[House Hearing, 110 Congress]
[From the U.S. Government Printing Office]



                    HUMAN RESOURCES CHALLENGES WITH
                   THE VETERANS HEALTH ADMINISTRATION

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

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

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

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                              MAY 22, 2008

                               __________

                           Serial No. 110-88

                               __________

       Printed for the use of the Committee on Veterans' Affairs






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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     HENRY E. BROWN, Jr., South 
Dakota                               Carolina
HARRY E. MITCHELL, Arizona           JEFF MILLER, Florida
JOHN J. HALL, New York               JOHN BOOZMAN, Arkansas
PHIL HARE, Illinois                  GINNY BROWN-WAITE, Florida
MICHAEL F. DOYLE, Pennsylvania       MICHAEL R. TURNER, Ohio
SHELLEY BERKLEY, Nevada              BRIAN P. BILBRAY, California
JOHN T. SALAZAR, Colorado            DOUG LAMBORN, Colorado
CIRO D. RODRIGUEZ, Texas             GUS M. BILIRAKIS, Florida
JOE DONNELLY, Indiana                VERN BUCHANAN, Florida
JERRY McNERNEY, California           STEVE SCALISE, Louisiana
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota

                   Malcom A. Shorter, Staff Director

                                 ______

                         SUBCOMMITTEE ON HEALTH

                  MICHAEL H. MICHAUD, Maine, Chairman

CORRINE BROWN, Florida               JEFF MILLER, Florida, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
PHIL HARE, Illinois                  JERRY MORAN, Kansas
MICHAEL F. DOYLE, Pennsylvania       HENRY E. BROWN, Jr., South 
SHELLEY BERKLEY, Nevada              Carolina
JOHN T. SALAZAR, Colorado            VACANT

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.






                            C O N T E N T S

                               __________

                              May 22, 2008

                                                                   Page
Human Resources Challenges with the Veterans Health 
  Administration.................................................     1

                           OPENING STATEMENTS

Chairman Michael Michaud.........................................     1
    Prepared statement of Chairman Michaud.......................    33
Hon. Jeff Miller, Ranking Republican Member......................     2
    Prepared statement of Congressman Miller.....................    33
Hon. Phil Hare...................................................     2

                               WITNESSES

U.S. Department of Veterans Affairs, Joleen Clark, Chief Officer, 
  Workforce Management and Consulting, Veterans Health 
  Administration.................................................    26
    Prepared statement Ms. Clark.................................    56

                                 ______

American Association of Nurse Anesthetists, Angela Mund, CRNA, 
  MS, Clinical Director, University of Minnesota Nurse Anesthesia 
  Area of Study, Minneapolis Veterans Affairs Medical Center, 
  Veterans Health Administration, U.S. Department of Veterans 
  Affairs........................................................     6
    Prepared statement of Ms. Mund...............................    42
American Federation of Government Employees, AFL-CIO, J. David 
  Cox, RN, National Secretary-Treasurer..........................     3
    Prepared statement Mr. Cox...................................    34
American Psychological Association, Randy Phelps, Ph.D., Deputy 
  Executive Director for Professional Practice...................     4
    Prepared statement of Dr. Phelps.............................    38
Disabled American Veterans, Adrian M. Atizado, Assistant National 
  Legislative Director...........................................    19
    Prepared statement of Mr. Atizado............................    54
Paralyzed Veterans of America, Fred Cowell, Senior Associate 
  Director for Health Analysis...................................    16
    Prepared statement of Mr. Cowell.............................    48
Nurses Organization of Veterans Affairs, Cecilia McVey, BSN, MHA, 
  RN, Immediate Past President, and Associate Director for 
  Patient Care/Nursing, Veterans Affairs Boston Healthcare 
  System, Veterans Health Administration, U.S. Department of 
  Veterans Affairs...............................................    18
    Prepared statement of Ms. McVey..............................    52
Vertical Alliance Group, Inc., Texarkana, TX, Jay W. Wommack, 
  Founder, President and Chief Executive Officer.................     8
    Prepared statement of Mr. Wommack............................    46

                   MATERIAL SUBMITTED FOR THE RECORD

Post Hearing Questions and Responses for the Record:
    Hon. Michael H. Michaud, Chairman, Subcommittee on Health, 
      Committee on Veterans' Affairs, to Hon. James B. Peake, 
      M.D., Secretary, U.S. Department of Veterans Affairs, 
      letter dated June 5, 2008, including questions from Hon. 
      Vic Snyder, and VA responses...............................    60

 
   HUMAN RESOURCES CHALLENGES WITH THE VETERANS HEALTH ADMINISTRATION

                              ----------                              


                         THURSDAY, MAY 22, 2008

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice, at 10:05 a.m., in 
Room 334, Cannon House Office Building, Hon. Michael Michaud 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Michaud, Snyder, Hare, and Miller.

             OPENING STATEMENT OF CHAIRMAN MICHAUD

    Mr. Michaud. The hearing will come to order, and I will ask 
the first panel to come forward.
    I would like to thank everyone for coming today.
    The Veterans Health Administration's (VHA's) mission is to 
provide patient-centered healthcare that is comparable to or 
better than care available in the non-U.S. Department of 
Veterans Affairs (VA) sector. To do this, VHA must have a 
viable healthcare workforce that is competent, well-trained and 
happy.
    Over the past 5 years, the VA has built a reputation of 
delivering healthcare efficiently and effectively. VA has been 
touted as the ``best care anywhere,'' and the Department has 
been recognized on numerous occasions for healthcare quality 
and patient satisfaction.
    However, in order to carry that banner forward, careful 
planning and efficient processes must be put into the system to 
ensure continued success.
    We know that VA's workforce is aging, with an average age 
of 48.6 years. We know that at the end of 2012 a significant 
percentage of the employees will be eligible to retire.
    This Subcommittee has held many hearings that have examined 
the appropriateness and quality of care and treatment that 
veterans receive within the healthcare system. This hearing 
today will focus on the human resource challenges that VHA must 
address in order to ensure that there will not be a gap in 
expertise and quality of care provided to our veterans.
    The Subcommittee realizes that this is a complex issue, but 
we also recognize that it is an important one that deserves 
serious thought and consideration as well.
    I would like to recognize Mr. Miller for any opening 
statement that he might have.
    [The prepared statement of Chairman Michaud appears on 
p. 33.]

             OPENING STATEMENT OF HON. JEFF MILLER

    Mr. Miller. Thank you very much, Mr. Chairman. I do 
appreciate you holding this hearing today to examine all those 
challenges the VA faces in regards to keeping the high-quality 
healthcare workers that are currently in the system. They are 
on the frontline of the healthcare issue every single day.
    Our servicemembers who have honorably served our country 
deserve high-quality healthcare, and we must do what we can to 
keep those professionals retained and recruit them as well. One 
of the most pressing problems we face as a Nation is a marked 
shortage in virtually all areas of the healthcare worker 
industry, including nurses, physicians, physicians' assistants, 
psychologists, pharmacists, and physical and occupational 
therapists.
    The VA system has been recognized for the significant 
benefit of its use of electronic medical records and focus on 
preventative care. To make sure that our veterans continue to 
receive the best care, it is critical that we see the VA as a 
workplace of choice. So I appreciate you putting this hearing 
together to focus and see what we can do better.
    I yield back the balance of my time.
    [The prepared statement of Congressman Miller appears on 
p. 33.]
    Mr. Michaud. Thank you.
    Mr. Hare.

              OPENING STATEMENT OF HON. PHIL HARE

    Mr. Hare. Thank you, Mr. Chairman. I want to thank you and 
Ranking Member Miller for holding this hearing today.
    The Veterans Health Administration is one of the most 
impressive healthcare delivery systems in the entire world, and 
that is in large part due to the dedicated medical 
professionals who make up the system. From doctors to nurses to 
technicians to psychologists, these are the men and women who 
are on the ground every day taking care of our Nation's 
veterans.
    The veterans population will undergo significant changes 
over the next two decades. And as such, the leadership at the 
VHA will have to be prepared to handle these challenges.
    One of the biggest challenges is the recruitment and 
retention of highly qualified medical personnel at a time when 
the overall health industry is facing massive shortages. The VA 
must be able to compete with the private sector for medical 
staff. And we must ensure that, as the VHA continues forward, 
that they have the tools and the funds necessary to guarantee 
adequate numbers of staff in order to continue the care of our 
veterans.
    Once again, Mr. Chairman, I want to thank you for holding 
the hearing today. I look forward to hearing from our panels. 
And thank you very much, Mr. Chairman. I yield back.
    Mr. Michaud. Thank you very much, Mr. Hare.
    Our first panel includes David Cox, a Registered Nurse (RN) 
who is the National Secretary-Treasurer for American Federation 
of Government Employees (AFGE) of the AFL-CIO.
    I want to welcome you, David, here this morning.
    And Dr. Randy Phelps, who is the Deputy Executive Director 
of the American Psychological Association (APA); and Angela 
Mund, who is a CRNA, the Clinical Director for Minneapolis VA 
Medical Center, who is here on behalf of the American 
Association of Nurse Anesthetists (AANA); and then Jay Wommack, 
President of Vertical Alliance Group, Inc.
    So I want to welcome our four panelists this morning and am 
looking forward to hearing your testimony.
    We will start off with Mr. Cox.

 STATEMENTS OF J. DAVID COX, RN, NATIONAL SECRETARY-TREASURER, 
  AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, AFL-CIO; RANDY 
   PHELPS, PH.D., DEPUTY EXECUTIVE DIRECTOR FOR PROFESSIONAL 
  PRACTICE, AMERICAN PSYCHOLOGICAL ASSOCIATION; ANGELA MUND, 
  CRNA, MS, CLINICAL DIRECTOR, UNIVERSITY OF MINNESOTA NURSE 
ANESTHESIA AREA OF STUDY, MINNEAPOLIS VETERANS AFFAIRS MEDICAL 
  CENTER, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 
 VETERANS AFFAIRS, ON BEHALF OF AMERICAN ASSOCIATION OF NURSE 
ANESTHETISTS; AND JAY W. WOMMACK, FOUNDER, PRESIDENT AND CHIEF 
EXECUTIVE OFFICER, VERTICAL ALLIANCE GROUP, INC., TEXARKANA, TX

                   STATEMENT OF J. DAVID COX

    Mr. Cox. Chairman Michaud and Ranking Member Miller and 
distinguished Members of the Subcommittee--it seems like I am 
getting off to a bad start here. I am tying my tongue up this 
morning. I have never been first on a panel; maybe that is what 
it is. Thank you for the opportunity to testify today. AFGE 
greatly appreciates the Subcommittee's continued attention to 
the impact of VA healthcare workforce problems on patient care.
    Veterans want to get their care from the VA because VA 
healthcare professionals are extremely dedicated to their 
patients and committed to the mission of the VA. In the 
eighties, labor management collaboration helped transform the 
VA into a healthcare leader in best practices, patient safety 
and healthcare information technology.
    AFGE believes the greatest human resources challenge facing 
VHA today is the continuing erosion of title 38 collective 
bargaining rights, as I will discuss shortly. First, I would 
like to address several other human resources issues of concern 
to AFGE.
    The hybrid title 38 process, which covers psychologists, 
social workers, pharmacists and licensed practical nurses 
(LPNs), among others, has become severely backlogged. It is 
also troubling that VHA employees lose their veterans' 
preference when they are converted to title 38 from title 5.
    Therefore, AFGE urges this Subcommittee to reject proposals 
to add more positions to title 38 and instead conduct a pilot 
project using a streamlined title 5 hiring process to compare 
the two systems. We would be pleased to work with you to 
develop this pilot project and believe it can provide valuable 
lessons for other Federal employers.
    AFGE also urges the Subcommittee to conduct oversight into 
the many implementation problems surrounding the 2004 physician 
pay law, such as secretive process for setting market pay and 
use of improper performance measures. Since Congress is still 
waiting for the VA's long-overdue report on how well the pay 
law is working and whether it is has reduced the VA's reliance 
on costly contract physicians, we urge the Subcommittee to 
conduct its own study on this important law instead.
    Nurse alternative work schedules provide full-time pay for 
working 3 12-hour days per week or 9 months per year. These 
schedules are very popular in the private sector and could be a 
valuable VHA recruitment and retention tool. Unfortunately, VHA 
refuses to offer this schedule option to its nurses, even 
though they were given this authority by Congress 4 years ago. 
AFGE recommends that Congress amend the law to require the VA 
to offer alternate work schedules based on a fixed formula that 
aligns facilities with their local labor markets.
    Turning to title 38 collective bargaining rights, we are 
very grateful to Chairman Michaud and Subcommittee Members 
Berkley, Brown and Doyle for cosponsoring H.R. 4089. This bill 
is an essential enforcement tool for past and future VHA 
recruitment and retention legislation.
    In 1991, Congress provided RNs, physicians and other pure 
title 38 providers with rights to challenge improper personnel 
policies through grievances, arbitrations and the court. 
Providers lost these rights because the VA began using an 
arbitrary interpretation of the three exceptions in section 
7422 of title 38: professional conduct and competency, peer 
review, and compensation.
    Management's section 7422 policy directly contradicts 
Congressional intent, as is evident by the plain language of 
the law and the legislative history. Management's section 7422 
policy is also inconsistent with its own position that it took 
in 1996 with a labor management agreement to allow grievances 
over indirect patient care matters, scheduling, and rights to 
pay survey data.
    The VA contends that amending section 7422 will allow labor 
to disrupt patient care. But management's rights to determine 
the agency's mission under title 5 already protect against 
that. And the VA cannot point to a single case where a 
grievance involved a challenge to medical procedures. VHA 
employees who have full grievance rights, such as LPNs, 
psychologists, and pharmacists, never use these rights to 
disrupt patient care.
    The VA also contends that current law gives title 38 
providers fair process for deciding when a grievance can be 
filed, pointing to a review by the Under Secretary for Health. 
We asked, fair to whom? In the past 3 years, 100 percent of 
these decisions have been in favor of management. Shouldn't VA 
healthcare dollars be spent on caring for veterans, not looking 
for ways to block legitimate concerns of hard-working, 
dedicated nurses and physicians?
    Thank you, Mr. Chairman. I would be glad to entertain any 
questions from the Committee.
    [The prepared statement of Mr. Cox appears on p. 34.]
    Mr. Michaud. Thank you very much.
    Doctor.

                STATEMENT OF RANDY PHELPS, PH.D.

    Dr. Phelps. Thank you, Mr. Chairman, Ranking Member Miller 
and distinguished Members of the Subcommittee. I am Dr. Randy 
Phelps, Deputy Executive Director for Professional Practice of 
the American Psychological Association.
    We are the largest association of psychologists, with 
approximately 90,000 full doctoral psychology members and 
another 50,000 graduate students in the pipeline. Our folks are 
engaged in the study, research and practice of psychology.
    I am currently a licensed clinical psychologist but 
formerly a practitioner myself, a clinical researcher and 
educator. And for the last 15 years, I have been on the APA 
Executive Staff and have served as APA's liaison to 
Professional Psychology in the Department of Veterans Affairs.
    We really appreciate the opportunity to testify today about 
human resources challenges within VHA.
    I should note at the outset that VHA is the workplace of 
choice for many of our members. There are over 2,400 
psychologists working nationwide in the system. And, in fact, 
VA is the largest single employer of psychologists in this 
country.
    Professional psychology was born as a result of the needs 
of returning soldiers from previous wars, particularly World 
War II. So we owe a great debt to the brave men and women who 
have served this country.
    I will shorten the remarks, obviously, for the oral 
testimony. There is a considerable amount of detail in the 
written testimony.
    But psychologists are very actively involved, particularly 
in the mental health side, of treatment of veterans in VA. The 
architects of the two evidence-based practice treatments for 
post traumatic stress disorder (PTSD) are psychologists. 
Psychologists are serving a very critical role in understanding 
diagnosis and treatment of traumatic brain injury (TBI), which 
is the other signature wound of the war, alongside nursing, 
neurologists and other folks.
    Recruitment of psychologists in the VA is actually in a 
good place at this point. It has not been until the last year 
and a half. And we applaud VHA's efforts to add 800 new 
positions for doctoral psychologists since 2005, bringing us up 
to that 2,400 psychologists in the system. Most of those folks, 
I should add, are young psychologists entering the system at 
GS-11.
    I should emphasize that every psychologist who comes out of 
a clinical or counseling program already knows how to treat 
PTSD, depression and so forth.
    The thing that I wanted to emphasize, though, about 
recruitment is that the staffing levels are a very recent 
developments. It was only 2 years ago where we reached the 
staffing levels of psychologists in the VA of the 1995 years. 
So the curve has been going down until just very recently with 
the hiring of this new cadre of psychologists.
    Additionally--and this gets to the issue of retention that 
I would like to spend a little bit more time on--additionally, 
the number of GS-14 and GS-15 psychologists in the system at 
the higher leadership levels are actually not increasing 
similarly. The GS-15 level is lower than it was in 1995.
    The VA has done a good job of recruiting new psychologists 
coming into the system because it is hiring its own. We have 
approximately 600 psychology training positions within VA, and 
75 percent of the new hires are past VA psychology trainees.
    There are three major problems, however, that affect 
retention of the workforce that I can elaborate on later if you 
have questions.
    One is a lack of uniform psychology leadership positions. 
We are the only mental health position without an officially 
designated leader at medical centers. There is a very 
inequitable access to key leadership positions throughout VA. 
And there are, as you have heard some from a colleague, very 
serious implementation issues with the hybrid title 38. In 
fact, I would describe the implementation of the hybrid title 
38 system as an absolute boondoggle, bureaucratically and 
otherwise, for the system.
    These problems--which, again, we can elaborate on later--
have led to a number of very chilling situations for 
psychologists throughout the country, where folks are leaving 
the VA to go to the private sector, losing their positions, 
inability to get advancement and so forth.
    And we consider those kinds of problems as the most serious 
obstacles to making VA the workplace of choice for 
psychologists now and in the future, because without clear 
advancement systems in place, VA faces critical long-term 
recruitment and retention problems. As psychologists come to 
believe that there is little possibility for advancement in the 
system, regardless of the level of complexity of their 
responsibilities, fewer VA psychologists will be willing to 
accept positions of greater responsibility.
    And, in addition, high-potential trainees coming into the 
system the VA would like to recruit for the future will 
increasingly, and are increasingly, seeing VA as a dead-end for 
their careers and will be attracted to other career options 
with more potential for advancement.
    And we thank you very much for this opportunity to testify 
today. Thank you.
    [The prepared statement of Dr. Phelps appears on p. 38.]
    Mr. Michaud. Thank you.
    Ms. Mund.

               STATEMENT OF ANGELA MUND, CRNA, MS

    Ms. Mund. Chairman Michaud, Ranking Member Miller and 
Members of the Subcommittee, good morning. My name is Angela 
Mund. I am a Certified Registered Nurse Anesthetist, or a CRNA, 
at the Minneapolis VA. I also serve as President of the 
Association of VA Nurse Anesthetists. And I am pleased to 
appear before you on behalf of my profession, the American 
Association of Nurse Anesthetists and its 39,000 members in the 
United States.
    You have my written statement, and I ask unanimous consent 
for it to be entered into the record.
    Mr. Michaud. Without objection.
    Ms. Mund. America's CRNAs provide some 30 million 
anesthetics annually in every healthcare setting requiring 
anesthesia care, and we provide that safely. The Institute of 
Medicine reported in 2000 that anesthesia is 50 times safer now 
than it was in the 1980s. For over 125 years, nurse 
anesthetists have met the mission of caring for our veterans, 
caring for those who have borne the battle, their widows and 
orphans.
    Nurse anesthetists are the predominant provider of 
anesthesia services in the VA and are the sole anesthesia 
provider in 12 percent of VA facilities. In the days before I 
left for this hearing, I personally provided anesthesia for our 
veterans. Any of the more than 500 CRNAs in the Veterans Health 
Administration could say the same.
    But the average VA CRNA is 53 years old, 7 years older than 
the profession's average, and is approaching retirement. In any 
recent year, nearly one in five VA CRNAs leaves or retires from 
the VA. Twenty-four VA facilities report CRNA vacancies. We 
believe that actual number is closer to 40, and the U.S. 
Government Accountability Office (GAO), in their report, used 
70 as the number. Contract personnel also fill about 150 of the 
VA CRNA posts.
    We are increasingly concerned that without a sufficient 
number of CRNAs in the VA system, our veterans won't get the 
care they need and deserve. They may have to wait too long for 
that care, which ultimately may increase cost to the U.S. 
Treasury.
    A report last December from the GAO confirmed what we, in 
the VA, have long known. The GAO found 54 percent of VA 
facilities have had to close operating rooms, and 74 percent 
have had to delay surgeries for lack of CRNAs. Twenty-six 
percent of VA CRNAs plan to retire within the next 5 years, and 
the agency has struggled to both recruit and retain nurse 
anesthetists. Seventy-four percent of VA respondents to the GAO 
survey said they had difficulty recruiting CRNAs.
    The VA's struggle has not been for lack of CRNAs in the 
marketplace. In 2007, accredited nurse anesthesia educational 
programs produced over 2,000 graduates, an 88 percent increase 
in just 5 years, in order to meet the growing demand for 
anesthesia services. Rather, the GAO found, and we agree, that 
the VA CRNA compensation is far below market levels in many 
localities.
    The issue of below-market compensation was cited by 90 
percent of chief anesthesiologists reporting difficulty 
recruiting CRNAs and by 77 percent of chief anesthesiologists 
reporting difficulty retaining CRNAs. In some facilities, bad 
working conditions also sent good CRNAs elsewhere.
    We have three recommendations to close this gap and to 
ensure American veterans have the necessary anesthesia care for 
the surgical and invasive diagnostic procedures they require.
    First is to enhance the VA relationship with the nurse 
anesthesia educational programs. Already some 70 VA hospitals 
serve as clinical practice education sites for nurse anesthesia 
schools. Many hospitals find serving these clinical practice 
sites helps them recruit new CRNAs.
    Second is to continue nurturing the VA's joint relationship 
with the U.S. Army Nurse anesthesia educational program at Fort 
Sam Houston, Texas, which educates CRNAs for VA service. The 
current program uses the VA Employee Incentive Scholarship 
Program, or EISP, to fund tuition, fees and salary 
reimbursement for nurse anesthesia students who then fulfill a 
service commitment to the VA.
    Third is to bring VA's CRNA compensation closer to local 
market rates. The GAO recommends VA facilities take advantage 
of VA locality pay policies. But that will not be enough to 
close the gap. In addition, Congress should act to lift the 
statutory cap on VA CRNA pay so that local facilities can set 
compensation at rates closer to market levels.
    Of all the options available to close the VA's CRNA 
workforce gap and ensure veterans gets the high quality of care 
they deserve, these three suggestions are the most cost-
effective and the easiest to carry out.
    Thank you, and I would be happy to take your questions.
    [The prepared statement of Ms. Mund appears on p. 42.]
    Mr. Michaud. Thank you very much.
    Mr. Wommack.

