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39–464 2008

HEALTHCARE PROFESSIONALS— 

RECRUITMENT AND RETENTION 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED TENTH CONGRESS 

FIRST SESSION 

OCTOBER 18, 2007 

Serial No. 110–55 

Printed for the use of the Committee on Veterans’ Affairs 

( 


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COMMITTEE ON VETERANS’ AFFAIRS 

BOB FILNER, California, Chairman 

CORRINE BROWN, Florida 

VIC SNYDER, Arkansas 

MICHAEL H. MICHAUD, Maine 

STEPHANIE HERSETH SANDLIN, South 

Dakota 

HARRY E. MITCHELL, Arizona 

JOHN J. HALL, New York 

PHIL HARE, Illinois 

MICHAEL F. DOYLE, Pennsylvania 

SHELLEY BERKLEY, Nevada 

JOHN T. SALAZAR, Colorado 

CIRO D. RODRIGUEZ, Texas 

JOE DONNELLY, Indiana 

JERRY MCNERNEY, California 

ZACHARY T. SPACE, Ohio 

TIMOTHY J. WALZ, Minnesota 

STEVE BUYER, Indiana, Ranking 

CLIFF STEARNS, Florida 

JERRY MORAN, Kansas 

RICHARD H. BAKER, Louisiana 

HENRY E. BROWN, JR., South Carolina 

JEFF MILLER, Florida 

JOHN BOOZMAN, Arkansas 

GINNY BROWN-WAITE, Florida 

MICHAEL R. TURNER, Ohio 

BRIAN P. BILBRAY, California 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida 

VERN BUCHANAN, Florida 

MALCOM A. SHORTER, Staff Director 

SUBCOMMITTEE ON HEALTH 

MICHAEL H. MICHAUD, Maine, Chairman 

CORRINE BROWN, Florida 

VIC SNYDER, Arkansas 

PHIL HARE, Illinois 

MICHAEL F. DOYLE, Pennsylvania 

SHELLEY BERKLEY, Nevada 

JOHN T. SALAZAR, Colorado 

JEFF MILLER, Florida, Ranking 

CLIFF STEARNS, Florida 

JERRY MORAN, Kansas 

RICHARD H. BAKER, Louisiana 

HENRY E. BROWN, JR., South Carolina 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Veterans’ Affairs are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process of converting 

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 


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C O N T E N T S 

October 18, 2007 

Page 

Healthcare Professionals—Recruitment and Retention ....................................... 1 

OPENING STATEMENTS 

Chairman Michael Michaud ................................................................................... 1 

Prepared statement of Chairman Michaud .................................................... 35 

Hon. Shelley Berkley ............................................................................................... 9 

WITNESSES 

U.S. Department of Veterans Affairs, William J. Feeley, MSW, FACHE, Deputy Under Secretary for Health for Operations and Management, Veterans 

Health Administration ......................................................................................... 24 

Prepared statement of Mr. Feeley ................................................................... 59 

American Federation of Government Employees, AFL–CIO, J. David Cox, 

R.N., National Secretary-Treasurer .................................................................... 18 

Prepared statement of Mr. Cox ....................................................................... 56 

American Legion, Joseph L. Wilson, Assistant Director for Health Policy, 

Veterans Affairs and Rehabilitation Commission ............................................. 14 

Prepared statement of Mr. Wilson .................................................................. 49 

American Physical Therapy Association, Jeffrey L. Newman, PT, Member, 

and Chief, Physical Therapy Department, Minneapolis Veterans Affairs 

Medical Center, Minneapolis, MN ...................................................................... 2 

Prepared statement of Mr. Newman .............................................................. 35 

Association of American Medical Colleges, Richard D. Krugman, M.D., Chair, 

Executive Council, and Dean and Vice Chancellor for Health Affairs, University of Colorado School of Medicine ............................................................... 4 

Prepared statement of Dr. Krugman .............................................................. 38 

CACI Strategic Communications, Jim Bender, Communications Services Manager ........................................................................................................................ 7 

Prepared statement of Mr. Bender ................................................................. 47 

Disabled American Veterans, Joy J. Ilem, Assistant National Legislative Director ..................................................................................................................... 16 

Prepared statement of Ms. Ilem ...................................................................... 51 

National Board for Certified Counselors, Inc. and Affiliates, Kristi McCaskill, 

M.Ed., NCC, NCSC, Counseling Advocacy Coordinator ................................... 6 

Prepared statement of Ms. McCaskill ............................................................. 43 

SUBMISSIONS FOR THE RECORD 

American Academy of Physician Assistants, statement ....................................... 63 

Miller, Hon. Jeff, Ranking Republican Member, and a Representative in Congress from the State of Florida, statement ........................................................ 65 

Nurses Organization of Veterans Affairs, statement ............................................ 65 

Salazar, Hon. John T., a Representative in Congress from the State of Colorado, statement .................................................................................................... 67 

MATERIAL SUBMITTED FOR THE RECORD 

‘‘The Best Places to Work in the Federal Government—2007 Rankings,’’ Veterans Health Administration Ranking Index Score, from the Partnership 

for Public Service and American University’s Institute for the Study of 

Public Policy Implementation ............................................................................. 68 


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iv 

Break down of the healthcare professionals hired within the last 9 months 

(particularly licensed professional counselors) (Monthly Distinct Employee 

for Non-Med Resident, GAIN, VHA (Occupation Name) January–September 

2007), requested by Chairman Michaud during the hearing ........................... 70 

Post Hearing Questions and Responses for the Record: 

Hon. Michael Michaud, Chairman, Subcommittee on Health, Committee 

on Veterans’ Affairs, to Jeffrey L. Newman PT, Chief Physical Therapy 

Department, Minneapolis VA Medical Center, and Member, American 

Physical Therapy Association, letter dated October 19, 2007, and response letter dated December 3, 2007 ......................................................... 73 

Hon. Michael Michaud, Chairman, Subcommittee on Health, Committee 

on Veterans’ Affairs, to Richard D. Krugman, M.D., Dean, University 

of Colorado Health Science Center School of Medicine, letter dated 

October 19, 2007, and response letter dated December 4, 2007 ............... 75 

Hon. Michael Michaud, Chairman, Subcommittee on Health, Committee 

on Veterans’ Affairs, to Jim Bender, Communications Services Manager, CACI Strategic Communications, letter October 19, 2007, and 

response from Deborah Lee, Project Manager, CACI, Inc., Strategic 

Communications Division, dated December 4, 2007 .................................. 78 

Hon. Michael Michaud, Chairman, Subcommittee on Health, Committee 

on Veterans’ Affairs, to Joseph L. Wilson, Assistant Director for Health 

Policy, Veterans Affairs and Rehabilitation Commission, American Legion, letter dated October 19, 2007, and response from Steve Robertson, 

Director, National Legislative Commission, American Legion, letter 

dated December 4, 2007 ............................................................................... 81 

Hon. Michael Michaud, Chairman, Subcommittee on Health, Committee 

on Veterans’ Affairs, to Joy J. Ilem, Assistant National Legislative 

Director, Disabled American Veterans, letter dated October 19, 2007 .... 83 

Hon. Michael Michaud, Chairman, Subcommittee on Health, Committee 

on Veterans’ Affairs, to J. David Cox, National Secretary-Treasurer, 

American Federation of Government Employees, AFL–CIO, letter dated 

October 19, 2007 ........................................................................................... 86 

Hon. Michael Michaud, Chairman, Subcommittee on Health, Committee 

on Veterans’ Affairs, to Hon. Gordon H. Mansfield, Acting Secretary, 

U.S. Department of Veterans Affairs, letter dated October 19, 2007 ....... 89 

Hon. Jeff Miller, Ranking Republican Member, Subcommittee on Health, 

Committee on Veterans’ Affairs, to Hon. Gordon H. Mansfield, Acting 

Secretary, U.S. Department of Veterans Affairs, letter dated October 

31, 2007 .......................................................................................................... 95 


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HEALTHCARE PROFESSIONALS—

RECRUITMENT AND RETENTION 

THURSDAY, OCTOBER 18, 2007 

U.S. HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON HEALTH, COMMITTEE ON VETERANS’ AFFAIRS, Washington, DC. 

The Subcommittee met, pursuant to notice, at 10:00 a.m., in 

Room 334, Cannon House Office Building, Hon. Michael Michaud 

[Chairman of the Subcommittee] presiding. 

Present: Representatives Michaud, Brown of Florida, and Berkley. 

OPENING STATEMENT OF CHAIRMAN MICHAUD 

Mr. MICHAUD. I would like to call the Subcommittee to order. 

Members will be here throughout the hearing. We will actually be 

having votes, as well as a journal vote, early, so we will try to start 

on time and recess if we are not done at that time. 

Today, the Subcommittee hearing will be on issues regarding recruitment and retention of healthcare professionals within the Veterans Health Administration (VHA) system. Healthcare professionals are VHA’s most important resources in delivering highquality healthcare for our Nation’s veterans. 

So without further ado, I request unanimous consent to have my 

full statement submitted for the record and any other Members 

when they return or come. 

[The prepared statement of Chairman Michaud appears on p. 

35.] 

Mr. MICHAUD. On the first panel today we have Jeffrey Newman, 

Chief Physical Therapist from the Minneapolis Veterans Affairs 

(VA) Medical Center, who is here on behalf of the American Physical Therapy Association (APTA). 

I want to thank you very much, Mr. Newman. It is great to see 

you. Once again, I did have a great opportunity to visit Minneapolis VA facility and was extremely impressed. 

Also on panel one is Dr. Krugman, Chair of the Executive Council for the Association of American Medical Colleges (AAMC), and 

Dean of the University of Colorado School of Medicine. I would like 

to welcome you, Doctor. 

And also Kristi McCaskill, Counseling Advocacy Coordinator for 

the National Board for Certified Counselors (NBCC), Inc. and Affiliates. I welcome you as well. 

And fourth on panel one is Jim Bender, Communications Services Manager for CACI Strategic Communications. I would also like 


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to welcome you, Jim, today and look forward to all of your testimony. 

And we will start off with Mr. Newman and work down the table. 

So, Mr. Newman. 

STATEMENTS OF JEFFREY L. NEWMAN, PT, MEMBER, AMERICAN PHYSICAL THERAPY ASSOCIATION, AND CHIEF, PHYSICAL THERAPY DEPARTMENT, MINNEAPOLIS VETERANS AFFAIRS MEDICAL CENTER, MINNEAPOLIS, MN; RICHARD D. 

KRUGMAN, M.D., CHAIR, EXECUTIVE COUNCIL, ASSOCIATION 

OF AMERICAN MEDICAL COLLEGES, AND DEAN AND VICE 

CHANCELLOR FOR HEALTH AFFAIRS, UNIVERSITY OF COLORADO SCHOOL OF MEDICINE; KRISTI MCCASKILL, M.ED., 

NCC, NCSC, COUNSELING ADVOCACY COORDINATOR, NATIONAL BOARD FOR CERTIFIED COUNSELORS, INC. AND AFFILIATES; AND JIM BENDER, COMMUNICATIONS SERVICES 

MANAGER, CACI STRATEGIC COMMUNICATIONS 

STATEMENT OF JEFFREY L. NEWMAN 

Mr. NEWMAN. Mr. Chairman, Members of the Subcommittee, 

thank you for the opportunity to testify on the recruitment and retention of healthcare professionals who work in the U.S. Department of Veterans Affairs (VA). 

I have practiced as a physical therapist in the VA system for 

more than 30 years and for 20 of those years, I have served as 

Chief of Physical Therapy at the Minneapolis VA Medical Center 

in Minneapolis, Minnesota. 

I come before you today as a member of the American Physical 

Therapy Association. In my experience, I have seen the physical 

therapy profession advance to meet the changing rehabilitation 

needs of our patients. 

The primary challenge to meet the rehabilitation needs of veterans is the recruitment and retention of physical therapists. This 

challenge is compounded by two trends that increase the need for 

physical therapists, chronic conditions associated with an aging 

veteran population and the complex impairments associated with 

returning veterans from the conflicts in Afghanistan and Iraq. 

In my remarks today, I will discuss the increased need for physical therapists in the VA, highlight current challenges with recruitment and retention, and make two specific recommendations to 

help meet these challenges and ensure our Nation’s veterans the 

accessibility and availability to the physical therapist services they 

need. 

These recommendations include the immediate approval and implementation of pending qualification standards and enhancements 

to current VA scholarship programs. 

With more than 1,000 physical therapists on staff, the VA is one 

of the largest employers of physical therapists nationwide. Physical 

therapists have a long history of providing care to our Nation’s veterans. In fact, our professional roots started by rehabilitating soldiers as they began returning from World War I. 

Today physical therapists in the VA render evidence-based, culturally sensitive care and have been recognized leaders in clinical 

research and education. The need for high-quality rehabilitation 


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provided by physical therapists has never been greater with the 

dual challenges of caring for the chronic diseases faced by aging 

veterans and the multifaceted profile of many of today’s wounded 

warriors. 

According to the VA, 9.2 million veterans are age 65 or older. 

Among this aging veteran population, many have diabetes. Physical therapists assist patients in regaining mobility and function 

lost due to diabetes and its complications as well as its prevention 

strategies. 

Many of our Nation’s recent veterans are facing unique injuries 

that require complex rehabilitation including spinal cord injury, 

amputee rehabilitation, and Traumatic Brain Injury (TBI). 

Physical therapists are a key part of the VA’s polytrauma rehabilitation centers caring for TBI patients in Tampa, Palo Alto, Richmond, and at my facility in Minneapolis. 

Minneapolis has had a TBI program with dedicated staff and TBI 

rehabilitation for over 10 years. We have physical therapists on 

staff who have received specialist certification in neurological, geriatric, and orthopedic physical therapy. 

My specific clinical background is in amputation rehabilitation. 

I have had the honor of caring for a generation of veterans and 

have been able to see the growing need for physical therapist services through the years. 

The number one obstacle to both the recruitment and the retention of physical therapists to serve in the VA is the severely outdated qualification standards that currently govern the salary and 

advancement opportunities for physical therapists employed by the 

VA. 

These standards have not been updated for nearly 25 years. For 

example, the current minimal requirement to become a physical 

therapist is to graduate with a Master’s Degree. Approximately 80 

percent of programs now are graduating at the doctoral level and 

pass a licensure test. 

The current VA qualification standards have a minimal requirement of obtaining a Bachelor’s Degree but do not recognize the 

Doctor of Physical Therapy Degree or DPT Degree programs. 

The need for immediate approval of these revised standards is 

due to several factors. First, the demand for physical therapy services is on the rise. 

Second, the increased need for services provided by qualified 

physical therapists in the VA due to aging veterans and meeting 

the complex needs of our soldiers returning from Iraq and Afghanistan. 

Third, the outdated qualification standards also limit the ability 

of a physical therapist to advance within the VA system once they 

have joined. The current standards do not recognize physical therapists that achieve specialty certification such as those needed in 

the polytrauma centers. 

Fourth, it has been at least 61⁄2 years since the VA first recognized that the standards needed to be updated, yet no revisions 

have been implemented. 

In addition to the immediate approval and implementation of revised qualification standards, I recommend enhancements to the 

current VA scholarship programs to help in both recruitment and 


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retention. Many new graduates are concerned with a high amount 

of student loan debt. 

I had the opportunity to serve on the Committee to review scholarship program applicants in the early nineties when the VA had 

a very successful scholarship program to attract new graduates. 

That scholarship program provided an incentive to serve right out 

of school, whereas the new program is poorly advertised and cumbersome. We are in need of better incentives to pull more graduates into the VA system. 

In closing, APTA recommends the immediate approval and implementation of the qualification standards for physical therapists 

and the investigation of options to enhance current programs offering scholarships, loan support, and debt retirement for physical 

therapists choosing to serve in the VA. This will assist in both the 

recruitment and retention of physical therapists to meet the needs 

of our veterans of today and tomorrow. 

Thank you, Mr. Chairman, for this opportunity. I would be happy 

to answer any questions from you or other Committee Members at 

this time. 

[The prepared statement of Mr. Newman appears on p. 35.] 

Mr. MICHAUD. Thank you very much, Mr. Newman. 

Doctor. 

STATEMENT OF RICHARD D. KRUGMAN, M.D. 

Dr. KRUGMAN. Good morning. And thank you, Mr. Chairman, for 

the opportunity to testify this morning on the retention and recruitment of health professionals at the VA. 

My name is Richard Krugman. I am Dean of the University of 

Colorado School of Medicine and Vice Chancellor for Health Affairs 

there. We are affiliated with the Denver VA Medical Center and 

the Rocky Mountain Veteran Integrated Services Network (VISN) 

Network 19. 

I am also Chair of the Association of American Medical Colleges 

and member of the VA Dean’s Liaison Committee of the AAMC 

which is a not-for-profit representing 126 accredited medical 

schools, 107 of which are affiliated with VAs and nearly 400 major 

teaching hospitals and health systems including 68 medical centers. 

We would like to thank the Committee for your support of the 

VA appropriation in 2008. Your leadership resulted in the House’s 

passage of $36.6 billion for VA medical care and $480 million for 

VA medical and prosthetics research. This funding is crucial to the 

continued success of the primary sources of VA physician recruitment and retention, namely academic affiliations, graduate medical 

education (GME), and VA research. 

While the VHA has made substantial improvements in quality 

and efficiency, the veteran service organizations cite excessive waiting times, delays as the primary problem in veterans’ healthcare. 

Without increases in clinical staff, the demand for healthcare will 

continue to outpace the VA’s ability to supply timely healthcare 

services and will erode the world-renowned quality of VA medical 

care. 

Concerns about physician staffing at the VA come at a time 

when the Nation faces a pending shortage of physicians. Recent 


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analysis by the AAMC’s Center for Workforce Studies indicates the 

United States will face a serious physician shortage in the next few 

decades. 

Our Nation’s rapidly growing population, increasing number of 

elderly Americans, an aging physician workforce, and a rising demand for healthcare services all point to this conclusion. 

The VA has been the first to respond with plans to increase its 

support for graduate medical education. Under the GME Enhancement Initiative, the VA plans to add an additional 2,000 physicians 

for residency training over 5 years. This will restore VA funded 

physicians to approximately 11 percent of the total GME physicians in the United States. The expansion began in 2007 when the 

VA added 342 physicians. 

The smooth operation at the VA’s academic affiliations is crucial 

to preserving the health professions workforce needed to care for 

our Nation’s veterans. The VA’s AAMC Dean’s Committee meets 

regularly to maintain an open dialog and provide advice on how 

better to manage our joint affiliations. 

The VA has consistently recognized that there is room for improvement. As such, the AAMC looks forward to working on other 

matters of concern. 

As medical care shifts to more satellite-based outpatient approaches, graduate medical education needs to follow suit. This 

strong shift to ambulatory care at multiple sites requires a similar 

locus of change in medical training. 

The dispersion of patients to multiple sites of care makes more 

difficult the volume of patient contact crucial to medical training. 

Similarly, faculty diffusion makes it more difficult as well. 

This is not exclusively a VA problem. And one of the key points 

I would like to make is that the issues faced by VA physicians are 

precisely the same that we as deans of medical schools face in recruiting and retaining faculty in the current economic environment 

in this country. 

Another concern at both VA and non-VA teaching hospitals is the 

growing salary discrepancy. This discrepancy continues to be a concern and it is increasingly difficult to recruit residents and students to our programs. 

In recent years, the funding for VA medical and prosthetics research has failed to provide the resources needed to maintain, upgrade, and replace aging facilities. Many VA facilities have run out 

of adequate research space. And, again, the recruitment of physicians who are interested in research and education and the support 

of those interests will be critical to retaining a VA workforce. 

The AAMC recommends an annual appropriation of $45 million 

in the VA’s minor construction budget dedicated to renovating existing research facilities to try to replace at least one outdated facility per year. 

Mr. Chairman, Members of the Committee, thank you for the opportunity to testify on this important issue. I hope my testimony 

today has demonstrated that the recruitment and retention of an 

adequate physician workforce is central to the success of the VA’s 

mission. 

The extraordinary partnership between the VA and its medical 

school affiliates coupled with the excellence of the VA medical and 


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prosthetics research program allows the VA to attract the Nation’s 

best physicians. 

Over the last 60 years, we have made great strides toward preserving the success of these affiliations and with our hard work, I 

am confident that this success will continue. 

Thank you. I would be happy to answer any questions at the appropriate time. 

[The prepared statement of Dr. Krugman appears on p. 38.] 

Mr. MICHAUD. Thank you very much, Doctor. 

Ms. McCaskill. 

STATEMENT OF KRISTI MCCASKILL, M.ED., NCC, NCSC 

Ms. MCCASKILL. Mr. Chairman and Honorable Members of the 

Veterans’ Affairs Committee, I appreciate the opportunity to 

present testimony regarding the need for additional mental 

healthcare providers in the VA. 

My name is Kristi McCaskill and I am the Counseling Advocacy 

Coordinator at the National Board for Certified Counselors. I possess a Master’s Degree in Counseling from the University of North 

Carolina at Chapel Hill. 

For the past few years, I have worked with professionals who 

have been certified by NBCC as they explain their qualifications to 

prospective employers, public, and legislators. I, too, am certified 

by the NBCC and understand the value of counseling and counseling credentials. 

NBCC is the Nation’s premier and largest professional certification board devoted to the credentialing of counselors holding 

Master’s level or higher degrees. These counselors must meet 

standards for the general and specialty practices of professional 

counseling. 

Founded in 1982 as an independent, nonprofit credentialing 

body, NBCC provides a national certification system for those counselors and administers the Ethics Code for those counselors. Currently we have more than 42,000 active certificates living and 

working in the United States and in over 40 countries. 

NBCC and licensed professional counselors are pleased with the 

passage of Public Law 109–461. This legislation explicitly recognizes licensed professional counselors as healthcare providers within the Veterans Healthcare Administration. 

Unfortunately, it appears to us that despite the passage of this 

law, licensed professional counselors still have a very limited role 

as mental health providers in the VA in the nearly 10 months since 

the law was enacted. 

Our veterans have unprecedented needs and these needs deserve 

to be met. Nationwide there are over 100,000 professional counselors licensed to practice independently and this number is growing. 

In addition to completing rigorous degree programs, professional 

counselors must document supervised, professional practice, pass a 

national counselor examination, submit a professional disclosure 

statement, and keep current their professional education. 

Following licensure, these individuals provide quality mental 

health services to citizens. Counseling treatment comes in many 

forms and deals with problems such as stress, anxiety, depression, 


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divorce, death, post traumatic stress disorder (PTSD), and other 

psychological or behavioral disorders common among our veterans. 

Congress has passed a law recognizing counselors as eligible to 

provide mental health services within the VA. In addition, a sufficient number of skilled professionals are available to provide these 

services. The VA and Congressional leaders must find a way to ensure that skills offered by counselors are readily available to meet 

the increasing mental health needs of our citizen heroes. 

NBCC stands ready, willing, and able to assist in this effort. 

Thank you for your time to speak on such an important subject. 

[The prepared statement of Ms. McCaskill appears on p. 43.] 

Mr. MICHAUD. Thank you. 

Mr. Bender. 

STATEMENT OF JIM BENDER 

Mr. BENDER. Mr. Chairman and Members of the Subcommittee, 

thank you for inviting CACI to contribute to the discussion on 

healthcare recruitment and retention. 

CACI has been instrumental in the advancement of recruitment 

marketing, research, and strategy and practice for more than 15 

years. Our clientele include the National Security Agency, the National Guard Bureau, the Corporation for National and Community 

Service, and the Veterans Health Administration. 

My name is Jim Bender and I am one of the architects of the VA 

Nurse Recruitment Pilot Study I will address today. 

In February of 2006, in response to the ‘‘Veterans Health Programs Improvement Act of 2004,’’ VHA’s Healthcare Retention and 

Recruitment Office (HRRO) contracted with CACI to conduct a 

pilot program to test and recommend innovative recruitment methods for hard-to-fill healthcare positions. 

From a pool of 17 pilot site applicants, the North Florida/South 

Georgia Veterans Health System was chosen as the pilot location. 

The system’s unique recruitment challenge was finding nurses with 

enough experience to fill higher level nursing positions. 

Our objective going into the North Florida/South Georgia System 

was to test methods to enhance effectiveness in four key areas. 

Number one, employer branding and interactive advertising strategies; number two, Internet technologies and automated staffing 

systems; number three, the use of recruitment, advertising, and 

communications agencies; and, number four, streamlining the hiring process. 

Subsequently the study was divided into two distinct operations. 

One was focused on recruitment marketing with a goal of increasing the number of qualified applications coming into the system. 

The second was business process reengineering with the goal of decreasing the administrative time between application receipt and 

job offer. 

An abundance of anecdotal evidence suggests that VA loses good 

candidates because of the lengthy boarding process. 

The program was conducted over 60 days beginning February 

5th, 2006. All activities were monitored and measured to evaluate 

the results. 

On the recruitment marketing side of the operation, the findings 

were exceptionally optimistic. The recruitment marketing campaign 


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generated 10,261 inquiries into nursing positions for experienced 

nurses. An inquiry was defined as a response to recruitment advertising or similar communications outreach. 

Of those inquiries, 115 candidates submitted applications. Most 

impressive was the percentage of applicants uniquely qualified to 

fill the advertised positions. 

During March of 2006, the only full calendar month of the study, 

the number of applicants for nursing services who passed the initial screening process increased by 83 percent over the month prior 

from 12 applications to 22 and 300 percent over the trailing 5- 

month average from 7.4 applicants to 22. 

The recruitment methods that garnered these results included a 

strategy based on the principles of employer branding and market 

segmentation in addition to vigorous use of interactive media and 

Internet technologies which delivered the highest return on investment of any media in the study. 

The pilot program recommendations embraced these methods 

and further suggested the use of database marketing, relationship 

building, especially with the student population, employee referral 

programs, budget modifications, and improvements to organizational communications. 

On the business process side, the results were equally optimistic. 

A comparison of current hiring processes to what-if scenarios revealed that a small number of process changes could significantly 

accelerate the time to hire. 

The process changes that would actualize these what-if scenarios 

include the delegation of approval authority for routine recruitment 

activities, the implementation of an automated recruitment and 

management work-flow system to eliminate delays in paper-based, 

mail-in processing, and several modifications to standard processes 

that build delays into the system. 

We at CACI believe healthcare recruitment at VHA is both 

strong and spirited. HRRO, in addition to the exceptional staff and 

leadership at the North Florida/South Georgia System, embraced 

this project with enthusiasm and sustained intellectual vigor. 

Since the pilot’s conclusion, we have seen continued movement 

toward the methods tested in the pilot project including increased 

use of targeted e-mail communications, expanded use of online job 

postings, and greater promotion of employee referral programs as 

well as a persistent hunger for new, progressive ways of engaging 

healthcare professionals. 

In closing, thank you once again for the opportunity to present 

CACI’s conclusions on the Nurse Recruitment Pilot Study and 

thank you for the opportunity to contribute to the continued health 

and welfare of our country’s veteran population. I look forward to 

your questions. 

[The prepared statement of Mr. Bender appears on p. 47.] 

Mr. MICHAUD. Thank you. 

I would like to thank once again all four panelists. Great testimony. And I will have a lot of questions. But at this time, because 

of the vote, we will recess. We should be back shortly. As I understand it, there is only one vote. So if you can hold your thoughts 

and get ready for the questions, I will try to drum up more Members to be here so that they can ask questions. 


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Do you have a question right now, Ms. Berkley? 

OPENING STATEMENT OF HON. SHELLEY BERKLEY 

Ms. BERKLEY. I am not going to be able to come back. We also 

have the swearing in of the new Member afterward and I think 

many people are going to be down. I was requested by the Speaker 

to be there. Can I just very quickly? 

I want to thank you for being here and providing us with your 

testimony. I represent Las Vegas and that is the fastest growing 

area in the United States with the fastest growing veterans’ population. 

We are in the process of building at the very early stages a huge 

VA facility, hospital, long-term care facility and outpatient clinic. 

We have trouble recruiting as it is healthcare professionals. I do 

not know what we are going to do to staff those buildings, particularly with the influx of new veterans coming to the Las Vegas Valley. So it is a tremendous challenge for me and that is why I especially appreciate your thoughts on this issue. 

Mr. MICHAUD. And there is no Member of the Committee that 

fights more diligently for VA facilities as well as VA employees 

than Congresswoman Berkley. I really appreciate your efforts. 

So with that, we will recess for the votes. Thank you. 

[Recess.] 

Mr. MICHAUD. I would like to call the hearing back to order. 

Once again, I apologize for the interruption because of the journal 

vote. 

Once again, I want to thank each of you for your testimony this 

morning and have several questions. 

If you look at last year, Congress passed the ‘‘VA Benefits 

Healthcare and Information Technology Act of 2006’’ (P.L. 109–461) 

authorizing the recognition of licensed professional counselors within the VA system. 

What specifically can licensed professional counselors offer the 

VA? And my second question: Are licensed professional counselors 

capable of taking care of patients with severe problems such as 

PTSD and psychiatric disorders? 

Ms. MCCASKILL. Thank you. 

Licensed counselors are specifically trained in the provision of 

mental health services and they are experienced in dealing with 

people that are going through crisis. They can provide services 

from screening all the way through individual work, group work. 

They can do assessments. 

We do these kinds of things for private citizens in the States 

where they are licensed and we are just looking to be able to do 

it for the veterans, for our returning heroes. 

As far as those dealing with the very severe things like psychosis, we do not do medicine. We are not medical doctors, but we 

have worked cooperatively with other professions like psychiatrists 

or general physicians as they provide the medical treatment and 

we provide the counseling. 

In fact, research has shown that when you do the two of them 

together, they are very effective in providing help for people going 

through severe difficulties. 


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Mr. MICHAUD. And do professional counselors receive evidencebased training? 

Ms. MCCASKILL. Yes, they do. The core coursework is what I 

mentioned a moment ago. They also have to have supervised experience before anybody becomes licensed. And in all 49 States that 

license counselors, the only one that does not is California. That 

State has legislation pending at this time. 

But all 49 States use NBCC examinations. These examinations 

are based on research done in the field of counseling on a routine 

basis so that the exam does accurately reflect the profession and 

the current developments. 

Mr. MICHAUD. Great. Thank you. 

And as we heard in testimony earlier as far as recruitment and 

retention and the healthcare professionals shortage that we currently have not only within the VA system but in private sector as 

well, what type of tools do you think would be most effective in recruiting and retaining a high-quality workforce, particularly in 

rural areas? Do you see more of a problem in rural areas versus 

urban areas? I guess I would turn it over to Dr. Krugman. 

Dr. KRUGMAN. Interestingly, Mr. Chairman, we are facing in this 

country now what we faced back in the late 1960s, early 1970s 

when I started my faculty career and that is a real workforce shortage, particularly in rural and under-served areas. 

And in the Rocky Mountain region, we have VA facilities in rural 

areas. Grand Junction, Colorado, is one hospital—and others. 

There is good evidence that the recruitment and retention of professionals to under-served areas can exist if we provide portions of 

their training in those institutions, in those areas; if we work to 

develop loan repayment and other types of programs that can attract people to those areas; and to go to the head of the pipeline, 

if we recruit people from rural and under-served areas to come into 

our health profession training programs. 

There is 30 years of work done by the Area Health Education 

Center’s programs in this country and in Colorado, we have one. 

And it works. The VA in Grand Junction as well as a VA facility 

in southeastern Colorado are part of our Area Health Education 

Network. 

We send students on rotations. We have them trained there. 

After we have taken them from those areas, we try to give them 

incentives to go back. And we keep them engaged in teaching because we know that is the best form of continuing education for 

any professional. 

If you have a student who wants to be like you, they will push 

you to keep learning and, in fact, will help you learn more. 

So I think the tools are there. The question is, can we get it done 

at a time when these programs, most of which were funded on the 

public health service side under title 7 are under severe budget 

pressure? 

I think we do not have to reinvent the wheel. We just need to 

pay attention to what we had to do 30 years ago and do it again 

better. 

Mr. MICHAUD. You had mentioned, Doctor, that part of the problem, and it is true, that when you look at higher ed, they do not 


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have the slots available for students who want to go in the 

healthcare field. 

What do you recommend that we do to encourage people to go 

into the field, as far as helping higher ed out, specifically in rural 

areas? Do you think a grant program or more collaboration between the VA and higher ed facilities in the rural areas would 

help? 

Dr. KRUGMAN. I think clearly recruitment and retention and 

scholarship and loan deferment programs targeted toward students 

from rural and under-served areas who want careers in medicine 

can work. 

It is similar to what the National Health Service Corps has done 

again on the public health service side, similar to what the Armed 

Forces has done with its scholarship program that pays students 

to come into health professional training in return for which they 

are expected to provide 4 to 8 years of service. 

I think if students can be attracted into a VA model program 

that will pay for their higher education and health professional 

training in return for which they do their graduate medical education and then serve in VA facilities for a particular period of 

time. 

The experience in the Armed Forces is that once you have put 

in 8 to 10 years, the retirement benefits are such that your retention is far more likely than if you do not have any hook at all. 

So I think there are models out there that the VA can take advantage of. And the AAMC and academic medical centers which already have these networks around the country would be delighted 

to collaborate in that effort. 

Mr. MICHAUD. And, Mr. Newman, do you want to add anything 

to that? 

Mr. NEWMAN. Thank you, Mr. Chairman. I do. 

Within the VA system, within the VA system network, we have 

community based outpatient clinics in rural communities in Minnesota and I would think that this same situation applies in your 

home State. 

We have plans underway in Minneapolis to add physical therapy 

clinics to some of those community based outpatient clinics or 

CBOCs as they are called within the system. I think that is a great 

way to get the rural communities involved, to get the care to those 

veteran patients that can stay closer to home. They do not have to 

travel miles to come to our facility in Minneapolis and they can get 

that quality of care locally. 

To do that, recruitment and retention standards and the passage 

of those would go a long way in attracting qualified physical therapists to come to the va to work in those community based outpatient clinics. 

Mr. MICHAUD. And I would like each of you to comment. When 

you look at the healthcare professionals shortage we currently have 

nationwide and when you look at what is happening with the war 

in Iraq and Afghanistan, particularly men and women who are 

coming back to their home State that might not have a job waiting 

for them, or they lost their job, or just cannot make ends meet because the job does not pay enough, do you think this is a great opportunity where we can help address the healthcare professionals 


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shortage we currently have in the system by focusing maybe first 

on providing slots for the men and women who served this country 

in the healthcare area? 

We will start with Mr. Newman and work down. 

Mr. NEWMAN. Mr. Chairman, great question. 

Two good stories for you on that particular issue. This past summer, we had a decorated Iraqi veteran come back to Minnesota, 

come back to going back to school at the University of Minnesota, 

and has a great interest in physical therapy. 

He has come to me. He has come to our facility as a volunteer 

and has performed admirably within the clinic setting working 

with our polytrauma patients, working with our other veterans 

who are coming to our clinic for physical therapy. 

Just Tuesday, before I came on to Washington, D.C., I had another Guardsman from Minnesota who served 2 years in Iraq who 

has a degree in biochemistry. He has an interest in physical therapy. He is going to begin volunteering for us in our clinic with 

hopes in going back to school using his benefits as an active-duty 

soldier to become a physical therapist. 

I think that is a tremendous asset for our physical therapy clinic 

and for our VA setting. It goes a long way in working with our 

polytrauma patients and our polytrauma patient families. They 

have been there. They have served. They can be in the clinic answering questions, working with our young veteran population. It 

goes a long way in rehabilitating these veterans. 

Mr. MICHAUD. Those are great stories. 

Dr. Krugman. 

Dr. KRUGMAN. I would concur that any individuals who have experienced healthcare on the side of being a patient who then want 

to come into any of our professions are likely to have a perspective 

and an empathy that would be welcome in the health professions 

provided they have had a good experience themselves. 

Mr. MICHAUD. Great. 

Ms. MCCASKILL. I would also echo the same comments. NBCC 

has been looking and is planning on trying to do an institute where 

we work with people to develop a specialty certification for those 

people who want to provide services to military personnel and returning veterans. 

We know that the military life is somewhat different. We know 

that there is some stigma attached to getting help, especially mental health service help. So that is part of the reason why we have 

been looking at additional things that we can do to help people. 

So people that have gone through it and have that awareness 

and understand the life of military and what they have gone 

through, I think, have a very deep respect and can help those who 

are having a hard time when they come back. 

Mr. BENDER. Mr. Chairman, the question is really beyond the 

scope of my expertise. I will say we have engaged in a number of 

communication campaigns reaching out to those transitioning out 

of the military on behalf of VA, those transitioning out of the military to encourage them and to tell them about the opportunities of 

employment at VA. 

Mr. MICHAUD. Let us focus a little bit on what your expertise is. 

I have a question on your organization which conducted a nurse reVerDate Aug 31 2005 03:06 Aug 19, 2008 Jkt 039464 PO 00000 Frm 00016 Fmt 6633 Sfmt 6633 E:\HR\OC\39464.XXX 39464

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cruitment pilot study. What would you say were the biggest lessons 

learned from this pilot study? I believe it was in an urban area? 

Have you done any studies in rural areas, and, if so, what were the 

differences, if any? 

Mr. BENDER. The area is the Gainesville, Lake City area in Florida. The difference between conducting the type of recruitment 

marketing that we do from an urban area to a rural area is not 

at this point going to be extreme. In other words, the difficulty 

level is not going to go up a number of notches. 

Prior to the Internet, it was a little bit different because of the 

penetration of media within certain areas. Obviously, you know, in 

a city, you have a large number of options and other places, you 

do not. So the difficulty of taking the message, the good message 

about VA to the people is not a tremendous concern right now. 

Getting back to the study, and there is a relationship between 

the two here, the method that works the best, especially with the 

young crowd now is Internet communication. People live on the 

Internet. It also happens to be the most cost-effective mode of communication. This study identified things such as e-mail campaigns 

and e-mail banners and so forth. 

Among all the media used, the most effective in reaching the 

number of candidates we had to reach and the most cost effective 

in having the lowest cost per lead, and obviously that is a medium 

that we can use in any part of the country. 

Mr. MICHAUD. Do you think VA should continue using private 

sector strategies in recruitment and retention efforts? 

Mr. BENDER. Yeah. It depends what those strategies are. When 

you bring a marketing mindset, marketing best practices to the 

process, what happens is you start to improve the quality of the 

communication going out to the nurses. In the pilot study, we mentioned methods such as targeted marketing, you know. 

When we are going out and we are hiring nurses or we are hiring 

psychiatrists, we make sure that we have the research about this 

particular market, about what this market’s cares are, how they 

feel about working for not only VA but also for the government at 

large. And then in the communication to these individuals, we 

make sure we address their specific concerns. 

So taking best practices within the marketing field and applying 

it to recruitment, I think, are one of the ways in which we can encourage a higher number of qualified applicants into the field. 

Mr. MICHAUD. Great. Thank you. 

In 2004, Congress passed the Physician Pay Bill, which established an improved and simplified pay structure for VA physicians 

that would increase salaries and make VA more competitive with 

the private sector. 

Do you think that legislation has been effective in retaining VA 

physicians? 

Dr. KRUGMAN. Mr. Chairman, I think it has helped, but my understanding is that in each VISN and in each part of the country 

where that Pay Bill was implemented, the dollars went primarily 

to surgeons—and let me speak to our VISN. It primarily went to 

surgeons and radiologists and did not go to some of those in internal medicine, particularly gastroenterology where there is still a 


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huge gradient left between the private community and the VA physicians. 

