VA HEALTH CARE

Actions Needed to 

Ensure Adequate and 

Qualified Nurse 

Staffing

Report to the Chairman, Subcommittee 

on Oversight & Investigations, 

Committee on Veterans’ Affairs, House 

of Representatives

October 2014

GAO-15-61

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-15-61, a report to the 

Chairman, Subcommittee on Oversight & 

Investigations, Committee on Veterans’ 

Affairs, House of Representatives

October 2014

VA HEALTH CARE

Actions Needed to Ensure Adequate and Qualified 

Nurse Staffing

Why GAO Did This Study

GAO and others have raised prior 

concerns about the adequacy and 

qualifications of VHA’s nurse staffing. 

In part to address these concerns, 

VHA issued a directive in 2010 

requiring all VAMCs to implement a 

standardized methodology for 

determining an adequate and qualified 

nurse workforce, which includes 

developing and executing nurse 

staffing plans. It also requires VAMCs 

to use the methodology on an ongoing 

basis to evaluate staffing plans. 

GAO was asked to provide information 

on nurse staffing at VAMCs. This 

report reviews the extent to which 

(1) VAMCs have implemented VHA’s 

nurse staffing methodology, and 

(2) VHA oversees VAMCs’ 

implementation and ongoing 

administration of the methodology. 

GAO reviewed documents and 

interviewed officials from VHA, seven 

VAMCs selected to ensure variation in 

factors such as geographic location, 

and regional offices for these VAMCs. 

GAO used federal internal control 

standards to evaluate VHA’s oversight. 

GAO also interviewed representatives 

of veterans service organizations, 

nursing organizations, and unions.

What GAO Recommends

GAO recommends VA: (1) assess 

VAMCs’ ability to implement the 

methodology, (2) monitor VAMCs’ 

ongoing compliance with the 

methodology, (3) complete timely 

evaluations, (4) improve the timeliness 

of communication with VAMCs, and 

(5) define areas of responsibility and 

reporting within VA’s management 

structure. VA concurred with the 

recommendations.

What GAO Found

The seven Department of Veterans Affairs medical centers (VAMC) in GAO’s 

review implemented the Veterans Health Administration’s (VHA) nurse staffing 

methodology, experienced problems developing and executing the related nurse 

staffing plans, and some reported improvements in nurse staffing. Specifically, 

GAO found that each of the seven VAMCs had developed a facility-wide staffing 

plan—which outlines initiatives needed to ensure appropriate unit-level nurse 

staffing and skill mix—and taken steps to execute it. However, VAMCs 

experienced problems—such as lack of data resources and difficulties with 

training—in both the development and execution of their staffing plans. Some 

VAMC staff reported improvements in the adequacy and qualifications of their 

units’ nursing staff when nurse staffing plan initiatives were executed. For 

example, at two VAMCs where the number of nurses was increased or where 

support services for nurses were put in place, such as a designated group of staff 

to assist in transporting patients to and from appointments off the unit, unit staff 

said the adequacy of the nursing staff had improved. However, some VAMC unit 

staff reported that unit nurse staffing continued to be inadequate and that nurse 

unit assignments and job duties were not always appropriate for their 

qualifications. 

VHA’s oversight is limited for ensuring its nurse staffing methodology is 

implemented and administered appropriately. GAO found the following internal 

controls were limited in VHA’s oversight process:

• Environmental assessment. VHA did not comprehensively assess each 

VAMC to ensure preparedness for implementing the methodology, including 

having the necessary technical support and resources, prior to the issuance 

of the directive requiring each VAMC to implement the methodology.

• Monitoring compliance. VHA does not have a plan for monitoring VAMCs 

to ensure compliance with the implementation and ongoing administration of 

the methodology.

• Evaluation. VHA has conducted limited evaluations of the methodology, and 

at least one of these evaluations has been significantly delayed.

• Timeliness of communication. VHA’s protracted timeline for 

communicating methodology-related information may have hindered the 

ability of VAMCs to appropriately develop their staffing plans and to execute 

the initiatives contained in those plans.

• Organizational accountability. VHA did not define areas of responsibility or 

establish the appropriate line of reporting within VA’s management structure 

for oversight of the implementation and ongoing administration of the 

methodology.

Without these internal controls in place, VHA cannot ensure its methodology 

meets department goals, such as establishing a standardized methodology for 

determining an adequate and qualified nurse workforce at VAMCs, and 

ultimately, having nurse staffing that is adequate to meet veterans’ growing and 

increasingly complex health care needs.

View GAO-15-61. For more information, 

contact Debra A. Draper at (202) 512-7114 or 

draperd@gao.gov.
Page i GAO-15-61 VA Nurse Staffing

Letter 1 

Background 5

VAMCs in Our Review Implemented VHA’s Nurse Staffing 

Methodology, Experienced Problems Developing and Executing 

Staffing Plans, and Some Reported Improvements in Nurse 

Staffing 13

VHA’s Oversight to Ensure Its Nurse Staffing Methodology Is 

Implemented, Administered Appropriately, and Contributes to 

an Adequate and Qualified Nurse Workforce Is Limited 20

Conclusions 27

Recommendations for Executive Action 28

Agency Comments 28

Appendix I Comments from the Department of Veterans Affairs 30

Appendix II GAO Contact and Staff Acknowledgments 35

Tables

Table 1: Types of Nursing Staff Position, Responsibilities, and 

Educational Requirements 6

Table 2: VA Medical Center (VAMC) Status for Development of 

VAMC-Wide Staffing Plan 14

Table 3: Examples of VA Medical Centers’ (VAMC) Staffing Plan 

Initiatives 15

Table 4: Examples of Problems VA Medical Centers (VAMC) 

Experienced Developing and Executing Staffing Plans 16

Figures

Figure 1: Timeline for Development and Implementation of the 

Veterans Health Administration’s (VHA) Nurse Staffing 

Methodology 7

Figure 2: VA Medical Center (VAMC) Process for Implementing 

the Veterans Health Administration’s (VHA) Nurse 

Staffing Methodology 8

Contents
Page ii GAO-15-61 VA Nurse Staffing

Abbreviations

FY fiscal year

LPN licensed practical nurse

NA nursing assistant

NDNQI National Database of Nursing Quality Indicators

NHPPD nursing hours per patient day

OIG Office of Inspector General

ONS Office of Nursing Services

RN registered nurse

VA Department of Veterans Affairs

VAMC VA medical center

VHA Veterans Health Administration

VISN Veterans Integrated Service Network

This is a work of the U.S. government and is not subject to copyright protection in the 

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without further permission from GAO. However, because this work may contain 

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Page 1 GAO-15-61 VA Nurse Staffing

441 G St. N.W.

Washington, DC 20548

October 16, 2014

The Honorable Mike Coffman

Chairman

Subcommittee on Oversight & Investigations

Committee on Veterans’ Affairs

House of Representatives

Dear Mr. Chairman:

The Department of Veterans Affairs’ (VA) Veterans Health Administration 

(VHA) provides medical care to millions of veterans each year. Nurses 

play an essential role in the medical care that veterans receive, and it is 

critical that VHA has an adequate and qualified nursing staff to meet 

veterans’ needs. Studies have shown that better care is provided when 

facilities have both an adequate number of nurses, and nurses that are 

appropriately qualified for the jobs to which they are assigned.1

For more than 10 years, concerns have been raised that VHA might not 

have an adequate and qualified nursing staff to care for the increasing 

number of veterans requiring more complex care. In 2002, Congress 

passed legislation requiring VA to develop a nationwide policy on staffing 

levels for the operation of VAMCs.

According 

to VHA, it employs more than 80,000 nurses, making it the largest 

employer of nurses in the country. The number of veterans receiving care 

at VA medical centers (VAMC) increased from 5.2 million in fiscal year 

(FY) 2009 to 5.8 million in FY 2013, and VHA estimates that it will serve 

close to 8.8 million veterans by 2020. Furthermore, more intensive 

nursing care is being required by a growing number of veterans returning 

from military operations in Afghanistan and Iraq, and by aging veterans 

from prior eras of service.

2

 

1

See, for example, R.L. Kane et al., Nurse Staffing and Quality of Patient Care, Pub. 

No. 07-E005, March 2007, Agency for Healthcare Research and Quality; and Kaiser 

Permanente Institute for Health Policy, Nurse Staffing and Care Delivery Models: A 

Review of the Evidence (Menlo Park, Calif.: March 2002).

Specifically, the law required VA to 

establish a nationwide policy on the staffing of VAMCs to ensure they 

have adequate staff, taking into account staffing levels and the mixture of 

2

Pub. L. No. 107-135, Title I, § 124, 115 Stat. 2446, 2452 (Jan. 23, 2002).
 