                  STATEMENT OF JAY W. WOMMACK

    Mr. Wommack. I would like to start with a quote. ``In times 
of change, learners inherit the Earth, while the learned find 
themselves beautifully equipped to deal with a world that no 
longer exists''--Eric Hoffer.
    I don't need to repeat the nursing shortage; everybody up 
here knows that. The baby boomers are about to retire. We, 2 
years ago, entered the first baby boomer turning age 60. This 
year, the first baby boomer started to retire at 62. And this 
generation looks like a basketball going through the belly of a 
snake, and behind it we do not have enough people to fill the 
needs in the healthcare industry.
    On top of that, we have a declining dollar. A declining 
dollar causes devaluation of the currency, which means the 
Canadian dollar is more powerful. We are seeing nurses leave 
the United States, to go back up north.
    We see all these things and we see the nursing shortage is 
in quite a state, but I think there is a worse shortage than 
that out there, and the worst shortage is the shortage of 
qualified, well-trained, recruiting personnel, not just to 
recruit nurses and medical personnel, but also to go out and 
actively recruit people to teach in the schools, because we are 
short on educators. We had to turn down 38,000-plus, in the 
last few years, going to schools to learn how to be medical 
personnel.
    Each month, millions of dollars are spent on advertising to 
draw people into not just the private sector, but into the 
public sector, both sectors, to draw them into the medical 
community, to recruit them for institutions. Millions of 
dollars are spent to generate leads and phone calls. And guess 
what happens? We have dealt with the private sector, and 82 
percent of the phone calls for people that would like to have 
jobs go unanswered. I cannot speak for the VA system; I haven't 
worked with them. But in the private sector, that is an 
astounding number, and that number is shocking.
    Mr. Chairman, Members of Subcommittee, my name is Jay 
Wommack. I am the Chief Executive Officer of a company called 
Vertical Alliance Group. We are an Internet-based training, 
recruiting company. We were founded in 1999. We have 80 Web 
sites, sub-domains and domains, of which a couple of them 
represent the medical community, one called NurseUniverse, one 
called MedVotech. Obviously, the names imply they are out to 
recruit nurses and people for the medical vo-tech schools. We 
operate those Web sites.
    And I have to tell you, I am honored to be here to make 
this presentation. It is a wonderful experience and wonderful 
opportunity, and I appreciate you all taking the time to hear 
us and our testimony.
    I don't make any claim to be a professional in the 
healthcare services area. However, we do know quite a bit. In 
the last 9 years, we have developed quite a bit about the 
process of recruiting and retaining good employees. Now, we do 
this with boot camps. And let me address that issue real quick.
    There is a dire lack of training for people that know how 
to go out and deal with the society today. The Internet changed 
everything. It made us an immediate-gratification society. 
Things happen fast. I mean, when I go to Amazon and I go and 
order a book, I want it, I want it now. I don't like waiting 
till tomorrow. And this is how people are when they are looking 
for jobs. They go fill out an application or make a phone call. 
These people are hanging up before 1 minute when no one is 
answering the telephone. They are sending in applications, and 
you have seen the medical applications. It takes time to fill 
out an application. They send those in, and they get no 
response.
    So what we did as a company is we started to develop 
processes that basically said we are going to train people from 
being paper processors, the old style of human resource, into 
active, proactive salespeople. Because that is what it takes to 
compete in this environment.
    We train them to be salespeople through our boot camps. We 
empower people and teach the salespeople--we call them 
salespeople--we teach them sales training. We teach them 
direct-response marketing. We teach them what it costs to 
actually recruit a nurse. Many people don't know. Advertising 
cost per hire is $10,000 to recruit a nurse, according to AMA. 
It costs between $35,000 and $70,000 to recruit a nurse, not to 
mention a nurse anesthetist. So we are training these people, 
we are empowering them, teaching them what it takes to go out 
and be a proactive recruiter.
    Have we had success? The standard average of a recruiting 
department gets between 1 and 2 percent closing on the people 
that apply for a job. Our companies, on a bell curve, at the 
top of it, get an average of 12 percent closing. Some, 
obviously, have gotten much more than that, some less, but on 
the average, on the bell curve. That is significant savings to 
the bottom line. The process lends itself to the lowest cost 
per hire.
    But you have to inspect what you train, and you have to 
continue to teach what you train. So we developed a process, an 
online, Internet, databased program that basically teaches, 
tracks, trains and follows up on all the education we provide 
at the boot camps. We do it daily, weekly, monthly. It is 
available 24/7.
    It doesn't just happen, though. In order for a program to 
be successful, it must have buy-in from the top. Obviously, we 
wouldn't be sitting here if there wasn't buy-in from the top.
    I visit with a number of VA healthcare facilities. The 
executives at those facilities, they absolutely care. They 
would like to push forward, and they have put together great 
programs, but they like to push forward and get their hiring in 
order.
    I am excited to be here. I appreciate the opportunity to 
speak, and I will be glad to answer any questions.
    [The prepared statement of Mr. Wommack appears on p. 46.]
    Mr. Michaud. Thank you very much. I appreciate it.
    My first question will be for Mr. Cox.
    You talked about H.R. 4089, the bill that is pending. If 
that is passed, what impact will that really have on 
recruitment and retention, in your opinion?
    Mr. Cox. We believe that it would give the registered 
nurses and physicians the same rights that other employees have 
in the VA; that if there are workplace disputes, that they 
would have an avenue to resolve those disputes and to seek 
relief in that arena.
    It is a message we hear from our membership and the VA 
employees over and over, and we believe that it would certainly 
make for a better workplace.
    Mr. Michaud. But as far as the recruitment or retention, do 
you think it will have a positive effect?
    Mr. Cox. I think it will definitely have a positive effect 
on the recruitment and retention, because, again, when you are 
able to resolve problems in the workplace through a negotiated 
agreement to resolve those issues, that makes people feel 
better. There is a way to seek relief if you believe things are 
wrong.
    I believe, also, the fact that the pay data, that we have 
all the locality pay systems, but now if a request is made to 
the VA, ``Share this data with us, show us what you are paying, 
give us information,'' it is, ``No, we do not have to provide 
that to you, because that is a section 7422 issue.'' I believe 
it would bring more light to the issue of pay and the 
recruitment process. But it would definitely be a positive 
impact.
    Mr. Michaud. Thank you.
    Dr. Phelps, you had mentioned the impact of the hybrid 
title 38. What impact would moving psychologists to title 38 
from the hybrid title 38 have on recruitment and retention of 
these professionals?
    Dr. Phelps. Mr. Chairman, that is an issue that we are--
because we are so frustrated with the difficulties and the 
implementation problems with the hybrid system, that is an 
issue that we are looking at very seriously right now.
    Preliminarily, we think it would be the way to go for 
psychologists. We are the only doctoral-level professionals in 
the VA system that are not in the title 38 system. So we are 
very much in favor of that direction.
    Mr. Michaud. Thank you.
    Ms. Mund, how many CRNA candidates rotate through the 70 VA 
training sites annually?
    And my second question is, out of that, how many of those 
candidates actually choose the VA upon completion of their 
training?
    Ms. Mund. I don't have those numbers with me, but I can 
have my staff look at that.
    However, what I can speak to is--I am clinical director of 
a nurse anesthesia program through the University of Minnesota. 
And the VA in Minneapolis is our primary clinical site. We have 
had a relationship with them 25 years, I believe, recently. And 
we send 10 students per year through the VA. We get some 
support from Central Office, which we appreciate. In previous 
years, as much as 75 percent of the graduating class have 
stayed at the VA. However, in the last 2 years, we have had one 
person out of 20.
    And a lot of that is due to low pay, is the main thing. I 
mean, they come out with student loans and are unable to have a 
salary that makes it easier to pay those student loans off.
    And the other big piece of it is the employee debt-
reduction program that the VA has, it is not entirely, through 
issues with human resources, lack of understanding of the 
program. Not everybody who has been eligible has been able to 
take advantage of that as a student loan payback. So they have 
chosen to go to places where they can see exactly, when they 
apply, HR can tell them, ``This is what you will make, this is 
what we will give you, and this is what your loan payback is.'' 
The VA is a little bit hazy on that, so students elect to go 
elsewhere.
    Mr. Michaud. I believe it was in your written testimony, 
you recommended $400,000 in fiscal year 2009 appropriations to 
expand the joint education program. How many additional CRNAs 
would this funding affect?
    Ms. Mund. What they have right now is they have had seven 
graduates and are working. They have three who are in what we 
call phase II, which a clinical portion, three that are in the 
first-year portion, and three that are starting.
    I believe that they would like to increase that number, and 
the Army is available with slots, with seats for those, but 
they need additional funding to have the students come.
    The benefit of going there is that you get your tuition, 
salary and your education paid for. And then they have a three-
year commitment after completing the program.
    Mr. Michaud. Thank you.
    My last question is for Mr. Wommack.
    What immediate action should the VA take to modernize their 
hiring system so that it is competitive with the private 
sector?
    Mr. Wommack. That is a very good question.
    The first thing I would do is I would start training the 
personnel on being very proactive. You have to train these 
people. They have the tools in place. The VA has done a great 
job of putting together a package of information, kits like 
that. But they have to be brought into the 21st century via the 
technology, the platforms of technology that they have at their 
disposal and that we offer.
    They have to be trained, and they have to be trained in the 
value of what they are doing, the lead. The half-life of a 
lead, when someone picks up that phone to call or when someone 
sends in an application, the half-life of that lead is probably 
less than 4 hours. In other words, if you don't touch it in 4 
hours, they are gone. That is what we found; it may be even 
shorter than that.
    So the first thing I would do is set up training for them. 
And then you have to follow up and monitor exactly what you 
have taught. You have to inspect it every single week. We do 
that with our existing clients. We train them, and then we 
follow up every single week, and we make them respond to us, 
because that is where you ferret out what the real problems 
are. You find out what is working, what is not working, and 
then you adjust it and you change it. And then you continue the 
education process.
    Mr. Michaud. Great. Thank you.
    Mr. Miller.
    Mr. Miller. Thank you, Mr. Chairman.
    Mr. Cox, can you give me a little feel for the difference 
between title 5 and title 38 in regards to the hiring process? 
How would title 5 be more or less stringent than title 38?
    Mr. Cox. Title 5 employees get on registers. They go 
through, as you know, the various places throughout the 
country. They apply with USAJOBS, those type things. They get 
on registries. They are hired. From that, they get veterans' 
preference, things of that nature.
    Title 38, like registered nurses and physicians, they can 
go to a VA medical center, fill out an application and be 
hired. There is a boarding process that title 38s have to go 
through, the credentialing process, things of that nature, 
which takes a very lengthy period of time. And that is what 
really holds up a lot of the hiring process at the VA in the 
title 38 arena.
    With the hybrid title 38s, again, the VA has not developed 
a lot of the qualification standards, so there is not the 
boarding processes to promote these people and to move them 
through the proper grades. It is a very, very complex hiring 
system.
    Mr. Miller. Well, you recommended establishing a pilot 
program streamlining title 5. I would like to know a little 
more in detail about, what that plan would--or how it would 
differ from the current title 5? Wouldn't it be just as useful 
to streamline or do a pilot program to streamline the hybrid 
title 38 hiring process?
    Mr. Cox. We believe that you can go to Office of Personnel 
Management (OPM) and the agency, VA, can work with OPM, do a 
demonstration project to--like, nursing assistants is one group 
that, if people are certified, that you could hire them through 
a title 5 process that would actually be easier than the hybrid 
title 38. Because with that, you have to develop the 
qualification standards, the boards that would then have to 
evaluate the people, determine their promotions and 
appointments and things of that nature.
    So we believe that there are procedures with OPM that could 
actually streamline title 5 and make it easier than hybrid 
title 38. And one thing that we believe that that would also 
help, it would maintain the veteran preference for the 
employees.
    Mr. Miller. Give me a little indication of how the 
retirement benefits differ from the Federal worker and the 
private sector right now.
    Mr. Cox. The difference in the retirement benefits?
    Mr. Miller. Yes.
    Mr. Cox. I am not sure that I could give you a total 
picture on that.
    Mr. Miller. More, less, better, worse?
    Mr. Cox. I retired from the Federal Government myself 2 
years ago, and I have friends that are in the private sector. 
And I would say, with the current FERS employees, it is about 
comparable to the private sector. Most employees in the private 
sector have some type of matching 401(k) plan and some other 
defined benefit plan, such as--available with that. But I would 
say this, we're fairly comparable in that arena.
    And, in some areas, I believe the private-sector retirement 
may be better; in others, obviously, the Federal Government. I 
am not sure that I am----
    Mr. Miller. What about health insurance?
    Mr. Cox. Health insurance, private sector, in many cases, 
is better than the Federal employee health insurance.
    Mr. Miller. Dr. Phelps, what benefits do you see in 
bringing psychologists fully into the title 38 program?
    Dr. Phelps. As I said, Mr. Miller, we are looking more 
closely at that. We have tried to be good citizens with the 
hybrid system. So the benefits would be to eliminate some of 
these kinds of problems with the hybrid system.
    Let me give you a couple of examples. As Mr. Cox said, that 
with the hybrid title 38 system there is required the creation 
of professional standards boards for each of those disciplines. 
Psychology has a national professional standards board, and it 
also has developed its quality standards. And so that process 
is under way.
    But what has been happening for the last year or so is that 
psychologists with additional scope of responsibility--running 
huge treatment programs, 60 psychology staff under them and so 
forth--who have submitted to the professional standard boards 
and have then been recommended nationally for a grade increase 
have then been stymied at the level of the local medical 
center, in most cases. Some cases, it is at division level.
    And the VA itself is issuing, in some cases certainly, 
informational missteps about who is qualified, who is not 
qualified, what do you have to submit and so forth.
    So moving into a system that is based on the title 38 
system, that is based simply on the professional is hired, 
promoted and retained based solely on their qualifications, as 
opposed to going through these very complex processes that VA 
has been unable to implement over the past 5 years. It has been 
5 years since the Congress changed the hybrid statutorily.
    So we believe that it would very much not only simplify the 
system for psychologists, but certainly improve the recruitment 
of new psychologists and, clearly, the retention of 
psychologists, the leadership. We have a lot of psychologists 
in the system who have been in 20 and 30 years that are 
operating at the GS-13 level. They are not there for the money. 
They are there because of the dedication to veterans. And they 
need to be the folks training the new cadre of professionals.
    Mr. Miller. Thank you very much.
    I apologize to Ms. Mund and Mr. Wommack. My time for 
questions has expired.
    Mr. Michaud. Mr. Hare.
    Mr. Hare. Thank you, Mr. Chairman.
    Ms. Mund, I was wondering, could you please compare the 
differences between hiring, retention or educational benefits 
packages offered by the VA and the private sector for CRNAs? 
And does the VA excel in any of those areas more than the 
private sector?
    Ms. Mund. Well, the main difference, I think, between the 
two is other places, what I have heard from my students, 
especially recent grads, are they can call up the University of 
Minnesota hospital and say, ``I am a new grad. What am I going 
to start at for salary? What kind of bonus am I going to get? 
What can I see for loan paybacks?'' And they can get that 
number from human resources immediately.
    The problem with the VA is often they will call human 
resources and they will get a range just like it is posted on 
VA Jobs. So the student does not know where they are starting 
until they sign on. Often they are not going to take that 
chance when the range is anywhere from $89,000 to $139,000. It 
is difficult to see where you would fit on that scale.
    The other thing is the employee debt-reduction program, 
which I spoke to before, which I think is a great recruitment 
tool. The problems is there is a 6-month window that, if you 
don't apply for it within that time, you are no longer 
eligible. Well, if for some reason paperwork has been lost, the 
human resources person covering that student has some lack of 
information, all of a sudden that 6-month window is gone and 
the debt-reduction program they are no longer eligible for. 
Other things related to that is human resources also, if it 
does not say on the Web site that you are eligible for the 
Education Debt Reduction Program (EDRP), they cannot offer that 
to you once you sign on.
    So I think a lot of it is the transparency for when 
students apply for jobs. They need to see that in the VA. They 
need to know that these things are going to be available and 
rather than getting lost in the shuffle of paperwork and time.
    Mr. Hare. Because it would seem to me, somebody graduates 
and they know at one hospital what their bonus is going to be, 
their salary is going to be, their compensation is going to be, 
almost to the penny----
    Ms. Mund. Right.
    Mr. Hare [continuing]. And then you have the VA who gives 
them a range. So if you are getting out of school with a lot of 
debt load, and I am sure the debt load is significant, it has 
got to really put us at a disadvantage, I am assuming.
    I can't blame the student, I mean, obviously, because they 
have spent this time and, as I said, built up a lot of debt.
    Ms. Mund. And I think the unfortunate thing is they 
primarily had their training site in the VA, and they loved 
taking care of veterans. There really is not another population 
that is like that. But after having the time and expense of 
school, sometimes you have to weigh those things. And I think 
that if we did a better job of a transparent benefit package, I 
think the VA could be very comparable.
    Mr. Hare. Mr. Cox, can you talk a little bit more about the 
hybrid hiring process and what makes it so long and complicated 
for prospective applicants?
    Mr. Cox. The hybrid--again, the VA has to develop 
qualification standards. The way that it is sold to everyone in 
the beginning is that, okay, hybrid, you can just walk in, fill 
out an application and apply for a job. That is fine; that 
process is simplified. But then there is the qualifications 
standards, the professional standards boards. These people have 
to be brought in. The boards have to meet. They have to review 
the qualifications of the people, then establish their grade, 
those type things.
    That is what really complicates the process. While it is 
not the actual application process, it is the professional 
standards boards, the qualifications standards that create the 
problems in it.
    Mr. Hare. And my last question here. Dr. Phelps, outside of 
fair compensation, how else would uniformed leadership in the 
VA facilities benefit recruitment and retention of 
psychologists?
    Dr. Phelps. The issue of uniformed leadership is this. In 
the mid-nineties, when Dr. Kaiser came in, regionalized the 
system, got rid of discipline-based services, what happened 
was, not just to psychology but with other professions as well, 
social work--I am most familiar with the mental health side--is 
we had staffs reporting to other disciplines who had no 
understanding of what the standards of practice are within that 
particular discipline.
    What has happened since then is a recognition by the system 
that the ability to certify the qualifications, the skill sets 
and so forth of psychologists in the system requires somebody 
in psychology. So we have a system where there is no 
uniformity. Facilities appoint a lead psychologist or a senior 
psychologist; there are many different terms. And this gets 
back to the issue of, sort of, fair pay for a fair day's work, 
Mr. Hare. Those folks operate in those positions in addition to 
their regular job description.
    And part of our issue with the hybrid is national standards 
boards and the quality standards have recognized that those are 
additional responsibilities that should bring additional pay, 
but there is no uniformity even at the level of what those 
types of positions are.
    Mr. Hare. Thank you.
    Thank you, Mr. Chairman.
    Mr. Michaud. Thank you, Mr. Hare.
    Once again, I would like to thank our panelists. We will 
have some additional questions for the record, so if you could 
answer the questions for the record, we would appreciate it 
very much. Once again, thank each and every one of you for 
coming out this morning.
    Our second panel is comprised of Fred Cowell, who works for 
the Paralyzed Veterans of America (PVA); Adrian Atizado, of the 
Disabled American Veterans (DAV); and Cecilia McVey, who is the 
Associate Director of Patient Care and Nursing in the VA Boston 
Healthcare System, and Immediate Past President of the Nurses 
Organization of Veterans Affairs (NOVA).
    I would like to welcome our second panel. I am looking 
forward to your testimony here this morning.
    And we will start off with Mr. Cowell.

STATEMENTS OF FRED COWELL, SENIOR ASSOCIATE DIRECTOR FOR HEALTH 
 ANALYSIS, PARALYZED VETERANS OF AMERICA; CECILIA McVEY, BSN, 
MHA, RN, ASSOCIATE DIRECTOR FOR PATIENT CARE/NURSING, VETERANS 
       AFFAIRS BOSTON HEALTHCARE SYSTEM, VETERANS HEALTH 
   ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS, AND 
   IMMEDIATE PAST PRESIDENT, NURSES ORGANIZATION OF VETERANS 
AFFAIRS; AND ADRIAN M. ATIZADO, ASSISTANT NATIONAL LEGISLATIVE 
              DIRECTOR, DISABLED AMERICAN VETERANS

                    STATEMENT OF FRED COWELL

    Mr. Cowell. Chairman Michaud, Ranking Member Miller and 
Members of the Subcommittee, on behalf of the Paralyzed 
Veterans of America, I am pleased to offer our views concerning 
the human resource challenges within the Department of Veterans 
Affairs.
    Mr. Chairman, the Subcommittee's interest in the issues 
concerning VA healthcare personnel is well-placed and timely. 
Congress must assist VA's efforts to recruit and retain its 
corps of healthcare professionals as the demand for healthcare 
increases because of today's wars and the aging of veteran 
population from previous wars.
    Currently, the Nation is experiencing serious shortfalls in 
its supply of physicians, nurses, pharmacists, therapists and 
psychologists. Competition for experienced medical personnel 
and newly licensed professionals is keen.
    PVA believes that Congress must take the lead in revamping 
outdated personnel policies and procedures, that includes 
salaries, benefits and working conditions, that may place VA at 
a disadvantage in today's labor market and will prevent VA from 
becoming a medical care employer of choice in the future.
    PVA also believes that the broken VA appropriation process, 
which delays VA funding, is a major barrier to VA's healthcare 
professional recruitment processes.
    VA nurse recruitment and retention efforts: As has been 
stated earlier, the United States is currently in the 10th year 
of a critical nursing shortage which is expected to continue 
through 2020. The current and emerging gap between the supply 
of and the demand for nurses may adversely affect the VA's 
ability to meet the healthcare needs of those who have served 
our Nation.
    The VA must be able to recruit the best nurses and retain a 
cadre of experienced, competent nurses. Providing high-quality 
nursing care to the Nation's veterans is integral to VA's 
healthcare mission.
    VA physician recruitment and retention: PVA is concerned 
about VA's current ability to maintain appropriate and adequate 
levels of physician staffing at a time when the Nation faces a 
pending shortage of physicians. Recent analysis by the 
Association of American Medical Colleges indicates the United 
States will face a serious doctor shortage over the next few 
decades. The subsequent increasing demand for doctors as many 
enter retirement will increase challenges to VA's recruitment 
and the retention efforts.
    VA's psychologist recruitment, retention and appropriate 
promotions: According to the American Psychological 
Association, VA is the largest single employer of psychologists 
in the Nation. Congress and VA have recognized the need to 
increase the number of psychologists and have added more than 
800 new psychologists since 2005, thereby raising the number of 
the psychologists in the VA system to approximately 2,400.
    VA must also strive to retain and promote its more 
experienced psychologists in order to meet new training and 
supervision requirements. Since the vast majority of new 
psychologist hires in VA are less experienced professionals, VA 
must ensure they are properly trained and supervised. VA must 
also strive to retain and promote its more experienced 
psychologists in order to meet new training and supervision 
requirements.
    Recommendations to enhance VA's recruitment retention 
efforts: Congress must revamp outdated VA personnel policies 
and procedures to streamline the VA hiring process and avoid 
recruitment delays that become barriers to employment.
    Conduct Congressional oversight hearings to determine the 
extent of problems regarding national standardization and 
availability of VA locality pay.
    Congress should implement a title 38 specialty pay 
provision for VA nurses providing care in VA specialized 
service areas, such as spinal cord injury, blind 
rehabilitation, mental health, and traumatic brain injury.
    Review and adopt the recommendations developed by the VA's 
National Commission on VA Nursing. PVA believes these 
recommendations have broad application and can serve as a 
template for improvements that can assist VA's human resource 
management recruitment and retention efforts.
    Congress should improve the provisions of VA's Education 
Debt Reduction Program, the EDRP. Currently, the EDRP is 
limited to not more than $49,000 spread out over 5 years of 
service. This program has not kept pace with the soaring costs 
of medical specialty education. Expanding benefit levels in 
EDRP will make VA more competitive than the national healthcare 
professional marketplace.
    VA must also become more flexible with its work schedules 
to meet the needs of today's healthcare professionals.
    Other benefits, such as child care, and a less stringent 
policy regarding mandatory overtime will make VA employment 
more attractive.
    Congress should also consider reinstating the VA Health 
Professional Education Assistance Scholarship Program. This 
program was sunset in 1998, and the program would be an 
excellent medical care student incentive to future VA 
employment.
    Finally, Mr. Chairman, PVA believes that Congress must find 
a solution to delays with the VA appropriation process. Delays 
in VA appropriations hamstring VA managers' recruitment efforts 
all across the country.
    Mr. Chairman, this concludes my remarks. I will be happy to 
answer any questions you may have.
    [The prepared statement of Mr. Cowell appears on p. 48.]
    Mr. Michaud. Thank you very much.
    Ms. McVey.

            STATEMENT OF CECILIA McVEY, BSN, MHA, RN

    Ms. McVey. Mr. Chairman and Members of the Committee on 
Veterans Affairs' Subcommittee on Health, the Nurses 
Organization of Veterans Affairs, NOVA, would like to thank you 
for inviting us to present testimony on human resource issues 
in VA.
    I am Cecilia McVey, Associate Director for Patient Care/
Nursing at the VA Boston Healthcare System, and I am here today 
as the Immediate Past President of NOVA. NOVA is the 
professional organization for registered nurses employed by the 
Department of Veteran Affairs.
    NOVA respects and appreciates what our labor organizations, 
such as AFGE and the National Association of Government 
Employees (NAGE), do for VA nurses. NOVA clearly deals with VA 
on RN professional matters, not working conditions, for which 
VHA RNs have the union representative. Because this Committee 
has invited NOVA to share its views on this bill however, I am 
here to offer the following observations.
    Nursing and other medical center workforce members are 
dependent on timely and efficient recruiting. Human resource 
departments across VHA are not able to function optimally due 
to systems that have not kept pace with our private-sector 
recruitment abilities. Although there are numerous barriers to 
timely and efficient recruiting, the following are the top 
three.
    Although certain pay flexibilities do exist, such as 
recruitment bonuses, retention allowances and the special rate 
authority, additional pay flexibilities are needed in order for 
VA to be able to successfully compete for the best candidates 
in the marketplace. The current general schedule and locality 
pay system, which works hand in hand with the classification 
system, is antiquated and cannot respond quickly enough and has 
a number of major barriers.
    For example, retention allowances are not considered base 
pay for benefits such as retirement and life insurance. And 
candidates have declined positions based on this limitation. 
VA's special pay rates--there are restrictions on how far the 
table can be expanded, and the approval process for special 
rates is too slow to address the current market conditions. 
Above-the-minimum rates allow a manager to appoint an applicant 
above the minimum step, but there is no mechanism, for example, 
to increase the pay of existing staff to maintain pay parity.
    The application process, how to apply, is very cumbersome 
and confusing to those in the private sector who are used to a 
much faster and simpler process. Staffing specialists must help 
many of the would-be applicants to navigate through the maze of 
the Federal application process.
    A consistent theme across the country is that applicants 
are looking for money for professional development, not just in 
clinical occupations but in administrative as well. Tuition 
reimbursement is limited to a few select occupations at this 
time, such as nurses, that still require expansion.
    Some suggested policy changes recommended are as follows: 
More pay flexibility should be provided. Pay reform similar to 
the physician pay reform, where there is a market pay 
component, would provide the needed flexibility for VA 
facilities at the local level.
    Classification standards are in need of review and 
revision. Many of them are too old and no longer reflective of 
the types of duties and responsibilities that are typically 
performed. Given that these are used to determine the pay, they 
can often serve as a barrier to appropriate and effective pay 
setting.
    Given the sizable number of employees at or near retirement 
age, succession planning is becoming increasingly important, 
especially for those critical positions.
    One other critical area of concern relates to the impact on 
patient care if 38 U.S.C. 7422 exclusions were to be repealed. 
Some of the issues that I foresee would have a negative impact 
on the care of our veterans include the following: RN 
reassignment decisions made on the basis of clinical 
competence, performance appraisals, and proficiency reports; 
fitness for duty issues as determined by a professional 
standard board; clinical competence issues as determined by a 
professional standard board; and disciplinary and major adverse 
actions based on patient care or clinical competence issues. 
Determination of clinical competence is best reserved for those 
responsible for ensuring that quality care is delivered.
    VA has been a leader in healthcare and has earned an 
excellent reputation as one of the best healthcare providers in 
the country. In order to continue this reputation, VHA's staff 
will need to have new skills and competencies to treat this new 
generation of veterans. Nimble and flexible human resource 
processes are critical to VA's future success.
    Thank you, Mr. Chairman and Members of this Subcommittee, 
for this opportunity to testify here about these important 
personnel issues. And I would be happy to answer any questions.
    [The prepared statement of Ms. McVey appears on p. 52.]
    Mr. Michaud. Thank you very much.
    Mr. Atizado.

