i'd like to thank everyone for coming today the veterans health administration mission is to provide patient centered health care that is compact comparable with or better than available in the on v a sector to do this v a must have a viable health care workforce that is competent and well trained and happy over the past five years the v a has built a reputation of delivering health care officially and effectively v a has been totted outed as the best care anywhere in the department has been recognized on numerous occasions for health care quality and patient satisfaction however in order to aging with an average age of forty eight point six years we know that at the end of two thousand and twelve a significant percentage of the employees will be eligible to retire this subcommittee has held many hearings  that examined the appropriateness same quality of care and treatment that veterans of see within the health care system this hearing today will focus on the human resource challenges that v a must address in order to assure that we will not have a gap in expertise and quality of care provided to all veterans the committee realizes that this is a complex issue but we also recognize that it is an important one that deserves serious thought and consideration as well so i'd like to recognize mr miller for any opening statement that he might have and thank you very much mr chairman i do appreciate you holding this hearing today to examine all those challenges that v a faces in regards to the keeping the high quality health care workers that are currently into the in the system you know they are on the front line of the health care issue every single day our service members who have honorably served our country deserve high quality health care and we must do what we can to keep those professionals retained and recruit them as well and one of most pressing problems we face as a nation is a marked shortage in virtually all areas of the health care worker industry including nurses physicians physicians assistants psychologist pharmacists and physical and occupational therapists so you know the system has been recognized for the significant  benefit for its usual electronic medical records and focus on preventative care and to make sure that our veterans consume to receive the best care critical that we see the the v a as a workplace of choice so i appreciate you putting this hearing together  focus and see what we can do better and i you know back about my time thank you mr hare i think this chairman i want to thank you and and the ranking member miller for holding this hearing today the veterans health administration is one of the most impressive health care delivery systems in the entire world and that is in large part due to the dedicated medical medical professionals who make up the system from doctors to nurses to technicians to psychologists these are the men and women who are on the ground every day taking care of our nation's veterans the veterans population will undergo significant changes over the next two decades and as such the leadership at the b h a will have to be prepared to handle these challenges one of the biggest challenges of the recruitment and retention of highly qualified medical personnel at a time when the overall health industry is facing massive shortages the v a must be able to compete with the private sector for medical staff and we must ensure that as the ha continues forward that they have the tools and the funds necessary to guarantee adequate numbers of staff in order to continue the care of our veterans once again mr chairman i thank you for holding the hearing today i look forward to hearing from our panels and thank you very much  minneapolis v a medical centers who's here on behalf of the american association of nurse and f s s and then j lo mack was president of vertical alliance group inc so want to welcome our  member ranking member miller and distinguished members of the subcommittee things like i'm getting off to a bad start here on my tongue out this morning i've never been first on a panel maybe that's what it is thank you for the opportunity to testify today a f g greatly appreciate the subcommittees continues attention to the impact of the a health care workforce problems on patient care veterans want to get their care from the v a because v a health care professionals are extremely dedicated to their patients and committed to the mission of the v a in the 's labor management collaboration helped transform the v a into a health care later and best practices patient safety and health care information technology a f g believes the greatest human resources challenge facing v a today is the continuing erosion of title thirty eight collective bargaining rights as i will discuss shortly first i would like to address several other human resources issues of concern to f g e the harbor title thirty a process which covers psychologists social workers pharmacists and why some practical nurses among others has become severely backlogged it is also troubling that employees lose their veteran's preference when they are converted to title thirty eight from title five therefore a f g urges the subcommittee to reject proposals to add more positions to title thirty eight and instead conduct a polyp project using a streamlined title five hiring process to compare the two systems we would be pleased to work with you to develop this polyp project and believe it can provide valuable lessons for other federal employers they have g also urges the subcommittee to conduct oversight into the many implementation problems surrounding the two thousand and four physician pay low such as sacred to process for setting market pay and use of improper performance measures since congress is still waiting for the v a s long overdue report on how well the pay law is working and whether it has reduced the v reliance on costly contract physicians we urge the subcommittee to conduct its own study on this important law instead nurse alternative work schedules provide full time pay for working three twelve hour days per week or nine months per year these schedules are very popular in the private sector and could be a valuable recruitment and retention tool unfortunately the refuses to offer the schedule option to its nurses even though they were given this authority by congress four years ago a f g recommends that congress amend the law to require the v a to offer alternate work schedules based on a fixed formula that alliance the scylla ts with their local labor markets turning to title thirty eight collective bargaining rights we are very grateful to chairman michel and subcommittees berkeley subcommittee members berkeley brown and dole  providers with rights to challenge improper personnel policies through grey vinces arbitrations and the court provider's loss these rights because of the a begin using an arbitrary and term potations of the three exceptions and section seventy four twenty two of title thirty eight professional conduct and competency here review and compensation management seventy four twenty two policy directly contradicts congressional intent as is didn't buy the plain language of the law and the legislative history management seventy four twenty two policy is also inconsistent with its own position that it took in one thousand nine hundred six with a labor management agreement to allow graven says over in direct patient care matters scheduling and rights to pay survey data the v a contends that amending section seventy four twenty two will allow labor to disrupt patient care but management's rights to determine the agency's mission under title  already protect against and the v a cannot point to a single case where a grave involved a challenge to medical procedures the employees will grievance rights such as lpn psychologists and pharmacists never use these rights to disrupt patient care the v a also contends that current while just total thirty eight providers a fair process for deciding when a grievance can be filed warning to a review by the undersecretary for help we asked fair to  do in the past three years one hundred percent of these decisions have been in favor of management shouldn't be a health care dollars they spent on caring for veterans not looking for ways to block legitimate concerns hardworking dedicated nurses physicians thank you mr chairman i would be glad to entertain any questions from the committee thank you very much doctor you mr chairman ranking member miller and distinguished members of the committee i'm dr randy phelps deputy executive director for professional practice of the american psychological association where the largest association of psychologists with proximately ninety thousand full doctoral psychology members and another fifty thousand graduate students in the pipeline in our folks are engaged in study research and practices psychology i am formally a license i'm currently a licensed clinical psychologist but formally a practitioner myself a clinical research or an educator and