[Senate Hearing 110-767]
[From the U.S. Government Publishing Office]
S. Hrg. 110-767
OVERSIGHT HEARING: MAKING VA THE WORKPLACE OF CHOICE FOR HEALTH CARE
PROVIDERS
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
APRIL 9, 2008
__________
Printed for the use of the Committee on Veterans' Affairs
Available via the World Wide Web: http://www.access.gpo.gov/congress/
senate
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COMMITTEE ON VETERANS' AFFAIRS
Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West Richard Burr, North Carolina,
Virginia Ranking Member
Patty Murray, Washington Arlen Specter, Pennsylvania
Barack Obama, Illinois Larry E. Craig, Idaho
Bernard Sanders, (I) Vermont Kay Bailey Hutchison, Texas
Sherrod Brown, Ohio Lindsey O. Graham, South Carolina
Jim Webb, Virginia Johnny Isakson, Georgia
Jon Tester, Montana Roger F. Wicker, Mississippi
William E. Brew, Staff Director
Lupe Wissel, Republican Staff Director
C O N T E N T S
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April 9, 2008
SENATORS
Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........ 1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North
Carolina....................................................... 2
Craig, Hon. Larry E., U.S. Senator from Idaho.................... 3
Prepared statement........................................... 5
Murray, Hon. Patty, U.S. Senator from Washington................. 6
Rockefeller, Hon. John D., IV, U.S. Senator from West Virginia... 36
Tester, Hon. Jon, U.S. Senator from Montana...................... 7
Wicker, Hon. Roger F., U.S. Senator from Mississippi............. 34
WITNESSES
Palkuti, Marisa W., M. Ed., Director, Health Care Retention and
Recruitment Office, Veterans Health Administration, Department
of Veterans Affairs............................................ 7
Prepared statement........................................... 9
Response to written questions submitted by:
Hon. Daniel K. Akaka....................................... 12
Hon. Patty Murray.......................................... 16
Response to questions arising during hearing from Hon. John
D. Rockefeller IV.......................................... 37
Cullen, Sheila M., Director, San Francisco VA Medical Center..... 16
Prepared statement........................................... 18
Response to written questions submitted by Hon. Daniel K.
Akaka...................................................... 20
Response to questions arising during hearing from:
Hon. Daniel K. Akaka....................................... 32
Hon. Roger F. Wicker....................................... 36
Kleinglass, Steven P., Director, Minneapolis VA Medical Center... 21
Prepared statement........................................... 23
Response to written questions submitted by Hon. Patty Murray. 24
Kanof, Marjorie, M.D., Managing Director, Health Care, U.S.
Government Accountability Office............................... 39
Prepared statement........................................... 41
McDonald, John A., M.D., Ph.D., Vice President for Health
Sciences and Dean, University of Nevada School of Medicine, on
Behalf of the Association of American Medical Colleges......... 56
Prepared statement........................................... 57
Response to written questions submitted by Hon. Patty Murray. 63
O'Meara, Valerie, N.P., VA Puget Sound Health Care System,
Professional Vice President, American Federation of Government
Employees Local 3197........................................... 64
Prepared statement........................................... 66
Response to written questions submitted by Hon. Daniel K.
Akaka...................................................... 71
Phelps, Randy, Ph.D., Deputy Executive Director, American
Psychological Association Practice Directorate................. 71
Prepared statement........................................... 74
Response to written questions submitted by:
Hon. Daniel K. Akaka....................................... 77
Hon. Patty Murray.......................................... 80
Strauss, Jennifer L., Ph.D., Health Scientist, Center for Health
Services Research in Primary Care, Durham VA Medical Center,
and Assistant Professor, Department of Psychiatry and
Behavioral Sciences, Duke University Medical Center, on Behalf
of the Friends of VA Medical Care and Health Research (FOVA)... 81
Prepared statement........................................... 82
Response to written questions submitted by Hon. Patty Murray. 84
APPENDIX
Cohen, Harvey Jay, M.D., Walter Kempner Professor and Chair,
Department of Medicine, Director, Center for the Study of Aging
and Human Development, Duke University Medical Center.......... 95
Converso, Ann, RN, President, United American Nurses, AFL-CIO.... 96
Ingoglia, Charles, Vice President of Public Policy on Behalf of
the National Council for Community Behavioral Healthcare....... 98
Marberry, Sara, Executive Vice President, and Anjali Joseph,
Ph.D., Director of Research at The Center for Health Design.... 99
OVERSIGHT HEARING: MAKING VA THE WORKPLACE OF CHOICE FOR HEALTH CARE
PROVIDERS
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WEDNESDAY, APRIL 9, 2008
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 9:35 a.m., in
room 418, Russell Senate Office Building, Hon. Daniel K. Akaka,
Chairman of the Committee, presiding.
Present: Senators Akaka, Rockefeller, Murray, Tester, Burr,
Craig, and Wicker.
OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN,
U.S. SENATOR FROM HAWAII
Chairman Akaka. This hearing will come to order. Good
morning. I welcome everyone to today's hearing.
Health care matters affecting veterans are very important
to this Committee and especially important to me. In recent
years, the Committee has, by necessity, spent much time and
effort delving into the health issues facing veterans today,
including TBI and invisible wounds. The simple truth of VA
health care is that its providers are the real backbone of the
system. If the providers are not present or are there but
unhappy in their jobs, it is likely that the veterans will not
receive the quality care they need and deserve.
The Department of Veterans Affairs faces a dangerous
shortage of health care professionals around the country.
Services for veterans at too many facilities are limited due to
staffing shortages. From nurses to senior executives to
psychologists, VA competes with other health care systems for
employees and too often comes up short.
In a recent publication by the Partnership for Public
Service on employee satisfaction, the Veterans Health
Administration ranked poorly in pay and benefits and in family
support. VHA also rated very low among younger employees.
However, a silver lining from this survey is that VHA has
improved in almost all rankings. So, while there has been
progress, clearly there is still much more to be done.
The task of this Committee and of the Congress is to
provide VA with the resources and tools necessary to enable VA
facilities to attract health care professionals of the highest
caliber. This fiscal year, Congress provided VA with a
significant infusion of funds. It is my expectation that we
will do so again this year for the next fiscal year.
During today's hearing, we will have the opportunity to
examine the tools VA now has and those it might need in the
future to bring in top-notch health professionals. In my view,
VA has the potential to recruit and retain the very best
clinicians. Scholarship programs used effectively could
alleviate student debt burdens. An effective pay system will
allow VA to compete in every labor market. VA operates a world-
class research system that attracts clinicians who seek to push
the boundaries of medical care. These are just a few examples
of the effective recruitment and retention tools at VA's
disposal. We must ensure that they are being fully utilized.
It is my hope that this hearing may lead to more effective
use of existing methods of recruiting the best and brightest
health care professionals to VA and then making sure that they
choose to stay. We also will seek to identify new approaches to
attract health care professionals to VA. Over the past decade,
VA has made tremendous strides in becoming the premier health
care provider for veterans. We must now ensure that VA can
employ premier employees.
I offer a special thanks to our witnesses here today. We
appreciate your taking the time to appear before the Committee
and for your service to veterans.
Now I will call on our Ranking Member, Senator Burr, for
his opening remarks.
STATEMENT OF HON. RICHARD BURR, RANKING MEMBER,
U.S. SENATOR FROM NORTH CAROLINA
Senator Burr. Aloha, Mr. Chairman. Thank you, and I thank
all of our witnesses today for what I think will be some very,
very important testimony.
It goes without saying that if the VA is to continue to
deliver top-notch health care to veterans, then it needs to be
able to attract and retain qualified medical professionals. Of
course, the challenge is that the VA competes for these
professionals in a marketplace where they are high in demand
and short in supply. The Health Resources Services
Administration estimates that in 2020, the nationwide supply of
primary care physicians will be around 270,000, but the need
will be for nearly 340,000. For rural and inner-city areas, we
can't wait until 2020. A shortage already exists today. In
States with growing populations, the problem is particularly
acute. In North Carolina, the provider-to-population ratio is
expected to drop by 8 percent to 19 percent by 2030.
With these numbers, Mr. Chairman, it is imperative that the
VA have the tools it needs to attract and to keep quality
doctors and nurses. This means that pay and benefits need to be
competitive. It also means that scholarship and debt repayment
programs in return for working at the VA need to be fully
utilized. And, of course, it means that a robust research
program at the VA, which has proven to be a powerful enticement
for the brightest of medical minds, needs to be supported.
I am pleased that we will hear today from Dr. Jennifer
Strauss, an Assistant Professor at Duke University Medical
Center's Department of Psychiatry and Behavioral Science, about
how VA research can be strengthened. I think we all look
forward to that testimony.
In addition, Dr. Harvey Cohen, the head of Duke
University's Department of Medicine and a career VA researcher,
has submitted testimony for the record to give the Committee
his thoughts on this subject.
In addition to research, one of the greatest recruiting
tools available to the VA is its noble mission. The job
satisfaction that comes with serving America's veterans is one
all of us on this Committee can attest to and it certainly
exists for those who provide veterans with health care on a
day-to-day basis.
Before I conclude, Mr. Chairman, let me make an important
point that is relevant to today's hearing. There are
approximately 24 million veterans living in America today.
Almost eight million of them are enrolled in the VA health
system. Thus, 16 million veterans currently receive health care
outside the VA system. The national shortage in medical
providers is just as real for these veterans as it is for the
VA patients. Although our primary focus for this hearing is on
the recruitment and retention of VA medical professionals, we
should also be aware of the impact that VA hiring has on the
larger health care system.
For example, VA has hired nearly 3,800 mental health
workers since the year 2005 and may add an additional 500 in
the near future. We need to ask the question, what impact does
this have on the available supply of mental health workers in
the communities both now and over the long term? Relevant to
this point, testimony submitted for the record by Charles
Ingoglia, Vice President of Public Policy for the National
Council for Community Behavioral Healthcare, suggests that VA
hiring is, and I quote, ``exacerbating an existing mental
health workforce shortage and may not meet the long-term
treatment and rehabilitation needs of returning veterans.''
Mr. Chairman, I dare say, something we have talked about on
this Committee is how we get the right amount of treatment as
quickly as we can in the most intense way. In fact, if we have
a medical professional shortage, we will be unable to do that
and treat veterans at the most important time. Mr. Ingoglia
suggests that rather than competing with the community-based
mental health organizations for available workers, VA could,
and I quote, ``pursue a targeted strategy of cooperation and
collaboration through service partnerships,'' unquote. Such
partnerships would have the added benefit of making care
available for veterans in rural communities.
What all this means is that we need to be prepared to take
a comprehensive view of addressing the problems and be prepared
to embrace the solutions that are in the best interest of the
health care of our veterans, wherever they reside.
Mr. Chairman, this is an extremely important hearing. Many
of the decisions that we make from here on out have effects
within the VA system on the direct care received by our
veterans, but also outside the VA system on the care that this
country's other veterans will receive, and the public at large.
I thank the Chair for the time.
Chairman Akaka. Thank you very much. By arrival time, let
me call on Senator Craig for your statement.
STATEMENT OF HON. LARRY E. CRAIG,
U.S. SENATOR FROM IDAHO
Senator Craig. Chairman Akaka, thank you very much, and
Ranking Member Burr, thank you for this hearing today.
I will submit my formal remarks for the record and react to
what Senator Burr has just said. Mr. Chairman, because clearly
we are headed into a time in health care--both for veterans and
non-veteran civilian populations--that is having substantial
stress on the resources available for a variety of reasons:
from desirability of workplace and conditions to pay to lack of
a Medicare system that stays sensitive to the constant needs of
the patient--a combination of things.
One of the things, though, that I find most fascinating
that you have just mentioned, Senator Burr, is that really--
while we may not get there now, we must get there some day, and
that is the idea that these are stand-alone systems and not
effectively integrated. We are doing a little of that today, a
little bit of that.
Senator Murray and I--while I was up in the Lewiston area,
and, of course, Lewiston, ID, and Clarkston and Asotin, WA,
come together right there at a point in geography and
transportation--we are standing up a CBOC that we are going to
open up out there in mid-May. I met with the folks from over in
Walla Walla and they had come over to walk me through it and
show me the work that was being done. But, they are also
contracting services with the local health care providers in
the community for the things they cannot provide that aren't
necessarily needed for travel on into Spokane or over to Walla
Walla. And, of course, that CBOC will serve Clarkston and
Asotin, WA, and Lewiston, ID.
That is really the kind of integration that we have got to
get at, the idea that we create bricks and mortar and walls,
but we don't have a payment system that shows some flexibility.
I have talked about that over time. Yesterday, I had a group of
young veterans in my office. All of them have served in Iraq
and Afghanistan and most of them live in rural Idaho. And they
said, ``Senator Craig, why can't we have a VA health card? Why
can't we have a card that allows us to go to our local
providers to get the service we need instead of traveling the
200 to 500 miles that you are now requiring us to travel to get
the health care that we are entitled to have?''
And again, I understand that, but as you know, as a Member
of this Committee longstanding, I have also argued that in the
dynamics of health care into the future, that the bricks and
mortar and the walls and the structures we have created, while
they have served us phenomenally well, may not serve us as well
if our focus is service to the veteran, access to health care,
period--access to health care--not the health care we define
you are eligible for within that structure and that building.
To me, that makes a great deal of sense, and when we talk
about the problems that you and Senator Burr have talked about,
we have got a marvelous system today. Again, VA gets top
ratings. The New England Journal of Medicine has just put us on
top again: access; quality; all of those kinds of things in
general. And yet a million nurses are talked about now, a near
shortage of a million nurses in the near future, 25,000
physicians by 2020. Why should health care systems be
competing? Should they not be complementing? I think that is
going to be our greater challenge in the out years as we put
money into this system to do so.
And, of course, as you know, I have to get in my
traditional punch. If we expand, if we are not focused on the
disabled and the poor of the VA system and we go to Priority 8s
and we add 1.4 million more to the system, from the standpoint
of eligibility, then the numbers we are concerned about today
simply go up. The demand goes up. And ought there not be a
greater way for us to provide for our veterans in the out
years, and looking at it in the modern sense that we may not be
looking at it today. We are still dedicated--and I have no
criticism of that--but to the bricks and mortar we have built
down through the years. But it isn't serving our veterans
across America as well as it should.
So, yesterday, I had that reality when that veteran held up
his hand and said, ``Senator, why can't I have a VA health card
that allows me to get my services in Salmon, Idaho, or in
Pocatello or somewhere in rural Idaho that provides quality
health care that has an association with the VA system?'' I
said to him, smile, work at it, become an advocate of it. Work
with your service organizations, because they, too, are stuck
in the tradition of supporting what we have instead of where we
ought to go.
Thank you very much.
[The prepared statement of Senator Craig follows:]
Prepared Statement of Hon. Larry E. Craig, U.S. Senator from Idaho
Chairman Akaka, Thank you for calling this hearing today. I just
want to make a few comments.
One thing that I cannot do often enough is to commend VA for the
excellent health care they provide for our veterans. In studies by
various well-respected publications, including the New England Journal
of Medicine, VA has outperformed Medicare and private insurance in
quality of care.
A key component of maintaining the high quality of VA health care
is recruiting and retaining a dedicated staff. However, we are also
facing a shortage across the country in many health care professions--
including physicians, nurses, and a variety of sub-specialties. A July
2007 report from the Health Research Institute of
PricewaterhouseCoopers found that the United States will be short
nearly one million nurses and 24,000 physicians by 2020. Specifically,
in my home State of Idaho we are grappling with a shortage of primary
care physicians to treat individuals living in rural areas. In the
midst of this nationwide shortage, VA must also continue to raise its
profile among potential health care professionals to recruit a quality
staff in order to maintain its stellar reputation as a health care
system. This is no small challenge.
I want to take this opportunity to point out that this is one of
the reasons why I am opposed to allowing Priority 8 veterans into the
VA health care system. While I think VA recognizes the need to
aggressively recruit health care professionals, we also need to be
realistic. We are being confronted with a nationwide shortage and if VA
is having recruitment challenges now, adding upwards of 1.4 million
individuals to the patient population would only exacerbate this
problem.
VA needs to continue to focus its health care delivery on our
disabled veterans.
With that being said, I want to commend VA on the excellent
workplace environment it has created and I look forward to hearing from
our witnesses about how they are addressing recruitment challenges.
Chairman Akaka. Thank you, Senator Craig.
Senator Murray?
STATEMENT OF HON. PATTY MURRAY,
U.S. SENATOR FROM WASHINGTON
Senator Murray. Thank you, Chairman Akaka, Senator Burr,
for holding this hearing on the recruitment and retention of
health care professionals in the Veterans Health
Administration. I look forward to the testimony from our
distinguished members of both panels. I especially want to
extend a welcome to Valerie O'Meara. She has traveled here
across the country to testify in front of us today as a nurse
practitioner from the Seattle VA Center. As I have said many
times, Mr. Chairman, our VA staff are some of the most caring
and compassionate people I know. They work hard. They are smart
and very caring. They understand the needs of the veteran
population that they serve; and they are critical as we see so
many returning veterans coming home today, as well as veterans
of previous wars. I appreciate the great job all of you and
your coworkers do.
Mr. Chairman, the doctors and nurses and mental health care
providers and many health care professionals who work at the VA
are the reason that the VA can stay true to its mission and to
provide the best quality of care anywhere. But, as the topic of
your hearing suggests today, the VA faces significant hurdles
as it tries to recruit and retain the kind of high-quality
health care professionals that the Department relies on to
serve the veterans today. So, I am very pleased, Mr. Chairman,
that we are holding this hearing to explore VA's workforce
needs.
I really think we have to get to the heart of this issue
and explore our options, not only to improve working conditions
for our current VA employees, but to ensure that the VA can
compete with the private sector and recruit the best and
brightest professionals. In order to do that, we have a lot of
work ahead of us because there are a number of challenges to
overcome.
The VHA employment process is overly complicated and takes
far too long. The VA doesn't pay health professionals as well
as the private sector does. Education and training
opportunities for workers have to be updated and revamped.
So, Mr. Chairman, I emphasize this hearing is not only
about the ways we can become more competitive as we recruit new
people into the VHA system, it is about retaining our current
employees, as well. And along that line, I am very concerned
that a recent study by the Partnership for Public Service found
that job satisfaction among VHA employees under the age of 40
is very low. If the VA is going to continue to provide the best
quality of care anywhere, that has to change.
So, Mr. Chairman, I look forward to hearing from the
witnesses today as we begin to address this issue. I do have
another hearing at the same time as this hearing, so I am going
to miss the first panel and their testimony, but my staff will
be here and I will be back for the second panel. I think this
is an extremely important topic, Mr. Chairman, and I thank you
for exploring it today.
Chairman Akaka. Thank you very much, Senator Murray. As you
know, Senator Murray plays a huge role on Veterans' Affairs,
and, of course, she is on the Appropriations Committee. We work
very well together in trying to get things done for veterans.
Thank you very much, Senator Murray.
I want to now welcome our witnesses from the Department of
Veterans Affairs. I appreciate your being here today and look
forward to your testimony. Will you please be seated.
First, I welcome Marisa Palkuti, Director of the VHA Health
Care Retention and Recruitment Office. I also welcome Sheila
Cullen, Director of the San Francisco VA Medical Center; and I
also want to welcome Dr. Wiebe, who I see here in the room.
Welcome and aloha, Dr. Wiebe, for being here today. Finally, I
welcome Steven Kleinglass, Director of the Minneapolis VA
Medical Center.
I want to thank all of you for joining us today. Your full
statements will appear in the record of this Committee.
Ms. Palkuti, please begin after I ask Senator Tester
whether he has any statement to make at this point in time.
STATEMENT OF HON. JON TESTER,
U.S. SENATOR FROM MONTANA
Senator Tester. Well, thank you, Mr. Chairman. That is very
gracious of you. I am sorry about being late.
I just want to tell you that from a Montana perspective,
recruitment and retention of our health care officials and our
support staff is really important. I have been around to most
of the veterans' facilities in the State of Montana, done some
public hearings and heard from veterans throughout the State
and I can tell you the one comment that I hear repeatedly is a
lack of staff.
I look forward to your statements. I really want to hear
what we are doing as far as recruitment and retention bonuses,
those kind of things, to get people on board. I have been told
by some of the health care professionals that the VA cannot pay
what the private sector is paying for health care folks. I
don't know what the thought process was there--whoever made
that rule--but, it is wrong-headed thinking. I think if we are
going to get the best people to take care of our veterans in
this country, we have got to be competitive; and if we start
out from a standpoint that we cannot meet basic wages, I think
it reduces the employment pool right out of the chute. And our
potential for keeping these people dwindles pretty quickly,
because they see what the opportunities are out in the private
sector.
So, your statements today are going to be critically
important. I will tell you that most of my questions are going
to revolve around recruitment and retention and how we can do a
better job and how I can help you do a better job in this
process.
So, with that, thank you, Mr. Chairman. I appreciate the
opportunity.
Chairman Akaka. Thank you very much, Senator Tester.
At this time, we will hear from Ms. Palkuti.
STATEMENT OF MARISA W. PALKUTI, M. ED., DIRECTOR, HEALTH CARE
RETENTION AND RECRUITMENT OFFICE, VETERANS HEALTH
ADMINISTRATION
Ms. Palkuti. Mr. Chairman and Members of the Committee,
thank you for the invitation to appear before you. I am honored
to be here today to share VA's ongoing efforts and challenges
to develop innovative and aggressive approaches to addressing
recruitment and retention of our health care workforce. My full
testimony will be in the record, so I will highlight a few of
the things that we are working on.
An informal study conducted of all VA facilities in 2007
revealed that 74 percent of the 800 psychologists hired over
the past 3 years received some training in professional
psychology at VA. This year, the office's academic affiliation
and patient care services have significantly expanded VA's
psychology training programs in anticipation of the ongoing
need for VA psychologists as well as psychologists to practice
in the community.
In an effort to initiate proactive strategies and aid in
the shortage of clinical faculty in nursing schools, VA has
launched the VA Nursing Academy to address the nationwide
shortage of nurses. Four partnerships were established in the
2007-2008 school year and four additional partnerships will be
selected each year in 2008 and 2009 for a total of 12
partnerships.
We have launched the VA Travel Nurse Corps, which is an
exciting new program establishing an internal pool of
registered nurses who can be available for short-term temporary
travel assignments in VA and centers throughout the country,
including rural care.
We have a multitude of student programs that have been
instrumental in helping VA meet its workforce needs. These
programs include the VA Learning Opportunities Residency
Program for baccalaureate prepared nurses and doctoral prepared
pharmacists--student career experience programs. We have
established a database for our interns and students so that we
can track them and use them as a better applicant pool for our
future needs.
We have a Graduate Health Administration training program
for practical work experiences for recent graduates of health
care administrative master's programs for hospital leadership.
We have a Technical Career Field Program. It is an entry-level
program designed to fill vacancies in fields such as budget,
finance, HR, engineering, and others where VA knows that there
is a critical need and VA-specific knowledge is necessary.
And we realize that our hiring process is cumbersome. This
spring and summer, we will be training medical center
leadership in human resources and systems redesign at a series
of human resources cluster meetings around the country.
My office works at the national level to promote
recruitment branding and provide tools and resources and other
materials to support both national and local recruiting
efforts. Some of the features we have recently integrated, our
VHA Internet Job Board with USA Jobs. We have done a complete
revision of that tool. We use Public Service Announcements,
online advertising, print advertising. We have a tool kit for
recruiters across the country to tap into our resources. We
have established National Recruitment Advisory Groups.
As highlighted already, we developed a very comprehensive
recruitment and marketing plan for mental health professionals
using the strategies mentioned above as well as a number of
financial incentives. Among the financial incentives, our
Employee Incentive Scholarship Program will pay up to $35,900
for academic and health care-related degree programs. We
currently have authorized over 7,200 scholarships to VA
employees and have over 4,000 graduates, closer to 4,300 at
this point. It shows through analysis that we also have
positive retention outcomes for that program.
Our Education Debt Reduction Program provides a tax-free
reimbursement of educational loans for clinical employees, and
as of March 31, we had authorized over 6,400 awards under the
Education Debt Reduction Program.
There is routine use of other financial incentives--
recruitment incentives, retention incentives, relocation
incentives, and special salary rates. And in fiscal year 2007,
we spent over $24 million in recruitment incentives nationwide
for over 3,150 employees in title 38 and hybrid occupations,
and over $34 million in retention incentives to 5,300 of our
clinical employees.
Regarding the physician pay bill, we truly believe that
this legislation has helped us to recruit and retain
physicians.
Our agency has one of the best and most comprehensive
workforce strategic plans in government. We have been
recognized by the Office of Personnel Management as a Federal
best practice. We have a commitment, a strong commitment, to
succession planning and ensuring that VA has a comprehensive
recruitment, retention, and development strategy for the
agency.
I would like to thank the Committee for their interest and
support in implementing legislation that allows us to compete
in an aggressive health care market, and Mr. Chairman, that
concludes my oral statement. I will be pleased to respond to
any questions.
[The prepared statement of Ms. Palkuti follows:]
Prepared Statement of Marisa W. Palkuti, M. Ed., Director, Health Care
Retention and Recruitment Office, Veterans Health Administration,
Department of Veterans Affairs
Mr. Chairman and Members of the Committee, Thank you for the
invitation to appear before you today to discuss the Department of
Veterans Affairs (VA), Veterans Health Administration (VHA) recruitment
and retention programs, work schedules, and other issues related to
creating a compassionate, qualified and diverse workforce of health
care professionals. As the Nation's largest integrated health care
delivery system, VHA's workforce challenges mirror those of the health
care industry as a whole. This country is in the midst of a workforce
crisis in health care and VHA experiences the same pressures as other
health care organizations. VHA performs extensive national workforce
planning and publishes a VHA Workforce Succession Strategic Plan
annually. As part of this process, workforce analysis and planning is
conducted in each Veterans Integrated Service Network (VISN) and
national program office and then is rolled up to create a national
plan. VHA's strategic direction addresses current and emerging
initiatives including recruitment and retention, mental health care,
polytrauma, Traumatic Brain Injury, and rural health to address
workforce efforts. I am honored to be here today to share VHA's ongoing
efforts and challenges to develop innovative and aggressive approaches
to addressing recruitment and retention of our professional health care
workforce.
efforts to recruit health care professionals
There is a growing realization that the supply of appropriately
prepared health care workers in this country is inadequate to meet the
needs of a growing and diverse population. This shortfall will grow
exponentially over the next 20 years. This situation exists for various
reasons. Enrollment in professional schools is not growing fast enough
to meet the projected future demand for health care providers. The
American Association of Colleges of Nursing has reported that more than
42,000 qualified applicants were turned away from nursing schools in
2006 because of insufficient numbers of faculty, clinical sites,
classroom space and clinical mentors. The availability of academic
programs to provide employees to meet qualification standards in other
health care occupations is being experienced in many other health care
occupations.
More than 100,000 health professions 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 that, overall,
following completion of VA learning experiences, trainees were twice as
likely to consider VA employment as before the experience. This
demonstrates that many trainees were not aware of VA employment
opportunities or the quality of VA's health care environment prior to
VA training but became considerably more interested after VA clinical
experiences.
An informal survey conducted of all VA facilities in 2007 revealed
that 74 percent of the 800 psychologists hired over the last 3 years
received some training in professional psychology through VA. This
year, the 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.
HRRO has produced a new recruitment brochure titled ``From
Classroom to Career'' that is targeted at and distributed to VA
trainees. The Office of Academic Affiliations in VA Central Office
emphasizes recruitment of trainees in interactions with education
leaders in the VA facilities. The Human Resource Committee of the VHA
National Leadership Board has raised the trainee recruitment issue to a
high priority and has included it as an important element of their
strategic plan.
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 purpose of the Academy
is to expand the number of nursing faculty in the 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.
VA Travel Nurse Corp is an exciting new program establishing an
internal pool of registered nurses (RNs) who can be available for
temporary, short-term assignments at VA medical centers throughout the
country. The VA Travel Nurse Corps meets nurses' needs for travel and
flexibility while meeting VA medical center needs for temporary top
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 considering leaving
the VA system; and to establish a potential pool of Registered Nurses
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 have been instrumental helping meet VA workforce
succession needs. These programs include the VA Learning Opportunities
Residency (VALOR) Program, the Student Career Experience Program
(SCEP), and the Hispanic Association of Colleges and Universities
Internship Program (HACU). VALOR is designed to attract academically
successful students of baccalaureate nursing programs and pharmacy
doctorate programs to work at VA. 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,
the pharmacy component was added in 2007 to address VA's need for
pharmacists. 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
Data base for Interns (VANDI) is a newly designed database developed to
track students in VA internship/student programs to create a qualified
applicant pool.
The Graduate Health Administration Training Program (GHATP)
provides practical work experience to students and recent graduates of
health care administration masters programs. GHATP residents and
fellows are competitively selected and upon successful completion of
the programs are eligible for conversion to a VA health system
management. The Technical Career Field (TCF) program is an entry level
program designed to fill vacancies in technical career fields (Budget,
Finance, Human Resources, Engineering, etc) 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 based on the changing needs of the workforce. Annually, the
target positions and number of intern slots are determined based on
projected workforce needs.
streamlining the hiring process
It is well known that the Government hiring process is cumbersome.
Last year, VA's Human Resource Committee chartered a workgroup 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. The recommendations
were piloted in Network 4 (Pittsburgh, PA) with the implementation and
results of the pilot rolled out nationwide. This spring and summer,
training in systems redesign will be offered nationally at Human
Resources Cluster meetings. At these sessions, we will focus on new
strategies and systems redesign elements that can be used to help meet
the daily challenges of attracting and retaining critical health care
professionals.
VA has direct appointment authority for several Title 38
occupations, including physical therapists. We recognize that the
physical therapist occupation is a key to the rehabilitation of
returning veterans and VHA is working with the Office of Human
Resources Management (OHRM) in the development of a new qualification
standard. The new standard is in the final stages of approval and it is
expected it will be implemented later this year.
national recruitment/media marketing strategies
VHA Health Care Retention & Recruitment Office (HRRO) administers
national programs to promote national employment branding with VHA as
the health care 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.
Results of recent marketing studies for nursing and pharmacy have
been the driving force to implementing many of our successful campaigns
as I will discuss. HRRO works at the national level to promote
recruitment branding and provide tools, resources, and other materials
to support both national branding and local recruiting. Some of these
features are:
The recent integration of VHA recruitment Web site
(www.VACareers.va.gov) with USAjobs (www.USAjobs.opm.gov) provides
consolidated information on careers in VHA, job search capability, and
information on Federal employment pay and benefits information.
Public Service Announcements (PSA) promote the ``preferred
health care employer'' image of VHA. PSA's emphasize the importance and
advantage of careers with VA and focus on the personal and professional
rewards of such a career.
Online advertising through a comprehensive web advertising
strategy, VA job postings are promoted on commercial employment sites
(CareerBuilder, Healthecareers, Google, etc.) and online health
information networks that expand our reach to over 5,000 discrete web
sites. The strategy includes banner advertising that drives traffic to
the VACareers web site for employment information. This advertising
results in over 100,000 visits to the VA recruitment web site each
month.
Print advertising includes both direct classified
advertising and national employment branding. The national program
provides ongoing exposure of VA messaging to potential hires with the
intent to promote VA as a leader in patient care. VHA print advertising
reaches over 34 million potential candidates.
VHA Health Care Recruiters' Toolkit, a unique virtual
community internal to VHA is an online management program that
coordinates national and local recruitment efforts for health care
professionals. The toolkit serves as a resource by providing available
recruitment tools, materials, ads, 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 embark address recruitment and retention.
In fiscal year 2007, HRRO developed a comprehensive
recruitment marketing plan for mental health professionals using
strategies mentioned above as well as financial recruitment incentives.
Funding was earmarked for Mental Health Enhancement Initiative (MHEI)
Education Debt Reduction Program (EDRP) positions. As of March 31,
2008, awards were made to over 100 participants. The total payout for
these participants is $4,394,671 over the 5-year service obligation
period. The average total award is $35,157.
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 health care-
related degree programs. Since the program began in 1999, approximately
7,200 VA employees have received scholarship awards for academic
education programs related to title 38 and Hybrid title 38 occupations.
Approximately 4,000 employees have graduated from their academic
programs. Scholarship recipients include registered nurses (93
percent), pharmacists, and many other allied health professionals.