Page 2 GAO-15-61 VA Nurse Staffing

staff skills required for providing care to veterans. The need for a new 

nurse staffing policy was highlighted in 2004 when VA’s Office of 

Inspector General (OIG) issued a report raising concerns about the 

adequacy of nurse staffing levels in VAMCs’ inpatient units.3 By 2008, 

however, no national policy on nurse staffing had been implemented. In 

October 2008, we issued a report raising concerns about the adequacy of 

nurse staffing, specifically for registered nurses (RN) in inpatient units, 

and the need to expeditiously proceed with developing and implementing 

a new nurse staffing system, among other issues.4

You expressed interest in obtaining information on nurse staffing at 

VAMCs. In this report, we review the extent to which (1) VAMCs have 

implemented VHA’s nurse staffing methodology, and (2) VHA oversees 

VAMCs’ implementation and ongoing administration of its nurse staffing 

methodology.

We recommended 

that VHA develop a detailed plan for implementing a new nurse staffing 

system and ensure it provided accurate nurse staffing estimates. In part 

to address these concerns, in 2010, VHA issued a directive requiring 

each VAMC to implement a nationally standardized methodology for 

determining an adequate and qualified nurse workforce, which includes 

the development and execution of nurse staffing plans. The staffing plans 

outline initiatives needed to ensure appropriate nurse staffing levels and 

skill mix in units to support high-quality patient care in the most effective 

manner possible. The directive also requires VAMCs to use the 

methodology on an ongoing basis to evaluate staffing plans at least 

annually.

To determine the extent to which VAMCs have implemented VHA’s nurse 

staffing methodology, we reviewed documents and interviewed officials 

from VHA. Specifically, we reviewed information and interviewed officials 

from VHA’s Office of Nursing Services (ONS)—the VHA office 

responsible for providing national policies, guidelines, and oversight for all 

VAMC nursing personnel—on the extent to which VAMCs have 

implemented the methodology in inpatient units (Phase I); VAMCs have 

 

3

See Department of Veterans Affairs, Office of the Inspector General, Healthcare 

Inspection: Evaluation of Nurse Staffing in Veterans Health Administration Facilities, 03-

00079-183 (Washington, D.C.: Aug. 13, 2004).

4

See GAO, VA Health Care: Improved Staffing Methods and Greater Availability of 

Alternate and Flexible Work Schedules Could Enhance the Recruitment and Retention of 

Inpatient Nurses, GAO-09-17 (Washington, D.C.: Oct. 24, 2008).
 

Page 3 GAO-15-61 VA Nurse Staffing

piloted the methodology in operating room, emergency department, and 

spinal cord injury units (Phase II); and VHA has developed plans for an 

automatic staffing system (Phase III). We interviewed officials and nursing 

staff from seven VAMCs located in: (1) Battle Creek, Michigan; (2) Bronx, 

New York; (3) Columbia, South Carolina; (4) Dallas, Texas, (5) Fort 

Harrison, Montana; (6) San Diego, California; and (7) Tampa, Florida 

about their experiences implementing VHA’s nurse staffing methodology. 

These VAMCs were selected to ensure variation in factors such as 

geographic location, rural versus urban location, complexity,5 RN turnover 

rate, and Magnet status.6 We did not independently assess the extent to 

which the VAMCs’ implementation of the staffing methodology contributed 

to an adequate and qualified workforce. Furthermore, the results of our 

review of the seven VAMCs are not generalizable across all VAMCs. We 

reviewed literature and interviewed researchers who have published in 

the area of nurse staffing, representatives of selected veterans service 

organizations,7 and representatives of selected nursing organizations and 

unions8

To determine the extent to which VHA oversees VAMCs’ implementation 

and ongoing administration of its nurse staffing methodology, we 

reviewed documents and interviewed officials from VHA. Specifically, we 

to gain their perspectives about the current environment for nurse 

staffing, nurse staffing methodologies in general, and VHA’s nurse 

staffing methodology.

 

5

VA assigns each VAMC a complexity score derived from multiple variables to measure 

facility complexity arrayed along four categories, namely: patient population served, 

clinical services offered, education and research complexity, and administrative 

complexity.

6

Magnet status is a designation of the Magnet Recognition Program®—a nationwide 

program developed by the American Nurses Credentialing Center, a subsidiary of the 

American Nurses Association, to recognize health care organizations for quality patient 

care, nursing excellence, and innovations in professional nursing practice. To attain 

Magnet status, hospitals must meet certain requirements, related to areas including 

staffing practices and quality monitoring.

7

We spoke with officials from the Disabled American Veterans and Paralyzed Veterans of 

America who are knowledgeable about nurse staffing methodologies in VAMC inpatient 

units, such as spinal cord injury units.

8

We interviewed officials from the American Nurses Association. We also contacted each 

of the nursing organizations that VHA officials told us work with VA nurses: American 

Federation of Government Employees, National Nurses United, National Association of 

Government Employees, National Federation of Federal Employees, and Nurses 

Organization of Veterans Affairs.
 

Page 4 GAO-15-61 VA Nurse Staffing

reviewed VHA documents, such as national directives, policies, and 

evaluation plans, to determine the extent to which VHA has provided 

VAMCs guidance regarding the implementation and ongoing 

administration of the staffing methodology. We interviewed officials from 

ONS, the seven VAMCs in our review, and the regional Veterans 

Integrated Service Networks (VISN)9 for these seven VAMCs regarding 

their oversight of VAMCs’ implementation of the staffing methodology. We 

also interviewed ONS officials and VAMC officials and staff about the 

extent to which VAMCs’ implementation of the staffing methodology 

contributes to an adequate and qualified nurse workforce. To determine 

whether VHA applied appropriate internal controls in its oversight of the 

nurse staffing methodology, we used relevant criteria from federal internal 

control standards. We also used relevant strategic planning and 

performance measures from the Government Performance and Results 

Act as enhanced by the Government Performance and Results 

Modernization Act of 2010, as incorporated in GAO’s guidance on 

assessing performance.10

We conducted this performance audit from September 2013 to October

2014 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.

 

9

Each of VA’s 21 VISNs is responsible for managing and overseeing VAMCs within a 

defined geographic area.

10GAO, Managing For Results: GPRA Modernization Act Implementation Provides 

Important Opportunities to Address Government Challenges, GAO-11-617T (Washington, 

D.C.: May 10, 2011); Executive Guide: Effectively Implementing the Government 

Performance and Results Act, GAO/GGD-96-118 (Washington, D.C.: June 1996); 

Standards for Internal Control in the Federal Government, GAO/AIMD-00-21.3.1

(Washington, D.C.: November 1999); Internal Control Management and Evaluation Tool, 

GAO-01-1008G (Washington, D.C.: August 2001); VA Dialysis Pilot: Increased Attention 

to Planning, Implementation, and Performance Measurement Needed to Help Achieve 

Goals, GAO-12-584 (Washington, D.C.: May 23, 2012); Managing For Results: Executive 

Branch Should More Fully Implement the GPRA Modernization Act to Address Pressing 

Governance Challenges, GAO-13-518 (Washington, D.C.: June 26, 2013).
 

Page 5 GAO-15-61 VA Nurse Staffing

Nurse staffing is a critical part of health care because of the effects it can 

have on patient outcomes and nurse job satisfaction. According to VHA, 

its staffing methodology aims to maximize nurses’ productivity and 

efficiency, while providing safe patient care by ensuring appropriate nurse 

staffing levels and skill mix.

VHA’s nurse workforce is primarily composed of RNs,11 licensed practical 

nurses (LPN),12 and nursing assistants (NA). These nurses provide 

care—ranging from primary care to complex specialty care—in inpatient, 

outpatient, and residential care settings at 151 VAMCs across the 

country.13 In addition to the size of the nursing workforce, the nursing skill 

mix—i.e., the share of each type of nurse (RNs, LPNs, or NAs) of the 

total—is an important component of nurse staffing. Units vary in their 

nursing skill mix, depending on the needs of their patients. For example, 

intensive care units require higher intensity nursing, and may have a skill 

mix that is primarily composed of RNs compared to other types of nursing 

units that may provide less complex care. (See table 1 for a general 

description of the types of nursing staff position, responsibilities, and 

educational requirements.)

 

11According to VHA, the workforce data for RNs also include RNs with advanced degrees 

such as nurse practitioners.

12LPNs and licensed vocational nurses have the same level of education and patient care 

responsibilities. For the purposes of this report, when we refer to LPNs, we are referring to 

both LPNs and licensed vocational nurses.

