VA Health Care: Many Medical Facilities Have Challenges in	 
Recruiting and Retaining Nurse Anesthetists (13-DEC-07, 	 
GAO-08-56).							 
                                                                 
Certified registered nurse anesthetists (CRNA), registered nurses
who have completed a master's degree program in nurse anesthesia,
provide the majority of anesthesia care veterans receive in VA	 
medical facilities. While the demand for CRNAs is anticipated to 
increase, many CRNAs employed by VA--VA CRNAs--are nearing	 
retirement eligibility age. Concerns have been raised about the  
challenges VA may face in maintaining its VA CRNA workforce. GAO 
(1) identified VA CRNA workforce challenges that VA medical	 
facilities may experience related to VA CRNAs, (2) identified the
key mechanisms that VA medical facilities can use to recruit and 
retain VA CRNAs, and (3) determined the extent to which 	 
facilities use the key mechanisms. To identify VA CRNA workforce 
challenges, GAO analyzed Web-based surveys it sent to VA chief	 
anesthesiologists, VA human resources officers, and VA CRNAs,	 
with survey response rates of 92, 85, and 76 percent,		 
respectively. GAO also identified the key mechanisms VA medical  
facilities can use to recruit and retain VA CRNAs and the extent 
that these mechanisms are used. 				 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-08-56						        
    ACCNO:   A78868						        
  TITLE:     VA Health Care: Many Medical Facilities Have Challenges  
in Recruiting and Retaining Nurse Anesthetists			 
     DATE:   12/13/2007 
  SUBJECT:   Anesthesiology					 
	     Employee incentives				 
	     Employee retention 				 
	     Employee training					 
	     Employee turnover					 
	     Health care personnel				 
	     Medical education					 
	     Nurses						 
	     Personnel recruiting				 
	     Policy evaluation					 
	     Program evaluation 				 
	     Veterans hospitals 				 
	     Veterans' medical care				 

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GAO-08-56

   

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Report to Congressional Requesters: 

United States Government Accountability Office: 

GAO: 

December 2007: 

VA Health Care: 

Many Medical Facilities Have Challenges in Recruiting and Retaining 
Nurse Anesthetists: 

VA Nurse Anesthetists: 

GAO-08-56: 

GAO Highlights: 

Highlights of GAO-08-56, a report to congressional requesters. 

Why GAO Did This Study: 

Certified registered nurse anesthetists (CRNA), registered nurses who 
have completed a masterï¿½s degree program in nurse anesthesia, provide 
the majority of anesthesia care veterans receive in VA medical 
facilities. While the demand for CRNAs is anticipated to increase, many 
CRNAs employed by VAï¿½VA CRNAsï¿½are nearing retirement eligibility age. 
Concerns have been raised about the challenges VA may face in 
maintaining its VA CRNA workforce. GAO (1) identified VA CRNA workforce 
challenges that VA medical facilities may experience related to VA 
CRNAs, (2) identified the key mechanisms that VA medical facilities can 
use to recruit and retain VA CRNAs, and (3) determined the extent to 
which facilities use the key mechanisms. To identify VA CRNA workforce 
challenges, GAO analyzed Web-based surveys it sent to VA chief 
anesthesiologists, VA human resources officers, and VA CRNAs, with 
survey response rates of 92, 85, and 76 percent, respectively. GAO also 
identified the key mechanisms VA medical facilities can use to recruit 
and retain VA CRNAs and the extent that these mechanisms are used. 

What GAO Found: 

Department of Veterans Affairs (VA) medical facilities have challenges 
in recruiting and retaining VA CRNAs for their workforce. About three-
fourths of all VA medical facility chief anesthesiologists responding 
to GAOï¿½s survey reported that they had difficulty recruiting VA CRNAs. 
The challenge recruiting VA CRNAs has made it difficult to fill 
existing VA CRNA vacancies at VA medical facilities. Overall, 54 
percent of VA medical facility chief anesthesiologists reported 
temporarily closing some operating rooms and 72 percent reported 
delaying some elective surgeries. VAï¿½s retention challenge comes from a 
projected substantial attrition rate. Based on the results of its 
survey, GAO projects that 26 percent of VAï¿½s CRNAs will either retire 
from or leave VA in the next 5 years. VA medical facility officials 
reported in GAOï¿½s survey that the recruitment and retention challenges 
are caused primarily by the low level of VA CRNA salaries when compared 
with CRNA salaries in local market areas. 

VA has three key mechanisms its medical facilities can use to recruit 
and retain VA CRNAs. VA medical facilities can give bonuses to VA 
CRNAsï¿½recruitment, relocation, and retention bonuses. In addition, VA 
has education payment programs that provide funding to cover CRNA 
education costs. Finally, medical facilities can also use VAï¿½s locality 
pay system (LPS) to determine whether to adjust VA CRNA salaries to 
help the facilities remain competitive with CRNA salaries in local 
market areas. 

Each of the three key recruitment and retention mechanismsï¿½bonuses, 
education payment programs, and VAï¿½s LPSï¿½are used by some VA medical 
facilities. GAO found that in fiscal years 2005 or 2006, just over one-
third of VA medical facilities that hired VA CRNAs gave recruitment 
bonuses. For VA medical facilities that have VA CRNAs, less than one-
third gave retention bonuses in fiscal years 2005 or 2006. In addition, 
all VA CRNAs that applied for funds to attend a CRNA school or to 
offset their educational debt and were eligible received these funds in 
fiscal years 2005 and 2006. GAO also found that more than half of VA 
medical facilities used VAï¿½s LPS to determine whether to adjust VA CRNA 
salaries in 2005 and in 2006. However, in the eight VA medical 
facilities visited, GAO found that although the facilities used VAï¿½s 
LPS, the majority of them did not fully follow VAï¿½s LPS policy 
correctly in either 2005 or 2006. Officials at these facilities did not 
always know or were not aware of certain aspects of the LPS policy, and 
VA has not provided training on the LPS to VA medical facility 
officials since the policy was changed in 2001. As a result, VA medical 
facility officials have not received LPS training that reflects VAï¿½s 
current LPS policy, and accordingly, cannot ensure that VA CRNA 
salaries have been adjusted as needed to be competitive. Although VA is 
in the process of developing a Web-based training course for the LPS, 
the department has not established a time frame for finalizing the 
development and implementation of this training course. 

What GAO Recommends: 

GAO recommends that VA expedite development and implementation of the 
training course on VAï¿½s LPS policy for VA facility officials 
responsible for compliance with the policy. VA generally concurred with 
the conclusions and recommendation and stated that it had developed a 
draft action plan. 

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.GAO-08-56]. For more information, contact Laurie 
E. Ekstrand at (202) 512-7114 or [email protected]. 

[End of section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

VA Medical Facilities Have VA CRNA Recruitment and Retention Challenges 
Partly Because of Noncompetitive Salaries: 

VA Can Offer Bonuses, Pay Education Costs, and Adjust Salaries to 
Recruit and Retain VA CRNAs: 

Some Medical Facilities Use the Key Recruitment and Retention 
Mechanisms, Though in Some Cases LPS Was Used Incorrectly: 

Conclusions: 

Recommendation for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Scope and Methodology: 

Appendix II: Analysis of GAO Survey of Certified Registered Nurse 
Anesthetists Employed by VA: 

Appendix III: Analysis of GAO Survey of Chief Anesthesiologists 
Employed by VA: 

Appendix IV: Analysis of GAO Survey of VA Medical Facility Human 
Resources Officers: 

Appendix V: Description of Education and Training Requirements for 
Anesthesia Practitioners: 

Appendix VI: Comments from the Department Of Veterans Affairs: 

Appendix VII: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Reported Effects of VA CRNA Vacancies on Delivery of Services 
at VA Medical Facilities: 

Table 2: Reported Reasons VA Medical Facilities Used Contract CRNAs, 
Fiscal Years 2005 and 2006: 

Table 3: Differences in VA CRNA Salaries and CRNA Salaries in Local 
Market Areas, as Reported by VA Chief Anesthesiologists, Fiscal Years 
2005 and 2006: 

Abbreviations: 

AA: anesthesiologist assistant: 

AANA: American Association of Nurse Anesthetists: 

BLS: Bureau of Labor Statistics: 

CRNA: certified registered nurse anesthetist: 

DOD: Department of Defense: 

EISP: Employee Incentive Scholarship Program: 

EDRP: Education Debt Reduction Program: 

HR: human resources: 

HRRO: Healthcare Retention and Recruitment Office: 

LPS: locality pay system: 

VA: Department of Veterans Affairs: 

United States Government Accountability Office: 

Washington, DC 20548: 

December 13, 2007: 

The Honorable Daniel K. Akaka: 
Chairman: 
Committee on Veterans' Affairs: 
United States Senate: 

The Honorable Ken Salazar: 
United States Senate: 

Certified registered nurse anesthetists (CRNA) provide the majority of 
anesthesia care[Footnote 1] veterans receive in medical facilities 
operated by the Department of Veterans Affairs (VA). CRNAs are 
registered nurses who have completed a 2 to 3 year master's degree 
program in nurse anesthesia and who typically provide anesthesia care 
in health care settings with anesthesiologists and surgeons. There are 
approximately 500 VA-employed CRNAs (VA CRNA) who provide anesthesia 
care to veterans in VA medical facilities. The demand for CRNAs in VA 
medical facilities has continued to increase because CRNAs are no 
longer used only in the operating room, but are used in other areas of 
a medical facility, such as administering anesthesia to patients who 
are undergoing cardiac catheterization and providing airway management 
to patients during cardiac emergencies. 

While the demand for CRNAs is anticipated to increase, many VA CRNAs 
are nearing retirement eligibility age. According to VA officials, more 
than half of VA CRNAs are over the age of 51, and the average VA CRNA 
is 7 years closer to retirement eligibility than the average CRNA 
nationally. Because CRNAs provide the majority of anesthesia services 
in VA medical facilities and facility officials have reported problems 
with recruiting and retaining VA CRNAs, concerns have been raised about 
the challenges VA may face in maintaining its VA CRNA workforce, 
particularly in some local market areas where the labor market for 
CRNAs can be highly competitive. 

You asked that we review VA's efforts to recruit and retain VA CRNAs. 
In this report, we (1) identify workforce challenges that VA medical 
facilities may experience related to VA CRNAs, (2) identify the key 
mechanisms that VA medical facilities can use to recruit and retain VA 
CRNAs, and (3) determine the extent to which VA medical facilities use 
the key mechanisms to recruit and retain VA CRNAs. 

To identify workforce challenges VA medical facilities may experience 
related to VA CRNAs, we analyzed data obtained from three of our Web- 
based surveys. The first survey, administered to VA CRNAs, obtained a 
response rate of 76 percent and allowed us to determine whether these 
VA CRNAs plan to retire or leave VA's health care system within the 
next 5 years. The second survey was administered to VA medical 
facilities' chief anesthesiologists and obtained a 92 percent response 
rate, and the third survey was administered to VA human resources (HR) 
officers and obtained an 85 percent response rate. We used the second 
and third surveys to identify the issues VA medical facilities face 
when recruiting and retaining VA CRNAs. We also analyzed data on VA 
CRNA vacancies--the number of unfilled VA CRNA positions at VA medical 
facilities--obtained from VA headquarters. These data were from 2005, 
the most recent year for which vacancy data were available. 
Additionally, we obtained data on VA CRNAs' salaries for 2005, 2006, 
and 2007 and compared these to salary data we obtained from the 
American Association of Nurse Anesthetists (AANA), a professional 
organization for CRNAs, to determine whether VA medical facilities' 
salaries for VA CRNAs are competitive with CRNA salaries in local 
market areas.[Footnote 2] We interviewed a representative from Kaiser 
Permanente, a large health care plan that primarily uses CRNAs to 
deliver anesthesia services, to identify what steps this health plan 
takes to ensure it has a sufficient number of CRNAs and to determine 
the indicators this plan uses to identify a CRNA shortage or potential 
future CRNA shortage. 

To ensure the reliability of the data we used, we interviewed VA and 
AANA officials about the quality checks and edits they performed on 
their data. In addition, we assessed the data obtained from our three 
Web-based surveys by performing a systematic review of the returned 
questionnaires. On the basis of our assessment we determined these data 
were adequate for our purposes. 

To determine the key mechanisms that VA medical facilities use to 
recruit and retain VA CRNAs, we reviewed VA's policies and directives 
related to VA CRNAs and obtained reports on VA CRNAs' salaries, 
bonuses,[Footnote 3] education programs, and qualification standards. 
We interviewed officials at VA headquarters and selected VA medical 
facilities. To determine the extent to which VA medical facilities use 
key mechanisms to recruit and retain VA CRNAs, we visited eight VA 
medical facilities located in Denver, Colorado; Houston, Texas; 
Minneapolis, Minnesota; New York, New York; Portland, Oregon; Seattle, 
Washington; Tampa, Florida; and Togus, Maine. We selected these 
facilities because they are geographically dispersed across the country 
and employ VA CRNAs. At each VA medical facility we visited, we 
interviewed chief anesthesiologists, VA CRNAs, HR officers, and other 
facility officials and asked them about their efforts to recruit and 
retain VA CRNAs. We also analyzed data obtained from our three Web- 
based surveys to determine the extent to which VA medical facilities 
use the key mechanisms to recruit and retain VA CRNAs. For a complete 
description of our scope and methodology, see appendix I. The results 
of our surveys are provided in appendixes II, III, and IV. We conducted 
our work from June 2006 through October 2007 in accordance with 
generally accepted government auditing standards. 

Results in Brief: 

VA medical facilities have challenges in recruiting and retaining VA 
CRNAs for their workforce. About three-fourths of all VA medical 
facility chief anesthesiologists responding to our survey reported that 
they had difficulty recruiting VA CRNAs. The challenge recruiting VA 
CRNAs has made it difficult to fill existing vacancies--or the number 
of unfilled VA CRNA positions--at VA medical facilities. Overall, 54 
percent of VA medical facility chief anesthesiologists reported 
temporarily closing some operating rooms and 72 percent reported 
delaying some elective surgeries. In addition, VA's retention challenge 
comes from a projected substantial attrition rate. On the basis of our 
survey results, we project that 26 percent of VA's CRNAs will either 
retire from or leave VA in the next 5 years. While some facilities are 
likely to experience substantially less than 26 percent attrition, many 
others are likely to have to manage with much higher rates. VA medical 
facility officials reported in our survey that the recruitment and 
retention challenges are caused primarily by the low level of VA CRNA 
salaries when compared with CRNA salaries in local market areas. 

VA has three key mechanisms its medical facilities can use to recruit 
and retain VA CRNAs. VA medical facilities can give bonuses to VA 
CRNAs--recruitment, relocation, and retention bonuses. Each of these 
bonuses can be up to 25 percent of a VA CRNA's salary, according to 
VA's policy. Further, VA CRNAs who are receiving a recruitment or 
relocation bonus are not eligible for a retention bonus while receiving 
either of the other two types of bonuses, according to a VA official. 
Additionally, VA has two education payment programs medical facilities 
may use to help recruit and retain VA CRNAs. One program provides 
funding to registered nurses for training to become a CRNA, and the 
other provides funding to offset educational debt incurred by VA CRNAs. 
Finally, medical facilities can use VA's locality pay system (LPS) to 
determine whether to adjust VA CRNA salaries to help the facilities 
remain competitive with CRNA salaries in local market areas. 

Each of the three key recruitment and retention mechanisms--bonuses, 
education payment programs, and VA's LPS are used by some VA medical 
facilities. We found that in fiscal year 2005, of the 47 VA medical 
facilities that hired VA CRNAs, 18 gave recruitment bonuses, and in 
fiscal year 2006, 15 of 43 facilities that hired VA CRNAs gave 
recruitment bonuses. In addition, less than one-third of VA medical 
facilities that employ VA CRNAs gave retention bonuses. Specifically, 
32 facilities gave retention bonuses in fiscal year 2005 and 36 
facilities gave them in fiscal year 2006. Two facilities gave 
relocation bonuses in fiscal year 2005 and 3 in fiscal year 2006. In 
addition, all VA CRNAs that applied for funds to attend a CRNA school 
or to offset their educational debt and were eligible received these 
funds in fiscal years 2005 and 2006. We also found that more than half 
of VA medical facilities that have VA CRNAs used VA's LPS to determine 
whether to adjust VA CRNA salaries. However, in the 8 VA medical 
facilities we visited, we found that although the facilities used VA's 
LPS, the majority of them did not fully follow VA's LPS policy 
correctly in either 2005 or 2006. Officials at these facilities did not 
always know or were unaware of certain aspects of the LPS policy. VA 
has not provided training on its policy to VA medical facility 
officials since the policy was changed in 2001. As a result, VA medical 
facility officials have not received LPS training that reflects VA's 
current policy, and accordingly, cannot ensure that VA CRNA salaries 
have been adjusted as needed to be competitive. Although VA is in the 
process of developing a Web-based training course for LPS, the 
department has not established a time frame for finalizing the 
development and implementation of this training course. 