                 STATEMENT OF ADRIAN M. ATIZADO

    Mr. Atizado. Mr. Chairman, Members of the Subcommittee, I 
thank you for inviting the Disabled American Veterans to 
testify on human resource challenges within the Department of 
Veterans Affairs' Veterans Health Administration.
    As you have been made aware by this panel, as well as the 
previous panel, the human capital needs of VHA are quite a 
concern. There are a few factors I think that we must talk 
about before I can fully deliver my oral testimony. We have to 
understand that the workforce shortage in the Nation is 
primarily defined in three factors: supply, demand and, 
obviously, the compensation package.
    Congress has seen fit to address compensation package with 
regards to the physician pay bill reform as well as VA changing 
the nurses' compensation package.
    Also, VA has been creating some new initiatives with 
regards to the supply end of the issue. You just heard the 
concern about not enough trainers and preceptors for the 
healthcare fields. And I think that should also be addressed, 
not only by VA, but by this Committee as well.
    I would like to highlight a few factors within VHA that 
drive the human capital needs of VHA. There is a distinct 
variation in demographics and behavior of the newest generation 
of VA's patient population compared to the veterans of previous 
conflicts.
    On the attrition of its workforce, by 2012, nearly 92,000 
VHA employees who would be eligible for full civil service 
retirement. Over 46,000 of those are projected to retire. In 
fact, the health resources and services administration division 
of the Department of Health and Human Services projected a 
national shortage of nearly 500,000 nurses by 2010 and over 1 
million by 2020.
    Moreover, the unbalanced matriculants and supply of 
prepared healthcare workers, as well as the maldistribution of 
these workers across the U.S., will demand much more of VHA's 
human resource program.
    Without question, recruitment management and providing 
direction for VA employees on such issues as hiring 
compensation, performance management, and organizational 
development are critical to the success of VHA's mission to 
provide high-quality care to sick and disabled veterans.
    While, as I have mentioned, most recent actions by Congress 
to affect the compensation package of VHA to offer to 
prospective employees necessitates additional implementation 
oversight, as mentioned by the previous panel.
    We believe an equally important problem within the realm of 
recruitment that requires additional attention is the Federal 
hiring process itself. This was touched upon by the previous 
panel. Hiring a new wave of Federal employees to succeed those 
that leave is paramount, given the frequent civil service 
hiring freezes of the past 2 decades and the inadequate funding 
levels in the unpredictable nature of the discretionary budget 
process.
    Fortunately, there is a perennial and widely acknowledged 
complaint by applicants for Federal employment about cumbersome 
Federal hiring procedures and practices which require too much 
time and excessive paperwork. Of those who submit applications, 
many say they never received feedback from agencies of 
interest.
    The most recent Merit Systems Protection Board's survey of 
entry-level hires and upper-level hires showed that substantial 
numbers had to wait 5 months or longer before being hired. This 
is much, much too long to expect a high-quality applicant to 
wait, particularly in the healthcare arena, which is extremely 
competitive.
    As the Subcommittee is aware, VHA's workforce is covered 
under title 5, title 38 and title 38 hybrid. The greater 
majority of VHA employees fall in title 38 as well as the title 
38 hybrid. Personnel rules under both were designed to allow 
greater flexibility and expedite VHA's hiring and promotion 
processes. However, the reality of hiring and promotion 
processes are facing extraordinary delays, particularly in the 
boarding process across health disciplines from nurses to 
psychologists, as well as background searches. The Federal 
hiring process is so daunting that it often reinforces 
applicants' worst fears of government as an ineffective, 
unresponsive and incomprehensible bureaucracy.
    In addition, at times there is often poor communication 
between Federal managers and Human Resource professionals on 
the qualities and skills needed in a candidate. Attrition of 
experienced VHA human resources employees has a direct impact 
on the quality of recruitment and retention efforts, as well as 
providing needed assistance to train new and inexperienced 
staff to successfully hire needed VHA employees. Only by 
insisting that VHA make recruiting talent a top priority, that 
both agency leaders and managers are held responsible for 
results, and that the individuals involved in the hiring 
process be held more accountable can we ensure that VHA 
recruits the talent needs to meet the challenges ahead.
    Mr. Chairman, this concludes my testimony. I will attempt 
to answer any questions you may have.
    [The prepared statement of Mr. Atizado appears on p. 54.]
    Mr. Michaud. Once again, I would like to thank all three of 
you for your testimony this morning. Just a couple of quick 
questions.
    You all touched upon retention and talked a lot more about 
recruitment. What additional programs or tools do you feel that 
the VA can use in trying to retain the employees that they 
currently have?
    I'll start with Mr. Atizado.
    Mr. Atizado. Well, the retention package of VA should first 
be seen in a different light than the recruitment package. As 
previously mentioned, there are certain things that current 
employees, direct healthcare providers in VHA, look to when 
they make a decision whether to stay in VA or not, whether it 
be the education reimbursement package which, by the way, my 
colleague has mentioned, has expired back in 1998. We believe 
and we actually recommended that be addressed in a previous 
testimony last year before the House Veterans' Affairs 
Committee.
    In addition, I believe there is a great concern in the 
Nurse Corps with regards to the pay bands. A lot of the well 
experienced nurses in VA are very much at the top tier of the 
pay band and have nowhere to go. They are, to look across the 
street at a private healthcare system, which will offer more; 
and obviously there is an unequal footing.
    Ms. McVey. The pay band cap is an issue for nurses and for 
nurses anesthetists as was testified early. That is one thing.
    Ongoing educational benefits are critical for retention and 
not just for nursing. I think it is very important for the 
succession planning for other deliverers of healthcare, such as 
human resource departments that support the work for nursing, 
and the workforce.
    To have educational moneys for these people for succession 
planning would also be very valuable support for the VA Nursing 
Academy program. This is a program I am not sure you are 
familiar with where the VA has funded last year four pilot 
programs with a VA and an adjoining university, to help bring 
more nurses into the workforce for VA. But it is also an 
opportunity for VA staff to become educators in these 
universities and give them additional opportunities, while 
still remaining a VA employee, to deliver care and also expand 
our workforce and give that workforce another opportunity to 
expand their horizon. And that would indeed also help 
retention.
    Mr. Cowell. Mr. Chairman, just to build on what has been 
said, I think VA needs to look at doing a better job with its 
internal scholarship programs. These are great incentives for 
people to improve their skills, get higher education, and 
remain loyal employees of the VA.
    We mentioned earlier the EDRP, the Education Debt Reduction 
Program, the cost, especially of medical education, is soaring. 
For people who want to improve their position, improve their 
skills and seek higher educational opportunities, these types 
of programs can help reduce some of that debt that goes with 
higher medical education. We think that would be an excellent 
incentive.
    Locality pay is certainly an issue. It needs to be more 
fairly distributed and available across the system.
    We think flexible schedules are important. It was testified 
about earlier. And in addition, you know, bonuses are not just 
a recruitment tool, but they are also a retention tool; and we 
think that pot of money needs to be more fairly distributed and 
available across the system. Even, perhaps, a set-aside pool of 
money in the VA for bonuses would be a good idea. Currently, we 
hear that local facility managers have to take that available 
money out of their existing FTEE budget, so when they do that 
and they have bonus money available, then they are not as able 
to hire the additional staff they really need.
    So it is a lot of issues out there and a lot of personnel 
issues. We think a review of section chapter 74 and 76, both 
the personnel and the educational benefits, to take a good 
look.
    Mr. Michaud. Thank you very much.
    Mr. Miller.
    Mr. Miller. Thank you, Mr. Chairman.
    Mr. Cowell, in your testimony--excuse me, I am sorry. I 
have this about the nurse organization.
    Ms. McVey, in your testimony you raise concerns about 
including matters relating to direct patient care and clinical 
competence in collective bargaining rights.
    Please explain in more detail your concerns.
    Ms. McVey. I think--if section 7422 were to be repealed, I 
think that it would cause perhaps some delays because inherent 
in the bargaining process itself is the element of time; and if 
certain issues needed to be negotiated, such as mandatory 
training on traumatic brain injury, as an example, it may 
delay--not always, but in some cases. The implementation of 
being able to effect that training might be one example.
    I also think there is some inconsistent application of 
section 7422 across the United States, and this may also be an 
issue. Perhaps it is invoked not appropriately when it should 
not have been or should have been; and I think that is some of 
the concern right now.
    Mr. Miller. Mr. Cowell, you reiterated in your testimony 
several recommendations for improving VA's recruitment process 
from the National Commission on VA Nursing.
    Can you give me an idea of what you think may be the top 
one, two, or three of those recommendations?
    Mr. Cowell. Yes.
    We had a meeting with Cathy Rick, who is the head of VA 
nursing, and we talked a lot about the Commission's 
recommendations. She told us that many aspects of that have 
been implemented, and it is becoming good policy. But she 
talked about some of the problems that VA nurses, even though 
they are in--somewhat always in need of more compensation; but 
there is a lack of organizational sharing responsibility that 
they feel would be a great incentive to make them feel more 
important and more a part of the healthcare team.
    That was something that really came through in our 
discussion with nurses across the system, that they just think 
they could share a greater responsibility in unit planning and 
unit organization and have a greater responsibility in the 
administration of those areas.
    Mr. Miller. What effect do you think specialty pay rates 
for certain nursing professions would have on the recruitment 
and retention of nurses and physicians that don't have 
specialty pay?
    Mr. Cowell. Well, we have--our analysis of the data of the 
spinal cord injury system, and that is our expertise, there is 
an agreement and a rule that the nursing service that works in 
the spinal cord injury service, 50 percent of those are 
supposed to be RNs. Our data reveals that very few of the 22 
SCI centers in the four long-term care facilities meet those 
requirements. So there is a dearth of RNs available to veterans 
with spinal cord injury. We think that is true in the other 
specialized services as well.
    One of the issues that happens, particularly in the spinal 
cord injury service, is that patients have high acuity needs, 
and it is labor-intensive work. Many of the nurses that work in 
spinal cord injury centers suffer personal injuries. They are 
on light duty. There is a lot of lifting to meet the needs of 
these veterans that are in these hospitals and centers. So it 
works as a disincentive to stay on board those services.
    We think specialty pay will help attract nurses to that 
type of labor-intensive work and help to fulfill that RN 
requirement.
    Mr. Miller. The VA has established a Travel Nurse Corps. 
Can you talk a little about that? Do you think it is----
    Ms. McVey. Yes. It is a pilot for the VA to have its, 
really what could be considered its own agency nurses, but 
these are VA employees; and the goal is to have a trained 
workforce of VA employees that could theoretically go anywhere 
in the country and serve in the VA in times of need. So there 
is a pilot project which is under way.
    I am not as familiar with it as perhaps Cathy Rick would be 
at this time, but I am aware of it and everyone is very pleased 
and seems to think it is a very good thing.
    Mr. Michaud. Mr. Hare.
    Mr. Hare. Thank you, Mr. Chairman. I just have one question 
for the panel. Maybe you could just each take a shot at this.
    Does the VHA coordinate in any capacity with Veterans 
Service Organizations (VSOs) as a resource or recruitment tool, 
to find veterans who could be hired here? And if not, how do 
you think that could be useful, if they are, you know, A, to 
what degree and how effective have you found that to be?
    Mr. Cowell. I would just say, in my experience, there 
hasn't been a great deal of collaboration between human 
resources people across the country and the VSOs that PVA has.
    As you know, PVA has started an employment program. It is 
in Minneapolis and in Richmond, Virginia, and it seems like the 
emphasis is on our end to try to discover what local physicians 
might feel available and how we can place a veteran in that 
kind of a position.
    But we haven't had much contact from the VA toward us.
    Mr. Hare. Would that be helpful to you? Do you think that 
is something that----
    Mr. Cowell. I think anything that can help get certainly 
our members employed and other veterans is a good idea. And I 
don't think it would be a real tough step to implement. I think 
it is a matter of communication.
    Ms. McVey. I also think it is a very excellent idea.
    We have collaborated with the PVA on local open houses at 
our facility in Boston, and it has worked very well. And as you 
said, any extension on collaboration and the ability to bring 
in more staff into the VA workforce is an excellent idea.
    Mr. Atizado. I agree, Mr. Hare. We, DAV, does not have a 
very established relationship with VA's human resources. It is 
not one of our fortes as more--as it would be for PVA, because 
it does affect directly on their membership, although we do 
work very closely with the ancillary organizations like NOVA 
and APA and those organizations to try and highlight VHA as a 
place to work.
    I do believe we would more than welcome in any kind of 
collaboration we can make with VHA to increase their exposure 
on that end.
    Mr. Hare. I am not sure how we would go about doing that, 
but it would seem to me that if the VHA would coordinate with 
the VSOs, you probably could give them a number of people, or 
at least it would be a resource for them.
    So that, given the need--I want to get the numbers again. 
The shortage of nurses that we are going to see is what? I am 
sorry; I forget who testified about that, but somebody 
mentioned the shortages now or what we are looking at down the 
road.
    What were those numbers again?
    Mr. Atizado. Half a million by 2010.
    Mr. Hare. Half a million.
    Mr. Atizado. One million through 2020. This is through 
Health Resources and Services Administration Division of the 
U.S. Department of Health and Human Services.
    Mr. Hare. We are going to have to get rolling, it would 
seem to me, because that is a huge, huge hole that we are going 
to have to try to fill.
    So, again, I think anything that would work, Mr. Chairman, 
getting the VHA to talk to the VSOs, would be great, because 
again you are great resources. You have the people, you know 
them; and when you are looking at that kind of shortages down 
the road, that just seems to me to be a natural thing to do.
    So I thank you, Mr. Chairman.
    Mr. Michaud. Thank you.
    Mr. Snyder.
    Mr. Snyder. Thank you, Mr. Chairman. I am sorry I was late 
getting here.
    Ms. McVey, before I started in this, I made my living as a 
family doctor, and I generally found if I did what the nurses 
say, I would stay out of trouble. So I am going to ask my 
question to you.
    I met with Mr. Wommack yesterday and did not hear his 
testimony today, but it seems like, as far as the veterans 
healthcare system--in order to get healthcare professionals on 
board it seems like there are two basic things. Number one, you 
can flood the input with such great numbers that sooner or 
later enough will float through and fill the positions; or you 
can deal with the input that is coming in in such a way that 
you can increase the percentage of those you end up hiring to 
fill your positions.
    And my question is, have you--have you done--do you do any 
kind of formal testing, your organization, where you either 
sample people, folks who are making application to the VA 
system? Or do you ever go online yourself or make the phone 
calls yourself just to see what the process is like?
    Do you have any formal way that you judge how people are 
treated when they actually are interested in working for the VA 
healthcare system?
    Ms. McVey. That is a excellent point.
    I chair our local succession planning Committee and we have 
not done that although we have discussed that. What we have 
done is, we have done some research; and we found that many VA 
employees, and nurses in particular, are vulnerable to leaving 
the system between the third and seventh year of employment.
    So what we did through our succession planning Committee 
was go out and survey a random group of these employee nurses, 
and other employees as well, that are thought to be at the 
point at which they may consider leaving VA employment, and 
tabulated the results to see why they stayed, with the thought 
being that if we could tap into those things and incentives to 
make them stay, we could have a better retention rate for all 
of our VA employees in the Boston VA Healthcare System.
    I am happy to say, for nursing RNs in particular, we have 
now a 5 percent turnover rate, which is extraordinarily low. 
Nine years ago it was 18 percent, so I think things are going 
well in that particular group.
    But we are also concerned about turnover, though we haven't 
had as much in the RN group; but that is not necessarily true 
across the country. There have been no other departments that 
support the work of nursing; there are challenges, and many of 
them--some of which I stated in my testimony--had to do with 
recognition, the ability for a career ladder for non-nursing 
personnel, the moneys for education, et cetera. So we have been 
trying to tackle those on a local level, and it has been very 
interesting.
    But I also like the thought of serving a group that has not 
yet come. We do hear informal feedback from our staff who are 
friends of the staff that have applied for positions, and that 
feedback is, they are very concerned about the very long and 
excessive timeline between when they apply for employment and 
when we are actually able to bring them in.
    And so they do tend to get discouraged, and that is a 
concern of ours.
    Mr. Snyder. You did bring up--in my simplistic analysis, 
the third component is, if you can cut down on people quitting, 
then you don't have so many openings that you need to fill.
    But the issue of--I have actually done this before in 
different things, where I get an internist, say, Here, call 
this help line, and here is the story I want you to read; see 
what kind of information.
    I would think that a group like yours could get some nurses 
and kind of test how quickly--once you make an inquiry, how 
quickly do you get responded to.
    As you know, the market is such out there, if somebody 
applies for a job or goes online and makes an initial inquiry, 
the nurses market being what it is, if it is a week or 2 or 3 
days before they hear back from somebody, they will have other 
job offers if they are very aggressive and have a reasonable-
to-average work record.
    That might be helpful information both for you and this 
Committee if you, with your--you probably have the ability to 
do something that we don't have, which is, you can do those 
kinds of test cases to different VAs around the country, and 
because I think that would be helpful.
    I know Mr. Wommack is concerned about streamlining. And the 
streamlining basically is, we need to have a description of 
what the current process is. And I don't know that we have that 
yet, but----
    Thank you for you all's participation today.
    Thank you, Mr. Chairman.
    Mr. Michaud. Thank you.
    Once again, I would like to thank our panelists for coming 
out and for your testimony as well. Thank you very much.
    Our last panel is Joleen Clark, who is the Chief Officer of 
Workforce Management and Consulting with the VHA.
    I want to thank you, Joleen, for your willingness to come 
here this morning as well. We probably will be having votes 
shortly, so if you can, summarize your written testimony and 
the complete copy will be submitted for the record.

STATEMENT OF JOLEEN CLARK, CHIEF OFFICER, WORKFORCE MANAGEMENT 
AND CONSULTING, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT 
                      OF VETERANS AFFAIRS