for the last fifteen years i have been on the a p a executive staff and have served as a liaison to professional psychology and the department of veterans affairs we really appreciate the opportunity to testify today about human resources challenges with a is the largest single employee employer of psychologists and in this country professional psychology was born it was as a result of the needs of returning soldiers obviously for the oral testimony there's considerable amount of detail in the written testimony but psychologists are very actively involved particularly in the middle health side of treatment of veterans in v a the architects of the two evidence based practice treatments for p t s d are psychologists psychologists are serving a very critical role in understanding diagnosis and treatment psychologists since two thousand and five bringing us up to that two thousand four hundred psychologists in the system most of those folks i should add are young psychologists entering the system a g s eleven i should emphasize that every psychologist who comes out of a cloud or counseling program already knows how to treat p t s d depression and so forth the thing that i wanted to emphasize though about recruitment is that the staffing levels are very recent developments it was all we two years ago where we reached the staffing levels of psychologists in the v a of the hundred ninety five years so the curve has been going down until just very recently with the hiring of this new cadre of psychologists additionally and this gets to the issue of retention that i'd like to spend a little bit more time on additionally the number of g e s fourteen's in g s fifteen psychologist's in the system at the higher leadership levels are actually not increasing the g s fifteen level is lower than it was in one nine hundred ninety five the s done a good job of recruiting new psychologist coming into the system because it is hiring its own we have approximately six hundred psychology workforce that i can elaborate later if you have questions one is a lack of uniform psychology leadership positions we're the only metal health position without a designated fishley designated leader at medical centers there thirty eight in fact i would describe the implementation of hybrid thirty eight system as an absolute boondoggle bureaucratically and otherwise for the system the the these  problems which again we can elaborate later have led to a number of very chilling situations for psychologists throughout the country where folks are leaving the v a to go to the private sector  losing their positions inability to get advanced meant and so forth and we consider those kinds of problems as the most serious obstacles to making v a the workplace a choice for psychologists now and in the future because without clear advancement systems in place faces critical long term recruitment and retention problems as psychologist come to believe that there is little possibility for advancement in the system regardless of the level of complexity of their responsibilities fewer v a psychologists will be willing to accept positions of greater responsibility and in addition high potential trainees coming into the system the v a would like to recruit for the future will increasingly and are increasingly seeing v a as a dead end for their careers and will be attracted to other career options with more potential for advancement we thank you very much for this opportunity to testify minneapolis v a i also serve as president of the association of the a nurse anesthetists and i'm pleased to hear to appear before you on behalf of my profession the american association of nurse anesthetists and its thirty nine thousand members in the united and we provide that care safely the institute of medicine reported in two thousand that anesthesia is fifty times safer now than it was in the one nine hundred eighty s and for over one hundred twenty five years nurse anesthetists have met the mission of caring for days prior before i left left for this hearing i personally provided anesthesia for our veterans any of the more than five hundred sierra is in the veterans health administration could state say the same but the ever to be a c n a is fifty three years old seven years older than the professions average and is approaching retirement in any recent year nearly one in five v a c n a is leaves or retires from the v a twenty four v a facilities report c n a vacancies we believe that actual numbers closer to forty and the g a o in their report use seventy is the number of contract personnel also filled out one hundred fifty of the v a c n a posts we are increasingly concerned that without a sufficient number of c n a as in the v a system our veterans won't get the care they need and deserve they may have to wait too long for that care ultimately may increase cost to the u s treasury a report last december from the government accountability office confirmed what we in the v a have long known the g a o found fifty four percent of v a facilities have had to close operating rooms and seventy four percent have had to delay surgeries for lack of  six percent of the a c s plan to retire within the next five years and the agency has struggled to both recruit and retain nurse anesthetists seventy four percent of the respondents to the g a o survey said they had difficulty recruiting the v a struggle has not been for lack of serenades in the marketplace in two thousand and seven accredited nurse anaesthesia educational programs produced over two thousand graduates and eighty eight percent increase in just five years in order to meet the growing demand francis services rather the g a o found and we agree that the v a c r nate compensation is far below market levels in many localities the issue of below market compensation was cited by ninety percent of three recommendations to close this gap and to ensure america's veterans have the necessary anesthesia care for the surgical and invasive diagnostic procedures they require first is to enhance the v a relationship with the nurse anesthesia educational program already some seventy v a hospitals serve as clinical practice education sites for nurse anesthesia schools many hospitals by and serving as clinical practice sites helps them recruit rates the g a o recommends v a facilities take advantage of v a locality pay policies but that will not be enough to close the gap in addition congress should act to lift the statutory cap on v a pay so that local facilities can set compensation at rates closer to market levels of all the options available to close the v a c n a workforce gap and ensure veterans get the high quality of care they deserve these three suggestions are the most cost effective and the easiest to carry out thank you and i would be happy to take your questions thank you very much i'd like to start with a quote in times of change learners inherit the earth while the learned find themselves beautifully equipped to deal with a world that no longer exist i don't need to repeat the nursing shortage your body up your nose that the baby boomers about to retire we two years ago they were the first baby boomer turning age sixty this year the first baby boomers started to retire at age sixty two and it looks like this generation looks like a basketball going through the belly of the snake and behind it we do not have enough people to fill them these in the health care industry on top of that we have a declining dollar declining all or causes devaluation the currency which means the canadian dollars more powerful we're seeing nurses leave the united states go back up north we see all these things and we see the nursing shortage is in quite a state but i think there is a war shortage than that out there in the war shortage is the shortage of qualified well trained recruiting personnel not just to recruit nurses and medical personnel but also to go out and actively recruit people to teach in the schools because we are short on educators we had to turn down thirty eight thousand plus in the last few years go on to go into schools to learn how to be medical personnel each month millions of dollars are spent on advertising to draw people into not just the private sector but into the public sector both sectors to draw them into the medical community to recruit them for institutions millions of dollars being spent to generate leads and phone calls and guess what happens we dealt with the private sector in eighty two percent of the phone calls were people that would like to have jobs go on answered i cannot speak for the v a system i haven't worked with them but in the private sector that is an astounding number and that number is shocking mr chairman member of the committee my name is jay want to become the chief executive officer of a company called vertical lines group we're an internet based training recruiting company we founded in  nine we have eighty web sites subdomains and domains which a couple of them represent the medical community one called nurse universe one