To improve VA's ability to recruit and retain VA CRNAs, we recommend 
that the Secretary of Veterans Affairs direct the Assistant Secretary 
for Human Resources and Administration to expedite development and 
implementation of the training course on VA's LPS policy for VA medical 
facility officials responsible for compliance with the policy. In 
commenting on a draft of this report, VA generally agreed with our 
conclusions. VA also concurred with our recommendation to expedite the 
development and implementation of the training course on VA's LPS 
policy and stated that it has developed a draft action plan for 
training staff on this policy and anticipates the on-line training 
course will be available by the end of fiscal year 2008. VA also 
provided technical comments, which we have incorporated as appropriate. 

Background: 

Anesthesia services are provided by anesthesia practitioners-- 
typically anesthesiologists and CRNAs. Anesthesiologists are physicians 
who have completed medical school and typically a 4-year anesthesiology 
residency. Both anesthesiologists and CRNAs administer anesthesia for 
all types of surgical procedures, working either as single providers or 
together. Anesthesia services can be provided by anesthesiologists 
alone, by anesthesiologists working with CRNAs, by CRNAs alone, or by 
anesthesiologist assistants (AA), working under the supervision of an 
anesthesiologist. AAs are graduates of a medical- school-based AA 
education program. (See app. V for the education and training 
requirements for anesthesiologists, CRNAs, and AAs.) 

The nurse anesthetist profession has made efforts to meet the demand 
for CRNA services in the public and private health care sectors. The 
profession has increased the number of accredited CRNA training 
programs, and as a result the number of CRNA graduates has increased-- 
over 2,000 graduates in 2007, 57 percent more than in the year 2000. 
The growth in the demand for CRNAs is expected to continue. 

A joint Department of Defense (DOD)/VA program in nurse anesthesia 
education was established in 2004 at Fort Sam Houston in San Antonio, 
Texas. This 30-month program, run by the United States Army, educates 
military personnel and VA registered nurses to become CRNAs. New VA 
CRNAs who complete this program have a 3-year service obligation to VA 
upon graduation. 

When hiring VA CRNAs, VA places them in one of five pay grades, based 
on the CRNA's education and experience. VA's qualification standards 
for VA CRNAs establish the five grades with grade I being the lowest. 
The grades ultimately determine the salary for each VA CRNA working in 
a VA medical facility. Within each grade, there are a number of steps-
-generally 12--that represent progressive increments of a 3 percent 
increase in salary within the grade. For example, the salary of a VA 
CRNA that is at grade II, step 2, is 3 percent more than a VA CRNA's 
salary at grade II, step 1. VA CRNA qualification standards indicate 
that new graduate VA CRNAs usually begin at grade I, receiving a lower 
salary because of the lack of work experience, whereas experienced VA 
CRNAs might start at grade II or III receiving a higher salary. VA 
medical facilities' salaries for a VA CRNA at a grade I, step 1, range 
from a low of $37,432 to a high of $104,575 in market areas where 
salaries are higher. 

VA CRNAs typically work under the medical direction of a chief 
anesthesiologist, who is responsible for supervising anesthesia 
clinical staff, such as other anesthesiologists and nurse anesthetists. 
Chief anesthesiologists are responsible for the quality and safety of 
anesthesia services provided in the medical facility. VA CRNA benefits 
and other personnel issues, such as hiring and setting base salaries, 
are managed by VA medical facilities' HR officers. HR officers are also 
responsible for issues related to compensation, employee and labor 
relations, recruitment, and performance management. 

VA medical facilities have clinical staff that are trained to provide 
different types of health care services. In many cases, the ability to 
provide health care services to veterans is dependent on the 
availability of numerous types of clinical staff that work in concert 
with one another to provide these services. If one of these types of 
staff is not available, the health care service may be delayed or not 
provided. For example, even though a CRNA is available to provide 
anesthesia services, if other personnel, such as operating room nurses 
or nurses that staff the post-anesthesia recovery unit, are not 
available, the surgical procedure may be delayed or cancelled. 
Likewise, if a CRNA, or other professional anesthesia staff, are not 
available, the surgical procedure may have to be delayed or cancelled. 

VA Medical Facilities Have VA CRNA Recruitment and Retention Challenges 
Partly Because of Noncompetitive Salaries: 

VA medical facilities have challenges recruiting and retaining VA 
CRNAs. Most surveyed officials reported that they had difficulty 
recruiting VA CRNAs at their facilities. The challenge recruiting VA 
CRNAs affects the ability of VA officials to reduce existing VA CRNA 
vacancy rates--the number of unfilled VA CRNA positions--at their 
medical facilities. These rates vary across VA, with 26 medical 
facilities having vacancy rates of 25 percent or more and 15 of them 
having vacancy rates of 40 percent or more.[Footnote 4] Overall, 54 
percent of the chief anesthesiologists responding to our survey 
reported temporarily closing some operating rooms and 72 percent 
reported delaying some elective surgeries because of VA CRNA vacancies 
in fiscal year 2006. On the basis of our survey results, in addition to 
their current recruiting challenges, VA medical facilities will likely 
face a challenge retaining VA CRNAs in the next 5 years due to the 
number of VA CRNAs projected to either retire from or leave VA. VA 
medical facility officials reported in our survey that the recruitment 
and retention challenges are caused primarily by the low level of VA 
CRNA salaries when compared with CRNA salaries in local market areas. 

VA Officials Report Challenges Recruiting CRNAs, and Projected VA CRNA 
Attrition Will Create a Retention Challenge in the Next 5 Years: 

Our survey results indicate that VA medical facilities have a challenge 
recruiting VA CRNAs. Of all VA medical facility chief anesthesiologists 
that responded to our survey, 74 percent reported that they had 
difficulty recruiting CRNAs in fiscal years 2005 and 2006. The 
recruiting challenges also affect VA medical facility officials' 
ability to reduce existing VA CRNA vacancy rates at their medical 
facilities. Additionally, VA medical facility officials responding to 
our survey reported that it takes VA facilities a long time--on average 
about 15 months--to fill a VA CRNA vacancy from the time facility 
management approval is granted to fill the position until the time the 
VA CRNA actually begins providing services at the facility. In 
particular, VA chief anesthesiologists at 11 medical facilities 
reported that their facilities took 2 years or more on average to fill 
a VA CRNA vacancy. In our survey, the shortest time taken to fill a 
vacancy as reported by the chief anesthesiologists was 2 months, and 
the longest was 60 months. 

The challenge of recruiting CRNAs limits the ability of VA officials to 
reduce existing vacancy rates at their medical facilities. VA's fiscal 
year 2005 vacancy data[Footnote 5] show VA had about a 13 percent VA 
CRNA vacancy rate systemwide, or 70 unfilled VA CRNA positions at 43 
medical facilities.[Footnote 6] These rates vary across VA, with 26 
medical facilities having vacancy rates of 25 percent or more and 15 of 
them having vacancy rates of 40 percent or more in fiscal year 2005. 
According to the director of Kaiser Permanente's school of anesthesia 
for nurse anesthetists, a vacancy rate of 40 percent or higher is 
considered indicative of a staffing problem. Like VA's vacancy data, 
our survey also suggests that VA CRNA vacancies are common across VA 
medical facilities. Of the chief anesthesiologists responding to our 
survey, 54 percent reported that they had VA CRNA vacancies at their VA 
medical facility, with the number of VA CRNA vacancies ranging from one 
to six. 

According to our survey, VA CRNA vacancies have impacted the delivery 
of services at VA medical facilities. For example, 54 percent of the VA 
chief anesthesiologists with VA CRNA vacancies reported that they 
temporarily closed operating rooms, 72 percent delayed elective 
surgeries, and 68 percent increased the use of overtime for VA CRNAs, 
as a result of VA CRNA vacancies in fiscal year 2006. Moreover, 44 
percent of chief anesthesiologists that had VA CRNA vacancies reported 
that contract CRNAs were used.[Footnote 7] In addition, almost one- 
third of the chief anesthesiologists whose vacancies were filled 
reported that they still had a shortage of VA CRNAs. See table 1 for 
the types of effects that VA CRNA vacancies have had on the delivery of 
services, as reported by chief anesthesiologists who reported VA CRNA 
vacancies. 

Table 1: Reported Effects of VA CRNA Vacancies on Delivery of Services 
at VA Medical Facilities: 

Type of effects that VA CRNA vacancies have had on delivery of 
services: Some elective surgeries were delayed; 
Percentage of chief anesthesiologists reporting type of effect: 72. 

Type of effects that VA CRNA vacancies have had on delivery of 
services: VA CRNA overtime increased; 
Percentage of chief anesthesiologists reporting type of effect: 68. 

Type of effects that VA CRNA vacancies have had on delivery of 
services: Some operating rooms were closed temporarily; 
Percentage of chief anesthesiologists reporting type of effect: 54. 

Type of effects that VA CRNA vacancies have had on delivery of 
services: Contract CRNAs were used; 
Percentage of chief anesthesiologists reporting type of effect: 44. 

Type of effects that VA CRNA vacancies have had on delivery of 
services: Other effects[A]; 
Percentage of chief anesthesiologists reporting type of effect: 34. 

Type of effects that VA CRNA vacancies have had on delivery of 
services: Some patients were diverted to other facilities; 
Percentage of chief anesthesiologists reporting type of effect: 32. 

Type of effects that VA CRNA vacancies have had on delivery of 
services: Intermittent or fee-basis CRNAs were used[B]; 
Percentage of chief anesthesiologists reporting type of effect: 30. 

Type of effects that VA CRNA vacancies have had on delivery of 
services: No effect on the medical facility; 
Percentage of chief anesthesiologists reporting type of effect: 2. 

Source: GAO survey of VA medical facility chief anesthesiologists. 

Note: Chief anesthesiologists may have reported more than one effect 
that VA CRNA vacancies have on the delivery of services. 

[A] A few of the other effects cited by the chief anesthesiologists 
include anesthesiologists working overtime or through their lunch hour, 
the use of contract anesthesiologists, and general staff 
dissatisfaction. 

[B] Intermittent CRNAs are those that work at VA on an irregular or 
occasional basis and whose hours or days of work are not on a 
prearranged schedule and they are paid only for the hours actually 
worked. Fee-basis CRNAs are those that work at VA on a limited basis 
and are paid per procedure and not on an hourly rate. 

[End of table] 

According to some VA chief anesthesiologists who responded to our 
survey, the use of contract CRNAs has increased over the last 3 years. 
In fiscal years 2005 and 2006, about 30 percent of VA medical facility 
chief anesthesiologists who responded to our survey reported using 
contract CRNAs to supplement their anesthesia workforce. See table 2 
for the reasons cited by chief anesthesiologists for using contract 
CRNAs. These chief anesthesiologists reported on our survey that they 
used an average of less than one full-time contract CRNA in both fiscal 
years 2005 and 2006. According to our survey, the chief 
anesthesiologists who reported data for both contract hours and 
contract costs reported a median hourly CRNA contract cost of $112 in 
fiscal year 2005 and $114 in fiscal year 2006.[Footnote 8] This 
compares to an hourly cost for a full-time VA CRNA of $82 in fiscal 
year 2005 and $84 in fiscal year 2006 for a VA CRNA earning the maximum 
statutory salary.[Footnote 9] 

Table 2: Reported Reasons VA Medical Facilities Used Contract CRNAs, 
Fiscal Years 2005 and 2006: 

Reasons VA medical facilities used contract CRNAs: Difficulty 
recruiting VA CRNAs; 
Percentage of chief anesthesiologists reporting reason in fiscal year 
2005: 52; 
Percentage of chief anesthesiologists reporting reason in fiscal year 
2006: 45. 

Reasons VA medical facilities used contract CRNAs: Shortage of CRNAs in 
the local market area; 
Percentage of chief anesthesiologists reporting reason in fiscal year 
2005: 41; 
Percentage of chief anesthesiologists reporting reason in fiscal year 
2006: 39. 

Reasons VA medical facilities used contract CRNAs: Difficulty retaining 
VA CRNAs; 
Percentage of chief anesthesiologists reporting reason in fiscal year 
2005: 27; 
Percentage of chief anesthesiologists reporting reason in fiscal year 
2006: 30. 

Reasons VA medical facilities used contract CRNAs: Short-term coverage 
for a VA CRNA's absence; 
Percentage of chief anesthesiologists reporting reason in fiscal year 
2005: 32; 
Percentage of chief anesthesiologists reporting reason in fiscal year 
2006: 27. 

Reasons VA medical facilities used contract CRNAs: Other reasons; 
Percentage of chief anesthesiologists reporting reason in fiscal year 
2005: 16; 
Percentage of chief anesthesiologists reporting reason in fiscal year 
2006: 16. 

Reasons VA medical facilities used contract CRNAs: Coverage for a VA 
CRNA called to active military duty; 
Percentage of chief anesthesiologists reporting reason in fiscal year 
2005: 16; 
Percentage of chief anesthesiologists reporting reason in fiscal year 
2006: 9. 

Reasons VA medical facilities used contract CRNAs: Retirement of a VA 
CRNA; 
Percentage of chief anesthesiologists reporting reason in fiscal year 
2005: 14; 
Percentage of chief anesthesiologists reporting reason in fiscal year 
2006: 14. 

Reasons VA medical facilities used contract CRNAs: Higher than 
anticipated surgical volume; 
Percentage of chief anesthesiologists reporting reason in fiscal year 
2005: 14; 
Percentage of chief anesthesiologists reporting reason in fiscal year 
2006: 11. 

Reasons VA medical facilities used contract CRNAs: Higher than 
anticipated VA CRNA vacancy rate; 
Percentage of chief anesthesiologists reporting reason in fiscal year 
2005: 9; 
Percentage of chief anesthesiologists reporting reason in fiscal year 
2006: 11. 

Reasons VA medical facilities used contract CRNAs: Hiring freeze; 
Percentage of chief anesthesiologists reporting reason in fiscal year 
2005: 5; 
Percentage of chief anesthesiologists reporting reason in fiscal year 
2006: 2. 

Source: GAO survey of VA medical facility chief anesthesiologists. 

Note: Chief anesthesiologists may have reported more than one reason 
why contract CRNAs were used. 

[End of table] 

In addition to the current challenges of recruiting CRNAs, VA medical 
facilities are also likely to face another workforce challenge in the 
future. Specifically, in the next 5 years VA medical facilities will 
likely have difficulty retaining VA CRNAs in their workforce and this 
trend could increase the number of VA CRNA vacancies across VA. On the 
basis of VA CRNA responses to our survey, we project a VA CRNA 
attrition rate of 26 percent across VA in the next 5 years--that is, 26 
percent of VA CRNAs either plan to retire or leave VA's health care 
system within the next 5 years.[Footnote 10] Overall, 93 VA CRNAs at 53 
of VA's 120 medical facilities that employ VA CRNAs reported that they 
plan to retire or leave VA's health care system. While the overall 
projected attrition rate across VA, on the basis of our survey results, 
is likely to be 26 percent, this rate will vary by medical facility. In 
27 VA medical facilities, we project that the attrition rate is likely 
to be 50 percent or higher. According to the director of Kaiser 
Permanente's school of anesthesia for nurse anesthetists, an attrition 
rate of 50 percent or higher is considered indicative of a future 
staffing problem. 

According to VA Officials and VA CRNAs, Difficulty Recruiting and 
Retaining VA CRNAs is Due to Noncompetitive VA CRNA Salaries: 

Our surveys of VA medical facility chief anesthesiologists and HR 
officers indicate that medical facilities have trouble recruiting and 
will have trouble retaining VA CRNAs because salaries for VA CRNAs are 
low compared to CRNA salaries in local market areas. Of the 69 chief 
anesthesiologists who reported having difficulty recruiting VA CRNAs 
during fiscal years 2005 and 2006, about 60 of them attributed this 
difficulty primarily to the fact that salaries for VA CRNAs at their 
medical facilities were not competitive with CRNA salaries in local 
market areas.[Footnote 11] Additionally, of the 46 chief 
anesthesiologists who reported having difficulty retaining VA CRNAs 
during fiscal years 2005 and 2006, 36 of them attributed this primarily 
to the fact that salaries for experienced VA CRNAs[Footnote 12] at 
their medical facilities were not competitive with CRNA salaries in 
local market areas. Other reasons most frequently cited by the chief 
anesthesiologists were indirectly associated with the level of VA CRNA 
salaries.[Footnote 13] 

Of the chief anesthesiologists surveyed, 72 percent (67) of chief 
anesthesiologists reported that VA CRNA starting salaries for new 
graduates at their facility were lower than local market area salaries 
in fiscal year 2005, and 69 percent (64) of chiefs reported this in 
fiscal year 2006. In fiscal years 2005 and 2006, 79 percent (73) of 
chief anesthesiologists estimated that salaries for experienced VA 
CRNAs at their medical facility were lower than local market area CRNA 
salaries. 

Furthermore, about 40 percent of chief anesthesiologists also reported 
that salaries for both new graduate and experienced VA CRNAs at their 
facility were $10,000 to $30,000 lower than CRNAs salaries in local 
market areas during fiscal years 2005 and 2006. See table 3 for the 
differences in VA CRNA salaries and CRNA salaries in local market areas 
in fiscal years 2005 and 2006, as reported by VA chief 
anesthesiologists. 