13VHA also employs nurses to work outside VAMCs, such as those employed within its

administrative offices. These nurses were not included in our review.

Background

VHA Nurse Workforce
 

Page 6 GAO-15-61 VA Nurse Staffing

Table 1: Types of Nursing Staff Position, Responsibilities, and Educational Requirements

Position type Responsibilities Educational requirements

Registered nurse 

(RN)

Assesses and provides care to patients, administers 

medications; documents patients’ medical conditions, 

including admissions and discharges; analyzes test 

results; establishes treatment plans; and operates 

medical equipment.

Highest educational requirements:

Has completed a nursing education program, met state 

licensing requirements, and passed a nurse licensing 

examination to obtain an RN license.

Licensed practical 

nurse (LPN)

Takes patient vital signs, provides basic care, and 

administers medications, but generally does not provide 

certain complex patient care services such as patient 

assessments or administration of intravenous 

medications.

a Fewer educational requirements than RNs:

Has a high school diploma or its equivalent and passed 

a licensing examination upon completion of a stateapproved program available at technical schools and 

community colleges, typically lasting 1 year.

Nursing assistant Attends to basic patient needs such as providing 

personal care to patients (e.g., assistance with bathing, 

dressing, and personal hygiene), carries out nonspecialized duties (e.g., measure blood pressure), and 

supports other nursing staff.

Less extensive educational requirements than RNs and 

LPNs:

Has registered as a nursing assistant with their state 

health department, and passed a written competency 

examination upon completion of a state-approved 

training program, generally lasting 3 to 12 weeks.

Source: VHA, nursing organizations, and literature. I GAO-15-61

a

Although the number of nurses at VAMCs increased from FY 2009 to 

FY 2013, VHA ranked nurses as the second most challenging occupation 

to recruit and retain. Specifically, the total number of nurses at VAMCs 

increased 13 percent from 72,542 in FY 2009 to 81,940 in FY 2013, with 

similarly proportionate increases within each position type—RN, LPN, and 

NA. During the same time period, the annual nurse turnover rate at 

VAMCs—the percentage of nurses who left VHA through retirement, 

death, termination, or voluntary separation—increased from 6.6 percent 

to 8.0 percent. Although RNs had the lowest turnover rate among nurses, 

VHA noted particular difficulty recruiting and retaining for the position, 

particularly for RNs with advanced professional skills, knowledge, and 

experience, such as RNs that provide services in medical and surgical 

care units.

LPNs and licensed vocational nurses have the same level of education and patient care 

responsibilities. In this table, when we refer to LPNs, we are referring to both LPNs and licensed 

vocational nurses.

14

 

14See Department of Veterans Affairs, Veterans Health Administration, 2013 Workforce 

Succession Strategic Plan (Washington, D.C.: 2013).

VHA projects that approximately 40,000 new nurses will be 

needed through FY 2018 to maintain current staffing levels and to meet 

the needs of veterans.
 

Page 7 GAO-15-61 VA Nurse Staffing

To help ensure adequate and qualified nurse staffing at VAMCs, in July 

2010, VHA issued VHA Directive 2010-034: Staffing Methodology for 

VHA Nursing Personnel. ONS, the VHA office responsible for providing 

national policies and guidelines for all VHA nursing personnel, led the 

development of the nurse staffing methodology, which began in 2007. 

(See fig. 1.)

Figure 1: Timeline for Development and Implementation of the Veterans Health Administration’s (VHA) Nurse Staffing 

Methodology

To implement the methodology, each VAMC is required to (1) develop a 

VAMC-wide staffing plan for its nurse workforce, comprised of individual 

unit-level staffing plans, and (2) execute that plan. (See figure 2 for an 

outline of the process for implementing VHA’s nurse staffing 

methodology.)

VHA’s Nurse Staffing 

Methodology
 

Page 8 GAO-15-61 VA Nurse Staffing

Figure 2: VA Medical Center (VAMC) Process for Implementing the Veterans Health Administration’s (VHA) Nurse Staffing 

Methodology

Each VAMC unit is to develop a staffing plan outlining recommendations 

on the appropriate nurse staffing levels and skill mix needed in that unit to 

support high-quality patient care in the most effective manner possible. 

Specifically, staffing plans are to be developed using expert panels and a 

data-driven analysis of nursing hours per patient day (NHPPD). VAMC 

nurse executives—members of senior management within each VAMC—

are responsible for implementing the staffing methodology in their 

respective VAMCs.

• Expert panels: advisory groups—at the unit and facility level—of 

VAMC staff with in-depth knowledge of nurse staffing needs. The use 

of expert panels is intended to apply principles of shared governance, 

which allows nurses to have influence over the delivery of patient care 

and involves stakeholders from across the VAMC. VAMC nurse 

executives are responsible for ensuring that the unit-based expert 

panels represent all nursing types (RN, LPN, NA) and developing the 

VAMC’s facility expert panel.

• Data-driven analysis of NHPPD: involves determining the number and 

skill mix of nurses needed for each unit by calculating the number of 

direct patient care nursing hours provided for all patients on that unit 

during a 24-hour period.15

 

15VHA’s directive defines direct patient care as all patient- or resident-centered nursing 

activities performed by staff assigned to the unit. These activities include nursing 

assessments, admission and discharge activities, and patient teaching and 

communication.

The use of NHPPD represents a move 
 

Page 9 GAO-15-61 VA Nurse Staffing

away from the more traditional nurse-to-patient ratios that assign a 

certain number of patients to each nurse. Some research suggests 

that NHPPD can better capture changes in nurses’ workloads and 

case mix resulting from admissions and discharges, as well as patient 

acuity levels, which can impact the amount of time nurses spend with 

each patient.16

After developing the staffing plan, each unit-based expert panel presents 

its plan, which includes staffing recommendations, to the VAMC’s facility 

expert panel. Those staffing recommendations may include, for example, 

initiatives to change the number and skill mix of nurses needed for each 

shift; change the number of nurses required for coverage during predicted 

absences, such as annual and sick leave; and develop support services 

for nurses, such as designated individuals to transport patients to other 

areas of the facility as needed. The facility expert panel—comprised of 

staff from across the VAMC—reviews each unit-based panel’s staffing 

plan and aggregates all of the unit plans into one VAMC-wide staffing 

plan. The VAMC nurse executive reviews the VAMC-wide staffing plan 

and forwards it to the VAMC director for review and approval. Once 

approved, the VAMC then begins execution of the initiatives outlined in 

the VAMC-wide staffing plan. The directive requires each VAMC to 

conduct an ongoing staffing analysis to evaluate staffing plans annually, 

at a minimum, and for VAMC directors to incorporate projected staffing 

needs into their annual budget review.

The staffing methodology is being implemented in three phases.

• In Phase I, VAMCs were to implement the staffing methodology in all 

inpatient units no later than September 30, 2011.

• In Phase II, VAMCs are to implement the staffing methodology for all 

other units, including the operating room, emergency department, and 

spinal cord injury units.17

 

16J. Spetz et al., “How Many Nurses Per Patient?” Health Services Research, vol. 43 

(October 2008):1674-1692; Carayon, P. and A. Gurses, “Nursing Workload and Patient 

Safety in Intensive Care Units: A Human Factors Engineering Evaluation of the Literature,” 

Intensive and Critical Care Nursing, vol. 21 (2005): 284-301; and American Association of 

Critical-Care Nurses, Standards for Establishing and Sustaining Healthy Work 

Environments (Aliso Viejo, Calif.: American Association of Critical-Care Nurses, 2005).

ONS has completed the Phase II pilot for 

17According to ONS officials, the staffing methodology for these units were to be 

implemented separately from those included in Phase I because of the potential need to 

modify the methodology to align with the special services these units provide.
 

Page 10 GAO-15-61 VA Nurse Staffing

operating room units, and VAMCs are expected to implement the 

methodology in their operating room units by October 1, 2014. 

Deadlines for the implementation in other Phase II units have not 

been set.

• In Phase III, VAMCs are to use an automated system developed by 

VHA that (1) merges VHA staffing data used in the staffing 

methodology and other VHA data, such as human resource data, into 

one data system, and (2) incorporates the data into staffing-related 

reports, such as quality-of-care reports. A deadline for Phase III 

implementation has not been set.