So it was a good start. But, unfortunately, the community sectors 

in many parts of the country, particularly in ours, the ability of 

physicians in the private community to garner technical fees in 

their own imaging centers and their own ambulatory surgery centers and other ways to supplement their professional fee income 

have made the salary gap more than double even with the Pay Bill. 

So retention is still going to be an issue. And I think it was a 

good start, but it has been variable in its penetrance. 

Mr. MICHAUD. Thank you. 

Any questions? There will be additional questions that will be 

submitted for the record and hopefully you will be able to respond 

in a timely manner. 

So once again, I would like to thank the four panelists. It has 

been very enlightening and look forward to working with you as we 

move forward on this very important issue. So once again, thank 

you very much. 

Dr. KRUGMAN. Thank you. 

Mr. NEWMAN. Thank you. 

Mr. MICHAUD. I would like to ask the second panel to come forward. 

On the second panel we have Joseph Wilson, Assistant Director 

for Health Policy, Veterans Affairs and Rehabilitation Commission 

for the American Legion; Joy Ilem, Assistant National Legislative 

Director for the Disabled American Veterans (DAV); and David 

Cox, National Secretary-Treasurer of the American Federation of 

Government Employees (AFGE), AFL–CIO. 

So I want to welcome the three panelists, and we will start off 

with you, Mr. Wilson, and work down. Thank you. 

STATEMENTS OF JOSEPH L. WILSON, ASSISTANT DIRECTOR 

FOR HEALTH POLICY, VETERANS AFFAIRS AND REHABILITATION COMMISSION, AMERICAN LEGION; JOY J. ILEM, ASSISTANT NATIONAL LEGISLATIVE DIRECTOR, DISABLED 

AMERICAN VETERANS; AND J. DAVID COX, R.N., NATIONAL 

SECRETARY–TREASURER, AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, AFL–CIO 

STATEMENT OF JOSEPH L. WILSON 

Mr. WILSON. Mr. Chairman and Members of the Subcommittee, 

thank you for this opportunity to present the American Legion’s 

views on recruitment and retention of VA’s healthcare—— Mr. MICHAUD. Is your microphone on? 

Mr. WILSON. What about now? 

Mr. MICHAUD. Okay. Yes. We can hear you now. 

Mr. WILSON. Mr. Chairman and Members of the Subcommittee, 

thank you for this opportunity to present the American Legion’s 

views on recruitment and retention of VA’s healthcare professionals. 

The Nation is facing an unprecedented healthcare shortage that 

could potentially have a profound impact on the care given to this 

Nation’s veterans. 


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The American Legion supports comprehensive efforts to establish 

and maintain the Department of Veterans Affairs as a competitive 

force in attracting and retaining healthcare personnel, especially 

nurses, essential to the mission of VA healthcare and commends 

the Subcommittee for holding a hearing to discuss this very important and urgent issue. 

The Federal Government estimates that by 2020, nurse and physician retirements will create a shortage of about 24,000 physicians 

and almost one million nurses nationwide. The American Legion 

strongly believes that what happens at the Department of Veterans 

Affairs medical centers often reflects the general state of affairs 

within the healthcare community as a whole. 

Shortages in healthcare staff threaten the Veterans Health Administration’s ability to provide quality care and treatment to veterans. 

During the American Legion’s recent site visits to polytrauma 

centers throughout the Nation, some facilities identified uncertainty of existing staff’s ability to handle an expected influx of patients as a challenge to providing care. 

One major polytrauma center which serves as a frontline medical 

center to those returning from Iraq and Afghanistan reported recruitment and retention as part of their major budgetary challenge. 

Although the utilization of a variety of tools to include relocation, 

recruitment, and retention bonuses to attract new employees and 

retain existing employees is a step in the right direction, the locality pay is insufficient to keep pace with respective surrounding 

healthcare employers. 

VA nurses are one of the most important resources in delivering 

high-quality, compassionate care to veterans. Currently, there are 

challenges in attracting nursing personnel to VA due to both the 

shortage of people entering the career field and VA’s inability to remain competitive in salary and benefits. 

The American Legion urges the VA and Congress to provide adequate resources to implement the Commission’s recommendations 

and urges VA to continue to strive to develop an effective strategy 

to recruit, train, and retain advanced practice nurses, registered 

nurses, licensed practical nurses, and medicine assistants to meet 

the inpatient and outpatient healthcare needs of its growing patient population. 

VA recently established a Nursing Academy to address the nationwide nursing shortage issue. The Nursing Academy has embarked on a 5-year pilot program that will establish partnerships 

with a total of 12 nursing schools. This pilot program will train 

nurses to understand the healthcare needs of veterans and increase 

the availability of nurses, thereby allowing VA to continue to provide veterans with the quality of care they deserve. 

The American Legion affirms its strong commitment and support 

for the mutually beneficial affiliations between VHA and the medical and nursing schools of this Nation. 

The American Legion is also appreciative of the many contributions of VHA nursing personnel and recognizes their dedication to 

veterans who rely on VHA healthcare. Every effort must be made 

to recognize, reward, and maximize their contributions to the VHA 

healthcare system because veterans deserve nothing less. 


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VHA currently conducts the largest coordinated education and 

training program for healthcare professions in the Nation. Their recent and newest recognitions as a leader providing safe, high-quality healthcare to the Nation’s veterans can be directly attributed to 

the relationship that has been fostered through medical school affiliations which allows VA to train new healthcare professionals to 

meet the healthcare needs of veterans and the Nation. 

Mr. Chairman and Members of the Subcommittee, the American 

Legion sincerely appreciates the opportunity to present testimony 

and looks forward to working with you, your colleagues, and staff 

to resolve this critical issue. 

Thank you for your continued leadership on behalf of America’s 

veterans. 

[The prepared statement of Mr. Wilson appears on p. 49.] 

Mr. MICHAUD. Thank you very much, Mr. Wilson. 

Ms. Ilem. 

STATEMENT OF JOY J. ILEM 

Ms. ILEM. Mr. Chairman and Members of the Subcommittee, 

thank you for inviting the DAV to testify today. 

Without question, recruitment and retention of high-caliber 

healthcare professionals is critical to VHA’s mission and essential 

to providing safe, high-quality healthcare services to sick and disabled veterans. 

Since 2000, VA has been working to address the ever-increasing 

demand for medical services while coping with the impact of a rising national nursing shortage. 

In 2004, VA’s Office of Nursing released its strategic plan to 

guide national efforts to advance nursing practice within VHA and 

to improve VA’s abilities to recruit and retain sufficient nursing 

staff. 

One of VA’s greatest challenges today is effective succession 

planning. VA faces significant anticipated workforce supply and demand gaps in the near future along with an aging workforce and 

an increasing percentage of VHA employees who become eligible for 

retirement each year. 

In a recent succession planning and workforce development conference, VHA identified registered nurses as its top occupational 

challenge. Over the past several years, VHA has been trying to attract younger nurses and create incentives to keep them in the VA 

healthcare system. 

To address this problem, VA created a Nursing Academy Pilot 

Program in which it plans to partner with four universities. Academy students will be offered VA funded scholarships in exchange 

for defined periods of VA employment following graduation. 

VA notes that in order for this program to move forward, legislation will be required to reactivate VA’s Health Professions Education Assistance Program authority. 

Although the Nursing Academy offers an innovative solution to 

recruitment and retention challenges, we would like to bring to 

your attention a number of reports dealing with VA nursing workplace issues. 

We continue to hear complaints about marginal nursing staff levels, overuse of mandatory overtime, unofficial hiring freezes and 


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delays in hiring for critical positions, reduced flexibility in tours of 

duty, limiting of nurse locality pay, and shortages of ward secretaries and other key support personnel. 

Many of these difficult working conditions continue to exist today 

for nursing staff despite VA’s efforts to make positive changes. We 

hope that VA will place greater emphasis on improving the work 

environment for nurses, to increase staff satisfaction, ensure the 

provision of safe, high-quality patient care. 

Likewise, DAV is concerned about the stressful working environment also confronting VA physician workforce. Recently DAV received a copy of a letter written by a group of VA physicians. I will 

mention only a few of the concerns it expresses. 

Complaints focused on the negative impact of provider shortages 

including understaffing of both nurses and doctors, increased panel 

size for doctors, increased turnover rates, difficulty in recruiting for 

key positions, and a lack of an adequate number of support staff. 

The following statement sums up the heavy burden these providers are shouldering, and I quote, ‘‘We state we must not compromise quality of care, access, and patient and provider satisfaction in the quest for increasing panel size. Providers who are already struggling will not be able to provide high-quality care and 

ultimately you will have fewer providers to provide that care. We 

have not been able to recruit new providers in the current climate. 

Our ability to recruit will be further hampered by the unbearable 

workload that would be created by an increased panel size. Preventing panel size increases is critical to the future quality of primary care within VA.’’

If the general situation in clinical care across the VA is anything 

like this report suggests, VA has a serious and rising morale problem that eventually may interfere with recruitment and retention 

as well as healthcare quality, safety, efficiency, and effectiveness. 

For these reasons, we ask that the Subcommittee consider conducting a survey of VA facilities to gauge conditions of employment 

and the current morale of the VA physician and nursing workforce. 

Mr. Chairman, in summary, we believe VA should establish innovative recruitment programs to remain competitive with private 

sector healthcare marketing and advertising strategies to attract 

high-caliber nurses and doctors to VA careers. 

While we applaud what VA is trying to do in improving its incentive programs, we believe these competitive strategies are yet to be 

fully developed or deployed in VA. 

Finally, we hope the Subcommittee will provide oversight to ensure sufficient provider staff levels and to regulate and reduce to 

a minimum VA’s use of mandatory overtime for nurses. We believe 

this practice endangers the quality of care and safety of veteran patients. 

Again, we thank you for this opportunity to testify and I will be 

happy to answer any questions you may have. Thank you. 

[The prepared statement of Ms. Ilem appears on p. 51.] 

Mr. MICHAUD. Thank you. 

Mr. Cox. 


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STATEMENT OF J. DAVID COX 

Mr. COX. Mr. Chairman and the Subcommittee, thank you for inviting AFGE to testify today. AFGE greatly appreciates the opportunity to share the views of our members working on the front 

lines of VA healthcare. 

I spent 23 years working as a registered nurse at the Salisbury 

VA Medical Center prior to becoming AFGE’s National SecretaryTreasurer. It was tremendously rewarding to care for these unique 

patient populations in a highly regarded healthcare system on the 

cutting edge of new treatments while regularly collaborating with 

management on patient care issues. 

The VHA workforce is a highly skilled professional and dedicated 

workforce that takes great pride in caring for our veterans. Many 

of these employees are covered by title 38 rules designed to expeditiously recruit and retain personnel. So why is this great 

healthcare system in a retention crisis? 

Seventy-seven percent of all nurses who resign from the VA do 

so within the first 5 years on the job. And on the other end of the 

spectrum, because 63 percent of VA’s registered nurses will be eligible to retire in 2010, the VHA will face a staffing shortage. 

I commend the VA for its efforts to address this impending crisis. 

And I represented AFGE on the National Commission on VA Nursing that focused on growing nurse shortages. However, AFGE believes many of the findings of the Commission have not been addressed by the VA. 

Congress has passed critical legislation over the past several 

years to address VHA recruitment and retention, but I fear that as 

long as VA’s funding is so uncertain, Congressional intent to place 

meaningful incentives will be frustrated by cash strapped facility 

directors reluctant to offer retention bonuses and competitive 

schedules. 

Recent legislation could achieve its potential if the VA Central 

Office exerted more control over local facility workforce policies. 

Nurse locality pay legislation has achieved mixed success because 

local management has complete discretion to decide when and how 

to conduct pay surveys and how to distribute pay increases. We 

have yet to see any evidence that nurse pay policies have reduced 

the VA’s reliance on agency nurses. 

Local discretion has also been a real impediment to implementing physician and dentist pay legislation. Many facilities excluded practitioners from groups setting market pay and performance pay criteria. Hereto, we still do not know if this legislation 

has been effective in reducing the VA’s reliance on fee-based care. 

Local discretion and underfunding have also frustrated Congressional intent to limit mandatory nurse overtime and promote compressed work schedules. Local facilities have complete discretion to 

determine when an emergency exists to justify mandatory overtime. We urge Congress to define emergency by statute as many 

States have done and limit local discretion which deprives VA 

nurses of compressed work week schedules. 

AFGE is skeptical of new fixes such as the Nursing Academy 

that promise to bring more nurses to the VA. It would be far more 

effective to invest more funds in oversight and the VA’s Employee 


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Debt Reduction Program that offers loans assistance in exchange 

for a commitment to work at the VA. 

In my career, I was able to spend much time serving on medical 

center Committees addressing patient care and workforce issues. 

But for the past 7 years, AFGE members and representatives have 

been shut out of such opportunities. 

If the VA once again permits meaningful labor management cooperation, we will achieve the same or greater goal of employee empowerment that the Magnet Program promises but has yet failed 

to demonstrate. And we could do this without diverting precious 

dollars away from patient care for Magnet applications and certification fees. 

I also note that we have not seen any evidence that VA medical 

centers with Magnet status have higher nurse retention or satisfaction rates. 

Another useful retention tool would be to allow title 38 employees under FERS Retirement System to apply unused sick leave toward their retirement benefit. More equal treatment for part-time 

nurses would be beneficial. They should have the right to earn permanent status and receive premium overtime and shift differential 

pay. 

Finally, recruitment and retention efforts should not be overlooked for other VHA employees who play a crucial role in the delivery of care including physician assistants, podiatrists, optometrists, and personnel supporting VHA information technology. 

Thank you, Mr. Chairman, for inviting us and we do look forward to working with you and the Committee and Members of the 

Subcommittee and VA management to tackle these many pressing 

workforce issues. 

[The prepared statement of Mr. Cox appears on p. 56.] 

Mr. MICHAUD. Once again, I would like to thank the three panelists for your testimony this morning. 

All of you discussed the fact that VA currently has difficulty in 

recruiting and retaining qualified healthcare providers. What effect 

has recruitment and retention had on, or has on, patient care? Has 

it affected patient care at all? And we will start with Mr. Wilson. 

Mr. WILSON. Mr. Chairman, I speak on my experience from visiting over 30 VA medical centers within the past year; and I would 

say it was fear of becoming complacent. I think healthcare employees were fearful because of the shortage within their respective VA 

Medical Center. Although cordial to patients, it had an effect on 

them, mainly physically. 

We are talking waiting lists and waiting time issues, which also 

frustrated healthcare employees because they were spending unexpected time at the VA Medical Center and putting off family duties, which really frustrated them, and also affected morale. 

Ms. ILEM. I think in speaking with both doctors and nurses, but 

one particular doctor that, you know, we had a conversation with, 

I mean, I think the stresses that they have had to absorb when 

they lose somebody in a primary care clinic and the other doctors 

have to absorb their patient panel which is sometimes in the thousands and the pressure that that puts on them that limit, the time 

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tween and they have to keep moving, you know, they feel frustrated. 

They had said because many of our patients have such chronic 

disabilities, they have a number of things they want to come in. 

And there is just not the time for them to spend with that patient, 

so they will say give me the top two things I can help you with 

today versus what they really want to do is to spend the appropriate time with the patient based on the needs of that patient. 

And so I think that would be an example of a direct impact on 

care. And all of us as patients, you know, how we would want to 

be treated, we do not want to know they have exactly 7 minutes 

to spend with us because they have to do some charting. They have 

to see, you know, a number of patients each day. 

And I think that is reflective throughout the VA healthcare system, the pressure they are under because of the limited number of 

people they have. And then when they lose someone, they are generally not replaced right away. 

The other one is in a women veterans clinic, we often hear 

about—a provider leaves. VA knows they are leaving ahead of time 

and suddenly they are gone. They are trying to recruit someone. It 

is a difficult position to recruit for. And what happens to those patients, those women veteran patients who expect high-quality care 

from a provider that really is proficient in women’s health? So I 

would think that is another example. 

Mr. MICHAUD. Thank you. 

Mr. COX. Mr. Chairman, I have worked for the VA for 23 years. 

There were many times we were short staffed. Now, one thing I believe nurses always do, they get work accomplished and they take 

care of their patients because they are dedicated. 

But the frustration level of saying when is help going to come, 

when are you going to hire more staff, and more recently, you 

know, can you hire staff because there are not applicants or the 

pay is inadequate or the staffing levels. 

I think the biggest issue that I hear from VA nurses is the patient ratios that a VA nurse has to what nurses have in the private 

sector is much greater and that the VA does not staff its facilities 

as adequately as private sector. 

So, therefore, yes, I think patient care suffers. I believe staff is 

very dedicated to try to meet the needs of every veteran, but, yes, 

there is a frustration level. If we could get staffing ratios that Congress would set as to how many nurses needs to be to take care 

of so many veterans, I believe it would certainly improve patient 

care in the VA. 

Mr. MICHAUD. My last question actually deals with staffing ratios. Have there been any studies done on the appropriate staff 

versus patient ratios? And if so, do they take into consideration 

where you might have one patient that might not need as much 

time as another patient? Do staff take nurse and patient ratio into 

consideration? 

Mr. COX. There is a lot of research that has been done on nurseto-patient ratios. I think the State of California has actually adopted State law that mandates various ratios. And you take into consideration, yes, this is a patient that may be in for observation or 


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this is a patient that has had surgery or one that has just had a 

heart attack or stroke. 

There are different levels and there are mechanisms that you use 

in nursing to evaluate the levels of care and the amount of time 

that it is going to take and also the level. Do you need the registered nurse, the licensed practical nurse, or the nursing assistant 

to provide the care? There is a lot of information, a lot of research 

out there. 

VA operates pretty much on a very fluid process. AFGE has 

never been able to find that staffing ratio in the VA. We asked 

about that. It is talked about a lot, but it is a moving target that 

can never be pinned down. 

Mr. MICHAUD. Thank you. 

Ms. Brown. 

Ms. BROWN OF FLORIDA. Thank you and thank you for holding 

this hearing. 

I am sorry. You know, as always, we have two or three meetings 

at the very same time and I wanted to be here when Panel Two 

was making the presentation. They did a study in the Gainesville 

area and I think they are still here in the room. And could one of 

the parties come and sit at the table because my question goes to 

Panel Two and Panel Three? 

Mr. MICHAUD. Yes. You are making reference to Panel One? 

Ms. BROWN OF FLORIDA. Panel One. I am sorry. 

Mr. MICHAUD. Mr. Bender, would you please come back. 

Ms. BROWN OF FLORIDA. As I listened to the discussion, I guess 

I am a little perplexed because I understand there are a lot of patients that need care. And it may be frustrating, but sometimes I 

do not know whether in the private sector it is realistic as far as 

the ratio. 

And how is the pay in comparison with other segments as far as 

nursing is concerned? 

Mr. COX. Are you speaking to me, Congresswoman? 

Ms. BROWN OF FLORIDA. Yes, sir, Mr. Cox. 

Mr. COX. Nurse pay in the VA, by law, the VA cannot be a leader 

in the community. What has happened, Congress tried to fix nurse 

pay, said that the VA had to give at least the GS cost of living 

raise, that is minus the locality pay, as a floor, that VA could go 

further and do locality pay studies. 

VA very rarely does those locality pay studies because there is 

an expense and time to do them. And usually we will give the floor 

what we are required by law to nurses. We do not give the cost of 

living plus the locality pay or even give greater amounts that surveys would show. 

Ms. BROWN OF FLORIDA. Uh-huh. So I guess my question to you 

is that, if we add additional financial incentives, do you think that 

would help as far as more satisfaction with the job? 

Mr. COX. I think additional financial incentive would definitely 

help. Younger nurses do not think as much about retirement as 

they do money up front. But I think getting some Congressional 

mandate on nurse-patient ratios because I believe Congress is 

going to have to establish those mandates and those numbers for 

the VA to be able to live by them just as Congress had to mandate 


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that you would give nurses a raise every year because the VA was 

not giving nurses a raise. 

Ms. BROWN OF FLORIDA. I guess right now I would not be comfortable doing that at this time. 

Mr. COX. I understand. 

Ms. BROWN OF FLORIDA. But, you know, as we move forward 

with discussion, I would want more information about that. 

Mr. Bender, would you like to respond as far as what you think 

we can do as far as recruitment is concerned? I think if we could 

expand on the pool of nurses, of course, the paperwork is another 

thing. There should be some way we could expedite the amount of 

time it takes to get a person that wants to work with the VA qualified and on the job. 

Mr. BENDER. Yes. Our study, we had to look at what the biggest 

challenge for the area was. The biggest challenge for the area was 

attracting experienced nurses which means we had to reach into 

the private sector and pull nurses from the private sector to ask 

them to come into VA. It can be a challenge. 

So what we did is when we looked back at the research, we found 

that because of the nursing shortage and because of the difficulties 

being experienced in all hospitals with patient overload and burnout and so forth, nurses in the private sector are also experiencing 

a large degree of burnout, but maybe to a greater extent than possibly the nurses at VA because they see the healthcare institution 

being run as a business. They see managed care doing things that 

they perhaps would not agree with, maybe the doctors, because I 

do not know. But they are frustrated by that attitude. 

So what we were able to do is through the communications campaign, open up a dialog about that particular point about the frustration that can be experienced within the midst of this nursing 

shortage and in the private sector and say it may be a little bit different at VA for a number of reasons. We think that is one of the 

reasons. And when I talk about the communication campaign, I am 

talking about the messages that were going through the media. 

That particular point we think in the Gainesville, Lake City area 

had a lot to do with opening the experienced private practice 

nurses’ eyes to what options are available and why they decided to 

check it out. 

I am sorry. Could you repeat the second——

Ms. BROWN OF FLORIDA. And just how successful is this program? 

Mr. BENDER. Oh, yes. And as we mentioned, it was a very successful program. The numbers of qualified nurses, those experienced nurses who anecdotally were coming from the private sector 

into the VA increased by, as I say, 80 some percent month over 

month and more than 300 percent over a trailing 5-month average. 

So the approach was very, very successful. 

In the business process side as has been noted, the length of time 

it takes to get through that entire application process from the 

time I hand it in until the time I am ultimately hired is a deterrent. And there are a number of things that can be done to expedite that process including the automation of the paperwork. The 

automation of the paperwork alone and the mailing either through 


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the Postal Service or through internal VA mail adds a number of 

days onto that entire practice. 

We have heard anecdotally through the years that this is a problem, the length of time. In other words, while a nurse, for instance, 

is considering a VA job, that length of time can have a negative impact because a private sector hospital can maybe get to that nurse 

first. 

So the automation of the paperwork, the elimination of some of 

the paper-based mail processing can have a large effect in bringing 

that time period down and making it more reasonable. 

Ms. BROWN OF FLORIDA. Can I continue? 

Mr. Wilson, I was concerned about your comment because you 

mentioned that a lot of the nurses, I guess the nurse’s profession 

was most frustrated with their job? 

Mr. WILSON. Yes. 

Ms. BROWN OF FLORIDA. I do not understand that. 

Mr. WILSON. Actually, I do not know if it was rumored through 

the employees’ respective division or mandated, but they were expecting an influx of employees to arrive; I guess the expected arrival date passed. 

I am speaking from a more tangible experience. In visiting these 

various VA Medical Centers, it was mainly sidebar conversations. 

A more accurate account is compiled in a report the American Legion publishes annually, which is also distributed to Congressional 

Members. Although I cannot be as definitive as in my reports, the 

overall subject matter here is that they spoke of issues affecting 

them. 

And part of the frustration also, there was no raise in pay. The 

pay was not so bad because it was used to attract them and even 

mentioning like in a whisper on the side that the locality pay was 

a challenge. 

For example, in one of the locales visited in California, the cost 

of living was pretty challenging. The average home was $750,000; 

it was an issue of locality pay, which employees, who reported to 

me that it would force them to relocate because of affordability. 

While they loved it there and loved the VA Medical Center, they 

could not afford to live there. 

Ms. BROWN OF FLORIDA. I see. I think this is something that we 

probably need to address. But, I feel like the allied health is like 

teachers and we do not pay these people enough. I agree. But it 

is rewarding to do what you really like to do. 

And hopefully maybe we could recruit differently and maybe we 

could work with scholarships early on like we do in some critical 

needs areas that you could get some kind of support as far as the 

college loans and other kinds of programs like that because we 

need people that are committed to the profession and really want 

to work with these veterans. 

Mr. MICHAUD. Thank you very much, Congresswoman, and I 

agree a hundred percent. 

Once again, I would like to thank this panel and Mr. Bender for 

coming back up for your excellent testimony and answering questions. So thank you very much. 

The last panel that we have is Mr. William Feeley, who is Deputy Under Secretary for Health for Operations and Management in 


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VHA. And he is accompanied by Nevin Weaver, who is the Chief 

Management Support Officer in VHA, and Joleen Clark, who is the 

Deputy Chief Management Support Officer in VHA. 

So I would like to welcome you, Mr. Feeley, and look forward to 

hearing your testimony. 

STATEMENT OF WILLIAM F. FEELEY, MSW, FACHE, DEPUTY 

UNDER SECRETARY FOR HEALTH FOR OPERATIONS AND 

MANAGEMENT, VETERANS HEALTH ADMINISTRATION, U.S. 

DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY 

NEVIN WEAVER, CHIEF MANAGEMENT SUPPORT OFFICER, 

VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 

VETERANS AFFAIRS; AND JOLEEN CLARK, DEPUTY CHIEF 

MANAGEMENT SUPPORT OFFICER, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS 

Mr. FEELEY. Good morning, Mr. Chairman and Members of the 

Committee. I want to thank you for the opportunity to discuss 

VHA’s Recruitment and Retention Program for Healthcare Professionals. 

One of the most critical obligations leaders in any organization 

have is taking steps to ensure that the organization has a solid 

workforce in the future. 

I am proud that the VHA’s workforce plan has been recognized 

by Office of Personnel Management as a Federal best practice and 

look forward to sharing with you some of the strategies that have 

gotten us to this point. 

I am joined today by Mr. Nevin Weaver, Chief Management Support Officer, and Joleen Clark, Deputy Chief Management Support 

Officer. 

I will begin my testimony by outlining a number of the key programs that VHA has implemented to improve recruitment and retention. My oral comments will be a reduced version of the written 

testimony to best use time. 

In April of 2007, VA launched a Nursing Academy to address the 

nationwide shortage of nurses. The purpose is to expand nursing 

faculty in schools and promote nursing education through clinical 

rotations in the VA. VA will assign its nursing staff to serve as faculty roles and will fund school faculty when they are not in the VA. 

This initiative is rolling out at four locations, in Gainesville, Salt 

Lake City, San Diego, and West Haven, Connecticut VA, and will 

expand to 8 other facilities over the next several years allowing us 

to impact on recruiting about 1,000 new nurses into the VA. 

The VA Learning Opportunities Residency Program is another 

program designed to attract students of baccalaureate nursing and 

pharmacy doctorate programs. Students are paid internship development competencies in the VA facility under the guidance of a 

preceptor. In 2006, VHA hired 89 nurses who graduated from this 

program. 

The Graduate Health Administration Training Program is a 

year-long paid training experience offering the graduates of a 

healthcare administration master’s program brought to our system 

and we have recruited 35 of these positions on an annual basis. 

The technical career field is intended to create a talent pool in 

critical occupations such as financial management, human reVerDate Aug 31 2005 03:06 Aug 19, 2008 Jkt 039464 PO 00000 Frm 00028 Fmt 6633 Sfmt 6633 E:\HR\OC\39464.XXX 39464

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sources, contracting, prosthetics, logistics, bio-med, and general engineering. In the past 5 years, 226 interns have completed the program and accepted positions in the VHA. 

The Student Career Experience Program offers students work experience related to their field of study by providing periods of work 

and study while attending school. It focuses on recruiting students 

from minority colleges and universities in mission-critical occupations for permanent employment following graduation. 

The VA Cadet Program targets high school students who come 

to us as volunteers. It introduces high school students to healthcare 

occupations and encourages them to pursue education and training 

in nursing and other allied health professions. 

We have some very interesting recruitment and retention tools. The Employee Incentive Scholarship Program pays up to $32,000 

for healthcare related degree programs. Since 1999, approximately 

4,000 employees have graduated from these programs. Recipients 

include registered nurses, 93 percent of the graduates, pharmacists, and other allied health professionals. 

The Education Debt Reduction Program provides tax-free reimbursement of educational loans to recently hired title 38 and hybrid 

title 38 employees. As of August 2007, there were 5,600 healthcare 

professionals in the program. Seventy-seven percent of these professionals were from three mission-critical occupations, nursing, 

pharmacy, and physician. 

The Physician Pay legislation has proven to be very successful. 

VA is committed to ensuring that the levels of annual pay for VA 

physicians and dentists are at the levels regionally comparable 

with the income of non-VA physicians and dentists. Since this legislation has gone into effect, physician employment has increased 

by 430 doctors. 

VHA also pays close attention to employee entrance and exit surveys. The entrance survey is an excellent tool to examine why individuals come to work for us in the first place. And as Congresswoman Brown has indicated, people need to have passion in their 

belly to do the job in wanting to serve veterans. In contrast, the 

exit survey tracks the reason why VHA staff leave. 

Results from the 2006 show the top reasons to work for the VA 

were advancement, career development opportunities, benefits 

package, and job stability. The mission of serving VA and pay were 

also highly admitted. 

The exit survey shows the top reasons for leaving VHA were normal retirement as we face an aging workforce, advancement, and 

other healthcare organizations, and family matters including relocation and people being in childbearing years. 

We want to thank the Committee for their interest and support 

for VHA’s succession planning. This concludes my statement and I 

look forward to responding to any questions you might have. 

[The prepared statement of Mr. Feeley appears on p. 59.] 

Mr. MICHAUD. Thank you very much, Mr. Feeley. 

You mentioned VA has been working on the pilot project for universities and colleges and the academic world. It sounded like all 

four of those were in urban areas. And as we know, that if you tend 

to get trained in a certain area, if it is a rural area, you tend to 

stay there. 


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What is VA doing, and you mentioned additional sites, to make 

sure that rural areas are taken care of, particularly when you look 

at the veterans’ population? Forty percent of our military are in 

rural areas. Rural areas are definitely going to need the help. So 

what are you doing to help recruit or retain healthcare professions 

and working with higher ed in the rural areas? 

Mr. FEELEY. I think this is a pilot initiative. It is going to have 

eight more schools enrolled in it. That is something I will take 

back. 

[The following was subsequently received:] 

Question: What plans does VA have in place to ensure that rural areas 

also have the opportunity to participate in the VA Nursing Academy Pilot 

Project? The four initial sites selected seem to be primarily in urban areas. 

Response: On April 16, 2007, the VA announced the VA Nursing Academy: Enhancing Academic Partnerships program by sending the Request 

for Proposals to every VA healthcare facility and VISN and to 609 schools 

of nursing with baccalaureate degree programs. VA received 62 Letters of 

Intent (LOI) to submit proposals involving 59 VA facilities and 68 schools. 

Each proposal was evaluated by a panel of VA and other Federal nurse experts with clinical, educational and faculty backgrounds, using a standard 

process in routine use by VA’s Office of Academic Affiliations, VA’s Office 

of Research Development, the National Institutes for Health and Non-Profit 

Foundations. The four sites selected received the highest scores. 

The following review criteria were used: 

1. Commitment by VA and Nursing School Leadership 

2. Commitment by Nursing School to increase enrollment 

3. Current/past relationships and activities between VA and Nursing 

School 

4. Experience of VA and Nursing School Program Directors to implement 

educational programs and innovations 

5. Ability to implement proposed partnership model 

6. Activities/learning opportunities included in the proposed program 

7. Availability/experience/interest of VA and School Faculty 

8. Proposed faculty development plan 

9. Proposed evaluation plan 

10. Agreement to fund travel for program planning and evaluation 

For the second year of the pilot, the applying sites will be classified by: 

(1) VA complexity level, which is an overall measure of size, complexity of 

healthcare services provided and research intensity; (2) rural-urban location; (3) inclusion of multiple schools and/or VA facilities in the proposed 

partnership; and (4) intensity and duration of relationships between VA(s) 

and school(s) in the proposed partnership. This will allow the peer review 

panel to take additional factors into account when scoring the applications. 

Mr. FEELEY. As a New Englander and as someone who spent 

some time in Damariscotta, Boothbay Harbor, and the Rangeley 

area, I know exactly what you are talking about. And I think we 

are going to have to find ways to incentivize it via tuition reimbursement, loan reduction. And I guess my preferred location at 

some point in my life would be a Cabot Cove type of environment. 

Mr. MICHAUD. That is good to hear. 

To date, has VA taken any steps to hire licensed professional 

counselors to provide the mental health services to our veterans? 

Mr. FEELEY. We have recruited in the last 15 months 3,500 additional mental health professionals over the base that we already 

had in 2005. This recruitment is with the benevolent generosity of 

Congress giving us additional money to prepare for the influx of 

mental health patients we are anticipating from the war. 


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I think that those are competed for at a local level and people 

have to reply. We actually used USA Today as an advertisement 

source. Got a very good response to that as we were trying to accelerate the recruitment process. 

I do not have a breakdown of how many counselors were hired. 

A historical pattern has been psychologists, Master’s trained social 

workers, and advanced nurse professionals. But counselors who are 

trained and certified can apply. They have to win the competition 

in a competitive interview process to get the job. 

[The following was subsequently received:] 

Question: Please provide a breakdown of the healthcare professionals 

hired within the last 9 months (particularly licensed professional counselors). 

Response: The breakdown (Monthly Distinct Employee for Non-Med Resident, GAIN, VHA (Occupation Name), January–September 2007) appears 

on p. 70. 

Mr. MICHAUD. You mentioned hiring dentists. I am not sure of 

the breakdown within the VA system as far as how many veterans 

actually need dentures. Often in the private sector, if you go to a 

dentist, it is a lot more expensive to get dentures than if you went 

to a denturist. And a lot of times dentists actually go to denturists 

to get the dentures which are much more expensive than going 

through a dentist. 

Have you looked at or evaluated cost efficiencies when you look 

at hiring denturists versus dentists? 

Mr. FEELEY. I think you are raising a very interesting question. 

We had a considerable challenge in meeting dental needs. About 18 

months ago, invested a fair amount of money to meet that backlogged need. And that included fee basis in rural areas to make 

sure people did not have to travel long distances. 

The question you are raising related to using another type of provider to do denture work, I am frankly just not up on what the 

proper answer to that would be. But we certainly can get back to 

you. And it is an interesting idea, unless Mr. Weaver or Ms. Clark 

have a thought on that. 

[The following was subsequently received:] 

Question: Has VA considered employment of denturists as opposed to dentists? Denturists prepare and fit dentures at much lower costs than dentists. 

Response: VA does not employ denturists at any of its facilities as the 

independent practice by denturists is not legal in most States. Denturists 

are dental laboratory technicians with additional training to provide denture services directly to patients. Denture services are provided to eligible 

veterans by VA dentists at a cost less than can be obtained through fee 

basis contract with dentists in private practice. 

Mr. MICHAUD. I appreciate you looking at it because you will 

hear from the dentist that they are the only ones that can do it. 

But, quite frankly, a lot of them go to denturists to get that care, 

which is a lot less expensive by far. And I think that is something 

that we ought to look at how we can best utilize our funding. 

When you look at providing healthcare providers within the VA, 

if you look at what is happening, particularly in the war in Iraq 

and Afghanistan, we had a panel a couple of weeks ago that said, 

I believe, 13 percent of our men and women who are coming back 

have some form of eye injury. 


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Is there a shortage currently within VA to deal with those types 

of issues and, if so, how are you addressing that shortage? 

Mr. FEELEY. We measure wait in a number of specialty areas. 

We actually measure waits in 50 clinics and 8 specialty areas. I believe the eye clinic is one of those areas that we measure. 

And I am not seeing in our data systems backlog or people waiting long periods of time for ophthalmology care, keeping in mind 

that a person who needs stat right-away care is going to get it immediately. Just like when you go to the emergency room, that is 

a different situation than going for your routine primary care. So 

an eye injury that occurs and is requiring active care is going to 

be seen right away. 

Mr. MICHAUD. Great. Thank you. 

Ms. Brown. 

Ms. BROWN OF FLORIDA. Thank you. 

I have a couple of questions. One, when you were giving those 

schools, you said Gainesville. Is that the University of Florida at 

Gainesville? 

Mr. FEELEY. Yes. 

Ms. BROWN OF FLORIDA. All right. Well, you know, there is another Gainesville somewhere. 

Mr. FEELEY. Okay. Yes. I am sorry. 

Ms. BROWN OF FLORIDA. What were those three other areas did 

you say? You said Gainesville, Florida, and what were the others? 

Mr. FEELEY. Salt Lake City, San Diego, and West Haven. 

Ms. BROWN OF FLORIDA. Okay. 

Mr. FEELEY. And we will expand to eight other schools in the 

next several years. 

Ms. BROWN OF FLORIDA. Yes. Well, some of those places sound 

pretty rural to me including Gainesville because Gainesville serves 

Gainesville, Lake City, you know, a lot of the rural areas. So the 

school will be serving the local communities, I assume. 

And now, the programs that you have at those schools, would 

you tell us quickly what the pilot programs encompass? 

Mr. FEELEY. I could not give a detailed explanation of that curriculum other than the over-arching objective is we are going to 

provide faculty for these schools because the schools actually have 

a shortage of teachers and that is a piece of what is leaving them 

unable to take applicants in. 

So we are moving our well-educated nursing staff into being faculty in those schools and they would get, these students would get 

the exact same curriculum that they would have gotten in the 

nursing school. 

Ms. BROWN OF FLORIDA. Okay. I guess the next question I am 

asking is, what kind of scholarship programs do you have to encourage internships or co-ops? What kind of program do you have 

working with young people because one of the problems now is the 

cost of education? And if you were providing some kind of a grants 

program to assist kids as they go to school, I mean, that is an incentive in itself. 

Mr. FEELEY. I am going to make a try at that and then ask my 

colleagues to help me. The Education Debt Reduction Program is 

a huge——


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Ms. BROWN OF FLORIDA. Oh, it is a great program. And we are 

not real sure how it is working with the VA. But I know I use it 

on my staff and basically even though your salary may be one 

thing, but if we are giving you a thousand dollars a month to pay 

off your loan, that is a big incentive. 

Mr. FEELEY. And we do that up to the tune of, I believe, $34,000? 

Ms. CLARK. It’s 38 funded centrally and $48,000—— Mr. FEELEY. Thirty-eight dollars funded centrally and—— Ms. BROWN OF FLORIDA. Okay. 

Ms. CLARK. Forty-eight thousand is the total amount that can be 

paid so the medical center can supplement if they want to pay off 

or give a provider additional funds. 

Ms. BROWN OF FLORIDA. Are you saying that a nursing student 

that is working for the VA, you will pay up to how much money? 

Ms. CLARK. Forty-eight thousand dollars. 

Ms. BROWN OF FLORIDA. For one student? 

Ms. CLARK. Yes. 

Ms. BROWN OF FLORIDA. Well, I mean, I think that is good. 

And so they have to be working there in order to get that? 

Ms. CLARK. For that program, yes, they do. 

[The following was subsequently received:] 

They received loan repayment at the end of each year up to a maximum 

of 5 years. 

Ms. BROWN OF FLORIDA. So how many people do you have enrolled in that program? 

Mr. MICHAUD. And could you turn your microphone on as well? 

Thank you. 

Ms. CLARK. Sorry. I thought it was on. 