called med tech obviously the names imply their out to recruit arses and people for the medical we operate those web sites and i got to tell you i'm honored to be here to make this presentation is a wonderful experience a wonderful opportunity prescience all taken time to hear us and our testimony i don't make any claim to be a professional in the healthcare services area however we do know quite a bit in the last nine years we've developed quite a bit about the process of recruiting and retaining good employees now we do this we do this with boot camps and we address that issue real quick there's a dire lack of training for people that know how to go out and deal with the society today the internet changed everything it made us an immediate gratification society things happen fast and i go to amazon i go and order a book i want i want now i don't like waiting till tomorrow in this is how people are when they're looking for jobs they go fill out an application they make a phone call you know these people are hanging up before one minute when no one's answering the telephone they're sent in the an applications and you'll see the medical applications it takes time to fill out an application they send those and they get no response so what we did as a company is we started to develop processes that basically said we're going to train people from being paper processors the old style of human resource into active proactive salespeople because that's what it takes to compete in this environment we train t salespeople through our boot camps we empower people we teach the salespeople we call them salespeople we teach them sales training we teach them direct response marketing we teach them what it costs to actually recruiting nurse many people don't know sitting here training these people were empowering them teaching them what it takes to go out and be a proactive recruiter if we had success the standard average of a recruiting department gets between one and two percent closing on the people that apply for a job our companies on a bell curve at the top of the average of twelve percent closing some obviously have got much more than that some less but on the average on the bell curve that is significant savings to the bottom line the process lends itself to the lowest cost for her but you have to inspect what you train and you have to continue to teach what you train so we develop process an online internet data based program that basically teaches tracks trains and follows up all the education we provided the bootcamps we do it daily weekly monthly it's available twenty four seven it doesn't just happen though in order for a program to be successful it must have buy in from the top obviously we wouldn't be sitting here if there wasn't buy in from the top a visit with a number of the health care facilities the executives at those  passed what impact would that really have on recruitment and retention in your opinion we believe that will give the registered nurses physicians the same rights that other employees have in the a that if there is workplace disputes that they would have a an avenue to resolve those two speeds and to seek relief and that arena it's a message we hear from our membership in the v a employees over and over and we believe that it would certainly make for a better work life but it would have as far as it recruitment our retention you think all have a positive i think it would actually have a positive effect on the recruitment retention because again when you are able to resolve problems in the workplace through a negotiated agreement to resolve those issues that makes people feel better there is as a way to seek relief if you believe things ar believe also the fact that the pay data that we have all the locality pay systems but now if a request is made to the v a share this data with us show us what you are paid give us information it's no we do not have to provide that to you because that's a seventy four twenty two issue i believe that would bring more light to the issue of pay and the recruitment process it would definitely be a positive impact thank you dr phelps that you've mentioned but the impact of the hybrid title thirty eight what impact would moving psychologist to title thirty eight from the hybrid title thirty eight have on recruitment and retention of these  professionals mr chairman it's that's an issue that we are because we're so frustrated with the difficulties in the implementation problems with the hybrid system that's an issue that we are looking seriously right now preliminarily we think it would be the way to go for psychologists were the only doctoral level professionals in the v a system that are not and the those numbers with me but i can have my staff look at that however what i can speak to is i'm clinical director of the nurse anastasia program through the university of minnesota and the v a in minneapolis is our primary clinical site we've had a relationship with the i'm twenty five years i believe recently and we send ten students per year through the v a we get some support from central office which which we appreciate in previous years as much as seventy five percent of the graduating class have stayed at the v a however in the last two years we've had one person out of twenty and a lot of that is due to low pay is the main thing i mean they come out with student loans and are unable to have a salary that makes it easier to pay those student loans off and the other big piece of it is the employee debt reduction program that the v a has is it's not entirely through issues with human resources lack of understanding of the program not everybody who's been eligible has been able to take advantage of that as a student loan payback so they've chosen to go to places where they can see exactly when they apply h r can tell them this is what you make working they have three who are in what we call phase two which is a clinical portion three that are in the first year portion and three that are starting i believe that they would like to increase that number and the army is available with slots with seats for those but they need additional funding to have the students come the benefit of going there is that you get your tuitions salary and your education paid for and then they have a three year commitment after completing the program  question is mr womack what immediate action should the v a take to modernize their hiring system so that it is competitive with the private sector that's a very good question the first thing i would do is i'd start training the personnel and being very proactive you've got to train these people they've got the tools in place to be is done a great job but together package information gets like that but they've got to be brought into the twenty first century via the technology the platforms of technology that they have at their disposal that we offer they've got to be trained and they've got to be trained in the value of what they're doing to lead the half life of a lead when someone picks up that phone call or when someone sins in that location the half life of that lead is probably less than four hours in other words if you don't touch it in four hours they are gone you know that is what we said maybe even shorter than that so the first thing i would do is set up training for and then you get to follow up and monitor exactly what you thought you got inspected every single week we do that with our existing clients we train them and then we follow up every single week and we make them respond to us because that is where you that's where you ferret out what the real problems are you find out what's working what's not working and then you adjust it you change it and then you continue the country plat usa today job those type things they get on registries they are hired from that they get that orange preferences things of that nature hydel thirty eight like registered nurses and physicians they can go to a a medical center fill out an application and be hired there is a boarding process that title thirty eight have to go through the credentialing process things of that nature which takes a very lengthy period of time and that's what really holds up a lot of the hiring process at the v a and the title thirty eight arena with the hybrid title thirty eight again the v a has not developed a lot of the qualification standards so there is not the boarding process is to promote these people and to move them through the proper grades it's a very very complex hiring system you recommended establishing a pilot program streamline titles like to know a little more in detail about you know what that what that plan would our how it would differ from the current title five and wouldn't be just as useful to streamline or do a pilot program to streamline the hybrid thirty eight hiring process we believe that you can go to zero pm and the agency the can work with  m do a demonstration project to like nursing assistants is one group that if people are certified that you could hire them through a