VA Health Care: Recruitment and Retention Challenges and Efforts 
to Make Salaries Competitive for Nurse Anesthetists (09-APR-08,  
GAO-08-647T).							 
                                                                 
Certified registered nurse anesthetists (CRNA), registered nurses
who have completed a master's degree program in nurse anesthesia,
provide the majority of anesthesia care in the Department of	 
Veterans Affairs (VA) medical facilities. There are approximately
500 VA-employed CRNAs (VA CRNA) who provide care to veterans in  
VA medical facilities. While the demand for CRNAs has increased, 
many employed by VA are nearing retirement eligibility age.	 
Concerns have been raised about the challenges VA may face in	 
making VA CRNA salaries competitive in order to maintain its VA  
CRNA workforce, particularly in local markets that can be highly 
competitive. This testimony is based on GAO work reported in VA  
Health Care: Many Medical Facilities Have Challenges in 	 
Recruiting and Retaining Nurse Anesthetists, (GAO-08-56, Dec. 13,
2007). This testimony (1) identifies workforce challenges that VA
medical facilities experience related to VA CRNAs, and (2)	 
identifies a key mechanism that VA medical facilities have to	 
help make VA CRNA salaries competitive and the extent to which VA
facilities use this mechanism. For the December 2007 report, GAO 
analyzed surveys sent to VA chief anesthesiologists, VA human	 
resources officers, and VA CRNAs. GAO also visited eight VA	 
medical facilities and interviewed facility officials about	 
efforts to recruit and retain VA CRNAs. 			 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-08-647T					        
    ACCNO:   A81610						        
  TITLE:     VA Health Care: Recruitment and Retention Challenges and 
Efforts to Make Salaries Competitive for Nurse Anesthetists	 
     DATE:   04/09/2008 
  SUBJECT:   Anesthesiology					 
	     Employee incentives				 
	     Employee retention 				 
	     Employee training					 
	     Employee turnover					 
	     Health care facilities				 
	     Health care personnel				 
	     Medical education					 
	     Nurses						 
	     Personnel recruiting				 
	     Policy evaluation					 
	     Program evaluation 				 
	     Salary increases					 
	     Skilled nursing facilities 			 
	     Veterans hospitals 				 
	     Veterans' medical care				 
	     Wage surveys					 

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GAO-08-647T

   

     * [1]VA Medical Facilities Have VA CRNA Recruitment and Retention

          * [2]VA Officials Reported Challenges Recruiting CRNAs, and Proje
          * [3]According to VA Officials and VA CRNAs, Recruitment and Rete

     * [4]VA Medical Facilities Can Use LPS to Help Make VA CRNA Salar

          * [5]To Recruit and Retain VA CRNAs, Medical Facilities Can Adjus
          * [6]The Majority of VA Medical Facilities Used LPS, but Instance

     * [7]Contact and Acknowledgments

          * [8]Order by Mail or Phone

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Testimony: 

Before the Committee on Veterans' Affairs, U.S. Senate: 

United States Government Accountability Office: 
GAO: 

For Release on Delivery: 
Expected at 9:30 a.m. EDT:
Wednesday, April 9, 2008: 

VA Health Care: 

Recruitment and Retention Challenges and Efforts to Make Salaries 
Competitive for Nurse Anesthetists: 

Statement of Marjorie Kanof: 
Managing Director:
Health Care: 

GAO-08-647T: 

GAO Highlights: 

Highlights of GAO-08-647T, a testimony before the Committee on 
Veteransï¿½ Affairs, U.S. Senate. 

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 in the Department of Veterans Affairs 
(VA) medical facilities. There are approximately 500 VA-employed CRNAs 
(VA CRNA) who provide care to veterans in VA medical facilities. While 
the demand for CRNAs has increased, many employed by VA are nearing 
retirement eligibility age. Concerns have been raised about the 
challenges VA may face in making VA CRNA salaries competitive in order 
to maintain its VA CRNA workforce, particularly in local markets that 
can be highly competitive. 