In May 2014, the VA OIG found that VAMCs in its review varied in their 

implementation of the staffing methodology. Specifically, the VA OIG 

reported that 8 of the 28 VAMCs reviewed had not fully implemented all 

components of the staffing methodology by September 2013, 2 years 

past the implementation date required by the VHA directive.18 As these 

findings were similar to those of its April 2013 report,19 the VA OIG stated 

in its 2014 report, “We re-emphasize the need for all facilities to fully 

implement the methodology and accurately address patient needs with 

safe and adequate staffing.”

Adequate and qualified nurse staffing at VAMCs is required to provide 

effective and continuous patient care and to maintain a stable and 

engaged workplace. The importance of nurse staffing on patient 

outcomes and nurse job satisfaction has been emphasized by various 

entities, including The Joint Commission;20 American Nurses 

Association;21 Institute of Medicine;22

 

18See Department of Veterans Affairs, Office of the Inspector General, Combined 

Assessment Program Summary Report: Evaluation of Nurse Staffing in Veterans Health 

Administration Facilities April – September 2013, Report No. 14-01072-140 (Washington, 

D.C.: May 12, 2014).

and Agency for Healthcare 

19See Department of Veterans Affairs, Office of the Inspector General, Combined 

Assessment Program Summary Report: Evaluation of Nurse Staffing in Veterans Health 

Administration Facilities, Report No. 13-01744-187 (Washington, D.C.: April 30, 2013).

20Joint Commission on Accreditation of Healthcare Organizations, Health Care at the 

Crossroads: Strategies for Addressing the Evolving Nursing Crisis (Chicago, Ill.: Joint 

Commission on Accreditation of Healthcare Organizations, 2002).

21See American Nurses Association, Principles for Nurse Staffing, Second Edition (Silver 

Spring, Md.: American Nurses Association, 2012).

Impact of Nurse Staffing 

on Patient Outcomes and 

Nurse Job Satisfaction
 

Page 11 GAO-15-61 VA Nurse Staffing

Research and Quality.23

• A link between the adequacy of nurse staffing and patient outcomes, 

particularly in inpatient units, such as intensive care and surgical 

units. For example, medication errors, pressure ulcers, hospital 

acquired infections, pneumonia, longer-than-expected stays, and 

higher mortality rates each have been associated with inadequate 

nurse staffing.

Additionally, research has linked the adequacy 

and qualifications of nurse staffing to patient outcomes and nurse job 

satisfaction. For example, studies have shown:

24

• A link between the qualifications of nursing staff and patient 

outcomes. For example, one study found that patients cared for in 

units utilizing more licensed and experienced nursing staff (RNs and 

LPNs) and fewer unlicensed aides (NAs) had shorter lengths of

stay.25 Other studies linked baccalaureate-prepared nurses to lower 

mortality rates.26

• A link between nurse staffing and job satisfaction. For example, some 

studies have linked low job satisfaction to heavy workloads and an 

 

22Institute of Medicine, The Future of Nursing: Leading Change, Advancing Health 

(Washington, D.C.: The National Academies Press, 2011).

23See R.L. Kane et al., Nurse Staffing and Quality of Patient Care, Pub. No. 07-E005, 

March 2007, Agency for Healthcare Research and Quality; and “Hospital Nurse Staffing 

and Quality of Care,” Agency for Healthcare Research and Quality, Research in Action, 

Issue 14, Pub. No. 04-0029 (Rockville, Md.: 2004).

24M.A. Blegen et al., “Nurse Staffing Effects on Patient Outcomes: Safety-Net and NonSafety-Net Hospitals,” Medical Care, vol. 49, issue 2 (April 2011), 406–414; J. Needleman

et al., “Nurse Staffing and Inpatient Hospital Mortality,” New England Journal of Medicine, 

vol. 364, issue 11 (March 2011), 1037-1045; L.H. Aiken et al., “Implications of the 

California Nurse Staffing Mandate for Other States,” Health Services Research, vol. 45, 

issue 4 (April 2010), 904–921; and P.W. Stone et al., “Nurse Working Conditions and 

Patient Safety Outcomes,” Medical Care, vol. 45, issue 6 (June 2007), 571-578.

25A.P. Bartel et al., “Human Capital and Productivity in a Team Environment: Evidence 

from the Healthcare Sector,” American Economic Journal: Applied Economics, vol. 6, 

issue 2 (2014), 231-259.

26A. Kutney-Lee, D.M. Sloane, and L.H. Aiken, “An Increase In The Number Of Nurses 

with Baccalaureate Degrees Is Linked To Lower Rates Of Postsurgery Mortality,” Health 

Affairs, vol. 32, issue. 3 (March 2013), 579-586; L.H. Aiken et al., “Effects of Hospital Care 

Environment on Patient Mortality and Nurse Outcomes,” Journal of Nursing 

Administration, vol. 38, issue 5 (May 2008), 223-229; and C.R. Friese et al., “Hospital 

Nurse Practice Environments and Outcomes for Surgical Oncology Patients,” Health 

Services Research, vol. 43, issue 4 (August 2008), 1145-1163.
 

Page 12 GAO-15-61 VA Nurse Staffing

inability to ensure patient safety.27 Other studies found that improving 

nurse staffing and working conditions may simultaneously reduce 

nurses’ burnout, risk of turnover, and the likelihood of medical errors, 

while increasing patients’ satisfaction with their care.28

Non-VA health care organizations use various approaches to ensure 

effective nurse staffing. For example, some use fixed nurse-to-patient 

ratios while others use adjustable, unit-specific minimum staffing levels,29

and there have been several efforts to address nurse staffing using these 

different approaches.30 For example, California has enacted legislation 

requiring regulations that mandate specific nurse-to-patient ratios that 

limit the number of patients cared for by an individual nurse. Other states 

have passed legislation or adopted regulations addressing nurse staffing 

without mandating specific ratios or staffing levels. For example, some 

states require hospitals to have committees responsible for developing 

unit staffing plans or require public reporting of staffing.

 

27J. Spetz, “Nurse Satisfaction and the Implementation of Minimum Nurse Staffing 

Regulations,” Policy, Politics, & Nursing Practice, vol. 9 (Feb. 2008, first published on 

April 3, 2008), 15-21; and L.H. Aiken et al., “Hospital Nurse Staffing and Patient Mortality, 

Nurse Burnout, and Job Dissatisfaction,” The Journal of the American Medical 

Association, vol. 288, issue 16 (October 2002), 1987-1993.

28A.W. Stimpfel, D.M. Sloane, and L.H. Aiken, “The Longer the Shifts for Hospital Nurses, 

the Higher the Levels of Burnout and Patient Dissatisfaction,” Health Affairs, vol. 31, issue 

11 (November 2012), 2501-2509; J.P. Cimiotti et al., “Nurse Staffing, Burnout, and Health 

Care-Associated Infection,” American Journal of Infection Control, vol. 40 (August 2012) 

486-490; and D.C. Vahey et al., “Nurse Burnout and Patient Satisfaction,” Medical Care, 

vol. 42, issue 2 (Feb. 2004), 57-66.

29Fixed nurse-to-patient ratios assign a certain number of patients to each nurse (e.g., one 

nurse for every five patients) while adjustable, unit-specific, minimum staffing levels assign 

minimum ratios of nurses to patients for each unit and shift that reflects the needs of the 

patient population and matches the skills and experience of the staff.

30These are illustrative examples of different approaches; we did not conduct a 

comprehensive review of all state requirements.
 

Page 13 GAO-15-61 VA Nurse Staffing

All seven VAMCs in our review developed staffing plans using VHA’s 

nurse staffing methodology and have taken steps to execute them. 

However, VAMCs experienced problems in both the development and 

execution of their staffing plans. Improvements in nurse staffing were 

reported by some of the VAMCs which had taken steps to execute the 

staffing plans.

The seven VAMCs in our review have implemented VHA’s nurse staffing 

methodology; specifically, each of these VAMCs has developed a facilitywide staffing plan, comprised of unit-level staffing plans for inpatient units, 

and has taken steps to execute it.31 Although each of the seven VAMCs 

in our review developed a staffing plan for FY 2013, only one had 

developed a plan per VHA’s directive—that is, used both expert panels 

and analysis of NHPPD—by September 30, 2011, the deadline specified 

in the directive. (See table 2.) Across all 151 VAMCs, according to ONS 

officials, VAMCs’ implementation of the nurse staffing methodology 

varied, with, for example, some VAMCs completing the development of 

their staffing plans during FY 2013, and some only beginning the 

development process.

 

31As previously described, VAMCs were required to implement the methodology in 

inpatient units (Phase I) no later than September 30, 2011. VAMCs were expected to 

implement the methodology in their operating rooms by October 1, 2014; requirements for 

implementation of Phase II in other units and Phase III of the methodology have not been 

set.