Focus group market research shows that 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 VA's equivalent to the Student Loan
Repayment Program (SLRP) sponsored under Office of Personnel Management
(OPM) regulations. The maximum award amount is capped at $48,000 due to
the budget, but carries an added value because of the tax exempt status
of the award. As of March 31, 2008, there were over 6,400 health care
professionals participating in EDRP. The average amount authorized per
student, for all years, is $18,392. The average award amount per
employee has increased over the years from over $13,500 in fiscal year
2002 to over $29,000 in fiscal year 2008 as education costs have
increased. While employees from 34 occupations participate in the
program, 75 percent are from three mission critical occupations--
registered nurse, pharmacist and physician. Resignation rates of EDRP
recipients are significantly less than non-recipients as determined in
a 2005 study.
VHA routinely uses hiring and pay incentives established under
Title 5, extended by the Secretary to title 38 employees. There is
routine use of financial recruitment incentives, retention incentives
(both individual and group), special salary rates, relocation
incentives and other incentives as documented in VHA's Workforce
Succession Strategic Plan. Recruitment and retention incentives are
other strategies used to reduce turnover rates and help fill vacancies.
In fiscal year 2007, nearly $24 million in recruitment bonuses were
given to over 3,150 title 38 and title 38 Hybrid employees. Over $34
million in retention bonuses were given to 5,300 title 38 and title 38
Hybrid employees.
The implementation of the physician pay legislation (Public Law
108-445) has been very successful for VHA. The pay of VHA physicians
and dentists consists of three elements: base pay, market pay, and
performance pay. Since the implementation of the pay bill and the end
of February 2008, we have increased the number of VA physicians by over
1,430 FTEE. We believe the legislation has helped VHA's ability to
recruit physicians and dentists. Also as a component of this
legislation, the Chief Nurse of VHA has the discretionary ability to
set Nurse Executive Pay to ensure we continue to successfully recruit
and retain nursing leaders.
VHA's workforce plan is one of the most comprehensive in government
and has been recognized by OPM as a Federal best practice. VA presented
at other Federal agencies and the OPM Conference, ``A Best Practice
Leadership Form on Succession Management'' as well as being featured on
the February 2008 edition of Government Executive, in the article ``VHA
Grooms a Younger Generation to Ride out the Retirement Wave.''
This year, VHA will benchmark its succession planning/developmental
programs against private industry health care and other organizations.
This will ensure that VHA is being as proactive as possible to meet the
Administration's future needs and ensure that we have the right people
in place at the right time. VHA has made a 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.
We want to thank the Committee for their interest and support in
implementing legislation that allows us to compete in the aggressive
health care market.
Mr. Chairman, that concludes my statement. I am pleased to respond
to any questions you or the Subcommittee members may have.
______
Response to Written Questions Submitted by Hon. Daniel K. Akaka to
Marisa W. Palkuti, M. Ed., Director, Health Care Retention and
Recruitment Office, Department of Veterans Affairs
Question 1. Committee oversight activities have made clear the
challenges in providing nurses with sufficient pay. How does VA deal
with compression of nurse salary grades?
Response. The Department of Veterans Affairs (VA) is experiencing
the kinds of workforce challenges every other health care organization
faces. VA's Nursing Service has implemented a number of provisions to
offset the challenges salary compression creates, including the
following:
Nurse locality pay schedules have been adjusted to
minimize the impact of salary grade compression by establishing pay
schedules with up to 26 steps, instead of the usual 12 steps.
Special pay bands have been established by facilities for
each nursing specialty, including clinical nurse specialists, certified
registered nurse anesthetists, nurse practitioners, and administrative
nurses.
Nurse managers are given two additional pay steps when
they assume clinical leadership roles.
Public Law (Pub. L.) 108-445, Physician Pay, provided VA a
comprehensive way to offer flexible compensation packages to nurse
executives. VA is authorized to grant special pay rates of $10,000 to
$25,000 per year to the nurse executive at each VA medical center, and
to nurse executives in VA Central Office Nursing Service based on the
scope and complexity of the nurse position; the nurse executive's
personal qualifications; the characteristics of the health care
facility, and demonstrated recruitment and retention difficulties.
Facilities have the discretion to use other tools,
including recruitment and retention incentives, relocation assistance,
educational support, and student loan reimbursement to relieve pay
compression.
Question 2. GAO has suggested that VA managers need better training
in the conduct of locality pay surveys. VA concurred with this
recommendation. What action has VA taken as of this time?
Response. Public Law 106-419 enabled VA facilities to use third
party salary surveys rather than VA-conducted surveys whenever
practicable. The use of third party survey data is VA's preference in
administering the locality pay system.
As a result, VA's Office of Human Resources Management (OHRM) has
focused on training managers in accessing the appropriate salary data
for a particular situation. When current data is unavailable from the
Bureau of Labor Statistics, facilities must use available third-party
data. When third party data is not available then VA-conducted surveys
are used, but only as a last resort. To assist facilities in conducting
surveys, a Web-based training module on VA-conducted surveys is
expected to be available by late summer 2008.
On-going training and education on administering the nurse locality
pay system includes a monthly national conference call targeted to
nurse executives and human resource managers. Topics of discussion
included how to obtain salary data; how to expand the local labor
market to capture effective survey data; additional pay authorities
available to facility directors; and sharing of ``best practices'' used
throughout the country. OHRM worked with the Veterans Health
Administration (VHA) to provide nurse locality pay training to more
than 80 interns in 2007.
OHRM will conduct a training session at a VA Health care Recruiters
Conference, to be held in the summer of 2008. The session will be
titled, Obtaining Salary Survey Data to Develop an Effective
Recruitment/Retention Program. Participants in the conference include
VA human resources management community, nurses, and other health care
recruiters. In addition, OHRM conducts technical review of all Locality
Pay Schedules (LPS) and special salary rate schedules at the Central
Office level, and provides appropriate direction and guidance.
VHA's Workforce Management and Consulting Office and the
Department's Strategic Human Resource Advisory Council are holding
cluster conferences in the summer of 2008, at which pay, flexibilities,
salary data, and special schedules will be discussed.
OHRM is also conducting market research to determine if a
contractor could provide a single source of third party salary survey
data for each VA facility. A request for information will solicit
contractors to submit information regarding their salary survey
products, processes and availability; a statement of work will be
created and posted for contract bidding if market research reveals a
potential salary survey product. If a contractor is available, VA would
be able to centrally identify appropriate job matches and ensure
consistency in the interpretation of salary data.
Question 3. Which VA medical centers, if any, do not conduct
locality pay surveys, and what is the rational for such inaction?
Response. There is a mandatory requirement for VA facilities to
collect salary survey data whenever the facility director determines a
significant pay-related staffing problem exists or is likely to exist.
Only when current Bureau of Labor Statistics or third party data is
unavailable may a facility conduct its own salary survey.
Facility directors have the discretion to collect appropriate
survey data at any time, and as often as necessary, to maintain
competitive rates of pay.
Title 38 U.S.C. 7451(e)(4) requires each facility director to
provide the Secretary an annual report on staffing for covered nurse
positions. This report is sent to the Senate and House Committees on
Veterans' Affairs. OHRM reviews each report to ensure salary survey
data is collected when specific criteria indicates that a pay-related
staffing problem exists, or is likely to exist. In the most recent
report dated October 2, 2007, only 24 (3.3 percent) of VA's 717
locality pay schedules met the criteria for the mandatory collection of
survey data. The 24 schedules required mandatory review at 21 different
VA facilities. As required by policy, those 21 facilities initiated the
appropriate collection of salary survey data within the required 90-day
timeframe, and those results were included in our report to Congress.
Question 4. There are over 700 locality pay schedules used by VHA.
While locality pay surveys and policies are set at the local level, the
VA Central Office is charged with overseeing the system. Do you believe
the current system is an efficient and effective method to address
geographically-related pay issues?
Response. VA's nurse locality pay system is unique. Unlike other
pay systems in the Federal Government, the nurse locality pay system
enables VA officials throughout the country to establish and adjust
nurse pay rates based on local survey data. This authority enables
facility directors to quickly respond to compensation trends within
specific local labor markets in order to maintain competitive rates
needed to recruit and retain high quality nursing staff. Nurse locality
pay continues to be an effective pay system to address geographically-
related pay issues.
Question 5. Education incentive programs have the potential to
improve recruitment and retention, but current average awards are out
of step with the cost of education. Can this program be adjusted to
better reflect the cost of education, and to better match the goals of
VHA and individual employees?
Response. VHA's educational incentive programs have statutory
limitations that are adjusted annually by the amount of the General
Schedule pay increase. The newly adjusted statutory award cap for the
Education Debt Reduction program (EDRP) is just over $50,000, based on
the General Schedule increase in January 2008. While the program is
generously funded at $15 million per year, there is not enough funding
to provide EDRP awards to every new hire with student loans. Priorities
and funding amounts are therefore established to enable VHA to make
awards to the largest number of individuals possible given budget
constraints and mission requirements. The average award is not entirely
reflective of the actual awards authorized to employees. Many
participants are authorized to receive reimbursement for their entire
loan. If the award is small, it can reduce the average of the total
award amounts. From fiscal year 2006 to fiscal year 2008, 40 percent of
the participants were authorized the maximum award. For fiscal year
2006 and fiscal year 2007 the maximum award was capped within VHA at
$38,000. In fiscal year 2008 the award cap was increased to $48,000.
This fiscal year, EDRP awards range from a low of $621 to the VHA
budgetary cap of $48,000.
We are seeing increases in the levels of debt new hires have
accumulated when they enter on duty. Many of these individuals have
educational loans in excess of $100,000. While the EDRP program doesn't
retire the complete debt, it makes a substantial contribution to
retiring student loans. Because EDRP awards are tax free, the financial
benefit to the individual extends beyond the actual value of the award.
In addition to EDRP, employees may participate in an additional
Federal program designed to retire student educational debt. Through
Section 401 of the College Cost Reduction and Access Act, (Pub. L. 110-
84), public service employees are eligible to have their student loans
forgiven after 10 years of service. This program can be used in
addition to an EDRP award.
Question 6. How are funds distributed for EDRP--at the national
level, or through each facility, or by another modality?
Response. Funds for EDRP are established through VHA's National
Leadership Board and allocated by the national VHA Health care
Retention and Recruitment Office (HRRO) to all Veterans Integrated
Service Networks (VISNs). Allocations are made proportionately based on
each VISN's total number of title 38 and Hybrid title 38 employees; the
previous year's usage, and other special need programs such as the
mental health enhancement initiative and the polytrauma rehabilitation
center start-up. Funds are allocated at the beginning of the fiscal
year to the VISNs. VISNs in turn allocate resources to the facilities
in its networks. HRRO staff monitors the funding on a weekly basis to
ensure that award funding can be redistributed between VISNs as
necessary throughout the year.
Question 7. Almost 4 years ago, Congress enacted sweeping reforms
of the physician and dentist pay system. At the time, VA was spending
huge sums on high-cost specialty care contracts. How much is VA still
spending on specialty care contracts, and have more physicians and
dentists been attracted to VA?
Response. The annual report to Congress on the pay of physicians
and dentists in VA (Pub. L. 108-445) delivered December 2007, provides
an in-depth analysis of VA's reduction in physician and dentist
contracts. From fiscal year 2006 to fiscal year 2007, $5.6 million in
contract dollars were saved for physician services. Since the new pay
system has been implemented, VA has seen a 10 percent increase in the
number of physicians it has hired.
Question 8. The quality of workplace facilities plays a significant
role in patient and staff satisfaction, from lighting to sound
abatement. What steps has VA taken to modify facilities to improve
patient and staff quality-of-life?
Response. Transforming Care at the Bedside (TCAB) is a national
project designed to transform care processes for ongoing improvement in
medical/surgical units. These transformations are accomplished by
engaging and empowering nurses and managers to identify needed changes;
rapidly conducting small tests of potential solutions or improvements
and determining whether changes should be implemented. As a result,
nurses on TCAB units report measurable improvements in work unit
vitality, patient safety and the efficiency with which the unit
delivers care, and the patient centeredness of the care delivered.
Some results of what TCAB has accomplished include:
Nine TCAB pilots units have gone 5 successive months or
more without a need for a full resuscitation code;
Three TCAB pilot units have gone 6 successive months
without patients having moderate or severe harm resulting from falls;
Average turnover rates for registered nurses on the TCAB
pilots units at all TCAB sites dropped from 5.8 percent in 2003 to 3.4
percent in 2006 (58 percent
decrease);
The percentage of time registered nurses spent in direct
patient care at TCAB hospitals increased from approximately 40 percent
in 2004 to greater than 50 percent in 2006;
Improved patient satisfaction with nursing care and with
all care;
Increased percentage of licensed nurse time in direct
patient care;
More self-accountability tools for patients to take
control of their own health; and,
More interdisciplinary focus on care planning.
TCAB projects were funded by the Robert Wood Johnson Foundation.
The work was initiated by the Institute for Health care Improvement and
involved 13 U.S. hospitals, including the Tampa VA Medical Center
(VAMC). The project has been expanded by the American Organization of
Nurse Executives to work with 68 hospitals nationwide, including
Central Arkansas Veterans Health Care System, Greater Los Angeles
Health care System, San Francisco VAMC and Zablocki VAMC in Milwaukee.
VA facilities have accomplished ward renovation projects to ensure
patient satisfaction. Doors, floors, and ceilings have been replaced as
a result of environment of care inspections. Complaints from staff and
patients about parking are being addressed at some facilities by
leasing additional parking or initiating parking garage projects.
Other strategies for workplace improvement include ongoing
supervisory, managerial, and executive training; educational and
mentoring programs for staff throughout the system, and initiatives to
improve workplace culture.
VHA managers and employees formulate action plans based on
information gathered in the annual Patient Survey and the All Employee
Survey. This analysis is a proactive approach to improve worker and
patient quality-of-life at facility and work unit level.
These projects provide an excellent opportunity for nurses within
VA to redesign care processes emphasizing nurse empowerment and process
improvement. Information and lessons from these projects can improve
the process and outcomes of delivering care for veterans.
Question 9. VA has the authority to assign a range of personnel to
alternative work schedules. Alternative work schedules have been
demonstrated to improve employee satisfaction. How does VA use these
schedules to improve recruitment, retention, and employee satisfaction?
Response. VA encourages facility managers to use alternate work
schedules for all eligible employees whenever feasible. This includes
compressed and flexible work schedules as well as alternate work
schedules that pertain only to registered nurses. As authorized by Pub.
L. 108-445, the use of the 36/40 work schedule and the 9-month/3-month
work schedule are available for registered nurses when managers
determine that such schedules are needed to be competitive in the local
markets. The use of alternate work schedules increases VA's visibility
as the employer of choice.
______
Response to Written Questions Submitted by Hon. Patty Murray to Ms.
Palkuti, Mr. Kleinglass and Ms. Cullen
alternative work schedule
Question. Can you all please explain why the VA is not using
Alternative Work Schedules more often?
Response from Ms. Palkuti on behalf of all. VA encourages facility
managers to use alternate work schedules for all eligible employees
whenever feasible. However, this legislation is discretionary; the law
provides the direction for establishing alternate work schedules.
Facilities are not mandated to use the alternate work schedules. There
are multiple types of alternate work schedules and many VA facilities
use at least one option of alternate work schedules for nursing staff
in order to provide attractive and competitive work hours and, to meet
staffing requirements. Individual facilities may choose to offer the
alternate work schedules if they believe these schedules would benefit
their posture of retaining well-qualified staff as an employer of
choice.
Alternate work schedules can be an expensive alternative to
staffing challenges, and is implemented judicially as appropriate in a
particular competitive marketplace.
Challenges in payroll, timekeeping, and tracking are being
addressed through modification of the time and attendance tracking
software. The Office of Human Resources Management, Work Life and
Benefits Service are currently researching and considering solutions
that can be implemented to address these systems issues.
Chairman Akaka. Thank you very much, Ms. Palkuti.
Ms. Cullen?
STATEMENT OF SHEILA M. CULLEN, DIRECTOR,
SAN FRANCISCO VA MEDICAL CENTER
Ms. Cullen. Mr. Chairman, Mr. Tester, thank you for the
invitation to appear before you today to discuss recruitment
and retention challenges faced by the San Francisco VA Medical
Center. I appreciate the opportunity to discuss our ongoing
efforts to recruit some of the finest employees in the VA
system and the challenges we face to retain those employees in
one of the most expensive areas of the country.
The San Francisco VA Medical Center has an outstanding
workforce of more than 1,900 dedicated staff. We are proud that
our medical center has had consistently high patient and
employee satisfaction scores. In a recent inpatient
satisfaction survey, we scored better than the national average
in several areas, including the categories of courtesy
exhibited by doctors, confidence and trust patients have with
their doctor, and the dignity and respect given to patients
during their stay.
In the recently conducted all-employee survey, nearly 76
percent of our employees responded and our scores were better
than the VHA national average in all areas except for
categories related to pay. Last year, our nurses participated
in the National R.N. Satisfaction Survey and we rated in the
top ten nationally for highest employee satisfaction scores.
We believe employee satisfaction and dedication to the
mission of serving veterans leads directly to good patient
care. To ensure that we maintain a highly talented and
motivated workforce, we have implemented several programs to
aid in our retention and recruitment efforts. We have a very
successful grow-our-own program for specialized occupations,
such as surgical technicians, nuclear medicine technologists,
and diagnostic radiology technicians. This program provides
educational and career advancement opportunities for staff in
specialized fields that are difficult to recruit and retain due
to the competitive health care market.
We have a very successful program in place to hire new
nurse graduates. Through this program, graduates are hired as
temporary nurses without benefits. They are assigned a
preceptor and they work 40 hours per week gaining experience in
clinical areas. After a 12-week rotation, they can compete for
permanent jobs. This program has an 88 percent retention rate.
Our overall vacancy rate is 3.5 to 4.5 percent, with a turnover
rate of just under 12 percent, and the primary reason for
turnover at our medical center is attributed to retirements.
Our success in physician recruitment and retention is
directly credited to our strong affiliation with the University
of California, San Francisco. In addition, our unique mission
of providing health care to veterans as well as our excellent
research and teaching programs play key roles. San Francisco
does have the largest research program in the VA nationally.
The physician pay bill has also clearly been instrumental in
helping us to maintain our top-notch medical staff.
We believe much of our success is due to our efforts to
provide a good work environment, which includes adequate
support staff, educational opportunities, state-of-the-art
equipment, and ongoing support of leadership.
Our recruitment and retention efforts are continually
challenged as a result of the high cost of living and non-
competitive salaries in the Bay area. According to the National
Association of Realtors, the median home price in the nine-
county Bay area is $720,000. That is three times as expensive
as the national average, and that is greatly reduced from what
it was last year and the year before that as a result of
national declining real estate values.
We fully utilize the authority to offer recruitment and
relocation bonuses. Last year, we paid out over $200,000 in
recruitment bonuses, $129,000 for relocation bonuses, and over
$1.8 million for retention pay.
In an effort to stay competitive, we use the special salary
rate authority as much as possible. This has been somewhat
successful for clinical support staff. Our medical center has
13.5 percent of our employees on special salary rates.
Excluding nurses, the annual additional cost to our medical
center budget is $5.7 million. We also have the highest
geographical pay in the country, which includes a 33.5 percent
locality pay adjustment for those on the General Schedule.
In order to keep our retention rates above the 80th
percentile, we have attempted to keep pace with community
hospitals by approving salary increases for our registered
nurses, which have ranged from five to 8 percent annually. The
2008 annual salary increases for all professional nurses was
nearly $3 million.
Another emerging pay situation is with our Certified
Registered Nurse Anesthetists, or CRNAs, who are compensated
under the Nurse Locality Pay System. Our CRNA pay schedule has
reached the statutory pay limit, so staff can only receive the
mandated annual cost-of-living increase. What this means is
that we cannot offer a salary any higher than the statutory
limit of $139,600, even though our local labor market shows
that salaries for a CRNA is at a median salary of over
$170,000. If we are unable to recruit or retain CRNAs, we will
be forced to use expensive contracts whose annual rate would be
approximately $300,000.
VA has many effective training programs that serve to
support our recruitment efforts and have proven their efficacy.
We are currently exploring possibilities for expanding these
programs to other professional areas.
In summary, the San Francisco VA Medical Center has made
great efforts to recruit and retain qualified personnel through
our innovative training programs, financial incentives, and
commitment to the advancement in growth of our staff. We are
committed to facing the challenges of the future and will
continue to look for innovative ways to enhance our workforce.
Mr. Chairman, this concludes my statement. I have a
slightly longer statement that was submitted for the record and
I am pleased to answer any questions that you may have.
[The prepared statement of Ms. Cullen follows:]
Prepared Statement of Sheila M. Cullen, Medical Center Director,
San Francisco VA Medical Center
Mr. Chairman and Members of the Committee, thank you for the
invitation to appear before you today to discuss recruitment and
retention challenges faced by the San Francisco VA Medical Center. I
appreciate the opportunity to discuss our ongoing efforts to recruit
some of the finest employees in the VA system and the challenges we
face to retain these employees in one of the most expensive cities in
the country.
The San Francisco VA Medical Center provides a full range of
primary and tertiary health care services. We are proud to have five
National Centers of Excellence, as well as the largest funded research
program in VA.
Our Medical Center has had consistently high patient satisfaction
scores. In our recent VA Office of the Inspector General (OIG) Combined
Assessment Program Review, we were very proud that the patient
interviews documented an impressive level of patient satisfaction with
care at our facility. In our recent inpatient satisfaction survey, we
scored better then the national average in several areas including the
categories of ``courtesy exhibited by doctors,'' ``confidence and trust
patients have with their doctor,'' and the ``dignity and respect given
to patients during their stay.''
We have also had consistently high employee satisfaction scores. In
the recently conducted VHA All Employee Survey, nearly 76 percent of
our employees responded to the survey and our scores were better than
the VHA national average in all areas except for categories related to
pay. In fiscal year 2007, our nurses participated in a national nurse
satisfaction survey. Our Medical Center rated in the top ten nationally
for highest employee satisfaction scores. Our nurses also had the
highest scores for our Network, VISN 21, in quality of care and overall
job satisfaction. These high levels of satisfaction are noteworthy
given our high cost of living and the challenges we face with
recruitment and retention. We believe employee satisfaction and
dedication to the mission of serving veterans directly leads to good
patient care.
accomplishments
In our ongoing efforts to ensure that we maintain a highly talented
and motivated workforce, we have implemented several programs to aid in
our retention efforts, as well as assist us in meeting the mission and
organizational needs of the Medical Center. Our upward mobility program
provides employees with an opportunity to obtain career positions
through on-the-job and formal training.
We have a very successful ``Grow Our Own'' program for specialized
occupations such as surgical technicians, nuclear medicine
technologists, and diagnostic radiology technicians. This program
provides educational and career advancement opportunities for staff in
specialized fields that are difficult to recruit and retain due to the
competitive health care market. Without these efforts, we would have to
rely on costly registry or contract staff to fill these vacancies.
We have a very successful program in place to hire new nurse
graduates. Through this program, graduates are hired as temporary
nurses without benefits. They are assigned a preceptor and work 40
hours per week gaining experience in clinical areas. After they
complete a 12-week rotation, they have the opportunity to compete for
permanent jobs. This program has an 88 percent retention rate. Our
overall vacancy rate for nurses is 3.5-4.5 percent with a turnover rate
of 11.95 percent. VA's national turnover rate is 10.55 percent, so we
consider this is be excellent, in spite of the high cost of living in
our area. The primary reason for turnover is attributed to retirements.
Our success in physician recruitment and retention can be credited
to our strong affiliation with the University of California San
Francisco. In addition, our unique mission of providing health care to
veterans, as well as our excellent research and teaching programs, play
key roles. The physician pay bill has also been instrumental in helping
us to maintain our top notch medical staff.
We believe much of our success is due to our efforts to provide a
good work environment, which includes adequate support staff,
educational opportunities, state-of-the-art equipment and ongoing
support of leadership.
challenges
While we have been successful in developing effective and
innovative programs to supplement our recruitment and retention
efforts, we are continually challenged as a result of the high cost of
living and non-competitive salaries in the Bay Area--specifically, we
note that Federal salaries across the board in the Bay Area are often
not competitive with local providers. According to the National
Association of Realtors, the median home price in the 9-county Bay Area
is $720,000--three times as expensive as the national average. The
median home price in San Francisco has increased by nearly 96 percent
since the early 1990's. We fully utilize the authority to offer
recruitment and relocation bonuses. Last year we paid out over $200,000
in recruitment bonuses, $129,000 for relocation bonuses and over $1.8
million for retention pay.
A large percentage of employees in many services are approaching
retirement age, while other services have a relatively young staff.
Both present unique challenges either in recruiting qualified
replacements for highly skilled retiring employees or retaining younger
staff in highly specialized areas in a very competitive job market.
Currently, more than 29 percent of our employees are eligible to
retire.
In an effort to stay competitive we use the special salary rate
authority, as much as possible. This has been somewhat successful for
clinical support staff. Our Medical Center has 13.5 percent of our
employees on special salary rates. Excluding nurses, the annual
additional cost to our Medical Center budget is $5.7 million. This is
on top of the fact that we already have the highest geographical pay in
the country which includes a 32.53 percent locality pay adjustment. In
order to keep our retention rates above the 80th percentile, we have
approved salary increases for our Registered Nurses which have ranged
from 5-8 percent annually. The 2008 annual salary increase for all
professional nursing categories was nearly $3 million.
Another challenge is the limitation in developing special salary
charts for difficult-to-fill occupations. Current law only allows the
General Schedule salary chart to be extended out an additional 18
steps. In our high cost economy we have reached our maximum
effectiveness with many of our GS direct patient care occupations. Due
to the 18-step limitation, our special salary charts for these
occupations has become severely compressed. Since most of these
employees are hired in difficult to recruit clinical specialties, their
salary is often set at the higher end of the pay range. This limits
their opportunities for future step increases.
Another emerging pay situation is with our Certified Registered
Nurse Anesthetists (CRNA), who are compensated under the Nurse Locality
Pay System. Our CRNA pay schedule has reached the statutory pay limit,
so staff can only receive the mandated annual cost of living increase.
What this means is that we cannot offer a salary any higher than the
statutory limit of $139,600 even though our local labor market shows
that salaries for a CRNA is at a median salary of $171,334. Therefore,
we have had to maximize the 25 percent retention incentive for this
occupation.
VA has many effective training programs that serve to support our
recruitment efforts and have proven their efficacy. We are currently
exploring possibilities for expanding these programs to other
professional areas.
The recent mental health initiative has given us the opportunity to
increase our mental health capacity. However, since so many facilities
nationwide are competing for limited numbers of psychiatrists and
psychologists it has been a challenge to fill all of our positions,
particularly in rural areas. In addition, recruitment of primary care
providers in rural areas proves to be increasingly difficult.
In summary, the San Francisco VA Medical Center has made great
efforts to recruit and retain qualified personnel through our
innovative training programs, financial incentives, and commitment to
the advancement and growth of our staff. As our work force ages, the
recruitment and retention of highly qualified employees will be even
more important and our challenges greater. We are committed to facing
these challenges head on and will continue to look for new and
innovative ways to maintain and enhance our workforce.
Mr. Chairman, this concludes my statement. I am pleased to answer
any questions you or the Committee members may have.
______
Response to Written Questions Submitted by Hon. Daniel K. Akaka to
Sheila M. Cullen, Medical Center Director, San Francisco VA Medical
Center; and Steven P. Kleinglass, FACHE, Director, Veterans Affairs
Medical Center, Minneapolis, Minnesota
Question 1. How many nurses under your direction work an
alternative work schedule, and how do you use these schedules to
improve recruitment, retention, and employee satisfaction?
Response. At the Minneapolis VAMC there are approximately 424
registered nurses, 79 licensed practical nurses, 46 nurse assistants
and 54 health technicians on compressed or non-traditional tours of
duty. Alternative work schedules improve recruitment, retention and
employee satisfaction. Allowing staff the option to choose non-
traditional tours of duty hours gives them the chance to find balance
between their work and home lives as they feel best suits their
individual needs. Many nurses go to compressed tours to attend school
for advanced educational purposes.
In general, alternative schedules are used for staff who work on
non-traditional tour hours, 9, 10 or 12 hour tours.
There are 100 San Francisco VAMC staff nurses who work under an
alternate work schedule/compressed work tour. In the past year, we have
seen considerable improvement in our vacancy rates, particularly in the
critical care units, because we offer these alternative tours of duty.
------------------------------------------------------------------------
Vacancy Rates 10/1/2007 4/7/2008
------------------------------------------------------------------------
Intensive care unit.......................... 6.4 percent 3.4 percent
Transitional care unit....................... 8.1 percent 1.0 percent
Hemodialysis unit............................ 14.5 percent 1.2 percent
------------------------------------------------------------------------
We have assessed through our new graduate nurse training program
that most new hires are highly interested in an alternative work
schedule. In addition, critical care unit staff have taken an interest
in expanding their nursing leadership roles, including furthering their
education. Alternative work schedules are effective in allowing staff
this opportunity. We believe that offering an alternative work schedule
improves recruitment, retention and employee satisfaction.
Question 2. Please detail each step you take in conducting locality
pay surveys.
Response. The local process at the VAMC Minneapolis starts with the
establishment of a Committee with representatives from:
Management (deputy nurse executive)
Technical advisor (human resources specialist)
Subject matter experts such as:
Registered nurse
Nurse practitioner
Certified registered nurse anesthetist (CRNA)
Operative room registered nurse (ORRN)
A survey team that consists of registered nurses, labor
representatives, and a technical advisor is formed to collect salary
databased on matching job duties with like positions in the private
sector. The teams identify local labor market areas and medical
facilities to contact that are similar to the VAMC. The team sends out
letters to private sector agencies requesting their participation then
schedules a time for interview at their location. The team requests
information on minimum, midpoint and maximum rates actually paid in a
given job category. Copies of job descriptions are requested to ensure
job matches and numbers of employees are the same. Once this process is
complete, a statistical analysis of this data is done to create a
summary of the results.
The human resources officer and human resources technical advisor
present options to the medical center director, nurse executive, fiscal
officer and chief nurse anesthetist for review and discussion. After
discussion, the medical center director approves pay scales and the
information is then sent to VA Central Office for final review,
approval, and input into the paid system.
Over the past years the medical center has consistently provided an
equitable pay increase to the nursing staff based on the data from the
locality pay survey.
The San Francisco VAMC partners with the Allied for Health Survey
Program to conduct the annual locality pay surveys. Once the survey
results are received, we use this information to set the beginning rate
for each grade. In choosing the beginning rate of pay, we consider the
geographic relationship of our facility to major establishments in the
survey area, the severity of recruitment or retention problems, local
non-VA employee benefit packages, and other factors, which affect our
ability to recruit and retain nurses. Normally, we set the beginning
rate for each grade at, or within 5 percent of, the average beginning
rate for comparable non-VA positions in the survey area. By law, we
cannot set a beginning rate above the highest beginning rate in the
community for corresponding positions. In order to keep our retention
rates above the 80th percentile, we have attempted to keep pace with
community hospitals by approving salary increases for our registered
nurses, which have ranged from 5-8 percent annually.
Question 3. Emergency situations in hospitals often create staffing
challenges. Under what emergency circumstances are nurses required to
work mandatory overtime?
Response. Since our nursing staff at the Minneapolis VAMC is
required to be on duty 24 hours per day, 7 days a week, there are
infrequent times when mandated overtime is needed to satisfy patient
care demands. It is medical center policy to avoid the use of mandates.
If there is a mandated situation, the medical center director is
informed of the reason for its occurrence. Some instances in which
nurses are required to work mandatory overtime are to cover unplanned
leave, sick leave, emergency annual leave, absenteeism, and tardiness
for duty by nursing staff.
Patient's safety and staffing levels at the San Francisco VAMC
would mandate an emergency situation. In the last 3 years, the San
Francisco VA Medical Center has implemented a mandatory overtime on ONE
occasion, and it was with the concurrence of the local bargaining
union.
Chairman Akaka. And I repeat that your full statements will
be included in the record.
Mr. Kleinglass?
STATEMENT OF STEVEN P. KLEINGLASS, DIRECTOR, MINNEAPOLIS VA
MEDICAL CENTER
Mr. Kleinglass. Thanks. Mr. Chairman and Mr. Tester, thank
you for the invitation to appear before you today to present
testimony on recruitment and retention issues at the
Minneapolis VA Medical Center. I am honored to be here today to
share some thoughts with you on these important issues.