    Ms. Clark. Thank you, Mr. Chairman and Members of the 
Subcommittee. Thank you for the invitation to appear before you 
to discuss human resource challenges within the Department of 
Veterans Affairs, Veterans Health Administration. As the 
Nation's largest integrated healthcare delivery system, VHA's 
workforce challenges mirror those of the healthcare industry as 
a whole.
    VHA performs extensive national workforce planning and 
annually publishes a workforce succession strategic plan. VHA's 
strategic plan addresses current and emerging initiatives, the 
areas of including, but not limited to, recruitment and 
retention, mental healthcare, polytrauma traumatic brain injury 
and rural health to address workforce efforts.
    VHA's workforce plan is one of the most comprehensive in 
government and has been recognized by OPM as a Federal best 
practice. It is important that the supply of appropriately 
prepared healthcare workers meets the need of a growing and 
diverse population. Enrollment in nursing schools needs to grow 
to meet the projected future demand for healthcare providers.
    In an effort to initiate proactive strategies to aid in the 
shortage of clinical faculty, VA launched the VA Nursing 
Academy to address the nationwide shortage of nurses. The VA 
Travel Nurse Corps is an exciting new program that establishes 
a pool of registered nurses in VA who can be available for 
temporary short-term assignments at VA medical centers 
throughout the country. This program is being piloted at two 
sites, Phoenix and San Diego.
    Student programs such as the VA Learning Opportunities 
Residency Program, the Student Career Experience Program and 
the Hispanic Association of Colleges and Universities 
Internship Program have helped VA meet the workforce succession 
needs. The Graduate Health Administration Training Program 
provides practical work experience to students and recent 
graduates of healthcare administration Master's programs.
    VA recognizes that rural communities face additional 
healthcare workforce challenges. VA is working to develop an 
effective rural workforce strategy to recruit locally for a 
broad range of healthcare professionals.
    Experiential training opportunities for young medical 
students are important investments for creating a veteran and 
rural friendly physician workforce. Last year VHA's Human 
Resource Committee chartered a work group to streamline the 
recruitment process for title 5 and for title 38 physicians 
within VHA. The work group initially analyzed the recruitment 
process and identified barriers and lengthy processes for 
registered nurses. The work group recommendations were then 
piloted and are now in the process of being implemented 
nationally.
    One retention strategy that has proven very successful for 
VHA was approved in Public Law 108-445. The public law improves 
VA's ability to recruit and retain the best qualified workforce 
capable of providing high-quality care for eligible veterans. 
The VHA Healthcare Recruitment and Retention Office administers 
national programs to promote employment branding within VHA as 
a healthcare employer of choice.
    Both a recruitment and retention tool, the Employee 
Incentive Scholarship Program pays up to $35,900 for academic 
healthcare-related degree programs. Between 1999 and May of 
2008, over 7,500 VA employees have received scholarship awards 
for academic education programs related to title 38 and hybrid 
title 38 occupations. And more than 4,200 employees have 
graduated from those programs.
    The Education Debt Reduction Program provides tax-free 
reimbursement of education loans debt to recently hired 
employees, both title 5 and hybrid title 38. EDRP is similar to 
the student loan repayment programs for title 5 employees. VHA 
routinely uses hiring and pay incentives established under 
title 5 and title 38. Recruitment and retention incentives are 
used to reduce turnover rates and help fill vacancies.
    In 2000, VA began to use an electronic database to capture 
survey information from employees entering and exiting VA's 
service. The entrance survey is an excellent tool for comparing 
and contrasting reasons new employees have come to work for 
VHA.
    The Under Secretary for Health has made a personal 
commitment to succession planning and ensuring VHA has a 
comprehensive recruitment, retention, development and 
succession strategy. This is a continuous process which 
requires ongoing modifications and enhancements to our current 
programs.
    I would like to thank the Subcommittee for your interest 
and support in implementing legislation that allows us to 
compete in the healthcare market. Thank you.
    Mr. Michaud. Thank you very much for that enlightening 
testimony.
    [The prepared statement of Ms. Clark appears on p. 56.]
    Mr. Michaud. Mr. Miller.
    Mr. Miller. Thank you, Mr. Chairman. I have several 
questions that I am going to submit for the record in view of 
time.
    [No questions were submitted.]
    Mr. Miller. But how does VA use the tools that it currently 
has at its disposal to help recruit staff that have been hard 
to recruit and retain?
    Ms. Clark. The Education Debt Reduction Program is one of 
the most successful tools that we do have, and that, as 
mentioned, has been used to recruit healthcare professionals in 
both title 38 and hybrid title 38. So far, over 6,500 
participants have received funding with an average award of 
$29,000. Right now, the cap is at just over $50,000 for those 
awards. And, yes, some students are coming out of school with 
higher debt than that, but it has been very effective in 
recruiting healthcare professionals.
    We also use recruitment incentives extensively in areas 
where they have felt that they are needed to recruit staff. We 
draw people in with our scholarship program, our Employee 
Incentive Scholarship Program that we have for both title 38 
and hybrid title 38 occupations.
    Mr. Miller. Talk to me about that just a little bit, the 
scholarship program.
    Ms. Clark. The scholarship program is available to 
employees after they have had 1 year of employment. We have had 
7,500 that have entered into the program. It is open to all 
occupations that fall under title 38 and hybrid title 38. It is 
up to 3 years of schooling, up to 35--it is over $35,000 that 
it pays out for scholarships in those occupations.
    Mr. Miller. Thank you.
    Ms. Clark. You are welcome.
    Mr. Michaud. Mr. Hare
    Mr. Hare. Thank you, Mr. Chairman.
    The RAND Corporation recently released reports stating that 
about 300,000 soldiers report symptoms of PTSD or major 
depression, and only half of those are seeking treatment. This 
conflict in particular has put a new focus on the importance of 
treating mental health problems.
    Should the VA be reexamining if psychologists should 
continue to be in the hybrid title 38 program, do you think?
    Ms. Clark. The difference between hybrid title 38 and title 
38 doesn't reside in how the person is boarded. It resides in--
the two things that are covered by hybrid title 38 are pay and 
appointments, and they are covered under title 5 for everything 
else.
    The setting of the pay and the grade that they go to is the 
same under title 38 and hybrid title 38, so that would not make 
a difference; and I don't know how it would make a difference 
in how care is provided.
    Mr. Hare. Do you think that VA should diversify its loan 
repayment or scholarship programs? For certain medical 
professions, a physician can accrue about $150,000 in debt in 
medical school costs, yet they are only eligible for about $46 
to $50,000 from the VA.
    Ms. Clark. Yes. We have found that many of the doctorate 
programs, along with the physicians, are coming out of school 
with debt in excess of $100,000. And although the Education 
Debt Reduction Program certainly helps with $50,000, you know, 
many of them would benefit from larger loan repayment.
    Mr. Hare. One last question I had asked the last panel 
because it seemed to make a little sense about the working 
with--the VA working with different VSOs to try to find some 
folks who might be interested in going into the field.
    I was, candidly, very alarmed when I asked the question 
about, you know, the half-million or 500,000 nurse shortage and 
then up to 1 million; and it just seemed to me that anything 
and everything that the VA can do, or that we can do, or 
whoever can go do to try to fill that hole, because we are 
going to see more veterans coming back. Obviously, the need is 
going to be greater.
    So I wonder if you had a thought or two on that.
    Ms. Clark. That was a great suggestion. There are new 
positions that have been added to the organization called 
Veterans Employment Coordinators, that are placed strategically 
through the country; and that will be a great opportunity for 
them to contact the local VSOs and try to coordinate with them 
and get information out on any of the recruitment activities 
that we have going on in the local areas.
    Mr. Hare. I appreciate that because, again, I think it 
would be--I think we have to have all hands on deck to try to 
help the program out here.
    Mr. Michaud. Ms. Clark, you had mentioned the VA's working 
to integrate rural areas into the residency rotation.
    How far along are you with that program and who are you 
working with to accomplish that.
    Ms. Clark. The Office of Academic Affiliations is working 
closely with the medical schools in the local areas to address 
that. I don't know how far they are along in that. I can get 
that information back to you.
    [The VA response is included in the response to Question 
#4(b) in the post-hearing questions for the record, which 
appears on p. 63.]
    Ms. Clark. But that is something that we have been really 
concerned about and thought, if we get those students, trainees 
and residents into those rural areas and have them do their 
training programs and residencies there, the likelihood that 
they would return and stay in that area for employment is much 
higher.
    So that was the thought behind doing that and increasing 
the employment in those areas in our critical occupations.
    Mr. Michaud. Do you have programs doing that and how many 
States are involved in that?
    Ms. Clark. There is not a pilot program yet. I am sure we 
will have pilot programs that we will have doing the rural 
health, the residencies in the rural areas.
    Mr. Michaud. You heard the other two previous panels talk 
about the hiring process and dealing with hybrid title 38, 
which is onerous and potentially actually could cause VA to 
lose good employees.
    What is the number one reason that candidates are turned 
down for employment within the VA system?
    Ms. Clark. We are aware of the problem, and as I mentioned 
we have done a redesign look and see at the whole process and 
our end process of implementing numerous changes.
    It is not just one thing. It is our paperwork; we have way 
too much paperwork. It is some of our internal policies that we 
are finding are really obsolete with some of the things we have 
to do with the credentialing process. Our credentialing process 
is very onerous, but very necessary to make sure that our staff 
have the appropriate credentials for patient care.
    But we are looking at a process that we can do 
simultaneously, so it doesn't take as long, eliminating steps 
that don't need to be taken.
    The background investigations that we have to do take some 
time, but also looking at combining processes and trying to 
eliminate unnecessary steps is helping tremendously. I think, 
just looking internally, we can probably, without changing 
regulation or statute, improve the process tremendously; and we 
are working toward that.
    In the pilot they showed that it can be done in 30 days to 
bring somebody on and going through all these credentialing 
processes and background investigations, et cetera; and we are 
rolling that out throughout the country, having targeted Human 
Resource cluster meetings so that word can get out, they can 
understand what we are looking for and assist them in getting 
there.
    Mr. Michaud. What do you believe VHA's number one challenge 
is in filling the shortage in the positions that you have? Is 
it more prominent in any one region of the country than 
another?
    Ms. Clark. I can't say that it is more prominent in any 
region, but there are specific areas, certain rural areas, 
certain demographic areas that might not have schools in the 
area that have greater challenges in certain occupations. 
Through our succession and workforce planning, we look at those 
things and try to build recruitment and marketing strategies to 
address those areas where we are having the recruitment 
problems.
    We have--throughout the Nation, when the workforce planners 
do their plans, we come up with a list of what we consider our 
critical occupations in VA; and we target those occupations for 
additional recruitment strategies to look and ensure that we 
have the appropriate workforce.
    Mr. Michaud. What are the top three critical occupations it 
needs?
    Ms. Clark. Medical doctor positions and pharmacists, are 
always our top three.
    Mr. Michaud. When you look at pharmacists, you are looking 
at working in the academic world as well? I know pharmacy 
schools are pretty expensive to have. Are you looking in that 
area as well--in the rural areas?
    Ms. Clark. We haven't looked at the rural areas yet.
    What they have just recently started, last year in 2007, is 
the VALOR program, VA Learning Opportunity Residency, for 
pharmacists; and they have increased the number this year. And 
some of those are in--I don't know if I would call them rural, 
but in less-populated areas, and they are continuing to expand.
    The pharmacy leadership has been really excited about how 
the program has taken off and is looking to expand it; and this 
is with the pharmacy doctorate programs. And it is working 
really well, and we are hoping that they stay in the VA after 
they finish their residency program.
    So we think this will be a great recruitment tool.
    Mr. Michaud. Is there anything that we can do to help deal 
with the shortage that you foresee?
    Ms. Clark. Thank you for the offer.
    Right now, what we are trying to do is work through some of 
the issues internally to see how we can improve the hiring and 
on boarding process; and if there is something you can do to 
help, we certainly will let you know. Thank you.
    Mr. Michaud. And how long is that internal review going to 
take? As you heard earlier, there is a severe problem out 
there, and the longer we wait, the less likely we are able to 
get these good, qualified healthcare providers in the VA 
system.
    Ms. Clark. We certainly understand that.
    We have already implemented it in several of our networks, 
and it is going to be a performance measure for all of the 
network and medical center directors for 2009 to have it down 
to the 30-day hiring process. We anticipate that it will be 
happening by the time 2009 gets here; though, you know, there 
are a lot of challenges. A lot of people are at really long 
timeframes, so will they get down to the 30. But we are hoping 
at least they can cut their timeframes in half.
    Mr. Michaud. What Veterans Integrated Services Network 
(VISN)?
    Ms. Clark. VISN 4 is the one that piloted the recruitment 
redesign, but several other networks have already implemented 
it as well.
    Mr. Michaud. What are you doing to work with the Office of 
Rural Health, as well, to look at some of these needs, 
realizing that the office is, in my opinion, adequately 
understaffed.
    Ms. Clark. We are working hand in hand with them in the 
recruitment issues to try to come up with a recruitment plan so 
that we can--they can identify some of the things and then we 
can work with them on how, trying to meet those challenges. And 
I think that is how Academic Affiliations came up with the plan 
for working with the schools to try to get some of those 
residents into those under-served areas.
    Mr. Michaud. My other question involves rural areas where 
there is a healthcare shortage, not only within the VA system. 
If you look at the Capital Asset Realignment for Enhanced 
Services (CARES) Process, 2004, when their report came out, 
they recommended a lot of access points, particularly in rural 
areas, and they haven't moved as aggressively as a lot of us 
would like to see.
    My question is, what are you, the VA, doing to work with 
local healthcare providers in States to deal with the 
healthcare shortage, and are there ways that you can partner 
with the healthcare providers currently out there, keeping in 
mind the CARES Process, might recommend to provide access 
points in rural areas?
    Ms. Clark. I am not sure what they are doing. I know that 
some local facilities do contract with those in areas where 
they have the clinics, et cetera, but I can take that question 
back for the record.
    [The VA response is included in the response to Questions 
#4(a) in the post-hearing questions for the record, which 
appears on p. 62.]
    Mr. Michaud. Do you have any additional questions?
    Once again there will probably be additional questions, 
later on, in writing.
    Mr. Michaud. We really appreciate your willingness to come 
today. It has been very helpful. This is an extremely important 
issue, one that we are going to have to deal with soon if we 
are going to make sure that our veterans have adequate 
healthcare here. Once again, thank you very much for your 
testimony today. We look forward to working with you as we move 
forward in this Congress.
    So if there are no other questions, this hearing is 
adjourned. Thank you.
    [Whereupon, at 11:40 a.m., the Subcommittee was adjourned.]



                            A P P E N D I X

                              ----------                              


        Prepared Statement of Hon. Michael H. Michaud, Chairman,
                         Subcommittee on Health
    Thank you everyone for coming today.
    The Veterans Health Administration's mission is to provide patient 
centered healthcare that is comparable with or better than care 
available in the non-VA sector. To do this, VHA must have a viable 
healthcare workforce that is competent, well trained and happy.
    Over the past 5 years, VA has built a reputation of delivering 
healthcare efficiently and effectively. VA has been touted as the 
``best care anywhere'' and the Department has been recognized on 
numerous occasions for healthcare quality and patient satisfaction.
    However, in order to carry that banner forward, careful planning 
and efficient processes must be put into the system to ensure continued 
success.
    We know that VA's workforce is aging, with an average age of 48.6 
years. We know that at the end of 2012 a significant percentage of the 
employees will be eligible to retire.
    This Subcommittee has held many hearings that examined the 
appropriateness and quality of care and treatment that veterans receive 
within the healthcare system.
    This hearing today will focus on the human resource challenges that 
VHA must address in order to ensure there will not be a gap in the 
expertise and quality of care provided to veterans.
    The Committee realizes that this is a complex issue. But we also 
recognize that it is an important one that deserves serious thought and 
consideration.
    Thank you again for coming today.

                                 
   Prepared Statement of Hon. Jeff Miller, Ranking Republican Member,
                         Subcommittee on Health
    Thank you, Mr. Chairman.
    I appreciate your holding this hearing today to examine the many 
challenges VA faces in hiring and keeping healthcare workers.
    Healthcare workers are the frontline of VA healthcare. Every day 
they care for our servicemembers who have honorably served our country. 
And the high quality of healthcare available to our veterans is 
dependent on the ability of VA to recruit and retain qualified 
healthcare personnel.
    One of the most pressing problems we face as a Nation is the marked 
shortage of virtually all healthcare workers. This includes, among 
others, nurses, physicians, physician assistants, psychologists, 
pharmacists, and physical and occupational therapists.
    Competition for these and other healthcare personnel is intense and 
VA must aggressively vie with the private sector to bring the very best 
staff into the VA system.
    To do that, VA must effectively use innovative recruitment tools 
and offer a good work environment with educational opportunities.
    The VA healthcare system has been recognized for the significant 
benefit of its use of electronic medical records and focus on 
preventative care. And, to make sure that our veterans continue to 
receive the best care, it is critical that it is also seen as the 
workplace of choice.
    I look forward to hearing from our witnesses today to learn about 
issues they see and ideas they have for improving VA's ability to 
recruit and retain a first-class healthcare workforce.
    Thank you, Mr. Chairman, and I yield back the balance of my time.

                                 
 Prepared Statement of J. David Cox, RN, National Secretary-Treasurer,
          American Federation of Government Employees, AFL-CIO
    The American Federation of Government Employees (AFGE) appreciates 
the opportunity to present its views on human resources challenges 
within the Veterans Health Administration (VHA). AFGE represents nearly 
160,000 employees in the Department of Veterans Affairs (VA), more than 
two-thirds of whom are VHA professionals on the front lines treating 
the physical and mental health needs of our veteran population.
    The vast majority of VHA's workforce is covered by personnel rules 
known as ``pure Title 38'' providers (e.g. registered nurses (RN), 
physicians and physician assistants (PA)) or ``hybrid Title 38'' (e.g. 
licensed practical nurses (LPN), pharmacists, psychologists and social 
workers). The Title 38 boarding process for appointment and promotion 
of these two groups of VHA professionals was designed to be more 
flexible and expeditious than Title 5, but as will be discussed, the 
process faces extreme delays and backlogs. A small number of VHA direct 
patient care positions remain under Title 5, e.g., Nursing Assistants 
and Medical Technicians.
    AFGE's testimony focuses primarily on two significant human 
resource challenges facing VHA today:

      Loss of grievance rights for ``pure Title 38'' employees;
      Extreme delays in the ``hybrid Title 38'' boarding 
process;

    In my nearly 25 years as a registered nurse and union official at 
the Salisbury, North Carolina VA Medical Center, I have seen the impact 
of many Veterans Health Administration (VHA) personnel policies on 
recruitment and retention of healthcare professionals. In the eighties, 
I saw first hand how regular collaboration between frontline providers 
and management helped transform the VA into a world-class healthcare 
system, becoming a model in patient safety, healthcare information 
technology, and best practices.
    Sadly, what I have seen over the past 7 years is a sea change in 
VA's personnel practices that now hurt, rather than help, recruitment 
and retention, and exclude frontline providers from medical affairs. 
The current culture of exclusion is very demoralizing to these 
dedicated providers who are extremely committed to the mission of the 
VA and work so hard to care for our veterans. For example, according to 
a January 2008 VA national RN satisfaction survey, for the past 2 
years, ``Participation in Hospital Affairs'' was one of two areas where 
RNs at VA medical facilities were the least satisfied.
        Loss of grievance rights for ``pure Title 38'' employees
    The most harmful, far-reaching VHA personnel policy in place today 
is the severe erosion of collective bargaining rights (hereinafter 
``grievance rights'') of RNs, physicians, PAs and other pure Title 38 
providers (``providers''.) These rights include the right to challenge 
management personnel actions through grievances, arbitrations, labor-
management negotiations, unfair labor practices (ULPs) and litigation 
before the Federal Labor Relations Authority (FLRA) and courts.
    VHA denies these rights by asserting an arbitrary and unsupported 
interpretation of 38 USC Sec. 77422 (``7422''), the law that provides 
collective bargaining rights to these providers. VA's 7422 policy 
blocks virtually every provider grievance on the basis of three narrow 
exceptions in the law: professional conduct and competence (defined as 
direct patient care or clinical competence); peer review; and 
compensation.
    VHA's 7422 policy has undermined Congress' attempts to improve VHA 
recruitment and retention through rights to better pay and schedules. 
The effect, to quote the old adage, is ``rights without remedies'' 
which ``are no rights at all.''
    AFGE greatly appreciates the support of Chairman Michaud and 
Subcommittee Members Berkley, Brown and Doyle for H.R. 4089, 
legislation introduced by Committee Chairman Filner to amend section 
7422 and restore these critical rights. This bill is an essential 
enforcement tool for all past and future legislation that addresses VHA 
recruitment and retention of pure Title 38 providers, as well as 
Federal statutes that provide rights to information and prohibit 
employment discrimination.
    VHA's 7422 policy directly contradicts Congressional intent as to 
the scope of these three exceptions. Specifically:

      Congress viewed Title 38 and Title 5 employees as having 
the same collective bargaining rights when it enacted the Civil Service 
Reform Act (CSRA) in 1978.
      Congress enacted section 7422 in direct response to a 
1988 Federal appeals court decision involving annual nurse 
``comparability pay'' increases. The Court held that the VA could not 
be compelled by the CSRA to engage in collective bargaining over 
conditions of employment for Title 38 providers. Colorado Nurses Ass'n 
v. FLRA, 851 F.2d 1486 (D.C. Cir. 1988).
      The plain language of the 1991 law narrows the scope of 
the exceptions by specifying that the matter must relate to ``direct 
patient care'' or clinical competence.''
      The 1990 House Committee report on the underlying bill 
defined the ``direct patient care'' exception as ``medical procedures 
physicians follow in treating patients.'' This report also cited 
guidelines for RNs wishing to trade vacation days as falling outside 
the exception. (H. Rep. No. 101-466 on H.R. 4557, 101st Cong., 2d 
Sess., 29 (1990)).

    VHA's 7422 policy also contradicts its own 1996 agreement with 
labor to clarify the scope of the law and resolve remaining disputes in 
a less adversarial manner. Sadly, the VA unilaterally abandoned this 
useful, inclusive agreement in 2003. More specifically, in that 
agreement:

      The VA committed to a new process for resolving 7422 
disputes that departed from the ``adversarial, litigious, dilatory . . 
. nature of past labor-management relations.''
      The VA acknowledged that providers provide valuable input 
into medical affairs: ``We recognize that the employees have a deep 
stake in the quality and efficiency of the work performed by the 
agency.''; ``The purpose of labor-management partnership is to get the 
frontline employees directly involved in identifying problems and 
crafting solutions to better serve the agency's customers and 
mission.''
      The VA recognized the narrow scope of the direct patient 
care exception, i.e., it does not extend to ``many matters affecting 
the working conditions of Title 38 employees [that] affect patient care 
only indirectly'' (emphasis provided).
      The VA agreed that scheduling matters may be grievable: 
``For example, scheduling shifts substantially in advance so that 
employees can plan family and civic activities may make it more 
expensive to meet patient care standards under certain circumstances. 
That does not relieve management of either the responsibility to assure 
proper patient care or to bargain over employee working conditions.''
      The VA agreed that pay matters other than setting pay 
scales are grievable: ``Under Title 38, pay scales are set by the 
agency, outside of collective bargaining and arbitration. Left within 
the scope of bargaining and arbitrations over such matters as: 
procedures for collecting and analyzing data used in determining 
scales, alleged failures to pay in accordance with the applicable 
scale, rules for earning overtime and for earning and using 
compensatory time, and alternative work schedules.''

    The 7422 appeals process:
    Section 7422 gives the Undersecretary of Health (USH) the sole 
authority to determine what matters are grievable. USH decisions are 
posted on the VA Web site (http://www1.va.gov/lmr/page.cfm?pg=28). The 
VA does not keep AFGE apprised of unpublished decisions or pending 
cases.
    AFGE is very concerned by the lack of meaningful, balanced review 
by the USH and by failure of local facilities to comply with the USH 
review process.
    A review of posted decisions and member reports received by AFGE 
reveals how VA's 7422 policies directly undermine recruitment and 
retention legislation passed over the past decade and deprive providers 
of a fair appeals process.
    For example:

      No right to grieve over denial of request to review nurse 
locality pay survey data

        Background: Congress enacted legislation in 2000 to 
authorize directors to conduct third party surveys to set competitive 
nurse pay (P.L. 106-419).
        USH Ruling: ``Compensation'' exception blocks 
employees' access to third party survey data. (Decision dated 1/06/05)

      No right to grieve over VA nurse mandatory overtime 
policy

        Background: Congress enacted legislation in 2004 
requiring facilities to establish policies limiting mandatory overtime 
except in cases of ``emergency'' (P.L. 108-445).
        USH Ruling: National grievance over definition of 
``emergency'' for requiring overtime is barred by the ``professional 
conduct or competence'' exception. (Decision dated 10/22/07).

      No right to grieve over composition of panels setting 
physician pay

        Background: Congress enacted legislation in 2004 to use 
local panels of physicians to set market pay that would be competitive 
with local markets (P.L. 108-445). AFGE contended that management 
unfairly excluded practicing clinicians and employee representatives 
from the panels.
        USH Ruling: Grievance barred by ``compensation'' 
exception. (Decision dated 3/2/07).

      Other grievances blocked by VA's 7422 policy (based on 
member reports of pending disputes or unpublished USH decisions)

        No right to challenge intimidation of arbitration 
witnesses: After two VA nurses testified for the union at arbitration, 
management sent them letters questioning their conduct and suggesting 
that they could be subject to discipline. The union filed an unfair 
labor practice with the FLRA which initiated steps to file charges 
against management. Management invoked the ``professional conduct or 
competence'' exception to suspend FLRA action pending an USH ruling.
        No right to challenge performance rating based on use 
of approved leave: Management invoked 7422 when a nurse tried to grieve 
the lowering of her performance rating that was based on her authorized 
absences using earned sick leave and annual leave, and carried out 
without any written justification.
        No right to challenge error in pay computation: 
Management invoked 7422 when a nurse was incorrectly denied a within-
grade pay increase because of lost time arising out of a work-related 
injury covered by workers compensation.
        No right to challenge low reimbursement for costs of 
required training: Management invoked 7422 when a nurse tried to grieve 
the amount of reimbursement she received for attending required 
training to maintain her Advanced Practice RN certification.
        Exclusion from hospital affairs: Management invoked 
7422 to block a local union's efforts to have input into the drafting 
of medical staff bylaws that impact personnel policies.
        No right to challenge unfair bonus policies: VA 
physicians are unable to challenge policies that are not in compliance 
with the 2004 physician pay law because managers set arbitrarily low 
bonuses and impose unfair performance measures based on factors beyond 
the physician's control.

    Recent court decisions confirm the need for Congressional action on 
7422:

      AFGE Local 446 v. Nicholson, 475 F.3d 341 (D.C. Cir. 
2007). The Federal court held that the VA operating room nurses could 
not file a grievance over denial of premium pay weekend and evening 
shifts.
      AFGE Local 2152 v. Principi, 464 F.3d 1049 (9th Cir. 
2006).

           A VA physician was removed from his surgical duties at age 
        76 and his specialty pay was discontinued. The court held that 
        the physician's grievance alleging unlawful age and gender 
        discrimination was barred by the ``professional conduct or 
        competence'' exception in 7422.
           The court rejected the union's contention that management's 
        7422 assertion was a mere pretext for unlawful discrimination. 
        Similarly, in a posted USH decision dated 6/1/07, a nurse 
        alleging that management's denial of specialized skills pay was 
        racially motivated was not allowed to pursue a grievance.

    Amending 7422 will not hurt patient care. Those defending VA's 
current 7422 policy are likely to suggest that labor will try to 
disrupt patient care if 7422 is amended. In fact, Title 5 makes the 
three exceptions in 7422 redundant and unnecessary. Federal sector 
unions are only authorized to negotiate on ``conditions of employment'' 
as that term is defined in 5 USC 7103(a)(14). In contrast, 5 USC 
7106(a)(1) makes it a management right (i.e., not to be modified at the 
bargaining table) for an agency to determine its ``mission.''
    Furthermore, a review of published cases that have come before the 
USH did not reveal even one attempt to interfere with medical 
procedures or other direct patient care matters.
    Finally, if grievance rights can interfere with VHA operations, 
then why do hybrid Title 38 providers hired under Title 5 and working 
side by side with ``pure'' Title 38 providers have rights to grieve 
over these prohibited matters? For example, psychologists have full 
grievance rights while psychiatrists do not; licensed practical nurses 
have full grievance rights while RNs do not.
    The current dispute resolution process for 7422 is broken and 
biased against employees. Those defending VA's current 7422 policy are 
also likely to argue that employees already have a fair process though 
the USH for resolving 7422 disputes. Numbers tell a very different 
story: Of the 25 published USH decisions over the past 3 years, the USH 
ruled in favor of management one hundred percent of the time. Opponents 
are unlikely to mention that many, many more cases never get to the USH 
even though the law clearly states that he has sole authority to make 
these rulings. Across the country, human resource departments with no 
authority regularly make 7422 determinations and refuse to go through 
the proper USH channels.
    The current 7422 process wastes taxpayer dollars. Finally, the VA's 
7422 policies result in a great waste of taxpayer dollars that would be 
much better spent on patient care. The Asheville case previously 
discussed was pending for seven years. HR departments in facilities 
around the country regularly block or delay the section 7422 review 
process, draining resources and staff time away from the VA's mission 
of caring for veterans.
         Extreme delays in the hybrid Title 38 boarding process
    Congress' primary objective in establishing hybrid Title 38 
positions (i.e., employees are hired under Title 5 but appointed and 
promoted at the facility level under Title 38) was to expedite the 
appointment and promotion of more VHA employees involved in direct 
patient care. Unfortunately, the hybrid boarding process has been 
anything but expeditious. Employees involved in medical care and mental 
health treatment, including the large numbers of psychologists and 
social workers the VA is trying to bring on board, are facing extreme 
delays in appointment and promotion
    A second concern is the impact of this process on veterans' 
preference in employment. OIF/OEF veterans experience great difficulty 
in securing and retaining employment, including reservists and members 
of the National Guard who return to Federal service following active 
duty. VA employees lose veterans' preference protections when they are 
converted from Title 5 to Title 38 status. All veterans, whether they 
are covered by Title 38 or Title 5, should have equal employment 
opportunities in the VA, which strives to be a model employer of 
veterans.
    We urge the Subcommittee to reject proposals to convert additional 
Title 5 employees to hybrid status. A substantial increase in the 
number of covered employees would be disastrous. Rather, we recommend 
the suspension of all hybrid boarding pending completion of a pilot 
project using a streamlined Title 5 hiring process and comparative 
study of the two systems. AFGE would like to work with the Subcommittee 
to develop this pilot project. A pilot project using an alternative 
Title 5 process can also provide valuable lessons for other Federal 
agencies.
                    Other human resources challenges
Physician Pay Law:
    AFGE urges this Subcommittee to conduct oversight into the many 
problems surrounding the implementation of the physician and dentist 
pay provisions in P.L. 108-445, Department of Veterans Affairs Health 
Care Personnel Enhancement Act of 2004.
    Congress' primary objective in enacting these provisions was to 
reduce the use of expensive fee basis physicians and dentists and fill 
vacancies at medical facilities has clearly not been achieved. The law 
required the VA to provide an initial report on progress toward this 
goal to Congress followed by five annual reports. AFGE is not aware of 
a single report having been published to date. Meanwhile, many 
facilities face severe recruitment problems and the VA continues to 
spend substantial sums on costly contract care, including Project HERO, 
a pilot project impacting 23 States.
    Problems are evident both in the law's market pay and performance 
pay systems for physicians and dentists, specifically:

      Improper composition of local compensation panels setting 
market pay for individual providers;
      Management's refusal to share market pay survey data;
      The VA's unilateral reduction of the maximum performance 
pay award set by Congress;
      In many facilities, there have been severe delays in 
developing performance pay criteria;
      Most criteria were developed without any input from 
frontline provider or employee representatives;
      Many of the criteria are improper, for example penalizing 
missed patient appointments, which is clearly beyond the provider's 
control.