Well, registered nurses, we had a total of 2,300, a little over 

2,300 that went through using the Education Debt Reduction 

since—— Ms. BROWN OF FLORIDA. That is a small percentage. Is it a limited amount of money in the program? 

Mr. FEELEY. It is 5,600 nationally, 2,300 nurses, but there is not 

a limitation, I think, that I am aware of. We are going to come forward and fund whoever we can. 

The other thing I would mention along the lines you are talking 

about, if someone comes to work for us as a nursing assistant or 

as an LPN, we will also pay their education to go on to a baccalaureate degree which is another good recruitment tool. 

Ms. BROWN OF FLORIDA. Oh, it has got to be. And it would help 

us get the people in the profession with that fire in the belly that 

we want, that want to help and work. 

My question is, what kind of programs do you have with the minority institutions? Florida A&M has one of the best pharmacy programs in the country. I was involved in helping to expand that program when I was a State representative in Florida. Do you all do 

recruitment at the black colleges and do you have, like you said, 

co-op programs working with these black institutions of higher education, the HBCV’s——

Ms. CLARK. Historically black colleges and universities (HBCV). 

Ms. BROWN OF FLORIDA. Yes, uh-huh. 

Mr. WEAVER. Yes, we do. In fact, with nursing, we have approximately 650 affiliations with nursing schools and I think it is about 


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30 to 35 percent of all nursing students do a rotation through the 

VA. 

Ms. BROWN OF FLORIDA. Do you pay those students while they 

are going through that program? 

Mr. WEAVER. Well, only if they are an employee. And if a person 

is going to school and they are not an employee of the VA, they do 

rotations through the VA. We have employees who work for the VA 

who go to these schools that we do provide tuition support if they 

have requested it. 

Ms. BROWN OF FLORIDA. Well, we should encourage that. And do 

you have the co-op type program? 

Mr. WEAVER. Yes, we do. We have co-op programs not only for 

nurses but other allied health and also technical career fields. 

Ms. BROWN OF FLORIDA. And my last question is, I was with 

someone Sunday and they had just received a Master’s in Mental 

Health. And I was talking to them about the VA and they indicated 

that you do not hire people with a Master’s Degree in mental 

health, VA, that you have to have it in social work. I am just kind 

of confused. 

I asked her to send me the curriculum because if that is the case, 

we need to take a look at it because, in fact, they have had more 

training working with people with, you know, problems directly related to mental health as opposed to a person with a Master’s in 

Social Work because that could be School of Social Work or, you 

know, it is very broad. 

Mr. FEELEY. I think that was what the first panel witness was 

pointing out. And, again, I think people need to apply and compete 

for these positions. And under the Public Law, they are able to do 

that. And I would encourage that person to make an application at 

their local VA. 

There is never a better time now——

Ms. BROWN OF FLORIDA. Oh, I told her that. 

Mr. FEELEY. Yeah. 

Ms. BROWN OF FLORIDA. And she is in Orlando, an excellent 

area, so I am definitely going to follow through with that person. 

But I am just wondering is it any kind of system in VA that does 

not encourage a person with a Master’s Degree in Mental Health 

to apply? 

Mr. FEELEY. Not that I am aware of. And I think the classification of what a person’s pay may be is going to be based on their 

educational experience. But I think my message would be there are 

a variety of jobs in mental health, please go knock on the door and 

put the application in. 

I would just share with you one unique experience related to an 

approach I have seen a number of facilities take. Some medical 

centers actually have seniors in high school who are the best and 

brightest attending their senior year at the VA Medical Center 3 

days a week. And they are getting preceptored by our clinical staff 

and they are walking around in doctor’s coats and x-ray coats. And 

I actually saw the graduation ceremony. These young people were 

going to very prestigious schools and all of them were going into 

healthcare. 


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So we are trying to reach down very deeply. I think grammar 

school is next, but I am pleased to see high school doing as well 

as it is doing. 

Ms. BROWN OF FLORIDA. High school is great. And, you know, 

junior high school is critical because that is when those are really 

areas that, you know, we want to put them on the right track. 

Thank you very much. 

And thank you, Mr. Chairman. 

Mr. MICHAUD. Thank you very much. 

I just have one additional question. It deals with a study that 

was sponsored by the Partnership for Public Service that recently 

came out that showed a large discrepancy in the workplace satisfaction in the Veterans Health Administration between workers 

who are over 40 and workers who are under 40. VHA workers who 

are over 40 reported a high satisfaction as far as their work; those 

under 40 reported a low satisfaction. 

What factors do you think account for that discrepancy and what 

are you doing to try to attract younger workers? 

Mr. FEELEY. We do an all employee survey each year and that 

all employee survey is done throughout the country with an 80 percent completion rate. Most of it is online, but if someone is unable 

to do it online, we will help them get it done in writing. 

We have it broken down by job category and by age. And so you 

can see it actually from 30 and under to 30 to 45, 45 and over, and 

even 60 and over. 

And clearly the trend you are describing is very prevalent. Part 

of what I think we have to do is find a way to engage the younger 

generation in, I think, the point Congresswoman Brown made, 

about the meaning that comes with this work. It is an honor to do 

this work. 

And we also have to work on workforce after five o’clock life balance. I want to be careful how I say this, but people of different 

eras were brought up differently related to work. And so what is 

a 60-hour-a-week standard in one era is now a 40-hour-a-week 

standard in another. 

So we have to find ways to adapt our workforce employment to 

take this all into consideration because I just turned 60 and I am 

concerned about how healthy it is going to be in the next 5 years. 

We want to make sure we are bringing young people in. 

Mr. MICHAUD. Great. 

Ms. Brown. 

Ms. BROWN OF FLORIDA. Mr. Chairman, in that survey, I am 

finding that even across fields, money is more of an incentive to 

young people and the amount of time they work and how much free 

time they have as to people that are over 40 because, you know, 

it is just a different mentality as far as the work is concerned. 

And I think money can be an incentive. I hate to keep talking 

about money, but it is a factor for a lot of young people. 

Mr. FEELEY. And we are trying to use all types of tools including 

relocation bonuses, retention bonuses. And as Mr. Cox said, if we 

are able to keep an employee beyond 5 years, they are going to be 

with us. It is that first five-year period to get them ignited and excited about working for the VA that is critical. 


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Ms. BROWN OF FLORIDA. And I think if you all could look seriously at expanding that student loan program and that repayment 

program because that is a great incentive if you all are paying a 

thousand dollars a month, I mean, because we use that in other offices and it makes a difference because we cannot compete with, 

you know, a lot of the jobs in the private sector. But when people 

have these huge loans they have to pay back, that is a bonus in 

itself. 

Mr. MICHAUD. Great. 

Ms. BROWN OF FLORIDA. So I would like to get an update on the 

program and exactly how many people you have and how are we 

advertising it to the employees. 

Thank you, Mr. Chairman. 

[The following was subsequently received:] 

Question: Please provide an update on the different student loan/scholarship/debt reduction programs. 

Response: 

Scholarship Programs 

Implemented in 2000 the Employee Incentive Scholarship Program (EISP) 

authorizes VA to award scholarships to employees pursuing degrees or 

training in healthcare disciplines for which recruitment and retention of 

qualified personnel is difficult. EISP awards cover tuition and related expenses such as registration, fees, and books. The academic curricula covered 

under this initiative include education and training programs in fields leading to appointments or retention in Title 38 or Hybrid Title 38 positions 

listed in 38 U.S.C. section 7401. The following data reflects the total employee participants through fiscal year 2007: 

• Total number of awards: 7,127 

• Total number of employees completing the program (graduates): 3,988 

• Total amount of funding for awards through FY 2012: $88,315,696 

• Average amount of award per participant $12,392 

The chart below identifies the total number of scholarships awarded to 

VHA employees since 2000, the number of employees who have completed 

their programs and the average amount of the scholarship awarded by occupation. 

Occupation 

Total # 

Awards 

Total # 

Completed Average Amount 

of Each Award 

Registered Nurse 6,595 3,634 $12,416 

Pharmacist 188 96 $17,601 

Licensed Practical Nurse 134 66 $7,196 

Physical Therapist 55 21 $9,593 

Physician Assistant 34 26 $6,388 

Registered Respiratory 

Therapist 34 16 $5,995 

Certified Registered 

Nurse Anesthetist 33 7 $15,920 

Audiologist 12 3 $5,949 

Occupational Therapist 12 6 $14,677 


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Occupation 

Total # 

Awards 

Total # 

Completed Average Amount 

of Each Award 

All other 30 16 —

TOTAL 7,127 3,988 $12,392 

An analysis of the average cost per award reveals that the average award 

($12,329) is substantially less than the maximum amount allowed ($35,024 

in FY 2007) by statue. Additionally, the average number of credit hours 

funded per employee (45 credits for undergraduate and for 36 credit hours 

graduate) is substantially less than the hours allowed by statue (90 credits 

for undergraduate and 54 for graduate). This demonstrates that the employees are selecting academic institutions with reasonable costs and the 

employees have self-funded a substantial part of the degree prior to applying for the scholarship award. 

Education Debt Reduction Program 

The chart below provides a snap shot of the number of employees who have 

participated in the Education Debt Reduction Program (EDRP) since its implementation in May 2002. The program is authorized in Chapter 76 of 

Title 38 of the United States Code. Designed to assist VA with recruitment 

and retention of hard-to-fill healthcare professions, it applies to Title 38 

and hybrid Title 38 occupations. Total expenditures for EDRP awards from 

the programs inception and continuing with award obligations authorized 

through FY 2012 are $96,870.402. 

Occupation 

Total # EDRP 

Awards 

Total # 

Completed Average Amount 

of Award 

Registered Nurse 2,704 1,475 $13,451 

Pharmacist 876 429 $23,595 

Physician 715 345 $24,790 

Licensed Practical/ 

Vocational Nurse 285 173 $5,499 

Physical Therapist 231 128 $21,522 

Physician Assistant 204 116 $21,254 

Occupational Therapist 105 75 $16,381 

Medical Technologist 97 38 $16,135 

Diagnostic Radiologic 

Technologist 80 34 $11,223 

Registered Respiratory 

Therapist 50 33 $11,860 

All other 23 occupations 309 138 

Total 5,656 2,984 $16,571 

VALOR—VA Learning Opportunity Residency Program 

Initiated in 1990, for students (junior class level) enrolled in schools of 

nursing with baccalaureate degree programs VALOR has provided opportunities for students to develop competencies in clinical nursing while at an 

approved VA healthcare facility. In FY 2007 there were 398 new VALOR 

nursing students and 193 continuing students. Outcomes of the program 


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have demonstrated that it is an excellent method of recruiting students 

when those students are retained into the senior year (over 50 percent of 

this group are hired). With the success of the nursing VALOR program, in 

2007 the VALOR program for pharmacy students began. In this inaugural 

year 14 students were selected. Additional sites and students will be approved as the program evolves and develops. 

Mr. MICHAUD. Thank you very much, Ms. Brown. 

And there will be additional questions for the record as well. 

So once again, I want to thank this panel for your outstanding 

testimony. As we move forward on this very important issue, I look 

forward to working with you as well. 

And I want to thank all the employees at VA. I know a lot of 

times, they get criticized. But, quite frankly, part of the blame belongs to the Administration and Congress for not providing adequate timely funding. 

So I do appreciate all the hard work that the VA employees do 

and we will continue to work with you. 

So this hearing is adjourned. Thank you. 

[Whereupon, at 11:57 a.m., the Subcommittee was adjourned.] 


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A P P E N D I X 

Prepared Statement of Hon. Michael H. Michaud, 

Chairman, Subcommittee on Health 

I would like to thank the members of the Subcommittee, our witnesses and all 

those in the audience for being here today. 

We are here to address the very important issue of recruitment and retention of 

health care professionals in the Veterans Health Administration. Health care professionals are the Veterans Health Administration’s most important resource in delivering high-quality health care to our Nation’s veterans. The VA must recruit and 

retain doctors, nurses, mental health providers, physical therapists, and many other 

health care professionals in order to stay true to their motto of ‘‘Best Quality of Care 

Anywhere.’’ Quality care can only come from quality care providers—but recruiting 

and retaining quality health care professionals is becoming increasingly difficult. 

Health care professionals often choose to work in the private sector because it offers 

more attractive pay and benefits packages than the VA offers. 

Not only does the VA need to maintain its current workforce, but the VA also 

needs to look to the future to ensure that its staffing needs can be met. Operation 

Enduring Freedom and Operation Iraqi Freedom veterans are returning and becoming eligible for VA services in record numbers. Additionally, a recent study by the 

Partnership for Public Service found that VHA employees under the age of 40 have 

very low job satisfaction. The VA needs to pay particular attention not only to its 

future workforce needs, but also to the work environment so that they will be able 

to retain younger workers. 

In our first panel this morning we will hear from representatives of health care 

providers. These organizations work closely with the VA to provide the best service 

possible to our Nation’s veterans. I want to send a special welcome to Kristi 

McCaskill representing the National Board of Certified Counselors. Last year, Congress passed the Veterans Benefits, Health Care, and Information Technology Act 

of 2006 which explicitly recognizes licensed counselors as health care providers 

within the Veterans Health Administration. As part of their recruitment plan moving forward, I would encourage the VA to use Licensed Professional Counselors as 

mental health treatment providers. Licensed Professional Counselors are qualified 

and eager to provide services to America’s Veterans. 

I look forward to hearing about the VA’s current recruitment and retention system as well as some ideas about how this system can be improved in the future to 

meet VA’s health care needs. 

f 

Prepared Statement of Jeffrey L. Newman, PT, Member, American Physical 

Therapy Association, and Chief, Physical Therapy Department, 

Minneapolis Veterans Affairs Medical Center, Minneapolis, MN 

Chairman Michaud, and members of the Subcommittee on Health, thank you for 

the opportunity to testify on the recruitment and retention of qualified healthcare 

professionals to work in the Department of Veterans Affairs’ (VA) Veterans Health 

Administration (VHA). These professionals, such as physical therapists, are vital to 

meet the rehabilitation needs of our Nation’s veterans today and tomorrow. 

I am proud to say I have practiced as a physical therapist in the VA system for 

more than 30 years, and for 20 of those years I have served as Chief of the Physical 

Therapy Department at the VA Medical Center in Minneapolis, Minnesota. As you 

may know, this facility is also one of the four designated Polytrauma Rehabilitation 

Centers (PRC) providing care to patients with a wide spectrum of rehabilitation 

needs including those with Traumatic Brain Injury (TBI). I come before you today 

as a member of the American Physical Therapy Association (APTA) which represents over 70,000 physical therapists, physical therapist assistants and students 


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1 At the end of fiscal year 2006, 1,024 physical therapists were employed by the VA Department of Veterans Affairs. 2 ‘‘Research in VA Geriatrics Centers of Excellence’’ Fact Sheet May 2006. Department of Veterans Affairs website. Accessed October 15, 2007. 3 Atul Gawande, ‘‘Casualties of War-Military Care for the Wounded from Iraq and Afghanistan,’’ The New England Journal of Medicine, vol. 351, issue 24 (December 2004) p. 2471. 

of physical therapy nationwide. I have served in several leadership posts within the 

Association including past President of the APTA’s Veterans Affairs’ section. 

In my experience providing physical therapist services and managing a team to 

provide rehabilitation services, I have seen the physical therapy profession advance 

to meet the changing rehabilitation needs of our patients. The primary challenge to 

continue to meet the rehabilitation needs of veterans is the recruitment and retention of physical therapists. This challenge is compounded by two trends that increase the need for physical therapist services: chronic conditions associated with 

an aging veteran population and the complex impairments associated with returning veterans from Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF) in Iraq. 

In my remarks today, I will discuss the increased need for physical therapists in 

the VA system, highlighting current challenges with recruitment and retention of 

physical therapists within a changing environment that only increases the need for 

rehabilitation led by these professionals. I will make two specific recommendations 

to help meet these challenges and ensure our Nation’s veterans the accessibility and 

availability to the physical therapists services they need to regain mobility and function to ensure they achieve the highest degree of independence and quality of life 

in their homes and communities. These recommendations are the immediate approval and implementation of pending qualification standards and focused enhancements to current VA scholarship programs for physical therapists. 

Physical Therapists in the VA: An Increasing Need For Rehabilitation Services 

Physical therapists (PTs) are health care professionals who diagnose and manage 

individuals of all ages, from newborns to elders, who have medical problems or other 

health-related conditions that limit their abilities to move and perform functional 

activities in their daily lives. Physical therapists examine and develop an individualized plan of care using treatment interventions to promote the ability to move, reduce pain, restore function, and prevent disability. Physical therapists also work 

with individuals to prevent the loss of mobility by developing fitness- and wellnessoriented programs for healthier and more active lifestyles. 

With more than 1,000 1 physical therapists on staff, the VA is one of the largest 

employers of physical therapists nationwide. Physical therapists have a long history 

of providing care to our active duty military and to our Nation’s veterans. In fact, 

our professional roots started by rehabilitating soldiers as they began returning 

from World War I. Back then, physical therapists were known as ‘‘reconstruction 

aides.’’ Today, physical therapists in the VA render evidence-based, culturally sensitive care and many have been recognized leaders in clinical research and education. Physical therapists in the VA practice across the continuum of care, from 

primary care and wellness programs to disease prevention and post-trauma rehabilitation. Clinical care practice settings that include physical therapists include inpatient acute care, primary care, comprehensive inpatient and outpatient rehabilitation programs, spinal cord injury centers and geriatric/extended care. 

The need for high quality rehabilitation provided by physical therapists has never 

been greater with the dual challenges of caring for the chronic diseases faced by 

aging veterans and the multifaceted profile of many of today’s wounded warriors. 

According to the VA, 9.2 million veterans are age 65 or older, representing 38% of 

the total veteran population. By 2033, the proportion of older veterans will increase 

to 45% of the total.2 Among this aging veteran population, a high prevalence of diabetes is a critical chronic disease challenge for health care providers. Physical therapists are specialists in facilitating or regaining mobility and function lost due to diabetes and its complications as well as its prevention strategies. 

The second trend that highlights the need to recruit and retain physical therapists in the VA is the changing profile of injuries and impairments of our returning 

service personnel. Enhancements in battlefield medicine have helped a larger portion of soldiers survive their injuries, compared to previous wars our Nation has 

fought.3 Many of our Nation’s recent veterans are facing unique injuries that require complex rehabilitation including spinal cord injury, amputee rehabilitation 

and traumatic brain injury. Physical therapists are a key part of the VA’s Polytrauma Rehabilitation Centers (PRCs) caring for TBI patients in Tampa, Palo Alto, 


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4 ‘‘2005–2006 Fact Sheet, Physical Therapy Education Programs.’’ Pg 4. American Physical 

Therapy Association. January 2007. 

Richmond, and at my facility in Minneapolis. PRCs have clinical expertise and include an interdisciplinary team to provide care for complex patterns of injuries, including TBI, traumatic or partial limb amputation, nerve damage, burns, wounds, 

fractures, vision and hearing loss, pain, mental health and readjustment problems. 

Physical therapists are also part of the specialized amputee rehabilitation center at 

the Brooke Army Medical Center at Fort Sam Houston, Texas. 

Physical therapists at the Minneapolis VA facility—and at other facilities—have 

been at the forefront in developing programs to care for our wounded warriors prior 

to the creation of the PRC designation. Minneapolis has had a TBI program with 

dedicated staff in TBI rehabilitation for over 10 years. We have physical therapists 

on staff who have received American Board of Physical Therapy Specialties (ABPTS) 

specialist certification in neurological, clinic specialists in geriatric, and orthopedic 

physical therapy. My specific clinical background is in amputation rehabilitation. I 

have had the honor of caring for a generation of veterans and have been able to 

see the growing need for physical therapist services through the years. 

Current Recruitment and Retention Challenges for Physical Therapists in 

the VA 

Given the increasing number of aging veterans and the number of OEF/OIF veterans needing physical therapist services, recruitment and retention of qualified 

physical therapists is vital to ensuring our veterans have access to the physical 

therapist services they need in a timely fashion. The number one obstacle to both 

the recruitment and retention of physical therapists to serve in the VA is the severely outdated qualification standards that currently govern the salary and advancement opportunities for physical therapists employed by the VA. These standards have not been updated for nearly 25 years. 

The physical therapy profession has evolved as the need for our services has expanded. Unfortunately the VA has not kept pace with current professional practice 

standards and is quickly falling behind clinical areas outside of the VA and other 

health care professionals with similar or lesser qualifications within the VA. The 

current minimal requirement to become a physical therapist is to graduate with 

a master’s degree (approximately 80% of programs now are graduating at the doctoral level 4 and pass a licensure test. The current VA qualification standards still 

only require a physical therapist to obtain a bachelor’s degree and do not recognize 

the doctorate of physical therapy or DPT degree. Not only is this severely out of 

date with current minimal education requirements but it is not competitive with 

clinical settings outside of the VA system. 

I recommend the immediate approval of revised qualification standards for physical therapists to establish a consistency between the VA and the current professional practice of physical therapy and to achieve equity with healthcare professionals of similar education, experience and expertise currently practicing in the VA. 

The APTA in representing physical therapists practicing in the VA, strongly supports the immediate approval of these qualification standards. 

APTA began working with the VA to update the qualification standards over six 

years ago and supports the following changes to establish consistency between the 

VA and the current professional practice of physical therapy as defined by the Guide 

to Physical Therapist Practice: 

• Recognition of Educational and Clinical Training of the Physical Therapist, 

• Clarification of a career ladder in the Department of Veterans Affairs for Physical Therapists, 

• Recognition of the Doctoral Degree in Physical Therapy, and 

• Expanded opportunities for career advancement for physical therapists. 

Unfortunately while the APTA has received feedback from the VA that changes 

need to be made to update the qualification standards, these recommendations have 

not been implemented. Establishing appropriate and up to date qualification standards will make it easier to both recruit and retain physical therapists to serve our 

Nation’s veterans. 

The need for immediate approval of these revised standards is due to several factors. First, the demand for physical therapist services is on the rise, and the outdated qualification standards have made it difficult to recruit physical therapists to 

the VA system. Second, the increased need for services provided by qualified physical therapists in the VA due to the two trends outlined above—providing services 

for our aging veterans and meeting the complex rehabilitation needs of our returning soldiers. Third, the outdated qualification standards also limit the ability of a 


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5 According to information on physical therapists from the HRRO Education Database provided to APTA by the Department of Veterans Affairs on October 15, 2007. 

physical therapist to advance within the VA system once they have joined. The current standards do not recognize physical therapists that achieve specialty certification such as those needed in the polytrauma centers. Fourth, it has been at least 

61⁄2 years since the VA first recognized that the standards needed to be updated. 

These pending regulations should be implemented immediately. 

In addition to the immediate approval and implementation across the board—not 

just in select facilities—of the revised qualification standards, I recommend enhancements to the current VA scholarship programs for physical therapists to help 

in both recruitment and retention. Many new graduates are concerned with a high 

amount of student loan debt when leaving school, scholarship and loan repayment 

programs are an important tool in recruiting additional physical therapists to meet 

the VA’s need. 

I had the opportunity to serve on the Committee to review scholarship program 

applicants in the early 1990s when the VA had—in my opinion—a very successful 

scholarship incentive program to attract new graduates. Over the course of that particular program, my facility in Minneapolis had five recipients. One of those original 

recipients is still in my facility, two of the other stayed for several years with only 

two leaving directly after their required service was complete. The previous scholarship program provided an incentive to serve right out of school whereas the new 

incentive program including the debt reduction program is poorly advertised and 

cumbersome for the potential applicants. In 2007, only 19 physical therapists have 

participated in the Education Debt Reduction Program and only 14 physical therapists have participated in the Employee Incentive Scholarship Program.5

In closing, APTA recommends the immediate approval and implementation of the qualification standards for physical therapists in the VA and the 

investigation of options to enhance current programs offering scholarships, 

loan support and debt retirement for physical therapists choosing to serve 

in the VA. This will assist in both the recruitment and retention of qualified physical therapists to meet the needs of our veterans today and tomorrow. 

Physical therapists are a vital part of the healthcare network that provides services to our Nation’s veterans. Ensuring that the qualification standards that govern 

the salary and advancement opportunities for physical therapists in the VA are up 

to date and reflective of the current professional practice of physical therapy as well 

as enhancing current scholarship opportunities will help recruit and retain more 

physical therapists to the VA system. 

Thank you for this opportunity Mr. Chairman, I would be happy to answer any 

questions you or the other committee members may have. 

f 

Prepared Statement of Richard D. Krugman, M.D., Chair, Executive 

Council, Association of American Medical Colleges, and Dean, and 

Vice Chancellor for Health Affairs, University of Colorado School of 

Medicine 

Good morning and thank you for this opportunity to testify on the recruitment 

and retention of health professionals at the Department of Veterans Affairs (VA). 

I am Dr. Richard Krugman, Dean of the University of Colorado School of Medicine 

and Vice Chancellor for Health Affairs, Chair of the Association of American Medical Colleges (AAMC) Executive Council, and a member of the AAMC VA-Deans Liaison Committee. The University of Colorado is affiliated with the Denver VA Medical Center of the Rocky Mountain Veterans Integrated Services Network (VISN 19). 

The AAMC is a nonprofit association representing all 126 accredited U.S. and 17 

accredited Canadian medical schools; nearly 400 major teaching hospitals and 

health systems, including 68 VA medical centers; and 94 academic and scientific societies. Through these institutions and organizations, the AAMC represents 109,000 

faculty members, 67,000 medical students, and 104,000 resident physicians. 

I would like to thank the committee for your support of the Veterans Health Administration (VHA) fiscal year (FY) 2008 appropriations. Your leadership resulted 

in the House’s passage of $36.6 billion for VA Medical Care and $480 million for 

VA Medical and Prosthetics Research. This funding is crucial to the continued success of the primary sources of VA’s physician recruitment and retention: academic 

affiliations, graduate medical education, and research. 


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VA Medical Care 

The mission of the Veterans Healthcare System is ‘‘to serve the needs of America’s 

veterans by providing primary care, specialized care, and related medical and social 

support services.’’ The VHA operates the largest comprehensive, integrated 

healthcare delivery systems in the United States. Organized around 21 Veteran Integrated Services Networks (VISNs), VA’s health care system includes 154 medical 

centers and operates more than 1,300 sites of care, including 875 ambulatory care 

and community based outpatient clinics, 136 nursing homes, 43 residential rehabilitation treatment programs, 206 Veterans Centers, and 88 comprehensive home-care 

programs. 

VHA has experienced unprecedented growth in the health care system workload 

over the past few years. The number of unique patients treated in VA health care 

facilities increased by 34 percent from 4.1 million in 2001 to more than 5.5 million 

in 2006. That same year, VA inpatient facilities treated 587,000 patients and VA’s 

outpatient clinics registered nearly 57.5 million visits. 

The VA healthcare system had 7.7 million veterans enrolled to receive VA health 

care benefits in 2006. To help VA manage health care services within budgetary 

constraints, enrolled veterans are placed in priority groups or categories. Unfortunately, with limited resources, VA has had to restrict the number of priority 8 veterans, higher-income veterans suffering from conditions not related to their service, 

who can receive VA care. 

Despite limiting access of this category of veterans, a significant backlog of delayed appointments has resulted from an inadequate supply of physicians. While the 

VHA has made substantial improvements in quality and efficiency, the Independent 

Budget veterans service organizations cite excessive waiting times and delays as the 

primary problem in veterans’ health care. Without increases in clinical staff, veterans’ demand for health care will continue to outpace the VHA’s ability to supply 

timely health-care services and will erode the world-renowned quality of VA medical 

care. 

Physician Shortage 

Concerns about physician staffing at the VA come at a time when the Nation 

faces a pending shortage of physicians. Recent analysis by the AAMC’s Center for 

Workforce Studies indicates the United States will face a serious doctor shortage in 

the next few decades. Our Nation’s rapidly growing population, increasing numbers 

of elderly Americans, an aging physician workforce, and a rising demand for health 

care services all point to this conclusion. 

Many areas of the country and a number of medical specialties are already reporting a scarcity of physicians. Approximately 30 million people now live in a federally 

designated shortage of physicians area. An acute national physician shortage would 

have a profound effect on access to health care, including longer waits for appointments and the need to travel farther to see a doctor. The elderly, the poor, rural 

residents, and the 20 percent of Americans who are already medically underserved 

would face even greater challenges as a result. 

Between 1980 and 2005, the Nation’s population grew by 70 million people—a 31- 

percent increase. As baby boomers age, the number of Americans over age 65 will 

grow as well. By 2030, the number of people over 65 will double from 35 million 

to 71 million. Patients age 65 and older typically average six to seven visits to a 

physician per year compared with two to four visits annually for those under 65. 

As the population ages, the AAMC projects that Americans will make 53 percent 

more trips to the doctor in 2020 than in 2000. As medical advances extend longevity 

and improve the quality of life for those with chronic conditions, the need for chronic 

health care services will increase. 

Currently, 744,000 doctors practice medicine in the United States. But 250,000—

one in three of these doctors—are over age 55 and are likely to retire during the 

next 20 years, just when the baby boom generation begins to turn 70. The annual 

number of physician retirees is predicted to increase from more than 9,000 in 2000 

to almost 23,000 in 2025. Meanwhile, since 1980, the number of first-year enrollees 

in U.S. medical schools per 100,000 population has declined annually. Consequently, 

America is producing fewer and fewer doctors each year relative to our continually 

growing population. 

Because it can take up to 14 years from the time new doctors begin their education until they enter practice, the AAMC believes that we must begin to act now 

to avert a physician shortage. Specifically: 

• The AAMC has called for a 30 percent increase in U.S. medical school enrollment by 2015, which will result in an additional 5,000 new M.D.s annually. 


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• To accommodate more M.D. graduates, the AAMC supports a corresponding increase in the number of federally supported residency training positions in the 

Nation’s teaching hospitals. 

Academic Affiliations 

The affiliations between VA medical centers and the Nation’s medical schools 

have provided a critical link that brings expert clinicians and researchers to the VA 

health system. The affiliations began shortly after World War II when the VA faced 

the challenge of an unprecedented number of veterans needing medical care and a 

shortage of qualified VA physicians to provide these services. As stated in seminal 

VA Policy Memorandum No. 2 published in 1946, the affiliations allow VA to provide veterans ‘‘a much higher standard of medical care than could be given [them] 

with a wholly full-time medical service.’’ Over six decades, these affiliations have proven to be mutually beneficial by affording each party access to resources that would otherwise be unavailable. It would 

be difficult for VA to deliver its high quality patient care without the physician faculty and medical residents who are available through these affiliations. In return, 

the medical schools gain access to invaluable undergraduate and graduate medical 

education opportunities through medical student rotations and residency positions 

at the VA hospitals. Faculty with joint VA appointments are afforded opportunities 

for research funding that are restricted to individuals designated as VA employees. 

These faculty physicians represent the full spectrum of generalists and specialists 

required to provide high quality medical care to veterans, and, importantly, they include accomplished sub-specialists who would be very difficult and expensive, if not 

impossible, for the VA to obtain regularly and dependably in the absence of the affiliations. According to a 1996 VA OIG report, about 70 percent of VA physicians 

hold joint medical school faculty positions. These jointly appointed clinicians are 

typically attracted to the affiliated VA Medical Center both by the challenges of providing care to the veteran population and by the opportunity to conduct disease-related research under VA auspices. 

At present, 130 VA medical centers have affiliations with 107 of the 126 allopathic 

medical schools. Physician education represents half of the over 100,000 VA health 

professions trainees. The VA estimates that medical residents contribute approximately 1⁄3 of the VA physician workforce. In a 2007 Learners Perceptions Survey, 

the VA examined the impact of training at the VA on physician recruitment. Before 

training, 21 percent of medical students and 27 percent of medical residents indicated they were very or somewhat likely to consider VA employment after VA training. After training at the VA, these numbers grew to 57 percent of medical students 

and 49 percent of medical residents. 

VA Graduate Medical Education 

Today, the VA manages the largest graduate medical education (GME) training 

program in the United States. The VA system accounts for approximately 9 percent 

of all GME in the country, supporting more than 2,000 ACGME-accredited programs 

and 9,000 full-time medical residency training positions. Each year approximately 

34,000 medical residents (30 percent of U.S. residents) rotate through the VA and 

more than half the Nation’s physicians receive some part of their medical training 

in VA hospitals. 

As our Nation faces a critical shortage of physicians, the VA has been the first 

to respond. The VA plans to increase its support for GME training, adding an additional 2,000 positions for residency training over five years, restoring VA-funded 

medical resident positions to 10 to 11 percent of the total GME in the United States. 

The expansion began in July 2007 when the VA added 342 new positions. These 

training positions address the VA’s critical needs and provide skilled health care 

professionals for the entire Nation. The additional residency positions also encourage innovation in education that will improve patient care, enable physicians in different disciplines to work together, and incorporate state-of-the-art models of clinical 

care—including VA’s renowned quality and patient safety programs and electronic 

medical record system. Phase 2 of the GME enhancement initiative has received applications requesting 411 new resident positions to be created in July 2008. 

VA–AAMC Deans Liaison Committee 

The smooth operation of VA’s academic affiliations is crucial to preserving the 

health professions workforce needed to care for our Nation’s veterans. The VA–

AAMC Deans Liaison Committee meets regularly to maintain an open dialogue between the VA and medical school affiliates and to provide advice on how to better 

manage their joint affiliations. The committee consists of medical school deans and 

VA officials, including the VA Chief Academic Affiliations Officer, the VA Chief ReVerDate Aug 31 2005 03:06 Aug 19, 2008 Jkt 039464 PO 00000 Frm 00044 Fmt 6604 Sfmt 6621 E:\HR\OC\39464.XXX 39464

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search and Development Officer, and three Veteran Integrated Services Network 

(VISN) directors. The committee’s agendas usually cover a variety of issues raised 

by both parties and range from ensuring information technology security to the integrity of solesource contracting directives. 

Recently, the VA–Deans Liaison Committee has reviewed the remarkable progress 

being made on several VA initiatives. These include: 

Establishment of the Blue-Ribbon Panel on Veterans Affairs Medical School Affiliations—This panel will provide advice and consultation on matters related to the 

VA’s strategic planning initiative to assure equitable, harmonious, and synergistic 

academic affiliations. During the panel’s deliberations, those affiliations will be 

broadly assessed in light of changes in medical education, research priorities, and 

the health care needs of veterans. 

Survey of Medical School Affiliations—The AAMC has worked with VA staff to 

develop criteria to evaluate the ‘‘health’’ of individual affiliation relationships. The 

‘‘Affiliation Governance Survey’’ will survey the leadership at both the VA medical 

centers and their affiliated schools of medicine on a range of topics including: 

• Overall satisfaction and level of integration; 

• Affiliation Effectiveness Factors (such as education, research, VA clinical practice environment, and faculty affairs); 

• Overall commitment to the affiliation relationship; 

• Academic affiliations partnership councils (Dean’s committees); and 

• Direction and value of school of medicine-VA medical center affiliations. 

Development of VA Handbook on VHA Chief of Staff Academic Appointments—To 

prevent conflicts of interest or the appearance thereof, the VA has determined that 

limits on receiving remuneration from affiliated institutions are necessary for VHA 

employees at levels higher than chief of staff. While it is important to ensure that 

remuneration agreements do not create bias in the actions of VHA staff, prohibition 

of certain compensation from previous academic appointments (e.g., honoraria, tuition waivers, and contributions to retirement funds) could significantly hinder the 

VA’s ability to recruit staff from their academic affiliates. The AAMC has worked 

with VA staff to develop a mutually acceptable agreement that considers this balance. 

Piloting the VA physician time and attendance/hours bank—Monitoring physician 

time and attendance for the many medical faculty holding joint appointments with 

VA medical centers has been complicated and inefficient. The VHA has accepted the 

‘‘hours bank’’ concept to improve the tracking of part-time physician attendance. 

Under the hours bank, participating physicians will be paid a level amount over a 

time period agreed to in a signed Memorandum of Service Level Expectations 

(MSLE). This agreement will allow the supervisor and participating physician to negotiate and develop a schedule for the upcoming pay period. A subsidiary record will 

track the number of hours actually worked, and a reconciliation will be performed 

at the end of the MSLE period to adjust for any discrepancies. A pilot for this program has been successfully completed and plans for nationwide implementation are 

underway. 

The VA has consistently recognized that there is always room for improvement. 

As such, the AAMC looks forward to working on other items of concern as the VA 

continues to evaluate its affiliation policies and processes. As medical care shifts to 

a more satellite-based outpatient approach, graduate medical education needs to follow suit. This strong shift to ambulatory care at multiple sites requires a similar 

change in the locus of medical training. A dispersion of patients to multiple sites 

of care makes more difficult the volume of patient contact that is crucial to medical 

training. Similarly, faculty diffusion to multiple sites also makes more difficult the 

development of a culture of education and training. This is not exclusively a VA 

problem and all of our Nation’s medical schools and teaching hospitals are struggling to cope with this shift. 

Another concern at both VA and non-VA teaching hospitals is the growing salary 

discrepancy between more specialized fields of medicine and the other disciplines. 

With the ‘‘Department of Veterans Affairs Health Care Personnel Enhancement Act 

of 2003’’ (P.L. 108–445, dubbed the ‘‘VA-Pay bill’’), the VA made significant strides 

beyond its private-hospital counterparts. However, this discrepancy continues to be 

an issue of concern. Once again, this is not exclusively a VA problem, but one faced 

by all medical schools and teaching hospitals. 


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VA Medical and Prosthetic Research Program 

To accomplish its aforementioned mission, VHA acknowledges that it needs to 

provide ‘‘excellence in research,’’ and must be an organization characterized as an ‘‘employer of choice.’’ The VA Medical and Prosthetic Research program is one of the 

Nation’s premier research endeavors and attracts high-caliber clinicians to deliver 

care and conduct research in VA health care facilities. The VA research program 

is exclusively intramural; that is, only VA employees holding at least a five-eighths 

salaried appointment are eligible to receive VA awards. Unlike other federal research agencies, VA does not make grants to any non-VA entities. As such, the program offers a dedicated funding source to attract and retain high-quality physicians 

and clinical investigators to the VA health care system. 

VA currently supports 5,143 researchers, of which nearly 83 percent are practicing physicians who provide direct patient care to veteran patients. As a result, 

the VHA has a unique ability to translate progress in medical science directly to 

improvements in clinical care. 

The VA Research Career Development Program attracts, develops, and retains 

talented VA clinician scientists who become leaders in both research and VA health 

care. For VA clinical investigators, the awards (normally 3–5 years) provided protected time for young investigators to develop their research careers. Awardees are 

expected to devote 75 percent time to research as well as to apply for additional VA 

Merit-Reviewed funding and non-VA research support. The remainder of their time 

is devoted to non-research activities such as VA clinical care or teaching. The program is designed to attract, develop, and retain talented VA researchers in areas 

of particular importance to VA. The Office of Research and Development supports 

approximately 458 awardees, at a cost of $55 million in FY 2006, in all areas of 

medical research including basic science, clinical medicine, health services and rehabilitation research. The VA retains approximately 56 percent of participants as VA 

principal investigators. Ths research program, as well as the opportunity to teach, 

is a major factor in the ability of VA to attract first class physician talent. 