title process that would actually be easier than the hybrid title thirty eight because with that you have to develop the qualification standards the board that would then have to evaluate the people determine their promotions and appointments and things of that nature so we believe that there's procedures with o that could actually streamline title five and make it easier the hybrid title thirty eight and one thing that we believe that that would also help would maintain the veteran preference for the employees  little how the retirement benefits differ from the federal worker in the private sector right now the difference in the retirement benefits i'm not sure that i could give you a total picture on that more last better worse i retired from the federal government myself two years ago and i have friends that are in the private sector and i would say with the current fors employee it is about comparable to the private sector employees in the private sector have some type of matching four  k plan and some other defined benefit plans such is available with that but i i would say they were fairly comparable and that arena and in some areas i believe the private sector retirement may be better in others obviously the government i'm not sure that i'm abbott health insurance things health health insurance private sector and many cases is better than the federal employee health insurance  benefits do you see in bringing psychologists fully into the title thirty eight program is i said mr miller we're looking more closely at that we have we have tried  to to be good citizens with a hybrid system so the benefits would be to eliminate some of these kinds of problems with the hybrid system let me give you a couple of examples as mr cox said that with the hybrid thirty eight system there is required the creation of professional standards boards for each of those disciplines psychology has a national professional standards board and it also has developed standards and so that process is underway what is what has been happening for the last year or so is that psychologists with additional scope of responsibility running huge treatment programs sixty psychology staff under them and so forth who have submitted to the professional standard boards and have then been recommended nationally for a great increase have then been stymied at the level of the local medical center in most cases some some cases it's at the vision level and the the the v itself is issuing in some cases certainly informational missteps about who's qualified who's not qualified what do you have to submit and so forth so moving into a system that is based on title thirty eight system that is based simply on the professional is hired posted in retained based solely on their qualifications as opposed to going through these very complex processes that v a has been able to implement over the past five years it's been five years since the congress changed the hybrid statutorily so we believe that it would very much not only simplify the system for psychologist but certainly improve the recruitment of new psychologists and clearly the retention of psychologists the leadership the we have a lot of psychologists in the system who have been and twenty and thirty years that are operating the g s thirteen level they're not there for the money i was wondering could you please compare the differences between the hiring and retention or educational benefits packages offered by the v a in the private as other plus other places what i've heard from my students specially recent grads are they can call up the university of minnesota hospital and say i'm a new grad where am i going to start for salary what kind of bonus am i going to get what can i foresee for loan paybacks and they can get that number from human resources immediately the problem with the v a is often they'll call human resources and they'll get a range just like how it's posted on a v a job so the student does not know where they're starting until they sign on well often they're not going to not going to take that chance in the ranges anywhere from eighty nine to one hundred thirty nine it's very difficult to see where you'd fit on that scale the other thing is the employee debt reduction program that i spoke to before which i think is a great retreat recruitment tool the problem is is there is a six month window that if you don't apply for it within that time you're no longer eligible well if for some reason paperwork has been lost the human resources person covering that student  has some lack of information all of a sudden that six month window is gone and the debt reduction program they're no longer eligible for other things related to that is human resources also if it does not say on the website that you are eligible for the e t r p they cannot offer that too once you sign on sol i think a lot of it is the transparency for when when students apply for jobs they need to see that in the v a they need to know that these things are going to be available and rather than getting lost in the shuffle of paperwork in time because it would seem to me so many graduates and they know at one hospital what their bonus is going to be this hour is going to be their conversation  to be and then they you know almost to the penny right and then you have the v a who gives them a range so if you're getting out of school with a lot of debt load and i'm sure the debt loads significant  a and they love taking care of veterans there really is not another population that is like that but after having an expensive school sometimes you have to weigh those weigh those things and i think that if we did a better job of of  transparent benefit package i think the v a the a can be very comparable mr cox can you talk a little bit more about the hybrid hiring process and what makes it so long complicated for prospective applican harbor again the v a has to develop qualifications standards the way that it's sold to everyone in the beginning is that a hybrid you can just walk in fill out an application apply for a job that's fine that process is simplified but then there's the qualification standards the professional standards boards these people have to be brought in and the boards have to meet they have to review the qualifications of the people then establish their grade those type things that's what really complicates the process well it's not the actual application process it's the professional standards boards the qualification standards that create the problems in my question dr phelps outside of fair compensation how else would uniform leadership in the v a facilities benefit recruitment or retention of psychologists system got rid of discipline based services what happened was not just with psychology but with other other professions as well social work i'm most familiar with mental health side  s we had staffs reporting to other disciplines who had no understanding of what the standards of practice are within that particular discipline what has happened since then is a recognition by the system that the ability to certify the qualifications the skill sets and so forth of psychologists in the system requires somebody in psychology so we have a system where there is no uniformity facilities appoint a lead psychologist or a senior psychologist or many different terms and those folks have this gets back to the issue of sort of fair pay for a fair day's work mr hare the the those folks operate in those positions in addition to their regular job description and part of irish you with the higher is national standards boards and the cost of hundreds have recognized that those are additional responsibilities that should bring additional passe but there is no uniformity even at the level of what those types of positions are thank you mr chairman thank you mr aird once again i like panel comprised of fred cowell who works for the paralyzed veterans of america as i don't know disabled there can veterans this morning and we'll start off with mister caldwell schaap ranking member miller members of the subcommittee on behalf of the paralyzed veterans of america i am pleased to offer our views concerning the human resource challenges within the department of veterans affairs mr chairman  subcommittees interest in the issues concerning v a health care personnel as well placed in timely congress must assist v a as efforts to recruit and retain its core of health care professionals as a demand for health care increases because of today's wars the aging of veteran population from previous wars currently the nation has experienced serious shortfalls in its supply of physicians nurses pharmacists and psychologist competition for experienced medical personnel a newly licensed professional is keen p v a believes that congress must take the lead and revamping outdated personnel policies and procedures that include salaries and benefits and working conditions that may place at a disadvantage in today's labor market and will prevent it from becoming a medical care employer of