    AFGE urges the Subcommittee to conduct its own study of the law's 
effectiveness, including the following criteria including in the law's 
reporting requirement: rates of pay by facility and specialty; rates of 
attrition; number of unfilled positions in each specialty and length of 
time positions have been unfilled; and, a yearly comparison of staffing 
levels, contract expenditures, and average salaries.
    Nurse Alternative Work Schedules: In 2004, Congress authorized 
facility directors to offer nurse alternative work schedules (AWS) in 
the form of full-time pay for three 12-hour work days. This schedule 
option is widely available in the private sector. AFGE is not aware of 
a single VA facility that has offered AWS to date. We urge the 
Subcommittee to stop relying on the discretion of facility directors 
who are resistant to implementing AWS, and mandate by law that 
facilities offer this option consistent with their prevalence in the 
local labor market.
    Equality for Part-Time Nurses: Part-time nurses represent a 
valuable resource to VHA. We recommend that Title 38 be amended to 
enable part-time nurses to earn the same rights and job security as 
their full-time colleagues. Also, many full-time nurses convert to 
part-time status for family and other personal reasons after they 
acquire permanent status. Changing to a part-time schedule should not 
result in a loss of permanent status.
    Thank you.

                                 
  Prepared Statement of Randy Phelps, Ph.D., Deputy Executive Director
     for Professional Practice, American Psychological Association
    Chairman Michaud, Ranking Member Miller, and distinguished Members 
of the Committee, I am Dr. Randy Phelps, Deputy Executive Director for 
Professional Practice of the American Psychological Association 
(``APA''), the largest association of psychologists, with approximately 
90,000 full members and 50,000 graduate student members engaged in the 
study, research, and practice of psychology. I am a licensed clinical 
psychologist, a former practitioner, clinical researcher and educator, 
and for the past 15 years on the APA executive staff, have served as 
APA's liaison to professional psychology in the Department of Veterans 
Affairs (VA).
    APA appreciates the opportunity to testify today about human 
resource challenges within the Veterans Health Administration (VHA) 
that have a direct impact on the recruitment and retention of doctoral 
psychologists to provide care to this Nation's heroes. I should note at 
the outset that VHA is the workplace of choice for many of our members, 
with about 2,400 psychologists currently in the system. VA is, in fact, 
the largest single employer of psychologists in the country. APA 
supports VA's recent and aggressive efforts to recruit new 
psychologists but has concerns about a number of policies and 
procedures which are negatively affecting both recruitment and 
retention.
                  APA's Contribution to Growing Needs
    Professional psychology as a discipline was ``born'' as a result of 
the needs of this Nation's returning World War II heroes, and 
psychologists are acutely aware of the debt we owe to those veterans 
and to the brave men and women who have followed in their footsteps, as 
well as to the system of care this country has evolved to minister to 
their healthcare needs.
    And, APA is acutely aware that there are over 200,000 homeless 
veterans on America's streets today; that the risks of Post Traumatic 
Stress Disorder (PTSD) and traumatic brain injury (TBI) appear to be at 
unprecedented levels in the population of 1.7 million servicemembers 
who have been deployed in the War on Terror; that there has been a 
resulting influx of veterans from previous theaters of war who are 
increasingly seeking VA services; and that the healthcare needs of 
aging veterans continue to grow.
    To assist with those needs, APA has many initiatives currently 
underway, including two Presidential Task Forces on the Needs of 
Military Servicemembers and Their Families, and the recently adopted 
``Blueprint for Change: Achieving Integrated Healthcare for an Aging 
Population'', which is consonant with VA's groundbreaking work on 
primary care integration.
    APA's Committee on Rural Health is addressing ways for 
psychologists to help extend services to veterans in rural areas where 
existing VA and Department of Defense (DoD) facilities are simply 
beyond the reach of patients. As well, APA's public interest component 
works on issues of direct concern to VA, such as homelessness, military 
sexual trauma, and family violence. In education, we are creating 
training pipelines for specialty training of psychologists and other 
mental health professionals regarding soldiers' pre and post deployment 
needs, through both the Center for Deployment Psychology (with the DoD) 
and in proposing expansion of our Graduate Psychology Education 
program. We also have recently provided testimony proposing funding 
increases over the Administration's FY '09 VA Medical and Prosthetic 
Research Account funding levels.
          Recruitment and the Psychology Workforce Within VHA
    As I indicated, VHA is the single largest employer of psychologists 
in the Nation, and has been for many years. Yet, VA continues to 
recognize the need to increase its psychology staffing levels in 
response to ever-increasing needs for services to veterans.
    As a result, VHA has added more than 800 new positions for 
psychologists since 2005; thereby rapidly increasing the number of 
psychologists in the system to a current high of approximately 2,400, 
now surpassing the previous 1995 high of approximately 1,800 
psychologists nationally. The 2,400 psychologists now employed by VA 
range from the GS-11 to GS-15 levels.
    The APA applauds VA for these tremendous and serious recent efforts 
to recruit additional psychologists into the system, and we have 
actively partnered with VA to promote the news of these openings, have 
attempted to assist with recruiting neuropsychologists (who are needed 
in increasing numbers due to TBI), and have worked to promote VA career 
choices by the newer generations of psychologists.
    I need to emphasize, however, that these increased psychology 
staffing levels are a very recent development over approximately the 
last year and a half only. Psychology staff levels were actually 
significantly BELOW 1995 levels until 2006. Moreover, the vast majority 
of new psychologist hires in VHA are younger, lesser experienced 
psychologists who have come into the system at the GS-11 to GS-13 
levels.
    However, the contrast between the VA's success in recruiting new 
professionals into the system versus VA's retention and promotion of 
those existing VA psychologists with years of experience treating 
veterans is dramatic.
    For example, at the end of 2007, the number of GS-14s in the entire 
system nationally was no different than it was 12 years prior in 1995 
(at 130 GS-14s total). Of additional concern to the APA is that the 
number of GS-15 psychologists nationally as of the end of 2007 
(approximately 50) was actually considerably lower than the number of 
GS-15s in 1995.
    To the system's credit, VA has also recognized and capitalized on 
the fact that the best source of recruiting new psychologists has been 
the Department's own training systems. Over the past 2 years, 
approximately 75 percent of all new psychologist hires have been prior 
VA trainees. And, VA is rapidly increasing its funding of psychology 
training. In the 2008-2009 training year, VA has added approximately 60 
new psychology internship positions and 100 new postdoctoral fellowship 
positions, spending approximately $5 million to do so. This will bring 
the total psychology training positions to approximately 620 per year 
nationwide.
                 Retention of the Psychology Workforce
    Despite positive developments in recruitment, VA's advancement and 
retention policies continue to be driven by outdated and overly rigid 
personnel and retention systems. In addition to hiring new staff, the 
VA needs to retain those existing psychologists who are qualified, 
possess specialized skills, and who are already acculturated within 
VHA. These psychologists are vital to service provision because of both 
their professional expertise and their knowledge of the system and its 
resources for veterans.

    1.  Lack of Uniform Psychology Leadership Positions

    Since 1995, independent mental health discipline services at most 
facilities have been replaced with interdisciplinary Mental Health 
Service Lines. As a result, there has been a decrease in the number of 
discipline chiefs across the system. The dissolution of discipline 
specific services has left a clear leadership gap in terms of 
professional practice accountability, guidance on the proper use of 
professional skills, and promotion and oversight of profession-specific 
staff and pre-licensure training.
    Psychology remains the only major mental health discipline without 
an officially designated leader in every medical center, analogous to 
the Social Work Executive. While there are a small number of ``Chief 
Psychologists'' remaining, the far more prevalent positions of 
discipline-based professional leadership are those such as 
``Supervisory Psychologist'', ``Lead Psychologist'', or ``Psychology 
Director''. Notably, these positions are all too frequently 
unrecognized at the level of additional pay for the additional 
professional leadership responsibilities they entail.

    2.  Inequitable Access to Key Leadership Positions

    Psychologists are also not represented equitably in all levels of 
leadership in the VA's healthcare delivery system. In 1998, the Under 
Secretary for Health (USH) attempted to correct this situation with the 
issuance of VHA Directive 98-018, later reissued in 2004 as VHA 
Directive 2004-004, which stated that ``it is important that the most 
qualified individuals be selected for leadership positions in mental 
health programs regardless of their professional discipline.''
    Unfortunately, the only requirement within the Directive was that 
announcements of VA mental health leadership positions not contain 
language that restricts recruitment to a specific discipline. As a 
result, this Directive has had little practical impact on the 
appointment of highly qualified psychologists to VA mental health 
senior leadership roles, particularly at medical school affiliated VA 
facilities.

    3.  Serious Implementation Problems in Hybrid Title 38

    Psychologists remain the only doctoral healthcare providers in VA 
who are not included in Title 38. In late 2003, the Hybrid Title 38 
system was statutorily expanded to provide psychologists (and a wide 
range of other non-physician disciplines) some of the same personnel 
and pay considerations as their physician counterparts. The hybrid 
model requires Professional Standards Boards to make recommendations on 
employment, promotion and grade for psychologists, and is still more 
subjective than a pure Title 38 program; unlike Title 38 where 
professionals are hired, promoted and retained based solely on their 
qualifications.
    The implementation of the new Title 38 Hybrid boarding process has 
been extremely variable and chaotic across the system. Many 
Psychologist leaders from facilities throughout the country have 
reported that their facilities and Veterans Integrated Service Networks 
(VISNs) have denied GS-14 and 15 promotions that have been recommended 
by the national boarding process. Even more frequent are reports of 
facilities and VISNs that have delayed or refused to forward boarding 
packets to the national board and/or have refused to reveal the results 
of the national board action.
    Informational missteps and technical problems have also plagued the 
national psychology boarding process. Just last month, VA Central 
Office (VACO) sent instructions to the field that eliminated the 
national cap on GS-14 levels for psychologists. However, these same 
instructions tied the award of GS-15 psychology positions to the 
facility's level of complexity, making many senior psychologist leaders 
ineligible for grade increases commensurate with the scope and 
complexity of their actual duties.
    APA was optimistic that the Hybrid Title 38 system would modernize 
the pay system and foster greater retention of senior psychologists 
within the VHA system. Given that 5 years after its passage, 
implementation continues to be such a boondoggle, we are now seriously 
reconsidering our support for the Hybrid system, and considering 
instead a policy change to bring psychologists fully into the Title 38 
system. The basic concept of Title 38 is ``rank-in-person'' rather than 
rank in position, basing rank and pay on one's qualifications brought 
to the job rather than on some of the duties of the position. Hybrid 5/
38 uses the procedures of Title 38 for recruitment, but not for rank 
and pay boards, preferring a mixture of Title 5 types of position 
descriptions, now re-titled in Title 38 language as ``functional 
statements''. The functional statements are used with Title 5 kinds of 
considerations, including scope of supervisory or managerial 
responsibilities, leaving no room for advancement in rank for senior 
psychology clinicians who are not part of medical staff.
    For example, efforts to make it easier for outstanding research 
clinicians to advance in rank have been virtually unsuccessful because 
in many cases it is written into their jobs as clinicians that research 
is part of their function; they are denied any special advancement for 
published papers, grants awarded from merit review bodies, etc. Indeed 
the bar of publications has been set so high that few of them have been 
able to advance in rank, again based on the kinds of measures one would 
have used under Title 5.
    Most physicians, under this rank in person concept, used to achieve 
a base pay equivalent to a GS-15, step 10. More recent changes to 
physician pay have resulted in psychiatric physicians being paid a 
minimum of $91,500 to a maximum of $225,000, with four levels of pay 
grade, each with a minimum and maximum, incorporating other elements 
such as ``market pay'' and ``performance pay.'' The result is that the 
typical psychologist, depending upon locality tops out at about 
$101,000 after 15-20 years of service (GS-13, step 10), while a senior 
physician typically may make 30 to 125 percent higher salary.
    Also, physicians have long had an annual bonus for board 
certification. Psychologists are now eligible for a one-time step 
increase, but only if they were to become newly board certified within 
a narrow window prior to, or since the inception of hybrid Title 5/38. 
Senior psychologists who have topped out in their grade (GS-13) are not 
eligible for anything other than a one-time award.
Additional Factors Affecting Recruitment and Retention of Psychologists
    1.  Medical Staff (Clinical) Privileges vs. Full Medical Staff 
Membership

    VA is based on a medical model, and doctoral psychologists are 
excluded from the decisionmaking process by being denied full medical 
staff privileges in many facilities, particularly those that are not 
affiliated with medical schools. Not being a member of the medical 
staff is to be a second class citizen. Psychologists are most typically 
``clinically privileged'' practitioners, i.e., those who are not full 
members of the medical staff, and who are called ``Licensed Independent 
Practitioners''. But they have no formal say in hospital policy, and 
may not sit on the governing body of the medical staff in those 
facilities where they are not members.
    There are a number of important reasons to support psychologists 
having full medical staff membership throughout the VHA healthcare 
system. In recent years there has been a significant increase in the 
number of psychologists who have assumed leadership roles in important 
medical center programs. These include many of the new post traumatic 
stress disorder (PTSD), Recovery, Pain, Substance Abuse programs, and 
so forth. These psychologists are responsible for the supervision of 
various disciplines and provide direct clinical care for the medical 
center. These are certainly responsibilities that are consistent with 
full membership on the medical staff. In addition, many of the new Home 
Based Primary Care (HBPC) psychologists are working independently and 
away from the physical umbrella of the VA medical centers. They are 
doing important and demanding work in the veteran's homes. Again, the 
level and complexity of work is what one would expect from a full 
member of the staff. Without membership, there is restricted input into 
many important decisions that impact programming and ultimately on 
patient care.

    2.  Prescriptive Authority

    One of the most difficult current challenges for VHA is how to 
extend care into those areas, particularly in rural America, where VA 
facilities do not exist or are at great distance from the veteran. One 
option that VHA has long resisted, but should more carefully consider, 
is granting expanded authority for appropriately trained psychologists 
to provide both psychological and psychopharmacological care to 
veterans in these under-served rural areas. Experience in both States 
where licensed psychologists have this expanded statutory authority to 
prescribe (New Mexico and Louisiana), as well as a decade of data from 
the original DoD psychopharmacology program, have shown these practices 
to be safe and effective for the public.
    Both New Mexico and Louisiana, States with large rural populations, 
have passed laws to allow psychologists to prescribe. New Mexico, which 
passed its prescriptive authority law in 2002, and Louisiana, which 
passed its law in 2005, permit appropriately trained licensed 
psychologists with additional postdoctoral training in 
psychopharmacology to prescribe. These laws have been very successful, 
and to date nearly 50 psychologists prescribing in these States have 
written more than 40,000 prescriptions without adverse incident.
    Furthermore, a Federal demonstration project set up nearly two 
decades ago has set a clear precedent that psychologists can 
successfully prescribe in a large Federal health system. The Department 
of Defense Psychopharmacology Demonstration Project (PDP) also proved 
that psychologists can be trained to prescribe safely and effectively. 
Begun in 1991, ten psychologists participated in the PDP, which was 
designed to train and use psychologists to prescribe psychotropic 
medications. These psychologists treated a wide variety of patients, 
including active duty military, their dependents and military retirees, 
with ages ranging from 18 to 65.
    The PDP was highly scrutinized. The American College of 
Neuropsychopharmacology (ACNP) conducted its own independent, external 
review of the PDP and in 1998 presented its final report to the DoD. 
Likewise, the General Accounting Office (GAO) issued a positive report 
on the PDP. Both reports repeatedly stressed how well the PDP 
psychologists had performed, and noted that with prescriptive 
authority, psychologists were able to offer holistic, integrative 
treatment, which includes psychotherapy and medication, where 
appropriate.
    It is clear that already licensed doctoral psychologists are being 
trained to prescribe safely and effectively. The precedent for the VA 
system to recognize psychologist prescriptive authority is clear both 
from State action and the DoD's program. In addition, APA Division 18 
psychologists--Psychologists in Public Service--including those who 
serve in the VA, are already supporting training of a cadre of public 
service psychologists to be able to prescribe as recognition expands 
along with the need for services. The VA should begin to utilize such 
professionals to the full extent of their licensure and training. 
Psychologists are willing and able to help fill the gap and ease the 
strain on the VA health system particularly in rural areas.
                          Summary and Examples
    Two dramatic, but not apparently unusual examples of how these 
problems are affecting services have recently crossed my desk. In one, 
a new hire, who happens to be a former State Psychological Association 
President and representative to APA's Committee on Early Career 
Psychologists, was dismissed during his probationary year after being 
hampered in his abilities to effectively discharge his dual leadership 
duties as the facility's new Local Recovery Coordinator as well as the 
Acting Supervisory Psychologist. In another facility, a more senior 
psychologist who was approved by the National Standards Board was 
denied locally for a GS-14 upgrade for her position as Psychology 
Program Manager and tendered her resignation on April 1st.
    APA considers the issues and problems addressed in this testimony 
as serious obstacles to making VA the workplace of choice for 
psychologists. Without clear advancement systems in place, VA faces 
critical long term recruitment and retention problems. As psychologists 
come to believe that there is little possibility for advancement, 
regardless of the level or complexity of responsibilities, fewer VA 
psychologists will be willing to accept positions of greater 
responsibility. In addition, high potential trainees whom the VA would 
like to recruit will increasingly see VA as a ``dead end'' for their 
careers, and will be attracted to other career options that offer more 
potential for advancement.
    Thank you for this opportunity to provide testimony today on behalf 
of the American Psychological Association. We stand ready to assist 
with the Committee's work to further improve recruitment and retention 
of psychologists to assist in providing care to this Nation's honored 
veterans.