Earmarks and Designation of VA Research Funds 

The AAMC opposes earmarks because they jeopardize the strengths of the VA Research program. VA has well-established and highly refined policies and procedures 

for peer review and national management of the entire VA research portfolio. Peer 

review of proposals ensures that VA’s limited resources support the most meritorious research. Additionally, centralized VA administration provides coordination 

of VA’s national research priorities, aids in moving new discoveries into clinical 

practice, and instills confidence in overall oversight of VA research, including 

human subject protections, while preventing costly duplication of effort and infrastructure. 

VA research encompasses a wide range of types of research. Designated amounts 

for specific areas of research compromise VA’s ability to fund ongoing programs in 

other areas and force VA to delay or even cancel plans for new initiatives. While 

Congress certainly should provide direction to assist VA in setting its research priorities, earmarked funding exacerbates resource allocation problems. AAMC urges 

the Committee to continue preserving the integrity of the VA research program as 

an intramural program firmly grounded in scientific peer review. These are principles under which it has functioned so successfully and with such positive benefits 

to veterans and the Nation since its inception. 

VA Research Infrastructure 

State-of-the-art research requires state-of-the-art technology, equipment, and facilities. Such an environment promotes excellence in teaching and patient care as 

well as research. It also helps VA recruit and retain the best and brightest clinician 

scientists. In recent years, funding for the VA medical and prosthetics research program has failed to provide the resources needed to maintain, upgrade, and replace 

aging research facilities. Many VA facilities have run out of adequate research 

space. Ventilation, electrical supply, and plumbing appear frequently on lists of 

needed upgrades along with space reconfiguration. Under the current system, research must compete with other facility needs for basic infrastructure and physical 

plant support that are funded through the minor construction appropriation. 

To ensure that funding is adequate to meet both immediate and long term needs, 

the AAMC recommends an annual appropriation of $45 million in the VA’s minor 

construction budget dedicated to renovating existing research facilities and additional major construction funding sufficient to replace at least one outdated facility 

per year to address this critical shortage of research space. 

Mr. Chairman and Members of the Committee, thank you for the opportunity to 

testify on this important issue. I hope my testimony today has demonstrated that 


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the recruitment and retention of an adequate physician workforce is central to the 

success of VA’s mission. The extraordinary partnership between the VA and its 

medical school affiliates, coupled with the excellence of the VA Medical and Prosthetics Research program, allows VA to attract the Nation’s best physicians. Over 

the last 60 years, we have made great strides toward preserving the success of our 

affiliations. With the hard work of VA–AAMC Deans Liaison Committee and the 

VA’s Blue Ribbon Panel on Medical School Affiliations, I am confident that this success will continue. 

f 

Prepared Statement of Kristi McCaskill, M.Ed., NCC, NCSC, 

Counseling Advocacy Coordinator, National Board for Certified 

Counselors, Inc. and Affiliates 

INTRODUCTION AND EXECUTIVE SUMMARY 

Mr. Chairman and Honorable Members of the Veterans’ Affairs Committee, I 

thank you for the opportunity to present testimony regarding the need for additional 

mental health care providers in the Department of Veterans Affairs (VA). As a representative of the National Board for Certified Counselors (NBCC), I believe that 

counselors play an important role in assisting the VA with health care recruitment 

and retention. 

By way of background, I am the Counseling Advocacy Coordinator at the NBCC. 

For the past two years, I have worked with certificants as they explain their certification and qualifications to prospective employers, to the public, and to legislators. 

As a certificant of NBCC, I understand the value of counseling and counseling credentials. I was trained as a school counselor at the University of North Carolina 

at Chapel Hill. Shortly after graduation and beginning work as a counselor in the 

schools, I completed my certification as a National Certified Counselor (NCC). The 

NCC is the flagship certification offered by the NBCC. I also possess the NBCC specialty certification for school counseling, the National Certified School Counselor 

(NCSC). 

NBCC is the Nation’s premiere professional certification board devoted to 

credentialing counselors who meet standards for the general and specialty practices 

of professional counseling. Founded in 1982 as an independent, non-profit 

credentialing body, NBCC provides a national certification system for professional 

counselors, identifies those counselors who have obtained certification, and maintains a registry of those counselors. 

NBCC is the largest certification agency for professional counselors in the United 

States, certifying more than 42,000 practitioners, living and working in the U.S. and 

over 40 countries. We also create and distribute all licensure examinations for 49 

states, District of Columbia and Puerto Rico. NBCC works closely with over 300 universities offering master’s level education in counseling throughout the United 

States as well as around the world. 

The practice of professional counseling involves the application of mental health, 

psychological, and human development principles, through cognitive, affective, behavioral or systematic strategies, that address wellness, personal growth, or career 

development, as well as pathology. Working with individuals, groups, families and 

organizations in a variety of settings, professional counselors are trained to address 

a wide range of issues including anxiety, depression, bereavement, addiction, coping 

with illness and disability, adjustments in living situations, family and relationship 

issues and job stress. Professional counselors also provide emergency services in 

times of catastrophic events, such as acts of terror and natural disasters, which can 

severely traumatize survivors. NBCC has established an enforceable Code of Ethics 

to foster ethical practices for all clients of NBCC credentialed counselors. 

Counselors certified by NBCC meet predetermined standards in education, training, and experience. For 25 years, NBCC has offered the NCC, the first general 

practice counseling credential with nationwide recognition. NBCC also offers specialty credentials for mental health counselors, addictions counselors, and school 

counselors. These specialized credentials require advanced knowledge and experience in these respective counseling fields. 

As a non-profit 501(C)(3) organization, NBCC continues to promote leadership, accountability and quality assurance within the counseling profession. 

NBCC and licensed professional counselors are pleased with the passage of the 

Veterans Benefits, Health Care, and Information Technology Act of 2006 (Public 

Law 109–461), which was signed into law on December 22, 2006, and we thank this 

Committee for working so hard to pass this legislation during the last session of 


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Congress. This groundbreaking legislation paved the way for licensed counselors to 

utilize their training and skills to meet the increasing needs of veterans. 

This legislation explicitly recognizes licensed professional counselors as health 

care providers within the Veterans Health Care Administration (VHA) (including licensed marriage and family therapists). It also delineates the qualifications mental 

health counselors need to be appointed to a position in the VA. This legislation is 

the result of years of work by the counseling profession and Congress to gain recognition of licensed counselors within the VA. Although rehabilitation counselors are 

recognized within the VA, licensed professional counselors have had only a limited 

role as mental health providers. Prior to passage of this law, the VA could not hire 

counselors for mental health professional positions at the same pay grade as clinical 

social workers, nor could licensed professional counselors apply for supervisory positions open to clinical social workers and others. 

Passage of this law will allow counselors access to better paying jobs as mental 

health specialists, with the potential for promotion into supervisory positions. This 

will increase the pool of mental health specialists the VA is able to draw upon in 

attempting to meet the growing health care needs of veterans. With enactment of 

the provision, the federal Office of Personnel Management (OPM) will be required 

to create a General Schedule (GS) occupational classification for mental health counselors, which is necessary for a counselor to be employed by the U.S. Government. 

In my position with NBCC, I understand the frustration that some counselors 

have experienced in their attempts to work within the VA health system. In the 

past, licensed professional counselors faced significant employment obstacles within 

the Veterans Health Administration (VHA) and its hospitals, clinics, and programs 

across the country. While some counselors have found positions within the agency, 

either on a contract or full-time basis, there continue to be barriers to independent 

practice, advancement, and hiring. 

While licensed clinical social workers were able to practice independently and 

serve as clinical supervisors in the VA, counselors found themselves struggling to 

achieve similar recognition. The VA remains the largest employer of clinical social 

workers in the country, and the VA employs very few counselors on a full-time 

basis. According to the VHA, most supervisory positions at Department hospitals 

and clinics are filled by psychiatrists, psychologists, and social workers. Many VHA 

positions in mental health services are developed by social workers on staff, and 

therefore the agency is most likely to hire social workers first. Psychiatrists, psychologists, and clinical social workers are specifically named in VA statutes. While 

VHA says there is no formal policy excluding licensed professional counselors from 

being hired, some have found that the VA does not recognize their licensure, and 

therefore refuses to hire them or relegates them to non-clinical positions. The lack 

of recognition of licensed professional counselors by OPM exacerbates this problem. 

We commend the United States Congress for recognizing the need for mental 

health counseling within the VA and thank you for passing such meaningful legislation. The inclusion of licensed counselors by the VA and the quality of the services 

they provide will make it easier for those who served our Nation and in need of 

mental health services to get the health care they need. This issue is especially important given the increasing number of veterans returning from Iraq and Afghanistan with symptoms of mental illness. 

I believe we are all familiar with the mental health needs of our returning service 

men and women and veterans from Iraq and Afghanistan. According to a report by 

the United Press (UP) in June of 2005, the Army’s first study of the mental health 

of our troops who fought in Iraq, found that about one in eight reported symptoms 

of post-traumatic stress disorder (PTSD), which can cause flashbacks of traumatic 

combat experiences and other severe reactions. By mid-2006, more than one in three 

soldiers and Marines returning from the wars in Iraq, Afghanistan and other locations later sought help for mental health problems. About 35 percent of soldiers are 

seeking some kind of mental health treatment a year after returning home under 

a program that screens returning troops for physical and mental health. I need not 

elaborate more to convey the immense impact PTSD and other mental health issues 

has on our soldiers, especially those with repeated and extended deployment to battle zones. PTSD and other effects of war linger and will require ongoing care for 

many years to come. 

The VA and the Pentagon have acknowledged a need to improve access to mental 

health treatment. NBCC is encouraged by the recent announcements of VA’s intention of hiring suicide prevention counselors at VA medical centers, providing readjustment counseling at VA community based Vets Centers, and increasing outreach 

and advocacy efforts for veterans of the Global War on Terror. However, NBCC is 

concerned that little has been accomplished in the 10 months that have passed since 

legislation was signed into law recognizing licensed professional counselors as 


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health care providers within the VHA. VA now has the statutory authority to make 

these changes, and we are concerned that licensed professional counselors are not 

being utilized to serve in the VA health system. 

There is a practical solution to the shortage of mental health care professionals 

available to veterans. By fully implementing Public Law 109–461 and creating a 

counselor job classification within the GS schedule, more than 100,000 clinically 

trained counselors would be added to the pool of possible candidates to these positions. 

THE NATIONAL BOARD FOR CERTIFIED COUNSELORS (NBCC) 

NBCC has created and maintained standards for professional counselors for 25 

years. These standards include specifications regarding education, experience, and 

required examinations for initial certification. Continuing education in the mental 

health field and adherence to NBCC’s Code of Ethics are required in order to maintain certification. Any applicant or certificant violating the Code of Ethics is subject 

to sanctions determined by a well-developed adjudication process. 

The initial, fundamental designation awarded by the NBCC is the National Certified Counselor (NCC) certification. To become certified as a NCC, the applicant 

must document graduation from (at least) a master’s-level CACREP-accredited program (or an equivalent curriculum), complete a specified minimum number of hours 

of supervised experience as a counselor, and pass a national counselor examination. 

Qualified NCCs who work as school counselors, clinical mental health counselors, 

or addictions counselors may apply for specialized credentials through NBCC. In 

order to obtain a specialized credential, additional education, experience, and assessment requirements must be met. NBCC also creates and distributes the licensure examinations for the 49 states that regulate the practice of counseling, District 

of Columbia and Puerto Rico. 

NBCC’s educational requirement and assessments are based on educational 

standards developed by the Council for the Accreditation of Counseling and Related 

Educational Programs (CACREP). In addition, NBCC adheres to the Standards for 

Educational and Psychological Testing (1999) and the U.S Federal Uniform Guidelines on Employee Selection Procedures (1978) in its commitment to providing assessments that test examinees’ ability to apply knowledge in ways that define safe 

and effective professional practice, with public protection as the ultimate goal. The 

Uniform Guidelines identify job analysis as the sine qua non of procedures for 

amassing content-related validity evidence for licensure testing. NBCC utilizes the 

job analysis framework, developing a detailed list of responsibilities that counselors 

routinely perform, as well as responsibilities that are essential to safe and effective 

practice of counseling. The validity of NBCC’s assessment development process, 

maintenance, and security processes is acknowledged nationwide as the standard for 

the counseling profession. Both the National Certified Counselor Certification and 

the Master’s Addiction Counselor Certification are accredited by the National Commission for Certifying Agencies (NCCA). Utilizing an assessment based on a national analysis of the work performed by professional counselors helps assure that 

NBCC’s certificants and the states’ licensees possess the knowledge essential to providing excellent service. 

LICENSED COUNSELORS 

In June 2007, Nevada passed counselor licensure legislation bringing the total 

number of states regulating the practice of counseling to 49. The only state without 

such provision is California where similar legislation is pending. Nationwide, there 

is a growing body of about 100,000 professional counselors licensed to practice independently. Under state laws, credentialed counselors have the authority to practice 

independently and increasing numbers may bill insurance companies for reimbursement of services provided. 

Professional counselors possess a master’s degree or higher from an accredited college or university. The degree program must cover specific coursework including 

counseling theories, group counseling, social/cultural foundations, human growth 

and development, appraisal/assessment techniques, etc. Additionally, professional 

counselors must document a supervised professional practice, pass a national counselor examination, submit a professional disclosure statement, and must keep current their professional education. 

Licensed counselors are well qualified professionals that assist people of all ages 

and abilities to develop life-enhancing skills. They utilize their skills to identify and 

treat emotional, psychological or behavioral disorders which may interfere with 

daily activities. While counselors are trained to understand mental illnesses, counselors approach issues from a developmental perspective. This perspective of 


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strength building encourages those who are struggling to seek help and reduces 

stigma. 

THE NEED FOR INCREASED MENTAL HEALTH SERVICE PROVIDERS 

In February 2007, a Presidential Task Force conducted an investigation on the 

psychological needs of U.S. Military Members and their families identified three 

main barriers to effective military mental health treatment: 

1. a shortage of professionals experienced in military life, 

2. the stigma of receiving mental health services, and 

3. difficulties assessing help due to long waiting lists, limited clinic hours, location, etc. 

Other important statistics found in this study include: 

• Over 23,000 have returned with physical wounds and permanent disabilities including traumatic brain injury. 

• As many as one-fourth of returning servicemen and women are struggling with 

psychological injuries. 

• There has been a 22% decrease of licensed clinical psychologists serving servicemen and women. 

• There are approximately 1,839 psychologists employed by the VA to serve more 

than 24.3 million veterans from previous wars as well as the rapidly growing 

number from the current conflict. 

The VA acknowledges the need for increased mental health providers. A tour of 

the VA website in the mental health section provides the following information: 

• ‘‘Suicide is the 11th most frequent cause of death in the U.S.: someone dies from 

suicide every 16 minutes.’’

• ‘‘The newest patients to the VA have been returning combat soldiers, men and 

women who served in Operations Enduring Freedom and Iraqi Freedom (OEF/ 

OIF).’’

• ‘‘In a recent study, Dr. Karen Seal and colleagues at the San Francisco Veterans Affairs Medical Center and USC, reviewed records for over 100,000 veterans, who separated from active duty between 2001–2005 and sought care from 

VA medical facilities.’’

• ‘‘The most common combination of diagnoses found was post traumatic stress 

disorder (PTSD) and depression.’’

• ‘‘Young soldiers were three times as likely as those over 40 to be diagnosed with 

PTSD and/or another mental health disorder.’’

• ‘‘VA is expanding counseling and mental health services to meet the needs of 

the returning veterans and provide early treatment.’’

In recent testimony provided to the President’s Commission on the Care of 

Wounded Warriors, Dr. Thomas Clawson, the President and CEO of NBCC, illustrated the connection between PTSD and the witnessing of traumatic events. His 

testimony included information regarding the occurrence rates of other disorders 

within the military—anxiety disorder (24%), adjustment disorder (24%), depression 

(20%) and substance abuse disorder (20%). Despite these numbers, Dr. Clawson 

noted that less than half with problems sought help because they were worried that 

it would have an adverse affect on their status within the military. Dr. Clawson also 

referenced a report from the Office of the Surgeon General of the U.S. Army Medical 

Command which stated the conditions under which our service men and women currently serve are unprecedented and have a significant influence upon them. 

This information is consistent with a statement by Vice Admiral Donald C. Arthur, MC, CSN, cochairman of the Department of Defense Task Force on Mental 

Health. According to Admiral Arthur, ‘‘Not since Vietnam have we seen this level 

of combat. With this increase in psychological need, we now find that we have not 

enough providers in our system.’’

Furthermore, in recent testimony, Dr. Antoinette Zeiss, Ph.D., Deputy Chief Consultant, Office of Mental Health Services, Department of Veterans Affairs, stated 

that the VA has seen many returning veterans with ‘‘injuries of the mind and spirit.’’ Recognizing the increasing need for mental health services, Dr. Zeiss’s testimony 

included a plan to expand the number of Vet Centers from 209 to 232 over the next 

two years. She elaborated that these centers are staffed by psychologists, nurses, 

and social workers. Dr. Zeiss projected that 686,306 servicemembers have been discharged since the end of the first quarter of FY 2007, and that of those, nearly 33% 

have sought care. Of the group that sought care, she reports that mental health 

problems are the second most common. 


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The implementation of licensed counselors in the VA system is one method of 

helping to address this increasing and apparent need for providers. Implementation 

will increase access to returning veterans and address the issue of long wait times 

for care and treatment by veterans. Furthermore, it is cost-effective to utilize licensed professional counselors who work at different pay grades than to psychiatrists and psychologists. 

THE DEPARTMENT OF VETERAN’S AFFAIRS (VA) AND P.L. 109–461 

With the passage of PL 109–461 in December 2006, licensed mental health counselors were recognized as mental health specialists by the Department of Veteran’s 

Affairs (VA). NBCC is concerned that in the ten months following the passage of 

PL 109–461, the VA has not made any visible progress and there still is not a General Schedule (GS) occupational classification for counselors, paving the way for licensed counselors to become recognized as service providers. 

The VA website references the U.S. Office of Personnel Management (OPM) as the 

primary method of determining basic qualifications for every job within the Federal 

Government. VA vacancy announcements provide additional qualifications needed 

for specific positions. Potential applicants are encouraged not to apply if they do not 

meet both the required minimum qualifications and any selective factors described. 

Without a new GS schedule specifically designed for counselors, it is difficult, if not 

impossible, for counselors to become employed at the VA, despite the passage of PL 

109–461. 

RECOMMENDATIONS 

NBCC would like to offer itself as a resource to military and government leaders, 

including the VA and the OPM, and we remain committed to developing long term 

solutions to the current and future mental health needs of our servicemembers and 

their families. As an organization with over 25 years experience, NBCC maintains 

close associations with other professional counseling organizations including the 

American Association of State Counseling Boards (AASCB), the organization representing state licensure boards. We are prepared and capable of connecting licensed counselors with the VA so that together we can provide services for the increasing mental health needs of veterans. Licensed counselors are well qualified 

professionals with training and experience in helping those who are struggling with 

depression, post-traumatic stress disorder (PTSD), stress/anxiety, and other mental 

health issues. P.L. 109–461 was an important step in adding qualified mental 

health service providers. We are enthusiastically poised for the next steps which 

would allow counselors to work for the VA. 

As a demonstration of our eagerness, we have compiled information which could 

be helpful to OPM in the creation of a job classification. By working together, NBCC 

and licensed counselors in the United States can help the VA in its mission to serve 

America’s veterans and their families with dignity and compassion and to help ensure that they receive appropriate services and support in recognition of their service to this Nation. 

On behalf of NBCC, I want to again express my appreciation to the members of 

the Subcommittee on Heath of the U.S. House of Representatives Committee on Veteran’s Affairs for their dedication to the provision of quality mental health services 

to our veterans. It would be our pleasure and an honor to work with you to establish 

a mechanism to allow licensed counselors to serve veterans who not only have given 

of themselves to protect our country, but who now need our help. 

NBCC stands ready, willing, and able to work cooperatively, effectively, and professionally with VA and Congressional leaders interested in developing a lasting solution to current and future mental health needs of our active duty servicemembers, 

veterans, and their families. 

f 

Statement of Jim Bender, Communications Services Manager, CACI 

Strategic Communications 

Mr. Chairman and Members of the Subcommittee: 

Thank you for inviting CACI to contribute to the discussion on health care recruitment and retention. CACI has been instrumental in the advancement of recruitment marketing research, strategy and practice for more than 15 years. Our 

clientele include the National Security Agency, the National Guard Bureau, the Corporation for National and Community Service, and the Veterans Health AdministraVerDate Aug 31 2005 03:06 Aug 19, 2008 Jkt 039464 PO 00000 Frm 00051 Fmt 6604 Sfmt 6621 E:\HR\OC\39464.XXX 39464

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tion. My name is Jim Bender, and I am one of the architects of the VA Nurse Recruitment Pilot Study I will address today. 

Given the impending retirement of the Baby Boom generation, in addition to severe shortages in certain health care occupations, we at CACI support efforts by the 

Federal Government and affected industries to advance recruitment marketing and 

retention. These efforts will help neutralize the competitive market pressures that 

would otherwise undermine the effectiveness of all but the highest paying health 

care systems in the country. 

The national supply of health care professionals in certain fields—especially nursing—is not keeping pace with demand. In April of 2006, the American Hospital Association reported 118,000 registered nurse vacancies nationwide, a vacancy rate of 

8.5 percent. The Health Resources and Services Administration projects a shortage 

of 1 million nurses by year 2020. As the Nation’s largest health care system, the 

VHA has a major stake in this game. 

In February of 2006, in response to the Veterans Health Programs Improvement 

Act of 2004, VHA’s Health Care Retention & Recruitment Office contracted with 

CACI to conduct a pilot program to test and recommend innovative recruitment 

methods for hard-to-fill health care positions. 

From a pool of 17 pilot site applicants, the North Florida/South Georgia Veterans 

Health System was chosen as the pilot location. The system’s unique recruitment 

challenge was finding nurses with enough experience to fill higher-level nursing positions. 

Our objective going into the North Florida/South Georgia system was to test 

methods to enhance effectiveness in four key areas: 

• Employer branding and interactive advertising strategies • Internet technologies and automated staffing systems • The use of recruitment, advertising and communications agencies • Streamlining the hiring process 

Subsequently, the study was divided into two distinct operations. One was focused 

on recruitment marketing, with the goal of increasing the number of qualified applications coming into the system. The second was business process reengineering, 

with the goal of decreasing the administrative time between application receipt and 

job offer. An abundance of anecdotal evidence suggests that VA loses good candidates because of the lengthy boarding process. 

The program was conducted over 60 days, beginning Feb. 5, 2006. All activities 

were monitored and measured to evaluate results. 

On the recruitment marketing side of the operation, the findings were exceptionally optimistic. 

• The recruitment marketing campaign generated 10,261 inquiries into nursing 

positions for experienced nurses. An inquiry was defined as a response to recruitment advertising or similar communications outreach. 

• Of those inquiries, 115 candidates submitted applications. 

• Most impressive was the percentage of applicants uniquely qualified to fill the 

advertised positions. During March of 2006, the only full calendar month of the 

study, the number of applicants for Nursing Services who passed the initial 

screening process increased by 83 percent over the month prior (from 12 applications to 22) and 300 percent over the trailing five-month average (from 7.4 

applicants to 22 applicants). 

The recruitment methods that garnered these results include a strategy based on 

the principles of employer branding and market segmentation, in addition to vigorous use of interactive media and Internet technologies, which delivered the highest return on investment of any media in the study. 

The pilot program recommendations embraced these methods and further suggested the use of database marketing, relationship building (especially with the student population), employee referral programs, budget modifications and improvements to organizational communications. 

On the business process side, the results were equally optimistic. A comparison 

of current hiring processes to what-if scenarios revealed that a small number of 

process changes could significantly accelerate the time-to-hire: 

• The average time-to-fill for new hires can be reduced from 72 days to 25 days. 

• The average time-to-fill for employee transfers can be reduced from 33 days to 

13 days. 

The process changes that would actualize these what-if scenarios include the delegation of approval authority for routine recruitment activities, the implementation 

of an automated recruitment management workflow system to eliminate delays in 


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paper-based mail and processing, a change in the timing of the VetPro credential 

verification process, and several modifications to standard processes that build 

delays into the system. 

We at CACI believe healthcare recruitment at VHA is both strong and spirited. 

HRRO, in addition to the exceptional staff and leadership at the North Florida/ 

South Georgia system, embraced this project with enthusiasm and sustained intellectual vigor. Since the pilot’s conclusion, we have seen continued movement toward 

the methods tested in the pilot project—including increased use of targeted email 

communications, expanded use of online job postings and greater promotion of employee referral programs—as well as a persistent hunger for new, progressive ways 

of engaging health care professionals. 

In closing, thank you once again for the opportunity to present CACI’s conclusions 

from the Nurse Recruitment Pilot Study, and thank you for the opportunity to contribute to the continued health and welfare of our country’s veteran population. I 

look forward to your questions. 

f 

Prepared Statement of Joseph L. Wilson, Assistant Director for Health 

Policy, Veterans Affairs and Rehabilitation Commission, American Legion 

Mr. Chairman and Members of the Subcommittee: 

Thank you for this opportunity to present The American Legion’s views on recruitment and retention of VA’s Health Care Professionals. The Nation is facing an unprecedented health care shortage that could potentially have a profound impact on 

the care given to this Nation’s veterans. The American Legion supports comprehensive efforts to establish and maintain the Department of Veterans Affairs (VA) as 

a competitive force in attracting and retaining health care personnel, especially 

nurses, essential to the mission of VA health care and commends the Subcommittee 

for holding a hearing to discuss this very important and urgent issue. 

The Federal Government estimates that, by 2020, nurse and physician retirements will create a shortage of about 24,000 physicians and almost 1 million nurses 

nationwide. The American Legion strongly believes that what happens at the Department of Veterans Affairs Medical Centers (VAMCs) often reflects the general 

state of affairs within the health care community as a whole. 

Shortages in health care staff threaten the Veterans Health Administration’s 

(VHA’s) ability to provide quality care and treatment to veterans. Shortages in 

health care staffing also influence VHA’s ability to provide timely access to quality 

care and, in some instances, its ability to provide certain types of care. 

During The American Legion’s recent site visits to Polytrauma Centers throughout the Nation, some facilities identified uncertainty of existing staff’s ability to 

handle an expected influx of patients as a challenge to providing care. Another challenge was acquiring staff trained in certain specialty fields. These specialties include: physical medicine and rehabilitation, blind rehabilitation, speech and language pathology, physical therapy, and certified rehabilitation nursing. Given the 

special rehabilitative and long-term care needs of combat wounded veterans returning from Iraq and Afghanistan—especially those residing in rural areas—shortages 

in these specialty fields will have a lasting impact on these veterans as they attempt 

to resume independent functioning. 

One major Polytrauma Center, which serves as a frontline medical center to those 

returning from Iraq and Afghanistan, reported recruitment and retention as part of 

their major budgetary challenge. Although the utilization of a variety of tools, to include relocation, recruitment, and retention bonuses, to attract new employees and 

retain existing employees is a step in the right direction, the locality pay is insufficient to keep pace with respective surrounding health care employers. 

VA Nurses 

VA nurses are one of the most important resources in delivering high-quality, 

compassionate care to veterans. Nursing personnel are the backbone of direct patient care in the VA health delivery system. There have been challenges in attracting nursing personnel to VA due to both the shortage of people entering the career 

field and VA’s inability to remain competitive in salary and benefits. 

VA nurses are consistently reporting that their staffing levels are inadequate to 

provide safe and effective care. A study published in The New England Journal 

of Medicine found there were shorter inpatient stays and lower complication rates 

in hospitals with higher staffing levels, while there were longer inpatient stays and 

increased urinary infections, gastrointestinal bleeding, pneumonia and shock or cardiac arrest in hospitals with lower staffing levels. 


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A study by the Center for Health Economics and Policy at the University of Texas 

Health Science Center in San Antonio, Texas identified three essential factors that 

affect the retention of nurses: 

• Work environment practices that may contribute to stress and burnout; • The aging of the Registered Nurse (RN) workforce combined with the shrinking 

applicant pool for nursing schools; and • The availability of other career choices that makes the nursing profession less 

attractive. 

Other factors cited most frequently for attrition of nurses included: 

• Lack of time with patients; • Concern with personal safety in the health care setting; • Better hours outside of nursing; and • Relocating. 

It should also be noted that 63 percent of those surveyed said that RN staffing is 

inadequate and that current working conditions jeopardize their ability to deliver 

safe patient care. 

VA nursing workforce data support the conclusion that it is likely that the number of current VA nurses in the workforce will decline sharply and rapidly. This decline is attributed to an aging workforce wherein a large number of nursing personnel will be eligible for retirement. 

VA must be able to retain and recruit well-qualified nurses in order to maintain 

the quality of care provided to veterans. A significant part of this recruitment and 

retention effort is VA-administered initiatives to enhance the educational preparation of nursing personnel, including scholarship and loan repayment programs. 

In its report, Caring for America’s Veterans: Attracting and Retaining a Quality 

VHA Nursing Workforce, the National Commission on VA Nursing (the Commission) 

addresses recruitment and retention tactics that VA could implement to attract 

more nursing staff. The Commission provided recommendations in areas of the profession that impact nurses’ satisfaction with their careers. These areas include leadership participation, professional development, work environment, respect and recognition, fair compensation, technology, and research/innovation. The Commission 

noted the importance of adequate resources from VA and Congress to implementing 

the recommendations should improve retention and recruitment. Recruitment and 

retention efforts should concentrate on these identified areas, which nurses consider 

key factors in their career satisfaction. 

The American Legion urges VA and Congress to provide adequate resources to implement the Commission’s recommendations and urges VA to continue to strive to 

develop an effective strategy to recruit, train, and retain advanced practice nurses, 

registered nurses, licensed practical nurses, and nursing assistants to meet the inpatient and outpatient health care needs of its growing patient population. 

VA’s Chiefs of Nursing have said that one of the most effective recruitment tools 

is to capture student nurses while they are in training or as they graduate. VA recently established a Nursing Academy to address the nationwide nursing shortage 

issue. The Nursing Academy has embarked on a 5-year pilot program that will establish partnerships with a total of 12 nursing schools. The initial set of partnerships implemented this year includes nursing schools in Florida, California, Utah 

and Connecticut. More partnerships will be selected over the next two years. This 

pilot program will train nurses to understand the health care needs of veterans and 

make more nurses available to allow VA to continue to provide veterans with the 

quality care they deserve. 

The American Legion affirms its strong commitment and support for the mutually 

beneficial affiliations between VHA and the medical and nursing schools of this Nation. 

The American Legion is appreciative of the many contributions of VHA nursing 

personnel and recognizes their dedication to veterans who rely on VHA health care. 

Every effort must be made to recognize, reward and maximize their contributions 

to the VHA health care system because veterans deserve nothing less. 

Medical School Affiliations 

VHA conducts the largest coordinated education and training program for health 

care professions in the Nation. The medical school affiliations allow VA to train new 

health professionals to meet the health care needs of veterans and the Nation. Medical school affiliations have been a major factor in VA’s ability to recruit and retain 

high quality physicians. It also affords veterans access to the some of the most advanced medical technology and cutting-edge research. VHA research continues to 

make meaningful contributions to improve the quality of life for veterans and the 


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general population. VHA’s recent and numerous recognitions as a leader in providing safe, high-quality health care to the Nation’s veterans can be directly attributed to the relationship that has been fostered through the affiliates. 

Mr. Chairman and members of the Subcommittee, The American Legion sincerely 

appreciates the opportunity to present testimony and looks forward to working with 

you, your colleagues and staff to resolve this critical issue. Thank you for your continued leadership on behalf of America’s veterans. 

This concludes my testimony. 

f 

Prepared Statement of Joy J. Ilem, Assistant National Legislative Director, 

Disabled American Veterans 

Mr. Chairman and Members of the Subcommittee: 

Thank you for inviting the Disabled American Veterans (DAV) to testify on recruitment and retention of healthcare professionals by the Department of Veterans 

Affairs’ (VA) Veterans Health Administration (VHA). Without question, recruitment 

and retention of high caliber healthcare professionals is critical to VHA’s mission 

and essential to providing safe, high quality healthcare services to sick and disabled 

veterans. Given the impact of the nationwide nursing shortage and reports of continued difficulty in filling nursing, specialty physician and other key positions in 

VHA, this is an important and timely hearing. 

NATIONAL COMMISSION ON VA NURSING 

The environment of VHA, like America’s health care enterprise in general, is everchanging and confronted with new challenges at every turn. Since 2000, VA has 

been working to address the ever-increasing demand for medical services while coping with the impact of a rising national nursing shortage. In 2001, VHA’s Nursing 

Strategic Healthcare Group released 

A Call to Action—VA’s Response to the National Nursing Shortage. Since that 

time, health manpower shortages, and plans to address them, have been dominant 

themes of numerous conferences, reports by the Government Accountability Office 

(GAO) and other reviewers, and Congressional hearings. 

One part of the equation that has remained paramount in the discussion, concerns 

VA’s ability to compete in local labor markets, given the barriers that impede nursing recruitment and retention in general. Based on work in this Subcommittee, in 

2002 the National Commission on VA Nursing (hereinafter the Commission), was 

established by Public Law 107–135. The Commission was charged to examine and 

consider VA programs, and to recommend legislative, organizational and policy 

changes to enhance the recruitment and retention of nurses and other nursing personnel, and to address the future of the nursing profession within VHA. The Commission members were a group of distinguished leaders in nursing, medicine, labor, 

academic management, veterans’ affairs and other relevant fields, including DAV’s 

Washington Headquarters Executive Director, David W. Gorman. The Commission 

envisioned a desired ‘‘future state’’ for VHA nursing, and made recommendations to 

achieve that vision. In May 2004, the Commission published its final report to Congress—Caring for America’s Veterans: Attracting and Retaining a Quality VHA 

Nursing Workforce. 

Illustrative of the Commission’s findings and recommendations is this synopsis in 

its final report: 

‘‘Recruiting and retaining nursing personnel are priority issues for every healthcare 

system in America. VHA is no exception. With the aging of the population, including 

veterans, and the U.S. involvement in military activity around the world, VHA will 

experience increasing numbers of enrolled veterans. Consequently, as the demand for 

nursing care increases, the Nation will grapple with a shortage of nurses that is likely to worsen as baby boomer nurses retire. VHA must attract and retain nurses who 

can help assure that VHA continues to deliver the highest quality care to veterans. 

Further, VHA must envision, develop, and test new roles for nurses and nursing as 

biotechnologies and innovations change the way healthcare is delivered.’’

The Office of Nursing Service in VA Central Office developed a strategic plan to 

guide national efforts to advance nursing practice within VHA, and engage nurses 

across the system to participate in shaping the future of VA nursing practice. This 

strategic plan embraces six patient-centered goals that encompass and address a 

number of the recommendations of the Commission. 


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• Leadership Development: supporting and developing new nurse leaders, and 

creating a pipeline to continuously ‘‘grow’’ nursing leaders throughout the organization; • Technology and System Design: creating mechanisms to obtain and manage 

clinical and administrative data to empower decisionmaking. The objective is to 

develop and enhance systems and technology to support nursing roles. The 

Commission report highlighted the importance of nursing input in the development stage of new technologies for patient care; • Care Coordination and Patient Self-Management: promoting and recognizing innovations in care delivery and facilitating care coordination and patient self-management. The objectives are to strengthen nursing practice for the 

provision of high-quality, reliable, timely, and efficient care in all settings and 

to enhance the use of evidence-based nursing practice. This goal also encompasses recommendations from the Commission related to the work environment 

of VA nurses; • Workforce Development: improving the recognition of, and opportunities for, 

the VA nursing workforce. Areas of emphasis are (1) utilization: to maximize 

the effective use of the available workforce; (2) retention: to retain a qualified 

and highly skilled nursing workforce; (3) recruitment: to recruit a highly qualified and diverse nursing staff into VHA; and (4) outreach: to improve the image 

of nursing and promote nursing as a career choice through increased collaboration with external partners. The Commission report addresses all of these areas 

as critical to the future of VA nursing; • Collaboration: forging relationships with professional partners within VA, 

across the Federal community, and in public and private sectors. The objective 

is to strengthen collaborations in order to leverage resources, contribute to the 

knowledge base, offer consultation, and lead the advancement of the profession 

of nursing for the broader community. The priorities of this goal align with 

VHA’s Vision 2020 and the Commission recommendations related to collaboration and professional development; and, • Evidence-Based Nursing Practice: identifying and measuring key indicators 

to support evidence-based nursing practice. The objective is to develop a standardized methodology to collect data related to nursing-sensitive indicators of 

quality, workload and performance within VHA facilities. 

DAV believes the Commission’s legislative and organizational recommendations 

served as a blueprint for the reinvention of VA nursing. Having followed that blueprint, the VHA’s strategic plan serves as a solid foundation for the creation of a delivery system that meets the needs of our Nation’s sick and disabled veterans while 

supporting those who provide their care. Therefore, we urge Congress to continue 

to provide appropriations for, and oversight of, VA health care to enable VHA to invest more resources—human, financial and technological—to carry out an aggressive agenda to improve VA’s abilities to recruit and retain sufficient nursing manpower while proactively testing new and emerging nursing roles in VA healthcare. 

CURRENT WORKFORCE—FUTURE NEEDS 

One of VA’s most significant challenges is dealing effectively with succession—es- pecially in the health sciences and technical fields that so characterize contemporary 

American medicine and healthcare delivery. DAV believes the Subcommittee and 

Full Committee should be particularly mindful of VA’s progress in gaining a greater 

foothold on succession planning. 

VHA’s Succession Strategic Plan for Fiscal Year (FY) 2006–2010 reports: ‘‘VHA 

faces significant challenges in ensuring it has the appropriate workforce to meet 

current and future needs. These challenges include continuing to compete for talent 

as the national economy changes over time, and recruiting and retaining health care 

workers in the face of significant anticipated workforce supply and demand gaps in 

the health care sector in the near future. These challenges are further exacerbated 

by an aging federal workforce and an increasing percentage of VHA employees who 

receive retirement eligibility each year.’’ In April 2007 VHA conducted a national conference, titled, VHA Succession Planning and Workforce Development. The conference report indicated the average age 

of all VHA employees in 2006 to be 48 years. It estimated that by the end of 2012, 

approximately 91,700 VHA employees, or 44% of current full time and part time 

staff, would be eligible for full civil service retirement. The report also indicated approximately 46,300 VHA employees are projected to retire during that same period. 

Additionally, a significant number of healthcare professionals in leadership positions 

would also be eligible to retire by the end of 2012. In a startling finding the report 

concluded that 97% of VA nurses in pay band ‘‘V’’ positions would be eligible to retire, and that 56% were expected to retire; and, that 81% of VA physicians in pay 


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category 16—including many current Chiefs of Staff, would be eligible to retire, with 

44% projected to actually retire from Federal service. 

In its assessment of current and future workforce needs, VHA identified registered nurses (RN) as its top occupational challenge, with licensed practical/vocational nurses and nursing assistants also among the top ten occupations with critical recruitment needs. Currently, VA employs over 62,000 nursing personnel, including about 42,000 registered nurses (RN), 11,400 licensed vocational or practical 

nurses, and 9,100 nursing assistants. According to VA in fiscal year 2005 (most recent data available), 77.7% of all VHA RN resignations occurred within the first five 

years of employment. Nurse turnover for that same period was 9.1%. Vacancy and 

turnover rates continue to be reported as lower than the national rates for all 

nurses, but did rise in 2004. 