In the greater Twin Cities geographic area, there are
numerous highly respected health care systems, hospitals,
outpatient clinics, nursing facilities, and pharmaceutical
branches that the Minneapolis VA competes with for the health
care worker. In the March 20 Sunday edition of the local
newspaper, the jobs section had four pages seeking applicants
for health care careers and all claimed that they were
exceptional places to be employed. So, from the very start, we
are competing for a limited number of applicants in a highly
competitive environment.
In addition, while pay is not the only driving factor, we
are in an area where our locality pay is higher than it is in
Washington, DC.
I would like to share with you some of our successes
regarding recruitment and retention and how they have impacted
our ability to maintain some of our stability within our
organization.
Without reservation, the physician and dentist pay
legislation is a major factor in our ability to attract
providers in our competitive area. Unlike most highly
affiliated teaching and research VA medical centers, we at
Minneapolis employ more than 160 full-time physicians and
dentists. We are able to do this because we have taken full
advantage of the pay legislation. While we still struggle to
employ physicians in the highly competitive sub-specialty
categories, we contract with our local affiliate for these
providers.
In the nursing profession, we have taken several proactive
measures to both attract and retain these highly-valued
employees. Each year, we do a nurse locality pay survey and
make necessary adjustments to nurse pay to stay competitive
with our community. During fiscal year 2007, 19 registered
nurse hires were former student nurse technicians from within
our own facility. Also, we use finders fees and other programs
and attend various health fairs throughout the State to attract
individuals.
In the pharmacy profession, we see keen competition for
both pharmacists and pharmacy technicians and the private
sector recruitment bonuses and starting salaries are highly
attractive to new graduates. Our competitive edge has been
starting these individuals above the minimum salary rates. We
then involve these individuals on the treatment team so they
work directly with physicians in prescribing appropriate drugs
for better patient outcomes. In addition, since we believe we
operate the largest single pharmacy in the State of Minnesota
with more than 5,000 outpatient prescriptions being processed
daily through our pharmacy, the volume, pace, and work affords
our staff an exciting work environment.
In the areas of other patient care support personnel, such
as diagnostic radiology technicians, medical record coders,
medical supply technicians, physical therapists, and Certified
Registered Nurse Anesthetists, there are numbers of issues that
we face both in recruitment and retention. Again, while pay is
an issue, the competition for these scarce employees is highly
competitive and our community has been willing to offer some
very interesting perks to both entice new grads and our current
employees. Some of our recruitment successes in these areas
have come from our having an onsite radiology technician and
CRNA school within the medical center, and this gives us a pool
to be able to recruit new graduates to work within our
facility.
Let me share some other approaches in general that we have
taken at the Minneapolis VA Medical Center in an effort to
maintain our workforce. As part of our annual budget process,
we have focused on identifying several departments where
succession planning would be a benefit for the medical center
and then we provide appropriate resources to these departments.
As a medical center, we strive to be an employer of choice and
we have done several things to reinforce this including the
following.
Between fiscal year 2006 and 2007, we have increased the
number of employees who receive performance awards by 750. We
have two major all-employee recognition functions each year to
recognize and thank our employees for the work they do. We
promote wellness in many ways and have a fitness center that is
available to our employees at no cost. We have an onsite day
care center where many of our employees' children receive their
day care each day, and employees can venture there during their
lunch hour to be with their children. We have a farmers' market
on site in the summer where employees and our patients can buy
produce. Finally, we believe that employee engagement is a key
to morale and retention. To this end, we have annual employee
forums, regular lunch-and-learn sessions with leaders, and
ongoing communications with our staff through a daily e-mail
message, a monthly newsletter, and walk-arounds from the
executive team as they dialog with employees.
In closing, while we do have issues with employee
recruitment and retention, I am pleased to report that during
fiscal year 2007 our overall employee turnover rate was less
than 10 percent. This is amongst the lowest when compared with
other similar VA medical centers in our system and lower than a
recent health care entity that was a Malcolm Baldridge award
winner.
Mr. Chairman, this concludes my statement. I would be
pleased to answer any questions that you or Mr. Tester may
have.
[The prepared statement of Mr. Kleinglass follows:]
Prepared Statement of Steven P. Kleinglass, FACHE, Director,
Veterans Affairs Medical Center, Minneapolis, Minnesota
Mr. Chairman and Members of the Committee. Thank you for the
invitation to appear before you today to present testimony on
recruitment and retention efforts at the Minneapolis, Minnesota VA
Medical Center. I am honored to be here today and to share with you
some thoughts on these important issues.
In the greater Twin Cities geographical area there are numerous
highly respected health care systems, hospitals, outpatient clinics,
nursing facilities and pharmaceutical branches that the Minneapolis VA
competes with for the health care worker. In the March 30th Sunday
edition of the local newspaper the ``Jobs'' section had four pages
seeking applicants for health care careers and all claimed that they
were exceptional places to be employed. So, from the very start, we are
competing for a limited number of applicants in a highly competitive
environment. In addition, while pay is not the driving factor, we are
in an area where our locality pay is higher than it is in Washington,
DC.
I would like to share some of our successes related to recruitment
and retention and how they have impacted our ability to maintain some
stability within our workforce.
Without reservation the physician and dentist pay
legislation is a major factor in our ability to attract providers in
our competitive area with few exceptions. Unlike most highly
affiliated, teaching and research VA medical centers, we employ more
than 160 full-time physicians and dentists. We are able to do this
because we have taken full advantage of the pay legislation. We still
struggle to employ physicians in the highly competitive sub-specialty
categories and so we contract for those services with our affiliated
medical school.
In the nursing profession we have taken several proactive
measures to both attract and retain these highly valued employees. Each
year we do a nurse locality pay survey, and make necessary adjustments
to nurse pay, to stay competitive within our community. During fiscal
year 2007, 19 Registered Nurse hires were former student nurse
technicians from our facility. Also, we use a finder's fee program and
attend various recruitment fairs.
In the pharmacy profession we see keen competition for
both pharmacists and pharmacy technicians and the private sector
recruitment bonuses and starting salary rates are highly attractive to
new graduates who are impressionable. Our competitive edge has been
starting these individuals above the minimum salary rates. We then
involve these skilled individuals on the treatment teams so that they
work directly with physicians in prescribing appropriate drugs for
better patient outcomes. In addition, since we believe we operate the
largest single pharmacy in the State of Minnesota with more than 5000
outpatient prescriptions being processed daily through our pharmacy the
volume and pace of work affords our staff an exciting work environment.
In the areas of other patient care support personnel such
as diagnostic radiology technicians, medical record coders, medical
supply technicians, physical therapists and certified registered nurse
anesthetists (CRNA) there are a number of issues that we face in both
recruitment and retention. Again, while pay is an issue, the
competition for these scarce employees is highly competitive and our
community has been willing to offer some very interesting ``perks'' to
entice both new grads and our current employees. Some of our
recruitment successes in these areas have come from having a radiology
technician and CRNA school on-site which provides a pool of new
graduates to recruit from every year.
Let me share with you some approaches in general we have taken at
the Minneapolis VAMC toward maintaining a workforce that meets our
needs.
As part of our annual budget process we have focused on
identifying several departments where succession planning would be a
benefit to the Medical Center and we then provide the appropriate
resources.
As a Medical Center we strive to be an employer of choice
and we have done several things to reinforce this including:
- Between fiscal year 2006 and fiscal year 2007, we increased the
number of employees who received performance awards by 750.
- We have two major all-employee recognition functions.
- We promote wellness in many ways and have a fitness center
available to employees without cost.
- We have an on-site daycare center where many employees' children
receive daycare.
- We have an on-site farmers market during the summer months.
- Finally, we believe that ``employee engagement'' is a key to
morale and retention. To this end, we have annual employee forums,
regular ``lunch and learn'' sessions with leaders and ongoing
communications with our staff through a daily e-mail, a monthly
newsletter and ``walk-a-rounds'' through the medical center by the
Executive Team.
In closing, while we do have issues with employee recruitment and
retention, I am pleased to report that during fiscal year 2007 our
overall employee turnover rate was less than 10 percent. This level is
amongst the lowest when compared with other similar VA medical centers
and lower than a recent health care entity that was a Malcolm Baldridge
winner.
Mr. Chairman, that concludes my statement. Thank you for allowing
me to provide these comments and I would be pleased to respond to any
questions.
______
Response to Written Questions Submitted by Hon. Patty Murray to Steven
P. Kleinglass, FACHE, Director, Veterans Affairs Medical Center,
Minneapolis, Minnesota
retention bonus issues
Question 1. Mr. Kleinglass, you mentioned during the hearing that
there are problems associated with the use of retention bonuses. Can
you please expand on what you mean by that statement?
Response. A recent request to provide retention bonuses across the
board to a particular group of nursing staff was not approved. A review
of the request found that approving this request would cause disparity
among other employees. At the Minneapolis VAMC, our government pay
scale falls behind the medical community as a whole, therefore, in
theory, we should have most of our employees on a retention bonus. The
Minneapolis VAMC has allowed bonuses in a limited fashion and mainly
for recruitment purposes with time pay back provisions. The Minneapolis
VAMC does have some retention bonuses in place, which are reviewed
annually and adjusted appropriately. In an effort to deal with the pay
and retention issues for the certified registered nurse anesthetist
(CRNA) staff, the Director has requested a site visit by the Chief,
Anesthesia and CRNA services within VHA. This site visit is scheduled
for June 10, 2008. During this consultative visit pay, performance,
scheduling and other associated issues related to CRNA staff will be
addressed.
Chairman Akaka. Thank you very much, Mr. Kleinglass.
Ms. Palkuti, thank you for your statement. You laid out
everything that your office is doing and I must tell you it is
impressive.
Ms. Palkuti. Thank you.
Chairman Akaka. But my simple question to you is, even with
that impressive service that you provide, is that enough? Are
there some other things that you can suggest?
Ms. Palkuti. What we do at the central level is to try to
help support the local facilities and their individual
recruitment needs and implementing the legislation as fully as
we can. We realize that continuing to work with individual
facilities to help them improve their recruitment planning, to
help them improve how they use the scholarships or strategize
how they can better use education debt reduction programs is
part of our mission and something that we work on consistently.
We are a very large system and so we are consistently working
in that endeavor.
I think the work that we are doing in expanding our
clinical programs and our training programs in psychology, what
we are doing with the expansion of the nursing academy, will
probably be the strongest direction that we go in in terms of
helping not only VA in the future, but communities, as well. We
do very closely monitor student satisfaction with their
clinical assignments and find that that is a very strong area
that helps improve our performance. This year, we are going to
be taking additional efforts to focus more intently, both my
office and the Office of Academic Affiliations and others, on
improving our recruitment from our student corps.
Chairman Akaka. Ms. Cullen, I would note that nurses at
your facilities have told us that they really believe you are
using all of the authorities bestowed upon you to ensure that
their pay is fair. You mentioned all the good things you have
done and did admit that pay was one of the areas that you are
looking at. My question to you is, knowing that your area is a
high cost-of-living area, what would you tell other directors
about how to achieve a similar level of success?
Ms. Cullen. Thank you, Mr. Chairman. It is all about
creating a positive work environment, and I think that that is
reflected in the results of the all-employee survey, not only
at the San Francisco VA Medical Center, but actually throughout
VISN 21, and that is under Dr. Wiebe's leadership. All of the
facilities in Northern California, Hawaii, and Northern Nevada
have consistently expressed satisfaction at levels higher than
the national average.
The strong commitment to veteran patient care and world-
class research are a key at San Francisco. The quality of staff
who come and stay do that because of the strong demonstrated
support for those dual missions. I believe that even non-
academicians, nurses included, are positively affected and
influenced by that high level of research and academic pride.
We have a viable partnership with our professional union,
the NFFE IAM Local 1 and President Patricia La Sala, who is
also a registered nurse and who keeps me on my toes and makes
sure I utilize every possible authority that can benefit our
nursing staff. We have a transparent and cooperative
relationship committed to the goals of the organization.
The positive press for VHA and the confidence that VHA
employees have that they work for one of the most successful
health care systems in the world absolutely helps recruitment
and retention. We certainly try to publicize the positive media
acclaim that VA has received wherever possible in employee
forums.
Of course, maintaining our success requires supportive
budgets, not to mention market-level health care clinical and
administrative salaries. I referenced earlier in my testimony
that we are absolutely bound to provide our staff with state-
of-the-art equipment, adequate support staff, educational
opportunities, and ongoing support of leadership.
Chairman Akaka. Going back to pay, do you feel that in
those high cost-of-living areas the pay is fair in your region?
Ms. Cullen. Well, I feel that we maximally utilize the
authorities that we have available to us. I feel that a much
broader issue, which is the OPM-set salaries, are woefully
inadequate for administrative staff. I think that goes beyond--
it is an issue beyond VA--however, despite the 33 and one-half
percent geographic COLA. We are able to keep pace with our
competitive institutions through special salary rates, and
while we are not allowed to be the pay leader, we are allowed
to catch up to pay in the surrounding area, and we take
advantage of that with annual adjustments for all of our
professions that have special salary rates.
Chairman Akaka. Thank you. Mr. Kleinglass, we will hear
from GAO in a bit about how difficult it is to recruit and
retain nurse anesthetists. Have you used the retention bonuses
for these professionals, and have you used them for temporary
hires to fill vacant spots?
Mr. Kleinglass. Mr. Chairman, as you state, it is difficult
to recruit these individuals. We have not used retention
bonuses in this field for our current employees because I
believe there are some overall issues with doing that, and I
can elaborate on that if you would like me to. When we do
recruit new hires, we do use that authority, and just recently
I did sign some recruitment bonuses for some new hires. We have
on occasion used some locum tenens in this area to be able to
maintain the level of staffing that we need for these
individuals.
Chairman Akaka. Thank you. Let me at this time call on
Senator Burr for his questions, and that will be followed by
Senator Tester.
Senator Burr. Mr. Chairman, I will be very brief. I have
only one question and it is to some degree off topic. I want to
take the opportunity to ask Ms. Palkuti, Federal Recovery
Coordinators were recently put in place to assist severely
injured servicemembers and their families in navigating
confusing layers of support that exist from rehabilitation and
recovery case managers. It took several months to hire eight.
One has died. One has quit. How long would it take to fill the
vacancies so that we get what I think most Members on this
Committee agree is an absolute necessity, and that is these
Recovery Coordinators, in place?
Ms. Palkuti. I am not personally involved with that
particular process, with that particular occupation, so I
didn't realize that it had--one had passed and one had not. But
the general process of recruiting for that occupation would
require announcing the position for whatever period of time and
then interviewing to find the best candidate. It could take as
short a period of time as 30 days. I would be more than happy
to take that question for the record and find out precisely
what is going rather than offering you just a theoretical time
line.
Senator Burr. I will save you the responsibility, but we
will follow through with the VA.
I just want to encourage all of you. There is a system in
place. You could tell me better than I could tell you whether
the system works as prescribed. It has been very frustrating to
me as to how long it is taking to get these Recovery
Coordinators in place. Now, if we have a process in place that
is cumbersome and duplicative and does not allow us to
aggressively go out and surge to an area that there is total
agreement we need to do--and this is in the best interest of
our veterans coming back--then tell us to change this; and we,
collectively, I think, can get our heads together and figure
out whether we can provide some legislative remedy to it, or,
at least we will review it to determine whether it needs to
stay in place.
But, I would say this to all three of you, just because
things are in statute certain ways, if they don't work, for
God's sake, tell us so that we can change them, so that we can
facilitate what it is you need in the positions that you hold
to make sure that recruitment and retention are much easier. I
think there is a tendency, Mr. Chairman, and I believe it is
probably very appropriate, that the pay challenges are probably
the number one thing. But if it was pay alone, then I think we
would be looking at a different universe of health care
professionals within VA.
There is more to it, and I really want you to reach in and
share with the Committee at some point those things that really
do make a difference in us being able to develop that delivery
system that reflects what the private sector does for the 21st
century. I dare say I am not sure that there is a private
sector entity that goes very long with a space unfilled because
that is a service they can't deliver, and it is hard for me to
believe how the best health care system in the world with the
most vulnerable population could go for so long with positions
unfilled. Because the net result to me is somebody is not
serviced to the degree that the commitment was made. We are
here to try to facilitate that and I encourage you.
I thank the Chair.
Chairman Akaka. Thank you very much, Senator Burr.
Senator Tester?
Senator Tester. Thank you, Mr. Chairman. I want to thank
the participants on this panel very much for the work you do. I
appreciate the pride that is exhibited by all of you in your
specific institutions, or medical facilities, I should say; and
I want to thank you for the work that you do. I think that it
is very important.
A couple of things. Again, it spins off of what Senator
Burr said about more to it than pay and things that make a
difference, and I think that the San Francisco VA Center and
Minneapolis VA Center did talk about some things--the fitness
center, the day care, the farmers' market on site. I applaud
that. Those kind of things are important, but then also from a
professional standpoint, Ms. Cullen, you talked about a nurse
rotation of 12 weeks. Eighty-eight percent of the folks who
went through that program that you hired stay on, 88 percent of
the time----
Ms. Cullen. That is correct. Those were new hires, new
nursing graduates.
Senator Tester. How long has that been in place?
Ms. Cullen. Over the last 2 years.
Senator Tester. Good.
Ms. Cullen. We are in our second year.
Senator Tester. And then, I think, if I recall, you both
talked about the physician pay bill and how that was important
to your success.
I don't know if you know this because you work in a pretty
urban setting, especially if you compare it to a place like
Montana--I don't know if any of you have been to Montana----
[Nodding heads.]
Senator Tester. That is good. You have all been there.
Good. Come back again. But it is a very rural State and your
boss, Secretary Peake, was out a few months ago and got a sense
of it. But some of the issues that bother me about what is
going on right now for veteran health care is the fact that
veterans who live in rural areas don't live as long, and I
don't think it is because the air is dirty or the water is
dirty or we get worse food there. I really do think it revolves
around health care. And it is not the VA's exclusive problem. I
mean, every small hospital in the State of Montana, every big
hospital in the State of Montana, has a hard time recruiting
and keeping people for a number of reasons.
But, one of the things that I think works pretty darn well
is that if you can have people do their intern programs in a VA
hospital or in a rural part of America if you are trying to
recruit, it really does work. So, the question I have for you,
Ms. Palkuti, is the bigger places have it. I mean, there are,
what, 100,000 health care professionals that you train at VA
facilities every year, and you need to be applauded for that.
Ms. Palkuti. Thank you.
Senator Tester. How many of those are in rural areas? How
many are trained in rural areas to really meet the needs of
veterans living in rural America? And if it is zero, that is
fine. We can fix it.
Ms. Palkuti. You know, personally, I don't have that number
for you at this point in time. I know that a number of places--
there was someone I was speaking to in Arizona, actually, and
they were designing part of their clinical process so that they
would have that particular set of residents rotate through
their more remote outpatient clinics. It is becoming something
that was actually a popular rotation among clinicians in that
area. So, they are looking at getting people out to some of
those CBOCs that are further out in the country.
Senator Tester. Good. My daughter happens to be a
registered nurse. She graduated from college--a 4-year program
in 2002, I believe--and she did do part of her--I forget what
the term is, but part of----
Ms. Palkuti. Clinical rotation?
Senator Tester. That is it--in a VA hospital in Helena,
Montana, and she liked it a lot. I guess I am wondering, does
the VA aggressively approach--there are a lot of nursing
schools in Montana.
Ms. Palkuti. Right.
Senator Tester. Do they aggressively approach these folks
to do their--it is not internship, but you know what I mean----
Ms. Palkuti. Rotation.
Senator Tester. Yes, rotation--there?
Ms. Palkuti. VA has academic affiliations with numerous
nursing schools around the country and encourages people to do
academic rotations. I think, through the project that we have
right now with the expanding in the VA nursing academy and
because of all the learner surveys that we do with all of the
clinicians who come through our organizations, we realize that
in-place rotation at a VA facility is critical to improving our
chance of hiring those people afterwards.
Senator Tester. So, what you are saying is they do reach
out to the colleges and technical schools to----
Ms. Palkuti. Yes.
Senator Tester. Pretty aggressively, in your opinion? I
mean----
Ms. Palkuti. From my knowledge, yes.
Senator Tester. OK. It needs to be very aggressive, I
think, from my perspective. And you have got to know that my
focus is on rural. We have got 930,000, 950,000 people in a
State that is pretty good-sized, and so it is really important.
You talked about $24 million in recruitment bonuses and you
had a figure of people that that impacted, and $34 million in
retention bonuses. Can you give me any idea on how much of that
money went to rural areas?
Ms. Palkuti. I can go back and have the data run that way.
Senator Tester. Could you, I mean, because the issue--could
you just run it for Montana? I am not going to pick up the
sheet and say, gosh, we are--I am not going to do that. I am
just curious, because burn-out is a big problem amongst our
professional folks and we have got some great people working in
these clinics and these hospitals. I am not kidding you. They
are incredibly committed to the health care system and to
veterans throughout the State and I am incredibly impressed by
them. But, they are burning out and so that is why I wonder,
because I think that if there were some dollars for incentives,
we could get them in. There might not be a lot of people there,
but there is some pretty good fishing and hunting and hiking
and those kinds of things.
Ms. Palkuti. My brother went out there for the antelope.
Senator Tester. There you go.
Ms. Palkuti. And never went back to Kentucky.
Senator Tester. Have him come to my house; I have too many.
At any rate, I wanted to ask--and you guys may or may not
know this, Ms. Cullen and Mr. Kleinglass--if a person is
sitting in a waiting room, are there limits of time that the
doctor spends with a client; and what is that?
Mr. Kleinglass. Well, I would like to respond for you.
Senator Tester. Sure.
Mr. Kleinglass. We do have standards that we look at to
measure this and I often talk with patients in the morning as I
come into the medical center and ask them. And what I am
realizing now is that patients are getting upset with us
because they are moving through the medical center so quickly,
and that is a very good thing. So, our waiting times now in our
primary care areas and our non-specialty areas are really quite
good. We have done a lot to help that by putting in more
support staff so that our professional staff can have more time
to do the professional things that they need to do.
We still have some longer waits in some of the sub-
specialties. In our eye clinic, in particular in orthopedics,
there are longer waits there and we see times that we don't
like and our patients don't like.
Senator Tester. There are actually two issues here and the
first one deals with the time in the waiting room, which I
applaud your efforts in minimizing that as much as possible.
The other one applies to the amount of time that the person
spends with the doctor in the examination room. Are there
limits on that time?
Mr. Kleinglass. There are set appointment times, but I
would hope and I feel fairly confident telling you that the
physicians will spend whatever time is necessary if there is an
issue with a patient, and that is going to complicate back-up.
Senator Tester. Yes, exactly; and it will complicate the
amount of time you spend in the waiting room. So, if your
physicians were told that they needed to funnel these folks
through, 15 minutes is the most they can spend with them, would
you object vigorously to that? You can answer, too, Ms. Cullen.
Ms. Cullen. Our appointments are for one-half hour for
routine appointments, 1 hour for a first-time appointment in
primary care. We do not schedule 15-minute appointments.
Senator Tester. Good.
Ms. Cullen. In some areas, there are 20-minute
appointments, but no shorter than that.
Senator Tester. Well, I think the problem is--because I
have heard this in Montana--I think the problem is lack of
staff. I think that they have to get them through because we
have got more people that need help than we have staff to take
care of them. I think that contributes, in a great part, to the
burn-out. Because there is nothing more frustrating than coming
to a Committee meeting and not being able to spend as much time
as you want asking you folks questions; and compound that
exponentially if you are a doctor or a nurse and you are trying
to give health care that you were trained to give and you don't
have enough time to give it.
So, I think you get my drift here. Like I said, it is not
just VA in rural America, but we are really in crisis when it
comes to health care. And I am on this Committee, and I think
that we need to do our best to make sure we live up to our
obligation to veterans, make no mistake about it.
I would love to work with all three of you individually to
figure out ways we can address health care in rural/frontier
America. I have got some ideas. I know you guys have more ideas
than I have. We have just got to figure out--as Senator Burr
said, it isn't all about money. I think a lot of it has to do
about training. I think a lot of it has to do about telling
folks the opportunities. I think a lot of it has to do about
stuff like on-site day care and fitness centers and farmers'
markets for availability. I mean, that is good stuff.
Go ahead.
Mr. Kleinglass. We will do anything that is innovative and
creative to help manage this. These are small things that we
do, but I think that when you measure these across, they mean a
lot to employees.
Senator Tester. Yes, in the end. I appreciate you guys'
work, but I am telling you, we do have a problem in rural
America. Because, number one, it is tough to get them, it is
tough to keep them, and we are burning out the ones we are
getting. So, it just compounds itself.
So, thank you.
Chairman Akaka. Thank you, Senator Tester.
Mr. Kleinglass, I understand from my staff that you have
been using Maxim Health Care Services to fill some of your
vacancies. Why have you resorted to temporary staffing of VA
with an outside entity? Have you not been able to recruit
professionals through the normal channels?
Mr. Kleinglass. Mr. Chairman, I am not familiar with Maxim
staffing. Is that an agency?
Chairman Akaka. Health Care Services, yes.
Mr. Kleinglass. There are times where we do use temporary
agencies to help supplement some of our staff. I personally
don't think that is a bad thing. It gives us some flexibility
in some areas where we flex up and flex down according to the
needs of what is going on. So, it depends specifically in what
area we are using those temporaries. We have used some
temporaries in some of our Community-Based Outpatient Clinics
because, quite honestly, it is a rural area, and as Senator
Tester said, it is sometimes difficult to recruit staff for
those areas. So, we do use temporaries--locum tenentes--in
those areas.
Chairman Akaka. Yes. Mr. Kleinglass and Ms. Cullen, could
you both please tell us what types of physician specialties you
still must contract for despite the success of physician pay
reform, and please give us an example of the sub-specialty
contract at your facility and how much you are currently paying
them. Ms. Cullen?
Ms. Cullen. We still have anesthesiologists on contract,
neuroradiologists, and those are the only two that come to
mind. Most of our physician staff are on staff.
Neuroradiologists remain out of our price range and
anesthesiologists are very difficult to recruit, and we have
some salary concerns there, as well. But truly, our affiliation
with UC San Francisco has been our strength for recruiting and
retaining staff.
Chairman Akaka. Mr. Kleinglass?
Mr. Kleinglass. Mr. Chairman, in our case, the physician
and dentist pay bill has been an outstanding tool that we have
and we have; used that pay bill to help us in lots of areas. We
struggle in the areas of therapeutic radiology, diagnostic
radiology, and cardiovascular surgeons, in particular. These
sub-specialties are both in high demand in the community and
command salaries that would exceed the limitations that we
have.
Chairman Akaka. Ms. Cullen, how much are you paying for
your anesthesiologist contract, for example?
Ms. Cullen. I don't have that dollar amount. I can
certainly get you that, specifically. But, we are currently
exceeding the amounts that are identified for
anesthesiologists. I will have to follow up and provide that.
[The response from Ms. Cullen follows:]
Response. The cost of an anesthesiologist on contract is $472,160
at VA Medical Center San Francisco.
Chairman Akaka. My final question is to Mr. Kleinglass and
Ms. Cullen. I am aware that some facilities give nurse managers
and supervisors greater locality pay than other nurses versus
increases for the staff nurses. Based on the results of the
locality pay surveys, how do you assign locality pay and how do
you justify higher locality pay for nurse managers and
supervisors?
Ms. Cullen. For our nurse managers, and particularly for
our nurse managers on inpatient units, we have two additional
steps of salary for that additional supervisory role. For the
most part, our larger geographic salary is allocated to the
nurses who work on inpatient units; and we find that we can
adequately recruit nurses in outpatient settings. It remains
difficult to recruit them for inpatient settings and for off-
hour shifts, as well. So, they are on a higher salary range,
not our nurse managers, but the nurses who work on inpatient
units.
Chairman Akaka. Mr. Kleinglass?
Mr. Kleinglass. Mr. Chairman, in fiscal year 2006, our
annualized RN locality pay survey resulted in an $850,000
annualized cost. In fiscal year 2007, it was $1.1 million in
annualized cost. We take the locality pay survey work extremely
seriously. We put a lot of effort into doing that and we do
want to match up as best we can, albeit staying below the
community rates, and over the many, many years that I have been
at Minneapolis, each year, we have provided a raise for these
individuals.
We do provide some extra money to our nurse managers and we
started that several years ago. We did that because of the
demands on those individuals, our expectations of them, and the
roles they play each day in managing patient care. So, they do
get some extra money. It is not a lot, and I don't have the
exact figures with me, but, in fact, they do get some extra
money.
Chairman Akaka. We are into our second round. Senator
Tester, do you have any questions?
Senator Tester. I do have just a couple of real quick ones.
I talked about the medical professionals in the first round. I
want to talk more about administrative folks, folks who answer
the phone, folks who do the schedules. A little less pressure
on the pool there, but I hear a lot of things about the length
of time it takes to hire somebody to answer the phone. Is the
bureaucracy that bulky? Do we need to do some things to change
it? Tell me the process and why it should take a long time to
hire somebody to----
Ms. Palkuti. Well----
Senator Tester. No, go ahead.
Ms. Palkuti. The process, depending on which hiring
authority you use, there is something called delegated
examining, which is commonly used to bring in people in
administrative positions because we don't have a direct hire
authority for most of those occupations. And so we are
delegated by OPM with the authority to hire and examine for
those positions.
Starting actually last summer, we did a total evaluation of
delegated hiring within the Veterans Health Administration and
we had 19 units around the country. Effective October 1 of
2007, we have completely reorganized that function, centralized
it under my office. We now have eight of the most high-
performing centers that have now been totally automated and are
performing the delegated examining function for the agency.
From the time that a complete package is received in those
examining units until a certificate is delivered to an H.R.
manager is--our March numbers showed that it was around 14
days. So, it depends on how long the position is open. If it is
open for 2 weeks, then--but generally, within 7 days of the
position closing, we actually do have the certificate back to
the hiring manager. And we have been monitoring our numbers in
that regard since the reorganization----
Senator Tester. And do you track it after the certificate
goes? Is there some tracking on that human resource person as
to when they hire the person?
Ms. Palkuti. Yes, we do. We track the process well beyond
the date that we produce the certificate----
Senator Tester. And there isn't a glitch there?
Ms. Palkuti. There is the timing that it takes a manager to
schedule interviews, do interviews, make a selection, check
credentials, and those kinds of things----
Senator Tester. OK. Are we understaffed in the human
resource end of things so that is holding up the process?
Ms. Palkuti. We have identified the human resources
occupation as one of our top ten priority occupations for the
agency. We have increased the number of folks that we are
hiring in new internships for developmental purposes to 42 this
year.
Senator Tester. OK.
Ms. Palkuti. We are looking at that.
Senator Tester. I mean, one of the things that really gets
the VA off to a bad start is if the first person they talk to
is a machine.
Ms. Palkuti. Correct.
Senator Tester. With the press the last couple days
reporting on credit cards, I'm inclined to ask this question to
both Ms. Cullen and Mr. Kleinglass. Are there people that you
have oversight over, yourselves included, that have VA credit
cards; and are there rules as to how those cards can be used?
Mr. Kleinglass. Please.
Ms. Cullen. Yes, I have a government credit card. Mine is
just for travel; and yes, we have a number of government credit
cards throughout our organization; and there are, indeed, rules
for how they are to be utilized.
Senator Tester. And I assume it is the same for you, Mr.
Kleinglass?
Mr. Kleinglass. Yes, Senator Tester. I have a government
credit card. We have many staff that have them. There are
rules. We have an Ethics Committee at our institution. We talk
about this regularly.
Senator Tester. I am not making any implications on your
particular facilities, let the record be clear on that. But do
you have any oversight of those credit cards within your
facilities or is it all done from this end?
Mr. Kleinglass. In our institution, our Chief Financial
Officer and his staff manage that for us and they regularly put
out guidance on the use of these cards and I know of no
problems at our institution.
Senator Tester. OK.
Ms. Cullen. Also, we do internal audits on the use of
purchase cards, and we occasionally have the benefit of visits
from our colleagues in central office who do the same, and from
the IG. They just--within this fiscal year, we had a random
audit of credit cards by the IG, as well.
Senator Tester. Thank you very much. Sorry I had to bring
up the messy subject, but I had to do it. Thank you.
Ms. Cullen. No problem.
Chairman Akaka. Thank you very much.