                                 
    Prepared Statement of Angela Mund, CRNA, MS, Clinical Director,
        University of Minnesota Nurse Anesthesia Area of Study,
      Minneapolis Veterans Affairs Medical Center, Veterans Health
   Administration, U.S. Department of Veterans Affairs, on behalf of
               American Association of Nurse Anesthetists
    Chairman Michaud, Ranking Member Miller, and Members of the 
Subcommittee:
    The American Association of Nurse Anesthetists (AANA) is the 
professional association that represents over 39,000 Certified 
Registered Nurse Anesthetists (CRNAs) across the United States. Over 
500 CRNAs are employed by the Department of Veterans Affairs (DVA) 
healthcare system. We appreciate the opportunity to present our 
testimony to the Subcommittee. With our military personnel and 
Veterans' access to safe and high quality healthcare our first 
priority, we want you to know that the profession of nurse anesthesia 
is working creatively and effectively with the Department of Veterans 
Affairs (DVA), in partnership with the U.S. Army, to improve its 
retention and recruitment of CRNAs, so that high quality anesthesia 
services remain available and accessible for our Nation's Veterans. 
This work is crucial for several reasons; most importantly, because the 
anesthesia workforce needs in the DVA are increasing. Our request of 
the Committee is to understand these needs and to examine more closely 
the VA anesthesia workforce to ensure the safest, most cost-effective 
anesthesia services for our Veterans.
                CRNAs AND THE VA: A TRADITION OF SERVICE
    Let us begin by describing the profession of nurse anesthesia, and 
its history and role with the Veterans Administration health system.
    In the administration of anesthesia, CRNAs perform the same 
functions as anesthesiologists and work in every setting in which 
anesthesia is delivered including hospital surgical suites and 
obstetrical delivery rooms, ambulatory surgical centers, health 
maintenance organizations, and the offices of dentists, podiatrists, 
ophthalmologists, and plastic surgeons. Today, CRNAs administer some 30 
million anesthetics given to patients each year in the United States. 
Nurse anesthetists are also the sole anesthesia providers in the vast 
majority of rural hospitals, assuring access to surgical, obstetrical 
and other healthcare services for millions of rural Americans.
    Since the mid-19th Century, our profession of nurse anesthesia has 
been proud and honored to provide anesthesia care for our past and 
present military personnel and their families. From the Civil War to 
the present day, nurse anesthetists have been the principal anesthesia 
providers in combat areas of every war in which the United States has 
been engaged. In May 2003, at the beginning of ``Operation Iraqi 
Freedom,'' 364 CRNAs had been deployed to the Middle East to ensure 
military medical readiness capabilities. For decades CRNAs have staffed 
ships, remote U.S. military bases, and forward surgical teams, often 
without physician anesthesiologist support. The U.S. Army Joint Special 
Operations Command Medical Team and Army Forward Surgical Teams are 
staffed by CRNAs.
    As our military personnel advance from active service to retired 
and Veteran status, their anesthesia care in VA facilities is provided 
predominantly by nurse anesthetists. In 12 percent of VA healthcare 
facilities, the necessary anesthesia services are provided solely by 
CRNAs, ensuring our Veterans the safe anesthesia care that they deserve 
and have earned.
    Our tradition of service to the military and our Veterans is 
buttressed by our personal, professional commitment to patient safety, 
made evident through research into our practice. In our professional 
associations, we state emphatically ``our members' only business is 
patient safety.'' Safety is assured through education, high standards 
of professional practice, and commitment to continuing education. 
Having first practiced as registered nurses (RNs), CRNAs are educated 
to the master's degree level, and some to the doctoral level, and meet 
the most stringent continuing education and recertification standards 
in the field. Thanks to this tradition of advanced education and 
clinical practice excellence, we are humbled and honored to note that 
anesthesia is 50 times safer now than in the early eighties (National 
Academy of Sciences, 2000). Research further demonstrates that the care 
delivered by CRNAs, physician anesthesiologists, or by both working 
together yields similar patient safety outcomes. In addition to studies 
performed by the National Academy of Sciences in 1977, Forrest in 1980, 
Bechtoldt in 1981, the Minnesota Department of Health in 1994, and 
others, Dr. Michael Pine, MD, MBA, recently concluded once again that 
among CRNAs and physician anesthesiologists, ``the type of anesthesia 
provider does not affect inpatient surgical mortality'' (Pine, 2003). 
Thus, the practice of anesthesia is a recognized specialty in nursing 
and medicine. Most recently, a study published in Nursing Research 
confirmed obstetrical anesthesia services are extremely safe, and that 
there is no difference in safety between hospitals that use only CRNAs 
compared with those that use only anesthesiologists (Simonson et al, 
2007). Both CRNAs and anesthesiologists administer anesthesia for all 
types of surgical procedures from the simplest to the most complex, 
either as single providers or together.
NURSE ANESTHESIA PROVIDER SUPPLY AND DEMAND: SOLUTIONS FOR RECRUITMENT 
                        AND RETENTION IN THE DVA
    While both types of health professionals can provide the same high 
quality anesthesia care, CRNAs provide the DVA an additional advantage 
of cost-effectiveness. Consequently, both our Veterans and our VA 
health system are best served by policies and initiatives that secure 
adequate numbers of CRNA employees in the DVA. We believe that this 
Committee can help accomplish this objective by supporting nurse 
anesthesia education programs, both within the VA itself and in 
partnership with military and civilian schools of nurse anesthesia.
    It is essential to understand that while there is strong demand for 
CRNA services in the public and private healthcare sectors, the 
profession of nurse anesthesia is working effectively to meet this 
workforce challenge. The AANA anticipates growing demand for CRNAs. Our 
evidence suggests that while vacancies exist, the demand for anesthesia 
professionals can be met if appropriate actions are taken. As of 
January 2008, there are 108 accredited CRNA schools to support the 
profession of nurse anesthesia. The number of qualified registered 
nurses applying to CRNA schools continues to climb. The growth in the 
number of schools, the number of applicants, and in production 
capacity, has yielded significant growth in the number of nurse 
anesthetists graduating and being certified into the profession. The 
Council on Certification of Nurse Anesthetists reports that in 2007, 
our schools produced 2,021 graduates, an 88 percent increase since 
2002, and 1,869 nurse anesthetists were certified. The growth is 
expected to continue. The Council on Accreditation of Nurse Anesthesia 
Educational Programs (COA) projects the 108 CRNA schools to produce 
over 2,300 nurse anesthetists in 2008.
    The number of VA anesthesia vacancies is causing us concern. We 
believe that they can be filled through creative partnership between 
the VA system and the profession of nurse anesthesia, and commitment by 
the DVA to effectively recruit and retain CRNAs. More than half of the 
VA nurse anesthesia workforce is over the age of 53, an age some years 
above the mean for all CRNAs nationally. The annual turnover and 
retirement rate among CRNAs within the VA has risen to about 19 percent 
over the past few years and continues to rise as the workforce ages, 
more lucrative employment is offered in the private sector, and new 
graduates from CRNA educational programs find the VA employment and 
practice package comparatively uncompetitive. Currently, 24 stations 
show vacancies on public Federal job posting sites. However, we have 
reason to believe that the numbers of stations with actual vacancies is 
closer to 40, with staff vacancies either being left vacant for 
extended periods of time, or filled by contract personnel. 
Approximately 150 CRNA slots in the DVA are being filled by contract 
personnel.
    As the nurse anesthesia profession is working to meet the demand 
for CRNAs generally, we believe that the DVA specifically can meet its 
CRNA recruitment needs by pursuing three strategies. First, DVA should 
expand its relationships with existing CRNA schools. Second, the DVA 
should expand its joint CRNA educational program together with the 
Department of Defense (DOD) health system. Third, the DVA should 
upgrade its recruitment, retention, and practice environment factors to 
make VA service more competitive with the private market for anesthesia 
services, within the context of the DVA's mission.
    To a degree, some of these strategies are already under way and 
achieving results for the VA health system. A recent AANA survey shows 
our nurse education programs use some 70 VA hospitals and healthcare 
facilities as clinical practice education sites, helping to educate 
CRNAs, provide superior patient care, and aid the VA in recruiting 
nurse anesthetists. In addition, we recommend that the DVA pursue nurse 
anesthesia resource sharing programs with civilian CRNA schools through 
faculty exchange initiatives.
    Because nurse anesthesia is a safe and highly cost-effective means 
to secure anesthesia services for our Veterans, we have expressed 
concern that the DVA has introduced ``anesthesiologist assistants'' 
(AAs) to the VA health system, through new qualifications standards 
that do not require them to be licensed in any State, or subject to any 
State's oversight or discipline, or to have graduated from an 
accredited educational program, or to have secured certification, or to 
be appropriately supervised by anesthesiologists in a manner consistent 
with AAs' training as assistants. Though the DVA handbook VHA-1123 
updated March 2007 authorizes anesthesiologists to delegate anesthesia 
care to unqualified, uncredentialed individuals, the VHA has not yet 
hired such individuals. There are other substantive concerns with the 
handbook. Our Veterans deserve better. We have requested the policy be 
withdrawn, and have met with the agency to promote our shared interest 
in ensuring our Veterans access to safe, high quality anesthesia care.
 U.S. ARMY-VA JOINT PROGRAM IN NURSE ANESTHESIA, FT. SAM HOUSTON, SAN 
                              ANTONIO, TX
    The establishment of the joint U.S. Army-VA program in nurse 
anesthesia education at the U.S. Army Graduate Program in Anesthesia 
Nursing, Ft. Sam Houston, in San Antonio, TX holds the promise of 
making significant improvements in the VA CRNA workforce, as well as 
improving retention of VA registered nurses in a cost effective manner. 
The current program utilizes existing resources from both the 
Department of Veterans Affairs Employee Incentive Scholarship Program 
(EISP) and VA hospitals to fund tuition, books, and salary 
reimbursement for student registered nurse anesthetists (SRNAs).
    This VA nurse anesthesia program started in June 2004 with three 
openings for VA registered nurses to apply to and earn a Master of 
Science in Nursing (MSN) in anesthesia granted through the University 
of Texas Houston Health Science Center. In the future, the program is 
granting degrees through the Northeastern University Bouve College of 
Health Sciences nurse anesthesia educational program in Boston, Mass. 
Due to continued success and interest by VA registered nurses for the 
school, the program increased to five openings for the June 2005 and 
2006 classes. This program continues to attract registered nurses into 
VA service, by sending RNs the strong message that the VA is committed 
to their professional and educational advancement. In order to achieve 
the goal of expanding the program further, it is necessary for full 
funding of the current and future EISP to cover tuition, books, and 
salary reimbursement.
    The 30-month program is broken down into two phases. Phase I, 12 
months, is the didactic portion of the anesthesia training at the U.S. 
AMEDD Center and School (U.S. Army Graduate Program in Anesthesia 
Nursing). Phase II, 18 months, is clinical practice education, in which 
VA facilities and their affiliates would serve as clinical practice 
sites. In addition to the education taking place in Texas, the agency 
will use VA hospitals in Augusta, Georgia, increasing Phase II sites as 
necessary. Similar to military CRNAs who repay their educational 
investment through a service obligation to the U.S. Armed Forces, 
graduating VA CRNAs would serve a 3-year obligation to the VA health 
system. Through this kind of Department of Defense--DVA resource 
sharing, the VA will have an additional source of qualified CRNAs to 
meet anesthesia care staffing requirements.
    At a time of increased deployments in medical military personnel, 
VA-DOD partnerships are a cost-effective model to fill these gaps in 
the military healthcare system. At Ft. Sam Houston nurse anesthesia 
school, the VA faculty director has covered her Army colleagues' 
didactic classes when they are deployed at a moment's notice. This 
benefits both the VA and the DOD to ensure the nurse anesthesia 
students are trained and certified in a timely manner to meet their 
workforce obligation to the Federal Government as anesthesia providers.
    We are pleased to note that the Department of Veterans Affairs 
Acting Deputy Under Secretary for Health and the U.S. Army Surgeon 
General approved funding to start this VA nurse anesthesia school in 
2004. In addition, the VA director has been pleased to work under the 
direction of the Army program director LTC Thomas Ceremuga, CRNA, PhD 
to further the continued success of this U.S. Army-VA partnership. With 
modest levels of additional funding in the EISP, this joint U.S. Army-
VA nurse anesthesia education initiative can grow and thrive, and serve 
as a model for meeting other VA workforce needs, particularly in 
nursing.
    We recently recommended that $400,000 be included in the FY 2009 
appropriations to expand this joint educational program.
                              LOCALITY PAY
    In order to meet demand for nurse anesthetists, each VA facility's 
administrator may make use of existing locality pay structures as 
authorized and funded by Congress. Competitive salaries assist the DVA 
with retention of CRNAs to provide anesthesia services for our Nation's 
veterans. Though providing competitive salaries for excellent employees 
is an ongoing challenge, using locality pay to keep personnel is most 
cost-effective. This is where Congress can help, by providing adequate 
funding for personnel through locality pay adjustments where base 
salaries are not sufficiently competitive with the local private 
market. Further, this Subcommittee should examine whether the 2004 
authorization to expand incentive professional pays for physicians and 
nurse executives should also be applied to the recruitment and 
retention of nurse anesthetists, or, alternatively, whether other means 
should be pursued to lift the statutory cap that keeps VA nurse 
anesthetist compensation below local market levels.
    For several reasons, ensuring sufficient locality pay flexibility 
is in the interest of both our VA and our Veterans. The DVA faced a 
severe shortage of CRNAs in the early nineties, which was moderately 
corrected with the implementation of a locality pay system in 1991. In 
1992, Congress expanded the authority to the local medical directors 
and allowed them to survey an expanded area to determine more 
competitive average salaries for CRNAs, which boosted pay and morale. 
Implementation of this expanded authority helped assist the DVA in 
making great leaps in retention and recruitment of CRNAs at that time. 
However, times and the local labor markets for healthcare professionals 
have continued to change. In the past few years CRNAs' salaries have 
increased in the private sector, while the VA has not adjusted to these 
new salary rates. This means that in some markets the DVA locality pay 
system is no longer competitive with the private sector, and new nurse 
anesthetist graduates are choosing not to work in the VA health system. 
We believe that the VA would benefit by providing CRNAs competitive 
salaries in VA facilities and making use of effective locality pay 
adjustments, which reduces VA hospital administrators' requirements for 
contracted-out services at higher rates.
    Though nurse anesthetists provide the lion's share of anesthesia 
services to U.S. Department of Veterans Affairs (VA) healthcare 
facilities, the agency is facing a wave of retirements and having 
challenges recruiting CRNAs because the compensation it offers is below 
local market levels, a Government Accountability Office (GAO) report 
highlighted (``Many Medical Facilities Have Challenges in Recruiting 
and Retaining Nurse Anesthetists,'' GAO-08-56, 12/13/2007) The GAO 
recommended that the VA apply its locality pay system more vigorously 
to recruit and retain nurse anesthetists.
    At the time the report was issued, the AANA issued a statement, 
saying, ``The profession of nurse anesthesia is committed to caring for 
our Nation's Veterans. Nurse Anesthesia continues to be a safe, 
flexible and highly cost-effective means for the VA to ensure our 
Veterans the healthcare that they need and deserve. We look forward to 
continuing work with the Department of Veterans Affairs, the Congress, 
and the members of the Association of Veterans Affairs Nurse 
Anesthetists (AVANA) to help carry out the recommendations of this 
report.''
    The GAO found that VA medical facilities have had to temporarily 
close operating rooms or delay elective surgeries due to a shortage of 
CRNAs. While demand for CRNA services is increasing, the report says 26 
percent of the VA's CRNAs are projected to retire or leave the 
department in the next 5 years. The GAO said that the VA's CRNA 
recruitment and retention challenges are caused primarily by the 
agency's below-market compensation compared with local market 
conditions around the country. The GAO made its findings based on 
surveys of VA CRNAs, VA managing personnel in local VA facilities and 
at VA headquarters, and through other data sources. The report says the 
nurse anesthesia profession has been working effectively to meet high 
U.S. demand for anesthesia workforce by increasing the number of 
qualified practitioners graduating from accredited nurse anesthesia 
programs.
    The report recommended that the agency deploy and carry out its 
existing locality pay system to adjust salaries so that they are more 
competitive. Any locality pay system should be structured to set 
competitive salary levels for nurse anesthetists working in VA 
healthcare facilities. The DVA could implement a system that guarantees 
accurate surveys on pay are being conducted in a timely manner. This 
salary data will be used to adjust Nurse 1 (Step 1) to be competitive 
within the local market to assist VA facilities in hiring new nurse 
anesthesia graduates.
    Finally, with adjustments in the pay structure to include 
professional pays for recruitment and retention of CRNAs, VA facilities 
may well realize cost savings by contrast with other arrangements for 
securing anesthesia services.
    Recently, Senator Daniel Akaka (D-HI) introduced the Veterans' 
Medical Personnel Recruitment and Retention Act of 2008 (S. 2969), and 
several of its provisions are intended to help the VA recruit and 
retain CRNAs to the VA healthcare system. We applaud Senator Akaka's 
efforts to bring VA healthcare professionals' pay closer to the private 
sector. Our first priority remains ensuring our Veterans' access to a 
high quality of healthcare. The quality of healthcare services, and the 
qualifications expected of healthcare professionals, and the numbers of 
healthcare professionals, all together have bearing on the quality of 
life of our Veterans, and should be kept in mind in equal measure.
                               CONCLUSION
    In conclusion, we recognize that the VA has nurse anesthesia 
staffing needs. Through an effective partnership with the nurse 
anesthesia profession, the DVA can help meet its future CRNA workforce 
requirements through three cost-effective models, which exist today and 
can be expanded. Our VA hospitals can serve as clinical practice sites 
for CRNA schools. Going one step further, the VA health system can 
pursue resource sharing and faculty exchange agreements with nurse 
anesthesia schools. Further still, the VA and DOD can share resources 
outright to educate nurse anesthetists for the Veterans and military 
settings alike, particularly with modest additional funding. This VA 
commitment to CRNA education helps secure the nurse anesthesia 
workforce our Veterans need, and attracts registered nurses into VA 
service, by sending the strong message that the VA is committed to RNs' 
professional and educational advancement. Last, the VA should examine 
and improve the effectiveness of its recruitment, retention and 
practice environment for CRNAs.
    Thank you. If you have further questions, please contact the AANA 
Federal Government Affairs Office at 202-484-8400.

                                 
      Prepared Statement of Jay W. Wommack, Founder, President and
 Chief Executive Officer, Vertical Alliance Group, Inc., Texarkana, TX
    Mr. Chairman and Members of the Committee, I am Jay Wommack, 
Founder, President and Chief Executive Officer of Vertical Alliance 
Group, Texarkana, TX. Thank you for the opportunity to express our 
views on the important issues relating to ``Human Resources Challenges 
within the Veterans Health Administration.''
    As the Nation's largest integrated healthcare system, the Veterans 
Health Administration (VHA), due in large to the efforts of this 
Committee has made impressive strides in improving the quality of care 
for our Nation's Veterans. VHA has established itself as the 
``Trendsetter'' in healthcare reform with programs such as the 
electronic medical records innovation. You are to be applauded.
    In the way of introduction, I make no claim to being an expert in 
the Health Service arena; rather, over the past 9 years, I have been 
involved in the development, evaluation, and evolution of a 
comprehensive recruiting process for businesses that include health 
services. If I were to provide a title for my testimony today it would 
be ``How to convert 40 percent of the applicants that come through 
VHA's door into employees.''
    I recall shortly after college when I applied for my first ``real'' 
job, taking an hour or more filling out an application, turning it in 
and waiting patiently by the mailbox for weeks for a response that 
never came. And you can probably recall the excitement of receiving 
that four-inch thick mail order catalog. How you thumbed through every 
page, in my case mostly the toy section, and the anticipation and 
anxiety as you waited the 4 to 6 weeks for delivery--now I order online 
and it is at my door by the next day. Paper applications are fast going 
the way of the Pony Express and the new Sheriff in town is the 
Internet. Fundamental changes to the way we perceive and process 
applications must emerge if we are to meet the demands of tomorrow's 
career markets. In today's world, instant gratification is the norm. 
Not only do employers want quality employees, they want them now. 
Potential employees want the job of their dreams and they want it now. 
Applicants are all too often greeted with outdated processes that might 
have worked well in the sixties but fail to meet the demands of our 
high tech, Internet savvy society. A dramatic paradigm shift must take 
place to allow the conversion of new technologies into our recruiting 
process. We must consider how we merge today's technology with this 
paperwork world. Applicants don't want to wait for the hiring process 
to find the job of their dreams while their application is subjected to 
the confines of an electronic maze, they want immediate, personalized 
attention. With just a few changes in how we view and respond to these 
applicants our process can become more effective and efficient 
providing a lower cost per hire ratio.
    In 1999 Vertical Alliance Group, Inc. (VAG) began a long and 
thorough process to find out what works ``BEST'' in attracting and 
recruiting employees. With great efficiencies come great rewards. 
Operating on the premise that the Internet provides the most efficient/
effective venue to attract and recruit quality employees VAG has 
created some proven processes that advance recruit productivity. 
Current statistics indicate the recruiting closing rate of U.S. 
businesses to be approximately 2 percent of all applications received. 
A forty percent (40 percent) closing rate doesn't constitute the norm, 
however, these results can and have been attained utilizing the process 
we developed. Recruiting, training and retaining quality employees is 
paramount to the success of any business and directly affect it's 
bottom-line. The amount of time, money and effort dedicated to 
recruiting/replacing staff can be reduced with just a few changes in 
our attitude and processes about how we recruit and what efforts are 
being made to retain quality employees.
    Our efforts have produced the following conclusions:

      All levels of management must buy into and participate in 
the recruiting process.

      Training of current personnel at all levels is an 
essential element if we are to change the dynamic of how we respond to 
leads and become more proactive in streamlining the hiring process. 
Conversion of Human Resource personnel from the world of paper 
processor to high tech ``Sales Ambassadors'' is essential to provide 
the immediate gratification demanded by today's society.
      We must provide timely follow-up to closure that 
ensure(s) prompt attention is given each lead.
      We must improve the ``quality'' of prospective 
applications received. A success rate of 2 percent of ``spammed'' or 
database derived leads cost money and wastes time.

    Training is the essential element to a quality recruiting process. 
All levels of management must understand and value the recruiting 
process and recognize their role not only in recruiting but also the 
retention of highly qualified personnel. Understanding the direct 
response marketing strategy that includes an industry overview, how to 
rate/rank leads, selling skills, technique to close, selling points, 
the hiring cycle, are all necessary skills in providing a quality 
recruiting process. Knowledge of the current ``shelf life'' of 
applications is essential. In this competitive market, often the first 
quality response, usually within minutes not hours, days or weeks wins 
the deal. Human Resource personnel who are properly trained, highly 
motivated and who understand the value of this process provide the 
largest ``bang for the buck'' in recruiting and maintaining a strong 
workforce.
    Understanding the benefits and limitations of modern technology and 
the balance between them can also improve your odds in closing the 
deal. The ``human'' element is still one of vital importance in the 
process. First impressions still count. Potential employees still want 
a response from a real person, not a computer. In the words of Walt 
Disney, ``There is no magic in magic, just details.'' Timely, polite, 
professional communication will work magic in the recruiting process.
    Massed, unranked or inappropriately filtered leads provide 
``volume'' but lack ``quality'' and generate large amounts of paperwork 
generally resulting in minimal success. Quality leads, appropriately 
ranked by source first allow Human Resource personnel to come out of 
the paper processor role and become more proactive in the recruiting 
process. Targeted leads focused on essential hiring criteria provide 
optimal potential for successful closure and lower cost for hire rates.
    In an agency the size of VHA arguments can be made pro and con 
between centralized and decentralized recruiting processes. Each has 
its own unique values and barriers. Training of all personnel in their 
respective roles in the recruiting and retention process will provide a 
more prolific recruiting effort on behalf of the VHA.
    There are a number of issues and complexities that challenge our 
Human Resource efforts . . . But the good news is, there are solutions. 
Amy Gruver, Call Center Team Leader for Swift Transportation Company, 
one of the largest trucking companies in America, has stated that the 
VAG process has resulted in their lowest cost per hire rate. Small 
businesses to Fortune 500 companies have effectively implemented and 
assimilated this process with phenomenal success saving valuable 
resources.
    Mr. Chairman, this concludes my remarks. I would be happy to answer 
any questions that you or other Members of the Subcommittee may have at 
the appropriate time.

                                 
      Prepared Statement of Fred Cowell, Senior Associate Director
           for Health Analysis, Paralyzed Veterans of America
    Chairman Michaud, Ranking Member Miller, and Members of the 
Subcommittee, on behalf of the Paralyzed Veterans of America (PVA), I 
am pleased to be here today to offer our views concerning the ``Human 
Resource Challenges within the Department of Veterans Affairs.''
    PVA's primary concern, and the basic reason for our existence, is 
the health and welfare of our members and of our fellow veterans. The 
thousands of VA healthcare professionals and all of those individuals 
necessary to support their efforts are at the core of VA's primary 
mission. These individuals serve on the front line every day, caring 
for America's wounded veterans from Iraq and Afghanistan and seeing to 
the complex medical needs of our countries older veterans from previous 
wars. PVA believes thatVA's most important asset is the people it 
employs to care for those who have served our Nation.
    Mr. Chairman, the Subcommittee's interest in the issues concerning 
VA healthcare personnel is well placed and timely. Congress must assist 
VA' efforts to recruit and retain its corps of healthcare professionals 
as the demand for healthcare increases because of today's wars and the 
aging of the veteran population from previous wars. Currently, the 
Nation is experiencing serious short falls in its supply of physicians, 
nurses, pharmacists, therapists and psychologists. Competition for 
experienced medical personnel and newly licensed professionals is keen.
    PVA believes that Congress must take the lead in revamping outdated 
personnel policies and procedures (salaries, benefits, and working 
conditions) that may place VA at a disadvantage in today's labor market 
and will prevent VA from becoming the medical-care employer of choice 
in the future. PVA also believes that the broken VA appropriation 
process, which delays VA funding, is a major barrier to VA's healthcare 
professional recruitment process.
America's National Nurse Shortage
    The United States is currently in the tenth year of a critical 
nursing shortage which is expected to continue through 2020. The 
shortage of registered bed-side nurses and registered nurse specialists 
is having an impact on all aspects of acute and long-term care. 
America's nursing shortage has created nurse recruitment and retention 
challenges for medical-care employers nationwide and is making access 
to quality care difficult for consumers.
    Three national issues are directly contributing to America's 
national nursing shortage. First, the number of new nursing students 
entering nursing education programs is insufficient to meet rising 
medical care demand. Second, the number of nursing students seeking 
admission to nursing schools is restricted because of a lack of 
qualified nursing educators. According to the American Association of 
Colleges of Nursing, 38,400 nursing school applicants were turned away 
because of a lack of faculty. Third, a large percentage of the Nation's 
nurse workforce is nearing retirement and will soon need to be 
replaced.
    The current and emerging gap between the supply of and the demand 
for nurses may adversely affect the VA's ability to meet the healthcare 
needs of those who have served our Nation. According to VA, it employs 
more than 64,000 nursing professionals, and has one of the largest 
nursing staffs of any healthcare system in the world. Of that 64,000, 
VA has 43,000 registered nurses, 12,000 licensed practical nurses, and 
9,000 nursing assistants. VA also says that approximately 4,300 nurses 
retire or leave each year. VA must be able to recruit the best nurses, 
and retain a cadre of experienced, competent nurses. Providing high 
quality nursing care to the Nation's veterans is integral to the 
healthcare mission of VA.
    Like other healthcare employers, VA must actively address those 
factors known to affect recruitment and retention of nursing personnel 
such as: fair compensation, professional development, work environment, 
respect and recognition, underlying issues of sucessful VA nurse 
recruitment and retention. Failure to do so will undermine the quality 
of VA care and will jeopardize the health of our veterans.
    Mr. Chairman, The National Commission on VA Nursing submitted its 
final report to then VA Secretary, Anthony J. Principi on March 18th, 
2004.\1\ The report titled, Caring for America's Veterans: Attracting 
and Retaining a Quality VHA Nursing Workforce is as vital today as it 
was then.
---------------------------------------------------------------------------
    \1\ National Commission on VA Nursing 2002-2004, Final Report, 
Caring for America's Veterans: Attracting and Retaining a Quality VHA 
Nursing Workforce.
---------------------------------------------------------------------------
    PVA supports the following recommendations contained in that report 
and believes they serve as a sound template for improvements to VA's 
policies and procedures that govern its healthcare workforce. The 
recommendations of the National Commission on VA Nursing were:
Leadership
      The facility nurse executive should have line authority, 
responsibility, and accountability for nursing practice and personnel.
      The facility nurse executive should be a member of the 
executive body at VISN and facility levels.
      The facility nurse executive should be accountable for 
(a) the effective performance of nurse managers, (b) leadership 
development of all nursing staff, (c) development and implementation of 
clinical leadership roles at the point of care, and (d) compliance with 
standardized Nurse Professional Standards Boards (NPSB) protocols.
      VHA should clearly define Nurse Qualification Standards 
to facilitate consistent interpretation across VA's system of care.
Professional Development
      VHA should structure career development opportunities to 
assure that every nurse in VHA can actualize his/her goals within one 
or more career paths with the opportunity for professional growth and 
advancement.
      VHA should establish policy guidelines for schools of 
nursing comparable to the medical school model and actively promote 
nursing school affiliations.
      VHA should assure that VA's Health Professionals 
Educational Assistance Program is funded and available nationwide.
Work Environment
      VHA should develop, test, and adopt nationwide staffing 
standards that assure adequate nursing resources and support services 
to achieve excellence in patient care.
        NOTE: PVA believes that nurse staffing standards must consider 
the acuity level of patients for these standards to be meaningful.
      VHA should review and adopt appropriate recommendations 
outlined in the Institute of Medicine report , Keeping Patients Safe: 
Transforming the Work Environment of Nurses, to determine specific 
strategies for implementation across VHA.
Respect and Recognition
      VHA should expand recognition of achievement and 
performance in its nursing service.
      VHA should create a sense of value and culture of mutual 
respect for nursing through all levels of VHA to include physicians and 
other colleagues, management, and stakeholders.
Fair Compensation
      VHA should amend Title 38 to establish procedures for 
assuring that RN locality pay policies are competitive with local RN 
employer markets.
        NOTE: PVA supports specialty nurse pay for VA nurses working in 
VA's specialty care areas such as: spinal cord injury rehabilitation 
and sustaining care, blind rehabilitation, mental illness and traumatic 
brain injury.
      VHA should change hiring and compensation policies to 
promote recruitment and retention of licensed practical nurses and 
nursing assistants.
      VHA should strengthen its human resources systems and 
departments to develop an active hiring and recruiting process for 
nursing staff that is consistent, to the extent possible, across 
facilities and VISN's.
Technology
      VHA should give priority to the continued rollout of the 
VA Nursing Outcomes Database (VANOD) as the repository for nursing 
performance standards and the evaluation of effective patient care 
delivery models.
      VHA should engage experts to evaluate and redesign 
nursing work processes to enhance patient care quality, improve 
efficiency, and decrease nurse turnover through the use of technology.
      The Agency for Healthcare Research and Quality (AHRQ) and 
VHA should partner in applying findings from information systems and 
technology research projects into patient care delivery.
Research and Innovation
      VHA should establish a Center for Excellence in Quality 
Nursing Care to create and implement a research agenda consistent with 
VHA mission.