Over the past several years VHA has been searching to attract younger nurses 

into VA healthcare, and to create incentives to keep them in the VA system. DAV 

is pleased that VHA continues its positive trend as an employer of choice for men 

and ethnic minorities in nursing careers. According to the Health Resources and 

Services Administration, by 2015 all 50 States will experience a shortage of nurses 

to varying degrees. However, the American Association of Colleges of Nursing has 

reported that three-fourths of the Nation’s schools of nursing acknowledge faculty 

shortages along with insufficient clinical practicum sites, lack of classroom space, 

and budget constraints as reasons for denying admission to qualified applicants. In 

2005 (most recent data available) schools and colleges of nursing turned away 

41,683 qualified applicants. 

Earlier this year, to address this problem and attain a more stable nursing corps, 

VA initiated a ‘‘Nursing Academy’’ pilot program. VA reports its Nursing Academy 

will be committed to nursing education and practice, and will address the nursing 

shortages in VA while aiding the Nation’s needs for nurses as well. VA’s pilot program for fiscal years 2007–2012 will partner with the University of Florida, San 

Diego State University, the University of Utah, and Connecticut’s Fairfield University, with their respective VA affiliates at Gainesville, San Diego, Salt Lake City 

and West Haven. The curriculum and the practicum policies of these affiliations will 

be developed jointly by the partners. Similar to VA’s longstanding relationships with 

schools of medicine nationwide, VA nurses with qualified expertise will be appointed 

as faculty members at the affiliated schools of nursing. Academy students will be 

offered VA-funded scholarships in exchange for defined periods of VA employment 

subsequent to graduation and successful State licensure. VA notes that in order for 

this program to move forward, legislation will be required to reactivate the VA’s 

Health Professions Educational Assistance Program (38 U.S.C. 7601–7636), an authority that expired December 31, 1998. 

We urge Congress to reauthorize and fund these provisions to aid VA in establishing the Nursing Academy. According to VA, funding for the five-year pilot program, (with a total five-year cost of $85 million), will be provided from available VA 

Medical Services funds, but to extend the pilot or expand it further will require new 

appropriations. VA is hopeful that the investment made in helping to educate a new 

generation of nurses, coupled with the requirement that scholarship recipients serve 

a period of obligated service in VA health care following graduation, will help VA 

cultivate and retain quality healthcare staff, even during a time of nationwide shortage. 

VA NURSING WORKPLACE ISSUES 

Mr. Chairman, DAV continues to hear reports that VHA staffing levels are frequently so marginal that any loss of staff—even one individual in some cases, can 

result in a critical staffing shortage and present significant local clinical challenges. 

Additionally, inadequate funding has resulted in ‘‘unofficial’’ hiring freezes in some 

locations. These freezes and delays in hiring have had a negative impact on the VA 

nursing workforce as some nurses have been forced to assume non-nursing duties 

due to shortages of ward secretaries and other key support personnel. These staffing 

deficiencies impact both patient programs and VA’s ability to retain an adequate 

nursing workforce. Staffing shortages or freezes on hiring can result in the 

cancelation or delay of elective surgeries and closure of intensive care unit beds. It 

can also cause unavoidable referrals of veterans to private facilities—ultimately at 

greater overall cost to VA. This situation is complicated by the fact that VHA has 

downsized inpatient capacity in an effort to provide more services on a primary care 

basis. The remainder inpatient population is generally more acute, often with comorbid conditions, lengthier inpatient episodes, complications, and needing more 

skilled care and staff-intensive aftercare. It has also been reported to us that in 

some locations, VA is overusing overtime, including ‘‘mandatory overtime;’’ reducing 

flexibility in tours of duty for nurses; and, limiting nurse locality pay. These actions, 


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driven by short financing and extremely tight local budgets, including the current 

situation of a Continuing Resolution that restricts overall management discretion 

nationwide, creates a working environment that compromises patient safety with 

staff burnout, creates morale problems, produces inadequate staffing levels, and requires the use of older, inferior technology in some VA facilities. Given that VA has 

made so much progress in establishing the current national standard of excellence 

in providing care to its large veteran population, these reports. 

Mr. Chairman, in testimony to this Committee in 2003, VA’s top nurse executive 

stated the following: ‘‘Published findings underscore the need to focus on improving 

the work environment for nurses in order to increase staff satisfaction and to ensure 

the provision of safe, high quality patient care.’’ We believe many of those difficult 

conditions in VHA continue to exist today for VA’s nursing staff, despite the best 

efforts and intentions of those involved. Therefore, we hope this Subcommittee will 

provide additional oversight to ensure a safe environment for both patients and 

staff. 

Like other health care employers, VHA must actively address those factors known 

to affect recruitment and retention of all health care providers and nursing staff, 

and take proactive measures to stem crises before they occur. We encourage VHA 

to continue its quest to deal with shortages of health manpower in ways that keep 

VHA at the top of the standards of care in this country. We are very encouraged 

with the Nursing Academy proposal, endorsed by the Nursing Commission and hope 

that it proves its worth early so that it can be expanded beyond the four pilot sites. 

We ask the Subcommittee to pay special attention to the development of that Academy and to encourage its expansion. 

PAY REFORM ISSUES FOR VA PHYSICIANS AND DENTISTS 

In 2004, as reported by this Committee, Congress passed the Department of Veterans Affairs Personnel Enhancement Act, Public Law 108–445. This new law reformed the pay and performance system used by VA in employment of physicians 

and dentists. This proposal was one of VA’s top legislative goals in the 108th Congress. Enactment of this proposal was supported by DAV and other organizations 

that expressed concern that VA needed new authority to attract and retain the best 

physicians and dentists for the care of sick and disabled veterans—particularly at 

a time of ongoing military engagements in Iraq and Afghanistan. VA implemented 

this new authority as required by the Act in January 2006, and began to announce 

new pay plans for VA physicians under its terms. This Act is the most significant 

reform of pay systems for VA employees since the enactment of the Civil Service 

Reform Act in 1978, and represents the first real reform in VA physician pay since 

1991. 

We believe the Committee should use its oversight authority to study the impact 

of Public Law 108–445 on recruitment and retention of VA physicians and dentists—especially those who practice in some of the more scarce specialties, including 

anesthesiology, orthopedics, and various surgical specialties. These subspecialties 

are very scarce and VA has historically had great challenges recruiting these practitioners to full-time employment. VA’s motivation to secure this new authority was 

driven by the exorbitant cost of procuring contract services of scarce medical specialists. One of the purposes of the Act was to give VA the tools to enable it to attract 

even these specialists to VA employment on a full-time basis. Also, the crafting of 

the bill was designed to attract to VA young physicians first entering their professional practices after residencies, and to provide them meaningful incentives that 

pointed them to full careers in the VA health care system. 

We believe the Committee should investigate whether the Act is resulting in VA’s 

improving its ability to achieve these goals. Physicians are essential caregivers, educators, and key biomedical researchers in the VA health care system. This Act was 

intended for their benefit, to attract them to VA careers and to keep them providing 

outstanding care to veterans. We would hope these purposes would be transparent 

and that VA would have moved implementation toward these goals, but we believe 

the Committee should confirm those intended results. 

VA PHYSICIAN WORKPLACE ISSUES 

Mr. Chairman, DAV is concerned about the stressful working environment now 

confronting the VA physician workforce. While the matters brought to our attention 

over the past few years as VA clinical workloads have grown might be dismissed 

as anecdotal and not indicative of the general national environment, they are no 

less disturbing. We have been told by numerous sources that many VA medical center directors have established arbitrary ‘‘caps’’ on the total bonus a VA physician 

may receive under the performance element of pay. While the Act gave the VA Secretary discretion by regulation to determine appropriate pay levels, it allowed for 


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annual performance pay up to $15,000 or not to exceed 7.5 percent of combined base 

and market pay amounts. Directors should not, given those limitations, be permitted 

to establish arbitrary performance pay amounts of as little as $1,000 (we have been 

told this to be the case in some facilities), thereby frustrating the purposes of the 

Act. Also, we are in possession of a letter written by a group of VA physicians. This 

was a signed letter to the clinical manager of a VA network. Let me excerpt only 

a few of the concerns it expresses, which we fear may be suggestive of the workplace 

situation across the VA system: 

‘‘First, we are understaffed. Over the past 11⁄2 years, we have lost a net of three 

physicians and one nurse practitioner at the lllll site. We all have had to absorb those provider panels into our own, at a rapid pace. You stated that we had 

grown by fewer than 200 new patients since January; however, that statistic misses 

how we have added literally thousands of our former colleagues’ patients into our 

own panels. Our CBOC colleagues are suffering from similar provider shortages and 

turnover; in a single month this spring the Bangor CBOC lost two out of seven providers. At llllll, half of us are at or above full panel, and the other half of 

us are virtually at full panel. We have had no success so far at recruiting new providers, and we do not see evidence of strong administration commitment to recruitment. Further, it was known many, many months in advance that we would be losing a Women’s Clinic provider to her deployment to Iraq, yet there was no leadership in making sure a temporary provider was ready to step into her place. In fact, 

there seemed to be obstruction to an on-site willing provider starting work in Women’s Clinic. Again, current providers have had to absorb the workload of the absent 

provider.’’

‘‘We are not only understaffed in terms of providers; we are also working without 

adequate numbers of support staff. Specifically, within the past year, we at 

lllll lost two pharmacists who used to work directly with us in the clinic; to 

date these positions have not been filled. Our CBOC colleagues are overwhelmed by 

the extra work that an understaffed pharmacy creates. At the CBOCs, the providers 

spend inordinate amounts of time writing and documenting prescriptions for veterans to fill locally, when our pharmacy does not fill the medications in a timely 

fashion. At both lllll and the CBOCs we now have fewer nurses as well.’’

We at DAV certainly hope these are isolated matters but we believe we could obtain similar responses from many other VA physician groups, in primary care and 

elsewhere, now shouldering a very heavy burden in caring for veterans. If the general situation in clinical care across the VA is anything like this report suggests, 

VA has a very serious and rising morale problem that eventually may interfere with 

health care quality, safety, efficiency and effectiveness. We ask the Subcommittee 

to consider conducting a survey of VA facilities to gauge conditions of employment 

and the current morale of the VA physician workforce. We believe this examination 

could be very informative to the Subcommittee, to VA Central Office, and to the 

VSO community that is so concerned about sustaining quality VA health care. 

SUMMARY AND CLOSING 

Mr. Chairman, in summary, DAV believes that VA must devote sufficient resources to avert the national shortage of nurses from creeping into and potentially 

overwhelming VA’s critical healthcare programs, and to minimize the impact that 

the nursing shortage on the care VA provides to sick and disabled veterans. In that 

regard, DAV supports VA’s strategic goals for nursing, including establishment of 

the innovative VHA Nursing Academy, and urges the Committee to act on legislation that would reauthorize the scholarship program. Also, we ask that you use your 

oversight powers to ensure the intent of Public Law 108–445 is fully realized. 

This Subcommittee should provide oversight to ensure sufficient physicians and 

nursing staffing levels, and to regulate, and reduce to a minimum, VA’s use of mandatory overtime for VA registered nurses. We believe this practice of mandatory 

overtime endangers the quality of care and safety of veterans in VA health care. 

We believe VA should establish innovative recruitment programs to remain competitive with private-sector health care marketing and advertising strategies, to attract 

nurses and doctors to VA careers. While we applaud what VA is trying to do in improving its nursing programs, these competitive strategies are yet to be fully developed or deployed in VA. Also, Congress must provide sufficient funding through regular appropriations that are provided on time, to support programs to recruit and 

retain critical nursing staff to VA. The routine annual Continuing Resolution process negatively impacts not only VA nursing but all of VHA. We also believe the VA 

workplace situation with respect to both nurses and physicians deserves greater 

oversight by the Subcommittee, and we hope you will take our recommendations in 

that regard into consideration. 


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Again, we thank you for this opportunity to testify. We ask the Committee to consider these situations as it deals with its legislative plans for this year. This concludes my testimony, and I will happy to address any questions from the Chairman 

or other Members of the Subcommittee. 

f 

Prepared Statement of J. David Cox, R.N., National Secretary-Treasurer, 

American Federation of Government Employees, AFL–CIO 

Dear Chairman and Members of the Subcommittee: 

The American Federation of Government Employees (AFGE) appreciates the opportunity to present its views on recruitment and retention tools for the Veterans 

Health Administration (VHA) workforce. AFGE represents more than 150,000 employees in the Department of Veterans Affairs (VA), more than two-thirds of whom 

are VHA professionals on the front lines treating the physical and mental health 

needs of our veteran population. 

The vast majority of VHA’s workforce is covered by ‘‘pure Title 38’’ or ‘‘hybrid 

Title 38’’ personnel rules that were designed to recruit and retain personnel through 

a more flexible, shorter process. A small number of direct patient care positions remain under Title 5, e.g., Nursing Assistants and Medical Technicians. In practice, 

hiring and promotion under Title 38 have turned out to be anything but quick and 

streamlined processes, further contributing to VHA’s inability to adequately recruit 

and retain needed personnel. Applicants awaiting credentialing and salary offers 

leave for other positions because of long delays. Current VHA employees are demoralized by delays and inequities in the Title 38 promotion process. The current 

credentialing system and boarding process for Title 38 should be evaluated to identify ways to eliminate these harmful disincentives. 

Congress has enacted a wide array of VHA recruitment and retention tools over 

the years that rely on educational assistance, pay, work schedules, and other workplace benefits to enable the VA medical facilities to compete with other health care 

systems for quality personnel. These tools complement VA’s most effective recruiting 

and retention tool: itself. Caring for our Nation’s veterans in this world class health 

care system offers a professional opportunity like no other. 

So why is the VA reporting such alarming workforce shortage statistics? 2007 VA 

data shows that new employees are practically fleeing VHA: 77% of all RN resignations occur within the first five years, and other professions have equally high attrition rates (71% of physicians, 77% of pharmacists and 79% of Licensed Practical 

Nurses (LPN.)) As a result, VHA’s workforce is steadily aging: the average age is 

now at 48.3 years. In five years, 44% of the current workforce will be eligible for 

full retirement. By 2010, 22,000 of VA’s 35,000 registered nurses will be eligible to 

retire. 

The VA pays dearly for its flawed retention and recruitment policies. The average 

VA-wide cost of turnover is $47 million for nurses, $90 million for physicians, and 

$9.6 million for pharmacists. 

Chronic staffing shortages result in other significant costs. Since injured veterans 

cannot wait for replacements to come on board, VA medical facilities are increasingly relying on contract nurses and physicians as a stopgap solution—a very costly 

one at that. AFGE anxiously awaits the findings of the pending GAO study of the 

impact of contract nurses on VA health care quality and cost. The use of contract 

nurses also hurts morale: agency nurses are given more desirable shifts than senior 

staff nurses (in part because they lack the specialized skills to function independently on evening and night shifts). Agency nurses also lack familiarity with the VA’s 

unique health care IT systems and patient safety policies. 

We also anxiously await the VA’s first report to Congress on how effective the 

2004 Physicians and Dentists pay bill (PL 108–445) has been at achieving its top 

objective: reducing spending on costly fee basis physicians. Based on our members’

very mixed experiences with market pay and performance pay awards coming out 

of the new law, we are doubtful that the VA has achieved the law’s objectives. 

While an urgent response to VHA’s growing workforce shortage is warranted, we 

urge Congress to be wary of new fixes that promise success under old conditions, 

such as the Nursing Academy and Magnet hospitals, as will be discussed. Such approaches divert precious health care dollars away from direct patient care and hiring of needed health care professionals. The same dollars can be put to better use 

investing in the excellent array of recruitment and retention tools that Congress has 

already created. AFGE firmly believes that these tools can meet current staffing 

needs, if properly funded and managed. 


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Funding is inextricably tied to recruitment and retention. As the Independent 

Budget points out, when VHA fails to receive its funding in a timely manner under 

a discretionary funding process, budget-strapped medical center directors are unable 

to adequately meet anticipated hiring needs. 

The effectiveness of the current tools also depends on adequate guidance from VA 

Central Office and regular Congressional oversight. VA’s implementation of recent 

nurse and physician legislation has been largely decentralized, leaving great discretion to directors to decide what incentives to offer to their staff and whether to allocate needed funds to achieve success. 

Pay Incentives: VHA’s success with using pay to recruit and retain professionals 

has been mixed. Title 38 has always permitted management to offer hiring and retention bonuses and special pay increases to employees hired under this authority 

that are underutilized. Congress recently augmented this authority with two profession specific pay laws: 2001 nurse locality pay legislation and 2004 physician/dentist 

pay legislation. 

The nurse locality pay law had two primary objectives: provide VA registered 

nurses with the National Employment Cost Index (ECI) based portion of the annual 

federal pay raise, and give hospital directors the authority to conduct third party 

locality pay surveys in order to set competitive pay rates for VA nurses. Unlike 

other federal employees, nurse locality pay portion is still at the discretion of their 

facility directors. Directors regularly refuse, especially in competitive markets, to 

conduct equitable pay surveys, even in the face of serious recruitment and retention 

problems. Or they conduct separate surveys for rank-and-file and nurse supervisors 

and provide higher percentage increases to the latter. 

The key test of whether the nurse locality pay law is working is whether the VA 

is able to recruit and retain nurses, reduce reliance on costly agency nurses, mandate less overtime and properly match staffing with patient acuity. The VA has yet 

to provide evidence of success in these indicators. 

The 2004 law (PL 108–445) to provide more competitive pay to VA physicians and 

dentists has also had its share of roadblocks. Employee representatives were excluded from national level groups that set the pay ranges for market pay. Local 

compensation panels setting market pay for individual providers at each facility 

largely excluded the frontline practitioners, despite requirements in the law to include them. In some cases, management excluded them overtly, in other cases; they 

‘‘accidentally’’ forget to inform them when the panels were meeting. AFGE’s re- quests for the survey data used by facilities to set market pay were denied without 

basis and after great delay. In short, AFGE and the physicians and dentists at the 

frontline do not know which surveys were used to set their pay or whether their 

pay is comparable to that of their peers. Anecdotally, we are aware of many examples where individual providers were denied market pay increases, and facilities 

that used questionable survey data to set pay. 

The performance pay provisions in the 2004 law have been severely weakened, 

first by VA’s blanket reduction of the maximum award from $15,000 to $5,000 in 

the first year, and similar blanket caps of a few thousand dollars that continue to 

be imposed by many facility directors. Providers are also frustrated by the great 

delay in issuing criteria for receiving performance pay, the inability to have input 

into the development of these criteria, and the fact that many of the criteria were 

improper or unrealistic. Clearly, Congressional intent to use performance pay as a 

retention tool for physicians and dentists has been frustrated. 

Again, the key test of whether the physician and dentist pay bill has fulfilled Congressional intent is whether the VA has been able to reduce the use of expensive 

fee basis physicians and dentists and fill vacancies at medical facilities. Hopefully, 

VA’s report to Congress will be released in the near future and shed some light on 

whether these objectives have been at least partially met. 

We also urge Congress to consider other nurse pay fixes that will aid in recruitment and retention. The VA cannot offer competitive pay to Certified Registered 

Nurse Anesthetists because under current law, they cannot earn more than facility 

nurse executives. In addition, we urge Congress to amend 38 USC § 7455 to remove 

the current cap on locality pay for Licensed Practical Nurses, as Congress previously 

did for physical therapists and pharmacists. 

Educational Assistance: The Nursing Academy, the VA’s newest education-based 

recruitment tool, carries a $40 million price tag for an initial five year pilot project. 

This initiative does not guarantee that the VA will be able to recruit any graduates 

of the Academy. VA already has an effective education-based tool in place that requires an employment commitment, and its effectiveness can be increased through 

better funding and management. The Employee Debt Reduction Program (EDRP) 

provides new graduates with educational loan repayments in exchange for a fixed 


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period of employment at a VHA facility. Our members report that nurses in hardto-recruit geographic areas have been turned away because EDRP funds have been 

exhausted, while excess EDRP funds remain unused in other locations. The Federal 

Government also has longstanding upward mobility programs that could be used to 

recruit health care professionals from within the VA but they appear to be woefully 

underutilized. 

Scheduling Incentives: 

The nurse alternative work schedule provisions that Congress enacted in 2004 

were intended to make the VA workplace a more desirable place to work by offering 

VA registered nurses the same popular compressed work schedule (CWS) (full-time 

pay for three 12 hour days) that private nurses are offered. Again, funding problems 

and local discretion have frustrated Congressional intent. Local directors are reluctant to offer CWS in part because it requires them to hire additional staff and in 

part because of a reluctance to make change. Since they can’t afford to hire, they 

lose prospective nurses but cannot attract others to replace them so they end up 

spending far more on agency nurses. We urge Congress to end this vicious cycle by 

ensuring that adequate funds are available for the VA to offer CWS and require the 

VA to conduct more oversight at the local level. 

The second scheduling incentive that Congress included in the 2004 law (P.L. 

108–445) was to reduce the VA’s reliance on mandatory overtime. The law prohibits 

the use of mandatory overtime except in cases of emergencies. To be competitive 

with other employers, all VA facilities should use the same, widely accepted, narrowly drawn definition of emergency adopted by a number of states to protect their 

nurses from excessive overtime. Instead, each facility is permitted to invoke the 

emergency exception to mandate overtime, even when staffing shortages are a result 

of their own mismanagement and could have been easily anticipated. AFGE urges 

Congress to adopt a statutory definition of emergency consistent with state law. In 

addition, the current overtime provision should also apply to Licensed Practical 

Nurses and Nursing Assistants. Finally, we urge Congress to strengthen and extend 

the current requirement that VHA certify as to status of overtime policies in all facilities. 

Other Recruitment and Retention Tools: 

Greater employee voice: Magnet certification is regularly touted as a highly effective recruitment and retention tool for VHA, because among other alleged benefits, 

it provides greater involvement by front line nurses. Long before magnets came on 

the scene, VHA endorsed employee involvement. That is why AFGE nurses regularly served on key committees such as patient safety, nurse innovation, qualification standards, and workforce planning. Sadly, we have been virtually excluded 

from such groups as of late. We doubt that magnet status will make VA management more open to frontline employee participation. What we are sure of is that 

many, many medical dollars are being diverted from patient care and nurse hiring 

in order to go to magnet certification fees and staff time to prepare magnet applications. This appears to be a questionable use of appropriated dollars as well as a 

questionable use of patient care dollars. 

Retirement benefits: Currently, most federal employees covered by the FERS retirement system cannot apply unused sick leave toward retirement, while their 

counterparts under the older CSRS system can. Congress carved out an exception 

under Title 38 for RNs several years ago. We urge that this benefit be extended to 

all VHA personnel as an added incentive for staying with the VA. 

Equality for Part-Time Nurses: Part-time nurses represent a valuable untapped 

source of personnel for VHA, but they face two disincentives. First, even if they 

were previously full-time nurses with permanent status, they enter probationary 

status with no employee rights for an indefinite period if they become part-time. We 

urge Congress to give part-time nurses permanent status after working at the VA 

for the equivalent of two years full-time. Part-time nurses are also denied most of 

the overtime, shift differential, and weekend premium pay earned by full-time 

nurses. To remain competitive with other employers who recognize the importance 

of flexible work schedules for nurses, the VA should update its policies for part-timers. 

Other professionals appointed under 38 USC § 7401(1): AFGE supports H.R. 2790 

to provide a full-time physician assistant advisor so that valuable role of physician 

assistants in VA health care can be better utilized. We also encourage a renewed 

look at the status of the other professionals appointed under this authority as chiropractors, podiatrists, and optometrists who are increasingly playing a key role in the 

treatment of OIF/OEF veterans. 


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CONCLUSION 

VHA clearly recognizes the recruitment and retention challenges that lie ahead. 

AFGE participated in the National Commission on VA Nursing several years ago 

that acknowledged that the ‘‘current and emerging gap between the supply of and 

demand for nurses may adversely affect the VA’s ability to meet the healthcare 

needs of those who have served our Nation.’’ We commend VHA for other efforts undertaken to address VHA workforce succession planning in recent years. We urge 

Congress to give the VA the financial support and direction it needs to address short 

and long term health care workforce needs in a cost effective manner that ensures 

that veterans receive high quality care. 

Thank you. 

f 

Prepared Statement of William J. Feeley, MSW, FACHE, 

Deputy Under Secretary for Health for Operations and Management, 

Veterans Health Administration, U.S. Department of Veterans Affairs 

Mr. Chairman and members of the Committee, thank you for the invitation to appear before you today to discuss the Department of Veterans Affairs (VA), Veterans 

Health Administration (VHA) recruitment and retention program for health care 

professionals. I appreciate the opportunity to discuss our ongoing efforts in workforce and succession planning as they relate to recruitment and retention. As the 

Nation’s largest integrated health care delivery system, VHA’s workforce challenges 

mirror those of the health care industry as a whole. The Nation is in the midst of 

a workforce crisis in health care and VHA experiences the same pressures. I am 

pleased to be here today to share VHA’s innovative approaches to addressing recruitment and retention of our professional health care workforce. 

Efforts to Increase the Pipeline of Health Care Workers 

There is a growing realization that the supply of appropriately prepared health 

care workers in the Nation is inadequate to meet the needs of a growing and diverse 

population. This shortfall will grow more serious over the next 20 years. Enrollment 

in schools of nursing is not growing fast enough to meet the projected future demand. The American Association of Colleges of Nursing has reported that more than 

42,000 qualified applicants were turned away from nursing schools in 2006 because 

of insufficient numbers of faculty, clinical sites, classroom space and clinical mentors. 

In April 2007, VA launched the VA Nursing Academy to address the nationwide 

shortage of nurses. The purpose of the Academy is to expand the number of nursing 

faculty in the schools, increase student nursing enrollment by 1,000 students and 

promote innovations in nursing education through enhanced clinical rotations in the 

VA. VHA research shows that students who perform clinical rotations at a VA facility are more likely to consider VA as an employer following graduation. 

The pilot program known as ‘‘Enhancing Academic Partnerships’’, selected four 

sites from among 42 applicants. The first year begins in conjunction with the 2007–

2008 academic school years. The four VA facilities and nursing schools selected include: the North Florida/South Georgia Veterans Health System and the University 

of Florida in Gainesville; the VA San Diego Healthcare System and San Diego State 

University; the VA Salt Lake City Health Care System and the University of Utah 

in Salt Lake City; and the VA Connecticut Healthcare System and Fairfield University in Fairfield, CT. Another four partnership sites will be selected in 2008 and 

2009, for a total of 12 partnership sites in the five-year pilot program. 

Another program designed to attract academically successful students of baccalaureate nursing programs and pharmacy doctorate programs to work at VA is the 

VA Learning Opportunities Residency (VALOR) Program. The purpose of this intern 

program is to develop a candidate pool of qualified and highly motivated candidates 

for employment. The VALOR program, offering a paid internship, gives the selected 

students the opportunity to develop competencies in their clinical practice in a VA 

facility under the guidance of a preceptor. In 2006, VHA hired 89 of the VALOR 

nurses who had graduated. In response to the success of the VALOR program for 

nurses, the pharmacy component was added in 2007 to address VA’s need for pharmacists. VHA hopes to mirror this success through the pharmacy program. 

The Student Career Experience Program (SCEP) offers students work experience 

directly related to their academic field of study by providing formal periods of work 

and study while the student is attending school. This program focuses on recruiting 

students from minority colleges and universities and in mission critical occupations. 

Mission critical occupations are those that may exhibit such things as an increasing 


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demand, high turnover, or a high volume position in VHA. VHA’s goal is to actively 

recruit these students for permanent employment following graduation. VA National 

Database for Interns (VANDI) is a newly designed database developed to track 

those individuals who participate in specific VA recognized internship/student programs. The strategy is to use the database to identify potential qualified applicant 

pool. VANDI will also assist with workforce development, diversity management 

and succession planning. The database will include: demographic data on interns, 

various educational information for interns and management officials (i.e. resume 

writing, Special Hiring Authorities, list of colleges and universities, links to various 

VA Offices, etc.), and statistical data for reports and evaluations. 

The VA Cadet program is a collaborative effort between VHA’s Healthcare Retention and Recruitment Office, the Office of Nursing Service and Voluntary Service. 

The program targets high school students who initially come to VHA as volunteers 

and later convert to student employment. The goal of the program is to introduce 

high school students to health care occupations and encourage the pursuit of education and training in nursing or other allied health professions. Students attending 

allied health programs may be appointed under the student career experience program and hired into vacant positions upon graduation. Once in a permanent position for one year, they are then eligible for Employee Incentive Scholarship Program 

(EISP) scholarships to advance their careers. 

The Graduate Health Administration Training Program (GHATP) provides practical work experience to students and recent graduates of health care administration 

masters programs. GHATP residents and fellows are competitively selected and 

upon successful completion of the programs are eligible for conversion to a VA 

health systems specialist position in hospital management. 

The Technical Career Field (TCF) program is an internship created to recruit 

journeyman level staff to fill vacancies in technical career fields where current and 

future shortages are predicted and knowledge of VA-related issues is critical to success. Recruitment is focused on local colleges and universities. Each intern is placed 

with an experienced trained preceptor in a VHA facility. Interns convene for an annual conference with their peers and the program is evaluated at the national level. 

The program is designed to be flexible based on the changing needs of the workforce. Annually, the target positions and number of intern slots are determined 

based on current and projected workforce needs and program evaluation data. 

Streamlining the Hiring Process 

It is well known that the Government hiring process is cumbersome. In May 2007, 

the Human Resource Committee chartered a process redesign workgroup to streamline the recruitment process for Title 5 and Title 38 positions within VHA. This included an analysis of the recruitment process and identification of barriers and 

lengthy processes. In August 2007, the workgroup presented their findings and recommendations for short, intermediate and long-term improvements intended to 

streamline processes at the facility level and facilitate change at the national level. 

VA has direct appointment authority for several occupations, including physical 

therapists. We recognize that the physical therapist occupation is a key to the rehabilitation of returning veterans and VHA is working with the Office of Human Resources Management (OHRM) to develop a new qualification standard. OHRM expects the revised standard to advance to collaboration with the labor unions in January 2008 and be approved for implementation in mid-summer of that year. During 

the interim, the existing qualification standard is being used for appointments. 

National Recruitment/Media Marketing Strategies 

VHA Health Care Retention & Recruitment Office (HRRO) administers national 

programs to promote national employment branding with VHA as the health care 

employer of choice. Established almost a decade ago, the brand ‘‘Best Care—Best 

Careers’’ reflects the care America’s veterans receive from VA and the excellent career opportunities available to staff and prospective employees. The brand has been 

reflected in the popular press in the January/February 2005 edition Washington 

Monthly magazine article ‘‘Best Care Anywhere’’ and in the recently published book 

Best Care Anywhere: Why VA Health Care is Better than Yours by Phillip Longman. 

HRRO works at the national level to promote recruitment branding and provide 

tools, resources, and other materials to support both national branding and local recruiting. Some of these features are: 

• VHA recruitment Web site (www.VACareers.va.gov) provides extensive 

information on careers in VHA, job search capability, and information on 

Federal employment pay and benefits information. 

• Public Service Announcements (PSA) promote the ‘‘preferred health care 

employer’’ image of VHA. PSA’s emphasize the importance and advantage 


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of careers with VA and focus on the personal and professional rewards 

of such a career. 

• Online advertising through a comprehensive web advertising strategy, 

VA job postings are promoted on commercial employment sites and online 

health information networks that expand our reach to over 5,000 discrete 

Web sites. The strategy includes banner advertising that drives traffic to 

the VACareers Web site for employment information. This advertising 

program generates millions of ad impressions and accounts for more than 

100,000 visits to the VA recruitment Web site each month. 

• Print advertising includes both direct classified advertising and national 

employment branding. Local classified advertising plans are built around 

single job announcements and using journals, newspapers, and the web 

to promote positions. The national program provides ongoing exposure of 

VA messaging to potential hires with the intent to promote VA as a leader in patient care and to clearly state the benefits of VA employment. 

With advertising placed in more than 35 health professional magazines 

and peer review journals, VHA targets readership of over 34 million potential candidates. 

• VHA Health Care Recruiters’ Toolkit, a unique virtual community internal to VHA is an online management program that coordinates national 

and local recruitment efforts for health care professionals. The toolkit 

helps recruiters combat the national recruitment shortage by placing all 

available recruitment tools, materials, ads, and information at their fingertips. 

• National Recruitment Advisory Groups, the VHA Nurse Recruiters Advisory Board and the National Nurse Recruiters group established in the 

early 90’s is a collaborative network of nurse recruiters from VHA facilities across the country. The group holds membership as a subchapter of 

the National Association of Healthcare Recruiters and works to educate 

and develop nurse recruiters in VHA and to share best practices. 

• National Pharmacy Recruitment Advisory Board and regional network of 

Pharmacy Recruiters was established in 2007. 

• In 2004, VHA conducted the Nursing Recruitment and Retention Study 

to examine attitudes toward careers in nursing and to develop and test 

recruitment marketing materials and messaging for development of ads, 

PSA’s, and brochures. In 2006, VHA conducted the Pilot Program to 

Study Innovative Recruitment Tools to Address Nursing Shortages at Department of Veterans Affairs. This study further developed recruitment 

and marketing approaches using online methods and refined recruitment 

marketing messages and recruitment materials for nursing occupations 

(e.g. brochures). 

• In July 2007, following qualitative research to determine why pharmacists are drawn to work at VA, the VHA Pharmacy Marketing Plan 

was developed. This research was supplemented by quantitative research 

performed by the Office of Academic Affiliations of both nurses and pharmacists in the first three and five years of employment respectively. 

These studies quantified the impact of student clinical experiences in VA 

on the decision to work at a VA facility as well as the impact of the work 

environment and work assignments on retention. 

• In fiscal year (FY) 2007, HRRO developed a comprehensive recruitment 

marketing plan for recruitment in mental health occupations that used 

strategies listed above as well as recruitment incentives to assist with 

quick recruitment of these providers nationally. 

Financial Incentives for Recruitment and Retention 

Both a recruitment and retention tool, the Employee Incentive Scholarship Program (EISP) pays up to $32,000 for academic health care related degree programs 

with an average of $12,000 paid per scholarship. Since the program began in 1999, 

approximately 7,000 VA employees have received scholarship awards for academic 

education programs related to Title 38 and Hybrid 38 occupations. Approximately 

4,000 employees have graduated from their academic programs. Scholarship recipients include registered nurses (93 percent), pharmacists, and many other allied 

health professionals. Focus group market research shows that staff education programs offered by VHA are considered a major factor in individuals selecting VA as 

their choice of employer. A 5-year analysis of program outcomes demonstrated the 

impact on employee retention. For example, turnover of nurse scholarship participants is 7.5 percent compared to a non-scholarship nurse turnover rate of 8.5 perVerDate Aug 31 2005 03:06 Aug 19, 2008 Jkt 039464 PO 00000 Frm 00065 Fmt 6604 Sfmt 6621 E:\HR\OC\39464.XXX 39464

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cent. Less than one percent of nurses leave VHA during their service obligation period (from one to three years after completion of degree). 

The Education Debt Reduction Program (EDRP) provides tax free reimbursement 

of education loans/debt to recently hired Title 38 and Hybrid Title 38 employees. 

EDRP is the Title 38 equivalent to the Student Loan Repayment Program (SLRP) 

sponsored under Office of Personnel Management (OPM) regulations for Title 5 employees. As of August 9, 2007, there were over 5,600 health care professionals participating in EDRP. The average amount authorized per student for all years since 

the program’s inception is $17,000. The average award amount per employee has increased over the years from over $13,500 in FY 2002 to over $27,000 in FY 2007 

as education costs have increased. While employees from 33 occupations participate 

in the program, 77 percent are from three mission critical occupations—registered 

nurse, pharmacist and physician. Resignation rates of EDRP recipients are significantly less than non-recipients as determined in a 2005 study. For physicians, the 

study found the resignation rate for EDRP recipients was 15.9 percent compared to 

34.8 percent for non-EDRP recipients. 

VHA routinely uses hiring and pay incentives established under Title 5, extended 

by the Secretary to Title 38 employees. There is routine use of financial recruitment 

incentives, retention incentives (both individual and group), special salary rates, relocation incentives and other incentives as documented in VHA’s Workforce Succession Strategic Plan. 

Innovative Retention Strategies 

One retention strategy that has been very successful for VHA was the approval 

of the physician pay legislation (Public Law 108–445, dated December 3, 2004) effective January 8, 2006. The pay of VHA physicians and dentists consists of three elements: base pay, market pay, and performance pay. The change was intended to 

make possible the recruitment and retention of the best qualified workforce capable 

of providing high quality care for eligible veterans. VA is committed to ensuring 

that the levels of annual pay (base pay plus market pay) for VHA physicians and 

dentists are fixed at levels reasonably comparable with the income of non-VA physicians and dentists performing like services. Since the physician pay legislation went 

into effect, physician employment has increased by 430 physicians. 

An overarching mission of VHA is to develop and retain our most valuable asset— those who provide quality care to our veterans and their families. VHA invests resources to nurture and maintain an exceptionally competent workforce that is committed to providing ‘‘the best quality care anywhere.’’ There is a direct impact in the relationship of organization culture and employee 

and patient satisfaction. For example, researchers demonstrated a positive relationship between group culture and patient satisfaction among inpatients and ambulatory care patients, such that the higher the group/teamwork culture the higher the 

patient satisfaction (Meterko, Mohr, & Young, Medical Care, 42(5), May 2004, 492– 498). 

VHA believes maintaining the health of the organization improves retention of 

employees in hard to recruit occupations and will continue to invest in the All Employee Survey, the Civility Respect and Engagement in the Workforce (CREW) program as well as others designed to improve organizational health. We strongly believe a healthy organizational culture ensures improved patient satisfaction and 

care for our veterans. 

Employee Entrance and Exit Survey Analysis 

In 2000, VA implemented the use of an electronic database to capture survey information from employees entering and exiting VA Service. The entrance survey is 

an excellent tool to compare and contrast reasons the new workforce has come to 

work for VHA and is an excellent tool to determine recruitment sources used by candidates (e.g. newspaper ads, employee referral, online job postings). In contrast, the 

exit survey tracks the reasons why staff leave VHA employment. 

Survey results of 2006 and the first half of 2007 show the top reasons to work 

for VA were advancement/development opportunities, benefits package and job stability. The mission of serving veterans and pay were also highly rated. The exit survey shows the top reasons for leaving VHA in FY 2006 and the first half of 2007 

were normal retirement, advancement elsewhere, and family matters (marriage, 

pregnancy, etc.). These findings provide valuable insight for developing recruitment 

marketing messages and establishing programs to improve retention. 

Workforce Succession Planning 

VHA performs extensive national workforce planning and updates and publishes 

a VHA Workforce Succession Strategic Plan annually. As part of this process, workforce analysis and planning is conducted in each Veterans Integrated Services NetVerDate Aug 31 2005 03:06 Aug 19, 2008 Jkt 039464 PO 00000 Frm 00066 Fmt 6604 Sfmt 6621 E:\HR\OC\39464.XXX 39464

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work (VISN) and national program office and then is rolled up to create a national 

plan. The plan addresses VHA’s strategic direction and emerging initiatives such as 

mental health care, polytrauma, TBI, and rural health. Mission critical occupations, 

which are considered shortage categories, are identified and initiatives are established at local, regional and national levels to address recruitment and retention. 

For each of the nationally ranked mission critical occupations a thorough historical 

and projected workforce analysis is conducted. Plans are established at every level 

to address turnover, the succession pipeline, developmental opportunities, and diversity issues. For each of the critical occupations, as well as the workforce nationwide, 

equal employment opportunity (EEO) comparison data is provided to ensure that 

VHA maintains a diverse workforce. 

