. Reauthorizing and 
funding these programs remain a necessity. Congress should ensure 
nursing students are eligible to receive such benefits to attend 
nursing schools regardless of the educational institution's tax status 
and ensure parity of treatment for hospitals and their workers 
regardless of tax status in federal health programs, including those 
enumerated in the Public Health Service Act.

      Reauthorize and increase funding for the National Health 
Service Corps (NHSC). This program awards scholarships and assists 
graduates of health professions programs with loan repayment in return 
for an obligation to provide health care services in underserved rural 
and urban areas. The AHA supports the Strengthening Community Care Act 
of 2023 (H.R. 2559) to extend funding for community health centers and 
the NHSC. The NHSC is a critically important program for both giving 
clinicians support to offset the substantial cost of their education, 
while also incentivizing practice in underserved rural and urban health 
professional shortage areas across the country.

      Increase GME slots. Address physician shortages, 
including shortages of behavioral health providers, by increasing the 
number of residency slots eligible for Medicare funding. AHA supports 
the Resident Physician Shortage Reduction Act of 2023, S. 1302, a 
bipartisan bill that would lift caps on Medicare-funded residency 
slots.

      Support foreign-trained health care workers. Support 
expedition of visas for foreign-trained nurses and continuation of visa 
waivers for physicians in medically underserved areas.

      Investigate travel nurse agency practices. We urge 
Congress to direct the Government Accountability Office to study the 
business practices of travel nurse staffing agencies during the 
pandemic, including potential price gouging and excessive profits, 
increased margins that agencies retain for themselves, impact of 
increased reliance on travel nurses in rural areas, and how these 
practices contribute to workforce shortages across the country.

CONCLUSION

    The AHA appreciates your recognition of the challenges ahead and 
the need to examine America's health care workforce issues. We must 
work together to solve these issues so our Nation's hospitals and 
health systems, post-acute and behavioral health care providers can 
continue to care for the patients and communities they serve.
                                 ______
                                 

                 Prepared Statement of Mary Jane Burke

    Chairwoman Miller-Meeks, Ranking Member Brownley, Chairwoman 
Kiggans, Ranking Member Mrvan and Members of the Health and Oversight 
and Investigation Subcommittees:
    Thank you for inviting the American Federation of Government 
Employees (AFGE) to participate in today's joint subcommittee hearing, 
``VHA Recruitment and Retention: Is Bureaucracy Holding Back a Quality 
Workforce?'' I am Mary Jean ``MJ'' Burke, and I am the first vice 
president of AFGE's National Veterans Affairs Council, representing 
more than 291,000 AFGE VA employees across the Veterans' Health 
Administration (VHA), Veterans Benefits Administration (VBA), and the 
National Cemetery Administration (NCA). I also am a practicing physical 
therapist at the Indianapolis VA in Indiana.
    AFGE and its National Veterans Affairs Council (NVAC) are pleased 
to provide our views and recommendations on VA staffing, recruitment, 
and retention, including improving compensation and work conditions and 
reversing the negative impact of human resources modernization on 
hiring and employee satisfaction.
    I want to State at the outset that I consider my decision to work 
for VA as one of the best decisions I've made professionally. The VA 
model for integrated care should be a model for all care. Additionally, 
the VA's veteran-specific expertise cannot be replicated outside of the 
VA. My comments in no way reflect a diminishment of that belief. VA 
must course correct to be able to continue to provide top-notch care to 
veterans who prefer to seek their care at the VA.
    VA staffing shortages remain an ongoing cause of concern for both 
veterans and the AFGE members who care for them. According to VA's 2023 
first quarter vacancy report, VA turnover, now at 9.95 percent, has 
been increasing in recent quarters. Although VA reports a net hiring of 
7,364 employees through March, its own data--inaccurate even five years 
after the Mission Act passage--still show over 70,000 vacancies. A 
recent survey of AFGE membership, conducted by the Veterans Healthcare 
Policy Institute (VHPI) with AFGE support, showed that 96 percent of 
VHA respondents believe their facility needs more frontline clinical 
staff to provide the level of care veterans deserve. Seventy-five 
percent said their facility needs more administrative staff. Seventy-
seven percent said that there are vacant positions for which no 
recruitment is taking place.
    Pay and benefits that are comparable to what competing employers 
provide, reasonable scheduling and streamlined hiring processes are all 
vitally necessary to attract and retain a high-caliber VA workforce 
capable of providing veterans the care they need.