This testimony is based on GAO work reported in VA Health Care: Many 
Medical Facilities Have Challenges in Recruiting and Retaining Nurse 
Anesthetists, (GAO-08-56, Dec. 13, 2007). This testimony (1) identifies 
workforce challenges that VA medical facilities experience related to 
VA CRNAs, and (2) identifies a key mechanism that VA medical facilities 
have to help make VA CRNA salaries competitive and the extent to which 
VA facilities use this mechanism. 

For the December 2007 report, GAO analyzed surveys sent to VA chief 
anesthesiologists, VA human resources officers, and VA CRNAs. GAO also 
visited eight VA medical facilities and interviewed facility officials 
about efforts to recruit and retain VA CRNAs. 

What GAO Found: 

GAO reported in December 2007 that VA medical facilities had challenges 
recruiting and retaining VA CRNAs. In GAOï¿½s report, most surveyed 
officials said that they had difficulty recruiting VA CRNAs at their 
facilities. The challenge of recruiting VA CRNAs affected the ability 
of VA officials to reduce existing VA CRNA vacancy ratesï¿½the number of 
unfilled VA CRNA positionsï¿½at their medical facilities. Vacancy rates 
varied across VA and, according to GAOï¿½s survey, impacted the delivery 
of services at VA medical facilities. On the basis of its survey 
results, GAO also found that in addition to their current recruiting 
challenges, VA medical facilities would 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 GAOï¿½s survey that the recruitment and retention 
challenges were caused primarily by the low level of VA CRNA salaries 
when compared with CRNA salaries in local market areas. 

GAO also reported that VAï¿½s locality pay system (LPS) is a key 
mechanism VA medical facilities can use to determine whether to adjust 
VA CRNA salaries to help the facilities remain competitive with CRNA 
salaries in local market areas. GAO also reported that the majority of 
VA medical facilities that employ VA CRNAs used LPS. However, at the 
eight VA medical facilities it 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. The problems some VA 
medical facilities had fully following VAï¿½s LPS policy, along with the 
explanations of facility officials, indicated that VA had not provided 
adequate training on its LPS policy. As a result, VA medical facility 
officials cannot ensure that VA CRNA salaries have been adjusted as 
needed to be competitive in local market areas. Training on the LPS is 
necessary to help ensure that VA medical facilities are competitive as 
an employer. In December 2007, GAO recommended that VA expedite the 
development and implementation of a training course for VA medical 
facility officials responsible for compliance with the policy. VA 
agreed with GAOï¿½s recommendation and in comments on GAOï¿½s draft report 
stated that it had developed a draft action plan for training staff on 
its LPS policy. VA anticipated that the online training course would be 
available by the end of fiscal year 2008. 

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-647T]. For more 
information, contact Marjorie Kanof, (202) 512-7114 or [email protected]. 

[End of section] 

Mr. Chairman and Members of the Committee: 

I am pleased to be here today as you discuss personnel issues in the 
Department of Veterans Affairs (VA). One such issue VA faces is an 
increased demand for the services provided by certified registered 
nurse anesthetists (CRNA), who provide the majority of anesthesia care 
veterans receive in medical facilities operated by 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. When hiring VA CRNAs, VA 
places them in one of five pay grades, based on the CRNA's education 
and experience. The demand for these practitioners 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 has continued 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. Given the increased demand for CRNAs and the important role 
they play in providing anesthesia services in VA medical facilities, 
concerns have been raised about the challenges VA may face in making VA 
CRNA salaries competitive in order to maintain its VA CRNA workforce, 
particularly in some local markets where the labor market for CRNAs can 
be highly competitive. 

In December 2007 we issued a report that examined the challenges VA 
faces recruiting and retaining VA CRNAs.[Footnote 1] My remarks today 
are based on this report. Specifically, I will (1) identify workforce 
challenges that VA medical facilities experience related to VA CRNAs, 
and (2) identify a key mechanism that VA medical facilities have to 
help make VA CRNA salaries competitive for recruitment and retention 
purposes and the extent to which VA facilities use this mechanism. 