choice in the future p v a also billie's of that the broken v a appropriation process which delays v a funding is a major barrier to v a s health care professional recruitment processes v a nurse recruitment retention efforts as was been stated earlier the united states is currently in the tenth year of a critical nursing shortage which is expected to continue through two thousand and twenty the current and emerging gap between the supply of and the demand for nurses may adversely affected ability to meet the healthcare needs of those who have served our nation v a must be able to recruit the best nurses and retain a qadri of experienced competent nurses providing high quality nursing care to the nation's veterans is and trickled to v a s health care admission fee a physician recruitment retention is concerned about v a s current ability to maintain appropriate inadequate levels of physician staffing at a time when the nation faces a pending shortage of physicians recent analysis by the association of american medical colleges and a case united states will face a serious doctor shortage over the next few decades the subsequent increasing demand for doctors as many enter retirement will increase challenges today's recruitment and retention efforts be a sick ologist recruitment retention and appropriate promotions according to the american psychological association b is the largest single employer of psychologists in the nation congress and v a have recognized the need to increase the number of psychologists and add more than a hundred new psychologists since two thousand and five there by raising the number of a psychologist in the v a system to approximately twenty four hundred v a most also strive to retain a promoted small restraint psychologist in order to meet new training and supervision says the vast majority of new psychologists ours in v a are less experienced professionals they must ensure they are properly trained and supervised v a must also strive to retain a promoted more experienced psychologist in order to meet new training  supervision requirements recommendations to enhance v a s recruitment retention efforts congress must revamp outdated v a personnel policies and procedures to streamline the v a hiring process and avoid recruitment delays  become barriers to employment conductors or congressional oversight hearings to determine the extent of problems regarding national standardization and of a veil ability of v a locality pay congress should implement a title thirty eight specially pay provision for v a nurses providing care and v a specialized service areas such as spinal cord injury blind rehabilitation mental health and traumatic brain injury review and adopt the recommendations developed by the v a s national commission on be a nursing p v a believes these recommendations have broad application and can serve as a template for improvements that can assist human resource management recruitment and retention efforts congress should improve the provisions of v a s education debt reduction program currently the d r p is limited to forty nine thousand dollars spread out over five years of service this program has not kept pace with the s g cost of medical specialty education expanding benefit levels in e d r p will make v a more competitive than the national health care professional marketplace v a most also become more flexible with his work schedules to meet the needs of today's health care professionals other benefits such as child care and a less trojan policy regarding managerial work will make employment more attractive congress should also consider reinstating the v a health professional education assistance scholarship program this program was sunset in one thousand nine hundred eighty eight and the program would be an excellent medical care student incentive to future v a employment and finally mr chairman mr chairman and members of the committee on veteran affairs subcommittee on how the nurses organization of veteran affairs nova would like to thank you for inviting us to present testimony on human resource issues and i am sicilia associate director for patient care nursing at the v a boston health care system and i'm here today as the immediate past president of nova the professional organization for registered nurses employed by the department of veteran affairs overthe facts and appreciates what our labor am here to offer the following observations nursing and other medical center work force members are dependent on timely and efficient recruiting human resource departments across are not able to function optimally due to systems that have not kept pace with ou private sector recruitment abilities although there are numerous barriers to timely and efficient recruiting the following are the top three although certain pay plex abilities do exist such as recruitment bonuses or tension allowances in the special rate authority additional pay plex abilities are needed in order for v a to be able to successfully compete for the best candidates in the marketplace the current general schedule and locality pay system which works hand in hand with a classification system is into created and cannot respond quickly enough and has a number of major barriers for example retention allowances and not considered base pay for benefits such as retirement and life insurance and candidates have declined positions based on this limitation be a special pay rate there are restrictions on all father table can be expanded in the approval process a special race is too slow to address the current market conditions above minimum rates allow a manager to appoint an applicant above the minimum step but there is no mechanism for example to increase a pay of existing staff to maintain pay parity the application process how to apply is very cumbersome and confusing to those in the private sector or used to a much faster and simpler process staffing specialist must help many of the would be applicants to navigate through the maze of the federal application process a consistent theme across the country is that applicants a looking for money for professional development not just in clinical occupations but in administrative as well tuitions reimbursement is limited to a few select occupations at this time such as nurses but still require expansion some suggested policy changes recommended are as follows more pay flexibility should be provided pay reform similar to the physician pay reform where there is a market pay component would provide the needed flexibility for v a facilities at the local level classification standards are in need of review and revision many of them a too old and no longer reflective of the types and duties of responsibilities that are typically performed given that these are used to determine the pay they can offer and serve as a barrier to appropriate and effective pay setting given the sizable number of employees at or near retirement age the session planning is becoming increasingly important especially for those critical position one of the critical area of concern relates to the impact on patient care of thirty eight u s c seven four two two exclusions were to be repealed some of the issues that i foresee would have a negative impact on the care of veterans include the following r n reassignment decisions made on the basis of clinical competence performance appraisals and proficiency reports fitness for duty issues as determined by a professional standards board clinical competency issues as determined by a professional standards board and disciplinary and major adverse actions based on patient care  clinical competence issues determination of clinical competence is best reserved for those responsible and ensuring that quality delivered v a has been a leader in health care and has earned an excellent reputation as one of the best health care providers in the country in order to continue this reputation v a staff will need to have new skills and competencies to treat this new generation of veterans nimble and flexible human resource prophecies a critical to the future success thank you mr chairman and members of the subcommittee for this opportunity to testify here about these impersonal important personnel issues and i would be happy to answer any questions thank you very much mr izod or mr chairman members of the subcommittee i thank you for shortage in the nation is primarily defined and in three factors supply demand and obviously the compensation package congress has seen fit to address compensation package with the guise of the position pay bill form and as well as being of previous conflicts the attrition of its workforce where by two thousand and twelve nearly ninety two thousand ph employees who would be eligible for full service or full civil service retirement over forty six thousand of more over the unbalance matriculants and supply of prepared health care workers as well as the maldistribution of these workers across the us will demand much more of the ha human resource program without question recruiting