VETERANS HEALTH 

ADMINISTRATION

Actions Needed to Better 

Recruit and Retain Clinical 

and Administrative Staff

Statement of Robert Goldenkoff, Director, Strategic 

Issues 

Debra A. Draper, Director, Health Care

Testimony 

Before the Subcommittee on Health, 

Committee on Veterans’ Affairs, House 

of Representatives

For Release on Delivery 

Expected at 2:00 p.m. ET

Wednesday, March 22, 2017

GAO-17-475T

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-17-475T, a testimony 

before the Subcommittee on Health, 

Committee on Veterans’ Affairs, House of 

Representatives.

March 22, 2017

VETERANS HEALTH ADMINISTRATION

Actions Needed to Better Recruit and Retain Clinical 

and Administrative Staff

What GAO Found

Challenges in recruiting and retaining both clinical and human resources (HR)

employees along with weak HR-related internal control practices are 

undermining the Department of Veterans Affairs’ (VA) Veterans Health 

Administration’s (VHA) ability to meet the health care needs of veterans.

• In July 2016, GAO found that VHA losses in its 5 clinical occupations with the 

largest staffing shortages, including physicians, registered nurses, and 

psychologists, increased from about 5,900 employees in fiscal year 2011 to 

about 7,700 in fiscal year 2015. Voluntary resignations and retirements were 

the primary drivers. VHA’s exit survey indicated that advancement issues or 

dissatisfaction with certain aspects of the work were commonly cited as the 

primary reasons people left.

• In September 2015, GAO found that VHA had multiple initiatives to recruit 

and retain its nurse workforce, but three of the four VA medical centers GAO 

reviewed faced challenges offering the initiatives due to, for example, a lack 

of sufficient HR support and competition with private sector medical facilities. 

GAO also found that VHA had not evaluated the training resources provided 

to nurse recruiters at VA medical centers. As a result, VHA is unable to 

determine to what extent its nurse recruitment and retention initiatives are 

effective and whether VHA has an adequate and qualified nurse workforce to 

meet veterans’ health care needs.

• In December 2016, GAO found that VHA’s limited HR capacity combined 

with weak internal control practices undermined VHA’s HR operations and its 

ability to improve delivery of health care services to veterans.

Long-standing, Systemic Human Capital Challenges Limit the Veterans Health 

Administration’s (VHA) Ability to Effectively Manage and Deliver Human Resources Services

VA has exempted 108 clinical and administrative occupations from the recent 

hiring freeze; however, HR occupations are not among the exempt positions. A 

prolonged freeze could further erode VHA’s capacity to provide HR services such 

as recruiting and hiring of staff who provide medical care to veterans.

View GAO-17-475T. For more information, 

contact Robert Goldenkoff at (202) 512-2757 

or goldenkoffr@gao.gov or Debra A. Draper at 

(202) 512-7114 or draperd@gao.gov.

Why GAO Did This Study

VHA’s ability to attract, hire, and retain 

top talent is critical to its mission to 

provide quality and timely care for our 

nation’s veterans. GAO’s prior work 

has found that VHA faces longstanding, systemic human capital 

challenges that limit its ability to

improve delivery of health care 

services to veterans. 

This statement is based on GAO 

reports issued between September 

2015 and December 2016 and 

discusses (1) the difficulties VHA is 

facing in recruiting and retaining staff 

for key clinical positions; and (2) VHA’s 

capacity to perform key HR functions 

essential to addressing these 

difficulties.

To conduct these studies, GAO 

reviewed VHA policies, directives, and 

other documents; analyzed VHA data; 

applied relevant federal internal control 

standards; and interviewed VA and 

VHA officials and staff in headquarters 

offices, as well as in eight VHA medical 

centers across the country.

What GAO Recommends

GAO previously made three 

recommendations to VA aimed at 

improving oversight of nurse 

recruitment and retention initiatives 

and seven recommendations directed 

at strengthening VHA’s HR capacity. 

VA concurred with GAO’s 

recommendations and is taking steps 

to implement them. GAO will monitor 

VA’s progress.
Letter

Page 1 GAO-17-475T 

Chairman Wenstrup, Ranking Member Brownley, and Members of the 

Subcommittee:

Thank you for the opportunity to participate in today’s hearing on the 

ability of the Department of Veterans Affairs’ (VA) Veterans Health 

Administration (VHA) to recruit and retain high-quality clinical and 

administrative employees.

VHA operates one of the largest health care systems in the country. As of 

fiscal year 2015, it included about 317,000 employees in Veterans 

Integrated Service Networks (VISN) overseeing 168 medical centers and 

more than 1,000 outpatient facilities.1 VHA provided care to about 6.7 

million veterans in fiscal year 2015 and the demand for its services is 

expected to grow in the coming years due, in part, to service members 

returning from the United States’ military operations in Afghanistan and 

Iraq and the growing needs of an aging veteran population. Attracting, 

hiring, and retaining top talent is critical to VHA’s mission to provide 

quality and timely care for our nation’s veterans.