VAMCs in Our 

Review Implemented 

VHA’s Nurse Staffing 

Methodology, 

Experienced 

Problems Developing 

and Executing 

Staffing Plans, and 

Some Reported 

Improvements in 

Nurse Staffing

VAMCs in Our Review 

Have Implemented VHA’s 

Nurse Staffing 

Methodology by 

Developing Staffing Plans 

and Taking Steps to 

Execute Them
 

Page 14 GAO-15-61 VA Nurse Staffing

Table 2: VA Medical Center (VAMC) Status for Development of VAMC-Wide Staffing 

Plan 

Status 

VAMC FY 2011 FY 2012 FY 2013

A ● ● ●

B o ● ●

C o ● ●

D o o ●

E o o ●

F o ● ●

G o ● ●

Source: Seven VAMCs in our review. I GAO-15-61

● VAMC-wide staffing plan complete per Veterans Health Administration (VHA) directive.

o VAMC-wide staffing plan not complete per VHA directive.

Note: VHA Directive 2010-034 required each VAMC to develop a VAMC-wide staffing plan for use in 

its inpatient units by September 30, 2011. The process for developing the staffing plans included the 

use of expert panels—at the unit level and at the facility level—and a data-driven analysis of nursing 

hours per patient day.

In addition to developing staffing plans, all seven VAMCs in our review 

had taken steps to execute their respective staffing plans. For example, 

VAMCs had taken steps to execute initiatives to increase the number of 

unit nurses or change the skill mix of nurses to address patient care 

needs. (See table 3 for examples of VAMCs’ staffing plan initiatives.) 

VAMC officials told us there are many factors that could affect the 

execution of staffing plan initiatives, such as available resources, the 

amount of time needed, and other strategic priorities.
 

Page 15 GAO-15-61 VA Nurse Staffing

Table 3: Examples of VA Medical Centers’ (VAMC) Staffing Plan Initiatives

Initiative Description

Number of nurses Increase the total number of unit nurses—for example, registered nurses (RN), licensed practical nurses 

(LPN), or nursing assistants (NA)—to meet direct patient care needs.

Skill mix Change skill mix of nurses to better meet patient needs—particularly having more RNs (rather than LPNs) 

to conduct timely patient assessments.

Contract nurse pool Develop contracts to use temporary nursing staff from external employment organizations to meet shortterm staffing needs.

Float pool Develop designated group of nurses to float to units on an as-needed basis.

Sitter pool Develop designated group of staff to provide one-on-one direct patient observation to allow nurses to better 

care for a broader group of patients.

Transport team Develop designated group of staff to assist in transporting patients to and from appointments off the unit so 

that RNs are able to remain on the unit.

Staff reassignment Reassign nursing staff from an overstaffed unit to an understaffed unit.

Patient census Temporarily reduce patient census by closing beds because of inadequate staffing.

Source: Seven VAMCs in our review. I GAO-15-61

Officials and nursing staff from the seven VAMCs in our review told us 

they experienced problems developing and executing staffing plans. (See 

table 4 for examples of problems.) Some VAMCs were able to devise 

solutions; however in many cases, the problems have persisted.

VAMCs Experienced 

Problems Developing and 

Executing Staffing Plans,

and Many of These 

Problems Persist
 

Page 16 GAO-15-61 VA Nurse Staffing

Table 4: Examples of Problems VA Medical Centers (VAMC) Experienced Developing and Executing Staffing Plans

Problems developing staffing plans

Problems executing 

staffing plans

VAMC

Lack of 

necessary data 

resources

Difficulty 

completing and 

understanding 

training

Time 

required

Lack of 

communication 

within VAMC

Difficulty 

integrating unit 

staff in expert 

panels

Hiring 

delays

Budget 

constraints

A x x x x 

B x x x x x x x 

C x x x x x x 

D x x x x x x 

E x x x x x 

F x x x x x x 

G x x x 

Source: Seven VAMCs in our review. I GAO-15-61

Problems Developing Staffing Plans. Staff and officials from each of 

the seven VAMCs in our review reported facing problems developing 

staffing plans.

• Lack of necessary data resources. Staff and officials at six of the 

seven VAMCs in our review said they did not have the appropriate 

data resources to effectively calculate NHPPD as required by VHA’s 

staffing methodology directive. Specifically, the directive instructs 

VAMC staff to calculate NHPPD using a wide range of data, such as 

number of admissions, transfers, and discharges; hours used for 

planning and treatment; and human resources data. We found that 

staff and officials needed to use multiple sources to collect the 

necessary data, in some cases manually, a process they said was 

time-consuming and potentially error-prone, and required data 

expertise they did not always have. For example, at one VAMC, the 

staffing methodology coordinator—a VAMC official who assists with 

the administrative tasks associated with the implementation process—

told us she struggled with some data analysis techniques, such as 

creating a spreadsheet to help track staffing data, but the VAMC did 

not have the financial resources to hire additional data analysts to 

support the methodology. In contrast, officials from two VAMCs in our 

review told us staffing methodology coordinators were assigned in 

part based on their data analysis expertise.
 

Page 17 GAO-15-61 VA Nurse Staffing

• Difficulty completing and understanding training. Staff from six of the 

seven VAMCs in our review said the ONS training on the 

methodology was time consuming to complete, and difficult to 

understand. In 2011, ONS switched from instructor-led, group training 

to individual, computer-based PowerPoint training. Many unit staff 

reported that because the computer-based training took many hours 

to complete, it was difficult to find the time to complete it, while also 

carrying out their patient care responsibilities. They told us they often 

had to start and stop the training to attend to patients, which 

diminished its effectiveness. Further, the course’s complex material 

was hard to absorb through an individual, computer-based course, 

with many staff suggesting their understanding would have been 

greatly improved with an instructor-led, group course where they 

could ask questions, ensure consistency of learning, and build 

camaraderie among unit expert panel members. To address the 

difficulties in completing and understanding the training, one VAMC 

developed its own instructor-led, group training provided to all its 

units.

• Time required. Staff and officials at all seven of the VAMCs in our 

review reported that developing staffing plans required a lot of staff 

time due to the complexity of the process. In particular, they said 

gaining an understanding of the methodology, collecting the 

necessary data, convening the unit expert panels, and preparing 

presentations for the facility expert panel were time-intensive tasks 

that, in some circumstances, took time away from patient care. For 

example, members from one unit expert panel estimated they spent, 

in total, about 160 hours (4 weeks) developing the unit staffing plan 

during the first year the staffing methodology was implemented in their 

unit. Some VAMCs’ staffing methodology coordinators developed 

specific processes designed to decrease the burden on nursing staff 

and improve efficiency. For example, they created templates for unit 

panel members to use in staffing plan development; such templates 

improved efficiency because unit panel members did not have to 

independently develop their presentation format. Further, facility 

expert panel members had to orient themselves to only one template, 

and were therefore able to more easily make facility-level 

comparisons and decisions.

• Lack of communication within VAMC. Unit expert panel members at 

four of the seven VAMCs in our review said there was a lack of 

communication between nurses and VAMC leadership regarding the 

status of the staffing plans, including plans for execution of the staffing 

plan initiatives. Staff at one of these VAMCs said they had not 

received any feedback on their FY 2012 or FY 2013 unit staffing 
 

Page 18 GAO-15-61 VA Nurse Staffing

plans; they added that developing the 2013 staffing plan without 

getting any feedback on the prior year’s plan felt “frustrating.” In 

contrast, at another VAMC, officials told us that all unit staff—not just 

staff involved in the unit panel—received regular updates on the nurse 

staffing process at their monthly unit staff meetings.

• Difficulty integrating unit staff into expert panels. Staff and officials at 

three VAMCs described challenges in integrating unit staff into expert 

panels. Some unit panel members told us that although they were 

considered members of their respective unit panels, they were not 

significantly involved in the development of their units’ staffing plans. 

For example, a unit panel member said the VAMC’s staffing 

methodology coordinator calculated the unit’s NHPPD, developed the 

corresponding unit staffing plan, and presented the unit staffing plan 

to the respective facility expert panel almost entirely without her unit’s 

input. As a result, there was limited involvement of the unit panel 

members in the expert panel and, consequently, limited shared 

governance. Officials at these VAMCs said that from their 

perspectives, there was interest in the methodology among unit panel 

members, but sometimes it was difficult for these staff to attend 

relevant meetings because of patient needs. In contrast, unit panel 

members at other VAMCs in our review described how they were fully 

integrated into the unit panels. They described in detail the data 

analyses they prepared, the meetings they participated in, and their 

experiences presenting their unit staffing plans to the facility expert 

panel. Members from one unit panel told us it was helpful to be able to 

use data to validate the unit’s staffing and share this data with the 

facility expert panel—VAMC staff “beyond the typical chain of 

command.” Officials at this VAMC noted that unit panel members felt 

“empowered” to present their work to the facility expert panels.