management and providing direction for v a employees on such issues as hiring compensation performance management and organization of element are critical to success of the ha's mission to provide high quality care to sickness able veterans well  mention most recent actions by congress to affect compensation package of the ha to offer to prospective employees incest states additional implementation oversight as mentioned by the previous panel we believe it is i an equally important problem within the realm of recruitment they're required to tell additional attention is the federal hiring process itself this was touched upon by the previous panel hiring new wave of federal employees to succeed those that leave as permanent given the frequent civil service hiring freezes of the past two decades in a client inadequate funding levels and predictable nature of discretionary budget process fortunately there is a perennial and widely acknowledged complaint by applicants for federal employment about cumbersome federal hiring procedures and practices which require too much time and excessive paperwork of those who submit applications many saying they never receive feedback from agencies of interest the most recent merits as a protection board survey of entry level hires and upper level hires show that substantial numbers had to wait five months or longer before being hired this is much much too long to expect a high quality applicant to wait particularly in the health care arena which is extremely competitive subcommittees where beaches work force is covered under title five tell thirty eight entitled thirty eight hybrid the greater majority of each employee's fall into thirty eight as well as the title thirty eight hybrid personal rules under both were designed to allow greater flexibility and expe process and promotion processes however the reality of hiring and promotion process is facing extraordinary delays particularly in the boarding process across health care disciplines from nurses to psychologist as well as background searches the federal hiring process is so daunting that it often reinforces applicants worst fears of government as an ineffective unresponsive an incomprehensible b ocracy and mission a time there is often poor communication between federal managers and h r professionals on the qualities and skills needed in a candidate attrition of experience b h a human resource resource employees has a direct impact on the quality of recruitment and retention efforts as well as he needed assistance to train new and inexperienced staff to successfully hire media v lees only by insisting that the ha would make recruiting talent a top priority that both leaders agency leaders and managers are held responsible for results and that the individuals involved in the hiring process be held more accountable testimony this morning and just a couple of quick questions you all touched upon recruitment and you talked a lot more about touched upon retention talked a lot more about recruitment what health care providers and the ha look to when they make a decision whether to stay in v a or not whether it be education remember reimbursement thank you education reimbursement package which by the way as my colleague mr coll here had mentioned has expired back in one thousand and eight we believe and we have actually recommended that be be addressed in our previous testimony last year before the hospital's f if they are to look across the street at a private health care system which will offer more than obviously on the whole footing other delivery of health care such as human resource departments that support the work for nursing and the workforce to have educational money so those people for succession planning would also be very valuable support for the v a nursing academy program this is a program i'm not sure if you're familiar with where the v a has funded last year for pilot programs and adjoining universities to help bring more nurses into the workforce but it's also an opportunity for a staff to become educators in these universities and give them additional opportunities while still remaining deliver care and also expand our workforce and give that workforce another opportunity to expand their horizon and that would indeed higher education and remain loyal employees of the we mentioned earlier the education debt reduction program because the specially middle education is soaring people who want to improve their position and prove their needs to be more fairly distributed and available across the system we think flexible schedules are important justified about earlier and in addition that you know bonuses are not just a recruitment tool but they're also a retention tool and we think that pool of money needs to be more fairly distributed available across the system even perhaps a set aside pool of money in the v a for bonuses would be a good idea currently we hear that local facility managers have to take that available money out of their existing f t e budget so when they do that and they have bonus money available then they're not able to hire the additional staff they really need so it's a lot of issues out there and a lot of including matters relating to direct patient care and clinical competence and collective bargaining rights please explain in more detail your concerns i think if seven four two two were to be repealed i think that would cause perhaps some delays because of inherent in the bargaining process itself is the element of time and a certain issues need to be negotiated such as mandatory training on traumatic brain injury is an example  not always but in some cases the implementation of being able to effect that training might be one example i also think this inconsistent application of seven four to two across united states and may also be an issue regenerated in your testimony several recommendations for improving v a s recruitment process from the national commission on be a nurse and can you give me an idea of what you think may be the top one two or three of those recommendations we head meeting with kathy records ahead of v a nursing and we talked a lot about about the commission's recommendations and she told us that many aspects of that have been implemented and it's becoming good policy she talked about some of the problems that the a nurses even though they are in somewhat always in need of more compensation but there is a lack of  organizational sharing responsibility that they feel would be a great incentive to make them feel more important and more a part of the health care team that was something that really came through in our discussions with nurses across the system that they just think they could share a greater responsibility and unit planning and you to an organization and i have a greater responsibility in the administration of those areas what effect do you think specially pay rates for certain nursing professions would have on the recruitment retention of nurses and physicians that don't especially pay well we have we all right allison of the data of the spinal cord injury system and that's our expertise there is an agreement and a rule that the nursing service that works in a spinal cord injury says service fifty percent of those are supposed to be our and our data reveals that very few of the twenty two sci centers in the for long term care facilities meet those requirements so there is a dearth of r n available to spinal cord injury we think that's true in the other specialized services and one of the issues that happens particularly in a spinal cord injury service pilot for the v a to have it's really what could be considered an agency narcisse but these the v a employees in the goal is to have a trained workforce of employees that could theoretically go anywhere in the country and serve in the v a in times of need so there is a pilot project which is underway i am not as familiar with it it's perhaps kathy rick would be at this time but i am aware of it now everyone is pleased seems to think it's a very good thing  and in richmond virginia and it's it seems like the emphasis is on our to try to discover what local bail and how we can place a veteran in that kind of a position but we haven't had much contact from the toward us excellent idea we've collaborated with the p b s local open houses at our facility in boston and it's worked very well and i think any as you said any extension on collaboration and the ability to bring in more staff into the v a workforce is excellent idea does affect directly on their membership although we do work very closely with the ancillary organizations like no and a p and things and those organizations to try and highlight  a place to work i do believe i mean we would more than welcome any kind of collaboration we can make would be a change to increase their exposure on that and i'm not sure how i would go again your great resources you have the people you know them and you know when you're looking at that kind of shortages down the road that just seems to me to be a