According to a June 2016 evaluation by the Commission on Care, VHA 

provides health care that is, in many ways, comparable or better in clinical 

quality to that generally available in the private sector.2 Still, the care is 

inconsistent from facility to facility. Our prior work has described the 

human capital challenges facing VHA, including difficulties ensuring it has 

the appropriate clinical and administrative workforce to meet the current 

 1

VHA organizes its system of care into regional networks called VISNs. Each VISN is 

responsible for managing and overseeing VA medical centers within a defined geographic 

area and reporting to the Deputy Under Secretary for Health for Operations and 

Management within VHA’s central office. In October 2015, VHA began realigning its VISN 

network, which included merging several VISNs; when complete, this realignment will 

decrease the number of VISNs from 21 to 18. See GAO, VA Health Care: Processes to 

Evaluate, Implement, and Monitor Organizational Structure Changes Needed,

GAO-16-803 (Washington, D.C.: Sept. 27, 2016).

2

In an effort to help VA address various management weaknesses, Congress enacted the 

Veterans Access, Choice, and Accountability Act of 2014, also known as the Choice Act 

(Pub. L. No. 113-146, 128 Stat. 1754 (August 7, 2014)) (hereafter, Choice Act), as 

amended by Pub. L. No. 113-175, 128 Stat. 1901 (Sept. 26, 2014) (Department of 

Veterans Affairs Expiring Authorities Act of 2014). Among other things, the Choice Act 

established the Commission on Care. This independent entity evaluated veterans’ access 

to VA health care and assessed how veterans’ care should be organized and delivered 

during the next 20 years.

Letter
Page 2 GAO-17-475T 

and future needs of veterans.3 In February 2015, we added managing 

risks and improving veterans’ health care to our list of federal high-risk 

areas, and we continue to be concerned about VA’s ability to ensure its 

resources are being used cost-effectively and efficiently to improve 

veterans’ timely access to health care and to ensure the quality and 

safety of that care.4

Our remarks today will focus on (1) the difficulties VHA is facing in 

recruiting and retaining staff for key clinical positions, and (2) VHA’s 

capacity to perform key human resources (HR) functions needed to 

address those difficulties. As requested, we will also discuss the 

implications of the recently imposed federal hiring freeze on VHA’s 

staffing levels and ability to meet its mission.

Our bottom line is that recruitment challenges and turnover among clinical 

and HR employees are threatening VHA’s ability to meet the health care 

needs of our nation’s veterans. In addition, VHA’s weak HR-related 

internal control practices have undermined its HR operations and its 

ability to effectively support its mission. Going forward, management 

attention—beginning with the recently confirmed VA Secretary—and 

continued strong congressional oversight will be needed to address those 

challenges.

This testimony is based on our recent work.5 For those studies, among 

other things, we reviewed key documents such as VHA directives, 

policies, and guidance; analyzed VHA employment and attitudinal data; 

reviewed applicable federal internal control standards; and interviewed 

knowledgeable officials from VHA and VA in both headquarters offices, as 

well as in eight VA medical centers across the country selected for such 

attributes as facility complexity and rural versus urban location. Our 

reports provide further details on our scope and methodology.

 3

See, for example, GAO, Veterans Health Administration: Management Attention Is 

Needed to Address Systemic, Long-standing Human Capital Challenges, GAO-17-30 

(Washington, D.C.: Dec. 23, 2016); Veterans Health Administration: Personnel Data Show 

Losses Increased for Clinical Occupations from Fiscal Year 2011 through 2015, Driven by 

Voluntary Resignations and Retirements, GAO-16-666R (Washington, D.C.: July 29, 

2016); and VA Health Care: Oversight Improvements Needed for Nurse Recruitment and 

Retention Initiatives, GAO-15-794 (Washington, D.C.: Sept. 30, 2015).

4

GAO, High-Risk Series: An Update, GAO-15-290 (Washington, D.C.: Feb. 11, 2015).

5

GAO-17-30, GAO-16-666R, and GAO-15-794.
Page 3 GAO-17-475T 

The work on which this statement is based was conducted 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.

VHA’s health care mission is broad in that it provides veterans with a wide 

range of health care services. These services include primary care and 

surgery and unique specialized care, such as treatment for post‐traumatic 

stress disorder, traumatic brain injury, and readjustment counseling. VHA 

is also a leader in medical research and the largest provider of health 

care training in the United States.6 As such, each medical center hires 

employees in a wide range of clinical and administrative professions, from 

nurses and physicians to hospital administrators, police, and 

housekeepers.7 These employees are covered by three types of 

personnel systems:8

• Title 5 of the U.S. Code (Title 5): The majority of federal employees 

across the government are hired under the authority of Title 5; at 

VHA, employees under this personnel system hold positions such as 

police officers, accountants, and HR management.9

• Title 38 of the U.S. Code (Title 38): VA’s separate personnel system 

for appointing medical staff including physicians, dentists, and 

registered nurses. These appointments are made based on an 

individual’s qualifications and professional attainments in accordance 

 6

According to VHA, the department provides clinical traineeships and fellowships to more 

than 100,000 students in more than 40 professions each year. 

7

In 2015, VHA had about 54,000 registered nurses, 19,000 physicians, 1,000 dentists, 

and 81,000 other staff including, among others, medical support assistants, administrative 

staff, and police.

8

In this testimony, for ease of comprehension, we refer to the respective personnel 

systems by the terms that VA uses, which loosely correspond to the applicable 

codification in the U.S. Code which authorizes those personnel systems. 

9

Title 5 of the U.S. Code provides the authority for government organization and 

employees.