Compensation

    Compensation that is timely, accurate and competitive with local 
market conditions is imperative to successfully attract and retain a 
high-caliber VHA workforce. VHA has been inconsistent and 
nontransparent in implementing pay laws and policies designed to make 
clinician pay competitive with the private sector. When these 
compensation practices are allowed to go unchecked, they result in 
barriers to hiring and retaining employees. This seems intuitively not 
in the public interest or consistent with congressional intent.
    The VA has different pay systems for physician and nurses. The 
current pay system for physicians, dentists and podiatrists is composed 
of market pay, performance pay and longevity pay. When they rolled out 
the three-tiered system pay system, it was intended to make pay more 
competitive with local markets and to incentivize individual 
professional performance, while also rewarding retention and 
experience. However, since this pay system was enacted nearly two 
decades ago, there have been widespread management inconsistencies with 
processes for setting market pay and performance pay.
    Market pay data are no longer required to be publicly reported in 
the Federal Register, so it is difficult to know how ``market pay'' is 
set and allocated. This has facilitated a lack of transparency and 
therefore little accountability for medical directors who don't set 
market pay fairly or rationally. Our members report indefensible levels 
of variation in market pay. For example, some similarly situated 
clinicians at facilities in similar markets receive radically different 
market pay. We frequently hear reports of long-serving, experienced, 
highly credentialed clinicians sometimes receiving lower market pay 
than new employees in the same facility.
    Short-sighted strategies to recruit new employees at the expense of 
existing employees only exacerbate problems with retention as new 
doctors increasingly see VA as a good place to train but not to stay. 
VA must develop policies that will attract physicians over the 
continuum of a career and across the spectrum of specialties and pay 
levels; otherwise fixes to one set of problems will only create new 
ones.
    Performance pay distribution has also been inconsistent. In some 
facilities, performance pay functions as a retention bonus or award. 
However, providers should expect to receive performance pay if they 
meet the performance goals as a component of their salary. In other 
facilities, the metrics used to assess performance don't align with 
what is in the physician's control and therefore can be unattainable. 
For example, a doctor may not get performance pay because it is tied to 
the number of appointments kept but that number may be affected by the 
number of no shows, which is not in the doctor's control and tends to 
be high at the VA.
    Among Title 38 positions, third party locality surveys for 
registered nurses (RNs) and physician assistants (PAs) are not being 
executed transparently even though by congressional intent and VA 
regulations they should be.
    The VA is mandated to perform third-party RN locality pay surveys, 
which are triggered by factors such as turnover rates, resignations due 
to dissatisfaction with pay, or other criteria set by the facility 
director. But it is mostly a big mystery to both employee 
representatives and employees when, or if, surveys are being executed. 
Directors are required to decide within 30 days after receiving the 
survey data back whether an increase is warranted. If an increase is 
warranted, it should be implemented within a pay period of that 
decision. But VA's lack of transparency about the underlying 
information needed to calculate turnover and vacancy rates makes it 
hard to determine whether the agency is compliant with its legal 
obligations under Title 38.
    Even though by law VHA cannot be a market leader in pay, existing 
processes designed to meet the market can and should be used far more 
effectively, starting with the restoration of labor-management 
collaboration. Our union can play an important and critical role in 
facilitating compliance with survey requirements if we had better 
information about the data and timelines that trigger survey 
requirements. However, we have often been denied access to pay data or 
provided access to the data without sufficient information about how 
and when it was collected. This undermines our ability to monitor 
whether surveys are being conducted in a timely and appropriate way.