Before I dismiss the first panel, I want to call on Senator
Wicker for any statement or questions you may have.
STATEMENT OF HON. ROGER F. WICKER,
U.S. SENATOR FROM MISSISSIPPI
Senator Wicker. Thank you, and I would ask a few questions.
I do want to thank Senator Tester for asking about the credit
cards. Some things we sometimes feel go without saying, or some
questions go without asking, and then we learn that, lo and
behold, the very obvious questions need to be asked. So, I
appreciated the question and appreciate the answer.
Let me just follow up, first of all, Mr. Kleinglass, with
your testimony about extra pay or incentive pay for nurse
managers and certain specialty areas among the nurses. Do you
find that your civilian counterparts are doing the same, or are
there differences in that particular area? Or do you have
conversations with your civilian counterparts?
Mr. Kleinglass. I do. I sit on the Minnesota Hospital
Association Board and I asked various questions of my
colleagues in town. What I would say to you is it is very
difficult to match up exactly, for lots of reasons. It is my
understanding when our nurse executive at our institution asked
me about doing this, she was interested in it because the
community in which we reside does this. She felt passionately
that in order to maintain the staff that we want, this would be
a good incentive for our nurse managers.
I didn't bring the numbers with me, but I am fairly
confident when I tell you the amount of money that we have
given to these nurse managers is really very small in the realm
of what we are asking them to do. They are really the backbone
to the nursing units and have responsibilities 24 hours-a-day/7
days-a-week, with a very large responsibility.
Senator Wicker. Well, I think, certainly, we can
acknowledge that the shortage across the board affects the
government health care providers and private and community-
based health care providers.
Let me just back up and see if someone on the panel can
give us an overview of the profile of physicians and nurses in
the VA. Do you get most of them straight from school, or do
they work a while in the private sector typically? And at what
point do we tend to lose them, both the doctors and the nurses,
to the private sector? Is there anything that we can learn
along those lines that might be helpful to the Committee?
Mr. Kleinglass. I would be pleased to answer that for you.
In our institution, and I am speaking only for the Minneapolis
VA, we have a combination of reasons why physicians come to us
and we get a mix from our affiliate through the medical school,
through the training programs, and then individuals that are
mid-career that have gone out and done some other things come
back to us.
When I talk to new physicians that come to work for us,
they come because of the affinity for taking care of veterans;
for the teaching opportunities; for the research opportunities;
and for the way we do our business--particularly with the
computerized patient medical record. That is a real bonus. They
also like the way we practice medicine within the VA. They are
getting very frustrated with what is going on in the private
sector--their inability to order tests or inability to really
practice--and so, they see the VA as a model of very high level
practice availability.
Senator Wicker. And why do you lose them at a certain
point?
Mr. Kleinglass. Well, I can give you one specific example.
We are losing a physician that we value greatly and he was kind
enough to tell me he was going to be leaving us. So, I asked
him to come up to my office and we spoke quite a bit. His words
to me were, ``I am leaving because of a family lifestyle
change, a location--that is, going back home--and not because I
am unhappy here in any way, and it is not because of pay.'' So,
I think there are those reasons.
Quite honestly, in some of the sub-specialties, particular
cardiology, diagnostic radiology, interventional cardiology, we
lose some physicians because of pay, and predominately pay. And
I have some examples of those that I could share with you where
we have tried to entice these people to stay. And it is very,
very difficult to compete with the pay that these people are
getting. I was successful a couple of years ago convincing one
of our valued cardiologists not to leave, and a year and one-
half later the offer just was way out of control from the
private sector.
Ms. Cullen. At San Francisco, our situation is similar to
what Mr. Kleinglass describes. We hire physicians at all
levels. Experienced, tenured physicians from other areas will
come to our medical center. The affiliation with our medical
school is the primary draw for recruitment and retention of
physicians. Our research program, which is the largest in the
VA, is an enormous magnet for recruitment and retention. We
lose physicians because they can get an academic promotion
elsewhere. Infrequently, but it does happen, we lose them due
to very attractive salary offers, sometimes outside academia.
Most recently, we have two pending physician losses that
will be very painful to us, one, an interventional cardiologist
who is leaving for an over $600,000 salary. The second is an
anesthesiologist who will be leaving us for a $300,000 sign-on
bonus and who will yet get to stay in the area. But, for the
most part, our physicians remain in an academic setting.
With nurses, we hire them as new grads and we try to
attract new nursing graduates, but the largest number of nurses
that we lose are through retirement, so they are people who
have had an extensive career with the VA--extensive and
successful career with VA. Sometimes we lose people because
families move elsewhere, but that is to be expected. Again, as
I think I mentioned in my testimony, our largest nursing loss
is due to retirements.
Senator Wicker. Well, thank you. And I guess this is a
question for the record, but if anyone on the panel could let
us know the percentage of people--nurses or doctors--who stick
with you the whole time. I realize that is not what we do in
society anymore. People have a number of careers nowadays,
whereas in my father's day, you picked one and that is what you
retired from. But, it would be interesting if you could supply
me--if you know off the top of your head or can supply for the
record--how many people make a total career out of it.
Thank you; and thank you, Mr. Chairman.
[The response from Ms. Cullen follows:]
Response. VA does not keep data on staff who remain with VA for
their entire careers.
Chairman Akaka. Thank you, Senator Wicker.
Senator Rockefeller, any statement or questions to the
first panel?
STATEMENT OF HON. JOHN D. ROCKEFELLER IV, U.S. SENATOR FROM
WEST VIRGINIA
Senator Rockefeller. Mr. Chairman, I am just interested in
the fact that in this question, and in response to what the
Senator previously said, my understanding was that the average
VA nurse has been there for 27 years. VA has also hired a lot
of people--specialists and general people--in the last 2 years
because you have had more money to do so--thanks to Patty
Murray--and that you plan on hiring some 500 more this year, if
that is correct. So, the question is sort of regarding the
people leaving for higher pay versus the 27 years tradition, if
that is still correct, and then the hiring on of new people
means that they are coming already knowing that there is higher
pay elsewhere, and that would make sense to me simply because
of the centrality of the veterans. The last several years have
really highlighted it. This Congress will never be the same, I
hope, as it has been in the past, unfortunately.
One thing that caught my attention was the question of
nurses seeking sort of overtime and the 3-day/12-hour-a-day
pattern, and that that seemed to make sense to them--and
obviously does to you because it probably wouldn't have been
suggested if that had not been the case. But then I am
confused, because you have the sole authority to decide which
workplace disputes can be grieved. Since 2002--I am just saying
``you'' generically--has ruled in favor of management and
against the employees' right to grieve in 100 percent of the
cases that have come before him, which couldn't be you, and
that interests me.
Ms. Palkuti. Sir, I am probably not the expert in the
employee relations arena. Can I take that question for the
record and respond to that?
Senator Rockefeller. Yes, if you could let me know. It is
just sort of a phenomenon that doesn't take place if they are
satisfied with it; and you are satisfied with it, but then
those who don't always lose. So, if you could take that for the
record, I would be very grateful.
Ms. Palkuti. Yes, sir. I would be glad to. Thank you.
Senator Rockefeller. That will be my only question for the
moment, Mr. Chairman.
[The response from Ms. Palkuti follows:]
Response. VA provided this information directly to Senator
Rockefeller's office.
Chairman Akaka. Thank you very much, Senator Rockefeller.
Senator Murray?
Senator Murray. Mr. Chairman, I had an opportunity to speak
earlier and I know the panel has been up here and you have got
a second panel. I will pass on my questions and submit them for
the record on this panel.
Chairman Akaka. Thank you very much.
I want to then thank our first panel. The kind of questions
we have had really were seeking to find out more of what you
are doing. You have been doing an incredible job and we want
others to learn from your experiences, as well. So, thank you
very much for being here today.
Senator Rockefeller. Can I----
Chairman Akaka. Just a second. Senator Rockefeller?
Senator Rockefeller. I didn't use all my time, did I? Let
me go back to the earlier part of that question. Is the 27-year
thing still fundamentally accurate?
Ms. Palkuti. Are you asking if----
Senator Rockefeller. That the average length of the VA
nurse's stay. I have used it all over my State, so I am hoping
that it is----
Ms. Palkuti. You are hoping it is correct.
[Laughter.]
Ms. Palkuti. I can confirm or determine whether that----
Senator Rockefeller. It is in that area.
Ms. Palkuti [continuing]. That average is----
Senator Rockefeller. I believe it is in that area, which
shows the dedication.
Ms. Palkuti. Yes.
Senator Rockefeller. But then you use the example of people
being attracted by higher salaries elsewhere, and, of course,
we all face that, particularly those of us who are surrounded
by much richer States. And you have hired a lot of people,
which meant they had to go through that calculus in their mind,
because they know what is being offered. Is there an
explanation for that?
Ms. Palkuti. Well, I guess we can refer back to some of our
workforce planning initiatives. We have turnover because of
retirement and other types of attrition, so we are continuously
hiring new employees. Many of them are coming from the private
sector at mid-career because they appreciate the way VA
practices medicine. There is a focus on the patient and less of
a focus on just decisions that are bottom-line business
decisions. We have a phenomenal health record that draws
people. And so, some people do make a decision and calculate
the differences in terms of salary to make a choice to come and
work for VA. Many people come to us because of the mission, and
some who don't come to us because they are mission-bound become
very attached to our mission very shortly after arriving.
We have some very good incentives. We have scholarship
incentives that draw people, especially associate and
baccalaureate degree nurses. We have a scholarship program
which is exceptional across the agency, so we draw them in for
their educational benefits. Our Education Debt Reduction
Program, which is offered to new hires, gives them an incentive
to stay for 5 years to collect all of those funds, and we found
very clearly that employees who stay in years three, four, and
five remain with the agency when those benefits expire.
So, we have some very good benefits that draw people into
the agency and help them see what a fine place it is to
practice and serve the country.
Senator Rockefeller. Has the intensity of these two wars
that are going on and the trauma of the wounded and injured--
physically, psychologically, both--has that, do you think,
helped the whole sense of mission?
Ms. Palkuti. To some degree, I would like to defer to my
colleagues who are more on the front lines and may be able to
speak to that even more.
Mr. Kleinglass. Mr. Rockefeller, the Minneapolis VA Medical
Center is one of VHA's five polytrauma centers, and so we have
a lot of experience with your question. I would say,
undoubtedly, the new staff that is coming in have this notion
of serving veterans is just a noble thing. They thoroughly
enjoy working with the returning soldiers. We have a
tremendously dedicated staff that work day-in and day-out with
the returning soldiers and thoroughly, thoroughly enjoy it. And
so, I think that in our case, at least, that has contributed to
some of our successes with the new people coming in.
Senator Rockefeller. Good. I have over-used my time and I
apologize, but I am glad to hear those answers.
Chairman Akaka. Thank you, Senator Rockefeller.
Let me say that speaking of dedication, there is a nurse at
the Albany VA Hospital who has just celebrated her 50th
anniversary as a nurse. That is something to shoot for, and I
want Senator Rockefeller and Senator Wicker to know that. There
is a 50-year-career at the Albany VA Hospital.
With that, again, thank you very much to our first panel
for being here and sharing your experiences.
Let me now welcome our second panel. I would like to thank
our second panel for being here today.
First, I welcome Marjorie Kanof, Managing Director for
Health Care in the Government Accountability Office.
Second, I welcome Dr. John McDonald, Vice President for
Health Sciences and Dean of the University of Nevada School of
Medicine.
I also welcome Valerie O'Meara, a nurse practitioner in the
VA Puget Sound Health Care System and Professional Vice
President of the American Federation of Government Employees
Local 3197.
Next, I welcome Randy Phelps, Deputy Executive Director of
the American Psychological Association Practice Directorate.
Finally, I welcome Dr. Jennifer Strauss, Assistant
Professor in the Department of Psychiatry and Behavioral
Sciences of Duke University Medical Center.
Again, I want to thank all of you for being here today and
let you know that your full statements will appear in the
record. We will begin with Dr. Kanof and your testimony.
STATEMENT OF MARJORIE KANOF, M.D., MANAGING DIRECTOR, HEALTH
CARE, U.S. GOVERNMENT ACCOUNTABILITY OFFICE
Dr. Kanof. Mr. Chairman, Mr. Rockefeller, and Ms. Murray, I
am pleased to be here today as you discuss personnel issues at
the Department of Veterans Affairs.
One such issue VA faces is an increased demand for the
services provided by Certified Registered Nurse Anesthetists
(CRNAs), who provide the majority of anesthesia care veterans
receive in VA medical facilities. The VA employs approximately
500 CRNAs and many of these CRNAs are nearing retirement
eligibility age. Given the increased demand for CRNAs, concerns
have been raised about the challenges VA may face in making
salaries competitive to maintain the CRNA workforce,
particularly in the areas where the local market can be highly
competitive.
In December 2007, GAO issued a report that examined the
challenges VA faces recruiting and retaining CRNAs. Based on
this report, I will discuss both the CRNA workforce challenges
and the key mechanisms VA facilities have to make CRNA salaries
competitive.
We reported that VA medical facilities have challenges both
recruiting and retaining CRNAs. Seventy-four percent of the VA
chief anesthesiologists that responded to our survey reported
that they had difficulty recruiting CRNAs. VA medical facility
officials responding to our survey reported that it took VA
facilities a long time, on average about 15 months, to fill a
CRNA vacancy. Based on fiscal year 2005 data, nationally, VA
had a 13 percent CRNA vacancy, or 70 unfilled positions at 43
medical facilities.
According to our survey, the CRNA vacancy impacted the
delivery of care to the veterans. For example, 54 percent of
our chief anesthesiologists reported that they temporarily
closed their operating rooms.
In addition to the challenge of recruiting CRNAs, we also
reported that VA medical facilities were likely to face a
challenge in retaining CRNAs. On the basis of the response to
our survey, we projected a CRNA attrition rate of 26 percent
across VA in the next 5 years. Overall, 93 CRNAs at 53
facilities reported that they plan to either leave or retire
from the VA in 5 years. VA medical facilities reported in our
survey that recruitment and retention challenges were caused
primarily by the level of VA's CRNA salaries when compared to
salaries in the local market area.
In December 2007, we also reported that VA's Locality Pay
System, known as LPS, is a key mechanism that facilities use to
determine whether to address salaries. The LPS provides
information on salaries paid to CRNAs in the facility's local
market area. We reported that the majority of VA facilities use
the LPS, but at the eight VA medical facilities we visited,
five did not use the LPS in accordance with VA's LPS policy. At
these five facilities, officials with oversight responsibility
for the LPS were not knowledgeable about the changes in the
policy. For example, one official told us that third-party
salary survey data wasn't available, so they used salary data
from the Hot Jobs Web site, which doesn't match the data
accuracy that is required by the VA protocol.
The problem some VA medical facilities had fully
understanding the LPS policy indicated that VA training had
been inadequate. Actually, VA had changed its policy in 2001,
but it had not conducted nationwide training since 1995. As a
result, VA medical facility officials cannot ensure that the
CRNA salaries have been adjusted as needed to be competitive in
local market areas. Training on the LPS is necessary to help
ensure that VA medical facilities are competitive as an
employer.
And so, to improve VA's ability to recruit and retain
CRNAs, in our December report, we recommended that VA expedite
the development and implementation of training; and VA agreed
with our recommendation and stated that it had developed a
draft action plan and they hope to complete online training by
the end of this fiscal year.
Mr. Chairman and Members, this concludes my opening
statement.
[The prepared statement of Dr. Kanof follows:]
Prepared Statement of Marjorie Kanor, Managing Director, Health Care,
U.S. Government Accountability Office
Chairman Akaka. Thank you very much, Dr. Kanof.
Dr. McDonald?
STATEMENT OF JOHN A. McDONALD, M.D., PH.D., VICE PRESIDENT FOR
HEALTH SCIENCES AND DEAN, UNIVERSITY OF NEVADA SCHOOL OF
MEDICINE, ON BEHALF OF THE ASSOCIATION OF AMERICAN MEDICAL
COLLEGES
Dr. McDonald. Thank you, Mr. Chairman, Mr. Rockefeller, Ms.
Murray. I appreciate the opportunity to speak on behalf of the
American Association of Medical Colleges and myself. I bring
somewhat a different perspective to this dialog. Prior to
assuming my current position in the State of Nevada, I was the
Chief of the Medical Service at the Utah Veterans
Administration Medical Center in Salt Lake City and was
responsible there for the care of veterans and also practiced
as a pulmonary physician and internal medicine specialist. Now,
I am seeing this dialog through a different set of eyes and
hope to share with you briefly some of my observations and
those of the AAMC.
This is about recruiting the very best and brightest to
serve those who have served the country, as Abraham Lincoln put
it so well. Unfortunately, we are all facing a major workforce
shortage in physicians as well as in nurses and other health
care professionals. Our workforce is aging, just as America is
aging. We also have a smaller pipeline to train health care
professionals, specifically with regard to physicians. Medical
school has not kept up with the growing population of the
United States.
In addition, residency training, and every physician in
order to become a licensed practitioner must train a minimum of
3 years and sometimes as many as 7 or 8 in order to practice a
specialty or sub-specialty, is capped in existing hospitals,
civilian hospitals that already have residency programs. This
does not make allowances for rapidly-growing States in the
West. One example of that: we are 47th out of 50 States with
respect to physicians in the workforce; and 50th out of 50 with
respect to nurses, and we have the lowest number of physicians-
in-training and residencies of any State in the Union with the
medical school. So, we are particularly aware, keenly aware, of
these problems with the pipeline.
The VA has taken a leadership role in trying to address
these issues. It has increased its residency training, as I
note in my written testimony, and has increased each year and
is trying to go from 9 percent to 11 percent of the total
training opportunities for medical residents in this country.
This is extremely important. Residents who train at the VA
are much more likely to have a favorable perception of working
in the VA, and I would like to add for the record that my own
perception of working in the VA, both in a leadership position
and as a practicing physician, was entirely positive. I left
the institution with great regard for the staff, the nurses,
the physicians, the leadership; particularly high regard for
the veterans who served our country; and for many reasons, it
can be a very attractive work environment for a physician. But
if you are not exposed to that environment, you won't learn the
benefits of working in it.
We heard in earlier testimony some of the challenges in
obtaining specialists to work in the VA, and I think that there
are a number of issues that could help in this regard. The
average medical student graduates with a debt of approximately
$140,000. That is before they enter their residency training.
Loan repayment, we think, and the legislation sponsored by
Senator Durbin is an important step forward in this regard--
would be a very attractive incentive. It has worked well to
recruit physicians to rural locations that are underserved in
the National Health Service Corps and I believe it would be a
very positive enhancement for the VA.
A robust academic affiliate is absolutely essential. You
heard from two of the best Veterans Administration hospitals
with respect to their relationships with their peer academic
institutions--from Ms. Cullen, the Director of the San
Francisco VA, and Mr. Kleinglass, the Director of the
Minneapolis VA. These are paradigms of what can be achieved
when there is a successful partnership between academia and a
Veterans Administration hospital. This standard is one we all
strive for. It is not always met because of challenges within
the local environment.
A critical part of this is Veterans Administration research
and development. One of the attractive lures for young
physicians to join the VA is access to a separate pot of money
which is restricted to VA physicians and researchers.
Unfortunately, over the past several years, despite this
Committee's great efforts in the past year to secure more
funding, the VA research infrastructure and the research budget
have suffered, and I believe that this is well worth the
attention of the Committee in terms of being a very positive
incentive for attracting promising young physician scientists
into the VA system. It is a crisis nationally.
Our young physicians, physician scientists like myself, are
simply not choosing an academic path because of the
difficulties in funding. The first independent research award,
for example, granted to M.D.s does not occur until the mid-
40's, which is an astonishing figure to me, and the VA research
environment can do a lot to reverse this trend and to recruit
the best and brightest into the VA hospitals.
That concludes my spoken testimony, Mr. Chairman. Thank
you.
[The prepared statement of Dr. McDonald follows:]
Prepared Statement of John A. McDonald, M.D., Ph.D., Vice President for
Health Sciences and Dean of the University of Nevada School of
Medicine; and Member of the Association of American Medical Colleges,
Veterans Affairs-Deans Liaison Committee
Good morning and thank you for this opportunity to testify on the
recruitment and retention of health professionals at the Department of
Veterans Affairs (VA). I am Dr. John McDonald, Vice President for
Health Sciences and Dean of the University of Nevada School of Medicine
and a member of the Association of American Medical Colleges (AAMC) VA-
Deans Liaison Committee. I also recently served as the Chief of
Medicine at the Salt Lake City VA Medical Center. The University of
Nevada is affiliated with the Reno and Las Vegas VA medical centers of
the Sierra Pacific and Desert Pacific Veterans Integrated Service
Networks (VISNs 21 and 22, respectively).
The AAMC is a not-for-profit association representing all 129
accredited U.S. medical schools; nearly 400 major teaching hospitals
and health systems, including 68 Department of Veterans Affairs medical
centers; and 94 academic and scientific societies. Through these
institutions and organizations, the AAMC represents 109,000 faculty
members, 67,000 medical students, and 104,000 resident physicians.
I would like to thank the committee for your support of the
Veterans Health Administration (VHA) in the fiscal year 2009 budget
resolution. Your leadership resulted in the Senate's passage of $48.2
billion for fiscal year 2009 discretionary veterans programs, including
medical care.
For the Veterans Health Administration programs in fiscal year
2009, the AAMC recommends $42.8 billion for VA medical care, $55
million for VA Medical and Prosthetic Research, and $45 million for VA
research facilities improvement. This funding is crucial to the
continued success of the primary sources of VA's physician recruitment
and retention: academic affiliations, graduate medical education, and
research.
physician shortage
Concerns about physician staffing at the VA come at the same time
the Nation faces a pending shortage of physicians. Recent analysis by
the AAMC's Center for Workforce Studies indicates the United States
will face a serious doctor shortage in the next few decades. Our
Nation's rapidly growing population, increasing numbers of elderly
Americans, an aging physician workforce, and a rising demand for health
care services all point to this conclusion.
Many areas of the country and a number of medical specialties are
already reporting a scarcity of physicians. Approximately 30 million
people now live in federally designated physician shortage areas. An
acute national physician shortage would have a profound effect on
access to VA health care, including longer waits for appointments and
the need to travel farther to see a doctor.
Currently, 744,000 doctors practice medicine in the United States.
But 250,000--one in three of these doctors--are over age 55 and are
likely to retire during the next 20 years, just when the baby boom
generation begins to turn 70. The annual number of physician retirees
is predicted to increase from more than 9,000 in 2000 to almost 23,000
in 2025. Meanwhile, since 1980, the number of first-year enrollees in
U.S. medical schools per 100,000 population has declined annually.
Consequently, America is producing fewer and fewer doctors each year
relative to our continually growing population.
Because it can take as many as 7 to 10 years after college
graduation until new doctors enter practice, the AAMC believes that we
must begin to act now to avert a physician shortage. Specifically:
The AAMC has called for a 30 percent increase in U.S.
medical school enrollment by 2015, which will result in an additional
5,000 new M.D.s annually.
To accommodate more M.D. graduates, the AAMC supports a
corresponding increase in the number of federally supported residency
training positions in the Nation's teaching hospitals.
recruitment incentives
With difficulty recruiting health professions, the VA in some cases
has similar characteristics to certain rural and urban areas,
population groups, or medical facilities designated as ``underserved''
by the U.S. Department of Health and Human Services. The National
Health Service Corps (NHSC) has a proven track record of expanding
access for underserved populations by supplying physicians to federally
designated shortage areas. The NHSC provides scholarship and loan
forgiveness awards in exchange for service in qualifying ``health
professions shortage areas'' (HPSAs). After 5 years of service, the
majority of physicians are able to forgive their entire educational
debt.
Similarly, the VA's Education Debt Reduction Program (EDRP)
provides newly appointed VA health care professionals with educational
loan repayment awards. However, the EDRP is limited to $49,000 spread
out over 5 years of service. As the average medical education
indebtedness has climbed to over $140,000 in 2007, the limited EDRP
awards fail to provide an adequate incentive for most physicians.
The AAMC has had initial discussions with Senator Dick Durbin's
office regarding the ``Veterans Health Care Quality Improvement Act of
2007'' (S. 2377), which has been referred to the Senate Committee on
Veterans Affairs for consideration. The AAMC is strongly supportive of
the bill's proposed increases for VA physician educational loan
repayment in exchange for at least 3 years of service in ``hard-to-fill
positions,'' as determined by the VA. Under this program, VA physicians
would be eligible for up to $30,000 in loan forgiveness per year until
their medical education debt had been repaid.
academic affiliations
The affiliations between VA medical centers and the Nation's
medical schools have provided a critical link that brings expert
clinicians and researchers to the VA health system. The affiliations
began shortly after World War II when the VA faced the challenge of an
unprecedented number of veterans needing medical care and a shortage of
qualified VA physicians to provide these services. As stated in seminal
VA Policy Memorandum No. 2 published in 1946, the affiliations allow VA
to provide veterans ``a much higher standard of medical care than could
be given [them] with a wholly full-time medical service.''
Over six decades, these affiliations have proven to be mutually
beneficial by affording each party access to resources that would
otherwise be unavailable. It would be difficult for VA to deliver its
high quality patient care without the physician faculty and medical
residents who are available through these affiliations. In return, the
medical schools gain access to invaluable undergraduate and graduate
medical education opportunities through medical student rotations and
residency positions at the VA hospitals. Faculty with joint VA
appointments are also afforded opportunities for research funding that
are restricted to individuals designated as VA employees.
These faculty physicians represent the full spectrum of generalists
and specialists required to provide high quality medical care to
veterans, and, importantly, they include accomplished sub-specialists
who would be very difficult and expensive, if not impossible, for the
VA to obtain regularly and dependably in the absence of the
affiliations. According to a 1996 VA OIG report, about 70 percent of VA
physicians hold joint medical school faculty positions. These jointly
appointed clinicians are typically attracted to the affiliated VA
Medical Center both by the challenges of providing care to the veteran
population and by the opportunity to conduct disease-related research
under VA auspices.
At present, 130 VA medical centers have affiliations with 107 of
the 129 allopathic medical schools. Physician education represents half
of the over 100,000 VA health professions trainees. In a 2007 Learners
Perceptions Survey, the VA examined the impact of training at the VA on
physician recruitment. Before training, 21 percent of medical students
and 27 percent of medical residents indicated they were very or
somewhat likely to consider VA employment after VA training. After
training at the VA, these numbers grew to 57 percent of medical
students and 49 percent of medical residents.
va graduate medical education
Today, the VA manages the largest graduate medical education (GME)
training program in the United States. The VA system accounts for
approximately 9 percent of all GME positions in the country, supporting
more than 2,000 ACGME-accredited programs and 9,000 full-time medical
residency training positions. Each year approximately 34,000 medical
residents (30 percent of U.S. residents) rotate through the VA and more
than half the Nation's physicians receive some part of their medical
training in VA hospitals.
As our Nation faces a critical shortage of physicians, the VA has
been the first to respond. The VA plans to increase its support for GME
training, adding an additional 2,000 positions for residency training
over 5 years, restoring VA-funded medical resident positions to 10 to
11 percent of the total GME in the United States. The expansion began
in July 2007 when the VA added 342 new positions. These training
positions address the VA's critical needs and provide skilled health
care professionals for the entire Nation. The additional residency
positions also encourage innovation in education that will improve
patient care, enable physicians in different disciplines to work
together, and incorporate state-of-the-art models of clinical care--
including VA's renowned quality and patient safety programs and
electronic medical record system. Phase 2 of the GME enhancement
initiative has received applications requesting 411 new resident
positions to be created in July 2008.
va-aamc deans liaison committee
The smooth operation of VA's academic affiliations is crucial to
preserving the health professions workforce needed to care for our
Nation's veterans. The VA-AAMC Deans Liaison Committee meets regularly
to maintain an open dialog between the VA and medical school affiliates
and to provide advice on how to better manage their joint affiliations.
The committee consists of medical school deans and VA officials,
including the VA Chief Academic Affiliations Officer, the VA Chief
Research and Development Officer, and three Veterans Integrated Service
Network (VISN) directors. The committee's agendas usually cover a
variety of issues raised by both parties and range from ensuring
information technology security to the integrity of sole-source
contracting directives.
Recently, the VA-Deans Liaison Committee has reviewed the
remarkable progress being made on several VA initiatives. These
include:
Establishment of the Blue-Ribbon Panel on Veterans Affairs Medical
School Affiliations--This panel will provide advice and
consultation on matters related to the VA's strategic planning
initiative to assure equitable, harmonious, and synergistic
academic affiliations. During the panel's deliberations, those
affiliations will be broadly assessed in light of changes in
medical education, research priorities, and the health care needs
of veterans.
Survey of Medical School Affiliations--The AAMC has worked with VA
staff to develop criteria to evaluate the ``health'' of individual
affiliation relationships. The ``Affiliation Governance Survey''
will survey the leadership at both the VA medical centers and their
affiliated schools of medicine on a range of topics including:
Overall satisfaction and level of integration;
Affiliation Effectiveness Factors (such as education,
research, VA clinical practice environment, and faculty
affairs);
Overall commitment to the affiliation relationship;
Academic affiliations partnership councils (Dean's
committees); and
Direction and value of school of medicine-VA medical
center affiliations.
Development of VA Handbook on VHA Chief of Staff Academic
Appointments--To prevent conflicts of interest or the appearance
thereof, the VA has determined that limits on receiving
remuneration from affiliated institutions are necessary for VHA
chiefs of staff and higher levels. While it is important to ensure
that remuneration agreements do not create bias in the actions of
VHA staff, prohibition of certain compensation from previous
academic appointments (e.g., honoraria, tuition waivers, and
contributions to retirement funds) could significantly hinder the
VA's ability to recruit staff from their academic affiliates. The
AAMC has worked with VA staff to develop a mutually acceptable
agreement that considers this balance.
Piloting the VA physician time and attendance/hours bank--
Monitoring physician time and attendance for the many medical
faculty holding joint appointments with VA medical centers has been
complicated and inefficient. The VHA has accepted the ``hours
bank'' concept to improve the tracking of part-time physician
attendance. Under the hours bank, participating physicians will be
paid a level amount over a time period agreed to in a signed
Memorandum of Service Level Expectations (MSLE). This agreement
will allow the supervisor and participating physician to negotiate
and develop a schedule for the upcoming pay period. A subsidiary
record will track the number of hours actually worked, and a
reconciliation will be performed at the end of the MLSE period to
adjust for any discrepancies. A pilot for this program has been
successfully completed and plans for nationwide implementation are
underway.
The VA has consistently recognized that there is always room for
improvement. As such, the AAMC looks forward to working on other items
of concern as the VA continues to evaluate its affiliation policies and
processes. As medical care shifts to a more satellite-based outpatient
approach, graduate medical education needs to follow suit. This strong
shift to ambulatory care at multiple sites requires a similar change in
the locus of medical training. A dispersion of patients to multiple
sites of care makes more difficult the volume of patient contact that
is crucial to medical training. Similarly, faculty diffusion to
multiple sites also makes more difficult the development of a culture
of education and training. This is not exclusively a VA problem and all
of our Nation's medical schools and teaching hospitals are working to
cope with this shift.
Another concern at both VA and non-VA teaching hospitals is the
growing salary discrepancy between more specialized fields of medicine
and the other disciplines. With the ``Department of Veterans Affairs
Health Care Personnel Enhancement Act of 2003'' (Pub. L. 108-445,
dubbed the ``VA-Pay bill''), the VA made significant strides beyond its
private-hospital counterparts. However, this discrepancy continues to
be an issue of concern. Once again, this is not exclusively a VA
problem, but one faced by all medical schools and teaching hospitals.
va medical and prosthetic research program
To accomplish its aforementioned mission, VHA acknowledges that it
needs to provide ``excellence in research,'' and must be an
organization characterized as an ``employer of choice.'' The VA Medical
and Prosthetic Research program is one of the Nation's premier research
endeavors and attracts high-caliber clinicians to deliver care and
conduct research in VA health care facilities. The VA research program
is exclusively intramural; that is, only VA employees holding at least
a five-eighths salaried appointment are eligible to receive VA awards.
Unlike other Federal research agencies, VA does not make grants to any
non-VA entities. As such, the program offers a dedicated funding source
to attract and retain high-quality physicians and clinical
investigators to the VA health care system.