VHA’s workforce plan is one of the most comprehensive in government and has 

been recognized by OPM as a Federal best practice. VA presented at other Federal 

agencies and the OPM Conference, ‘‘A Best Practice Leadership Forum On Succession Management.’’ The Under Secretary for Health has made a personal commitment to succession 

planning and ensuring VHA has a comprehensive recruitment, retention, development and succession strategy. This is a continuous process which requires on-going 

modifications and enhancements to our current programs. 

We want to thank the Committee for their interest and support in implementing 

legislation that allows us to compete in the aggressive health care market. 

Mr. Chairman, that concludes my statement. I am pleased to respond to any questions you or the Subcommittee members may have. 

Thank you. 

f 

Statement of American Academy of Physician Assistants 

On behalf of the nearly 65,000 clinically practicing physician assistants (PAs) in 

the United States, the American Academy of Physician Assistants (AAPA) is pleased 

to submit comments in support of H.R. 2790, a bill to amend title 38, United States 

Code, to establish the position of Director of Physician Assistant Services within the 

office of the Under Secretary of Veterans Affairs for Health. The AAPA is very appreciative of Representatives Phil Hare and Jerry Moran for their leadership in introducing this important legislation. AAPA believes that enactment of H.R. 2790 is 

essential to improving patient care for our Nation’s veterans, ensuring that the 

1,600 PAs employed by the VA are fully utilized and removing unnecessary restrictions on the ability of PAs to provide medical care in VA facilities. Additionally, the 

Academy believes that enactment of H.R. 2790 is necessary to advance recruitment 

and retention of PAs within the Department of Veterans Affairs. 

Physician assistants are licensed health professionals, or in the case of those employed by the Federal Government, credentialed health professionals, who—

• practice medicine as a team with their supervising physicians 

• exercise autonomy in medical decisionmaking 

• provide a comprehensive range of diagnostic and therapeutic services, including 

performing physical exams, taking patient histories, ordering and interpreting 

laboratory tests, diagnosing and treating illnesses, suturing lacerations, assisting in surgery, writing prescriptions, and providing patient education and counseling 

• may also work in educational, research, and administrative settings. 

Physician assistants’ educational preparation is based on the medical model. PAs 

practice medicine as delegated by and with the supervision of a physician. Physicians may delegate to PAs those medical duties that are within the physician’s scope 

of practice and the PA’s training and experience, and are allowed by law. A physician assistant provides health care services that were traditionally only performed 

by a physician. All states, the District of Columbia, and Guam authorize physicians 

to delegate prescriptive privileges to the PAs they supervise. AAPA estimates that 

in 2006, approximately 231 million patient visits were made to PAs and approximately 286 million medications were prescribed or recommended by PAs. 

The PA profession has a unique relationship with veterans. The first physician 

assistants to graduate from PA educational programs were veterans, former medical 

corpsmen who had served in Vietnam and wanted to use their medical knowledge 

and experience in civilian life. Dr. Eugene Stead of the Duke University Medical 

Center in North Carolina put together the first class of PAs in 1965, selecting Navy 

corpsmen who had considerable medical training during their military experience as 

his students. Dr. Stead based the curriculum of the PA program in part on his 

knowledge of the fast track training of doctors during World War II. Today, there 


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are 139 accredited PA educational programs across the United States. Approximately 1,600 PAs are employed by the Department of Veterans Affairs, making the 

VA the largest single employer of physician assistants. These PAs work in a wide 

variety of medical centers and outpatient clinics, providing medical care to thousands of veterans each year. Many are veterans themselves. 

Physician assistants (PAs) are fully integrated into the health care systems of the 

Armed Services and virtually all other public and private health care systems. PAs 

are on the front line in Iraq and Afghanistan, providing immediate medical care for 

wounded men and women of the Armed Forces. Within each branch of the Armed 

Services, a Chief Consultant for PAs is assigned to the Surgeon General. PAs are 

covered providers in Tri-Care. In the civilian world, PAs work in virtually every 

area of medicine and surgery and are covered providers within the overwhelming 

majority of public and private health insurance plans. PAs play a key role in providing medical care in medically underserved communities. In some rural communities, a PA is the only health care professional available. 

The current position of Physician Assistant (PA) Advisor to the Under Secretary 

for Health was authorized through section 206 of P.L. 106–419 and has been filled 

as a part-time, field position. Prior to that time, the VA had never had a representative within the Veterans Health Administration with sufficient knowledge of the PA 

profession to advise the administration on the optimal utilization of PAs. This lack 

of knowledge resulted in an inconsistent approach toward PA practice, unnecessary 

restrictions on the ability of VA physicians to effectively utilize PAs, and an underutilization of PA skills and abilities. The PA profession’s scope of practice was not 

uniformly understood in all VA medical facilities and clinics, and unnecessary confusion existed regarding such issues as privileging, supervision, and physician 

countersignature. 

Although the PAs who have served as the VA’s part-time, field-based PA Advisor 

have made progress on the utilization of PAs within the agency, there continues to 

be inconsistency in the way that local medical facilities use PAs. In one case, a local 

facility decided that a PA could not write outpatient prescriptions, despite licensure 

in the state allowing prescriptive authority. In other facilities, PAs are told that the 

VA facility cannot use PAs and will not hire PAs. These restrictions hinder PA employment within the VA, as well as deprive veterans of the skills and medical care 

PAs have to offer. 

The AAPA believes that a full-time Director of PA Services within the VA Central 

Office is necessary to recruit and retain PAs in the Department of Veterans Affairs. 

PAs are in high demand in the private marketplace. 

• The U.S. Bureau of Labor Statistics (BLS) projects that the number of PA jobs 

will increase by 50 percent between 2004 and 2014 and has ranked the profession as the fourth fastest growing profession in the country. 

• US News & World Report named the PA profession within its 2007 list of 25 

best careers. 

• Money magazine ranked the PA profession number five in its 2006 list of top 

careers; CNN listed the PA profession as number four in its 2006 list of top U.S. 

careers. 

The growth in PA jobs is in the private sector, not the Federal Government. AAPA 

believes that the Federal Government, including the Department of Veterans Affairs, will not be able to compete with the private market unless special efforts are 

made to recruit and retain PAs. According to the AAPA’s 2006 Census Report, an 

estimated 3,545 PAs are employed by the Federal Government to provide medical 

care. Unfortunately, AAPA’s Annual Census Reports of the PA Profession from 1997 

to 2006 document an overall decline in the number of PAs who report Federal Government employment. In 1991, nearly 13.4% of the total profession was employed 

by the Federal Government. This percentage dropped to 6% in 2006. 

The Academy also believes that the elevation of the PA Advisor to a full-time Director of Physician Assistant Services, located in the VA central office, is necessary 

to increase veterans’ access to quality medical care by ensuring efficient utilization 

of the VA’s PA workforce in the Veterans Health Administration’s patient care programs and initiatives. PAs are key members of the Armed Services’ medical teams 

but are an underutilized resource in the transition from active duty to veterans’

health care. As health care professionals with a longstanding history of providing 

care in medically underserved communities, PAs may also provide an invaluable 

link in enabling veterans who live in underserved communities to receive timely access to quality medical care. 

Thank you for the opportunity to submit a statement for the hearing record in 

support of H.R. 2790. AAPA is eager to work with the House Committee on VetVerDate Aug 31 2005 03:06 Aug 19, 2008 Jkt 039464 PO 00000 Frm 00068 Fmt 6604 Sfmt 6621 E:\HR\OC\39464.XXX 39464

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erans’ Affairs Subcommittee on Health to improve the availability and quality of 

medical care to our Nation’s veteran population. 

f 

Statement By Hon. Jeff Miller, Ranking Republican Member, Subcommittee 

on Health, and a Representative in Congress from the State of Florida 

VA physicians, nurses, physical therapists, mental health and other health care 

professionals are at the side of every veteran patient. They are the front line of VA 

health care. They use their expertise, experience, and compassion to provide a continuum of care that our veterans need and deserve. 

As a large employer of health care providers, VA must compete with the private 

sector to attract qualified personnel into the VA system. 

One of the major challenges VA faces is the recruitment of Registered Nurses 

(RNs). The rising demand for nursing care, with an aging RN workforce and fewer 

new nurses entering the profession is creating a shortage of RNs. It poses a problem 

to maintaining RN staffing levels across the United States. 

For the past four years, VA has reported an increase in the average nurse vacancy 

rate. In an effort to mitigate this situation, VA recently created a new multi-campus 

Nursing Academy through partnerships with baccalaureate nursing schools. While 

I am pleased with VA’s actions, it is my hope that VA will expand its partnerships 

to include associate degree nursing schools. Expanding the program will help increase the number of nurses that will see VA as a desirable employer. 

VA’s ability to recruit and retain a first-class health care workforce is critical to 

addressing the dynamic healthcare needs of our veterans. 

f 

Statement of Nurses Organization of Veterans Affairs 

• Retention & Recruitment 

The Nurses Organization of Veterans Affairs (NOVA) has identified retention and 

recruitment of healthcare staff members as a critically important issue in providing 

high quality health care to veterans. Shorter lengths of stay, higher patient acuity, 

more sophisticated technologies and procedures, and increasing care complexity 

place greater demands on health care workers today. For VHA to provide high quality health care, there must be a dramatic increase in retention and recruitment efforts. 

As VHA executives face growing vacancies, elevated turnover due to retirements 

is imposing an additional tremendous burden on VHA facilities, especially in a time 

of shortage. The result is lost productivity, increased use of premium labor, escalating recruiting expenditures, and damage to employee morale. 

There are several key issues that impact the ability of VHA to provide excellent 

health care. 

• Nurse Executive Pay and Pay Cap 

Another important issue for retention and recruitment involves Nurse Executive 

pay. Recent changes in pay for non-SES leaders in VHA have worsened the issue 

of pay inequity. Nurse Executives do not receive pay comparable with their peers. 

Due to the recently implemented Physician Pay Bill, Medical Center Chiefs of Staff 

received substantial pay increases averaging 8% to an average level of $210,000 and 

reaching $250,000 at the most complex (Tier 1) VA medical centers. 

The mean salary for Nurse Executives is $129,000. Many Nurse Executives did 

not receive additional pay in the form of a bonus that is included in retirement computation under Public Law 108–445, because the bonus was not mandatory. This 

underscores the need for VA to move quickly to remedy a problem that is already 

manifesting itself in turnover and in recruitment problems for key upper level positions in the organization. 

Currently, individuals appointed under section 7306 of Title 38 serve in executive 

level positions that are equivalent in scope and responsibility to positions in the 

Senior Executive Service. Examples of such positions are the Director, Pharmacy 

Benefits Management Strategic Health Group; Director of Optometry; Director of 

Podiatry; and Director of Dietetics. The pay schedule for section 7306 appointees is 

adjusted each year by Executive Order and is capped at the pay rate for Level V 

of the Executive Schedule (currently $136,200). Locality pay is also paid up to the 

rate for Level III of the Executive Schedule (currently $154,600). 


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In addition there is a need to increase the pay limitation contained in 38 U.S.C. 7451(c)(2) for VA nurses from Level V (currently $136,200) to Level IV (currently 

$145,400) of the Executive Schedule to address the pay disparity between the Nurse 

V maximum rate and the GS–15 maximum rate in some geographic areas. 

A change to 38 USC 7451 is needed to increase the pay cap under the nurse locality pay system. With an increase to EL–IV, each nurse pay schedule that is currently limited by the EL–V cap would be recalculated based upon the existing beginning rate for the grade. 

• CRNAs 

This change will also address a growing recruitment and retention problem with 

Certified Registered Nurse Anesthetists (CRNA). Presently, the pay of 286 of the 

531 CRNAs (54%) in VA is frozen at the ELV level ($136,200). A search of a commercial website that lists job openings for CRNAs revealed that in 66.8% of the listings, the potential pay rates advertised exceed the EL–V salary cap. 

We see this as a potential challenge for the VA in terms of retaining our skilled 

CRNA workforce and attracting new candidates. 

The alternative to hiring CRNAs is utilizing more, higher priced Anesthesiologists 

(currently a scarce medical specialty that commands high market pay rates). 

• Lack of Human Resources Support 

The loss of experienced human resources staff throughout VHA has had a significant impact on nursing retention and recruitment. Inexperienced staff members do 

not have the expertise to provide needed assistance to medical center staff to assist 

them to successfully recruit and retain qualified healthcare staff. The VA has developed a succession plan to address this but the loss of experienced staff is an issue. 

• Delays in Background Investigations 

Delays related to security and background checks have significantly impacted 

VHA’s ability to hire. The increased security requirements cause several months’ delay in bringing staff into VHA facilities. The delays are so extensive that facilities 

are losing valuable staff members who cannot wait for long lengths of time for the 

background checks to be completed. These delays are particularly frustrating due 

to poor communication of reasons for delays. In addition, background checks for students are creating an additional burden for schools and universities. For example, 

most students have already had background checks and fingerprints completed but 

must complete another set for VHA. The delays these cause are so severe in some 

areas that VHA facilities are losing students, a valuable source of future employees. 

• Information Technology Issues 

The VA, as the Nation’s largest healthcare organization, has the potential to be 

the leader in defining 21st century evidence-based quality nursing care. EvidenceBased Practice (EBP) is a national nursing strategic goal, which will help to ensure 

that patients have the best possible outcomes and that resources are allocated appropriately. The Office of Nursing Services (ONS) and the National Nurse Executive 

Council (NNEC) selected a program team to develop the VA Nursing Outcomes 

Database—VANOD. 

CPRS re-engineering and redesign to focus on nursing software improvements 

necessary for VANOD have not occurred in a timely manner. Plans for a new and 

improved CPRS that will allow for ICU equipment connectivity; customization to reflect clinical care and safety; and documentation designed to match clinical workflow 

have not met implementation schedules. These critical changes will result in increased patient safety, software usability, and data standardization for integrated, 

consistent, comparable, longitudinal patient health records across the system and 

must be supported. 

• Performance of Non Nursing Tasks 

The National Commission on VA Nursing’s Work Environment recommendation 

#1 was to eliminate performance of non nursing tasks by nursing staff. The top five 

issues were: clerical tasks, finding patient care equipment and supplies, housekeeping tasks, troubleshooting technology, and transporting patients. It remains 

challenging in many parts of the country to recruit and retain these valuable workers. 

• VA Nursing Academy 

The VA Nursing Academy is a collaborative program established between the Office of Academic Affiliations (OAA) and the Office of Nursing Services (ONS). 

Through an expansive network of affiliate partnerships between local VA Medical 


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Centers (VAMC) and schools of nursing, the VA Nursing Academy will meet nurse 

recruitment/retention and nurse faculty needs for the VA and may ultimately impact the nursing shortage nationwide. 

• Health Professions Scholarship Program 

As part of the Academy, financial assistance will be provided to competitively selected VA and non-VA nursing students in exchange for VA service obligations upon 

graduation and licensing. The authority to provide this financial assistance will be 

established by extending the expiration date of the Department of Veterans Affairs 

Health Professional Scholarship Program (HPSP) described in 38 USC 7611–7618 

and 38 CFR 17.600–17.612. 

The scholarship program will pay tuition, fees, miscellaneous expenses and a 

monthly stipend to competitively selected participants. There is no other scholarship 

program available to non-VA employees at this time. 

• Patient and Staff Safety 

VA Nursing has prioritized the prevention of musculoskeletal injuries to nursing 

staff in collaboration with national nursing and specialty organizations. The American Nurses Association launched the ‘‘Handle with Care’’ campaign in 2003 to focus 

education and research efforts on this topic. The VA Patient Safety Center of Inquiry (Tampa, FL) has created and tested a series of activities known as the Safe 

Patient Handling and Movement (SPHM) program, and ONS is supporting this program as a top initiative for FY2006. 

These SPHM programs have been found to decrease the number and severity of 

nursing injuries, while improving job satisfaction and patient quality of care and 

quality of life. Funding to support full implementation of both of these programs will 

contribute significantly to recruitment and retention of health care staff. 

• Clinical Nurse Leader 

The Clinical Nurse Leader (CNL) initiative was launched in 2004 to deliver clinical leadership at the microsystem level (individual patient care units). The CNL is 

an advanced generalist that delivers and directs practice, evaluates outcomes, assesses risks and works to improve the overall coordination and delivery of care for 

an individual/group of patients at the unit level in all VA health care settings. Evidence suggests that a positive relationship exists between the numbers and educational level of professional nurses involved in direct patient care and the quality 

of the care outcomes. Support for this innovative role is critical for retention. 

• Succession Planning 

The Office of Nursing Services has placed emphasis on succession planning for 

nurse executives. There is a program manager dedicated to implementing a program 

providing support for new nurse executives. In addition, there is a need for formal 

succession planning for nurse managers, with the development of an assistant nurse 

manager role. This is in progress through the Office of Nursing Services. 

• Magnet Hospital Environment 

The magnet characteristic was used in the 1981 study of hospitals conducted by 

Margaret McClure and colleagues of the American Academy of Nursing. The study 

determined that a hospital that successfully attracted and retained nurses possessed 

certain characteristics. In the early 1990s the American Nurses Credentialing Center launched the Magnet Recognition Program which was based on hospitals (and 

other health care organizations which were added later) demonstrating these magnet characteristics. 

Magnet environments provide supports for the work of nursing—autonomy, maximized participation in Medical Center governance, adequate support personnel, are 

just some tenets of the Magnet environment. 

It is critical that VHA support the environment necessary to provide a model that 

results in professional satisfaction for the nurse. Although not necessarily magnet 

status, the support of the Magnet environment is critical. 

f 

Statement of Hon. John T. Salazar, a Representative in Congress from the 

State of Colorado 

Thank you, Mr. Chairman. 

I would like to also thank our panel today and give a special welcome to Dr. Richard Krugman, Dean of the University of Colorado School of Medicine. 


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1The ten ‘‘best in class’’ categories: employee skills/mission match, strategic management, 

teamwork, effective leadership, performance based rewards and advancement, training and development, support for diversity, pay and benefits, family friendly culture and benefits, and 

work/life balance. The categories that have the highest impact on VHA’s index score are effective 

leadership, employee skills/mission match, and strategic management. 

The issue of recruitment and retention is one of great importance to me. 

As you know, Dr. Krugman, my congressional district encompasses almost 60% 

of the State of Colorado; much of it is very rural. 

Presently, it’s not uncommon for a veteran to drive five hours of mountainous terrain to reach a VA medical facility; with a predicted nationwide shortage of 

healthcare professionals it can only get worse for veterans living in rural areas. 

In Colorado we have a great opportunity for the VA to work with the University 

of Colorado medical school. 

The medical school has relocated to the old Fitz-Simmons campus and if the VA 

is able to negotiate a land purchase they will also build a new state of the art medical facility adjacent to the medical school. 

This will give medical students the opportunity to work directly with the VA on 

rotation and give VA additional opportunities to recruit new healthcare professionals. 

Again, thank you for your testimony today and I look forward to working together 

to tackle this tough issue. 

Ultimately, the answers we find to address the shortage of healthcare professionals within the VA could translate to addressing these shortages in communities 

across America. 

f 

PARTNERSHIP FOR PUBLIC SERVICE 

The Best Places to Work 

In The Federal Government—2007 Rankings 

The Partnership for Public Service and American University’s Institute for the 

Study of Public Policy Implementation use data from the Office of Personnel Management’s Federal Human Capital Survey to rank federal agencies and subcomponents. These organizations are ranked according to a Best Places to Work index 

score, which measures overall employee engagement. In addition to this employee 

engagement rating, agencies and subcomponents are also scored in 10 workplace environment (‘‘best in class’’) categories.1

Veterans Health Administration (VHA) 

Mission: To provide primary care, specialized care, and related medical and social 

support services to U.S. veterans. 

Overall Rank: 18 of 222 agency subcomponents. 

Key Agency Findings: 

• In 2007, VHA’s index score was 12 percentage points above total government. 

This shows dramatic improvement for the agency from 2005, when it was 4 percentage points above government. 

• VHA improved in almost every workplace category since 2005, and had substantial increases in performance based rewards and advancement (+24 percent 

change), teamwork (+16.8 percent change) and effective leadership (+8.7 percent 

change). 

• Although VHA ranks well, the Department of Veterans Affairs (VA) as a whole 

is declining VA’s score has decreased 6.5 percent since 2005. VA has also declined in every single workplace category. 

• Although the highest-ranking subcomponent within the V A, VHA ranks in the 

lowest quartile for both pay and benefits and family friendly culture and benefits. VHA also has high satisfaction among employees 40 and over, but very low 

satisfaction among its younger cohort. 

Additional Information: 

According to the Partnership for Public Service’s 2007 Where the Jobs Are report, 

the VA will hire 22,000 nurses, physicians, and pharmacists by 2009. 


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2The total number of agencies included in each ranking varies. Some agencies did not participate in every category. 

Category Rank 

Overall Index Score 18/222 

Best in Class scores Rank 

Employee Skills/Mission Match 2/222 

Strategic Management 26/222 

Teamwork 42/222 

Effective Leadership 37/222 

Performance Based Rewards and Advancement 36/222 

Training and Development 44/222 

Support for Diversity 68/222 

Pay and Benefits 185/222 

Family Friendly Culture and Benefits 182/222 

Work/Life Balance 70/222 

Score by Demographic Rank2

Female No data/222 

Male No data/222 

40 and Over 12/222 

Under 40 112/222 

American Indian No data 

Asian No data 

Black and African-American 5/222 

Hispanic or Latino No data 

Multi-racial No data 

White 26/222 

2


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Monthly Distinct Employee for Non-Med Resident, GAIN, VHA (Occupation Name), January–September 2007 

All 

Grade 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Notes 

0101 Social Science 162 11 102 42 3 4 0102 Social Science Aid and 

Technician 45 2 15 11 9 1 6 1 

0180 Psychology 815 458 70 64 223 Trainees: 394 0181 Psychology Aid and 

Technician 103 3 3 10 12 38 4 33 

0185 Social Work 1464 512 210 644 99 8 2 Trainees: 470 0186 Social Services Aid 

and Assistant 13 2 4 3 2 2 

0187 Social Services 11 5 5 1 0188 Recreation Specialist 1 1 0189 Recreation Aid and 

Assistant 11 4 2 4 1 

0601 General Health Science 435 46 1 33 1 55 105 68 2 60 34 27 3 Trainees: 39 0602 Medical Officer 1977 71 1907 Medical 

Residents: 367 

0603 Physician’s Assistant 245 80 1 7 18 26 88 25 Trainees: 74 0604 Chiropractor 3 2 1 0605 Nurse Anesthetist 78 27 7 13 31 0610 Nurse 4619 99 2666 1430 397 21 5 1 1 1 Trainees: 65 0620 Practical Nurse 1494 86 187 298 635 285 3 0621 Nursing Assistant 1338 23 16 15 125 521 614 25 0622 Medical Supply Aide and 

Technician 203 3 6 2 10 39 86 51 4 2 

0625 Autopsy Assistant 2 2 0630 Dietitian and Nutritionist 226 131 1 13 15 60 4 1 1 Trainees: 125 


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Monthly Distinct Employee for Non-Med Resident, GAIN, VHA (Occupation Name), January–September 2007

—Continued 

All 

Grade 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Notes 

0631 Occupational Therapist 142 85 4 10 26 18 1 Trainees: 65 0633 Physical Therapist 210 99 5 16 45 46 1 1 Trainees: 79 0635 Corrective Therapist 8 5 3 0636 Rehabilitation Therapy 

Assistant 58 1 6 11 10 22 6 1 1 

0638 Recreation/Creative Arts 

Therapist 68 1 2 7 18 41 

0639 Educational Therapist 1 1 0640 Health Aid and 

Technician 772 41 2 7 40 107 252 170 136 11 4 1 1 

0642 Nuclear Medicine 

Technician 4 2 2 

0644 Medical Technologist 273 2 2 2 1 50 188 8 14 5 1 0645 Medical Technician 200 1 3 5 20 100 52 7 12 0646 Pathology Technician 30 1 1 17 5 4 2 0647 Diagnostic Radiologic 

Technologist 277 5 15 73 33 45 57 36 5 6 2 

0648 Therapeutic Radiologic 

Technologist 10 1 3 1 1 1 2 1 

0649 Medical Instrument Technician 168 10 9 28 29 57 27 8 0651 Respiratory Therapist 12 10 1 1 0660 Pharmacist 800 831 2 3 255 147 12 Trainees: 272 0661 Pharmacy Technician 483 12 15 66 71 192 123 3 1 0662 Optometrist 190 134 24 26 4 2 Trainees: 127 0664 Restoration Technician 2 1 1 


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Monthly Distinct Employee for Non-Med Resident, GAIN, VHA (Occupation Name), January–September 2007

—Continued 

All 

Grade 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Notes 

0665 Speech Pathology and 

Audiology 245 158 12 15 58 1 1 Trainees: 135 

0667 Orthotist and Prosthetist 29 6 2 3 2 12 3 1 0668 Podiatrist 110 63 1 18 12 16 Trainees: 52 0669 Medical Records 

Administration 33 8 1 1 1 7 8 3 3 1 

0670 Health System Administration 87 32 1 6 1 16 28 1 1 1 0671 Health System Specialist 49 2 11 9 16 7 4 0672 Prosthetic Representative 7 1 2 2 2 0673 Hospital Housekeeping 

Management 9 2 1 4 2 

0675 Medical Records Technician 140 1 9 28 22 48 30 2 0679 Medical Support 

Assistance 906 1 2 4 4 183 683 26 1 2 

0680 Dental Officer 76 76 Medical 

Residents: 188 

0681 Dental Assistant 139 5 7 93 32 2 0682 Dental Hygiene 14 1 10 3 0683 Dental Laboratory Aid 

and Technician 17 1 3 2 7 4 4 9 5 

0690 Industrial Hygiene 22 0699 Medical and Health Student 

Trainee 1262 1069 22 33 120 10 1 6 1 Trainees: 42 

TOTAL 20098 


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QUESTIONS FOR THE RECORD 

Committee on Veterans’ Affairs 

Subcommittee on Health 

Washington, DC. 

October 19, 2007 

Jeffrey L. Newman, PT 

Chief, Physical Therapy Department 

Minneapolis VA Medical Center 

117 D One Veterans Drive 

Minneapolis, MN 55417 

Dear Mr. Newman: 

Thank you for testifying before the U.S. House of Representatives Committee on 

Veterans’ Affairs Subcommittee on Health at the hearing on ‘‘Healthcare Professionals—Recruitment and Retention’’ held on October 18, 2007. 

Please provide answers to the following questions to Chris Austin, Executive Assistant to the Subcommittee on Health, by December 4, 2007. 

General Challenges—There is currently a shortage of medical professionals in the 

United States. As new graduates enter the workforce, they are making choices about 

where they want to work. 

• What types of tools do you think would be most effective in recruiting and retaining a high-quality workforce? 

• We know that many healthcare professionals under age 40 are ‘‘very 

unsatisfied’’ with working at the VA. Why do you think this is? What can the 

VA do to improve this situation? 

Again, thank you for your testimony. The Subcommittee looks forward to receiving your responses by December 4, 2007. 

Sincerely, 

MICHAEL H. MICHAUD 

Chairman 

American Physical Therapy Association 

Alexandria, VA. 

December 3, 2007 

Hon. Michael H. Michaud 

Chairman, Subcommittee on Health 

House Veterans’ Affairs Committee 

335 Cannon House Office Building 

Washington, DC 20515 

Dear Chairman Michaud and Members of the Subcommittee on Health: 

Thank you for the opportunity to present testimony at the House Veterans’ Affairs 

Committee, Subcommittee on Health’s hearing on ‘‘Healthcare Professionals—Recruitment and Retention’’ held on October 18, 2007. I appreciated the opportunity 

to answer your questions during the hearing and am happy to respond to your additional written questions. As I mentioned during the hearing, I hope that physical 

therapists in the future have the opportunity to have a long, fulfilling career serving 

our Nation’s veterans as I have had over the past 30 years as a physical therapist 

in the Department of Veterans Affairs (VA). As you know from testimony at the 

hearing, there are many challenges to meet in order for that to be possible. 

Question 1: What types of tools do you think would be most effective in recruiting and retaining a high-quality workforce? 

Our number one obstacle to recruiting and retaining physical therapists to serve 

in the Veterans Administration are the severely outdated qualification standards. 

I appreciate your leadership in supporting the revision of these standards to make 

them more in line and competitive with settings outside of the VA. The immediate 

approval of qualification standards for physical therapist would be the most effective 

tool to ensuring that the VA retains and is able to recruit physical therapists to 

meet the increasing demand for physical therapy in the VA. In addition to the immediate revision of the qualification standards (which currently hinder recruitment 


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and retention by not recognizing the current minimal education standards and restricting the career ladder of physical therapists in the VA), the following tools or 

initiatives would be helpful in recruiting and retaining a high quality physical therapist workforce: 

Recruitment & Retention 

Initiatives to encourage young returning veterans to become healthcare providers in 

the VA system 

As you noted in a question during the hearing, young returning veterans who 

have an interest in healthcare offer us a huge opportunity to help meet the current 

and future need for healthcare professionals to serve in the VA. I have personally 

witnessed several young men and women who have volunteered at my facility in 

Minneapolis and who have been moved by the experience of helping their fellow veterans and have then chosen to go on and get their degree in physical therapy. As 

you know, many of today’s returning veterans are young—some are Reservists or 

National Guard members who may have joined to help pay for college. Offering veterans scholarships, finance assistance or loan repayment to pursue a physical therapist degree program would provide an opportunity to enhance healthcare in the VA. 

These initiatives would provide veterans the opportunity to serve as healthcare providers who have a unique understanding of the battlefield and the ability to relate 

to a fellow veteran. An initiative to specifically recruit returning veterans into 

healthcare careers has the potential to be an untapped resource for the VA and provide a great incentive for returning veterans to make an impact in improving 

healthcare for their colleagues. 

Improving current VA scholarship programs 

As noted in my testimony, enhancements to the current VA scholarship programs 

for physical therapists will help recruitment and retention. Many new graduates are 

concerned with a high amount of student loan debt when leaving school, and scholarship and loan repayment programs are an important tool in recruiting physical 

therapists to meet the VA’s need. A specific program for physical therapists is needed to meet the growing demand for rehabilitation among our aging veterans and 

those returning from current conflicts. 

I had the opportunity to serve on the Committee to review scholarship program 

applicants in the early nineties when the VA had—in my opinion—a very successful 

scholarship incentive program to attract new graduates. I had several recipients at 

my facility—several of whom chose to stay beyond their required amount of service. 

The previous scholarship program provided an incentive to serve right out of school, 

whereas the new incentive program including the Education Debt Reduction Program and the Employee Incentive Scholarship Program are poorly advertised and 

cumbersome for the potential applicants. A targeted program to promote the current 

programs and a specific strategy to enhance scholarship programs would assist in 

recruiting and retaining physical therapists in the VA. 

Another prominent reason physical therapists leave the VA is to pursue a higher 

degree. Unfortunately the current structure does not recognize the physical therapists who have achieved their doctor of physical therapy (DPT) or advanced degree. 

Revising the physical therapist qualification standards to recognize the DPT would 

help the VA keep pace with the physical therapy field and other employers. Another 

tool would be incentives to allow physical therapists to seek advanced degrees while 

employed in the VA. Programs to assist financially or with flexible work arrangements to encourage advanced study would be an asset to physical therapists employed in the VA. 

Improving VA Employee Benefits Packages 

Continuing education credits 

It is also important for recruitment initiatives to include easily accessible funds 

for continuing education credits. Jobs that freely and openly offer support for employees to attend continuing education classes and strongly encourage their employees to attend these courses will attract and retain physical therapists. The VA had 

a program that ended in 2003 that allowed continuing education funds to be allocated to professions that had documented recruitment and retention problems, such 

as physical therapy. The current funding is not distributed in this way and is allocated to each VA service line, therefore putting professions who are experiencing recruitment and retention challenges in the same category as other professions competing for continuing education funding. 


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Promote immediate implementation of on-call float pools 

Clinic managers should be able to cover unplanned leave with an on-call pool of 

qualified therapists/assistants. The current system burdens staff to absorb workload 

of those individuals on emergency absence. When we are already facing a shortage 

of physical therapists, asking those currently employed to just keep ‘‘doing more 

with less’’ is not an acceptable scenario for either the provider or the patients we 

serve. 

Flex tours and other benefits 

Allow staff to determine a schedule that best suits the agency mission and personal need. VHA is not and should not be an 8:00 am to 4:30 pm operation any 

longer. To be competitive with the private sector, it is also important to offer VA 

employees benefit packages that can compete with options such as maternity leave 

and healthcare benefit packages for employees. 

Question 2: 

We know that many healthcare professionals under age 40 are ‘‘very 

unsatisfied’’ with working at the VA. Why do you think this is? What can 

the VA do to improve this situation? 

For physical therapists, I believe part of this could be due to the qualification 

standards for physical therapists being severely out of date. They do not currently 

allow experienced physical therapist clinicians enough of an opportunity to move up 

the career ladder. It is also understandable for an employee who has gone on to receive specialist certification or their Doctorate of Physical Therapy (DPT) degree to 

be disappointed not to be recognized for their additional investment in their education. Physical therapy, like many other healthcare professions, is a dynamic field 

and it is vital for practitioners to continue to seek the best evidence and training 

to meet their patients’ needs. Recognizing those physical therapists who have received additional training is especially critical considering the veteran population, 

some who have complex impairments such as amputations and traumatic brain injuries. The VA can immediately implement revised qualification standards for physical therapists to improve this situation. Revising the qualification standards would 

provide opportunities for advancement and help make salaries competitive with 

other professions with equal educational requirements. This would be the best strategy to reverse the current job satisfaction rating among professionals under 40 

years of age. 

Other factors important to many employees—especially younger employees—are 

mentorship programs. Formal mentoring programs that pair a younger healthcare 

professional with an experienced leader in the field could improve satisfaction and 

also provide prospective employees the opportunity to practice in clinical centers of 

excellence. 

Thank you again for the opportunity to testify at the hearing. I look forward to 

continuing to be a resource for you, your staff and the entire Committee on issues 

impacting physical therapists and the veterans we have the opportunity to care for. 

If you need additional information or have further questions, please feel free to contact me at Jeffrey.Newman@va.gov or 612–467–3071 or Rachel Reiter in the Congressional Affairs department at the American Physical Therapy Association at 

rachelreiter@apta.org or 703–706–8548. 

Sincerely, 

Jeffrey L. Newman, PT 

Member, American Physical Therapy Association 

Chief, Physical Therapy Department, Minneapolis VA Medical Center 

f 

Committee on Veterans’ Affairs 

Subcommittee on Health 

Washington, DC. 

October 19, 2007 

Richard D. Krugman, M.D. 

Dean 

University of Colorado 

Health Science Center School of Medicine 

4200 East Ninth Avenue, Box C–290 

Denver, CO 80262 

Dear Dr. Krugman: 


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Thank you for testifying before the U.S. House of Representatives Committee on 

Veterans’ Affairs Subcommittee on Health at the hearing on ‘‘Healthcare Professionals—Recruitment and Retention’’ held on October 18, 2007. 

Please provide answers to the following questions to Chris Austin, Executive Assistant to the Subcommittee on Health, by December 4, 2007. 

General Challenges—There is currently a shortage of medical professionals in the 

United States. As new graduates enter the workforce, they are making choices about 

where they want to work. 

• What types of tools do you think would be most effective in recruiting and retaining a high-quality workforce? • We know that many healthcare professionals under age 40 are ‘‘very 

unsatisfied’’ with working at the VA. Why do you think this is? What can the 

VA do to improve this situation? 

Again, thank you for your testimony. The Subcommittee looks forward to receiving your responses by December 4, 2007. 

Sincerely, 

MICHAEL H. MICHAUD 

Chairman 

University of Colorado 

Health Science Center School of Medicine 

Denver, CO. 

December 4, 2007 

The Honorable Michael Michaud 

Chair, Subcommittee on Health 

Committee on Veterans’ Affairs 

United States House of Representatives 

335 Cannon House Office Building 

Washington, DC 20515 

Dear Mr. Chairman: 

The following is in response to your questions regarding my October 18, 2007, testimony on ‘‘Healthcare Recruitment and Retention at the U.S. Department of Veterans Affairs’’ before the House Veterans’ Affairs Subcommittee on Health. 

General Challenges—There is currently a shortage of medical professionals in the 

United States. As new graduates enter the workforce they are making choices about 

where they want to work. 

What types of tools do you think would be most effective in recruiting 

and retaining a high-quality workforce? 

The United States will face a serious doctor shortage in the next few decades. As 

this shortage comes to fruition, the VA will likely have an even more difficult time 

competing with their private counterparts for both new and more tenured physicians. With difficulty recruiting health professions, the VA can be likened to the 

rural and urban areas, population groups, or medical facilities designated as ‘‘underserved’’ by the U.S. Department of Health and Human Services. Programs under the 

Health Resources and Services Administration (HRSA) are effective tools in recruiting and retaining a high-quality health professions workforce. 

HRSA manages several programs authorized by Title VII of the Public Health 

Service Act that recruit students to careers in health professions and subsequently 

direct health professionals to underserved areas. There could be an opportunity for 

the VA to collaborate with HRSA programs such as the Title VII Centers of Excellence (COE), Health Career Opportunities Program (HCOP), and Area Health Education Centers (AHECs) to increase recruitment of health professions to the VA. 

However, a dramatic 50 percent cut of the Title VII appropriations in FY 2006 continues to threaten the ability of these programs to fulfill their missions. 

The National Health Service Corps (NHSC) has a proven track record of expanding access for underserved populations by supplying physicians to federally designated shortage areas. The NHSC provides scholarship and loan forgiveness 

awards in exchange for service in qualifying ‘‘health professions shortage areas’’

(HPSAs). After five years of service, the majority of physicians are able to forgive 

their entire educational debt. Similarly, the VA’s Education Debt Reduction Program (EDRP) provides newly appointed VA healthcare professionals with eduVerDate Aug 31 2005 04:56 Aug 19, 2008 Jkt 039464 PO 00000 Frm 00080 Fmt 6604 Sfmt 6621 E:\HR\OC\39464.XXX 39464

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cational loan repayment awards. However, the EDRP is limited to $44,000 spread 

out over five years of service. As the average medical education indebtedness has 

climbed to over $140,000 in 2007, the limited EDRP awards fail to provide an adequate incentive for most physicians. 

The VA Medical and Prosthetic Research Program plays an integral role in recruiting physicians to the VA. The VA research program is exclusively intramural; 

that is, only VA employees holding at least a five-eighths salaried appointment are 

eligible to receive VA awards. Unlike other federal research agencies, VA does not 

make grants to any non-VA entities. As such, the program offers a dedicated funding source to attract and retain high-quality physicians and clinical investigators to 

the VA healthcare system. 

State-of-the-art research requires state-of-the-art technology, equipment, and facilities. Such an environment promotes excellence in teaching and patient care as 

well as research. It also helps VA recruit and retain the best and brightest clinician 

scientists. In recent years, funding for the VA medical and prosthetics research program has failed to provide the resources needed to maintain, upgrade, and replace 

aging research facilities. Many VA facilities have run out of adequate research 

space. Ventilation, electrical supply, and plumbing appear frequently on lists of 

needed upgrades along with space reconfiguration. Under the current system, research must compete with other facility needs for basic infrastructure and physical 

plant support that are funded through the minor construction appropriation. 