Human Resources Modernization

    The success of VHA's human resource practices has varied widely 
across facilities. Facilities with experienced managers, good labor-
management relationships, and an adequate number of trained and 
experienced HR specialists fare better than others. It is important 
that management and HR specialists understand the law and their own 
policies that improve recruitment and retention. The quality and 
quantity of care VHA is able to provide to veterans depends upon it.
    Unfortunately, VA's misguided HR modernization effort, which has 
removed HR personnel from facilities and centralized the HR function at 
the VISN level augmented by automation, has significantly undermined 
recruitment and retention efforts. Half of respondents in the VHPI 
survey said that the VHA's Human Resources Modernization Project has 
exacerbated delays in hiring and is contributing to staff leaving the 
VA. Just over 90 percent said HR delays had deterred interested 
candidates.
    VHA's transition to HR Smart and a virtual environment has further 
depersonalized the HR process, leaving unions and employees further 
marginalized from efforts to recruit and retain clinicians. Union 
representatives are now forced to go to the USA Jobs website to find 
out what positions are being recruited. The paper organizational charts 
which showed which positions have been funded or approved are not easy 
to locate or are nonexistent. As a result, it is difficult to know what 
the true VA vacancy rate is.
    VHA's transition to a predominantly technology driven environment 
devoid of face-to-face interaction has also damaged workplace morale. 
As we have testified previously, when VHA overuses data metrics to try 
to increase clinician productivity, it further drives hard-to-recruit 
personnel into the private sector. Because VA by law cannot be a pay 
leader, VA employment has historically appealed to clinicians drawn to 
serve its unique patient population while having an adequate work-life 
balance. If these clinicians were motivated solely by income, they 
would choose the higher paying private sector environment. But the 
combination of clinician shortages that are driving up pay outside the 
VA while simultaneously exacerbating VA employee workloads are making 
the VA a less attractive place to work.
    Widespread human resource errors create further barriers to 
retention and recruitment and tarnish VA's reputation as a good faith 
employer. Prospective employees accept VA job offers based on salaries, 
duties and schedules outlined in tentative offer letters. When they 
report to the job, they are informed by HR or their manager that their 
salary, job description or schedule differs from the offer made by VA. 
These individuals may have given notice at a previous job, declined a 
competing offer, or relocated based on these erroneous offers. 
Congressional oversight is needed in this area, specifically.
    Additionally, VA employees receive debt letters to recoup money 
they were erroneously paid due to HR coding mistakes. New employees 
already on the job have been hit with debt letters when HR discovers 
that they were paid more than they should have due to a coding or job 
offer mistake by HR. The employees are informed that not only will they 
receive a wage or salary reduction, but that the payroll department 
will claw back the money already paid to them.
    It not AFGE's belief that inexperienced HR officials intentionally 
miscode personnel records. Rather, the agency seems to have a lack of a 
formalized, mentoring and teaching curriculum for VHA, specifically 
developed for the necessary HR coding requirements within HR smart that 
matches VHA complex policy and personnel system to assure mastery. Most 
troubling, if a miscoding error by a HR official occurs that results in 
employee debt, the agency seemingly has no systematic after-action 
plans for correction within a learning module, so these errors don't 
happen again. Historically, VA has sought to remedy issues like this by 
asking to streamline HR processes by moving more employees to Title 38. 
But that is not the answer. Rather, VA must develop a stringent 
complete curriculum related to those HR errors that resulted in 
employee debt to prevent those actions from occurring again.
    Underlying many of the problems related to compensation and HR are 
limitations on employees gaining redress for them under 38 U.S.C. 
Sec. 7422, which prevents employees from using grievance procedures 
from a collective bargaining agreement ``for any matter or question 
concerning or arising out of the establishment, determination, or 
adjustment of employee compensation.'' The bar on grieving compensation 
means that employees cannot grieve paycheck errors even if it is clear 
that VA is at fault. Further, VA uses an overly broad interpretation of 
Sec. 7422 to improperly deny union access to information about whether 
market pay surveys are done at all, citing the inability to grieve 
compensation under Sec. 7422 as a complete bar to obtaining information 
about locality pay surveys mandated separately under 38 U.S.C. 
Sec. 7451.