VA currently supports 5,143 researchers, of which nearly 83 percent
are practicing physicians who provide direct patient care to veteran
patients. As a result, the VHA has a unique ability to translate
progress in medical science directly to improvements in clinical care.
The VA Research Career Development Program attracts, develops, and
retains talented VA clinician scientists who become leaders in both
research and VA health care. For VA clinical investigators, the awards
(normally 3-5 years) provide protected time for young investigators to
develop their research careers. Awardees are expected to devote 75
percent time to research as well as to apply for additional VA Merit-
Reviewed funding and non-VA research support. The remainder of their
time is devoted to non-research activities such as VA clinical care or
teaching. The program is designed to attract, develop, and retain
talented VA researchers in areas of particular importance to VA. The
Office of Research and Development supports approximately 458 awardees,
at a cost of $55 million in fiscal year 2006, in all areas of medical
research including basic science, clinical medicine, health services
and rehabilitation research. The VA retains approximately 56 percent of
participants as VA principal investigators. This research program, as
well as the opportunity to teach, is a major factor in the ability of
VA to attract first class physician talent.
Since 2005, inadequate funding for VA research has forced the
Department to cap many VA merit-review awards at a mere $125,000
annually. The current cap fails to keep pace with biomedical inflation
and VA's commitment to scientific innovation. The cap--which is
significantly lower than the average award at comparable Federal
research programs--is a tradeoff that VA leadership has had to make to
continue funding the same number of grants it has historically
supported. To compete with its private counterparts, funding for VA
research must be steady and sustainable while allowing for innovative
scientific growth to address critical emerging needs. For fiscal year
2009, the AAMC recommends an appropriation of $555 million for the VA
Medical and Prosthetic Research program.
earmarks and designation of va research funds
The AAMC opposes earmarks because they jeopardize the strengths of
the VA Research program. VA has well-established and highly refined
policies and procedures for peer review and national management of the
entire VA research portfolio. Peer review of proposals ensures that
VA's limited resources support the most meritorious research.
Additionally, centralized VA administration provides coordination of
VA's national research priorities, aids in moving new discoveries into
clinical practice, and instills confidence in overall oversight of VA
research, including human subject protections, while preventing costly
duplication of effort and infrastructure.
VA research encompasses a wide range of types of research.
Designated amounts for specific areas of research compromise VA's
ability to fund ongoing programs in other areas and force VA to delay
or even cancel plans for new initiatives. While Congress certainly
should provide direction to assist VA in setting its research
priorities, earmarked funding exacerbates resource allocation problems.
AAMC urges the Committee to continue preserving the integrity of the VA
research program as an intramural program firmly grounded in scientific
peer review. These are principles under which it has functioned so
successfully and with such positive benefits to veterans and the Nation
since its inception.
va research infrastructure
State-of-the-art research requires state-of-the-art technology,
equipment, and facilities. Such an environment promotes excellence in
teaching and patient care as well as research. It also helps VA recruit
and retain the best and brightest clinician scientists. In recent
years, funding for the VA medical and prosthetics research program has
failed to provide the resources needed to maintain, upgrade, and
replace aging research facilities. Many VA facilities have run out of
adequate research space. Ventilation, electrical supply, and plumbing
appear frequently on lists of needed upgrades along with space
reconfiguration. Under the current system, research must compete with
other facility needs for basic infrastructure and physical plant
support that are funded through the minor construction appropriation.
To ensure that funding is adequate to meet both immediate and long
term needs, the AAMC recommends an annual appropriation of $45 million
in the VA's minor construction budget dedicated to renovating existing
research facilities and additional major construction funding
sufficient to replace at least one outdated facility per year to
address this critical shortage of research space.
Mr. Chairman and Members of the Committee, thank you for the
opportunity to testify on this important issue. I hope my testimony
today has demonstrated that the recruitment and retention of an
adequate physician workforce is central to the success of VA's mission.
The extraordinary partnership between the VA and its medical school
affiliates, coupled with the excellence of the VA Medical and
Prosthetics Research program, allows VA to attract the Nation's best
physicians. Over the last 60 years, we have made great strides toward
preserving the success of our affiliations. With the hard work of VA-
AAMC Deans Liaison Committee and the VA's Blue Ribbon Panel on Medical
School Affiliations, I am confident that this success will continue.
______
Response to Written Questions Submitted by Hon. Patty Murray to John A.
McDonald, M.D., Ph.D., Vice President for Health Sciences and Dean,
University of Nevada School of Medicine on Behalf of the Association of
American Medical Colleges, Veterans Affairs-Deans Liaison Committee
Dear Senator Murray: Thank you for your inquiry regarding my
testimony before the Senate Committee on Veterans' Affairs. Here are my
responses.
incentives for recruitment
Question 1. Dr. McDonald, I know that many questions have been
discussed to deal with the VHA's workforce issues. Things such as
signing bonuses, loan repayment, relocation expenses, and retention
bonuses for those already employed.
What are some of the other things that we can do to attract people
to the VHA, particularly with regard to rural areas?
Response. Several possible strategies are worth considering,
including:
Providing medical student scholarships with forgiveness
for service clauses, emphasizing students from rural areas. Our own
students who come from rural Nevada are more comfortable there, and
more likely to relocate to rural areas upon completion of training.
Create robust telemedicine links between rural practices
and VA medical centers, to create a more supportive virtual environment
for the solo or small group clinic.
Set up a formal mentorship/partnership between rural
providers and VA facilities the rural provider will be referring
patients to.
Work with the AAMC, ACGME and schools of medicine to
encourage residency training in VA rural sites as part of their
outpatient experience. As I noted in my testimony, exposure to the VA
medical environment is key in altering perceptions of caregivers.
va research cuts
Question 2. Dr. McDonald, in your testimony you mentioned that the
VA Medical and Prosthetic Research program ``attracts high-caliber
clinicians to deliver care and conduct research in VA health care
facilities.'' As you know, the President cut funding for this critical
program in his fiscal year 2009 budget request.
Can you discuss in more detail what budget cuts to the VA's
research budget does to the morale of VA's current workforce and how it
impacts the department's ability to recruit high quality health care
professionals?
Response. My experience includes serving as chief of medicine in a
VA facility, NIH funded investigator within the VA system, brief tenure
as ACOS for Research and Development, and meetings with central VA
administration. Based on this and discussions with fellow deans of
medicine, I believe that the diminishing VA research budget, combined
with aging and inadequate research facilities at many stations, has a
very deleterious effect upon morale, recruitment and retention.
Historically, the VA has been seen as an environment fostering the
development of young physician investigators and Ph.D. scientists. It
was this atmosphere of inquiry and scholarship that attracted and kept
the best and brightest investigators and physicians within the VA. Now,
more than ever, the VA and those it serves will benefit from the
development and application of new diagnostic and therapeutic
modalities, driven by these highly motivated individuals.
dod and va collaboration
Question 3. Over the past couple of years, there has been a lot of
attention focused on the seamless transition between the VA and the DOD
when it comes to information sharing.
Thinking along those lines, is there any way that the VHA and the
DOD could pool together and share some of their resources to fill in
some of the gaps in clinical coverage?
Response. I have read the testimony presented for the Record by the
Honorable Gordon England, Deputy Secretary of Defense, and the
Honorable Gordon Mansfield, Deputy Secretary of Veterans Affairs before
the Senate Committee on Armed Services on 13 February 2008. I have
little to add to this report, as this specific topic is not one that I
have experience in. It would appear as you point out that the move
toward seamless sharing of medical information between DOD and VA is of
particular benefit in facilitating the care of our wounded veterans. In
addition, where possible, sharing physicians and other care givers
between VA and DOD facilities could be used to extend services of
scarce specialties or ameliorate local shortages in care givers.
Chairman Akaka. Thank you very much, Dr. McDonald.
Ms. O'Meara?
STATEMENT OF VALERIE O'MEARA, N.P., VA PUGET SOUND HEALTH CARE
SYSTEM, PROFESSIONAL VICE PRESIDENT, AMERICAN FEDERATION OF
GOVERNMENT EMPLOYEES LOCAL 3197
Ms. O'Meara. Chairman Akaka, Mr. Rockefeller, and Ms.
Murray, thank you for inviting me here to testify today. My
name is Valerie O'Meara. I am from Seattle, Washington. I have
worked as a primary care and emergency room nurse practitioner
at the VA Puget Sound Health Care System for the past 13 years,
which is my entire career as a nurse practitioner. I am also a
union representative for the nurses, physicians, and other
health care professionals at my facility.
In 1993, the VA paid all of my tuition plus a stipend so I
could attend the University of Pennsylvania to pursue my
master's degree in nursing. In exchange, I had to work at the
VA for 2 years. Obviously, I am still there, and why is that?
It is because I love working with the veterans and taking care
of the veterans. I get so much professional fulfillment from
helping them and knowing that they really need the care that we
provide. My own father is a Korean War veteran, and I can think
of no better place to gain valuable experience than as a front-
line health care provider in the VA. We get exposed to such a
wide range of medical issues. The VA is a terrific learning
environment, as has been attested to, as well.
At Puget Sound, we get to consult often with the medical
faculty of the University of Washington. We have regular in-
services where we discuss ongoing research and how to apply it
to our practice. The VA is a true culture of learning.
So, why am I seeing so many nurses quit the VA after a few
years, especially ward nurses or staff nurses? First, it is so
difficult for them to get the type of pay they see nurses
getting in private hospitals right nearby. Our nurses are not
getting the flexible work schedules that are so popular in
nursing today. And with too little staff to care for the
veterans, the work environment becomes highly stressful and low
on respect for the employees' ability to make good decisions.
When it comes to getting educational help, not everyone has
had as good of an experience as I had. For example, right now,
I am battling a case for a nurse practitioner in which the VA
is trying to withhold the remaining 3 years of her promised
EDRP, or Education Debt Reduction Program payments, because
they are insisting--incorrectly, we believe--that she
transferred to an ineligible nursing position. Management is
not only reading the law wrong, they are letting this drag on
for over 3 years. Both the local and the central office EDRP
managers, each are denying that they have authority for
declaring that nurse ineligible.
We fought another battle over educational assistance that
shows how often management doesn't understand these programs.
An R.N. at Puget Sound got her master's degree to become a
nurse practitioner with the help from the NNEI Program, but
human resources and nursing refused to hire her when an NP
vacancy came up in the area she was already working in as a
nurse, claiming she didn't have enough experience as a nurse
practitioner. In the meantime, we had to fight just to get her
enough hours to maintain her new license, because you do have
to practice in the State of Washington to maintain your
licensure. She finally quit out of frustration and got hired
immediately as a nurse practitioner at the University of
Washington.
EDRP and other education assistance programs are clearly a
win-win for management, veterans, and employees carrying large
school debts. But, managers need to understand them and
facilities need enough sense so applicants are no longer turned
away, especially when funds are lying around unused in other VA
facilities.
We all know how expensive education is these days, and as a
parent, I certainly worry about it. It would also be helpful to
increase the amount of assistance that can be given to each
employee in the program to keep up with today's tuition costs.
A few years ago, we learned that the VA was no longer
offering EDRP for continuous open announcements. Instead,
rather, it was linking EDRP offers to specific position
announcements and I think this is short-sighted. EDRP should be
offered throughout nursing and throughout other professional
jobs. I also think it could be a great retention tool if it
were offered not to just new employees, because it would help
hold on to the nurses the VA has already invested in.
I also don't understand why management is so resistant to
conducting nurse locality pay surveys to keep us competitive--
and we have to stay competitive. In Seattle, the private sector
lures our nurses away with huge pay increases all the time.
When management does these surveys, we, as employees and union,
are kept in the dark. They don't tell us when they conduct
third-party surveys at my facility, for example; and when we
tried to access the survey data--data that we need to be sure
that our pay is being correctly set--we are turned down and
told we can't challenge it through the grievance process.
We recently had to go through a long and difficult process
to get more pay for advanced practice nurses. First, we asked
for a one-time retention pay increase from our nurse executive.
And the reason we did that is because she had declared us
officially ``difficult to recruit and retain'' about 6 months
prior. She insisted on tying the retention bonus or pay to a
performance standard, even though that is not what the law
says. We submitted a petition with approximately 20 signatures
of advance practice nurses, and only after the new director had
recently arrived, he saw the petition and that is when we
learned that, in fact, a locality pay survey had recently been
done. He looked at it again and decided to give us a raise, and
we do want to give him kudos for that. He acted very quickly
and we got a substantial raise.
The Locality Pay System definitely needs to be more
transparent and conducted with a better understanding of the
survey process. so nurses don't have to go through such
frustration and delays.
I am fortunate that the VA lets me work part-time so I can
spend more time with my 4- and 6-year-old boys. But I only
learned recently, after the fact, that there is a real cost to
being a part-time nurse at the VA. I worked full-time for
approximately 5 years before switching to part-time, and as a
full-time nurse, I went through my two-year probationary period
and became a permanent employee with grievance rights,
reduction-in-force rights, and other appeal rights. No one ever
explained to me that I would lose all of these rights and
essentially had become an ``employee at will'' when I became
part-time.
And parents are not the only ones who may need to work
part-time. Since I started at Puget Sound, the nursing
workforce has gotten noticeably older. There are nurses who
have worked at the VA for a very long time who want to switch
to part-time because, out of many reasons, one is that they are
caregivers for their elderly parents or they need to reduce the
stress of this very demanding job.
It seems only fair that full-time nurses become permanent
employees with appeal rights and job security after 2 years,
that part-timers should earn the same rights when they work the
equivalent of 2 years. And for nurses like me who already went
through a 2-year probationary period, we should not have to go
through it again just because we now fall under a different
section of the law. One thing is certain. I am going to make
top priority to educate our nurses about the tradeoffs of part-
time employment.
I want to close by expressing my hope that we can go back
to the labor-management partnerships that used to be in place
at the VA, to work together to improve patient care and working
conditions. Nurses at Puget Sound who are part of these
partnerships tell me how great it was to have their opinions
valued and to feel like they had an equal voice in making VA
health care even better for the veterans. Isn't it easier to
work together than to be at odds, after all?
Thank you again for the great honor of testifying before
this Committee.
[The prepared statement of Ms. O'Meara follows:]
Prepared Statement of Valerie O'Meara, N.P., Professional Vice
President, AFGE Local 3197, VA Puget Sound Health Care System, Seattle,
Washington, on Behalf of American Federation of Government Employees,
AFL-CIO
Dear Chairman and Members of the Committee: On behalf of the
American Federation of Government Employees (AFGE), I thank you for the
opportunity to testify regarding recruitment and retention of
Department of Veterans' Affairs (VA) health care professionals.
Throughout my thirteen-year career as a Nurse Practitioner (NP), I
have worked at the VA Puget Sound Health care System in Seattle,
Washington. As the Professional Vice President of AFGE Local 3197 at
Puget Sound, I am also in regular communication with other nurses and
health care professionals at my facility. Through my participation in
the VISN 20 Advanced Practice Nurse (APN) Advisory Group to the Office
of Nursing Service and AFGE National VA Council discussion forums, I
also hear a great deal about what health professionals at other
facilities are experiencing.
We feel as if we have to fight harder each year for the pay and
working conditions that we should be entitled to by law. The VA is
losing nurses to private sector jobs where the pay is more competitive,
shifts are more flexible and their input into hospital matters are more
valued. In my facility, I see many RNs and NPs leave in frustration
after only a few years with the VA. This turnover is very expensive. As
I recently pointed out to management in an effort to secure APN
retention pay, nursing research shows that the replacement cost of a
nurse in an acute care facility is at least twice that nurse's regular
salary. By the VA's own estimates, it costs $100,000 to bring on a new
nurse.
At the same time, our older nurses retire as soon as they can, and
many go on to work in the private sector. Nationwide, nearly two-thirds
of VA's registered nurses will be eligible to retire in 2010. Since I
have gotten there, the average age of nurses at Puget Sound has
increased noticeably.
It is especially frustrating for us to see Congress take steps to
address this impending crisis with good pay and scheduling laws, only
to have VA management undermine Congress' intent through loopholes,
delay, and inaction.
Our facility is less short staffed than some others, but we have
still seen an impact on veterans' care. Whenever our ICU is full, we
cannot take ambulance calls and veterans must be diverted elsewhere.
This seems to happen each winter, especially. As a result of huge
backlogs for outpatient care in urology, podiatry, and other
subspecialty clinics, patients with chronic illnesses such as diabetes
are not getting monitored as frequently as they should. Puget Sound has
massively increased its use of fee basis, non-VA providers to address
these backlogs. Better recruitment and retention policies would be a
preferable and less expensive alternative in the long run.
nurse locality pay
Nurse locality pay is a big source of frustration for VA nurses. In
my facility, we were facing a serious recruitment and retention problem
for APNs. We asked for retention bonuses and the Chief Nurse did
declare us ``hard to recruit.'' But instead of just giving us the
bonuses, she wanted to tie our bonuses to our performance and require
us to ``highly perform'' based on new criteria. We tried to explain to
her and Human Resources what the law said and submitted a petition
signed by almost 20 people. When the director arrived, he looked at a
locality pay survey (LPS) that we did not even know existed, and
decided to give us additional pay instead to address recruitment and
retention.
I believe that if management received more training on LPS, there
were be fewer problems across the country. Locality pay should be
provided based on local labor market conditions, and be paid according
to consistent rules, not on how hard employees fight for it or whether
a particular manager decides to pay it.
I hear many stories from other facilities about delays in
conducting surveys and management's unwillingness to share survey
information. It is also very troubling that in many facilities, nurse
managers receive their locality pay through separate, more favorable
survey data.
The 2000 law also requires the VA to report annually on turnover
rates, vacancies, staffing problems, and survey information from each
facility. I have never seen this data and would find it very valuable.
Therefore, I urge the Committee to strengthen these reporting
requirements.
Nurse Premium and Overtime Pay
RNs have expressed frustration at the inconsistent application of
premium pay (weekend pay and night shift differential pay) and overtime
pay. At Puget Sound, management attempted to deny overtime pay for work
above 8 hours because it involved charting, which management contended
was not direct patient care. Here, too, it was only after the union
contested this policy did they pay overtime according to the law.
Perhaps additional training on these pay provisions would also be
helpful.
Another problem is that nurses working on a part-time schedule are
not consistently receiving overtime pay for shifts longer than 8 hours
when the shift spans two calendar days.
More generally, we believe that the VA's premium and overtime pay
policies must be competitive with those of other workplaces. We urge
the Committee to take steps to ensure that premium pay is available to
all RNs who perform services on weekends or off shifts, work overtime
on a voluntary or mandatory basis, or work during on call duty, and
that overtime rules are applied properly.
Other Needed Pay Adjustments
CRNA Pay: Facilities around the country are finding it increasingly
difficult to recruit CRNAs. To ensure that VA's CRNAs can receive
locality pay increases needed to keep the VA competitive with local
market conditions, AFGE recommends lifting the current statutory pay
cap that prohibits any RN pay to exceed that of the facility's chief
nurse.
LPN Pay: Under current law (39 U.S.C. 7455), VA health care
personnel who are not covered by specific pay legislation can receive
special pay increases at the discretion of their directors to achieve
competitive pay levels. This provision sets a cap on the size of this
increase. Congress has exempted other professions (CRNAs, physical
therapists, and pharmacists) from this in order to keep their pay
competitive. LPNs are now facing similar problems receiving needed
special pay. Therefore, we urge this Committee to add LPNs to the
exempted group.
i. competitive nurse work schedule policies
In 2004, Congress provided VHA with two additional tools for
recruitment and retention of RNs: alternative work schedules (AWS) and
restrictions on mandatory overtime. As a result of delay and resistance
by the VA at the national and local levels, both tools have failed to
meet their potential for addressing VA nurse recruitment and retention
problems.
Currently, local directors have complete discretion as to whether
to offer AWS In my facility. The AWS schedule (either three 12-hour
days or 9 month schedules) are not offered, even though they are
available to nurses at other Seattle hospitals. Other VA nurses around
the country report the same problem. If we attempt to challenge this,
management says AWS is a nongrievable patient care issue under 39
U.S.C. 7422 (to be discussed.) It seems as if the law was never passed.
AFGE urges this Committee to hold the VA more accountable for
proper implementation of the AWS law. An important first step would be
to require the VA to provide data to Congress comparing the prevalence
of AWS in the VA as compared to private employers, by each local labor
market, in order to determine whether and to what extent the VA needs
to offer AWS to its nurses to remain a competitive nurse employer.
Restrictions on Mandatory Overtime
We are fortunate at Puget Sound that voluntary nurse overtime meets
the current need. However, I am aware of widespread problems in other
facilities, where nurses are forced to work overtime on a frequent
basis.
Once again, Congress' attempt to make VA hospitals safer and lessen
nurse burnout has been thwarted. The law permits the VA to require
overtime in cases of emergency. AFGE filed a national grievance to
require the VA apply a nationally uniform definition of emergency
consistent with common usage even though nine States (including
Washington) have passed such laws, VA successfully blocked our
challenge to the policy on emergencies based on ``7422.'' As a result,
facility directors continue to invoke the emergency exception when
staffing shortages are the result of easily anticipated scheduling and
hiring problems. AFGE urges the Committee to protect VA nurses and the
safety of their patients by enacting a statutory, workable definition
of emergency.
AFGE also supports expansion of overtime protections to LPNs and
Nursing Assistants.
Finally, AFGE urges the Committee to strengthen the requirement in
the overtime provision that VHA provide a report to Congress certifying
that facilities have implemented nurse overtime policies. Reports
issued to date appear to grant, without explanation, a large number of
waivers to facilities that have not developed overtime policies.
ii. part-time nurses
During my first 5 years at Puget Sound, I was full-time which meant
I had job security in the event of a RIF and grievance and arbitration
rights. When I switched to part-time to raise a family, I lost these
rights--but no one made me aware of this at the time. I have seen the
same thing happen to older nurses who have worked a decade or more for
the VA who switch to part-time because of the stress of their job or to
care for their aging parents. Now that I understand this two-tier
system, it is a top priority for me as a union representative to
educate our nurses about the tradeoffs of becoming part-time.
Part-time RNs represent a valuable resource for the VA. They should
be able to accrue the rights of permanent employees after they work the
equivalent of 2 years, just like their full-time colleagues. This will
be a valuable recruitment and retention tool for the VA. We urge the
Committee to take action to address this inequity.
iii. educational programs
The VA has excellent educational programs to use as recruitment and
retention tools, including the Education Debt Reduction Program (EDRP)
and National Nursing Education Initiative (NNEI). With adequate
funding, better resource allocation, and more national direction, these
programs could be even more effective. VA has a long tradition of
``growing its own'', i.e., training employees in lower level positions
to become registered nurses, and training RNs to become NPs.
One of the problems we are seeing is that once the employee
completes his or her training, the VA does not provide a suitable
position. At Puget Sound, one of our RNs got assistance through the
NNEI program to become an NP but management refused to hire her when an
opening came up so she quit.
Nurses at other facilities report problems with EDRP, a highly
effective program that ties tuition loan repayment to a commitment to
work at the VA. Applicants are being turned away at some facilities
because EDRP funds have been exhausted, while EDRP funds in other
facilities remain unused. In addition, the EDRP grant amounts need to
be raised to better match current educational costs.
iv. nurses need to be heard
I am proud that VA nurses have played such an essential role in the
past in transforming its health care system into a world leader in
health care quality and cost effectiveness.
According to a January 2008 VA national RN satisfaction survey, for
the past 2 years, ``Participation in Hospital Affairs'' was one of two
areas (along with staffing) where RNs were the least satisfied. Yet, VA
increasingly deprives front line nurses of meaningful opportunities for
input into groups shaping policies on key issues such as patient safety
and qualification standards. This hurts the veteran and the taxpayer as
well.
The VA keeps saying that magnet status is its most effective nurse
recruitment and retention tool because it is said to offer nurses a
voice in organizational decisionmaking. I hear reports from nurses in a
number of facilities that patient care dollars and substantial staff
time are being diverted to the process of preparing magnet applications
and paying large certification fees.
I find this very troubling and wasteful. VA has a long and
successful track record in soliciting and using input from front-line
nurses. The Department simply needs to return to a more collaborative
approach and bring the nurses back into policy setting groups where
they were once welcome, not use an expensive third party to hear from
its nurses.
v. recruitment and retention challenges in other
va health care professions
AFGE also urges the Committee to examine obstacles to VA's ability
to recruit and retain physicians and other professionals. In a health
care system of this magnitude that encompasses three different
personnel systems (Title 38, Title 5, and Hybrid Title 38) and hundreds
of local labor markets, one size will surely not fit all, but swift
action is needed nonetheless.
Physicians
VA physicians are facing great pressures to meet current patient
demand without additional resources. In my facility, management wants
to require physicians who take sick leave or vacation leave to make up
the clinics they canceled, either on the weekends, evenings or during
their administrative days that they need for other duties. If there
were enough physicians in the VA workforce, others could cover when
someone takes leave he or she has earned and needs.
At Puget Sound, we just lost our ER Director who was growing more
and more frustrated at management for refusing to provide extra staff.
Instead, ER doctors are required to work longer shifts. The ER has to
draw from other pools on an ad hoc basis to find physicians to fill the
gap. Clearly, a longer range staffing plan would be preferable.
Here too, the VA is undermining a valuable retention tool: the 2004
physician pay law (Pub. L. 108-445). Reduced reliance on contract
physician services was at the top of Congress' agenda when this
legislation. Based on our members' very mixed experiences with market
pay and performance pay awarded under the new law, we are very doubtful
that Congressional intent has been well served to date.
Unfortunately, the VA has not been forthcoming with its own data on
recruitment, retention, and contract care. Although the pay bill has
been in effect for 27 months, we have still not seen the 18 month
report that Congress required the VA to provide. We believe veterans
and the taxpayers deserve to see the evidence of whether contract care
is the best solution to current VA physician shortages. More
transparency in the pay process is greatly needed. In the market pay
process that was first conducted 2 years ago, management excluded
employee representatives from national groups that set pay ranges and
selected survey. Front line practitioners were largely excluded at the
local level from compensation panels setting individual pay, despite
requirements in the law to include them. AFGE's own attempts to obtain
information through the Freedom of Information Act were denied.
Annual physician performance pay awards under this law have been
inconsistent and unjustifiably lower than the maximum amounts set by
Congress. At many facilities, management has imposed improper
performance criteria that determine bonuses based on factors beyond the
practitioner's control, such as missed appointments. In very rare
instances have front line physicians been allowed to have input in the
selection of these critical criteria.
Unreasonable panel sizes are also causing severe morale problems
among VA physicians, particularly in primary care and psychiatry. Many
facilities keep raising their panel sizes, while others have simply
lifted the ceiling altogether! As a result, practitioners do not have
adequate time to assess the medical needs of new patients (e.g., no
additional time is allowed for a first time exam of veterans with
Traumatic Brain Injury) or enough patient openings to schedule needed
follow up for veterans with chronic illnesses that require frequent
monitoring. Management is also requiring them to work more weekend and
evening hours without compensation to meet growing demand.
Other VA Health Care Professionals
AFGE members report significant recruitment retention problems in
other VA professions due to pay policies and other factors. For
example:
Physician Assistants: Like physicians, physician assistants (PAs)
are also trying to deliver care in the face of unreasonable panel
sizes. In addition, PAs lack an effective voice for their profession at
the facility and national levels because the PA Advisor is only a part-
time position. AFGE supports pending House legislation (H.R. 2790) to
establish a full-time PA Advisor. AFGE also urges legislative action to
more closely align PA pay and benefits, including professional
education assistance, with the private sector.
Podiatrists: The demand for podiatry services is rising among
elderly veterans with chronic illnesses and injured OEF/OIF veterans.
Unfortunately, the VA's compensation package for podiatrists has been
largely unchanged since 1976. As a result, the pay gap between the VA
and private sector is widening, causing severe recruitment and
retention problems.
Psychologists and the Hybrid Boarding Process: As part of the
``hybrid Title 38'' group of VA health care professionals,
psychologists are required to go through a one-time boarding process to
secure hybrid status and obtain promotions. Delays in the boarding
process have been especially long and demoralizing: some psychologists
have still not received their promotions 2 years after issuance of the
board's recommendation. At a time when the VA is significantly
increasing its mental health capacity, it is especially important that
oversight from Congress and VA Central Office is increased to ensure
that local facilities are carrying out the hybrid boarding process
properly. More generally, AFGE is concerned about widespread delays in
the hybrid boarding process that in some cases, are greater than hiring
under Title 5. As a result, applicants awaiting credentialing and
salary offers end up leaving for other positions because of long
delays.
vi. other recruitment and retention issues
FERS Sick Leave: Currently, most Federal employees covered by the
FERS retirement system cannot apply unused sick leave toward
retirement, while their counterparts under the older CSRS system can.
Congress carved out an exception under Title 38 for RNs several years
ago. We urge that this benefit be extended to all VHA personnel as an
added incentive for staying with the VA.
Disincentives in the Current Funding Process: Recruitment and
retention strategies depend on a workable funding process. So long as
VA health care relies on discretionary dollars, the system will suffer
from unpredictable and inadequate funding. In turn, facility directors
will continue to be rewarded for keeping a lid on their spending
through fewer pay increases, promotions, and less hiring.
Title 38 Collective Bargaining Rights: As noted, VA's health care
professionals are unable to challenge workplace policies on pay,
scheduling, and other policies that hurt recruitment and retention,
even when these policies are directly inconsistent with Congressional
intent. Management asserts ``nongrievability'' under 38 USC 7422 in
more and more instances. We greatly appreciate the important step that
Senator Rockefeller and cosponsors Senators Webb, Brown, and Mikulski
have taken by introducing S. 2824 to restore these critical rights.
Thank you.
______
Response to Written Questions Submitted by Hon. Daniel K. Akaka to
Valerie O'Meara, N.P., VA Puget Sound Health Care System, Professional
Vice President, American Federation of Government Employees Local 3197
Question 1. How effective is the locality pay system at your
facility? Does your facility employ temporary health workers,
particularly in the area of nursing?
Response. The locality pay system could be improved at our
facility. There is no transparency so it is impossible for me to state
how effective it is. The most disturbing example of this occurred in
the summer of 2007. Several of my Nurse Practitioner (NP) colleagues
had commented to me that they felt they were not being competitively
paid. In response, as the unit professional vice president, I drafted a
memo to this effect to management that was signed by many of the NP
staff. At this time the facility had a relatively new Director. Within
approximately 2 weeks the Chief Nurse Executive and the Director met
with the NPs and told them they had decided to take another look at a
recent salary survey and in doing so had decided that an approximately
13% salary raise was in order. Staff believed this confirmed that
salary survey data was only acted upon via staff complaints and has led
to mistrust of the locality pay system.
My facility does employ temporary health workers. For example,
there is only one staff emergency room physician. All the rest are fee
basis or locum tenens. There are temporary nursing staff throughout the
hospital.
Question 2. Multiple alternative work schedules are available at
facilities around the country, from condensed work weeks to intensive 9
month schedules. How prevalent is use of the various alternative work
schedules at your facility, and how could VA make better use of these
schedules while maintaining quality of care for veterans?
Response. The use of alternate work schedules is concentrated in
the areas of intensive care and emergency room, where compressed
schedules are used. However, there is no use of the schedules
authorized by Public Law 108-445. One reason given by Management why
these alternate work schedules are not used is that there is no patch
in the pay system to allow them. The other reason that the alternate
schedules cannot be used is because there are not enough nursing staff
overall to fill the staffing need created by the schedules. The reason
given for not enough staff is that nurses are not applying for the
jobs. VA needs to create an attractive work environment to compete for
nursing personnel, which may mean spending a little more money.
Question 3. What role have VA education incentive programs played
in your careers, and how do you think these programs could be improved
to encourage further education and improve recruitment and retention?
Response. VA education incentive programs have been very popular at
my medical center. I am a good example. I received a Health
Professional Scholarship which paid for my Master's Degree in Nursing
that included tuition, books, and a stipend.
The program required a 2-year work commitment and I have been with
VA for 14 years. The Health Professional Scholarship program should be
re-instated. It was a very simple process, with tuition paid directly
to the school. This is a powerful incentive to recruitment and
retention. There also needs to be a guarantee that the participant will
be offered an appropriate assignment upon graduation that is the
responsibility of management rather than the participant. One problem
currently is that Nurse Practitioners are graduated but then not
offered an assignment as a NP, so are forced to leave VA in order to be
able to maintain their state licensure and board certification. This
defeats the purpose of the programs.