Background
Page 4 GAO-17-475T 

with standards established by VA’s Secretary.10

• Title 38-Hybrid: Employees under this personnel system hold 

positions such as respiratory, occupational, or physical therapists; 

social workers; and pharmacists. This system combines elements of 

both Title 5 (such as for performance appraisal, leave, and duty 

hours) and Title 38 (such as for appointment, advancement, and 

pay).11

Each of these personnel systems has different requirements (and 

flexibilities) related to recruitment and hiring, performance management, 

and other areas served by VHA’s HR staff.

VHA’s HR functions are decentralized. Each of VHA’s VISNs has an HR 

office that oversees the medical center-level HR offices within its network. 

In general, each VA medical center has its own HR office led by an HR 

officer. Individual HR offices are responsible for managing employee 

recruitment and staffing, employee benefits, compensation, employee 

and labor relations, and overseeing the annual employee performance 

appraisal process. Medical center HR offices also provide HR services to 

employees at VHA’s community-based living centers, rehabilitation 

centers, and outpatient centers. VHA’s HR staff are classified as either an 

HR specialist, who manages, supervises, and delivers HR products and 

services; or an HR assistant, who provides administrative support to HR 

specialists.

 10Title 38 of the U.S. Code provides the authority for veterans’ benefits and includes 

provisions which cover certain employees of the VA. 

11The appointing authority for employees under Title 38 and Title 38-Hybrid differ. Title 38 

employees are appointed under the authority of 38 U.S.C. § 7401 and Title 38-Hybrid 

employees are appointed under the authority of 38 U.S.C. §§ 7403 or 7405.
Page 5 GAO-17-475T 

In our 2016 report on VHA clinical employee retention,12 we noted that in 

2015 VHA had about 195,900 clinical employees in 45 types of 

occupations.13 To meet the growing demand for care, VHA implemented 

a number of targeted hiring initiatives, such as a mental health hiring 

initiative, which brought on about 5,300 staff nationwide from 2012 to 

2013.

Despite these hiring efforts, we and others have expressed concerns 

about VHA’s ability to ensure that it has the appropriate clinical workforce 

to meet the current and future needs of veterans, due to factors such as 

national shortages and increased competition for clinical employees in 

 12GAO-16-666R.

13The 195,000 clinical employees are employed specifically in the VHA occupations 

covered by 38 U.S.C § 7401—a specific section of law that provides VHA with the 

authority to hire clinical employees. This number does not include employees of the 

veteran canteen service, the VHA central office, health care providers who provided 

services through contracts, or medical residents or trainees that were intermittently 

employed or in non-pay status. This number does include some types of trainees, such as 

interns and post-doctoral fellows. For fiscal year 2016, VHA changed the occupations 

counted as clinical employees to not include occupations that were in the process of being 

moved to Title 38 positions, but had not completed that transition. If VHA had used this 

method to estimate clinical employees in fiscal year 2015, the number would have been 

reduced by about 4,200 employees.

Attrition in Clinical 

Positions Driven by 

Voluntary 

Resignations and 

Retirements

VHA Losses for the 5 

Occupations with the 

Largest Shortages 

Increased from Fiscal Year 

2011 through 2015
Page 6 GAO-17-475T 

hard-to-fill occupations.14 VHA officials have expressed concern with their 

hiring capabilities since 2014, when a well-publicized series of events 

called into question the ability of veterans to gain timely access to care 

from VHA.15

Our 2016 report found that for the 5 VHA clinical occupations with the 

largest staffing shortages (as identified by the VA Office of Inspector 

General in January 2015), the number of employees that VHA lost 

increased each year, from about 5,900 employees in fiscal year 2011 to 

about 7,700 in fiscal year 2015 (the 5 occupations were physicians, 

registered nurses, physician assistants, psychologists, and physical 

therapists).16 This attrition accounted for about 50 percent of VHA’s total 

losses across all clinical occupations during this period. We found a 

similar trend for all clinical occupations across VHA—losses increased 

annually during this period. (See table 1).

 14See GAO, VA Primary Care: Improved Oversight Needed to Better Ensure Timely 

Access and Efficient Delivery of Care, GAO-16-83 (Washington, D.C.: Oct. 8, 2015); VA 

Mental Health: Clearer Guidance on Access Policies and Wait-Time Data Needed, 

GAO-16-24 (Washington, D.C.: Oct. 28, 2015); VA Health Care: Oversight Improvements 

Needed for Nurse Recruitment and Retention Initiatives, GAO-15-794 (Washington, D.C.: 

Sept. 30, 2015); VA Health Care: Actions Needed to Ensure Adequate and Qualified 

Nurse Staffing, GAO-15-61 (Washington, D.C.: Oct. 16, 2014); Department of Veterans 

Affairs Office of the Inspector General, Veterans Health Administration, Audit of Physician 

Staffing Levels for Specialty Care Services, 11-01827-36 (Washington, D.C.: Dec. 27, 

2012), and Department of Veterans Affairs Office of the Inspector General, OIG 

Determination of Veterans Health Administration’s Occupational Staffing Shortages, 15-

00430-103 (Washington, D.C.: Jan. 30, 2015).