Scheduling

    VA staffing shortages are driving longer hours for clinicians at 
the same time that VA salaries lag the market. VHA bookable clinical 
hour standards are making working conditions for already underpaid 
clinicians untenable. Under the standard, 80 percent of a provider's 
total outpatient clinically mapped time must be booked for in-person, 
telehealth or telephone direct care. While this standard sounds 
reasonable on its face, at times, it isn't achievable when you have too 
many patients to see (often doctors must cover for vacant positions) 
and insufficient administrative staff. Many clinicians report working 
excessive hours off-the-clock to meet the 80 percent standard while 
also responding to time-sensitive inquiries known as view alerts for 
other patients who are not booked for purposes of meeting the 
productivity standard.
    VA nursing is currently experiencing similar strains. VA shifts and 
days off have become less predictable. Nursing supervisors often lack 
the hands-on experience to understand the experiences and needs of 
front-line nurses. Nurses fear they will be punished with a bad 
schedule or have requests for days off denied if they speak up.
    Despite their preference to work with veterans, nurses will leave 
for the private sector where they can get predictable schedules and be 
paid full-time for three 12-hour days. In addition, private sector 
nurses have extensive collective bargaining rights that are absent at 
the VA, including the right to bargain over pay and patient safety 
issues.
    I also want to highlight to the committee that this hearing falls 
in the middle of police week. AFGE and the NVAC is proud to represent 
thousands of VA Police at facilities across the country and appreciates 
the sacrifice and service these employees, 90 percent of whom are 
veterans themselves, make every day to protect veterans and VA 
employees. To help honor that dedication, AFGE strongly encourages the 
passage of H.R. 1322, the "Law Enforcement Officers Equity Act.'' This 
bipartisan legislation would grant more than 30,000 federal officers, 
including VA Police Officers, ``6(c)'' retirement benefits (under 5 USC 
8336(c)) and the ability to retire after 20 years of service at the age 
of 50, or after 25 years of service at any age. Last Congress, this 
bill gathered 105 bipartisan co-sponsors, and I want to thank House 
Veterans Affairs' Committee Chairman Bost, Ranking Member Takano, and 
Reps. Mrvan, Brownley, and Deluzio, who have co-sponsored the bill this 
Congress at the time this statement was submitted.

AFGE Recommendations:

      VHA must provide HR officials with proper training to 
code VHA personnel records and create mandated after-action plans when 
they inadvertently create employee debt.
      VHA should make third-party locality pay surveys 
accessible to help more front-line RNs and PAs secure needed pay 
adjustments.

      Union representatives should receive the same training on 
the locality pay survey process that managers receive.

      There must be more serious accountability for HR's 
responsibilities to follow appropriate processes and to provide all 
allowable compensation, including the use of flexibilities (such as 
special salary rates, recruitment and retention bonuses, student loan 
repayment, education debt reduction program awards and performance 
pay).

      Congress should enact H.R. 543, the ``VA Continuing 
Professional Education (CPE) Modernization Act,'' which passed this 
committee last Congress in a bipartisan vote andwould increase the 
eligibility for VA clinicians to receive CPE, increase the 
reimbursement amount, and adjust the amount for inflation.

      Changes to law or policy are needed to improve the 
union's access to recruitment and retention information, specifically 
which positions and types of recruitment efforts are being made. We 
also need staffing information, such as access to information about 
nursing hours per patient day, turnover rates, vacancies, and 
authorized ceilings (the maximum number of people allowed to be hired 
for a specific unit). We should not have to file a grievance to get 
this critical information.

      VA should regularly report information about each VA 
entity that conducts a market pay evaluation including whether a market 
pay adjustment was made following the evaluation (per occupation and 
specialty) and whether employees and local union representatives were 
notified of the evaluation.

      VHA should change scheduling policies so that they are 
sustainable for employees.

      VHA should develop staffing requirements for high-risk 
individuals with service-connected mental health problems. The length 
of time before for follow-up visits and the volume of patients assigned 
needs congressional oversight to ensure that patients can get 
recommended care.

      Congress should amend 38 U.S.C. Sec. 7422 to allow for 
full collective bargaining rights for title 38 employees including the 
ability to grieve violations of VA pay policies.