To do the work for our December 2007 report, we analyzed Web-based 
surveys we sent to all VA chief anesthesiologists, VA human resources 
(HR) officers, and VA CRNAs, with survey response rates of 92, 85, and 
76 percent, respectively. 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 at the time of our 
review. Additionally, we obtained data on VA CRNAs' salaries for 2005, 
2006, and 2007 and compared these to national salary data we obtained 
from the American Association of Nurse Anesthetists (AANA), a 
professional organization for CRNAs. We visited eight VA medical 
facilities[Footnote 2] and interviewed chief anesthesiologists, VA 
CRNAs, HR officers, and other facility officials about their efforts to 
recruit and retain VA CRNAs. We also interviewed a representative from 
Kaiser Permanente, a large health care plan that primarily uses CRNAs 
to deliver anesthesia services, to identify what steps this 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 survey and 
national salary data we used, we performed a systematic review of the 
returned questionnaires and interviewed VA and AANA officials about the 
quality checks and edits they performed on their data. We determined 
that the data we used were adequate for our purposes. We conducted our 
work from June 2006 through October 2007 in accordance with generally 
accepted government auditing standards. Those standards require that we 
plan and perform the audit to obtain sufficient, appropriate evidence 
to provide a reasonable basis for our findings based on our audit 
objectives. We believe that the evidence obtained provides a reasonable 
basis for our findings based on our audit objectives. 

In summary, in December 2007 we reported that VA medical facilities had 
challenges recruiting and retaining VA CRNAs. Seventy-four percent of 
the VA chief anesthesiologists who responded to our survey reported 
that they had difficulty recruiting VA CRNAs in fiscal years 2005 and 
2006. The challenge of recruiting VA CRNAs affected the ability of VA 
officials to reduce existing VA CRNA vacancy rates at their medical 
facilities. In our survey, 54 percent of the VA chief anesthesiologists 
with VA CRNA vacancies reported that they temporarily closed operating 
rooms, and 72 percent reported that they delayed elective surgeries as 
a result of VA CRNA vacancies in fiscal year 2006. Based on our survey 
results, we also found that in addition to their current recruiting 
challenges, VA medical facilities would 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 were caused primarily by the low level of VA CRNA salaries 
when compared with CRNA salaries in local market areas. In December 
2007 we also reported that VA's locality pay system (LPS) is a key 
mechanism that VA medical facilities can use to determine whether to 
adjust VA CRNA salaries to help the facilities remain competitive with 
CRNA salaries in local market areas. We reported that the majority of 
VA medical facilities that employ VA CRNAs used LPS. However, at the 
eight VA medical facilities we visited, we found that although the 
facilities used VA's LPS, five of these facilities did not fully follow 
VA's LPS policy correctly in either 2005 or 2006. The problems some VA 
medical facilities had fully following VA's LPS policy, along with the 
explanations of facility officials, indicated that VA had not provided 
adequate training on its LPS policy. As a result, VA medical facility 
officials cannot ensure that VA CRNA salaries have been adjusted as 
needed to be competitive in local market areas. Training on the LPS is 
necessary to help ensure that VA medical facilities are competitive as 
an employer. 

To improve VA's ability to recruit and retain VA CRNAs, we recommended 
that the Secretary of Veterans Affairs direct the Assistant Secretary 
for Human Resources and Administration to expedite development and 
implementation of a training course on VA's LPS policy for VA medical 
facility officials responsible for compliance with the policy. VA 
generally agreed with our conclusions and recommendation and stated 
that it had developed a draft action plan for training staff on this 
policy and anticipated that an online training course would be 
available by the end of fiscal year 2008. 

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

We reported in December 2007 that VA medical facilities had challenges 
recruiting and retaining VA CRNAs. On the basis of our survey results, 
we found that VA medical facilities had challenges in recruiting VA 
CRNAs at their facilities and will likely face challenges in 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 were caused 
primarily by the low level of VA CRNA salaries when compared with CRNA 
salaries in local market areas. 