natural thing to do thank  chairman i'm sorry i was late getting here mr mcveigh i'm a before i started in this made my living as a family doctor and i generally found if i did with the nurses say i'd stay out of trouble so i'm going to ask my question to you i  met with mr womack yesterday and did not hear testimony today but it seems like we have as far as the veterans health care system in order to get health care professionals on board seems like there's two two basic things number one you can flood the input with such great numbers that sooner or later enough will flow through and fill the positions or you can deal with the input that's coming in in such a way that you can increase your percentage of those we end up hiring to fill your folks who are making application the v a system or do you ever go online yourself or make the phone calls yourself to see what the process was like do you have any formal way that you judge how people are treated when they actually are interested in working for the v a health care system  that's an excellent point i actually chair a local succession planning committee and we have not done that although we've discussed that what we have done we've done some research and we found that many v a employees and nurses in particular are vulnerable to leave the system between the third and seventh year of employment so what we did through the succession planning committee was go out and survey a random group of these employee nurses and other employees as well that are thought to be at the point at which they are leaving the employment and tabulated those results actually to see why they stayed with the thought being that if we could tap on those things and incentives to make them to stay we would be able to have a better retention rate for all of these in the boston v a health care system i'm happy to say for nursing r n s in particular we have now a five percent turnover rate which is extraordinarily low and nine years ago was eighteen percent so i think things are going well in that particular group but we are also concerned about turnover though we haven't had as much in the air and group but that is not necessarily true across the country there have been other departments that support the work of nursing that there are challenges and many of them with some of which i stated in my testimony had to do with recognition the ability for  personnel the monies for education etc so we've been trying to tackle those on a local level and it's been very interesting but i also like the thought of serving a group that has not yet come we do hear informal feedback from our staff who are friends of the staff that have applied for positions and that feedback is they are very concerned about the very long and excessive time line between when they apply for employment and when we're actually able to bring the men and so they do get tend to get discouraged and that's a concern of ours he did bring up the in mice simplistic analysis the third the third component is if you can cut down on people quitting then you don't have so many openings that you need to fill but  issue of i've actually done this before and different things right i get an intern and say here call this help line and here's a story i want you to read and see what kind of information i would think that a group like yours could could get some there's and you know this kind of testing you know how quickly is that once you make an inquiry how quickly the you get responded to that as you as you know the market is such out there if somebody applies for a job or goes online and makes an initial inquiry the nursing market be what it is if it's a week or two or three days before they hear back from somebody they will have other job offers of their very aggressive and have a very reasonable the right to average work record that might be helpful information both for you and for this committee if you all with you or with your you probably have the ability there's some that we don't have which is you can do those kinds of test cases to different v a s around the country and  we probably will be having vote shortly so if you can summarize your your written testimony and the complete copy will be submitted for the record thank you mr chairman and members of the committee thank you for the invitation to appear before us to discuss human resource challenges within the department of veterans affairs that runs health administration as the nation's largest integrated healthcare delivery system v a workforce challenges mirror those  the health care industry as a whole the ha performs extensive national workforce planning and annually publishes a workforce accession strategic plan b h a strategic plan addresses current and emerging initiatives in areas including but not limited to recruitment and retention mental health care policy trauma traumatic brain injury and rule health to address workforce alford's the h g s workforce plan is one of the most comprehensive in government and has been recognized by o as a federal best practice is porton that's the supply of a properly prepared health care workers meets the need of a growing and a first population enrollment in nursing schools needs to grow to meet the projected future demand for health care provider in an effort to initiate proactive strategies to agents aid in the shortage of clinical faculty v a launched launched the v a nursing academy to address nationwide no shortage of nurses the v a travel nurse corps is an exciting new program that establishes a pool of registered nurses in v a who can be a vailable for temporary short term assignments at v a medical centers throughout the country this program is the i'm piloted at two sites in its san diego students program such as the v a learning opportunity residency program that student career experience program in the panic association of colleges and universities internship program has helped the a meet the workforce session needs the graduate health administration training program provides practical work experience to students and recent graduates of health care and ministration masters programs be a recognized as a real community space additional health care workforce challenges b a s working to develop an effective rule workforce strategy to recruit locally for a broad range of health care professionals it's exponential to reigning for opportunities for young medical students are important vestments for creating a veteran and rule friendly physician workforce last year b h j s human resources committee charted a workgroup to streamline the recruitment process for title five and for title thirty eight positions within b h a the work group initially analyzed the recruitment and identified barriers and lengthy process as for registered nurses the group work group recommendations were then piloted and are now in the process of being implemented nationally one retention strategy that has proven very successful through v h a was approved in programs to promote employment branding within v h a as a health care employer of choice both a recruitment and retention tool the employee and son of scholarship program pays up to thirty five thousand nine hundred forty academic healthcare related degree programs hundred one in may of two thousand and eight seventy five hundred over seventy five hundred b employees have received scholarship programs for academic education programs related to title thirty eight and hybrid title thirty eight occupations and more than top forty two hundred employees have graduated from those programs the education debt reduction program provides tax free reimburse me of education loans debt to recently hired employees both title five and hybrid title thirty eight eighty r p s similar to the student loan repayment whole program for title five boys b h a retune lee uses hiring a pay incentive established under title five and ta to thirty eight recruitment retention incentives are used to reduce turnover rates and help fill h the undersecretary for help has made a personal commitment to succession planning and ensuring v a has a comprehensive recruitment retention development and succession strategy this is a continuous process which requires ongoing modifications and enhancements to our current programs i would like to thank the committee for your interest and support in implementing legislation that allows us to compete in the health care market thank you thank you very much for staff that have been hard to recruit and retain the education debt reduction program as one of the most successful tools that we do have and that as as mentioned has been used to recruit health care professions and both title fi title thirty eight excuse me and hybrid title thirty eight so far over sixty five hundred participants have received funding with an average of ward of twenty nine thousand dollars right now the cap is at just over fifty thousand for those awards and yet some students are coming out of school with higher debt than they are but has been very effective in