    Thank you for giving me the opportunity to testify at today's 
hearing. I look forward to answering any questions you may have.

                       Statements for the Record

                              ----------                              


           Prepared Statement of American Medical Association

    The American Medical Association (AMA) appreciates the opportunity 
to submit the following statement to the U.S. House of Representatives 
Committee on Veterans' Affairs for the oversight hearing entitled, 
``VHA Recruitment and Retention: Is Bureaucracy Holding Back a Quality 
Workforce?'' The AMA commends the Committee for focusing on this 
critically important issue as it is imperative that our Nation's 
veterans receive the best health care possible.
    ``The Veterans Health Administration (VHA) is the largest 
integrated health care system in the United States, providing care at 
1,298 health care facilities, including 171 VA Medical Centers and 
1,113 outpatient sites of care of varying complexity (VHA outpatient 
clinics) to over 9 million Veterans enrolled in the VA health care 
program.'' \1\ Since the VHA is such a large health care system, the 
actions it takes, especially in terms of how it recruits and retains 
its health care workforce, could have an immense impact on health care 
in its entirety. As the largest professional association for physicians 
and the umbrella organization for state medical associations and 
national medical specialty societies, the AMA is committed to ensuring 
that there is proper access to physicians for all veterans and that 
physicians are well supported in their role as the leader of the health 
care team. Increasing recruitment, retention, and fixing administrative 
burdens within the VHA will go a long way in helping to increase the 
number of physicians in the VHA which will lead to healthier 
communities and, ultimately, a healthier country as access to much-
needed medical care increases for our Nation's veterans.
---------------------------------------------------------------------------
    \1\ https://www.va.gov/health/
aboutvha.asp#:8:text=The%20Veterans%20Health% 
20Administration%20(VHA,Veterans%20enrolled%20in%20the%20VA.

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VHA Health Care Workforce Expansion

    The AMA understands the importance and need to have an adequately 
staffed health care facility. As such, we suggest that additional 
funding is provided to the VHA to hire and train more physicians in 
accordance with our recommendations below.

Provide Additional Funding to the VHA to Create More Graduate Medical 
Education Slots

    The Association of American Medical Colleges (AAMC) predicts a 
shortage of 139,000 physicians by 2033, including a projected shortage 
of primary care physicians of between 21,400 and 55,200.\2\ This, in 
part, is due to the aging U.S. population, which is growing in size and 
has more complex health needs, meaning that the demand for health 
professionals across the country will continue to grow. This shortage 
is also being caused by our aging physician population, many of whom 
will soon retire, leaving gaps in community care since there has not 
been a significant enough increase in medical students to fill their 
spots upon retirement.\3\ Furthermore, the pandemic has put an 
incredible strain on our health care system and this crisis has 
drastically exacerbated physician shortages in many rural and 
underserved communities across the U.S. As such, more residency 
programs and slots are desperately needed to begin to address the 
current and impending physician shortage.
---------------------------------------------------------------------------
    \2\ https://www.aamc.org/news-insights/us-physician-shortage-
growing.
    \3\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7006215/.
---------------------------------------------------------------------------
    The VA is the largest provider of health care training in the 
United States. ``In general, each year approximately 43,000 individual 
physician residents receive their clinical training by rotating through 
about 11,000 VA-funded physician FTE residency positions at VA medical 
facilities.'' \4\ However, approximately 99 percent of the VA's 
programs are sponsored by outside medical schools or teaching 
hospitals. Functionally, this limits the amount of expansion that can 
occur in the VA system as those who train at VA locations must still be 
housed under a third-party graduate medical education (GME) program 
with full accreditation and administrative functioning. Therefore, the 
VA should work to create more of its own GME residency positions as 
well as continue to work with medical schools to expand existing 
partnerships and shared training slots. A few of the ways this could be 
accomplished include expanding the VA Pilot Program on Graduate Medical 
Education and Residency \5\ and expanding the number of positions 
available via the VA MISSION Act of 2018 and the Veterans Access, 
Choice, and Accountability Act.\6\ Expansions could be made through the 
Department of Veterans Affairs Office of Academic Affiliations to help 
preserve and expand GME within the VHA. The expansion of GME within the 
VHA has already proven to be successful in retaining physicians. For 
example, the annual Trainee Satisfaction Survey administered by the VA 
Office of Academic Affiliations to physician residents consistently 
finds that residents have a more positive opinion regarding a career at 
the VA after completing their rotations, with over half (55 percent) 
responding they would consider a career at a VA medical center.\7\ If 
the full funding for the direct and indirect costs of GME positions was 
expanded within the VA more physicians would be able to work within the 
VA, which would decrease existing shortages while providing high 
quality care for veterans.
---------------------------------------------------------------------------
    \4\ https://sgp.fas.org/crs/misc/R44376.pdf.
    \5\ https://www.Federalregister.gov/documents/2022/02/04/2022-
02292/va-pilot-program-on-graduate-medical-education-and-residency.
    \6\ https://www.govinfo.gov/content/pkg/COMPS-15905/pdf/COMPS-
15905.pdf.
    \7\ https://journals.lww.com/academicmedicine/Fulltext/2022/08000/
Veterans_Affairs_Graduate_Medical_Education.37.aspx.