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

In December 2007 we reported our survey results indicating that VA 
medical facilities had a challenge recruiting VA CRNAs.[Footnote 3] Of 
all VA medical facility chief anesthesiologists who responded to our 
survey, 74 percent reported that they had difficulty recruiting VA 
CRNAs in fiscal years 2005 and 2006. The recruiting challenges also 
affected 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 
took 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 limited the ability of VA officials 
to reduce existing vacancy rates at their medical facilities. VA's 
fiscal year 2005 vacancy data show that VA had about a 13 percent VA 
CRNA vacancy rate systemwide, or 70 unfilled VA CRNA positions at 43 
medical facilities. These rates varied 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 suggested that VA CRNA vacancies were 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 facilities, with the number of VA CRNA vacancies ranging from 
one to six. 

According to our survey, VA CRNA vacancies 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 supplied by outside companies were used to 
supplement the VA facilities' VA CRNA workforce. In addition, almost 
one-third of the chief anesthesiologists whose vacancies were filled by 
VA CRNAs reported that they still had a shortage of CRNAs. 

In addition to the challenges of recruiting VA CRNAs, we also reported 
that VA medical facilities were likely to face another workforce 
challenge in the future. Specifically, we found that in the next 5 
years VA medical facilities would 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 projected a VA CRNA attrition rate of 26 percent across VA 
in the next 5 years--that is, 26 percent of VA CRNAs either planned to 
retire or leave VA's health care system within the next 5 
years.[Footnote 4] 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, will likely be 26 
percent, this rate will vary by medical facility. In 27 VA medical 
facilities, we projected that the attrition rate would likely 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, Recruitment and Retention 
Challenges Are Due to Noncompetitive VA CRNA Salaries: 

Our surveys of VA medical facility chief anesthesiologists and HR 
officers indicated that medical facilities had trouble recruiting and 
will have trouble retaining VA CRNAs because salaries for VA CRNAs were 
low compared to CRNA salaries in local market areas. Specifically, 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 5] 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 
6] 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 7] 

Of the chief anesthesiologists we surveyed, 72 percent (67) 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) 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 1 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 1: 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. 

Notes: The data are from a GAO survey of 120 VA medical facility chief 
anesthesiologists. 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] 

In December 2007, we reported that to address recruitment challenges 
related to VA CRNA salaries, VA CRNAs and the director of VA's 
anesthesia services told us that they were revising VA's CRNA 
qualification standards. These standards establish the five pay grades-
-grade I being the lowest--that VA CRNAs are placed into when hired, 
based on CRNAs' education and experience. According to the officials, 
the change to VA's qualification standards will have the effect of 
increasing starting salaries for new graduate VA CRNAs from grade I to 
grade II. However, we found that 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 would 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. 

We found similar challenges related to the retention of VA CRNAs. At 
the time of our review, more than half of all VA CRNAs earned the 
maximum statutory salary cap[Footnote 8] for a VA CRNA in 2006, which 
was $133,900. However, at 107 of VA's 120 medical facilities that 
employ VA CRNAs the 2006 maximum statutory salary cap was at least 
$20,000 lower than 2006 CRNA salaries in local market areas. The 2007 
maximum statutory salary cap increased to $136,200. According to VA 
officials, VA is developing proposed legislation to increase this 
maximum statutory salary cap for VA CRNAs by $9,200. Our analysis 
comparing AANA 2007 salary data for CRNAs to VA's CRNA 2007 maximum 
statutory salary cap indicated that increasing the VA CRNA maximum 
statutory salary cap by $9,200 would not, at a majority of VA medical 
facilities, make VA CRNA salaries competitive with CRNA salaries in 
local market areas. Specifically, using 2007 rates, we found that after 
the proposed change, 70 of the 120 VA medical facilities' VA CRNA 
salaries would still be at least $20,000 or lower than the local market 
area CRNA salaries. 

VA Medical Facilities Can Use LPS to Help Make VA CRNA Salaries 
Competitive, and While Majority of Facilities Have Used LPS, Some Have 
Not Followed VA's LPS Policy: 

In December 2007, we reported that VA's LPS system is a key mechanism 
that VA medical facilities can use to determine whether to adjust VA 
CRNA salaries to help the facilities remain competitive with CRNA 
salaries in local market areas. We also reported that the majority of 
VA medical facilities that employ VA CRNAs used LPS. However, at the 
eight 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. 