15In 2014, news outlets began reporting about extended wait times for veteran 

appointments at VHA medical facilities. Subsequent investigations by us, the VA Office of 

Inspector General (OIG), and others substantiated allegations of extended wait times and 

we found that VHA employees responsible for scheduling appointments at certain facilities 

engaged in inappropriate practices to make wait times appear more favorable.

16The VA OIG reviewed VHA data on occupational attrition rates and vacancies and 

facilities’ rankings of occupations for which they have a critical need. The VA OIG then 

weighted these rankings based on additional factors, such as the total number of facilities 

that ranked an occupation as a critical need. 
Page 7 GAO-17-475T 

Table 1: Number of Employees, Losses, and Loss Rate for the Five Shortage and All Clinical Occupations at VHA, Fiscal Year 

2011 through 2015

2011 2012 2013 2014 2015

Five shortage occupations 

Total number of employees lost 5,897 6,332 6,726 7,254 7,734

Average number of employees 80,420 81,892 85,299 89,460 94,109

Loss rate (percent) 7.3 7.7 7.9 8.1 8.2

All clinical occupations

Total number of employees lost 11,843 12,588 13,523 14,788 15,901

Average number of employees 162,809 167,344 177,315 185,962 195,914

Loss rate (percent) 7.3 7.5 7.6 8.0 8.1

Source: GAO analysis of Veterans Health Administration (VHA) personnel data. | GAO-17-475T

From fiscal year 2011 through 2015, occupation loss rates for each of the 

5 shortage occupations varied annually, though most saw an overall 

increase in losses during this period (see figure 1). Physician assistants 

consistently had the highest loss rate among the 5 shortage occupations. 

The loss rate for physician assistants increased from 9.3 to 10.9 percent 

during this period. The loss rate for physical therapists decreased from 

fiscal year 2011 to 2012 (from 8.3 to 6.4 percent), but then increased to 

8.0 percent in fiscal year 2015.
Page 8 GAO-17-475T 

Figure 1: Loss Rates for Each of the Five Shortage Occupations, Fiscal Years 2011 

through 2015

In addition to our review of VHA’s 5 shortage occupations, we also 

identified the 10 clinical occupations within VHA with the highest loss 

rates as of fiscal year 2015 (they were physician assistant, medical 

support assistant, medical supply aide and technician, optometrist, 

nursing assistant, medical records technician, health technician 

(optometry), physician, practical nurse, and medical records 

administration). The loss rates for these 10 occupations also varied 

(ranging from 5.3 percent to 10.9 percent each year from fiscal years 

2011 through 2015). We found that 2 of the 5 shortage occupations—

physician assistants and physicians—were among this group of the 10 

highest loss-rate occupations each year from fiscal year 2011 through 

2015.

Additionally, 2 other occupations—medical support assistants and nursing 

assistants—were also consistently among this group of the 10 highest 
Page 9 GAO-17-475T 

loss-rate occupations each year during this period.17 The 6 remaining 

occupations were technical positions that were generally small in overall 

number, such as medical supply aides and technicians. According to VHA 

HR officials, employees in these occupations generally do not require 

specialized education or licensing; thus, they tend to be more easily 

replaced than those in the 5 shortage occupations.

According to VHA’s personnel data, voluntary resignations and 

retirements accounted for about 90 percent of VHA’s losses from the 5 

shortage occupations annually from fiscal year 2011 through fiscal year 

2015 (see figure 2).18

Figure 2: Reasons Employees Left the Five Shortage Occupations, 5-Year Average for Fiscal Years 2011 through 2015

Notes: Resignations include employees who quit and voluntarily transferred to other government 

agencies. Retirement includes voluntary retirements and retirements due to disability or special 

situations, such as voluntary early retirement. Removals include terminations that occurred during a 

 17Medical support assistants schedule veterans’ appointments and thus play a critical role 

in ensuring veterans’ access to care and nursing assistants attend to basic patient needs 

and support other nursing staff.

18Resignations include employees who quit and voluntarily transferred to other 

government agencies. Retirement includes voluntary retirements and retirements due to 

disability or special situations, such as voluntary early retirement.

Voluntary Resignations 

and Retirements Were the 

Primary Drivers of VHA 

Losses, though Reasons 

Differed for Some 

Occupations
Page 10 GAO-17-475T 

probationary period and removals due to adverse actions. Other reasons employees may depart VHA 

include death; separations due to a reduction in force (layoffs) or an employee entering into a 

uniformed service; and expirations of nonpermanent, time-limited appointments, including trainees, 

such as interns or post-doctoral fellows.

Totals may exceed 100 percent due to rounding.

The percent of losses due to voluntary resignations from the 5 shortage 

occupations averaged 54 percent during this period, and retirements 

averaged 36 percent. However, for some occupations, voluntary 

resignations and retirements accounted for a smaller proportion of 

employee losses. For example, for physical therapists and psychologists, 

the resignation rate averaged about 44 percent and retirement averaged 

about 19 percent during the 5-year period. In these occupations, other 

reasons—primarily expiration of their appointments—averaged about 35 

and 33 percent of losses, respectively. According to VHA officials, 

expirations of appointments occur when a nonpermanent, time-limited 

appointment ends due to the expiration of the work or the funds available 

for the position. For physical therapists and psychologists, the use of 

trainees, such as interns or post-doctoral fellows, accounted for the 

majority of losses due to expirations of appointments. Removals 

accounted for a small proportion (5 percent or less, on average) of losses 

in each of these 5 occupations.19

Voluntary resignations and retirements accounted for 84 percent of VHA’s 

losses from the 10 occupations with the highest loss rates annually from 

fiscal year 2011 through fiscal year 2015. The percentage of losses due 

to voluntary resignations from these 10 occupations averaged about 55 

percent during this period and retirements averaged 30 percent.