Table 3: Differences in VA CRNA Salaries and CRNA Salaries in Local 
Market Areas, as Reported by VA Chief Anesthesiologists, Fiscal Years 
2005 and 2006: 

VA CRNA salaries lower than CRNA salaries in local market areas by 
$10,000 or less; 
Percentage of chief anesthesiologists reporting for fiscal year 2005: 
New graduate VA CRNA[A]: 12; 
Percentage of chief anesthesiologists reporting for fiscal year 2005: 
Experienced VA CRNA[B]: 13; 
Percentage of chief anesthesiologists reporting for fiscal year 2006: 
New graduate VA CRNA[A]: 9; 
Percentage of chief anesthesiologists reporting for fiscal year 2006: 
Experienced VA CRNA[B]: 12. 

VA CRNA salaries lower than CRNA salaries in local market areas by 
$10,001 to $30,000; 
Percentage of chief anesthesiologists reporting for fiscal year 2005: 
New graduate VA CRNA[A]: 41; 
Percentage of chief anesthesiologists reporting for fiscal year 2005: 
Experienced VA CRNA[B]: 40; 
 Percentage of chief anesthesiologists reporting for fiscal year 2006: 
New graduate VA CRNA[A]: 42; 
Percentage of chief anesthesiologists reporting for fiscal year 2006: 
Experienced VA CRNA[B]: 42. 

VA CRNA salaries lower than CRNA salaries in local market areas by more 
than $30,000; 
Percentage of chief anesthesiologists reporting for fiscal year 2005: 
New graduate VA CRNA[A]: 19; 
Percentage of chief anesthesiologists reporting for fiscal year 2005: 
Experienced VA CRNA[B]: 26; 
 Percentage of chief anesthesiologists reporting for fiscal year 2006: 
New graduate VA CRNA[A]: 18; 
Percentage of chief anesthesiologists reporting for fiscal year 2006: 
Experienced VA CRNA[B]: 23. 

Not checked[C]; 
Percentage of chief anesthesiologists reporting for fiscal year 2005: 
New graduate VA CRNA[A]: 8; 
Percentage of chief anesthesiologists reporting for fiscal year 2005: 
Experienced VA CRNA[B]: 3; 
 Percentage of chief anesthesiologists reporting for fiscal year 2006: 
New graduate VA CRNA[A]: 9; 
Percentage of chief anesthesiologists reporting for fiscal year 2006: 
Experienced VA CRNA[B]: 7. 

Not applicable[D]; 
Percentage of chief anesthesiologists reporting for fiscal year 2005: 
New graduate VA CRNA[A]: 20; 
Percentage of chief anesthesiologists reporting for fiscal year 2005: 
Experienced VA CRNA[B]: 18; 
 Percentage of chief anesthesiologists reporting for fiscal year 2006: 
New graduate VA CRNA[A]: 23; 
Percentage of chief anesthesiologists reporting for fiscal year 2006: 
Experienced VA CRNA[B]: 17. 

Source: GAO survey of VA medical facility chief anesthesiologists. 

Note: Column totals may not add to 100 percent due to rounding and not 
all chief anesthesiologists who reported salaries were lower specified 
how much lower. 

[A] New graduate VA CRNAs have less than 2 years experience. 

[B] Experienced VA CRNAs have 2 or more years of experience. 

[C] Represents the chief anesthesiologists who did not provide a 
response to this question. 

[D] Represents the chief anesthesiologists who reported that VA CRNA 
salaries were not lower than the local market area. 

[End of table] 

Although the majority--about 79 percent--of VA medical facility chief 
anesthesiologists reported that VA CRNA salaries are not competitive 
with local market CRNA salaries, less than half of VA medical facility 
HR officers who responded to our survey concurred. Our survey results 
for new graduates and experienced VA CRNAs showed that in fiscal years 
2005 and 2006 about 45 percent of HR officers reported that their 
facilities' starting salaries for new graduate VA CRNAs were low when 
compared with CRNA salaries in local market areas.[Footnote 
14],[Footnote 15] In addition, about 47 percent of HR officers reported 
that salaries for experienced VA CRNAs were low when compared with CRNA 
salaries in local market areas in fiscal years 2005 and 2006. Further, 
our survey asked HR officers to report how much lower VA salaries were 
than local market area salaries for new graduate and experienced VA 
CRNAs. Our survey results showed that 17 percent of HR officers 
reported that salaries for new graduate VA CRNAs were $10,001 to 
$30,000 lower than CRNAs' salaries in local market areas in fiscal 
years 2005 and 2006. Also, about 19 percent of HR officers reported 
that salaries for experienced VA CRNAs were $10,001 to $30,000 lower 
than CRNAs' salaries in local market areas in both fiscal years. 

Furthermore, of the VA CRNAs who responded to our survey, 69 percent 
(250) of VA CRNAs reported that higher starting salaries for new 
graduate CRNAs would strengthen VA's recruitment efforts.[Footnote 16] 
When VA CRNAs who are considering retirement were asked what would make 
them postpone retirement, 91 percent (94) reported that higher salaries 
would delay their retirement from a VA medical facility. In addition, 
when VA CRNAs who are not eligible to retire in the next 5 years were 
asked what would keep a VA CRNA from leaving VA, 82 percent (119) of VA 
CRNAs reported that a higher salary would keep them working at 
VA.[Footnote 17] 

A VA headquarters official acknowledged that some medical facilities 
currently face recruitment challenges related to VA CRNA salaries. This 
official stated that according to anecdotal reports, there are CRNA 
recruiting challenges in some local market areas, while in other market 
areas there are no problems with recruitment. To address this problem, 
VA CRNAs and the director of VA's anesthesia services told us they are 
revising VA CRNA qualification standards, which will have the effect of 
increasing starting salaries for new graduate VA CRNAs from grade I to 
grade II. However, this revision to VA CRNA qualification standards-- 
increase in grade and resulting starting salary--would be unlikely to 
make most VA CRNA starting salaries competitive with local market area 
CRNA starting salaries. We compared VA CRNA 2007 salary schedules to 
projected AANA 2007 salary data to determine whether VA CRNA salaries 
would be competitive with local market area CRNA salaries if salaries 
for new graduate VA CRNAs were changed from grade I to grade II. Our 
analysis showed that this revision to VA CRNA qualification standards 
will not make most VA CRNA starting salaries competitive with local 
market area starting CRNA salaries. Specifically, 75 of 120 VA medical 
facilities that employ VA CRNAs would have VA CRNA starting salaries 
below local market area CRNA salaries by $20,000 or more. 

Similar challenges exist related to the retention of VA CRNAs. More 
than half of all VA CRNAs earned the maximum statutory salary 
cap[Footnote 18] for a VA CRNA in 2006, which was $133,900. However, at 
107 of VA's 120 medical facilities that employ VA CRNAs this maximum 
statutory salary cap is at least $20,000 lower than CRNA salaries in 
local market areas, based on our analysis comparing AANA salary data 
for CRNAs to VA's maximum statutory salary cap of $133,900. According 
to VA officials, VA has proposed legislation to increase the maximum 
statutory salary cap. The proposal would increase the maximum statutory 
salary cap for VA CRNAs by about $9,000. Our analysis comparing AANA 
salary data for CRNAs to VA's CRNA maximum statutory salary cap 
indicated that increasing the VA CRNA maximum statutory salary cap by 
about $9,000 will not, at a majority of VA medical facilities, make VA 
CRNA salaries competitive with CRNA salaries in local market areas. 
Specifically, we found that after the proposed change, 70 of the 120 VA 
medical facilities' VA CRNA salaries would still be $20,000 or more 
below the local market area CRNA salaries.[Footnote 19] 

VA Can Offer Bonuses, Pay Education Costs, and Adjust Salaries to 
Recruit and Retain VA CRNAs: 

VA has three key mechanisms its medical facilities can use to recruit 
and retain VA CRNAs. VA medical facilities can award recruitment, 
relocation, and retention bonuses of up to 25 percent of a VA CRNA's 
salary, according to VA's policy. Additionally, VA has two education 
payment programs medical facilities may use to help recruit and retain 
VA CRNAs. One program provides funding to registered nurses for 
training to become a CRNA, and the other provides funding to offset 
educational debt incurred by VA CRNAs. Finally, medical facilities can 
use VA's LPS to determine whether to adjust VA CRNA salaries to help 
the facilities remain competitive with CRNA salaries in local market 
areas. 

VA Medical Facilities Can Use Bonuses to Recruit and Retain VA CRNAs: 

VA medical facilities can use two types of bonuses--recruitment and 
relocation--to recruit VA CRNAs, and another type of bonus--retention-
-to retain VA CRNAs.[Footnote 20] Recruitment, relocation, and 
retention bonuses can be used to recruit and retain employees in 
positions that are difficult to fill, such as VA CRNAs. VA's policy 
allows medical facility officials to approve bonuses up to 25 percent 
of VA CRNAs' salaries for each year the VA CRNA agrees to work for the 
VA medical facility. Before approving a bonus, medical facility 
officials are required to document that certain criteria have been met, 
such as whether the facility is having difficulty recruiting and 
retaining VA CRNAs, whether the facility's VA CRNA salaries are 
competitive with CRNA salaries in local market areas, or whether the 
facility has a high VA CRNA turnover rate.[Footnote 21] VA medical 
facilities may terminate an agreement to pay a recruitment, relocation, 
or retention bonus if this payment does not meet the needs of VA, such 
as a lack of medical facility funds. Medical facility directors have 
discretion to determine whether to pay a bonus to VA CRNAs. 

To receive a recruitment bonus, a VA CRNA must agree to work a minimum 
of 6 months and the bonus may be given for a maximum service period of 
4 years. There is a great deal of flexibility in paying out this bonus, 
according to VA officials. Facility officials can choose to pay all or 
part of the bonus up front or split the bonus over any number of pay 
periods. VA medical facilities have authority to use a recruitment 
bonus if they are likely to have difficulty recruiting VA CRNAs. 

VA CRNAs may receive a relocation bonus to entice them to relocate to 
the area where the VA medical facility is located. To receive this 
bonus, a VA CRNA must agree to work a minimum of 6 months. Relocation 
bonuses are given to CRNAs who must change their job sites and 
physically relocate to a different geographic area. 

A retention bonus may be given to a VA CRNA for an unlimited service 
period and is paid out after the service period is completed if paid on 
any basis other than biweekly. VA medical facilities may give a 
retention bonus if a special need exists for the VA CRNA's services and 
it is likely that the VA CRNA will resign without the bonus. VA CRNAs 
who are receiving a recruitment or relocation bonus are not eligible 
for a retention bonus while receiving either of the other two types of 
bonuses, according to a VA HR official. 

Two VA Education Payment Programs Allow Medical Facilities to Provide 
Funding to Cover CRNA Education Costs to Recruit and Retain VA CRNAs: 

Medical facilities also have two VA education payment programs to aid 
in recruiting and retaining VA CRNAs--VA's Employee Incentive 
Scholarship Program (EISP) and VA's Education Debt Reduction Program 
(EDRP). VA's Healthcare Retention and Recruitment Office (HRRO) manages 
these two programs.[Footnote 22] VA's EISP was established in March 
2000 and is a scholarship program for VA registered nurses who attend 
CRNA training programs.[Footnote 23] These registered nurses are 
eligible for an EISP scholarship after a minimum of 1 year of 
continuous VA employment. VA's student CRNAs can use EISP funding to 
pay for the cost of their tuition, books, and for other related 
educational expenses, such as registration and fees. Additionally, EISP 
covers half of the salary of a registered nurse to replace the CRNA 
student and the other half is paid by the VA medical facility where the 
student will work once the CRNA training program is completed. VA CRNA 
students may use EISP funds to attend the joint DOD/VA nurse anesthesia 
training program. In fiscal year 2006, the lifetime maximum amount of a 
scholarship that could be paid to a VA CRNA through EISP was $35,024, 
and the VA CRNA then had a service obligation to VA for 3 years. 

VA's EDRP, a student loan repayment program established in May 2002, is 
available to newly hired clinicians, such as VA CRNAs, and is used as a 
recruitment tool by VA medical facilities. In fiscal year 2006, the 
maximum amount that could be paid to a VA CRNA for EDRP was $38,000 
divided into annual payments over a 5-year period. 

The distribution of funds for both EISP and EDRP varies by medical 
facility and is contingent upon the availability of VA funds. 
Applicants must be recommended by the medical facility director and 
approved by HRRO. VA medical facility selection criteria for both EISP 
and EDRP include an individual's career goals, work performance, 
workforce needs of VA, and a recommendation from an immediate 
supervisor. 

Medical Facilities Can Adjust VA CRNA Salaries Using VA's LPS: 

While VA CRNA grades, which establish VA CRNA salaries, are initially 
determined by VA's qualification standards for VA CRNAs, VA medical 
facilities have the option of adjusting these salaries to recruit and 
retain VA CRNAs.[Footnote 24] When adjusting VA CRNA salaries, VA 
medical facilities are required to use a process known as LPS.[Footnote 
25] The system is intended to help VA medical facilities determine 
whether to adjust VA CRNA salaries to be regionally competitive. VA's 
LPS supports these goals by providing information on salaries paid to 
CRNAs in a facility's local market area. To collect data for the LPS, 
medical facility directors, who are responsible for their facility's 
LPS, can either use a salary survey conducted by another entity or 
conduct their own survey in order to determine the CRNA salary levels 
paid by health care establishments in the local market area. VA's LPS 
policy requires that a medical facility director initiate an LPS survey 
if the director determines that a significant pay-related staffing 
problem exists or is likely to exist for any occupation or specialty. 

VA's LPS policy instructs medical facilities to use a survey conducted 
by the Bureau of Labor Statistics (BLS); however, if data from this 
survey are not available or not current, facilities are to use a third- 
party locality pay survey. Third-party surveys include those that are 
purchased from a third-party service that collects compensation data on 
salaries of health care occupations. These surveys can also include 
salary data collected by local hospital associations for their member 
health care establishments. When BLS or other third-party surveys are 
not available or do not contain sufficient salary data, facilities are 
to conduct their own locality pay survey. 

Under VA's LPS policy, a third-party locality pay survey must include 
data from at least three non-VA health care establishments, such as 
hospitals and outpatient clinics. VA's LPS policy requires that a third-
party survey cover an appropriate local market area, which is defined 
by VA as one that includes the county in which the VA medical facility 
is located and includes health care establishments that compete for the 
same type of clinical employees, such as CRNAs. The health care 
establishments that participate in a third-party survey should provide 
job descriptions that include the duties, responsibilities, and 
education and experience requirements of CRNAs and should be able to be 
readily job-matched to VA's description of the VA CRNA grade levels. 

If a VA medical facility conducts its own LPS survey, VA's LPS policy 
requires that the geographic area surveyed be defined. In order to be 
valid, three health care establishments must have job descriptions for 
CRNAs that can be job-matched to VA CRNA grade levels. A VA medical 
facility may expand the geographic area surveyed when the surveyed area 
will not adequately reflect the local market area salaries for CRNAs or 
there are less than three job matches.[Footnote 26] 

Once the survey is completed, a facility's HR officer reports the 
results to the medical facility director and based on the survey data, 
recommends whether to adjust VA CRNA salaries. The facility director 
makes the final decision on whether to adjust VA CRNA salaries and, 
therefore, may choose not to adjust existing salaries regardless of 
what the survey data show, according to VA's policy. VA medical 
facility directors consider the competing demands for funding across 
the facility when making decisions about VA CRNA salary increases. 

VA's LPS policy requires VA medical facilities to report annually to VA 
headquarters on VA CRNA staffing, such as the vacancy and turnover 
rates for VA CRNAs within the recent fiscal year. VA medical facilities 
are also required to report whether the facility had a pay-related 
staffing problem as determined by the medical facility director and 
whether a medical facility director used a locality pay survey to 
determine if VA CRNA salaries should be adjusted. VA reported that in 
2005 and 2006 all VA medical facility directors who determined that a 
significant pay-related staffing problem existed or was likely to exist 
at their facility used a locality pay survey to determine whether VA 
CRNA salaries should be adjusted. 

Some Medical Facilities Use the Key Recruitment and Retention 
Mechanisms, Though in Some Cases LPS Was Used Incorrectly: 

Each of the three key recruitment and retention mechanisms--bonuses, 
education payment programs, and VA's LPS--are used by some VA medical 
facilities. We found in fiscal years 2005 or 2006, of those VA medical 
facilities that hired VA CRNAs, just over one-third gave recruitment 
bonuses. In addition, less than one-third of all VA medical facilities 
that employ VA CRNAs gave retention bonuses, and a few gave relocation 
bonuses. We also found, according to data we obtained from VA, that all 
who applied and were eligible for EISP and EDRP funds for CRNA training 
received these funds. Further, more than half of the VA medical 
facilities responding to our survey reported using VA's LPS in 2005 and 
in 2006 to determine whether to adjust VA CRNA salaries. However, five 
of the eight VA medical facilities we visited did not fully follow VA's 
LPS policy in either 2005 or 2006, and officials at these facilities 
did not appear to understand certain aspects of the policy. These 
problems indicate VA has not provided adequate training on the LPS 
process since the policy was changed in 2001. 