Chairman Akaka. Thank you, Ms. O'Meara.
Dr. Phelps?
STATEMENT OF RANDY PHELPS, PH.D., DEPUTY EXECUTIVE DIRECTOR,
AMERICAN PSYCHOLOGICAL ASSOCIATION PRACTICE DIRECTORATE
Mr. Phelps. Thank you, Mr. Chairman. Chairman Akaka,
Senator Murray, and Senator Rockefeller, I am Randy Phelps,
Deputy Executive Director for Professional Practice at the
American Psychological Association. We are the largest
association of psychologists, with approximately 90,000
doctoral members and another 50,000 graduate student members in
the pipeline to become psychologists, 75 percent of whom will
become practitioners and a great number of whom we hope will
serve this Nation's veterans. I am also a licensed clinical
psychologist and former practitioner, but for the past 15
years, on APA's executive staff. I have also served as APA's
liaison to professional psychology in the Department of
Veterans Affairs.
We at APA appreciate the opportunity to testify on making
VA the workplace of choice for psychologists. I should note,
unlike some of the other testimony today, bring to your
attention that VA is already the workplace of choice for many
psychologists. There are about 2,400 psychologists in the
system currently and, in fact, VA is the single largest
employer of psychologists in the Nation. We at APA applaud VA's
recent and very aggressive attempts, successful attempts, to
recruit new psychologists, but we have many concerns, less so
on the recruitment side and more so on the retention side, and
I will skip most of this oral statement in the interest of time
and focus in on those retention issues.
With regard to the current staffing pattern, however, this
is a very recent development. It was only until about 2006,
mid-2006 that VA began hiring additional psychologists as a
result of influx and needs, mental health needs and TBI needs
and so forth due to the War on Terror. In 2006, we finally
achieved the psychology, doctoral psychology staffing levels
that we had in 1995, so it was on the decline. Again, most
recently, VA has been very aggressive to bring new
psychologists into the system.
You should be aware that the vast majority of those new
psychologists hired, and new FTEs hired, in the last year and
one-half are functioning as GS-11 and 13 levels. With regard to
leadership of psychology across the system nationally, we are
still at essentially the 1995 levels in GS-14s. There are
approximately 130 GS-14s in the Nation, psychologists; and only
approximately 50 GS-15 leaders nationally currently, which is
actually below the level in 1995.
We think that VA's success in recruiting new psychologists
has to do in many cases with the outstanding efforts to bring
its own trainees into the system, and as you have heard, VA has
increased the psychology training slots. Seventy-five percent
of all new psychologist hires in the system have been prior VA
trainees. So, we applaud those efforts.
With regard to retention, however, the VA needs to not only
recruit new and young staffers for careers at VA, but to retain
those existing staff who have many years, as we have heard with
regard to other disciplines, of dedication to service to this
Nation's veterans. Like the other staff in VA, psychologists
are not drawn to the money. They are drawn to the work and to
the honor in providing care for the heroes of this country.
There are three basic issues that are covered in great
detail in our extended remarks for the record with regard to
processes that we feel are working against retention of
psychologists. One is, there is a lack of uniform psychology
leadership positions in the VA system. Senior psychologists--
20, 30 years' experience--range from, in some cases, chief
psychologist designations to, in most others, lead
psychologists, manager psychologists, and so forth.
There is also inequitable access across the VHA system for
psychologists to achieve the highest levels of leadership
positions in the VA. The under secretary--two under secretaries
now--have reaffirmed a VHA directive that states that it is
important that the most qualified individuals be selected for
leadership positions in mental health programs regardless of
their professional discipline. That directive has had very
little practical impact in terms of the appointment of highly-
qualified psychologists to VA senior leadership positions.
Most recently, and of great concern to us currently at the
VA is the Congress's and the VA's attempt to address
recruitment and retention problems through the inclusion of an
expansion of the Hybrid 38 program. It has led to very variable
and chaotic processes across the system. Many, many
psychologist leaders from facilities throughout the country
report to us that in their facilities and in their Veterans
Integrated Service Networks, that psychologists who have been
qualified by the National Professional Standards Boards to
advance to GS-14s and 15 levels, for example, and have been
recommended to do so, have been stopped at the local level.
There are also tremendous informational missteps and technical
problems that have plagued the National Psychology Boarding
process in this system.
I will just give but two examples that are not in the
written testimony--they just crossed my desk, literally, in the
last 48 hours--of how problems affect not only the retention of
senior psychologists and journey psychologists in the system,
but also the new psychologists coming into the system.
One regards a new hire. I just spoke with him this weekend
at our board meeting. He happens to be a former--young but very
bright star--State Psychological Association president and he
happens to be a representative to APA's National Committee on
Early Career Psychologists. He told me a story of being
dismissed a few months ago in his probationary year after he
was unable to effectively discharge what ended up being a dual
leadership position thrust upon him in the medical center as
the Local Recovery Coordinator, as was discussed earlier, and
also in the role of Acting Supervisory Psychologist. This kind
of thing has a very chilling effect on our young psychologists'
interests.
In another facility, a psychologist who was approved by the
National Standards Boards as qualifying for a GS upgrade was
denied locally her position as Psychology Program Manager in
her facility, and as a result, she tendered her resignation on
April 1.
APA considers these problems the most serious obstacle 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 our psychologists come
to believe that there is little possibility for advancement in
the system regardless of the level or the complexity of their
responsibilities, fewer VA psychologists will be willing to
accept those positions of greater responsibility; and in
addition, high-potential trainees whom the VA would like to
attract will increasingly see VA as dead ends--the VA as a dead
end for their careers--and will certainly be attracted to other
career options that offer more potential for advancement
outside the system.
I thank you very much for the opportunity today.
[The prepared statement of Mr. Phelps follows:]
Prepared Statement of Randy Phelps, Ph.D., Deputy Executive Director
for Professional Practice, American Psychological Association
Chairman Akaka and distinguished Members of the Committee, I am Dr.
Randy Phelps, Deputy Director for Professional Practice of the American
Psychological Association (``APA''), the largest association of
psychologists, with more than 148,000 members and affiliates engaged in
the study, research, and practice of psychology. The APA appreciates
the opportunity of testifying before you today on behalf of our member
psychologists who are dedicated to serving the very pressing needs of
our country's veterans. VA's need for the health and mental health,
primary care, research, and other, often unique, services that
psychologists provide has perhaps never been greater.
growing needs
Over 200,000 homeless veterans will be sleeping on America's
streets tonight. Worse yet, Operation Iraqi Freedom (OIF) and Operation
Enduring Freedom (OEF) veterans are becoming homeless faster than their
predecessors. After Vietnam, it took 9 to 12 years for veterans'
circumstances to deteriorate to the point of homelessness. Today, the
high incidence of Post Traumatic Stress Disorder (PTSD) and Traumatic
Brain Injury (TBI) will contribute to increased homelessness unless
dramatic measures are taken to mitigate this trend. Other issues for
servicemembers and their families are repeated deployment, National
Guard and Reserve deployment, women in combat and the extended duration
of the Global War on Terrorism (GWOT).
More than one million servicemembers in the Active and Reserve
components of the military have been deployed in OEF/OIF; more than
449,000 of those have been deployed more than once. Of the troops
returning from deployment, 31% of Marines, 38% of Soldiers, and 49% of
National Guardsmen report psychological symptoms. This doesn't take
into account those making multiple deployments or the psychological
needs of their families.
There were 686,306 OIF and OEF veterans who separated from active
duty service between 2002 and December 2006 who were eligible for
Department of Veterans Affairs (DVA) care; 229,015 (33%) of those
accessed care at a DVA facility. Of those 229,015 veterans who accessed
care since 2002, 83,889 (37%) received a diagnosis of or were evaluated
for a mental disorder, including PTSD (39,243 or 17%), non-dependent
abuse of drugs (33,099 or 14%), and depressive disorder (27,023 or
12%).
psychologists' roles within health care systems
Psychologists are unique professionals in terms of their training
and skill sets. No other mental health profession requires as high a
degree of education and training in mental health as psychology.
Accredited doctoral programs in clinical, counseling and other health
services psychology involve a median of 7 years of training beyond an
undergraduate degree. Psychologists are licensed, independent
practitioners with specialized clinical and research skills.
Psychologists provide a holistic approach to mental health care
with their keen understanding of how the mind and the body interact.
Our members include the specially trained neuropsychologists who
understand those disorders of perception, memory, language, and
behavior that result from brain injury, an essential skill in dealing
with the new generation of veterans returning from theater in large
numbers with Traumatic Brain Injuries (TBI).
Psychologists' skills in program development, team building,
research/outcome and program evaluation, and in assessment and
treatment interventions equip psychologists to be leaders in planning
and providing a coordinated service approach. This includes models and
practices of care that encompass inpatient, partial hospitalization and
outpatient services including Community Based Outpatient Clinics
(CBOC), psychosocial rehabilitation programs, homeless programs,
geriatric services in the community, residencies and the home.
Psychologists initiate and evaluate innovative programs, such as
tele-mental health services. They go beyond the provision of service to
initiate, plan and evaluate the efficacy of such services and their
clinical and cost benefits.
recruitment of psychologists in vha
It is critical to note that VA is already the single largest
employer of psychologists in the Nation, and has been for many years.
However, VA continues to recognize the need to increase its psychology
staffing numbers in response to ever-increasing needs for services to
veterans. For example, the Veterans Health Administration's (VHA)
provision of mental health services to veterans has skyrocketed from
1996 to 2006, going from 565,529 veterans served to 934,925 and rising.
In response, VHA has hired more than 800 new psychologists since 2005;
thereby, increasing the number of GS-11 through 15 psychologists and
surpassing its 1995 high of approximately 1,800 psychologists.
The APA applauds VA for its tremendous and serious recent efforts
to increase psychology staffing levels, such that there are now
approximately 2,400 psychologists employed by VA nationwide across the
GS-11 to GS-15 levels. However, that is a very recent accomplishment.
It was not until 2006 that psychology staffing levels exceeded those of
1995 levels. Moreover, the vast majority on new psychologist hires in
VHA are younger, lesser experienced psychologists who have come into
the system at the GS-13 level or below. In contrast, as of the end of
2007, the number of GS-14s in the entire system nationally was
essentially the same as it was in 1995, at approximately 130 GS-14
psychologists. Of additional concern to the APA is that the number of
GS-15 psychologists nationally as of the end of 2007 (approximately 50)
was still considerably lower than the number of GS-15s in 1995.
VA has also recognized and capitalized on the fact that the best
source of recruiting new psychologists has been the Department's own
training system. Over the past 2 years, approximately 75% 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
Here is the dilemma: while the VA is employing more psychologists
than ever, 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 are
already institutionalized within the system. These psychologists are
vital to service provision because of their professional expertise and
knowledge of the system and its resources. However, there are several
glaring obstacles to retention, covered in some detail below.
lack of uniform 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. Interdisciplinary management
within mental health services can have advantages in terms of cross-
discipline coordination of care and clearer accountability at the
individual program level. However, 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. For Psychology, this problem is
further complicated by the fact that the lack of recognized psychology
discipline leadership at many facilities translates into a significant
lack of oversight, structure and support for the growing number of
psychologists working in non-mental health areas such as primary care,
geriatrics, and Home & Community Based Care (HBPC), among others.
In 2002, the VA remedied this situation for Social Work with the
appointment of a Social Work Executive at each facility that lacked an
independent Social Work Service (VHA Directive 2002-029). The creation
of the Social Work Executive position has been highly effective in
ensuring the integrity of Social Work practice and training within an
inter-disciplinary management structure. Since 2003 there have been
efforts to create an analogous Psychologist Executive role. However, at
present, Psychology remains the only major mental health discipline
without an officially designated leader in every medical center. While
the number of ``Chief Psychologists'' is now increasing, a far more
prevalent position is the ``Lead Psychologist,'' a position which is
all too frequently unrecognized at the level of additional pay for
additional responsibilities.
inequitable access to key leadership positions
Nor are psychologists represented equitably in the all levels of
leadership in the VA's health care 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.
implementation problems in hybrid 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 Title 38 Hybrid is a combination of Title
38 and Title 5 provisions for non-physician health care professionals
at the VA.
Historically, Title 38 was created to alleviate severe shortages of
health care personnel, especially for physicians in VA, by reducing the
bureaucratic red tape of the civil service recruiting and hiring system
and the restrictive compensation practices inherent in Title 5.
Psychologists remain the only health care providers requiring the
doctorate who are not included in Title 38. The Title 38 Hybrid was
created to provide a middle ground solution for health care
professionals that needed some of the same 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 on
the number of GS-14 and 15 psychologists is currently very mixed. Many
Psychologist leaders from facilities throughout the country have
reported that their facilities and Veterans Integrated Service Networks
(VISN) 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. This leaves the psychologists in question
with considerable leadership responsibilities, but with little or no
recourse regarding their boarding status and consequent grade level.
Informational missteps and technical problems have also plagued the
national psychology boarding process. An unknown, but apparently
significant, number of boarding packets have been adversely affected by
incorrect information provided by local human resource (HR) officials
regarding the required format and content of the packets. This has
resulted in the submission of a number of packets that may have
described GS-14 or above responsibilities, but that were unable to be
boarded at that level due to packet content errors.
Of particular concern are reports that a number of psychologists
throughout the country were instructed by their facilities to only
submit special achievements occurring during the previous 3 years,
despite the fact that Psychology Boards were authorized to consider
achievements throughout the psychologists' VA careers for the one-time
Special Advancement for Achievement. This meant that significant and
creditable achievements occurring earlier in the psychologists' VA
careers would never have an opportunity to be considered for a Special
Advancement for Achievement (SAA).
On March 7, 2007, instructions were sent from the VA Central Office
(VACO) to the field that eliminated the national cap on GS-14
psychologists. This was a beneficial step that has removed one of the
reasons often cited by local and VISN management for failure to approve
justified grade increases to the GS-14 level.
However, the same set of instructions tied the award of GS-15
psychology positions to the facility's level of complexity. Per these
instructions, only psychologists at complexity level 1A facilities are
eligible for promotion to GS-15. Senior psychologist leaders at non-1A
facilities, regardless of the scope and complexity of their actual
duties and regardless of the question of whether they meet the VA's own
qualification standards for GS-15 would be ineligible for promotion to
that grade level. In addition, complexity 1A facilities without current
GS-15 psychologists would need to petition VACO for an increase in
their GS-15 ceiling should the boarding process recommend, and the
facility management concur, in moving a psychologist manager to the GS-
15 level.
These new field instructions will accelerate the already steep
decline in the number of GS-15 level psychologists. They will also
create equity problems in that psychologists from non-1a facilities who
supervise many programs and individuals will be ineligible for a GS-15,
whereas facility complexity 1a psychologists with more limited
supervisory responsibility will be eligible for the grade as long as
they meet the minimum GS-15 requirements of the VA's Qualification
Standard.
Part of the difficulty with these new instructions is that they
treat psychologist promotion in a manner that is characteristic of
Title 5. Dissimilar positions are compared against one another
according to some overarching standard of complexity. Typically, in the
case of psychologists, the comparison is made to the grade level of the
Associate Director.
As doctoral level Title 38 Hybrid clinicians, it would be more
appropriate to treat the issue of psychologist promotion as being
similar to the Title 38 process. In this approach, the full performance
level (GS-13) is defined by the journeyperson clinical
responsibilities. Additional administrative and program management
responsibilities warrant higher grade levels, provided that these
additional responsibilities meet established scope and complexity
requirements for those levels. This is essentially the approach that
was taken in the VA's own Qualification Standard for Psychology.
The decline in the availability of upper grade level positions
presents VA with a serious recruitment and retention issue. As
psychologists come to believe that there is little possibility for
advancement, regardless of the level or complexity of responsibilities,
fewer high potential 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.
______
Response to Written Questions Submitted by Hon. Daniel K. Akaka to Dr.
Randy Phelps, Deputy Executive Director, American Psychological
Association Practice Directorate
Question 1. The number of veterans rolling into the VA mental
health care system is significantly growing each year of the Global War
on Terror. The VA system is already stretched with a need for trained
mental health professionals to deal with the unique needs of the
veteran population and their families. Additionally, veterans in rural
areas remain underserved due to the lack of VA access in non-
metropolitan areas. The Committee is aware that the Department of
Defense successfully conducted a demo project giving prescribing
authority to psychologists. In your opinion, would giving VA
psychologists the authority to prescribe psychotropic drugs ease the
strain on the system; especially in rural areas?
Response. APA continues to look for ways to extend services to
veterans in rural areas where existing VA and DOD facilities are simply
beyond the reach of patients. We continue to advocate for prescriptive
authority for appropriately trained doctoral psychologists,
particularly in those rural areas where providers are few and far
between.
For Americans living in rural areas, the problem of access to care
is particularly acute. The Final Report of the President's New Freedom
Commission on Mental Health states that the ``vast majority of all
Americans living in underserved, rural, and remote areas also
experience disparities in mental health services . . . . In rural and
other geographically remote areas, many people with mental illnesses
have inadequate access to care, limited availability of skilled care
providers, lower family incomes, and greater social stigma for seeking
mental health treatment than their urban counterparts'' which is
compounded by ``the fact that rural Americans have lower family incomes
and are less likely to have private health insurance benefits for
mental health care than their urban counterparts.''
VA data shows that 19% of the Nation lives in rural America, and
that 44% of U.S. military recruits come from those rural areas. This
disproportionate number of OEF/OIF rural veterans has created a crisis
in which they do not have sufficient access to VA healthcare. Having
psychologists ready to accept the challenge of serving these rural
veterans, including through psychotherapy, prescribing or unprescribing
medication as needed, carrying out medication management and compliance
tasks, and any combination of these services, via telehealth or through
placement in a Community-Based Outpatient Clinic or satellite clinic in
a rural or remote area, would serve well our Nation's veterans from
rural and frontier areas.
With a focus on psychologist prescription privileges, the private
healthcare sector and states are also grappling with how to ensure
access to health and mental health services in rural areas. To address
pressing mental health needs, 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, allow
appropriately trained and certified psychologists 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) 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 its report on the
PDP. Both reports repeatedly stressed how well the PDP psychologists
had performed. According to the 1999 GAO report, ``an outside panel of
psychiatrists and psychologists who evaluated each of the graduates
rated the graduates' quality of care as good to excellent.'' The 1998
ACNP review stated that ``they had performed safely and effectively as
prescribing psychologists, and that no adverse outcomes had been
associated with their performance.''
Psychologists are highly trained mental health specialists, many of
whom have acquired this additional post-doctoral training in
psychopharmacology in order to collaborate with physicians about their
patients' medications. With prescriptive authority, they can offer a
holistic, integrative model of 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 PDP. 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.
Question 2. In written testimony, APA discussed the challenges of
recruiting psychologists in light of a growing national shortage. How
can VA recruit more mental health providers to work in rural locations
in particular? Could partnerships with community providers be
effective, without compromising quality of care?
Response. As the Committee is aware, the VA is not alone in the
need to recruit psychologists and other practitioners to provide
services in the rural areas of our country. Many private and public
employers are working to ensure services in these areas as well. The
issue of psychologist recruitment has its own unique aspect, since
psychologists are far more numerous than psychiatrists and therefore
available to provide services in rural areas, while at the same time,
social workers, though relatively more numerous and available, simply
do not have the training to deliver the range of psychotherapeutic and
testing services that psychologists provide to patients.
The testimony provided by various panelists during the hearing
demonstrate that the VA is finding innovative ways to recruit health
care professionals into VA service, including in rural areas. The APA
would return to our testimony, however, in emphasizing the need to hire
and promote psychologists beyond the GS-13 level, particularly through
a more effective use of the Title 38 Hybrid process. Pay and promotion
must be competitive for psychologists in the VA if the department hopes
to be effective in recruiting and retaining psychologists for service
in rural areas.
Beyond the fundamental issue of pay and promotion, the APA strongly
suggests that the VA look to its current authority to provide mental
health services to veterans outside of the VA system. It is now clearly
apparent that with the influx of returning OEF/OIF veterans on top of
the current mental health needs of the aging veteran population, that
the need for mental health services has reached a crisis situation. The
recent RAND Corporation study is telling:
300,000 returning U.S. troops are suffering symptoms of
PTSD or depression but only about half are receiving care. We cannot
emphasize strongly enough, the importance of treating these conditions
early for effective treatment.
320,000 returning troops have suffered possible TBI during
deployment. Psychologists are key providers in treating TBI.
18.5% of the more than 1.5 million deployed troops in the
two war zones are suffering stress disorder and depression.
Undoubtedly, many of these soldiers will need psychological care when
they separate from service.
As our answer to the first question indicates, a relatively large
proportion of veterans are from rural areas, therefore the need for
mental health services in rural areas is going to tremendously
increase, considering the mental health needs indicated in the RAND
study. The VA has authority to contract with non-VA facilities and
individual providers, including community providers, for the provision
of mental health services. Some of this authority is specific to the
provision of mental health services in current statute, such as for the
provision of readjustment counseling
and related mental health services by a physician or psychologist (see
38 U.S.C. Sec. 1712A(b)(1)).
While we do not have sufficient knowledge or information on how the
VA has used this contracting authority for fee-basis care to ensure
adequate mental health services in rural areas in the past, we would
assume that given the current situation, the VA should utilize its
authority more expansively in this time of crisis. Therefore, the APA
respectfully suggests that the Committee strongly urge the VA to use
this authority now.
The Committee could also approve S. 38, a bill that would establish
a program for the provision of readjustment counseling and other mental
health services for
OEF/OIF veterans. The House already has passed a measure, the Veterans'
Health Care Improvement Act, H.R. 2874, which has similar provisions.
Certainly, enactment of S. 38 would help address the Committee's query
concerning partnering with community providers for care, since the bill
would promote these services through ``qualified entities,'' including
community mental health providers. We would further suggest that the
term ``qualified entity'' be made more clear so as to include
psychologists and other mental health providers whether in facilities
or in private or group practice.
Beyond encouraging the VA to use its current authority to contract
with psychologists for fee-basis care, the Committee should commend and
encourage the VA to continue its efforts to recruit more psychologists
into service and urge the VA to contract with psychologists to provide
services within VA facilities as needed, particularly for VISNs with
large rural populations. All of these initiatives should go a long way
in addressing the tremendous need for mental health services for
veterans at this time.
Question 3. What effect do VA's hiring processes have on
recruitment, and how do you believe it can be improved and accelerated
while still ensuring quality care for veterans?
Response. VA is already the single largest employer of
psychologists in the Nation, and has been for many years. VA continues
to acknowledge the need to increase its psychology staffing numbers in
response to ever-increasing needs for services to veterans.
VA has capitalized on the fact that the best source of recruiting
new psychologists has been the Department's own training system. Over
the past 2 years, approximately 75% 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 post-
doctoral fellowship positions, spending approximately $5 million to do
so. This will bring the total psychology training positions to
approximately 620 per year nationwide.
VA has also recently made tremendous efforts to increase psychology
staffing levels, so that there are now approximately 2,400
psychologists employed by VA nationwide across the GS-11 to GS-15
levels. However, that is a very recent accomplishment. It was not until
2006 that psychology staffing levels exceeded those of 1995 levels.
Moreover, the vast majority of new psychologist hires in VHA are
younger, lesser experienced psychologists who have come into the system
at the GS-13 level or below.
In contrast, at the end of 2007, the number of GS-14s in the entire
system nationally was essentially the same as it was in 1995, at
approximately 130 GS-14 psychologists. Of additional concern to the APA
is that the number of GS-15 psychologists nationally at the end of 2007
(approximately 50) was still considerably lower than the number of GS-
15s in 1995.
In 2007 a VA instruction lifted the cap on GS-14 psychologists. The
numbers are slowly increasing, but not enough to keep up with the
growing demand on the system. On the other hand, promotions of GS-15
psychologists remain incredibly low with the cap remaining firmly in
place. In fact, the same VA instruction that lifted the cap on GS-14's
also tied the promotion to GS-15 for psychologists to the facility's
level of complexity. In short, a psychologist must work at a level 1A
facility to have a serious chance at promotion to GS-15.
The new promotion process created as a result of the Title 38
Hybrid legislation has been chaotically and unevenly implemented across
facilities. There are common reports of medical centers sitting on
promotion packages, denying promotion after the national board's review
and approval, or misinformation regarding what is to be submitted as
part of a board package resulting in the denial of a submitter's
package.
Also, there remains a lack of uniform psychology leadership
positions in the VA. Psychology is the only major mental health
discipline without an officially designated leader in every medical
center. Such a position is critical for purposes of professional
practice within a facility and as a representative of the facility
without. In addition, psychologists are not represented equitably at
all levels of leadership in the VA healthcare delivery system. There
have been some attempts by the VA to address this but with little
practical impact at this time.
In sum, the VA has been making progress in its psychologist
recruitment efforts, partly by taking advantage of recruitment from its
own psychology training structure. Psychology staffing levels are
improving but promotions to the GS-14 and
GS-15 levels must be accelerated. Serious implementation problems with
the Hybrid Title 38 system should be addressed, as well as the lack of
uniform psychology leadership positions and the current inequitable
access to key leadership positions within the VA in general that
psychologists face.
______
Response to Written Questions for the Record Submitted by Hon. Patty
Murray to Dr. Randy Phelps, Deputy Executive Director, American
Psychological Association Practice Directorate
Question 1. Over the past couple of years, there has been a lot of
attention focused on the seamless transition between the VA and the DOD
when it comes to information sharing.
Thinking along those lines, is there any way that the VHA and the
DOD could pool together and share some of their resources to fill in
some of the gaps in clinical coverage?
Response. The APA greatly appreciates the Committee's active
interest and work toward addressing mental health issues as they relate
to efforts for a seamless transition between VA and DOD, particularly
at a time when so many returning
OEF/OIF soldiers are returning with PTSD, TBI, and many other mental
health and substance use issues. We further appreciate that the VA and
DOD have made concerted efforts to address mental health issues through
the work of the Senior Oversight Committee, as reflected in the April
23rd joint testimony before the Committee by The Honorable Gordon
England, Deputy Secretary of Defense and The Honorable Gordon
Mansfield, Deputy Secretary for Veterans Affairs.
We believe that the Committee should continue to oversee and
encourage the current DOD and VA transition activities with regard to
mental health and substance use services. These activities and
initiatives include: the improvement to the Disability Evaluation
System, the DOD Center of Excellence for Psychological Health and
Traumatic Brain Injury, and the widespread dissemination and
implementation of standard clinical practice guidelines for PTSD and
other serious mental and substance use disorders. In addition, the
departments should be further encouraged in improving TBI screening and
health information sharing, as well as collaborative efforts to address
PTSD and PTSD research.
In addition, the APA urges the Committee to encourage the DOD and
VA to fully implement the Wounded Warrior title in the recently enacted
National Defense Authorization Act, particularly those that relate to
the mental health needs of returning soldiers. We share the belief with
the Committee and the departments that these needs are extremely
pressing at this time, and full and timely implementation is critical
to ensure that services are fully available now.
Chairman Akaka. Thank you, Dr. Phelps.
Dr. Strauss?
STATEMENT OF JENNIFER L. STRAUSS, PH.D., HEALTH SCIENTIST,
CENTER FOR HEALTH SERVICES RESEARCH IN PRIMARY CARE, DURHAM VA
MEDICAL CENTER, AND ASSISTANT PROFESSOR, DEPARTMENT OF
PSYCHIATRY AND BEHAVIORAL SCIENCES, DUKE UNIVERSITY MEDICAL
CENTER, ON BEHALF OF THE FRIENDS OF VA MEDICAL CARE AND HEALTH
RESEARCH
Ms. Strauss. Hello, Chairman Akaka, Ranking Member Burr,
Members of the Committee. On behalf of the Friends of Medical
Care and Health Research, I thank you very much for this
opportunity to testify.
I am a clinical psychologist and a health scientist at the
Durham VA Medical Center and a recipient of a VA Research
Career Development Award. The primary focus of my research is
the treatment of Post Traumatic Stress Disorder in women
survivors of military sexual trauma. Today, I have been asked
to share my reasons for choosing a career as a VA clinician
researcher and specifically how research opportunities impact
the Department of Veterans Affairs's ability to recruit and
retain clinicians.
Let me say at the outset that I love my job. The
opportunity to conduct research greatly enhances my job
satisfaction and has played a large role in my decision to
remain at VA.
VA is not the only venue in which a clinician can conduct
research, but understand that I have come of age professionally
in the post-9/11 era. The opportunity to apply my clinical and
research training in support of veterans traumatized by their
war experiences continues to resonate very strongly with me.
This war has presented numerous clinical challenges, and in
many ways, we are still learning as we go. To make progress, VA
must foster partnerships between research and clinical services
and must recruit clinician investigators to guide these
efforts.
Towards this end, VA offers exceptional research and
training opportunities for clinicians like me who are
interested in research careers. Among these is the Research
Career Development Program. This is a highly competitive
mentored award that typically provides 3 to 5 years of
structured research training. Clinicians who receive these
awards are relieved of 75 percent of their clinical duties,
allowing for dedicated time to focus on training and developing
an individual program of research.
Despite the many advantages VA offers, it is not
necessarily easy to build a career as a clinician investigator
at VA and I would like to highlight several ways in which I
believe VA can improve recruitment and retention of clinicians
such as me, who are interested in integrating research into
their careers.
To date, the VA has invested in 5 years of my research
training. Yet what happens when my Career Development Award,
and the dedicated research time it affords, expires in 2 years
is an open question. Unlike clinicians at most academic medical
centers, VA clinicians may not fund a portion of their salaries
through research grant support. If a non-clinician VA
researcher is awarded research funds, those funds can be used
to pay salary for time devoted to the research project. But VA
clinicians often perform research duties early in the morning
or very late into the night after a long day of seeing
patients.
I recommend that VA consider a model that is more in line
with what is available to clinician researchers working in
other academic medical settings, namely to foster recruitment
of the best care providers and to encourage clinicians to
conduct research by ensuring dedicated research time.
Current space constraints are an additional obstacle to the
clinician researcher career path. Space is at such a premium at
our facility that some of our researchers may soon be moving
offsite. A geographic divide between research labs and clinics
will do little to enhance the type of collaborations that I
believe are essential to move VA research forward in a manner
that will best inform the clinical care of veterans. Continued
investment in the Durham research infrastructure and similar
investments at other VA facilities are imperative.
The last obstacle I want to mention is data security in the
context of research. Absolutely, veterans' privacy and research
data must be safeguarded. That is paramount. However, while I
know it is not intentional, it has become extremely difficult
to share data even among VA facilities, and collaborating with
non-VA organizations can be even more problematic. I urge VA to
ensure that its security policies guarantee the safety of data
but still allow shared research to continue. With improvements
in security technology, I hope the current situation will get
better. But right now, managing research data in compliance
with VA policies is a significant challenge.
Serving veterans is what I do, and I am filled with pride
by the opportunity to do so. That feeling is considerably
deepened by the opportunity to combine clinical care with
research, to compete for Career Development Awards, and to be
linked with mentors willing to nurture my research interests.
These are significant factors in why I came to and remain at
VA; and apparently many of my colleagues also feel this way.
When surveyed by VA in 2002, 61 percent of clinician
respondents indicated that they would not work at VA without
research opportunities.
Mr. Chairman, thank you again for inviting me today and I
am happy to answer any questions. Thank you.
[The prepared statement of Ms. Strauss follows:]
Prepared Statement of The Friends of VA Medical Care and Health
Research (FOVA) presented by Jennifer L. Strauss, Ph.D., Health
Scientist, Center for Health Services Research in Primary Care, Durham
VA Medical Center and Assistant Professor in Psychiatry and Behavioral
Sciences, Duke University Medical Center
Chairman Akaka, Ranking Member Burr, and Members of the Committee,
on behalf of the Friends of VA Medical Care and Health Research, thank
you for the opportunity to testify. FOVA is a coalition of over 90
national academic, medical and scientific societies; voluntary health
and patient advocacy groups; and veteran service organizations
committed to ensuring high-quality health care for our Nation's
veterans.
I am a clinical psychologist and health scientist at the Durham VA
Medical Center and a recipient of a VA Research Career Development
Award. The primary focus of my research is the treatment of Post
Traumatic Stress Disorder in women survivors of military sexual trauma.
Today I have been asked to share my reasons for choosing a career as a
VA clinician-researcher, and specifically, how VA research
opportunities impact the Department of Veteran Affairs' ability to
recruit and retain talented clinicians.