    Mr. Chairman, while these recommendations for VA improvement were 
directed toward VA's Nursing Service PVA believes that they have broad 
application to VA's entire healthcare workforce.
Specialty Pay for VA's Specialized Services Nurses
    PVA would very much appreciate the committee's consideration of 
providing specialty pay for nurses providing care in VA's specialized 
service programs such as: spinal cord injury/disease (SCI/D), blind 
rehabilitation, mental health and brain injury.
    Mr. Chairman, veterans who suffer spinal cord injury and disease 
require a cadre of specialty trained registered nurses to meet their 
complex initial rehabilitation and life-long sustaining medical care 
needs. PVA's data reveals a critical shortage of registered nurses who 
are providing care in VA's SCI/D center system of care. The complex 
medical and acuity needs of these veterans, makes care for them 
extremely difficult and demanding. These difficult care conditions 
become barriers to quality registered nurse recruitment and retention. 
Many of VA's SCI/D nurses are often placed on light duty status because 
of injuries they sustain in their daily tasks. When this happens it 
becomes a significant problem because it places additional patient care 
responsibility on those SCI/D nurses not on light duty. PVA believes 
SCI/D specialty pay is absolutely necessary if nurse shortages are to 
be overcome in this VA critical care area.
    We strongly encourage your committee to create a Title 38 specialty 
pay provision that will assist VA's efforts to recruit and retain 
nurses in these specialized areas. PVA is eager to assist Committee 
staff in developing legislative language that will create specialty pay 
for VA nurses working in these critical care areas.
Nurse Anesthetists
    VA is currently facing serious challenges to the recruitment and 
retention of Certified Registered Nurse Anesthetists (CRNA) who provide 
the majority of anesthesia care for veterans receiving care in VA 
medical facilities. GAO has reported that VA medical facilities have 
current challenges recruiting and retaining VA CRNAs and that these 
facilities will likely face challenges in retaining CRNAs over the next 
5 years due to the number of VA CRNAs projected to retire from or leave 
VA.\2\ The GAO further reported that their surveys of VA officials 
indicated that low VA salaries were the major barrier to VA's 
recruitment and retention efforts for this critical nursing skill.
---------------------------------------------------------------------------
    \2\ GAO Report April 9, 2008, VA Health Care: Recruitment and 
Retention Challenges and Efforts to Make Salaries Competitive for Nurse 
Anesthetists, GAO-08-647T.
---------------------------------------------------------------------------
VA Physicians
    PVA is concerned about the VA's current ability to maintain 
appropriate and adequate levels of physician staffing at a time when 
the Nation faces a pending shortage of physicians. Recent analysis by 
the Association of American Medical Colleges (AAMC) indicates the 
United States will face a serious doctor shortage in the next few 
decades.\3\ The AAMC goes on to say that currently, ``744,000 doctors 
practice medicine in the United States, but 250,000--one in three are 
over the age of 55 and are likely to retire during the next 20 years.'' 
The subsequent increasing demand for doctors, as many enter retirement, 
will increase challenges to VA's recruitment and retention efforts.
---------------------------------------------------------------------------
    \3\ Statement before the Senate Committee on Veterans Affairs, 
April 9, 2008, Making VA the Workplace of Choice for Health Care 
Providers, by John A. McDonald, M.D., Ph.D. Vice President for Health 
Services and Dean of the University of Nevada Medical School and member 
of the Association of American Medical Colleges, Veterans Affairs--
Deans Liaison Committee.
---------------------------------------------------------------------------
    Mr. Chairman PVA has serious concerns regarding VA's current and 
future ability to match or exceed private sector physician salaries. 
Additionally, PVA believes that VA's recruitment efforts are hampered 
because VA's Education Debt Reduction Program (EDRP) is limited to 
$49,000 spread out over 5 years of service. The average medical 
education indebtedness has climbed to over $140,000 in 2007, therefore 
the limited VA EDRP awards fail to provide an adequate incentive for VA 
recruitment.
    PVA is also concerned that the P.L. 108-445, the Department of 
Veterans Affairs Personnel Enhancement Act, is being manipulated by 
facility management to reduce operation costs. The American Federation 
of Government Employees (AFGE), AFL-CIO testified before the Senate 
Committee on Veterans Affairs that, ``At many VA facilities, management 
has imposed improper performance criteria that determine bonuses based 
on factors beyond the practitioners control, such as missed 
appointments.''\4\ The AFGE goes on to say that annual physician 
performance pay awards under this law have been inconsistent and 
unjustifiably lower than the maximum amounts set by Congress.
---------------------------------------------------------------------------
    \4\ Statement before the Senate Committee on Veterans Affairs, 
April 9, 2008, Making VA the Workplace of Choice for Health Care 
Providers by Valerie O. Meara, N.P. Professional Vice President, AFGE 
Local 3197 VA Puget Sound Health Care System, Seattle, Washington.
---------------------------------------------------------------------------
    The Independent Budget veterans service organizations (IBVSOs) 
believe that appropriate committees should use their oversight 
authority to study the impact of P.L. 108-445 on recruitment and 
retention of VA physicians and dentists.
VA Psychologists
    According to the American Psychological Association (AAPA), VA is 
the largest single employer of psychologists in the Nation. Congress 
and VA have recognized the need to increase the number of psychologists 
and have added more than 800 new psychologists since 2005, thereby 
raising the number of psychologists in the VA system to approximately 
2,400. The demands placed on VA's mental health service have increased 
dramatically because of the wars in Iraq and Afghanistan (OIF/OEF). 
However, it should be noted that these increased psychology staffing 
levels are a recent development. Since the vast majority of new 
psychologist hires in VA are less experienced professionals, VA must 
ensure they are properly trained and supervised. VA must also strive to 
retain and promote its more experienced psychologists in order to meet 
new training and supervision requirements.
    Despite VA's positive recruitment efforts, VA's advancement and 
retention policies continue to be driven by outdated and overly-rigid 
personnel and retention mandates. PVA urges the Subcommittee to utilize 
its oversight authority to investigate VA's on-going psychologists 
recruitment efforts to determine if VA is providing adequate levels of 
mental healthcare to meet the demands imposed by OIF and OEF while 
ensuring that adequate treatment opportunities continue to exist for 
veterans with prior service.
Summary
    Mr. Chairman, the Veterans Health Administration has made great 
strides over the last decade to improve the quality of care it provides 
to our Nation's veterans. Despite these gains, VA now finds itself in a 
precarious situation if it expects to retain its position as a vastly 
improved healthcare system. Challenges associated with maintaining a 
highly qualified medical care workforce are a major issue for VA. 
Competition to hire medical care professionals, during a national 
period of low supply, is making it more-and-more difficult for VA to 
successfully recruit and retain qualified personnel.
    If VA is to succeed it must have the resources required to offer 
competitive salaries and benefits and to make improvements to its work 
environment. VA must better utilize existing policy provisions that 
provide locality pay, premium and overtime pay, create flexible work 
schedules, relieve restrictions on mandatory overtime, and fully fund 
its excellent educational programs such as the Education Debt Reduction 
Program and the National Nursing Education Initiative.
    Mr. Chairman, PVA believes that Congress must assist VA's 
employment efforts by up-dating provisions of Title 38 that will 
enhance VA's competitive position as it vies to attract healthcare 
professionals to its ranks. Additionally, Congress must embrace a VA 
appropriation process that promptly funds the VA healthcare system so 
VA management can be confident that resources are available to support 
a health-care workforce that can meet the medical care demand of a 
growing veteran population.
    Mr. Chairman, this concludes my remarks. I will be happy to attempt 
to answer any questions you or Members of the Subcommittee may have.

                                 
 Prepared Statement of Cecilia McVey, BSN, MHA, RN, Associate Director
  for Patient Care/Nursing, Veterans Affairs Boston Healthcare System,
  Veterans Health Administration, U.S. Department of Veterans Affairs,
 and Immediate Past President, Nurses Organization of Veterans Affairs
    Mr. Chairman and Members of the Committee on Veterans' Affairs 
Subcommittee on Health, the Nurses Organization of Veterans Affairs 
(NOVA) would like to thank you for inviting us to present testimony on 
Human Resource issues in the VA.
    I am Cecilia McVey, BSN, MHA, RN, Associate Director for Patient 
Care/Nursing at the VA Boston Healthcare System and am here today as 
the Immediate Past President of NOVA. NOVA is the professional 
organization for registered nurses employed by the Department of 
Veterans Affairs.
    NOVA respects and appreciates what our labor organizations, such as 
AFGE and NAGE, do for VA nurses. NOVA clearly deals with VA on RN 
professional matters, not working conditions for which VHA RNs have 
their union representatives. Because this Committee has invited NOVA to 
share its views on this bill, however, I am here to offer the following 
observations.
    The Veterans Health Administration (VHA) is the third largest 
civilian employer in the Federal Government and one of the largest 
healthcare providers in the world. VHA is facing significant challenges 
in ensuring it has the appropriate workforce to meet both current and 
future workforce needs. This workforce is critical to ensure we are 
able to provide the care our Nation's heroes deserve. These challenges 
are further exacerbated by an aging workforce in general and in nursing 
specifically and the high number of employees' retirement eligible each 
year.
    Nursing and other Medical Center workforce members are dependent on 
timely and efficient recruiting. Human Resources Departments across VHA 
are not able to function optimally due to systems that have not kept 
pace with private sector recruitment abilities.
    Although there are numerous barriers to timely and efficient 
recruiting the following three are the top three:

    1.  Although certain pay setting flexibilities do exist, such as 
recruitment bonuses/retention allowances, above minimum entry rates, 
and the special rate authority, additional pay flexibilities are needed 
in order for VA to be able to successfully compete for the best 
candidates in the marketplace. The current general schedule and 
locality pay system which works hand in hand with the classification 
system is antiquated, cannot respond quickly enough and has a number of 
major barriers. For example:

      a.  Retention allowances.

         1.  They are not considered base pay for benefits such as 
retirement and life insurance. Candidates declined positions based on 
this limitation.

      b.  Special pay rates.

         1.  There are restrictions on how far the pay table can be 
expanded.
         2.  You cannot use special rates to address recruitment/
retention issues of a subgroup within an occupation
         3.  Approval process for special rates is too slow to address 
current market conditions.
         4.  The major focus of the criteria is whether you are getting 
qualified candidates to apply and not whether the candidates are highly 
qualified.

      c.  Above minimum rates.

         1.  Allows manager to appoint the applicant above the minimum 
step. There are many situations where the manager needs to offer a 
highly qualified candidate more money than the existing experienced 
staff. There is no mechanism to increase the pay of the existing staff 
to maintain pay parity.
         2.  The application process (how to apply) is too cumbersome 
and very confusing for those in the private sector who are used to a 
much faster and simpler process. Staffing Specialists must help many of 
the would-be applicants to navigate through the maze of the Federal 
application process. Applicants are frustrated by the duplication of 
information that they are required to provide, such as the information 
on Federal application for employment, information for background 
investigations, and credentialing. The enormous amount of paperwork, 
data base entries, and checklists associated with fulfilling all of the 
hiring requirements further delays the process. This leads to hiring 
additional FTEs to manage the processes.
         3.  A consistent theme across the country is that applicants 
are looking for money for professional development not just in clinical 
occupations but administrative as well. Tuition reimbursement is 
limited to a few select occupations at this time such as Nurses.

    Some suggested policy changes recommended are as follows:

    1.  More positions should be converted to Excepted Service, i.e., 
hybrid Title 38 such as Nursing Assistants, Health Technicians, Medical 
Support Assistants, Radiation Safety Officers, and Information 
Technology Specialists, for example. Due to the constraints associated 
with recruiting through the Delegated Examining Units, the process is 
often too difficult and generally does not provide a list of ``highly 
qualified candidates'' and discourages potential hires.
    2.  More pay flexibilities should be provided. Pay reform similar 
to the Physician pay reform where there is a market pay component would 
provide the needed flexibility for VA facilities at the local level. 
Another option would be to provide legislation that would address the 
barriers in paragraph 1 above.
    3.  Classification Standards are in need of review and revision. 
Many of them are too old and no longer reflective of the types of 
duties and responsibilities that are typically performed. Given that 
these are used to determine the pay, they often serve as a barrier to 
appropriate and effective pay setting.
    4.  Given the sizeable numbers of employees at or near retirement 
age, succession planning is becoming increasingly more important, 
especially for critically important positions. In order to successfully 
transition workload from retirees who possess a wealth of experience to 
their successors; transitional recruitment is required, which can take 
up 3 to 6 months of addition FTE per situation.

    One other critical issue of concern relates to the impact on 
patient care if 38 U.S.C. 7422(b) exclusions were to be repealed. Some 
of the issues that I foresee would have a negative impact on the care 
of our Veterans include the following:

      RN reassignment decisions made on the basis of clinical 
competence.
      Performance appraisals/proficiency reports.
      Fitness for duty issues as determined by Professional 
Standards Boards.
      Clinical competence issues as determined by Professional 
Standards Boards.
      Disciplinary and major adverse actions based on patient 
care or clinical competence issues.

    Determination of clinical competence is best reserved for those 
responsible in ensuring that quality patient care is delivered. Our 
veterans deserve the best that VA has to offer, and although the 
majority of our employees are excellent, there are a few marginal 
performers who put patient safety at risk. Moreover, clinical 
supervisors and managers must retain the authority to make clinical 
decisions such as which personnel are best suited for particular 
assignments and the appropriate staff mix for a given clinical setting.
    Inherent in bargaining is the element of timeliness. If an employee 
needs to be removed from direct patient care or if providers' hours 
must be extended to meet growing patient care needs, those changes must 
be made immediately and cannot wait for the completion of protracted 
negotiation. National Level bargaining on policy or program changes is 
currently taking 120 days or longer. Local bargaining usually takes 
less time but still can result in delays, despite the best of 
intentions. If clinical matters were subject to bargaining, critical 
clinical programs such as extending the hours of mental health clinics 
or mandating traumatic brain injury training for all providers could 
not be implemented for months, which would unacceptably put patients at 
risk.
    VHA has been a leader in healthcare and has earned an excellent 
reputation as one of the best healthcare providers in the country. In 
order to continue this reputation, VHA staff will need to have new 
skills and competencies to treat this new generation of Veterans. 
Nimble and flexible HR processes are critical to VA's future success.
    Thank you, Mr. Chairman and Members of the Subcommittee, for the 
opportunity to testify here today about these important personnel 
issues.

                                 
                Prepared Statement of Adrian M. Atizado,
  Assistant National Legislative Director, Disabled American Veterans
    Mr. Chairman and Members of the Subcommittee:
    Thank you for inviting the Disabled American Veterans (DAV) to 
testify on human resources challenges within the Department of Veterans 
Affairs' (VA) Veterans Health Administration (VHA).
    The human capital needs of VHA are driven by needs of the 
population VA serves. VA is experiencing a gradual slowdown in the 
growth of its enrollees due to declining veteran population, mortality 
in the Priority 8 enrollee population since the suspension of 
enrollment, and deaths in the pre-enrollee population. New enrollments 
of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) 
veterans do not reverse the trend. Further, the reliance and 
utilization rates of veteran enrollees from prior conflicts are more 
established and better defined than the medical care consumerism of the 
OEF/OIF enrollee population.
    A number of undefined variables, such as duration of the conflict, 
demobilization requirements, and impact of outreach efforts, will 
influence the number and types of services that VA will need to provide 
OEF/OIF veterans. What is known today is that the current OEF/OIF 
veterans appear to have different utilization patterns than the rest of 
the VA enrollee population, needs that will demand greater flexibility 
in human resource management within the VA. Specifically, initial 
findings indicate OEF/OIF enrollees use half as much inpatient surgery 
and acute medicine, but it is expected that they will need three times 
the number of PTSD residential rehabilitation services, and have 
greater needs for physical medicine, prosthetics and outpatient 
psychiatric and substance abuse services. Correspondingly, enrollees 
from previous wars making up the vast majority of the population 
continue transitioning to higher enrollment priorities, and the aging 
morbidity of this population are driving the type and intensity of 
healthcare needs--even with the acknowledged declining reliance on VA 
once they qualify for Medicare.
    In the general civil service arena, the Office of Personnel 
Management (OPM) estimates about one-third of full-time government 
workers will retire by 2012, but some occupations are more sensitive to 
external forces and agency initiatives than others. In April 2007, VHA 
conducted a national conference, titled, VHA Succession Planning and 
Workforce Development. The conference report indicated the average age 
of all VHA employees in 2006 was 48 years. It estimated that by the end 
of 2012, approximately 91,700 VHA employees, or 44 percent of current 
full time and part time staff, would be eligible for full civil service 
retirement. The report also indicated approximately 46,300 VHA 
employees are projected to retire during that same period. In addition, 
a significant number of healthcare professionals in leadership 
positions would also be eligible to retire by the end of 2012. With 
regard to the three mission critical occupations--registered nurse, 
pharmacist and physician, a startling finding in the report concluded 
that 97 percent of VA nurses in pay band ``V'' positions would be 
eligible to retire, and that 56 percent were expected to retire; and, 
that 81 percent of VA physicians in pay category 16--including many 
current Chiefs of Staff, would be eligible to retire, with 44 percent 
projected to actually retire from Federal service.
    Furthermore, the supply of healthcare providers poses an added 
hurdle for VA to be a patient-centered and integrated healthcare 
organization for veterans providing excellence in healthcare, research, 
and education; an organization where people choose to work; an active 
community partner and a back-up for national emergencies. In 
recognition, VA's more recent commonly used description is that, 
``[t]here is a growing realization that the supply of appropriately 
prepared healthcare workers in the Nation is inadequate to meet the 
needs of a growing and diverse population. This shortfall will grow 
more serious over the next 20 years. Enrollment in professional schools 
is not growing fast enough to meet the projected future demand for 
healthcare providers.''
    Without question, recruitment, management, and providing direction 
for VA employees on such issues as compensation, hiring, performance 
management, and organizational development are critical to the success 
of VHA's mission to provide safe, high quality healthcare services to 
sick and disabled veterans. While the most recent actions by Congress 
to affect the compensation package VHA may offer to prospective 
employees necessitates additional implementation oversight, an equally 
important problem within the realm of recruitment that requires 
attention is the Federal hiring process itself.
    Hiring a new wave of Federal employees to succeed those that leave 
is paramount given the frequent civil-service hiring freezes of the 
past 2 decades due to cross-government rescissions and dictated 
``management efficiency'' savings, inadequate funding levels, and the 
unpredictable nature of the discretionary appropriations process. 
Moreover, the passive approach to recruiting applicants by Federal 
agencies including VA puts themselves on unequal footing compared to 
the recruitment and retention programs used by many competitive private 
employers. With over 100,000 healthcare trainees receiving clinical 
learning experiences annually in VA facilities, hiring from this pool 
should provide VHA with an increased advantage over private healthcare 
facilities. Unfortunately, there is the perennial and widely 
acknowledged complaint by applicants for Federal employment about 
cumbersome Federal hiring procedures and practices, which require too 
much time and excessive paperwork. Of those who do submit applications, 
many say they never receive feedback from agencies of interest.
    According to a survey conducted by the Merit Systems Protection 
Board (MSPB), supervisors and upper-level new employees reported that 
the hiring process is complex and takes too long. The most recent MSPB 
survey of entry-level hires and upper-level hires showed that 
substantial numbers had to wait 5 months or longer before being hired--
much too long to expect a high-quality applicant to wait. These 
findings harken back to the 2002 survey indicating an average of about 
3 months are required for the government to hire anyone, while 70 
percent of college students say that they are unwilling to wait more 
than 4 weeks for a job offer.
    OPM has publicly acknowledged this problem in Federal hiring and 
has agreed that the process has become cumbersome. To address this, it 
has urged Federal agencies to take advantage of recent laws that 
encourage quick hiring decisions and permit the use of bonuses to 
recruit and retain Federal employees. Unfortunately, a myriad of rules 
and procedures are still in place to restrict the use of these tools. 
These restrictions in Federal hiring decisions were designed to ensure 
equity, consistency, and accountability, while also protecting against 
fraud, waste and abuse. This design does not compete well with private 
sector recruitment practices.
    While Federal job applications are only the first tedious part of 
the process, agencies require approval from their personnel 
departments, which in turn cannot go beyond the level of appropriated 
or designated funds. If the agency, department, or facility does get 
approval, its managers must produce a proper position description, get 
the vacancy announcement approved and posted, rate the applicants, 
interview the candidates, get higher-level approval for the hire, then 
conduct boarding, and finally complete any required background checks, 
(and for professionals, complete credentialing and privileging). Each 
step adds more time to the process. In some cases security and 
background checks have caused several months delay due to increased 
security requirements. Candidates for the top tier career appointments 
to the Senior Executive Service (SES must pass yet another review 
board, composed of SES members. The 5-month average for the government 
to hire anyone is infeasible for many applicants--especially younger 
job-seekers.
    VA recently testified on streamlining its cumbersome hiring 
process, stating the Human Resource Committee of the VHA National 
Leadership Board chartered a workgroup last year to streamline the 
recruitment process for title 5 and title 38 positions within VHA. This 
included an analysis of the recruitment process and identification of 
barriers and lengthy processes that could be streamlined. The 
recommendations were piloted in Veterans Integrated Service Network 
(VISN) 4 (generally, Pennsylvania) with the implementation and results 
of the pilot rolled out nationwide. During the spring and summer of 
2008, training in systems redesign will be offered nationally at Human 
Resources Cluster meetings. At these sessions, VA testified it will 
focus on new strategies and systems redesign elements that can be used 
to help meet the daily challenges of attracting and retaining critical 
healthcare professionals.
    In addition to time, there is often poor communication between 
Federal managers and HR professionals on the qualities and skills 
needed in a candidate. Attrition of experienced VHA human resources 
employees has had a direct impact on the quality of recruitment and 
retention efforts as well as providing needed assistance to train new 
and inexperienced staff to successfully hire needed VA healthcare 
providers. In the end, those individuals who make it to the end of this 
process are often not the optimum candidates, nor the best qualified 
for the position. In fact, in the 2006 Federal Human Capital Survey, 
less than half of government workers said that their work unit is able 
to hire people with the right skills.
    VHA's workforce is covered under Title 5, Title 38, and Congress 
has provided VHA a unique Title 38 ``hybrid'' authority, combining 
elements of both titles. As the greater majority of VHA employees fall 
under Title 38 and Title 38 hybrid systems, personnel rules under both 
were designed to allow greater flexibility and expedite VHA's hiring 
and promotion processes. The Title 38 hybrid model requires 
Professional Standards Boards to make recommendations on employment, 
promotion and grade. This model is viewed as more subjective due to the 
level of transparency than Title 38, where professionals are hired, 
promoted and retained based solely on their professional 
qualifications. Moreover, the reality of the hiring and promotion 
processes under Title 38 hybrid is facing extraordinary delays 
particularly in the boarding process across healthcare disciplines from 
nurses to psychologists.
    The Federal hiring process is so daunting that it often reinforces 
applicants' worst fears of government as an ineffective, unresponsive 
and incomprehensible bureaucracy. Only by insisting that agencies make 
recruiting talent a top priority and that both agency leaders and 
managers be held responsible for results, can we ensure that the 
government recruits the talent it needs to meet the challenges ahead. A 
simple practice (but time consuming due to inadequate VHA human 
resources staffing) that could be employed is to ensure that the human 
resources staffs responsible for recruiting applicants provide some 
meaningful and timely feedback to job applicants. Feedback, which puts 
some personal touch to an impersonal process, can help maintain 
applicants' interest in the agency as well as throughout a hiring 
process that can be lengthy as I have indicated.
    Again, we thank you for this opportunity to testify. This concludes 
my testimony, and I will be happy to address any questions from the 
Chairman or other Members of the Subcommittee.