Some VA Medical Facilities Give Bonuses to VA CRNAs: 

According to VA data, of the 47 VA medical facilities that hired a VA 
CRNA in fiscal year 2005, 18 of these facilities paid recruitment 
bonuses. Five facilities gave recruitment bonuses of $15,000 or more, 
seven gave recruitment bonuses of between $10,000 and $14,999, and five 
gave recruitment bonuses of less than $10,000. One facility gave 
recruitment bonuses in two of the categories--the more than $15,000 and 
less than $15,000 categories. In fiscal year 2006, of the 43 VA medical 
facilities that hired a VA CRNA, 15 of these facilities paid 
recruitment bonuses. Five facilities gave recruitment bonuses of 
$15,000 or more, six gave recruitment bonuses of between $10,000 and 
$14,999, and three gave recruitment bonuses of less than $10,000. One 
facility gave recruitment bonuses in two of the categories--the more 
than $15,000 and less than $10,000 categories. According to VA HR 
officers who responded to our survey, facilities gave recruitment 
bonuses to VA CRNAs because VA CRNA salaries at VA facilities were 
lower than local market area salaries. 

According to VA data, 32 and 36 VA medical facilities gave retention 
bonuses to VA CRNAs in fiscal years 2005 and 2006, respectively. The 
majority of these facilities gave a retention bonus of $10,000 or more. 
According to more than one-fourth of VA medical facility HR officers 
who responded to our survey, retention bonuses are used to make VA CRNA 
salaries competitive with CRNA salaries in local market areas. 

Compared with recruitment and retention bonuses, relocation bonuses are 
less frequently used by VA medical facilities. According to VA data, 
two VA medical facilities paid relocation bonuses of about $31,000 in 
fiscal year 2005 to two VA CRNAs. In fiscal year 2006, VA data show 
that three VA medical facilities gave relocation bonuses to four VA 
CRNAs, with three bonuses ranging from $8,000 to $10,000, and one bonus 
of $25,000. 

VA Medical Facilities Use VA's Education Payment Programs for Nurse 
Anesthetist Training: 

VA medical facilities use VA's education payment programs, EISP and 
EDRP, to expand the VA CRNA workforce. According to data we obtained 
from VA, from March 2000 through September 2006, 25 VA registered 
nurses at various medical facilities that were enrolled in nurse 
anesthetist training programs applied for and were awarded EISP 
scholarships. For fiscal years 2005 and 2006, 13 registered nurses 
received EISP scholarships, of which 8 attended the joint DOD/VA CRNA 
training program. Two of the eight VA medical facilities we visited had 
approved an EISP award for students attending the joint DOD/VA CRNA 
training program. 

In addition to the EISP scholarships, VA CRNAs may be eligible for VA's 
EDRP funds. VA data show that seven VA CRNAs applied for and were 
approved to receive tuition reimbursement through the EDRP in fiscal 
year 2005, and in fiscal year 2006, three VA CRNAs applied and were 
approved to receive this funding. Two of the eight VA medical 
facilities we visited had approved a total of three EDRP awards. At one 
of these facilities, officials told us that they had remaining EDRP 
funds in fiscal year 2006 because there were no employee applications, 
so these funds were not used. VA medical facility officials determine 
which occupations have priority in receiving EDRP funds based on 
difficulty in recruiting these occupations. 

A Majority of Medical Facilities Use VA's LPS to Determine Whether to 
Adjust VA CRNA Salaries, but Instances of Incorrect Use Indicate 
Inadequate Training on LPS Policy: 

According to VA's 2005 data, 86 VA medical facilities that employ VA 
CRNAs used VA's LPS to determine whether to adjust salaries of VA CRNAs 
at their facilities. Of those that used VA's LPS, 63 facilities used a 
third-party survey to obtain data on local market area salary rates for 
CRNAs. 

While VA's data showed that a majority of VA medical facilities that 
employ VA CRNAs are using VA's LPS, we found that five of the eight 
facilities we visited did not use the LPS in accordance with VA's LPS 
policy in 2005 or 2006. The policy is designed to ensure that facility 
officials have a mechanism to determine whether their VA CRNA salaries 
should be adjusted to be competitive in recruiting and retaining VA 
CRNAs. By not fully following this policy, officials at these five 
facilities are making decisions to adjust or not adjust VA CRNA 
salaries without sufficient data on the salaries of CRNAs in their 
local market areas. 

At the five VA medical facilities that did not fully follow VA's LPS 
policy correctly, facility officials with oversight responsibility for 
the LPS were not knowledgeable about certain aspects of the LPS policy. 
One facility official told us that the third-party salary survey data 
were determined to be insufficient, so the facility used salary data 
from a Hot Jobs Web site to determine whether to adjust VA CRNA 
salaries. The official was unaware that this data source cannot be 
considered valid survey data for the purpose of adjusting VA CRNA 
salaries. At one facility, officials applied an outdated methodology 
for adjusting VA CRNA salaries and in doing so did not fully follow the 
most current LPS policy. The outdated policy only permitted VA medical 
facility officials to adjust salary rates for each VA CRNA grade at 5 
percent above or below the beginning CRNA salary rates in local market 
areas. In contrast, VA's current LPS policy allows facility officials 
to adjust these salaries in order to be competitive. The remaining 
three facilities did not have sufficient salary data to determine 
whether VA CRNA salaries should be adjusted, and believed they could 
not use salary data of CRNAs that work for organizations that contract 
CRNA anesthesia services. These officials were unaware that VA's policy 
allows them to expand their data collection to include this type of 
salary data if the data they had previously collected were 
insufficient. 

The problems some VA medical facilities had fully following VA's LPS 
policy, along with the explanations of facility officials, indicate 
that VA has not provided adequate training on its LPS policy. 
Currently, VA medical facility officials can refer to VA's LPS policy 
when they have questions, or they can contact VA headquarters, 
according to a VA official. VA last changed its LPS policy in 2001, 
which resulted in a number of changes, such as the use of third-party 
surveys and the use of salary data of CRNAs that work for organizations 
that contract anesthesia services. VA, however, has not conducted 
nationwide training on its LPS policy since 1995.[Footnote 27] As a 
result, VA medical facility officials have not received LPS training 
that reflects VA's current LPS policy, and accordingly, cannot ensure 
that VA CRNA salaries have been adjusted as needed to be competitive. 

VA is in the process of developing a Web-based training course for the 
LPS that VA medical facility officials can complete on-line. VA is 
early in the development of this project because it is assigned to two 
staff that have other job priorities, according to a VA official. 
Because VA has not made the training a priority, it has not established 
a time frame for finalizing the development and implementation of this 
training course. 

Conclusions: 

VA's difficulty recruiting and retaining VA CRNAs has created workforce 
challenges that the department must confront now and in the future. 
Because a significant number of VA CRNAs plan to retire or leave VA's 
health care system in the next 5 years and because many VA medical 
facilities do not have salaries that attract CRNAs, some VA medical 
facilities may face significant challenges delivering anesthesia 
services to veterans. It is important that VA maximize its ability to 
recruit and retain VA CRNAs. A key mechanism VA medical facilities have 
is the LPS, which is used to help facilities determine to what extent 
VA CRNA salaries are competitive with the CRNA salaries paid by 
competing health care establishments. 

While the LPS is used across VA, at five of eight facilities we visited 
officials used it incorrectly and appeared unaware of some of the 
policy requirements related to the LPS. The lapses at the five 
facilities reveal a larger problem: VA has not taken the necessary 
steps to ensure that VA officials are aware of the current LPS policy 
and can use it correctly. VA last provided training on the LPS in 1995, 
but since then some aspects of the policy have changed. While VA has 
indicated that it is developing Web-based training on the LPS, VA has 
not made the development of this training a priority or indicated when 
the training will be available. Current training on the LPS is 
necessary to help ensure that VA medical facilities are competitive as 
an employer by allowing medical facility officials to make salary 
decisions for VA CRNAs with sufficient information on the CRNA salaries 
in their local market areas. 

Recommendation for Executive Action: 

To improve VA's ability to recruit and retain VA CRNAs, we recommend 
that the Secretary of Veterans Affairs direct the Assistant Secretary 
for Human Resources and Administration to expedite development and 
implementation of the training course on VA's LPS policy for VA medical 
facility officials responsible for compliance with the policy. 

Agency Comments and Our Evaluation: 

In commenting on a draft of this report, VA generally agreed with our 
conclusions. VA also concurred with our recommendation to expedite the 
development and implementation of the training course on VA's LPS 
policy and stated that it has developed a draft action plan for 
training staff on this policy and anticipates the on-line training 
course will be available by the end of fiscal year 2008. VA provided 
technical comments, which we have incorporated as appropriate. 

VA expressed reservations about our reliance on information obtained 
from VA CRNAs and VA chief anesthesiologists who responded to our 
surveys. VA stated that those being surveyed may have inflated their 
perceptions of recruitment and retention challenges with the hope that 
findings may encourage additional resources for their professions. We 
recognize there is a potential for bias in self-reported data; however, 
we used other information to corroborate our survey findings. 
Specifically, we also used information obtained from interviews with VA 
headquarters officials, as well as survey data obtained from VA medical 
facilities' human resources officers. 

VA expressed concern about our projected VA CRNA attrition rate. On the 
basis of VA CRNAs who reported they would retire or leave the VA within 
the next 5 years, we projected a 26 percent attrition rate of VA CRNAs 
systemwide. We anticipate that this rate will vary by VA medical 
facility, with some facilities having a rate of 50 percent or higher 
and others having a much lower rate. In commenting on our projected VA 
CRNA attrition rate, VA noted that the 26 percent attrition rate 
indicated that the VA CRNA turnover rate during the 5 years would 
average 5.2 percent annually and that this turnover rate was low 
compared to VA's actual turnover rate for VA CRNAs, which has ranged 
from a low of 10.02 percent to a high of 15.6 percent. 

VA also commented that our report highlighted the fact that more than 
50 percent of VA CRNAs are over 51 years of age and nearing the 
retirement eligibility age, implying that VA is at risk of losing a 
significant number of VA CRNAs to retirement. VA stated that these VA 
CRNAs are not necessarily retirement eligible or inclined to retire 
when eligible. This information was included in the report with other 
demographic information about VA CRNAs to provide some prospective on 
VA's CRNA workforce. VA's written comments are reprinted in appendix 
VI. 

We are sending copies of this report to the Secretary of Veterans 
Affairs and other interested parties. We will also provide copies to 
others upon request. In addition, the report is available at no charge 
on the GAO Web site at [hyperlink, http://www.gao.gov]. 

If you or your staff members have any questions about this report, 
please contact me at (202) 512-7114 or at [email protected]. Contact 
points for our Offices of Congressional Relations and Public Affairs 
can be found on the last page of this report. GAO staff members who 
made major contributions to this report are listed in appendix VII. 

Signed by: 

Laurie E. Ekstrand: 

Director, Health Care: 

[End of section] 

Appendix I: Scope and Methodology: 

We examined the Department of Veterans Affairs' (VA) certified 
registered nurse anesthetists (CRNA) workforce issues and the 
mechanisms that VA medical facilities use to recruit and retain VA 
employed CRNAs (VA CRNA). Specifically, we (1) identified workforce 
challenges that VA medical facilities may experience related to VA 
CRNAs, (2) identified the key mechanisms that VA medical facility 
officials can use to recruit and retain VA CRNAs, and (3) determined 
the extent to which VA medical facilities use the key mechanisms to 
recruit and retain VA CRNAs. 

To identify workforce challenges that VA medical facilities experience 
related to VA CRNAs, we analyzed data from our three Web-based surveys, 
which captured information from fiscal years 2005 and 2006. Each of the 
three surveys contained questions that helped us identify current and 
future challenges that VA medical facilities will experience in 
recruiting and retaining VA CRNAs. The first survey was administered in 
December 2006 to 474 VA CRNAs. We contacted officials at all VA medical 
facilities to determine whether they employed VA CRNAs both on a full- 
time or part-time basis, and for those that did, obtained e-mail 
addresses for the VA CRNAs. We verified our list of VA CRNAs with a 
list obtained from VA's Personnel Accounting Integrated Data system, 
which houses VA's payroll and human resources (HR) information. This 
survey of VA CRNAs covered various workforce issues, including their 
plans to retire or leave VA's health care system, the use of contract 
CRNAs to supplement VA CRNAs, and recruitment and retention of VA 
CRNAs. The survey had an overall response rate of 76 percent, which 
allowed us to generalize to the VA CRNA population. The second survey 
was administered in May 2007 to 125 chief anesthesiologists working in 
the VA medical system.[Footnote 28] We obtained the contact list for 
chief anesthesiologists from VA headquarters anesthesia services. This 
survey covered CRNA workforce issues, including VA CRNA salaries, 
staffing, recruitment and retention, the effect of vacancies on medical 
facilities' services, and the use of contract CRNAs. The survey had an 
overall response rate of 92 percent, which allowed us to generalize to 
all VA medical facilities that employ VA CRNAs. The third survey was 
administered in May 2007 to HR officers at 170 VA medical 
facilities.[Footnote 29] We obtained the contact list for VA HR 
officers from VA. The survey covered CRNA workforce issues including 
salary, locality pay surveys, and bonuses given for recruitment and 
retention. This survey had an overall response rate of 85 percent, 
which allowed us to generalize to all VA medical facilities that employ 
VA CRNAs. We also obtained VA medical facility data on the number of VA 
CRNA vacancies and VA CRNA vacancy rates. These data are reported by VA 
medical facilities to VA headquarters and were included in VA's 2006 
annual report to Congress on staffing. 

Additionally, we obtained VA CRNA salary schedules for 2005, 2006, and 
2007 from VA headquarters for each VA medical facility. These salary 
schedules contained the VA CRNA salary rates for grades I through V and 
steps 1 to 12 for each of the grades. Using these salary schedules, we 
compared VA CRNA salaries with CRNA salary data we obtained from the 
American Association of Nurse Anesthetists (AANA), a professional 
organization for CRNAs. AANA's salary data for CRNAs was compiled in 
its 2006 Practice Profile Survey--a national survey of AANA's 
membership--and included self-reported 2005 salary information that was 
reported by state.[Footnote 30] To compare salaries for 2006 and 2007, 
we projected the 2005 AANA salary data using the Bureau of Labor 
Statistics (BLS) employment cost index.[Footnote 31] According to VA 
officials, VA is seeking legislation that would increase VA CRNAs' 
maximum statutory salary cap.[Footnote 32] On the basis of this 
proposed legislation, we used VA's 2007 VA CRNA maximum statutory 
salary cap that was $136,200 and would increase to $145,400 with the 
proposed legislation. We compared VA's proposed increase to AANA's 2007 
salary data for each state in which a VA medical facility is located to 
determine whether increasing VA's maximum statutory salary cap as VA 
proposes would make VA CRNA salaries competitive with local market area 
salaries. We used the 90th percentile AANA CRNA salary in each state 
for this comparison because this percentile represents the higher end 
of the salary range for the local market area. In addition, we compared 
VA CRNA qualification standards to VA's proposed revision, which would 
increase starting salaries for new graduate VA CRNAs from grade I to 
grade II. We compared 2007 VA CRNA salary schedules at the grade II 
level for each facility to AANA's CRNA salary data for each state in 
which a VA medical facility is located to determine whether grade II 
salaries would be competitive with local market area salaries. We used 
the 25th percentile AANA salary in each state for this comparison 
because this percentile represents the lower end of the salary range 
for the local market area. 

We interviewed the director of Kaiser Permanente's school of anesthesia 
for nurse anesthetists to identify what steps this director takes to 
ensure it has a sufficient number of CRNAs to deliver anesthesia 
services and to learn the indicators used to identify a CRNA shortage 
or potential future shortage. We also interviewed the director of VA 
headquarters anesthesia services to obtain information on VA CRNA 
workforce challenges. 

To determine the key mechanisms that VA medical facilities use to 
recruit and retain VA CRNAs, we reviewed VA's policies and directives 
related to VA CRNAs and obtained reports on VA CRNA salaries. We also 
reviewed and analyzed policies, legislation, and regulations on VA's 
locality pay system (LPS), and VA's authority to give recruitment, 
relocation, and retention bonuses to VA CRNAs. In addition, we reviewed 
legislation and policies related to two VA employee education programs-
-the Employee Incentive Scholarship Program (EISP) and the Education 
Debt Reduction Program (EDRP). We interviewed officials at VA 
headquarters, including HR officers. We interviewed chief 
anesthesiologists, VA CRNAs, HR officers, and other officials at 
selected VA medical facilities. We also interviewed officials from VA's 
Healthcare Retention and Recruitment Office (HRRO), located in New 
Orleans, Louisiana, to obtain information about the implementation of 
EISP and EDRP. 