Problems Executing Staffing Plans. Staff and officials from six of the 

seven VAMCs in our review noted problems executing staffing plans once 

approved by the VAMC director.

• Hiring delays. Staff and officials from six of the seven VAMCs in our 

review said they often faced hiring delays that impacted their ability to 

execute staffing plan initiatives. Some VAMC staff noted it could take 

more than 6 months to fill unit vacancies. Although staff from one 

VAMC said hiring was slowed by the dearth of qualified nurses in their 

community, staff from other VAMCs in our review said the supply of 

nurses was not the problem, but rather the problem was the VHA 

hiring process, which took months to complete for each candidate. 

Additionally, VAMC staff noted that new hires also needed to 
 

Page 19 GAO-15-61 VA Nurse Staffing

complete necessary internal trainings before joining a unit full time, 

which added to the delays, and that some new hires were hurried 

through this training process because their units were so desperate to 

have them on staff.

• Budget constraints. Staff and officials from five of the seven VAMCs in 

our review said their VAMCs were not able to fully execute their 

staffing plans due to budget constraints. For example, at one VAMC, 

one of the approved staffing plan initiatives was the hiring of a large 

number of nurses for its units, in part, to address the VAMC’s inability 

to increase their nursing staff over a period of years. The official told 

us that, due to budget constraints, the VAMC was going to phase in 

this hiring initiative over the next few years.

Some VAMC staff reported improvements in the adequacy and 

qualifications of their units’ nursing staff when nurse staffing plan 

initiatives were executed. For example, at two VAMCs at which the 

number of nurses was increased or support services for nurses, such as 

patient transporters or sitters, were put in place,32

Some VAMC staff said they also had seen improvements in patient 

outcomes and nurse job satisfaction. For example, nursing staff at one 

VAMC said that after creating sitter positions—as indicated by their 

VAMC’s staffing plan—they saw a decrease in patient falls. The staff said 

sitters were able to monitor patients more closely, and as a result, 

patients were less likely to fall during walks to the bathroom, for example. 

Similarly, nursing staff in a mental health unit at another VAMC said that 

by having more staff they had decreased their restraint use because there 

unit staff said the 

adequacy of the nursing staff had improved. Furthermore, improvements 

in the qualifications of unit nursing staff were noted by staff in VAMC units 

where, for example, skill-mix changes were made or the amount of 

floating of nurses from their home unit to an unfamiliar unit was 

decreased. Both VAMC officials and unit staff noted improvements in 

staffing when nurses’ qualifications were more appropriately matched to 

the right level of work (for example, having RNs rather than LPNs 

available to provide more complex patient care) and to the right units (for 

example, the units for which they were hired and trained).

 

32Transport teams are staff who assist in transporting patients to and from appointments 

off the unit. Sitters are staff who provide one-on-one direct patient observation.

Improvements in Nurse 

Staffing Were Reported 

When VAMCs Executed 

Staffing Plan Initiatives
 

Page 20 GAO-15-61 VA Nurse Staffing

were more staff available to meet veterans’ needs. Additionally, nursing 

staff we interviewed at one VAMC that had made staffing changes based 

on staffing plans said they were better able to provide the type of nursing 

care “veterans deserve,” and this made them feel more positive about 

their work. Some nurses at this VAMC also said the shared governance 

aspect of the methodology was empowering, which, combined with their 

enhanced understanding of staffing at their VAMC, helped improve their 

overall job satisfaction.

However, some VAMC unit staff reported that unit nurse staffing 

continued to be inadequate and that nurse unit assignments and job 

duties were not always appropriate for their qualifications. For six of the 

VAMCs in our review, staff from at least one unit interviewed said their 

unit staffing levels were inadequate. Staff said ensuring adequate staffing 

was particularly challenging when there were unplanned staff absences 

and they had to “scramble” to provide coverage. Some unit staff noted 

that this situation often resulted in units forcing nurses to work overtime or 

nurses floating to other units where they did not always have the 

qualifications to provide care. At some VAMCs, staff said there were 

increased staff injuries due to inadequate staffing. Furthermore, staff at 

one VAMC reported that where there had not been any changes made 

based on the unit staffing plans, their units continued to be understaffed 

to the detriment of both patient care and their job satisfaction.

Our review of VHA’s oversight of its nurse staffing methodology found 

that some internal controls—those related to environmental assessment, 

a plan for monitoring compliance, evaluation, timeliness of 

communication, and organizational accountability—are limited. The 

implementation of internal controls is necessary for ensuring initiatives 

achieve intended outcomes and for minimizing operational problems. 

Without these internal controls in place, VHA cannot ensure that its 

methodology meets department goals, such as establishing a 

standardized methodology for determining adequate and qualified nurse 

staffing at all VAMCs, and ultimately, having nurse staffing that is 

adequate to meet veterans’ health care needs.

Environmental Assessment. VHA did not comprehensively assess each 

VAMC to ensure preparedness for implementing its methodology, 

including having the necessary technical support and resources, prior to 

the issuance of the methodology directive in 2010. Furthermore, as of 

August 2014, VHA did not have a plan for assessing whether VAMCs 

have the necessary resources to execute their approved nurse staffing 

VHA’s Oversight to 

Ensure Its Nurse 

Staffing Methodology 

Is Implemented, 

Administered 

Appropriately, and 

Contributes to an 

Adequate and 

Qualified Nurse 

Workforce Is Limited
 

Page 21 GAO-15-61 VA Nurse Staffing

plans. Under federal internal control standards, successful organizations 

monitor their internal and external environments continuously and 

systematically, and by building environmental assessments into the 

strategic planning process, are able to stay focused on long-term goals 

even as they make changes to achieve them.

VHA did not assess VAMCs’ technical resources to determine if all 

VAMCs would be able to successfully implement the methodology. For 

example, the directive recommended that VAMCs use comparative data 

from external sources, such as the National Database of Nursing Quality 

Indicators (NDNQI) when analyzing unit-level staffing data. According to 

some VAMC officials, due to the costs and complexity of contracting,33

not all VAMCs had access to this data source.34

 

33NDNQI was created as part of the American Nurses Association’s Patient Safety and 

Quality Initiative to identify the linkages between staffing and patient outcomes. The 

database contains data on quality indicators and staff levels collected from approximately 

2,000 hospitals that submit data on nursing-sensitive indicators, such as pressure ulcers 

and patient falls. According to the American Nurses Association, 98 percent of all Magnet 

facilities use some aspect of NDNQI data.

Each VAMC was 

responsible for establishing its own contract to purchase access to 

NDNQI data, which some VAMC officials said was expensive and timeconsuming to set up, noting that it would have been helpful to have 

assistance in coordinating the contracting process. Officials from ONS 

reported that they are discussing the possibility of having a VHA-wide 

contract so that all VAMCs would have access to NDNQI data. In addition 

to access to comparative data, according to the directive, VAMCs need 

appropriate data system capabilities—in particular an automated staffing 

system for information such as patient admission, transfer and discharge 

data, and human resources data—to facilitate implementation of the datadriven methodology and calculation of NHPPD. However, not all VAMCs 

in our review had an automated staffing system in place even 3 years 

after the release of the directive. Officials at a VAMC without an 

automated staffing system told us staff were collecting and inputting data, 

in many cases manually, into a spreadsheet to calculate NHPPD, and 

that this process was extremely time-consuming and potentially errorprone. ONS officials said they knew VAMCs needed automated staffing 

34According to the staffing methodology directive, a comparative analysis of NHPPD data 

from other resources is also recommended, such as from the Labor Management Institute 

and NDNQI. Labor Management Institute data compare direct, indirect, and total worked 

hours of care by hospital and unit type, and NDNQI data contain information on quality 

indicators and staff levels.
 

Page 22 GAO-15-61 VA Nurse Staffing

systems when the directive was published in 2010. However, they 

thought Phase III—a national automated staffing system—would be 

forthcoming, and did not fully review whether VAMCs had alternative data 

capabilities to assist them in the interim.

When we asked how they assessed the readiness of VAMCs for 

implementation of the methodology, ONS officials told us that they did not 

do this as well as they should have for Phase I implementation in 

inpatient units, despite its 2009 Phase I pilot evaluation to better 

understand the potential capabilities and weaknesses of VAMCs. 