Let me say at the outset that I love my job. The opportunity to
conduct research greatly enhances my job satisfaction and has played a
large role in my decision to remain at the VA for 7 years. From the
time I applied to graduate school, my goal was to pursue training and
professional opportunities that would allow me to blend my clinical and
research interests. And VA provides an environment to do just that.
VA is not the only venue in which a clinician can conduct research.
Academic medical centers are frequently the landing pad for individuals
like me. But understand that I have come of age professionally in the
post-9/11 era. I earned my doctorate in June of 2001. Shortly
thereafter we were at war. I wanted to help and I had a specific skill
set that could allow me to do so quite directly. The opportunity to
apply my clinical and research training in support of veterans
traumatized by their war experiences continues to resonate very
strongly with me, as I believe it does with many of my VA colleagues.
I treat women survivors of military sexual trauma while also
conducting research to make those treatments more effective. I am a
small piece of a shared vision to provide the best possible care to our
Nation's veterans. And I am well aware of how lucky I am to be able to
say that. This war has presented numerous clinical challenges and, in
many ways, we are still learning as we go. To make progress, VA must
foster partnerships between research and clinical services, and must
recruit clinician investigators to guide these efforts.
Towards this end, VA offers exceptional research and training
opportunities for clinicians like me who are interested in research
careers. Among these is the Research Career Development Program. This
is a highly competitive mentored award that typically provides 3-5
years of structured research training. Clinicians who receive these
awards are relieved of 75% of their clinical duties, allowing for
protected time to focus on training and developing an individual
program of research.
This award is specifically designed to attract, develop, and retain
talented researchers in areas of particular importance to VA, and it is
a powerful recruitment tool. I am currently in the second year of my
Research Career Development award. For this privileged opportunity, I
aim to repay VA and our Nation's veterans hefty dividends on their
investment in me, in the currency of high quality care and clinically-
informed research to improve the care of veterans.
As a VA research career development awardee, I am in a unique and
fortunate position. I benefit from truly exceptional research mentoring
and training, and I have the luxury of devoting a substantial portion
of my time to developing a research program at VA. At the Durham VA's
Center for Health Services Research in Primary Care, I am one of 31
core investigators, half of whom are clinicians and many of whom are
young investigators, who jointly attract over $10 million of research
grant support annually. The Center's success is a reflection of
exceptional leadership, a sophisticated research infrastructure, and a
talented, collegial, multidisciplinary faculty who are unusually
invested in fostering the careers of junior faculty. The common thread
is a deep respect for our nations' veterans and a drive to provide them
with the highest quality care and to constantly seek improved
treatments. I believe my success to date is largely a reflection of the
exceptional opportunities afforded to me in this environment and it is
these opportunities that give me such professional satisfaction and
keep me at the VA.
Despite the many advantages VA offers, it is not necessarily easy
to build a career as a clinician investigator at VA. I would like to
highlight several ways in which I believe VA can improve recruitment
and retention of clinicians such as myself, who are interested in
integrating research into their careers. I offer what follows from the
perspective of a field worker. I know there are numerous constraints on
implementing the ideal in the short run. But I also firmly believe that
longer-term goals should be kept in mind for the good of the veterans
we are all committed to serve.
To date, VA has invested in 7 years of my research training. Yet
what happens when my Career Development award, and the protected
research time it affords, expires in 2 years is an open question.
Unlike clinicians at most academic medical centers, VA clinicians may
not fund a portion of their salaries through research grant support. If
a non-clinician VA researcher is awarded research funds, those funds
can be used to pay salary for time devoted to the research project. But
VA clinicians cannot do this and typically must donate their time,
often performing research duties early in the morning or very late into
the night after a long day of seeing patients. I do not think this is
in the best interest of VA or the veterans we serve. I strongly
recommend that VA adopt a model that is more in line with what is
available to clinician researchers working in academic medical
settings. Namely, to foster recruitment of the best care providers and
to encourage clinicians to conduct research by providing protected
research time. The objective, of course, is to hasten development of
the new and more effective treatments that are urgently needed.
There are several other ways in which I believe VA could better
facilitate clinicians' involvement in research. Currently, the primary
research funding mechanism for VA investigators is a merit review
award. For health services researchers like myself, these are typically
3-5 year studies with relatively large budgets. Understandably, these
studies are generally awarded to mature investigators who have already
completed a substantial body of work in the research area. Currently
missing from the VA research funding portfolio in my area of health
services research is a grant mechanism that would allow individuals to
conduct research on a smaller scale. I believe this type of funding
mechanism, akin to the R03 program offered by the National Institutes
of Health, would be particularly attractive to VA clinicians interested
in taking on research without the commitment of time and resources that
large scale studies demand.
Current space constraints are an additional obstacle to the
clinician-researcher career path. Space is at such a premium at our
facility that some of our researchers may soon be moving off-site. A
geographic divide between research labs and clinics will do little to
enhance the type of collaborations that I believe are essential to move
VA research forward in a manner that will best inform the clinical care
of veterans. Continued investment by VA in the Durham research
infrastructure and a similar investment at other facilities are
imperative.
The last obstacle I want to mention is data security in the context
of research. Absolutely, veterans' privacy and research data must be
safeguarded; that is paramount. However, while I know it is not
intentional, it has become extremely difficult to share data even among
VA facilities, and collaborating with non-VA organizations can be even
more problematic. I urge VA to ensure that its security policies
guarantee the safety of data, but still allow shared research to
continue. With improvements in security technology I hope the current
situation will get better. But right now, managing research data in
compliance with VA policies is a significant challenge. The reasoning
behind some of the obstacles is understandable; the consequences can be
severe.
Finally, I think the career opportunities available at VA remain a
too well-kept secret. A VA career never occurred to me until a trusted
graduate school mentor encouraged me to take a closer look. Coming from
a traditional academic training environment, VA simply wasn't on my
radar. It is time to let this secret out of the bag. For the reasons I
have described, VA is an elite venue for clinicians and researchers
alike and should recruit accordingly.
Serving those who have served our country is what my colleagues and
I do. And we are filled with pride by the opportunity to do so. That
feeling--that attachment--is considerably deepened because of the
opportunity to combine clinical care with research, to compete for
Career Development awards, and to be linked with mentors willing to
nurture our research interests. These are significant factors in why I
came to and remain at the VA. And apparently many of my colleagues feel
similarly. When surveyed by VA in 2002, 79% judged that research
opportunities and support were very or extremely important for
recruiting and retaining high quality clinicians in VA, and 61% of
clinician respondents indicated that they would not work in VA without
research opportunities.
Mr. Chairman, thank you again for inviting me today. I am happy to
answer any questions that you or the other committee members may have.
______
Response to Written Questions Submitted by Hon. Patty Murray to
Jennifer L. Strauss, Ph.D., Health Scientist, Center for Health
Services Research in Primary Care, Durham VA Medical Center and
Assistant Professor in Psychiatry and Behavioral Sciences, Duke
University Medical Center
balance between research and clinical duties
Question 1. Given the need for the VA to do research in areas
critical to the health and well being of our veterans, how do we strike
a balance between protecting research time for present and prospective
VA employees, while still keeping enough clinicians on the ``front
line'' to meet the acute needs of our veterans, given an urgent
shortage in this area?
Response. This is a very good question and I think the concept of
``balance'' between front line clinical care and investment in research
is a critical point. In my opinion, one step in this direction would be
to allow clinicians to fund a portion of their salary (e.g., 1/8th-2/
8th) through VA funding and to allow the medical center to use the
salary support offset to backfill the clinicians' time. This would be
analogous to the NIH model which provides salary support commensurate
with the investigator's level of effort on the project, in addition to
the amounts provided for the direct and indirect costs of the grant.
This approach would allow clinician researchers to devote a specific
portion of their time to research without disrupting the availability
of clinical care to veterans.
In contrast, the current method of providing ``protected'' time for
researchers is to use VERA dollars to backfill clinical positions. The
concern, which I have heard voiced loudly and repeatedly at the annual
VA HSR&D meeting, is that VERA dollars are used by medical center
directors to fund many competing demands. Additionally, the VERA
research allocation is based on prior year funds and the amounts
provided to each medical center are not tied to specific projects. With
the caveat that I am not a subject matter expert on VA budgets, VERA or
the allocation process, what I am suggesting is a more direct means of
ensuring the support of clinicians conducting research and the
continued provision of front line clinical care to veterans.
Bear in mind that the vast majority of clinicians do not want to
conduct research. But I think those who do will play a critical role in
improving VHA's ability to provide the best possible care to our
veterans, for decades to come. It is arguably short-sighted to not
invest in both our ability to provide timely, high quality care today,
and to advance the standard and improve the quality of care provided by
tomorrow's VHA. In other words, we must strike a balance between VHA's
investment in front line clinical care and research.
dod and va collaboration
Question 2. Over the past couple of years, there has been a lot of
attention focused on the seamless transition between the VA and the DOD
when it comes to information sharing.
Thinking along those lines, is there any way that the VHA and the
DOD could pool together and share some of their resources to fill in
some of the gaps in clinical coverage?
Response. Broadly speaking, I am certainly in favor of greater
collaboration between these agencies, but it is not within my scope of
expertise to suggest how best to achieve this goal. That said, one
promising idea that has been suggested by others is a common electronic
medical record, accessible by both DOD and VHA personnel. If tenable, I
believe a shared medical record system would help to smooth transitions
between DOD and VA care. From a health services research perspective, a
shared electronic medical record would also foster our ability to
conduct research on veterans' functioning before and after active duty
and deployments, as well as after their transition to veteran status.
An additional means of strengthening ties between agencies may be to
assign some VHA staff to DOD, to facilitate transitions and access.
Chairman Akaka. Thank you very much, Dr. Strauss.
I understand that the opportunity to conduct research at VA
has influenced the course of your career.
Ms. Strauss. Yes, it has.
Chairman Akaka. In your view, how could the hiring system
be modified to attract and retain more researchers like
yourself? What was it about VA research that made it an
attractive option to you as a clinician? I would just like to
note per Dr. McDonald's comments that Congress provided the VA
research program with a $69 million increase this year and we
are pushing for yet another substantial increase.
Ms. Strauss. Which is much appreciated. You know, there are
several factors that I think brought me to this career. One
really is a specific interest in serving veterans and in
conducting the type of research that I think is necessary to
increase the quality of care that we are providing over time.
So, the mission of that resonates very strongly with me.
I am very fortunate to be at a facility, the Durham VA,
that has a very strong research infrastructure and is highly
supportive of research and of young clinical investigators like
myself, and I am also really blessed with tremendous
mentorship.
Looking forward, I think a concern that is on everybody's
minds who is in a position like myself, or certainly on my own
mind, is some assurance that we will be allowed to continue to
conduct research while also providing patient care. What that
means is some mechanism, and I am not the individual, I don't
think, to speak to what that mechanism should be or how it
should be organized, but some allowance that there can be some
dedicated time for us to continue research activities while
also taking care of patients.
Chairman Akaka. Thank you, Dr. Strauss.
Dr. McDonald, over the course of your career, you have both
hired contractors in your capacity as a VA administrator and
clinician and you have been hired to work in VA as a
contractor, so you have been through both of those systems.
Does VA have the authority and resources to fully staff its
facilities on its own, or do you believe VA will be required to
expand contractor agreements?
Dr. McDonald. Chairman Akaka, I believe that the answer to
that is a qualified yes, and it really depends upon the size of
the station or the VA hospital and the relationship with the
affiliate medical school. In the case of Durham, San Francisco,
Minneapolis, these are tight affiliations. I trained as a
medical student at Duke, in fact, in the old Durham VA, and so
that relationship goes back many, many years. So, except for
some very highly remunerated specialties, such as
neuroradiology, interventional radiology, interventional
cardiology, for the most part, I believe that the VA will be
able to.
I think the current pay scale, although it is a great
improvement, is still not adequate to recruit scarce
specialties to a VA hospital. It takes--and it is not money, it
is really the other elements of working in the VA system. It is
the integrated medical record, it is caring for veterans, it is
the team approach to health care, it is being in a vertically-
integrated health care system. If these appeal to physicians
and we expose our medical students and our residents to these
environments, then I believe the VA will be successful if it
can offer a career path for investigation and scholarship as
well as simply seeing patients. If you are simply doing the
same thing as a VA physician that all other physicians in the
community are doing and getting paid half as much, then it is
going to be very difficult to rationalize on pure economic
means why you should work at the VA.
Where I believe the Veterans Administration faces
particular challenges is in marketplaces like the one in which
I serve. Our school has the largest group practice in the State
of Nevada. We run two campuses 450 miles apart. For Easterners,
that is the distance between Boston and Washington, DC. It is a
very competitive health care market. So, our Reno VA, which is
not a tertiary care referral VA, often has to refer patients,
as we say, across the hill, across the Sierra Nevada to San
Francisco, and similarly, Las Vegas is the largest metropolitan
area without a dedicated VA hospital. There is an integrated
VA-DOD facility, but as you are keenly aware, they are building
a new VA hospital.
In those circumstances, it is imperative, I believe, for
the VA to really reach out to the academic affiliates to build
these strong lasting ties so that there is a mutual
interdependence, because I believe that our missions and vision
and values are really very similar to the VA. In fact, most of
those, particularly those who have served within the VA, hold
it up as a paradigm of health care for this country. Thank you.
Chairman Akaka. Thank you so much, Dr. McDonald.
This question is for the entire panel. What effect does
VA's hiring process have on recruitment, and how do you believe
it can be improved and accelerated while still ensuring quality
care for veterans? This is for the GAO as well as the
providers. Dr. Kanof?
Dr. Kanof. I don't have the answer, but at least I can give
you some data. I mean, when we did our surveys--and, granted,
this was in 2005 and 2006--we surveyed VA officials that were
responsible for H.R. activity and the average took 15 months.
In one case, it was as short as 3 months, and this is for the
CRNAs. But in another case, it was as long as 60 months. So,
clearly, wherever you are, either 15 months or 60 months, that
is too long.
The previous panel went through some of the steps, but it
really takes a concerted effort to, as soon as you have made
the decision to hire someone, to the posting, to the
interviewing, to the job offering, to knowing are you going to
be offering retentions? Are you going to be doing relocation
bonuses? All that needs to be known from step one so that the
timeframe could be significantly shortened.
Chairman Akaka. Dr. McDonald?
Dr. McDonald. Yes, sir, Chairman Akaka. There is one piece
of the VA hiring puzzle which is not broken and I would urge
the Committee to consider this when thinking about changes.
That is that currently the VA--and I don't know the situation
with nursing, I am sure we can hear about that--but currently,
the VA is allowed to hire an employee, a physician, who is
licensed in any State in the Union to practice exclusively in a
VA facility. That is extremely important, because it may take--
in our case, in Nevada--it takes a minimum of 6 months to
obtain a medical license and an additional 3 to 6 months before
a physician in the civilian sector is fully credentialed with
payers. So, essentially, the VA is treating licensure in any
State as a national medical license, which I think that is a
piece that works very well.
I used to think, until I joined the State of Nevada, that
the VA had a cumbersome bureaucracy. I am now disillusioned. I
think that we can probably match the Federal system for hiring
any day, and I think there probably are some streamlining steps
we can take. But, on the other hand, I also realize, as a
leader who recruits a lot of other leaders, that it is very
important to cast a broad net when you are looking for the most
qualified individual. And so, some of the things that seem to
be ponderous and slow, hopefully, as long as we get rid of the
unnecessary steps, are, I think, very important parts of
ensuring a quality workforce. Thank you.
Chairman Akaka. Thank you, Dr. McDonald.
Ms. O'Meara?
Ms. O'Meara. Thank you, Chairman Akaka. From what I have
seen, one thing, I keep track of the newspaper ads for the VA
and they are pretty few and far between. I always wonder why
they don't advertise more just in the Sunday paper, which a lot
of people get the Sunday paper.
Another issue, from experience, I think that H.R. needs to
be fully staffed at my facility and better trained in the
process, especially for title 38, because it seems there are
many, many people with roles to play in hiring the title 38
professional staff--from the nurse recruiter to the chief nurse
executive, then to HR, then to the staffing director. It
appeared to me that there wasn't a whole lot of working
together. It is like they are working separately and have their
own piece. But, if no one is really overseeing the whole
process, it can just be slow. Personal experience.
Chairman Akaka. Thank you. Dr. Phelps?
Mr. Phelps. I would echo what is being said about human
resources policies and procedures, but I wonder if I could also
add--and it is on the recruitment side but it is also the
retention side--about research. Psychologists are kind of a
unique discipline. We are trained at the doctoral level to not
only be service delivery providers, but also as researchers,
and so Dr. Strauss is a great example of our best and
brightest. If we are recruiting psychologists to one or the
other role in the system, we are missing the skills and the
expertise that psychologists like Dr. Strauss bring to the
system.
So, the point that she made about release time to do
research--because psychologists, again, are not bench
researchers as you see in medicine and other places. We
research clinical processes, the delivery of service and how
best to do that. For example, the two evidence-based practices
that VA cites for the treatment of PTSD, those were developed
by clinical researchers in VA, those are people who live in the
delivery system as well as do research.
The way the system is configured currently, and this is my
experience at a number of facilities around the country, is in
many cases, psychologists have 5 percent release time to do
research. What they do is get together and pool their 5 percent
time across eight people and hand it to somebody in the
psychology staff to do research. That is a very foolish waste
of research and clinical activity, in my opinion. So, a system
that recruits people at their skill level and expertise to fill
real needs in the system, I think would go a long way.
Chairman Akaka. Thank you very much, Dr. Phelps.
Dr. Strauss?
Ms. Strauss. Let me see. What can I add to this? Probably
distinct from other members of the panel, I am on the early
side of my career and I have a very fortunate position in VA
right now. My hiring was not through the normal course, because
I was able to pursue a research path through a grant award
early on.
It is not that long ago, though, that I graduated, and I
have to say that if I were on the market looking for a job and
I understood that it might take 6 months or so for a position
at VA to become available or for the offer to come through, I
don't know that I would have been able to afford to wait that
long. I don't know if I would have felt terribly welcome or
wanted.
Because I haven't been in this position, I am not sure if
such things are clarified up front. But, I think it would be
really important to express clearly up front to new hires what
the package is. So, obviously, for a psychologist like myself
interested in research, that would be a piece of the puzzle.
The potential for other benefits, like loan repayment programs,
would also factor in, and I think would actually be crucially
important for people just coming out of school. I think that
that is a real factor.
I guess the upshot is, when one graduates, one knows one
needs to get a job and wants to land someplace where they are
going to feel welcome and really want to build a career. And
some of the timelines that I am hearing about, I think could be
problematic in recruiting people at the highest level, because
hopefully you are talking about people who also have options
elsewhere.
Chairman Akaka. Thank you all so much. Let me call on
Senator Burr for his questions.
Senator Burr. Thank you, Mr. Chairman, and I would
appreciate it if nobody would take it personally that I missed
the first four and got back for Dr. Strauss. It is a scheduling
problem.
Dr. McDonald, let me assure you, coming from a guy that
represents a State that is over 600-plus miles from one end to
the other, I understand what 450 can be and how challenging it
can be.
I wanted to just make an observation on your remark about
the national licensure process. It does make it easier for the
VA to access, in a timely fashion, health professionals. It
comes with a tremendous amount of responsibility on the part of
VA to make sure that we have gone through the review of these
individuals thoroughly. So, I just caution us that speed is not
the lone objective, it is the quality of the individuals, and
we have had incidences of late where we have gone back and
realized that we had a breakdown in our system. I don't think
there are any of us that are proponents that we change
something in that national licensure, but I think we constantly
are reminded that we need to remind the entire system of the
responsibility to proceed with caution as we go through it.
Ms. O'Meara, your statement mentioned several bills signed
into law that have failed to be fully implemented by the VA
through either inaction or delay. Specifically, you mentioned
provisions involving contract physicians, provisions to enhance
recruitment, retention, and pay improvements. Would you just
briefly tell me where you think this disconnect is occurring?
Ms. O'Meara. Well, the first area is with alternative work
schedules for nurses. I do not know of any facility where the
36-hour week paid as full-time 40-hour week has actually been
implemented. Neither has a 9-month work year been offered. So,
it was as if the bill was never written, the law was never
passed. That is the first area.
I think the EDRP program is not fully--the amounts that are
even authorized now are not being fully given to individuals
and the amounts could be higher, given the cost of education.
Those are the two areas I have the most familiarity with.
Senator Burr. Great. Thank you very much.
Dr. Phelps, you highlighted several problems, as well, that
are obstacles to retention of VA psychologists. Let me ask you
what the normal turnover rate among VA psychologists is and if
you have identified any problems that contributed directly to
an accelerated departure by psychologists.
Mr. Phelps. Senator Burr, I do not have the data on
turnover rate for psychologists in VA. Anecdotally, having
worked with psychologists for a long time in the system,
psychologists tend to stay for a long time. We just have had
retirement parties for at least four senior psychologists there
30 years, and I am sure those data would be available from the
VA system.
My experience, though, is once you are in, you are in. That
has changed of late, though, with the promise of advancement
through the Hybrid 38 system for many psychologists who have
operated--I know many psychologists who have been in senior
leadership positions across the country for 20 years who are
still at a GS-13 level, which is the journeyman level in the
system. The statute was passed to expand that system in 2003.
Here we are 5 years later with what we consider very
complicated red tape, bureaucratic systems, that essentially
are holding our psychologists at bay, continuing to ask them to
perform far above the duties of just service delivery or
research but rather leadership position of teams, treatment
units, whole components of VA and not being able to advance in
the system despite qualifying for advancement through the new
National Professional Standards----
Senator Burr. If I made the statement that I personally
don't think that the VA delivery system responds the same way
that the private delivery system does to technology, to
research and the findings from that research, would you agree
with that?
Mr. Phelps. I would agree with it mostly, Senator. The
issue of the electronic medical record, however, in the VA is
one at least we at the APA--we are studying and participating
in national efforts for a national medical record--we see that
as a world-class system. Now, this is not to say there are not
problems with the system, but with regard to personnel and
staffing patterns--and I am really not attempting to introduce
turf into this hearing, because I have great respect for our
physician colleagues, our nurse colleagues, our occupational
therapist colleagues, and so forth--but VA, to simplify, VA's
hiring procedures and personnel procedures, at least with
regard to health care delivery professionals, are ones that
were born out of the days when health care in this country was
really driven by what we call the doctors' workshop.
And sir, what that means, the doctors' workshop is the
hospital. People don't talk about that much anymore. We have
seen radical improvements, and I think this Committee has a
large responsibility here; over the last 10 years in a great
deal of new and modern thinking in the VA's delivery system so
that it has moved out of the hospital, into the community. It
still needs to go further. The real frontier is the rural
frontier, as we heard earlier. But many, many, the development
of the electronic record and so forth. But the personnel system
is one that was rooted about 40 years ago, back to the doctors'
workshop.
Senator Burr. Let me add to something that you said and
that is that we might agree that it doesn't happen naturally
within the VA and there is a progression that happens naturally
in the private health system.
Mr. Phelps. Yes.
Senator Burr. You are right. It has been prodded by
Congress. It has been prodded by you. It has been prodded by
associations that might represent veterans. I think it is safe
to say that with the exponential change that health care is
seeing in the future, we can't wait for the VA to be prodded to
do something if we expect it to be on the cutting edge of
research and development. And I think most of us on the
Committee believe that as it relates to Traumatic Brain Injury,
PTSD, to other mental health challenges, that the data is
sufficient in the system to say the faster you can get people
in, the more intense the treatment and the rehabilitation can
be, the more you can affect the outcome on the other end.
I am sure at some point we will prod to a point that we
will actually believe that not only do we have a system that is
conducive to that, but we also have the right incentives on the
patient side to make sure that, in fact, they are accessing
that treatment at an early point in an intense way with their
expectations being, ``I am going to get better.''
I have got to move to Jennifer just real quick, if I can,
because you talked about a number of things. You talked about
the need to have the right type of facilities. Here is the
challenge for this Committee and for the VA as a whole. If you
look at the veterans' population, it continues to age, though
we have an infusion now, the result of the War on Terror. How
much of our responsibility is it to make sure that our
investment in facilities reflects where our veterans are
living?
It is pretty easy to look at Nevada and see the growth
numbers and say, this is a good place to put a VA facility. It
is easy to look at North Carolina and the growth projections,
but more importantly, the retiring military families and say,
gee, we could start building today and we probably couldn't
meet the need.
I think we have to go further, and I believe that we have
got to get it even closer than just a couple places in a State,
and I think Senator Tester said this. Even though you are not
going to look at Montana and find a growth pattern that would
say, this requires a tremendous investment right now, it still
requires us to look at where the population is and decide
whether we can restructure the delivery system in a way that we
can provide the services in a fashion that more people take
advantage of it.
The Chairman and I have exchanged thoughts as it relates to
our ability to not dislocate a veteran from his family, not
dislocate a veteran and his family from his community to access
care. That is how the private system begins to set up. So, I
think we have got to think of new efforts in the future.
I am curious to know how much of the research that is done
at the Duke VA is driven based upon the tightness of the
affiliation with Duke University and the understanding of
today's academic institutions about the need to perfect and to
focus on research?
Ms. Strauss. Let me make sure I am understanding your
question. How much of----
Senator Burr. If Duke University wasn't next door and had
the tight affiliation with the Durham VA, do you believe the
Durham VA would be involved in the degree of research that they
are currently involved in?
Ms. Strauss. I am actually not sure, but I think that the
Duke academic community is a tremendous resource.
Senator Burr. I agree with you totally. My answer would be,
probably not. It would probably not be involved in research to
the degree that they are, and I think somebody alluded to it
earlier--Dr. McDonald or Dr. Phelps--that it really is
leveraging knowledge learned from a standpoint of research from
the academic world into the clinical world, and understanding
where it is appropriate within the Veterans Administration for
us to really drive research that, quite frankly, we can't get
anywhere else. This is a gold mine if you pick the right types
of things.
In Wilmington, North Carolina, we have one of the largest
diabetes research studies being done in a community health
center. Now, most people around the world would never believe
that that would be a beneficial pool to do a study on diabetes.
In fact, it is probably the richest pool, and outside of a
community health center, I am not sure that you could find the
cross-section like you could there.
I think we are going to be challenged in the future as to
how we take more of the VA facilities and have that tight
relationship with an academic institution, even if it is not
right there on the same footprint like Durham exists. I don't
think there is any question that we will continue to be
challenged to find new ways to market the VA, and this is my
last question.
You made a statement that if it hadn't have been for an
academic mentor, you might not have gone to the VA and worked.
Let me just say----
Ms. Strauss. I think my statement was the quality of
mentorship available at my facility----
Senator Burr. OK.
Ms. Strauss [continuing]. Was a very strong attraction to
me.
Senator Burr. My question is, how does the VA change its
marketing strategy to market itself to these unbelievable
academic institutions and begin to cultivate in these medical
students a desire to work at the VA? Is that something we
should be doing that we are not doing today?
Ms. Strauss. Probably. In my written testimony, one of the
things I mentioned is that I was coming from a very traditional
academic medical environment, and honestly, VA wasn't on my
radar when I first started looking for positions. It was a very
trusted graduate school mentor to whom I am quite grateful who
suggested to me that given my research interests, this would be
a really good fit. On my own, I am not sure I would have
considered it, just because in the ivory tower that is academic
research, it wasn't on my radar.
Senator Burr. I look at a nurse with a 4-year degree who is
being recruited by people from six different States 6 months
before she graduates based upon the market today and the need
for nurses. The same is true for every health care
professional, and I guess the point I was beginning to make is
that VA can no longer silently sit by, waiting until people
graduate, and hope that VA is in the mix of consideration.
Do we not have to reprogram to where we proactively go out
into the community and begin to pull students in; because there
is a story to tell, and the story, as Dr. McDonald said, it is
not always the highest pay. It is not always the most
responsive system. But the mission that they carry out is a
mission that is more fulfilling than anywhere else somebody in
the health profession can work.
Listen, we have gone well over the time that I know the
Chairman allotted and asked you to be here. And again, I
apologize that I have been out and in. I can't thank all of you
enough for the value of the information. And Mr. Chairman, I
look forward to trying to figure out exactly how we use this in
a very positive way with you.
Chairman Akaka. Thank you. Thank you very much, Senator
Burr.
As you know, this hearing is focusing on making VA the
workplace of choice and what we are finding out are many facts
here, directly from you, the providers. Before we adjourn, I
want to ask the panel on your own to say a few last words about
making VA the workplace of choice for health care providers.
Thinking about that, thinking about what Senator Burr has
asked, what can you add to this about making VA the workplace
of choice?
Dr. Kanof. Well, I will start. I am going to echo some of
the comments that other members have said, and it is not in our
statement, but it goes back to our report. Interesting enough,
when we did a survey--and again, this was just the CRNAs--
salary, while important, was not one of the drivers for what
the CRNAs were looking for in terms of improvement. I mean,
they really did want the flexibility in their work schedule. We
didn't know to ask them about a market as they do in San
Francisco, but they wanted flexibility. They wanted child care.
They wanted those elements of quality-of-life that actually the
Federal Government and many private sector hospitals are
providing.
Chairman Akaka. Dr. McDonald?
Dr. McDonald. Thank you, Mr. Chairman. From the AAMC's
perspective and from my own personal perspective, I would say
that it is to continue to grow graduate medical education, to
carefully consider more robust loan repayment schedules for VA
physicians, and to ensure that the tradition and importance of
a strong affiliate relationship with the VA is true not just at
the large premier institutions, but at some of the smaller
institutions, such as the two that I am responsible for
affiliates with. Thank you.
Chairman Akaka. Ms. O'Meara?
Ms. O'Meara. Thank you, Chairman. I think there are several
convergence areas for this to make it the workplace of choice.
The pay issues, we have discussed all of those and all of them
are important, retention pay, recruitment incentives. I think
the VA could definitely start a marketing campaign. I don't
think I really see that, you know, what Mr. Burr was talking
about, to attract people to the mission. I think that sounds
wonderful.
One other area that shows up in nursing research a lot is
the workplace environment is very important to nurses
particularly, and I am sure other health care professionals.
The work environment, which has to do with collegiality, with
being treated with respect, having a say in your workplace,
things like staffing, things like flexible work schedules, if
those things aren't implemented, they will be going other
places, and for the newer generation coming in, the Gen X-ers,
VA has been shown that they will move along. They will not stay
in an environment that they don't enjoy. And so, as opposed to
the older generation where we have the 27-year tenures, I don't
think we will see that, unless the VA changes. Thank you.
Chairman Akaka. Thank you. Dr. Phelps?
Mr. Phelps. Yes. I think the VA's--this is a little beyond
the personnel systems--the VA's continued innovation and
modernization of the health care system toward more integrated
care models, team-based care, all of these are the modern
approach to treatment; world class electronic recordkeeping;
and that sort of thing; continued innovation in VA so that it
is truly seen as the world class health care delivery system
that it can be is probably the strongest marketing point, shall
we say, not only for veterans seeking care in the system but
for health care professionals to come in. And finally, of
course, fair pay for a fair day's work for health care
professionals.
Chairman Akaka. Thank you. Dr. Strauss?
Ms. Strauss. Thank you. I guess what I can add or at least
reiterate from what already has been said, salary, of course,
is an issue--fair pay for what we are doing. I will also say
that if salary were the driving issue, I wouldn't be here
because I could be paid better elsewhere. And so that is not
the thing that keeps me here, although I certainly appreciate
the opportunity to be paid fairly.
One of the big driving things that attracted me and keeps
me here is truly the mission of what we do and how it makes me
feel about myself and the time that I am spending doing it,
which is quite a bit of time. And I think that once people
enter the system, their commitment and attachment to what we
are doing only grows.
I think VA could do a better job, potentially, of marketing
the quality of training that is offered in this environment. As
I mentioned, when I was in graduate school, it really wasn't on
my radar. I had no idea, truly, what the resources were and
what a tremendous environment this is to grow a career. So, it
is a bit of a kept secret and I wish that weren't the case.
And for the record, I plan to be here for many years to
come, so I have every intention and very much hope to continue
to build a career at VA.
Chairman Akaka. Thank you very much, Dr. Strauss.
In closing, I again want to thank this panel for appearing
today. Your input on these issues is valuable to this Committee
as we work to make VA the employer of choice in our country,
and especially for health care professionals in the years to
come.
I want you to know that we will be submitting additional
questions to you for the record, and again, I want to say
thanks so much for your responses today.