To determine the extent to which VA medical facilities use the key 
mechanisms to recruit and retain VA CRNAs, we analyzed data from our 
three Web-based surveys. We analyzed data included in VA's 2006 annual 
report to Congress on staffing, which included information on each VA 
medical facility's use of LPS. We also obtained data from VA 
headquarters on the number and amount of recruitment, relocation, and 
retention bonuses paid to VA CRNAs in fiscal years 2005 and 2006. 
Additionally, we obtained data from VA's HRRO on funds distributed to 
VA medical facilities for the EISP and EDRP. 

To gain further information on the extent to which VA medical 
facilities use the key mechanisms, we visited eight VA medical 
facilities. We selected these facilities to obtain anecdotal examples, 
which are supported by our data collection. The findings from these 
eight facilities cannot be generalized to all VA medical facilities. We 
also selected the facilities based on geographical variation and 
because they employed VA CRNAs. The eight VA medical facilities we 
visited are located in Denver, Colorado; Houston, Texas; Minneapolis, 
Minnesota; New York, New York; Portland, Oregon; Seattle, Washington; 
Tampa, Florida; and Togus, Maine. At each medical facility, we 
interviewed chief anesthesiologists, VA CRNAs, HR officers, and other 
facility officials. In addition, we obtained copies of locality pay 
surveys for 2005 and 2006 from the eight medical facilities. 

We obtained data from VA headquarters and AANA and surveyed VA CRNAs, 
VA chief anesthesiologists, and VA HR officers. Data obtained from VA 
headquarters included CRNA salaries for each VA medical facility by VA 
CRNA grade and step, medical facility VA CRNA vacancy rates, and type 
of VA CRNA locality pay survey used at each VA medical facility. We 
also obtained from VA headquarters data from its Personnel Accounting 
Integrated Data (PAID) system that contained the amounts of individual 
VA CRNA recruitment, relocation, and retention bonuses. We contacted VA 
officials responsible for these data sets to gain an understanding of 
the completeness and accuracy of the data VA headquarters provided and 
whether quality checks were performed by VA on these data. In addition, 
we obtained 2005 salary data from AANA as reported in their members' 
annual survey. We interviewed AANA officials to determine the quality 
checks they performed on the data from this survey. The AANA members' 
survey has an overall response rate of 60 percent and has had a similar 
response rate for the last 25 years. AANA noted that the income data 
from the survey is self reported by AANA members and in some of the 
smaller states the number of respondents was small. We also conducted 
Web-based surveys of VA CRNAs, VA chief anesthesiologists, and VA HR 
officers to identify workforce challenges that VA medical facilities 
experience related to VA CRNAs. A systematic review of the returned 
questionnaires was performed, checking for factors such as key 
questions being answered, skip patterns being followed, written entries 
clearly entered, and quantitative entries within scope. On the basis of 
our assessment of the reliability and limitations of VA headquarters' 
data, AANA members' survey data, and our three Web-based surveys, we 
determined that the data used in this report were adequate for our 
purposes. 

We conducted our work from June 2006 through October 2007 in accordance 
with generally accepted government auditing standards. 

[End of section] 

Appendix II Analysis of GAO Survey of Certified Registered Nurse 
Anesthetists Employed by VA: 

To obtain the views of VA CRNAs on various recruitment and retention 
issues, we conducted a Web-based survey of all VA CRNAs employed at VA 
medical facilities. The questionnaire contained questions on topics 
such as CRNAs' views on recruitment and retention incentives, use of 
contract/agency CRNAs at the medical facility where they work, and the 
CRNAs' plans to leave the VA medical facility in the next 5 years. Not 
all column totals will add to 100 percent due to rounding, multiple 
answers to questions that ask respondents to check all that apply, and 
no response by VA CRNAs to some questions. 

Table: Q1. Of the factors listed, which five factors attracted you to 
work at this VA medical facility? 

1. Salary; 
Checked (percentage): 26.6; 
Number of respondents: 361. 

2. Recruitment incentive; 
Checked (percentage): 10.3; 
Number of respondents: 361. 

3. Relocation incentive; 
Checked (percentage): 3.9; 
Number of respondents: 361. 

4. Promotion potential; 
Checked (percentage): 4.4; 
Number of respondents: 361. 

5. Reimbursement for continuing education; 
Checked (percentage): 5.0; 
Number of respondents: 361. 

6. VA's education debt reduction; 
Checked (percentage): 9.4; 
Number of respondents: 361. 

7. Retirement benefits; 
Checked (percentage): 67.6; 
Number of respondents: 361. 

8. Leave benefits (annual and sick); 
Checked (percentage): 64.0; 
Number of respondents: 361. 

9. Flexible work schedule; 
Checked (percentage): 23.0; 
Number of respondents: 361. 

10. Broader scope of practice; 
Checked (percentage): 49.9; 
Number of respondents: 361. 

11. Complexity of surgical cases; 
Checked (percentage): 33.2; 
Number of respondents: 361. 

12. Working with/supervising student CRNAs; 
Checked (percentage): 17.7; 
Number of respondents: 361. 

13. Job security; 
Checked (percentage): 48.8; 
Number of respondents: 361. 

[End of table] 

Table: Q2. Of the factors listed, which five factors keep you working 
at this VA medical facility? 

1. Salary; 
Checked (percentage): 25.0; 
Number of respondents: 361. 

2. Retention incentive; 
Checked (percentage): 14.4; 
Number of respondents: 361. 

3. Promotion potential; 
Checked (percentage): 1.1; 
Number of respondents: 361. 

4. Reimbursement for continuing education; 
Checked (percentage): 6.1; 
Number of respondents: 361. 

5. VA's education debt reduction; 
Checked (percentage): 5.8; 
Number of respondents: 361. 

6. Retirement benefits; 
Checked (percentage): 71.8; 
Number of respondents: 361. 

7. Leave benefits (annual and sick); 
Checked (percentage): 63.2; 
Number of respondents: 361. 

8. Flexible work schedule; 
Checked (percentage): 25.8; 
Number of respondents: 361. 

9. Broader scope of practice; 
Checked (percentage): 36.8; 
Number of respondents: 361. 

10. Complexity of surgical cases; 
Checked (percentage): 28.0; 
Number of respondents: 361. 

11. Working with/supervising student CRNAs; 
Checked (percentage): 19.1; 
Number of respondents: 361. 

12. Job security; 
Checked (percentage): 45.2; 
Number of respondents: 361. 

[End of table] 

Table: Q3. Are you eligible to retire now or within the next 5 years? 

1. Yes, I am eligible to retire now; 
Checked (percentage): 10.0; 
Number of respondents: 361. 

2. Yes, I am eligible to retire within the next 5 years; 
Checked (percentage): 26.0; 
Number of respondents: 361. 

3. No; 
Checked (percentage): 64.0; 
Number of respondents: 361. 

[End of table] 

Table: Q4. If you are eligible or when you become eligible, do you plan 
to retire? 

1. Yes; 
Checked (percentage): 43.9; 
Number of respondents: 130. 

2. No; 
Checked (percentage): 20.8; 
Number of respondents: 130. 

3. Don't know; 
Checked (percentage): 35.4; 
Number of respondents: 130. 

[End of table] 

Table: Q5. Of the factors listed, which three factors would encourage 
you to postpone retiring? 

1. Higher salary; 
Checked (percentage): 91.3; 
Number of respondents: 103. 

2. Shorten the number of years to advance to the next grade level; 
Checked (percentage): 11.7; 
Number of respondents: 103. 

3. More monetary awards; 
Checked (percentage): 47.6; 
Number of respondents: 103. 

4. Reimbursement for continuing education; 
Checked (percentage): 30.1; 
Number of respondents: 103. 

5. Feeling valued; 
Checked (percentage): 35.0; 
Number of respondents: 103. 

6. Broader scope of practice; 
Checked (percentage): 12.6; 
Number of respondents: 103. 

7. More involvement in decisions involving this VA medical facility's 
anesthesia services; 
Checked (percentage): 35.0; 
Number of respondents: 103. 

[End of table] 

Table: Q6. After you retire from the federal government, do you plan to 
work as a CRNA outside of VA's health care system? 

1. Yes; 
Checked (percentage): 60.2; 
Number of respondents: 103. 

2. No; 
Checked (percentage): 10.7; 
Number of respondents: 103. 

3. Don't know; 
Checked (percentage): 28.2; 
Number of respondents: 103. 

[End of table] 

Table: Q7. Do you plan to leave this VA medical facility within the 
next 5 years? 

1. Yes, to work for another VA medical facility; 
Checked (percentage): 4.7; 
Number of respondents: 232. 

2. Yes, to leave VA's health care system; 
Checked (percentage): 15.5; 
Number of respondents: 232. 

3. No; 
Checked (percentage): 37.5; 
Number of respondents: 232. 

4. Don't know; 
Checked (percentage): 37.1; 
Number of respondents: 232. 

[End of table] 

Table: Q8. Of the factors listed, which three factors not currently 
available at this VA medical facility would keep you working here? 

1. Higher salary; 
Checked (percentage): 81.5; 
Number of respondents: 146. 

2. Shorten the number of years to advance to the next grade level; 
Checked (percentage): 13.0; 
Number of respondents: 146. 

3. More monetary awards; 
Checked (percentage): 32.2; 
Number of respondents: 146. 

4. Reimbursement for continuing education; 
Checked (percentage): 34.9; 
Number of respondents: 146. 

5. Greater availability of VA's education debt reduction program funds; 
Checked (percentage): 10.3; 
Number of respondents: 146. 

6. Feeling valued; 
Checked (percentage): 26.7; 
Number of respondents: 146. 

7. Broader scope of practice; 
Checked (percentage): 13.0; 
Number of respondents: 146. 

8. More involvement in decisions involving this VA medical facility's 
anesthesia services; 
Checked (percentage): 24.0; 
Number of respondents: 146. 

[End of table] 

Table: Q9. Has this VA medical facility used contract/agency CRNAs 
during the last 2 years (from October 1, 2004 through September 30, 
2006)? 

1. Yes; 
Checked (percentage): 47.7; 
Number of respondents: 361. 

2. No; 
Checked (percentage): 46.8; 
Number of respondents: 361. 

3. Don't know; 
Checked (percentage): 5.0; 
Number of respondents: 361. 

[End of table] 

Table: Q10. Is there a shortage of CRNAs at this VA medical facility? 

1. Yes; 
Checked (percentage): 65.4; 
Number of respondents: 361. 

2. No; 
Checked (percentage): 28.8; 
Number of respondents: 361. 

3. Don't know; 
Checked (percentage): 5.3; 
Number of respondents: 361. 

[End of table] 

Table: Q11. Of the factors listed, which five factors would strengthen 
recruitment of CRNAs at this VA medical facility? 

1. Higher salaries for CRNAs with experience; 
Checked (percentage): 90.9; 
Number of respondents: 361. 

2. Higher salaries for new CRNA graduates; 
Checked (percentage): 69.3; 
Number of respondents: 361. 

3. Shorten the number of years to advance to the next grade level; 
Checked (percentage): 36.0; 
Number of respondents: 361. 

4. Using more recruitment incentives; 
Checked (percentage): 39.1; 
Number of respondents: 361. 

5. Higher recruitment incentives; 
Checked (percentage): 31.3; 
Number of respondents: 361. 

6. Greater availability of VA's education debt reduction program funds; 
Checked (percentage): 26.9; 
Number of respondents: 361. 

7. Reimbursement for continuing education; 
Checked (percentage): 52.1; 
Number of respondents: 361. 

8. Timely hiring practices; 
Checked (percentage): 45.4; 
Number of respondents: 361. 

9. Ability to quote a firm starting salary prior to hiring a CRNA; 
Checked (percentage): 44.6; 
Number of respondents: 361. 

10. Broader scope of practice for VA CRNAs; 
Checked (percentage): 19.7; 
Number of respondents: 361. 

[End of table] 

[End of section] 

Appendix III: Analysis of GAO Survey of Chief Anesthesiologists 
Employed by VA: 

To obtain the views of VA's chief anesthesiologists on various 
recruitment and retention issues, we conducted a Web-based survey of 
all VA chief anesthesiologists employed at VA medical facilities. The 
questionnaire contained questions on topics, such as the chief 
anesthesiologists' views on CRNA recruitment and retention issues; CRNA 
vacancies, the effects of the vacancies, and the time it takes to fill 
CRNA vacancies; whether CRNA salaries at VA medical facilities are 
competitive with CRNA salaries in local market areas; and the use of 
contract CRNAs. Not all column totals will add to 100 percent due to 
rounding, multiple answers to questions that ask respondents to check 
all that apply, and no response by VA chief anesthesiologists to some 
questions. 

Table: Q1. How many months on average did it take to fill a vacant VA 
CRNA position from the time the request to fill the vacancy was 
approved to the time the vacancy was filled? 

Months: 2; 
Checked (percentage): 2.3; 
Number of respondents: 43. 

Months: 3; 
Checked (percentage): 7.0; 
Number of respondents: 43. 

Months: 4; 
Checked (percentage): 2.3; 
Number of respondents: 43. 

Months: 5; 
Checked (percentage): 4.7; 
Number of respondents: 43. 

Months: 6; 
Checked (percentage): 16.3; 
Number of respondents: 43. 

Months: 8; 
Checked (percentage): 2.3; 
Number of respondents: 43. 

Months: 9; 
Checked (percentage): 7.0; 
Number of respondents: 43. 

Months: 10; 
Checked (percentage): 2.3; 
Number of respondents: 43. 

Months: 11; 
Checked (percentage): 4.7; 
Number of respondents: 43. 

Months: 12; 
Checked (percentage): 14.0; 
Number of respondents: 43. 

Months: 14; 
Checked (percentage): 2.3; 
Number of respondents: 43. 

Months: 18; 
Checked (percentage): 7.0; 
Number of respondents: 43. 

Months: 20; 
Checked (percentage): 2.3; 
Number of respondents: 43. 

Months: 24; 
Checked (percentage): 16.3; 
Number of respondents: 43. 

Months: 36; 
Checked (percentage): 4.7; 
Number of respondents: 43. 

Months: 42; 
Checked (percentage): 2.3; 
Number of respondents: 43. 

Months: 60; 
Checked (percentage): 2.3; 
Number of respondents: 43. 

[End of table] 

Table: Q2. What were the effects on this facility of having VA CRNA 
vacancies? 

1. Some operating rooms were closed temporarily; 
Checked (percentage): 54.0; 
Number of respondents: 50. 

2. Some patients were diverted to other facilities; 
Checked (percentage): 32.0; 
Number of respondents: 50. 

3. Some elective surgeries were delayed; 
Checked (percentage): 72.0; 
Number of respondents: 50. 

4. VA CRNA overtime increased; 
Checked (percentage): 68.0; 
Number of respondents: 50. 

5. Contract CRNAs were used; 
Checked (percentage): 44.0; 
Number of respondents: 50. 

6. Intermittent, per diem, and /or fee-basis CRNAs were used; 
Checked (percentage): 30.0; 
Number of respondents: 50. 

7. No effect; 
Checked (percentage): 2.0; 
Number of respondents: 50. 

[End of table] 

Table: Q3. As of September 30, 2006, did this facility have a shortage 
of CRNAs even though all its VA CRNA allocated positions were filled? 

1. Yes; 
Checked (percentage): 29.0; 
Number of respondents: 93. 

2. No; 
Checked (percentage): 39.8; 
Number of respondents: 93. 

3. Don't know; 
Checked (percentage): 31.2; 
Number of respondents: 93. 

[End of table] 

Table: Q4. What were the effects on this facility of having a shortage 
of VA CRNAs? 

1. Some operating rooms were closed temporarily; 
Checked (percentage): 28.6; 
Number of respondents: 56. 

2. Some patients were diverted to other facilities; 
Checked (percentage): 3.6; 
Number of respondents: 56. 

3. Some elective surgeries were delayed; 
Checked (percentage): 35.7; 
Number of respondents: 56. 

4. VA CRNA overtime increased; 
Checked (percentage): 30.4; 
Number of respondents: 56. 

5. Contract CRNAs were used; 
Checked (percentage): 16.1; 
Number of respondents: 56. 

6. Intermittent, per diem, and /or fee-basis CRNAs were used; 
Checked (percentage): 12.5; 
Number of respondents: 56. 

7. No effect; 
Checked (percentage): 0; 
Number of respondents: 56. 

[End of table] 

Table: Q5. Has this facility had any difficulty in recruiting CRNAs in 
the last 2 years (October 1, 2004 - September 30, 2006)? 

1. Yes; 
Checked (percentage): 74.2; 
Number of respondents: 93. 

2. No; 
Checked (percentage): 25.8; 
Number of respondents: 93. 

[End of table] 

Table: Q6. What are the reasons this facility has had difficulties in 
recruiting CRNAs? 

(Continued From Previous Page) 

1. Salary level for new graduate VA CRNAs is low compared to the local 
market area; 
Checked (percentage): 88.4; 
Number of respondents: 69. 

2. Salary level for experienced VA CRNAs is low compared to the local 
market area; 
Checked (percentage): 85.5; 
Number of respondents: 69. 