According to ONS, it still has not conducted such an assessment of all 

VAMCs even though it has moved forward with planning the national 

rollout of Phase II in operating room, emergency department, and spinal 

cord injury units. ONS, however, has assessed some of the available 

resources of the sites that have participated in the pilots for Phase II in 

spinal cord injury units. For example, ONS officials told us that they asked 

these participating sites questions about their access to data and nurse 

turnover within the pilot units to determine their ability to fully and 

successfully participate in the pilot. According to ONS officials, all sites 

reported that they were able to fully participate in the pilot. By not 

comprehensively assessing the VAMCs’ technical support and resources 

to determine if they were prepared to implement the methodology, VHA 

had no assurance that the VAMCs would be successful.

Plan for Monitoring Compliance. ONS did not develop a plan for 

monitoring VAMCs to ensure they were in compliance with the 

implementation and ongoing administration of Phase I of the 

methodology. Under federal internal control standards, plans should be 

designed to ensure that ongoing monitoring occurs in the course of 

normal program operations, and managers should identify performance 

gaps in compliance with program policies and procedures.

ONS reported implementing two mechanisms for obtaining information 

from VAMCs—a 2013 questionnaire sent to all VAMCs and monthly 

methodology conference calls with VAMCs—but neither was an adequate 

mechanism for comprehensively assessing the compliance of each 

VAMC. The questionnaire, sent nearly 2 years after the deadline for 

implementation of Phase I of the methodology, asked VAMCs to report 

their status of staffing plan development, but because of lack of clarity in 

the questions asked, inconsistency in medical center responses, and lack 

of validation of the self-reported responses, it was not reliable for 

determining the extent to which VAMCs had developed staffing plans. 

ONS officials reported that they have no plans to survey VAMCs again on 
 

Page 23 GAO-15-61 VA Nurse Staffing

their status of developing staffing plans. Furthermore, the monthly 

methodology conference calls that started when the directive was 

published in 2010 did not provide an adequate mechanism for monitoring 

compliance because they too relied on VAMCs to self-report problems. A 

VAMC official told us that participants were reluctant to raise problems, 

such as not developing staffing plans on time, during these monthly calls.

In addition, the directive requires VAMCs to evaluate their staffing plans 

for Phase I annually, or more frequently if needed, but ONS officials told 

us that they did not have a systematic plan for monitoring compliance with 

this evaluation beyond the 2013 questionnaire and the monthly 

methodology conference calls. Moving forward, ONS officials said they 

plan to review whether all VAMCs implemented both the unit and facility 

expert panels, but, as of August 2014, had no detailed plan or timeline for 

conducting this review or for monitoring VAMCs’ ongoing evaluation of 

their staffing plans. The lack of a plan for monitoring VAMCs’ compliance 

with the implementation and ongoing administration of the methodology 

hinders VHA from being able to ensure that all VAMCs are staffing their 

nurses using the same, standardized methodology.

Evaluation. There have been limited evaluations of the methodology, and 

one of these evaluations has been significantly delayed. Under federal 

internal control standards, measuring performance allows organizations 

to track the progress they are making towards program goals and 

objectives, and provides managers important information on which to 

make management decisions and resolve any problems or program 

weaknesses.

• Evaluation of Phase I pilot (conducted in September 2009)—ONS 

identified VAMC challenges with implementing the methodology—

such as difficulties accessing data, and staff nurses having an overall 

lack of knowledge of the methodology process. The evaluation 

contained recommendations, such as developing a training guidebook 

and providing guidelines on the role of the expert panels, to improve 

the methodology process. According to ONS, most of the 

recommendations from this 2009 evaluation have been addressed; 

however, we found that weaknesses identified in the 2009 evaluation 

still existed for all of the seven VAMCs included in our review.

• Evaluations of Phase I national implementation and training (began 

early 2014, preliminary results were expected August 2014). Similarly, 

ONS did not begin an evaluation of the national implementation of the 

methodology until January 2014, more than 2 years after VAMCs 

were required to have implemented it, and, as of August 2014, had 
 

Page 24 GAO-15-61 VA Nurse Staffing

still not been completed. According to ONS officials, the Phase I 

national evaluation was to review VAMCs’ experiences during 

implementation, including a review of the training provided to VAMCs 

during that phase. The lengthy delay in the evaluation of Phase I was 

potentially problematic because the ongoing difficulties that VAMCs 

have experienced during implementation may have been avoided or 

resolved more quickly if the evaluation results had been available and 

corrective actions put into place. VAMC staff we interviewed told us 

they have been struggling with components of the methodology since 

the directive was issued. For example, some VAMC staff expressed 

difficulty completing and understanding the data analysis process for 

calculating NHPPD. An earlier evaluation of the methodology could 

have helped identify this problem, as well as potential solutions to 

address it. Furthermore, the delay limited ONS’s time to apply lessons 

learned from Phase I evaluations to the implementation of Phase II, 

portions of which are already nearly complete.

• Phase II pilot training evaluation (began in early 2014 with results 

expected November 2014)—ONS is conducting an evaluation of the 

training that was provided to the VAMCs involved in the Phase II pilots 

in operating room, emergency department, and spinal cord injury units 

to determine if the training provided to these units needs to be 

changed in preparation for the national rollout. ONS officials told us 

that they have completed the operating room pilot; the national rollout 

of the methodology in operating room units in all VAMCs began in 

February 2014 and is expected to be completed by October 1, 2014. 

ONS officials said that it has completed the pilot for the emergency 

department units, but has not completed the pilot for spinal cord injury 

units; ONS has not scheduled deadlines for their national 

implementation.

VHA’s delays in completing evaluations of the methodology limit its ability 

to identify and resolve VAMC implementation and administration 

problems, and thus help to ensure successful rollouts of subsequent 

phases of the methodology.

Timeliness of Implementation and Communication. The long timeline 

for implementing the pilots and national rollouts of Phases I and II, as well 

as evaluating Phase I of the staffing methodology—more than 7 years—

and for communicating methodology-related information to VAMCs may 

have hindered the ability of VAMCs to develop their staffing plans and to 

execute the initiatives contained in those plans. Under federal internal 

control standards, timeliness in the development of a program or 

implementation of a policy is needed to maintain relevance and value in 
 

Page 25 GAO-15-61 VA Nurse Staffing

managing operations and making decisions. When information regarding 

a policy or program is not provided in a timely manner, there can be a 

loss of stakeholder support, which can affect how stakeholders make 

decisions. For example, staff from some VAMCs involved in the Phase II 

pilot stated that they believed the data and reports generated from the 

methodology were only a paper exercise because they had not gotten 

any feedback from ONS on next steps. ONS officials told us they have 

communicated information on the Phase II pilot, such as the status of the 

pilot and feedback obtained from the training sessions, through their 

monthly conference calls with VAMCs; however, based on our interviews, 

this information did not reach many staff at the VAMCs in our review that 

participated in the Phase II pilot.

Furthermore, ONS officials have not adequately communicated to VAMCs 

the status of Phase III of the methodology—development of a national 

automated staffing system. According to the directive, a national 

automated staffing system was to be developed to support VAMCs in the 

implementation of the methodology. Because this automated staffing 

system has yet to be developed as per the directive, officials from two 

VAMCs told us they bought their own systems, which helped to effectively 

administer the methodology. ONS officials told us at the time the directive 

was published in 2010, Phase III implementation was an aspirational 

goal. ONS officials said they had expected VHA data system teams to 

begin the process of developing a national automated system; however, it 

was not made a department goal, and is not currently on the list of 

projects under consideration for funding. Having a variety of staffing 

systems, and thus inconsistent data variables across VAMCs, inhibits 

ONS’s ability to adequately evaluate the effectiveness of the staffing 

methodology. If an automated staffing system is eventually developed 

under Phase III, VAMCs likely will have to dismantle the staffing systems 

they have created and restructure their data analysis processes, which

likely will be time-consuming and costly. VHA’s long timelines for the 

implementation and communication of methodology-related information 

put stakeholder support of the methodology at risk and increase the 

potential for duplication of efforts.

Organizational Accountability. VHA did not define areas of 

responsibility or establish the appropriate line of reporting within the 

framework of VA’s management structure for the ongoing administration 

and oversight of the methodology. Under federal internal control

standards, an agency’s organizational structure should provide 

management with a framework for planning, directing, and controlling 

operations to achieve agency objectives; a good internal control 
 

Page 26 GAO-15-61 VA Nurse Staffing

environment requires that the agency clearly defines key areas of 

authority and responsibility. VHA does not require VAMCs to submit any 

information or reports on the implementation and ongoing administration 

of the methodology to ONS or the VISNs. Such information, if it were 

shared, may have been used to inform ONS of any systematic problems 

that necessitate changes to help ensure the continued viability of its 

methodology, as well as identify any best practices that have been 

implemented by VAMCs across the country. ONS officials told us that 

they did not require the VAMCs to submit any such documentation to 

ONS, because they made a conscious decision to not “micro-manage” 

the local process of nurse staffing.