To ensure that funding is adequate to meet both immediate and long term needs, the AAMC recommends an annual appropriation of $45 million in the VA’s minor 

construction budget dedicated to renovating existing research facilities and additional major construction funding sufficient to replace at least one outdated facility 

per year to address this critical shortage of research space. 

We know that many healthcare professionals under age 40 are ‘‘very 

unsatisfied’’ with working at the VA. Why do you think this is? What can 

VA do to improve the situation? 

Until the early 1990s, the VA healthcare system was seen as substandard and 

physicians that worked there were viewed as second rate. Today, VA healthcare is 

touted for its remarkable transformation and has been rated higher by the American Customer Satisfaction Index than its private counterparts. Unfortunately, an 

unjustified stigma of VA employment remains in the physician community, if only 

at a subconscious level. While this may only be prevalent in more seasoned physicians, under their mentorship this impression still manages to trickle down to new 

physicians as they enter the field. 

A crucial tool in reversing the negative impression of VA employment is exposing 

young physicians to the new quality associated with VA healthcare. In a 2007 

Learners Perceptions Survey, the VA examined the impact of training at the VA on 

physician recruitment. Before training at the VA, 21 percent of medical students 

and 27 percent of medical residents indicated they were very or somewhat likely to 

consider VA employment after VA training. After training at the VA, these numbers 

grew to 57 percent of medical students and 49 percent of medical residents. 

The VA plans to increase its support for GME training, adding an additional 

2,000 positions for residency training over five years, restoring VA-funded medical 

resident positions to 10 to 11 percent of the total GME in the United States. The 

expansion began in July 2007 when the VA added 342 new positions. These training 

positions address the VA’s critical needs and provide skilled healthcare professionals 

for the entire Nation. The additional residency positions also encourage innovation 

in education that will improve patient care, enable physicians in different disciplines to work together, and incorporate state-of-the-art models of clinical care—

including VA’s renowned quality and patient safety programs and electronic medical 

record system. Phase 2 of the GME enhancement initiative has generated applications for 411 new resident positions to be created in July 2008. 

There is some evidence that the VA will become a more competitive employer with 

future generations of physicians. Initial research into the practice decisionmaking 

of new physicians indicates that new physicians favor ‘‘employee settings’’ to traditional practice settings. However, VA will have to overcome difficulties inherent in 

government agencies to compete with other sectors. The draw of ‘‘employee’’ practice 

settings is spurred by new physicians’ desire for having fewer nights and weekends 

on call, a decrease in administrative work (particularly dealing with insurance companies), access to state-of-the-art medical care resources and an electronic medical 

record and linkages to academia and research. These factors can outweigh the draw 

of the large salaries available in the private practice setting. This is an area in 

which hopefully the Veterans Health Administration and the academic medical education community through the AAMC can work together and make some progress. 


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Thank you again for the opportunity to testify on this important issue. 

Sincerely, 

Richard D. Krugman, M.D. 

f 

Dean 

Committee on Veterans’ Affairs 

Subcommittee on Health 

Washington, DC. 

October 19, 2007 

Jim Bender 

CACI 

650 Washington Road 

6th Floor 

Pittsburgh, PA 15228 

Dear Mr. Bender: 

Thank you for testifying before the U.S. House of Representatives Committee on 

Veterans’ Affairs Subcommittee on Health at the hearing on ‘‘Healthcare Professionals—Recruitment and Retention’’ held on October 18, 2007. 

Please provide answers to the following questions to Chris Austin, Executive Assistant to the Subcommittee on Health, by December 4, 2007. 

General Challenges—There is currently a shortage of medical professionals in the 

United States. As new graduates enter the workforce, they are making choices about 

where they want to work. 

• What types of tools do you think would be most effective in recruiting and retaining a high-quality workforce? 

• We know that many healthcare professionals under age 40 are ‘‘very 

unsatisfied’’ with working at the VA. Why do you think this is? What can the 

VA do to improve this situation? 

Again, thank you for your testimony. The Subcommittee looks forward to receiving your responses by December 4, 2007. 

Sincerely, 

MICHAEL H. MICHAUD 

Chairman 

CACI Response to Questions 

from Oct. 18, 2007 Hearing on 

Healthcare Professionals—Recruitment and Retention 

CACI, Strategic Communications Division 

December 4, 2007 

Point of Contact: Deborah Lee, Project Manager 

QUESTION 1 & 2 CONTEXT 

There is currently a shortage of medical professionals in the United States. As new 

graduates enter the workforce, they are making choices about where they want to 

work. 

QUESTION 1 

What types of tools do you think would be most effective in recruiting and retaining a high-quality workforce? 

RESPONSE 1 

CACI’s recommendations for recruiting healthcare professionals are outlined in 

detail in the July 2006 study titled ‘‘Pilot Program to Study Innovative Recruitment 

Tools to Address Nursing Shortages at Department of Veterans Affairs.’’ The report 

identified 18 recommendations within seven major recruitment marketing categories. A subset of those recommendations is listed below: 


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1. Interactive Media 

a. Implement regular email communication of open positions: More 

than 5,000 individuals responded to an email blast promoting the availability of hard-to-fill nursing positions, the highest response of all pilot 

program advertising tactics. The high number of responses and the reasonable cost of email also resulted in the lowest cost-per-lead. Automated 

email communications were also used to send alerts of new job postings 

to 333 people who signed up for this service on the pilot program Web 

page. Seventy people also chose to send the pilot program Web page address to a friend via the automated email link provided on the site. VA 

is pursuing this recommendation with multiple email campaigns over 

the past year that promote hard-to-fill occupations and include send-toa-friend functionality. 

b. Use Internet job postings: Internet job sites have replaced newspapers as the preferred source of job leads. The pilot study’s Internet job 

postings resulted in the second highest number of trackable leads and 

the second lowest cost-per-lead. VA actively uses Internet job postings 

for hard-to-fill job openings, and it is augmenting this effort by integrating USAJOBS search functionality into the VACareers job site. 

c. Design and launch an automated system to allow all VACareers 

visitors to register for notification when new jobs are posted: The 

pilot program gave all visitors who responded to pilot program media the 

opportunity to register to be notified of new job postings. A total of 333 

registered, indicating a market preference for automated email alerts. 

This recommendation is being pursued through a redesign of VACareers 

and integration of USAJOBS email notification functionality. 

d. Provide ‘‘send to a friend’’ email functionality on all job postings: 

Seventy visitors took advantage of the ‘‘send to a friend’’ button to alert 

friends or relatives of jobs available at VA. The cost of the functionality 

is nominal, resulting in a very strong return on investment. The redesign of VACareers and the partnership with USAJOBS are addressing 

this recommendation. 

e. Promote the most difficult-to-fill positions with a graphic logo on 

the VACareers home page: About 10 percent of the people who viewed 

the VACareers home page, regardless of place of residence or visiting intent, clicked on a graphically designed logo promoting positions in the 

pilot area, North Florida/South Georgia (NF/SG). Difficult-to-fill positions 

are promoted on the new VACareers site in a section entitled Careers 

in Demand. This section will be promoted on the home page of 

VACareers when Phase 2 upgrades go live. 

2. Employer Branding 

a. Continue to focus on employee benefits and quality care: Focus 

groups have demonstrated that the decision criteria used most by nonVA employees are employee benefits (e.g., child care, education support, 

and paid days off) and quality care. The current tagline (The Best Care/ 

The Best Careers) reflects those messages. VA actively abides by these 

principles in all current recruitment marketing. 

b. Segment market and speak directly to the unique needs and concerns of each segment (e.g., student nurses, military nurses, male 

and minority nurses, clinical specialties, etc.): This pilot program 

focused its attention on experienced nurses. Previous focus group research revealed that experienced private sector nurses suffer a great 

deal of dissatisfaction from the private sector’s ‘‘big business’’ approach 

to healthcare. The primary advertisements in the pilot program communicated VA’s answer to the nurses’ concern. The headline read, ‘‘Patient 

Care Is Not a Business Decision.’’ The response to the message, 10,261 

direct visits to VACareers, confirms the research and underscores the 

importance of talking to each segment’s unique needs and concerns. VA 

is implementing this recommendation. Each of VA’s strategic recruitment marketing plans over the past two years has incorporated focus 

group research and a market segmentation strategy based on that research, to include segmented email blasts, print ads, and Web content. 

c. Raise community awareness with Public Relations efforts: Public 

Relations efforts focused on ‘‘The Best Care/The Best Careers’’ message 

can help reverse old, negative stereotypes that may exist concerning VA’s 


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career opportunities and quality of care. These efforts have resulted in 

numerous positive press articles about VA over the last couple of years. 

d. Establish employer branding at the national level: In order to keep 

the employer branding message consistent across all VA facilities nationwide, every facility should adopt the national VHA brand (The Best 

Care/The Best Careers) in all recruitment promotional activities. VA has 

pursued this recommendation by making all recruitment ads, brochures, 

and exhibit displays available to local recruiters via the VHA Healthcare 

Recruiters’ Toolkit Web site. 

3. Database Marketing 

a. Nurture relationships with applicants who are qualified but not 

appointed: Qualified applicants who have already shown an interest in 

VA remain strong candidates for future employment. The pilot program 

originally included a direct mail campaign to reengage qualified job applicants who were not offered the first position for which they applied. 

However, the campaign was not executed due to the lack of a database 

with pertinent applicant data. 

4. Relationship Building 

a. Build relationships with nursing schools: NF/SG does not have difficulty hiring student nurses. This is because the Malcom Randall VA 

Medical Center is located in very close proximity to the University of 

Florida. Student nurses from the university are well aware of the opportunities at VA and many complete their training through VA. Although 

the health system has a distinct geographic advantage over other VA 

health systems, its relationship with nursing students and its full quota 

of young nurses testifies to the importance of nurturing relationships 

with nursing schools. VA currently has hundreds of academic affiliations 

with nursing, pharmacy, medical, and allied health schools around the 

country, with more than 100,000 students rotating through the VA system every year. Programmatic relationship-building activities include 

the VA Nursing Academy (now in pilot stage) and the VA Learning Opportunities Residency (VALOR) Program. 

b. Conduct regular Open House events: An Open House event was conducted during the pilot program that allowed visiting nurses the opportunity to meet and talk with VA RNs at several dedicated discussion 

booths, including: VA Benefits, Current Opportunities, Applications, and 

VA Technology. Interested attendees were also invited to take a guided 

personal tour of the facilities and interview with a hiring manager. The 

promotion for the Open House event attracted 65 experienced nurses to 

the doorstep of the Malcom Randall VA Medical Center. From these 65 

candidates, 13 people were selected at the conclusion of the pilot (20% 

of attendees and 20.3% of all new hires during the pilot period), with 

more applications pending. These numbers illustrate the importance of 

having interested candidates visit VA facilities and meet with recruiters 

to learn more about what VA has to offer. Names and other information 

were collected from attendees so that NF/SG recruiters may use this information to follow up or to use for future marketing initiatives. Open 

houses are happening regularly at VA facilities nationwide. HRRO is 

supporting these efforts via an event planner on the VHA Healthcare 

Recruiters’ Toolkit, as well as with national recruitment brochures and 

banner stands. 

5. Employee Referral Program 

a. Create and promote employee referral programs: According to VA 

Entrance Survey results for FY04 through First Quarter FY06, more 

new employees (34.9 percent of females and 32.5 percent of males) 

learned about VA through current employees than through any other 

source. The original pilot design included the creation and promotion of 

a referral program to test the ability of such a program to increase the 

number of referrals from employees. However, the program was not approved until the last week of the pilot program and therefore could not 

be implemented at that time. VA facilities should continue efforts to revamp employee referral programs and look for innovative, creative ways 

to compensate employees for referring friends and colleagues, such as offering Employee of the Month recognition, a special parking place, or 

paid enrollment in a CEU activity. VA has taken steps over the past two 


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years to promote employee referrals via facility posters, banner stands, 

and other promotional material. 

6. Recruitment Budgeting 

a. Create a funding source for recruitment marketing that is linked 

to an approved recruitment plan and managed at the recruiter 

level: Before the pilot study, nurse recruiters at NF/SG did not have a 

budget for nurse recruiting. Each expenditure, from single newspaper 

advertisements to recruitment functions, required approval obtained 

through a cumbersome, slow process. The result was that nurse recruiters were unable to execute their mission with the speed and agility required to compete in a very competitive recruitment market. Since the 

pilot study, a request for a dedicated nurse recruitment budget has been 

approved. Outside of NF/SG, the availability of a dedicated recruitment 

budget is mixed. 

QUESTION 2 

We know that many healthcare professionals under age 40 are ‘‘very unsatisfied’’

with working at VA. Why do you think this is? What can VA do to improve this 

situation? 

RESPONSE 2 

CACI is unaware of the conditions addressed in this question. Furthermore, the 

improvement of employee moral is an interdepartmental activity that goes beyond 

the boundaries of CACI’s specialty, which is recruitment marketing. 

f 

Committee on Veterans’ Affairs 

Subcommittee on Health 

Washington, DC. 

October 19, 2007 

Joseph L. Wilson 

Assistant Director for Health Policy 

Veterans Affairs and Rehabilitation Commission 

American Legion 

1608 K Street, N.W. 

Washington, D.C. 20006 

Dear Mr. Wilson: 

Thank you for testifying before the U.S. House of Representatives Committee on 

Veterans’ Affairs Subcommittee on Health at the hearing on ‘‘Healthcare Professionals—Recruitment and Retention’’ held on October 18, 2007. 

Please provide answers to the following questions to Chris Austin, Executive Assistant to the Subcommittee on Health, by December 4, 2007. 

1. Academic Affiliations—Several witnesses stated that one of the most effective 

recruitment tools the VA has is its academic affiliations because they capture students while they are still training. 

• What can the VA do to strengthen their academic affiliations? 

• What other tools can the VA use to recruit newly trained healthcare providers? 

2. Future Needs—Recently the VA has had difficulty recruiting and retaining 

healthcare professionals such as nurses and pharmacists. 

• What is the greatest recruitment challenge facing the VA right now? What 

healthcare professions are in the shortest supply? 

• Looking into the future, what challenges does the VA anticipate facing in 10 

years? 20 years? 

Again, thank you for your testimony. The Subcommittee looks forward to receiving your responses by December 4, 2007. 

Sincerely, 

MICHAEL H. MICHAUD 

Chairman 


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The American Legion 

Washington, DC. 

December 4, 2007 

Honorable Michael Michaud, Chairman 

Subcommittee on Health 

U.S. House of Representatives 

335 Cannon House Office Building 

Washington, DC 20515–6335 

Dear Mr. Congressman Michaud: 

Thank you for allowing The American Legion to participate in the Committee 

hearing on the ‘‘Health Care Professionals—Recruitment and Retention’’ on October 

18, 2007. I am pleased to respond to your specific questions concerning that hearing: 

1. Academic Affiliations. Several witnesses stated that one of the most effective 

recruitment tools the VA has its academic affiliations because they capture students 

while they are training. 

a. What can the VA do to strengthen their academic affiliations? 

The American Legion believes that VA medical school affiliates should be 

appropriately represented as a stakeholder on any national Task Force, 

Commission, or Committee established to deliberate on veterans health 

care. 

b. What other tools can the VA use to recruit newly trained health care 

providers? 

The American Legion concurs that other effective tools the VA can utilize to recruit newly trained health care providers, to include the continuous effort in striving 

to develop an effective strategy, such as competitive benefits, to retain quality 

health care providers. 

2. Future Needs. Recently the VA has had difficulty recruiting and retaining 

health care professionals such as nurses and pharmacists. 

a. What is the greatest recruitment challenge facing the VA right now? 

What health care professions are in the shortest supply? 

The American Legion believes the greatest recruitment challenge currently facing the VA is adequate funding which would allow VA to offer employee benefits comparable to the private sector. 

Currently, there is a physician and nursing shortage within the VA. 

b. Looking into the future, what challenges does the VA anticipate facing 

in 10 years? 20 years? 

The American Legion believes the greatest challenge faced by the VA in 

10 years include a shortage of physicians and nurses nationwide, which 

would stagnate quality care and treatment to veterans. Due to a shortage, 

there would be the probability of complacency amongst physicians and 

nurses, which would be due in part to working overwhelming hours, in addition to an increase in patients. 

Due to the declination of medical school enrollment and anticipated increase in retirement of physicians (250,000) by 2025, the shortage would obviously become worse in 20 years, which would continue to affect quality 

care and treatment to veterans. 

Thank you once again for all of the courtesies provided by you and your capable 

staff. The American Legion welcomes the opportunity to work with you and your 

colleagues on many issues facing veterans and their families throughout this Congress. 

Sincerely, 

Steve Robertson, Director 

f 

National Legislative Commission 


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Committee on Veterans’ Affairs 

Subcommittee on Health 

Washington, DC. 

October 19, 2007 

Joy J. Ilem 

Assistant National Legislative Director 

Disabled American Veterans 

807 Maine Avenue, S.W. 

Washington, DC 20024–2410 

Dear Ms. Ilem: 

Thank you for testifying before the U.S. House of Representatives Committee on 

Veterans’ Affairs Subcommittee on Health at the hearing on ‘‘Healthcare Professionals—Recruitment and Retention’’ held on October 18, 2007. 

Please provide answers to the following questions to Chris Austin, Executive Assistant to the Subcommittee on Health, by December 4, 2007. 

1. Academic Affiliations—Several witnesses stated that one of the most effective 

recruitment tools the VA has is its academic affiliations because they capture students while they are still training. 

• What can the VA do to strengthen their academic affiliations? 

• What other tools can the VA use to recruit newly trained healthcare providers? 

2. Future Needs—Recently the VA has had difficulty recruiting and retaining 

healthcare professionals such as nurses and pharmacists. 

• What is the greatest recruitment challenge facing the VA right now? What 

healthcare professions are in the shortest supply? 

• Looking into the future, what challenges does the VA anticipate facing in 10 

years? 20 years? 

Again, thank you for your testimony. The Subcommittee looks forward to receiving your responses by December 4, 2007. 

Sincerely, 

MICHAEL H. MICHAUD 

Chairman 

POST-HEARING QUESTIONS FOR JOY ILEM, ASSISTANT NATIONAL 

LEGISLATIVE DIRECTOR OF THE DISABLED AMERICAN VETERANS, 

TO THE U.S. HOUSE OF REPRESENTATIVES COMMITTEE ON 

VETERANS’ AFFAIRS, SUBCOMMITTEE ON HEALTH, 

AT THE HEARING ON HEALTHCARE PROFESSIONALS RECRUITMENT 

AND RETENTION 

QUESTION: Academic Affiliations—several witnesses stated that one of the most 

effective recruitment tools the VA has is its academic affiliations because they capture students while they are still training. 

• What can the VA do to strengthen their academic affiliations? 

• What other tools can the VA use to recruit newly trained healthcare providers? 

RESPONSE: 

DAV is pleased to provide our perspective on these questions. The VA’s affiliations 

programs were inaugurated after World War II by visionary VA leaders. They foresaw the wisdom and value in linking post-war VA hospitals to State schools of medicine through affiliation agreements. That model of mutual cooperation has served 

VA and veterans well for over 50 years, and it helped to train several new generations of physicians for the whole Nation. In the mid-nineties, VA shifted its 

healthcare delivery system from hospitalization to primary care, and simultaneously 

VA created and empowered its Network management to coordinate nearly all functions except national policies. Until the advent of the Veteran Integrated Services 

Networks (VISNs), VA hospitals (now called VA medical centers [VAMCs]) and their 

affiliated medical schools were the locus of actions, decisions and relationship building, through their firmly established Dean’s Committees under title 38 United 

States Code § 7313. 


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Through the Dean’s Committee relationship both VA and affiliates benefited from 

the conjoined missions of caring for sick and disabled veterans and educating America’s health professions. However, an unintended consequence of the advent of the 

VISNs was to have distilled that classic one-to-one relationship of a VA hospital to 

a school of medicine. This metamorphosis contributed to a shifting of the schools’ focus away from the Dean’s Committee system at the local level, to the Network office, since the key decisions affecting the medical centers are made at the Network 

level—not by the individual medical center director. As a result, the Dean’s Committees no longer function as originally designed: As a result, they are not powerful 

advisory bodies governing two close affiliates, each aimed at a common purpose. 

Most of VA’s affiliates are components of State universities, but Network offices are 

often located in different States from those of the schools, or in distant cities. Decision makers in those offices are often remote and uninvolved in local VAMC activities. Negotiations important to the affiliates (and to their VAMCs) are made much 

more problematic in this kind of environment. Today there is more variability in VA 

affiliations throughout the healthcare system than ever before. Most of the original 

spirit of affiliation ‘‘agreements’’ has devolved into a form of contract management. 

The Networks face challenges at a global level, involving major allocation of resources among competing programs and facilities, human resource, strategic planning, construction management, planning issues, and other large scale matters. At 

times they do not fully appreciate the environment of an associated VA facility and 

its affiliate. 

The VA has adopted a broad system of performance measures and quality indicators. These techniques are used within the system for management, and serve as 

one of the bases for VA’s major quality improvements seen over the past dozen 

years. While VA has established a large number of measures in the clinical arena, 

what performance measures have been established for its academic and research 

missions? Do we know today on any measureable basis what VA locally, regionally 

or nationally expects from its academic affiliations, and how that expectation relates 

to VA’s needs and plans? What are the metrics VA would use to determine those 

needs? How are they evaluating the experiences of medical students and residents 

who progress through those affiliations and may consider VA as a career option? 

Without some benchmark or measurement system, VA cannot position itself to take 

full advantage of its affiliations as a basis for staff recruitment. We believe that VA 

could strengthen relationships with the affiliates by applying the successful performance measurement policy to these programs. VA could create real and measurable metrics in conjunction with its academic partners, and thereby improve both 

the immediate relations and promote a better future for the affiliations and for VA. 

VA has a number of qualities that attract newly trained healthcare providers— one opportunity that is especially attractive to young physicians completing residency training is VA’s well-established and proven Research Career Awards program. Unfortunately that program is highly dependent on available, state-of-the-art 

research space, laboratory facilities and ample equipment for use by these inquisitive clinician-investigators. Maintaining these programs and infrastructure could 

prove to be especially crucial to attracting future VA career practitioners in cardiology, gastroenterology, hematology, surgery, anesthesiology, and numerous other 

specialty fields that are otherwise extremely difficult for VA to recruit. 

Also, we believe that the highly stressful environment of VA healthcare delivery 

has contributed to deterioration in affiliation relationships. For example, we know 

of at least one school that has pulled all of its residents from VA primary care clinics because VA could not arrange a setting where male and female patients were 

available in sufficient numbers to support training requirements of the school. Also, 

some VA operational requirements for its physician workforce are difficult for residents to meet due to their other training and clinical responsibilities. VA facilities 

that are truly committed to affiliations should be more sensitive to their partner 

schools’ needs when designing and managing clinical programs. At the same time, 

the schools need to consider VA’s operating needs in designing the clinical practice 

to be observed by their students and residents. In absence of a more balanced relationship, sick and disabled veterans suffer the consequence of a lack of cooperation 

by a VA facility and its academic affiliate. 

We understand that the Veterans Health Administration (VHA) has established 

a Blue Ribbon Panel on Veterans Affairs Medical School Affiliations, and that the 

Association of American Medical Colleges (AAMC) has established and will be conducting a national survey of VA’s medical school affiliations. We hope these efforts 

will serve to identify ways to further improve the relationship between VA and its 

academic affiliates, and point the way to a better future for these relationships. Information from those efforts could be very helpful to the Subcommittee as well, especially if academic affiliates fully participate in the process. 


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Academic affiliations have played an integral role in VA healthcare over the 

years, contributing major elements to VA’s noted rise in quality and recognition as 

America’s best healthcare system. A current assessment of the needs of both the VA 

and its academic partners is timely and warranted by the Subcommittee to continue 

and improve these successful and symbiotic relationships. 

QUESTION: Future Needs—Recently the VA has had difficulty recruiting healthcare professionals such as nurses and pharmacists. 

• What is the greatest recruitment challenge facing the VA right now? What 

healthcare professions are in the shortest supply? • Looking into the future, what challenges does the VA anticipate facing in 10 

years? 20 years? 

RESPONSE: 

VA’s greatest recruitment challenge is likely the shortage the Nation faces as a 

whole for both nurses and specialty physicians. We often hear from VA facility 

sources that VA has the authority to hire for particular positions but are unable to 

identify qualified applicants. Additionally, VA’s ability to compete with attractive 

hiring bonuses and other incentives offered routinely by private sector providers create unique challenges for VA. The top five ‘‘key occupation challenges’’ identified at 

a VHA Succession Planning and Workforce Development Nursing Conference held 

April 18, 2007, are: 

• Registered Nurse • Physician • Pharmacist • Practical Nurse • Diagnostic Radiology Technologist 

To answer the last question about future challenges we refer the Subcommittee 

to VHA’s Succession Strategic Plan for Fiscal Year (FY) 2006–2010 which states: ‘‘VHA faces significant challenges in ensuring it has the appropriate workforce to 

meet current and future needs. These challenges include continuing to compete for 

talent as the national economy changes over time, and recruiting and retaining 

healthcare workers in the face of significant anticipated workforce supply and demand gaps in the healthcare sector in the near future. These challenges are further 

exacerbated by an aging federal workforce and an increasing percentage of VHA employees who receive retirement eligibility each year.’’ Additionally, we continue to hear reports that use of VA’s website for employment 

opportunities is cumbersome and that interested and qualified applicants often get 

bogged down in hiring practice delays and by other VA human resources requirements. It is our observation of VA that the hiring for all types of positions are treated relatively co-equally by human resources management. If VA’s overall human resources management performance were judged without regard to the distinctions 

among differing elements of its workforce, VA could be judged to be doing a good 

job. However, the maintenance of a committed clinical workforce requires more 

nuanced policies, especially given the competitiveness of the local labor markets for 

experienced healthcare providers, and in this respect, VA’s performance needs significant improvement. The reforms discussed earlier that were put in place by a 

former VA Under Secretary were correct in establishing performance metrics, but 

clinicians complain that in the succeeding years performance metrics have become 

additive, so that it is difficult to judge which performance elements are the most 

important. VA has issued a significant number of these measurements but only a 

minority may be truly meaningful to healthcare outcomes. This form of ‘‘piling on’’

has had a corrosive effect on VA physician morale. In a similar vein, the establishment of clinical reminders and so-called ‘‘prompts’’ in the VistA computerized patient care record system was a novel and essential development in improving VA 

quality of care; however, this, too, has become an additive system. Apparently no 

reminder or prompt is ever dropped from VistA. All must be responded to, whether 

the particular issue or variance from norms is significant or not. Given VA’s tremendous primary care caseload, these kinds of tedious requirements are draining for 

both the physician and nurse workforces. 

We believe one of the biggest challenges VA faces in the next decade or more relates to the continuing deterioration of its capital infrastructure. Within that overall 

deficit but often overlooked are VA’s research laboratories. The research laboratories 

at the 60 most active VA affiliations struggle to meet basic requirements for electrical and other energy needs, sanitation, negative-positive air flow separation, and 

other essential regulations, including human protections and safety regulations. 

Neither VA nor Congress have made this a priority and dedicated resources to keep 


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these laboratories up to par. In recent years, several potential serious hazards in 

VA laboratories have been averted—but only on an emergency basis when further 

delay could not be tolerated. As time goes on, these laboratories will likely see more 

crisis conditions develop. This is reminiscent of the conditions that led to the recent 

Minneapolis interstate bridge collapse. That bridge safely and routinely supported 

heavy vehicle traffic for decades, and because it ‘‘worked,’’ its structural problems 

and known, documented deterioration hazards were ignored by public officials—

until it collapsed. Therefore, not only for purposes of improving VA’s prospects for 

recruiting career-minded physicians and others as clinician-investigators, but also to 

protect the general safety of staff and patients, a major initiative should be funded 

to bring VA’s research laboratory and related research space up to contemporary 

standards of practice in American medicine. Without these contributions, VA will 

not be able to attract or keep top-flight providers and clinical investigators. In turn 

VA will not be able to continue to provide a system of quality healthcare for veterans, and VA will lose its role as a provider of future physicians and other caregivers to the Nation. 

We hope the Subcommittee will provide strong oversight to address these key 

issues, and will support funding to ensure VA’s research infrastructure receives the 

resources it needs to both assure safety and sustain an important tool to recruit new 

generations of caregivers to VA healthcare careers. 

Again, DAV appreciates the opportunity to provide these comments as an addendum to our testimony during the October 18th hearing. 

f 

Committee on Veterans’ Affairs 

Subcommittee on Health 

Washington, DC. 

October 19, 2007 

J. David Cox 

National Secretary-Treasurer 

American Federation of Government Employees, AFL–CIO 

80 F Street, N.W. 

Washington, D.C. 20001 

Dear Mr. Cox: 

Thank you for testifying before the U.S. House of Representatives Committee on 

Veterans’ Affairs Subcommittee on Health at the hearing on ‘‘Healthcare Professionals—Recruitment and Retention’’ held on October 18, 2007. 

Please provide answers to the following questions to Chris Austin, Executive Assistant to the Subcommittee on Health, by December 4, 2007. 

1. Academic Affiliations—Several witnesses stated that one of the most effective 

recruitment tools the VA has is its academic affiliations because they capture students while they are still training. 

• What can the VA do to strengthen their academic affiliations? 

• What other tools can the VA use to recruit newly trained healthcare providers? 

2. Future Needs—Recently the VA has had difficulty recruiting and retaining 

healthcare professionals such as nurses and pharmacists. 

• What is the greatest recruitment challenge facing the VA right now? What 

healthcare professions are in the shortest supply? 

• Looking into the future, what challenges does the VA anticipate facing in 10 

years? 20 years? 

Again, thank you for your testimony. The Subcommittee looks forward to receiving your responses by December 4, 2007. 

Sincerely, 

MICHAEL H. MICHAUD 

Chairman 


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AFGE RESPONSES TO QUESTIONS FOLLOWING THE OCTOBER 16, 2007 

HVAC SUBCOMMITTEE ON HEALTH HEARING ON ‘‘HEALTHCARE PROFESSIONALS—RECRUITMENT AND RETENTION’’

1. Academic Affiliations 

• What can the VA do to strengthen their academic affiliations? 

i. Provide incentives to include performance pay to encourage VA 

healthcare professionals to pursue teaching and other academic activities. 

ii. Strengthen the current link between the VA and state physician residency programs to increase the exposure of residents to VA job opportunities. (For example, there is no link between the Togus, ME VAMC 

and the state’s only Internal Medicine Program at the Maine Medical 

Center in Portland.) 

iii. The VA should get more involved in sponsoring or cosponsoring medical 

education activities. This will have the double benefit of providing VA 

medical professionals with more CME opportunities while exposing 

non-VA professionals to the VA. Many professionals outside the VA are 

very interested in working with OIF/OEF veterans. 

iv. More VA clinicians should give lectures at community hospitals where 

residents will be in attendance. 

v. The VA should strengthen ties with local scientific organizations, thereby increasing the VA’s position as a scientific, research oriented workplace. 

• What other tools can the VA use to recruit newly trained healthcare providers? 

i. Enact HR 4089 to restore the grievance rights and other workplace 

rights of frontline clinicians that are afforded to other federal employees and private sector clinicians who have a voice in scheduling, assignment, staffing and other patient care and clinical competence issues. 

ii. Make all P/T employees appointed under Title 38 permanent after the 

equivalent of two years of employment. 

iii. Offer the same alternative work schedules that are available to nurses 

in the private sector. 

iv. Limit mandatory overtime consistent state laws that have clear definitions of ‘‘emergency’’ to justify mandatory O/T. 

v. Expand scholarship programs for internal promotion, e.g. promoting 

physical therapy assistants to physical therapists, and nursing assistants to RNs and Nurse Practitioners. Also, ensure that positions are 

available to graduates of these programs. More generally, increase upward mobility opportunities for current VA employees, for example, 

nurse training for employees in administrative positions. Ensure that 

RNs with two year degrees have the same employment opportunities 

as BSN nurses. 

vi. Increase assistance with student loans for all VA healthcare professionals. More specifically, improve allocation of EDRP funds to ensure 

that applicants in areas with greater demand are able to receive funding. Currently, funds are evenly distributed across facilities regardless 

of the number of applications received at each medical center. An 

AFGE Nurse Leader in Seattle reports due to scarce EDRP funds, 

EDRP offers have gone from continuous open announcements to attaching an EDRP offer to specific positions, presumably because of poor 

funding. 

vii. Encourage residents who train at the VA to stay on as staff physicians 

through fair market pay and performance pay policies, fair annual 

leave policies, rights to grieve and arbitrate over indirect patient care 

issues and other workplace issues, compensatory time for evening and 

weekend duties and a greater voice in the workplace through inclusion 

in medical director meetings, input into medical by-laws, and other 

medical center policy setting groups. 

viii. Too often, there is only one clinical instructor trying to cover more than 

one nursing unit. If there were more instructors, nursing students 

would have a better experience and feel more positive about seeking 

employment with the VA. 

ix. Expand the funding for VALOR students within the VA. This will provide nursing students with summer jobs that enable them to learn the 

VA system and get hands on experience, which, in turn, will encourage 


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more of them to seek VA employment upon completion of their education. 

x. Expand use of the VA nurse awards program (both the number and 

size of the awards). 

xi. Ensure that supervisors issue fair performance ratings for front line clinicians. 

xii. Expand the use of recruitment and retention bonuses. 

xiii. Ensure fair locality pay adjustments through greater oversight of local 

survey processes. 

xiv. The VA needs to be careful that their recruitment efforts do not alienate the employees already on staff. There needs to be some retention 

efforts done simultaneously or otherwise this will just create animosity 

amongst employees—new and old. 

xv. Improve retirement benefits for Title 38 professionals under FERS, i.e. 

afford them the same rights to use accrued sick leave toward retirement as their counterparts under Title 5. (Only VA RNs can currently 

do so, while physicians, PAs or other Title 38ers still cannot.) 

xvi. Increased continuing education opportunities for nurses: Currently, 

RNs at the VA do not have time to pursue education. The VA now relies on computer assisted mandatory reviews where there is no opportunity for human interaction or to have discussions or ask questions, 

even though there are documents embedded into these classes such as 

Station or VISN policies that employees are held accountable as knowing. Often, employees do not have the time to go through the actual 

module but test out due to lack of time. 

xvii. CME: Management does not comply with the current statutory requirement to reimburse physicians annually for CME expenses. More generally, all VHA healthcare professionals should have more definite 

rights to annual CME reimbursement, rather than leaving it to the discretion of management and budget uncertainties. 

2. Future Needs 

• What is the greatest recruitment challenge facing the VA right now? 

(This comes from an AFGE nurse leader in Seattle) Recruitment of Registered 

Nurses (RNs) is the greatest recruitment challenge for VHA. The average RN in 

VHA is approximately 48 years old. Registered Nurses are the most numerous direct 

caregivers in the healthcare setting. As the baby boom population ages, so do RNs. 

Nursing is a physically as well as emotionally demanding occupation. Most RNs are 

women who also bear the majority of the care giving burden for dependent children 

and aging parents/relatives. They are being stretched thin. Despite numerous policies in place to help VHA with recruitment and retention, they are underutilized 

by VHA. The culture of top-down management and the restrictions of Title 38 USC 

7422(b) do not allow RNs the appropriate level of involvement in decisions about 

care delivery and quality or the ability to challenge poor managers in a meaningful 

way. Our Renal Dialysis unit went 2 years before finding an RN to manage the clinic. Retention bonuses are rarely used. Our Nurse Executive told a group of Nurse 

Practitioners that she had a hard time getting locality pay information from area 

hospitals, due to a fear that we would ‘‘poach’’ their RNs. 

• What healthcare professions are in the shortest supply? RNs are in very short 

supply, as well as pharmacists. As noted below, we are facing an imminent, 

substantial shortage of mental health clinicians. 

• Looking to the future, what challenges does the VA anticipate facing in 10 

years? 20 years? 

i. UNPRECEDENTED DEMAND FOR LONG TERM MENTAL 

HEALTHCARE FOR OIF/OEF VETS: We are going to face a vast 

shortage of providers to meet this future need if current weak recruitment and retention policies continue. 

ii. AGING PATIENT POPULATIONS: In the next 10–20 years the aging 

of the population across the board is going to be the biggest challenge 

for VHA and the Nation as a whole. As people age, they acquire multiple chronic conditions that are management-labor intensive and require costly medications to remain alive and out of the hospital. In particular, the VA needs to increase its focus on diabetes; it is a lifestyle 

disease that is associated with a metabolic syndrome that also increases the risk of heart disease, high blood pressure, kidney failure, 

blindness, amputation, and stroke. 


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iii. AGING WORKFORCE: The VA has historically relied on employees 

who stayed with the system until normal retirement. This is no longer 

the case. Even though the VA is facing a workforce crisis due to an imminent wave of retirements, many older employees feel that there is a 

concerted effort to go after them, forcing them to retire early with a reduced annuity, rather than stay employed at the VA. The VA needs to 

increase retention incentives for older employees including better pay 

and benefits for P/T employees, permanent status, and more flexible 

schedules. 

iv. SHORT STAFFING: The VA is adding more and more clinical reminders, lengthy and cumbersome referral forms on the computer that help 

them with keeping track of numbers, but staffing is the same or less 

with a lot more documentation. The turnover and the acuity of inpatients have been immense. Yet the nurses are tied down with all the 

documentation rather than patient care. 

v. SUPERVISOR PROBLEMS: There is inadequate support from supervisors and all the way up in the organization. Even if the staff is overwhelmed, the supervisors say just do it while they go off to their meetings or are away at VISN/National Meetings. They have not touched 

a patient in years yet they are quick to criticize or discipline. The Supervisors and upper Managers do not have a finger on the pulse of 

what is happening at their work site. They are too busy looking at overall numbers that get reported to VACO. 

f 

Committee on Veterans’ Affairs 

Subcommittee on Health 

Washington, DC. 

October 19, 2007 

The Honorable Gordon H. Mansfield 

Acting Secretary 

U.S. Department of Veterans Affairs 

810 Vermont Ave., NW 

Washington, D.C. 20420 

Dear Secretary Mansfield: 

Thank you for testifying before the U.S. House of Representatives Committee on 

Veterans’ Affairs Subcommittee on Health at the hearing on ‘‘Healthcare Professionals—Recruitment and Retention’’ held on October 18, 2007. 

Please provide answers to the following questions to Chris Austin, Executive Assistant to the Subcommittee on Health, by December 4, 2007. 

1. Workplace satisfaction—A study sponsored by the Partnership for Public 

Service recently came out that showed a large discrepancy in workplace satisfaction in the Veterans Health Administration between workers over 40 and 

workers under 40. VHA workers over 40 report ‘‘high satisfaction’’ and those 

under 40 report ‘‘very low satisfaction.’’

• What does the VA plan to do to attract and keep younger workers? 

2. Future Needs—Recently the VA has had difficulty recruiting and retaining 

healthcare professionals such as nurses and pharmacists. 

• What is the greatest recruitment challenge facing the VA right now? What 

healthcare professions are in the shortest supply? 

• Looking into the future, what challenges does the VA anticipate facing in 10 

years? 20 years? 

3. Current programs—The VA has several current programs for recruitment 

and retention of healthcare professionals. 

• How many people are currently in these programs? 

• How much do these programs cost? 

• Are these programs successful? How is success measured? 