3. Recruitment incentives are not available; 
Checked (percentage): 29.0; 
Number of respondents: 69. 

4. Recruitment incentives are not sufficient; 
Checked (percentage): 46.4; 
Number of respondents: 69. 

5. Tuition reimbursement is not available; 
Checked (percentage): 29.0; 
Number of respondents: 69. 

6. Tuition reimbursement is not sufficient; 
Checked (percentage): 18.8; 
Number of respondents: 69. 

7. Reimbursement for continuing education expenses is not available; 
Checked (percentage): 33.3; 
Number of respondents: 69. 

8. Reimbursement for continuing education expenses is not sufficient; 
Checked (percentage): 34.8; 
Number of respondents: 69. 

9. Shortage of CRNAs in the local market area; 
Checked (percentage): 66.7; 
Number of respondents: 69. 

10. Lengthy hiring process; 
Checked (percentage): 71.0; 
Number of respondents: 69. 

11. Inability to make salary offer promptly; 
Checked (percentage): 53.6; 
Number of respondents: 69. 

12. Inability to hire new CRNAs prior to them passing their boards; 
Checked (percentage): 14.5; 
Number of respondents: 69. 

[End of table] 

Table: Q7. Has this facility had difficulty with VA CRNAs leaving or 
with retaining VA CRNAs in the last 2 years (October 1, 2004-September 
30, 2006)? 

1. Yes, difficulty with VA CRNAs leaving; 
Checked (percentage): 12.9; 
Number of respondents: 93. 

2. Yes, difficulty with retaining VA CRNAs; 
Checked (percentage): 14.0; 
Number of respondents: 93. 

3. Both - difficulty with VA CRNAs leaving and with retaining VA CRNAs; 
Checked (percentage): 22.6; 
Number of respondents: 93. 

4. No; 
Checked (percentage): 50.5; 
Number of respondents: 93. 

[End of table] 

Table: Q8. What are the reasons this facility has had difficulty with 
VA CRNAs leaving or with retaining VA CRNAs? 

(Continued From Previous Page) 

1. Salary level for new graduate VA CRNAs is low compared to the local 
market area; 
Checked (percentage): 45.7; 
Number of respondents: 46. 

2. Salary level for experienced VA CRNAs is low compared to the local 
market area; 
Checked (percentage): 78.3; 
Number of respondents: 46. 

3. Retention incentive is not available; 
Checked (percentage): 21.7; 
Number of respondents: 46. 

4. Retention incentive is not sufficient; 
Checked (percentage): 47.8; 
Number of respondents: 46. 

5. Reimbursement for continuing education expenses is not available; 
Checked (percentage): 26.1; 
Number of respondents: 46. 

6. Reimbursement for continuing education expenses is not sufficient; 
Checked (percentage): 32.6; 
Number of respondents: 46. 

7. Scope of practice includes complex procedures not routinely 
performed by CRNAs in non-VA facilities; 
Checked (percentage): 8.7; 
Number of respondents: 46. 

8. Scope of practice does not include complex procedures not routinely 
performed by CRNAs in non-VA facilities; 
Checked (percentage): 0; 
Number of respondents: 46. 

[End of table] 

Table: Q9. How did VA CRNA annual salaries at this facility generally 
compare with local market area CRNA salaries from October 1, 2004-
September 30, 2005 for new graduate CRNAs? 

1. VA CRNA salaries were higher; 
Checked (percentage): 4.3; 
Number of respondents: 93. 

2. VA CRNA salaries were lower; 
Checked (percentage): 72.0; 
Number of respondents: 93. 

3. VA CRNA salaries were commensurate; 
Checked (percentage): 6.5; 
Number of respondents: 93. 

4. Don't know; 
Checked (percentage): 14.0; 
Number of respondents: 93. 

[End of table] 

Table: Q10. How did VA CRNA annual salaries at this facility generally 
compare with local market area CRNA salaries from October 1, 2004-
September 30, 2005 for experienced CRNAs? 

1. VA CRNA salaries were higher; 
Checked (percentage): 4.3; 
Number of respondents: 93. 

2. VA CRNA salaries were lower; 
Checked (percentage): 78.5; 
Number of respondents: 93. 

3. VA CRNA salaries were commensurate; 
Checked (percentage): 9.7; 
Number of respondents: 93. 

4. Don't know; 
Checked (percentage): 7.5; 
Number of respondents: 93. 

[End of table] 

Table: Q11. If this facility's 2005 VA CRNA salaries were higher than 
local market area salaries, how much higher were the salaries for new 
graduate CRNAs? 

1. $5,000 or less; 
Checked (percentage): 1.1; 
Number of respondents: 93. 

2. $5,001 to $10,000; 
Checked (percentage): 1.1; 
Number of respondents: 93. 

3. $10,001 to $20,000; 
Checked (percentage): 1.1; 
Number of respondents: 93. 

4. $20,001 to $30,000; 
Checked (percentage): 1.1; 
Number of respondents: 93. 

5. $30,001 to $40,000; 
Checked (percentage): 1.1; 
Number of respondents: 93. 

6. $40,001 to $50,000; 
Checked (percentage): 0; 
Number of respondents: 93. 

7. Over $50,000; 
Checked (percentage): 0; 
Number of respondents: 93. 

8. Not applicable; 
Checked (percentage): 62.4; 
Number of respondents: 93. 

[End of table] 

Table: Q.12. If this facility's 2005 VA CRNA salaries were higher than 
local market area salaries, how much higher were the salaries for 
experienced CRNAs? 

1. $5,000 or less; 
Checked (percentage): 0; 
Number of respondents: 93. 

2. $5,001 to $10,000; 
Checked (percentage): 2.2; 
Number of respondents: 93. 

3. $10,001 to $20,000; 
Checked (percentage): 1.1; 
Number of respondents: 93. 

4. $20,001 to $30,000; 
Checked (percentage): 2.2; 
Number of respondents: 93. 

5. $30,001 to $40,000; 
Checked (percentage): 0; 
Number of respondents: 93. 

6. $40,001 to $50,000; 
Checked (percentage): 1.1; 
Number of respondents: 93. 

7. Over $50,000; 
Checked (percentage): 0; 
Number of respondents: 93. 

8. Not applicable; 
Checked (percentage): 61.3; 
Number of respondents: 93. 

[End of table] 

Table: Q13. If this facility's 2005 VA CRNA salaries were lower than 
local market area salaries, how much lower were the salaries for new 
graduate CRNAs? 

1. $5,000 or less; 
Checked (percentage): 2.2; 
Number of respondents: 93. 

2. $5,001 to $10,000; 
Checked (percentage): 9.7; 
Number of respondents: 93. 

3. $10,001 to $20,000; 
Checked (percentage): 17.2; 
Number of respondents: 93. 

4. $20,001 to $30,000; 
Checked (percentage): 23.7; 
Number of respondents: 93. 

5. $30,001 to $40,000; 
Checked (percentage): 10.8; 
Number of respondents: 93. 

6. $40,001 to $50,000; 
Checked (percentage): 4.3; 
Number of respondents: 93. 

7. Over $50,000; 
Checked (percentage): 4.3; 
Number of respondents: 93. 

8. Not applicable; 
Checked (percentage): 20.4; 
Number of respondents: 93. 

[End of table] 

Table: Q14. If this facility's 2005 VA CRNA salaries were lower than 
local market area salaries, how much lower were the salaries for 
experienced CRNAs? 

1. $5,000 or less; 
Checked (percentage): 1.1; 
Number of respondents: 93. 

2. $5,001 to $10,000; 
Checked (percentage): 11.8; 
Number of respondents: 93. 

3. $10,001 to $20,000; 
Checked (percentage): 22.6; 
Number of respondents: 93. 

4. $20,001 to $30,000; 
Checked (percentage): 17.2; 
Number of respondents: 93. 

5. $30,001 to $40,000; 
Checked (percentage): 11.8; 
Number of respondents: 93. 

6. $40,001 to $50,000; 
Checked (percentage): 10.8; 
Number of respondents: 93. 

7. Over $50,000; 
Checked (percentage): 3.2; 
Number of respondents: 93. 

8. Not applicable; 
Checked (percentage): 18.3; 
Number of respondents: 93. 

[End of table] 

Table: Q15. How did VA CRNA annual salaries at this facility generally 
compare with local market area CRNA salaries from October 1, 2005-
September 30, 2006 for new graduate CRNAs? 

1. VA CRNA salaries were higher; 
Checked (percentage): 3.2; 
Number of respondents: 93. 

2. VA CRNA salaries were lower; 
Checked (percentage): 68.8; 
Number of respondents: 93. 

3. VA CRNA salaries were commensurate; 
Checked (percentage): 6.5; 
Number of respondents: 93. 

4. Don't know; Checked (percentage): 17.2; 
Number of respondents: 93. 

[End of table] 

Table: Q16. How did VA CRNA annual salaries at this facility generally 
compare with local market area CRNA salaries from October 1, 2005-
September 30, 2006 for experienced CRNAs? 

1. VA CRNA salaries were higher; 
Checked (percentage): 4.3; 
Number of respondents: 93. 

2. VA CRNA salaries were lower; 
Checked (percentage): 78.5; 
Number of respondents: 93. 

3. VA CRNA salaries were commensurate; 
Checked (percentage): 9.7; 
Number of respondents: 93. 

4. Don't know; 
Checked (percentage): 7.5; 
Number of respondents: 93. 

[End of table] 

Table: Q17. If this facility's 2006 VA CRNA salaries were higher than 
local market area salaries, how much lower were the salaries for new 
graduate CRNAs? 

1. $5,000 or less; 
Checked (percentage): 1.1; 
Number of respondents: 93. 

2. $5,001 to $10,000; 
Checked (percentage): 3.2; 
Number of respondents: 93. 

3. $10,001 to $20,000; 
Checked (percentage): 0; 
Number of respondents: 93. 

4. $20,001 to $30,000; 
Checked (percentage): 0; 
Number of respondents: 93. 

5. $30,001 to $40,000; 
Checked (percentage): 0; 
Number of respondents: 93. 

6. $40,001 to $50,000; 
Checked (percentage): 0; 
Number of respondents: 93. 

7. Over $50,000; 
Checked (percentage): 0; 
Number of respondents: 93. 

8. Not applicable; 
Checked (percentage): 72.0; 
Number of respondents: 93. 

[End of table] 

Table: Q18. If this facility's 2006 VA CRNA salaries were higher than 
local market area salaries, how much lower were the salaries for 
experienced CRNAs? 

1. $5,000 or less; 
Checked (percentage): 0; 
Number of respondents: 93. 

2. $5,001 to $10,000; 
Checked (percentage): 3.2; 
Number of respondents: 93. 

3. $10,001 to $20,000; 
Checked (percentage): 1.1; 
Number of respondents: 93. 

4. $20,001 to $30,000; 
Checked (percentage): 0; 
Number of respondents: 93. 

5. $30,001 to $40,000; 
Checked (percentage): 0; 
Number of respondents: 93. 

6. $40,001 to $50,000; 
Checked (percentage): 0; 
Number of respondents: 93. 

7. Over $50,000; 
Checked (percentage): 0; 
Number of respondents: 93. 

8. Not applicable; 
Checked (percentage): 71.0; 
Number of respondents: 93. 

[End of table] 

Table: Q19. If this facility's 2006 VA CRNA salaries were lower than 
local market area salaries, how much lower were the salaries for new 
graduate CRNAs? 

1. $5,000 or less; 
Checked (percentage): 2.2; 
Number of respondents: 93. 

2. $5,001 to $10,000; 
Checked (percentage): 6.5; 
Number of respondents: 93. 

3. $10,001 to $20,000; 
Checked (percentage): 20.4; 
Number of respondents: 93. 

4. $20,001 to $30,000; 
Checked (percentage): 21.5; 
Number of respondents: 93. 

5. $30,001 to $40,000; 
Checked (percentage): 11.8; 
Number of respondents: 93. 

6. $40,001 to $50,000; 
Checked (percentage): 2.2; 
Number of respondents: 93. 

7. Over $50,000; 
Checked (percentage): 4.3; 
Number of respondents: 93. 

8. Not applicable; 
Checked (percentage): 22.6; 
Number of respondents: 93. 

[End of table] 

Table: Q20. If this facility's 2006 VA CRNA salaries were lower than 
local market area salaries, how much lower were the salaries for 
experienced CRNAs? 

1. $5,000 or less; 
Checked (percentage): 1.1; 
Number of respondents: 93. 

2. $5,001 to $10,000; 
Checked (percentage): 10.8; Number of respondents: 93. 

3. $10,001 to $20,000; Checked (percentage): 23.7; 
Number of respondents: 93. 

4. $20,001 to $30,000; 
Checked (percentage): 18.3; 
Number of respondents: 93. 

5. $30,001 to $40,000; 
Checked (percentage): 10.8; 
Number of respondents: 93. 

6. $40,001 to $50,000; 
Checked (percentage): 7.5; 
Number of respondents: 93. 

7. Over $50,000; 
Checked (percentage): 4.3; 
Number of respondents: 93. 

8. Not applicable; 
Checked (percentage): 17.2; 
Number of respondents: 93. 

[End of table] 

Table: Q21. What were the reasons this facility used contract CRNAs 
from October 1, 2004-September 30, 2005? 

1. Retirement of VA CRNAs; 
Checked (percentage): 13.6; 
Number of respondents: 44. 

2. Short-term coverage for an absence of a VA CRNA; 
Checked (percentage): 31.8; 
Number of respondents: 44. 

3. Hiring freeze; 
Checked (percentage): 4.6; 
Number of respondents: 44. 

4. Shortage of CRNAs in the local market area; 
Checked (percentage): 40.9; 
Number of respondents: 44. 

5. Higher than anticipated vacancy rate; 
Checked (percentage): 9.1; 
Number of respondents: 44. 

6. Higher than anticipated surgical volume; 
Checked (percentage): 13.6; 
Number of respondents: 44. 

7. Difficulty in recruiting VA CRNAs; 
Checked (percentage): 52.3; 
Number of respondents: 44. 

8. Difficulty in retaining VA CRNAs; 
Checked (percentage): 27.3; 
Number of respondents: 44. 

9. Coverage for VA CRNAs called to active duty; 
Checked (percentage): 15.9; 
Number of respondents: 44. 

[End of table] 

Table: Q22. What were the reasons this facility used contract CRNAs 
from October 1, 2005-September 30, 2006? 

1. Retirement of VA CRNAs; 
Checked (percentage): 13.6; 
Number of respondents: 44. 

2. Short-term coverage for an absence of a VA CRNA; 
Checked (percentage): 27.3; 
Number of respondents: 44. 

3. Hiring freeze; 
Checked (percentage): 4.6; 
Number of respondents: 44. 

4. Shortage of CRNAs in the local market area; 
Checked (percentage): 38.6; 
Number of respondents: 44. 

5. Higher than anticipated vacancy rate; 
Checked (percentage): 11.4; 
Number of respondents: 44. 

6. Higher than anticipated surgical volume; 
Checked (percentage): 11.4; 
Number of respondents: 44. 

7. Difficulty in recruiting VA CRNAs; 
Checked (percentage): 45.5; 
Number of respondents: 44. 

8. Difficulty in retaining VA CRNAs; 
Checked (percentage): 29.6; 
Number of respondents: 44. 

9. Coverage for VA CRNAs called to active duty; 
Checked (percentage): 9.1; 
Number of respondents: 44. 

[End of table] 

[End of section] 

Appendix IV Analysis of GAO Survey of VA Medical Facility Human 
Resources Officers: 

To obtain the views of VA human resources officers on various 
recruitment and retention issues, we conducted a Web-based survey of VA 
human resources officers, one representing each VA medical facility. 
The questionnaire contained questions related to CRNAs recruitment and 
retention issues, such as CRNA salary, locality pay surveys, and 
bonuses given for recruitment and retention. Not all column totals will 
add to 100 percent due to rounding, multiple answers to questions that 
ask respondents to check all that apply, and no response by VA medical 
facility human resources officers to some questions. 

Table: Q1. Over the last 2 years what criteria were used to determine 
whether a VA CRNA was paid a recruitment incentive? 

1. Local market area starting salaries are higher for new graduate 
CRNAs; 
2005 Checked (percentage): 27.4; 
2005 Number of respondents: 73; 
2006 Checked (percentage): 28.8; 2006 Number of respondents: 73. 

2. Local market area starting salaries are higher for experienced 
CRNAs; 
2005 Checked (percentage): 31.5; 
2005 Number of respondents: 73; 
2006 Checked (percentage): 35.6; 
2006 Number of respondents: 73. 

3. Salary at this facility does not match a CRNA's previous employer's 
salary; 
2005 Checked (percentage): 28.7; 
2005 Number of respondents: 73; 
2006 Checked (percentage): 36.9; 
2006 Number of respondents: 73. 

4. Local market area tuition reimbursement is higher; 
2005 Checked (percentage): 4.1; 
2005 Number of respondents: 73; 
2006 Checked (percentage): 6.9; 
2006 Number of respondents: 73. 

5. Local market area benefit package is more competitive; 
2005 Checked (percentage): 6.9; 
2005 Number of respondents: 73; 
2006 Checked (percentage): 9.6; 
2006 Number of respondents: 73. 