recruiting health care professionals we also use recruitment and recruitment incentives extensively in areas that they thought that there needed to recruit staff we draw people in with our scholarship program or and florian son of scholarship program that we have for both title thirty eight and hybrid title thirty eight occupation talk to me about that just a little bit the scholarship program  scholarship program is available to employees after they've had one year of employment we've had seventy five hundred that have entered into the program is open to all occupations that fall under title thirty eight and hybrid title thirty eight it's u thank you mr chairman the rand corporation recently released report stating that about three hundred thousand soldiers report symptoms of p t s d or major depression only half of those are seeking treatment this conflict in difference between hybrid type of thirty eight and title thirty eight doesn't raise side and how the person is or did it resides in the two things that are covered by hybrid title thirty eight are pay and appointments and then they're covered under title five for everything else the setting up the pay and the grade that they go to is the same under title thirty eight and hybrid title thirty eight so that would not make a difference and i don't know how it would make a difference in health care is provided do you think the v a should diversify its loan repayment or scholarship programs for certain medical professions  physicians can accrue about one hundred fifty thousand dollars in debt in medical school costs yet they're only eligible for about forty six to fifty thousand of the v a yes we have found that many of these doctoral programs along with the physicians are coming out of school with that nexus of hundred thousand dollars and although that education that reproduction program certainly helps with fifty thousand dollars you know many of them would benefit from a large around long repayment leave very alarmed when i asked a question about a half a million or five hundred thousand nurse shortage and then up to a million and it was just seem to me that anything and everything that the v a can do or that we can do or whoever can do to try to help fill that hole because we're going to see more veterans coming back obviously the needs going to be greater so i wonder if you had a thought or two of that that was a great suggestion and there is a new positions that have been added to the organization called veterans employment coordinators that are being placed strategically throughout the country and that would be a great opportunity for them to contact the local vs always and try to coordinate with them and get them information out on any of the recruitment activities that we  the office of academic affiliations as working closely with the medical schools in the local areas to address that i don't know how far the law they are along in that i can get that information back to you but that is something that we've been really concerned about and thought if we get those students trainees and residents into those rural areas and him do their training programs and residencies there that the likelihood that they would return to that or year and stay in that area for employment is much higher so that was the thought behind doing that title thirty eight which is older and potentially actually could cause a v a to lose good good employees what's the number one reason that candidates are turned down employment  within the v a system we were aware of the the problem as i mentioned we have done a redesign look and see the whole process and are in the area and process of implementing numerous changes it's not just one thing it's our paperwork we have way too much paperwork is some of our internal policies that we're finding are really obsolete with some of the things that we have to do with a credentialing process our credentialing process is very owner onerous but very necessary to make sure that our staff are have the appropriate credentials to you know for patient care but we are looking at process that we can do simultaneously so it doesn't take as long a lemonade steps that don't need to be take in the background investigations that we have to do take some time but also looking at combining processes and trying to eliminate unnecessary step is helping tremendously i think just looking internally we can probably without changing regulation or shoot improve the process tremendously and we are working towards that in the pilot they show that it can be done in thirty days to bring somebody on and going through all of these credentialing processes and background investigation successor and we are r that out throughout the country having targeted h r cluster meetings so that the word can get out they can understand what we're looking for and and assist them and getting there what do you believe  number one challenge is in filling the shortage in the positions that you have been more prominent in the region of the country than the other i can't say that it's more prominent in any region but there is specific areas certain real areas certain demographic areas that might not have schools in the area that have greater challenges and certain occupations and through our succession and workforce planning we look at those things and try to build recruitment in marketing strategies to address those areas where we are having the recruitment problems we have through throughout the nation when the workforce planners do their plans we come up with a list of what we consider are critical occupations a and we target those occupations for additional recruitment strategies to look at to ensure that we have the appropriate workforce in what are the top three critical occupation balor program the v a learning opportunity residency for pharmacist and they have increased the number this year and some of those are in i don't know if i'd call him or old but it's a less populated areas and they are continuing to expand  pharmacy leadership have been really excited about how the program has taken off and looking to expand and this is what dr at the pharmacy doctorate programs and it's working really well and we're hoping that they stay in the v a after they finish their residency program so we think this will be a great recruitment tool is there anything that we can do to help deal with the shortage but for see thank you for the offer right now what we're trying to do is work through some of the issues internally to see how we can improve the hiring and boarding process and if there's something you can do to help we certainly will let you know thank you how long that internal review going to take take as you heard earlier i mean there is a severe problem out there and the longer we wait the less likely we're able to get these good qualified health care providers and to be a system certainly understand that we have already implemented it in several of our networks and it is going to be a performance measure follow the network of medical center directors for two thousand and nine to have it down to the thirty days hiring process we  anticipate that it will be happening by the time two thousand thousand nine hundred eighty you know there's a lot of challenges a lot of people are at really long time frame so will they get down to the thirty but we're hoping at least they can cut their time frames  e what does in this and for us the one a pilot at the at the recruitment redesign but several other networks have already implemented it as well in what what are you doing to work with the office of rural health as well to look at some of these needs realizing that the offices my pain and adequately understand we're working hand in hand with them and the recruitment issues to try to come up with a recruitment plan so that we can to they can identify some of the things and then we can work with them how to trying to meet those challenges and i think that's how academic affiliations came up with the plan for working with number of years well two thousand and four they came out with it its report they recommended a lot of access points particularly in rural areas and they haven't moved this aggressive really as a lot of us would like to see my question is what are you the a doing to work with local health care providers in the state to deal with the health care shortage is there a way that you can partner with the health care providers currently out there keeping in mind the carers process they might recommend an access point in a rural area i am not sure what they're doing i know that some local facilities do contract with with those and in areas where they have the clinic been very helpful this is an extremely important issue one that we're going to have to deal with soon going to make sure that veterans are has the adequate health care needs here so once again thank you very much for your testimony today look forward to working with you as we move forward in this congress so there's no other question this hearing is closed thank you