The following summarizes the reasons for leaving VHA cited by exit 

survey respondents in the 5 shortage occupations:20

• 28 percent said opportunities to advance and 21 percent said that 

dissatisfaction with certain aspects of the work, such as concerns 

about management and obstacles to getting the work done, was the 

 19Removals include terminations that occurred during a probationary period and removals 

due to adverse actions.

20VHA’s exit survey is offered to employees who voluntarily resign or retire. The response 

rate for the 5 shortage occupations averaged about 30 percent over the past 5 years. For 

each question, some respondents may have opted not to respond or provided a response 

other than what is summarized here. Percentages are approximate.
Page 11 GAO-17-475T 

primary reason they were leaving. Other than retirement, these were 

the most commonly cited reasons.21

• 71 percent said that a single event generally did not cause them to 

think about leaving, while 28 percent reported that it did.

• 65 percent were generally satisfied with their jobs over the past year, 

while 25 percent reported that they were not.

• 50 percent indicated that they were generally satisfied with the quality 

of senior management, while 31 percent were not.

• 69 percent said that their supervisors did not try to change their minds 

about leaving, while 30 percent reported that they did.

• 73 percent felt that their immediate supervisors treated them fairly at 

work, while 15 percent reported that they did not.

• 67 percent felt that they were treated with respect at work, while 19 

percent reported they were not.

• 50 percent reported that one or more benefits would have encouraged 

them to stay, such as alternative or part-time schedules (25 percent) 

or student loan repayment or tuition assistance (12 percent), among 

others.22

VHA’s exit survey results were similar for respondents from the 10 

occupations with the highest loss rates to those in the 5 shortage 

occupations. For example, respondents from these 10 occupations also 

said that advancement issues (34 percent) and dissatisfaction with certain 

aspects of the work (20 percent) were among their primary reasons for 

leaving. Additionally, the majority said that a single event generally did not 

cause them to think about leaving (71 percent) and about 47 percent 

reported that one or more benefits would have encouraged them to stay, 

such as an alternative or part-time schedule (22 percent) or student loan 

repayment or tuition assistance (12 percent), among others.

 21We grouped like responses together to create these categories. For example, we 

aggregated the number of responses for ‘“advancement—lack of opportunity within VHA”

and “advancement—unique opportunity elsewhere” into a single category, “advancement.”

22Exit survey respondents were instructed to either select all benefits that may have 

encouraged them to stay or to select “no benefits would have helped.” Of the 9,623 

employees from the 5 shortage occupations who completed an exit survey from fiscal 

years 2011 through 2015, about 60 percent (5,830) reported that no benefits would have 

helped encourage them to stay. Because respondents who did not select “no benefit 

would have helped” could select more than one response, the responses by the different 

benefit categories are not mutually exclusive.
Page 12 GAO-17-475T 

We and others have highlighted the need for an adequate and qualified 

nurse workforce to provide quality and timely care to veterans. As we 

have previously reported, it is particularly difficult to recruit and retain 

nurses with advanced professional skills, knowledge, and experience, 

which is critical given veterans’ needs for more complex specialized 

services.

In our 2015 report—which included staff interviews at four medical 

centers—we found that VHA had multiple system-wide initiatives to recruit 

and retain its nurse workforce, but three of the four VA medical centers in 

our review faced challenges offering them.23 VHA identified a number of 

key initiatives it offered to help medical centers recruit and retain nurses, 

which focused primarily on providing (1) education and training, and (2) 

financial benefits and incentives. VA medical centers generally had 

discretion in offering these initiatives.

The four medical centers in our review varied in the number of initiatives 

they offered, and three of these medical centers developed local 

recruitment and retention initiatives in addition to those offered by VHA. 

While three of the four medical centers reported VHA’s initiatives 

improved their ability to recruit and retain nurses, they also reported 

challenges. The challenges included insufficient HR support for medical 

centers, competition with private sector medical facilities, a reduced pool 

of advanced training nurses in rural locations, and employee 

dissatisfaction.

In our 2015 report we also found that VHA provided limited oversight of its 

key system-wide nurse recruitment and retention initiatives. Specifically, 

VHA conducted limited monitoring of medical centers’ compliance with its 

initiatives. For example, in the past, VHA conducted site visits in response 

to a medical center reporting difficulty with implementation of one of its 

initiatives and to assess compliance with program policies, but VHA 

stopped conducting these visits. Consistent with federal internal control 

standards, monitoring should be ongoing and should identify performance 

gaps in a policy or procedure. With limited monitoring, VHA lacks 

assurance that its medical centers are complying with its nurse 

recruitment and retention initiatives, and that any problems are identified 

and resolved in a timely and appropriate manner.

 23GAO-15-794.