6. Difficulties in commuting to this facility; 
2005 Checked (percentage): 4.1; 
2005 Number of respondents: 73; 
2006 Checked (percentage): 4.1; 
2006 Number of respondents: 73. 

7. Did not offer any recruitment incentives; 
2005 Checked (percentage): 27.4; 
2005 Number of respondents: 73; 
2006 Checked (percentage): 28.8; 
2006 Number of respondents: 73. 

[End of table] 

Table: Q2. Over the last 2 years what criteria were used to determine 
whether a VA CRNA was paid a relocation incentive? 

1. Local market area starting salaries are higher for new graduate 
CRNAs; 
2005 Checked (percentage): 6.9; 
2005 Number of respondents: 73; 
2006 Checked (percentage): 12.3; 
2006 Number of respondents: 73. 

2. Local market area starting salaries are higher for experienced 
CRNAs; 
2005 Checked (percentage): 9.6; 
2005 Number of respondents: 73; 
2006 Checked (percentage): 13.7; 
2006 Number of respondents: 73. 

3. Salary at this facility does not match a CRNA's previous employer's 
salary; 
2005 Checked (percentage): 5.5; 
2005 Number of respondents: 73; 
2006 Checked (percentage): 11.0; 
2006 Number of respondents: 73. 

4. Local market area tuition reimbursement is higher; 
2005 Checked (percentage): 2.7; 
2005 Number of respondents: 73; 
2006 Checked (percentage): 5.5; 
2006 Number of respondents: 73. 

5. Local market area benefit package is more competitive; 
2005 Checked (percentage): 2.7; 
2005 Number of respondents: 73; 
2006 Checked (percentage): 4.1; 
2006 Number of respondents: 73. 

6. Difficulties in commuting to this facility; 
2005 Checked (percentage): 2.7; 
2005 Number of respondents: 73; 
2006 Checked (percentage): 2.7; 
2006 Number of respondents: 73. 

7. Did not offer any relocation incentives; 
2005 Checked (percentage): 60.3; 
2005 Number of respondents: 73; 
2006 Checked (percentage): 58.9; 
2006 Number of respondents: 73. 

[End of table] 

Table: Q3. Over the last 2 years what criteria were used to determine 
whether a VA CRNA was paid a retention incentive? 

1. Local market area salaries are higher for experienced CRNAs; 
2005 Checked (percentage: 27.4; 
2005 Number of respondents: 73; 
2006 Checked (percentage): 32.9; 
2006 Number of respondents: 73. 

2. CRNA has an alternative job offer; 
2005 Checked (percentage: 20.6; 2005 Number of respondents: 73; 
2006 Checked (percentage): 27.4; 
2006 Number of respondents: 73. 

3. Delay retirement of CRNAs; 
2005 Checked (percentage: 8.2; 
2005 Number of respondents: 73; 
2006 Checked (percentage): 16.4; 
2006 Number of respondents: 73. 

4. Prevent or delay CRNAs leaving this VA facility; 
2005 Checked (percentage: 32.9; 
2005 Number of respondents: 73; 
2006 Checked (percentage): 37.0; 
2006 Number of respondents: 73. 

5. Local market area benefit package is more competitive; 
2005 Checked (percentage: 4.1; 
2005 Number of respondents: 73; 
2006 Checked (percentage): 8.2; 
2006 Number of respondents: 73. 

6. Difficulties in commuting to this facility; 
2005 Checked (percentage: 1.4; 
2005 Number of respondents: 73; 
2006 Checked (percentage): 1.4; 
2006 Number of respondents: 73. 

7. Did not offer any retention incentives; 
2005 Checked (percentage: 41.1; 
2005 Number of respondents: 73; 
2006 Checked (percentage): 31.5; 
2006 Number of respondents: 73. 

[End of table] 

Table: Q4. What types of CRNA salary information were included in the 
2005 locality pay survey? 

1. Did not conduct a locality pay survey; 
Checked (percentage): 7.3; 
Number of respondents: 82. 

2. Salaries of CRNAs employed by universities, colleges and hospitals; 
Checked (percentage): 68.3; 
Number of respondents: 82. 

3. Salaries of CRNAs employed by free standing ambulatory surgical 
centers; 
Checked (percentage): 3.7; 
Number of respondents: 82. 

4. Salaries of CRNAs employed by physicians groups, offices and 
clinics; 
Checked (percentage): 9.7; 
Number of respondents: 82. 

5. Salaries of CRNAs employed by CRNA only groups; 
Checked (percentage): 0; 
Number of respondents: 82. 

6. Salaries of CRNAs employed by the government or military; 
Checked (percentage): 11.0; 
Number of respondents: 82. 

7. Salaries of CRNAs working through an agency; 
Checked (percentage): 1.2; 
Number of respondents: 82. 

8. Salaries of CRNAs working as independent contractors; 
Checked (percentage): 2.4; 
Number of respondents: 82. 

9. Don't know; 
Checked (percentage): 3.7; 
Number of respondents: 82. 

[End of table] 

Table: Q5. In the 2005 locality pay survey, did a sufficient number of 
respondents provide survey data? 

1. Yes; 
Checked (percentage): 64.6; 
Number of respondents: 82. 

2. No; 
Checked (percentage): 17.1; 
Number of respondents: 82. 

[End of table] 

If yes, what actions did Human Resources take to address the 
insufficient number of survey respondents? 

1. Expanded the geographic boundaries of the local labor market area; 
Checked (percentage): 11.4; 
Number of respondents: 35. 

2. Contracted for a new survey; 
Checked (percentage): 2.9; 
Number of respondents: 35. 

3. Expanded the types of establishment surveyed; 
Checked (percentage): 5.7; 
Number of respondents: 35. 

4. Conducted own survey; 
Checked (percentage): 11.4; 
Number of respondents: 35. 

5. Raised wages to match the annual cost of living adjustment (COLA); 
Checked (percentage): 22.9; 
Number of respondents: 35. 

6. No action was taken; 
Checked (percentage): 8.6; 
Number of respondents: 35. 

[End of table] 

Table: Q6. Overall were you satisfied with the CRNA salary information 
you received in the 2005 locality pay survey? 

1. Yes; 
Checked (percentage): 59.8; 
Number of respondents: 82. 

2. No; 
Checked (percentage): 17.1; 
Number of respondents: 82. 

[End of table] 

Table: Q7. How did 2005 VA CRNA annual salaries at this facility 
generally compare with local market area annual salaries for new 
graduate CRNAs? 

1. VA CRNA salaries were higher; 
Checked (percentage): 2.7; 
Number of respondents: 110. 

2. VA CRNA salaries were lower; 
Checked (percentage): 43.6; 
Number of respondents: 110. 

3. VA CRNA salaries were commensurate; 
Checked (percentage): 8.2; 
Number of respondents: 110. 

4. Don't know; 
Checked (percentage): 39.1; 
Number of respondents: 110. 

[End of table] 

Table: Q8. How did 2005 VA CRNA annual salaries at this facility 
generally compare with local market area annual salaries for 
experienced CRNAs? 

1. VA CRNA salaries were higher; 
Checked (percentage): 1.8; 
Number of respondents: 110. 

2. VA CRNA salaries were lower; 
Checked (percentage): 48.2; 
Number of respondents: 110. 

3. VA CRNA salaries were commensurate; 
Checked (percentage): 15.5; 
Number of respondents: 110. 

4. Don't know; 
Checked (percentage): 27.3; 
Number of respondents: 110. 

[End of table] 

Table: Q9. If this facility's 2005 VA CRNA annual salaries were higher 
than local market area salaries, how much higher were the VA CRNA 
salaries for new graduate CRNAs? 

$5,000 or less; 
Checked (percentage): 1.8; 
Number of respondents: 110. 

$5,001 to $10,000; 
Checked (percentage): 0.9; 
Number of respondents: 110. 

$10,001 to $20,000; 
Checked (percentage): 0.9; 
Number of respondents: 110. 

$20,001 to $30,000; 
Checked (percentage): 0.9; 
Number of respondents: 110. 

$30,001 to $40,000; 
Checked (percentage): 0.9; 
Number of respondents: 110. 

$40,001 to $50,000; 
Checked (percentage): 0; 
Number of respondents: 110. 

Over $50,000; 
Checked (percentage): 2.7; 
Number of respondents: 110. 

Not applicable; 
Checked (percentage): 74.5; 
Number of respondents: 110. 

[End of table] 

Table: Q10. If this facility's 2005 VA CRNA annual salaries were higher 
than local market area salaries, how much higher were the VA CRNA 
salaries for experienced CRNAs? 

$5,000 or less; 
Checked (percentage): 2.7; 
Number of respondents: 110. 

$5,001 to $10,000; 
Checked (percentage): 0; 
Number of respondents: 110. 

$10,001 to $20,000; 
Checked (percentage): 0; 
Number of respondents: 110. 

$20,001 to $30,000; 
Checked (percentage): 0; 
Number of respondents: 110. 

$30,001 to $40,000; 
Checked (percentage): 1.8; 
Number of respondents: 110. 

$40,001 to $50,000; 
Checked (percentage): 0; 
Number of respondents: 110. 

Over $50,000; 
Checked (percentage): 2.7; 
Number of respondents: 110. 

Not applicable; 
Checked (percentage): 74.5; 
Number of respondents: 110. 

[End of table] 

Table: Q11. If this facility's 2005 VA CRNA annual salaries were lower 
than local market area salaries, how much lower were the VA CRNA 
salaries for new graduate CRNAs? 

$5,000 or less; 
Checked (percentage): 6.4; 
Number of respondents: 110. 

$5,001 to $10,000; 
Checked (percentage): 13.6; 
Number of respondents: 110. 

$10,001 to $20,000; 
Checked (percentage): 12.7; 
Number of respondents: 110. 

$20,001 to $30,000; 
Checked (percentage): 4.6; 
Number of respondents: 110. 

$30,001 to $40,000; 
Checked (percentage): 4.6; 
Number of respondents: 110. 

$40,001 to $50,000; 
Checked (percentage): 0; 
Number of respondents: 110. 

Over $50,000; 
Checked (percentage): 0; 
Number of respondents: 110. 

Not applicable; 
Checked (percentage): 47.3; 
Number of respondents: 110. 

[End of table] 

Table: Q12. If this facility's 2005 VA CRNA annual salaries were lower 
than local market area salaries, how much lower were the VA CRNA 
salaries for experienced CRNAs? 

$5,000 or less; 
Checked (percentage): 7.3; 
Number of respondents: 110. 

$5,001 to $10,000; 
Checked (percentage): 15.5; 
Number of respondents: 110. 

$10,001 to $20,000; 
Checked (percentage): 14.6; 
Number of respondents: 110. 

$20,001 to $30,000; 
Checked (percentage): 6.4; 
Number of respondents: 110. 

$30,001 to $40,000; 
Checked (percentage): 5.5; 
Number of respondents: 110. 

$40,001 to $50,000; 
Checked (percentage): 0.9; 
Number of respondents: 110. 

Over $50,000; 
Checked (percentage): 0; 
Number of respondents: 110. 

Not applicable; 
Checked (percentage): 39.1; 
Number of respondents: 110. 

[End of table] 

Table: Q13. What types of CRNA salary information were included in the 
2006 locality pay survey? 

1. Did not conduct a locality pay survey; 
Checked (percentage): 6.1; 
Number of respondents: 82. 

2. Salaries of CRNAs employed by universities, colleges and hospitals; 
Checked (percentage): 67.1; 
Number of respondents: 82. 

3. Salaries of CRNAs employed by free standing ambulatory surgical 
centers; 
Checked (percentage): 4.9; 
Number of respondents: 82. 

4. Salaries of CRNAs employed by physicians groups, offices and 
clinics; 
Checked (percentage): 7.3; 
Number of respondents: 82. 

5. Salaries of CRNAs employed by CRNA only groups; 
Checked (percentage): 0; 
Number of respondents: 82. 

6. Salaries of CRNAs employed by the government or military; 
Checked (percentage): 11.0; 
Number of respondents: 82. 

7. Salaries of CRNAs working through an agency; 
Checked (percentage): 0; 
Number of respondents: 82. 

8. Salaries of CRNAs working as independent contractors; 
Checked (percentage): 0; 
Number of respondents: 82. 

9. Don't know; 
Checked (percentage): 3.7; 
Number of respondents: 82. 

[End of table] 

Table: Q14. In the 2006 locality pay survey, did a sufficient number of 
respondents provide survey data? 

1. Yes; 
Checked (percentage): 64.6; 
Number of respondents: 82. 

2. No; 
Checked (percentage): 15.9; 
Number of respondents: 82. 

[End of table] 

Table: Q15. Overall were you satisfied with the CRNA salary information 
you received in the 2006 locality pay survey? 

1. Yes; 
Checked (percentage): 62.2; 
Number of respondents: 82. 

2. No; 
Checked (percentage): 13.4; 
Number of respondents: 82. 

[End of table] 

Table: Q16. How did 2006 VA CRNA annual salaries at this facility 
generally compare with local market area annual salaries for new 
graduate CRNAs? 

1. VA CRNA salaries were higher; 
Checked (percentage): 2.7; 
Number of respondents: 110. 

2. VA CRNA salaries were lower; 
Checked (percentage): 46.4; 
Number of respondents: 110. 

3. VA CRNA salaries were commensurate; 
Checked (percentage): 5.5; 
Number of respondents: 110. 

4. Don't know; 
Checked (percentage): 38.2; 
Number of respondents: 110. 

[End of table] 

Table: Q17. How did 2006 VA CRNA annual salaries at this facility 
generally compare with local market area annual salaries for 
experienced CRNAs? 

1. VA CRNA salaries were higher; 
Checked (percentage): 2.7; 
Number of respondents: 110. 

2. VA CRNA salaries were lower; 
Checked (percentage): 45.5; 
Number of respondents: 110. 

3. VA CRNA salaries were commensurate; 
Checked (percentage): 19.1; 
Number of respondents: 110. 

4. Don't know; 
Checked (percentage): 25.4; 
Number of respondents: 110. 

[End of table] 

Table: Q18. If this facility's 2006 VA CRNA annual salaries were higher 
than local market area salaries, how much higher were the VA CRNA 
salaries for new graduate CRNAs? 

$5,000 or less; 
Checked (percentage): 1.8; 
Number of respondents: 110. 

$5,001 to $10,000; 
Checked (percentage): 1.8; 
Number of respondents: 110. 

$10,001 to $20,000; 
Checked (percentage): 0.9; 
Number of respondents: 110. 

$20,001 to $30,000; 
Checked (percentage): 0; 
Number of respondents: 110. 

$30,001 to $40,000; 
Checked (percentage): 0.9; 
Number of respondents: 110. 

$40,001 to $50,000; 
Checked (percentage): 0; 
Number of respondents: 110. 

Over $50,000; 
Checked (percentage): 1.8; 
Number of respondents: 110. 

Not applicable; 
Checked (percentage): 73.6; 
Number of respondents: 110. 

[End of table] 

Table: Q19. If this facility's 2006 VA CRNA annual salaries were higher 
than local market area salaries, how much higher were the VA CRNA 
salaries for experienced CRNAs? 

$5,000 or less; 
Checked (percentage): 1.8; 
Number of respondents: 110. 

$5,001 to $10,000; 
Checked (percentage): 2.7; 
Number of respondents: 110. 

$10,001 to $20,000; 
Checked (percentage): 0; 
Number of respondents: 110. 

$20,001 to $30,000; 
Checked (percentage): 0; 
Number of respondents: 110. 

$30,001 to $40,000; 
Checked (percentage): 0.9; 
Number of respondents: 110. 

$40,001 to $50,000; 
Checked (percentage): 0; 
Number of respondents: 110. 

Over $50,000; 
Checked (percentage): 1.8; 
Number of respondents: 110. 

Not applicable; 
Checked (percentage): 73.6; 
Number of respondents: 110. 

[End of table] 

Table: Q20. If this facility's 2006 VA CRNA annual salaries were lower 
than local market area salaries, how much lower were the VA CRNA 
salaries for new graduate CRNAs? 

$5,000 or less; 
Checked (percentage): 5.5; 
Number of respondents: 110. 

$5,001 to $10,000; 
Checked (percentage): 13.6; 
Number of respondents: 110. 

$10,001 to $20,000; 
Checked (percentage): 11.8; 
Number of respondents: 110. 

$20,001 to $30,000; 
Checked (percentage): 5.5; 
Number of respondents: 110. 

$30,001 to $40,000; 
Checked (percentage): 4.5; 
Number of respondents: 110. 

$40,001 to $50,000; 
Checked (percentage): 0; 
Number of respondents: 110. 

Over $50,000; 
Checked (percentage): 1.8; 
Number of respondents: 110. 

Not applicable; 
Checked (percentage): 46.4; 
Number of respondents: 110. 

[End of table] 

Table: Q21. If this facility's 2006 VA CRNA annual salaries were lower 
than local market area salaries, how much lower were the VA CRNA 
salaries for experienced CRNAs? 

$5,000 or less; 
Checked (percentage): 3.6; 
Number of respondents: 110. 