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Hire More Physicians

    For the first time in years the staffing shortages within the VHA 
have intensified, resulting in a 22 percent increase in occupational 
staffing shortages in 2022 compared to 2021.\8\ Some of the professions 
with the severest shortages within the VHA include psychiatrists, 
primary care physicians, and gastroenterologists.\9\ Simultaneously, 
the VHA has not been accurately counting all of the physicians 
providing care within its facilities, including trainees, to fully 
understand where shortages exist and appropriately adjust hiring 
practices. The GAO has consistently found that the VHA is unable to 
accurately count the total number of physicians who provide care in its 
VA medical centers (VAMC) and the VA has disagreed with the 
recommendation of the GAO to develop and implement a process to 
accurately count all physicians providing care at each medical 
center.\10\, \11\ As such, the VHA should put in place a 
system to accurately count all of the physicians that it employs and 
hire more physicians where they are needed.
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    \8\ https://www.va.gov/oig/pubs/VAOIG-22-00722-187.pdf.
    \9\ https://www.va.gov/oig/pubs/VAOIG-22-00722-187.pdf.
    \10\ https://www.gao.gov/products/gao-18-124#summary_recommend.
    \11\ https://www.gao.gov/assets/gao-22-105630.pdf.
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    Another potential solution to the physician shortage is to hire 
more physicians and provide additional benefits to physicians working 
within the VA to help with retention. Within the VHA, physician 
salaries are determined according to a combination of base pay, market 
pay, and performance pay. Moreover, under 38 U.S.C. 7431(e)(1)(A)\12\, 
every two years the Secretary must prescribe for Department-wide 
applicability the minimum and maximum amounts of VHA physicians annual 
pay.\13\ Therefore, under this statue, it would be possible to increase 
the pay offered to physicians within the VHA which would help with 
recruitment and retention. Furthermore, the VA should enhance its loan 
forgiveness and scholarship efforts to further incentivize physician 
recruiting and retention and improve patient access in the Veterans 
Administration facilities.
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    \12\ https://www.govinfo.gov/content/pkg/USCODE-2018-title38/html/
USCODE-2018-title38-partV-chap74-subchapIII-sec7431.htm.
    \13\ https://www.federalregister.gov/documents/2019/12/09/2019-
26435/annual-pay-ranges-for-physicians-dentists-and-podiatrists-of-the-
veterans-health-administration-vha.
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    Additionally, ensuring that all physician specialties are direct 
hires and streamlining the hiring process in general will help with the 
efficient and timely staffing of physicians. The hiring process for 
international medical graduates (IMG) should also be streamlined, 
including providing/expanding the exception to the 2-year home country 
return requirement if an IMG works for the VHA for a designated period 
of time. The VA states for all its jobs that the hiring process ``may 
take a while.'' In line with this, 94 percent of respondents to a 
survey about VA hiring stated that they had lost an interested 
candidate due to delays in the HR hiring process.\14\ As such, changes 
need to be made to the hiring and onboarding process so that good 
candidates are not lost to other jobs.
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    \14\ https://www.afge.org/globalassets/documents/generalreports/
2023/03/vhpireport_v2.pdf.