                                 
           Prepared Statement of Joleen Clark, Chief Officer,
  Workforce Management and Consulting, Veterans Health Administration,
                  U.S. Department of Veterans Affairs
    Mr. Chairman and Members of the Committee, thank you for the 
invitation to appear before you to discuss ``Human Resources 
Challenges'' within the Department of Veterans Affairs (VA) Veterans 
Health Administration (VHA). Our challenges cover recruitment and 
retention programs, improving and streamlining the recruitment process, 
and other issues related to developing and maintaining a qualified and 
diverse workforce of healthcare professionals.
    As the Nation's largest integrated healthcare delivery system, 
VHA's workforce challenges mirror those of the healthcare industry as a 
whole. VHA experiences pressures equal to or greater than other 
healthcare organizations. VHA performs extensive national workforce 
planning and annually publishes a Workforce Succession Strategic Plan 
that includes workforce analysis and planning for each Veterans 
Integrated Service Network (VISN) and national program office. VHA's 
Strategic Plan addresses current and emerging initiatives in areas 
including, but not limited to, recruitment and retention, mental 
healthcare, polytrauma, traumatic brain injury, and rural health to 
address workforce efforts.
    VHA's Strategic Plan identifies mission-critical occupations which 
are considered shortage categories, as well as recruitment and 
retention initiatives at the local, regional and national levels. For 
each of the nationally ranked mission critical occupations, VA conducts 
a thorough historical and projected workforce analysis. Plans are 
established at every level to address turnover, succession planning, 
developmental opportunities, and diversity issues. VHA uses equal 
employment opportunity comparison data for each of the critical 
occupations, as well as the workforce nationwide, to ensure that VHA 
maintains a diverse workforce.
    VHA's workforce plan is one of the most comprehensive in government 
and has been recognized by OPM as a Federal best practice. VA has 
presented it to other Federal agencies as well as by means of OPM's ``A 
Best Practice Leadership Forum On Succession Management'' conference.
Efforts to Recruit Health Care Professionals
    It is important that the supply of appropriately prepared 
healthcare workers meet the needs of a growing and diverse population. 
Enrollment in nursing schools needs to grow to meet the projected 
future demand for healthcare providers.
    More than 100,000 health professional trainees come to VA 
facilities each year for clinical learning experiences. Many of these 
trainees are near the end of their education or training programs and 
become a substantial recruitment pool for VA employment as health 
professionals. The annual VHA Learners' Perceptions Survey shows 
trainees were twice as likely to consider VA employment after 
completing their VA learning experiences than they were before. This 
demonstrates many trainees were not aware of VA employment 
opportunities or the quality of VA's healthcare environment prior to VA 
training, but became considerably more interested after their VA 
clinical experiences.
    An informal survey of all VA facilities in 2007 found that 74 
percent of the 800 psychologists hired over the last 3 years received 
some training in professional psychology through VA. This year, VHA's 
Offices of Academic Affiliations (OAA) and Patient Care Services 
significantly expanded VA's psychology training programs in 
anticipation of the ongoing need for additional VA psychologists.
    The Healthcare Retention and Recruitment Office (HRRO) is 
distributing a new recruitment brochure titled ``From Classroom to 
Career'' to VA trainees. The Office of Academic Affiliations in VA 
Central Office emphasizes trainee recruitment to education leaders in 
VA facilities. The VHA leadership has raised the trainee recruitment 
issue to a higher priority.
    In an effort to initiate proactive strategies to aid in the 
shortage of clinical faculty, VA launched the VA Nursing Academy 
(Academy) to address the nationwide shortage of nurses. The purpose of 
the Academy is to expand the number of nursing faculty in schools, 
increase student nursing enrollment by 1,000 students, increase the 
number of students who come to VA for their clinical learning 
experience, and promote innovations in nursing education and clinical 
practice. Four partnerships were established for the 2007--2008 school 
year. Four additional partnerships will be selected each year in 2008 
and 2009 for a total of twelve partnerships.
    The VA Travel Nurse Corps is an exciting new program that 
established a pool of registered nurses (RNs) in VA who can be 
available for temporary, short-term assignments at VA medical centers 
throughout the country; this program is being piloted at two sites, San 
Diego and Phoenix. The VA Travel Nurse Corps meets nurses' needs for 
travel and flexibility while meeting VA medical center needs for 
temporary, high quality nurses. The goals of the program are to 
maintain high standards of patient care quality and safety; reduce the 
use of outside supplemental staffing; improve recruitment of new nurses 
into the VA system; improve retention by decreasing turnover of newly 
recruited nurses; provide alternatives for experienced nurses who may 
leave the VA system; and establish a potential pool of RNs for national 
emergency preparedness efforts. The VA Travel Nurse Corps program may 
also serve as a model for an expanded multidisciplinary VA Travel Corps 
in the future.
    Student programs, such as the VA Learning Opportunities Residency 
(VALOR) Program, the Student Career Experience Program (SCEP), and the 
Hispanic Association of Colleges and Universities (HACU) Internship 
Program, have helped VA meet its workforce succession needs. VALOR is 
designed to attract academically successful students of baccalaureate 
nursing programs and pharmacy doctorate programs. VALOR offers a paid 
internship and gives the honor students the opportunity to develop 
competencies in their clinical practice in a VA facility under the 
guidance of a preceptor. In response to the success of the VALOR 
program for nurses, VA added a pharmacy component in 2007. SCEP and 
HACU offer students work experience related to their academic field of 
study. VHA's goal is to actively recruit these students for permanent 
employment following graduation. VA National Database for Interns is a 
newly designed database developed to track students in VA internship/
student programs and to create a qualified applicant pool.
    The Graduate Health Administration Training Program (GHATP) 
provides practical work experience to students and recent graduates of 
healthcare administration masters programs. On an annual basis, 40-45 
GHATP residents and fellows are competitively selected and, upon 
successful completion of the programs, are eligible for conversion to a 
permanent position. The Technical Career Field program is designed to 
fill entry level vacancies in areas like Budget, Finance, Human 
Resources, and Engineering, where shortages are predicted and VA-
specific knowledge is critical to success. Recruitment is focused on 
colleges and universities. Each intern is placed with an experienced 
preceptor in a VHA facility. The program is designed to be flexible and 
responsive to the changing needs of the workforce, as the target 
positions and the number of intern slots are determined based on 
projected needs.
Challenges Hiring Health Professional in Rural Areas
    VA recognizes that rural communities face additional healthcare 
workforce challenges. Many of the access and quality challenges rural 
patients face begin with a shortage of healthcare providers. VA is 
working to develop an effective rural workforce strategy to recruit 
locally for a broad range of health-related professions.
    Experiential training opportunities for young medical students are 
important investments for creating a veteran- and rural-friendly 
physician workforce. VA is working to integrate rural areas into 
residency rotations, since evidence shows those who serve residencies 
in rural areas are more likely to practice in rural areas.
Streamlining the Hiring Process
    Last year, VHA's Human Resource Committee chartered a workgroup to 
streamline the recruitment process for Title 5 and Title 38 positions 
within VHA. The workgroup initially analyzed the recruitment process 
and identified barriers and lengthy processes for Registered Nurses. 
VHA conducted a pilot program in VISN 4 (Pittsburgh, PA) where the 
group's recommendations were put into practice. The recommendations 
were piloted there with the implementation and results of the pilot 
rolled out nationwide using information from this pilot. This spring 
and summer, VA is offering training in systems redesign nationally at 
Human Resources Cluster meetings. These sessions will focus on new 
strategies and systems redesign elements that can be used to help meet 
the daily challenges of attracting and retaining critical healthcare 
professionals.
    VA has direct appointment authority for several Title 38 
occupations, including physical therapists. We recognize that physical 
therapists are essential to the rehabilitation of injured veterans, and 
VHA is in the final stages of working with the Office of Human 
Resources Management to develop a new qualification standard, which 
should be implemented later this year.
    In October 2007, VHA consolidated the Delegated Examining Units 
from 19 decentralized units to eight centralized units, fully automated 
offices which process all VHA requests for external Title 5 job 
applicants. The centralization, consolidation and automation of this 
function have helped VHA achieve reductions in the timeframes for 
announcing Title 5 positions to the general public; qualifying 
candidates and generating certificates of eligible candidates for 
hiring managers. Metrics have been established and tracking implemented 
to measure the competitive hiring process within VHA. Improvements in 
timelines for processing are expected to continue throughout the year.
Innovative Retention Strategies
    One retention strategy that has proven very successful for VHA was 
approved in Public Law 108-445 (dated December 3, 2004 and effective 
January 8, 2006). VHA physician and dentist pay consists of three 
elements: base pay, market pay, and performance pay. P.L. 108-445 
improves VA's ability to recruit and retain the best qualified 
workforce capable of providing high quality care for eligible veterans. 
VA is committed to ensuring the levels of annual pay (base pay plus 
market pay) for VHA physicians and dentists are fixed at levels 
reasonably comparable with the income of non-VA physicians and dentists 
performing similar services. Between the time the pay bill went into 
effect and the end of February 2008, we have increased the number of VA 
physicians by over 1,430 FTE. Also as a component of this legislation, 
VA has the discretionary ability to set Nurse Executive Pay to ensure 
we continue to successfully recruit and retain nursing leaders.
National Recruitment/Media Marketing Strategies
    The VHA Healthcare Retention & Recruitment Office (HRRO) 
administers national programs to promote employment branding with VHA 
as the healthcare employer of choice. Established almost a decade ago, 
the brand ``Best Care--Best Careers,'' reflects the care America's 
veterans receive from VA and the excellent career opportunities 
available to staff and prospective employees.
    Recent marketing studies for nursing and pharmacy have been the 
driving force for many of our successful campaigns. HRRO works at the 
national level to promote recruitment branding and to provide tools, 
resources, and other materials to support both national branding and 
local recruiting. The current annual recruitment advertising budget is 
$1.8 million. Some of the features of this program are:

      Integration of VHA's recruitment website search engine 
(www.VACareers.va.gov) with the USA Jobs (www.USAjobs.opm.gov) search 
engine. This combined resource provides consolidated information on 
careers in VHA, job search capability, and information on Federal 
employment pay and benefits information. This integration was completed 
in March 2008.
      Public Service Announcements (PSAs) promote the 
``preferred healthcare employer'' image of VHA. PSAs emphasize the 
importance and advantage of careers with VA and focus on the personal 
and professional rewards of such a career.
      A comprehensive online advertising strategy where VA 
positions are promoted on commercial employment websites like Career 
Builder, Healthcareers, and others. Advertising on online health 
information networks expands our reach to over 5,000 discrete websites 
at a cost of just over $500,000 annually. VA's strategy includes banner 
advertising directing traffic to the VACareers website for employment 
information and adding keyword searches to Google and Yahoo! to elevate 
VA jobs to the top of the list of search results on these sites. This 
advertising results in over 100,000 visits to the VA recruitment 
website each month.
      Print advertising includes both direct classified 
advertising and national employment branding. The national program 
provides ongoing exposure of VA messaging to potential employees and 
promotes VA as a leader in patient care. VHA print advertising reaches 
over 34 million potential candidates.
      VHA Health Care Recruiters' Toolkit is a unique virtual 
community internal to VHA. This toolkit is an online management program 
coordinating national and local recruitment efforts for healthcare 
professionals and serves as a resource by providing available 
recruitment tools, materials, advertisements, and other related 
information at recruiters' fingertips.
      VHA's National Recruitment Advisory Groups represent top 
mission critical occupations that collaborate on an interdisciplinary 
approach to address recruitment and retention.

    In Fiscal Year 2007, HRRO developed a comprehensive recruitment 
marketing plan for mental health professionals using some of the 
strategies mentioned earlier, as well as financial recruitment 
incentives. Funding was dedicated for Mental Health Enhancement 
Initiative Education Debt Reduction Program (EDRP) positions. As of May 
1, 2008, awards had been made to 144 participants. The total payout for 
these participants is over $5,235,000 over a 5-year service period. The 
average total award is $36,355.
Financial Incentives for Recruitment and Retention
    Both a recruitment and retention tool, the Employee Incentive 
Scholarship Program (EISP) pays up to $35,900 for academic healthcare-
related degree programs. Between 1999 and May 1, 2008, 7,524 VA 
employees have received scholarship awards for academic education 
programs related to Title 38 and Hybrid Title 38 occupations, and more 
than 4,200 employees have graduated. Scholarship recipients include RNs 
(93 percent), pharmacists, and many other allied health professionals. 
Focus group market research shows staff education programs offered by 
VHA are considered a major factor in individuals selecting VA as their 
choice of employer. A 5-year analysis of program outcomes demonstrated 
positive employee retention. Less than 1 percent of nurses leave VHA 
during their service obligation period, from one to 3 years after 
completion of degree.
    The Education Debt Reduction Program (EDRP) provides tax free 
reimbursement of education loans/debt to recently hired Title 38 and 
Hybrid Title 38 employees. EDRP is similar to the Student Loan 
Repayment Program, under Office of Personnel Management (OPM) 
regulations. VA has the authority to award up to $50,824. Currently, 
the maximum award amount is capped at $48,000 and is tax free. The 
maximum award amount is usually increased each fiscal year. As of May 
1, 2008, 6,467 healthcare professionals were participating in EDRP. The 
average amount authorized per student, since the inception of EDRP, is 
$18,394. The average award amount per employee has increased each 
fiscal year from over $13,500 in FY 2002 to over $29,000 in FY 2008 as 
education costs have increased. While employees from 34 occupations 
participate in the program, 75 percent are from three mission critical 
occupations: registered nurses, pharmacists and physicians. These 
figures include the mental health initiative EDRP awards discussed 
previously.
    Resignation rates of EDRP recipients are significantly less than 
non-recipients as determined in a 2005 study that showed:

      The resignation rate for nursing EDRP recipients was 14.3 
percent while the resignation rate for non-EDRP recipients was 28 
percent--a 13.7-percent difference. The resignation rate for physician 
EDRP recipients was 15.9 percent while the resignation rate for non-
EDRP recipients was 34.8 percent--an 18.9-percent difference. The 
resignation rate for pharmacy EDRP recipients was 13.4 percent while 
the resignation rate for non-EDRP recipients was 27.6 percent--a 14.2-
percent difference.

    A study of the EDRP program retention rates in 2007 showed 75 
percent of pharmacists and nurses who received EDRP awards in 2002 were 
still employed by VA at the end of the initial 5-year period of the 
program's operation. Among physicians, 65 percent were still employed. 
Although a smaller percentage, it represents a substantial retention 
level.
    VHA routinely uses hiring and pay incentives established under 
Title 5 and Title 38. Financial recruitment incentives, retention 
incentives (both individual and group), special salary rates, 
relocation incentives and other incentives are routinely used and 
documented in VHA's Workforce Succession Strategic Plan. Recruitment 
and retention incentives are used to reduce turnover rates and help 
fill vacancies. In Fiscal Year 2007, nearly $24 million in recruitment 
incentives were provided to over 3,150 Title 38 and Title 38 Hybrid 
employees, while more than $34 million in retention incentives were 
given to 5,300 Title 38 and Title 38 Hybrid employees.
Employee Entrance and Exit Survey Analysis
    In 2000, VA began using an electronic database to capture survey 
information from employees entering and exiting VA service. The 
entrance survey is an excellent tool for comparing and contrasting 
reasons the new workforce has come to work for VHA and for determining 
recruitment sources used by candidates (for example, newspaper 
advertisements, employee referrals, online job postings, etc.). The 
exit survey tracks the reasons why staff leaves VHA employment.
    Survey results of 2006 and the first half of 2007 show advancement 
and development opportunities, benefits, and job stability were the top 
reasons to work for VA. VA's mission of serving veterans and pay were 
also highly rated. The exit survey shows the top reasons for leaving 
VHA in FY 2006 and the first half of 2007 were normal retirement, 
advancement opportunities elsewhere, and family matters (marriage, 
pregnancy, etc.). These findings provide valuable insight for 
developing recruitment marketing messages and establishing programs to 
improve retention.
Conclusion
    The Under Secretary for Health has made a personal commitment to 
succession planning and ensuring VHA has a comprehensive recruitment, 
retention, development and succession strategy. This is a continuous 
process which requires on-going modifications and enhancements to our 
current programs.
    I would like to thank the Committee for your interest and support 
in implementing legislation that allows us to compete in the healthcare 
market.

                                 
                   MATERIAL SUBMITTED FOR THE RECORD

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                       June 5, 2008
Honorable James B. Peake, M.D.
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

Dear Secretary Peake:

    Thank you for the testimony of Joleen Clark, Chief Officer, 
Workforce Management and Consulting, Veterans Health Administration, at 
the U.S. House of Representatives Committee on Veterans' Affairs 
Subcommittee on Health hearing that took place on May 22, 2008 on 
``Human Resources Challenges Within the Veterans Health 
Administration.''
    Please provide answers to the following questions by July 17, 2008, 
to Chris Austin, Executive Assistant to the Subcommittee on Health.

    1.  In your statement you reference the VHA's Strategic Plan and 
that it identifies mission-critical occupations which are considered 
shortage categories.

        Could you tell this Subcommittee what are the top three 
mission-critical occupations?
        What initiatives have been undertaken in the past year 
to help alleviate the shortages of these three critical occupations?
        How successful have the initiatives been?

    2.  Let's talk about the hiring process. We know that the 
application process is extremely onerous to a potential employee, not 
to mention it takes months to fill a position.

        For the mission-critical occupations, what is the 
average length of time it takes to fill a position?
        What is the number one reason a potential candidate 
turns down employment with VA?
        What has VHA done to help expedite the hiring process?

    3.  What do you believe is VHA's number one challenge in filling 
shortage positions?

    4.  Regarding the challenges facing VHA with hiring in rural areas. 
You state in your testimony that ``VA is working to integrate rural 
areas into residency rotations, since evidence shows those who serve 
residencies in rural areas are more likely to practice in rural 
areas.''

        How does that program work and who are you working with 
to accomplish that?
        Please tell me how far along VHA is with ``working to 
integrate rural areas into residency rotations?

    Additionally, please answer the following questions for Congressman 
Vic Snyder:

    1.  For each category (i.e. Title 38, Title 5 and hybrid), what is 
the current total cost per hire?

    2.  What are the existing advertising costs?

        What are the total advertising costs per hire?

    3.  What is the total volume of generated leads by source per 
month?

        What is the average hire rate based on that source?

    4.  What are the projected staffing requirements (RN nurse 
positions only) considering existing vacancies, losses due to 
anticipated turnover, and anticipated retirement losses through 2015?

    5.  What is the current cycle timeframe from a commitment to hire 
an application and to actual hire date?

    6.  Would you please rank in descending order the percentage of 
closing of each source (i.e., walk-ins, Internet, phone inquiries, 
billboard, radio, etc.)?

    Thank you again for taking the time to answer these questions. The 
Committee looks forward to receiving your answers by July 17, 2008.

            Sincerely,
                                                 MICHAEL H. MICHAUD
                                                           Chairman

                               __________
                        Questions for the Record
               The Honorable Michael H. Michaud, Chairman
                         Subcommittee on Health
                  House Committee on Veterans' Affairs
                              May 22, 2008
  Human Resources Challenges within the Veterans Health Administration
    Question 1(a): In your statement you reference VHA's Strategic Plan 
and that it identifies mission-critical occupations which are 
considered shortage categories. Could you tell this Subcommittee what 
are the top three mission-critical occupations?
    Response: The top three mission-critical occupations within the 
Veterans Health Administration (VHA) are registered nurses, physicians, 
and pharmacists.
    Question 1(b): What initiatives have been undertaken in the past 
year to help alleviate the shortages of these three critical 
occupations?
    Response: The Department of Veterans Affairs (VA) has undertaken 
several initiatives to help reduce the shortages of mission-critical 
occupations:

      Offering student loan repayment
      Tuition support/scholarship programs
      Special salary rates may be authorized for hybrid, title 
38 and title 5 positions when:

         hiring or retention efforts are likely to become 
significantly handicapped due to factors such as higher rates of pay 
being offered by private sector employers
         the duty station is in a remote location
         the nature of the work or working condition is 
unfavorable (i.e., exposure to occupational or health hazards)

      Retention/Recruitment Incentives (recruitment and 
retention payments provide monetary incentives for individuals to 
accept employment or remain employed in Federal Service) and
      Developmental/promotional opportunities

    Question 1(c): How successful have the initiatives been?
    Response: The initiatives have been successful in reducing turnover 
rates in the top three mission-critical occupations. Since 2002, these 
initiatives have been successful in reducing turnover rates in the top 
three mission-critical occupations. VA has also brought on board more 
employees in these occupations in fiscal year (FY) 2007 than any time 
in the last 10 years and increased the end-of-year onboard head count 
by an additional 968 physicians (6.3-percent increase), 2,449 
registered nurses (6.2-percent increase), and 238 pharmacists (4.8-
percent increase). This is more than double the increase seen in most 
of the previous 10 years for these occupations. VA expects to see a 
larger increase in each of these occupations this year. VA is 
projecting 7.2 percent, 8.7 percent, and 6.2 percent increases for the 
end of FY 2008. This means that our recruiting efforts have been 
phenomenal and our human resources shops have been working incredibly 
hard to bring on the additional physicians, nurses, and pharmacists VA 
needs to fulfill the mission.
    Question 2(a): Let's talk about the hiring process. We know that 
the application process is extremely onerous to a potential employee, 
not to mention it takes months to fill a position. For the mission-
critical occupations, what is the average length of time it takes to 
fill a position?
    Response: After identifying a candidate, the average length of time 
to fill a mission-critical occupation is approximately 10 days (if 
being hired as temporary) to 180 days. There are a number of steps in 
the hiring process that must be completed before a candidate can be 
appointed on a permanent basis. VA performs reference checks and 
credentials are verified through the necessary sources. Title 38 and 
hybrid title 38 candidates must be evaluated by a Professional 
Standards Board, and compensation panels need to recommend pay for 
physicians and dentists. Additionally, preemployment physicals have to 
be performed and candidates have to give proper notice to their 
previous employer.
    Question 2(b): What is the number one reason a potential candidate 
turns down employment with VA?
    Response: Non-competitive salary with the local market is the 
number one reason why a potential candidate turns down employment with 
VA.
    Question 2(c): What has VHA done to help expedite the hiring 
process?
    Response: VHA has several initiatives underway to shorten the 
hiring and review process. The initiatives involve: policy revisions, 
software development, retooling and focusing on streamlining the hiring 
process. VHA is looking at credentialing timelines and background 
investigations. In addition, facilities are undertaking a systems 
redesign process that will focus on improving the staffing process.
    Question 3: What do you believe is VHA's number one challenge in 
filling shortage positions?
    Response: VHA's number one challenge in filling shortage positions 
is the limited supply of medical professions, particularly in 
specialized areas. Private and Federal sectors are competing for hard-
to-fill positions with a limited pool of professionals in certain 
specialties. This makes recruiting and retaining medical professionals 
in these core professions a challenge.
    Question 4(a): Regarding the challenges facing VHA with hiring in 
rural areas. You state in your testimony that ``VA is working to 
integrate rural areas into residency rotations, since evidence shows 
those who serve residencies in rural areas are more likely to practice 
in rural areas.'' How does that program work and who are you working 
with to accomplish that?
    Response: The VHA Office of Academic Affiliations (OAA) oversees an 
extensive portfolio of training programs around the country, 
encompassing over 100,000 trainees per year having clinical experiences 
at VA sites. In recent years, OAA has encouraged and incentivized 
training in rural areas. Over 400 paid trainees (including 125 
physician residents) and over 4,000 unpaid trainees participate in 
training at rural sites. Training programs exist at 22 out of 31 
medical centers that support rural or highly rural markets.
    Through an initiative known as the graduate medical education (GME) 
enhancement program, OAA has funded medical training experiences in 
more remote VA sites. One specific component, New Affiliations and New 
Sites of Care, encourages trainee rotations at community based 
outpatient clinics (CBOC), as well as at other new sites of care. To 
date, OAA has funded over 80 new physician resident positions in 21 
sites through this program; over 13 of these positions have been 
allocated to officially designated rural sites. More than 10 additional 
positions have been awarded to rural locations not officially 
designated as such (Boise, Idaho; Northampton, Massachusetts; and the 
CBOC in Pine Bluff, Arkansas).
    VHA also recognizes the need for more infrastructure support at 
rural sites in order to ensure that residents have an excellent 
educational experience--without which they are unlikely to view rural 
practice in a favorable light. Thus, OAA and the Office of Rural Health 
are currently discussing the feasibility of partnering in order to 
further expand OAA's GME enhancement initiative to include more 
resource support for rural and highly rural hospitals and CBOCs as 
training locations.
    Question 4(b): Please tell me how far along VHA is with ``working 
to integrate rural areas into residency rotations.''
    Response: VHA's efforts to integrate rural sites into training 
programs are still evolving. VA's care initiatives, including new 
affiliations and new sites, are only in the second year of 
implementation. The Office of Rural Health is in the process of 
collaboration with OAA to pursue these initiatives.
                        Questions for the Record
                            Hon. Vic Snyder
    Question 1: For each category (i.e. Title 38, Title 5, and hybrid), 
what is the current total cost per hire?
    Response: VHA does not track the total cost per hire due to the 
complexities of allocating direct and indirect costs of multiple 
staffers involved in the hiring process.
    Question 2: What are the existing advertising costs? What are the 
total advertising costs per hire?
    Response: The Healthcare Recruitment and Retention Office (HRRO), a 
part of the Workforce Management Office, spends approximately $2.5 
million per year on print advertising, collateral materials (brochures, 
flyers, and promotional items), web design and promotion and by 
participating in career fairs, conferences, trade shows and other 
events annually. HRRO also provides local and national VA recruiters 
with valuable tools through its toolkit of developed ads, banners, and 
event displays to promote consistent branding in support of recruitment 
efforts.
    VA does not track the total advertising cost per hire due to 
complexities of properly allocating funds VHA may have expended at the 
local and national level to fill a position.
    Question 3(a): What is the total volume of generated leads by 
source per month?
    Response: VA does not collect data that provides the total volume 
of generated leads by source per month or data that provides the 
average hire rate based on that source; however, based on entrance 
surveys, we know that the number one method applicants find out about 
open positions is through the Internet--employee referral is the second 
source.
    Question 3(b): What is the average hire rate based on that source?
    Response: VA does not track the data that gives the exact breakdown 
as multiple sources could have influenced a new employee to accept a 
position within VA.
    Question 4: What are the projected staffing requirements (RN nurse 
positions only) considering existing vacancies, losses due to 
anticipated turnover, and anticipated retirement losses through 2015?
    Response: Currently, there are an estimated 1,700 vacancies (which 
equate to 10.7 percent vacancy rate) for registered nurses. The 
turnover rate for this fiscal year 2008 has been approximately 5 
percent. Projections for future hires through 2013 are projected at an 
increase of 19 percent from approximately 42,000 to 50,000.
    There is projected to be a loss of 7,600 registered nurses due to 
retirement by the year 2013 or approximately 15 percent over that same 
time period.
    Question 5: What is the current cycle timeframe from a commitment 
to hire an applicant and to actual hire date?
    Response: Generally, it takes approximately 30 to 180 days from a 
commitment to hire an applicant to the actual hire date. Many 
facilities are moving closer to the 30-day timeframe as a result of 
ongoing initiatives.
    Question 6: Would you please rank in descending order the 
percentage of closing of each source (i.e. walk-ins, Internet, phone 
inquiries, billboard, radio, etc.)?
    Response: Based on the 2007 Entrance Survey Results, the following 
sources in descending order represent how a new hire heard about job 
opportunities within VA.

a.

(33.25 percent) VA Internet Job Opportunities Site--www.vacareers.va.gov

b.

(32.38 percent) VA Employee Referrals

c.

(15.34 percent) Other (i.e. friend, veteran, colleague, conference)

d.

(7.92 percent) College or University

e.

(5.71 percent) Newspapers & Magazines

f.

(4.58 percent) Office of Personnel Management Job Notice

g.

(0.68 percent) Career Counselor

h.

(0.13 percent) No Response