$5,001 to $10,000; 
Checked (percentage): 19.1; 
Number of respondents: 110. 

$10,001 to $20,000; 
Checked (percentage): 12.7; 
Number of respondents: 110. 

$20,001 to $30,000; 
Checked (percentage): 4.5; 
Number of respondents: 110. 

$30,001 to $40,000; 
Checked (percentage): 3.6; 
Number of respondents: 110. 

$40,001 to $50,000; 
Checked (percentage): 2.7; 
Number of respondents: 110. 

Over $50,000; 
Checked (percentage): 0.9; 
Number of respondents: 110. 

Not applicable; 
Checked (percentage): 41.8; 
Number of respondents: 110. 

[End of table] 

Table: Q22. Has this facility ever requested approval to rehire VA 
CRNAs retired from federal service without affecting their retirement 
pay under the provisions of the Health Care Programs Enhancement Act of 
2001 (P.L. 107-135)? 

1. Yes; 
Checked (percentage): 7.3; 
Number of respondents: 110. 

2. No; 
Checked (percentage): 92.7; 
Number of respondents: 110. 

[End of table] 

[End of section] 

Appendix V: Description of Education and Training Requirements for 
Anesthesia Practitioners: 

Table 4: 

Description: Description of practice; 
Anesthesiologists: Anesthesiologists are physicians who administer 
anesthesia services to relieve pain and medically manage a patient's 
vital life functions throughout any surgical, obstetrical, or other 
medical procedure; 
Certified Registered Nurse Anesthetists (CRNA): CRNAs are registered 
nurses that work with anesthesiologists, surgeons, or dentists. In some 
states, CRNAs do not have to have direct supervision; 
Anesthesiologist Assistants (AA): AAs are allied health professionals 
that work under the supervision of a licensed anesthesiologist to 
deliver anesthesia services. 

Description: Education and training; 
Anesthesiologists: Must have a bachelor's degree to enter medical 
school. During medical school, students rotate through internal 
medicine, family practice, obstetrics, gynecology, pediatrics, 
psychiatry and surgery. Following medical school, they have a 4-year 
anesthesiology residency program, which includes a year of clinical 
medicine, two years of anesthesiology, and one year of concentrated 
study and experience with anesthetic complications. Following 
residency, they may pursue additional training in specific areas of 
anesthesiology; 
Certified Registered Nurse Anesthetists (CRNA): Registered nurses with 
a bachelor's degree, current licensure, and at least 1 year's 
experience in an acute care setting. Trained in anesthesia techniques 
and procedures for all types of surgery and obstetrics. Must have 
performed 550 anesthesia cases to be eligible for certification; 
Anesthesiologist Assistants (AA): Premedical undergraduate courses. 
Completion of an accredited anesthesiologist assistant program. Trained 
in patient monitoring, anesthesia delivery systems, patient assessment, 
and life support systems. Typically, have a minimum of 2,000 clinical 
hours in direct patient anesthesia-related care. 

Description: Training programs; 
Anesthesiologists: 129 medical schools with anesthesia programs in the 
United States; 
Certified Registered Nurse Anesthetists (CRNA): 106 accredited graduate-
level programs in the United States; 
Anesthesiologist Assistants (AA): 4 programs within a school of 
medicine in the United States. 

Description: Length of training program; 
Anesthesiologists: 4 years of undergraduate school; 
4 years of medical school; and 4 years of residency; 
Certified Registered Nurse Anesthetists (CRNA): 24-36 months in a CRNA 
training program; 
Anesthesiologist Assistants (AA): 24-28 months in an AA training 
program. 

Description: Degree conferred; 
Anesthesiologists: Doctor of Medicine (MD) or a Doctor of Osteopathic 
Medicine (DO); 
Certified Registered Nurse Anesthetists (CRNA): Masters or doctoral 
degree from an accredited CRNA education program; 
Anesthesiologist Assistants (AA): Master of Science degree. 

Description: National Certification Examination; 
Anesthesiologists: Must obtain a state license to practice in a state. 
Anesthesiologists may obtain board certification by passing an 
examination. They must periodically meet continuing medical education 
credit requirements that vary by state; 
Certified Registered Nurse Anesthetists (CRNA): CRNAs must hold a 
current registered nurse license and pass a national certification exam 
to obtain a national certification. They recertify every 2 years by 
obtaining 40 continuing medical education credits and must attest to 
being involved in 850 hours of practice involving anesthesia; 
Anesthesiologist Assistants (AA): At a minimum, AAs must obtain a 
national certification and must recertify every 2 years by submitting 
40 continuing medical education credits. Every sixth year, AAs must 
pass a written board examination. 

Sources: The American Society of Anesthesiologists, American 
Association of Nurse Anesthetists, and American Academy of 
Anesthesiologist Assistants. 

[End of table] 

[End of section] 

Appendix VI: Comments from the Department Of Veterans Affairs: 

The Secretary Of Veterans Affairs: 
Washington: 

November 14, 2007: 

Ms. Laurie E. Ekstrand: 
Director, Health Care: 
U. S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Ms. Ekstrand: 

The Department of Veterans Affairs (VA) has reviewed the Government 
Accountability Office's (GAO) draft report, VA HEALTH CARE: Many 
Medical Facilities Have Challenges in Recruiting and Retaining Nurse 
Anesthetists (GAO-08-56) and generally agrees with GAO's conclusions 
and concurs with GAO's recommendations. 

While the Department agrees with GAO's conclusion, we have reservations 
about GAO's reliance on self-reporting surveys of certified registered 
nurse anesthetists (CRNA) and Chiefs of Anesthesiology in developing 
its report. Using such an approach may increase the natural tendency of 
those being surveyed to inflate their perceptions of recruitment and 
retention difficulties with hopes that findings might encourage 
additional resource support for their professions. 

GAO states that its surveys indicate that 26 percent of VA's CRNAs 
reported that they would retire or leave VA employment in the next 5 
years. Taken literally, this would indicate the CRNA turnover during 
that time would average 5.2 percent annually. In fact, this represents 
a very low potential turnover rate. To put these figures in 
perspective, over the past 5 years, CRNA turnover in VA has ranged from 
a low of 10.02 percent in fiscal year (FY) 2004 to a high of 15.6 
percent in FY 2005. In FY 2007, the rate was 13.22 percent. While a 
turnover rate over 10 percent is considered significant, these turnover 
rates are not alarming when compared with some other VA health care 
occupations. For example, according to J. Walter Thompson (JWT) 
Employment Communications, a major national employment advertising, 
communications and consulting firm, yearly turnover rates in private 
sector health care occupations average more than 20 percent. 

The report also highlights the fact that more than 50 percent of VA 
CRNAs are over 51 years of age, implying that VA is at increased risk 
for losing a significant number of CRNAs to retirement. The fact that 
an employee is 51 years old does not necessarily mean that the employee 
is retirement eligible or inclined to retire when eligible. VA's 
official personnel data estimate that only about 14 percent of VA CRNAs 
were eligible to retire in FY 2007. This percentage is projected to 
gradually increase to 24 percent retirement eligibility in FY 2013. 
Based on past retirement rates, the projected percentage of CRNAs who 
will retire ranges from 2 percent in FY 2008 to a high of 4 percent in 
FY 2013. 

In summary, despite concerns about the study methodology, the 
Department acknowledges GAO's conclusions about the recognized 
obstacles faced in recruiting and retaining qualified CRNAs. Statutory 
salary caps for CRNAs have indeed presented fundamental obstacles in 
our recruitment and retention efforts, as GAO reports, but because of 
the concerted efforts of VA managers at all levels of the organization 
to give credence to VA's reputation as an "employer of choice," we have 
been fairly successful thus far to balance workload and staffing 
demands. 

The enclosures specifically addresses GAO's recommendation and provides 
technical comments to the draft report. VA appreciates the opportunity 
to comment on your draft report. 

Sincerely yours, 

Signed by: 

Gordon H. Mansfield: 
Acting: 

Enclosures:  

Department of Veterans Affairs (VA) Comments to Government 
Accountability Office (GAO) Draft Report VA Health Care: Many Medical 
Facilities Have Challenges in Recruiting and Retaining Nurse 
Anesthetists (GAO-08-56): 

* GAO recommends that VA expedite development and implementation of the 
training course on VA's LPS policy for VA medical facility officials 
responsible for compliance with the policy. 

Concur ï¿½ The Department of Veterans Affairs (VA) concur with GAO's 
recommendation that VA expedite development and implementation of a 
training course on VA's locality payment system (LPS) policy. 

A draft action plan is provided below. While many of the specific tasks 
and deliverables associated with the course development remain to be 
identified, we anticipate delivery of on-line curriculum by the end of 
fiscal 2008. 

Nurse Locality Pay System: 

Draft e-Learning Action Plan: 

Task: Identify learning objectives: Defining the local labor market 
area; 
Identifying third party salary surveys; 
Planning and conducting VA salary surveys; 
Constructing salary schedules. 
Anticipated Completion Date: TBD. 

Task: Develop course content to include tasks and activities; 
Anticipated Completion Date: TBD. 

Task: Create links to VA policy and legal statutes; 
Anticipated Completion Date: TBD. 

Task: Activate training module for nationwide use; 
Anticipated Completion Date: 9/30/2008. 

Technical Comments: 

GAO states that VA has not provided training since VA policy was 
revised in 2001. It should be clarified VAs last major LPS policy was 
implemented on October 25, 2002. Nationwide training on newly added 
provisions was conducted via a 2-hour conference call on November 7, 
2002, and was followed with the provision of job tools and aids such as 
worksheets. 

[End of section] 

Appendix VII: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Laurie E. Ekstrand at (202) 512-7114 or [email protected]: 

Staff Acknowledgments: 

In addition to the contact named above, Marcia A. Mann, Assistant 
Director; N. Rotimi Adebonojo; Michelle M. Alletto; Mary Ann Curran; 
Linda Diggs; Martha A. Fisher; Krister Friday; Molly Ryan; James R. 
Walker; and Suzanne Worth made key contributions to this report. 

[End of section] 

Footnotes:  

[1] Anesthesia care involves the administration of anesthesia to 
patients undergoing surgical or other invasive procedures. 

[2] For this report, we used the salaries reported by AANA CRNA members 
in the state where a VA medical facility is located as a proxy for the 
salary of CRNAs in the local market area. We used CRNA salaries 
excluding benefits because although we could obtain quantifiable 
benefits data from VA, we could not obtain the same data from non-VA 
sources. We also learned from a VA official that salaries, rather than 
benefits, were more important to new CRNA graduates. 

[3] The Office of Personnel Management regulations use the word 
incentive in lieu of the word bonus. However, for the purposes of this 
report, we continue to use the term bonus. 

[4] Eight of 15 VA medical facilities that had a 40 percent or more 
vacancy rate had three or fewer VA CRNA positions. Therefore, one 
vacant VA CRNA position represents a large proportion of their total VA 
CRNA workforce. 

[5] Fiscal year 2005 is the most current VA vacancy data available. 

[6] According to VA's 2005 vacancy data, vacancy rates varied 
significantly across VA's medical facilities. Many factors contribute 
to the difficulty in recruiting VA CRNAs, including difficulty finding 
suitable CRNA candidates in the local market area and difficulties or 
delays in the hiring process. 

[7] Contract CRNAs work for companies that VA medical facilities 
contract with to supplement their VA CRNA workforce. 

[8] Not all VA chief anesthesiologists who reported using contract 
CRNAs in our survey provided data on the number of full-time contract 
CRNAs used, the number of hours contracted by their facilities, and the 
total contract costs. These numbers represent data for VA medical 
facilities that reported both the number of hours and the cost for 
contract CRNAs on our survey of VA chief anesthesiologists. These 
chiefs reported contracting for CRNAs for a total of 64,938 hours at a 
cost of $6,043,826 in fiscal year 2005 and 61,989 hours at a cost of 
$5,577,092 in fiscal year 2006. 

[9] The VA CRNA hourly rates exclude any recruitment or retention 
bonuses. We assumed that full-time VA CRNAs work 40 hours per week or 
2,080 hours a year. We also calculated benefits at 30 percent of the VA 
CRNA's maximum statutorily prescribed base salary, which was $131,400 
in fiscal year 2005 and $133,900 in fiscal year 2006. See 38 U.S.C. 
ï¿½7451(c)(2)(2000). Because VA CRNA salaries differ across locations 
with some locations paying higher salaries, this comparison of VA CRNA 
salaries with contract CRNA salaries will differ by location. 

[10] While CRNA respondents reported their plans for retirement or 
departure from VA, some will change their plans. On the basis of our 
survey of VA CRNAs, about one-third of those eligible to retire were 
unsure of their retirement plans. However, others who indicated that 
they plan to stay may change their plans as well and leave VA. Thus, 
this measure is an approximation of likely attrition. 

[11] Other reasons that were most frequently cited by chief 
anesthesiologists were VA's lengthy hiring process and a shortage of 
CRNAs in the local market area. 

[12] Experienced VA CRNAs have 2 or more years of experience. 

[13] The reason contributing to the difficulty in recruiting and 
retaining VA CRNAs most frequently cited by the chief anesthesiologists 
besides CRNA salary was inadequate retention bonuses, which, according 
to VA HR officers, are often paid because VA CRNA salaries are lower 
than the local market area CRNA salaries. 

[14] In fiscal year 2005, 44 percent (48) of HR officers reported that 
their facilities' starting salaries for new graduate VA CRNAs were low 
when compared with CRNA salaries in local market areas, and in fiscal 
year 2006, 46 percent (51) of HR officers reported this. 

[15] In fiscal year 2005, 48 percent (53) of HR officers reported that 
salaries for experienced VA CRNAs were low when compared with CRNA 
salaries in local market areas, and in fiscal year 2006, 45 percent 
(50) of HR officers reported this. 

[16] As reported in appendix II, VA CRNAs responding to our survey 
indicated that benefits and a broader scope of practice initially 
attracted them to work at VA. Survey respondents, however, also 
reported that higher salaries for new graduate CRNAs would improve 
recruitment. 

[17] Only VA CRNAs who are not eligible to retire in the next 5 years 
and who expressed a future employment preference were included in this 
analysis. 

[18] The maximum statutory salary cap is the maximum base salary a VA 
CRNA can earn. 

[19] We used VA CRNAs' current fiscal year 2007 maximum statutory 
salary cap to determine whether this salary cap when increased by 
$9,200, as proposed by the legislation, would be competitive with CRNA 
salaries in local market areas. We compared VA CRNA's fiscal year 2007 
maximum statutory salary cap, which is currently $136,200 and would 
increase to $145,400 with the proposed legislation, with AANA's 2007 
salary data for each state in which a VA medical facility is located to 
determine whether increasing VA's maximum statutory salary cap as VA 
proposes would make VA CRNA salaries competitive with local market area 
salaries. 

[20] 38 U.S.C. ï¿½7410(2000) (authority that VA relies on for relocation 
bonuses); 38 U.S.C. ï¿½7458(2000) (authorizes payments for recruitment 
and retention bonuses). See also 5 U.S.C. ï¿½5753(2000). 

[21] Evidence that these factors were considered must be fully 
documented in the request to pay a bonus. 

[22] See 38 U.S.C. ï¿½ï¿½7671-75; ï¿½ï¿½7681-83(2000). 

[23] EISP provides funding to VA employees, not just VA CRNAs, who are 
pursuing educational degrees or training. 

[24] Title 38 U.S.C. ï¿½7451(d)(2000). VA medical facilities may not set 
the minimum rate of basic pay for a grade so that it is greater than 
the beginning pay rates for comparable positions at health care 
establishments in local market areas. 38 U.S.C. ï¿½7451(d)(3)(E)(2000). 

[25] The LPS is also used for other occupations, such as registered 
nurses. 

[26] VA medical facilities may still use salary data if there are fewer 
than three job matches at a VA CRNA grade level if the facility 
believes the salary data collected are representative of the rates paid 
in the local market area and further expansion of the surveyed area 
will not be useful. 

[27] VA stated in its comments on our draft report that a 2-hour 
conference call in November 2002 provided nationwide training on the 
new provisions in VA's LPS policy. However, none of the VA medical 
facility officials we interviewed mentioned this training session. 

[28] Some of the chief anesthesiologists surveyed reported that they 
did not have VA CRNAs at their facility. 

[29] We sent the HR survey to 170 VA medical facilities because 
facilities were answering for both VA CRNA and VA registered nurse 
workforce issues. We will be issuing a report on VA registered nurse 
workforce issues in fiscal year 2008. 

[30] AANA provided salary tables for CRNAs employed in a variety of 
health care settings that included the mean, median, 25th percentile, 
and 90th percentile for each state. 

[31] The BLS employment cost index for wages and salaries in 2006 and 
2007 was 2.8 and 3.4 percent, respectively. See BLS, "Employment Cost 
Index news release text" (Washington, D.C., 2007) [hyperlink, 
http://www.bls.gov/news.release/eci.nr0.htm] (accessed Aug. 14, 2007). 

[32] The maximum statutory salary is the maximum base salary a CRNA can 
earn. 

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