Oversight Improvements 

Needed for Nurse 

Recruitment and Retention 

Initiatives
Page 13 GAO-17-475T 

In addition, VHA has not evaluated the training resources provided to 

nurse recruiters at VA medical centers or the overall effectiveness of the 

initiatives in meeting its nurse recruitment and retention goals, or whether 

any changes are needed. Consistent with federal internal control 

standards, measuring performance tracks progress toward program goals 

and objectives and provides important information to make management 

decisions and resolve any problems or program weaknesses. For 

example, we found that VHA did not know whether medical centers had 

sufficient training to support nurse recruitment and retention initiatives. In 

particular, VHA did not provide face-to-face training specifically for nurse 

recruiters, but regular training was available to those assigned to a HR 

office as part of training available to all HR staff.

Representatives from a national nursing organization reported that clinical 

nurse recruiters at VA medical centers often feel less prepared for the 

position than those assigned to HR offices, but VHA has not evaluated 

this disparity or its effects. Without evaluations of its collective systemwide initiatives, VHA is unable to determine how effectively the initiatives 

are meeting VHA policies and the provisions of the Veterans Access, 

Choice, and Accountability Act. Nor can VHA ultimately determine 

whether it has an adequate and qualified nurse workforce at its medical 

centers that is sufficient to meet veterans’ health care needs.

On January 23, 2017, the administration issued an across-the-board 90-

day hiring freeze applicable to federal civilian employees in the executive 

branch.24 As of January 22, 2017, no existing vacant positions could be 

filled and no new positions could be created. The memorandum stated 

that the head of any executive department or agency may exempt from 

the hiring freeze positions that it deems necessary to meet national 

security or public safety responsibilities.

In accordance with the memorandum, as of mid-March, VA has exempted 

108 VHA occupations from the freeze because they were necessary to 

meet VA’s public safety responsibilities. They included the 5 shortage 

 24The White House, Memorandum of January 23, 2017 on the Federal Civilian Employee 

Hiring Freeze, Daily Comp. Pres. Docs. 2017 No. 00062, p.1, 82 Fed. Reg. 8493 (Jan. 25, 

2017). Within 90 days of the date of the memorandum, the Director of the Office of 

Management and Budget, in consultation with the Director of the Office of Personnel 

Management, are to recommend a long-term plan to reduce the size of the of the federal 

workforce through attrition. 

VA Has Exempted 108

VHA Occupations from the 

Hiring Freeze
Page 14 GAO-17-475T 

occupations noted earlier (physician, registered nurse, physician 

assistant, psychologist, and physical therapist), as well as, for example, 

pharmacist, medical records technician, chaplain, and security guard.

The recruitment and retention challenges VHA is experiencing with its 

clinical workforce are due, in part, to VHA’s limited HR capacity, including 

(1) attrition among its HR employees and unmet staffing targets, and (2) 

weak HR-related internal control functions. Until VHA strengthens its HR 

capacity, it will not be positioned to effectively support its mission.

In our December 2016 report on VHA’s HR capacity, we found that 

attrition of HR staff grew from 7.8 percent (312 employees) at the end of 

fiscal year 2013 to 12.1 percent (536 employees) at the end of fiscal year 

2015.25 In comparison, attrition for all VHA employees was generally 

consistent during the same period, from 8.4 percent in fiscal year 2013 to 

9 percent at the end of fiscal year 2015 (see figure 3).

 25GAO-17-30.

VHA Needs to 

Strengthen Its HR 

Capacity to Better 

Serve Veterans

Attrition of VHA’s HR Staff 

and Unmet Staffing 

Targets Undermine VHA’s 

HR Capacity
Page 15 GAO-17-475T 

Figure 3: Attrition for Veterans Health Administration Human Resources Staff Has 

Increased Since Fiscal Year 2013

Note: Veterans Health Administration (VHA) data include permanent, temporary, full-time, and parttime employees in pay status. Data exclude medical residents and intermittent employees. Between 

fiscal years 2011 and 2015, the average total N=4,000 VHA human resources (HR) staff, and total 

average N=295,912 VHA employees in all occupations. Government-wide data include permanent, 

temporary, full-time, and part-time executive branch HR staff in pay status. Data do not cover the U.S. 

Postal Service, intelligence agencies, or judicial branch employees. Between fiscal years 2011 and 

2015, the average total N=39,917 HR staff.

Most of the turnover is due to transfers to other federal agencies, followed 

by resignations and voluntary retirement. In fiscal year 2015 HR 

specialists transferred to other federal agencies at a rate six times higher 

than all VHA employees.

We found that between fiscal years 2011 and 2015, the majority of 

medical centers fell short of VHA’s HR staffing goals, even with new hires 

to partially offset annual attrition (see figure 4). VHA established a target 

HR staffing ratio of 1 HR staff to 60 VHA employees to manage 

consistent, accurate, and timely delivery of HR services. However, in 
Page 16 GAO-17-475T 

fiscal year 2015 about 83 percent (116 of 139) of medical centers did not 

meet this target.26 Of these 116 medical centers, about half had a staffing 

ratio of 1 HR staff to 80 VHA employees or worse. In other words, each 

HR employee at those medical centers was serving 20 to 80 more 

employees than recommended by VHA’s target staffing ratio. According 

to the HR staff we interviewed, this has reduced HR employees’ ability to 

keep pace with work demands and has led to such issues as delays in 

the hiring process, problems with addressing important clinical hiring 

initiatives, and an increased risk of personnel processing and coding 

errors.