4. Physicians Pay Bill—In 2004 Congress passed the Physicians’ Pay Bill which 

established an improved and simplified pay structure for VA physicians that 

would increase salaries and make VA more competitive with the private sector. 

• How effective has the Physicians Pay Bill been in retaining VA physicians? 


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• When will VA be delivering the report to Congress on the 2004 Physicians 

Pay Bill? 

Again, thank you for your testimony. The Subcommittee looks forward to receiving your responses by December 4, 2007. 

Sincerely, 

MICHAEL H. MICHAUD 

Chairman 

Questions for the Record 

The Honorable Michael Michaud, Chairman 

Subcommittee on Health 

House Committee on Veterans’ Affairs 

Healthcare Professionals—Recruitment and Retention Hearing 

Question 1: Workplace satisfaction—A study sponsored by the Partnership for Public Service recently came out that showed a large discrepancy in workplace satisfaction in the Veterans Health Administration between workers over 40 and workers 

under 40. VHA workers over 40 report ‘‘high satisfaction’’ and those under 40 report 

‘‘very low satisfaction.’’

Question 1a: What does the VA plan to do to attract and keep younger workers? 

Response: The Department of Veterans Affairs (VA) has an extensive array of recruitment and retention tools available to employees including scholarship programs, continuing education, student debt reduction, entry-level career training programs that offer promotion potential and residency and fellowship training programs. Recruitment strategies are targeting college students in Veteran Health Administration’s (VHA) primary occupational categories to encourage them to consider 

VA as a career option. Additionally, to address employee satisfaction efforts, VHA 

requires action plans be developed at every organizational level to address issues 

with satisfaction which were identified in its annual All Employee Survey. 

Question 2: Future Needs—Recently the VA has had difficulty recruiting and retaining healthcare professionals such as nurses and pharmacists. 

Question 2a: What are the greatest recruitment challenges facing the VA right 

now? What healthcare professionals are in the shortest supply? 

Response: The greatest recruitment challenge is retaining new hires in the VA system. While turnover decreased for VHA overall by a small amount (0.1 percent), 

turnover increased for physical therapists (4.3 percent), pharmacists (0.5 percent), 

and physicians (0.1 percent) from fiscal year (FY) 2005 to FY 2006 and decreased 

for nurses in the same time period by 0.5 percent. New hires in each of the key 

positions have increased by a significant amount, with increases of 33 percent to 44 

percent among these occupations in FY 2007. 

All Loss Turnover for VHA FT/PT Employees (Excludes Medical Residents, 

Trainees, and Intermittent) 

FY 

2005 

FY 

2006 Change 

Gain 

FY 

2005 

Gain 

FY 

2006 

Gain 

FY 

2007 

All VHA 9 .55% 9 .45% ¥0 .10% 19,270 23,692 32,412 

0602 Physician 9 .70% 9 .80% 0 .10% 1,754 1,842 2,473 

0610 Nurse 9 .00% 8 .50% ¥0 .50% 3,196 3,872 5,553 

0660 Pharmacist 6 .50% 7 .00% 0 .50% 311 383 534 

0633 Physical 

Therapists 6 .39% 10 .70% 4 .31% 110 132 175 


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On-board numbers for mental health positions in direct patient care are also increasing, with 387 more psychologists, 842 more social workers, and 157 more psychiatrists in FY 2007. 

On-Board for Mental Health Positions with Direct Care Cost Centers for 

FT/PT Employees (Excludes Medical Residents, Trainees, and Intermittent) 

FY 2005 FY 2006 FY 2007 

0180 Psychology 1604 1768 2155 

0185 Social Work 4263 4607 5449 

0602 Physician, Assignment Code 31, 

Psychiatry 1922 1977 2134 

VHA develops a workforce succession strategic plan each year. The plan is developed with input from network and program offices throughout VHA. Identified in 

this plan are the ‘‘top critical occupations’’ within VHA for the current year. For the 

FY 2008–2012 plan, the following occupations were identified: registered nurse, physician, pharmacist, practical nurse, diagnostic radiology technologist, medical technologist, physical therapist, nursing assistant and medical records technician. 

Question 2b: Looking into the future, what challenges does the VA anticipate facing in 10 years? 20 years? 

Response: The major workforce drivers within healthcare include an increasing demand for health services driven largely by an aging population that exhibits multiple chronic health conditions; and an aging healthcare workforce that is not being 

adequately replaced by younger workers. Two of the largest veteran cohorts, those 

who served in World War II and Vietnam, are aging and increasingly relying upon 

VHA for their healthcare needs. On the other hand, we have a growing population 

of younger veterans of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/ 

OIF). This generation has a greater expectation for state-of-the-art medical treatment options and many return from combat severely injured, arriving at VHA facilities with polytraumatic injuries that would have been fatal in previous conflict eras. 

These injuries require different types of rehabilitation as well as increased need for 

mental health treatment. 

While anticipating the needs of this next generation of veterans is of great importance to VHA, we also realize that equally important are the broad-based changes 

in the age and demographics of World War II, Korean, and Vietnam-era veterans. 

With the median age of all living veterans being approximately 60 years of age, the 

number of veterans aged 85 and older has grown from 164,000 in 1990 to 1,075,000 

in 2005. By 2011, the number of veterans aged 85 and older will grow to more than 

1.3 million. This large increase in the oldest segment of the veteran population has 

had, and will continue to have, significant ramifications on the demand for 

healthcare services, particularly in the areas of long-term care and home-based care. 

VHA’s workforce is also aging and becoming eligible for retirement in greater 

numbers. At the end of FY 2007, 11.5 percent of VHA’s 218,000 full- and part-time 

employees were eligible for regular retirement. It is expected that within the next 

10 years, approximately 30 percent of VHA employees will need to be replaced as 

a result of regular retirements. In that same time period, VHA will need to replace 

approximately 85 percent of all senior leaders, including senior executives, medical 

center directors, nurse executives/directors of patient care services, associate/assistant and deputy network directors, and chiefs of staff. We anticipate that competition 

for workers will increase significantly over the next 20 years and that competition 

for healthcare workers will be especially strong. 

Question 3. Current programs—The VA has several current programs for recruitment and retention of healthcare professionals. 

Question 3a: How many people are currently in these programs? 

Response: Scholarship Programs Implemented in 2000—the Employee Incentive 

Scholarship Program (EISP) authorizes VA to award scholarships to employees pursuing degrees or training in healthcare disciplines for which recruitment and retention of qualified personnel is difficult. EISP awards cover tuition and related expenses such as registration, fees, and books. The academic curricula covered under 

this initiative include education and training programs in fields leading to appointVerDate Aug 31 2005 04:56 Aug 19, 2008 Jkt 039464 PO 00000 Frm 00095 Fmt 6604 Sfmt 6621 E:\HR\OC\39464.XXX 39464

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ments or retention in title 38 or hybrid title 38 positions listed in 38 U.S.C. Section 

7401. The following data reflects the total employee participants through FY 2007: 

• Total number of awards: 7,127 

• Total number of employees completing the program (graduates): 3,988 

• Total amount of funding for awards through FY 2012: $88,315,696 

• Average amount of award per participant: $12,392 

The chart below identifies the total number of scholarships awarded to VHA employees since 2000, the number of employees who have completed their programs 

and the average amount of the scholarship awarded by occupation. 

Occupation Total # 

Awards 

Total # 

Completed 

Average 

Amount 

of Each 

Award 

Registered Nurse 6,595 3,634 $12,416 

Pharmacist 188 96 $17,601 

Licensed Practical Nurse 134 66 $7,196 

Physical Therapist 55 21 $9,593 

Physician Assistant 34 26 $6,388 

Registered Respiratory Therapist 34 16 $5,995 

Certified Registered Nurse Anesthetist 33 7 $15,920 

Audiologist 12 3 $5,949 

Occupational Therapist 12 6 $14,677 

All other 30 16 —

TOTAL 7,127 3,988 $12,392 

An analysis of the average cost per award reveals that the average award 

($12,329) is substantially less than the maximum amount allowed ($35,024 in FY 

2007) by statute. Additionally, the average number of credit hours funded per employee (45 credits for undergraduate and 36 credit hours for graduate) is substantially less than the hours allowed by statute (90 credits for undergraduate and 54 

for graduate). This demonstrates that the employees are selecting academic institutions with reasonable costs and the employees have self-funded a substantial part 

of the degree prior to applying for the scholarship award. 

Question 3b: How much do these programs cost? 

Question 3c: Are these programs successful? How is success measured? 

Response: The scholarship program has graduated 423 new healthcare personnel 

in the following occupations: registered nurse anesthetists (4); certified respiratory 

therapy technicians (1); dental hygienist (1); licensed practical nurses (64); occupational therapist (2); pharmacist (5); physician assistants (4); registered nurses (331); 

registered respiratory therapist (11). The remaining scholarship participants are 

employees who pursued an advanced degree in their profession. Additionally, the 

scholarship program supports workforce succession planning by offering flexible use 

of the scholarship to achieve more than one academic degree. For example, 202 of 

the 3,886 successful graduates through FY 2007 include 100 registered nurses who 

completed both a baccalaureate and a masters program and 1 registered nurse who 

completed a masters and a doctoral degree. As the organization identifies the competency and knowledge level, the employee can use the scholarship program to meet 

those needs as well as reinforcing VA as the preferred employer. The scholarship 

program was identified as one of the primary reasons for working for VA in all marketing materials. 


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1 Horn, & Berger. (2004). College persistence on the rise? Changes in 5-Year degree completion 

and postsecondary persistence rates between 1994 and 2000. (No. NCES 2005–156). Washington, 

DC: U.S. Department of Education, National Center for Education Statistics. 

When considering impact of the scholarship program on employee retention, the 

first issue of significance is the program completion rate of participants. The U.S. 

Department of Education in its most recent report (2004) stated that the rates of 

college degree attainment have not changed over several decades despite an increase in the total number of college students. Approximately 6 out of 10 traditional 

students and 4 out of 10 nontraditional students who entered college in 1995 had 

actually completed a degree by 2001 (Horn & Berger, 2004).1 All of the employee 

participants in this scholarship program would meet the criteria for the nontraditional student and would thus be in the highest risk category. However, the VA employee scholarship participants have had an overall attrition rate of 15 percent in 

contrast to the national norm of 60 percent. A review of the first time degree VA 

scholarship participants (which would be in the highest risk category for attrition) 

reveals that even their attrition rate 25 percent remains substantially below the attrition national norm for all first time college attendees. 

The next criterion related to retention asks if scholarship participants have a 

higher VA employment retention rate when compared to non scholarship participants. A study (2005) of the 3844 registered nurse (RN) scholarship participants 

demonstrated that 7.4 percent of RNs enrolled in the scholarship program left VA 

employment compared to the 10.6 percent leave VA rate for all VA registered 

nurses. Additionally, of those scholarship participants who left VA less than 1 percent (0.6 percent) left during their service obligation period. Thus in this study 

group which represents 95 percent of all awards, the scholarship program had a significant impact on employee retention in VHA. 

The final retention criterion addresses the impact of the required service obligation period relative to employee retention. The average service obligation period for 

all awards is 2.2 years following completion of the degree. A review of the 1172 employees who have breached their scholarship agreement reveals that only 102 (9 percent of breaches or 1 percent of all awards) breached during their service obligation 

period. Thus 99 percent of award recipients who complete their degree also complete 

the service obligation period. Additionally, an effective oversight program is in place 

and assures appropriate collection of all financial liabilities incurred as a result of 

breached agreements. 

The criterion for measuring success is the direct impact in our workforce of the 

recruitment and retention of title 38 and hybrid title 38 occupations. The effectiveness of the scholarship programs in recruitment of healthcare professionals is measured primarily by determining if the programs impact on professionals’ decisions to 

work at VA, if the programs are generating new first-time licensed healthcare personnel, and if the programs contribute to the workforce succession plan. 

The criteria for measuring retention efforts include comparing the student attrition rate using national benchmarking data from the Department of Education; 

comparing employee attrition rates of scholarship participants with that of the general VHA registered nurse population; and determining if the mandatory service obligation period contributes to employee retention. 

Education Debt Reduction Program The chart below provides the number of 

employees who have participated in the education debt reduction program (EDRP) 

since its implementation in May 2002. The program designed to assist VA with recruitment and retention of hard-to-fill healthcare professions, applies to title 38 and 

hybrid title 38 occupations. Total expenditures for EDRP awards from the programs 

inception and continuing with award obligations authorized through FY 2012 are 

$96,870,402. 

Occupation Total # EDRP 

Awards 

Total # 

Completed 

Average 

Amount of 

Award 

Registered Nurse 2,704 1,475 $13,451 

Pharmacist 876 429 $23,595 

Physician 715 345 $24,790 


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Occupation Total # EDRP 

Awards 

Total # 

Completed 

Average 

Amount of 

Award 

Licensed Practical/Vocational 

Nurse 285 173 $5,499 

Physical Therapist 231 128 $21,522 

Physician Assistant 204 116 $21,254 

Occupational Therapist 105 75 $16,381 

Medical Technologist 97 38 $16,135 

Diagnostic Radiologic 

Technologist 80 34 $11,223 

Registered Respiratory Therapist 50 33 $11,860 

All other 23 occupations 309 138 —

Total 5,656 2984 $16,571 

VALOR—VA Learning Opportunity Residency Program Initiated in the 

Summer 1990, for students (junior class level) enrolled in bachelors degree nursing 

program, VALOR has provided opportunities for outstanding students to develop 

competencies in clinical nursing while at an approved VA healthcare facility. In FY 

2007, there were 398 new VALOR nursing students and 193 continuing students 

from the 2006 scholars. Outcomes of the program have demonstrated that it is an 

excellent method of recruiting students when those students are retained into the 

senior year (over 50 percent of this group are hired). The success of the nursing 

VALOR program led to the launching in 2007 of a VALOR program for pharmacy 

students. In this inaugural year there were 14 students selected. Additional sites 

and students will be approved as the program evolves and develops. 

Question 4: Physicians Pay Bill—In 2004 Congress passed the Physicians’ Pay Bill 

which established an improved and simplified pay structure for VA physicians that 

would increase salaries and make VA more competitive with the private sector 

Question 4a: How effective has the Physicians Pay Bill been in retaining physicians? 

Response: The new physician and dentist pay system has provided VA with a comprehensive way to offer flexible compensation packages making VA more competitive in the recruitment and retention of physicians and dentists. Through the use 

of the new pay flexibilities, VA has been able to increase the overall number of physicians and dentists employed by 574 additional staff. Many of the additional staff 

are in clinical specialties which had previously experienced significant difficulty attracting candidates. 

In addition to improvements in recruitment, VA has also benefited from improvements in the retention of physician and dentist staff. A comparison of the loss rates 

for 2006 (9.60 percent) and 2007 (4.18 percent) show a more than 50 percent improvement in the retention of physicians and dentists. The significance of this improved rate of retention is most evident when compared against the historical loss 

rates for physicians and dentists. 

Physicians Loss Rate Dentists Loss Rate 

2000 11.69% 2000 8.48% 

2001 10.88% 2001 4.23% 

2002 10.76% 2002 6.92% 


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Physicians Loss Rate Dentists Loss Rate 

2003 10.37% 2003 6.82% 

2004 10.22% 2004 4.91% 

2005 9.69% 2005 9.15% 

2006 9.60% 2006 9.68% 

2007 4.18% 2007 4.32% 

We believe the new pay system has significantly contributed to the overall decrease in physician and dentist separations. 

Question 4b: When will VA be delivering the report to Congress on the 2004 Physicians Pay Bill? 

Response: The first annual report on the pay of physicians and dentists was delivered to the Congress on November 16, 2007, a copy of which is attached. 

f 

Committee on Veterans’ Affairs 

Subcommittee on Health 

Washington, DC. 

October 31, 2007 

Honorable Gordon H. Mansfield 

Acting Secretary 

U.S. Department of Veterans Affairs 

810 Vermont Ave., NW 

Washington, DC 20420 

Dear Secretary Mansfield: 

On Thursday, October 18, 2007, William J. Feeley, MSW, FACHE, Deputy Under 

Secretary of Health for Operations and Management, Veterans Health Administration, U.S. Department of Veterans Affairs (VA), testified before the Subcommittee 

on Health on VA Healthcare—Recruitment and Retention. As a followup to this 

hearing, I request that Mr. Feeley respond to the following questions in written 

form for the record. Each question should be listed on the page with the answers 

immediately following the question. 

1. The American Physical Therapy Association (APTA) testified, ‘‘only 19 physical therapists have participated in the Education Debt Reduction Program 

and only 14 physical therapists have participated in the Employee Incentive 

Scholarship Program.’’

a. Do you consider this a low level of participation? 

b. What has VA been doing to promote and increase the utilization of these 

programs? 

c. How does VA plan to improve promotion of the Education Debt Reduction Program and the Employee Incentive Scholarship Program? 

2. APTA testified that proposed updates to the VA qualification standards for 

Physical Therapists have been pending for six years. 

a. Why is the process taking so long and when do you anticipate issuing 

updated standards? 

b. Are there other categories of healthcare employees that have qualification standards under review? If so, please list those categories of 

healthcare employees, the date they were proposed, and the date you expect to complete the review process. 

3. How does VA monitor professional licensure criteria to ensure it employs the 

most up-to-date requirements? 

4. The 2006 CACI pilot study evaluated innovative recruitment tools to address 

nursing shortages and made five recommendations to improve the hiring procVerDate Aug 31 2005 04:56 Aug 19, 2008 Jkt 039464 PO 00000 Frm 00099 Fmt 6604 Sfmt 6621 E:\HR\OC\39464.XXX 39464

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ess: (1) delegate approval authority; (2) make greater use of recruitment advertising; (3) streamline and standardize the processes; (4) implement an 

automated recruitment management workflow system; and (5) adjust Vet Pro 

to coordinate with date of entry. Has VA implemented any of the CACI recommendations? If so, please provide a description of the steps VA has taken 

to implement each recommendation. 

5. The CACI report found ‘‘[t]he majority of current processes are manual processes in a paper-based system. One of the greatest opportunities for process 

improvement and reduced time-to-hire is the elimination of paper-based manual systems and the introduction of electronic document workflow’’ (p. 28). 

Furthermore, the report noted, ‘‘VA’s HR2020 Task Force has also chartered 

a National Automation workgroup to implement a national strategy for an integrated HR information system as well as establishment of outcome-based 

metrics specifically related to the timeliness of recruitment’’ (p. 29). 

a. Has VA implemented a plan for an integrated HR information system? 

b. How much progress has been made on the integrated HR information 

system? If no progress has been made, please explain why and provide 

a timeline for VA action. 

6. What is the average time it takes for VA to fill a vacant healthcare position? 

How does this timeline compare with that of the private sector? 

7. Based on the CACI study, do you think VA could benefit from using an outside recruitment, advertising and communications agency to speed up the hiring process? 

8. Public Law 108–445, the ‘‘VA–Pay bill’’ reformed the VA physician pay and 

performance system. 

a. What difference has this legislation made on VA’s ability to recruit and 

retain the best physicians? 

b. What effect has the ‘‘VA–Pay bill’’ had on VA’s reliance on part-time 

physicians? 

9. The Partnership for Public Service and American University’s Institute for 

the Study of Public Policy Implementation rankings from the Office of Personnel Management’s (OPM) Federal Human Capital Survey rank VHA 18th 

out of 222 Federal agencies as the ‘‘Best Places to Work’’. Do you find that 

this survey is a valid representation of VHA staff? 

10. The Partnership for Public Service analysis of the OPM survey shows a high 

satisfaction rate among employees 40 and over (12 of 222), but very low satisfaction among its younger cohort (112 out of 208)? How would you explain 

this difference? 

The attention to these questions by Mr. Feeley is much appreciated, and I request 

that they be returned to the Subcommittee on Health no later than close of business, 5:00 p.m., Friday, November 30, 2007. If you or your staff have any questions, 

please call Dolores Dunn, Republican Staff Director for the Subcommittee on 

Health, at 202–225–3527. 

Sincerely, 

Jeff Miller 

Ranking Member 

The Honorable Jeff Miller 

Ranking Minority Member 

Subcommittee on Health 

House Veterans’ Affairs Committee 

Healthcare Professionals—Recruitment and Retention 

Question 1: The American Physical Therapy Association testified, ‘‘only 19 physical 

therapists have participated in the Education Debt Reduction Program and only 14 

physical therapists have participated in the Employee Incentive Scholarship Program? 

Question 1(a): Do you consider this a low level of participation? 


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Response: It is true that 19 of 119 recently appointed physical therapists participated in the Education Debt Reduction Program. The data shows that 16 percent 

of physical therapists hired during fiscal year (FY) 2007 received EDRP awards. 

However, in spite of being a small component of the Veterans Heath Administration 

(VHA) workforce; physical therapist ranks fifth in the total number of EDRP awards 

allocated since the program inception in 2002. The total number of awards to physical therapists as of FY 2007 was 231. An analysis of the EDRP program for the 

first group of recipients (from 2002) shows that EDRP may be less effective as a 

retention tool for the physical therapy occupation (59 percent remained employed by 

VHA for the duration of the award) than nursing (75 percent) or pharmacy (75 percent) indicating there may be other market-based factors contributing to retention, 

including pay disparity with private sector. VHA will continue using EDRP as appropriate to recruit and retain physical therapists in addition to using other Title 

5 recruitment and retention pay incentives. 

Fifty-five physical therapists have participated in the Employee Incentive Scholarship Program (EISP). The low number of physical therapists returning to college is 

not surprising as they are hired into VHA with the masters or doctorate degree as 

is required to practice in the occupation. By comparison nurses are often hired with 

associate degrees and use EISP extensively to advance to bachelor or masters degrees. However, as the occupation’s academic preparation moves from the masters 

degree to the doctorate degree at the entry-level, we anticipate more of VHA’s masters prepared physical therapists will apply for EISP scholarships to obtain doctorate degrees. 

Question 1(b): What has VA been doing to promote and increase the utilization 

of these programs? 

Response: To promote and increase use of these program VHA conducts monthly 

conference calls for field liaisons and participates in discipline specific national conference calls to communicate information about these programs for field-based managers. National recruitment advertising materials contain information about scholarship and debt reduction programs. Strategies for using these programs are integrated into VHA Workforce Succession Planning conference curricula and regional 

presentation. 

Question 1(c): How does VA plan to improve promotion of the Education Debt Reduction Program and the Employee Incentive Scholarship Program? 

Response: The Healthcare Retention and Recruitment Office is working in concert 

with leadership in Patient Care Services to communicate availability of both EDRP 

and EISP scholarships to both field-based PT managers and practitioners. Of particular interest will be enhancing the academic credentials for existing staff and 

eliminating any reason for physical therapists to resign from VHA to return to 

school. 

Question 2: APTA testified that the proposed updates to the VA qualification 

standards for Physical Therapists have been pending for six years. 

Question 2(a): Why is the process taking so long and when do you anticipate 

issuing updated standards? 

Response: The original request to revise the physical therapist qualification standard was received in the Office of Human Resources Management (OHRM) in March 

2004. The passage of Public Law 108–170 (the Veterans Health Care, Capital Asset 

and Business Improvement Act of 2003) on December 6, 2003, converted 22 occupations from Title 5 to the Title 38 employment system. Conversion required the development of new qualification standards for each of the 22 new hybrid occupations. 

Therefore, all work to revise existing qualification standards, including the physical 

therapist, was suspended until after completion of the new 22 standards, which included collaboration with bargaining unit representatives as required by PL 108–

170. 

Work on the physical therapist standard resumed in February 2006 following an 

eight-step process that ensures consistency with the Uniform Guidelines on Employee Selection Procedures and the principles of equal pay for equal work established in 5 United States Code 5104, the Equal Pay Act 1963, Title VII of Civil 

Rights Act 1964, Age Discrimination in Employment Act 1967, and Title I of Americans with Disabilities Act 1990. OHRM launched a new initiative and training was 

provided to the subject matter experts in March 2006. Since that time OHRM and 

VHA have been working together to produce the required supporting documentation. 

The new physical therapist qualification standard is in the final review stage, and 

in April 2008, will go through statutorily-mandated collaboration with bargaining 


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unit representatives. By statute, collaboration requires a minimum of 90 days, and 

in the past, it has taken 120 days including the preparation and issue of required 

reports to Congress. The qualification standard will move to the formal concurrence 

process, and can be expected to be available for implementation in early to late-summer/early-fall 2008. 

The revised qualification standards will address several concerns by: 

1. Considering appropriate entry and full performance grade levels; 

2. Recognizing the Doctor of Physical Therapy (DPT) degree, and; 

3. Providing for many new assignments above the full performance level to allow 

for advancement. 

Question 2(b): Are there other categories of healthcare employees that have qualification standards under review? If so, please list those categories of healthcare employees, the date they were proposed and the date you expect to complete the review 

process. 

Response: We are currently revising or developing new qualification standards for 

these additional healthcare occupations: 

Occupation Received Anticipated 

completion 

Blind Rehabilitation Specialist 11/2004 Winter 2008 

Nurse Anesthetist (CRNA) 

(Certified Registered Nurse Anesthetist) 5/2006 Winter 2008 

Occupational Therapist 3/2006 Spring 2008 

Pharmacist 1/2004 Summer 2008 

Social Worker 5/2004 Summer 2008 

Program Offices have inquired about revising the qualification standards for: 

Medical Instrument Technician 

Physician Assistant 

Respiratory Therapist 

Therapeutic Radiologic Technologist 

Veterinary Medical Officer 

Question 3: How does VA monitor professional licensure to ensure it employs the 

most up-to-date requirements? 

Response: VA requires all licensed healthcare professionals to practice within the 

scope of their licensure. When privileges or scopes of practice are granted, 

verification with the licensing board confirms that the practitioner’s license allows 

for each element to be granted. Licensure is verified at the time of initial appoint 

and at expiration for all licensed healthcare practitioners. For privileged practitioners it is verified initially and at the time of reappraisal, which occurs at a minimum of every 2 years. As privileges or scopes of practice are reviewed, confirmation 

of the scope of practice allowed by licensure is also reviewed. The verifications are 

completed by local human resources staff. 

Question 4: The 2006 CACI pilot study evaluated innovative recruitment tools to 

address nursing shortages and made five recommendations to improve the hiring 

process: (1) delegate approval authority; (2) make greater use of recruitment advertising; (3) streamline and standardize the processes; (4) implement an automated recruitment management workflow system; and (5) adjust VetPro to coordinate with 

the date of entry. Has VA implemented any of the CACI recommendations? If so, 

please provide a description of the steps VA has taken to implement each recommendation. 

Response: The Veterans Health Administration (VHA) commissioned a task force 

in May 2007, VHA recruitment process redesign workgroup (RPRW), to consolidate 

findings from several VHA recruitment processing studies and make recommendations for action. This workgroup incorporated findings and recommendations from 

the CACI study (a study limited in geographical scope) and multiple other VHA reVerDate Aug 31 2005 04:56 Aug 19, 2008 Jkt 039464 PO 00000 Frm 00102 Fmt 6604 Sfmt 6621 E:\HR\OC\39464.XXX 39464

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cruitment and hiring timeline studies. The workgroup incorporated aspects of the 

CACI study into its final work product which was published on August 20, 2007. 

This study was presented to the VHA National Leadership Board in October 2007. 

A pilot project has been initiated at one facility to implement the approved recommendations. However, other networks/facilities will simultaneously move forward 

with the recommendations. The workgroup recommendations identified recruitment 

barriers and recommendations for resolution that covered short-term, intermediate 

and long-term actions. 

As an example, the VA Medical Center in Alexandria, Louisiana, has implemented a number of changes in its hiring processes and achieved the ability to hire 

a nurse within 30 days of accepting the application. They have implemented a practice that uses the VetPro system as the nursing application and provide applicants 

with easy access by setting up convenient work stations. Modifications were made 

in the timing of preemployment physicals and performing process steps concurrently 

versus sequentially. These practices are being shared across the administration to 

improve hiring timelines. 

Building on the CACI recommendations, the RPRW further recommended complete automation of the application process, to include electronic integration with 

various human resource systems. Once these systems are electronically integrated, 

job applicants will only have to provide the necessary information once at the beginning of the recruitment process and the various systems will be automatically populated by this information. Accomplishment of this recommendation will eliminate 

what is presently a redundant, frustrating process which causes VHA to lose highly 

desirable applicants. 

Communication of new recruitment processes and expectations must be far-reaching to include human resources, credentialing and privileging, selecting officials, and 

job applicants. A recommendation presented by the RPRW was to have facility 

points of contact communicate early and often with applicants to ensure they have 

reasonable expectations of the timeframe for the process to unfold. 

Question 5: The CACI report found ‘‘[t]he majority of current processes in a paperbase system. One of the greatest opportunities for process improvement and reduced 

time-to-hire is the elimination of paper-based manual systems and the introduction 

of electronic document workflow’’ (p. 28). Furthermore, the report noted, ‘‘VA’s HR 

2020 Task Force has also chartered a National Automation workgroup to implement 

a national strategy for an integrated HR information system as well as establishment of outcome-based metrics specifically related to the timeliness of recruitment’’

(p. 29). 

a. Has VA implemented a plan for an integrated HR information system? 

b. How much progress has been made on the integrated HR information system? 

If no progress has been made, please explain why and provide a timeline for 

VA action. 

Response: The VHA Strategic Human Resources Advisory Council (SHRAC) established a 2020 goal for automating human resources. This goal was to have all 

human resources processes be highly automated, streamlined, efficient and consistent nationwide. The SHRAC formed a work group to examine the best means 

of meeting this goal. The work group endorsed a plan to pilot VA Greater Los Angeles, human resource automation efforts to include their automated request for personnel action (ARPA). Over the past 18 months pilots were initiated: in four Veteran 

Integrated Services Networks (VISN). The initial project moved beyond the first pilots and evolved to five major initiatives: 

• Centurion—process for assigning permissions and rights 

• PAID—Net—standardized reports for all human resources offices 

• Web HR—standardized portal for all VHA staff 

• ARPA—standardized process for automating requests for personnel actions. 

• HR Forms—standardized employment forms 

To ensure consistent and integrated implementation with other technology, additional work groups have been added to the initial project: 

• HR METRICS 

• POLICIES/BUSINESS RULES 

• DEFINITIONS–CENTURION 

• DEPLOYMENT 

• APPLICATIONS/DATABASES 

• TRAINING 

• REQUIREMENTS 


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TARGET ROLL OUT: 

PAID Net—Available to all sites December 2007 

Centurion and ARPA—Initiate roll-out for HR office sites March 2008,Web HR—

January 2008, HR Forms—March 2008 

Question 6: What is the average time it takes for VA to fill a vacant healthcare 

position? How does this compare with that of the private sector? 

Response: The average time to fill healthcare positions is highly variable depending on the labor market. In labor markets where there are adequate candidates, the 

timeframes for pre-employment processing (credential verifications, suitability clearance, medical clearance, etc.) range from 30 days to over 90 days after a selection 

is made. In many facilities, the timeframe has been much longer. With the implementation of recommendations from the process redesign workgroup, we anticipate 

the timeframes will be shortened significantly. Automated recruitment databases 

will be used to monitor and evaluate improvements. Considerable efforts are underway to reduce the time it takes to fill healthcare positions in VHA. We are closely 

monitoring these efforts as well as continually sharing best and most effective practices as they are identified. 

Data on private sector hiring times is not readily available for comparative purposes. However, private employers are required to perform many of the same 

screening procedures as VA, such as primary source verification of credentials; background and reference checks; and pre-employment physical examinations. Therefore, 

we believe the timeframes would be somewhat comparable. We recognize, however, 

that Federal employers are held to more stringent standards in many aspects of employee security and suitability. 

Question 7: Based on the CACI study, do you think VA could benefit from using 

an outside recruitment, advertising and communications agency to speed up the hiring process? 

Response: VHA has been actively using the services of external recruitment, advertising and communication agency for more than 17 years and have found these services invaluable. We continue to advertise in professional journals, public service announcements, and newspapers but have expanded into extensive use of online advertising and use of commercial job boards as technologies have changed. Our recruitment Web site has undergone extensive redesign with CACI as our contractor 

and we are currently in phase 2 of the redesign process. Each step has been based 

on research into best practices for developing recruitment Web sites and marketing 

materials that are both attractive and designed to increase interest in job applications. Several recruitment marketing research studies have been completed and 

each has advanced both our approach to how we create the messages we use to target our recruitment to healthcare professionals. Our major recruitment campaigns 

are tested with focus groups to determine what messages are best received and likely to prompt actions on the part of the potential job candidate. 

Question 8: Public Law 108–445, the ‘‘VA-Pay bill’’ reformed the VA physician pay 

and performance system. 

Question 8(a): What difference has this legislation made on VA’s ability to recruit 

and retain the best physicians? 

Response: The new physician and dentist pay system has provided VA with a comprehensive way to offer flexible compensation packages making VA more competitive in the recruitment and retention of physicians and dentists. Through the use 

of the new pay flexibilities, VA has been able to increase the overall number of physicians and dentists employed by 574 additional staff. Many of the additional staff 

are in clinical specialties which had previously experienced significant difficulty attracting candidates. 

In addition to improvements in recruitment, VA has also benefited from improvements in the retention of physician and dentist staff. A comparison of the loss rates 

for 2006 (9.60 percent) and 2007 (4.18 percent) show a more than 50 percent improvement in the retention of physicians and dentists. The significance of this improved rate of retention is most evident when compared against the historical loss 

rates for physicians and dentists. 


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Physicians Loss Rate Dentists Loss Rate 

Year Percentage Year Percentage 

2000 11.69 2000 8.48 

2001 10.88 2001 4.23 

2002 10.76 2002 6.92 

2003 10.37 2003 6.82 

2004 10.22 2004 4.91 

2005 9.69 2005 9.15 

2006 9.60 2006 9.68 

2007 4.18 2007 4.32 

We believe the new pay system has significantly contributed to the overall decrease in physician and dentist separations. 

Question 8(b): What effect has the ‘‘VA-Pay bill’’ had on VA’s reliance on part-time 

physicians? 

Response: The physician and dentist pay reform has improved the ability of our 

medical facilities to recruit both full-time and part-time physicians. In all of circumstances, there is not a need to hire a physician in a certain specialty on a fulltime basis, so part-time employment is preferred over full time. In many instances, 

highly qualified academic physicians hold part-time appointments with both VA and 

affiliated medical schools. This arrangement is beneficial to VA in that it allows us 

to hire a higher quality physician than we would if we required that they work fulltime with VA, where they would not be able to pursue the teaching and research 

opportunities available through a joint appointment. Certainly, the new pay system 

has improved facilities’ ability to recruit full-time physicians when that is the preferred arrangement. 

Question 9: The Partnership for Public Service and American University’s Institute 

for the Study of Public Policy Implementation rankings from the Office of Personnel 

Management’s (OPM) Federal Human Capital Survey rank VHA 18th out of 222 

Federal agencies as the ‘‘Best Places to Work.’’ Do you find that this survey is a 

valid representation of VHA staff? 

Response: VHA administers an All Employee Survey (AES) annually to all full-and 

part-time VHA employees. Response rates during in 2007 were as high as 76.2 percent, which is 164,905 employees. The AES can therefore be considered a census (as 

opposed to a sample) of VHA employees and a more reliable measure of employee 

satisfaction that the survey from the Partnership for Public Service. The AES includes Job Satisfaction Index:—a scale that consists of 13 questions and concerns 

related to the respondent’s current level of job satisfaction. The rated aspects of job 

satisfaction include: type of work, amount of work, pay, coworker relationships, direct supervision, senior management, opportunities for promotion, working conditions, perceived customer satisfaction, amount of praise, quality of work, overall satisfaction, and overall satisfaction compared to 2 years ago. 

Question 10: The Partnership for Public Service analysis of the OPM survey shows 

a high satisfaction rate among employees 40 and over (12 of 222), but very low satisfaction among its younger cohort (112 out of 208)? How would you explain the difference? 

Response: The results of AES Job Satisfaction Index:—for the rated aspects of job 

satisfaction include: type of work, amount of work, pay, coworker relationships, direct supervision, senior management, opportunities for promotion, working conditions, perceived customer satisfaction, amount of praise, quality of work, overall satisfaction for these two age groups is presented below:. 

The first selection of the data discussed below includes ratings from all AES respondents in 2007. The second selection of the data included ratings from the AES 


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respondents in the clinical occupations only (such as physicians, pharmacists, registered nurses, licensed practical nurses, clinical laboratory employees and others). 

For each data selection, respondents’ ratings were examined separately for the following age groups: Younger than 20; 20–29; 30–39; 40–49; 50–59; and 60 or older. 

The mean ratings of each aspect of job satisfaction were computed for each of these 

age groups. The following survey ratings were the basis for computing the means: 

1=Not at all satisfied, 2=Not very satisfied, 3=Neither satisfied or dissatisfied, 

4=Somewhat satisfied, 5=Very satisfied. Ratings above 4 are considered highly satisfied, ratings between 3.3 and 4 (including these values) are considered moderately 

satisfied, ratings between 2.8 and 3.2 (including these values) are considered neutral, and ratings below 2.8 are considered low in this report. 

In the all AES respondents’ data, only one job aspect, opportunities for promotion, 

demonstrated low mean satisfaction ratings for some of the age groups: for 40–49, 

for 50–59, and for the respondents who did not indicate their age. Mean satisfaction 

ratings for all the other job aspects, including the most important summary score: 

the overall satisfaction, showed either neutral or better ratings for all of the age 

groups. Quality of work showed highly satisfied ratings, for all the age groups. Type 

of work showed highly satisfied ratings for all the age groups except younger than 

20, where the ratings were moderately satisfied. Relationships with coworkers 

showed highly satisfied ratings for the age groups 20–29, 50–59, and 60 or older, 

and moderately satisfied ratings for all of the other age groups. Customer satisfaction showed highly satisfied ratings for the age group of 60 or older, and moderately 

satisfied ratings for all of the other age groups. 

Overall satisfaction ratings were moderately satisfied only, for all of the age 

groups; and overall satisfaction compared to two years ago had neutral ratings for 

all of the age groups. Satisfaction with amount of work, direct supervision, and 

working conditions all showed moderately satisfied ratings, for all of the age groups. 

Data for the AES respondents in the clinical occupations only (the total of 58,151 

individuals) showed a pattern that was overall consistent with the all AES respondents’ data, with the exception of three low satisfaction ratings. Opportunities for 

promotion were rated low by respondents younger than 20 and those who did not 

indicate their age, and amount of praise was rated low by respondents younger than 

20. Mean satisfaction ratings for all the other job aspects, including the most important summary score: the overall satisfaction, showed either neutral or better ratings 

for all of the age groups. Quality of work showed highly satisfied ratings only, for 

all the age groups. Type of work showed highly satisfied ratings for all the age 

groups except younger than 20. Relationships with coworkers showed highly satisfied ratings for all the age groups except younger than 20 and respondents who did 

not indicate their age: these two groups had moderately satisfied ratings. Customer 

satisfaction showed highly satisfied ratings for the age group of 60 or older and 

moderately satisfied ratings for all of the other age groups. Overall satisfaction ratings were moderately satisfied only, for all of the age groups; and overall satisfaction compared to 2 years ago had neutral ratings for all of the age groups. Satisfaction with amount of work, direct supervision, and working conditions all showed 

moderately satisfied ratings, for all of the age groups. Taken together, these data 

suggest overall acceptable (i.e. neutral or better) levels of satisfaction of VHA employees with the comprehensively assessed various aspects of their jobs. 

Æ 


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