Furthermore, VHA has not sufficiently utilized the VISN-level 

management structure in the implementation or ongoing administration of 

the methodology. While the methodology directive described a role for the 

VISNs, that role was limited to ensuring that resources are available to 

VAMCs as they try to staff their units; the directive did not mention a role 

in the implementation or ongoing administration of the actual 

methodology. As a result, VISNs have not been consistently aware of 

problems experienced by VAMCs in their region, and have not provided 

support or education. In our interviews with VISN officials representing 

each of the seven VAMCs in our review, we found that three of the VISNs 

were not substantively involved in the implementation and ongoing 

administration of the methodology. According to ONS, in many VISNs, 

discussions of staffing methodology implementation were minimal, and 

rather than VISN leadership, the nurse executives, in addition to their 

responsibilities within their individual VAMCs, had the responsibility of 

disseminating staffing methodology-related information to the VAMCs 

within the VISN.

Staff from three VISNs that were more substantially involved in the 

implementation of the methodology provided oversight for the nurse 

staffing methodology and acted as liaisons for VAMC nurse executives for 

network-level issues. One VISN official we interviewed was developing 

oversight mechanisms for VAMCs in the region, including a requirement 

for nurse executives to submit a quarterly staffing report. According to the 

official, having such a reporting requirement at the VISN level would give 

the right amount of emphasis to the process and provide support to nurse 

executives implementing the methodology in the VAMCs. The quarterly 

report could also help inform VISN officials about issues with the 

methodology. This official was developing these mechanisms 

independently of ONS, but they could be considered potential best 

practices to be shared across all VISNs.
 

Page 27 GAO-15-61 VA Nurse Staffing

ONS officials told us they thought ideas or problems across VAMCs 

related to the methodology would be shared through the VAMC nurse 

executives. They also hoped that VISN leadership would be interested in 

the methodology and, as a result, schedule VISN-level briefings to aid in 

its implementation. VHA, however, did not specify either of these roles in 

the directive or take steps to ensure that they were occurring. Moving 

forward, ONS officials said they are considering developing a VISN-level 

staff position that would specifically focus on educating VAMCs within the 

region about the methodology, and assisting them with implementing it. 

Without clearly defined roles and responsibilities within VA’s 

organizational structure, VHA’s ability to improve its oversight of the 

implementation and administration of the staffing methodology and 

provide VAMCs with additional resources to assist with problems is

compromised.

As the number of veterans requiring care in VAMCs and the complexity of 

services needed by many of these veterans increase, the need for an 

adequate and qualified nurse workforce is increasingly critical. Although 

VHA’s nurse staffing methodology was intended to provide a nationally 

standardized methodology for determining and ensuring adequate and 

qualified nurse staffing at VAMCs, its ability to do so across all 151 

VAMCs is not likely to be realized unless existing weaknesses are 

addressed. Although some improvements in nurse staffing were reported 

with the implementation of the staffing methodology, the seven VAMCs in 

our review experienced problems developing and executing the related 

staffing plans, including problems pertaining to data resources, training, 

and communication. Many of these problems persist as the seven 

VAMCs continue to administer the methodology.

We also found that VHA’s oversight of the staffing methodology is limited 

and in many cases lacks sufficient internal controls, which could diminish 

VHA’s ability to ensure an adequate and qualified nurse workforce. In 

particular, VHA has not adequately assessed the needs or preparedness 

of VAMCs to effectively implement the methodology, does not have a 

formal mechanism to ensure VAMCs’ ongoing compliance with the 

methodology, has not clearly defined a role in oversight for VISNs, and 

does not regularly communicate with VAMCs or VISNs to cull and share 

best practices system-wide. Furthermore, delays in VHA’s evaluations of 

early phases of the staffing methodology have made them too late to be 

useful in designing future phases or helping VAMCs with implementation. 

Because the implementation and administration of the nurse staffing 

methodology is ongoing, it is critical that VHA improve its oversight to 

Conclusions
 

Page 28 GAO-15-61 VA Nurse Staffing

help ensure an adequate and qualified nurse workforce across all 

VAMCs.

To help ensure adequate and qualified nurse staffing at VAMCs, we 

recommend that the Secretary of Veterans Affairs direct the Interim Under 

Secretary for Health to enhance VHA’s internal controls through the 

following five actions:

1. Provide support to all VAMCs to meet the objectives of the VHA 

directive, including:

a. training that more clearly aligns with the needs of VAMC staff and

b. a systematic process for collecting and disseminating staffing 

methodology best practices;

2. Conduct an environmental assessment of all VAMCs, including an 

assessment of their data analysis needs, to determine their 

preparedness to implement the remaining phases of the methodology, 

and use that information to help guide and provide the necessary 

support for the implementation of the remaining phases and for the 

ongoing administration of the methodology;

3. Develop and implement a documented process to assess VAMCs’ 

ongoing compliance with the staffing methodology, including 

assessing VAMCs’ execution of staffing plans and more clearly 

defining the role and responsibilities of all organizational components, 

including VISNs, in the oversight and administration of the 

methodology;

4. Complete evaluations of Phase I and Phase II and make any 

necessary changes to policies and procedures before national 

implementation of Phase II in all VAMCs; and

5. Improve the timeliness and regularity of communication with VAMCs, 

including unit-level staff, regarding the status of the various phases of 

the methodology.

We provided a draft of this report to VA for its review and comment. VA 

provided written comments, which are reprinted in appendix I. In its 

written comments, VA generally agreed with our conclusions and 

concurred with all five of the report’s recommendations. To address the 

recommendations, VA indicated that VHA will take a number of actions, 

such as developing a written document specifying its process for 

assessing ongoing compliance with the staffing methodology and 

Recommendations for 

Executive Action

Agency Comments
 

Page 29 GAO-15-61 VA Nurse Staffing

improving the timeliness and regularity of communication with VAMCs 

through face-to-face regional training sessions. VA indicated that target 

completion dates for implementing these recommendations range from 

September 2015 through September 2016. Regarding the 

recommendation that VA complete evaluations of Phase I and Phase II 

before national implementation of Phase II in all VAMCs, VA indicated 

that, by September 2016, it would complete its evaluations and determine 

what opportunities exist to modify policies and procedures, but did not 

explicitly state that the evaluations would be completed before national 

implementation. We continue to emphasize the importance of completing 

the evaluations before national implementation of Phase II in all VAMCs.

As agreed with your office, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 30 days from the 

report date. At that time, we will send copies of this report to appropriate 

congressional committees, the Secretary of Veterans Affairs, and other 

interested parties. In addition, the report will be available at no charge on 

the GAO Web site at http://www.gao.gov. 

If you or your staff have any questions about this report, please contact 

me at (202) 512-7114 or draperd@gao.gov. Contact points for our Offices 

of Congressional Relations and Public Affairs may be found on the last 

page of this report. GAO staff who made key contributions to this report 

are listed in appendix II.

Sincerely yours,

Debra A. Draper

Director, Health Care
Appendix I: Comments from the Department of 

Veterans Affairs

Page 30 GAO-15-61 VA Nurse Staffing

Appendix I: Comments from the Department 

of Veterans Affairs

Subsequent to receiving 

VA’s letter, the report 

number, GAO-14-838, 

was revised to 

GAO-15-61.
Appendix I: Comments from the Department of 

Veterans Affairs

Page 31 GAO-15-61 VA Nurse Staffing
Appendix I: Comments from the Department of 

Veterans Affairs

Page 32 GAO-15-61 VA Nurse Staffing
Appendix I: Comments from the Department of 

Veterans Affairs

Page 33 GAO-15-61 VA Nurse Staffing
Appendix I: Comments from the Department of 

Veterans Affairs

Page 34 GAO-15-61 VA Nurse Staffing
Appendix II: GAO Contact and Staff 

Acknowledgments

Page 35 GAO-15-61 VA Nurse Staffing

Debra A. Draper, (202) 512-7114 or draperd@gao.gov

In addition to the contact named above, Janina Austin, Assistant Director; 

Jennie Apter; Kathryn Black; Jacquelyn Hamilton; Kelli Jones; 

Vikki L. Porter; and Karin Wallestad made key contributions to this report.

Appendix II: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(291153)
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