Figure 4: Few Department of Veterans Affairs (VA) Medical Centers Have Met the Target Ratio of 1 Human Resources Staff to 

60 Employees, Fiscal Years 2011-2015

Note: N= 139 VA medical centers. Ratios reflect all Veterans Health Administration employees on 

board in both pay and non-pay status.

In addition, VHA’s All Employee Survey results from 2015 indicate that 

HR staff reported feeling more burned out and less satisfied with their 

 26Although VHA has 168 individual medical centers, it reports data at the “parent” medical 

center level. There are 140 parent medical centers. However, one medical center did not 

have sufficient data to be included in our analysis.
Page 17 GAO-17-475T 

amount of work compared to the VHA-wide average in these areas.27

Specifically, about 48.1 percent of those who identified as HR specialists 

reported being satisfied with the amount of work compared to about 62.5 

percent of employees VHA-wide.

As noted above, as of mid-March 2017, VA has exempted 108

occupations from the current hiring freeze because VHA maintained they 

were necessary to meet VA’s public safety responsibilities. However, the 

broad list of exemptions, ranging from physicians to housekeeping staff, 

did not include HR specialists, even though VHA ranked HR management 

as third on a list of mission critical occupations in its 2016 Workforce and 

Succession Strategic Plan.28 Given the attrition rate that we identified 

among HR specialists and the HR staffing shortfalls at many VA medical 

centers, a prolonged hiring freeze could further erode VHA’s capacity to 

provide needed HR functions.

In our 1982 report on hiring freezes under prior administrations, we 

concluded that government-wide freezes are not an effective means of 

controlling federal employment because they ignored individual agencies’

missions, workload, and staffing requirements and could thus disrupt 

agency operations. We noted that improved workforce planning, rather 

than arbitrary across-the-board hiring freezes, is a more effective way to 

ensure that the level of personnel resources is consistent with program 

requirements.29

In our December 2016 report, we noted that weaknesses in HR-related 

internal control functions reduce VHA’s ability to deliver HR services. 

Federal standards for internal controls require agencies to (1) establish 

an organizational structure that includes appropriate lines of 

accountability and authority, (2) evaluate the competencies of HR staff 

and ensure they have been appropriately trained to do their jobs, and (3) 

 27VHA’s National Center for Organization Development develops and administers the All 

Employee Survey, an annual census survey that is intended to gauge employees’

experiences at VA. Among other things, the survey captures the extent to which 

employees feel burned out on their job on a scale from 0 to 6, with 0 meaning never, and 

6 meaning every day.

28Veterans Health Administration, VHA Workforce and Succession Strategic Plan, 2016

(2016).

29GAO, Recent Government-Wide Hiring Freezes Prove Ineffective In Managing Federal 

Employment, FPCD-82-21 (Washington D.C.: March 10, 1982).

Weak Internal Control 

Practices Adversely Affect 

Key HR Functions
Page 18 GAO-17-475T 

design information systems to meet operational needs and use valid and 

reliable data to support the agency’s mission.30 We found shortfalls in 

each of these practices at VHA. Moreover, as shown in figure 5, the twin 

challenges of weak internal controls and limited HR capacity have had a 

compounding effect, creating an environment that undermines VHA’s HR 

operations and impedes its ability to improve delivery of health care 

services to veterans.

Figure 5: Long-standing, Systemic Human Capital Challenges Limit the Veterans Health Administration’s (VHA) Ability to 

Effectively Manage and Deliver Human Resources Services

 30GAO, Standards for Internal Control in the Federal Government, GAO-14-704G 

(Washington, D.C.: September 2014). 
Page 19 GAO-17-475T 

We reported that key areas for improvement include the following: 

Strengthen oversight of HR offices. VHA is structured so that the 

central HR offices at VA and VHA have inadequate oversight of medical 

center HR offices in order to hold them accountable. This lack of 

oversight contributes to issues with VHA’s capacity to provide HR 

functions and limits VHA’s ability to monitor HR improvement efforts and 

ensure that HR offices apply policies consistently. Our Standards for 

Internal Control requires an agency’s organizational structure to provide a 

framework for planning, directing, and controlling operations to achieve 

agency objectives.31 VA and VHA’s central HR offices are primarily 

responsible for developing HR policy, guidance, and training, while VISN 

and medical center HR offices are responsible for implementing HR 

policies and managing daily HR operations. However, as shown in figure 

6, there is not a direct line of authority between the VISN and medical 

center HR offices and the central HR offices in VA and VHA.

 31GAO-14-704G. 
Page 20 GAO-17-475T 

Figure 6: Department of Veterans Affairs’ and Veterans Health Administration’s Human Resources Organizations and Lines of 

Authority

Note: In addition to the Deputy and Assistant Deputy Under Secretary positions shown in this figure, 

the following positions also report to the Under Secretary for Health: Chief of Staff, Chief Officer of 

Readjustment Counseling Service, Executive Director of Research Oversight, and Chief of Nursing.

According to the director of VA’s Office of Oversight and Effectiveness, 

the department’s organizational structure enables medical center 

directors to effectively respond to the needs of veterans and other clients 

using available resources. However, VA and VHA HR officials with whom 

we spoke said that the organizational structure limits the department’s 
Page 21 GAO-17-475T 

ability to oversee individual HR offices, improve hiring processes, train 

HR staff, and implement consistent classification processes.