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Improve the Community Cares Program

    Finally, increasing access to the Community Cares program when 
physician employment gaps cannot be filled will help to ensure that 
veterans continue to receive the care they need and increase access to 
physician services. However, the implementation of this program needs 
to be improved. For example, a 225-bed health care system in South 
Carolina had $22.7 million in outstanding VA claims at the beginning of 
FY 2022 with $16.7M (83 percent) over 90 days due. On top of this, the 
health care system had to write off approximately $12.7M during FY 2022 
because the VA claims were over 300 days old. As such, increasing 
reliability of payment for services rendered as part of the Community 
Cares Program and increasing the number of physicians and other health 
care professionals who are part of the program could help to fill 
workforce gaps.
    In line with this, the VHA should pay private physicians a minimum 
of 100 percent of Medicare rates for visits and approved procedures to 
ensure adequate access to care and choice of physician and ensure that 
clean claims submitted electronically to the VA are paid within 14 days 
and that clean paper claims are paid within 30 days. This would 
increase the willingness and variety of providers who would care for 
our veterans.

Ensure the Quality of Care While Hiring More Providers by Maintaining 
the Physician Led Care Team

    With more than 10,000 hours of clinical experience, physicians are 
uniquely qualified to lead health care teams. Non-physicians such as 
physician assistants, nurse anesthetists, and optometrists do not have 
the same rigorous and comprehensive education as physicians. For 
example, physician assistant programs are two years in length, require 
2,000 hours of clinical care, and have no residency requirement.\15\ 
Similarly, nurse anesthetists complete only two-three years of graduate 
level education and have no residency requirement. Students of 
optometry rarely complete postgraduate education and are trained in 
primary eye care. They are not exposed to standard surgical procedure, 
aseptic surgical technique, or medical response to adverse surgical 
events. Simply put, non-physicians do not have the education and 
training necessary to practice medicine. The educational programs 
undergone by non-physicians do not prepare them to develop clinical 
judgment similar to a physician. For this reason, physicians and non-
physicians are not interchangeable on a care team.
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    \15\ https://www.ama-assn.org/system/files?file=corp/media-browser/
premium/arc/ama-issue-brief-independent-nursingpractice.pdf.
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    In accordance with this, there is strong evidence that increasing 
the scope of practice of nurse practitioners and physician assistants 
has resulted in increased health care costs. For example, a high-
quality study published as a working paper by the National Bureau of 
Economic Research in 2022 compared the productivity of nurse 
practitioners and physicians (MDs/DOs) practicing in the emergency 
department using Veterans Health Administration data. The study found 
that nurse practitioners use more resources and achieve worse health 
outcomes than physicians. Nurse practitioners ordered more tests and 
formal consults than physicians and were more likely than physicians to 
seek information from external sources such as X-rays and CT scans.\16\ 
They also saw worse health outcomes, raising 30-day preventable 
hospitalizations by 20 percent, and increasing length of stay in the 
emergency department. Altogether, nurse practitioners practicing 
independently increased health care costs by $66 per emergency 
department visit.\17\ The study found that these productivity 
differences make nurse practitioners more costly than physicians to 
employ, even accounting for differences in salary.\18\ Not only does 
the increased resource use by nurse practitioners result in increased 
costs and longer lengths of stay, but it also means patients undergo 
unnecessary tests, procedures, and hospital admissions.
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    \16\ Productivity of Professions: Lessons from the Emergency 
Department, Chan, David C. and Chen, Yiqun, NBER, Oct. 2022.
    \17\ Id.
    \18\ Id.
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    In addition, a recent study from the Hattiesburg Clinic in 
Mississippi found that allowing nurse practitioners and physician 
assistants to function with independent patient panels in the primary 
care setting resulted in higher costs, higher utilization of services, 
and lower quality of care compared to panels of patients with a primary 
care physician. Specifically, the study found that non-nursing home 