This hearing is adjourned.
[Whereupon, at 12:20 p.m., the Committee was adjourned.]
A P P E N D I X
----------
Duke University Medical Center,
Durham, NC, April 7, 2008.
Hon. Daniel K. Akaka,
Chairman,
Senate Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.
Dear Chairman Akaka: My name is Harvey Jay Cohen, MD. I am the
Professor and Chairman of Department of Medicine at Duke University
Medical Center, having recently retired from the Department of Veterans
Affairs after 35 years of service. I am extremely sorry that I cannot
accept the invitation to appear in person before your Committee to
offer testimony regarding the VA Research Service. Unfortunately,
unavoidable prior scheduling conflicts preclude my doing so. However, I
am delighted to respond to the opportunity to write today to express my
strongest support for the VA Research Service. I do so because it is my
belief that my own career mirrors many others in the VA, and can offer
an example of how the VA can be a pivotal driving force in the
recruitment and retention of physicians for the Department of Veterans
Affairs. In many respects I owe the greatest debt of gratitude to the
VA Research Service for offering me the opportunity to initiate and
develop essentially my whole career within the VA and in affiliation
with Duke University. I believe this a model replicated many times over
across this country.
Let me illustrate. In 1971 I was a young faculty member, just
having joined the faculty at Duke University one year before. As you
may know, our institution is closely affiliated with the VA Medical
Center in Durham, located just across the street. I had done part of my
residency training and fellowship training at the VA, and had an
excellent experience. When asked if I would consider spending my
clinical time in hematology and oncology at the VA, I initially
hesitated because in addition to my commitment to clinical and
educational activities, I was interested in developing my research
career as well. When I learned that I could compete for an opportunity
to receive a Research Career Development Award, I seized that
opportunity immediately. I was fortunate enough to compete successfully
and became a VA Research Clinical Investigator the following year. I
set up my laboratory at the VA, and became a full time VA investigator
and clinician. In ensuing years, I became the Chief of the Hematology/
Oncology section at the VA, and then Chief of the Medical Service from
1976 through 1982. Throughout that period I remained funded by
competitive grants under the VA merit review program. I also held
funding through the NIH, but based that entire activity at the VA.
In subsequent years I became interested in the new discipline of
geriatrics and led the effort at our institution to secure a Geriatric
Research Education and Clinical Center in the early 1980's, and from
that point forward concentrated my efforts on geriatrics with an
emphasis on cancer in the older individual. This further cemented my
ties with the VA as we continued to expand and develop our programs.
Those programs became the basis for the development of the entire
geriatrics program at Duke University as well as the VA, a program that
has for the last several years been consistently ranked in the top five
in the country. Over those years, as my research interests evolved, the
VA Research Service offered me the opportunity not only to compete for
more basic research, but subsequently for more health services-oriented
research and cooperative studies. Each of these, I hope, made
contributions to our ability to care for our patients better, but also
offered me wonderful opportunities which further cemented my
relationship with the VA. This is just one example of how the broad
spectrum of the portfolio of VA research can accommodate and encourage
physicians with many different interests to serve within the VA system.
Personally the VA Research Service allowed me the opportunity to take
on clinical and administrative roles which kept me within the system
for virtually my entire career. I could not be more enthusiastic about
the potential of the VA Research Service.
However, currently there are great challenges despite the
tremendous opportunities that continue to exist. Among these challenges
is that over the years, the clinical load has increased for many of the
physicians within the VA, and this has had consequences in the ability
to devote time to research. This is not a problem for people in the
career development program. However, for those who are in the clinical
service, despite having funding for merit review grants, the time to do
the research is difficult to carve out. While it is my understanding
that accommodations have been made for this through the VERA modeling,
and funding is supposed to be provided to support these investigators'
research time, it would appear that because of tight budgetary
constraints and other priorities, these dollars do not end up
supporting that time directly. It seems to me that the VA might
consider an option somewhat like one that the NIH uses when money is
awarded to the VA Research Service, such that when physician
investigators apply for research grants a portion of their time and FTE
could be budgeted directly on the grant, and thus will directly protect
that time for the research activity. A second challenge is that science
has evolved. In past years, when I was beginning my career the
individual investigator working in his laboratory, perhaps with some
collaborations, could be successful. Currently, however, with the
evolution of scientific technology, it is rare that this situation
occurs. Rather, science has become a team game. One needs an
environment that is supportive both in terms of infrastructure and in
terms of colleagues with complementary scientific expertise. This is
sometimes difficult to achieve within a given VA institution's walls,
although at some of the more complex tertiary care medical centers with
substantial affiliations this can be done. However, even in those
circumstances, a flexible and fluid approach to location and activities
for any budding investigator must be encouraged, to allow the best of
translational science to bring the best of care for the future, to the
VA.
Despite these challenges I believe that the VA research system
still has great potential. In particular, it has substantial advantages
related to the patient population. This is a national system with
national databases and the potential to provide accurate patient
descriptions (sometimes referred to as the phenotype) which can inform
research in many different areas, in particular genomics research. This
would allow the VA to participate actively in the coming revolution in
the approach to personalized medicine. The databases within the VA are
a natural for large-scale epidemiologic work, and the patient
population is a natural for cooperative studies. Moreover, as the
proportion of women now being cared for by the VA has increased, the
patient population becomes even more representative for such studies.
Finally, let me say a bit about the critical role that VA research
has played in supporting the growth of certain areas and disciplines.
Perhaps the best example of this is geriatrics. My own career parallels
the growth of geriatrics in this country, a growth largely initiated
and sustained by funding of centers such as the Geriatrics Research
Education and Clinical Centers, and subsequently MIRECs and others.
These have been able to focus activity through groups of investigators
with similar interests to work together and have made great advances,
both for the VA and the country at large. Such centers, especially the
GRECCS, are under substantial budgetary threats. I would urge the
Committee, as it looks at VA research, to find ways to protect these
jewels in the VA's crown.
As you can tell, I am most enthusiastic about the VA and its
research. Why should I not be? It has afforded me the ability to grow
my career while being able to be of service to the veterans in this
country to whom we owe so much. Thank you for the opportunity to
provide this testimony.
Sincerely,
Harvey Jay Cohen, M.D.,
Walter Kempner Professor and Chair, Department of Medicine,
Director, Center for the Study of Aging and Human Development,
Duke University Medical Center.
______
Prepared Statement by Ann Converso, RN, President,
United American Nurses, AFL-CIO
I would like to thank the Chairman, Ranking Republican Member, and
Members of the Committee for the opportunity to provide testimony for
the hearing on ``Making the VA the Workplace of Choice for Health Care
Providers.'' My name is Ann Converso and I have been a registered nurse
in acute medical/surgical units and later I.V. therapy at the VA
Western New York Health Care in New York's VISN 2 region for more than
30 years. I have also been an active member of my union, the United
American Nurses (UAN), AFL-CIO, during that time. I am testifying today
as the President of the United American Nurses, a union representing
registered nurses--6,000 of whom are VA nurses.
There exists a health care crisis in our country regarding the
shortage of registered nurses. A 2002 report by the Health Resources
and Services Administration states that by 2020, hospitals will be
short 808,416 RNs. In a 2002 survey by the United American Nurses,
three out of every ten nurses said it was unlikely they would be a
hospital staff nurse in 5 years. The VA health care system has by no
means been immune to the shortage.
As nurses leave the VA system, new nurses are not joining the VA at
comparable rates, and patient load is increasing. In its own report,
``A Call to Action,'' the VA states that it must replace up to 5.3
percent of its RN workforce per year to keep up with RNs retiring. By
all accounts, that is not happening. In its Web site documentation of
system-wide capacities, VA statistics show that between 1996 and 2002
the number of full-time-equivalent RNs went down by 8.4 percent. During
that same time period, the number of ``unique patients'' treated at the
VA went up by 55 percent.
In my years as a VA nurse, I have experienced several nursing
shortages firsthand. I believe I speak for other VA nurses when I say
that we love our jobs and the important work we do in caring for our
Nation's veterans. With that said, registered nurses are leaving the
bedside in favor of the many other job options now available to us,
from clinic jobs, outpatient jobs, computer jobs, quality management,
doctors' offices, pharmaceutical jobs or leaving nursing entirely. A
contributing factor causing registered nurse to leave the VA is
problems they are experiencing with section 7422 of title 38.
Congress amended Title 38 to provide medical professionals who work
at VA facilities with collective bargaining rights, which include the
rights to use the negotiated grievance procedure and arbitration. Under
38 U.S.C., section 7422, covered employees can negotiate, file
grievances and arbitrate disputes over working conditions except ``any
matter or question concerning or arising out of:''
professional conduct or competence (defined as direct
patient care or clinical competence;
peer review; or
the establishment, determination, or adjustment of
employee compensation.
Increasingly, VA management has interpreted these exceptions very
broadly, and has refused to bargain over significant workplace issues
affecting medical professionals. Recent court decisions are upholding
VA's broad reading of Section 7422, even when management raises it
after completion of the arbitration process.
Congress passed this law in 1991 to strengthen the bargaining
rights of VA medical professionals. By its own admission, the VA
recognizes the critical role that health care professionals play in
improving quality of care. According to the VA Office of Nursing, ``VA
nurses have been widely recognized for their instrumental work in
initiating, developing, implementing, and monitoring the practices and
policies that made VHA one of the world's foremost authorities in
patient safety and quality outcomes evidenced by performance measures--
an exceptional achievement by any assessment.'' (DVA Web site, April
30, 2007)
In practice, VA health care professionals have a shrinking role in
quality assurance and patient safety. Too often, the Human Resource
staff is making health care decisions instead. The VA's current 7422
policy goes directly against good medicine and Congressional intent.
Employees leave the VA for other public and private health care systems
where they have more rights, which in turn pose's a threat on
recruitment and retention at the VA. Congress needs to amend section
7422 of Title 38 to ensure that the VA complies with Congressional
intent and that registered nurses are able to care for veterans with
dignity, respect and the basic bargaining rights they were intended to
have.
To address this problem, Senator Rockefeller, along with Senators
Webb, Brown, and Mikulski introduced S. 2824, a bill that would improve
collective bargaining rights of registered nurses in the Department of
Veterans Affairs. The UAN is pleased by the introduction of this
legislation and strongly endorses it. The UAN strongly urges Members of
the Committee to support and work for the passage of this important
legislation.
Thank you again for opportunity to provide testimony regarding this
important issue. The UAN looks forward to working with the Committee to
protect registered nurses and the veterans they take care of.
______
Prepared Statement Submitted by Charles Ingoglia, Vice President of
Public Policy on Behalf of the National Council for Community
Behavioral Healthcare
The National Council for Community Behavioral Healthcare
appreciates the opportunity to submit testimony on behalf of its 1,400
member agencies who provide medical and rehabilitative treatment and
support services to nearly six million adults, children, and families
with mental and addiction disorders in every community across America.
We appreciate the Committee's interest in meeting the physical and
behavioral health needs of our Nation's veterans. Since the initiation
of OEF and OIF, nearly 800,000 servicemembers have been discharged and
are eligible for VA care. Of those, more than one-third sought medical
care within the VA. The Department has also acknowledged that mental
disorders are the second most commonly reported health concern by
veterans seeking care.
A June 2007 Army study found that 49% of Army National Guard
soldiers and 43% of Marine reservists reported symptoms of PTSD,
anxiety and depression. At the end of their tours of duty, these
citizen soldiers return to their families and communities, oftentimes
miles away from a VA facility.
To meet this need, the VA has hired nearly 3,800 mental health
workers, including physicians, nurses, pharmacists, social workers, and
clinical psychologists, since 2005. Most of these professionals have
been hired in the past 18 months. The Department has expressed interest
in hiring at least an additional 500 mental health workers in the near
future.
The VA's interest in hiring permanent full time staff to meet this
need is based on a stated desire to assure sustainable, evidence-based
programs. This approach, however, is exacerbating an existing mental
health workforce shortage, and may not meet the long-term treatment and
rehabilitation needs of returning veterans.
Most Americans with serious mental illnesses receive their
treatment from government sponsored or not-for-profit community-based
mental health organizations. From California to Maine, and in every
State in between, there is currently a shortage of qualified mental
health workers. While the shortage of psychiatrists and nurses is the
most severe, there are shortages in all areas, including social
workers, mental health counselors, and psychologists.
The VA's recent efforts to increase its mental health workforce
have exacerbated this shortage. Community-based mental health
organizations around the country report that staff are being recruited
away by the VA, leaving them unable to serve current clients and
looking once again for qualified replacements in a market with few to
choose from. This situation is even more acute in rural areas of the
country.
While it is clear that many returning servicemembers are currently
seeking care for mental disorders, it is less than clear what their
long-term treatment needs will be. Instead of providing for a ``surge
capacity'' to meet the current need, the VA is hiring permanent, full
time staff in a system where the average employee remains until
retirement. Such as approach would also provide the Department, and
Congress, time to understand the long-term treatment needs of Veterans
and to develop effective programs to meet them, as opposed to building
a system that may not be relevant to what veterans need or want.
In our view, rather than competing with, or recruiting from,
existing community-based mental organizations, the VA could pursue a
targeted strategy of cooperation and collaboration through service
partnerships. Such a course of action would provide immediate treatment
capacity, as well as ameliorate the ongoing damage to the private
sector inflicted by VA recruitment of mental health professionals.
Further, the establishment of service partnerships with existing
community-based organizations would also extend the ability of the VA
to provide needed treatment services in rural areas of the country
where many returning National Guard and Reserve component veterans
live. The stigma associated with mental illnesses already serves as a
barrier to care, veterans do not need the further barrier of long
travel times to access care.
Effective service partnership would be characterized by VA control
of the referral process, as well as minimum standards for clinical
training. Community organizations participating in such arrangements
would be required to hire veterans as peer outreach workers, and to be
competent in understanding the military culture and mindset.
Additionally, all treatment records would be transmitted to the VA for
inclusion in the veteran's electronic medical record to assure
continuity of care.
Such models of cooperation exist, albeit in short supply. It is
recognized that any such arrangements would be in existence only as
long as the need existed and are not intended to replace the existing
network of VA controlled care.
We would welcome the opportunity to work with the Committee to
further develop these issues in support of our troops, and I would be
pleased to answer any questions you might have. Please feel free to
contact me by telephone at 301.984.6200, ext. 249, or via email--
[email protected].
______
Prepared Statement of Sara Marberry, Executive Vice President, and
Anjali Joseph, Ph.D., Director of Research at The Center for Health
Design
Chairman Akaka and distinguished Members of the Committee, I am
Sara Marberry with The Center for Health Design, along with my
colleague Anjali Joseph. Thank you for the opportunity to present our
thoughts on how the design of the physical environment of health care
can help increase patient and staff safety and satisfaction, and worker
efficiency.
The Center for Health Design, which was founded in 1993, is a
nonprofit research, education, and advocacy organization of forward-
thinking health care, elder care, design, and construction
professionals who are leading the quest to improve the quality of
health care facilities and create new environments for healthy aging.
Our mission is to transform health care settings into healing
environments that improve outcomes through the creative use of
evidence-based design.
Traditionally, health care environments have been organized to
support the individual work efforts of practitioners in various roles
and disciplines (doctors, nurses, therapists, dieticians, and many
others) who work primarily in their areas of expertise and attempt to
coordinate with others by orders, notes, phone calls, pages and other
methods of individual communication. Patients and families have
traditionally been viewed as passive recipients of care rather than as
active experts in their own life and health conditions.
In contrast, a growing body of evidence compiled by The Center for
Health Design and others demonstrates that health care work happens
most effectively when practitioners work highly interdependently in
well-functioning teams, with active participation by patients and
families (McCarthy & Blumenthal, 2006; Uhlig, Brown, Nason, Camelio, &
Kendall, 2002). As care moves from simply ``treating disease'' to
healing the individual in a holistic sense--physically, emotionally and
psychologically--health care teams must increasingly work seamlessly
together and include the patient and family as integral team members.
A disconnect has arisen between the traditional, individual-centric
health care organizational and physical infrastructure of the workplace
and the way that health care practitioners, patients, and families
optimally must work together. This manifests itself in the form of
inefficiencies, communication breakdowns, occupational stress, medical
errors, and other operational failures that are alarmingly common in
health care today.
Further, the physical environment of the health care workplace,
along with other factors such as culture and work processes, also
impacts the health and safety of the health care workforce. According
to the Peter D. Hart Research Associates' (2001) survey of registered
nurses (RN), the primary reason why nurses leave health care other than
for retirement reasons is to find a job that is less stressful and
physically demanding. In a survey of nurses conducted by the American
Nurses Association (2001), 76% of the nurses stated that unsafe working
conditions interfered with their ability to provide quality care.
In order to understand and address these problems, it is necessary
to consider the health care workplace as an interdependent system
comprised of the physical environment, work processes, organizational
culture (e.g. formal and informal values, norms, expectations and
policies, etc.), workforce demographics, and information technology
(Becker, 2006). It is important to consider the interdependencies and
patterns of interaction between these elements, rather than focusing on
individual elements alone.
While several studies indicate that the physical environment
impacts staff outcomes in health care settings, it is clear that a
well-designed environment alone is unlikely to achieve its intent
without a supportive work culture and the technology in place.
Likewise, a supportive work culture such as one that promotes family
and patient participation in care processes is unlikely to function
successfully without the presence of design features (such as space for
families in patient rooms) that make this possible.
Hospital redesign and renovation projects provide the opportunity
to consider how these different elements might interact. The challenge
is to create settings where the physical environment, technology and
organizational culture together support ways of working that ensure
health, safety and effectiveness for all in health care.
hospitals are dangerous places to work
Of the 14 industries with the highest numbers of occupational
injuries and illnesses, three are in health care, with the top two
being hospitals and nursing and residential care facilities. Health
care workers are exposed to various occupational hazards on a daily
basis. They are exposed to airborne infections in the hospital as well
as those acquired through direct contact with patients. Taking care of
patients in the hospital is often back breaking work with nurses
required to manually lift heavy patient loads. This is an issue of
great concern today with the increasing bariatric population in US
hospitals.
For night shift nurses, poorly entrained circadian rhythms and lack
of sleep contribute to stress, fatigue and health deterioration. In
addition, other environmental stressors such as high noise levels,
inadequate light and poorly designed workspaces impact staff health and
safety. Proper design of health care settings along with a culture that
prioritizes the health and safety of the care team through its policies
and values can reduce the risk of disease and injury to hospital staff
and provide the necessary support needed to perform critical tasks.
Health care employees are at serious risk of contracting infectious
diseases from patients due to airborne and surface contamination
(Clarke, Sloane, & Aiken, 2002; Jiang et al., 2003; Kromhout et al.,
2000; Kumari et al., 1998; Smedbold et al., 2002). Factors such as poor
ventilation and fungal contamination of the ventilation system that
have been linked to the spread of nosocomial infections among patients
may also impact staff. For example, one study that examined the
relationship between indoor environmental factors and nasal
inflammation among nursing personnel found the contamination of air
ducts with Aspergillus fumigatus to be the source of infection
(Smedbold et al., 2002). A recent study conducted in the wake of the
SARS epidemic in China found that isolating SARS cases in wards with
good ventilation could reduce the viral load of the ward and might be
the key to preventing outbreaks of SARS among health care workers,
along with strict personal protection measures in isolation units
(Jiang et al., 2003).
While ventilation system design and maintenance is critical to
controlling the spread of airborne infections, infections are often
spread through direct and indirect contact with patients. Ulrich and
colleagues (2004) in their extensive literature review concluded that
poor handwashing compliance among staff is the primary cause of contact
transmission of infections. They suggest that providing environmental
supports to increase handwashing including visible, conveniently placed
sinks, handwashing liquid dispensers, and alcohol rubs might be more
successful in improving and sustaining handwashing compliance than
education programs alone (Ulrich, Zimring, Joseph, Quan, & Choudhary,
2004). They also document several studies that clearly show that
nosocomial infection rates are lower in single patient rooms as
compared to semiprivate rooms (Ulrich, Zimring, Joseph, Quan, &
Choudhary, 2004). These environmental measures that are linked to
increased patient safety are also likely to protect staff from
infection.
44% of injuries to staff are strains & sprains
Nursing work has become increasingly complex with changing
technology, changing work practices, and increasing documentation
requirements. Further, nurses are growing older and the patient
demographics are changing as well. Lower back pain is a pervasive
problem among nursing staff and is a result of poor fitness, long
periods of standing and efforts far exceeding workers' strengths
(Brophy, Achimore, & Moore-Dawson, 2001; Camerino et al., 2001; Miller,
Engst, Tate, & Yassi, 2006). Patient lifting in particular is a major
cause of injury to health care workers. According to Fragala and Bailey
(2003), 44% of injuries to nursing staff in hospitals that result in
lost workdays are strains and sprains (mostly of the back), and 10.5%
of back injuries in the United States are associated with moving and
assisting patients. Reducing injuries that result from patient-lifting
tasks cannot only result in significant economic benefit (reduced cost
of claims, staff lost workdays), but also reduce pain and suffering
among workers.
Ergonomic programs, staff education, a no-manual lift policy, and
use of mechanical lifts have been successful in reducing back injuries
that result from patient-handling tasks (Engst, Chhokar, Miller, Tate,
& Yassi, 2005; Garg & Owen, 1992; Garg, Owen, Beller, & Banaag, 1991;
Joseph & Fritz, 2006; Miller, Engst, Tate, & Yassi, 2006). When
PeaceHealth in Oregon installed ceiling lifts in most patient rooms in
their intensive care unit and neurology unit, they found that the
number of staff injuries related to patient handling came down from 10
in the 2 years preceding lift installation to two in the 3 years after
lift installation (Joseph & Fritz, 2006). The annual cost of patient
handling injuries in these units reduced by 83% after the lifts were
installed (Joseph & Fritz, 2006).
This study, as well as others, has emphasized the importance of
instituting a no-manual lift policy (along with the installation of
mechanical lifts) in hospitals to prevent such injuries from occurring.
Another environmental design feature that has been linked to reduced
discomfort (particularly for the lower extremities and lower back) for
workers who spend large amounts of time on their feet, is using softer
floors (such as rubber floors) (Redfern & Cham, 2000).
Ergonomic evaluations of the work area of different types of
nursing staff might provide solutions to problems that are specific to
different groups. For example, based on an ergonomic evaluation of the
work area of scrub nurses in the operating room, Gerbrands and
colleagues (2004) provided short term solutions for reducing the neck
and back problems experienced by this group as well as suggested
guidelines for operating room design.
Noise levels in hospitals are louder than a jackhammer
The effects of noise on patients are well known. However, few
studies have examined the impact of noise on health care staff. Ulrich
and colleagues (2004) analyzed several studies that measured noise
levels in hospitals and found that background noise levels in hospitals
were typically in the range of 45 dB to 68 dB, with peaks frequently
exceeding 85 dB to 90 dB, which is as loud as a jackhammer. This is
well above the values (35 dB) recommended by the World Health
Organization guidelines (Berglund, Lindvall, & Schwela, 1999).
Staff perceive higher sounds levels as interfering with their work
(Bayo, Garcia, & Garcia, 1995) and higher sounds levels are also
related to greater stress and annoyance among nursing staff (Morrison,
Haas, Shaffner, Garrett, & Fackler, 2003). Importantly, noise-induced
stress in nurses correlates with reported emotional exhaustion or
burnout (Topf & Dillon, 1988). Blomkvist and colleagues (2005) examined
the effects of changing the acoustic conditions on a coronary
intensive-care unit (using sound absorbing versus sound reflecting
ceiling tiles) on the same group of nurses over a period of months.
During the periods of lower noise, many positive outcomes were observed
among staff including improved speech intelligibility, reduced
perceived work demands and perceived pressure and strain (Blomkvist,
Eriksen, Theorell, Ulrich, & Rasmanis, 2005).
designing better workplaces can reduce errors & increase efficiency
The tasks performed by the health care team involve a complex
choreography of multiple activities including direct patient care,
indirect care such as filling meds, coordination with care team
members, accessing and communicating information, documentation of
patient records and other housekeeping tasks (Lundgren & Segesten,
2001; Tucker & Spear, 2006). Studies have shown that increased nursing
time per patient results in better patient outcomes (Institute for
Health care Improvement, 2004; Tucker & Spear, 2006).
However, the fact remains that nurses spend less than half their
time delivering direct patient care (Institute for Health care
Improvement, 2004). Nurses spend a lot of their time searching for
other staff, materials, missing meds and supplies and also are
frequently interrupted during their work to address these problems
(Tucker & Spear, 2006). In one study, a hospital nurse was interrupted
43 times during a 10-hour period, including 10 instances when necessary
materials, equipment and personnel were unavailable (Potter et al.,
2004).
At the root of the inefficiencies in health care is a physical and
organizational infrastructure that is completely out of sync with the
optimal practice of health care. It is becoming increasingly clear that
poorly designed physical environments along with other factors such as
lack of social support and an unsupportive work culture, reduces the
effectiveness of staff in providing care and potentially leads to
medical errors.
Nurses spend a lot of time walking
According to an unpublished time and motion study by Hendrich and
colleagues (cited in the 2004 Institute of Medicine Report, Keeping
patients safe: Transforming the work environment of nurses, pp. 251),
most of nurses' time is spent walking between patient rooms, the
nursing unit core and the nurses' station. Most older existing hospital
units have centralized nursing stations with different configurations
such as radial, racetrack, single or double corridor where the nursing
station is located centrally and patient rooms are located around the
perimeter. This kind of arrangement necessitates frequent trips between
patient rooms and the nurses' station to look for supplies, charting,
filling meds, and so on. According to one study, almost 28.9 percent of
nursing staff time was spent walking (Burgio, Engel, Hawkins, McCorick,
& Scheve, 1990). This came second only to patient-care activities,
which accounted for 56.9 percent of observed behavior.
A few studies have examined the impact of unit layout on the amount
of time spent walking (Shepley, 2002; Shepley & Davies, 2003;
Sturdavant, 1960; Trites, Galbraith, Sturdavant, & Leckwart, 1970) and
two studies showed that time saved walking was translated into more
time spent on patient-care activities and interaction with family
members. Shepley and colleagues (2003) found that nursing staff in a
radial unit walked significantly less than staff in a rectangular unit
(4.7 steps per minute versus 7.9 steps per minute). Two other studies
also found that time spent walking was lower in radial units as
compared to rectangular units (Sturdavant, 1960; Trites, Galbraith,
Sturdavant, & Leckwart, 1970). It must be noted that in the units
examined in these studies, the nursing station was centralized with
rooms arrayed around it.
These studies seem to suggest that bringing staff and supplies
physically and visually closer to the patients helps in reducing the
time spent walking. Centralized location of supplies, however, could
double staff walking and substantially reduce care time irrespective of
whether nurses stations were decentralized (Hendrich, 2003). There is
also anecdotal evidence that staff members who move from a centralized
nursing unit to a decentralized unit often feel isolated and miss the
camaraderie and support of the centralized unit. The social
interactions that occur within the care team are critical for
information sharing and effective communication. While the
decentralized unit potentially has many benefits, it is important to
consider how the design might impact staff interactions.
98,000 needless deaths a year
According to the IOM report, ``To err is human: Building a safer
health care system'', more than 98,000 people die each year in U.S.
hospitals due to medical errors (Kohn, Corrigan, & Donaldson, 1999).
According to Reiling and colleagues (2004) while some errors (active
failures) occur at the point of service (for example, a nurse
administering the wrong drug), most occur due to flaws in the health
care system or facility design--such as due to high noise levels or
inadequate communication systems.
Inadequate lighting and a disorganized chaotic environment are
likely to compound the burden of stress for nurses and lead to errors.
A few studies have shown that lighting levels and workplace design can
impact errors in dispensing medication in pharmacies. One study
examined the effect of different illumination levels on pharmacists'
prescription-dispensing error rate (Buchanan, Barker, Gibson, Jiang, &
Pearson, 1991). They found that error rates were reduced when work-
surface light levels were relatively high (Buchanan et al., 1991). In
this study, three different illumination levels were evaluated (450
lux; 1,100 lux; 1,500 lux). Medication-dispensing error rates were
significantly lower (2.6%) at an illumination level of 1,500 lux
(highest level), compared to an error rate of 3.8% at 450 lux.
This is consistent with findings from other settings that show that
task performance improves with increased light levels (Boyce, Hunter, &
Howlett, 2003). Two investigations of medication dispensing errors by
hospital pharmacists found that error rates increased sharply for
prescriptions when an interruption or distraction occurred, such as a
telephone call (Flynn et al., 1999; Kistner, Keith, Sergeant, &
Hokanson, 1994). Thus, lighting levels, frequent interruptions or
distractions during work, and inadequate private space for performing
work can be expected to worsen medication errors.
physical environment impacts staff & patient satisfaction
There is evidence that a supportive physical work environment,
along with other factors such as high autonomy, low work pressure and
supervisor support, positively impacts job satisfaction and burnout
among nurses (Constable & Russell, 1986; Mroczek, Mikitarian, Vieira, &
Rotarius, 2005; Tumulty, Jernigan, & Kohut, 1994; Tyson, Lambert, &
Beattie, 2002). Further, studies show that environments (i.e. physical
environment, culture and work processes) that include patients and
families as active participants in the care process (as opposed to
passive recipients of care) result in higher levels of satisfaction
among patients and families (Sallstrom, Sandman, & Norberg, 1987;
Uhlig, Brown, Nason, Camelio, & Kendall, 2002).
Studies show that physical design changes in long-term care
settings such as interior design modifications, natural elements,
furniture repositioning to support social interaction, design supports
for resident independence (such as large clocks, handrails, additional
mirrors) and orientation (large, clear signposts and reality
orientation boards), and artwork were related to improved morale and
satisfaction among staff (Christenfeld, Wagner, Pastva, & Acrish, 1989;
Cohen-Mansfield & Werner, 1999; Jones, 1988; Loeb, Wilcox, Thornley,
Gun-Munro, & Richardson, 1995; Parker et al., 2004). Tumulty and
colleagues (1994) suggest that if staff were allowed to make small
design modifications to their existing environments, their satisfaction
with their jobs might increase.
Other studies, primarily conducted in long-term-care settings,
suggest that smaller units contribute to reduced stress and increased
staff satisfaction. A cross-sectional survey of 1,194 employees and
1,079 relatives of residents in 107 residential-home units and health-
center bed wards found that large unit size was related to increased
time pressure among employees and reduced quality-of-life for residents
(Pekkarinen, Sinervo, Perala, & Elovainio, 2004). Other studies found
that small unit sizes were positively associated with increased
supervision and interaction between staff and residents in a special-
care unit for residents with dementia (McCracken & Fitzwater, 1989).
However, no consistent numbers are offered on what makes a unit large
or small (Day, Carreon, & Stump, 2000) and it is also not clear how
these findings translate to acute care settings. Further, even in small
units, it is important to consider how the design impacts staff ability
to monitor residents. Morgan and Stewart (Morgan & Stewart, 1998) found
that in a newly designed, low-density special-care unit with private
rooms, enclosed charting spaces, and secluded outdoor areas and
activity areas, staff spent increased time monitoring and locating
residents.
An important point that is emphasized in many of these studies is
that design changes alone are not likely to impact staff behavior,
satisfaction and stress. They must be accompanied by a supportive
culture and progressive work practices to result in overall beneficial
outcomes for patients and staff.
now is the time
We believe there is an urgent need to address the inherent problems
in the health care workplace that lead to staff injuries, medical
errors, and waste. The physical environment plays an important role in
improving the health and safety for staff, increasing effectiveness in
providing care, reducing errors and increasing job satisfaction. By
utilizing available evidence to plan and design new facilities, VA
hospitals can create work environments that help reduce staff turnover
and increase retention, two key factors related to providing quality
care.
However, it has become increasingly clear to us that efforts to
improve the physical environment alone are not likely to help any
health care organization achieve its goals without a complementary
shift in work culture and work practices. While the studies we cited in
this testimony demonstrate that well designed physical workplaces can
support staff in their work and increase health and safety for both
staff and patients, there is a definite need for more research
examining the effectiveness of new design innovations such as acuity
adaptability, standardized patient rooms, and decentralized nursing
stations within the larger context of any health care organization's
culture, technology changes, and work practices.
Respectfully submitted,
Sara Marberry & Anjali Joseph,
The Center for Health Design,
1850 Gateway Boulevard, Suite 1083,
Concord, CA 94520,
Tel. 925.521.9404; www.healthdesign.org.
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