Identify and address critical competency gaps. Federal standards for 

internal control require an agency to ensure that its workforce is 

competent to carry out assigned responsibilities in order to achieve the 

agency’s mission. Additionally, our prior work has identified principles for 

human capital planning that recommend an agency identify skills gaps 

within its workforce, implement strategies to address these gaps, and 

monitor its progress.32 However, VA and VHA’s model for assessing the 

competencies of HR staff is incomplete and fragmented. As one example, 

VHA’s internal human capital reviews have consistently found that HR 

staff competencies are not being assessed and HR staff lack the 

necessary skills to deliver high-quality services. Further, although both VA 

and VHA provide a variety of training programs, HR staff with whom we 

spoke described barriers to completing them, including a lack of time to 

take training and train new hires, limited course offerings, and lengthy 

waiting lists for courses.

Address long-standing information technology challenges. To have 

an effective internal control system, agencies should design their 

information systems to obtain and process information to meet 

operational needs.33 Likewise, our prior work on strategic human capital 

management notes that high-performing organizations leverage modern 

technology to automate and streamline personnel processes to meet 

customer needs.34 Data that are valid and reliable are critical to assessing 

an agency’s workforce requirements. However, VA faces long-standing, 

significant information technology (IT) challenges that include outdated, 

inefficient IT systems and fragmented systems that are not 

interoperable.35 With respect to HR IT systems, in May 2016 we reported 

that VA’s department-wide HR system, Personnel and Accounting 

 32GAO, Human Capital: Key Principles for Effective Strategic Workforce Planning, 

GAO-04-39 (Washington, D.C.: Dec. 11, 2003).

33GAO-14-704G.

34GAO, A Model of Strategic Human Capital Management, GAO-02-373SP (Washington, 

D.C.: Mar. 15, 2002).

35GAO-15-290. Interoperability is the ability of two or more IT systems or components to 

exchange information and to use the information that has been exchanged.
Page 22 GAO-17-475T 

Integrated Data (PAID), is one of the federal government’s oldest IT 

systems and that VA is in the process of replacing it.36

As part of efforts to replace PAID, VA is developing and implementing an 

enterprise-wide, modern web-based system called HR Smart.37 VA 

officials told us that HR Smart will be implemented in phases across the 

department. According to agency documentation, HR Smart will enable 

HR staff to better manage information on employee benefits and 

compensation; electronically initiate, route, and receive approval for 

personnel actions; monitor workforce planning efforts and vacancies by 

medical center and across the department; and generate reports and 

queries.

As VA continues to develop and implement its new HR system, VHA HR 

staff must rely on several separate enterprise-wide IT systems to handle 

core HR activities such as managing personnel actions and hiring and 

recruiting efforts. HR staff with whom we spoke stated that the amount of 

time they spent entering duplicate data into four or more noninteroperable systems and reconciling data between the systems has 

made their jobs more difficult and has taken time away from performing 

other critical HR duties. According to VA officials, once HR Smart is fully 

implemented, it should reduce HR offices’ reliance on multiple HR 

systems and local tools and help to streamline HR processes. For 

example, according to program documentation, VA plans to implement 

functionality in HR Smart that will allow managers to initiate, review, and 

approve basic personnel actions independently. In these cases, HR staff 

would no longer be responsible for data entry.

In conclusion, VHA’s challenges recruiting and retaining clinical and HR 

employees are making it difficult for VHA to meet the health care needs of 

our nation’s veterans. The prior reports on which this testimony is based 

made three recommendations to VA aimed at improving the oversight of 

nurse recruitment and retention initiatives and seven recommendations 

directed at strengthening VHA’s HR capacity. Key recommendations 

included developing a process to help monitor medical centers’

compliance with key nurse recruitment and retention initiatives and 

 36GAO, Information Technology: Federal Agencies Need to Address Aging Legacy 

Systems, GAO-16-468 (Washington, D.C.: May 25, 2016). 

37Note that we did not undertake a comprehensive assessment of HR Smart’s system 

development and implementation as part of this review.
Page 23 GAO-17-475T 

establishing clear lines of authority between VA and VHA’s central 

personnel offices and those offices in individual medical centers to hold 

them accountable for improving HR functions. VA concurred with our 

recommendations and said they are taking steps to implement them. We 

will monitor VA’s progress in addressing our recommendations and report 

the results of those efforts to Congress.

Chairman Wenstrup, Ranking Member Brownley, and Members of the 

Subcommittee, this completes our prepared statement. We would be 

pleased to respond to any questions that you may have. 

If you have any questions on matters discussed in this statement, please 

contact Robert Goldenkoff at (202) 512-2757 or by e-mail at 

goldenkoffr@gao.gov, or Debra Draper at (202) 512-7114 or by email at 

draperd@gao.gov. Contact points for our Offices of Congressional 

Relations and Public Affairs may be found on the last page of this 

statement. Other key contributors to this testimony include Lori Achman, 

Assistant Director, Janina Austin, Assistant Director, Tom Gilbert, 

Assistant Director, Heather Collins, Analyst-in-Charge, Dewi Djunaidy, 

Sarah Harvey, Meredith Moles, Steven Putansu, Susan Sato, and 

Jennifer Stratton.

GAO Contacts and 

Staff 

Acknowledgments

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