To Recruit and Retain VA CRNAs, Medical Facilities Can Adjust Salaries 
Using VA's LPS: 

In December 2007, we reported that VA CRNA pay grades--and thus 
salaries--are initially determined by VA's qualification standards for 
VA CRNAs. Although VA medical facility directors are required to use 
the LPS to determine if VA CRNA salaries should be adjusted, they have 
the option of adjusting these salaries to recruit and retain VA CRNAs. 
[Footnote 9] When adjusting VA CRNA salaries, VA medical facilities are 
required to use a process known as LPS.[Footnote 10] The system is 
intended to help VA medical facilities determine whether to adjust VA 
CRNA salaries to be regionally competitive. VA's LPS supports this goal 
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 has an LPS policy, which 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. 

Once the survey is completed, a facility's HR officer reports the 
results to the medical facility director and on the basis of the survey 
data, recommends whether to adjust VA CRNA salaries. The facility 
director makes the final decision on whether to adjust the facility's 
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. 

The Majority of VA Medical Facilities Used LPS, but Instances of 
Incorrect Use Indicated Inadequate Training on LPS Policy: 

In December 2007 we reported that according to VA, the majority--86 out 
of 120--of the 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 facilities that used VA's LPS, 63 used a third- 
party survey to obtain data on local market area salary rates for 
CRNAs. 

We also reported that, while VA facilities that employed VA CRNAs used 
LPS, five of the eight facilities we visited did not use the LPS in 
accordance with VA's LPS policy in 2005 or 2006. VA's LPS 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 made 
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 from their own 
facility-conducted surveys to determine whether VA CRNA salaries should 
be adjusted, and officials from these facilities told us they 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 
the use of salary data of CRNAs that work for organizations that 
contract anesthesia services 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, indicated 
that VA had not provided adequate training on its LPS policy. 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, had not conducted nationwide training 
on its LPS policy since 1995.[Footnote 11] As a result, VA medical 
facility officials had not received LPS training that reflected VA's 
current LPS policy and, accordingly could not ensure that VA CRNA 
salaries had been adjusted as needed to be competitive. 

In our December 2007 report we noted that VA was in the process of 
developing a Web-based training course for the LPS that VA medical 
facility officials could complete online. We reported that because VA 
had not made the training a priority, it had not established a time 
frame for finalizing the development and implementation of the training 
course. In our December 2007 report we recommended that VA expedite the 
development and implementation of the training course for VA medical 
facility officials responsible for compliance with the policy. VA 
agreed with our recommendation and in comments on our draft report 
stated that it had developed a draft action plan for training staff on 
its LPS policy. VA anticipated that the online training course would be 
available by the end of fiscal year 2008. 

Mr. Chairman, this concludes my prepared remarks. I would be happy to 
answer any questions you or other members of the committee may have. 

Contact and Acknowledgments: 

For more information regarding this testimony, please contact Marjorie 
Kanof at (202) 512-7114 or [email protected]. Contact points for our 
Offices of Congressional Relations and Public Affairs may be found on 
the last page of this statement. In addition, Marcia Mann, Assistant 
Director; N. Rotimi Adebonojo; Mary Ann Curran; Melanie Egorin; and 
Krister Friday made key contributions to this testimony. 

[End of section] 

Footnotes: 

[1] GAO, VA Health Care: Many Medical Facilities Have Challenges in 
Recruiting and Retaining Nurse Anesthetists, [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-08-56] (Washington, D.C.: Dec. 
13, 2007). 

[2] The eight VA medical facilities we visited were 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. 

[3] [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-56]. 

[4] 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. 

[5] 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. 

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

[7] 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. 

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

[9] [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-56]. 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. See 38 U.S.C. ï¿½7451(d)(3)(E)(2000). 

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

[11] VA stated in its comments on our 2007 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 during our review mentioned this 
training session. 

[End of section] 

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