Medicare ACO patient spend was $43 higher per member, per month for 
patients on a nurse practitioner/physician assistant panel compared to 
those with a primary care physician. Similarly, patients with a nurse 
practitioner/physician assistant as their primary care provider were 
1.8 percent more likely to visit the ER and had an 8-percent higher 
referral rate to specialists despite being younger and healthier than 
the cohort of patients in the primary care physician panel. On quality 
of care, the researchers examined 10 quality measures and found that 
physicians performed better on nine of the 10 measures compared to the 
non-physicians.
    Other studies further suggest that nurse practitioners tend to 
overprescribe and overutilize diagnostic imaging and other services, 
contributing to higher health care costs. For example, a 2020 study 
published in the Journal of General Internal Medicine found 3.8 percent 
of physicians (MDs/DOs), compared to eight percent of nurse 
practitioners met at least one definition of overprescribing opioids 
and 1.3 percent of physicians compared to 6.3 percent of nurse 
practitioners prescribed an opioid to at least 50 percent of 
patients.\19\ The study further found that, in states that allow 
independent prescribing, nurse practitioners were 20 times more likely 
to overprescribe opioids than those in prescription-restricted 
states.\20\
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    \19\ MJ Lozada, MA Raji, JS Goodwin, YF Kuo, ``Opioid Prescribing 
by Primary Care Providers: A Cross-Sectional Analysis of Nurse 
Practitioner, Physician Assistant, and Physician Prescribing 
Patterns.'' Journal General Internal Medicine. 2020; 35(9):2584-2592.
    \20\ Id.
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    Multiple studies have also shown that nurse practitioners order 
more diagnostic imaging than physicians, which increases health care 
costs and threatens patient safety by exposing patients to unnecessary 
radiation. For example, a study in the Journal of the American College 
of Radiology, which analyzed skeletal X-ray utilization for Medicare 
beneficiaries from 2003 to 2015, found ordering increased 
substantially--more than 400 percent--by non-physicians, primarily 
nurse practitioners and physician assistants, during this time 
frame.\21\ A separate study published in JAMA Internal Medicine found 
nurse practitioners ordered more diagnostic imaging than primary care 
physicians following an outpatient visit. The study controlled for 
imaging claims that occurred after a referral to a specialist.\22\ The 
authors opined this increased utilization may have important 
ramifications on costs, safety, and quality of care. They further found 
greater coordination in health care teams may produce better outcomes 
than merely expanding nurse practitioner scope of practice.
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    \21\ D.J. Mizrahi, et.al. ``National Trends in the Utilization of 
Skeletal Radiography,'' Journal of the American College of Radiology 
2018; 1408-1414.
    \22\ D.R. Hughes, et al., A Comparison of Diagnostic Imaging 
Ordering Patterns Between Advanced Practice Clinicians and Primary Care 
Physicians Following Office-Based Evaluation and Management Visits. 
JAMA Internal Med. 2014;175(1):101-07.
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    Nurse practitioners and physician assistants are integral members 
of the care team, but the skills and acumen obtained by physicians 
throughout their extensive education and training make them uniquely 
qualified to oversee and supervise patients' care. Physician-led team-
based care has a proven track record of success in improving the 
quality of patient care, reducing costs, and allowing all health care 
professionals to spend more time with their patients. Moreover, it 
allows each practitioner to do what they do best and reduces the 
burnout and stress associated with being required to go above and 
beyond a non-physician practitioner's training.

Conclusion

    The physician workforce shortage within the VHA is well documented, 
and the pandemic has only served to magnify these workforce issues and 
other structural problems. The AMA thanks the Committee for holding 
this hearing and for its careful consideration of solutions to improve 
the physician shortage in the VHA. We look forward to working with the 
Committee and Congress to seek bipartisan policy solutions that will 
ensure that veterans are provided the best care possible and that 
barriers are addressed to resolve the physician workforce shortage and 
preserve patient access to care within the VHA.

             Prepared Statement of National Nurses United 

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   Prepared Statement of American Association of Nurse Anesthesiology

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